Every finding on record at The Orchards at Lapeer

This citation pertains to intake Number 3046775. Based on interview and record review, the facility failed to implement procedures to prevent elopement for one resident (R4) of three residents reviewed for elopement, resulting in one resident exiting the building unsupervised. Findings include: Resident #4 (R4): R4 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include bronchitis, hyperlipidemia, schizophrenia and hypertension. R4 has a brief interview for mental status (BIMS) score of 13, indicating they are cognitively intact. On 7/14/26 a 9:56am, R4 was observed in bed resting, R4 was well dressed and a wanderguard was observed on the left ankle. R4 was asked how her stay has been going so far. R4 stated that she would like to get out of here and be on her own again, but she would settle for another nursing home. R4 was asked how everyone treats her in the facility. R4 stated the staff treat her nice and they are respectful, but that she is ready to go home again. R4 was asked how long she has been in the facility. R4 stated that she has been here for about three months. R4 was asked why she has the wanderguard on her ankle. R4 stated the facility put it on her because she left the building. R4 was asked about leaving the building and what area did she leave from. R4 stated, I was in the cafeteria and there is a door and I just went out the door that way. It was nighttime and no one else was in the room with me. R4 was asked why she wanted to go outside. R4 stated, I just wanted to go home. R9 stated I really just planned to walk around the building and come back in the front door, but then I got lost and I went up the street a bit. R4 was asked if any staff came to find you. R4 stated, yes. R4 was asked if staff followed her out of the building or did they find you up the street. R4 stated the staff found me up the street and then they brought me back here. R4 was asked if she suffered any injuries. R4 stated that she had a small cut on her foot On 7/14/26 at 10:05am, record review revealed that on 5/18/26 R4 had an elopement risk score of 2, indicating they are low risk for elopement. On 7/14/26 at 10:07am, record review revealed a progress note dated 6/7/26 at 12:17pm. The nurse questioned R4 about leaving the facility. R4 stated that she wanted to go home. R4 stated I should not have left. R4 apologized for the incident. Assessed the cut to bottom of left food. A circular band-aid intact to the pad of left foot. R4 stated she is tired today. On 7/14/26 at 10:10am, record review of a psychiatric evaluation from 5/14/26 revealed that judgement and insight were intact, impulse control is intact and there are no signs of resistance, impulsiveness, or oppositional behavior. On 7/14/26 at 10:20am, record review of the 5-day investigation from 6/7/26 revealed that R4 has a BIMS of 13 and is cognitively intact. Prior to the incident R4 had a BIMS of 11, indicating mild cognitive impairment. As of 6/3/26 R4 was deemed incompetent to make decisions on her own and a guardian was put in place. On 6/7/26 at 1:15am, facility staff were unable to locate R4 after last seeing her in her room at 12:22am by the assigned nurse, an immediate in facility search was conducted. When R4 was unable to be located, an external search of the building was started. The Director of Nursing (DON) and administrator were notified at 1:18am. The police were contacted at 1:20am. The DON arrived at the facility at 1:30am Staff initiated an external search of the surrounding area. At 1:35am with the assistance of staff and police, R4 was observed just north of the railroad tracks by the facility at a residence. R4 returned to the facility at 1:40am with staff. The root cause of the incident was determined to be a staff member responded to the door alarm but shut it off and did not execute a search immediately. The police were notified at 1:20am and discovered R4 at 1:35am. The alarm was activated at 12:05am and staff responded at 12:25am, at this time the alarm was silenced, and staff did not conduct a search or alert any other staff. The alarm was functioning after maintenance tested it. The guardian and medical director were notified. R4 indicated she chose to exit the facility because she wanted to go home and this was influenced by emotional distress following a phone call with her daughter earlier in the day. A head-to-toe assessment was completed on R4 and noted a cut on the foot, a wanderguard was applied after completing a new elopement assessment, the care plan was updated, a treatment was put in place for the cut, door and wanderguard alarms were checked and functioning. Root cause was noted to be that staff did not respond timely to the alarm sounding and then shut it off without executing a proper search. The night shift staff was disciplined after this incident. All-staff were re-educated on the elopement policy and the roles of each staff member. The staff member that turned off the alarm and didn't tell any other staff members, no longer works at the facility and could not be reached for interview. The nurse who returned R4 to the facility was attempted to be contacted, her phone would not accept calls, and no message could be left. On 7/15/26 at 12:05pm, an interview was conducted with Certified Nursing Assistant (CNA) C. CNA C stated that R4 was in my set that night and I was her primary CNA. CNA C was asked if they could hear the alarm going off in the cafeteria. CNA C stated that there were a few alarms going off that night, so it is hard to distinguish. CNA C was asked how they discovered that R4 was potentially missing. CNA C stated I was going through some personal stuff at the time and not paying attention and the nurse poked me and was like R4 is missing. CNA C stated that once the code was paged, we went outside and looked for her. The police located her and the nurse brought her back to the facility. On 7/15/26 at 1:40pm, an interview was conducted with the Director of Nursing (DON). The DON was asked what they discovered from their investigation. The DON stated, I found concern with the staff not knowing which alarms were which. The DON stated that the door R4 exited from in the dining room does tend to get caught by the wind and cause the alarm to sound. We know now that wasn't the case and the door to the dining room should have been locked. The DON stated we have added a louder alarm to that door and ensure that the dining room is locked when the kitchen staff leaves for the night. The DON stated, I wrote up all of the nurses and aides that worked on the shift that night. The rest of the third shift staff received education and not a formal write up. Review of the policy titled, Elopement, Potential Resident, Procedure: 8. If a resident cannot be located, the staff member identifying the situation should:a. Notify the charge nurse and determine if the resident is out on authorized leave or pass.b. Notify all staff to initiate search by using facility code.c. Initiate a thorough search of the building, this includes every room, closets, bathrooms, storage closets, walk-ins, stairwell, under/behind furniture and premises. See supervisor to obtain keys to locked rooms.e. The charge nurse shall assign employee(s) to physically check each alarmed exit to determine if all alarms are in working order.

This citation pertains to intakes 3073775 and 3073809. Based on observation, interview and record review, the facility failed to implement procedures for skin management for two residents (R1, R9) of three residents reviewed for skin management, resulting in missed/inaccurate skin assessments and care plans not being updated. Findings include:Resident #1 (R1): R1 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include severe sepsis, pneumonia, pleural effusion and methicillin resistant staphylococcus aureus (MRSA) infection. R1 has a brief interview for mental status (BIMS) score of 15, indicating R1 is cognitively intact. On 7/14/26 at 11:04am, R1 was observed in bed, dressed in a gown, no odors present, the room is clean and his heels are elevated with a pillow, his right foot turns inward and there is a dressing on the outside of the right ankle dated 07/13/26. R1 was asked what the dressing was for on the outside of his ankle. R1 stated that he had a scab on his ankle and they have it covered up. R1 was asked to provide additional information about the area on his right ankle. R1 was unable to offer any more information on the area, he began to discuss other topics. On 7/14/26 at 3:10pm, an interview was conducted with Wound Care (WC) A. WC A was asked if R1 has any pressure injuries. WC A stated, yes, he has an area on his right ankle on the outside. WC A was asked if R1 admitted with this area on his ankle. WC A stated, yes, it was a small scab on admission, and he has picked at it and now it is open. WC A was asked how big the area is. WC A stated that it is about the size of a quarter. WC A was asked when the scab opened up. WC A stated that 06/14/26 was the day it opened. WC A was asked what interventions they had in place for pressure injury prevention. WC A stated that they have protective boots and floating the heels of R1. WC A was asked if R1 will wear his protective boots. WC A stated that lately has been better at wearing them, but when he first got here, he would take them off. On 7/15/26 at 12:30pm, record review revealed that a head-to-toe skin assessment was completed on 5/31/26. There is no documentation of scabs on the assessment.On 7/15/26 at 12:44pm, an interview was conducted with Registered Nurse (RN) B. RN B was covering for wound care today. RN B was asked if they have seen the right ankle wound. RN B stated that they had not seen it today but stated it started out as a scab. RN B stated that R1 had scabs on his knees, ankles and face on admission. RN B then stated that R1 will pick at his scabs, he is a picker. RN B was asked if this scab was present on admission. RN B stated that on 6/7/26 there is documentation that there is scattered scabbing on his body. RN B was asked if nurses should document these areas of scabbing on admission in the event, they ever become an open area. RN B stated that some of the nurses might not document scabs on admission, but they probably should. RN B reviewed the nurses skin assessment of R1 from admission, and it didn't note the scabbing on admission. On 7/15/26 at 12:55pm, record review revealed a care plan titled, I have actual impairment to skin integrity of the right ankle and knee. Created date 06/24/2026. RN B was asked if that care plan should have been initiated as soon as the facility identified the skin impairment on the right ankle. RN B stated, yes, one should have been put in place earlier.Resident #9 (R9):R9 is [AGE] years old and admitted to the facility most recently on 03/29/2023 with diagnoses that include peripheral vascular disease, dementia, hypertension and anxiety disorder. R9 has been receiving hospice services since 6/20/2024. R9 was observed resting in bed with a dressing on his right pinky toe and heel boots in place.On 7/14/26 at 3:30pm, record review revealed that skin assessments were not being completed timely. A skin assessment was completed on 4/23/26, the next one was completed on 5/14/26 and then one was completed on 6/16/26.On 7/14/26 at 3:35pm, record review revealed a care plan titled, SKIN: I have potential for pressure ulcer development & impaired skin integrity. Created date 08/02/2020, revision date 02/14/2024.On 7/15/26 at 1:00pm, an interview was conducted with RN B. RN B was asked when they noted the wound on the right pinky toe. RN B stated it was noted on 6/23/26. RN B was asked what interventions were in place prior to the wound developing. RN B stated that R9 had the protective boots on to help with prevention, but they didn't protect the top of his feet. RN B was asked how they think the wound developed. RN B stated that the right pinky toe of R9 turns inward and it rubs on the bed and that is what caused the area to develop, it was almost like a rug burn. RN B stated that R9 wears his boots all day long and he is compliant. RN B was asked who updates care plans for skin integrity. RN B stated that the wound nurse does that. RN B stated the care plan for skin is generated automatically on admission, if there is an issue the care plan will state that there is actual impairment. If a wound develops after admission, then we would enter a care plan for actual skin impairment. RN B was asked how often skin assessments are completed on residents. RN B stated that they are done weekly. The SA and RN B reviewed the weekly skin assessments and verified lapses in time of completion. RN B was asked why the assessments weren't done weekly. RN B stated that they just weren't done, I don't know why they wouldn't complete them. RN B was made aware there is a potential for pressure ulcer development care plan and it was last revised on 02/14/2024. RN B was asked if the care plan should have been updated when the pressure area developed. RN B stated, yes, it should be updated to an actual skin impairment care plan.On 7/15/26 at 1:24pm, an interview was conducted with the Director of Nursing (DON). The DON was asked if care plans should be updated when there is actual skin impairment noted. The DON state, yes, there should be one preventative and one actual. The DON was asked who updates the care plans for skin. The DON stated that the wound care nurse is supposed to update them after the wound doctor does the rounds and then I follow up to ensure they are completed. The DON was asked often skin assessments are completed. The DON stated that the nurses do the weekly skin assessments and the wound nurse does pressure and non-pressure skin concerns weekly. The DON was made aware of the care plan concerns and concerns with weekly skin assessments.Review of the policy titled, Pressure Ulcer and Skin Care Management, revealed:Procedure:1. A licensed nurse checks the resident's body for the presence of pressure ulcers, wounds and other skin conditions:-At admission or readmission to the facility.-Whenever the resident arrives by medical transport-Weekly on residents, and-Prior to discharge.2. The licensed nurse documents the body check was completed on the resident's weekly head to toe skin assessment.5. The interdisciplinary team reviews skin risk and initiates or updates care plans accordingly.7. The interdisciplinary team will develop a care plan addressing risk factors and periodically review and update the care plan as needed to minimize risk and promote healing.

This citation pertains to Intake Numbers 2732659 and 2739632.Based on interview and record review, the facility failed to ensure that a wound to the ankle was assessed, monitored and provided treatment for, for one resident (Resident 73) of three reviewed for wounds, resulting in the resident's ankle wound worsening, and developing an infection that resulted in the amputation of the leg.Findings include: Resident #73 (R73):A review of the complaint for Resident 73 (R73) revealed that the Resident admitted into the facility for wound care for a diabetic ulcer on the bottom of R73's foot. The Complainant KK explained that a new wound formed on R73's ankle while residing at the facility. The Resident went to an appointment due to an x-ray that showed dislocation but was sent from the appointment to the hospital for amputation of the leg due to necrotizing fasciitis. A review of R73's medical record revealed an admission into the facility on 1/8/26 with diagnoses that included acute osteomyelitis of left ankle and foot, non-pressure chronic ulcer of left lower leg, diabetes, diabetic neuropathy, and acquired absence of right leg below knee (below the knee amputation). The Resident had a discharge to acute care hospital on 1/28/26. A review of R73's progress notes revealed the following:1/20/26 at 7:28 AM, .Upon assessment residents left ankle was swollen w (with)/ fluid. (Dr. Name) numbed area w/lidocaine, lanced and drained 60 cc (cubic centimeters) serosanguinous fluid from ankle. Resident tolerated procedure will w/no pain or discomfort. While treating ankle and foot wound, (Dr.) heard popping/cracking noises upon movement coming from joint area. Resident states he has no feeling in his left foot and has not had feeling for years. He stated he does ride the bike in therapy every day. He has no pain on movement and was unaware of swelling that occurred. (Dr.'s name) notified. Xray ordered, non-weight bearing until further orders, immobilizer ordered, culture obtained from drainage, and currently on ABT (antibiotic) until 1/30. 1/21/26 at 11:39 AM, Xray resulted with deformity is seen in the tibiotalar joint, with widening of this joint space, with evidence also of deformities of the distal portion of the calcaneus bone and talus and navicular bones, with adjacent corticated bone densities related to old injuries. Diffuse soft tissue edema is seen in the lower portion of the leg and surrounding the ankle, more along the medial aspect, resection of pockets of air collections in the soft tissues adjacent to the distal tibia and the medial malleolus, from soft tissue emphysema. Underlying cellulitis podiatry considered. No obvious evidence of underlying osteomyelitis however is seen. A few vascular calcifications are seen. Orders for resident to follow up with ortho.1/23/26 at 2:14 PM, Nursing Progress Note: Resident was noted to have a swollen left ankle. (Dr. name) laced the area with noted pussy substance coming out, retrieved a culture and it was negative. Xray of the area indicated Sharko Foot. Review of the wound culture with a collection date on 1/21/26 and report date on 1/21/26 revealed a summary of abnormal values No Organism Detected. A review of the Weekly Wound Healing Record for Wound #2, dated 1/27/26 revealed wound to left ankle, acquired during resident's stay on 1/20/26, with epithelial tissue present, granulation tissue present, slough tissue present, and moist. Drainage: bloody, moderate. Wound measurements Length 2.0 cm, Width 3.0 cm, Depth 2.0 cm. Treatment: cleanse with NS (normal saline) apply Medi honey, cover with ABD, wrap with kerlix.A review of R73's Wound Care Assessment, dated 1/20/26, revealed, . Since last visit patient is noted to has a left ankle valgus deformity. Patient has no pain to his limb. The left ankle now displays a medical displacement with significant effusion. Once anesthetized a #11 scalpel was used to make a cruciate incision. Approximately 60 cc of serous-sanguinous, brownish fluid was expressed. The site was once cleansed and again swabbed with betadine. Treatment Please cleanse the wound with wound cleanser and dry. Please treat wound with xeroform dressing and cover with kerlex or border foam dressing. Change dressing daily/PRN (as needed).A review of R73's Wound Care Assessment, dated 1/27/26, revealed, .Wound #2 Location: Left lateral ankle, Type: effusion with erosion, Description: At the site of aspiration noted on last visit the area is eroded open revealing white, pink-yellow granulation tissue. There is areas of fatty debris and tissue appreciated in the wound base which is partially removed using sharp dissection. The area is nontender. There is no odor. There is scant to moderate serous exudate. Wound edges are unattached with undermining appreciated from 11:00 to 3:00 deepest point being 1.8 cm. There remains mild subcutaneous emphysema in the area. Without signs of infection. There also appears to be some tendon exposure. Dimensions: 2.0 cm x 3.0 cm x 2.0 cm. A review of Resident 73's Treatment Administration Record (TAR) and orders revealed an order dated 1/27/26 to Cleanse left ankle w/wound cleanser, pat dry w/gauze, apply Medi honey to wound bed, cover with ABD pad, wrap w/kerlix every day shift for Diabetic ulcer. The TAR revealed one documented dressing change on 1/28/26. There was no order or documented dressing changes to the left ankle area from 1/20/26 when the swollen ankle was lanced to 1/27/26 with wound care team assessing the wound a week later. The review of assessments and progress notes failed to identify the worsening of the wound. A review of R73's hospital records for date of service at the hospital from the emergency room that started on 1/28/26 revealed the following:-Dated 1/28/26, X-Ray of left ankle Impression: 1. Severe deformity at the ankle with absence of the talus and advanced degenerative changes of the mid and hindfoot. 2. Moderate subcutaneous emphysema surrounding the ankle suggestive of gas-forming infection such as necrotizing fasciitis.-Doctor MM, I saw and examined the patient in the ER. We were asked to see the patient for a left foot wound. He has extensive gas in the soft tissues and was read out by radiology as concerning for necrotizing soft tissue infection. I agree with that assessment he has infection on the lateral aspect of the ankle with complete degeneration of the joint, purulent fluid draining and I am concerned about the possibility of necrotizing fasciitis. I am concerned about his debility and inability to mount an effective immune response. Based on this I would like to bring him emergently to the operating room for surgical intervention with ankle disarticulation and any needed procedures. I am concerned about the possibility of life-threatening worsening of his condition if we do not operate on him now.-Dated 1/29/26, a left amputation below knee was completed. Operative Report revealed date of service 1/29/26 with Postoperative Diagnosis: Necrotizing fasciitis left lower extremity.-On 2/6/26 a left amputation above knee was completed. On 3/3/26 at 2:12 PM, an interview was conducted with the Wound Care Nurse (WCN) - regarding R73's ankle wound. A review of Resident 73's medical record was conducted with the WCN. The Practitioner had lanced the swollen left ankle on 1/20/26 with a scalpel and from that point it was indicated the Resident had an open wound. When asked about their assessment, the WCN indicated she had not done one on the 20th, but the Practitioner had notes on the procedure. A review of the TAR revealed no dressing changes documented as completed on the left ankle until 1/27/26 when the wound care team had seen the Resident. It was reviewed with the WCN of lack of assessment, monitoring and treatment of R73's wound to the left ankle. It was determined that the Resident went to the Orthopedic Doctor's appointment and from there went to the acute care hospital and had not returned. On 3/3/26 at 3:22 PM, an interview was conducted with the Director of Nursing (DON) regarding R73's ankle wound with the lack of assessment, monitoring and dressing changes. The DON reported doing a timeline of the wound and stated, Yes, I have an issue with that also, and indicated, when the skin got worse, the Nurse should have gotten treatment and notified the Doctor and there should have been an order for a dressing change. The DON was asked about skin care policy, and they indicated they would follow the pressure ulcer policies for skin care. A review of the facility policy titled, Pressure Ulcer Preventative Measures, revealed, .2. Residents should be monitored during care and consistently by licensed nurses to identify potential areas for skin breakdown and integrity of overall skin. 5. The nurse inspects any reddened areas and/or breaks in the resident's skin and documents the inspection. A review of the facility policy titled, Pressure Ulcer & Skin Care Management, revealed, .a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and reduce the risk of new pressure ulcers developing. 8. The nursing staff reviews the pressure ulcer prevention and treatment procedures with the resident's physician. They select the treatment procedures appropriate for the resident and the type of pressure ulcer or wound. The licensed nurse implements the wound care treatment procedures in accordance with current standards of practice.

Based on interview and record review, the facility failed to submit payroll-based, direct care staffing information to the CMS/Centers for Medicare and Medicaid Services for the 4th fiscal quarter (July 2025 - September 2025), as required by CMS. Findings Include: A review of the Payroll Based Journal Staffing Data Report for FY/Fiscal Year Quarter 4 2025 (July 1- September 30), indicated the following: This Staffing Data Report identifies areas of concern that will be triggered (e.g., requires follow-up during the survey). Failed to Submit Data for the Quarter: Result- Triggered; Definition- Triggered = No Data Submitted for Quarter.On 3/4/2026 at 1:15 PM the Administrator was interviewed about the PBJ direct care staffing information for the fourth fiscal quarter July 2025-September 2025 that was not submitted to CMS. The direct care staffing data identifies the type, number and hours worked for clinical staff caring for the needs of the residents. The Administrator said the facility's corporate office was supposed to submit the staffing documents to CMS and the information was not sent in. The Administrator said she was aware that it was required for the payroll based direct care staffing data to be sent to CMS every quarter.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area, resulting in the potential to spread food borne illness to all residents who consume food from the kitchen. Findings Include:On 03/02/2026 at 9:17 AM observed an open bag of fresh cut salad with a no open date and a use by date of 2/28/26 in the walk-in cooler. Dietary Manager (DM) E removed the bag to be disposed of.On 03/02/2026 at 9:20 AM observed a container of fruit cocktail without a label or date in the kitchen two door refrigerator. DM E removed the container from the unit.On 03/02/2026 at 9:49 AM observation of the resident fridge located in the dining room found the following items: three lemons cut down the center in a plastic bag and lettuce in a plastic bag without date marking. Open package of bologna inside a plastic bag with a receive date of 1/12/26, without an open or discard date. A container with an orange substance inside, without a label identifying substance and dated 2/7/26. Opened hot dog package with a date of 2/9/26 without discard date. During this observation, DM E indicated, the hotdogs should've been thrown away by now.On 03/03/2026 at 8:31 AM an interview conducted with the DM E found dates should be marked seven days after opening.A record review of the facility provided policy entitled Safe Storage & Handling of Outside Food, states that Any food which is not going to be consumed immediately must be covered and labeled with the resident's name, and date the food was brought into the facility . All food that is stored in the refrigerator & not consumed within 3 days will be discarded by the facility staff daily.A record review of the facility provided policy entitled Safe Storage of Food, states that All foods will be stored wrapped or in covered containers, labeled and dated . According to the 2022 Food Code, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.On 03/02/2026 at 12:09 PM observed two quarter pans sitting above the steam table during lunch service. At this time, the temperature of the pureed turkey was taken with a rapid read thermometer and found to be 179 F. The temperature of the meat patties was taken and found to be 180 F.On 03/02/2026 at 12:35 PM the temperature was taken of the two quarter pans sitting above the steam table, with the following temperatures noted: pureed turkey: 120-122 F, and meat patties: 107-122 F.On 03/02/2026 at 12:43 PM an interview with DM E found they like to see the temperature of food on the steam table at 145 F or higher. Once informed of temperature in quarter pans, DM E removed pans to be reheated. According to the 2022 FDA Food Code section 3-501.16 TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57C (135F) or above; or (2) At 5C (41F) or less.

Based on observation, interview and record review, the facility failed to: 1). follow CDC guidelines for management of residents with Respiratory illness for 3 residents (#22, #38 and #60) of 3 residents reviewed for respiratory illness; 2). ensure prevention of cross contamination of ice scoopers and ice containers; 3). provide a workspace that prevents cross contamination of linen; 4). follow CDC guidelines for Transmission Based Precautions and Personal Protective Equipment/PPE use during wound care for 1 resident (#45), and 5) the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). Findings include: Deficient Practice Statement #1: Based on observation, interview and record review, the facility failed to: 1). follow CDC guidelines for management of residents with Respiratory illness for 3 residents (#22, #38 and #60) of 3 residents reviewed for respiratory illness; 2). ensure prevention of cross contamination of ice scoopers and ice containers; 3). provide a workspace that prevents cross contamination of linen; 4). follow CDC guidelines for Transmission Based Precautions and Personal Protective Equipment/PPE use during wound care for 1 resident (#45), Findings include: Infection Prevention and Control Program. On 3/4/26 at 11:18 AM, an interview was conducted with the Infection Control Preventionist (ICP) BB regarding the facility infection control program. A review was conducted with the ICP of line listings. A review of Residents in February with upper respiratory signs and symptoms were reviewed. Resident 22 (R22) and 38 (R38) were two residents that carried over from the month before who had respiratory illness signs and symptoms with R22 having cough and congestion and R38 with a dry cough and congestion per the ICP. The ICP reported the residents did not have a fever, pains or aches and did not present with signs of the flu. The concern, if not testing for influenza with respiratory illness signs and symptoms, then may lack the opportunity for treatment, the resident may have more than one illness, and medications such as acetaminophen or ibuprofen may mask other symptoms. The ICP was unsure what their policy indicated and reported they would go with the doctor's recommendations. The ICP reported the doctor had not ordered for influenza testing. The ICP reported they had tested for Covid but not for influenza. When asked if they had an Influenza policy, the ICP reported they did not and were going to reach out to corporate for assistance. When asked if they follow CDC (Centers of Disease Control) recommendations, the ICP reported they do. The ICP referenced on her computer the CDC guidelines for testing and reported that the CDC recommended testing for influenza with respiratory signs and symptoms. When reviewing residents in December with respiratory signs and symptoms of illness, there were multiple residents listed. When asked if they had been tested for Influenza, the ICP reported they had not tested for the flu but did test for Covid. According to the CDC (Centers for Disease Control and Prevention, https://www.cdc.gov/flu/hcp/testing-methods/nursing-homes.html, .2. Test any resident with symptoms of COVID-19 or influenza for both SARS-CoV-2 and influenza viruses as soon as possible. Symptomatic residents should be tested for SARS-CoV-2 and influenza to distinguish between COVID-19 and influenza and other respiratory viral diseases and to guide decisions about treatment and infection prevention and control measures. Because antiviral treatment for either COVID-19 or influenza is indicated early in the course of illness and should be started soon after symptom onset, a symptomatic resident's antiviral treatment options should be assessed immediately. Because a resident can have multiple exposures or co-infection with SARS-CoV-2 and influenza viruses, an incorrect clinical diagnosis could result in missed opportunities for treatment and sub-optimal infection prevention measures. Cross contamination of ice scoopers and ice containers. On 3/2/26 a Confidential Group of Residents were together for a group meeting at approximately 3:00 PM. The Group consisted of seven Residents, all who were able to answer questions and six engaged in conversations and discussions. The group was asked about concerns with care received at the facility that included the following: -Residents having to deal with other Residents with behaviors, staff do not watch the Residents or staff say, oh, she's ok' and 'that's just him/her' when the Resident with behaviors was having issues, wandering in rooms, interacting inappropriately, or touching things that don't belong to them. The Group reported that they were having to deal with or redirect the Residents themselves and watched as Residents play with the food of trays being set up and getting into the ice bucket and ice scooper that were in the hallways. The Group reported watching Residents getting ice from the hallway ice containers. One Resident reported seeing a resident pick their nose and has seen the same resident getting into the ice containers. The Group indicated they should not be watching over other Residents or have them touching something they will be consuming. On 3/4/26 at 11:18 AM, an interview was conducted with the Infection Control Preventionist (ICP) BB. When asked about the hydration stations of ice in a thermal bucket with an ice scooper, how did the facility ensure residents not getting into the ice. The ICP reported that staff were supposed to send it back to dietary to be cleaned. When asked what if staff does not see the residents, the ICP stated, That is an issue and reported they used to keep them behind the nurses' station and will address a solution. Infection Control PPE Resident #45: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #45 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: history of wound infection with multi-drug-resistant organisms, osteomyelitis (bone infection from a wound), respiratory failure, diabetes, and hypertension. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and the resident needed some assistance with all care. On 3/02/2026 at 10:11 AM, Resident #45 was observed lying in his bed. He said he had a sore on his bottom and the dressings to it were changed daily, usually on day shift. He said he'd had the wound for several months. On 3/2/2025 at 4:09 PM, wound care was observed with Nurse II. The resident was in Enhanced Barrier Precautions related to a very large sacral wound (approximately 8 cm long x5 cm wide x 4 cm deep) that had a history of infection with a multi-drug-resistant organism and an indwelling urinary catheter. The nurse wore gloves and an isolation gown and cleansed the wound. She removed her gloves, performed hand hygiene replaced her gloves and then packed the wound with Dakins soaked rolled gauze. She used her hands to pack the roll of gauze into the wound that had deep tunneling. She did not remove her gloves, perform hand hygiene and replace her gloves after using her fingers to pack the gauze into the wound, before applying the top dressing. Nurse II then removed her gloves performed hand hygiene and with her soiled gown on went to the treatment cart outside the room in the hallway to retrieve a marker and returned to the resident's room. A review of the facility policy titled, Initiating Isolation, undated revealed, Purpose: Isolation precautions will be initiated when there is reason to believe that a resident has an infectious or communicable disease. A review of the CDC/Centers for Disease Control and Prevention: Long-term Care Facilities- Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated April 2, 2024 provided, . 1. Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality. 2. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities . Respiratory Infection Resident #60: A record review of the Face sheet and MDS assessment indicated Resident #60 was admitted to the facility on [DATE] with diagnoses: acute and chronic respiratory failure, COPD, atrial fibrillation, Heart failure, chronic kidney disease, history of a stroke, history of pneumonia, hypothyroidism, hypertension, and anxiety. There was no MDS assessment; the resident needed assistance with care related to weakness. On 3/02/2026 at 2:01 PM, Resident #60 was observed sitting in a wheelchair in her room. She had oxygen via nasal cannula set at 4 liters/minute from an oxygen concentrator. The water container for humidification was empty on the concentrator. When asked about the settings for her oxygen, the resident said the facility had been changing her settings. A record review of the physician orders identified an order for oxygen therapy for Resident #60 on 3/2/2026 at 8:00 AM, Continuous O2 @ 4L (liters) via nasal cannula. Notify MD if O2 Sat <86%, start date 3/2/2026. On 3/2/2026 at 7:00 PM, an order was identified for Resident #60, Change in condition charting q (every) shift for 10 days. Pneumonia, (shortness of breath), lung sounds. The resident was started on antibiotics Azithromycin on 3/2/2026 at 5:00 PM and Rocephin on 3/2/2026 at 8:00 PM; a breathing treatment on 3/3/2026 at 11:30 AM and prednisone on 3/3/2026 at 8:00 PM. A review of the progress notes indicated Resident #60 had a cough on 3/1/2026, low oxygen saturation rates in the 80's and a chest x-ray showed she had right lung infiltrates. Further review of the medical record for Resident #60 identified a physician's order to monitor for signs and symptoms of Covid-19 dated 2/16/2026. There was no mention of Influenza monitoring or testing for Influenza when the resident's respiratory condition declined. On 3/4/2026 at 1:20 AM a progress note revealed, Writer notified by CNA (Certified Nursing Assistant) that resident mentioned wanting to transfer due to not feeling well. Residents O2 reassessed, stating at 76%. NP (Nurse Practitioner notified, advised giving addition breathing treatment to reach 88%. 86% reached yet not maintained dropping back down to 77%. 911 called. A transfer note provided, Transferred out at 1:50 AM. DPS #2: Based on observation, interview and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility. Findings Include: On 03/02/2026 at 11:00 AM observed the washing machine positioned adjacent to and facing the hopper in the laundry washer room. The door handle was situated on the side opposite the walkway, requiring staff to move past the hopper to access it. Director of Housekeeping Services (DOHS) CC stated the hopper is used frequently. On 03/02/2026 at 1:50 PM an interview conducted with DOHS CC found it is difficult for staff to work around and load linen due to the tight space. On 03/03/2026 at 10:14 AM an interview with Infection Preventionist (IP) BB found they were unaware of any concerns in laundry regarding hopper location. IP BB stated they did not see any concern until it was pointed out. On 03/03/2026 at 11:43 AM an interview with DOHS CC found the washing machine has been there for the past four years. A record review of the facility provided policy entitled Description of Steps in the Laundry Process, states It is very important to properly transport and store soiled linens to prevent the spread of infection . The laundry room must have a process in place to effectively sort soiled linen without cross contaminating clean linen .Laundry employees should be conscious of heavily soiled linens, such as blood or fecal matter. Proper handling of these linens will prevent possible exposure to bloodborne pathogens . According to the Center for Disease Control and Prevention Guidelines for Environmental Infection Control in Health-Care Facilities dated January 8, 2024 A laundry facility is usually partitioned into two separate areas – a dirty area for receiving and handling the soiled laundry and a clean area for processing the washed items.1259 To minimize the potential for recontaminating cleaned laundry with aerosolized contaminated lint. On 03/03/2026 starting at 8:37 AM an environmental tour was conducted with the Administrator and Social Worker. The Maintenance Director was not available to participate. On 03/03/2026 at 8:39 AM an interview was conducted with Administrator regarding the spa room and stated there has been no beautician for about three months. When asked if the spa room is used, Administrator said no. On 03/03/2026 at 8:40 AM observed an out-of-order sign taped to the bathroom door in the front entry way. An interview at this time with Administrator found there is a leak around the toilet line and the bathroom has been out of order for two weeks. Administrator was unaware if maintenance had been flushing the sink and toilet. On 03/03/2026 at 8:42 AM observed no water coming from sink faucet when nozzles were moved in the Main Hall med room. During this observation, Administrator was interviewed on how long it has been nonfunctional, and Administrator stated they were not sure how long it had been. Observed a plastic bin under the sink plumbing line with dried brown substance along the inner edges of container and brown streaks coming from plumbing line. On 03/03/2026 at 8:45 AM observed a functional tub in East Hall shower room. During this observation, an interview with Social Worker (SW) AA found the shower is used but not the tub. An interview conducted at this time with the Administrator regarding whether the tub is flushed found they were unaware. On 03/03/2026 at 8:47 AM observed a functional tub in the South Hall shower room. During this observation, when asked if the tub was flushed, Administrator stated they were unaware. On 03/03/2026 at 8:49 AM observed a functional tub in the North Hall shower room. When the tub fixture was turned on, yellow discolored water was observed coming from the faucet for a few seconds before running clear. During this observation, Administrator asked what that was in reference to the discolored water. SW AA confirmed they saw the discolored water. When interviewed at this time on whether the tub was flushed, Administrator was unsure if the tub was flushed. On 03/03/2026 at 8:55 AM observed a small pool of water at the base of a hopper in the North Hall hazardous material storage room. An interview conducted at this time with SW AA found the room is only used for trash and linen. Further observation of the hopper revealed the cold-water handle was turned off and the hot water line releasing a slow stream from the faucet. The flush apparatus was unable to flush, and the spray hose located next to the hopper was shut off. An interview at this time with Administrator found they were not sure if the hopper or hose was flushed and if the hose line was still connected to the plumbing main line creating a possible stagnant line. On 03/03/2026 at 9:00 AM an interview was conducted with Administrator regarding the last time the water management team met. Administrator indicated they had not in the time they had been here and stated it may have happened before they got here in September. On 03/03/2026 at 10:42 AM an interview regarding the water management plan was conducted with Maintenance Director (MD) L. MD L indicated flushing is done monthly when it pops up on Tels to flush and purge all sinks. When asked if there was a flushing log, MD L indicated there is not, and it is completed when it comes on Tels. On 03/03/2026 starting at 10:48 AM, an environmental tour was conducted with the Maintenance Director. On 03/03/2026 at 10:53 AM observed a functional tub in the South Hall shower room. An interview at this time with MD L found the tub is flushed monthly. On 03/03/2026 at 10:55 AM an interview was conducted with MD L regarding whether the spa room is flushed, MD L stated it is on the list for flushing. On 03/03/2026 at 10:58 AM observed an out-of-order sign taped to the bathroom door in the front entry way. At this time MD L was asked about how long the restroom had been out of order, MD L stated they had no idea how long it has been out of order. Upon entering the bathroom, a strong odor was present in the room. When sink faucet was turned on, black particulates came out in water for a second before running clear. MD L indicated this room was not a part of flushing. On 03/03/2026 at 11:10 AM observed a pool of yellow water at the base of the hopper in the North Hall hazardous material storage room. When MD L tried to flush, the flush apparatus was unable to flush. When the hot water handle was turned on, a slow stream was released from the faucet. During this observation, MD L indicated the cold-water faucet had been turned off due to a corroded pipeline, and indicated the hopper was on the flushing schedule. Observation of the spray hose located next to the hopper was found to be shut off. When asked at this time if the hose is flushed, MD L indicated it is supposed to be flushed. Further observation found the sink faucet discharging yellow discolored water when turned on for a few seconds before running clear. On 03/03/2026 at 11:48 AM MD L was asked when the water management team had last gotten together to discuss the water management plan, MD L indicated, they had not in the month they had been working here. On 03/03/2026 an interview with the Director of nursing (DON) found maintenance is responsible for bringing up water management concerns at QAPI, however, indicated they have never had a sit-down meeting to discuss water management, and that meetings regarding water management are impromptu. A record review of the facility Legionella Water Management Program states The water management team will consist of at least the following personnel: a. The infection preventionist; b. The administrator; c. The medical director (or designee); d. The director of maintenance; and e. The director of environmental services A record review of the facility Legionella Water Management Program states QAPI [DATE] Legionella Environmental Assessment Form completed. The Water Management Program will be reviewed at least once a year. The Program includes work orders indicating flushing schedule for various fixtures. Including: purge deadheads and bathtubs. Recommended Schedule. Every 3 months.Instructions. Purge deadheads and bathtubs per location map. Sanitize shower heads and sink aerators. Recommended Schedule. Every 3 months. Instruction. Inspect, clean, and sanitize shower heads and sink aerators. inspect all purge all sinks. Recommended Schedule. Monthly. Instructions. Inspect and purge all sinks in facility. Verify draining properly and look for leaks. Document findings and repair as needed or generate work order. According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Flush low-flow piping runs and dead legs at least weekly. Flush infrequently used fixtures (e.g., eye wash stations, emergency showers) regularly as needed to maintain water quality parameters within control limits. Eliminate dead legs, which are sections of no- or low-water flow.

Based on interview and record review, the facility failed to ensure that grievances were addressed timely for a Group of Confidential Residents of seven residents that had concerns voiced during Resident Council meetings and the issues continued to recur.Findings include:On 3/2/26 a Confidential Group of Residents were together for a group meeting at approximately 3:00 PM. The Group consisted of seven Residents, all who were able to answer questions and six engaged in conversations and discussions. The group was asked about concerns with care received at the facility that included the following:-Hallways blocked with items on both sides of the hall. The Group reported that this has been brought up at Resident Council meetings, it will get better for a couple days than it goes right back to items on both sides of the wall and the medication cart positioned at an angle making it hard to get around. One Resident stated, it's like dodging cars, another reported it was like playing Frogger, and another said you have to zig-zag your way down the hall. One Resident reported that when you have to go down the hallway in your wheelchair, it was very difficult to go around the equipment, they tried to keep the items on one side, but it does not stay that way.-The majority of the Group reported phone use by staff while providing care. All the Residents in the Group reported they had this happen or seen it happen. The Group reported that staff would wear ear buds and be talking to someone, they could not tell if the staff was talking to them or to someone on their phone. One Resident reported you can call the staff's name 3 or 4 times and they don't hear you. Multiple Residents reported that they could see and heard another person on the staffs' phone and reported some staff have Facetime while they were working. The Group reported a concern of staff playing music on their phone and had it in their pocket. One Resident reported that quiet time was to be at 10:00 pm, they are talking while I am trying to sleep, use loud voices when taking care of roommates during the night, staff turn the lights on bright, laugh, talk in loud voices in the middle of the night, and have music playing on their phone. One Resident stated, it is their daytime, but it is our nighttime and we are trying to sleep. Another Resident stated, they lost the ability to care.-The Group reported concerns of staff being rude or have an attitude while receiving or asking for help. One Resident reported they complained of a staff member being rude and felt like they were retaliated against and was afraid to voice further concerns. Another Resident reported feeling retaliated against and had to apologize for concerns voiced. The Group as a whole reported concerns about staff rudeness and attitudes. The Group reported it had been brought up in Resident Council but there were ongoing issues. Multiple Residents reported they were afraid to voice concerns of staff being rude. Multiple Residents reported that staff use phrases of not my job if they don't want to do whatever it was that needed to be done and gave example of smelly or overflowing trash can and clogged toilets. When asked about knocking on the door before entering, the Group reported some staff do and some don't knock and announce they were entering.-When asked about call light response, the whole group reported concerns with staff response to call lights activated. Concerns included having to wait an hour for someone to show up, nurses don't answer the call lights, the call lights turned off, and staff report they will be back, then don't show back up. The Group reported that any time of day it was a concern but worse during shift change. The Group reported concerns of staff leaving the building and not being available when call lights were on. The Group reported that staff will go out to smoke multiple times and hear comments made by CNAs of I need a cigarette after that one and leave to go smoke. The Group reported it had been a concern brought up multiple times in Resident Council and the issue continued.-A Resident brought up the concern of not getting fresh water. One resident reported having to go to the dining room to get fresh water and that they don't change it out in their room regularly. Another resident said, They tell me to drink more water because my urine is dark, well get me water and I will drink it. It was brought up that on some weekends it is the same cup from Friday to Monday. The group expressed that when they do them, they date them and sometimes they do them in the evening and date it for the next day. It was the consensus of the whole group of it being an issue with getting fresh water passed to the rooms. It was brought up that they have complained as a group about this issue at Resident Council Meetings and the issue continues to be a problem.-When asked if the Group felt concerns were addressed and resolved, the group reported They don't follow up on complaints. A Resident voiced, There is a repetition, we complain over and over at every meeting, have to ask for them to take it seriously. Another Resident voiced, They say they discuss it on the town hall (staff meeting), they don't bring it up, even if it is told at the town hall, it doesn't get resolved, they just say it was brought up but the issue is not taken care of, it's like a revolving door. Seven of the Seven Resident indicated there has been no resolution to voiced concerns.A review of Resident Council Minutes revealed the following concerns/issues voiced during Resident Council meetings that included:March 2025: DON/Nursing: Nurse is on her phone during her whole shift. Talking on speaker phone. Nurse has a foul mouth and bad attitude. Nurse stated doesn't like this place. Nurse takes it out on residents. CNA: Staff are on their phones in resident's rooms.May 2025: CNA: Concern with call lights at night. Concern with CNAS on phones or computers.August 2025: Housekeeping: Staff member has an attitude towards other residents, talks down, treats them with disrespect. Goes in and out of room without permission. CNA: Fresh water still not being given to (room number) at times.September 2025: DON/Nursing: CNA's sitting in nursing station on phones and not being productive. CNA: Wheelchairs and hoyers are not staying on one side of the hall so easily can pass through. Concern form: Aids on North Hall had an attitude feel care has declined since new owners. Quiet time not respected. Phones still in room. Staff wearing earbuds having conversation and ignoring residents. Nursing disturbing resident while blasting music from phone in pocket. Nurse keeping cart angled in hallway instead of respectfully leaving to the side.October 2025: DON/Nursing: Negative comments are being discussed in hallways, in front of residents. Staff not knocking before entering. Nurse being rude to the residents in 24. CNA: A certain staff member being rude to residents-it's her way or no way. When addressing residents' needs in a room, noise should be quiet and no bright lights turned on. Especially in the early morning hours. Water passes still a hit or miss.November 2025: Administration: Safety concern for residents. Need to address concerns aggressively. Facility feels like it's becoming a psychiatric ward, accepting anybody and everybody. DON/Nursing: Address every one of our concerns and not just announce it at the meeting. Make sure staff understands residents' concerns responsibly and effectively. CNA: Respectively knocking on doors before entering. Residents having to call main number to get assistance. Waters still an issue-certain staff that never take care of it.December 2025: DON/Nursing: Some issues with new night nurse giving attitude. Ensure quiet time is adhered to during times of 10 pm to 6 am. CNA: Water pass is still an issue with certain aides.January 2026, CNA: Water pass is still an issue, and some have no water in room to take medication or occasionally sip of water if needed for a cough.February 2026: Administration: Some residents felt that they are not being respected in general by staff and feel they should be seen and not heard. Being talked down to like children. DON/Nursing: Disturbing the residents while blasting music from phone in pocket. Nurse keeps cart angled in hallway instead of respectfully leaving to the side. CNA: Aids on north hall had an attitude said resident would get shower on Saturday but did not receive. Feel the care has declined since new owners took over. Soiled briefs being thrown on the floor. Toilet in 44 was plugged up and dirty and residents were told to still use it. Phones are still being used in room. Quiet time not respected. Staff wearing ear buds and having conversations and ignoring residents. A review of facility documents titled Concern Form that were with Resident Council (RC) minutes revealed the following:Concern form with September RC minutes revealed:-Information about your Concern: Please describe the concern: Aids on North Hall had an attitude feel care has declined since new owners. Quiet time not respected. Soiled briefs left on floor. Phones still in room. Assisted feeding time at dinner not being followed. Staff wearing earbuds having conversation and ignoring residents. The rest of the questions were not answered on the concern form such as: When did the problem or incident occur, Who else knows about the problem or incident?, How can we address you issues?, Is this an ongoing problem?, Have you contacted us in the past about this issue? There was a signature of person completing report that was not legible and dated 2/22/26. The Corrective Action to be Taken: Discuss in town hall and nurse/CNA mtg (meeting) 2/26/26. The Outcome or Satisfaction Level portion of the form was not filled out.- Information about your Concern: Please describe the concern: Nursing disturbing resident while blasting music from phone in pocket. Nurse keeping cart angled in hallway instead of respectfully leaving to the side. Dated 8/11/26. The rest of the questions were not answered on the concern form such as: When did the problem or incident occur, Who else knows about the problem or incident?, How can we address you issues?, Is this an ongoing problem?, Have you contacted us in the past about this issue? There was a signature of person completing report that was not legible and dated 2/22/26. The Corrective Action to be Taken: Discuss in town hall and nurse/CNA mtg (meeting) 2/26/26. The Outcome or Satisfaction Level portion of the form was not filled out. Concern form with October RC minutes revealed:-Concern Form: CNAs sitting in nurses station on phones not being productive; Wheelchairs and Hoyers not on one side of hallway so easier to get through. Dated 9/10/25. The Corrective Action to be Taken: Audit to be completed by the IDT members in October and added to Nurse/CNA meeting, dated 10/11/15. The Outcome or Satisfaction Level portion of the form was not filled out. Concern form with November RC minutes revealed:-Concern Form: A staff member being rude to resident-her way or no way. When addressing or answering lights in room especially during sleep hours, need to be respectful of other residents. No bright lights on or loud noise. Once you punch in for shift, you should not leave right away to get food. Dated 10/13/26. The rest of the questions were not answered on the concern form such as: When did the problem or incident occur, Who else knows about the problem or incident?, How can we address you issues?, Is this an ongoing problem?, Have you contacted us in the past about this issue?. The Facility Response: spoke with different aides and nurses during working hours about concerns listed. Corrective Action to be Taken: will discuss in town hall (the rest was not able to be read as well as the signature and date.) The Outcome or Satisfaction Level portion of the form was not filled out.-Concern Form: Information about your Concern: Nursing staff not showing up. Not enough staff somedays. Negative comments being discussed in front of Residents. Staff not knocking before entering and a Nurse being rude to ladies in room (number). When did the problem or incident occur: Within the last few weeks, dated 10/13/25. The Facility Response: spoke with different aides and nurses during working hours about concerns listed. Corrective Action to be Taken: will discuss in town hall (the rest was not able to be read as well as the signature and date.) The Outcome or Satisfaction Level portion of the form was not filled out. Concern Forms with the December RC minutes revealed:- Concern Form: Information about your Concern: Not just announce it at town Hall, ensure staff is taking residents concerns responsibly and effectively. Still staffing issue, showing up late or not at all. Night nurse not be around enough to assist, dated 11/18/25. Facility Response: There is currently no open nursing positions. Mgmt monitors attendance daily. There have been no issues with staff coming late or not showing up to work. There are 2 nurses on nights and they assist when able. Corrective Action to be Taken: Let nursing staff know about above concerns. Educate nursing staff on resident concerns responsibility and effectively, dated 12/4/25. The Outcome or Satisfaction Level portion of the form was not filled out.Concern Forms with the January RC minutes revealed:- Concern Form: Information about your Concern: Concerns need to be addressed aggressively. Feeling like facility is becoming a psychiatric ward, accepting anyone, dated 11/18/25 and 12/3/25. Facility Response: Central intake assigns admissions-yellow-means Admin/DON review for appropriateness. Denying some personality d/t (due to) behaviors. Corrective Action to be Taken: Spoke with Central intake Spoke with DON and Admissions. Signed by the Administrator, dated 12/3/25. The Outcome or Satisfaction Level portion of the form was not filled out. Concern Forms with the February RC minutes revealed:- Concern Form: Information about your Concern: CNAs to empty trash and urinals before end of shift and have them on hand also. Water pass is still an issue, missing water to take meds with, dated 1/15/26. Facility Response: Meeting with the Aides and Nurses addressing the concerns. Corrective Action to be taken: Rounding, monitoring, correcting any issues, dated 1/16/26. The Outcome or Satisfaction Level portion of the form was not filled out. On 3/4/36 at 10:32 AM, an interview was conducted with the Administrator (NHA) regarding grievances and concerns brought forth by the Confidential Group of Residents and concerns from the Resident Council minutes with concern forms. When asked about the Town Hall meetings, the NHA reported the meetings were where they get together every month, go to the dining room, takes about 30 minutes, discuss concerns the Residents have, change in policies and anything in the past month that needs addressed. When asked if Residents go to the meetings, the NHA reported they have in the past, but they don't need to be there. Regarding repeated concerns, the NHA reported some concerns would be brought up at the Town Hall, and the Activity Staff fills out the concern form. The NHA reported that concerns should be going to social services and respective departments. Regarding rudeness of staff and issues with Resident 29, the NHA reported that she was aware of complaints, it was investigated and the staff was let go and stated, It took a lot of stress out of the building. It was reviewed with the NHA that the Group of Confidential Residents did not feel like their concerns were heard and addressed. The NHA reported she had gone to Resident Council meeting and discussed the issue with getting behavioral residents. It was reviewed with the NHA that the Group of Confidential Residents did not feel like their concerns were heard and addressed. On 3/4/26 at 2:22 PM, an interview was conducted with the Director of Nursing (DON) regarding issues brought up through the Confidential Resident Group meeting. The DON reported that the facility had tried to do an afternoon supervisor and weekend manager, but it was hit or miss and that guardian rounds were done to capture concerns and issues, but the guardian rounds were not consistent. The DON reported the facility had programs, but it was hit or miss with them being completed. The DON reported coming in on off hours and on weekends and they were not seeing the issues the Residents were reporting like staff use of the phones. The DON reported it was not allowed to restrict staff personal phones out of care areas and if able to do that, it would help with that concern. The DON reported being aware that the Residents were afraid of retaliation and won't give names, but indicated that when she does not know, then she has to guess on who the staff were they were having issues with. A review of the facility policy titled, Resident Rights, revealed, .Resident Rights 1. Resident rights. The Resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 5. Respect and dignity. The resident has a right to be treated with respect and dignity, including c The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences.10. Grievances. The resident has the right to: a. Voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished; and the behavior of staff and of other residents; and other concerns regarding their LTC (long term care) facility stay. b. The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have. A review of the facility policy titled, Concern/Grievance Policy, revealed, Policy: Residents and their family members may voice complaints, concerns and/or grievances to the facility or other entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. The facility will make prompt efforts to resolve grievances. Fundamental Information: The Administrator has been designated as the Grievance Official and is responsible to receive and assure complaints, concerns and/or grievances are addressed timely according to the procedures outline. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations. b. The grievance form will be forwarded to the Grievance Official. c. The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. i. The form includes a section where the resident/representative can provide feedback on satisfaction level of the resolution. The facility should encourage this feedback to determine satisfaction level of the resolution taken.

Based on observation, interview and record review, the facility failed to ensure a clean, sanitary, homelike environment with concerns of privacy curtains with stains, offensive odors in the rooms/hallways and ceiling tiles stained and not in good repair for one resident (Resident #37), of three residents reviewed for environment and for a Confidential Group of Residents. Findings include: Confidential Group of Residents On 3/2/26 a Confidential Group of Residents were together for a group meeting at approximately 3:00 PM. The Group consisted of seven Residents, all of whom were able to answer questions and six engaged in conversations and discussions. The group was asked about concerns that they wanted to relay in the group meeting and revealed the following: -Odors in the hallway. One Resident expressed concerns about odors in the hallway. Another Resident stated, It smells like piss and (bowel movement) all the time, expressing that they can smell it all down the hallway. The two Residents resided in different areas of the facility. Another Resident stated, I go by a room and can smell it, they leave a dirty diaper in the trash. You can smell it from the hall wheeling by. Another Resident reported CNAs were not emptying the garbage and stated, We get 'it's not my job', when explaining the response by CNAs of trash left with soiled briefs in the garbage. It was a consensus of the group of Residents that there were issues with foul odors in the hallways and some rooms. -Toilets getting clogged. It was expressed that toilets were getting clogged and most of the Confidential Group of Residents had experienced it or seen/heard it occurring. A resident reported that a toilet that four residents used, had gotten clogged. The Resident reported they had to find another toilet, and it was inconvenient. Another Resident reported a toilet was not working and the CNA told them to use it anyway, indicating it needed to be plunged but staff reported to them it was not my job to plunge the toilet. On 3/4/36 at approximately 4:00 PM, an observation was made of odors in the hallway in the South area and by the front office. One of the toilets in the front office area had a sign on it that stated the restroom was out of order. Maintenance L was asked about why the restroom was out of order and reported he thought it had been leaking. The Maintenance Director opened the door, and a foul odor was in the room. When flushing the toilet, it worked successfully. The Maintenance Director reported the smell might be coming from the drain of the sink since the water in the trap had likely evaporated. He was unsure how long the restroom had been out of order. On 3/02/2026, at 8:52 AM, an observation of room [ROOM NUMBER] revealed both residents in their bed. There was a strong smell of urine in the room and in the hallway. The floor appears to be freshly mopped and half dried. On 3/02/2026, at 10:02 AM, Resident #37 was resting in their bed. They had 2 privacy curtains encircling their bed. Resident #37 offered, they like it that way. Resident #37 was asked if they knew what the soiled areas were and Resident #37 offered, oh, can you remind them to clean them. Both curtains were soiled with reddish/purple splashes approximately 2 feet by 2 feet areas. On 3/02/2026, at 10:38 AM, Near room [ROOM NUMBER] in the North hallway was noted with a strong smell of urine. On 3/02/2026, at 4:06 PM, The soiled privacy curtains remain in Resident #37's room. On 3/03/2026, at 8:46 AM, Resident #11 was resting in bed. There was a bag of trash on the floor near the right side of their bed. There was also a trash can that had a liner with trash inside it. On 3/03/2026, at 10:00 AM, an observation of room [ROOM NUMBER] revealed an odor urine in the room and in the hall outside of room [ROOM NUMBER]. The floor appeared to be freshly mopped and was still completely wet. On 3/03/2026, at 12:02 PM, Resident #11 remained in their room. The bag of trash remained on the floor near their bed. On 3/03/2026, at 12:51 PM, there was a strong urine smell noted to the North hallway near the exit door. On 3/4/2026, at 11:00 AM, an observation of Resident #37's room revealed new clean hanging privacy curtains. On 3/4/2026, at 11:10 AM, Environmental Director (ED) L was interviewed regarding the new privacy curtains. ED offered they had a monthly schedule for cleaning the privacy curtains. ED L was asked to provide the schedule for review. ED L was asked who changed the privacy curtains for Resident #37 and ED L offered they were from another facility. On 3/4/2026, at 3:00 PM, a ceiling vent in main hallway appears to be falling out of the ceiling not secured. There were strong odors present in all of the main hallways. There was an out of order sign on the bathroom near the Administrator's office. The facility was asked to open the bathroom door as the odor appeared stronger. There was a strong sewer gas smell coming from the bathroom. The Administrator entered the hallway and was asked if the facility had any sewer problem or work done recently. The Administrator offered that they had called the local gas company to come check the smell and they felt it was coming from outside of the building being pulled inside the hallways via the circulation system. The Administrator was asked for the correspondence and/or any documentation from the company which was not provided. On 3/4/2026, at 4:00 PM, an observation along with Human Resources (HR) F of the hallways revealed strong sewer odors. The exit doorway near the beauty shop was unlocked per HR F. Outside of the building was observed to be free of any sewer smell. The outside air smelled fresh and normal. Upon reentry into the hallway from the outside, the odor remained to be a strong sewer smell. The odor remained in all three of the hallways from the entry door to the beauty shop and to the day room.

This Citation pertains to Intake Number 2739632. Based on observation, interview and record review, the facility failed to assist with meal service for one resident (Resident #40) and ensure dignified care for one resident (Resident 29), and a Confidential Group of Residents, of three residents reviewed for dignity. Findings include: Resident 29: On 3/3/26 at 11:57 AM, an interview was conducted with Resident 29 (R29) who answered questions and engaged in conversation. The Resident was asked about any concerns with care and was asked about comments made by a CNA regarding her recent surgery. The Resident reported that CNA JJ had told her the day before her surgery the doctor was not any good. R29 reported the CNA talked about him being a bad doctor and stated, I only met him a couple of times and didn't really know him, and reported that she didn't know she should trust him after talking with the CNA. When asked how she felt the Resident stated, It really upset me. I felt uncomfortable and nervous. I was going under the knife the next day, I was scared. The Resident reported she had the surgery about 3 weeks ago and it went good without problems. On 3/3/26 at 4:30 PM, an interview was conducted with Nurse FF regard comments made by CNA JJ to Resident 29 prior to her surgery. The Nurse indicated she was aware of the situation and reported the CNA had gave her thoughts about the doctor and (R29's name) was upset, she should not have given her opinion. The Nurse reported that administration was aware and that it was not abuse but more of a customer service issue. Confidential Group of Residents: On 3/2/26 a Confidential Group of Residents were together for a group meeting at approximately 3:00 PM. The Group consisted of seven Residents, all who were able to answer questions and six engaged in conversations and discussions. The group was asked about concerns with care received at the facility that included the following: -Hallways blocked with items on both sides of the hall. The Group reported that this has been brought up at Resident Council meetings, it will get better for a couple days than it goes right back to items on both sides of the wall and the medication cart positioned at an angle making it hard to get around. One Resident stated, it's like dodging cars, another reported it was like playing Frogger, and another said you have to zig-zag your way down the hall. One Resident reported that when you have to go down the hallway in your wheelchair, it was very difficult to go around the equipment, they tried to keep the items on one side, but it does not stay that way. -Residents having to deal with other Residents with behaviors, staff do not watch the Residents or staff say, oh, she's ok' and 'that's just him/her' when the Resident with behaviors was having issues, wandering in rooms, interacting inappropriately, or touching things that don't belong to them. The Group reported that they were having to deal with or redirect the Residents themselves and watched as Residents play with the food of trays being set up and getting into the ice bucket and ice scooper that were in the hallways. The Group indicated they should not be watching over other Residents or have them touching something they will be consuming. Four of the seven indicated they had concerns with the behaviors of other Residents that affected them. -The majority of the Group reported phone use by staff while providing care. All the Residents in the Group reported they had this happen or seen it happen. The Group reported that staff would wear ear buds and be talking to someone, they could not tell if the staff was talking to them or to someone on their phone. One Resident reported you can call the staff's name 3 or 4 times and they don't hear you. Multiple Residents reported that they could see and heard another person on the staffs' phone and reported some staff have Facetime while they were working. The Group reported a concern of staff playing music on their phone and had it in their pocket. One Resident reported that quiet time was to be at 10:00 pm, they are talking while I am trying to sleep, use loud voices when taking care of roommates during the night, staff turn the lights on bright, laugh, talk in loud voices in the middle of the night, and have music playing on their phone. One Resident stated, it is their daytime, but it is our nighttime and we are trying to sleep. Another Resident stated, they lost the ability to care. -The Group reported concerns of staff being rude or have an attitude while receiving or asking for help. One Resident reported they complained of a staff member being rude and felt like they were retaliated against and was afraid to voice further concerns. Another Resident reported feeling retaliated against and had to apologize for concerns voiced. The Group as a whole reported concerns about staff rudeness and attitudes. The Group reported it had been brought up in Resident Council but there were ongoing issues. Multiple Residents reported they were afraid to voice concerns of staff being rude. Multiple Residents reported that staff use phrases of not my job if they don't want to do whatever it was that needed to be done and gave example of smelly or overflowing trash can and clogged toilets. When asked about knocking on the door before entering, the Group reported some staff do and some don't knock and announce they were entering. -When asked about call light response, the whole group reported concerns with staff response to call lights activated. Concerns included having to wait an hour for someone to show up, nurses don't answer the call lights, the call light turned off, and staff report they will be back, then don't show back up. The Group reported that any time of day it was a concern but worse during shift change. The Group reported concerns of staff leaving the building and not being available when call lights were on. The Group reported that staff will go out to smoke multiple times and hear comments made by CNAs of I need a cigarette after that one and leave to go smoke. The Group reported it had been a concern brought up multiple times in Resident Council and the issue continued. A review of 12 months of Resident Council Minutes revealed the following concerns/issues voiced during Resident Council meetings that included: March 2025: DON/Nursing: Nurse is on her phone during her whole shift. Talking on speaker phone. Nurse has a foul mouth and bad attitude. Nurse stated doesn't like this place. Nurse takes it out on residents. CNA: Staff are on their phones in resident's rooms. May 2025: CNA: Concern with call lights at night. Concern with CNAS on phones or computer. August 2025: Housekeeping: Staff member has an attitude towards other residents, talks down, treats them with disrespect. Goes in and out of room without permission. September 2025: DON/Nursing: CNA's sitting in nursing station on phones and not being productive. CNA: Wheelchairs and hoyers are not staying on one side of the hall so easily can pass through. Concern form: Aids on North Hall had an attitude feel care has declined since new owners. Quiet time not respected. Phones still in room. Staff wearing earbuds having conversation and ignoring residents. Nursing disturbing resident while blasting music from phone in pocket. Nurse keeping cart angled in hallway instead of respectfully leaving to the side. October 2025: DON/Nursing: Negative comments are being discussed in hallways, in front of residents. Staff not knocking before entering. Nurse being rude to the residents in 24. CNA: A certain staff member being rude to residents-it's her way or no way. When addressing residents' needs in a room, noise should be quiet and no bright lights turned on. Especially in the early morning hours. Concern Form: CNAs sitting in nurses station on phones not being productive; Wheelchairs and Hoyers not on one side of hallway so easier to get through. November 2025: Administration: Safety concern for residents. Need to address concerns aggressively. Facility feels like it's becoming a psychiatric ward, accepting anybody and everybody. DON/Nursing: Address every one of our concerns and not just announce it a meeting. Make sure staff understands residents' concerns responsibly and effectively. CNA: Respectively knocking on doors before entering. Residents having to call main number to get assistance. Concern Form: A staff member being rude to resident-her way or no way. When addressing or answering lights in room especially during sleep hours, need to be respectful of other residents. No bright lights on or loud noise. December 2025: DON/Nursing: Some issues with new night nurse giving attitude. Ensure quiet time is adherd to during times of 10 pm to 6 am. February 2026: Administration: Some residents felt that they are not being respected in general by staff and feel they should be seen and not heard. Being talked down to like children. DON/Nursing: Disturbing the residents while blasting music from phone in pocket. Nurse keeps cart angled in hallway instead of respectfully leaving to the side. CNA: Aids on north hall had an attitude said resident would get shower on Saturday but did not receive. Feel the care has declined since new owners took over. Soiled briefs being thrown on the floor. Toilet in 44 was plugged up and dirty and residents were told to still use it. Phones are still being used in room. Quiet time not respected. Staff wearing ear buds and having conversations and ignoring residents. On 3/4/26 at 2:22 PM, an interview was conducted with the Director of Nursing (DON) regarding issues brought up through the Confidential Resident Group meeting. The DON reported that the facility had tried to do an afternoon supervisor and weekend manager, but it was hit or miss and that guardian rounds were done to capture concerns and issues, but the guardian rounds were not consistent. The DON reported the facility had programs, but it was hit or miss with them being completed. The DON reported coming in on off hours and on weekends and they were not seeing the issues the Residents were reporting like staff use of the phones. The DON reported it was not allowed to restrict staff personal phones out of care areas and if able to do that, it would help with that concern. The DON reported being aware that the Residents were afraid of retaliation and won't give names, but indicated that when she does not know, then she has to guess on who the staff were that they were having issues with. On 3/4/26 at 10:32 AM, an interview was conducted with the Administrator (NHA) regarding concerns voiced by a group of confidential residents. When asked about facility policy on staff using personal phones, the NHA reported they are not supposed to be using their phone while providing care or on the floor. Regarding the complaints of not respecting quiet time, the NHA reported it should be quiet during that time, and they are not to be using headphones, ear buds or playing music on their phones. The NHA reported staff should be using softer voices and going in turning on minimal amount of lights to provide care, staff should be respectful of residents and their rest time. A review of the facility policy titled, Resident Rights, revealed, .Resident Rights 1. Resident rights. The Resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 5. Respect and dignity. The resident has a right to be treated with respect and dignity, including: c. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. Review of the facility Employee Handbook revealed the directive for Telephone Usage Policy, revealed, .Under no circumstances should any employee bring a phone containing a camera, an(actual camera or any device which contains a camera), into a resident area. The use of personal cellular telephones and/or pagers are only permitted in the employee designated break room during meal periods and designated break periods and may not be brought into resident care areas. Resident #29 (R29): R29 admitted to the facility on [DATE] with diagnoses that include hemiplegia affecting the left side and hemiparesis following cerebral infarction. On 03/02/2026 at 12:52PM, during an interview with R29, she stated that the staff will tell her to use her brief to go to the bathroom. R29 says that she uses a Hoyer lift for transfers and that the staff won't take her in the bathroom because of that. On 03/03/2026 at 1:34PM, an interview was conducted with Family DD of R29. Family DD stated that R29 went out to the hospital for a planned surgery and R29 had requested to be showered and have her brief changed prior to the transfer. Family DD stated the staff did not perform the care that was requested and they told me they couldn't do it because they were short on staff. Family DD stated that when R29 got to the hospital for her surgery she was soaked in urine and that was embarrassing for her. Family DD stated that there was a time the staff put R29 on the sit to stand to take her to the bathroom and pulled her pants down in the room and the curtains were open on the window and she was exposed. Family DD stated I don't want my sister embarrassed, and they need to protect her dignity. Resident #40: On 3/2/2026, at 12:27 PM, an observation of CNA K was conducted for Resident #40's meal service. There were 3 bowls on the tray with 2 of them empty. 1 bowl housed turkey, mashed potatoes and vegetable blend. CNA K blended all the food items together with a spoon in one bowl and began to feed Resident #40 the mixed food items with the spoon. On 3/2/2026, at 1:00 PM, a record review of Resident #40's electronic medical record revealed an admission on [DATE] with diagnoses that included Schizophrenia, Dementia and Multifocal motor neuropathy with borderline intellectual function. A review of the COGNITION care plan revealed COGNITION: I display cognitive impairment . A review of the ADLs: (activities of daily living) care plan revealed: I have an ADL self care deficit r/t . cognitive deficits/mental impairment . Interventions . EATING: I can be independent with eating sometimes depending on my mood. Assist me with eating when I require assistance Date Initiated: 09/28/2019 Revision on: 02/23/2026 . The care plan does not state to mix food items together. On 3/3/2026, at 12:15 PM, in the main dining room, Resident #40 was assisted by CNA B for their lunch meal. There was fish, potatoes and a vegetable all separate on their plate. Resident #40 was assisted with each item with separate bites. CNA K was asked if the resident likes their food all mixed together and CNA K offered, no, we're not supposed to do that. On 3/4/2026, at 2:15 PM, CNA K was asked if they normally mix food items for Resident #40 and CNA K stated, yes that the resident chews and swallows better with the mixed textures. On 3/4/2026, at 2:30 PM, the Director of Nursing (DON) was asked if residents are being assisted with meal service if it the facilities procedure to mix all the food together and the DON offered, no, not unless it's care planned that way. The DON was alerted of the observation for Resident #40 on day 1 of the survey.

This Citation Pertains to Intake Number 2656620. Based on observation, interview, and record review the facility failed to ensure there was 1.) adequate staff to meets the needs of the residents, resulting in resident verbalizations of waiting long periods of time to answer call lights timely; receive assistance with activities of daily living (ADL), including toileting and incontinence care, and showers and 2.) adequate nurses including RN's to care for the needs of the residents, from a census of 68 residents, resulting in resident dissatisfaction, frustration, and unmet care needs. Findings Include: Confidential Group of Residents: On 3/2/26 a Confidential Group of Residents were together for a group meeting at approximately 3:00 PM. The Group consisted of seven Residents, all who were able to answer questions and six engaged in conversations and discussions. The group was asked about concerns with care received at the facility that included the following: -When asked about call light response, the whole group reported concerns with staff response to call lights activated. Concerns included having to wait an hour for someone to show up, nurses don't answer the call lights, the call light turned off, and staff report they will be back, then don't show back up. The Group reported that any time of day it was a concern but worse during shift change. The Group reported concerns of staff leaving the building and not being available when call lights were on. The Group reported that staff will go out to smoke multiple times and hear comments made by CNAs of I need a cigarette after that one and leave to go smoke. The Group reported call light response had been a concern brought up multiple times in Resident Council and the issue continued. -One Resident voiced concerns of not enough staff to help during mealtimes, and not enough staff to pass meal trays with voiced concerns of seeing the carts with trays set up and no one bringing them down the hall, they sit on the hall, up to 40 minutes. Another Resident reported their roommate needed help with sitting up and setting up the tray by opening items, it (the meal tray) had sat there for 45 minutes, by that time someone came in, it had been sitting for close to an hour, it must have been so cold. Another Resident reported their roommate needed to be fed and sometimes the staff were not available to assist the resident. -Regarding staffing, the group voiced some really good aides, but some are not, new staff come in for a couple days and then they don't show back up, not enough staff at night , not enough help that meets their needs timely, if someone (CNA) doesn't show up (for work) that is a problem, the other CNA has to take on more, and no longer a shower aide to help get showers done. It was the consensus of the Group of issues with not enough staff to meet needs timely. Facility Resident #27: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #27 was admitted to the facility on [DATE] with diagnoses: Heart failure, respiratory disorder, anemia, deep vein thrombosis, and hypertension. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 14/15 and the resident needed assistance with activities of daily living (ADL) including dependent for assistance with transfers, toileting, dressing and maximum assistance with bathing. On 3/02/2026 at 2:12 PM, Resident #27 was observed in his room. When asked about receiving assistance with care, the resident stated, They don't have enough people, to answer call lights. The resident said he was frustrated that she had to wait long periods of time to receive assistance with care. Resident #31: A record review of the Face sheet and MDS assessment indicated Resident #31 was admitted to the facility on [DATE] with diagnoses: diabetes, heart failure, hypertension, GERD, recent urinary tract infection/UTI and arthritis. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a BIMS score of 15/15 and the resident needed assistance with all care. On 3/02/2026 at 11:11 AM, Resident #31 was interviewed in her room and said she was in her bathroom, and it took 45 minutes for staff to answer her call light while she sat in the bathroom waiting. The resident stated, There are not enough staff. Resident #31 said they thought the food was cold when it was delivered the day before because there were not enough staff. Resident #32: A record review of the Face sheet and MDS assessment indicated Resident #32 was admitted to the facility on [DATE] with diagnoses: diabetes, heart disease, heart failure, hypertension, Gerd. The MDS assessment dated [DATE] indicated the resident had full cognitive abilities with a BIMS score of 15/15 and needed assistance with all care. On 3/02/2026 at1:37 PM, Resident #32 was interviewed in her room when asked if she received assistance with care she said there were multiple instances when there were long wait times to have her call light answered. Resident #32 said at time it took up to 1 hour to have staff respond to her call light. Resident #70: A record review of the Face sheet for Resident #70 identified an admission date of 2/20/2026 and the resident needed assistance with care. The MDS assessment was not yet completed. On 3/02/2026 at 12:18 PM, Resident #70 was observed sitting in a wheelchair in his room. He said his call light was not always answered timely. When asked if this occurred on a specific shift he said it was sometimes both shifts, days and nights. A record review of the Daily Staffing Report sheets, that the facility completes and posts daily showing the facilities daily census of residents, and numbers of Registered Nurses/RN's, Licensed Practical Nurses/LPN's and Certified Nursing Assistances/CNA's indicated the documents were not completed and posted daily, as evidenced by the Daily Staffing Report sheet posted near the front of the building by the office on 3/2/2026. It was dated 2/26/2026, 5 days prior than the day observed. On 3/4/2026 at 11:45 AM, the Director of Nursing/DON was interviewed about staffing, as the facilities Payroll Based Journal/PBJ staffing report containing clinical staff information, that is required to be submitted to CMS/Centers for Medicare and Medicaid Services each quarter was not sent to CMS by the facility in the 4th fiscal quarter- July 2025- September 2025. The DON said the corporate office for the facility was responsible for submitting the data. The DON was also asked about the Daily Staffing Sheets and she said the scheduler EE had the forms and she started them and the nurses updated them with changes to the schedule each day. She said the forms were to be posted every day with correct information. During the interview, on 3/4/2026 at 11:45 AM, the DON was asked about clinical staffing, as there were several complaints from the residents, as they felt there were not enough staff nurses and CNA's to care for their needs. The residents were saying they had long call wait times, sometimes their food became cold while the resident was waiting for it to be delivered, and there were some residents who were frustrated and discouraged about this. The DON was asked if there were enough staff and she said several nurses had left the facility recently and several more had left in the fall of 2025. She said many of the staff were working over their 12 hour shifts and also working extra days. The DON said because of this, she said she had to work on the floor as there were not enough nurses. The DON was asked how often she worked as a floor nurse and she said it depended, but sometimes several days in a row. The DON was asked how many hours at a time she was working on the floor, and she said sometimes a 12 hour shift and then later that day also. The Daily Staffing Reports for July 2025 to Current 3/4/2026 were requested. The DON was asked if the reports were kept in a binder and she said the scheduler EE had the documents. Clinical staff schedules and assignment sheets were also requested to be reviewed. The DON said the scheduler had all of the documents. On 3/4/2025 at 1:10 PM, scheduler EE was observed in her office sorting stacks of documents. The scheduler was asked to review the Daily Staffing Reports and she said she was sorting them. When asked if she kept the documents in a binder or folder, she said no, she kept the Daily Staffing Report, daily schedule and daily assignment sheets stapled together for each day. Reviewed with the scheduler they did not need to be separated as all needed to be reviewed. The scheduler was asked to view them all. On 3/4/2025 at 1:15 PM, the Administrator was interviewed about the staffing documents. She said the scheduler was working on them and would send them in batches. Reviewed with the Administrator that the 4th quarter PBJ staffing report submission was not received by CMS. She said she was aware. She said the report was submitted quarterly by the corporate office, but it was not submitted for the 4th fiscal quarter (July 2025- September 2025). The Administrator was asked about clinical staffing, as the Daily Staffing Report was not current on the initial entry into the building on 3/2/2026, as it was dated 2/26/2026. She said it was supposed to be updated every day. The daily posted nursing forms Daily Staffing Report as called by the facility, is required to be accurate for each shift with CNA, RN and LPN hours listed for each day, so that any visitor or resident can see what staffing is provided. The PBJ staffing report is utilized by CMS to see if the facility is providing enough staff to care for the needs of the residents and to ensure there is adequate RN coverage during every 24 hour day: 8 hours of consecutive RN coverage daily. On 3/4/2026 at 1:15 PM, during the interview with the Administrator, she was asked if there were enough nurses, including RN's to care for the residents. She said some of the nurses had left and they were working on replacing them. The Administrator was asked about the DON working on the floor for extended hours and days and she said that was true. The DON's position at the facility was as a full-time DON, but she was also working many days as a nurse on the floor. Also reviewed with the Administrator that there were complaints from the residents that there were not enough staff, and they were waiting for long periods of time to have their call lights answered, especially on the night shift; she said they were trying to work on this. Upon review of the clinical staffing documents, including the Daily Staffing Reports, daily schedules and daily assignment sheets. It was identified that some of the documents were not received, including the days immediately prior to survey entry: 3/1/2026, 2/28/2026, 2/27/2026, 2/25/2026 and 2/24/2026. Each month received from 9/1/2026 through February 2026 had missing days of documents. During the review of the staffing documents, it was identified that there were many days that the Daily Staffing Report sheets did not include the name of the facility or identify the nurses as RN's or LPN's it said Nurse and the number of nurses on the day shift (6:00 AM to 6:30 PM) and the number on the night shift (6:00 PM to 6:30 AM): This included 11/16/2025 when 4 nurses were listed on dayshift and 2 on night shift and the Daily Schedule Report indicated on the night shift one nurse would work until 2am instead of 6:30 AM. Leaving one nurse to work by themselves for 4 hours. The report also indicated on 11/16/2025 there were 2 aides on night shift for a census of 68 residents. At times someone would write in ink next to the shift and include RN and LPN. Further review of the clinical staffing documents detected days when the Daily Staffing Report identified days when there were a low number of clinical staff. On 9/1/2025, 9/2/2025 and 9/3/2025 the Daily Staffing Report did not identify RNs or LPNs (it said Nurse). On 9/21/2025 the Daily Staffing Report listed 1 nurse on night shift for a census of 62 residents. On 9/23/2025 the Daily Staffing Report was absent. On 9/26/2025 the Daily Staffing Report did not identify RNs or LPNs, it said Nurse. On 9/27/2025 the Daily Staffing Report did not list RNs or LPNs. On 9/28/2025 the Daily Staffing Report listed 3 LPNs and no RNs working. On 10/9/2025 the Daily Staffing Report listed 2 nurses on the night shift and 2 nurse aides for a census of 65 residents. On 10/11/2025 (Saturday) the Daily Staffing Report listed 1 RN on the day shift and 2 LPNs on the night shift for a census of 67 residents. On 11/16/2025 the Daily Staffing Report identified 2 nurses on nights and 2 nurse aides for a census of 68 residents. On 11/19/2025 the Daily Staffing Report listed 3 nurses on the night shift and 2 nurse aides for a Census of 67 residents. On 12/27/2025 the Daily Staffing Report did not identify an RN working that day. On 1/3/2026 and 1/4/2026 the Daily Staffing Report did not list an RN working either day. On 2/5/2026 the Daily Staffing Report listed 2 day shift nurses. On 2/6/2026 the Daily Staffing Report did not identify any RN's working that day. A review of the Daily Schedule Reports identified the following: 1/2/2026: The DON worked on the floor from 6:00 AM- 10:30 PM. (20 hours) and returned the next morning at 6:00 AM because there was no nurse. 1/3/2026: 1 nurse was listed on the report (LPN) for the day shift from 12:00 PM- 8:00 PM. There were no additional nurses scheduled for the day shift. The DON worked from 6:00 AM-6:30 PM and was the only nurse from 6:00 AM-12:00 PM. 1/4/2026: The DON worked on the floor at 6:00 AM – 10:30 PM as the 2 day shift nurses did not start until 10:00 AM that day. 1/5/2026: There was 1 nurse scheduled to work on the night shift the DON worked from 8:30 AM- 5:00 PM as the DON and then on the floor from 6:00 PM to 10:30 PM. A review of the Employee list identified 5 RN's that worked on the floor, and not all were full time. A review of the undated Facility Assessment indicated it was a template that was partially completed. It provided examples of 2 staffing models one was incomplete and the other identified the following: Example 1. Evaluation of overall number of facility staff needed to ensure a sufficient number of qualified staff are available to meet each resident's needs. Refer to the guidance in the various tags that have requirements for staffing to be based on/in accordance with the facility assessment, for example, Nursing (F725). Enter number of staff needed or an average or range: Licensed nurses providing direct care: Total number Needed or Average or Range- 3 days/2 nights can fluctuate depending on acuity. Nurse Aides: 12. A review of the facility policy titled, Staffing and Scheduling undated provided, Purpose: To assure adequate, competent staff is available to provide care for residents. The DON should work closely with the staffing coordinator to identify nursing staffing needs and hire nursing staff accordingly. Pulling staff to cover open positions leads to turnover and job dissatisfaction. Hiring of staff is a high priority duty and should be dispersed among nursing management.

Based on observation, interview and record review, the facility failed to ensure that oxygen tanks were available for resident use for one resident (Resident #58) and a confidential group of residents, available on the crash cart for emergency use, and nebulizer equipment was stored appropriately for one resident (Resident #23) of three residents reviewed for oxygen use. Findings include: Confidential Group of Residents: On 3/2/26 a Confidential Group of Residents were together for a group meeting at approximately 3:00 PM. The Group consisted of seven Residents, all who were able to answer questions and six engaged in conversations and discussions. During the group meeting, one Resident who was on oxygen by way of an oxygen concentrator, had an alarm go off on his machine. The Resident became upset and expressed he was in trouble if his concentrator was not working. The Resident had an E-tank for oxygen on the back of his wheelchair. When asked if he needed assistance to have someone hook up the oxygen to the tank, the Resident said it was empty. Another Resident reported that there were no tanks of oxygen available throughout the facility. Another Resident reported to the Resident with the oxygen that he had rolled his wheelchair over the oxygen tubing. The Resident was able to adjust the wheelchair and the alarm stopped. The Resident reported being ok and the meeting continued. The Resident reported being unable to freely wander through the facility without an available E-tank that had oxygen due to needing oxygen all the time and reported having to stay in the room until the delivery came in. On 3/2/26 at 4:06 PM, an interview was conducted with the Director of Nursing (DON) regarding the Group complaints of lack of oxygen supply in the portable tanks. The DON confirmed a lack of oxygen in the portable tanks. The DON reported that they had come to deliver the tanks on Saturday but due to no key available to the shed where the tanks were stored, the company did not leave any. The DON reported being informed of the situation this afternoon. The DON reported that Resident will be on concentrators in their rooms until the oxygen is delivered, indicating later that evening around 7 PM. The DON reported there were enough concentrators for the Residents on oxygen. The DON reported that the crash cart had a tank she could grab if needed. An observation of the crash cart at a Nurses' Station, across from the DON's office, revealed the tank was on red, which indicated it was empty. The DON reported that it was the only crash cart in the facility. Resident #23 On 03/02/2026 at 9:46AM, during an interview with R23, nebulizer equipment was observed next to the bed. There was condensation noted in the medication cup on the nebulizer, it was stored together, hanging on a towel bar on the nightstand and not covered. R23 was asked when she last had a nebulizer treatment. R23 states the last nebulizer treatment she had was at 8am this morning. On 03/03/2026 at 8:11AM, during an interview with R23, the nebulizer equipment was observed next to the bed. The nebulizer equipment was again observed to be together, with condensation in the medication cup and hanging on a towel bar on the nightstand. R23 stated her last nebulizer treatment was at 6:30am this morning. On 03/03/2026 at 8:13AM, an interview was conducted with License Practical Nurse (LPN). FF. LPN FF was asked when is the last time R23 had a breathing treatment. LPN FF stated that it appears the last treatment was a PRN (as needed) albuterol treatment this morning. LPN FF was asked what the process is for storing nebulizers after the treatments are done. LPN FF stated we clean it out and then place it back at the bedside. LPN FF was made aware that the nebulizer equipment for R23 was being stored on a towel bar on the nightstand. On 03/03/2026 at 1:17PM, record review revealed a physician's order for, Ipratropium-Albuterol Solution 0.5-2.5(3)MG/3ML 3ML, inhale orally every 8 hours related to Chronic Obstructive Pulmonary Disease The March 2026 Medication Administration Reconciliation (MAR) revealed there had not been a nebulizer treatment signed out this month. Resident #58 On 03/02/2026 at 1:51PM, an interview was conducted with R58, who had just returned from an appointment approximately 30 minutes ago. R58 stated he left the facility for an appointment with a full tank of oxygen. R58 stated that he was out too long on his appointment and he ran out of oxygen and still made it back to the facility. R58 stated he requested another tank so he could leave his room again and was told by a staff member that they are out of oxygen tanks. R58 was upset that no one told maintenance that they were out of oxygen tanks in the building. R58 stated the staff placed him on his concentrator and at this time he would have to stay in his room. Review of the policy titled, Respiratory Equipment Care & Handling of, revealed: 11. Reusable equipment must be cleaned with disinfectant, sprayed onto the outside of the body of the equipment following each resident use. -Compressors, concentrators, oxygen analysis, regulators, -Empty intermittently used nebulizers after use and rinse with tap water, shake dry and place on a clean paper town to air dry. After drying, place in a plastic bag, which is then hung from the flow meter.

Based on interview and record review, the facility failed to provide fresh water for five residents (R11, R21, R23, R33, R37) of five reviewed for hydration and a confidential group of residents. Findings include: Confidential Group of Residents: On 3/2/26 a Confidential Group of Residents were together for a group meeting at approximately 3:00 PM. The Group consisted of seven Residents, all who were able to answer questions and six engaged in conversations and discussions. The group was asked about concerns with care received at the facility and the Group brought up concerns with menus not being followed. A Resident brought up the concern of not getting fresh water. One resident reported having to go to the dining room to get fresh water and that they don't change it out in their room regularly. Another resident said, They tell me to drink more water because my urine is dark, well get me water and I will drink it. It was brought up that on some weekends it is the same cup from Friday to Monday. The group expressed that when they do them, they date them and sometimes they do them in the evening and date it for the next day. It was the consensus of the whole group of it being an issue with getting fresh water passed to the rooms. It was brought up that they have complained as a group of this issue at Resident Council Meetings and the issue continues to be a problem. A review of Resident Council Minutes revealed the following concerns/issues voiced during Resident Council meetings, of fresh water not passed, that included: -August 2025, CNA: Fresh water still not being given to (room number) at times. -October 2025, CNA: Water passes still a git or miss. -November 2025, CNA: Waters still an issue-certain staff that never take care of it. -December 2025, CNA: Water pass is still an issue with certain aides. -January 2026, CNA: Water pass is still an issue, and some have no water in room to take medication or occasionally sip of water if needed for a cough. Resident #23 (R23): On 03/02/2026 at 9:49AM, during an interview with R23, a Styrofoam cup full of water was observed on the bedside table, dated 2/28/26. R23 stated the staff tells her that they run out of cups and just refill the old cups over and over. R23 stated sometimes we get fresh water, but not always. On 03/02/2026 at 11:09AM, during an interview with R33, a Styrofoam cup of water dated 2/27/26. R33 stated that the staff tells her that they are out of Styrofoam cups, so they refill ours. R33 was asked if they get fresh water every day. R33 stated we don't always get fresh water. On 03/03/2026 at 8:50AM, an interview was conducted with Dietary Manager F. Dietary Manager F was asked who orders cups for the residents drinking water. Dietary Manager F stated that she orders cups for the kitchen and central supply orders for the rest of the building. Dietary Manager F was asked if they have heard of the facility running low on cups for the residents. Dietary Manager F stated, not recently, but in the last 6 months the staff has mentioned that they are low on cups at times. On 03/03/2026 at 11:59AM, an interview was conducted with Central Supply EE. Centra Supply EE was asked if they order the cups for the residents. Central Supply EE stated, I do now, prior to me ordering, the kitchen wanted specific cups to be ordered. I was going through a lot of cups every week. The kitchen now orders their own lids and cups, and I order my own cups and lids now. Central Supply EE was asked if the facility was short on drinking cups for the residents. Central Supply EE stated we had an issue with not having enough cups and that was a few months ago. Central Supply EE (who also is the nurse staff scheduler) was asked if there an issue with the aides passing fresh water to the residents. Central Supply EE stated there is an issue with aides passing the water timely and there is an issue with labeling and dating water cups. Central Supply EE was asked what the current schedule for passing water to the residents is. Central Supply EE stated in the morning at 6am the residents should be getting the fresh cup and getting rid of last night's cup. Central Supply EE was asked if the aides date the water cups. Central Supply EE' stated yes, and they put the room number and the shift it was given on. Central Supply EE was asked if there is any reason why there were cups dated 2/27/26 still on the resident bedside tables? No, there is no reason, they should have been changed out. There is no reason they couldn't have new cups and fresh water. On 3/02/2026, at 9:36 AM, during initial pool, Resident #11 was sitting in their wheelchair in their room. There was a Styrofoam cup with a date 2-22-26 handwritten on it. The resident had the cup in their hand. Nurse A was asked if they could assist with removing the lid. There was a small amount of what appeared to be pop inside. Nurse A offered they must have gotten the old cup out of their nightstand. The nightstand was open and housed 3 cans of Pepsi, a few brown bananas under what appeared to be a towel or washcloths and no Styrofoam cups. On 3/02/2026, at 9:58 AM, Resident # 21 was in their bed with a Styrofoam cup in their hand. The cup had a dark line which appeared to be from a tea stain. There was a small amount of tea in the cup. Resident #21 was asked if they were thirsty and Resident #21 stated, I can't take a drink. I can't find a straw. There was no date on the cup. There was no other cup on the resident's overbed table and there were no straws. On 3/02/2026, at 10:02 AM, Resident #37 was in their bed. They offered they got water sometimes and sometimes we don't. A review of the undated HYDRATION policy provided by the facility revealed It is the policy of this facility to assist residents to maintain adequate hydration whenever possible . Assure fresh bedside drinking water is available at all times, unless contraindicated. Assist residents to periodically take a drink throughout the day .

Based on observation, interview and record review, the facility failed to ensure that recent State Surveys and Plans of Correction were readily accessible, affecting all residents in the facility of a census of 68, resulting in residents, resident representatives, visitors and staff being unable to review the survey results and plans of correction. Findings include: Confidential Group of Residents:On 3/2/26 a Confidential Group of Residents were together for a group meeting at approximately 3:00 PM. The Group consisted of seven Residents, all who were able to answer questions and six engaged in conversations and discussions. The group was asked that without having to ask, were the results of the State inspection available to read? A couple of the Residents in the Confidential Group of Residents indicated they were unaware of there being a survey book that can be accessible to residents and family. Other Residents in the Group reported that the survey results used to be kept in a binder and kept by the front office. One Resident stated, There used to be one they could look at but it is missing. Other Residents reported they have not seen the binder available for a while now, but indicated there used to be one. On 3/3/26 at 3:22 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked where the survey book could be located. An observation was made of a wire rack on the wall by the front office. The DON indicated it was usually stored in there, but the binder was not in the wire rack and not in the vicinity of the wire rack. The DON took out other papers and reported those should not be in there. It was brought to the attention of the DON that the wire rack was higher than what can be easily accessible to a Resident in a wheelchair. The DON was unaware of where the survey binder was stored and indicated the NHA may know. On 3/4/36 at 10:32 AM, an interview was conducted with the Administrator (NHA) regarding concerns brought up in the Group meeting of Confidential Residents. The NHA was asked about the binder of recent survey results and plan of correction. An observation was made of the wire rack by the front office area without the survey binder. The NHA was informed that the wire rack, where survey results were usually kept, was not easily accessible to a Resident in a wheelchair without standing up to retrieve something out of the wire rack. The NHA reported she would have that fixed today and would try to locate the binder with survey results.A review of the facility policy titled, Resident Rights, revealed, .Resident Rights. 7. Information and communication. The resident has the right to be informed of his or her rights and of all rules and regulations governing resident conduct and responsibilities during his or her stay in the facility. k. The Resident has a right to- i. Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility.

Based on observation, interview and record review, the facility failed to provide Life Enrichment activities and care plan interventions for two residents (Resident #11, Resident 43) of two residents reviewed for activities, resulting in no activities provided. Findings include:Resident #43 On 3/02/2026, at 10:11 AM, Resident #43 was lying in their bed. The room was dark. The television (tv) was off. On 3/03/2026, at 8:55 AM, Resident #43 was sitting on their bed. The room was dark. The tv remained off. There was a tv remote on the over bed table. Resident #43 was asked if they wanted the tv on and Resident #43, shook their head yes. Moments later the resident closed their eyes and appeared to be resting. On 3/03/2026, at 9:10 AM, a record review of Resident #43's electronic medical record revealed an admission on [DATE] with diagnoses that included aphasia, mood disorder and stroke. Resident #43 required extensive assistance with activities of daily living and had severely impaired cognition.A review of the care plans revealed no care plan was provided for life enrichment activities. A review of the most recent LIFE ENRICHMENT ASSESSMENT was dated 10/17/2025.A review of the Activity Notes revealed the following visit dates: 2/25/2026 12/30/2025 12/9/2025 11/30/2025 A review of the Individual Needs Assessment revealed the resident liked the following activities: Observes others in common area/people watch Exercise in facility, walks, self-propels w/c Reads mail, newspapers, books, etc Watches TV Participates in in-room activity Attempt 1:1 depending on sleeping or moodOn 3/03/2026, at 10:11 AM, Nurse A was asked if they could assist Resident #43 with their tv as they had the master remote in their hand. Nurse A entered Resident #43's room. Resident #43 opened their eyes. Nurse A , while holding the master remote for the tv, stated, he has his own remote and he can turn it on himself. Nurse A left out of the room. Resident #43 was asked if they could turn the tv on and Resident #43 nodding, no multiple times.On 3/03/2026, at 10:46 AM, an observation of Resident #43's tv and tv remote with Maintenance worker J was conducted. Maintenance worker J attempted to turn on the tv with the remote with no success. Maintenance worker J offered, that the batteries must be dead, took the remote to replace the batteries. Moments later, Maintenance worker J returned to Resident #43's room and turned the tv on. Resident #43 rolled over and began to watch tv. On 3/04/2026, at 8:54 AM, Resident #43 was lying in bed facing the tv. The tv was on.On 3/04/2026, at 10:39 AM, a record review with Life Enrichment Director (LED) I of Resident #43's electronic medical record was conducted which revealed the last activity note was 2/25/2026 with no visits in January. LED I was asked if Resident #43 liked to watch tv and LED I stated, yes he does. LED I was asked how often they should provide activities for residents and LED I at least twice a week. Resident #11: On 3/02/2026, at 3:53 PM, Resident #11 was resting in bed with their wife at the bedside. Resident #11 was asked if they would like to get up and Resident #11 stated, I'd like to. On 3/3/2026, at 1:30 PM, a record review of Resident #11's electronic medical record revealed an admission on [DATE] with diagnoses that included injury of head, dementia and psychotic disturbance. Resident #11 required extensive assistance with all activities of daily living and had severely impaired cognition. A review of the ACTIVITIES: I will pivot more towards person-centered 1:1 or self-directed activities that honor my needs and autonomy and quiet Date Initiated: 01/26/2026 . Interventions I do enjoy watching sports and my favorite is golf . I do like to watch TV and movies and keep up with news . I wish to visit with pets when present in the building . It is important for my wife to be involved in discussions about my care . My wife visits weekly . On 3/04/2026, at 1:07 PM, LED I was interviewed regarding Resident #11's activity preferences. LED I provide his wife visits weekly.A record review of the activity notes revealed no activities had been provided since admission. And LED I offered, they will do the education for not seeing this resident. A review of Life Enrichment Programming Overview January 2020 revealed the facility shall provide for an ongoing program of activities designed to meet, the interests and physical, mental, and psychological well-being of each resident . Each resident's Life Enrichment plan should be planned around the resident's goals for his/her own life. Residents who prefer to pursue their own activities should be monitored to assure their mental and psychological needs are being met . The resident's comprehensive assessment, care plan, Life Enrichment progress notes, and Life Enrichment attendance records shall identify individual resident history, needs, interests and capabilities, degree of participation, and outcomes/responses to Life Enrichment interventions .

Based on observation, the facility failed to provide an updated daily staffing report, resulting in a four-day old staff list and the inaccessibility for residents, visitors and staff to what staff was working. Findings include. On 3/02/2026, at 9:05 AM, a record review of the DAILY STAFFING REPORT hanging on the wall in the main entry was conducted. The report was dated 2/26/2026

Based on observation, interview and record review the facility failed to ensure that residents received pain medication in a timely manner and as ordered for 1 resident (Resident #2) of 1 resident reviewed for pain management. Findings Include: Pain Management Resident #2:A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #2 was admitted to the facility on [DATE] with diagnoses: History of a stroke, Diabetes, hypothyroidism, hydronephrosis, urinary stents, history of digestive surgeries, GERD, chronic sinusitis, right foot drop, sacral pressure ulcer, history of urinary tract infections, bronchitis, and hypertension. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and needed assistance with some activities of daily living.On 3/02/2026 at 11:50 AM, Resident #2 was observed lying in bed. She said she was newer to the facility and stated, When I first got here, they didn't have my pain medication, and I had to wait over 24 hours to get it. The resident was asked if the pharmacy had delivered her medication and she stated, They said it is out of state. The resident was asked if she received any type of pain medication after she was admitted and she said the facility said they had Tylenol, but that didn't work well for her. Resident #2 said she kept asking for pain medication and she could not sleep because of the pain. Resident #2 said she had been taking a different pain medication at another facility prior to arriving at the facility. She said she was now receiving the pain medication.A record review of progress notes for Resident #2 indicated she was admitted to the facility at approximately 5:30 PM on 2/13/2026.A record review of the Physician orders for Resident #2 identified the following:An order for Acetaminophen/Tylenol dated 2/13/2026 at 6:35 PM.An order for Tramadol dated 2/14/2026 at 4:41 PM.An order for Norco tablet 5-325 mg, dated 2/18/2026 at 1:03 PMA review of the Medication Administration Records/MAR's for Resident #2 identified the following:She received one dose of Acetaminophen/Tylenol 650 mgs on 2/15/2026 at 3:45 PM. She didn't receive any Tylenol prior to or after this date.Tramadol HCl Tablet 50 mg every 4 hours as needed for moderate and severe pain: The resident received the first dose of Tramadol on 2/14/2026 at 9:42 PM for a pain level of 6/10. She received a total of 6 doses over a 5-day period (2/14/2026 to 2/18/2026). This was the first dose of pain medication the resident had received since she was admitted on [DATE] at 5:30 PM: approximately 28 hours after admission.Norco tablet 5-325 mg, give 1 tablet by mouth every 8 hours as needed for moderate pain. This was ordered on 2/18/2026 and the Tramadol was discontinued on 2/18/2026. The resident received the first dose of Norco on 2/22/2026.During a review of the transferring facility documents including the medication list for Resident #2, it was identified that the resident had been receiving Tramadol 50 mg every 4 hours as needed prior to being admitted to this facility.A review of the Nursing admission Assessment with Care Plan for Resident #2, indicated the assessment was started by the nurse on 2/14/2026 at 2:14 AM: approximately 9 hours after the resident was admitted . A review of the Pain section of the assessment, revealed it was initiated at 2:32 AM on 2/14/2026, approximately 9 hours after the resident was admitted . The question Does the resident have the presence of Pain? was documented Yes.On 3/03/2026 at 12:05 PM Nurse HH was interviewed about resident's who were newly admitted . Nurse HH was asked how long it took to receive the resident's medications, and she said if the pharmacy was notified of new orders that day, they could deliver them that evening or early the next morning. The Nurse was asked if some medications were available in the facility's back up medication dispensing system and she stated, Yes, some were available.On 3/3/2026 at 12:15 PM the Director of Nursing/DON was interviewed about pain medication availability in the medication dispensing system. She said both Tramadol and Norco should be in there. Upon a tour of the medication room containing the Medication Dispensing machine, the DON said Tramadol 50 mg and Norco 5/32/5 mg were both in the backup. The DON was asked how long after admission a resident should have to wait to receive pain medication, she said it would take about 3 hours to process the orders, send them to the physician for signature and then send the order to the pharmacy. The DON was asked if it should take over 24 hours and she said it should never take that long.On 3/03/2026 at 12:23 PM, Resident #2 was interviewed in her room; she said she had previously taken Tramadol, and it was working for her, then the doctor changed it to Norco. She said she was still upset she had to go through being in pain for so long.A review of the Care Plan for Resident #2 identified a Pain care plan dated 3/14/2026: I have the potential for pain/discomfort r/t (related to) generalized weakness and wounds, date initiated 2/14/2026 and revised 2/16/2026 with one Intervention: Observe/report my complaints of pain or requests for pain treatment, dated 2/14/2026. There was no mention of providing pain medication or any type of pain management for the resident.A review of the facility policy titled, Pain Management undated provided, The facility will assess and identify residents experiencing pain, determine the type and severity of the pain and develop a care plan for pain management. The care plan is implemented and continually evaluated for its effectiveness. The staff monitors and documents the resident's response to pain management interventions. A Pain Evaluation must be completed: a. Upon admission.

Based on observation, interview and record review, the facility failed to provide necessary care of an indwelling urinary catheter for 1 resident (Resident #45) of 2 residents reviewed for urinary catheters, resulting in a lack of documentation of catheter care and an observation of the resident's catheter lying flat on the floor. Findings Include: Urinary CatheterResident #45:A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #45 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: history of wound infection with multi-drug-resistant organisms, osteomyelitis (bone infection from a wound), sacral wound, respiratory failure, diabetes, and hypertension. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and the resident needed some assistance with all care.On 3/02/2026 at 10:26 AM, Resident #45 was observed lying in bed in his room. An indwelling urinary (foley) catheter was observed hanging on the side of the bed with sediment in the tubing. The resident said he had had the catheter and a colostomy for approximately 2 months after he was hospitalized .On 3/2/2026 at 4:09 PM, during a wound care observation for Resident #45 with Nurse II the resident's foley catheter was observed lying flat on the floor; it was not hanging from the side of the bed to ensure urine could flow freely into the bag, or to prevent contamination from the floor.A review of the physician orders for Resident #45 identified the following: Foley catheter care q (every) shift and prn (as needed) per protocol, every day and evening shift, start date 12/20/2025. Foley Catheter type: 16 FR Balloon size: 10cc Change catheter every 30 days as needed, Check q shift, every day and evening shift, start date 12/20/2025. Foley output q shift, every day and evening shift, start date 12/20/2025.A review of the Medication Administration Record and Treatment Administration Records identified the following:Treatment Administration Record February 2026: Foley catheter care q shift and prn per protocol every day and evening shift for foley, there were 8 days missing documentation that the foley catheter care had been completed, this included 7 times on nights and 2 times on day shift.Treatment Administration Record February 2026: Foley catheter type: 16 FR Balloon size: 10cc change catheter every 30 days as needed, Check q shift, every day and evening shift for wound, there were 10 missing entries for documentation that the foley catheter had been checked, 7 on night shift and 3 on day shift.Treatment Administration Record February 2026: Foley output q shift, every day and evening shift for foley, there were 12 days missing documentation that the foley catheter output was identified, 10 entries on night shift and 4 on day shift.The urinary catheter care and urinary output for Resident #45 was not consistently documented as completed.On 3/4/2026 at 10:55 AM, during an interview with the Director of Nursing/DON about Resident #45's foley catheter, the missing documentation of catheter care and urinary output was reviewed. The DON said the catheter care should have been completed and documented, and the urinary output should have been recorded every shift.A review of the facility policy titled, Indwelling Catheter Care, undated provided, Purpose: Routine catheter care helps prevent infections and other complications, and is usually performed daily. Inspect the catheter and tubing periodically to detect compression or kinking that could obstruct urine flow. Empty the collection bag at least every 8 hours.

This citation pertains to Intake Number 2679077. Based on observation, interview and record review, the facility failed to provide supervision for one resident (Resident #14) of three residents reviewed for accidents, resulting in a resident-to-resident altercation. Findings include: Resident #14 (R14): R14 admitted to the facility on [DATE] with diagnoses that include cognitive communication deficit, dementia, unspecified psychosis and paranoid personality disorder. On 03/02/2026 at 1:26PM, an interview was conducted with daughter GG of R14. Daughter GG was interviewed about the resident-to-resident altercation her mother had with another male resident. Daughter GG stated, my mom had only been here about two weeks at the time and another resident hit her. Daughter GG' stated my mom had wandered into his room, he was startled and he hit her. Daughter GG stated she was told that the resident that did it knew better, but it still happened. Daughter GG stated it would be very difficult to prevent these kinds of events unless residents are on one-on-one supervision at all the times. An interview was attempted with R14, however, due to her confusion she had no recollection of the incident. On 0302/2026 at 2:00PM, review of a Facility Reported Incident (FRI) revealed that R14 was involved in a resident-to-resident altercation with another resident that resulted in R14 being struck in the face. Through investigation, the facility determined that R14 entered the room of another resident, startled him and resulted in the male resident striking R14 in the face. On 11/15/25 at approximately 4:47am an unwitnessed altercation occurred between R14 and a male resident. Prior to the incident R14 was out in the hallway, looking for her room. According to staff statements about the incident, no staff was present at the time of the incident. On 03/03/2026 at 10:12AM, a Wanderguard was noted to the right ankle of R14. R14 is observed self-propelling around the facility independently and not monitored. On 03/03/2026 at 10:20AM, review of progress notes for R14 revealed she has a history of going into other resident rooms. A behavior note dated 11/5/2025 at 05:44AM, revealed R14 was showing signs of behavior during the shift. Resident kept wandering in other resident's rooms trying to get inside of the bed with them. Resident was redirected multiple times throughout the night. Resident proceeds to wander and had aides/nurse rotating on watching her one-to- one throughout the night. On 03/03/2026 at 12:47PM, an interview was conducted with Social Work (SW) AA. SW AA was asked if R14 receives psych services in the facility. SW AA stated, she was, I believe they see her quarterly now. SW AA' was asked if they provide any psychiatric care for R14. SW AA stated, I try to stop in weekly to see her and see if she has any needs. Most of her behaviors are at night so I miss a lot of those. SW AA' was asked if there has been any consideration of one-to-one care or seeking out alternate placement. SW AA stated I spoke with the daughter yesterday about possibly moving her to another facility in the area that has a secure unit. The daughter said she would consider this; she would just like to speak with the family first and see if everyone else agrees. SW AA was asked if there has been consideration for a one-to-one observation. SW AA stated, I spoke with the administrator and she said no, this is due to staffing and how small we are as a building. SW AA stated I try to keep her (R14) with me all day, but she does go off on her own. On 03/03/2026 at 1:26PM, R14 was observed exiting room [ROOM NUMBER] (not her room) and closing the door, no staff is present. R14 was then observed entering room [ROOM NUMBER] (not her room), staff intervened and redirected her out of the room. On 03/04/2026 at 10:01AM, an interview was conducted with the Director of Nursing (DON). The DON was asked about the incident between R14 and a male resident. The DON stated that on 11/15/25, R14 went and opened the room door of R74. R74 got up and walked to the door and hit her in the face. There was an aide nearby, but it was not witnessed. I was notified immediately of this incident and came to the facility. The staff immediately tended to R14 and brought her up to the front of the building. At the time there was no bruising, then bruising developed. On 03/04/2026 at 2:15PM, R14 was observed reaching her hand out to another resident passing by her, this resident refused her handshake, at this time R14 turned around and followed the resident into the dining room. Upon entering the dining room R14 approached the resident who did not want a handshake, at this time, the staff present intervened and redirected her out of the dining room on her own. On 3/02/2026, at 11:36 AM, during dining observation, there were multiple residents sitting at tables. There were no CNA's nor nurses in the dining room. The double doorway into the kitchen hallway was closed. The single doorway into the kitchen behind the steam tables was open. There was no kitchen staff in the dining room. Resident #14 was observed in their wheelchair wandering around the dining room. Resident #14 entered the area near the steam tables and entered the kitchen. Surveyor followed behind Resident #14 into the kitchen where kitchen staff N' stated, (Resident #14) you can't be in here and assisted the resident backwards out of the kitchen. While Resident #14 was behind the steam tables, multiple residents were calling out Resident #14's name and yelling you can't be there hey, got out of there. Kitchen staff N then placed the rolling silverware cart in a manner that blocked the area behind the steam tables. At 11:49 AM, Resident #14 remained wandering throughout the dining room with no staff in the area. Resident #14 propelled up to a female resident and then wandered up to a male resident and stood still without speaking. Then Resident #14 propelled across the dining room up to another male resident and stopped with their knees touching the male resident's knees. Both residents did not speak to each other. At 11:51 AM, Resident #14 propelled to the back of the dining room and sat near another male resident. Resident #14 had a scowl on their face. There were alert residents (Resident #19 and Resident #41) sitting at a table. The residents were asked if they have ever observed other residents pick on Resident #14. Both residents offered, sometimes the guys pick on her. Dietary Manager (DM) E entered the area at this time. Resident # 41 offered, the other day she got mad at me, right (DM E) with DM E responded, she can get agitated. At 11:53 AM, the Director of Nursing (DON) entered the dining room with another staff member and was approached by Resident #14. At 11:54 AM, the DON and staff member exited the dining room. At 12:10 PM, Resident #14 remained wandering about in the dining room in their wheelchair. There were no nursing staff in the dining room. Resident #14 propelled to the back of the dining room and Resident #14's Family Member H entered the dining room looking for Resident #14. Family member H introduced themselves as they looked on and observed Resident #14. At 12:12 PM, Resident #14 propelled to a table in-between Resident # 19 and Resident #41, picked up a purse of Resident #19's. Both Resident #19 and Resident #41 grabbed onto the purse as Resident #14 struggled to pull it away. At this time, Family Member H walked quickly to Resident #14 and stated, you can't take her purse. The purse was pulled in a strong manner out of Resident #14's hands. AT 12:13 PM, There were still no nursing staff in the dining room. On 3/02/2026, at 1:00 PM, The DON was made aware of the above. On 3/04/2026, 9:30 AM, Resident #14 was observed in the hallway near room [ROOM NUMBER]. Resident #14 entered a male residents' room where two male residents were in their beds. There was a family member visiting. Resident #14 propelled up to the visitor, sat for a moment, then turned and left out of the room. Family member G offered, she comes in all the time and just stares. They offered they say hi and then she just leaves out. Resident #14 quickly propelled down the hall into room [ROOM NUMBER] where a staff member quickly pulled the resident backwards out of the room and stated, oh you don't want to go into that room. The staff member left the area. On 3/04/2026, at 9:37 AM, Resident #14 entered room [ROOM NUMBER] for a moment, backed out and went down towards East Hall where they sat near the Medication cart where a nurse was standing. At 9:41 AM, Resident #14 propelled toward the exit door and entered room [ROOM NUMBER]. The nurse remained standing at the medication cart which was facing the wall. At 9:42 AM, CNA M entered room [ROOM NUMBER] with bed linen. Resident #14 was sitting quietly. CNA M assisted Resident #14 out of the room and asked Resident #14 if they could help with anything. Resident #14 offered, they needed a bathroom. CNA M assisted the resident to the bathroom.

Based on observation, interview and record review, the facility failed to properly assess and identify the need for podiatry services for one resident (Resident #10) of 1 resident reviewed for foot care, resulting in resident frustration, the development of long, curved toenails, discomfort and delay in needed treatment. Findings include: Resident #10: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Diabetes, Chronic peripheral venous insufficiency, hypertension, and paranoid schizophrenia. The MDS assessment dated [DATE] indicated the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and the resident needed assistance with lower body care including personal hygiene. On 3/02/2026 at 10:50 AM, Resident #10 was observed lying in bed awake. She said she had some problems with her feet and lifted her sheet to show her feet. Her toenails were very long, some curled over the ends of her toes, chipped and breaking. The resident said she did not know when the last time her toenails were trimmed. When asked if she wanted someone to trim her toenails she responded, Yes, please. In addition, the resident was observed to have several large, scabbed areas on her lower right leg, one was approximately 1 cm x 1cm and the other was approximately 2 cm x 1 cm with several smaller scabs surrounding it. A record review of the Care Plans for Resident #10 identified the following: I need assistance with my ADL's (activities of daily living) r/t (related to) weakness, diabetes, venous insufficiency. dated initiated 7/23/2025 and revised 3/2/2026 with Interventions including: I need (1 person assistance) from you with personal hygiene and oral care, date initiated 7/23/2025 and revised 8/29/2025. I have Diabetes Mellitus, date initiated 7/23/025 and revised 9/19/2025 with Interventions including: Check my whole body for breaks in skin and treat me promptly as ordered by my doctor, initiated 7/23/2025; Refer me to the podiatrist to monitor/document foot care needs and to cut long nails, date initiated and revised 7/23/2025. A review of the Kardex for Resident #10 indicated there was no mention of nail care or toenail care for the resident. A review of a Social Services note dated 7/17/2025 provided, Resident added to podiatry. A review of a Podiatry Group note dated 12/30/2025 indicated the resident was seen by the Podiatrist on this date and her toenails were trimmed. The note included an entry titled, Recall: As medically necessary but no sooner than 60 days. On 3/4/2026 at 9:25 AM, Nurse Aide K was interviewed in Resident #10's room about the resident's toenails. Resident #10 was lying in bed, when asked if her toenails could be observed she said yes and the Nurse Aide lifted the bed sheet. Resident #10 was observed to have several bloody, open areas on her lower right leg and there were 2 large pieces of broken off toenails lying on her bottom bed sheet; each piece was approximately 1.5 cm long x 0.5 cm wide and 1 piece was lying near the toes of the left foot and right foot. When asked about the broken pieces of toenail, the resident said she was not aware of it. Nurse Aide K asked the resident if she could soak her feet and the resident stated, Yes. The Nurse Aide provided a warm clean washcloth to the toes on each foot and the resident stated, Oh, that feels good. On 3/4/2026 at 10:30 AM, the Director of Nursing and Social Services AA were interviewed about Resident #10's toenails. Social Services AA said the resident was on the list to be seen by the Podiatrist on 3/9/2026 and had been seen on 12/30/2025. The Director of Nursing/DON said the resident could be seen sooner and the 60 days was based on billing for the service. She asked the Social Services AA to request the resident to be seen more often. The DON was asked about the resident's last skin assessment, and she said it was completed 3/3/2026. There was no mention of the scabs or bleeding areas on the resident's lower right leg or the resident's toenails that were in need of trimming, as they were broken and growing over some of the resident's toes. The Social Services AA said the staff had not mentioned to him that the resident's toenails needed to be cared for sooner than every 60 days. The DON said someone should have identified the resident's toenails needed to be trimmed and they would take care of it.

Based on observation, interview and record review, the facility failed to implement interventions to prevent the development of a pressure injury for one resident (R29) of four residents reviewed, resulting in a blister developing and eventually opening. Findings include:Resident #29 (R29): R29 admitted to the facility on [DATE] with diagnoses that include hemiplegia affecting the left side, type 2 diabetes mellitus and hemiparesis following cerebral infarction. R29 has a brief interview for mental status (BIMS) score of 15, indicating she is cognitively intact. On 03/02/2026 at 12:45PM, an interview was conducted with R29. R29 was asked if she had any issues with her skin. R29 stated that she has a blister on her left heel that developed at the facility. R29 says she needs a new pair of heel boots, R29 feels the ones she has aren't in good shape anymore. Observation revealed two heel boots sitting on top of the closet in the room. On 03/03/2026 at 1:52PM, record review revealed a Braden Scale assessment was completed on 12/9/25 with a score of 16, indicating R29 was at mild risk for developing pressure injuries. R29 is noted to be a problem with friction and shear due to needing assistance with bed mobility. A care plan was present in the medical record, titled, I need assistance with my activities of daily living (ADL) related to left sided weakness. I often refuse to assist with my care and completing tasks I am able to complete. Dated 06/25/2025. Interventions include Bed Mobility: I am dependent on staff to turn and reposition me frequently while I am in bed. Date initiated 06/25/2025, last revised on 07/11/2025. Another care plan is present titled, I have limited physical mobility related to left sided weakness. dated 06/25/2025. On 03/04/2026 at 10:27AM, an interview was conducted with Wound Care HH. Wound Care HH was asked about the left heel blister on R29. Wound Care HH stated that R29 currently has an open blister on the left heel. Wond Care HH stated, this blister is not new, we had it closed before and it reopened. Wound Care HH stated the blister was acquired here in the facility on 1/12/26 and we resolved it two weeks later. Wound Care HH was asked how the blister initially developed. Wound Care HH stated, we try to keep the heel boots on her, she had heel boots on her at the time it developed. Wound Care HH was asked if the facility is floating R29's heels. Wound Care HH stated, R29 will float her heels, and we try to keep the boots on her as well. It reopened again recently, staff noted the fluid filled blister on her heel, it popped open in the shower, we started to treat it with betadine and Dr. [NAME] saw her the next time he was here. I do rounds every Tuesday with the doctor, I update care plans as needed, as treatments change and as wounds resolve. Wound Care HH was asked if they though there were enough interventions in place to prevent the blister from forming. Wound Care HH stated, yes, she has a low air loss mattress in place and we try to keep the boots on her, but in the morning, I will notice she has them off, we try to get her out of bed, she works with restorative so we get her out of bed for that. We do all that we can to keep the pressure down. I don't believe it was a pressure injury; it was a fluid filled blister; we had interventions in place. The current treatment in place is padded and helps prevent friction in any way. On 03/04/2026 at 11:18AM, record review revealed a care plan is in place for the left heel blister. The care plan is dated 01/12/26 and indicates that a left soft heel boot was put in place on 1/8/26. The care plan intervention for the left soft heel boot being on at all times, was resolved on 02/11/2206. There were no heel boots in place prior to the development of the left heel blister. On 03/04/2026 at 11:37AM, record review revealed a weekly head to toe skin assessment dated [DATE], that there as a pressure injury on the left heel 4cmx4cmx0cm in size, suspected deep tissue injury (SDTI) and that a left heel boot as applied. On 03/04/2026 at 11:43AM, a weekly head to toe skin assessment, dated 2/18/2026 revealed the left heel blister had opened up again. On 03/04/2026 at 12:09PM, an interview was conducted with the Director of Nursing (DON). The DON was asked about the left heel blister on R29. The DON stated that on 1/8/26, when I saw the left heel, it was a SDTI. When I saw it, it was dark and purple and not fluid filled. By the time the doctor saw it, it could have changed to a fluid filled blister. The DON was asked how they thought the SDTI developed. The DON stated that R29 is prone to having that area open on and off because R29 rubs her left foot back and forth on the bed. On 03/04/2026 at 12:14PM, an interview was conducted with R29. R29 was asked for additional information on her left heel pressure area. R29 states the purple spot on her heel developed from resting on the bed and then it turned into a blister. R29 was asked if they were wearing heel boots or if the staff was keeping her heel elevated prior to the blister developing. R29 stated, no, they didn't give me the boots until the blister developed and they didn't elevate my heels either. I have a hard time getting the staff to put the boots on. R29 was asked if they have ever refused to wear the boots. R29 stated, no, I have never refused to wear them even though they can make my feet hot. R29 stated, I have been told I refuse a lot of things that I never have. On 3/04/2026 at 12:20PM, an interview was conducted with Certified Nursing Assistant (CNA) D. CNA D was asked if R29 has ever refused to wear heel boots for you. CNA D stated, no, she has not refused for me. The night shift tells me that she will refuse sometimes, I noticed they were not on this morning when I got here, I am not sure if she refused or the boots just weren't applied. CNA D stated that R29 says the boots make her feet hot, so I leave them open on the top and she never has an issue with that. Review of the Policy Titled, Pressure Ulcer Preventative Measures, revealed:Policy:Residents at risk for the development of pressure ulcers receive interventions to reduce the risk of pressure ulcers.Procedure:11. As needed, use lubricants, protective films (transparent film dressings and skin sealant), protective dressings (hydrocolloid), and/or protective padding to reduce friction injuries. Obtain a physician order as needed.16. For residents in bed, who are completely immobile, use devices that relieve pressure on the heels, most commonly by raising the heels off the bed. Use pillows under the length of the lower leg, suspending the heels. When using a specialty support surface, follow manufacturer's instructions.

This Citation pertains to Intake Number MI00143170. Based on observation, interview and record review, the facility failed to ensure appropriate interventions were in place and supervision was provided to prevent a fall with injury for one resident (Resident #56) of 3 residents reviewed for falls, resulting in Resident #56 falling out of bed and suffering a femur fracture. Findings Include: Resident #56: Accidents On 4/29/2024 at 12:15 PM during a tour of the facility, Resident #56 was observed lying in bed, alert and talkative. Her bed was in a very low position near the floor. Her lunch tray was present and sitting on the bedside table, which was positioned much higher than the resident's height in the bed. Resident #56 was observed attempting to roll over in bed to reach her tray that was on the bedside table. She couldn't reach it and continued to lean over and reach up in an attempt to reach the tray. A staff member was notified in the hallway that the resident needed assistance. The resident was identified A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #56 was admitted to the facility on [DATE] with diagnoses: heart failure, diabetes, atrial fibrillation, hypertension, depression, arthritis, obesity and history of falls. The MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 2/15. A review of the progress notes indicated Resident #56 had fallen seven times at the facility from 9/8/2023- 4/29/2024 including: 9/8/2023, 9/14/2023, 9/28/2023, 12/5/2023, 1/23/2023, 4/21/2023, and 4/29/2023. A review of the Incident and Accident Reports for each fall, indicated the falls occurred in the late afternoon, evening and night. 9/8/2023 at 5:09 PM: Was called to room [ROOM NUMBER], observed resident sitting on the floor in front of w/c (wheel chair), legs straight out in front of her . 9/14/2023 at 5:15 PM: Writer called into room regarding resident being observed on the floor. Staff entered room and resident was sitting on her buttocks leaning against her bed with feet in front of her . 9/28/2023 at 5:00 PM: Writer to room rounding on resident, observed resident on floor between beds laying parallel to beds face up flat on back . 12/5/2023 at 5:50 PM: Writer went to dining room after code green called overhead to dining room. Found resident lying on left on the floor in front of wheel chair . small skin tear on left elbow . 1/23/2024 at 12:25 AM revealed the following: Writer called to residents room to find resident on the floor face down. Resident had pulled side rail off of bed prior to falling on the floor. Resident assessed for injuries. Resident noted with edema and bruising to forehead. Small scrape to left knee . abrasion left knee, bruise top of scalp . A record review of the progress notes indicated Resident #56 fell and fractured her left femur on 1/23/2024 at 12:25 AM. She was transferred to the hospital on 1/23/2024 after the fall, for pain in her left knee. She was admitted to the hospital and returned to the facility on [DATE]. The resident did not have surgical repair of the fracture and returned with a left knee immobilizer in place. 4/21/2024 at 1:40 AM: Resident sitting on floor next to bed leaning against bed . 4/29/2024 at 10:25 PM: Writer called to resident's room. Resident on floor next to bed. Lying on her side . Each of the falls, that Resident #56 had, were unwitnessed. On 5/6/2024 at 9:56 AM, wound care was observed for Resident #56 with Nurse D. She said the resident had developed a pressure ulcer/ left outer ankle at the facility from the left knee immobilizer not fitting well and on the right outer ankle from immobility and pressure lying in bed. The resident was crying out in pain when turned and repositioned. Nurse D said the resident did not have surgical repair of the left femur fracture and had pain at times. A review of the Care plans for Resident #56 revealed the following: After Resident #56 fell on [DATE] the Care plan was updated with an intervention Anticipate and meet my needs; Be sure my call light is in reach .prompt response. 9/14/2024 I need a safe environment . After the resident fell on [DATE], there was no update to the Care plan. After the resident fell on [DATE], there was no update to the Care plan to aid in preventing future falls. After the resident fell on [DATE], the Care plan was updated with, Educate the resident /family/caregiver about safety reminders and what to do if a fall occurs; dycem to wheelchair. After the resident fell on [DATE] the Care plan was updated with ,PT evaluate and treat as ordered or prn (as needed); Call daughter to try and alleviate resident anxiety. The next fall was on 1/23/2024 and the resident fractured their left femur. The intervention was I am at risk for falls related to confusion and anxiety; Bed to be in low position at all times when care is not being provided; I am at risk for falls rt confusion and anxiety. After the resident fell on [DATE] the Care plan interventions were, Monitor me, due to high fall risk; Encourage resident to keep the bed at 30 degrees related to resident sliding. The resident interventions were basic fall prevention strategies and often not initiated until after the resident had fallen multiple times. The resident was At risk for fall . months before she fell and fractured her left femur, but the intervention was initiated on 4/21/2024. After several of the falls, no new interventions were identified and the resident continued to fall. There was no mention of ensuring supervision for Resident #56 to aid in preventing falls, as each fall was unwitnessed. There was also no mention of the time of day that the falls occurred, many were around meal time or late in the day. On 5/06/24 at 4:16 PM, during an interview with the Director of Nursing/DON and Administrator, Resident #56's falls were reviewed. The fall prevention interventions were reviewed for Resident #56. The DON said she was aware that the resident had multiple falls including the fall with fracture and was looking into it. A review of the facility policy titled, Accidents and Incidents- Investigating and Reporting, dated revised July 2017 provided, All accidents and incidents involving residents . shall be investigated and reported to the Administrator . Incident/Accident reports will be reviewed by the Safety Committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. A review of the facility policy titled, Safe Environment, dated revised July 2017 provided, . Resident safety and supervision and assistance to prevent accidents are facility- wide priorities . The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision . Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs .

Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures for pressure ulcer (wounds caused by pressure) identification, care, and prevention for one resident (Resident #10) of three residents reviewed, resulting in lack of implementation of interventions to prevent pressure ulcer development, lack of accurate identification, knowledgeable assessment, and documentation of unstageable Deep Tissue Injury (DTI) and Stage II pressure ulcers, lack of professional standards of practice during incontinence/wound care, resulting in Resident #10 developing unstageable and Stage II pressure ulcers, and the likelihood for delayed healing, infection, and decline in overall health status. Findings include: On 1/31/22 at 2:40 PM, Resident #10 was observed in their room. The Resident was wearing a hospital gown, positioned on their back in was in bed with their heels/feet directly on the mattress. Heel boots (pressure reduction boots) were noted sitting on a wheelchair in the room. Multiple open wounds were present and visible on the Resident's arms and upper chest. Resident #10 was asked about the open sores and indicated they were itchy. When queried regarding the level of assistance they required for care, Resident #10 revealed they were unable to get out of bed and/or turn themselves without assistance. When queried regarding bowel and bladder continence, Resident #10 disclosed they were continent but utilized briefs because it was too difficult for staff to get them out of bed. Resident #10 specified staff had to use a Hoyer lift (mechanical device to transfer individuals) to transfer them in and out of bed. When queried regarding pain, Resident #10 replied, My right heel hurts. When asked to rate their pain, on a scale of zero to 10 with 10 being the worst, Resident #10 stated, Six. When queried regarding pressure ulcers, Resident #10 revealed they had in the past, but staff had not told them they had any currently. Record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required extensive to total assistance to perform all Activities of Daily Living (ADLs) with the exception of eating. The MDS further revealed Resident #10 was at risk for developing pressure ulcers and had pressure reducing devices in place on their bed and chair. Review of Resident #10's progress note documentation in the Electronic Medical Record (EMR) revealed the following: - 8/16/21: It was brought to this writer's attention that resident had a new open area of skin on left buttock. Upon assessment . observed a 3 CM (centimeter) X 1CM X 0.3 CM open area, shallow with red/pink wound bed and small amount of serosanguineous drainage . -8/26/21: Nursing Progress Note . Weekly wound rounds performed by RN. Resident presents with . MACD (Moisture Associated Skin Damage) to b/l (bilateral) buttocks, with an open area on left buttock that measures 7CM X 5CM X0.01 CM. The wound bed is red/pink and has a small amount of bloody drainage . has an air mattress . -10/6/21: Nursing Progress Note . Weekly wound rounds performed by LPN. Resident presents with . MASD to b/l buttocks, with an open area on left buttock that measures 2CM X 1CM X 0.01 CM . wound bed is red/pink and has a small amount of bloody drainage. Wound edges are well-defined with an irregular shape . (Resident #10) has an air mattress . - 10/13/21: Nursing Progress Note . Weekly wound rounds performed by LPN. Resident presents with . MASD to b/l buttocks, with an open area on her left buttock that measures 1.2CM X 1CM X 0.01CM. Improvement noted in measurements and appearance since last week. The wound bed is red/pink. Wound edges are well-defined with an irregular shape . refuses to have an air mattress . - 11/11/21: Nursing Progress Note . Weekly wound rounds performed by LPN. Resident presents with . MASD to b/l buttocks, with an open area on left buttock that measures 0.5CM X 0.5CM X 0.1CM. No drainage . refuses to have an air mattress . - 11/30/21: Nursing Progress Note . Weekly wound rounds performed by LPN and NP. Resident presents with . MASD to b/l buttocks, with an open area on left buttock that measures 0.4CM X 0.4CM X 0.1CM. No drainage . refuses to have an air mattress . - 12/14/21: Nursing Progress Note . Weekly wound rounds performed by LPN and NP. Resident presents with . MASD to b/l buttocks, with an open area on left buttock that measures 0.5CM X 0.7CM X 0.1CM. small amount of blood . Will continue to monitor. - 1/4/22: Nursing Progress Note . Weekly wound rounds performed by LPN and NP (Nurse Practitioner). Resident presents with . MASD to b/l (bilateral) buttocks, with an previous open area on left buttock that is now closed . Will continue to monitor. - 1/11/22: Nursing Progress Note . Weekly wound rounds performed by LPN. Resident presents with . has MASD to b/l buttocks, with a history of open areas on buttocks . Will continue to monitor. Review of Resident #10's Assessment/Evaluation documentation revealed seven separate Skin & Wound Evaluation forms were completed on 1/20/22. All the forms indicated they were for Open [CONDITION(S)] but did not include a location of the wounds. Review of Resident #10's care plans revealed a care plan entitled, Skin: I have actual skin impairments: open areas . MASD with open areas to buttocks r/t (related to) incontinence . At times I do not allow staff to assist with repositioning and incontinence care . The care plan included the interventions: - Administer treatments as/if ordered and monitor for effectiveness (Initiated: 9/22/20) - Apply barrier cream/ointment after each incontinence and prn (as needed) (Initiated: 9/22/20) - Asses(s) my skin daily when providing care and notify charge nurse of any new areas such as redness, bruising, open areas ect. (Initiated: 9/22/20) - Encourage and Assist with repositioning frequently hours/prn. If I refuse, please remind me the importance of repositioning, allow me time to reconsider and reapproach. If I continue to refuse, please document and notify my charge nurse (Initiated: 5/8/20; Revised: 9/22/20) - Float my heels off of bed using positioning device . (Initiated: 5/8/20; Revised: 7/7/21) - I have a pressure reducing mattress on bed (Initiated: 5/8/20) At 3:46 PM on 2/1/22, Resident #10 was observed in their room. The Resident was lying in bed, positioned on their back with their heels/feet positioned directly on the mattress. The wheelchair with heel boots on the seat were noted in the same position in the room. On 2/2/22 at 9:58 AM, Resident #10's call light was observed to be on. Upon entering the room, a foul permeating bowel odor was immediately noted. The Resident was laying on their back in bed with their feet/heels directly on the mattress. The heel boots remained in the same position on the seat of the wheelchair. The front of the Resident's hospital gown was visibly soiled with food crumbs and a dark, brown/red colored substance with the seeming appearance of dried blood. When queried regarding their call light, Resident #10 revealed they had a bowel movement and needed staff to clean them. Resident #10 was asked how frequently staff reposition them in bed, so they are not laying directly on their back, and revealed staff do not reposition them. When asked why they are not assisted to be repositioned in bed, Resident #10 revealed staff only enter their room to provide care when called and to deliver food trays. Resident #10 was then queried regarding heel boot use and indicated they did not know what heel boots were. After pointing out the heel boots on the wheelchair, Resident #10 stated, The slippers. At 10:06 AM on 2/2/22, Certified Nursing Assistant (CNA) R and CNA S entered Resident #10's room. When asked about the heel boots on the wheelchair in Resident #10's room, CNA R stated, Supposed to wear them. At this time, Resident #10 stated, The nurse told me I did not need to wear them anymore. When queried how long ago they were told that, Resident #10 replied, Four months ago. An observation of care occurred at this time. After removing Resident #10's blankets, the bowel odor became stronger and a different, overtly putrid odor permeated the area. The Resident's bedding was observed to be visually soiled with unknown substances of various colors with scattered chunks of various sized unknown substances. Resident #10's right foot was on an angle with their heel and lateral aspect of their foot directly on the mattress. Bowel Movement (BM) was present in-between the front of the Resident's legs and on their catheter. CNA S began cleaning the Resident from the front of their peri-area at this time. CNA S was observed wiping down and then up the catheter tubing toward the urethra. CNA R and CNA S then rolled the Resident onto their side. The pull pad under the Resident was saturated with red colored, bloody drainage from open wounds on the Resident's buttocks and sacral areas. The drainage had saturated through the pad, fitted bed sheet, and onto the mattress. Resident #10's right buttocks and sacral area was a dark red/purple color. An open wound was observed on the Resident's right buttocks/sacral area. The wound was irregularly shaped and approximately the size of a quarter. The wound bed was open and varying shades of pink and red in color with sanguineous drainage noted. Multiple open areas, with active bleeding, were noted within the gluteal crevice. At this time, Licensed Practical Nurse (LPN) Q entered the Resident's room, handed the CNA staff a medication cup containing white colored cream, and exited the room without observing the Resident's skin. After cleaning the Resident's right buttocks/sacral areas and gluteal crevice, CNA S applied the white colored cream inside the gluteal crevice, over the Resident's entire right side of their buttocks/sacral area, and directly over the bed of the open wound. CNA S did not change their gloves and/or perform hand hygiene after cleaning the BM and prior to applying the cream. The same gloved hand was used to apply the cream over the open wound bed as had been used to apply cream directly in the gluteal crevice. CNA S and CNA R proceeded to roll the Resident. After rolling, an open wound was observed on the Resident's left buttocks. The wound bed was irregularly shaped and approximately the size of a half dollar. The wound bed was pink with white colored tissue and dark brown/black colored tissue at the proximal aspect of the wound bed. The surrounding skin was dark red/purple in color. After cleaning BM, the CNA R proceeded to put the white colored cream over the Resident's entire left buttocks including the open wound. Staff did not change their gloves and/or perform hand hygiene. During care, Resident #10 displayed facial grimacing and appeared to pull away when staff touched the open wounds. Resident #10 was asked if they were having pain and stated, My butt hurts. Following restoration of hygiene and wound care treatment, CNA R and CNA S proceeded to position Resident #10 directly on their back with their heels/feet directly on the mattress. Upon request, an observation of Resident #10's heels/feet were completed. A dark purple area slightly larger than a dime was present on the Resident's left lateral malleolus (ankle), directly over the bony prominence of the ankle. A dark red/ purple colored area, slightly larger than a nickel, was also noted on the lateral aspect of Resident #10's right lateral malleolus directly over the bony prominence. The area was noted to be non-blanchable. An interview was completed with CNA S on 2/2/22 at 10:31 AM. When queried regarding Resident #10 open wounds on their buttocks/sacrum, CNA S stated, It was new a few days ago. With further inquiry, both CNA's revealed nursing staff had been notified and Wound Care Licensed Practical Nurse (LPN) C was seeing the Resident for their pressure ulcers. When asked if they had completed ADL care for Resident #10, CNA S revealed they had not. When asked why daily AM care had not been delivered, an explanation was not provided. When queried regarding Resident #10 always being observed in bed wearing a hospital gown, CNA S replied, (Resident #10) has been like that for a long time and indicated the Resident did not get up. When asked why the Resident was positioned in the same place on their back following care, CNA S replied, (Resident #10) can't breathe. With further inquiry regarding the use of pillows and/or wedges for slight movement to relieve pressure, an explanation was not provided. The staff was then asked why the Resident's feet/heels were not elevated off the bed but did not provide an explanation. CNA S was then asked if nursing staff normally bring cream for them to apply to open wounds, CNA S replied, Some do, some don't. An interview was conducted with Wound Care Licensed Practical Nurse (LPN) C on 2/2/22 at 10:38 AM. Wound Care LPN C was asked when they last assessed Resident #10 and stated, We used to follow (Resident #10) for wound rounds every week. When asked the last time they assessed Resident #10, Wound Care LPN C reviewed the Electronic Medical Record (EMR) and stated, Started seeing in September and last seen on 1/11/22. LPN C was queried where wound care assessments are documented and revealed they document in a nurses note. When asked why multiple, incomplete Skin & Wound Evaluation assessments were present in Resident #10's medical record on 1/20/22, LPN C stated (RN E) seen (Resident #10) the week I was off (for wound care). When asked why the location of the wound was not included in the assessment, LPN C revealed there were pictures and the wound locations could be figured out from them. The pictures were not present/accessible in the EMR access provided to this surveyor and were requested from Wound Care LPN C at this time. Wound Care LPN C was then queried regarding facility policy/procedure related to notification when a resident develops a new wound/pressure ulcer and stated, The nurses on the floor usually tell me and I collect the skin assessments. When asked for clarification pertaining to collection of skin assessments, LPN C revealed nursing staff complete weekly skin assessments which they collect and review to determine if any residents have new alterations in skin integrity. When queried if assessment of all areas of the skin and pressure points are assessed as part of the nursing skin assessment, such as resident heels and ankles, Wound Care LPN C replied, I can't say that. Wound Care LPN C was asked if they assess all pressure points when completing wound care treatments and stated, No. I look at the open wound and the area surrounding it. When queried if Resident #10 was a high risk for pressure ulcer development, Wound Care LPN C stated, I would say yes. Wound Care LPN C was then questioned how the facility assesses and monitors pressure ulcer development risk and indicated the Braden scale (standardized scale used to determine pressure ulcer development risk) is utilized to determine and identify risk. When queried about Resident #10's risk per Braden scale assessment, Wound Care LPN C reviewed the Resident's medical record and stated, Last Braden in November, High Risk. Wound Care LPN C was then asked what interventions are implemented for residents assessed to be at high risk for pressure ulcer development and replied, An alternating air mattress. When asked why Resident #10 did not have an alternating air mattress in place, Wound Care LPN C stated, I don't have a good answer for that. I guess I need to pay better attention to the Braden's. When queried regarding documentation of the Resident having an air mattress and also refusing in October 2021 and why the air mattress was removed, Wound Care LPN C did not provide an explanation. Wound Care LPN C was then asked why placement of an alternative to an air mattress had not been attempted and/or investigation regarding the reason the Resident did not want the air mattress replaced and replied, I don't know. Wound Care LPN C was then queried regarding the heel boots observed in Resident #10's room including use of the boots as an intervention to prevent pressure ulcer development. After reviewing Resident #10's care plan, Wound Care LPN C replied, No. When asked if CNA staff are allowed to apply treatments to open wounds, per facility policy/procedure, Wound Care LPN C stated, Oh my God, No. Wound Care LPN C was informed of the wounds observed during care at this time and revealed they were not aware. An observation of Resident #10's heels and lateral ankles was completed with Wound Care LPN C at this time. After observation, Wound Care LPN C was asked what they observed and replied, Pressure ulcers. When asked if the pressure ulcers were unstageable Deep Tissue Injuries (DTI- Purple or maroon colored area of intact skin due to underlying tissue damage from pressure and/or shearing which may rapidly evolve and open), Wound Care LPN C indicated it could be. Resident #10's buttock/sacral wounds were not observed with Wound Care LPN C due to the Resident requesting to wait. An interview was completed with LPN Q on 2/2/22 at 11:10 AM. When queried if nursing staff are supposed to give treatment cream for wounds to CNAs to apply, LPN Q stated, Yeah, they have been doing it. LPN Q was asked if they had seen and assessed the open wound on Resident #10's buttocks/sacrum and replied, No. On 2/2/22 at 5:21 PM, an interview was conducted with the Director of Nursing (DON). When queried regarding the lack of implementation of interventions to prevention pressure ulcers and/or pressure related injuries for Resident #10, the DON indicated they would need to review the Residents medical record. When queried regarding the Skin & Wound Evaluation assessments completed on 1/22/22 not including documentation of the actual wound location, the DON stated, It is a new system (for wounds) and (the nurse) forgot to put it in. The DON further revealed they were made aware of the wound locations not being included in the assessments from Wound Care LPN C and stated, I had them do it. When asked how staff were accurately able to recall the location of seven separate wounds, the DON indicated there are pictures of the wound. When asked if the pictures were close-up images of the wound, the DON revealed they were. When queried regarding facility policy/procedure regarding timely documentation, the DON reiterated it was a new system for wound documentation. Observation of Resident #10's peri-care and pressure ulcers were discussed with the DON at this time. The DON was queried regarding Resident #10 having unstageable DTI pressure ulcers on their heels and, at least two, Stage II pressure ulcers on their buttocks/sacrum and lack of interventions in place to prevent pressure ulcer development. An explanation was not provided. When asked why the pressure ulcers were identified by this Surveyor and not facility nursing staff, the DON did not provide rationalization. The DON reviewed Resident #10's care plan at this time and indicated an alternating air mattress was included on the Resident's care plan. The DON was then asked to review the detailed edit history for the care plan with this surveyor. Review of the detailed edit history revealed the care plan had been edited today, 2/2/22, to include the addition of an alternating air mattress and refusal by the Resident. When asked what alternatives had been attempted, no further explanation was provided. At 11:53 AM on 2/3/22, Resident #10 was observed in their room. The Resident was in bed, positioned on their back with their heels/feet directly on the mattress. Additional review of Resident #10's medical record documentation on 2/3/22 revealed the following progress note written by Wound Care LPN C: - 2/2/22 at 12:20 PM: Nursing Progress Note . Writer notified of changes in residents skin. Resident has MASD to buttocks and a stage 2 to bilateral malleolus . Order obtained from NP for foam boots to bilateral feet while in bed. Resident agrees to wear them at this time. Resident refuses an air mattress . On 2/3/22 at 2:05 PM, an interview was completed with the ADON. The ADON was asked what constitutes a stage two pressure ulcer and replied, the wound is open. An observation of Resident #10's skin was completed with the ADON at this time. Upon entering the room, Resident #10 was noted to be in bed, position on their back with their heels/feet directly on the mattress. A dark purple/burgundy colored area, approximately the size of a nickel was observed on Resident #10's right lateral malleolus area of their lower extremity. When asked if the area was blanchable, the ADON applied pressure and stated, Non-blanchable. Observation of Resident #10's left lower extremity revealed a dark purple area, approximately the size of a dime over the lateral malleolus. When asked if the area was blanchable, the ADON applied pressure and replied, Slow to blanche. An interview was conducted with the ADON following the wound observation. When asked if the areas on Resident #10's bilateral lateral malleoli were caused from pressure, the ADON responded that they were. When queried if they were stage two pressure ulcers, the ADON indicated they were not because they were not open. When asked why Wound Care LPN C documented them as stage two pressure ulcers in Resident #10's EMR when the pressure ulcers were also not open on 2/2/22, the ADON was unable to provide an explanation. When queried if the areas were unstageable DTI pressure ulcers, the ADON indicated they were and stated, I will document. An interview was completed with the DON on 2/3/22 at 2:12 PM with the DON and ADON. Observations of Resident #10's bilateral lateral malleoli were discussed. When queried why Wound Care LPN C would document the pressure ulcer as a stage two when it did not meet the classification criteria, the DON replied, (Wound Care LPN C) is learning. When queried why a staff member who is learning but has not demonstrated competence is performing and responsible for wound care within the facility, the DON indicated they had completed a basic training course for wounds. No further explanation was provided. On 2/3/22 at 2:16 PM, Wound Care Nurse Practitioner (NP) P was contacted via telephone. A voicemail with return number was left but a return call was not received by the conclusion of the survey. On 2/3/22 at 2:30 PM, a wound care observation of Resident #10's buttock/sacral wounds occurred with the ADON, Wound Care LPN C, and another State Surveyor. Upon entering the room, Resident #10 was observed in bed. The Resident was positioned on their back with their feet/heels directly on the mattress. After uncovering the Resident, the pad and sheet under them were noted to be visually saturated and wet with an unknown substance. Resident #10 was positioned on their right side in bed by staff and the left buttocks/sacral wound was visualized. The wound was irregularly shaped with defined edges and visible depth. The wound bed was noted to have dark brown/black colored tissue at the proximal aspect. The rest of the wound bed was pink with white colored tissue covering approximately 10 percent. Upon request, Wound Care LPN C measured the wound. Wound Care LPN C utilized a paper measuring tape and stated, 2.6 (cm) by 1.2 (cm). When asked the depth of the wound, Wound Care LPN C attempted to place the paper tape into the wound bed. When asked if that was how they always measured wounds, Wound Care LPN C indicated it was. When queried why they did not use the packaged Q-tip brought into the room, Wound Care LPN C did not respond but opened the Q-tip package on the visibly wet and saturated bedding. Wound Care LPN C proceeded to attempt to measure the wound by inserting the wood and not the cotton tip end of the Q-tip into the wound bed. While doing this, the cotton end was touching the saturated bedding. When asked why they were using the wood end, Wound Care LPN C revealed they did not know and then flipped the Q-tip and inserted the cotton end, which had been on the soiled bed, and inserted into the wound bed. Wound Care LPN C stated the depth of the wound was 0.1 (cm). After rolling the Resident, the wound on their right buttocks/sacral area was irregularly shaped with defined edged and approximately the size of a quarter. The wound bed was pink and red in color with actively bleeding observed. Resident #10's bilateral sacrum and coccyx was noted to be dark red/purple in color. An interview was conducted with the ADON on 2/3/22 at 2:48 PM. When queried regarding the etiology and classification of Resident #10's buttocks/sacral wounds, the ADON revealed they would classify the wounds as pressure related. With further inquiry, the ADON revealed the wounds were Stage two. The ADON was then queried regarding observations of Wound Care LPN C including performance of wound measurements and contamination of the pressure ulcer. The ADON did not provide an explanation but indicated Wound Care LPN C would need additional education. No further explanation was provided. An interview was conducted with the facility Administrator on 2/3/22 at 2:56 PM. When queried regarding Resident #10's pressure ulcers, including inaccurate documentation, missing and inconsistent documentation, lack of implementation of interventions, and lack of infection control principles and knowledge of wounds demonstrated by Wound Care LPN C, the Administrator indicated they understood the concerns and revealed they are diligently working to improve care provided at the facility. Review of facility policy/procedure entitled, Prevention of Pressure Ulcer/Injuries (Reviewed 10/2020) revealed, The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions . 4. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs . e. Reposition resident as indicated on the care plan . Mobility/Repositioning . 2. At least every hour, reposition residents who are chair bound or bed-bound with the head of the bed elevated 30 degrees or more. 3. At least every two hours, reposition residents who are reclining and dependent on staff for repositioning. 4. Reposition more frequently as needed, based on the condition of the skin . Review of facility policy/procedure entitled, Wound Care (Revised October 2010) revealed, Purpose . provide guidelines for the care of wounds to promote healing . 1. Use disposable cloth to establish a clean field on resident's overbed table . 7. Use no-touch technique . 10. Wear sterile gloves when physically touching the wound . Documentation . 3. The position in which the resident was placed . 5. Any change . 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound . Reporting . 1. Notify the supervisor if the resident refuses the wound care .

This Citation contains two Deficient Practice Statements (DPS). DPS #1. This Citation pertains to Intake Numbers MI 856, MI 594, MI 595, MI 771, MI 788 and MI 919. Based on observation, interview and record review, the facility failed to prevent the elopement, provide adequate supervision and ensure the safety of one resident (Resident #15) of seven residents reviewed for the potential for elopement, resulting in an Immediate Jeopardy when Resident #15 eloped from the facility on [DATE] at 5:07 PM, unbeknownst to facility staff. Facility staff did not respond appropriately or correctly to audio alarms and flashing strobe lights which activated when the resident eloped from the building, resulting in a high likelihood of harm, injury and/or death due to Resident #15 being outside alone and unsupervised. The facility is situated near a railroad crossing and a busy thoroughfare that runs through town. The Immediate Jeopardy started on [DATE]. The Immediate Jeopardy was identified on [DATE]. The Administrator was notified of the Immediate jeopardy on [DATE] and was asked for a plan to remove the immediacy. The Immediate Jeopardy was removed on [DATE] based on the implementation of the removal plan as verified onsite on [DATE]. Findings include: Resident #15: A review of Resident #15's medical record revealed an admission into the facility on [DATE] with a re-admission on [DATE] with diagnoses that included urinary tract infection, unspecified [CONDITION(S)], major depressive disorder, [CONDITION(S)] with behavioral disturbance, anxiety disorder and Alzheimer's disease. A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15 indicating severe cognitive impairment and needing supervision with setup help only for locomotion on unit and off unit and needed limited assistance with one-person physical assist for walking in room and walking in corridor. A review of the Elopement Risk Assessment, dated [DATE], scored 9 that indicated the Resident was at risk to elope and the Elopement Risk Assessment, dated [DATE], scored 11 that indicated the Resident was at high risk to elope. Resident #15 had a care plan with a focus of I am an elopement risk/wanderer related to a history of attempts to leave the facility unattended and an impaired safety awareness, initiated on [DATE]. The interventions included the use of a Wander Guard and the checking for the placement and the functioning every shift. The facility was checking the placement and functioning twice a day. There was no indication in the medical record of the date the battery of the Wander Guard was replaced, inserted, or if it had ever expired. On [DATE] at 4:05 PM, an observation was made of Resident #15 sitting in her room in a wheelchair. The Resident was dressed and dozing while sitting up in the wheelchair. The Resident opened her eyes when this writer knocked on the door. The Resident answered a couple basic simple questions but did not elaborate. The Resident was observed to be able to maneuver their wheelchair around in the room. The resident did not have a roommate. There was no decorations on the walls and the Resident had a partially deflated balloon that was situated lower than the bedside table and between the wall and bedside table, not readily visible. An observation was made of closed coloring books piled on the overbed table. When queried if the Resident liked to color, the Resident reported she liked to cook but did not elaborate further on the conversation or on inquiries regarding cooking. Staff came in and assisted resident to walk from the wheelchair to the doorway. The Resident had a Wander Guard bracelet that was fastened to her ankle. On [DATE] at 4:05 PM, Resident #15 was observed in their wheelchair in the hallway. Staff was nearby as Resident. Resident was propelling herself in the wheelchair down the hallway. A review of the Facility Reported Incidents (FRI) for Resident #15 revealed the Resident had eloped from the facility unattended by staff on [DATE], [DATE] and [DATE]. A review, of the Investigation Report dated [DATE], of Resident #15's elopement, revealed the Incident Summary: Resident eloped out of the building, resident was said to have been seen walking out of the building and in fact walked out of the building without staff present. However, staff were right outside and were able escort resident into the building. Investigation Summary/Actions Taken: Resident was seen hovering by facility door and was told by (Maintenance) she was not go out of the door for safety. Resident CNA went to get items for other residents. Wander Guard alarm was set off, staff immediately went outside triggered door. Facility staff found resident half clothed by trash can. Resident continued to attempt leaving facility thereafter and became aggressive with staff, resident shattered window in effort to vacate. Resident was sent to hospital for psych. A review, of Incident/Unusual Occurrence documentation in the investigation report dated [DATE] at 6:47 PM, revealed, RN Unit Manager was in main hall nursing station charting when the Wander Guard alarm went off. Upon assessment, it appeared that the south hall alarm had been breached. A code search was called to the hallway, RN observed resident's room which was vacant but there was a window visitor present. RN exited through the south hall exit door and found the resident with her window visitor on the outside of her room who is her significant other (Name). It appeared that the resident had exited the building in an attempt to meet with him. She had no visible injuries noted . Resident was escorted by her visitor back inside the building via the south hall exit door . A review, of the Investigation Summary, dated [DATE], of Resident #15's elopement, revealed, .Description of Incident: On [DATE] (2021), (Resident #15's name) was reported to have went outside and considered an elopement. Staff report they were either on break or giving care to other residents during this time. Resident was found outside, shortly after wander alert system rang. Results of Investigation . Abuse coordinator reviewed documentation provided in incident and accident report, along with written statements with no further questions upon review. Cameras were reviewed, in which resident was seen wheeling to outside courtyard where she is taken outside, resident is able to make needs known at times although impaired. Resident questioned on [DATE] about leaving the facility and if she was trying to go home, resident responded What with apparent confusion. Staff were viewed responding appropriately to elopement alarm system once triggered upon resident returning into facility. Resident was retrieve from (Nurse N). Facility alarm system is not as audible on east or south. EVS (Maintenance) will contact (alarm system company) to place additional speakers for elopement risk. Resident remains safe at this time . A review of the witness statements in the investigation report revealed the following: -Dated [DATE], CNA VV wrote, I did not witness (Resident #15) exit the facility during my shift from 2p to 10:30 pm. I was on South from 230 pm during her elopement until 1030 pm. -Dated [DATE], CNA UU wrote, The last time I saw (Resident #15) she was up in her chair rolling around, I let (Nurse N) know I was going to smoke and (CNA XX) was on the Hall. (Resident #15) got out the side smoke door and (Nurse N) let me know. She was then back to her room and laid in the bed. -Dated [DATE], CNA WW wrote, I told my nurse around 5 I was going to get food. When I arrived back I was told that (Resident #15) got out the building last time I seen (Resident #15) before I left she was in the building in bed. -Not dated, CNA XX wrote, At the time the resident in 38 A got outside I was helping the resident in 32 cut up his food and then I fed the resident in 34 A. There was a lack of interviews or written statements from the staff that were assigned to the North Hall, Nurse A and CNA SS or the Dietary Aide YY that was passing trays at the time that Resident #15 had eloped from the building. A review of Resident #15's incident report, dated [DATE] at 6:39 PM, written by Nurse N, revealed, .Incident Description: Nursing Description: writer was passing medications on south hall when I went to walk towards the main hall nurses station. I heard the alarm going off and I checked to see where it was coming from, noticing the residents wheelchair at the exit door empty. I immediately went that way when she was coming inside from outside. No injuries observed, called nurse manager, left voicemail with daughter, doc aware . On [DATE] at 2:30 PM, an observation was made of the door alarms and Wander Guard alarm system with Maintenance Staff HH. The West exit door, where Resident #15 had exited the building on [DATE] was opened by Maintenance HH. The door had to be pushed on for approximately 15 seconds and was noted to have an alarm once the door was pushed on and then alarmed louder and consistent once the door was opened. The Wander Guard system alarmed after the doorway was breeched with the testing Wander Guard that was like the Wander Guard on Resident #15's ankle. The Maintenance Staff reported the Mag lock alarm sounds when the door is opened and continues to sound until the door is shut off using the card the staff had to disarm/shut off the alarm and the Wander Guard system had a keypad with a code to shut off the alarm that was positioned on the wall near the door. The door alarm was loud at the door and the Wander Guard alarm was not as loud but could be heard. Maintenance Staff reported that the Wander Guard alarm sounded throughout the building and there was a code pad that alarmed at the North Hall Nurses Station and one on the Main Hall Nurses Station. The code pad indicated which door was breeched with the Wander Guard. The Maintenance Staff reported the blue strobe lights also went off in the hallways once the Wander Guard system was tripped after passing through the threshold of the exit doors. An observation was made of the flashing blue lights and alarms sounding on each exit door that was tested . The Maintenance Staff was queried regarding the activity of Resident #15 after elopement out the West exit door on [DATE] and reported there was no camera footage outside and once the door was closed the Resident could not be visualized. The West exit door opened up to an area that had a grassy area, sidewalks and a gazebo. Walking west from the building would lead to the interstate highway that was a busy thorough fare that passed through town and just north of the facility was a railroad crossing. When queried regarding which door Resident #15 had exited when eloped on [DATE], the Maintenance Staff indicated the South Hall exit door. An observation was made of the outside area of the South hall with the dumpster's approximately 25 yards from the door. On [DATE] at 3:30 PM, an interview was conducted with the Administrator (NHA) regarding Resident #15's elopement from the facility on [DATE] and the investigation report information. The NHA reported that Nurse N had said she couldn't hear the alarm and had not responded immediately and stated, there are strobe lights also when the Wander Guard is activated, both a visual and audible alarm. The NHA stated, Even with the barriers (doors closed) you can hear the alarm and see the strobe light. It wasn't the system failure, it was the staff. The NHA reported one CNA had gone out for break and had told the Nurse that she was going, another CNA had gone out for a smoke break that had not informed the Nurse that she was going and stated, She (Nurse N) did not know. She would not let two go at the same time. The NHA reported that another CNA was feeding residents and did not respond to the alarm. The NHA reported having two nurses on at the time Resident #15 had eloped out of the facility and that staff in the building had not responded timely to the door alarm from the video footage from security cameras that had been reviewed. On [DATE] at 3:50 PM, video coverage was viewed with Maintenance Staff HH, of the date and time Resident #15 had eloped out of the facility. The camera footage was for the date of [DATE]. At 17:07:09 (5:07 and 9 seconds PM) that showed Resident #15 at the South exit door on the Main Hall of the facility. The Resident stood up from her wheelchair and at 17:07:37 was seen pushing on the door to open it. The Maintenance Staff was queried regarding the door alarm and Wander Guard alarm and indicated the door alarm beeps while pressing on the door and has a 15 second delay before releasing, opening and alarming. The door was equipped with a mag lock (magnetic device on the door to allow exit through the door after a 15 minute delay often installed for emergency exit purposes). The Maintenance Staff indicated that the Wander Guard alarm may not have gone off until the Resident actually breeched the doorway but reported that sometimes it goes off when they get near. At 17:07:47, of the camera footage, showed Resident #15 had opened the door and stepped outside and the door closed. A review of the camera footage of the hallway, at that time, revealed no staff responded to the door alarm (mag lock) system or Wander Guard alarm. The Maintenance Staff indicated that the mag lock would sound a continuous alarm at the door that was breeched until staff shut off the alarm by swiping a badge and the Wander Guard alarm is turned off by the keypad near the door. Other camera footage throughout the facility was observed at the time the door and Wander Guard alarms were sounding when Resident #15 eloped from the building and was outside, unsupervised and not observed by staff. There was no camera footage of the area outside and Resident #15 was no longer seen after going through the door and the door closing behind her on the video footage. Other camera footage within the facility was observed with Maintenance Staff. Maintenance Staff HH identified a male staff member, dietary aide, passing food trays in the East Hall and was observed to not respond to the alarms. Nurse N was observed in the South Hall at the treatment/medication cart and seen going into a Resident's room, came back out of the room and back to the cart and into another Resident's room. The Maintenance Staff was queried if the alarm had been sounding and reported there was no audible to the footage but pointed to a strobe on the camera footage that was seen blinking in the South Hall where Nurse N was seen in the hallway. A review of the North Hall had staff sitting at the Nurses Station and was observed to not respond to the alarm. No staff from the North Hall had responded to the alarm. When queried if the alarm was sounding in the North Hall, the Maintenance Staff reported the alarm box that identified what door Resident #15 had exited was behind the Staff sitting at the Nurses Station and reported a strobe light was also in the North Hall and both would have been alarming. Further review of the camera footage identified Nurse N going to the four corners (junction of the halls) at 17:11:46, went to the Nurses Station on Main came out and checked the front door at 17:12:06, returned to the Nurses Station, observed to leave the Nurses Station on Main Hall at 17:13:36 and headed to the empty wheelchair positioned at the exit door where Resident #15 had exited the building. At 17:13:57, the West Exit door was seen opening and Resident #15 was inside the doorway as Nurse N approached the empty wheelchair. Nurse N disabled the alarm at 17:14:15, no other staff was observed to have responded to the alarms in the Main Hall. On [DATE] at 11:30 AM, an interview was conducted with Nurse A regarding the Wander Guard alarm. The Nurse indicated the alarm is loud on the North Hall and stated, I can definitely hear it. The Nurse reported that a light flashes blue in the hallway and the alarm sounds at the Nurse's Station with the box at the Nurse's Station that reads which door was opened. When queried if she could hear the alarm when in a Resident's room, the Nurse stated, I think I can. When queried what the procedure was when an alarm goes off, the Nurse stated, Stop what you are doing, look at the alarm (box at Nurse's Station), go to the door, go out the door to look. When queried who is responsible to respond to door alarms and Wander Guard alarms, the Nurse stated, Everyone is responsible to respond to the door, CNA, Nurse, everyone, anyone on site. On [DATE] at 1:38 PM, video footage for [DATE] at the time of Resident #15's elopement was reviewed again with Maintenance HH. A review of the Staff at the North Hall Nurse's Station around 17:11 (5:11 PM) was reviewed and identified by Maintenance HH as Nurse A who was sitting at the Nurses Station with her back to the box on the wall when the alarms were sounding after Resident #15 had eloped from the facility. The Nurse was observed to not check the alarm box or respond by leaving the Nurse's Station. On [DATE] at 2:27 PM, an interview was conducted with Nurse A regarding Resident #15's elopement from the facility on [DATE]. The Nurse reported she had worked that day. The Staff Schedule was reviewed and had Nurse A assigned for the Main Hall and Nurse N assigned to the North Hall. Nurse A reported that she had switched assignments and that she had worked the North Hall. When queried what the Nurse was doing at the time the Wander Guard had sounded at 5:07 PM, the Nurse stated, I don't know what I was doing. I might have heard the alarm. When queried why they had not responded to the alarm, the Nurse reported she did not know what she did and stated, I don't remember from that long ago, and did not remember if she had checked the alarm box at the Nurse's Station or responded to check the door that was alarming. The Nurse stated, I did a head count on Sunday. I remember that. Everyone was there on my unit, but did not remember at what time or had documented the count of the Residents. On [DATE] at 9:00 AM, an interview was conducted with Nurse N regarding Resident #15's elopement from the building on [DATE]. When queried regarding the elopement, Nurse N reported she was passing medication on South Hall which was the observation unit. The Nurse reported having the assignment of the South, Main and East Residents that included Resident #15. The Nurse reported that on the South hall it was difficult to hear the alarm and didn't remember the flashing blue strobe light that was on the South Hall. The Nurse indicated after she left the South Hall, she had heard the alarm and went to the Main Nurses Station and looked at the Wander Guard alarm pad on the wall and stated, The box said break room, then came back out and seen the wheelchair, went towards the wheelchair and Resident #15 was letting herself back into the West exit door. The Nurse was queried regarding the CNA breaks and reported CNA WW had told her she was going on break. When queried regarding CNA UU going on a smoke break, the Nurse stated, She didn't tell me, and reported the Staff did not have a set time for breaks and that they should sign out and tell the Nurse they are going. When queried regarding the alarms once she arrived at Resident #15 coming back into the facility, the Nurse reported that both the door alarm and the Wander Guard had been alarming and she had turned both of the alarms off. When queried who is responsible for responding to the alarms, the Nurse stated, Everyone is to respond to alarms. When queried if alarms could be heard on the North Hall, the Nurse reported that on the North Hall the Wander Guard was able to be heard and that strobe lights were in the hallways also. On [DATE] at 10:27 AM, an interview was conducted with CNA XX. The CNA reported she had not been scheduled to work on [DATE] but there was a call in and she had come in to work. When queried what she was doing at the time Resident #15 had eloped from the facility, the CNA stated, When the alarm went off I was feeding (Resident's name) and I was helping (Resident's name) cut up his meal, and reported she was getting ready to do a check and change and had gone to the supply room for needed items. CNA XX was aware that CNA WW was going on dinner break but stated, The CNA said she was getting ready for break, but I didn't know she actually left. The CNA indicated she was not told the other CNA had gone on a smoke break and stated, Everyone can't go on break at the same time. I was the only aide on the floor. I can't feed and watch (Resident #15). When queried if she had responded to the alarm, the CNA reported she had not and stated, It was partially my fault but there was 3 aides and a nurse. The CNA reported there were two alarms and one was flashing and had seen the flashing strobe light and stated, I was expecting another aide or the Nurse to go and get her. On [DATE] at 10:57 AM, an interview was conducted with CNA UU who was assigned care of Resident #15 on [DATE]. CNA UU reported that Resident #15 tries to get out a lot. You have to keep a close eye on her. When queried what happened during the time Resident #15 had eloped from the building, the CNA reported she had not been in the building when the alarms had sounded and had gone out for a smoke break. The CNA reported that she had let Nurse N know that she was going out and stated, I had gone out right around dinner time. The CNA reported that trays get passed around 4:45 PM to 5:30 PM. When queried if trays were being passed at the time she had taken the smoke break, the CNA stated, not yet I don't believe. When queried if she knew CNA WW was taking her dinner break, the CNA stated, I knew she was going, I just didn't know when exactly. The CNA reported that the other CNA was aware she was going on a smoke break and stated, She didn't wait for me to come back. When I came back in she was already gone. The CNA indicated she was not in the building when Resident #15 had eloped from the facility. On [DATE] at 1:48 PM, an interview was conducted with CNA WW regarding Resident #15's elopement on [DATE]. The CNA reported she let Nurse N know she was going on break. When queried regarding break during meal times the CNA reported she was a float and helping out and there was enough on the floor to help with meal pass and assist Residents. The CNA was queried if CNA UU had let them know they were going on a smoke break and reported she did not know the CNA was going on break and stated, I did not see her prior to telling my Nurse and the other CNA that I was going on break. I was never told she was going. The CNA indicated she had checked on the Residents prior to leaving and Resident #15 was in bed watching TV, she had left about 5:00 PM and had let the Nurse know she was leaving. The CNA was queried who is responsible for responding to a door alarm and stated, Everyone. On [DATE] at 3:20 PM, an interview was conducted with CNA VV regarding Resident #15's elopement on [DATE]. When queried regarding her assignment on [DATE], the CNA reported she was the CNA for the South Hall and was working as the only CNA in that area which was the observation unit where Residents are under investigation for Covid-19 infection. When queried what she was doing with the Wander Guard alarm sounded, the CNA reported she was in a room doing resident care, had come out of the room and stood in the hallway and stated, I did not leave the floor due to me the only one (CNA) there on the floor. The CNA was queried if they could hear the alarm and reported she did hear the alarm and that was why she came out of the resident's room and stated, The Nurse went to the other side (of the building) to look. The elopement policy was requested and reviewed. The policy titled, Elopements, reviewed ,d+[DATE], lacked directive for staff to respond to the Wander Guard system or door alarms. Upon review of the facility Emergency Procedures and Disaster Preparedness Manual, a policy titled, Responding to Activated Door Alarm, reviewed [DATE], revealed, 1. Purpose: To ensure the safety of our residents, all exterior doors are alarmed. In the event that an alarm is activated, all employees are expected to respond as appropriate. 2. Policy: When an audible door alarm sounds, the procedures outlined in this document must be performed. 3. Procedure: Respond to the door when alarm sounds and determine if a resident has exited the building. If a resident is outside the building, assist the resident back inside. If help is needed, page for assistance. Leave the alarm sounding until resident is back inside. Close the door and reset the alarm. If the reason for the alarm activation is unknown, check the immediate area outside the door. Notify the Administrative Person in Charge. The Administrative Person in Charge will page for CNA's to check their area and account for those residents under their care. Administrative staff will review video recording to determine cause of the alarm. CNA's will do a head count of their assigned residents and report results to Charge Nurse. Charge Nurses will notify the Administrative Person in Charge of results of head count. If a resident is determined to be missing, refer to the process in the procedure Missing Residents. A review of the facility policy, obtained from the facility on [DATE], titled, Responding to Activated Door Alarm and Missing Resident, reviewed and revised on [DATE], revealed, 1. Purpose: To ensure the safety of our residents, all exterior doors are alarmed. In the event that an alarm is activated, all employees are expected to respond as appropriate. 2. Policy: When an audible door alarm sounds and strobe lights activate, the procedures outlined in this document must be performed. 3. Procedure: 1. All staff must check exit doors close by, designated staff members will check security system for triggered door. Alarm will continue to sound if door is ajar, and Dr. Walker will be paged. If resident is near triggered door, alarm will be silenced. The following steps will occur for staff once Dr. Walker is paged: a. Leave the alarm sounding until resident is back inside and every resident is accounted for. b. Administrative staff or charge nurse will check the perimeter of building outside. a. CNA's will do a head count of their assigned residents and report results to Charge Nurse. b. Charge Nurses will notify the Administrative Person in Charge of results of head count. c. Administrative staff will review video recording to determine cause of the alarm. d. Once resident is located, staff will close a jar door and reset alarm system. e. Responsible nurse will call Administrator and DON outside of business hours for notification and further steps. If a resident is determined to be missing, refer to the process in the procedure Missing Residents. The Facility Abatement Plan for the Immediate Jeopardy at F-689 was received and approved on [DATE] with a removal date on [DATE]. A tour of the facility on [DATE] to confirm enactment of the Abatement plan included the following: Element #1 Resident was seen by psychologist on [DATE] with no noted concerns and follow up visit with the facility Social Worker. Resident seen by PA psychiatrist on [DATE] with no noted medication changes. Last documented behavior for exit seeking on [DATE] with no adverse outcomes. Resident placed on 1:1 (one staff for one Resident) for first and second shift on [DATE] for safety. [DATE] Resident care planned and remains 1:1 for exit seeking behavior and safety at this time. IDT (Inter-disciplinary Team) will review resident behaviors and interventions for four weeks. Resident will be assessed for effectiveness of intervention. IDT plans to titrate 1:1 when indicated as necessary down to frequent checks. Element #2 IDT completed house elopement risk assessment on [DATE]. The house assessment identified four prior elopement risk residents. IDT reviewed care plans and interventions for effectiveness on [DATE]. Elopement risk assessments are to be completed quarterly and or as needed by the nursing department. [DATE] DON altered elopement risk assessment for additional identification of wandering in and outside of facility. Resident care plans and interventions reviewed for accuracy with no noted changes. Resident remains at risk. Elopement binders updated for nurses' stations on [DATE] by administrator, social service manager will ensure binders are accurate for every nurse with every resident identified as elopement risk on [DATE]. Binders remain in a visualized area by behavior charting book for floor staff. Element #3 [DATE] Facility administrator reported elopement to the State of Michigan and began investigation of elopement. Facility administrator reviewed cameras, completed interview with staff member present during the time of the elopement and implemented appropriate interventions as followed: [DATE] Resident #15 remained with activities during the 1st shift from 8 am-5 pm or later, for facilitated activities according to resident interest. Resident interest changes frequently. [DATE] Education provided to all staff responsible for elopement on [DATE]. [DATE] Nurse and CNA staff associated with inappropriate break times, received education regarding handbook and scheduled breaks. It is not permissible for two CNA staff members to break at the same time, CNA must seek approved break times by designated charge nurse to ensure compliance is maintained. Nurses are not to break at the same time. Maintenance continues to complete door alarm checks for any barriers daily. Nursing staff continues to monitor for wander guard placement and functionality (battery efficiency) as ordered twice daily. [DATE] IDT reviewed Abuse &Neglect, missing resident, alarm activation and elopement policy. [DATE] Administrator queried floor staff on alarm system and if they could hear the alarm, majority of staff asked stated they were not able to hear main and east alarm on south. Strobe lights remain intact, staff can see lighting. [DATE] Maintenance Director realized strobe light was inactive on east hall during wander guard checks. [DATE] Maintenance Director completed assessment on alarm systems, asserting you can hear the alarm on south when fire doors are opened. Maintenance Director facilitated additional speakers on south where alarm system was alleged to not be as audible and replace inactive strobe light. All remaining strobe lights remain active and alarm system is active with no additional barriers currently. Exit doors are identified as advised by life safety regulatory compliance. Facility maps are located on every hall, with designated of where they are at currently. [DATE] Administrator and Assistant Maintenance Director completed elopement drill on 2nd shift staff that failed to respond appropriately to alarm system. Administrator met with all staff 1:1 to provide education on abuse and neglect, responding to alarm, redirecting elopement risk residents, breaks and possible outcomes for failing to do so to protect resident safety. [DATE] All facility staff received education on Abuse& Neglect, Elopement policy and responding to activation of alarm system. [DATE] Maintenance Director facilitated east strobe light replacement, with additional speaker on south on [DATE]. [DATE] Administrator merged all three policies to reflect as one. [DATE] IDT completed root cause analysis during risk meeting with physician, regarding Resident #15 for safety and review of behaviors for resident as additional follow up. House Elopement risk assessment completed, identifying four residents with appropriate interventions at this time. Residents identified were prior elopement risk. Resident #15's 1:1 remains intact

Based on observation, interview and record review, the facility failed to ensure appropriate interventions were in place and supervision was provided to prevent a fall with injury for one resident (Resident #59) of six residents reviewed for falls, resulting in Resident #59 falling seven times with hospitalization twice for head injuries and a laceration. Findings Include: Resident #59: On 1/13/21 at 3:30 PM, during a tour of the facility, Resident #59 was observed sitting in a wheelchair in the doorway to his room on the Covid-19 Observation Monitoring unit and staff were talking to him from the hallway. 1/13/21 at 6:00 PM, Resident #59 was observed sitting in a wheelchair in the hallway eating dinner. CNA D was asked why the resident was eating in the hallway on the Covid Observation Unit and said the resident had fallen and needed to be watched, because it wasn't his first fall. The CNA said there were 2 aides on the Covid Observation/Monitoring unit for approximately 12 residents. All were in Transmission-Based Precautions and the Nurse was also working on 2 other units. The unit was observed to have several residents with behaviors including, attempting to transfer themselves without assistance. At 6:10 PM on the same day 1/13/21, the resident's roommate said he returned from an appointment and couldn't open the room door because the resident had fallen and was lying behind it. On 1/14/21 at 12:21 PM, Resident #59 was observed sitting in his wheelchair in his room fidgeting with a pair of sweatpants that he was holding in the air. A review of the Face Sheet, progress notes and assessments indicated Resident #59 was admitted to the facility on [DATE] and most recently readmitted on [DATE] with Diagnoses: [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated severe cognitive loss. A review of the progress notes indicated Resident #59 had experienced 7 falls since 12/27/20: 12/27/20, 1/1/21, 1/5/21, 1/9/21, 1/12/21 and twice on 1/13/21. The resident's room was located on the Covid-19 Observation Monitoring unit secondary to hospitalization s for injuries following falls on 1/5/21, 1/9/21 and 1/12/21. A summary of each fall follows: 12/27/20 at 5:00 AM- . Resident was laying prone in between the two beds on the floor. Resident was also incontinent of urine, stated I fell out the wrong side of bed. Immediate Action Taken: included, . Patient education. Injury: Right knee front . complained of pain Incontinent, Gait imbalance, Weakness . 1/1/21 at 4:58 PM: Resident observed rolling out of his bed to reach for his wheelchair. No injuries . Immediate Action Taken: Educated on using his call light . Predisposing Physiological Factors: Confused, Gait imbalance, Impaired Memory . Refused to ask for assistance and refused to ask for help. *1/5/21 at 1:35 PM: Observed resident on floor next to bed. Resident stated he fell out of bed and hit his head . Immediate Action Taken: Resident transported to ER for further evaluation . Predisposing Physiological Factors: Current UTI (urinary tract infection), Impaired Memory . *1/9/21 at 2:30 AM: . called into resident's room by CNA on duty stating he fell out of his wheelchair. He was laying on his right side parallel between the two beds with his head towards the window. There was blood on the ground from a deep cut under his eyebrow. The resident stated, I was trying to pick my razor up off the floor, then boom Wound was deep and located under eyebrow and above eye . Resident taken to hospital: Yes . Predisposing Physiological Factors: Drowsy, Incontinent, Weakness . 1/12/21 at 1:05 PM: Found resident sitting on floor next to bed. Resident slid out of wheelchair while trying to adjust himself in wheelchair . Immediate action taken: included assisted into wheelchair . No injuries . Predisposing Physiological Factors: Confused, Gait Imbalance, Impaired Memory, Weakness . 1/13/21 at 4:45 PM: Resident was self- transferring to the bathroom and was observed behind bedroom door. Resident Description: Unable to state, poor historian . Immediate Action Taken: included, Resident placed in wheelchair . No injuries . Level of Consciousness: Lethargic (Drowsy) . 1/13/21 at 9:40 PM: . patient was on floor upon entering room, noted patient sitting upwards on floor with back against wall, legs stretched outwards . Stated trying to get into bed, nurse asked why he didn't use call light for help and patient stated I couldn't find it. Call light was on bed . Immediate Action Taken: included, Patient assisted to bed . put call light in reach . Confused . A review of the progress notes provided the following: 1/13/2021 at 5:06 PM, Resident was self-transferring to the bathroom and was observed on the floor. 1/12/2021 at 1:11 PM, Found resident on floor next to bed . 1/11/21 at 8:19 PM, . noted a change in resident since he fell . Resident does not speak as clearly as he did . 1/9/2021 at 2:57 AM, . called into resident's room by CNA . stating he fell out of his wheelchair . There was blood on the ground from a deep cut under his eyebrow . had drool coming from his mouth and slurred speech . EMS were called for emergency transport . 1/8/2021 at 2:28 PM, Resident arrived via EMS from hospital . 1/5/2021 at 1:35 PM, Found resident on floor next to bed . stated he rolled out bed and hit his head . is more lethargic and is unable to answer simple questions . which is abnormal rom resident's baseline. Called ER to give report . 1/1/2021 at 4:42 PM, . I was in the room giving medication to a resident and resident leaned over and rolled out of bed . 12/30/2020 at 12:25 AM, Resident is confused and disoriented. Speech is slurred . family asked if resident had Dementia due to new onset memory issues . 12/27/2020 at 7:16 AM, . called into room. Resident was laying prone in between the two beds on the floor . There was no progress note related to the resident's fall on 1/13/2021 at 9:40 PM. A review of the Care Plans for Resident #59 identified a Care Plan titled, I am at risk for falls related to Gait/Balance problems, unaware of safety needs . non-compliant with transfer status, dated 12/17/2020 and updated 1/15/2021 with Interventions: 12/17/2020: There were 3 interventions- Anticipate and meet the resident's needs; Be sure the resident's call light is within reach . The resident needs prompt response to all requests for assistance; review information on past falls and attempt to determine root cause . 12/30/2020: 2 interventions were added- PT (physical therapy) evaluate and treat as ordered or prn; the CNA said there were 2 aides on the Covid Observation/Monitoring unit for approximately 12 residents. All were in Transmission-Based Precautions and the Nurse was also working on 2 other units. The resident needs a safe environment with Bedside mats on the floor of each side of his bed (cancelled the same day). 1/4/2021: 1 intervention added- Encourage me to ask for assistance. 1/6/2021: 1 intervention added- Check on me frequently. 1/11/2021: 1 intervention added- Follow facility Fall protocol. 1/13/2021: 2 interventions added- Encourage the resident to participate in activities . such as therapy services .; Dycem to wheelchair. 1/14/2021: 1 intervention- Offer to assist me with toileting frequently and prn (as needed). The resident's Fall Care Plan had few interventions, and it not until the resident fell and was transferred to the hospital with a head and face injury (1/5/2021) was an intervention added to Check on me frequently; After Resident #59 fell again on 1/9/2021 and was transferred to the hospital with a head injury, the intervention was added to follow the facility Fall protocol; an intervention Offer to assist me with toileting frequently and prn, was not initiated until the resident had fallen 7 times. On multiple occasions, including the first fall on 12/27/20, Resident #59 was incontinent of urine or attempting to take himself to the bathroom. A review of the facility Staffing Schedules dated January 2nd, 2021 to January 13th 2021, indicated there were multiple instances of 1 CNA scheduled for the South Hall/Covid Observation unit and 1 Nurse. The Nurse often was assigned to simultaneously care for residents on 2 additional units. The Covid Observation unit was a closed unit with no way for stay to observe the residents from the hallway when outside the door. On 1/15/21at 12:32 PM, during an interview with Assistant Director of Nursing (ADON) M, she was asked about Resident #59's recent hospitalization s and stated, He fell and was lethargic and I felt it was appropriate to send him out. Then he fell again and that is when he hit his head and had to have stitches above his eye. The ADON was asked about the intervention Check on me frequently. She said the stay tried to do that while working on the Observation unit. When asked where it was documented that staff were checking the resident frequently, she said it wasn't. An interview with the Director of Nursing on 1/21/21 at 8:49 AM, related to Resident #59's falls provided, He is very impulsive. Staff have educated him. That is why his care Plan was updated to say check on him frequently. With the 2 staff that are back there. They do Rounding. Answer his call light. On 1/21/21 at 8:50 AM, an interview with the Director of Nursing and Administrator related to the Baseline Care Plan initiated on admission 12/15/20 and not completed until 1/2/21. The DON confirmed the Baseline Care Plan for Resident #59 was not completed until 18 days after admission. By the time it was completed the resident had fallen twice. Care Plan was not completed and provided to the resident within 48 hours of admission. The resident fell twice during this timeframe: 12/27/20 and 1/1/21 and may have benefited from the Care Plans interventions, including Fall Prevention. On 1/20/21 at 4:12 PM, Confidential Person Y was interviewed and asked about Resident #59's falls and stated, When I first found out he was there, he was walking, and one night I guess he wanted to go home. One night I got a call and they said he had to go out because he fell and had to have stitches. The stitches was the second time they called me but not before that. I haven't heard what they are doing to prevent him from falling. I guess they leave him in his chair until he falls asleep and falls out of the chair. He told me they used to walk him and now they don't. He told me, They just leave me sitting here all day. They don't answer when I call them. They ignore me. When he first got there he was walking, but by hitting your head that can knock you off balance too. One time they found him unconscious. He was unresponsive. They kept him a couple of days and then he went back and got the stitches. He told me he fell before he got the stitches. At the hospital they did exercises with him. He enjoyed it. I'm not for sure what was going on. In the hospital he had someone sitting with him watching him to get him what he needs. A review of the facility policy titled, Falls- Clinical Protocol, dated Revised September 2012 and Reviewed 09/2020 revealed, . Staff will ask the resident and the caregiver or family about a history of falling . The staff will document risk factors for falling . lightheadedness or dizziness, multiple medications, gait and balance disorders, cognitive impairment, weakness, confusion . The staff will evaluate and document falls that occur while the individual is in the facility . many categories of medications and especially combinations of medications in several of those categories, increase the risk of falling . staff will identify pertinent interventions to try to prevent subsequent falls . The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling .

This Citation has two Deficient Practice Statements. This Citation Pertains to Intake Number MI 259. DPS #1: Based on observation, interview and record review, the facility failed to provide acceptable quality of care in accordance with professional standards of practice and the resident's care plan for one resident (Resident #103), by its failure to maintain an operable emergency electrical power system adequate to ensure electric power to life support systems in the event of a power outage. Resident #103 had a [MEDICAL CONDITION] (trach) that required continuous oxygenation and frequent intermittent suctioning of secretions that could clog [MEDICAL CONDITION] they were not cleared, which could lead to serious harm, injury or death. On [DATE] the facility experienced an electrical power outage from 12:30 AM to 10:30 AM. The emergency generator activated, but only enabled power to emergency lighting, fire alarms and sprinklers and emergency outlet/red plugs; there was only one identified emergency outlet in the building on the North Hall. There was no emergency outlet (red plug) near Resident #,[DATE]'s room on the Main Hall. The back-up diesel generator that was supposed to enable full power to the building did not activate. The nurse transferred Resident #103 to the hospital due to his need for suctioning of oral secretions from [MEDICAL CONDITION] a higher dose of continuous oxygen. The facility was not able to care for him without electrical power in or near his room. Immediate Jeopardy: The Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was identified on [DATE]. The Administrator was notified on [DATE] of the Immediate Jeopardy that began on [DATE]. The IJ Abatement (Removal) Plan was approved on [DATE] with a Removal Date of [DATE]. Findings Include: On [DATE] at 1:30 PM, Resident #103 was observed lying in bed, awake. Nodded, mouthed words, and motioned when spoken to. He was wearing [MEDICAL CONDITION] over [MEDICAL CONDITION] and oxygen was running at 5 liters (L) a minute. A feeding pump was running at the bedside to infuse enteral feeding via a stomach (PEG) tube. A suction machine was on a stand in the room. A record review indicated Resident #103 was initially admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had a memory problem and needed assistance with all care. On [DATE] Resident #103 transferred to the hospital after he was found in his room with [MEDICAL CONDITION] out and bleeding from the mouth. He returned on [DATE]. He was transferred to the hospital 3 times previously; twice [MEDICAL CONDITION] dislodgement ([DATE] and [DATE]) and once on [DATE] when the facility did not have electrical power to adequately perform tracheal suctioning to maintain the resident's airway. The resident returned to the facility after the electrical power was reinstated. In total, Resident #103 was transferred to the hospital four times related to an unstable airway. A review of Resident #103's Care Plan titled, [MEDICAL CONDITION] related to impaired breathing mechanics, injury . date initiated [DATE] with Interventions: Suction as necessary, dated [DATE], O2 at 5 liters [MEDICAL CONDITION] Continuous dated [DATE], .6 liters per minute O2 via concentrator . dated [DATE]. There was a discrepancy between the two interventions for oxygen. A review of the Physician order [REDACTED]. There were orders for monitoring the resident's respiratory condition, but not an order for [REDACTED].>Further review of the Nurses notes, assessments and scanned documents into the electronic medical record indicated there was no documentation on [DATE] from 12:30 AM through 7:30 AM related to transfer of Resident #103 to the hospital or why he went to the hospital during the power outage. An interview with the Director of Nursing (DON) on [DATE] at 4:52 PM related to the power outage revealed the facility transferred Resident #103 to the hospital to provide respiratory care and maintenance of the trach. The DON said the facility did not have a red emergency plug/outlet in the resident's room at the time of the power outage on [DATE] and there was only one identified emergency red plug/outlet in the building. The facility now has additional working outlets, because there was an emergency plug in the hallway outside the resident's room (#103) on the Main hallway, but it was white instead of red and the staff did not know it was an emergency plug. The DON stated, They changed it (to red) to show it was an emergency plug. An interview with Maintenance Director C on [DATE] at 9:55 AM related to the power outage on [DATE] from 12:30 AM to 10:30 AM revealed, We got a call from the facility that there wasn't any power. (Maintenance Tech Y) came in within an hour. Emergency power was on. The other generator is manual and only maintenance fires that up. It didn't start. It was turning and turning, something with the starter. (The mechanical repair company) repaired it that morning. The Maintenance Director was asked about the emergency red plugs/outlets and stated, There are 4 now. One in each hallway, Main, South, East and North. Being now that we have a concern, we have (a mechanical/electrical company) coming in on Monday [DATE]th, to put in a new plug in his (Resident #103's) room. Maintenance Technician Y was interviewed on [DATE] at 10:30 AM related to the power outage on [DATE], They called me at approximately 1:30 AM, I got up there immediately, a little after 2:00 AM. I made sure everything was running good on the emergency generator. We moved one resident to the North Hall from the South Hall. I got the hospital grade extension cords to ensure the equipment could be plugged into the red outlet. I was monitoring the emergency generator and we started to try to kick that over about an hour after I got here. About 2:30 AM or closer to 3:00 AM, the KW35 or Diesel (generator), it did not start. The Emergency generator powers the fire equipment, emergency ports/plugs and emergency lights. (Mechanical company) was in at about 5:30 AM and it was fixed almost immediately. They tinkered with the starter and it kicked right on. On [DATE] at 5:30 PM, during an interview with Nurse Z she said that she had transferred Resident #103 to the hospital because she couldn't suction [MEDICAL CONDITION] power. She stated, I was nursing on Main Hall. I sent one (Resident #103), he was [MEDICAL CONDITION], his oxygen concentrator went out and I hooked him up to a tank, but I couldn't suction him without electricity. I couldn't get the mucous out and couldn't stabilize him without suction. His 02 sats (oxygen saturation in the blood) were fluctuating between 89% to 92% (,[DATE]% is normal for someone with a trach) . he looked like he did not have enough oxygen. I couldn't write a note because the system (computer) was out. Only the hallway lights went on in certain areas of the building. My area (Main Hall) was black. On the other end of the building (North Hall), they had some lights and a red plug. I had to move another patient to the North that needed oxygen. She's on ,[DATE] liters and gets real bad anxiety. I moved her down there and plugged everything up in the hallway. Maintenance came in right after the power went out, but it wasn't lighting my end of the building. They called DTE, but it was going to take too long. An interview with Confidential Person W, on [DATE] revealed Resident #103 was transferred to the Hospital emergency room from the facility on [DATE], because the facility did not have any electrical power and the resident had [MEDICAL CONDITION] needed oxygen and suctioning. Confidential Person W stated, To have [MEDICAL CONDITION] that needed suctioning and the facility did not have back-up power? I don't know how they can admit patients if they can't take care of them. A review of the facility policies revealed the following: [MEDICAL CONDITION] Care Level III, dated revised [DATE] indicated The purpose of this procedure is to guide [MEDICAL CONDITION] care and the cleaning of reusable [MEDICAL CONDITION] cannulas . [MEDICAL CONDITION] care should be provided as often as needed . A suction machine . must be available at all times . Suctioning the Lower Airway (Endotracheal (ET) or [MEDICAL CONDITION]), dated revised [DATE] revealed, The purpose of this procedure is to remove secretions, maintain a patent airway and prevent infection of the lower respiratory tract . Verify that there is a physicians order for this procedure . test equipment before use. Determine if suction equipment is generating appropriate negative pressure . if oxygen saturation drops below 90 percent (or 5 percent from baseline) discontinue suctioning and reventilate and re-oxygenate the resident . Generator Operation Inspection and Testing, received on [DATE] and dated [DATE] and revised/reviewed [DATE] provided, Purpose: To develop a policy and procedure that meets or exceeds the requirement of NFPA (National Fire Protection Association) 101, NFPA 110, NFPA 99 as well as other State and Federal rules and regulations .including all appurtenant (important) components, shall be inspected weekly and shall be exercised under load monthly . Policy: Each week facility staff will inspect the Emergency Power Supply System (EPSS). This inspection will include the following . Fuel System, Oil Level, Exhaust System, Battery Electrolyte Level, Battery Charger, Electrical System General Inspection, Generator General Condition . Weekly Inspections will be conducted by Maintenance department staff and documented on the form Weekly EPSS Inspections Monthly Test, the standby generator will be tested and exercised under load monthly . Annual Load Test . This procedure involves measuring the load on the generator and adding load to reach 75% of the rated capacity of the generator . run for 90 minutes . There was no documentation that the Diesel generator was tested weekly, monthly or yearly per the policy and guidelines. And Emergency Procedure-Utility Outage, received on [DATE] and dated revised [DATE] revealed, Residents will remain safe and comfortable during a temporary loss of power . 1.) Announce CODE BLACK overhead unless electrical power is out . 9.) Ensure back-up systems (emergency generators, emergency lighting .) are available and operating as designed in accordance with requirements . Facility Abatement Plan for IJ F684 received and approved on [DATE]. A tour of the facility on [DATE] to confirm enactment of the Abatement plan included the following: 1. 1. [DATE]- The Mechanical Services company installed 3 additional emergency outlets for facility usage on the South, East and Main Halls. They are labeled and coded Red. 2. [DATE]- Education for Emergency Preparedness and use of red emergency outlets was initiated with facility nursing staff. 3. [DATE]- An emergency red outlet was installed in room [ROOM NUMBER]. This is the only emergency outlet in a resident room. 4. [DATE]- The facility developed detailed instructions for operating the generator. It is manually turned on. 2. The switch to start the generator gets turned on by pushing down to the run section. 3. When the generator runs, the switch gets put back to the idle position (off) to run continuously. 4. The fuel lever gets pushed back in to turn the diesel generator off. 5. [DATE]- The Diesel Generator will now be tested weekly and it will be documented on a Generator Log meeting appropriate guidelines 6. The facility is not admitting residents with tracheostomies until the facility is able to install more Emergency/red outlets in resident rooms. 7. The Admissions Liaison was educated regarding not admitting residents with trachs. 8. [DATE]- All Staff will be trained on Emergency Preparedness procedures related to power outages. 9. [DATE]- The Safety Committee began Quarterly Safety Drills. 10. [DATE]- The facility purchased paper progress notes for nurses to document on during a power outage. 11. [DATE]- Active Order Summary and Paper Medication Administration Records and Treatment Administration Records will be printed and place din binders assigned to each unit at the minimum of monthly for nurses to document their medication pass during a power outage. Medical Records department will upload the documents to the residents electronic charts. 12. [DATE]- All Staff began education related battery life of electrical medical devices. 13. [DATE]- All Staff began education related to placement of an extension cord on the Crash Cart and 3 additional cords in the Environmental Services office. 14. [DATE]- Audits of the processes began. This Citation Pertains to Intake# MI 521. Deficient Practice Statement #2: Based on interview and record review, the facility failed to operationalize policies and procedure and professional standard of practice to assess and monitor a resident with a change in respiratory status the included a lack of assessment of a respiratory infection with the use of antibiotics, physician notification of abnormal oxygen saturation, timely physician follow up of a change in condition and obtain and review ordered laboratory test and cat scan (CT) timely for one Resident (Resident #100) of three residents reviewed for a change in condition, resulting a in signs and symptoms of a respiratory infection to go unrecognized and untreated, a delay in treatment and Resident #100 hospitalized for [REDACTED]. Findings include: A review, of Resident #100's medical record, revealed an admission into the facility on [DATE] with a re-admission on [DATE] with [DIAGNOSES REDACTED]. The Resident had a PEG tube (percutaneous endoscopic gastrostomy- a tube into the stomach to provide a means of feeding and medication administration) and a [MEDICAL CONDITION] (a tube into the trachea to maintain an airway). A review of the Minimum Data Set assessment revealed the Resident had moderate cognitive impairment, needed limited assistance with dressing and toileting and was total dependent of one-person physical assistance with eating. A review of Resident #100's medical record revealed the following: -Date [DATE] at 5:41 AM, Progress Note, pt (patient) educated on importance [MEDICAL CONDITION]. Pt has been hesitant the last few times writer attempted to [MEDICAL CONDITION]. He states it is sore. Writer did [MEDICAL CONDITION], pt has yellow purulent drainage from trach, very strong odor. Neck slightly red around stoma. (Doctor) texted by the writer. -Dated [DATE] at 6:21 AM, Progress Note, resident has an increase of green/yellow sputum that has increased odor when he coughs. Mostly [MEDICAL CONDITION] is done, education on [MEDICAL CONDITION] when it is given, washing of hands, but he still cringes when care is given. The odor is a smell of infection. -Dated [DATE] Medication Administration Record [REDACTED]. -Dated [DATE] at 4:06 AM, orders transcribed for sputum culture, stat (immediate) chest x-ray, CMP (comprehensive metabolic panel laboratory tests) and CBC (complete blood count laboratory test) related to fever. -Dated [DATE] at 3:44 PM, Progress Note, x-ray done and read with no abnormalities. X-ray results revealed, with comparison to [DATE]th, with results of Improved RLL (right lower lobe) infiltrate. Resolving pneumonia. -Dated [DATE], sputum culture positive of Citrobacter koseri and started on antibiotic Cipro. -Dated [DATE] at 3:45 PM, Progress Note of Medical Visit Note by Physician, .Telehealth visit was completed via Skype due to the restrictions of the COVID-19 pandemic . Pt was started [MEDICATION NAME] mg on ,[DATE] for Citrobacter koseri in his sputum. CXR improved from prior one. Pt had CT of the head and neck performed by (Hospital) last week but results and recommendations are not available. Pt has lost 8.2 lbs since admission 4 months ago . Lungs rhonchi RUL (right upper lobe) -Dated [DATE] at 7:07 PM, Progress Note, Infection follow up note (complete each shift while receiving ATB (antibiotic)/Treatment . Sputum is yellow and runny when he coughs. There is odor. He [MEDICAL CONDITION] BID (twice a day) .[MEDICATION NAME] BID, bacteria in sputum. No adverse effects. -Dated [DATE] at 11:25 AM, Progress Note, Infection follow up note (complete each shift while receiving ATB (antibiotic)/Treatment) . Pt has thick light green sputum of which he as to clear his airway effectively. -Dated [DATE] at 6:30 PM, Progress Note, Infection follow up note (complete each shift while receiving ATB/Treatment) . Lungs diminished in B/L (bilateral) bases and sputum is light yellow. Thick to thin . -Dated [DATE] at 6:04 PM, Progress Note, Progress Note, Infection follow up note (complete each shift while receiving ATB/Treatment) . Sputum is yellow and thick, some odor. -Dated [DATE] at 6:26 AM, Change in Condition Evaluation, with documented change in condition of Shortness of breath and respiratory distress. Vital signs with documented heart rate of 145 beats per minute, respirations 28 per minute and SpO2 (oxygen saturation) 59%. Description of respiratory signs and symptoms, spo2 started at 54% now at 71%. -Dated [DATE], Nursing Home to hospital Transfer Form, .Additional Relevant Information: suctioned resident, thin yellow odorous secretions are coming from trach, cannula wont stay in, pulse 145, resp 28, spo2 54%, alert times 3, sent to ER (emergency room ) for eval and treat . -Dated [DATE] at 3:23 PM, Progress Note, Writer called the hospital and this resident has been admitted to the hospital. -Dated [DATE] at 11:27 AM, a fax received after the Resident had been transferred to the hospital from an appointment with Otolaryngology on [DATE] that included imaging on [DATE] of the chest, revealed, Extensive debris and mucous plugging involving the bilateral lower lung airways as above with moderate regions of airspace disease, tree-in-bud nodularity, and tiny left pleural effusion most consistent with aspiration pneumonia/infectious [DIAGNOSES REDACTED] with parenchymal bilateral lower lobe areas of atelectasis/pneumonia. This is significantly worsened especially on the right. Other patchy nodular opacities within both lungs, increased in size on the right and new on the left are likely infectious/[MEDICAL CONDITION] in etiology. -Dated [DATE] at 9:58 PM, Progress Note of an Admission Note, .Lungs with course sounds,[MEDICAL CONDITION] from T-bar [MEDICAL CONDITION] at 2 L/M (liters per minute) O2 . -Dated [DATE] at 5:17 PM, Progress Note, Pt stable,[MEDICAL CONDITION] changed and cannula replaced. Suctioned x (times)2 in the am no additional sectional (suctioning) needed, sputum light green and clear, resident advised to [MEDICAL CONDITION] on to avoid entry of bacteria . -Date [DATE] at 11:30, Progress Note, This nurse was at the med cart when a CNA (certified nursing assistant) yelled 'you need to come, he is vomiting all over'. This nurse was half way down the hall when the CNA yelled 'run, he is vomiting blood' . Suctioning, Ambu (ventilate with bag over mouth or trach) and CPR (cardio-pulmonary resuscitation) on and off until EMTs (emergency medical technician) arrived . Hospital called requesting resident paper work to be faxed-done. Questioned how resident was to be notified resident had passed. A review of the MAR for [DATE] for Resident #100 included the following: -Scheduled Suction [MEDICAL CONDITION] PRN (as needed) for secretions every day and night shift. Documented as completed twice a day from [DATE] to [DATE]. There was no documentation of the assessment of the suctioned secretions, assessment of the [MEDICAL CONDITION] site or lung sound assessment. -Scheduled [MEDICATION NAME]-[MEDICATION NAME] Solution . two times a day . with an 88% on [DATE] day shift, 89% on [DATE] day shift and night shift, 88% on [DATE] day shift, 86% on [DATE] day shift, 89% on [DATE] day shift, 86% on [DATE] day shift, 86% on day shift and 78% on [DATE] day shift. -Scheduled Respiratory Assessment Post Nebulizer TX (treatment) two times a day [MEDICAL CONDITION]. O2 sats were documented as 89% on [DATE] day shift, 89% on [DATE] day and night shift, 90% on [DATE] day shift, 90% on [DATE] day shift, 89% on [DATE] on day shift, no documentation on [DATE] day shift and 78% on [DATE] day shift. -Scheduled O2 (oxygen) at 3L (liters) via [MEDICAL CONDITION] ATC (around the clock) every day and night shift, with O2 sats of readings of 88% on [DATE] day shift, 89% on [DATE] on day and night shift, 88% on [DATE] day shift, 87% on [DATE] on day shift, 89% on [DATE] day shift and 78% on [DATE] day shift. A review of Resident #100's Emergency Department Chart, with a date of service on [DATE], included the following: -Chief Complaint: Respiratory Distress. -Progress Status: The patient is seen and evaluated in the emergency department with above complaint. Patient comes from ECF (extended care facility) with concerns of [MEDICAL CONDITION]. Patent has a [MEDICAL CONDITION] and was found to be hypoxic at 60% . Patient's chest x-ray does reveal pneumonia . Patients found to be in [MEDICAL CONDITION], antibiotics were started after blood cultures were obtained. -Clinical Impression: acute pneumonia, suspect gram negative, [MEDICAL CONDITION]. A review, of Resident #100's hospital record of the History of Present Illness (HPI), with a date of service on [DATE], included the following: -HPI (age of patient) with [MEDICAL CONDITION] due to obstructing head and [MEDICAL CONDITION] presents from ECF due to [MEDICAL CONDITION] and fever of 100.2 this morning. Patient was hypoxic down into the 60s and on arrival required significant suctioning of thick copious amounts of yellow brownish sputum with significant improvement of his oxygenation . He was being treated for [REDACTED]. However the amount of sputum is not improving and he spiked a fever this morning with [MEDICAL CONDITION] so he was sent to the hospital . -Plan of Care, Assessment: Bilateral lower lobe healthcare associated pneumonia complicated with [MEDICAL CONDITION] suspect gram-negative; [MEDICAL CONDITION] on presentation . A review, of Resident #100's medical record of the Discharge Summary, dated [DATE] included: - Hospital course: .presents to select s/p (status [REDACTED]. He was treated with IV (intravenous) antibiotics and pulmonology was consulted. Patient underwent thoracentesis for significant right sided effusion concerning for empyema and had pigtail catheter placed on ,[DATE]. Patient then underwent [MEDICATION NAME] concerning for tube feed aspiration. Tube feedings were adjusted to daytime feedings and this improved. He underwent CT lungs that shower (showed) persistent large loculated right-sided effusion and underwent thoracotomy with decortication and chest tube placement on [DATE]. [MEDICATION NAME] washing culture showed [DIAGNOSES REDACTED] resistant to [MEDICATION NAME] and susceptible to Bactrim. Patient completed 7 day course of Bactrim. Chest tube removed on [DATE]. He was doing well medically but had a difficulty time weaning from the ventilator so decision was made to pursue LTAC (long term acute care) for continued vent weaning . A review of Resident #100's physician notification and assessment of the respiratory change in condition revealed the physician was notified with the change of secretions on [DATE] but no follow up or physician orders [REDACTED]. On [DATE], Resident #100 had an oxygen saturation (O2 sat) of 89% and temperature of 99.8 degrees Fahrenheit (F) with no documentation of the physician aware of the desaturation and elevated temperature. The Resident had scheduled Tylenol 650 mg every six hours. On [DATE], orders were transcribed for laboratory test of a CBC and CMP, chest x-ray and a sputum culture. The laboratory results of the CBC and CMP were not documented in the medical record. The Resident had laboratory tests scheduled every thirty days with a start date on [DATE], for a CBC and CMP. The results for the lab test for [DATE] were not documented in the medical record. On [DATE], the result of the sputum culture was positive for Citrobacter koseri and the Resident was started on antibiotic Cipro. On [DATE], a Telehealth visit was completed, with the attending physician, with documented review of the sputum culture and chest x-ray, but did not mention a review of the laboratory tests, CBC and BMP, that had been ordered on [DATE]. The Resident had been to a follow up appoint where a CT of the head and neck was performed but results and recommendations were not available per the physician note. The facility had a lack documented communication with the hospital to obtain the results of the CT completed on [DATE], to obtain the results timely. Results were faxed to the facility on [DATE] after the Resident had been seen again by Otolaryngology on [DATE] and were in the documented progress notes from Otolaryngology following the appointment on [DATE]. A review of Resident #100's progress notes in the medical record, revealed infection follow up notes that were to be completed each shift (twice a day) while receiving antibiotic treatment. The [MEDICATION NAME] been ordered on [DATE] to continue for 10 days. The infection follow up notes had been documented once a day, on [DATE], [DATE], [DATE] and [DATE]. A review of Resident #100's oxygen (O2) saturations revealed no documentation that the physician was notified of oxygen saturations below 90% (normally SpO2 is between 90 and 100%). On [DATE], the O2 saturation was documented at 78% with a breathing treatment and 78% post breathing treatment. There was a lack of documentation of the action taken or that the physician had been notified of the low O2 saturation level. A review of the O2 Sats Summary had the documented 78% O2 saturation at 10:30 AM and the next O2 saturation of 91% at 3:03 PM, approximately four and a half hours later. There was a lack of a progress note depicting the Resident's condition or of any actions taken in that time frame. On [DATE] at 10:15 AM, an interview was conducted with the Director of Nursing (DON). A review, with the DON, was conducted of Resident #100's progress notes and medical care of the Resident with the change in condition, identified on [DATE], with yellow purulent drainage [MEDICAL CONDITION] a strong odor of infection. A review of the sputum culture order was obtained on [DATE], five days after the change in the tracheal secretions. The DON verbalized she was checking the Resident's medical record and stated, right, and indicated antibiotics were started after the culture results had been reported. The physician televisit on [DATE], eight days after the change in condition of tracheal secretions, was reviewed with the DON. When queried when follow up by the physician should take place with these concerns, the DON stated, (Physician) should have seen him that day or at least by that Monday ([DATE]). When queried regarding communication with the hospital of evaluation paperwork and CT results, the DON explained that the facility had requested the documentation on [DATE] due to the appoint was on [DATE], a Friday, and the office was closed upon the return of the Resident back to the facility, and received the documentation on [DATE]. When queried regarding the appointment on [DATE] and if there was communication regarding the CT scan and recommendations, the DON reviewed the chart and stated, I'm not seeing it, and indicated they would call the hospital and get that documentation to see what occurred. A review, of Resident #100's oxygen desaturations and lack of follow up assessments, were reviewed with the DON. The DON indicated the CNAs (certified nursing assistant) would be communicating the abnormal oxygen saturations and there should be follow up with a progress note as to why the saturation was so low, notify the physician and stated, It's a teachable moment for the nursing department. The DON was queried if the Infection Control Preventionist had been reviewing the Resident's respiratory infection. The DON indicated the Infection Control Nurse was no longer working at that time. The DON was queried regarding the infection follow up note, that was to be completed each shift, while receiving antibiotic treatment. The DON stated, I noticed there are issues with that being consistent, and indicated the processes were not in place previously but they were looking to get it in place for better monitoring. On [DATE] at 4:48 PM, an interview was conducted with the Infection Control Preventionist (ICP) Nurse B. The Nurse indicated they had started as ICP Nurse on [DATE]. The Nurse indicated she had been assigned care of Resident #100 and indicated the Resident would desat and with suctioning he would come back up. The Nurse reported the Resident needed suctioning once or twice a shift. When queried regarding documentation of suctioning, the Nurse indicated documentation would include amount, color and consistency. When queried regarding documentation for a resident receiving antibiotic therapy for a respiratory infection, the Nurse reported documentation was to include, temperature, vital signs, lung sounds, capillary refill and anything about the secretions, consistency, color, amount. The Nurse indicated a progress note for infection follow up note was to be complete each shift while the resident was receiving antibiotics. When queried regarding a Resident's response to antibiotics, when would improvement be expected. The ICP Nurse stated, You should see it in 24 to 48 hours, at least by 72 hours there should be a significant improvement. On [DATE] at 5:16 PM, Resident #100's laboratory results were reviewed with the DON. The laboratory test results for the CBC and BMP ordered on [DATE] were requested from the DON after the results had not been located in the Resident's medical record. A review of the test results obtained from the DON was reviewed with the DON. The date of the laboratory results drawn was on [DATE]. The DON indicated the results had not been available in the chart and had the results sent to the facility on [DATE]. When queried if the physician had been aware of the results with a WBC (white blood cell count) elevated at 12.74 (reference range of 4XXX,[DATE].00), the DON did not find a progress note, was unsure if the physician had reviewed the lab results and after a review of the physician note stated, There is no mention of reviewing the labs and no mention of ordering more labs. When queried regarding the date of the draw on [DATE] with an order for [REDACTED]. The DON indicated they had called the Lab and they could not find results for [DATE] and would locate the lab book to look for the requisition. On [DATE] at 10:25 AM, an interview was conducted with the DON regarding Resident #100's ordered laboratory test

This Citation Pertains to Intake Number MI 259 Based on observation, interview and record review, the facility is placed in Immediate Jeopardy due to the facilities failure to maintain an operable emergency electrical power system adequate to ensure electrical power to life support systems in the event of a power outage for 1 resident (Resident #103) with a [MEDICAL CONDITION] requiring continuous oxygenation, a need for intermittent suctioning to maintain an open airway and an electrical pump for gastric tube feedings and which could effect all 55 residents in the facility who may have electric beds, specialty air beds for pressure relief, IV pumps, [MEDICAL CONDITION] (Continuous Positive Airway Pressure) machine or [MEDICAL CONDITION] (Bilevel Positive Airway Pressure) machine both to enable maintenance of an open airway during sleep and continuous oxygen administration. The absence of power for life support systems could lead to serious injury, harm or death. On 7/10/20 at approximately 12:30 AM, the facility experienced an electrical power outage. The emergency generator activated, but only enabled power to emergency lighting, fire alarms and sprinklers and emergency outlet/red plugs; there was only 1 in the building. There was no emergency outlet (red plug) near Resident #103/84's room. The back-up diesel generator that was supposed to enable full power to the building did not activate until a mechanical repairman identified the problem 5 hours later. The nurse transferred Resident #103/84 to the hospital due to his need for suctioning of oral secretions from [MEDICAL CONDITION] a higher dose of continuous oxygen. The facility was not able to care for him without power. Immediate Jeopardy: The Immediate Jeopardy began on 7/10/20. The Immediate Jeopardy was identified on 8/10/20. The Administrator was notified on 8/10/20 of the Immediate Jeopardy that began on 7/10/20. The IJ Abatement (Removal) Plan was approved on 8/12/20 with a Removal Date of 8/12/20. Findings Include: On 7/30/20 at 1:30 PM, Resident #103 was observed lying in bed, awake. Nodded, mouthed words, and motioned when spoken to. He was wearing [MEDICAL CONDITION] over [MEDICAL CONDITION] and oxygen was running at 5 liters (L) a minute. A feeding pump was running at the bedside to infuse enteral feeding via a stomach (PEG) tube. A suction machine was on a stand in the room. A record review indicated Resident #103 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had a memory problem and needed assistance with all care. On 8/4/20 at 1:02 PM, an interview with Maintenance Director C provided, The power was only out for a few hours on July 10th (2020): 12:30 AM to 10:30 AM. We were only out for about 10 hours. We have 2 generators and one was repaired during the survey (January 2020) we had the board replaced. On July 10th they called and said the power was out and (Maintenance Tech Y) was here in less than an hour. They had already sent out the resident (#103). An interview with the Director of Nursing (DON) on 8/4/20 at 4:52 PM related to the power outage revealed the facility transferred Resident #103 to the hospital to provide respiratory care and maintenance of the trach. The DON said the facility did not have a red emergency plug/outlet in the resident's room at the time of the power outage on 7/10/20 and there was only one identified emergency red plug/outlet in the building. The facility now has additional working outlets, because there was an emergency plug in the hallway outside the resident's room (#103) on the Main hallway, but it was white instead of red and the staff did not know it was an emergency plug. The DON stated, They changed it (to red) to show it was an emergency plug. On 8/5/20 at 10:50 AM, during an interview with Maintenance Director C and Administrator in training A, they said the facility had obtained a bid for electrical services to install an additional emergency power outlet/red plug in (Resident #103's) room related to his medical needs. At 12:05 PM the Administrator in Training A said the red plug would be installed in the resident's room on the following Monday (August 10, 2020). This was one month after the resident was transferred to the hospital due to a lack of emergency power in his room. On 8/6/20 at 9:30 AM, the Director of Nursing provided information for the following: The facility had 9 residents receiving oxygen, 2 residents with IV medications via an electric IV pump, 1 resident with enteral tube feeding via an electric pump and 7 residents with specialty beds requiring electricity to provide therapeutic functioning. The DON said the facility had back up oxygen via portable tanks, but the life of the tank was dependent upon the amount of oxygen the resident was receiving. One or two residents were able to plug into the one red emergency outlet plug on the North Hall. An interview with Maintenance Director C on 8/6/20 at 9:55 AM related to the power outage on 7/10/20 from 12:30 AM to 10:30 AM revealed, We got a call from the facility that there wasn't any power. (Maintenance Tech Y) came in within an hour. Emergency power was on. The other generator is manual and only maintenance fires that up. It didn't start. It was turning and turning, something with the starter. (The mechanical repair company) repaired it that morning. The Maintenance Director was asked about the emergency red plugs/outlets and stated, There are 4 now. One in each hallway, Main, South, East and North. Being now that we have a concern, we have (a mechanical/electrical company) coming in on Monday August 10th, to put in a new plug in his (Resident #103's) room. During the interview, the Maintenance Director was asked if any of the residents' beds (they were all electric), air mattresses, IV pumps, Tube Feeding pumps or any other electrical equipment would work during the time that the electrical power was out and only the Emergency generator was running and he said No, they would not. He confirmed all of the residents beds were electrical, but was not aware of how many residents had electrical medical equipment that needed to be plugged into an emergency red plug during a power outage. The Maintenance Director could not identify specific staff training for access to emergency red plugs or how to accommodate the resident's needs during a power outage, prior to this survey. Maintenance Technician Y was interviewed on 8/6/20 at 10:30 AM related to the power outage on 7/10/20, They called me at approximately 1:30 AM, I got up there immediately, a little after 2:00 AM. I made sure everything was running good on the emergency generator. We moved one resident to the North Hall from the South Hall. I got the hospital grade extension cords to ensure the equipment could be plugged into the red outlet. I was monitoring the emergency generator and we started to try to kick that over about an hour after I got here. About 2:30 AM or closer to 3:00 AM, the KW35 or Diesel (generator), it did not start. The Emergency generator powers the fire equipment, emergency ports/plugs and emergency lights. (Mechanical company) was in at about 5:30 AM and it was fixed almost immediately. They tinkered with the starter and it kicked right on. During the interview, the Maintenance Tech was asked if the Diesel generator that powered the entire building during an outage, was monitored routinely to ensure it was working properly and said the facility routinely checked and documented monitoring of the Emergency generator, but not the Diesel generator; We have it in a policy now to check the Diesel every week. On 8/6/20 at 5:30 PM, during an interview with Nurse Z she said that she had transferred Resident #103 to the hospital because she couldn't suction [MEDICAL CONDITION] power. She stated, Only the hallway lights went on in certain areas of the building. My area (Main Hall) was black. On the other end of the building (North Hall), they had some lights and a red plug. I had to move another patient to the North that needed oxygen. She's on 3-4 liters and gets real bad anxiety. I moved her down there and plugged everything up in the hallway. Maintenance came in right after the power went out, but it wasn't lighting my end of the building. They called DTE, but it was going to take too long. An interview with Confidential Person W, on 8/7/20 revealed Resident #103 was transferred to the Hospital emergency room from the facility on 7/10/20, because the facility did not have any electrical power and the resident had [MEDICAL CONDITION] needed oxygen and suctioning. Confidential Person W stated, To have [MEDICAL CONDITION] that needed suctioning and the facility did not have back-up power? I don't know how they can admit patients if they can't take care of them. On 8/10/20 at 3:35 PM, a review of the Field Service Report dated 7/10/20 and untimed, indicated Service Technician CC provided service for the facilities Diesel Generator (Manufacturer: ONAN: GEN SET, Model: LTA, Serial # L 1321, Product Hours: 6,529.3) due to Not start in outage. The cause was documented as Unit shut down in overcrank. Correction: Arrived on sight and gained access to generator. Unit is not a (company brand) unit. Unit built by Atlas Corp. Tried starting unit and unit would not start. Primed fuel systems and got unit started. Heard noise coming from flywheel housing and unit had fault for overcrank. Unit keeps engaging starter while running. Turned unit in off position and unit stayed running. Talked with customer and unit will not shut off till stop button on side of unit is pushed. Shut down unit and restarted with no issues. Shut run switch to off and closed breaker. Unit assumed load and stayed running. Advised customer to make sure switch is off while unit is running so starter does not engage while running. Closed all doors job is complete. The Field Service Report dated 7/10/20 was reviewed with the Maintenance Director, Administrator and Administrator in Training on 8/10/20 at 3:35 PM. The Maintenance Director indicated the Diesel Generator was repaired, but on review of the policy, it was noted that this was not the case. The Service Technician identified the starter was malfunctioning and the generator was not working appropriately. He provided a workaround process, but the generator was not repaired. A review of the facilities Generator Log for 2020 indicated there were 26 weekly entries from 2/27/20 to 8/6/20 for the Emergency Generator. There was no entry for the Diesel Generator. The log indicated the following areas were checked for the Emergency Generator: Weekly Automatic Load Test Start/Stop, Fuel System, Oil level, Exhaust System, Battery Charger, Electrical System General Inspection, Generator General Condition, Battery Volts (13.5). The Diesel Generator had no documentation that these areas were inspected to ensure it would operate appropriately during a power outage. A review of the facility policies titled, Generator Operation Inspection and Testing, received on 8/10/2020 and dated 8/6/2010 and revised/reviewed 1/21/2020 provided, Purpose: To develop a policy and procedure that meets or exceeds the requirement of NFPA (National Fire Protection Association) 101, NFPA 110, NFPA 99 as well as other State and Federal rules and regulations .including all appurtenant (important) components, shall be inspected weekly and shall be exercised under load monthly . Policy: Each week facility staff will inspect the Emergency Power Supply System (EPSS). This inspection will include the following . Fuel System, Oil Level, Exhaust System, Battery Electrolyte Level, Battery Charger, Electrical System General Inspection, Generator General Condition . Weekly Inspections will be conducted by Maintenance department staff and documented on the form Weekly EPSS Inspections Monthly Test, the standby generator will be tested and exercised under load monthly . Annual Load Test . This procedure involves measuring the load on the generator and adding load to reach 75% of the rated capacity of the generator . run for 90 minutes . There was no documentation that the Diesel generator was tested weekly, monthly or yearly per the policy and guidelines. And Emergency Procedure-Utility Outage, received on 8/11/2020 and dated revised August 2018 revealed, Residents will remain safe and comfortable during a temporary loss of power . 1.) Announce CODE BLACK overhead unless electrical power is out . 9.) Ensure back-up systems (emergency generators, emergency lighting .) are available and operating as designed in accordance with requirements . The facility was unable to page overhead nor was their adequate emergency lighting in all resident hallways or rooms, due to the generator failure. The facility did not perform routine checks as required to ensure the Diesel generator was functioning appropriately. The Diesel generator was not repaired by the service technician on 7/10/20. He identified why the generator was malfunctioning (the starter) and informed the facility of a workaround to continue to use the generator, as the generator once started would not turn off when the power switch was turned to the off position. An Abatement Plan was received from the facility on 8/11/2020, approved on 8/12/20. A tour of the facility on 8/19/20 to confirm enactment of the Abatement plan included the following: 1. 7/13/20- The Mechanical Services company installed 3 additional emergency outlets for facility usage on the South, East and Main Halls. They are labeled and coded Red. 2. 7/14/20- Education for Emergency Preparedness and use of red emergency outlets was initiated with facility nursing staff. 3. 8/10/20- An emergency red outlet was installed in room [ROOM NUMBER]. This is the only emergency outlet in a resident room. 4. 8/10/20- The facility developed detailed instructions for operating the generator. It is manually turned on. 2. The switch to start the generator gets turned on by pushing down to the run section. 3. When the generator runs, the switch gets put back to the idle position (off) to run continuously. 4. The fuel lever gets pushed back in to turn the diesel generator off. 5. 8/10/20- The Diesel Generator will now be tested weekly and it will be documented on a Generator Log meeting appropriate guidelines. 6. 8/10/20- The Generator Policy was updated and place into the Emergency Preparedness binders. 7. 8/10/20- Facility wide comprehensive emergency preparedness training began related to audits and testing of generator equipment and use of electrical equipment during an emergency to include: IV pumps, Portable oxygen and extension cords. 8. 8/11/20- Three additional extension cords were purchased. 9. 8/13/20- Audits for the Diesel generator test and outcome of each load test began.

This Citation Pertains to Intake Numbers MI 259 and MI 521. This Citation has 2 Deficient Practice Statements (DPS). DPS #1: Based on observation, interview and record review, the facility failed to appropriately monitor and assess a resident with a [MEDICAL CONDITION] (trach) after a fall and to ensure proper placement of [MEDICAL CONDITION] maintained for necessary oxygenation for one resident (Resident #103) of two residents reviewed for [MEDICAL CONDITION] care, resulting in Resident #103 developing an unstable airway, dislodgement of the trach, bleeding, respiratory distress and transfer to the hospital. Findings Include: Resident #103: On [DATE] at 1:30 PM, Resident #103 was observed lying in bed, awake, nodded, mouthed words, and motioned when spoken to. He was wearing [MEDICAL CONDITION] over [MEDICAL CONDITION] and oxygen was running at 5 liters (L) a minute. A feeding pump was running at the bedside to infuse enteral feeding via a stomach (PEG) tube. A suction machine was on a stand in the room. A record review indicated Resident #103 was initially admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had a memory problem and needed assistance with all care. On [DATE] at 4:37 AM, a nursing progress note/ Incident/Unusual Occurrence provided, Description of Event: resident stated he was reaching for his call light . and fell out of bed . Unwitnessed . No new interventions at this time. Vital signs were documented but no additional assessment or mention of the resident's [MEDICAL CONDITION]. The next documented nursing note was [DATE] at 9:59 AM and did not mention the [MEDICAL CONDITION], placement, or securement. On [DATE] at 2:05 PM, Resident #103 transferred to the hospital after he was found in his room with [MEDICAL CONDITION] out and bleeding from the mouth. He returned on [DATE]. He was transferred to the hospital 3 times previously; twice [MEDICAL CONDITION] dislodgement ([DATE] and [DATE]) and once on [DATE] when the facility did not have electrical power to adequately perform tracheal suctioning to maintain the resident's airway. In total Resident #103 was transferred to the hospital four times related to an unstable airway. A review of Resident #103's Care Plan titled, [MEDICAL CONDITION] related to impaired breathing mechanics, injury . date initiated [DATE] with Interventions: Suction as necessary, dated [DATE], O2 at 5 liters [MEDICAL CONDITION] Continuous dated [DATE], .6 liters per minute O2 via concentrator . dated [DATE]. There was a discrepancy between the two interventions for oxygen. A review of the Physician Orders revealed, O2 at 5 liters [MEDICAL CONDITION] Continuous every day and night shift dated [DATE]. There was one Resident Respiratory Assessment, undated and written by a Registered Respiratory Therapist MM. The document had a Clinician signature and date line that was only signed by the RRT. The line entry for Nurse signature and date was blank. Many of the assessment questions on the document were blank. The questions were not answered and the assessment was incomplete. The assessment question for MD order for O2 (oxygen) was blank; Respiratory [DIAGNOSES REDACTED]. A progress note written by Nurse LL on [DATE] at 2:05 PM, Resident was heard coughing and wheezing from hallway so when I entered, I noticed the resident appeared to be in distress. Upon seeing resident face to face I noticed that [MEDICAL CONDITION] out and blood was coming from the open area (tracheotomy site). The obturator was retrieved but at this point the appliance was facing resistance when attempting to reinsert . Resident expressed that he was in respiratory distress . Ambulance was called and arrived in 4 minutes . Resident left facility via stretcher to (hospital) . On [DATE] at 12:41 PM, Nurse LL was interviewed about Resident #103's fall on [DATE] and stated, I worked 6 am to 6 PM on [DATE]. I had (Resident #103) that day and heard he had fallen in the night. The night shift nurse said he fell 2 hours before. We are supposed to immediately assess. The facility has a document that tells you what to do if the patient falls. Fall charting each shift for 3 days. Neuro's, pain dizziness, nausea etc. We post it on the dashboard (on the computer). When I went in there [MEDICAL CONDITION] intact. When the (nurse aide) got him up, she left him sitting in the wheelchair by his bed, that cord from [MEDICAL CONDITION] the machine is short. I heard him coughing and I saw [MEDICAL CONDITION] his lap and then I saw blood. I tried to put [MEDICAL CONDITION] in. [MEDICAL CONDITION] was swollen, and blood was coming out. I placed the oxygen tubing so that he could get air. I placed the oxygen tubing so he could get air. We called 911 and they put a rebreather on him. The hospital said they had to take him to the OR (operating room). They had to stitch [MEDICAL CONDITION] in to hold it in place. Before it was so loose you had to be delicate with it. If someone falls you have to do an assessment while they are on the ground. You are supposed to immediately assess. A review of the facility policies revealed the following: [MEDICAL CONDITION] Care Level III, dated revised [DATE] indicated The purpose of this procedure is to guide [MEDICAL CONDITION] care and the cleaning of reusable [MEDICAL CONDITION] cannulas . [MEDICAL CONDITION] care should be provided as often as needed . and at least every eight hours for residents with unhealed tracheostomies . A suction machine . must be available at all times . Suctioning the Lower Airway (Endotracheal (ET) or [MEDICAL CONDITION]), dated revised [DATE] revealed, The purpose of this procedure is to remove secretions, maintain a patent airway and prevent infection of the lower respiratory tract . Verify that there is a physicians order for this procedure . test equipment before use. Determine if suction equipment is generating appropriate negative pressure . if oxygen saturation drops below 90 percent (or 5 percent from baseline) discontinue suctioning and reventilate and re-oxygenate the resident . Documentation: Assessment data before and after the procedure . DPS #2: Based on interview and record review, the facility failed to appropriately monitor and assess a resident with a change in secretions from a [MEDICAL CONDITION] for one resident (Resident #100) of two residents reviewed for [MEDICAL CONDITION] care, resulting in Resident #100 having a respiratory infection that worsened, oxygen desaturation and transfer to the hospital with respiratory distress and [MEDICAL CONDITION]. Findings include: Resident #100: A review, of Resident #100's medical record, revealed an admission into the facility on [DATE] with a re-admission on [DATE] with [DIAGNOSES REDACTED]. The Resident had a PEG tube (percutaneous endoscopic gastrostomy- a tube into the stomach to provide a means of feeding and medication administration) and a [MEDICAL CONDITION] (a tube into the trachea to maintain an airway). A review of the Minimum Data Set assessment revealed the Resident had moderate cognitive impairment, needed limited assistance with dressing and toileting and was total dependent of one-person physical assistance with eating. A review of Resident #100's medical record revealed the following: -Date [DATE] at 5:41 AM, Progress Note, pt (patient) educated on importance [MEDICAL CONDITION]. Pt has been hesitant the last few times writer attempted to [MEDICAL CONDITION]. He states it is sore. Writer did [MEDICAL CONDITION], pt has yellow purulent drainage from trach, very strong odor. Neck slightly red around stoma. (Doctor) texted by the writer. -Dated [DATE] at 6:21 AM, Progress Note, resident has an increase of green/yellow sputum that has increased odor when he coughs. Mostly [MEDICAL CONDITION] is done, education on [MEDICAL CONDITION] when it is given, washing of hands, but he still cringes when care is given. The odor is a smell of infection. -Dated [DATE] Medication Administration Record [REDACTED]. -Dated [DATE] at 4:06 AM, orders transcribed for sputum culture, stat (immediate) chest x-ray, CMP (comprehensive metabolic panel laboratory tests) and CBC (complete blood count laboratory test) related to fever. -Dated [DATE] at 3:44 PM, Progress Note, x-ray done and read with no abnormalities. X-ray results revealed, with comparison to [DATE]th, with results of Improved RLL (right lower lobe) infiltrate. Resolving pneumonia. -Dated [DATE], sputum culture positive of Citrobacter koseri and started on antibiotic Cipro. -Dated [DATE] at 3:45 PM, Progress Note of Medical Visit Note by Physician, .Telehealth visit was completed via Skype due to the restrictions of the COVID-19 pandemic . Pt was started [MEDICATION NAME] mg on ,[DATE] for Citrobacter koseri in his sputum. CXR improved from prior one. Pt had CT of the head and neck performed by (Hospital) last week but results and recommendations are not available. Pt has lost 8.2 lbs since admission 4 months ago . Lungs rhonchi RUL (right upper lobe) -Dated [DATE] at 7:07 PM, Progress Note, Infection follow up note (complete each shift while receiving ATB (antibiotic)/Treatment . Sputum is yellow and runny when he coughs. There is odor. He [MEDICAL CONDITION] BID (twice a day) .[MEDICATION NAME] BID, bacteria in sputum. No adverse effects. -Dated [DATE] at 11:25 AM, Progress Note, Infection follow up note (complete each shift while receiving ATB (antibiotic)/Treatment . Pt has thick light green sputum of which he as to clear his airway effectively. -Dated [DATE] at 6:30 PM, Progress Note, Infection follow up note (complete each shift while receiving ATB (antibiotic)/Treatment . Lungs diminished in B/L (bilateral) bases and sputum is light yellow. Thick to thin . -Dated [DATE] at 6:04 PM, Progress Note, Progress Note, Infection follow up note (complete each shift while receiving ATB (antibiotic)/Treatment . Sputum is yellow and thick, some odor. -Dated [DATE] at 6:26 AM, Change in Condition Evaluation, with documented change in condition of Shortness of breath and respiratory distress. Vital signs with documented heart rate of 145 beats per minute, respirations 28 per minute and SpO2 (oxygen saturation) 59%. Description of respiratory signs and symptoms, spo2 started at 54% now at 71%. -Dated [DATE], Nursing Home to hospital Transfer Form, .Additional Relevant Information: suctioned resident, thin yellow odorous secretions are coming from trach, cannula wont stay in, pulse 145, resp 28, spo2 54%, alert times 3, sent to ER (emergency room ) for eval and treat . -Dated [DATE] at 3:23 PM, Progress Note, Writer called the hospital and this resident has been admitted to the hospital. -Dated [DATE] at 11:27 AM, a fax received after the Resident had been transferred to the hospital from an appointment with Otolaryngology on [DATE] that included imaging on [DATE] of the chest, revealed, Extensive debris and mucous plugging involving the bilateral lower lung airways as above with moderate regions of airspace disease, tree-in-bud nodularity, and tiny left pleural effusion most consistent with aspiration pneumonia/infectious [DIAGNOSES REDACTED] with parenchymal bilateral lower lobe areas of atelectasis/pneumonia. This is significantly worsened especially on the right. Other patchy nodular opacities within both lungs, increased in size on the right and new on the left are likely infectious/[MEDICAL CONDITION] in etiology. -Dated [DATE] at 9:58 PM, Progress Note of an Admission Note, .Lungs with course sounds,[MEDICAL CONDITION] from T-bar [MEDICAL CONDITION] at 2 L/M (liters per minute) O2 . -Dated [DATE] at 5:17 PM, Progress Note, Pt stable,[MEDICAL CONDITION] changed and cannula replaced. Suctioned x (times)2 in the am no additional sectional (suctioning) needed, sputum light green and clear, resident advised to [MEDICAL CONDITION] on to avoid entry of bacteria . -Date [DATE] at 11:30, Progress Note, This nurse was at the med cart when a CNA (certified nursing assistant) yelled 'you need to come, he is vomiting all over'. This nurse was half way down the hall when the CNA yelled 'run, he is vomiting blood' . Suctioning, Ambu (ventilate with bag over mouth or trach) and CPR (cardio-pulmonary resuscitation) on and off until EMTs (emergency medical technician) arrived . Hospital called requesting resident paper work to be faxed-done. Questioned how resident was to be notified resident had passed. A review of the MAR for [DATE] for Resident #100 included the following: -Scheduled Suction [MEDICAL CONDITION] PRN (as needed) for secretions every day and night shift. Documented as completed twice a day from [DATE] to [DATE]. There was no documentation of the assessment of the suctioned secretions, assessment of the [MEDICAL CONDITION] site or lung sound assessment. -Scheduled [MEDICATION NAME]-[MEDICATION NAME] Solution . two times a day . with an 88% on [DATE] day shift, 89% on [DATE] day shift and night shift, 88% on [DATE] day shift, 86% on [DATE] day shift, 89% on [DATE] day shift, 86% on [DATE] day shift, 86% on day shift and 78% on [DATE] day shift. -Scheduled Respiratory Assessment Post Nebulizer TX (treatment) two times a day [MEDICAL CONDITION]. O2 sats were documented as 89% on [DATE] day shift, 89% on [DATE] day and night shift, 90% on [DATE] day shift, 90% on[DATE] day shift, 89% on [DATE] on day shift, no documentation on [DATE] day shift and 78% on [DATE] day shift. -Scheduled O2 (oxygen) at 3L (liters) via [MEDICAL CONDITION] ATC (around the clock) every day and night shift, with O2 sats of readings of 88% on [DATE] day shift, 89% on [DATE] on day and night shift, 88% on [DATE] day shift, 87% on [DATE] on day shift, 89% on [DATE] day shift and 78% on [DATE] day shift. A review of Resident #100's Emergency Department Chart, with a date of service on [DATE], included the following: -Chief Complaint: Respiratory Distress. -Progress Status: The patient is seen and evaluated in the emergency department with above complaint. Patient comes from ECF (extended care facility) with concerns of [MEDICAL CONDITION]. Patent has a [MEDICAL CONDITION] and was found to be hypoxic at 60% . Patient's chest x-ray does reveal pneumonia . Patients found to be in [MEDICAL CONDITION], antibiotics were started after blood cultures were obtained. -Clinical Impression: acute pneumonia, suspect gram negative, [MEDICAL CONDITION]. A review, of Resident #100's hospital record of the History of Present Illness (HPI), with a date of service on [DATE], included the following: -HPI (age of patient) with [MEDICAL CONDITION] due to obstructing head and [MEDICAL CONDITION] presents from ECF due to [MEDICAL CONDITION] and fever of 100.2 this morning. Patient was hypoxic down into the 60s and on arrival required significant suctioning of thick copious amounts of yellow brownish sputum with significant improvement of his oxygenation . He was being treated for [REDACTED]. However the amount of sputum is not improving and he spiked a fever this morning with [MEDICAL CONDITION] so he was sent to the hospital . -Plan of Care, Assessment: Bilateral lower lobe healthcare associated pneumonia complicated with [MEDICAL CONDITION] suspect gram-negative; [MEDICAL CONDITION] on presentation . A review, of Resident #100's medical record of the Discharge Summary, dated [DATE] included: - Hospital course: .presents to select s/p (status [REDACTED]. He was treated with IV (intravenous) antibiotics and pulmonology was consulted. Patient underwent thoracentesis for significant right sided effusion concerning for empyema and had pigtail catheter placed on ,[DATE]. Patient then underwent [MEDICATION NAME] concerning for tube feed aspiration. Tube feedings were adjusted to daytime feedings and this improved. He underwent CT lungs that shower (showed) persistent large loculated right-sided effusion and underwent thoracotomy with decortication and chest tube placement on [DATE]. [MEDICATION NAME] washing culture showed [DIAGNOSES REDACTED] resistant to [MEDICATION NAME] and susceptible to Bactrim. Patient completed 7 day course of Bactrim. Chest tube removed on [DATE]. He was doing well medically but had a difficulty time weaning from the ventilator so decision was made to pursue LTAC (long term acute care) for continued vent weaning . A review, of Resident #100's respiratory assessments, upon return to the facility on [DATE], revealed in the MAR from [DATE] to [DATE], a schedule to monitor for symptoms of Respiratory changes every day and night shift that included monitoring for a cough, shortness of breath, sore throat and temperature but did not include assessment and monitoring of the lung sounds. The Progress Notes revealed lung sounds assessed on admission, on [DATE], to have course sounds. On-going nursing assessment of lungs sounds were not documented upon the Resident's return to the facility on [DATE] through facility stay to [DATE] when the Resident was transferred to the hospital. On [DATE] at 10:15 AM, an interview was conducted with the Director of Nursing (DON). A review, with the DON, was conducted of Resident #100's progress notes of yellow purulent drainage from trach, very strong odor, increase of green/yellow sputum that has increased odor when he coughs, and odor is a smell of infection, documented on [DATE] and a review of the oxygen saturation below 90%. The DON stated, They (Nurses) should be doing a follow up SpO2 after suctioning. Moving forward with a plan of correction, if below 90% before suction, checking O2 sat for improvement and trigger a progress note on how the patient tolerated the process. The DON continued with explaining that an assessment was to be completed that included, lung assessment and monitoring of the stoma site to make sure nothing is going on with the skin and doing more assessment to make sure we are catching it (change in conditions). The DON was queried regarding a lack of follow up assessment of tracheal secretions. The DON indicated after suctioning of a [MEDICAL CONDITION] there should be documentation of an assessment of secretions and stated, I will add secretions to [MEDICAL CONDITION]. A review of Resident #100's oxygen desaturations and lack of follow up assessments were reviewed with the DON. The DON indicated the CNAs (certified nursing assistant) would be communicating the abnormal oxygen saturations and there should be follow up with a progress note as to why the saturation was so low, notify the physician and stated, It's a teachable moment for the nursing department. A review of respiratory assessments with the lack of documented lung sounds upon the return after hospitalization on [DATE] was reviewed with the DON. The Discharge Summary of the hospital course was reviewed with the DON and queried regarding respiratory assessments needed upon Resident #100 return to the facility. The DON stated, They (Nurses) should have been doing the lung sounds with his respiratory symptoms (monitoring). A review of the facility policy, Pulse Oximetry (Assessing Oxygen Saturation), revised [DATE], revealed, The purpose of this procedure is to monitor arterial blood oxygen saturation (SaO2) without the use of invasive devices . 2. Normally SpO2 is between 90 and 100 percent; SpO2 below 70 percent is life threatening . 11. If SpO2 is less that 90%: a. Reposition the probe and re-evaluate readings. b. If SaO2 is less than acceptable level for resident's condition, notify the physician . A review of the facility policy, Suctioning the Lower Airway (Endotracheal ET or [MEDICAL CONDITION]), revised ,[DATE], revealed, The purpose of this procedure is to remove secretions, maintain a patent airway, and prevent infection of the lower respiratory tract . Assessment 1. Identify the following risk factors for impaired airway clearance or aspiration: a. Impaired cough or gag reflex; b. Dysphagia; c. Weak respiratory muscles, d. [MEDICAL CONDITIONS]; e. [MEDICAL CONDITION] infection; f. Presence of feeding tube .2. Assess for the following signs and symptoms of respiratory distress/[MEDICAL CONDITION]/hypoxemia: a. Diminished breath sounds; b. Tachypnea; c. Dyspnea; d. Gurgling, crackling or wheezing upon inspiration; e. Cyanosis, f. Decreased oxygen saturation (SpO2} . Documentation The following information should be recorded in the resident's medical record: .4. Amount, color and characteristics of secretion (color, odor, thickness, etc.) . 6. Cardio-pulmonary status, including lung sounds, during the procedure. 7. Assessment data before and after the procedure .

This Citation Pertains to Intake #MI 695 Based on observation, interview and record review, the facility 1) failed to ensure pressure ulcers were assessed and monitored, 2) wound care was provided and 3) appropriate interventions were in place for 1 resident (Resident #83) of 3 residents reviewed for pressure ulcers, resulting in Resident #83 developing multiple facility-acquired Stage 2 pressure ulcers on her buttocks and a painful left heel Stage 3 pressure ulcer without application of a wound dressing. Findings Include: During a tour of the facility on 7/30/20 at 1:40 PM, Resident #83 was observed lying in bed. When asked how she was doing, she said she Was wet and had asked for someone to change her at about 12:00 PM. She said she was very uncomfortable. Nurse J arrived during the conversation with the resident's medication. The nurse was informed the resident had been waiting for Almost 2 hours to receive assistance. Nurse J said she would find staff to assist and returned in about 5 minutes with 2 Nurse aides DD and EE. At 1: 50 PM, Nurse J and Certified Nursing Assistants DD and EE assisted in providing incontinence care for Resident #83 who was observed to be very wet. The resident was saying her bottom hurt. The resident's buttocks were bright red and there were 5 open areas on her left buttock; each was round with peeling skin and about 0.5 cm length and width with some bleeding. The resident also had an open area in the fold between her left buttock and upper thigh. Nurse J was asked if the areas were new and she said she was not aware of them before then. The nurse and nurse aides were asked if the resident had any type of wound treatment and they said the resident had an ointment that was applied after incontinence. The resident said the areas were Painful. During the interview, Nurse J was asked if Resident #83 had any other wounds and she pointed at the resident's left foot and said, She has a wound on her left foot and she should have a dressing on it. I don't know why it isn't there. Resident #83 was observed to have a dry, scaly open area on her left heel. There was no wound dressing. The resident was asked about the dressing and said she did not know when it was last applied and stated, I informed them there is a wrapping every 3 days. Nurse J and the nurse aides were asked if Resident #83 was assisted with repositioning off her back/bottom and Nurse J said No, she won't do it. The resident then said, I want to lay on my side facing the TV. The nurse aides and nurse assisted her to her left side. A record review of the face sheet and Minimum Data Set (MDS) assessment for Resident #83 indicated the resident was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed). The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 15/15. The resident needed 2- person assistance with bed mobility, transfers, dressing, hygiene, and toileting. A review of the physician orders [REDACTED]. Change every three days and prn (as needed). A review of the Care Plan titled, Non-healing stage 3 pressure ulcer on left heel related to impaired mobility, complicated by obesity and [MEDICAL CONDITION] lower extremities, date initiated 5/245/20, with Interventions: Treatment as ordered/indicated, date initiated 5/24/20. As of 8/19/20, the Care Plan had not been updated to include the open areas on Resident #83's buttocks or measures to aid in healing and further prevention of breakdown. A review of the Treatment Administration Record (TAR's) for July and August 2020 for Resident #83 revealed the following: July 2020 TAR: A treatment Left heel Cleanse with normal saline, pat dry, apply [MEDICATION NAME] AG to wound bed, cover with ABD pad and wrap with kerlix. Change every three days and prn, one time a day every 3 days, order date 7/13/20. The wound care was not documented as completed on 7/29/20. The entry was blank. A review of the Progress notes revealed the following: There was no progress note or assessment that identified the open areas on the resident's buttocks, what they looked like or the size. A Skilled Nursing Note-after 72 hr charting is completed, dated 8/1/20 at 11:15 AM revealed, . Skin . 8/1/2. Chafing/irritation continues to bilateral buttocks/upper thigh region with [MEDICATION NAME] ordered. Reinforced purpose/benefits of repositioning and resident mildly receptive. Treatment to left heel continues . A wound note titled Wound Weekly Observation Tool (Licensed Nurse) dated 7/27/20- Left Heel . pressure . Pressure Ulcer Stage 3, granulation tissue present (beefy red) . Wound Measurements: Length 0.9 cm x Width 1.6 cm x Depth 0.5 cm . Peri-wound Tissue . calloused, dry . There was no mention of any open areas on the buttocks. A Skin Observation Tool- (Licensed Nurse), dated 8/1/20 at 11:14 AM Treatment continues to left heel and verified floated (with pillows). Chafing/irritation to bilateral buttocks/upper thigh region with [MEDICATION NAME] continues . The note indicated the resident was educated regarding receiving incontinence care, but there was no mention of prompt assistance from the staff to aid in preventing further breakdown and promote healing of the damaged skin. Review of a Skin Observation Tool, note dated 8/8/20 and Wound Weekly Observation Tool, note dated 8/10/20 indicated neither mentioned the size of the open areas on Resident #83's buttock or if they were healing. An interview with the Director of Nursing and Administrator in Training on 8/10/20 at 11:55 AM related to Resident #83 waiting for incontinence care for almost 2 hours, which resulted in skin redness and breakdown, no documentation on the Care Plan related to the skin breakdown on the buttocks and absence of documentation of wound care to the left heel as ordered provided, They should have done that. I will check into that. A review of the facility skin policies revealed the following: Pressure Ulcers/Skin Breakdown- Clinical Protocol, dated revised March 2014 revealed, The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores . In addition, the nurse shall describe and document/report the following: Full assessment of pressure sore including location, stage, length, width, and depth . Pain assessment . Pressure Ulcer/Injury Risk Assessment, dated revised July 2017 The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing pressure ulcer/injuries . If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin . Develop the resident centered care plan and interventions based on the risk factors . the interventions must be based on current, recognized standards of care, the effects of the interventions must be evaluated . the care plan must be modified as the resident's condition changes . The following information should be recorded in the resident's medical record . Any change in the resident's condition . The condition of the resident's skin (i.e., the size and location of any red or tender areas) . Any problems or complaints made by the resident . Prevention of Pressure Ulcers/Injuries, dated revised July 2017, The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions . Identify any signs of developing pressure injuries . Inspect pressure points . Moisture, Keep the skin clean and free of exposure to urine and fecal matter . Choose a frequency for repositioning based on the resident's mobility . At least every hour, reposition resident who are chair-bound or bed-bound .

This Citation pertains to Intake #: MI 250 Based on observation, interview and record review, the facility failed to comprehensively assess all possible causes for weight loss, consistently document food acceptance, provide needed assistance with meals and respond to an abnormal [MEDICAL CONDITION] function test for 1 resident (#104) of 3 residents reviewed for nutrition, resulting in Resident #104 having a significant weight loss of over 30 pounds (lbs.)/15.05% in less than 90 days, an overall decline in condition, ability to feed self and quality of life . Findings Include: On 6/25/20 at 10:00 AM, during a tour of the facility, Resident #104 was observed lying in bed on her back, with a nightgown on, bare feet and confused speech. Nurse I and Certified Nursing Assistant (CNA) S were observed repositioning the resident. The resident was yelling out in discomfort. She was not able to turn herself and did not assist with the mobility. When asked if Resident #104 sat up in the bedside chair daily, the CNA said, No. On 6/25/20 at 10:35 AM, during an interview with CNA EE she was asked if Resident #104 sat up in a chair daily and she said, She needs 2 people and she yells a lot, so sometimes she doesn't. CNA EE was asked if the resident had eaten breakfast and she said the resident had not eaten much, about 25% and drank sips of fluid. The CNA said she would go in and out of the room to help her. The CNA did not stay in the resident's room to help her with the meal. A record review of the face sheet and MDS assessment indicated Resident #104 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The quarterly MDS assessment dated [DATE] revealed the resident had severe memory loss and needed extensive assistance with all activities of daily living (ADL), except eating- she needed 1-person limited assistance (scored 2,2); ambulation had not occurred enough to be scored. The resident had experienced a significant decline in ADL ability from the prior quarterly MDS assessment on 3/23/20 and was no longer able to transfer self, walk independently or consistently feed herself (scored 0,1 on 3/23/20). A review of the resident's Weights & Vitals indicated she weighed 215.9 lbs. on 4/22/20 and 183.4 lbs. on 7/3/20; a 32.5 lb. weight loss: 4/22/20 215.9 lbs., 5/5/20 203.5 lbs., 6/1/20 191.8 lbs., 6/23/20 185.1 lbs., 7/3/20 183.4 lbs. A 15.05% weight loss in ~2.5 months (less than 90 days). The staff documentation for the amount of food eaten by Resident #104 at each meal (3 meals a day) was recorded in the electronic medical record under What percentage of the meal was eaten? for June 9, 2020 - July 7, 2020 and revealed the following: Food Acceptance for each meal was not consistently documented. There were only 2 meals a day documented on 6/10/20, 6/12/20, 6/13/20, 6/15/20, 6/26/20, 6/30/20, 7/2/20, 7/3/20 and 7/5/20. Food Acceptance was documented for only 1 meal on 6/14/20. Food Acceptance was not documented for any meals on 6/22/20, 6/27/20 and 7/1/20. Almost 50% of the meals were not recorded appropriately from June 9, 2020 - July 7, 2020. Of the meals that were recorded, the resident usually ate either 25-50% or 50-75%. Without consistent documentation of the amount of food Resident #104 was eating, the facility was not able to appropriately monitor the resident's nutritional status and ensure her needs were adequately met. A review of Resident #104's lab results indicated an abnormal [MEDICAL CONDITION] function test (TSH/[MEDICAL CONDITION] stimulating hormone) dated 1/23/20: Results- 43.6 High (normal range 0.350-5.500). This result indicated low [MEDICAL CONDITION] function/ [MEDICAL CONDITION] (If the [MEDICAL CONDITION] stimulating hormone (TSH) result is high, the [MEDICAL CONDITION] function is low.) A review of the physician orders identified the resident was receiving [MEDICATION NAME] 112 mcg daily from 9/6/19 to 1/24/20. On 1/24/20 the [MEDICATION NAME] dose was increased to 125 mcg daily. An order was written on 1/24/20 to obtain another TSH and T4 lab tests in 6 weeks. A review of the medical record indicated there were no additional TSH or T4 lab results. There was no documentation to say whether the tests were obtained or not, as per the order on 1/24/20. A review of the physician progress notes [REDACTED]. There was no mention of the abnormal [MEDICAL CONDITION] function. The note said, Legs stay swollen . LE (lower extremity) [MEDICAL CONDITION] and shins . continue currents meds and therapies, labs and vitals per protocol . The only other physician note was by the Psychiatry group on 6/12/20 which provided, . Resident has history of yelling out . sadness, tearfulness, anxiousness, restlessness, agitation, verbal and physical aggression . Resident states I want a sandwich. Redirected resident to bedside table with her food on her plate. Resident states thank you and started to eat . There were no additional primary physician/provider notes. The abnormal [MEDICAL CONDITION] level was not addressed. The Mayo Clinic 2020, . [MEDICAL CONDITION] (underactive [MEDICAL CONDITION]) is a condition in which your [MEDICAL CONDITION] doesn't produce enough of certain crucial hormones . Over time, untreated [MEDICAL CONDITION] can cause a number of health problems . Accurate [MEDICAL CONDITION] function tests are available to diagnose [MEDICAL CONDITION]. Treatment with synthetic [MEDICAL CONDITION] hormone is usually simple, safe and effective once you and your doctor find the right dose . Symptoms . may include: Fatigue, muscle weakness, muscle aches, tenderness and stiffness, pain . impaired memory . TSH tests also play an important role in managing [MEDICAL CONDITION]. They help your doctor determine the right dosage of medication . A review of a Monthly Summary for Long Term, assessment for Resident #104 did not indicate that she had experienced significant weight loss and noted No abnormal labs. There was not mention of the prior abnormal TSH of 43.6 or ordered follow-up labs. A review of the Resident's Care Plans revealed the following: .ADL Self Care Performance Deficit . date initiated 7/8/19 and revised 3/25/20 with Interventions: Does prefer to sleep in recliner, dated 12/20/19, She has a recliner chair in her room for her to sit in and elevate feet as tolerated and she prefers to sleep in the recliner chair, dated 3/2/20. There was no recliner chair in her room; Bed Mobility: The resident is able to assist to turn and reposition, assist/supervise as needed, dated 7/8/19 and updated 6/12/20. The resident needed 2-person extensive assistance with repositioning; Eating: The resident is able to hold cup, feed self, eat finger foods independently, supervise, assist if needed, dated 7/8/19. The care plan had not been updated to indicate the resident needed increased assistance with eating. . [MEDICAL CONDITION], refusing medication, level HIGH, 45.10, unsafe to draw blood, date initiated 7/8/19 and revised 3/25/20 with Interventions: . notify physician if refusal (medication), dated 9/6/19, Give [MEDICAL CONDITION] replacement therapy as ordered, dated 7/8/19 and revised 9/6/19. There were only 2 interventions and no mention of why it was unsafe to draw blood or any interventions to aid in drawing blood. . nutritional problems . weight fluctuations, particularly losses are anticipated, date initiated and revised 6/6/20 with Interventions: Monitor/document/report . Refusing to eat . dated 7/10/19, Monitor/record/report to MD PRN signs/symptoms of malnutrition: Emaciation, muscle wasting, significant weight loss: 3 lbs. in 1 week, >5% in 1 month, >7% in 3 months, >10 % in 6 months, dated initiated 7/10/19; Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated 7/10/19 with revision on 3/26/20; . wants to have an Ensure Clear and a Magic Cup with each meal, dated 6/8/20; Provide, serve diet as ordered. Monitor intake and record q (every) meal, offer replacements for uneaten food . dated 7/1/20; RD (Registered Dietitian) to evaluate and make diet changes . dated 7/10/19 and revised 3/25/20 . An interview with Confidential Person II on 6/29/20 at 10:40 AM, revealed (On 6/28/20 the resident) was laying there crying and screaming and they went out and shut the door. I could see it through the window. They say they are feeding her, but I don't know. I think she needs help. She can't get her hand up there. They come in and give her a few bites and leave and don't come back. While interviewing the DON on 6/30/20 at 1:55 PM, she was asked about Resident #104's significant decline in ADL ability and need for increased assistance with eating, as well as a 30-pound weight loss since April 22, 2020. The DON stated, I can see that she had a decline. During the same interview, the DON was asked about the resident's prior improvement in condition and removal from Hospice services in March 2020 and return to Hospice services in May 2020 after a decline and said she would check on that. The DON was asked why there was a lack of physician notes in the resident's medical record and said the previous physician had left in May 2020 and a new physician started after that. The DON said the notes should be scanned into the medical record. Reviewed with her that the last physician note was 4/13/20 and also a Psychiatry note in June 2020. She said she would check on that. There were no physician notes addressing the resident's weight loss. An interview with Hospice Nurse CC on July 7, 2020 at 10:25 AM provided, We took her off Hospice because she wasn't showing any declines; probably end of February or March. Then she had showed decline and (family) called and asked for (Hospice) re-evaluation. I have seen that she needs assistance. Two or Three visits around lunch time and her food is untouched. I have told the aides that she needs help with feeding. I've seen her look at it and not try to eat. Last visit her tray was there and I just handed her the sweet roll and she took it. The Hospice Nurse said an order was placed on July 6, 2020 for additional lab work: TSH, [MEDICATION NAME] and Total Protein. To monitor [MEDICAL CONDITION] function and nutritional status. A review of the Dietary Notes for Resident #104 revealed the following: 6/5/2020 - . significant weight change . 12% less than she weighed 90 days ago . oral intake is up and down, varying greatly but her intake of fluids is usually always good . 6/9/20 - . agreed to drink a clear apple ensure with all three meals. She stated she likes ice cream. She will receive a magic cup with all three meals . 6/24/20 - Weight loss of 3.7 pounds noted for 6/19/20 . There was no mention of the resident's abnormal [MEDICAL CONDITION] lab or lack of monitoring of food acceptance to better determine appropriate interventions to aid the resident in comfort and quality of life. A progress note dated 7/8/2020 - . resident being followed for significant change . On July 7, 2020 at 10:55 AM, Certified Dietary Manager (CDM) D was interviewed related to Resident #104's significant weight loss and stated, She had Covid. Some people would not eat. We would try to send a Magic cup and soup. She was eating by herself with cueing, but some days she needs 1:1. She cries a lot. She will drink Apple Clear Ensure. Hit or miss with the Magic Cup. She will sit there and cry. You have to comfort her. The CDM was asked if there was documentation of the amount of Clear Ensure and Magic Cup the resident was taking and said she would look in the resident's chart. An interview with Registered Dietitian (RD) DD on 7/8/20 at 8:40 AM provided, I started on May 19, 2020 and work at the facility 24 hours a week. The RD was asked about the significant weight loss for Resident #104 and stated, She has varied intake. She agreed to a Magic cup and Ensure Clear. The inconsistent documentation of the resident's food acceptance was reviewed with the RD. She said it was supposed to be documented. The RD was asked if there was documentation of how much the resident was consuming of the Clear Ensure and Magic Cup and she said it should be documented. When asked about the lack of monitoring of the resident's [MEDICAL CONDITION] function (TSH 43.6), the RD said she was not aware of the resident's abnormal [MEDICAL CONDITION] labs nor had she spoken with the physician about the resident's weight loss. The RD said a Nurse Practitioner also sees the resident, but he had not been placing his notes in the medical record. The RD was asked about the Nutrition Care Plan that mentioned unavoidable weight loss and would it still be unavoidable if abnormal labs were not addressed and the resident's food acceptance was not documented to aid in identification of potential dietary issues and stated, When I say unavoidable weight loss, I am referring to interventions we put in place. On 7/8/20 at 2:12 PM, CDM D was interviewed and stated, . supplement intake was not being monitored. I met with the Unit Manager and DON and the supplements were not being documented, but now the nurses will do that. A review of the facility policy titled, Weight Assessment and Intervention, dated revised September 2008 provided, The multidisciplinary team will strive to prevent, monitor and intervene for undesirable weight loss . Weight assessment: . 1 month - 5% weight loss is significant: greater than 5% is severe; 3 - months 7.5% weight loss is significant, greater than 7.5% is severe; 6 months - 10% wight loss is significant, greater than 10% is severe . Assessment information shall be analyzed by the multidisciplinary team .Approximate calorie, protein and other nutrient needs compared with the resident's current intake . The relationship between current medical condition or clinical situation and recent fluctuations in weight .The physician and the multi-disciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss . Care planning for weight loss or impaired nutrition will be a multidisciplinary effort .Interventions for undesirable weight loss . Nutrition and hydration needs of the resident, Functional factors that may inhibit independent eating .

This Citation pertains to Intake #'s: MI 842, MI 892, MI 517, MI 250 Based on observation, interview and record review, the facility failed to ensure pressure ulcers were assessed, monitored, wound care was provided and appropriate interventions were in place for 3 residents (#'s 101, 103, 104) of 4 reviewed for pressure ulcers, resulting in Resident #101 developing multiple facility acquired pressure ulcers to the ears (Stage 2), left hip (suspected deep tissue injury) and back/sacral area (suspected deep tissue injury), Resident #103 developed infected, unstageable pressure ulcers on the heels and sacrum and Resident #104 developed a boggy, dark red, painful heel with no preventive measures in place. Findings Include: Resident #101 A record review indicated Resident #101 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive loss and needed extensive assistance with all care except for eating and needed supervision. Bathing was not assessed (did not occur in the prior 7-day period). The resident was diagnosed with [REDACTED]. An interview with Confidential Person HH, on 6/29/20 at 3:17 PM related to Resident #101's skin breakdown revealed, 'I completed the admission assessment in the ICU. It was April 5th, when he came from ER to the ICU. In my years as a nurse, those were the worst wounds I have ever see. I cried it was so bad. There were pressure ulcers behind his ears from the oxygen tubing, on his heels, butt and one on his back. I had someone help me and we measured them. He also had a rash on his face and wounds on his lower legs. The worst was the one on his buttock. It was Unstageable/dark purple, open and oozing. National Pressure Injury Advisory Panel (NPIAP) September 2016, Pressure Injury and Stages, A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense pressure, prolonged pressure or pressure in combination with shear . A review of the Hospital records indicated Resident #101 arrived in the emergency room (ER) from the facility on 4/5/20 at 6:41 PM and was transferred to the Intensive Care Unit (ICU) on the same day 4/5/20 at 8:18 PM, due to [MEDICAL CONDITION]. The ICU admission assessment completed by Confidential Person HH revealed Resident #101 had 6 wounds identified: #1 - Bilateral Ears, Stage II (NPIAP, September 2016, Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister .). #2 - Left Hip, Suspected deep tissue injury/ red area 5 x 5 cm. (NPIAP, September 2016, Persistent non-blanchable deep red, maroon or purple discoloration, Intact or non-intact skin .Pain and temperature change often precede skin color changes . This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface .) #3 - Umbilicus, bruises on either side. #4 - Face, around mouth and chin, maceration, beefy red, drainage, serous. #5 - Back, left side, Suspected deep tissue injury, 5 x 8.5 cm. #6 - Buttock, right, Suspected deep tissue injury/Unstageable Pressure Injury, red area, 14 x 10 cm, black area 8 x 4 cm,/ left buttock, red area 11 x 7 cm, black area 10 x 7 cm. National Pressure Injury Advisory Panel, September 2016, Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (yellow, brown, wet stringy dead skin) or eschar (brown or blackened dead skin tissue). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed . National Pressure Injury Advisory Panel, September 2016, Stage 3 Pressure Injury: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer . Stage 4 Pressure Injury: Full-thickness loss of skin and tissue with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage of bone in the ulcer. Slough and/or eschar may be visible . A review of the facility progress notes prior to Resident #101's discharge to the hospital revealed the following: 2/19/20 a Skin Monitoring: Comprehensive CNA Shower Review note signed by Nurse JJ Buttocks pink and is blanchable, Intervention: Turn (every) 2 hours, Skin barrier. There was a signature on the document on a line titled DON (Director of Nursing) Signature: dated 3/17/20; almost 1 month later. 3/16/20 a Skin Observation Tool (Licensed Nurse) written by Nurse KK . Mild redness to bilateral buttocks and blanchable with barrier cream applied with all episode of incontinence. 3/23/20 a Skin Observation Tool (Licensed Nurse) written by Nurse Z; There was no mention of the reddened area on the resident's buttocks. 3/30/20 a Skin Observation Tool (Licensed Nurse) assessment did not mention reddened buttocks. 4/2/20 at 4:09 AM, a progress note written by Nurse BB provided, (Resident #101) has a couple of purple nonblanchable areas on his buttocks. This was reported to (Nurse T) RN/wound nurse. He is being turned (every) 2 hours and prn (as needed) and his heels are floating. There was no additional mention of other areas of skin breakdown. 4/4/20 at 9:29 PM, Covid-19 . results are positive . 4/5/20 the resident was transferred to the hospital for productive cough, elevated temp., appetite has decreased . sips of water. A review of the physician orders [REDACTED]. 3/17/20 Apply barrier cream/ointment after each incontinence and prn. There were no additional orders, treatments or interventions ordered for the resident's buttock redness, as mentioned in the 4/2/20 progress note. A review of the Care Plan titled, . at risk for impairment to skin integrity . date initiated 10/9/19 and revised 3/28/20 with Interventions, Pressure relieving cushion, while up in chair, dated 10/9/19 and revised 3/2/8/20, Pressure relieving/reducing mattress, dated 10/9/19 and revised 3/28/20 and Weekly skin assessment, dated 3/28/20. Resident #101 had been in the facility since 9/20/19 and the 3 interventions dated 3/28/20 were preventive measures that could have been enacted sooner to aid in preventing skin breakdown. There was no updated intervention on the Care Plan to address the purple nonblanchable areas noted on the resident's buttocks on 4/2/20. An interview with the facility Wound Care Nurse I on 6/30/20 at 2:30 PM, revealed she was new at the facility; starting in June 2020 and was not familiar with Resident #101. The nurse was asked what the facilities process is when a nurse identifies a wound and said, They should do something. An interview with the Director of Nursing on 7/7/20 at 11:21 AM related to Resident #101's wounds provided, It was documented that (Nurse T) was the Wound Care Nurse. I spoke with her and she was only assisting the former DON with wounds. There were no treatment orders written. I asked if she recalled being informed about any wounds for (Resident #101) and she said she did not. Resident #104 On 6/25/20 at 10:00 AM, during a tour of the facility, Resident #104 was observed lying in bed on her back, with a nightgown on, bare feet and confused speech. Nurse I and Certified Nursing Assistant (CNA) S were observed repositioning the resident and providing incontinence care. Her brief was observed unfastened/hanging loose, soaking wet with dark yellow urine and pieces of congealed brief were lying on the bed. The resident was yelling out in discomfort while being assisted with repositioning to the left side. She was not able to turn herself and did not assist with the mobility. When asked if Resident #104 sat up in the bedside chair daily, the CNA said, No. The nurse and CNA were asked if the resident transferred herself or walked and they said she did not. During the observation, Nurse I assessed Resident#104's heels for skin breakdown. The resident yelled Oh, that really hurts, when the nurse assessed the reddened left heel for blanching. The resident's heels were lying flat on the bed with no interventions to prevent a pressure ulcer/skin breakdown. A record review of the face sheet and MDS assessment indicated Resident #104 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment dated [DATE] revealed the resident had severe memory loss and needed extensive assistance with all activities of daily living (ADL), except eating- she needed 1-person limited assistance (scored 2,2); ambulation had not occurred enough to be scored. The resident had experienced a significant decline in ADL ability from the prior MDS assessment on 3/23/20 and was no longer able to transfer self, walk independently or consistently feed herself (scored 0,1 on 3/23/20). A review of the MDS assessment section M-Determination of Pressure Ulcer/Injury Risk, revealed Is this resident at risk of developing pressure ulcers/injuries? The question was answered Yes. A question Turning/repositioning program was answered No. A review of the resident's Weights & Vitals indicated she weighed 215.9 lbs. on 4/22/20 and 183.4 lbs. on 7/3/20; a 32.5 lb. weight loss. A review of skin assessments for Resident #104 revealed the following: No skin assessments from 4/17/20-5/14/20. 6/1/2020 at 11:39 AM: Describe any impairments in skin integrity: Right antecubital- skin tear; Coccyx- redness, Groin- redness. 6/2/2020: Skin Monitoring: Comprehensive CNA Shower Review, identified both feet had dryness. A nurse signed the form on 6/2/2020 and the section for Interventions, was blank, as was the DON Signature line. 6/19/2020: Skin Observation Tool - (Licensed Nurse),No open areas or concerns identified. Superficial scratches on (bilateral) arms and knees. 6/26/2020: Skin Observation Tool - (Licensed Nurse), Heels are slightly reddened however they are blanchable. There were no interventions noted. A review of the physician orders [REDACTED]. There was no order mentioning the heels, as of 7/7/20. A review of the Resident's Care Plans provided the following: . potential for pressure ulcer development related to incontinence, refusal of care . date initiated 7/8/19 and revised 6/12/20 with Interventions: . can turn self . dated 7/8/19, Clean skin when soiled, if she refuses, leave and attempt again later, dated 9/3/19 (there was no indication for how long to wait before returning to provide care) or other interventions to attempt to promote care, Weekly skin assessment with bathing, dated 3/25/20 (9 months after admission). Per the MDS assessment dated [DATE] the resident needed extensive 2-person assistance with bed mobility to turn and reposition. .ADL Self Care Performance Deficit . date initiated 7/8/19 and revised 3/25/20 with Interventions: Ambulation: assist with ambulation as able, report unsteadiness, dated 7/8/19 revised 6/12/20. It does not indicate the amount of assistance needed, Does prefer to sleep in recliner, dated 12/20/19, She has a recliner chair in her room for her to sit in and elevate feet as tolerated and she prefers to sleep in the recliner chair, dated 3/2/20. There was no recliner chair in her room. Bed Mobility: The resident is able to assist to turn and reposition, assist/supervise as needed, dated 7/8/19 and updated 6/12/20. The resident needed 2-person extensive assistance with repositioning. Eating: The resident is able to hold cup, feed self, eat finger foods independently, supervise, assist if needed, dated 7/8/19. The care plan had not been updated to indicate the resident needed increased assistance with eating. Toileting: requires extensive assistance of 1 . dated 7/8/19 and updated 6/12/20. Per the recent MDS, the resident needed 2-person extensive assistance. Transfer: 1-person extensive assistance, dated 7/8/19 and updated 6/12/20. The care plan had not been updated to show Resident #104 needed 2-person assistance with transfers. On 6/25/20 at 10:35 AM, during an interview with CNA EE she was asked if Resident #104 sat up in a chair daily and she said, She needs 2 people and she yells a lot, so sometimes she doesn't. CNA EE was asked if the resident had eaten breakfast and she said the resident had not eaten much and she would go in and out of the room to help her. The CNA did not stay in the resident's room to help her with the meal. An interview with Confidential Person II on 6/29/20 at 10:40 AM, revealed (On 6/28/20 the resident) was laying there crying and screaming and they went out and shut the door. I could see it through the window. They say they are feeding her, but I don't know. I think she needs help. She can't get her hand up there. They come in and give her a few bites and leave and don't come back. An interview with Wound Care Nurse I on 6/30/20 at 2:30 PM, she said she had updated the resident's Care Plan to include pressure relief/to offload the heels. When asked about assessment of the resident's skin, she said the nurses on the floor were responsible for completing weekly skin assessments. During an interview with Hospice Nurse CC on July 7, 2020 at 10:25 AM, about Resident #104's decline in condition and complaints of discomfort of her left reddened heel, the nurse said she would provide the resident with a pressure relieving heel boot. During an interview with the DON on 7/8/20 at 12:23 PM, she said the facility had ordered a pressure relieving air mattress for the resident, initiated a significant change MDS assessment related to an overall decline in condition and significant weight loss and ordered lab work related to an abnormal [MEDICAL CONDITION] function test (TSH 43.6 from January 2020). Resident #103 According to the Admission Record, printed on 6/29/2020, Resident #103 was a [AGE] year old male admitted to the facility on [DATE], hosptalized on [DATE], readmitted on [DATE], hospitalized again on 4/22/2020 and readmitted on [DATE] and discharged on [DATE]. The [DIAGNOSES REDACTED]. The first mention of a skin problem was noted in the nursing progress notes on 3/10/2020 at 9:42 PM the Wound Care Update documented a reddened area on right buttock with superficial open area measuring 1.5 cm (centimeters) by 4 cm by 0.1 cm. 2.5 cm by 1.6 cm open area on left buttock with area surrounding 15 cm by 5 cm of red tissue. The Wound Bed Description was, Bright red with uneven wound edges. The Odor, drainage, pain control was noted as No odor. Has small amount of serosanguinous drainage. According to the Merriam-Webster dictionary, serosanguinous is both clear and bloody, consisting of serous fluid and blood. The current treatment was to wash the area with normal saline, pat dry and apply a thick layer of Zinc ointment over the area. Turning Resident #103 from side to side and limit time on his buttocks to being up for meals only. The physician assessed the area on 3/12/2020 and documented Multiple scattered stage one and 2 wounds bilateral sacrum and buttocks. The treatment the physician outlined for Resident #103 included a [MEDICATION NAME] dressing to the buttocks daily with frequent position changes. A [MEDICATION NAME] dressing turns to gel when there is moisture, or drainage, added. According to the National Pressure Injury Advisory Panel (NPIAP), 2016, a stage 1 pressure injury was described as localized damage to the skin and underlying soft tissue. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. A stage 2 pressure injury was described as partial-thickness loss of skin with exposed dermis (underlying skin tissue). The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Granulation tissue, slough (dead tissue) and eschar (black or brown leathery skin) are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. A stage 3 pressure injury was described as full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. A stage 4 pressure injury was described as full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. An unstageable pressure injury was described as full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. The next entry on the progress notes regarding the wounds on the buttocks of Resident #103 were entered by the physician on 3/23/2020 when she documented Stage 1 and 2 pressure wounds buttocks and sacrum. The next entry on the progress notes for Resident #103 related to the wounds were on 3/30/2020 noted as a Wound Care Update. Right heel 3.5 cm by 2.5 cm by 0.05 cm, bright red circular wound bed with 10% black slough tissue. surrounding tissue appears boggy and macerated. According to the medical dictionary, macerated means soft and in a state of deterioration due to prolonged contact with moisture. The treatment ordered was to cleanse wound bed with normal saline and apply santyl (an ointment that helps to break up and remove dead skin) to affected area. Cover with [MEDICATION NAME] dressing and change every evening and as needed when soiled. The wound on the right buttock was measured as 5.5 cm by 4.5 cm and described as 100% slough black necrotic tissue circular wound bed, surrounding skin consist of moderate [DIAGNOSES REDACTED] on surrounding edges and mild peeling. The treatment for [REDACTED]. The next entry on the progress notes for Resident #103 related to the wounds were on 4/2/2020 noted as a Wound Care Update. Wound #1 Right buttock 5 cm by 8.3 cm., and increase in size from 3/30/2020, with a 100% slough black necrotic tissue with minimal serosanguinous drainage. And Wound #2 Right heel 5.5 cm by 3.5 cm by less than 0.05 cm, unstageable, presents as a peeling white cover of skin surrounding resident's heel with a black center. Resident #103 was discharged to the hospital on [DATE] with respiratory distress. The hospital notes for 4/11/2020 through 4/20/2020, the date of his discharge, stated, Patient was admitted to the hospital for Covid 19 pneumonia. He was also found to have a large sacral decubitus ulcer with purulent drainage. He was treated with IV antibiotics however due to the size of the wound decision was made by family to electively debride the wound to allow chance to heal. We have multiple discussions with the family given the fact that he is not eating and drinking in his advanced age and dementia the wound is unlikely to heal however they wish to proceed. Cultures were taken and ID (Infectious Diseases) recommended they go on meropenem for 6 weeks. Also in the hospital notes, Patient came with coccyx/bilateral buttock wounds and bilateral heel wounds. According to hospital records, on 4/17/2020, a surgeon at the hospital performed a surgical debridement of the bilateral sacral wounds of Resident #103 to remove the dead tissue to improve the possibility of healing. The surgical removal of the eschar of the right and left sacral wounds were described as, electrocautery (a small probe with electric current running through it used to burn skin) was used, severe malodorous smell was expressed upon entering the tissue, the necrotic soft tissue was taken down until healthy and viable tissue and muscle was visualized. Electrocautery was used to control the bleeding. The tissue was removed until the bony surface of the sacrum was observed. The wounds were classified as a stage 4 after the debridement and a wound vac (vacuum assisted closure) was applied. A wound vac is used to provide a negative pressure environment in the wound, thought to improve healing and decrease the chances of infection. Following the surgery, the right sacral wound was measured as 11 cm by 1 cm by 2 cm, and the right sacral wound was measured as 9 cm by 8 cm by 2 cm. The discharge instructions included directions for the peripherally inserted catheter (PICC) line and directions to administer Meropenem, 500 milligrams every 6 hours, intravenously for 42 days. The Patient Transfer and Assessment, dated as 4/20/2020, clearly stated that Resident #103 had a PICC line, was to receive a wound vac for his sacral pressure ulcers. The facility Readmission Assessment with an admission date of [DATE] with a time of 00:00, had an Effective Date of 4/20/2020 and time of 11:21 PM and Admission of 4/23/2020. Under the section for skin issues listed the Right heel as a Pressure under Type with nothing filled in for length, width, or depth, and Unstageable under the Stage column, the Left heel was also listed as Pressure with nothing under the columns for length, width, or depth, and Unstageable under the Stage column, and the Sacrum listed as Pressure and no length, width, or depth, with Unstageable under the column for Stage. The admission note in the Nursing Progress Note dated 4/20/2020 at 6:38 PM, had no additional identification or description of the wounds. The progress note did state that the physician was notified and the orders were verified. When Resident #103 was readmitted to the facility on [DATE], the Meropenem was ordered, but not recorded on the April 2020 Medication Administration Record [REDACTED]. When asked if Resident #103 had been administered the IV Meropenem, the DON answered, It was not delivered from pharmacy. The DON also reviewed the electronic medical record and said, It doesn't look like they stated a wound vac in the orders, and, the admissions department would have ordered the wound vac for use at the facility. On 7/1/2020 at 2:15 PM, staff member LL, the Licensed Practical Nurse (LPN) who worked in the admissions department was interviewed by telephone. LPN LL stated that she could not recall and could not find documentation that the wound vac for Resident #103 had been ordered from a supply company that provided such equipment to the facility, although, she could see in the hospital referral from 4/20/2020 that he had the wound vac. On 4/21/2020 at 1:54 AM, a Nursing Progress Note documented that Resident #103 had arrived at the facility, that the wound vac dressings and tubing has arrived, but we are still waiting on the actual wound vac to arrive. Resident #103 was sent back to the hospital on [DATE] and was seen in the emergency room at 7:59 PM by a physician who documented, Apparently the patent's wound VAC was not attached while at The Villages and it is uncertain if the patient received any IV Merem doses as prescribed. Additional hospital records indicated that Resident #103 returned to the facility on [DATE] under the services of hospice for comfort care. The Admission-Readmission Nursing Assessment, with an effective Date of 4/20/2020 at 6:36 PM and an admission date of [DATE] was a blank form, with no date entered under Most Recent Admission and nothing entered under the section for skin issues. There was a Nursing Progress Noted dated 4/23/2020 at 5:50 PM that stated, Resident arrived via ambulance stretcher, . There were no vital signs recorded and no description or measurements of the wounds. The facility policy and procedure for Pressure Ulcer/Injury Risk Assessment, dated as revised 7/2017, stated that The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing pressure ulcers/injuries. The 5th step in the procedure directed that The risk assessment should be conducted as soon as possible after admission, but no later than eight hours after admission is completed. Step six was the direction to repeat the risk assessment weekly for the first four weeks. The facility pressure Ulcers/Skin Breakdown - Clinical Protocol, dated as revised 3/2014, stated that the documented risk assessment for development of a pressure ulcers, and a full assessment of pressure sore, including location, stage, length, width, and depth, presence of exudates or necrotic tissue. The staff will examine the skin of a new admission for ulcerations or alterations in skin. There was no time frame in the policy for how quickly after the admission the assessment should be performed. There was a section for Monitoring, which stated that, During resident visits, the physician will evaluate and document the progress of wound healing - especially for those with complicated, extensive, or non-healing wounds. Again, there was no time frame mentioned in the policy, procedure, or protocols for how often the physician was to evaluate these wounds. The Nursing Progress Note, dated 4/24/2020 with a time of 5:35 AM, listed vital signs and a pulse oxygen saturation of 92%. There was a statement included bilateral (both) heels open areas, wound dressing treatment 4/22, wet to dry dressing. Redness right hip scattered, right knee old surgical scar, bilateral buttocks redness noted. Right lower calf redness and [MEDICAL CONDITION] noted. There were no measurements or description of the open areas. This was not what had been identified in the hospital transfer records from 4/23/2020. On 4/24/2020, the facility physician documented in the Progress Notes that Resident #103 had not received any IV antibiotics since his admission and the wound vac was not to vacuum. In addition, the physician documented Stage 4 pressure wound sacrum with [DIAGNOSES REDACTED] (bone infection). The first measurements and descriptions of the pressure wounds of Resident #103 were documented on 4/29/2020 at 12:57 PM, six days after admission. These were documented in the Progress Notes as Wound Care Update: Right buttock 8.3 cm by 8 cm with tunneling 1.3 cm by 1 cm by 2 cm by 1 cm, left buttock 6.5 cm by 4 cm with tunneling 3.5 cm by 1.5 cm by 0.5 cm by 2 cm. Right heel 3.8 cm by 1.3 cm by less then 0.05 cm. Right and left buttock wound bed is circular with black/yellow edges and pink/white center. Right heel is covered with eschar. Right and left buttocks have minimal odor and a small amount of serosanguinous drainage. There was no description or measurement of the left heel. None of the wounds were assigned a stage in the documentation. The treatments listed for the right and left buttocks was to cleanse with normal saline and pack with kerlix were to dry and cover with abdominal pads. The right heel was to cleanse with normal saline, apply Santyl, cover with non-adhesive pad and wrap with Kerlix. There was no documentation of the left heel wound. During a telephone interview with Registered Nurse (RN) T on 6/30/2020 at 3:08 PM, RN T stated that she did not recall Resident #103. RN T said that the process for pressure ulcer monitoring was, at the time Resident #103 had resided in the facility, for the floor nurses to monitor and measure wounds weekly. The nurses would perform skin checks on admission and re-admission and document on the admission assessment, for every admission and re-admission, in the section specifically for skin. During a telephone interview with the Director of Nursing (DON) on 6/30/2020 at 3:06 PM, The DON reported that there was no readmission assessment for Resident #103 on 4/23/2020. There was, the DON stated, a detailed progress note, that stated he was oriented to the room, vital signs were recorded, and an admission assessment was initiated with a skin check, but there wound measurements did not get documented until 4/29/2020. The DON said that the weekly wound measurements, were done on 2/27/2020, 3/5/2020, 3/12/2020, 3/19/2020, and 3/26/2020, but, she did not see weekly measurements after the entry on 3/26/2020. The charts were all in the electronic medical record according to the DON, there were no paper charts. In a follow-up telephone interview on 7/1/2020 at 11:54 AM, the DON reported that at the time of Resident #103's admissions there was no nurse responsible for monitoring the wounds of the residents. The DON also confirmed that there was no wound assessment documented until 4/29/2020.

This citation pertains to intake MI 901. Based on interview and record review, the facility failed to 1) ensure the safety and supervision of one resident (Resident #102) during feeding who was Dysphagic (difficulty swallowing) and 2) ensure one staff member (Nursing Assistant/CNA Q) was orientated per facility policy prior to receiving resident assignments, of 3 residents reviewed for Therapeutic Diets, resulting in Aspiration Pneumonia with septic shock (pneumonia due to food particles ingested into lungs with infection throughout the body), hospitalization , intubation (an artificial airway, endotracheal tube), ventilatory dependency due to [MEDICAL CONDITION] (ventilator dependent for oxygenation) and having a Endoscopic Gastrostomy tube placement (feeding tube). Finding Include: Review of the Face Sheet, Minimum Data Set (dated 4/29/20), physician progress notes [REDACTED].(dated 5/21/20 through 6/2/20), Dietitian note's (dated 5/20/20 & 6/4/20) and physician orders [REDACTED].#102 was [AGE] years-old, admitted to the facility on [DATE], was confused and dependent on staff for Activities of Daily Living (ADL's) and was a one-on-one feeding due to Dysphagia. The resident was transferred to the hospital on [DATE], with a [DIAGNOSES REDACTED]. The resident's [DIAGNOSES REDACTED]. Review of the physician order [REDACTED]. Review of Dietary note's dated 6/4/20, stated 1:1 (one-on-one) feeding assistance. Review of the Nutritional Risk assessment dated [DATE], revealed the resident had swallowing difficulties and Choking on thin liquid and was on a Mechanical soft diet. Review of the resident's Admission-Readmission Nursing assessment dated [DATE], stated Assistance: Requires constant assistance and/or supervision throughout meal. Review of the resident's care plan dated 6/4/20, revealed no documentation of instructions that the resident was a non-on-one with feeding. During a phone interview done on 6/30/20 at 3:10 p.m., the Director of Nursing (DON) confirmed there was no documentation of feeding instructions were put on the resident's care plan and stated, it should have been on there. Review of the nursing notes dated 6/18/20 at 3:30 a.m., stated Resident was observed by staff with difficulty breathing, lung sounds diminished bilaterally, (Resident #102) continued to holler out loud I'm choking nurse I'm choking, suctioned large amounts of thick greenish secretions from back of throat. Review of the nursing notes dated 6/18/20 at 7:10 a.m., stated Resident was transferred to Hospital via 911 due to respiratory distress. Review of the hospital Emergency Department Chart dated 6/18/20, stated (Ambulance staff) states that he ate a solid meal he is normally not supposed to eat solid food and became short of breath. On arrival patient is hypoxic (low oxygen) and has a rhonchorous breath sounds (abnormal breath sounds). Patient was coid (COVID) positive approximately 4-6 weeks ago. Diagnosis: [REDACTED]. Review of the hospital X-ray dated 6/24/20, stated Scattered bilateral infiltrates are unchanged. Review of the ED (Emergency Department) Summary dated 6/18/20, stated On arrival is hypoxic, patient is using accessory muscles (sign of respiratory distress). Respiratory performed suction was able to get some phlegm and food out of his throat. Patient was monitored and patient becoming more lethargic, patient is agreeable to intubation (a trachea put in, artificial breathing tube in throat). Patient did have sputum and food particles coming out of his trachea and was suctioned multiple times. Review of the hospital HPI (history information) dated 6/18/20, stated Chief Complaint: Aspiration, Presented to the ED from (the facility) with complaints of shortness of breath. He (Resident #102) had a large amount of white material aspirated, patient unable to maintain adequate oxygenation and required intubation. Review of the hospital ICU (Intensive Care Unit) notes dated 6/19/20, stated Brought to emergency department with labored respiration and determined to have aspirated. He required intubation and mechanical ventilation ([MEDICAL CONDITION]; put on a ventilator). The resident was diagnosed with [REDACTED]. Review of the hospital Operative Report dated 6/24/20, revealed the resident had a Endoscopic Gastrostomy tube placement (feeding tube) due to dysphagia (difficulty swallowing). During a phone interview done on 6/29/20 at 3:20 p.m., Family Member N stated They were giving (Resident #102) regular food, he was laying in bed when they were feeding him. She (CNA Q) fed him laying down in bed, (Resident #102) was choking and she raised the bed up and gave him something to drink (while choking on food), he then had a hard time. I was outside the window (of the resident's room due to COVID-19 restrictions), I witnessed it. During an interview done on 6/30/20 at 9:15 a.m., CNA Q stated On the 17th (6/17/20, one day prior to Resident #102's hospital transfer), I went in and fed him dinner (approximately 5:00 p.m. to 5:30 p.m.). I didn't have his head of the bed up when I was feeding him. I didn't get all the training here (at facility). I got two days of in service, I didn't do my check off list on the floor. CNA Q revealed, when the resident started choking on his food, then she raised the head of his bed up. CNA Q was unable to recall what she had fed Resident #102 on 6/17/20. During a phone interview done on 6/29/20 at 1:40 p.m., CNA K stated I know he did not eat his breakfast and was choking (on 6/18/20, the day the resident was transferred to the ED); the nurse said not to feed him that day and then he was sent out. During a phone interview done on 6/29/20 at 2:19 p.m., CNA O stated The head of the bed should be up like 45 degrees to 80 degrees (when feeding a bedbound resident). During an interview done on 6/30/20 at 1:46 p.m., CNA P stated The head of the bed has to be up with feeding. Review of CNA Q's Human Resource file revealed documentation of employment dated 6/5/20, without any documentation found of a skill check list completed (including feeding a resident in bed and feeding safety measures). During an interview done on 6/30/20 at 10:00 a.m., Human Resource staff member R was unable to locate any skills check-off documentation in CNA Q's file and stated, it's not here. During an interview done on 6/30/20 at 10:40 a.m., the DON stated When (previous facility educator) walked out, (Facility Compliance Officer, Nurse, RN A) was responsible for new hires orientation. During an interview done on 6/30/20 at 10:47 a.m., the Administrator stated she (Nurse A) should have been going over everything, she has been sick). During a phone interview done on 6/30/20 at 3:10 p.m., the DON said CNA Q should have had completed the check off questions in orientation and she verbalized how not being assessed for feeding a resident in bed during orientation played a part in the feeding of Resident #102 when the head of the bed was left in a low position during feeding. Review of the facility Nursing Staff Competency Assessment (un-dated, a check off of several topics including basic resident care) revealed, during orientation CNA's were to fill out the resident care check off questions. Review of page 23 of the Nursing Staff Competency Assessment, was documented that eating was part of residents ADL care. The Competency Assessment stated Develops and follows a person-centered plan of care addressing each resident's range in ability to perform activities of daily living (ADL's) (e.g., bathing, grooming, toileting, bed mobility, eating, transfer and locomotion). Supports residents in order to help them maintain their highest level of functioning. During an interview done on 6/30/20 at 10:47 a.m., CNA Supervisor S said the facility used the Nursing Competency Assessment as the CNA skills check off for orientation. CNA Supervisor S stated They (CNA's) have training on the floor with the competency list (Competency Assessment tool); they are supposed to get it all checked off. Review of the facility Orientation manual (un-dated) stated Each position requires that certain tasks are reviewed during your orientation period and then annually. If you have a position that involves direct resident care, such as a licensed nurses, CENAs (CNA's), ect. that need to have task check off lists completed to ensure that your skills are maintained up to date. The right (Residents Rights) to reside and receive services in the facility with reasonable accommodation of resident needs and preferences (including basic needs such as feeding). Review of the facility Orientation Program for Newly Hired Employees, Transfers, Volunteers policy (un-dated), stated An introduction to resident care procedures which includes but is not limited to: a review of the facility's Nursing Assistant's Training Program. Our orientation program is an in-depth review of our facility's policies and procedures. A checklist is used to record materials reviewed with each employee. Review of the facility Emergency Orientation Program dated March 2020, revealed new employees would be educated on a brief description of resident population, job description, resident rights and personnel policies only. Review of the Emergency Orientation Program revealed no documentation of any CNA resident centered orientation, nor a date that the newly hired CNA's would be orientated on resident care (including feeding a resident in bed). No further documentation was made available by the facility.

This citation pertains to MI 892. Based on interview and record review, the facility failed to administer an intravenous antibiotic medication to one resident (#103) out of two residents reviewed for medication administration resulting in the potential for serious negative health outcomes and re-hospitalization . Findings include: According to the Admission Record, dated 6/29/2020, Resident #103 was a [AGE] year old male originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Nursing Progress Note, dated 4/11/2020, Resident #103 was sent to the hospital where he was diagnosed with [REDACTED]. The physicians prescribed the intravenous antibiotic medication Meropenem 500 Milligrams (mg) to be given intravenously (IV) every six hours for 42 days. A physician consult for the infected wound with suspected bone infection on 4/14/2020. A physician note on 4/20/2020 stated that Resident #103 was also found to have a large sacral decubitus ulcer with purulent drainage. He was treated with IV antibiotics . The decision was made by the infectious disease doctor to place Resident #103 on Meropenem for 6 weeks. The hospital admitting [DIAGNOSES REDACTED]. According to the Census List, printed on 6/29/2020, Resident #103 was readmitted on [DATE] at 6:36 PM. The hospital transfer medication sheet, printed 4/20/20 at 2:28 PM, listed the last dose of Meropenem as having been administered at 11:02 AM and due at 5:00 PM, with instructions that the Meropenem was a time critical medication, administration must be within 30 minutes of the scheduled time. During a telephone interview with Registered Nurse (RN) T on 6/30/2020 beginning at 3:08 PM, RN T stated that she did not recall Resident #103, but explained the process for ordering medications for residents upon their admission. RN T explained that the medication orders were entered into the computerized system, after conferring with the physician. If the medications were not available in the facility, the nurse could call the pharmacy for an immediate drop shipment. When a nurse needed to contact a physician, there was a mechanism in the computer system where the nurse could check a box for physician notification, and the contact would be made by the system, or, the nurse could directly call the physician. The Nursing Progress Note for Resident #103 on 4/20/2020 at 6:38 PM, documented that the physician had been contacted and the medication list had been verified as well as the wctm, but there was no explanation for what the wctm was. According to the facility physician orders, printed on 6/29/2020, the Meropenem 500 mg IV every 6 hours was ordered on [DATE] at 6:00 AM. The Medication Administration Record [REDACTED]. The doses that were to be administered on 4/21/20 at 6:00 AM, 12:00 PM and 6:00 PM and 4/22/2020 at 12:00 AM were coded as 9 and the dose for 4/22/20 at 6:00 AM was coded as 5. The codes 9 and 5 meant the medication was not given and to see nurses notes, however, there were no nurses notes for those five missed medication administration times. The Meropenem ordered on [DATE] was not given at all, with no explanation. The Meropenem was discontinued on 4/23/20. The nurses notes also did not mention a change of condition or sending Resident #103 back to the hospital, but there was a nursing progress note on 4/23/2020 at 5:50 PM that stated, Resident arrived via ambulance stretcher . The Census List in the electronic medical record showed a discharge at 11:03 AM on 4/22/2020 with a readmission on 4/23/2020 at 5:48 PM. On 4/27/2020 the attending physician at the facility conducted a telehealth visit with Resident #103 at 4:23 PM utilizing Skype, noting the readmission on 4/23/2020, stating Pt had not received any IV ABX (antibiotics) since admission. The note from the physician in the emergency roiagnom on [DATE] at 7:59 PM, stated it is uncertain if the patient received any IV Merem doses as prescribed. The hospital noted on 4/23/2020 at 3:00 PM that a hospice consult was obtained and the family was agreeable to hospice services after a discussion about Resident #103's poor prognosis and the physician recommendation of comfort care. On 7/1/2020 at 11:54 AM, a telephone interview was conducted with the Director of Nurses (DON). The DON was asked about the IV Meropenem order for Resident #103 and if Resident #103 ever received the ordered IV antibiotic medication, the DON stated, it was not delivered from the pharmacy. The DON stated that she did not find documentation that the physician had been notified that the IV Meropenem had not been administered. According to the facility policy and procedure for Administering Medications via Secondary Tubing, dated as revised December 2012, the purpose of the procedure was to provide guidelines for the safe and aseptic administration of medications intravenously through a secondary (piggy back) line. The steps under the section for Reporting instructed that the physician be notified if the medication was not infused. According to the facility policy and procedure for Accepting Delivery of Medications, dated as revised April 2007, included in the policy statement, Any errors noted in receiving medications shall be brought to the attention of the Pharmacist and Director of Nursing Services. The procedure included: Before signing to accept the delivery, the Nurse must reconcile the medications in the package with the delivery ticket/order receipt.; If an error is identified when receiving medications from the pharmacy, the Nurse verifying the order shall: a. Inform the delivery agent of discrepancies and note them on the delivery ticket; . d. If the number of a medication or packages of medications is incorrect, and the medication is an emergency order, the order may be accepted and the accepting nurse shall write that information onto the delivery ticket/order receipt. The dispensing pharmacy, consultant pharmacist, and Director of Nursing Services shall be notified of medication order errors.

This Citation pertains to Intake Numbers MI 563 and MI 578 Based on observation, interview and record review, the facility failed to follow accepted Infection Control standards of practice to ensure the appropriate Personal Protective Equipment/PPE (the use of facial masks) was made available for staff usage when caring for residents during the onset of the facility's COVID-19 outbreak of a census of 58 residents, resulting in increased COVID-19 cross contamination, 25 facility residents with reported positive COVID-19 tests (Residents #301, #302, #303, #304, #305, #306, #307, #308, #309, #310, #311, #312, #314, #315, #316, #319, #320, #321, #322, #323, #324, #325, #326, #327 and #328), numerous staff members with reported positive COVID-19 test results, 6 resident deaths (Residents #312, #314, #315, #316, #319 and #324), and the potential for further cross contamination of other residents residing in the facility with possible hospitalization and death. Immediate Jeopardy: This immediate jeopardy began on [DATE], when the former Director of Nursing F came into the facility therapy room and told Occupational Therapist/OT B to remover her own personal protective face mask and told OT B she was not going to wear the mask in her building. This was during a worldwide pandemic of the COVID-19 virus. According to the Michigan Department of Health and Human Services (dated [DATE]), Lapeer County had the first case reported of the [MEDICAL CONDITION] on [DATE]. Thirty four cases had been reported in Genesee County (adjacent county) and the total reported COVID cases in Michigan that were reported on [DATE], had reached 1,791, up from 1,328 the day before. Two Nursing Assistants had been sent home from working at the facility on [DATE], by previous Director of Nursing/DON F, for wearing their own protective face mask while caring for facility resident's. The County Health Department reported during a phone interview done on [DATE] at 10:55 a.m., that the facility had a total of 22 residents with a positive COVID-19 test result. As of [DATE], there was a total of 25 residents who tested positive for COVID-19. The immediate jeopardy was identified on [DATE] at 4:00 p.m., the Administrator and Interim Director of Nursing were notified on [DATE] at 11:04 a.m.; accepted by the Interim Director of Nursing on [DATE] at 11:17 a.m., of the immediate jeopardy that began on [DATE], due to the facility's failure to follow accepted Infection Control standards of practice to ensure and provide the appropriate Personal Protective Equipment and allow staff to wear protective face masks. Findings Include: PPE is equipment that is to be worn to minimize exposure to a variety of hazards. The Employer obligations include, a hazard assessment, identifying and providing appropriate PPE for employees and training employees in proper usage of PPE. Employers must pay for PPE for their employees, on [DATE] this OSHA rule went into effect. The standard makes clear that employers cannot require workers to provide their own PPE and the worker's use of PPE they already own must be completely voluntary. OSHA Healthcare Workplace Classified as Very High or High Exposure Risk for Pandemic Influenza (would include COVID-19), OSHA Publication No. 3328, Pandemic Influenza Preparedness and Response Guidance for Healthcare Workers and Healthcare Employers Long-term care facilities should ensure all staff are using the appropriate PPE while giving care and interacting with residents to the extent PPE is available and per CDC (Center for Disease Control) guidance. The facilities are to determine the amount necessary for daily use and ensure the proper PPE is made available at each shift. CDC Up-date [DATE], CMS (Centers for Medicare & Medicaid Services), COVID-19 Long Term Care Facility Guidance, [DATE] All Long-term care facilities should require those involved in direct patient care to wear a mask per standard recommendations. If national and local supplies are at contingency levels, only direct care staff should use one mask per shift. https://www.cdc.gov/coronavirus/2019 Timeline of Facility COVID-19 Positive cases: During a phone interview done on [DATE] at 10:08 a.m., the county Health Department spokesperson I stated I have 22 resident's that have tested positive, some of the residents are in the hospital and 2 have died (as of [DATE]). During a phone interview done on [DATE] (at 4:17 p.m. and again at 4:50 p.m.), Physician MD K and Infection Control Nurse, RN L, revealed as of [DATE], the facility had a total of 17 residents that had tested positive for the COVID-19 virus and 3 residents who also had tested positive for [MEDICAL CONDITION] and had deceased . During a phone interview done on [DATE] at 11 :50 a.m., the current DON Q and SW C revealed there was a total of 25 residents who had positive COVID-19 lab results and a total of 6 residents with positive COVID-19 lab results who had deceased . Review of documentation provided by the facility on [DATE], 1 staff member resigned, 3 said they would not return because of the media coverage of 101 staff members employee, 12 had tested positive for COVID-19, 6 COVID-19 tests were still pending and 19 other staff were on out due to illnesses and self-quarantine. During a phone interview done on [DATE] at 10:15 a.m., the current DON N stated According to the documentation provided to that (the above statement) is true. During an interview done on [DATE] at 3: 44 p.m., the Administrator and Infection Control Nurse L revealed the facility had 15 residents in the building with positive COVID-19 tests on the East unit, 6 residents with COVID-19 signs/symptoms and/or positive tests in the hospital and 8 residents who had positive COVID-19 positive tests who had deceased . Review of the typed note by DON N dated [DATE] sent at 4:04 p.m., stated We currently still have 6 residents in the hospital (4 of the 6 residents had a positive test for COVID-19, Residents #326, #327, #328 and un-sampled #329). Review of the hospital and facility lab results for residents who had tested positive for the COVID-19 virus and facility residents who had deceased are as follows: -Resident #301, on [DATE], the resident tested positive for COVID-19. Review of the lab dated [DATE], revealed COVID19 was detected. -Resident #302, on [DATE], the resident tested positive for COVID-19. Review of the lab dated [DATE], revealed COVID19 was detected. -Resident #303, on [DATE], the resident tested positive for COVID-19. Review of the lab dated [DATE], revealed COVID19 was detected. -Resident #304, on [DATE], the resident tested positive for COVID-19. Review of the lab dated [DATE], revealed COVID19 was detected. -Resident #305, on [DATE], the resident tested positive for COVID-19. Review of the lab dated [DATE], revealed COVID19 was detected. -Resident #306, on [DATE], the resident tested positive for COVID-19. Review of the lab dated [DATE], revealed COVID19 was detected. -Resident #307, on [DATE], the resident tested positive for COVID-19. Review of the lab dated [DATE], revealed COVID19 was detected. -Resident #308, on [DATE], the resident tested positive for COVID-19. Review of the lab dated [DATE], revealed COVID19 was detected. -Resident #309, on [DATE], the resident tested positive for COVID-19. Review of the lab dated [DATE], revealed COVID19 was detected. -Resident #310, on [DATE], the resident tested positive for COVID-19. Review of the lab dated [DATE], revealed COVID19 was detected. -Resident #311, on [DATE], the resident tested positive for COVID-19. Review of the lab dated [DATE], revealed COVID19 was detected. -Resident #312, on [DATE], the resident tested positive for COVID-19. The resident deceased on [DATE]. Review of the lab dated [DATE], revealed COVID19 was detected. -Resident #314, on [DATE], the resident tested positive for COVID-19. The resident deceased on [DATE]. Review of the lab dated [DATE], revealed COVID19 was detected. -Resident #315, on [DATE], the resident tested positive for COVID-19. The resident deceased on [DATE]. Review of the lab dated [DATE], revealed COVID19 was detected. -Resident #316, on [DATE], the resident tested positive for COVID-19. The resident deceased on [DATE]. Review of the lab dated [DATE], revealed COVID19 was detected. -Resident #319, Per interview done on [DATE] at 4:17 p.m., Physician K revealed on the residents Death Certificate was put COVID-19. The resident decreased on [DATE]. -Resident #320, on [DATE], the resident tested positive for COVID-19. Review of the lab dated [DATE], revealed COVID19 was detected. -Resident #321, on [DATE], the resident tested positive for COVID-19. Review of the lab dated [DATE], revealed COVID19 was detected. -Resident #322, on [DATE] the resident tested positive for COVID-19. Review of the ab dated [DATE], revealed COVID19 was detected. Review of the lab dated [DATE], revealed COVID19 was detected. -Resident #323, on [DATE], the resident tested positive for COVID-19. Review of the lab dated [DATE], revealed COVID19 was detected. -Resident #324, on [DATE], the resident tested positive for COVID-19. The resident deceased on [DATE]. Review of the lab dated [DATE], revealed COVID19 was detected. -Resident #325, on [DATE], the resident tested positive for COVID-19. Review of the lab dated [DATE], revealed COVID19 was detected. -Resident #326, on [DATE], the resident tested positive for COVID-19. Review of the lab dated [DATE], revealed COVID19 was detected. -Resident #327, on [DATE], the resident tested positive for COVID-19. Review of the lab dated [DATE], revealed COVID19 was detected. -Resident #328, on [DATE], the resident tested positive for COVID-19. Review of the lab dated [DATE], revealed covid19 was detected. During a phone interview done on [DATE] at 9:11 a.m., previous DON F stated we had enough masks and PPE, I was saving them. She (Administrator) said she's keeping the masks in her office locked only.; she kept them on a little table in the corner of her office. During a phone interview done on [DATE] at 12:20 p.m., the Administrator said the facility had enough masks and PPE in the building on [DATE], for staff to use (including masks). The Administrator said the facility had N-95 face masks, gowns, gloves, face shields and hand sanitizer in the facility. She said the masks were available to staff. The Administrator stated, I am so sick, I got a hold of my doctor, she changed my antibiotic. I am going to get tested (for COVID-19). The Administrator said she had been in the facility every day, even on the morning of [DATE]. The Administrator said she had cough, congestion, some body aches and was taking Tylenol. The Administrator had a high potential for being a vector (transmit pathogen) passing the COVID-19 virus to residents and staff at the facility. During a phone interview done on [DATE] at 10:13 a.m., the current Director of Nursing, RN N revealed her first day as the DON was [DATE], she just started as the DON and said the Administrator was not in the facility at this time; DON N stated The Administrator does not have a doctor note yet (to be cleared to be in the facility after having signs/symptoms of COVID-19), waiting for one to come back to facility. Review of the Physician typed note dated [DATE], revealed the Administrator may return to work on [DATE]. The typed note also revealed the Physician had seen the Administrator in the office on [DATE], and again per phone on [DATE]. The Administrator had been in the facility prior to having a Physician release to return to work. Review of the facility COVID-19 policy (un-dated), stated If you have cold symptoms, such as cough/sneezing/fever or feel poorly, request sick leave or work from home if able. If you have being (been) close contact with someone infected by COVID-19, with high chances of being infected yourself, request work from home. You will also be asked not to come into physical contact with any colleagues during this time. During an interview done on [DATE] at 2:15 p.m., Occupational Therapist/OT B stated, It happened on [DATE], I was with a resident (in the therapy room). She (DON F) told me I was not to wear a mask, she said it's not helping me. I told her it was helping me I didn't know who I have been in contact with. She said, you're going to take it off. I said no, she said not in my building, she stormed off. The Administrator was in the hall, so I told her (DONF) is sending people home for wearing a mask. I called my boss (Therapy manager) and he called the (Owner/Physician G). The next day (on [DATE]), (DONF) came storming in the therapy room and told me not to wear a mask. I told her no for the second time. She said she didn't care what the (Physician G) said. She asked me, was I choosing to go home if I didn't take it off; I went and told the Administrator. Then the two of them started yelling in the Administrators office. The next day the Administrator asked me if there was anything wrong and was there anything else, I wanted to complain about. During a phone interview done on [DATE] at 1:38 p.m., Nursing Assistant/CNA E said she was wearing her own paper facial mask at the facility as she was caring for the residents and DON F told her to take it off or go home. CNA E stated I just got my results back this morning (on [DATE], positive COVID-19 results). CNA E stated, They (management) took the PPE and locked it up, there was no PPE available at the nursing station at this time (on [DATE]). My last day was [DATE]th ([DATE]), as of this time there was no PPE at the nursing station. (DON F) told us we had to provide our own PPE. (DON F) and the Administrator had them (the PPE) locked up. I got my positive results today ([DATE]), there are 8 CNA's who tested positive. On [DATE] at approximately 1:45 PM, an interview was conducted with Social Worker C. It was explained their previous DON (Nurse F) was provided with samples of what other facilities were implementing in preparation for COVID 19. Nurse F provided pushback on implementing the necessary changes in the building, as Nurse F felt the facility did not need to prepare as there were no positive COVID 19 residents or staff. Social Worker C reported they just recently were able to implement all the necessary changes in the building. She continued, many of facility staff are upset and refusing to work as they feel they were exposed to COVID 19 from a resident or staff member. During a phone interview done on [DATE] at 10:10 a.m., CNA P stated She (DON F) put me on leave because my throat was sore, this was about the 24th (2020) or 25th (2020). When I called (DON F) and asked her if they were wearing masks, she said no. She said, we are not wearing masks, she said she took the PPE out of the building, nobody was allowed to wear it. I said I would have to consider if I was coming back to work, I haven't been back to work since. During a phone interview done on [DATE] at 11:45 a.m., CNA M revealed the facility had paper masks on the doors of the residents who had respiratory signs & symptoms of COVID-19 virus. CNA M said she had used a paper mask from the facility on [DATE], [DATE] and [DATE] without anyone telling her not to wear it. Then on [DATE], she stated (DON F) said we (CNA's) were uneducated enough to wear one (a masks). She said if you're not willing to take our masks off, we could go home. She said you can leave my building now. During a phone interview done on [DATE] at 9:11 a.m., DON F stated I told the Administrator when this first came about, there were several staff who had masks on. There were 2 or 3 , they said they didn't want to get the [MEDICAL CONDITION]. I told them we were checking temps and didn't want to alarm the residents and we wanted to save these masks. I went to one of the therapists (OT B) and a couple staff; I told them they did not need to wear them, and they shouldn't wear them in the building and the residents were getting upset. The therapist called (Physician G), then the Administrator said to let them wear them. The Administrator knew I was telling them (staff) not to wear them (masks) and she didn't say anything to me until (Physician G) was called. She told them the same thing, I heard her say that to them, and we talked about it in the morning meeting. Review of DON F's facility Human Resource/HR file revealed on [DATE], she verbally resigned from the facility. Review of the typed note dated [DATE], in DON F's Facility HR file stated On [DATE] at approximately 9:30 am, (the Administrator) asked me (HR Manager O) to be part of a conversation with (DON F) regarding employees wearing masks as PPE. When (the Administrator) told (DON F) that the staff needs to be allowed to wear masks, per Doctors, (DON F) told her to ask them how long of a notice they need because she is going to quit. (DON F) stated that she does not want her instruction undermined or gone around because it makes her ineffective in her role. Review of DON F's HR file revealed a history of facility concerns (on [DATE]) regarding the interactions between management (DON F) and staff. The Administrator talked to (DON F) with HR present regarding the proper procedure when dealing with staff and disciplinary action. During a phone interview done on [DATE] at 12:20 p.m., the Administrator stated the (DON F and Infection Control Nurse L) were doing swabs of the throat tests on all (residents with signs/symptoms). All tests (COVID-19 tests) came from (the local Health Department). (DON F) quit, she said she was not coming back, and the staff was mad at her, she would not let them wear masks because it would cause a panic. Some of the staff were wearing masks, she was sending them home. I told her they could wear masks if they wanted to. I told her this on [DATE]. (OT B) came to me and said (DON F) was sending people home for wearing masks; I told them they could wear masks if they wanted. During an interview done on [DATE] at 9:30 a.m., Social Worker C stated A lot of our staff said they were not going to return because she (DON F) was here. She was telling them not to use masks. I called one CNA (CNA E), she was one of the first CNA's to get COVID. She said she couldn't breathe. I called (DON F) after the phone call with the CNA (CNA E) and she said she told the staff not to wear masks and she locked up the stuff (PPE) in the Beauty Parlor and Medical Supply and in (the Administrators) office. You can't deny someone the right to wear the masks. During a phone interview done on [DATE] at 12:46 p.m., the DON (Interim Director of Nursing on [DATE]) stated I haven't work since [DATE], she (DON F) didn't let them wear masks. The Administrator called me on [DATE] and asked me is this the truth (staff not allowed to wear masks), I said no and tell them they are welcome to any PPE available. I did training on COVID-19 on [DATE] (twice) and [DATE] (four times). In my opinion, she (DON F) is at fault, I am going to report her to the Board of Nursing. Observations made on [DATE] at 3:55 p.m., revealed a total of 15 residents on East Hall who had positive COVID-19 lab tests. Observation was made of all PPE available to staff, including PPE at nursing stations and in the Beauty Parlor (all were unlocked and available to staff). All 15 residents were observed by this surveyor at the time with no verbalizations of any complaints. During an interview done on [DATE] at 4:03 p.m., Nurse, LPN W said she had enough PPE available and no one at the facility had told her or staff not to use masks or any other PPE. Review of the facility Isolation Categories of Transmission-Based precautions policy dated [DATE], stated Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. Review of the facility Personal Protective Equipment-Using Face Masks policy dated [DATE], stated the use of masks was, to prevent transmission of infectious agents through the air, to protect the wearer from inhaling droplets, to prevent transmission of some infections that are spread by direct contact with mucous membranes. Masks were to be used, when providing treatment or services to a patient who has a communicable respiratory infection, when providing treatment or services to a patient and the use of a mask is indicated; and when performing a task that may involve the splashing of blood or body fluids into the mouth or nose. The Immediate Jeopardy was abated on [DATE], based on observation via virtual tour of the facility staff wearing the proper PPE, including protective facial masks while interacting and caring for residents and on confirmation during interviews conducted on [DATE] 3:55 p.m., that the facility had implemented the following to remove the immediate jeopardy. 1. On [DATE], facility personal protective equipment (PPE) was available for all staff, to care for residents. 2. On [DATE], the previous director of nursing F (who resigned without notice on [DATE]) was corrected by the nursing home Administrator and Corporate Compliance Officer. She was notified at that time that staff are free to wear PPE at any time in the facility, and that sending them (staff) home if they did not take it off was an incorrect directive, was not supported by facility culture or policy. The facility had enough PPE available to staff in the PPE supply areas. 3. On [DATE], staff members who were sent home by the former Director of Nursing (DON F), were notified by facility administration that the directive was inappropriate, and they can return to work wearing the PPE of their choosing. This was also conveyed on [DATE] via PCC (electronic medical record). However, some of these staff members failed to return to work. The Administrator ensured a back-up of supply of PPE was made available for staff use. 4. The facility had received 1 official resignation and 3 staff members who have stated due to media coverage, they were not returning to work but have not contacted the facility administration or Human Recourse. Of the 101 staff members currently employed, 12 staff have tested positive for COVID-19, 6 staff members with pending test results and 19 other staff members who are out for a combination of illness, self-quarantine or other personal reasons. Necessary and enough care is occurring for residents at the facility, starting [DATE] additional staffing resources from 6 staffing agencies were elected for service. 5. As of [DATE], residents that have tested positive for COVID-19, are isolated at the facility (on East Hall) and staff are continuing to monitor for signs and symptoms and risk factors for the COVID-19 virus. Any residents exhibiting with symptoms are tested for Covid-19 and staff are sent for testing. 6. Effective [DATE], the facility initiated segregating staff (staff working on the East unit) to maintain working with those residents that have tested positive. 7. As of [DATE], all staff members were wearing appropriate PPE. Infection Control Standards continue to be practiced, including but not limited to proper PPE equipment for all staff, and CDC expectations specifically referring to COVID -19 guidelines (with CDC daily updates as needed). Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at scope and severity for potential for more than minimum harm pending the facility's ability to sustain compliance as verified by the State Agency.

This citation has 2 Deficient Practice Statements (DPS). DPS #1: Based on observation, interview and record review, the facility is placed in Immediate Jeopardy due to the facility's failure to maintain safe and comfortable temperatures for the South Hall of the facility, when the South Hall's heating system failed on Friday, 01/10/20 and a heating contractor was not summoned to repair it until Monday, 01/13/20 at 2:30 PM, during which time temperatures in residents' rooms on the South Hall dropped significantly below 71 degrees Fahrenheit. The facility is also placed in Immediate Jeopardy for its failure to perform necessary and routine maintenance of the heating, ventilation and air conditioning (HVAC) system, including in residents' rooms. Due to the compromised immune systems of the elderly population that the facility serves, this deficient practice is likely to cause serious adverse outcomes including, but not limited to, 1) loss of body heat, 2) infection, 3) sickness, 4) lack of nourishment, and 5) social isolation. This Immediate Jeopardy began on 1/10/2020 when the boiler that provides heat to the South Hall of the facility ceased working. On Monday, January 13, 2020 at 0900 hours, temperatures of all rooms in the facility were recorded by the Sanitarian on the survey team. Eight of the facility's thirty-one rooms had temperatures substantially below 71 degrees Fahrenheit, all on the South Hall. The Immediate Jeopardy was identified on 1/13/2020. During a meeting on 01/13/2020 at 04:27 PM, the NHA and DON were verbally notified of the Immediate Jeopardy and preliminary survey findings that included seven rooms with a temperature of less than 71 degrees F. The NHA stated Interim Director of Maintenance B had not told her that rooms are still temping out of range. The DON stated she did not know there was a problem with the temperatures in the resident rooms until now. It had been 26 hours since Maintenance Worker F said the cold rooms were first reported. The NHA and DON were notified in writing on 1/14/2020 at 11:34 AM of the Immediate Jeopardy that began on 1/10/2020. The Immediate Jeopardy was due to the facility's failure to maintain safe and comfortable temperatures for the South Hall of the facility, when the South Hall's heating system failed on Friday, 01/10/20 and a heating contractor was not summoned to repair it until Monday, 01/13/20 at 2:30 PM, during which time temperatures in residents' rooms on the South Hall dropped significantly below 71 degrees Fahrenheit. The facility was also placed in Immediate Jeopardy for its failure to perform necessary and routine maintenance of the heating, ventilation and air conditioning (HVAC) system, including in residents' rooms. The 2nd iteration of the facility's Immediate Jeopardy Removal Plan was received on 01/15/20 at 1653 hours and was approved on 01/16/20 with a Removal Date of 01/13/20. Findings Include: During the initial pool interview for Resident #14 on 1/13/2020 at 08:45 AM, the room felt cold. Resident #14 stated, I'm really upset because it's cold in here. I don't want to talk to anyone right now. Resident observed to be covered with four different blankets from head to toe. No part of her body was visible beneath the blankets. Interim Maintenance Director B came to the room at 08:50 AM and measured the temperature at 58 degrees Fahrenheit (F). The temperature of the room across the hall (Resident #51 and #54) from Resident #14 was checked and measured at 68.5 degrees F by Interim Maintenance Director B. Interim Maintenance Director B, stated that temperatures should average between 72-75 degrees F. During an interview with Interim Maintenance Director B, on 1/13/2020 at 08:45 AM he explained the he came to the facility last night at 7:45 PM and stayed until midnight. Interim Maintenance Director B said that during the time he was at the facility last night he checked the boilers and turned up the heat in the hallway. Interim Maintenance Director B said that after he turned up the heat in the hallway, Resident #14's room temped at 73 degrees F. Interim Maintenance Director B explained that Maintenance worker F called him after he bled the lines and they went dry. Based on that, Interim Maintenance Director B suspected something might be wrong and called a heating and cooling company for emergency service while he was at the facility Sunday night (1/12/2020). The heating and cooling company told him they were backed up and could not be to the facility until first thing 1/13/2020. Interim Maintenance Director B, said he arrived this morning (1/13/2020) at 8:00 AM and just got off the phone with the heating and cooling company and they said they would be here today. Interim Maintenance Director B, stated, The boilers are old, and I have not had training on them. I'm trying to figure out why it's cold in the rooms at the end of the hallways. During an interview with Nurse E on 1/13/2020 at 09:00 AM she stated she was freezing. Nurse E said she was not made aware of rooms being cold in report this morning. During initial pool interview on 1/13/2019, Resident #51 and #54 both complained that their room has been cold since Friday or Saturday. Resident #51 said today was the first time she saw someone check the temperature in her room. During initial pool interview with Resident #8 he stated the maintenance was just here and said the vent was blowing out cool air and temped at 66 degrees F. Resident #8 said It was cold last night. During an interview with the Nursing Home Administrator (NHA) on 01/13/20 at 01:27 PM, she was asked if she was notified of the decreased room temps over the weekend. The NHA replied, I don't know if anyone called me this weekend. Let me check on that. During a follow up interview with Interim Maintenance Director B, on 01/13/20 at 02:46 PM he explained that the heating and cooling company arrived at 2:30 PM and there was a line that must be bled. Interim Maintenance Director B, felt the heating would be working correctly within 20 minutes (3:06 PM). Interim Maintenance Director B, said he felt the heating and cooling company was needed sooner than this afternoon and stated, I felt this was an emergency. Interim Maintenance Director B, explained he called two heating and cooling companies and went with whoever could get here sooner. Interim Maintenance Director B, said that they do not have a contract with a heating and cooling company for regular maintenance or emergency services. Interim Maintenance Director B, said he called the NHA last night and was told to temp the rooms and call a heating and cooling service If it dropped below 70. He said the temperature of the rooms needs to be between 73-77 degrees F. Interim Maintenance Director B, said, I got here at 8:45 PM and I took temps when I got here and then again at about 11:45 PM. Interim Maintenance Director B, said he didn't have any low temperatures below 70 but called the heating and cooling company Just to be on the safe side and make sure things were working properly. During an interview with Maintenance Worker F on 01/13/20 at 02:57 PM he said he was working in the facility Friday through Sunday (1/10/2020-1/12/2020). Maintenance Worker F said he called Interim Maintenance Director B, on Sunday because he was Bleeding the line and the line went dry. He explained that he was bleeding the lines because that is what you are supposed to do when there is no heat. He further explained that rooms [ROOM NUMBERS] had no heat. Maintenance Worker F recalled that someone (could not recall name of new 1st shift CNA) told him at the beginning of his shift on Sunday (about 2:45 PM) that the heat was not working in rooms [ROOM NUMBERS]. He said at that time he bled the lines into a bucket of water for about 4 to 5 hours. When asked how long it normally takes to bleed the lines, Maintenance Worker F stated, It usually only takes a few minutes. He explained that at the 5 hour mark the system went dry and that's when I called (Interim Maintenance Director B). He continued, When (Interim Maintenance Director B) got here, he bled two lines. When asked what time he called the maintenance director, maintenance worker F checked his phone log on his cell phone and said he called Interim Maintenance Director A at 7:45 PM and called Interim Maintenance Director B at 8:09 PM. Maintenance Worker F said Interim Maintenance Director A instructed him to keep bleeding the lines. Maintenance Worker F said because the lines were dry, he couldn't continue bleeding them so he called Interim Maintenance Director B, who said he would be right over and got here within 30 minutes. When asked if he called the NHA, Maintenance Worker F said, No. When asked what the temperature of rooms [ROOM NUMBERS] were prior to him bleeding the lines he said he did not take any temperatures but knew it wasn't working properly because he felt the register and felt coolness. When asked if this was the first time that residents in room [ROOM NUMBER] or 24 complained of cold rooms, Maintenance Worker F said, There was a complaint of it three weeks ago and I bled the lines then and it got better. When asked if he took temperatures of the rooms when there was a complaint three weeks ago, he said he did not. When asked if there is a policy or procedure that he follows when heat is not working, Maintenance Worker F said there is not. When asked if he was trained on how to bleed the lines, Maintenance Worker F said he had training, but it was [AGE] years ago when he first started working at the facility. During a follow up interview on 01/13/20 at 03:24 PM with Interim Maintenance Director B he was asked what the facility policy was for loss of heat and maintenance of the heating and cooling system. He replied, I couldn't tell you what the policy is right now it's in the book, but I do know that anything below 71 is an emergency. When asked if there was a plan for Resident #14 while her room was cold and to ensure the comfort of all residents, Interim Maintenance Director B stated, If all the rooms were online we would have moved her into a room that the heat was working. He explained that there are rooms that are offline (not being used) due to being mid-remodel. When asked how often the facility had problems with controlling the temperature of the rooms, Interim Maintenance Director B responded, (Maintenance Worker F) had to bleed the lines three weeks ago. When asked how often they bleed the lines, Interim Maintenance Director B said They should be done 2-3 times a month and said he has it set up on a schedule now but did not in the past. When asked how often the heating system has maintenance performed, Interim Director of Maintenance B stated, I have been here three years and have not seen them being cleaned. There is no paperwork to show nor have I heard of it being done. Interim Maintenance Director B stated, I'm going to check the temperature of resident rooms every couple hours. If temps drop below 70, I will call the heating company back and I'm going to document it. At the time of interview the following documents were requested: 1. Maintenance log for the past year for boilers/heating system, 2. Policies and procedures related to heat outages, heating/cooling, boilers, 3. Maintenance Director and Supervisor job descriptions, and 4. Manual for each type of boiler. A written plan for ensuring safe and comfortable temperatures for the residents until temperatures were stable was also requested at the time of interview. Interim Maintenance Director B stated, The filing system is all over the place, I might not be able to find it tonight, but I will get it to you first thing in the morning On 1/13/2020 at 3:47 PM Interim Director of Maintenance brought in an emergency preparedness binder that was last updated on 7/1/2014 with the old name of the building on the documents. He also brought two binders for the north hall boilers (last inspection document 2016) and south boilers (last inspection [DATE]). On 1/13/2020 at 3:50 PM An updated emergency preparedness binder was requested and received from the Director of Nursing (DON). There was no policy within the binder related to loss of heat or maintenance of the HVAC system. During an interview with Resident #14 on 01/13/2020 at 04:09 PM she stated, It's cold and asked surveyor to feel her hands. Residents hands were cold to touch. Resident #14 stated, It's not getting better and she wanted to go to another room where it was warm. Certified Nursing Assistant (CNA) G was in the room at the time of interview and stated, It's always cold in here. On 01/13/2020 at 04:27 PM during a meeting with the NHA and DON, they were verbally notified of the Immediate Jeopardy and preliminary survey findings that included seven rooms with a temperature of less than 71 degrees F and one room with temperature of 58 degrees F. The NHA stated that she had been given a proposal from the heating and cooling company and that Interim Director of Maintenance B had not told her that rooms are still temping out of range. The DON stated she did not know there was a problem with the temperatures in the residents' rooms until now. It has been 26 hours since Maintenance Worker F said the cold rooms were first reported. On 1/13/2020 at 6:20 PM, the perimeter baseboard [MEDICATION NAME] heat fin tubes in resident rooms [ROOM NUMBERS] were observed to not be functioning as designed as evidenced by being cold to the surveyor's touch. At this time the temperatures taken by the surveyor revealed a temperature of 64 degrees F in room [ROOM NUMBER], a temperature of 71 degrees F in room [ROOM NUMBER], and an outdoor temperature of 35 degrees F. On 01/13/2020 at 6:30 PM, during a tour of the mechanical room on South Hall a noticeable odor that smelled like combustion exhaust was observed in the room. On 01/13/2020 between 7:17 PM, and 7:45 PM, during a visual inspection of the HVAC equipment on the roof of the facility with the Interim Maintenance Director, staff B, the surveyor observed that one of the roof top units (RTU) servicing the East Hall was not in operation as the main breaker mounted on the side of the unit was observed in the off position along with a neighboring unit's exhaust fan not running while in operation. On 01/13/2020 at 6:30 PM, record review of a work invoice from a heating contractor, dated 1/13/2020, revealed that the contractor found the water valve to the four boilers completely closed upon arrival and explained that the boilers needed major cleaning and the thermocouples needed to be replaced. On 01/13/20 at 7:30 PM, upon interview with staff B regarding the East Hall RTU staff B explained that the HVAC contractor at the time the new Bryant RTU was installed told them that the East Hall RTU needed to be replaced. On 1/14/2020 at 8:44 AM the following documents were requested again, 1. Maintenance log for the past year for boilers/heating system, 2. Policies and procedures related to heat outages, heating/cooling, boilers, 3. Maintenance Director and Supervisor job descriptions, and 4. Manual for each type of boiler. During an interview with Resident #14 on 01/14/2020 at 08:50 AM she stated that her new room feels better and I like it. Resident #14 was pleasant and talkative this morning, opposite of yesterday. Resident #14 stated she feels better today and said she only got out of bed to go to the bathroom yesterday because it was so cold. Resident #14 said she did not eat yesterday because she did not feel good and was cold. Resident #14 was observed with head and limbs outside of blanket and smiling. Call light was out of reach hanging on a hook on the wall towards the bottom of her bed. During a peri-care and wound care observation performed by RN H and CNA G on 01/14/2020 at 08:53 AM, Resident #32 stated, This room is so hot I'm going to throw up. I was not well all night. During an observation on 01/14/2020 at 09:32 AM Resident #5 was sitting by the heat vent in his room wrapped in a blanket and stated, I don't feel good, I'm cold. During an interview with the NHA and Interim Director of Maintenance B on 01/14/2020 at 9:38 AM their plan for ensuring the comfort of the residents was discussed. The Interim Director of Maintenance B stated, The thermostat in the hallway controls the heat in the hallway. He said they will turn that down and he thinks that will help regulate the temperatures in the hallway and the rooms. Interim Director of Maintenance said that the heating and cooling company will have a supervisor come out tomorrow at the latest. At that time, they are going to evaluate the cleaning, couplings and put together a regular maintenance schedule. He explained, they will have to completely shut down the boilers to clean them. It was requested at this time to update surveyors when they know what parts they need and what the cleaning and maintenance schedule would be. Interim Director of Maintenance B said he will take temperatures every hour and will start with all the rooms. He explained that the rooms that were too cold are now too hot. He also said that all the boilers are running now at the same time and he did not expect how hot it would be until he started taking temps. When asked about his training on the boilers, Interim Director of Maintenance B said he has not had training on how to maintain the boilers and is not really familiar with the older boilers that are here at the facility. When asked if a loss of heat or maintenance of heating system policy was located, the Interim Director of Maintenance said he had not been able to locate the policy and agreed that if he is not able to locate a policy, he is not able to follow it. The NHA said that when they are doing temps, they are also interviewing the residents as well to ask their comfort level. The NHA and Interim Director of Maintenance B did not know the frequency of the water being passed today. They explained they always pass water every shift and denied adding additional water passes to their routine while rooms and hallways were now temping above 81 degrees F. When asked if nurses know what they are supposed to do clinically if residents are too hot or too cold and if the nurses were informed of the abnormal temperatures in morning report, the NHA was unsure. At the time of interview the following records were requested: 1. Employee files, job descriptions and training records for Interim Director of Maintenance A and B, 2. Policies and procedures related to loss of heat and maintenance of the heating system, 3. Maintenance logs/invoices for the heating system for the past year and 4. The manuals for each type of boiler. During an interview with the NHA on 01/14/2020 at 09:54 AM, she said the water being off caused the system to go down. The NHA said she knew about the issue Monday morning, but knew it wasn't working correctly Sunday night. The NHA did not know which heating and cooling company they had a contract or if they had a contract with anyone. The NHA said to ask Interim Director of Maintenance A who they were contracted with because he had been working at the facility for ten years. During an interview with Resident #261 on 01/14/2020 at 10:25 AM he was concerned his drain was not draining correctly since he admitted (9/25/2019). He said recently someone came in the room at 3:00 a.m. to put something in there to fix it but it didn't work. Resident #261 turned on faucet until half of the sink bowl was filled. Water observed not draining appropriately. Resident #261 stated, it takes a half hour to drain when it is half full. Resident #261 also complained of a very strong odor of urine in his bathroom and stated he has almost thrown up after being in the bathroom. Housekeeper R, present at the time of interview, said she had worked at the facility since February 2019 and the bathroom had always smelled like that. Housekeeper R said she tries to clean that bathroom twice a day. Housekeeper R also said that Resident #261's toilet and sink both have a slow drain to them. At the time of interview room was hot and housekeeper R said it's so hot and explained the temperature of the rooms vary quite a bit depending on the weather outside. Resident #14's new room temped on 01/14/20 at 10:51 AM at 81 degrees F (taken by Sanitarian). Call light remained out of reach in the same position as previous observation. Resident #14's room was unkempt and disorderly. Resident #14's belongings were moved from her old room and piled on the floor of the room she was moved to. On 1/14/2020 at 4:04 PM, Interim Maintenance Director B stated he only took temperatures once today with the Sanitarian. At the time temperatures were taken, room [ROOM NUMBER] was 92 degrees F. At the time of interview current temperatures of rooms [ROOM NUMBERS] were requested due to feeling cold. The temperatures at the time of interview were recorded as 62 degrees F in room [ROOM NUMBER] and 65 degrees F in room [ROOM NUMBER]. During an interview with CNA D on 01/14/2020 at 04:39 PM she stated Resident #14 did not eat yesterday. CNA D said maintenance must have moved Resident #14's belongings down to her room and that she did not see Resident #14 taking items from her old room to her new room and placing them on the floor. CNA D stated that once she got warm in her new room last night, Resident #14 got up and wandered in the halls like she normally does, She has been out of bed all day today. During an interview with Interim Maintenance Director A, on 01/16/2020 at 10:05 AM, he said he was responsible for general maintenance of the building and repairs as needed. He explained if something needs to be repaired that requires a license, they call in a professional. He said he was responsible for maintenance policies and procedures. When asked how often he updates the maintenance policies and procedures he stated, I'm supposed to annually, I have not been able to since in this position (July 2019). When asked if the facility had a policy for loss of heat or management of the HVAC system, he said the NHA made an emergency policy for loss of heat on Tuesday and said prior to that we did not have one. A copy of the emergency policy for loss of heat was requested again on 01/16/2020 at 10:09 AM. When asked how he knew what steps to take to ensure the safety of the residents during a loss of heat or how he knew how often to maintenance the HVAC system if there were no policies, he stated, I just knew to repair as needed. When asked how often the heating system should have maintenance, he said they had annual inspections but nothing indicated we had to have it done monthly. When asked if the boiler manuals indicated how often to bleed the lines or how often to maintenance them, Interim Director of Maintenance A said they did not have manuals for the boilers because we don't touch them. When asked if a manual might include information on maintenance requirements for the system, he said no. When asked when the problems with temperature regulation started, Interim Director of Maintenance A said Maintenance Worker F bled the lines on Saturday (1/11/2020) and notified him on Sunday that there was a potential for the heating to be down and he instructed Maintenance Worker F to bleed the lines again. Interim Director of Maintenance A said he was not called back after that so he thought everything was kosher. When asked if Maintenance Worker F had training on the boiler system, Interim Director of Maintenance A said Maintenance Worker F had worked at the facility for thirty-one years and stated, I'm assuming he got training from the previous owner. Interim Director of Maintenance A said when he first started the previous owner trained him. When asked who the facility is contracted with for maintenance and emergency maintenance, Interim Director of Maintenance A said there were not contracted with anyone. He said they were going to start using the heating and cooling company that came out yesterday on a regular basis now. He said the heating company that came out yesterday to look everything over, did a repair and got the boiler back up and running without fault. When asked about temperature audits, Interim Director of Maintenance A said the we are completely fine and staying within parameter and said midnight shift on Tuesday was the last abnormal temperature they recorded. When asked when the thermocouples would be replaced, he said they are planning to order and repair the older parts and are getting a quote and a more solidified date for maintenance of the system. At the time of interview inspection/maintenance records for the heating system for the past year were requested. Upon review of the records provided by Interim Director of Maintenance A it was noted that three of the boilers were inspected by a plumbing company on 9/30/2019. No other records of inspection/maintenance were provided. Resident #8 requested an interview with surveyor on 1/21/2020. During the interview at 11:30 AM, Resident #8 said the facility lost heat Friday (1/17/2020) afternoon for a short time, enough time for registers to get cold again. Resident #8 explained he used to own a farmhouse with hot water heat and knew that the heating system was not functioning properly. He stated, It's acting like it has some air in the line and all they do here is turn up the heat and think it's going to fix it. Resident #8 reported that the heat was off again on Monday (1/20/2020). Resident #8 said Maintenance Worker F was in his room at 6:00 PM and felt the register was ice cold. Resident #8 reported that three residents down North Hall had to move rooms over the weekend and stated one resident he saw shivering because the temperature of their room was in the 60's Resident #8 also said, I heard they lost their heat gun to check the temperatures with. During an interview with Interim Director of Maintenance A and new Maintenance Director UU (hired 1/16/2020) on 1/21/2010 at 2:27 PM, They denied concerns with temperatures over the weekend. When asked if residents were moved over the weekend due to the temperature in their room, Interim Director of Maintenance A and Maintenance Director UU explained, room [ROOM NUMBER] was moved on Sunday (1/19/2020) because they felt cold. They further explained, There was a little draft coming through the window. Maintenance Director UU said the residents felt a chill so the best thing to do was accommodate them and all three residents wanted to move and said all three residents moved back to room [ROOM NUMBER] yesterday (1/20/2020). Interim Director of Maintenance A confirmed that Maintenance Worker F misplaced his temperature gun overnight, so they bought a new one and found the misplaced one today. During an interview with Unit Manager I on 01/22/2020 at 09:36 AM she confirmed that three residents from room [ROOM NUMBER] were cold over the weekend so Resident #40 moved to room [ROOM NUMBER] with Resident #14 and Resident #53 moved to Resident #15's room. When asked what Resident #40 used for a call light since room [ROOM NUMBER] was observed to have one call light, Unit Manager I said they gave Resident #40 a pull cord call light and educated her how to use it. Observation of pull cord call light was requested. Unit Manager I showed surveyor a personal body alarm and explained that Resident #40 was educated to pull the magnetic tab to trigger the alarm if she needed anything. room [ROOM NUMBER] was at the end of the hallway far away from the nurses station. During an interview with Maintenance Director UU, on 01/22/2020 at 09:40 AM he stated, they have a total cleaning scheduled for the heating system, but it had not been done yet. Maintenance Director UU was not able to give a date of the scheduled cleaning at the time of interview. During an interview with Resident #53 on 1/22/2020 she confirmed she spent the night in another resident's room the night before last. Resident #53 resided in room [ROOM NUMBER], an end room on the north hall. Resident #53 reported that Maintenance Worker F measured the temperature of her room with the gun thing at 57. Resident #53 said the facility offered to move her because it was so cold but stated, I'm used to it, it is always cold and One time last year we had to evict for the same reason. During an interview with Maintenance Worker F on 01/22/2020 at 2:54 PM regarding the temperatures in room [ROOM NUMBER], he said the night before last the temperature was 67. He explained, the ladies in the room were cold so we moved them. He also said he notified his manager and the NHA was notified. Review of Temperature Logs completed by the facility during the survey documented the following room temperatures were out of range. No date or time documented on log: room [ROOM NUMBER] was 70 degrees F No date or time documented on log: room [ROOM NUMBER] was 70 degrees F Labeled PM, no date: room [ROOM NUMBER] 70 degrees F. Labeled 3rd no date: room [ROOM NUMBER] was 82 degrees F. Labeled 2nd no date: room [ROOM NUMBER] was 70 degrees F. Labeled 1 am, no date: room [ROOM NUMBER] was 70 degrees F, room [ROOM NUMBER] was 70 degrees F, room [ROOM NUMBER] was 70 degrees F. Labeled PM, no date: room [ROOM NUMBER] was 70 degrees F. Labeled PM, no date: room [ROOM NUMBER] was 70 degrees F 1/14/2020 at 11:00 AM room [ROOM NUMBER] was 92 degrees F. 1/16/2020 at 9:00 AM: room [ROOM NUMBER] was 70 degrees F. 1/16/2020 at 11:00 AM: room [ROOM NUMBER] was 70 degrees F. 1/16/2020 at 2:00 PM: room [ROOM NUMBER] was 70 degrees F. 1/18/2020 at 7:50 PM: room [ROOM NUMBER] and 24 were 69 degrees F. 1/19/2020 at 8:00 PM: room [ROOM NUMBER] was 82 degrees F, room [ROOM NUMBER] was 82 degrees F, room [ROOM NUMBER] was 83 degrees F, room [ROOM NUMBER] was 84 degrees F, room [ROOM NUMBER] was 83 degrees F, room [ROOM NUMBER] was 83 degrees F, room [ROOM NUMBER] was 83 degrees F, room [ROOM NUMBER] was 84 degrees F, room [ROOM NUMBER] was 87 degrees F, room [ROOM NUMBER] was 87 degrees F, room [ROOM NUMBER] was 84 degrees F, room [ROOM NUMBER] was 84 degrees F, room [ROOM NUMBER] was 85 degrees F, room [ROOM NUMBER] was 83 degrees F, room [ROOM NUMBER] was 85 degrees F, room [ROOM NUMBER] was 84 degrees F. Documented within range by 9:00 PM. No temps recorded at 10:00 PM. 1/20/2020 at 2:00 AM: room [ROOM NUMBER] was 82 degrees F. 1/20/2020 at 7:00 AM: room [ROOM NUMBER] was 70 degrees F. 1/20/2020 at 1:00 PM: room [ROOM NUMBER] was 70 degrees F. 1/20/2020 at 2:00 PM: room [ROOM NUMBER] was 70 degrees F. 1/20/2020 at 7:00 PM: room [ROOM NUMBER] was 70 degrees F. 1/20/2020 at 10:00 PM: room [ROOM NUMBER] was 68 degrees F Labeled air vents no date or time documented: room [ROOM NUMBER] was 70 degrees F, room 46 was 69 degrees F and room [ROOM NUMBER] was 69 degrees F. Labeled 3 am, no date: room [ROOM NUMBER] was 67 degrees F Labeled 5 am,no date: room [ROOM NUMBER] was 68 degrees F Labeled 6 am, no date: room [ROOM NUMBER] was 67 degrees F. Labeled 7 am, no date: room [ROOM NUMBER] was 70 degrees F. 1/21/2020 at 11:00 AM room [ROOM NUMBER] was 84 degrees F. 1/21/2020 at 1:00 PM room [ROOM NUMBER] was 83 degrees F. No action taken/correction measures documented on the logs for abnormal temperatures. Review of facility policy titled, Heat Outage (revised 1/2020) stated the purpose of the policy was, Utility emergencies may be caused by a disaster inside the facility or adjacent to it. They can be a planned of unplanned interruption by the malfunction or organization providing the service. Policy: In the event of a utility emergency, i.e., loss of heat, the plant operations supervisor will immediately contact a service provider for information about restoration of the service. This information will be used to determine any further steps necessary to ensure resident safety. Procedure: The Plant Operation Supervisor will advise the Administrator of the Administrative Person in charge on the procedures that must be taken during the service outage. The plant operations supervisor and the Administrator will have available at their workstations the following information. List of utility companies, List of HVAC providers, i.e. heating and cooling, Back up support to these utilities. Page 2/2 of policy not available. Requested policy multiple times a

Based on observation, interview and record review the facility failed to assess, monitor and provide treatment to prevent social isolation for one resident (Resident #58) of two residents reviewed for behavior resulting in unmet psychosocial needs, isolation, increased signs and symptoms of depression, excessive sleep pattern and loss of interest or pleasure in activities. Findings include: Resident #58: According to the document titled, Admission Record (printed 1/15/2020), Resident #58 was an [AGE] year-old female admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. During initial pool observation, on 1/13/2020 at 08:43 AM, Resident #58 was in bed with her head leaning to the left with a neck pillow in place. During multiple observations on 1/14/2020 Resident #58 was sleeping. The Resident woke to her name and allowed initial pool interview and went back to sleep. During an observation on 01/15/20 at 04:37 PM, Resident #58 was sleeping. During an observation on 01/16/20 at 09:20 AM, Resident #58 was observed in bed asleep, leaned to the left and hunched over with her breakfast tray at her bedside untouched. At the time of the observation, four Certified Nursing Assistants (CNA's) were sitting in the day room and one CNA was in the break room. Resident #58 was on contact precautions at the times of the observations. Resident #58 was noted to have a severe neck contracture and used a neck pillow and pillows at her left side to assist with positioning. A review, of Resident #58's medical record, revealed she was being treated for [REDACTED]. Resident #58 had a mental health Nurse Practitioner visit progress note on 8/2/2019 that revealed Resident #58 was new to service, psychiatric evaluation requested by attending physician due to depress/dementia. The note mentioned Resident #58's history of depression, history of sadness, tearfulness and irritability. The note stated, no recent mood or behavior concerns documented. The note said Resident #58 was alert and cooperative at the time of evaluation and she described her mood as I think good. The note said Resident attends mealtimes in the dining room and participates in group activities. The note said residents sleep was within normal limits. The note also said, monitor mood and behavior. Document concerns. Notify service of any changed. Provide supportive reassurance. Further review of Resident #58's progress notes revealed no further documentation of her sleeping patterns or signs and symptoms of depression. A review, of Resident #58's most recent annual Minimum Data Set (MDS) Resident Assessment tool (dated 12/29/2019), documented that Resident #58 felt tired or had little energy 2-6 days (several days) out of 7 days and that her Brief Interview for Mental Status (BIMS) score was a 14/15 indicating her cognition was intact. During an interview, with Nurse II on 01/15/2020 at 04:43 PM, the Nurse reported Resident #58 does sleep a lot. Nurse II said Resident #58 was on pain medication for her contracted neck but was not on a high dose of pain medication or psych meds that would make her drowsy. Nurse II said Resident #58 had an infection and doesn't get up and do much or much activity since she has had the infection. Nurse II denied Resident #58 having behaviors and no behaviors were observed. During an interview on 01/16/20 at 09:38 AM, with Restorative CNA VV (Unit Manager I present), she explained that Resident #58 was participating in restorative roughly six days a week up until she was on precautions. CNA VV said the infection control nurse told her restorative had to be put on hold due to Resident #58 being on contact precautions for [DIAGNOSES REDACTED]. and stated, We couldn't take our equipment in her room and she couldn't come out of her room. CNA VV said Resident #58 was on precautions three separate times since October 2019. CNA VV said Resident #58 was active while not on precautions and would attend activities, go to the day room and go to the dining room. Restorative program notes for Resident #58 included documentation of missed restorative program visits while Resident #58 was on contact precautions. Restorative program notes for September 2019-present was reviewed with CNA VV included: 9/7/17 always a willing participant. She is doing great . 11/7/19 . has been on precautions due to [MEDICAL CONDITION] 12/10/19 .finally off her precautions and we have started to wean her back into her program . 12/18 We've been able to work with (resident) again for almost 2 weeks. She had gotten pretty weak while she was confined to her room while on precautions. There has been a slight improvement in her neck range of motion and her lower body strength .Her mental state is where I see the biggest improvement. She was having a decline in that area while in confinement. 12/26 (Resident) continues to improve in every area we are working on even her mental state is continuing to improve along with her general mood. 1/9/2020 (Resident) has been put on contact guard precautions once again and is confined to her room. Her restorative program is on hold again. During an interview with Occupational Therapist (OTR) DD on 01/16/20 at 10:38 AM, she said Resident #58 enjoyed therapy and stated, She is super agreeable to everything, she would even come to the therapy room when she wasn't on therapy. When asked if therapy or ROM exercises can be done in Resident #58's room when she is on contact precautions, OTR DD said yes. During an interview with Infection Control Nurse J on 1/16/2020 at 11:16 AM she confirmed Resident #58 tested positive and was treated for [REDACTED]. Infection Control Nurse J said residents with [DIAGNOSES REDACTED] cannot come out of their room until 48 hours after their last loose stool. Infection Control Nurse J said that the Certified Nursing Assistant (CNA's) have said Resident #58 doesn't want to eat and stated, I think they do think she is more depressed because she is confined to her room. Infection Control Nurse J said, I would really like to see her come off precautions. During an interview with Activity Director T on 01/16/20 at 02:55 PM, she said Resident #58 was marked on her activity attendance record as unable to attend for multiple entries. Activities Director T said she would look at why Resident #58 was unable to attend and see if she was a candidate for one to one activity. A review of Resident #58's Individual Resident Daily Participation Record for July, August and September 2019, revealed she was regularly attending and participating in activities. The record, for October 2019, revealed Resident #58 was documented as unable to attend on a more regular basis as the month progressed. The record, for November, December 2019 and January 2020, revealed Resident #58 was marked unable to attend/participate most of the time. Activity Director T reviewed the participate records and said since Resident #58 is unable to attend a majority of the time now, she would most likely need one to one activities. Resident #58 had a care plan for depression that included an intervention to encourage Resident #58 to participate in social activities (initiated 3/7/2018). The goal of Resident #58's depression care plan was to remain free of signs and symptoms of depression (revised 1/15/2020). Resident #58's care plan focus area, potential for low activity group participation . (initiated 1/7/2016; revised 7/5/2018) had interventions that included inviting her to activities, assist/escort her to activities (initiated 1/7/2016; revised 3/6/2018). Resident #58 did not have a care plan for one to one activity in her room or any related interventions for the timeframe she was isolated to her room due to her [DIAGNOSES REDACTED]. Resident #58's care plan focus area, The resident has[DIAGNOSES REDACTED] (initiated 11/4/2019; revised 1/15/2020 had interventions that included place in private room with contact isolation precautions. Interventions to prevent social isolation and encourage activity while on precautions were not included. Facility policy titled, Activity Evaluation (dated 6/10/2019), said the purpose of the policy was to promote the physical, mental and psychosocial well-being of residents . Facility policy titled, Behavioral Assessment, Intervention and Monitoring (dated 6/6/2019) said the purpose of the policy was 1. Behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment. 2. Residents who do not display symptoms of , or have not been diagnosed with [REDACTED]. Residents will have minimal complications associated with the management of altered or impaired behavior Appropriated assessment and treatment of [REDACTED]. status, behavior, and cognition, including: onset, duration, intensity and frequency of behavioral symptoms. Any precipitating or relevant factors, or environmental triggers ((example) medication changes, infection .; and appearance and alertness of the resident and related observations. The policy said the interdisciplinary team would thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the residents change in condition including infection, pain, change in medications, boredom, loneliness, and decline in functional ability. The policy also said non-pharmacologic approaches will be utilized to the extent possible to avoid or reduce the use of medication to manage symptoms. Upon entrance conference the Nursing Home Administrator (NHA) said Social Worker XX and YY were the social workers. During an interview with MDS Nurse K she said she was filling in for the social worker role as needed while they were between social workers. On January 21, 2020 human resources folder for social worker was requested at 10:21 AM. Upon review of file received from NHA, a job offer letter noted that social worker XX was hired on 1/10/2020 and scheduled to start on 1/11/2020. The file also contained the license and application for social worker YY that said he could start on 11/19/2019. The file did not include a job offer letter or signed acceptance of job offer for social worker YY like it did for social worker XX When asked when the previous social worker left, during an interview on 01/22/20 at 02:59 PM, the NHA stated, um I'm not sure we've had one. When asked when interim social worker YY's last day worked for the facility was, NHA stated, I don't know, HR isn't here today. When queried if she could recall an approximate date, the NHA said she did not remember the last time Social Worker YY was here or how often he was at the facility and said she did know how to find out. Interim Social Worker YY's timecard was requested at the time of interview and was never received. The NHA stated that Social Worker XX started in April 2019 and they kept her on the whole time. Human Resource's record for Social Worker XX included documentation that said she was hired 1/10/2020 and started 1/11/2020. The NHA stated that Social Worker XX had training on 1/13/2020 and was still working at another facility until the end of March. The NHA stated that Social Worker XX was working in the afternoons and weekends or as needed until she completed her work at her other job. On 1/16/2020 a typed letter was observed on multiple resident bed side tables that explained what to do if they needed to speak to a social worker. The NHA was not able to articulate if a social worker or someone designated to meet the psychosocial and behavioral health care needs of the residents was available to the residents at the facility.

Based on observation, interview and record review, the facility failed to implement interventions, per care plan and standards of practice, to ensure effective pain management prior to wound care to a pressure ulcer, Stage IV (full thickness tissue loss with exposed bone, tendon or muscle and often include undermining and tunneling) for one resident (Resident #45) of three residents reviewed for pain management, resulting in the lack of pain assessment and intervention prior to wound care for a severely cognitively impaired and non-communicative resident, non-verbal signs and symptoms of pain, unmanaged pain, and psychosocial distress utilizing the reasonable person concept. Findings include: A review, of Resident #45's medical record, revealed an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment, dated 12/20/19, revealed the Resident had severely impaired cognitive skills for daily decision making and was total dependent with transfers and eating and needed extensive assistance with bed mobility, toilet use and personal hygiene. Further review of the MDS assessment revealed speech clarity: no speech-absence of spoken words; makes self understood: rarely/never understood; and ability to understand others: rarely/never understands. Further review of the medical record, revealed the Resident had a stage IV sacral wound. A review of Resident #45's medical record, revealed progress notes that included the following: -Effective Date: 12/16/2019 11:30 (AM) Type: Wound Care Update Wound Measurements: Coccyx: 4.8 cm (centimeters) x (by) 3.8 cm x 2.8 cm. Wound spreads open in the left side and back 3.8 cm. On the right side it spreads open 3 cm. Wound Bed Description: Wound bed is red with bleeding present. Able to view bone. Odor, drainage, pain control: No odor. Small amount of bright red bleeding on the left side of wound. (Resident's name) did moan when wound was cleaned and packed. Did packing slowly to decrease discomfort. Will medicate prior to next dressing change. Current Treatment: Cleansed wound with normal saline and patted dry. Lightly packed wound with 8 inches of saline soaked gauze and covered with an ABD pad. Will contact WCC (wound care clinic) nurse for input on treatment. Author: (Nurse Consultant L) - Effective Date: 12/20/2019 06:53 (AM) Type: Nursing Progress Note Note Text: Resident observed with discomfort, whining, and facial grimacing while completing wound care to coccyx region. Current pain medication scheduled Q (every) 12 hours. Note to MD (medical doctor) to please assess for PRN (as needed) pain medication or increase scheduled medication; noted on 24 hour report. -Effective Date: 12/20/2019 18:20 (6:20 PM) Type: Nursing Progress Note Spoke with (Physician BB) about facial grimacing and pain with wound care, new order to administer Tylenol 3 ([MEDICATION NAME] with [MEDICATION NAME]), 30 minutes prior to wound care. Orders up to date. - Effective Date: 12/30/2019 16:14 (4:14 PM) Type: Wound Care Update Wound Measurements: Coccyx:6.4 cm x 4.0 cm x 3.5 cm. Wound Bed Description: Red with patches of thick yellow tissue. Able to visualize bone. Wound edges are intact, no rolling noted. Area surrounding is reddened with several 1 cm size abrasion-type wounds noted. Probably from tape. Odor, drainage, pain control: Foul odor and gray, serosanguinous drainage from wound and on dressing. (Resident's name) will moan when he is repositioned and when wound was cleansed. Current Treatment: Cleansed wound with normal saline and patted dry. Loosely packed wound with three strips of calcium alginate and then covered with two ABD pads (an absorbent dressing) without tape due to the several abraded areas from previous tape. Author: (Nurse Consultant L) A review, of Resident #45's Medication Administration Record, [REDACTED] -Tylenol with [MEDICATION NAME] #3 tablet 300-30 MG (milligrams) ([MEDICATION NAME]-[MEDICATION NAME]) Give 1 tablet via PE[DEVICE] (Percutaneous Endoscopic Gastrostomy-a tube through the stomach wall into the stomach to provide nutrition and medication administration) every 12 hours for -pain/wound, with an order date on 12/14/2019. - Tylenol with [MEDICATION NAME] #3 tablet 300-30 MG (milligrams) ([MEDICATION NAME]-[MEDICATION NAME]) Give 1 tablet via PE[DEVICE] as needed for WOUND/PAIN-ADMINISTER 30 MINUTES PRIOR TO WOUND CARE TREATMENT, with an order date on 12/20/2019. A review, of Resident #45's care plan, included the following: -Focus: The resident has, chronic pain r/t (related to) Disease process, wound, non communicable, Date Initiated: 12/27/2019. Interventions: Administer [MEDICATION NAME] Tylenol #3 routine as per orders. Give PRN ½ hour before treatments or care, as needed, i.e.: prior to wound care, Date Initiated: 12/27/2019. -Focus: (Resident's Name) is admitted with a Stage IV Pressure Injury on his coccyx . There is bone showing in the middle of the wound. Wound bed is red and has bright red bleeding . Date Initiated: 12/16/2019, Revision on 12/27/2019. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness, Date Initiated: 12/16/2019 . Medicate (Resident's name) for pain approximately 30 minutes before dressing change as needed to decrease his discomfort during the treatment Date Initiated: 12/16/2019. On 1/13/20 at 7:27 AM, an observation was made of Resident #45 lying in bed with the head of the bed turned to face the wall where the TV was positioned. The Resident was awake but was not engaged in watching the TV that was on. The Resident did not respond to questions asked but looked around the room. The Resident did not provide meaningful responses or communication to questions. The Resident was positioned with a pillow behind his left side. On 1/15/20 at 10:12 AM, an observation was made of Resident #45's wound care to the sacral pressure ulcer, stage IV, with Nurse Consultant L, Nurse II, and Certified Nursing Assistant OO. The Resident was observed on their side. The old dressing had been removed, Nurse II was setting up to do the dressing change and Nurse L completed the measurements of the wound. After the measurements were done, Nurse II completed wound cleaning. The wound was cleansed with 4 x 4 gauze pads saturated in wound cleanser. As the wound area was cleansed, the Resident showed signs and symptoms of pain by grimacing, wrinkling face, squirming slightly and trying to move their buttock away when the wound was cleansed. The wound was packed with the alginate dressing, with the Resident again grimacing and squirming to move away from the activity at their buttock area. After the dressing change was completed, Nurse II was queried when the Resident had their last pain medication. The Nurse reviewed the medical record and reported the Resident was on scheduled pain medication and last had pain medication on 1/14/20 at 9:25 PM last night. On 1/15/20 at 10:39 AM, an observation was made during a medication administration for Resident #45 with Nurse II. The Nurse was observed to review the Resident's Medication Administration Record [REDACTED] -Tylenol with [MEDICATION NAME] #3 tablet 300-30 mg ([MEDICATION NAME]-[MEDICATION NAME]), one tablet, for pain/wound. -[MEDICATION NAME] tablet 2000 units, one tablet. -[MEDICATION NAME] tablet 250 mg (milligrams), one tablet. -[MEDICATION NAME] 125 mcg (micrograms), one tablet, for [MEDICAL CONDITION]. -Multivital-M tablet (multiple vitamins and minerals), one tablet. -Levetiracetam tablet 500 mg, for [MEDICAL CONDITION], one tablet. -[MEDICATION NAME] tablet 10 mg, one tablet, for [MEDICAL CONDITION]. The Nurse put the tablets together in a bag and crushed the medications together. Nurse II put the crushed medications into a cup and added water. Upon administration of the medications, the Nurse put the crushed dissolved medications into the syringe that was placed in the Resident's PEG tube and added more water after the medications went through the tube. On 1/16/20 at 10:52 AM, an interview was conducted with Director of Nursing (DON), Nurse Consultant L and Staff Development Coordinator FF, regarding Resident #45's wound care. A review was conducted of Resident #45's pressure ulcer care, monitoring and the dressing change completed without the pre-medication of the Tylenol #3. On 1/21/20 at 10:42 AM, an interview was conducted with Nurse II regarding the Resident showing signs/symptoms of pain during the dressing change and the care planned intervention to pre-medicate the Resident prior to dressing changes. The Nurse indicated the times for the pain medication could be increased and given before the dressing change. A review was conducted with Nurse II of the pain medication given after the dressing had been completed, the Nurse stated, I see. On 1/22/20 at 10:54 AM, an interview was conducted with Nurse Consultant L regarding Resident #45's dressing change on 1/15/20. The Nurse verified the Resident had Tylenol #3 at 9:25 PM on 1/14/20 and on 1/15/20 at 10:55 am. The Nurse indicated the Resident had signs and symptoms of pain with dressing changes and needed to be pre-medicated with pain medication prior to dressing changes. A review of the facility policy entitled, Wound Care, dated 6/12/19, revealed, . Preparation: . 2. Review the resident's care plan to assess for any special needs of the resident. a. For example, the resident may have PRN orders for pain medication to be administered prior to would (wound) care .

Based on observation, interview and record review the facility failed to provide respiratory treatment for two residents (Resident #42 and Resident #260) and ensure a [MEDICAL CONDITION] was ordered, care planned and used for one resident (Resident #309) of four residents reviewed for respiratory care, resulting in the potential for respiratory decline for each resident. Findings Include: Resident #309: A record review of the Face Sheet and MDS assessment indicated Resident #309 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment was not yet completed. A nursing note dated 1/15/20 at 6:03:PM, indicated the resident was A&Ox 4 (Alert and oriented times- person, place, time and location). During the initial tour of the facility on 1/13/20 (Monday) at 8:15 AM, an undated opened bottle of sterile water was observed on Resident #309's windowsill. The resident said it is for his [MEDICAL CONDITION] (Continuous Positive Airway Pressure machine- to aid in breathing during sleep); I've been here since Wednesday (1/8/20- 5 days). They said they would help me with it. I'm still waiting. The doctor said I am supposed to use it at night. I sleep better with it on. It helps me breathe. The resident's [MEDICAL CONDITION] machine was observed sitting on the floor. A review of the physician orders [REDACTED]. A review of the Medication Administration Record [REDACTED]. On 1/15/20 at 8:50 AM while observing Nurse H provide care, Resident #309 said he had not been able to use his [MEDICAL CONDITION] machine and said if he had a reminder by the staff it would help him. Nurse H said she would put an entry in the Treatment Administration Record/TAR to ensure staff help the resident with his [MEDICAL CONDITION]. Resident #309 said he didn't use it last night because he forgot, I think I need someone to remind me. A review of the resident's Care Plan on 1/14/20 and 1/21/20 indicated there was no mention of the [MEDICAL CONDITION]. On 1/22/20 at 11:30 AM, during an interview with the Director of Nursing, she was asked about the resident's [MEDICAL CONDITION] and lack of assistance by the staff and said she would look into it. A review of the policy provided by the facility titled, [MEDICAL CONDITION] and [MEDICAL CONDITION] Cleaning and Maintenance, dated 4/29/19 did not provide information related to use and monitoring of the resident. The policy reference cleaning of the machine- Daily: It is recommended on a daily basis to wipe your mask off with a damp cloth to get rid of the oils from your skin. You should rinse out your humidifier and refill it with distilled water . The resident was not able to maintain his machine on his own and required assistance. Resident #42: According to Admission Record, (printed 1/14/2020), Resident #42 was a [AGE] year-old mailed admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During initial pool interview on 01/13/20 at 09:29 AM, Resident #42 was observed. He had a [MEDICAL CONDITION], oxygen via [MEDICAL CONDITION] mask set to 3 liters, compressor set to 30 pounds per square inch (PSI) and [MEDICAL CONDITION] humidification (set to 35) bottler was empty. An open and used suction catheter was at bedside, not dated. Resident #43 was coughing up dark red/brown (bloody) sputum. During an observation on 01/14/20 at 10:36 AM humidification bottle empty again. patty Review of Resident #42's physician orders [REDACTED]. Review of Resident #42's December 2019 Medication Administration Record [REDACTED]. Review of Resident #42's January 2020 MAR indicated [REDACTED]. It was observed empty at 9:29 AM. During an interview with Nurse II on 01/15/2020 at 08:48 AM she said every nurse that reads Resident #42's [MEDICAL CONDITION] orders are supposed to verify when they go in his room that his settings are right. Nurse II could not locate an order for [REDACTED]. Nurse II said the facility had not done any [MEDICAL CONDITION] training since the RT left in the summer of 2019. During an interview with Nurse H on 01/15/20 at 09:06 AM she said she received education on [MEDICAL CONDITION] care about 9 months ago by a lady that worked in the office that used to be a respiratory therapist. Nurse H could not recall the trainers name. Nurse H said she also went over [MEDICAL CONDITION] care with Staff Development Nurse FF and Infection Control Nurse J about a month ago as a refresher. When asked about Resident #42's [MEDICAL CONDITION] settings, Nurse H said he is at 28% and said the first thing she does when she walks in his room is make sure the canister is full. When asked how many liters of oxygen Resident #42 was supposed to be set at, Nurse H stated, I think he is supposed to be on 2-3 liters. Resident #42's orders were reviewed with Nurse H. Nurse H said she did not see an order that said how many liters of oxygen Resident #42 was supposed to have and said there should be an order for [REDACTED].#42 had a [MEDICAL CONDITION] care plan. During an interview with Nurse CC on 01/15/20 at 09:22 she said we just had a little in-service about a week ago, on [MEDICAL CONDITION] care. Nurse CC explained she was given a pamphlet by Staff Development Nurse FF and was also given a link to a you-tube video to watch. Nurse CC said no one has observed her [MEDICAL CONDITION] or suctioning to ensure her competence in the skill. During an interview with the Director of Nursing (DON) on 01/15/2020 at 09:36 AM she said the facility has someone they contract with that comes to see residents with respiratory care needs upon admission, weekly and as needed. During an interview with Respiratory Therapist WW from a contracted service on 1/16/2020 at 2:18 PM she said Resident #42's order required the PSI to be set at 20 and oxygen at a flow rate of 2 L to make 28% T-mist. RT WW said she verbally told the staff at the facility the accurate settings when she set it up upon admission. RT WW said she has never seen an order like that, when she reviewed Resident #42's order [MEDICAL CONDITION] 28% T-mist. During an interview with Staff Development Nurse FF she said she watched three nurses perform [MEDICAL CONDITION] care when she provided education to them last month, but she did not document it and could not remember their names. Staff Development Nurse FF provided two in-service documents for related to [MEDICAL CONDITION] care. The first training was dated 4/1/2019 and was a sign in sheet with no outline or agenda for watch was discussed and did not say who presented the material. The second in-service topic [MEDICAL CONDITION] plan/trach care. The summary of the training said, see attached plan. Six nurses signed the in-service. Two of the six were managers. The [MEDICAL CONDITION] Plan included, when [MEDICAL CONDITION], the nurse must immediately dispose of all used care supplies . and Humidification system shall ALWAYS be filled with distilled water to [MEDICAL CONDITION] are kept think for easier expectoration. During a follow up observation on 01/22/2020 at 09:38 AM, oxygen was set at 3 liters, supposed to be 2 liters per RT. Absence of humidification can lead to respiratory complications such as infection and difficulty breathing if secretions thicken. Facility policy titled Respiratory Therapy Care (dated 6/18/2019) said the purpose of the policy was to guide [MEDICAL CONDITION] care. The guidelines of the policy said, 1. Respiratory therapist is called is notified when admission on [MEDICAL CONDITION] patient is pending, 2. Respiratory therapist is available for in line treatment, 3. Respiratory therapist is notified for Inservice, 4. Respiratory Therapist is notified and or contracted to remove or decannulated, 5. Respiratory therapist can be consolidated in change in orders. Resident #260: During an interview with Nurse E on 01/13/2020 at 09:47 AM she said Resident #260 had pneumonia and she was giving cough syrup as needed. Nurse E said Resident #260 also gets breathing treatments. Resident observed coughing. During observation and interview on 01/13/2020 at 10:13 AM Resident #260's oxygen was not on. Resident was observed with oxygen on at 3 litters via nasal cannula prior to being transferred out of bed and into her wheelchair by certified nursing assistant. The CNA's did not check Resident #260's oxygen saturation. Resident #260 said she wears the oxygen all the time and that she feels short of breathe sometimes. Resident #260's Grand-daughter wanted to take her for a walk in her wheelchair in the hallway. During a follow up observation on 01/13/2020 at 12:04 PM, it was noted that Resident #260 did not have an oxygen tank holder on the back of her wheelchair. Resident #260's grand-daughter said she put the oxygen back on her grandma when she got back in bed. Review of Resident #260's physician orders [REDACTED].#260 also had orders for two antibiotics; [MEDICATION NAME] 1/9/2020-1/16/2020 and [MEDICATION NAME] 1/11/2020-1/16/2020. Resident #260 had a care plan focus area for The resident has, Pneumonia . (initiated 1/14/2020). Resident #260's interventions for pneumonia included, oxygen therapy as ordered 2-3 liters per nasal cannula for oxygen saturations below 92% (initiated 1/14/2020). Facility policy titled, Oxygen Administration (dated October 2010) said the purpose of the policy was to provide guidelines for safe oxygen administration. The policy said physician order [REDACTED]. The policy also said to notify the supervisor if the resident refuses oxygen.

Based on observation, interview and record review, the facility failed to ensure appropriate interventions were in place to prevent falls with injury and assess a resident with an injury after a fall for three residents (Resident #59, Resident #159 and Resident #310) of four residents reviewed for falls, resulting in all three residents having a fall with injury to the head/face, hospitalization , and the potential for further falls, injury and subsequent death for Resident #59. Findings include: Resident #159: A review, of Resident #159's medical record, revealed an admission into the facility on [DATE] with a re-entry on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment revealed moderately impaired cognitive skills for daily decision making and the Resident needed extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. A review of Resident #159's event reports included the following: -Date of event [DATE] at 7:08 PM, incident description, Resident found lying on left on floor next to bed. Head toward the foot of bed. Non skid footwear on feet. Resident Description: Resident stated that he didn't fall. Immediate Action Taken Description: head to toe assessment completed. Alert and oriented x 2. Able to move all extremities. Bruise to right upper back next to arm joint. No other injuries noted. Witnesses: No witnesses found. Notes dated [DATE], (Resident's name) sat himself up on the side of the bed and due to his weakness he slide off of the bed on to the floor. Did develop a bruise on his right upper back by arm joint. Will place a concave mattress on the bed, author Nurse Consultant L. -Date of event [DATE] at 7:45 AM, incident description, Approx. 7:45 am Resident was observed lying in prone position on floor next to bed. Resident had horizontal laceration to middle of forehead that was bleeding, also currently on anticoagulant. Laceration size was consistent in shape and form with nightstand handle next to bed. Writer of this entry had been in residents room and gave him a drink of water and talked with resident approx. 7:40 am. At 7:40 am when writer of this entry exited room resident was lying in bed with pillow and covered up with blanket. Call light attached and within reach. Resident description: Resident stated, his pillow had fallen on floor and he was reaching down to pick it up. Immediate Action Taken Description: Pressure immediately applied to [MEDICAL CONDITION], physical assessment completed, resident was sent out via 911/EMS. Level of Consciousness: Alert, Mental Status: Oriented to Person, Oriented to place, Oriented to time. Notes: Pain was unable to be determined r/t (related to) emergent situation, resident was out of building via EMS within few minutes of occurrence. Injuries Report Post Incident: No injuries observed post incident . Other info: Per resident he was leaning to reach for pillow and went right over. Witnesses: No witnesses found, prepared by Nurse JJ. Notes dated [DATE], (Resident's name) was having increased confusion and he was sent to the hospital and he had a UTI (urinary tract infection). He is now on ABT (antibiotic therapy) and he has returned to his baseline. He does recall what happened he just wasn't strong enough to reach for the pillow and sit back up in the bed. He was also supposed to have a concave mattress and the maintenance man didn't put it on prior to this fall. He was counseled and the concave mattress is on his bed now. He also has an electric bed and it is to be in the lowest position, author Unit Manager I. A review, of Resident #159's care plan related to falls, revealed the following: -Focus: The resident is, at risk for falls r/t (related to) Deconditioning, impaired mobility. Revision on [DATE]. -Goal: The resident, will be free of falls through the review date. Revision on [DATE]. -Interventions: The resident needs, a safe environment with: even floors free from spills and/or clutter: adequate, glare-free light; a working and reachable call light, the bed in low position at night: Revision on [DATE]. Anticipate and meet needs. Revision on [DATE]. Apply concave mattress to bed to maintain upper and lower body alignment. Date Initiated: [DATE]. Be sure call light is within reach and encourage to use it for assistance as needed. Revision on : [DATE]. PT (physical therapy) evaluate and treat as ordered or PRN (as needed). Date Initiated: [DATE]. The care plan had not been updated after the occurrence of the fall on [DATE] and did not reflect falls that had occurred on [DATE], [DATE] and [DATE]. The intervention to apply the concave mattress to the bed was not completed after the initiation of the intervention on [DATE]. There was no care plan in place for actual skin impairment of the laceration to the forehead with sutures that the Resident had received after the transfer to the hospital. The Resident had returned to the facility on [DATE]. A review of Resident #159's medical record of the document Nursing Home to Hospital Transfer Form, revealed the date of the transfer documented as [DATE] to the hospital, with the report called in to (Hospital) ER/RN (emergency room /Registered Nurse) on the date of [DATE] at the time of 12:27 PM. The form was documented as completed by Nurse JJ and sent on [DATE] at 12:55 PM. A review, of Resident #159's medical record of the document SBAR Communication Form, revealed the situation on [DATE] of a fall with laceration to forehead. The Background information revealed the Resident Evaluation of the mental status evaluation left blank. A review, of Resident #159's medical record of progress notes, revealed no progress notes of the occurrence of the fall on [DATE], resident assessment, a complete neurological assessment, the time the Resident had transferred to the hospital or follow-up evaluation of the event. On [DATE] at 11:00 AM, an interview was conducted with the Director of Nursing (DON), Nurse Consultant L and Staff Development Coordinator FF, regarding Resident #159's fall on [DATE]. The incident report had been requested on [DATE] and [DATE], during the survey, but had not been received until this interview and indicated there was an issue with getting the documents printed. A review of the incident report was conducted with the DON. The DON was queried what the cognitive impairment was of Resident #159 at the time of the fall and reported the Resident had moderately impaired cognition. Staff Development Coordinator FF reported the fall was unwitnessed after review of the incident report. The DON was queried what time the Resident had left the facility to go to the emergency room . Staff Development Coordinator FF reviewed the medical record and reported the transfer details indicated [DATE] and stated, It didn't pull correctly (time and date). The DON was queried regarding assessment and neurological (neuro) checks, reviewed the medical record and stated, I'm not seeing it, and indicated neuro checks and assessments should be done and documented. Nurse Consultant L offered information that was obtained from the emergency room (ER) notes that the Resident had gotten to the ER at 8:21 AM. A review, of Resident #159 having an unwitnessed fall, cognitive impairment, an injury to the head, needing to be transferred to the hospital, on an anticoagulant medication and lack of documentation in the medical record, was conducted and the DON was queried regarding an investigation into the event. There was no investigation information provided and the Staff Development Coordinator FF indicated Unit Manager I had made a note on the event. The DON confirmed that the note on the incident report made on [DATE] by Unit Manager I was the extent of the investigation and stated, That is all that is written on it. The DON was queried if Resident #159's fall with the head injury was reported as a FRI (Facility Reported Incident). The DON stated, I would say that it's not reportable, and indicated the Resident was reaching for a pillow and could tell us what happened, he was educated, had an electric bed and that it was to be in the lowest position. A review of the documentation not representing an accurate representation of the Resident's fall, injury, assessment, time and date of transfer to the hospital was conducted. With the discussion of multiple documentation issues that did not give an accurate representation of the actual experiences of the resident and include enough information to provide a representation of the care provided, progress, response to treatments, change in condition, plan of care goals, objectives and interventions, the DON stated, Yeah I know it. I understand, and indicated documentation was lacking. On [DATE] at 4:10 PM, an interview was conducted with Unit Manager I regarding Resident #159's alleged fall on [DATE]. The note on the incident report was read with the Unit Manager and they reported the mattress was not on and it had been placed on the Resident's bed. When queried regarding the note on the incident report made on [DATE] and the gap in time with the occurrence on [DATE], the Unit Manager reported the gap in time could have been a weekend ([DATE] was Sunday) but was unsure and stated, That's when I got to it. The Unit Manager reported they could not keep up with them timely and that she had been pulled to work the floor as direct care staff. When queried regarding the Interdisciplinary Team's (IDT) investigation into the occurrence, the Unit Manager indicated the team would discuss events in the morning meeting and she would write a note. The note did not indicate the team had reviewed the event and the Unit Manager was unsure if the team had met regarding the incident back in October. When queried if the incident report was part of the medical record, the Unit Manager reported it was not part of the medical record and that documentation would go in as a progress note. A review of the electronic medical record revealed no progress note regarding the investigation or review of the occurrence of the injury to Resident #159. Resident #59: A record review of the Face Sheet and MDS assessment for Resident #59 indicated the resident was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment dated [DATE] revealed the resident had moderate cognitive loss and needed extensive 2-person assistance with bed mobility, transfers, dressing, toileting, hygiene and bathing. The resident died on [DATE]. A record review of the assessments and progress notes indicated Resident #59 had fallen at the facility, but they did not identify the day and time the fall occurred. A note dated [DATE] at 4:00 AM revealed, Resident eyes very bruised with significant swelling post fall. Denies pain but states it is sore . orbital swelling and bruising to eyes. There were no notes or assessments describing how the resident fell , on what date or time, why she fell , if there was an injury, if treatment was needed and if the responsible party and physician were notified. A Medical Visit note from Physician BB dated [DATE] at 12:17 PM, Reason for visit . Left forehead hematoma . Pt fell . by getting up on her own. Pt sustained a large hematoma on her left forehead/eyebrow . did say her forehead is tender to touch . tender ,[DATE] cm raised hematoma left forehead, bilateral periorbital bruising; left neck bruise . Plan continue neuro-checks to monitor for s/s (signs and symptoms) . A review of the resident's Care Plan titled, At risk for falls related to muscle weakness, lack of coordination, decreased mentation and history of self-transfers . date initiated [DATE], last reviewed [DATE]; canceled on [DATE] (after the resident died on [DATE]). Interventions: last updated [DATE]. There was no review or update of the Care Plan after the resident fell and injured her head in [DATE]. On [DATE] at 3:50 PM, during an interview with Unit Manager I about the resident's fall and the lack of documentation about the fall in the medical record or update to the Care Plan to aid in preventing future falls and ensuring the resident received the care she needed, she confirmed the Care Plan was not updated nor was there a note describing the event in the medical record and there should have been. She said the facility no longer completes a post- fall assessment form but documents the assessment on the Unusual Occurrence Report, which was not included in the medical record. On [DATE] at 4:30 PM, Unit Manager I provided a copy of an Incident and Accident Report dated [DATE] at approximately 9:00 AM, (for Resident #59) and written by Nurse EE, Titled Witnessed Fall, . This nurse heard code green called to dining area when this nurse arrived, noted resident lying on the floor on her left side. (Left upper extremity) under her trunk, (Right upper extremity) extended outward. (Bilateral lower extremities) were bent, with (right lower extremity) across (left lower extremity). Resident stated she was trying to stand up . This nurse assessed to find a large, round, purple bump above resident's left eye. This nurse also noted an abrasion on the side of resident's face . Injury Type: Abrasion face, Hematoma Face . Predisposing Environmental Factors: None .Predisposing Physiological Factors: Confused, Incontinent, Gait Imbalance, Impaired Memory . Witnesses: No witnesses found . Care plan reviewed/updated . There was no mention of interventions to aid in preventing the resident from falling and injuring herself again. The care plan was not updated. The document said no witnesses found, but the title of the form is Witnessed Fall. There were no statements from any potential witnesses in the dining room. Resident #310: A record review of the Face Sheet and MDS assessment indicated Resident #310 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment dated [DATE] identified severe cognitive decline (BIMS/Brief Interview for Mental Status score of ,[DATE]), 2-person assist with transfers and 1-person assistance with transfers and toileting. On [DATE] at 8:15 AM, Resident #310 was observed awake, lying on her back in bed. She was alert and asked, Who's there? but was unable to appropriately answer questions. The resident was observed to have an abrasion on her nose with purple bruising on her face and a skin tear on her right arm. A review of the medical record for Resident #310 revealed she had fallen 3 times since admission: [DATE], [DATE] and [DATE]. Two of the falls were in the resident's room on the Main hall and one in the dining room on the North hall. A progress note dated [DATE] at 11:30 AM revealed, . Resident getting up to use restroom and fell . This nurse saw resident standing toward the end of her bed . Resident's (right lower extremity) rubbed across the foot board, breaking open 2 prior skin tears and fell flat on her buttocks . re-educated on use of call light, re-educated resident on high fall risk & she needs help to get out of her bed . New intervention implemented: Re-educating resident: call light placement & use; high fall risk & the need for assistance. A progress note dated [DATE] at 4:15 PM, . Resident had an unwitnessed fall in activity room . Current Interventions: see care plan . New Intervention implemented: Re-educated. A progress note dated [DATE] at 2:56 AM, Pt (patient) heard yelling out in room. Pt immediately assessed and observed on the floor on the left side of the bed between bed and the wall. Chair was also on the left side of the bed. Pt was observed laying on her right side. Skin tear noted to bridge of nose, RUE (right upper extremity), right knee and skin tear to (right lower extremity) re-opened. Raised area noted to left side of forehead. Pt was incontinent of urine . pt (complains of) pain to bridge of nose . unwitnessed . New intervention: Moved bed to wall on left side. Fall mat placed on the floor on the right side of bed. A review of the resident's assessments revealed 1 post-fall review in the medical record dated [DATE]. A review of the Resident #310's Care Plans revealed the following: Baseline Care Plan dated [DATE] and lock date [DATE], . Falls/Accidents- Initial Care Plan Focus: . History of falls-prevent additional falls . Will have no serious injuries from falls or accidents . Interventions/Action Steps . Assist with mobility needs, ensure skid proof footwear, respond to distress . There was no mention of supervision or monitoring the resident or a plan for toileting. Care Plan titled, The resident has bladder bowel incontinence related to dementia . date initiated [DATE]. The resident was incontinent twice when attempting to transfer self. There was no plan for toileting until the resident had been at the facility 14 days and fallen 3 times. Care Plan titled, (Resident) has had an actual fall with minor injury, date initiated [DATE] with revision [DATE]. There was 1 intervention- Neuro-checks x 72 (hours) reporting to MD abnormal's, date initiated [DATE]. The care plan was not updated after the resident fell on [DATE] or [DATE]. Care Plan titled, High risk for falls related to impaired balance, very poor safety awareness, unable to rationalize with, dated initiated [DATE], with revision [DATE], and Interventions: [DATE]- Follow facility fall protocol. There were no interventions to address monitoring or toileting. The care plan was not updated after the resident's fall on [DATE]. On [DATE] at 9:15 AM, during a tour of the facilities South, Main and East hallways, no staff were observed in the hallway or assisting resident's in their rooms. Resident's meal trays were sitting in their rooms waiting for assistance. 3 Certified Nursing Assistants (CNA's) were observed sitting in the Day room on the Main Hall, with another 4th CNA who was providing 1:1 monitoring of a resident. There were no CNA's observed monitoring residents or assisting with care on the South, East or Main Hallway. The CNA's were asked why no one was assisting residents on the floor and CNA RR arose from her seat and said they were just resting their feet (during the resident's meal). She left the room and went to her assignment and said there was 1 aide still on the floor, although upon looking, she could not find her. The other 2 CNA's stayed in the Day room. CNA RR was asked who was assisting the residents while they were all sitting in the Day room? She didn't answer but began to go room to room to assist residents. Immediately following the conversation with CNA RR, Nurse Manager I was observed passing medications on the Main Hall; she was asked why the nurse aides were sitting in the Day room talking during a meal, when the residents needed assistance and said she would check on it right then, but as she was working administering medications, she was not aware they were not where they were supposed to be. At that moment CNA QQ was observed exiting the break room. There was not 1 aide on the floor for South, Main and East halls. On [DATE] at 10:30 AM, the Director of Nursing was asked about the lack of staff on the floor to assist and monitor residents and said she had just talked to the nurse aides about it. On [DATE] at 11:40 AM, the resident's falls and injuries were discussed with the Director of Nursing; she said she was aware the residents had fallen. A review of the facility policy titled, Falls and Fall Risk, Managing, dated revised [DATE] provided, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling . if falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach still remains relevant . the staff will monitor and document each resident's response to interventions intended to reduce falling . if the resident continues to fall, staff will re-evaluate .

Based on observation, interview and record review, the facility 1) failed to ensure that appropriate interventions were in place to prevent a facility-acquired pressure ulcer for one resident (Resident #260) and 2) failed to assess, monitor and provide appropriate treatment for [REDACTED].#38, Resident #45, Resident #260 and Resident #310) of seven residents reviewed for pressure ulcers, resulting in Resident #260 developing a new facility-acquired pressure ulcer that was unstageable with slough and necrotic tissue and pain with dressing changes, and inappropriate wound care, monitoring and documentation, with the potential for wounds worsening, delayed wound healing, infection and overall deterioration in health status for Residents #38, #45, #260 and #310. Findings include: Resident #45: A review, of Resident #45's medical record, revealed an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment, dated 12/20/19, revealed the Resident had severely impaired cognitive skills for daily decision making and was total dependent with transfers and eating and needed extensive assistance with bed mobility, toilet use and personal hygiene. Further review of the MDS assessment revealed speech clarity: no speech-absence of spoken words; makes self understood: rarely/never understood; and ability to understand others: rarely/never understands. Further review of the medical record, revealed the Resident had a stage IV sacral wound. A review of Resident #45's Treatment Administration Record (TAR) for January 2020, revealed an order to Cleanse wound bed with normal saline or wound cleanser thoroughly. Loosely pack wound bed with calcium alginate, and cover with [MEDICATION NAME] dressing. Change every day and PRN (as needed) when soiled. Every day shift for wound healing. Order Date 12/20/2019. A review of Resident #45's medical record of the Admission-Readmission Nursing Assessment, with an effective date on 12/13/2019, revealed, .Integumentary R. Skin issues, Site Coccyx, Type Pressure, Length 4.8 cm (centimeters), Width 3.8 cm, Depth 2.8 cm, Stage IV. S. Describe any impairments in skin integrity: Coccyx wound is deep extending to the left 3.8 cm, the right side of wound extends in 3.0 cm. In the middle of the wound there is bone showing and that depth is 2.8 cm. Wound bed that is visible is red with bright red drainage. On 1/13/20 at 7:27 AM, an observation was made of Resident #45 lying in bed with the head of the bed turned to face the wall where the TV was positioned. The Resident was awake but was not engaged in watching the TV that was on. The Resident did not respond to questions asked but looked around the room. The Resident did not provide meaningful responses or communication to questions. The Resident was positioned with a pillow behind his left side. On 1/16/20, a review of Resident #45's medical record, revealed progress notes that included the following: -Effective Date: 12/16/2019 11:30 Type: Wound Care Update Wound Measurements: Coccyx: 4.8 cm (centimeters) x (by) 3.8 cm x 2.8 cm. Wound spreads open in the left side and back 3.8 cm. On the right side it spreads open 3 cm. Wound Bed Description: Wound bed is red with bleeding present. Able to view bone. Odor, drainage, pain control: No odor. Small amount of bright red bleeding on the left side of wound. (Resident's name) did moan when wound was cleaned and packed. Did packing slowly to decrease discomfort. Will medicate prior to next dressing change. Current Treatment: Cleansed wound with normal saline and patted dry. Lightly packed wound with 8 inches of saline soaked gauze and covered with an ABD (absorbent dressing) pad. Will contact WCC (wound care clinic) nurse for input on treatment. Author: (Nurse Consultant L) -Effective Date: 12/23/2019 11:06 Type: Wound Care Update Wound Measurements: Coccyx: 5.9 cm x 4.0 cm x 2.9 cm. Wound Bed Description: Red tissue with a small amount of serosanguinous drainage on dressing when removed. Odor, drainage, pain control: No odor, small amount of bloody drainage. (Resident's name) will moan during repositioning. Current Treatment: Cleansed with normal saline. Wound lightly packed, covered with abdm pain (ABD pad. Author: (Nurse Consultant L) - Effective Date: 12/30/2019 16:14 Type: Wound Care Update Wound Measurements: Coccyx:6.4 cm x 4.0 cm x 3.5 cm. Wound Bed Description: Red with patches of thick yellow tissue. Able to visualize bone. Wound edges are intact, no rolling noted. Area surrounding is reddened with several 1 cm size abrasion-type wounds noted. Probably from tape. Odor, drainage, pain control: Foul odor and gray, serosanguinous drainage from wound and on dressing. (Resident's name) will moan when he is repositioned and when wound was cleansed. Current Treatment: Cleansed wound with normal saline and patted dry. Loosely packed wound with three strips of calcium alginate and then covered with two ABD pads without tape due to the several abraded areas from previous tape. Author: (Nurse Consultant L) - Effective Date: 1/5/2020 00:16 Type: Nursing Progress Note Note Text: nurse aids called me into room observed resident had a bm (bowel movement) and stool got onto dressing covering his buttock/coccyx wound. Dressing removed, area cleansed with normal saline and new packing applied via kerlix strip soaked in normal saline wet to dry dressing abd's placed over packing as ordered. At beginning of packing wound a large piece of flesh fell off easily, has foul odor and was placed into specimen cup for review. Resident tolerated procedure well had some discomfort during tx. Pain med given as scheduled with good effect. -Effective Date: 1/15/2010 11:28 Type: Wound Care Update Wound Measurements: Coccyx: 5.4 cm x 3.5 cm x 3 cm. Left side of wound tunnels back 5.4 cm. Right side of wound tunnels back 2.5 cm. Wound Bed Description: Wound bed red, beefy. edges intact. Odor, drainage, pain control: No odor, has small amount of bloody drainage. Current Treatment: Cleansed with normal saline and patted dry. Lightly packed wound with alginate and covered area with a border gauze. Has an appointment set up on February 2, 2020 at the wound clinic. Contacted mother regarding current status and appointment at wound clinic. Author: (Nurse Consultant L) On 1/16/20 at 10:52 AM, an interview was conducted with Director of Nursing (DON), Nurse Consultant L and Staff Development Coordinator FF, regarding Resident #45's wound care. A review was conducted of Resident #45's pressure ulcer care, monitoring and measurements. Nurse Consultant L was queried regarding the lack of measurements for the tunneling of the wound on 12/30/19 and 12/23/19. Nurse L reported the Resident did not have tunneling but the wound widens up in that direction. Nurse Consultant L stated, I don't know why it's not done on these. I might have it in my book, and indicated measurements were kept in a book that was maintained with wound measurements but was not a part of the electronic medical record. When queried regarding facility policy on wound measurements, Nurse Consultant L reported measurements were to be done weekly. When queried why measurements were not documented in Resident #45's medical record from 12/30/19 to 1/15/20, the Nurse Consultant L stated, I must have them in my book. I will get them for you and update the chart. The DON and Nurse Consultant L was queried regarding the progress note on 1/5/20 that revealed, at beginning of packing wound a large piece of flesh fell off easily, has foul odor and was placed into specimen cup for review, and reported that the part that had fallen out was the calcium alginate dressing that the wound had been packed with. A review of Resident #45's medical record of the TAR for January 2020 revealed the dressing change documented in the progress note on 1/5/20, was not documented on the Treatment Administration Record or followed the prescribed treatment for [REDACTED]. Resident #260: According to Admission Record, printed 1/14/2020, Resident #260 was a [AGE] year-old female admitted to the facility on [DATE] (re-admitted [DATE]) with [DIAGNOSES REDACTED]. According to MDS resident assessment tool dated 12/17/2019, Resident #260 had a Brief Interview for Mental Status (BIMS) score of 13, indicating her cognition was moderately impaired. During an interview on 01/15/2020 at 02:20 PM, the resident representative for Resident #260 complained that the resident has not been repositioned all day. Resident's Representative stated that they had not even come in to offer to reposition her. Resident's representative arrived at the facility at 8:30 AM. Resident's Representative stated that resident had two new pressure ulcers on her bottom that appeared one day ago and the nursing staff did not put a dressing on it when it was brought to their attention yesterday. Resident #260's physician's orders were reviewed with RN II on 1/15/2020 at 2:25 PM. Resident #260 had one treatment order to apply a barrier cream to her coccyx to prevent skin breakdown. RN II said there were no other treatment orders for her coccyx. RN II said she was not aware of Resident #260 having a pressure ulcer until her family member told her today and she was making her way to put a dressing on. The surveyor requested to observe wound care. RN II stated that RN L would come and get the surveyor when she came to assess Resident #260's coccyx. RN II and RN L did not come and get the surveyor for the observation. Progress note, dated 11/26/2019 at 4:39 PM, revealed that Resident #260 was admitted to facility with a Stage 2 pressure ulcer on her left buttock. The wound bed was described as pink/red with a small amount of clear drainage. Resident #260's Skin Observation Tool, dated 11/29/2019, noted, intact skin. There were no other Skin Observation Tools since the one completed on 11/29/2019 Progress note dated, 12/2/2019 at 1:53 PM, described the Stage 2 pressure ulcer on the coccyx to have a superficial wound bed, ulcerated, and a minimal amount of clear drainage surrounded by redness. No measurements were included. Physician's progress note, dated 12/2/2019 at 2:26 PM, stated that the doctor saw Resident #260 to examine her Stage 2 pressure Ulcer Left Buttocks due to bleeding after wiping. No measurements were included. According to Admission-Readmission Nursing Assessment, dated 12/10/2019, Resident #260 had a Stage II pressure ulcer that measured 0.2 x 0.3. No other pressure ulcers were noted on the assessment. According to Admission-Readmission Nursing Assessment, dated 1/04/2020, Resident #260 had red coccyx skin, no breakdown .at the time of her 1/04/2020 re-admission. Upon follow up review of Resident #260's physician's orders, a new order was prescribed on 1/15/2020 that said to cleanse the coccyx with normal saline, pat dry, and apply [MEDICATION NAME] dressing every three days and as needed for wound care. This order was written on 1/15/2020 at 4:15 PM. According to Wound Care Update progress note written by RN L on 1/15/2020 at 4:10 PM, Resident #260 had a wound on the left buttock by upper gluteal fold: 3 centimeters (cm) X 5.8 cm, superficial open area. This area extends across to the right buttock where there is an area that is 2.2 cm X 1 cm superficial open area. Across the top of the wound is a butterfly shaped necrotic area that is dark brown/pale yellow in color. The note said that Resident #260 complained that the wound hurt with cleansing. During an interview on 01/16/2020 at 01:59 PM, RN L confirmed she was first notified yesterday (1/15/2020) of Resident #260's wound. She said she assessed the wound, obtained an order for [REDACTED].#260 had upon admission. That wound had healed. During wound care observation on 1/16/2020 at 2:20 PM, RN L and RN FF were observed performing wound care on Resident #260's coccyx. Resident #260's doctor was present and stated, we need to get santyl on that slough. The wound was observed to have slough and necrotic tissue present at the time of observation. Nurse FF stated the wound was unstageable. Nurse L said she did not know how long Resident #260 had the wound but knew that it wasn't open when she was recently readmitted from the hospital. When asked what interventions were in place to prevent the wound from worsening or the development of additional pressure ulcers, Nurse L said they were turning her every two hours and keeping her clean and dry. Resident #260 had a Care Plan focus area related to skin that read, The resident admitted with stage II pressure ulcer buttocks . (Initiated: 12/18/2019; Revision on: 01/14/2020). Interventions for that focus area included, assistance and encouragement to turn/reposition at least every 2 hours, more often as needed or requested, administer treatments as ordered and monitor effectiveness, assess/record/monitor wound healing and report improvements and declines to the doctor all initiated 12/18/2019. On 1/15/2020 a new Care Plan was initiated that explained that Resident #260 had a wound on her bilateral buttocks. The care plan states that resident was refusing to let staff provide care to her at times and is dependent on staff to reposition her which can cause shearing. New interventions included to keep skin clean and dry and use a draw sheet to move resident. Upon review of Resident #260's Treatment Administration Records (TAR) for the months of December 2019 and January 2020, it was noted treatment opportunities were missed. From 11/26/2019 to 12/10/2019, Resident #260 had an order for [REDACTED]. Resident #260 also had an order to cleanse the left inner buttocks wound with normal saline or wound cleanser and apply barrier cream every shift (ordered 12/10/2019). This treatment was not administered on the 12/13/19 evening shift, 1/7/2020 evening shift or 1/8/2020 on midnight shift. No reason for missed treatments was documented. For all missed opportunities, the TAR was blank. Facility policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol (dated 6/10/2019) said, the physician will help the staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. Resident #38 A record review of the Face Sheet and Minimum Data Set (MDS) assessment indicated Resident #38 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities 15/15 Brief Interview for Mental Status Score (BIMS) and needed extensive assistance with all care, although the resident could feed himself with set up. During the initial tour on 1/14/20 at 11:10 AM, Resident #38 was observed lying in bed. He said he had [MEDICAL CONDITION] and his hands were contracted. The resident said he had several wounds on his bottom. A review of the Admission-Readmission Nursing Assessment, dated 9/6/19 at 2:00 PM, revealed the following: . Skin Issues . 53) Sacrum, Pressure, 0.5 cm (length) x 3 cm (width) x 4.5 cm (depth), IV (Stage 4 Pressure Ulcer). The National Pressure Ulcer Advisory Panel, 2016 definition, Stage 4 Pressure Injury: Full-thickness skin and tissue loss, Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. A review of a Skin Assessment Tool, dated 9/13/19, Sacrum, surgical incision, 3.5 cm x 0.25 cm. 1.2 cm . Treatment continues to groin region with scrotum having moderate redness. There was no additional assessment data describing the wound. A record review of the progress notes and assessments indicated 2 Skin Observation Tool, assessments that were blank with no identifying wound information except for the following: 12/17/19- Resident had shower tonight. No new skin issues. Skin is clean, dry and warm. Resident continues tx (treatment) to coccyx and BLE (bilateral lower extremity). Tx (treatment) to both coccyx and BLE done. 1/8/2020- Red blotches on bilateral lower legs, wound on coccyx continues to be open and with the wound closer to rectum is larger and the one above that is a pin-point opening. Neither skin assessment had a description of the wounds, drainage, odor or size. Further record review revealed the most recent wound note with measurements, in the medical record, was dated 12/19/19 and identified 3 wounds: Coccyx 1 cm x 0.5 cm x 0.7 cm, Right buttock 1.4 cm x 1.5 cm x 5 cm and Left buttock 2.5 cm x 1.5 cm x 5 cm. On 1/16/20 at 10:10 AM, wound care for Resident #38 was observed performed by Nurse L and assisted by Nurse JJ. Nurse L said the resident had received pain medication about 20 minutes prior to the procedure. Nurse L removed the prior dressing and several large wounds were observed on the resident's buttocks and coccyx with the following measurements: coccyx 0.5 cm x 0.5 cm x 1.3 cm, right buttock 0.5 cm x 1.0 cm x 6.3 cm, left buttock 2.0 cm x 2.1 cm x 6.0 cm. When the nurse measured the depth of the wounds there was bloody drainage on the cotton tipped swab. The nurse packed the wounds with wet gauze. The resident exclaimed Ow, with complaints of discomfort and pain. Resident #38 stated, The left one hurts worse, like a razor-sharp poker. The resident's coccyx wound had worsened since admission and the right and left buttock wounds were new. After the procedure, Nurse L was asked about the lack of skin assessments and wound measurements in the medical record and said the nurses were supposed to complete a weekly skin assessment. Nurse L said there was additional wound documentation in the office that had not been placed in the medical record. On 1/21/20 Nurse L provide a copy of Wound Care Update, notes from October 2019- January 7, 2020, with wound descriptions and measurements. From December 19, 2019 to January 7, 2020 the notes said, Late Entry. There were 3, December 19, 2019 notes; one was not a late entry (left buttock) and 2 were late entrys (coccyx and right buttock). The notes indicated the wound treatment had been the same since 10/2/2019. None of the wound notes had pressure ulcer staging documented. The resident's wounds had significantly worsened since admission. A review of the physician orders provided: Cleanse wound on coccyx with normal saline. Wet to dry dressing. Moisten kerlix with normal saline and lightly pack in to the wound. Cover with a gauze dressing. Change on days and evening shift, related to Pressure Ulcer of Sacral region order date 10/2/2019, The resident had 3 wounds: right buttock, left buttock and coccyx and only 1 order for a dressing to the coccyx. A review of the Treatment Administration Record revealed the coccyx dressing had not been completed as ordered on 7 occasions: no documentation on 1/3/20 (evening) or 1/16/20 (days), on 1/6/20, 1/9/20, 1/10/20, 1/11/20 and 1/20/20 the dressing was not completed on the dayshift (per refusal and see notes). A review of the progress notes did not provide an explanation for the missing wound care. A review of Resident #38's Care Plans indicated a Care Plan dated 9/18/19 titled, The resident admitted with pressure ulcers, stage IV on sacrum, right heel DTI (deep tissue injury) left heel stage 2, DTI right lower leg . The Care Plan was updated on 12/6/19 to say . admitted with stage IV pressure injury on his left buttock next to the gluteal fold and a unstageable injury on his coccyx and right buttock next to the gluteal fold. Both the coccyx and right buttock wounds are tunneling . date initiated 12/6/2019 and revised 12/20/2019 with Interventions: Administer treatments as ordered, assess/record/monitor wound healing, Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress . weekly skin documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate . There was no measurement or documentation of the wounds on admission, as described in the 12/6/19 Care Plan. There were inconsistencies in documentation and assessment, and a lack of wound description in the medical record. Resident #310 A record review of the Face Sheet and MDS assessment indicated Resident #310 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment was not yet completed. The resident needed assistance with all care. On 1/13/20 at 8:15 AM, Resident #310 was observed awake, lying on her back in bed. She was alert and asked, Who's there? but was unable to appropriately answer questions. A review of the Admission-Readmission Nursing Assessment, dated 12/31/19 at 1:51 PM indicated the resident was admitted with a Stage 3 pressure ulcer on the right hip measuring 55 cm length x 5 cm width. Additionally, there were abrasions noted on the right lower leg and left forearm with no measurements or description. (National Pressure Injury Advisory Panel, 2016, A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful . Stage 3 Pressure Injury: Full-thickness skin loss, Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible .). A review of the progress notes for Resident #310 revealed the following: 1/2/2020 at 6:08 AM, Note text: Cleanse right hip wound daily with NS (normal saline), pat dry and apply a foam dressing in the evening for wound care. Start Date: 12/31/2019, Pt (patient) tolerated well. [DIAGNOSES REDACTED] (redness) noted to peri wound. Slough noted to wound bed. Foam dressing not available. Applied ABD pad for protection. There were no additional skin assessments or wound measurements identified in the progress notes or assessments. A review of the Baseline Care Plan, for Resident #310 dated 1/2/2020 at 1:51 PM and Lock Date 1/4/2020 at 8:12 AM, provided . b5. Skin Integrity-Initial Care Plan Focus, 3. Resident's skin is intact and has high risk of developing impairment, b6. Skin Integrity-Initial Care Plan Goal, 1. Resident will not develop skin impairment, b7. Interventions/Action Steps to Reach Skin. Integrity Goals: Clean skin as soils, Turn and reposition while in bed. There was no mention of the identified pressure ulcer or abrasions from the admission assessment and no mention of treatment to the areas to promote healing. A review of the Care Plan titled, The resident has, potential/actual impairment to skin integrity related to admitted with stage II pressure ulcer, Right Hip, at risk for worsening or further breakdown, impaired mobility, Hospice, impaired cognition, Date initiated 1/13/2020, revision 1/13/2020 with Interventions: The resident needs, pressure relieving/reducing cushion in wheelchair, date initiated 1/13/2010, the resident needs, pressure relieving/reducing mattress, date initiated 1/13/2020, Monitor/document location, size and treatment of [REDACTED]. to MD, date initiated 1/13/2020, Treatment as ordered, date initiated 1/13/2020. The resident did not have interventions to monitor and assess or use pressure reducing devices until 1/13/2020; she was admitted on [DATE]. A review of the physician orders for Resident #310 revealed: Cleanse right hip wound daily with NS, pat dry and apply a foam dressing in the evening for Wound care, order date 12/31/2019 at 4:15 PM. A review of the resident's TAR for January 2020 indicated there were several days that the treatment to the right hip pressure ulcer was not completed: 1/6/20, 1/8/20 and 1/12/20. On 1/16/20 at 2:59 PM, wound care for Resident #310 was observed with Nurses L and J. The resident had multiple wounds including the right hip pressure ulcer: 3 areas on the right knee and lower leg- Nurse L said she was admitted with some areas stating, They broke open during a fall here. 1 abrasion, 2 skin tears, 1 large purple bruise- right lower leg. There were steri-strips on the right knee skin tear. The nurse cleansed the wounds and applied a Vaseline gauze dressing and kerlix wrap to the right lower leg. Nurse L said the wound on the right hip was an old area with a small scabbed area. Nurse L further said the order was for a foam dressing to the right hip, but the facility didn't have any, so the nurse used border gauze. We don't have any foam, but the delivery truck is supposed to be here today. The old dressing removed by Nurse L was dated 1/15/20 and was not foam either; it was a border gauze. The nurse was asked why no one was documenting that they were not following the physician's order and that the necessary wound care supplies were not available, she said she didn't know. During the wound care observation, the resident was noted to have 3 skin tears on the right lower/mid arm area and 1 large dark purple bruise (all were from falls at the facility per Nurse L). The Nurse cleansed the areas and applied Vaseline gauze and kerlix wrap. The areas were in varying degrees of healing- the old dressing on the arm was stuck to the wound and even after being moistened with normal saline it pulled the scab and new skin from the wound. Discussed the wounds lack of ability to heal with current treatment sticking to the wound and reviewed missing wound documentation with the nurse and she said, Yes, she was aware. No measurements were taken of the wounds during the wound care and no measurements were identified in the resident's medical record to determine wound healing. The TAR for January 2020 also identified missing documentation of wound care for the resident's leg and arm wounds acquired at the facility: 1/6/20, 1/8/20, 1/9/20, 1/12/20 and 1/13/20 (right leg skin tear). On 1/21/20 at 11:30 AM, during an interview with the Director of Nursing, she was asked about the missing wound care supplies and lack of wound care completion and she stated, No one told me about that. A review of the facility policies titled: Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated June 10, 2019 . In addition, the nurse shall describe and document/report the following: Full assessment of pressure sore including, location, stage, length, width, and depth, presence of exudates or necrotic tissue . Prevention of Pressure Ulcers/Injuries, dated June 12, 2019, The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factor and interventions for specific risk factors . Review the resident's care plan . Assess the resident on admission . repeat the risk assessment weekly and upon changes in condition . Evaluate, report and document potential changes in the skin, review the interventions and strategies for effectiveness on an ongoing basis . Pressure Ulcer/Injury Risk Assessment, dated June 12, 2019, The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing pressure ulcers/injuries . Use only (the facilities) approved risk assessment . repeat the risk assessment weekly for the first four weeks, if there is a significant change in condition, or as often as is required . conduct a comprehensive skin assessment with every risk assessment . once inspection of skin is completed document the findings on the (facilities) approved skin assessment tool . Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition . The interventions must be based on current, recognized standards of care . the effects of the interventions must be evaluated . The care plan must be modified as the resident's condition changes or if current interventions are deemed inadequate . The following information should be recorded in the resident's medical record . type of assessment . date and time and type of skin care provided . name and title of the individual who conducted the assessment . change in the resident's condition . if the resident refused the procedure . documentation in medical record addressing, family, guardian or resident notification if new skin alteration noted . Wound Care, dated June 12, 2019, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing . Verify that there is a physician's order for this procedure . Review the resident's care plan .

Based on observation, interview and record review, the facility failed 1) to ensure the assessment and treatment of [REDACTED].#159 and Resident #260,) and 2) to ensure that wound dressings were applied, as ordered, for 3 residents (Resident #159, Resident #259, and Resident #309) of 19 residents reviewed. This deficient practice resulted in Resident #159 and Resident #260 experiencing abnormally low blood sugars, including hospitalization for Resident #260, and Residents #159, Resident #259 and Resident #309 lacking the prescribed and necessary wound care to promote healing, which could lead to complications including infection and worsening wounds. Findings Include: Resident #309: A record review of the Face Sheet and MDS assessment indicated Resident #309 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment was not yet completed. A nursing note, dated 1/15/20 at 6:03:PM, indicated the resident was A&Ox 4 (Alert and oriented times- person, place, time and location). During the initial tour of the facility on 1/13/20 (Monday) at 8:15 AM, Resident #309 said he was new to the facility and was there because he had back surgery and had an infection in the wound on his back. An IV pole was next to the bed and the resident said he received IV antibiotics twice a day. On 1/15/20 at 8:34 AM, Nurse H was observed changing the dressing on the resident's back. The dressing was observed on the mid-back region and it was dated 1/14/20 with Nurse H's name and initials; the nurse stated, That's mine- the one I put on yesterday. They didn't change it last night so I will do that now. Nurse H said she had worked the day shift on the previous day and had changed the dressing, because it was loose and it was scheduled to be changed on the night shift. The Nurse removed the old dressing: saturated with serosanguinous drainage, 6 sutures, some redness. That's where the infection was. Nurse H cleaned the area (surgical incision) with normal saline and applied a thick gauze pad and secured it with tape. A review of the physician's orders for Resident #309 revealed an order for [REDACTED]. May remove dressing for showers, pat dry, apply new gauze at bedtime for wound care, order date 1/9/2019. A review of the Medication Administration Record [REDACTED]. The dressing was not documented as completed on 1/12/20 and on 1/14/20 Nurse M signed that she changed the dressing, but the dressing had not been changed since Nurse H changed it that morning. On 1/16/20 at 8:10 AM, during an interview with Nurse M, she said that she was newly hired and had just started working at the facility on 1/10/20 with an orientation of 1 hour and 45 minutes with the Nurse Educator. Nurse M did not have any skills check off for wound care and received orientation on the floor for 2 days. On the night shift 1/14/20-1/15/20, there were 2 nurses on the floor for the entire building. The TAR for Resident #309 was reviewed with the nurse who stated, I did not change the dressing on 1/14/20. I must have signed it without realizing it. It was really busy. On 1/15/20, a review of the resident's Care Plan revealed, The resident has, infection of the back, need PICC, IV antibiotics, date initiated 1/13/2020, revision 1/13/2020, Interventions: There were no interventions mentioning wound care. There was no Care Plan for skin issues or for the wound. Review of the resident's Care Plans again on 1/21/20 indicated there was still no Care Plan for skin issues or the wound. On 1/22/20 at 11:35, during an interview with the Director of Nursing, she was asked about the missing and incorrect wound documentation and said she was not aware of it. A review of the facility policy titled, Wound Care, dated June 12, 2019, revealed The purpose of the procedure is to provide guidelines for the care of wounds to promote healing . Review the resident's care plan to assess for any special needs of the resident . The following information should be recorded in the resident's medical record: The date and time the wound care was given . the name and title of the individual performing the wound care . Resident #159: Resident #159 regarding a drain in the abdomen: A review, of Resident #159's medical record, revealed an admission into the facility on [DATE] with a re-entry on 1/6/20 with [DIAGNOSES REDACTED]. A review of the Minimum Data Set assessment revealed moderately impaired cognitive skills for daily decision making and the Resident needed extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. A review, of Resident #159's medical record, Admission-Readmission Nursing Assessment, with an date of admission on 1/6/20, revealed, Integumentary, Site: right upper arm; Type: picc line; S. Describe any impairments in skin integrity: right upper arm picc line in place, right knee front has two small red scabs, right big first toe has all black toe nail, left foot big toe has partial black toe nail, left heel foot small red scab, J-Prat drain (Jackson-Pratt drain-a closed suction device to drain bodily fluids) right side of body. A review, of Resident #159's medical record, revealed a progress note, dated 1/6/20 at 18:10 (6:10 PM) of an Admission Note, Specialized treatment . : Right upper arm midline, right side JP drain from liver abscess. A review, of Resident #159's medical record of the Treatment Administration Record (TAR) for January, 2020, revealed no scheduled dressing or assessments documented since the Resident's readmission into the facility on [DATE] for the abdominal drain. The review, of Resident #159's medical record, revealed that the Resident was readmitted , on 1/6/20, into the facility, with the JP drain, but there was no documentation of an order for [REDACTED]. On 1/14/20 at 4:30 PM, an interview was conducted with Nurse Consultant (NC) L regarding Resident #159's JP drain assessment and dressing to the insertion site. The Nurse reviewed the Resident's medical record and was unable to find an assessment or order for a dressing of the site of the JP drain. A review of the care plan with the Nurse revealed no interventions or directive for assessment or dressing changes for the JP drain. NC L stated, There should be an order for [REDACTED]. On 1/14/20 at 4:43 PM, an observation was made, with Nurse Consultant L and Nurse EE, who was assigned care of Resident #159, of the Resident's drain. The Resident was on isolation precautions with personnel protection equipment available prior to entering the room. The Resident was lying in bed and an accordion drain was on the right side of the Resident's abdomen. The Resident consented to the observation of the abdominal drain insertion site. Nurse EE lifted the Resident's gown to provide an observation of a clear dressing that was rolled up and loose at the drain insertion site. The Nurse was able to lift the loose dressing from around the insertion site to expose the skin around the tube that was clear of redness or moisture. The site contained a small amt of dried drainage under the dressing. No date was noted on the dressing. Nurse EE was not aware there was a dressing to the site and reported she had not been assigned care of the Resident since his re-admission until today. It was reported the Resident had an abscess in the liver with VRE ([MEDICATION NAME]-Resistant [MEDICATION NAME]) requiring the isolation precautions. Nurse EE reported they would call the Physician to obtain an order for [REDACTED]. On 1/15/20 at 4:45 PM, Nurse Consultant L reported the facility did not have a policy for the care of and assessment for JP drains. Resident #159 Blood Glucose monitoring: A review of Resident #159's medical record of blood glucose monitoring and progress notes, revealed the following: -On 9/24/19 at 8:39 AM, blood glucose 47. No documentation of the Physician notified, Resident assessment or course of treatment given. Blood glucose at 8:54 AM, 82. -On 9/27/19 at 7:34 AM, blood glucose 41. No documentation of the Physician notified, Resident assessment or course of treatment given. Blood glucose at 8:30 AM, 110. -On 10/7/19 at 8:15 AM, blood glucose 49. No documentation of the Physician notified, Resident assessment or course of treatment given. Blood glucose at 11:19 AM, 172. -On 10/13/19 at 6:23 PM, a progress note revealed, BS (blood sugar) at supper time 70, he refused supper but requested ensure. 8 ounces of ensure given. -On 10/14/19 at 12:02 AM, blood glucose 58. A progress note, dated 10/14/19 at 8:05 AM, revealed . This nurse measured resident's BS at 58. This nurse administered food and OJ (orange juice). Recheck BS at 87. Continuing to monitor recheck BS at 77. Administered cranberry juice. Recheck BS at 102. All insulin held. WCTM (will continue to monitor). -On 10/18/19 at 7:42 AM, blood glucose 42, 8:50 AM 95. A progress note, dated 10/18/19 at 19:44 (7:44 PM), revealed, Patient woke up with 42 sugar fasting today, recovered with food and drinks. Please review. He has low appetite, probably related to getting used to HD ([MEDICAL TREATMENT]). Came tired from HD. A review of Resident #159's Medication Administration Record, [REDACTED] -Humalog (Insulin [MEDICATION NAME]) inject as per sliding scale: If 0-200 = 0 units; 201-250 =2 units; 251-300 =4 units; 301-350=6 units; 351-400=8 units; 401-500=10 units and notify MD; 501-999=10 units Give 10- units and notify MD, subcutaneously before meals and at bedtime for dm II (diabetes type II), order date 1/15/20. -Humalog (Insulin [MEDICATION NAME]) inject as per sliding scale: If 151-200 = 1 units; 201-250 =2 units; 251-300 =4 units; 301-350=5 units; 351-400=6 units; 401+ =8 units and notify Physician, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus with diabetic [MEDICAL CONDITION], unspecified, order date 11/30/19, discontinue date 1/6/20. -Humalog (Insulin [MEDICATION NAME]) inject as per sliding scale: If 0-150 = 0 units; 151-200 =2 units; 201-250 =4 units; 251-300=6 units; 301-350=8 units; 351-400=10 units; 400+ Call Physician, subcutaneously before meals and at bedtime for dm II (diabetes type II), order date 9/21/19. On 1/21/20 at 11:00 AM, a review was conducted of Resident #159's blood glucose monitoring with the Director of Nursing (DON), Nurse Consultant L and Staff Development Coordinator FF. There was a lack of documentation of the Resident's condition or treatment for [REDACTED]. The DON reported the staff may not notify the Doctor if they were not showing signs of [DIAGNOSES REDACTED]. When queried regarding assessments for [DIAGNOSES REDACTED] with the low blood glucose levels, Staff Development Coordinator FF reviewed Resident #159's medical record and indicated they were unable to find assessments. The DON was asked if the facility policy gave direction of when the Nurse was to notify the Physician with abnormal blood glucose readings. After reviewing the policy, the DON indicated parameters for the low blood sugars were needed from the physician as to when the physician wanted to be notified. A review of the documentation of the abnormal blood glucose monitoring, lack of documented assessment, treatment given, response to treatment, timing of the rechecking of blood glucose testing and notification of the Physician, was conducted with the DON. The DON was queried if the documentation contained accurate representation of the actual experiences of the resident, interventions, response to treatments, progress and a plan of care. The concern, of the lack of drain site assessment for Resident #159 and the failure to obtain an order for [REDACTED]. The DON stated, Yeah I know it. I understand, and indicated documentation was lacking. On 1/22/20 at 11:11 AM, an interview was conducted with Physician BB, regarding notification of abnormal blood glucose monitoring. The Physician indicated they would expect staff would communicate if the blood glucose level is below 70 or the resident was having symptoms and when the level was above 400. The Physician stated, they should call to make sure the treatment is appropriate, and discussed the clinical picture of hyper and hypoglycemic residents. When queried regarding physician notification of blood glucose levels below 50, the Physician reported that it would be a concern that should be communicated to the Physician and stated, It would be a concern for anyone that low. A review of the facility policy entitled, Diabetes-clinical Protocol, dated June 18, 2019, revealed, . Monitoring and Follow-Up. 1. The Physician will follow up on any acute episodes associated with a significant change in blood sugars or deterioration of previous glucose control and document resident status at subsequent visits until the acute situation is resolved. 2. The Physician will order appropriate lab tests (for example, periodic finger sticks or A1C (laboratory test)) and adjust treatments based on these results and other parameters such as glycosuria, weight gain or loss, hypoglycemic episodes, etc . 4. The Physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management. a. The staff will incorporate such parameters into the Medication Administration Record [REDACTED]. The staff will identify and report complications such as foot infections, skin ulceration, increased thirst, or [DIAGNOSES REDACTED] . b. The Physician will help the staff clarify and respond to these episodes. 6. The staff and Physician will manage [DIAGNOSES REDACTED] appropriately. a. It is important to avoid over-treatment of [REDACTED]. b. For example, a borderline low blood sugar in the absence of signs and symptoms may not need any acute intervention and may or may not suggest the need to modify oral [DIAGNOSES REDACTED] medications or insulin. c. An example of appropriate treatment of [REDACTED]. For someone who is lethargic but not comatose, treatment might include oral glucose paste rubbed onto the [MEDICATION NAME] mucosa, intramuscular [MEDICATION NAME], or intravenous 50% [MEDICATION NAME] . Resident #259: According to Admission Record, printed 1/15/2020, Resident #259 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to his in progress Minimum Data Set (MDS) Resident Assessment Tool dated 1/10/2020, Resident #259's cognitive and decision-making skills were severely impaired. During an observation on 01/13/20 at 08:24 AM, Certified Nursing Assistant (CNA) LL performed peri-care after Resident #259 had a bowel movement. Skin breakdown was observed on Resident #259's left and right buttock surround his rectum. Staff Development RN FF assisted CNA LL and said that Resident #259 seemed to have some excoriation. Staff Development RN FF said she saw two spots and described them as denuded. After CNA LL and RN FF finished peri-care, CNA LL applied A & D ointment to Resident #259's buttocks with gloves soiled from peri-care. Upon review of Resident #259's physician's orders, there was not an order for [REDACTED].#259 had for his buttocks was [MEDICATION NAME] and that the CNA LL would return to apply the [MEDICATION NAME] to Resident #259 according to the order. According to Resident #259's baseline care plan, his skin was intact upon admission. According to admission Minimum Data Set (MDS) Resident Assessment Tool (dated 1/16/2020), Resident #259 was at risk for pressure ulcers. During an interview with Wound Care Nurse L on 01/16/2020 at 03:58 PM, she was asked if Resident #259 had skin breakdown on his buttocks and rectal area. Wound Care Nurse L stated she would go take a look and said that no one had made her aware he had skin breakdown. During a follow up interview on 01/21/2020 at 11:11 AM, Wound Care Nurse L said she examined Resident #259's buttocks and there was no pressure ulcer, but that he did have a fungal infection that is now being treated and is clearing. Resident #260: According to Admission Record, printed 1/14/2020, Resident #260 was a [AGE] year-old female admitted to the facility on [DATE] (re-admitted [DATE]) with [DIAGNOSES REDACTED]. According to MDS resident assessment tool, dated 12/17/2019, Resident #260 had a Brief Interview for Mental Status (BIMS) score of 13, indicating her cognition was moderately impaired. During the initial pool interview on 01/13/2020 at 10:09 AM, Resident #260's representative stated his wife has been hospitalized three times since she being admitted to the facility on [DATE]. He stated the hospitalization s were for her blood sugar dropping, [MEDICAL CONDITION] and low blood count. He also said his wife had fallen at the facility and believed that her low blood sugars were the root cause of her falling. Resident #260 had a care plan focus area that said she was at risk for altered nutrition related to her diagnosed diabetes (initiated 12/18/2019). Interventions included: diabetes medication as ordered by doctor and monitor/document/report to doctor as needed signs and symptoms of low blood sugar, and confusion, all initiated 12/18/2019. Resident did not have a baseline care plan and did not have a care plan for diabetes/low blood sugar management until after her hospitalization (12/4/2019-12/10/2019). Review of progress note, dated 12/3/2019 at 01:24 AM, revealed Resident #260 complained of feeling dizzy and nausea's. The progress note stated that at the time of complaint, Resident #260's blood sugar was 119. The nurse offered Resident #260 orange juice and a snack. The note continued that Resident #260 stated, I used to have [MEDICAL CONDITION] (a spinning sensation), but nothing helped. This isn't a cardiac problem. I just feel dizzy and my eyes can't focus. The note did not specify whether or not Resident #260's physician was immediately notified. The progress note did state, Requesting doctor to visit. Review of progress note, dated 12/3/2019 at 04:40 AM, revealed Resident #260 complained of dizziness and nausea and had a blood sugar of 73. The note said 16 ounces of orange juice and four graham crackers were administered. The note said that Resident #260 started dry heaving and was given a cool rag. The note did not say Resident #260's physician was notified. Review of Blood Sugar Summary revealed that a blood sugar of 73 was documented at 4:00 AM. A follow up progress note, dated 12/3/2019 at 05:23 AM, said that follow up blood sugar check was 80. A blood sugar level below 70 is low and can cause harm. According to the American Diabetic Association (ADA) dizziness and nausea are signs and symptoms of low blood sugar. The ADA recommends 4 ounces (oz) of juice and to recheck blood sugar after 15 minutes. According to this progress note, the nurse gave Resident #260 four times the recommended amount of juice to raise her blood sugar and did not recheck Resident #260's blood sugar timely. Review of progress note, dated 12/3/2019 at 07:28 AM, revealed Resident #260 was more forgetful and repeating herself. The note said no to practitioner visit during shift. According to the ADA, confusion is a sign/symptom of low blood sugar. This progress note did not include blood sugar level or action taken by the nurse to treat low blood sugar symptoms. Review of blood sugar summary revealed Resident #260's blood sugar was 74 on 12/3/2019 at 7:02 AM. Progress noted, dated 12/3/2019 at 7:52 PM note, revealed, Please be careful with patient, went hypoglycemic (low blood sugar) without DM2 (type 2 diabetes) appropriate snack before bedtime. This progress note also said Resident #260's physician was notified of her blood glucose trends and ordered a decrease in Resident #260's [MEDICATION NAME]from 30 units at bedtime to 20 units at bedtime. Resident #260's Medication Administration Record [REDACTED]. It is unclear if the insulin was given or held on 12/3/2019. Review of progress note, dated 12/4/2019 at 06:43 AM and written by Nurse SS, revealed that Resident #260 complained of feeling sweaty at 5:40 AM. Blood sugar was 53 at that time and Nurse SS documented she Administered 16 oz orange juice and [MEDICATION NAME] PO. The note further stated that Resident #260's blood sugar was re-tested at 05:57 and went up to 66. The note said Resident #260's physician was notified. A follow up progress note at 06:59 AM (greater than 15 minutes after last low blood sugar) said Resident #260's blood sugar was 122. According to the ADA, sweating and clamminess are signs/symptoms of low blood sugar. Nurse SS did not recheck Resident #260's blood sugar level timely after intervention. [MEDICATION NAME] is a by mouth (PO) medication used to lower blood sugar in people with Type 2 diabetes. Review of Resident #260's physician's orders revealed no order for [MEDICATION NAME]. Further review of Resident #260's December 2019 Medication Administration Record [REDACTED]. It is unclear what Nurse SS administered. An attempt was made to call Nurse SS on 1/21/2020 at 01:57 PM for clarification. No answer and voicemail box was full. Progress noted, dated 12/4/2019 at 4:00 PM, revealed that Resident #260 was complaining of dizziness and not feeling well. The note said Resident #260's physician was notified and plans to see resident tomorrow am. No blood sugar noted in this progress note. Review of Blood Sugar Summary printed 1/21/2020 was reviewed. No low blood sugars were documented on 12/4/2019. Progress noted, dated 12/4/2019 at 6:10 PM, revealed Resident #260 had a [MEDICAL CONDITION] that lasted two to three minutes at approximately 4:50 PM. The note said Resident #260's physician was notified and ordered to send her to the emergency room for evaluation and she discharged to the hospital at 5:30 PM. Progress noted, dated 12/10/2019 at 6:15 PM, revealed that Resident #260 was readmitted to the facility with a [DIAGNOSES REDACTED]. Resident #260's cognition was noted alert and oriented X 2, a decline from 12/4/2019 at 1:34 AM when she was documented to be alert and oriented X 4 and able to make her needs known. During an interview on 01/21/20 at 02:48 PM, Nurse JJ said that on the morning of 12/4/2019 she received report at 6:00 AM and was told Resident #260 had several low blood sugars and they were being monitored. Nurse JJ said she did not monitor Resident #260's blood sugars more frequently on 12/4/2019 because there was no order to. Nurse JJ said she checked Resident #260's blood sugars according to order. Reviewed progress note written by Nurse JJ on 12/4/2019 at 4:00 PM and Nurse JJ remembered that Resident #260 was not acting like herself even though her vital signs were fine. Nurse JJ said she did contact Resident #260's doctor and said, she did not order anything to me directly. Nurse JJ said they were waiting on the results of some labs that were drawn. Nurse JJ said Resident #260's blood sugar was not low at the time of the [MEDICAL CONDITION]. During an interview on 01/21/20 01:37 PM, Physician BB stated that she could not remember the specifics of Resident #260's low blood sugar episodes without reviewing her chart. Upon review of progress notes and blood sugar levels verbally over the phone, Physician BB stated that she would need to review and call back. During a follow up interview on 01/22/2020 at 11:11 AM, Physician BB explained that Resident #260 had a low blood sugar episode on December 26th and was given [MEDICATION NAME]. When asked if a low blood sugar episode could cause [MEDICAL CONDITION] activity, Physician BB said that Resident #260 did go to the hospital for a [MEDICAL CONDITION], but her blood sugars were normal at the time that she was sent to the hospital. Physician BB said she reviewed Resident #260's notes and said Resident #260 missed some doses of [MEDICATION NAME], a medication used to manage [MEDICAL CONDITION]. Physician BB explained that sometimes medications do not come from pharmacy when first ordered. Physician BB said while at the hospital, Resident #260 had extra doses of [MEDICATION NAME]. When asked if she knew about Resident #260's signs and symptoms of low blood sugar on 12/3/2019 and 12/4/2019 leading up to her [MEDICAL CONDITION], Physician BB could not recall getting called for a blood sugar of 73 and signs and symptoms of low blood sugar at 4:00 AM on 12/4/2019. Physician BB said she felt that Resident #260's dizziness and nausea symptoms were related to history of [MEDICAL CONDITION] and not low blood sugar but did acknowledge that Resident #260 also had a history of [REDACTED].#260 was refusing to eat or take medications on occasion and stated, It's been difficult with the sugars. When asked if nursing staff informed her of Resident #260 not eating and consulted with her regarding the giving or holding of insulin, Physician BB said, they don't necessarily call me when she isn't eating, but do call me with critical lows. Physician BB said she wants to be notified of blood sugars below 70 or when the nurse feels like the resident is experiencing a change in their responsiveness or condition. Physician BB said, They need to use their clinical judgement and call if necessary. During a review of Resident #260's task report for Nutrition - Amount Eaten for 12/24/2019 to 1/21/2020, it was noted that Resident #260 refused a meal five times during that 30-day time period. The record revealed that 10/30 days of meal consumption documentation was incomplete; one or two out of three daily meals were not documented as eaten or refused (blank). The report only gave a lookback period of 30 days. The amount of eaten on 12/3 and 12/4/2019 were not available on the report. According to the American Diabetes Association (ADA) website (https://www.diabetes.org/diabetes/medication-management/blood-glucose-testing-and-control/[DIAGNOSES REDACTED] ), signs and symptoms of low blood sugar happen quickly. The ADA explains that each person's reaction to low blood sugar is different. The ADA list of signs and symptoms of low blood sugar include: Feeling shaky Being nervous or anxious Sweating, chills and clamminess Irritability or impatience Confusion Fast heartbeat Feeling lightheaded or dizzy Hunger Nausea Color draining from the skin (pallor) Feeling Sleepy Feeling weak or having no energy Blurred/impaired vision Tingling or numbness in the lips, tongue, or cheeks Headaches Coordination problems, clumsiness Nightmares or crying out during sleep [MEDICAL CONDITION] For treatment of [REDACTED]. If it's still below 70, the ADA suggests having another serving. The ADA explains that the 15-15 rule can help avoid blood sugar levels from shooting way up and causing high blood sugar. The ADA included the following recommended items/servings to raise a low blood sugar: Glucose tablets Gel tube 4 ounces (1/2 cup) of juice or regular soda (not diet) The ADA recommends making note of the low blood sugar and following up with a health care provider to help prevent future episode. According to the Mayo Clinic, the brain needs glucose to function. Therefore, complications of prolonged untreated episodes of low blood sugar can cause [MEDICAL CONDITION], loss of consciousness and death.

This Citation Pertains to Intake Number MI 394 Based on observation, interview and record review, the facility failed to prevent staff-to-resident abuse for 1 resident (Resident #102) of 3 residents reviewed for abuse, resulting in a staff member using verbally abusive language and behavior, swearing at and pinching Resident #102 during care. Findings Include: A record review of the Face Sheet and Minimum Data Set (MDS) assessment for Resident #102 indicated the resident was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment dated [DATE] indicated Resident #102 had severe cognitive loss and needed 2-person assistance with all care except for eating. On 9/24/19 at 2:30 PM, during an interview with Resident #102, when asked how she was doing today, the resident said I'm leery of them, but they haven't bothered me lately. I can't think of her name. I have a disease that effects my memory and movement. You think of it and you forget things. You want to say something, and it just vanishes. Sometimes I have problems getting out what I want to say, but she got kind of snooty with me. Another nurse came in and said, She has a thinking problem. The one said, What do you mean? and the other one said, Hey, take it easy, and the one said, I will if I want to, and the other one said, I will kick you out of here, and I haven't seen her since. I think the nurse who was taking my part told her to go someplace or something. The resident motioned towards her arm. A review of a Facility Reported Incident (FRI) dated 9/7/19 revealed Certified Nursing Assistant (CNA) G reported to Nurse F at approximately 8:56 PM on 9/7/19, that (CNA B) was cursing at (Resident #102) and she pinched her left arm, CNA G said the incident occurred about 7:30 PM when we were changing her. The CNA stated, When (CNA B) and I were walking into (Resident #102's) room (the resident) started yelling 'No, not her!' as she pointed to (CNA B). (The resident) was being combative and pinched (CNA B). (CNA B) said 'Don't (f .ing) pinch me again or I will pinch you back.' (Resident #102) pinched (CNA B) again and I saw (CNA B) pinch (Resident #102's) left arm. (The resident) yelled out Ow! What is your name? Because I am going to report you!' (CNA B) said 'Stop (f .ing) yelling or you will give yourself a [MEDICAL CONDITION].' As (CNA B) and I were walking out of the room, (CNA B) threw the blanket over (the resident's) head. Nurse F interviewed Resident #102 asking Do you feel safe here? and the resident replied, Sometimes yes. Sometimes no. A review of a witness statement by CNA G provided, . on 9/7/19 for (2:00 PM - 10:30 PM) shift, I went into (Resident #102's) room . at approximately 7:25 PM with (CNA B) As we began to change her, (the resident) kept yelling at (CNA B) to stop and that she did not want her to touch her. (CNA B) said I'm not dealing with this (f .ing sh ) today. (The resident) began to hit (CNA B) and that is when (CNA B) pinched (the resident's) left mid arm. (The resident) then yelled ouch, stop it or else I'm going to tell on you. After that I told (CNA B) come on now. (CNA B) then said, You better calm down now before you have a (f .ing) [MEDICAL CONDITION]. As I was walking out of the room (CNA B) threw the blanket over (the resident's) head. (Resident #102) began to yell and scream . A review of a witness statement from CNA B dated 9/10/19 revealed, .regarding the incident on 9/7/19 at 7p-7:30p. I was assigned 45C-50C on 9/7/19. I went into the room . and went to the resident to change her. I rolled her my way and she was going to pinch me, and I said don't freaking pinch me . On 9/24/19 at 3:55 PM, the Director of Nursing (DON), Social Worker P and the Administrator were interviewed about the incident that occurred between Resident #102 and CNA B. The DON said that once the Administrator and DON were notified of the incident (9/7/19 at approximately 9:05 PM), CNA B was removed from her assignment and the police were contacted. The DON said the resident could not confirm the incident occurred, because of her Dementia and confusion, but had conflicting statements of feeling safe. The Administrator said she told Nurse F to contact the police and Officer D arrived at the facility on 9/7/19 after 9:10 PM to interview staff and investigate. Both the DON and Administrator said CNA B was terminated from employment on 9/16/19, after the investigation of the incident was completed. The DON said they had not received a copy of the police report. Social Worker P said he had interviewed the resident, but she was not able to recall. The Social Worker was asked if he had followed-up with the resident, as she readily discussed the incident with this surveyor and Social Worker P said, he hadn't because he didn't want her to have to bring up bad memories and go through it again. A copy of the police report from Officer D was received on 9/25/19 at 1:39 PM. The report said Resident #102 was upset, yelling and not cooperative with answering questions. The report noted . (CNA B) advised that her and (CNA G) had entered (the resident's) room to change her and get her ready for bed. (CNA B) advised that (the resident) is always hitting and pinching her when she walks in. (CNA B also advised that (Resident #102) is verbally abusive to the employees, stating that they are going to die and calling them names . (CNA B) advised that the resident stated she was going to pinch (CNA B). (The nurse aide) stated she said under her breath in a manner that (the resident) could not hear her you better not freaking pinch me . The police report continued, (CNA G) advised she went in the room with (CNA B) to change (the resident). As they began to change her, (the resident) was yelling and hitting as she usually does. (CNA G) stated that (CNA B) yelled at her and said, stop f .ing hitting me, I'm not dealing with this s t today. (CNA G) advised she witnessed (CNA B) pinch (the resident's) left arm near her elbow right after she said that. (CNA G) stated (the resident) said stop it, I'm telling on you. (CNA G) advised she told (CNA B) come on now. (CNA G) advised she did not know what else to say. She stated as they were getting ready to leave the room, (CNA B) threw a blanket on top of (the resident's) head and (the resident) continued to yell as she walked out of the room. On 9/25/19 at 4:00 PM, during the exit conference, the Director of Nursing (DON) asked if she should report CNA B to the Licensing Board, as the police officer responding to the incident said his report would be forwarded to the Prosecuting Attorneys office for review. The Officer's report was reviewed with the Administrator and DON, as they had not received a copy from the police department, and it said Action Taken: Report will be forwarded to the Prosecutor's Office for their review of any potential charges . A review of the facility Abuse Policy titled, Resident Abuse, Neglect, Exploitation, Misappropriation, undated provided, Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish . It includes verbal abuse . physical abuse and mental abuse . Willful, as used in this definition of abuse, means the individual must have acted deliberately .

This citation pertains to Intake Numbers MI 510 and MI 414. Based on observation, interview and record review, the facility failed to 1.) ensure interventions were enacted for supervision, reassessments were completed for elopement risk and an elopement was investigated for Resident #4 who had eloped from the facility and 2.) operationalize fall management policy to ensure interventions were enacted to prevent falls and injury for Resident # 10 of five reviewed for falls and elopement, resulting in Resident #4 eloping from the facility with the potential for harm, injury or death and Resident #10 falling and sustaining a neck fracture, pain and subsequent death. Findings include: Resident #4: A review of Resident #4's medical record revealed an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment revealed the Resident had severely impaired cognition and needed supervision to walk in room and corridor and locomotion on and off unit. Further review of the MDS revealed wandering-Presence and Frequency documented as the behavior of this type occurred 1 to 3 days and Wandering-Impact documented for the question Does the wandering place the resident at significant risk of getting to a potentially dangerous place (e.g., stairs, outside of the facility)? entered as No. Further review of Resident #4's medical record revealed: -Admission Assessment for admission on [DATE] at 11:30 PM with an effective date on [DATE] at 5:18 AM, revealed, Elopement Assessment: [NAME] Resident is 3) Ambulatory Without Assistance, B. Resident is: 2.) cognitively impaired, with poor decision-making skills and/or pertinent diagnosis (e.g., dementia, [MEDICAL CONDITIONS], mental illness), C. Resident has: 2) Been evaluated by two physicians and deemed incapacitated, D. History of wandering: 1) Yes, Inside, E. Resident has attempted: 3) or has had behaviors, body language or other actions indicating an elopement may be forthcoming. -Admission Note on [DATE] at 2:05 PM, revealed, . Wanderguard placed, resident is elopement risk, roams hallways with steady gait . -Nursing Progress Note, [DATE] at 7:34 PM, revealed, RN (Registered Nurse) and CNA (Certified Nursing Assistant) alerted by Wanderguard alarm. Resident had attempted to leave facility via the front door and head to the street. RN and CNA followed resident out of the facility. Resident was very agitated and did not want to come back in. She proceeded to walk around the bldg.(building). She stated to the nurse you are the one that tells all the lies. RN was able to convince her to come back into the bldg. by telling her that we could call her daughter (Name) on the phone. Resident agreed and we came in via the back door of the facility. Resident no longer wanted to call daughter once in bldg. She agreed to color in coloring book with CN[NAME] Notified Administrator (Name) and was instructed to re-locate resident to room [ROOM NUMBER], 1:1 (one staff to one Resident supervision) sitter X 3 days, and continue Wanderguard alarm. Notified emergency contact (Name) via telephone, she stated that she verbalized understanding and would bring guardianship papers to facility. She also stated that resident has a HX of leaving home and leaving prior facility. RN Unit manager placed 1:1 sitter at this time. -Incident/Unusual Occurrence documented in the Progress Notes, dated [DATE] at 4:30 PM, revealed Description of event: Elopement attempt: RN and CNA alerted by Wanderguard alarm sounding. CNA had visualized resident leaving the building and called for RN to come help. Resident had attempted to leave facility via the front door. RN and CNA followed resident out of the facility to the front of the building. Resident was very agitated and did not want to come back in. She stated that she was heading for the street. She proceeded to walk around the entire bldg. into the back parking lot. RN attempted to convince her to come back into the building. She stated to the nurse I know who you are, you are the one that tells all the lies. RN was able to convince her to come back into the bldg. by telling her that we could call her daughter (name) on the phone . -Nursing Progress Note, dated [DATE] at 9:40 PM, revealed, LATE ENTRY: CNA reported to author that resident was actively exit seeking while 1:1. Reported that resident approached 'Exit' door and attempted to open door to exterior of facility. CNA reported that she was able to redirect and maintain safety. -Nursing Progress Note, dated [DATE] at 8:43 PM, revealed, Resident observed ambulating through facility, frequently stopping at exterior exit sites and peering outside. Resident vocalized x 2 that she had to 'leave'. Staff able to redirect and remained 1:1 to maintain safety. PRN [MEDICATION NAME] administered at HS due to increased restlessness and to aid rest. -Behavior Note, dated [DATE] at 10:21 PM, revealed, Objective description of behavior, such as(wandering, pacing, striking others, cursing, etc):: Resident actively seeking exit from facility. Author advised by 1:1 CNA that resident did attempt to open exit doors x 2 and attempt to exit facility. CNA was able to easily redirect. Assessment to rule out medical/other cause of behavior: Resident continues to pace throughout facility; PRN [MEDICATION NAME] administered at HS. Non-pharmacological interventions implemented and effectiveness:: 1:1 to ensure safety. Notifications of MD/DO, NP/PA, and family/resp party (who, when and outcome - orders rec'd, etc)): (Unit Manager A) UM advised of attempt. -Behavior Note, dated [DATE] at 3:07 PM, revealed, Objective description of behavior, such as(wandering, pacing, striking others, cursing, etc):: Wandering, Exit Seeking, Increased Anxiety, Voiced I will just end it all now. Assessment to rule out medical/other cause of behavior: No recent med changes, (Vital signs) Denies any pain. Non-pharmacological interventions implemented and effectiveness:: 1:1 with CNA, Redirection and Reassurance. Notifications of MD/DO, NP/PA, and family/resp party (who, when and outcome - orders rec'd, etc)): Unit Manager, Social Services, pending Psych consult. -Social Service Progress Note, dated [DATE] at 3:30 PM, revealed, After hearing screaming and cursing in the hall, I ran out of my office and found (Resident #4) at the front door, with a CENA calmly trying to redirect her from exiting the building. (Resident #4) was calling her names and swearing at her. Approached resident with my dog next to me, and she instantly directed her attention toward the dog, petting her, and baby talking to her. I convinced (Resident) to walk with the dog and I, and took her back to her room. Attempted to converse with (Resident) with simple, brief statements, but she was unable to respond appropriately. (Resident) was anxious and referenced suicide. Her sentences didn't make sense, but she did use the words suicide and kill myself. At one point, she said she would find something to kill herself with. Once in the bedroom, I directed resident to the bathroom, where she had a large loose bowel movement. Assisted her with peri-care, changed her brief, and asked resident if she would like to lay down. (Resident) declined to lay down, but she sat in her chair and asked what she could eat. Found snacks in her room (Cheetos and cookies) and offered them to her. (Resident) thanked me and seemed content, so I left the room. Informed CENA that (Resident #4) had a BM. She said it was the third large loose she'd had that day. -Nursing Progress Note, dated [DATE] at 4:37 PM, revealed, (Resident #4) is calmer during the day, but about 3pm she starts getting restless, increase wandering and attempts to walk out the doors. She continues with a Secure guard ankle bracelet and within eyesight vision after 3pm throughout the night and she is just supervision during the day. Family has been in multiple times through out the week visiting with her. She is accepting the supervision and within eyesight supervision well. -Behavior Note, dated [DATE] at 10:40 PM, revealed, Objective description of behavior, such as(wandering, pacing, striking others, cursing, etc):: Exit seeking x 2 with attempt to exit facility. Resident vocalized need to leave facility and approached exit doors x 2 with intent to leave building. Staff remained with resident during second shift due to 2 attempts to exit building. Non-pharmacological interventions implemented and effectiveness:: Redirection with snack/activity offered, mildly receptive. Resident very difficult to redirect with staff taking turns to monitor safety 1:1. -Behavior Note [DATE] at 6:49 PM, revealed, Objective description of behavior, such as (wandering, pacing, striking others, cursing, etc):: Resident was observed by receptionist exiting the building through the front door. Receptionist followed resident. Writer and Unit manager arrived outside after hearing wander guard alarm. Resident redirected and assisted back into the building. Assessment to rule out medical/other cause of behavior: No new injuries or change in condition. -Incident/Unusual Occurrence, dated [DATE] at 7:00 PM, revealed, Description of event: Resident left out of the front door of building. Four staff with her at this time. She had walked down behind the house on the property. Took a little bit of coaxing to get her back into the building. Unwitnessed or Witnessed by:: Witnessed by 2 CNA's and two other staff Current Interventions: Resident being monitored by everyone. -Nursing Progress Note, dated [DATE] at 2:27 AM, revealed, Resident attempted to exit court yard door with CNA walking with her. CNA was able to redirect resident. -Nursing Progress Note, dated [DATE] at 5:58 PM, revealed, Exiting seeking this am, patient was kept in view of staff with 1:1 assistance throughout dash. Patient wandering throughout building and patient safety was maintained. -Incident/Unusual Occurrence, dated [DATE] at 2:56 AM, revealed, Description of event: Front door and wonder guard alarm sounding, CNA responded immediately saw resident outside of front door looking through the window trying to get in. Unwitnessed or Witnessed by:: Unwitnessed Current Interventions: wonder guard, 1:1 Notifications of MD/DO, NP/PA, and family/resp party (who, when and outcome - orders rec'd, etc)): (Doctor's name) notified, Administrator, DON, author Nurse D. On [DATE] at 2:47 PM, a review of the surveillance camera of the front lobby door was reviewed and showed Resident #4 approach the facility front door at 23:11 (11:11 PM), open the door and walked out of the building. No staff were present when the Resident breached the front door of the facility. At 23:12 (11:12 PM), the video showed a shadow of the resident standing at the closed door. At 23:13 (11:13 PM) an observation of the video revealed a CNA coming around the corner of the front entrance, opened the door and let the Resident inside the building. On [DATE] the investigation report of the elopement of Resident #4 on [DATE] was requested from the Administrator but was not received until [DATE], at 3:20 PM, the incident report for the occurrence on [DATE], at 11:30 PM was received with a note on the document dated, [DATE] that revealed, She continues to wander the facility, refuses medications, and is non-compliant with care at times. She was being supervised from a distance at that time and she went out the front door and cna heard the alarm going off and immediately went to the front door and she seen her standing outside of the door with a white blanket on her. The camera was reviewed immediately after adm. (Administrator) and DON were notified and she was in view of the camera the entire time until a staff member was able to bring her back in. She will then continue the direct 1:1. On [DATE] at 9:14 AM, an interview was conducted with Unit Manager (UM), Nurse A regarding the Incident/Unusual Occurrence on [DATE] with Resident #4's elopement from the facility. The UM indicated she had worked that night as a floor care nurse. The UM was queried regarding the event and stated, She (Resident #4) was on eyesight supervision on [DATE] night shift when she got out. She (Resident #4) was sitting at north hall at the end of the desk in the hallway area. I was sitting there doing charting. It happened a couple times during the night. She got up and was walking. The UM was queried if staff had the Resident in eyesight and stated, I did briefly when she got up and I assumed that someone in the hall would see her. They (CNAs) had all been out in the hallway just prior to that, I thought there was one CNA in the hall at the time that she was walking. When queried if she had alerted staff that the Resident had gotten up and was walking, she stated, No. I was sitting there charting and doing things on the computer. Someone came and told me she got out the door. The Unit Manager was queried if the incident had been investigated and reported to the State Agency and stated, I called (Administrator) and spoke to her. We brought it up to morning meeting and I asked if it was reported and (Director of Nursing) said it didn't need to be reported because the interventions were affective, we were alerted by the alarm and we were able to bring her back in. The two minute time lapse of the video when the Resident had pushed open the door, walked outside and the door shut behind her with out staff in sight of the Resident until the CNA was seen coming around the corner and opened the door for the Resident to re-enter the building, was reviewed with the Unit Manager. When queried if the intervention of being in eyesight meant that someone was to be watching her at all times, the UM stated, Right. When queried if the intervention had failed, the UM did not answer. When queried if staff had eyesight on her when she walked out the door, the Unit Manager stated, No. (CNA Q) was in a room, she came out and heard the alarm and came out to try and determine which door was alarming. I was in the North hall and I could not hear it. When queried if an investigation was done on the incident, the Unit Manager stated, We wrote a witness statement that she had gone out the door. (CNA Q) wrote it and we both, me and (Nurse D) signed it. When queried why when the investigation was asked for the witness statement was not provided, the Unit Manager stated, The statement can't be found. When queried who the statement was given to the Unit Manager indicated she was unsure where the statement had gone. When queried if the Resident getting out of the facility was a reportable incident, the Unit Manager stated, I reported it to my Administrator and DON. On [DATE] at 2:25 PM, an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) regarding Resident #4's elopement risk. When queried about the elopement risk score on the admission assessment that was documented as a 3, the DON was unsure what the score indicated on the Elopement Assessment that was part of the Admission Assessment. After a review of the Elopement Assessment documentation, the DON indicated she did not know how the score was tabulated with consensus that three did not indicate the Resident was at high risk for elopement. The DON stated, The MDS Nurse would know. The MDS Nurse N was summoned and an interview was conducted with the NHA and DON present regarding the elopement assessment. The MDS Nurse reviewed the Admission Assessment documentation and opened up a page that had various documented scores and indicated the Resident's Elopement Risk score was 10, and stated, Ten is moderate risk. The MDS Nurse was queried when an updated assessment needed to be completed and stated, Her assessment is done. Her behavior that the Resident has, we know she is at high risk because she eloped. We didn't need to do a reassessment. The MDS Nurse left and the interview continued with the NHA and DON. A review of the observation made of the video surveillance, of the date on [DATE], of the Resident coming around the corner where the entrance to the facility is located, pushing on the door, opening the door, going outside and the door closing behind the Resident with the shadow of the Resident outside the door, until a CNA is seen approaching the corner of the hallway, walking to the door and opening the door for the Resident that was outside with the expanse of time of approximately 2 minutes. When queried if the Resident was on one to one staffing at the time of the incident on [DATE] the DON stated, Absolutely, I did not take her off one to one. When queried if supervision from a distance required a staff member to be visibly watching the Resident, the NHA stated, I would think so, unless they were going to the bathroom or around the corner. When queried why the incident was not reported to the State Agency, the NHA stated, She was in sight the entire time. When queried if she was insight of the staff or the camera, the NHA stated, She was insight the entire time. A review of the facility policy entitled, Missing Resident-Potential/Actual Elopements, effective date on [DATE], revealed, Policy Statement. Staff will attempt to prevent any elopements from the facility but if an elopement occurs the facility staff will investigate and report all cases of missing resident . A review of the facility policy entitled, Accidents and Incidents-Investigating and Reporting, revised ,[DATE], revealed, Policy Statement. All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator . 7. Incident/Accident reports will be reviewed by the Safety Committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. Resident #10 A record review of the Face Sheet and Minimum Data Set (MDS) indicated Resident #10 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment dated [DATE] indicated the resident had severe cognitive decline and needed 2-person assistance with transfers, dressing and toileting and 1-person assistance with eating, hygiene and bathing. The resident fell on [DATE] and was transferred to the hospital where she was diagnosed with [REDACTED]. Resident #10 was readmitted to the facility on [DATE] with Hospice services and died on [DATE]. A review of the progress notes revealed the following: [DATE] at 3:22 PM: Nursing Progress Note,- Resident restless most of the morning wanting to get up out of bed and then moving around in her wheelchair, but she sat in her wheelchair after breakfast and her daughter came to visit; she did not even open her eye when she was here. Very tired. After lunch she requested to lay down to take a nap. Certified Nursing Assistant (CNA) toileted her first and then CNA put her into bed but within minutes she was trying to get out of the bed. CNA put her into her wheelchair which she was somewhat restless and leaning forward in the chair needing prompts to sit back. [DATE] at 3:10 PM: Incident/Unusual Occurrence,- Vital Signs: ,[DATE], 90% 4L NC (oxygen saturation with 4 liters of oxygen nasal cannula applied), 20 resp (respirations), temp 97.6, Description of Event: resident tried to get up out of bed so staff transferred her to her wheelchair. She was in her room doorway. Unit manager walked by and observed her leaning forward in her chair and got her to sit back. 2 CNA's observed her leaning forward and got her to sit back, all this in approx. ,[DATE] minutes, she leaned forward and fell face first to the floor. Unit Manager applied pressure to her forehead which was bleeding . instructed to send to ER . A review of the Incident and Accident Reports for Resident #10 indicated she fell 5 times in 2 weeks: [DATE], [DATE], [DATE], [DATE] and [DATE]. The resident did not have a history of frequent falls prior to this. [DATE] at 9:50 PM: Nurse Aide came to me and stated resident is on the floor. I entered room and observed her lying on her right side of body with right elbow actively bleeding. Resident facing room door entrance . spo2 (O2 saturation) 83% (very low) room air (without oxygen) . oxygen placed on resident . [DATE] at 8:05 AM: Author paged to room . observed resident at the foot of bed #2 lying in front of the wheelchair on the left side of her body with bilateral legs moderately bent at the knees . vital signs .92% (O2 sat) room CNA advised author that she was providing care to bed #2 when she realized that (Resident #10) was in the room and observed her bending over to retrieve an item on the floor . observed minor abrasion to bilateral knees with bruising beginning to area . [DATE] at 12:20 AM: Called to room by nurse aid observed resident on the floor right side of bed lying on landing strip . v/s (vital signs not documented) taken and transferred to w/c (wheelchair) . [DATE] at 4:20 AM: CNA walking into room, witnessed (resident) roll out of bed on to landing strip as she was reaching for something . Vitals taken, O2 (oxygen) @ 2L via nasal cannula started do to O2 of 79% (very low- normal ,[DATE]% oxygen saturation). Rechecked O2 90% . [DATE] at 1:25 PM: Resident fell front first out of her wheelchair to the floor. Pressure applied to the forehead and bridge of nose where bleeding was coming from. Body check done with no other injuries observed. 3 assist with gait belt to transfer her to her wheelchair and to her bed. Observation don on the extent to forehead . transfer to ER ordered . Injury type: Laceration, . Predisposing Physiological Factors: Recent change in Medications/New . Recent change in cognition . diagnosed with [REDACTED]. signs of being restless today . refused to stay in bed after lunch for a nap . She has had a couple of falls this past week . left her with some bruising . VS (vital signs) are WNL (undocumented, no oxygen saturation level) . The CNA transferred her to her wheelchair and put her by her bedroom door. The CNA observed her leaning forward and instructed her to put her body back, a minute later the Unit Manager came down the hall and observed this resident leaning forward and instructed her to hold her head up and sit back . the unit manager went to her office a couple of doors away and heard the CNA telling resident to lean back . seconds later CNA was charting . heard a thud and observed resident on the floor . The resident was repeatedly observed leaning forward and told by staff to sit back. The resident had severe cognitive decline and was being treated for [REDACTED]. No one assessed the resident to identify any intervention other than to tell the resident to sit back, prior to the resident falling forward out of the wheelchair. A review of the physician orders revealed: Order Date [DATE], discontinued [DATE], O2 (oxygen) via NC (nasal cannula) @ ,[DATE]L (liters) for SPO2 <88% as needed related to Chronic Obstructive [MEDICAL CONDITION] Disorder; Order date [DATE], Monitor SPO2 (oxygen saturation) without oxygen to see if SPO2 drops below 88%; Order date [DATE], oxygen ,[DATE] liters via nasal cannula for comfort, if she is mouth breathing, you can place the NC at the base of her lips. A review of the Medication Administration Record [REDACTED]. A review of the (MONTH) 2019 MAR/TAR's and Vital signs indicated oxygen saturation rates were not taken daily as ordered. A review of the progress notes and assessments indicated the physician was not notified when the resident was assessed to have repeatedly low oxygen saturation levels with 3 falls. The facility did not apply oxygen to the resident until after each fall. New orders to address and treat the low oxygen levels were not obtained. Mayo Clinic, 2019, 'Hypoxemia is a below level of oxygen in your blood, specifically in the arteries. Hypoxemia is a sign of a problem related to breathing or circulation and may result in various symptoms, such as shortness of breath . Normal pulse oximeter readings usually range from ,[DATE]% . A review of Resident #10's Care Plan At Risk/actual for Falls r/t gait imbalance problems, decreased strength, fatigue history of falls, dated [DATE] with Interventions last updated: [DATE] . bed is to remain up against the south wall . [DATE]- Bilateral bolsters to bed . The Fall care plan was not reviewed or updated after the falls on [DATE] or [DATE]. Generalized Weakness with decreased functional mobility, endurance, related to becoming short of breath, decreased strength and decreased range of motion . date initiated [DATE] with Interventions last updated [DATE]: . wearing appropriate shoes . bilateral upper extremity active assist range of motion . explain who you are . give rest periods during restorative activities . Self-care performance deficits related to decreased strength, mobility and decreased awareness of her needs secondary to fatigue and dementia, date initiated [DATE] with Interventions: Bed Mobility: extensive assist . with positioning, revised [DATE], provide extensive assistance of 2 to reposition every 2 hours and as needed, revision [DATE] . At risk for cardiac distress related to . heart failure . [MEDICAL CONDITION] . date initiated [DATE] with Interventions: If shortness of breath doesn't resolve with rest notify charge nurse and MD as needed, dated [DATE] . Monitor changes in mental status: Lethargy, somnolence, fatigue . and notify MD, dated [DATE] . Monitor vital signs as scheduled and as needed. Notify MD of significant changes . dated [DATE] . There was no mention in the care plans that the resident had low oxygen saturation levels identified with the recent falls. There was no intervention for monitoring or applying oxygen. A review of the Hospital records for Resident #10 provided the following: Date of Admit ,[DATE]/ 19 at 2:30 PM . History of present Illness: . fall from wheelchair. Patient struck her forehead on impact . Radiology: (MONTH) 30, 2:36 PM, CT cervical Spine . Nondisplaced fracture at the base of the dens extending to the body of the C2 segment . (MONTH) 30, 2019 at 4:19 PM- Right hand pain with bruising . There is a small age indeterminate avulsion fracture at the distal tip of the ulnar styloid. Soft tissue swelling surrounds the wrist. (MONTH) 30, 2019 at 4:36 PM . Forearm right, pain and bruising . age indeterminate compression deformity distal dorsal radial metaphysis . (MONTH) 30, 2019 6:38 PM, Right shoulder pain and swelling, fall . soft tissue swelling . Plan: admit to trauma service . neurosurgery consult, no surgical intervention, Pain management . C-Collar (a collar worn around the neck to immobilize and prevent movement) ,[DATE] . On [DATE] at 10:40 AM, Nurse P was interviewed about Resident #10 and stated, Normally she sat upright and would rock side-to-side. We would bring her by the nurse's desk to watch. Nurse P was asked if the care plans were reviewed for effectiveness and updated with new interventions to aid in preventing future falls and said, The nurses would update the care plan after a fall. Nurse P was asked what intervention would be provided if the resident repeatedly leaned forward in the wheelchair and said, She would be assessed to see if she needed to use the bathroom, was tired, hungry, wanted to go to bed. On [DATE] at 11:00 AM, Unit Manager A was interviewed about Resident #10's fall on [DATE] and stated, I was walking down the hallway and she was leaning forward in her wheelchair with her eyes open. I stopped and asked her to sit up. She sat up. I went back into my office. I heard one of the other CNA's come by and ask her to sit up. I was finishing what I was doing and heard when she hit the floor. Two people were already there. She was bleeding with a laceration on the forehead about 1.5 inches long. She said her nose hurt. The nurse said the resident was to have a pull alarm on her bed and wheelchair, but no alarm was sounding at the time of the fall. The Unit Manager said when the resident came back from the hospital, she began receiving Hospice services and died a few days later. A review of the facility policy titled, Falls-Clinical Protocol, revised (MONTH) 2012 provided . While many falls are isolated individual incidents, a significant proportion occur among a few residents/patients. Those individuals may have a treatable medical disorder or functional disturbance as the underlying cause . In addition the nurse shall assess and document/report the following: vital signs . often multiple factors in varying degrees contribute to a falling problem . the staff and physician will continue to collect and evaluate information until either the cause of the falling is identified . staff will try various relevant interventions, based on assessment . until falling reduces or stops or until a reason is identified .if the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons .

This citation pertains to Intake Number MI 497. Based on observation, interview and record review, the facility failed to supervise a Resident after a physical altercation occurred between Resident #5 and #6, when, on 8/2/19, after a verbal altercation, Resident #6 hit Resident #5 across the cheek of the face, Resident #6 sought further physical altercation with Resident #5 following the incident on 8/2/19 and threatened Resident #7 with physical aggression, for three Resident's (#5, 6, and 7) of 7 reviewed for abuse and neglect, resulting in Resident #5 having redness and pain in the cheek after being hit, feelings of shock, fear of being stalked, movement in facility restricted, feelings of isolation, intimidation and discontentment with the facility and Resident #7 being anxious, intimidation and fearful of being physically attacked and a decline in the overall psychosocial wellbeing of both Residents, #5 and 7. Findings include: Resident #5 A review, of Resident #5's medical record, revealed an admission into the facility on [DATE], with an original admitted on 10/19/17, with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment, revealed the Resident was cognitively intact and needed supervision with bed mobility, transfers and walking in room and was independent with locomotion on and off unit. The Resident used a walker and wheelchair for a mobility device. Resident #6 A review, of Resident #6's medical record, revealed an admission into the facility on [DATE] with a re-entry on 10/12/16 with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment, revealed the Resident had severely impaired cognition and was independent with bed mobility, transfer, walking in room and in corridor and with locomotion on and off unit. The Resident used a walker for a mobility device. Resident #7 A review, of Resident #7's medical record, revealed an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the MDS assessment revealed the Resident was cognitively intact and needed extensive assistance with bed mobility, transfer, locomotion on and off the unit and used a wheelchair as a mobility device. A review of the incident and accident report for Resident #5, revealed: -Date: 8/2/2019 18:26 (6:26 PM). -Incident Description. Nursing Description: Yelling and shouting heard down toward the end of the hallway. Resident had slight pink area to right cheek. No c/o (complaints of) further pain. No bruising. No open areas of skin. -Immediate Action Taken. Description: Ice pack was applied to cheek for 15 minutes. A review of the statements in the investigative report for the altercation between Resident #5 and 6, revealed: -Statement, on 8/5/19, signed by Resident #6 with DON and Nurse P, revealed, Recalling events of 8/5/2019 (8/2/19) (Resident #5) just doesn't like me . *When queried re: possibly 'slapping (Resident #5) in the face': on Friday Aug. 2, 2019 at about 6:15 PM, (Resident #6) replied: Yes, I did because she called me a [***] ! I told her afterwards to leave me alone & that I would pray for her . I know I shouldn't have struck her, that's why I started praying right away . -Witness Statement, signed by Certified Nursing Assistant (CNA) Q, revealed, (Resident #5) came over to me and asked me to have (Resident #6) turn her light off (call light) because she would not stop pressing it. (Resident #5) said something then they both ran/wheeled to one another calling each other names (fu-ing [***] es). (Resident #6) then went to slap (Resident #5) on the side of (Resident #5's) face. Her right side of her face. (Resident #6) then hit (Resident #5) in the back of the head. (CNA U) ran to separate them. The three nurses ran over as well to separate them . -Witness Statement, signed by CNA U, revealed, I was in room [ROOM NUMBER] when I heard yelling. I walked out of the room and saw (Resident #5) sitting in the doorway of 25. Then (Resident #5) called (Resident #6) a fu-cking [***] and (Resident #6) said no one calls me that. Then I saw (Resident #6) slap (Resident #5) across the face. I ran in between them and tried my best to keep (Resident #6) from hitting again . -Interview with Resident #5, on 8/5/19, signed by the DON, revealed, At /about 6:15 PM on [DATE] I went to find a nurse to help (Resident V). I was going down the hall in my wheelchair. I found a nurse (Nurse I) who said to tell (Resident V) I am on my way down. I turned around to go back to let them know. (Resident #6) was standing in her doorway & when I told (Resident V) that the nurse was on her way, (Resident #6) said who the hell do you think you are getting into my business, you 'fu-ing [***] .' Before I knew it, she was charging at me & struck the right side of my face with opened palm hand-she made my head turn to the left side. I didn't even react because I was so shocked. Then she came around to my other side & the nurse & 2 aides came & got (Resident #6) away from me . A review of the Progress Notes, for Resident #5, reveals: -8/3/19 at 12:06 AM, Resident was slapped across the right cheek by resident (Resident #6). There was a slightly pink area to cheek following this incident. Residents were separated by staff. No further marks on residents face. Resident put ice on the area for pain. No further c/o (complaints of) pain to the area. Skin is intact. Will continue to monitor with cares, author: Nurse C. -8/5/19 at 10:41 AM, (Resident #5) was interviewed regarding the incident that occurred on Friday 8/2/2019. She offers no complaint of pain to the right side of the face or elsewhere. (Resident #6) has not interacted with (Resident #5) or struck out at her any further since 8/2/2019. (Resident #5) relates that she does not have any fear of Res #(#6) nor does she wish to move at this time. Supportive listening provided during the interview, author Director of Nursing (DON). -8/8/19 at 2:52 PM, a Medical Visit Note, Reason for visit: follow up on assault. History of Present Illness: Asked to evaluate pt (patient) after being slapped by another resident after a verbal altercation on 8/2/19. Pt states she was called a [***] by the other resident and then slapped hard on the right cheek. Staff says the pt called the other resident 'fu-ing [***] ' before she was slapped. Pt states she was just trying to help the other resident by looking for the nurse and the other resident told her to stay out of her business which started the heated exchange. Pt states her check was swollen and the ice packs helped. Staff reports it was slightly red but no swelling. Currently no face or neck pain or bruising. Pt states her right ear is still tender to touch. Pt called the police the next day to report the assault. No charges being pressed at this time. Pt was moved to another room in another hallway. Pt feels like she is being punished because she had to move but did admit she is glad to now be rooming with her friend. Pt states the other resident hit her 2 other times in past 2 months but nothing was reported per staff, author, Physician [MI] -8/14/19 at 2:13 PM, a Social Service Progress Note, Met with (Resident #5) in regards to her concerns of an aggressive client. (Resident #5) reported other client 'stalks' her. (Resident #5) reported the other client signed a throat cutting gesture with her thumb across her neck and said to (Resident #5), 'This is what is going to happen to you.' (Resident #5) also stated, 'She came into my room when I wasn't there looking for me.' 'I'm tired of watching over my stuff and always watching over my back' 'I'm not physically afraid of her.' 'I'm more afraid I'm going to go back at her.' 'When I'm upset with her, I just walk away.' Client reported she feels safe eating her lunch in the day room. (Resident #5) expressed she feels better now knowing that she was heard, author Social Service Director (SW) M. -8/14/19 at 3:58 PM, a Social Service Progress Note, I was present ion the interview room when this exchange took place. This had been brought to our attention by the state surveyor in the building and this is what the patient related. She categorically denied being afraid or fearful at this time of Resident (#6). The Resident states that she 'stays away' from Resident (#6) 'when I see her.' 'No, I feel very safe here. I appreciate that you have listened to me.' I'm not afraid to leave and go to the dining area for lunch.' Resident thanked Social Worker and this writer, author DON. A review of Progress Notes in the medical record for Resident #6, revealed: -8/2/19 at 6:59 PM, Behavior Note, revealed, Objective description of behavior, such as (wandering, pacing, striking others, cursing, etc):: Resident struck another resident in the hallway. Resident is verbally abusive toward peer, yelling and cussing. Assessment to rule out medical/other cause of behavior: Resident denies pain. Resident refuses routine medication Non-pharmacological interventions implemented and effectiveness:: Resident redirected with coffee and 1:1 staff conversation and is effective. Notifications of MD/DO, NP/PA, and family/resp party (who, when and outcome - orders rec'd, etc): MD, POA, DON, Nurse Manager notified. no orders received., author Nurse C. -8/5/19 at 3:37 PM, Nursing Progress Note, revealed, Eventually spoke with the resident at approximately 2:45 PM. Resident was cheerful and discussed situation that occurred on 8/2/2019. Resident was able to recall events from Friday. Resident offers no complaints of any type: no physical, mental, psychosocial or spiritual issues. The resident declines to move her room or to have any other interventions implemented that may alleviate ongoing disagreements with Resident 24 B DM. Staff report no issues with this resident since incident, author DON. -8/8/19 at 2:53 PM, Medical Visit Note, revealed, Reason for visit (acute issue, regulatory visit, etc): follow up for aggressive behavior History of Present Illness: Asked to evaluate pt due to a verbal and physical altercation with another resident that happened on 8/2/19. Pt states she slapped the other resident because she was called a [***] . Pt calm today and has not had any further incidents. Pt states she has been ignoring the resident she struck. Pt knows the other resident was moved to another hall. During interview, pt repeating herself and asking the same questions repeatedly, author Physician [MI] A review of Resident #6's care plan revealed the following: -Focus (Resident #6) has a HX (history) of being physically aggressive and she has the potential to be verbally abusive r/t (related to) Dementia with Behavioral Disturbance, poor judgment and insight, Poor impulse control, Histrionic personality disorder, and Depression. IDT (interdisciplinary team) reviewed 4/27/19. Hit another resident 8/2/19, revision on 8/8/19. -Interventions after altercation of Resident #6 hitting Resident #5: Document any behavioral manifestations, date initiated, 8/8/19; If she is walking through an area in the hallway that is congested, assist her so she doesn't get upset trying to get through on her own, date initiated 8/8/19. On 8/14/19 at 10:22 AM, an interview was conducted with CNA N regarding behaviors of Resident #6. The CNA stated, (Resident #6) will tell us to get out of her room and refuse cares at time. She wants to get out of here. When queried regarding Resident #6 hitting other Residents, the CNA indicated she had not seen it but heard that Resident #6 had hit Resident #5. When queried if any other Residents had complained of Resident to Resident abuse, the CNA stated, Yes, (Resident #7). She had a doctors appointment, either the 8th or 9th (of (MONTH) 2019) and she wanted me to go with her. She was telling her family at the doctor's office. She wanted me in there while she told he family. She told me, '(Resident #6) threatened to hit me.' (Resident #7) said that (Resident #6) had threatened her that she went into her room and actually threatened her. She threatened to hit her and (Resident #7) was covering her knee to protect them because she has to have surgery on it. When queried if the CNA had reported the allegations, the CNA stated, We had a meeting about (Resident #6 hitting Resident #5). I took her right to the DON (Director of Nursing) after she told me, after the meeting when we got back from the doctors appointment. I reported it to my superiors. I told the DON what I just said to you. When we got back (from the doctor's office), I told her (Resident #7) we got to address this right away. When queried what happened after the DON was notified, the CNA stated, They moved her right away. When queried if Resident #7 wanted to be moved, the CNA stated, Yes. She (Resident #7) was scared. She wanted to be moved right away. A review of Resident #6's and #7's medical record, revealed no documentation of the allegations of Resident #6 threatening to hurt Resident #7 or follow up on Resident #7's psychosocial wellbeing. On 8/14/19 at 10:38 AM, an interview with Nurse P, who was assigned care of Resident #6, was queried regarding changes in the plan of care for the Resident after the physical altercation with Resident #5 had occurred on 8/2/19. The Nurse was queried regarding behaviors and stated, (Resident #6) can be very aggressive. A few months ago, she threw her walker at one of the Residents. I heard a scream, it was another Resident, when I got there (Resident #6) came up to me and said 'I didn't do anything,' the Resident had a red mark on her cheek. I also know that (Resident#5) has a friend and they close the door, (Resident #6) gets upset over that. She is very aggressive, she thinks everyone is talking about her. When queried regarding the plan of care for Resident #6, the Nurse stated, We tried [MEDICATION NAME] jell, but she was non-compliant with that. We moved her and she is now in a private room, and explained the Resident does not do well with a roommate. When queried regarding changes in care after the incident on 8/2/19, the Nurse stated, I have not seen anything new with (Resident #6). We moved (Resident #5 and 7). We can't keep moving everyone from the hall. The Nurse was queried regarding fifteen minute checks or increased monitoring and stated, No, nothing new on the care plan, we just separated them afterwards. When queried regarding one on one staffing after the occurrence for Resident #6, the Nurse stated, No, not that I was aware of. On 8/14/19 at 10:50 AM, an observation was made of Resident #5 in the day room playing cards. The Resident was seated in a wheelchair and indicated she wanted to talk in her room and wheeled herself to her room that was near the day room. The Resident's roommate (Resident X) was in the room and wanted her to stay. The Resident was queried regarding her stay at the facility and stated, It's not going good. I had a Resident attack me last Friday. When she found out I got moved, she comes looking for me. The other day in the day room, she stuck her tongue out at me and made a raspberry noise and put her finger across her throat. Resident X stated, She (Resident #6) comes down here and asks 'where is she,' 'I want to know where she is,' I tell her she isn't here, this isn't your room, and indicated the Resident then leaves. Resident #5 was queried if she feels safe and stated, No. She was actively looking for me before I got moved. Now she is looking for me here. I feel like I am being stalked. The Resident and her roommate indicated they had not informed staff that Resident #6 was looking for Resident #5. When queried if Staff had questioned her regarding the incident, the Resident indicated that Nurses asked her about it the night it happened and stated, (DON's name) was off on the weekend so I had to talk to her on Monday. I had called the police myself. I was in such shock so I didn't call them that night but I did the next day. When queried if she had asked staff to call the police, the Resident stated, No, they would tell me that I didn't need to call the police. They act like I am in the wrong. They said they were going to make it so she couldn't come to where I was at. That lasted about one day. It's impossible to stay away from her, we were in the same hall. I tried to have staff there with me when I went back to my room, but not all the time. I had to use the visitor bathroom until she was laying down, then I could go to my room. It was hard to stay away from her. It worked the first day then it was hard after that. I couldn't go down to my room unless she was in her room or they (staff) would go with me. On 8/14/19 at 1:23 PM, an observation was made of Resident #7, seated in her wheelchair with her legs elevated. The Resident was queried regarding any issues in the facility and responded, (Resident #6), I thought she was going to hit me. When queried when it occurred the Resident stated, Last week (uncertain of the day). I was in 25 B room. I was in bed. She just walked right in. When queried if the Resident had invited Resident #6 into her room, the Resident stated, No, I did not. She gave me an evil eye (Resident demonstrated by squinting her eye and pursing her lips together) and came up with her hands (Resident demonstrated with arms and hands up and fingers curled). I told her not to touch me and she said 'I am not done with you yet' and motioned with her finger across her neck (Resident demonstrated by motioning with her index finger across her neck). She almost hit me, I told her this is not your room to go to your own room. Then she left my room. When queried if she had reported the incident to staff, the Resident stated, I told (CNA U) that night and I told (Nurse Manager B) and she said she would do something about it. (CNA N) went with me the last time (to the doctor's office), I told her. After the doctor's appointment, I talked to (Nurse Manager B) and (DON). When queried what was told to the DON the Resident stated, (DON's name), I told her what I just told you. The Resident was queried regarding how she felt about the allegations from Resident #6 and stated, I feel all these residents are in danger, that I am in danger. I asked for a room change. The Resident explained her room was in the same hall as Resident #6 and stated, I would check the hall or have the aide check to make sure she wasn't there (before coming out of her room). On 8/14/19 at 2:20 PM, an interview was conducted with Nurse C who was assigned care of Resident #5 and 6 on 8/2/19. When queried regarding an assessment of Resident #5 after the altercation with Resident #6, the Nurse stated, She had a red area on her right check. (Resident #5) said she had an open hand when she smacked her. The Nurse was queried regarding the activity of the Residents after the occurrence and stated, (Resident #5) went down to the day room to play cards. As far as (Resident #6) goes, she refused her pills and she went down to the dining room, then she went back to her room and I didn't see her the rest of the night. I went down to see (Resident #5) in the day room, after the first hour there was no redness or pain to that area. When queried regarding changes in the plan or care for Resident #6, the Nurse stated, Redirect. When queried regarding further issues that night, the Nurse stated, Just that staff had to redirect Resident #6, just that and (Resident #5) was playing cards in the day room. On 8/14/19 at 2:36 PM, an interview was conducted with CNA U regarding the incident between Resident #5 and #6 on 8/2/19. The CNA stated, I heard like loud yelling, (Resident #5) said you're a fu-ing [***] , (Resident #6) said 'no one calls me that' and she slapped her full force on the cheek. I tried to keep her (Resident #6) away from her (Resident #5). When queried regarding the CNA's assignment on 8/2/19 the CNA stated, I was on main and was helping (CNA Q). When queried regarding a plan of care after the incident occurred, the CNA stated, We were just told to keep them separated. If (Resident #6) was in the hall then we would let (Resident #5) know, then we would escort her and take (Resident #6) somewhere else. When queried if the Residents were together during the night, the CNA stated, When (Resident #5) wanted to go back to her room (Resident #5 had gone to the day room after the incident) then I walked with her because she said she was scared. The Residents resided in the same hallway of the facility. When queried if the hallway was monitored continuously by staff, the CNA stated, We tried to be down there but as aids we had to go into rooms, we just tried to be aware. Through the night we would do our check and changes, we helped each other (CNA Q). At times the hall was not being monitored by us two. I don't know if the nurse was down there or not. The CNA was queried if Resident #7 had voiced allegations of being threatened by Resident #6 and stated, She told me that she was in her room and she said that (Resident #6) went by and said your next and made a motion with her hand across her neck. The CNA was queried when that occurred and stated, Maybe last week. When queried if she had reported it, the CNA stated, I went to the nurse that was the closest, but did not remember which nurse was informed. The CNA was asked if anyone had questioned her regarding the allegations and stated, No one asked me about it afterwards but I heard they were talking about room changes. On 8/14/19 at 2:51 PM, an interview was conducted with CNA Q regarding the incident that occurred on 8/2/19 with Resident #6 hitting Resident #5. The CNA indicated he was assigned care of both Residents that night. The CNA stated, I came out of room [ROOM NUMBER] and (Resident #5) wheeled over to me to ask if I could get the light. She wheeled back down the hall, I don't know what was said but (Resident #6) slapped (Resident #5) and they wee swearing at each other. Before they separated (Resident #6) tried to punch (Resident #5) in the head. When queried regarding the plan of care after the incident the CNA stated, We separated them right away. Divert them. When queried if the Residents were together after the incident the CNA stated, (Resident #6) came out of her room, later on, maybe an hour or hour and half and she asked me where (Resident #5) was with some swear words and said she wanted to hit her some more. We went and told the nurse that (Resident #6) wanted to go after her. When queried regarding Resident #7 threatened by Resident #6, the CNA stated, She always asked us to double check to see if (Resident #6) was out there before she came out of the room. She thought she was going to come after her. When queried when that had started, the CNA stated, The day the altercation happened. That night she was very nervous and scared about everything. When queried regarding interventions to monitor Resident #6, the CNA stated, (Resident #6) mostly stayed in her room, came out once or twice, mentioned that she wanted to hit her again, but mostly stayed in her room. When queried if one to one staffing was instituted after the verbal and physical altercation on 8/2/19, the CNA stated, No, if she was out then we just stayed with her to make sure nothing happened. When queried if staff was in the hall the whole night, the CNA stated, I was down that hall and I had other halls too. She was all the way down the end of the hall. When queried if the Resident would not have been seen if she had come out, the CNA said, I was in other rooms but I would keep an ear out for her. On 8/14/19 at 5:20 PM, an interview was conducted with the DON, the Nursing Home Administrator (NHA) and the Unit Manager B regarding the Resident to Resident altercation. When queried regarding when the investigation was started, the DON indicated the Nurse Consultant I had been in the facility and had gotten the staff statements and checked on Resident #5 and that the DON had continued the investigation on Monday (8/5/19). When queried regarding interventions after the altercation occurred, the DON stated, We separated them. (Resident #5) to the day room and (Resident #6) to her room. (Resident #5) said she would steer clear of (Resident #6). That was her words. For obvious reasons we have to keep them separated . (Resident #5) needed to be accompanied to the day room and back to her room. Somebody with them when they were in the hall together. When I got report on Saturday and Sunday, they were both OK. We offered to have the room changed. There was no keeping them apart because they were staying apart . (Resident #5) came to see me on Monday. She signed the interview. She ended up deciding to move into the room with her friend. The DON indicated she had interviewed Resident #6 on Monday and stated, She could tell me all on Monday, by Wednesday she had no recollection of the incident. A review of the investigation report was conducted, the DON stated, (Resident #5) called her a F-B first, there was verbal and physical and two residents with behaviors. Was she instigating it (referring to Resident #5). When queried regarding the allegations of Resident #6 threatening Resident #7, the Unit Manager stated, She came to me on Friday. She wanted her room changed. When asked why, the Unit Manager stated, Because (Resident #5) told me that (Resident #6) told her (Resident #5) that she was next. That is what (Resident #7) told me that (Resident #5) told her. When queried if that was an allegation, there was no answer. When queried if it had been investigated, the Unit Manager stated, No. When queried why the allegation was not investigated, the NHA stated, It was hearsay, and the Unit Manager stated, Yeah it was hearsay. I asked if she felt safe and she said she did. The Unit Manager indicated that she had worked on getting Resident #7's room changed. The NHA, DON and Unit Manager was queried if the police were notified. The Unit Manager stated, I did not notify the police. The Unit Manager was queried why the police were not called, she responded, Because it was not a suspicion of a crime. When queried if anyone else called the police, the Unit Manager stated, (Resident #5) said she called the police. When queried why did the Resident call the police, the Unit Manager stated, She called because (Resident #6) slapped her. The Unit Manager was queried regarding any assessment or follow up with the Resident after the Resident had called the police and stated, No, indicating she had not talked to Resident #5 and stated, They came in on Saturday. I gave them (police) their names and dates of birth. The DON was queried regarding any follow up psych assessment after the Resident called the police and reviewed the Resident's medical record. The DON stated, I am looking for assessment, eval, follow-up, and shakes her head no. The Unit Manager shakes her head no to indicated there was no documented follow up care after the Resident had called the police. On 8/20/19 at 9:15 AM, an interview was conducted with Resident #5 in the Day room. The Resident stated, (Resident #6) is still following me around. I was pulled into the office. I am not allowed to go up South Hall at all. They said they don't want me to go there. Well (Resident's friend) is on South Hall. I can't go to see him. He has to come to the Day room to visit with me. I use to be able to go see him when I wanted, now I can't. (Resident #6) can go anywhere she wants. It's not fair. I have been so upset with her and so mad. I had a really bad [MEDICAL CONDITION] yesterday. I think all this started it. I have [MEDICAL CONDITION] too. When queried regarding calling the police the next day after the altercation on 8/2/19, the Resident stated, I was in shock. They (staff) weren't doing anything so I reported the assault myself. I was so frustrated. I had to use the visitor's bathroom because I couldn't go up the hall. They told me to avoid any interaction with her and stay off of South Hall. When queried if she slept in her room, the Resident stated, Yeah, I had my door closed and I put my wheelchair propped up just in case. When queried if any staff had talked to the Resident after she had called the police, the Resident stated, No one (from the facility) came to talk to me that weekend. I talked to the police. On 8/20/19 at 10:19 AM, an interview was conducted with the NHA and Unit Manager B regarding a time line regarding interventions after the verbal and physical altercation between Resident #5 and 6 on 8/2/19. When queried regarding the start of the investigation on 8/5/19 by the DON the NHA stated, Right and (Nurse Consultant I) collected statements from the staff the night it happened. Called the State on 8/2. The 5 day, turned in on the 12th. When queried regarding Resident #7, the Unit Manager stated, She had the Doctor's appointment on 8/8. We move her on 8/10. When queried regarding an incident and accident report of the allegations of Resident #6 threatening Resident #7, the NHA and Unit Manager were not aware that one was completed due to the allegations being hearsay. CNA N was interviewed with the Unit Manager and NHA present. The CNA was queried regarding Resident #6 threatening Resident #7 and stated, (Resident #6) had made threats to (Resident #7). She said she was trying to protect her legs, (Resident #6) came into her room or was in the hall and was threatening her. The CNA indicated that after the doctor's appoint with Resident #7, the CNA had taken the Resident to see the DON and stated, I told (DON's name) that she had been threatened by (Resident #6). When queried if the CNA had been interviewed or was asked to write a statement, the CNA stated, No questions afterwards. No statement. The NHA was queried if the allegation of being threatened needed to be investigated, the NHA after making a phone call to the DON stated, According to the DON, she talked to (Resident #7) and felt it was hearsay and did not need to be investigated since she had a history of [REDACTED].#6) had threatened (Resident #7), the NHA stated, She said it was hearsay and that it didn't need to be investigated. The Unit Manager was queried regarding interventions in place while the investigation was underway on 8/5/19, after a review of the medical record the Unit Manager stated, I am not seeing anything directly here. I know they were separated and redirected immediately until they were calmed down. In the care plan it says to keep away from them and redirect the thoughts. It's (Resident #7's) care plan that she had previously. The Unit Manager indicated Resident #6 was put on one to one staffing on 8/14/19 after Resident #5 complained that she was being stalked and stated, She wasn't having any behaviors, she wasn't going by (Resident #5 or 7) so she was taken off (one to one staffing) on Friday evening (8/16/19). When queried if Resident had free roam of the facility after the occurrence on 8/2/19, the Unit Manager stated, She if being taken to the dining room when seen heading that way. Staff is aware to monitor behaviors. She is monitored to make sure she is not going by the day room and (Resident #5's) room. She is able to ambulate on her own in the hallway. On 8/20/19 at 11:55 AM, an interview was conducted with Nurse C who was assigned care of Resident #5 and 6 on 8/2/19 when the altercation between the Residents took place. The Nurse indicated that there were two Nurses on that night and she had worked from six to ten PM but had stayed until approximately midnight. When queried if CNA U or CNA Q had contacted her regarding Resident #6 coming out of her room after the altercation ha

This Citation pertains to Intake Number MI 199. Based on observation, interview and record review, the facility failed to identify a change of condition for 1 resident (Resident #1) of 4 residents reviewed for constipation and change of condition, resulting in Resident #1 becoming non-responsive requiring hospitalization with [DIAGNOSES REDACTED]. Findings Include: A record review of the Face Sheet and Minimum Data Set (MDS) assessment indicated Resident #1 was initially admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment dated [DATE] revealed the resident had severe cognitive decline and needed extensive to total assistance with all care and 2-person assistance with transfers and toileting. A review of the progress notes indicated Resident #1 was hospitalized from [DATE]-6/13/19 after becoming non-responsive. A progress note dated 6/6/19 at 3:15 PM provided, Resident has been sleeping throughout entire morning and afternoon. Did not eat breakfast or lunch. Was unable to give medications. (Vital Signs) as follows BP (Blood Pressure) = 112/77, (Heart Rate) =109 (High), (Respiratory rate) = 16, Oxygen saturation= 94% on room air . does not withdraw or open eyes to sternal rub or verbal stimulation. Unit nurse (B) Notified Doctor (L) . received orders to monitor . There was no assessment of the resident's abdomen or bowel sounds. There was no mention if the resident had voided during the shift. The resident had not received any food or fluids since the day before. No intervention was provided. Further review revealed a progress note dated 6/6/19 at 4:00 PM, Arrived on shift resident unresponsive, unable to awaken even with sternal rub. Oxygen saturation 89-90% room air (low). Heart rate 110-114 (high) beats per minute. (Family) at bedside. 02 (oxygen administered) at 2 liters/minute per nasal cannula . Rechecked 02 saturation 93%, heart rate 85%. Still unresponsive. Unit manager aware . transferred out to hospital. On 8/13/19 at 12:29 PM, Confidential Person X was interviewed and stated, He was unresponsive all day long and they did not notify me. They did the chest rub . My (family member) went to visit and called and said what was going on. I went up there and said I wanted him to go to the hospital. I looked at the surveillance videos. The nurse aides were observed outside and in the room, but no nurse. The hospital said he was impacted (Medline Plus.gov, (MONTH) 29, (YEAR), A fecal impaction is a large lump of dry, hard stool that stays stuck in the rectum. It is most often seen in people who are constipated for a long time .) and dehydrated. He also had an infection. They put him on antibiotics, cleaned him out (removed the impaction) and gave him IV fluids. He was unresponsive for 2 days in the hospital. Since then he hasn't been able to eat by mouth. He was gagging and on 7/12/19 they put in a feeding tube. On 8/2/19, I went up there and he did not have a dressing on the (abdominal insertion site of the feeding tube). His abdominal binder was bunched up over his chest and he had no clothes on and no blanket. He was lying there. It is physically impossible for him to move the binder or remove his shirt. I have made 3 separate appointments to talk to the DON (Director of Nursing). She's canceled each time. Saturday, the nurse aide had 2 halls on the afternoon shift; 16 residents. They do not have enough staff. Sometimes his hair is greasy and they are not giving him a shower. That is their job. A review of the hospital records for the resident's admission on 6/6/19 provided, Emergency Department Chart: 6/6/19 7:30 PM, Complaint: Decreased mental status .presents to the ED via EMS (ambulance) with a chief complaint of altered mental status. Unresponsive for 13 hours. Staff notice low pulse and [MEDICAL CONDITION] 88% (low oxygen saturation). Patient is typically verbal and oriented x1 . BP 94/78 (low), pulse 97, Respirations 20, Temperature 36.6 Celsius (C), 02 saturation 91% room air. Vital sign interpretation: Hypotensive (low blood pressure) . unresponsive to sternal rub . Chest x-ray . Distended small and large bowel loops upper abdomen with elevated diaphragms . CT scan Abdomen: Prominent fecal residue within the rectum and sigmoid colon consistent with impaction . Laboratory Results: WBC ([NAME] blood count) 20.88 (normal 4.5-10.0), Lactic Acid 2.2 (normal 0.5-2.0) BUN (Blood urea Nitrogen-kidney function) 45 (normal 7-22) . The resident was started on IV antibiotics secondary to the increased WBC's and increased Lactic Acid with suspected pressure ulcer infection. The resident was readmitted to the facility on [DATE]. A review of the Care Plans for Resident #1 indicated there was no Care Plan for Constipation until 6/20/19, after the resident was hospitalized with a fecal impaction- Goal: The resident will pass soft formed stool at the preferred frequency of at least every 3 days . A review of the Bowel Elimination-P[NAME] Response History for 5/25/19-6/6/19 revealed Resident #1 did not have a bowel movement on 5/28/19, 5/29/19, 5/30/19 or 5/31/19. Four days in a row. There was also no bowel movement on 6/2/19 and 6/5/19. The documentation did not specify the amount or consistency of the bowel movements charted on 6/1/19, 6/3/19, 6/4/19 or 6/6/19. A review of the Medication Administration Record [REDACTED]. A nursing progress note dated 6/2/19 at 6:00 am provided No BM for 3 days. Guest had BM 6/1/19. There was no further description or documented assessment of the resident's bowel sounds, abdomen or if the resident had any discomfort. On 8/13/19 at 12:54 PM, an interview with Nurse B about Resident #1's change of condition revealed, The nurse told me that he wasn't very responsive. He's like that sometimes. I called the doctor and she said to monitor. We did everything we were supposed to. The nurse was asked why only vital signs were documented for the assessment, but there was no mention of the resident's current vital signs compared to his normal and that his oxygen saturation was dropping with increased Heart rate. There was no mention of lung sounds, abdominal sounds, abdominal distention or discomfort and why it took all day before someone assessed Resident #1. Nurse B said We gave him oxygen and sent him to the hospital. The nurse was asked if the resident was assessed and transferred to the hospital after the family requested it and responded, Yes, they were here. An interview with Certified Nursing Assistant U on 8/13/19 at 5:19 PM revealed, (Nurse B) came and talked to me and told me what I should say to you. She told me to tell you we put oxygen on him (Resident #1) and did everything we were supposed to. That didn't happen and it made me very uncomfortable. I got here to work and he was not acting normal. His oxygen was very low. I told her his oxygen was 88% and she said she wouldn't put oxygen on him until it was 87%. Oxygen was not put on by her; another nurse took care of it. The (family) was very upset. (Nurse B) said, I'll get to (them) when I get to (them). The nurse aide was asked if she could discuss this with the Director of Nursing or Administrator and said, They are both gone a lot. A review of the AHRQ: Agency for Healthcare Research and Quality, Advancing Excellence in Healthcare, Patient Safety, Long Term Care, Module 1: Detecting Change in a Resident's Condition, (MONTH) 2014, . things to watch for in residents include physical and non-physical changes: . urination and bowel patterns, level of weakness, vital signs . demeanor, appetite, sleeping, speech, confusion or agitation . constipation can worsen over time and can progress to serious problems resulting from impaction. Sometimes liquid stool can come out around retained stool and appear to be diarrhea . When there is suspicion of clinical change, vital signs should always be taken and compare to baseline vital signs . Illness can effect a person's mood or behavior by changing how the brain works . Changes in appetite may signify many conditions and should always be reported . A review of the facility policy titled, Acute Condition Changes- Clinical Protocol, revised (MONTH) (YEAR) revealed, . the nurse shall assess and document the following baseline information: vital signs, neurological status, current level of pain, level of consciousness . onset, severity, duration . the nursing staff and physician will discuss possible causes of the condition change based on factors including resident history, current symptoms, medication regimen and existing test results .

This citation pertains to MI 112. Based on observation, interview, and record review, the facility failed to provide supervision and care according to the plan of care and to add interventions to the care plan to prevent a fall with an injury for one resident (#61) and failed to assure fall prevention measures were in place and functioning for two residents (#61 & #62) out of three residents reviewed for falls resulting in a fall with a fractured collar bone. Findings include: Resident #61: According to the Admission Record, dated 4/2/2019, Resident #61 was a [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set Assessment, dated 3/17/2019, Resident #61 scored a five on the Brief Interview for Mental Status indicating severe cognitive impairment. On 4/2/2019 at 10:00 AM, the Nursing home Administrator was asked to provide incident and accident reports with investigations for the incidents for the last three months for Residents #61 and #62. On 4/2/2019 at 11:00 AM, the Nursing Home Administrator was asked to provide a copy of the interviews performed during the investigations for the incidents for Resident #61 that had happened on 3/3/2019 and 3/5/2019. No copies of interviews were provided by the end of the survey. According to the incident report dated 2/4/2019, Resident #61 had been found sitting on her buttocks on the floor of her room in front of her closet at 7:50 AM. It was noted that her underwear were wet and Resident #61 had stated, I need to get to the bathroom. The incident report stated that Resident #61 was not wearing shoes or socks at the time of the incident. Whether Resident #61 had last been observed in a wheel chair or in her bed was not documented. The Notes section of the incident report identified that Educated on appropriate foot ware (sic) and encouraged resident to ask for assistance were the measures taken. However, Resident #61 had a care plan intervention dated 3/12/2014 to Ensure that is wearing non-skid footwear when out of bed and gripper socks when she is in bed. and an intervention dated 2/26/2018 that identified that Resident #61 did not use the call light for assistance while she was in her room. The incident report did not identify who was educated about the appropriate foot wear that were not in place per the care plan intervention dated 3/12/2014. An additional entry in the Notes section, dated 2/9/2019, recorded that Resident #61 had Dementia and was legally blind, tried to do as much as she could for herself, and had been more forgetful lately. The note stated that Resident #61 needed frequent queues (sic) to wear appropriate footwear and wait/call for assistance with transfers and setting up for hygiene. Staff will anticipate her needs and set up for activities of daily living. Resident #61 had a care plan intervention dated 5/25/2016 that stated she was able to dress herself if you provide supervision/set up. *** often needs reminders and cueing to stay on task. According to the Minimum Data Set Resident Assessment (MDS), dated [DATE], Resident #61 required extensive assistance of one staff for dressing and limited assistance of one staff member for hygiene and toileting needs. A care plan intervention, dated 3/12/2014, included a reachable call light and the bed in low position at night. No new care plan interventions were put into place following the incident of 2/4/2019. According to an incident report dated 2/17/2019 at 6:45 AM, Resident #61 was observed to fall as she lost her balance while opening her bedroom door. Resident #61 was reported to state, I just need to go to the bathroom. The report indicated that the Immediate Action Taken was All wheelchairs and a table taken out of her room so to have no obstacles in the residents way. Resident #61 had in place an intervention for the risk of falls, dated 7/5/2018 that all wheel chairs used in her room would be stored outside of her room so she would not trip on them. The incident report did not indicate if Resident #61 had last been observed in her bed or in a wheel chair. An additional note indicated that on 2/17/2019 Resident #61 was placed on a restorative walking program to help regain some strength. An incident report dated 3/3/2019 at 4:29 PM indicated that Resident #61 had fallen at 4:15 PM and a visitor of her roommate had gotten Resident #61 up off the floor and had taken her to the bathroom. It was not noted if Resident #61 had been last seen in her bed or her wheel chair before the fall. The author of the incident report stated that she had confirmed the event with the visitor and who said that Resident #61 was already getting up. The Immediate Action Taken following the incident was to educate the visitor and for the nursing assistant to take Resident #61 to the toilet after activities and meals. Resident #61 had a plan of care that addressed her deficits in her ability to perform activities of daily living that had been initiated on 3/12/2014. The interventions for required assistance of one staff to meet her needs for eating, toileting, bathing had been initiated on 3/11/2019. However, according to the MDS dated [DATE], Resident #61 required assistance of one staff for dressing, hygiene, and toileting so these interventions should have already been in place on her care plan as the facility policy for Care Plans, dated as revised 9/9/2018, instructed that the care plan would include services each resident needed to meet nursing needs. An incident report dated 3/5/2019 at 7:45 AM indicated that Resident #61 had been heard to call for help in her room and was observed lying on the floor at the end of a bed. Following this incident, Resident #61 had a small skin tear and, according to the progress notes dated 3/6/2019, had an x-ray that was positive for a fracture of her right collar bone. There was no witness to the incident according to the incident report dated 3/5/2019. It was not noted if Resident #61 had last been seen in her wheel chair or in bed. The incident report indicated that on 3/12/2019, a bed alarm had been placed for Resident #61 at the request of the family. A bed alarm would notify staff once Resident #61 was in motion. The incident report indicated that a referral would be made to therapy services to evaluate Resident #61's strength and transfer abilities. Despite the fact that three of the four incidents, the falls on 2/4/2019 at 7:50 AM, on 2/17/2019 at 6:45 AM, and 3/5/2019 at 7:45 AM had taken place before breakfast, no interventions had been implemented to address what the facility would do to prevent falls from happening early in the morning. None of the incident reports identified if Resident #61 had already been assisted into a wheel chair to go to breakfast or if she had still been in the bed before she had been found on the floor each time. According to the facility policy Falls- Clinical Protocol, dated as revised 2/1/2019, falls should be categorized and for each individual who had fallen, staff would attempt to define possible causes of the fall. If the staff was unable to identify the underlying causes of falls, relevant interventions were to be tried based on an assessment of the category of the fall. An incident report dated 3/21/2019 at 5:05 AM indicated that Resident #61 had been found on the floor of her room near a bed. This incident report had a note that the Bed alarm was missing from bed and that the nursing assistant was unaware that Resident #61 was supposed to have a bed alarm. Following this incident, no additional interventions were added to Resident #61's care plan. On 4/2/2019 at 8:45 AM, Resident #61 was observed sitting in a wheel chair in the hallway outside of her bedroom. A tab alarm was noted hooked onto her wheel chair and clipped to her clothing. No mention of a tab alarm on her wheel chair was noted on her plan of care reviewed on 4/2/2019. On 4/2/2019 at 2:10 PM, Resident #61 was observed sitting in a lounge chair next to her bed in her room. Certified Nursing Assistant (CNA) D was asked if he thought Resident #61 could reach her call light where it was clipped to the side of her bed well past the reach of Resident #61. Without answering, CNA D moved the call light to a place within reach of Resident #61. Resident #62: According to the MDS dated [DATE], Resident #62 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An incident report dated 2/2/2019 revealed that at 4:00 AM, Resident #62's alarm was heard sounding and Resident #62 was observed sitting on his bottom on the floor. The report stated that Resident #62 had been up in his wheel chair. An incident report dated 3/26/2019 at 8:30 AM stated that Resident #62 had been found on the floor following an attempt to transfer himself from a regular chair to his wheel chair in the dining room. The notes of the incident report stated that a non slip mat was to be placed in his wheel chair on top of the chair alarm. On 4/2/2019 at 9:35 AM, Resident #62 was observed sitting in his wheel chair in the dining room. An alarm box connected to a pad alarm was observed on the back of his wheel chair. No light indicator was on the alarm that would indicate the pad alarm was functioning. CNA A was in the dining room and was called over to Resident #62's chair. CNA A was asked if the alarm was functioning, looked at the alarm and answered, No, it is not on. CNA A then turned the alarm on.

This citation pertains to Intake# MI 36 Based on observation, interview and record review, the facility failed to document changes in a pressure ulcer, skin assessments and wound care per professional standards and implement treatment to prevent skin breakdown and further worsening of wounds for 6 (#'s 20, 22, 43, 62, 66, and 67) residents of 8 reviewed for pressure ulcers, resulting in Resident's #20 with a stage I ulcer with an order for [REDACTED].#67 developed a coccyx wound with inconsistent documentation of wound care. Findings Include: Resident #22 A review of the Face Sheet and Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #22 was admitted to the facility on [DATE], discharged to the hospital on [DATE] with a right [MEDICAL CONDITION] and readmitted on [DATE] with Diagnoses: [REDACTED]. The resident was receiving Hospice Services beginning 2/2/19. The MDS dated [DATE] revealed the resident needed extensive 1-2-person assistance with care and used a [MEDICAL CONDITION] (Bilevel positive airway pressure machine/similar to a ventilator) to aid in breathing. The MDS also indicated the resident had mild cognitive decline 14/15 Brief Interview for Mental Status Score (BIMS), but the resident could only answer yes/no questions. The MDS assessment dated [DATE] indicated the resident did not have a pressure ulcer. A review of the resident's Care Plan Skin .1/22/19- Stage II to coccyx . dated 6/5/18 and 2/6/19 with Interventions: Skin Assessments per facility protocol, dated 6/5/18 and 2/6/19. A review of the progress notes and assessments revealed the following: Wound Care Update Note dated 1/4/19 revealed Wound Measurements: bilateral buttocks and coccyx areas are resolved .bilateral buttocks and coccyx areas are blanchable . A Pressure related wound care progress note, date 2/19/19 revealed .Pressure ulcer, coccyx, Stage II-III, Wound Measurement: 4.1 cm length x 6 cm width x 0.3 cm depth, Wound Bed description: Yellow attached slough 2.6 cm length x 4 cm width in middle of wound bed with reddened area surrounding, no odor noted, Minimal drainage from wound bed, peri-wound red, Evidence of Wound Improvements: (nothing was documented). A Skin Observation Tool, note dated 2/25/19 read, Coccyx, pressure; Left trochanter(hip), surgical incision; bruising. There was no description of any of the wounds or further documentation. A review of documentation of the completion of the weekly Skin observation tool, revealed the skin assessments were not completed weekly. In February, they were only completed twice 2/18/19 and 2/25/19 and in (MONTH) 1/2/19, 1/9/19, 1/22/19 and 1/29/19. The wound documentation was inconsistent. On 2/27/19 at 10:35 AM, observed wound care with Nurse O and Certified Nursing Assistant (CNA) H, the resident had an undated dressing on the right coccyx area. The dressing was foul smelling with yellow-green drainage. The wound had black areas and yellow slough (stringy fibrous dead tissue) over 90% of the wound (the wound was unstageable). A large amount of drainage had seeped out onto the pad under the resident. Nurse O stated, There isn't any date on the dressing. The dressing order was: cleanse with normal saline, apply skin prep and place [MEDICATION NAME] dressing (every 7 days). A review of the physician orders [REDACTED]. Resident #43 A review of the Face Sheet and MDS assessment dated [DATE] revealed the resident was admitted to the facility on [DATE] with Diagnoses: [REDACTED].) one on each hip and 2 unstageable (NPUAP: Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer, cannot be confirmed because it is obscured by slough or eschar), Diabetes, Weakness, Lack of expected Normal physiological development in childhood and Difficulty in walking. The MDS indicated the resident had severe cognitive loss BIMS 2/15 and needed extensive 1-2 person assistance with all care except for eating and was able to feed self with supervision. A review of the Care Plan admitted with multiple wounds . dated 1/4/19 with Interventions: Administer treatments as ordered and monitor for effectiveness, dated 1/4/19, Skin assessments per facility protocol, dated 1/4/19 . A review of the (MONTH) 2019 Treatment Administration Records (TAR's) indicated multiple missing wound treatments: 1) Hydrogel apply to left hip topically every day shift .cleanse area with saline, pat dry apply hydrogel to wound bed, cover with dry dressing ordered 1/4/19- the dressing was not completed 4 times- 1/5/19, 1/11/19, 1/12/19 and 1/19/19, 2) Santyl ointment to right buttock every day shift .began 1/4/19 with 4 missing treatments: 1/5/19, 1/11/19, 1/12/19, 1/19/19, 3) Santyl to sacrum topically every day shift .ordered 1/4/19 with 4 missing treatments: 1/5/19, 1/11/19, 1/12/19, 1/19/19. A review of the progress notes and TAR for (MONTH) 2019 revealed multiple instances of missing wound care: The coccyx wound treatment initiated 2/19/19 Cleanse coccyx wound with wound cleanser, apply hydrogel to wound base pack with Opticell and cover with [MEDICATION NAME] .change every other day and as needed, was not completed on 2/21/19. Wound vac to bilateral hips .every day and night shift, ordered 2/1/19, was not documented as completed on day or night shift on 2/21/19. On 2/27/19 at 10:58 AM, wound care to the coccyx for Resident #43 was observed provided by Nurse O with CNA H assisting. The dressing was yellow brown with drainage and Nurse O stated, There's no date on this one either. The dressing was soaked with yellow-brown foul drainage and the wound with yellow slough and 1 black small area at the top. The nurse cleansed the wound with normal saline, placed Santyl to the yellow slough (80% of wound bed) packed with 1 moist gauze and covered with [MEDICATION NAME] dressing. I don't measure the wounds. I believe the MDS nurse does that. A review of the progress notes indicated the last wound measurement documented in the medical record was 2/19/19 (8 days prior): Coccyx, 4.5 cm length x 3.5 cm width x 1 cm depth, Wound Bed Description: moist, pink with slight slough, edges attached, no odor, scant serous drainage, continue current treatment. A review of the Wound Care Update, notes for (MONTH) and (MONTH) 2019 revealed the notes with measurements were completed less than weekly: 2/19/19, 2/1/19, 1/15/19, 1/4/19. An interview with the DON on 2/27/19 at 11:12 AM, related to wound measuring, Right now we don't have a specific person. It is supposed to be weekly. (Nurse F) is doing wounds by default. She has not had a competency training here. We know we have a problem with wounds here. Discussed lack of documentation in the skin assessments, I k : now it is an issue. We are working on it. Resident #62 On 2/25/19 at 9:02 AM, during an interview with Resident #62 he said he had a sore on his bottom. A review of the Face Sheet and Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #62 was originally admitted to the hospital on [DATE], discharged to the hospital on [DATE] and readmitted on [DATE] with Diagnoses: [REDACTED]. On 1/29/19, a left buttock wound culture was positive for infection including a multi-drug resistant organism. The MDS revealed the resident had mild cognitive impairment with a Brief Interview for Mental Status Score of 11/15 and needed 2-person assistance with bed mobility, transfers, dressing and bathing. A review of the resident's Care Plan Altered Skin Integrity, date initiated 11/15/13 with Interventions: Follow facility policies/protocols for the prevention/treatment of [REDACTED]. There was no mention of the severity of the resident's wound or any new or updated interventions since 5/26/16 Observe (Resident #62's) skin when providing daily care and notify nurse of any areas of concern. On 2/25/19 at 11:15 AM, wound care was observed for Resident # 62's left buttock wound with Nurse F and Certified Nursing Assistant (CNA) H. When they rolled the resident to the right to expose the left wound there was no dressing intact or present in the brief. The resident was incontinent of stool and there was bloody drainage from the wound on the green cloth pad on the bed. Nurse(NAME)said, There is no dressing on the wound. Wound measurement-6.4 L x 7.3 W x 0.8 1 depth with 1 very small open area at the bottom (distal end) of the wound- the wound nurse did not measure it and when asked about it the Nurse said, Oh that is new, and measured 0.4 depth with a swab. Nurse F commented, The nurses are supposed to complete skin assessments weekly and I measure weekly. They are looking to hire a new wound care nurse. A review of the Skin Observation Tool, notes and Wound Care Update, notes for (MONTH) and (MONTH) 2019 indicated the skin assessments and wound measurements were not completed weekly. There was only 1 Skin Observation Tool, assessment dated [DATE] completed in February. The Wound Care Update, notes with measurements were dated 1/21/19, 2/4/19, 2/19/19 and 2/25/19. The 1/21/19 note said the resident was . readmitted (on 1/7/19) with UTD (an unstageable ulcer) to left buttocks This was the first Wound Care Update, note since readmission. There were no weekly documented wound measurements or skin assessments. buttocks. A review of the measurements of the left buttocks wound per the Wound Care Update, notes (completed less than weekly) provided: 1/21/19: Now measures 7 x 10 cm with 80% slough and 20% black eschar (dead tissue) in the wound base . 2/4/19: 5.0 x 7.0 x 0.6 cm .wound bed is covered with thick stringy yellow/white slough. Wound is surrounded by (redness), heavy green drainage with foul odor . 2/19/19: Left ischium (buttock): 4.5 cm x 5.5 cm x unable to determine unstageable .moderate size thick yellow stringy slough, no odor, large amount of serous (yellowish clear) drainage. 2/25/19: Left ischium wound now presents as Stage III, measures 6.4 x 7.3 cm x 0.8 cm with 0.2 x 0.21 x 04 tunnel present at 6 o'clock .thick stringy yellow slough present, moderate serosanguinous (yellow/red) drainage present. Current treatment: will continue . An interview with the Administrator on 2/27/19 at 5:00 PM provided, Our MDS nurse is trying to fill in as the wound nurse. We are trying to hire a new one. When queried about the lack of skin assessments and wound care documentation per the resident's care plan she said, We are trying to do better. Resident #66 A review of the Face Sheet and MDS assessment dated [DATE] indicated Resident #66 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS revealed the resident had moderate cognitive impairment BIMS 10/15 and needed extensive 1-2-person assistance with all care except for eating and was able to feed self with set up. A review of the physician orders [REDACTED]. A review of the TAR's for (MONTH) 2019 revealed there was no documentation that the treatment had been completed. A review of the Skin Assessment Tool, dated 2/25/19 did not mention any wounds and provided, No new skin issues noted. A review of the nurses Skilled Nursing Notes, from 2/21/19 to 2/26/19 do not mention the open area on Resident #66's scapula. A review of the Care Plan admitted with Stage II to sacrum and right buttocks .s/p blister apex of left shoulder, dated 2/9/19 with Interventions: Administer treatments as ordered and monitor for effectiveness, dated 2/9/19. Resident #67 A review of the Face Sheet and MDS assessment for Resident #67 indicated the resident was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS dated [DATE] revealed the resident was cognitively intact and needed extensive 2 person- assistance with transfers, bed mobility, toileting and bathing and 1-person assistance with hygiene. A review of the Skin Assessments for Resident #67 revealed: 11/29/18 Skin cdi (clear dry intact) and a Skin assessment dated [DATE] 0.5x0.5-centimeter open area on coccyx. A review of the physician orders [REDACTED]. A review of the (MONTH) (YEAR) TAR's for 12/4/18 to 12/13/18 Cleanse coccyx with normal saline, Pat dry, apply [MEDICATION NAME] dressing every 72 hours, showed that no documentation for wound care was completed. A review of the Care Plan Impairment to Skin Integrity, date initiated 12/4/18 with one intervention dated 12/4/18, Encourage frequent repositioning. There was no Skin Prevention Care Plan or interventions in place prior to the Care Plan for the dressing on 12/4/18. There were still no preventive measures on the care plan. A review of the facility policies titled, Pressure Ulcer/Skin Breakdown-Clinical Protocol, undated revealed The nursing staff .will assess and document . and Wound Care, dated revised 2/1/19 The purpose of theis procedure is to provide guidelines for the care of wounds to promote healing, Review the resident's care plan to assess for any special needs of the resident .Record in the resident's medical record: the type of wound care given, the date and time the wound care was given, any change in the resident's condition, how the resident tolerated the procedure .if the resident refused the treatment and the reasons why, the signature and title of the person recording the data . Resident #20 A review of Resident #20's medical record revealed an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the MDS, dated [DATE], revealed the Resident had severely impaired cognition and needed extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Further review of the medical record, revealed the following orders for a dressing to Resident #20's coccyx area on the Treatment Administration Record (TAR), that revealed: Dated 2/6/19, for [MEDICATION NAME] (dressing) to the coccyx in the morning every 7 days. Clean with NS (normal saline), pat dry and apply [MEDICATION NAME] if dressing falls off or if there is greater than 75% strikethrough/soak, scheduled every Tuesday and was last documented on 2/19/18 as completed. Dated 2/6/19, for [MEDICATION NAME] to coccyx as needed, clean area with NS (normal saline), pat dry, apply [MEDICATION NAME] if dressing falls off or there is greater then 75% strikethrough/soak (drainage), to be done PRN (as needed), last documented on 2/22/19 as completed. A review, of Resident #20's medical record of wound care update notes, revealed the following: On 1/24/19 at 5:39 PM, Wound Measurements: Coccyx 1.8cm (centimeters) x (by) 2.8cm. Wound Bed Description: New pink tissue, healing . On 2/6/19 at 2:08 PM, Wound Measurements: resolved tissue fragile. Wound Bed Description: area pink, wound is resolved but tissue is fragile . On 2/19/19 at 12:20 PM, Wound Measurements: Coccyx: 3cm x 2.5cm x 0cm. Stage 1. Wound Bed Description: pink, moist, edges are attached . On 2/25/19 at 11:56 AM, an observation was made of Resident #20, checked for incontinence and repositioned, with CNA (certified nursing assistant) D. The Resident did not have a dressing over the coccyx area. On 2/25/19 at 4:15 PM, an inquiry was made of why there was no dressing to Resident #20 earlier when care was observed. The CNA responded, She did not have a dressing on since I was here. The Nurse put it on today. Nurse O was queried regarding the dressing and stated, I put it on about 2:30. When queried why was there not a dressing on prior to 2:30 PM today, the Nurse stated, I don't know, it might have fallen off. There should be one on. CNA D verified that the dressing was not on since the beginning of her shift. CNA FF, who was assigned care of the Resident's in that hall 2/24/19, stated, She had one on yesterday. On 2/25/19 at 5:15 PM, an interview with Unit Manager, Nurse G was conducted regarding Resident #20's order for a coccyx dressing. When queried why the Resident did not have a dressing in place as ordered and about facility policy, the Nurse stated, I don't know why there wasn't one. There is supposed to be one. Sometimes they get rolled up. It's the Nurses responsibility to make sure it's on. The policy says that if the aide sees a change or the dressing needs to be replaced, they let the nurse know. They are depending on the aids to tell them. When queried if there was a miss-communication between the CNA and the Nurse, the Unit Manager stated, Correct. On 2/26/19 at 10:39 AM, a review of Resident #20's Treatment Administration Record and order for the dressing on Resident #20's coccyx area was reviewed with the DON. The DON responded that there should be a dressing on the Resident's coccyx area as ordered. The review of the TAR revealed that Nurse O had not documented that the dressing had been placed on 2/25/29 and the DON stated, The dressing is due to be changed today but since it was not documented that it was completed yesterday, the Nurse today would not know that it was changed yesterday, and indicated the dressing change needed to be documented.

This citation pertains to Intake #MI 974 and MI 484. Based on interview and record review, the facility failed to obtain daily assessments and vital signs every shift (three times a day) for Resident #3 and obtain an ordered STAT (immediately) chest x-ray for Resident #4 for two Residents (#3 and #4) of three residents reviewed for assessing and monitoring, resulting in medical conditions to go undetected and untreated and leading to hospitalization for Residents #3 and #4 and subsequent death for Resident #4. Findings include: Resident #3: A review, of Resident #3's medical record, revealed an admission on 7/8/18 with a readmission on 8/17/18 with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment revealed the Resident had severely impaired cognition. Further review, of Resident #3's medical record, revealed: The Resident had a transfer to the hospital on [DATE] with a returned to the facility on [DATE] and another transfer to the hospital on [DATE] with a return to the facility on [DATE]. A progress note, dated 7/26/18 at 18:00 (6:00 PM), revealed, Received report form (Nurse at Hospital) at 18:00 PM. Reason for hospital admission = A-fib with RVR ([MEDICAL CONDITION] with rapid ventricular response (fast heart rate), UTI (urinary tract infection) [MEDICAL CONDITION], and dehydration. Resident post hospital Peg (percutaneous endoscopic gastrostomy) tube placement, on 7/24/18 . A Progress Note, dated 7/28/18 at 12:19 PM, revealed, continues to respond only by mumbling, does not open eyes, is restless and moving arms around. Urine output up until now has been noted as very small amount, is very dark brown in color. A Progress note, dated 7/30/18 at 00:06 (12:06 AM), revealed, Resident condition change. Moan with painful stimuli to chest. Family at bedside. (Doctor) called. DON (Director of Nursing) called. Resident was having periods of apneic breathing, urine in Foley was black, heart rate was 174, SPO2 (oxygen saturation) was 81% on room air, b/p (blood pressure) was 94/56. Sent to hospital. A review, of Resident #3's nursing assessments, from the Resident's readmission on 7/26 until transfer to the hospital on [DATE], revealed the following: An Admission-Readmission Nursing Assessment completed on 7/26/18. No Skilled Charting assessments completed on 7/27/18, 7/28/18 and 7/29/18, prior to the Resident being sent back out to the hospital. A review of Resident #3's documented Weights and Vitals Summary, from 7/26/18 to 7/29/18, revealed the following: Blood pressure documented on 7/26/18 at 7:47 PM, 7/27/18 at 6:03 PM, 7/28/18 at 9:25 PM and 7/29/18 at 5:18 PM. Temperature documented on 7/26/18 at 7:47 PM, 7/28/18 at 9:30 AM, and 7/29/18 at 8:12 AM. Oxygen saturation documented on 7/26/18 at 7:47 PM. On 9/10/18 at 2:40 PM, an interview, with the Director of Nursing (DON), was conducted regarding Resident #3's readmission to the facility on [DATE] and then transferred back to the hospital on [DATE]. The DON stated, From (MONTH) 8th to (MONTH) 22nd, you could see the decline and that something was wrong. We sent her out on (MONTH) 22nd, when she came back, her behavior was worse, flailing her arms, combative with care. She was sent out again. When she had come back (July 26th), things were not right. There was clearly something, something just was not right. She got so sick, we sent her out the second time. The Resident's vital signs and skilled charting assessments were reviewed with the DON. When queried what is obtained when getting vital signs on a Resident, the DON stated, It would include blood pressure, temp., heart rate and respirations, O2 sat (oxygen saturation). When queried why the O2 sats were obtained on admission on 7/26/18, with a reading of 94% and not documented until transferring the Resident back to the hospital with a recorded O2 sat of 81%, the DON stated, They should be done with the vitals. The DON was queried regarding the facility policy on skilled charting assessments and stated, If (the Resident) is Medicaid Managed Care, then they get skilled charting every shift. A review of the Resident's chart revealed the Resident was Medicaid Managed Care. When queried if Skilled Charting assessments had been done per facility policy after a return from the hospital with [DIAGNOSES REDACTED]. There should have been assessments and full set of vital signs every shift. A policy for the Skilled Charting was requested. On 9/10/18 at 5:10 PM, an interview with the DON was conducted regarding assessments for Medicaid Managed Care Residents and stated, They should have charted daily the assessments and done vital signs three times a day. It would be the same as the Medicare. A review of the facility policy entitled, Charting Guidelines, dated 3/1/18, revealed, General Rules for Charting and Documentation . Chart as often as necessary and as the need arises. a. Medicare-Chart daily. All three shifts must chart. (e.g Vital signs, eating, condition of the resident, etc.) Prior to the end of the survey, no policy specific to Skilled Charting assessments, was provided by the facility. Resident #4: A review, of Resident #4's medical record, revealed an admission on 7/17/18 and discharged on [DATE] with [DIAGNOSES REDACTED]. A review, of the MDS assessment, revealed the Resident had intact cognition. The Resident was provided nutrition through a PEG tube. A review of Resident #4's Progress Notes in the medical record revealed the following: Dated 7/27/18 at 6:00 PM, Medical Visit Note, . Chest: . lungs with rales b/l (bilateral) lower lungs and diminished breath sounds RLL (right lower lobe). Dated 7/30/18 at 12:04 AM, Resident in resp. distress at start of shift, family at bed side. (Doctor) called. Resident sent to hospital. DON notified. Dated 7/30/18 at 1:35 AM, Residents family members arrived at facility stating that resident had passed at the hospital. Writer assisted daughter in helping pack up belongings . (Hospital emergency room ) called and confirmed that resident did pass. A further review, of Resident #4's medical record, revealed an order, dated 7/27/18, that indicated, portable chest x-ray, 2 view, STAT STAT for diminished breath sounds, dyspnea. Results of the chest x-ray were not found in the medical record. A review, of Resident #4's hospital emergency department medical records, revealed a date on 7/29/18 at 15:07 (3:07 PM) of triage, with the Chief Complaint Shortness of Breath. HPI (history) . nurse states that she began having some difficulty in breathing with a cough last night and that is worse 7/29/18 . Clinical Impression Diagnoses/Severity of Illness: Acute healthcare associated pneumonia with septic shock. On 9/10/18 at 6:50 PM, an interview with the DON was conducted. When queried regarding Resident #4's STAT chest x-ray that was ordered on [DATE], the DON reviewed the Resident's chart and did not find the x-ray report and indicated they would look for the x-ray. On 9/11/18 at 8:25 AM, an interview was conducted, with Physician Assistant (PA) K, who had assessed Resident #4 on 7/27/18 and ordered the STAT chest x-ray, with the DON present. The PA stated. The (Resident's) lungs sounded more diminished and had adventitious sounds, rales in her lungs. Fluid versus pneumonia. Was there infection or did she need an extra [MEDICAL TREATMENT] treatment. The PA indicated she had ordered the STAT chest x-ray. When queried regarding follow up on the x-ray, the PA stated, I did not. It was on a Friday and another doctor covers. I didn't come back until Monday and she was already passed at that time. When queried regarding the time frame that a STAT chest x-ray would be completed, the PA stated, Done in a four hour time frame and the other doctor would be covering for on call. The other doctor would be taking over after that time frame. When queried if the PA had informed the nursing staff that a STAT chest x-ray had been ordered, the PA stated, I let the floor Nurse know or the Unit coordinator. I can't remember exactly, but that is what I normally would do. I talked to her that day and told her many things. The PA indicated they had reviewed the Resident's chart but did not find the X-ray results. On 9/11/18 at 8:45 AM, an interview was conducted with the DON regarding Resident #4's ordered chest x-ray and stated, I think the chest x-ray might have been missed . It's not in her chart. It was ordered on a Friday (7/27/18) and (the Resident) was transferred out on Sunday (7/29/18). (Nurse J) had her (Resident #4) that day. She said the call light went off and she had (Nurse L) check the Resident and seen she was short of breath and they sent her out by EMS at 3:01 (PM). On 9/11/18 at 8:50 AM, an interview was conducted with Nurse J, with the DON present regarding Resident #4's status prior to transfer to the hospital. The Nurse indicated the tube feeding was completed around noon and stated, I took it off. I kept her head of the bed elevated. The daughter had come in and had put the light on. I asked (Nurse L) to go in and see what they needed. (Nurse L) seen she was having resp difficulty. She sounded gunky like she aspirated, and we called EMS to have her transferred . She didn't have a cough this day and lungs were clear. When queried regarding report from the shift before the Nurse denied any report of a cough or difficulty in breathing. When queried regarding doctor's orders for a STAT chest x-ray, the Nurse stated, You need to call (x-ray company) for a STAT x-ray. You can fax them or call them, and they will let you know how long it will be. On 9/11/18 at 9:30 AM, the x-ray company was called, and an interview was conducted with X-Ray Staff I, regarding a STAT chest x-ray ordered for Resident #4. Staff I stated, There was nothing done that day for that Resident. No file on record. No fax or call. On 9/11/18 at 10:00 AM, an interview with the DON was conducted regarding the STAT chest x-ray ordered for Resident #4. When queried if the chest x-ray had been completed as ordered, the DON stated, The x-ray should have been done. On 9/11/18 at 11:06 AM, Nurse E, who was assigned care of Resident #4 on 7/27/18, was contacted by phone but there was no answer. The Nurse had returned the call at 4:10 and an interview was conducted regarding Resident #4's ordered STAT chest x-ray. The Nurse explained that at that time she was a new employee and had not learned how to do orders. The Nurse indicated the Unit Manager, who no longer worked at the facility, would have been the one to complete any orders put into the Resident's chart. When queried if communication was made from the PA regarding the STAT x-ray, the Nurse stated, I don't remember the PA telling me of a STAT x-ray.

Based on observation, interview, and record review, the facility failed to monitor, assess, and treat pressure ulcers as ordered by physicians for two residents (#68 and #14) of four residents reviewed for pressure ulcers, from a total sample of 19, resulting in residents not receiving appropriate care to prevent worsening of pressure ulcers and promote wound healing, and one resident (#68) transferred to the hospital for a wound infection. According to the Admission Record, dated 10/26/2017, Resident #68 was a [AGE] year old female originally admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. On 02/08/18 at 11:32 AM a request was made to the Licensed Practical Nurse (LPN) Unit Manager, Staff T, for Resident #68's two admission assessments, all of the wound assessments & notes, all physician orders, treatment administration records (TARS), and care plans. According to the nursing progress notes, Resident #68 had been admitted to the facility on [DATE] and a wound vac was noted as in place on 9/30/2017. Typically, a wound vac is used when a wound has a lot of drainage that impedes healing. The first dated assessment provided of the wound on Resident #68's sacrum was located on the Minimum Data Set Assessment (MDS), dated [DATE]. The MDS reported that Resident #68 had two Stage 1 pressure ulcers (intact skin with non-blanchable redness), seven Stage 2 pressure ulcers (partial thickness loss of skin with a shallow open ulcer), and one Stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle.) The wound measurements provided were 8 centimeters (cm) by 7 cm and 1.5 cm. deep. The documentation included a notation of slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps or is mucinous) present in the pressure ulcer. The care area assessment (CAA)worksheet, dated 10/12/2017, stated that Resident #68 had been admitted with a Stage 4 pressure ulcer to her sacrum, two Stage 1 ulcers to the toes of her right foot and seven Stage 2 pressure ulcers to both of her lower legs. No additional measurements or descriptions of the wounds were located. The CAA reported that a wound vac treatment was in place for the Stage 4 pressure ulcer on the sacrum and daily dressing changes for the wounds on her lower legs. The print out of the MARs and TARs for September 2017 revealed that No order data for TREATMENT ADMINISTRATION RECORD, thus no TAR was provided for September 2017 for Resident #68. The MARs for September 2017 recorded that Resident #68 had been prescribed the antibiotic [MEDICATION NAME] to be given intravenously (IV) every 8 hours beginning on 9/29/2017 related to the sacral pressure ulcer and had been documented as administered twice on 9/30/2017. The October MARs documented that the antibiotic [MEDICATION NAME] had been administered three times a day via the IV route from 10/1/2017 through 10/20/2017. The October 2017 TARs for Resident #68 listed the dressing changes for her lower extremities three times beginning on 10/2/2017. According to the TAR, the dressing changes were to be done every other day. A nursing note documented the dressing changes for Resident #68's lower legs had been done on 10/2/2017, but the TAR did not document a dressing change for the lower legs until 10/6/2017. The October TAR indicated that from 10/2/2017 , the wound vac dressing to the stage 4 pressure ulcer on her sacrum was to be changed three times a week. The first documented treatment for [REDACTED]. The facility policy entitled, Wound Assessment and Monitoring, with a revised date of 1/9/18 stated, The (Facility) shall have in place a system for assessment and monitoring of the progress of pressure ulcers, vascular ulcers, and diabetic/neuropathic ulcers. Policy: It is the goal of the facility to provide care to residents in order to prevent the occurrence of pressure ulcers, vascular ulcers, and diabetic/neuropathic ulcers. Routine skin checks will be done on all residents at admission and on a regular ongoing basis . The course of treatment will be documented until the problem is resolved. Procedure: The Wound Care Nurse or Licensed Nurse will assess the ulcer and complete the Wound Evaluation Flow Sheet weekly and PRN . Two Wound Weekly Observation Tool forms were provided for review for Resident #68. One was dated 10/17/2017. The wound measurements were 8 cm by 6.5 cm. and 1 cm. deep. The sacral wound was described as a Stage 4 with a small amount of bloody drainage and the wound bed was described as 40% slough. The left edge of the wound was noted to have some areas of darker coloring. It was also noted that there was less undermining on the lower edge. On 10/20/2017 at 3:43 PM, , the nursing notes indicated that the physician was contacted related to change in condition and the change in the sacral wound and Resident #68 was transferred to the hospital. A hospital note dated 10/24/2017 indicated that Resident #68 had developed a fever on the day of admission and the wound vac was removed to reveal evidence of necrotic tissue and a foul-smelling sacral ulcer. At the hospital on [DATE], Resident #68's IV antibiotics were changed to [MEDICATION NAME] and [MEDICATION NAME]. The facility nursing notes indicated that Resident #68 was readmitted on [DATE]. The scheduled wound dressing changes for Resident #68's lower legs was not documented as performed on 10/26/2017. The November 2017 TARs revealed the dressing changes to Resident #68's lower legs were not documented as performed on five of the 14 scheduled days. The wound vac dressing changes to Resident #68's stage 4 pressure ulcer was no documented as performed on four of the scheduled days for the dressing change according to the November TARs. The second Wound Weekly Observation Tool for Resident #68 for the time period of 9/29/2017 through 12/1/2017 was dated 11/22/2017. This tool identified that the overall impression of the sacral wound was Worsening. The wound bed was described as 1% necrosis (black brown or tan tissue that adheres firmly to the wound bed) and 30% slough. The wound measurements were 10 cm. by 7 cm and 1.1 cm deep with 1 cm. of [MEDICAL CONDITION] tissue around the whole perimeter of the wound. On 02/08/18 at 12:21 PM the LPN, Staff V, who had been the unit manager during the time Resident #68 had resided in the facility was asked about how the wound documentation was supposed to have been done. LPN Staff V stated that the facility had started having floor nurses to do documentation and it didn't go well. Resident #68's wound was not monitored and assessed weekly and according to the TARs reviewed, the dressing changes were not performed as ordered by the physician. On 2/5/18 at 1:22 PM, an interview was conducted with Resident #14. The Resident stated, I have a sore on my foot, it is almost healed. and stated they wore boots on the lower legs, day in and day out. At 1:26 PM, the Wound Care Nurse JJ was observed performing a dressing change to Resident #14's wound to the left heel. Nurse JJ, cleansed and redressed the wound with hydrogel and alginate to the wound bed, covered with 4x4 gauze and secured with kerlix gauze. The wound bed was pink in color. Nurse JJ was queried about the progression of the wound and stated, It was active a month ago when I started coming here. The Doctor debrides it. The dressing is changed every Monday, Wednesday and Friday. Only changed on Friday by the nurse assigned to (the Resident). I change the dressing on Monday and when the Doctor comes in on Wednesday and measures it and debrides it as needed. It is getting better. When queried if the wound was acquired at the facility or if the Resident came in with the wound, Nurse JJ stated, I believe it was acquired here. On 2/7/18 at 4:15 PM, a review of Resident #14's medical record revealed an admission into the facility on [DATE] and a readmission on 6/20/17 with [DIAGNOSES REDACTED]. A review of the Minimum Data Set assessment, dated 11/17/17, revealed the Resident was cognitively intact and needed assistance with activities of daily living such as dressing, hygiene and bathing. A review of the documentation of the left heel wound revealed the following: Wound Weekly Observation Tool: Dated 6/8/17, Left Heel, admitted with wound, type: pressure, stage undetermined, necrotic and dry with measurements of 5.4 cm (centimeters) length x (by) 4.9 cm width x 0 cm depth. Dated 6/22/17, same documentation of the wound description as 6/8/17 with measurements of 4.3 cm x 5 cm x 0 cm. Dated 7/7/17, same description with measurements of 4.1 cm x 3.6 cm x 0 cm. Dated 8/12/17, same description with measurements of 4.2 cm x 2.3 cm x 0 cm. Dated 11/22/17, left heel, acquired during the residents stay, type: pressure, Current Stage II, [MEDICATION NAME] tissue present, slough tissue present, moist, small amount of purulent drainage, measurements of 2.0 cm x 1.0 cm x 0.3 cm. Dated 12/6/17, Left heel, Stage II with [MEDICATION NAME] tissue present, dry, no drainage. Measurements of 2.2 cm x 1 cm. Dated 1/17/18, Left heel, Stage III with granulation tissue present, no drainage. Measurements of 2.5 cm x 1.5 cm x 0.5 cm. Wound had been debrided. Dated 1/24/18 Left heel, Stage III with granulation tissue present, scant serosanguinous drainage. Measurements of 2 cm x 1 cm x 0.5 cm. Dated 1/31/18, Left heel, Stage III, moist with small amount of serosanguinous drainage. Measurements of 2.2 cm x 1 cm x 0.5 cm. Dated 2/7/18, Left heel, Stage III with [MEDICATION NAME] tissue present, no drainage. Measurements of 1.5 cm x 1 cm x 0.5 cm. A review of the Progress Notes for Resident #14 revealed the following documentation for the pressure wound to the left heel with assessment and/or measurements: Dated 9/1/17, left heel measurements 3.3 cm x 2.2 cm. Dated 9/29/17, Left heel unstagable; 4.0 cm x 1.6 cm x 1.6 cm, brown eshar, scant amount of light brown drng (drainage), odorous. Dated 11/10/17, culture results from left heel received, notified Dr. (Doctor KK), new orders noted. Dated 11/14/17, abt (antibiotic) in progress without adverse reaction, pale yellow drainage, no odor, 2.0 cm x 1.0 cm and 0.4 cm deep. Progress notes for 11/16/17, 11/17/17, 11/19/17, 11/20/17, 11/30/17, 12/2/17, 12/3/17, 12/10/17, 12/17/17 have mention of the wound to the heel but no measurements provided. The Wound Care Nurse JJ provided documentation from 12/18/17 to present. On 2/08/18 09:15 AM, an interview with the Director of Nursing (DON) B was conducted regarding the progression of Resident #14's wound to the left heel. The documentation in the medical record was reviewed with the DON regarding the confusion of the progression of the wound and the lack of assessment of the wound. When queried about the progression of the pressure ulcer to the left heel and if the Resident was admitted with the wound or if the wound was facility acquired, the DON stated, It looks like (the Resident) had two wounds. (The Resident) was admitted with a wound and it looks like this one was a facility acquired wound. (The Resident) is healing slow but they have debrided it to increase the healing process. (The Resident) came in with it and healed then (the Resident) acquired another one. When queried if the cause was from pressure, the DON stated, Yes. A review of the progress notes for skin assessments was conducted with the DON but none were found in the progress notes reviewed. The DON was queried regarding the lack of skin assessments and stated, There should have been skin assessments done. I don't see any. We are lucky we don't have more wounds because they were not getting done. The nurses should be doing one on the shower day and making a note of it in the progress notes. Even if they refuse a shower then a skin assessment should still be done. A review of the Treatment Administration Record (TAR) with the DON was conducted. The Wound Care Nurse was completing the dressing change on Monday and Wednesday with Nursing Staff to complete the dressing change on Fridays, the DON stated, Correct. A review of the TAR for January showed no documented dressing change done on 12/12/17 and 12/26/17 and no PRN (as needed) dressing changes were charted. It looks like it was not being done. When queried about interventions that should have been done to prevent the occurrence of pressure wounds the DON stated, Twice weekly assessing of the skin. To me that is the biggest thing I see and brought in the (Wound Care Nurse JJ) and dressing changes as ordered. Yes, they should have been done. On 2/8/17 at 10:00 AM, a further review of Resident #14's TAR documentation revealed a treatment to the left heel that stated, Santyl ointment . apply to Left Heel topically every day and evening shift related to pressure ulcer of left heel, unstageable. Wash with normal saline, apply Santyl and a dry dressing, order date 8/30/17 with a discontinued date of 11/29/17. The dressing change was scheduled twice a day in the day and evening shift. The dressing change was not documented as completed for 29 out of 60 scheduled treatments in the month of September 2017 and 11 of 62 scheduled treatments in the month of October 2017. A review of the facility policy entitled, Wound Assessment and Monitoring, with a revised date of 1/9/18 stated, The (Facility) shall have in place a system for assessment and monitoring of the progress of pressure ulcers, vascular ulcers, and diabetic/neuropathic ulcers. Policy: It is the goal of the facility to provide care to residents in order to prevent the occurrence of pressure ulcers, vascular ulcers, and diabetic/neuropathic ulcers. Routine skin checks will be done on all residents at admission and on a regular ongoing basis . The course of treatment will be documented until the problem is resolved. Procedure: The Wound Care Nurse or Licensed Nurse will assess the ulcer and complete the Wound Evaluation Flow Sheet weekly and PRN .

This pertains to Intake #'s , , Based on observation, interview and record review, the facility failed to ensure Resident's received the required number of staff for assistance, implemented effective interventions, and updated the resident's Care Plans with new interventions after an accident, including falls, for 3 (#'s 401, 403, 408) of 3 residents sampled for falls and 1 (#402) resident left unattended outside during hot weather greater than 85 degrees, from a total sample of 8, resulting in Resident #'s 401 and 408 falling after only receiving assistance with 1 person instead of 2, and Resident #401 obtaining hip and pelvic fractures, Resident #408 falling in the bathroom unassisted, resulting in a hip fracture and Resident #402 experiencing heat exhaustion. Findings Include: Resident #401 On 10/30/17 at 11:00 am, an interview with Resident #401, revealed, I hate it here. I want to get out of here. They have a lot of agency staff. No one wants to work here. They (staff) say, When I get a second and never come back. A record review on 10/30/17 at 12:30 pm, revealed Resident #401 was admitted to the facility on [DATE] and readmitted [DATE] with Diagnoses: [REDACTED]. The Minimum Data Set (MDS) assessment, dated 8/21/17 revealed, the Resident had mild cognitive impairment, and required 2 person assistance with bed mobility, transfers and bathing and 1 person assistance with dressing, eating and toileting. On 8/8/17 the resident was transferred to the emergency room after family were notified the Resident fell from bed on 8/7/17, because 1 CNA was assisting her with bed mobility, instead of the required 2 person assistance. Resident #401 was diagnosed with [REDACTED]. The Fall and ADL (Activities of Daily Living) Care Plan for the resident had not been up-dated since 5/31/17. A review of the Care Plans for Resident #401, on 10/30/17 at 3:35 pm revealed, ADL self -performance deficit related to quadriplegia .Bed Mobility, extensive assist of 2 . revised 5/29/17. The Care Plan was not updated after the fall with fracture on 8/6/17 or with the Quarterly MDS on 8/21/17. The MDS was updated on 10/12/17 to include, Transfer with mechanical lift and 2 staff. An interview with the Director of Nursing on 10/31/17 at 3:38 pm provided, They should have used 2 staff to assist (Resident #401). We know we have a staffing issue here. On 10/31/17 at 1:35 pm, and interview with Confidential Person J provided, (Resident #401) is unhappy there. When she fell from bed on 8/7/17, we had to tell them to send her to the hospital. The Emergency Department diagnosed right hip and pelvic fractures. They were supposed to use 2 people to turn (the resident) in bed. The CNA did it by herself and then she was caught doing it again by herself on Friday (10/27/17). When she was asked if that was how the other fall happened she said, uh, huh. They use a lot of agency staff there. I don't know how much training they have. We just want good care for (Resident #401. Resident #402 On 10/30/17 at 1:30 pm- Resident #402 was admitted to the facility on [DATE] and readmitted on [DATE] with Diagnoses: [REDACTED]. The MDS assessment dated [DATE], was not completed and the prior MDS dated [DATE] revealed the resident required 2 person assistance with all Activities of Daily Living (ADL's) except for eating. The resident had mild cognitive impairment. A record review, on 10/30/17 at 2:45 pm- A Facility Reported Incident (FRI) dated 9/28/17 and reported to the State Agency on 10/11/17, indicated Resident #402 was assisted outside in a wheelchair, by CNA AA on 9/23/17 and left to sit outside by themself. The weather was 85-90 degrees and the resident sat out there for 1 hour and 38 minutes, when Resident #402 was assisted back into the building (3:45 pm-5:23 pm). The resident became ill and vomited that evening. A review of the Resident's medical records and Care Plans, did not indicate the resident had been assessed for the ability to sit outside by themself. An interview with Resident #402, on 10/31/17 at 7:50 am, revealed The Sun got to me. That night I was sick to my stomach and felt hot like I had a fever. That night I vomited. I wanted to go out, but I will not do that again. On 10/31/17 at 10:25 am, Confidential Person K was interviewed and stated, They never told me about the incident on 9/23/17. I didn't know what's going on. There is so much confusion. (The resident) and roommate told me. All the staff are gone. I'm not real happy with the place. On 10/31/17 at 10:45 am, a facility surveillance video was viewed with Staff M and it showed Resident #402 being assisted via wheelchair, by CNA AA, outside and left by themself. There were no other residents or staff outside with the resident. On 10/31/17 at 2:40 pm, an interview with Nurse E revealed, I was the nurse on 9/24/17. My nurse aide came and got me and told me there was dried emesis on the bed. I checked (the resident) out for aspiration. The told me (Resident #402) was left outside. I think I did a late entry . The physician was contacted but I don't know when. I did not contact the family. A nurses progress note dated 9/24/17 and written on 9/28/17 by Nurse E revealed, .at approximately 1000 in the morning, it was reported to writer that (Resident #402) had an emesis . There was no further documentation of assessment information related to the incident, or notification of the physician or family. An interview with the Director of Nursing and Administrator, on 10/31/17 at 3:40 pm, provided both are newly hired to the facility and could not provide a policy or indicate what interventions were in place to prevent this incident from happening again to the resident or other residents. CNA AA no longer worked at the facility. Resident #408 A record review on 10/30/17 at 11:15 am, revealed Resident #408 was admitted to the facility on [DATE] and readmitted on [DATE], after sustaining a left hip fracture on 10/6/17 at the facility. The MDS Significant Change Assessment started by the facility with an ARD (assessment reference date) 0f 10/17/17, because the resident was no longer able to walk, transfer or reposition themself, was incomplete. The 8/21/17 MDS indicated the resident was previously independent with bed mobility, transfers and walking, but needed 1 person assistance with toileting. The resident had severe cognitive dysfunction. On 10/30/17 at 11:40 am, Resident #408 was observed sitting in the hallway in a wheelchair, with their feet behind the wheelchair pedals. The resident had confused speech and was unable to answer questions. On 10/30/17 at 12:30 pm, a review of the Facility Reported Incident for Resident #408, dated 10/6/17, indicated the following: Called into room by resident's roommate. Resident found sitting on floor between toilet and wall in bathroom. Walker in bathroom. Resident's pants were pulled beneath her knees with right shoe off, right leg lying flat and left knee slightly bent. Resident attempting to move left leg with extreme pain, written by Nurse CC. (Resident #408) was going to BR (bathroom) by (themselves) as usual. Observed on the floor in the bathroom. The floor was wet with urine She said she had to (urinate) . written by Nurse DD. Facility Recommendations were to buy the resident looser pants, because hers were snug and this may have caused the fall, written by Nurse DD on 10/12/17. No one mentioned the resident was assessed to need 1 person assistance with toileting on 8/21/17 per the MDS. On 10/30/17 at 1:40 pm, the Fall Care Plan for Resident #408 was reviewed and revealed the Care Plan was updated on 10/12/17 to include, Staff assist times 2 to assist (Resident #408) with toileting every 2 hours/prn (as needed), the last time the Fall Care Plan had interventions updated was 12/4/16. Per the Fall Care Plan, Resident #408 had a history of [REDACTED]. None were provided prior to exit on 10/31/17. 10/31/17 at 3:00 pm, an interview with Nurse E revealed, (Resident #408) always walked around on her own independently. They called a code green (fall). I found her sitting on the floor in the bathroom. Urine was on the floor and her shoes were wet. I think she went into go to the bathroom and started urinating and slipped and fell . We had been trying to watch her, but it's hard. An interview with the Director of Nursing on 10/31/17 at 3:38 pm revealed, We know we have a staffing issue here. Resident # 403 On 10/30/17 at 9:15 a.m., record review revealed that resident #403 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The last Minimum Data Set (MDS) assessment dated [DATE] revealed that the Resident was rarely understood, and requires total assistance for transfers, dressing and eating. On 10/30/17 a 10:29 a.m., Resident #403 was observed in room, lying in beds, heel boots on and mats on both sides of the bed. On 10/30/17 at 10:45 a.m., incident reports were requested from the Director of Nursing (DON), including all falls that have occurred for Resident #403. On 10/30/17 at 12:22 p.m., a review of the Fall Risk Assessment indicates that the last fall risk, dated 6/14/17 indicated moderate risk for falls. There were no new assessment or care plan after reported fall on 10/7/17. On 10/30/17 at 12:50 p.m., an incident report, dated 10/7/17 was received. The facility incident report revealed, The Certified Nursing Assistant (CNA) was getting patient for dinner, couldn't get no assistance and used the hoyer lift to put her in chair, made the bed then residence slip to pedals and was lowered to the floor. Notified nurse. On 10/31/17 at 1:20 p.m., an interview was conducted with Confidential Person Q who stated that resident had slipped when aide was moving here and it was suppose to be two people moving her and it was one. Confidential Person Q also stated, Resident fell before when trying to get out of bed and they always notify me. On 10/31/17 at 2:35 p.m., paper charts were reviewed and revealed the following: Doctor's note indicates that activity of daily living (ADLs) is total care. Progress Note dated 6/6/17 - Quarterly assessment completed. Dependent for most ADL care. Transfer with mechanical lift and her roam of motion (ROM) remains within functional limits. On 10/31/17 at 1:39 p.m., a return call was received from LPN P who stated, The day it happened, I had just came on and DON asked me to call responsible party because I knew him. Resident showed no signs of distress and I really didn't know all the details but called and told him she had a fall. The LPN P made no other explanation regarding the fall. On 10/31/17 at 3:00 p.m., an interview was conducted with CNA O. When queried regarding the mechanical list, CNA O stated, That should have never happened. We use our belt when lifting resident. We can't take a chance. The CNA and the Charge Nurse listed on the incident report are agency nurses and according to RN H they are no longer employed at the facility. On 10/31/17 at 2:45 p.m., DON was queried regarding the use of the mechanical lift for Resident #403, and stated, There should have been two people. They should always have a partner when doing the lift. We are going to turn it around. We will be educating them. The DON made no other explanation about the resident and the proper use of the mechanical lift. On 10/31/17 at 3:10 p.m., the facility policy, Mechanical Lift, effective date 4/18/1994 with a revision date of 1/22/15 revealed, A mechanical lift is used to transfer residents for whom the need for a mechanical lift is documented in the resident's Care Plan and ADL record per CNA Charting policy and procedure .An unattended resident can be injured. Stay with the resident at all times during the procedure Have an attendant steady the resident during transport. On 10/31/17 at 3:50 pm, the facility policy, Fall Prevention Program, dated 4/5/17 revealed, Assessment for resident specific fall-related risks will be started within 24 hours of: Admission,readmission, Significant Change, as scheduled thereafter, Fall risk evaluations and care plan updates will be done by Unit Manager/licensed nurse .Resident's plan of care will be updated to include all preventative measures chosen for the resident .

This citation pertains to Intake #MI 376. Based on interview and record review, the facility failed to provide cardiopulmonary resuscitation (CPR) to one (#801) of eights sampled residents that requested CPR as part of their advance directive, resulting in an immediate jeopardy (IJ) when Resident #801 expired and the potential for further harm, serious injury and/or death for other residents. The immediate jeopardy was identified on [DATE] at 1:30 p.m. The Administrator was notified of the immediate jeopardy on [DATE] at 2:50 p.m., and a plan of correction to remove the IJ was requested at this time. The IJ was removed on [DATE] based on the provider's implementation of corrective actions on [DATE], as verified onsite on [DATE], during the completion of the extended survey. Although the IJ was removed, the facility's deficient practice remained at isolated. No actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings include: On [DATE] at 10:00 a.m., the facility's Administrator and Director of Nursing were interviewed regarding the Facility Reported Incident #MI 376. The Director of Nursing (DON) stated, "This is the chronology of events, based upon our investigation to this point. About 4:00 a.m. on Monday [DATE], (nurse identified as 'C'), the only nurse scheduled on that night shift until 4:00 a.m., noticed (resident identified as #801) was restless. The resident had pain from a fractured left hip which was surgically repaired at the hospital prior to admission. (Nurse 'C') stated she gave resident (801) a pain medication and stayed with the resident (801) for a few minutes, then left the room to seek assistance from (nurse identified as 'A'). Nurse "A" had just arrived for the start of her 4:00 a.m. shift. Nurse "A" told me (DON) she entered the resident (801) room, saw an expiratory wheeze from resident (801), and then confirmed the absence of vital signs. Certified Nurse Assistant (CNA "B") who was working, told me she asked about resident (801s) code status while the nurses were in the room. CNA "B" said she and Nurse "C" left the room to go to the nurses' station to check her code status. Meanwhile, Nurse 'A' called me to inform me the resident was 'gone.' This was at 4:20 a.m. I asked Nurse 'A' if she was comfortable calling the family, and she said 'yes." Nurse 'A' made no mention of the resident's (801) code status. The Administrator and I have interviewed both nurses and the CNA; we believe the nurses didn't know the resident's code status until they called the family at 4:30 a.m. The nurses did not start CPR and did not call 911, contrary to our policy, for a resident in [MEDICAL CONDITION] who was a full code." On [DATE] at 11:00 a.m., a review of resident #801's facility record revealed the following: admission into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented "moderately impaired" cognitive skills for daily decision making as well as total dependence on two staff persons for bed mobility and transfers, total dependence on one staff person for dressing, and extensive assistance of one staff person for eating and personal hygiene/bathing. During this same record review, a "Legal/Health Care Document and Directives" form was noticed to be included in Resident #801's record. This form was signed by Resident #801's son on [DATE], who was identified as her Durable Power of Attorney for Health Care. Under the section titled "Advanced Directives for Health Care" was a mark signifying "Yes" for CPR. A nurse's note dated [DATE] at 4:15 a.m., and authored by Nurse "C," read: "Entered resident's room to give pain medication and noted vital signs had ceased." The next progress note dated [DATE] at 4:15 a.m., and authored by Nurse "A" read: "Confirmed all vital signs ceased." On [DATE] at 12:35 p.m., Nurse "A" was interviewed by telephone. Nurse "A" confirmed that she had been an employee at the facility for approximately five years, and upon inquiry stated the following: "I had just come into work at 4:00 a.m. on Monday [DATE]. I heard a yell for help from (nurse identified as 'C'). I got to the resident's (#801) room; I heard an expiratory gasp of air. I got a blood pressure cuff and a pulse oximeter (a machine used to monitor oxygen saturation in the blood) and I couldn't get any vital signs. I used my stethoscope to listen for a heart beat, and I couldn't hear any. This was about 4:15 a.m. on Monday. I called our DON, then I called the family." When queried, Nurse "A" stated, "We should have went back into her room once we found out she was full code, started CPR, and called 911 (Emergency Medical Services)." When asked, Nurse A stated "I am not CPR certified." On [DATE] at 2:15 p.m., CNA "B" was interviewed by telephone. CNA "B" confirmed she was an employee at the facility and stated "Yes, I remember what happened. I was working my night shift on Monday [DATE] when (nurse identified as 'C') came out of the resident's (#801) room and said 'She's dying on me.' I grabbed (nurse identified as 'A'), a nurse who had just come into work. We went into her (#801's) room, the resident was barely breathing at this time; it was about 4:15 a.m. I asked about her (resident 801) code status. Nurse "C' and I left the room to look up her code status. Nurse 'C' found it in her chart and told nurse 'A' that she (#801) was a full code. They both looked shocked, and didn't do anything. When queried, CNA B stated "It was about five to ten minutes from the time we left her (resident 801) room to the time nurse 'C' found the code status." When asked, CNA "B" stated, "I am not CPR certified." On [DATE] at 3:00 p.m., Nurse "C" was interviewed by telephone. Nurse "C" confirmed she was an employee at the facility and stated "Yes, I remember the incident. The resident (#801) was restless, so I gave her a pain medication. I got her to drink some water. Then she started to have trouble breathing, so I turned up the air flow on her oxygen concentrator. This was about 4:10 a.m. I went out to the hall to call for help. (Nurse identified as 'A'), the other nurse who had come into work at 4:00 a.m., tried to get vital signs and couldn't. I went out to go look for her code status, picked up the wrong chart at first, and then found out (resident identified as #801) was a full code. (Nurse identified as 'A') and I talked about it and we decided to lie and just say we found her dead." Nurse "C" also stated "It was about five minutes between the time we observed her (resident #801) to not have any vital signs and we found out her code status. We should have started CPR and called 911. I am not currently CPR certified." On [DATE] at 3:45 p.m., the facility's policy and procedure titled "Activation of EMS System" dated [DATE] was reviewed and revealed the following under "Purpose: to develop a standard response to critical or acute changes in a resident's condition." Under a section titled "Procedure: Priority 1-Life Threatening Situation-Enlist the help of other staff members to provide emergency care and activate the EMS system (dialing 911). Under a section titled "Other Considerations: Staff shall consider the resident's advanced directives and code status related to those directives in determining their course of action." The facility submitted a plan of correction ( POC) dated [DATE] that indicated: "Element 1: Resident #801 expired. Element 2: Any resident that might suffer a [MEDICAL CONDITION] that has advance directives for CPR could have the potential to be affected by the deficient practice. We have audited records of all residents to ensure we are aware of their current code status and advanced directives. Additional information of residents with full code status ha been placed on their name plate on their room door (a blue dot). Element 3: As of noon on [DATE] both nurses involved in the incident had been suspended pending the outcome of our investigation. It is anticipated that nurses will be terminated and reported to the licensing board upon completion of the facility and state survey agency's investigation. As of the afternoon of [DATE], the facility audited the CPR certification status of all active professional nurses and has maintained at least one licensed nurse with current CPR credentials on each shift. As of Monday evening, a system for staff to determine code status while in the resident's room was put into place. A blue sticker was placed on the name tag of each resident to denote full code status. Staff has been trained to recognize and use the new system. They have also been trained on how to respond to questions from families and residents on what the sticker indicates while still maintaining HIPAA compliance. All nursing staff members present between 6:30 a.m. on [DATE] and 6:30 a.m. on [DATE] have been advised of the incident that has occurred and the above changes that have taken place and trained to the new method of quickly referencing code status. It was reinforced that in the absence of advance directive to the contrary, CPR is to be initiated anytime as indicated by the resident's condition. Additional staff will be trained as they are scheduled to work. As of 9:00 p.m. on [DATE], all active professional nurses that are currently scheduled now have current CPR credentials. The facility offered two CPR certification classes for nursing personnel to get recertified; they were held on [DATE] from 10:00 a.m. to 5:00 p.m. and on [DATE] from 2:30 p.m. to 9:00 p.m. These CPR classes used the American Heart Association (AHA) BLS professional rescuer curriculum and were taught by a certified AHA instructor. A total of 8 nurses and 4 support staff successfully completed the CPR course. We have reviewed our policies regarding advance directives and the activation of the EMS system and found them to be proper and appropriate. The QA committee met [DATE] and discussed the incident and the Administrator was directed to correct the issues identified. The Medical Director was in attendance and involved in the planning. Element 4: 1. The QA committee will review all facility deaths to insure advance directives were followed. 2. QA committee will audit CPR credentials and expiration dates to ensure recertification opportunities are provided for staff annually. 3. QA will conduct CPR drills monthly for 3 months and quarterly thereafter. 4. The QA committee will monitor communication of code status monthly." ( ).

This citation pertains to Intake # MI 395. Based on interview and record review the facility staff failed to monitor, assess, and seek medical treatment for one of four sampled Residents (#501) who displayed signs and symptoms of respiratory distress from a total sample of four, when Resident #501 expressed having difficulty breathing and was transferred to a local [MEDICAL TREATMENT] clinic instead of the emergency department for medical evaluation. This deficient practice resulted in Resident #501's subsequent admission to the intensive care unit at the local acute care hospital. Findings include: On 05/21/13 at 10:45 a.m., review of the clinical record revealed that Resident #501 was a [AGE] year old female admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to a care plan initiated on 2/12/2012 and updated on 2/15/13, Resident #501 was at risk for a change in cardiac/pulmonary status related to [DIAGNOSES REDACTED]. The goal for this care plan was for Resident #501 to have vital sign within normal and limits and "if she (#501) is having SOB (shortness of breath) oxygen will be given and will not have any further complications thru next assessment period." Interventions to promote this goal included "oxygen to maintain SPO2 (oxygen saturation) levels above 90%; 2-4 (2 to 4) liters/minute (of oxygen) per nasal cannula or 6-10 liters/minute (of oxygen) per simple face mask." On 05/21/2013 at 12:00 p.m. an interview was conducted with Resident #501 who explained that on 04/12/2013, she (#501) experienced difficulty breathing and informed the nursing staff. "I told them that I couldn't breathe, but nobody did anything for me. They sent me to the [MEDICAL TREATMENT] center and when they ([MEDICAL TREATMENT] center staff) took one look at me, they transferred me to the hospital immediately." According to a nurse's notes dated 04/12/2013, Resident #501 was hospitalized on that date (4/12/2013). Review of the Emergency Department (ED) Clinical Report dated 04/12/2013 revealed that Resident #501 was admitted to the critical care unit with acute [MEDICAL CONDITION] with [MEDICAL CONDITION] (reduction of oxygen supply); hypercapnia (too much carbon [MEDICATION NAME] in blood); and acute exacerbation of [MEDICAL CONDITIONS]. On 05/21/13 at 1:30 p.m. an interview was conducted with Unit Clerk #14 from the local [MEDICAL TREATMENT] center. Unit Clerk #14 explained, "She (#501) was brought in to the [MEDICAL TREATMENT] center and the nursing home facility staff left her by the bathroom door without telling anyone that she was there or that she wasn't feeling well. When we discovered that she (#501) was in the [MEDICAL TREATMENT] facility, she didn't look right. She was assessed and the patient (#501) never opened her eyes. Her cheeks were puffy and she was having difficulty breathing. She was gasping for breaths..." On 05/21/13 at 1:50 p.m. an interview was conducted with the Director of Nursing (DON) about the physical condition of Resident #501 on the morning of 04/12/2013. The DON stated, "We had some concerns with her (#501) that morning....I didn't like the way that she was responding to the nurse. She (#501) was moving in slow motion. We did a double take when we noticed that she was not her usual self." The DON was asked what was done for Resident #501 when she (DON) noticed that Resident #501 was not her usual self. The DON said, "She was on her way out the door to go to [MEDICAL TREATMENT]. We were going to make a call to [MEDICAL TREATMENT], but we didn't have a chance to make the call." When asked if she or the unit manager assessed Resident #501 that morning, the DON answered "no." It was unclear why the facility did not assess Resident #501 when they noticed that she had a change in condition, or why Resident #501 was taken to [MEDICAL TREATMENT] rather than an acute care facility. On 05/21/2013 at 2:45 p.m. Licensed Practical Nurse (LPN) #3 was interviewed. LPN #3 explained that she was the nurse assigned to provide care for Resident #501 on 04/12/2013. LPN #3 said that when she (LPN #3) saw Resident #501 before she (#501) was sent out to the [MEDICAL TREATMENT] facility, "She (#501) didn't look right. She seemed not as responsive as usual. She was a little lethargic and had some shortness of breath. Her SPO2 kept fluctuating." When asked about the Resident #501's SPO2, LPN #3 could not remember what the SPO2 was, but said that the oxygen saturation level should have been documented in Resident #501's clinical record. When queried about what was done for Resident #501 when she (LPN#3) discovered that Resident #501 was short of breath and lethargic, LPN #3 said that she informed her unit manager about Resident #501's condition and, in turn, the unit manager spoke to the DON. However, according to LPN #3, Resident #501 was sent out to [MEDICAL TREATMENT]. "I was told at the end of the shift that the resident (#501) was transferred to the hospital." On 05/22/2013 at 10:40 a.m. Unit Manager (UM) #11 was queried about the incident surrounding Resident #501's condition on 04/12/2012. UM #11 said, "I (UM #11) did not assess the resident (#501) because I was dealing with another patient that morning. Myself and the DON discussed the resident (#501), but when I was told about (#501), I was in the middle of dealing with two other patients. Later, I received a call from the [MEDICAL TREATMENT] center. I was told that the resident (#501) was having difficulty breathing and was transferred to the hospital." On 05/22/2013 at 12:30 p.m. review of the clinical record for Resident #501 revealed no documentation relating to her respiratory condition or level of consciousness on the morning of 4/12/2013. There was no documented monitoring of Resident #501's SPO2 levels, even though LPN #3 stated that her SPO2 levels were fluctuating. On 05/29/2013 at 8:13 a.m., an interview was conducted with [MEDICAL TREATMENT] Facility Registered Nurse (RN) #16. RN #16 explained that on the morning of 04/12/2013 Resident #501 was dropped off at the [MEDICAL TREATMENT] center by a nursing home staff person. "She (#501) was really sick. She was so short winded, I listened to her lungs and they were full. She was very short of breath and she was looking puffy in the face. She is a DNR (Do Not Resuscitate) so I asked her if she wanted to go to the hospital and she (#501) said to me (RN #16), 'I've (#501) been telling them (nursing home staff) that I needed to go (to the hospital). I'm having difficulty breathing and they didn't do anything for me.' We ([MEDICAL TREATMENT] staff) didn't even know when she (#501) was brought into the [MEDICAL TREATMENT] facility; (Unit Clerk #14) just happened to be walking down the hall and noticed that she (#501) was just left by the bathroom." Further review of the hospital records revealed Resident #501 "was referred to the emergency department...where she was found to be having severe chronic [MEDICAL CONDITION] and [MEDICAL CONDITION] and was subsequently admitted to the ICU (Intensive Care Unit) for further management and close monitoring...family counseled...regarding the patient's critical condition..." According to the facility policy entitled "Notification of Changes" revised 07/14/2006 "...The facility will immediately consult with the Resident's physician and notify the Resident's legal representative or interested family member when there is...a significant change in a Residents physical, mental or psychosocial status...Nurses should assess the Resident's condition and determine what signs and symptoms to report to the nursing supervisor or attending physician...take vital signs, assess the Resident's overall condition, level of consciousness and function...all changes of condition must be completely and objectively documented in the medical records..."

THIS CITATION PERTAINS TO INTAKES NUMBER MI 004 AND MI 496. BASED ON INTERVIEWS AND RECORDS REVIEW, THE FACILITY FAILED TO PREVENT RESIDENT TO RESIDENT ABUSE IN 3 OF 9 SAMPLED RESIDENTS (RESIDENTS #102, #103, AND #104), FROM A TOTAL OF 12 RESIDENTS, RESULTING IN AN IMMEDIATE JEOPARDY WHEN RESIDENT #102 CHOKED RESIDENT #104 BY THE NECK AND RESIDENT #102 PUSHED A PILLOW OVER THE FACE OF RESIDENT #103, RESULTING IN THE POTENTIAL FOR SERIOUS HARM, INJURY, AND/OR DEATH FOR A TOTAL OF 12 RESIDENTS IDENTIFIED WITH WANDERING/AGGRESSIVE BEHAVIORS. FINDINGS INCLUDE: RESIDENT #102: THE FACE SHEET REVEALED RESIDENT #102 WAS A [AGE] year OLD MAN admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #102 OCCUPIED room [ROOM NUMBER] BED B. THE HOSPITAL'S TRANSFER INFORMATION TO THE FACILITY INCLUDED A HISTORY AND PHYSICAL, DATED 8/20/2011, AND A DISCHARGE SUMMARY, DATED 8/25/2011, WHICH DOCUMENTED RESIDENT #102 HAD BEEN admitted to the hospital with [REDACTED]." DOCUMENTATION INCLUDED THAT THE RESIDENT REQUIRED A ONE-TO-ONE SITTER AT THE HOSPITAL AND THE RESIDENT WAS "PLACED IN RESTRAINTS SECONDARY TO AGGRESSIVENESS." THE MINIMUM DATA SETS (MDS), dated [DATE], REVEALED RESIDENT #102 WAS SEVERELY COGNITIVELY IMPAIRED, AND EXPERIENCED BOTH LONG AND SHORT TERM MEMORY LOSS. REVIEW OF THE COGNITIVE CARE PLAN (INITIATED 9/14/2011) AND THE BEHAVIORS CARE PLAN (INITIATED 9/23/2011), REVEALED RESIDENT #102 WAS IMPAIRED FOR DAILY DECISION MAKING ABILITIES, EXPERIENCED BOTH LONG AND SHORT TERM MEMORY LOSS, AND had a history of [REDACTED]. INTERVENTIONS INCLUDED ALLOWING THE RESIDENT TO WANDER FREELY AND SAFELY WITHIN THE FACILITY WITHOUT ENTERING OTHER RESIDENTS' ROOMS, AND TO RE-DIRECT HIM TO HIS OWN ROOM. STAFF WERE TO DOCUMENT ALL BEHAVIORS ON A BEHAVIOR FORM, AND, IF ABUSIVE, RESIDENT #102 WAS TO BE SEPARATED FROM OTHER RESIDENTS AND RE-DIRECTED BACK TO HIS ROOM. THERE WERE NO ADDITIONAL UPDATES TO RESIDENT #102'S CARE PLANS UNTIL 11/1/2011 WHEN RESIDENT #102 WAS PLACED ON 1:1 SUPERVISION. OCTOBER 3, 2011 ACCORDING TO THE FACILITY INVESTIGATION REPORT, DATED 10/10/2011 (UNTIMED), RESIDENT #104, LOCATED IN room [ROOM NUMBER] BED A, WAS HEARD TO YELL OUT "STOP" AND "HELP" ON 10/3/2011 AT 6:45 A.M. CERTIFIED NURSING ASSISTANT #4 (CNA) RESPONDED TO RESIDENT #102'S CALLS FOR HELP AND OBSERVED RESIDENT #102 STANDING AT THE HEAD OF RESIDENT#104'S BED. RESIDENT #104 WAS DOCUMENTED AS TELLING CNA #4 THAT HE HAD BEEN CHOKED BY RESIDENT #102. THE RESIDENTS WERE REPORTED AS SEPARATED. DURING AN INTERVIEW 11/3/2011 AT 10:30 A.M., RESIDENT #104, AN [AGE] year OLD MAN WITH [DIAGNOSES REDACTED].#102) TRIED TO CHOKE ME. HE PUT HIS HAND ON MY NECK, HARD. IT HURT ME." DURING AN INTERVIEW ON 11/3/2011 AT 10:40 A.M., CNA #4 SAID, "I SAW RESIDENT #102 STANDING OVER THE BED OF RESIDENT #104 ON 10/3/2011 AT 6:45 A.M. RESIDENT #104 TOLD ME RESIDENT #102 CHOKED HIM. THERE WERE RED MARKS AROUND HIS NECK. I TOLD TWO NURSES. HE (RESIDENT #102) HAS STRUCK OUT AT ME BEFORE AND IS VERBALLY AGGRESSIVE; I TOLD THE DIRECTOR OF NURSING (DON) ABOUT THIS BEFORE." DURING AN INTERVIEW ON 11/3/2011 AT 3:10 P.M., A REGISTERED NURSE (RN #5) SAID, "I HEARD COMMOTION. I WENT IMMEDIATELY TO room [ROOM NUMBER], SHARED BY RESIDENTS #102 AND #104. RESIDENT #104 TOLD ME RESIDENT #102 TRIED TO CHOKE HIM; THERE WERE RED MARKS ON EITHER SIDE OF HIS NECK." DURING AN INTERVIEW ON 11/4/2011 AT 8:20 A.M., A LICENSED PRACTICAL NURSE (LPN #6) SAID, "I HEARD YELLING. I FOLLOWED THE YELLING TO room [ROOM NUMBER]. I SAW CNA #4 WITH RESIDENT #102 AT THE HEAD OF RESIDENT #104'S BED. CNA #4 WAS RE-DIRECTING RESIDENT #102. RESIDENT #104 WAS YELLING REPEATEDLY, 'HE CHOKED ME.' RESIDENT #104 WAS IN HIS BED WITH HIS BED SHEET PULLED UP TO HIS UPPER CHEST AREA. HE HAD RED MARKS ON HIS NECK AND COMPLAINED OF A SORE THROAT. THE RIGHT SIDE OF HIS NECK HAD A THICKER AREA OF RED THAN THE LEFT SIDE. THE LEFT SIDE OF HIS NECK HAD A THINNER MARK ON IT. RESIDENT #104 WAS TERRIFIED, VERY, VERY UPSET. EVEN AS I EXAMINED HIM, HE SHOOK. HE HAS [MEDICAL CONDITION] AND NORMALLY SHAKES, BUT THIS WAS SHAKING BEYOND, WAY BEYOND, WHAT I SEE WITH HIM. HE SOILED HIMSELF. HE DOES HAVE INCONTINENCE ISSUES, BUT USUALLY NOT STOOL. RESIDENT #104 STAYED WITH ME MOST OF THE DAY, AND KEPT REPEATING 'HE CHOKED ME.' RESIDENT #102 WAS KNOWN FOR VERBAL, ANGRY OUTBURSTS TOWARDS STAFF AND OTHER RESIDENTS." DURING AN INTERVIEW ON 11/4/2011 AT 9:55 A.M., THE DIRECTOR OF NURSING (#2) SAID RESIDENT #102 WAS PLACED ON 1:1 SUPERVISION WITH FACILITY STAFF FOR 48 HOURS AFTER THE EVENT OF 10/3/2011; NO FURTHER EVENTS WERE KNOWN TO HAVE OCCURRED. OCTOBER 22/2011 ACCORDING TO THE FACILITY INVESTIGATION REPORT, DATED 10/28/2011 (UNTIMED), RESIDENT #103, LOCATED IN room [ROOM NUMBER] BED C, WAS HEARD TO YELL OUT ON 10/22/2011 AT 8:30 P.M. A LICENSED PRACTICAL NURSE (LPN #7) RESPONDED TO RESIDENT #103'S CALLS FOR HELP AND OBSERVED RESIDENT #102 STANDING AT THE HEAD OF RESIDENT#103'S BED, HOLDING A PILLOW OVER THE HEAD OF RESIDENT #103. LPN #7 WAS REPORTED TO HAVE REMOVED THE PILLOW FROM THE HANDS OF RESIDENT #102 AND DIRECT HIM FROM THE ROOM. RESIDENT #103 WAS DOCUMENTED TO HAVE SUSTAINED NO PHYSICAL INJURY. DURING AN INTERVIEW ON 11/3/2011 AT 9:55 A.M., RESIDENT #103, A [AGE] year OLD MAN WITH [DIAGNOSES REDACTED].#102 HAD PLACED A PILLOW OVER HIS HEAD AND PUSHED IT AGAINST HIS FACE. RESIDENT #103 GESTURED HE USED HIS LEFT UPPER EXTREMITY TO DEFEND HIMSELF UNTIL A NURSE (WITNESS #7) RESPONDED TO HIS SCREAMS FOR HELP. DURING AN INTERVIEW ON 11/3/2011 AT 2:40 P.M., LPN #7 SAID, "BOTH RESIDENTS (RESIDENTS #102 AND #103) SHARED THE SAME ROOM. RESIDENT #102 WAS NOT A 1:1 SUPERVISION AT THAT TIME. I WAS DOING MEDPASS TWO DOORS DOWN FROM THEIR ROOM, room [ROOM NUMBER]. I HEARD RESIDENT #103 YELLING VERY LOUDLY, JUST YELLING 'CAUSE HE CAN'T SPEAK. I WENT TO THE ROOM IMMEDIATELY AND SAW RESIDENT #102 BENT OVER RESIDENT #103 WITH HIS HANDS ON EACH SIDE OF A PILLOW; THE PILLOW WAS TOUCHING THE FACE OF RESIDENT #103 WHO WAS LAYING IN HIS BED. I JUST RUSHED OVER AND PULLED THE PILLOW OUT OF RESIDENT #102'S HANDS, THEN PULLED RESIDENT #102 AWAY FROM RESIDENT #103'S BEDSIDE. I COULDN'T TELL IF RESIDENT #102 WAS EXERTING FORCE ON THE PILLOW OVER THE FACE OF RESIDENT #103. I ASSESSED RESIDENT #103, THEN ASSIGNED A NURSE AIDE TO SUPERVISE RESIDENT #102, ONE TO ONE. RESIDENT #103 CONTINUED TO YELL OUT; HE WAS FRIGHTENED AND ANGRY. HE KEPT POINTING TO THE PILLOW, THEN TO HIS FACE FOR THE NEXT FIVE TO SIX MINUTES BEFORE CALMING DOWN." THE NURSE SAID RESIDENT #102 WAS RELOCATED TO A PRIVATE ROOM, AND PLACED ON 1:1 SUPERVISION AT HER DIRECTION. DURING AN INTERVIEW ON 11/9/2011 AT 2:10 P.M., THE NURSING HOME ADMINISTRATOR #1 SAID THE FACILITY HAD ZERO TOLERANCE OF ABUSE. DURING AN INTERVIEW ON 11/9/2011 AT 2:50 P.M., THE DIRECTOR OF NURSING #2 SAID THE FACILITY HAD ZERO TOLERANCE OF ABUSE. ON 11/4/2011 AT 5:25 P.M., THE ADMINISTRATOR #1 WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 10/3/2011 WHEN THE FACILITY STAFF FAILED TO PREVENT RESIDENT #102 FROM CHOKING RESIDENT #104, AND THEN PREVENTED A SECOND INCIDENT WHEN RESIDENT #102 PUT A PILLOW OVER THE FACE OF RESIDENT #103 ON 10/22/11. ON 11/7/2011, THE SURVEYOR CONFIRMED THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1) TRANSFERRED RESIDENT #102 TO AN INPATIENT GERIATRIC PHYCHIATRIC UNIT FOR EVALUATION AND TREATMENT ON 11/4/2011 AT 9:00 P.M. 2) BEGINNING ON 11/4/11, RESIDENTS WITH AGGRESSIVE BEHAVIORS WERE IDENTIFIED. 3) BEGINNING 11/5/11, INSERVICED FACILITY STAFF ON POLICY CHANGES REGARDING RESIDENTS WITH BEHAVIORS RE: WANDERING, SUPERVISION, AND ADMISSIONS 4) BEGINNING ON 11/7/11, ALL RESIDENTS ASSESSED TO DETERMINE IF AFFECTED BY RESIDENT #102 ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON 11/7/2011, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF PATTERN, AND SEVERITY OF NO ACTUAL HARM BUT POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY, DUE TO SUSTAINED COMPLIANCE HAD NOT BEE VERIFIED BY THE STATE AGENCY.