Every finding on record at The Orchards at Wayne

This citation pertains to intake 3073834 Based on observation, interview and record review, the facility failed to ensure staff adhered to Enhanced Barrier Precautions (EBP) by wearing the required personal protective equipment (PPE) during wound care for one resident (R1105) of three residents reviewed under EBP due to colonization or risk factors associated with multidrug-resistant organisms (MDROs). The failure to utilize required isolation gowns during high-contact resident care increased the risk of transmission of MDROs and other infectious pathogens among residents. Findings include: On 7/15/2026 at 12:45 PM, observed R1105's wound care with wound care nurse (WCN) License Practical Nurse (LPN) A and certified nurse assistant (CNA) B. The staff failed to wear full Personal Protective Equipment PPE when performing dressing change and hygiene care. The staff did wear disposable gloves but failed to wear isolation gowns. Review of electronic medical record (EMR) indicated resident was originally admitted on [DATE]. R1105 had the following diagnosis: CHRONIC RESPIRATORY FAILURE WITH HYPOXIA, TRACHEOSTOMY STATUS, DYSPHASIA, TRANSIENT CEREBRAL ISCHEMIC ATTACK, MALIGNANT NEOPLASM OF CERVIX UTERI, MALIGNANT NEOPPLASM OF CAROTID BODY, PARALYSIS OF VOCAL CORDS and DISEASES OF ANUS AND RECTUM. Review of Minimum Data Set (MDS) date 6/16/26 Brief Interview for Mental Status (BIMS) was 0/15 which indicated R1105 was severely cognitively impaired. On 7/15/26 at 12:55PM, interviewed the WCN and they acknowledged not wearing full PPE. The WCN said PPE should have been worn because the R1105 had an open wound. On 7/15/26 at 1:00 PM, CNA was interviewed and said PPE should be worn to protect the spread of infection. On 7/15/26 at 1:15PM, interviewed the Director of Nursing (DON) and they said staff are educated at every meeting about EBP and they expect the staff to follow the policy, On 7/15/2026 at 2:00 PM, the Nursing Home Administrator (NHA) was interviewed, and they said they expect signage to be posted, and staff should follow EBP to prevent transmitting anything between residents. Reviewed facility policy titled, Enhanced Barrier Precautions (EBP) (undated) documented, EBP requires the use of gowns and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. The policy defines high contact care requiring gowns and gloves included but not limited to providing hygiene and wound care and any opening requiring a dressing.

This citation pertains to intake 3039764. Based on observation, interview and record review, the facility failed to protect R103's right to be free from verbal abuse by staff. Findings include: Record review revealed the following: on 5/22/2026, a verbal altercation occurred between R103 and Nurse A within the facility. During this incident, Nurse A was overheard by Nurse E stating, I am not your wife, I will blow you out. According to R103, Nurse A said she had a pistol and was going to blow him away. The Police Department was called, and Nurse A was sent home. On 6/16/2026 at 1:15 PM, R103 was interviewed and stated, (Nurse A) threatened to shoot me with her pistol. When queried about how this made him feel, he stated, It made me feel challenged. R103 said he was an ex-marine and stated, I felt like I had to prepare to defend myself. R103 also said that he has nurses within his family, so he is familiar with appropriate behaviors expected of nurses. R103 stated, I know how staff should behave and (Nurse A) is in the wrong field. R103 said he heard Nurse A have a verbal altercation with someone else in the hallway minutes before she threatened him. R103 stated, She already had a bad attitude before we engaged. Record review of R103's Minimum Data Set (MDS) dated [DATE] revealed R103 had a Brief Interview of Mental Status (BIMS) score of 14/15 indicating R103 was cognitively intact. On 6/16/2026 at 2:45 PM, the Director of Nursing (DON) was interviewed regarding the allegation of verbal abuse incident against R103 by Nurse A. The DON stated, We suspended (Nurse A) pending an investigation and informed her that she couldn't handle residents like that. She was educated, trained and given a warning. She resigned the next day. When queried about the expectations of professional standards. The DON stated, The staff are expected to treat all residents with respect and should not engage in arguments with them. On 6/16/2026 at 5:41 PM, Licensed Practical Nurse (LPN) E was interviewed regarding the allegation of verbal abuse incident. LPN E stated, I heard a shouting match between (Nurse A) and (R103). I intervened, sent (Nurse A) home and called the police. LPN E was asked about the disposition of Nurse A. LPN E stated, She was already upset with another staff person regarding sharing the care needs of another resident before the incident with (R103). Review of the facility' Policy on Abuse entitled, Abuse and Neglect Prohibition Policy revised 02/17/2020, read in part: Each resident has the right to be free from abuse, mistreatment, neglect, exploitation, involuntary seclusion, misappropriation of property and mental abuse facilitated or enabled through the use of technology. Verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. According to the State Operations Manual; verbal aggression includes intimidation.

This citation pertains to intake 3017670.Based on observation, interview and record review the facility failed to administer medications as ordered and failed to notify the physician when missed medications were not administered for one resident (R902) out of three residents reviewed. Findings include:Record review of electronic medical records (EMR) revealed admission into facility on 10/4/25 with a pertinent diagnosis of Multiple Sclerosis (chronic autoimmune disease) and depression. Review of Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 (intact cognition).An observation and interview were conducted on 6/4/26 at 10:03 AM with R902, The resident was observed lying in bed cleaned and groomed appropriately. it was reported that prescribed medications Duloxetine (antidepressant) were not administered as ordered by the physician. It was further reported that nursing staff told R902 it was not available at the facility, and they (staff) were waiting for it to be delivered by the pharmacy.Record review of Physician Orders revealed R902 was prescribed the medication Duloxetine 60 mg capsule-Give one capsule by mouth one time a day for depression.Record review of Medication Administration Record (MAR) for April 2026, it was documented on the 29th and 30th with number nine and Licensed Practical Nurse (LPN) A 's initials. Review of MAR for May 2026 documented on 6th, 7th, and 11th with a number 9 and LPN B's initials.An interview was conducted on 6/4/26 at 11:15 AM with Director of Nursing (DON) it was reported that documentation of the number nine indicates to review the nursing progress notes.Record review of R902's nursing progress notes indicated on April 29th, no reason was documented. April 30th and May 6, 7, 11 the documented reason was on order. Further review of R902's progress notes found no documentation that the physician was made aware that the medication was not given on those days.An interview was conducted on 6/4/26 at 12:25PM with Director of Nursing (DON), it was reported that the medication Duloxetine was always available in the facility's emergency medication back up system.An observation on 6/4/26 at 12:30 PM of the facility's emergency medication back up system revealed the medication Duloxetine was available in 30mg (milligram) capsules.On 6/4/26 at 12:50 PM a phone interview was conducted with LPN A, it was reported that when the number nine is documented the medication was not available and was not given. LPN A further reported that the physician was not called when the medication was not administered on 4/29, 4/30 and 5/11.On 6/4/26 at 1:03 PM a phone interview was conducted with LPN B, It was reported that when the number nine is documented that the medication was not given and was not able to retrieve the medication from back up. It was further reported that the physician was not notified on 5/6 and 5/7 when the medication was not administered.On 6/4/26 at 1:54 PM an interview was conducted with the DON; it was reported that anytime a medication is not administered the physician should be informed. It was further reported that the medication for R902 was available in the emergency backup system, and nursing staff should have retrieved the medication and administered it to R902.Record review of facility's policy Medication and Administration and General Guidelines' dated 2024 documented the following: .12. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (e.g. resident not in facility at scheduled dose time, initial dose of antibiotic), the space provided on the front of the MAR for that dosage administration Is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. The physician must be notified when a dose of medication has not been given. If an electronic medical record is being utilized than the caregiver administering the medication will enter the correct documentation that will then be electronically stamped with their initials.

Based on interview and record review, the facility failed to ensure that an allegation of misappropriation of resident property for one (R35) of four residents reviewed for abuse was immediately reported to the State Agency. This failure resulted in the facility not reporting an allegation of missing funds, placing R35 at risk for further potential misappropriation and lack of external investigation.Finding include:On 9/23/2025 at 11:29 AM, R35 was interviewed and said they had missing personal items and missing money. R35 stated, I had clothing, personal items and $200 that went missing. R35 said they reported the missing items to a staff member whose name they could not recall.On 9/24/2025at 11:29 AM, R35's family member was interviewed by phone and said R35 told them about the missing money and they had reported it to staff. The family member said they had spoken with facility staff regarding the missing money and purchased a lock box to secure R35's belongings. The family member stated, I would have purchased a lock box earlier if I had known they needed one.On 9/25/2025 at 9:05 AM, the Nursing Home Administrator (NHA) was interviewed regarding the allegation of missing money. The NHA stated, We investigated the allegation of missing money but could not verify that R35 ever had $200. If we had been able to verify that, we would have replaced the money. When the NHA was queried why the allegation of missing funds was not reported to the State Agency, the NHA stated, Because we could not verify whether R35 ever had $200. The NHA confirmed that no report had been made to the State Agency regarding the allegation of misappropriation.Record review of a document titled Concern Form, dated 5/26/2025 and signed by R35, revealed R35 documented the following items were missing: Febreze, socks and $200. The facility response, dated 5/27/2025, documented they replaced the Febreze and discussed the missing money with R35's family. There was no documentation that the allegation of missing funds was reported to the State Agency.Review of document titled Pay Source Acknowledgement, dated for 2024, revealed R35 had checked the box indicating they chose to manage their own personal funds.Record review revealed that R35 was admitted on [DATE] with a pertinent diagnosis of Paralytic Syndrome following Cerebral Infarction (left side weakness after stroke), Hydrocephalus (fluid on the brain), Neurocognitive Disorder, Major Depressive Disorder, Slurred Speech, Repeated Falls, Traumatic Brain Injury and Chronic Pain.Record review of R35's Minimum Data Set (MDS) dated for 6/28/2025 noted R35's Brief Interview for Mental Status (BIMS) was a 15 out of 15 indicating R35 was cognitively intact.

Based on observation, interview, and record review the facility failed to provide a comfortable homelike environment for one resident (R87) out of four residents reviewed for safe, clean, homelike environment resulting in R87's personal items getting wet.Findings include: On 9/22/2025 at 10:57 AM, R87 was observed in bed with an approximate two feet by four feet puddle on the floor at the head of bed. When R87 was asked about the puddle, R87 stated There is a leak in the window. It does that every time it rains. My stuff on the windowsill gets wet. When asked if R87 reported the leak, R87 stated, Yes, they are aware of it. It was actively raining during the interview.On 9/23/2025 at 3:29 PM, R87's roommate R82 was interviewed and said the window or air conditioning unit has been leaking for about a year when it rains.On 9/23/2025 at 3:44 PM, R87 was interviewed and said the staff mopped up the water yesterday.On 9/24/2025 at 9:03 AM, there was an active leak on R87's windowsill. It was raining.On 9/24/2025 at 9:03 AM, R87's window was observed with Maintenance Director (MD) B. MD B acknowledged there was an active leak in the window. MD B said it looked like the bottom window seal was bad and was letting rainwater in the room. When MD B removed R87's personal items from the windowsill a picture frame and stuffed animal were dripping water. Record review of R87's Electronic Health Record (EHR) revealed he was admitted to the facility on [DATE] with a diagnosis of Traumatic Brain Injury.Review of R87's Brief interview for Mental Status assessment performed on 9/2/25 revealed a BIMS of 14/15 intact cognition. Record review of R82's Electronic Health Record (EHR) revealed he was admitted to the facility on [DATE] with a diagnosis of Acquired Right Below Knee Amputation.Review of R82's Brief interview for Mental Status assessment performed on 7/28/2025 revealed a BIMS of 15/15 intact cognition. Review of R82's maintenance room audits for August and September 2025 did not reveal any issues.On 9/24/2025 at 11:30 PM the Nursing Home Administrator (NHA) was interviewed and said the expectation is for resident rooms to be clean and comfortable without window leaks. Review of the facility policy titled Resident Rights undated, revealed in part. 9. Safe Environment The resident has the right to a safe, clean, comfortable and homelike environment.

Based on observation, interview, and record review, the facility failed to update the care plan for one (R28) of four residents reviewed for behavior care plans to include R28's one on one sitter to monitor behaviors. Findings include:On 9/22/2025 at 10:44 AM, R28 was observed sleeping in bed with Certified Nursing Assistant (CNA) C sitting near R28's room's door. When CNA C was asked what she was observing CNA C stated, I'm here to watch R28, I don't know why though.On 9/23/25 at 8:40 AM, CNA C was observed sitting in R28's room. When asked what her job assignment was, CNA C was replied, I'm here for a one on one with R28. When asked the reason, CNA C replied, I'm not sure.On 9/23/2025 at 1:55 PM, Licensed Practical Nurse (LPN) H was interviewed and said R28 had a one-on-one for behavior issues, a history of drinking hand sanitizer, and using marijuana products. LPN H further said that she talked to CNA C upon shift change and let them know to look out for odd behaviors such as drinking hand sanitizer and hiding marijuana products. LPN H said the one-on-one should be on the Kardex (CNA reference) and care planned (EHR). Record review of R28's Electronic Health Record (EHR) revealed R28 was admitted to the facility on [DATE] with diagnoses of Bipolar Disorder, Psychoactive Substance Abuse with other Psychoactive Substance-Induced Disorder, Alcohol Abuse with Alcohol-Induced Mood Disorder, and Suicidal Ideations.Review of R28's Brief interview for Mental Status assessment performed on 7/19/2025 revealed a BIMS of 15/15 (intact cognition). Record review of the Progress Note dated 7/21/25 revealed, Resident observed with red and glassy eyes, slurring of speech while complimenting staff members on their looks. Suspicious behavior was notified to the DON (Director of Nursing) and physician. Resident is on 1 on 1 monitoring until further notice. VSS 134/78 P 87 RR 18 02 96%Oncoming nurse given report.On 9/24/2025 at 10:19 AM the Director of Nursing (DON) was interviewed and said R28 had a sitter placed on 7/21/25 due to behaviors -drinking hand sanitizer. R28's care plan was reviewed with the DON and did not reveal a one-on-one sitter to monitor behaviors. The DON said R28 did not have a one-on-one siter care plan/Kardex and should. The DON explained the care plan and Kardex are important . so the sitters know what to look for and what to report to the nurse.Review of the facility policy titled, Comprehensive Plan of Care (undated) revealed in part.The comprehensive plan of care must be periodically reviewed and revised by the interdisciplinary team as changes in the resident's care and treatment occur. Re-evaluate and modify care plans: as necessary to reflect changes in care, service and treatment.

Based on observation, interview and record review the facility failed to maintain the physical environment in the dish room in a safe sanitary manner and repair and replace a warming device. This deficient practice had the potential to affect 106 of the 111 residents in the facility. On 9/23/25 at approximately 12:00 P.M. and on 9/24/2025 at 1:28 P.M., during an observation in the dish room the following were observed: The ceiling vents and adjacent ceiling tiles were soiled with ash, lint and residue. Visible strings of lint were attached to the vent covers.The plate warmer used during meal service was broken and not heating plates.The caulking between the dish room table and wall was cracked and detached from the wall. Cracked crevices were noted the entire length of the scrape table.The back splash on the dirty end of the dish machine was not easily cleanable, and the perimeters of the panel had a mold-like substance adhering to the panel edges.Underneath the clean end of the dish machine table, a large hole was present in the wall. There was no excursion or covering to prevent the entry of rodents and vermin.In addition, floor tiles and cove bases around the perimeter of the dish room needed to be replaced or repaired.The threshold entering the kitchen from the hallway was missing, leaving a gap causing spillage of liquid items placed on residents' trays.On 9/24/25 at 1:28 P.M., during an interview with corporate staff members F and C both reported multiple requisitions had been submitted to the Regional Maintenance Director for repairs of the identified concerns, with the most recent request submitted 8/19/25. Regional Manager F indicated the broken plate warmer had recently stopped functioning and the other plate warmer was awaiting service.Review of the 2013 Food Code under 4-501.11 Equipment shall be maintained in good repair. Section 6-101.11 materials for floors/walls, and ceilings, should be smooth, durable and easily cleanable under normal use.On 9/25/25 at 9:00 A.M. Maintenance Director B reported being aware of the identified concerns but provided no explanation why the repairs or replacements of the equipment had not been completed or was delayed.On 9/25/2025 at 12:30 P.M., upon exiting the facility, no other information was provided pertaining to why the repairs had not been addressed in a timely manner.

Based on observation, interview, and record review, the facility failed to ensure that only authorized health care professionals administered medication for one resident (R102) out of two residents reviewed for medication administration. Findings include: On 7/2/25 at 10:37 AM, R102 was observed awake and lying in bed. A square shaped, undated patch was observed on the outer part of R102's right knee. Three sides of the square patch appeared smooth, but the fourth side appeared coarse and rough as if it had been cut in two. R102 said the knee patch was applied yesterday along with another one on the tailbone/lower back area. During an observation and interview on 7/2/25 at 11:07 AM of R102's knee with Licensed Practical Nurse/Unit Manager (LPN/UM) D, R102 stated, I was in pain yesterday, and (Therapy Director [TD] E) put patches on me. After exiting R102's room, LPN/UM D said any medication administered to a resident required a physician's order and should be administered by a nurse. On 7/2/25 at 11:13 AM, TD E said R102 was currently receiving physical and occupational therapy. TD E added R102 had arthritis of the right knee and was unable to fully extend the leg. TD E said that yesterday while receiving treatment in the Therapy Department R102 complained of pain and a pain patch was applied. TD E said the pain patch was supplied by LPN F. TD E did not document that a pain patch was administered to R102. On 7/2/25 at 11:29 AM, LPN F said today R102's orders were changed so that R102 could receive a pain patch. LPN F denied having a conversation with TD E about R102's pain, but added that last week, therapy asked for a pain patch, and it was obtained for therapy from Central Supply because it was an over-the-counter medication. On 7/2/25 at 11:45 AM, LPN/UM D said over-the-counter medications for residents were to have a physician's order and be administered by the nurse. R102's July 2025 Medication Administration Record (MAR) generated at 11:01 AM was reviewed with LPN/UM D and did not document an order for R102 to receive a pain patch or pain gel to the knee. LPN/UM D added that pain patches were to be dated and initialed by the nurse when applied. On 7/2/25 at 11:51 AM, during a return visit to see R102 with LPN/UM D, R102 stated, I told them to cut it (the pain patch) in half. The patch on R102's knee had been removed, and LPN/UM D observed that there was no patch on R102's lower back area. A review of the clinical record for R102 documented an initial admission date of 12/1/11 and readmission date of 4/28/25. R102's diagnoses included functional quadriplegia and pain in the right leg. A Minimum Data Set assessment dated [DATE] documented intact cognition. Record review of R102's orders documented the following, Icy Hot External Patch (Menthol (Topical Analgesic)). Apply to affected area topically one time a day for pain apply to lower back, left shoulder, right knee. Ordered on 7/2/25 at 11:19 AM by LPN F. On 7/2/25 at 1:25 PM, the Director of Nursing (DON) said staff in the Therapy Department were not legally able to apply a pain patch to a resident. The DON added that when R102's pain was identified, an order should have been obtained for the patch and the pain patch should have been applied by a nurse not the therapist. The nurse would have documented the administration of the pain patch on the MAR. The DON said R102 had not been evaluated and approved for self-administration of medication. The DON acknowledged that she observed the patch on R102's right knee. It appeared to have been half of a patch and that it was not dated or signed. A review of a facility policy titled, Medication Administration and General Guidelines, dated 2022, documented in part the following: - Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so. Medications are prepared, administered, and recorded only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations to administer medication. - Medications are administered in accordance with written orders of the attending physician. - The resident's MAR is initialed by the person administering a medication. On 7/2/25 at 2:10 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information when asked.

This citation pertains to intakes MI00147383 and MI00147811. Based on observation, interview, and record review, the facility failed to ensure enough kitchen staff were available to prepare and serve meals in a timely manner. Findings include: It was reported to the State Agency that meals were late because of staffing issues. On 11/6/24 at 8:35 AM, LPN A was observed in the 1000 Hall and said breakfast was normally served between 8:30 - 9:30 AM. On 11/6/24 at 8:37 AM, LPN C was observed in the 800 Hall and said breakfast was usually served about 8:00 AM. On 11/6/24 at 8:43 AM, R101 was observed awake, alert, lying in his bed, and able to answer questions. R101 had not been served breakfast at the time of this interview. R101 said that breakfast was served at 10:00 AM. R101's Minimum Data Set assessment dated [DATE] documented intact cognition. On 11/6/24 at 8:45 AM, breakfast meal carts were not observed on Unit 500, Unit 800, Unit 1000 or the large dining room. On 11/6/24 at 9:25 AM, R101 indicated he was still waiting for breakfast to be served. On 11/6/24 at 1:01 PM, Dietary Manager (DM) H was observed pushing a meal cart out of the kitchen and transporting the cart to a housing unit. An unidentified staff member stated, They must be short because I saw the (dietary) manager pushing a cart. On 11/6/24 at 1:39 PM, unidentified female Dietary Aide (DA) J, was asked if DM H could come and speak with the State Surveyor. DA J asked the State Surveyor to wait because they were still running the tray line. On 11/6/24 at 1:42 PM, unidentified male DA K was observed transporting a meal cart to Unit 900. DA K stated, See, we still don't have staff. Just like the last time you were here. On 11/6/24 at 1:43 PM, DM H said breakfast and lunch meal services were supposed to start at 8 AM and 12 PM respectively. DM H stated, We are short (of staff) today. We were late for breakfast because of (lack of) staffing. I've been here for a week. Four out of my seven days, we have been short. DM H stated there should have been two dietary aides and one cook for breakfast meal service. There was only a cook, plus DM H until 9:00 AM. DM stated, Once you're behind in the morning, it will carry over for the rest of the day. Ideally if lunch starts at noon, the last cart should come out at 1 PM. On 11/6/24 at 2:24 PM, the Nursing Home Administrator (NHA) said the kitchen should be staffed with two dietary aides, one cook, and the dietary manager. A review of a facility document, titled Meal times, undated but received during the survey, revealed the following: Breakfast: 8:00 AM to 9:00 AM Lunch: 12:30 PM to 1:30 PM Dinner: 5:30 PM to 6:30 PM On 11/6/24 at 4:00 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information when asked.

This citation pertains to intake number MI00147248. Based on interview and record review, the facility failed to initiate a Code [NAME] (Notification for a missing resident) in a timely manner for one resident (R703) that was missing from the facility, after identifying that the resident had left the faciity on [DATE], unbeknownst to staff, of five residents reviewed for elopement, resulting in the potential for serious injury or death from the resident being outside and unsupervised for an extended period of time. Findings include: The Immediate Jeopardy (IJ) started on 9/25/24 and was identified on 10/3/24. The Administrator was notified of the IJ on 10/3/24 at 3:18 PM, and was asked for a plan to remove the immediacy. The IJ was removed on 9/26/24, based on the facility's implementation of the removal plan as verified onsite on 10/3/24. Although the immediacy was removed, the facility's deficient practice was not corrected and remained isolated with the potential for actual harm that is not immediate jeopardy. On 10/2/24 at 11:15 AM, Activity Aide (AA) H was interviewed regarding the elopement of R703 on 9/25/24. AA H indicated that they were coming to work at the facility at approximately 11:00 AM, and observed R703 on the sidewalk in their wheelchair approximately a mile and a half from the facility. AA H further indicated that upon observing R703, they contacted the facility and themselves and two other staff were able to bring R703 back to the facility. On 10/2/24 at 11:22 AM, R703 was met in their room and attempted to be interviewed. A one to one staff was observed in R703's room and R703 was observed to be sleeping. On 10/2/24 at 11:25 AM, the Director of Nursing (DON) was asked to provide the names and phone numbers of the staff assigned to R703 on 9/25/24 on day shift. The DON provided the requested information for Certified Nursing Assistant (CNA) B and Nurse/LPN (Licensed Practical Nurse) C, and stated, Both staff were terminated following the elopement incident for not following the facility's elopement policy. On 10/2/24 at 12:52 PM, R703 was met with again in their room and interviewed regarding the elopement incident which they were involved in. R703 indicated that they exited the front door of the facility on 9/25/24, After 11:00 AM, and stated, I was wheeling around all night. R703 indicated that they returned to the facility on [DATE], with no time provided by R703. On 10/2/24 at 12:55 PM, Certified Nursing Assistant (CNA) B was attempted to be contacted by phone for an interview regarding the elopement of R703 on 9/25/24. CNA B did not answer their phone and a voicemail message was left for them A review of a written statement completed by CNA B regarding the elopement of R703 indicated that CNA B stated that they had last seen R703 in the facility at 9:30 AM, on 9/25/24. Further review of CNA B's written statement revealed that CNA B approached Nurse C twice between the morning hours and After lunch and asked Nurse C if R703 was in the building. On 10/2/24 at 1:00 PM, Nurse C was attempted to be contacted by phone for an interview regarding the elopement of R703 on 9/25/24. CNA C did not answer their phone and a voicemail message was left for them. A review of a written statement completed by Nurse C regarding the elopement of R703 indicated that Nurse C stated that they had last seen R703 in the facility between 8:00 AM-9:00 AM, on 9/25/24. Nurse C's written statement also indicated that CNA B approached them in the the morning and after lunch to ask if R703 was present in the building. On 10/3/24 at 9:15 AM, Nurse/LPN F was interviewed regarding the elopement involving R703. Nurse F indicated that they last saw R703 on/around 7:00 AM when they administered medication to [R703]. On 10/3/24 at 1:31 PM, Nurse C was contacted by phone and interviewed regarding the elopement involving R703 on 9/25/24. Nurse C was asked when they suspected that R703 had eloped from the building. Nurse C stated, I knew they were gone around 11:45 AM-12:00 PM. I thought I saw [R703] when I did my rounds, I had his medications pulled to go, but got sidetracked with something else and didn't get to [R703]. Nurse C was asked how they knew R703 was gone from the facility on 9/25/24. Nurse C stated, The CNA came to me and said, 'I don't think [R703] is here.' That's when we did the search. Nurse C was asked how long the search for R703 lasted and stated, It was going on at the time I left on 9/25/24 at around 8:00 PM-8:30 PM, and continued the next day. Nurse C was asked if they had ever witnessed R703 try to leave previously. Nurse C stated, No, but [R703] would make statements that they were going to go. [R703] was always looking out. Nurse C was asked if they knew how R703 got out of the building and which door they exited out of. Nurse C stated, No, I don't know what door. On 10/3/24 at 2:10 PM, the Administrator was interviewed about the elopement involving R703 on 9/25/24, and asked about the timeline of initiating a Code [NAME] for R703. The NHA indicated that Code [NAME] was initiated at 1:55 PM on 9/25/24. The NHA indicated that the code should have been initiated immediately when Nurse C realized that R703 was missing. A progress note located in R703's electronic medical record (EMR) which was dated, 9/25/2024 14:53 (2:53 PM) was reviewed and revealed the following, Alert Note Note Text: Writer was alerted by staff that resident could not be located. Code [NAME] was called, and the facility and grounds were searched by staff. Police were called and a simultaneously search of the community was initiated. Resident has a BIMS (Brief interview for mental status) of 6 and is mobile independently in [their] wheelchair. Staff were interviewed and the charge nurse stated [they] administered [R703] A.M. medication just prior to breakfast and [R703] propelled [themselves] towards the Oaks side of the building. C.N.A.(Certified Nursing Assistant) [indicated] [they] observed resident watching TV (television0 in the Oaks TV area after punching in this morning 9/25/2024. State agency notified, MD (Medical Doctor) notified, family notified. Further review of R703's progress notes revealed the following, 9/26/2024 11:03 [AM] Alert Note Note Text: Activity staff called the facility to report resident being seen in [their] wheelchair on [Main roads within a mile and a half from the facility]. Staff drove and picked resident up. Resident was in good spirits laughing and joking with staff. Resident asked where he went, and [R703] responded that [they] had to go to work, and [were] on [their] way back home. Writer asked resident where he was. Resident stated he was with [their] brother. Resident spoke with [their] sister and mother on the phone and assured them [that they were] doing well. Resident was given breakfast and provided a shower he remains in good spirits and remains up in his wheelchair. Resident placed on 15-minute checks. Review of R703's EMR revealed that R703 was admitted into the facility on [DATE] with diagnoses that included Traumatic brain injury and Alcohol abuse. R703's most recent quarterly minimum data set assessment (MDS) dated [DATE] revealed that R703 had severely impaired cognition and required extensive assistance for all activities of daily living (ADLs). Review of a quarterly elopement assessment completed on R703 on 9/6/24 revealed that R703 Had no history of wandering; No diagnosis of .cognitive impairment, and had no reported episodes of exit seeking behavior in the past six months. R703 was evaluated to be at Low Risk for elopement. A facility policy titled, Missing Resident Hazard Code [NAME] with no date, was reviewed and revealed the following, Policy: It is the policy of this facility to reasonably protect the residents from harm through the prevention of elopemements. A missing resident is one that cannot be located within the facility and has not been signed out. Procedure: If it is determined that the resident was not signed out, the charge nurse will immediately announce over the paging system Code Green. This will be repeated three times. IJ Removal Plan-F689 1. Facility educated staff on policy of Code Green. Policy reviewed, updated, and education conducted on 9/25/24 and 9/26/24. 2. The Code [NAME] will be enacted immediately upon staff noticing that resident missing and not on appointment or LOA. Staff will page overhead Code [NAME] (Resident Room Number) three times. Staff will initiate head count of residents, search of rooms, grounds, other offices, and surrounding areas. Staff will page periodically Code [NAME] until the resident is located. The facility alleged compliance is September 26, 2024.

This citation pertains to intake MI00146507. Based on interview, and record review the facility failed to prevent a resident to resident physical abuse incident, for two sampled residents (R701 and R702) of three residents reviewed for abuse. Findings included: A review of the intake noted, It was reported there was a resident to resident incident that resulted in no injuries. On 10/2/2024 at 12:42 PM, R702 was asked about the incident with R701. R702 explained, R701 was over on 900 hall. R702 stated, I was with my boyfriend and [R701] was coming after him, then after me. R702 continued and explained that R701 hit them in the face and then pulled on their wheelchair. R702 stated, I put my hand up over my face. I guess I wasn't fast enough and [R701] got me in the face. A review of R702's medical record revealed, 8/22/24 20:38 Writer witnessed resident getting hit with close fist on left side of face, neck and shoulder by another resident. Resident denies pain or discomfort, no injuries noted at his time. Assessed Resident head to toe, ROM and VS WNL. Denies being Unsafe or threatened. Law enforcement was called, and Resident interviewed by police. Licensed Practical Nurse (LPN H). On 10/02/2024 at 2:04 PM, LPN H was interviewed via phone and was asked about the incident. LPN H reported that R701 was verbally abusive towards staff and had attacked staff that day but they were able to get [R701] back to their room. LPN H continued and explained, when R701 came back out of their room, R702 went down hallway towards R702 and times and hit R702 three times in the arm, before they were able to separate the residents. Further review of R702 medical record revealed, R702 was admitted to the facility on [DATE], with diagnosis of Chronic obstructive pulmonary disease. A review of R702's quarterly Minimium Data Set (MDS) assessment dated [DATE] noted R702 with an intact cognition. A review of R701's medical record revealed, R701 was admitted to the facility on [DATE] and discharge on 8/28/24 with diagnosis of Metabolic encephalopathy, Delirium due to known physiological condition, Bipolar disorder, Adjustment disorder with mixed anxiety and depressed mood, Cognitive communication deficit, Impulsiveness. A review of R701's MDS noted R701 with an impaired cognition. Further review of R701's care plan noted, BEHAVIOR: I am at risk of behaviors and can be demanding and at times and may be verbally aggressive to staff. I am accusatory towards staff and other residents. I have a history of impulsiveness and transfer without waiting for assistance. I will state understanding of needing to wait, but if someone is not right there, I will decide to transfer and do so without asking for help. I have a history of sitting on the floor and self transferring, resulting in falls. I can be hyperverbal and eager to express negative feelings towards others. At times, I become focused on events that occurred in the past as if they are current events. I have anxiety Date Initiated: 08/08/2019. Goal: I will have fewer than three behavioral episodes per week throughout the next review date. Date Initiated: 05/21/2021. Intervention: Approach and speak in a calm manner. Divert my attention and remove me from a situation as needed. Date Initiated: 03/30/2016. Focus: I am verbally aggressive. I frequently become verbally aggressive towards staff during my shower I frequently make accusations and complaints non health related. [R701] makes statements that she is allowed to speak to people however she wishes without consequence. I am a hoarder and I keep personal items all around me at my bedside which contributes to my safety concerns Date Initiated: 03/10/2017. Goal: I will verbalize understanding of the need to control my verbally abusive behavior, through the review date. I will be redirected by staff during times of inappropriate verbalization with fewer outbursts through next review. Date Initiated: 03/10/2017. Intervention: When I become agitated: Intervene before my agitation escalates; Guide me away from the source of distress; Engage calmly in conversation; If my response is aggressive, walk calmly. Date Initiated: 05/23/2022. Continued review of R701's progress notes revealed, a history of verbal and physical aggressive behavior. R701's Progress notes: 8/21/2024 16:45 Behavior Note Text: Writer observed resident in hallway with feces from head to toe. [CNA] says I have been trying to change [R701] for about 15 minutes now but [R701] keeps calling me a [expletives] and is trying to sling poop on me. Resident says You [expletives] right I called her a [expletives] because she is one and I will let her change me when I'm good and ready too. Writer asked resident to come to shower that writer and [CNA] CNA give resident a shower. Resident says [expletives] you too [expletives] you don't tell me what to do. I'm not taking no shower. Resident began to throw Wash clothes covered in BM on writer and [CNA]. After roughly 30 min resident agreed to take shower. Once in the shower room the resident says I hate you funky stankin [expletives]. Yall ain't [expletives] but a bunch of raggedy [expletives] y'all [expletives] stank. Hurry the [expletives] up and give me a shower. Writer and [CNA] were quiet while resident continued with insults. Resident tested water and agreed to temp. writer and [CNA]began washing residents body. Resident continued saying What the [expletives] are y'all looking at I'm sick of you [expletives]. The began taking water from vaginal area that was filled with BM and throwing it on writer and [CNA]. Both writer and [CNA]moved away from resident. While moving away resident grabbed shower head out of [CNA] hand and began spraying water on [CNA] and writer. At this time resident slid from shower chair onto shower floor. Resident did not hit head and resident was able to move all extremities. Resident reports pain 0/10. Guardian and MD made aware of fall. Unit Manager I. 8/21/2024 19:53 Behavior Note Text: Resident physically assaulted A resident [R702]. Writer observed resident run into the other resident with her wheelchair and strike with close fist 3 times. writer ran and got in the middle to Sheild resident [R702] and removed resident SM back. Police called and on the way. LPN H. 8/21/2024 20:16 Behavior Note Text: Resident still attempting to hit and threaten other residents. Resident punch writer 4 times and other staff multiple times. 8/21/2024 22:33 Nurses Note Text: Resident interviewed by police denied punching another resident on face with a close fist or being verbally and physically aggressive towards staff. Resident was calm noncombative or aggressive when police present. Resident transported to (local hospital) via stretcher EMS . 8/21/2024 23:06 Nurses Note Text: Resident physically assaulted A resident [R702]. Writer observed resident run into the other resident with [R701's] wheelchair and strike with close fist 3 times, left side of face, neck and shoulder. writer ran and got in the middle to sheild resident [R702] and removed resident [R702] back. Police called and on the way. police arrived writer directed law enforcement to residents room. Resident interviewed by police denied punching another resident on face with a close fist or being verbally and physically aggressive towards staff. Resident was calm noncombative or aggressive when police present. Resident transported to (local hospital) . On 10/03/24 at 4:47 PM, the Director of Nursing was asked about the incident with R701. The DON explained that R701 was never abusive towards residents it was always staff. A review of the facility's policy titled Abuse and Neglect Prohibition Policy, revealed, Policy: Each resident has the right to be free from abuse, mistreatment, neglect, exploitation, involuntary seclusion, misappropriation of property and mental abuse facility or enabled through the use of technology. Each resident will be free from chemical or physical restraints imposed for purposes of discipline or convenience that are not required to treat residents symptoms . C. Prevention . 4. Staff is to report any signs of stress from family and other individuals involved with the resident that may lead to abuse, neglect, or misappropriation of resident property, and intervene as appropriate. 5. Residents identified by staff as being self-injurious or exhibiting abusive behavior, which require professional services not provided in the facility, will be reviewed by the physician as soon as possible and treatment plans modified as appropriate .

Based on observation, interview, and record review, the facility failed to properly dispose of rubbish and maintain cleanliness of the outside garbage area, resulting in a visually unappealing property and the potential for harborage of pests. Findings include: On 7/30/24 at 8:34 AM, the gates to the outside fenced in dumpster area were opened. Three dumpsters, approximately 4 to 6 yard bins, were located within the fenced in area. The grounds of the fenced in area were littered with overgrown vegetation and trash, such as a mop handle, used cups, used gloves, used lids, disposable food containers, plastic bags, flattened cardboard boxes, a call light pull cord, smashed cans, two 8-foot metal frames, and a 55-gallon trash can which was half full of dark, murky water and also contained a plastic trash bag and green vegetation. On 7/30/24 at 12:10 PM, the outside dumpster area was observed with District Manager of Environmental Services (DMES) F and Dietary Manager (DM) G. The dumpster area remained littered with trash and the middle dumpster lid was opened. DMES F said the dumpster area needs attention because of the trash. DM G said the dumpster lid needed to be closed to prevent animals and water from getting inside. On 8/1/24 at 9:18 AM, Maintenance Director (MD) C said keeping the outside dumpster area clean was a group effort and that moving forward, keeping the dumpster area clean will be part of the maintenance department's preventative maintenance. On 8/1/24 at 11:48 AM, the Nursing Home Administrator (NHA) said that maintenance should have a cleaning schedule to maintain the cleanliness and sanitation of the outside dumpster area. A review of the policy titled, Waste Disposal, undated but provided during the survey, documented in part that the outside dumpsters will be maintained in a clean manner. Trash will not be overflowing and lids will remain closed at all times. The area around the dumpster should be kept clean and swept of debris. On 8/1/24 at 3:30 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information regarding this citation when asked.

Based on observation, interview, and record review, the facility failed to: 1. Ensure kitchen sinks were in good repair and warm water was available for hand washing; 2. Properly date-label food stored in the walk-in cooler; 3. Ensure proper cooling of cooked, potentially hazardous (time-temperature for safety) food, mixed vegetables; 4. Ensure pans were properly cleaned; 5. Effectively clean surfaces in the kitchen and commercial ice machine; 6. Maintain cleanable walls in the kitchen; and 7. Ensure used meal trays were not placed on a meal cart during meal pass. These deficient practices had the potential to affect all the residents who consumed food from the kitchen and consumed ice from the ice machine, resulting in the potential for food-borne illness. Findings include: On 7/30/24 at 8:40 AM, during an observation of the kitchen with Dietary Manager (DM) G the following was observed: 1. Caulking around the hand washing sink near the Dietary Manager's office was cracked and separated. DM G said water can get through the cracks. 2. The following food items, observed in the walk-in cooler, were dated as indicated but the date marking did not specify if the date was the delivery date, opened date, or use-by date. - An opened one-gallon container of mayonnaise dated 7/11. - An opened 32-ounce container of minced garlic dated 6/7. - An opened packaged of shredded Monterey [NAME] cheese dated 7/25. - An opened 80-ounce bag of shredded cheddar cheese dated 7/29. - An opened bag of sliced turkey ham dated 7/27. DM G said date labeling needed to include the date received, date opened, and use-by date. 3. An undated full-size pan of cooked mixed vegetables was stored in the walk-in cooler. The cooling log was reviewed. The last item documented on the cooling log were biscuits cooked and cooled on 5/25/24. DM G acknowledged the mixed vegetables cooked yesterday should have been on the cooling log and they were not. 4. The following pans soiled with food debris were observed stored in the clean pot/pan area: one full-size pan, one full-size perforated pan, two one-third size pans, one full-size sheet pan, and one sixth-size pan. DM G said the pots and pans should be air dried with no remaining food particles. 5. The back splash of the dish tank area was observed stained with a black substance that was easily removed with a paper towel. 6. Cove base tiles, located on the end cap wall between the dish tank area and main kitchen, were missing, exposing a surface that was not easily cleanable. DM G said maintenance was told about the missing tiles but probably forgot about it. DM G acknowledged that the surface was not cleanable. The front faceplate inside of the ice machine, located in resident nourishment room, was observed stained with a black slimy appearing substance that was easily removed with a paper towel. DM G said that maintenance was responsible for cleaning the ice machine. On 7/31/24 at 12:53 PM as Resident #43 (R43) was returning to his room, he asked Certified Nurse Aide (CNA) I if he could be served lunch. CNA I said yes and obtained R43's lunch tray from the enclosed meal cart. After R43's tray was delivered, the contents of the meal cart was examined with CNA I. There were two finished (soiled) meal trays, one from breakfast, that had been placed on the same side of the meal cart as unserved meal trays. CNA I said placing dirty trays with unserved meal trays can cause food contamination. CNA I stated, It's very unsanitary for sure. On 8/1/24 at 9:18 AM, Maintenance Director (MD) C said that maintenance was responsible for cleaning the ice machine. MD C stated, If it was dirty, it should have been cleaned. On 8/1/24 at 11:33 AM, the hot water faucets of the kitchen handwashing sink located near the DM G's office and the automatic handwashing sink were turned on and allowed to run for approximately two minutes. The water temperatures, as measured by DM G, were 74 F (Fahrenheit) and 71 F respectively. DM G felt the water and stated, The water is not warm. It's room temperature. The water should be warm. On 8/1/24 at 11:48 AM, the Nursing Home Administrator (NHA) said she expects the kitchen to be a sanitary department and to uphold their policies and procedures. A review of a document provided during the survey titled, How To Clean a Commercial Ice Machine, documented in part that commercial ice machines harbor dangerous bacterial growth and contamination if not cleaned properly. Frequent cleaning prevents the formation of biofilm. Biofilm protects harmful organisms, and once established, is difficult and expensive to remove. According to the 2013 FDA Food Code: -Section 3-501.14 Cooling. (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 135 F to 70 F; and (2) Within a total of 6 hours from 135 F to 41 F or less. -Section 3-501.17, Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. Refrigerated, 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 41 degrees F or less for a maximum of 7 days. -Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. -Section 5-202.12 Handwashing Facility, Installation. Warm water is more effective than cold water in removing the fatty soils encountered in kitchens. An adequate flow of warm water will cause soap to lather and aid in flushing soil quickly from the hands. ASTM (American Society for Testing and Materials) Standards for testing the efficacy of handwashing formulations specify a water temperature of 100 to 108 F. - Section 6-201.11 Floors, Walls, and Ceilings. Except as specified under S 6-201.14 and except for antislip floor coverings or applications that may be used for safety reasons, floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable On 8/1/24 at 3:30 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information regarding this citation when asked.

Based on interview and record review, the facility failed to notify the Responsible Representative (RR) of a facility-initiated discharge for one (R76) resident reviewed for transfer. Findings include: A review of the Admission Record for Resident #76 (R76) revealed an initial admitted [DATE], readmitted [DATE], and the designation of RR N as R76's emergency contact and guardian. R76's was diagnosed with schizoaffective disorder. A Minimum Data Set (MDS) assessment dated [DATE] documented severe cognitive impairment. A review of R76's clinical record documented the following: Behavior progress note of 11/20/23, created on 11/21/23: Resident spitting at staff, screaming in hallway, pulling at brief, throwing brief contents at staff and at other residents, did not make contact with others, throws self on floor, attempted to distract with candy, TV, activities, unable to distract, continued to scream, swinging arms at staff, unapproachable most of the time due to aggressiveness towards anyone who approaches her. NP (nurse practitioner) from (company providing psychiatric/psychological services) in to evaluate, unable to have a conversation with resident, she kept screaming and spitting and swinging arms when approached or attempts to engage in conversation. Admission's note dated 11/22/23: At 12pm, resident arrived from (local hospital) via stretcher with 2 EMS personnel. appear stable, verbally aggressive, cursing, yelling and attempting to fight staff during assessment. vital signs WNLs (within normal limits). Lungs clear to auscultate, and no signs of SOB (shortness of breath) noted. Abdomen round and non-distended with active bowel sound in all quadrants. skin intact with old scar on abdomen, right lower leg and left lateral shin. welcome and oriented to her room. bed place in the lowest position with the HOB (head of bed) elevated to improve lung ventilation. safety measures and fall precaution implemented. call light and all personal belonging place within reach. In-House NP verified all prescribe medications and new orders updated in the MAR (medication administration record). On 7/31/24 beginning at 1:05 PM, the Director of Nursing (DON) reviewed R76's clinical record and confirmed that R76 was transferred to the hospital on 11/20/23. The DON said she thought the facility had petitioned the resident out but was unable to provide corroborating documentation. The DON was also unable to provide documentation that R76's RR was notified of the transfer. On 8/1/24 at 11;48 AM, the Nursing Home Administrator (NHA) said R76's guardian should have been notified because she was being sent out to the hospital due to a change in condition. A review of the facility document titled, Transfers and Discharges, undated but provided during the survey, documented in part that for emergency transfers to notify resident and/or resident representative. On 8/1/24 at 3:30 PM during the exit conference, the NHA and DON did not offer additional documentation or information regarding this citation when asked.

Based on observation, interview, and record review, the facility failed to provide an appropriately sized wheelchair for one resident (R79) of one resident reviewed for accommodation of needs, resulting in discomfort. On 7/30/24 at 10:51 AM R79 was observed sitting in standard wheelchair (18-inch-wide seat) with abdominal girth and thighs resting directly on the metal part of the wheel chair arms. On 7/31/24 at 8:24 AM R79 was observed self-propelling in a standard wheelchair down the hallway. R79 was asked about her comfort in the wheelchair and stated My wheelchair is too tight. My legs push against the sides. I'm not comfortable. R79 said she was going to the dining hall for breakfast and spends most of the day in the wheelchair. Record review of R79's Electronic Medical Record (EMR) revealed admitted to facility on 3/8/24 with pertinent diagnosis of Mononeuropathies of bilateral lower limbs, Chronic Congestive heart failure. Review of the Minimum Data Set (MDS) dated [DATE] for R79 revealed a Brief interview for Mental Status (BIMS) of 13/15 intact cognition and required a wheelchair for ambulation. Record review of R79's care plan dated 3/8/24 revealed in part, I need tray delivery & setup help @ mealtimes, moderate help with UB(upper body) tasks & substantial help with most LB(lower body) ADL's r/t (activities of daily living related to) obesity & weakness. BMI (body mass index) classified as obese. I have actual impairment to skin integrity of the (Bilateral lower legs and under abdominal folds) r/t skin tears to lower leg. On 7/31/24 at 11:21 AM Therapy Manager A said the therapy department provides wheelchairs for new admits. Therapy Manager A provided documentation that R79 was assessed by physical and occupational therapy on 3/11/24. On 7/31/24 at 2:16 PM Licensed Practical Nurse B agreed R79 required a wider wheelchair due to her abdominal girth and thighs pushing against the arms of the wheelchair. In an interview on 8/1/24 at 8:43 AM the Director of Nursing (DON) said resident wheelchairs should fit correctly so that residents are comfortable. Review of the facility policy titled Unit Rounds undated revealed in part .The purpose of unit rounds is to monitor residents throughout the day to assure their needs are met.

Based on observation and interview the facility failed to provide timely ADL (Activities of daily living) care to include nail care for one resident (R50) of six residents reviewed for ADL care resulting in dissatisfaction with care. Findings include: On 7/30/24 at 10:24 AM R50 was observed in bed sleeping with both hands contracted into fists with long dirty fingernails. On 7/31/24 at 8:14 AM R50 was observed in bed sleeping with both hands contracted into fists with long dirty fingernails. On 7/31/24 at 1:11 PM R50 stated, My nails need to be cut they are too long. Record review of R50's Electronic Medical Record (EMR) revealed admitted to facility on 10/13/22 with pertinent diagnosis of bed confinement status. Review of the Minimum Data Set (MDS) dated [DATE] for R50 revealed a Brief interview for Mental Status (BIMS) of 15/15 intact cognition and dependent for personal hygiene. On 7/31/24 at 2:18 PM Licensed Practical Nurse (LPN) B was interviewed and agreed R50's fingernails were long with debris under the nails. LPN B stated, No one told me her nails were long or that she had refused to get them cut. LPN B then asked R50 would you let me cut your nails and R50 agreed. Record review of R50's care plan revealed intervention date initiated 10/25/22 Bathing/Showering: Check my nail length-file and clean them on my bath day as necessary. Report any changes to the nurse. On 8/01/24 at 8:44 AM the Director of Nursing (DON) was interviewed and said dependent residents are expected to have ADLs including nails trimmed timely. Review of the facility policy titled Unit Rounds undated revealed in part .The purpose of unit rounds is to monitor residents throughout the day and assure their needs are met. Resident: Fingernails/Toenails clean and trimmed.

Based on interview and record review the facility failed to address Medication Regimen Review (MRR) recommendations timely for one resident (R54) of five residents reviewed for a medication regimen review, resulting in the potential for the continuance of unnecessary medications and lack of communication of recommended medication changes between pharmacist and physician. Findings include: On 8/01/24 at 10:34 am review of the clinical record documented R54 was initially admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, type 2 diabetes mellitus with diabetic neuropathy, panic disorder, episodic paroxysmal anxiety, undifferentiated schizophrenia, and bipolar disorder. According to the admission Minimum Data Set assessment, R54 had moderate impaired cognition and dependent for most activities of daily living. Review of R54's physician orders documented the resident's current medications as follows: - Cymbalta Oral Capsule Delayed Release Particles 30 MG (Duloxetine HCl) Give 30 mg by mouth one time a day for Mood. Start date 7/20/24. - Abilify Oral Tablet 10 MG (Aripiprazole) Give 10 mg by mouth one time a day for Mood with Psychosis. Start date 7/20/24. - Norco Oral Tablet 7.5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 8 hours for Pain. Start date 7/3/24. -Insulin Glargine Solution 100 unit/ml Inject 35 unit subcutaneous once daily for Diabetes Mellitus. Start date 7/3/24. Review of monthly pharmacy recommendations in the electronic medical record documented the following: 5/29/24- See report for any noted irregularities and/or recommendations. Additional information: 6 types of recommendations. On 8/1/24 at 11:00 a.m. the facility was asked to provide the detailed pharmacy reports and recommendations. They were not located in the electronic medical record (EMR). On 8/1/24 at 2:00 p.m. the Nursing Home Administrator (NHA) was asked again to provide the pharmacy report and recommendation for R54. The NHA said the first request was missed and will be provided. On 8/1/24 at 2:50 p.m. the facility was asked to provide the facility's policy for Medication Regimen Review (MRR). On 8/1/24 at 4:00 p.m. the survey team exited the facility and the facility had not provided the pharmacy report and the facility's policy for MRR as requested prior to exiting.

This citation pertains to Intake MI00142000 and MI00142648. Based on observation, interviews and record review, the facility failed to respond to a resident's call light in a timely manner for one resident (R616) out of four residents reviewed for call light response times, resulting in the potential for resident frustration and unmet care needs. Findings include: In an observation on 3/20/24 at 8:14 a.m., a screen at the nurses station revealed R617's call light was on for 29 minutes. At 8:17 a.m., the call light was on for 32 minutes and 8:20 a.m. for 35minutes. In an observation and interview on 3/20/24 at 8:24 a.m., R617's call light was not on. R617 reported the call light was on for over an hour and staff just turned it off one minute ago. R617 reported asking for some milk but was told to wait. In an interview on 3/20/24 at 8:26 a.m. Licensed Practical Nurse (LPN) C reported a call light should be answered within 5 to10 minutes. LPN C then reported Certified Nursing Assistant (CNA) D was assigned to R617. In an interview on 3/20/24 at 8:29 a.m., CNA D reported she was pulled to the kitchen about 30 minutes to 1 hour ago. In an interview on 3/20/24 at 8:32 a.m., LPN C reported the assignment changed because CNA D has been pulled to the kitchen. Review of an Admission Record revealed, R617 readmitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnoses which included Congestive Heart Failure, End Stage Renal (kidney disease), and Acute Pulmonary Edema. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R617 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 15, out of a total possible score of 15. In an interview on 3/20/24 at 3:11p.m., CNA F reported call lights are answered as soon as possible. In an interview on 3/20/24 at 3:16 p.m., CNA E reported call lights should be answered within 15 minutes. In an interview on 3/20/24 at 4:23 p.m., the Director of Nursing (DON) reported call lights can be answered by all staff. The DON then reported call light should be answered in at least 15 minutes. Review of a Call light Policy revised 2/17/20 documented, It is the policy of this facility to answer call lights as promptly as possible. Procedure 1. Call lights should be answered by available staff as promptly as possible .

This citation pertains to Intake MI00141842 and MI00142000. Based on observation, interview and record review, the facility failed to ensure pressure ulcer treatments were consistently provided as ordered for one (R616) out of three residents reviewed for pressure ulcers. Findings include: Review of an Admission Record revealed, R616 readmitted to the facility on [DATE] with pertinent diagnoses which included Pressure Ulcer of Sacral Region Stage 3 (full-thickness skin loss potentially extending into the subcutaneous tissue layer) and Type 2 Diabetes. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R616 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 15, out of a total possible score of 15 and had a stage 4 pressure ulcer (exposing underlying muscle, tendon, cartilage or bone) that was not present on admission. Review of Physician orders revealed R616 had orders to treat the left ischial every day shift, which was last revised on 2/6/24. Review of a Treatment Administration Record (TAR) for December through March 2024 revealed treatment to the left ischial was not documented on 12/1, 12/4, 12/6, 12/7, 12/8, 12/11, 12/20, 1/4, 1/5, 1/9, 1/11, 2/6, 2/9, 3/8, and 3/16/24. In an observation on 3/20/24 at 7:46 a.m. R616 had a small open area on the left ischial. In an interview on 3/20/24 at 8:05 a.m. Wound Nurse A reported the nurses are responsible for wound care when the wound nurse is not present. In an interview on 3/20/24 at approximately 3:30 p.m., Staff Development Coordinator (SDC) B reported unit managers and nurses are responsible for wound care when the wound nurse is not present. In an interview on 3/20/24 at 4:19 p.m. the Director of Nursing (DON) reported the floor nurses and unit managers are responsible for wound care when the wound nurse is not present.

Based on observation, interview and record review, the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting all residents who receive oral food meal services out of the facility's total census of 116 residents. Findings include: 1. On 5/16/23 at 10:32 AM, Cook, staff C, was observed donning gloves prior to washing their hands after touching refrigerator door handles, prep counters, the upright stove door handles and baking sheets. On 5/16/23 at 10:44 AM, staff C, was observed donning gloves prior to washing their hands after touching their clothing, refrigerator door handles, thermometers, and food prep counters. On 5/16/23 at 10:36 AM, 11:29 AM, and at 11:33 AM, staff C was observed not washing their hands between removing and donning gloves while conducting food preparation. On 5/16/23 at 11:39 AM, surveyor inquired with the Dietary Supervisor, staff A, on the hand hygiene expectations for staff when they choose to use gloves as a hand barrier to which they replied, wash their hands before they put them on. At this time the surveyor requested the facility's hand hygiene policy to review to which staff A replied, they know what to do, but I'm still working on updating our written policies, so right now I've been verbally educating my staff on this, not just the newer ones. Review of the U.S. Public Health Service 2017 Food Code, Chapter 2-301.14 When to Wash directs that: FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLEUSE ARTICLES and: and contamination and to prevent cross contamination when changing tasks; (H) Before donning gloves for working with FOOD; and (I) After engaging in other activities that contaminate the hands. 2. On 5/17/23 between 11:18 AM and 1:04 PM, the walls and ceiling in and around the dish machine area and janitor's closet were observed damaged with peeling paint, open drill holes from attaching previous shelving units and equipment, and with dark staining in multiple locations. Additionally, during this time frame multiple ceiling and wall tiles were observed missing in the kitchen's janitorial closet. On 5/17/23 at 11:49 AM, the surveyor inquired with Dietary Supervisor, staff A, on the current state of the ceiling and walls in the kitchen and its support spaces to which they stated, there have been several work orders placed with maintenance since I've been here, but I do know they are very busy. Review of the U.S. Public Health Service 2017 Food Code, Chapter 6-101.11 Surface Characteristics, directs that: (A) Except as specified in (B) of this section, materials for indoor floor, wall, and ceiling surfaces under conditions of normal use shall be: (1) SMOOTH, durable, and EASILY CLEANABLE for areas where FOOD ESTABLISHMENT operations are conducted;

This citation pertains to MI 859 and MI 861. Based on observation, interview, and record review, the facility failed to prevent development of a pressure ulcer (open area on skin) for one resident (Resident #602) of three residents reviewed for pressure ulcers, resulting in a Stage 4 pressure ulcer, infection, and the potential for continued skin breakdown. Findings include: Review of a Pressure Ulcer & Skin Management policy with no implementation date revealed, A resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the resident's clinical condition demonstrates that they were unavoidable; and a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and reduce the risk of new pressure ulcers developing . Resident #602 Review of an Admission Record revealed, Resident #602 admitted to the facility with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment, with a reference date of 10/9/21 revealed Resident #607 had severe cognitive impairment and had a unstageable pressure ulcer. In an observation and interview on 11/8/21 at 3:15 p.m., Resident #602 laid in bed. Wound Nurse C prepared to perform wound care for Resident #602. Resident #602 had a large open area on the buttocks. Wound Nurse C reported Resident #602 had wound treatments twice a day. Review of an Weekly Head-to-Toe assessment with a date of 8/4/21 revealed, Resident #602 did not have a open area on the buttocks (sacrococcyx). Review of an Braden Scale (predicting pressure sore risk) assessment with a date of 8/4/21 revealed, Resident #602 had a score of 10.0 which indicates high risk for skin breakdown. Review of a Progress Note with the date of 8/7/21 at 7:26 p.m. revealed, Upon rounding when beginning shift writer entered room and cna asked writer to look at resident buttock /coccyx area, small fluid filled blisters were noted . Review of an Weekly Head-to-Toe assessment with a date of 8/7/21 revealed, Resident #602 had a blister on the coccyx. Review of an Weekly Wound Healing Record with a date of 8/18/21 revealed, Resident #602 had a unstageable pressure ulcer on the sacrum (between hip bones) acquired on 8/13/21. On 11/4/21 Resident #602 had a Stage 4 pressure ulcer on the Sacro coccyx/bilateral buttocks. Review of a Progress Note with the date of 8/26/21 at 6:53 p.m. revealed, Resident was seen by wound care team R/T (related to) weekly wound assessment and Tx (treatment). Writer and wound care NP (Nurse Practitoner) observed an unstageable pressure ulcer with obscured (not clear) full thickness to skin and tissue loss, a large amount of sero-sanguineous (blood and clear liquid) drainage . Review of a Progress Note with a date of 8/27/21 at 1: 50 a.m. revealed, Resident to start ABT (antibiotic) [MEDICATION(S)] for infection to wound on coccyx . Review of Physicians order revealed, Resident #602 had an order Sacro coccyx/Bilateral Buttocks cleanse with dakins 1/4 strength pat dry apply dakins 1/4 strength soaked gauze to area then apply 4*4 cover with border gauze every day and night shift for wound care AND every 8 hours as needed with a start date of 11/4/21. Review of a Treatment Administration Record (TAR) for August through November 2021 revealed, Resident #602 did not receive wound care per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 11/9/21 at 10:26 a.m., Wound Nurse C reported when a resident has twice a day dressing changes the assigned nurse is responsible for the scheduled wound treatment. In an interview on 11/10/21 at 11:19 a.m., Wound Nurse C reported Resident #602's pressure ulcer started off with redness and a blister. Wound Nurse C then reported the area opened a couple of days later. Wound Nurse C reported interventions should have been put in place when the redness was noticed. In an interview on 11/10/21 at 11:42 a.m., Director of Nursing (DON) B reported Resident #602 had a blister before the pressure ulcer. DON B stated, We don't know what's going on in his body to cause the issues, regarding the development of Resident #602's Stage 4 pressure ulcer. In an interview on 11/10/21 at 12:54 p.m., DON B reported Resident #602's blister was noticed on 8/7/21. On 8/18/21 the area was classified as an unstageable pressure ulcer. DON B' then reported Resident #602's open area was classified as a Stage 4 pressure ulcer on 10/28/21. In an interview on 11/10/21 at 1:02 p.m., DON B reported the assigned nurse is responsible for night wound treatments for Resident #602.

This citation pertains to intakes MI 414 and MI 32. Based on observation, interview and record review the facility failed to prevent physical abuse, effecting one resident (R#115) out of nine residents reviewed for abuse, resulting in a traumatic hematoma of R#115's lower left leg, and evolving into a chronic vascular ulcer (an opening related to decrease circulation). Findings include: Review of statement dated 12/5/20 at 8:20 am and signed by Administrator V documented: Administrator met the resident to discuss the incident that he had encountered with the cena (competency evaluated nursing assistant), the resident indicated he was up in his wheelchair in his room drinking water and then the cena pushed his wheelchair into the bed and his left leg hit the metal on the bed and patient sustained a skin tear to left lower front of leg. Review of Minimum Data Set (MDS) dated [DATE], revealed R#115 had intact cognition. Review of Wound Progress Notes dated 10/13/20, noted at bottom of page Pt (patient) has no wounds. Review of hospital documents revealed an admission to local hospital on 12/5/20 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R#115 then was transferred to another hospital for examination by their trauma department. Resident then received and incision and drainage procedure. On 12/18/20 it was documented The patient was noted to have a left lower extremity wound, which measures 19 cm (centimeters) in length x 9 cm in width x 2 cm in depth. Review of Separation Notice dated 12/7/20 revealed Certified Nursing Assistant (C.N.A. U) was relieved of employment at facility related to Category 3 Work Rules which documented, .These offenses are most serious, and violations will subject an employee to immediate suspension without pay pending an investigation and, if verified, will lead to termination. #38. Employees may not physically, verbally, emotionally, or psychologically abuse a resident, visitor, or another employee or engage in a serious violation of a resident's rights. During observation on R#115's room on 5/4/21 at 10:05 AM, resident had an open wound on left lower extremity measured by Registered Nurse (RN C) at 16 cm (length) by 11 cm (width) by 0.2 depth. Review electronic medical records revealed R#115 had been originally admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS dated [DATE], R#115 had intact cognition and was extensive assist with Activities of Daily Living (ADLS). In an interview with Acting Director of Nursing (RN E) on 5/4/21 at 10:30 AM it was reported that According to the documentation by Administrator V the incident did happen, RN E reported that C.N.A. was let go related to Work Rule #38. Review of facility's Abuse and Neglect Prohibition policy documented: Each resident has the right to be free from abuse, mistreatment, neglect, exploitation, involuntary seclusion, misappropriation of property and mental abuse facilitated or enabled through the use of technology. Each resident will be free from chemical or physical restraints imposed for purposes of discipline or convenience that are not required to treat resident symptoms.

This citation has two Deficient Practice Statements (DPS). DPS#1 pertains to intakes: MI 303, MI 717, MI 821, MI 414. Based on observation, interview, and record review, the facility failed to conduct wound care assessments and treatments in accordance to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R#114: During an observation and interview on 5/3/21 at 12:30 PM R#114 was observed laying semi-upright in her bariatric bed, with a soiled brief. During interview R#114 said, I have been left wet for long periods of time and now I have a bed sore on my backside. The resident went on to say, I'm not getting my bedsore treated every other day, like I'm supposed to. They say they do not have enough staff to help turn and reposition me. The wound care doctor comes on Wednesday and she doesn't do my wound care because there aren't enough people to help her. R#114 was noted to have an abdominal pannus (flaps of tissue, or an apron of lower abdominal skin and fat) that were reddened with orange peel textured skin and weeping clear yellow fluid. Both pannus areas are laying on blue absorbent incontinence pads that were saturated with clear yellow fluid. There were no dressings on the pannus areas. The left pannus had multiple nickel-sized open ulcerated areas with yellow slough over them. According to the R#114's Minimum Data Set (MDS), dated [DATE] the resident has resided at the facility since 2016 with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated that R#114 had no cognition deficits, was totally dependent on two or more staff for all ADLs. R#114 was identified to be 'always' incontinent of bowel and bladder. The MDS indicated that R#114 had no pressure ulcers, no open [CONDITION(S)], and did not have any moisture associated skin disorder (MASD). According to the care plan for 'actual skin impairment' initiated on 10/2/2019 the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included the following; pressure reducing mattress, keep skin clean and dry, use lotion, observe and document the location of any skin impairment and report to nurse as soon as possible, and use a draw sheet to reposition resident. A review of R#114's electronic medical record revealed that on 1/16/21 the physician ordered a 'wound care consult' for left buttock wound. There are no additional progress notes, skin assessments, or orders until 2/20/21. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to R#114's February 2021 and March 2021 Treatment Administration Records (TAR), the resident did not receive four of 12 prescribed treatments (2/23, 2/24, 2/28, 3/1). A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1) Cleanse left lateral gluteal with Dakin's solution or soap and warm water, pat dry, cover with opticel 4 x 4 gauze and large border gauze every other day shift. 2) Cleanse left medial gluteal with Dakin's solution or soap and warm water, pat dry, cover with opticel 4 x 4 gauze and large border gauze every other day shift. 3) Cleanse right gluteal with Dakin's solution or soap and warm water, pat dry, cover with opticel 4 x 4 gauze and large border gauze every other day shift. 4) Cleanse right lateral pannus with Dakin's solution or soap and warm water, pat dry, apply Dakin's-soaked gauze cover with 4x4 and ABD pads every other day shift. According to R#114's March 2021 Treatment Administration Records (TAR), the resident did not receive 8 of 14 prescribed treatments on all four areas (3/5, 3/9, 3/11, 3/15, 3/19, 3/23, 3/29, 3/31). According to R#114's April 2021 TAR, the resident did not receive 11 of 15 prescribed treatments on all four areas (4/2, 4/4, 4/6, 4/14, 4/16, 4/18, 4/20, 4/24, 4/26, 4/28, 4/30). A review of the Wound Care Progress Notes, dated 3/10/21, 3/12/21, and 3/24/21, document that the R#114's 1) Left gluteal is to be treated with calcium alginate to the wound bed. 2) Right lateral pannus is to be treated with [MEDICATION(S)] and calcium alginate. 3) Left lateral pannus is to be cleansed with Dakin's solution and calcium alginate applied to the wound bed. The last 'Wound Care Progress Note' in the electronic medical record was dated 4/14/21. According to that progress note, R#114's Left gluteal abrasion and Left pannus area are to be treated with [MEDICATION(S)] and border gauze applied every other day. A continued review of R#114's electronic medical record, including the physician orders, progress notes, medication administration records, and TARs for March 2021, April 2021, and May 2021 revealed these skin treatment orders were never processed, transcribed to the TAR, nor administered to the resident. During an interview on 5/5/21 at 9:00AM, Licensed Practical Nurse (LPN) C and the Physician Assistant for Wound Care (PA) Y, PA Y confirmed that the last time she had seen R#114's wound was on 4/14/21, three weeks ago. PA Y said that R#114 often refuses her wound care treatments and there isn't enough staff to assist with turning the resident. At this time R#114 was interviewed about wound care along with PA Y and LPN C. The resident readily agreed to wound care assessment and treatment. R#114 said that she does not refuse wound care treatments every time. It's only because they do not have enough staff to help turn and hold me over during the treatment that it does not get done. During observation of R#114's wound care on 5/5/21 at 9:20 AM with LPN C, PA Y, CDON E, and five additional nursing staff members to assist in turning the resident, the resident's left lateral posterior thorax area had a border gauze dressing that was saturated with bloody foul-smelling drainage. The date on the dressing was not discernable. PA Y and LPN C confirmed that this is the area identified as the 'left lateral gluteal area' on the progress notes. The resident's bottom sheet had a large wet ring of reddish-brown drainage under her left lateral back side, soaking half of the sheet. The resident's mattress was also wet with multiple dried white rings on it. PA Y cleaned the left posterior wound and revealed a large skin abrasion or MASD area with multiple small open areas that were draining large amounts of serosanguinous fluid (clear liquid tinged with blood). PA Y said that the left posterior area had increased in size since she had last observed it. The resident was extremely edematous with [CONDITION(S)] on her abdominal and bilateral lower extremeties. The resident's left pannus area was observed to be wet with clear pale-yellow drainage weeping from the underside and outside edge of the skin flap. PA Y confirmed R#114's left pannus area had also deteriorated since her last visit on 4/14/21. There were several nickel-sized open areas covered with a light-yellow slough (compromised of dead skin cells, white blood cells, and debris). PA Y said she would be changing the treatment orders for R#114 to include 'med honey' and 'calcium alginate' on the left lateral pannus area. During an interview with PA Y on 5/5/21 at approximately 9:50 AM she confirmed she had not seen R#114 since 4/14/21, three weeks earlier. PA Y could not recall what treatments she had ordered last, and wrote the incorrect date of 4/28/21 on today's (5/5/21) wound care observation note. R#115 Review of statement dated 12/5/20 at 8:20 am and signed by Administrator V documented: Administrator met the resident to discuss the incident that he had encountered with the cena, the resident indicated he was up in his wheelchair in his room drinking water and then the cena pushed his wheelchair into the bed and his left leg hit the metal on the bed and patient sustained a skin tear to left lower front of leg. Review of hospital documents revealed an admission to local hospital on 12/5/20 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R#115 then was transferred to another hospital for examination by their trauma department. Resident then received and incision and drainage procedure. On 12/18/20 it was documented The patient was noted to have a left lower extremity wound, which measures 19 cm (centimeters) in length x 9 cm in width x 2 cm in depth. Observation of R#115 on 5/4/21 at 9:00 AM in Hall 500. Resident was seen ambulating in wheelchair down hall. Resident had a large bandage macerated with soft ball sized dark green drainage in center of bandage. Bandage was dated 4/28/21. Resident reported that bandage had not been changed in days. On 5/4/21 at 10:05 AM, observation of wound care was observed in R#115's room. Registered Nurse (RNC) confirmed date on bandage was 4/28/21. RNC confirms that residents bandages should be changed as ordered by the physician. RNC confirms wound order should be completed daily. It was observed that resident had, an open wound on left lower extremity measured by Registered Nurse (RN C) at 16 cm (length) by 11cm (width) by 0.2 depth. Wound bed was pink and had intact perimeter. Drainage was green purulent drainage with a putrid odor. RNC reported when I am not here wound treatment should be administered by nurse on floor. Interview with Acting Director of Nursing (RN E) on 5/4/21 at 10:30 AM, RN E confirmed residents wounds should be changed as ordered. RN E confirmed date on bandage as 4/28/21. RN E confirmed from documentation that this area was originally from incident on 12/5/20. Record review of Treatment Administration Record (TAR) revealed order [MEDICATION(S)] Solution 0.25%. Apply to Left lower lateral extremity topically every day shift. Review of April 2021 TAR and May 2021 TAR revealed no documentation completing ordered wound care from 4/29/21 through 5/3/21. DPS #2 This citation pertains to MI 663 and MI 550,MI 423. Based on interview and record review the facility failed to consistently: 1.) assess and monitor a resident after a fall. 2. assess blood sugars as ordered in 1 of 3 residents (R#121) reviewed for quality of care, resulting in the potential for missed opportunities to assess and monitor abnormal changes of condition, and provide treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: Review of Progress notes dated 4/23/21 at 12:41 AM, documented, Nurse on duty was notified that the resident was observed on floor.Started neuro checks. (Tool used to assess and monitor for changes in brain condition) Review of Neurological assessment dated [DATE] at 12:00 AM and Neurological assessment dated [DATE] at 14:31 (2:31 PM) revealed these were the only neurological assessments that were completed after R#121's fall. In an interview Interview with Social Worker R reported, R#121's blood sugar on admission to the hospital was 386 (abnormal high blood sugar). Review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Licensed Practical Nurse/ Unit Manager (LPN W) on 5/6/21 at 11:46 AM, LPN W reported the doctor gave an order to start neuro checks for 24 hours. LPN W stated, Neuro checks after a fall is protocol. LPN W confirms that physician was called, and order was not put into electronic chart. LPN W stated, I told nurse verbally to start neuro checks. Interview with Director of Nursing (DON BB) on 5/6/21 at 11:50 AM, DON BB confirms R#121's blood sugar was not completed and should have been documented on 4/26/21 at 8:00AM. DON BB stated, If Neuro checks are ordered by a physician, they should be done. DON reported that neuro checks were not completed by nursing staff for R#121 as per protocol when ordered by physician. Review of Neuro Checks (no date) documented the following: Purpose: A neurological assessment establishes a baseline, recognizes neurological trends, and changes in the resident's condition, and provides an evaluation tool for reference when evaluating the resident's neurological status. Fundamental Information: neurological assessment is a simple, quick assessment tool used in combination with a complete neurological examination. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This is performed by a licensed nurse.

Based on observation, interview and record review, the facility failed to: 1.) perform wound care per physician't orders, 2.) provide care to prevent the development and/or worsening of pressure ulcers, consistent with professional standards of practice, and 3.) perform wound care timely to increase opportunties for healing a pressure ulcers for 5 out of 11 residents (Resident #105, #109, #107, #102 and #103) reviewed for pressure injuries, resulting in the worsening of a pressure ulcer for Resident #105, the development of avoidable pressure ulcers, feelings of embaraassment, and the potential for infection and overall deterioration in health status. Findings include: Review of the facility policy Pressure Ulcer Preventative Measures (no date) revealed, Policy-Residents at risk for the development of pressure ulcers receive interventions to reduce the risk of pressure ulcers. Procedure-1. Maintain or improve current activity level, mobility, and range of motion. 2. Residents should be monitored during care and consistently by licensed nurses to identify potential areas for skin breakdown and integrity of overall skin. 3. The nurse aide inspects the resident's skin during bathing, dressing and undressing, assisting with toileting or incontinent care. 4. The nurse aide reports to the nurse any reddened areas and/or breaks in the resident's skin. 5. The nurse inspects any reddened areas and/or breaks in the resident's skin and documents the inspection. 6. Clean skin at routine intervals and after each incontinence .9. Minimize skin exposure to moisture due to incontinence, perspiration, or wound drainage .13. Minimize skin injuries due to friction and shear through proper position, transfer and turning techniques. 14. Establish a repositioning schedule .reposition bed and chair bound residents at least every two hours. 15. For residents in bed, use positioning devices, such as pillows or foam wedges to keep bony prominences (knees or ankles) from direct contact with one another. 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 .18. Use pressure redistribution .23. Document approaches and interventions on the care plan. Resident #105 Review of a Face Sheet revealed Resident #105 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of 6/11/21 revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, which indicated Resident #105 was moderately cognitively impaired. Review of the Functional Status revealed that Resident #105 required extensive 1 person physical assist for bed mobility, toileting and personal hygiene and total dependence of 2 persons for transferring. Review of Resident #105's Braden Scale dated 6/29/21 revealed, Resident #105 was at risk for the development of pressure ulcers. (Used to determine the risk of skin breakdown). Review of Resident #105's Care Plan revealed, I need assistance with my ADL's (Activities of Daily Living) r/t (related to) MS ([CONDITION(S)]) . BED MOBILITY: I require extensive x1 assistance by staff to turn and reposition me frequently while in bed .I have limited physical mobility MS diagnosis .assist me with mobility as needed. Date Initiated .I have a Pressure Ulcer (SPECIFY location), Immobility, MS .I need assistance to turn/reposition at least every 2 hours, more often as needed or requested . Review of Resident #105's Kardex revealed, .I need assistance to turn/reposition at least every 2 hours, more often as needed or requested .BED MOBILITY: I require extensive x1 assistance by staff to turn and reposition me frequently while in bed . Review of Resident #105's Physician Orders and Care Plan revealed no documentation that Resident #105 was to remain in bed throughout the day. During an interview on 07/12/2021 at 3:36 P.M., Resident #105 reported that she had [CONDITION(S)] (MS) and did not have her wheelchair at the facility. Resident #105 reported that she had been using a facility wheelchair, but it was no longer available for her to use. Resident #105 reported that her MS had increased to the point where she could no longer walk and had little ability to move self in her bed. Resident #105 began to cry and reported her bottom was painful, and she had pressure ulcers. Resident #105 reported that she is left in bed all day and it had caused her to have an increase in her pain levels on her buttocks. Resident #105 reported that she wanted to be up in a wheelchair or chair. Review of Resident #105's room revealed no gerichair or wheelchair in Resident #105's room or in the hallway. Review of Resident #205's Physician Order with a start date of 7/7/21 revealed, Right Glut (buttock) cleanse area with NS (Normal Saline), pat dry, apply [MEDICATION(S)] (wound treatment), cover with border gauze every day shift for wound. Review of Resident #105's July Treatment Administration Record printed on 7/13/21 revealed, Right Glut cleanse area with NS, pat dry, apply [MEDICATION(S)], cover with border gauze every day shift for wound care. There were no initials in the box for 7/10/21, 7/11/21, or 7/12/21 indicating the treatment was not completed. During an observation on 07/12/2021 at 4:22 P.M., Resident #105 wound care was performed. Resident #105 required the assistance of 2 staff to reposition her on her side during the wound care. Licensed Practical Nurse (LPN) O removed the soiled bandages and discarded the bandages into the waste basket. LPN O did not perform hand hygiene or don new gloves and then cleansed the wound with 4x4 gauze and normal saline. The wound did not appear to have drainage and the wound bed appeared to have healthy tissue. LPN O did not perform hand hygiene and did not don clean gloves after cleansing the wound. LPN O then put [MEDICATION(S)] on the border gauze and placed it on Resident #105's right buttock. LPN O did not put [MEDICATION(S)] on 4x4 gauze and pack the wound. During an observation and interview on 07/14/2021 at 6:40 A.M., Resident #105 was in bed with the head of the bed greater than 45 degrees. Resident #105 did not have any pillows behind her to offload pressure to her buttocks. Resident #105 reported that her bottom was sore and reported she would like to be out of bed. During an observation and interview on 07/14/2021 at 8:13 A.M., WPA Y was completing wound assessment and dressing change on Resident #105. WPA Y reported that [MEDICATION(S)] should be applied to a 4x4 (gauze pad) and packed in the wound to ensure the [MEDICATION(S)] reached the wound bed. WPA Y reported that the [MEDICATION(S)] should not be placed on the border dressing and then placed on the resident. WPA Y removed Resident #105's border dressing on the right buttock and yellow purulent drainage was noted to be draining from the wound. WPA Y measured the wound and determined it was 3.2 (height) by 10.2 (width) by 7.0 (depth). WPA Y reported that there was muscle tissue visible. WPA Y reported that because of the noted drainage she would begin an antibiotic for Resident #105 and the wound cleaning would now be done with Dakins solution (made from bleach used as strong antiseptic to kill bacteria) and no longer normal saline. Resident #105 reiterated that she wanted to get out of bed and in a wheelchair. During an interview on 07/14/2021 at 7:42 A.M., Wound Physician Assistant (WPA) Y reported that Resident #105 should be getting out of bed and should not remain in bed all day. WPA Y reported no order had been written for Resident #105 to remain in bed. WPA Y stated she would never restrict anyone to bed and increased mobility improves the outcome for wounds. WPA Y reported that she had ordered to have labs drawn on 7/7/21 for Resident #105 and it was not completed. During an interview on 07/14/2021 at 12:45 P.M., Director of Nursing (DON) B reported that Resident #105 had utilized a gerichair while she had been a resident at the facility. DON B reported that she would ensure the resident would get a gerichair in her room. During an interview and observation on 07/14/2021 at 12:46 P.M., Resident #105 was in bed on her back with no repositioning devices behind her to offload pressure. Resident #105 reported that she had not had a gerichair while she had been at the facility but did a have a wheelchair to use at one point. Resident #105 stated, I've been laying here like a dead person. Reported she had been wanting to get up but has not had assistance to do so. DON B entered Resident #105's room and verified that Resident #105 did not have a wheelchair or gerichair available to her in the room. During an interview on 07/14/2021 at 12:33 P.M., LPN J reported that Resident #105 used to have a gerichair in her room and Resident #105 would get up in it. Resident #109 Review of a Face Sheet revealed Resident #109 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #109, with a reference date of 6/25/21 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #109 was cognitively intact. Review of the Functional Status revealed that Resident #109 required extensive 1 person physical assist for bed mobility, transferring, dressing, toileting, and personal hygiene. Review of Resident #109's Braden Scale dated 7/6/21 revealed that Resident #109 was At Risk of the development of a pressure ulcer/skin breakdown. Review of Resident #109's Care Plan revealed, I am incontinent of Bowel and/or Bladder (SPECIFY) Date Initiated: 06/22/2021 . My skin will not become impaired r/t (related to) incontinence by next review Date Initiated: 06/22/2021 . Check me at least every two hours during the day and change my brief if needed. Date Initiated: 06/22/2021 . During an interview on 07/12/2021 at 12:17 P.M., Resident #109 reported that she had been incontinent of stool and had to wait nearly 1 hour for assistance. Resident #109 was unable to ambulate to the bathroom and clean herself up. Resident #109 relied on the assistance from staff for episodes of incontinence. During an observation and interview on 07/13/2021 at 9:39 A.M., Resident #109's call light was turned on. Resident #109 was in her bed crying loudly and appeared anxious and uncomfortable. Resident #109 reported that she had had turned her call light on before her incontinence episode because she needed to have a bowel movement but no staff came to assist her at that time which caused her to be incontinent. Resident #109 reported that she had her call light on for quite some time after she was incontinent of stool. There was a strong odor of stool in the room. Certified Nursing Assistant (CNA) T entered the room and shut off the call light and reported to the resident that she would be assisted after CNA T completed care with a different resident. Resident #109 reported feelings of embarrassment and disgust. At 9:51 A.M. CNA Q entered the room and exited to obtain supplies and assistance with care. Resident #109 was assisted at 10:03 A.M. (approximately 24 minutes). Resident #109 was assisted with incontinence care and the stool had overflowed from her brief (in the front of her brief and out of the sides) and was on her bed pad and her sheets. Residents entire buttocks was bright red and her left upper inner gluteus had 2 small, pencil eraser size open areas. CNA T verified that there were open areas on Resident #109's left upper inner glut. During an interview on 07/14/2021 at 2:10 P.M., Wound Physician Assistant (WPA) Y reported that she assessed Resident #109's buttocks and noted some minor breakdown on Resident #109's buttocks. WPA Y reported that she ordered a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #107 Review of a Face Sheet revealed Resident #107 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Minimum Data Set (MDS) assessment for Resident #107, with a reference date of 6/16/21 revealed a Brief Interview for Mental Status (BIMS) score of 0, out of a total possible score of 15, which indicated Resident #107 was severely cognitively impaired. Review of the Functional Status revealed that Resident #107 required extensive 2 person physical assist with bed mobility and personal hygiene, total dependence of 2 persons for transferring, and extensive 1 person assist with toileting. Review of Resident #107's Braden Scale revealed that Resident #107 was at High Risk for the development of a pressure sore. Review of Resident #107's Care Plan revealed, I have increased potential for skin alteration r/t (related to) Bowel/Bladder incontinence and decreased/impaired mobility d/t (due to) residual deficits from a prior CVA (stroke) with [CONDITION(S)] (one sided weakness) &Dx of DM (and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] @ right heel r/t recently healed wound. I have fragile skin@ buttocks r/t prior area of PU (pressure ulcer)(healed) I require extensive to max staff assistance for all eliminations, hygiene & turning/repositioning tasks Date Initiated: 09/27/2019 . Place a pressure reducing cushion in my chair and observe the condition of my pressure reducing mattress - report if replacement is needed .BED MOBILITY: I require extensive to total assistance by staff to turn and reposition me in bed at least every 2 hours as tolerated & prn (as needed) Date Initiated: 09/30/2014 . During an observation on 07/12/2021 at 12:16 P.M., Resident #107 was in bed on her back. There were no pressure relieving devices in place. Resident #109 did not have a pressure reducing mattress. During an observation on 07/12/2021 at 12:50 P.M., Resident #107 was in bed on her back. There were no pressure relieving devices in place. During an observation on 07/12/2021 at 2:13 P.M., Resident #107 was in bed on her back. There were no pressure relieving devices in place. During an observation on 07/12/2021 at 4:48 P.M., Resident #107 was in bed on her back. There were no pressure relieving devices in place. During an observation on 07/13/2021 at 4:21 P.M., Resident #107 did not have a pressure reducing mattress. During an interview on 07/14/2021 at 7:34 A.M., Certified Nursing Assistant (CNA) H reported that Resident #107 did not have a pressure reducing mattress in place. CNA H reported that facility staff assist Resident #107 with repositioning. During an interview on 07/14/2021 at 12:33 P.M., Licensed Practical Nurse J reported that Resident #107 did not have a pressure reducing mattress in place. During an interview on 07/12/2021 at 4:42 P.M., Assistant Director of Nursing (ADON) C reported that all immobile residents are on an every 2 hour repositioning schedule based on standards of practice. During an interview on 07/14/2021 at 12:38 P.M., Infection Preventionist (IP) M reported that any resident in bed or immobile must be repositioned at least every 2 hours. Resident #102 Review of a Admission Record revealed Resident #102 was a [AGE] year-old, with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #102 payer source was Medicaid. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 5/25/21 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #102 was cognitively intact. According to the Medicaid Provider Manual dated July 1, 2021, Per Medicare guidelines, the term room and board in a (Nursing Facilities) NF includes the performance of personal care services that a family caregiver would provide if the individual were at home. This includes assistance in the activities of daily living such as bathing, grooming, toileting, dressing, meal service, socializing, companionship, hobbies, administration of medication, maintaining the cleanliness of the beneficiary's bed and room, and supervising/assisting in the use of durable medical equipment (DME) and prescribed therapies (e.g., range of motion, speech and language exercises) . Hospice covered beneficiaries residing in the NF must not experience any lack of NF services or personal care due to their status as a hospice beneficiary. NFs must offer the same drugs, services, medical supplies and DME to all residents who have elected the hospice benefit in the same manner that services are provided to other residents in the facility who have not elected hospice care. If a service is normally furnished as part of the facility's per diem, the service must also be provided to hospice beneficiaries. If services are provided for needs associated with a non-terminal illness and are normally furnished and billed by another provider, that practice would continue. In an interview on 7/13/21 at 2:55 PM, Nursing Home Administrator (NHA) AA Business Office Manager (BOM) EE and FF reported that Hospice covers the physician visit cost for the wound care visits for Resident #102. In an interview on 713/21 at 1:20 PM, Hospice Nurse (HN) BB sees (Resident #102) every other week on a Monday or Tuesday and the other Hospice nurse will see him on the other week. HN BB reported that Resident 102 had a bunch of wounds on his glut (bottom) the last time she looked at his wounds and the orders were changed, due to the [MEDICATION(S)] not helping. HN BB stated that there was a wound team that follows the resident, but the wound team only follows once a month and that is all that hospice will allow, I am not sure who pays for it wound physician, but if they are on Hospice, they are only be seen once a month by a wound doctor. HN BB reported that when residents sign up for Hospice, there blood draws are no longer covered, Hospice will only cover pain meds and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 12/14/21 at 11:40 PM, Physician Assistant Wound Consultant (PAWC) Y stated I really need to see (Resident #102) weekly, and he needs to have that area by his coccyx debrided to promote wound healing, and the wound treatment to be changed for the gluteal area needs to be changed to [MEDICATION(S)] with calcium alginate so he has less moisture. In an interview on 7/12/21 at 1:20 PM, Resident #102 was sitting in his bed he was in a T-shirt and a brief and reported that his wounds are not healing now they are down to the bone, they have been debrided (removed damaged tissue) too many times due to them being necrotic. Resident #102 reported that he will stay up in his wheelchair a couple hour then transfer back to bed, he reported that his dressing to his coccyx and sacral wounds was changed once a day. Resident #102 reported that he wakes up every morning in fluid from the wounds the CNA's will put a dry brief on him, but the nurse will not change the dressing. Resident #102 reported that he has not refused to have his dressing changed. In an interview on 7/12/21 at 1:40 PM, Licensed Practical Nurse (LPN) N reported that Resident #102 got out of bed just before lunch and she would change his dressing when he got back in bed, LPN N stated he never refuses dressing changes. In an interview on 7/13/21 at 11:12 AM, LPN J reported that she had been doing wound rounds for the past few week, because the wound nurse was on medical leave. LPN J reported that on 7/7/21 she requested that the order for his wound treatment be changed because he was not healing and called Hospice to order something that would promote healing. LPN J reported that the other order had been in place for a while, referred to orders 6/5/21. Review of the Treatment Administration Record (TAR) dated June 2021, revealed 1 incomplete out of 25 opportunities incomplete for an order dated 6/5/21 cleanse right gluteal with wound cleanser or soap and warn water, pat dry pack wound with [MEDICATION(S)] (medication to help treat wound infection) cover with 4x4 and ABD every day shift (no documented refusal noted). Cleanse right gluteal with wound cleanser or soap and warm water, pat dry pack wound with [MEDICATION(S)] cover with 4x4, and ABD as needed. (No documentation that any wound care was completed as needed). Review of the TAR dated June 2021, revealed 1 incomplete of 25 opportunities for an order dated 6/5/21 Cleanse left gluteal with wound cleanser or soap and warm water, pat dry pack wound with [MEDICATION(S)] cover with 4x4, and ABD every day shift. Cleanse left gluteal with wound cleanser or soap and warm water, pat dry pack wound with [MEDICATION(S)] cover with 4x4, and ABD as needed. (No documentation that nay wound care was completed as needed.) Review of the TAR dated June 2021, revealed 1 incomplete of 25 opportunities for an order dated 6/5/21 Cleanse right gluteal with wound cleanser or soap and warm water, pat dry pack wound with [MEDICATION(S)] cover with 4x4, and ABD every day shift. Review of the TAR dated June 2021, revealed 3 out of 12 opportunities were incomplete for wound care on coccyx area. Review of the TAR dated July 2021, revealed 3 out of 12 opportunities were incomplete for wound care on the left and right gluteal area. Review of the TAR dated July 2021, revealed no opportunities for as needed wound care had been provided to Resident #102 as of 7/12/21. Review of the Weekly Wound Healing Record - dated 6/10/21, Left Glut, overall impression, unchanged, slough tissue present, moist, 15.2 cm x 11.8 cm edges intact, [MEDICATION(S)] treatment. Review of the Weekly Wound Healing Record - dated 6/17/21, Left Glut, overall impression, worsening, moist, odor, 16.1 cm x 12. cm x 3.6 cm edges intact, [MEDICATION(S)] treatment. Review of the Weekly Wound Healing Record - dated 6/23/21, Left Glut, overall impression, worsening, necrotic tissue present (30 % necrotic), 16.0 cm x 12.0 cm x 3.6 cm edges intact, [MEDICATION(S)] treatment. Review of the Weekly Wound Healing Record - dated 6/30/21, Left Glut, overall impression, unchanged, slough tissue present, necrotic tissue present (30 % necrotic), 16.1 cm x 12.1 cm x 3.6 cm edges intact, [MEDICATION(S)] treatment. Review of the Weekly Wound Healing Record - dated 7/7/21, Bilateral Glut, overall impression, worsening, moist, 21.8 cm x 19.2 cm edges intact, plan to change treatment. Review of the Weekly Wound Healing Record - dated 6/10/21, Right Glut, overall impression, unchanged, slough tissue present, moist, serosangenous drainage, 11.4 cm x 12.6 cm edges intact, [MEDICATION(S)] treatment. Review of the Weekly Wound Healing Record - dated 6/17/21, Right Glut, overall impression, epithelial tissue, moist, serosangenous drainage, 12.0 cm x 12.0 cm x 3.6 cm edges intact, [MEDICATION(S)] treatment. Review of the Weekly Wound Healing Record - dated 6/24/21, Right Glut, overall impression, worsening, necrotic tissue present, moist, moderate serosangenous drainage, 12.0 cm x 13.0 cm x 3.6 cm edges intact, [MEDICATION(S)] treatment. Review of the Weekly Wound Healing Record - dated 7/1/21, Right Glut, overall impression, unchanged, slough tissue present, necrotic tissue present (30% necrotic and slough), moist, moderate serosangenous drainage, 12.0 cm x 13.0 cm x 3.6 cm edges intact, [MEDICATION(S)] treatment. Review of the Weekly Wound Healing Record - dated 6/10/21, Sacrum, overall impression, unchanged, epithelial tissue present, moist, 1.2 cm x 1.5 cm x 2.0 cm edges intact, [MEDICATION(S)] treatment. Review of the Weekly Wound Healing Record - dated 6/17/21, Sacrum, overall impression, worsening, moist, serosangenous drainage, 1.8 cm x 2.0 cm x 2.4 cm edges intact, [MEDICATION(S)] treatment. Review of the Weekly Wound Healing Record - dated 6/24/21, Sacrum, overall impression, worsening, moist, necrotic tissue present, moderate serosangenous drainage, 2.0 cm x 2.2 cm x 2.4 cm edges intact, [MEDICATION(S)] treatment. Review of the Weekly Wound Healing Records provided to the surveyors did not have a 7/1/21 record for sacrum or coccyx measurement. Review of the Weekly Wound Healing Record - dated 7/7/21, coccyx, overall impression, worsening, necrotic tissue present (45% necrosis), moderate serosangenous drainage, 5.1 cm x 6.0 cm edges intact, treatment changed to [MEDICATION(S)]. Review of the order dated 7/7/21 revealed. 1. Bi Lateral Gluts cleanse area with dankins (Dakins solution promotes healing), pat dry, apply hydrogel (a moisture gel), cover with 4x4 and ABD (type of bandage), every day shift for wound care AND every 8 hours as needed for wound care. 2. Right Glut cleanse area with dankins, pat dry, pack with hydrogel-soaked gauze cover with 4x4 and ABD every day shift for wound care AND every 8 hours as needed for wound care. 3. Left glut cleanse area with dankins, pat dry, pack wound with hydrogel-soaked gauze, cover with 4x4 and border gauze, every day shift AND every 8 hours as needed for wound care. 4. Coccyx cleanse area with dankins, pat dry, apply [MEDICATION(S)] (used for wound care) cover with 4x4 and ABD every day shift for wound care AND every 8 hours as needed for wound care (SIC). In an interview on 7/12/21 at 2:00 PM, Certified Nursing Assistant (CNA) Z reported that she had laid Resident #102 down at about 1:45 PM and his dressing to his bottom was still dry. During an observation on 7/12/21 at 3:16 PM, Assistant Director of Nursing (ADON) A entered the room and washed her hands then donned gloves. LPN N entered the room with wound care items on a tray and placed them on a table in the room. LPN N washed her hands for hands under running water for less than 5 seconds then donned gloves. Resident #102 was rolled on his right side, noted brief was wet and dressing to wound was saturated, necrotic tissue was noted in the upper part of the coccyx the right and left gluteal areas appeared pink and beefy. ADON A removed her gloves, cleaned hand with hand sanitizer and donned clean gloves, LPN N placed Dakins in a bowl with 4x4 and placed the soaked 4x4's over the exposed pink tissue on the gluteal area, while she used a syringe to place Dakins in the tunneling area on the left side, and flushed tunneling area, she then removed the 4x4's soaked in Dakins and place in the trash, (did not pat the area dry) placed hydrogel on a 4x4 packed in tunneling area in left hip, then put hydrogel on ABD pad, (did not cover area with hydrogel then place the 4x4 prior to placing the ABD pad) and placed it on the exposed gluteal area and taped in place, put [MEDICATION(S)] on an ABD pad and placed it over the coccyx (did not place the [MEDICATION(S)] on the coccyx then place the 4x4 then place the ABD pad) and taped it in place. (Resident #102) was turned to work on right hip, tunneling cleaned with Dakins, a syringe was used to cleanse the tunneling area on right hip, then hydrogel 4x4 packed in the tunneling area with most of the 4x4 sticking out, hydrogel was liberally squirted out of the bottle over the ABD pad and placed over open area of the gluteal skin and taped in place (no 4x4's were used on between the ABD pad and the skin). In an observation on 7/14/21 at 6:23 AM, LPN P who was working as a CNA on night shift reported that she had emptied (Resident #102's) urinal during the night but did not look at his brief since the resident changes his own ostomy bay and the nurse would change the dressing so could not tell me if the brief was wet or not. LPN P reported that the resident had been up in the same position during the night and had not been repositioned, she had offered in the past, and he would not do it. Resident #103 Review of an Admission Record revealed Resident #103 was a [AGE] year-old, with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 10/22/20 revealed a Brief Interview for Mental Status (BIMS) score of 6, out of a total possible score of 15, which indicated Resident #103 was cognitively impaired. During an observation on 7/12/21 at 12:32 PM, resident laying on back on bed appeared to be sleeping, television was on he had no shirt on, sheet was pulled up to about his waist, oxygen was in his nose via nasal cannula on a concentrator. During an observation on 7/12/21 at 4:00 PM, resident laying on back on bed, oxygen was in his nose via nasal cannula on a concentrator. During an observation on 7/13/21 at 9:50 AM, resident laying on back on bed sleeping, television was on he had no shirt on, oxygen was in his nose via nasal cannula on a concentrator. During an observation on 7/13/21 at 3:00 PM, resident laying on back on bed has no concerns at this time watching television, oxygen was in his nose via nasal cannula on a concentrator. During an observation on 7/12/21 at 1:50 PM, resident laying on his back in the bed watching television, he had a brief on, and oxygen was attached via a nasal cannula to his cheek under his right eye, he reported that he did not want to join in with the activities that were going on and stated that his clothing was still gone due to the flood. During an observation on 7/14/21 at 6:40 AM, Certified Nursing Assistant (CNA) S entered (Resident #103's) room and placed gloves on without cleaning her hands, then assisted to LPN P who had washed her hands and donned clean gloves to open tell the resident what they were going to do. Supplies were at bedside and resident was already on his back his brief was removed in the front and perineal care was preformed and the area was dried after he was washed, he was asked to turn to his left side and his bottom was cleaned and dried. On the right side of his bottom there were 2 area approximately 0.5 x 0.5 cm depth of one approximately 0.05 cm, one appeared to be excoriated, and one appeared to be a stage 2 pressure ulcer. The brief that was removed was saturated with urine. LPN P stated we offer to turn him, but he will move back to his back, he will throw the pillows on the floor if you use those to reposition him. LPN P reported that the area of skin was noted on Saturday and reported to LPN L at that time and charted in the CNA charting. Resident was repositioned for comfort after A & D lotion applied to bottom and brief placed. CNA S washed hands for 5 seconds and LPN P removed gloved took the trash and cleaned her hands promptly. In an interview on 7/14/21 at 6:59 AM, LPN L reported that the skin concern with (Resident #103) was brought to my attention on Saturday and we put [MEDICATION(S)] lotion on it, LPN L is a nurse acting as a CNA I did not know that it had progressed further, I did not chart it. During an observation on 7/14/21 at 7:14 AM, Licensed Practical Nurse (LPN)L and Unit Manager (UM) V entered (Resident #103's) room, did not wash hands, just put gloves, went to the resident loosened his brief, and ask him to turn toward th [TRUNCATED]

This citation pertain to Intake # MI 897, MI 944 Based on observation, interview and record review, the facility failed to thoroughly assess, monitor and treat a [MEDICAL CONDITION] resulting from a fall in a timely manner for one resident (#704) of three sampled residents reviewed for falls, resulting in a delay in treatment, and the potential for further decline in physical well -being from prolonged pain/discomfort. Findings include: On 12/17/18 at 10:21 a.m., R#704 was observed resting in bed, alert and oriented to person only. R#704 denied any pain at that time and was unable to recall the incident. The Resident was observed lying in bed with the right leg and right hip immobile. The resident was observed with a wound dressing applied to the right knee. When R# 704 was asked, what happened to the right knee, R# 704 was unable to answer. At that time nurse A was in the room and stated, He had a fall. On 12/17/18 at 11:05 a.m., review of R# 704's clinical record documented the Resident was initially admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Annual MDS assessment dated [DATE] noted: severe cognitive impairment, incontinent of bowel and bladder, and required total one-person assistance with activities of daily living (ADLs). On 12/17/18 at 11:20 a.m., review of the nurse progress notes dated 11/16/18 documented, Staff approached the Nurse and said that the resident fell on the floor while they were pushing him in the wheelchair, and resident was picked up by staff prior to notifying the nurse for evaluation. Nurse immediately went to assess the resident and observed the resident sitting in his wheel chair. He had facial grimacing with the right knee assessment. There was no documentation informing the physician the full details of the fall. There also was not any documentation of including witness interviews with the activities staff explaining the position of the fall, or documented range of motion performed. Review of the nurses progress notes also documented, The physician notified, new orders to x-ray the right knee, and to give Tylenol five hundred milligram extra strength every six hours as needed for pain. The nurse's notes documented, the continuing monitoring was endorsed to the oncoming nurse to notify the physician of increased pain and the x-ray results. On 11/17/18 documented x-ray results negative for fracture or discoloration; the patella is intact and no pain. On 11/18/18, Day two of the post fall follow up documented, no pain at the right knee, medicated times two, CTM (continue to monitor) for pain. Review of the Mobilex USA Radiology report x-ray results for the right knee dated 11/16/18 revealed the results: Findings: There is no fracture of discoloration. The patella is intact. There is no effusion. Further review of the nurse progress notes dated 11/22/18 documented, RN called by CENA, purple/yellowish bruise (A bruise that has turned yellow is usually a sign that your body is healing from trauma .The bruise then turns various shades of blue and purple) to the resident right hip and femur with [MEDICAL CONDITION] to lower right extremity. RN reviewed notes and saw resident had a fall on 11/16/18, and right knee was x-rayed. Rn attempted Range of Motion on right lower extremity and the resident winced (give slight involuntary grimace or shrinking movement of the body out of or in anticipation of pain or distress). Physician paged and left message on her home phone. RN spoke with the physician, informed her of bruising and [MEDICAL CONDITION] to right hip and femur. She ordered a stat x-ray of right hip and femur for pain/bruising. On 11/23/18 at 09:12, MD notified of x-ray results. MD ordered for resident to be seen 11/23/18 by orthopedic, resident verbally stated, he had pain upon touching, and ADLS care with facial grimaces. Resident went to Beaumont Annapolis Hospital for unrelieved pain to right femur. Resident returned 11/23/18 at 13:52 with order to keep leg/Hip immobile in the bed until seen by the orthopedic doctor for follow up appointment. On 12/17/18 at 12:10 p.m., review of the x-ray dated 11/22/18, revealed a result: There is a fracture involving right subtrochanteric femur with moderate displacement and angulation ([MEDICAL CONDITION]). On 12/17/18 at 2:33 p.m., during an interview with Activities Aide B stated, The resident fell because, he was sitting on the edge of his wheel chair, he has been doing it for a while. The resident transferred himself to the couch in the dining room, no one was pushing him. Two activities aids put him back in his chair, I held the chair, and then the nurse came a while afterward. On 12/17/18 at 2:41 p.m., during an interview with Restorative Aide/CENA C stated, Around 3:40 p.m. or 4:00 p.m. in the dining room when he seen the resident on the floor already, another activity aide was standing over him, so they together put the resident back into his chair. When asked what the resident position at that time was, Restorative Aide/ CENA C stated, On his butt, not sitting directly on the butt, but half lying down. On 12/17/18 at 4:04 p.m., interview with 7a.m. to 7 p.m. Nurse C stated, I never got a report he fell . The CENA (Certified Nursing Assistant) got him up, he reported of pain, bent over, resident stated,' he was hurting.' The resident was put back to bed before lunch and ate dinner in bed. He had on blue jean and stating he wasn't comfortable, Tylenol was giving then. When asked, what was the resident pain level on a scale 0-10, Nurse C stated, I didn't do a 0-10 pain level. When asked, was there a pain assessment done at this time, Nurse C stated, I 'm not going to lie. I don't know if he felt better or not after the Tylenol was given. I didn't do a pain assessment afterward. Nurse C also stated, We do not have a twenty-four-hour board to communicate, it's just word of mouth, On 12/17/18, review of the clinical record revealed R#704 's care plan date initiated 9/16/16, documented under interventions, observe me or ask me if I am having any s/s (sign and symptoms) of pain. I have scheduled Tylenol & PRN (as needed) Tylenol that relieves my pain. If pain is un-relieved, notify nurse/physician. On 12/17/18 at 5:05 p.m., the facility's policy titled, Fall Management Guidelines, with no revision dates documented, Practice Guidelines as follow: When a fall occurs, the nurse should assess the resident for injury and provide the appropriate first aid based on standard of practices . After each fall, the nurse will assess for pain and document findings. If the resident complains of pain or has a new onset of pain, the pain evaluation form should be completed . The licensed nurse will document the incident on: The Unusual Occurrence Report, 24Hour Report, Nurse's note, Post-Fall Assessment (if the incident is a fall), Charting in the nurses notes over the next 72 hour, Update the care plan .The Nurses will communicate via the 24-hour report to the interdisciplinary team of the resident fall.

This citation pertains to intake #MI 512 Based on observation, interview, and record review, the facility failed to implement effective interventions to prevent elopement for one Resident (#201), who is legally blind, with a history of successful elopement from the facility's window, out of three residents reviewed for elopement, out of a total sample of five residents, resulting in the resident eloping from the facility through a window, with the potential for future elopement from the facility, that could cause serious injury, harm, or death. This deficient practice resulted in an immediate jeopardy. The immediate jeopardy was identified on 7/6/17. The administrator was notified on 7/6/17 and a plan of correction was requested to remove the immediacy. The immediacy was removed on 7/7/17 based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the immediacy was removed, the facility's deficient practice was not corrected and remained isolated with the potential for harm that is immediate jeopardy. Findings include: On 7/6/17 at 10:00 am, a review of Resident #201's clinical record was conducted and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #201's most recent Minimum Data Set assessment dated [DATE] indicated severely impaired cognition. Resident #201 was ambulatory with assistance, and had no range of motion deficits. A review of a progress note dated 7/2/16 by Registered Nurse (RN) 'A' indicated that Resident #201 had eloped out of the facility through his bedroom window. RN 'A' documented that Resident #201 had removed the bolts from the window. A review of previous progress notes (including a note from December 2016) was conducted and it was discovered that Resident #201 had eloped from his bedroom window in December as well. Resident #201's elopement assessments were reviewed and the most recent assessment (prior to the elopement on 7/2/17) indicated he was a high risk for elopement by a score of 13, with anything greater than 11 being a high risk. A review of Resident #201's care plan revealed an elopement risk care plan and an intervention (prior to the elopement on 7/2/17) indicating Resident #201 was to have a one on one sitter on the afternoon shift. On 7/6/17 at 10:20 am, a review of Resident #201's room was conducted. Resident #201's room was a private room with one tall, horizontally sliding window. Review of the window revealed a metal window stopper device that attached to the bottom window run. The stopper device was held in place by a thumb screw and prevented the window from completely opening. It was noted that the thumb screw on the window stopper device could be turned and the window stopper device removed. It was also observed that a screw had been drilled into the window run to prevent opening the window, and a vertical stack of bolts had also been drilled into the bottom window run to prevent the window from sliding open. The sliding window had another metal stopper device attached to the top window run and this metal stopper device was also held in place by a thumb screw. On 7/6/17 at 11:00 am, a tour of the facility's long term care bedrooms and activity room was conducted. During the tour, room #601's windows were observed to have the metal window stopper devices on the bottom window run removed. The stopper devices were observed on the window ledge. The top window stopper devices were secured with thumb screws and were able to be unscrewed and removed. An observation of the facility's activity room was conducted at that time. The activity room was located at the end of the hallway and staff were not visibly present in the area. The activity room door was open and did not contain a lock. The room had four tall, horizontally sliding windows. Two of the four windows had metal window stopper devices on the top and bottom window runs. The devices were secured with thumb screws and were observed to be loose, enabling the removal of the devices. On 7/6/17 at 11:20 am, an interview with the facility's Director of Nursing (DON) was conducted regarding Resident #201 and his elopement history. During the interview, the DON indicated that Resident #201 had exhibited exit seeking behaviors in the past. The DON was then asked to clarify physician's orders [REDACTED]. The DON explained that on 4/7/17 an order was placed to have Resident #201 with a one to one sitter around the clock. She explained that the one to one sitter was discontinued on 4/18/17 and Resident #201 only required a one to one sitter for the afternoon shift. When asked why there was not an order for [REDACTED]. On 7/6/17 at 11:50 am, an interview with RN 'A', the nurse caring for Resident #201 on 7/2/17 was conducted. During the interview, RN 'A' indicated that Resident #201 was able to ambulate. When asked about Resident #201's elopement she explained that she did walking rounds to check on all of her Resident's between 3:05 pm and 3:10 pm. She indicated that Resident #201 was in his room at that time. When asked if a sitter was present, RN 'A' indicated that there wasn't a sitter there when she checked on him. She explained that Certified Nursing Assistant (CNA) 'C' was going to be the afternoon sitter but had to finish up her day shift CNA work before she would be sitting for Resident #201 for the afternoon shift. RN 'A' said that at approximately 3:40 pm, she was made aware by CNA 'C' that Resident #201 had exited the facility from his bedroom window. RN 'A' explained that Resident #201 was supposed to have a one to one sitter on the afternoon shift, starting at 3:00 pm and stated, Someone should have been with him. RN 'A' was then asked if she recalled how the window looked, RN 'A' indicated that the bottom window stopper had been removed. On 7/6/17 at 12:05 pm, an interview with CNA 'C' was conducted. CNA 'C' was asked to explain the events surrounding Resident #201's elopement on 7/2/17. CNA 'C' explained that she worked her normal day shift as a CNA and had signed up for extra time to be Resident #201's sitter on the afternoon shift at 3 pm. She continued to explain that she requested to take a break after her day shift, before she began the afternoon shift sitting for Resident #201. She was told by RN 'D' to check on Resident #201 before going on her break. It was when she checked on him she said she observed him outside of his room in the yard of the facility. CNA 'C' was asked what time she observed him outside of the facility, and approximated the time as somewhere between 2:45 pm and 3:30 pm. When asked what she had been doing between 2:45 and 3:30 pm (when she approximated she discovered Resident #201 outside of the facility), CNA 'C' indicated she was finishing up her CNA tasks from her day shift. CNA 'C' was then asked about what she observed with Resident #201's window. CNA 'C' explained that the blinds on the window were up and the window was open. CNA 'C' stated, The bottom was open wider than the top, it was kind of slanted When asked if she noticed the metal window stopper, CNA 'C' explained that the window stopper had a thumb screw to secure it and that it had been removed from the window run. On 7/6/17 at 1:20 pm, an interview and tour of the facility with the facility's Maintenance Director was conducted. The Maintenance Director was asked if he was aware of Resident #201's elopement from the facility, he indicated he was aware. When asked if he looked at the window in Resident #201's room after the elopement he indicated he did. The Maintenance Director was queried about what he observed and described that one of the window stoppers had been removed and he replaced it after the elopement. He also indicated that he put the screw and the stack of bolts into the window run and had begun auditing the presence of window stoppers on windows in resident rooms. A review of the activity room windows was then conducted with The facility's Maintenance Director. It was pointed out to the Maintenance Director that the window stoppers were loose on the the windows, no staff was visible in the vicinity of the activity room at that time, and the activity room door did not have a lock for securement. The Maintenance Director was queried about auditing the activity room windows for proper use of the window stoppers and indicated the Maintenance Staff did not audit the activity room, only the Resident rooms. On 7/6/17 at 2:10 pm, an interview with the facility's Regional Director of Operations (RDO) was conducted. During the interview he was asked about the use of the window stoppers with thumb screws and observations of loose or missing window stoppers through the facility. The RDO stated, I can see how they could get those off. On 7/6/17 at 2:20 pm, an interview with the facility's DON was conducted regarding the absence of the one on one sitter at the approximate time of the elopement. The DON explained that it could have been possible he was aware the sitter wasn't there. On 7/6/17 at 4:00 pm, a review of the facility's policy titled, Elopement, Potential Resident with a revision date of July 2013 read, It is the policy of this facility to provide residents with a safe and secure environment .Residents with cognitive loss who leave the facility without authorization and without and escort will be considered an elopement . The facility was asked if the had any additional information to provide regarding the concern, none was received by the end of the survey. The facility submitted the following acceptable plan including supporting documentation to remove the immediacy on 7/7/17: Plan of Correction Removal of IJ related to F323 Element 1: Resident was assessed for injury. No injuries noted. Administrator and DON notified. Resident placed on 1:1 supervision from the date of the incident through current. Interventions were reviewed and revised upon return to facility. Resident continues to reside at facility Element 2: Residents in the facility who trigger for elopement risk could be affected by this practice. Elopement risk status was reassessed for all residents deemed to be high risk for elopement. Residents that were deemed high risk care plans were updated and interventions were initiated as needed. Window stoppers were audited to ensure that they were on the windows securely. Stoppers that were noted to be lose or missing were replaced. Element 3: Elopement policy was reviewed and was deemed appropriate. Staff was re-educated on the elopement policy and checking the window stoppers to ensure they are secure. Window stoppers were replaced with a more secure stopper. Element 4: Facility started audits on the window stoppers and they are being completed daily. Window stoppers that are observed to be lose or missing are being fixed or replaced during the audit. Audit will be completed weekly x4 and then monthly until deemed in compliance. Findings will be reported to the QAPI committee. Social Worker will continue to audit elopement assessments scores and elopement book weekly x4 weeks and then monthly until QAPI deem in compliance. Results will be reported to QAPI monthly. Element 5: Administrator and the DON will be responsible for sustained compliance. Date of Compliance: 7/7/17

Based on interview and record review, the facility failed to ensure that nursing staff properly transfered a Resident using a mechanical lift (Hoyer) for one (#965) of six sampled Residents reviewed for falls in a total sample of 24, resulting in the Resident falling from the lift when one of the four sling straps were not in place and sustained a large hematoma on the back of the head, skin tear to the left calf, and subsequent hospitalization for further evaluation and treatment. Findings include: On 10/25/16 at 11:30 a.m., during an interview with Resident #965 it was reported, In July I was dropped from a hoyer lift. My head had a contusion the size of a golf ball!. When asked about what she thought may have been the underlying cause of the fall, Resident #965 reported, The two CNAs (Certified Nursing Assistants) said they had to hurry to go to lunch. The strip on the side (strap of the sling used with the mechanical lift) wasn't hooked up right and when they went to move me I fell on my head. I looked up and they were already starting to lift me without the strap in place. I was scared to get out of the bed with the lift after that. Experienced aides (CNAs) should know how to properly hook up (mechanical lift sling). According to the face sheet, Resident #965 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of both the Quarterly (9/28/16) and Annual (6/28/16) Minimum Data Set (MDS) assessments documented Resident #965 was cognitively intact (scored 15/15 on mental status exam) and totally dependent upon two plus persons for transfers. Review of the progress notes from 7/1/16 - 10/24/16 included an entry on 7/26/16 at 3:15 p.m. which read, At 1210 pm. Resident was being transferred via Hoyer from bed to w/c (wheelchair) with 2 Cena's attending. the Hoyer pad gave way and Resident fell to floor. Upon assessing: Resident has a Large hematoma to R (right) side Back of head. Heaviness of Chest with Pain. Pain on R side of Back upon palpation. Skin tear to Back of L Calf .New order to send to Hosp for Cat Scan . On 10/26/16 at 1:00 p.m., the Administrator was asked about the facility's investigation of the Resident's fall in July. At that time, the Administrator reported, Yes, we have a soft file on that. Review of the documentation provided by the facility included: An Unusual Occurence Report dated 7/26/16 at 12:10 pm which documented: 2 CNA's were transferring resident in hoyer (mechanical lift) from bed to chair. Resident head came in contact with floor during transfer. Nature of Occurrence: Fall Indicate location of Injury - back of head (occiput) abrasion right elbow Resident Outcome: Skin tear, Abrasion, Head Trauma Intervention .tylenol pain, ice pack to head, sent to ER (emergency room ) for eval The section of this document which read, What did you do to try to prevent the incident from happening again? was left blank. The sections for Physician Statement (injury, treatment, disposition) and signature for Physician/Medical Director were left blank. Further review of the soft file revealed there was no documented investigation of the cause of the Resident's fall with injury. According to witness statements dated 7/26/16 from the two CNAs who transferred Resident #965 on 7/26/16 included: CNA N reported, CNA 'M' asked for help to put Resident #965 in the chair, she already hooked her as we lift her up to put her in the chair one end of sling went off and she fell down. CNA M reported, Rt (Resident #965) was on hoyer lift, about to be put in the chair and the sling came off the lift back rt (right) failed. On 10/26/16 at 1:40 p.m., the Administrator was asked about the Resident's fall and reported that they believe one of the straps had flipped off during the transfer but they were unable to confirm how the strap of the sling came off . When asked about the facility's lack of documented investigation following the Resident's fall, the Administrator reported she would follow up with the Director of Nursing. At that time, when asked about what specific education was provided to the nursing staff, the Administrator reviewed the documents in the Resident's soft file and confirmed there was no specific detailed evidence of education provided, only an agenda. The Administrator further reported she would attempt to obtain the specific education and facility investigation however there was no further documentation provided by the end of the survey. ( )

This citation pertains to intake #MI 359. Based on interview and record review, the facility failed to ensure adequate positioning of a Resident during incontinence care for one (#2001) of three sampled Residents reviewed for falls in a total sample of five, resulting in Resident #2001's fall from the bed, sustaining a C-2 fracture, lacerations to the forehead and lip, hematomas to the eye, swelling and bruising to bilateral eyes, nose, and cheeks, large amount of bleeding and hospitalization . Findings include: On 7/8/16 at 11:40 a.m., a phone interview was conducted with the Complainant who expressed concern that Resident #2001 had sustained severe injuries following lack of adequate care on the evening of 6/16/16. The Complainant also reported that the Resident had not returned to the facility, but had transferred to another facility following a week long hospitalization . On 7/11/16 at 8:30 a.m., review of the hospital records identified that Resident #2001 was admitted into the hospital on [DATE]. Documentation identified that laceration repair was completed while the Resident was in the emergency department. Additionally, review of the physician progress notes [REDACTED].The patient was in her rehab facility when she fell out of bed. she landed on her face. She has bumps and bruises all over her face. She has complaints of neck pain as well .CT cervical spine showed C2 fracture (C2 is the second vertebrae of the spine) .CT face was also completed, which showed soft tissue injuries. The patient is currently in a hard collar . (CT/Computerized tomography is a narrow beam of x-ray that scans the area in successive layers to evaluate disease, bone structure, joint abnormalities, and trauma/fractures.) According the the CT images completed in the hospital, the following was concluded: CT of the Head without IV contrast, Impression .Frontal scalp hematoma .Acute and chronic right maxillary sinusitis . CT of the Spine Cervical without IV contrast, Impression .C2 fracture . According to the MRI (Magnetic Resonance Imaging - is a non-invasive structural imaging procedure that uses powerful magnetic field and radio frequency waves to create an image) completed at the hospital, the following was concluded: MRI of the Spine Cervical without IV contrast, Impression .marked edema like signal and effusion within the prevertebral soft tissues extending from the craniocervical junction through the level of C4-C5 compatible with trauma with evidence of acute C2 fracture . MRI of the Brain without IV contrast, Impression .Contusion/hematomas of the anterior midline and right lateral scalp soft tissues On 7/11/16 at 10:20 a.m., an interview was conducted with the Director of Nursing (DON). When asked about Resident #2001's fall on 6/17/16, the DON reported the Resident had a stroke which affected her right side which was weak and required one person assistance for incontinent care. The aide had one hand on her, the Resident was on her right side and used her left hand to pull towards the pictures to grab from bedside dresser and she went down. Review of the facility's investigation for Resident #2001 dated 6/20/16 which was completed by the DON documented, Resident rolled out of bed onto the floor during care. Resident has right sided [DIAGNOSES REDACTED]. She was on right side while being changed and reached for her pictures on bedside table with left arm. She then rolled to the floor. The CNA (Certified Nursing Assistant) said she had kept one hand on resident during care and while reaching for cream .Interviews with other CNA/staff state that she (Resident #2001) does reach out for her personal pictures . Further review of the clinical record revealed Resident #2001 was admitted into the facility on [DATE] and transferred to hospital on [DATE]. According to the face sheet, Resident #2001's [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #2001 scored 12/15 on the Brief Interview for Mental Status (BIMS scores between 8 and 12 indicate moderate cognitive impairment), required extensive assistance of one person for hygiene, and was incontinent of bladder and bowel. On 7/11/16 at 12:55 p.m., an interview was conducted with the Social Worker (SW D) who had been assigned to Resident #2001 during her stay at the facility. When asked if she was aware of any behaviors exhibited by Resident #2001 such as restlessness, or impulsiveness during care, SW D reported, She was alert and oriented, spoke loudly because of her hearing impairment but did not have any behavior issues. She always had the news on and kept current with events. On 7/11/16 at 3:45 p.m., an interview was completed by phone with CNA A who confirmed she had been assigned to Resident #2001 on the midnight shift for 6/16/16 into 6/17/16. When asked to recall the Resident's fall on 6/17/16 at 3:00 a.m., CNA A reported, I went in and put the bed up (in an elevated position). It was time for me to change her. She asked me to put cream on her bottom. I guess I put her too close to the edge. I'm not sure if she was messing with the pictures. Normally I took care of her. She was facing the window. The table next to the bed had her pictures and flowers, she was always talking about her family She was too close to the edge probably. Happened so fast. When she fell I'm not sure if she hit the table but I saw she was bleeding. She wanted to get up but I told her no and I went to get the nurse. On 7/11/16 at 4:05 p.m., when asked about whether anyone had considered the potential concern about the positioning of the Resident during incontinence care and if staff were aware of Resident #2001's tendency to grab items such as pictures during care, why hadn't interventions been in place to potentially eliminate the concern, the DON reported that interventions were changed after the fall to have two people assist with hygiene and move the table and pictures upon Residents return to the facility, but felt it wasn't a positioning concern. On 7/12/16 at 7:55 a.m., an interview was conducted with Nurse Manager I who confirmed he was on duty the morning of 6/17/16. When asked to recall the incident, Nurse Manager I reported, Resident #2001 was laying face down. I secured her head/body, log rolled her over. She complained of neck pain. Her face was quite swollen and I held her in position until EMS came to take her. I spoke to CNA A and she said she had been doing her care and she just went over off the edge while cleaning her up. ( )

Based on observation, interview and record review, the facility failed to medicate for pain prior to pressure ulcer wound care treatment for one (#1108) of 13 sampled residents reviewed for pain management from a total sample of 24, resulting in unnecessary suffering with unrelieved pain during wound care. Findings include: On 1/13/15 at 10:15 a.m., review of Resident #1108's face sheet from the clinical records revealed an initial admitted of 8/10/00 and a readmission date of [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #1108's cognition was scored as severely impaired and she was totally dependent for activities of daily living (ADLs) such as toileting, personal care and bathing. Resident #1108 was incontinent of bowel and had a urinary catheter. The MDS described Resident #1108 as having a stage three pressure ulcer (full tissue loss), measuring 2.0 centimeters (cm) by 8.0 cm by 1.0 cm. The "Numeric Score" for pain documented that Resident #1108 had an "8 out of a 0-10 scale" (10 being the worse pain and zero being no pain). January 2015 physicians' orders for Resident #1108 included to give "[MEDICATION NAME] Extended Release 30 milligrams by mouth twice a day (9:00 a.m. and 5:00 p.m.) as needed," and to perform a "pre and post (medication administration) pain level." On 1/13/15 at 11:40 a.m., a wound care observation was conducted with two wound care nurses, nurses "B" and "C". Nurse C explained that she was Nurse "B's" supervisor and would oversight Nurse "B's" provision of wound care for Resident #1108. During provision of care, Resident #1108 began to exhibit signs and symptoms of pain by wincing, frowning and squirming away from Nurse "B's" touch. As Nurse "B" wiped the wound, Resident #1108 stated, "Ouch, you are hurting me. Please stop, I can't do it." As Nurse "B" continued to apply the treatment, Resident #1108 squirmed, frowned, and yelled, "Stop." When Nurse "C" was asked if Resident #1108 was medicated for pain prior to providing wound care, Nurse "C" responded, "Yes. I was told she (#1108) was (medicated)." On 1/13/15 at 12:00 p.m., Nurse "D" who was responsible for Resident #1108's medication administration was queried about when the last time Resident #1108 was medicated for pain. Nurse "D" responded, "she (#1108) wasn't medicated today. I can medicate her now though." Review of the Medication Administration Record [REDACTED]. When the MAR indicated [REDACTED]. On 1/13/15 at 12:05 p.m., an interview with Resident #1108's husband concerning knowledge of wound and pain management revealed the following, "[MEDICATION NAME] is the only drug that touches it (the pain)...She (#1108) has a lot of pain. I know. I am here twice a day for about two hours each time. I have never seen them medicate her for pain during wound care and I know it hurts her." Resident #1108 complained that her "bottom hurts. It hurts down there (buttock)" during the interview with her husband. On 1/13/15 at 12:10 p.m., during an interview, Certified Nursing Aid (CNA) "E" was queried concerning Resident #1108 experiencing pain with pericare (care of the perineum area after incontinence) or with activities of daily living. CNA "E" stated, "Sometimes she is in pain and hurts down there (buttock)." CNA "F" was also queried about Resident #1108's pain. CNA"F" responded, "she (#1108) complains of pain and it is when I do pericare, but she also has painful arms and when I washed her up this morning she complained, 'watch my arms.'" Both CNAs alerted the nurses of Resident #1108's pain when they said they knew of it. According to the facility's Clinical Operating Guidelines for Pain Management, with the Revision Date of January 2011, "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." On 1/14/15 at 1:15 p.m., the Director of Nursing (DON) was interviewed concerning pain management for Resident #1108. The DON was not able to explain the lack of pain relief provided to Resident 1108 prior to receiving wound care. ( )

THIS CITATION PERTAINS TO INTAKE: MI 414 BASED ON INTERVIEWS AND RECORD REVIEWS, THE FACILITY FAILED TO PROVIDE TIMELY/ADEQUATE PAIN CONTROL TO 1 (#106) OF 8 SAMPLED RESIDENTS REVIEWED FOR PAIN CONTROL FROM A TOTAL SAMPLE OF 10, RESULTING IN SEVERE PAIN FOR RESIDENT #106. FINDINGS INCLUDE: ACCORDING TO THE FACILITY'S UNUSUAL OCCURRENCE REPORT DATED 12/30/12, ON 12/29/12 AT APPROXIMATELY 9:30 A.M., RESIDENT #106 REPORTED TO CERTIFIED NURSING ASSISTANT (CNA) #12 THAT SHE WAS DROPPED BY AN UNIDENTIFIED CNA ON THE PREVIOUS AFTERNOON SHIFT, DURING A TRANSFER BACK TO BED, AND THAT HER LEFT LEG HAD BEEN IN PAIN EVER SINCE. ON 12/29/12 AT 8:00 P.M. X-RAYS WERE TAKEN THAT REVEALED A LEFT FEMORAL NECK FRACTURE. THE FACILITY INITIATED AN INVESTIGATION WHILE RESIDENT #106 WAS SENT OUT TO THE HOSPITAL FOR SURGICAL REPAIR OF THE FRACTURE. A CLINICAL RECORD REVIEW REVEALED THAT RESIDENT #106 WAS AN [AGE] year OLD FEMALE WHO HAD BEEN RESIDING AT THE FACILITY SINCE 2004, AND HAD MULTIPLE [DIAGNOSES REDACTED].#106'S LEFT SIDE PARALYZED, WITH A SEVERE CONTRACTURE OF HER LEFT HAND. THE MINIMUM DATA SET (MDS) assessment dated [DATE] IDENTIFIED RESIDENT #106 AS ALWAYS BEING ABLE TO MAKE HER NEEDS KNOWN CLEARLY, AND BEING ALWAYS ABLE TO UNDERSTAND OTHERS. RESIDENT #106 SCORED A 14/15 ON HER BRIEF INTERVIEW FOR MENTAL STATUS AND HAD NOT DEMONSTRATED ANY PROBLEMS WITH MEMORY. DURING AN INTERVIEW ON 2/4/13 AT 10:05 A.M., RESIDENT #106 SAID THAT ON 12/28/12 DURING THE AFTERNOON SHIFT, SHE ASKED A CNA TO PUT HER BACK TO BED. THE CNA SAID SHE COULD NOT FIND ANYONE TO HELP HER AND ATTEMPTED TO PUT RESIDENT #106 BACK TO BED BY HERSELF. RESIDENT #106 SAID SHE TOLD THE CNA THAT SHE (#106) COULD NOT BEAR WEIGHT ON HER LEFT LEG BUT THE CNA ATTEMPTED TO GET HER (RESIDENT #106) BACK TO BED ANYWAY, AND SHE (#106) fell on TO THE FLOOR. RESIDENT #106 SAID SHE TOLD THE CNA THAT HER LEFT LEG WAS IN PAIN, BUT THE CNA ASKED HER (#106) NOT TO TELL ANYONE THAT SHE DROPPED HER (#106) AND DID NOT RETRIEVE THE NURSE FOR HER. RESIDENT #106 SAID THAT SHE WAITED UNTIL THE MIDNIGHT SHIFT AND THEN TOLD THE MIDNIGHT SHIFT CNA (#13) WHAT HAD HAPPENED, AND THAT HER LEFT LEG WAS REALLY HURTING. RESIDENT #106 SAID SHE THOUGHT SHE RECEIVED SOME PAIN MEDICATION, BUT IT DID NOT HELP. RESIDENT #106 SAID THAT SHE WAS IN SO MUCH PAIN THAT NEXT DAY THAT SHE COULD NOT SIT UP FOR BREAKFAST AND FELT NAUSEOUS. RESIDENT #106 THAT SAID IT WASN'T UNTIL AFTERNOON SHIFT ON 12/28/12 THAT SHE WAS FINALLY TRANSFERRED OUT TO THE HOSPITAL FOR EVALUATION AND GIVEN SOMETHING TO RELIEVE HER PAIN. A REVIEW OF THE NURSING NOTES WRITTEN BY LICENSED PRACTICAL NURSE (LPN) #7, DATED 12/28/12 AT 9:30 A.M., REVEALED THAT RESIDENT #106 COMPLAINED OF LEFT LEG PAIN, AND PAIN MEDICATION WAS GIVEN. AT 11:00 A.M., RESIDENT #106 WAS STILL COMPLAINING OF PAIN. NURSING NOTES FURTHER DOCUMENTED THAT RESIDENT #106 "SCREAMED" WHEN LPN #7 TOUCHED HER (#106) LEFT LEG/HIP AREA. LPN #7 NOTIFIED THE PHYSICIAN AT 2:45 P.M. OF RESIDENT #106'S UNCONTROLLED PAIN AND INCIDENT THAT OCCURRED ON 12/28/12 DURING THE AFTERNOON SHIFT, 6 HOURS AFTER THE RESIDENT INITIALLY COMPLAINED OF SEVERE PAIN AND LPN #7 WAS AWARE THE RESIDENT fell . DURING AN INTERVIEW ON 2/5/13 AT 10:10 A.M., LPN #7 SAID THAT SHE WAS NOTIFIED BY CNA #12 THAT RESIDENT #106 WAS IN PAIN AND REFUSED TO SIT UP AND EAT BREAKFAST. LPN #7 SAID SHE WENT TO RESIDENT #106 AND GAVE HER (#106) A PAIN PILL. LPN #7 SAID THAT AT 11:00 A.M., CNA #12 CAME BACK TO HER AND SAID THAT RESIDENT #106 WAS STILL IN PAIN. LPN #7 SAID SHE ONLY TOUCHED RESIDENT #106'S LEFT THIGH AREA AND SHE (RESIDENT #106) SCREAMED IN PAIN. LPN #7 SAID THAT AROUND 3:00 P.M., SHE (LPN #7) NOTIFIED THE PHYSICIAN OF RESIDENT #106'S PAIN AND X-RAYS WERE ORDERED. LPN #7 SAID THE SHE DID NOT REALIZE 4 HOURS HAD GONE BY BEFORE SHE NOTIFIED THE PHYSICIAN ABOUT THE RESIDENT'S FALL AND PAIN LEVELS. LPN #7 WAS ASKED TO REVIEW RESIDENT #106'S Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. LPN #7 COULD NOT IDENTIFY ANY PAIN MEDICATIONS THAT WERE ADMINISTERED TO THE RESIDENT, NOT EVEN THE PAIN MEDICATIONS PRESCRIBED FOR A 'AS NEEDED' BASIS. A REVIEW OF THE RESIDENT'S MEDICATION ADMINISTRATION RECORDS (MAR) REVEALED THAT THE RESIDENT ONLY RECEIVED HER REGULARLY SCHEDULED PAIN MEDICATION ([MEDICATION NAME]/[MEDICATION NAME] 7.5/750 MG) ON 12/28/12 AT 6:00 P.M., 12/29/12 AT 6:00 A.M., AND AGAIN ON 12/29/12 AT 6:00 P.M. REVIEW OF THE MAR indicated [REDACTED].M., AS WAS WRITTEN IN THE NURSING NOTES. THERE WAS NO DOCUMENTATION TO INDICATE RESIDENT #106 WAS GIVEN ANY PAIN MEDICATION AT 2:45 P.M., WHEN THE NURSE NOTIFIED THE PHYSICIAN THAT RESIDENT #106 HAD SEVERE PAIN IN HER LEFT LEG, AFTER SUSTAINING A FALL. IT WAS NOTED THAT RESIDENT #106 HAD an order for [REDACTED]. DURING AN INTERVIEW ON 2/4/13 AT 9:30 A.M., THE ADMINISTRATIVE DIRECTOR OF NURSING (DON) #2 SAID THAT RESIDENT #106 REPORTED THE INCIDENT TO CERTIFIED NURSING ASSISTANT (CNA) #12 ON 12/29/12 AT 9:30 A.M., BUT THE PHYSICIAN WAS NOT NOTIFIED UNTIL 12/29/12 AT 2:45 P.M. X-RAYS WERE REPORTED TO THE PHYSICIAN AT 8:00 P.M., AND THE RESIDENT WAS TRANSFERRED OUT TO THE HOSPITAL AT APPROXIMATELY 10:30 P.M. DON #2 COULD NOT PROVIDE ANY DOCUMENTATION INDICATING THAT RESIDENT #106'S PAIN LEVEL WAS ASSESSED, OR THAT ANY ADDITIONAL PAIN MEDICATIONS WERE PRESCRIBED OR ADMINISTERED TO RELIEVE THE RESIDENT'S PAIN. DON #2 COULD NOT EXPLAIN WHY LICENSED PRACTICAL NURSE (LPN) #7 WAITED NEARLY 6 HOURS BEFORE NOTIFYING THE PHYSICIAN OF RESIDENT #106'S UNCONTROLLED PAIN. DURING AN INTERVIEW ON 2/5/13 AT 12:45 P.M., CNA #12 SAID THAT ON 12/28/12, SHE (CNA #12) HAD BEEN ASSIGNED TO PROVIDE CARE FOR RESIDENT #106 DURING THE DAY SHIFT. AT APPROXIMATELY 9:30 A.M., RESIDENT #106 REFUSED TO GET UP FOR BREAKFAST BECAUSE HER LEFT LEG WAS IN SO MUCH PAIN. CNA #12 SAID SHE (CNA #12) ASKED (RESIDENT #106) WHAT HAPPENED AND THE RESIDENT TOLD HER THAT SHE HAD BEEN DROPPED ONTO THE FLOOR AND HURT HER LEFT LEG. CNA #12 SAID SHE REPORTED IT TO THE NURSE IMMEDIATELY. CNA #12 SAID THAT SHE DID NOT KNOW IF RESIDENT #106 EVER RECEIVED ANY PAIN MEDICATION DURING THAT DAY SHIFT, BUT THE RESIDENT DID NOT EAT ALL DAY, COMPLAINED OF BEING NAUSEOUS AND VOMITED AT END OF HER SHIFT. ( )

THIS CITATION PERTAINS TO INTAKE: MI 414 BASED ON INTERVIEWS AND RECORD REVIEWS, THE FACILITY FAILED TO PROVIDE ADEQUATE EQUIPMENT AND SUPERVISION DURING A TRANSFER IN 1 (#106) OF 5 SAMPLED RESIDENTS REVIEWED FOR FALLS, IN A TOTAL SAMPLE OF 10, WHEN RESIDENT #106, A NON-AMBULATORY RESIDENT, WHO REQUIRED A MECHANICAL LIFT FOR TRANSFER, WAS TRANSFERRED FROM A WHEELCHAIR TO A BED, WITH THE ASSISTANCE OF ONLY 1 STAFF MEMBER, RESULTING IN RESIDENT #106 BEING DROPPED ONTO THE FLOOR AND FRACTURING HER LEFT FEMORAL NECK. FINDINGS INCLUDE: ACCORDING TO THE FACILITY'S UNUSUAL OCCURRENCE REPORT DATED 12/30/12, ON 12/29/12 AT APPROXIMATELY 9:30 A.M., RESIDENT #106 REPORTED TO CERTIFIED NURSING ASSISTANT (CNA) #12 THAT SHE WAS DROPPED BY AN UNIDENTIFIED CNA ON THE PREVIOUS AFTERNOON SHIFT, DURING A TRANSFER BACK TO BED, AND THAT HER LEFT LEG HAD BEEN IN PAIN EVER SINCE. X-RAYS WERE TAKEN THAT REVEALED A LEFT FEMORAL NECK FRACTURE. THE FACILITY INITIATED AN INVESTIGATION WHILE RESIDENT #106 WAS SENT OUT TO THE HOSPITAL FOR SURGICAL REPAIR OF THE FRACTURE. A CLINICAL RECORD REVIEW REVEALED THAT RESIDENT #106 WAS AN [AGE] year OLD FEMALE WHO HAD BEEN RESIDING AT THE FACILITY SINCE 2004, AND HAD MULTIPLE [DIAGNOSES REDACTED].#106'S LEFT SIDE PARALYZED, WITH A SEVERE CONTRACTURE OF HER LEFT HAND. THE MINIMUM DATA SET (MDS) assessment dated [DATE] IDENTIFIED RESIDENT #106 AS ALWAYS BEING ABLE TO MAKE HER NEEDS KNOWN CLEARLY, AND BEING ALWAYS ABLE TO UNDERSTAND OTHERS. RESIDENT #106 SCORED A 14/15 ON HER BRIEF INTERVIEW FOR MENTAL STATUS AND HAD NOT DEMONSTRATED ANY PROBLEMS WITH MEMORY. THE THERAPY PROGRESS NOTES, THE CARE PLAN, AND THE CNA RESIDENT STATUS RECORD, UPDATED ON 9/20/12, INDICATED THAT RESIDENT #106 REQUIRED THE USE OF A MECHANICAL LIFT (HOYER) AND 2 STAFF MEMBERS FOR TRANSFER. DURING AN INTERVIEW ON 2/4/13 AT 9:30 A.M., THE ADMINISTRATIVE DIRECTOR OF NURSING (DON) #2 SAID THAT RESIDENT #106 HAD BEEN A 2 PERSON TRANSFER WITH A HOYER LIFT SINCE HER ADMISSION. DON #2 SAID THAT DURING HER INVESTIGATION OF THE INCIDENT, SHE DETERMINED THAT CNA #22 HAD IMPROPERLY TRANSFERRED RESIDENT #106 ON THE 12/28/12 DURING THE AFTERNOON SHIFT AND DID NOT REPORT IT TO THE NURSE IN CHARGE THAT EVENING. CNA #22 HAD ATTEMPTED TO TRANSFER RESIDENT #106 BY HERSELF AND DROPPED THE RESIDENT ON THE FLOOR. CNA #22 THEN ASKED CNA #23 TO ASSIST HER WITH GETTING THE RESIDENT BACK INTO BED. CNA #22 HAD BEEN TERMINATED FOR FAILURE TO FOLLOW THE FACILITY'S TRANSFER AND INCIDENT REPORTING POLICY. CNA #23 HAS BEEN RE-EDUCATED ON THE FACILITY'S INCIDENT REPORTING POLICY. DURING AN INTERVIEW ON 2/4/13 AT 10:05 A.M., RESIDENT #106 SAID THAT ON 12/28/12 DURING THE AFTERNOON SHIFT, SHE ASKED A CNA TO PUT HER BACK TO BED. THE CNA SAID SHE COULD NOT FIND ANYONE TO HELP HER AND ATTEMPTED TO PUT RESIDENT #106 BACK TO BED BY HERSELF. RESIDENT #106 SAID SHE TOLD THE CNA THAT SHE (#106) COULD NOT BEAR WEIGHT ON HER LEFT LEG AND THAT OTHER STAFF ALWAYS USED A LIFT TO GET HER (#106) INTO BED. RESIDENT#106 SAID THE CNA ATTEMPTED TO GET HER (RESIDENT #106) BACK TO BED ANYWAY, AND SHE (#106) fell on TO THE FLOOR. RESIDENT #106 SAID SHE TOLD THE CNA THAT HER LEFT LEG WAS IN PAIN, BUT THE CNA ASKED HER (#106) NOT TO TELL ANYONE THAT SHE DROPPED HER (#106). RESIDENT #106 SAID THAT SHE WAITED UNTIL THE NEXT SHIFT (MIDNIGHT) AND REPORTED THE INCIDENT TO ANOTHER CNA (#13). RESIDENT #106 SAID SHE THOUGHT SHE HAD RECEIVED SOME PAIN MEDICATION, BUT IT DID NOT HELP. RESIDENT #106 SAID DURING THE DAY SHIFT (12/29/12), HER LEFT LEG WAS HURTING SO BADLY THAT SHE REFUSED TO GET UP FOR BREAKFAST AND REPORTED THE INCIDENT AGAIN TO CNA #12 (THE DAY SHIFT CNA). RESIDENT #106 SAID THAT SHE WAS IN SO MUCH PAIN THAT DAY THAT SHE VOMITED. IT WASN'T UNTIL AFTERNOON SHIFT ON 12/29/12 THAT SHE WAS FINALLY TRANSFERRED OUT TO THE HOSPITAL FOR EVALUATION. ATTEMPTS TO INTERVIEW CNA #22 AND CNA #23 WERE UNSUCCESSFUL DUE TO THE CNA #22'S PHONE NUMBER BEING DISCONNECTED AND CNA #23 NOT RETURNING ANY CALLS. DURING AN INTERVIEW ON 2/5/13 AT 12:45 P.M., CNA #12 SAID THAT ON 12/29/12 AT APPROXIMATELY 9:30 A.M., RESIDENT#106 REFUSED TO GET UP FOR BREAKFAST BECAUSE HER LEFT LEG WAS IN SO MUCH PAIN. CNA #12 SAID SHE ASKED WHAT HAPPENED AND THE RESIDENT TOLD HER THAT SHE WAS TRANSFERRED LAST NIGHT WITH ONLY 1 PERSON AND SHE fell on TO THE FLOOR AND HURT HER LEFT LEG. CNA #12 SAID SHE REPORTED IT TO THE NURSE IMMEDIATELY. CNA #12 SAID THAT RESIDENT #106 REQUIRED A HOYER LIFT AND 2 PEOPLE FOR TRANSFERS BECAUSE SHE HAD NO STRENGTH ON HER LEFT SIDE AND HER LEFT HAND WAS CONTRACTED. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED PROVIDE PAIN RELIEF FOR TWO (#809 AND #813) OF 13 RESIDENTS REVIEWED FOR PAIN FROM A TOTAL OF 20 SAMPLED RESIDENT RESULTING IN COMPLAINTS OF PAIN; AND FAILED TO ENSURE FLUID WAS NOT LEFT AT THE BEDSIDE FOR ONE (#803) OF ONE SAMPLED RESIDENT AND ONE (#3) OF THREE OFF-SAMPLED RESIDENTS REVIEWED FOR HEMO-[MEDICAL TREATMENT] SERVICES RESULTING IN A POTENTIAL FOR FLUID OVERLOAD AND ASSOCIATED MEDICAL COMPLICATIONS. FINDINGS INCLUDE: ON 11/2/11 AT 1:45 PM, DURING THE TREATMENT OBSERVATION OF AN ABSCESS ON RESIDENT #809'S LEFT BUTTOCKS, RESIDENT #809 WAS OBSERVED MOANING, GRIMACING, AND PULLING AWAY AS THE TREATMENT NURSE AND NURSE "G" CLEANED RESIDENT #809 AFTER A BOWEL MOVEMENT. RESIDENT #809 WAS OBSERVED TO HAVE EXTREMELY REDDENED SKIN BETWEEN HIS BUTTOCKS, THE UPPER POSTERIOR THIGHS, UNDER HIS SCROTUM, IN HIS GROIN THAT WAS EXTREMELY RED, RAISED AND SHINY. THE TREATMENT NURSE AND NURSE "G" REPEATEDLY WIPED THE REDDENED SKIN WITH DRY TOILET TISSUE. THE TREATMENT NURSE ASKED RESIDENT #809 IF HE WAS IN PAIN AND RESIDENT #809 STATED, "YES". HOWEVER, NEITHER THE TREATMENT NURSE NOR NURSE "G" PAUSED OR CHANGED THEIR METHOD OF CLEANING THE RESIDENT. THE TREATMENT NURSE THEN TOOK "PERI WASH" SPRAY (A CLEANING SOLUTION USED IN PLACE OF SOAP AND WATER) AND SPRAYED IT ON THE REDDENED SKIN. RESIDENT #809 JUMPED. THE TREATMENT NURSE ASKED RESIDENT #809 AGAIN IF HE WAS IN PAIN. RESIDENT #809 STATED, "YES". THE TREATMENT NURSE AND NURSE "G" DID NOT STOP CLEANING THE RESIDENT. DURING INTERVIEW AT THIS TIME, THEY WERE ASKED IF RESIDENT #809 HAD RECEIVED ANYTHING FOR PAIN. THE TREATMENT NURSE REVEALED RESIDENT #809 HAD GOTTEN EXTRA STRENGTH TYLENOL AT 1:00 PM. THE TREATMENT NURSE AND NURSE "G" PROCEEDED TO WIPE THE AREA DESPITE RESIDENT #809'S COMPLAINTS OF PAIN. RESIDENT #809 ALSO JUMPED AND TUCKED HIS BUTTOCKS IN AS THE TREATMENT NURSE PACKED HIS ABSCESS, HOWEVER THE PROCEDURE CONTINUED. THE TREATMENT NURSE WAS ASKED WHAT WAS USED TO TREAT RESIDENT #809'S REDDENED AREA. THE TREATMENT NURSE REVEALED SHE WAS NOT AWARE IT WAS THERE. THE TREATMENT NURSE REVIEWED THE TREATMENT ADMINISTRATION RECORD AND STATED, "HE DOESN'T HAVE A treatment for [REDACTED]. ON 11/2/11 AT 1:30 PM, THE CERTIFIED NURSE AIDE (CNA) "H" WAS ASKED IF SHE PROVIDED INCONTINENCE CARE TO RESIDENT #809 THIS MORNING. CNA "H" REVEALED SHE HAD BETWEEN BREAKFAST AND LUNCH. CNA "H" WAS ASKED IF SHE NOTICED THE REDDENED AREA ON RESIDENT #809'S BUTTOCKS AND GROIN. SHE STATED, "YES". CNA "H" REVEALED SHE HAD USED THE PERI WASH BECAUSE HE HAD A BOWEL MOVEMENT. WHEN CNA "H WAS ASKED IF SHE TOLD ANYONE ABOUT HIS EXCORIATION, SHE STATED, "NO, MY MISTAKE." WHEN ASKED WHY SHE HAD NOT REPORTED IT, SHE STATED, "IT'S BEEN A HECTIC MORNING." ON 11/2/11 AT 3:10 PM, THE DIRECTOR OF NURSING (DON) REVEALED THE FACILITY NO LONGER USED BATH BASINS BECAUSE AT A "STATE INFECTION CONTROL MEETING THEY WERE TOLD NOT TO USE BASINS." THE DON REVEALED THAT RESIDENT #809 HAS "A LOT OF STOOLS" AND [MEDICATION NAME] SHOULD BE USED ON HIS REDDENED AREAS. THE DON ALSO REVEALED THE NURSE AIDE SHOULD HAVE COMPLETED THE "EARLY WARNING" REPORT AND GIVEN IT TO THE TREATMENT NURSE. THE DON HAD NO EXPLANATION WHY CNA "H" HAD NOT REPORTED THAT RESIDENT #809 PERINEAL AREA WAS REDDENED OR WHY HE WAS NOT GETTING THE TREATMENT TO THE HIS SKIN. ON 11/2/11 AT 3:15 PM, THE CHARGE NURSE ON D-HALL WAS ASKED WHAT TIME RESIDENT #809 RECEIVED PAIN MEDICATION. SHE REVEALED SHE HAD JUST GOT AN ORDER TO GIVE HIM TYLENOL EXTRA STRENGTH AT 1:00 PM BECAUSE THE FACILITY HAD RUN OUT HIS ORDERED PAIN MEDICATION OF [MEDICATION NAME] 7.5/325 MG. ON 11/3/11, A REVIEW OF THE FACILITY POLICY "PERINEAL CARE" DATED DECEMBER 2008, STATED, "REPORT AND DOCUMENT ANY CHANGE IN SKIN CONDITION". A REVIEW OF THE FACILITY POLICY "PAIN MANAGEMENT", REVISED 1/2011, STATED, "2. OBSERVE RESIDENT FOR INDICATORS OF PAIN...MOANING..., WINCING OR FROWNING, AND OTHER FACIAL EXPRESSIONS, BODY POSTURE SUCH AS GUARDING OR PROTECTING AN AREA." HOWEVER, THE POLICY ON PAIN MANAGEMENT FAILED TO INSTRUCT STAFF ON WHAT ACTION TO TAKE IF A RESIDENT EXHIBITS SIGNS OF PAIN DURING A PROCEDURE. ( ) ON 11/1/11 AT 10:00 A.M., DURING THE INITIAL TOUR RESIDENT #804 WAS OBSERVED WITH A WATER PITCHER CONTAINING 1000 CUBIC CENTIMETERS (CC'S) OF WATER AT HIS BEDSIDE. PRIOR TO THE TOUR, RESIDENT #804 WAS OBSERVED SITTING IN THE FRONT HALLWAY WAITING FOR THE VAN TO PICK HIM UP AND TRANSPORT HIM TO THE [MEDICAL TREATMENT] CENTER. ON 11/1/11 AT 10:15 A.M., REVIEW OF THE PHYSICIAN'S ORDERS DATED 10/1/11-10/31/11 REVEALED RESIDENT #804 WAS ORDERED THE FOLLOWING DIET: MECHANICAL SOFT, REGULAR MEAT, RENAL NO ADDED SALT, 1200 CC'S FLUID RESTRICTION. LARGE PORTION PROTEIN (ALL MEALS). ACCORDING TO THE NUTRITIONAL ASSESSMENT THE FLUID RESTRICTION WAS TO BE DIVIDED AS FOLLOWS: 840 CC-DIETARY AND 360 CC-NURSING. ON 11/1/11 AT 10:30 A.M., DURING INTERVIEW WITH NURSE "D " CONCERNING HOW STAFF IDENTIFIED RESIDENTS ON FLUID RESTRICTIONS, THE NURSE STATED, "...NURSE AIDES PASSED WATER, AND IF THE RESIDENT'S NAME OR ROOM NUMBER WAS ON THE FLUID RESTRICTION LIST, THEN THE RESIDENT WOULD NOT RECEIVE WATER. NURSE "D" STATED, "RESIDENT #804 SHOULD NOT HAVE A WATER PITCHER IF HE IS ON A FLUID RESTRICTION." ON 11/2/11 AT 10:00 A.M., REVIEW OF THE DIETARY CARE PLAN, DATED 2/21/11, IDENTIFIED THE FOLLOWING PROBLEMS: READMISSION 7/25/11 "*I HAVE HAD A CHANGE IN MY CONDITION AS EVIDENCED BY NEED FOR [MEDICAL TREATMENT] TREATMENT. *I MAY EXPERIENCE SOME CHANGES IN MY INTAKE, WEIGHTS, LABS RELATED TO BEING A NEW [MEDICAL TREATMENT] PATIENT. ADJUSTMENT/ ACCEPTANCE OF NEED FOR TREATMENT. *I HAVE A FLUID RESTRICTION ORDERED RELATED TO [MEDICAL CONDITION]. *I AM NON-COMPLIANT WITH FOOD/FLUID RESTRICTIONS." ON 11/2/11 AT 10:05 A.M., REVIEW OF A DIETARY PROGRESS NOTE DATED 7/29/11, DOCUMENTED RESIDENT #804 had a history of [REDACTED]. SUBSEQUENT PROGRESS NOTES FROM 9/13/11 THROUGH 10/26/11, DID NOT ADDRESS THE RESIDENT'S NON-COMPLIANCE WITH HIS FLUID RESTRICTIONS. ON 11/3/11 AT 10:30 A.M., DURING INTERVIEW WITH THE DIETARY TECHNICIAN CONCERNING RESIDENT #804'S FLUID RESTRICTION, IT WAS REPORTED THE RESIDENT WAS "NON-COMPLIANT". WHEN QUERIED ABOUT THE EXTRA FLUIDS OBSERVED AVAILABLE TO THE RESIDENT, THE TECHNICIAN STATED, "I CANNOT ANSWER, THAT HE SHOULD NOT HAVE ANY EXTRA FLUIDS." ON 11/3/11 AT 1:30 P.M., REVIEW OF THE FACILITY'S POLICY ENTITLED " FLUID RESTRICTION," DATED 8/2011, DOCUMENTED THE FOLLOWING (NOT INCLUSIVE): ......3. THE RESIDENT SHOULD BE DISCOURAGED FROM DRINKING ADDITIONAL FLUIDS AS THIS CAN LEAD TO IMBALANCE IN FLUID TOLERANCE OF THE RESIDENT'S BODY. ....4. RESIDENTS WHO REFUSE TO FOLLOW THE FLUID RESTRICTION SHOULD BE PERIODICALLY INFORMED OF THE RISKS ASSOCIATED WITH NON-ADHERENCE TO FLUID RESTRICTIONS. REVIEW OF THE ADMISSION FACE SHEET FOR RESIDENT #804 DOCUMENTED THE RESIDENT WAS RE-admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM (MDS) data set [DATE], DOCUMENTED RESIDENT #804 WAS ALERT AND ORIENTED, AND REQUIRED ONE PERSON PHYSICAL ASSISTANCE WITH ACTIVITIES OF DAILY LIVING. ( ) DURING THE INITIAL TOUR ON 11/1/11 AT APPROXIMATELY 10:20 A.M., RESIDENT #3 WAS OBSERVED WITH A WATER PITCHER AT THE BEDSIDE. IT WAS REPORTED THIS RESIDENT RECEIVED [MEDICAL TREATMENT] SERVICES. ON 11/1/11 AT 10:30 A.M., REVIEW OF THE PHYSICIAN'S ORDERS DATED 8/16/11, REVEALED THE RESIDENT WS PRESCRIBED THE FOLLOWING THERAPEUTIC DIET: RENAL DIET WITH 1500 CC'S OF FLUID PER DAY, 840 CC'S-DIETARY, 660 CC'S-NURSING, GIVE HEALTH SHAKE FOUR TIMES A DAY BETWEEN MEALS IN ADDITION TO FLUID RESTRICTION. ON 11/3/11 AT 1:40 P.M., REVIEW OF THE MEAL TICKET FOR RESIDENT #3 REVEALED THE FOLLOWING AMOUNTS OF FLUID WERE SERVED: BREAKFAST: 360 CC'S LUNCH: 360 CC'S DINNER: 360CC'S THE TOTAL AMOUNT OF FLUID PROVIDED TO RESIDENT #3 FROM DIETARY EQUALED 1080 CC'S. 1080 CC'S PLUS THE FLUIDS PROVIDED BY NURSING OF 660 CC'S EQUALED 1740 CC'S OF FLUID PROVIDED TO RESIDENT #3, WHICH WAS 240 CC'S MORE THAN THE WHAT WAS PRESCRIBED BY THE PHYSICIAN. REVIEW OF THE DIETARY CARE PLAN DATED 6/9/11, REVEALED THE FOLLOWING IDENTIFIED PROBLEMS: *I REQUIRE [MEDICAL TREATMENT] R/T [MEDICAL CONDITION]. I GO TO [MEDICAL TREATMENT] THREE DAYS A WEEK. *I AM ON FLUID RESTRICTION. MY RENAL REGISTERED DIETITIAN OFFERED TO D/C THIS HOWEVER I DECLINED, BUT I REMAIN NON-COMPLIANT WITH FLUID RESTRICTIONS. FURTHER REVIEW OF THE FACILITY'S LIST OF RESIDENTS ON FLUID RESTRICTIONS REVEALED RESIDENT #804 AND RESIDENT #3 SHOULD HAVE NO WATER CUPS AVAILABLE TO THEM AT THEIR BEDSIDE. ( ) ON 11/2/11 AT 10:00 A.M., DURING THE GROUP INTERVIEW MEETING, RESIDENT #813 STATED SHE ASKED FOR PAIN MEDICATION LAST WEEKEND (10/29/11), BETWEEN 7:30 P.M. AND 8:30 P.M., AND DID NOT RECEIVE HER PAIN MEDICATION UNTIL APPROXIMATELY 11:00 P.M. THAT NIGHT. DURING AN INDIVIDUAL INTERVIEW ON 11/3/11 AT 9:00 A.M., RESIDENT #813 STATED, "I THINK THE WEEKENDS ARE THE WORST (FOR EXPERIENCING PAIN)...I HAD TO WAIT FOR MY PAIN MEDICINE ALMOST FOUR HOURS. I TOLD AN AIDE THAT CAME AND WENT OUT OF MY ROOM AT LEAST THREE TIMES THAT I WAS STILL WAITING...THE AIDE STATED SHE WOULD LET SOMEONE KNOW... I WENT OUT TO THE HALLWAY...I COULDN'T TAKE IT ANYMORE... BY THEN I WAS CRYING. I HAD REACHED MY TOLERANCE LEVEL." RESIDENT #813 STATED, "I DID NOT RECEIVE MY PAIN MEDICINE UNTIL 11:00 P.M." DURING RECORD REVIEW ON 11/2/11 AT 12:40 P.M., RESIDENT #813'S FACE SHEET REVEALED SHE WAS ORIGINALLY admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. REVIEW OF THE "ADMISSION NURSING ASSESSMENT" SHEET, DATED 10/22/11, REVEALED RESIDENT #813 REQUIRED THE ASSISTANCE OF ONE PERSON FOR TRANSFERS, AMBULATION, DRESSING, TOILET USE, AND ACTIVITIES OF DAILY LIVING (ADL'S) DUE TO IMPAIRED MOBILITY. THERE WAS NO EVIDENCE A PAIN ASSESSMENT WAS COMPLETED ON ADMISSION. REVIEW OF RESIDENT #813'S PHYSICIAN'S ORDERS, DATED 10/22/11, REVEALED RESIDENT #813 WAS PRESCRIBED [MEDICATION NAME] (MEDICATION FOR PAIN) 5 MG/325 MG (MILLIGRAM), 1-2 TABLETS, PO (BY MOUTH), Q (EVERY) 4 HOURS AS PRN (AS NEEDED). DURING A REVIEW OF RESIDENT #813'S Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"PROOF OF USE SHEET", IT WAS REVEALED RESIDENT #813 RECEIVED [MEDICATION NAME] 5 MG/325 (PAIN MEDICATION) ON 10/29/11 AT 3:00 A.M., 9:00 A.M., 4:30 P.M., AND 11:00 P.M. (AFTERNOON SHIFT). PRE-MEDICATION PAIN LEVELS DOCUMENTED BY NURSING STAFF FROM 10/23/11 TO 10/31/11, REVEALED THE RESIDENT WAS NOT CONSISTENTLY ASSESSED FOR PAIN EACH SHIFT. WHEN THE NURSES DOCUMENTED THE RESIDENT'S PAIN WAS ASSESSED, THE RESIDENT REPORTED A PAIN LEVEL RANGED (BEFORE REQUESTING MEDICINE) FROM "4 TO 8" ON A PAIN SCALE OF 10, ("0" REPRESENTS "NO PAIN" AND "10" REPRESENTS THE WORST AMOUNT OF PAIN IMAGINABLE). POST-PAIN ASSESSMENT (WHICH WERE NOT COMPLETED CONSISTENTLY) INDICATED THE RESIDENT'S PAIN WENT TO A "2" AND ONLY ONCE, ON 10/26/11 AT 10:00 P.M., THE RESIDENT INDICATED SHE WAS TOTALLY "PAIN-FREE". ON 11/3/11 AT 3:05 P.M., DURING INTERVIEW WITH AFTERNOON SHIFT REGISTERED NURSE (RN) "E" (WHO PROVIDED CARE TO RESIDENT #813 ON 10/29/11), IT WAS REPORTED THAT SHE CALLED THE PHARMACY TWICE FOR A "STAT ORDER" OF 15 TABLETS OF [MEDICATION NAME] TO BE GIVEN EVERY 4 HOURS (SCHEDULED). REGISTERED NURSE "E" FURTHER STATED, "THE MEDICATION WAS NOT HERE (ON 10/29/11)... THAT'S WHY I HAD TO CALL FOR A STAT ORDER." ON 11/3/11 AT APPROXIMATELY 3:20 P.M., DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING REGARDING RESIDENT #813'S PAIN MANAGEMENT, NO EXPLANATION WAS PROVIDED. REVIEW OF THE FACILITY'S PAIN MANAGEMENT POLICY, DATED 1/11 INDICATED THE FOLLOWING: "PAIN EVALUATION MUST BE COMPLETED UPON ADMISSION... THE ORIGIN, LOCATION, SEVERITY, ALLEVIATING, EXACERBATING FACTORS, CURRENT TREATMENT, AND RESPONSE OF TREATMENT..." THERE WAS NO EVIDENCE THIS WAS DONE. ( )