Every finding on record at The Villa at Silverbell Estates

This citation pertains to intake: 3006638.Based on interviews and record reviews the facility failed to ensure consistent and appropriate wound management by not completing an admission Braden assessment, not ensuring the timely implementation of wound treatments as ordered by the wound clinician, failing to consistently provide prescribed wound care treatments, failing to timely identify and report to the Physician of the worsening of the wound, and failing to complete labs as directed by the Physician for one (R404) of one resident reviewed for pressure wounds, which resulted in a change of condition and required prolonged hospitalization. Findings include:A review of a complaint submitted to the State Agency (SA) documented in part . the resident was admitted to the hospital with a major infection, rectal bleeding, and stage 3 (full-thickness loss of skin, in which fat may be visible in the ulcer) and stage 4 (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) bedsores with infection to the bone. The complainant states the doctors are trying to be hopeful but don't know if the resident will recover.On 6/1/26 at 10:12 AM, a telephone interview was conducted with the complainant. When asked, the complainant reported that R404 was still hospitalized at a higher acuity specialty hospital receiving intravenous antibiotics for their infection from their bedsore.A review of the medical record revealed R404 was admitted to the facility on [DATE], with diagnoses that included: hemiplegia (paralysis of one entire side of the body) and hemiparesis (muscle weakness or partial paralysis affecting only one side of the body) following intracerebral hemorrhage affecting the right dominant side and mild cognitive impairment. The resident was dependent on staff for all Activities of Daily Living (ADLs).A review of the admission skin assessments revealed two assessments completed. The first assessment dated [DATE] at 10:58 PM, documented the resident's skin integrity to be Intact. The second assessment dated [DATE] at 1:21 AM, documented the skin integrity to have Open areas.A review of a Nursing note dated 2/16/26 at 9:08 AM, documented in part . Resident with pressure wound. Small open area noted to coccyx.A review of the medical record revealed no documentation of an admission Braden to have been completed.A review of a facility policy titled Skin Protection Guideline dated 7/7/21, documented in part . Our facility utilizes the BRADEN Scale. It is an evidenced based tool that provides a scale to identify potential categories that would contribute to conditions for breakdown. Our facility may utilize the Braden Scale. Upon admission and re-admission.A review of the February 2026 Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented . Wound Care for open area to sacrum: Cleanse sacrum with normal saline, pat dry, apply TAO (triple antibiotic ointment), cover with border foam dressing; one time a day. The first application of this order was noted at 2/18/26, two days after the resident admitted to the facility.A review of an admission Nutrition Assessment dated 2/17/26 at 10:59 AM, revealed no documentation of the identified coccyx/sacrum wound.A review of a facility policy titled Skin Protection Guideline dated 7/7/21, documented in part . The dietician will be notified. With changes in skin integrity.On 6/2/26 at 2:49 PM, Registered Dietician (RD) B was interviewed and asked how they obtain their information to complete the admission nutritional assessments. RD B explained they review the chart and hospital documentation. When asked why the admission nutritional assessment for R404 failed to identify their pressure wound and a collaborative interdisciplinary approach for wound healing, RD B replied they would like to look into their notes and follow back up. At 3:16 PM, RD B returned and acknowledged they failed to identify the wound on the admission assessment due to reviewing the admission skin assessment that noted the resident's skin to be intact.A review of a wound consultation dated 2/19/26, documented in part . Wound #1 Coccyx is a Stage 2 Pressure Injury Pressure Ulcer. Initial wound encounter measurements are 0.7cm (centimeters) length x 1cm width x 0.1 cm depth, with an area of 0.7 sq (square) cm and a volume of 0.07 cubic cm. There is a small amount of sero-sanguineous drainage (watery, clear, or slightly yellow/tan/pin fluid separated from the blood and presents as drainage) noted. Plan. Cleanse wound with Normal Saline. Apply Calcium Alginate QDay (everyday)/PRN (as needed) Apply Triad Paste QDay/PRN - To periwound. Cover with secondary dressings. Plan of Care discussed with Treatment Nurse. Nursing home staff was instructed to monitor aforementioned wounds for erythema, purulent discharge, fever, any sign of infection, or any worsening of the documented wounds. Nursing home staff has been advised to contact the provider in the event of any of these changes become evident in the aforementioned wounds.A review of the Physician orders and TARs and MARs revealed the facility staff failed to implement the above order as instructed by the wound clinician.A review of the medical record revealed no explanation on why the order was not implemented. The facility staff continued to apply the triple antibiotic ointment to the wound.The resident was seen by the wound clinician on 2/26/26, 3/5/26 and 3/12/26. All consultations documented the order of . Cleanse wound with Normal Saline. Apply Calcium Alginate QDay/PRN, Apply Triad Paste QDay/ PRN - To periwound. Cover with secondary dressing.Despite the wound clinician orders for the wound the facility staff continued to apply the triple antibiotic ointment to the wound until 3/14/26.A review of the March 2026 MAR and TAR revealed no treatment applied to the residents wound on 3/15 or 3/16. On 3/17/26, the facility staff implemented the order as directed above by the wound clinician. The treatment was not applied on 3/18 or 3/19.A review of a Wound consultation dated 3/19/26, documented the following . Coccyx is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. measurements are 5cm length x 5.4cm width x 0.1cm depth, with an area of 27 sq cm and a volume of 2.7 cubic cm. The wound is deteriorating. Multiple scattered lesions. Wound is deteriorating. Plan. Cleanse wound with Normal Saline. Apply Calcium Alginate QDay/PRN - Plus Santyl, Apply Triad Paste QDay/PRN - To periwound. Wound is deteriorating. Please closely monitor. Will add Santyl to treatment plan. Will order sacral x-ray to R/O (rule out) osteo, CBC with total protein/albumin to assess nutritional status and consult dietary. Cover with secondary dressing. Plan of Care discussed with Treatment Nurse. Nursing home staff was instructed to monitor aforementioned wounds for erythema, purulent discharge, fever, any sign of infection, or any worsening of the documented wounds. Nursing home staff has been advised to contact the provider in the event of any of these changes become evident in the aforementioned wounds.A review of the medical record revealed no documentation of the facility staff identifying or reporting the worsening of the wound until identified and documented by the would clinician on 3/19/26.A review of the facility policy titled Skin Protection Guideline dated 7/7/21, documented in part . Monitoring of Skin Integrity. Skin will be observed daily during care by the nursing assistants. Should there be a change in skin integrity, the nurse will be notified for continued evaluation. If a skin concern or change is observed. The Notification of Change Guideline will be followed. Physician consulted and orders will be transcribed for treatment. The plan of care will be modified based upon root cause analysis investigation.A review of the progress notes revealed the following:On 4/19/26 at 3:49 PM, a Nursing note documented . Resident had complaints of not feeling well and is lethargic. Resident B/p (blood pressure) was 95/52, (medication name) was given b/p was rechecked 117/64. On call Doctor was contacted. gave orders for CBC & BMP, and to continue to monitor his blood pressure.A review of the medical record revealed the CBC & BMP was never completed as directed by the Physician.On 4/20/26 at 2:54 PM, a Nursing note documented . patient being transferred to hospital from dialysis center. Dialysis center was called multiple times time with no response.A review of the medical record revealed no documentation of a dialysis communication note for the date of 4/20/26.On 6/2/26 at 12:29 PM, the facility's Wound Nurse (WN) C was interviewed and asked about their responsibilities as the Wound Nurse. WN C reported they round with the wound doctor every Thursday. WN C reported they complete the wound treatments as they round and if the wound doctor changes the resident's treatment they change the treatments as ordered by the wound doctor. WN C explained they usually would change all treatment orders the following day after the wound rounds. When asked about the Braden assessments, WN C reported that Braden assessments should be done on admission and weekly for four weeks after. At this time WN C was asked to have the Director of Nursing (DON) join the interview. The DON explained how they were newly hired at the facility and started employment almost two weeks prior to this survey. At 12:41 PM, WN C and the DON was interviewed together. WN C and the DON were both asked about the admission Braden for R404, the consistently delayed implementation of the treatment ordered by the wound clinician for the coccyx/sacrum wound, the identified missed days of treatment to the wound, the failure of the facility staff to identify & report the worsening of the wound and the ordered CBC and BMP that was not completed. WN C and the DON stated they would look into the concerns and follow back up.On 6/2/26 at 2:02 PM, a second interview was conducted with the DON and WN C . They confirmed they were unable to find an admission Braden assessment and were unable to provide an explanation or documentation for review on the additional concerns noted above. The DON stated that the resident was known to be non-compliant with care. It was discussed that the medical record contained one note of the resident to have refused treatment changes to their wounds. The DON and WN C acknowledged the concerns and were unable to provide any additional explanation or documentation.Further review of the medical record revealed preadmission documents provided to the facility from the transferring hospital upon R404's admission to the facility that noted the following: . Discharge Info. Wound Pressure Injury 02/05/26 Coccyx. Wound Length (cm) 20. Wound Width (cm) 20. Wound Surface Area. 314.16. Slough (%) 50. Pressure Injury Stage U (unstageable).On 6/2/26 at approximately 2:10 PM, the DON and WN C was asked about the hospital documentation of the identified unstageable pressure injury and the facility's assessment to have initially identified a stage II for the same area, with treatment of only triple antibiotic ointment to have been applied and neither provided an explanation or further documentation for review.

This citation pertains to intake: 3006638.Based on interview and record reviews the facility failed to acknowledge, investigate and follow up on concerns reported by the family of one R404 of one resident reviewed for grievances.Findings included:A review of complaint submitted to the State Agency (SA) documented in part . $20.00. was missing from (R404) bedside drawer. the resident's cell phone was missing. these items went missing after (the complainant) complained to staff about the lack of care being provided to the resident. The complainant states she sent several emails to the head nurse, administrator, nursing staff and head office person, but had not received a response.A review of the medical record revealed R404 was admitted to the facility on [DATE], with diagnoses that included: hemiplegia (paralysis of one entire side of the body) and hemiparesis (muscle weakness or partial paralysis affecting only one side of the body) following intracerebral hemorrhage affecting the right dominant side and mild cognitive impairment. The resident was dependent on staff for all Activities of Daily Living (ADLs).An email thread submitted to the SA dated 4/23/26 at 9:03 AM, with confirmed receipt of the facility's Administration staff to have received it, documented in part, . Family is here to pick up belongings. Currently missing a phone, white extension cord and $20. Also he was sent to cardio with no shoes. Family attached please respond. This email response was documented by the facility's Social Service Director (SSD) D.On 6/2/26 at 12:54 PM, SSD D was interviewed and confirmed they had received an email from the family and forwarded to the correct parties. SSD D was asked to provide the email thread that revealed the parties the concern was forwarded to.A review of the email thread dated 4/23/26 provided by SSD D noted the Administrator to have been included on the email.On 6/2/26 at 12:48 PM, the Administrator and Director of Nursing (DON) were asked to provide all grievances and incident reports from admission to discharge for R404. A second request was at 1:54 PM. At 1:58 PM, the Administrator reported they had no grievances or incident reports for the resident.On 6/2/26 at 2:20 PM, the Administrator was interviewed and asked about the reported missing money, cell phone and care concerns. The Administrator stated in part . First of all, I never knew about any missing money or cellphone. When discussed that they were included in the email that reported the concerns to the facility, the Administrator stated they received one email and denied having been aware of the concerns.A review of the facility policy titled Grievance Guideline dated 11/28/17, documented in part . The facility grievance process will be overseen by the Administrator / designee who will be responsible for receiving and tracking grievances through their conclusion. A grievance or concern can be expressed orally to the Grievance Official or facility staff or in writing using a grievance form. Any employee of this facility who receives a complaint shall immediately attempt to resolve the complaint within their role and authority. If a compliant cannot be immediately resolved the employee shall escalate that complaint to their supervisor and the facility Grievance Official. the Grievance Official will review the grievance, determine immediately if the grievance meets a reportable complaint. The facility will strive for a prompt resolution outcome for all grievances or complaints rendered.No further explanation or documentation was provided for review by the end of the survey.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 05/04/2026 at 8:45 AM on a kitchen tour with Dietary Manager (DM) S observed the walk-in freezer with frozen condensate build up on shelving and floor. Also observed the interior of the walk-in cooler door damaged with the surface material pulling away from the door creating an exposed sharp edge and the surface is no longer smooth and cleanable. When queried during these observations, DM S said that repair requests have been entered in the electronic maintenance tracking system for both issues.On 05/04/2026 at 9:50 AM observed Pinegrove dining room ice machine drain tray full of water and overflowing onto the floor surface. When queried, the Regional Dietary Manager (RDM) T brought the maintenance director (MD) K to also observe the backed-up drain. MD K indicated that it would be addressed right away.On 05/04/2026 at 9:55 AM observed Pinegrove dining room resident/personal food refrigerator holding at 47 F. This was indicated on the unit thermometer and verified with a digital thermometer. When queried about monitoring of this unit, RDM T brought the Director of Nursing (DON) who indicated they are considering relocating this unit out of the central dining area where it can be more closely monitored.According to the 2022 FDA Food Code section 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair.On 05/04/2026 at 9:00 AM Observed dried red-brown debris coating the top of the dish machine and the dish machine pressure and temperature gauges, both were missing plastic covers. When queried about this, DM S indicated they had been advised to not clean around the gauges because they could get damaged. Regional Maintenance Director (RMD) R indicated that the vendor for the dish machine should be contacted for service as this is a rented unit. Also observed at this time in the dish washing area: no caulk along the gap between the stainless drainboard area and the wall surface, several missing wall tiles behind the dish machine, and a buildup of a black substance on the wall along the top of the stainless drainboard surround area on the pre-wash side where there was no caulk.According to the 2022 FDA Food Code section 4-602.13 Nonfood-Contact Surfaces. NonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues.According to the 2022 FDA Food Code section 4-402.11 Fixed Equipment, Spacing or Sealing. (A) EQUIPMENT that is fixed because it is not EASILY MOVABLE shall be installed so that it is: .(3) SEALED to adjoining EQUIPMENT or walls, if the EQUIPMENT is exposed to spillage or seepage.According to the 2022 FDA Food Code section 6-501.11 Repairing. PHYSICAL FACILITIES shall be maintained in good repair.According to the 2022 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean.On 05/04/2026 at 11:45 AM observed approximately half of the domed plate covers being used for lunch service were heavily worn and the interior surface was peeling and no longer smooth and cleanable. When queried, DM S indicated replacement plate covers will be ordered this week. According to the 2022 FDA Food Code section 4-202.11 Food-Contact Surfaces. (A) Multiuse FOOD-CONTACT SURFACES shall be: (1) Smooth; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfectionsOn 05/04/2026 at 3:45 PM observed the Beechwood dining room ice machine drain line was directly connected to the handsink wastewater discharge line. It was noted that this ice machine was temporarily out of order. When queried, RMD R indicated that the required air gap will be provided on this drain line prior to returning the unit to use. MD K followed up to indicate that a broken sensor pad was in the process of being replaced for this unit. According to the 2022 FDA Food Code section 5-402.11 Backflow Prevention.a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed.

Based on observation and interview, the facility failed to properly dispose of waste and maintain the dumpster area to mitigate the presence of pests, potentially affecting all residents in the facility. Findings include:On 05/04/2026 at 9:40 AM observed the outside garbage enclosure with several items within and adjacent to the enclosure including a pile of approximately 10 wood pallets, a grill, a small refrigerator, and a cabinet unit. Also observed many pieces of loose litter items including food wrappers and used gloves on the ground in the adjacent wooded area. On 05/04/2026 at 3:45 PM interviewed maintenance director (MD) K about the items stored in and adjacent to the garbage enclosure and it was indicated that they were intended for disposal and would be removed as soon as possible, including large items into the dumpster as space was available.

Based on observation and interview, the facility failed to maintain general repair and safe conditions of the premises. This resulted in an increased potential for safety concerns and contamination and a possible decrease in satisfaction of living (including for residents R40 and R87). Findings Include: R87 On 5/3/26 at approximately 9:37 AM, R87 was observed lying in bed. An extension cord that was covered with plastic was plugged into the wall and ran across the resident bed. The resident reported that they use the extension cord to charge their cell phone. On 5/5/26 at approximately 1:16 PM, the extension cord was still plugged into the wall and lying on the resident's bed. R40 On 5/3/26 at approximately 9:53 AM, R40 was observed lying in bed. They had an extension cord plugged into the wall and their cell phone was attached to the cord that ran across their bed. On 5/3/26 at approximately 1:20 PM, the extension cord remained plugged into the wall and the resident's phone was attached. On 05/05/2026 at 11:05 AM observed an extension cord running from wall outlet to the bed for R87. On 05/05/2026 at 2:30 PM interviewed MD K and RMD R about personal extension cord use. RMD R said that maintenance staff keeps an eye out for extension cords used in resident rooms knowing families will bring them in. And indicated they would do a sweep to remove them and then return to families. On 05/05/2026 at 2:15 PM On a tour with Maintenance Director (MD) K and Regional Maintenance Director (RMD) R observed missing and damaged floor tiles and damaged concrete around the floor drain in the Oakland Hall central shower room. Also, observed the plastic molding at the wall base separated from the wall and some was missing. Observed throughout the facility in 4 unit hallways that many of the wooden handrails are worn such that the coating has eroded leaving an exposed surface that in some places is damaged and splintered. In several locations the handrail corner endcaps were missing leaving an exposed sharp corner. During these observations, all noted items were acknowledged by MD K and RMD R and it was indicated that needed repairs will get logged into the electronic tracking system and addressed.

Based on interview and record review the facility failed to ensure irregularities identified by consultant pharmacist were addressed and noted in the resident's electronic record for five (R4, R6, R8, R11 and R36) of five residents reviewed for monthly medication regimen reviews (MRR). Findings Include:R6 A review of R6's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: type II diabetes, schizophrenia, and post-traumatic stress disorder Continued review of R6's clinical record revealed the following MRRs notes dated: 3/29/26, 2/24/26, 10/28/25, 9/10/25, and 8/24/25 documented See reports for comment. There was no documentation available in the resident's clinical record of what the reports documented and/or the physician response to the pharmacy recommendations. R8 A review of R8's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: senile degeneration of brain, type II diabetes and dementia. Continued review of R8's clinical record revealed the following MRR notes dated: 3/29/26, 2/26/26, 12/1/25. 12/28/25, 11/1/25, and 9/13/8/31 documented See reports for comment. There was no documentation available in the resident's clinical record of what the reports documented and/or the physician's response to the pharmacy recommendations. *It should also be noted that there were no MRRs noted for the months of January 2026 and October 2025. R4 A review of R4's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: senile degeneration of brain, type II diabetes and depressive disorder. Continued review of R4's clinical record revealed the following MRR note dated 3/29/26 documented See reports for comment. There was no documentation available in the resident clinical record of what the report documented and/or the physician's response to the pharmacy recommendation. R11 Review of the clinical record revealed R11 was admitted into the facility on 2/18/20 with diagnoses that included: paranoid schizophrenia, delusional disorders, vascular dementia, severe, with other behavioral disturbance, and generalized anxiety disorder. Further review of the pharmacy documentation included monthly pharmacy medication regimen reviews (MRR) from June 2025 to May 2026 that included two dates which documented See report for comment on 3/30/26 and 11/26/25. All other monthly reviews were noted as No irregularities noted. There was no documentation available in the resident's clinical record of what these reports documented, or what the Physician's response was to those recommendations. R36 Review of the clinical record revealed R36 was admitted into the facility on [DATE] with diagnoses that included: unilateral primary osteoarthritis right knee, type 2 diabetes mellitus with hyperglycemia, dysphagia oral phase, insomnia due to other mental disorder, anemia, essential hypertension, adjustment disorder with mixed anxiety and depressed mood, paranoid schizophrenia, moderate intellectual disabilities, chronic kidney disease, and acquired absence of left leg above knee. Further review of the pharmacy documentation included monthly pharmacy medication regimen reviews (MRR) from June 2025 to May 2026 that included five dates which documented See report for comment on 2/26/26, 1/29,/26, 12/29/25, 12/17/25, and 6/24/25. All other monthly reviews were noted as No irregularities noted. There was no documentation available in the resident's clinical record of what these reports documented, or what the Physician's response was to those recommendations. On 5/3/26 at 12:42 PM, the facility was requested via email, Can you clarify where the pharmacy irregularities and physician follow-up documentation is kept? I don't see those scanned into the EMR. On 5/4/26 at 10:06 AM, the facility was requested via email, Can you also follow up regarding my request yesterday for the pharmacy medication regimen reviews and where that information is maintained? I haven't received any follow up yet. On 5/5/26 at 10:15 AM, the DON was asked about the facility's process of maintaining MRRs and the physician follow-up. The DON reported those should be scanned into the EMR. When informed there were several residents that did not have information available for review, the DON reported they had a new medical records clerk.On 5/5/26 at 10:21 AM, an interview was conducted with the Medical Records Director (Staff 'L'). When asked about their process for ensuring medical records were scanned into the electronic medical records (EMR), Staff 'L' reported they had recently started working at the facility and also functioned as the central supply and unit clerk but had many documents that needed to be scanned. Staff 'L' was provided with a list of residents and the specific dates that the MRRs were noted to See Report for R4, R6, R8, R11, and R36. On 5/5/26 at 10:30 AM, the Director of Nursing (DON) reported they wanted to get clarification of what the survey team was looking for and reviewed the documentation provided to Staff 'L'. The DON was informed about the lack of MRRs available in the EMR and they reported that documentation should be scanned under the miscellaneous tab. The DON was informed that documentation was not available and they reported they would work on providing that documentation. On 5/5/26 at 11:00 AM, the DON reported they had concerns with the documentation they obtained regarding the MRRs were only showing one for R36 for December and they would follow-up with the pharmacy to try to find out more details but also reported that prior to January 2026 they were not working in the facility at that time. On 5/5/26 at 3:00 PM, during the exit conference with the Administrator, DON, Assistant (ADON), and Corporate Clinical staff while concerns were discussed regarding MRRs, the DON and Corporate Clinical staff reported they were still gathering the information requested. The DON further reported most of the dates requested were prior to them starting at the facility as well as the need to scan in many documents via medical records. The facility team were informed that the MRR information should be provided to the survey team by the exit. The Corporate Clinical staff reported they had further information to provide and the DON also expressed concern they had reached out to the pharmacy for the dates provided earlier and was informed that there were no recommendations for those dates. The facility was informed that the dates requested were directly from the pharmacy documentation in the EMR which did not indicate there were no irregularity and did document to see their report. The facility expressed frustration in not having enough time to get everything together and were informed of the multiple requests since 5/3/26. They were informed they could provide the documentation they had at this time into the EGRESS system. There was no additional documentation provided for review. According to the undated facility policy titled, Pharmacy Services Overview: .Help establish procedures for condcuting the monthly medication regimen review (MRR) for each resident in the facility .

Based on observation, interview and record review, the facility failed to ensure medications and biologicals were appropriately stored in a safe/sanitary manner in one of two medication carts, and one of one treatment cart reviewed for medication storage. Findings include:On 5/3/26 at 8:30 AM, observation of the treatment cart in the hallway outside of the small dining room revealed the cart was unlocked and there were treatment/biological supplies were stored in the cart.On 5/4/26 at 9:41 AM, observation of the medication cart with Nurse 'F' revealed the following concerns:The drawer that contained several bottles of liquids was heavily soiled with sticky debris on the bottom of the drawer.A bottle of liquid nutritional supplement was labelled as opened on 4/15/26 and was observed to have a dark tan sticky substance around the lid and on the side of the bottle.The same dark tan, sticky substance was also observed covering a package of generic heartburn relief medication that was labelled as opened on 3/25/26 in another storage compartment of the same medication drawer.When asked about the soiled status and contents in the medication cart, Nurse 'F' reported they could not offer any further explanation but would have to follow-up to clean it up.On 5/5/26 at 8:35 AM, an interview was conducted with the Director of Nursing (DON). When asked about the facility's process for monitoring medication carts to ensure they were maintained in sanitary manner, the DON reported each nurse is responsible for ensuring the carts are clean.According to the facility's policy titled, Medication Storage dated May 2022: .The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner .Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals shall be locked when not in use .

Based on observation, interview, and record review, the facility failed to ensure the call light was accessible to the resident for three (R8, R47, and R93) of three residents reviewed for accommodation of needs. Findings include:R8 On 5/3/26 at approximately 9:27 AM, R8 was observed lying in bed. The resident was alert and able to answer some questions asked. R8 reported that they were very thirsty and wanted a soda pop. The resident was asked to press their call light for assistance. The resident reported that they did not have a call light. R8's roommate stated that they would press theirs. Two Certified Nursing Assistants (CNAs) identified as CNA P and CNA Q responded to R8's roommate's call light. Both CNAs could not locate the resident's call light and told the resident they could not provide a soda pop as R8 needed to give them money to purchase it. R8 did not have the money, and the CNAs left the room. The Administrator entered R8's room and R8 again asked for the soda pop and noted that they did not have a call light to press. The Administrator was able to locate the call light and reported that the call light was out of the resident's reach and should have been placed in reach of the resident. A review of R8's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: senile degeneration of brain, type II diabetes and dementia. R47 On 5/3/26 at 10:19 AM, R47 was observed lying in bed with the head of bed elevated. The call light was observed behind the head of the bed on the mechanical portions of the bed underneath and out of reach. When asked if they knew where their call light was if they needed to ask for assistance, R47 reported they couldn't find it and if they needed help, they wouldn't be able to right now. R93 On 5/3/26 at 10:21 AM, R93 was observed seated in a wheelchair to the left side of their bed. The call light was observed on the floor on the other side of the bed. The call light was not within reach of the resident. When asked how they would request assistance, R93 reported when they were in the bed, they usually could reach it but that they couldn't right now. On 5/3/26 at 10:22 AM, Certified Nursing Assistant (CNA 'E') was about to enter the room and when asked if they were assigned to R47's room, CNA 'E' reported they were and had just started their shift. CNA 'E' entered the room and began talking with both residents. When asked about the placement of the call lights for both R47 and R93, CNA 'E' stated, Oh, why all your call lights are not on you? They should be placed here (side of bed) where they are so they can reach it. On 5/4/26 at 3:01 PM, an interview was conducted with the Director of Nursing (DON). When asked what the facility's process was for call light placement, the DON reported the call lights should be within reach wherever the resident is within the room. When asked if they had identified any issues with call light placement prior to this survey, the DON reported they did not. According to the facility policy titled, Answering the Call Light dated 11/2013: .The purpose of this procedure is to respond to the resident's requests and needs .When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident .

Based on observation, interview, and record review the facility failed to consistently identify targeted symptoms and implement non-pharmacological interventions to manage impulsive and anxious behavior prior to the administration of multiple PRN (as-needed) anti-anxiety medication for one (R5) of one resident reviewed for chemical restraints, resulting in the resident being chemically restrained for staff convenience and the inability to monitor the effectiveness of the prescribed treatment due to lack of supporting documentation. Findings include:On 5/3/26 at 10:38 AM, R5 was observed self-propelling throughout the hallway while seated in a wheelchair. R5 was attempted to be interviewed but there was no response and then proceeded down the hallway. A staff member who observed this interaction expressed use of caution because R5 was easily agitated.Review of the clinical record revealed R5 was admitted into the facility on 1/5/26 and readmitted on [DATE] with diagnoses that included: unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, epilepsy unspecified intractable with status epilipticus, traumatic subdural hemorrhage with loss of consciousness, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, adjustment disorder with depressed mood, mild neurocognitive disorder due to known physiological condition without behavioral disturbance, insomnia, repeated falls, contracture right hand, other specified disorders of brain.According to the Minimum Data Set (MDS) assessment dated [DATE], R5 had moderately impaired cognition, exhibited several mood concerns such as: had little interest or pleasure in doing things nearly every day, feeling down, depressed, or hopeless half or more of the past 14 days, trouble falling or staying asleep or sleeping too much nearly every day, feeling tired or having little energy half or more of the days, has poor appetite or overeating half or more of the days, trouble concentrating on things, such as reading the newspaper or watching television half or more of the days. There were no concerns identified with hallucinations or delusions, and behaviors.Review of the interdisciplinary progress notes included multiple EMAR (electronic medication administration record) entries of lorazepam medication being administered to R5 either orally, or via powder on the wrist. Most of the EMAR entries did not identify any details such as the specific behaviors that occurred, or what non-pharmacological interventions had been attempted (ie. combative - with no details of how, when and with who). There were a few entries that documented R5 had instances of falls that occurred after these administrations and some identified that due to R5 standing up from the wheelchair, or attempting to walk, the medication was administered. Additionally, there was no documentation to support why both the oral and powder lorazepam were administered at/near the same time in some instances.Progress notes entries included:An entry on 5/5/26 at 7:17 AM read, Resident had a witnessed fall at the nurse's station AT 0630. Resident stood up from his wheelchair in a very swift motion and dropped to the floor landing on his left knee.An entry on 5/4/26 at 11:20 PM an EMAR - Administration Note read, Lorazepam Powder Apply to bilateral wrist topically every 4 hours as needed for agitation/restlessness for 14 Days apply 0.5 mg to bilateral wrist (hairless area). There was no other documentation included of any details of behaviors, or what non-pharmacological approaches were used prior to administering this medication.An entry on 5/3/26 at 7:35 PM read, Writer observed resident on his knees in his room in front of his roommate's bed.An entry on 5/3/26 at 4:47 AM by Nurse 'N' read:Resident continues to be restless and agitated. Resident started to become combative due to trying to stand up and self transfer. PRN (as needed) administered. He was placed back in bed, in lowest position and is calm and cooperative at this time. Will continue to monitor.An entry on 5/3/26 at 4:00 AM EMAR - Administration Note read, Ativan Oral Tablet 0.5 MG Give 1 tablet by mouth every 12 hours as needed for agitation, restlessness for 14 Days. There was no supporting documentation of what specific behaviors occurred at the time of administration, or what non-pharmacological interventions were attempted.An entry on 5/3/26 at 1:05 AM by Nurse 'N' read:Resident was continuously restless, agitated, fidgeting throughout the night. Resident was trying to self-transfer multiple times. PRN was administered, writer watched him until he fell asleep. He was put in bed, in lowest position, stable. No signs of distress noted at this time. Care continues.An entry on 5/2/26 at 11:34 PM an EMAR - Administration Note read, Lorazepam Powder Apply to bilateral wrist topically every 4 hours as needed for agitation/restlessness for 14 Days apply 0.5 mg to bilateral wrist (hairless area). There was no supporting documentation of what specific behaviors occurred at the time of administration, or what non-pharmacological interventions were attempted.An entry on 4/25/26 at 3:44 AM by Nurse 'O' read:Writer observed the resident exhibiting combative behaviors toward staff who were assisting in maintaining his safety. Writer attempted to redirect the resident by engaging him in conversation about his family, which led to the resident requesting to speak with his daughter.Review of R5's Medication Administration Records (MARs) revealed in addition to the scheduled anti-anxiety medication Buspirone HCL (hydrochloride) 15 MG (milligrams) give 1 tablet by mouth three times (TID) a day for Anxiety Disorder to be given at 9:00 AM, 1:00 PM, and 9:00 PM and had been increased from 10 MG TID on 4/24/26, the resident was also prescribed an oral and powder form of lorazepam (another anti-anxiety medication) on a PRN (as needed) basis. Further review of the documented administrations revealed R5 received multiple administrations which included both oral and powder administrations without adequate indication of use (order indicated this was for agitation/restlessness) or supporting clinical rationale.The MAR documentation from January 2026 - May 2026 revealed multiple orders for the lorazepam medication that were re-ordered every 14 days. The MAR documentation revealed R5 was administered the following 58 PRN doses of lorazepam (either oral, powder, or both) from 4/2/26 - 5/4/26:Lorazepam oral tablet 0.5 MG on:4/2 at 3:38 PM4/3 at 8:11 PM4/4 at 9:33 AM4/5 at 12:55 AM4/9 at 5:15 AM, and 8:54 PM4/10 at 7:41 PM4/11 at 3:35 PM4/13 at 3:31 AM4/13 at 7:33 PM4/15 at 12:06 AM, and 9:37 PM4/16 at 2:17 PM4/18 at 8:27 AM4/20 at 2:34 PM4/21 at 2:48 AM, and 8:21 PM4/22 at 12:40 PM4/23 at 4:56 AM, and 9:25 PM4/24 at 12:29 PM4/25 at 5:56 PM4/26 at 11:06 AM4/29 at 8:33 AM4/30 at 1:20 PM5/2 at 12:38 AM, and 3:00 PM5/3 at 4:00 AM, and 9:38 PM Lorazepam Powder apply to bilateral wrist topically every 4 hours as needed for agitation/restlessness for 14 Days apply 0.5 mg to bilateral wrist (hairless area) was given on:4/10 at 8:00 AM4/11 at 3:35 PM, and 11:34 PM4/12 at 5:19 AM, 10:25 AM, and 7:18 PM4/13 at 12:42 AM4/14 at 9:43 PM4/15 at 9:38 PM4/16 at 10:12 AM, and 7:56 PM4/19 at 12:10 AM, and 3:23 PM4/20 at 1:39 PM4/22 at 8:42 AM, and 7:33 PM4/23 at 2:47 PM4/25 at 12:48 AM, and 2:18 PM4/26 at 12:14 AM4/27 at 3:50 PM5/1 at 8:54 AM, and 7:44 PM5/2 at 12:46 AM, 7:57 AM, 7:28 PM and 11:34 PM5/3 at 9:38 PM5/4 at 11:20 PM On 5/5/26 at 12:48 PM, an interview was conducted with the Director of Nursing (DON) and Assistant DON. When asked to explain the facility's process for administering PRN psychotropic medication, the DON reported the nurses should be documenting why they were giving it in the EMAR note. When asked if they should be attempting non-pharmacological interventions, the DON reported they should and that should also be documented. When asked about the lack of clinical rationale for the order for lorazepam for agitation/restlessness, the ADON acknowledged the concern and reported those were symptoms and not an indication and further expressed that would have to get clarified. When asked about the clinical rationale, the DON reported R5 has had an increase in restless behaviors since a seizure and hospitalization. When asked about clinical rationale and who was following these medications, the DON reported that was their psych provider. When asked to review the most recent psych evaluation which was from 4/2/26, the DON reported there might be others that are not scanned into the EMR and was asked to provide any additional documentation of clinical rationale from the providers (there was no further documentation provided). The DON confirmed there was no mention of R5's use of lorazepam or clinical rationale including specific targeted behaviors and justification and reasoning with using duplicate anxiolytic medication for the scheduled and PRN powder and oral anti-anxiety medication.The DON was asked why they were utilizing anti-anxiety medication for someone that is at high fall risk and has multiple attempts to get up unassisted and is at risk for continued falls if drowsy, weak and the DON reported that since the seizure, R5 had been more restless, combative with staff and held an emergency care conference with the family in which they identified the resident prefers to be more isolative than with others. When asked why that was not incorporated into the documentation and plan of care, the DON offered no further explanation.The DON was asked to review the nursing documentation for the administrations and acknowledged some staff were documenting minimal details, but that most of the administrations had no supporting documentation.According to the facility's policy titled, Psychotropic Medications Guideline dated 5/30/2025: .The resident should not start medication that is not required to treat a resident's medical symptoms, and which may cause symptoms consistent with sedation.Psychotropic medications should be the last resort for treatment and not used for staff convenience.Prior to the initiation of psychotropic medication, the facility shall document behavioral and nonpharmacological interventions unless contraindicated.If psychotropic medications are initiated or increased, the medical record should show a rationale for the change in the medication regimen and a new consent obtained.Appropriate monitoring will be documented.

Based on observation, interview, and record review, the facility failed to develop an individualized care plan to address a resident's use of psychotropic medication and specific targeted behaviors, and non-pharmacological interventions for one (R5) of 18 residents reviewed for care planning. Findings include:On 5/3/26 at 10:38 AM, R5 was observed self-propelling throughout the hallway while seated in a wheelchair. R5 was attempted to be interviewed but there was no response and then proceeded down the hallway. A staff member who observed this interaction expressed use of caution because R5 was easily agitated.Review of the clinical record revealed R5 was admitted into the facility on 1/5/26 and readmitted on [DATE] with diagnoses that included: unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, epilepsy unspecified intractable with status epilepticus, traumatic subdural hemorrhage with loss of consciousness, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, adjustment disorder with depressed mood, mild neurocognitive disorder due to known physiological condition without behavioral disturbance, insomnia, repeated falls, contracture right hand, other specified disorders of brain.According to the Minimum Data Set (MDS) assessment dated [DATE], R5 had moderately impaired cognition, exhibited several mood concerns such as: had little interest or pleasure in doing things nearly every day, feeling down, depressed, or hopeless half or more of the past 14 days, trouble falling or staying asleep or sleeping too much nearly every day, feeling tired or having little energy half or more of the days, has poor appetite or overeating half or more of the days, trouble concentrating on things, such as reading the newspaper or watching television half or more of the days. There were no concerns identified with hallucinations or delusions, and behaviors. However, there was documentation during this time of multiple administrations of as needed (PRN) anti-anxiety medication according to the medication administration records.Review of the current physician orders included scheduled anti-anxiety, anti-depressant and multiple PRN anti-anxiety medications.Review of the care plans revealed there were none initiated for R5's use of multiple psychotropic medications, including any specific targeted behaviors and non-pharmacological approaches to be attempted.On 5/5/26 at 12:48 PM, an interview was conducted with the Director of Nursing (DON) and Assistant DON to discuss the concerns regarding R5's use of multiple lorazepam orders, what the resident specific targeted behaviors were and what non-pharmacological interventions were identified to implement when needed. When asked about the lack of a care plan to address R5's use of psychotropic medication, the DON and ADON reviewed the medical record and confirmed there was none initiated and would put one in place now. When asked who was responsible to ensure this was completed, the DON reported they held weekly at-risk meetings with the MDS nurse, social worker and dietary staff to review and was unable to offer any further explanation as to why this was not done for R5. According to the facility's policy titled, Behavior Management Program dated 11/28/2017: .Ongoing evaluation of potential risks and care plan effectiveness is part of the overall treatment plan for all residents .Continue or change and update care plan accordingly .Care plan interventions are updated and made available to care giving staff .

Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms) and engage gown and glove use during high contact resident care for wound care dressing changes for one (R72) of one reviewed for Enhanced Barrier Precautions. Findings include.Clinical record review revealed R72 was admitted to the facility for long term care on 7/24/23 with a medical history of Chronic Obstructive Pulmonary Disease (COPD) malnutrition, and peripheral vascular disease. A Brief Interview of Mental Status (BIMS) dated 2/2/26 scored 8/15 indicating R72 had mild cognitive impairment.On 5/03/26 at 10:03 AM, during initial pool interview, R72 was observed with their right foot elevated on a thick folded blanket dressed in white gauze and closed with tape. When inquired, R72 said they had a sore on their ankle, and the Nurses are putting medications on it. Upon exiting the room there was no signage observed for R72 on Enhanced Barrier Precautions (EBP).Record review revealed on 4/24/26 R72 was identified with an open vascular wound to their right outer ankle. Review of the care plan and orders for EBP were not documented.On 4/25/26 orders were implemented to apply Santyl Ointment (topical medication used to remove dead or damaged tissue from wounds) apply to right ankle topically every day shift for wound care, cleanse open area with normal saline apply Santyl to wound bed and cover with moistened gauze with Dakins (antiseptic medication) and cover with gauze.On 5/4/26 at 1:35 PM, an observation of Licensed Practical Nurse (LPN) B was conducted changing the right foot dressing. LPN B was observed not donning Personal Protective Equipment (PPE), specifically a gown. The soiled gauze dressing was removed, and LPN B hair was observed draping loosely over and touching into the removed soiled dressing.When questioned if R72 was on precautions for the dressing change, LPN B stated they did not have an active infection and did not require enhanced barrier precautions. LPN B indicated there was no sign and PPE cart in front of the room which is how they would know R72 was on precautions.On 5/4/26 at 2:10 PM, the Director of Nursing (DON) and Infection Control Register Nurse (RN) C were interviewed and questioned if Enhanced Barrier Precautions were indicated for R72's right wound dressing. Both acknowledged wound care that required dressing changes were to be on enhanced barrier precautions. The DON acknowledged R72 was not on precautions.

This citation pertains to intake #2737537. Based on interview and record review, the facility failed to honor an advanced directive for one resident (R902) of one resident reviewed for code status/advanced directives, resulting in five rounds of CRP/chest compressions (Cardiopulmonary Resuscitation) being performed against their wishes and subsequent emergency transfer to an acute care hospital. Findings include:On [DATE] a concern submitted to the State Agency (SA) was reviewed which alleged the facility did not honor a residents' advanced directive/code status.On [DATE] at 10:59 a.m., during an interview with the Director of Nursing (DON), the DON was queried if the facility had completed any recent CPR/Code events on any younger male residents in the facility, and they reported that R902 had a Code Blue ran on them in late January/early February.On [DATE] at approximately 11:05 a.m., The DON was queried regarding R902's CPR event on [DATE] and they reported they had identified some issues with the process of administering CPR to R902. The DON reported the Nursing staff that had performed CPR on R902 had failed to check R902's advanced directive and that after review of the event, R902 had signed a DNR (Do-not resuscitate) form and should not have had CPR performed on them. On [DATE] the medical record for R902 was reviewed and revealed the following: R902 was initially admitted to the facility on [DATE] and had diagnoses including Osteomyelitis of Left hand and Major depressive disorder [recurrent].A facility document titled Code Status-Elective Form that was signed by R902 and their attending Physician on [DATE] revealed the following: [checked] Do Not Resuscitate-(No Code) Code Status: DNR-Do not attempt resuscitation.Do-Not-Resuscitate Order. I have discussed my health status with my Physician.I request that in the event my heart and breathing should stop, no person shall attempt to resuscitate me. This order is in effect until it revoked by me. Being of sound mind, I voluntarily execute this order, and I understand its full import.A Physician's order dated [DATE] revealed the following: Advance Directive: DNRA Social service evaluation dated [DATE] revealed the following: 8. Does the resident have advanced directives? [Yes].If yes, check all that apply: G. DNR.Are copies of the Advanced Directive in the resident's chart? 12. [Yes].An incident/accident note dated [DATE] at 23:20 revealed the following: Resident found unresponsive on bathroom floor. No respirations and no palpable pulse noted. Pipe and cigarette lighter observed on bathroom floor next to resident; substance unknown. Code Blue initiated. CPR started immediately by staff at 23:03. Five rounds of CPR completed. Resident regained spontaneous respirations and palpable pulse prior to EMS (Emergency Medical System) arrival. Oxygen applied per protocol. Resident remained unresponsive but breathing spontaneously. EMS arrived and assumed care. Resident transferred out of facility for higher level of care.On [DATE] at approximately 11:45 a.m., Nurse Supervisor G (NS G) was interviewed regarding the Code Blue that was conducted on R902 on [DATE]. They reported that R902 had been found in the bathroom and was unresponsive with no pulse and no respirations. NS G reported they had performed CPR on R902 as a result. NS G was asked if the Nurses that performed CPR had verified R902's code status before starting it and they reported they did not because they had thought that R902's Nurse had previously verified it. NS G reported it was the Nursing standard to quickly verify code status of a resident before starting CPR. NS G reported they gave five rounds of chest compressions to R902 in which R902 regained a pulse and the code was transferred to EMS when they arrived. On [DATE] at approximately 12:35 p.m., Social Service Director G was asked if they had discussed advanced directives with R902 during their initial assessment and they reported they had and that R902 had stated they wanted to have a code status of DNR because it was their choice and that's what they were in the hospital. SSD G was asked if they had explained that DNR means to R902 and they reported they had.On [DATE] at approximately 12:58 p.m., Nurse I was queried regarding the Code Blue conducted on R902. They reported they were R902's Nurse at that time but did not perform any CPR on them. They reported that Nurse G had performed the CPR on R902. Nurse I was asked if they had verified R902's code status before the Nursing team had started CPR and they reported they had not and that they had learned later that R902 was a DNR and CPR should not have been performed. On [DATE] at approximately 2:24 p.m., during a conversation with the Director of Nursing (DON) the DON was queried regarding the Past Non-Compliance pertaining to R902's Code Blue and they reported that all Nurses had been in-serviced on the appropriate steps to take when a resident is found unresponsive including checking the advanced directives of the resident. The DON Stated the management had audited the faculty's medical records and corrected any inconsistencies with Advanced Directives and that chart audits were ongoing.A facility document titled Coaching/Corrective Action document for NS G dated [DATE] revealed the following: Written Warning .Reasons [Job Performance] .Details of Offense-Staff failed to acknowledge resident correct advance directive code status .A facility document titled Advanced Directives was reviewed and revealed the following: Policy Statement-Advance directives will be respected in accordance with the state law and facility policy .10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive .A secondary document titled Advance Directive revealed the following: It is extremely important to know the patients code status or advanced directives before administering CPR. If a patient is unresponsive without a pulse, please check for code status before initiating CPR. If that patient is without a pulse and is DNR, do not perform CPR. Alert management and authorities to your findings. If that patient is a full code or allows for CPR, please initiate compressions immediately. Nurses, please lean who your DNR residents are at that start of your shift to prevent having to wait for someone to look through the chart before you can start CPR. Please respect the patient's wishes. this is a legal document .During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included.Nursing education on advanced directives and a facility audit on advanced directives in all resident charts. The facility was able to demonstrate monitoring of the corrective action and maintained compliance

This Citation pertains to Intake #2685189Based on observation, interview and record review the facility failed to ensure a safe transfer via a Hoyer lift for one (R701) out of two residents reviewed for falls, resulting in R701 sustaining a fracture to the right femur that required surgery and an extensive hospital stay. Findings included: Based on observation, interview and record review the facility failed to ensure a safe transfer via a Hoyer lift for one (R701) of two reviewed for falls, resulting in a fall with fracture to the right femur, pain and Hospital stay. Findings include:On or about 11/21/25 a FRI (Facility Reported Incident) was reported to the State Agency (SA) that noted on 11/21/25, R701 was being transferred from their bed to a wheelchair via a Hoyer lift and the sling snapped and the resident fell to the floor. R701 complained of pain , x-rays were ordered, and the resident was sent to the Hospital.Hospital records dated 11/21/25 were reviewed and documented, in part: (R701) .is coming from (facility) for concerns of right femur fracture. She was in a Hoyer lift when it broke, causing her to fall to the floor. Patient states that she fell about 2 feet. Additional orthopedic hospital records noted: The patient sustained a mechanical fall landing from a Hoyer lift directly onto the hip with immediate onset of pain and inability to ambulate prompting a visit to our emergency room where she was diagnosed with a closed, displace R (right) proximal femur fracture.no issues with the hip prior to this incident.Physical Exam: Gen: alert and oriented.we discussed their signs, symptoms and imaging at length. We discussed surgical versus conservative measures. At this time, the recommendation was made to proceed with surgical management in the form of R hip nail to avoid complications associated with conservative management including bed sores.On 12/17/25 at approximately 10:11 AM, R701 was observed lying in bed. The resident was alert and able to answer questions asked. R701 was asked about the accident that occurred on 11/21/25. They reported that there was something wrong with the Hoyer lift and they fell and fractured their hip and had to stay in the hospital. R701 noted that they were still in pain, but it was getting better.A review of R701's clinical record revealed R701 was initially admitted to the facility on [DATE] with diagnoses that included: fracture right femur, morbid obesity, type II diabetes and schizoaffective disorder. The resident most recent BIMS (Brief Interview for Mental Status) score was 15/15 (intact cognition). A review of the facility's Incident/Accident (IA) report and accompanying interviews documented the following:11/21/25: Incident Summary: On 11/21/25 at 10:43 AM, staff was transferring (R701) from the bed to the wheelchair with a Hoyer lift. While transferring the Hoyer sling snapped and resident fell to the floor.Certified Nursing Assistant (CNA) A statement: I.worked on 11/21/25 on the day shift. I was assigned to (R701)I had an orientee (CNA B) , we went into the resident room to get her up for the day, we used the Hoyer lift, while we were transferring her from the bed to the wheelchair the Hoyer sling snapped. I did notice when I put the sling under her is <sic> wasn't that much room. I did not notice the sling had frayed edges. After she fell the nurse came and assessed she was right outside the door.CNA B statement: I.worked 11/21/25 on the day shift, I was orienting with (CNA A) and I went into the room to get the resident up, she was being transferred from the bed to the wheel chair with a Hoyer lift, when we were transferring her the slip snapped and the resident fell to the floor. *It should be noted that an attempt to contact CNA B was made on 12/17/25 at approximately 11:06 AM. A voice message was left. No contact was made with CNA B prior to the exit.On 12/17/25 at approximately 11:31 AM, a phone interview was conducted with CNA A. CNA A was asked about the incident involving R701 on 11/21/15. They reported they were assigned to R701. They were working with CNA B who was in training. They wanted to transfer the resident from their bed to their chair. They went and grabbed a Hoyer sling from the laundry area as that is where the slings were kept. They noted that they did not really take a good look at it before they placed it underneath the resident. They then hooked it to the lift and tried to get R701 out of bed and the sling tore and the resident fell to the floor. They immediately grabbed a nurse to come assess the resident. CNA A reported that after the incident they saw that the sling was old and slightly ripped. They noted that they received education as to the use of Hoyer lift including the slings.On 12/17/25 at approximately 11:50 AM, Laundry Staff 'C and Laundry Manager (LM) D were interviewed in the laundry room. They both reported that they were not employed by the facility but worked for a contracted laundry service. When asked about how Hoyer slings are cared for LM D stated that they had a number of slings that are washed in the laundry room and then pointed to an area where they are stored. LM D stated that they were made aware of the incident that occurred with R701 and currently they changed their protocol regarding Hoyer sling care. They stated they look them over carefully and if they are not in good condition they get replaced. They also stated that they now make sure that the size of the sling is visible to all staff.On 12/17/25 at approximately 1:00 PM, an interview was conducted with the Director of Nursing (DON) and the Administrator regarding the incident. They noted that the sling that was used on 11/21/25 was not in good standing and should not have been used for transfer. The Administrator reported that following the fall the facility reeducated staff on how to assess the slings prior to use, in addition all the residents that needed a Hoyer for transfer were reviewed. In addition, new Hoyer slings were purchased and those not in good condition were thrown out.During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included equipment review and new purchases, care plans and kardex review, mechanical lift check list and staff education and labeling slings. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to Complaint #2582127.Based on observation, interview, and record review, the facility failed to report an injury of unknown origin to the Administrator/Abuse Coordinator within the required timeframe for one (R801) of two residents reviewed for abuse. Findings include: A review of a complaint submitted to the State Agency revealed an allegation that on 7/25/25 at 8:00 PM, R801 was observed to not be herself, she wasn't speaking and seemed to have a change in condition. It was alleged R801 had bruising around the resident's collar bone area. A full body assessment was completed, the Administrator was contacted, and R801 was sent to the hospital for further assessment. It was alleged R801 was dropped from the (mechanical) lift by (Certified Nursing Assistant - CNA 'B' earlier in the day.On 9/2/25 at 8:07 AM, an interview was conducted with the complainant. When queried about what happened with R801, the complainant reported they believed R801 was injuring while being given a shower by CNA 'B'. The complainant reported R801 had a broken collar bone and significant bruising on her body. When queried about whether R801 was able to say what happened, the complainant reported at the time of the injury, R801 had a change in condition and was not as responsive as they typically were. The complainant asked other staff if that was normal for R801 and they said it was not and R801 was sent to the hospital.On 9/2/25 at 10:18 AM, R801 was observed lying in bed. When asked if she recently had an injury, R801 reported she did. When asked how it happened, R801 stated, I fell. When asked for additional details and how the fall occurred, R801 stated, I don't remember. When asked what kind of injury she had, R801 stated, I don't remember but said it was her shoulder. A review of R801's clinical record revealed R801 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: dementia and contracture of the left hip. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R801 had moderately impaired cognition, no behaviors, had impairment to one side in the lower and upper extremities, required substantial/maximal assistance for showers/bathing and rolling left and right, and was dependent on staff for assistance with standing from a sitting position, transferring from the chair to bed and the bed to chair, toilet transfers, and tub/shower transfers. It was documented that R801 did not walk.A review of R801's progress notes revealed a Health Status Note dated 7/25/25 at 2:45 AM, written by Licensed Practical Nurse (LPN) 'C', that noted, Writer was notified by aide that she observed skin discoloration on right arm and breast around to middle of back from shoulder to mid trunk. Colors ranging from yellow to dark purple. per resident no pain wasn't dropped, and she didn't fall or afraid to be at facility .sending resident to hospital .A review of a Facility Reported Incident (FRI) submitted to the State Agency revealed the incident occurred 7/25/25 at 2:30 AM and was discovered at the same time. The incident was reported to the State Agency on 7/25/25 at 2:36 AM. It was documented in the Investigation Summary that On July 25, 2025, during care, (R801) presented with discoloration to her chest and arm area. (CNA 'B') first noted the discoloration and notified her nurse immediately. (LPN 'C') was the assigned nurse. (LPN 'C') completed an assessment and reported the findings to the Administrator as an Injury of Unknown Origin .(R801) stated that she did not recall anything happening to her .Physician was notified, and order was obtained to have patient transferred to hospital for further evaluation related to discoloration and history of chronic fractures. (R801) was admitted to (hospital). All x-rays and MRIs were negative for acute fractures .received a blood transfusion for her anemia and re-admitted back to (facility) .A review of the nursing staff schedule, assignment sheets, and time punches for CNA 'B' for 7/24/25 and 7/25/25, revealed CNA 'B' was assigned to R801 on 7/24/25 during the afternoon shift and punched out at 10:30 PM, four hours prior to when LPN 'C' reported the injury to the Administrator (at 2:30 AM on 7/25/25). On 9/2/25 at 1:20 PM, an interview was conducted with CNA 'B' who was assigned to R801 on 7/24/25 during the afternoon shift. CNA 'B' acknowledged she was familiar with R801 and was assigned to her on 7/24/25. When queried about what happened during that shift, CNA 'B' reported she did not know what actually happened, but she noticed bruising to R801's arm. CNA 'B' asked another CNA if that was normal for the resident and they said it was. CNA 'B reported another CNA assisted R801 into bed and CNA 'B' then undressed R801 to wash her up and put a gown on and I started freaking out because it (the bruising) was really bad. CNA 'B' said R801 had bruising to the right side of her arm, under her breast, and going down her back. CNA 'B' ran to get the nurse because she had not worked with R801 in a while and asked the nurse to assess the resident. CNA 'B' explained the nurse came to R801's doorway and did not enter the room, then asked CNA 'B' to feel under R801's arm for warmth and said it meant she did not fall and walked out of the room. CNA 'B' said she started asking R801 questions about what happened and R801 said she did not know. R801 said she did not have pain, but CNA 'B' said when her arm was moved or when touched it was obvious that she had pain. CNA 'B' said she told the next shift CNA what was going on and heard they sent the resident to the hospital the next day. When queried about the time when she notified the nurse, CNA 'B' reported it was around 7:00 or 8:00 PM. R801 was in a wheelchair at the beginning of the shift. R801 needed to be changed but refused to lay down and wanted to wait for her husband. Assistance was provided with dinner. And around 7:00 PM or 8:00 PM, CNA 'F' helped CNA 'B' put R801 in bed and that was when the bruising was seen. When queried about what the bruises looked like, CNA 'B' reported they were various colors that ranged from yellow, green, and burgundy. When queried about the facility's protocol for when a resident had a suspicious injury of unknown origin, CNA 'B' explained they reported to the nurse and Administrator. CNA 'B' explained she only reported to the nurse.On 9/3/25 at 9:05 AM, an interview was conducted with CNA 'I' via the telephone. CNA 'I' confirmed she was assigned to R801 on 7/23/25 on the midnight shift (approximately one whole day prior to when the bruising was reported to the Administrator). When queried about R801 and if she was aware of any injuries to the resident, CNA 'I' said on 7/23/25 she noticed bruises to R801's breast area and said the bruises did not appear fresh and stated, It was more like it had been there for a minute. When queried about what she did after she noticed the bruising, CNA 'I' said she did not do anything and said the previous CNA did not report anything to her. CNA 'I' said she should have notified the nurse.On 9/3/25 at 9:15 AM, an interview was conducted with CNA 'F' via the telephone. CNA 'F' confirmed she worked on the afternoon shift on 7/24/25 and was not R801's assigned CNA. When queried about any interaction she had with R801 on that shift, CNA 'F' reported a coworker asked for help getting R801 into the bed. When they got R801 into the room, CNA 'F's coworker (CNA 'B') showed her the bruises on R801's arm. CNA 'F' said they did not know what happened and R801 said she did not remember so CNA 'B' talked to the nurse. CNA 'F' reported she transferred R801 into the bed by picking her up around her back and once in bed CNA 'B' took over providing care and CNA 'F' left the room. On 9/3/25 at 9:32 AM, an interview was conducted with CNA 'G' via the telephone. CNA 'G' confirmed she worked on 7/24/25 on the afternoon and midnight shifts. When queried about what happened with R801, CNA 'G' reported around shift change, at approximately 11:00 PM, the nurse on shift (LPN 'C') asked CNA 'G' if she was familiar with R801 and if how she was presenting was normal for the resident. CNA 'G' said when she saw R801 she was not in the condition she was usually in. CNA 'G' said R801 was not responding to staff's questions and appeared out of it. CNA 'G' reported R801 typically communicated with staff. CNA 'G' said she saw a dark colored bruise on her breast, back area, and collar bone area. CNA 'G' stated, I was really concerned about the resident. At that time, LPN 'C' called 911 and reported it to the Administrator. Further review of the facility's FRI investigation revealed the following handwritten and signed statements from staff:CNA 'H' (worked the midnight shift on 7/24/25) - Around 1 (1:00 AM) I was approached by the nurse, she asked if I was familiar with (R801) .She said another aid <sic> brought it to her attention (R801) had bruises and since she was unfamiliar with her she wanted me to verify if any abnormalities were found. When she went to assess (R801) I went with her and did notice that (R801) had very bad bruising on her right side under her arm and it went up to her breasts and down her back in about a foot's length. I told her it was not normal. She started to report the incident .CNA 'I' - I had (R801) July 23, 2025 .When I changed her I saw bruises. I believe on her chest and/or arm .Other than that I don't recall the last time I had that set. Also, no one told me about them, so I assumed someone knew. I should have told the nurses!CNA 'G' - I was asked by (LPN 'C') to come in the room (R801) to assess the resident. (LPN 'C') look at the patient arm and noticed bruises on her left arm. (LPN 'C') observed the patients skin for assessment also (LPN 'C') pulled the gown down to look further and noticed a big bruise on her chest, left breast and also noticed a large lump on shoulder near chest area. She immediately contacted the administrator. (LPN 'C') asked multiple staff did anyone know how her patient status is and everyone said they don't know what was her status before this state that she was in . I told (LPN 'C') this was not her normal state she is usually very alert and responsive. And the patient was not really responding to questions that (LPN 'C') was asking. (LPN 'C') sent patient out for evaluation due to the condition she was in.CNA 'B' (telephone interview) - .(CNA 'F') put her (R801) to bed .her right arm was yellow/green around 8pm .She didn't want to lay down .When (CNA 'B') undressed her she noticed the rest of her bruises on the right side of body .Reported to (LPN 'C') .Asked resident if she fell and resident stated 'I don't remember' .no pain except to the touch .LPN 'C' - Writer was informed by aide resident have a bruise on right arm. The aide stated she's not familiar with the resident and don't know if it's the normal for resident. Writer responded telling aide I'm not familiar with the resident, but it's not orders for skin injuries. Writer proceeded to the room with a aide who know resident. That is when writer notice the resident had more than just bruise on the arm. Writer observed discoloration and a know the size of a grapefruit. Writer asked resident did she fall or get injured. Resident stated no. Proceed to ask if afraid to be in facility. Resident said no. Writer contacted Administrator at this time to report abuse.On 9/3/25 at 12:01 PM, an interview was conducted with the Administrator who was the Abuse Coordinator for the facility. The Administrator was not employed by the facility at the time on the investigation. The former Administrator was no longer employed with the facility. The Administrator was asked to explain the facility's protocol when an injury of unknown origin was identified. The Administrator reported if an injury is identified, it was reported to the nurse, but that it should always be reported to the Administrator as well. When queried about what was considered an injury of unknown origin, the Administrator reported anything abnormal such as a bruise, cut, or open area that cannot be explained should be immediately reported to the Administrator. At that time, the FRI investigation was reviewed with the Administrator. When queried about the statement written by CNA 'I' that noted she identified bruising on 7/23/25 but did not report to anyone, the Administrator reported the injury should have been reported at that time. When queried about LPN 'C' not reporting to the Administrator until 2:30 AM on 7/25/25, when CNA 'B' notified her of the bruising on 7/24/25 during the afternoon shift, the Administrator reported it should have been reported immediately based on the extent of the bruising. A review of a facility policy titled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, dated 11/28/17, revealed , in part, the following: .An injury should be classified as an injury of unknown source when both of the following conditions are met .The source of the injury was not observed by any person or the source of the injury could not be explained by the resident .The injury is suspicious because of the extent of the injury or the location of the injury .or the number of injuries observed at one particular point in time of the incident of injuries over time .Investigation of injuries of Unknown or Suspicious injuries: must be immediately investigated to rule out abuse: .injuries include, but are not limited to .bruising of the .chest .and breast .bruises of an unusual size, multiple unexplained bruises, and/or bruising in an area not typically vulnerable to trauma .The facility will ensure that all alleged violations .including injuries of unknown source .are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .to the administrator of the facility and to other officials .

This citation pertains to Complaint #2582127.Based on observation, interview, and record review, the facility failed to adequately assess the resident's skin and conduct a thorough assessment for a potential change in condition for one (R801) of two residents reviewed for abuse. Findings include: A review of a complaint submitted to the State Agency revealed allegations that on 7/25/25, when rounding on the residents, R801 appeared to not be herself, she wasn't speaking and seemed to have a change in condition. It was alleged R801 had bruising around the collar bone area and was sent to the hospital. On 9/2/25 at 10:18 AM, R801 was observed lying in bed. When asked if she injured herself recently, she said she did. When asked how it happened, she said she fell. When asked for more details she said I don't remember. When asked what kind of injury she had she said I don't remember but said it was her shoulder. R801 appeared contracted in the lower extremities as her legs were bent up toward her body. A review of R801's clinical record revealed R801 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: dementia and left hip contracture. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R801 had moderately impaired cognition.A review of R801's progress notes revealed a note written by Licensed Practical Nurse (LPN) 'C' on 7/25/25 at 2:45 AM that noted, Writer was notified by aide that she observed skin discoloration on right arm and breast around to middle of back from shoulder to mid trunk. colors ranging from yellow to dark purple. per resident no pain wasn't dropped and she didn't fall or afraid to be at facility .sending resident to hospital . On 9/2/25 at 8:07 AM, an interview was conducted with LPN 'C'. When queried about R801, LPN 'C' reported when she worked on 7/24/25-7/25/25, R801 had an injury to her collar bone. LPN 'C' reported R801 was typically able to participate in conversations, but on that shift she was assessed to have a change in condition and was not as responsive as she usually was. LPN 'C' reported she confirmed the resident's presentation as being not typical with other staff who were more familiar with the resident. On 9/2/25 at 1:20 PM, an interview was conducted with CNA 'B' who was assigned to R801 on 7/24/25 during the afternoon shift. CNA 'B' acknowledged she was familiar with R801 and was assigned to her on 7/24/25. When queried about what happened during that shift, CNA 'B' reported she did not know what actually happened, but she noticed bruising to R801's arm and then when she provided care, she noticed bruising to the right side of her arm, under her breast, and going down her back and said it was really bad. CNA 'B' ran to get the nurse because she had not worked with R801 in a while and asked the nurse to assess the resident. CNA 'B' explained the nurse came to R801's doorway and did not enter the room, then asked CNA 'B' to feel under R801's arm for warmth and said it meant she did not fall and walked out of the room. CNA 'B' said she started asking R801 questions about what happened and R801 said she did not know. R801 said she did not have pain, but CNA 'B' said when her arm was moved or when touched it was obvious that she had pain. CNA 'B' said she told the next shift CNA what was going on and heard they sent the resident to the hospital the next day. When queried about the time when she notified the nurse, CNA 'B' reported it was around 7:00 or 8:00 PM. When queried about what the bruises looked like, CNA 'B' reported they were various colors that ranged from yellow, green, and burgundy.On 9/3/25 at 9:32 AM, an interview was conducted with CNA 'G' via the telephone. CNA 'G' confirmed she worked on 7/24/25 on the afternoon and midnight shifts. When queried about what happened with R801, CNA 'G' reported around shift change, at approximately 11:00 PM, the nurse on shift (LPN 'C') asked CNA 'G' if she was familiar with R801 and if how she was presenting was normal for the resident. CNA 'G' said when she saw R801 she was not in the condition she was usually in. CNA 'G' said R801 was not responding to staff's questions and appeared out of it. CNA 'G' reported R801 typically communicated with staff. CNA 'G' said she saw a dark colored bruise on her breast, back area, and collar bone area. CNA 'G' stated, I was really concerned about the resident. At that time, LPN 'C' called 911 and reported it to the Administrator. A review of an investigation conducted by the facility revealed statements written by staff that revealed the following:CNA 'G' - I was asked by (LPN 'C') to come in the room (R801) to assess the resident. (LPN 'C') look at the patient arm and noticed bruises on her left arm. (LPN 'C') observed the patients skin for assessment also (LPN 'C') pulled the gown down to look further and noticed a big bruise on her chest, left breast and also noticed a large lump on shoulder near chest area. She immediately contacted the administrator. (LPN 'C') asked multiple staff did anyone know how her patient status is and everyone said they don't know what was her status before this state that she was in . I told (LPN 'C') this was not her normal state she is usually very alert and responsive. And the patient was not really responding to questions that (LPN 'C') was asking. (LPN 'C') sent patient out for evaluation due to the condition she was in.Further review of R801's progress notes revealed no documentation by the nurse of the presentation of the discoloration to include the size and color of the discoloration. It should be noted that the progress note written by LPN 'C' only documented what the CNA reported to her. There was no documentation of how R801 was monitored after CNA 'B' reported the bruising on the afternoon shift until R801 was sent to the hospital at 2:30 AM. There was no documentation of the change in condition reported by LPN 'C' and CNA 'G' in the above-mentioned interviews.A review of R801's vital signed revealed the last vital signs were taken at 5:19 PM on 7/24/26, approximately nine hours before R801 was sent to the hospital.A review of R801's Skin Observation assessments revealed no documented skin assessment between 7/5/25 and 7/30/25. Further review of the investigation conducted by the facility revealed a statement by CNA 'I' that noted she saw bruising to R801's chest and/or arm on 7/23/25 but did not report it to anyone. On 9/3/25 at 12:30 PM, an interview was conducted with the Director of Nursing (DON). When queried about the facility's protocol when a resident had a potential change in condition, the DON stated, In an emergency like that (referring to R801) you just want to ensure the safety of the patient. When queried about what changed between the afternoon shift and the midnight shift that made LPN 'C' decide to send R801 to the hospital, the DON reported she was on vacation during that time, but R801 was sent out for bruising and did not have a change in condition. The DON reported she expected the nurses to inspect skin and pain and if the resident did not say she was in pain, the nurse probably just continued on with passing medications. The DON reiterated that she was not working during the time of the hospital transfer, but that nobody reported a change in condition, just the bruising. It should be noted that the former Administrator conducted the investigation that noted staff's statements about the change in mentation. The DON was not aware no skin assessments were completed between 7/5/25 and 7/30/25. On 9/3/25 at 12:39 PM, an interview was conducted with the Assistant Director of Nursing (ADON) who said she returned to work the day R801 was sent to the hospital. When queried about the assessment protocol when a resident had a potential change in condition, the ADON said a full assessment of the resident should be done, including skin assessment, pain assessment, and vital signs and they would be documented in the progress note and/or evaluations. The ADON did not have an explanation as to why there was no assessment or monitoring between the afternoon shift when CNA 'B' first reported the bruising to LPN 'C and 7/25/25 at 2:30 AM when R801 was sent to the hospital. The ADON reported she was not aware R801 was acting differently.

Based on observation, interview, and record review, the facility failed to prevent a fall with major injury for one Resident (R47) of two residents reviewed for falls. This resulted in actual harm for R47, who sustained a left ankle fracture, and a subsequent infection. Findings include: On 6/16/25 at 9:34 a.m., R47 was observed seated in their manual upright wheelchair in the dining room. R47 was leaning to the right side, with their weight distributed mainly over their right hip. Neither leg was supported by footrests. On 6/16/25 at 9:36 a.m., R47 stated, I was standing up to get in my wheelchair and I fell. I broke my foot a few months ago. I have healed up good .They put metal in it (surgical fixation to anchor the joint). R47 explained they fell transferring from their bed to their wheelchair, and they had to have surgery to fix their foot. R47 showed this Surveyor one finger, and stated, There was one person (staff assisting them), and I think there should have been two (staff assisting them) . Review of R47's Accident and Incident report, dated 12/05/24, revealed R47 had a witnessed fall in their room on 12/05/24 at 6:54 a.m. The report described an unnamed Certified Nurse Aide (CNA) was assisting R47 with a transfer from their bed to wheelchair when their knees buckled, and the CNA lowered R47 to the floor. After the fall, R47 complained of pain in their left ankle. R47 was assisted by two CNAs (Unnamed) back to their wheelchair. An X-ray was ordered to assess for further injury. R47 reported their pain level was 10/10 with 10 the highest pain level. The report revealed R47 was fully oriented. Review of R47's SBAR (Situation, Background, Assessment, and Recommendation) nursing assessment, dated 12/05/24 at 6:59 a.m., revealed, .(R47) had a fall. The fall was witnessed. CNA (one aide unnamed) was assisting resident with transfer from bed to wheelchair. Resident knees buckled and CNA lowered resident to floor .No injury .(R47) current fall score 5/20/25 showed (R47) remains at high risk for falls Review of R47's Minimum Data Set (MDS) admission assessment, dated 9/26/25 (prior to R47's fall with fracture), revealed they were admitted to the facility with diagnoses including stroke, hemiplegia or hemiparesis (one-sided weakness or paralysis), and dementia. The assessment revealed R47 required moderate assistance with bed mobility and transfers. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 12/15, which showed cognitive impairment. Review of R47's MDS significant change assessment, dated 12/27/25, (after their fall), revealed they required moderate assistance for bed mobility (sit to lying) and maximal assistance for transfers, and a BIMS score of 13/15, which showed they were cognitively intact. Review of R47's post-fall evaluation dated 12/05/25 at 7:03 a.m., showed a score of 6, with a score above 5 indicating a resident was at high risk for falls .The report further revealed: There is new pain, post fall. 10/10 (with 10 the highest pain) in (left) ankle There is not a noted pattern to falls. The resident does not have any injury noted. New interventions for this fall that are being implemented: Have 2 CNA's (Certified Nurse Aides) for transfers to decrease risk for falls . Review of R47's 12/08/24 health status noted showed x-ray results shared with on-call provider, and (R47) to stay on bedrest until NP (nurse practitioner) follows up tomorrow. Continue with ice and PRN (as needed) pain medications . It was unclear why the x-ray was taken three days after R47's fall, when they had pain on 12/05/25 when the fall with injury occurred. Review of R47's 12/10/2024 health status note showed R47 stated that ice continued to manage pain in LLE ankle. PMR (Physical Medicine and Rehabilitation Physician) consulted with resident and referred resident to ortho. Review of R47's 12/17/24 health status note showed R47 had an ortho consult on 12/16/24, where R47 was scheduled for an ORIF (open reduced internal surgical fixation for stabilization) of their left ankle, due to minimally displaced bimalleolar fracture of LLE ankle on 12/20/24. Review of R47's 12/21/24 health status note revealed they returned to the facility after surgical fixation of their left ankle, wearing a large cast to their left leg, with elevation prescribed. On 1/03/25 at 10:51 a.m., R47's health status note revealed, (R47) had surgery f/u (follow up) appointment on 12/30/24. Surgeon (orthopedic) reports x-rays show ok healing. Incisions healing well, retained sutures removed and steri strips applied. Resident c/o (complaints of) no pain and wants to weight bear. Physician recommendations are to allow WBAT (weight bear as tolerated) on LLE (left lower extremity) with walking boot on. Bactrim DS (antibiotic was prescribed) BID (twice daily) for 14 days, wound care for wound infection and PT (Physical Therapy) for AAROM (active assistive range of motion) .Resident is to f/u in 2 weeks . This note showed R47 required surgery and an antibiotic for an infection after their fall. On 2/01/25 at 10:15 a.m., R47's IDT (Interdisciplinary Team Note) revealed, IDT met and discussed resident risks. Clinical- (R47) had redness and swelling on incision site. Culture results came back (positive for infection) and ABt (antibiotic) was changed. (R47) encouraged to elevate and keep treatment on incision .Skin - dehisced (reopening) of incision . On 2/21/25 at 10:49 a.m., R47's nursing progress note showed, .(R47) had f/u with Ortho (physician) this date. Ortho reports that (R47) continues to have purulent (thick and milky drainage from a wound, often from an infection) drainage with positive culture. X-ray shows hardware solidly bridged. Ortho ordered continued oral antibiotics for 14 more days at 4x's a day and ordered resident to have scheduled outpatient removal of hardware ASAP (as soon as possible) . Review of R47's 3/16/35 progress note at 3:41 a.m., revealed, Infection Note: (R47) continues on oral ABT (antibiotic) Bactrim .r/t (related to) infected hardware r/t ortho surgery x 2 weeks, until 3/25/25 . Review of R47's Kardex (care instructions to CNAs), accessed 6/17/25, revealed staff were using a mechanical lift/Hoyer lift when transferring R47. On 6/17/25 at 10:16 a.m., R47 was asked to clarify how they were currently transferring. R47 reported staff were using the sit to stand lift, not a Hoyer lift, and stated some staff were transferring them with one person assistance without the sit to stand lift. R47 reported sometimes they felt safe and sometimes they did not feel safe with one-person pivot transfers, depending upon which staff were transferring them. R47 stated they wished staff would always use the sit to stand lift, as it was easier to pull up their pants, as they struggled to stand. On 6/17/25 at 12:28 p.m., CNA D confirmed they regularly worked with R47. CNA D reported they completed a one-person pivot transfer for R47 to get them in and out of bed, or to use the toilet, but used a sit-to-stand lift when R47 was weak. CNA D stated a couple weeks prior they had used a sit-to-stand mechanical lift, as R47 had a urinary tract infection. CNA D stated before R47's fall they were a one-person transfer, as R47 stood up well at that time, and after the fall they required a full body mechanical lift to transfer. CNA D confirmed R47 had increased pain after their fall in December 2025. CNA D was asked if they had told the nurse when R47 was weak with transfers and stated they had not. On 6/17/25 at 2:37 p.m., CNA E was asked how they transferred R47 to and from their bed. CNA E reported they had worked with R47 the other day and stated R47 wanted to go to bed early and required a two-person assisted stand pivot transfer to transfer them from their wheelchair to bed, as R47 was declining. CNA E reported R47 was a one-person transfer prior to their fall. CNA E was asked if they shared with the nurse, management, or therapy R47 was declining, and stated they had not. On 6/17/25 at 5:25 p.m., a phone call was made to Registered Nurse (RN) V, who the nurse the Nursing Home Administrator (NHA) confirmed had worked with R47 at the time of their fall to set up an interview. No call was returned during the survey. On 6/18/25 at 8:34 a.m., this Surveyor requested a full investigation report via email, which would have included a Root Cause Analysis (RCA) for the fall, and witness statements, and a schedule of who worked with R47 on the date of the incident when they fell. On 6/18/25 at 8:36 a.m., CNA F and CNA G were observed transferring R47 from their bed to their manual wheelchair, with R47 granting permission for Surveyor observation. CNA G was observed to assist R47 in sitting up on the edge of their bed from laying down by pulling R47 up by grasping their upper arm. CNA F and CNA G were next observed to stand pivot transfer R47 to their wheelchair by lifting them and grasping them under and around their arms, without a gait belt, both times placing R47 at risk for injury. On 6/18/25 at 8:44 a.m., this Surveyor asked CNA F and CNA G about sitting R47 up from laying down by pulling on R47's right arm and grasping them by the arms during the transfer. CNA G reported using the gait belt scared them and they believed it was more supportive to hold R47 under their arms and hold the back of their pants. Both reported they didn't have extra gait belts handy in the facility, as only therapy used them to transfer residents, and they were not in the closets and bathrooms. Both reported sometimes they used a standing mechanical lift to transfer R47 with a second person and had told nursing management they needed to be using the standing lift with R47, as this was much easier. On 6/18/25 at 9:39 a.m., the Electronic Data file system was viewed, and it was noted R47's fall investigation report nor any witness statements were not loaded. On 6/18/25 at 9:40 a.m., the NHA was asked about the investigation report. The NHA reported they had some documents, which included the SBAR and fall assessments but no investigation report, which was brought to their attention. The NHA reported they would continue to look for the report. The NHA confirmed CNA H was the staff who transferred R47 when they fell, and CNA J assisted after R47's fall on 12/05/24 when they fractured their left ankle. On 6/18/25 at 9:48 a.m., CNA H was asked what happened during a phone interview when R47 fell on [DATE]. CNA H stated they were getting R47 up for the day and normally they used a sit-to-stand mechanical lift with R47 because they maybe had a stroke. CNA H explained they stood R47 up with the sit-to-stand lift, and R47 started to rush them and was standing up and began moving more than they should have been, when they noticed R47 was about to fall. CNA H reported they tried to put R47 back into bed when their legs buckled out and they were still buckled in the lift. CNA H reported they ran out of the room to get CNA I to assist them and said R47 did not fall but was sliding towards the ground. CNA I was asked if there was another way they could have obtained assistance, as leaving R47 in a mechanical lift may have placed them at risk for further injury. CNA H stated they had to leave R47 to get assistance. CNA H reported R47 blamed them for the incident. CNA H reported CNA I came into the room to assist them, and they pulled R47 up in the lift. CNA H explained they had worked with R47 prior to the fall and had not had problems transferring them. Review of R47's Care Plan, accessed 6/18/25, showed at the time of their fall on 12/05/25 they required physical assistance, however the type and amount of physical assistance was not specified, such as one or two person transfers, and how much assistance. There was no mention in the Care Plan at that time (on 12/05/25) of any mechanical lift being designated to transfer R47, only physical assistance, unspecified. On 6/18/25 at 10:03 a.m., CNA I was asked what they observed when R47 fell on [DATE] during a phone interview. CNA I stated they were coming from the nurse's station and CNA H asked them if they could help them get R47 off the floor. CNA I was asked to describe the scene, and stated R47 was on their knees by their wheelchair with their feet bent, and one foot was underneath the wheelchair. CNA I clarified they were absolutely positive there was no lift in the room or near R47. When asked how R47 transferred at that time, CNA I stated R47 required two-person transfers or the sit-to-stand lift, at that time, and further described they were not wearing a gait belt. CNA I stated R47 reported their foot was hurting, however they did not have an x-ray done for one to two days. When asked if anything different could have occurred, CNA I reported CNA H was a newer aide at the time and said they could have asked for assistance. They did not recall the nurse who was working that day. CNA I reported they recalled filling out a witness statement and turning it into nursing management. On 06/18/25 at 10:14 a.m., CNA H was asked who the nurse was on 12/05/24 when R47 fell and stated, I don't remember. CNA H was asked if they were positive they used a sit-to-stand lift to transfer R47 and said Yes. CNA H was asked if they completed a witness statement and responded Yes. On 6/18/25 at 10:29 a.m., the former Assistant Director of Nursing, ADON W, was called, with no return call by the end of the survey. On 6/18/25 at 10:30 a.m., RN V was called a second time, with no return call by the end of the survey. On 6/18/25 at 10:50 a.m., the NHA was emailed another request for any investigation report and or witness statements related to R47's fall on 12/05/24, with no response. Review of R47's Kardex, access on 6/18/25, revealed their transfer status had been changed from a mechanical/full body lift to two-person transfers. Review of R47's therapy records, received from the facility per request, revealed their PT discharge evaluation on 9/21/24 before their fall showed they transferred with partial/moderate assistance from bed to wheelchair and return. On 6/18/25 at 10:37 a.m., the NHA was asked again about the missing investigation report and witness statements, which two staff shared they completed during interviews. The NHA reported they knew they were completed, and they would find them. When asked who oversaw the investigation, the NHA acknowledged the former ADON, ADON W, completed some of the facility documentation, and Unit Manager, LPN A, had assisted them. The NHA was asked if they had another phone number for RN V, and reported the number they called was the same as the phone number the Surveyor had called. The NHA asked this Surveyor to look in the Electronic File System to see what they had loaded. This Surveyor reviewed with the NHA and noted the SBAR, x-rays, and the Rehab physician consult but shared there was no investigation report. The NHA stated they would keep looking for the investigation report and any witness statements. On 6/18/25 at 11:13 a.m., LPN A was asked if they had R47's fall investigation report and witness statements from 12/05/24, and if they investigated R47's fall with left ankle fracture on 12/05/25. LPN 'A shared the ADON W investigated R47's fall on 12/05/24, and explained they had reviewed the fall as well. LPN A reported R47 initially had no complaints of pain, and staff were not aware they were injured. LPN A said they had not been able to find an investigation report or witness statements related to the incidents, although they had reviewed R47's risk management report. LPN A stated R47 was being transferred by two aides from their bed to wheelchair when they were lowered to the floor but then acknowledged upon further review of the risk management report with this Surveyor the report showed one aide transferred R47, and they were assisted up by two CNA's. LPN A reported the left ankle fracture was found after a couple days, when R47 developed pain. This Surveyor shared staff discrepancies from the description of the incident, including CNA H reporting they used a sit to stand lift. LPN A shared there was no report made to them or discovered during their investigation which showed R47 was on a sit to stand lift when the fall with injury occurred on 12/05/24. LPN A confirmed no x-ray was taken until 12/08/25, three days after R47's fall, as they developed pain afterwards, despite the initial reports showing 10/10 pain at the time of the incident. Review of R47's Risk Management (Accident and Incident report), dated 12/05/25, reviewed with LPN A, showed R47 was being transferred by one aide (CNA), and was assisted afterwards by two CNAs. Review of R47's Care Plan, accessed 6/18/25 with LPN A, showed at the time of their fall on 12/05/24, R47 needed physical assistance but the type and amount were not specified. LPN A reported they understood the concern, which could have led to staff inconsistencies with the level of assistance provided. LPN A confirmed therapy would be the department who made changes in the level of assistance typically, and this would not be in the CNA's scope of practice or job responsibilities, so they understood the concern. LPN A stated, Yes, there should be a number in there . designating one- or two-person assistance with transfers. Review of the Medication Administration Treatment (MAR) and (TAR) for the month of December 2024 with RN A revealed R47 had no complaints of pain on 12/05/24 documented, and 5/10 pain on 12/06/24, and 4-5/10 pain on 12/07/25, showing documentation inconsistencies. On 6/18/25 at 11:25 a.m., LPN A was asked about the observation of R47 being transferred on this date (6/18/25) by staff without a gait belt and being handled by their arms. LPN A confirmed staff should have used a gait belt for R47's transfer this morning, and they understood the concern. LPN A stated a gait belt should have been in R47's closet. LPN A was asked why it took three days for R47 to have an x-ray when staff and documentation showed they had some pain when they were injured. LPN A stated they always had generalized pain. LPN A confirmed R47's hardware became infected when their pain increased on 12/21/24 to 9/10, they received an as needed dose of narcotic pain medication (per the MAR), and were transferred out emergently. On 6/18/25 at 11:52 a.m., R47 agreed to a brief follow-up interview, stating, Go ahead. R47 was asked if staff were using a mechanical lift when they were transferred at the time of their fall with fracture on 12/05/24. R47 stated, No. Just one person (transfer assistance). On 6/18/25 at 11:58 a.m., the Rehabilitation Director, Occupational Therapist (OT), J, was asked about staff transferring R47 today (6/18/24) without use of a gait belt for the transfer in their room from bed to wheelchair. OT J stated per standards of practice a gait belt would be recommended to be used for R47, and any resident who needed more than stand by assistance (physical assistance) to transfer. OT J was asked to review the therapy documentation prior and post R47's fall with injury on 12/05/25. OT J reported they did not know this resident personally, as they were newer to their position but the PT in the building was familiar with R47. OT J confirmed R47 required moderate (partial) transfer assistance prior to their fall, and had been picked up by therapy on 5/29/25, and now required maximal assistance. This Surveyor asked if they could interview the physical therapist assistant in the building who had worked with R47 per OT J. No physical therapy staff followed up with this Surveyor by facility exit. On 6/18/25 at 12:09 p.m., the NHA was asked about no investigation report or witness statements being found by LPN A or provided in the Electronic data share system. The NHA reported they knew there was an investigation report with witness statements, and they would follow up with the DON (Director of Nursing) and continue looking for them. This Surveyor followed up with additional emails, including at 12:42 p.m. No investigation report or witness statements were received by survey exit. On 6/18/25 at 1:44 p.m., the NHA was interviewed about R47's fall with major injury, left ankle fracture on 12/05/24, and concerns found related to no investigation report, which would include a root cause analysis, and witness statements. This Surveyor shared concerns related to staff inconsistencies with how they transferred R47 at the time of the fall and currently, and the unsafe transfer observed on 6/18/25 by two staff. This Surveyor shared they were unable to reach RN V or the former ADON W. The NHA confirmed they did not have the investigation report or witness statements, and they were not received by survey exit. The NHA reported they understood the concern related to staff observed transferring R47 without a gait belt on this date and had begun education with staff. They had no additional comment regarding the other concerns. Review of the Policy, Accidents, revised 6/29/21, To ensure the environment is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents through a systemic approach. Accidents: Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. This does not include other types of harm, such as adverse outcomes that are a direct consequence of treatment or care that is provided in accordance with current professional standards of practice (e.g., drug side effects or reaction). Avoidable Accident means that an accident occurred because the facility failed to: Identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices. Evaluate/analyze the hazards and risks and eliminate them, if possible, or, if not possible, identify and implement measures to reduce the hazards/risks as much as possible. Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident. Monitor the effectiveness of the interventions and modify the care plan as necessary, in accordance with current professional standards of practice . Review of the policy, Gait Belt Use, Effective 11/28/17, revealed, A gait belt is a safety device made of cloth that buckles securely around a resident's waist. The device provides a secure grasping surface to aid during transfer and ambulation. Commonly used for residents who are at risk for falls and those who require assistance during transfer. A gait belt can support a lower ot the floor if the resident begins to fall or loses balance during transfer. A gait belt can support a lower to the floor if the resident begins to fall or loses balance during transfer or ambulation. When combined with proper body mechanics a gait belt improves caregiver safety and prevents back injury .

R80 Record review revealed R80 was a long-term resident of the facility, originally admitted on [DATE]. R80 had a recent hospitalization and they were readmitted back to the facility on 3/18/25. R80's admitting diagnoses included pneumonia, congestive heart failure, chronic kidney disease, major depressive disorder, and gout. Based on Minimum Data Set (MDS) assessment dated [DATE], R80 had a Brief Interview for Mental Status (BIMS) score 9/15, indicative of moderate cognitive impairment. R80 had a guardian (daughter) who was making decisions on their behalf. An initial observation was completed on 6/17/25 at approximately 10:20 AM, R80 was observed in their bed with a brief. They had their eyes closed but opened their eyes when called upon but did not answer to any questions. At approximately 11:15 AM, during a follow up observation from the doorway, R80 was observed with a brief only, no other clothes. Certified Nursing Assistant (CNA) T assigned to care for R80 was observed in the hallway and reported that R80 were not feeling well and did not want any clothes on and they were just trying to keep them comfortable. Later that day, at approximately 1:20 PM, R80 was observed in bed with a lunch tray on their bedside table. The tray had a sloppy joe, potatoes, vegetables and dessert. The servings appeared that they were not eaten. The tray had an empty juice glass. R80 stated that they were not hungry. R80 added that their back was bothering them and they needed someone to reposition them in bed. Review of R80's Electronic Medical Record (EMR) revealed an order dated 6/9/25 for blood tests that included CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel) and urine tests that included UA C&S (Urinalysis - Culture and Sensitivity). R80 also had an order to start Intravenous (IV) Fluids which was changed hypodermoclysis (fluids administered through skin) on 6/9/25. Review of R80's weight record revealed that R80 had weight fluctuations after they were readmitted back to the facility. The Registered Dietician note dated 6/9/25 revealed that R80 had been eating at more than 51% of their meals and they were going to monitor weights weekly. Review of R80's amount eaten record between 5/30/25 and 6/17/25 revealed 20 entries with less than 50% of intake and 9 entries where R80 refused their meals. There were no additional interventions added to address the recent change until the concern was brought to the facility's attention on 6/17/25. Review of R80's Practitioner progress note dated 6/9/25 read in part, Patient seen and examined per nursing for increase in lethargy and some disorientation .He states he is not hungry. The plan section of the note had multiple orders that included check CBC, CMP and UA C&S, nutritional support, start peripheral IV 0.9 NS (normal saline) etc. Review of R80's lab results dated 6/12/24 revealed multiple abnormal lab values including low hemoglobin, high creatinine, low protein, low sodium, low potassium etc. The results for the urinalysis (including culture and sensitivity) to rule out any infection were not in R80's EMR. Further review of R80's records did not reveal any evidence that the physician or the practitioner were notified of abnormal labs. There was no evidence of urine test results (ordered on 6/9/25) including culture and sensitivity to rule out any potential infection. There was no evidence of follow up by the physician or practitioner. There were no nursing progress notes between 6/1/25 to 6/17/25 with pertinent assessments/follow-ups on recent changes with R80's condition. There was one skin observation note and one care conference between 6/1/25 and 6/17/25. Review of the physician communication book/log revealed one entry for R80 dated 6/8/25 that read in part can we get labs, more lethargic declining . There were no further entries on the log that showed that the abnormal lab results were communicated with the physician/practitioner. An interview with CNA T was completed on 6/17/25 at approximately 11:40 AM. CNA T reported that were familiar with the resident and confirmed that they were assigned to care for R80 during that shift. They added that they typically worked on another unit. They were queried if R80 had their breakfast and how they were doing. CNA T reported that R80 had not been feeling well and they did not want to get dressed. They had put a gown on earlier and R80 had ripped it off. They added that R80 did not eat well and depended on the day and food. They added that R80 had not been feeling well and they were keeping them comfortable. An interview with Licensed Practical Nurse (LPN) C who was assigned to care for R80. They were questioned on how R80 was doing. LPN C reported that R80 refused to eat at times and they gave pain medication some time ago. LPN C also added that R80 function varied depending on the day. An interview with Unit Manager (UM) U was completed on 6/17/25 at approximately 2:35 PM. They were questioned about the R80 recent change in condition and how often physician/practitioners were following up. UM U reported that the practitioner comes into the facility three times/week to see the residents. They added that R80 was seen on 6/9/25 and they ordered labs and fluids that were administered. They were queried about the lab results. They reviewed the EMR and shared the blood test results and checked for urine test results on the lab portal. After reviewing the lab portal UM U reported that they were not able locate the urine test results. They added they believed that sample was picked up, but were not sure what happened. They confirmed that that there was no evidence on EMR and lab portal on what happened with the urine test. They added that they would check with the Director of Nursing (DON) and report back. A follow-up interview with the Unit Manager UM U was completed on 6/18/25 at approximately 8:05 AM. They were questioned if they had any additional information about the urine test results. UM U reported that they spoke with the DON and was notified that the facility had done a dip stick test (a urine dipstick test is a method to analyze urine for various substances and conditions, using a plastic strip with chemical pads that change color to indicate the presence or concentration of specific substances - Source: Mayo Clinic) and the test was negative. They were queried further about the evidence of negative dip stick test results, communication with the practitioner on the urine and abnormal blood test results. They reported that they were having problems with their lab services and they had recently taken over the responsibility for the lab follow up, approximately two weeks ago. They were not in the facility on 6/13/25 and not sure what happened. They added that they were trying to streamline the process and did not provide any further explanation. They were notified of the concern regarding timely/ongoing follow-up with change in condition and notification of physician/practitioner. UM U agreed on the concern and reported that they would be following up with their staff. An interview with R80's guardian was completed on 6/18/25 at approximately 11:45 AM. They added that they lived 45 minutes away from the facility. They added that R80 had been more withdrawn lately, in the last week. The guardian also reported that a staff member from the facility had called earlier today and notified them of the lab results from last week (after the concern was brought to the attention of the facility). An interview with the DON was completed on 6/18/25 at approximately 10:15 AM. The DON was shared on the observations and queried about urine test results that were not completed,the recent change in condition for R80, and the physician/practitioner notification on abnormal labs and their follow up. They reported that all their nursing staff did not have a log in and nursing leadership including the DON, ADON (Assistant Director of Nursing), and their Unit Managers had access. They added that unit managers had printed the labs and left in them in the physician book for review and follow up. They added they completed the urine dip stick test. They did not know if anyone had notified the practitioner of the lab results. The dip stick test results were added to the physician book. The DON did not provide any further explanation. They were notified of the concerns and they agreed and reported that they had already started educating their staff. On 6/18/25 at approximately 12:40 PM, the facility administrator was notified of the concerns with R80's overall change in condition, interdisciplinary team follow-up, physician/practitioner notification and follow up after tests were ordered. The Administrator reported the concerns were shared by the DON and they understood the concerns. A facility provided document titled Notification of Changes Guideline with a revision date of 7/24/19 read in part, Purpose: It is the practice of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate (hereafter designated as the physician). The resident and/or their representative will be educated about treatment options and supported to make an informed choice about care preferences when there are multiple care options available. All pertinent information will be made available to the provider by the facility staff. Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative, and the resident's physician, to ensure best outcomes of care for the resident. The facility will update physician contact information and resident representative(s) mail, email and phone number periodically for compliance with 483.15 (c) (2). Responsible Party: Clinical Guideline CENTERS FOR MEDICAID AND MEDICARE SERVICES (CMS) - DEFINITIONS Non-Physician Practitioner (NPP): include Nurse Practitioner, Physician Assistant and Certified Nurse Specialist NP - Nurse Practitioner PA - Physician Assistant CNS -Certified Nurse Specialist Significant Change in status - deterioration in health, mental or psychosocial status in life threatening conditions or clinical complications Significant alteration in treatment - A need to alter treatment significantly. A significant treatment alteration includes the need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment. OBJECTIVE OF THE NOTIFICATION OF CHANGE GUIDELINE The objective of the notification guideline is to ensure that the facility staff makes appropriate notification to the physician and delegated Non-Physician Practitioner and immediate notification to the resident and/or the resident representative when there is a change in the resident's condition, or an accident that may require physician intervention. The intent of the guidelines is to provide appropriate and timely information about changes relevant to a resident's condition or change in room or roommate to the parties who will make decisions about care, treatment and preferences to address the changes. OVERVIEW OF COMPONENTS OF THE GUIDELINE 1. Requirements for notification of resident, the resident representative and their physician: 1) An accident involving the resident, which results in injury and has the potential for requiring physician intervention. 2) A significant change in the resident's physical, mental, or psychosocial status. (i) A significant change includes deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications. 3) A need to alter treatment significantly. (i) A significant treatment alteration includes the need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment. 2. Requirements for notification of resident and/or resident representative(s), consistent with their authority. (i) A change in room or roommate assignment (483.10 (e) (6). (ii) A change in resident rights under Federal or State law or regulations (483.10 (e) (10). (ii) A change in room or roommate assignment (483.10 (e) (6). (ii) A change in resident rights under Federal or State law or regulations (483.10 (e) (10). (iii) A decision to transfer or discharge the resident from the facility as specified in 483.15 (c) (1) (ii) . Based on observation, interview and record review, the facility failed to notify a physician and monitor and assess a change in condition for two residents (R80, R86) of two residents reviewed for a change in condition. Findings include: R86 A review of the record revealed that on 4/13/25 a progress note was written at 5:07 PM, stated in summary At approx. (approximately) 1320(1:20PM) resident propelled self to go outside to smoke and told staff with resident that she was having a hard time breathing but continued to smoke about half a cigarette, resident then came inside and was taken by activity staff to room. Resident noted to have discoloration and difficulty breathing upon arrival in room at 1330(1:30PM) . At approx. 1334(1:34PM) , resident was assessed by nurses on staff, and was noted to have no pulse and was no longer breathing. Resident NP(nurse practitioner) .notified at approx. 1340(1:40PM). Resident TOD(time of death) was at 1336(1:36PM). EMS (emergency medical services) and .sheriff arrived on scene and retrieved statements from staff and verified resident DNR(do not resuscitate). Resident guardian called and message left for guardian to call back at approx. 1340(1:40PM). Resident guardian called at approx. 1412(2:12PM) again with no answer and message left for guardian to call facility. Resident guardian called again, and message left at approx. 1545(3:45PM) . A review of the record revealed that on 4/12/25 at 3:36 PM, there was a documented oxygen saturation (O2 stat) of 82% (normal is 90-100%). A further review of the record indicated that the medical doctor was not contacted, nor was any interventions put in place or carried out regarding the low reading. R86's Brief Interview for Mental Status Score(BIMs) was an 11 (completed on 4/1/25), which indicated mild cognitive impairment. On 6/17/25 at 10:25 AM, an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON was asked what the facility's policy for a change in condition was, what is considered a change in condition and would they treat a person with the code status of DNR the same a full code. The ADON reported that a change in condition was considered something different from an individual's baseline. The DON explained that the facility staff would assess, take vitals and call the physician, execute orders if any were given and if its life threatening and needs immediate intervention, call 911 to send them out. The ADON reported that, the same assessment would be completed for a person with a DNR code status. On 6/17/25 at 10:45 AM, an interview with Nurse AA was conducted. Nurse AA was asked, who was responsible for taking vital signs for residents and what was the process for a resident who experienced a change of condition. Nurse AA reported that the Certified Nurse Assistant (CNA) was responsible for taking vital signs and supposed to report anything abnormal. For a change in condition, Nurse AA stated they would take vitals, assess the resident, call the physician and family, get orders if any are given, and if it's needed send the resident to the hospital. Nurse AA was asked about R86's decrease in O2 saturation, and if they where aware of the change in condition. Nurse AA reported they did not and that R86 presented how they usually did, short of breath and wanted to smoke. Nurse AA did not recall if someone told them about the decrease in O2 saturation. On 6/17/25 at 11:00AM, CNA Z was called via phone and interviewed. CNA Z was asked what the protocol was when they obtained vital signs that were not within normal limits. CNA Z reported that, normally when a vital sign was out of range, they would report it to the nurse before charting it into the system, because the nurse would recheck them. CNA Z was then asked about the O2 recorded for R86 on 4/12/25 of 82%, CNA Z reported that they told the nurse because it looked wrong, but could not remember the nurse they reported it to. On 6/17/25 at 12:46PM, Activities Aide BB was interviewed and asked how was R86 presenting when they went for the 1 PM smoke break. Activities Aide BB reported that, R86 was coughing a whole lot and could not stop. The Activities Aide BB reported that they told R86 that they should not smoke, but R86 insisted and did. On the way back in, R86 needed help to get back to their room, so the smoke supplies were locked back up and then Activities Aide BB reported they rolled them back to their room, bent down to put their oxygen on, and R86 was blue. Activities Aide BB reported they ran to get the CNA on the unit and then the CNA got the nurse. On 6/17/25 at 11:35 AM, the Director of Nursing (DON) was interviewed and asked what would be expected for staff if a resident had and oxygen saturation of 82%. The DON reported that the nurses usually would send someone out to the hospital with saturations low. The DON was asked what happened with R86 who had an O2 saturation of 82% the day before they expired. The DON reported, they were sure the staff would have done something, (but did not document it), R86 had COPD (Chronic Obstructive Pulmonary Disease) and they would have not made it to the next day at 82%. The DON was asked to provide the information to show what staff did for the resident with a change in their saturation level. The DON reported they understood the concern and did not have any additional documentation to provide.

Based on interview and record review, the facility failed to provide adequate staffing to meet the care needs of the residents, with the potential to affect all residents (including R10 and R85). Findings include: Review of the data staffing report submitted to the State Agency for the Second Quarter of 2025 (January 1, 2025, through March 31, 2025) revealed the facility triggered for low weekend staffing and had a one-star rating for staffing (below average staffing), yielding staffing concerns for the facility. On 6/16/25 at 9:05 AM, R85 was observed sitting in a wheelchair. When asked about care at the facility, R85 explained it depended on how many staff were working on the weekends, especially when there was not enough staff. R85 explained what would normally take a half hour would take two hours or more. R85 was asked what specifically would take that long. R85 explained since they required two staff plus a mechanical lift, getting into or out of bed was difficult when there was not enough staff. On 6/17/25 at 11:00 AM a Resident Council meeting was conducted with seven residents who asked to remain anonymous. When asked about care provided at the facility, residents expressed a concern as to low staffing, specifically on weekends. On 6/17/25 at 3:08 p.m., R10 reported they sometimes waited a half hour to go to bed, which was a longer time for them to wait, but they knew staff were very busy. On 6/17/25 at 12:07 p.m., Licensed Practical Nurse (LPN) M was asked about nursing staffing. LPN M reported they needed four nurses during the day shift to adequately meet the needs of the residents, however sometimes there were only three nurses on the shift. LPN M reported when they had three nurses, they had 34 to 35 residents under their care, and it was too much. LPN M reported when the census went under 90 residents, there were only three nurses assigned in the facility when they worked the day shift, as one of the nurses had less residents on the higher acuity rehab unit and was responsible for new admissions as well. When asked about the night shift, LPN M reported three nurses were scheduled but when there were call offs, only two nurses were present, making them responsible for 80 to 90 residents (giving them over 40 residents each), usually after 11:00 p.m. which was difficult. On 6/17/25 at 12:40 p.m., Certified Nurse Aide (CNA) D was asked about staffing. CNA D reported CNAs worked three eight-hour shifts, and said when they had 18 residents, they were responsible for on the afternoon shift, it was not fully manageable. CNA D reported residents complained about waiting too long for their call lights to be answered, and for their check and change, to change their incontinence briefs timely, or to lay down for the night, which upset some of the residents, including R10. On 6/17/25 at 2:45 p.m., CNA E was asked about staffing during their shifts. CNA E reported they worked on either the day or afternoon shifts. CNA E reported they could get their residents' care needs met when they had 10 or 11 residents, however reported when they had 16 to 20 residents, this was not adequate staff. CNA E explained when they had to feed a resident, answer call lights, change their residents including bedding, provided showers, or had residents who were two-person transfers, this was not enough staff. CNA E explained this winter, they had 22 residents one day, when the residents were ill, and this was not adequate staffing to meet their residents' care needs. CNA E reported they were told by management the nurses could help them, however the nurses had too many residents and medications to pass, and some were responsible for wound care and could not assist them. On 6/18/25 at 8:51 a.m., CNA G was asked about staffing in the facility, and reported they usually worked the midnight shift. CNA G reported they typically had at least 18 residents at night, however this winter from January to March, they recalled being short staffed, and had 21 to 22 residents, which was not enough staff to meet their resident care needs timely. CNA G reported there was a day when there were only two aides this winter (at night), and they were one of them. CNA G clarified, That night I had at least 40 residents, and explained there were over 80 residents in the building. CNA G reported they needed four aides in the building to be adequately staffed at night, and explained when there were three aides, they had 28 to 29 residents each, when there was a census of about 87 residents. CNA G stated it was a struggle to meet the residents' care needs timely, and this was hard on them and the nursing staff. They reported residents complained when this occurred in the past few months, and recently. On 6/18/25 at 1:38 p.m., the Nursing Home Administrator (NHA) was made aware of collective staff and resident concerns about low staffing. This Surveyor reviewed the Facility Assessment data which showed with a census of 80 to 85 residents, adequate staffing was three aides during the day shift and two aides during the night shift, and asked if this was adequate staffing, given the night CNAs had 40 to 43 residents each. The NHA reported this was their minimum staffing expectation, with less than 90 residents, and acknowledged this occurred occasionally. This Surveyor asked if it was acceptable for the nurses to have 40 or more residents under their care, and responded, Yes, but acknowledged they tried to have managers support when this occurred. This Surveyor discussed the staffing triggers from the staffing report for low weekend staffing in this year's second quarter, from January 1, 2025, through March 31, 2025. The NHA had no additional comment about staffing. This Surveyor requested timecards. Review of Nursing Staff (nurses and CNAs) timecards provided by facility (in the State electronic filing data share system) on 6/19/25 at 2:43 a.m. confirmed on 1/01/25, 1/02/25 and 1/03/25 two or less nurses worked the midnight shifts, with a census of about 90 residents. And on 1/02/25 two CNAs worked the night shift. No additional timecards were received by facility exit. Review of the policy, Staffing, dated 4/03/09, revealed, Our facility provides adequate staffing to meet needed care and services for our resident population .1. Our facility maintains adequate staff on each shift to ensure that our resident's needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services. 2. Certified Nursing Assistants (CNAs) are available on each shift to provide the needed care and services of each resident outlined on the resident's comprehensive care plan .4. Staffing is adjusted as needed throughout the day based on the changing needs of the residents. 6. Inquiries or concerns relative to our facility's staffing should be directed to the Administrator or his/her designee . Review of the Facility Assessment Tool, dated August 2024, revealed the facility had the ability to take 106 residents, and showed an average census of 80 to 86 residents. Requirement: Nursing facilities will conduct, document, and annually review a facility-wide assessment, which includes both their resident population and the resources the facility needs to care for their residents (§483.70(e)). The requirement for the facility assessment may be found in Attachment 1. Purpose: The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being. The intent of the facility assessment is for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the residents require .Staffing Plan: Based on your resident population and their needs for care and support, describe your general approach to staffing to ensure that you have sufficient staff to meet the needs of the residents at any given time. This is building specific. The facility uses the staffing ladders method to ensure appropriate staffing is being followed per mandatory federal regulation. Staffing ladders is also practiced to meet the needs of the facility and its population. The facility considers characteristics of building, such as size, demographics and case mix when creating the staffing assignments. Staffing ladders is a structural measure that affects the processes and outcomes of nursing care and continuity of care. The staffing ladders takes into account the levels and clinical mix of services provided for sufficient care needs at any time. The facility also has residents with defined care needs in selected areas of the building The (facility) will review its staffing needs based on census per unit and acuity levels / ADL needs of all residents per unit, per shift. The facility maintains a PPD to ensure that staff are appropriately assigned, and resident needs are met. Hands -on staffing is designed to also meet all required ratios as determined by state and federal requirements. The facility assessment revealed the staffing quotas as follows: Licensed Nurses (LN): RN, LPN, LVN providing direct care: DON: 1 DON RN full time Days. Asst (Assistant DON): 1 (ICP- Infection Control Preventionist also). RN or LPN Charge Nurse - days: 3. RN or LPN Charge Nurse - nights: 2. Direct Care staff: C.n.a. - 7+ (CNAs) days (on the day shift). C.n.a. - 6+ afternoons. C.n.a. - 3+ midnights . The facility assessment showed given a census of 80 to 85 residents, there needed to be at least three nurses in the building during the days, and only two nurses at night, which confirmed a night nurse could have between 40 to 43 residents, given a census of 85 residents. Review of the staff postings showed the census was frequently higher than 90 residents. -

On 6/16/25 at approximately 9:07 AM, a refrigerator located in the large resident dining room was observed. A piece of paper was taped on the door that read: Resident Fridge Only ensure food is labeled and dated. Upon opening the refrigerator, the following medications were observed in the bottom drawer: Semglee (insulin), Lantus (insulin x2), TPN (Total Parenteral Nutrition x2 bags), Thiamine (Vitamin B1 x2), Infuvite (multivitamin x2) and SMOFLipid (lipid injectable used in parenteral nutrition x2). On 6/16/25 at approximately 10:34 AM, an observation and interview were conducted with the Director of Nursing (DON). The DON was queried as to why resident's medications were stored in the Resident Fridge (Only). The DON reported that the fridge located in the storage room was not working and a new fridge was ordered. The DON was not able to provide the date the fridge stopped working and an actual order form. On 6/17/25 at approximately 10:34 AM and again on 6/18/25 prior to exit at approximately 2:00 PM, the medication noted above remained the large Resident Fridge Only. The facility policy titled, Medication Labeling and Storage (undated) was reviewed and documented, in part: Policy Statement: The facility stores all medications and biologicals in locked compartments .Only authorized personnel have access to keys .Compartments .including .refrigerators .containing medications and biologicals are locked when not in use .Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurse's station or other secured location .Medication Labeling .Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements .The medication label includes at a minimum .medication name, prescribed dose, strength, expiration date, resident's name, route of administration . Based on observation and interview the facility failed to properly label and store medications in two out of four medication carts and failed to properly secure (multiple) medications (stored in resident refrigerator in the dining room) with potential for harm due to unrestricted access to medications and unsafe medication administration. Findings include: During an observation completed on 6/17/25 at approximately 11:30 AM, the medication cart for [NAME] unit had a (watch) charger stored with glucometer. Licensed Practical Nurse (LPN) AA was queried about the charger and they reported that it might been a resident property who might have gone out to the hospital, but they were unsure. When queried about facility process and storage of resident's personal supplies in the medication cart, LPN AA reported that they should not store personal properties in the medication cart. During an observation on the medication cart for Oakland unit with LPN C there were five loose pills on the top drawer and over 20 loose pills on the bottom drawer under the medication packages. An interview with LPN C was completed during the observation. They reported that they were unaware how they got on the bottom of the cart and they followed the process when they pulled the medications out and understood the concern. An interview with Director of Nursing (DON) was completed on 6/17/25 at approximately 12:30 PM. The DON was notified of the observations and questioned about the facility process. The DON reported that staff were expected to follow the facility process when they pulled the medication and they had a process in place to audit the medication carts every 2 weeks and they were unsure how it got missed. DON reported that they understood the concerns. On 6/18/25 at approximately 12:40 PM during an interview with the facility administrator, they were notified of the observations and they reported that it was brought to their attention by the DON and they understood the concerns.

Based on observation, interview and record review, the facility failed to protect the resident's right to be free from physical and verbal abuse by a resident for two (R53 and R78) of four residents reviewed for abuse, resulting in R53 and R78 verbally abusing and intimidating each other on multiple occasions leading to R53 punching R78 in the stomach and on a different occasion, R78 hitting R53 in the face. Findings include: R53 On 6/16/25 at approximately 8:54 AM, R53 was observed sitting in a wheelchair in their room. The resident was only wearing a brief and indicated that he usually does not care to wear other clothes. R53 was queried about care in the facility and reported that a few days prior another resident hit him, pointing to the area on his right side. The resident noted that it caused pain. R53 was not able to provide the name of the resident but did provide a description. R53 reported the resident who hit him is always in the hallway yelling. A review of R53's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: cerebral infarction (stroke), Type II diabetes and memory deficit. A review of the resident's Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) of 8/15 (moderate impaired cognition). Continued review of R53's clinical record noted the following: 5/19/25: Miscellaneous: Resident verbally abusive to roommate and others in the hallways. Pushing and throwing things in his room when asked to go to his side of the room and to put a shirt on. 5/24/25: Behavior Narrative Note: Resident was noticeably agitated when another resident was yelling at him over not wearing a t-shirt, resident felt threatened by the other resident so he started yelling back at the other resident saying he would, kiss his ass before he killed me and was giving the other resident the middle finger . *It should be noted that there were no further notes regarding resident to resident incidents specifically related to what was reported on 6/16/25. Care Plan: Focus: The resident has behavior r/t (due to) tendency to take off clothes and come out of room in briefs. Resident redirected and asked to dress appropriately, however he continues to refuse .(date initiated 4/21/22) .Interventions: Psychiatric consult as indicated (4/21/22) .Provide a calm and safe environment .(initiated 4/21/22) .Provide resident with area for decreased stimulation .(initiated 4/21/22) . *It should be noted that there were no additional behavioral interventions put into R53's care planning after 4/21/22. A request for all IA's (incident/accident) reports and grievances initiated on 6/17/25 at approximately 9:14 AM. At approximately 1:20 PM, the only IA pertaining to resident-to-resident incidents in 2025 was as follows: Resident to Resident Altercation: R53 .Date 6/13/2025 .Writer Assistant Director of Nursing (ADON) B ) heard loud commotion coming from hallway. Writer observed verbal altercation between the resident and another resident. Writer began to yell and run down the hallway. As writer came in close parameters of the two residents, resident began to make physical contact with each other and writer, along with other staff, intervened .Resident (unclear as to which resident) stated that he said he was going to get up and kick his a** and put up the middle finger. Then (R78) walked up to him and they both was swinging at each other .Resident has new skin issue (small minor scratch to nose area) . *It should be noted that there were no notes in R53's clinical record addressing the incident noted above and no IA's for the incidents noted for 5/19/25 and 5/24/25. R78 On 6/16/25 at 9:25 AM, R78 was observed standing in their room. R78 was asked if he had any concerns at the facility. R78 explained he would walk around the whole facility for exercise . had clocked it so he knew how many miles he walked a day . there was another resident, he only knew their first name, that would always flip his middle finger at him every time he walked past . one day he was walking and this resident had his wheelchair in the doorway of his room . he ignored him when he went past . the next time around this resident was all the way in the hall . he thought he wanted to talk to him so he stopped and asked what he wanted . the resident flipped him the middle finger, so he grabbed his finger . the resident hit him in the stomach, so he pushed his index fingers in his eyes . the nurses came and were yelling at us . he put his hands up and stepped away from the resident. Review of the clinical record revealed R78 was admitted into the facility on 2/8/25 with diagnoses that included: epilepsy, stroke, mild neurocognitive disorder due to known physiological condition without behavioral disturbance and adjustment disorder with anxiety. According to the MDS assessment dated [DATE], R78 was cognitively intact. Review of R78's progress notes revealed a Behavior Narrative Note by Licensed Practical Nurse (LPN) S on 5/24/25 at 8:30 AM that read in part, .Writer was . notified by CNAs (Certified Nursing Assistants) . that writer was needed because 2 residents were about to get into a fight. Writer ran . to deescalate [sic] the situation. When writer arrived at the situation (R78) was standing up and in a very low voice was stating 'I could kill you, you fat f***' to a resident at the nurse's station who had upset (R78) because he wasn't wearing a shirt. (R78) was upset because the other resident was out in the hallway without his shirt on. Writer asked that resident to put a shirt on and resident did at the time . (R78) would not leave the resident alone and was using intimidation towards the other resident which was causing the other resident to be upset who started yelling back at (R78) saying he wouldn't let him kill him because he would 'kick his a** first.' . the other resident went to his room but was worried that (R78) was going to come after him. (Local Sheriff) was called because (R78) was standing at the entrance to the sunroom with an intimidating look. The officer arrived and the resident using vulgar language and stating the 'fat f*** gets to do what he wants.' The officer said to the resident that he needed to calm down and the way he was standing and acting was intimidating. He told the officer that the other resident was making threats towards him and that if the other resident assaulted him that he would kill him. The officer brought up to writer that he would recommend petitioning (mental/physical evaluation) him. Writer notified management about behavior and what resident said, they agreed to send resident out . Review of a document titled, Transfer to Hospital or other Facility dated 5/24/25 that read in part, .Key clinical information: Resident is becoming more threatening and intimidating to staff and residents . Reason(s) for transfer: Making threats to other resident's saying he is going to kill them . On 6/17/25 at 9:30 AM, LPN S was interviewed by phone and asked who was the other resident involved in the incident with R78 on 5/24/25. LPN S explained it was R53 . that R78 did not like it that R53 was not wearing a shirt . R78 got verbally aggressive, said he would kill R53 and would start with his eyes, that is when R53 became aggressive and said he would kick R78's a**. LPN S was asked if she had called the Sheriff. LPN S explained after they separated the two residents, R78 went and stood by the sunroom very intimidating, so she called 911 . R78 was very aggressive towards the Deputies and told them it was self defense so he could kill R53. When asked if she had notified anyone, LPN S explained she had called and told the Administrator and tried to get a doctor to petition R78 out, but none would so she sent R78 to the hospital, and the hospital sent him right back the same day. Further review of R78's progress notes revealed a late entry Health Status Note created by the Assistant Director of Nursing (ADON) on 6/17/25 at 11:08 AM with an effective date of 6/13/25 at 12:30 PM that read in part, Writer heard loud commotion coming from hallway. Writer observed residents hitting each other. Writer and other staff assisted with separating resident from each other. Resident went into this room to calm down. Both resident was [sic] separated by staff . On 6/18/25 at 7:56 AM, the ADON was interviewed and asked about the incident on 6/13/25. The ADON explained she was in her office when she heard yelling, she ran out and saw R53 and R78 in front of R53's room yelling at each other. The ADON was asked if she saw any physical contact between the residents. The ADON explained she did not see any physical contact, but R53 had a small scratch by his eye and R78 said he pulled R53's finger and that R53 hit him. When asked why the progress note had been written on 6/17/25 when the incident happened on 6/13/25, the ADON explained she had forgotten to write the progress note. On 6/17/25 at approximately 1:51 PM, an interview was conducted with Social Service Worker (SSW K). SSW K was asked if they were aware of the incidents that occurred between R53 and other residents and what, if any behavioral interventions were put in place to prevent further incidents. SSW K reported that they were not aware of the incidents. SSW K did report that R53 is often boisterous and is seen by psychiatric services. On 6/17/25 at approximately 10:30 AM, an interview was conducted with the Administrator/Abuse coordinator regarding the two incidents noted between R53 and R78. The Administrator reported that they were aware of the incidents and did not rise to the level of abuse with respect to reporting. The Administrator noted that a full investigation was not completed for the incident on 5/24/25 and could not provide any further information. The Administrator was not able to provide any information that indicated attempts were made to prevent abuse from occurring again. The facility policy titled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property (Effective date 11/28/17) was reviewed and documented, in part, the following: Purpose: It is the practice of the facility to encourage and support all residents .to report any suspected acts of abuse .Definitions: Abuse: Abuse is the willful infliction of injury .intimidation .with resulting physical harm, pain or mental anguish .Abuse includes verbal abuse .verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogator terms to residents Examples of verbal abuse include, but are not limited: Threats of harm, saying things to threaten a resident .Physical abuse include hitting, slapping .

This citation pertains to intake(s): MI00140190 & MI00140245. Based on interview and record review the facility failed to ensure accurate wound assessments, timely implementation of treatment for identified wounds, coordination of care and wound services and ensure a collaborative approach for wound healing was completed with the dietician for two (R's 501 & 506) of three residents reviewed for pressure wounds, resulting in R506 to have developed an infected unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) buttocks/sacral wound (after debridement identified as a Stage III- full thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissues and rolled wound edges are often present- buttock/sacral wound) that required the resident to be transferred and admitted to the hospital due to sepsis from an infected buttock/sacral ulcer. Findings include: R506 Review of a complaint submitted to the State Agency (SA) documented the concern of the facility to have failed to prevent pressure ulcers which became infected. Review of the medical record revealed R506 was admitted to the facility on [DATE] with a readmitted [DATE] and diagnoses that included: hemiplegia and hemiparesis affecting right dominant side, dementia, and senile degeneration of the brain. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12 and required staff assistance for all activities of daily. Further review of the medical record revealed R506 had an appointed legal guardian in place. Review of a Braden Scale for Predicting Pressure Sore Risk dated 3/22/23, documented a score of 18 which indicated At Risk. Review of the July 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented the following order Wound Prevention: Apply triad paste daily every day shift for skin . Start Date 6/18/23. Review of a Skin Observation dated 7/8/23 at 1:18 PM, documented in part . Does the Resident have any NEW Skin Issues Observed . Yes . Left gluteal fold- skin tear . Left thigh (rear)- dime size skin tear . Review of the medical record revealed no documentation of the physician to have been notified of the identified skin impairments and no new treatment implemented. Review of Nursing note by the Director of Nursing (DON) dated 7/11/23 at 11:30 AM, documented in part . Resident has NEW skin issue(s) observed. 1 . unstageable, Left buttock - stage III pressure . sacral/coccyx region . resident noncompliant of [NAME] <sic> hygiene repositioning and brief changing . Review of a care plan titled . The resident has potential for impairment to skin integrity . documented . Resident's unwillingness to offload once he is up in his w/c (wheelchair) for the day, can be resistive to check and change . Review of the medical record revealed one incident documented on 3/17/23 of the resident to have been noncompliant with care prior to the identification of the sacral/coccyx wound. Review of the medical record revealed no documentation of treatment implemented for the . unstageable, Left buttock Stage III pressure . sacral/coccyx region . identified on 7/11/23, until more than a week later on 7/19/23. Review of the July 2023 MAR and TAR documented the following order in part, . cleanse left buttock and coccyx with dankins, apply calcium alginate and medi honey and cover with ABD pad. Document any refusals every evening shift every Wed (Wednesday) for skin healing . Start Date- 07/19/2023 . This order was implemented more than a week after the initial identification of the sacral/coccyx wound. Review of the wound consultations revealed the following: On 7/14/23 at 10:49 AM, documented in part . being seen for wound to buttock . Functional Assessment: Total Dependence . Pressure injury of deep tissue of sacral region . Acute moist area with eschar in gluteal fold of sacrum. Unable to perform full assessment. Resident refuses to leave wheelchair . Dietician to participate to optimize nutrition. Report changes to provider. Pressure injury to left buttock, stage2 (Partial-thickness loss of sin with exposed dermis, presenting as a shallow open ulcer) . Unable to perform full assessment. Resident refuses to leave wheelchair 2 open area left buttock. Dressing has small amount of serosanguinous drainage . Pressure injury to the right buttock, stage 2. Active Acute open area right buttock with small open area. Unable to measure size due to resident refusing exam . On 7/18/23 at 4:16 PM, documented in part . Pressure injury of deep tissue of sacral region Active Acute resident sitting in wheelchair - declined exam Monitor wound . Report changes to provider . Pressure injury of left buttock, stage 2 Active Acute resident sitting in wheelchair - declined exam. Monitor wound care . Report changes to provider . Pressure injury of right buttock, stage 2 Active Acute resident sitting in wheelchair - decline exam Monitor Wound care . Dietician to participate to optimize nutrition. Report changes to provider . On 7/21/23 at 10:18 AM, documented in part . being seen for wound to buttock . Pressure injury of deep tissue of sacral region Stable. Chronic Area in gluteal fold moist. Approximate size 2 x 2 x 0.125 inches. Base of wound dark in color . Report changes to provider. Pressure injury of right buttock, stage 2 Stable Chronic Improving. Approx 2 x 1.5 inches . Dietician to participate to optimize nutrition. Report changes to provider . Review of the medical record revealed no documentation of the clarification of the staging of the wounds completed by the DON on 7/11/23 that documented an unstageable and Stage III wounds compared to the clinician assessments as documented on 7/14/23, 7/18/23 and 7/21/23, of the wounds documented as stage 2's. Further review of the medical record revealed no documentation of the dietician to have been notified of R506's wounds and no documentation of the dietician to have acknowledged the development of R506's wounds at that time. Review of a Nursing note dated 7/23/23 at 8:00 PM, documented in part . T (temperature): 101 . BP (blood pressure): 99/54 . P:92 irregular, R (respirations): 40, SPO2% 89%-91% on room air . odor coming from coccyx area . Resident transferred to (hospital name) via ambulance . Review of the hospital documents revealed the following: A Wound Care Progress Note dated 7/26/23 at 5:54 PM, documented in part . unstageable pi (pressure injury) to gluteal cleft that surgery is managing. Stage 3 pi (pressure injury) to left gluteus . A Operative Report dated 7/27/23 at 2:05 PM, documented in part . Sacral Wound Debridement . Preoperative Diagnosis- Unstageable Sacral Wound . Postoperative Diagnosis- Stage 3 Sacral wound, 9 x 5 x 1.5 cm (centimeters) . Sharp excisional debridement was performed to the sacral wound down to and including the presacral fascia. There was a moderate amount of purulent/necrotic fluid that was expressed from the wound . There is noted to be 5 cm (centimeters) of undermining along the 10-11 o'clock region, in order to provide adequate exposure to the wound, the wound was unroofed with exposure of more necrotic tissue that was debrided. The debridement was taken until there was healthy bleeding tissue within the wound bed . The new wound measurement were 9 x 5 x 1.5 cm. Given the size and location of the sacral wound it was decided to place a wound VAC to allow for adequate healing . Findings- 9 x 5 x 1.5 cm stage III sacral wound, Moderate amount of purulent/necrotic fluid expressed from wound . An Infectious Disease Progress Note dated 7/27/23 at 6:18 PM, documented in part . Chief Complaint- EMS (emergency medical services) reports AMS (altered mental status) per NH (nursing home). EMS reports pt (patient) is normally A&Ox3 (alert and oriented times three) . admitted from an extended care facility . due to altered mental status and hypotension. On admission patient was noted to have a . sacral decubitus ulcer which had been foul-smelling and draining purulent drainage. On admission . had leukocytosis and tachycardia. Patient had hypotension, which improved with administration of fluids. He was placed on empiric antibiotics in the form of vancomycin. Blood cultures are pending at this time . The surgical service has seen this patient and there are plans for debridement of the sacral ulcer . Impression . Infected unstageable decubitus ulcer in the coccygeal area, at the natal cleft . Sepsis, secondary to #1 (infected unstageable coccygeal ulcer) . Recommendations . Continue Zosyn 4.5 g (gram) IV (intravenous) every 8 hours, vancomycin (per dosing pharmacy), pending culture results from the OR (operating room) . Monitor temperatures and white blood cell count . Continue local care to decubitus ulcer- anticipate need for further debridement . On 4/3/24 at 3:19 PM, Registered Dietician (RD) E was interviewed and asked their involvement with residents that have pressure wounds. RD E stated they are to be notified once the wound is identified and they complete an assessment on the resident and modify the residents care as necessary. RD E was asked to look into their assessment, files, and notes for any documentation of having to been notified of R506's wounds. On 4/4/23 at 9:17 AM, a follow up interview was conducted with RD E who stated they had not been notified of R506's wounds prior to their hospitalization . RD E stated that usually they are notified when the skin impairment is first identified. On 4/4/24 at 10:17 AM, the Director of Nursing (DON) (who also served as the wound nurse during July 2023) was interviewed and asked how a skin tear initially identified on 7/8/23 could worsen to an unstageable and stage III wounds (buttock/coccyx) in three days without the front-line staff (nurses and aides) to have been able to identify and notify the physician of the worsening of the wound. The DON was also asked to clarify their assessment that was documented on 7/11/23 describing the wound as an unstageable and stage III wound. The DON was asked why treatment was not implemented for the identified wounds from 7/11/23 to 7/19/23 and why the dietician was not notified of R506's wounds to have a collaborative interdisciplinary approach to promote the healing of R506's wounds. The DON stated the facility had up until a month (per the facility's protocol) to ensure the dietician's involvement in wound care and would look into the other concerns and follow back up. At 11:00 AM, the DON returned and stated the coccyx had an unstageable wound and the left buttocks had a stage III wound. The DON stated R506 was a difficult case for them, and the DON pointed out the refusals made by the resident to not be assessed by the wound clinician on the wound care days, the DON was then asked why the facility staff failed to coordinate the wound care for R506 with the wound clinician and the facility staff. The DON was asked how a resident who requires total dependence for all care was placed in their wheelchair every wound clinic day, knowing the resident would refuse to lay back down once in their wheelchair (as documented in the resident's care plan), the DON stated it was the resident's right to get in their wheelchair and right to refuse the wound assessment. The DON stated during the time of July 2023 they had so many issues with the wound physicians/clinicians and ended up changing wound care providers in September 2023. No further explanation or documentation was provided by the end of the survey. 34275 R501 A complaint was filed with the State Agency (SA) that alleged when they were noted on or about 1/24/24 that R501 had two pressure sores, one on their penis area and one on their bottom. The complainant noted that they were discharged to the Hospital on 2/5/24 and again informed the resident had multiple pressure ulcers in those locations when they arrived at the Hospital. A review of R501's clinical record revealed the resident was initially admitted to the facility on [DATE] and their last admitted was 2/13/24 with diagnoses that included, in part: diabetes, chronic kidney disease, obesity and heart failure. A review of the Minimum Data Set (MDS) dated [DATE] noted the resident's Brief Interview for Mental Status (BIMS) score was 15/15 (intact cognition) and noted the resident needed one to two person assistance for most Activities of Daily Living (ADLs). Review of Section M of the MDS noted the resident did not have a pressure ulcer. Continued review of R501's clinical record, documented, in part, the following: Skin Observation(1/2/24): Resident has NO New skin issues . (authored by the DON). Health Status Note (1/22/24): Writer and wound care nurse notified by aide that resident had a new open area to sacrum and penis. Wound care nurse and writer did observe open area to sacrum noted as shearing r/t (due to) transfers. Open area to penis noted r/t new placement of foley .Wound care NP (nurse practitioner) to eval . *It should be noted that there were no notes in the resident's electronic record that indicated he was see by the wound care NP. Order (1/22/24): Wound Care: Apply Triad paste to open area on penis. One time a day for wound care and every 24 hours as needed for wound care. Care Plan (4/18/23): Focus: The resident has potential skin impairment r/t (related to) incontinence, generalized weakness, history of masd (moisture associated skin damage), pressure and incisions .Interventions: Monitor skin when providing cares, notify nurse of any changes to skin appearance (2/23/17) .Educate resident/family/caregivers of causation factures and measures to prevent skin injury (7/31/23) .Encourage good nutrition and hydration in or to promote heathier skin (7/31/23) .Focus: The resident has actual impairment to skin integrity r/t fx (fracture) with incision, assistance needed with mobility/ADLs .will refuse care until an aide he approves of is available to provide care .Interventions: .Assist to turn and reposition when in bed as tolerated (9/16/2020) . *It should be noted that there were no interventions noted for skin impairment following the discovery of open wounds dated 1/22/24. Hospital Records (2/5/24): ED (emergency department) 2/5/24 .H & P (history and Physical exam) .patient was seen and examined on February 5, 2024 .Assessment and Plan .sacral decubitus ulcer .Will have Wound care evaluate the patient .Wound History: Stage 2 pressure injury coccyx .assessment: Wound Length: 5.5 cm x Wound Width: .6 cm .Wound surface area: 3.3 cm .Wound: Penis: Wound bed tissue assessment: Yellow; sloughing; red; bleeding; painful; fragile .length 1.5 cm .width: 4 cm . R501 returned to the facility on [DATE]. A skin observation (2/14/24) documented: .scrotum are open areas multiple, Coccyx open area . (Authored by Wound Nurse F). Skin Observation (2/14/24): .Resident has NEW skin issue(s) observed 1 Other (specify)- groin 3 open pressure .Other (specify) penis pressure, right gluteal fold- stage III pressure . Three Skin and Wound Evaluation dated 2/16/24 did not provide necessary information as to the type, location, acquired status, stage. Wound measurements were noted. Wound Evaluations with accompanied photos provided only measurements and noted as undiagnosed . A review of the MAR/TAR noted R501 did not receive any treatments to open areas on the scrotum and/or penis from 2/14/24 through 2/16/24. On 4/4/24 at approximately 10:25 AM, an interview was conducted with the DON. Wound Nurse F was also present during the interview. The DON was asked as to R501's facility acquired pressure ulcers noted on 1/22/24. The DON reported that they believed the only open area found on 1/22/24 was on the resident's penis. When asked if there was any documentation as to the staging and description, location, measurements of the wound as noted, the DON reported that there was not as they believed the wound had healed. When asked if the resident was seen by the Nurse Practitioner (NP), the DON reported No. When asked as to the notes from the Hospital that noted the resident had wounds including those on the coccyx and penis upon admission on 2/5/24, the DON reported that the pictures were different than the hospital notes. When asked why the assessments were not fully completed upon R501's return from the hospital on 2/14/24, Wound Nurse F reported that they were not fully checked as completed. When asked what treatments were put in place for multiple open areas on the scrotum and/or penis, the DON did not provide a response. A review of the facility policy titled, Skin Protection Guideline (7/7/21), noted, in part: .Purpose: .To ensure residents that admit and reside at our facility are evaluated and provided individualized interventions to prevent, reduce and treat skin breakdown .Evaluation: Our facility applies a process to identify residents with or at risk for developing a pressure injury: upon admission/readmission .Transfer out/in . With significant changes in condition and Routinely .process includes: .Implementing, monitoring and modifying interventions to stabilize, reduce or remove underlying risk factors .Because a resident can develop a PU/PI (pressure ulcer/injury) within hours .the at risk resident needs to be identified and have interventions implemented promptly at attempt to prevent PU/PI .Skin should be assessed as soon as possible .where possible .within the first 2 hours .Planning: An individualized plan of care will be developed based on predicting factors for skin breakdown .

This citation pertains to intake #'s MI00135735, MI00136041, and MI00136457 Based on observation, interview, and record review, the facility failed to accurately assess skin upon re-admission, document interventions to prevent the worsening of pressure ulcers, and ensure/clairify appropriate treatment orders for pressure ulcers for two residents (R#'s 140 and 240) of three residents reviewed for pressure ulcers, resulting in worsening of pressure ulcers. Findings include: A review of a facility provided policy titled, Skin Management Guideline effective 11/28/17 was conducted and read, Purpose: To ensure residents that are admitted to the facility are evaluated to determine appropriate measures to be taken by the interdisciplinary care team to determine appropriate measures and individualized interventions to prevent, reduce and treat skin breakdown. It is the practice of this facility to properly identify and evaluate residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care . R140 A review of R140's closed clinical record was conducted on 6/7/23 and revealed they admitted to the facility on [DATE], they were sent to the hospital on 2/26/23, readmitted on [DATE], and again they were sent to the hospital on 3/14/23. R140's diagnoses included: femur fracture, diabetes, dementia, altered mental status, pneumonia, severe protein calorie malnutrition and gastrointestinal hemorrhage. R140's Minimum Data Set (MDS) assessment dated [DATE] indicated R140 had moderately impaired cognition, was non-ambulatory, and required extensive to total assistance from one to two staff members for all activities of daily living. A review of R140's hospital record for the admission from 2/26/23 thru 3/3/23 was conducted and revealed that on 3/1/23 two pressure injuries had been identified. The first wound was documented as a pressure injury to the sacrum and the assessment read, .Wound Bed Tissue Assessment .Dry; Non-blanchable erythema .Peri-Wound Assessment: Red; Peeling .Dressing .Foam . The second wound was documented as a pressure injury to the right heel and the assessment read, Wound Bed Tissue Assessment: Dry; Purple .Dressing: Open to air . A review of R140's re-admission Nursing Evaluation .V -8 dated 3/3/23 was reviewed and No had been marked to the question .Does the resident have skin integrity concerns? . A review of a Daily Skilled Nursing Evaluation - V 5 dated 3/3/23 was reviewed and did not indicate R140 was receiving skilled services for wound care. Section K. on the evaluation read Skin/Wound, and was noted to be blank for the prompt of Additional Skin/Wound Comments: A review of a wound consult dated 3/8/23 by Nurse Practitioner (NP) 'E' was conducted and revealed R140 had an unstageable (full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed) pressure ulcer on their coccyx with yellow slough and an unstageable pressure ulcer on their right lateral heel wound with hard eschar. It was further documented on the consultation form NP 'E' recommended an air mattress, heel boots, and treatments to the affected areas every Monday, Wednesday, Friday, and as needed. The consultation did not indicate the worsening of wounds or development of new wounds would have been unavoidable. A review of R140's physician's orders, treatment administration records, (TAR), and care plans was conducted and indicated the first treatments and care planned interventions for the coccyx and heel wounds were dated 3/8/23. A review of a R140's Certified Nursing Aide Task (CNA) documentation did not indicate any turning and repositioning for R140 nor was there documentation that heel boots or the air mattress were present prior to 3/8/23. A review of R140's Daily Kardex Reports from 3/3/23 to 3/10/23 was conducted and the Kardex did not indicate an assignment or a CNA task for an air mattress or heel boots until 3/10/23. On 6/7/23 at 3:17 PM, an interview was conducted with NP 'E', and said their only involvement with R140 was the consultation and the recommendations for treatments and interventions. On 6/8/23 at 9:23 AM, an interview was conducted with the facility's Assistant Director of Nursing (ADON)/Supervisor of the Wound Care Program regarding R140. They said when R140 readmitted to the facility on [DATE], they did not have any wounds, but they had, areas of concern on their coccyx and right heel. They further reported the hospital wanted both of the wounds left open to air and reported the coccyx wound opened on 3/8/23. They were asked about the two nursing assessments conducted on 3/3/23 and why they did not indicate there were any, areas of concern identified on the skin assessments and they had no explanation. They said they implemented the air loss mattress and heel boots on 3/3/23 upon re-admission. They were asked to provide documentation of the interventions prior to the wound consult on 3/8/23 and the only documentation provided was a PRN (as needed) CNA task for Pressure Reducing Device. The ADON admitted the task was, vague and said the CNA's did not document on the presence of the interventions on their shifts because the task was PRN (as needed). 38271 Resident #240 On 6/6/23 a concern submitted to the Stage Agency was reviewed which alleged R240 did not receive appropriate care/treatments for their pressure ulcer. On 6/8/23 The medical record for R240 was reviewed and revealed the following: R240 was initially admitted to the facility on [DATE] and last readmitted on [DATE] with diagnoses that including Heart failure and Intracerebral hemorrhage. A review of R240's MDS (minimum data set) with an ARD (assessment reference date) of 3/12/23 revealed R240 needed extensive assistance with most of their activities of daily living. R240's BIMS score was 15 indicating intact cognition. A Physicians order dated 2/27/23 and a discontinued date (d/c) of 3/20/23 revealed the following: cleanse stage 2 pressure wound with wound cleanser/ normal saline, pat dry apply santyl cream to wound and cover with dry dressing daily and prn one time a day for wound care. A Physicians order dated 3/1/23 with a d/c date of 3/20/23 revealed the following: : Cleanse coccyx wound with Dakins OR wound cleanser, then apply medihoney gel onto wound bed, cover with a border foam. Must be done Every Monday, weds, fri and PRN every day shift every Mon, Wed, Fri for coccyx wound. A Wound care Nurse Practitioner evaluation dated 3/1/23 revealed the following: Wound Assessment and Plan: Wound #1-Coccyx-unstageable .Treatment-Medihoney Gel .Frequency-M, (Monday), W (Wednesday), F (Friday) and PRN (as needed) A Wound care Nurse Practitioner evaluation dated 3/8/23 revealed the following: Wound Assessment and Plan: Wound #1-Coccyx-unstageable-Multiple bridges .Wound bed-30% eschar .Treatment-Medihoney Gel .Frequency-M, W, F and PRN. A Wound care Nurse Practitioner evaluation dated 3/15/23 revealed the following: Wound Assessment and Plan: Wound #1-Coccyx-unstageable-Multiple bridges .Wound bed-50% eschar .Treatment-Calc Alg (Calcium alginate) Medihoney Gel .Frequency-M, W, F and PRN. Further review of the three Wound care Nurse Practitioner evaluations did not indicate continuing the Santyl treatment to R240's pressure ulcer. A review of R240's March 2023 TAR (treatment administration record) documented R240 had the Santyl treatment being applied every day from 3/1/23 through 3/16/23 and the Medihoney Gel treatment being applied with dakins/wound cleanser on 3/3, 3/6, 3/8, 3/10 and 3/13. On 6/8/23 at approximately 12:45 p.m., during a conversation with Assistant Director of Nursing A (ADON A), ADN A was queried regarding R240's wound care. ADON A indicated R240 only had one wound which was on his sacral coccyx area which was present upon admission. A review of R240's wound treatment was done and ADON A was queried regarding the continuation of the Santyl treatment along with completing the Medihoney treatment after coming the hospital and they indicated they did now know why it was not discontinued. ADON A reported the Santyl treatment was not addressed by the Wound Care Nurse Practitioner on their evaluations and only indicated that Medihoney Gel was to be the treatment for R240's coccyx wound. On 6/8/23 at approximately 1:10 p.m., during a conversation with Wound Care NP E (WCNP E), WCNP E was queried regarding R240's wound on their coccyx and reported that they Initially ordered Medihoney gel on 3/1 then changed the order to Medihoney gel with calcium alginate on 3/15. WCNP E was queired regarding the co-occurring Santyl order for R240's coccyx that was being done every day and on some days being done on same day as the Medihoney Gel treatment and reported that it must have been from hospital and was overlooked/missed and that the treatment for R240's wound was supposed to be Medihoney Gel not Santyl. WCNP E reported that Santyl treatments were not for wounds that contain eschar in which R240's wound had.

This citation pertains to Intake #'s MI00128558, MI00128904 and MI00134127 DPS #1 Based on interview and record review, the facility failed to ensure phyisican ordered follow-up urinary catheter care was provided for one (R806) of six residents reviewed for indwelling catheters resulting in discomfort, blood in the urine, expected infection and hospitalization . Findings include: A complaint was filed with the State Agency on 1/11/23 that alleged in part, .on November 10th (R806) had surgery to get a suprapubic catheter put in. This operation involves putting the catheter through her abdomen . On November 15th they did not bring her to the postoperative follow up appointment . on December 2, she was in the emergency room . Her incision was infected and the catheter was clogged . She stayed in the hospital for six days to recover . Review of the closed record revealed R806 was admitted into the facility on [DATE] with diagnoses that included: heart failure, schizoaffective disorder and neuromuscular dysfunction of bladder. According to the Minimum Data Set (MDS) assessment dated [DATE], R806 was cognitively intact, required the extensive assistance of staff for all activities of daily living (ADL's) and had an indwelling catheter. Review of R806's suprapubic (SP) catheter care plan revealed an intervention dated 11/29/22 that read, UTI (urinary tract infection): Evaluate resident for S/SX (signs and symptoms) UTI, if appropriate request UA/C&S (urinalysis/culture and sensitivity) and treatment as indicated from Physician. Review of R806's progress notes revealed a nursing note dated 11/10/22 at 6:21 PM read in part, Resident returned from facility after having supra pubic placement . Resident came back with new orders to monitor for bleeding, and supra pubic care orders . Review of R806's hospital discharge paperwork dated 11/10/22 after the SP catheter placement read in part, .Follow-Up Appointment: 8 Days . Medication: cephalexin (Keflex 500 mg (milligrams) oral capsule), 1 CAPLET, Oral, Every 6 Hours . Change your dressing every day. Change the dressing more often if it falls off, becomes dirty, or has absorbed a lot of drainage . Further review of R806's progress notes revealed: A nursing note dated 11/24/22 at 12:53 PM read, .dressing soiled bleeding light discharge coming from site not smell at this time resident says it isuncomfortable [sic] dressing changed . A nursing note dated 11/26/22 at 10:51 PM, Pt (patient) suprapubic has come out of place. Pt voiding in brief . pts urinal bag had no urine noted. Pt needs urology appointment Writer will endorse to incoming nurse. A nursing note dated 12/1/22 at 10:33 AM read, Supra pubic catheter draining straw colored urine. No c/o (complaint of) pain or discomfort. No redness/swelling/tenderness at ostomy site . It should be noted that the creation date of this note was 12/22/22 by the Director of Nursing (DON), 20 days after R806 was discharged from the facility. A SBAR (Situation, Background, Assessment, and Recommendation) note dated 12/2/22 at 1:59 PM read, resident supra pubic not draining. UTI expected. Attempted to get sample unable to get urine return . Signs and Symptoms: Has hematuria (blood in urine). Has urinary hesitancy . A nursing note dated 12/2/22 at 4:06 PM read, Resident presenting with complaints of discomfort in her bladder region. Nurse assessed resident noted an odor from supra pubic site, sentiment [sic] in foley line and bag, distended bladder . new order to flush foley and send for UA. Nurse attempted to flush catheter with no return. New order to change supra pubic, unsuccessful attempt resident complaining of too much pain. New order to send resident to ER (emergency room ) . Review of R806's November 2022 Medication Administration Record (MAR) revealed the antibiotic cephalexin had not been ordered or given. On 4/26/23 at 1:15 PM, Receptionist E, who was in charge of making outside appointments was interviewed and asked if R806 had a follow-up appointment with the surgeon after having a SP catheter. Receptionist E explained she did not keep a record of appointments she made. When asked if there was any log or record kept of resident appointments, Receptionist E explained after a resident was discharged , she would shred the record. On 4/27/23 at 1:03 PM, the DON was interviewed and asked if R806 had been sent for a follow-up appointment after the SP catheter placement. The DON explained they had not received the discharge paperwork until R806's family member brought it to them, it was uploaded into their computer system on 11/17/22. When questioned if they had contacted the Urologist's office as it was standard to follow-up with an Urologist after a surgical procedure, the DON had no answer. The DON was asked when progress notes on 11/24/22 and 11/26/22 documented problems with R806's SP catheter, why there was no follow-up with Urology. The DON had no answer. DPS #2 Based on interview and record review, the facility failed to provide bladder training per orders one (R809) of six residents reviewed for indwelling catheters resulting in R809 being pressured to get an indewlling catheter. Findings include: Review of a complaint filed with the State Agency on 1/27/23 revealed allegations that read in part, .Resident may have to have a catheter put in because the facility does not have enough staff to provide assistance to him . Review of the closed record revealed R809 was admitted into the facility on [DATE] with diagnoses that included: cord compression, epilepsy and neurogenic bladder. According to a Brief Interview for Mental Status (BIMS) tool dated 1/27/23, R809 was cognitively intact. Review of a nursing admission assessment dated [DATE] at 6:00 PM read in part, .Resident is alert. Resident is orientated x4 (person, place, time & situation) . Resident is incontinent of bladder. Resident does not have urinary symptoms/concerns . Review of R809's progress notes revealed: A nursing note by Registered Nurse (RN) D dated 1/26/23 at 8:30 read in part, order received (Nurse Practitioner - NP G) to insert indwelling catheter as resident has ongoing urinary incontinence, and hs (history) of urinary retention . A nursing note by RN D dated 1/26/23 at 9:05 PM read in part, Resident refused to have foley catheter inserted- I don't need one, I want to use the urinal- Explained that although he is voiding on his own it it [sic] difficult to measure the volume of urine and that he has a history of retaining urine, still refuses tohave [sic] indwelling catheter and insists on using the urinal. Review of R809's hospital discharge paperwork dated 1/26/23 read in part, .Spinal Cord Injury (SCI): Managing Your Bladder: After an SCI, your bladder may not work the same way as before. During your rehab (rehabilitation), your healthcare team gave you a bladder program to help you adjust to and manage these changes. Going forward, it'll be up to you to follow this program on a regular basis. By taking control of your body and managing your bladder, you'll help prevent accidents, infections, and other complications . Neurogenic Bladder: .Start on bladder program including IC (intermittent catheterization) Q4 (every 4 hours) if patient doesn't void or PVRs (post-void residual) > (greater than) 250cc (cubic centimeters), keep IC volumes < (less than) 400cc . On 4/26/23 at 3:54 PM, NP G was interviewed by phone and asked if urinary incontinence was an acceptable reason to order an indwelling catheter. NP G explained she would never order a catheter for incontinence, but retention would be a reason for a catheter. NP G was asked about the order for a catheter for R809. NP G explained the nurses would call her a home and ask her about catheters. On 4/26/23 at 5:00 PM, RN D was interviewed and asked why she thought R809 needed an indwelling catheter. RN D explained the hospital had been using straight catheterization on a regular basis for residual urine, and the facility thought an indwelling catheter might be less a risk of infection and a better way to measure output. On 4/27/23 at 1:22 PM, the DON was interviewed and asked why they wanted an indwelling catheter for R809 when IC catheterization and PVR's were used at the hospital for bladder training. The DON explained they did not have a bladder scanner at the facility, so they could not do PVR's. The DON was asked why the facility agreed to accept R809 when they were not able to provide his bladder training. The DON explained he was not involved in R809 coming to the facility. Review of a facility policy titled, Urinary Indwelling Catheter Management Guideline dated 11/28/17 read in part, .To ensure resident who enter our facility without an indwelling catheter are not catheterized unless the resident's clinical condition demonstrates and meets standard of practice supporting his justification . Urinary retention that cannot be treated or corrected medically or surgically, for which alternative therapy is not feasible and which is characterized by: 1. Document post void residual volumes in a range over 200 ml (milliliters)/ 2. Inability to manage the retention / incontinence with intermittent catheterization . Intermittent catheterization is preferable to indwelling catheterization . Additional care practices should include: .Monitoring post void residual .

This citation pertains to Intake MI00134127 Based on interview and record review, the facility failed to ensure three physician ordered anticonvulsant medications were available for one (R809) of three residents reviewed for medications resulting in R809 statements of feeling unsafe and wanting to go to the hospital. Findings include: Review of the closed record revealed R809 was admitted into the facility on [DATE] with diagnoses that included: cord compression, epilepsy and neurogenic bladder. According to a Brief Interview for Mental Status (BIMS) tool dated 1/27/23, R809 was cognitively intact. Review of hospital discharge paperwork dated 1/27/23 read in part, Medication List: .(carBAMazepine 200 mg (milligrams) oral tablet), 1 Tab (tablet), By Mouth, Two times daily . (brivaracetam 100 mg oral tablet), 1 Tab, By Mouth, Two times daily . (lamoTRIgine 100 mg oral tablet), 1 Tab, By Mouth, Two times daily . Epilepsy - Last seizure reported 2-3 months ago . 12/29: Continue Carbamazepine 200 mg (milligrams) BID (two times a day), Lamotrigine 100 mg BID, Brivaracetam 100 mg BID; On seizure and aspiration precautions . Review of R809's January 2023 Medication Administration Record (MAR) revealed: Brivaracetam Oral Tablet 100 MG, Give 1 tablet by mouth two times a day for seizures. Order Date 1/26/23 at 6:40 PM. None were given, boxes were marked with the code 09 for Other/See Nurse Notes. carBAMazepine Oral Tablet 200 MG, Give 1 tablet by mouth two times a day for seizures. Order Date 1/26/23 at 6:15 PM. None were given, boxes were marked with the code 09. lamoTRIgine Oral Tablet 100 MG, Give 1 tablet by mouth two times a day for seizures. Order Date 1/26/23 at 6:56 PM. The 8:00 AM dose on 1/27/23 was marked as given. The 5:00 PM dose on 1/27/23 was marked with the code 09. Review of R809's Medication Administration progress notes revealed R809's medications were On order. Review of a Health Status Note dated 1/27/23 at 5:49 PM read in part, Resident stated he was calling 911 because he did not feel safe. Writer, nurse and management explained pharmacy delivery times with medications . Resident stated he was going tothrow [sic] himself out of bed to break his neck. Resident stated he will do harm to himself at any expense . Resident requested to call 911 because he was going to harm himself . Review of a Discharge/Transfer Summary note dated 1/27/23 at 6:05 PM read in part, Resident transported by EMS (Emergency Medical Services) to hospital for evaluation . On 4/26/23 at 5:00 PM, Registered Nurse (RN) D was interviewed and asked how often medications were delivered by pharmacy. RN D explained they received two deliveries a day, approximately 5:30 PM and sometime on the midnight shift . to get medications delivered during the midnight shift, orders needed to be put in by 7:00 PM. to get medications by 5:00 PM, ordered needed to be put in before 11:00 AM. On 4/27/23 at 9:17 AM, Assistant Director of Nursing (ADON) C was interviewed by phone and asked why R809 did not get his ordered anticonvulsant medications. ADON C explained the hospital had sent prescriptions for the Carbamazepine and the Lamotrigine, but did not send one for the brivaracetam, so that was part of the delay. When asked if controlled substance medications could be sent with an emergency supply until a controlled medication form (C2) could be filled out by a physician, ADON C agreed it could. ADON C was asked why the two medications with prescriptions were not available. ADON C had no explanation. On 4/27/23 at 1:22 PM, the Director of Nursing (DON) was interviewed and asked about R809 not receiving his anticonvulsant medications. The DON explained pharmacy delivers medications at 5:00 AM and 5:00 PM. The DON was asked if medications could be requested at other times. The DON explained they could call pharmacy after 7:00 PM to try to get additional medications on the 5:00 AM shipment, or else pharmacy would have to make another shipment of medications to the facility. When asked why R809's anticonvulsant medications were not requested to be drop shipped by the pharmacy, the DON had no answer. The DON was asked if R809's feelings of being unsafe and wanting to harm self to go to the hospital could have been exacerbated by a known epilepsy diagnosis, and at 5:49 PM knowing two doses of three anticonvulsant medications should have been given (six pills), and only one pill had been given at 8:00 AM, and it was unknown when the medications would be at the facility. The DON agreed R809 might have been anxious about his medications. Review of a facility policy titled, Pharmacy Services for Nursing Facilities dated April 2018 read in part, .Providing routine and timely pharmacy service as contracted, and emergency pharmacy service 24 hours per day, seven days per week. a. Emergency or stat medications are available for administration no more than [4] hour(s) after the order is received by the pharmacy .

This citation pertains to Intake #MI 287. This citation has two deficient practices. Deficient Practice #1 Based on observation, interview, and record review, the facility failed to assess, monitor, and implement interventions for one (R#228) of five residents reviewed for bowel management, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in an Immediate Jeopardy (IJ) when the resident did not have a bowel movement in four days (96 hours), was not assessed or treated, was experiencing abdominal pain, and was ultimately diagnosed with a mild colonic ileus (occurs when normal movement of the bowels are interrupted which can lead to an intestinal obstruction). This deficient practice resulted in the likelihood of a repeated bowel obstruction with serious complications such as tissue necrosis, perforation of the bowel, and infection which if left untreated could result in death. Findings include: The IJ began on 3/4/21. The IJ was identified on 3/4/21 at 4:00 PM. The facility was initially notified of the IJ on 3/4/21 at 5:50 PM and a plan to remove the immediacy was requested. The facility was notified of an amended IJ on 3/5/21 at 2:00 PM. The immediacy was removed on 3/5/21 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 actual harm that is not immediate jeopardy. On 3/2/21 at 12:30 PM, R#228 was observed lying on their back in bed. The resident appeared thin and had a Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube surgically placed into the stomach to deliver nutrition) and an indwelling urinary catheter. When addressed R#228 attempted to speak but was unable to be understood. R#228 appeared to answer some yes and no questions appropriately. On 3/3/21 at 11:15 AM, R#228's tube feeding was observed to be turned off. The tube feeding formula bottle noted it was hung on 3/3/21 at 3:00 AM. This was confirmed by Licensed Practical Nurse (LPN) L who reported it was hung and started on the night shift and R#228's physicians orders were to receive tube feeding around the clock. There was approximately 50 cubic centimeters (cc) of formula infused from the bottle, as confirmed by LPN L. On 3/5/21 at approximately 1:00 PM, R#228's tube feeding was observed to be turned off during an observation made with Occupational Therapist (OT) DD and confirmed by LPN L. R#228 was talking but was not understood. According to OT DD, R#228 appeared much more animated and agitated than usual. OT DD reported it appeared R#228 was experiencing pain but was not sure where. OT DD asked R#228 if he was in pain. R#228 stated, Yes. OT DD asked R#228 to point to the area where he was experiencing pain with his functional hand (left hand). R#228 moved his left hand to touch his abdominal area. A review of R#228's clinical record was conducted and revealed the following: R#228 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) assessment dated [DATE] documented R#228 had severely impaired cognition, unclear speech, was rarely/never understood, and rarely/never understands others. The MDS documented R#228 had PEG tube, an indwelling urinary catheter, and was always incontinent of bowel. A review of the Census for R#228 revealed the resident had four hospitalization s since 12/6/20. Hospital records for R#228 revealed the resident was hospitalized from 1/15/21 through 2/2/21, at which time they were readmitted into the facility. A History and Physical completed by the facility attending physician (Physician Z) on 2/3/21 documented, .sent to the hospital for SOB (shortness of breath) and distended abdomen, CXR (chest X-ray) showed RUL (right upper lobe) consolidation possible aspiration, CT abdomen/Pelvis showed large bowel obstruction 2/2 (secondary to) fecal impaction, had multiple disimpaction .Plan:Bowel Protocol . Hospital records for R#228 revealed the resident was hospitalized from 2/21/21 through 2/26/21, at which time the resident was readmitted into the facility. A Patient Summary from the hospital provided to the facility at the time of readmission documented R#228's Medications That Have Not Changed, in part, as follows: [MEDICATION(S)] 100 mg twice a day as needed for constipation for 21 Days. A History and Physical completed by Physician Z on 3/1/21 documented, .Plan: .Bowel Protocol . A Nursing Evaluation (Admit/Readmit, Qtly (quarterly), Annual, Sig Change) dated 2/26/21 (the date of R#228's last readmission into the facility) documented R#228 was incontinent of bowel and their Normal Bowel Pattern/Routine was Every 2-3 days. It was documented R#228 took medications to help move their bowels and the medication listed was ([MEDICATION(S)] sodium) PRN (as needed). On 3/4/21 at 2:30 PM, R#228's POC Response History (documentation completed by Certified Nursing Assistants - CNAs) for the Bowel Movements and Bowel Continence task was reviewed. It was documented on the [NAME] Continence task that R#228's last bowel movement was on 2/28/21 at 5:46 PM (as evidenced by a check mark under incontinence on the bowel continence POC response history task), however the Bowel Movements task documented R#226 did not have a bowel movement between 2/26/21 and 3/4/21. On 3/4/21 at 2:45 PM, a review of R#228's progress notes was conducted. There were no progress notes that documented R#228 had a bowel movement on any of the above mentioned dates. Active physicians' orders for R#228 were reviewed and revealed an order with a start date of 2/26/21 for [MEDICATION(S)] ([MEDICATION(S)] Sodium) Give 100 mg via PEG-Tube every 12 hours as needed for constipation. A review of R#228's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #228's readmission to the facility on [DATE]. R#228's care plans were reviewed and revealed a care plan initiated on 8/17/20 that documented, The resident has bowel incontinence. Interventions initiated 8/17/20 documented, Check and change every two hours, and as needed and Provide pericare after each incontinent episode. There was no care plan that addressed R#228's history of and risk of constipation and bowel obstruction/fecal impaction. On 3/4/21 at 3:01 PM, the Director of Nursing (DON) was interviewed. The DON was queried about the facility's bowel management protocol. The DON reported there was no specific bowel protocol (as was the documented plan by the admitting physician), but typically if a resident did not have a bowel movement after three days, the physician would be contacted and the resident would receive milk of magnesia, if no bowel movement after that, then [MEDICATION(S)] would be ordered. The DON further reported that if after administration of laxatives, the resident still did not have a bowel movement, it could result in being transferred to the hospital. The DON reported there would be a standing order in place for the nurses to follow. At that time, the facility's policy for bowel management was requested from the DON. The DON was queried about R#228 and the lack of documented interventions, assessments, and physician notification and/or orders after they had no documentation of a bowel movement in the past four days. The DON reported they would look into it. On 3/4/21 at 4:35 PM, the DON stated, I see what you see. When asked for clarification, the DON reported they did not see any documented bowel movement for R#228, no interventions were implemented, and it did not appear that the physician was contacted. The DON reported residents who had not had a bowel movement in three days would be brought up in the daily IDT (interdisciplinary team) meeting each morning and further reported R#228 was not brought up in the IDT meeting and he was unaware of the lack of bowel movements. On 3/4/21 at 4:15 PM, LPN CC was asked to see the resident's abdominal area. LPN CC reported they were busy and asked CNA BB to do it instead. CNA BB' entered R#228's room. R#228 was making a groaning noise. CNA BB asked R#228 if he was in pain and R#228 stated, Yes. CNA BB lightly touched R#228's abdominal area and the resident made a groaning noise and was talking in an unclear manner. When CNA BB asked R#228 if it hurt when she touched his stomach, R#228 stated, Yes. On 3/5/21 at 9:41 AM an interview was conducted via the telephone with Physician Z. When queried about what was meant by bowel protocol in R#228's history and physical completed on 3/1/21, Physician Z reported that the bowel protocol is different for every facility. Physician Z further reported that due to R#228's history of fecal impaction, she would want to be contacted if R#228 did not have a bowel movement in one or two days in order to determine the appropriate treatment. When asked if she was notified that R#228 had not had a bowel movement in four days, Physician Z reported she was contacted last night and was told R#228 did not have a bowel movement in two days (this was after the survey team brought the concern to the facility's attention and after it had been over three days). On 3/5/21 at 10:45 AM, an interview was conducted via the telephone with CNA JJ (the CNA who documented R#228 was incontinent on 2/28/21. CNA JJ reported he remembered R#228 had two bowel movements on 2/28/21 and one of them was runny and dark. When queried about whether it was reported to a nurse that R#228 had a runny and dark bowel movement, CNA JJ reported he could not remember. A review of progress notes for 2/28/21 did not reveal any documentation from the nurse regarding a runny and dark bowel movement. A Radiology Results Report for R#228 documented an abdomen X-ray was conducted on 3/4/21 at 11:10 PM. The Reason for Study documented, .PAIN, UNSPECIFIED . The results documented, Dilated loops of bowel .Colonic fecal residual is noted .Conclusion: Ileus type pattern favored, obstruction not excluded. Recommend CT or follow-up as clinically warranted . A Radiology Results Report for R#228 dated 3/5/21 at 9:25 AM documented, .Results: There is mild colonic dilation consistent with ileus. The small bowel loops are unremarkable .Conclusion: Mild colonic ileus . Further review of R#228's progress notes on 3/5/21 revealed the following: A Health Status Note (nurses note) dated 3/4/21 at 6:00 PM (after the facility was notified of the identified IJ by the survey team) documented, Assessed resident for bowel sounds. Bowel sounds are active in all 4 quadrants. No complaints of pain or discomfort in all 4 quadrants upon palpation. Abdomen soft and non-tender. Resident was given a suppository, awaiting results of intervention. A Health Status Note (nurses note) dated 3/4/21 at 6:35 PM (after the facility was notified of the identified IJ by the survey team) documented, .Physician notified of resident not having a BM (bowel movement) for over 3 days. orders noted for [brand name redacted] enema (a medication used to treat constipation and is administered directly into the rectum) and [MEDICATION(S)] (an oral medication used to treat constipation). On 3/5/21 at approximately 1:00 PM, and observation of R#228 was made with Occupational Therapist (OT) DD. OT DD reported R#228 appeared to be more animated and agitated than usual. When OT DD asked R#228 if he was experiencing any pain, R#228 stated, Yes. OT DD instructed R#228 to point to the areas where he was experiencing pain using his functional left hand. R#228 moved his hand to his abdominal area. When asked by OT DD if he had pain in his stomach, R#228 stated, Yes. OT DD reported to LPN L that R#228 was experiencing pain. Further review of R#228's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A policy provided by the facility titled, Bowel and Bladder Management (effective date 11/28/17) was reviewed and it documented the following: .It is the practice of this facility to conduct a comprehensive evaluation to ensure each resident with bowel or bladder incontinence will receive appropriate treatment and services to restore as much bowel or bladder functioning as possible. Facility practices include: 1. Identification of history and patterns of bowel and bladder function .4. Identification of appropriate treatment plans for the resident .The resident's plan of care will be individualized to address the issue, goals and appropriate interventions . There was no policy provided that addressed the specific bowel protocol that that facility followed for residents who did not have a bowel movement. Deficient Practice #2 Based on observation, interview and record review, the facility failed to provide appropriate care to residents with indwelling urinary catheters and discontinue a catheter according to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R#8 On 3/2/21 at 3:58 PM, a catheter bag inside of a privacy bag touching the floor was observed attached to the bottom of the resident's bed. When asked about it, R#8 stated it was just reinserted the other day, unsure of the reason why. An IV (Intravenous) antibiotic bag (Ertapenem Sodium Solution Reconstituted 1 GM. Use 1 gram intravenously one time a day for UTI for 7 Days) was hung on the IV pole at the bedside. When asked why they were receiving IV antibiotics, R#8 replied, because of that catheter. A review of the clinical record revealed the following: R#8 was admitted into the facility on [DATE] with a readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 6 (indicating severely impaired cognition) and required staff assistance for all Activities of Daily Living (ADLs). A hospitalization for a UTI was noted in the resident's chart from 11/2/20 until 11/4/20. A Physician/PA (physician assistant)/NP (nurse practitioner) Progress Note dated 1/10/21 at 7:30 pm which documented in part, . Patient recently completed antibiotics for the UTI. Patient's Foley catheter needs to be changed every 2 weeks . Patient is on Foley catheter and she is a Foley catheter dependent due to bladder problems. Due to indwelling Foley catheter patient is getting UTIs for which I recommended to change the Foley catheter every 2 weeks rather than every month . Foley catheter care regularly . A Physician/PA (physician assistant)/NP (nurse practitioner) Progress Note dated 2/16/21 at 5:45 pm documented in part, . Patient seen, and evaluation done for follow-up of her UTI. I ordered the change of catheter ASAP (as soon as possible). I also ordered change of catheter every 2 weeks . Patient has indwelling Foley catheter which looks dirty that is why recommended to change the Foley catheter and send the urinalysis urine culture sensitivity sample after change of catheter . Plan: Recommended immediate change of Foley catheter, after change of Foley catheter to send the urine analysis and urine culture sensitive sample ASAP . An Infectious Disease: Recurrent UTI's history and physical consultation dated 2/23/21 documented in part, . patient has been having recurrent UTI's . Patient has been treated multiple time with IV (Intravenous) and PO (by mouth) antibiotics . Patient has current orders in place to have Foley catheter exchanged every 2 weeks . It appears that the UA (urinalysis) C/S (culture and sensitivity) is checked around these times, however, it is unclear if patient is having any symptoms of UTI at the time the UA C/S is checked . Continue exchange of Foley catheter Q2 weeks as ordered . A urology consultation dated 2/26/21 documented in part, . f/u (follow up) from procedure . 16F foley cath change and return . no complications . A review of the resident's February and March 2021 Treatment Administration Record (TAR) documented the following catheter orders: *Change foley bag one time a day every 1 month(s) starting on the 4th for 1 day(s) (8 PM). Staff documented that it was changed on 2/4/21. Change foley catheter every night shift every 15 day(s) (NOC- midnight shift)- this order was never signed off as completed by a staff member. Change Foley catheter today x1. One time only for prophylactic for 1 Day - this order is signed as completed on 2/16/21. Foley Catheter Change . every evening shift every 14 day(s) for prophylactic - this order is signed completed by staff on 2/17/21 (1 day after the 2/16/21 catheter change). Foley Catheter Change . every evening shift every 30 day(s) for catheter use (PM shift) - this order is signed as completed by staff on 2/28/21 (2 days after the 2/26/21 catheter change complete at the urologist appointment.) Change Foley bag as needed for infection prevention, PRN (as needed) The review of the TAR revealed the lack of coordination of foley catheter changes implemented by the facility staff. The resident was receiving more changes to their catheter as recommended by the Infectious Disease provider and per the physician recommendations. The care plans titled The residents has a Urinary Tract Infections . The resident has bladder incontinence . The resident has a <sic> Indwelling Catheter: unable to void on her own. [CONDITION(S)] bladder . On 3/04/21 at 2:00 PM, the Director of Nursing (DON) was queried on the various foley catheter change orders and the potential increase of a UTI due to the lack of coordination of the resident's catheter care. The DON replied, they would have to look into it. At 2:39 PM, the DON returned and stated in part, I too was confused; the unit manager is fixing that now. (physician name redacted) wants it changed every 14 days, so that will be implemented now. R#54 On 3/2/21 at approximately 1:35 PM, R#54 was observed sitting in his wheelchair. The resident's catheter bag was observed to be filled to the top with urine. The resident was asked when the last time his catheter bag was emptied. The resident reported the bag was emptied yesterday and stated, this happens often. Sometimes it backs up and my brief gets wet. R#54 also reported having UTIs while at the facility. The resident was asked to push his call light in an attempt to get staff to empty the bag. Activity Staff L entered the room and took the resident to an activity event with the catheter bag still full. A review of R#54's clinical record indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/03/21 at approximately 12:17 PM, the DON was interviewed and reported that catheter bags should be drained at a minimum every shift but should never reach the top. R#224 On 3/2/21 at 9:00 AM, R#224 was observed lying in bed. When asked about the care in the facility, R#224 stated, Everything is fine, except nobody will tell me why I have this catheter. A urinary catheter drainage bag was observed hooked to the handle of the bottom drawer of R#224's nightstand. The drainage bag made direct contact with the floor and the tubing was stretched from the bottom of the night stand across to the resident who was lying in the bed. The drainage bag was observed to be almost full with urine with approximately 200 milliliters of space left in the bag. When queried about the location of the urinary drainage bag, R#224 reported staff hung it on the nightstand. When queried about the last time the drainage bag was emptied, R#224 stated, Last night before I went to bed. On 3/2/21 at 1:15 PM, a second observation of R#224 was. The urinary catheter drainage bag was hung on the handle of the bottom drawer of the nightstand and was completely full of urine. On 3/2/21 at 1:55 PM, Certified Nursing Assistant (CNA) H was interviewed. When queried about who was responsible for emptying urinary catheter drainage bags, CNA H reported the CNAs were responsible. When queried about R#224 and the last time her drainage bag was emptied, CNA H reported she just emptied it. When queried when it was emptied prior to her emptying it, CNA H reported it was emptied this morning by the previous shift. When queried about why it was almost full around 9:00 AM and was not emptied until now, CNA H reported they do they best they can do. CNA H reported she was the only CNA for the unit that R#224 resided on. An observation of the location of R#224's drainage bag was made with CNA H. When queried about why the bag was on the floor and hung on the bottom drawer handle, CNA H stated in front of R#224, She probably did that. R#224 replied, I didn't put that there. A review of R#224's clinical record was conducted and revealed the following: R#224 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) assessment dated A progress note dated 2/22/21 documented R#224 was transferred to the hospital after she was found unable to follow basic commands, lethargic, and not able to eat. incontinent of urine while in bed . A readmission Nursing Evaluation completed for R#224 on 2/26/21 documented R#224 was continent of urine and did not have an indwelling catheter. A Daily Skilled Note dated 2/27/21 documented R#224 had an indwelling catheter. Physicians Orders were reviewed since R#224's readmission into the facility on [DATE]. There were no physicians' orders for the indwelling urinary catheter. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/2/21 at approximately 4:00 P.M., Licensed Practical Nurse (LPN) CC was interviewed. When queried about whether R#224 was supposed to have an indwelling catheter, LPN CC reviewed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/3/21 at 10:38 AM, the Director of Nursing (DON) was interviewed. The DON was queried about the facility's protocols when residents are admitted into the facility with an indwelling urinary catheter. The DON reported the resident must have a valid reason for the catheter and there would be physicians' orders for the type of the catheter, size of the balloon, size of french, and when to replace it according to Centers for Disease Control and Prevention (CDC) guidelines. The DON further reported there would be a care plan in place. When queried about when the drainage bag should be emptied, the DON reported the CNAs should empty it every shift or as needed. When queried about when a catheter should be discontinued if there was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R#224's care plans revealed there was no care plans to address R#224's catheter. A facility policy titled Urinary Indwelling Catheter Management Guideline dated 11/28/17 documented in part was reviewed and contained no guidance for the above deficient practice. A policy provided by the facility titled, Urinary Indwelling Catheter Management Guideline (effective 11/28/17) documented, .Medically justified indwelling catheters will require physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Rather, catheters and drainage bags should be changed based on clinical indications such as: infection .obstruction .When the closed system is compromised .Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Ensuring the catheter is secured to eliminate dislodgement or irritation resulting from tension or pulling on the tubing .Drainage collection devices will remain off all floor surfaces at all times to eliminate the exposure of microorganisms .Developing a plan of care upon admission and/or placement .

Based on observation, interview, and record review, the facility failed to identify and implement interventions to address changes in range in motion (ROM) for one (R#228) of one resident reviewed for limited range in motion, resulting in the resident developing contractures of the right upper extremities. Findings include: On 3/2/21 at 12:30 PM, R#228 was observed lying on their back in bed. The resident appeared very thin and had a Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube surgically placed into the stomach to deliver nutrition) and an indwelling urinary catheter. When addressed R#228 attempted to speak but was unable to be understood. R#228 appeared to answer some yes and no questions appropriately. R#228's fingers of the right hand appeared bent with some fingers closed into the palm of the hand. R#228's right elbow was bent, and the right arm was pressed against the resident's chest and the right hand rested near his shoulder. R#228 appeared able to move his left arm and hand. There were no splints or devices observed applied to R#228's upper extremities. On 3/4/21 at 7:40 AM, R#228 was observed lying on their back in bed. There were no splints or devices applied to the resident's upper extremities. Licensed Practical Nurse (LPN) E was interviewed and queried about whether any splints or devices were ordered for R#228. LPN E reported she did not know. A review of R#228's clinical record was conducted and revealed the following: R#228 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) assessment dated [DATE] documented R#228 had severely impaired cognition, unclear speech, was rarely/never understood, rarely/never understood others, required extensive assistance or was totally dependent on staff for bed mobility, transfers, and all activities of daily living (ADLs), and was not rated for functional limitation in ROM. Previous MDS assessments dated 8/24/20 and 11/24/20 revealed R#228 was not assessed for functional limitation in ROM. A Census report for R#228 documented R#228 went to the hospital and was readmitted on the following dates: 12/16/20 through 12/21/20 1/14/21 through 2/2/21 2/22/21 through 2/26/21 An OT (Occupational Therapy) Evaluation & Plan of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Musculoskeletal System Assessment section documented R#228 had Impaired ROM to the right and left upper extremities including the right and left shoulders, elbow/forearm, wrist, and hand. It was documented R#228 did not have any contractures. An OT Recert, Progress Report & Updated Therapy Plan for a certification period of 9/16/20 through 10/15/20 documented, .Patient is compliant with Plan of Treatment and Patient is progressing with current treatment interventions and Plan of Treatment . It was documented R#228 continued to require OT services five time a week for 30 days. A Therapy Note dated 10/14/20 documented, PT/OT screen completed for contracture management. No evaluation warranted at this time, no observed contractures noted during screen. An Admission Summary note dated 2/2/21 documented, .Bed bound with minor contractures to bil (bilateral) hands and feet . A Nursing Evaluation dated 2/2/21 documented, .hand contractors .Resident has contracture(s). Site: Bil hands, bil feet . On 3/5/21 at 12:30 PM, the Director of Rehab (DOR) was interviewed. When queried about any therapy services R#228 received since his initial admission into the facility on [DATE], the DOR stated, We haven't had him on therapy that much because Medicaid denied our requests. When queried about whether R#228 had any contractures of the upper extremities when he was admitted into the facility on [DATE], the DOR reported she would look into it and the OT could perform an assessment of R#228's current ROM. On 3/5/21 at approximately 1:00 PM, the DOR and OT DD reported R#228 did not have any contractures when he was admitted in 8/19/20 and was discharged from therapy in September 2020. It was explained R#228 was not picked back up for therapy due to being denied by Medicaid. At that time, an observation of R#228 was made with OT DD. OT DD reported he was familiar with R#228 and was the treating OT when he was involved in therapy in August 2020 and September 2020. OT DD reported he had not evaluated R#228 since then. Upon observation, OT DD stated, (R#228)'s right hand and arm definitely looks much different than when I last saw him. Previously, the right hand and arm presented with the same functional ability as the left side. R#228 was able to move his left hand and arm on command at the time of the observation. OT DD attempted to straighten R#228's fingers on his right hand and attempted to move the right arm at the elbow joint without success. OT DD reported it appeared that R#228 was experiencing pain and did not want to exacerbate it due to not knowing the source of the pain. OT DD stated, Based on what I see, he needs to be referred to therapy for the right arm, as it is not in a functional position and is a decline from before. On 3/5/21 at 2:54 PM, the DOR was further interviewed. When queried about the facility's process for referring residents for rehabilitation/therapy services, the DOR reported if a resident required therapy, herself would be notified by the unit manager or therapy themselves if additional therapy was needed. The DOR reported all residents were screened upon admission or readmission into the facility to determine if therapy services were needed. When queried about R#228 and if he had been screened upon all readmissions into the facility, the DOR reported due to the resident having straight Medicaid, the screening would consist of reviewing previous notes and looking at the resident, but not actually making contact with the resident physically. The DOR reported that for Medicaid or private pay residents, the therapy department required a referral from nursing in order to evaluate or treat the resident. When queried about whether any referrals were made for R#228, the DOR reported no referrals were made from nursing for physical or occupational therapy. The DOR provided all screening completed for R#228 which consisted of the initial screening upon admission on 8/19/20, a screening for speech therapy on 8/18/20, and a screening for evaluation for contractures on 10/12/20. The Rehabilitation Screen form dated 10/12/20 documented, No PT (Physical Therapy)/OT eval warranted at this time for contracture mgmt (management) .No contractures . There were no screening forms provided for R#228's readmissions from the hospital on 12/21/20, 2/2/21, and 2/26/21. The DOR was further queried about how decline in ROM was prevented for residents who had Medicaid and were denied for therapy services. The DOR reported the resident could be involved in a restorative nursing program or the facility could pay for therapy services out of pocket. Further review of R#228's clinical record was conducted. Physicians' Orders revealed no order for restorative nursing. An order dated 10/1/21 documented, PT/OT to eval for contracture management. There were no additional orders written for therapy services. A History & Physical completed by Physician Z on 12/23/20 (after R#228 was readmitted into the facility on [DATE]) documented, .PHYSICAL EXAM .Musculoskeletal: Bilateral hands and fingers are contracted. Limited ROM of both upper and lower extremities .Plan: .PMNR <sic> (Physical Medicine and Rehabilitation) Consult .Case discussed with nursing staff . A History & Physical completed by Physician Z on 2/3/21 (after R#228 was readmitted into the facility on [DATE]) documented, .Bilateral hands and fingers are contracted. Limited ROM of both upper and lower extremities .Plan: PMNR consult .Care discussed with nursing staff . A History & Physical completed by Physician Z on 3/1/21 (after R#228 was readmitted into the facility on [DATE]) documented, .Bilateral hands and fingers are contracted. Limited ROM of both upper and lower extremities .Plan: .Rehabilitation with PT/OT .PMNR consult .Care discussed with nursing staff . No orders or consultations from a PM&R physician were present in the clinical record. No orders for Rehabilitation with PT/OT were written after 3/1/21. A policy provided by the facility titled, Order Entry by Therapy Staff (Effective 8/1/17) documented, .Nursing received an order from the Physician to have Therapy (PT/OT/ST) evaluate and treat the resident. Therapy completes the initial evaluation to determine the treatment(s) that are indicated .Therapy verbally notified nursing know of new orders in queue to be acknowledged. Nursing acknowledges the treatment orders entered by the therapist for processing .Daily, at Clinical Start up, the Interdisciplinary Team will review all orders within the prior 24 hours and will be responsible to ensure this process if followed . A policy provided by the facility titled, Restorative Nursing Guideline (Effective Date: 10/1/2019) documented, .A resident with limited range of motion receives appropriate treatment and services to include range of motion and/or to prevent further decrease in range of motion .The resident's comprehensive assessment should include and measure, as appropriate, a resident's current extent of movement of his/her joins <sic> and the identification of limitations, if any opportunities for improvement .The resident-specific, comprehensive assessment should identify individual risks which could impact the resident's range of motion .The facility will provide a Restorative Nursing Program with interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible .Facility systems that may aide in identification of residents who require Restorative Nursing may include, but are not limited to: Participation in a skilled therapy program .MDS completion .Clinical Start Up .Care Management Meeting .Restorative Nursing Resident Review .

This citation pertains to MI 128: Based on observation, interview, and record review the facility failed to consistently and accurately assess resident skin to promptly identify changes in skin condition, implement timely interventions and treatment after changes in skin were identified, and prevent the development and worsening of pressure ulcers for two (R#804, #805) of three residents reviewed for pressure ulcers, resulting in R#804 developing a wound to the left heel classified by the facility's wound care provider as a deep tissue injury (persistent non-blanchable deep red, maroon, or purple discoloration) and by the facility as an unstageable (obscured full thickness skin and tissue loss) pressure ulcer, and R#805 developing moisture associated skin damage classified by the facility which worsened to a stage III pressure ulcer (Full-thickness loss of skin) classified by the facility's wound care provider. Findings include: R#804: On 8/13/20 at 9:30AM R#804 was observed sitting up to the side of their bed with their dining tray in front of the resident. The resident's bare feet were observed to be resting on the floor of the resident's room. R#804 explained that their left foot was their bad foot, and said their right foot was getting that way too. On 8/13/20 at 11:45AM, R#804's left heel wound was observed with Unit Manager (UM) 'G'. R#804's left heel wound was observed to be black in color, was described as unstageable, and no visible treatment was observed to be present to the resident's left heel wound. The clinical record for R#804 was reviewed and revealed the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's significant change minimum data set (MDS) assessment dated [DATE] documented the resident scored seven out of fifteen on a brief interview for mental status exam, which indicated the resident was severely cognitively impaired. Per this assessment R#804 required the extensive assistance of one person for bed mobility, and the extensive assistance of two plus persons for transfers. Also, per this assessment it was documented the resident was at risk for pressure ulcers/injuries and had one unstageable wound with slough and/or eschar, documented as present on admission, entry, or re-entry per the assessment. However, it was noted that the facility's roster matrix form identified R#804 as having a facility acquired unstageable pressure ulcer. Review of a Skin/Wound Note (Narrative) dated 6/10/20 at 4:16PM documented, in part, .Writer was notified by resident that his heel on his left foot was hurting. Writer assessed and took a picture of the heel. Writer observed heel to be black and boggy Review of a REPORT OF RESIDENT SKIN CONDITION (event date 6/10/20 at 2:30PM) revealed, in part, the following: Resident c/o (complained of) a sore heel. Writer assessed heel and observed a black discoloration to bottom of heel. Resident stated his heel has been hurting for some time. Per the type of skin event, pressure ulcer had been selected. It was documented the resident had a pressure ulcer with the following description: discoloration to L heel accompanied by pain 2/10. The form also documented the following question: Is this skin event a pressure ulcer? Yes, had been selected as the response to the question. Per the form the pressure ulcer had been classified as unstageable, the resident did not have the wound when admitted to the facility, the resident had not had a history of [REDACTED]. Per a physician order [REDACTED]. Review of a visit note from the facility's wound care provider dated 6/12/20 documented, in part, the following: Wound Assessment(s) Wound #2 Left Heel is a Deep Tissue Injury and has received a status of Not Healed. Initial wound encounter measurements are 6cm (centimeter) length x 7cm width, with an area of 42 sq (square) cm. Wound bed has Dark Maroon Base [MEDICATION NAME] .Diagnosis.: Deep Tissue Injury L (left) Heel . Continued review of physician orders [REDACTED]. Start date 6/10/20: (Brand Name liquid wound dressing) to bilateral heels and (Brand Name) boots on at all times. Review of R#804's Medication Administration Record [REDACTED]. Documentation on the MAR pertaining to the orders for application of boots and (Brand Name liquid wound dressing) to the bilateral heels began on 6/10/20. Orders were not observed prior to 6/10/20 on the resident's MAR indicated [REDACTED]. Per an order with a start date of 1/1/20 it was documented, Skin Checks Weekly every evening shift every Wed for Monitoring Complete Skin Observation Evaluation. Review of skin assessments for R#804 revealed R#804 had a Skin Observation evaluation present in the electronic medical record dated 5/13/20 (documented as weekly assessment). The next documented Skin Observation evaluation for R#804 was dated 6/10/20 (type documented as other). Skin Observation evaluations were not observed in the resident's clinical record between the dates of 5/13/20 and 6/10/20. Review of R#804's Skin Observation-V1 assessment dated [DATE] revealed, in part, the following: 1. Does the Resident have ANY Skin Issues Observed? No was selected as a response to the question. Per the body diagram section of the assessment, sites identified did not include the resident's left heel. Per the question, 4. New Wound, Wound Team Evaluation Needed a response was selected to indicate No. Review of R#804's Skin Observation-V1 assessment dated [DATE] revealed, in part, the following: 1. Does the Resident have ANY Skin Issues Observed? Yes was selected as a response to the question. Per the body diagram section of the assessment, the site identified was the left heel, described on the assessment as a deep tissue injury. Per the question, 4. New Wound, Wound Team Evaluation Needed a response was selected to indicate Yes. Review of a plan of care for R#804 dated 6/10/20 documented, Resident has risk of skin impairity <sic>. (Brand Name) boots to be worn at all times. On 8/13/20 at 2:10PM the facility's Director of Nursing (DON) was queried regarding pressure ulcers at the facility. The DON explained the facility had a Wounds on Wednesdays program which consisted of unit managers or other designated nurses taking photos of and evaluating wounds. In addition, weekly head to toe skin assessments would be completed by the nurses. The DON explained the wound care Nurse Practitioner (NP) came on Fridays. When queried as to how a resident would be seen by the wound practitioner, the DON explained if there was skin breakdown, a change in skin condition, or skin integrity concerns upon admission then the resident would be placed on wound rounds, the nurse would communicate with the unit manager, the Unit manager would notify the wound Nurse Practitioner, then it would be at their discretion. When queried as to what staff were to do if they noticed a new area on a resident's skin, the DON explained treatment would be put in place, the Unit Manager would be notified, a photograph would be taken of the wound, the resident would be referred to wound care, and notifications would be made. When queried as to who was able to stage and measure pressure ulcers at the facility, the DON responded any nurse trained on measuring and those trained on (facility wound program name) could complete the photos. Per the DON when staff took the photo that nurse would complete the staging, and RNs (Registered Nurses) and LPNs (Licensed Practical Nurses) could stage. The DON explained the facility had an algorithm that would be recommended to the physician pertaining to treatment. The DON explained an incident report and progress note would be completed if a change in skin condition was identified. When queried who was responsible for ensuring skin assessments were being completed, the DON responded this was left to the Unit Managers. The DON acknowledged she had not been made aware of skin assessment concerns. When queried regarding R#804, the DON explained the resident had been seen by the wound care NP on 6/12/20 and it did not appear the resident was seen after that. Per the DON the resident's wound had a cap on it, the nurses were saying R#804's wound was an unstageable pressure ulcer, and when queried the DON acknowledged she agreed with this assessment. When queried as to how R#804 developed the pressure ulcer in the first place, the DON was unable to provide a response. R805 On 8/13/20 at 9:45 AM, R805 was observed lying on their back in bed. A low air loss mattress was observed to be on. When interviewed, R805 was difficult to understand. A review of R805's clinical record was conducted and revealed the following: R805 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A MDS assessment dated [DATE] documented R805 had severely impaired cognition, no behaviors including rejection of care, and required extensive assistance for bed mobility, two person assistance for transfers, and was totally dependent on staff for toilet use. Resident data provided by the facility indicated that R805 had a facility acquired Stage III Pressure Ulcer. A review of what was explained to be the facility's weekly Wound Rounds typically conducted by a unit manager revealed one assessment dated [DATE] which documented a Stage III pressure ulcer to R805's right buttock. It was documented the pressure ulcer had been debrided (dead tissue removed) and had light serosanguineous drainage (serum and blood) and measured 3.5 cm x 4.5 cm x unknown depth. On 8/6/20 at 9:48 AM, a request for access to the Wound Rounds documentation was made to the Administrator. A review of R805's Skin Observations evaluations was conducted and revealed the following: A skin observation dated 3/12/20 documented, admitted with moisture associated redness on sacral area .Skin is currently intact . Pink scar tissue on coccyx . The next skin observation was documented two months later on 5/14/20 and documented, .coccyx .nickel size reddened area . Approximately one month after the 5/14/20 skin observation, a skin observation dated 6/10/20 documented, .excoriation to right and left buttock .tx (treatment) in place .On 7/1/20, a skin observation documented, .coccyx treatment in progress - no new areas of concern The subsequent skin observations were as follows: 7/16/20 .Sacrum .treatment in place 7/22/20 Left buttock, right buttock, groin. There was no description of what was observed at those areas. 7/29/20 Left buttock, right buttock with no description of the areas. 8/5/20 Right buttock, left buttock 8/12/20 Left buttock, right thigh (front) .tx in place A review of R805's progress notes revealed no documentation of the changes in R805's skin integrity between May 2020 and August 2020 besides a Daily Skilled Note dated 6/10/20 that documented R805 was receiving skilled services for wound care. On 8/13/20 at 11:50 AM, the DON and Administrator reported the Wound Rounds documentation could be accessed with a staff member and reported the documentation from the outside wound practitioner would be scanned into the electronic medical record. On 8/13/20 at 2:50 PM, Wound Rounds documentation, risk assessment documentation, and R805's clinical record was reviewed with the DON. The following was documented: On 3/18/20 (upon readmission into the facility), R805 was assessed to be at risk to develop pressure ulcers according to their Braden Score (a standardized assessment used to assess residents' risk of developing pressure ulcers). R805 was assessed to be at risk on 4/1/20 as well. There were no assessments of the moisture associated redness documented in the skin observation on R805's sacral area. The skin observation did not include any description or size of the reddened area. At that time, the DON was queried about interventions that were in place for R805's change in skin integrity to the sacrum. Physician orders [REDACTED]. It was documented that R805 was discharged to the hospital on [DATE] and readmitted into the facility on [DATE] at which time they were assessed to be at risk of pressure ulcer development. On 6/3/20, R805 was assessed to be at moderate risk for pressure ulcer development. The first Wound Assessment Details Report (Wound Rounds assessment) for R805's coccyx (sacrum) was dated 5/20/20 and documented facility acquired Moisture Associated Skin Damage (MASD) due to incontinence. The clinical stage was documented as Superficial and the area measured 0.60 cm x 2.10 cm x 0.10 cm with scant bloody exudate (drainage). The next Wound Assessment Details Report dated 5/27/20 documented MASD to R805's coccyx. The clinical stage documented, denuded (excoriated). The wound measurements were significantly larger than the last assessment at 6.5 cm x 6.0 cm x 0.10 cm with light bloody exudate. At that time, the current plan documented a comment on the form to indicate R805 was to receive a [MEDICATION NAME] dressing every three days. A review of physician's orders [REDACTED]. From 5/20/20 until 6/12/20, R805 received only a barrier cream to the peri-area. A Wound Assessment Details Report dated 6/4/20 documented MASD to R805's coccyx. The clinical stage documented denuded. The documented wound measurements were 6.5 cm x 6.0 cm x 0.10. The current plan and comments documented, wound is opening further. considering changing order to xeroform gauze with boarder <sic>gauzed dressing. will have wound care np (nurse practitioner) round on resident tomorrow. Physicians Orders did not document an order for [REDACTED].>The wound NP did not evaluate R805 until 6/12/20 at which time the wound consult progress note written by the wound NP documented, Wound #1 Coccyx/R (right) buttock is a Stage 3 Pressure Injury Pressure Ulcer .Initial wound encounter measurements are 5 cm length x 7 cm width x 0.4 cm depth .Yellow Base [MEDICATION NAME], minimal Yellow Slough (non-viable yellow, tan, gray, green or brown tissue) . At that time, a collagen and silver gel wound treatment was ordered. R805's care plans were reviewed at that time and revealed the following: A care plan initiated on 7/18/18 documented, The resident is at risk for skin impairment r/t (related to) limited mobility, episodes of incontinence, Dx (diagnosis) of IDDM (insulin dependent diabetes mellitus), needs extensive assist for transfers. All interventions were from 2016 and 2017, except one intervention initiated 3/12/20 that documented, Apply barrier cream to help protect skin from excess moisture every shift and after episodes of incontinence. A second care plan initiated on 7/18/18 documented R805 had an actual impairment to skin integrity on the coccyx due to pressure. Interventions were initiated on 7/24/18 and included evaluating and treating the area according to physicians orders and evaluating for signs and symptoms of infection. There were no care plans that addressed the current Stage III pressure ulcer to R805's coccyx or interventions implemented after the development of the wound. The DON was queried about how the nurses who conducted the skin observations would know if a resident's pressure ulcer worsened or changed. The DON reported they would review the wound assessment in Wound Rounds, get report from the previous shift, and talk with one another. When queried about how R805 went from MASD (from the facility's assessments) from 3/12/20 through 6/10/20 to a Stage III pressure ulcer (according to the wound NP) on 6/12/20, the DON did not offer a response. Review of a facility policy titled, Skin Management Guideline dated 11/28/17 documented, in part, Purpose: To ensure residents that are admitted to the facility are evaluated to determine appropriate measures and individualized interventions to prevent, reduce and treat skin breakdown. It is the practice of this facility to properly identify and evaluate residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care B. Monitoring of Skin Integrity -Skin will be observed daily during cares by the nursing assistants. If any skin concerns are noted, they are to be reported to the licensed nurse. -Weekly skin observation on the bath/shower day will be performed by a Licensed Nurse. -If a skin concern is noted, refer to the skin and wound care formulary -The Care Plan for Skin Integrity is to be evaluated and revised based on response, outcomes, and needs of the resident. -The physician will be consulted with changes suggesting impairment in skin integrity .

This citation pertains to intake: MI 958 Based on interview and record review the facility failed to accurately complete a medication reconciliation upon readmission into the facility, discontinued an insulin dependent resident's fast acting insulin and blood sugar (BS) checks against the hospital directive for one (R#702) of three residents reviewed for diabetic care, resulting in the insulin dependent resident to not receive their insulin coverage for breakfast, lunch, dinner and hour of sleep for multiple consecutive days, a change of condition, agonal breathing, with no pulse and was pronounced dead at the facility. Findings include: On [DATE] a complaint was submitted to the State Agency which documented in part, . (R#702 name redacted) was in distressed <sic> and needed his insulin but, (nurse name redacted) never went to check on (R#702's name redacted) or pull the med (medication) from back up box to give to (R#702's name redacted). (R#702's name redacted) was pronounce deceased . A review of the records revealed R#702 was admitted into the facility on [DATE] (with a readmission date of [DATE]) with [DIAGNOSES REDACTED]. R#702 was dependent on staff for all ADL's (Activities of Daily Living). A record review of the clinical record was conducted and revealed the following: Preadmission paperwork sent to the facility (dated [DATE] at 11:59 am) by the discharging hospital documented in part, . The patient is a (age redacted) gentleman with past medical history of [REDACTED]. on insulin - poor control . Blood sugar levels not well controlled . HGBA1C (measures average blood sugar levels over the past three months) 12.9 (High) . A review of [DATE] Medication Administration Record [REDACTED] Admelog [MEDICATION NAME] 100 Unit/Ml (milliliter) Solution pen-injector (fast acting insulin), Inject as per sliding scale . subcutaneously before meals and bedtime . Basaglar KwikPen 100 Unit/Ml Solution pen-injector (long acting insulin), Inject 35 units subcutaneously at bedtime . A Physician note dated [DATE] at 20:17 (8:17 pm), documented in part . Pt (patient) is non responsive and BS (blood sugars) are high despite of [MEDICATION NAME] injections . RN (Registered Nurse) called me around 1:15 PM, I ordered pt. to be sent to (hospital name redacted) for further evaluation and treatment . A Nurses note dated [DATE] at 15:59 (3:59 pm) documented in part, . Pt arrived to facility via stretcher accompanied by 2 EMT (Emergency Medical Technician) . Pt is post hemorrhagic stroke and Vena Cava filter placement. Right sided weakness present r/t (related to)[MEDICAL CONDITION](stroke) . Hospital discharge medication reconciliation paperwork dated [DATE] documented in part, . insulin [MEDICATION NAME] ([MEDICATION NAME]) 100 unit/mL injection (long acting insulin), inject 35 units under the skin at bedtime - Today (last administration) Insulin [MEDICATION NAME] (Humalog) 100 unit/mL injection (fast acting insulin), Inject ,[DATE] Units under the skin 4 (four) times a day (before meals and nightly- Today (last administration) A Discontinue Order (completed by Nurse C) dated [DATE] at 2:04 am, documented in part . Order Summary: Admelog [MEDICATION NAME] 100 UNIT/ML Solution pen-injector (fast acting insulin), inject as per sliding scale: if ,[DATE] = 2 units; ,[DATE] = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units contact MD (medical doctor) if greater than 350 or less than 60, subcutaneously before meals and at bedtime for ANTIDIABETICS . Communication Method: Phone . Reason for Discontinue: re-admit . A review of [DATE] Medication Administration Record [REDACTED]. On [DATE] at 1:12 pm, a telephone interview was conducted with the Nurse C that discontinued R#702's Ademelog [MEDICATION NAME] Solution pen-injector, blood sugar checks and sliding scale. When asked why they discontinued the order upon the resident's readmission on [DATE], Nurse C replied in part . I don't recall . I was assisting another nurse who didn't complete the admission like she was supposed to. When the discontinue order was reviewed with Nurse C and asked why an order for [REDACTED]. A telephone interview was conducted ([DATE] at 1:32 pm) with the Doctor B whose name was on the discontinued insulin order upon the resident's readmission to the facility. When asked why they discontinued the resident's Admelog [MEDICATION NAME] Solution pen-injector, blood sugar monitoring and sliding scale, Doctor B stated in part . I never said to discontinue the order, I said to continue the orders from the hospital . A Nurses note dated [DATE] at 20:46 (8:46 pm), documented Resident's blood sugar was 531. It is normally in the 100's. He has no short acting insulin. I called (doctor name redacted) and he ordered a sliding scale, but insulin is only to be given while he is receiving tube feeding, which he is the majority of the time. Further review of [DATE] MAR indicated [REDACTED]. On [DATE] at 2:04 pm, Nurse A was queried on why they called the physician for the insulin and sliding scale order on [DATE] but never administered it to the resident and stated in part . I really don't remember . In total the resident went without their fast-acting insulin (per sliding scale) and blood sugar checks for the following dates: [DATE]- 5 pm and 9 pm, ,[DATE], ,[DATE], ,[DATE] and ,[DATE]. A Nurses note dated [DATE] at 4:51 am, documented Walked in resident room approximately 0305 and found to have agonal breathing and no pulse. CPR was initiated and 911 was called. EMTs arrived . CPR for approximately 1 hour. Despite all efforts resident's cardiac rhythm remained in Asystole . pronounced time of death at 0353 . Spouse will call back to advise of funeral home arrangements. On [DATE] at 2:44 pm, the Director of Nursing (DON) was queried on why R#702's short acting insulin was discontinued and why the Nurse A obtained the order (on [DATE] for the short acting insulin, blood sugar checks and sliding scale) but did not administer a dose to the resident (whose BS at that time was 531). The DON responded in part . We weren't aware until you started interviewing the staff . When asked if the facility investigated and reviewed the events that led up to the R#702's death the DON stated in part . We reviewed the notes and that the BS was high and that the nurse put in the orders for the insulin to start on the next day . When asked to provide the education and training that was provided to the staff to prevent any repeated errors in the future, the DON stated that none was provided thus far being that the facility was just made aware of it today ([DATE]- 23 days after the resident's death). At that time the DON was requested to provide the documentation of the code called on R#702 on [DATE], the EMT's documentation, the facilities investigation into the death, any education/training provided to the staff and any other documentation surrounding the pertained to this event. On [DATE] at 4:43 pm, the Administrator stated the DON had no further information to provide. No additional information was provided by the end of survey. A facility policy titled Diabetes Management (Effective Date [DATE]) documented in part, . Blood glucose (BS) monitoring . Results . > 400 indicate . [MEDICAL CONDITION] require immediate follow up . Evaluate signs and symptoms of diabetes complications: . [MEDICAL CONDITION] and stroke, Vital sign changes . question individual about changes in bladder function or urine output . questions/ monitor individual about constipation, urine retention (frequent voiding), palpitations . Notify the physician of any findings which suggest worsening of hypo or [MEDICAL CONDITION] symptoms, infection or any other complication of diabetes and / or comorbidities . Medication management . Blood glucose monitoring including use of glucometer, reportable parameters, Administration of insulin including sliding scale as ordered, Administration schedule (Including what to do if a dose is missed), Hypo & Hyper-glycemia treatment and reporting . Provide instruction on reportable symptoms of instability or complications: Sweating, Anxiety, restlessness, Confusion, Light-headedness, Lethargy and [MEDICAL CONDITION] .

This citation pertains to intake: MI 872 & MI 933. Based on interview and record review the facility failed to accurately screen, identify and consistently monitor resident's that exhibited signs and symptoms consistent to COVID-19 for six (R#'s 701, 702, 703, 704, 705 and 706) of six residents reviewed for the COVID-19 focused survey, and failed to follow the CDC (Centers for Disease Control) guidelines for cohorting a resident (R# 704) with a resident suspected of COVID-19 (R#705), which had the ability to affect multiple residents and/or the same resident(s) by repeated occurrences that resided at the facility to be exposed or develop COVID-19. The failure to implement policies and CDC guidance for COVID-19 resulted in serious health complications from COVID-19 including the risk of death, for many of whom were at high risk due to age and co-morbidities. Findings include: Review of complaints filed with the State Agency on [DATE] and [DATE] included allegations that the facility failed to follow current guidance related to infection prevention and control. On [DATE] at 12:05 PM, interview with a complainant by phone included concerns regarding the facility's lack of monitoring for changes in resident's status (such as vital signs which included: temperature, respirations, and pulse oximetry) following the facility's lockdown on [DATE] related to the coronavirus pandemic. An onsite investigation into the above complaint was conducted from [DATE] to [DATE]. On [DATE] at 9:10 AM, an interview was conducted with the Administrator who reported Wednesday [DATE] would be the last day as the facility's Administrator, and that the Assistant Administrator would be taking over at that time. On [DATE] at 10:45 AM, an interview was conducted with the Assistant Director of Nursing (ADON) who also functioned as the facility's Infection Control Nurse (ICN). When asked who the facility had identified as the first confirmed COVID-19 positive resident, the ADON reported it was R#702. When asked about the facility's process for tracking and monitoring residents for signs and symptoms of COVID-19, the ADON reported tracking was not initiated until the beginning of April. The ADON further reported, We've had 46 residents affected in the building. Was 45 of our own and one admitted with. We've had 11 residents expire that were either COVID-19 positive or suspected positive. The ADON further reported there were multiple staff that had tested positive as well, including the ADON who had been out of the facility starting [DATE]th for ten days due to having some symptoms related to COVID-19. Resident #704 & #705: A review of the census revealed R#704 and R#705 became roommates on [DATE]. R# 705 Review of the records revealed R#705 was admitted into the facility on [DATE] with a readmission date of [DATE] with diagnoses that included [MEDICAL CONDITION], hypertension and dementia. A review of the nurse's notes revealed the following: On [DATE] at 12:37 am, Resident restless attempting to climb out bed. Resident not responding appropriate to all questions . On [DATE] at 4:24 pm, .Altered mental status continued with 0 changes noted. Resident ate 50% of breakfast and 50% of fluids. Resident noted refusing meals and beverages at lunch time . On [DATE] at 4:42 pm, Residents' vital signs checked at the beginning of shift .T (temperature): 99.5 orally .NP (nurse practitioner) called and notified of residents' appetite, vital signs, and also made aware that resident is refusing fluids . A review of the CDC guidance for long term care facilities regarding COVID 19 documented in part, .Older adults with COVID-19 may not show common symptoms such as fever or respiratory symptoms. Less common symptoms can include new or worsening malaise, headache, or new dizziness . The census revealed R#705 became roommates with R#704 on [DATE]. A review of CDC's guidance for long term care facilities regarding COVID 19 documented in part, .Residents in the facility who develop symptoms consistent with COVID-19 could be moved to a single room pending results of [DIAGNOSES REDACTED]-CoV-2 (COVID 19) testing. They should not be place in a room with a new admission .Resident with new-onset suspected or confirmed COVID-19- Ensure the resident is isolated and cared for using all recommended COVID-19 PPE (Protective Personal Equipment) . On [DATE] at 11:29 am, Late Entry: Note Text: QuickVue flu swab negative On [DATE] at 12:59 am, .Resident has c/o (complaints of) not feeling well. Resident vital signs b/p (blood pressure) ,[DATE], temp 99.8 .Residents skin is cool and clammy, resident has a dry non-productive cough. Writer contacted NP received new orders for a stat (immediate) chest x-ray, resident is to <sic> placed on isolation for droplet precautions, NP also ordered a <sic> influenza swab . The census revealed R#705 remained roommates with R#704 despite the NP order to place the resident in isolation for droplet precautions. On [DATE] at 10:49 am, Resident family (sister name redacted) notified R/T (related to) COVID 19 positive test results. R#704 Review of the clinical record revealed R#704 was admitted into the facility on [DATE] with diagnoses that included acute and chronic [MEDICAL CONDITION] with [MEDICAL CONDITIONS], hypertension and [MEDICAL CONDITION]. The census revealed R#704 became roommates with R#705 on [DATE]. Review of R#704 vital signs revealed the following: [DATE] at 3:54 am- 99.4 [DATE] at 5:33 am- 99.0 A review of the Nurses notes revealed the following: On [DATE] at 10:00 am, Writer entered room to give AM meds (medications) and resident was laying in bed with headphones on. Observed mouth breathing and shallow respirations. Resident did not respond to verbal or sternal. SpO2 checked and was 51 % on 2 liters via NC (nasal cannula) with pulse of 125. Emergency code called .Physician notified of Emergency transfer and daughter notified and was enroute <sic> to (hospital name redacted). On [DATE] at 1:01 pm, Daughter called back to update that her Mom was being placed on a vent (ventilator). Asked writer to pack her belongings for them to pick up . On [DATE] at 1:42 pm, the Director of Nursing (DON), ICN and Administrator was queried (via email) on why R#704 was initially moved into the room of R#705, due to the fact that R#705 started to exhibit signs and symptoms consistent with COVID-19 on [DATE] (two days before R#704 became roommates with R#705). The Administrator responded and stated R#705 did not have a temp >100 until ,[DATE]. At 4:04 pm, the DON, Regional Nurse I and Administrator (via a telephone interview) was queried on why on R#704 was not removed from the room again on ,[DATE] when isolation was ordered for R#705? And the statement was made in part .She shouldn't have been in the room with her . Resident #703: A review of the clinical record revealed R#703 was admitted into the facility on [DATE] with a readmission date of [DATE] and diagnoses that included hypertension, adult failure to thrive and dementia. A review of the resident's vital signs revealed the following: [DATE] at 2:28 pm- O2 stat (oxygen in the blood, normal is greater than 92%) 87 % on Room Air (RA). There was no documented follow up regarding this low 02 stat. [DATE] at 3:40 am- T (temperature) 99.0 [DATE]- no temperature documented on the residents Temperature Summary. [DATE] at 5:43 am- T (temperature) 99.0 [DATE] at 8:55 pm- T- 100.0, 02 stat 85% on RA. A review of the residents' progress notes revealed the following: On [DATE] at 12:26 pm, (Social Service Note) documented in part, .updated on her mother temp (temperature) 99 yesterday, eating, no other s/s <sic> virus . On [DATE] at 9:19 pm, a nurses note documented in part .Fever 100.3, SpO2 dropped to 85%, Lethargic, Altered MS (mental status). Eyes were fixated on the <sic> sealing, resident verbally unresponsive .orders to send to (hospital name redacted) . On [DATE] at 1:42 pm, the DON, ICN and Administrator was queried (via email) on why the facility did not identify R#703 as suspected/presumptive for COVID-19 despite exhibiting signs and symptoms consistent with COVID-19. The reply in part documented .(R#703 name redacted) was not presumptive because she did not present with temp of 100 or decrease in pox (02 stat) until ,[DATE] . Resident #706: A review of the clinical record revealed R#706 was admitted into the facility on [DATE] with a readmission date of [DATE] with diagnoses that included type 2 diabetes mellitus, hypertension, asthma and obesity. A review of the resident's Temperature Summary revealed the following: On [DATE] at 6:06 am- 99.1 On [DATE] at 4:34 am- 99.0 A review of the resident's progress notes revealed the following: On [DATE] at 6:29 am, a Nursing note documented in part .Admits to productive cough . On [DATE] at 2:53 pm, a Nursing note documented Resident stated that <sic> has a constant cough, resident stated that she has been assessed by NP, resident stated her symptoms are not new. Resident was educated on the risk and benefits of remaining in her room and [MEDICATION NAME] social distancing. Will continue to monitor. On [DATE] at 9:03 pm, a Nursing note documented in part .Resident complained of SOB (shortness of breath), diaphoresis (excessive abnormal sweating), loss of appetite, and fatigue .B/P (blood pressure) ,[DATE], P (pulse) 100, Resp. (respirations) 32, SpO2 89%. Contact made to NP .V/O (verbal orders) send resident to hospital immediately . The facility list of Resident Deaths from COVID-19 documented that R#706 expired at the hospital. On [DATE] at 1:42 pm, the DON, ICN and Administrator was queried (via email) regarding why the facility failed to identify the resident as suspected/presumptive with COVID-19 after exhibiting signs and symptoms consistent with COVID-19. The Administrator documented in part, .pox (02 stat) never below 97%. I <sic> addition (resident initials redacted) has dx (diagnoses) of [MEDICAL CONDITIONS] and asthma. On ,[DATE] 14:53 (2:53 pm) the NP reviewed (resident initials redacted) chart and resident stated that this was not new, resident has h/o (history of) constant cough. Resident additionally d/c (discharge) to hosp (hospital) for bowel obstruction/ not respiratory related. Further review of the resident's clinical record revealed no [DIAGNOSES REDACTED]. The last note in the resident's progress note clearly indicated the resident was transferred to the hospital for respiratory distress as well as other symptoms consistent with COVID-19. Resident #701: A review of the clinical record revealed R#701 was admitted into the facility on [DATE] and discharged home on [DATE]. Diagnoses included: [MEDICAL CONDITION] stage three, [MEDICAL CONDITION], diabetes mellitus type 2, [MEDICAL CONDITION], and closed head injury. A review of R#701's [DATE] physician orders [REDACTED]. A physician order [REDACTED]. There was no documentation this had been done (blank entries) on [DATE] and [DATE]. A physician order [REDACTED]. There was no documentation this had been done (blank entries) on [DATE]. A review of the electronic clinical records vitals tab revealed on [DATE], there were temperatures obtained at 3:28 AM and 5:12 AM. An order which began on [DATE] which continued until discharge read, Vitals: BP (Blood Pressure)/Pulse/Resp (Respirations)/Temp/O2 Sats (oxygen saturation - level of oxygen in the blood) one time a day. At that time and currently, CDC recommendations and facility policy were for vitals to be completed at least every shift. Resident #702: A review of the clinical record revealed R#702 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: COVID-19 (upon readmission/RA on [DATE]), [MEDICAL CONDITION], extended spectrum beta lactamase (ESBL) resistance (upon RA on [DATE]), other [MEDICAL CONDITION] pneumonia (upon RA on [DATE]), [MEDICAL CONDITION], and acute [MEDICAL CONDITION] (upon admission [DATE]). Further review of the clinical record revealed R#702 had been hospitalized on [DATE], been diagnosed as COVID-19 positive upon hospitalization , transferred from that hospital to a dedicated temporary COVID-19 hospital, and readmitted to the facility on [DATE]. A review of the physician orders [REDACTED]. A review of R#702's MARs from March to [DATE] revealed concerns with the facility's documentation of the resident's vital signs. There were multiple missing (blank) entries, vital signs were not completed at least once every shift, and there were several documented entries of elevated temperatures in March and [DATE] without corresponding documentation of any follow up, such as whether the vitals had been rechecked, or the physician had been notified. On [DATE] at 1:40 PM, an interview was conducted with the Assistant Administrator and MDS Nurse A. When asked about the facility's nursing staff and times of shifts worked, both reported the nurses worked eight-hour shifts. When asked to clarify the facility's process to obtain vital signs, it was reported vital signs should be done every shift. When asked if there should be documentation available, at least three times a day, both reported it should. Upon review of R#701 and R#702's clinical record and vital sign documentation, the Assistant Administrator and MDS Nurse A confirmed the lack of documentation and were unable to offer any further explanation. A facility policy titled Infection Prevention and Control Interim Guideline for Suspected or Confirmed Coronavirus (COVID-19) with a revision date of [DATE] documented in part, .It is the practice of this facility to minimize exposures to respiratory pathogens and promptly identify residents with Clinical Features and an Epidemiologic Risk for the COVID-19 .A resident with known or suspected COVID-19, immediate infection prevention and control measures will be put into place .place on both contact and droplet precautions .if resident is exhibiting symptoms of any respiratory infection (i.e. cough, fever, shortness of breath, etc.) to determine appropriate placement .Prompt detection, triage and isolation of potentially infected residents. Ongoing, frequent, active screening of residents for fever and respiratory symptoms every shift .

This citation pertains to Intake Number MI 664. Based on interview and record review, the facility failed to do an admission nursing assessment to assess for safety and medical stability, obtain physician orders [REDACTED].#803) of six residents reviewed for accidents who was newly admitted into the facility with a bone infection, multiple wounds, a peripherally inserted central catheter (PICC) line, required intravenous (IV) antibiotics, and had a [MEDICAL CONDITION] resulting in an immediate jeopardy (IJ) when R#803 was permitted by staff to leave the facility without medications, was not located for two days, and was subsequently admitted to the hospital for a dysfunctional PICC line with a suspected infection. This put the resident at risk of serious injury, serious harm, and/or death due to the likelihood of development and/or worsening infections, wound complications, and/or overall safety of the resident due to having a [MEDICAL CONDITION]. Findings include: The IJ began on [DATE]. The IJ was identified on [DATE]. The Administrator was notified on [DATE] at 1:30 P.M. and a plan to remove the immediacy was requested. The immediacy was removed on [DATE] based on the facility's implementation of an acceptable plan of removal verified on-site by the surveyor. Although the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not been verified by the State Agency. A complaint was received by the State Agency that alleged, .a resident (unknown) signed themselves out of the facility on [DATE] and has yet to return. The facility is unaware of the residents whereabouts. The resident has a guardian and the guardian does not know where the resident is as well . An unannounced, onsite visit to the facility was conducted on [DATE] and [DATE] to investigate the complainant's concerns. A review of residents admitted into and discharged from the facility for the past 30 days revealed R#803 was admitted and discharged on the same day ([DATE]) to home. A review of R#803's clinical record revealed the following: R#803 was admitted into the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. A progress note written by Nurse D on [DATE] at 1:04 P.M. documented, .Resident arrived at Facility via care <sic> at 11:15 AM. He is coming from (name of other nursing facility redacted) . A progress note written by Nurse C on [DATE] 3:00 P.M. documented, .Resident left LOA (leave of absence) with friend at 3 PM. A progress note written by Nurse F on [DATE] at 6:51 P.M. documented, .PC (phone call) made to guardian to inform that resident has gone LOA from 3pm today. No answer, call made to (name redacted) 2nd contact to inform of above. NP (Nurse Practitioner) from (Physician's name redacted) notified. Resident not to go LOA until PICC line has been removed at the end of his treatment . A progress note written by Nurse C on [DATE] at 11:20 P.M. documented, .Called 911 to report resident not returning to facility. Information give to the dispatcher: .Friend picked him up from the facility .History of [MEDICAL CONDITION]. A progress note written by Nurse C on [DATE] 12:22 [NAME]M. documented, (County name redacted) Sheriff left facility after report was made regarding resident that did not return to the facility. A Late Entry progress note written by Nurse D on [DATE] 9:47 [NAME]M. documented, Resident was received on Saturday ([DATE]) at 11:15 ([NAME]M.) from (nursing facility name redacted). He was A&OX3 (Alert and oriented times three - to person, place, and time). VS (vital signs) ,[DATE] P (pulse) 82 POX (Pulse oximetry) 98% RA (room air). R (respirations) 18 Weight 253 pounds. Skin was intact. Unable to evaluate bilateral feet for treatment due to resident refusal. Wound was notified and she was coming in to take pictures and evaluate feet for treatment. Picc line in left arm intact for IV therapy . On [DATE] at 10:30 [NAME]M., a phone interview was attempted with Nurse C. There was no answer and a message was left. Nurse C was unavailable for interview prior to the end of the survey. On [DATE] at 10:50 [NAME]M., a phone interview was attempted with Certified Nursing Assistant (CNA) B who was assigned to R#803 on [DATE]. The phone number provided was not in service. CNA B was unavailable to interview prior to the end of the survey. On [DATE] at 10:51 [NAME]M., an interview was conducted with Nurse D who was the nurse assigned to R#803 at the time of his admission. When queried about R#803, Nurse D stated, (R#803) arrived (to the facility) by car. I got vitals and weights. He refused to let me look at his feet. He had osteo[DIAGNOSES REDACTED] and ulcers. He told me only his doctor could remove the dressing. He had amputations of his right great toe and partial amputations of the second and third toes. I called (Nurse F) the wound nurse and said 'He won't let me look at his feet.' She (Nurse F) said she will evaluate and take pictures. Apparently (R#803) went up to (Nurse C), the afternoon nurse and said his cousin was right up the street and he wanted to leave and (Nurse C) said 'Here's the book to sign out.' By the time (Nurse F) came to see (R#803), he had taken off and signed himself out. Nurse D further reported Housekeeper L was walking out of the facility and R#803 walked out with her and told her he called someone to pick him up. Nurse D stated, He did not show back up. I came in the next morning and they had called the police. (The Director of Nursing - DON) was frantic. The DON said if he showed up to notify the physician that he has not had meds, has a PICC line, and tell him he has been without antibiotics for so many hours. He came back, we were instructed to get a drug screen, and he was sent out by ambulance to the hospital and sent to psych from ER. I later found out he had a guardian. We were sick to our stomachs that this happened . On [DATE] at 11:10 [NAME]M., incident reports and investigations regarding R#803 were requested from the Administrator. On [DATE] at 11:25 [NAME]M., Housekeeper L was interviewed. When queried about R#803 on [DATE], Housekeeper L stated, I went to clock out at 3pm and walked out toward the lobby doors. A nurse (Nurse C) said (R#803) had signed out and him and another gentleman walked out before me. When asked if R#803 returned to the facility, Housekeeper L stated, I'm not sure if he came back or not. All of his belongings were still there and he wasn't in his room on Sunday ([DATE]). On [DATE] at 11:40 [NAME]M., Nurse F was interviewed. Nurse F reported that she was the Wound Rounds Nurse and worked on Tuesdays and Wednesdays and occasional picked up a shift. When queried about R#803 on [DATE], Nurse F stated, I got a call regarding (R#803) to come in and look at his wounds. I came in around 3:15 P.M. and punched in. I went to his paperwork, looked at orders, and reviewed his paperwork. I hadn't met him yet at that point and was just checking the admission. I went to get my phone to take picture of his wounds and (Nurse C) said, 'Oh, he left on LO[NAME] He signed out.' I asked her, why did he go LOA and she said, 'I don't know. He went with a friend. He wanted to smoke. The only reason he came here (from the other facility) was to smoke. (Nurse C) didn't even document that he left. Then I looked and I saw he had a guardian and asked (Nurse C) 'Did you know he had a guardian?' and she said she didn't. So I called the guardian and second contact. The second contact was from the facility he came from and asked, 'Are you letting him smoke there? That's why he wanted to come here. He'll probably be back.' I called the DON and Administrator, and the on call physician which was the NP to ask how they would like us to deal with this. The NP said, 'I don't want him to go LOA until the PICC line comes out. If he comes back intoxicated we will have to make sure he doesn't get any contraindicated medications.' When asked if R#803 returned to the facility, Nurse F stated, I don't know if he came back because I left around 6pm. On [DATE] at 12:00 P.M., the Administrator reported there were no incident reports for R#803. When queried about any investigations conducted by the facility, the Administrator stated, There's an investigation with the nurse not following the process but not with the resident. When queried about what happened, the Administrator stated, I got a call from (Nurse F) that we got a resident who was admitted on Saturday [DATE] who transferred from another facility and he had signed out LO[NAME] (Nurse C) said there was a transfer order from (previous facility's name redacted) that he can go on LOA and had a guardian .Residents are not to leave without being seen or reviewed by the physician. The Administrator was asked about what Nurse C should have done. The Administrator stated, The admission assessment process should be done within 2 hours of admission. Residents are not to leave without doctor review. She didn't see that (R#803) had a guardian. It was further reported by the Administrator that she had Nurse C call the police. They could not get the guardian on the phone. The police came and gave report number. The Administrator stated, (R#803) came back Monday morning ([DATE]) at 10:30AM and said he went up north to a festival. After I spoke to the guardian she said she wanted to have him committed. The DON did an assessment and he was fine. He was sent to the ER and went with the sheriff. The Administrator provided an investigation that contained, in part, the following documents: An Admission Notification dated [DATE] that documented, .Clinical needs: PICC line, wounds, IV pole .Needs 4 weeks of IV antibiotics and then he is going home. He is coming here because we are a smoking facility . A Release of Responsibility for Leave of Absence form that indicated R#803 signed himself out on [DATE] at 3:00 P.M. A Physician order [REDACTED].#803 was transferred from (orders were not active at the current facility until reviewed and ordered by the current facility physician) that included an order from [DATE] (MONTH) go on LOA with meds. An Employee Discipline Form for Nurse C dated [DATE] documented, Resident did not have nursing assessment, or doctor order, guardian not notified, prior to resident being able to sign out LO[NAME] An Employee Discipline Form for Nurse D dated [DATE] documented, Educated on proper assessments to complete during admission/readmission . On [DATE] at 12:15 P.M., R#803's clinical record was further reviewed and there was no documented assessment in R#803's clinical record after he returned to the facility per the Administrator's statement. Hospital records for R#803 were reviewed and revealed the following: An Emergency face sheet documented R#803 was admitted to the emergency roiagnom on [DATE] at 10:56 [NAME]M. from a non-health care facility and arrived with law enforcement. A ED Adult Triage Form dated [DATE] at 11:28 [NAME]M. documented, .Mode of Triage Arrival: Security/Police vehicle .Chief Compliant- Triage: IV ABX (antibiotics) .Known or Suspected Infection: Yes .Focused Assessment: IV ABX, eloped from multiple facilities .Vital Signs .Pulse Rate: 112 BPM (beats per minute - normal range is typically between 60 and 100 bpm) .Systolic BP (blood pressure): 152 mmHg (indicating high blood pressure) .Pain Score: 7 (out of 10, with 10 being the highest amount of pain) .Pain Location Site .: Foot . An ED Physician Note dated [DATE] at 11:07 [NAME]M. documented, .history of .NIDDM (non-insulin dependent diabetes mellitus, [MEDICAL CONDITION] (TBI) and cocaine abuse presents to the emergency department by police for the complaint of a psych evaluation .Patient brought in for a psychiatric evaluation. He has a history of [MEDICAL CONDITION] and he is not his own legal guardian .He has been eloping from his care facilities, where he resides. He is currently on [MEDICATION NAME] (an antibiotic) for osteo[DIAGNOSES REDACTED] of the left foot. His left foot is in a cast. I did speak with .the podiatrist. He says that he saw the wound a few days ago and the cast is mainly for support for the Charcot foot (bone deformity due to nerve damage) .He needs to be on the [MEDICATION NAME] for the osteo[DIAGNOSES REDACTED] but it did not appear to be worse in the office a few days ago. Patient does have a PICC line here in the site after being evaluated by VAT (Vascular Access Team), who is concerned for it to be infected. He also may need a psychiatric evaluation here as petition was filled out but given the osteo[DIAGNOSES REDACTED] and access issues we will admit him medically . A IM (Internal Medicine) History and Physical dated [DATE] documented, .Chief Complaint .Noncompliance to IV antibiotics for osteo[DIAGNOSES REDACTED] .The patient has disability due to a [MEDICAL CONDITION] at the age of 14 .He has had osteo[DIAGNOSES REDACTED] in his left foot for the past 2 weeks for which he is supposed to be getting IV [MEDICATION NAME] for 6 weeks. However, 2 days ago, he ran away from his group home (nursing facility) and was unaccounted for until earlier today. When he returned to his nursing home today, he was sent to the ED. He is under the care of her <sic> guardian .and her social worker assistant .I spoke to (guardian assistant) who told he that he has run away from him nursing homes multiple times and that she is concerned that he is at danger for risk to himself and needs a psychiatric consultation. Speaking to the patient was difficult as he goes off on tangents and does not give direct answers .VAT evaluated the PICC line and reports that it is unusable due to redness, lack of dressing coverage and lack of feeling clinginess at the site. As per the nurse, it is possible that the patient was using IV drugs using his PICC line but the patient denies this .ED Course: At presentation, the patient was [MEDICAL CONDITION] at a heart rate of 112, hypertensive 152/(76). His blood glucose level was 198, his hemoglobin is 8.9, platelet count 647,000, RDW increased at 16.9 .[MEDICATION NAME] level was 0.03, his urinary drug screening is pending . An addendum to the IM History of Physical documented, .PICC line looks dirty and infected as he run away from the group home for a while and has not been on Abx anymore .His wound should be examined and due to the bad condition of his PICC line, it will be removed . A Progress Note - IM dated [DATE] documented, .PICC line also appeared infected and was removed. Patient has history of TBI and is not his own guardian. Per legal guardian he has been eloping from the facility and there is concern that he will need a more supervised setting .Patient has started IV [MEDICATION NAME] TID (three times a day) which was his previous regimen. he will need a new PICC line once blood cultures are negative . A Consultation Report dated [DATE] documented, The patient states that he has been accused of eloping several times from various places where he actually did not. He said that he was given permission to sign out and go off the floor at another nursing home where he was for his IV antibiotics. He chose to go to a corner gas station and he was gone for 2 hours. He does not see anything wrong with that, but stated that part of the reason was he got lost on the wait <sic> there and it took him more time because he had to double back and then go again. He then took off up north with a relative and from the 2nd nursing home, they called the police and had him brought here. He said that this is not unusual for him that ever since his head injury he has been known to make impulsive decisions. He said that his intention is not to elope, but he often leaves without giving any adequate notice and stays gone for several days .The patient states that he had closed head injury when he was 14 as a passenger in a car. He feels that he as a result has been left impulsive and immature because it affected his emotional growth .He said he had one beer on Monday before being brought to the hospital . As of [DATE], R#803 remained admitted at the hospital and no further hospital documentation was available prior to the end of the survey. On [DATE] at 11:30 [NAME]M., the DON was interviewed. When queried about R#803's return to the facility, the DON reported she was working and he returned the morning of [DATE]. The DON reported that he was assessed as soon as he returned and went to the hospital via the county sheriff vehicle. The DON reported that the physician ordered R#803 to go to the hospital after being gone from the facility for two days and My primary concern was to get him to the ER. The DON reported she documented the assessment of the resident in the progress notes. When queried about why R#803 was not sent to the ER via EMS, the DON stated, Because the guardian wanted him committed and the police were already here. A SNF (Skilled Nursing Facility) to ED Handoff Form completed by the DON on [DATE] at 10:30 [NAME]M. documented R#803 had a guardian. Key clinical information documented, .has osteo[DIAGNOSES REDACTED] of foot, treatment is vanco 3 times daily, IV. Resident went LOA without medication .Reason for transfer: Resident went LOA for extended period, did not take medication or seek treatment for [REDACTED]. Guardian, SW (social worker) wishes to commit related to harm to self . No vital signs were documented. It was documented R#803 had a PICC line, wounds on the left foot, and a confirmed soft tissue infection. There was no progress note regarding the assessment of R#803 written by the DON. R#803's clinical record was further reviewed on [DATE] and the following was documented: The following physician's orders [REDACTED].#803 left the facility according to Nurse F) and not administered while R#803 was gone from the facility from [DATE] through [DATE]: - (MONTH) NOT go LOA until PICC line removed after treatment - Wound treatment: Left foot (lg toe and 4th toe, Plantar mid foot) .every evening shift for wound care - Wound treatment: Right foot (lg toe and 2nd toe) .every evening shift for wound care - Diabetic foot check every evening shift - Accucheck two times a day for blood sugar monitoring - [MEDICATION NAME] (an antibiotic) 2 grams intravenously every 8 hours for osteo[DIAGNOSES REDACTED] - [MEDICATION NAME] HCl 1000MG (milligrams) by mouth two times a day for diabetes mellitus - [MEDICATION NAME] 25 MG by mouth two time a day for hypertension - Naltrexone (a drug used to treat alcohol and drug dependence) 50 MG by mouth one time a day - Sash kit ,[DATE].9 unit/ML (milliliter)-%([MEDICATION NAME] & NaCl - sodium chloride) Lock Flush) Use 10 cc (cubic centimeters) intravenously every 8 hours for PICC line maintenance A Letters of Guardianship form for R#803 documented R#803 had a full legal guardian as of [DATE]. The form documented, .In the matter of (R#803) Legally Incapacitated Individual .(guardian's name redacted) You have been appointed Full guardian of the individual named above. Having filed an acceptance of appointment, you have the care, custody, and control of that individual . Policies regarding elopement, leave of absence, and guardianship were requested from the Administrator on [DATE] at 12:00 P.M. The Administrator reported the facility did not have a written policy on leave of absence. An undated policy titled, Wander/Elopement Risk Observation documented, .It is the responsibility of the admission nurse to complete initial elopement risk observation . An undated policy titled, Missing Person/Elopement Management documented, .Should an employee discover that a resident is missing from the facility, he or she should: .Complete incident report. Document appropriate notations in the medical record .Upon return of the resident to the facility, the Director of Nursing or Charge nurse should: a. Examine the resident for injuries .Fill out incident report .Make appropriate entries into the resident's medical record . A policy regarding guardianship was not received prior to the end of the survey. A policy regarding admission assessments was requested and not provided prior to the end of the survey. A policy titled, Physician Services Guideline dated [DATE] documented, .A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident' immediate care and needs . The facility submitted the following plan to remove the immediacy: F689 Abatement Plan/Removal Plan Element 1 Resident 803 was admitted [DATE] and signed out LOA with nurse approval. The nurse failed to confirm a physician order, guardian approval and resident 803 had a PICC line in place. DON met with resident when he returned [DATE] with full body assessment completed resident wounds were not able to be assessed related to hard cast on left leg, PICC line intact in left arm. Resident was noted to be alert and oriented to time, place and person. Indicated that he had meant to call but his phone died . Physician and guardian notified. Physician ordered resident to be transferred to the acute care facility for ER work up and evaluation on [DATE] at 11am by Director of Nursing. Facility staff unable to receive any further information/updates about resident 803 at this time. Element 2 All new residents have the potential to be affected. All current resident medical records were reviewed and care-plan updated related to LOA and guardianship. Residents that frequently participate in the LOA process with active guardianship were reviewed to ensure LOA orders were in place. Element 3 The Administrator and DON reviewed the process for LOA and updated to include checking for guardianship, DPOA (Durable Power of Attorney) and physicians order. Administrator and DON reviewed nursing admission process and updated to include the need for the Comprehensive nursing assessment to be completed prior to allowing a resident to discharge on LO[NAME] 100% of Licensed staff and Department Heads were educated on [DATE] thru [DATE] regarding LOA process, DPOA definition, Guardian definition, and the difference between activated DPOA and nonactivated. Nurses educated to check for responsible party, guardians and (Physicians) if no order is in place before allowing any resident to leave the premises. Nurses educated not to allow residents with PICC line access to leave the facility without special permission from Physician and obtain a special order related to LOA with venous access. Nurses educated that the Comprehensive Nursing Assessment must be completed within 2 hours of admission and all admission nursing evaluations must be completed prior to resident leaving for LO[NAME] Social services will ensure that all residents have appropriate responsible party listed to include guardian, Activated DPOA etc. Advance directives and DPOA status will be reviewed in morning stand-up during clinical review for new admissions and orders from previous day. Physicians were contacted on [DATE] and Orders have been placed received for residents that frequently participates in LO[NAME] ADH[NAME] QAPI (quality assurance performance improvement) conducted. Comprehensive Nursing Assessment and Evaluations for new/readmissions will be audited daily M-F to ensure completion during clinical stand-up. Audit will be conducted daily M-F to ensure admission checklist is completed on new/readmissions in clinical stand-up. Random review of Comprehensive assessments and admission checklists will be completed by DON and Administrator weekly. Findings of audits will be corrected immediately and shared with QAPI monthly x 3 months or until compliance is met. Element 4 Administrator and Director of Nursing will be responsible for sustained compliance. Element 5 Date of Abatement - (MONTH) 2, 2019

This citation pertains to MI 533 Based on interview and record review the facility failed to assess, monitor and to promptly inform the physician of a resident's change of condition (altered mental status, decline in eating and a decline in verbal communication) for one (R#802) of three residents reviewed for quality of care, resulting in a formal complaint submitted to the State Agency, the resident urinary tract infection [MEDICAL CONDITION] to go unnoticed and untreated requiring the resident to be hospitalized and ultimately released under hospice care. Findings include: On 10/01/19 at 5:47 PM, a telephone interview with the complainant revealed in part, . My brother called me and told me that our mother wasn't acting right. He said that she had been that way for a week and that he told the nurses but they weren't doing anything about it. I called after we hung up to talk to the Nurse and she said There isn't nothing wrong with your mother. She is fine. I had to fly up there to get my mother proper treatment and for someone to even listen . When I got there and seen my mother, I demanded that she be seen by a doctor and the staff told us that everyone went home for the evening and she would be seen tomorrow. We were there bright and early the next day and wasn't leaving until my mom was seen by a doctor. The doctor came in and seen her and sent her right out to the hospital . She was septic from a UTI. She was admitted to the Intensive Care Unit (ICU) from the emergency room (ER) . Her body wasn't responding to the antibiotics and they approached us about placing her into hospice care. We knew that we would eventually lose our mother one day, but not like this . An Emergency Medical Services (EMS) report dated 8/14/19 at 16:22 (4:22 PM) documented in part, . SNF (Skilled Nursing Facility) staff and family report recent mental status change with decreased L[NAME] (level of consciousness) for one week. Staff did not offer baseline orientation but report PT (patient) is normally able to answer simple questions but is not oriented only to self. Presents malaise and generally more lethargic . A review of the Emergency Physician Record (EPR) note (dated 8/14/19 at 4:38 PM) documented in part, . Per EMS pt (patient) has had a decrease responsiveness and AMS (altered mental status) for one week . Patient AMS secondary to UTI. WBC (white blood cell) > (greater than) 12.6 . Time of Recognition of [DIAGNOSES REDACTED]. IV (intravenous) [MEDICATION NAME] (antibiotic) given in ED (emergency department). A review of the HPI (History of Present Illness) note (dated 8/14/19 at 7:27 PM) documented by the ER Nurse Practitioner (NP) documented in part, . The patient is (age redacted) . UTI w (with)/sepsis; ESBL (Extended Spectrum Betalactamases- a type of enzyme/chemical produced by some bacteria, which cause some antibiotics not to work for treating bacterial infections.)/proteus bacteremia (gram-negative bacteria) presented to emergency department from (nursing home name redacted) with acute mental status change, one set of symptoms 1 week, on presentation to ER patient was lethargic . Will be admitted . for further evaluation and treatment . A Discharge Summary Medical dated 8/22/19 at 15:31 (3:31 PM), documented in part . (age redacted) female with dementia was hospitalized for [REDACTED]. Pt unable to get off pressors (used to treat low blood pressure) and family decided on hospice care . On 10/2/19 to 10/3/19, an onsite investigation into the complainant's allegation was conducted. A review of R#802's clinical record revealed that R#802 was admitted into the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) as a No to not be conducted as resident is rarely/never understood. R#802 required a two-person physical assistance for bathing and transfers and a one-person physical assistance for bed mobility, dressing, eating, toilet use and hygiene. On 10/2/19 at 2:03 PM, Registered Nurse (RN) K was queried (via a telephone interview) on any changes noticed with R#802 prior to being sent out to the hospital on [DATE]. RN K stated in part, . Her daughter came in from out of state and was concerned about her mother's pain and she wasn't eating and I left it on the doctor's log and told the unit manager. I'm not use to her; I didn't know what her normal behavior was . On 10/3/19 at 12:11 PM, Certified Nursing Assistance (CNA) I was queried on any changes noticed with R#802 prior to being sent out to the hospital on [DATE]. CNA I stated in part, . She was eating less. The family would say that she was in pain and they asked me to lay her down and that's what I did . On 10/3/19 at 12:24 PM, CNA J was queried on any changes noticed with R#802 prior to being sent out to the hospital on [DATE]. CNA J stated in part, . She wouldn't eat. We started feeding her because she wouldn't eat, she would get angry and it was kind of odd for her. She stopped talking. She used to hold conversations with us before, but she had stopped talking . On 10/3/19 at 12:35 PM, Licensed Practical Nurse (LPN) [NAME] was queried on any changes noticed with R#802 prior to being sent out to the hospital on [DATE]. LPN [NAME] stated in part, . She wasn't looking good, but when the daughter came in that's when they (facility staff) responded and she (the daughter) was very upset . A Nursing SNF to ED transfer note dated 8/14/19 at 14:43 (2:43 PM), documented in part . Key clinical Information: lethargic Reason for Transfer: not eating pail <sic> in color family request for eval (evaluation) Vital Signs: BP (blood pressure) 102/56 . Position: Lying l (left)/arm P (pulse) 60 . Pulse Type: Regular R (respiration) 18.0 . T (temperature) 98.9 . Route: Oral O2 94 % . Method: Room Air . Not alert A Medical Professional Progress Note dated 8/14/19 at 14:46 (2:46 PM) documented in part, . Follow Up Visit; Family Concern . Pt (patient) was seen per family request d/t (due to) pt appearing to be in pain, refused to eat, holding her R (right) hip. Pt also is very pale and unable to wake her up. Pt is alert though . Summary: send pt to (hospital name redacted) hospital per family request for mental status changed . R#802's clinical record was reviewed and revealed no documentation of any changes of condition noted prior to 8/14/19, when the resident was transferred to the hospital. R#802's vital documentation was reviewed and revealed no documentation for a blood pressure, heart rate, temperature or respiration rate for the months of (MONTH) to (MONTH) 2019, with the exception of 8/1/19 and 8/14/19 when R#802 was assessed prior to being transferred to the hospital. A physician order [REDACTED]. A Review of R#802's 2019 Medication Administration Records (MAR) for January, (MONTH) and (MONTH) revealed no documentation. For the months of March, April, (MONTH) and (MONTH) of 2019, the MAR indicated [REDACTED].) A review of R#802's eating task documented for the month of (MONTH) 2019 revealed R#802's percentage of meal consumed on most days to range around the 51% to 75% and 76% to 100% ranges. For the month of (MONTH) 2019 R#802's eating task documented a decline with mostly 51% to 75%, 26% to 50% and 0% to 25% being documented by the facility staff up until R#802's transfer to the hospital on [DATE]. A review of R#802's care plans revealed the following: A care plan titled The resident has an acute urinary tract infection. She was readmitted with Bacteremia R/T (related to) UTI, (dated 4/11/2017) documented in part, . The resident will be free from complications related to infection . Monitor/document/report to MD (medical doctor) s/sx (signs/symptoms) of [MEDICAL CONDITION]: Changes in behavior, Altered mental status, wide variation in cognitive function throughout the day, Communication decline, Disorientation Periods of lethargy, Restlessness and agitation, Altered sleep cycle . A care plan (dated 8/6/18) titled The resident has bladder incontinence and bowel incontinence r/t (related to) Dementia, Confusion, Physical limitation, Impaired Mobility . documented in part, . She is unaware of her toileting needs . Encourage fluids during the day to promote prompted voiding responses . Monitor report to nurse/nurse to document: for s/sx of UTI: . altered mental status, change in behavior, change in eating patterns . A care plan titled The resident has [MEDICAL CONDITION] r/t (related to) Kidney disease CKD stage 2 (dated 8/6/18) documented in part, . Monitor VITAL SIGNS prn and as ordered, Notify MD (medical doctor) of significant abnormalities . A care plan titled, The resident has a communication problem r/t impaired cognition (dated 11/27/18) documented in part, . Anticipate and meet needs . Monitor/document for physical/nonverbal indicators of discomfort or distress, and follow-up as needed . A care plan titled, . severe cognitive function deficit/dementia . (dated 11/27/18) documented in part, . Monitor/document/report PRN (as needed) any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self . level of consciousness, mental status that is different from her baseline . On 10/2/19 at 3:41 PM, the Director of Nursing (DON) was queried on why the facility staff had not reported R#802's change of condition to the physician promptly before the family intervened. The DON acknowledged that they weren't informed of R#802's change of condition prior to being transferred to the hospital on [DATE]. The DON then stated, . The nurse should've called the doctor, not put it in the doctor's log. Especially if the family is requesting the doctor to see the resident. My expertise is that the family is usually right when they say that something is wrong with their family member . On 10/3/19 at 1:25 PM, the DON was queried on how often R#802's vital signs were supposed to be monitored, given the fact that R#802 had a history of [REDACTED]. Monthly vitals and weights should be documented for every resident, except hospice. The DON was asked to provide any other documentation of monthly vitals from (MONTH) to (MONTH) of 2019 and for the month of (MONTH) 2019 leading up to the resident being transferred to the hospital on [DATE]. The DON stated that they would look into it. When asked how the facility monitors changes in condition for the facility residents the DON stated, We have morning meetings every day. The staff are expected to bring up any acute changes at that time so that we can discuss them. Nurses are expected to document any change of condition and report it to the doctor. When queried on the concerns of R#802's decrease in food intake, mental status and decrease verbal communication that was relayed by the facility staff but not reported to the physician until R#802's family requested it, the DON stated I'm very concerned and am already looking into things to change. On 10/3/19 at 2:17 PM, it was confirmed by the DON that no other documentation regarding R#802's vitals could be provided. The DON and Administrator was asked to provide any additional information regarding the change of condition with R#802 and none was provided by the end of survey. A facility policy titled Notification of Changes Guideline dated 7/24/19 documented in part, . It is the practice of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician . The resident and/or their representative will be educated about treatment options . Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative, and the resident's physician, to ensure best outcomes of care for the resident . The objective of the notification guideline is to ensure that the facility staff makes appropriate notification to the physician . when there is a change in the resident's condition . to provide appropriate and timely information about changes relevant to a resident's condition or change . to the parties who will make decisions about care, treatment and preferences to address the changes . Notification is provided to the physician to facilitate continuity of care and obtain input from the physician about changes additions to or discontinuation of treatment . The facility shall promptly notify the resident . and his or her physician or delegate of changes in the resident's condition or status in order to obtain orders for appropriate treatment and monitoring . The nurse will immediately notify the resident, resident's physician and the resident representative(s) for the following . A significant change in the resident's physical, mental or psychosocial status that is a deterioration . Document the notification and record any new orders in the resident's medical record .

This citation refers to Intake Number(s) MI 541 and MI 649. Based on observation, interview and record review, the facility failed to ensure resident care was provided in a safe manner for one (#801) of three residents reviewed for falls, from a total sample of three, resulting in a fall out of bed and a broken hip that required surgery. Findings include: A incident was reported to the state agency by the facility on 3/17/16 that documented Resident #801 rolled out of bed while Certified Nursing Assistant (CNA) A was performing incontinence care and was transferred to the hospital. On 4/6/16 at 10:00 A.M., Resident #801's clinical record was reviewed and revealed the following: Resident #801 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 2/23/16, documented that Resident #801 had moderately impaired cognition and required total physical dependence on two staff members for assistance with transfers and bed mobility. On 4/6/16 at 10:10 A.M., Resident #801 was observed lying in bed. Resident #801 was very soft spoken and difficult to understand. When asked if she fell , Resident #801 nodded her head. When asked how it happened, Resident #801 did not provide an answer. Resident #801 acknowledged by nodding her head that she hurt herself when she fell . Resident #801's clinical record was further reviewed on 4/6/16 at 10:30 A.M. and documented the following: An Incident Note, dated 3/17/16 at 12:38 A.M., written by Nurse B, that documented, Called to resident's room at 9:45 P.M., told 'She's on the floor.' Entered room to find resident lying on face on the floor next to bed. Sent to hospital per physician . A H&P (History & Physical) completed by the physician, dated 3/22/16, documented, .Right hip fracture . A History and Physical from the hospital, dated 3/17/16, documented, .fell out of bed at a nursing home .During transfer from the bed, she slipped, landing on her right side. She struck the right side of her head but did not lose consciousness. She has a hematoma on the right side of her forehead and an abrasion .CT pelvis showed a fracture of the right intertrochanter (upper part of the thigh bone) . An Operative Report from the hospital, dated 3/18/16, documented, Preoperative Diagnosis: [REDACTED].Procedure: Intramedullary nailing of right hip fracture (surgery to repair the broken bone) . An Incident Report completed by Nurse B, dated 3/16/16 at 9:45 P.M., documented, .Called to res (resident) rm (room) to discover resident lying face down on floor next to bed .CNA stated she turned res. away from her in bed to do HS (night time) care and she rolled over onto floor . The incident report documented that Resident #802 had a bump on her right forehead, scratches on her face, and expressed pain by saying ouch, ouch. The corrective measure taken was documented as, Transfer to hospital for evaluation . Witnesses were listed as CNA A. Two attempts to contact CNA A via the telephone were made on 4/6/16 at 11:30 A.M. and 2:15 P.M. However, CNA A did not return the phone calls and therefore, was unavailable for interview prior to the end of the survey. Nurse B was contacted via the telephone on 4/6/16 at 11:30 A.M. and a message was left. The Director of Nursing (DON) and Administrator were asked to contact Nurse B. No response from Nurse B was received prior to the end of the survey. The facility's investigation of the incident mentioned above was reviewed on 4/6/16 at 1:20 P.M. and revealed the following: A statement from CNA A obtained via a phone interview on 3/17/16. The statement documented that CNA A performed incontinence care on Resident #801 on 3/16/16 and while turning her toward the wall, the bed moved away from the wall and Resident #801 tumbled to the floor. The statement documented that CNA A asked CNA C for assistance prior to performing care, but he was unavailable at the time and CNA A didn't want to leave Resident #801 uncomfortable so she started to change her. The facility's Verification of Investigation form documented the following: CNA did not follow the plan of care. Resident is care planned as a 2 person assist with turning and repositioning. CNA turned and repositioned resident without assistance, which resulted in resident rolling out of bed onto the floor. Resident was transferred to the hospital for evaluation where it was determined that resident sustained [REDACTED].(CNA A) was terminated from employment on 3/24/16 . On 4/6/16 at 2:07 P.M., CNA C was interviewed regarding Resident #801's fall on 3/16/16. CNA C reported that he was standing at the nursing station and he heard that Resident #801 fell . CNA C stated, A nurse and me went down to the room .She was on the other side of the bed, I think she was on her right side, between the bed and the wall. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were interviewed on 4/6/16 at 2:30 P.M. where CNAs would find care instructions for residents. The ADON reported that the care plan interventions are generated to the Kardex and the CNAs can view them on the kiosk (CNA electronic charting system). Resident #801's care plans were reviewed at this time and revealed the following: A care plan for Resident #801, dated 8/25/15, documented, .Bed mobility: The resident requires total assistance by 2 staff to turn and reposition in bed Q 2 hours and as necessary . On 4/6/16 at 8:40 A.M., the Director of Nursing reported that the facility identified a deficient practice on 3/17/16 and implemented the following plan of correction with a completion date of 3/24/16: Past Non-Compliance Plan of Correction Element #1 On 3/16/16 at approximately 10:30 PM (Resident #801) was transported to Crittenton Hospital via EMS for evaluation following the fall. (CNA A) was immediately placed on administrative suspension pending the outcome of the investigation. Element #2 All resident Kardexes were reviewed by the Assistant Director of Nursing and the Director of Nursing regarding the number of staff assist for bed mobility. Any necessary changes were made to the Kardex to reflect the number of staff necessary to assist the resident with bed mobility. Element #3 Nursing staff (Nurses and CNA ' s) were educated on following the plan of care for each resident, specifically, the Resident Kardex. Element #4 Audits are performed to ensure that the Resident Kardex is reviewed by the CNA and followed for the proper number of staff to assist residents with bed mobility. Audits are performed 5 days per week for 4 weeks and then weekly for three months. Any deficient practices are corrected immediately. Results of the audits will be reviewed by the QA Committee for recommendations. The Director of Nursing is responsible for overall compliance. Completion date: 3/24/16 ( )

This citation pertains to intake numbers MI 344 and MI 453. Based on observation, interview and record review the facility failed to provide supervision during toileting for one (#201) of three Residents reviewed who were identified at risk for falls and requiring supervision from a total sample of three, resulting in a fall from the toilet with a hematoma to the left forehead and discoloration around the eyes requiring emergent hospital transport. Findings include: On 6/23/15 at 10:00 a.m., The facility Administrator stated He (Certified Nursing Assistant A) was trained and knew what to do. She (Resident #201) has a chair alarm and he left her on the toilet while he took her tray out to the cart and she fell in that brief moment. We did terminate him. He did several things wrong. She was a two person assist to commode. He should not have taken her to the bathroom or left her. A review of the facility investigation and conclusion with the facility Administrator revealed that Resident #201 was taken to the toilet by a Certified Nursing Assistant (CNA A) and left alone on the toilet while the CNA went to answer a call light. Resident (#201) was found sitting on the floor of the bathroom by the CNA. She (Resident #201) stated she fell and hit her head on the bathroom door. Resident (#201) was noted with a hematoma to the left side of her forehead and sent to the hospital for evaluation because she was on Asprin therapy. The CNA was suspended and subsequently terminated. On 6/23/15 at 10:15 a.m., Resident #201 was observed in her room at the facility. Resident #201 had an approximately 2 centimeter by 2 centimeter raised hematoma (a localized collection of blood outside the blood vessel) on her upper left forehead and dark discoloration under both eyes, and on the outside of the left eye. She had an alarm in place on the bed and a sensor alarm in the geri chair. A bedside commode was observed in the room. When queried if she recalled having a fall she stated A young man put me in the bathroom on the toilet and he went down there (pointing out in hall). I put the light on but no one came. I cleaned myself up. Next thing I knew I was on the floor. When asked more questions related to the fall she said she was unable to remember. A review of the facility incident Report dated 6/12/15 at 5:40 p.m. approximately revealed, Resident (#201) sitting on floor on buttocks in bathroom.Resident (#201) stated Had to go to the bathroom, no one came back. I fell .swelling noted to left forehead.Emergency Medical Services called.Resident (#201) Sent to emergency room for evaluation related to Asprin usage. On 6/23/15 at 11:00 a.m., CNA Staff A was interviewed per phone regarding Resident (#201)'s fall. CNA A stated I was working on that hall for the first time. I took her (Resident #201) dinner tray into her. Ten minutes latter she was done and asked to go to the bathroom. I took her into the bathroom and then took out her dinner tray. I saw a call light on and answered it.When I came back she had her bathroom call alarm sounding and was on the floor.I didn't get a chance to look at my ADL (activities of daily living) sheets. It was what I did wrong. I shouldn't have left her in the bathroom. After she fell I looked at the ADL's. She was suppose to be a two person assist to the commode. It was only 1-2 minutes from when I left her to when I came back and she had fallen. She was sitting on her butt with her legs straight out. She said she stood up and fell into the door and hit her head.I did not hurt or leave her on purpose but it was my fault for leaving her alone and not checking my ADL's.As soon as I saw her on the floor I saw the big bump on her head. She wanted me to get her up, I told her no stay there and I got the Nurse.I am not trying to make excuses, it is my fault. On 6/23/15 at 11:35 a.m., The Afternoon Supervisor, staff C, stated per phone, she was informed of the fall for Resident (#201) about 6-6:10 p.m., and went to assist with paperwork. The Residents daughter brought her to the nurse's station. she had a large bump on the left side of her forehead.It was only a minute or two before the ambulance arrived. On 6/23/15 at 12:15 p.m., staff Nurse B stated she was in the dining room and was informed about 5:45-6:00 p.m., by (CNA A) that Resident #201 had fallen. She stated in less than one minute I was in the room and she (Resident #201) was sitting on the floor, back against the wall feet straddling the toilet. I asked her what happened and she said, 'I had to go to the bathroom and no one came back and I fell .' She is a fall risk and is not suppose to be left alone and is suppose to use the bedside commode per the families request. I asked (CNA A) what happened and he said he put her on the toilet and left. She is oriented but can be confused at times. I told him to stay with her after I assessed her, and went to call 911. Then called the Shift supervisor and was still on the phone with her when the daughter came in. When I hung up I told her (Resident #201's daughter) what happened.The daughter was there within five minutes of me being notified.I asked him (CNAA) why was she on the toilet and why did you leave her. He (CNA A) said he wasn't aware of how she transferred. I asked if he looked at the ADL book. He said 'no, I've been working since I got here.' CNA's are suppose to look in the ADL book. On 6/23/15 at 12:40 a.m., a review of the clinical record for Resident #201 revealed an original admission into the facility on [DATE] and a readmission on 6/4/15. [DIAGNOSES REDACTED]. Per the Minimum Data Set (MDS) assessment dated [DATE] documented Resident #201 was moderately cognitively impaired. Per the Resident Status Sheet undated (referred to as ADL sheet by staff) Resident (#201) required 2 person assist for transfer and was to use the bedside commode. Assistive devices included bed and chair sensor alarms. Mental status was documented as Alert and Confused. The care plan titled Bowel and Bladder dated 3/24/15 documented date 6/10/15 toilet using bedside commode and CNA stay with Resident. The care plan titled Alteration in ADL dated 5/6/15 documented 2 (two) person assist with all transfers and toileting, stand and pivot with rolling walker. The 6/4/15 fall risk assessment documented a score of 10 (total score of 10 or greater equals high risk). The Admission Fall Risk Assessment 2 dated 6/4/15 documented Resident (#201) as 13- moderate risk. The Nurse's note dated 6/12/15 at approximately 5:40 p.m., documented Resident (#201) observed on floor sitting on buttocks in bathroom.Resident has swollen lump on left forehead. Resident denies pain. Cold compress applied intermittently. 911 notified to transport to hospital related to resident on blood thinners. Dr. (name) notified. Order to transport to hospital related to post fall head trauma.Daughter here at facility at 6:10 p.m. A review of the personnel file for CNA Arevealed he signed the facility paperwork documenting I (name) understand that I must follow the resident's ADL sheet at all times including correct mode of transfer on 4/21/15. The Administrator provided a letter documenting CNA A was terminated effective 6/17/15. A review of the facility policy titled Providing Supervision to Residents During Toileting dated 1996, documented Purpose: To ensure safety of resident while maintaining resident's rights to respect, privacy and dignity during toileting. All residents will be provided supervision during toileting unless otherwise indicated in resident's care plan. Protocol: 1. Check resident ADL Guide for any special instructions. 2. Observe correct transfer techniques as outlined on ADL sheet. 3. Do not leave the vicinity while resident is on toilet. Remain right outside the bathroom door or directly behind cubicle curtain if resident is using commode. 4. Residents with the following conditions my never be left unattended on the toilet: A. Residents with chair alarms. B. Residents with cognitive impairments/safety awareness. C. Residents with balance control or residents who reach, lean or grab. D. Residents with behavioral disturbances. On 6/23/15 the facility submitted the following noncompliance packet which was accepted. Date of Event: 6/12/15 Was the resident injured: Yes If yes, describe the injury: Hematoma to the left forehead with discolored Description of Deficient Practice (why and how did it happen): Nursing Assistant left resident alone on the toilet. Plan of Correction: The nursing assistant responsible for incident has been terminated. All other nursing assistance re-educated on following resident ADL Guides & properly supervising resident's during toileting. In-Depth analysis of how the deficiency occurred: Assigned Nursing Assistant failed to follow facility protocol. How facility identified resident(s) affected and residents with potential to be affected by the same deficient practice: All residents requiring supervision during toileting are at risk Corrective action taken for resident affected: Review of Care plan. Remains a 2 person transfer. Measures or system changes made to ensure that deficient practice will not occur and affect others: Protocol reviewed and deemed to be appropriate. Nursing staff reeducated on protocol. How facility monitors its corrective actions to ensure deficient practice was corrected and will not recur: Random Quality assurance rounds will be conducted weekly by Nursing Administration to ensure that Nursing assistants who are toileting residents are following ADL guide & facility protocol. The results of these checks will be submitted to the QA committee who will direct any further follow up. The Director of Nursing will be responsible for the implementation & monitoring of this program and sustained compliance. Date of Completion of plan of correction: 6/12/15

This citation has two deficient practices: Deficient Practice #1 Based on observation, interview, and record review, the facility failed to provide assistance based on resident's assessed needs during a breakfast meal for one (#813) of five sampled residents reviewed for supervision/accidents, out of a total of 19, resulting in second degree burns on both thighs. Findings include: On 9/24/13, at 9:30 a.m., the unit manager (nurse "H") reported that resident #813 had wounds that resulted from burns. Nurse "H" was queried whether the burns were present prior to admission or if they were acquired at the facility. Nurse "H" stated, she was burned here." Nurse "H" went on to report that resident #813 was confused and required total care with all activities of daily living (adl's). On 9/24/13 at 9:45 a.m., resident #813 was observed sitting in activities asleep in her chair. On 9/24/13 at 3:15 p.m., review of resident #813's face sheet revealed an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data set (MDS), dated [DATE], indicated that resident #813 was severely cognitively impaired, required extensive assistance with most adl's, and was totally dependent upon others for eating. Review of resident #813's "Hot Liquid Assessment," dated 7/19/13, revealed documentation/determination that she was not able to hold a cup/bowl safely while sitting in chair (1st quarter assessment, 7/26/13). On 9/24/13 at 3:25 p.m., Review of resident #813's ADL care plan, initiated on 8/1/13, revealed the following interventions related to meals: "Staff to feed, keep hot foods away from edge of table, and inform resident the location of items." On this same care plan, new interventions were added on 8/16/13 to "Wear 2 clothing protectors for all meals; around her neck and one in her lap." On 9/25/13 at 4 p.m., review of the facility's form entitled "Incident Report," dated 8/16/13 at 7:50 a.m., revealed the following documentation: "Resident yelled out, CENA (certified nursing assistant) went to her at DR (dining room) table and found oatmeal bowl on floor, cereal on right thigh. Unable to answer, confused." The Incident report revealed documentation for the cause as "food place toward the center of table." The Incident report indicated that resident #813 sustained a discolored (reddened) area on her right thigh that measured 5.5 centimeters (cm) X 13.0 cm. and the area was painful. On 9/26 at 10:20 a.m., review of the nurses' notes revealed the following entries: Nurse's note on 8/16/13 at 7:50 a.m., revealed the following documentation: "Resident in DR (dining room), meal tray in front of resident. She yelled out. It was noted cereal bowl on floor and oatmeal on right thigh. (Adult bib in place but did not cover the area). Returned to room and assessment completed. 13 cm w (width) x 5.5 l (length) redness noted. Cold compress applied..." Later, on the same day, another nurse's note at 2:20 p.m., revealed the following documentation: "Right anterior thigh burn has two blistered areas measuring 1.5 cm x 0.8 cm (medial) and 1.5 cm x 1.0 cm (lateral)...new order for Silvadene cream to right anterior thigh." Review of the nurse's note, dated 8/21/13 at 3 p.m., revealed the following documentation: "Observed three areas 1 on left thigh 2.5 cm x 1.3 cm dried blister (total area)..." On 9/26/13 at 11:30 a.m., the director of nurses (DON) was queried regarding resident #813's burns. The DON stated, "they thought it (the oatmeal) was out of her reach. The area was red (resident 813's thigh) red when it happened (oatmeal spilled onto her thighs). Later, two other areas raised on her leg. The doctor was notified right away. The daughter visited the same day and she was notified." On 9/26/13 at 11:50 a.m., a skin observation of resident #813's burns was conducted with the assigned staff nurse (nurse "Q"). The right thigh revealed a 1.3 cm X 1.2 reddened area with the first layer of the skin missing. There was no drainage noted. The left inner thigh revealed a 2.2 cm X 1.2 cm red intact blister. A dry cap was noted covering the area. On 9/27/13 at 11:50 a.m., the certified nursing assistant (CNA "O") that placed the oatmeal within resident #813's reach on 8/16/13, was interviewed. CNA "O" stated, "I was present during the time of the burn. I gave her the oatmeal, put brown sugar, and milk in it. I placed a lid on it. She grabbed it and spilled it on her. She had never done it before. I placed the oatmeal near the center of the table..." On 9/27/13 at 12:10 p.m., review of CNA "O" written statement revealed the following documentation: "I was passing trays in the Beechwood dining room at breakfast time on 8/16/13. I took her (resident #813) food tray and placed on the table slight away from her. I thought it was out of her reach. I then went back to serving breakfast to the other residents. After I finished passing all the rest of the breakfast trays, a CNA told me that she (resident #813) pulled her bowl off the table and the oatmeal had spilled into her lap." On 9/27/13 at 1:10 p.m., the administrator was queried regarding resident #813's burns. The administrator stated, "The DON informed me. We spoke with corporate. There were no further incidents. We did corrective actions. The incident was not reported to the state because it was of known origin." On 9/30/13 at 2:30 p.m., review of the facility's policy entitled, "Assisting Residents for Meals," dated 4/1996, revealed documentation that read: "Assist resident with feeding according to their individual care plan." ( ) Deficient Practice #2 Based on observation, interview and record review, the facility failed to safely secure a sharps container filled with contaminated needles, 11 disposable razors, and two chemical cleaning agents in one of two shower rooms (the shower room located on the Orion Terrace Hall) resulting in the potential for accidents. Findings include: On 9/24/13 at 3:40 p.m., during general observations of the environment, a partially filled, red colored, "sharps container" (medical waste container used to stored used needles until final disposal), 11 disposable razors, an 18 ounce can of germicidal cleaning agent and a spray bottle of disinfectant were observed stored in an unlocked cabinet in the shower room on the Orion Terrace Hall. The door to the shower room was observed open at time of discovery. The lock used to normally lock the cabinet was on a chain hanging near the cabinet, but was not in use at the time of discovery. On 9/24/13 at 3:45 p.m., the facility's Director of Nursing (DON) was queried in regards to the unlocked storage cabinet in the restroom. The DON stated, "it's supposed to be locked (the storage cabinet). That's why it's got the safety lock on it (i.e. hanging from chain next to the cabinet)." On 9/27/13 at 3:50 p.m., the facility's policy entitled, "Chemical Storage Policy", dated 7/96, revealed, "All chemicals shall be locked up when not in use or kept under the supervision of the responsible employee when using the chemical." An additional policy provided by the facility, entitled, "Storage of Supplies", dated 7/96, revealed, "Supplies such as razors, needles, scissors, nail clippers, etc. which may be injurious to residents shall remain locked until being used." ( )

THIS CITATION PERTAINS TO INTAKE NUMBER (S) MI 046, MI 068, MI 145 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT INJURY FOR ONE RESIDENT (#502) OF FOUR RESIDENTS REVIEWED FOR SUPERVISION AND FALLS OF A TOTAL OF FOUR SAMPLED RESIDENTS RESULTING IN #502 SUSTAINING A HEAD INJURY DURING TOILETING WITH SUBSEQUENT SUBDURAL HEMATOMA AND INTRACRANIAL BLEED. FINDINGS INCLUDE: ON 2/27/13 AT 11:00 A.M., DURING A TOUR OF THE FACILITY AND #502'S ROOM, LICESNED PRACTICAL NURSE (LPN) #1, WHO WAS PRESENT REPORTED, "...I WAS TOLD THAT SHE (#502) WAS POSITIONING HERSELF ON THE TOILET WHEN SHE LOST HER BALANCE AND HIT HER HEAD ON THE HAND RAIL. THE RAIL WASN'T PADDED AT THE TIME. CERTIFIED NURSING ASSISTANT (CNA) (#2) WAS IN THE BATHROOM WITH HER. THE SAME THING HAPPENED AGAIN THE NEXT TIME THEY (STAFF) TOILETED HER BUT THIS TIME, SHE DIDN'T HIT HER HEAD..." ACCORDING TO LPN #1, #502 WAS SENT TO THE HOSPITAL FROM AN APPOINTMENT AND HAD NOT RETURNED TO THE FACILITY YET. ACCORDING TO THE FACILITY FACE SHEET AND [DIAGNOSES REDACTED]. A REVIEW OF THE FACILITY'S "INCIDENT REPORT" DATED 2/16/13 REVEALED, "...CAUSE OF INCIDENT: HIT HEAD ON GRAB BAR IN BATHROOM..." A "COMPUTED TOMOGRAPHY" (CT SCAN) REPORT DATED 2/21/13 REVEALED, "...status [REDACTED]. THERE IS ACUTE RIGHT SIDED SUBDURAL HEMATOMA WITH ACUTE BLOOD PRODUCTS. THERE IS A LEFT FRONTAL SCALP HEMATOMA PRESENT..." A REVIEW OF THE HOSPITAL "EMERGENCY DEPARTMENT/ED" NOTES DATED 2/21/13 REVEALED, "...CHIEF COMPLAINT: fell OFF TOILET, HIT HEAD ON HANDRAIL, +CEREBRAL BLEED, +NAUSEA AND VOMITING, +CONFUSION, +DIZZY. IMPRESSION AND PLAN: HEAD INJURY, TRAUMATIC INTRACRANIAL HEMORRHAGE, ACUTE RIGHT SUBDURAL HEMATOMA, CONDITION: CRITICAL. DISPOSITION: ADMIT TO INTENSIVE CARE UNIT..." A REVIEW OF #502'S HOSPITAL "HISTORY AND PHYSICAL" REPORT DATED 2/21/13 REVEALED, "...THIS IS A [AGE] year OLD FEMALE WHO HAD A FALL ON SATURDAY (2/16/13) AND HIT HER HEAD AGAINST THE WALL. THE PATIENT DOES HAVE BRUISES ON HER FACE, AROUND HER EYES, A LITTLE BIT MORE ON THE LEFT SIDE. SHE DOES HAVE BRUISE ON BOTH KNEES AS WELL..." THE MINIMUM DATA SET ((MDS) dated [DATE] REVEALED THAT #502 REQUIRED EXTENSIVE TO TOTAL ASSISTANCE OF STAFF FOR ALL ACTIVITIES OF DAILY LIVING (ADLS) INCLUDING BD MOBILITY, TRANSFERS, LOCOMOTION ON AN OFF UNIT, DRESSING, PERSONAL HYGIENE, BATHING AND TOILETING. THE MDS REVEALED THAT #02 REQUIRED TWO+ PERSONS PHYSICAL ASSIST WITH TRANSFERS, BATHING AND TOILETING. THE MDS FURTHER REVEALED THAT #502 WAS "...ALERT AND ORIENTED TO SELF AND MOSTLY TO SITUATION WITH CONFUSION TO EXACT TIME AND TIME FRAMES AND HAD A SCORE OF 12/15 ON HER BIMS (ASSESSMENT OF COGNITIVE IMPAIRMENT) TEST..." A SCORE OF 8-12 INDICATED MODERATELY IMPAIRED COGNITIVE SKILLS FOR DECISION MAKING. A REVIEW OF THE "CARE AREA ASSESSMENT WORKSHEET" DATED 7/16/12 REVEALED "...BALANCE PROBLEMS DURING TRANSITION, NOT STEADY, ONLY ABLE TO STABILIZE WITH STAFF ASSISTANCE OF TWO, MOVING ON AND OFF TOILET NOT STEADY, ONLY ABLE TO STABILIZE WITH STAFF ASSISTANCE OF TWO..." A REVIEW OF #502'S "FALLS" CARE PLAN INITIATED 7/19/12 REVEALED, "...AT RISK FOR INJURY/FALL RELATED TO POOR STANDING BALANCE, IMPAIRED TOILETING, IMPAIRED TRANSFERS, LOW ENDURANCE, DECREASED MUSCLE STRENGTH, IMPAIRED COGNITIVE STATUS..." A "TRANSFER/CONTINUING PATIENT CARE" FORM FROM THE HOSPITAL REVEALED, "...ACTIVITY ORDERS: TOTAL ASSIST..." A physician's orders [REDACTED]. A THERAPY "PROGRESS NOTE" DATED 1/25/13 REVEALED, "...TRANSFER MODERATE ASSIST X 2 PERSON, NON-AMBULATORY. SHE (#502) WEARS POSTURE STRAPS TO MAINTAIN AN UPRIGHT POSTURE AS SHE IS PRONE TO BEND FORWARD REACHING FOR ITEMS AND HAS FALLEN FROM CHAIR IN THE PAST..." THERE WAS NO ASSESSMENT AVAILABLE FOR REVIEW THAT INDICATED #502 HAD BEEN REEVALUATED UPON RETURN FROM THE HOSPITAL AND NO DOCUMENTED RATIONALE WHICH INDICATED WHY #502 CAME FROM THE HOSPITAL AS A TOTAL ASSIST AND CHANGED TO MODERATE ASSIST WITHOUT ASSESSMENT. A "RESTRAINT ASSESSMENT" DOCUMENT DATED 1/29/13 REVEALED, "...RETURN FROM HOSPITAL. RESIDENT HAS POSTURE STRAPS. RESIDENT REACHES FORWARD, HAS HAD A LOSS OF BALANCE..." A REVIEW OF THE MANUFACTURERS "WHEELCHAIR POSTURE SUPPORT" DOCUMENT REVEALED, "...PURPOSE: INTENDED TO PROVIDE POSTURE CONTROL FOR WHEEL CHAIR RESIDENTS WHO LEAN OR FALL FORWARD..." ON 2/27/13 AT 11:30 A.M., DURING AN INTERVIEW, THE DIRECTOR OF NURSING (DON) REPORTED, "...THE NURSE CALLED ME AND TOLD ME #502 BUMPED HER HEAD ON THE GRAB BAR AND HAD SOME BRUISING. SHE CALLED ME BACK LATER THAT AFTERNOON AND SAID THE BRUISING HAD TRAVELED TO OTHER AREAS OF HER FACE..." WHEN ASKED IF #502 WAS ALONE AT THE TIME OF HER INJURY, THE DON REPORTED, "...CNA #2 WAS WITH HER, THEN SHE TOOK HER TO THE DINING ROOM FOR BREAKFAST..." WHEN ASKED IF #502 HAD FALLEN WHILE BEING TOILETED, THE DON SAID, "NO." ALTHOUGH THE DON REPORTED THAT #502 HAD NOT FALLEN, REVIEW OF #502'S HOSPITAL RECORDS INDICATED THAT #502 HAD IN FACT FALLEN. ON 2/27/13 AT 12:56 P.M., DURING AN INTERVIEW, CNA #1 REPORTED, "...I ASSISTED (CNA #2) WITH GETTING (#502) UP FROM THE BED TO THE WHEELCHAIR THEN TO THE TOILET. I TRANSFERRED HER TO THE TOILET AND (CNA #2) WAS BEHIND THE WHEELCHAIR. I LEFT ONCE (#502) WAS ON THE TOILET. WHEN (#502) WAS DONE, (CNA #2) CAME AND GOT ME FROM ROOM #5 DOWN THE HALL AND TOLD ME THAT SHE (CNA #2) WAS READY TO GET (#502) UP. WE WENT IN THE ROOM AND I SAW A RED MARK TO THE LEFT SIDE OF HER (#502) HEAD. (CNA #2) SAID (#502) BUMPED HER HEAD. (#502) CAN'T WALK BUT SHE'S WEIGHT BEARING. THE ADL SHEET DIDN'T SAY THAT, BUT SHE (#502) WAS A 2-PERSON ASSIST..." ON 2/28/13 AT 11:10 A.M., #502 WAS OBSERVED IN HER ROOM IN BED WITH HER FAMILY MEMBER (FM #1) AT BEDSIDE. RESIDENT #502 WAS NOTED TO HAVE FACIAL SWELLING AND BRUISING. WHEN ASKED ABOUT HER INJURIES, #502 REPORTED, "I fell !" WHEN ASKED HOW SHE fell , #502 REPORTED, "...THAT GIRL LET ME FALL..." ON 2/28/13 AT 11:25 A.M., CNA #2 WAS INTERVIEWED AND REPORTED THE FOLLOWING: "...I GOT HER (#502) CLOTHING AND TOLD HER I WAS GOING TO GET HER UP. I WENT TO GET (CNA #1) AND WE TRANSFERRED HER FROM HER BED TO THE WHEELCHAIR AND PUSHED HER INTO THE BATHROOM. (CNA #1) PUT HER ON THE COMMODE THEN LEFT. I WAS BY THE SINK GETTING HER TOWELS READY. (#502) SAID SHE NEEDED TO SCOOT BACK SOME ON THE TOILET AND I TOLD HER THAT SHE WAS FINE WHERE SHE WAS BUT SHE KEPT TRYING TO SCOOT BACK. I WAS GETTING HER TOWELS READY TO WASH HER UP WHEN SHE LIFTED HERSELF UP OFF THE COMMODE. I DON'T KNOW IF SHE SLIPPED OR WHAT AND HER HEAD HIT THE GRAB BAR..." WHEN ASKED IF #502 HAD FALLEN, CNA #2 SAID, "NO." WHEN ASKED WHERE SHE (CNA #2) WAS POSITIONED WHEN #502 INJURED HER HEAD, CNA #2 SAID, "...I WAS STANDING AT THE SINK TO HER RIGHT. I WAS GETTING HER TOWELS READY..." CNA #2 WAS QUERIED ABOUT #502'S ORDER TO WEAR A POSTURE SUPPORT (PS) WHILE UP IN WHEELCHAIR AND #502'S POSITIONING AND REPORTED, "...I KNEW WHAT THE PS WAS FOR. (#502) SLUMPS TO THE SIDE AND TENDS TO LEAN FORWARD. SHE (#502) ALSO HAS A TENDENCY TO LEAN HER HEAD FORWARD ON HER CHEST..." WHEN ASKED WHY SHE DIDN'T ASSIST #502 WHEN SHE INITIALLY ASKED FOR HELP WITH REPOSITIONING HERSELF ON THE TOILET, CNA #2 OFFERED NO RESPONSE. WHEN ASKED WHY SHE (CNA #2) WASN'T WATCHING #502 AS OPPOSED TO PREPARING TOWELS AND WHY SHE WAS NOT POSITIONED IN FRONT OF #502 IN LIGHT OF HER DOCUMENTED HISTORY OF LEANING AND FALLING FORWARD AND LOSS OF BALANCE, CNA #2 REPORTED, "...IF I HAD STOOD IN FRONT OF HER, I COULD HAVE CAUGHT HER. AFTER SHE WAS IN HER WHEELCHAIR, I NOTICED THE BUMP SWELLING UP EVEN MORE..." ON 2/28/13 AT 12:35 P.M., DURING AN INTERVIEW, THE DON REPORTED, "...(CNA #2) WAS STANDING NEXT TO (#502). HITTING HER HEAD WAS AN ACCIDENT BUT SHE (CNA #2) SHOULD'VE BEEN STANDING IN FRONT OF (#502) BECAUSE OF THE VERY REASONS THE PS WAS NEEDED IN THE FIRST PLACE. SHE (CNA #2) SHOULD HAVE FOCUSED MORE ON THE RESIDENT INSTEAD OF GETTING TOWELS READY..." THE DON COULD NOT EXPLAIN WHY CNA #2 FAILED TO GIVE PROPER ATTENTION TO #502 WHO WAS BEING TOILETED AT THE TIME, RESULTING IN #502 FALLING INTO THE GRAB BAR IN AN ATTEMPT TO REPOSITION HERSELF ON THE COMMODE. THE FACILITY'S "FALLS PREVENTION" PROGRAM WAS REVIEWED AND DID NOT ADDRESS SUPERVISION OF RESIDENTS DURING TOILETING.

Based on record review, observation and interview the facility failed to 1) provide adequate pain management for 1 of 6 sampled residents (#102) resulting in prolonged, unresolved pain, 2) adequately assess and monitor resident condition after a fall in 1 of 6 sampled residents (#101) resulting in a delay in treatment and the potential for post fracture complications. Findings include: Resident #102 Resident #102 was a resident at the facility at the time of the unannounced investigation from 4/6/11 to 4/13/11. Resident #102 was admitted to the facility on [DATE] and according to the facility face sheet had a medical history of [REDACTED]. According to the MDS (minimum data set) dated 2/4/11 Resident #102 was able to make herself understood and was able to understand others, had no behavioral issues, alert and oriented x 3, was totally dependent on staff for transfers to and from bed to chair, moving around the unit, dressing, toileting and all other activities of daily living. On 4/6/11 at 10:20 AM Resident #102 was heard approximately 25 feet from the Nurses Station desk in the "Pinegrove" Dining Room. Resident #102 was sitting in a wheelchair, crying, her hands were shaking attempting to sip a glass of water, wiping her eyes with a Kleenex . When approached by this surveyor about why she was crying she responded that she "gets a [MEDICATION NAME] (the patch was in place and dated 4/5/11) but the pain relief from it varies. When I can get the pain medication every 4-6 hours it helps me a lot, I don't like it when my pain in not controlled but I feel guilty if I ask for pain meds for my break through pain". Resident #102 began sobbing more intensely stating "I'm so sorry but I hurt so". When asked on a scale from 1-10 (facility scale 0-5) what number she rated her pain Resident #102 replied "4-5, no one except my nurse today and you asks me about my pain I have been a nurse for [AGE] years and never treated my patients like this I get a pill at 5 am the rest of the time I must always ask, sometimes they make me feel guilty for asking for pain pills". This surveyor approached LPN (Licensed Practical Nurse) #2 at 11:10 AM at the medication cart to inquire about the status of Resident #102's pain medication. LPN #2 replied while checking the MAR (medication administration record) "she had something at 5 AM, she got her pain patch yesterday, her nurse is at lunch I don't have the cart keys" then left the area and did not return for 35 minutes. Resident #102's nurse LPN #3 had not yet called the physician for ATC (around the clock) [MEDICATION NAME] when asked about the pain medication did give the resident pain medication ([MEDICATION NAME]) and called the attending physician for every 6 hour pain medication around the clock. Review of Physician order [REDACTED]. Review of the facility MAR indicated Pain Scale 0-5 at time of administration & 0-5 with acceptable/unacceptable 1 hour after administration" revealed there was no numerical scale completion present on the record regarding pain scale level assessments. Review of Facility Nursing Care Plan for Resident #102 dated 1/22/10 for "alteration in comfort related to right total shoulder" Goal: resident will maintain acceptable level of comfort through next review 1-2 on scale of 10" (facility scale being 0-5). Plan: Monitor for s/s (signs and symptoms) of pain; restlessness, agitation, moaning/grimacing. Monitor effectiveness of pain med per pain scale, pain scale prior to [MEDICATION NAME] and 1 hour after". Review of Facility Nursing Notes dated from 1/6/11 to 4/6/11 revealed one 1/26/11 one nursing entry related to pain, 2/16/11 one nursing entry related to pain, 3/6 & 3/8/11 one nursing entry for pain. On 3/24/11 Resident #102 requested and a Physician order [REDACTED]. The next entry related to Resident #102's pain was on 4/6/11 "resident had an increased c/o (complains of) pain r/t (related to) generalized pain in shoulder. Writer called doctor for scheduled medication every 6 hours ATC (around the clock). The call to the physician was made after this surveyor had brought Resident #102's pain to the attention of facility staff. Resident #102 was observed by this surveyor on 4/13/11 at 8:20 AM stating "I feel so much better than the last time you saw me, my pain is much better I did have a reaction to the patch so that's gone now, but I get [MEDICATION NAME] scheduled and feel so much better I cried so much before that pain was terrible, but I'm doing 100% better, I can talk now without crying I'm calmer yes 100% better". Resident #101 Resident #101 was not a resident at the facility at the time of the unannounced investigation from 4/6/11 to 4/13/11. Resident #101 was admitted to the facility on [DATE] and discharged on [DATE] and according to the facility face sheet had a medical history of [REDACTED]. The MDS (Minimum Data Set) dated 3/11/11 indicated that Resident #101 had the ability to usually make herself understood and usually had the ability to understand others, moderately impaired cognitive skills for daily decision making. Resident #101 required limited one person assistance for transfers, eating, walking in the room and required extensive one person assistance for activities of daily living. Balance during walking, moving from seated to standing position, moving on and off the toilet and surface to surface was not steady only able to stabilize with human assistance. Resident #101 was frequently incontinent of both bowel and bladder. Review of the Facility Fall Evaluation dated 3/11/11 Fall History: History prior to admission. Fall witnessed: no. Injury: Head Trauma. Environment at time of fall: recent room change (from room [ROOM NUMBER]-2 to 10-1 at some point within the previous 16 hours exact date & time was not recorded on the medical record). According to Facility Incident Record dated 3/11/11 Resident #101 was observed on the floor on 3/10/11 at 11:45 PM next to the room door. Cause of incident: "resident has no safety awareness". Appearance of involved part: discoloration; Yes "middle of forehead reddened". Pain; yes, "generalized discomfort". Type of Injury: Hematoma. Review of the facility staff witness statement dated 3/11/2011 written by RN #5 "resident states she is having pain asked to point to area. Resident points to right hip". Review of the facility "24 hour post fall follow up procedure" Assess and document the following: 1) head to toe assessment for signs/symptoms of injury: bruising, discoloration, swelling, 2) Range of motion (ROM) of all extremities: a) pain, b) decrease in (ROM). Facility Fall Risk assessment dated [DATE] (date of admission) was "18", total score above 10 represents high risk for falls. Facility Fall Risk assessment dated [DATE] after the fall on 3/11/11 in the facility 24 post fall follow up procedure "complete falls risk assessment attached" the score dated for 3/11/11 was "12". Review of the Facility Nurses Notes dated 3/11/11 at 12 AM revealed Resident #101 was observed on the floor by resident room door lying on left side. Resident has raised reddened area on forehead, complains of pain right hip. The Nurses Noted entry on 3/11/11 timed 12:30 AM "DON called left message on machine will monitor". The entry dated 3/11/11 at 6:30 AM "Resident daughter was made aware of resident fall and Dr's answering service notified". In an interview with the Attending Physician/Medical Director on 4/6/11 at 11:25 AM he stated "I wanted to be called when it happened, that's my expectation I would have ordered x-rays earlier but I didn't get the choice". He also added that he remembers receiving two calls the first early sometime after 6 AM on 3/11/11 with a message left with his answering service "I didn't speak to anyone with the first call" and the second call was from the DON (Director of Nurses) later the in the morning (medical record documents the call at 9:30 AM) informing him Resident #101 had significant right upper thigh/hip pain and he then ordered the stat x-ray after the second call from the DON. In an interview with RN (Registered Nurse) #5 on 4/13/11 at 8:40 AM she stated while reviewing the medical record that according to her charting she called the DON (Director of Nurses) at 12:30 AM "it is the policy to call with every fall, I left a message on the cell phone and did not speak directly to the her". When asked about the 6:30 AM entry notifying the physician and family about the fall at 12 AM RN #5 stated "Not sure if I called at 6:30 AM or not or just rushing to finish, but that's what I wrote". RN #5 continued stating she checked vital signs every 15 minutes for the 1st hour because the fall was not witnessed and due to a possible head injury then every 2 hours then according to head trauma assessment sheet (sheet states every 15 minutes X 4, every 2 hours X 4, every 4 hours X 4 then every 8 hours X 4). She also stated that Resident #101 was assisted to the bathroom by herself and CNA #8 and did a full weight bearing pivot from wheelchair to toilet and toilet to wheelchair. RN #5 also stated that Resident #101 did not complain about pain and was given a scheduled dose of Tylenol at 5 AM, "she didn't ask for anything the rest of the night, I looked at the hip area a couple of times but didn't check for ROM (range of motion, moving all extremities to full extent it can move) she was able to squeeze my hands". When this surveyor asked RN #5 if she had specifically completed ROM and visually checked Resident #101 right leg RN #5 responded "I don't remember anything negative". In an interview with EMT #13 (emergency medical technician) on 4/7/11 at 12:30 PM he stated that upon arrival to the facility on [DATE] at 2:50 PM that the initial assessment was noted Resident #101 had "rotation and shortening of the right leg with extreme pain, she rated her pain 8-10 for me, she had a mark on her forehead between her eyes an abrasion with redness, pain was positional, staff told me that she had fallen on her right hip, I thought to myself it's fractured when I saw her lying in bed". Review of Hospital records dated 3/11/11 Resident #101 arrived at the emergency room at 3:53 PM where a [MEDICAL CONDITION] femoral head was diagnosed . ( )