Every finding on record at The Villa at West Branch

Based on interview and record review, the facility failed to notify a representative of the Office of the State Long-Term Care Ombudsman's office of pending transfers/discharges for the last three years and for two residents (Resident #6, Resident #10) 2 residents reviewed for hospitalization, resulting in the lost opportunity of the State Office of Long-Term Care Ombudsman's office to offer additional support and advocacy to the residents with no notice of pending transfers/discharges for 3 years. Findings include:Resident #6: Record review of Resident #6's February 2026 progress notes revealed that the resident was sent to the hospital. Resident #6 was readmitted on [DATE]. Resident #10:Record review on 06/09/2026 at 4:16 PM of Resident #10's admission/discharge census tab revealed that Resident 10 was hospitalized at 2/27/26 for 24 hours and discharged to hospital on 5/4/2026 and returned on 5/7/2026 to facility. In an interview on 06/08/2026 at 11:42 AM while sitting in the main dining room the resident could not recall why he went to the hospital. Possible infection he did not know. but he came back to the facility. In an interview on 06/10/2026 at 11:50 AM the Corporate Operations Consultant (COC) J and the Nursing Home Administrator (NHA), revealed that the facility has not sent the ombudsman notification of transfers/discharges/or admissions for three (3) years. The facility social worker was a designee and had not been sending the Ombudsman notifications. THE COC stated that the sister facility does send the Ombudsman notices as required by regulation, but that the current facility does not have. The COC stated that there were no notice records to review. In an interview and record review on 06/10/2026 at 12:04 PM, the Regional Social Worker (RSW) K stated that the corporation does yearly training for the 21 buildings owned with the social workers. RSW K revealed that there was a form/spreadsheet format with date/transfer/disposition that the social service designee was to send at the end of the month to the state long-term ombudsman. Record review of the corporate educational material noted a power point presentation and spreadsheet form to fill out. Record review of the facility 'Transfer and Discharge Guidelines' revised date 5/5/2025 revealed: Notifications- The interdisciplinary team designee will meet with the resident and resident representative as applicable to review the discharge/transfer notice and its contents. (c.) A copy of the discharge notice is sent to the State Office of Long-Term Care Ombudsman. The Ombudsman office may offer additional support and advocacy to the residents.

Based on observation, interview and record review, the facility failed to implement and operationalize a comprehensive Infection Control (IC) program including 1) Accurate outcome and process surveillance comprising identification of potential trends and a system to identify and prevent spread of potential infections and communicable disease 2) Hand hygiene during meals, 3) Enhanced Barrier Precautions for one resident (Resident #12), 4) Cleaning of multi-resident use glucometers, and 5) Maintenance of indwelling urinary catheters in a sanitary manner for one resident ( Resident #11) resulting in a lack of accurate and comprehensive infection control tracking, surveillance and data monitoring/analysis. Findings include: Dining Observation: Observation on 06/08/2026 at 11:46 AM of the main dining room revealed 24 residents seated in the dining room with two dietary staff and two Certified Nursing Assistances (CNA) in the room assisting with beverages being passed to residents. Staff and residents hand hygiene was not observed as being performed. Observed staff to pass trays with no hand sanitation between trays, staff remove lids and set up the residents and apply the clothing protector and move onto the next the resident. No hand hygiene offered to residents prior to meal or post meal. Observation on 06/9/2026 at 12:24 PM observations of hallway tray pass for the noon meal revealed no hand hygiene offered to residents pre or post meal. Record review of the facility 'Dining Experience Guideline' dated 4/11/2023 noted that to provide a positive dining experience for residents, staff will be educated on hygienic practices and be able to perform properly hygiene for the safety of the residents. Residents will be offered hand sanitizer . Enhanced Barrier Precautions during Medication Administration: Observation was made on 06/09/2026 at 9:02 AM with Registered Nurse (RN) I of Resident #12's Vancomycin 1.25gm/250ml normal saline bag to a Peripherally Inserted Central Catheter (PICC) line double lumen, with Total Parenteral Nutrition (TNP) in one port. PICC line occlusive Dressing date 6/7/26, Blue caps noted on ports, RN I donned Gloves, picked up the port, scrubbed with alcohol wipe, flushed with Normal Saline 10 ml syringe flush, connected the vancomycin 1.25gm/250ml NS bag, programed the medication pump at 167ml per hour/ for 250 ml, to run 90 minutes. Removed her gloves and walked out of the room. The state surveyor noted a red 'Enhanced Barrier Precaution' sign posted below the resident's room number to the left side of the doorway upon entrance to the room. No enhanced barrier of a gown was worn while in the room. In an interview on 06/10/2026 at 7:47 AM, Infection Control Preventionist (ICP) B explained the procedure for Enhanced Barrier Precautions. ICP B described that the nurse should have gone into the room, washed her hands, gloved and gowned, to protect the spread of infections, before touching the PICC line, Record review of the facility 'Enhanced Barrier Precautions' policy, dated 3/2024, revealed that Enhanced Barrier Precautions (EBP) are utilized to reduce the transmission of multi-drug-resistant organisms (MDROs) to residents. EBP employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing the high contact resident care activity . Glucose Monitoring Cleansing: In an observation on 06/09/2026 at 7:31 AM, Registered Nurse (RN) I went to perform glucose blood sugar check for unsampled Resident in room [ROOM NUMBER], blood sugar check 103. RN I placed the glucose monitor device into a clear plastic cup along with alcohol wipes and lacets. RN I went back to the medication cart to document the blood sugar level in the resident record. RN I stated that she likes to check resident blood sugars before the breakfast meal for glucose levels. The state surveyor continued to observe RN I as she checked for the next residents record for blood sugar checks. No glucose machine cleaning was performed, left in the clear plastic cup. Observation on 06/09/2026 at 7:35 AM with RN I of Resident #59's blood sugar check of 148, no insulin was needed. RN I placed the glucose monitor device into a clear plastic cup and went back to the medication cart to document the blood sugar level in the resident record. No glucose machine cleaning was performed, left in the clear plastic cup. Observation on 06/09/2026 at 7:40 AM with Registered Nurse (RN) I went to perform glucose blood sugar check of Resident #19, blood sugar check 77. RN I placed the glucose monitor device into a clear plastic cup and went back to the medication cart to document the blood sugar level in the resident record. No glucose machine cleaning was performed, left in the clear plastic cup on top of the medication cart. Record review of the facility 'Blood Glucose Meter Cleaning' policy, dated 10/5/2018, revealed if blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions to prevent carry-over blood and infectious agents. Disinfection protocol: Glucometers shared by multiple patients will be thoroughly wiped and allowed to air dry after every use and between every patient: Use a fresh wipe each time the glucometer is used, wipe all surfaces, top, bottom and sides, allow to air dry before use on the next resident Observation was made on 06/09/2026 at 7:50 AM with Registered Nurse (RN) I of Medication room [ROOM NUMBER] with Pyxis medication dispensing machine to get the Lisinopril 10mg tablet. RN I stated that she needed 5mg and needed to cut the tablet in half. RN I cut the tablet in half with a pair of bandage scissors from the treatment cart in the medication room. RN I cut the table into her bare hand and put half of the tablet into the drug buster bottle. Observation was made on 06/09/2026 at 7:58 AM with Registered Nurse (RN) I of medication administration. Resident #59 received Dorzol/Timol 2-0.5% one drops to both eyes was administered, and oral tablets given all with the same pair of gloves. RN I rearranged items on the over bed table and then administered the second eye drop Brimonidine 0.2% eye drop one in both eyes was administered, with the same pair of gloves, In an interview on 06/10/2026 at 7:22 AM, Licensed Practical Nurse (LPN)/Infection Control Preventionist (ICP) B explained the Glucose monitoring procedure- to check the residents glucose gather test strips, glucose monitor, gloves, lancet, go to resident room, place a barrier to table, put on my gloves, clean the residents finger with alcohol swabs, place test strip in glucose monitor device, poke finger with lancet, wipe the finger with alcohol wipe, place drop of blood on test strip, wait for results, gather up the supplies, place lancet into the sharps, remove gloves, use a bleach wipe or purple top germicidal wipe and clean the glucose monitor, Air dry the machine for an amount of time. The glucose monito device should be cleaned between residents. The state surveyor inquired as to why do we clean the machine- ICP B stated to stop the spread of anything, it is going room to room and that is how it is spread. Cross contamination glucose monitoring device. In an interview on 06/10/2026 at 9:20 AM with the acting Director of Nursing (DON) the state surveyor notified the DON of multiple cross contamination examples during the medication administration task of not cleaning the Glucose monitoring device between residents and Enhanced barrier precautions are not followed by staff. Resident #11: Record review of Resident #11's Kardex resident care guide on 6/9/2026 revealed the resident was a two-person transfer with a mechanical; lift, one person assists with activities of daily living, and used a Broda chair when out of bed. Bladder/Bowel to keep drainage bag lower than level of bladder. Observation on 06/09/2026 at 6:54 AM of Resident #11 was noted to be asleep in his bed lowered to the lowest level with urinary catheter bag and hose on the floor. The state surveyor observed staff walking by the room. The state surveyor requested the acting Director of Nursing (DON) into the room. Both the Surveyor and DON observed the urinary catheter on the floor. The DON did not apply gloves and attempted to place urinary catheter off the floor, but the bed is in the lowest position, due to fall risk. In an interview on 06/09/2026 at 2:27 PM, Registered Nurse (RN)/Unit manager A stated that a urinary catheter bag or tubing should not be on the floor, and if it's on the floor is a cross-contamination risk. In an interview on 06/10/2026 at 7:39 AM, Licensed Practical Nurse (LPN)/Infection Control Preventionist (ICP) B revealed that she had not educated nursing/staff to use a barrier from the floor but had educated staff to keep the catheter off the floor due to Cross contamination from floor to catheter. Resident #12: On 6/9/26 at 10:41 AM, a sign was observed outside Resident 12's door detailing the Resident had EBP in place. Upon entering the room, Registered Nurse (RN) I was observed flushing Resident #12's Peripherally Inserted Central Catheter (PICC –intravenous [IV] catheter inserted in the arm and fed to the top of the heart used for longer term IV medication administration). RN I was wearing gloves and no other Personal Protection Equipment (PPE). RN I was then observed removing their gloves, donning new gloves and lifting the Resident's gown brief to assess the Resident's colostomy bag (drainage collection bag on abdomen covering a surgically created opening to allow for the passage of stool), abdominal wound dressing, and skin in their peri-area. RN I did not perform hand hygiene after removing gloves and prior to donning new gloves and did not wear a gown at any time while in Resident #12's room. An interview was conducted with the Director of Nursing (DON) and Clinical RN N on 6/9/26 at 12:10 PM. When queried what PPE should be worn when flushing a PICC line and/or assessing a wound for a resident on EBP, both the DON and RN N responded that a gown and gloves should be worn. The DON and RN N were informed of observation of RN I providing care to Resident #12 without wearing a gown and verbalized understanding of concern. No further explanation was provided. An interview and review of the facility IC program was completed with IC Licensed Practical Nurse (LPN) B on 6/10/26 at 9:42 AM. LPN B was asked when staff should wear gown and gloves for residents with EBP in place and replied, Anytime do anything with PICCs, wounds, caths (indwelling catheters), ostmys (surgically created opening in the abdomen to allow for the passage of urine or stool). When queried what facility staff should do after removing gloves and before donning a new pair of gloves, LPN B verbalized that hand hygiene should be performed. When queried regarding observation of the care RN I provided to Resident #12 without wearing a gown and without performing hand hygiene after removing gloves, LPN B responded that was not okay. When queried regarding IC education for staff, LPN B verbalized they provide IC education for staff including education related to EBP. IC LPN B was then asked if the facility had any communicable disease outbreaks and replied, Covid last year in December. When queried what actions are taken if a communicable disease outbreak occurs, LPN B stated, For Covid, upon the first positive we tested the hall and if there were two positives, we implemented additional IC precautions. IC LPN B was asked what additional IC precautions were implemented and replied, Masks if come out of rooms and staff universal masking. When queried if they were referring to residents who had tested positive for Covid-19, LPN B clarified they were referring to residents who were not Covid positive. When queried regarding ongoing testing, LPN B responded that they followed the facility policy/procedure. LPN B was then asked who their contact was at the Health Department and revealed they were unsure of the name of the facility contact at the Health Department. When queried if they had reported the Covid outbreak to the Health Department, LPN B replied, (The Administrator) spoke to them and followed up. When asked why the Administrator, who is not a nurse, contacted the Health Department and not them, LPN B provided no further explanation. LPN B was asked if the Health Department provided any feedback and/or recommendations related to the outbreak and responded that there were not aware of any recommendations. When queried how many residents tested positive for Covid-19 during the outbreak, LPN B reviewed the monthly IC summary for December 2025 and responded 13. The facility IC data and documentation for December 2025 was reviewed with LPN B at this time. A IC documentation provided for December 2025 included a mapping tool, line list, and written IC summary. The December 2025 IC Summary detailed, The facility had 24 residents treated with antibiotics and antifungals in December. 20 antibiotics and antifungals were started in-house, and 12 antibiotics were started in the hospital. Trends: UTI (Urinary Tract Infections) decreased since November. Respiratory increased. There were 13 cases of Covid in December. Upon first positive test, residents and family were notified, residents were placed on covid monitoring. Contact/Droplet precautions implemented. The facility implemented covid outbreak precautions and activities and meals were held in rooms. Testing was completed for all positive residents on day 3, 5, and 7. If negative on any tests, residents were able to discontinue contact/droplet precautions. The summary did not specify what type of testing was completed for diagnosis of Covid-19 infection. When queried regarding the summary indicating Covid positive residents were on droplet precautions (procedural or surgical mask and eye protection) and not airborne precautions (N-95 respirator mask), LPN B indicated an N-95 mask was utilized. The facility policy/procedure for Transmission Based Isolation Precautions (TBP) was requested at this time. When queried if the information in the summary meant there were 32 total infections that were treated with antimicrobial medications (20 in-house plus 12 from the hospital) plus the 13 Covid positive infections for a total of 45 infections during the month, LPN B confirmed. Review of the line list for December 2025 included 33 infections treated with antimicrobial medications and 13 Covid infections for a total of 46 infections. The mapping tool indicated 32 infections with antimicrobial treatment and 13 Covid infections for a total of 45 infections. When queried regarding the discrepancies in the number of infections, LPB B confirmed the discrepancy. The line list for the month included the sections, Etiology, Resident Name, Unit, Room, Current Prescription, Infection Type, Infection, Infection Site, Diagnosis, Isolation. Resident #62 was included on the line list as having a facility acquired viral skin infection caused by Herpes Simplex Virus (HSV- Lifelong viral infection which can cause painful blisters or ulcers. There are two types of HSV. HSV-1, commonly called oral herpes, and spread person to person through saliva. HSV-2, commonly called genital herpes, is spread person to person through sexual contact). The line list specified the Resident was on isolation and received Acyclovir (antiviral medication) 800 milligrams (mg) from 11/29/25 to 12/6/26. The line list did not include what the Resident's sign/symptoms were, when the signs/symptoms started, if any diagnostic testing was completed, and when/what type of TBPs were implemented. When queried what type of precautions were implemented, LPN B responded, It would have been contact. LPN B was asked what date the Resident was placed in TBP and responded, It would have been when we noticed it. When queried the date that the Resident's symptoms began and what their symptoms were and LPN B revealed they would need to review the Resident's Electronic Medical Record (EMR) as the information was not included on the line list. LPN B was then asked if a Health Care Provider (HCP) order was required for TBP and stated, Yes. Review of Resident #62's EMR revealed an order dated 12/1/25 for Contact Isolation r/t (related to) dx (diagnosis) of Shingles (herpes zoster- viral infection caused by the varicella-zoster virus). LPN B was asked if the Resident had HSV or shingles and responded shingles. When queried if a laboratory Polymerase Chain Reaction (PCR) swab test was completed to diagnose Shingles, LPN B responded that the HCP diagnosed shingles and no testing was completed. When asked why the line list specified the Resident had Herpes Simplex not shingles (herpes zoster), LPN B did not provide an explanation. When queried why Acyclovir was started on 11/29/25 and precautions were not initiated until 12/1/25, LPN B was unable to provide a rationale. When asked when the Resident's signs/symptoms of infection started and what they were, LPN B began reviewing the Resident's EMR. After review, LPN B verbalized there was an SBAR form dated 11/28/25 at 2:25 PM which detailed, Hospice nurse here for visit. Stated that resident appears to have shingles above coccyx. Start Acyclovir. as well as an Infection Screening Evaluation dated 11/28/25 at 7:44 PM for a general infection which detailed Resident #62 had a Vesicular rash (small, fluid-filled blisters). When queried if the rash was disseminated (spread outside of primary area), LPN B indicated they would need to review the EMR further. When queried if the Resident was on Airborne (Airborne and Contact precautions are recommended by the Centers for Disease Control [CDC] for disseminated infection as well as localized infection in immunocompromised individual) as well as Contact precautions, LPN B responded they were not. Resident #34 was also listed as having a facility acquired viral infection caused by Herpes Simplex Virus (HSV). The infection site was listed as groin. The line list specified the Resident was on isolation precautions and received Acyclovir 800 mg from 11/30/25 to 12/7/26. The line list did not include what the Resident's sign/symptoms were, when the signs/symptoms started, if any diagnostic testing was completed, when and what type of Transmission Based Isolation Precautions (TBP) were implemented. When queried if there was a trend between the two viral herpes infections, LPN B responded there was not but did not provide further explanation. When queried what Resident #34's symptoms were and when they started, LPN B revealed they would need to review the Resident's EMR. Review of the monthly IC summary did not include any mention of two residents having and receiving treatment for HSV infection. When queried if they identified any infection trends during the month, other than Covid-19, LPN B replied, UTIs, had quite a few. Review of the line list revealed a discharged Resident was listed as having a UTI upon admission to the facility and received levofloxacin (antibiotic) 500 mg from 12/10/25 to 12/11/25. The line list specified the Resident was in room [ROOM NUMBER] but did not include any signs/symptoms of infection, the date the infection and/or treatment started, if the Resident had an indwelling urinary catheter, and/or the causative organism of the infection. When queried what the causative organism of the infection was, LPN B revealed they did not know and would need to review the Resident's EMR and hospital medical records. When asked how they are able to accurately monitor for the spread of infection and identify potential causative factors related to the infection without knowing the organism, LPN B reiterated they would be able to get the information if needed. When asked if the Resident had an indwelling urinary catheter, LPN B responded that they would need to review the EMR. A second discharged Resident was listed as being in room [ROOM NUMBER] and receiving intramuscular (IM) Rocephin (antibiotic) for having a facility acquired suspected UTI. The causative organism of the UTI was not included on the line list, nor were the signs/symptoms of infection, the date the sign/symptoms and/or treatment started, and if the Resident had an indwelling urinary catheter. When queried if they evaluated for a potential trend with the UTI's related to the causative organism, the resident's being in the same room, and potential cleaning/environmental factors, LPN B revealed they had not considered the potential. With further inquiry regarding discharge and admission dates of the Residents, LPN B verbalized they would need to review the Residents EMRs to provide a response. Further review of the line list revealed another discharged resident and Resident #8 were both listed as having facility acquired UTIs caused by Escherichia Coli (E-coli - bacteria normally found in the digestive tract and stool). Both Resident's resided on the same unit of the facility (Side Two). The line list did not include the signs/symptoms of infection, the date the sign/symptoms started, and/or if the infection was associated with an indwelling urinary catheter. The discharged resident was started on ertapenem 1 gram injection (intravenous [IV] antibiotic) on 12/11/25 and Resident #8 started on ceftriaxone sodium (antibiotic) on 12/16/25. When queried if a potential trend was identified in the infections, LPN B did not respond. When queried what is the potential concern when there are UTIs caused by E-coli, LPN B responded peri care. LPN B was asked if additional surveillance was initiated related to correct completion of peri-care, LPN B revealed no specific education related to peri-care was completed that month. LPN B was then asked who the first resident diagnosed with Covid was, as no dates were included on the line list, and responded, The Director of Nursing (DON) had that info. When asked where the information was, LPN B indicated it was on a shared computer file and stated, I don't have access to it now. When queried why they did not have access to the file, LPN B revealed they had access to enter information during the outbreak but were unable to access any of the information now. The interim DON entered the interview at this time. When queried if they had access to the permanent DONs computer file related to the Covid outbreak in December 2025, the interim DON stated they did not. With further inquiry, both LPN B and the interim DON verbalized understanding of the concern of not having IC tracking data available and/or available to review. When queried regarding process surveillance in the facility and audits completed for December 2025, LPN B provided forms for planned observations of PPE donning/doffing for two staff, one form for an observation of perineal care, and one form for an observation of urinary catheter care. LPN B was asked if the audits were random observations or if they asked staff to complete the task and documented their performance and responded that they asked staff to perform the task while they watched. When queried what shifts the audits were completed on, LPN B replied, Days. LPN B was asked why no random observations of IC practices such as hand hygiene, appropriate utilization of PPE, peri care, and point of care testing had been completed and did not provide an explanation. When asked if they had completed any other audits during the month, LPN B replied, No. When queried, LPN B verbalized the laundry was completed within the facility. LPN B was asked how frequently they complete IC rounding in the laundry room, LPN B revealed rounding is not completed at a specific frequency. When queried how they track residents with potential infection who do not receive treatment with an antimicrobial medication, LPN B revealed potential infections are not tracked. When queried how they are able to comprehensively identify and mitigate the potential spread of infection when they do not track signs/symptoms of potential infection, LPN B verbalized understanding but did not provide further explanation. When queried, LPN B revealed they were unfamiliar with the Federal Regulations and F-tags related to IC in nursing homes and had not been provided the information. Review of facility policy/procedure entitled, Infection Prevention and Control Program (Dated 2017) revealed, It is the policy that this facility's Infection Prevention and Control Program (IPCP). prevent, recognize and control the onset and spread of infection. The IPCP program includes: 1. A system for preventing, identifying, reporting, investigating and controlling infections and communicable disease. The facility policy/procedure for Transmission Based Isolation Precautions (TBP) was requested but not received by the conclusion of the survey. Review of facility provided policy/procedure entitled, Infection Prevention and Control Interim Guideline for Suspected or Confirmed Coronavirus (COVID-19) (Revised: 6/2025) revealed, Guideline: 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 and to adhere to Federal and State/Local recommendations (to include, for example: Admissions, Visitation, Precautions: Standard, Contact, Droplet and/or Airborne Precautions, including the use of eye protection). When the facility is in a COVID-19 outbreak (meaning 1 or more resident cases) universal masking is the decision of the Director of Nursing (DON), unless otherwise dictated by the local health department or the CDC. Personal Protective Equipment HCP (Health Care Providers) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Transmission Based Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Dining Observation on 6/8/26: Observation made on 6/8/26 at 11:54 a.m., in the main dining room, revealed staff were serving the residents' their noon meal. Staff were noted to go resident-to-resident (setting meal on tables, taking plastic wrap off foods and putting on clothing protectors) and not washing their hands or using hand sanitizer between residents'. During an interview done on 6/10/26 at 7:45 a.m., Infection Control Nurse, LPN B stated They (staff) should wash their hands between residents when serving foods. I educate them on handwashing. Review of the facility Handwashing/Hand Hygiene policy, dated May 2022, stated Before and after direct resident contact, before and after eating or handling food. Alcohol-Based Hand Rubs: Before and after direct contact with residents'. Review of the facility Hand Hygiene Guideline dated 4/16/2025, stated The following are indications for hand hygiene: Before eating or assisting a resident with meals.

Based on interview and record review, the facility failed to ensure the dignity of residents by not answering residents' call lights in a timely manner for 6 of 7 confidential residents from the Resident Council Group, and 1 resident (Resident #57) of 20 sampled residents reviewed for dignity, resulting in anger, frustration, depression, verbalizations of being embarrassed, and a resident soiling themself. Findings Include: Resident #57:Review of the Face Sheet, nurse's notes, Cognitive assessment tool (BIMS), dated 3/12/26, and care plans, dated 12/25 to 6/26, revealed Resident #57 was [AGE] years old, alert (BIMS of 14), her own person, admitted to the facility on [DATE], dependent on staff for Activities of Daily Living/ADL. The residents' diagnosis included Depression, Anxiety, Bipolar, Fibromyalgia, obesity, difficulty walking, and chronic kidney disease.During an interview done on 6/8/26 at 11:30 a.m., Resident #57 stated, I had to wait one time over an hour and I did wet myself, yes it's embarrassing, it p .ed me off. I don't think that's right. On the weekends it's really bad, especially at night. It takes them about half an hour to answer my light. Sometimes they shut it off and don't take care of me. They don't have enough staff.During the confidential Resident Council Meeting held on 6/9/26 at 2:00 p.m., 6 of 7 resident's verbalized staff don't answer call lights timely on night shift and on the weekends. 6 confidential residents said it takes approximately 30 minutes for staff to answer their lights and stated, There is not enough staff on the weekends, and if there is a call-in, the nurse does not replace them. It takes them (staff) at least a half an hour to answer them, or they (staff) come in and shut it off and don't take me to the bathroom, they say the aide will come in. It's mostly on the weekends, everything is laxed on the weekends. They (staff) sit residents by the nurse's station; no TV, no music, nothing for them. An unidentified Certified Nursing Assistant (CNA) tells us to just wet our pants.Review of the Resident Counsel meeting notes dated 5/5/26, stated Concerns: Waiting for call light to be answered.Review of the Resident Counsel meeting notes dated 2/3/26, stated Call lights where Residents can.Review of the Resident Counsel meeting notes dated 11/11/25, stated Call light's not being answered in a timely manner.Review of the facility Answering the Call Light policy dated 11/2013, stated Answer the call light as soon as possible.Review of the facility Resident Rights policy dated 11/28/2017, stated resident's have the right to be treated with respect and dignity.

Based on observation, interview and record review, the facility failed to ensure safe medication storage, dispose of expired medications, date multi-dose open medications/treatments and date a glucometer stick bottle for 2 of 4 carts reviewed and 2 of 2 treatment carts reviewed and for two residents (Resident #39, Resident #59), resulting in expired medications/treatments, opened and undated medications/treatments, and medications left at residents' bedsides. Findings Include: Resident #39: Review of the Face Sheet, orders dated 8/26, and nursing note's dated 5/26 through 6/26, revealed, Resident #39 was [AGE] years old, admitted to the facility on [DATE], had a cognitive assessment score dated 1/5/26, of 5 (BIMS-5: cognitively impaired), and was dependent on staff for all Activities of Daily Living/ADL's. The residents' diagnosis included Stroke with Hemiplegia and right sided Hemiparesis, Memory Deficit, Diabetes, Chronic Lung Disease, Alzheimer's disease and Post-Traumatic Stress. The resident had coccyx wounds being treated with topical medication. Review of the facility Medication Storage policy dated May 2022, stated Medications and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Compartments containing medications and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. Observation made on 6/8/26 at 11:00 a.m., during the initial tour revealed Resident #39 in his bed, there was a urinalysis specimen cup filled with a thick white cream sitting on the stand by his bed. No resident name, room number or topical medication name was on the container. During an interview done on 6/8/26 at 11:10 a.m., Nurse Manager, RN A was unable to identify the white cream in the specimen cup, and said it should not have been at the residents bedside, it should not have been in a urine specimen cup in the first place, and no medication was to be put in a different container then what it came in. Nurse Manager A took it out of the room. Medication Storage and Labeling: Observation and interview on 06/08/2026 at 9:25 AM with Registered Nurse (RN) Nurse G standing at the opened medication cart located on A hall, the surveyor reviewed the medication cart and located two small peach-colored tablets with EP 155, non-scored tablets loose in the second drawer of cart. RN G could not state why tablets were loose in the cart. Observation revealed facility used punch out pill cards for medication administration/bubble packs. Computer research of the peach-colored tablets EP-155 were identified as hydrochlorothiazide 12.5mg tablets. Observation and interview on 06/09/2026 at 7:02 AM with Licensed Practical Nurse (LPN) L Review of the D-E hallway medication cart revealed that the Ultra trak glucose test strips were opened and not dated. LPN L stated that she went through the medication cart the previous day to mark all containers. Observation of Resident #43's Ventolin inhaler label peeled off and there was no date on the bag or device when opened. Observation of the Ventolin inhaler had no red tape on the end and the device is used. Observation and interview was conducted on 06/09/2026 at 8:47 AM of the Medication room [ROOM NUMBER] located on the A-B Unit with Registered Nurse I. It revealed treatment cart drawers contained: Coloplast hydrophilic wound dressing cream 6oz., multi-dose tube used, opened with no date when opened, green pain-relieving gel 4oz tube with menthol multi-dose tube used, opened with no date when opened. Coloplast Collagen dressing wound hydrogel 3 oz multi-dose tube used, opened with no date when opened. Solosite wound gel 3 oz. pharmacy date issued 2/2016 with manufacture expiration date 8/1/2025 x 2 tubes, both multi-dose tubes were used, with no date when opened. SilvaKollagen gel silver collagen wound gel manufacturer date expiration date 1/4/2026 was multi-dose tube used, opened with no date when opened, Derma Syn/Ag silver antibacterial wound gel manufacturer expiration dated 3/29/2025 multi-dose tube was available in the treatment carts for use. Observation on 06/09/2026 at 2:08 PM with Licensed Practical Nurse (LPN) M of the Medication Cart C1 revealed Resident #69's Olanzapine 5mg 30 tablet multi-dose bottle dispensed 5/28/26 take 1 tablet 2 times daily. There was no date when the bottle was opened. Observation and interview were conducted on 06/10/2026 at 9:20 AM with acting Director of Nursing (DON) about the lack of glucometer cleaning and enhanced barrier precautions are not used, when a sign clearly states to use on a resident 's door. The DON agreed that the glucometer needs to be cleansed and air dried between residents and that enhanced barrier precautions should be followed by all staff. The state surveyor walked with the DON to review Medication room [ROOM NUMBER] on the A-B unit: Treatment cart review-Coloplast hydrophilic wound dressing cream 6oz., multi-dose tube used, opened with no date when opened, [NAME] pain-relieving gel 4oz tube with menthol multi-dose tube used, opened with no date when opened. Coloplast Collagen dressing wound hydrogel 3 oz multi-dose tube used, opened with no date when opened. Solosite wound gel 3 oz. pharmacy date issued 2/2016 with manufacture expiration date 8/1/2025 x 2 tubes, both multi-dose tubes were used, with no date when opened. SilvaKollagen gel silver collagen wound gel manufacturer date expiration date 1/4/2026 was multi-dose tube used, opened with no date when opened, Derma Syn/Ag silver antibacterial wound gel manufacturer expiration dated 3/29/2025 multi-dose tube was available in the treatment carts for use. All the same treatment creams or ointments were still in the treatment cart available for nursing staff to use in wounds as on the previous day. The DON stated that 'We have expired wound care treatments that are expired and available for use in the cart. the treatment cart is not being monitored. The facility has a wound treatment nurse Licensed Practical Nurse (LPN) H. The state surveyor and DON went to the Unit managers' office to speak with LPN H. In an interview and observation on 06/10/2026 at 9:30 AM, Licensed Practical Nurse (LPN)/Wound Care/unit manager/Restorative H stated that the Treatment carts are in cared for by floor nurses, As the wound care nurse LPN H stated that she does use the treatment carts when doing wound rounds, once a week normally Wednesday, LPN H stated that she did the dressing changes for the building already for the day. LPN H stated that the Treatment carts were reviewed couple weeks ago, LPN H stated that she audited the carts on 5/26/2026 I do it all within the same 2 days but does not document anything. LPN H agreed that multi-dose treatment/creams should have an open date when first used. Observation while in the Medication room on the D-E Unit medication room [ROOM NUMBER] revealed: Triad hydrophilic wound dressing 6 oz. multi-dose tube was opened and not dated. Triamcinolone acetonide cream 1% tube used not dated Iodosorb 10g tube 0.35oz was used and opened and not dated with no resident name on the tube or box. Record review of the facility pharmacy 'Medication Storage in The Facility' policy, dated 4/2018, the provider pharmacy dispenses medications in containers that meet regulatory requirements, including standards set forth by the United States Pharmacopeia (USP). Medications are kept in containers . (H.) Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal and recorded . Expiration dating (Beyond-use dating): When the original seal of a manufacturers container or vial is initially broken, the container or vial will be dated. 1.) The nurse shall place a Date opened sticker on the medication and enter the date opened and the new date of expiration .

Based on observation, interview and record review, the facility failed to implement procedures and monitoring to ensure the assessment and clinical appropriateness of medication self-administration for one resident (Resident #55) of one resident reviewed. Findings include:Resident #55: On [DATE] at 11:31 AM, Resident #55 was observed sitting in a wheelchair in their room. An Albuterol inhaler (prescription fast acting rescue respiratory inhaler used to treat bronchospasms) was observed sitting on the Resident's overbed table. Resident #55 was observed self-administering two puffs, back-to-back without waiting one minute between puffs, of the albuterol inhaler medication without staff present. A sticker was present on the inhaler with Date Opened: [DATE]; Expired: [DATE] written on the inhaler. The built-in dose count number on the inhaler revealed there were 40 doses remaining in the inhaler. When queried regarding the date ([DATE]) written on the inhaler indicating the medication was expired and the built-in dose count number on the inhaler specifying there were 40 doses remaining, Resident #55 stated, Probably due to me not taking every dose. Resident #55 was asked how long they had the inhaler in their room and indicated they kept it in there but was unable to provide a date and/or state where they had gotten the inhaler from. Record review revealed Resident #55 was originally admitted to the facility on [DATE] with diagnoses which included Congestive Heart Failure (CHF), acute and chronic respiratory failure, and falls. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required supervision/touching assistance for transfers and maximum assistance for bathing. A review of Resident #55's Electronic Medical Record (EMR) revealed the Resident did not have an assessment for medication self-administration. Review of Resident #55's Health Care Provider (HCP) orders and Medication Administration Record (MAR) in the EMR revealed the Resident had an order for Ventolin (Albuterol) HFA (Hydrofluoroalkane) Aerosol Solution (inhaler) 108 (90 Base) mcg (micrograms)/Act (actuation), 2 puff inhale orally three times a day for SOB (Shortness of Breath) The times on the MAR specified the inhaler was to be administered at 8:00 AM, 4:00 PM, and 8:00 PM. All doses were documented as administered by facility nursing staff. An interview was completed with the Director of Nursing (DON) on [DATE] at 11:44 AM. When queried regarding the facility policy/procedure related to resident self-administration of medications, the DON responded, It should be on the care plan if a Resident is able to self-administer medications. When queried regarding observation of Resident #55 having an expired albuterol inhaler, per written expiration date on the inhaler, on their overbed table and observation of self-administration, the DON verbalized Resident #55 should not have the medication on their overbed table and self-administer the medication without an assessment. The DON further confirmed that expired medication should be disposed of. Review of Resident #55's EMR with the DON revealed a care plan and/or care plan interventions pertaining to self-administration of medications including inhalers were not present. The DON verbalized understanding of the concern. A review of progress note documentation in Resident #55's EMR revealed no documentation of assessment for medication self-administration. Review of facility policy/procedure entitled, Self-Administration of Medications Management (Effective: [DATE]) revealed, If a resident requests to self -administer medication(s) that the interdisciplinary team will assess the resident to determine if it is clinically appropriate to honor the resident's choice, in order to maintain the resident's highest practicable level of functioning. A resident may only self-administer medications after the IDT has determined which medications may be safely self-administered. If resident requests self-administration of respiratory inhalants only, complete the Self-Administration Evaluation of Respiratory Inhalants form. A periodic evaluation of the resident's ability to self-administer medication will be performed by the IDT, based on changes in the resident's medical and decision-making status. A physician's order will be obtained and recorded in the chart. The order also will include which specific medications can be kept at the bedside.

Based on observation, interview and record review, the facility failed to ensure that Activities of Daily Living (ADL) care, including clean bedding and bathing per preference, was provided to two residents (Resident #12 and Resident#55) of two residents reviewed. Findings include:Resident #12: On 6/8/26 at 12:10 PM, Resident #12 was observed in their room in bed. An interview was completed at this time. When queried if they need assistance to get out of bed and complete ADL care, Resident #12 verbalized that they do and revealed they are currently receiving therapy. Resident #12 was queried regarding showers and stated, I have only had one shower because of the time limit. When asked what they meant, Resident #12 stated, There is a queue and only one person to do it (showers). Resident #12 revealed the staff give them a bed bath when there is not enough time for a shower. Resident #12 was asked if they would rather have a bed bath or a shower and responded, Shower. Resident #12 expressed that before they became ill and went to the hospital, they took one to two showers a day a home. Record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses which included infection, nutritional deficiencies, and intestinal fistula (tunnel like connection between the intestine and another organ/skin) Review of Bathing documentation for the past 30 days Resident #12's Electronic Medical Record (EMR) revealed the task, Bathing: Wednesday/Saturday. Review of the documentation detailed the Resident received one shower on 6/7/26 and four bed baths on 5/24/26, 5/27/26, 5/30/26, and 6/6/26. On 6/9/26 at 10:41 AM, Resident #12 was observed in their room in bed. When queried if they had gotten washed up for the day or had their teeth brushed yet, Resident #12 stated they had not. When asked if they needed assistance brushing their teeth, the Resident responded that they do because they are unable to get to a sink themselves. Resident #12 then stated, I have to ask to brush teeth and revealed facility staff do not offer. When queried regarding their normal toothbrushing routine, prior to coming to the facility, Resident #12 revealed they always brushed their teeth first thing in the morning. Resident #12 stated, I would always brush my teeth and shower - (shower) in the morning and sometimes twice daily. A review of Resident #12's care plans revealed the Resident did not have a care plan specifically related to bathing/showers and/or individual bathing preferences. An interview was completed with the Director of Nursing (DON) on 6/9/26 at 2:45 PM. When queried regarding Resident #12's statements regarding there being a queue for showers due to only having one staff available for showers, the DON revealed the facility typically assigns one Certified Nursing Assistant (CNA) to provide showers, but other CNAs are able to provide showers. When queried why Resident #12 was not receiving showers when they stated they preferred showers, the DON responded that (Resident #12) should get a shower if that is their preference. Resident #12's bathing documentation was reviewed with the DON at this time. The DON verbalized understanding of the concern but did not provide further explanation. Resident #55: On 6/8/26 at 12:45 PM, an interview was completed with Resident #55 in their room. The Resident was in bed, positioned on their back with a food tray in front of them on the overbed table. The Resident's bed sheets were observed to have a significant and highly visible amount of a dried, dark red colored substance with the appearance of dried blood. When queried regarding the substance on their bed sheets, Resident #55 stated, I had a bloody nose last night. With further inquiry, Resident #55 revealed nursing staff assisted them to get their bloody nose to stop bleeding. At 12:49 PM, Certified Nursing Assistant (CNA) O entered Resident #55's room. As CNA O was leaving the room, they were stopped and queried regarding the dried blood on Resident #55's sheets. CNA O revealed they had not seen the blood when they were in the Resident's room previously and were not sure what it was from. Record review revealed Resident #55 was originally admitted to the facility on [DATE] with diagnoses which included Congestive Heart Failure (CHF), acute and chronic respiratory failure, and falls. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required supervision/touching assistance for transfers and maximum assistance for bathing. Review of Resident #55's progress note documentation in the EMR revealed a Nurses Note dated 6/8/26 at 3:11 AM which specified, Resident with nosebleed, estimated blood loss 50 cc (cubic centimeter). An interview was completed with the Director of Nursing (DON) on 6/9/26 at 11:44 AM. When queried if resident bedding should be changed when visibly soiled, the DON confirmed it should. The DON was informed of interview with Resident #55 on 6/8/26 regarding their nose bleed during the night, documentation of nosebleed in the EMR, and observation of dried blood on the bed sheet. When asked why Resident #55's bed sheets still had blood on them at 12:45 PM when the nosebleed was documented in the EMR at 3:11 AM, the DON verbalized the Resident's bedding should have been changed and verbalized they would address the concern. Review of facility policy/procedure entitled, Activities of Daily Living (ADL), Supporting (Revised: March 2018) revealed, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on interview and record review, the facility failed to implement procedures to ensure weight monitoring for two residents (Resident # 10 and Resident #50) of four residents reviewed for nutrition resulting in a lack of weight monitoring for residents with a known risk for nutrition deficiencies and with significant weight loss. Findings include: Resident #10: In an observation and Interview on 06/08/2026 at 11:43 AM, Resident #10 was observed at a table in the main dining room at the back windows seated up in a wheelchair with 3 other residents at his table. Resident #10 appeared thin with loose skin noted to his face and arms. Resident #10 stated that the food is OK, but nothing to brag about. In an observation and interview on 06/08/2026 at 11:48 AM, Resident #10 was observed to remove the lid to his hot tea beverage and able to drink by himself. Observed plates of pureed food items. Resident #10 was able to self-dine but needed encouragement to eat. Resident #10 stated that he has lost weight and that he does not know why. In an observation and interview on 06/08/2026 at 12:32 PM, the surveyor observed Resident #10 to have a pureed diet plate with pureed pot pie, mashed potatoes, butterscotch pudding with boost drink, and water thin consistency. Resident #10 prefers to just drink hot tea and not eat. Will check his weight log and dietary notes. Record review of Resident #10's dietary progress notes, dated 2/26/2026 at 2:08 PM, revealed: Resident has not been eating, writer tried talking to resident asking if he needed help eating, he stated he would do it if he knew how. Suggesting that resident go down to the main dining room so that he can get some assistance eating. Will keep observing to see if this helps with his eating. Dietary notes for Resident #10 dated 4/9/2026 at 2:20PM revealed the residents triggered for significant weight loss -6.9% x 30days. oral supplements added that magic cup one time daily, boost one time daily and House 2.0 supplement added 120ml daily. Dietary progress note dated 5/11/2026 at 9:02PM revealed admission weight back on 2/24/2026= 217.8 pounds. Weight on 4/5/2026= 196 pounds. Weight on 5/4/2026- 185.5 pounds and reweight obtained 5/7/2026- 184 pounds. Weight down 12 pounds over the past month and down 33.8 pounds (-15.6%) x 90 days which is significant month weight loss was not planned. Record review of Resident #10's care plans revealed an elderly male with medical diagnoses of Barrett's esophagus with dysplasia, heart failure, heart disease, gastro-esophageal reflux disease (GERD), nutritional deficiency, diabetes, muscle wasting, abnormal involuntary movements, dysphagia, memory deficit, depression, kidney failure, anemia and anxiety were a few of the diagnoses. Record review of the nutritional care plan revealed: Resident #10 is ordered and consumes a mechanically altered diet related to dysphagia. He has nutritional risk related to advanced age, diagnosis of encephalopathy, diabetes with insulin use, GERD, Barrett's esophagus, atrial fib, heart disease There were noted Registered Dietitian recommendations for 5/11/2026 noted in the focus section of the care plan. Record review of the Intervention section of the care plan noted that there were no added interventions after 3/5/2026 to a dress the weight loss. An interview and record review was conducted on 06/09/2026 at 10:39 AM with Registered Dietitian (RD) Q, who had been employed for three weeks at the facility. Prior to her arrival there was a hired RD and a contracted RD, but she has never met them. Record review of Resident #10's weight log with RD Q revealed: Starting weight on 2/24/26 of 217.8 lbs. On 03/23/2026, 30 days look back revealed Resident #10 weighed 204.5 lbs. which is a -6.11% Loss. On 05/04/2026, close to a 60 day look back Resident #10 weighed 185.5 lbs. which is a -9.29% Loss. Record review of a quarterly weight comparison revealed on 03/23/2026, the residents weighed 204.5 lbs. On 06/02/2026, the resident weighed 182.5 lbs. which is a -10.76% Loss. Registered Dietitian (RD) Q stated that she evaluated Resident #10's record yesterday, but had not seen him, I just reviewed his orders and increased his supplements on 6/4/2026. Resident #50: Record review revealed Resident #50 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cerebral infarction (stroke) with resulting left sided hemiplegia and hemiparalysis (one-sided paralysis), dysphagia (difficulty swallowing), aphasia (impaired speech and communication), heart failure, and muscle wasting. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required moderate to total assistance to complete all Activities of Daily Living (ADLs) with the exception of supervision for eating. Review of Resident #50's Electronic Medical Record (EMR) weight documentation revealed the Resident weighed 143.5 lbs. on 5/11/26 and 135 lbs. on 6/4/26 which is a 5.92% Loss. There were three weights documented in Resident #50's EMR. The three weights included: - 5/11/26: 143.5 lbs. (pounds)- wheelchair scale - 5/15/26- 141.0 lbs. – wheelchair scale - 6/4/26 – 135.0 lbs. – wheelchair scale Review of documentation in Resident #50's EMR revealed Resident #50 was supposed to weighed weekly. An IDT: Care Conference note dated 5/8/26 at 12:26 PM specified, Dietary/Nutrition. Resident is tolerating diet. on a mechanical soft/nectar thick liquid. eats 25-50% of meals. Only have his first week's weight 143.5, will monitor weight weekly. A Dietary: Nutrition Assessment dated 5/24/26 was noted in Resident #50's EMR. The assessment included, Measurements. Ideal Body Weight: 154. Assessment. initially admitted to facility on 5/6/26. sent out on 5/13/26, before readmitting on 5/15/26. Wt following initial admission obtained 5/11/26 = 143.5. readmission wt on 5/15/26=141. Wt down slightly since initial admission, with BMI of 21.4 just below optimal range. Intake appears appropriate to support needs. Further review of progress note documentation in Resident #50's EMR did not include identification of weight loss. Review of Resident #50's EMR revealed a care plan entitled, (Resident #50) has potential for impaired nutritional status. diet with modified texture (mechanical soft) and thickened liquids (nectar thick) with meds also in place having known potential to impact nutritional status and/or wts (weights) (Initiated: 5/8/26). The care plan included the interventions: - Monitor and report to MD s/sx (signs/symptoms) malnutrition: emaciation (cachexia), muscle wasting, significant weight loss of 3lb in 1 week, 5% in 1 month, 7.5% in 3 months, or 10% in 6 months (Initiated: 5/8/26) - Registered dietitian to evaluate and make recommendations as indicated (Initiated: 5/8/26) An interview was conducted with Registered Dietician (RD) Q on 6/9/26 at 2:41 PM. When queried if Resident #50 was supposed to be weighed weekly, RD Q reviewed the Resident's EMR and confirmed they were. When asked if the Resident was supposed to be weighed weekly, RD Q confirmed they were. RD Q was asked why weights were not completed weekly and responded they did not know. When queried regarding the Resident's most recent weight on 6/4/26, RD Q reviewed the Resident's EMR and confirmed the Resident had lost more weight. When queried how much weight Resident #50 had lost, RD Q responded, 5.9 %. When asked, RD Q confirmed Resident #50's weight loss percentage was significant for a month period. RD Q then stated they would request a reweight for Resident #50. RD Q verified the concern with lack of weight monitoring and Resident #50's significant weight loss when asked. An interview was completed with the Director of Nursing (DON) on 6/10/26 at 9:18 AM. When queried regarding lack of weekly weights for Resident #50 and the Resident's 5.9% weight loss, the DON confirmed the Resident should have been weighed weekly due to being a new admission/readmission. Review of facility policy/procedure entitled, Weight Monitoring Guideline (Revised: June 7th, 2023) revealed, Purpose. the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance. Guideline: Residents will be weighed; documentation will be recorded. Upon admission and re-admission. Weekly for four weeks post admission and / or until the weight is determined to be stable. Monthly by the 10th of each month.

Based on observation, interview and record review, the facility failed to implement policies and procedures for the care and management of respiratory equipment and the administration of oxygen per Health Care Provider (HCP) orders for two residents (Resident #50 and Resident #55) of two residents reviewed.Findings include:Resident #50: On 6/8/26 at 9:25 AM, an observation of Resident #50's room was completed. A nebulizer machine was observed sitting on a stationary chair in the room at the foot end of the bed. The nebulizer administration set was connected and clear, visible fluid was present in the medication administration chamber. An oxygen concentrator was present with nasal cannula (NC) oxygen delivery tubing connected. The NC tubing was dated 5/28. Record review revealed Resident #50 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cerebral infarction (stroke) with resulting left sided hemiplegia and hemiparalysis (one-sided paralysis), dysphagia (difficulty swallowing), aphasia (impaired speech and communication), heart failure, and muscle wasting. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required moderate to total assistance to complete all Activities of Daily Living (ADLs) with the exception of supervision for eating. Review of Resident #50's Medication Administration Record (MAR) in the Electronic Medical Record (EMR) revealed the Resident was receiving Ipratropium-Albuterol (DouNeb) 0.5-2.5 mg (milligram)/3mL (milliliter) solution four times a day at 5:00 AM, 11:00 AM, 5:00 PM and 11:00 PM. The medication was documented as last administered on 6/8/26 at 5:00 AM. On 6/9/26 at 11:00 AM, Resident #50 was observed in their room, laying in bed with their eyes closed. Resident #50's NC was observed on the other side of the room laying on the floor near the concentrator. At 11:21 AM on 6/9/26, an interview and observation of Resident #50 was completed with Registered Nurse (RN) I. When queried regarding Resident #50's oxygen NC being on the floor, RN I picked up the oxygen tubing and placed it on top of the Resident's wheelchair but did not dispose of the tubing. When asked if the Resident was supposed to be receiving supplemental oxygen, RN I replied, They are trying to wean them off of it. A review of Resident #50's Electronic Medical Record (EMR) revealed the Resident had an active HCP order for administration of continuous oxygen via NC at 2 Liters (L) per minute. Further review of Resident #50's EMR revealed a care plan entitled, Resident has oxygen therapy r/t (related to) Emphysema, COPD (Chronic Obstructive Pulmonary Disease) (Initiated: 5/6/26). The care plan included the intervention, Oxygen Settings: O2 via nasal prongs @ 2L (Liters) continuous (Initiated: 5/7/26). Resident #55: On 6/8/26 at 12:45 PM, Resident #55 was observed in their room in bed. The Resident was receiving oxygen via NC at 5L/minute with humidification. An uncovered and uncontained Continuous Positive Airway Pressure (CPAP) mask was observed sitting on top of the dresser next to the Resident's bed along with multiple other items. A nebulizer administration mask was observed sitting in the open top drawer of the dresser beside the Resident's bed. The nebulizer administration set was connected with visible fluid and condensation noted in the medication chamber of the administration set. When queried, Resident #55 verbalized they utilized the oxygen therapy continuously as well as both inhalers and nebulizer treatments. Record review revealed Resident #55 was originally admitted to the facility on [DATE] with diagnoses which included Congestive Heart Failure (CHF), acute and chronic respiratory failure, and falls. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required supervision/touching assistance for transfers and maximum assistance for bathing. Review of Resident #55's EMR revealed a care plan entitled, Resident has oxygen therapy r/t COPD (Initiated: 1/6/26). The care plan included the intervention, (Resident) uses a CPAP. (Initiated: 1/26/26). Review of Resident #55's MAR revealed the Resident had PRN (as needed) orders for two different nebulizer treatments but had not received either treatment during the month of June 2026.An interview was conducted with the Director of Nursing (DON) on 6/9/26 at 11:55 AM. When queried regarding the facility policy/procedure related to storage and maintenance of nebulizers, the DON responded that the nebulizer should be rinsed and sat out to dry on a barrier to dry after each use. When queried regarding observations of fluid in the administration chambers of both Resident #50 and Resident #55's nebulizer administration sets, the DON confirmed fluid should not remain in the chamber and verbalized understanding of concern. When queried if Resident #50 is supposed to receive continuous supplemental oxygen via NC, the DON reviewed Resident #50's EMR and stated, Should be in place and confirmed the Resident had an active order for continuous oxygen therapy. The DON was informed of observation of Resident #50 having their oxygen in place as well as interview with RN I. When queried regarding RN I picking up the NC that was on the floor and sitting it on the Resident's wheelchair, the DON responded that the NC tubing should have been disposed of because it had been on the floor. Review of facility policy/procedure entitled, Oxygen Administration (Revised: October 2010) revealed, Policy. 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 15. When O2 supplies is not in use, will store in designated storage bag to keep free from dust and dirt.A policy/procedure pertaining to nebulizer storage was requested but not received by the conclusion of the survey.

Based on observation, interview and record review, the facility failed to ensure the accurate narcotic count and documentation of controlled substance usage for 1 of 4 medication carts. Findings include: Narcotic Reconciliation:In an observation and interview on 06/09/2026 at 11:26 AM with Registered Nurse (RN) I, an observation was made of the A-B Unit Medication Cart's controlled substance drawer. The Narcotic 'Controlled Substance Shift Inventory' form dated for 6/9/2026 noted 47 total narcotics. Observation and physical count of the A-B Unit medication cart noted 44 punch cards in the drawer, minus 1 used, equaled 45 and plus one in the medication room refrigerator equaled 46, The narcotic count was off by 1 missing narcotic for two consecutive 12-hour nursing shifts that were counted by facility nursing staff, but not found until RN I counted the narcotics with the state surveyor three times in attempt to locate the missing controlled substance. Observation, interview and record review was conducted on 06/09/2026 at 11:38 AM with the acting Director of Nursing (DON) in the A-B Unit Medication room [ROOM NUMBER], to review the Narcotic 'Controlled Substance Shift Inventory' form. Observed and counted 46 meds 44 meds in the cart, and 1 in the refrigerator which equals 45 controlled substances, one medication form competed or used up, for a total of 46 narcotics, and a count sheet stated total of 47. In an interview and record review of an 'Emergency Drug Kit Slip' undated for a discharged resident in room [ROOM NUMBER], Lorazepam 1mg/strength 2mg, there was no seal number, or lock number when closed, and no nurse's signature or date and time noted on the slip, but that the Ativan 2mg vial was not in the back up emergency kit. Observation, interview and record on 06/09/2026 at 12:51 PM with the Clinical Regional Director N counted the medication cart A-B Hall of 44 controlled substances in the narcotic drawer, Observation of Medication room [ROOM NUMBER] refrigerator had only one controlled substance, and she agreed that there is one missing. Regional Clinical N and DON agreed with the narcotic count of 45 total medications. They will continue with the investigation. In an interview on 06/09/2026 at 1:44 PM, the Clinical Regional Director N and the acting Director of Nursing (DON) stated that they found a narcotic sheet in the DON's office from empty cartridge yesterday by Registered Nurse (RN) G. It was not subtracted from the card count for 2 shifts, last night and this morning. So, the nurses did not catch that the card count was off for 2 shifts. The current process is that the oncoming and outgoing nurse count the total narcotics and then by each card. They missed it. They did not follow the complete narcotic process. Record review of the facility 'Controlled Substances' policy, dated 11/2020, revealed that the facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of schedule II and other controlled substances. Implementation: (9.) Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together, they must document and report any discrepancies to the Director of Nursing Services. (10.) The Director of Nursing Services shall investigate and discrepancies in narcotic reconciliation to determine the cause and identify and responsibility parties and shall give the Administrator a written report of such findings.

Based on observation, interview and record review, the facility failed to implement policies and procedures for personal in-room refrigerator food storage, monitoring and disposal for one resident (Resident #56) of one resident reviewed. Findings include:On 6/8/26 at 10:17 AM, Resident #56 was observed in bed with their eyes open. A small personal refrigerator was present in the room. An interview was completed at this time. When queried regarding the level of assistance they require for ADL care, Resident #56 revealed they do not get out of bed to use the bathroom and rarely leave their room. When queried regarding the fridge in their room, Resident #56 responded that the staff will get them items from it when they ask and indicated it mainly contained pop. Resident #56 provided permission to look in the refrigerator. A temperature log with temperatures and staff initials was present on the outside of the refrigerator. There were several cans of pop, a bottle of sauce, a package of cheese slices, cheese sticks, and an individual single serving container of sour cream in the fridge. Five cheese sticks (expired 11/2025) and an individual expired package of sour cream were expired and none of the food was dated when it was brought to the facility. When queried regarding the cheese sticks, Resident #56 revealed they love cheese and eat it frequently. When asked, Resident #56 was unable to provide a date of when they acquired the food. Record review revealed Resident #56 was admitted to the facility on [DATE] with diagnoses which included seizure disorder, anxiety, depression, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required maximum to total assistance to complete Activities of Daily Living (ADLs) with the exception of set-up for eating. An interview was completed with the Director of Nursing (DON) and Clinical Registered Nurse (RN) N on 6/9/26 at 12:12 PM. When queried regarding the facility policy/procedure related to food storage and disposal of expired foods in residents personal in-room refrigerators, the DON and RN N both verbalized that a facility staff member should ensure there are no expired food items in resident refrigerators. When asked what staff are responsible for monitoring and disposal of expired food items, the DON and RN N revealed they need to review the procedure. After being informed of the expired items in Resident #56's refrigerator, the DON responded they would address the concern. No further explanation was provided. A policy/procedure pertaining to resident in room refrigerators was requested at this time. Review of facility policy/procedure entitled, Personal Food Guideline (Effective: 3/12/18) revealed, It is our practice to support food brought for residents from outside sources. Food provided for a resident by family and visitors will be stored separately for facility food under safe and sanitary conditions. Safe food handling procedures will be shared with residents and facility members to ensure safe and sanitary food storage. and consumption. Food brought from outside sources. will be. labeled. Labeling will include. Received date, Use by date (no longer that 3 days), Staff members initials.

Based on interview and record review, the facility failed to ensure that the daily posting of nurse staffing data was posted in a prominent place, included the hours worked of licensed and unlicensed nursing staff, and accurate documentation of staff numbers and actual hours worked, resulting in incomplete and inaccurate nurse staffing information. Findings include:On 6/9/26, the facility posted nursing staffing data was not observed near the visitor/front entrance of the facility nor in a visible area upon entering the Resident care area of the facility from the main entrance. An interview was completed with the Director of Nursing (DON) on 6/9/26 at 12:10 PM. When queried where the facility posted nurse staffing data was, the DON revealed they were interim at the facility and were unsure. After contacting another staff member, the DON indicated the staffing information was posted across from the Side Two nurses' station. The Side Two nurses' station was on the opposite side and end of the building from the visitor's entrance. The posting was dated 6/9/26 and included census and number of Registered Nurses (RNs), Licensed Practical Nurses (LPN), and Certified Nursing Assistants (CNAs) for three shifts. All three shifts were filled out with the number of staff who were scheduled to work during that timeframe. The form did not include the actual hours worked for any shift but did include a section titled, Actual Hours worked (# and shift worked). Upon request, the Administrator provided the last 18 months of posted nurse staffing sheets. Review of the sheets revealed none of the sheets included the total number of actual hours worked for RNs, LPNs, and CNAs. A copy of the timeclock punch sheets for 6/8/26 were requested at this time. A comparison of the posted staffing sheet and timesheet clock ins for 6/8/26 was completed with Human Resources (HR) Director P. The total number of CNA staff did not match the timeclock punches provided. When queried why the sheets did not match, Director P responded that a CNA called in and was not taken off the posted staffing sheet. An interview was completed with the facility Administrator on 6/9/26 at 4:25 PM. When queried why the nurse staffing information was not posted in a visible area where all residents, staff, and visitors would be able to see it, the Administrator indicated they were advised to post it there previously. When queried regarding the posting not including the actual hours worked and total number of staff worked as required, the Administrator indicated they were unaware of the Federal Regulation requirements for the posting. When queried who is responsible for updating the posting if there are call ins and/or staffing changes, the Administrator revealed either they update it or a manager. When queried regarding the posted staffing information for 6/8/26, the Administrator did not provide further explanation. When queried regarding accuracy of posted staffing data, the Administrator verbalized understanding.

This Citation pertains to Intake Numbers 2575723 and 2589048. Based on interview and record review, the facility failed to operationalize procedures to ensure a timely response, appropriate coordination of care, and comprehensive/accurate documentation for a change in condition for one resident (Resident # 701) of three residents reviewed, resulting in a lack of comprehensive assessment, a lack of coordination with Hospice services and unnecessary pain.Findings include:Resident #701:A review of intake documentation revealed a concern that the facility did not coordinate care in a timely manner with Hospice when Resident #701 experienced a change in condition and a decline, resulting in prolonged and unnecessary pain and discomfort prior to their death in the facility on 08/12/25.An interview was completed with Hospice Registered Nurse (RN) A on 8/20/25 at 9:00 AM. When queried regarding Resident #701, RN A revealed they were the Resident Hospice nurse. RN A was asked about the Resident's care in the facility and revealed they had seen Resident #701 on Tuesday 8/5/25. RN A verbalized they were concerned with Resident's pain level and spoke to the facility Physician regarding medication adjustments. RN A verbalized saw Resident #701 on 8/6/25 to follow up and make sure the medication changes were effectively managing their pain. RN A then stated, I didn't hear back from the facility until Monday (8/11/25) at approximately 9:00 PM when the facility requested a nurse visit. RN A verbalized when they arrived in Resident #701's room, the Resident was in bed on their left side in the fetal position. RN A stated, (Resident #701) was very stiff, guarding, had facial grimacing, and moaning. RN A stated the Resident felt hot and they had a temperature. RN A was asked if Resident #701 was able to rate their pain using a numeric scale and indicated they were not. RN A stated, PAINAD (pain level using a scale to assess and measure pain levels in individuals with cognitive impairments) was a nine (out of 10 with 10 being the highest) for me. When queried if the facility nurse was present in the room and/or spoke to them, RN A replied (Licensed Practical Nurse [LPN] C) greeted me and went back to (passing) meds. When queried if LPN C went into Resident #701's room with them, RN A indicated they did not but did speak to them regarding the Resident. When asked what they were told by LPN C, RN A replied, When (LPN C) came in (at 6:00 PM), the day shift nurse had them go in (Resident #701's) room because they had been vomiting. When queried if LPN C provided any other information such as the number and volume of Resident #701's emesis, RN A responded they asked LPN C additional questions and were informed they did not know how many times on day shift because they were not told. RN A verbalized LPN C told them Resident #701 had vomited around 6:00 PM when they started their shift and again around 8:50 PM and told them they were not sure if it was vomit or chocolate pudding. When asked if the substance was vomit or chocolate pudding, RN A responded that the Resident had vomited, and the vomit had also come out of their nose. RN A then stated, There was still vomit (on Resident #701) when they arrived to assess the Resident and provide care.When queried if the Resident had vomited again, RN A revealed they could not say for certain but there was both hardened and moist dark brown colored emesis on the Resident's face, arms and the bedding. RN A verbalized they started to clean Resident #701 up and called the Certified Nursing Assistant (CNA) to assist. When asked if nausea/vomiting was new for Resident #701, RN A replied, (Resident #701) has a long history of coughing when they eat. RN A revealed the Resident had choose Hospice care because they did want feeding tube placement and had difficulty swallowing following their stroke. RN A verbalized Resident #701's illness was terminal, but their concern was that Hospice was not notified of the change in condition sooner. RN A disclosed they spoke to CNAs at the facility and were informed that Resident #701's condition had worsened over the weekend and Hospice was not notified. When asked, RN A stated, (CNA D) told me they noticed (Resident #701) wasn't in the dining room the day before (Sunday) and said something to (CNA E) and (CNA E) told them that (Resident #701) was end of life and not getting out of bed. RN A stated, (CNA F) said (Resident #701) was coughing worse on Saturday and it wasn't fair to the other residents in the dining room. RN A verbalized Resident #701's illness was terminal, but their concern was that Hospice was not notified of the change in condition sooner. RN A stated, (Resident #701) was covered in vomit and in so much pain. It took so much pain med to make them comfortable. Nobody deserves to suffer and die like that. That is what we (Hospice) are here for. All they (facility) had to do was call. RN A revealed Resident #701 passed away at 4:00 AM. Record review revealed Resident #701 was admitted to the facility on [DATE] with diagnoses which included heart failure, weakness, and cerebral infarction (stroke) with resulting dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required maximum to total assistance to complete Activities of Daily Living (ADLs). Further review of Resident #701's Electronic Medical Record (EMR) revealed the Resident was admitted to Hospice services in April 2024.Review of Resident #701's EMR revealed the following progress note and assessment documentation from 8/8/25 to 8/12/25:- 8/11/25 at 10:03 PM: Health Status Note. Hospice nurse at facility and assessed resident, new order: increase Morphine (narcotic pain medication) 20mg (milligrams)/mL (milliliter), give 0.5 mL PO (orally) Q (every) 2 (hours) scheduled, may give 0.5 mL PO Q 1H (hour) as needed for pain. Ativan (antianxiety) 0.5 mg tablet, Give one tablet PO Q4H as needed for anxiety/restlessness.- 8/12/25 at 4:20 AM: Health Status Note. Res without resp, pulse. Two LPN's verified that time of death 0400. Family at res bedside and aware of passing.A review of Resident #701's Documentation Survey Report for August 2025 revealed the following:- Resident #701's last bowel movement was on 8/7/25.- Documentation for the task Locomotion - high back wheelchair revealed the Resident did not get up into the wheelchair at all on 8/10/25 and 8/11/25.- Resident #701 did not eat any food on 8/11/25 when they had eaten a percentage of two to three meals on all other days during the month.- Resident #701 refused their PM/HS (bedtime) Snack on 8/9/25 at 9:04 PM, 8/10/25, and 8/11/25.Review of Vital Sign documentation in Resident #701's EMR revealed the Resident's vital signs including temperature were taken sporadically with no discernable pattern. Review revealed Resident #701's temperature was taken on 8/11/25 at 12:02 PM using a forehead (non-contact) thermometer. The temperature reading was documented as 97.3 degrees Fahrenheit (F). The Resident's documented temperature prior to that was also 97.3 F on 7/28/25 at 10:07 AM.An interview was completed with CNA G on 8/20/25 at 2:00 PM. When queried regarding Resident #701, CNA G revealed they were not working when the Resident passed and stated, (Resident #701) had been declining rapidly. CNA G was asked what declining rapidly meant and stated, Coughing more and not eating as much. With further inquiry, CNA G revealed the Resident had been declining slowly and had seemed to worsen quickly the weekend before they passed.On 8/20/25 at 2:10 PM, an interview was conducted with CNA E. When queried if they had provided care to Resident #701, CNA E stated, I worked the shift before they passed. They passed that night shift. When queried if Resident #701 usually gets up in their wheelchair to eat in the dining room, CNA E replied, We usually go in and get (Resident #701) up first due to the level of assistance needed. When asked if Resident #701 got up and went to the dining room on 8/11/25, CNA E stated, No, they kept falling back asleep. CNA E then stated, (Resident #701) only needed to changed three times that day. When asked, CNA E clarified that the Resident only had three wet briefs all day which was abnormal for them. When asked if they told the nurse, CNA E stated, I did. CNA E was asked what the nurse said and revealed they did not provide any additional instruction. When queried if they told anyone that Resident #701 was at the end of life, CNA E stated, I did. I told the nurse and the other CNA. CNA E was asked if Resident #701 seemed to be in pain during their shift and replied, Yes, when I rolled (Resident #701), they were in a lot of pain. When queried if Resident #704 vomited during their shift, CNA E replied, Yes, right before shift change. CNA E continued, The hall was crazy, and I kept trying to clean (Resident #701) up. I told the next CNA. When asked if they were saying they did or did not clean the vomit off of Resident #701, CNA E replied, I couldn't get it off. CNA E was asked why they could not get the vomit off of the Resident and replied, It was like chocolate pudding, and it was stuck. It was sticky. CNA E was asked if the Resident had a beard that the substance was stuck in and responded they did not. When queried if Resident #701 ate chocolate pudding that day, CNA E indicated the Resident takes their medications in pudding. When queried how many times they went into Resident #701's room to clean the vomit, CNA E replied, Not sure. I kept getting pulled to do something else. When asked if Resident #701 had vomited more when they went back in their room, CNA E replied, I couldn't tell you. It looked like the same amount every time I went in.Review of facility provided investigation documentation pertaining to Resident #701 included the following:- Resident #701's face sheet, care plan, and current orders at time of death and CNA P.- Typed Statement from CNA L dated 8/20/25. The statement detailed, 8/20/25 Interview statement. I took care of resident on 8/9/25, Resident was not feeding self in the morning, and I started to feed them, and food was running out of their mouth, so I stopped. Later in the shift resident was given something from the nurse by mouth and they did not eat lunch. There were not other change in condition noted. The statement was signed by the Director of Nursing (DON) and Facility Administrator.- Typed Statement from CNA P dated 8/20/25. The statement detailed, 8/20/25 Phone Interview. I never told (Hospice Staff) that resident had a change over the weekend. I was not even (Resident #701's) aide. The statement was signed by the Director of Nursing (DON) and Facility Administrator.- Typed Statement from Hospitality Aide M dated 8/20/25. The statement detailed, 8/20/25 Interview statement. I worked with resident on 8/10/25. I noticed resident was tired and they did not eat very much that day. But, they did not vomit. There was nothing out of the ordinary that I remember seeing. The statement was signed by the Director of Nursing (DON) and Facility Administrator.- Typed Statement from Registered Nurse (RN) H dated 8/15/25. The statement detailed, 8/15/25 Interview Statement. According to (RN H) on 8/12/25 (Resident #701) had no increased change in condition during their day shift. (RN H) stated, ‘(Resident #701) ate and had chocolate pudding around their mouth in the afternoon and I had to provide oral care and instructed my aide to also provide oral care.' When (RN H) was asked if resident was vomiting or has any significant change in condition, stated, ‘no, (Resident #701) was normal self.' (RN H) was asked if there as anything else that stood our that the day with (Resident #701) and stated, ‘no, I checked on them several times throughout the day.' No further questions at this time. The typed statement was signed by the DON and facility Administrator.Note: RN H did not provide care to Resident #701 on 8/12/25.- Written and Signed Statement from RN N (no date): Writer was nurse for patient 8/8/25 -8/10/25. I did not notice anything unusual in regards to resident expect on Sunday 8/10/25 resident had increased secretions after dinner to which I performed moth care and resident wanting to lay down adamantly. Aide laid resident down. Checked on resident numerous times throughout night due to increased secretions. Resident was at baseline.- Written and Signed Statement from LPN O dated 8/12/25: I, (LPN O) did not care for (Resident #701). I went into resident's room and resident was passed. (Family member) was present.A review of the requested schedule/assignment sheet and Medication Administration Record (MAR) for 8/10/25 revealed the staff assigned to care for Resident #701 on day shift were CNA M and LPN I and CNA R and RN N on night shift.A review of the requested schedule/assignment sheet for 8/11/25 revealed the staff assigned to care for Resident #701 on day shift were CNA E and RN H and CNA Q and LPN C on night shift.Review of Resident #701's MAR for August 2025 revealed documentation for Pain - Evaluate Pain every shift for Pain Evaluation. The MAR specified all Resident #701's documented pain levels were one out of 10 (with 10 being the highest) on 8/11/25 Day shift and zero out of 10 on 8/11/25 Night shift.Further review of the MAR revealed that on 8/11/25, Resident #701 received the following:- 10 milligrams (mg) of morphine at 1:00 AM for a pain level of three out of 10- 10 mg of morphine at 5:00 AM for a pain level of five out of 10- 10 mg of morphine at 9:00 AM for a pain level of one out of 10- 10 mg of morphine at 1:00 PM for a pain level of five out of 10- 10 mg of morphine at 5:00 PM for a pain level of five out of 10- 10 mg of morphine at 9:00 PM for a pain level of zero out of 10- 10 mg of morphine at 10:00 PM for a pain level of four out of 10- 10 mg of morphine at 10:15 PM (no pain level documented)- 20 mg of morphine at 10:30 PM for pain level of four out of 10Per the MAR on 8/12/25, Resident #701 received:- 10 mg of morphine at 12:00 AM for a pain level of four out of 10- 10 mg of morphine at 2:00 AM for a pain level of one out of 10Review of Resident #701's EMR revealed a care plan entitled, (Resident #701) receives hospice services. (Initiated: 4/23/24). The care plan included the intervention, Notify (Hospice Company). for changes in condition.An interview was completed with LPN C on 8/21/25 at 9:30 AM. When asked if they took care of Resident #701 the night they passed, LPN C replied, I did. LPN C was asked what happened and revealed they received report from Registered Nurse (RN) H. LPN C stated, (RN H) told me they didn't know what was going on or what was on (Resident #701's) face so we went in (Resident #701's) room together. LPN C added, (RN C) said it was coming out of (Resident #701's) nose too. When asked what happened, LPN C replied, We cleaned (Resident #701) up and I started my med pass. LPN C was queried regarding their observations when they went into Resident #701's room with RN C and replied, Just looked like it was coming out of their mouth. LPN C stated, After we cleaned (Resident #701) up, they were on their side, and I could tell it was out of their nose too. Their nose and mouth. LPN C revealed RN C told them they thought it was chocolate pudding because that was something the Resident #701 liked to eat and the color was the same. LPN C stated, Later when I figured out that it wasn't food the day shift was already gone. With further inquiry, LPN C stated, It was just strange that (Resident #701) was in bed. (Resident #701) was never really in bed. LPN C revealed Resident #701 was usually up and would always try to get into the water that they couldn't have because they were on thickened liquids. LPN C indicated they went back to check on Resident #701 and stated, I went back and noticed (Resident #701) was still having that drainage. I needed some help trying to figure out what to do for (them). When asked if that is why they called Hospice at that time, LPN C stated, To me it looked like a change in condition for (Resident #701) and that is why I called hospice.An interview was completed with RN H on 8/21/25 at 11:08 AM. When queried if they were Resident #701's nurse on 8/11/25 during the day shift, RN H confirmed they were. RN H was asked if they recalled who they gave nurse to nurse report to and replied, (LPN C). When asked if they went to Resident #701's room with LPN C when they gave report, RN H replied, Can't honestly say. When queried if Resident #701 vomited that day, RN H replied, (Resident #701) coughs and had chocolate pudding around their mouth. RN H then stated, The CNA and I worked and got (Resident #701) cleaned up. When asked if they cleaned up Resident #701 with the CNA or with LPN C, RN H repeated it was the CNA. When asked if they knew the CNAs name, RN H described CNA E. RN H was informed of CNA E stating the substance was sticky and they were unable to clean it off the Resident. When asked if they recalled that, RN H replied, No. When queried if Resident #701 ate on 8/11/25, RN H revealed the Resident did not eat breakfast and stated, We just attributed it to the time of the day. When asked if the Resident ate anything for lunch, RN H replied, I don't know. RN H was asked why they assessed Resident #701's temperature on 8/11/25 and revealed they did not remember. When queried when they would contact Hospice, RN H stated, A change in condition. RN H was asked if Resident #701 not eating not eating for a day, vomiting, and not having a bowel movement for four days would constitute a change in condition, RN H did not provide further explanation.On 8/21/25 at 11:44 AM, an interview was completed with LPN I. When queried regarding Resident #701, LPN I responded they had taken care of the Resident the weekend prior to their passing. When queried if Resident #701 had any vomiting over the weekend, LPN I stated, No. When asked if there was anything different with the resident over the weekend, LPN I stated, (Resident #701) did have some muscle spasms that were intermittent. When queried if the Resident had increased coughing, LPN I revealed they did and stated, (Resident #701) would cough and cough and food would just run out of their mouth. An interview was completed with Witness K on 8/21/25 at 11:50 AM. When queried regarding Resident #701, Witness K revealed they were contacted by the Hospice nurse to come to the facility. Witness K revealed they live approximately 15 minutes away from the facility and came immediately. Witness K was asked about the Resident's condition when they arrived to the facility and stated, When I got (to facility), (Resident #701) was in a fetal position and moaning in pain. Then (the Resident) started to cough up stuff. Witness K continued, (Resident #701) looked awful, looked like a skeleton and their color was horrible.An interview was attempted to be completed with CNA D on 8/21/25 at 12:03 PM and 3:47 PM. CNA D's voicemail was full and a text message with sent with a return phone call requested. CNA D sent a return text message on 8/21/25 at 3:52 PM specifying they would return to work on Tuesday of next week and indicated they were unavailable for interview with State Surveyor.An interview was completed with CNA F on 8/21/25 at 12:05 PM. When queried if they worked the weekend of 8/9/25 and 8/10/25, CNA F confirmed they did. CNA F was asked about Resident #701 that weekend and stated, I wasn't on that side of the building so didn't work with (Resident #701). When queried if they remembered seeing the Resident in the dining room and/or anything unusual, CNA F replied, Not that I recall.On 8/21/25 at 12:07 PM, an interview was attempted to be completed with CNA J. A voice mail message was left with a return phone number. A return phone call was not received by the conclusion of the survey.Review of Resident #701's Hospice Provider documentation revealed the following:- 8/11/25: In Home Time. 9:08 PM. Temperature 103.6 (F). Temporal. Pulse: 129. Oxygen Saturation. 70 (%) (Normal - 92- 100 %) . Pain. 9 (out of 10) . Pain. Noisy Labored Breathing. Occasional Moan or Groan. Facial Grimacing. Knees Pulled Up. Unable to Console, Distract, or Reassure. Total Score (Pain): 0. Severe Pain. Cardiovascular. Arrhythmia, Pallor. Tachycardiac, Irregularly irregular. Narrative: RN PRN (as needed) visit. Upon arrival to facility greeted by (LPN C). (LPN C) stated that (Resident #701) had been having brown emesis throughout day starting on day shift. (LPN C) was unsure of how many but knew (Resident #701) had one at 6:00 PM and one at 8:45 PM. (LPN C) stated, ‘(Resident #701) had a chocolate pudding at dinner so I didn't know if that was that.' (Resident #701) laying on side with knees pulled up to chin. Elevated resp. rate. Noisy respirations, Facial Grimacing, Unable to consol or distract. [NAME] emesis in mouth, nose, on face, on arms, and on bedding. Writer started cleaning (Resident #701's) face and hands and put on call light to call CNA for assistance. (Resident #701) hot to touch. Vital signs assessed. HR (Heart Rate) 130, TEMP 103.6, O2 (oxygen saturation) 70% ON RA (Room Air). Respiratory Rate 36 (normal 12-20). Lungs with crackles (abnormal) heard at bases. CNAs arrived to take over cares. Left room to call (Family). Notified (Physician) of condition and received new orders to increase (morphine). and increase Ativan (controlled medication for anxiety) . HOB (Head of Bed) elevated and cool cloth placed on forehead. (Resident #701) continued with rapid noisy respirations. Reminded. (LPN C) to call hospice if (Resident #701) remains uncomfortable or with any needs or concerns during night.An interview was completed with the Director of Nursing (DON) on 8/21/25 at 1:09 PM regarding Resident #701. Why asked why they did not interview the assigned staff working the on the day shift prior to and on the shift when the Resident passed as part of their investigation, the DON replied, (LPN C) called to let me know (Resident #701) was passing and let me know when they passed. The DON was then asked if not eating for a day would be considered a change in condition and replied, Not for (Resident #701). They were non-compliant with their diet. The DON did not provide an explanation when queried regarding Resident #701's intake documentation specifying they ate one to two meals a day previously during August 2025. When asked how frequently temperatures are obtained for Hospice patients, the DON replied, Only when requested. When asked why RN H took Resident #701's temperature on 8/11/25 at 12:02 PM, the DON replied, Not sure why checked. The DON was then informed of interviews completed with LPN C and RN H. When queried regarding the discrepancies in the interview statements, the DON was unable to provide an explanation. When asked what pain scale was used for Resident #701, the DON replied, PAINAD if (Resident #701) can't talk to you. The DON then stated, (Resident #701) would be able to tell you. The DON was then queried regarding the discrepancy between the pain level documented by the facility and the pain level documented by hospice on 8/11/25 and replied, That would be my word against theirs. When asked about the lack of documentation in the EMR related to the reason Hospice was contacted, the DON did not provide an explanation. The DON then stated, (Hospice Nurse) is also very aggressive with pain meds. When queried regarding the amount of morphine Resident #701 received to control their pain on 8/11/25 and the documented physical assessment of the Resident by the Hospice provider, the DON did not provide further explanation.An interview was completed with CNA Q on 8/21/25 at 3:49 PM. When queried if they were Resident #701's CNA when they passed, CNA Q confirmed they were. CNA Q was asked what happened and replied, I got report that (Resident #701) was declining. (Resident #701) wasn't eating and was getting worse. With further inquiry, CNA Q stated, (Resident #701) had not ate at all that day. CNA Q was asked if Resident #701 had gotten out of bed that day (8/11/25) and stated, I don't believe so. When queried if the CNA they received report from told them Resident #701 had vomited during the day, CNA Q replied, I believe so. When asked if they went to Resident #701's room first after getting report or if they had other things to do first, CNA Q replied, Had other stuff to do. CNA Q was then asked if Resident #701 have vomited during their shift and stated, Yeah. When asked how many times the Resident vomited, CNA Q replied, I think once for me. I let the nurse know. CNA Q continued, The nurse came in. (The Nurse) said there was something all over (Resident #701's) face and I had it wipe it off and then it started coming out of (Resident #701's) nose. CNA Q was asked if the substance on Resident #701's face was the same substance that started coming out of their nose and replied, Yes. CNA Q added, The nurse didn't know what it was, so they called the hospice nurse. CNA Q was asked if they had ever observed Resident #701 have that substance on their face in the past and stated, No, not like that. It was stuck. When queried if Resident #701 displayed signs and symptoms of pain when they were cleaning them up, CNA Q replied, Yeah, a bit. (Resident #701) was like moaning a flinching. When queried if they had taken care of Resident #701 recently prior to their passing, CNA Q verbalized they had but was unable to recall a specific date. CNA Q stated, (Resident #701) was a lot better than that. They were eating and was (getting) up. When (Resident #701) started not wanting to feed themselves, we knew they were declining. CNA Q was asked if they recalled anything else and stated, I remember when the hospice nurse came in, (Resident #701) was running a fever and when we rolled (the Resident), they were just screaming in pain. When queried if Resident #701's skin felt hot when they touched them, CNA Q replied, Yes, very hot. CNA Q was asked if they informed the nurse and replied, Yeah. CNA Q then stated, It was the hospice nurse who said to take (Resident #701's) vitals.Review of facility policy/procedure entitled, Change in a Resident's Condition or Status (Revised: February 2021) revealed, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an). d. significant change in the resident's physical/emotional/mental condition; e. Need to alter the resident's medical treatment significantly; f. refusal of treatment or medications two (2) or more consecutive times) . 2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b. impacts more than one area of the resident's health status; c. requires interdisciplinary review and/or revision to the care plan. 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.Review of facility provided policy/procedure entitled, Hospice Program (Revised July 2017) revealed, Hospice services are available to residents at the end of life. 9. In general, it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions, including the following: a. Determining the appropriate hospice plan of care. c. Providing medical direction, nursing and clinical management of the terminal illness. e. Providing medical supplies, durable medical equipment, and medications necessary for the palliation of pain and symptoms. 10. In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. These responsibilities include the following: a. Twenty-four-hour room and board care; b. Administering prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care; c. Notifying the hospice about the following: (1) A significant change in the resident's physical, mental, social, or emotional status. (2) Clinical complications that suggest a need to alter the plan of care. (4) The resident's death. d. Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day.

Based on observation, interview and record review, the facility failed to store medications, medical supplies, labeling and storage in 3 of 4 medication carts and 1 of 2 medication rooms, resulting in a medication cart being left unlocked and unattended, a lack of dating of multi-dose medications after opening, and the potential for residents to receive medications with altered efficiency. Findings include: Record review of the facility 'Medication Storage' policy dated ,d+[DATE], revealed (C.) Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmic, nitroglycerin tables, blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. (D.) When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. (1.) The nurse shall place a 'Date opened sticker on the medication and enter the date opened and the new date of expiration (NOTE: the best stickers to affix contain both an open date and expiration notation line). The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating. Observation on [DATE] at 10:07 AM with Registered Nurse D of the A-B hall medication cart: Resident medications were reviewed for the following residents: Resident #211 had medications of Cirpofloxin sol 0.3% eye drop multi-dose bottle, opened [DATE] with no expiration date. Multi-dose bottle of Fluticasone 50mcg/act nasal spray open date [DATE] with no expiration dates. Resident #210 had a multi-dose bottle of Fluticasone 50mcg nasal spray opened and [DATE] with no expiration. Resident #2 had a multi-dose bottle of Fluticasone 50 mcg/act open date [DATE] with a second bottle of Fluticasone 50 mcg/act open date [DATE] and neither bottle had an expiration date. Resident #209 had a multi-dose LISPRO insulin pen with open date with no expiration date noted on pen or package and a Lantus insulin pen Opened with no open or expiration dates on pen or package. Resident #6 had a multi-dose Novolog insulin pen opened [DATE] with no expiration date. Resident #12 had two Lantus insulin pens, one open dated [DATE] and one open dated [DATE], and an Aspart insulin pen open dated [DATE], there were no expiration dates on the pens. Resident #31 had two Novolog insulin pens with open dates of [DATE] and [DATE], with no expiration dates. Observation of the medication carts Second drawer noted loose tablets of large white tablet and a peach oval small tablet. Observations on [DATE] at 10:23 AM with Licensed Practical Nurse (LPN) K of the C-hall Cart1 revealed: Resident medications were reviewed for the following residents: Resident #22 had Ofloxacin 0.3% eye drops with no lid on dropper bottle. No expiration dates or open date on bottle or package. Atropine sulfate 1% Ophthalmic ointment open date with no Expiration date. Erythromycin 5mg/ml Ophthalmic ointment open dated with no expiration date. Timolol 0.5% solution/drops Polymyxin trimethp ,d+[DATE].1% eye drop open date of [DATE] with no expiration date. Resident #7 had multi-dose Lantus insulin open date [DATE] with no expiration date. Resident #108 had multi-dose NovoLog insulin pen open dated [DATE] with no expiration date. Resident #25 had multi-dose Liraglutide 18mg/3ml injection pen opened [DATE] with no expiration date. Resident #37 had multi-dose Liraglutide 18mg/3ml pen open dated [DATE] with no expiration date. Resident #3 had multi-dose Humalog insulin pen opened dated [DATE] with no expiration date. Resident #9 had Ipratropium 3ml multi-doses ampules not in foil packet and not dated 30 pack with 4 loose ampules in the cart. Resident #21 had an Arnuity Ellipta 200mcg aerosol device open dated [DATE] with no expiration date noted on device or baggie. Observation on [DATE] at 08:04 AM of the D-E Hall medication cart with Licensed Practical Nurse (LPN) F revealed that Ipratropium Bromide solution inhalation ampules a 30-foil packet with ampules missing one loose ampule noted out of the baggie. Observation on [DATE] at 12:17 PM with Licensed Practical Nurse (LPN) E of C-hall Medication cart was left unlocked with computer open to screen, of medical information of Resident #3 . In an interview on [DATE] at 10:12 AM with the Director of Nursing related to the Medication administration and storage concerns, the DON stated that Licensed Practical Nurse (LPN) E did let the DON know that the medication cart was noted to be unlocked in the hallway. Record review of the facility 'Preparation and General Guidelines Medication Administration' policy dated ,d+[DATE], revealed (16.) .medication cart is kept closed and locked when out of sight of the medication nurse . 49944 On [DATE] at 07:52 AM, observation of the Side 1 medication room revealed: -Three bottles of expired povidone iodine, expired ,d+[DATE]. -One bottle of Microdot bleach wipes expired [DATE]. These findings were verified with Unit Manager (UM) E and Licensed Practical Nurse (LPN) C

Based on observation, interview and record review, the facility failed to implement and operationalize procedures to ensure proper sanitization and food handling processes in the kitchen for 57 of 57 Residents who eat food prepared in the kitchen, resulting in the potential for contamination, consumption of expired food items, and food borne illness, Findings include: A tour of the facility kitchen was completed on [DATE] at 10:00 AM. An entrance to the kitchen was located in the main resident dining room. The door was locked and was opened by Dietary Staff V after knocking. There were no hairnets present outside or directly inside of the entrance door. When queried regarding hairnet location, Staff V indicated they were located at the other entrance, located off the employee hallway and proceeded to obtain and provide a hairnet. Upon entering the kitchen, a handwashing sink was not seen. When queried where staff wash their hands upon entering the kitchen, Staff V directed this Surveyor to a sink located in the dishwashing area of the kitchen. Staff W was observed in the dishwashing area of the kitchen, doing dishes, and not wearing a hairnet. Staff W exited the kitchen. A shelf was present near the hallway entrance doors with multiple uncovered and opened beverages, including open cans, sitting on the top shelf. When queried regarding the beverages, Staff V stated, They are ours. Staff V was asked to clarify if they were saying the open beverages were the kitchen staffs, and confirmed they were. When queried if they are supposed to have opened beverages there, Staff V responded that is where they were told to put them. When queried who was in charge of the Kitchen at this time, Staff V indicated Staff U. Staff U was observed sitting in the kitchen office. At 10:05 AM, Staff W was observed reentering the kitchen. Staff W did not wash their hands prior to entering the food preparation area and touching food items. Stacked bowls and plates were noted in the kitchen on a shelving unit. Moisture and liquid were observed and felt in the stacked bowls. When asked, Staff U confirmed the bowls were not dry and stacked together. When asked if the bowls should be stacked when they are not completely dry, Staff U verbalized dishes should be completely dry before being stacked. Small plates were stacked next to the bowls. Moisture was felt on the stacked plates when touched. Staff U was asked about the plates and confirmed they felt damp. A container of Whipped Spread (Expiration Date ,d+[DATE]) was sitting on the food preparation table. When asked if the whipped spread was supposed to be sitting out, Staff U stated, Should have been put away. The food preparation table was observed to be dirty with significant amounts of unknown food substances and crumbs on it. A cleaning/sanitizer bucket was not observed. When asked where the cleaning/sanitixing bucket was, Staff U revealed it was kept in the dishwashing area and pointed out where the bucket was. When asked how staff confirm the level of sanitizer in the bucket, Staff U obtained chemical testing strips. Upon request, Staff U testing the level of sanitizer present in the bucket. The sanitizer level was zero parts per million (ppm). When asked what the level of sanitizer is supposed to be, Staff U replied, Supposed to be at 400 (ppm). The following items were present in the reach-in refrigerator: - One gallon container of Peppermill Honey Dijon Mustard Dressing, Open and Undated - Package of ham, Labeled as expired on [DATE] - Five-pound container of Sour Cream, Labeled as expired [DATE] Within the dry food storage area, two 48-ounce bottles of canola oil were expired. When queried, Staff U removed the items from service. The following items were observed in the upright freezer in the dry storage area: - The individual serve ice cream cups were not frozen solid to touch. When queried regarding the individual cups feeling squishy and soft, Staff U confirmed the cups did not feel frozen solid to touch. - A package of diced chicken. Labeled as expired [DATE]. - A package of pork roast was in a plastic bag, covered in ice, and freezer burnt. - A package of beef roast was in a plastic bag, covered in ice, and freezer burnt. Staff U was asked about the diced chicken and confirmed it was expired and should have been removed from the freezer. When queried regarding the port and beef roasts. Staff U verified both were covered in ice and freezer burnt. When asked if there had been any problems with the freezer, Staff U replied, Not that I know of. A thermometer was not observed inside of the freezer. When queried how staff monitor the temperature, Staff U verbalized the temperature reading on freezer door is documented. The following items were noted in the walk-in refrigerator: - A white colored, greasy textured substance was present on the tops of the one-gallon containers of Whipped Topping. - A box of 15 dozen grade A eggs was sitting on the floor on the right side of the door. Open ,d+[DATE] (2025) and Use By ,d+[DATE] (2025) was written on the side of the box with a sharpie style marker. The manufacturer label on the box specified the expiration date for the eggs was [DATE]. - A package of thawing ham was sitting on top of a box on the bottom shelf of the refrigerator. The door to the walk-in freezer was in the walk-in refrigerator. Upon entering the walk-in freezer, there were multiple boxes of frozen food sitting directly on the floor of the freezer. The freezer condenser was covered in ice and had leaked onto the shelving unit below. Large icicles were present on the shelving unit below the condenser. The boxes of food on the floor prohibited movement and entry into the freezer. A tour of the walk-in refrigerator and freezer was then completed with Staff U. When queried regarding the substance on the Whipped Topping containers, Staff U checked the containers and revealed they believed it was whipped topping. When asked if one of the containers had leaked, Staff U stated they were making lunch and will check when they are done. When asked about the ham on the top of the box of produce, Staff U confirmed the meat was thawing. When asked if it is the normal procedure to place thawing meat on top of a box, Staff U replied, It depends on the space situation. When asked if thawing meat should be on top of something else, Staff U replied, No. Staff U was then asked what the expiration date was of the box of 15 dozen eggs and stated, [DATE]nd. When queried regarding the manufacture expiration date of the eggs, Staff U reviewed the label and stated, [DATE]rd. When queried regarding the date written on the box, Staff U explained staff write a use by date on the box. Staff U was asked when the eggs should be used by and indicated [DATE]. Staff U stated manufacturer expiration date trumps. When queried regarding the items on the floor in the freezer, Staff U stated the food was delivered on Friday and it had not been put away yet. When queried regarding the ice build up in the freezer, Staff U revealed Maintenance staff defrost the freezer, and they were unaware of the schedule. At 10:50 AM on [DATE], the facility Administrator entered the kitchen. The Administrator was observed donning a hairnet inside the dishwashing area of the kitchen, near the dishwasher where the clean dishes were left to air dry after going through the dishwasher. The Administrator was asked about the open and uncovered employee beverages sitting on the shelf in the dishwasher area of the kitchen and responded that is where supposed to put them. A tour of the kitchen was completed with the Administrator at this time. The food preparation table remained visibility soiled with the same food materials as previously observed. Staff V was preparing items for resident lunches on the table. The food substances were pointed out to the Administrator, and they were informed of prior observation. When asked, the Administrator verbalized the table should have been cleaned and asked Staff U to clean the table. When queried regarding the wet stacked bowls, the Administrator did not provide an explanation. The Administrator was then taken to the upright freezer and informed of individual ice cream cups not feeling frozen solid as well as expired and freezer burnt food items. When queried if a second thermometer should be present inside the freezer to confirm temperature, the Administrator replied there should be and opened the freezer to look for a thermometer. The Administrator was unable to locate a thermometer in the freezer. The Administrator was then shown the walk-in refrigerator and freezer. When queried regarding the ham on top of the produce box, the substance on the whipped topping containers, and the date on the eggs, the Administrator did not provide an explanation. When asked about the food items on the floor in the freezer as well as the icicles and ice build, an explanation was not provided by the Administrator. Upon preparing to exit the kitchen, the Administrator removed their hairnet and threw it away in the garbage located by the handwashing sink on the clean dishes side of the dishwashing area and then proceeded to walk past the clean dishes towards the exit door. When queried if hairnets are required to be worn upon entering the kitchen, the Administrator responded that hairnets do not need to be worn until going into the food preparation and cooking area of the kitchen and were not required in the dishwashing area of the kitchen. An interview was conducted with the Director of Nursing (DON) and Infection Control (IC) Licensed Practical Nurse (LPN) M on [DATE] at 12:41 PM. When queried if hairnets should be worn in the dishwasher area of the kitchen, the DON asked if staff were not wearing a hairnet. Observations and interviews of staff in the kitchen were relayed to IC LPN M and the DON at this time. The DON responded, Should wear a hairnet and revealed they thought there was a line in the kitchen, at the entry door to signify where hairnets had to be worn after crossing. When queried regarding observations of staff open and uncovered beverages on the shelf in the dishwashing area of the kitchen, the DON verbalized staff should not have personal beverages there. According to the 2022 US Food and Drug Administration Food Code ([DATE] Version), Food employees shall wear hair restrains . that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, clean equipment, utensils, and linens; and unwrapped single-service and single-use articles . Review of facility policy/procedure entitled, Hair Restraints/Jewelry/Nail Polish (Revised 2017) revealed, Policy: Food and nutrition serves employees shall wear hair restraints and bear beards Procedure: Hairnets will be worn at all times in the kitchen . Review of facility policy/procedure entitled, Food Safety Requirements Guideline (Revised: [DATE]) revealed, It is the practice of this facility to provide safe and sanitary storage, handling and consumption of all foods . Safety Precautions . Use proper hand hygiene before and after serving food . Refrigeration . Freezers must keep frozen foods frozen solid. The following are methods to determine the proper working order of the refrigerators and freezers: Document the temperature of external and internal refrigerator gauges . Freezers must be cold enough to keep foods frozen solid to touch . Check for situation where potential for cross-contamination is high (e.g. raw meat stored over ready to eat items). Check the firmness of frozen food and inspect the wrapper to determine if it is intact enough to protect the food .

Based on observation, interview and record review, the facility failed to implement and operationalize a comprehensive Infection Control (IC) program, encompassing outcome and process surveillance including surveillance resulting in lack of accurate and comprehensive infection tracking, surveillance and data monitoring/analysis and failed to ensure a urinary catheter drainage bag was maintained off the floor for one resident (Resident #4) of two residents reviewed resulting in the potential for infection and the likelihood for spread of microorganisms and illness to all 58 facility residents. F indings include: An interview was and review of facility IC data was completed with IC Licensed Practical Nurse (LPN) M and the Director of Nursing (DON) on 4/29/25 at 12:41 PM. When queried, IC LPN M revealed they had been working at the facility for less than a month and had never worked in IC prior to taking their current position. IC LPN M revealed the only IC data they had worked on and were familiar with was for April 2025. The facility IC data provided for April 2025 included a Monthly Infection Control Log (Line List) and an infection mapping tool. The data was reviewed with IC LPN M and the DON at this time. Review of the Mapping tool revealed 21 infections listed comprised of seven UTI (Urinary Tract Infection), nine URI (Upper Respiratory Infection), three skin infections, and two other infections. Review of the Monthly Infection Control Log (Line List) for April 2025 detailed 28 infections which all received antimicrobial treatment for 26 Residents. When queried regarding the discrepancy in the number of infections, IC LPN M replied, Some residents were discharged . When asked if they have a system in place to distinguish/identify if a resident is discharged and/or if they have a room change on the line list and/or mapping tool, IC LPN M revealed they did not. When queried how they would identify potential concerns related to environmental contamination and spread of infection without including the information in their surveillance, IC LPN M verbalized understanding and indicated they would incorporate the information in their surveillance. When asked again about the discrepancy in the number of infections between the line listing and the mapping tool, IC LPN M responded that some residents had multiple infections but only one infection was included on the mapping tool. Review of the line list revealed two residents were listed as having multiple infections. Resident #9 had pneumonia, a UTI, and a yeast infection and Resident #211 had a respiratory infection and conjunctivitis (pink eye). The mapping tool did not designate each of the infections for both residents. IC LPN M was queried further as discrepancy in the number of infections remained, after the residents with multiple infections were excluded and indicated they did not include the residents with prophylactic antibiotics on the mapping tool. Review of the line listing revealed four residents were listed as receiving prophylactic antibiotics. Two out of four residents receiving prophylactic antibiotics were included on the mapping tool. IC LPN M reiterated they were new and must have missed something. IC LPN M also stated they were not done with the IC data for the month. IC LPN M preferred to review April 2025 when asked as it was the only month they had worked with the data. The Monthly Infection Control Log (Line List) for April 2025 did not include any carryover infections from the prior month. When asked if they had any carry over infections, IC LPN M and the DON revealed they were not sure. A review of the Monthly Infection Control Log (Line List) for March 2025 revealed there were seven carryover infections which included respiratory/pneumonia, skin, and UTI. When asked about surveillance and mitigation of potential spread, IC LPN M and the DON verbalized understanding. The Monthly Infection Control Log (Line List) for April 2025 did not include any infections and/or potential infections which were not treated with an antimicrobial medication. When queried regarding surveillance for potential infections, IC LPN M revealed they were not tracking any infection and/or potential infection which was not treated with an antimicrobial medication. The infection mapping tool April 2025 revealed five Residents were marked with the color designated for URI's in one hall of the facility. When asked if they had any concerns when they identified multiple residents in the same area of the facility with the same infection, IC LPN M replied, If I saw a trend I would educate. Comparison of the URI's with the information on the Monthly Infection Control Log (Line List) revealed one resident was listed as having a respiratory infection, two were listed as pneumonia and the resident in room [ROOM NUMBER] had a UTI and not a URI. When queried regarding the colored dots on the map not correlating with the infection type listed on the Monthly Infection Control Log (Line List), IC LPN M reiterated they were new, had not finished for the month, and indicated they made a mistake. The Monthly Infection Control Log (Line List) included headings for name, admitted , room, infection type and date of onset, culture date, organism, and antibiotic resistance, antibiotic and date of onset, and if the infection met criteria. Clinical Registered Nurse (RN) J entered the room at this time. Review of the line listing detailed Resident #14 revealed the Resident was treated with Macrobid (antibiotic) for a UTI. The line listing specified that the Resident began to have symptoms on 4/12/25 and a Urinalysis (UA) was sent on 4/12/25. An organism was not included on the line listing. Upon request for a copy of the UA culture and sensitivity (C&S), IC LPN M indicated they did not have a copy. The DON reviewed the Resident's EMR and stated, No C&S. It was never done. When queried why an antibiotic was started without a C&S, IC LPN M responded that the doctor ordered it. When queried regarding best practice for antibiotic use and treatment, RN J stated, Best practice is to wait for a C&S. When queried regarding antibiotic stewardship, no further explanation was provided. When queried what criteria is used, IC LPN M replied, McGeer. When asked if a risk vs benefit was completed for antibiotic use without a C&S, the DON and IC LPN M revealed there was not. Resident #43 was listed as having a respiratory infection on the line listing. The line listing detailed the Resident began having symptoms on 4/3/25 and a culture was obtained on 4/4/25 which was negative for infection. Per the line listing, the infection met McGeer Criteria, and the Resident received Azithromycin (antibiotic). The line listing did not include signs/symptoms of infection. When queried regarding the Resident's signs and symptoms of infection, IC LPN M stated, Cough and runny nose. They did not meet criteria. The DON then stated, Has a risk vs. benefit note. When queried why an antibiotic was administered for signs and symptoms of a common cold, the staff reiterated that was what the physician ordered. Resident #41 was listed as having facility acquired pneumonia. When queried, the DON verbalized the Resident had came to the facility from the hospital with pneumonia on 3/14/25 and they did not think the Resident fully recovered from it. When queried if a culture was obtained at the hospital, the DON revealed the facility has a difficult time obtaining cultures and results from the hospital. The line list further detailed Resident # 46 was treated for a UTI. Per the line listing, the Resident's symptoms began on 4/14/24, a UA was completed that day, but a C&S was not indicated. The Resident was treated with Keflex (antibiotic) starting on 4/14/25. Review of Resident #46's UA revealed Microscopic (C&S) indicated. When queried why the line listing specified a C&S was not indicated when the UA specified it was, the DON revealed the Resident's medical record and stated, The order does not say to do a C&S if indicated. The order says just collect UA not to do a C&S. The DON revealed the wrong order was entered. When asked why facility staff did not follow up to ensure the C&S was completed and that the appropriate antibiotic was being utilized, an explanation was not provided. When queried regarding process surveillance, IC LPN M indicated they were unsure what that was. When asked if they were completing audits, IC LPN M revealed they had not completed any yet but verbalized they had a hand hygiene audit to complete for the month. When queried regarding concerns and processes identified, Clinical RN J verbalized they were aware of the need for improvement in the IC program and were working with IC LPN M and the DON to implement changes and improve the program. Review of facility policy/procedure entitled, Infection Prevention and Control Program (Dated 2017) revealed, The primary mission is to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . The Infection Prevention and Control Program includes: 1. A system for preventing, identifying, reporting, investigation, and controlling infections and communicable diseases . 3. An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use . 22927 Resident #4: Observation and interview an 04/27/25 at 11:08 AM with Resident #4 stated I got the catheter when I came here to this building, I had a Urinary Tract Infection, and they are giving me some pills for it. I couldn't pee on my own, and I use to do a straight stick catheter. The state surveyor Observed urinary catheter at bedside in privacy bag, with tubing touching/lying on the floor. Observation on 04/28/25 at 12:28 PM of Resident #4 was seated at edge of bed awaiting her noon meal tray. The state surveyor Observed urinary catheter and tubing laying on the floor outside of the privacy bag. Resident #4 stated that she did not know what was going on with the catheter bag. The staff /girls take care of the catheter for me. Observation on 04/28/25 at 12:30 PM Activities aide A brought in her lunch tray, she did not know anything about the urinary catheter. On 04/28/25 at 12:32 PM the state surveyor went to find Licensed Practical Nurse B and returned with the surveyor to Resident #4's room. Both LPN B and state surveyor Observed urinary catheter on the floor outside the privacy bag. LPN B stated I don't know why the catheter was out of the privacy bag and on the floor, I know that Resident #4 doesn't like to get out of bed. LPN B put on gloves and picked up the catheter from the floor with no enhanced barrier PPE put on. ON 04/28/25 12:36 PM Resident #4 stated that she had not been into the bathroom or out of bed.

Based on observation, interview and record review, the facility failed to ensure that the medication error rate was less than 5% when three medication errors were observed from a total of 25 opportunities for two residents (#36, #37) of five residents reviewed. This deficient practice resulted in a medication error rate of 8% and the potential for the risk of adverse medication effects and decreased medication efficacy. Findings include: Resident #37: Observation on 04/27/25 at 10:47 AM of Resident #37's resident room revealed there to be an intravenous (IV) bag of Meropenem 1gm/100ml solution antibiotic mixed and hanging in room dated 4/27/25. Both Residents that resided in the room were noted to be awake and able to answer questions. In an observation and interview on 04/27/25 at 10:51 AM with the Licensed Practical Nurse (LPN) K and state surveyor walked into Resident #37's room and observed the hanging medication on the pole. LPN K stated that she mixed the IV around 6:00 AM-6:30 AM and was going to start it but the resident was sleeping and just left it in the room. In an interview on 04/27/25 at 11:37 AM with Licensed Practical Nurse (LPN) E Unit manager for D-E halls was on call. LPN E stated I was called in because of a staff call-in, or a no-show. I don't usually work the medication carts so I am not very fast at it. Observation and interview on 04/27/25 at 11:53 AM with Licensed Practical Nurse (LPN) E stated it (intravenous medication) was already hung, but not given, its scheduled for 6:00 AM but I administered that bag after 11:00 AM, it is a late dose, and I let the physician know. It was mixed and left on the pole in the resident room, so I gave it to the resident. Observation and interview on 04/27/25 at 11:56 AM with Licensed Practical Nurse (LPN) E were observed to discontinued the Meropenem IV that was administered at 11:15 AM for Resident #37 and stated I am taking it down and flushing the left arm Peripheral Inserted Central Catheter (PICC) line. That medication was due at 6:00 AM. Record review of Resident #37's April Medication Administration Record revealed that Licensed Practical Nurse (LPN) K had signed out the Meropenem IV antibiotic as administered at 6:00 AM. Resident #36: Observation on 4/28/2025 at 8:08 AM of Resident #36's medication administration by Licensed Practical Nurse (LPN) F. Medications of levothyroxine (Synthroid) were administered long with loratadine, Norvasc, Probiotic, cyclobenzaprine, gabapentin, guaifenesin. Resident #36 stated that She was waiting for her breakfast tray to come. Observation of Resident #36 bedside table revealed medication cups with 3 white tablets and a light green tablet in them. Resident #36 stated that the night nurse left those 3 tablets for her last night at bedside. Record review of Resident #36's physician orders with LPN F revealed that there were no orders for Tums antacid as a standing order. Observation and interview on 04/28/25 at 08:10 AM with Licensed Practical Nurse (LPN) F during medication pass of Resident #36 revealed 3 white large tables noted in a medication cup on the bedside table and Resident #36 stated the night nurse last night gave me those to moisturize my mouth and the tums also. The state surveyor and Licensed Practical Nurse (LPN) F observed three white large tablets in the med cup at bedside, and a green tums tablet in another cup at bedside. LPN F removed the 3 tablets and tum's left at the bedside. Record review of the medication computer on medication cart D-E revealed Resident #36 was ordered Xyilomelts one tablet at bedtime. Breakfast tray was delivered to the resident's room. In an interview on 04/28/25 at 08:39 AM with Resident #36 revealed she did already have her breakfast tray, stating they just took it out, breakfast was good this morning. Record review of the 'Nursing 2017 Drug Handbook' page 875, noted levothyroxine medication should be given at the same time each day on an empty stomach, preferably 1/2 to 1 hour before breakfast. In an interview and record review on 04/29/25 at 10:12 AM with the Director of Nursing related to the Medication administration policy- and the medication errors observed. (1.) Meropenem Intravenous antibiotic Mixed by night shift Licensed Practical Nurse (LPN) K at 6 AM, then left hanging in resident room until administered after 11:00 AM by LPN E Unit manager, it was the same medication that was mixed by another nurse. The DON stated that No, never leave a medication for someone else to pass. (2.) Tablets left at bed side by night nurse- The DON stated there should not be any medications left at the bedside. Staff did tell me about that yesterday and I am aware. The nurse was asked about it and educated. Tums given with no orders- the DON stated, that's not the usual practice of that night nurse. (3.) Levothyroxine given at 8:08 AM with breakfast and other medications- The DON stated that will make the levothyroxine in effective. Yes, we could educate the resident on the effects of levothyroxine and document it. Record review of the facility 'Preparation and General Guidelines Medication Administration' policy dated 5/2022, revealed medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally to do so. Administration: (7.) the person who prepares the dose for administration is the person who administers the dose. (12.) Medications are administered with in 60 minutes of scheduled time, except before, with or after meal orders, which are administered. Unless other wise specified by the prescriber, routine medications are administered according to established medication administration schedule for the facility. (16.) .medication cart is kept closed and locked when out of sight of the medication nurse .

Based on interview and record review the facility failed to ensure that arbitration agreements were explained in a manner that can be understood for three residents (R9, R35, R213) and 6 of 6 residents in resident council reviewed for arbitration agreements, resulting in residents being unsure of what they signed and agreed to. Findings include: On 04/27/25 at 10:06 AM, an interview was conducted with the nursing home administrator (NHA). The NHA was asked if the facility offers binding arbitration agreements to the residents. The NHA stated they do offer them, and they believe that most of the residents in the facility have signed and agreed to them. A list of residents who had signed the agreement was requested. On 04/28/25 at 08:13 AM, an interview was conducted with Admissions Director G. Admissions Director G was asked to explain the process that they go through to explain the arbitration agreements. Admissions Director G stated, I go through the admissions agreement step by step and explain everything. I explain the arbitration agreement to the residents but let them know that it is not necessary to agree just to get admitted . Most of the time they agree to the arbitration agreement, but we do have residents that don't sign. I tell residents you have 30 days from the day you signed to make changes to the arbitration agreement. Admissions Director G was asked if they retain copies of the signed agreements. Admissions Director G stated yes, I let every resident or responsible party know that they can have a copy of the arbitration agreement or the admission packet if they want one. If the resident is not alert, I go over the agreement with the responsible party or guardian. If the resident does not have a guardian and is not alert, then I have to wait to get things signed. On 04/28/25 a list was provided of all the residents in house who have signed an arbitration agreement. Three cognitively intact residents were chosen from the list Resident # 9 On 04/28/25 an interview was conducted with R9. R9 admitted to the facility on [DATE] and has a brief interview for mental status (BIMS) of 13, indicating they are cognitively intact. R9 was asked if they knew what the arbitration agreement was that they signed when they came to the facility. R9 was unable to give an answer and was generally not aware of what the arbitration agreement was. Resident # 35 On 04/28/25 an interview was conducted with R35. R35 admitted to the facility on [DATE] and has a BIMS of 15, indicating they are cognitively intact. R35 was asked if they understood the arbitration agreement they signed when they admitted to the facility. R35 couldn't give an answer on what they thought it was. R35 seemed confused about what she signed. Resident # 213 On 04/28/25 an interview was conducted with R213. R213 admitted to the facility on [DATE] and has a BIMS of 13, indicating they are cognitively intact. R235 was asked if they understood what the arbitration agreement was that they signed on admission. R235 stated they were not aware of what they signed. R235 was asked if the arbitration agreement was explained to her. R235 said it was not explained to her. On 04/28/25 at 02:45 PM, an interview was conducted with the NHA. The NHA was asked about the process for explaining arbitration agreements with incoming residents. The NHA stated, I have watched the admissions director do admission paperwork. She takes her time and is very thorough with everything she does. If anything could be adjusted, maybe the arbitration agreements could come up sooner in the admission packet. Maybe it would be in our best interest to bring this up in resident council or QA. 22927 Resident Council: In an interview and record request on 04/28/25 at 09:53 AM with the Activity director L the state surveyor requested 6 months of Resident Council meeting minutes to review prior to the scheduled meeting. Activity Director L revealed that the council meet in the main dining room. Resident Council meeting on 04/28/25 at 10:03 AM noted 6 Residents attended the confidential meeting with the state survey agency. During the resident council meeting the residents in attendance were asked about Arbitration agreements. One confidential resident responded that it was a trust issue for them and that the facility give a new admission/arbitration agreement so much information the first week that the resident does not remember what was signed. Another confidential resident stated that they did not know what arbitration was or what it means. The State surveyor inquired if any of the six confidential residents attending the meeting knew what the arbitration agreement was? and 6 of 6 residents did not understand the arbitration process or what it meant.

Based on observation, interview and record review the facility failed to ensure that residents were treated in a dignified manner for three residents (R4, R108, R208) of 16 residents reviewed for dignity, resulting in uncovered urine collection bags and lack of respect for residents individuality. Findings include: Resident #208 (R208): R208 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include neuromuscular dysfunction of the bladder, hypertension, anxiety and a history of colon cancer. On 04/27/25 at 10:37 AM, R208 was observed sitting in bed and watching TV. R208 was noted to have an indwelling urinary catheter in place. The urine collection bag was not covered, urine was present in the bag. On 04/28/25 at 08:36 AM, R208 was observed in the dining room eating breakfast, the urine collection bag was not covered, and urine was present in it. On 04/28/25 at 01:40 PM, record review of R208's electronic medical record (EMR) revealed a physician's order for the indwelling catheter, an appropriate diagnosis of obstructive uropathy and it was dated 04/07/25. On 04/28/25 at 03:18 PM, an interview was conducted with the director of nursing (DON). The DON was asked if the facility has dignity bags that cover the urine collection bags. The DON replied, yes, we do have dignity bags that the urine collection bags slip into, and we have urine collection bags with built in covers. The DON stated they are available to staff, and they can use them. The DON was asked if the urine collection bags should be covered. The DON replied, yes, they should be covered. 22927 Resident #4: Observation and interview an 04/27/25 at 11:08 AM with Resident #4 stated I got the catheter when I came here to this building, I had a Urinary Tract Infection, and they are giving me some pills for it. I couldn't pee on my own, and I use to do a straight stick catheter. The state surveyor Observed urinary catheter at bedside in privacy bag, with tubing touching/lying on the floor. Observation on 04/28/25 at 12:28 PM of Resident #4 was seated at edge of bed awaiting her noon meal tray. The state surveyor Observed urinary catheter and tubing laying on the floor outside of the privacy bag. Resident #4 stated that she did not know what was going on with the catheter bag. The staff/girls take care of the catheter for me. Observation on 04/28/25 at 12:30 PM Activities aide A brought in her lunch tray, she did not know anything about the urinary catheter. On 04/28/25 at 12:32 PM the state surveyor went to find Licensed Practical Nurse B and returned with the surveyor to Resident #4's room. Both LPN B and state surveyor observed urinary catheter on the floor outside the privacy bag. LPN B stated I don't know why the catheter was out of the privacy bag and on the floor, I know that Resident #4 doesn't like to get out of bed. LPN B only put on gloves and picked up the catheter from the floor with no enhanced barrier PPE put on. On 04/28/25 12:36 PM Resident #4 stated that she had not been into the bathroom or out of bed. Resident #108: Observation and interview during the initial screen process at the start of the survey on 04/27/25 at 10:41 AM of Resident #108 noted a urinary catheter visible from the doorway hanging at bed side with a volume measure burette (Urometer) on front of bag with yellow solution noted with no privacy bag in place. Resident #108 stated he has been at the facility a week, but that no one has told him anything and that they need to respond to the buzzer faster, because he waits 30 minutes to 45 minutes. In an observation and interview on 04/29/25 at 08:24 AM of Resident #108 was lying in bed with his breakfast meal. Observation of urinary catheter was noted to have a blue privacy bag in place today. Resident #108 stated that the girls added that cover bag yesterday afternoon. The Resident #108 did not know why they waited till then after everyone that walked by saw it.

Based on interview and record review, the facility failed to ensure that advance directive forms were completed by a designated responsible party for one resident (Resident #8) of two residents reviewed for advance directives. Findings include: Resident #8: On [DATE] at 2:55 PM, Resident #8 was observed in their room sitting in a semi reclined position in a Broda chair. When asked questions, Resident #8 was pleasantly confused and unable to provide answers to questions related to medical conditions and/or care. Record review revealed Resident #8 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia, and falls. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required substantial/maximum assistance. Review of Resident #8's Electronic Medical Record (EMR) revealed the Resident was admitted to Hospice Services in [DATE]. A Physician's Evaluation of Resident's Competency To Make Health Care Decisions Form was present in Resident #8's EMR. The form specified the Resident was incompetent to make medical decisions and was signed by a Physician on [DATE] and a Clinical Psychologist on [DATE]. Further review of Resident #8's EMR revealed the most recent Advance Directive form specifying Code Status was entitled, MDHHS-5836, Michigan Physician Orders for Scope of Treatment (MI-POST). The form was dated as prepared on [DATE]. The form detailed the Resident's code status was DO NOT attempt Resuscitation/CPR (Cardiopulmonary Resuscitation). (No CPR, allow Natural Death) . Medical Interventions . Comfort-Focused Treatment . The form was signed by Resident #8 (no date), Former Assistant Director of Nursing (ADON) O on [DATE], and Physician N on [DATE]. Further review of Resident #8's EMR revealed DPOA paperwork with a patient advocate designated. An interview was completed with Social Services Designee (SSD) P on [DATE] at 1:52 PM. When queried who signed Resident #8's most recent Advance Directive/DNR order, SSD P reviewed Resident #8's EMR and stated, (Resident #8) did. SSD P was then asked if Resident #8 was deemed incompetent and replied, Yes. When asked why Resident #8 signed the form after she was deemed incompetent to make medical decisions, SSD P stated, It was probably an error on the nurses part. When asked to clarify if they were saying Resident #8 should not have signed the form, SSD P confirmed the Resident should not have signed the form due to being incompetent. On [DATE] at 11:59 AM, an interview was completed with the Director of Nursing (DON). Resident #8's Advance Directive DNR form from February 2025 and incompetency documentation were reviewed with the DON. When queried why the Resident signed the DNR Advance Directive form, the DON did not provide an explanation. Review of facility policy/procedure entitled, Advance Directives and Care Planning Guidelines (Effective [DATE]) revealed, It is the practice of the facility to establish, implement and maintain written guidelines for advance directives . The resident will be evaluated periodically for decision-making ability capacity .

Based on observation, interview and record review, the facility failed to implement procedures to ensure Activity of Daily Living (ADL) care per preference was provided to one resident (Resident #13) of two residents reviewed for ADL care. Findings include: Resident #13: On 4/27/25 at 11:59 AM, Resident #13 was observed in their room. The Resident was in bed, positioned on their back, wearing a hospital style gown. The Resident had an unkept appearance and their face was unshaven. An interview was completed at this time. When asked if they liked their facial hair or if they preferred to be shaved, Resident #13 replied, I like to be shaved. When asked why they weren't shaven when they like to be, Resident #13 stated, Only do when go to the shower room. On 4/28/25 at 12:21 PM, Resident #13 was observed in their room. The Resident was in bed, positioned on their back. The Resident's face remained unshaved. On 4/28/25 at 4:00 PM, an interview was completed with Certified Nursing Assistant (CNA) Q. When queried regarding the frequency in which male resident's faces are shaved, CNA Q replied, Shaving is done when showered. When asked about Resident #13 stating they preferred to be shaved and saying they were only shaved when they received showers, CNA Q confirmed that is the usual facility procedure. Record review revealed Resident #13 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included heart disease, Alzheimer's disease, and cerebral infarctions (strokes) with resulting left and right sided paralysis and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired, had one sided upper and lower impaired Range of Motion (ROM) and required moderate assistance to complete personal hygiene and maximum assistance with toileting and transfers. Review of Resident #13''s Electronic Medical Record (EMR) revealed a care plan entitled, The resident has actual ADL self-care performance deficit r/t (related to) Activity Intolerance, confusion, R and Left sided paralysis as a result of CVA (Cerebral Vascular Accident - stroke). Res often refuses to get out of bed throughout the day . prefers to stay in bed. Muscle weakness . (Initiated: 3/14/25). The care plan included the interventions: - Bathing: 1 person Physical Assist Tuesday, Saturday and PRN (as needed) (Initiated: 3/14/25) - Dressing: 1 person Physical Assist (Initiated: 3/14/25) - Transfers: Resident requires 2 person physical assistance (Initiated: 3/14/25) At 9:13 AM on 4/29/25, an interview was completed with the Director of Nursing (DON). When queried regarding observations of Resident #13 being unshaven and the Resident stating they are only shaved on shower days but like to be clean shaven and shaved more frequently than only on shower days, the DON stated, (Resident #13) is alert. They can ask if they want to be shaved. No further explanation was provided related to the Resident's impaired cognition. Resident #13's complete Documentation Survey Report for January to March 2025 were requested at this time. Review of provided January to March 2025 Documentation Survey Report for Resident #13 revealed the Task Only report was provided. The report specified Resident #13 was scheduled to receive showers on Tuesday and Saturdays. The documentation report did not delineate shaving from other areas of hygiene provided.

This Citation pertains to Intake Number MI00144251 Based on interview and record review the facility failed to 1. Complete a bowel assessment and monitoring with resident's complaints of pain and rectal bleeding; 2. Document the clinical rationale for the administration of an enema and 3. Perform the proper administration of an enema for one resident (Resident #61), resulting in the inappropriate administration of an enema, multiple partial thickness anal mucosa tears, full thickness rectal tear and partial thickness anal mucosa laceration that required surgical repair. Findings Include: Resident #61: On 5/6/2024 at 11:40 AM, a review was completed of Resident #61's medical records and it revealed he was admitted to the facility on [DATE] with diagnoses of Anemia, Chronic Kidney Disease, Diabetes and Heart Disease. Resident #61 was cognitively intact and able to make his needs known. Further of his records yielded the following: Care Plan: The resident has Anemia .monitor/document/report PRN following s/sx (signs and symptoms) of anemia: Pallor, Fatigue, Dizziness, Syncope, Headache, Palpations, Weakness, feeling cold, low hgb/hct (hemoglobin/hematocrit), SOB (shortness of breath), Sore tongue, Chest pain, Tinnitus, Changes in cognition . On 5/7/2024 at 1:55 PM, an interview was conducted with Resident #61 regarding the enema he received at the facility and subsequent transfer to the emergency room . Resident #61 shared he pressed his call light as he needed assistance to the restroom to have a bowel movement. Staff took a while to respond by the time staff arrived, he was constipated and no longer could pass the stool. Resident #61 informed staff of this and stated he would likely require an enema. They prepared the resident for the procedure and positioned him in bed. He stated the nurse did not have lubricant and he informed her that she needed it. Upon lubricating the tip of the enema container Nurse B started poking the tip of enema in/out of his anal canal multiple times. Resident #61 reported the nurse poked my colon full of holes and tore it. Resident #61 shared during the enema he was in excruciating pain and screamed throughout the entire procedure. After the enema was completed, he went to the bathroom and was bleeding rectally. Resident #61 reported he was moved to a different room after the enema and pleaded to be sent to the emergency room for his rectal bleeding but they would not call 911. The resident stated because his wishes were not being honored, he called his friend to the facility to advocate for him and after eight hours of agony the nurse finally called 911 to have him transferred to the emergency room . While in the ER he received two bags of blood and was transferred to another hospital and had rectal surgery to repair the multiple lacerations and tears in his rectum. Progress Notes: 1/3/2024 at 17:15: .93 yom (year old male) admitted to hospital on 12/27/2023 from doctors office r/t (related to) low hemoglobin of 7.0 received 1 unit of blood. Current hemoglobin 7.6 .last BM (bowl movement) was 1/2/24, cont (continue) B/B (bowel/bladder) uses urinal . 1/9/2024 at 11:45: EMAR - Administration Note: Fleet Enema Enema 7-19 GM/118ML Insert 1 application rectally every 24 hours as needed for Constipation.IF NO BM DOCUMENTED X 4 DAYS FOLLOWING ADMINISTRATION OF DULCOLAX SUPPOSITORY .per resident request r/t (related to) having constipation, noted to be having blood in stool r/t straining. 1/9/2024 at 11:46: Resident states that has been having constipation for the last four days. noted to have blood in toilet from straining, resident has no noted bowel movement noted at the rectum. Resident assisted to lay down on side and enema give, with noted hard stool in the rectum, blood noted to be coming out of the rectum along with enema solution. Resident feeling pressure, assisted to the toilet, noted to have small hard stool with red blood . 1/9/2024 at 12:47: Resident assisted to the toilet again with noted blood in the stool with XXL stool noted in the toilet . 1/9/2024 at 18:57: resident states he feeling shaky and hot. Assessment completed. family at bedside . 1/9/2024 at 19:15: resident transferred to (emergency room ) via (EMS) with family present. Documentation Survey Report: Review was completed of Resident #61 bowel continence during his time at the facility. Resident #61 had bowel movements on the following days: - 1/5/2024 at 14:25 had a medium, formed/normal bowel movement. - 1/5/2024 at 21:52, had a medium, formed/normal bowel movement. - 1/7/2024 at 14:29, had a medium, formed/normal bowel movement. - 1/9/2024 at 02:46, had a medium, formed/normal bowel movement. - 1/9/2024 at 13:37, had a large, formed/normal bowel movement. January MAR (Medication Administration Record): - Milk of Magnesia Suspension 400 MG/5ML o Administered 1/8/2024 at 1115 - Fleet Enema 7-19 GM/118ML o Administered on 1/9/2024 at 1145 Pain Level Assessment: 1/9/2024 at 10:06: 0 1/8/2024 at 08:07: 0 1/4/2024 at 20:30: 0 1/4/2024 at 10:39: 0 EMS (Emergency Medical Services) Run Report 1/9/2024: Dispatch: (facility) for male who thinks his hemoglobin is low and shaking .pt (patient) seated in chair with 4 or 5 blankets wrapped around per family .because he was shivering and cold pt was to weak to stand and pivot even with help so he was lifted by family and crew using sheet .When pt uncovered from all the blankets he was hot to the touch. Per RN pt was complaining of being cold and no intervention was done other than calling 911 . It can be noted from review of the Resident #61's bowel continence log he had four bowel movements at the facility prior to the enema being administered on 1/9/2024. There was no other documentation located that indicated why other bowel protocol methods were not initiated prior to administration of the enema. Furthermore, Resident #61 was not assessed by the facility prior to being sent to the emergency room at his behest even after complaints of rectal pain. His last documented pain assessment was on 1/9/2024 at 10:06 AM which was an hour and forty-five minutes before his enema (administered at 11:45 AM) and nine hours before he was transported to the emergency room (approximately 7:01 PM). Emergency Department Notes 1/9/2024-1/10/2024: .93-year -old male presenting to the emergency department chief complaint of abdominal pain that is generalized and worsening throughout the day. He did receive an enema earlier today at nursing home and states he is having rectal bleeding since .Temp: 100.6. Pulse: 104 .Patient was given 1 L (Liter) normal saline initially and given the injury to the rectum CT of abdomen and pelvis was obtained .It does show trauma to the rectal region with subcutaneous air into the rectus femoris on the right. This is consistent with rectal perforation. Patient was given IV Rocephin on arrival .he did speak with (physician) and he recommended transfer to facility with colorectal surgery he precipitously declined in his condition requiring 2 units of packed red blood cells for hypotension and blood loss after repeat H&H (hemoglobin and hematocrit) showed drop in hemoglobin to 7.0 .Patient was transferred for acute GI (gastrointestinal) bleed secondary to rectal laceration .Pt arrives via EMS from nursing home. C/O abd pain and rectal bleeding after an enema . On 5/7/2024 at 3:05 PM, an interview was held with Nurse A regarding Resident #61's assessment and monitoring prior to being transported to the emergency room . Nurse A explained he had transferred from the other unit and was her patient for a just few hours. The nurse recalled he had an enema earlier in the day, but she was not the one that administered it. Nurse A recalled Resident #61's face being flushed and his adamancy about being sent the hospital for rectal bleeding as he stated he hurt down there. She attempted to adjust the thermostat but was not successful as it's for the entire unit and not per room. She stated she was not sure if the room was just too warm for the resident. Nurse A was asked if an assessment was completed of the resident to include his rectum, and she stated she completed vitals and neuro checks which were stable and the rest of the assessment would be listed in a progress notes. Nurse A and this writer reviewed her progress notes for Resident #61, and Nurse A did not see where she completed an assessment of the resident as it related to his complaints of rectal bleeding. Nurse A was queried as to the potential complications from a an enema and she responded bleeding, tearing at that bowel and perforated rectum. During an assessment she would look for bleeding at the rectum, change in vital signs and respiratory status. Nurse A was unable to recall why Resident #61 was so adamant regarding being transferred to the emergency room but she contacted the physician and received orders to send him out per his request. On 5/7/2024 at 5:08 PM, an interview was conducted with Nurse B regarding the enema administered to Resident #61. The nurse recalled the resident being upset as he was struggling to have a bowel movement and there was some blood in his stool when pushing. Nurse B stated he requested an enema, and she informed him she did not feel comfortable administering one, but he was insistent and she obliged. With the assistance of CNA R they positioned Resident #61 on his right side, and he was facing the aid. Nurse B lubricated the tip of the enema but struggled to advance it into the anal canal as there was a lot of stool at the opening and she felt resistance. Nurse B reported she pulled the tip out and reinserted it multiple times from side to side and upon pulling it out the tip was covered with feces. Nurse B stated the majority of the liquid came back out and Resident #61 requested manual deimpaction but she declined as she was not comfortable doing that given the blood in his stool. She stated she did complete rectal stimulation around the anal canal with her knuckles after the enema was completed. Review was completed of Nurse A and B facility training record and it yielded the following results: Nurse A Nurse A completed facility competency on 7/11/2023 that stated she Meets/Exceeds Standards, in the following areas: -Enemas: Identifies situations requiring an enema. Demonstrates process for administering an enema. -Change of Condition- General: Explains stop and watch process. Demonstrates ability to monitor and document vital signs. Understands specific assessments needed for change of conditions and charting. Identifies when to perform Neuro checks. Describes the 24 hour report, where to find it and how to use it. -Change of Condition- Genitourinary Assessment: Performs Genitourinary assessment to incorporate color, odor, amount, pain with urination, abdominal discomfort, fever, quality of stream and bladder incontinence. -Charting: Nurse properly demonstrates charting for the following situations: antidepressants, behaviors, I&O. appetite, and monitoring/weight changes. -Rectal Checks/Suppository Insertion: demonstrates ability to perform rectal checks . identified situations requiring suppository use. Demonstrates ability to properly inset and remove suppository. Nurse B Nurse Skills Checklist completed on 6/5/2023 included the following skills area that Nurse B was deemed competent in: -Suppository Administration -Enemas Nurse B completed facility competency on 7/11/2023 that stated she Meets/Exceeds Standards, in the following areas: -Enemas: Identifies situations requiring an enema. Demonstrates process for administering an enema. -Rectal Checks/Suppository Insertion: demonstrates ability to perform rectal checks . identified situations requiring suppository use. Demonstrates ability to properly inset and remove suppository. On 5/8/2024 at 11:26 AM, an interview was conducted with CNA R regarding Resident #61's enema that she assisted Nurse B with. CNA R recalled answering the residents light and him requesting an enema to help him have a bowel movement. The CNA informed the nurse and then assisted with the procedure. Once Resident #61 was positioned Nurse B inserted the enema and he began to yell out that it hurt but insisted they continue with the procedure. CNA R recalled the resident being impacted as the nurse stated there was a lot of stool in the canal and maybe that was why it hurt during insertion. CNA R stated the entire enema was administered and much of the fluid came back out upon completion and the tip of the enema was covered in feces. EMS Run Report 1/10/2024: .Dispatched to (emergency room ) for STAT ALS (Advanced Life Support) transfer to (hospital). Report from RN (Registered Nurse): pt is 93 y/o M brought from nursing home c/o (complaints of) abd (abdomen pain) after an enema. Tests show he has perforated rectum and severe hemorrhage. Pt was given blood and blood pressure was monitored by an art line in ED (Emergency Department) .Pt is being transferred to (hospital) for colo-rectal surgery . Resident #61 was transferred to a secondary hospital on 1/10/2024 for rectal surgery and the records indicated the following: Patient was evaluated by (physician) from general surgery, will plan to go to the OR for further treatment and evaluation of possible injury to the rectal wall .Postoperative Diagnosis: Anorectal trauma; Procedure Name: Rectal examination under anesthesia with repair two full-thickness anorectal injuries .Operative Summary [AGE] year-old male who had some constipation issues over the past few days .The reportedly did some manual disimpaction followed by enema. Patient reported extreme pain during the enema which was described as without lubricant and very forceful. He began having rectal bleeding after this and presented to an outside facility. He was found to have perirectal subcutaneous emphysema .Upon examination in the emergency department a laceration was visualized anteriorly .I recommended he undergo emergency rectal examination under anesthesia with repairs as indicated .Operative technique: .A [NAME] rectal retractor was then used to inspect the anorectal mucosa circumferentially. The anterior injury began in the anal mucosa and extended proximally into the rectal mucosa and was full thickness in its midportion and proximally. In addition there were multiple nearly circumferential partial-thickness injuries to the anal mucosa without active bleeding .Non bleeding hemorrhoidal disease was also visualized. In the posterior midline there was a laceration visualized 2 cm proximal to the dentate line with full-thickness component through the rectal wall approximately 1/2 cm in length. This area was thoroughly irrigated and inspected. The injury was closed with a running 3-0 locking Vicryl suture. The anterior injury was also irrigated and closed with running locking 3-0 Vicryl suture .Findings: Multiple nearly circumferential partial-thickness tears of the anal mucosa. Posteriorly 1-1/2 cm full-thickness rectal tear 2 cm proximal to the dentate line washed out and repaired .Anteriorly 3 cm partial-thickness lacerations of the anal mucosa extending into rectal mucosa with full-thickness component also repaired .Gelforam soaked in thrombin packed into anorectal canal XXX[AGE] year-old male .who is admitted after a transfer from outlying emergency department with complaints of anorectal pain. Patient has had issues constipation, and at outlying nursing facility had an enema. Almost immediately after the enema, began having severe rectal bleeding and pain. He was transferred to our facility for surgical evaluation. He did have imaging done at outside facility, which showed subcutaneous emphysema tracking from the gluteal cleft to the sphincter complex .Patient went for rectal examination under anesthesia on 1/10/2024, found to have full thickness and rectal injuries .He was started on broad-spectrum IV antibiotics for infection prophylaxis .discharged home once general surgery cleared him . On 5/9/2024 at 12:50 PM, an interview was conducted with the DON (Director of Nursing) regarding Resident #61's enema and subsequent injuries. The DON reported the day he was transferred to the emergency room he had two large bowel movements and had requested an enema. When the nurse started to insert the enema, she could feel fecal matter and she pulled out the enema and observed feces on the tip of it. The DON recalled the nurse calling about the resident's request to be sent out to the emergency room and agreeing with the report of the resident she presented. The DON was informed the account this writer received versus what was told to her did not align. The DON was informed of the account of the procedure provided by Nurse B and she stated she would have expected the nurse to complete external stimulation of the anal canal prior to the enema if the resident was impacted. Review was completed of facility policy entitled, Constipation Protocol, revised 10/2020. The policy stated, .Any resident with history of fecal impaction will be checked routinely for active bowel sounds and abdominal distention .If a resident had not had a bowel movement in the past 48-72 hours notify the residents attending physician .The following is suggested protocol .Day 1: Give Polyethylene Glycol such as (Miralax) 17 grams with 8 ounces of fluid. Day 2: If no BM give Bisacodyl suppository such as (Dulcolax). If no BM give Saline enema such as (Fleets). Review was completed of facility policy entitled, Ready to Use Enema, revised 10/2010. The policy stated, .13. Separate the buttocks so you can see the anal area; 14. Gently insert the enema tip through the anus into the rectum; 15. Slowly squeeze the enema bottle until all the solution has been expelled from the bottle into the rectum . Review was completed of, [NAME] and [NAME] Clinical Nursing Skills & Techniques, 9th edition, copyright 2024.Administering an Enema .If pain occurs or you feel resistance at nay time during procedure, stop and discuss with health care provider. Do not force 4. Insert lubricated tip of container gently into anal canal toward umbilicus. Adult 7.5-10 cm(centimeter) (3-4 inches) .5. Roll plastic bottle from bottom to tip until all solution has entered the rectum and colon. Instruct patient to retain solution until urge to defecate occurs, usually 2 to 5 minutes if impaction is present, remove it (see Skill 35.2) .Fecal impaction .6. Lubricate gloved index finger and middle finger of dominate hand with anesthetic lubricant; 7. Instruct patient to take slow deep breaths during procedure. Gradually and gently insert gloved index finger and feel anus relax around finger. Insert middle finger; 8. Gradually advance fingers slowly along rectal wall toward umbilicus; 9. Gently loosen fecal mass by moving fingers in scissors motion to fragment fecal mass. Work finger into hardened mass; 10. Work stool downward toward end of rectum. Remove small sections of feces and discard in bedpan .Contraindications for Fecal Management Systems .Fecal impaction .

This Citation Pertains to Intake Numbers MI00134226, MI00134335, and MI00136587. Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedure for pressure ulcer (wounds caused by pressure) prevention and management and ensure accurate and complete documentation for four residents (Resident #9, Resident #36, Resident #59, and Resident #67) of four residents reviewed, resulting in a lack of implementation of planned and meaningful interventions, pressure ulcer development, pressure ulcer worsening, unnecessary pain, and the likelihood for decline in overall health status. Findings include: Resident #9: On 5/6/24 at 11:10 AM, Resident #9 was observed sitting in a powered wheelchair in their room. Their spouse was present in the room and an interview was completed. When queried regarding their stay at the facility, Resident #9 revealed they came to the facility for therapy after being in the hospital and planned to discharge home. When queried regarding their electric wheelchair, Resident #9 revealed it was their personal chair from home. Resident #9 revealed they had Multiple Sclerosis (MS- disabling autoimmune of the central nervous system causing permanent disability) and limited mobility. Resident #9 was asked if they had any wounds and stated, Pressure ulcer on my butt. When queried if the pressure ulcer developed at the facility, Resident #9 replied that it did. Resident #9 was asked if they experienced pain from the pressure ulcer and replied yes. Record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses which included MS, diabetes mellitus, paraplegia (lower extremity paralysis), acute respiratory failure, tracheostomy (surgically created opening in the front of the neck to the trachea to allow air exchange), suprapubic catheter (surgically created opening through the abdominal wall to the bladder to allow for urine drainage), cerebral infarction (stroke) affecting right side, and weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required substantial/maximum to total assistance to complete dressing, bathing, and mobility. The MDS further revealed the Resident was at risk for pressure ulcer development but did not have any pressure ulcers. Review of the facility-provided CMS-802 form detailed Resident #9 had a facility-acquired (FA) Stage 3 (full thickness tissue loss with visible subcutaneous fat). Review of Resident #9's Electronic Medical Record (EMR) revealed a care plan entitled, The resident has actual impairment to skin integrity AEB (As Evidenced By) wound to tracheostomy r/t tracheostomy status, Accidental decannulation requiring ER visit to reinsert. 4/23/24- Trach removed by ENT / Decannulated. 4/30/2024- Stage 3 PI (Pressure Injury) to Right posterior thigh (Initiated: 4/17/24). The care plan included the following interventions: - Evaluate resident for S/SX (signs/symptoms) of possible infections (Initiated: 4/18/24) - Pain: Evaluate residents for changes in pain level and if appropriate request a scheduled pain medication from physician (Initiated: 4/18/24) - Ensure that heels are elevated while resident is lying in bed (Initiated: 5/1/24) - Encourage res to only stay in her WC an hour at a time for off-loading purposes (Initiated: 5/1/24) - Follow facility protocols for treatment of injury (Initiated: 5/1/24) - The resident needs APM (Alternating Pressure Mattress) mattress to protect the skin while in bed (Initiated: 5/1/24) - The resident needs WC cushion to protect the skin while up in chair (Initiated: 5/1/24) - Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations (Initiated: 4/18/24). A second care plan entitled, The resident has potential for impairment to skin integrity r/t (related to) Multiple sclerosis, Decreased mobility Right Hemiplegia s/p (status post) CVA (stroke) . (Initiated: 4/15/24) was noted in Resident #9's EMR. The care plan included the following interventions: - Apply barrier cream per facility protocol to help protect skin from excess moisture (Initiated: 4/15/24) - Encourage that heels are elevated while resident is lying in bed (Initiated: 4/15/24) - Dietary Consult as needed (Initiated: 4/15/24) - Monitor skin when providing cares, notify nurse of any changes in skin appearance (Initiated: 4/15/24) - Nutritional Supplements as ordered (Initiated: 4/15/24) - Pressure reduction bed mattress (Initiated: 4/15/24) - Wheelchair pressure reduction cushion (Initiated: 4/15/24) Review of Resident #9's Visual/Bedside Kardex revealed the Resident required two assist for bed mobility and two assist with a Hoyer (full mechanical lift) for transferring in and out of bed. Review of documentation in Resident #9's EMR revealed the following: - 4/28/24 at 5:38 AM: Daily Skilled Nursing Note . Resident is receiving skilled services for . Wound Care . New skin issue noted this shift . to right buttocks, to be abrasion W/TX (with treatment) in place - 4/28/24 at 11:13 AM: Wound Evaluation . MASD (Moisture Associated Skin Damage) . Rear Right Thigh . New . Length 4.14 cm (centimeters) . Width 2.52 cm . Wound Bed: Granulation . Bleeding . Exudate . Moderate . Sanguineous/Bloody . Periwound: Edges: Attached . Surrounding Tissue: Denuded (exposed, damaged, or missing tissue) . Excoriated (skin erosion) . Treatment . Calcium alginate . foam . Notes: history of MASD and wounds to bilateral buttock . Will address pressure as well as potential for MASD turning into pressure injury. APM mattress ordered. Res has own [NAME] with built in cushion. Res and family declined ROHO cushion. Incontinence cares continued to keep resident dry. Education Res encouraged to turn and reposition at least q 2 hours as well as only get up in WC (wheelchair) for 1 hour at a time . - 4/28/24 at 2:18 PM: Daily Skilled Nursing Note . Resident is receiving skilled services for . Wound Care . Resident with pressure wound . open area to buttocks. Encouraged resident to lay down after meals; treatment in place. - 4/30/24 at 8:30 AM: Wound Evaluation .Pressure - Stage 3 . Rear Right Thigh . Deteriorating - 2 days old . Acquired: In-House Acquired . Length: 7.28 cm . Width: 5.06 cm . Deepest Point: 0.1 cm . Wound Bed . Granulation . 50% . Slough (dead tissue that is liquid or wet) . 50% . Exudate . Light . Serosanguineous . Edges: Attached . Surrounding Tissue: Fragile, Macerated . Treatment . Calcium alginate . Foam, Silicone . Additional Care . Cushion . Incontinence management . Moisture barrier . Moisture control . Healable . Progress: Deteriorating . Notes: APM mattress ordered. Res declined ROHO cushion to WC as has a built-in cushion on [NAME] 'specially made for (them)'. Dark areas noted to wound are blanchable. - 5/1/24 at 1:10 PM: Skin/Wound Note . APM mattress ordered . declined ROHO cushion to WC as has a built-in cushion on [NAME] (electric wheelchair) 'specially made for (Resident)'. Dark areas noted to wound are blanchable. Res encouraged not to stay in wc (wheelchair) for more than 1 hour at time. Also, encouraged to turn and reposition at least q (every) 2 hours to off load right buttock area. Review of Resident #9's Health Care Provider Orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR) revealed the following: - Rt (right) gluteal fold -- cleanse with NS (Normal Saline), apply calcium alginate (wound care treatment indicated for moderate to heavily draining wounds including stage three to four pressure ulcers) to wound bed . Cover with comfort foam, Apply zinc (protective skin barrier ointment) to peri wound every night shift for wound care (Start Date: 4/28/24; Discontinued: 5/1/24). Note: the treatment was not completed on 5/1/24 - Santyl External Ointment (debriding wound care treatment used to remove necrotic/dead tissue) 250 unit/gm (gram) . Apply to Right Posterior Thigh topically as needed for Missing / Soiled Dressing (Start Date: 5/1/24) The treatment was documented as completed once on 5/5/24. - Santyl External Ointment 250 unit/gm . Apply to Right Posterior Thigh (pressure ulcer) topically every day shift for Stage 3 . Cleanse Right Posterior thigh with normal saline. Pat dry. Apply Santyl to wound base. Cover with large silicone foam (Start Date: 5/2/24) Note: The treatment was not completed on 5/4/24. - APM mattress to bed. Settings: Comfort Level #3. Check for proper functioning q shift. every shift for APM (Start: 5/6/14 at 6:00 PM) On 5/7/24 at 11:26 AM, Resident #9 was sitting in their electric wheelchair in their room near the doorway. The Resident was grasping their hands together and displayed an uncomfortable appearance. When asked how long they had been sitting up in their chair, Resident #9 responded they had been up since before breakfast because they got a shower in the morning. Resident #9 was asked if they recalled what time they got up and revealed they did not know but that it had been a few hours. Resident #9 then stated they were waiting for a staff member to assist them to go back to bed but had to wait because their Certified Nursing Assistant (CNA) went to lunch. Resident #9 verbalized they were told they should not sit up in their chair all day because of the pressure ulcer on their bottom. When queried why they had to wait for their CNA to go to lunch before going back to bed, Resident #9 explained the CNA had answered their call light and told them they would put them back in bed after they took their lunch break and found another staff member to help. Resident #9 was then asked if they were able to reposition themselves in the chair and indicated they could not. When asked if the staff assisted to reposition them in the chair when they were sitting up, Resident #9 replied they did not. On 5/8/24 at 8:36 AM, an observation of Resident #9 was completed in their room. The room lighting was dim with the shade covering three quarters of the window and the room lights off. The Resident was in bed, positioned on their back with their eyes open. When queried regarding pain, Resident #9 stated their butt hurt. Resident #9 was asked to rate the pain on a numerical scale from zero (no pain) to 10 (worst imaginable pain) and stated, Eight. At 8:38 AM on 5/8/24, an interview was completed with Registered Nurse (RN) A. When queried regarding Resident #9's wound, RN A confirmed the Resident had a facility-acquired pressure ulcer. RN A was asked when they would be completing Resident #9's dressing change and stated, Usually in afternoon. RN A indicated they would inform this Surveyor prior to wound care treatment completion for observation. An observation of wound care for Resident #9 was completed on 5/8/24 at 11:07 AM with Unit Manager Wound Care RN P and RN A. RN P was observed obtaining supplies from the treatment cart prior to entering the room. When queried regarding the current wound and treatment, RN P stated, Santyl to the right posterior thigh. RN P also stated they were also obtaining wound cultures because it (wound) is worsening. When asked if the wound had an odor, RN P verbalized it did and they had contacted the Physician to get an order for wound cultures. RN P was asked if they were going to obtain wound measurement and stated, We do pictures (computer image program which calculates wound length and width). When asked it the pictures measure wound depth, RN P replied, No. Okay, I see your point. Upon entering the room, Resident #9 was observed in bed positioned on their back. When queried if they had gotten out of bed since our last conversation, Resident #9 indicated they had not. Resident #9 was positioned on their left side by RN A and RN P. The staff removed the Resident's brief, and a pungent, foul odor was immediately noted. The dressing in place over the right rear buttocks/thigh was observed to be thoroughly saturated with a grey colored drainage which had leaked onto the surrounding skin and was present on the removed brief. RN P proceeded to remove the soiled dressing and the pungent, foul odor increased and permeated the room. The soiled dressing was saturated with a distinct malodorous off-white/ grey/light green colored drainage. The foul odor remained after the wound bed was cleansed by RN P with normal saline on a gauze pad. The wound was semi-circular shaped and slightly smaller than a softball with defined borders. The wound bed was approximately 90% necrotic black colored eschar and white slough with detectable depth. A visible area of tunneling was observed within the wound bed. When queried regarding the tunneling, RN P revealed they were not aware of any tunneling previously. When queried regarding the depth of the wound/tunnel, RN P measured the depth and stated, 2.7 (cm). RN P proceeded to measure the wound bed and stated, 7.5 (cm) by 8 (cm). RN P was observed applying Santyl ointment to the wound bed to the entire bed of the wound and areas of healthy tissue surrounding the wound bed. RN P then applied a new dressing and the Resident was positioned on their back in bed by RN A and RN P. An interview and review of Resident #9's EMR was completed with RN P on 5/8/24 at 12:15 PM. When queried regarding Resident #9's pressure ulcer, RN P verified the pressure ulcer was facility-acquired. RN P was asked about facility documentation indicating the pressure ulcer was a Stage 3 and stated, It is unstageable (full thickness tissue loss where the actual depth of the wound cannot be determined due to the wound bed being covered with slough and/or eschar) now. RN P revealed the pressure ulcer had progressively deteriorated. When queried regarding the pressure ulcer development and the Resident's skin integrity upon admission in that area, RN P replied, Tissue looked good when they got here. RN P was then asked the Resident's risk for pressure ulcer development upon admission and revealed they were at high risk. When queried what interventions are implemented for Resident's admitted to the facility with a high risk for pressure ulcer development, RN P indicated all facility mattresses are pressure redistributing. RN P was asked to clarify if they were saying Resident #9 had an alternating air mattress in place since they were admitted and responded they did not. RN P explained that the regular mattress facility mattresses are pressure redistributing, and that the facility does not implement specialty/alternating air mattresses until a Resident develops a pressure ulcer. RN P indicated the care plan and interventions in place at the time the pressure ulcer developed where included on the potential for impairment to skin integrity care plan. A follow up interview was conducted with RN P on 5/8/24 at 2:06 PM. When queried regarding the Wound Evaluation documentation in Resident #9's EMR classifying the wound as MASD on 4/28/24, RN P stated, We thought it was moisture at first. When queried why they thought it was moisture, as the Resident had a urinary catheter and documentation indicates the Resident's skin was consistently warm and dry, RN P did not provide an explanation. RN P indicated the pressure ulcer developed quickly. When asked if anything had changed in the Resident's medical condition and/or mobility status prior to the pressure ulcer being identified, RN P stated, The family brought in the (electric wheelchair) and they like to sit in it. When queried if the cushion on the electric wheelchair was pressure reducing as indicated on the care plan, RN P replied, The family was adamant regarding the cushion in place on the wheelchair now. RN P explained the family had told them that the cushion was made for that electric wheelchair and to fit the Resident and they did not want the facility to remove the attached cushion and place one on top of the plain seat. When asked if they were saying the family was concerned that a generic pressure reduction wheelchair cushion would not fit the electric chair appropriately and create other concerns, RN P indicated the Resident's family believed the cushion was a pressure reduction cushion. RN P was asked if they had investigated the current cushion in place on the electric wheelchair and/or looked for pressure reduction cushions designed for that electric wheelchair and replied, No. When asked why they had not, if they were concerned that sitting in the electric wheelchair was a cause of the pressure ulcer, RN P revealed they had not thought of that. When asked if staff should be assisting the Resident to reposition in their chair when sitting up, RN P replied, If they let us. When asked if staff should document if a Resident refuses to turn/reposition, RN P stated, Yes, the nurse should. RN P revealed CNA's are supposed to inform the Resident's nurse and the nurse documents the refusal as CNA's do not have access to the same documentation system. When queried what specific interventions were implemented prior to Resident #9's developing a pressure ulcer, RN P stated, Regular, pressure redistribution mattress, barrier cream with incontinence, and an RD (Registered Dietician) consult. When queried if Resident #9 should have been turned and repositioned due to their high risk of pressure ulcer development, RN P confirmed. RN P was asked the frequency in which dependent Resident's should be turned and repositioned, RN P replied, Every two hours. When asked why that intervention was not included on the care plan, RN P did not provide a response. When asked if staff document when and/or the frequency in which Residents are turned/repositioned, RN P stated, Do not document. When queried if Resident #9 required two-person assistance for turning and repositioning, RN P confirmed they did. When queried how they knew the Resident was being turned and repositioned every two hours prior to the pressure ulcer developing, RN P revealed they were unable to say they were. When asked why more frequent turning and repositioning following the pressure ulcer development, RN P did not provide a response. RN P was then asked why the alternating air mattress was not added to the Resident's care plan until 5/1/24 and not added to the TAR with settings until 5/6/24 when the area was first identified on 4/28/24. RN P was unable to explain the different dates on the care plan and the TAR. When asked when the alternating air mattress was actually applied to the Resident's bed, RN P verbalized the mattress was ordered on 5/1/24 but was unable to state when it was applied. RN P stated they would look for a work order for the mattress application. Resident #9 was observed in their room on 5/9/24 at 8:54 AM. The Resident was in bed, positioned on their back. When queried regarding the frequency in which staff reposition them in bed, Resident #9 stated, They don't. With further inquiry, Resident #9 revealed staff turn them in their bed when they provide incontinence care and when they place the sling under them to get them in and out of bed. When asked how frequently that occurs, Resident #9 indicated three or four times a day. Resident #9 was then asked if staff had spoken to them about the cushion in their electric wheelchair and indicated they had. Resident #9 revealed the cushion was made for the chair and that was the reason they did not want staff to remove it. When asked if they would be open to a different cushion, if it would provide better pressure reduction/redistribution and was fitted to the chair, Resident #9 replied they would be. An observation of the electric wheelchair revealed it was a Pride Mobility brand. The seat cushion was black, approximately 3 inches tall, and felt like foam when depressed. A copy of a Delivery Order for Resident #9's alternating air mattress was received and reviewed. The Order detailed, Submitted: 5/1/24 . Updated: 5/6/24 . The document included a delivery date of 5/1/24 but did not indicate if the date was the actual or planned delivery date. Resident #59: Review of intake documentation dated received 1/12/23 and 1/17/23 detailed concerns related to Resident #59 developing a pressure ulcer and infection while at the facility. An interview was completed with Confidential Witness S on 5/7/24 at 10:17 AM. When queried regarding Resident #59, Confidential Witness S revealed the Resident passed away. When asked about their stay at the facility, Confidential Witness S revealed Resident #45 fell at home, broke their hip, and had been sent to the facility for therapy. Confidential Witness S detailed they were present when Resident #59 was admitted to the facility and revealed the facility staff would not take the Resident to their room or assist them to get comfortable until all the admission documentation was signed. Confidential Witness S stated, (Resident #45) was hurting so bad and they were sitting in a wheelchair. Confidential Witness S indicated they should have taken the Resident out of the facility right then because the care continued to decline. When queried regarding their concerns, Confidential Witness S stated, (Resident #59) got a bedsore while they were there and specified Family Member Confidential Witness T, who is a nurse, found the pressure ulcer and informed facility staff. Confidential Witness S stated, The person (nurse) who was there when (Confidential Witness T) noticed it (pressure ulcer) didn't even know (Resident #59) had it. When queried how Confidential Witness T identified the pressure ulcer, Confidential Witness S indicated they were assisting to provide care to the Resident. Confidential Witness S stated, They didn't have enough staff. When asked why they stated the facility did not have adequate staff, Confidential Witness S replied, While we were there, no one even came in to move (turn/reposition) (Resident #59). Confidential Witness S verbalized someone from the Resident's family was at the facility daily to assist Resident #59. With further inquiry, Confidential Witness S revealed the pressure ulcer became infected and stunk. Per Confidential Witness S, the Resident was transferred to the hospital at the request of the family and did not return to the facility. On 5/7/24 at 10:32 AM, an interview was completed with Confidential Witness T. When queried regarding Resident #59's stay at the facility, Witness T verbalized the Resident developed a pressure ulcer and had an elevated [NAME] Blood Cell (WBC) count (indicating infection) that was not addressed in a timely manner. Confidential Witness T revealed they were with the Resident when they were discharged from the hospital and observed the hospital staff complete a skin assessment prior to discharge. Confidential Witness T stated, (Resident #59's) butt was a bit red but not open. Confidential Witness T continued, Three or four days after (Resident #59) was (at facility), they started complaining that their butt hurt so bad. When asked if the facility staff assessed Resident #59's complaints of pain, Confidential Witness T replied they did not. Confidential Witness T then stated, The next day Physical Therapy was in there (Resident #59's room). We turned (the Resident) and there was a hole, a huge decub (decubitus or pressure ulcer). They (staff) didn't even know about it. When queried if they were referring to Physical Therapy or nursing staff not knowing about the pressure ulcer, Confidential Witness T verbalized neither were aware. Confidential Witness T then stated, The nurse came in and was really rude to me. Confidential Witness T revealed the nurse left the room and then came back in and told me (Resident #59) had a really high WBC a couple days prior. I think it was 30 (normal is less than 11). When asked what happened then, Confidential Witness T stated, The nurse asked me if I thought (Resident #59) needed to go to the ER and I said absolutely. (Resident #59) went to the ER that day and got admitted . Confidential Witness T revealed the Resident got lots of IV's (intravenous medications) and wound care. Never went back to the facility. Confidential Witness T was asked how frequently they were at the facility and replied, Every day. When queried how frequently staff turned and repositioned the Resident, Confidential Witness T stated, I never saw them turn (Resident #59). When asked if the Resident has a specialty and./or alternating air mattress in place, Confidential Witness T replied, No. Resident #59's medical records were not present in the facility Electronic Medical Record (EMR). An interview was conducted with the Director of Nursing (DON) and Clinical Director Registered Nurse O on 5/7/24 at 9:30 AM. Per the staff, a different EMR system was in use at the time of Resident #59 stay in the facility. Records from the previous EMR, including Medication Administration Record (MAR), Treatment Administration Record (TAR), order summary of all healthcare provider orders during stay, care plan, progress notes, wound documentation, face sheet, and all Incident and Accident Reports were requested from the facility Director of Nursing (DON) at this time. An email was received from the facility Administrator on 5/7/24 at 1:47 PM stating there were no Incident and Accident reports for Resident #59. Review of Resident #59's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses which included right femur fracture and nondisplaced sacrum fracture, falls, dementia, and heart disease. Review of the Nursing Evaluation Admission assessment dated [DATE] revealed the Resident was alert and orientated to person place, time, and situation, required staff assistance to complete Activities of Daily Living (ADL), and had no alterations in skin integrity. The medical record revealed Resident #59 was discharged from the facility and transferred to the hospital emergency department on 1/10/24. Review of documentation in the EMR revealed the following: - 1/3/23 at 1:47 PM: Nursing Evaluation (Admit .) . Resident admitted from (hospital) . Skin Integrity: The resident has skin integrity concerns. 0 . Resident is alert. Resident is oriented x 4 (person, place, time, & situation) . Resident has no nutritional risk factors noted . incontinent of bladder . incontinent of bowel . weakness . needs assistance with ADL's . Signed by Nurse U - 1/3/23 at 1:47 PM: Nursing Evaluation (Admit .) . Resident admitted from (hospital) . Skin Integrity: The resident has skin integrity concerns. 0 . Resident has nutritional risk factor r/t (related to) presence of pressure ulcer. Resident has nutritional risk factor r/t: surgical incision . Resident is confused . continent of bladder . continent of bowel . needs assistance with ADL's . Signed by Nurse U and Nurse V. The provided documentation did not indicate when the assessments were signed. - 1/4/23 at 1:35 PM: Skin & Wound Evaluation . Pressure . Deep Tissue Injury: Persistent non- blanchable deep red, maroon or purple discoloration . Location: Coccyx . Present on Admission . New . Length: 5.2 cm . Width: 1.5 cm . Depth: Not Applicable . Wound Bed . Pink or Red . Treatment (Blank) . Additional Care: (Blank) . Progress: New . - 1/8/23 at 3:06 PM: Health Status Note (nurses note) . 1+ pitting edema noted in BLE (Bilateral Lower Extremities); increased edema noted on right femur fracture side. (Family) states increased confusion/ changed mentation in resident. Dr. notified. New orders received and noted. - 1/10/23 at 10:59 AM: Skin & Wound Evaluation . Pressure . Stage 2 (partial thickness tissue loss) . Location: (Blank) . In-House acquired . New . Length: 2.7 cm . Width 2.5 cm . Wound Bed . Intact serum filled blister . Surrounding Tissue . Blister . Erythema: Redness of the skin - may be intense bright red to dark red or purple . Edema (swelling) . Pitting edema extends < 4 cm around wound . Treatment (Blank) . Additional Care: (Blank) . Progress: New . - 1/10/23 at 11:07 AM: Skin & Wound Evaluation . Pressure . Deep Tissue Injury . Coccyx . Present on Admission . New . Length: 4.4 cm . Width: 2.6 cm . Depth: 0.2 cm . Wound Bed . Eschar . Exudate: Light . Sanguineous/Bloody . Pain Frequency: Continuous . Treatment (Blank) . Additional Care: (Blank) . Progress: Deteriorating . - 1/10/23 at 1:55 PM: Health Status Note (nurses note) . res with abnormal labs WBC of 30, worsening of wounds. orders to send to ER for eval. (Family) in room [ROOM NUMBER] called report given . No wound images were included/provided with the Skin & Wound Evaluation assessments to assist in identifying unidentified wound location. A review of the provided Order Summary Report for Resident #59 was completed. There were no orders with a Start Date of 1/8/23. A copy of Resident #59's care plan and MAR were requested but not received. Review of Resident #59's TAR and order summary the Resident had a wound care order and treatment for their right hip surgical incision but there were no orders and/or treatments in place for a coccyx pressure ulcer and no new orders for the pressure ulcer identified on 4/10/24. An interview was conducted with Wound Care RN P on 5/8/24 at 2:06 PM. Provided wound documentation for Resident #59 was reviewed with RN P at this time. When queried regarding the location of the newly identified Stage two pressure was on 1/10/23, RN P confirmed the assessment did not specify and they did not know. When queried regarding the lack of treatment and/or interventions, RN P was unable to provide an explanation. An interview and review of provided documentation for Resident #59 was completed with RN O on 5/9/24 at 9:00 AM. When queried regarding the location of the facility acquired stage two pressure ulcer on 1/10/23, RN O confirmed the assessment did not include the location of the wound. When queried regarding the coccyx wound worsening, RN O indicated they would need to review the medical record. With further inquiry regarding the wound location, treatments for both pressure ulcers, and interventions in place to prevent worsening, RN O stated they would review the documentation and follow up with responses. No additional information was received by the conclusion of the survey. The facility wound care/treatment and pressure ulcer policies/procedures were requested from the Administrator on 5/7/24 at 9:42 AM. The policy/procedure entitled, Skin Protection Guide (Effective Date: 7/7/21) was received. Review of the policy/procedure revealed, To provide evidenced based practice standards for the care and treatment of skin. To ensure residents that admit and reside at our facility are evaluated and provided individualized interventions to prevent, reduce and treat skin breakdown . Evaluation . The first step in the prevention of PU/PI's, is the identification of the resident at risk . An admission evaluation helps identify residents at risk of developing a PU/PI, and residents with existing PU/PI's. Because a resident at risk can develop a PU/PI within hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent PU/PI: Skin should be examined as soon as possible upon admission, re-admission or return. Where possible, prioritize completion of the skin evaluation within the first 2 hours . Pressure is the primary cause of pressure injuries. An effective turning and repositioning schedule can help reduce the risk of developing a pressure injury . 22927 Record review of the National Press [TRUNCATED]

This Citation Pertains to Intake MI00138286 Based on observation, interview and record review, the facility failed to implement and operationalize pressure ulcer (wounds created by pressure) care, per Health Care Provider (HCP) order and professional standards of practice, for one resident (Resident #701) of three Residents reviewed. This deficient practice resulted in lack of effective collaboration and communication between external wound care HCP and facility nursing staff, lack of implementation of ordered wound care treatments, lack of completion of ordered wound care treatments, lack of clear and concise wound documentation, lack of wound assessment/monitoring following debridement, development and worsening of pressure ulcers, and Resident #701 requiring emergency medical treatment and blood transfusions due to unidentified bleeding from debrided pressure ulcer. Findings include: Review of intake documentation detailed Resident #701 developed two wounds on the buttocks around January 2023 which became unstageable due to the facility not turning the resident. Per the intake, the wounds were debrided in the facility on 7/11/23 which resulted in the Resident being found in a pool of blood on 7/13/22. The Resident subsequently required emergency medical treatment and blood transfusions due to their hemoglobin (oxygen carrying portion of red blood cells) being down to 6.4 (normal is 13.2-16.6 grams/deciliter). Review of the facility provided CMS-802 form, received 8/30/23, indicated Resident #701 had stage two, stage three, and stage four facility acquired pressure ulcers. On 8/30/23 at 3:40 PM, Resident #701 was observed in their room. Resident #701 was in bed, with the head of the bed elevated. The Resident was positioned on their back with their legs bent at their knees, and their feet near their buttocks with their left lateral lower extremity positioned directly against the mattress making them appear slightly twisted in the bed. An Intravenous (IV) pump was on the right side of the bed with an antibiotic infusing. The IV pump was beeping. A tube feeding pump, with no active infusion, was observed on the left side of the bed. Resident #701 had a tracheostomy with a Passy Muir Valve (valve which covers the external hub of a tracheostomy tube to allow for talking) in place. An indwelling urinary catheter drainage bag, not contained in a dignity bag, was present on the left side of the bed. Resident #701 had an air mattress in place on their bed. The air mattress settings were set to float and not alternate. An interview was completed at the time. When queried on how long they had the air mattress on their bed, Resident #701 replied, A few months. Resident #701 was asked if they had pressure ulcers and stated, Yes. When queried if the pressure ulcers developed at the facility, Resident #701 replied, Some and revealed they think they had two pressure ulcers when they were admitted from sitting in their wheelchair all day at home. When asked how many pressure ulcers they developed at the facility, Resident #701 revealed they were unsure of the number. Resident #701 was asked how many pressure ulcers they currently had and revealed they were not sure. When queried regarding the wound care HCP and treatment at the facility, Resident #701 replied, (Wound Care Nurse Practitioner [NP] C) is okay, expect for the debriding. Resident #701 was asked what happened and stated, I didn't know I was bleeding. There was blood but I though it was sweat. Resident #701 revealed they sweat a lot because of their MS. When asked to clarify if they were saying they thought they were sweating but it was actually blood, Resident #701 confirmed it was. With further inquiry, Resident #701 revealed their back and bottom where they are laying on the bed usually feel moist from the bed, so they had no idea it was blood and not sweat. When queried if the staff turn and reposition them in bed, Resident #701 stated, I don't move much, it's hard with my legs. Resident #701 specified their legs were very contracted which made it very difficult and painful for them to be moved and repositioned, so they are not actually turned very often. When queried if the staff utilized positioning devices, such as pads for positioning assistance, Resident #701 revealed staff will put pillows behind their back and some staff put a gel cushion between their legs but not all. At this time, Registered Nurse (RN) B entered the Resident's room to address the alarming IV. When queried the reason Resident #701 was receiving IV antibiotics, RN B specified it was due to an infection in their pressure ulcer. When queried how many pressure ulcers Resident #701 had, RN B replied, Ten. Record review revealed Resident #701 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included Multiple Sclerosis (MS), hereditary deficiency of blood clotting factors, respiratory failure, gastrostomy (surgically created opening through the abdominal wall to the stomach with a tube for the provision of food/nutrition), tracheostomy (surgically created opening in the front of the neck to the trachea [windpipe] for breathing), weakness, and abnormal posture. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact, required extensive to total assistance to complete all Activities of Daily Living, and had impaired Range of Motion (ROM) in both upper and lower extremities. The MDS further detailed the Resident had both facility and community acquired pressure ulcers including one stage two (partial thickness tissue loss with exposed dermis), one stage three (full thickness tissue loss with exposed adipose tissue), one stage four (full thickness tissue loss with exposed muscle, tendons, or bone), and five unstageable (full thickness tissue loss with unknown depth) pressure ulcers. Review of previous MDS assessments for Resident #701 revealed the following information: - 12/8/22: Three stage 2, one stage 3, one stage 4, and two unstageable pressure ulcers. - 3/26/23: One stage 2, one stage 4, and two unstageable pressure ulcers. Review of Resident #701's care plans revealed a care plan entitled, The resident has actual impairment R/T (related to) multiple pressure ulcer/wounds: 1) Right Trochanter #1 2) Right Ischial Tuberosity #28 3) Left Ischial Tuberosity #44 4) Right Shin #51 5) Right shin DTI #54 6) Right Buttock #56 (Initiated: 3/16/23). The following interventions were included in the care plan: - Evaluate and treat per physician's orders (Initiated: 6/2/21) - Encourage resident to have heels elevated while resident is lying in bed (Initiated: 12/29/22) - Antifungal per order to excoriated area abdomen and between legs (Initiated: 11/23/22) - Attend wound clinic as ordered (Initiated: 1/12/23) - Encourage [Name of Resident] to reposition with cares and brief check and change. Report declines in care for repositioning (Initiated: 11/9/22) - Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration etc. to MD. (Initiated: 11/9/23) - Pressure redistribution mattress. Pressure redistribution cushion to chair (Initiated: 11/23/22) - Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations (Initiated: 7/20/21) Review of Resident #701's progress note documentation in the Electronic Medical Record (EMR) revealed the following: No progress notes were present in the EMR on 7/11/23 and 7/12/23. - 7/13/23 at 5:29 AM: Health Status Note . At 2200 (10:00 PM), went to resident's room with CNA (Certified Nursing Assistant) to perform dressing changes on wounds. Resident stated . had a shower, had been turned not long ago and was too sore to be turned again and did not want a dressing change. DON aware. - 7/13/23 at 2:49 PM: SBAR- General . excessive bleeding from wound to L ischial; soaked through dressing in 2 hours and blood soaked through bedding as well . Send to ED for Eval . - 7/13/23 at 2:51 PM: SNF to ED Handoff . Key clinical Information: --has Factor 5 clotting disorder -left ischial tuberosity wounds were debrided on Tuesday 7/11 --large amount of bright red and dark clotted blood/bleeding from those wounds --dressings saturated with blood within 2 hours of being changed -- resident is pale and clammy . Wounds: left ischial tuberosity, right ischial tuberosity x2, right hip, left medial ankle, left medial foot, right shin (upper), right shin (lower) . - 7/13/23 at 2:54 PM: Health Status Note . Notified at 1200 that resident bleeding from wound more than normal. Resident slight pale no other changes noted at this time. Dressing changed at that time and notified physician. New orders to obtain a CBC (blood laboratory test). Entered room at 1400 to obtain CBC. Noted Bled through dressing and large amount of bloody drainage in bed pad. Resident pale, clammy and shaky at this time. Notified the physician immediately and obtained order to ship to ED for eval. Changed dressing and wrote time and date for reference for Hospital. Family notified and EMS called. - 7/13/23 at 3:12 PM: Health Status Note . Observed that resident looked pale at 0700 (AM); (Resident #701) stated was feeling fine. 1200: Called into resident by CNA stating that resident was bleeding. Observed large amount of [NAME] bleeding from left ischial tuberosity wounds; soaked through cloth under pad, draw sheet, and fitted sheet. Notified (RN I) and asked them to assess. (RN I) notified Dr. and received new CBC order. Directive given to pack wounds and apply dressing. 1400: Notified by (RN I) that left ischial tuberosity dressings were saturated with blood . notified Dr. and order given to send to ER. Left ischial tuberosity wounds packed with dry gauze, covered with ABD, and secured with tape. DON aware . - 7/14/23 at 1:40 AM: Health Status Note . Resident returned from (hospital) via EMS and stretcher after receiving 2 units of blood. Currently dressings to wounds are holding and there is no visible sign of bleeding. - 7/17/23 at 8:35 PM: Physician/PA/NP - Progress Note (Narrative) . Late Entry . Problem visit involving emergency department visit for intractable bleeding to hip wound. Patient was sent to the emergency room for rapid evaluation and treatment of intractable bleeding hip wound that was passing large clots. While in emergency department patient was noted to be severely anemic and blood transfusion was performed for 2 units of packed red blood cells. Patient was noted stable following this and was discharged back to the facility for continued treatment . Critical Anemia- Resolved presently. Patient received 2 units packed red blood cells during emergency department visit Likely due to wound debridement with significant bleeding. Review of Resident #701's medication orders and Medication Administration Record (MAR) for July 2023 revealed the Resident was receiving Apixaban (Eliquis- anticoagulant medication) 5 milligrams (mg) twice a day. An interview was completed with the Director of Nursing (DON) and RN A on 8/31/23 at 10:00 AM. When queried regarding Resident #701's wound care provider documentation, the staff revealed wound care providers do not document in the EMR. When asked if the Resident had a bedside debridement on 7/11/23, RN A stated, (Wound Care NP C) did at bedside and (Resident #701) had bleeding the next day. RN A then stated, (Resident #701) was sent to the hospital and got a blood (transfusion). When asked if the bleeding which necessitated emergency transfer was from the pressure ulcer which had been debrided, the staff indicated it was. The DON stated, (Resident #701) has a clotting disorder. When asked which clotting disorder Resident #701 has, as it was not specified on the Resident's face sheet diagnoses, RN A replied, Factor V (inherited disorder which causes abnormal blood clotting). When queried if NP C was aware of the Resident's medical history, both the DON and RN A indicated they were. The DON revealed [NAME] Clerk F was present when the debridement occurred and stated, (Ward Clerk F) told (NP C) about Resident #701's medical history. When queried if consent was obtained for the bedside procedure prior to completion, RN A indicated NP C documented verbal consent was obtained but a written informed consent was not obtained. Wound documentation including wound care provider notes were requested at this time. Review of Resident #701's Wound Care Visit Report note dated 7/6/23 revealed, Multiple sites on BLE (Bilateral Lower Extremities) . Pressure . Modifying factors: contractures, inc (incontinence), immobility, hx. (history) of excessive sweating . Wound Assessments . - Wound #2 Right, Proximal Lower Leg shin . Unstageable Pressure Injury Obscured full thickness skin and tissue loss Pressure Ulcer . Not Healed . measurements 2.5 cm (centimeter) length X 1.4 cm width . small amount of serosanguineous drainage . 75 100-% slough . - Wound #3 Left Ischial . Stage 3 Pressure Injury Pressure Ulcer . 6.9 cm length X 3 cm width X 0.2 cm depth . muscle and adipose are exposed . small amount of serosanguineous drainage . Wound bed had 76-100 % granulation, no slough . improving . - Wound #4 Right Ischial . Stage 3 Pressure Injury Pressure Ulcer . 4.6 cm length X 3.7 cm width X 0.1 cm depth . muscle and adipose are exposed . moderate amount of serosanguineous drainage . 76-100 % granulation . improving . - Wound #5 Left, Medial Ankle . Unstageable Pressure Injury Obscured full thickness skin and tissue loss Pressure Ulcer . 1.4 cm X 0.8 cm . Wound bed has 76-100 % slough . deteriorating . area debrided . - Wound # 6 Perineum buttocks . dermatologic/rash not healed . improving . - Wound #7 Left Hip . Unstageable Pressure Injury Obscured full thickness skin and tissue loss Pressure Ulcer . 2.6 cm X 1.9 cm with no measurable depth .Scant amount of sero-sanguineous drainage .Wound bed has 25-50 % slough, 26-50% eschar . deteriorating . Area now unstageable with 50% eschar and slough covering wound bed . - Wound #8 Left malleolus . Stage 3 Pressure Injury Pressure Ulcer . 0.8 cm X 1 cm . adipose is exposed . improving . area with decreased depth . -Wound # 9 Left, Medial Foot . Unstageable Pressure Injury Obscured full thickness skin and tissue loss Pressure Ulcer . 1.4 cm X 1 cm . no measurable depth . Scant amount of sero-sanguineous drainage . wound bed has 26-50 % slough, 26-50 % eschar . deteriorating . Procedures . - Wound #2 . Right, Proximal Lower Leg shin. A skin/subcutaneous tissue/muscle/fascia level excisional/surgical debridement . was performed . to remove . slough . Post Debridement Measurements: 2.5 cm X 1.4 cm . Unable to debride wound bed, some slough remains and is covering wound bed . - Wound #5 . Left, Medial Ankle . A skin/subcutaneous tissue/muscle/fascia level excisional/surgical debridement with a total debrided area of 1.05 sq (square) cm . was performed . to remove . slough . Post Debridement Measurements: 1.5 cm X 0.7 cm . Unable to debride 100%, debrided top layer but slough still remains in wound bed, unable to debride to base . Wound Orders: - Wound #2 Right, Proximal Lower Leg shin . Dakin's Solution (antiseptic wound cleansing solution) . Medihoney (ointment used to promote moist wound healing) . Foam Dressing . Daily and PRN (as needed) if soiled . - Wound #3 Left Ischial . Dakin's Solution . Periwound Skin Care: Magic Butt Cream- Nystatin and Zinc Oxide . Primary Dressing: Medihoney . ABD Pad (dressing) - Avoid any tape/adhesive when possible . 2 X per day and PRN if soiled . - Wound #4 Right Ischial . Dakin's Solution . Periwound Skin Care: Magic Butt Cream- Nystatin and Zinc Oxide . Primary Dressing: Medihoney . ABD Pad (dressing) - Avoid any tape/adhesive when possible . 2 X per day and PRN if soiled . - Wound #5 Left, Medial Ankle . Dakin's Solution . Medihoney . Foam Dressing . Daily and PRN (as needed) if soiled . - Wound #7 Left Hip . Dakin's Solution . Periwound Skin Care: Magic Butt Cream- Nystatin and Zinc Oxide . Primary Dressing: Medihoney . ABD Pad (dressing) - Avoid any tape/adhesive when possible . 2 X per day and PRN if soiled . - Wound #8 Left malleolus . Dakin's Solution . Zinc Oxide . Foam Dressing . Daily and PRN if soiled . -Wound # 9 Left, Medial Foot . Dakin's Solution . Medihoney . Foam Dressing . Daily and PRN (as needed) if soiled . - Wound # 6 Perineum buttocks . Wash with soap and water .Magic Butt Cream Zinc Oxide and Nystatin cream BID (twice a day) . No brief in bed . 3X per day TID (three times/day) and PRN . Repeat Diflucan (oral antifungal medication) X 1 . Review of Resident #701's Wound Care Visit Report note dated 7/11/23 revealed, Multiple sites on BLE (Bilateral Lower Extremities) . Pressure . Modifying factors: contractures, incontinence, immobility, hx. (history) of excessive sweating . - Wound #2 Right, Proximal Lower Leg shin . Unstageable Pressure Injury Obscured full thickness skin and tissue loss Pressure Ulcer . measurements 2.3 cm (centimeter) length X 2.9 cm width . improving . 75% slough . - Wound #3 Left Ischial . Stage 3 Pressure Injury Pressure Ulcer . 8 cm length X 3 cm width X 0.2 cm depth . muscle and adipose are exposed . amount of serosanguineous drainage . deteriorating . - Wound #4 Right Ischial . Stage 3 Pressure Injury Pressure Ulcer . 5 cm length X 3.4 cm width X 0.1 cm depth . muscle and adipose are exposed . moderate amount of serosanguineous drainage . no change . - Wound #5 Left, Medial Ankle . Unstageable Pressure Injury Obscured full thickness skin and tissue loss Pressure Ulcer . 1 cm X 0.8 cm . improving . - Wound # 6 Perineum buttocks . dermatologic/rash not healed . improving . - Wound #7 Left Hip . Unstageable Pressure Injury Obscured full thickness skin and tissue loss Pressure Ulcer . 4.5 cm X 3.4 cm with no measurable depth . 76-100% eschar . deteriorating . - Wound #8 Left malleolus . Stage 3 Pressure Injury Pressure Ulcer . 0.5 cm X 0.5 cm . adipose is exposed . much improved . -Wound # 9 Left, Medial Foot . Unstageable Pressure Injury Obscured full thickness skin and tissue loss Pressure Ulcer . 1.8 cm X 1.3 cm . no measurable depth . wound bed has 51-75% slough, 1-25% eschar . deteriorating . - Wound #10 Right Hip is a Stage 2 Pressure Injury Pressure Ulcer . Initial wound encounter measurements are 1 cm X 1 cm . no measurable depth . small amount of fresh blood drainage . - Wound #11 Right, Medial Ankle . Unstageable Pressure Injury Obscured full thickness skin and tissue loss Pressure Ulcer . Initial wound encounter measurements are 1 cm X 0.8 cm . no measurable depth . wound bed had 76-100% slough . - Wound #7 Pressure Ulcer is located on the Left hip. An excisional/surgical debridement . Total area debrided was 15.3 sq (square) cm . performed by (NP C). Adipose, dermis epidermis, muscle, and subcutaneous were removed to remove devitalized tissue: necrotic/eschar . Pain control achieved using N/A . minimal amount of bleeding . controlled with pressure . Post Debridement measurements: 4.5 cm X 3.4 cm X 0.2 cm . Post debridement State notes as Unstageable Pressure Injury Obscured full thickness skin and tissue loss . Wound Orders: - Wound #2 Right, Proximal Lower Leg shin . Dakin's Solution (antiseptic wound cleansing solution) . Medihoney (ointment used to promote moist wound healing) . Foam Dressing . Daily and PRN (as needed) if soiled . - Wound #3 Left Ischial . Dakin's Solution . Medihoney . ABD Pad (dressing) - Avoid any tape/adhesive when possible . Daily and PRN if soiled - Wound #4 Right Ischial . Dakin's Solution . Medihoney . ABD Pad - Avoid any tape/adhesive when possible . Daily and PRN if soiled . - Wound #5 Left, Medial Ankle . Dakin's Solution . Medihoney . Foam Dressing . Daily and PRN (as needed) if soiled . - Wound #7 Left Hip . Dakin's Solution . Medihoney . ABD Pad - Avoid any tape/adhesive when possible . Daily and PRN if soiled . - Wound #8 Left malleolus . Dakin's Solution . Zinc Oxide . Foam Dressing . Daily and PRN if soiled . -Wound # 9 Left, Medial Foot . Dakin's Solution . Medihoney . Foam Dressing . Daily and PRN (as needed) if soiled . - Wound #10 Right Hip . Dakin's Solution . Zinc Oxide . ABD Pad - Avoid any tape/adhesive when possible . Daily and PRN if soiled . - Wound #11 Right, Medial Ankle . Dakin's Solution . Medihoney . Foam Dressing . Daily and PRN (as needed) if soiled . - Wound # 6 Perineum buttocks . Wash with soap and water . House antifungal . No brief in bed . 3X per day TID (three times/day) and PRN . Review of Resident #701's Health Care Provider Orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR) for July 2023 revealed the following orders and treatments were in place and completion from 7/1/23 to 7/14/23: - Right shin: Cleanse with NS (Normal Saline) and pat dry. Apply Medihoney and cover with 4x4 comfort foam every day shift for wound care (Start Date: 6/26/23; Discontinued: 7/14/23). The TAR was blank, indicating the treatment was not completed on: 7/3/23, 7/6/23, 7/8/23, 7/10/23, and 7/14/23. Note: Right shin is Wound #2 per facility wound documentation. - Right ischial tuberosity: Cleanse with 1/2 strength Dakins, apply Medihoney to wound bed, and cover with ABD pad every day shift for wound care (Start Date: 6/26/23; Discontinued: 7/14/23). The TAR was blank, indicating the treatment was not completed on: 7/3/23, 7/6/23, 7/8/23, 7/10/23, 7/12/23, and 7/14/23. Note: Right ischial tuberosity is Wound #4 per facility provided wound documentation. - Right hip: Cleanse with NS and pat dry. Apply antifungal cream and leave open to air every day shift for wound care (Start Date: 6/26/23; Discontinued: 7/14/23). The TAR was blank, indicating the treatment was not completed on: 7/3/23, 7/6/23, 7/8/23, 7/10/23, 7/12/23, and 7/14/23. Note: Facility Provided Wound Documentation did not indicate a pressure ulcer/wound on Resident #701's right hip. - Left ischial tuberosity (Wound #3): Cleanse with 1/2 strength Dakins, apply Medihoney to wound bed, and cover with ABD pad every day shift for wound care (Start Date: 6/26/23; Discontinued: 7/14/23). The TAR was blank, indicating the treatment was not completed on: 7/3/23, 7/6/23, 7/8/23, 7/10/23, 7/12/23, and 7/14/23. Note: Left ischial tuberosity is Wound #3 per facility provided wound documentation. - L medial ankle and L medial foot wipe with barrier wipe and leave OTA (Open To Air) Q (every) day and prn every day shift for wound cares (Start Date: 6/26/23; Discontinued: 7/14/23). The TAR was blank, indicating the treatment was not completed on: 7/6/23, 7/8/23, 7/10/23, 7/12/23, and 7/14/23. Note: Left medial ankle is Wound #5 and L medial foot is Wound #9 per facility provided wound documentation. - Nystatin External Cream (antifungal cream) 100000 Unit/Gm (gram) Apply to buttocks topically every day and night shift for MASD (Moisture Associated Skin Damage) Magic butt cream (Start Date: 6/28/23; Discontinued: 8/11/23). The TAR was blank, indicating the treatment was not completed on: 7/6/23 Day, 7/8/23 Day, 7/10/23, Day and 7/12/23 Day. Note: Buttocks is Wound #6 per facility provided wound documentation. There was no treatment in place for Resident #7's left hip (Wound #7) and left outer malleolus (Wound #8) as specified on the Wound Care Provider NP C's documentation. Additionally, review revealed the orders and treatments in place on the TAR in the Electronic Medical Record (TAR) did not match orders indicated on Wound Care Provider NP C's documentation for the left ischial pressure ulcer treatment and buttock treatment frequency. On 8/31/23 at 11:00 AM, Resident #701 was observed in their room. The Resident was in bed, in the same position as on 8/30/23. When queried if they had their dressing changed today, Resident #701 stated, They did it at 4:00 AM today. They were gonna do it last night, but they didn't have the staff. When queried if they occasionally refuse to allow staff to change their wound dressings and/or reposition them in bed, Resident #701 replied, I used to. Resident #701 was asked the reason they had refused and stated, Pain because of the way they turned me. They were rough. An interview was completed with Physician D on 8/31/23 at 4:00 PM. When queried regarding Resident #701's pressure ulcers, Physician D revealed the facility was trying to find a more appropriate placement with greater wound care capabilities due to the Resident's extensive needs. Physician D was asked if they recalled Resident #701's transfer to the hospital on 7/13/23 in which they received two units of PRBCs prior to returning to the facility and revealed they did. When asked what occurred, Physician D indicated they were contacted by facility nursing staff and stated, I was alerted (Resident #701) had a bedside debridement on 7/11/23 and were now having uncontrolled bleeding. When queried if they were aware the wound had been debrided, Physician D revealed they were not and stated, I do not feel they (wound care provider) should have done it (debridement). I would have advised against it. With further inquiry, Physician D stated, I would never have given (medical) consent (for a bedside procedure) for someone with a known bleeding disorder. Physician D specified the Resident required closer observation following the procedure due to their co-morbidities. When asked if they typically speak with and discuss Resident plans of care with wound care providers prior to completion of bedside procedures, Physician D revealed they were not made aware of planned and/or completed procedures by the wound care provider who visits the facility. When asked how they coordinate the Resident's plan of care without communication, Physician D indicated they are able to review the wound care provider documentation in the Resident's medical record. An interview was conducted with CNA/Ward Clerk F on 8/31/23 at 2:03 PM. When queried if they worked on 7/11/23, [NAME] Clerk F confirmed they had. When queried regarding Resident #701's wound care treatment on that day, [NAME] Clerk F stated, I was asked to go with the wound doctor (NP C) when they completed wound care rounds in the facility. [NAME] Clerk F was queried who had asked them to go with NP C and specified it was a facility nurse. When queried if they typically rounded with Wound Care NP C, [NAME] Clerk F revealed the nurses or Unit Managers usually round with wound care providers. When queried why the nurses/Unit Managers did not round with NP C on 7/11/23, [NAME] Clerk F stated, The Unit Managers got pulled to work the floor. [NAME] Clerk F continued, I did it (rounded with Wound Care Provider) two weeks in a row. [NAME] Clerk F was asked what they did when they accompanied NP C and replied, I helped with all the (wound) treatments. When queried how they assisted, [NAME] Clerk F stated, I wrote down measurements and what (NP C) told me. [NAME] Clerk F revealed they would also obtain additional supplies as needed and stated, I would hold them (residents) and (assist) with positioning. When queried if they were present and recalled Resident #701's wound care treatment on 7/11/23, [NAME] Clerk F revealed they did. When asked, [NAME] Clerk F indicated they assisted with positioning the Resident and documentation of wound measurements dictated by NP C. With further inquiry, [NAME] Clerk F revealed they observed NP C complete the bedside debridement of Resident #701's left hip pressure ulcer. [NAME] Clerk F was asked what occurred and stated, (NP C) had all the stuff (surgical debridement instruments) with them. [NAME] Clerk F continued, (NP C) told (Resident #701) it (pressure ulcer) needed to be debrided. [NAME] Clerk F specified they informed NP C that Resident #701 had a blood clotting disorder prior to the debridement and recalled NP C asking the Resident what type of clotting disorder they had. [NAME] Clerk F revealed NP C completed the debridement. When queried if the pressure ulcer was bleeding, [NAME] Clerk F stated, It was. When asked how much the pressure ulcer was bleeding, [NAME] Clerk F replied, A lot. [NAME] Clerk F was asked how much was a lot and replied, Enough to make me say a lot. When queried what occurred after the debridement, [NAME] Clerk F indicated NP C applied pressure to the wound and then did the treatment. When queried if the wound was still bleeding when the dressing was applied, [NAME] Clerk F stated it was. On 8/31/23 at 2:20 PM, an interview was conducted with NP C. When queried if they recalled Resident #701, NP C indicated they did. NP C was asked if they recalled debriding the Resident's wounds on 7/11/23 and stated, I debrided their wounds before. There was nothing different. NP C was queried if prior bedside debridement of Resident #701's pressure ulcers included the same extent and type of tissue removal and indicated they would need to review the Resident's medical record to provide specific details. When asked if a facility nurse was present in the room when they completed the debridement, NP C replied there was. When queried the name of the nurse, NP C was unable to recall. NP C was then asked if (Ward Clerk F name) was who had accompanied them and confirmed. NP C was asked why they completed a bedside surgical procedure with [NAME] Clerk F and not a nurse, a response was not provided. When queried if a facility nurse normally accompanies them when they complete wound rounds and/or bedside procedures, NP C replied, There was a couple times I didn't have one. When asked if they were aware of the Resident's specific blood clotting disorder and current medications when they completed the debridement, NP C indicated they were. When asked if they were aware the Resident was receiving an anticoagulant medication (Eliquis), NP C stated they were unable to talk at this time and would need to continue the phone interview at a later time. An interview was completed with RN I on 8/31/23 at 3:26 PM. When queried if they were working 7/13/23 when Resident #701 was transferred to the hospital due to bleeding, RN I confirmed they were. When queried what occurred, RN I revealed they were working on the other side (of building) that day. RN I stated, At approximately noon, I think (Licensed Practical Nurse [LPN] G) went in to do dressing change. (LPN G) called me in because they noticed more bleeding than normal. When queried how much bleeding there was, RN I replied, The dressing was saturated. RN I was queried further regarding the amount of bleeding and type of dressing that was saturated and replied, ABD (abdominal) pad (large dressing used to absorb large amounts of wound drainage). RN I revealed the wound was actively bleeding when asked. When asked what they did after identifying the bleeding, RN I stated, I called the Doctor and got an order for labs. RN I was asked what Resident #701's vital signs were at that time and revealed they did not obtain the Resident's vital signs at that time. When queried if they obtained the blood work, RN I revealed they went in after lunch to obtain the blood sample and stated, (Resident #701's) bed was soaked with blood. They were pale, clammy, and shaky. RN I was asked to elaborate how much blood there was and revealed the Resident's bedding was completely saturated. RN I stated, (Resident #701) was a total bed

This Citation pertains to Intake Number MI00137092. Based on interview and record review the facility failed to respond timely and appropriately to Resident #401's change in condition, resulting in Resident #401's drastic mentation decline that continued until he was unresponsive with agonal respirations, low heart rate, cool to the touch, with no response to painful stimuli and no interventions until paramedics arrived. Resident #401 subsequently died . Findings include: Resident #401: On [DATE] at 3:28 PM, an interview was conducted with LPN (Licensed Practical Nurse) A regarding Resident #401's change in condition on [DATE]. LPN A explained the resident was normally alert and oriented x 3 and when she initially assessed him, he was only alert to self. She shared his breathing had been labored for 15- 20 minutes prior to EMS (Emergency Medical Services) arrival with no intervention implemented on her part. LPN A further reported she left the resident in his highly compromised state to call EMS. Nurse A was asked to provide a timeline of the events of that morning prior to Resident #401 being transported to the emergency room . LPN A shared around 9 AM/9:30 AM she administered the resident his morning medications and he was only alert to self at that time. She stated during medication administration she attempted to reorient him to no avail and did not obtain vitals at this point. She admitted there was a steep change in condition that she did not address until later in the morning. She added he was not answering any of her questions as he normally did. Prior to leaving the room she repositioned him on his back and added pillows on the side of him for comfort. Approximately 30 to 45 minutes later his aide alerted her that Resident #401 was moaning and obtained vitals. LPN A stated his oxygen levels were low at about 80 and his pulse was low as well. LPN A left the residents room to notify the physician and call 911 and recalled Central Dispatch instructing her to take the AED (Automated External Defibrillator) into the room. Once LPN A returned to the room Resident #401 was pale and gasping for air, because he was not receiving enough oxygen. LPN A placed oxygen (nasal cannula) on the resident but did not recheck his vitals to verify if oxygen administration was effective. LPN A admitted Resident #401 was on black but HOB (Head of Bed) was elevated slightly. LPN A was asked if the AED was applied, and she stated it was not. LPN A recalled checking his blood sugar between 8 AM - 10 AM but does not know if it was rechecked after. LPN A was queried if at any time she requested assistance from other facility nurses, called a code, applied the AED, or started CPR (Cardiopulmonary Resuscitation) and she stated No. She stated it was a chaotic day and only one other nurse was in the facility. LPN A reported prior to EMS arrival the resident became unresponsive and LPN A admitted she did not provide life saving measures. Upon EMS arrival LPN A shared they were visibly annoyed and told her Resident #401 was dying and LPN A was doing nothing at an attempt to save him. Which LPN A agreed that she did not do anything at an attempt to intervene while Resident #401 was in respiratory distress. LPN A was asked if her inaction during Resident #401's change in condition and failure to administer lifesaving intervention aligned with nursing standards of practice, she answered they did not. She further expressed she should have checked his vitals when she noticed his initial change in condition during medication pass, completed frequent visual checks to monitor his change in condition and called to send him out sooner. With his deterioration she should have notified the other nurse for additional assistance, turned Resident #401 on his side, applied the AED and retrieved the crash cart. LPN A stated she was unsure why she did not administer lifesaving interventions but reiterated it was chaotic day. LPN A and this writer reviewed Resident #401' record for a detailed account of what occurred, and the only thing LPN A charted was acute change in mentation. LPN A was queried if her documentation provided a clear account of the true events that occurred with Resident #401's change in condition and Nurse LPN A agreed her documentation greatly lacked. Record review revealed Resident #401 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus, kidney disease, weakness, metabolic encephalopathy (drain dysfunction caused by chemical imbalances in the blood from organ malfunction), cerebral infarction (stroke) with resulting hemiplegia/hemiparalysis (one sided paralysis), dysphagia (difficulty swallowing), and aphasia (difficulty communicating). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required limited to extensive assistance to complete all Activities of Daily Living (ADL) with the exception of eating. Further review of Resident #401's records indicated the following: Progress Notes: [DATE] at 10:49: .pulse rate 36 manual acute change in mentation .P (pulse): 36, R (Respirations): 16, O2 (oxygen): 80% 1051 Method: Room air . [DATE] at 06:17: Resident in hospital from massive heart attack per report. Vital Signs from [DATE]: Pulse: 36 bmp at 10:20 AM Respirations: 16 Breaths/min at 10:20 AM Blood Sugar: 105 at 10:15 AM O2 Saturation: 80% at 10:51 AM Review was completed of Resident #401's real time medication administration and medication administration record indicated LPN A administered 16 units of fast acting insulin to Resident #401 at 8:41 AM. The order stated, subcutaneously before meals and at bedtime . Review of the FAR (Food Administration Record) indicated Resident #401 ate 0% of his breakfast. While Resident #401 did have a PEG tube in place for fluid flushes he still received meals from dietary. EMS Run Report: Dispatched at 10:30 AM, on scene at 10:37 AM, at patient at 10:39 AM, departed scene at 11:15 AM .Dispatched to (facility) .for male with low heart rate .crew updated en route that there have been mental status changes. Upon arrival, staff met the crew at the door, and causally walked to the patients room. When the staff were asked what the complaint was, the response was A heart rate in the 30's. As this medic walked in the room, the pt (patient) was observed in a supine position, and as having agonal respirations at approximately 6 BPM. The nurse was asked how long the pt has ben trying to breath like this, and the responses was ,d+[DATE] minutes. There had been no interventions done by the NH (Nursing Home) staff. The nurse stood there holding the paperwork, and showed no effort to intervene by providing care. Pt was no on oxygen upon our arrival, nor had a BGL been take. Pt is diabetic. The Pt was unresponsive, pale, cold to the touch, agonal respiration's, and non-palpable carotid pulse. GCS (Glasgow Coma Scale- clinical scale used to reliably measure a person's level of consciousness after brain injury. The range is 3 (completely unresponsive) to 15 (responsive) of 3. A request for (another crew) was made. The Pt was immediately loaded onto the cot, and taken directly to the ambulance, pads were applied, BVM (Bag- Valve-Mask) with oxygen at 12 LPM (liters per minute) utilized to assist with ventilation. Pupils were equal, but non-reactive. EMT (F) attempted to insert combitube, but the Pt's teeth were clenched. (2nd) crew arrived and the LUCAS was applied, due to undetectable pulse, CPR initiated, pads showed a HR (heart rate) in the 30's, but with an indiscernible rhythm. HR fluctuated rapidly between the 30's to 50's. Paramedic (E) inserted IO's (Intraosseous infusion- process of injecting medications, fluids or blood products directly into the marrow of a bone) bilaterally in the tibias. After a period of time, an administration of Epi 1 MG (milligram) x 2, and Atropine 0.5 MG x 2, the Pt had some movement of his feet and head. Pt had clenched fists. Capnography (Instrument used to measure the amount of carbon dioxide in exhaled air) never went about 22 mmHg (millimeters of mercury- normal values are ,d+[DATE] mmHg), SpO2 fluctuated between the low 60's to 95% at one point. SpO2 typically was in the 73% range. Initial BGL (blood glucose level) of 30. Administration of D-50 and a D-10 Drip. BGL went up to 300 after dextrose. Pt has no remarkable response to any interventions. A faint pulse in the femoral artery was detected, so compressions were discontinued, ventilation improved via BVM. Pt had abnormal and severe swelling in his right hand, origin unknown .Pt loaded onto cot via bed draw sheet. Pt loaded into ambulance on the cot. Pt assessed, treated, and monitored on scene with both crews in back to address immediate life threats. Pt was transported to (emergency room ) . P1 . Per the records Resident #401's oxygen levels were checked at 10:51 AM when all other vitals were recorded between 10:15 AM - 10:20 AM. Furthermore, EMS arrived at the facility at 10:39 AM and it brings into question when the Resident's vitals were truly assessed and if the documentation is accurate as EMS documentation negated LPN A accounts of the events and documented vital signs. On [DATE] at approximately 9:45 AM, an interview was conducted with the complainant , who stated that the nurse caring for Resident #401 was negligent and failed to provide any lifesaving interventions that led to the death of the resident. The complainant reported that the nurses were not bothered by Resident #401's deteriorating condition. On [DATE] at 10:15 AM, an interview was conducted with DON (Director of Nursing) and Director of Clinical Operations J, regarding their expectations of their staff during an acute change in condition. The DON reported they would expect nurses to complete a thorough assessment once the change in condition was observed or brought to their attention. Staff need to always remain with the resident to monitor for further decline. They stated it is not appropriate for them to continue doing other nursing tasks if a resident is in distress. They were informed of the incident that occurred with Resident #401 the DON and Director of Clinical Operations J, stated they were unaware of the incident. Review was completed of the documentation and reported the charting did not accurately depict what occurred. On [DATE] at 12:00 PM, an interview was conducted with Certified Nursing Assistant (CNA) B regarding Resident #401's transfer to the hospital on [DATE]. CNA B stated she arrived to work around 6:45 AM and completed walking rounds with CNA H who informed her Resident #401 didn't look good. CNA A observed Resident #401 lying in bed, grunting loudly and lethargic. CNA B informed LPN A of her observations at 7 AM/7:30 AM and was instructed to obtain vitals. CNA B reported his heart rate would not register and she completed it manually and it was 32. CNA B provided the set of vitals to LPN B who informed her she would check on the resident momentarily. CNA B admitted she thought it was odd LPN A did not respond hurriedly when provided with his low heart rate and his mentation change, as he is typically lively and talkative. CNA B was uncertain if LPN checked on the resident after she initially informed her of his change in condition. CNA B stated about an hour later she informed LPN A again of Resident #401's declining condition, she stated the resident was groaning loudly that another resident asked if he was ok. CNA B stated his temperature was not registering, he was cold to the touch, his head was slumped to the side, his breathing was shallow and not responding to physical stimuli. Once LPN A came in the room with her and listened to his heart, she left the resident to call the doctor and EMS. Upon her return she had the AED but did not place it on the resident. CNA B was asked if LPN A provided any interventions to Resident #401 and she reported she did not. She stated he was not on oxygen nor does she recall LPN A checking his blood sugar. Upon EMS arrival they were visibly upset at the condition of Resident #401 and asked how long he had been breathing like that and LPN A responded ,d+[DATE] minutes, CNA B stated that was inaccurate as he had been breathing shallow and gasping for air for longer than that. CNA B reported EMS said the resident was in respiratory distress, transferred the resident to their gurney and then into their ambulance but sat in the parking lot for ,d+[DATE] hour to 45 minutes before they left. CNA B was asked to clarify how many times she alerted LPN A to Resident #401's change in condition and CNA B responded twice. CNA B reiterated Resident #401 was unresponsive prior to EMS arrival, and it sounded like he was drowning as he was making a gurgling noise. She stated the crash cart was not in room, the AED was not applied to the resident, nor was oxygen and LPN A did not provide any interventions as Resident #401 was in respiratory distress. On [DATE] at 1:50 PM, EMT (Emergency Medical Technician) F was interviewed regarding their response on [DATE] for Resident #401. EMT F stated he was partnered with Paramedic B when they were dispatched to the facility for an ill resident with a change in mentation. Upon their arrival to the facility Resident #401 had agonal breathing at 6 BPM, when nursing staff were asked how long he had been breathing like this they responded ,d+[DATE] minutes. Resident #401 was laying on his back, head of bed elevated about 5 degrees and supplemental oxygen was not in place. EMT F and Paramedic B asked if they had completed a blood glucose check and they responded they had not. EMT F' and Paramedic B rushed the resident to their ambulance and called for assistance as they rendered aide to the resident. Once in the ambulance Resident #401 did not have a pulse and they began CPR with the LUCAS, administered epinephrine, intraosseous access in his shins, attempted combitube but his jaw was clenched and they were unable to insert anything, amongst many other lifesaving interventions until they could stabilize him for transfer. EMT F explained when they arrive to the facility Resident #401 was unresponsive with agonal breathing. He was not receiving proper oxygenation to his brain and was retaining carbon dioxide. All the while nursing staff stood there with no urgency for his deteriorated state with a stack of papers in their hand. EMT F staff did absolutely nothing. Paramedic B was interviewed on [DATE] at 2:11 PM regarding their response to the facility on [DATE] for Resident #401. Paramedic B stated upon arrival Resident #401 was observed laying supine in bed with agonal respirations. When LPN A was questioned how long he had been in this state she responded ,d+[DATE] minutes. Paramedic B said LPN A just stood there with transfer paperwork in her hand and the CNA was on the other side of the bed but they did not provide any treatment to the distressed resident. Paramedic B reported he was unresponsive, and his body was starved for oxygen. She continued it was negligent of the nurse to not begin CPR and provide some type of intervention until they arrived on scene. Paramedic B reported his blood glucose was 30 and it's not plausible for it to drop that low in minutes. The lack of urgency and disregard for their resident was alarming. On [DATE] at 3:35 PM, EMT I was asked to recount the events of [DATE] when they responded to the facility to assist the primary rig with Resident #401. EMT I stated a full code was being completed, the LUCAS had been deployed, Resident #401 was being bagged with BVM, medications were being administered consistent with ALS protocol and IO's in his legs. This all occurred in the facility parking lot. EMT I stated the initial dispatch was mental status change and low heart rate but when the primary rig arrived Resident #401 was not conscious with agonal respirations while the nurse (LPN A) stood there with the transfer paperwork. The nurse just stood there, dumbfounded, and was not completing any life saving measures. EMT I explained all their equipment to perform a code was in their rig, as the call came out as mention change; which was grossly inaccurate. EMT I stated they worked on the resident until was stable enough to transport to the emergency room that is only 2 miles from the facility. On [DATE] at 5:40 PM, an interview was conducted with Paramedic E regarding their response to the facility on [DATE] for Resident #401. Paramedic E stated they were the 2nd unit that responded, and the resident was hypoglycemic at 30 and his pulse would not read on the monitor. They started IO access and there was no movement from the resident during a procedure that is highly painful. Paramedic E stated they administered dextrose to combat his hypoglycemia and other ALS protocol medications. He recalled he had an unusual rhythm. He continued the facility did not intervene on Resident #401's behalf and they worked to stabilize him prior to transfer. A follow up interview was conducted with LPN A on [DATE] at 11:44 AM. When queried if they recalled working and providing care to Resident #401 on [DATE] when they were transferred to the hospital, LPN A indicated they did. LPN A was then asked if they administered Resident #401's insulin prior to or after the Resident ate their breakfast and replied, Before. When queried when Resident #401's blood glucose level was obtained, LPN A replied, I did it at the same time (as medications were administered). LPN A was asked what time breakfast is served to Residents and revealed all breakfast trays are served by 7:30 AM. When queried why Resident #401's insulin was not administrated until 8:41 AM, as documented on the real time medication administration report, if they administered the insulin prior to the Resident eating, LPN A replied, My morning medication pass was behind. LPN A was asked to clarify if they were saying they checked the blood glucose level and administered Resident #401's insulin after breakfast and stated, Yes. LPN A was asked if they rechecked Resident #401's blood glucose at all prior to being transferred to the hospital and revealed they checked the Resident's blood glucose level when the CNA (Certified Nursing Assistant) informed them they were concerned about the Resident. When queried why Resident #401's blood glucose level was 30 when checked by EMS but they documented it was 105 at 10:15 AM, LPN A replied, I don't know. Maybe the long acting kicked it. LPN A was asked if Resident #401 ate their breakfast on [DATE] when they administered 16 units of rapid acting insulin and stated, I assumed (Resident #401) had eaten. With further inquiry, LPN A revealed they did not know if the Resident had eaten or not and stated, I should have checked with their CNA. When queried when they first saw Resident #401 on [DATE], LPN A revealed it was when they administered their morning medications and stated, (Resident #401) wasn't feeling well. When asked what was wrong, LPN A did not respond. With further inquiry regarding the Resident's change in condition and transfer, LPN A stated, The CNA came and told me (Resident #401) wasn't feeling well. I went back and gave pain meds. LPN A was then queried what happened after that and revealed they left the room. LPN A revealed the CNA located them and reported additional concerns related to Resident #401. LPN A stated, That is when we went in (to Resident #401's) room and got vitals. I called the doctor and EMS. (Resident #401's) oxygen and apical pulse were low. LPN A was asked what they did in response to the Resident's critical change in condition, LPN A stated, I needed to come out (of room) and get discharge orders. When queried what, if any actions, they took upon identifying the Resident's change in condition at that time, LPN A stated, I put oxygen on via nasal cannula. When queried regarding the oxygen rate, LPN A replied, I think 3L. When asked if what the Resident's SPO2 (blood oxygen level) increased to after the oxygen was applied, LPN A did not provide a response. When asked if they rechecked the Resident's SPO2 level after application of oxygen via nasal cannula, LPN A revealed they did not. When asked why EMS documentation specified Resident #401 did not have supplemental oxygen in place when they arrived at the facility, LPN A stated, I sent the CNA to go get the (oxygen) concentrator. LPN A was asked if they left the Resident to obtain/gather transfer paperwork before asking the CNA to obtain an oxygen concentrator, LPN A replied, Yes. LPN A was asked to clarify if they were saying they left Resident #401 in the room, without providing any emergency care including supplement oxygen while they were in respiratory distress and with no other licensed staff present, LPN A stated, Yes. LPN was then asked if it was possible Resident #401 did not have oxygen in place when EMS staff arrived at the facility and replied, Yes. LPN A was asked if they were BLS (Basic Life Support) certified and stated, Yes. LPN A was asked if Resident #401 was unresponsive, had poor perfusion and circulation including an unpalpable pulse and agonal and/or altered respiratory status and replied, Yes. When queried why they did not initiate CPR, LPN A replied, Because (Resident #401) still had a heart rate. When queried how long Resident #401 was unresponsive, LPN A stated, ,d+[DATE] minutes. When queried if there were any actions and/or care for Resident #401 that was not completed but should have been, LPN A stated, Should have made sure (Resident #401) ate before gave insulin, should have stabilized their oxygen and applied the AED (Automated External Defibrillator). When asked why they did not, LPN A did not provide an explanation. When queried if they responded quickly enough to the Resident's change in condition, LPN A replied, No. I should have pulled the other nurse in with me and pulled the crash cart in with me. LPN A was not truthful about the events surrounding Resident #401's change in condition unless provided with documented facts from the resident's records. LPN A documentation related to the events were minuscule and believed to be intentional, to avoid additional clarifying questions regarding her inaction. She failed to administer any interventions as Resident #401 was in respiratory distress and rapidly deteriorating while under her care. EMS arrived, transported him to the ambulance and for 45 minutes (in the facility parking lot), administered lifesaving interventions to stabilize the resident prior to transfer to the emergency room . Resident #401 was intubated, and life flighted to an outlying emergency department where he ultimately passed away at 3:10 AM on [DATE]. LPN A inability to provide comprehensive nursing care, disregard for human life and negligence and failure to act timely during a change in condition are directly related to Resident #401's death. A review was completed of the facility's LPN Job Description and it stated the following: .the Licensed Practical Nurse (LPN) assumes responsibility and accountability for a group of residents/patients for a shift of duty. Nursing care is provided through assessment, implementations, and evaluation of the plan of care. The LPN adheres to the standards of care for the area .Duties/Responsibilities: Provides routine care for patients during respective shifts. Provides required patient assessments/observations and interventions. Plans and manages patient care according to each patient's needs .obtains patient vital signs, including pulse, blood pressure, temperature and reparation. Provides licensed care to assigned residents as ordered by physician and in accordance with facility, federal, state and local standards, guidelines and regulations .Appraises the DON/Unit Manager of resident/patient status changes in condition Provides respiratory care, e.g. oxygen .Prepares and administers medications and performs treatments as ordered by the Physician .Charts nurses notes in an informative and descriptive manner that reflects the care provided as well as the resident's/patients response to the care Informs physician of resident/patient change of condition .Closely monitors and supervises all facility residents per facility policies and as warranted by good nursing judgement . Review was completed of Resident #401's which indicated he was initially transferred a local emergency room , he subsequently emergently life flighted to another emergency room and admitted to ICU (Intensive Care Unit) where he passed away. [DATE]: Unresponsive per (facility) staff for 15 minutes -patient given x 2 epinephrine by EMS and CPR started o arrival patient has agonal breathing-CPR in progress on arrival. EMS report patient glucose was 30 on their arrival- given D50 followed by D10 drip .Bradycardia present .He is unresponsive .cardiac failure .intubation .Case discussed in great length with attending emergency department physician .He accepts the patient and adds that he will send the helicopter for his facility . The patients blood pressure decreased to ,d+[DATE] .he was transferred in stable condition . Resident #401 was life flighted to a secondary Emergency Department for treatment: .The patient was at skilled nursing facility and was found unresponsive with low blood sugar when EMS arrived .In route to hospital he did undergo PEA (Pulseless electrical activity) arrest. Upon arrival to outlying emergency department the patient was in and out of PEA arrest multiple episodes of ROSC (Return of Spontaneous Circulation) achieving then loosing pulses for total of ,d+[DATE] minutes per ER physician at bedside .The patient was emergently life flighted to our facility for further care .Ventilator at bedside has respiratory rate 22, tidal volume 420, PEEP of 5, FiO2 of 60% .The patient has fixed and dilated pupils not responding to any pain at this time .Cardiopulmonary arrest, acute hypoxic respiratory failure status post oral intubation, septic/cardiogenic shock, acute metabolic/anoxic encephalopathy .high morbidity and mortality risks, discussed with family at bedside, holding his mother, whom decided to change code status to comfort measure only per patient previous wishes knowing his previous poor quality of life ,high morbidity and mortality risk, proceed with terminal extubation and hospice consult if needed . patient passed away and time of death was 0310 .Patient was in cardiac arrest with return of spontaneous circulation .Chest x-ray upon arrival shows satisfactory placement of endotracheal tube .patient will require admission to intensive care unit . An interview was completed with Physician R on [DATE] at 4:54 PM. When queried regarding facility policy/procedure related to contacting them for transfer orders when there is a change in Resident condition necessitating emergency transfer, Physician R indicated it was dependent upon the situation. When asked if they want staff to call them prior to transferring out a Resident in unstable condition, Physician R stated, I would want them sent out. Physician R indicated the Resident's health and well-being was more important than contacting them. When asked if facility nursing staff were able to transfer residents without obtaining a Health Care Provider order, Physician R confirmed nursing staff can transfer residents to the hospital in emergency situations and contact them afterwards to inform them of what had occurred. Physician R was asked if they recalled Resident #401 including their change in condition and transfer to the hospital on [DATE]. Physician R revealed they recalled the resident but were unable to access the facility medical records at this time. When queried if they were aware Resident #401 was known to be unresponsive and in respiratory and cardiac distress for ,d+[DATE] minutes with no interventions implemented, Physician R revealed they were unaware that occurred. When asked if LPN A contacted them to obtain orders to transfer Resident #401, Physician A checked their phone records and stated, Gave order (to transfer) at 10:14 (AM). Review of the EMS Report for Resident #401's transfer on [DATE] detailed the facility called 911 at 10:29 AM. When queried regarding the timeframe between their order and the 911 call, Physician A was unable to provide an explanation. When queried if there was any reason supplemental oxygen was not implemented when Resident #401 was experiencing agonal respirations and decline in level of consciousness, Physician A indicated they were unaware of any concerns related to the Resident's care at the facility and/or transfer. Resident #401's EMS Report was reviewed with Physician R at this time. After review, Physician R expressed concern related to the lack of care and stated, That is not acceptable. Physician R reiterated they were unaware of the lack of care provided to Resident #401 by the facility nurse and verbalized dissatisfaction with the care provided.

This Citation pertains to Intake Number MI00137749. Based on interview, and record review the facility failed to obtain the temperature of hot water prior to distribution to Resident #402 and utilize their policies and procedures for serving resident hot liquid. Resulting in, Resident #402 sustaining 2nd degree burns on his right lateral thigh, front of right thigh and right shin, his wounds became infected at the facility, and he required hospitalization in a burn unit and cadaver skin graft was completed during his hospital course. Findings include: On 6/29/23 at approximately 2:00 PM, a walkthrough of the facility kitchen was completed with Dietary Manager L. An industrial coffee brewer was observed to have dual brewers and hot water spicket. Manager L explained the coffee is dispensed into air pots and prior to any hot liquids being served to residents the temperature must be 150 degrees. If the temperature is higher than 150, dietary staff will add ice cubes until it reaches their desired temperature. The hot water is dispensed from the water spicket into the crafts and the same cooling process is completed as the coffee. Temperature logs from April to 6/29/2023 were requested for Dietary Manager L. The manager explained as of June 1st they have new temperature logs as the prior log did not have a column for hot water nor re-temp of coffee once cooled. The new Coffee and Hot Water Temp Log, was reviewed and for hot water there was not a second column that indicated the temperature once it was cooled. Manager L stated while the new temperature log process was implemented on 6/1/2023 a resident suffered burns from hot chocolate shortly after implantation. It was explained every morning Resident #403 requests hot chocolate from dietary staff but on this day he requested two cups of hot chocolates and provided one to Resident #402. Resident #402 spilled the hot chocolate and suffered 2nd degree burns. From this incident dietary staff can no longer serve directly from the kitchen. Residents would ring the dietary door bell and request items from the kitchen staff but this process is no longer in effect. Manager L stated dietary staff were temping the hot water but did not document it. On 6/29/23 at 2:55 PM, Dietary Aide M was interviewed and stated Resident #403 request hot chocolate daily about 7:00 AM. On this day he requested two cups of hot chocolate which the aide thought was odd but just assumed he wanted an extra cup and did not question him further regarding his request. Upon his request Aide M dispensed the hot water from the brewer spicket into the cups, stirred in the hot chocolate and gave both cups to Resident #403. Aide M was asked if the temperature of the water was taken prior to providing it to Resident #403 and the aide responded it was not. Aide M explained the temperature of the coffee was consistently taken prior to leaving the kitchen but not the hot water. Aide M reported she did not know he was going to give the 2nd cup of hot chocolate to another resident. Aide M, continued prior to this incident they always dispensed the hot water from the side spicket on the brewer. Resident #403 was observed enjoying an activity with other residents on 6/29/23 at 3:15 PM. Resident #403 stated he has drank hot chocolate every morning for over [AGE] years. The resident stated he did request two hot chocolates and provided one to Resident #402. He stated Resident #402 placed the hot chocolate on the armrest of his reclining chair, fell asleep and the hot chocolate spilled on him causing his injuries. On 6/30/2023 at 9:30 AM, an interview was conducted with DON (Director of Nursing) and Director of Clinical Operations J, regarding Resident #402's burn. DON stated Resident #402 received two hot chocolates from the kitchen and provided one to Resident #402 and then went back to his room. A CNA (Certified Nursing Assistant) heard the resident screaming and discovered he spilled the hot chocolate and had burns. The nurse was able to assess his burns which were red and blistered. Resident #402 was transported to the emergency room and returned to the facility where their wound care team followed him. The DON and Director J' expressed the Silvadene was not an effective treatment for his wounds, and they worsened and became infected. They described his thigh wound as full thickness with yellow slough. He was sent back to the emergency roiagnom on [DATE] and transferred to a burn unit where he underwent a cadaver graft for his wounds. The DON and Director J acknowledged dietary staff provided hot chocolate directly from the spicket to a resident without a temping the hot liquid. We reviewed the temperature logs from June 2023 and there were over 45 temperatures not documented on their form. The DON and Director J did not have an answer to why there were so many holes in their June 2023 temperature log. On 6/30/2023 at approximately 9:45 AM, a review was completed of Resident #402's medical records and it revealed the resident was admitted to the facility on [DATE] with diagnoses that included, Chronic Obstructive Pulmonary Disease, Gastroesophageal Reflux Disease, Dysphagia, Alzheimer's Disease and Atrial Fibrillation. Resident #402 was assessed as being severely cognitively impaired. Further review was completed of Resident #402's record it showed the following: Physician Orders: - Silver Sulfadiazine External Cream 1 % (Silver Sulfadiazine)Apply to R (right) leg burn topically one time a day for Second degree burn to right leg for 30 Days until finished Care Plan: . Resident has GERD .Dietary: avoid food or beverages that tend to irritate esophageal lining i.e. alcohol, chocolate . Progress Notes: 6/3/2023 at 8:57 AM: Resident suffered a severe burn this morning from hot chocolate that he spilled on his lap. Resident sent out to hospital . 6/5/2023 at 8:56 PM: Problem involving burn to bilateral thigh occurring roughly 1 day prior to arrival. Patient is noted to have spilled coffee on his lap in the morning and resulted in partial thickness burns .Partial-thickness burn Silvadene to continue to be applies monitor to resolution cool compresses applied . 6/7/2023 at 2:31 PM: Reviewed incident on 6/3/23 of burn to rt (right) leg. Resident sustained burn from hot chocolate in a foam cup given to him by another resident . 6/8/2023 at 6:48 PM: Spoke to (physician) r/t (related to) wound orders received for CBC to r/o (rule out) infection not to start ABT till CBC resulted. Results obtained and WBS 14.5 orders to start Rocephin 1gm q day x7 days and to obtain wound culture prior to start of ABT . 6/12/2023 at 10:42 AM: Burn L thigh and lower leg. Infection needs wound debridement increased pain redness . Hospital Records: 6/3/2023: Patient is [AGE] year old male with a history of Alzheimer's dementia who presents to a burn to his right thigh. He states he spilled hot chocolate over his thigh and he has a lot of pain .he was noted to have blistering over the medial thigh and a small area over his right calf .Area of 2nd degree burn to the right medial thigh approximately 5% and a small 2 cm area over his calve also second degree less than 1%, tenderness with blistering, sensation intact .Body surface 5% with second-degree partial thickness burn .He was given wound care precautions and outpatient follow up with burn center/wound clinic patient was discharged home in stable condition . emergency room Notes: 6/12/23: And here with right medial thigh redness and lower leg swelling and redness. Patient burned his right medial thigh on hot chocolate believed to be about 9 days ago. Patient now has increased redness around the area and has been receiving Rocephin daily which started on June 9th .Wound 12 inches x 10 inches right medical thigh with another wound on right lower calf measuring 3 inches x 3 inches .Large partial thickness wound with erythema right medial thigh and right calf .R thigh wound is now red with yellow discharge. Picture of the right medial thigh wound and right calf wound was included in the medical records. The medial thigh wound began at his groin to the top of his knee. It spanned from his inner leg to the middle of his thigh. The area surrounding the room was reddened and the wounds were black/brown in color with yellow discharge. Burn Unit Progress: Presented to (burn unit) ED 6/13/23as transfer . for care of infected burns. Patient spilled hot chocolate on to his right thigh one week PTA did not seek treatment until the day of presentation due to the development of erythema and swelling concerning cellulitis . S/p (status post) E & D with cadaver 6/1 . and E&D with STSG (Split Thickness Skin Graft) .left lower extremity donor site open to air with some sanguineous oozing noted .RLE (Right Lower Extremity) as below with large area of necrotic wound to right lateral thigh and inner right calf also with erythema .Approx 3-4% TBSA partial thickness burn wound to right thigh/lower leg with severe cellulitis. On 6/30/2023 at 11:15 AM, hot water was dispensed from the brewer and was temped at 165 degrees. The brewer had screen that displayed the temperature of the hot water as 200 degrees. On 6/30/2023 at 4:10 PM an interview was conducted with Nurse Q regarding Resident #402's burn. Nurse Q stated she was completing medication pass and her aide alerted her to Resident #402's burns on his legs from spilling hot chocolate. Upon entering the room Resident #402 was standing in the corner, punching the dresser and swearing. Resident #402 expressed he was in a tremendous amount of pain. Upon assessment his left thigh area was lobster red and blistered, she stated she contacted the physician while in the room with him to obtain an order to send him out. She stated she applied burn creme and ABD pad and placed the resident in loose fitting hospital pants per his request. Nurse Q reported the burn started at his groin/inner thigh and descended to his knee, there was a spot on his hip and calf as well. Nurse Q reported she questioned the resident on where he received the hot chocolate and was informed Resident #403 brought Resident #402 hot chocolate to his room that was in a Styrofoam cup. Nurse Q continued she had a week off work and upon her return was assigned to Resident #402. She stated when she assessed his wounds, they were hard to the touch and black and needed debridement. Resident #402 was transported to the emergency room for treatment of his infected wounds. Further review was completed of Resident #402's wound documentation. It can be noted the facility did not follow the recommendation of their wound care team to complete whirlpool bath with tepid water. 6/7/2023: Wound Care Team .Wound #1: R medial lateral thigh & R medical calf 2nd degree burns blisters, some intact, some not .Wound Bed: moist, pink, red/beefy red, yellow .Covering: OTA no pants in room, clean cotton pants when out, no dressing. BID . try whirlpool bath on shower days tepid water. Wound Care Measurements: 6/5/2023: Right Shin: - Measurements of 6.0 x 3.1 x 2.8. 2nd degree burn is a reddened intact blister Right Lateral Thigh: - No measurements provided in the assessment. 2nd degree burn that was pink/red ruptured blisters. Front Right Thigh: - No measurements completed in the assessment. 6/7/2023: Lateral Thigh: 4x2 cm x 2.8 cm x 2.0 cm x 0.1 cm Front Right Thigh: 155 cm x 154 cm x 14.5 x 0.1 cm Right Shin: 14.9 cm x 5.5 cm x 4.0 cm x 0.1 cm 6/12/2023: Right Medial Thigh: Measurements 4.7cm x 3.1 cm x 2.0.cm Right Shin: 4.6 cm x 3.1. cm x 2.0 cm Right Front Thigh: 165.6 cm x 15.6 cm x 15.3 cm On 7/6/2023 at 11:10 AM, an interview was conducted with CNA N regarding the discovery of Resident #402's burns. CNA N stated around 8:30 AM she heard Resident #402 ringing his bell (there were issues with functionality of the call lights and residents were provided with bells), she knocked on his door and he told her to come in. Upon entering the room Resident #402 was observed to not have on any pants and was sitting in his chair and kept saying, its hurts, its hurts, but would not tell her what hurts. CNA N stated he was visibly agitated and he began punching the dresser and then pointed to his thigh and as she looked down she knew it was burns and rushed to alert the nurse. CNA N stated the burn were red with yellow tinted pustules and there were also two spots by his ankle. CNA N asked the resident how his burns occurred and he stated he spilled the damn cup of stuff , as she was exiting the room she noticed the empty Styrofoam cup on his table. A few hours after the incident she asked the nurse how Resident #402 was doing and was informed he suffered 2nd degree scalding burns. CNA N stated historically dietary staff at the facility does not temp hot liquids before providing them to facility residents. On 7/6/2023 at 12:30 PM, the DON and this writer reviewed Resident #402's Hot Liquid Evaluation dated 12/26/2022 and 3/28/2023. The evaluation has three questions and per the directions if the answer to any of the three questions is No, the resident requires assistance with hot liquids. The evaluator answered No, to Safe decision-making ability, and under Criteria, indicated the answer was yes to all the above questions which was inaccurate based on the directions listed in the evaluation. The DON was reviewed the assessment and stated the answer should have been No under criteria and further assessment of Resident #402 to determine his ability to safely handle hot liquids should have been completed and documented. On 7/11/2023 at 3:00 PM, a review was completed of the facility policy entitled, Hot Liquid Handling Guideline, effective 6/1/2023. The policy stated, Hot liquids can cause burns and injury The degree of injury depends on the temperature of the liquid, durations of exposure and amount of skin exposed. The facility will provide hot liquids to residents in a manner that both promotes safety and accounts for resident preference. 1. Hot liquid temperatures will be checked in the kitchen before distribution for appropriate temperature; 2. Resident ability to manage hot liquids will be evaluated upon admission/readmission, quarterly and with a change in condition .4. Residents that require assistance will receive assistive devices/clothing protectors as indicated. Interventions will be individualized and noted in the plan of care.

Based on interview and record review, the facility failed supervise the meal and to check the airway of one unresponsive resident (Resident #114), resulting in Resident #114 being found unresponsive in bed with food noted in the oral cavity and being declared deceased /dead by facility staff without checking the resident's airway. Findings include: Record review of the facility 'Foreign-Body Airway Obstruction and Management (Choking Interventions)' policy, dated [DATE], revealed most cases of foreign-body airway obstruction is adults occur while they are eating. If severe obstruction develops; you must intervene quickly to relieve the obstruction; anoxia resulting from the obstruction may cause brain damage and death in 4 to 6 minutes. Intervene by administering abdominal thrusts; also called the Heimlich maneuver, which uses a sub diaphragmatic abdominal thrust to create diaphragmatic pressure in the static lung below the foreign body sufficient to expel the obstruction. Abdominal thrusts are used in conscious adult patients who cannot speak, cough . If a resident becomes unconscious despite your efforts, start cardiopulmonary resuscitation (CPR) immediately. Record review of facility 'Resident Rights', dated [DATE], revealed accommodation of needs and preferences and homelike environment guideline (undated) revealed it is the practice of this facility to identify and provide reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. Record review of the facility 'Accidents' policy, dated [DATE], revealed that Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. Risk: refers to any external factor, facility characteristic (staffing or physical environment) or characteristic of an individual resident that influences the likelihood of an accident. Supervision/Adequate Supervision: refers to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff, and the frequency of supervision needed. This determination is based on the individual resident's assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident. Record review of the facility 'CPR-Cardiopulmonary Resuscitation' policy, dated [DATE], revealed the facility nursing staff are educated to initiate CPR, as recommended by American Heart Association standards. Death: Resident #114: Record review of Resident #114's Comprehensive Nutrition Assessment progress note, dated [DATE], revealed that the resident was not to eat in a recliner, must be supervised while eating and to cut food into small bites. Record review of Resident #114's Comprehensive Nutrition Assessment progress note dated [DATE], revealed that the resident's preferred eating style was with hands and very fast. Record review of Resident #114's Comprehensive Nutrition Assessment progress note, dated [DATE], revealed resident nutrition-related activities of daily living: supervision. Indication/need for speech therapy evaluation: due to difficulty speaking. Assessment: Resident is independent with meals, though supervision is beneficial. Resident history: Dementia, mood disorder, dysphagia (speech impairment), intellectual disabilities, osteoporosis, hernia, and anxiety. Nutrition diagnosis: High nutritional risk as evidence by diagnosis of dementia and dysphagia. Speech therapy evaluation is indicated related to difficulty speaking. Record review of Resident #114's Behavioral Care note, dated [DATE], revealed that staff reported that the resident does not use the call light but will yell repeatedly when she needs assistance. Record review of Resident #114's physician progress note, dated [DATE] at 5:36 PM, revealed the resident residing in the facility secondary to intellectual disability, hypertension, anxiety disorder and psychotic symptoms. Last visit [DATE] secondary to altered mental status and increased agitation. Depakote increased to related to behavioral disturbances. Medical history: significant for vascular dementia, mood disorder, mobility unsteadiness, dysphagia, intellectual disabilities . depressive disorder with psychotic symptoms and generalized anxiety disorder. An interview on [DATE] at 2:25 PM with Certified Nurse Assistant (CNA) B revealed that he had worked on [DATE] on the 4:00 AM to 4:30 PM shift and was Resident #114's aide. CNA B stated that Resident #114 was completely fine for him. CNA B stated that Resident #114 went to all meals in the main dining room and that she could propel herself in her wheelchair. After lunch that day she asked to lay down and he put her to bed. Interview and record review was conducted on [DATE] at 01:57 PM with Nursing Home Administrator (NHA) on the death on [DATE] of Resident #114. NHA stated that Resident #114 was found with food in her mouth, gray in color and with blue lips. But she had lower leg edema and was put to bed to elevate her legs. She was given her evening meal tray in bed. Surveyor requested investigative documents if there were any. Witness statements were reviewed. Record review of Resident #114's facility witness statements: Certified Nurse Assistant Y statement noted that at on [DATE] at 5:30 PM she gave Resident #114 her meal tray and put the head of the bed up and gave her the call light before exiting the room. CNA Y noted that she walked away to deal with another resident. When CNA Y went back to pick up the dinner tray she noticed that Resident #114 had food in her mouth and that her eyes were closed. CNA Y noted that she tried to wake Resident #114 and could not. CNA Y noted that she put an oxygen sensor on resident but did not document a reading level. CNA Y noted that she went to get her nurse and told the nurse she could not wake up the resident and the nurse stated that she would try. An interview on [DATE] at 8:13 AM with Certified Nurse Assistant (CNA) Y revealed that she gave Resident #114 her dinner tray while she was in bed and went out of the room. CNA Y stated that she was either passing other meal trays or picking meal trays up and then went back to check on resident. CNA Y state that Resident #114 was not responding to her and that she could not get the resident awake. CNA Y stated that she let the agency nurse know and then she was told the resident had died . CNA Y stated that she filled out a witness form. CNA Y stated that she is a new CNA and took the resident's passing really badly and was in tears. CNA Y stated that she just got her CNA certificate [DATE]th, 2023, and did not want to lose it. CNA Y stated that Resident #114 was eating a hotdog and Barbeque chips for her dinner. CNA Y state that the nurse (LPN GG) checked the residents wrist pulse and put the head of the bed flat and told her the Resident #114 was gone/dead. CNA Y stated that LPN GG touched the resident's wrist for a pulse and that she was gone and told me to do postmortem care. The LPN GG stated that the resident aspirated and to get the green oral swabs and to clean as much of the chips out of her mouth. Her mouth was full of Barbeque chips, they were stuck to the roof of her mouth, she could see the chips as the resident laid with her mouth open. CNA Y stated that she was too upset to do postmortem care and that CNA EE and CNA HH did the postmortem care. Record review of Resident #114's facility witness statements: Certified Nurse Assistant EE statement noted that on [DATE] at 6:50 PM. CNA EE was answering call lights when she was notified that Resident #114 has passed away. CNA EE went the Resident #114's room to see for herself if the resident had passed. CNA EE noted that she proceeded into Resident #114's room and noted observing Resident #114 in bed with blue lips and vomit on her shirt and food in the mouth. CNA EE offered to do the postmortem care due to CNA Y being so upset. CNA EE noted asking CNA HH to assist her. During the postmortem care oral care, removed food from Resident #114's mouth appeared to be chips (large amount) were collected from the mouth and roof of the mouth and shown to the LPN GG. An interview on [DATE] at 02:26 PM with Certified Nurse Assistant (CNA) EE revealed that the CNA did do the postmortem care and that she did write a witness statement. It looked like she aspirated on food. Mouth was full of Dorito's or a Barbeque chips it was orange in color. I saw her lying flat when I got to her room. The nurse, Licensed Practical Nurse (LPN) GG, had put the head of the bed flat down. LPN GG stated that she aspirated on food. CNA EE revealed that she did postmortem oral care and had an estimated 1 inch of chips stuck to the roof of Resident #114's mouth. When I got that out I placed it in a cup to show LPN GG (agency nurse) that she choked. Resident #114 was not my resident that day, she was the new CNA Y's resident that day. Resident #114 had to be seated up in a chair or in the dining room when eating for supervision. It looked like an inexperienced CNA and neglect of getting the resident up for the meal. CNA HH assisted me with postmortem care, and Dietary Manager L came down to the room and saw the chips. An interview and record review on [DATE] at 02:45 PM with Dietary Manager L revealed that she knew that Resident #114 had a hotdog and a bag of Barbeque chips for her meal. Dietary Manager L revealed that Resident #114 usually was up in the dining room for her meals, but did not know why she was not that day up in the dining room. Record review of the facility menu for residents revealed that alternative choices included hotdogs. Record review of Resident #114's facility witness statements: Certified Nurse Assistant HH statement noted that on [DATE] CNA HH went to Resident #114's room and observed the resident with blue lips and a mouth full of food. CNA HH noted that Resident #114 was not up for the dinner and ate her food in her bed. CNA HH noted that she assisted with postmortem care and noted vomit and drool on the resident's shirt. Record review of Resident #114's facility witness statements: Certified Nurse Assistant that no longer worked at the facility dated [DATE] noted that the last time the CNA saw Resident #114 was before dinner and at that time reminded CNA Y that Resident #114 and two other residents have to be in the dining room for the meal. Record review of Resident #114's facility witness statements: Licensed Practical Nurse (LPN) FF, agency nurse for the day shift, noted that she instructed the CNA's to put Resident #114 in bed to elevate her legs due to swelling. LPN FF noted she was giving (shift) report to LPN GG when CNA Y came in and said that she could not wake up Resident #114. LPN GG and LPN FF were noted to go to Resident #114's room to find her gray and not breathing. LPN FF left the room to verify code status. LPN FF noted that when she returned to the resident's room, she listened to the resident's chest and did not hear anything and notified the Director of Nursing. An interview on [DATE] at 08:56 AM with Licensed Practical Nurse (LPN) FF Agency nurse revealed that she did work that day shift on [DATE], it was her first day at the building. LPN FF was giving report and when CNA Y came into the room and stated that she could not get Resident #114 to wake up. and that she was going to get a pulse ox on the resident. We continued with report, and we had just finished when the CNA Y came back and said that she does not know what is going on, because she could not get a pulse ox reading on Resident #114. The nurse LPN GG said that she would go check on Resident #114 and I was walking toward the front office area door where you put in a secure number to open it. Resident #114 room was right next to the door. LPN FF heard LPN GG stated Oh shit, and LPN FF went into the room and saw Resident #114 with food in her mouth and gray in color. LPN FF stated that she went to check the code status of Resident #114. LPN GG was putting the head of bed down. LPN GG listened to her chest and LPN FF stated that she did a second check, and they called the resident #114 dead. LPN FF stated that the CNA's afterward said that there was a walnut size or large ball of food mass stuck to the roof of the resident's mouth. She was known to chipmunk/pocket her foods. LPN FF stated that she believed Resident #114 was to be supervised when dining or having meals. LPN FF when asked by state surveyor that no, Heimlich maneuver was done, and that Resident #114 was a very large woman, and she was dead and gray in color. Record review of Resident #114's facility witness statements: Licensed Practical Nurse (LPN) GG revealed that on [DATE] the nurse was finishing counting narcotic medications at 6:30 PM when Certified Nurse Assistant (CNA) Y came walking up saying to interrupt but that she could not get Resident #114 to wake up. CNA Y did not seem concerned. LPN GG noted that she stated OK, and she would go check on the Resident #114. LPN GG noted that she went to Resident #114's room and noticed she was gray in color and had blue lips and asked LPN FF to check a code status. LPN GG noted that she listened and could not hear a heartbeat with no respirations noted. LPN FF confirmed no pulse and DNR status. LPN GG noted that Resident 3114 was found with the head of the bed at 45 degrees. An interview on [DATE] at 4:10 PM, Licensed Practical Nurse (LPN) GG Agency nurse revealed she came into work and there was a newer Certified Nurse Assistant Y came up nonchalant/casually stated that she could not wake up Resident #114. LPN GG stated that she went to Resident #114's room and noted the resident was gray with blue lips and started to put the head of the bed down while LPN FF went to get the code status was DNR. LPN GG stated that she called the Director of Nursing with her concern that Resident #114 was always in the dining room for her meals, at 6:00 PM she is always in the dining room and her concern was why Resident #114 had eaten in bed. LPN GG stated that Resident #114 had food in her mouth and that the resident had thrown up and there was food on her [NAME] and chest. It was not until later that there was a lot of food in her mouth. LPN GG stated that when she first saw Resident #114, she was gray and was dead. LPN GG stated that she had been a nurse for [AGE] years and that she knows when someone is dead. LPN GG' stated that she checked for a pulse in arm radial pulse and put her hand on the resident's chest and put her ear next to the residents and checked with a stethoscope and had LPN FF check also. In an interview on [DATE] at 10:06 AM, the Nursing Home Administrator (NHA) stated that it was believed that it was a cardiac issue Resident #114 had been declining. Earlier in the day Resident #114 had increased edema to the lower legs, no the resident was not on oxygen, Record Review of facility handwritten witness statements with the NHA reviewed the CNA's statement that Resident #114 had history of pocketing food, that day the nurse wanted her in bed. The NHA stated that usually went to dining room, because she pocketed foods, the CNA left her alone in the room to eat per investigation and CNA statement. The NHA and State surveyor reviewed the facility 'Foreign body airway' policy dated [DATE]. The NHA Presented education on eating in bed and change of condition reporting was aimed at CNA's and nurses, nurses did not feel any urgency to check the resident. There was no staff education presented to surveyor related to check/clear the airway of a resident noted with food in the mouth. In an interview on [DATE] at 11:35 AM, the Interim Director of Nursing/Infection Control Preventionist/Corporate clinical nurse was asked about the speech evaluation indicated on [DATE] nutritional assessment. The Interim DON revealed that there was no speech evaluation done for Resident #114 as indicated by nutritional assessment.

Based on interview and record review the facility failed to prevent Urinary Tract Infections (UTI) for two residents (Resident #5, Resident #20), resulting in facility-acquired, recurrent urinary tract Infections (UTI) for Resident #5 and Resident #20 with recurrent antibiotic therapy and the likelihood for infection and a decline in overall health status. Findings include: Record review of the facility 'Infection Prevention and Control Guideline' policy, dated 11/28/2017, revealed the infection prevention and control program includes a system for preventing, identifying, reporting, investigating, and controlling infections . Surveillance: a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility. Occupational Health: Monitoring and evaluating for clusters or outbreaks of staff illness. Hand hygiene: procedures to be followed by staff in direct resident contact. Antibiotic stewardship: includes antibiotic use protocols and a system to monitor antibiotic use. Record review of the facility 'Infection Surveillance Guideline' policy, dated 11/28/2017, revealed infection prevention begins with ongoing surveillance to identify infections that are causing, or have the potential to cause, an outbreak. The facility closely monitors all residents who exhibit signs/symptoms of infection through on going surveillance and has a systematic method for collecting, consolidating, and analyzing data concerning the frequency and cause of a given disease or event, followed by dissemination of that information to those who can improve the outcomes. The intent of surveillance is to identify possible communicable diseases or infections before they can spread to other persons in the facility. In addition, surveillance is crucial to the identification or possible clusters, changes in prevalent organisms, or increases in the rate of infection promptly. The results should be used to plan infection control activities, direct in-service education, and identify individual resident problems in need of intervention. Resident #5: In an interview on 05/21/23 at 11:32 AM, Resident #5 stated that she went to the hospital with a bad urinary tract infection and then came back after they treated the infection, and now she is in hospice care. Record review on 05/23/23 at 11:15 AM of Resident #5's electronic medical record revealed that the resident has had multiple Urinary Tract Infections (UTI) over the last 7 months- see copies. Record review of antibiotic stewardship antibiotic tracking/line listing for December 2022 'Monthly Infection Control Log (Line List)' revealed on 12/13/2022 Resident #5 was diagnosed with a facility-acquired urinary tract infection with catheter with Escheria coli identified and received macrobid antibiotics. Record review of antibiotic stewardship antibiotic tracking/line listing for February 2023 'Monthly Infection Control Log (Line List)' revealed on 02/03/2023 Resident #5 was diagnosed with a facility-acquired urinary tract infection and hospitalized . Record review of antibiotic stewardship antibiotic tracking/line listing for April 2023 'Monthly Infection Control Log (Line List)' revealed on 04/30/2023 Resident #5 was diagnosed with a facility- acquired urinary tract infection with pseudomonas aerginosa organism identified and received Levoquin and macrobid antibiotics. Record review of antibiotic stewardship antibiotic tracking/line listing for May 2023 'Monthly Infection Control Log (Line List)' revealed on 05/04/2023 Resident #5 was readmitted from hospital with a facility-acquired urinary tract infection on Amoxicillin antibiotics. Resident #20: Record review of antibiotic stewardship antibiotic tracking/line listing FOR June 2022 'Monthly Infection Control Log (Line List)' revealed on 06/27/2022 Resident #20 was diagnosed with a facility- acquired urinary tract infection with proteus mirabilis and received Doxycycline antibiotics. Record review of antibiotic stewardship antibiotic tracking/line listing for July 2022 'Monthly Infection Control Log (Line List)' revealed on 07/20/2022 Resident #20 was diagnosed with a facility-acquired urinary tract infection with proteus mirabilis and received Rocepin antibiotics. Record review of antibiotic stewardship antibiotic tracking/line listing for October 2022 'Monthly Infection Control Log (Line List)' revealed on 10/12/2022 Resident #20 was diagnosed with a facility-acquired urinary tract infection with proteus mirabilis and received Levoquin antibiotics. Record review of antibiotic stewardship antibiotic tracking/line listing for November 2022 'Monthly Infection Control Log (Line List)' revealed on 11/10/2022 Resident #20 was diagnosed with a facility-acquired urinary tract infection with no organisms identified and received Cefdinir antibiotics. Record review of antibiotic stewardship antibiotic tracking/line listing for April 2023 'Monthly Infection Control Log (Line List)' revealed on 04/17/2023 Resident #20 was diagnosed with a facility-acquired urinary tract infection and was diagnosed in the emergency room (ER) and received Cephalexin and Ampicillin antibiotics.

This Citation pertains to Intake Numbers MI00132816, MI00133022, and MI00133025 and contains two Deficient Practice Statements (DPS). DPS One pertains to Intake Number MI00133022. Based on observation, interview and record review, the facility is placed in Immediate Jeopardy for its failure to implement and operationalize its policies and procedures to prevent the willful resident-to-resident sexual abuse of one resident (Resident #904) of eight residents reviewed, resulting in Resident #905, a cognitively-intact male, luring and sexually assaulting Resident #904, a severely cognitively-impaired female who lacked the ability to consent, into performing sexual acts on him for approximately seven minutes in the central dining room of the facility. Immediate Jeopardy (IJ): This deficient practice resulted in Immediate Jeopardy (IJ), sexual abuse, a delay in reporting to the State Agency, a delay in implementation of policies and procedures to protect and prevent further abuse, and the likelihood for psychosocial distress utilizing the reasonable person concept. The Immediate Jeopardy began on 10/15/2022. The Immediate Jeopardy was identified on 12/01/2022. The Administrator was notified of the Immediate Jeopardy in writing on 12/07/2022 at 1:46 PM. A plan to remove the immediacy was requested. The Immediate Jeopardy was removed on 10/16/2022 based on the facility's implementation of the plan removal as verified onsite on 12/07/2022. Although the IJ was removed, the facility's deficient practice remained at isolated with actual harm that is not immediate jeopardy. Findings include: Review of Facility Reported Incident (FRI) documentation, submitted 10/16/22 at 12:40 PM, revealed that an incident had occurred involving Resident #904 and Resident #905 in the facility dining room. Per the intake documentation, Resident #905's pants were rolled down, but details of what had transpired were not included. On 12/01/22 at 11:15 AM, an interview was completed with the facility Administrator. When queried regarding the incident involving Resident #904 and Resident #905, the Administrator revealed they had not reported the sexual abuse allegation to the State Agency in a timely manner. When asked to elaborate, the Administrator indicated they were notified by staff of a potential concern and went in to start the investigation on 10/15/22. The Administrator revealed they completed interviews but took it at face value and did not dig into it. The Administrator revealed they left the faciity on [DATE], thought further about what had occurred including Resident #905's history of sexually inappropriate behaviors, and realized they made a mistake by not thoroughly investigating the allegation. The Administrator then stated, I feel so awful it happened here. When asked what specifically had transpired, the Administrator disclosed the facility had saved the video footage on a flash drive for review . The Administrator was asked again what had transpired and revealed that a sexual assault occurred in the main facility dining room. The Administrator indicated the residents were alone in the dining room and Resident #905 began talking to Resident #904 from approximately six feet away and continued to move closer until they were approximately one foot apart. The Administrator revealed Resident #905 pulled down their pants, said something to (Resident #904), and (Resident #904) began touching (Resident #905) (genital area). When asked where facility staff were when this occurred, the Administrator was unable to provide an explanation. The Administrator was then queried regarding actions taken by the facility and reiterated their feelings of regret for not acting sooner. The Administrator indicated that they returned to the facility on Sunday (10/16/22), investigated further, and reported the incident. When asked if the Police were notified, the Administrator revealed they were. The Administrator specified Resident #904's child (POA- Witness A) had also been notified. With further inquiry, the Administrator revealed the Police and Witness A both reviewed the video. When queried regarding Witness A's response to what had occurred, the Administrator replied, (Witness A) was upset. The Administrator then stated, I think it is hard with dementia to accept who their parent is now versus who they were. The Administrator was then asked if Resident #904 possesses the cognitive capacity to provide informed consent for sexual activity and she replied, No. When queried, the Administrator revealed that Resident #904 does not remember what happened. When queried regarding Resident #905's cognitive status and ability to provide consent, the Administrator revealed they were cognitively intact. When asked when the Residents were separated, the Administrator indicated the Residents participated in the same activity following the sexual abuse and Resident #905 was not placed on 1:1 supervision until the following day, 10/16/22. When asked to clarify if they were saying that the facility did not immediately implement interventions and protect Resident #904 and other potential Residents from sexual abuse by Resident #905, the Administrator confirmed no actions were taken to protect Resident #904 and/or other Residents until 10/16/22. Review of facility investigation documentation related to the reported incident involving Resident #904 and Resident #905 revealed the following: - Resident #905 Incident and Accident Report: Incident Date/Time: Saturday, October 15, 2022, 9:35 AM . Type: Alleged Abuse . Activity: Sitting . Representative Notified: (Resident #905) is own person . Cognition Prior to Incident Oriented x3 . Allegation . Sexual Abuse . Perpetrator (Resident #904) . Actions . One on one supervision implemented . Resident Education . Residents separated . Conclusion: (Resident #905) per his statement had his pants rolled down in the dining room. (Resident #904) waved (Resident #905) closer to them and had their hands near his abdomen / brief / pants area. (Resident #905) has BIMs of 15 while (Resident #904) has BIMs of 7 . placed on 1:1 supervision while out of bed and not in stationary chair . Problem Statement: It has been determined through (Resident #905's) statement that he had exposed himself (brief pulled down) in the dining room while (Resident #904) was present . Why #1: (Resident #905) stated that he had been 'playing with himself, I am sorry' . - Resident #905 Interview (as told to LPN F), dated 10/15/22: States he ate breakfast in the dining room then tooled around and looked for something to eat . States visited with (Resident #904) after ate a little bit. Says nothing happened with (Resident #904). Does not remember if she touched him. Admits to having pants partway down. 'I was playing with myself. I'm sorry'. - Resident #905 Typed Interview with Administrator, dated: 10/15/22 at 12:14 PM: Told (Resident #905) Administrator was needing to discuss what happen in the dining room this morning and the discussion with (LPN F). You told (LPN F) you were 'playing with self' in the dining room . (Resident #905) Answer: 'It was wrong, and I should not have done. I am embarrassed' . - Resident #905 Interview/Statement (written and signed by DON), dated 10/25/22: This writer met with (Resident #905) as a follow up to their conversation in the hall with another Resident that was overheard by this writer. (Resident #905) was asked how things are going? . states . 'ok.' (Resident #905) states he knows he is not on restrictions when asked . stated he needs to have 1:1 supervision when he leaves his room . When asked if he remembered the event in the dining room that lead to the 1:1, he asked what event . When (Resident #905) was reminded of the incident with him and (Resident #904), (Resident #905) stated, '(Resident #904) was interested in what was in my pants.' (Resident #905) then stated he 'went up to talk to her about it and she grabbed at my pants. I should have ran, well wheeled away.' (Resident #905) was asked 'what was in your pants?' He stated, 'Well you know, it is attached to me.' Asked (Resident #905) again what was in his pants, he stated, 'You know, my penis.' (Resident #905) was asked why (Resident #904) asked him/showed interest in what was in his pants? (Resident #905_ stated he did not know. When asked how the conversation came up about what was in his pants, (Resident #905) stated, 'I do not remember, I don't want to talk about it' . - Resident #904 Incident and Accident Report: Incident Date/Time: Saturday, October 15, 2022, 9:35 AM . Type: Alleged Abuse . Activity: Sitting . Representative Notified: (Witness A) 10/15/22 1:34 PM . Cognition Prior to Incident Oriented x1, Oriented x2, Poor safety awareness, Forgetful . Allegation . Sexual Abuse . Perpetrator (Resident #905) . Actions . Residents separated . Conclusion: (Resident #904) was in dining room where (Resident #905) per his statement had his pants rolled down and 'I was playing with myself .' when (Resident #904) waved for (Resident #905) to come closer . (Resident #904) was then noted to have her hands near his abdomen / brief area. Susan's BIMs is 7 and his is 15 . Problem Statement: It has been determined through (Resident #905's) statement that he had exposed himself (brief pulled down) in the dining room while (Resident #904) was present . - Resident #904 Interview (as told to LPN F), dated 10/15/22: Says 'yes' ate breakfast in the dining room. Says 'no' when asked she visited with any other residents. 'I think there was a few people [in the dining room] but I didn't talk to them'. Says 'no' again when asked if talked to anyone in the ding room. Laughs and says 'no' when asked if saw anything unusual. Says 'I don't remember, I don't think so.' When asked if say by anyone in dining room. Says 'no' when asked if she touched anyone or if anyone touched them. - Police Report: Date Reported: Sunday 10/16/22 1410 (2:10 PM) . Description: Resident on Resident Sexual Contact . Incident . On 10/16/22, I was contacted by Administrator regarding an incident that occurred between two residents on 10/15/22. Administrator requested a joint investigation into two residents having sexual contact with each other in a common area . Investigations: I met with Administrator . to review video footage of the incident. Also present during the review of the video was (DON), (Social Services Director G), and (Witness A). The video showed (Resident #905) and (Resident #904) sitting in the large dining alone on 10/15/22 at/or about 0856 hrs (8:56 AM). It should be noted there is no audio, and the recorded time was not linked up with the actual time. This was discovered by the Administrator and relayed to me. (Resident #905) is in a motorized wheelchair. The two appear to be conversing for a short period of time . (Resident #904) . stimulating (Resident #905's) genitals with hands in an up and down manner. This went on for a few minutes until other residents and a staff member came into room . (Resident #904) remained in the same location . Interview with (Resident #905) . (Resident #905) stated he was embarrassed and just wanted to forget what happened. (Resident #905) stated he met (Resident #904) at the facility and spoke with her a few different times, usually in the dining room . (Resident #905) described where he and (Resident #904) were at during the incident, which coincided with the video footage. I asked what the two of them were talking about prior to the incident, which (Resident #905) stated he didn't really remember . stated he didn't remember what was being said during the incident . stated he didn't remember what caused (Resident #904) to stop and didn't remember if anyone came into the room . (Resident #905) stated this was the first time anything like this happened, and there were no talks about what happened leading up to the incident . Additional Information: (Social Services Director G) reported that (Resident #904) did not have any (recollection) of the incident due to her disease. (Witness A) . did not want to press charges, but wanted to make sure this couldn't happen again . - Activities Staff E Statement, dated 10/18/22: As I assisted (a Resident) via wheelchair into the dining room for morning activities, which was approximately 9:35 AM, as I turned right into the dining room rom E hall, I glanced over to the right and saw (Resident #905) and (Resident #904) near the corner table from the piano. (Resident #905) was rolling his sweat pants back up as (Resident #904) was pulling her right arm (only) back to her sitting position. When I came in, I noticed approximately that (Resident #905) had 3-4 inches of his sealants down, exposing his lower abdomen . did not notice his depends down . I could not clearly see (Resident #904's_ hand touching (Resident #905's) skin but her reaching was close to his skin, approximately an inch or two on (Resident #905's) left abdominal area. I redirected (Resident #905) to the far end of the dining room table and proceeded to have (Resident #905) to the other end of the table opposite from each other. I felt it was necessary to find a nurse on duty to report this, so I went to (LPN H) at nurses' station 2 to inform them of what I witnessed. I chose (LPN H) as I felt I was in direct line of the dining room as other residents were going into the dining room for activities. (LPN H) instructed me to find (LPN F) at nurses' station one to let them know of the incident I witnessed. After I reported this to (LPN F), I immediately went back to the dining room to start the activity . #1: Yes. (Resident #905) will occasionally make inappropriate sexual comments. Not specifically towards me but more so of what he would like to do . #2: Yes. (Resident #905) has on occasion, make comments verbally regarding sexual wishes when other staff and residents have been around . - LPN F Statement, dated 10/18/22: Writer was notified by (Staff E) of an interaction that occurred at 0935 in the dining room. (Staff E) stated that (Resident #905) and (Resident #904) were the only ones in the dining room at that time and that they were seated approximately six feet apart in their wheelchairs, facing one another . (Resident #905) had his pants pulled down 3-4 inches, exposing his lower abdominal skin . (Resident #904) was leaning forward toward (Resident #905). (Staff E) was unsure if any physical contact occurred. Writer interviewed (Resident #905) and (Resident #904) in their respective rooms after they were moved apart by (Staff E) and participated in the group activity in dining room . #2: (Resident #905) has made sexually inappropriate verbal comments about CNA's (females) while this nurse has administered med to him as well as in passing in the hallway . - CNA C Statement, dated 10/16/22: (Resident #905) . has made comments . such as 'Go ahead and rub my balls', 'My balls itch can you scratch them?' . things along those lines. There have been a few times when giving care that these comments ant attempts to touch me occurred. I simply have stated to him to stop it, knock it off, and his verbal response is 'okay' and he would restart doing it. There was one time that he was doing it and I had him sit back down in his chair and I went to report it to the nurse then returned to finish up cares. - CNA I Statement, dated 10/16/22: . Many times (Resident #905) has said to me I want a girl and could I help him with that. When giving him a shower, he had said touch my balls and I have told him that is inappropriate. He talk about wanting his private area touch . - Dietary Staff J Statement, dated: 10/17/22: (Resident #905) . #1 . said sexual things in front of people. That is just (Resident #905). #2: He says weird things to me. I just told him that is inappropriate . He associates my name with his ex-wife and makes comments about her being a whore . random inappropriate comments such as wanting to put a baby in them and how he used to like to f*ck his wife . - Director of Nursing (DON) Statement, dated 10/16/22: I was not in the building . I received a phone call from (LPN F) . I instructed (LPN F) to call the Administrator . The call I received from (LPN F) was at 10:37 AM. Spoke with (Administrator) at 10:43 when they called to let me know they got the call and again at 12:53 updating me on the incident. (Resident #905) had not made comments to me nor have I heard directly of comments. When I 1st started here in September, the previous Interim DON went to his room and spoke to him about sexual comments that had been made to staff . - CNA K Statement, dated 10/17/22: . (Resident #905) has made remarks about wanting me to go to bed with him . - CNA N Statement, dated 10/17/22: (Resident #905) . had made comments . looking for a wife are you interested, don't get to do . sex anymore . - Admissions Staff M Statement, dated 10/17/22 at 8:45 AM: . I have been out in the floor at times and witnessed (Resident #905) place his hand on his crotch area while in scooter. - LPN O Statement, dated 10/17/22 at 10:39 AM: (Resident #905) . made sexual statements wanting to find someone to have his children . Multiple times to staff and residents . Did not report . - Housekeeper L Statement, dated 10/17/22 at 10:35 AM: (Resident #905) . has said to me to bad you're married! He told me he doesn't understand why they can't take a road trip to the strip clubs so he can get a little. There have been many other comments that I can't recall at this time. - Staff P Phone Statement, dated 10/17/22 at 3:08 PM: (Resident #905) . with transferring him, he would grab my inner thigh or butt and say 'Ooh baby' . There were seven additional Staff Statements which all indicated Resident #905 had either touched or spoke to them in a sexually inappropriate manner. A timeline of the facility investigation was included in the provided documentation. Review of the timeline revealed the following overview: - 10/15/22 at approximately 9:35 AM- Sexual abuse in dining room involving Resident #905 and Resident #904 - 10/15/22 at 10:37 AM: DON notified and instructed staff to contact Administrator - 10/15/22 at 10:40 AM: Administrator notified of alleged sexual abuse by LPN F - 10/15/22 at 11:46 AM: Administrator arrive at facility - 10/15/22 at 11:52 AM: Administrator interview Staff E - 11/15/22 at 12:05 PM: Administrator interview LPN F. Resident #904 was interviewed by LPN F. Resident #904 visiting with family and not available for an interview. - 11/15/22 at 12:14 PM: Administrator interview Resident #905. - 11/15/22 at 12:30 PM: Administrator obtain staff statements from DON mailboxes. - 11/15/22 at 1:34 PM: Administrator notify Resident #904's POA (Witness A) of incident. - 11/15/22 at 1:34 PM: Administrator notify Social Services Director G of incident. - 11/16/22 at approximately 7:30 AM: Administrator arrive to building to review camera. - 11/16/22 at 9:00 AM: (Cooperate Staff Q) notified of incident on 10/15/22 and camera review. Social Services Director G called to come into building. 1:1 staff initiated for Resident #905. - 11/16/22 at 10:17 AM: Police notified of incident. - 11/16/22 at 12:40 PM: FRI submitted to the State Agency. - 11/16/22 at 12:45 PM: Administrator updated Witness A (Resident #704's POA) on investigation via phone. The timeline detailed, A camera time check indicated a 24-minute delay indicating that statement timeline is correct. Resident #904: Record review revealed Resident #904 was originally admitted to the facility on [DATE] with diagnoses which included dementia without behavioral disturbances and repeated falls. Review of Resident #904's Electronic Medical Record (EMR) revealed the Resident was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of seven on 10/16/22 and 11/22/22. Review Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required extensive, one-person assistance to complete all Activities of Daily Living (ADL's) with the exception of eating and locomotion in a wheelchair. Further review of Resident #904's EMR revealed the Resident was determined to be unable to make their own decisions and had an activated Power of Attorney (POA) for decision making. On 12/2/22 at 1:30 PM, Resident #904 was observed in their room of the facility. The Resident was laying in bed with their eyes open. When spoke to, Resident #904 responded and smiled. The Resident was pleasantly confused and unable to provide meaningful responses when asked questions. When asked questions, Resident #904 responded by saying, You're so pretty and nice and What can I do to help you? Review of Resident #904's Electronic Medical Record (EMR) revealed the following progress notes: Note- There were no progress notes for 10/15/22 in Resident #904's EMR. - 10/16/2022: Psychosocial Note: Met with resident today in room. Resident resting in recliner. Asked how she was doing, she stated fine. Asked her if she had any concerns from today or yesterday, she stated no. Asked her if any other resident had made sexual comments to her, she stated no. Asked resident if she had and sexual contact with any other resident, she stated no . - 10/17/2022: Psychosocial Note: Psychosocial visit with resident today r/t 10/15 incident. Resident resting comfortable in recliner. Asked resident how she was doing today, she stated very good. Also asked resident if she had any concerns, she stated no. Asked resident if anyone has ever made sexual comments toward her or touched her in an unwanted manor, she stated no, everyone is so nice . - 10/19/2022: Psychosocial Note: Psychosocial visit with resident this afternoon. She is resting comfortably in her recliner holding her stuffed black cat. Asked resident if she had any concerns, she stated no. Asked her if she felt safe at facility, she stated no. Asked her if anyone has ever made sexual comments to her at facility, she stated no. Note: No follow-up was noted from Resident #904 stating they did not feel safe in the facility. - 10/21/22: Health Status Note (nurses note) . activities informed this writer that when . assisting (Resident #904) to turn left out of the MDR (Multi-purpose Day Room) and around (a resident room), (Resident #904) raised her hand in a wave to (resident in room) saying, 'Goodbye snot face' . - 10/21/22: IDT (Interdisciplinary Team Note) . NHA (Administrator) spoke with resident in her room with (LPN O) to ask her if she wave at someone and say Good Bye snot face. She relied no, I do not remember that. If I did I am sorry . Resident #904 was started on an antibiotic for a Urinary Tract Infection (UTI) on 10/24/22. - 11/11/22: Health Status Note (nurses note) . CNA brought resident to this writer stating that she was trying to get out the door and was brought to the desk. Resident wanting to go home. Resident does not want to participate in anything activities, does not need the bathroom, is not hungry, resident near nurse station propelling w/c (wheelchair). Staff aware of resident exit seeking . - 11/16/22: Behavior Narrative Note . Resident upset this hs (evening) stated 'I want to go home' crying asking 'Where is my family' exit seeking. Staff able to redirect resident and she went to bed. Later CNA reported that while getting residents vitals resident asked CNA to get in bed with her. This nurse talked with resident and resident stated she did not remember saying that at all. Review of Resident #904's progress notes, from January 2022, revealed Resident #904 did not demonstrate any exit seeking and/or verbal behaviors towards others prior to the sexual abuse. An interview was conducted with Witness A on 12/6/22 at 7:30 AM. Witness A was queried regarding the sexual abuse allegation involving Resident #904, Witness A revealed they were aware and had watched the video. When asked what happened, Witness A stated, It went on a long time, and something definitely happened. Witness A revealed it happened in the dining room of the facility and stated, (Resident #905) came to (Resident #904) and instigated it the whole way. (Resident #905) knew what they were doing. Witness A revealed they expressed their concern related to Resident #905's instigation with the facility. Witness A revealed the video did not have audio, but they were able to tell that Resident #905 exposed themselves and said something to coerce Resident #904 rub their genitals in a sexual nature. Witness A was queried regarding Resident #904's ability to make decisions and revealed the Resident had severe dementia and was in the facility because they were no longer able to make their own decisions and live safely by themselves. When asked how Resident #904 would have responded to a situation where a man exposed themselves in front of them prior to having dementia, Witness A stated, (Resident #904) would have punched them. (Resident #904) would have been mortified. At this time, Witness A stated, I was pissed. (Resident #904) would have never done that, never if she was in her right mind. When queried if Resident #904 had verbalized anything regarding the abuse to them, Witness A stated, (Resident #904) doesn't remember, she has dementia. When queried regarding interventions implemented by the facility after the abuse occurred, Witness A indicated staff are watching Resident #904 better and stated, They (Resident #904 and Resident #905) were alone in the dining room. (Resident #904) was there a long time alone with (Resident #905). Witness A reiterated, (Resident #904) would have been mortified and stated they were also concerned about all the other women in the facility. When asked why they decided to not press criminal charges against Resident #905, Witness A revealed the facility did not tell them Resident #905 was cognitively intact and able to make their own decisions. Witness A indicated that upsets them. Witness A then stated, It was just wrong. They (staff) are supposed to take care of (Resident #904) and protect her. I don't know why they were in there so long with no one actually checking. Witness A then stated, I just don't want (Resident #904) to get in trouble. When asked why they were concerned that Resident #904 would get in trouble, Witness A revealed they were concerned the staff would blame Resident #904 for what had happened. On 12/6/22 at 11:59 AM, an interview was completed with Certified Nursing Assistant (CNA) C. When queried regarding Resident #904, CNA C stated, (Resident #904) is the sweetest who just goes with whatever needs to happen. When asked if they were working on 10/15/22, CNA C revealed they were not. When queried if Resident #904 had ever displayed any behaviors, including sexual behaviors, CNA C stated, No. With further inquiry regarding the Resident's personality, CNA C indicated Resident #904 will do whatever is asked of them. On 12/6/22 at 12:30 PM, an interview was conducted with CNA D. When queried regarding Resident #904, CNA D stated, (Resident #904) is just sweet and will do whatever you ask of them. Resident #905: On 12/2/22 at 1:20 PM, Resident #905 was not present in their room. Record review revealed Resident #905 was originally admitted to the facility on [DATE] with diagnoses which included bipolar disorder, schizophrenia, depression, and difficulty walking. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required supervision to extensive assistance to complete Activities of Daily Living (ADL) and utilized both a walker and wheelchair for mobility. Review of Resident #905's care plans revealed the Resident had a history of sexually inappropriate behavior. One care plan was titled, Resident chooses to masturbate (Initiated: 12/2/21) and included the following interventions: - If (Resident #905) expresses a desire to masturbate while outside of room, remind resident to return back to room and provide with privacy (Initiated: 10/28/22) - Provide resident opportunity to discuss feelings of loneliness and wanting a partner, with appropriate staff (Initiated: 2/23/19) - Provide resident with privacy. Pull curtain (Initiated: 2/23/19) Resident #905 had a second care plan titled, The resident has a psychosocial wellbeing problem r/t (related to) schizophrenia. Can become sexually inappropriate towards staff (Initiated: 12/2/21). The care plan included the intervention, If resident verbalizes sexual innuendos redirect and remind resident that it is inappropriate (Initiated: 2/23/19). A third care plan titled, The resident has a behavior problem r/t to being sexually inappropriate towards staff. Incident of sexually inappropriate with another resident 10/15/22 (Initiated: 12/2/19) was present in Resident #905's Electronic Medical Record (EMR). This care plan included the interventions: - Psychiatric/Psychogeriatric consult as indicated. *Referral sent to (Mental Health Provider) for psychiatric care services visit post 10/15/22 incident . scheduled to see resident 10/19/22 - visit completed with recommendations rec'd (received) (Initiated: 10/17/22) - 1:1 supervision when not in bed or stationary chair effective 10.19.2022 (Initiated: 10/16/22) - Assist the resident to develop more appropriate methods of coping and interacting by providing (Resident #905) with opportunities to talk to appropriate staff about feelings of loneliness. Encourage the resident to express feelings appropriately (Initiated: 2/23/19) - If behavior occurs explain to (Resident #905) why behavior is inappropriate and/or unacceptable (Initiated: 10/16/22) - Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed (Initiated: 10/16/22) - RESOLVED: Room move to more visual area by nursing station (Initiated: 10/19/22; Resolved: 12/1/22) A fourth care plan was noted in Resident #905's EMR. This care plan was titled, The resident uses psychotropic medications . has a history of being sexually inappropriate towards women . (Initiated: 12/2/21). The care plan included the interventions: - If behaviors occur, remind (Resident #905) about appropriate behavior. Praise appropriate behaviors (Initiated: 9/15/21). - Monitor/record occurrence of for target behavior symptoms sexually inappropriate behaviors towards staff/residents and document per facility protocol (Initiated: 10/17/22) Review of Progress Note documentation in Resident #905's EMR detailed the following: - 9/21/22: Health Status Note (nurses note) . cont (continue) with behaviors telling (CNA's) oh oh oh when they are washing him the (CNA) states that is inappropriate res. states sorry and then will do it again - 9/22/22 at 3:30 AM: Behavior Narrative Note . during 2 am brief change he told CNA to scratch or rub him, (CNA) told him that was unappropriated he said I am sorry but immediately repeated himself then said sorry again . - 10/15/22 at 1:32 PM: Behavior Narrative Note . This nurse approached by activity aide . stated that as entered the dining room at 0935, saw (Resident #905) and (Resident #904) seated in their wheelchairs facing each other but approximately six feet apart . observed that (Resident #905) had his pants pulled down 3-4 inches, showing skin, and that (Resident #904) was leaning toward him . - 10/16/22: Psychosocial Note . Met with resident today within his room. Asked resident what happened yesterday. He stated I'm sorry. I asked him what he was sorry for, he said I guess I was bad. Asked resident to explain bad, he said I d [TRUNCATED]

This Citation pertains to Intake Number MI00132816. Based on interview and record review, the facility failed to implement and operationalize policies and procedures to ensure thorough investigation, as well as appropriate and timely reporting of abuse allegations, and protection of residents for three residents (Resident #901, Resident #902, and Resident #908) of eight residents reviewed, resulting in a lack of comprehensive investigation of allegations of staff-to-resident verbal abuse, lack of prevention and protection of residents from ongoing abuse, and residents' verbalizations of emotional distress including feelings of fear, anxiety, and unhappiness. This deficient practice allowed staff-to resident abuse to occur on multiple occasions from 07/24/2022 until 11/21/2022. Findings include: Review of intake documentation revealed a Facility Reported Incident (FRI) initially submitted 11/11/22 which detailed, Incident Summary: (Resident #901) stated to the RN (Registered Nurse) on duty that after hearing that (Certified Nursing Assistant [CNA] S) was going to be their aide (CNA) tonight it caused them to have chest pain. (Resident #901) stated that this aide has been treating them bad and ridiculing them . With the additional resident interviews that were completed, it was determined that the alleged staff member did have unprofessional interactions with other residents. The event has been substantiated . (CNA S) is no longer employed with (facility) . Resident #901: On 12/5/22 at 1:25 PM, Resident #901 was observed laying in bed, in their room. An interview was completed at this time. When queried how they are treated by facility staff, Resident #901 replied, They can be [NAME] and controlling. Resident #901 was asked what they meant and stated, Like telling me my toileting schedule is every two hours. When asked if they were saying the staff were asking them if they needed to use the toilet, Resident #901 replied, No, telling. Resident #901 was then asked if they were referring to all staff or certain staff and stated, (CNA S). Resident #901 continued, She is very rude, like you have to go to bed when I (CNA S) say you go to bed. Has to be to their convenience. When queried if they had told anyone, Resident #901 stated, (The Director of Nursing (DON) and Assistant Director of Nursing (ADON). Resident #901 was asked what happened after they spoke to the DON and ADON and stated, They told (CNA S) they are not allowed to care for me anymore. Resident #901 then stated, Even if they weren't my aide, (CNA S) would come to the door and look it at me. Resident #901 then stated, Every time (CNA S) would open the door she would yell, so loud. It would go right though me, like a corrections officer. Resident #901 expanded, I could hear (CNA S) in other resident rooms. When asked if CNA S had ever hurt them or been rough with care, Resident #901 replied, No, just verbally and emotionally. Resident # 901 then stated, (CNA S) called me stupid. Told me not to be a cry baby and women don't cry. Resident #901's eyes were noted to become tear filled during their retelling of these interactions with CNA S. When asked if it made them feel bad when CNA S said those things to them, Resident #901 replied, Correct. Resident #901 was asked how else it make them feel and stated, Like I was worthless, like (CNA S) was so far above me. Resident #901 continued, (CNA S) would ask me if I though I was special. When asked the circumstances in which CNA S said that Resident #901 disclosed it occurred more than once. Resident #901 revealed they would tell CNA S that they were special, they were special, and all of God's children were special. Resident #901 was queried how CNA S would respond and stated, (CNA S) would say if you think so. Resident #901 was asked if there was anything else they wanted to share about CNA S and revealed that even when CNA S did not say anything, their tone was rude and demeaning. When asked when CNA S had said these things to them, Resident #901 was unable to recall specific dates but indicated it had been going on for a long time. Resident # 901 stated, When you have had enough, you've had enough and (CNA S) knew how to push my buttons. Resident #901 was asked what they meant and replied, (CNA S) would always say it was me and not them. Resident #901 was asked to explain and revealed they would put their call light on because they could not reach something, and CNA S would blame them and make them feel bad even if they did not put it somewhere they could reach it. Resident #902 reiterated they reached a point where they could not take it anymore and went to the DON. Record review revealed Resident #901 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included heart failure, one sided paralysis, and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact, displayed no behaviors, and required supervision to extensive assistance to complete Activities of Daily Living (ADL). Review of Resident #901's care plans revealed a care plan entitled, The resident has reported staff r/t (related to) treating bad and ridiculing them. (Resident #901) focuses and relives historical events r/t aide cares that has previously been reported (Initiated: 11/14/22). The care plan included the goal, The aide . will no longer be assigned to care for (Resident #901) (Initiated: 11/21/22) and the following interventions: - Provide a calm and safe environment to allow resident to express feelings as needed (Initiated: 11/14/22) - Cares in pairs - resident will frequently talk about other staff when staff are independently providing cares (Initiated: 11/14/22) Review of Resident #901's Electronic Medical Record (EMR) revealed the following progress note documentation: - 11/9/22: Physician/PA/NP - Progress Note . Patient is seen for readmission s/p (status post) hospitalization for NSTEMI (Non-ST Elevation Myocardial Infarction - Heart Attack) . denies chest pain today . - 11/10/22 at 8:29 PM: Physician/PA/NP - Progress Note . Admission visit for non-ST elevation MI (heart attack). Patient is noted with NSTEMI likely secondary to hypertensive (elevated blood pressure) urgency . Patient is noted with multiple hospitalization s for this issue within the last 6 months . - 11/11/22 at 10:30 AM: Health Status Note (nurses note) . resident c/o (complain of) chest pain 10/10 given ASA (aspirin) 81mg (milligrams) and Nitro (medication used to treat chest pain) SL (sublingual) x 1, pain reduced to 1/10 after five minutes . - 11/11/22 at 11:51 AM: Health Status Note (nurses note) . Resident states that after hearing that (CNA S) was going to be their aide tonight it caused them to have chest pain . states that this aide has been treating them bad and ridiculing them . - 11/14/22 at 6:39 PM: Social Service Note . Visit with resident, in pleasant mood. Stated is happy to be back at facility. No concerns noted . Resident #901 was placed in respiratory isolation precautions on 11/16/22 due to testing positive for Covid-19 on 11/16/22 and no further social services follow up assessments/notes were completed/documented. Review of facility provided investigation documentation included the following: - CNA S Interview/Statement Record, dated and signed 11/11/22: To my knowledge, I have always treated and taken care of (Resident #901) with care and dignity. I feel that (Resident #901) and I have gotten along well. I have always answered their call promptly and done everything to help (Resident #901) with their needs and wants. (Resident #901) has always called be 'baby girl'. To my knowledge, I have never ridiculed or talked down to (Resident #901) nor will I ever mistreat my residents. When (Resident #901) was having chest pains, I answered their call light promptly and sat with them until they felt better. They thanked me repeatedly. - Resident #901 Interview/Statement Record, written and signed by the ADON, dated 11/14/22: (Resident #901) asked me to do them a favor . stated they wanted me to make sure (CNA S) is not assigned to take care of them. (Resident #901) told me they become very anxious and experiences chest pains when they know (CNA S) is their aide. When asked why, (Resident #901) responded that (CNA S) is mean to them and belittles them. (Resident 3901_ stated they feel threatened by (CNA S) due to how (CNA S) treats them, not by verbal threats. (Resident #901) stated (CNA S) accuses them of intentionally wetting the bed. - An Interview/Statement Record form, written and signed by the DON, dated 11/16/22 day shift. The form detailed, I completed interviews/audits with the residents in the building . When asked if anyone ever spoke to you in a way that made you feel ridiculed, demeaning, or derogatory way? . 2. (discharged Resident) Yes- would not give further information as 'I don't want to get in trouble'. It was day/night CNA's crabby. 3. (Administrator) made me feel bad a couple of different times. Now I will be getting a lecture from (Administrator) . always turns it around and makes you feel like it is your fault. 4. (Administrator) - I feel like they would best be retired. They are condescending. It is their way or no way. 5. Yes but I forgive- no further comments. 6. Two residents- roommates (One discharged Resident and one Unsampled Resident): 1-2 weeks ago- demeaning hs (night) shift- darker skin/darker hair female. 7. (Resident #901) Yes (CNA S) is controlling . Note: CNA S has dark hair and a darker complexion. - CNA S Personal Action Notice detailing the staff members employment was terminated on 11/21/22. The document further identified their last day worked at the facility was 11/10/22. The facility Administrator was suspended and no longer works at the facility per Regional Director of Operations Q. CNA S's Employee file and education/training were requested and reviewed on 12/5/22. Review revealed CNA S's employment began on 3/19/21. The following documents were noted in the employee file: - Employee Coaching Form, dated 7/28/22 and signed by CNA S. The form detailed, Constructive Feedback . 1. Customer Service- how to approach a resident, understanding resident rights (i.e. - privacy curtain). 2. What we say to our residents and how we say it (i.e. - comments make while cleaning a resident). 3. Attitude - being 'bossy' . - Resident #902 Interview/Statement Record, dated 7/24/22 at 3:00 PM: In hallway, (Resident #902) was propelling in wheelchair at 2:45 PM. I asked them how they were doing. Stated not to good. I asked why, (Resident #908) stated that they wish they didn't come here. Asked why, (Resident #902) said the girl I have at night is mean . bossy, told me not to look at her or follow her, said to use call light. (Resident #902) stated that when (CNA S) was washing them up that the odor burns their eyes (yeast under right breast). I asked (Resident #902) if they felt safe here, said yes, but (CNA S) makes me nervous. The interview was written and signed by Licensed Practical Nurse (LPN) T. - Resident #902 Interview/Statement Record, dated 7/24/22: Approximately 2:45 PM, (LPN) T informed me that pt (patient) stated they wish they did not come here. The girl I have at night is mean and bossy. (LPN T) further interviewed pt. This writer notified DON (Director of Nursing) approx. 3 PM via phone. Approx. 4PM this writer spoke with Administrator. Administrator wanted to know if an assignment change was needed. Approx. 4:05 PM, this writer spoke privately with pt in small dining room. (Resident #902) does not want (CNA S) taking care of them because it makes them feel nervous. 4:10 PM CNA assignment changed. (CNA S) directed not to go in (Resident #902's) room at this time. Signed by Registered Nurse (RN) but unable to discern name from signature. - Resident #908 Interview/Statement Record, dated 7/24/22: Around lunch time, pt tells this writer that they had a melt down and was crying and couldn't stop for a long-time last night. (Resident #908) said (CNA S) is really mean and they don't know what they did wrong. Last (night) privacy curtain was moved away from between beds and (CNA S) would not allow them to keep it over there (near end bed). (Resident #908) explained they moved it because when staff turn off the call light they know over stuff on the bedside table because the curtain is in the way . also explained it helpers when they moved their table it don't get caught. (Resident #908) feels (CNA S) talks down to them . denied being scared of (CNA S). (Resident #908) did say CNA S could take care of them but (CNA S) needs a talking to so they understand. (Resident #908) also mentioned that they told (CNA S) they were dirty and an hour later (CNA S) and (CNA U) came to clean them. (Resident #908) explained that (CNA S) might be mad at them because of Friday. I asked what happened Friday and (Resident #908) said that they dropped their remote and couldn't find it. (CNA S) did assist with finding the remote but said in a mean way, 'It's always something with you (Resident #908)' . Informed DON via phone approx. 3 PM. An interview was conducted with the Administrator and Regional Director of Clinical Operations Registered Nurse (RN) R on 12/5/22 at 3:30 PM. When queried regarding the information in CNA S's employee file indicating Resident #902 and Resident #908 had verbalized concerns related to the CNA in July 2022, the Administrator reviewed the documentation and stated the incidents were Treated as poor customer service. When asked if the incident was reported to the State Agency, the Administrator replied, No and indicated it was not reported due to being treated as a customer service concern. The Administrator was asked to review Resident #902 and Resident #908's statements. After review, the Administrator was asked how the concerns verbalized by the Residents were different than the concerns verbalized by Resident #901 about CNA S which were reported. The Administrator was unable to provide an explanation other than Resident #902 and Resident #908's concerns were treated as poor customer service. When queried if the facility completed a comprehensive investigation following the allegations in July 2022, the Administrator replied, No. The Administrator was asked if there was any additional information related to the allegations and indicated there might be a soft file. Any further information/documentation was requested at this time. At 3:50 PM on 12/5/22, an interview was conducted with RN R and the DON. When queried regarding the Resident statements and Employee Coaching Form present in CNA S's file, RN R stated they were not aware of the allegations. The DON did not begin employment at the facility until September 2022 and was unaware of the incident. RN R and the DON were asked what was different between the concerns verbalized in July that were not reported and the reported FRI. RN R was unable to provide an explanation and stated the verbal abuse allegations for CNA S in July 2022 should have been reported. When asked if the facility should have completed an investigation into the allegations, RN F replied, Yes. When asked, the DON agreed the allegations should have been reported to the State Agency and an investigation completed. Resident #902: Record review revealed Resident #902 was admitted to the facility on [DATE] with diagnoses which included anxiety, seizures, and repeated falls. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required extensive assistance to complete all ADL with the exception of eating. Review of Resident #902's progress notes in the EMR revealed the following: - 7/27/22 at 7:26 AM: Other Note (only if no appropriate other note exists) . This writer gave (Resident #902) an informational sheet with the ombudsman's phone number for if they should want to get a hold of them. - 7/29/22 at 3:34 Type: *IDT (Interdisciplinary Team Note . Summary of discussions with resident. NHA met with (Resident) in small dining room on July 27, late afternoon on Sunday 7/24/22 being informed that they wanted to go back to (other facility). (Resident #902) was tearful, I asked why was crying and stated she missed (friend) . also expressed some care concerns from night prior. Vague about details, then stated 'I just feel nobody has time for me.' . My visits with (Resident) since has appeared content . Note: There were no progress notes dated 7/24/22 and no progress note documentation of social services assessment. An interview was conducted with Resident #902 on 12/7/22 at 11:51 in their room. When queried regarding how they were treated by staff in the facility, Resident #902 revealed they had problems with one of the CNA staff. When asked who the staff member was, Resident #902 stated, (CNA S). Resident #902 was queried what they meant by problems and revealed there had been multiple issues since they had been at the facility. When asked to provide an example, Resident #902 stated, I had a hard time peeing and (CNA S) said we can't do this all the time. When asked, Resident #902 revealed it made them upset because they cannot control it. Resident #902 was asked if this happened before or after they filed the complaint and replied, After. When queried if CNA S provided care to them after they had filed the complaint in July 2022, Resident #902 stated, Yes. When asked how that made them feel, Resident #902 looked down but did not provide a response. Resident #908: An interview was attempted to be completed with Resident #908 on 12/6/22 at 11:30 AM. Resident #908 was receiving treatment for acute illness (Covid-19) with negative reaction to medications and was unable to provide meaningful responses to questions due to acute confusion. Record review revealed Resident #908 was admitted to the facility on [DATE] with diagnoses which included intracerebral hemorrhage (brain bleed) with resulting dysphagia (difficulty swallowing), left sided hemiplegia (paralysis), and ataxia (impaired balance/coordination), and dysarthria (difficulty articulating speech). Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required extensive assistance to perform all Activities of Daily Living (ADL) with the exception of eating. Review of Resident #908's progress note documentation in the EMR revealed the following: - 7/25/22 at 9:52 PM: Social Service Note . Resident requesting to speak to the writer . stated that was upset with a nurse aid that really likes because (the CNA) has been bossy. Asked resident (if) wanted to have a different (CNA) to care for them . said no would like to talk to the CNA. I formed (sic) resident that this writer will inquire about that CNA's next shift. DON and NHA (Nursing Home Administrator) notified - 7/29/22 at 3:26 PM: IDT (Interdisciplinary Team Note . Follow up regarding NHA and Director of Nursing notification of (Resident #902) concerns. The Director of Nursing spoke with aide regarding resident statement that felt a nurse aide was bossy and appropriate customer service with all interactions with resident. - 7/29/22 at 5:47 PM: IDT (Interdisciplinary Team Note . Checked in on (Resident) this evening at approximately 4:45 . aide was in room discussing getting up for dinner. Aide left room to get assistance for transfer. I asked (Resident) if everything going better with aide . stated yes . is being nice last night and tonight. I told (Resident) the Director of Nursing had followed up the aide and from what I heard as I entered the room everything seems to good now (sic) with the resident and aide . Note: There were no progress notes dated 7/24/22 and no documentation of ongoing social services monitoring. A phone interview was conducted with CNA S on 12/5/22 at 4:54 PM. When queried regarding the incident with Resident #901, CNA S stated, I don't know what happened and revealed they did not understand why their employment at the facility had been terminated. CNA S was then asked about their interactions with Resident #901. CNA S stated, (Resident #901) likes me. I don't know. I have never had anything like this (Resident complaint) before. CNA S was then asked was had occurred in July 2022 involving Resident #902 and Resident #908 and indicated they were unclear about the question. CNA S was then asked about the Employee Coaching Form, dated 7/28/22 they received in their employee file and stated, That was not supposed to be in my record. When asked what they meant, CNA S revealed the DON at the time of the incident had just talked to them about it and they weren't in trouble. CNA S stated, The (prior) DON said (Resident #908) cries a lot and you can't believe what they say anyway. CNA S was asked to clarify and stated, (Resident #908) cries about every little thing. When queried regarding Resident #902, CNA S replied, When I asked them (Resident #902) about it, they said it wasn't me and it was another staff. When asked if they were saying they provided care to Resident #902 after the incident in July, CNA S replied, Yes. When asked why they continued to provide care to them, CNA S stated, Because. No further explanation was provided. When asked if they reported to anyone that Resident #902 told them it was a different staff member, CNA S replied, No. They (administrative) staff should have followed up but it wasn't supposed to be a big deal anyway. When asked about one of the Resident concerns from July mentioning they had told a Resident they smelled, CNA S quickly stated, I didn't do that. It was someone else, the Resident told me. When asked about Resident concerns referencing them being bossy, CNA S stated, I am not. CNA S was then queried if they ask or tell Residents what they would like them to do while providing care and stated, Well, I tell them sometimes because they need to do stuff on their own. CNA S was then queried how they would feel if they were being told what to do and replied, I don't want them to lose their mobility. When asked if they explained the rationale for wanting them to perform some tasks with less assistance to the Resident, CNA S replied, No. With further inquiry, CNA S stated, I guess I can come off harsh sometimes. On 12/6/22 at 11:59 AM, an interview was completed with CNA C. When queried if they had ever worked with CNA S, CNA C indicated they had, but not often. When queried regarding working with CNA S, CNA C stated, They were hard, kind of rude and demeaning. When asked, CNA C revealed they were referring to how CNA S would speak and treat other staff. CNA C revealed they confronted CNA S and told them, Hey, I don't appreciate being spoke to like I am beneath you. When asked how CNA S responded, CNA C stated, (CNA S) said that is just how they talk. When queried if they had ever observed CNA S interact with residents, CNA C indicated they had. CNA C stated, (CNA S) had the same tone (with residents). Very rough. When asked if CNA S had a bossy tone when speaking to residents, CNA C replied, Yes. CNA C revealed it was Always more the tone of how (CNA S) would say things. When queried if they had ever had any residents complain to them about CNA S, CNA C revealed they had. When asked if they had followed up and reported the complaint, CNA C indicated the Resident had gone to facility Administration. An interview was conducted with the DON and RN R on 12/6/22 at 10:00 AM. The DON and RN R were queried regarding CNA S's work assignments and revealed they typically were assigned to care for Resident #901, Resident #902, and Resident #908. Staffing assignment sheets for 7/24/22 to 8/24/22 at this time. When queried regarding CNA S stating they confronted Resident #902 and Resident #908 regarding the concerns they verbalized with care and CNA S stating the Resident's had told them they were talking about a different CNA, the DON and RN R and the DON indicated both Residents were placed in an uncomfortable situation. When asked if it was appropriate for CNA S to confront the Residents regarding their concerns, both the DON and RN R replied, No. The DON and RN R were then asked how CNA S confronting the Residents would make them feel. RN R stated, That is horrible. The DON agreed. When queried if CNA S confronting the Residents would be intimidating, both the DON and RN R verbalized confirmation. No additional documentation pertaining to Resident allegations of verbal abuse in July 2022 by CNA S. Review of facility policy/procedure entitled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property (Effective Date: 11/28/17) revealed, Purpose: It is the practice of the facility to encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect . involuntary seclusion . from abuse, neglect . Any nursing home employee or volunteer who becomes aware of abuse . shall immediately report to the Nursing Home Administrator . Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Abuse includes verbal abuse . mental abuse . Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families . iv. Mental abuse includes but is not limited to, humiliation, harassment, threats of punishment, deprivation, inappropriate use of social media or comments about a resident or a resident's needs . It is the policy of the Facility that each resident will be free from Abuse . Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility . D. Identification: Abuse Policy Requirements: It is the policy of this facility that all staff monitor residents and will know how to identify potential signs and symptoms of abuse . E. Investigation . It is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated . Procedure: The investigation is the process used to try to determine what happened . will begin the investigation immediately. A root cause investigation and analysis will be completed . All staff must cooperate during the investigation to assure the resident is fully protected . Law Enforcement: All reports of suspected crime and/or alleged sexual abuse must be immediately reported to local law enforcement to be investigated . I t is the policy of this facility that the resident(s) will be protected from the alleged offender(s) . Immediately upon receiving a report of alleged abuse, the Administrator, and or designee will coordinate delivery of appropriate medical and/or psychological care and attention. Ensuring safety and well-being for the vulnerable individual are of utmost priority . Procedures must be in place to provide the resident with a safe, protected environment during the investigation: i. The alleged perpetrator will immediately be removed, and resident protected . iii. If the alleged perpetrator is a facility resident, the staff member will immediately remove the perpetrator from the situation and another staff member will stay with the alleged perpetrator and wait for further instruction from administration . G. Reporting and Response . It is the policy of this facility that abuse allegations . are reported immediately, but not later than 2 hours after the allegation is made .

This Citation Pertains to Intakes MI 328, MI 386, MI 388, and MI 329. Based on observation, interview and record review, the facility failed to operationalize policies and procedures to ensure implementation of planned, timely, and meaningful interventions to prevent falls for three residents (Resident #703, Resident #704, and Resident #705) of three residents reviewed resulting in a lack of implementation of planned and consequential interventions to prevent falls, multiple resident falls with injury including Resident #703 falling and suffering a [CONDITION(S)] necessitating emergency treatment and staples, Resident #704 fracturing their hip following a fall, Resident #705 falling and experiencing a subdural hematoma as well as a fractured hip and scapula, unnecessary pain, and the likelihood for additional falls, injury and decline in overall health status. Findings include: Resident #703: Review of Intake documentation revealed Resident #703 had an unwitnessed fall on 8/28/22 which resulted in a [CONDITION(S)] and necessitated emergency transfer and treatment at the hospital. On 10/3/22 at 12:45 PM, an observation occurred of Resident #703 sitting in a recliner in their room. The recliner was directly across from the room door, near the window in the room, and visible from the hall. Upon entering the room, an uneaten food tray was noted on the overbed table in front of the Resident. The Resident's bed was on the other side of the room from the recliner. A walker with a urinal hanging on it was in the room but was not in reach of the Resident. The Resident was not wearing non-slip socks. When spoke to, Resident #703 was tearful, confused, and unable to provide rational responses to questions. At 12:52 PM on 10/3/22, the Director of Nursing (DON) was present in the hall. When asked who Resident #703's nurse was, the DON indicated they would find the staff member. On 10/3/22 at 12:57 PM, Certified Nursing Assistant (CNA) T approached and indicated the DON had instructed them to locate this surveyor. When queried regarding Resident #703 being tearful and confused, CNA T indicated the Resident had been fine earlier. When asked if they were familiar with Resident #703, CNA T stated they had not worked with (Resident #703) often. CNA T revealed they actually worked as a Restorative Aide but had been pulled to work the floor as a CNA. When queried regarding the frequency they are pulled to work on the floor, CNA T did not provide a response. CNA T was asked if they were familiar with Resident #703's fall in the facility and revealed they were not. Record review revealed Resident #703 was admitted to the facility on [DATE] with diagnoses which included weakness, difficulty walking, repeated falls, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #703 was severely cognitively impaired and required extensive, two-person assistance to perform Activities of Daily Living (ADLs) with the exception of eating. The MDS further indicated Resident #703 had two or more falls with no injury. Review of Resident #703's care plans revealed a care plan entitled, Fall Risk - Resident is high risk for falls (Initiated: 9/22/22). The care plan included the interventions: - Assure resident is properly hydrated. Dehydration increases risk for falls (Initiated: 8/13/21) - Gripper pad under w/c (wheelchair) cushion (Initiated: 8/13/21) - Gripper socks and/or shoes on at all times (Initiated: 12/15/21) - Monitor pain and alleviate using non-pharmacological interventions and medications as ordered (Initiated: 8/13/21) - Anticipate and meet the resident's needs (Initiated: 8/13/21) - Ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed (Initiated: 8/13/21) - If resident becomes agitated, do not leave resident unattended and call for staff assistance until behavior has resolved (Initiated: 12/3/21) Another care plan entitled, The resident has had an actual fall (Initiated: 9/22/22). This care plan included the interventions: - Date and description of other interventions put in place after a fall: (specify) (8/15/21) Better fitting gripper socks (blue); (8/20/21) Ensure resident has gripper socks on at all times; (8/21/21) Lipped mattress; (9/9/21) Bed moved against wall to improve access to recliner from bed; (2/12/2022) moved O2 concentrator to closer to bathroom, Placed bedside commode at foot of bed, will request green tubing from (Vender) if available; (3/6/2022) OT (Occupational Therapy) eval and treat; (4/4/2022) Use 7 ft (foot) oxygen tubing to prevent trip hazard; (4/22/22) Ensure urinal is within reach when in room; (5/11/22) Privacy curtain to be pulled 1/2 way during the day (Initiated: 3/6/22) - Ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance (Initiated: 8/16/21) - 9-7-22 One time OT screen R/T fall (Initiated: 9/7/22) - Ensure resident has a clear, dry path between recliner and bed (Initiated: 8/28/22) - Offer resident toileting before and after meals and with all care interaction (Initiated: 9/8/22) - Pharmacy consult to evaluate medications (Initiated: 8/16/21) Review of Resident #703's progress note documentation revealed the following: - 2/12/22 at 3:48 PM: Incident Note . resident with a fall at approx. 1535 (3:35 PM) staff responded to resident calling out for help. resident observed lying on back, on the floor near the bathroom door. O2 (oxygen) tubing near head, tubing stretched across room from concentrator plugged into wall. call light in reach, but not on. resident with hard-soled shoes on and using walker at time of incident . denied pain or injury . attempting to get up on own . Hoyer lift used to assist resident from the floor and into recliner. Resident stated . tripped over that (oxygen) tube . - 3/6/22 at 7:31 PM: Fall . 2 PM Resident observed on buttocks. Assessment completed. No apparent injuries. Resident denies hitting head. Neuro's initiated due to unwitnessed. Resident stated that took shoes off and was trying to stand up from sitting on bed and slipped . - 4/4/22 at 5:42 PM: Fall . Resident was found sitting on buttock on the floor in bedroom next to recliner. Resident had shoes on, walker in use and urinal at time of incident. Denies any pain or discomfort. Neuro's WNL (Within Normal Limits) resident also denies hitting head. Skin assessment and pain assessment done, both negative . - 4/22/22 at 4:37 PM: Incident Note . Resident observed on knees, in front of recliner, attempting to stand . resident alert as normal, denied pain, injury, or striking head. Resident attempting to stand independently. staff provide x 2 contact assist, and resident able to stand with own ability . resident stated . had walked over to bed to get urinal and was using it. Finished using the urinal, and tripped on O2 tubing, 14 ft O2 tubing in place (had been changed by [vendor] the prior day). Tubing replaced with a shorter 7 ft tube, and urinal placed within reach - 5/11/22 at 5:51 PM: Health Status Note . 2 PM resident lost balance while pulling privacy curtain to use urinal . fell on to buttocks. Neuro's initiated. No apparent injuries observed with assessment . - 8/28/22 at 6:12 PM: Incident Note . (Unsampled resident) came up to desk stating that (Resident #703) was on the floor. Observed resident sitting on the floor, oxygen tubing wrapped around legs, with walker on lap and a spilled cup of coffee to left. Observed moderate puddle of blood under the edge of bed, coming from an approximately 3-inch laceration on the right back of head. Denied pain. Ice applied to slow the bleeding and resident Hoyer lifted into bed . Sent to ER for laceration closure . - 9/8/22 at 3:38 PM: Post-Fall Evaluations (multiple evals) . Post-Fall . HIGH risk for falls . There is a noted pattern to falls. Resident attempts to use walker to ambulate in room. The resident has the following injury/s noted: Two skin tears present: to left hand and right elbow. New interventions for this fall that are being implemented: Place walker across the room. Leave wheelchair next to resident. Educated resident to use wheelchair Skin Observation: Resident does not have a new skin issue . Review of facility provided investigation documentation related to Resident #703's fall with injury on 8/28/22 included the following: - Full QA Report . Incident Date/Time: Sunday August 28, 2022; 5:00 PM . Fall . Ambulating . Witnesses: No . Ambulance Called: Yes . Care Prior to Fall . CNA asked resident if needed to use the restroom, declined. CNA left urinal and call light in reach . Visually Observed: 8/28/22; 4:30 PM . Details . Found on floor . Sitting on floor . spilled cup of coffee, oxygen tubing wrapped around legs . Preventative Measures . Bed in lowest position: No . Call light: Off . Call light in reach: No . Injuries: Laceration: Back of Head right side . Date/Time: 8/28/22 at 9:00 PM . Approximate 3 inch laceration . transferred to the ER for Evaluation and treatment . Conclusion: Resident Sustained a fall related to poor safety awareness and severe cognitive impairment . was standing to use urinal and lost balance, hitting head and causing a laceration to the back of head . root cause of the resident fall is related to poor safety awareness and cognitive impairment . - FSI- Fall Scene Investigation Report . 8/28/22 . Found on floor (unwitnessed) . Resident room . Ambulating . Alone and unattended . Last time toileted . Charted 1429 (2:29 PM) . walker . What appears to be the root cause of the fall: Environmental clutter/spill . Describe initial interventions to prevent future falls: Apply padding to the metal wheel covers on the exposed side of the bed; Ensure resident has a clear dry path between recliner and bed . - Licensed Practical Nurse (LPN) D Interview/Statement Record dated 8/28/22 (no time): Observed Resident sitting on the floor. A spilled cup of coffee was to (Resident's) left and oxygen tubing was wrapped around legs . walker was on lap. Observed a moderate puddle of blood under the edge of bed and also blood on head . Applied pressure and ice to the back of head when an approximate 3-inch laceration (bleeding) was . Hoyer (mechanical lift) lifted to bed. Vital gotten and placed in gown . sent to (hospital) . - CNA U Interview/Statement Record dated 8/28/22 at 5:30 PM: (Another resident) alerted me that (Resident #703) was on the floor. (Resident #703) stated they were trying to standup to use the bathroom. I alerted the nurse and went into room . bleeding from the back of head . helped up with a Hoyer lift and back into bed until EMS showed up. - CNA V Interview/Statement Record dated 8/28/22 at 5:00 PM: I went to let a couple family members to the front door. When I was returning the other CNA stated (Resident #703) fell . I did not them fall or hit their head. I was in (Resident #703's) room at 430 PM . did not need to use backroom . Nurse was notified and also in room when I got there. Review of Resident #703's fall risk assessment documentation in the Electronic Medical Record (EMR) revealed Fall Risk Evaluation Assessments were completed on 4/22/22, 5/13/22, and 9/14/22. All assessments determined the Resident was a high risk for falls. Incident and Accident Reports/Documentation related to Resident #703's other falls in the facility were requested and reviewed. Review detailed the following: - 2/12/22 at 3:35 PM: Unwitnessed fall in Resident room. Fall Details . Found on floor . lying on back, near bathroom door . Bed in lowest position: No . Call light: Off . Conclusion: Resident attempted to go to bathroom with nasal cannula on. Cannula did not reach bathroom . Room rearranged . Root Cause: Resident self-transferring to the bathroom and had O2 on. O2 tubing caused resident to fall . - 4/4/22 at 4:25 PM: Unwitnessed fall in Resident room. Fall Details . Resident was visualized sleeping in recliner at 1600 (4:00 PM) . Found on floor . sitting on floor legs straight out holding on to walker . Call light: Off . Conclusion: Resident was standing to use urinal. Took a step backward, tripped on oxygen tubing. Oxygen tubing switched from 14 ft to 7 ft to prevent further incidents . Root Cause: Tripped on oxygen tubing . - 4/22/22 at 4:30 PM: Unwitnessed fall in Resident room. Fall Details . Found on floor . on knees facing chair . Call light: Off . Call light in reach: No . Changed out 14 ft O2 (oxygen) tubing for 7 ft O2 line . Conclusion: Resident fell while ambulating to retrieve urinal. Oxygen tubing replaced with shorter tubing. Care plan updated to keep urinal within reach when in room . Root Cause: Urinal was not within reach of the resident, causing them to have to walk across the room, when went to return to chair longer than necessary tubing was strung across the floor causing then to trip and fall to knees . Note: No vital signs were documented following the fall. -5/6/22 at 2:00 AM: Unwitnessed fall in Resident room. Fall Details . Fall caused by patient intent or behavior . on buttocks, back towards bed . Footwear: Socks . Call light: Off . Bed in lowest position: No . Actions . Employee Education (CNA X) . Conclusion: Resident stated they were sitting at edge of bed, took shoes off and attempted to stand up then fell . OT to eval and treat . Root Cause: Blank . - 5/11/22 at 2:00 PM: Unwitnessed fall in Resident room. Fall Details . Visually Observed: 5/11/22 at 1:45 PM . Found on Floor . on buttocks . Bed in lowest position: No . Conclusion: Resident fell attempting to pull privacy curtain closed to use urinal. Privacy curtain to be pulled 1/2 closed at all times during day . Root Cause: Resident needed privacy to use urinal . - 9/8/22 at 1:45 PM: Unwitnessed fall in Resident room. Fall Details . Fall caused by patient intent or behavior . lying on floor . Pain Symptoms: Using hand gesture to indicate right hip area . Call light: N/A . Injuries: Skin Tear: Left hand . right elbow . Left hand between thumb and first finger . Conclusion: Resident continues to be impulsive, and thinking can complete tasks without asking for assistance . sustained skin tears . Root Cause . impulsiveness, poor safety awareness, and cognitive impairment . An interview and review of Resident #703's falls was completed with the DON, Administrator, Social Services Director Q, and Clinical Registered Nurse (RN) Y on 10/13/22 beginning at 1:30 PM. When queried regarding Resident #703's fall on 2/12/22 including what interventions were implemented following the fall, the staff revealed their Resident's oxygen concentrator was moved closer to the bathroom, a bedside commode was placed in the room, and green oxygen tubing was implemented. When queried what green oxygen tubing was, RN Y indicated it was longer. The staff were queried regarding the level of assistance Resident #703 required at the time and revealed they needed limited to extension one person assistance. The staff were queried if Resident #703 was in bed prior to the fall but revealed they were unable to determine from the documentation. When asked if the Resident was incontinent at the time of the fall and/or if they urinal was in reach, the staff were unable to provide a response. When asked if the oxygen tubing was changed as indicated if available on the care plan, Director Q indicated it had been. The Administrator was then asked if the planned interventions to prevent falls were in place including a raised edge (lipped mattress), bed against wall, and gripper socks were in place when the Resident fell and stated, I'm not certain. Resident #703's fall on 3/6/22 was reviewed at this time. When asked what socks meant as documented on the Incident Report, both the DON and RN Y revealed the Resident was wearing regular (not grip) socks. When asked why employee education was listed under the Action Section of the report, RN Y replied, I don't know. Per Resident #703's care plan, the Resident was supposed to have on blue gripper socks on at all times. When queried why Resident #703 was not wearing gripper socks, the staff were unable to provide an explanation. When queried if the Resident was wearing gripper socks currently, the DON revealed they would go check. After returning to the conference room, the DON was asked if Resident #703 had gripper socks in place and replied, They do now. The DON revealed Resident #703 was wearing socks with regular socks. When asked, the DON stated the Resident should have gripper socks on even if they are wearing shoes. When queried regarding interventions implemented to prevent further falls, RN Y revealed an OT evaluation was ordered and both physical and occupation therapy were recommended. A copy of the evaluation was requested at this time. When queried regarding the root cause of the fall, none of the staff were able to provide a response. When queried regarding the lack of comprehensive investigation to determine the cause of the fall in order to implement effective interventions, RN Y replied, I'm not either. When asked what interventions were implemented following Resident #703's fall on 4/4/22, Director Q replied, 7 foot instead of 14 foot oxygen tubing. When queried if the oxygen concentrator positioned closer to the bathroom as previously care planned, the staff indicated they were unsure. When queried if staff had completed a Fall Scene Investigation form with a drawn picture, RN Y reviewed the reporting system and provided the form. Review of the Fall Scene Investigation form revealed a drawn image displaying the oxygen concentrator sitting directly next to Resident #703's recliner, on the right side. The oxygen concentrator was not near the bathroom. The form also detailed the Resident was wearing socks and not gripper socks. When queried regarding documentation on the form, none of the staff were able to provide an explanation for the lack of implementation of the planned intervention. The staff were then asked about the fall on 4/22/22. When asked if Resident #703's fall on 4/22/22 was a result of their urinal not being in reach and lack of implementation of planned intervention related to oxygen tubing length, RN Y and the DON both stated, Yes. When queried why the planned intervention related to the oxygen tubing from the fall on 4/7/22 was not implemented, an explanation was not provided. When queried if Resident #703 should have a care plan intervention in place related to using/having their urinal in reach prior to this fall, the DON designated they should have. When queried how that intervention was meaningful when in should have been in place prior, the staff verbalized understanding but did not provide further explanation. When asked why vital sign documentation was not completed, the DON inferred vital signs should have been obtained and documented. When queried regarding the Resident's fall on 5/11/22, the staff revealed the updated intervention was to have the privacy curtain pulled halfway during the day. When queried how that intervention would prevent falls when the Resident preferred to sit in their chair and the curtain did not come close to nor around the area where their chair was, an explanation was not provided. The staff were then queried regarding Resident #703's fall on 8/28/22 with resulting [CONDITION(S)]. When queried regarding the length of Resident #703's oxygen tubing, the staff reviewed the medical record. RN Y stated, I'm not sure, it doesn't say. When asked about the position of the oxygen concentrator, the staff were also unable to provide a response. The staff were asked what intervention was implemented following the fall. The Administrator stated, Tried padding the wheel on the bed but it was not appropriate. When asked what they meant, the Administrator indicated the facility was unable to move the bed if needed when there was padding on the wheels. With further inquiry, Director Q stated the intervention on the care plan was to ensure a clear and dry path. When asked if it was a standard of care to have a clear and dry floor to prevent falls, the Administrator replied, I would think so. The staff were then asked if that was a meaningful intervention and RN Y stated, No. When queried regarding other potential interventions such as non-slip floor strips in front of their recliner, the Administrator revealed that had not been considered. When queried regarding alternative methods to secure/maintain the oxygen tubing and room placement as the Resident was unable to use the call light, an explanation was not provided. When queried if Resident #703's call light was in reach when they fell on [DATE] due to the call light being marked as N/A on the incident form, the staff were unable to provide an explanation. When asked if all other interventions were in place, the staff were unable to determine. When queried regarding both 7- and 14-foot oxygen tubing being listed as interventions on the care plan, an explanation was not provided. Review of Resident #703's Rehabilitation Department Fall Screen dated 3/7/22 revealed the Resident did not have a history of falls and had zero falls in the past year. PT and OT were recommended. Hospital medical records for Resident #703 was obtained and reviewed. Review of records dated 8/28/22 detailed the following: - Emergency Department (ED) . Chief Complaints: Fall; Head Injury . Diagnoses: Fall . Scalp laceration . admitted /Time: 8/28/22 1752 (5:52 PM) . Urgent . Means of Arrival: Ambulance . Level of Service . High Severity . - ED Provider Notes . presenting today . after a fall that was unwitnessed . laceration to the crown of head, there was no known loss of consciousness . Skin: Positive for wound (small laceration to crown of head) . BP (Blood Pressure) 175/92 (Elevated) . Musculoskeletal . some external rotation of the right leg, this may be chronic, unsure with history . Laceration Repair . Risks discussed: Infection and pain . Laceration details . Scalp . Crown . Length (cm- centimeters): 3.5 . Skin repair . Staples; Number of staples: 7 . The Hospital medical record revealed Resident #703 was discharged from the ED on 2/28/22 at 10:40 PM. Resident #704: Review of intake documentation for Resident #704 revealed Resident #704 fell in the facility on 9/5/22 and suffered a left hip fracture necessitating emergency medical treatment and surgical repair. On 10/3/22 at 12:10 PM, Resident #704 was observed in their room in bed. An untouched food tray was present on the overbed table next to the bed. An interview was completed at this time. Resident #704 was pleasantly confused. When asked if they fell at the facility, Resident #704 replied they had attempted to make a straight [NAME] and then fell . The Resident stated, I had already left the area I was and moved to the area I was going to be in. It was an unpopulated area. When asked if they were hurt, Resident #704 replied, It hurt bad. Oh God, it was so painful. A wheelchair and a walker were present in the Resident's room, neither were within reach of the Resident. When asked if they use the walker or wheelchair, Resident #704 indicated staff want them to use the wheelchair, but they can't get it without leaping to it. The Resident revealed they would prefer to use the walker but that was farther away. Review revealed Resident #704 was admitted to the facility on [DATE] with diagnoses which included repeated falls, [CONDITION(S)], cerebral infarction (stroke), and abnormalities of gait/mobility. Review of the MDS assessment dated [DATE] revealed Resident #704 was moderately cognitively impaired and required extensive one-to-two-person assistance to perform ADLs with the exception of eating. The MDS further revealed Resident #704 had a history of falls including one fall with no injury and one fall with major injury. Review of Resident #704's Fall Risk Evaluation Assessments revealed the Resident was a high risk for falls. Review of Resident #704's care plans revealed a care plan entitled, The resident has had an actual fall with no injury 7/30/22, 8/7/22, 8/20/22, 8/23/22 . 9/5- major injury (Initiated: 8/20/22). The care plan included the interventions: - Date and description of other interventions put in place after a fall: (7/30/22) gripper pad to w/c (wheelchair) seat; (8/7/22) Educate resident to wait for staff assistance; (8/20/22) additional gripper pad to seat of w/c (one on top of roho cushion and one under roho cushion); (8/23/22) Offer toileting during rounds; (9/5/22) Place gripper strips in front of recliner. Educated on call light use. Room change to a more visual area (Initiated: 8/20/22) - Place gripper strips in front of recliner. Educated on call light use. (Initiated: 9/5/22) A second care plan entitled, The resident is at risk for falls (Initiated: 9/17/22) included the following interventions: - Encourage resident to stay properly hydrated, educate that dehydration increases risk for falls (Initiated: 7/25/22) - Ensure assistive device (such as cane, walker) is within reach when in a chair or bed (Initiated: 7/25/22) - Evaluate gait and ambulation capabilities, identify abnormalities (Initiated: 7/25/22) - Review resident medications associated with fall risk, such as diuretics, antiepileptics, hypnotics, analgesics, and antidepressants. Discuss possibility of dose reduction with MD if appropriate (Initiated: 7/25/22) - Anticipate and meet the resident's needs (Initiated: 7/25/22) - Ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance (Initiated: 7/25/22) - Follow facility fall protocol (Initiated: 7/25/22) Review of Resident #704's Clinical Census in the EMR revealed the Resident was in the same room from 7/21/22 until their transfer to the hospital on 9/5/22. The room Resident #704 resided in during this time frame was at the end of the hallway and not in view of the nurses' station. Review of Resident #704's progress notes in the EMR revealed the following: - 9/5/22 at 11:01 AM: Post-Fall Evaluations (multiple evals) . HIGH risk for falls . no new pain, post fall. 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: Place gripper strips in front of recliner. Educated on call light use . Neuro Observation: Resident is: alert. Resident is NOT oriented x 4; oriented to person, oriented to place, Pupils . right pupil brisk; left pupil sluggish . Speech is clear. Responds to simple commands. Verbalizes appropriately. There are no noted changes in baseline speech clarity. Hand grasp equal bilaterally . Movement and sensation intact in all 4 extremities . - 9/5/22 at 11:13 AM: Incident Note . 1000 (AM): Notified by Side 2 nurse that resident had fallen. Observed CNAs taking vitals on resident, who was seated in wheelchair. Resident stated was getting stiff sitting in recliner so got up to walk. Call light was off; CNAs stated they were in the adjoining bathroom and heard a thump. Resident stated bumped the side of head against dresser when fell . Denies pain; no bruising or swelling noted. No visible injuries; VSS (Vital Signs Stable) and ROM (Range of Motion) WNL (Within Normal Limits) for resident. Dr. notified- vitals every 4 hours for 24 hours as resident hit head. Also monitor closely as resident is on [MEDICATION(S)] (blood thinner medication) . At 11:43 AM on 9/5/22, Resident #704 received 1000 milligrams (mg) of Tylenol for pain as needed. Pain level not documented in Medication Administration Note. - 9/5/22 at 11:53 AM: SNF to ED Handoff . Key clinical Information: fell at 1000 (AM) . L hip/thigh pain w/movement of any kind . Usual Mental Status: Alert, disoriented, follows commands. Usual Functional Status: Ambulates with assist . - 9/5/22 2:38 PM: Health Status Note . 1215 (PM): Resident lying in bed and c/o (complain of) severe left hip/thigh pain. Swelling at left hip site; left leg shorter than right. PRN Tylenol given. Dr. notified and order for ER evaluation received and noted . - 9/5/22 2:45 PM: Health Status Note . Called ER for an update: resident being admitted for L hip fracture . Review of facility provided investigation related to Resident #704's fall on 9/5/22 included the following: - 9/5/22 at 10:00 AM, Incident Report: Unwitnessed fall in resident room. Fall details . Found on floor . sitting on floor, leaning on right hip, against dresser . Walker: None; Wheelchair: Note in use . No injuries noted . Conclusion: Resident sustained a fall, stating to one nurse did not hit head, but then telling the other nurse that hit head on nightstand, but no apparent injury at the time of the fall. Approximately one hour later, resident complained of sever left hip pain, about 20 minutes after being toiled and transferred to wheelchair by two staff members . sent to the ER for evaluation and treatment. X-ray revealed a left hip fracture admitted for surgery . returned to facility on 9/7/22. Resident will admit to a new room, closer to nurses' station and where more ever can be planed upon them . Root Cause . impulsiveness, forgetfulness, and cognitive impairment. Resident frequently attempts to self-transfer without asking for assistance, resulting in falls . - FSI- Fall Scene Investigation Report . (Resident #704) . (No date) 10:00 AM . Gait Assist devices at time of fall: None . Did vision or hearing contribute to fall? Yes- glasses not on . Primary Nursing Assistant (CNA I) . description . I last checked on (Resident #704) at 9:10 AM before I went on 1st break. I asked if they needed anything, they said no . The drawn image included in the FSI did not include the location of the call light. - Hospitality Aide A statement, dated 9/5/22 at 12:00 PM: During morning / midmorning checks, in bathroom helping resident using restroom, heard a loud hand in room next door, checked next door room to see (Resident #704) had fallen . Immediately got help and notified nurses. - CNA X statement, dated 9/5/22 at 12 AM: When resident fell I and (Hospitality Aide A) was in the joined bathroom with a resident . was in the middle of transfer and heard loud bang so I open the door to the room and seen resident on floor. Couldn't leave bathroom to help and yelled for help. Continued with resident in bathroom. Nurse came to door, and I told them to go next door resident on floor. - Licensed Practical Nurse (LPN) L statement, dated 9/5/22 (no time): Called by aide that resident fell , entered room resident laying partially on right side. Resident stated I am fine just got up from chair. Resident denies claim of pain. Able to move all extremities without complaint of pain or discomfort. Resident stated did not hit head. After assessing for pain or limited mobility assisted resident with two assist to wheelchair in locked position. Notified side one nurse of fall. - LPN D statement, dated 9/5/22 (no time): Notified by side 2 nurses that resident had fallen. Entered room and observed sitting in wheelchair and (CNA Z) and (Hospitality Aide A) getting vitals . (Resident #704) said was getting stiff sitting in recliner and got up to walk. (CNA Z) said was sitting by dresser on right hip. Resident said bumped head on dresser. No visible injuries . Approximately 45 minutes later assisted with transfer off toilet and from wheelchai [TRUNCATED]

This Citation Pertains to Intake Numbers MI 995 and MI 157. Based on observation, interview and record review, the facility is placed in Immediate Jeopardy for its failure to develop, implement, and operationalize policies and procedures for comprehensive assessment and monitoring per professional standards of practice for two residents (Resident #704 and Resident #707) of three residents reviewed. This deficient practice resulted in 1) A lack of routine staff monitoring of Resident #704 from 2:53 AM to 6:59 AM on [DATE]. Resident #704 was without ordered supplemental oxygen during that timeframe, was found unresponsive, and required emergency medical treatment including mechanical ventilation due to hypoxemia (decreased oxygen levels). This deficient practice also resulted in 2) A lack of comprehensive assessment and documentation of Resident #707, a lack of identification of signs and symptoms of bowel obstruction and [CONDITION(S)] (infection throughout the body), and subsequent death as a result of an ischemic bowel obstruction. Immediate Jeopardy: The Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was identified on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:34 PM. A plan to remove the immediacy was requested. The Immediate Jeopardy was removed on [DATE], based on the facility's implementation of the plan removal as verified onsite on [DATE]. Although the immediacy was removed, the facility remained out of compliance at a Scope of Isolated and a Severity of No actual harm with potential for more than minimal harm that is not immediate jeopardy, pending a revisit to verify compliance by the State Agency (SA). Findings Include: Resident #704: Record review revealed Resident #704 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required extensive, one-to-two-person assistance to perform Activities of Daily Living (ADLs). At 10:30 AM on [DATE], the Administrator revealed Resident #704 had been transferred to the hospital over the weekend and was not in the facility. On [DATE] at 9:55 AM, Resident #704 was not present in their room and there was no bedding on the bed. Review of intake documentation detailed, (Resident #704) needs assistance with medication management, meals, mobility, and transportation . The intake documentation included concerns related to the facility staff not providing adequate and necessary assessment and monitoring of Resident #704 including vital sign monitoring. Per the intake, (Resident #704) was found unresponsive and had been that way for an unknown amount of time . oxygen (SPO2) was at 40% (greater than 92% is normal) . was taken to a hospital and put on a ventilator . Review of Resident #704's Electronic Medical Record (EMR) revealed the following documentation: - [DATE] at 11:20 PM: Daily Skilled Note . Neurological: Abnormal Neuro Check Findings (Blank) . Cardiovascular: Abnormal Cardiovascular Findings (Blank) . Respiratory: Alteration in Respiratory Status: SOB (Shortness of Breath) Upon Exertion Breath Sounds Left: Clear; Breath Sounds Right: Clear . - [DATE] at 7:11 AM: SNF to ED Handoff . Key clinical Information . (oxygen saturation -SPO2) ,d+[DATE], frothy vomit around mouth, nonresponsive. Reason for Transfer: [CONDITION(S)] . Vital Signs: BP (Blood Pressure) ,d+[DATE] - [DATE] 23:23 (11:23 PM) . P (Pulse) 104 (elevated) - [DATE] 15:06 (3:06 PM) . [DATE] 15:06 . T (Temperature) 96.9 - [DATE] 23:24 Route: Tympanic . O2 (SPO2) 96.0 % - [DATE] 23:30 Method: Room Air . Usual Functional Status: Non ambulatory Devices/O2: 02 3.5 L (Liters/minute) . - [DATE] at 11:40 AM: Health Status Note . CNA entered resident's room at 0700 and noted O2 tubing wrapped around resident's hand and off . face. 02 sating (SPO2) in 40's. Noted resident pale, cool, and clammy. White froth around mouth. Crackles heard throughout lungs. Nonresponsive. Raised head of bed, turned 02 to 5L. Vitals as follows bp ,d+[DATE], HR (Heart Rate) ,d+[DATE], 02 ,d+[DATE], resp 22, temp 97.0. Eyes open to name as 02 sat increased gradually. Notified (Physician G) of condition. Order to ship to ED . - [DATE] at 1:22 PM: Health Status Note . Resident admitted to (hospital) with [CONDITION(S)] and altered mental status. Notified DON (Director of Nursing) and physician. Review of Resident #704's care plans revealed the following care plans and interventions: Care plan: The resident has oxygen therapy . (Initiated: [DATE]). The care plan included the interventions: - If the resident is allowed to eat, oxygen still must be given to the resident but in a different manner (e.g., changing from mask to a nasal cannula). Return resident to usual oxygen delivery method after the meal (Initiated: [DATE]) - Monitor for s/sx (signs/symptoms) of respiratory distress and report to MD (Medical Doctor) PRN (as needed): Respirations, Pulse oximetry, Increased heart rate ([CONDITION(S)]), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin color (Initiated: [DATE]) Care plan: The resident has altered respiratory status/difficulty breathing R/T (related to) [CONDITION(S)] and SOB (Initiated: [DATE]). The care plan included the intervention, Oxygen Settings: O2 (Oxygen) via nasal cannula @ ,d+[DATE]L at rest (Initiated: [DATE]) Review of Resident #704's Order Summary Report of all active, completed, on- hold, pending and discontinued orders revealed the following orders pertaining to oxygen therapy: - Change O2 tubing every day shift every Thu (Thursday) and as needed . (Communication Method) Verbal (Order Status) Active . (Start Date) [DATE] . - Continuous O2 Via (NC/MASK) at _,d+[DATE]__lpm every shift . (Communication Method) Verbal (Order Status) Active . (Start Date) [DATE] . - Monitor O2 Saturation Every Shift every shift . (Communication Method) Verbal (Order Status) Active . (Start Date) [DATE] . On [DATE] at 12:50 PM, Resident #704 was not in their room. Their oxygen concentrator was on and set at 4.5 liters. An interview was conducted with Resident #704 on [DATE] at 12:55 PM. Resident #704 was pleasant when spoke to but was unable to provide any information regarding their transfer to the hospital on [DATE] when asked. An interview was completed with Registered Nurse (RN) A on [DATE] at 1:05 AM. When queried regarding Resident #704, RN A revealed the Resident had been sent to the hospital twice recently. RN A then stated, (Resident #704) just got back (from hospital) and then went out for seizures and come back. With further inquiry regarding Resident #704 having a [CONDITION(S)], RN A revealed the Resident was sent to the hospital due to having a [CONDITION(S)] and were found to have low potassium in the ER. The Resident returned to the facility after receiving treatment in the ER. When queried if they were working on [DATE] when Resident #704 was transferred to the hospital, RN A indicated they were. RN A was asked what had occurred and stated, They went out for [CONDITION(S)] and [CONDITION(S)]. RN A continued, The CNA (Certified Nursing Assistant) entered (Resident #704's) room and their O2 (tubing) was wrapped around (their) hand. With further inquiry, RN A revealed Resident #704 was nonresponsive, cool and clammy. RN A indicated the CNAs placed the oxygen on the Resident. When asked what the oxygen rate was set at, RN A revealed it was at 3.5 (L) when they entered the room. RN A was asked what actions and/or care they provided upon entering the room and stated, Turned up the O2, raise the head of the bed, notify the doctor, and sent out. When asked, RN A revealed Resident #704's SPO2 was 38 to 40% when they first checked it. RN A was asked if that was the Resident's SPO2 prior to their oxygen being put back on, RN A replied, No and indicated they checked the SPO2 level after the supplemental oxygen was placed back on the Resident. RN A was asked who the CNAs were that found the Resident and stated, (CNA B) and (CNA C). When queried regarding the last time they saw the Resident prior to the CNA's finding them, RN A replied, It was around 7:00 AM. I had not saw (Resident #704) yet. RN A revealed their shift started at 6:00 AM. RN A then stated, The CNAs start at 4:00 AM and indicated they may have seen Resident #704. When queried if they had received any information regarding Resident #704 from the night shift nurse during shift-to-shift report, RN A revealed they had not. An interview was completed with CNA B on [DATE] at 1:15 PM. When queried if they had provided care to Resident #704 on [DATE], CNA B revealed they had. CNA B stated, Me and (CNA C) found (Resident #704). When asked if they recalled what time they found the Resident, CNA B replied, It was around 7:00 AM. CNA B was then asked if they had provided incontinence care and/or checked on the Resident prior to that time and replied, I didn't. CNA B revealed they were assisting CNA C who was the was the Resident's assigned CNA and they were helping them. On [DATE] at 1:20 PM, a phone interview was attempted to be completed with CNA C and a message with return number was left. A return call was not received by the conclusion of the survey. An interview was conducted with the facility Administrator on [DATE] at 2:30 PM. When queried regarding the frequency in which staff should monitor and observe Residents, the Administrator did not provide a response. The Administrator was then queried regarding the availability of video camera footage and revealed the facility video camera system retained footage for two weeks. A request to review video footage of [DATE] of Resident #704's room was made at this time. Video footage of the hall outside of Resident #704's room was reviewed with the Facility Administrator, Social Worker E, and the Director of Operations Staff D on [DATE] at 5:15 PM. The video footage showed the hall outside of Resident's room with the Resident's room door was clearly visible. Video review of [DATE] showed the Resident's door was closed and no staff were near the Resident's room and/or entered their room from 2:53 AM until 6:59 AM. When queried regarding facility policy/procedure regarding the frequency in which staff monitor/observe and/or round on Residents, the Administrator indicated they would need to review facility policy. When queried regarding the facility standard of practice for rounding on residents, the Director of Operations Staff D stated, Well the Standard is every two hours. When asked why Resident #704 was not visualized by staff for almost four hours when the standard of care is every two hours, an explanation was not provided. The Administrator and Director of Operations D were then asked how long Resident #704 went without oxygen and a response was not provided. The Administrator and Director of Operations D were then queried if Resident #704 may have had their oxygen off from 2:53 AM to 6:59 AM and both D replied, Yes. Review of Resident #704's hospital documentation from their admitted d [DATE] detailed the following: - H&P . [DATE] at 1:08 PM . Chief Complaint: Unresponsive . Prior to presentation to ER, NH (Nursing Home) reports (oxygen) saturation of 40%. When paramedics arrived on the scene, (Resident #704) was on 10 L and still sating in the 70's. They put (Resident #704) on a nonrebreather (oxygen mask for delivery of high flow oxygen and the first choice for constant flow supplemental O2 in an acute medical emergency). Upon arrival to ED, patient diaphoretic/altered LOC (Level of Consciousness)/SPO2 70's on 15L . intubated (medical procedure where a tube is inserted into the mouth and into the trachea to maintain patency of the airway, provide oxygenation and ventilation via machine) . oxygen saturation included to 96% with skin color changed from dusky to pink . Metabolic workup (laboratory tests) essentially unremarkable . WBC (White Blood Count) 16.1 (elevated- indicative of infection) . Patient admitted for Respiratory failure with [CONDITION(S)] . Assessment and Plan . Currently vented . Presumably respiratory failure multifocal in origin secondary to possible pneumonia . - Progress Notes . [DATE] at 8:06 AM . Plan: Acute on chronic hypoxic hypercapnic (retention of carbon [MEDICATION(S)]) respiratory failure . Secondary to noncompliance of home [CONDITION(S)] (Continuous Positive Airway Pressure- non-invasive machine typically used at night to provide increased oxygenation) . Intubated in ED, plan for extubation today . Baseline 3L (O2) nasal cannula . Continue to encourage home [CONDITION(S)] . nightly . Concern for [CONDITION(S)] Source possibly [CONDITION(S)] versus pneumonia . Further review of Resident #704's facility medical record revealed the Resident did not have an active order and/or care plan for [CONDITION(S)]/[CONDITION(S)] use. A discontinued order for [CONDITION(S)]/[CONDITION(S)] per settings, on q hs (bedtime) in the morning off in AM . (Discontinued: [DATE]) was noted. Additional review of Resident #704's care plans revealed the discontinued intervention, Resolved: [CONDITION(S)] Settings . (Initiated: [DATE]; Resolved: [DATE] within the care plan, The resident has altered respiratory status/difficulty breathing . (Initiated: [DATE]). Review of facility nursing evaluation documentation following Resident #704's readmittance from the hospital on [DATE] included the following: - [DATE] at 10:03 AM: Nursing Evaluation . admitted from (hospital) . Oxygen via Nasal Cannula . Neurological: Resident is confused . speech is clear . Knows familiar staff members, denies that they were in the hospital . Breath sounds are clear on right and left side . diminished bilaterally . no cough . using assessory muscles. Has SOB or trouble breathing with exertion. Has SOB or trouble breathing when lying flat. While a resident oxygen is being used. The rate is: 3 (L) Via nasal cannula. According to hospital records, resident is supposed to be on [CONDITION(S)] . On [DATE] at 12:57 PM, Resident #704 was observed in their room. The Resident was sitting in their wheelchair with their oxygen in place via nasal cannula. The oxygen flow rate was set at 4.5 liters. Resident #707: Review of intake documentation pertaining to Resident #707 detailed, (Resident #707) went to the facility on [DATE] for therapy from a fractured neck. (Resident #707) was in pain but doing ok. For the first 4 days, (Resident #707) was talking and walking around. On Sunday, they put (the Resident) on [MEDICATION(S)] (narcotic pain medication for severe pain), they were already on ([MEDICATION(S)]). So . [MEDICATION(S)] every 4 hours and Oxy every 6 hours. Sunday (Resident #707) was fine and playing cards and walking. Monday, (Resident #707) started puking and (became) incoherent. This continued thru out the week and just kept getting worse. (Resident #707) starting hallucinating and talking nonsense. On Friday [DATE] I visited (Resident #707) and told them (facility staff) that (Resident #707) has been sick and puking for 5 days that they needed to do something . When I visited (Resident #707) Saturday [DATE], they could not speak and were moaning in pain and holding their stomach. I went to the nurses' station and told them they needed to come check . When they took (Resident #707's) vitals their blood pressure was ,d+[DATE] (severely low). I told them (facility staff) to call an ambulance and they asked me if I was sure (Resident #707) needed it. When we were on our way out with the ambulance another family member heard the nurse say (Resident #707) should have went to the hospital yesterday. The intake documentation further revealed the Resident passed away on [DATE] related to lack of blood perfusion to their small intestines causing ischemia and tissue death. The intake relayed, If (Resident #707) was taken to the hospital sooner, their small intestines would not have died . On [DATE] at 1:00 PM, an interview was completed with Resident #707's Family Member Witness H. When queried regarding Resident #707, Witness H stated, (Resident #707) died on [DATE]. Their bowels were dead. When asked what happened, Witness H replied, (Resident #707) fell at home on [DATE] and ended up with a C2 (Cervical Spine - neck vertebra). Witness H revealed Resident #707 lived at home alone prior to the fall and had gone to the facility from the hospital to receive therapy and gain strength to return home. When queried regarding Resident #707's stay at the facility, Witness H revealed Resident #707 was admitted to the facility on Wednesday [DATE]. Witness H continued, On Friday ([DATE]), (Resident #707) was hallucinating and by Saturday ([DATE]), they were puking. Witness H indicated they were concerned about the Resident not eating and taking pain medication, so they brought Ensure (nutritional supplement) to the facility for the Resident. Witness H was asked about the Resident's pain and revealed Resident #707 had been having pain in the hospital related to the fall but it had been controlled in the hospital. Witness H continued, When they got to the facility, their pain kept getting worse and they (facility) just kept adding pain meds. They started (Resident #707) on Oxy ([MEDICATION(S)]- narcotic medication for severe pain), [MEDICATION(S)] (narcotic medication for severe pain) and other meds. When queried regarding the location of Resident #707's pain, Witness H revealed the Resident did not specify the location of their pain and stated, They were just moaning and crying out in pain. When asked if they observed staff administer pain medication, Witness H indicated they had. When queried if the staff asked the Resident the location and severity of their pain prior to administering the medications, Witness H replied, No. With further inquiry, Witness H revealed Resident #707 became progressively more confused from Friday ([DATE]) and continued to vomit and have diarrhea until they insisted the Resident be transferred to the hospital on Saturday ([DATE]). Witness H stated, (Resident #707) was screaming in pain and holding their stomach on Saturday. When asked if they had spoke to the facility staff regarding Resident #707's mental status change, pain, and gastrointestinal (GI) distress prior to the day the Resident was transferred to the hospital, Witness H revealed they and other family members had spoke to facility nursing staff. When queried regarding facility nursing staff response to their concerns regarding Resident #707's mental status change, GI distress, and pain, Witness H indicated the staff did not seem to take it seriously and just keep adding more pain meds. Witness H stated, (Resident #707) did not even know me or my (siblings) but they (facility nursing staff) would tell us (Resident #707) was talking and fine. When asked if they recalled the names of the nursing staff who they had spoken to regarding their concerns, Witness H disclosed they did not recall any names and indicated the facility staff did not always introduce themselves. Witness H specified, The one nurse I talked to the most doesn't work there anymore. When queried regarding the day Resident #707 was transferred to the hospital, Witness H revealed they had to insist the Resident be transferred because the staff were not going to transfer them. Witness H stated, (Resident #707's) blood pressure was ,d+[DATE] at the facility, their intestines died (from their blood pressure being low for too long). Witness H indicated that was the reason Resident #707 died . Witness H was asked the etiology of their statement and replied, They (Health Care Providers) at the hospital told us. (Resident #707) was not a candidate for surgery (to remove/repair bowel) because of their fracture, not being able to get anesthesia, and they had infection from it. Witness H was then asked if Resident #707 was eating and drinking while at the facility and stated, Not really. Witness H continued, They were puking and had the diarrhea. That is why I brought the Ensure but they (staff) never gave it to (Resident #707). When queried how they knew the Resident did not receive the Ensure, Witness H replied, It was all still there when Resident #707's personal items were obtained from the facility. At the end of the conversation, Witness H revealed they were concerned about other people in the facility and did not want what happened to (Resident #707) to happen to anyone else. Record review revealed Resident #707 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required extensive assistance to perform all ADLs with the exception of eating. Review of Resident #707's Electronic Medical Record (EMR) revealed the following care plans and interventions: Care plan: The resident has actual acute/chronic pain r/t (related to) C2 fracture, Dorsalgia, and Arthritis (Initiated: [DATE]). Interventions included: - Administer analgesia as per orders (Initiated: [DATE]) - Anticipate the resident's need for pain relief and respond immediately to any complaint of pain (Initiated: [DATE]) - Monitor/document for probable cause of each pain episode. Remove/limit causes where possible (Initiated: [DATE]) - Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician (Initiated: [DATE]) - Monitor/record/report to Nurse any s/sx of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing) (Initiated: [DATE]) - Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain (Initiated: [DATE]) - Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal or resistance to care (Initiated: [DATE]) - Report to Nurse any change in usual activity attendance patterns or refusal to attend activities related to s/sx (signs/symptoms) or c/o (complaints of) pain or discomfort (Initiated: [DATE]) Care plan: The resident has little or no activity involvement r/t at the moment wants to concentrate on PT/OT so can go home . (Initiated: [DATE]) Review of Resident #707's EMR revealed the following progress note and assessment/evaluation documentation: - [DATE] at 6:50 PM: Nursing Evaluation (Admit .) . Is alert . oriented to person . place . time . situation . has clear speech . Pupils: PERRLA (Pupils Equal, Round, Reactive to Light and Accommodation) .Breath sounds are clear on right and left side . not diminished . no cough . Heart sounds . audible . rate is regular . resident does not have [CONDITION(S)] . Gastrointestinal: Upper R (right) quadrant . Lower R quadrant . Upper Left quadrant . Lower left quadrant bowel sounds normal. Abdomen is free from distention. Abdominal palpation is soft. Resident has no GI symptoms . The resident is continent of bowel. Date of last BM (Bowel Movement): [DATE]. BM at least daily . - [DATE] at 7:03 PM: Admission Summary . Resident arrived at 15:30 (3:30 PM) via Family car with (family) . - [DATE] at 10:54 AM: Care Management . Discharge Plan . resident plans to live in their home . will require homemaking assistance . part time . - [DATE] at 2:42 PM: Daily Skilled Note . Resident is receiving skilled services for: Physical Therapy, Occupational Therapy Medication Management/IV Therapy, Post-Surgical Care . Cognition: Orientation: Person, Place, Time, Situation . Post-Surgical Care: Breath Sounds Right: Clear Breath Sounds Left: Clear . Braces/Splints/Immobilizers per MD order: c-collar wore soft for shower . Note: Resident #707 did not have surgery. - [DATE] at 10:39 AM: Daily Skilled Evaluation . Reason for skilled services: PT/OT, Ortho (C-2 fracture, Pain . Orientation: Person . Place . Time . Situation . Is there a change in the residents baseline cognition: No . Additional Comments: Pain medication regime increased for better pain control . The assessment did not include documentation of pain management and/or basic cardiovascular, respiratory, and/or GI/GU system assessment. - [DATE] at 10:39 AM: Daily Skilled Note . receiving skilled services for: Physical Therapy, Occupational Therapy Medication Management/IV Therapy . Medication Management: Antibiotic Therapy . Infection Type: [CONDITION(S)] (Urinary Tract Infection) Antibiotic therapy is not complete . - [DATE] at 10:44 PM: Daily Skilled Evaluation . Reason for skilled services: PT/OT, Ortho (C-2 fracture, Pain . Orientation: Person . Place . Time . Situation . Is there a change in the residents baseline cognition: No . Current Plan of Pain Management Appear to be Effective: No . Pain Management Concerns . (Resident #707) woke up in excruciating pain again this morning. Spoke to (Physician G) and pain meds are now scheduled q (every) 4 hrs . The assessment did not include documentation of basic cardiovascular, respiratory, and/or GI/GU system assessment. - [DATE] at 11:51 AM: Health Status Note . (Physician G) in on rounds new orders received and noted - [DATE] at 3:38 PM: Daily Skilled Evaluation . Reason for skilled services: PT/OT, Ortho (C-2 fracture, Pain . Orientation: Person . Place . Time . Situation . Is there a change in the residents baseline cognition: No . Does the resident walk: Yes . The assessment did not include documentation of pain management and/or basic cardiovascular, respiratory, and/or GI/GU system assessment. - [DATE] at 4:00 PM: Health Status Note . Resident moaning in pain this morning. (Physician G) in the building, new orders noted. - [DATE] at 8:29 PM: Daily Skilled Evaluation . Does the resident walk: No . Medication Monitoring .pain meds that may not be agreeing with (Resident) stomach . Mood/Behavior . Very pleasant . Respiratory: CTA (Clear to Auscultation) . GI/GU: Cont. (continent) of bladder . Additional Comments: Noted to have nausea after (receive) pain meds . - [DATE] at 12:19 AM: Health Status Note . Res had call light on and noted to be nauseated. Just as started to vomit . Res feels the pain meds making them sick. - [DATE] at 1:59 PM: Daily Skilled Evaluation . Reason for skilled services: PT/OT, Ortho (C-2 fracture, Pain . Orientation: Person . Place . Time . Situation . Does the Resident walk: Yes . Additional Medication Management Comments: PRN N/V (Nausea/Vomiting) med given . Mood/Behavior . cooperative . Cardiovascular . regular heart rate . Respiratory . BBS (Bilateral Breath Sounds) clear . GI/GU . active bowel sounds; small emesis and c/o nausea . - [DATE] at 3:59 PM: Daily Skilled Note .Orientation: Person, Place, Time, Situation . Nonpharmacological Interventions) Do Not Appear to be Effective . Pain management concerns: [MEDICATION(S)] ER (Extended Release) was increased but then I spoke to (Physician G) about resident puking multiple times a day since starting that . switched to [MEDICATION(S)] ER. (Family) updated . - [DATE] at 10:42 PM: Daily Skilled Evaluation . Reason for skilled services: PT/OT, Ortho (C-2 fracture, Pain . Orientation: Person . Place . Situation . Is there a change in the residents baseline cognition: No . Most Recent Blood Pressure . ,d+[DATE] ([DATE] at 11:54 PM) . Pulse: 85 ([DATE] at 11:54 PM) . (SPO2) 98% room air ([DATE] at 11:54 PM) . Additional comments: Pain better controlled, no nausea or vomiting this shift . The assessment did not include documentation of basic cardiovascular, respiratory, and/or GI/GU system assessment. - [DATE] at 6:06 PM: Daily Skilled Evaluation . Reason for skilled services: PT/OT, Ortho (C-2 fracture, Pain . Orientation: Person . Place . Situation . Is there a change in the residents baseline cognition: No . Additional Comments: Very drowsy today . Pain location: Neck and R knee . (no pain level documented) . Suspected Cause of Pain: C2 fracture and chronic knee pain . Current Plan of Pain Management (Medications, Treatments, Nonpharmacological Interventions) Appear to be Effective: No . Pain management concerns: Very drowsy from [MEDICATION(S)] ER. That has been DC'd (discontinued) and will start scheduled ibuprofen to help with headaches . The assessment did not include documentation of basic cardiovascular, respiratory, and/or GI/GU system assessment. - [DATE] at 6:06 PM: Daily Skilled Note . Orientation: Person, Place, Situation . Very drowsy today . The resident does not walk . - [DATE] at 10:10 PM: Daily Skilled Note . Orientation: Person, Situation . There has not been a change in the resident's baseline cognition . - [DATE] at 10:10 PM: Daily Skilled Evaluation . Reason for skilled services: PT/OT, Ortho (C-2 fracture, Pain . Orientation: Person . Situation . Is there a change in the residents baseline cognition: No . Most Recent Blood Pressure . ,d+[DATE] ([DATE] at 11:33 PM) . Pulse: 96 ([DATE] at 11:33 PM) . (SPO2) 92% room air ([DATE] at 11:33 PM) . There were no additional comments and/or assessment documentation including basic neurological, cardiovascular, respiratory, and/or GI/GU system assessment. - [DATE] at 11:04 AM: SNF to ED Handoff Form . Key Clinical Information: Blank . Reason for Transfer: Blank . Most Recent Blood Pressure . ,d+[DATE] ([DATE] at 11:33 PM) . Pulse: 96 ([DATE] at 11:33 PM) . O2 Sats . 92% room air ([DATE] at 11:33 PM) . - [DATE] at 11:32 AM: Health Status Note . Resident very confused, blood pressure ,d+[DATE]. P (Pulse) 138 . ED called, and report given to Nurse. Ambulance p/u (pull out) at 11:30 . Family at facility . Review of Resident #707's Medication Order Summary and Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - Acetaminophen Tablet- Give 1000 mg (milligrams) by mouth every 6 hours as needed for Mild Pain (Start Date: [DATE]) - Ibuprofen Tablet 200 mg- Give 600 mg by mouth three times a day for Pain (Start Date: [DATE]; Discontinued: [DATE]) - [MEDICATION(S)] 4 % Apply to L foot topically in the morning for nerve pain (Start Date: [DATE]) - [MEDICATION(S)] Tablet 500 mg- Give 500 mg . every six hours as needed for muscle spasms . (Ordered: [DATE]; Discontinued: [DATE]) - [MEDICATION(S)] Tablet 500 mg- Give 1 tablet by mouth four times a day for muscle spasms (Start Date: [DATE]) - [MEDICATION(S)] Tablet Extended Release 15 mg ([MEDICATION(S)] Sulfate ER)- Give 1 tablet by mouth two times a day for pain (Ordered: [DATE]; Discontinued: [DATE]). Reason indicated for discontinuation, See new order. - [MEDICATION(S)] Tablet Extended Release [TRUNCATED]

This Citation Pertains to Intake Numbers MI 806, MI 811, and MI 813. Based on interview and record review, the facility failed to implement and operationalize policies and procedures to prevent staff-to-resident physical and verbal abuse for three residents (Resident #703, Resident #704, and Resident #705) of five residents reviewed. This deficient practice resulted in a nurse telling Resident #703 here are your f___ing pills when requesting medications for pain, an Activity Staff Member calling Resident # 704 a dickhead, and Resident #705 being subjected to [NAME], yelling, disrespectful speech and then being physically dragged down the hall by staff after experiencing a fall in the hallway of the facility, and psychosocial distress, utilizing the reasonable person concept. Findings include: Facility investigation documentation for Resident #'s 703, 704, and 705 was requested from the facility Administrator on 3/14/22. Upon request for investigation documentation, the Administrator indicated the facility had a PNC (Past Non-Compliance) for abuse. Resident #703: Review of intake documentation revealed a Facility Incident Report (FRI) was submitted to the State agency on 1/31/22. The FRI specified a concern regarding medication delivery and call light response had been received by the facility from Resident #703's family member. The FRI detailed it was reported that while (Registered Nurse [RN] N) was passing medication, they handed (Resident #703) their pain medication and stated, 'Here are your [OBSCENITY] ing pills.' . Upon conclusion (of facility investigation) it was determined that (RN N) did in fact make the alleged statement and admitted to this behavior. (RN N) was terminated for poor customer service and failure to conduct themselves in a professional manner . Record review revealed Resident #703 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired, required limited to extensive assistance to complete all Activities of Daily Living (ADLs) with the exception of eating. The MDS also revealed the Resident displayed no behaviors and experienced occasional pain. On 3/16/22 at 10:45 AM, RN N was attempted to be contacted at the phone number provided by the facility. The phone voicemail not not set up and a message was unable to be left. On 3/16/22 at 10:54 AM, Resident #703 was attempted to be contacted via phone. A message with return number was left but a return call was not received by the conclusion of the survey. Resident #703's medical record revealed the Resident was admitted to the facility for short term skilled therapy and discharged home on 2/11/22. Review of documentation in Resident #703's Electronic Medical Record (EMR) revealed the following progress notes: - 1/30/22 at 7:38 PM: Daily Skilled Note . Reason for Skilled Services: PT (Physical Therapy)/OT (Occupational Therapy) . Rib Fractures, Pain, Skin (Left Diabetic foot/SDTI [Suspected Deep Tissue Injury- pressure wound] left lateral ankle . [CONDITION(S)] . Orientation: Person, Place, Situation . Mood/Behavior: Resident with behaviors today. Yelling at this nurse because I was late giving a pain pill. Later came up to the Nurses station and was filming (RN A) and I charting . - 1/31/22 at 4:23 PM: Psychosocial Note . This writer asked to do psychosocial visit with resident r/t (related to) resident (family) spoke with NHA (Nursing Home Administrator) and had some concerns. Informed (Resident #703) that NHA and DON (Director of Nursing) were aware of concerns and actively looking into them. (Resident #703) said 'Thank you' . - 1/31/22 at 5:20 PM: IDT (Interdisciplinary Team Note . NHA received a call this am from (Resident #703's family member) expressing concerns regarding care. (Family member) had also spoke with the Director of Nursing earlier today. SS (Social Services) Designee interviewed resident as well as the DON. NHA returned to call to the (family member) advising that facility is following up on the concerns . - 2/1/22 at 4:26 PM: Psychosocial Note . Psychosocial visit with resident today. No concerns noted. Resident in good mood today. Talking with staff in therapy room. - 2/2/22 at 3:31 PM: Psychosocial Note . Resident is polite in verbal interactions. No concerns or complaints voiced. Flat affect; minimal conversation. - 2/6/22 at 7:59 AM: Health Status Note (nurses note) Late Entry . Spoke with resident while administering medications. Resident states now that pain medication is scheduled, pain is well managed. States satisfied with care . A review of facility provided investigation documentation was completed. The investigation included a summary of the incident, RN N interview/statement, Certified Nursing Assistant (CNA) O interview/statement, CNA P interview/statement, and Local Police Contact Information. Detailed review of the documentation revealed the following: - Summary Statement, signed by DON, Undated: I received a call on 1/31 at 1:27 PM from (Resident #703's family) . stated (Resident #703) told them that the previous night, a nurse got angry, threw medications on the table and said, 'Here are your f-ing pills' . I then spoke to (Resident #703) . (Resident #703) stated the night before, had asked for pain medication but the nurse refused to give it to them. When the nurse finally brought pain medication to them, they stated, 'I can only do so [OBSCENITY] ing much, here's your goddamn medication.' Then the nurse ran out of the room crying. Then (Resident #703) told me when they needed to go to the bathroom, they pressed the call light, but nobody came to help . then walked to the bathroom by self .went to the bathroom by themselves 2 or 3 times . (The Resident) then walked out to the hall and saw 2 nurses sitting at the nurses' station . grabbed their phone to take a video and stated, 'This is what they do when they're supposed to be working'. One of the nurses told them, 'We're not on the clock' . (Resident #703) then told me they asked for Preparation H. The nurse brought it in, threw it on the table and said, 'Here it is.' (Resident #703) told the nurse they can't put it on themselves. The nurse again gestured to the Preparation H and said, 'Here it is' . stated feel they are being ignored . Note: The statement did not include a date/time when they spoke to Resident #703. - RN N Interview/Statement Record, dated 1/31/22 at 3:20 PM: Yesterday 1/30/22, after my shift, (RN A) and I was charting on falls and regular charting. (Resident #703) walked up to the Nurses station behind up, pointed their phone at us, and said, 'This is what they do when they are suppose to be working.' (RN A) told (Resident #703) that we don't have the keys anymore so we can't them and I said we are off the clock. Earlier in the day, I walked into (Resident #703's) room to give them . pain pill and (the Resident) yelled at me stating I was an hour late. I yelled back and said I was sorry that I have 30 other patients to take care of. I put (Resident #703's) pill on the bedside table and said here is your f-ing pill, Later I was checking (Resident #703's) blood sugar and (the Resident) stated they were sorry they yelled at me, and I said I was sorry too. - CNA O Interview/Statement Record, dated 2/3/22 at 10:00 AM: On Sunday, Jan. 30, 2022 around 5 AM, I answered Resident call light. (Resident #703) asked for pain pill. I let (Nurse) know . said (Resident #703) can only have them every 8 hours and it was not time yet. I went back to let Res know and (the Resident) started yelling at me about how bad broken ribs hurt and they should have them (pain meds) every 4 hours. I went back to nurse to let them know (Resident #703) was upset. (The nurse) went in to talk to (the Resident) later in the day (afternoon sometime. I heard (Resident #703) yelling at the nurse, swearing. Then I seen (RN N) briskly leaving the room. I went into the room to see what was going on. Res was yelling at me about the nurse not giving them their pills on time. I tried to explain to them that the nurse was behind on everyone's meds . - CNA P Interview/Statement Record, dated 2/4/22 at 2:45 PM: Resident had call light on the help to bathroom . was incontinent of stool I helped resident to bathroom. Provided with toilet paper . said they couldn't do it, so I cleaned them up, assisted back to bed. A few minutes later, light on. (Resident ##703) needed to go back to bathroom . was assisted out of bed, walked to bathroom . back to bed . covered up . An interview was conducted with the DON on 3/16/22 at 11:50 AM regarding the incident between Resident #703 and RN N. The DON was queried regarding RN N and revealed the nurse was no longer employed at the facility. When asked if their employment was terminated solely as a result of the investigation results, the DON revealed RN N was immediately suspended but they were not certain as (the Administrator) made the call. When queried regarding the facility substantiating the abuse, the DON indicated they believed it was determined to be more of a customer service issue. When asked the date of the occurrence, the DON stated, It happened on 1/30/22, Sunday. When queried regarding the investigation, including RN N's written statement, the DON replied, (The Administrator) and I were both talking to (RN N) and then had (RN N) write it out. With further inquiry, the DON stated, (RN N) told us they were very stressed, and it was just kind of the straw that broke the camel's back. The DON continued, (RN N said Resident #703) was asking and kept asking for their pain meds. It irritated them because (the Resident) kept asking for it and asking for it. The DON was asked if RN N addressed the Resident's uncontrolled pain such as implementation and/or provision of non-pharmacological interventions for pain and/or contacting the Health Care Provider regarding their pain and replied, As far as I know, (RN N) did not. Resident #703's EMR documentation, medication orders, and Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review revealed the following active orders: - [MEDICATION(S)] (narcotic pain medication) Tablet 5/325 mg (milligrams) ([MEDICATION(S)]-Acetaminophen): Give 1 tablet by mouth every 6 hours for Rib fractures (Ordered: 1/26/22; Discontinued: 1/31/22). Per the MAR, the medication administration times were at 2:00 AM, 8:00 AM, 2:00 PM, and 8:00 PM. - [MEDICATION(S)] Tablet 5/325 mg . Give 1 tablet by mouth every 4 hours as needed for pain (Ordered: 1/26/22; Discontinued: 1/31/22). Administration of [MEDICATION(S)] 5/325 mg was documented three times on the MAR for this order. Resident #703 received the pain medication on 1/28/22 at 9:24 AM, 1/30/22 at 6:30 AM, and 1/31/22 at 6:19 AM. There was no documentation indicating the Resident's pain was uncontrolled, that non-pharmacological interventions were implemented, and/or that the Health Care Provider was contacted related to pain. When asked why the RN N did not administer the ordered PRN (as needed) pain medication to the Resident is they were having pain, the DON was unable to provide an explanation. The DON was then asked why there was not a signed/dated statement from Resident #703 included in the investigation documentation and replied, I interviewed them and referred to the investigation summary document they had signed. When asked what time the interview occurred, the DON was unable to provide a specific time. The DON was then queried regarding Resident #703's emotional and psychosocial status when they interviewed them. The DON stated, (Resident #703) was very upset. With further inquiry, the DON stated, (Resident #703) was definitely upset about their pain but they kept saying (RN N) just slammed the cup down and said here's your [OBSCENITY] ing pill. They stilled seemed upset about that. The DON was asked what time on 1/30/22 that the incident occurred, the DON replied, It was the afternoon. When asked about RN N's statement and documentation in the medical record related to staff, including RN N sitting at the nurses' station charting when they were no longer working, the DON replied, They were there at 7:40 PM. The shift ends at 6:30 PM. When asked why the staff were still documenting and if the facility was short staffed that day, the DON indicated the facility was not short staffed and stated, There were falls and general nursing home stuff. Staffing sheets including assignment sheets for 1/30/22 were requested from the DON at this time. A follow up interview was completed with the DON on 3/16/22 at 3:00 PM. The DON was asked for the staffing and assignment sheets for 1/30/22 again and replied, We can't find them. The DON then stated they could re-create the staffing sheets. The DON was asked they were able to assure accuracy of reproduced documents without the originals and revealed they could attempt to recreate based upon documentation present in resident medical records but would not be able to guarantee complete accuracy. Review of RN N employee file revealed their employment was terminated on 2/7/22 due to Uncontrollable, Rule/Policy Violation. Investigation Substantiated. The document indicated RN N had been suspended on 1/31/22. A written document titled; Investigation Follow-Up was noted in the file. The document detailed, 2/7/22 at 5:08 PM: Called (RN N) to discuss the outcome of the investigation that was pending. Notified (RN N) that the investigation was substantiated, and their employment had been terminated effective immediately . The document was signed by the Administrator, DON, and Human Resource (HR) Director R. RN N's employee file did not contain documentation of the employee being suspended. On 4/6/22 at 5:28 PM, a return phone call was received from Resident #703. When queried regarding their stay at the facility, Resident #703 revealed they were dissatisfied with the care they had received. Resident #703 stated, I had eight broken ribs. The pain was horrible and the meds (pain medication) they (facility staff) gave me was only good for about four hours. When asked how they were treated by facility staff, Resident #703 revealed they had been requesting something for pain and stated, When the nurse came in, they slammed the pill down and said, 'Here's your [OBSCENITY] ing pills'. Resident #703 was asked how that made them feel and stated, I was upset and mad. I was there for help, and they didn't even care. Resident #703 revealed another nursing staff member entered their room after the incident with the pills and asked them what they did to upset the nurse. When asked, Resident #703 was unsure if the second staff member was a CNA or a nurse and indicated the staff did not consistently identify themselves and their role. When asked what happened at that time, Resident #703 revealed they were very upset and felt like the staff had a vendetta against them. Resident #704: FRI intake documentation, submitted to the State agency on 1/31/22 revealed Resident #704 requested to speak to the facility Social Services Director E on 1/31/22 and reported that on January 27th or January 28th, (Activities Aide S) called them a 'dick head' during smoking time. The report revealed the Resident was asked why they did not report immediately and replied, I had to sit and [NAME] it. Per the FRI documentation, Activities Aide S was suspended pending investigation and their employment was terminated following completion of the investigation for terminated for poor customer service and failure to conduct themselves in a professional manner. Record review revealed Resident #704 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required extensive, one-to-two-person assistance to perform Activities of Daily Living (ADLs). Review of facility provided investigation documentation included the following: - Activity Aide S Interview/Statement Record, signed and dated 1/31/22 at 12:45 PM: On Friday, during both morning smoke break breaks, due to weather, they were not allowed to go out an smoke. (Resident #704) came down several times to line up early and go out. I told him to go back to room. At 11:00 smokes, (Resident #704) came down one time at 11:40 (approx.) and again at 12:10 and I told him to go back to their room, they haven't even ate lunch yet. - Activity Aide S Interview/Statement Record, (unsigned), dated 2/2/22 at 11:40 AM, Location of Interview: Phone . Additional Interview . (Resident #704) was sitting in hallway last Friday, too cold to go out to smoke . kept coming down, getting agitated 9 A to 11 AM came numerous times. (Activity Aide S) was asked if she ever referenced to (Resident #704) or called (Resident #704) a dick head. No never. Interviewers Signature: (Administrator) . - Social Services Director E Statement, typed, signed, and dated 1/31/22 (no time): (Resident #704) asked to speak to this writer . had a complaint about (Activity Aide S) . Asked resident what the complaint was and they stated, 'It was some time lst week, (Activity Aide S) was arguing with me and called me a dick head'. I asked resident where this occurred . stated outside in the smoking area. (Resident #704) also stated, '(Activity Aide S) is always bossing me around'. This writer asked for (Resident #704) to give an example to which they said, 'like where I can sit'. I explained to (Resident #704) that if a resident is not following the smoking policy that the staff assigned to the smoke break should be telling them what needs to be done per the policy. (Resident #704) stated they understood that . - Interview/Statement Record with Resident #711 completed by the Administrator, signed and dated 2/1/22 at 11:30 AM: NHA: Have you ever heard any activity staff (be) rude or disrespectful to residents while out in smoking [NAME], or) and anywhere, anyone, or any verbal exchange between (Resident #704) and (Activities Aide S) . Resident #711: Yes bad . NHA: Bad from (Resident #704) to (Activities Aide S)? A long time ago or last week? . Resident #711: Bad by (Activities Aide S) . NHA: Rude or disrespectful? . Resident #711: It's bad, I don't know why but bad . 2/2/22: NHA: Follow up from our conversation yesterday . Resident #711: Yes- above agreed accurate . NHA: Have you ever heard (Activities Aide S) call (Resident #704) a dickhead? . Resident #711 response: Yes . Resident #71 gestured and indicated (Activities Aide S) was inside of door from smoke [NAME] . A drawn image including the location of Resident #704, Resident #711, and Activity Staff S was included on Resident #711's statement. Activity Aide S was attempted to be contacted via phone on 3/16/22 at 11:14 AM and 8:29 PM. A message was left with return time with both attempts but a return call was not received by the conclusion of the survey. A review of Activity Aide S's employee file revealed the following disciplinary actions: - Employee Disciplinary Form . Date: 8/9/20 . 3rd Step . Recommend for Suspension . Job Performance/Behavior Deficient: Employee failed to report an allegation of abuse to nursing staff . Signed: 8/16/22 . The form did not include any further details related to the incident including the type of abuse allegation and/or if the employee received coaching and/or education related to abuse. - Personnel Action Notice . Effective Date of Action: 2/7/22 . Employment Action: Terminated . LDW (Last Day Worked) 1/31/22; Terminate: 2/7/22 Uncontrollable Policy/rule violation. Investigation Substantiated . - Investigation Follow-up (handwritten): 2/7/22 4:56 PM . Called (Activity Aide S) and LM (Left Message) to return call . An interview was conducted with Resident #704 on 3/17/22 at 12:55 PM. When spoke to, the Resident was pleasant and calm. When queried how they were treated by staff, Resident #704 indicated they had no problems with staff. When asked if they had any concerns related to staff treatment in the past, Resident #704 did not provide a direct response. When asked if a staff member had ever called them a name, Resident #704 revealed they aren't here anymore but did not elaborate further. Resident #705: Review of FRI intake documentation received by the State agency on 11/7/21 at 9:43 PM revealed a staff member reported observing (CNA T and Licensed Practical Nurse [LPN] U) dragging (Resident #705) down the hall by their arms and the waistband of their pants . The intake documentation detailed, Summary of Incident: On the night of November 6, 2021, received a phone call from charge nurse (LPN V) . wanted to report an abuse situation . (LPN V) and (LPN W) relayed a similar story . They had been walking down the cross hall to assist a family member out of the building, and they witnessed employees (LPN U) and (CNA T) . dragging (Resident #705) down the hall, by holding them under arms, and by holding the back of their pants. They reported that at one point, (Resident #705) went down to their knees, and they offered to assist to stand (Resident) back up, but (LPN U) and (CNA T) hoisted back up and continued to walk back to their room . Upon completion of investigation, it has been determined that no abuse occurred during this event. There were procedures that were not followed following a fall, and staff ambulated resident at what appeared to be a hasty rate of speed . Record review revealed Resident #705 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required limited to extensive assistance from one staff member to complete all ADLs with the exception of eating and bed mobility. The MDS further revealed the Resident was not steady during transitions and walking and had fell in the facility. Resident #705 passed in the facility on 11/27/21. Review of Resident #705's EMR documentation revealed the following: - 11/6/21 at 7:16 PM: Fall . Res up ambulating with fast pace walk trying to go in and out of rooms. Req (Request) 1 to 1 at this time. Res noted to have be inc. (incontinent) of bowel. Staff assisted with peri care and changed clothes. Very difficult to redirect 2nd to dementia. This nurse left medcart to pass meds to peer where res was noted to be with staff member. While this nurse was peer room heard a bang, Res noted on the floor outside of peers room. Noted to have possibly lost footing where the floors come together on Hall A . Res very difficult to get on feet. Staff had to almost drag to feet, (Resident #705) would not stand and kept legs bent. No s/s (signs/symptoms) of injuries noted other than previous ones. DON notified, came in to assist and had staff come to help with 1 to 1 while res remained awake . Res noted to move all ext (extremities) without problems. Sitting in chair. Very difficult to redirect . will stiffen up or lock legs . - 11/6/21 at 7:30 PM: Fall . Res in chair. Much encouragement required to keep seated in chair . Review of facility investigation documentation for Resident #705 revealed the following: - LPN W: Interview/Statement Record . Date of Interview: 11/7/21 . While walking a resident's family from the building . heard screaming coming from (LPN U) towards (CNA T). (Resident #705) was being carried from outside of nurses' station) and was having difficulty walking. I had seen (LPN U- on the right_ and (CNA T - on the left holding (Resident #705) by their pants and arms, and their knees dragging repeatedly as they attempted to carry to room. I had went to offer a wheelchair to (LPN U) when seeing the struggle and (LPN U) had refused . - LPN V: Interview/Statement Record . 11/6/21: Walking family members to the door (front) Heard loud yelling. When reaching station 2 note CNA and (LPN U) dragging resident by their underarms, with knees dragging on floor. (LPN U) was yelling uncontrollably. I told (LPN U) they needed to calm down . Later (LPN U) approached me still yelling now directed at me, stated I run my hall. - CNA X: Interview/Statement Record . (No Date) . On Saturday Nov. 6th around 7:25 PM, I . heard (LPN U) yelling so I went to see what was wrong. When I got to the nurses station . seen Resident #705) on the floor and (CNA T) standing next to them . I could still hear (LPN U) yelling saying they make the rules on their halls and that (the DON) can come in and deal with it. - CNA T Handwritten statement/letter: To Whom It May Concern . While working on Saturday [DATE]th at approximately 7:15 to 7:30 PM, I was caring for (Resident #705). (The Resident) had unsteady gait. I felt they needed extra care . Later with (Resident #705) and (LPN U) at nurses station . (another resident) stated yelling by name from bathroom . I asked (LPN U) if they could watch (Resident #705) for few minutes so I could help (other resident) in bathroom. (LPN U) stated, 'NO.' I asked what I am supposed to do and (LPN U) stated, 'You got to do what you got to do' and walked away . went to help (other resident). (LPN U) started yelling at me to come so loud everyone from other side of building also come running to see what the commotion was all about. (LPN U) . stated . 'Help me get (Resident #705) to their room.' . (LPN U) made me do something that was not right with (Resident #705). I've been in health care field for about [AGE] years . CNA last 8.5 years and never had to deal with a nurse that refused to help . - CNA Y: Interview/Statement Record (No date) . I did not witness anything that happened between (Resident #705) and their fall on 11/6/21). The investigation did not include an Incident and Accident (I and A) form or a statement from LPN U. An interview was completed with CNA T on 3/16/22 at 3:48 PM. When queried regarding Resident #705, CNA T stated, (LPN U) was upset and told me I had to take care of (Resident #705) and there was a Resident yelling at me from the bathroom. (Resident# 705) seemed more steady so I went to the other Resident. CNA T stated they had asked LPN U for assistance, but LPN U refused. CNA T was then queried regarding Resident #705 falling and stated, (LPN U) picked (Resident #705) up and made me help them get (Resident #705) in their room. (Resident # 705) was screaming I'm okay. (LPN U) was yelling and I think that upset (Resident #705). CNA T continued, (Resident #705) lifted their feet up. (LPN U) was walking really fast and screaming and yelling at me. CNA T was asked if they utilized a gait belt and revealed they did not. When queried if they were lifting the Resident by their arms, CNA T stated, Yes, I know this is wrong, but I didn't know what to do. I don't know what to do when people yell and scream at me. CNA T was asked to explain what happened when the Resident lifted their legs and replied, Carried (Resident #705) by back of pants. When queried why they did not get a wheelchair for the Resident or additional assistance, CNA T revealed other staff offered to assist but LPN U refused. When queried if they believed what happened was abuse towards the Resident, CNA T replied, Yes. CNA T revealed LPN U treated other Resident's inappropriately as well and stated, (LPN U) was mad at another guy (Resident) earlier and went off yelling at them that they can't keep putting on the call light. CNA T then stated, I know (LPN U) didn't check on (Resident #705) after they fell , and I didn't think it was right when the Resident put their legs up and we had to carry them. When queried why they did not report LPN U, CNA T revealed it was normal for (LPN U) to not help with Residents. CNA T then stated, I felt ignored by the DON. I tried to explain (what happened) but they would not listen. On 3/16/22 at 8:32 PM, a phone interview was conducted with LPN U. When queried if they recalled Resident #705 including the fall and events on 11/6/21, LPN U revealed they did. When asked what had happened, LPN U stated, I told (CNA T) not to leave (Resident #705) and they left them. (CNA T) is pretty much useless. They left (Resident #705) and I got in trouble for it. LPN U was asked to explain what happened after the Resident fell and stated, I was my med pass and (Resident #705) fell right outside the room. When asked if facility staff were assisting other Residents when Resident #705 fell , LPN U indicated they were not and stated, It was a lazy CNA that didn't want to deal with it. They just let (Resident #705) fall. When queried what they did after the Resident fell , LPN U replied, I called my immediate supervisor (DON) and I never went back to work. LPN U was asked if the DON came into the facility and replied, I wanna say they did. When queried who found Resident #705 on the floor, LPN U stated, Me and (CNA Y) I want to say. When asked what they did after finding the Resident, LPN U replied, Picked them up, not the right way with a Hoyer (mechanical) lift but just picked them up. LPN U was asked if the Resident was able to walk on their own, LPN U stated, I think we put them in the wheelchair. LPN U then stated, I'm not sure but pretty sure that (CNA Y) and I took (Resident #705) to their room and to their recliner. LPN U was asked what Resident #705's required level of supervision was and replied, They weren't one to one. When queried if they yelled at (CNA T), LPN U stated, Yes, I did. When queried if they yelled at (CNA T) in front of Resident #705, LPN U replied, The aide (CNA) that was there was not (CNA T) because (CNA T) is useless. When asked why they did not provide a witness statement as part of the facility investigation, LPN U was then queried why all statements and the facility investigation detailed Resident #705 was carried back to their room by LPN U and CNA T, LPN U was unable to provide an explanation. LPN U was then asked why a wheelchair was not used and replied, It happened so fast, I guess I can't remember. When queried regarding documentation indicating Resident #705 had been dragged down the hall, LPN U replied, It was no malicious intent at the Resident if they were dragged. When asked if they were angry, LPN U replied, Yeah, I was angry. LPN U was then asked why they did not take a break and calm down if they were angry but did not provide a response. On 3/16/22 at 3:30 PM, an interview was completed with LPN V. When queried what occurred on 11/6/21 involving Resident #705, LPN V revealed they were escorting a Resident's family to the exit for of the facility when they heard yelling from station two. LPN V stated, I heard yelling and screaming at the top of someone's lungs. It was (LPN U) screaming at (CNA T) and belittling them. When queried what they heard LPN U saying, LPN V replied, This is all your fault you should have watched (Resident #705). LPN V stated, I told (LPN U) that they needed to calm down. When asked where the staff and Resident were in the facility, LPN V replied, It was just at the nurses station. LPN U stated, They (LPN U and CNA T) had (Res [TRUNCATED]

This citation refers to Intake Numbers MI 053 and MI 731. Based on interview and record review, the facility failed to provide supervision for one resident (Resident #165), which resulted in a fall and one resident (Resident #39), which resulted in a resident-to-resident altercation. This deficient practice resulted in Resident #165 falling and fracturing her right hip. Findings include: Resident #165: A review of Resident #165's medical record revealed she admitted to the facility on [DATE] with diagnoses including heart failure, depression, and anxiety. Further review of her record revealed she was admitted as a hospice respite stay. A review of an incident and accident report for Resident #165 dated 7/23/21 revealed the following: Resident (#165) became very restless and combative after lunch today. She was screaming, hitting, kicking, scratching, pulling oxygen off, pulled call light out of wall and threw across the room and grabbing staff by there clothing and pulling them around. Pt (patient) then attempted to self transfer out of WC (wheelchair) and fell on to her right side in her room at roughly 1348 (1:48 p.m.) Fall to floor: unwitnessed . Preventative measures: call light: kept in reach . Injury: Fracture. Right hip fracture . upon thorough investigation and analysis, it is determined that resident fall (fell ) as a result of ambulating unassisted with both her call light cord and oxygen cords being pulled along with her. She suffered a major injury of a fracture of the right hip. Immediate intervention; one-on-one supervision while agitated The director of activities (Activities Director M was with resident prior to fall, but resident became agitated and began ripping activities director's (personal protective equipment gown) off. Activities director went to seek help and asked a therapy assistant (Physical Therapy Assistant N) to watch resident until resident pulled her call light out of the wall, then the therapy assistant left to seek help. Resident fell approximately 2 minutes after the therapy assistant left the room. A review of an note in the facility investigation folder revealed a timeline from the video surveillance which revealed the following: 1304 (1:04 p.m.) Activities Director M in (to room of Resident #165). 1322 (1:22 p.m.) PTA N in (to room) 1325 (1:25 p.m.) Activities Director M out (of room) 1326 (1:26 p.m.) PTA N out (of room) 1328 (1:28 p.m.) fall in doorway. A review of progress notes for Resident #165 revealed the following: 7/20/21 Res (Resident) has been agitated, restless . She (hospice nurse) said she (Resident #165) does this when hypoxic (having low oxygen) . in w/c (wheelchair) at this time and doing one on one. A review of Activities Director M and PTA N's personnel files revealed they received no education or disciplinary actions for leaving Resident #165 unattended prior to her fall with fracture. On 10/13/21 at 11:39 a.m., an Interview was conducted with PTA N who reported that she had entered the room to work with the roommate of Resident #165 and Activities Director M had asked her to keep an eye on Resident #165 as she was agitated and she was going to go get help. PTA N reported that the roommate of Resident #165 did not want to participate in therapy so she was going to leave to go to her next tasks and witnessed Resident #165 sitting in the arm chair with the call light draped across the bed to her chair. PTA N reported she did move the call light so it was sitting on the bed instead because she was fearful Resident #165 would try to get up and would trip on the call light. PTA N reported she could hear the voice of the Activity Director N in the hallway so she exited the room to go down and to talk to her. PTA N reported it was just a minute later when they heard screaming and when they entered the room Resident #165 was on the floor with the call light and her oxygen tubing underneath her. PTA N reported Resident #165 must have pulled the call light cord out of the wall when she got up. PTA N stated, She was sitting down in her chair. I felt like it was ok to go down hall to get (Activities Director M). When asked where Activities Director M was when she found her, PTA N stated, She was standing there talking to the nurses. She kind of left me stranded there with (Resident #165). PTA N was asked if she received any education after this incident and confirmed that she had not. On 10/13/21 at 3:38 p.m., an interview was conducted with Activities Director M who reported that she had been in the room to do her assessment with Resident #165 when all of a sudden she grabbed at my gown and was pulling it down and trying to get herself out of the chair. Activities Director M then reported that PTA N entered and she asked her to stay here with the resident because she didn't want the resident to fall. Activities Director M then continued to report that she had walked out and looked for the nurse to let them know something was going on when PTA N walked out of the room and informed her that Resident #165 had pulled her call light out of the wall. Activities Director M was asked if she had received any education regarding supervision after this incident and reported that she had not. Activities Director M reported that she didn't want to leave because she didn't want the Resident to fall, but that she needed help. On 10/13/21 at 3:45 p.m., the Director of Nursing (DON) was asked about the fall incident that occurred on 7/23/21. The DON reported that he had done the investigation. When asked why both staff left the Resident alone to get help, the DON stated, The Activities Director kind of left the room in a hurry. The DON went on to report that PTA N was in the room with the Resident until she had pulled the call light out of the wall, but after it was pulled out she left the resident to seek help. When asked if the expectation was for staff to leave a Resident without a call light unattended if they feared that she would fall, the DON reported that he understood the concern. The DON confirmed that the two staff who had left Resident #165 unattended had not received any education or disciplinary actions. Resident # 39: A review of Resident #39's medical record revealed she admitted to the facility on [DATE] with diagnoses including [CONDITION(S)] (brain associated disease), pancytopenia (lack of blood cells), muscle weakness, unsteady feet and [CONDITION(S)]. A review of the Verification of Investigation Form dated 8/15/21, included the following: RESIDENT INTERVIEW / SUMMARY OF FINDING OR ALLEGATION: 8/15/21 Resident (#166) had an altercation with another resident (Resident #39). She (Resident #166) grabbed the other resident (#39), shook her, and attempted to pull her off of her walker. At the time that the resident (#166) was not being supervised, staff stated that no on (one) had been assigned . Resident had recent history of an altercation with another resident (8/9/2021) and was care planned to be provided one-on-one supervision while awake until alternate placement could be obtained. The investigation form included: MODIFIED INTERVENTIONS TO THE PLAN OF CARE TO PREVENT RE-OCCURRENCE dated 8/15/21, Resident (#166) immediate (sic) assigned a staff member to provide direct supervision while out of bed . The investigation form included: SUMMARY OF FACTUAL INVESTIGATIVE FINDINGS: Factual findings revealed: Staff were not providing one-on-one supervision because of a failure to pass information from shift to shift. Education will be provided to nursing staff During an interview on 10/11/21 at 2:30 PM, Resident # 39 addressed the incident and said, They did not watch her (Resident #166) close enough as far as I was concerned . I was sitting with my hand on a railing, and she grabbed my arm. She did it two times. I could not pull away from her. I reported that she needed more help. During an interview on 10/13/21 at 10:18 AM, the DON said Resident #166 previously had an incident with another resident and was put on a one on one (a staff member was assigned to be with the resident throughout the day). The DON reported there was a period of time the nurse did not know Resident #166 was one on one and the incident between Resident #39 and Resident #166 occurred. During an interview on 10/13/21 at approximately 1:45 PM, Certified Nurse Aide (CNA) U said she was present when Resident #166 had Resident #39 up against the wall. CNA U helped separate the two residents. Resident #166 was very agitated but CNA U was able to calm her, and then was re-assigned to be with her one on one. CNA U stated, That day, she (Resident #166) was not a one on one until that happened. A review of Resident #39's Care Plan had a focus on 8/9/21 on Behaviors: (Resident #166) has potential to be physically aggressive . The interventions included: Provide direct supervision while out of bed .

This Citation contains two Deficient Practice Statements (DPS). DPS #1: Based on interview and record review, the facility failed to ensure the infection control program was maintained, and failed to ensure that isolation precautions were in place for two residents (Residents #7 and Resident #168) out of two residents reviewed for infection isolation. This deficient practice resulted in the spread of a Carbapenem-resistant Enterobacterales (CRE - a class of infections that are resistant to antibiotics) to Resident #168, with the potential to effect all 62 Residents within the facility. Findings include: A review of the facility infection control monthly tracking revealed the following: There were no monthly surveillance logs, summaries, or mappings completed for October 2020, November 2020, and January 2021. A review of the December 2020 Infection Control Monthly Surveillance revealed listings for 12 Residents that did not include the organism of infection. The listings also did not include the duration of the infection or whether it resolved with the ordered antibiotic. A review of the February 2021 monthly tracking revealed that the monthly nosocomial (infections started within the building) rate had not been calculated. A review of the March 2021 Infection Control Monthly Surveillance revealed 9 residents were started on antibiotics that month. 7 listings on the surveillance log (one Resident listed for three different antibiotics, a total of 5 residents) were incomplete regarding the signs symptoms, antibiotic, and whether it resolved. The monthly nosocomial rate had also not been calculated. There was also no mapping completed for the month. A review of the April 2021 monthly surveillance revealed the summary data was not reviewed and dated until 6/23/21. A review of the June 2021 Monthly Surveillance revealed that no rate of nosocomial infection was calculated. The June summary report was dated as completed on 7/27/21. A review of the July 2021 monthly surveillance revealed, GI Outbreak. 8 identified residents with GI symptoms . No monthly nosocomial rate was calculated for the month. A review of the line listings revealed Resident #7's line as . onset date: 7/13/21. S/S (signs and symptoms of)infection: [MEDICATION(S)] (an antibiotic). Location of Infection: K (lower respiratory tract). Risk factors: F ([CONDITION(S)]) . Date of culture: 7/11/21. Organism: bilateral (lower) lobe pneumonia. Antibiotic name and start date: [MEDICATION(S)] 750 mg (milligrams). Status of infection: N (nosocomial). Isolation: (dashed - none). A review of Resident #168's line revealed the following: .Onset date: 7/25/21. S/S Infection: redness, draining, pain. Location of Infection: D (skin). Risk factors: K (other) . Organism: wound infection. Antibiotic name and start date: [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)]. Status of Infection: CA (community acquired). Isolation: (dash - blank). Further review of the July Monthly Infection data revealed a document titled, (Name of Resident #7) CRE Exposure Timeline which revealed the following: 6/1/21 Resident (#7) admitted into room [ROOM NUMBER] -c no roommate. 6/2/21 Resident (#7) transferred to (Hospital) related to low oxygen levels. 7/9/21 Resident (#7) readmitted to room [ROOM NUMBER]-2 no roommate. 7/11/21 (Resident #168) admitted to room [ROOM NUMBER]-3 7/27/21 both Residents (#7 and #168) transferred to room [ROOM NUMBER]. 8/2/21 (Resident #168) discharged (home) 8/11/21 Resident (#7) transferred to (hospital) for PICC line placement and wound debridement, no additional roommate admitted to this room. 8/16/21 Resident (#7) readmitted to room [ROOM NUMBER]-2 private room. 8/19/21 Resident (#7) moved to room [ROOM NUMBER]- private room related to ESBL & [CONDITION(S)] infection with contact precautions related to colonized wound infection. 8/23/21 email received from (state contractor) related to a CRE infection noted on 6/24/21 (for Resident #7), droplet precautions initiated, Staff education initiated; resident updated. A review of Resident #7's record revealed he originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #7's hospital progress note scanned into the Electronic Medical Record (EMR) dated 6/25/21 revealed, . Rare-few Acinetobacter baumannii positive culture . Assessment: multidrug resistant Acinetobacter infection of the lung and tracheobronchitis . A review of Resident #7's discharge summary sent to the facility on [DATE] revealed, . Discharge orders of Physician: Infection/Isolation info: contact precautions for Klebisella - Sputum (a mix of saliva a mucous from the respiratory tract). Resident #168: A review of Resident #168's medical record revealed he admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the 7/14/21 Minimum Data Set (MDS) assessment revealed he scored 14/15 on the Brief Interview for Mental Status (BIMS) assessment, indicating moderately intact cognition. A review of Resident #168's 7/30/21 wound culture and sensitivity revealed the following: . Many acinetobacter baumannii . The sensitivity showed that the infecting organism was resistant to [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]/sulfa. On 10/13/21 at 11:57 a.m., an interview was conducted with Infection Preventionist/Registered Nurse (RN) K who when asked about the CRE timeline document for Resident #7 stated, We received email an email from another facility, we weren't aware he (Resident #7) admitted with it. When asked to clarify that Resident #7 was not on the ordered precautions on admission due to the Klebisella or the CRE, RN K reported that was correct, because they had not been aware until they received the email on 8/23. A review of an email to RN K revealed the following, .Per our discussion, the patient (Resident #7) had a CRE positive tracheal aspirate culture on 6/24/21 for Carbapenem-resistant Acinetobacter baumannii with an OXA-23-like carbapenamase gene. When a patient with an [CONDITION(S)] (multi drug resistant organism) is transferred from one facility to another we try to follow up with the receiving facility . 1. Place the patient in a single patient room on Enhanced Barrier Precautions for the duration of their admission. 2. In addition, place all residents who reside on the same unit as the index resident who are at high-risk to acquire a multidrug resistant organisms ([CONDITION(S)]) on Enhanced Barrier Precautions . a use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of [CONDITION(S)]'s to staff hands and clothing . On 10/13/21 at 3:45 p.m., an interview was conducted with the Director of Nursing (DON) and RN K. The DON and RN K confirmed they had not been aware of the CRE or need for contact precautions until the email on 8/20/21. When asked why the discharge paperwork that noted that Resident #7 needed to be in contact isolation were not followed, RN K reported she hadn't seen that. When asked why the review of the hospital records that showed Resident #7 had an [CONDITION(S)] infection, RN K and the DON reported that they hadn't seen that in the records. A review of the facility policy titled, Infection Surveillance Guideline dated 11/28/17 revealed, Infection prevention begins with ongoing surveillance to identify infections that are causing, or have the potential to cause, an outbreak. The facility closely monitors all residents who exhibit signs/symptoms of infection through ongoing surveillance and has a systematic method for collecting, consolidating, and analyzing data concerning the frequency and cause of a given disease . The Infection Preventionist (IP) reviews data on a regular basis including: . culture results or other diagnostic test results consistent with potential infections . laboratory cultures and antibiograms (antibiotic susceptibility profiles) . medical record reviews of all new admissions . DPS #2: Based on observation, interview, and record review, the facility failed to maintain appropriate infection control measures pertaining to the use of glucometers for four residents (Residents #34, #44, #45, and #48) of four residents observed for glucometer use. This deficient practice resulted in the potential for the spreading of infection causing agents from resident to resident. Findings include: Resident #34's face sheet contained an admitted [DATE] and medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #44's face sheet revealed an admitted [DATE] and medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #45's face sheet revealed an admitted [DATE] and medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R #48's face sheet revealed an admitted [DATE] and medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/13/21 at 6:32 a.m., Registered Nurse (RN) G was observed checking Resident #45's blood sugar. RN G then proceeded to check Resident #44's blood sugar using the same glucometer. The glucometer was not disinfected after checking Resident #45's blood sugar and prior to checking #44's blood sugar. RN G then checked Resident #48's blood sugar with the same glucometer without disinfecting it. On 10/13/21 at approximately 6:58 a.m., RN G was asked what the policy was pertaining to disinfecting glucometers between residents. RN G said she had been instructed to disinfect the glucometers between residents, but she was trying to be expedient. During an observation of Resident #34's blood sugar check on 10/13/21 at 7:03 a.m., Licensed Practical Nurse (LPN) L was observed setting the glucometer directly on Resident #34's bedside table. After checking Resident #34's blood sugar, LPN L wiped down the glucometer with alcohol swabs. During an interview on 10/13/21 at 7:24 a.m., LPN L was asked about barrier usage when administering medications. LPN L said, I see what you're saying, I should have used one to prevent the spread of germs. LPN L said the glucometers were wiped down with alcohol swabs to disinfect them. A copy of the facility's Specific Medication Administration Procedures IIB1: Administration Procedures for all Medications, dated 2018 contained the following information, in part, Policy to administer medications in a safe and effective manner. Procedures: .G. Use a barrier (e.g. clean disposable tray or plastic tray or plastic cup) to carry medication containers into a the resident's room .This will serve as a barrier between the supplies and the over-the-bed table or other surface on which the supplies are place while the medication is administered . 10/13/21 10:52 AM DON and the RN/Infection Control Nurse wipe with Clorox bleach wipes between each use, alcohol is not an acceptable substitute should be Clorox bleach wipes. should be a barrier placed when setting down insulin pens and glucometer on a bedside table to prevent the spread of infectious agents from resident to resident. Blood Glucose Meter Cleaning policy dated October 5, 2018 revealed the following information, in part, To provide a standardized approach with cleaning and disinfection when shared glucometers are utilized. Responsible Party: Clinical Guideline Whenever possible, blood glucose meters should be assigned to an individual person and not shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over blood and infectious agents. Point of care devices, including blood glucose meters, if used for multiple residents, must be cleaned and disinfected after each use according to manufacturer's instructions. If the manufacturer does not specify steps for cleaning and disinfection, between uses of a blood glucose meter, the device should not be used for more than one resident. If the manufacturer recommendations do not specify agents for cleaning and disinfection between uses, the device should not be used for more than one resident. Disinfection Protocol The disinfectant recommended by our facility: [Name Brand] Bleach Germicidal Wipes Glucometers shared by multiple patients will be thoroughly wiped and allowed to air dry after every use and between every patient: a. Use a fresh wipe each time the glucometer is used; b. Wipe all surfaces, top, bottom, and sides; c. Allow to air dry before use on the next patient .

This Citation Pertains to Intake Numbers: MI 143, MI 985, MI 003, and MI 117. This Citation contains two Deficient Practice Statements. Deficient Practice Statement #1: Based on observation, interview, and record review, the facility failed to operationalize policies and procedures to thoroughly review and implement interventions to prevent falls for two residents (Resident #701 and Resident #706) of three residents reviewed for falls, resulting in a lack of interventions to prevent falls, Resident #701 experienced multiple falls with injury including a fractured wrist. Resident #706 fell multiple times suffering a fractured clavicle (collarbone), unnecessary pain, and the likelihood for decline in overall health status. Findings include: Resident #701: Review of intake documentation pertaining to Resident #701 revealed Resident #701 fell in the facility on 6/16/21 and suffered a fracture of their left wrist. Review of separate intake related to the Resident detailed, The facility started (Resident #701) on [MEDICATION(S)] to try to calm them. They have become a fall risk and falls increased with the [MEDICATION(S)] (antiseizure medication also used to treat mental health disorders). During one of the recent falls, (Resident #701) ended up with a . fracture of the wrist, in which they did a soft cast on it . On 7/16/21 at 10:00 AM, an interview was completed with Family Member B. When queried regarding Resident #701's care in the facility, Family Member B verbalized multiple concerns related to care that the Resident was receiving including notification of changes in the Resident's condition and treatment. When asked if Resident #701 had fallen in the facility, Family Member B replied, Yes, and (the Resident) broke their wrist too. When asked how many times the Resident had fallen, Family Member B replied, We don't really know and that is part of it (concern). When asked for clarification, Family Member B stated, The other day on the phone (video visit) (Resident #701) was saying their ankle and foot hurt. They (staff) said it was just their sock. Family Member B revealed they insisted that staff remove the Resident's sock and stated, Their ankle was all bruised. When asked if they were aware of the cause of the bruising, Family Member B replied, From getting into the wheelchair. Family Member B elaborated that the family could not be sure that they were being informed of all times the Resident had fallen because of instances such as that when the facility did not assess nor inform them of their ankle injury. When queried regarding the Resident's plan of care and interventions to prevent falls, Family Member B revealed they were not aware of what the facility was really doing to prevent the Resident from falling and becoming injured. Family Member B further revealed the Resident started falling more after the facility started them on [MEDICATION(S)]. With further inquiry regarding the medication, Family Member B stated, After the fall where (Resident #701) broke their wrist, they put them on [MEDICATION(S)] (narcotic pain medication) four times a day because they didn't want (Resident #701) to get up. Family Member B was asked why they thought the pain medication was started for that reason and stated, The Nurse told me they do not want (Resident #701) to get up. Family Member B then stated, I have been scared to speak up because I was scared, they (facility staff) would take it out on (Resident #701). When queried what had changed, Family Member B revealed they were also concerned about the other residents in the facility. Family Member B stated, We were told we could see (Resident #701) anytime because they are on Hospice and then when the facility would not let us in, enough is enough. What about the people who have no one to look out for them? Record review revealed Resident #701 was most recently admitted to the facility on [DATE] with diagnoses which included heart failure, subdural hemorrhage (brain bleed), supplemental oxygen dependence, and history of falls. Review of the Minimum Data Set (MDS) assessment, dated 5/12/21, revealed the Resident was severely cognitively impaired and required extensive to total assistance to perform all Activities of Daily Living (ADLs). Additional review of Resident #701's medical record revealed the Resident was receiving Hospice services and was assessed to be a high risk for falls. On 7/16/21 at 1:00 PM, Resident #701 was observed sitting alone in a wheelchair in front of the nurses' station. The wheelchair was noted to have a seatbelt restraint and a gait belt wrapped around the back of the wheelchair. The Resident had a universal (for left or right) wrist brace with a visible Walgreen's tag in place on their left wrist. The Resident was visibly and audibly yawning. When asked if they were tired, Resident #701 replied, Yes. Resident #701 was pleasantly confused, with a calm demeanor, but unable to provide meaningful responses to complex questions. An interview was completed with Licensed Practical Nurse (LPN) C on 7/16/21 at 1:10 PM. When queried regarding the reason Resident #701 was wearing a brace on their wrist, LPN C stated, I think it was a fracture. When asked how the Resident got a fracture, LPN C replied, I think they fell . LPN C was then asked if the Resident had always had that brace and replied, I think so. When asked if the Resident had been evaluated by an Orthopedic provider and if the Walgreen's brace was their recommendation, LPN C replied, They are on Hospice and indicated they were unsure who had recommended the brace. On 7/16/21 1:15 PM, an interview was completed with Certified Nursing Assistant (CNA) J. When queried regarding Resident #701's Walgreen's wrist brace, CNA J revealed the Resident fell and broke their wrist. With further inquiry, CNA J stated, (Resident #701) fell and always had that one (since the fall). When asked if they had noted any other changes in Resident #701's level of functioning following their falls in their facility, CNA J replied, (Resident #701) leans to the left when they walk now. CNA J was then queried why Resident #701's wheelchair had a gait belt and a seat belt hooked around the back of the wheelchair. CNA J replied, I've never used it but they (staff) might put it on when (Resident #701) is trying to get up to walk. Review of Resident #701's care plan revealed a care plan entitled, Falls . high risk for falls due to confusion, poor safety awareness, sees things and responds to them, need of oxygen, restlessness . frequently gets up by self to get into closets and drawers . hx (history) of getting out of bed unassisted . not cognitively able to use call light or be educated on safety . (Initiated: 4/26/21). The care plan included the interventions: - Do not leave resident unattended in the bathroom (Initiated: 4/26/21) - Encourage fluids to keep resident hydrated. Dehydration increases risk for falls (Initiated: 4/26/21) - Ensure resident's shoes/gripper socks have adequate traction (Initiated: 4/26/21) - Intercept resident when observed ambulating unassisted or attempting to self-transfer. Attempt to determine what trying to do and assist. Assure (Resident) is seated or in bed prior to leaving the room (Initiated: 4/26/21) - Review resident medications associated with fall risk routinely and as needed. Request med reviews post-fall and PRN (as needed). Discuss possibility of dose reduction with MD if appropriate (Initiated: 4/26/21) - Anticipate and meet the resident's needs (Initiated: 4/26/21) - Ensure the resident's call light is within reach in event turns it on. If turns on light, respond promptly (Initiated: 4/26/21) - Follow facility fall protocol, and assure safety interventions are in place as indicated (Initiated: 4/26/21) - Resident is confused and sometime sees things/situations that are not there. Provide reassurance and offer assistance to decrease anxiety or self-transferring (Initiated: 4/26/21) Resident #701 had another care plan in place pertaining to falls titled, Falls: Resident has had a fall with major injury (Initiated: 1/30/21). The care plan included a Resolved intervention that had been both initiated and resolved on 4/26/21. The resolved intervention included multiple sub-interventions with various typed dates, including dates after the intervention had been resolved. Review of facility provided Incident and Accident Reports for Resident #701 revealed the following: - 11/7/20 at 1:25 PM: Description of Event . Heard resident's table rolling then her yelling help. She landed on her buttocks on the floor next to her bedside table. She bumped her chin on the right side, no redness or swelling noted . Unwitnessed . Walking unassisted . Resident room . Where was the resident's last known location? Sitting in recliner . Was the resident injured? No . Resident family/responsible party notified . (Yes) . A new Plan of Care/Intervention has been completed to prevent further events . Notification . Management Review: Administrator Not Reviewed . DON (Director of Nursing)/ADON (Assistant Director of Nursing): Not Reviewed . -11/26/20 at 9:00 AM: Description of Event . Got called into room by CNA (Certified Nursing Assistant). Resident was laying on her back, more towards the right side with her head against the door. Resident stated she hit her head on the door, small hematoma noted to the back, right side of head slightly bruised [purple in color] . Witnessed . Resident room . Sitting in recliner . Was the resident injured? Yes . Minor injury . Hematoma . Small hematoma to back right side of head, purple bruise noted . Resident family/responsible party notified . (Yes, but no documented date and time) . A new Plan of Care/Intervention has been completed to prevent further events . Notification . Management Review: Administrator Reviewed [DATE] . Comment: NHA aware of incident . DON (Director of Nursing)/ADON (Assistant Director of Nursing): Not Reviewed . -12/3/20 at 6:35 PM: Description of Event . res (resident) sitting on floor on butt with legs out in front of her in front of recliner with back towards it walker slightly to the left of her . Unwitnessed . Resident room . Where was the resident's last known location? Recliner eating dinner . Was the resident injured? Yes . Minor injury . Abrasion . approx. 4 cm (centimeters) abrasion to lower back . Resident family/responsible party notified . (Yes) . A new Plan of Care/Intervention has been completed to prevent further events . Notification . Management Review: Administrator Reviewed [DATE] . DON (Director of Nursing)/ADON (Assistant Director of Nursing): Not Reviewed . -1/1/21 at 5:30 PM: Description of Event . Resident observed sitting on buttocks with BLE (bilateral lower extremities) tucked up in front of recliner . Unwitnessed . Resident room . Where was the resident's last known location? Sitting in recliner . Was the resident injured? No . Resident family/responsible party notified . (Yes) . A new Plan of Care/Intervention has been completed to prevent further events . Notification . Management Review: Administrator Reviewed [DATE] . DON (Director of Nursing)/ADON (Assistant Director of Nursing): Not Reviewed . -1/11/21 at 12:00 PM: Description of Event . Staff were in hallway passing lunch trays and heard a loud noise from resident's room and entered room. Resident was observed sitting on floor in front of closet. Resident stated that she was putting stuff away in closet and slipped . Unwitnessed . Resident room . Where was the resident's last known location? In recliner . Was the resident injured? No . Resident family/responsible party notified . (Yes) . A new Plan of Care/Intervention has been completed to prevent further events . Notification . Management Review: Administrator Reviewed [DATE] . DON (Director of Nursing)/ADON (Assistant Director of Nursing): Not Reviewed . -1/14/21 at 12:50 PM: Description of Event . pt (patient) got up from chair without assist. Walking by room observed pt on floor lay on L (left) side . Unwitnessed . Resident Room . Was the Resident Injured . No . Resident family/responsible party notified . (Yes) . A new Plan of Care/Intervention has been completed to prevent further events . Notification . Management Review: Administrator Reviewed 3/7/21 . DON (Director of Nursing)/ADON (Assistant Director of Nursing): Not Reviewed . -1/30/21 at 11:35 PM: Description of Event . observed res sitting on floor mat, leaning against her bed . Where was the resident's last known location? In bed sleeping . Was the resident injured? No . Resident family/responsible party notified . (Yes) . A new Plan of Care/Intervention has been completed to prevent further events . Notification . Management Review: Administrator Reviewed [DATE] Comment NHA was made aware of incident . DON (Director of Nursing)/ADON (Assistant Director of Nursing) Reviewed [DATE] . upon thorough investigation and root cause analysis, it is determined that resident fell due to tripping on the padded floor mat nest to her bed. She had self-transferred to the bathroom and was returning to bed. She suffered no injury. She stated that she hit her head, but no injury was observed. Immediate intervention: Removed floor mat . -2/20/21 at 4:40 PM: Description of Event . Alerted to resident side per roommate stating, she fell . Arrived to resident side to find resident sitting on buttocks, right leg flexed at knee, left leg extended out. Gripper socks on, call light within reach, walker at bedside with brakes locked. Resident tells one staff member she was trying to get up to help somebody, she tells me, I didn't fall I got down there to help somebody. Resident assessed for injury, no apparent injury noted, assisted up to recliner per two staff members . Unwitnessed . Resident room . Where was the resident's last known location? recliner . Was the resident injured? No . Resident family/responsible party notified . (Yes) . A new Plan of Care/Intervention has been completed to prevent further events . Notification . Management Review: Administrator Reviewed [DATE] . DON (Director of Nursing)/ADON (Assistant Director of Nursing): Not Reviewed . -4/3/21 at 3:30 PM: Description of Event . 3:30 PM Resident noted to be on buttocks with left shoulder against corner of closet, holding on to a glass with a small amount in it, the rest of the water was spilled on the floor. Resident said she was getting a glass of water. Resident assessed and assisted off the floor after water was cleansed up. Resident c/o (complained of) her left shoulder hurting, noted approx. 7 (inches) x (by) 2 redden area. ROM WNL (Within Normal Limits) . Walking unassisted . Resident room . Where was the resident's last known location? Recliner . What assistive devices and interventions were in use at the time of the event by the resident? Other [explain] Walker was not near resident .Was the resident injured? No . Resident family/responsible party notified . (Yes) . A new Plan of Care/Intervention has been completed to prevent further events . Notification . Management Review: Administrator Not Reviewed . DON (Director of Nursing)/ADON (Assistant Director of Nursing): Not Reviewed . -4/26/21 at 2:40 PM: Description of Event . Resident's roommate called activity aid into the room after resident had slid from chair and aid notified this nurse. This nurse entered room and observed resident sitting on floor in front of recliner. Resident stated she was reaching for something and slid out of her chair. She indicated the magazine that had fallen between her chair and bed. Noted resident wearing shoes and gripper strips in place in front of chair . Unwitnessed . Resident room . Where was the resident's last known location? in recliner . Was the resident injured? No . Resident family/responsible party notified . (Yes) . A new Plan of Care/Intervention has been completed to prevent further events . Notification . Management Review: Administrator Reviewed [DATE] . DON (Director of Nursing)/ADON (Assistant Director of Nursing): Not Reviewed . -5/2/21 at 8:20 PM: Description of Event . Resident was ambulating, went to sit on her walker and it wasn't locked resident slide to floor. Head to toe assessment completed no injury . Walking unassisted . Hallway . Where was the resident's last known location? hallway . Was the resident injured? No . Resident family/responsible party notified . (Yes) . A new Plan of Care/Intervention has been completed to prevent further events . Notification . Management Review: Administrator Not Reviewed . DON (Director of Nursing)/ADON (Assistant Director of Nursing): Not Reviewed . -6/14/21 at 3:35 PM, Description of Event . Side 1 nurse was in room 122 and heard resident calling out. She entered resident's room and observed resident at the doorway crawling on her hands and knees. Resident stated, 'I was looking for them.' Resident was assisted to a sitting position and this nurse assessed for injuries. Resident stated that the right side of her head and cheek hurt and said, 'I chipped a tooth.' Assessed the resident's mouth and noted no broken teeth. No other injuries noted as well. Unwitnessed . Resident room . Where was the resident's last known location? Recliner . Was the resident injured? No . Resident family/responsible party notified . (Yes) . A new Plan of Care/Intervention has been completed to prevent further events . Notification . Management Review: Administrator Reviewed Jun 27 2021 . DON (Director of Nursing)/ADON (Assistant Director of Nursing): Not Reviewed . -6/16/21 at 3:45 PM: Description of Event . called to room by nurse aide where resident was sitting on floor with Small laceration to L (left) eyebrow. Unwitnessed fall . Unwitnessed . Resident room . Where was the resident's last known location? In chair sitting in room . Was the resident injured? yes . Laceration ½ cm laceration L eyebrow . Resident family/responsible party notified . (Yes) . A new Plan of Care/Intervention has been completed to prevent further events . Notification . Management Review: Administrator Reviewed Jun 27 2021 . DON (Director of Nursing)/ADON (Assistant Director of Nursing): Not Reviewed . -6/21/21 at 5:30 PM: Description of Event . Housekeeper notified this nurse and 1730 (5:30 PM) that resident was on the floor. Entered resident's room. Observed resident laying on L. side with recliner behind her and walker to her left. Resident stated, 'I tried to sit down and ended up on the floor.' . Unwitnessed . Resident room . Where was the resident's last known location? In recliner . Was the resident injured? No . Resident family/responsible party notified . (Yes) . A new Plan of Care/Intervention has been completed to prevent further events . Notification . Management Review: Administrator Reviewed Jun 27 2021 Comment NHA was made aware of incident . DON (Director of Nursing)/ADON (Assistant Director of Nursing): Not Reviewed . -6/24/21 at 4:15 PM: Description of Event . Found resident lying on the floor in her room by her sink . Unwitnessed . Resident room . Where was the resident's last known location? Bed . Was the resident injured? No . Resident family/responsible party notified . (no name documented but date and time documented 6/24/21 at 6:16 PM) . A new Plan of Care/Intervention has been completed to prevent further events . Notification . Management Review: Administrator Not Reviewed . DON (Director of Nursing)/ADON (Assistant Director of Nursing): Not Reviewed . Review of facility provided document titled, Injury of Unknown Origin, not dated with the date the document was completed, for Resident #701 included the following: - Date and Time of Incident: 6/17/21 at 12:00 PM - Incident: On 6/16/2021, resident was complaining about left wrist pain following a fall in room earlier that day. An x-ray was ordered. The x-ray was completed on 6/17/2021. The results came back at 12 PM and showed that resident had a deformity of her left distal radius, suspect for an acute, non-displaced fracture. Resident is a poor historian and cannot express if this injury resulted from fall. - Immediate actions taken: (Physician I) was notified of injury. Resident's daughter notified of incident. New fall intervention-med (medication) review with changes, excessive clutter removed from closet. Resident's care plan updated. Staff interviews conducted. - Resident Interviews: (Resident #701) is alert to self only, with a BIMS score of 3 (severely cognitively impaired). She has poor recall, poor attention span, and cannot comprehend verbal communication without difficulty. She is a current hospice patient. She requires limited to extensive assistance with transfers/ambulation due to dementia and instability. She has her own wheeled walker that she uses for ambulation. She is very focused on her dresser and will frequently self-transfer to her dresser and pack her belongings. She moves items from her closet to her bed because she is 'moving'. - Staff Interviews: CNA P was the first staff member to observe (Resident #701) after the fall. (CNA P) stated that (Resident #701) was observed sitting on coccyx, in front of closet. Some items had fallen out of the closet and were by (the Resident's) feet. (CNA P) stated that (Resident #701) was complaining of left wrist at the time of the fall. - Nurse Interview: (RN Q) was the nurse who responded to the fall . noted that resident was complaining of left wrist pain as well, as back pain. (RN Q) contacted (Physician I) and received an order for the x-ray . had also seen (Resident #701) self-transferring in room and had redirected back into bedside recliner. - Conclusion: Based on a thorough investigation, it is determined that resident suffered their fracture as a result of fall, and not by any abuse. Prior to the fall, (Resident #701) had not been complaining of left wrist pain. When (Resident #701) was first observed following the fall, they stated they had stumbled and fallen, and was observed in front of closet with obstacles that had fallen out of the closet next to feet. - Fall Scene Investigation Report: .Date of Fall 6-16-21, Time of Fall: 1545 (3:45 PM) . Fall Summary: Found on the floor [unwitnessed] . Fall Location: Resident room . What was resident doing during or just prior to fall? Ambulating, Attempting self-transfer . What type of assistance was resident receiving at time of fall? Alone and unattended . Review of Resident #701's EMR progress note documentation revealed the following: - 11/26/20 at 9:00 AM: Incident Note . Got called into room by CNA. Resident was laying on back, more towards the right side with head against the door. Resident stated hit head on the door, small hematoma noted to the back, right side of head slightly bruised (purple in color). Resident denied pain anywhere else . Neuro eval WNL, no other injuries or bruising noted . - 12/3/20 at 7:03 PM: Incident Note . (CNA) was answering call light (roommate put on) observed res sitting on floor on butt with legs out in front . recliner to back, walker in front and slightly to the left . asked (resident) if they were hurt said my low back is sore observed a reddened approx. 4 cm (centimeter) abrasion to lower back said from that pointed to walker tire and brake area. roommate said (resident) slid on it . - 1/1/21 at 5:47 PM: Fall . Resident observed sitting on buttocks in front of recliner in room. Resident states bumped head. No mark or lump noted . Resident states was moving things in room. Over bedside table in middle of room with water pitcher spilled on the floor. Shoes on . - 1/11/21 at 12:00 PM: Health Status Note . Staff were in hallway passing lunch trays and heard a loud noise from resident's room and entered room. Resident was observed sitting on floor in front of closet. Resident stated they were putting stuff away in closet and slipped. Resident stated they hit their head and had slight pain of 1 or 2. No injury noted . - 1/14/21 at 3:39 PM: Fall . walking by room observed resident on floor laying on L side on floor mat. Assessed for injury and no apparent injuries observed. Assisted resident to standing position. Able to ambulate with no limp . educated call light use before getting up . - 1/14/21 at 11:14 PM: Incident Note . no injury noted from fall earlier today. res continues with impulsiveness, unsteady gait. has been up ambulating this evening . unable to redirect res with snacks, activities, music . - 1/30/21 at 6:11 PM: Fall Risk Evaluation . There is new pain, post fall mild pain to back of head Resident has a bump back of head . - 1/30/21 at 6:35 PM: Incident Note . Resident slid on floor mat while walking in room fell back and sat on bed, then hit head on the wall on the other side of the bed. (Staff witnessed) Neuro checks ok . - 1/30/21 at 11:55 PM: Incident Note . (CNA) called fall response at 2340 (11:40 PM) res was observed on buttocks sitting on left leg. leaning against bed .res said came back from br (bathroom) and tripped on floor mat and went down. res was bare foot, said thinks hit head and pointed to bed frame, no redness or bruising noted. neuro wnl (within normal limits) assist res up back into bed, no increase . pain except was rubbing rt (right) forehead. removed floor mat, bed in lowest position, and put gripper sock on res . res often removes socks/ gripper socks and doesn't utilize call light . - 2/20/21 at 5:12 PM: Incident Note . Alerted to resident side per roommate stating, '(they) fell '. Arrived to resident side to find resident sitting on buttocks, right leg flexed at knee, left leg extended out. Gripper socks on, call light within reach, walker at bedside with brakes locked . Resident assessed . no apparent injury . - 4/3/21 at 5:25 PM: Fall . 3:30 PM Resident noted to be on buttocks with left shoulder against corner of closet, holding on to a glass with a small amount in it, the rest of the water was spilled on the floor. Resident said . getting a glass of water. Resident assessed and assisted off the floor . Resident c/o left shoulder hurting, noted approx. 7x 2 redden area. ROM (Range of Motion) WNL . Around 5 PM resident c/o arm and neck feeling stiff, ice applied with effective results . -4/6/21: Physician/PA/NP - Progress Note . Problem visit involving fall that occurred on April 3. Fall was unwitnessed but is noted to have not resulted in any injury immediately at examination. patient now relates that they are experiencing [MEDICATION(S)] spine pain . Note: Nursing Progress Note Documentation indicated the Resident was not having any pain following the fall on 4/3/21. - 4/6/21 at 1:05 PM: Incident Note: [MEDICATION(S)] spine Xray ordered . - 4/7/21 at 12:23 AM: Health Status Note .res. had a fall with no injuries . - 4/24/21 at 6:00 PM: Fall . Resident fell in room next to recliner today at 17:20 (5:20 PM). No injury . - 4/25/21 at 12:37 AM: Incident Note .res. had a fall today no injuries noted . - 4/26/21 at 2:51 PM . Incident Note . Resident's roommate called activity aid into the room after resident had slid from chair and aid notified this nurse. This nurse entered room and observed resident sitting on floor in front of recliner. Resident stated they were reaching for something and slid out of chair. Noted resident wearing shoes and gripper strips in place in front of chair. No injury . - 4/26/21: IDT (Interdisciplinary Team Note . Resident has frequent falls due to confusion, poor safety awareness, seeing objects or responding to nonexistent situations . unable to use call light or be educated on safety. Resident's care plan was reviewed and updated as appropriate . - 5/2/21 at 9:23 PM: Incident Note . Resident was ambulating in the hallway, this nurse came out of another residents room and observed the resident on the floor, on bottom in front of walker. Resident was trying to sit on walker and slid to the floor. No injury. resident denies hitting head . - 5/4/21 at 12:06 AM: Health Status Note . res. had a fall with no injuries and no s/s (signs/symptoms) of discomfort . - 5/4/21 at 3:58 PM: Health Status Note . Resident's daughter also concerned that [MEDICATION(S)] is ineffective and may be causing some of resident's falls . -6/10/21 at 2:20 PM . Health Status Note . notified by (staff) that resident got startled when they entered the room and that resident stumbled into a sitting position on the seat of their walker. This nurse checked lower back and buttocks for injuries, and none noted . -6/14/21 at 6:23 PM: Incident Note . Side 1 nurse was in room 122 and heard resident calling out . entered resident's room and observed resident at the doorway crawling on her hands and knees. Resident stated, 'I was looking for them'. Resident was assisted to a sitting position and this nurse assessed for injuries. Resident stated that the right side of her head and cheek hurt and said I chipped a tooth. Assessed the resident's mouth and noted no broken teeth . Family also concerned that [MEDICATION(S)] may be contributing to falls . -6/14/21 at 10:43 PM: Incident Note . res with no injury noted from fall. res doesn't utilize call light, or walker most of time. confused increase anxiety/restlessness noted often looking for kids or husband. becomes agitated with redirection at times . -6/16/21 at 6:16 PM: Incident Note . At 1545 (3:45 PM) on 6/16/21 I was called to patient's room. Observed Pt. sitting on floor with small laceration on L eyebrow. Unwitnessed fall. Pt. is very confused and will not stay in chair and has no safety awareness. Did not bleed much . steri-strip applied. No other injury. noted. C spine 2 view (X-ray) ordered due to c/o of neck pain. Able to move all extremities without any pain. Call light education done and placed within reach. - 6/16/21 at 11:22 PM: Incident Note .Res continues with laceration and bruising, swelling to left eyebrow and start of bruising to check from fall earlier today. Steri-strips in place. tender to touch res isn't c/o (complain of) neck this evening. staff assisting with cares. res cont. to not utilize call light. x-rays ordered . - 6/17/21 at 12:03 PM: Physician/PA/NP - Progress Note . Problem visit involving fall that occurred on June 16. Fall was unwitnessed but is noted to have resulted in (an) injury to wrist and face. patient wrist on x ray is noted fractured. wrist brace is ordered. steri-strip noted applied to eye . -6/17/21 at 2:45 PM: Incident Note . Had fall 6/16/20. Splint applied to L wrist due to chip Fx (fracture) L (left) distal ulna. laceration to L eyebrow closed with no drainage. Steri-strip intact . - 6/19/21 at 4:09 PM: Follow from fall 6-16-21: left wrist brace in place for wrist fracture. Intact steri-strip in place above left eyebrow. Blue/brown left periorbital bruising present. States 'left hand hurts' . - 6/19/21 at 10:27 PM: Health Status Note . Left wrist brace in place for wrist fracture. Intact steri-strip in place above left eyebrow. Blue/brown left periorbital bruising present. States 'left hand hurts' . - 6/21/21 at 5:51 PM: Incident Note . Housekeeper notified this nurse . that resident was on the floor. Entered resident's room. Observed resident laying on L. side with recliner behind them and walker to their left. Resident stated 'I tried to sit down and ended up on the floor [TRUNCATED]

This citation pertains to Intake Number MI 093. Based on observation, interview and record review, the facility failed to properly transcribe a physician's orders [REDACTED].#7) of 13 residents reviewed for physicians' orders, resulting in a Urinary Tract Infection [MEDICAL CONDITION] progressing to urosepsis (infection throughout body), [MEDICATION NAME] Resistant [MEDICATION NAME] (VRE) not being properly treated, a decrease in mental status and hospitalization with IV antibiotic therapy. Findings: The antibiotic, [MEDICATION NAME], was ordered at 600 mg, twice a day for 10 days. The facility incorrectly transcribed [MEDICATION NAME] as being ordered at 600 mg, twice a day every 10 days, Record review of the facility's 'Urinary Tract Infections/Bacteriuria- Clinical Protocol', dated 10/2010, revealed, Monitoring' (4.) When someone's urinary tract infections persist or recurs after treatment with and initial course of antibiotics, the physician should review the situation carefully with the nursing staff and possibly examine the individual before prescribing repeated courses of antibiotics. Record review of the facility's 'Antibiotic Stewardship Program' (ASP) policy, undated, revealed that the CDC (Center for Disease Control and Prevention) estimates that up to 70% if nursing home residents receive an antibiotic at least once a year. Of those antibiotics prescribed, up to 75% may be suboptimal, due to incorrect antibiotic selection, dose, frequency, and/or duration of therapy. Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program and in accordance with CDC recommendations. Our program encompasses the core elements, as described by the CDC: Leadership commitment, accountability, drug expertise, action, tracking, reporting, and education. Accountability section: (2.) All members of the antibiotic stewardship team (AST) will be responsible for the initiatives and outcomes of the ASP. Action section: Required documentation of antimicrobial indication, dose, and duration for any antimicrobial ordered. Policy interpretation and implementation: (1.) The purpose of our antibiotic stewardship program is to take actions that will improve antibiotic use in order to reduce adverse events, prevent emergence or resistance, while leading to better outcomes for our residents. (4.) Prescribers will provide complete antibiotic orders including the following elements: (a.) Drug name; (b.) Dose; (c.) Frequency of administration; (d.) Duration of treatment start/stop date or number of days of therapy. (9.) When a culture and sensitivity (C&S) is ordered: (a.) Results will be treated as a priority. (b.) Lab results will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. (c.) Antibiotic time out will be performed by the infection preventionist/ This time out will be a reassessment of the ongoing need for and the choice of an antibiotic and should be completed within 72 hours of initiation of antibiotics. The time out should include the following, as indicated: Confirming a bacterial infection that will respond to antibiotics; confirmation that most appropriate antibiotic, dose, and route of administration has been ordered; assessment if antibiotic can be narrowed or duration of therapy shortened; and any additional follow up with infectious disease specialist needed. (16.) the infection preventionist will be responsible for gathering data for tracking purposes. This data will include the following: Documentation of clinical assessment, prescription documentation, antibiotic selection, patterns of use. (days of therapy) and adverse outcomes . Record review of Resident #7's Minimum Data Set (MDS), dated upon readmission on 2/11/19, revealed an elderly female with multiple medical [DIAGNOSES REDACTED]. Observation on 6/11/19 of Resident #7's room [ROOM NUMBER] revealed that it was a private room located close to the front door and close to the nurse's station on the front side of the facility. Resident #7 no longer resided in the facility at the time of the investigation. Record review of Resident #7's hospital discharge summary, dated 4/10/19, revealed a primary discharge [DIAGNOSES REDACTED]. Resident #7 was admitted back to the facility. Record review of hospital laboratory urinalysis results, dated 4/12/19, signed by facility Registered Nurse (RN) B, and initialed by nurse, noted a star next to Linezolid S susceptible. A handwritten notation was, 4/12/19 600 mg BID. Record review of Resident #7's physician's orders [REDACTED]. It was written by Registered Nurse B. In an interview on 6/6/19 at 10:08 AM via phone, Registered Nurse (RN) B revealed that she remembered Resident #7 and that she received the lab results and called the physician. RN B stated that her intention was to write for: Linezolid 600 mg PO (oral) BID (twice a day) for 10 days. But what she actually wrote was Linezolid 600 mg PO (oral) BID (twice a day) every 10 days. Record review of the 'Nursing (YEAR) Drug Handbook', provided by Registered Nurse Unit Manager G, revealed on pages 881-884, dosage of 600 mg IV or PO (oral) every 12 hours for 14 to 28 days. Under section Nursing Considerations: Inappropriate use of antibiotics may lead to development of resistant organisms; carefully consider other drugs before starting therapy, especially in outpatient setting. A record review of Resident #7's Medication Administration Record [REDACTED]. Page 5 revealed, Linezolid tablet 600 mg, give 1 tablet by mouth two times a day every 10 days for UTI until 4/23/19. On 4/13/19 there were two doses administered, one at 8:00 AM and a second at 8:00 PM. There were no other doses documented as administered. Record review of Resident #7's nursing progress notes, dated 1/31/19 through 4/15/19, revealed that on 4/13/19 at 3;02 PM nurse documented for Resident #7: Compliant with antibiotic with no adverse effects. On contact precautions for VRE in the urine. Will continue to monitor. No antibiotic medication was given after 4/13/19. On 4/14/19 at 3:02 AM (Midnight shift) nurse documented: Resident continues on antibiotic related to VRE/urine; no adverse reactions noted. On 4/14/19 at 1:24 PM (Day shift) nurse documented: Compliant with antibiotic with no adverse effects. On contact precautions for VRE in the urine. On 4/15/19 at 0:15 AM (Midnight shift) nurse documented: Resident continues on antibiotic related to UTI; no adverse reactions noted. Fluids encouraged. No complaints of pain/discomfort/urgency/frequency noted. Resident continues in contact precautions related to VRE/urine. Will continue to monitor. Record review of Resident #7's (MONTH) Medication Administration Record [REDACTED]. On 4/15/19 Resident #7 was sent from the [MEDICAL TREATMENT] center to the emergency room for evaluation of mental status changes. Record review of Resident #7's Emergency Department Nursing Record, dated 4/15/19 at 7:09 AM, revealed 'Pt. arrived by EMS (Emergency Medical Services) from [MEDICAL TREATMENT]. Per EMS before [MEDICAL TREATMENT] started Pt. had altered mental status and not answering questions. Record review of the nurse narrative notes revealed, 0900 Nurse R at (facility) contacted in regards to Linezolid dosing every 10 days- after confirmation of order- Nurse R states Linezolid order was supposed to be given for 10 days 2x daily R/T (related to) UTI (Urinary Tract Infection). States that antibiotics were given on 4/13/19 X2 doses, and not given again. ER provider notified. Record review of Licensed Practical Nurse (LPN) R's progress note, dated 4/15/19 at 2:59 PM for Resident #7, revealed 'Resident went LOA (Leave of Absence) for [MEDICAL TREATMENT] and [MEDICAL TREATMENT] sent her to ER (emergency room ) for evaluation and treat. Hospital admitted resident with Urinary Tract Infection with VRE ([MEDICATION NAME] Resistant [MEDICATION NAME]) and swelling of the brain. Family notified. Doctor Notified. Unit manager notified'. On 6/6/19 at 10:35 AM an interview was conducted with the Director of Nursing (DON), which included a record review of Resident #7's urine lab result for Resident #7, dated 4/12/19 and initialed by RN B. The DON was then shown the (MONTH) order recap summary for Resident #7's antibiotic, Linezolid 600 mg po every 10 days. Record review of the Medication Administration Record [REDACTED]. The DON explained the order process for the facility: The orders are written by the nurse, reviewed by clinical team in the morning start-up meeting, and also reviewed by the Unit Manager. The DON stated that the physician reviews orders once a month at the end of every month. The DON stated that the facility prints off a once a month recap and the physician reviews it. The DON was asked if he/she was aware of the transcribing error for Resident #7 and the DON stated that they were not aware of the situation. An interview on 6/6/19 at 10:50 AM with Registered Nurse unit Manager G, revealed that RN G is usually notified of an antibiotic order in the morning meeting in report via verbal notification and through the infection control nurse. RN G was shown the urine lab result page for Resident #7, dated 4/12/19 and initialed by RN B. RN G was then shown the (MONTH) order recap summary for Resident #7's antibiotic which stated, Linezolid 600 mg po every 10 days. Record review of the Medication Administration Record [REDACTED]. RN G reviewed the 'Nursing (YEAR)' drug handbook, pages 881-884, with the surveyor- Linezolid 600 mg oral every 12 hours for 14-28 days, usual dosing. RN G stated that she was not aware that there had been an error in the administration of the antibiotic order, until the state surveyor pointed the error out. In an interview on 6/6/19 at 12:40 PM, Physician C revealed that the physician intended Linezolid 600 mg po (oral) BID (twice a day) for 10 days. Record review of Resident #7's Hospital record, dated 4/15/19 through 4/26/19, revealed a Medicine Discharge Summary: On 4/15/19 it was noted, elderly female with end stage [MEDICAL CONDITION] who is a resident of a local ECF (Extended Care Facility) went for her [MEDICAL TREATMENT] today and was noted to have mental status changes. She is sleepy, difficult to arouse. She did not have [MEDICAL TREATMENT] and she was sent over to the ER. In the ER, she was noted to be sleepy and was responding to painful stimuli. In the ER urinalysis was abnormal. Review of records revealed that she did have a urine culture on 4/9/19 revealing VRE. Apparently, the patient was started on Linezolid, but the dose was Linezolid 600 mg twice a week. She was admitted with [DIAGNOSES REDACTED].

This citation pertains to Intake Number MI 846. Based on observation, interview and record review, the facility failed to ensure that 1 resident (Resident #11), who was agitated with repeated attempts to get out of bed (on 6/5/19), had a recent pacemaker put in, history of [MEDICAL CONDITION] (dizziness) and an extensive history of falls, was adequately supervised, of 5 residents reviewed for falls, resulting in a right [MEDICAL CONDITION], pain, hospitalization with surgery (an open reduction internal fixation) and two units of blood given due to acute blood loss [MEDICAL CONDITION] (low red blood cells due to blood loss during surgery). Findings Include: Review of the Face Sheet, facility Nursing admitted d 6/4/19, facility Wander/Elopement Risk Evaluation dated 6/4/19, Facility Fall Evaluation dated 6/4/19 and hospital records dated 6/3/19 through 6/7/19, revealed Resident #11 was 80-years-old, was a full code, required staff assistance with transfers and Activities of Daily Living (ADL's), had a history of [REDACTED]. The resident was admitted to the facility on [DATE], at approximately 8:00 p.m. and fell at in his room unsupervised at approximately 12:00 a.m.; resulting in a [MEDICAL CONDITION] hip, he was sent to the hospital and underwent right hip surgical repair. The resident's [DIAGNOSES REDACTED]. Review of the hospital records, dated 6/3/19, revealed on 6/3/19 Resident #11 had a permanent pacemaker put in due to recurrent [MEDICAL CONDITIONS] and orthostatic [MEDICAL CONDITION] with a history of frequent falls. Review of the facility Falls and Fall Risk Managing policy, dated 12/17, stated Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Review of the facility Wander/Elopement Risk Evaluation, dated 6/4/19, revealed Resident #11 was cognitively impaired. During an interview done on 6/11/19 at 12:55 p.m., MDS Nurse, RN P stated he (the resident) is cognitively impaired. Review of the facility Resident Transfer Ability Tool, dated 6/4/19, revealed Resident #11 was unable to transfer per self and required physical assistance with transfers. Review of the facility Fall Risk Evaluation, dated 6/4/19, revealed Resident #11 had previous recent falls, generalized weakness, limited/poor mobility, confusion/disorientation/impulsivity and was scored as a 12 for risk for falls (a score of 12 indicates a high risk for falls). A fall risk care plan was initiated due to the resident being at high risk for falls related to poor safety awareness. Review of the facility Fall care plan, dated 6/4/19, revealed Resident #11 was at high risk for falls due to poor safety awareness; staff were to anticipate and meet the resident's needs. Review of the facility ADL care plan, dated 6/4/19, revealed Resident #11 required physical assistance with transfers. Review of the facility nurse's notes, dated 6/4/19 through 6/5/19, are as follows: -On 6/4/19 at 9:17 p.m.: admitted (Resident #11) with dx (diagnosis) of brady cardia ([MEDICAL CONDITION]) with new insertion of pacemaker. Hx (history) of multiple falls. Alert with confusion, no c/o (complaints) of pain at this time (prior to fall). -On 6/4/19 at 11:34 p.m.: Resident restless, keeps throwing legs out of bed, sitting up at side of bed. Bed in low position, floor mats placed to both sides of bed for safety. -On 6/5/19 at 12:00 a.m.: Called to room by CNA (Nursing Assistant). Observed resident lying on the floor on his right side at the end of his bed and between bed 2. Resident had a BM (bowel movement) on the floor. Stated he was getting up because he didn't want to sit in it. Resident c/o (complained) right shoulder and hip pain. Unable to move right leg, right shoulder moved freely. Skin tear to right elbow. (Physician) notified, order received to transfer to hospital for X-rays. Review of the facility Fall Scene Investigation report, dated 6/5/19, revealed on 6/5/19 at 2400 (12:00 a.m.), Resident #11 was found by staff on the floor in his room. Factors that contributed to the fall were, Resident lost their balance and attempting self-transfer. The resident stated he had a BM and & didn't want to sit in it. No BM in bed only on floor. A & O (alert and orientated) x 1 (confused), restless, and had a Foley catheter in. The fall scene revealed, (Resident #11) was very restless and moving around in bed, trying to get out of bed a few times. Resident very restless since arrival (8:00 p.m.) (with) several attempts to get out of bed. Root Cause: Bathroom urgency for BM, Resident has a Foley catheter. Conclusion: Res (resident) transferred from bed and had BM on floor. Has Hx (history) of falls, [MEDICAL CONDITION], and [MEDICAL CONDITION](high blood pressure), Foley attached to bed. Observation was done on 6/7/19 at 10:15 a.m., accompanied by the Administrator and Director of Nursing/DON of the facility video, dated 6/4/19 at 8:00 p.m. through 6/5/19 at 11:58 p.m., of the hall of Resident #11's room. The facility video revealed the following: -On 6/4/19 at 8:12 p.m.: CNA's N and K go in resident's room. -On 6/4/19 at 8:15 p.m.: CNA's N and K come out of resident's room. -On 6/4/19 at 8: 20 p.m.: CNA's N and K go in resident's room CNA K came right out. -On 6/4/19 at 8:35 p.m.: CNA L went in resident's room. -On 6/4/19 at 8:35 p.m.: CNA L came out of resident's room. -On 6/4/19 at 8:35 p.m.: CNA K went in resident's room. -On 6/4/19 at 8:40 p.m.: CNA K came out of resident's room. -On 6/4/19 at 8:43 p.m.: CNA N went in resident's room. -On 6/4/19 at 8:45 p.m.: CNA N went out of resident's room. -On 6/4/19 at 9:18 p.m.: CNA N went in resident's room. -On 6/4/19 at 9:20 p.m.: CNA N went out of resident's room. -On 6/4/19 at 9:21 p.m.: CNA's N and Nurse, LPN M went in resident's room. -On 6/4/19 at 9:22 p.m.: CNA Nurse M came out of resident's room. -On 6/4/19 at 9:25 p.m.: CNA Nurse M went in resident's room. -On 6/4/19 at 9:28 p.m.: Nurse M came out of resident's room. -On 6/4/19 at 9:29 p.m.: CNA N came out of resident's room. -On 6/4/19 at 9:32 p.m.: Nurse M went in resident's room. -On 6/4/19 at 9:32 p.m.: Nurse M came out of resident's room. -On 6/4/19 at 9:33 p.m.: Nurse M went in resident's room. -On 6/4/19 at 9:35 p.m.: Nurse M came out of resident's room. -On 6/4/19 at 10:02 p.m.: CNA N went in resident's room. -On 6/4/19 at 10:03 p.m.: CNA N came out of resident's room. -On 6/4/19 at 10:09 p.m.: CNA N went in resident's room. -On 6/4/19 at 10:11 p.m.: CNA N came out of resident's room. -On 6/4/19 at 10:19 p.m.: CNA N went in resident's room. -On 6/4/19 at 10:19 p.m.: CNA N came out of resident's room. -On 6/4/19 at 10:45 p.m.: CNA's N and K went in resident's room. -On 6/4/19 at 10:48 p.m.: CNA's N and K came out of resident's room. -On 6/4/19 at 10:49 p.m.: CNA K went into the resident's room pushing a Geri chair. -On 6/4/19 at 10:52 p.m.: CNA N went in the resident's room caring floor mats. -On 6/4/19 at 10:54 p.m.: CNA's N and K left the resident's room. The Geri chair and floor mats were left in the resident's room. -On 6/4/19 at 10:57 p.m.: CNA N went in the resident's room. -On 6/4/19 at 10:57 p.m.: CNA N left the resident's room. -On 6/4/19 at 11:17 p.m.: Nurse M went in the resident's room. -On 6/4/19 at 11:18 p.m.: Nurse M left the resident's room. -On 6/4/19 at 11:20 p.m.: CNA K went in resident's room. -On 6/4/19 at 11:22 p.m.: CNA K left the resident's room. A 38-minute gap was observed at this time on the facility video. No staff member went into the resident's room on 6/4/19 at 11:22 p.m. to 6/4/19 at 11:58 p.m. -On 6/4/19 at 11:58 p.m.: CNA N went in the resident's room and quickly ran out. The resident was observed on the floor by CNA N at this time. Review of the hospital emergency room records, dated 6/5/19, stated PT (patient) brought to ER (emergency room ) RM (room) 04 via EMS (Emergency Medical Response) on stretcher. Pt brought via stretcher (from the facility) pt was walking with cane and fell on to right side. Right hip, shoulder pain. Pt had pacemaker placed 1 and half days ago (put in on 6/3/19). Pt reports to have pain 10/10 (in a scale of 0 to 10, the resident's pain was at a 10, worst pain) in the right hip and right shoulder. Pt given [MEDICATION NAME] (narcotic pain medication) per orders. Skin tear to right elbow noted. Swelling to right hip, above right knee. Review of the hospital X-ray, dated 6/5/19, stated Acute interochanteric right femoral fracture ([MEDICAL CONDITION] hip). Review of the hospital Hip/Pelvis Pain record, dated 6/5/19, stated fell while getting up to go to bathroom, pain at right hip, R (right) shoulder, hip fx ([MEDICAL CONDITION]). Review of the hospital physician note 6/5/19, stated [AGE] year-old, had recent medical conditions where he has been seen at multiple hospitals, most recently (Hospital named) where he had pacemaker placed on 06/03/2019. He was discharged yesterday to the (facility) but tried to get up during the night and fell resulting in a right [MEDICAL CONDITION]. Patient is A&O (alert and orientated) x 1 (confused, unable to make healthcare decisions) and is very limited with any information on medical history. Patient will be admitted to surgical floor for further treatment and evaluation. Ordered [MEDICATION NAME] (narcotic pain medication) and [MEDICATION NAME] (narcotic pain medication) PRN (as needed) for pain. [MEDICATION NAME] (medication given for nausea) for nausea. Review of the hospital physician Pre-Surgical Assessment, dated 6/5/19, stated (Resident #11) hemoglobin (red blood cells) is stable in the 10 range. This was Resident #11's normal hemoglobin blood level, he had a [DIAGNOSES REDACTED]. Review of the hospital Operative report, dated 6/5/19, stated Procedure: Open reduction internal fixation intertrochanteric [MEDICAL CONDITION]. Review of the hospital physician note, dated 6/6/19, stated The patient was seen this morning and the nursing staff called me with critical results of his hemoglobin being low at 5.9 (normal= 11.5 to 18.0, the residents normal was around 9 to 10). He is chronically anemic around 9. The patient was given 2 units of blood. Chronic [MEDICAL CONDITION] due to MDS (medical [DIAGNOSES REDACTED]. Due to blood loss during the residents right hip surgical repair, he received 2 units of blood. Review of the hospital lab, dated 6/5/19, revealed the resident's hemoglobin was 9.3 (acutely low, required blood 2 [MEDICAL CONDITION]). Review of the hospital physician note, dated 6/6/19, stated Hypertension, Partially controlled. There is likely an element of pain (caused by the right [MEDICAL CONDITION]). Review of the facility Investigation, dated 6/5/19, revealed It was determined that this injury was not the result of abuse, neglect or mistreatment but likely a fall. Staff had appropriately assessed his risk for falls and implemented fall prevention interventions. Observation was done on 6/11/19 at 12:18 p.m., of Resident #11 who had returned to the facility, sitting in his wheelchair in the dining room for his noon meal. When this surveyor asked the resident if he had any pain he said, yes, it's about a 7 to 8 now. It was a 10 when I got hurt (on 6/5/19 when he fell and received a fracture of his right hip). During an interview done on 6/7/19 at 11:30 a.m., MDS Nurse RN P was asked by this surveyor if staff were able to move a resident closer to the nurses desk during the night shift if they thought they were at risk for falling, she stated, Nurse's can make the judgement to move resident closer to the station. During an interview done on 6/11/19 at 1:50 p.m., Nurse, LPN M stated I admitted him, he was confused, no pain, good vital signs. The hospital did not give me a report on him, the EMT's (Emergency Medical Transport) did have a packet of information on him when he was admitted ; I just scanned over it, I was in the middle of passing meds (medications). I think he did come with a red band (on his arm) from the hospital which means he was a fall risk. I did know he was a fall risk. He was getting kind of restless; he was confused he kept tell me what kind of tractor he was driving. He did have a Foley catheter in. He kept throwing his legs out of the bed, he kept sitting at the side of his bed. I talked to him and told him what he was here for and what time of night it was, I put floor mats down, his bed was way low. We were going to put him in the Geri chair but we decided no. I did not implement (put the resident in the Geri chair and bring him to the nurses station), but the CNA's did check on him frequently. You can move someone out of a room and put another one in there; I don't know why I did not put him closer to the station. I did not put him in a chair Geri chair or wheelchair) and bring him to the station, I guess I thought he would just go to sleep. I think it could have been prevented if I would have had him in a Geri chair up by us. We can call in a CNA for one-on-one but usually they don't come. We can call the DON, but I didn't feel he was that restless. During an interview done on 6/11/19 at 2:15 p.m., CNA L stated I was in his room because we have one in the room that can be a bugger at night, he was not being a bugger that night. The resident I introduced myself, anybody new we check on them. The other CNA told me he was turning in bed, his legs were going and he was being restless. I wasn't his Aide (CNA), I should of mentioned something about we should of gotten him up. I have been here [AGE] years. It possibly could have been prevented if we put him in a Geri chair or a wheelchair and set him were we usually set other people when they are not staying in bed. If I am the Aide on the hall I say what I should do, but if I am not the Aide on the hall, I don't want to boss them (other staff members). During an interview done on 6/11/19 at 2:27 p.m., CNA K stated We had lunch between 10:00 p.m. and 10:30 p.m. (on 6/5/19). We did not know if we wanted to leave him in his room. We ended up taking pillows and cradling him in bed because the Geri chair was not assigned to him (the resident); Nurse M told us the Geri chair was not assigned to him. We left it in there so if we decided to use it, it would be right there. We could have used a shower chair. It was always my understanding we cannot give another resident someone else's equipment. I guess we could have used a shower chair. It is a chair made out of PVC-like looking stuff, it's like a normal chair. We had other rooms available by the nursing station, we did make a comment to the nurse (Nurse M) and she agreed with me. This was when he was being fidgety earlier in the night. We did not put the other residents in his room in the Geri chair, we just left it in there. I guess it could have been prevented if we would have put him in the Geri chair and brought him up to the station. During an interview done on 6/11/19 at 2:46 p.m., CNA N stated I was in there (in the residents room frequently on 6/4/19-6/5/19) because they (EMT's) said he was restless and confused. He fidgety, sometimes he was trying to go off the side, he was two assist (for transfers). CNA K and I brought the Geri chair down, we did use it and didn't put the other residents in the room in it. We were going to put him in that chair and bring him back out up where we were setting. I have heard before we can't use that chair because it was someone else's. (CNA K) had said we could go downstairs and get a chair, I said just take that one. I think it could have been prevented if we would have just got him up in the Geri chair. I had said something to the nurse (Nurse M), but nothing happened. During an interview done on 6/11/19 at 1:10 p.m., the Director of Nursing (DON) was asked by this surveyor what preventive measures does the facility put in place for a resident with a history of falls and who is agitated and restless; DON stated We look into pain, offer food, offer the bathroom, give medications for pain and agitation and we have moved them closer to the nursing station. During an interview done on 6/11/19 at 3:05 p.m., the Administrator was asked by this surveyor if Resident #11's fall could have been prevented and she stated I don't' think so, I think that all the staff that were in there, getting the mat in front of his bed, no I do not. I don't know why the Geri chair was brought down. Extra wheelchairs are available in the therapy room, it's locked; I believe the nurses have a key. I would expect them to look in the service room for equipment, the nurses have keys and in the basement. If there is anything available and not in use (including the Geri chair), they can use it. I would think certainly they know that. Approximately 20 minutes later (on 6/11/19 at 3:25 p.m.), the Administrator stated I did check with the one of the nurses on duty and they said they do have access to the therapy room, there is a key on their rings. During a phone interview done on 6/11/19 at 3:10 p.m., Family Member Y stated He's (Resident #11) been going down hill. He thought he was herding his cow's back. I talked to him today (6/11/19), he said he was in a lot of pain.

This citation pertains to MI 760 Based on interview and record review, the facility failed to prevent verbal abuse and involuntary seclusion for one resident (Resident #1) out of 3 residents reviewed for abuse from a total sample of 3 residents resulting in verbal abuse and involuntary seclusion that has caused psychosocial harm and anguish since the incidents occurred. Findings include: A facility face sheet dated [DATE] at 9:46 a.m., reflected Resident # 1 was a [AGE] year old female admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Resident #1 had a Brief Interview of Mental Status Score done on [DATE] and scored 12 out of 15 indicating Resident #1 was cognitively intact. During an interview with Nursing Home Administrator (NHA) " A " on [DATE] at 9:30 a.m., NHA " A " stated that they have substantiated the care concerns of the family member who complained and that LPN " E " has been terminated. There were two issues that were identified: NHA " A " stated the initial investigation discovered a CNA (CNA " H " ) was verbally inappropriate and was suspended pending completion of the investigation. NHA " A " stated that LPN " E " kept Resident #1 from the dining room for " sanitation issues " . According to a facility investigation submitted to the state agency dated [DATE] (no time noted), On [DATE] at approximately 11:50 a.m., Resident #1 ' s daughter called Nursing Home Administrator (NHA) " A " who called the Director of Nursing (DON) " C " to be on the call. The call was placed on speaker phone (with permission) from Resident #1 ' s daughter who had a health care concern that was expressed to her by Resident #1 who called this daughter the evening of [DATE]. This facility report reflected, " Her mother (Resident #1) stated to her that she was rushed to get ready to go to dining room for lunch and felt (her) brief was not on correctly, the aid had told her it was. She (Resident #1) went to lunch in the dining room and either coughed or sneezed which released her urine, causing urine on the floor, in the dining room. Later (Resident #1) was told by a staff member that she could not go to the dining room for dinner because of what happened at lunch ". This document also reflected, " (name of Resident #1) expressed mental anguish initially but by midday of [DATE]th she expressed to the NHA she was grateful and happy the issue was being resolved ". A physician order [REDACTED].#1 reflected that Resident #1 received [MEDICATION NAME] 25 milligrams one table at 10:00 a.m., two hours before lunch. [MEDICATION NAME] is a diuretic (water pill) that treats water retention. During an interview with Resident #1 on [DATE] at 1:00 p.m. in her room, Resident # 1 was asked what occurred on [DATE] around lunch time. Resident # 1 stated, " This is hard to go through again ". Resident #1 was asked if the occurrence bothered her and she stated, " Oh yeah because I have to go through it again. I am feeling .... " and then Resident #1 trailed off and stared out the window to her left. Resident # 1 went on to explain how she was readied for lunch by having an incontinence brief applied. Resident #1 stated that CNA " F " (called her the incorrect name but very similar to the CNA ' s name) helped her apply her brief before lunch. She went on to say CNA " F " needed to place her (Resident #1) in bed to position the brief. Resident #1 stated she had difficultly with the briefs because of several hernias. Resident #1 was noted to be 5 foot 2 inches tall and 281 pounds in her Minimum (MDS) data set [DATE] and a [DIAGNOSES REDACTED]. Resident #1 was asked if she was rushed during this process of applying a brief and Resident #1 stated, "No". Resident #1 was asked if she was aware of the incorrect application of the brief before proceeding to the dining room. Resident #1 stated that she had no idea the brief was not placed correctly until she had an incontinent episode in the dining room and the brief leaked urine. Resident #1 added she remembered the midday meal was served late and she stated this was bad for her because the longer she waited, the more she had to urinate. Resident #1 stated she ate a dry piece of food (she believed a piece of cake and confirmed she was not choking) and coughed. Resident #1 continued, "I felt the need to urinate. I peed on the floor. It was the most embarrassing time of my life.. I wanted to finish my meal before I left the dining room.". Resident #1 self-propelled her wheelchair to her room and a CNA said, "You peed the floor, " and laughed. Resident #1 identified CNA " H " as the staff who made the remark. Resident #1 recalled CNA " H " then said, " You probably peed all the way home ". Resident #1 said, "I felt embarrassed and cried " . Resident #1 was asked if this comment still bothered her and she stated, " Yes, it always will. I felt like such a criminal. Why am I so bad? I didn't understand ". Resident #1 stated when she returned to her room, Licensed Practical Nurse (LPN) " E " told her, " I ' m sorry to tell you since you peed on th floor, you aren't able to go to dinner" . LPN " E " had asked if the incontinence was intentional and Resident #1 told LPN " E " that she had not urinated on purpose. Resident #1 was asked if she wanted to go to dinner in the dining room and she replied, "Yes, so I can be with my friends ". Resident #1 was asked a second time if LPN " E " told her she had to stay in her room and Resident #1 said, " Yes. I felt like a little child in a crib, eating my hot dog. I felt I could not leave my room. I know I could leave my room but I better not". Resident #1 mentioned she was worried about retaliation although this had not occurred. Resident #1 said someone asked her how she felt about (name of the facility) and she told them, " I might leave. I feel like an animal ". An interview with Social Worker (SW) " G " on [DATE] at 11:55 a.m., confirmed she had been conducting daily follow up visits with Resident #1 following the occurrence on [DATE]. SW " G " confirmed that Resident #1 stated CNA " H "made the comment to Resident #1 after her incontinence " There goes (name of Resident #1) peeing all the way home ". SW " G " stated Resident was seeing a Licensed Master degree Social Worker (LMSW). Resident #1 had seen this LMSW in the past and had a professional relationship with her. SW " G " confirmed that Resident #1 had behaviors; however, urinating on purpose on the floor is not one of her behaviors. SW " G " added that Resident #1 had a history of [REDACTED].#1 was told by LPN " E " that she had to stay in her room for dinner on [DATE]. SW " G " stated Resident #1 was confused why this had occurred. A nursing note created by LPN " E " on [DATE] at 3:11 p.m. for Resident #1 documented, "This morning in the dinning (sic) room resident requested ES (extra strength) Tylenol, it was only 6:30 a.m. and she (Resident #1) had her [MEDICATION NAME] only about an hour ago I told her to give it a little bit longer to let the pain pill work, she told me that don't work that only the ES Tylenol works for her bulge (sic) on her leg. She (Resident #1) became very rude and mean when I told her to wait. During lunch in the dinning (sic) room the resident urinated on the floor while she was eating. After lunch when she had returned to her room I went into her room and explained to her that urinating on the dinning (sic) floor wasn't appropriate and explained to her that she wasn't going to eat in the dinning (sic) room for dinner if she wanted to do that. She told me that I didn't understand incont (incontinence) and told me that I was giving her the third degree and told me to get out of her room. She said that she was going to eat in her room then. Will continue to monitor ". Another nurses note for Resident #1 dated [DATE] at 2:23 p.m., a day before the occurrence, created by LPN " E " documented, " Resident (#1) was in the dinning (sic) room this AM. She (Resident #1) was angry and clapping her hands yelling at me to go into the kitchen and tell them that she needed her two cups of coffee and that it was coffee time. I asked her to stop clapping her hands and yelling and she got very upset with me. I told her that the kitchen knows what time to serve drinks and that I wasn't going to tell them how to do their job. She told me that I was being rude to her and told me to bring her the trash can but then asked if that wasn't my job. I told her that she (Resident #1) didn't need to talk to me like that and I left the dining room ". An interview on [DATE] at approximately 9:40 a.m. with Registered Nurse (RN) " D " was conducted and she was asked if she worked on [DATE]. RN " D " confirmed she worked the day of [DATE] in " C " Hall but was not in the dining room to see what had occurred. RN " D " was asked if LPN " E " was angry with Resident #1 and she stated, " Yes. " and added, "Throughout the day, LPN " E " seemed " agitated, annoyed " . RN " D " was asked how staffing was that day and if any other staff members appeared stressed to which RN " D " stated, "Staffing was fine and no other staff member appeared stressed". In a written statement by RN " D " undated. documented , " [DATE] (name of LPN "E" notified this writer that she was having resident (Resident #1) stay in her room for dinner". This statement was signed by RN " D " . RN " D " confirmed she did not ask the reason behind LPN 's decision. RN "D" confirmed she was trained on staff burn out (this past week) but denied LPN " E " exhibited signs of burn out. RN " D " stated that staff worked together and if LPN " E " needed any help she usually asked her for assistance. RN " D " confirmed that LPN " E " did not ask for assistance on [DATE]. RN " D " was asked if a resident was kept in their room against their wishes, was that considered abuse? RN " D " said, " Yes, when it is a punishment ". RN "D" was asked if keeping Resident #1 was in her room as a punishment and RN " D " stated, " Now that I ' m aware of the whole situation, yes". RN "D" was further asked if she heard any remarks from staff about Resident #1 ' s incontinence and she stated she heard chatter but nothing specific or inappropriate. A phone interview on [DATE] at 11:00 a.m. with LPN " E " confirmed she worked on [DATE]. LPN " E " stated she was in the dining room when she noted a large puddle of urine under Resident #1 ' s wheel chair. LPN " E " stated she waited until Resident #1 was in her room when she spoke to her. LPN " E " asked Resident #1 if she realized she urinated on the floor. Resident #1 told LPN " E " she coughed or sneezed and urinated. LPN " E " then told Resident #1 she should stay in her room near the commode. Further phone interview with LPN "E " elicited the following: denied that she required Resident #1 to eat dinner in her room; Resident #1 was upset and told her to leave her room; confirmed staffing was good on [DATE]; was concerned for other residents with urine on the dining room floor and tried to prevent this occurrence; and denied she was angry at Resident #1. LPN " E " was asked if having a resident stay in their room could be a form of abuse and LPN " E " stated, " Yeah, if they didn't want to ". LPN " E " was asked if she was punishing Resident #1 by having her eat dinner in her room. LPN " E " stated, " I am not punishing her (Resident #1) at all ". LPN " E " was asked if she heard any remarks made to Resident #1 by CNA " H". LPN "E" stated, "The remarks were made only to me not near Resident #1 and the remarks were quiet and discreet, just mentioned urine ". Resident #1's care plans were reviewed (no date noted) which stated, " Feeding: (name of resident) feeds herself independently. Provide set up of each meal tray within reach, apply condiments, etc. She (Resident #1) prefers to eat in the large dining room for meals ". An interview by phone with CNA " H " was completed on [DATE] at 11:15 a.m., who confirmed that she worked on [DATE]. CNA " H " stated she was seated at a table in the middle of the dining room when staff came to her and reported the urinary incontinence of Resident #1. CNA " H " stated she then told LPN " E " who remarked that this was not the time or the place to address the incontinence of Resident #1. CNA " H " was asked if she made any comments about the incontinence to Resident #1. CNA " H " denied making any comment. CNA " H " stated she left the facility at 2:30 p.m., before dinner. CNA "H " denied that LPN " E " was acting any differently. Review of a facility policy, revised ,[DATE], titled " Policy Regarding The Prohibition of Abuse, Neglect, and Mistreatment of [REDACTED]. " This policy defines abuse as: 1) " Mental and Emotional Abuse refers to actions which result in humiliation, harassment or threats of punishment or deprivation. Verbal abuse is primary source of mental or emotional abuse and involves the use of oral, written or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend or disability. " 2) " Involuntary Seclusion relates to a type of mental or emotional abuse that involves the separation of a resident from other residents or from his or her room or confinement to his/her room (with or without roommates) against the resident ' s will or the will of the resident ' s legal representative, which is performed for the purpose of infliction of injury, physical harm, or pain or mental anguish. " DON " C " was interviewed on [DATE] at 11:54 a.m. who confirmed that forcing Resident #1 stay in her room was involuntary seclusion. DON " C " explained that her interviews with other facility staff could not confirm CNA " H " was verbally abusive. The allegation of verbal abuse was obtained through interview of Resident #1. This was the reason for the 5 day suspension for CNA "H". The facility 5 day investigation on [DATE] documented that during an interview with CNA " H " , on [DATE] at approximately 7:00 a.m. she stated as she entered the NHA office, " Don't let (name of Resident #1) throw me under the bus, she does not like me, and we have a history ". CNA " H " then stated, " Someone said something to me about a puddle under (name of Resident #1). I told (name of two CNAs ) to address it with LPN " E " and I kept my mouth shut because of my history with (name of Resident #1) ". During an interview on [DATE] at 2:00 p.m. with NHA " A " and DON " C " , NHA "A" stated she will consult with her facility corporation to see what the procedure was on reporting CNA " H " to the state agency. CNA " H " was on a 5 day suspension which will be complete on [DATE]. However, a decision to terminate CNA "H" and LPN " E" was relayed on [DATE]. ( )

Based on observation, interview, and record review,the facility failed to ensure that drug regimens for five sampled residents ( # 1, 2, 7, 11 and 14) out of 6 residents receiving antipsychotic/antianxiety medication out of a total 15 sampled residents were free from medications used without adequate indications for it's use, without adequate monitoring and in the presence of adverse conditions resulting in an increased risk of side effects of falls for residents #14, 11, 7 and 2, and the harmful side effect of tardive dyskinesia (involuntary movement of the jaw) for Resident #1. Findings include: According to the Admission Record dated 4/9/2014 Resident # 1 was a [AGE] year old female resident admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A review of Resident # 1's medical record including the nurses notes, physician orders, and psychotherapy notes along with Behavior Management review notes from 2013 and 2014 was conducted on 5/21/14. According to the Anti-psychotic Medication Flow Sheet dated 6/5/12 , Resident # 1 was ordered the anti-psychotic medication Ability 2 milligrams (mg) by mouth each day on 6/5/12. On 8/13/12 the medication was placed on hold for reassessment. On 8/21/12 the medication Ability was reordered at 2 mg by mouth each day. On 9/4/12 the [MEDICATION NAME] was increased to 5 mg by mouth each day. On 9/14/12 the medication was increased to 7.5 mg by mouth each day. on 9/28/12 the medication was increased to 10 mg by mouth each day. On 4/29/13 the [MEDICATION NAME] was increased to 15 mg by mouth each day. According to information obtained in the medical record on admission, as documented in the Admission Physical dated 4/4/12, there was no admitting [DIAGNOSES REDACTED]. Only one Risk Benefit statement relating to the medication Ability was found in the medical record of Resident # 1 and that was dated 8/22/12. The statement stated that Resident #1 had difficulty adjusting to the facility, wandered about the facility and displayed some paranoia. Resident #1 was started on [MEDICATION NAME] and was better but the high cost to the family required the medication to be discontinued for a short time. Resident #1 was then noted to have increased anxiety and seek her parents. The medication was then reorder. There were no further risk benefit notes in the medical record even though the medication had been increased and Resident #1 had [MEDICAL CONDITION] with a by-pass graft in her admission diagnoses. According to the manufactures warnings as documented in the Geriatric Dosage Handbook 18 th Edition by Lexicomp, residents with cardiovascular disease are at high risk for further [MEDICAL CONDITION] and [MEDICAL CONDITION] (strokes). There is also a statement "[MEDICATION NAME] is not approved for the treatment of [REDACTED]. On 5/22/14 at 11 am the facility social worker (staff B) was asked to provide the AIMS Scales ( abnormal involuntary movement scale which is used to measure movements that are related to the medication's adverse effect . The side effects or adverse effects can be reversible or irreversible). Staff (B) was also asked to provide any other risk benefit statements that were available. It was also noted that there were no orthostatic blood pressures (a measure of the blood pressure when a resident goes from lying to sitting to standing) which should be monitored when a resident is on antidepressant, antianxiety and antipsychotic medications according to the manufacturers of the medications. According to the manufacturer of [MEDICATION NAME] as stated in the Geriatric Dosage Handbook 18 th edition by Lexicomp, "[MEDICATION NAME] has a delayed onset of action and a long half life which may limit its role in treating [MEDICAL CONDITION]. This delay in action and long half life has the potential to cause orthostatic [MEDICAL CONDITION] and should be monitored". On 5/21/14 at around 3:30 PM Staff (B) provided an AIMS sheet dated 6/5/12 which did not list any abnormal movements to all but one area which was scored as a one or minimal for the tongue movement. The next was done on 10/27/12 which marked a one for lips and perioral area, and tongue movements. On 1/17/13 there was only one marked for the jaw movement all others were 0. On 4/27/13 the jaw was marked with a one; all others were 0. On 4/16/14 there was a increase in abnormal movement in that the jaw was marked 2 or mild, the lower extremities were marked a 2 ( included the legs, knees, ankles and toes showed involuntary movementa) and the area #8 which stated severity of movement was marked a 2. The documentation showed an increase in the abnormal movement or tardive dyskinesia. According to the manufacturer as in the Geriatric Dosage Handbook, "[MEDICATION NAME] may cause extrapyramidal symptoms including pseudoparkinsonism, and tardive dyskinesia". Even though the AIMS showed an increase in the extrapyramidal symptoms, the physician continued to increase the dosage of the [MEDICATION NAME] without any current risk benefit analyis. Resident # 1 was noted, while being observed on 5/21/14 at 3:05 p.m., on 5/22/14 at 8:00 a. m. and 5/23/14 at 8 a.m. with the constant jaw movement that would appear to be moderate or a 3 on the AIMS. On 5/21/14 a review of the physician order [REDACTED]. The reason was for [MEDICAL CONDITION]. On 3/25/14 the Physician order [REDACTED]. On 4/22/14 the [MEDICATION NAME] was dropped to 5 mg per day and on 5/14/14 the [MEDICATION NAME] was discontinued. On 5/21/14 Resident # 1 was noted to exhibit the continuous involuntary abnormal movement of the jaw . On 5/22/14 at around 10 a.m. the Director of Nursing (staff A) was asked to provide a facility policy on antipsychotic medication usage, to provide nursing notes related to the reasons for the increase in the [MEDICATION NAME] dosage on 4/29/13, and to provide monitoring documentation of the orthostatic blood pressures for the use of [MEDICATION NAME] and the antidepressant [MEDICATION NAME]. On 5/22/14 Staff (A) provided nurses notes from 1/17/13 to 5/14 and the notes did not justify nor show a reason for the increase in the [MEDICATION NAME] on 4/29/13. There was no documentation in the notes about the abnormal involuntary movements noted on the AIMS which were only completed every six months. Staff (A) could not produce any regularly documented orthostatic blood pressures because they were not monitoring the blood pressures. Staff (A) provided a policy on "Antipsychotic Drugs" revised 4/28/2005, The policy stated, "It shall be the policy of this facility that based on a comprehensive assessment of a resident, the facility will only use antipsychotic medications to treat a specific condition. (see INTERPRETIVE GUIDELINE 483.25 (1) (2) (i) for a list of indications) It further stated that "Antipsychotics will be considered only after documented behavioral programing has failed. The need for the medication will be periodically reevaluated every three months and a resident will be continually monitored for adverse effects include the AIMS test upon initiation and every six months. If Tardive Dyskinesia develops, the physician must determine the risk vs benefit ratio and decide whether the antipsychotic is to be continued. If the antipsychotic is to be continued, the risk vs benefit must be documented in the progress notes by the physician". This policy was not followed since there was only one documented risk vs benefit in the medical record dated last 2012. Three behavior management review sheets were provided dated 6/6/13, 7/3/13 and 10/28/13. It listed the target behavior crying, looking for parents, and [MEDICAL CONDITION] for the rationale of prescribing the Abilfy. On the sheet's Root cause, it listed confusion, r/o (rule out) pain, offer fluids, food and bathroom for probable erasons for teh behaviors. Under the recommendation sections the following was listed: continue redirection, reassure, request increase in [MEDICATION NAME]. Itw as unclear what type of [MEDICAL CONDITION] was exhibited by Resident #1 and if the behaviors were distressing to the resident. Resident # 1 was observed several times during the period of 5/21/14 through 5/23/14. She was observed in the Corner Cove, a closed activity room for the residents with behaviors. On 5/21 at 3:05 p.m. she was noted to sit still in her chair in the area but she had continuous jaw movement which was noticeable. On 5/22 and 5/23 at around 8 am she was noted walking from her room to the Corner Cove to start her day and eat breakfast in the room. Her gait was slow but steady and she was not assisted by the staff. She found her way from her room to the corner cove without help. Her constant jaw movement was present all day. Resident #1 was also seen going from the Corner Cove to the bathroom which was around the corner and needed some direction at those times but she found her way back to the Cove. The resident received the medication [MEDICATION NAME] for [MEDICAL CONDITION]. The facility failed to monitor the side effects of the medication and even though the AIMS test showed an increases in abnormal involuntary movements the medication was increased without justification. There were no risk vs benefit statements as required by their facility policy and the documentation for the increases were not substantial to indicate the need for the increase. The medication [MEDICATION NAME] was discontinued on 5/14/14; however, the abnormal involuntary movement of the jaw continued as Resident # 1 had suffered the harmful adverse effects of the medication. According to the facility Admission Record dated 7/11/13 Resident # 11 was an [AGE] year old male admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Later a [DIAGNOSES REDACTED]. A review of the medical record of Resident # 11 documented in the physicians orders that the resident was ordered and was taking [MEDICATION NAME] 50 mg by mouth twice a day. [MEDICATION NAME] is an atypical antipsychotic medication. According to the manufacturer the medication can cause a drop in blood pressure and should have orthostatic blood pressures monitored. Because of the specific black box warning relating to use in residents with cardiovascular disease, a risk vs benefit statement should be documented initially and with any increase in the dosage of the medication. On 5/23/14 a review of the behavior tracking sheets provided target behaviors but further review of the medical record did not provide documentation of orthostatic blood pressures or any risk vs benefit statements in the progress notes. These are required by the facility policy on [MEDICAL CONDITION] medications which was provided by Staff (A) on 5/22/14. On 5/22/14 Staff (A) was ask to provide the behavior monitoring sheets, orthostatic blood pressures and the risk vs benefit statements for Resident # 11. The behavior sheets were provided there was no documented orthostatic blood pressures nor the risk vs benefit statements from the physician. According to the minimal (MDS) data set [DATE], Resident # 11 is confused and scored 3 out of 15 for cognition 15 being cognitively able to make decisions and adheres to safety. According to the balance section of the minimal data set of 4/9/14, Resident # 11 is a 1/1 for balance or not able to walk without assist of 1 and a walker for balance. The lack of balance places Resident # 11 at risk for falls and the addition of potential orthostatic [MEDICAL CONDITION] also added to the potential for falls. Resident # 11was taking an antipsychotic medication ([MEDICATION NAME]) which had the potential side effect for falls and there was no monitoring of his orthostatic blood pressures. There was no risk vs benefit statements required by the facility policy to justify the use of [MEDICATION NAME] and it's side or adverse effects. ( ) According to a facility face sheet dated 4/24/14 at 12:04 p.m., Resident #2 was a [AGE] year old male admitted readmitted into the facility on [DATE] with the cumulative Diagnosis: [REDACTED]. A "Gradual Dose Reduction Tracking Report" dated 4/28/14 reflected Resident #2 was started on [MEDICATION NAME] for the [DIAGNOSES REDACTED]. Elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotic drugs are at an increased risk of death. [MEDICATION NAME] is not approved for the treatment of [REDACTED]. reference: http://www.drugs.com/pro/[MEDICATION NAME].html. Resident #2 was diagnosed with [REDACTED]. There was no mention of [MEDICAL CONDITION]. [MEDICAL CONDITION] is a mental disorder characterized by symptoms, such as delusions or hallucinations that indicate impaired contact with reality. Reference: http://dictionary.reference.com/browse/[MEDICAL CONDITION] Review of "(Name of consulting agency) Progress Notes", dated 12/29/13 to 5/5/14, there was no notation of hallucinations or delusions. The facility provided 3 "Behavior/Mood Symptom Tracking Tools." but none had Resident #2's name, there were no dates, there were no resident specific behaviors and there was no notations of behaviors of Resident #2. Review of the consent for [MEDICATION NAME] (no date noted) reflected that Resident #2's behaviors for the medication were, "danger to self and others, fighting, hitting, swearing". During an interview on 5/21/14 at 2:10 p.m. Social Worker "B" confirmed that orthostatic blood pressures were not being monitored for Resident #2 while being on [MEDICATION NAME]. Resident #2 was able to ambulate in his room and the hall with the assist of two persons. SW "B" was asked what behavioral interventions were tried before beginning [MEDICATION NAME]. SW "B" was unable to answer this question. SW "B" stated that she had begun working at the facility at the end of 2013. SW "B" was asked what Resident #2's behaviors were and she stated that Resident 2 was impulsive and had a "personal space issue". Review of facility Interdisciplinary Progress Notes reflected that Resident #2 was having angry outbursts towards others including other residents, was impulsive and experiencing [MEDICAL CONDITION] (OCD) behaviors. According to a "(name of consulting agency) Progress Notes", dated 12/29/13 (no time noted) reflected, "His (Resident #2) OCD is what he (Resident #2 centers his routine and purpose on.. Resident #2 is very particular and "does not like change... Resident #2 requires a lot of personal space". Resident #2 was not experiencing [MEDICAL CONDITION]. Resident #2 had dementia. Resident #2 was not being monitored for behaviors, their root causes, and no behavioral interventions and their evaluation. Resident #2 was not being monitored for orthostatic [MEDICAL CONDITION] putting him at a higher risk for a fall. Resident #2's facility care plan dated 2/28/14 reflected, "high risk for falls related to history of fall with [MEDICAL CONDITION], history of weakened right sided hemiparalysis that requires staff assist with all transfers and ambulation". This citation pertains to MI 4010 According to a facility face sheet dated 3/14/14 at 8:13 a.m., Resident #14 was an [AGE] year old female readmitted into the facility on [DATE] with the Diagnoses: [REDACTED]. A facility document titled, "Behavior/Mood Symptom Tool" dated 3/2014 reflected that beginning on 3/11/14, Resident #14 was exhibiting, "hitting table and stating 'I am God', standing and yelling about God, telling others to 'shut the f---- up', trying to hit others, grabbing other residents, refusing to sit, throwing food.". "Behavior/Intervention Monthly Flow Sheet" for 4/2014 reflected Resident #14 was having "paranoid delusions, kicking, striking out/hitting, yelling, pinching, resident a danger to others and staff, and sexual verbalization". These behaviors continued up to 4/6/14 when the documentation of behaviors for Resident #14 stopped. According to the facility document titled, "Behavior/Mood Symptom Tool" dated 5/2014, from 5/2/14 to 5/4/14 Resident #14 was experiencing sleepiness and the intervention was "try to arouse". An interview with Resident #14's anonymous family member on the phone on 5/22/14 at 9:05 a.m. revealed that several members phoned Resident #14 the morning of the past several days and they felt that Resident #14 sounded "stoned". Not at all themselves. A few days later, the family member called again in the morning and Resident #14 mumbled while she spoke. This family member could not remember if any family member talked to anyone at the facility about the concern of oversedation of Resident #14. This anonymous family member also stated that the Resident #14 fell quite a few times during her stay in the facility. During an interview on 5/22/14 with Director of Nursing (DON) "B", DON "B" was asked when [MEDICATION NAME] was begun for Resident #14. DON "B" reflected that [MEDICATION NAME] 0.5 mg (milligrams) by mouth every 6 hours was started on 3/9/14, 4 days after Resident #14's readmission into the facility. DON "B" then recalled that [MEDICATION NAME] 0.5 mg was changed to twice a day and also given every 4 hours as needed. DON "B" stated the [MEDICATION NAME] for Resident #14 was discontinued on 4/29/14. "[MEDICATION NAME] is a medication is used to treat anxiety. [MEDICATION NAME] belongs to a class of drugs known as benzodiazepines which act on the brain and nerves (central nervous system) to produce a calming effect. Some side effects of [MEDICATION NAME] can be : Drowsiness, dizziness loss of coordination, headache nausea, blurred vision, change in sexual interest/ability, constipation heartburn or change in appetite may occur. If any of these effects persist or worsen, tell your doctor or pharmacist promptly. Remember that your doctor has prescribed this medication because he or she has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects. Tell your doctor right away if you have any unlikely but serious side effects, including: mental/mood changes (such as hallucinations, depression thoughts of suicide), slurred speech or difficulty talking, vision changes, unusual weakness, trouble walking, memory problems, signs of infection (such as fever, persistent sore throat, trouble breathing (especially during sleep) ". Reference used: "http://www.medicinenet.com/[MEDICATION NAME]-oral/article.htm". [MEDICATION NAME] was routinely administered during the time period Resident #14 experienced falls and was not assessed as a possible contributing cause for Resident #14's repeated falls. The [MEDICATION NAME] was given upon admission before any behavioral interventions were implemented . [MEDICATION NAME] was given in the presence of two acute infectious conditions causing [MEDICAL CONDITION]. A facility document titled, "(Name of physician) Routine Visit" dated 3/6/14 (no time noted), reflected Resident #14 was alert and oriented to person, place and time but "forgetful". A facility document titled, "(Name of physician) Routine Visit" dated 3/19/14 (no time noted) reflected that Resident #14, was "very confused, [MEDICAL CONDITION]. Assessment: [MEDICAL CONDITION]. "[MEDICAL CONDITION] is a serious disturbance in a person's mental abilities that results in a decreased awareness of one's environment and confused thinking. The onset of [MEDICAL CONDITION] is usually sudden, often within hours or a few days. [MEDICAL CONDITION] can often be traced to one or more contributing factors, such as a severe or chronic medical illness, medication, infection, surgery, or drug or [MEDICAL CONDITION]. The symptoms of [MEDICAL CONDITION] and dementia can be similar and input from a family member or caregiver may be important for a doctor to make an accurate diagnosis." Reference used: http://www.mayoclinic.org/diseases-conditions/[MEDICAL CONDITION]/basics/definition/CON- 982 A facility "Medication Observation Record" for Resident #14 dated 3/2014 reflected that Resident #14 was receiving [MEDICATION NAME] 250 mg one daily for 4 days for Pneumonia (an antibiotic) from 3/8/14 to 3/11/14. Resident #14 also received Bactrim DS (double strength) one by mouth twice a day for seven days from 3/21/14 to 3/27/14 for a urinary tract infection. Both infections can cause symptoms of [MEDICAL CONDITION] for Resident #14. Resident #14 received an anti anxiety drug since admission to the facility with the [DIAGNOSES REDACTED]. [MEDICATION NAME] was routinely administered during the time period Resident #14 experienced falls and this was not considered to contribute to Resident #14's falls. The [MEDICATION NAME] was given upon admission before non pharmacological interventions were implemented for behaviors. There was no root cause for the behaviors for Resident #14. [MEDICATION NAME] was given in the presence of two acute infectious conditions which were causing [MEDICAL CONDITION]. ( ) Resident # 7 was a [AGE] year old female re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident # 7's [MEDICAL CONDITION] medications listed on the physician order [REDACTED].# 7 was on the the anti-psychotic medication [MEDICATION NAME] 50 milligrams (MG), 1 tablet, to be given by mouth once per day with the original physician order [REDACTED]. According to the Drug Information Handbook, American Pharmacist's Association drug reference, copyright 2012, [MEDICATION NAME](Quetiapine), an antipsychotic agent is to be monitored for abnormal involuntary movement scale (AIMS), and has the potential to affect orthostatic [MEDICAL CONDITION]. On 5/21/14 at approximately 3:05 p.m., an interview was conducted with staff nurse 'D' to request documentation copies to verify the medication [MEDICATION NAME] was being monitored adequately for potential adverse affects. Staff nurse 'D' indicated AIM's is done annually and will begin to be monitored quarterly per new directive. Staff 'D' indicated he would look for orthostatic blood pressures as he was not doing them; however, thought nursing may be. On 5/21/14 at approximately 3:45 p.m., staff nurse 'D' presented documentation of orthostatic blood pressures which he stated were being done quarterly related to resident # 7's "Fall Risk". On 5/21/14 at approximately 3:45 p.m., an interview was conducted with staff 'B' to request the current facility policy used to address monitoring of potential side effects of ant-psychotic medication. The facility policy, undated was received and failed to indicate the parameters for timely orthostatic blood pressure checks. The AIM's testing was indicated to be done on initiation of any anti-psychotic medication and every 6 months following. These were not implemented. ( )