Every finding on record at Villa at Beecher Place

This Citation Pertains to Intake Number 3107980. Based on observation, interview and record review, the facility failed to ensure that interventions were implemented to ensure mechanical lifts were 1) Identified by type, brand and lift capability (weight); and 2) Inspected routinely for safe lift function for all 22 mechanical lifts used on the 200, 300 and 400 units, including the use of a mechanical lift to transfer one resident (Resident #7). Findings Include: Resident #7: A record review of the electronic medical record for Resident #7 indicated an admission to the facility on 6/30/2021 with diagnoses: Morbid obesity, heart failure, CPD, Bipolar disorder, anxiety, arthritis, polyneuropathy, gout and history of falls with fracture. The Minimum Data Set/MDS assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status/BIMS score of 13/15 indicating mild cognitive decline and the resident was dependent on staff assistance with transfers and bathing. On 8/17/2026 at 1:59 PM, Resident #7 was observed lying in bed awake. She said she was frustrated because she missed her showers on 8/12/2026 and 8/15/2026. She said during an attempted transfer via a mechanical lift and staff assistance from the bed to a shower bed, she said the lift started to make a noise during the transfer and she felt like she was tipping and returned to her bed. She pointed at a transfer sling lying in the corner of her room and she said that it was not a shower sling and she needed a bariatric shower sling to transfer to the shower bed. The resident was asked where the mechanical lift was and she said she thought it was in the hall. On 8/17/2026 at 2:50 PM, two mechanical lifts were observed in the 300 short hall near the nurses desk. An inspection sticker on the 1st lift said the inspection was due 6/20/2025 and the last inspection was 1/28/25. The cross bar on the lift was broken; a crack ran the width of one side of the plastic bar covering the metal equipment. Underneath a portion of the mechanical lift bar was a weight capacity and it said 850 lbs; the lift had the brand Linak HB-52-004 identified on the handheld controls for the lift. There was no additional brand identification on the lift. There was an additional similar mechanical lift with a sticker that said it was last inspected1/28/25 and was due for another inspection on 6/20/2025. On 8/17/2026 at 2:50 PM, Nurse Aide J was interviewed about the 2 mechanical lifts stored in the hallway. The Aide was asked how to identify the lifting weight capability of the mechanical lifts and said she thought it was listed on the lift. The weight was identified on a sticker underneath a bar of the lift and it said 850 lbs. Nurse Aide J was asked about the inspection stickers on the lift and identified the sticker that said the lift was last inspected on 1/28/25 and due 6/20/25. The Maintenance Director K was interviewed on 8/17/2026 at 3:50 PM and he provided copies of a Calibration/Test Report for the scales function on the mechanical lifts: Linak 1143582-0005; Linak1143582-0009; Linak 1143582-0010; Linak 2548420-0054; Linak CBJ2026-02; Linak n/a #2; Direct Supply E119922-0053 (a chair scale, not a lift); Detecto E32724-0053 located in the Beauty Salon- not a lift; Linak WWW007709-0006; Linak WW107689-0093; Linak WW116317-0002; Linak WW126375-0009. Ten of the reports were for scale weight calibrations for the Linak mechanical lifts and 2 of the reports were for other identified scales used to weigh the residents. During the interview on 8/17/2026 at 3:50 PM, the Maintenance Director was asked if there were documented inspections of the mechanical lifts for proper function of the lifts in addition to the scales calibration reports. He said he had a list of the lifts and would provide a copy of the inspections. On 8/18/2026 at 9:00 AM, the Maintenance Director K provided a copy of a Maintenance Log: Hoyer log written at the top. It included 16 entries. The mechanical lifts did not have an identifying name and a column titled, Repair concern was listed as Good for all but 2 lifts: #10 said repair/out of order and #13 said repair with no additional comments. There was no date as to when the lifts were inspected or who completed the inspections. Beneath the Parts Ordered heading, 7 lifts had writing that was not readable. The Maintenance Director was asked about the document, and he said numbers on each lift corresponded to each entry on the document 1-16. On 8/18/2026 at 3:45 PM, the Maintenance Director K also provided a document titled, Invacare Mechanical Lifts Inspection, RPL 450, 600, RPS 350, [NAME] and Roze. He said the lifts were from Invacare. A copy of an undated and unsigned document titled Instructions listed Invacare RPL 450, 600, RPS 350, [NAME] and Roze on it and provided Conduct mobile lift safety inspection the document had 34 specific inspection instructions, including Follow manufacturer's recommendations for lubrication type and frequency. During a review of the Invacare Mechanical Lifts Inspection, RPL 450, 600, RPS 350, [NAME] and Roze document, it was identified that Invacare was a specific brand and the facilities lifts were not Invacare. The types of lifts identified in the document were specific to Invacare products. Per the Calibration/Test Report 10 of the mechanical lifts were Linak the remainder were not identified. On 8/19/2026 at 9:45 AM, a mechanical lift in the hallway of the 3rd floor was observed to have a 3 written on it and the handheld control said, Linak HB-52-004. On 8/19/2026 at 11:37 AM, the Administrator was interviewed about the Mechanical lifts, as they were not the brand name as identified in the inspection report. She said the Maintenance department was working to identify and inspect each mechanical lift. A review of the facility policy titled, Full Body Mechanical Lift Equipment and Guideline, effective date 3/22/2018 provided, Purpose: This outlines the actions that re required for mechanical lift application and use. Always read the manufacturer's guideline prior to using any mechanical lift or equipment for the care and service of our residents. Refer to the Resident's Care Plan or Care Card to determine the intervention for transfer and mobility assistance; Operating the full body mechanical lift will require 2 trained caregivers. Place the sling under the Resident and make sure it is centered. Defer to the manufacture's guideline for sling care. Comply with all parameters of this guideline and defer to the manufacture's guidelines prior to use of all mechanical lifts.

This Citation Pertains to Intake Number 3093672Based on observation, interview and record review, the facility failed to ensure that residents' rooms, hallways and common areas had 1) Comfortable air temperatures; 2) Functioning air conditioning/PTAC units that were in good repair; and 3) Residents' rooms did not have leaking sinks in their bathrooms and standing water on the floors. Findings Include: On 8/17/2026 at 1:45 PM, during a tour of the facility on the 300 unit, many rooms were noted to be very warm and the air conditioning units/PTAC (packaged terminal air conditioner) units were not all functioning appropriately; A PTAC (Packaged Terminal Air Conditioner) is a single-chassis HVAC system containing the compressor, condenser, evaporator, fan, and controls in one sealed cabinet.During the facility tour on the 300 unit following was identified in the residents' rooms:301- the air register was not working; a fan was on and the temperature in the room was 76 degrees F. 306- the air conditioning/PTAC unit was not on. The room was stuffy and the temperature on the thermostat said the room was 78 degrees Fahrenheit/F.309- the PTAC unit was blowing warm air. A resident in the room stated, It's hot in here. It shouldn't be 81 it should be 77. The thermostat said the room temperature was 81 degrees F.311- the room temperature was 80 degrees F and the PTAC unit was not on.313- the room temperature was 80 degrees F and the PTAC unit was blowing warm air.316- the sink in the bathroom was leaking; a wash basin was filling with water under the sink.317- the PTAC unit was dusty and rusting on the top grates and appeared sharp.318- a wash basin was under the sink in the bathroom and appeared stained with dried water from the sink.319- a fan was running in the room; it had long strands of brown dust blowing from it. The window had been leaking into the room the day prior.322- the air conditioning unit was not working and the room was stuffy. In the bathroom, a hand sanitizer was partially on the wall and covered in drywall dust.334- the temperature in the room was 80 degrees F. and the resident stated, It's too warm.During the tour of the 300 unit, on 8/17/2026 at 2:37 PM, the day room was noted to be very warm, and the temperature was 78 degrees F. The short hallway near the nurses desk did not have air circulating or blowing from the overhead vent and was very warm. On 8/17/2026 at 3:05 PM, Maintenance Assistant L was asked about the resident's, day room and hallways being very warm and said work orders would need to be put in if the rooms were too warm.On 8/17/2026 at 3:50 PM the Maintenance Director K was interviewed about the lack of ventilation in the hallway and several rooms on the 3rd floor, with some PTAC units not working or blowing warm air with many of the temperatures in the upper 70's, 80 and 81 degrees. Some of the residents were verbalizing it was Too hot. He said the facility had placed a work order to buy new PTAC units.On 8/19/2026 at 10:04 AM room [ROOM NUMBER] was observed to be very warm with the wall temperature reading 78 degrees F. The resident stated, It's hot. I can't breathe.On 8/19/2026 at 10:10 AM, standing water was observed on the floor entering room [ROOM NUMBER]. The bathroom also had standing water on the floor. There were several towels on the floor against the base of the north wall in the bathroom. Housekeeper N came to the doorway of the room and was asked about the water on the floor. She said it appeared there was a water leak coming form the bottom of the wall. She said she had just talked to the Maintenance Director K about it, as she had not seen it leak like that previously.On 8/19/2026 at 11:37 AM, the facility Administrator provided copies of two invoices for new PTAC units. She also provided a list of where the units were to be placed: common area- Main building 4 units; room [ROOM NUMBER] and room [ROOM NUMBER]. There were no PTAC units purchased for the 3rd floor resident rooms. The Administrator was asked about fans for the residents' rooms, and she said the facility did not provide fans, but a few of the residents brought their own fans from home. When asked when the PTAC units currently purchased would arrive, she said they were ordered 7/30/2026 would arrive in October 2026. Discussed with the Administrator that many residents were voicing that they were uncomfortable and the facility was too hot for them.During the interview with the Administrator on 8/19/2026 at 11:37 AM, she also provided a copy of a temperature log with dates ranging from 6/29/2026 to 8/14/2026. The temperature log identified areas such as 3rd floor east, 3rd floor north and 3rd floor west. This was the same for the 2nd and 4th floor resident areas. There were no identified temperatures in specific locations on each floor and there was no listing of room temperatures. The temperature log document included the following: All buildings are required to maintain an ambient temperature throughout resident and patient areas in a temperature range of 71 to 81 degrees Fahrenheit. the variance in temperatures must not adversely affect resident or patient health and safety. While meeting the requirement for the indoor air temperature, it is also important to consider the effective air temperature and the impact that humidity and air movement in the building may be having on comfort.

This Citation Pertains to Intake Number 3093672.Based on observation, interview and record review, the facility failed to ensure that wounds were assessed, monitored, and that appropriate interventions were in place, including hand hygiene, during wound care for one resident (Resident #13) of 3 residents reviewed for wounds. Findings Include: Resident #13:A record review of the Face Sheet and Minimum Data Set/MDS assessment indicated Resident #13 was admitted to the facility on [DATE] with diagnoses: Spinal narrowing, history of a stroke, difficulty swallowing, acute kidney failure, bipolar disorder, anxiety, depression, Schizophrenia, history of falls, parkinsonism, protein calorie malnutrition.The MDS assessment dated [DATE] revealed Resident #13 had moderate cognitive loss with a Brief Interview for Mental Status/BIMS score of 10/15, and the resident needed assistance with all care.On 8/18/2026 at 10:25 AM wound care for Resident #13 was observed with Nurse G and Nurse Aides H and I. The resident was observed lying in bed on his side and the Nurse Aides were assisting him with care as his incontinence brief was soiled. Nurse G entered the room, and the soiled incontinence brief was folded over and left next to the residents right buttock.During the wound care observation on 8/18/2026 at 10:30 AM, Nurse G said the resident had several wounds: coccyx, right and left ischium, and both heels. The following was identified: The resident was observed not to have a dressing on the left ischium wound that was approximately 1.5 width x 2 cm length with dark black eschar (dead tissue).The right ischium wound had a soiled dressing dated 8/16/2026: the wound was approximately 1 cm x 2.5 cm with dark black eschar.The coccyx dressing was dated 8/18/2026: the wound was approximately 6 cm x 1.5 cm open with stringy yellow slough (dead tissue) and 1.25 cm deep. The area surrounding the wound was red.The left heel dressing was dated 8/16/2026: the wound was approximately 0.5 cm x 1.5 cm. With 2 areas with black necrotic tissue.The right heel dressing was dated 8/17/2026 and had a gauze wrap falling off it: the wound was approximately 1.0 cm x 1.5 cm with dried flaky skin on top.A 4x4 dressing was observed half on Resident #13's left upper calf. During the continued observation of wound care for Resident #13, Nurse G sanitized her hands and applied gloves before beginning the wound care. She then removed the coccyx dressing. The nurse did not remove the soiled gloves, perform hand hygiene and put on clean gloves before cleansing the wound. She removed the soiled gloves but did not perform hand hygiene before putting on clean gloves and applying a new dressing to the resident's coccyx wound. The Nurse proceeded to remove soiled dressings and cleanse the resident's wounds one at a time but did not replace her gloves until she applied a new dressing. She did not perform hand hygiene during the wound care observation of 6 wounds.Nurse G was asked about the missing wound dressing to the left ischium, and she confirmed it was not present. During the interview and observations of wound care on 8/18/2026 at 10:50 AM, Nurse G was asked about the dressing on Resident #13's left calf and said she was not aware of a wound to that area. She removed the undated dressing and a long thin dark purple area was observed. It was approximately 0.5 cm x 4 cm with a reddened area on the distal end. The Nurse said she would look into it. A record review of the physician orders for Resident #13 identified the following: Wound Care-Coccyx: Cleanse area, pat dry, pack wound with Dakin's solution (a bleach solution)- soaked gauze, and cover with dry dressing. Change daily and as needed, every day shift, start date 8/14/2026. Wound care-Left ischium-Cleanse area, pad dry, apply medihoney to wound bed, cover with dry dressing. Change daily and as needed, every day shift, start date 7/15/2026. Wound care-Right Ischium-Cleanse area, pat dry, apply medihoney to wound bed, cover with dry dressing. Change daily and as needed, every day shift, start date 7/15/2026. Wound care-Left heel- Cleanse area, pat dry apply betadine moistened gauze to wound bed, cover with dry dressing. Change daily and as needed, every day shift, every other day, start date 7/29/2026. Wound care-Right heel-Cleanse area, pat dry, apply medihoney to wound bed, cover with dry dressing. Change daily and as needed, every day shift, start date 7/15/2026. A review of the Treatment Administration Records for Resident #13 revealed wound care with dressing changes was not provided to the resident's coccyx, left ischium, or right ischium on 8/15/2026 or 8/17/2026. A review of the progress notes for Resident #13 identified the following: 8/15/2026 at 6:38 PM provided, Wound care-Coccyx. resident refused to be laid back down, and a progress note dated 8/15/2026 at 6:40 PM provided, Wound care-Left ischium. resident refused to be layed back down. There was no mention of the wound care to the right ischium.8/17/2026 at 4:14 PM, Wound care- Right ischium-. refused. There was no mention of the left ischium or coccyx wounds. There were no additional notes indicating wound care was attempted more than once.A review of the progress notes identified a Nurses note dated 8/18/2026 at 10:00 AM, Resident is noted to have a left lateral lower leg blister. new treatment orders to clean and cover with dry dressing daily. A review of the skin assessments and progress notes revealed there were no measurements of the wound, or description of color.A review of the Care Plans identified the following: Skin: Resident has actual skin breakdown r/t (related to) right/left heel blister, left/right ischium MASD (Moisture associated skin damage) pressure to coccyx, date initiated 6/3/2026. The interventions did not mention providing wound care.On 8/18/2026 at 1:50 PM, the Director of Nursing/DON was interviewed about the observed wound care for Resident #13 with Nurse G; reviewed the nurse changed gloves at times, but not consistently between soiled and clean wound care. In addition, the nurse did not perform hand hygiene after removing her gloves and prior to donning clean gloves. The DON said the nurse should know how to perform hand hygiene during wound care. Also, reviewed the resident's wound care had not been completed as ordered and there was no documentation that the nurses had attempted more than once to complete the care. The DON said she would look into that.A review of the facility policy titled, The purpose of this procedure is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers, date reviewed 11/2013 provided . 1. Review the resident's care plan for any special needs of the resident. Wash hands before treatment. Apply gloves. Remove soiled dressing and place in opened plastic bag. Also remove soiled gloves and place in the place in the plastic bag. Wash hands. Apply gloves. Documentation: . Resident refusal of the treatment and the reasons why, and that risks of not complying, benefits of complying and alternatives explained.A review of the facility policy titled, Hand Hygiene Guideline, revised 04/16/2025 revealed, Purpose: Hand hygiene is one of the most effective ways to prevent the spread of microorganisms. Clean hands can stop germs from spreading from one person to another and throughout an entire facility or community.

This Citation Pertains to Intake Numbers 3093672 and 3154455.Based on observation, interview and record review, the facility failed to ensure Care Plans were reviewed and revised after a behavioral incident for two residents (Resident #4 and Resident #9) of 13 residents reviewed. Findings Include: Resident #4:A record review of the Face Sheet and Minimum Data Set/MDS assessment indicated Resident #4 was initially admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses: Respiratory failure, protein-calorie malnutrition, nutritional deficiency, Pulmonary disease, COPD, bacterial pneumonia, Dysphagia (difficulty swallowing), cognitive communication deficit, anxiety, enlarged heart, history of a stroke with left side weakness, Bipolar disorder, GERD, Sacral Stage 3 pressure ulcer, Heart failure, anemia, Schizophrenia, Dementia, PTSD and alcohol abuse.The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and needed assistance with care.On 8/18/2026 at 1:44 PM, the Director of Nursing/DON was interviewed about Resident #4, she said it had been reported by the staff that the resident was observed eating hand sanitizer. She said the resident had been to the hospital several times and then the facility arranged for her to receive treatment in a Substance Abuse Rehabilitation facility. She said since the resident came back she was doing much better. She said her color improved and she was not attempting to eat the hand sanitizer.On 8/19/2026 at 10:08 AM, Resident #4 was observed lying in bed awake. Answered questions very quietly and appeared very thin. She was wearing oxygen at 2L/minute via nasal cannula.On 8/19/2026 at 10:15 AM, during an interview with Nurse Aide A, she said the staff had caught Resident #4 emptying hand sanitizer from the dispensers in her bathroom and hallway into her hand and eating it. They reported it to the facility management. She said the resident was transferred to the hospital because she became ill. Nurse Aide A said the resident had not been observed trying to eat the sanitizer since her return.On 8/19/2026 at 10:17 AM, Nurse Aide B was interviewed about Resident #4 and said she had not observed the resident eating hand sanitizer, but she said the hand sanitizers in the resident's room and near her room in the hallway had been removed at that time. She said since then the hand sanitizer had been replaced.On 8/19/2026 at 10:18 AM, Nurse C was interviewed about Resident #4 and she said the resident was observed eating the hand sanitizer. She said it was reported to the facility management and healthcare provider. She said the resident had received treatment for alcohol abuse and was no longer attempting to eat products with alcohol in them.The Social Services Director D was interviewed about Resident #4 and said the staff had observed her eating hand sanitizer, but it wasn't until the resident returned that she said she was also eating shaving cream; She was trying to find something with alcohol in it. She said she couldn't control it.A review of the Care Plans for Resident #4 identified the following: (Resident #4) requires daily assist with daily care needs r/t (related to) Pneumonia, COPD, history of falling, PTSD, Alcohol Abuse, date initiated 5/11/2026. There were no interventions mentioning observing the resident for consumption of hand sanitizer, shaving cream or products with alcohol in them. (Resident #4) has ineffective coping r/t substance use disorder AEB (as evidenced by) dx/diagnosis of Alcohol Abuse, date initiated 6/15/2026. There was no mention the resident was ingesting substances with alcohol in them such as hand sanitizer or shaving cream. (Resident #4) has GERD and is at risk for complications, date initiated 8/18/2026 with Interventions including, Encourage resident to avoid: alcohol, chocolate, citrus juices, coffee, fatty foods, garlic and onions, date initiated 8/18/2026. There was no mention of hand sanitizer or shaving cream on any of the Care Plans.Resident #9:A record review of the Face Sheet and MDS assessment indicated Resident #9 was admitted to the facility on [DATE] with diagnoses: Schizophrenia, anxiety, depression, hypothyroidism, and PTSD. The MDS assessment dated [DATE] revealed the resident had a BIMS score of 11/15 indicating moderate cognitive decline and needed some assistance with care.A review of a Facility Reported Incident/FRI identified an incident between Resident #9 and another resident occurred on 7/29/2026. Resident #9 was reported as throwing water and swinging her arms at another resident.A review of the progress notes for Resident #9 identified the following:7/26/2026 at 11:26 AM, a Behavior Note, CENA(Certified Nursing Assistant) reported resident extremely agitated throwing ice water, milk and various items onto floor.7/29/2026 at 11:00 PM, a Nurses Note, At the beginning of my shift during report from the off-going nurse, I was informed of a altercation between two residents that occurred prior to the start of my shift. I was informed the resident threw water on another resident.An interview with Unit Manager Nurse F on 8/18/2026 at 9:34 AM about Resident #9 revealed the Nurse Manager F had been notified by Nurse Aide E that there was an incident in the dayroom between Resident #9 and another resident. She said Resident #9 threw water on the other resident and had been the aggressor in several other incidents. She said there had been no additional incident between the two residents.On 8/19/2026 at 9:41 AM, Nurse Aide E was interviewed and said a resident had reported to her that Resident #9 threw water and swung her arms at the resident while they were in the day room. Nurse Aide E said a puddle of water was observed on the floor in the day room and the other resident's clothes were wet. The residents were separated from each other and assisted to their rooms. She said it was reported to the Unit Manager F.The Director of Nursing/DON was interviewed on 8/18/2026 at 1:33 PM about the incident between Resident #9 and another resident. She said she became aware of the incident from the Unit Manager Nurse F. She said the residents were monitored. When asked if Resident #9 had a history of aggressive behavior towards other residents, she stated Yes.A review of the Care Plans for Resident #9 identified the following: I have potential to demonstrate behavior- related trauma from physical abuse. date initiated 06/12/2026. There were no interventions related to aggressive behavior towards other residents. I have the potential for mood difficulties r/t dx of Schizophrenia, Personality Disorder, Depression, Mood disorder and PTSD. date initiated 04/15/2025. The most recent intervention was dated 2/17/2026, Supervise resident closely during periods of increase behavioral activity. The Care Plan had not been updated since then. I have the potential to demonstrate physical behaviors (hitting, kicking, resistive to care, biting, slapping, repetitive movements) r/t diagnoses. I have a history of anger, date initiated 9/13/2024. The last intervention was initiated 2/6/2026, Encourage resident to utilize anger management skills. The resident's Care Plans were not dated reviewed or revised after the incident with another resident on 7/29/2026.

This Citation Pertains to Intake Number 3093672. Based on observation, interview and record review the facility failed to ensure nail care was routinely provided for two residents (Resident #4 and Resident #8) of 3 residents reviewed for activities of daily living (ADL). Findings Include: Resident #4:A record review of the Face Sheet and Minimum Data Set/MDS assessment indicated Resident #4 was initially admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses: Respiratory failure, protein-calorie malnutrition, nutritional deficiency, Pulmonary disease, COPD, bacterial pneumonia, Dysphagia (difficulty swallowing), cognitive communication deficit, anxiety, enlarged heart, history of a stroke with left side weakness, Bipolar disorder, GERD, Sacral Stage 3 pressure ulcer, Heart failure, anemia, Schizophrenia, Dementia, PTSD and alcohol abuse.The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and needed assistance with care.On 8/19/2026 at 10:08 AM, Resident #4 was observed lying in bed awake. Answered questions very quietly and appeared very thin. She was wearing oxygen at 2L/minute via nasal cannula. The resident was observed to have very long, soiled fingernails and toenails. She was asked if staff assisted her to trim her nails and she showed her hands and stated, Will you do it now? Resident #4 was asked if she wanted her fingernails trimmed now and she stated, Yes.On 8/19/2026 at 10:12 AM, Nurse Aide B was asked about Resident #4's nails and she said she could clip them, then she said she was going to take a break. A review of the Care Plans for Resident #4 provided, (Resident #4) requires assist with daily care needs r/t (related to) Pneumonia, COPD, history of falling, PTSD, Alcohol Abuse, date initiated 05/11/2026 with Interventions including, Assist resident with ADL's (activities of daily living), date initiated 05/11/2026; Bath/shower: Partial/Moderate assistance x 1 staff, date initiated 05/11/2026; Personal Hygiene: Substantial/Maximal assistance x 1 staff, date initiated 05/11/2026. Resident #8:A record review of the Face sheet and MDS assessment indicated Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Alzheimer's Dementia, depression, anxiety, Schizophrenia, hypothyroidism, arthritis, COPD, Peripheral vascular disease, and weakness. The MDS assessment dated [DATE] revealed the resident had mild cognitive decline with a BIMS score of 14/15 and she needed assistance with all care.On 8/19/2026 at 10:20 AM, Resident #8 was observed lying in bed, awake. The resident's fingernails were observed to be very long and unkempt. She was asked if she wanted her fingernails trimmed and she stated, Yes, you can do it.A review of the Care Plans for Resident #8 provided, (Resident #8) requires assist with daily care needs r/t PVD, Alzheimer's disease, Muscle weakness, date initiated 03/13/2026 with Interventions including: Assist resident with ADL's, date initiated 03/13/2026.On 8/19/2026 at 2:05 PM, the Director of Nursing/DON was interviewed related to Resident #4 and Resident #8 needing and wanting their nails trimmed. She said the Nurse Aide could provide nail care for the residents.A review of the facility policy titled, Fingernails/Toenails, Care of, revision date February 2018 provided, Purpose: The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. 1. Nail care includes daily cleaning and regular trimming. 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.

This citation pertains to Intake Number 3051417. Based on interview and record review, the facility failed to implement care plan interventions for one resident (Resident #2), complete a thorough investigation for an elopement for one resident (Resident #70), and ensure a safe transfer using a mechanical lift for one resident (Resident #20) of six residents reviewed for accidents, resulting in a fall with a fracture for Resident #2. Findings include: Resident 20 (R20): On 6/24/26 at 11:35 PM, an interview was conducted with Resident 20 who answered questions and engaged in conversation. The Resident was asked about any incidents that had happened recently with transfers. The Resident reported she had gotten hurt when she was getting from her bed into the shower bed in the hallway when the Hoyer lift (mechanical lift used to transfer a person with limited mobility from one location to another) tipped over on top of her. The Resident said she wanted to get into the shower bed from the side instead of the foot of the shower bed. The Resident reported the staff had not made a wide enough turn and had come up to the side of the bed, side by side, and when started to be lowered, she came down really fast and the Hoyer lift had fallen on top of her. The Resident reported having more than usual pain in her left shoulder and arm that had twisted when she dropped onto the bed. The Resident reported she had x-rays done, had to go to the hospital for more testing, was told there was a fracture, then told there was not a fracture but a torn ligament and stated, I don't know what is really going on. The Resident reported going to her own orthopedic specialist the next day, who had completed x-rays on that shoulder a couple months back and the physician will be able to compare the x-rays. The Resident reported that she has had more pain in her shoulder and arm since the incident occurred and stated, All I know is it hurts like crazy. The Resident indicated that a lot of stuff was in the hallway and the staff were unable to turn with enough room. The Resident reported stuff on both sides of the hallway An observation in the hallway near the resident's room revealed, a cart, mattress, Hoyer lift and shower bed. A review of R20's progress notes dated 6/17/26 revealed, Note Text: Res (Resident) arm injured during transfer into shower bed using hoyer lift while in hallway with two staff members. Unit manager, NP (Nurse Practitioner) notified, bilat arm xray ordered. No bruising noted at this time. Res pain 5 left shoulder right arm, states oxy that she received at 0910 is helping to dull the pain. Vitals wdl. Active rom (range of motion) in both extremities. A review of Resident 20's medical record revealed an admission into the facility on 6/30/21 with diagnoses that included morbid obesity, muscle weakness, difficulty in walking, pain in right elbow and left shoulder and anxiety disorder. A review of the Resident's Minimum Data Set assessment revealed a Brief Interview of Mental Status score of 15/15 that indicated intact cognition and the Resident was dependent with tub/shower transfers. On 6/24/26 at 12:26 PM, a phone call was made to Nurse II regarding Resident 20's incident with transfer with the Hoyer lift. The Nurse reported that once they got the Resident from the bed in her room to the shower bed that was in the hallway, I was told by (CNA RR ) that (Resident 20) wanted to go parallel to the shower bed. I was holding her under the sling. She was going to lower it and then we went fast onto the shower bed. It happened really fast, when I looked up, she (resident) started to scream. I could see the Hoyer was tipped, my arms were under (Resident 20) and (CNA RR) was caught under the Hoyer. On 6/24/26 at 1:45 PM, an interview was conducted with the Director of Nursing (DON) regarding Resident 20's incident on 6/17/26 with the transfer into the shower bed using the Hoyer lift. The DON reported that the issue was the staff came to the shower bed sideways and it had tipped over when getting the resident onto the shower bed. The DON reported that they could have come at it straight on, but the wall would have prevented the wheels from going far enough. They needed to go straight in from the head and then slide her down. The DON indicated the Resident had a preference; they did it her way and the Hoyer tipped over to the side. The DON reported that they should have done the transfer from the end of the bed and repositioned her once on the shower bed, and reported, they were trying to make the resident happy but that was not a safe way to transfer the resident. The DON reported education was given to the Nurse and CNA, education was started and we are still in the process of doing education for everyone, started the education but it is not complete. A review of the staff working on this day was compared to the education list provided and not all the staff working were educated. A review of the facility document Resident Transfer Incident Summary, for Resident 20, included the following: -Incident occurred on June 17, 2026, at approximately 10:00 AM during a Hoyer lift transfer to a shower bed. -Resident was being transferred by a Registered Nurse and CNA when the Hoyer lift became unbalanced and tilted toward the shower bed. -Resident lowered into the shower bed and subsequently reported right arm and left shoulder pain. -Diagnostic imaging was ordered on June 17, 2026, including bilateral shoulders and additional upper extremity studies. -Initial imaging suggested an appearing fracture involving the surgical neck and glenoid of the right shoulder/humerus. -Repeat imaging was obtained of the surgical neck and glenoid for clarification and ultimately showed no acute fracture of dislocation. NP informed, transfer to ER for recommended CT (cat scan) per the radiologist of the humerus. -The CNA reported that the resident preferred to be transferred parallel to the shower bed and that staff had educated the resident regarding the safety concerns of this method. -The assigned CNA who provided the resident's shower on June 13, 2026, was also interviewed and reported the resident had requested the same transfer method during that shower. -Investigation findings determined that staff deviation from established Hoyer lift transfer procedures to accommodate resident preference was the likely contributing factor. -Corrective action included staff re-education emphasizing proper Hoyer transfer and that resident preference does not supersede safe transfer practices. Resident #70: On 6/15/2026, at 10:32 AM, Resident #70 was sitting on their bed and dressed for the day. Resident #70 stared at didn't answer any question. There was a staff member sitting in a chair inside the room. On 6/15/2026, at 1:39 PM, a record review of Resident #70's electronic medical record revealed an admission on [DATE] with diagnoses that included Disorganized Schizophrenia, altered mental status and hypoxic ischemic encephalopathy. Resident #70 required assistance with activities of daily living and had impaired cognition. A review of the progress notes revealed 5/31/2026 20:10 (8:10 PM) . Earlier in shift resident was found lying in bed with his wander guard off, when asked why it was off he seemed confused as to what it was, making statements that it's his mom necklace. Writer immediately placed wander guard back on and continued with current plan of care. Later in the day resident got past exit door while wander guard was in place and exited building via north stairwell. Resident was located by staff member walking into the parking lot coming from [NAME] st. Resident walked back to facility independently, front desk receptionist notified the floor for assistance, cena and nurse present at this time and returned resident to assigned floor. Code white called and elopement drill initiated. Resident safely walked himself back into the building and was met by staff and assisted back to the floor. Resident is at baseline and has been reoriented to facility and reeducated that he is not to go off the floor without staff, Administrator, DON, and management notified. On call provider and guardian also notified. Floor staff re-educated on protocol for when alarm goes off. Statements taken, resident wanderguard in place, working. Care plan reviewed, updated to increase monitoring. On 6/15/2026, at 1:45 PM, the Administrator was interviewed regarding Resident #70's elopement and if they had reported the incident. The Administrator stated, no. The administrator offered they had an investigation file on the elopement and would provide it. On 6/15/2026, at 3:08 PM, Unit Manager F was interviewed regarding Resident #70. UM Fprovided the resident was placed on one-to-one (staff observation) for safety. UM F provided that the resident did cut off his wander guard but then was placed right back on over that weekend. UM F was asked to explain the elopement and if Resident #70 did elope and UM F stated, Yes, from my understanding he didn't leave the parking lot. On 6/15/2026, at 4:20 PM, a record review of the elopement investigation revealed the following: 5/31/2026 18:50 (6:50 PM) Elopement . Resident exited building via north stairwell. Resident was located by staff member walking into the parking lot coming from [NAME] st. Resident walked back to facility independently, front desk receptionist notified floor for assistance, cena and nurse present at this time and returned resident to assigned floor . Immediate action taken . Code white called and elopement drill initiated. Resident safely walked himself back into the building and was met by staff and assisted back the floor. Resident is at baseline and has been reoriented to facility and reeducated that he is not to go off the floor without staff. Administrator, DON, and management notified. On call provider and guardian also notified. Floor staff reeducated on protocol for when alarm goes off. Statements taken. Resident wander guard in place, working. Care plan reviewed, updated to increase monitoring . 5-31-2026 was doing my charting when I heard 414 bathroom light going off as I got up to answer the light I heard door alarm going off looked down toward the west wing seen (resident) coming from that direction I directed him to come back this way, went to answer the bathroom light as soon as I walked out the phone was ringing so I answered the phone and was ask to come down stairs, I went down stairs right away to find (resident) and staff trying to get him to come back up, I asked him to come back up and he got on the elevator and come up with me . (CNA J) . I was on my break sitting in my car, I looked up and (resident) coming down [NAME] Street towards the building. I saw resident stop near the entrance of the parking lot + began looking around + standing there. I blew my horn + resident began walking towards the building + goi inside . The facility was asked to provide a scanned copy of the file. On 6/15/2026, at 4:30 PM, a record review of Social Service Comprehensive evaluation . 5/08/2026 . Section C. BIMS score of 4 . Section F . Is the resident at risk to wander/elope . NO . was check marked. A review of the (resident) is an elopement risk/wander r/t (related to) poor impulse control, impaired cognition, Wandering F06F7E, expiration date 4/2028 Date Initiated: 05/12/2026 Goal The resident will not leave the facility unattended through the review date Date Initiated: 05/12/2026 Interventions Ensure that all staff are aware of resident's elopement/wandering risk Date Initiated: 05/12/2026 Ensure that exit and stairwell alarms are responded to in a timely manner Date Initiated: 05/12/2026 Ensure that facility check in/check out log is utilized appropriately Date Initiated: 05/12/2026 Ensure that resident's photo in on the wander/elopement list Date Initiated: 05/12/2026 Monitor resident frequently Date Initiated: 05/12/2026 Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes, Date Initiated: 05/12/2026 Use personal safety device (wander guard) to resident's, Ensure device is checked regularly, F06F7E, exp 4/2028 Date Initiated: 05/12/2026 A review of the Resident is at risk for elopement and requires monitoring for safety Date initiated: 05/07/2026 Goal Resident will remain free from elopement incidents. Date Initiated: 05/072026 Interventions Reorient Resident as needed to place, time, and situation if he shows exit seeking behavior. Date Initiated: 05/07/2026 On 6/16/2026, at 12:20 PM, an interview with Nurse W regarding Resident #70's elopement was conducted. Nurse W stated they were on break sitting in their car. When they entered the building, the resident was standing at the front desk. Nurse W offered, they understood that the housekeeper eric had observed the resident; I guess he walked from the back of the building, into the parking lot and back through the front door. Nurse W was asked what time this happened and Nurse W stated, about 6:10 PM. Nurse W offered, the alarm sounds in the whole building and they have to check the panel to find out what alarm is going off and have to double tap the alarm button to shut it off. On 6/16/2026, at 12:47 PM, CNA J was interviewed regarding Resident #70's elopement. CNA J explained they were charting and heard the door alarm going off. Resident #70 was near the west end door but did not leave through the doorway. CNA J offered, they shut the west end alarm off via the panel. CNA J provided that they instructed the resident to stay with them while they answered a bathroom light. CNA J provided that the resident stood outside the doorway, and they could see him but once CNA J exited the bathroom (was in the room approximately 5 minutes), the resident was gone out of view. CNA J heard the alarm and the phone ringing once they exited the room. CNA J stated, they answered the phone and the receptionist instructed them to come downstairs right away. CNA J entered the elevator and went to the lobby where they found Resident #70. CNA J offered, the resident came back to the floor with them via the elevator with no difficulty. CNA J offered it was about 6:00 PM. CNA J was asked if the alarm was going off at north doorway and CNA J stated, I didn't hear it loudly. Call lights were going off and it wasn't high pitched. CNA J offered, there is no visual light for the stairwell doors. CNA J provided, they did have to put the code in the elevator to get the resident back upstairs so yes, he did have on the wander guard. On 6/16/2026, at 1:12 PM, the Director of Nursing (DON) was asked regarding Resident #70's elopement and if there was video of the elopement. The DON provided, the administrator did the full investigation. The DON was asked if the facility had a timeline of the event and exactly how long the resident was unaccounted for and the DON stated, there definitely should be a timeline, let me look. On 6/16/2026, at 2:00 PM, the Administrator was in their office and was asked how long Resident #70 was outside/unaccounted for and the Administrator stated, maybe 15 to 20 minutes but he never left the property. The Administrator was asked if they had video to prove that and the Administrator stated, I believe (Maintenance Director (MD) B) may have reviewed it. Corporate staff marcy quickly offered, we don't have the video. On 6/16/2026, at 3:28 PM, Maintenance Director (MD) B was interviewed regarding their part in Resident #70's elopement. MD B offered, they came to the facility to reset the alarms and they reviewed the video and that they observed Resident #70 go towards the north end stairwell and not return but was unable to see the resident exit the actual doorway due to the camera placement. MD B was asked to explain the sounds of wander guard alarm and MD B provided, the wander guard alarm is only at the elevator and the alarm going off was the fire egress door alarm. On 6/16/2026, at 3:30 PM, a record review of the facility provided video of Resident #70's elopement was conducted with MD B which revealed the following 17:09 . Resident #70 was observed in the hallway at the nurses station walking towards the north door stairwell. MD B stated, this is when he doesn't come back into view. At this time, MD B was asked to provide the video of the front entrance door/lobby camera starting at 17:09. The video played from 17:09 until 17:12 when Resident #70 was observed entering the building and stops at the front desk until 1713. The front desk has an opening that faces into the therapy hallway and into the front lobby. At 17:13, Resident #70 enters the therapy hallway and goes out of view until 1717:11 when they reenter the lobby near the elevators. At 1717:11, CNA J was observed exiting the elevator and immediately assisted Resident #70 onto the elevator. MD B was asked to provide the video surveillance of the therapy hallway starting at 1713. Resident #70 was not observed at any time on this camera angle. At this time, MD B was asked exactly what time the video footage was, and MD B stated, the time stamp is 1 hour off exactly. On 6/22/2026, at 12:29 PM, the Administrator was again asked if they reviewed the video footage of Resident #70's elopement and the Administrator stated, I did not. On 6/22/2026, at 1:00 PM, a record review of the summary of (Resident #70) incident: that revealed: . Around 6pm the housekeeper noted (the resident) was walking at the side of the building. He was redirected into the facility . There was no mention of exactly how long the resident was outside or unaccounted for. Resident #2 (R2): R2 was admitted to the facility most recently on 03/24/26 with diagnoses that include left femur fracture, pneumonia and falls. R2 has a brief interview for mental status (BIMS) score of 14, indicating they are cognitively intact. On 06/16/2026 at 8:14AM, an interview was conducted with R2 about a fall that occurred in January 2026. R2 stated she was getting her brief changed by a certified nursing assistant (CNA). R2 stated the CNA was on my left side by the bed and rolled me up on my right side away from him. I told him I was slipping but he wasn't paying attention. The third time I mentioned that I was sliding off the bed, I hit the floor. R2 was asked if they were injured in the fall. R2 stated, yes, I broke a bone in my left leg and then I ended up having surgery on it. I was in the hospital for close to a week with the surgery. R2 was asked how many CNAs were present for the care at the time of the fall. R2 stated that it was just the one CNA that was providing care. On 06/16/2026 at 8:28AM, record review of a fall on 1/5/26 at 20:00pm revealed that R2 was observed on the floor next to her bed, face down on her stomach after rolling out of right side of the bed. R2 denies blocking head impact with hands. R2 stated, I was being changed by the CNA and was on my side, I started to roll and couldn't catch myself. Assessment completed, hoyered back into bed. Neuro checks initiated and skin assessments completed. Pain meds administered per orders. An x-ray was ordered for the left knee due to complaints of pain. R2 was taken to [NAME], returned to the facility on 1/9/26. On 06/16/2026 at 8:35AM, record review the bed mobility care plan revealed that R2 was an extensive two person assist for bed mobility at the time of the fall. There was one person assisting at the time of the fall. On 06/16/2026 at 8:55AM, record review of a progress note dated 1/6/2026 at 11:05AM, titled Nursing: Antigravity Team Note Date of Fall: 1/5/2026, Root Cause(s) of Fall: Non-adherence to the residents required 2-person assist during bed toileting and mobility. New Interventions: Resident care plan updated to specify 2-person assist with bed toileting and mobility. Resident/Resident Representative Notification: Resident is her own responsible party. Attendees: ID Team. On 06/16/2026 at 10:14AM, an interview was conducted with the Director of Nursing (DON). The DON was asked if the facility did an investigation for this fall. The DON stated, yes, we did an investigation. The DON was asked what was concluded from the investigation. The DON stated the root cause of the fall was the resident being pulled over too far to support herself. The Aide had one hand on her and was reaching for other supplies. The DON was asked what was R2's assistance level for bed mobility at the time of the fall. The DON stated at the time of the fall, R2 was a one assist for bed mobility and one assist for hygiene. The DON stated we reached out to our corporate staff, and they reviewed the fall as well and determined there was no deficient practice because R2 was a one assist for bed mobility at the time of the fall. This surveyor provided evidence that R2 was a two assist at the time for bed mobility. The DON was made aware of a progress note that the facility noted the root cause of the fall was staff not following the care plan for two person transfers. The DON was asked if staff should have used two staff members to assist R2 while turning in bed. The DON stated, yes, they should have used two people.

Based on observation, interview and record review, the facility failed to follow care-planned interventions, implement the interventions timely, and assess, monitor, and prevent the new development of pressure ulcers for five residents (Resident #2, Resident #6, Resident #13, Resident #34 and Resident #38) of five residents reviewed for pressure ulcers, resulting in delayed assessment, new pressure injuries, and pain. Findings include. Resident #13: On 6/15/2026, at 9:32 AM, Resident #13 was sitting in their wheelchair. There was a dressing to their right heel with a date of 6/14. Their feet were resting on the foot pedals. On 6/15/2026, at 12:45 PM, Resident #13 was sitting in their wheelchair and declined a skin observation. On 6/15/2026, at 2:15 PM, Resident #13 remained in their wheelchair. On 6/15/2026, at 10:43 AM, a record review of Resident #13's electronic medical record revealed an admission on [DATE] with diagnoses that included protein calorie malnutrition, mild intellectual disability and Dysphagia following stroke. According to the most recent Minimal data set assessment; Resident #13 required extensive assistance with Daily Living Activities and moderately impaired cognition. A review of the progress notes revealed the following: 6/1/2026 . Writer alerted to a skin alteration on patients r heel. Patient observed in bed, skin flap to R heel, dry flakey skin peri-wound. Patient stated, I don't know how that happened. Patient denies all pain at this time. Nurse Supervisor notified. MD notified of skin alteration, new orders to cleanse wound with NS, pat dry, soak wound in betadine, cover with non-adherent pad, wrap with kerlix until healed. New order to consult with wound team. A review of the Nursing: Weekly Skin Check . 5/18/2026 revealed . Current skin issues Bruising Other Wound . Open area to RT lower buttock, scattered discoloration and bruising to coccyx, sacrum . Sacrum discoloration, scattered bruising Right gluteal fold Open area, bloody drainage, no odor present . A review of the physician's ordered revealed an order on 5/18/2026 . Wound Care Consult r/t open area to RT Lower Buttock . A review of the TREATMENT ADMINISTRATION RECORD 5/1/2026 – 5/31/2026 revealed no treatment was provided to Resident #13's coccyx wound. A review of the TREATMENT ADMINISTRATION RECORD 6/1/2026 – 6/30/2026 revealed the treatment to the right lower buttock/coccyx started during the survey on Mon 15 of June; 35 days after the open skin was documented / observed. A review of the Physician orders revealed Order Details Order Date: 5/18/2026 . Description Wound Care Consult r/t open area to RT Lower Buttock Order Type: Ancillary Orders Signed By: (NP KK) Signed Date: 5/18/2026. The was no follow up provided for the buttock wound by the medical team despite the signed physician order. A review of the WOUND ASSESSMENT DETAILS REPORT 6/10/2026 Right heel revealed Classification Blister Facility-acquired Date Identified 06/03/2026 . Necrotic Hard, Firm, Adherent =100% . Size (centimeters) 3.50 x 4.00 x 0.00 . The wound picture revealed a thick black (eschar) scabbed wound. According to the Minimal data Set Assessment, PPS Part A Discharge . Accepted 06/15/2026 . Section M . F Unstageable – Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar . Number of unstageable pressure ulcers . 0 was check marked. A review of the SKIN: (RESIDENT) has potential for skin breakdown r/t S/P (status post) Bariatric Surgery, Hypothyroidism, Protein-Calorie Malnutrition Other Symptoms and Signs Concerning Food and Fluid intake Date Initiated: 04/03/2026 . Assist and encourage resident to turn and reposition every two hours and PRN (as needed) Date Initiated: 04/23/2026 Encourage proper body alignment Date Initiated: 04/23/2026 Monitor for adequate food and fluid intake. Date Initiated: 04/23/2026 Monitor for adequate urine output. Date Initiated: 04/23/2026 Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care. Date Initiated: 04/03/2026 Protect elbows and heels if being exposed to friction. Date Initiated: 04/23/2026 Provide skin care after each incontinent episode. Date Initiated: 04/23/2026 . Skin assessment at least weekly Date Initiated: 04/03/2026 Therapeutic mattress in bed and cushion in chair as appropriate. Date Initiated: 04/23/2026 . Use lift sheet to assist with bed mobility Date Initiated: 04/23/2026 Use pressure redistribution surface if bed-or-chair-bound. Date Initiated: 04/23/2026 Initiated: 04/23/2026 . A review of the SKIN: Resident has actual skin breakdown r/t Right heel blister, Date Initiated: 06/03/2026 . Goal Will remain free of further skin complications throughout next review . Interventions . The only new added interventions for the pressure ulcers was . Administer medication for pain as needed prior to wound treatment Date Initiated: 06/03/2026 Assess and document of progress of areas weekly. Date Initiated: 06/03/2026 . Maximal remobilization. Date Initiated 06/03/2026 . On 6/16/2026, at 8:25 AM, Resident #13 was sitting in their wheelchair with their feet resting on the foot pedals. On 6/16/2026, at 2:11 PM, a record review along with Unit Manager (UM) F regarding Resident #13's electronic record was conducted. UM F reviewed the skin assessment dated [DATE] regarding the bruising and new open wound to their buttock area. UM F was asked why medical care was not provided to the documented open skin and UM F reviewed the physician orders and stated, the order was placed wrong. UM F A review of the TREATMENT ADMINISTRATION RECORD 5/1/2026-5/31/2026 with the UM F revealed no medical care was provided to Resident #13 for their open buttock/coccyx wound. UM F stated, the bruising and open skin was never reported. UM F was asked if Resident #13 had any medical follow up or any wound assessment to documented open area after 5/18/2026 until the survey and UM F stated, No. On 06/16/2026, at 2:26 PM, UM F provided they updated the wound consult order for Resident #13. The order was placed as an ancillary order so they pulled the original order forward so the wound would be assessed on the next day the wound physician visits. On 6/22/2026, at 10:00 AM, a further record review of Resident #13's record revealed the following: 6/18/2026 . Interdisciplinary Note Text: Resident wounds assessed by wound care provider. Resident wound to right heel remains stable. Resident has a new Unstageable pressure to coccyx. New treatment orders in place for coccyx, treatment orders for right heel remains effective . 6/17/2026 . Nutrition/Dietary . Rec (recommend) to change Prostat AWC 30 ml BID to help increase energy/protein to help promote wound healing . WOUND ASSESSMENT DETAILS REPORT 6/17/2026 Coccyx revealed . Pressure Ulceration Facility-acquired . Clinical Stage Unstageable . Size (centimeters) 2.00 x 1.50 x Unknown (Length by Width by Depth) The wound picture revealed a thick black (eschar) scabbed center measuring nearly the entire wound with the skin edges noted to be bright red. Resident #34: On 6/14/2025 at approximately 10:05 AM, Resident #34 was observed resting quietly in bed. He shared he has been requesting to see the podiatrist but has not seen one as he is typically at dialysis when they visit the facility. He reported the podiatrist will document that he refused when that is not the case. Resident #34 continued he has a wound on his right toe that needs to be addressed and he showed his guardian. He reported he has not taken the sock off in about a month and does not know if the wound has worsened. The resident agreed to allow Nurse II to assess the area. On 6/14/2025 at approximately 10:58 AM, Nurse II assessed Resident #34's right foot. After removing the residents' sock there was a black, irregular shaped, nickel sized debris that fell onto the bed along with other flaky skin particles. The 1st toe had an open circular wound with slough, bloody drainage and a slight odor. The nail was lifted about ¾ inch from his toe bed. His 2nd toe had a black wound on the side of the toe, and the nail bed was blackened on the side with blood-tinged drainage. In between the residents' other toes was thick buildup of skin debris and other particles. Nurse II reported this was a new wound that the facility was not aware of. On 6/15/2026 at 11:42 AM, a review was conducted of Resident #34's record and it indicated he was admitted to the facility on [DATE] with diagnoses that included: End Stage Renal Disease, Heart Failure, Hyperlipidemia, Chronic Kidney Disease, Hypotension and Schizoaffective Disorder. Further review yielded the following: Progress Notes: 6/14/26 at 14:42: Res (resident) self-reported area of concern on right foot. Upon assessment open area observed on 1st and 2nd right toe.Wound care team consult and order for wound care completed. 6/17/2026 at 14:43: Resident had initial wound assessment performed by wound care provider. Residents has excoriation to right dorsal hallux. Resident has treatment orders in place and will continue to be followed by wound care weekly until wound resolution. Skin Assessments: 6/14/26: Right toes- open area first two right toes. 6/17/2026: .Trauma -excoriation -facility acquired. Tissue: Necrotic soft. 1.10 x 1.10 x0.00. Care Plan: .notify nurse immediately of any new areas of skin breakdown.Skin assessment at least weekly.observe for signs of skin irritation and or breakdown. Report irritation/breakdown to the physician. Wound Care Assessment: 6/17/2026: This resident is s 59YO (year old) make being seen on consultation by wound care.This patient has developed a wound to hi8s right dorsal hallux.Patient is unsure as to he procured this wound.Type: Partial thickness excoriation. Description: wound base- tan necrotic hard eschar. Non-tender, edges attached, no tunneling, no undermining. No heat radiating off of the wound surface. Dimension: 1.1 CM (centimeter) x 1.1 CM X necrotic eschar. Initial visit. On 06/16/2026 at 10:29 AM, Resident #34 reported yesterday (6/16/26) the wound care treatment for his toe was not completed. He continued the last time it was completed was on Sunday (6/14/26) when the toe wound was discovered. Review was conducted of the TAR (Treatment Administration Record) for June 2026 and the entry in the TAR for Resident #34's right 1st and 2nd toe was blank. On 6/16/2026 at 11:25 AM, Social Worker Z reported Resident #34 was on the list to be seen by podiatry on 4/13/26 but he was at dialysis and hence not evaluated when they were on site. Social Worker Z shared typically podiatry will wait until he returns to see him and she was unsure why they did not occur in April 2026. There was no other documentation located in Resident #34's chart related to his toe wound prior to discovery on 6/14/2026. Resident #2 (R2): On 06/14/2026 at 10:05AM, an interview was conducted with R2. R2 was asked if she had any concerns with her skin. R2 stated she had a sore on her right ear and indicated that she has an open area on her left ankle/foot. R2 was asked what the area on her left ankle is from. R2 stated she had a leg immobilizer on after a surgery in January and the immobilizer caused it. A dressing was observed on the back of the right ear and left ankle. On 06/14/2026 at 1:48PM, an interview was conducted with Unit Manager (UM) L. UM L was asked what the spot on the back of the right ear is from. UM L stated it is either her glasses or the oxygen tubing, or both that caused it. UM L stated this is a new spot and I cleaned it, put the gauze on it. UM L was asked if there are interventions that could be put in place to prevent that. UM L stated, yes, I just put foam coverings on the oxygen tubing. UM L was asked if nurses should be looking behind the ears for skin assessments. UM L stated, yes, they should be looking behind the ears on assessments. On 06/15/2026 at 12:59PM, an interview was conducted with R2. R2 was asked she first noticed the spot behind her ear. R2 stated, I noticed it about a week ago. I told the unit manager about it yesterday (06/14/26), prior that I had told the staff. But it's like it goes in one ear and out the other. R2 was asked if there was anything on the oxygen tubing that could've prevented this area from opening. R2 stated, no, they didn't put anything on to help with that until yesterday (6/14/26). On 06/15/2026 at 1:56PM, record review revealed that a skin assessment was completed on 1/26/26 at 11:24AM, it does not indicate any skin issues on the left ankle. On 06/15/2026 at 1:59PM, record review of the active wounds revealed a pressure ulcer on the left lateral ankle that was identified on 1/28/26. On 06/15/2026 at 2:09PM, record review of progress notes revealed that R2 sustained a fall with left femur fracture on 1/15/26. R2 was in a leg immobilizer after surgery and then developed a pressure injury on the outside of her left ankle. A care plan was initiated for monitoring the skin under the immobilizer on 2/20/26. On 06/15/2026 at 2:13PM, record review revealed a physician's order to monitor skin integrity under the immobilizer, dated 2/20/26. On 6/15/26 at 2:30PM an interview was conducted with the Director of Nursing (DON). The DON was asked what the area behind the ear being classified as. The DON stated that right now it is an excoriation. The DON was asked how did the area on the ear start. The DON stated It is either from her oxygen tubing, glasses or both. The DON was asked how the pressure injury on the left lateral ankle started. The DON stated that it started from her leg immobilizer. It is being classified as pressure, and it is improving every week, she had the immobilizer on for probably around 6 weeks or so. The DON was asked what the nursing staff should do when a resident has an immobilizer in place. The DON stated that there should be a duration of how long to have the immobilizer on and to check the skin integrity under the immobilizer. The DON was asked how often would staff check under the immobilizer. The DON stated the staff should check that daily. The DON was asked if there was an order to check the integrity of the skin under the immobilizer. The DON stated there is a discontinued order in the electronic medical record (EMR). The DON was asked when that order was put in place. The DON stated the order was started on 2/20/26 and ended on 3/18/26. The DON realized the order was started 24 days after the development of the pressure ulcer under the immobilizer. The DON was asked if they enter a care plan for the immobilizer to monitor the skin. The DON stated yes there was a care plan in place, but it was not started until 2/20/26. The DON was asked who is ultimately responsible for ensuring that the order for skin monitoring and care plan is in place. The DON stated the nurse on the floor is responsible for that and I am too. The DON was asked why an order to monitor under the immobilizer, and a care plan wasn't put in place. The DON stated, I don't know, it was just missed. Review of the policy titled, Prevention of Pressure Injuries, Skin Assessment 3. Inspect the skin on a daily basis when performing or assisting with personal care or activities of daily living (ADL's). Device-Related Pressure Injuries 1. Review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application and ability to secure the device. 2. Monitor regularly for comfort and signs of pressure injury. Resident #6: An interview on 06/14/2026 at 10:05 AM with Resident #6 revealed that she had a wound to her heel and hip/buttocks areas, she is diabetic and eats what she wants to eat. Surveyor observed left heel to be resting on mattress; she stated that there was a wound there. Air mattress on bed, but no heel support device, boots or pillow to support heel off the mattress noted. Record review of Resident #6's 'Wound assessment Details Report' with photo, dated 6/10/2026 at 12:34PM, noted new active trauma excoriation that was facility-acquired on 6/10/2026. Measurements of 1.50cm x 1.00 cm. Record review of Resident #6's June 2026 Treatment Administration Record (TAR) noted on 6/11/2026 new order: Wound Care-Left Heel-Cleanse area, pat dry, apply betadine moistened gauze to wound bed, cover with dry dressing. Change daily and as needed, everyday shift for wound care. Observation on 06/15/2026 at 12:59 PM with Licensed Practical Nurse (LPN) L/Wound Care /Unit manager went into Resident #6's room with surveyor, put on gloves and touched the resident's foot dressing, was going to cut off the dressing and then surveyor asked if she was going to measure the wound. LPN L then put the dressing down on the bedding, removed her gloves and went to the treatment cart in the hallway. LPN L Went to the linen room to get soaker pad for dressing change, opened the room door to the linen room and came back out, texted on her phone to another unit manager that the phlebotomist could not draw blood. On 06/15/2026 at 1:05 PM with LPN L/wound care nurse/unit manager went back Resident #6's room, put on gloves, and a gown, did not wash her hands or sanitize did not clean scissors from her pocket, did not clean the scissors, cut off dressing, switched gloves did not sanitize hands. 06/15/2026 at 1:08 PM observation wound with measurements 06/15/2026 1:10 PM 1.2cm x 1.6cm depth 0.2cm, used a wooden Q-Tip applicator handle to obtain depth measurement, placed on wound measurement tape device ad was noted to be 0.2-0.3cm depth, deep pink tissue noted in bottom of wound bed, not an excoriation, left foot noted to be in resting position right on the heel wound, foot drop noted, Hiba cleanse wiped, betadine 4x4 gauze applied to wound, ABD dressing pad applied, nurse forgot the gauze wrap, had to have staff bring dressing wrap to room. Observed no left heel support device boots or pillows on the bed, or in the room. Licensed Practical Nurse (LPN) L/Wound Care /Unit manager stated its excoriation, An interview was conducted on 06/22/2026 at 1:55 PM with Licensed Practical Nurse (LPN) L/Wound Care /Unit manager regarding Resident #6's left heel wound that was facility-acquired. LPN L stated that We did measure that wound and we got 0.2cm. Excoriation is the rubbing away of skin and we don't know what caused the excoriation> It just rubs on something. Surveyor requested definitions of skin conditions and staging of wounds. Resident #38: An interview on 06/16/2026 at 12:52 PM with Resident #38, revealed that the left foot heel wound he received while living in the facility. Resident #38 stated that he got the left heel sore from the other mattress; he got the air mattress after he got the heel sore then they did something. No, they don't use a pillow under the foot, they put my pillow from my head under my foot when they change the dressing, and now he does not have a head pillow. No other pillows were observed in the resident's room. Record review of Resident #38's admission assessment dated [DATE] at 1:08PM revealed no left foot skin issues. Record review of Resident #38's 'Weekly Skin Check/Skin Condition' form, dated 5/7/2026 at 5:21 PM, revealed a left foot deep tissue injury. No description, skin color or warmth, no location of where on the foot was documented on the weekly skin assessment tool. Record review of Resident #38's progress notes, dated 5/7/2026, revealed that there was a purple pressure injury noted to resident's left heel. Record review of Resident #38's physician's provider notes, dated 5/20/2026, noted skin warm dry and intact, extremities pulses present, no clubbing, cyanosis, or edema. Limited range of motion noted to all extremities. There was no assessment or acknowledgement of left heel blister. in an observation on 06/16/2026 at 1:05 PM with Licensed Practical Nurse (LPN) W of Resident #38's left foot heel dressing change, the LPN had to go out to her car to get scissors for dressing change and left the floor. On 06/16/2026 at 1:21 LPN W came back to the floor with scissors and with wound supplies. LPN W went into dining room to wash hands, needed to get key again to the treatment cart. opened the cart and gathered wound care supplies, 4x4 gauze iodine bottle, normal saline to gauze, placed all items in a wash basin. LPN W went to the medication cart reviewed Resident #38's wound care order on PCC at the medication cart. On 06/16/2026 at 1:29 PM LPN W and the surveyor went into Resident #38's room, Certified Nurse Assistant (CNA) J both gowned. LPN W gloved then put on the gown and then gloved again over the 1st pr of gloves. CNA J held the left foot off the bedding while LPN W Removed dressing with scissors from her pocket, dressing stuck to wound, scrapped off old dressing with fingernail in gloves. LPN W started with saline washing, no barrier was used under the wound, nurse did not change her gloves or wash her hands, iodine soaked 4x4 applied, gauze wrap applied dated and signed. nurse wore 2 pairs of gloves but did not remove a pair of gloves between old dressing and applying new dressing. Observed left heel to be black in color with deflated blister (deep tissue injury) and cratering inward making a scooped-out indentation of the wound area. Wound measurements were not performed by nurse. Record review of Resident #38's 'Wound Assessment Details Report' with photo, dated 6/10/2026 at 9:53 AM, documented the wound, identified on 5/13/2026, as facility-acquired blister with measurements of 2.80cm x 4.30cm tissue necrotic (black in color).

Based on observation, interview and records review, the facility failed to account for narcotic reconciliations for three months and account for a loose narcotic tablet in the controlled substance drawer. Findings include: Observation and interview on 06/15/2026 at 7:05 AM with Licensed Practical Nurses Q and S of the shift-to-shift Narcotic count of the third-floor medication cart, #2. The narcotic count revealed a loose white round narcotic tablet found in the bottom of the controlled substance locked box. If the card count was correct, where did the loose narcotic come from? Before notifying any management of a loose narcotic tablet, both LPN Q and S disposed of the controlled substance in the sharp's container attached to the medication cart. Record review of the facility 'Controlled Substance Accountability Guideline' undated [NAME]-page booklet with 10 chapters. Chapter 2- Change of Shift Reconciliation: Two (2) licensed nurses (the nurse arriving on duty and the nurse departing from duty) are required to conduct reconciliation (i.e. Change of Shift Count) of controlled substances and sign a signature log attesting to the completion and accuracy of the count. The reconciliation process should include: A count comparing the Controlled Substance Count Inventory Log (the mater list of the individual count sheets) with the actual individual count sheets. A count comparing the number of medication packages (i.e. Cards, boxes, bottles, vials, etc ) versus the number of controlled substances count sheets; the number of medications packages and the number of controlled substances count sheets should be equal; for each package, there should be a corresponding inventory count sheet . Both nurses performing the reconciliation should visualize both medications being counted and the count sheet Chapter 3: Controlled Substance Count Sheets, the Director of Nursing (DON) or designee should reconcile all controlled substances count sheets upon completion of the current supply of medication and/or the destruction following the discontinuation of a controlled substance order or in preparation for resident discharge . When the supply of a controlled substance is exhausted or destroyed, the records of usage must be immediately scanned and added to the resident's electronic medical record. An interview was conducted on 06/15/2026 at 8:26 AM with Licensed Practical Nurse (LPN)/unit manager L regarding the narcotic count on Cart #2 of the west hall. LPN Q and LPN S found a loose narcotic tablet in the narcotic drawer, LPN S placed it in the sharps bin on the cart. LPN L stated the controlled substance tablet should have been placed in the drug buster. There should never have been a loose tablet in the locked narcotic drawer, and they should have reported it to the unit manager or the DON. In an interview and records review on 06/16/2026 at 8:58 AM, the Director of Nursing (DON) reviewed the Narcotic reconciliation and destruction logs. The DON stated that she currently does not have any medications on hold in the office. The controlled substance is kept in the medication carts until she collects the medications and then destroys the medications. Procedure: DON collects the medications, brings them down to her office and destroys with 2 licensed nurses present. Destruction logs reviewed. There were missing destruction logs from November 2025 through January 2026. The DON stated that the facility switched their pharmacy from One Care to Polaris in November 2025. Record review of the destruction log from 10/31/2025 is One Care pharmacy, then in November 2025 switched to Polaris pharmacy. There are missing destruction logs from November 2025 through January 2026, The DON stated that the former Nursing Home Administrator (NHA) was holding the narcotics in her office for months. Then in February 2026 the company placed a different NHA. There are no destruction sheets for that time frame November 2025 through January 2026. The DON stated that she was behind with the transitioning from the new pharmacy company, So I did not get the reports done. There are individual sheets that we have signed off on but that there was no destruction log. Record review of the individual controlled substance sign-out sheets revealed that the sheets were signed by two nurses at the medication carts when removed, but that there were no destruction signatures. In an interview on 06/16/2026 at 11:31 AM, the Clinical Regional Director (CRD) P explained that the facility had an evacuation from another facility and took in 35 residents on 5/14/2026 due to water main brake at the other facility. Our staff got residents off the buses, and the narcotics were all together in a single bag, there were loose pills, in the bag, CRD P reconciled those narcotic cards, and placed the cards in the med cart, not certain if there could have been a missed tablet. That pill could have been in the narcotic cart box for weeks. The surveyor asked about the 3-month destruction logs. CRD P stated that the former Nursing Home Administrator (NHA), had locked up the narcotics in her office, and the NHA left and we had to go into her office and destroy the backup narcotics. The former NHA was a social worker and not a nurse, the former NHA did not maintain narcotic logs, Polaris is to reconcile the narcotics that are destroyed.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents who consume food from the kitchen. Findings include:On 06/14/2026 at 8:32AM during the initial kitchen tour, a leaking faucet was observed at the hot water valve to the garbage disposal. On 06/14/2026 at 8:33AM yellow grime build up was observed on the interior wall of the ice machine. In addition, the drain line to the ice machine was observed sitting inside the drain. On 06/14/2026 at 8:36AM chopped lettuce with prep date of 6/11 and discard date of 6/25 was observed in the two-door fridge. On 06/14/2026 at 8:38AM brown murky water filled to the brim of a drain to the prep sink was observed with an air gap between the drain line and drain present. On 06/14/2026 at 9:17AM two undated bologna sandwiches with cheese were observed in the fridge in the dining room located on the second floor. On 06/14/2026 at 9:38AM plastic cups and lids were observed laying around on the lower shelf of the storage shelf, with more lids falling outside of their storage box in the dietary storage room. On 06/14/2026 at 9:39AM crumbs and plastic lids were observed inside the mixer stored in the dietary storage room. On 06/14/2026 at 10:19AM during interview with Certified Dietary Manager (CDM) A, CDM A acknowledged the yellow build up on interior wall of ice machine and stated it's cleaned every day, but it's sanitized every 6 months and there are not any logs for when the ice machine is sanitized. On 06/14/2026 at 10:25AM interviewed CDM A on the brown murky water at the brim of the drain at the prep sink and he stated that the drain has been like that for about 6 months, but the prep sink isn't being used. An Out of order sign was observed at the prep sink. On 06/14/2026 at 10:26AM interviewed CDM A on the chopped lettuce with the prep date of 6/11 and discard date of 6/25 and he stated that it was labeled wrong and they only hold onto food for 6 days. On 06/14/2026 at 10:29AM interviewed CDM A on the mixer with crumbs in the dietary storage and he stated they haven't used it since he's been working here, which has been three years. According to the FDA 2022 Food Code, 5-205.15 System Maintained in Good Repair, A plumbing system shall be: repaired according to law.and maintained in good repair.According to the 2022 FDA Food Code, 5-402.11 Backflow Prevention, (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed.According to the FDA 2022 Food Code, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, Equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations, nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.According to the 2022 Food Code, 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition, Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.According to the 2022 Food Code, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.According to the 2022 FDA Code, 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, Except as specified in (D) of this section, cleaned equipment and utensils, laundered linens, and single-use service and single-use articles shall be stored: In a clean, dry location .Where they are not exposed to splash, dust, or other contamination; and .At least 15 cm (6 inches) above the floor.

Based on observation, interview and record review, the facility failed to 1) Implement a comprehensive infection control program including outcome and process surveillance for all residents and employees, 2) Ensure that hand hygiene and enhanced barrier precautions (EBP) were followed during medication administration, dining and wound care; 3) Review the infection control policy annually; and 4) Store personal items separately, resulting in the worsening and spreading of ongoing infections. Findings include: Resident #3: On 6/15/2026, at 2:21 PM, Resident #3 remained flat in bed. Nurse V entered, donned a pair of gloves, obtained the syringe that was on the nightstand then, entered the bathroom with their gloved hands touching the door handle. Nurse V exited the bathroom, shut off the enteral feeding pump and unhooked the tubing from the resident. Nurse V drew up 50 milliliters of water into a syringe and administered it into the residents percutaneous tube by push method. Nurse V then drew up 70 milliliters more and administered the water. Nurse V did not reposition the resident and administered the water flush while the resident was lying flat. On 6/15/2026, at 3:30 PM, a record review of Resident #3's electronic medical record revealed an admission on [DATE] with diagnoses that included Gastrostomy status, Stoke and Dementia. The resident had severely impaired cognition and required extensive assistance with Activities of Daily Living. A review of physician orders revealed Enhanced Barrier Precautions every shift . Active . Start Date 5/8/2026 . On 6/16/2026, at 9:45 AM, an observation of the 4th floor shower room was conducted along with UM F. There was a wash basin that housed the following unlabeled items: 3 dirty rusty razors 2 shaving creams 6 body lotions 5 body powders 5 shampoos Um F was asked if the personal items should be shared together unlabeled and UM F stated, no. On 6/16/2026, at 4:45PM, the facility was asked to provide the last three months of Infection Control line listing to include surveillance data, resident and employee illnesses, and catheter care/hand hygiene audits. On 6/22/2026, at 9:55 AM, during infection control task with the Director of Nursing (DON) who is also the Infection Control nurse, the DON was alerted of shower room observation, lack of personal protection equipment during cares, lack of hand hygiene during medication administration and wound cares. The DON was asked if the facility had any outbreaks or unusual illnesses in the past year and the DON provided, no. The DON was again asked to provide the last three months of Infection Control documents to include April, May and June 2026. The DON stated, they don't have June because June is still running. The DON was asked to clarify, the DON stated they do not have a line listing for June as of yet and they pull off a report from emr (electronic medical record data) which is completed with a report of residents who are on antibiotics. The DON offered, they fill out the report at the end of the month and then do their mapping and analyzing at that time. The DON was asked when they complete the mapping and the DON offered, once they pull the antibiotic report, then they do the mapping at the end of the month. The DON was asked to provide June 2026 data they have so far for any illnesses or signs and symptoms of illnesses in the facility. The DON ran the Infection by unit report and provided it. The DON was asked how they know if someone has signs and symptoms of illness and/or require enhanced barrier precautions (ebp) and the DON offered, the ebp is built into IC via (emr) at the end of the month. The DON was asked again when they do the infection surveillance and the DON stated, at the end of the month. The DON was asked how they monitor employee illness and the DON stated, we have a running list at the front desk. An observation of a binder at the front desk was conducted with the DON. The DON provided the current month of June 2026 of employee call-ins. The months of May and April were not filed in the binder. The DON was asked to provide May and April, 2026 employee illnesses tracking. The DON asked the receptionist for the call off list as they were not located at the desk. On 6/22/2026, at 10:07 AM, back in the DON's office, the DON was still looking for the May and April employee illnesses tracking and the DON was asked if they had them and the DON stated, I'm going to go with I don't have them. The DON was asked if they were aware of Residet #20's urine sample from May that was still housed in the upstairs refrigerator and the DON, stated, no. A review of the Infection By Unit Report for June 2026 revealed no antibiotics listed and the Organisms column was blank for the entire report. A review of the 7 page facility provided Infection Control policy revealed Infection Prevention and Control Guideline Effective Date: 11.28.2017 . Revised: . There was no review date noted. On 6/22/2026, at 11:04 AM, The DON was asked if they had any more infection control data for June and the DON stated, now again that's all we have so far. The DON was asked if Resident #3 was on the line listing and the DON stated, no. The DON provided employee illness log June 2026 which revealed 6-15-26 time call received 238 pm The columns for GI and FLU was check marked. There was no documented follow up for the employee's illness noted. A review of the May Infection Surveillance Report May 01, 2026 – May 31, 2026 revealed Resident #20 was no listed on the report despite they had signs and symptoms for urinary tract infection and a urine collected. Medication Administration: Observation and record review on 06/15/2026 at 8:38 AM with Licensed Practical Nurse (LPN) U agency nurse. The surveyor noted the nurse was wearing gloves to pass medications. LPN U prepared the medications of Resident #81. Observed glucose monitor sticks bottle not dated when opened, nurse used them. Observed the computer medication administration record on 06/15/2026 at 8:47 AM noted insulin is colored red on screen. LPN U stated insulin should have been given at 7Am its late, that's why it's colored red. LPN U stated that she was agency nurse and had no log in to the PCC program, that's why all the 7 o'clock medications are in the red zone. LPN U into resident room blood sugar is 173 and resident needs 2 units. With the same gloves on LPN U opened the medication cart, insulin pen removed from the cart, top of cartridge was not alcohol wiped, needle placed on cartridge. Pen not primed. LPN U went back to residents' room and administered the medication. Observation on 06/15/2026 at 8:53 AM with Licensed Practical Nurse (LPN) U left the medication cart unlocked in hallway, went into the resident #81's room, went into the bathroom looking for the resident, and then came back out into the hallway and started up the hall then realized that the cart was unlocked again. LPN U found the resident in the main dining room, assisted resident back to his room and did not prime the insulin pen, injected into left upper arm, with same gloves on that she had worn for the entire medication pass. Observation on 06/15/2026 at 9:18 AM with Licensed Practical Nurse (LPN) V prepared Resident #100 oral meds. LPN V did not sanitize or wash her hands before starting the medication pass at the medication cart, punched out the medications and over the counter medications, walked to the resident's room, moved items on the overbed table and administered the medications to the resident. The nurse walked back to the medication cart and started the next resident's medication pass, no hand hygiene between resident medication pass noted. Observation on 06/15/2026 at 9:38 AM with Licensed Practical Nurse (LPN) W of Resident #108 medication pass. Observed LPN W to use the computer mouse, and opened the PCC program for medication pass, opened drawers to obtain the medications needed for the resident, put her hands in and out of her pockets, picked up the cup and went to residents' room. Resident #108 was in the bathroom, LPN W knocked on the bathroom door and waited for the resident to come out and administered the medications. LPN W performed No hand washing until after the meds were given. Observation on 06/15/2026 at 9:39 AM with Licensed Practical Nurse (LPN) W of Resident #24. LPN W wen to residents' room obtained wrist blood pressure cuff used, took the blood pressure 124/58, 57. LPN W went back to the medication cart, proceeded to punch out the medications and over the counter medications, LPN W got the narcotic book out of the cart tray, flipped through the pages and signed out Vimpat 1 tablet and clonazepam one tablet, removed the medications from the narcotic drawer. Locked up the drawer with the keys. LPN W went to the resident's room and set the medications on the over table and observed resident to take the medications whole with water. No hand hygiene was noted in the administration. Hand hygiene performed after medication passed. Observation on 06/16/2026 at 7:29 AM with Registered Nurse (RN) Y of Resident #41 medication administration. RN checked blood sugar level of 202, went back to the cart and retrieved Novo log insulin pen of 100 unit/ml. RN Y dialed up 9 units, air bubble noted in pen window, RN Y did not prime the pen, did not wipe the top of cartridge with alcohol wipe, and placed needle top on cartridge. Entered into resident #41's room, gloved her hands, explained to the resident the insulin dose while the resident was lying in bed and RN Y injected subcutaneous in the abdomen at the left lower quad. In an interview on 06/16/2026 at 9:57 AM with Director of Nursing (DON) was asked about insulin pens were not dated and labeled for the resident's name? DON stated that of course insulin pen's should be labeled and dated, Insulin are good for 14 to 28 days, depending on the type of insulin, Open dates should be on the pens, when labeled with resident name, Pen administration procedure dial up dose wipe the skin clean top of pen prior to needle application, clean the skin, apply to skin 5-10 seconds. then remove from skin. Prime the pen should be done with 2 units of insulin. DON stated that hand hygiene should be done between each resident medication administration, after glove use and when handling resident dressing changes. The surveyor requested medication administration and hand hygiene policies and the wound/dressing change policies. At the end of the survey the policies requested were not loaded into the egress document system by the facility. Dining Observation: Observation on 06/14/2026 at 11:56 AM of the 4th floor noon meal trays by Certified Nurse Assistant (CNA) EE to the residents' rooms, aides take trays to the residents in their rooms and set-up the tray, move items from the overbed table and remove [NAME] dome lid and go Back to the meal cart in the hallway and get the next resident's tray. Observation 06/15/2026 12:32 PM Observed meal trays to the floor, coffee cart behind the nursing station supervised. Nursing staff grabbed the meal cart and took it to the [NAME] end of the hall. 06/15/2026 12:36 PM First tray to room, only 1 Certified Nursing Assistant (CNA) DD passing trays. left the cart door wide open, no hand hygiene observed for 2 room passes. On 06/15/2026 at 12:39 PM Licensed Practical Nurse (LPN) unit manager told the CNA DD to close the meal cart doors. Observation on 06/16/2026 at 8:33 AM of resident breakfast meal trays being passed by Certified Nursing Assistant's (CNA) during the medication pass observations. Observed CNA to enter Resident #6's room, left her meal tray and went back to meal cart for the next resident's meal tray with hand hygiene with meal tray passing observed. Record review of the facility 'Dining Experience Guideline' dated 4/11/2023 to provide a positive dining experience for residents . Residents will be offered hand sanitizer and clothing protectors. Wound care: Resident #6: In an interview on 06/14/2026 at 10:05 AM with Resident #6 revealed that she had a wound to her heel and hip/buttocks areas she is diabetic and eats what she wants to eat. Surveyor observed left heel to be resting on mattress; she stated that there was a wound there. Air mattress on bed, but no heel support device, boots or pillow to support heel off the mattress noted. Observation on 06/15/2026 at 12:59 PM with Licensed Practical Nurse (LPN) L/Wound Care /Unit manager went into the resident #6's room with surveyor, put on gloves and touched the residents foot dressing was going to cut off the dressing and then surveyor asked if she was going to measure the wound. LPN L then put the dressing down on the bedding, removed her gloves and went to the treatment cart in the hallway. LPN L Went to the linen room to get soaker pad for dressing change, opened the room door to linen room and came back out, texted on her phone to another unit manager that the phlebotomist could not draw blood. On 06/15/2026 at 1:05 PM with LPN L/wound care nurse/unit manager went back Resident #6's room, put on gloves, and a gown, did not wash her hands or sanitize did not clean scissors from her pocket, did not clean the scissors, cut off dressing, switched gloves did not sanitize hands. 06/15/2026 at 1:08 PM observation wound with measurements 06/15/2026 1:10 PM 1.2cm x 1.6cm depth 0.2cm, used a wooden Q-Tip applicator handle to obtain depth measurement, placed on wound measurement tape device ad was noted to be 0.2-0.3cm depth, not an excoriation. Resident #38: Observation on 06/16/2026 at 1:05 PM with Licensed Practical Nurse (LPN) W of Resident #38's left foot heel dressing change the LPN had to go out to her car to get scissors for dressing change and left the floor. On 06/16/2026 at 1:21 LPN W came back to the floor with scissors and with wound supplies. LPN W went into dining room to wash hands, needed to get key again to the treatment cart. opened the cart and gathered wound care supplies, 4x4 gauze iodine bottle, normal saline to gauze, placed all items in a wash basin. LPN W went to the medication cart reviewed Resident #38's wound care order on PCC at the medication cart. On 06/16/2026 at 1:29 PM LPN W and surveyor into Resident #38's room, Certified Nurse Assistant (CNA) J both gowned. LPN W gloved then put on the gown and then gloved again over the 1st pr of gloves. CNA J held the left foot off the bedding while LPN W Removed dressing with scissors from her pocket, dressing stuck to wound, scrapped off old dressing with fingernail in gloves. LPN W started with saline washing, no barrier was used under the wound, nurse did not change her gloves or wash her hands, iodine soaked 4x4 applied, gauze wrap applied dated and signed. nurse wore 2 pairs of gloves but did not remove a pair of gloves between old dressing and applying new dressing.

This citation pertains to Intake Numbers 3051417 and 3052791. Based on observation, interview, and record review, the facility failed to maintain a clean sanitary environment by maintaining plumbing fixtures, dining rooms and the structural integrity of the facility. Findings include: On 6/16/26, at 2:00 PM, an observation of the 4th floor Dining Room revealed the doorway/door jamb into the dining area was marked up with black residue. There was paint chips noted. The right door to the credenza was broken and hung down. On 6/16/26, at 2:30 PM, an observation of the main Dining Room revealed the door and door jamb with gross amounts of black build up. There was paint scraped off. The floor was dirty with dusty dirt residue. The baseboard had a large area of chipped paint which revealed brown paint, yellow paint and also pink paint showing through. The floor air vents had large amounts of dusty build-up. There was a dining chair that faced the front window with a hand-written sign that read do not sit. The chair appeared to be broken. On 06/14/2026 at 8:53AM the floor was flooded, covered with a towel, and a wet ceiling tile was observed in the visitor's bathroom across from the rehab department. On 06/14/2026 at 9:04 AM, the tub in the bathroom in the unused room [ROOM NUMBER] was observed. The water continued to run with the hot water knob torn from the wall and the tub surface was discolored with a yellowish tint. On 06/14/2026 at 9:07AM a black substance was observed inside the toilet bowl in the unused room [ROOM NUMBER]. On 06/14/2026 at 9:12AM the warped floor near the tub was observed in the bathroom in the unused room [ROOM NUMBER]. In addition, a hole in the dry wall was observed directly above the tub. On 06/14/2026 at 9:14AM the tub in the bathroom in the unused room [ROOM NUMBER] was observed. The water continued to run and a green discoloration was observed on the tub surface and severe calcification buildup on the tub fixture. On 06/14/2026 at 9:45AM the floor was observed flooded throughout the bathroom to room [ROOM NUMBER]. A drip leak was observed from the hand sink drain line while the sink was turned off, and once the sink was turned on, water began to spew out from the drain line and onto the floor. In addition, the ceiling above the tub showed signs of a previous water leak and the ceiling was deteriorating. On 06/14/2026 at 10:36AM interviewed Certified Dietary Manager A on whether there was a previous leak in the dining room, and he stated there was a leak in the dining room a couple weeks ago, but the ceiling tile has since been replaced and the dining room was closed off during the leak. On 06/14/2026 at 1:01PM interviewed Maintenance Director B on the warped floor in room [ROOM NUMBER], and he stated there was a leak at one point in that bathroom which is why the floor is warped and a hole in the wall at the tub. On 06/14/2026 at 1:04PM interviewed Maintenance Director B on why the tubs in room [ROOM NUMBER] and room [ROOM NUMBER] are continuing to run, and he stated the hot water stem needs to be replaced to the tub in room [ROOM NUMBER], and there aren't any local shut off valves to the tubs, only the main shut off valve, so they would have to shut the water off to the whole building. On 06/15/2026 at 9:11AM wet ceiling tile was observed above the nurse's station on the 4th floor. On 06/15/2026 at 9:21AM interviewed Maintenance Director B on what was causing the leak on the fourth floor above the nurse's station, and he stated the roof leak just happened yesterday due to the rain and there were a couple cracks on the flat roof, which have been sealed this morning. Maintenance Director B stated this is the first time there has been a roof leak, and he described the flat roof as having a white sheet that can get rips in it. On 06/15/2026 at 9:35AM interviewed Maintenance Director B on the tub that continued to run in room [ROOM NUMBER], and he stated it was fixed and was the reason for the ceiling leak in the first-floor visitor's bathroom. On 06/16/2026 at 10:18AM interviewed Administrator on when the roof was installed and whether a roofing contractor has ever evaluated the roof, and she stated in the past year if there were any issues with the roof, maintenance would fix it, and it has been the same roof since Maintenance Director B has been working at the facility, which has been eight years. Record review of the facility's maintenance logs for room [ROOM NUMBER] with a creation date of 5/15 states Water running in bathtub for weeks. Need to be turned off with vice grips because its stripped to shut it off. The work order was updated on 6/15 and comments were noted, Main water of building had to be shut off to change tub hot water stem. Record review of the facility's maintenance logs for room [ROOM NUMBER] hand sink with a creation date of 6/15 states, Replace broken pipe under sink completed same day 6-14-26. The work order status was updated at the same time as the creation date. On 06/14/2026 at 8:35AM, observation revealed the visitor's restroom on the first floor had a wet towel on the floor. Upon opening the bathroom door water fell from the ceiling and the ceiling tile was wet. On 06/14/2026 at 8:45AM, observation revealed that the bathtub is running hot water in room [ROOM NUMBER] (this room is not in use) and leaking into the public restroom on the first floor. The handle is off the hot water faucet so it cannot be turned off. The sink is dripping as well. On 06/14/2026 at 9:50AM, observation revealed eight (8) oxygen tanks in the bathroom of room [ROOM NUMBER]. They are not in a cart and freestanding. Findings were verified with Unit Manager (UM) M.

Based on observation and interview, the facility failed to treat residents in a dignified manner for five residents (R2, R6, R15, R103, R112) of five residents reviewed for dignity and a confidential group of residents, resulting in long call light response times and call lights not in reach. Findings include: Record review of the Health Care Association of Michigan 'Rights of Residents in Michigan Nursing Facilities copyright 2024 revealed, residents have the right to be treated with respect and dignity, including: The right to reside and receive services in the facility with reasonable accommodation of their needs and preferences except when to do so would endanger the health or safety of the resident or other residents. Resident #6: In an interview on 06/14/2026 at 9:59 AM with Resident #6 while in the resident's room revealed that Call lights take 30 minutes to an hour to get responded to. The resident stated that she knows to push the call light early to get assistance. In an observation and interview on 06/15/2026 at 1:20 PM, during the dressing change observation, the nurse forgot the Krelix gauze wrap and the call light was activated. Staff came to assist the nurse. Resident #6 stated that was the fastest that she has seen staff respond to her call light. Resident #15: In an interview on 06/14/2026 at 9:09 AM with Resident #15, it was revealed that the staff are rude and short with residents, as if they are bothered to help. When asked about her call light response time, Resident #15 stated that the call light takes an hour to get it answered. Resident #15 keeps her door closed, because they are not nice and I can hear them talk about residents. Resident #112: In an interview on 06/14/2026 at 9:16 AM with Resident #112, during the screening process of the survey, the resident stated that the staff sit in the dining room, talk on their phones, and talk to each other and laugh. If Resident #112 uses the call light at the bed it takes over an hour, if he uses the bathroom pull light they come running, so sometimes I go into the bathroom to use the call light to get them after I waited for an hour. Resident#2 (R2): R2 was admitted to the facility on [DATE] with diagnoses that include pneumonia, emphysema, chronic pain and heart failure. R2 has a brief interview for mental status (BIMS) score of 14, indicating they are cognitively intact. On 06/14/2026 at 10:08AM, an interview was conducted with R2. R2 was asked if the facility staff answers her call light in a timely manner. R2 responded, no, it takes a long time to get anyone to help you out. R2 was asked how long it takes to get her call light answered. R2 stated that most times she waits two to four hours to get her call light answered. R2 was asked if any shift is worse than the other for long call light response time. R2 stated that all the shifts are bad and this happens all the time. Resident #103 (R3): R103 was admitted to the facility on [DATE] with diagnoses that include dementia, chronic pain, repeated falls and restlessness and agitation. R103 does not have a BIMS score, as she is often rarely understood and confused. On 06/14/2026 at 9:16AM, observation revealed R103 lying in bed, positioned close to the exit side of the bed and asking for food. The call light is observed to be on the opposite side of the room, not in reach and resting on the floor. Certified Nursing Assistant (CNA) K entered the room, and the findings of the call light being out of reach were verified. CNA K picked up the call light and placed it in reach for R103. When asked why the call light was on the other side of the room CNA K stated they were unsure. On 06/16/2026 at 1:03PM, observation revealed the call light was once again on the opposite side of the room, on the floor and not in reach. A CNA entered the room, picked up the call light and then assisted R103 with eating the lunch meal.

This citation pertains to Intake Number 3032293. Based on interview and record review, the facility failed to ensure that facility employees did not falsify one resident's (Resident #26) medical records of one resident reviewed for professional standards, resulting in approximately 33 fallacious entries. Findings Include:On 6/14/2026 at approximately 1:00 PM, a review was conducted of Resident #26's medical records and it revealed he was admitted to the facility on [DATE] with diagnoses that included, Chronic Kidney Disease, Abdominal Aortic Aneurysm, Amnesia, Heart Disease, Chronic Obstructive Pulmonary Disease and Hypertension. Resident #26 has a guardian and was not allowed to leave facility premises without staff supervision. Review was conducted of the Resident Sign In & Out form that per facility management is used when residents go outside to smoke. Resident #26 signed out at 5:16 PM on 5/26/2026 and never signed back into the facility. On 6/15/2026 at 9:08 AM, Receptionist PP reported when Resident #26 signed out on 5/26/26 at about 5:20 PM, he reported that he was going to smoke. She provided him with his lighter and the one cigarette he had remaining. On 6/15/2026 at 10:30 AM, Resident #26 stated on the afternoon of 5/26/26 he made the decision he no longer wanted to be at the facility. He took his wallet, coat and a box of Kleenex when he left out. He walked to the Walgreens up the street and caught the bus with intentions of going to Mio/Fairview area. He did not realize the buses only routed around the city and would not take him out of town until a Police Office at the bus station informed him. The officer transported him to an overnight shelter where he remained until Noon on 5/27/26. The shelter releases everyone at Noon and they can return at 1:00 PM, Resident #26 stated there was no point in him returning and he hitchhiked to the Hill Rd area in Grand [NAME]. He stated he was on the highway for about 30 minutes trying to catch a ride when someone pulled up who was going to transport him. But at the same time a police officer arrived and began to question him and scared off his ride. Shortly after this staff from the facility observed him on the highway and he was transported back to the facility. The facility was unaware Resident #26 was missing for over 16 hours. In total he was unaccounted for approximately 20 hours. Review was conducted of charting completed on Resident #26 from 5/26/26 after 5:30 PM to 5/27/2026 at 2:15 PM when he was missing from the facility. There were 33 falsified entries during this timeframe related to medications administered, cares provided/observed, assessment and treatments. They are as follows:May 26, 2026:Atorvastatin Calcium Tablet 80 MG (milligrams) administered at 8:47 PM.Sertraline HCI Tablet 25 MG administered at 8:47 PMPain rated 0 at 8:47 PMSnack offered at 10:04 PMRefused to shower at 10:04 PMAte 51%-75% of his dinner at 7:10 PMDocumented Bed mobility status as independent at 7:10 PM.Documented Hygiene (Oral, Toileting, Personal) as independent at 7:10 PM.Documented Locomotion (Walk 10ft Wheel 150 ft) as independent at 7:10 PM.Documented Transfers as independent at 7:11 PM.Applied ointment at 7:11 PM.Documented No behaviors observed at 7:11 PM.Documented he voided and was continent at 7:11 PM.Documented resident did not have a bowel movement at 7:10 PMMay 27, 2026:Snack offered at 4:24 AMDocumented Bed mobility status as independent at 2:46 AM and 4:21 AM.Documented Hygiene (Oral, Toileting, Personal) as independent at 2:47 AM and 6:48 AMDocumented Locomotion (Walk 10ft Wheel 150 ft) as independent at 2:47 AM and 4:23 AM.Documented Transfers as independent at 2:47 AM and 4:23 AM.Applied ointment at 2:49 AM and 4:23 AM.Documented No behaviors observed at 2:49 AM and 4:23 AM.Documented he voided and at 2:49 AM and 4:24 AM.Documented he did not have a bowel movement at 2:49 AM.Documented he had a small bowel movement at 4:24 AM.Pressure relieving device was placed in chair at 2:49 AM.Offered and consumed 100% of snack at 2:49 AM On 6/16/2026 at 12:50 PM, an interview was conducted with the DON (Director of Nursing) regarding the falsification of Resident #26's record. She stated CNA NN was newer to the facility and still becoming acclimated. She thought who she saw and was charting on was Resident #26, but it wasn't him. CNA MM reported she documented all shift cares were completed for Resident #26 at the start of her shift. She stated she is not responsible for knowing the whereabouts of patients and that is the responsibility of the guardian and front desk. The CNA could not understand her culpability in the situation. The DON was queried regarding the midnight census that was completed. She reported it was completed for the 3rd floor and it indicated all residents were accounted for the night of 5/26/26 going into 5/27/26. The DON reported the facility staff that falsified documentation when Resident #26 was not in the facility was Nurse LL, CNA MM and CNA NN. On 6/16/2026 at 2:20 PM, an interview was conducted with Nurse OO regarding Resident #26. She stated she arrived at work at 7 AM on 5/27/2026 and received report from the night shift nurse. There was nothing communicated in report that was of concern and there was no mention that Resident #26 was missing. She went into Resident #26's room to administer his eye drops and he was not there, so she assumed he was outside smoking. About 20 minutes later Nurse OO circled back to his room and the resident was still not there and had not passed her in the hallway. The nurse asked his roommate who stated Resident #26 left yesterday around dinnertime and had not returned. Nurse OO stated once provided with that information she alerted management. They located him later in day by Hill Road in Grand [NAME]. Nurse OO shared prior to Resident #26's roommate informing her he had left, the facility was not aware he was unaccounted for. The midnight census is when they should make sure that everyone is back in the facility and properly accounted for. On 6/16/2026 at 2:40 PM, an interview was conducted with CNA NN regarding Resident #26's elopement and her inaccurate documentation. The CNA reported on 5/26/26 she worked 11 PM- 7 AM shift and report between the aides is sometimes walking rounds or verbal but she could not recall who she took report from that evening. When CNA NN went to Resident #26's room she did not see him and assumed he was outside smoking or in the common area. She stated she assumed he was in the facility but never laid eyes on him during her 8 hours shift nor did she alert her nurse that she had not observed Resident #26. CNA NN admitted to completing all the shift charting that triggered for Resident #26 in their system. She stated the tasks/cares she marked off as completed were erroneous as she had not Resident #26 the entire shift. CNA NN reported she understood that what she did was falsification of records. On 6/19/2026 at 12:45 PM, an interview was conducted with Agency Nurse LL regarding Resident #26. On 5/26/2026 she reported to work at 7:00 PM and could not gain access to their medical records system until around midnight (medication audit reports show invalidated this statement as untrue based on times medications were timed). Upon doing her medication pass she went into Resident #26's room and he was not there, she saw four gentlemen sitting outside (from the window) and assumed one of them was Resident #26. Nurse LL was asked if she ever went outside to verify that one of the men was Resident #26 and she stated she did not. She continued as she clearing the MAR she marked off Resident #26's medications as administered. She made a mental note to go back and strike it out as he does not take off his medications. Nurse LL was asked if at anytime during her shift she observed Resident #26 and she stated she did not. Review was conducted of facility witness statements obtained:Nurse LL completed on 5/27/26 at 9:59 AM, I popped his meds, I did sign out medications out like I gave them, but I have them in a cup. I was thinking that this was one of the patients that was already gone. CNA NN on 5/27/26 at 1:24 PM, .Last seen him in bed at the beginning of my shift approximately around 11:30p.He was laying in bed when I dropped off his water cup at around 11:30 PM. CNA MM on 5/27/26 at 1:40 PM, .I was assigned to him for the afternoon shift on 5/26/26. I spoke to him about taking a shower, he walked past me and said he would take one later. I last seen him during dinner time. On 6/22/2026 at 1:10 PM, the Administrator was queried regarding the falsification of Resident #26's records by facility staff in his absence. The Administrator reported upon interviewing Nurse LL she stated she went in the room to administer medications and Resident #26 was not in his room and she never went back to follow up or look for him. When they initially called her she was panicking and repeating OMG (oh my god). She admitted to dispending his medications in a cup and signing them out but never administering them to him. Nurse LL did call management or alert the oncoming shift to Resident #26's absence. CNA MM completed charting for all her residents (including Resident #26) at the beginning of her shift. She began her shift at 3:00 PM and completed all shift charting at 5:00 PM. When the aide was asked about this, she stated she knows the residents and has been working with him for a long time and knows his routine. CNA MM could not understand the error with her actions. CNA NN was newly certified nurse aide and new to the facility. She shared she thought Resident #26 was a different resident and that is why her charting was inaccurate. Review was conducted of the facility, Code and Standards of Conduct. It stated .Negligence or any careless action which endangers the life or safety of another person.Dishonesty, falsification or alteration of facility's records or other documents. Falsification, alteration, destruction or other changes to resident charts, medical records or similar data.

Based on observation, interview and record review, the facility failed to ensure catheter assessment and monitoring and urinalysis laboratory follow up for four residents (Resident #1, Resident #11, Resident #13 and Resident #20) of 5 residents reviewed, resulting in a lack of assessment and appropriate monitoring. Findings include: Resident #13: On [DATE], at 9:32 AM, Resident #13 was sitting in their wheelchair. There was a urinary catheter hooked under their wheelchair. The tubing had yellow cloudy urine with some sediment noted. On [DATE], at 10:43 AM, a record review of Resident #13's electronic medical record revealed an admission on [DATE] with diagnoses that included protein calorie malnutrition, mild intellectual disability and Dyshpagia following stroke. According to the most recent Minimal data set assessment; Resident #13 required extensive assistance with Daily Living Activities and moderately impaired cognition. A review of TREATMENT ADMINISTRATION RECORD [DATE]-[DATE] revealed Foley Catheter Care Every Shift every shift -Start Date- 06/142026. A review of TREATMENT ADMINISTRATION RECORD [DATE]-[DATE] revealed no documented catheter care nor foley catheter changes. A review of TREATMENT ADMINISTRATION RECORD [DATE] – [DATE] revealed no documented catheter care nor foley catheter changes. A record review of the discontinued order summary revealed the only catheter related order was Change foley catheter prn as needed 14F no directions specified . Revision Date [DATE] A second care plan FOLEY: (Resident) requires use of an indwelling catheter r/t BPH with Lower Urinary Tract Symptoms, Obstructive and Reflux Uropathy Date Initiated: [DATE] Goal Will remain free of complications and infection of foley catheter placement . Interventions Assess for continued need of indwelling catheter Date Initiated: [DATE] Change catheter as ordered. Date Initiated: [DATE] Educate resident on proper handwashing technique Date Initiated: [DATE] Empty Foley bag every shift and as needed. Date Initiated: [DATE] Keep drainage bag lower than level of bladder Date Initiated: [DATE] Keep draining bag covered to promote privacy Date Initiated: [DATE] Keep tubing free from kinks Date Initiated: [DATE] Maintain closed drainage system. Date Initiated: [DATE] Monitor for s/s (signs and symptoms) of UTI: flank pain, strong odor, increase temp, decreased output, hematuria Date Initiated: [DATE] Notify MD of abnormal findings. Date Initiated: [DATE] Provide catheter care and empty bag every shift and as needed Date Initiated: [DATE] Staff to monitor patency of catheter. Date Initiated: [DATE] On [DATE], at 3:04 PM, Unit Manager (UM) F was asked how to locate the documentation to ensure catheter care was provided and UM F provided they had just placed an order for catheter care which was started the day prior Foley Catheter Care Every shift -Start Date- [DATE]. UM F was asked to provide catheter assessment and/or catheter changes since admission for the resident. A review of the progress notes revealed the following: [DATE] . Urinary Catheter; care completed as ordered T (temperature) 101.8 . Resident has indwelling foley catheter . [DATE] . SBAR-UTI . (the resident) is exhibiting sign and symptoms of a UTI . Bacteria Klebsiella Urine Culture Results . Temperature: T 101.8 . The patient has an indwelling foley catheter . Recommendation/Response: Physician orders: cipro q (every) 12h (hours) x (times) 7 days [DATE] . Resident has urinary catheter for retention . Resident is on oral Abx (Antibiotic) Therapy . Resident has an infection; UTI . Resident has indwelling foley catheter . On [DATE], at 2:26 PM, UM F was asked again for documentation assessing for foley catheter changes and catheter care for Resident #13 since admission and UM F provided the catheter care was placed as an ancillary order so the order never forwarded to the treatment record. There was no catheter care nor catheter changes/assessments prior to the survey start ([DATE]). Resident #11: On [DATE], at 9:48 AM, Resident #11 was resting in their bed and asked for surveyor to stop back by later. On [DATE], at 12:30 PM, Resident #11 was in their bed with family at bedside. On [DATE], at 9:45 AM, a record review of Resident #11's electronic medical record revealed an admission on [DATE] and a readmission on [DATE] with diagnoses that included Quadriplegia, Stroke and Neuromuscular dysfunction of bladder. Resident #11 required extensive assistance with Activities of Daily Living and had According to the admission Minimal data set assessment Date 2-11-2026 . Section H . Indwelling catheter. was checked yes. A review of the Order Listing Report revealed the following: Change Foley Catheter every 30 days or PRN as indicated . Active Revision Date [DATE] Change Foley Catheter Drainage Bag Every 2 weeks and PRN . Active Revision Date[DATE] Foley Catheter Care Every Shift . Active Revision Date [DATE] Foley Catheter: Size 16fr; Balloon 5ml for diagnosis of Neurogenic Bladder Active Revision Date [DATE] A review of the Focus FOLEY: Resident requires use of an indwelling catheter r/t Neuromuscular dysfunction of bladder Date Initiated: [DATE] . Interventions . Change catheter as ordered. Date Initiated: [DATE] . Provide catheter care and empty bag every shift and as needed Date Initiated: [DATE] . On [DATE], at 3:00 PM, an observation along with CNA JJ of Resident #11's urinary catheter was conducted. The catheter tubing had milky white urine with bloody sediment floating in the tube. Resident #11 offered that sometimes it leaks. Resident #20: In an interview on [DATE] at 10:09 AM with Resident #20 during the screening process at the start of the survey, Resident #20 stated that she was tested for Urine infection but never heard what the results were and did not start antibiotics. The resident stated that the nurses have poor communication with her, they say that she is behavioral. Resident #20 wanted the surveyor to Check results from lab on the urine sample. Record review of Resident #20's nursing progress notes, dated [DATE] at 4:10 PM, noted vaginal bleeding is about a quarter size, not heavy or light flow, just spotting. Residents also complained of pain in the lower abdomen. Healthcare provider was notified. Ordered a UA, CMP and CBC. Order is in. Record review of Resident #20's nursing progress notes, dated [DATE] at 6:10 AM, noted spoke to resident about any immediate concerns at facility regarding care. Resident denied any concerns or complaints . Did obtain urine sample for UA (Urinalysis) ordered via sterile technique at this time. Resident tolerated the procedure well; amber slightly cloudy urine sample placed in lab fridge for pick-up. Record review of Resident #20's physician's orders, dated [DATE], revealed TruUTI with ABR (antibiotic resistance panel is an advanced molecular urine test that identifies both the exact bacteria causing the infection and any genes that make those bacteria resistant to specific medications, utilizing polymerase chain reaction (PCR). the order noted **SENT to lab [DATE]. Observation on [DATE] at 10:23AM of the 3rd floor soiled utility room there was a white mini refrigerator plugged up. A yellow ladder was propped against the door of the refrigerator and a yellow bucket with soiled linen or trash was pushed against the ladder. To the side of the refrigerator was another bucket that was pushed close to the refrigerator. Upon gaining access to the refrigerator there was ice buildup in the shape of U that was 6 in x 6in approximately. That is connected to the ceiling of the refrigerator. Inside the refrigerator are browns spots of an unknown substance throughout the refrigerator. There is pool of dried brown substances on the bottom of the refrigerator. On the top shelf there was a specimen bag with a urine sample for Resident #20 that was dated [DATE] on the lid of the specimen. In an interview on [DATE] at 3:00PM with Licensed Practical Nurse (LPN) unit manager L revealed that the white mini refrigerator in the soiled utility room was the lab specimen refrigerator. LPN L was asked if Resident #20's urine sample from [DATE] was still good and LPN L stated the specimen from [DATE] was expired. Record review on [DATE] at 11:24 AM of Resident #20's medical record revealed that the last reported urinary lab was documented in [DATE]. During a survey team meeting on [DATE] at 12:21 PM the team Identified that Resident #20's urine sample was left in 3rd floor refrigerator with urine sample dated [DATE] was still in the refrigerator on [DATE]. In an interview on [DATE] at 12:37 PM with a contracted phlebotomist CC out of the Detroit/[NAME] area revealed that the lab does urinalysis, the urine is taken to the lab, but she did not know the turn around on the urinalysis report return. Record review of the facility 'Lab and Diagnostic Test Results- Clinical Protocol', dated 3/2024, revealed the physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. The laboratory, diagnostic provider, or other testing source will report test results to the facility. A nurse will review all results. (2.) A nurse will try to determine whether the test was done: to assess a condition change or recent onset of signs and symptoms . Resident #1 (R1): R1 was admitted to the facility on [DATE] with diagnoses that include end stage renal disease, dependence on renal dialysis and anxiety. On [DATE] at 1:27PM, R1 was observed in bed, stating he had just returned to the facility from an outing. Observation revealed that R1 had an indwelling catheter and the urine collection bag was between the footboard and the mattress. On [DATE] at 3:32PM, record review revealed no physician order for the indwelling catheter, catheter size, when to change it and the diagnosis for it. Record review also revealed no documentation of catheter care being completed for R1. On [DATE] at 9:04AM, R1 was observed in bed, the urine collection bag was hanging below the bed, there is a dignity bag present, but it is not covering the urine collection bag. On [DATE] at: 10:39AM, an interview was conducted with the Director of Nursing (DON). The DON was asked if there should be an order for a resident with an indwelling catheter and what information does it contain. The DON stated there is a batch order for indwelling catheters, it allows you to put a diagnosis, monitor and check catheter, catheter size and change schedule. The DON was asked how staff would know to provide catheter care. The DON stated that catheter care goes on to the Treatment Administration Record (TAR) and nurses know to complete it. The DON stated It does come up for the aides to complete the care as well. The findings that there is no physician's order for the indwelling catheter or task to complete catheter care were verified with the DON. The DON was asked what the facility does when a resident with an indwelling catheter admits to the facility. The DON stated that in the morning meeting staff reviews the catheter/ostomy tag in the Electronic Medical Record (EMR), then they go through and ensure that all the orders, care plan and tasks are put in place. The DON was asked how these items were missed for R1. The DON stated she didn't know and would make the corrections.

Based on interview and record review the facility failed to ensure sufficient staffing to meet the care needs of all 111 facility residents. Findings Include:Resident Council was held on 6/15/2026 at 1:30 PM and they were questioned regarding facility staffing and their care needs being met. The 19 residents in attendance reported the following:There are not enough nurses to meet their needs with many of them being employed through a contracted agency.Their medications are often 2+ hours late.Call lights take 45 minutes to an hour to answer and they can hear staff in the hallways talking amongst themselves. Call lights on night shift are worse than 1st and 2nd shift During the annual survey there were numerous deficient practices identified related to resident care and subsequently indicating the facility cannot sufficiently meet the needs of residents with their current nursing staff. Deficient practices include the following, immunizations, wounds, monitoring of skin conditions, range of motion, falls with major injury, weight loss, tube feeing management, catheter care, call lights, monitoring of antibiotic usage and infection control program.On 6/22/2026 at 10:10 AM, an interview was held with Staffing Coordinator QQ, regarding current staffing needs at the facility. She reported they currently have 17 open nursing positions, and they have two staffing agencies they utilize daily due to their nursing shortages. She added they have plethora of call ins as well. 6/22/2026 At 1:10 PM, the Administrator reported the facility is struggling with hiring nurses as they cannot accommodate specialized schedules. They currently have 17 open licensed nursing positions. They currently have enough aides, but they frequently call off work. The aides will agree to work an abundance of overtime shifts and then call off for their regular scheduled shift as they are burned out The Administrator continued agency is in the facility daily to meet their needs and within the last three months management has only had to work the floor a handful of times. During the 2nd quarter of the year they were on the floor more due to their staffing shortages, which is why they increased the PPD. Review was conducted of May and June 2026 staff call ins, and it indicated the following:35 staff members called in in May 202618 staff call-ins thus far in June 2026

Based on interview and record review the facility failed to complete annual competencies for six of six facility staff reviewed during the staffing task.Findings Include:On [DATE] at approximately 11:43 AM, reviews were conducted of six facility staff (three nurses and three Certified Nurses' Aides). Requested Human Resource files to include their professional license/certification, on-hire background check, annual competency and CPR (Cardiopulmonary Resuscitation) certification for nurses. Upon review of the documents provided there were no annual competencies included. Corporate Nurse P was queried regarding the competencies, and it was explained they completed a competency blitz with staff. The competencies checklist was for Nurse E, F, G, and CNA J, I, J. The following competencies were provided from last year: CNA J-last annual competency was completed [DATE].Initial hire date of 5/2001CNA I- last annual competency was completed on [DATE].Initial hire date of 1/2017Nurse G- last annual competency was completed on [DATE].Initial hire date of 5/2024Nurse E- last annual competency was completed on [DATE].Initial hire date of 5/2024Nurse F - last annual competency was completed on [DATE].Initial hire date of 5/2024.The facility was unable to provide the annual competency for CNA H. The facility was unable to provide competency checklist for 2026 for the above six staff members.

Based on observation, interview, the facility failed to ensure that expired supplies were discarded and ensure that medication and treatment carts were locked, and labeling and dating of medications for 4 of 5 medication carts, and 2 of 3 treatment carts and 2 of 2 crash/respiratory carts reviewed, resulting in unlocked medication and treatment carts, expired supplies being accessible for staff use, and opened and undated multi-dose medications. Medication Storage and Labeling Medication Carts review: Observation on [DATE] at 9:28 AM 4th floor medication cart #1 with an agency Licensed Practical Nurse noted loose medications in the cart drawers: One white round scored tablet, one white oblong table, one white half tablet, one yellow round tablet, one round peach tablet, two oval peach-colored tablets. Resident #4 fluticasone 50mcg inhaler opened and used with 42 doses left, not dated on device or box. Resident #55 inhalation device Spiriva 18 mcg [NAME]-dose with 16 doses left. No date on device or box when opened. Resident #55 fluticasone propionate HFA 220mcg multi-dose aerosol inhaler, 2 puffs daily multi-dose device used and no date when opened. Observation on [DATE] at 9:58 AM on the 3rd Floor [NAME] medication Cart with Registered Nurse II revealed: Resident #26 xdemvy ophthalmic 0.25% solution multi-dose bottle for eye mites opened and not dated, Resident #31 Neomycin/polymyxin-Dexameth 3.5-10000 0.1% suspension bottle opened no expiration date on bottle. Resident #119 Brimonidine tartrate 0.2% solution opened [DATE], expiration date there is not one. Resident #20 Arformoterol tartrate inhalation Nebulization solutions 15mcg/2ml 5 pack with 3 vials left in the pack with no date when opened. Observed one loose pink tablet with writing L151 one side of tablet and a scored backside of tablet. One white oval tablet with F 91 on the back side of tablet. Observation on [DATE] at 10:39 AM with Registered Nurse (RN)/Unit manager M 2nd floor medication cart reviewed, Resident #59 latanoprost 0.005% solution eye drops opened and no expiration date. Not found on Resident #59's physician orders possible discontinued. Resident #21 lactulose 10/15ml bottle opened with no date when opened, seal broken, Resident #103 Haloperidol solution 2mg/ML date dispensed [DATE] with no open date. Not found on Resident #103's physician orders possible discontinued. Resident #103 Risperidone solution 1mg/ML was opened with no date on the bag or bottle. Resident #16 Latanoprost 0.005% solution eye drop had a open dated [DATE] on the bag and written on the bottle [DATE] Unit manager M could not say what day the medication was opened or when it would expire. Observation on [DATE] at 7:23 AM of the 4th floor with Licensed Practical Nurse (LPN) V 4th floor west cart #2 found 4 loose tablets: 3 round white scored tablets, one oblong half tablet white. Observation on [DATE] at 7:32 AM 4th floor East Cart #1, with Licensed Practical Nurse (LPN) W found one round white tablet scored tablet with L122 on the backside of tablet, and a blue capsule DL x 30. Observation on [DATE] at 8:53 AM with Licensed Practical Nurse (LPN) U put on gloves at the medication cart and left the medication cart unlocked in the hallway accessible to staff and residents. LPN U went into the resident #81's room, went into the bathroom looking for the resident, and then came back out into the hallway and started up the hall then realized that the cart was unlocked. LPN U found the resident in the main dining room, assisted back to his room and did not prime the insulin pen, injected into left upper arm, with same gloves on that she has worn for the entire medication pass from, pills whole with water. Observation on [DATE] at 7:35 AM surveyor observed unlocked medication cart on 3rd floor. Licensed Practical Nurse (LPN) U and LPN T both stated the medication care should have not been left unlocked, LPN U an LPN T both walked away from the medication cart leaving the cart unlocked the surveyor observed the cart. Medication Cart observed parked in the hallway accessible to residents and staff. Observation on [DATE] at 7:23 AM with Registerd Nurse (RN) Y medication cart revealed four loose tablets in cart: 2 round white tablets, 1 tan oblong tablet, 1 white oblong tablet. Treatment Carts review: Observation on [DATE] at 9:28 AM of the 4th Floor Hall treatment cart was observed to be unlocked and parked in the hallway close to the nursing station with residents passing by. Observation of the interior drawers of the treatment cart revealed: Purple pair of scissors noted in top drawer of unlocked treatment cart in the hallway. Ketoconazole foam 2% bottle 50gram. multi-dose bottle, box open with no date, bottle with no date when opened, no resident name. used. Bacitracin Zinc treatment 1 oz opened and used with no date opened or manufacturer expiration 3/2026. Diclofenac sodium topical gel 3% multi-dose tube opened with no date and no resident name. Silver sulfadiazine cream 1%, 85grams x2 multi-dose tubes both opened and used with no open date Santyl 250 units/gram, 30-gram multi-dose tube Manufacturer date 5/2026, no resident name, or date when opened. Skin integrity Hydrogel 4oz multi-dose tube with manufacturer date expiration date 4/2026. Dimethicone 5% cream 4oz multi-dose tube opened and no date Mupirocin ointment 2% tube 22gram multi-dose tube opened and not dated when opened, no resident name. Observation on [DATE] at 10:39 AM with Registered Nurse (RN)/Unit manager M 2nd floor treatment cart was reviewed after the medication cart was reviewed. 2nd floor Treatment cart review: Santyl ointment 250 units/g 30g tube well used with no open date manufacturer expiration date 2/2026, Resident #115 Mupirocin external ointment 2% in a 22grams tube was opened and used with no open date. Resident #75 Nystop Powder 10000 60 grams opened and not dated. Multi dose antifungal cream 3.75 oz tube opened and not dated. Multi-dose [NAME] Pain-Relieving Gel 4 oz tube opened not dated. Multi-dose Ketoconazole shampoo 2% 4oz bottle opened with manufacture expiration date 12/2025. multi-dose Wound cleanser 8 oz used with no open date. Dakin's solution full strength 16 oz. bottle opened used half bottle with no open date noted. povidone iodine prep solution 16 oz bottle with 1/8 bottle left well used no open dated noted. Hibiclens antiseptic skin cleanser 4 oz, opened and well used, with 1/4 bottle left no open date. Bandage roll x2 4.5in x 4.1 yards 6 ply expiration date [DATE]. Crash carts reviewed: Observation on [DATE] at 7:23 AM with Licensed Practical Nurse (LPN) V of the 4th floor med room review Crash cart review noted expired suction catheters with tray x2 expired [DATE], Suction extension hose x2 expired [DATE], opened ABD dressing pack left in the cart in the wrapper. Observation of the medication room revealed Blue top lab tubes expired [DATE] x2. Observation on [DATE] at 9:58 AM on the 3rd floor medication room review: Crash cart reviewed- Shiley size 6 DIC cannula trach expired [DATE]. Curaplex suction catheter 6 French expired [DATE]. Full set nebulizer kit with mouthpiece expired [DATE]. nonconductive connective oxygen tubing 20-inch length expired [DATE]. non-conductive connecting tube 6ft length by 3/16th diameter expired [DATE]. Continu-flo solution set 10 drops/ml set expired [DATE] x2 sets IV start kit with transparent dressing expired [DATE]. In an interview on [DATE] at 9:57 AM, the Director of Nursing (DON) was asked about insulin pens which were not dated and labeled with the resident's name. DON stated that of course insulin pens should be labeled and dated, Insulin are good for 14 to 28 days, depending on the type of insulin, Open dates should be on the pens, when labeled with resident name, Pen administration procedure dial up dose wipe the skin clean top of pen prior to needle application, clean the skin, apply to skin 5-10 seconds. then remove from skin. Prime the pen should be done with 2 units of insulin. DON stated that hand hygiene should be done between each resident medication administration, after glove use and when handling resident dressing changes. The surveyor requested medication administration, multi-dose medication dating policy, hand hygiene policies and the wound/dressing change policies. At the end of the survey the policies requested were not loaded into the egress document system by the facility. On [DATE] at 9:06AM, observation revealed the treatment cart on the second floor is unlocked and a drawer is open. There are medications visible and accessible to the residents. There are a pair of scissors observed in the top drawer. All of these items are accessible to the residents. These findings were verified with Registered Nurse (RN) D. RN D stated they would take care of it and close the cart. On [DATE] at 9:45AM, observation revealed the treatment cart on the 2nd floor is still open and accessible to residents. On [DATE] at 1:03PM, observation revealed the 3rd floor medication cart is unlocked and unattended. The water on the medication cart is dated 6/14.

Based on interview and record review, the facility failed to accurately assess and provide Influenza, Pneumonia and Covid-19 immunizations for five residents (Resident #3, Resident #6, Resident #11, Resident #13, Resident #70) of five residents reviewed for immunization status, resulting in no immunizations provided. Findings include: On 6/22/2026, at 1:26 PM, Director of Clinical (DOC) P was interviewed regarding immunizations the facility provided and DOC P offered, we don't have a process from what's needed for declinations and what's need for consents for immunizations although they have the MCIR's.A record review with DOC P was conducted of provided immunization information that revealed: A review of Resident #5's Resident Vaccination History & Consent Form Date 10-24-2024 revealed the resident declined all immunizations and marked yes for Covid-19. The MCIR was not provided. A review of Resident #13's provided MCIR revealed the resident was DUE NOW for PCV15/PCV20/PCV21(pneumonia); Covid-19 2025-2026. A review of Nursing admission 4/24/2026 . Has the resident had an influenza vaccination this year? N/A Resident admitted outside of influenza season . was check marked . Has the resident received any of the below listed pneumonia vaccines? . Unaware of what vaccine was received . was check marked. A review of Resident #3's provided MCIR revealed no immunizations dispensed or given for any pneumonia, influenza or Covid-19 vaccines. A review of Nursing admission 5/7/2026 . Has the resident had an influenza (flu) vaccination this year? . N/A Resident admitted outside of influenza season Has the resident received any of the below listed pneumonia vaccines? . Unaware of what vaccine was received . was check marked. A review of Resident #11's provided MCIR revealed DUE NOW Seasonal Influenza . Covid-19 . A review of Nursing admission 2/5/2026 . Has the resident had an influenza (flu) vaccination this year? . No, would like to receive at the facility . was check marked. Has the resident received any of the below listed pneumonia vaccines? . Unaware of what vaccine was received . was check marked. There was no facility provided documentation the resident received any flu, pneumonia or Covid-19 vaccines since admission. A review of Resident #70's provided Nursing admission 5/6/2026 . Has the resident received any of the below listed pneumonia vaccines? . Unaware of what vaccine was received . was check marked. There was no MCIR provided for the resident. A further interview with DOV P who was asked for any additional documents/information the facility assessed and provided the required immunizations and DOC P responded, I don't have the declinations or the consents. DOC P was provided additional time to obtain personal immunization documents for the above residents although was unable to produce. DOC P was asked to provide a list of residents that had received vaccinations in the facility. On 6/22/2026, at 4:17 PM, DOCP offered a line listing Medication Class: VACCINES . June 22 2026 16:16 PM (4:16 PM) . and clarified that was the list of residents that had received any vaccine since November 1, 2025. A record review along with DOCP revealed only five listed residents had received any vaccine from the facility. DOCP was asked how they could ensure going forward the facility would assess the need for all influenza, pneumonia and Covid-19 vaccines and DOCP stated, we need to reeducate the process. A review of the facility provided INFLUENZA AND PNEUMOCOCCAL DISEASE PREVENTION policy revealed In order to reduce the disease, morbidity and mortality associated influenza and pneumococcal disease, influenza and pneumococcal vaccines are offered to all residents .

Based on interview and record review, the facility failed to ensure that two residents (Resident #12 and Resident #112) or their guardians/representatives were fully informed, per consent, of the diagnosis/treatment for the use of psychotropic and/or antidepressant medications they were receiving of 5 residents reviewed, Findings include: Resident #12:Record review on 06/15/2026 at 3:41 PM of Resident #12's physician's orders noted medications of antipsychotic or antidepressant classifications. Physician's orders included: Lamictal 150mg give 1 tablet by mouth every 12 hours for bipolar, Celexa 10mg one table by mouth one time daily for depression, Quetiapine 200mg give 1 tablet two times a day for schizophrenia consent signed in 2025 In an interview and records review on 06/16/2026 at11:42 AM, Social Worker Z revealed that the facility policy was to get consents by drug classification. It's a nursing department to handle all the consents. Record review of Resident #12's medical record revealed that the social worker could not find a consent for Lamictal 150mg for bipolar disorder. The social worker reviewed the miscellaneous and evaluation tabs and found no consent for the Lamictal. An interview on 06/16/2026 at 12:04 PM with Social Worker Z revealed that the order is for Lamictal 150mg for bipolar disorder. There is no consent for bipolar use. Per psych note of 11/28/2025, Lamictal 150mg is for seizure management. The nursing staff used the wrong diagnosis. Resident #112: Record review on 06/15/2026 at 3:11 PM of Resident #112's physician's orders revealed antianxiety medication Ativan 1mg, every 8 hours for anxiety, lamotrigine 25mg one time daily for depression, and Trazadone 300mg at bedtime for mood. No consent was found in the medical record. In an interview and records review on 06/22/2026 at 10:34 AM, Social Worker Z reviewed the medical record of Resident #112 with the surveyor and stated that the physician's orders needed consents for Ativan 1mg every 8 hours for anxiety, Lamotrigine 25mg one time daily for depression, and Trazadone 300mg at bedtime for mood. There were no consents found in the electronic medical record. Social Worker Z stated they must be paper consents, and she would have to look for the documentation and get with medical records person. In an interview on 06/22/2026 at 10:46 AM, Social Worker Z revealed that no consents found in the evaluations that had been pulled apart. Social Worker Z stated that she knew that Ativan and Trazadone mood medication needed consents prior to the nurse giving the medications. The consents may be filed in medical records, In an observation, interview and records review on 06/22/2026 at 11:17 AM, Medical Records Staff BB in her office revealed that her process is to pick-up records at the nursing floor, come back to her office, separate and organize the paperwork then go to the front office and scan everything into the system, Point Click Care (PCC) system. Medical Records Staff BB accessed the PCC program for Resident #112. Observation of the medical record on Staff BB computer screen revealed that there were no consents in the system. Medical Records Staff BB stated that when she puts medication consents in the system, the consents are placed under the signed consent tab. Review of the consent tab just has the consent for behavioral health to treat the resident. Medical Records Staff BB stated that once the paper consent is scanned, the psychotropic consents are held for 30 days in a folder and then she shreds them. The facility told the employee to get rid of the forms. Review of the hold folder revealed that there were no forms for Resident #112 being held. Record review of the facility 'Psychotropic Medication Use' policy, dated 7/2022, revealed residents will not receive medications that are not clinically indicated to treat a specific condition. (2.) Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: anti-psychotics, anti-depressants, anti-anxiety medications and hypnotics. Residents, families and/or the representative are involved in the medication management process. Psychotropic medication management includes indication for use, dose, duration, adequate monitoring for efficacy and adverse consequences, and preventing, identifying and responding to adverse consequences.

Based on observation, interview and record review, the facility failed to assess, monitor, notify the physician and investigate an injury/open wound of unknown source for one resident (Resident #3) of three residents reviewed for injuries of unknown source, resulting in an open wound. Findings include:Resident #3:On 6/16/2026, at 8:50 AM, a record review of Resident #3's electronic medical record revealed an admission on [DATE] with diagnoses that included Gastrostomy status, Stroke and Dementia. The resident had severely impaired cognition and required extensive assistance with Activities of Daily Living. On 6/15/2026, at 2:21 PM, during enteral feeding care, Nurse V was asked what they saw on Resident #3's right hand and Nurse V provided, a dressing dated 6/14. On 6/15/2026, at 2:30 PM, a record review of Resident #3's treatment orders with Nurse V was conducted. Nurse V offered, I don't see a treatment order when asked why the resident had a dressing/treatment to their right hand. On 6/15/2026, at 2:57 PM, Unit Manager (UM) F was alerted that Resident #3 had a dressing to their right hand with no order. UM F offered that they would follow up. On 6/16/2026, at 9:07 AM, an observation of Resident #3's skin along with CNA JJ and UM F was conducted. There was a large border dressing that covered the entire back right hand/lower arm area with a handwritten date of 6/15. The dressing was grossly adhered to their arm hair. UM F was asked why they needed such a large sticky bandage. UM F offered, they were unsure what the order was. Um F removed the dressing and the resident flinched as the bandage was removed their arm hair. UM F used a warm wet cloth to assist with the bandage removal. The dressing had small amount of dark bloody drainage. There was Vaseline gauze covering the back of the hand. UM F removed the Vaseline gauze to reveal a reddened area approximately 2 inches by 2 inches with a center area with missing skin that measured approximately 1.5 centimeters by 1.5 centimeters and was approximately 2 millimeters deep. There was a small half pea sized scab to the outside edge. UM F was asked if the doctor had assessed the area and UM F offered, he'll probably look at it next day. Um F was asked how it happened and UM F was unsure how the injury happened. On 6/22/2026, at 9:08 AM, UM F was asked if they investigated and figured out what happened to Resident #3's right hand and UM F answered, No. I thought I told you that.On 6/22/2026, the facility did not provide an explanation as to how Resident #3's right hand injury happened prior to exit.

This citation pertains to Intake Number 299655.Based on interviews and record review, the facility failed to ensure that wishes for no life-sustaining treatment (Do-Not-Resuscitate) were followed for one resident (Resident #101) of 4 sampled residents reviewed for advance directives, resulting in an unwanted resuscitation and prolonged suffering.Immediate Jeopardy:The Immediate Jeopardy (IJ) began on [DATE].The Immediate Jeopardy (IJ) was identified on [DATE].The Administrator was notified of the Immediate Jeopardy (IJ) on [DATE] at 3:10 PM. A plan to remove the immediacy was requested.The Immediate Jeopardy was removed on [DATE], based on the facility's implementation of the removal plan.Findings Include:Resident# 101 (R101):According to the Facility's soft File Investigation on R101's incident, R101 was [AGE] years old, admitted to the facility on [DATE], and was discharged to the hospital on [DATE]. R101, upon admission on [DATE], was enrolled in hospice. A Do Not Resuscitate (DNR) order was signed by the legal representative (son) on [DATE]. On [DATE], R101 was discharged from hospice.R101's Brief Interview of Mental Status Score or BIMS Score, assessed on [DATE], was 10/15. A score of 10 indicates that an individual has moderately impaired cognition.R101 Determination of Decision-Making Capacity Form dated [DATE] determined that R101 is not able to participate in medical treatment decisions and handle his/her own financial affairs. Both were signed by the Attending Physician and a Psychologist, dated [DATE].Do-NOT- RESUSCITATE (DNR) Order Guardian Consent was noted signed by the Family Responsible Person (son) and dated by the family legal representative dated [DATE] and the Physician dated [DATE]R101 CODE Status (Advance Directives)On [DATE] at 1:30 PM, R101's Medical Treatment Decision Form was reviewed. R101's legal guardian indicated having selected the choice indicating, Do-Not-Resuscitate (DNR specifically: I have discussed my health status with my physician. I request that no person shall attempt to resuscitate me. I understand the full importance of this order and assume responsibility for its execution. This order will remain in effect until it is revoked as provided by law. The form was signed by the son (identified as the legal representative) on [DATE], and the physician's signature was noted on the form dated [DATE].A DNR (Do-Not- Resuscitate) Order Form was reviewed on [DATE] at 1:30 PM. It revealed: I authorized that in the event the ward's heart and breathing should stop, no person shall attempt to resuscitate the ward. I understand the full import of this order and assume responsibility for its execution. This order will remain in effect until it is revoked as provided by law. I acknowledge that I have attempted meaningful communication with the ward and that the ward has either agreed to this Do-Not-Resuscitate Order or has not communicated any objection to this Do-Not-Resuscitate Order. I further acknowledge that I have discussed the ward's condition with the ward's attending physician, and the physician believes that a Do-Not-Resuscitate Order is appropriate for the ward.A review of a recent care conference for R101 was held on [DATE], where the Son (guardian was present according to the IDT (Interdisciplinary Team) Care Conference. It was noted on the Social Services section in the Quarterly review noted by the social worker (dated [DATE]) that: Resident (R101) has a guardian-son (full name mentioned). It was written, No changes to advance directives as desired. Code status was reviewed and unchanged. There has not been a change in the resident's cognitive status since the last review. Care Plan Review and Education: Plan of care was reviewed, and any revisions/updates were completed. Diagnosis reviewed and updated as needed. PASARR reviewed. No education was provided during the care conference. The resident is doing well. She remains DNR. She has a guardian, her son (first name mentioned). R101 also has a designated conservator (full name differs from guardian was written).A review of R101's care plan for Advance Directives identified the following:R101's Care plan for DNR, initiated on [DATE], revealed that R101 received information and education concerning Advance Healthcare Directives and End-of-Life options as described in the POLST document and has chosen to be a DNR, or Do Not Resuscitate Status. Goal: Resident wishes for DNR status as specified in advanced directive documents will be honored and delineated in the medical record in compliance with state law, through next review.According to the family's Legal Representative D, interviewed by phone on [DATE] at 2:36 PM, the facility did not contact him when R101's condition changed. No one had contacted him about an emergency situation. R101 was sent to the Emergency Room, and the facility did not call him. I am the legal guardian. The facility waited 24 or 48 hours before contacting me. They said staff are being retrained and disciplined, but I don't know what happened and why. The family's legal representative thought it was odd. He spoke to the facility administrator and the DON. Damily D stated: I don't know. They called me to apologize. Neither the DON nor the Administrator said the reason why. Staff are being retrained and disciplined. But why? What happened. What does the retraining and discipline have to do with what happened? Later, I learned that my mom was found unresponsive, they did CPR, and called 911. No one from the facility had called me to say that something was wrong with my mother. I got a call from the hospital, which notified me of where she was and her condition. Family D revealed that he had spoken with the facility's Social Worker and confirmed the DNR. As her (R101) Legal Guardian. I wanted to make sure my mother's wishes were followed. I was part of every care she received. At the hospital, they asked if I was confused because her status was DNR in the previous hospitalization.I want to know what happened, andWhy did they not follow their wishes?Why were Emergency Services called?They found my mom unconscious, so why was the legal guardian not called and notified of the emergency change in condition?According to the Risk Management Report dated [DATE] at 0800 AM:Nursing Description: During rounds at shift change, CENA T (CENA A) informed me (unknown) she needed assistance in the resident room. I (unknown)immediately went to the room and noticed she was sitting up at a 40 degree angle in her bed, with shallow breath, asked for the crash cart, and directed staff to call 911 and code blue. Per CENA T resident (R101) stated, I feel I am about to die.Description: Code Blue initiated, applied oxygen/ambubag, attempted to get vitals, started CPR, Unit manager informed, DON informed, provider notified.Was the Incident Witnessed: NResident taken to the hospital: NA review of the Facility's SoftFile Report created by the Director of Nursing (DON) conducted on [DATE] at 1:30 PM revealed:Date the incident occurred: [DATE]. Upon verification, the DON indicated she realized the date in question was written in error on her part. The DON stated, It happened on [DATE] and not [DATE].The following details were included in the facility report:CODE time stamp0745 AM: CENA A (name mentioned in actual report) was concerned about R101 and went out to her nurse.0750 AM: Nurse B (name mentioned in actual report) hears R101 saying her breathing is bad this am, and Nurse B goes to get breathing treatment for her.0800 AM: CENA A returns to room and R101 is doing worse- calls to hall for more help; Nurse C comes to room to get vitals and assess.0810: CODE was called by Nurse C. Staff were directed to call 911 and to get the crash cart.08:18 Ambulance arrived.08:24 Police arrived.08:33 Paramedic arrivedAED used was not advised.0834: [NAME] was placed on R101 (*LUCAS device {[NAME] University Cardiopulmonary Assist System} is an automated, battery-operated mechanical CPR {Cardiopulmonary Resuscitation} machine)0836: first attempt IV unsuccessful0837: second attempt IV successful right hand0843: Pulse returned0846: Resident left enroute to the nearby hospital (name of hospital mentioned)Statements:CENA A statement written submitted by the DON: . I was holding her hand telling her (R101) the nurses were coming and she stopped breathing, I ran out to tell everyone to come on. The nurses came in. Nurse C was doing compressions, and I was getting the ambu bag and starting breathing (giving breaths via ambu bag). I was relieved by another nurse.Nurse C statement written submitted by the DON: . CENA A came out of the room stating she needed help for the patient, stating: We have a code. I (nurse C) responded to the code. When I walked in, I told them to get the cart and call 911. I initiated CPR with another nurse and CENA in the room. Someone started compressions, but it did not look correct, and I took over compressions while directing them to grab the Ambu bag. I directed the CENA to put the Ambu bag over her mouth, and we would be doing thirty (30) compressions for two (2) breaths. Within a few minutes, EMS arrived and took over CPR. I went to print a facesheet and get information to EMS. It was then that I saw the DNR Code status. I reported it to the Unit Manager, and the Day Shift Unit Manager Q went into the room and gave the face sheet to EMS.The DON on [DATE] at 1:30 PM was interviewed and admitted that she had done the risk management investigation. The DON was asked whether Nurse B or Nurse C had documented the incident in the EMR (Electronic Medical Record) or recorded the assessment of the event in the nurse's progress notes. The DON did not answer. The DON was asked whether she had written in R101's progress notes on [DATE]; she confirmed that she did not. The DON indicated that the late entries in R101's Progress notes were written by their Regional Clinical Nurse (RCN E), who entered the note the next day, [DATE]. The DON was asked if the Regional Clinical Nurse RCN Ewas present during R101's CODE incident on [DATE]. The DON indicated No, but the RCN E has remote access to our electronic medical record and has full access to the facility record remotely. Lastly, the DON was asked whether Nurse B or Nurse C should have written in R101's progress notes regarding the code incident and assessments on the day of the code incident. The DON stated, Yes. But they did not enter any notes. According to the statement written in the soft file investigation, the DON wrote, I was notified by the Unit Manager Q at 0830 AM on [DATE] that staff was doing CPR on a resident who was a DNR. I went upstairs to assist with the code, but R101 was already taken to the hospital.During the interview on [DATE] at 12:00 PM, the Administrator admitted that Nurse C initiated the CPR without checking R101's code status. 911 was called, a paramedic arrived and continued resuscitation, and R101 was transferred to the hospital. The Nursing Home Administrator admitted that the nursing staff made an error when they called the code and started CPR without verifying R101's Advance Directive status. They performed CPR when she was a DNR.When the administrator was asked how she learned about the event, she described that on [DATE], the administrator came to the morning meeting, and it was reported at the meeting that the code incident occurred when the resident was provided with CPR, called 911, was transferred to the hospital, but she was a DNR.The Administrator revealed that, from what she could gather, the CNA (A) got the nurse and stated she (R101) was scared to die and Nurse C called for a Code Blue, Code Blue meant to be a code for a medical emergency either a person/individual is having a cardiac or respiratory arrest requiring CPR (Cardiopulmonary resuscitation) or an Advanced Life Support (ALS).The Administrator asked where and what the facility failed to do?The Administrator indicated that Nurse B (the day shift assigned to R101) and Nurse C (the outgoing midnight nurse for R101) both failed to check the resident's (R101) code status, perform CPR, and call for Code Blue. She stated: Our policy for situations like DNR is that they give specific directives such as provide oxygen (O2) and other comfort measures. They should not do anything like CPR to DNR. That was the problem. The code status was not verified. And R101's wishes were not followed. It was written on R101's Face Sheet and all over the resident's record. The code status was specifically written as DNR. The staff discovered that she was a DNR only when EMS came to relieve them and after the nurses printed out the paperwork for hospital transfer.On [DATE] at 2:30 PM. The administrator and surveyor were reviewing the resident's Advance Directives Audit of the facility. While doing so, it was determined that the audit was incomplete because there were two (2) residents that did not have a designated advance directive identified. The Administrator agreed that the 2 residents were missed during the facility wide audit and therefore the two (2) residents will be added to a full code list. Without verifying if they do have an existing code status or not, the administrator was reminded facility's Resident's Rights and the Advanced Directive Policies to follow. Nurse C:An interview with Nurse C was conducted by phone on [DATE] at 1:47 PM. Nurse C admitted that during her assessment with R101 on [DATE], she observed that the resident (#101) started coding, so she initiated CPR (Cardiopulmonary Resuscitation). Nurse C described that she yelled and called for a Code, asked for the crash cart, used the AED (Automated External Defibrillator), and asked staff to call 911. All staff came to the scene and helped. Nurse C indicated that when EMS took over, they continued providing CPR. It was then discovered that R101 was DNR (Do Not Resuscitate) when they printed the face sheet and gathered the documents for the ambulance transfer. They saw R101's code status was DNR. Nurse C admitted that she did not verify code status before she started CPR. She did not recall if anyone else looked at and verified R101's code status. Nurse C revealed, There were many nursing staff who helped during the CPR, but nobody had validated the code status. Nurse C explained that she initiated the code because she believed the policy required CPR to be administered immediately if the code status was unknown. Nurse C stated that she believed the facility policy was to perform CPR if the resident's code status was unknown. According to Nurse C, she did not recall who was delegated to obtain the resident's code status, nor whether anyone checked the code status for R101. The error was that nobody had verified the code status. Nurse C admitted that she did not verify whether the resident was a full code or DNR before starting CPR.After the incident, the Code Meeting took place, and staff received in-service training discussing post-Code. Staff discussed the recap of the R101 code and told us the legal way was to determine the resident's code status before we provide CPR; we needed to figure out how to obtain the code status more quickly. We discussed what the meeting was about.Nurse B:An interview with Nurse B by phone was conducted on [DATE] at 1:30 PM. Nurse B stated she was assigned to R101 that day (7 a.m. to 7 p.m.) Nurse B revealed Nurse C started CPR to R101 when she was at the scene. Code was announced, and she ran to get the crash cart. She noticed the pads were missing from the crash cart, so she decided to get the AED from the second floor instead. AED pads were applied to the resident. Nurse B recalled she saw Nurse C let the head of the bed down and start CPR immediately. Nurse C Stated: I did not verify the code status, and because Nurse C started CPR, I assumed she (Nurse C) already knew the code status. Nurse B did not remember if she documented for R101 in PCC and noted the code event on [DATE]. There was a lot going on that day. She left her shift at 7:30 pm on [DATE].CENA A:An interview with CENA A was conducted on [DATE] at 1:20 PM. CENA A stated she had a rough week because they had 3 deaths that week. Nurse C was the MN Nurse assigned to R101. She was the outgoing nurse that morning. R101, during my morning rounds, was having difficulty breathing, and breathing became heavier. I called out for help and held her hand. Code blue was announced, and the crash cart came in. I left the scene. I stayed outside the door in case they needed anything. Nurse C started the CPR. She knew that R101 came out of the room on a stretcher with the ambulance people. There was no mention of DNR from what I remember.NURSE Q Unit Manager:Nurse Q was interviewed on [DATE] at 1:20 PM. When asked if she remembered that Monday morning on [DATE]? She revealed that although she came into the scene at the end. The ambulance stretcher was leaving, and LUCAS 101. [NAME] had already been applied for by the paramedic. I came in at about 9:00 am. I saw her when [NAME] was already on her. She documented in R101's EMR under SBAR, but it was a late entry in the nurse's notes for [DATE]. Nurse Q admitted it was written the day after the incident occurred. Nurse Q apologized for the late documentation.A review of the Nursing Progress Notes was conducted on [DATE] at 12:29 PM. There were no Nursing Notes entered by any of the nurses. Nurse B, who was assigned to R101 during the morning shift of [DATE] when the CODE occurred, did not document. Nurse C did not document in the progress notes after the successful CPR was initiated for R101, and the patient was transferred to the nearby hospital by ambulance. No nursing progress notes were found by any of the nurses who directly responded to the code and participated in R101's CPR on [DATE].A review of a Late Entry Progress note created by the Corporate Nurse Practitioner on [DATE] for [DATE] was noted.EMS RUN SHEET dated [DATE]EMS Run sheet was reviewed on [DATE] at 12:00 PM. The following details were noted:Incident #:2219326Incident date: [DATE]Type of Service Requested: Emergency ResponseDispatch reason: Cardiac Arrest/DeathResponse Mode to scene: Emergent response.Additional Response Mode Description: Lights and sirensEMS Narrative Notes: Responded Emergent with lights and sirens to find an [AGE] year-old female with cardiac arrest. Vitals as follows: Blood P: 0/0, Heart rate: 0 Resp: 0, SPO2: 0 Procedure Performed:Administered CPR. ManualMedications given:Administered Oxygen at 15 Liters/minuteNarrative: Dispatched 911 tier level:1, upon arrival to the facility (address mentioned) to find patient in cardiac arrest with nursing staff doing CPR. EMS took over CPR. Per nursing staff, the patient was a witness to a cardiac arrest.High-quality CPR was continued for 10 minutes. Until the county medic arrived at the scene. [NAME] device was placed on R101.IV started. After a round of CPR. Pulse was checked. R101 had ROSC (Return of Spontaneous Circulation)at 0842 [DATE].HOSPITAL RECORDS:Hospital Records were requested on [DATE] and were received electronically from the Hospital's Health Information Department on [DATE] at 11:00 AM. According to the Hospital Discharge Documentation, R101 was admitted on [DATE] and was discharged on [DATE] (deceased ). Length of Stay: 7 days.Chief Complaint: Respiratory arrest from the facility (name of the facility mentioned) brought in by a county paramedicHospital Course:An [AGE] year-old female with a history of cardiomyopathy, non-obstructive CAD (Coronary Artery Disease), hypertension, and multiple comorbidities presented following a witnessed cardiac arrest at a nursing facility. Patient (R101) was found in PEA (Pulseless Electrical Activity) arrest by EMS andunderwent one round of CPR with subsequent return of spontaneous circulation (ROSC). She was intubated in the field and transported to the emergency department.Patient remained intubated and unresponsive throughout hospitalization despite discontinuation of sedation. ete of Anoxic brain injury and poor prognosis for meaningful recovery, the decision was made to transition to comfort care measures on [DATE]. Patient passed peacefully in the early morning hours of [DATE]. A view of the facilities policies revealed the following:ADVANCE DIRECTIVESThe facility's Advance Directives and Care Planning Guidelines (effective date [DATE]) revealed, Guideline Purpose: It is the practice of the facility to establish, implement, and maintain written guidelines for advance directives. The resident has the right, and the facility will assist the resident in formulating an advance directive at their option. The facility will inform and provide the resident with a written description of the facility's advance directives. The resident has the right to accept, request, refuse, and/or discontinue medical or surgical treatment and to participate in or refuse to participate in experimental research.Definitions: Advance Care Planning is a process used to identify and update the resident's preferences regarding care and treatment at a future time, including a situation in which the resident subsequently lacks the capacity to do so, for example, when a situation arises in which life-sustaining treatments are a potential option for care, and the resident is unable to make his or her choices known.Advance directive means, according to 42 C.F.R. (489.100), a written instruction, such as a living will or durable power of attorney for healthcare, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. Some States also recognize a documented oral instruction.Addendum in the Advance Directives and Care Planning Guidelines (effective Date: 11.28.2017 is an Attorney-Client Privileged in Anticipation of Litigation CPR Evaluation Checklist. The purpose of the process is to confirm the facts of the occurrence to preserve the event accurately and completely, to identify opportunities, and to have a standardized process for root cause analysis, communication, and a plan for correction.The Facility's Post- Incident CPR Investigation Checklist:Question #5: Was the Code Status checked?Question #6: By whom was the code status checked?Question #7: How long did it take to check the code status?Question #8: Was the DNR or full code status complied with? . The facility's Policy for Residents' Rights (effective date: [DATE]) was reviewed. Purpose: It is the practice of this facility to provide for an environment in which residents may exercise their rights each day. Our residents have certain rights and protections under Federal Law. Our facility meets and provides these rights through care and related services at all times.Facility Removal Plan:The facility is providing the following information to demonstrate that the immediacy of the cited deficiencies has been removed.RESIDENT AT RISKResident #101 was transferred to the nearby hospital on [DATE] from the facility and died on [DATE]On 4.13.2026 at approx. 8:10 AM, the resident called out that she was dying and wanted help. She asked the CENA to hold her hand as she took her last breaths. The CENA called for help, and the nurse responded, initiating CPR, calling out to check CODE STATUS. EMS arrived at 0818 and took over CPR. The resident was transferred to the hospital and was on a ventilator until passing away on [DATE].IDENTIFYING OTHER RESIDENTS AT RISKResidents in the facility have the potential to be affected.On 4.15.2026, an audit was completed to review 100% of the current residents for appropriate code status was entered in PCC.PROCESSES IMPLEMENTED TO PREVENT FURTHER OCCURRENCEOn 04.13.2026, within an hour of the event, nursing leadership educated all clinical staff in the facility on the policy to check code status prior to initiating CPR. Staff that was not in the facility at time of the event were educated prior to taking care of any residentsPNC for advanced directive was started with a compliance date of [DATE] achieved.On 05.14.2026 an audit was conducted by social services to verify that all residents had proper code status entered in PCC. 100% compliance was noted in that auditOn 05.14.2026 an audit of all clinical staff in the facility was completed asking them to answer the question, what is the very first thing you do when someone stops breathing? There was 100% compliance that nurses answered to check the code status and CENAs answered to get the nurse and understood that there was no CPR until the code status was verified.MONITORINGThe DON/ Designee will interview 5 clinical staff members for what to do if a resident stops breathing (nurses expected response= check code status; CENA response get the nurse and check the code status) weekly x 4 weeks, then monthly x 3 months to ensure adherence to the facility's guidelines and practices.Results will be reported to the QA committee for monitoring and follow-up.The DON is responsible for substantial compliance of this Plan of Action.The facility alleges that the immediacy of these discrepancies has been removed on [DATE].

This citation pertains to Intake Number 2704522. Based on observations, interviews, and record review, the facility failed to protect two residents' (R401 and R403) right to be free from physical abuse by a resident (R402) of 8 residents reviewed for abuse, resulting in potential for psycho-social decline, fear of recurrent assault, and fear of pain and discomfort from physical assault. Findings include: Incident #1: (Residents R402 and R403 altercation on 12/7/25): A review of the Facility Risk Management Report #1333, dated 12/7/25 at 14:45 (2:45 PM), revealed: Type of Incident: Resident-to-Resident Altercation. Incident Location: Dining Room. Nursing Description: Was informed resident was in the dining room on the first floor and was hit in the face 3 times by another resident. Resident Description: Resident was unable to give a description. Other info: Resident (R403) was in the dining room waiting for smoke break time. Writer (Nurse A) was informed that another resident (R402) hit him in the face. A review of the following statements pertaining to the resident-to-resident altercation on 12/7/25 revealed:Nurse A on 12/7/25 wrote: There was a page overhead for help in the downstairs Dining Room. The writer was informed that my resident (R403) was hit in the face three (3) times by another resident (R402). He was brought back to his room on the 3rd floor. DON was aware of the situation. The current Administrator #2 on 2/11/26 at 2:00 PM revealed that, after the 12/7/25 incident (R402 and R403 altercation) was reviewed, we deemed the incident should have been reported to the state. The timeliness for this particular investigation showed that the Verification of Investigation Summary was completed on 2/5/26, equivalent to 60 days to be exact, from the incident of Resident-to-Resident Altercation that occurred on 12/7/2025. The facility investigation concluded: In conclusion: The facility acknowledges that the allegation of a physical altercation between residents was identified and taken seriously. Prompt follow-up, interviews by the administration were conducted with all parties involved. Certified Nurse Aide (CNA B) statement on 12/7/25 revealed: Standing at the counter, just arrived, looked in the dining room, and Resident (R402) hit Resident (R403) in the face three (3) times I went to stop it, and he (R402) then hit me in the face. After we separated R402 and R403 he (R402) went after another resident, B.B. Then Nurse B.J. Had a hard time assisting the resident back to the unit for safety. CNA B during the interview by phone conducted on 2/11/26 at approximately 7:45 AM, indicated that she witnessed R402 attack R403 in the first-floor dining room. CNA B described that she was standing at the receptionist desk when she heard yelling, and saw R402 punch R403 on the face three (3) times. R402 was standing on top of R403, who was sitting in his chair. R403 was unable to fight back. CNA B quickly tried separating both and received a hard punch on her face from R402. CNA B described how strong and hard a punch was. After successfully separating residents, R402 started swinging at other residents and staff. CNA 'B observed R403's apparent bruising on the face. When asked how R402 is like, CNA B described R402 as easily getting agitated, swearing and yelling a lot, and repeating the same words loudly. Staff E on 12/7/2025, wrote, R402 came out of the elevator towards the first floor dining room, cussing and yelling out the F word. CNA B told Staff E that R402 had the same behavior as yesterday. Staff E and CNA B noticed R402 was getting louder. Staff E said that CNA B walked towards the Dining Room, and CNA B yelled that R402 had hit another resident (R403). Staff E got up from the front desk office towards the Dining Room and saw R402 standing and swinging at CNA B while CNA B tried to keep R402 separated from R403. Staff E called other floor staff for help. Staff AP on 12/7/25 wrote, noted that she brought R402 back upstairs immediately, while the nurse (writer) told Staff AP that R402 was arguing with another resident, BB, and hit R403 in the face 3 times in the dining room.In the facility Risk Management Report, it was noted that the Director of Nursing (DON) was notified on 12/7/25 at 1624 (4:24 PM), approximately 2 hours after the incident occurred. According to the Director of Nursing (DON), during an interview conducted on 2//12/26 at 12:15 PM, she was aware of the resident-to-resident altercation incident that occurred on 12/7/25 between R402 and R403. The DON revealed that the abuse coordinator determined it was not reportable. Although it was witnessed by staff, R403 was unharmed and gave a thumbs-up when asked if he was okay. Abuse was not substantiated and was not reported to the state. Resident 403 (R403): R403 was [AGE] years old and was admitted to the facility on [DATE]. According to the Psychiatry follow-up dated 11/28/2025, his Brief Interview for Mental Status (BIMS) score is 0/15. A score of zero indicates severe cognitive impairment. It suggests the individual has significant difficulty with memory, orientation, and understanding. It is the lowest possible score, typically reflecting an inability to recall words or answer questions correctly. R403 was diagnosed with Hemiplegia and Hemiparesis affecting the Right dominant side after an intracranial bleed, Major Depression and Anxiety Disorder, in addition to other diagnoses. R403 was taking paroxetine HCL 10 mg 1X daily for mood, divalproex 250 mg delayed release 1 tablet daily (Mood stabilizer), and Seroquel 25 mg 1 tablet by mouth at bedtime. On 2/12/26 at 11:30 AM, a review of R402 and R403 clinical records was conducted. , there were no follow-up progress notes, post-assault assessments, entered in the Electronic Medical Record EMR pertaining to the resident-to-resident altercation. There was no follow-up assessment after 3 blows to R403's face were received. No notes, no description as to facial redness, bruising, or discoloration. No progress notes regarding R403's physical, social, or emotional status. There was no follow-up documentation for the signs and symptoms of pain. There was no record of a post incident assessment made by a Physician or Nurse Practitioner/physician assistant being in R403's records. There was no psych service referral, evaluation, or therapy referral performed for both residents, post incident. Resident #402 (R402): R402 was [AGE] years old admitted to the facility on [DATE]. According to the Social Service Director (SW I) dated 12/23/25, R402 had a BIMS score of 11/15. According to Cleveland Clinic (9/9/25), a BIMS score of 11 indicates the person has mild cognitive impairment (BIMS scores range from 8-12). According to his psychiatry follow-up dated 11//28/2025, R402 was on 3 medications: recommended by pharmacy for a Gradual Dose Reduction, namely, Seroquel 100 mg tablet for Dementia with associated psychotic and or agitated behaviors, and Depakote 500 mg tablet extended release 24 hours for Mood Stabilizer, and Sertraline 100 mg tablet for antidepressant. According to the Nurse practitioner, R402 is stable with no distress or worsening of behavior. After the incident on 12/7/25, R402 did not receive any psych or behavior referral until 1/13/26. During this follow-up psychology visit, the evaluation did not mention or refer to any incidents related to a resident-to-resident altercation that happened on 12/7/25 and 12/27/25. A Physician's Recommendation/Response for R402 post incident on 12/7/25 at 16:09 (4:09 PM), noted: Send to hospital for further evaluation and treatment as indicated related to behaviors. However, a Decline Order was noted on R402's Nurses Notes dated on 12/7/25 at 16:09. Noted text: Send patient out to hospital for further evaluation and treatment related to behaviors. After a mental status change, the resident is not being sent out per management request; the resident is going to be one-on-one for behaviors. The DON on 2/12/25 at 12:10 PM explained that: It must have been the Abuse Coordinator's decision to not send him out instead to provide 1:1. On 2/12/26 at 12:15 PM, the surveyor requested documentation and behavior observations related to the one-on-one (1:1) details starting on 12/7/25; however, the corporate staff and DON were unable to locate any documents to support the one-on-one supervision. A midnight staff member was assigned for 1:1 on 12/7/25, but none was presented to the surveyor on the next day or any day thereafter. There was no documentation of the start and end dates for the one-on-one planned intervention. No documentation of outcomes was found to demonstrate the intervention's effectiveness. A review of R403 progress notes found no entries after 12/7/25 until 12/30/25. This was confirmed by the facility's corporate nurse, who was on-site on 2/12/26 at 1:39 PM. When the corporate staff was asked, she did not respond. Staff member E on 2/11/26 at (time) described the incident that occurred on 12/7/25. She was the receptionist that day and stayed behind the receptionist and did not see the hitting but heard all the yelling and called for other staff overhead after she heard CNA B screaming that R402 was hitting R403. CNA 'B' saw the hit and was trying to separate the 2 residents. Staff E called other staff by paging them overhead to come to the first-floor dining room, where the altercation occurred. After the review of records, the Director of Nursing and Corporate Nurse at the facility on 2/12/26 at 1:39 PM confirmed that no documentation was entered in R403's Progress notes post-incident regarding the resident-to-resident altercation on 12/7/2025. There was no record of follow-up assessments. No post incident assessment was done by the MD/NP, and no psych referral notes were found in R403's clinical record. On 2/11/26 at 3:30 PM, SW1 stated she did not see R402 and R403 post incident. Not seen by a psych, not received psych services.2/12/26 at 12:15 Maintenance stated no video was retrieved. There is a video, but only available for a week. He did not recall looking for a specific incident, a resident-to-resident case in the dining area for both residents in question. SW I admitted not seeing the R402 after the 12/27/25 incident with R401. His BIMS Score is 11, but we don't know what triggers him to get agitated. The surveyor asked whether he often exhibits impulsive behavior. SW I stated that it has been observed often as his baseline, and they do monitor him on the behavior log called Task Behaviors. We tried putting him on anger management, but he was not receptive to it. He is delusional without triggers and unpredictable. SW I continued and described R403 as a sweet person and would never initiate any violent or physical altercation. He has a BIMS of zero. R403 was not seen by behavior services after the December 7, 2025, incident. He was seen later on January 8, 2026 (1 month after the incident). When asked why it took a month for Psych Services to see him. SW I did not have an answer. SW I revealed that she did not have a progress note entry for R403 because I did not know or hear about it. But the DON wrote about a referral, but they did not inform her. SW I denied knowing about the referral she was supposed to schedule. She did not send any referrals to psych services for both R402 and R403.Psychiatry Follow-up services dated 1/8/2026 were noted that R403 was last seen on 11/28/25. There was no indication in the 4-page evaluation that the Nurse Practitioner was aware of the resident-to-resident physical altercation that occurred on 12/7/25. Incident #2: Resident-to-Resident Altercation on 12/27/25 (R401 & R402): On 2/10/26 at 4:00 PM, the document labeled DON Investigation dated 1/2/26 (no time) was reviewed. It wrote: Resident R401's (first and last name was written) was interviewed and reported that she was assaulted in the day room near the refrigerator when another resident entered the area. R401 reported that R402 (the resident's initials were written) became visibly agitated and struck her multiple times, knocking her glasses off. Staff immediately intervened upon observing the interaction and separated both residents. The DON was interviewed on 01/26/2026 at 3:30 PM and requested the facility's investigation of the R401 and R402 incident that occurred on 12/27/2025. The DON verified that she was notified by phone about the incident on 12/27/25. She explained that since it happened on the weekend, she was not present at the facility. Instead, she completed the Facility Risk Management documentation and the investigation upon her return on 1/2/2026 (7 days after the incident). The DON stated no abuse occurred, and the incident was deemed not reportable because they did not substantiate that abuse took place. On 1/26/25 at 4:00 PM, the facility administrator #1, who was also the abuse coordinator, was not able to provide a full investigation at the time of the request. The Administrator #1 explained that it was not substantiated and was not deemed reportable. The Abuse coordinator was asked how they analyzed and came up with the conclusion of not substantiating abuse. She stated that there was no witness that she was assaulted. The Abuse coordinator was then asked if an alleged assault was reportable according to your policy. The abuse coordinator did not respond. The timeliness for this particular investigation Incident #2 involving (R401 and R402) showed that the facility's Verification of Investigation Summary was completed on 1/27/26. It took the facility 31 days to be exact, to complete the investigation and determine if the abuse is substantiated or not after a witnessed Resident-to-Resident Altercation occurred. The facility investigation concluded: that Res. #2 (R402) reported making physical contact with Res #! (R401) .In conclusion: The facility has determined that the allegation of abuse is unsubstantiated . A review of the police report dated 12/27/25 at approximately 6:29 PM revealed that officer F responded to the 911 call and, upon arrival, interviewed the complainant (referred to as R401), who stated that R402 (referred to as the assailant) punched her on the face. Officer F noted in his report that he observed a slight redness on the right side of R401's face. R401 was asked by the officer if she knew why R402 punched her. R401 replied that she was not sure why R402 punched her on the face. During the interview with R402, Officer F written report revealing that R402 was described as having difficulty communicating. When Officer F asked R402 if he punched R401 on the face? R402 told the officer Yes, and then he made a motion like he balled his fist up and swung a punch. Although the police officer's report redacted some words, the officer clearly wrote that Due to the male's (redacted words) was unable to be placed in handcuffs or lodged at jail (name of county mentioned). Reviewed Police report Case No. 2539906252 on 2/10/26 at 4:00 PM. Resident 401 (R401): R401 was [AGE] years old and admitted on [DATE] with the diagnosis of Bilateral Osteoarthritis of the knee, Post-Traumatic Stress Disorder (PTSD), Major Depressive Disorder, Schizophrenia, and anxiety disorder in addition to other diagnoses. According to the assessment dated [DATE], R401's BIMS score was 13/15. A score of 13-15 indicates that a person is cognitively intact. It signifies normal memory and thinking skills with little to no cognitive impairment. R401 takes Depakote 250 mg delayed-release (2 tablets at bedtime), Paxil 20 mg (1 tablet daily), Fluphenazine decanoate 25 mg/ml injection every 2 weeks, and trazodone 100 mg tablet daily. Nurse's notes dated 12/27/25 at 1815 (6:15 PM) were reviewed. Nurse wrote: Resident was attacked in the day room by R402 (writer used the resident's room number as identifier). An interview with R401 was conducted on 2/11/26 at 4:38 PM. She was asked if she recalled the incident on 12/26/25, and R401 revealed: I was assaulted about maybe ten (10) times on the head. My glasses flew off the floor from the hit; it scared me. When asked how it happened, R401 indicated that she was on the chair asleep in the dining room (2nd floor) and all of a sudden boom, 10-12 hits on her face. I screamed for help! The man pulled me off the chair, so I fell off, and he started kicking me on the floor. No one was there until CNA P arrived and helped me. After the incident, I just wanted to be by myself in my room because I did not feel safe here. Staff doesn't make me feel safe. Did the nurse examine you? She said, I was telling them I was in Pain and I was bleeding from my mouth. They found blood on my pillow the following day. I think it loosened my teeth, and I saw the dentist after that. It just started bleeding after I was hit hard on the face. R401 emphasized that she was so scared the entire time, until R402 was finally moved upstairs to the 4th floor last week. An interview with CNA D was conducted on 2/10/26 at 3:15 PM. She indicated that on 12/27/25, she was at a resident's room feeding and heard Help! Help! Help! She came out to respond and saw R401in contact with R402. I did not see him hit her, but she was on the floor next to her chair while R402 was sitting at the edge of his wheelchair, making loud outbursts, on top of her with both of his arms in motion to strike her. I separated them immediately by pulling R402 away from R401 and locked his wheels. I then gave R401 a hand so she could go back to her chair. Since R401 was a one-transfer assist, I got her up without calling the nurse because she appeared very scared. I told the nurse what happened, and she took over. We then called 911. R401 was so scared that she did not leave her room for 2 days. That is very unusual for R401. No other staff or residents were in the dining room at the time of the incident. The nurse and other CNA were providing patient care. CNA D did not recall if R402 was placed on 1:1. CNA D had a full set of residents. She denied being assigned to do a 1:1 bot on Saturday and Sunday. A follow-up nurse's notes dated 12/28/25 and 12/29/25 revealed: 12/28/25 at 1658 (4:58 PM) Nurses Notes revealed (Day1 post allegation of attack): Note Text: Resident (R401) sister here, noticed blood on her sheet, which was not there earlier this afternoon. states her tooth is bleeding and is concerned that it could be from her being attacked last night. Assessed resident noticed some old blood around the tooth, and the tooth slightly loose. 12/29/25 at 07:22 AM Nurses Notes revealed (Day 2 Post allegation of attack) Note Text: resident has blood spots on her down, dried, stated it's from her tooth, encouraged to gargle with salt water, refused, Nope. On 12/31/25, at 15:25 (3:25 PM) R401's Pain level was documented at 10/10. 10 being the highest pain level. On 2/12/26 at 12:00 PM, The DON was asked if she can find more documentation from the nurse who assessed R401, if she had documented where the pain was, the quality/ type of pain and what she administer for pain relief? The DON returned with no documented information except that it was unusual for R401 to have a 10-pain scale. The DON indicated that R401 average pain level was at 4 or 5 but never a 10. The nurse who documented this pain was not available for interview at the time of the query. CNA D revealed the following day, Sunday,12/28/25, they observed blood on her covers. R401's sister caught my attention. She was bleeding from the mouth. It might have been because of the altercation the day before. The CNA D stated R401 did not have bleeding or blood stains on her pillow before. She was often assigned to her and observed no episodes of bleeding prior to the incident. She just expressed herself as being afraid. R401 was observed to be more withdrawn and stayed in her room. She often plays Bingo and participates in all the activities downstairs. After the incident, she stayed in her room and asked me (peeking her head at the door), Is he out there?CNA G was interviewed by phone on 2/11/26 at 7:36 AM. CNA G stated that, She was afraid after the incident. She did not want to leave her room and said to CNA G, I'm scared. CNA G went and told the nurse. When CNA G was asked about R402, he said, He has seen him angry, and he just reminds him to calm down. He did not remember if he was on 1:1 after the incident. He was not assigned to do 1:1 supervision. Activity Director H noted in R401's progress notes her observed decline in activity participation following the incident. Progress Notes dated 1/14/26 at 11:39 AM, noted Activities Participation Note. Note Text: Writer spoke with the resident regarding her decline in activity participation and asked if there was anything special that she would like to do. Resident states she has not been coming out of her room as much as she once did and that she has been enjoying her peaceful time, noting her sister has been visiting her often. The resident states she still attends bingo and other activities that she is interested in, but not as often as she once did. The writer asked if there were any activity materials she would like at bedside, and she states she is fine. The Activities Director H was interviewed on 2/12/26 at 10:40 AM. Activities Director H verified that. I noticed I haven't seen her to couple of bingo. And the church service lady for the evening service did not come. R401 said she was just relaxing. The Activities Director H noticed she had not been in bingo, and the spiritual lady asked about her and noted her absence and participation. Social Worker I was interviewed on 2/11/26 at 3:15 PM. When queried about the R401 and R402 Altercation incident on 12/27/25, SW I stated she was off during the time it happened and did not hear about it until her return post New Year. It was almost a week later when I returned on January 2nd. R401 appeared groggy but did not look scared. R401 did not want to talk about the incident. The Administrator #1 saw R401 on 1/5/26 and said she was fine. She was not seen for psych services post-incident. The Facility's Policy entitled The Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, dated 11/28/2017. Abuse Policy (Page 4 of 14) revealed: 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. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection.E. Investigation (page 8 of 14) 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.G. Reporting and Response (page 11 of 14) It is the policy of this facility that 'abuse' allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the alleged violation is made. The Administrator #2 on 2/11/26 at 2:20 PM validated that the 2 incidents of Resident-to-Resident (physical) altercation witnessed or unwitnessed or an allegation of abuse should have been reported and taken seriously by the Abuse Coordinator (Administrator #1).

This Citation pertains to Intake Numbers MI00144801, MI00146247, MI00146288 and MI00146298. Based on observation, interview, and record review, the facility failed to provide equipment (mechanical lift) which was safe and ensure that it was in good repair to transfer residents for one resident (Resident #12) of three residents reviewed for falls, resulting in a fall, while being transferred using a mechanical lift, resulting in multiple fractures at T11, L1, L2, L3, L4, and L5 and left shoulder dislocation, requiring hospitalization , pain control management for severe pain, surgical intervention, and potential for complications and a decline in medical condition. Findings include: Resident #12 (R12): A review of the Facility's Incident and Accident (I/A) Report dated 8/8/24, noted as follows: -Date and time of incident: 8/8/24 10:20 AM . -Nursing Description: CENAs (Certified Nursing Assistants) was getting her up with Hoyer Lift (mechanical lift) when the strap broke resident fell on her back, cenas notified . -Resident Description: resident stated strap broke and she fell out of lift . -Immediate Action: writer sent guest to hospital (hospital name mentioned) . -The facility described the incident as: Malfunction Hoyer lift. On 8/9/24, a review of the facility investigation revealed the facility identified areas during the facility investigation related to R12's fall sustaining multiple injuries as follows: 1. Hoyer slings were fraying, holes and/or malfunctions after laundry. 2 CNAs witnessed (R12's name) fall and described the fall happened so quickly. They revealed that the sling used during (R12's name) transfer was defective and ripped from the seam, causing the sudden fall straight down, landing on her bottom and lying down across the legs of the lift in an awkward position with (R12's) back (Shoulder) on one of the lifts leg and her hips on the other leg of the lift. 2. Employees are to receive education/ training on the proper use of Hoyer lifts before using the Hoyer lift. 3. Residents requiring a Hoyer lift for transfers were audited for using the appropriate of the sling. On 8/14/24 at 4:00 PM, a review of R12's Emergency Department/Hospital Records revealed: -(R12's name) arrived at the Emergency Department (ED) on 8/8/24 at 10:33 am and presented as a Fall (approximately 4 feet from the ground) at her facility. Following the fall, the patient was reporting mid and low back pain. Patient admitted for pain control with: Chief complaint: Fall patient was in Hoyer lift at (facility named). Fall from a height greater than 3 feet caused by the strap on Hoyer lift broke, and the patient fell to floor . -During the course at ED on 8/8/24, Radiology revealed the following: Computed Tomography or CT of the thoracic and lumbar spine revealed an oblique fracture involving the anterior half of the T11 vertebral body without significant height loss or retropulsion. Additionally, there is a fracture involving the right transverse of L1, L2, L3, L4, through L5. - Xray Left shoulder and Left Humerus 8/8/24 at 17:30. Final Result revealed: Indication: left shoulder pain .Impression: Antero-inferior left shoulder dislocation. On 8/14/24 at 7:45 am, R12's Electronic Medical Record (EMR) was reviewed. R12 was [AGE] years old admitted to the facility on [DATE] with the following diagnosis: Hemiplegia and Hemiparesis following Cerebral Infarction affecting the left non-dominant side, Type 2 Diabetes Mellitus with Hyperglycemia, and Chronic Obstructive Pulmonary Disease with acute Exacerbation in addition to other diagnoses. R12's Care Plan was reviewed, revealing that R12 has an ADL (Activities of Daily Living) Self Care Performance Deficit related to Hemiplegia S/P CVA. Interventions and tasks specified extensive assistance, particularly for personal hygiene and grooming, extensive assistance in bathing and dressing, needed two to extensive assistance with bed mobility, and was totally dependent on two staff using mechanical lift with two staff assistance with transfers initiated on 5/17/2024. R12's Brief Interview of Mental Status BIMS Score=15/15 assessment dated on 7/25/24 that indicated intact cognition. The facility's Nursing Progress Notes dated 8/8/24 at 9:15 AM revealed: Date of Fall 8/8/24. Pain assessment:10. Vitals B/P=205/167, P-97, R-20, T97.88, O2 Sat 98% The facility's Practitioner Progress Notes dated 8/8/24 at 10:30 AM revealed: Provider received a phone call from the nursing manager and was made aware that the patient had a fall from the Hoyer sling. A verbal order was given to transfer the patient to the ER for evaluation. According to the Director of Nursing (DON) on 8/13/24 at 11:00 am, the DON indicated that R12 fell on [DATE] while on a Hoyer lift, and the sling was defective and broke while transferring R12 from the bed to the wheelchair. The DON described how R12 fell , which was that R12 fell out of the sling and landed on top of the legs of the Hoyer lift. There were 2 CENAS, and two nurses were called in the room after the fall. The strap of the sling broke and the Resident fell on the floor. The DON further explained that the fall was caused by a defective sling used in the Hoyer lift for R12. The strap of the sling ripped while the resident was on the lift and R12 fell out of the lift. The Administrator, on 8/13/24 at 11:12 am, explained that: The deficiency was that the staff did not inspect and look at the condition of the sling before they used it on a resident. As a result, R12 fell and was sent to the hospital for further evaluation and severe pain. We later learned that R12 sustained a fracture of T11, L1 up to L5. The Administrator explained, we looked at the incident and the root cause. We assessed every sling in the building and identified the ones to be defective. R12 weight 273. 2 lbs. with total dependence on staff during transfers and mobility was reviewed. When the Administrator was asked if they had kept the sling that R12 was on before falling, she said that they had discarded the sling used during R12's fall and got rid of most of the damaged slings found to be defective and unsafe. CENA A was interviewed on 8/13/24 at 11:57 am. CENA A recalled that she assisted CENA B in transferring R12 from the bed to the wheelchair, and R12 was already lying on top of the sling by the time CENA A arrived to help CENA B at the scene. CENA A positioned herself by the Hoyer lift post and operated the remote, while CENA B was by R12 as the Resident was lifted. When CENA B turned R12 towards the chair, the strap broke, and R12 slid and fell out of the sling. It just ripped. When CENA A was queried if she had observed or inspected the condition of the sling used before the transfer, she said: I did not see the condition of the sling that was used because (R12) was already on the sling when I got there. I went and got the nurses, and they came to assess (R12) after she had already fallen. The sling ripped from the seam of the sling. (R12) was screaming in pain while she was laying uncomfortably on both legs of the lift. (R12) was crying. The CENA indicated she did not recall any recent Hoyer Lift in-service education but had it when she first started 5 years ago and annually. An interview with CENA B was conducted. CENA B revealed on 8/13/24 at 11:30 am that she was assigned to R12 when she was getting ready to get R12 up at around 9:00 am on 8/8/24. CENA B has asked another CENA (CENA A) for assistance. CENA B explained that she was a newly hired CENA who had started about two weeks ago. The other CENA (CENA A) was doing the remote and stand by. CENA B recalled that the sling R12 was in ripped, and the resident fell . CENA B was asked how high R12 was on the lift when she fell . The CENA reported, it was high enough above the bed, and as R12 was turned, the sling ripped, and R12 fell so quickly, landed on her bottom first, and then fell on her left side with R12's shoulders and hips positioned across both legs of the lift. CENA B recalled that R12 was screaming in pain and they called for the nurses right away. Nurse C, during an interview conducted on 8/13/24 at 11:13 am, stated: We were called to (R12's name) room and found (R12) was laying across the two legs of the Hoyer Lift when we got there. One of the lift straps broke, and (R12) fell from the lift. (R12) was yelling in pain. Upon arrival at the scene, (R12) was assessed at the pain scale level of 10/10 on her lower and mid back. We found her lying on the floor with her shoulder and hips resting on both Hoyer Lift legs. (R12) was yelling out in pain. Nurse C recalled that although R12 was screaming in pain at a 10/10 level, Nurse C did not administer any pain medications. Nurse C said she was worried about why the ambulance took so long to arrive and was calling R12's emergency contact. Nurse C indicated the sling was defective and ripped from the seam. Nurse C further stated that the sling must have been ripped before but was not inspected before R12 was lifted. Nurse C indicated that during the audit after the fall, they found more damaged, frayed slings with some having tears and holes on the slings. Nurse D was interviewed on 8/13/24 at 11:46 am. Nurse D revealed she was passing medications assigned to her when Nurse C asked for help with R12. R12 was not assigned to Nurse D at the time of the incident. Nurse D described how R12 was found on the floor when both nurses arrived at the scene. R12's shoulders and thighs were positioned on the Hoyer lift's legs (across the 2 bars)and R12 was crying in pain and discomfort. Nurse D assessed R12, and when she asked what had happened, Nurse D reported that R12 pointed at the broken strap and was saying, I'm hurt repeatedly. R12 was removed from the uncomfortable Hoyer legs and used a different sling transfer her back to bed. Once the transfer was completed, Nurse D left to continue with the medication administration. When Nurse D was asked how R12 fell , Nurse D stated that: I was not there and did not see what happened. Nurse D, however, indicated that she asked the resident what happened and R12 pointed at the strap of the lift, which was broken. An observation was conducted at the facility to find slings on 8/13/24 from 1:00 PM to 1:30 PM. Nurse C with the surveyor, went around the facility to search for slings from the laundry room on the 1st floor to every floor from the 2nd floor, 3rd floor, and 4th floor linen storage rooms and residents' area, but there were no slings available at the entire facility found. The residents were on their slings individually, and the surveyor could not inspect the condition of the slings because the residents were sitting on them. The surveyor asked the nursing manager and the Administrator for any slings in the facility that were currently not in use. No slings were available at the time. The facility policy on mechanical lifts was not the same brand and model used at the facility. The lift that was found in R12's room was colored Blue with LINAK Brand Type: CBJX00XWE112171 ITEM: CBJ2026-02, LINAK Designed in [NAME] DK-6430 Nordborg Type: BAJ100001XX1, Item: BAJ1010-00 Date 01/16/2023 W/O # 805304-011.The lifts at the facility were observed and noted as not a Sunshine Manufacturer/Brand. They were incompatible with the operator's manual used to provide education/in-service to the facility staff. When queried, the Administrator 8/13/24 at 2:30 PM revealed they did not have a facility policy on the use of mechanical lifts. They use the Sunshine Medical (Brand) Mechanical Lift as a reference for the staff during post-incident/fall education after the 8/8/24 fall incident. The Administrator confirmed that the facility used the same reference manual even if the mechanical lifts are from different manufacturers. They do not currently have the manufacturer/product manual for the Linak Mechanical Lift or the Agiliti Mechanical Lift, which is presently used at the facility for residents requiring mechanical lifts for safe transfers. The Administrator stated that they reached out to the Hoyer Lift companies for the procedure/product manual and waiting for reply. A review of the Mechanical Lift Reference Manual revealed the following: .Company/Product Name: Hoyer Heavy Duty Patient Lift Manufactured for Sunrise Medical Model Number: HPL 600 Date of Manual: undated Important Safeguards/ Warning: . Hoyer floor lifts are specifically designed for Hoyer slings and accessories. Slings and accessories designed by any other manufacturer are prohibited and will void Sunrise Medical's warranty. Use only Hoyer slings and accessories to maintain user safety and product utility . . Hoyer lifts must be used by a caregiver with proper training to work with the person to be transferred . . Do not use a sling that is not recommended for the lift . .Never use a damaged, torn, or frayed sling . A review of the Facility Incident Report dated 8/8/24 at 10:20 am revealed: Nursing Description: CENAS was getting her up with the Hoyer lift when the strap broke. The resident fell on her back, CENAS notified .Resident Description: The strap broke and fell out of the lift .Immediate Action: Sent guest (R12) to the Hospital . Pain: (Numerical) 10 .Injuries Report Post Incident: Unable to determine . Nurse C confirmed on 8/13/24 at 11:13 am that she had filled out the I/A Report and sent R12 to the hospital. However, Nurse C revealed that she did not provide the resident pain relief despite the complaint of 10/10 pain. When asked why, Nurse C justified that she got busy getting R12 ready for the ER and calling the emergency contact. The facility Policies submitted were reviewed on 8/13/24 at 3:00 PM: -Incident Reporting- Accident and supervision (Revised date: 6/23) -Fall Reduction Policy-( Revised date: 4/23) -General Washing Procedure for Slings Sling & Chemical or Heat Sensitive Item Laundering Procedures (not dated) -Hoyer Heavy Duty Patient Lift Model HPL600 (Installation and Instruction Manual (undated) The policies submitted above did not contain the specific educational content to correct the deficiency of ensuring the use of proper slings according to the mechanical lift manufacturer's brand and staff checking the condition of the slings and appropriateness prior to patient use.

Based on interview and record review, the facility failed to ensure that a resident's pain medication was administered as ordered to treat pain for one resident (Resident #46 ) of 1 resident reviewed for pain management, resulting in the resident's verbalizations of unrelieved pain, frustration and helplessness. Findings Include: A review of the facility policy titled, Pain Management, date reviewed/revised 1/24 provided, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standard of practice, the comprehensive person-centered care plan, and the resident's goals and preferences .The facility utilizes a systematic approach for recognition, assessment, treatment, and monitoring of pain .To help a resident attain or maintain his/her highest practicable level of well-being and to prevent or manage pain, the facility should: Recognize when the resident is experiencing pain . The interventions for pain management will be incorporated into the components of the comprehensive care plan .As general reference, unless otherwise specified, when a numerical scale is utilized to evaluate level or severity of pain, consider the scale as below: a. Mild Pain (#1-3); Moderate Pain (#4-7); Severe Pain (#8-10) . Resident #46: Pain Management A review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #46 indicated the resident was readmitted to the facility on [DATE] and again on 8/16/2023 with diagnoses: history of a stroke, dysphagia, irritable bowel syndrome, epilepsy, dementia, depression, hypertension diabetes, atrial fibrillation, bipolar disorder, COPD, gastrostomy tube, asthma, chronic pain, acquired absence of left leg below knee, GERD and heart disease. The MDS assessment dated [DATE] indicated the resident had moderate cognitive loss with a Brief Interview for Mental Status (BIMS) score of 11/15 and the resident needed assistance with all care. During a tour of the facility on 5/19/24 at 11:39 AM, Resident #46 was observed rubbing his legs, especially his left upper leg. The resident was asked if he was having pain and he stated, My knee and hip are killing me and have been for the last week, but especially today. The resident was asked if he normally received pain medication and he said he usually received pain medication. When asked if he received it that morning, he said he didn't know. On 5/19/2024 at 11:40 AM, Nurse K was observed outside the door of Resident #46 with her medication cart. The nurse was asked if the resident received pain medication and she said Resident #46 was scheduled to receive a Norco/oxycodone/acetaminophen at 12:00 noon. Nurse K said she would give it to him soon. Discussed with Nurse K that the resident appeared very uncomfortable and was repeatedly rubbing his legs. The Nurse said Resident #46 was to receive the Norco every 4 hours via a feeding tube/peg tube. During the interview with Nurse K on 5/19/2024 at 11:40 AM, the surveyor asked Nurse K to review the narcotics log for Resident #46's Norco pain medication. The narcotics log showed the Norco was signed out on 5/19/2024 at 8:00 AM and 11:00 AM. The nurse was asked if she already gave Resident #46 the pain medication and she said she was going to give it. Nurse K was asked where the Norco pill was if she already took it out of the cassette but did not give it to the resident. The nurse did not respond and then pointed at the top drawer of the medication cart. It was unclear what she was pointing at; she then removed a small medication cup from the back of the drawer; the medication cup said 16-2. The nurse said the resident was in room [ROOM NUMBER]-2. There were approximately 10 pills in the cup. Nurse K was asked if it contained the Norco and she said it did. The Norco pills in the medication cassette were compared to the pills in the medication cup and it was confirmed there were 2 Norco in the cup, plus a variety of other medications. The resident had not received his morning medications, including the Norco at 8:00 AM or 12:00 PM. On 5/19/2024 at 11:50 AM, Nurse K took the resident's medications including the 2 Norco, crushed them and administered them to Resident #46 via the feeding tube/peg tube. A review of the physician orders for Resident #46 revealed he had an order for Hydrocodone-Acetaminophen tablet 5-325 mg every 4 hours, revision date 4/1/2024 and start date 4/1/2024. A review of the May 2024 Medication Administration Record for Resident #46, identified the following: Hydrocodone-Acetaminophen 5-325 mg: Give 1 tablet by mouth every 4 hours for pain, start date 4/1/2024. This included a Pain Level assessment to be completed every 4 hours when the resident received his pain medication. On 5/19/2024 the resident had the following Pain Level ratings on a scale of 0-10 with 10 being the highest level of pain experienced: 12:00 AM = 0; 4:00 AM = 4; 8:00 AM = 0; and 12:00 PM = 8. The resident's pain scores were usually between 0-5. The resident was asked what his pain level was based on the 0-10 scale and then the nurse recorded it. On 5/19/2024 at approximately 12:00 PM, Resident #46 rated his pain a high score of 8. He had not received his 8:00 AM or 12:00 PM doses of pain medication. On 5/19/2024 at 12:20 PM, the Director of Nursing/DON was interviewed related to Nurse K removing Resident #46's medications including narcotic pain medication from the narcotics drawer and not providing them to the resident. He said he was not aware of that. He said Nurse K was a Nurse Manager and had picked up an extra shift 5/19/2024 (Sunday). Reviewed with the DON that Nurse K had signed Resident #46's narcotics out of the double locked medication drawer, placed them into a single locked drawer and chose not to give them to the resident, until she was repeatedly asked where the medication was. He said that was not acceptable and he would look into it. The DON was asked for a copy of the Medication Administration Record with times administered for Resident #46 on 5/19/2024. Resident #46's 7:00 AM medications were all documented on the Medication Admin Audit Report as given at 9:30 AM, but they were still in the medication cup in the top drawer of the medication cart at 11:40 AM, as confirmed with Nurse K. The 8:00 AM Norco was documented as given at 9:24 AM, but it was also in the medication cup. The 12:00 PM Norco was documented as given at 11:47 AM. This was the time Nurse K was observed giving all of the morning and noon medications. A review of the nurses notes on 5/19/2024 and on 5/22/2024 indicated the nurse had not notified the physician that she had withheld two doses of Resident #46's narcotic pain medication and did not provide the resident with his medications as ordered. An MDS note dated 5/17/2024 identified the following: Interview and assessment done, resident is alert and able to make needs known . Resident states frequent left hip pain over last 5 days and rates it an 8 on zero to 10 scale, states that pain meds help to relieve pain . A review of the Care Plans for Resident #46 provided: I am at risk for pain related to diabetes, COPD, PVD(peripheral vascular disease), CAD(coronary artery disease), phantom pain left limb status post below the knee amputation, date initiated 8/17/2023 and revised 5/21/2024, with Interventions including: Administer analgesia as per orders. Give 1/2 hour before treatments of care, date initiated 5/21/2024; Anticipate my need for pain relief and respond immediately to any complaint of pain, date initiated 8/17/2023 and revised 5/21/2024. On 5/29/2024 at 8:45 AM, the Administrator was interviewed about Nurse K intentionally not providing Resident #46 with his medications, including his narcotic pain medication. The Administrator said Nurse K walked out of the facility and quit 5/22/2024 in the middle of her shift. A review of the facility policy titled, Resident Rights, dated reviewed/revised 2/24 provided, The facility will inform the resident both orally and in writing, in a language that the resident understands of his or her rights .All residents will be treated equally . The facility will ensure that all direct care and indirect care staff members, including contractor and volunteers, are education on the rights of the residents and the responsibility of the facility to properly care for its residents . The right to receive the services and/or items included in the plan of care .

Based on observation, interview and record review, the facility failed to protect a resident's right to be free from neglect for one resident (Resident #46), of one resident reviewed for neglect, resulting in Resident #46 having necessary medications, including narcotics, withheld without his knowledge or his physician's approval, which lead to pain, suffering, distress, and the potential for narcotic diversion. Findings Include: Resident #46: A review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #46 indicated the resident was readmitted to the facility on [DATE] and again on 8/16/2023 with diagnoses: history of a stroke, dysphagia, irritable bowel syndrome, epilepsy, dementia, depression, hypertension diabetes, atrial fibrillation, bipolar disorder, COPD, gastrostomy tube, asthma, chronic pain, acquired absence of left leg below knee, GERD and heart disease. The MDS assessment dated [DATE] indicated the resident had moderate cognitive loss with a Brief Interview for Mental Status (BIMS) score of 11/15 and the resident needed assistance with all care. During a tour of the facility on 5/19/24 at 11:39 AM, Resident #46 was observed rubbing his legs, especially his left upper leg. The resident was asked if he was having pain and he stated, My knee and hip are killing me and have been for the last week, but especially today. The resident was asked if he normally received pain medication and he said he usually received pain medication. When asked if he received it that morning, he said he didn't know. On 5/19/2024 at 11:40 AM, Nurse K was observed outside the door of Resident #46 with her medication cart. The nurse was asked if the resident received pain medication and she said Resident #46 was scheduled to receive a Norco/oxycodone-acetaminophen at 12:00 noon. Nurse K said she would give it to him soon. Discussed with Nurse K that the resident appeared very uncomfortable and was repeatedly rubbing his legs. The Nurse said Resident #46 was to receive the Norco every 4 hours via a feeding tube/peg tube. During the interview with Nurse K on 5/19/2024 at 11:40 AM, the surveyor asked Nurse K to review the narcotics log for Resident #46's Norco pain medication. The narcotics log showed the Norco was signed out on 5/19/2024 at 8:00 AM and 11:00 AM. The nurse was asked if she already gave Resident #46 the pain medication and she said she was going to give it. Nurse K was asked if she signed the narcotic pain medication Norco for Resident #46 out at 11:00 AM (40 minutes prior) and she then scribbled out the 11:00 AM and changed the time to 12:00 PM. Nurse K was asked how she could change the time to 12:00 PM when she had already taken the narcotic out at 11:00 AM. The nurse did not have a response. The surveyor asked Nurse K to see the narcotic cassette that contained the Norco for Resident #46; it was in a locked drawer inside the medication cart. The nurse unlocked the drawer and lifted the medication cassette out. Nurse K showed the cassette for the Norco for Resident #46 and it showed 14 pills remained in the cassette. The narcotics log was reviewed for the resident's Norco and it also showed 14 pills were documented as remaining in the cassette after Nurse K signed that she took one out at 11:00 AM. Nurse K was asked where the Norco pill was if she already took it out of the cassette but did not give it to the resident. The nurse did not respond and then pointed at the top drawer of the medication cart. It was unclear what she was pointing at. She then removed a small medication cup from the back of the drawer and the medication cup read 16-2. The nurse said the resident was in room [ROOM NUMBER]-2. There were approximately 10 pills in the cup. Nurse K was asked if it contained the Norco and she said it did. The Norco pills in the medication cassette were compared to the pills in the medication cup and it was confirmed there were 2 Norco in the cup, plus a variety of other medications. The resident had not received his morning medications, including the Norco. On 5/19/2024 at 11:50 AM, Nurse K took the resident's medications including the 2 Norco, crushed them and administered them to Resident #46 via the feeding tube/peg tube. On 5/19/2024 at 12:20 PM, the Director of Nursing/DON was interviewed related to Nurse K removing Resident #46's medications including narcotic pain medication and not providing them to the resident. He said he was not aware of that. He said Nurse K was a Nurse Manager and had picked up an extra shift 5/19/2024 (Sunday). Reviewed with the DON that Nurse K had signed Resident #46's narcotics out of the double-locked medication drawer, placed them into a single-locked drawer and chose not to give them to the resident, until she was repeatedly asked where the medication was. He said that was not acceptable and he would look into it. The DON was asked for a copy of the Medication Administration Record with times administered for Resident #46 on 5/19/2024. The Medication Admin Audit Report for Resident #46 was received on 5/22/2024. The report identified what time the resident's medications were to be administered/Schedule Date and Time; Administration Time and what time they were documented as given to the resident/Doc'd Time. Further review of the Medication Admin Audit Report for Resident #46 revealed the resident was to receive the following medications at 7:00 AM: Omeprazole 20 g capsule for GERD; Sertraline 50 mg tablet for Depression; Lactobacillus Capsule for nutritional supplement; Aripiprazole 5 mg tablet for Bipolar disorder; Aspirin 81 mg for his heart; Metoprolol 100 mg for hypertension; Multaq 400 mg tablet for a heart dysrhythmia; Docusate 100 mg capsule for constipation. The Resident was supposed to receive one medication: Hydrocodone-Acetaminophen (Norco) 5-325 mg tablet at 8:00 AM. Resident #46 was to receive one medication at 12:00 PM: Hydrocodone-Acetaminophen (Norco) 5-325 mg tablet. The 7:00 AM medications were all documented on the Medication Admin Audit Report as given at 9:30 AM, but they were still in the medication cup in the top drawer of the medication cart at 11:40 AM, as confirmed with Nurse K. The 8:00 AM Norco was documented as given at 9:24 AM, but it was also in the medication cup. The 12:00 PM Norco was documented as given at 11:47 AM. This was the time Nurse K was observed giving all of the morning and noon medications. A review of the nurses' notes on 5/19/2024 and on 5/22/2024 indicated the nurse had not notified the physician that she had withheld two doses of Resident #46's narcotic pain medication and did not provide the resident with his medications as ordered. On 5/29/2024 at 8:45 AM, the Administrator was interviewed about Nurse K intentionally not providing Resident #46 with his medications, including his narcotic pain medication. The Administrator said Nurse K walked out of the facility and quit on 5/22/2024 in the middle of her shift. A review of the facility policy titled, Abuse, Neglect and Exploitation, dated reviewed/revised 6/23 provided, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of property . Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . A review of the facility policy titled, Resident Rights, dated reviewed/revised 2/24 provided, The facility will inform the resident both orally and in writing, in a language that the resident understands of his or her rights .All residents will be treated equally . The facility will ensure that all direct care and indirect care staff members, including contractor and volunteers, are education on the rights of the residents and the responsibility of the facility to properly care for its residents . The right to receive the services and/or items included in the plan of care . A review of the facility policy titled, Administration Procedures for All Medications, effective date 09-2018 and revision date 08-2020 provided, Medication will be administered in a safe and effective manner . A review of the facility policy titled, Medication Storage in the Facility, dated June 2019 provided, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, and record keeping in the facility in accordance with federal, state and other applicable laws and regulations . Schedule II-IV controlled substances and other medications subject to abuse or diversion are stored in a permanently affixed, double-locked compartment separate from all other medications .

This Citation pertains to Intake Number MI00143932 Based on observation, interview, and record review the facility failed to: 1. Assess, monitor, and document after witnessed resident fall for Resident #127 and 2. Ensure competency of agency staff working in the facility, resulting in Resident #127 sustaining a fall on 3/24/24 at approximately 12:05 AM, without facility intervention until 3/26/24 at approximately 10:15 (56 hours), which resulted in a hip fracture that required surgical intervention and undue suffering due to neglect of duties. The agency nurse assigned to Resident #127 admitted she failed to complete required assessments/documents and that they lacked orientation/training from the facility prior to scheduled shifts. Findings Include: Resident #127: On 4/16/2024, a review was completed of Resident #127's medical records and it indicated she readmitted to the facility on [DATE] with diagnoses that included, Fracture of right femur, Wedge compression fracture of fifth lumbar vertebra, Major Depressive Disorder, Anxiety and Dementia. Prior to Resident #127's fall she was ambulatory, wandered the floor consistently, and cognitively impaired. On 4/17/2024 at 8:20 AM, an interview was conducted with CNA (Certified Nursing Assistant) O regarding Resident #127's fall. CNA O stated the day after the fall Resident #127 slept most of the day but that was not alarming as there were times she would sleep this long. She checked on the resident, provided her with her meals and coffee and she had no complaints at that time. Two days after the fall she went into Resident #127's room to assist her to the restroom and found that she was incontinent which was uncommon for her. As she attempted to help her out the bed she started screaming in pain and said it was her leg. CNA O alerted the nurse, and the Nurse Practitioner assessed the resident and sent her to the hospital for evaluation for possible fracture. CNA O reported they were never informed Resident #127 fell and that is pertinent information that would have been passed along in shift change. On 4/17/2024 R 8:36 AM, an interview was conducted with Nurse Q regarding Resident #127. Nurse Q stated the resident is typically ambulatory, independent with eating and toileting. On 3/26/2024 Nurse Q heard Resident #127 call out and asked CNA O to go into room to meet her need. Shortly after, the CNA informed Nurse O that Resident #127 was not able to get out of bed and was incontinent. Nurse O stated this was a change in condition and she called their Nurse Practitioner who was already in the building to assess. After assessment it was found Resident #127's right hip was swollen, she was unable to move nor was she able to tell them what occurred. The resident was transferred the hospital an underwent surgery for her fractured hip. Nurse O stated they were not aware the resident had a fallen a few days prior as there was no documentation nor passed along in report. On 4/17/2024 at approximately 10:05 AM, Resident #127 was observed sitting in her wheelchair working with therapy. On 4/17/2024 at 2:40 PM, an interview was conducted with Nurse W regarding Resident #127's fall on 3/24/2024. Nurse W is an agency nurse and had worked in the facility three or four times prior to this incident. Nurse W reported Resident #127 fell during her shift and it was witnessed by one of the aides. She was informed the resident was washing her hands at the sink in the day room and as she was getting a paper towel, her legs buckled, and she fell on her left side. Nurse W assessed Resident #127 and she had complaints right side pain but stated it was not from the fall and pain medication was administered. Nurse W reported she denied pain to the left side (which is the side she fell on ). Nurse W reported after the resident was assessed and back in bed, she did not complete the necessary fall documentation (it can be noted there was no documentation from Nurse W in Resident #127's chart regarding the fall). Nurse W stated she was simultaneously dealing with another resident that had a steep change in condition and that resident consumed her time as she was concerned about the resident's rapid decline. Nurse W admitted she did not completed neuros, notify the provider, management or family, complete subsequent documentation (progress notes, assessments, fall incident and accident report). Nurse W stated while she understands these were nursing standards that should have been completed, she was not properly trained by the facility. The nurse expressed there was no protocol provided regarding where to access their fall I&A's, for the other resident she was not able to locate medical equipment for an hour and other facility nurses were unavailable to assist. Nurse W stated there was no onboarding provided by the facility to familiarize agency staff with the facility and their policies/procedures. Further review of Resident #127's records yielded the following: Progress Notes: 3/27/2024 at 12:10: Event occurred on 3/26/2024 at 10:16 AM. Resident unable to get out of bed on own, staff went into check, resident unable to move without pain. Resident did report shed had fallen. Physician and responsible party notified. 3/26/2024 at 11:12: Event occurred on 03/26/2024 10:16 AM. Resident unable to get out of bed on own, staff went into check, resident unable to move without pain. Resident did report she had fallen .Physician and responsible party notified. 3/26/2024 at 00:00: .She is being seen today at request of nursing. Nursing reports that the resident is not her usual self this AM, she is not getting up out of bed and has been incontinent of urine. At baseline she is continent of bladder and bowel and ambulates independently. On exam at this time, she is resting in bed. She is oriented to her name. Pleasantly confused. She reports pain in right leg and is rubbing extremity. RLE presents slightly internally rotated. There is noted edema at left hip and upper thigh. No bruising. Patient hollers out with any slight movement of extremity . Acute pain of right lower extremity suspected fracture of RLE/hip based on presentation and report of fall . Risks versus benefits evaluated for imaging at facility vs transfer to ER, due to patient's RLE internal rotation, severe pain associated with movement and nursing reports of patient no longer ambulating, will send patient to ER for further evaluation to reduce delay in care . 4/1/2024 at 12:05: Resident returned from (hospital) via ems with 2 personnel. resident is currently sleeping. no signs of distress noted. no signs of pain observed. resident was able to be aroused easily. will continue to monitor resident. NP notified of resident arrival. resident will be seen today. There was not nursing documentation completed by the Nurse W the night of Resident #127's fall on 3/24/24 at approximately 12:05 AM. Readmission Assessment 4/1/2024: .Right trochanter (hip) surgical incision 15 cm (centimeter) .2 staples right outer surgical incision . FRI (Facility Reported Incident) and PNC (Past Non-Compliance) Investigation: FRI Investigation: Summary Incident: .The administrator and DON (Director of Nursing) were informed by a physician that the resident was being send to the hospital due to swelling and pain in her right hip and leg area. During the clinical chart review it was learned that the resident had an intertrochanteric fracture of the right femur .DON was informed that the resident had a fall prior in the day room on the 2nd floor Description of Incident (PNC): Resident had a witnessed fall while in the day room. Per witnesses, the resident was at the sink and when she returned to go back to her room, it appeared as if her leg gave out on her. The resident fell to the floor and safely returned to her room. The nurse did not follow proper procedures for documenting Change in Condition. Interviews: Nurse W: The DON was informed by nurse that the resident had a fall while in the day room. The nurse reported that the Cena's reported to her that the resident was observed walking into the day room and going to the sink area and when she turned to go back to her room, as she turned it appeared as if her leg have out on her and she fell to the floor .The resident was placed in her wheelchair and safely returned to her room back to bed. CNA V: (Resident #127) was walking around in the dining room towards the exit, she went to turn around and as soon as her foot hit the ground it looked as if her leg gave out and (Resident #127) fell on the floor .The nurse and I helped (Resident #127) into her wheel chair and wheeled her into her room and the nurse and I helped (Resident #127) into her bed .She did say she had pain in her right thigh as she was grabbing at it. CNA X: .The resident came out of her room into the day room. She went to the sink are and when she went to walk away from the sink she just dropped. I thought her leg gave out on her .Then we got the nurse. she came in and assessed her ad we all got her up into the wheelchair and back into her room safely . CNA X (interviewed a 2nd time): .She stayed in the bed most of the night. On this night she yelled out and moaning as if she was uncomfortable. I was thinking it was because of the fall from yesterday. Nurse BB: .The resident was cursing loudly which is her norm, saying she is cold. When she is shouting and exhibiting these behaviors, I would ask her if she was in pain. She is either in pain, wants a snack or cup of coffee. I had even gone to get her a cup of coffee before going into her room. Her room was a little chilly. She then pointed to her back area and grimaced. I asked her if she was in pain and she said, yes. I gave her PRN pain medication and I turned on the heat and covered her with blankets . Video Review: The resident is seen leaving her room on 3/24/2024 at 12:05 am and going into the day room. It appeared as if the resident had a cup in her hand. The resident went toward the sink area and is observed turning around from the sink and falling onto the floor on her left side . Radiology Report 3/26/2024: .Intertrochanteric proximal right femoral fracture . In Conclusion: The facility has concluded that there is no evident of abuse associated with the incident based on the evident presented .The radiological reports support .that the resident suffered a wedge compression fracture ad superolateral apex angulation from a fracture through the intertrochanteric proximal right femur . The facility's investigation and subsequent PNC failed to address/interview the nurse regarding reasoning for not completing any assessments, notifications or documentation related to Resident #127's fall. The interview with Nurse W lacked thoroughness and hindered the ability of the facility to locate other potential facility deficiencies. Nurse W expressed to their writer there was no training prior to working and was unprepared to complete their documentation as they did not know where to access it. Resident #127 went approximately 58 hours without the facility recognizing she had fallen and subsequently fractured her hip. On 4/18/2024 at 2:04 PM, an interview was conducted with the DON (Director of Nursing) regarding agency staff competency prior to working in their facility. The DON reported agency staff should have an orientation that includes competency evaluation and training on the floor to acclimate them to where things are. Prior to them working in the facility they complete an online zoom session through the corporation that provided education on their policies/procedures. The DON was asked to provide documentation that Nurse W completed the online zoom session, competency evaluation, floor training and any agency training. The DON explained Resident #127 fell on [DATE] but the facility was not aware of the fall until 3/26/2024. Through their investigation they were able to pinpoint when the fall occurred and that the nurse failed to do what was required post fall to include neurological checks, progress notes, assessments, notifications, and Fall I&A. The DON was asked why the nurse was not interviewed on what occurred during her shift that she neglected Resident #127 following her fall. The DON reviewed Nurse W's statement and reported while it is not documented he believed the nurse stated she was in middle of transferring another resident to the hospital and as time passed, she forgot to do what was required for a fall. A discussion was held with the DON regarding the lack of thoroughness of the PNC investigation and the missed opportunities due to their investigation. The DON was alerted their PNC would not be accepted. It can be noted Nurse W training documents were requested from the facility during the interview with the DON and upon exit on 4/18/2024. There was no documentation received from the facility that proved Nurse W was provided with appropriate training prior to working in their facility. Resident #127 fell on [DATE] per staff and video accounts and post fall there was no documented action taken by facility staff until over 56 hours later. Per staff accounts the resident expressed pain but given they were unaware of the fall on 3/24/2024 they treated the pain with medications as needed and no further evaluation. Review was completed of facility policy entitled, Change in Condition, revised 7/20. The policy stated, It is the policy of this facility to inform residents/legal representative, attending physician or designee of a change in the resident's condition .The facility will inform the resident; consult with the residents physician: and notify, consistent with his or her authority, the resident representatives when there is- a. An accident involving the resident which results in injury and has the potential for requiring physician intervention . Review was completed of facility policy entitled, Fall Reduction Policy, revised 4/23. The policy stated, .When any resident experiences a fall the facility will: a. assess the resident; b. Complete a Post-Fall Assessment; c. Complete a Risk Management Incident Report; d. Notify physician and responsible party . Review was completed of facility policy entitled, Abuse,Neglect and Exploitation, revised 6/23. The policy stated, .Neglect means failure of the facility, its employee, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain. mental anguish, or emotional distress .

Based on interview and record review, the facility failed to: (1.) Re-weigh and update interventions on the nutritional care plan timely for one resident (Resident #116), who had a significant weight loss and (2.) Follow Physician orders and care plans for two residents (Resident #129, Resident #130) for meal assistance and supplements, resulting in weight loss not being identified and the likelihood for further weight loss and a decline in overall health and likelihood of hospitalization . Findings include: Record review of the facility 'Weight Monitoring' policy dated 1/2021 revealed that compliance guidelines: Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period) may indicate a nutritional problem. (6.) Weight analysis: The newly recorded resident weight should be compared to the previous recorded weight to determine if a re-weight is necessary. (7.) A significant change in weight is defined as: (a.) 5% change in weight in 1 month (30 days). (b.) 7.5% change in weight in 3 months (90 days). (c.) 10% change in weight in 6 months (180 days). Resident #116: Record review of Resident #116's weight log from July 2023 through April 2024 was reviewed. Weight recorded on 12/3/2023 at 12:09 PM was 244.8 pounds with mechanical lift. Weight recorded on 1/3/2024 at 2:59 PM was 196.6 pounds. 244.8 minus 196.6 = 48.2 pounds loss in one month. Both weights were noted to be performed by the same staff person. Significant weight loss of 7.5% weight change in one month. Resident #116 was not re-weighted until 1/17/2024 (14 days later) at 11:44 AM weighing 195.5 confirming actual weight loss of 49.3 pounds. In an interview on 4/15/24 at 3:04 PM with the corporate Registered dietitian (RD) B electronic record review of Resident #116's weight logs revealed that the weight on 12/3/2023 was 244.8 pounds and then on 1/3/2024 was 196.6 pounds, that was a loss of 48.2 pounds. Why no re-weight done? RD B stated 'I have no comment.' Nutrition note was not done until 1/18/2024 that was 15 days after the weight loss. Record review of Resident #116's January 2024 Medication Administration Record and Treatment Administration Record (MAR/TAR) revealed that on 1/18/2024 at 9:00 PM Med Pass 2.0 three times a day of 120 milliliters was started and on 1/24/2024 an order to obtain weight every day shift Wednesday for monitoring for 4 administrations was added to the MAR/TAR. Record review of the Resident #116's December 2023 progress notes only noted a pharmacy medication regimen review note. Record review of the Resident #116's January 2024 progress notes noted: -On 1/2/2024 at 8:43 PM the Nursing Home Administrator visited with the resident as he was being extremely negative and verbal. The administrator was noted to take the resident a bag of chips. -The next progress note was dated 1/5/2024 at 8:09 AM revealed that the writer noted making rounds at 5:45 AM in resident's room. Resident was observed asleep and at 8:00 AM noted resident watching television. There was no mention of weight change. -Progress note dated 1/8/2024 at 9:01 AM noted that the resident stated that his call light had not been answered. Staff was in the resident's room with management on the phone and the resident declined to answer yes or no to if his call light was answered. There was no mention of weight change. -Progress note dated 1/9/2024 at 4:14 PM written by social worker noted a wellness check on resident and a behavioral noted dated 1/9/2024 at 4:32 written by the same social worker about misconstruing information related to his care. Again, no mention of weight loss. -Progress note dated 1/9/2024 at 4:37 PM the Nurse manager met with resident to discuss his skin. -Progress note dated 1/10/2024 at 3:51 PM the social worker noted a wellness check. -Progress note dated 1/11/2024 at 3:58 PM the social worker noted a wellness check. -Progress note dated 1/12/2024 at 12:17 PM the social worker noted a wellness check. -Progress note dated 1/13/2024 at 9:29 PM pharmacy medication regimen review with irregularities. -Progress note dated 1/16/2024 at 11:15 AM the social worker noted speaking to resident about psych medication management. -Progress note dated 1/18/2024 at 12:49 PM nutrition risk note revealed significant weight loss of 10% change over 180 days (21.0%, 52.0) Record review of Resident #116's dietary progress note dated 1/18/2024 at 12:49 PM noted a significant weight change 10% change over 180 days (21.0%, 52.0). Weight loss of 48 pounds in one month does not seem feasible. Resident receives Lasix 20 mg (diuretic) every day for edema, however dose has not changed since 7/29/2023. Per FAR's (Food Acceptance Records) resident consuming 100% of most meals. Spoke with resident in room. Resident does feel that he has lost weight. When asked why, he said that he does not like the food here. Lunch tray observed at bedside with one bite taken Will add med pass supplement 120 milliliters three times daily to provide 720 kilo Cals per day, 30 grams protein daily. Will follow on weakly weights. In an interview on 4/16/2024 at 10:46 AM with Registered Dietitian (RD) B of Resident #116's weight loss: yes, there was a 48-pound weight loss, but he was care planned that he refused weights/to get out of bed. He had behaviors, refused to get out of bed. Should there have been a note that the resident refused or documented? We only have the former dietitian's nutritional note on the 1/18/2024. He was weight 4 times in January- the policy for Weight monitoring is what we would follow. The State surveyor noted weight procedure step #6. On the policy: The newly recorded resident weight should be compared to the previous recorded weight to determine if a re-weight is necessary. Weights 12/3/2023 244.8 pounds and on 1/3/2024 196.6 a total loss of 48.2 pounds. Yes, that is more than a 10% change in 30 days. We tracked the food acceptance, and the dietitian can see the weights on the computer, and it's flagged as a weight loss significant change. It triggers/flags a change in weight and then when the nutrition note is put in that deletes' the trigger/flags. Record review of the Weight log revealed weights of 1/17/24 195.5, 1/24/2024 195.5, 2/1/2024 196.5 pounds. 39059 Resident #129: On 4/16/24, at 9:18 AM, Resident #129 was lying flat in their bed eating their breakfast meal. There was no health shake on their tray. There was no staff assistance with the breakfast meal. On 4/17/24, at 1:00 PM, a record review of Resident #129's electronic medical record revealed an admission on 1/28/2020 with diagnoses that included Paranoid Schizophrenia, Dementia and Protein-Calorie Malnutrition. Resident had severely impaired cognition and required extensive assistance with all Activities of Daily Living. A review of the Physician orders revealed House Supplement with meals . Start Date 2/23/2024 . A review of the Kardex revealed . Eating/Nutrition EATING: The resident requires extensive one person assist . A review of the Nutritional Assessment Date: 4/2/2024 revealed . 91.8 lbs . requires mechanically altered diet . 1:1 feeding assistance with meals . neuropsychological problems severe Dementia or Depression . Res to continue w/POC . On 4/18/2024, at 12:42 PM, Resident #129 was lying flat in their bed with their lunch meal. There was no health shake provided on the meal tray. There was no staff member assist offered for the lunch meal. Resident #130: On 4/16/24, at 9:18 am, Resident #130 was lying in their bed. Their breakfast meal was provided and set on their bedside table. There was no health shake provided on their tray. There was no staff assistance for the breakfast meal. On 4/16/2024, at 10:30 AM, RD B was questioned regarding the definition of supervision with meals and what that meant and RD B offered, that would be supervising by the CNA. On 4/17/24, at 1:30 PM, a record review of Resident #130's electronic medical record revealed an admission on 08/22/2022 with diagnoses that included protein-calorie malnutrition, dementia, and schizoaffective disorder. A review of the Physician orders revealed House Shake 4 oz (ounce) with meals health shake tid (three times a day) . Start Date 1/23/2024 . A review of I have the potential for a nutritional/hydration problem r/t (related to) paranoid schizophrenia, dysphagia, dementia. Mechanically altered diet r/t dysphagia, is edentulous, BMI is underweight, I receive supplementation to help with gradual weight gain/stability . Date Initiated: 01/22/2024 . Revision on: 04/02/2024 . Interventions/Tasks . My supplement/s is/are: MedPass, HealthShakes Date Initiated: 04/02/2024 . A review of Resident #130's weights revealed a 16 pound weight loss: 12/21/2023 101.9 lbs (pounds) 1/3/2024 95.6 lbs 1/31/2024 87.7 lbs 2/1/2024 89.3 lbs 2/7/2024 91.0 lbs 3/7/2024 87.4 lbs 3/28/2024 87.3 lbs 4/3/2024 88.3 lbs 4/9/2024 85.6 lbs 4/10/2024 85.6 lbs A review of the Nutritional Assessment Date: 4/2/2024 revealed . Body Mass Index 15 . requires a mechanically altered diet . set up assistance and supervision with meals. Needs prompting/encouragement . Neuropsychological problems Severe Dementia or Depression . My nutrition goals while here are: is to maintain fair-good appetite, consuming at least 50% or more of most meals. To have weight gain towards BMI of >18.5, as medically feasible . Wt appears to be stable near 87 lbs (pounds) w/slight fluctuations . Res continues w/HealthShakes TID (240 Kcal, 112 g/pro per serving . for added nutritional support & to promote wt stability . On 4/18/24, 12:42 PM, Resident #130 was lying in their bed. The lunch meal was provided to the bedside table. There was no health shake provided. There was no staff assistance provided for the lunch meal. On 4/18/2024, at 12:55 PM, Nurse staff T was questioned regarding Resident #130's ability to feed themselves and Nurse staff T stated, that with set up assistance they do pretty good and that they have been feeding themselves. On 4/18/24, at 12:50 PM, an observation of the 4th floor refrigerator revealed no health shakes. Nurse H offered that the facility was using health shakes in place of medication pass a couple weeks prior as they were out of medication pass supplement. On 4/18/24, at 12:55 PM, an observation of 3rd floor refrigerator revealed no health shakes. Staff I, S and T all mentioned they hadn't seen health shakes on the trays in quite a while which was defined as more than a week by the staff members. On 4/18/24, at 1:00 PM, Kitchen cook J was asked if the kitchen provided the health shakes on the meal trays and Kitchen Cook J stated, yes, the kitchen does but they were out. Kitchen cook J was asked to explain why there wasn't any in the building and Kitchen Cook J stated, apparently (Kitchen L) does the ordering and sends the list to another manager at another location to be sent it and/or maybe they didn't come on the truck. On 4/18/24, at 1:05 PM, an observation along with Kitchen staff K of the freezer and walk-in cooler was conducted. There were no health shakes in the freezer nor the walk-in cooler. On 4/18/24, at 1:30 PM, the Director of Nursing (DON) was asked to provide a list of all residents who had health shakes ordered and the DON, offered that (kitchen staff L) was out with the credit card to purchase Ensure at the local warehouse store.

This Citation pertains to Intake Number MI00139583 Based on observation, interview, and record review the facility failed to prevent a fall with fracture for one resident (Resident #502), that resulted in a clavicle fracture and multiple rib fractures when an inappropriate level of assistance was utilized during incontinence care. Findings Include: Resident #502: On 9/28/2023 at 12:26 PM, Resident #502 was observed to have a sling on his left arm while resting in bed. When asked what occurred for him to need to the sling, he shared he dislocated his arm when he rolled out of bed and onto the floor while being changed. Resident #502 was asked how many CNA (Certified Nursing Assistant's) there were when he fell and he stated, one. He further stated during incontinence care there is normally only one CNA completing it and this day was no different. The CNA was on the left side of the bed, rolled him toward the right and he just continued to roll and landed on the tile floor. On 9/29/23 at approximately 9:30 AM, a review was completed of Resident #502's medical record. The resident was admitted to the facility on [DATE] with diagnoses that included, Myocardial Infarction, Diabetes, Major Depressive Disorder, Cerebrovascular Disease, Hemiplegia and Hemiparesis following Cerebral Infarction affecting left side. Per MDS (Minimum Data Set) assessment Resident #502 required two-person physical assist for bed mobility. Further review of Resident #502's record revealed the following: Care Plan: Focus: (Resident #502) has an ADL self-care performance deficit r/t: CVA with Hemiplegia . Tasks: .Bed Mobility: (Resident #502) extensive two person assist. Revision on 5/20/2021 .Toilet use: (Resident #502) is extensive assist with 2 staff. Initiated on 1/3/2018 . Progress Notes: 9/4/2023 at 23:15: CNA notified nurse @1945 that resident had rolled out of bed during a brief change, upon arrival resident is observed on his back, resident was asked if he was hurt, resident states my leg hurts c/o pain 6/10 (PRN Norco given @1952),resident verbalizes that he rolled off the bed & hit his head on the floor, skin assessed for injury;quarter size hematoma present above left eye brow, perimeter drawn to monitor enlargement . resident is able to move all extremities to baseline (Left side deficit related to stroke hx), resident placed back to bed with Hoyer lift, bed placed in lowest position, call light placed within reach . 9/4/2023 at 09:54: Date of Fall: 9/4/2023 Root Cause(s) of Fall:: Resident rolled out of bed, while receiving ADL care. Prior Interventions:: call light within reach Educate [NAME] to ask staff for assistance Non skid shoes/slipper while up New Interventions:: Staff educated on following Kardex when performing ADL care . 9/5/2023 at 18:48: Resident continues neuro checks for fall. Resident is able to move right side range of motion without discomfort. Resident complains of pain to left shoulder no edema observed to right hand or bruising NP notified resident receives order for x-ray. Pain medication administered as ordered. 9/6/2023 at 13:42: X-ray tech at bedside completing x-rays at this time. 9/6/2023 at 21:00: X-ray report reviewed by this provider .Acute left clavicular fracture with slight displacement. Left sided rib fractures noted, has a current order for PRN Norco and Tylenol for pain control. Mild subluxation of left humeral head, unable to determine if acute or chronic process as no prior imaging is available for comparison. Will utilize sling for immobilization, recommend repeat X-ray in 6 weeks for re-evaluation. Imaging Results: Acute fracture of the distal left clavicle, with slight displacement of the distal component. Several left rib fractures are seen .Slightly displaced acute distal left clavicular fracture . Review was completed of CNA K Human Resource File and included the following: - Counseling notice dated 9/7/2023 that stated, On September 4, 2023 at 7:45 PM while providing care to resident in 419-1, he rolled out of bed on the opposite side from you. Which resulted in patient sustaining a hematoma over left eyebrow and leg pain. 9/7/2023 facility was notified resident having acute fracture of the distal left clavicle, with slight superior displacement of distal fracture component and several left rib fractures. Employee was suspended on 9/7/2023, pending further investigation. - Counseling notice dated 9/11/2023 stated, Employee's employment at (facility) was terminated on September 11, 2023. On 9/29/2023 at 11:33 AM, Resident #513 (Resident #502 roommate) was interviewed regarding his roommate's fall. He reported the aide came in to change his roommate and was on the left side of the room. The CNA pulled up on the draw sheet to roll Resident #502, but he kept rolling and fell underneath his bed. He continued the bed was about waist height of the CNA when he rolled out and he added it was only one CNA in the room changing Resident #502. On 9/29/2023 at 1:30 PM, an interview was conducted with DON (Director of Nursing) and Administrator regarding Resident #502's fall. The DON stated Resident #502 was a two-person assist since April 2021 and there were other staff available, but CNA K did not go retrieve them. The DON explained CNA K preformed incontinence care on Resident #502, and as she utilized the draw sheet to turn him toward the right, he continued to roll and fell on to the floor. The DON stated CNA K was truthful and stated she turned the resident away from her, the bed was at the CNA's waist level (whom is taller) and she did not have on hand on Resident #502 when she turned him. We all agreed there were multiple issues with the incident beginning when CNA K completed incontinence care alone, turned the resident away from her and did not secure him during the turn. The Administrator and DON shared that after this incident they completed education with all staff on using the assessed level of assistance during resident care, return demonstration of incontinence care on a mannequin, ad hoc checks on CNA's during resident care, updated all fall assessments, ensured residents care plans, Kardex's and tasks list matched, audits and ongoing monitoring in QA. On 9/29/2023 at 2:16 PM, CNA K was interviewed regarding Resident #502 rolling off the bed while she performed incontinence care. CNA K shared Resident #502 requested to be changed and at that time one CNA was on break, the other was outside with resident smokers and the nurses were completing shift change. CNA K reported she attempted to wait for one of aides to return to the floor but Resident #502 had a bowel movement and it was smeared up his back. CNA K stated she made the decision to change him. CNA K reported she is 5'10'' in height and his bed was positioned at her waist-level, she undressed the resident and cleaned him. As she continued to stand on the left side of the resident, she placed the brief underneath him and used the pad (underneath him) to roll him away from her, but he continued to roll and ultimately fell . CNA K reported she was able to grab his feet prior to him falling but was not able to pull him back onto the bed before he hit the floor CNA K was queried if she was holding him when she rolled him, and she stated she was not. CNA K stated Resident #502 was laying on his left side and was complaining of pain in his arm. CNA K immediately retrieved the nurse who assessed the resident, and he was placed back into bed with the mechanical lift. Review was completed of the Facility's Investigation related to this incident: Summary of Incident: The administrator was informed that on September 4, 2023, the resident was receiving ADL Care and during the care process he rolled out of the bed onto the floor. The staff utilized the Hoyer lift to place the resident back in bed safely. During neuro checks the staff noticed a hematoma developing in the area above the resident's left eyebrow. The resident was treated accordingly .The next day, September 5, 2024, the resident expressed pain in both the left shoulder and leg. An X-Ray was ordered related to expressed pain areas. The x-ray findings revealed an Acute fracture of the distal left clavicle, with slight superior displacement of the distal fracture component. The left acromioclavicular joint remains intact. There is subluxation of the left humeral head with narrowing of the sub-acromial space. Several left rib fractures are seen. Visualized portions of the left upper thorax are otherwise unremarkable. No gross soft tissue abnormalities are appreciated . Witness Statements: Per roommate, he observed the Aide cleaning the resident up and changing him. And when she pulled the pad underneath him over a little he rolled out the bed on the floor. The staff came in and assessed the resident for injuries and asked him questions about his pain and if was hurt. CNA K: The DON spoke with the cena staff person regarding the residents fall. The staff person informed the DON while she was providing ADL care the resident turned over and rolled over too far and onto the floor. Cena was standing on the opposite side of the resident and unable to secure his position while in the bed. Cena called for the nurse to ensure the resident was safely placed in the Hoyer lift and back into his bed. The resident was then assessed by staff. Nurse T: (Nurse T) stated she assessed the resident while on the floor and completed ROM, observed a small hematoma on the resident's forehead over brow area and patient expressed leg one in the Hoyer lift. Conclusion: During the interview process, the resident maintained that he got out of bed and walked across the room and tripped, hit his foot, toe ad fell on to the floor. The facility understands that the resident has a diagnosis of cerebrovascular disease which includes variety of medical conditions that affect the blood vessels of the brain and cerebral circulation. This may cause confusion at times and physical deficiencies such as with the resident above with cerebral infraction affecting an unspecified side. The facility has determined that the resident had a fall during care and sustained injuries to both the left shoulder and several rib fractures to the left side. Therefore, the investigation is substantiated for neglect. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included the below interventions/actions to correct the past noncompliance. On 9/29/2023, a review was completed of the facility's timeline for their process change which included the following: The following plan has been implemented for compliance: - Review of Incident and Accidents over the past 7 days to ensure ADL status in the EMR. - Fall Audit completed on 9/8/2023 by Administrator. - Review and update as needed fall assessment for all residents requiring extensive, 2-person assistance during ADL care to ensure current. - Nursing staff to be re-educated on providing ADL Care to residents and following the current Kardex, Task List, and Care Plan for guidance for all residents requiring extensive 2-person assistance during ADL care. - There will be random ADL care audits and Ad Hoc return demonstration with training with nursing staff. Areas identified requiring quality improvement: Nursing staff were re-educated by DON or designee on [NAME] clinical skills and techniques, Safety and Comfort, and Safe Patient Handling and Mobility including return demonstration for providing ADL care to residents and deemed appropriate. Also, following the Care Plan, Kardex, and Task List. ADL care for residents requiring extensive 2-person assistance will be monitored by DON/Clinical IDT and reviewed in daily morning clinical meetings to ensure staff are maintaining compliance, Any identified concerns will be addressed immediately. Actions to prevent Occurrence/Reoccurrence: The Director of Nursing/Designee will complete audits of Incident & Accidents related to falls weekly x 4 weeks to ensure process was followed accordingly and ADL status was updated in EMR as required. Results of audits will be reported to QAPI committee monthly for review and further recommendations. The Regional Clinical Director will review the audit process monthly x 3 for sustained compliance. The facility was able to demonstrate monitoring of the corrective action and maintained compliance. Therefore, Past Noncompliance will be granted with the Compliance Date of 09/15/2023.

This Citation contains two Deficient Practice Statements (DPS). Deficient Practice Statement #1: Based on observation, interview and record review, the facility is placed in Immediate Jeopardy for its 1) Failure to provide extra Tracheostomy (TRACH) tubes at bedside for three residents (Resident #37, Resident #48, and Resident #101) out of three residents reviewed for Tracheostomy care; 2) Failure to ensure that Trachesotomy follow-up care was provided and ensure a person-centered care plan for one resident (Resident #37), 3) Failure to ensure that competent nursing staff could provide Tracheostomy care, 4) Failure to store and clean respiratory equipment for two residents (Resident #30 and Resident #101), and 5) Failure to ensure that oxygen was provided and managed per physician's order for one resident (Resident #48), resulting in unsafe Tracheostomy care, respiratory masks exposed to contaminants, lack of respiratory assessments, and Tracheostomy/Respiratory care needs not met with the likelihood of respiratory complications going unnoticed or untreated. Immediate Jeopardy: Immediate Jeopardy began on 02/17/2023. Immediate Jeopardy was identified on 04/20/2023. The Nursing Home Administrator (NHA) was notified of the Immediate Jeopardy on 004/20/2023 at 12:39 PM. Immediate Jeopardy was abated or removed on 04/20/2023. Findings include: Resident #30: On 4/18/23, at 12:15 PM, Resident #30 was lying in their bed. Their CPAP/BiPap mask was lying face down on their bedside table. On 4/19/23, at 11:30 AM, Resident #30 was lying in their bed, Their mask was lying on top of the bedside table with the face side up. The mask was uncovered. Resident #30 stated, Yes, when asked if they wear it at night. On 4/20/23, at 12:31 PM, a record review of Resident #30's electronic medical record revealed an admission on 3/27/23 with diagnoses that included Congestive Heart Failure, Stroke, urinary tract infection and Sleep apnea. Resident #30 was alert and orientated with some confusion and required assistance with all Activities of Daily Living. A review of the physician orders revealed no order to maintain, clean or manage all the components of the CPAP/BiPap machine including the mask and tubing. A review of the progress notes revealed 3/30/23 . Admission . Note Text: Late entry . Resident arrived via stretcher . BiPap was delivered for bedtime . Resident #37: On 4/19/23, at 8:57 AM, Resident #37 was lying in their bed. Nurse Y entered the room. Nurse Y was asked where they kept the emergency tracheostomy supplies and Nurse Y began to search in the drawers. Nurse Y stated, they typically are up here but you caught me stocking. Resident #37's tracheostomy was surrounded by bunched up gauze that appeared wet. Resident #37 agreed to allow Nurse Y to complete tracheostomy care later at 10:30 AM. On 4/19/23, at 9:03 AM, Infection Control Nurse (IC Nurse) B entered the floor with a replacement tracheostomy tube for Resident #37. Nurse Y entered Resident #37's room and placed it on the table. Resident #37 agreed along with Nurse Y an observation of tracheostomy care. On 4/19/23, at 9:20 AM, a record review of Resident #37's electronic medical record revealed an readmission on 2/16/23 with diagnoses that included ruptured abdominal aortic aneurysm, Tracheostomy status and anxiety disorder. Resident #37 required assistance with Activities of Daily Living and had intact cognition. A review of the progress notes revealed no mention of follow up appointments offered with the pulmonologist or surgeon who placed the tracheostomy tube. A review of the care plans revealed Focus I have Tracheostomy Date Initiated: 02/17/2023 . Interventions/Tasks . Keep extra trach tube and obturator at bedside Date Initiated: 02/17/2023 . There was no personalized details regarding resident's anxiety with the tracheostomy care, what type of tracheostomy care needed, what type of tube the resident had and who was following up with the tracheostomy tube care and/or removal. On 4/19/23, at 11:31 AM, Resident #37 was lying in bed. Nurse Y was standing over the resident tightening their tracheostomy collar and placing a split sponge around the tube. IC Nurse B was on the left side of the bed. There were supplies on the bedside table on top of a barrier. There was a pile of 3 pairs of nonsterile gloves half on the table and half on the barrier leaning against a drink cup. The right side of the sterile barrier was touching a dirty urinal that had 300 milliliters of urine inside. There were no sterile glove packages opened or closed noted on the table nor in the garbage can under the table. Nurse Y removed their right-hand dirty glove placed it into their left hand and used their right hand to look through the supplies in the room for an inner cannula as they quietly stated, I must have changed it already. IC Nurse B stated to Nurse Y, It's on the tray. Nurse Y then put her dirty glove they were holding in their left hand back onto their right hand and picked up the inner cannula. Nurse Y while holding the inner cannula in their right hand leaned over Resident #37 inspecting the tracheostomy tube opening. Resident #37 was not coughing nor had any secretions that needed suctioning at the time and appeared to have a tracheostomy tube that was permanent. The tracheostomy tube opening did not have a clipped inner cannula that was removable. Nurse Y had the inner cannula end approximately a half centimeter from the opening and Nurse Y was asked if they had already removed the inner cannula and IC Nurse B was overheard stating to Nurse Y, there's already one in there. At this time, Nurse Y was asked to stop and go get their Director of Nurses. IC Nurse B remained in Resident #37's room. On 4/19/23, at 11:57 AM, IC Nurse B began to clean up the supplies on the table. IC Nurse B was asked where the peroxide or sterile gloves were and IC Nurse B stated, we do have kits with peroxide. IC Nurse B was unable to find peroxide or sterile gloves in the room. IC Nurse B left out of the room. On 04/19/23, at 12:07 PM, Resident #37 stated, that's why I don't want anyone touching it because they don't know what they're doing. Resident #37 stated, it scares me. Resident #37 stated, the doctor told me not to let anyone change it ever. Resident #37 denies having a follow up appointment with the doctor who placed the tracheostomy tube and wondered if they even needed anymore. On 4/19/23, at 1:52 PM, the DON entered the conference room and offered that they had called numerous supply companies because it looked like Resident #37 had a tracheostomy tube that appeared permanent and needed it changed at the doctors. The DON further offered that they were trying to figure out why the resident was ever admitted with that type of tracheostomy tube. The DON was asked to explain why they thought it was a permanent tracheostomy tube and the DON stated, that they went to look at it and it doesn't appear the cannula is removable. The DON planned to call the respiratory doctor who placed the tracheostomy tube to find out the care needed. The DON also stated, that they had called numerous nurses that worked with the resident in the facility and nobody had changed cannula. The DON was asked to clarify and DON stated, I have not talked to one nurse that had changed it yet. The DON was asked what they planned to do next, and the DON stated, they planned to call the doctor who put the trach in so they could educate the nurses on how to care for it. On 4/19/23, at 2:16 PM, while in the conference room, the DON called Nurse Practitioner (NP) LL and discussed with NP LL that Resident #37 appeared to have a permanent tracheostomy tube and asked what they would expect the facility to do if Resident #37's tracheostomy tube dislodged and NP LL stated, you could always go smaller referring to replacement of the tracheostomy tube into the neck opening. NP LL ordered the DON to have Resident #37 follow up with their pulmonologist. On 4/19/23, at 3:22 PM, The DON entered the conference room and called Resident #37's pulmonologist (MD) SS. The phone was on speaker. MD SS stated, the size was 6. The DON alerted MD SS that there was no way to remove the inner cannula (Shiley) and appeared the tube was permanent and MD SS stated, the resident needs to follow up and to get the tracheostomy tube removed. MD SS was asked if the tube was dislodged what the facility should do until EMS arrived and MD SS stated, to intubate the resident or place a smaller tracheostomy tube; a 4 or a 6 would be fine. MD SS ordered the DON to make follow up appointments for Resident #47's tracheostomy assessment and care prior to ending the call. The DON was asked if the facility should have assessed Resident #47's tracheostomy needs prior to admitting the resident and the DON stated, yes. On 4/20/23, at 8:41 AM, an interview with Staffing Coordinator DD in their office was conducted regarding Nurse competencies. Staffing Coordinator DD was asked where the Nurse Competencies are filed and Staffing Coordinator DD stated, in their personnel files. Staffing Coordinator DD was asked to provide the personnel files for Nurse Y, AA and B. Staffing Coordinator DD began looking through two stacks of manila folders and in two file cabinets. Staffing Coordinator DD continued to search for the three nurses personnel files and offered that Nurse Y is from the float pool and stated, generally in orientation they hand out the competency form, the nurses get it filled out and then they hand it to her or put it in her mailbox. On 4/20/23, at 8:52 AM, Staffing Coordinator DD located the personnel file for Nurse Y and Nurse B. On 4/20/23, at 8:53 AM, a record review of both Nurse Y' and Nurse B's personnel file revealed no Nurse Competency documentation. On 4/20/23, at 8:58 AM, Staffing Coordinator DD continued to search in the file cabinets and the piles on top of the filing cabinets for the Nurse Competencies and the remaining Nurse AA''s personnel file. Staffing Coordinator DD was asked to provide copies of Nurse Competency check list they handed out on hire. While standing at the copy machine with Staffing Coordinator DD, the Administrator walked up and was alerted that Staffing Coordinator DD was having a hard time finding the nurse competency requested and the Administrator stated to check with (Scheduler EE.) Staffing coordinator DD walked back to their office, picked up the phone and called Scheduler EE who answered and was asked if they had nurse competencies in their office. Scheduler EE stated, no. On 4/20/23, at 9:03 AM, an observation of Staffing Coordinator DD's mail box along with Staffing Coordinator DD revealed no Nurse competency forms for any nurse. On 4/20/23, at 09:20 AM, a record review along with The DON was conducted of a power point document left in the conference room and the DON stated, I don't know what that is. I did an in-service on tracheostomy care and used the facility policy last night with both shifts and got as many nurses as they could. The DON was asked to provide the education and any sign in sheets on the tracheostomy care in-service. On 4/20/23, at 9:22 AM, IC Nurse B explained that they started with the facility in January 2023. IC Nurse B was asked if they assisted with any of the Nurse Competencies and IC Nurse B stated, that they did watch the nurses for hang hygiene, donning and doffing personal protective equipment. On 4/20/23, at 9:23 AM, Regional Clinical Director Z offered that the nurse competencies are in the old DON's office. Regional Clinical Director Z stated that they will have to look in the old DON's office and will have to wait for the key. The DON walked up, and surveyor offered to go along with the DON and Regional Clinical Director Z to the old DON's office to look for the Nurse Competency files. The DON stated, that they had cleaned the office and Regional Clinical Director Z clarified that the office was cleaned and that no nurse competencies were in the DON's office. On 4/20/23, at 9:26 AM, a record review along with Regional Clinical Director Z of the Initial Competency Checklist Charge Nurse RN and Initial Competency Checklist Charge Nurse LPN revealed no detailed education regarding tracheostomy care. On 4/20/23, at 9:30 AM, along with Regional Clinical Director Z, Staffing Coordinator DD was asked to provide the General Orientation Agenda which revealed no detailed education regarding tracheostomy care. On 4/20/23, at 10:50 AM, the DON offered a sign in sheet for education on tracheostomy care and stated there wasn't any detailed education listed as they educated on the facility tracheostomy policy. On 4/20/23, at 11:47 AM, Resident #47 was in their room and was asked how they felt about the tracheostomy care the day prior and Resident #47 offered, it was scary and was disappointed. Resident #47 offered that they were going to the doctors to have it looked at later that day. On 4/25/23, at 8:30 AM, a further record review of Resident #37's physician orders revealed TRACH: Bag Lavage as needed . Start Date 4/20/2023 TRACH: Shiley #6, no inner cannula . TRACH: Ambubag and spare trach at head of bed for emergency purposes every shift for Dislodged trach . Start Date 4/20/2023 . Trach Care twice a per day . Appointment scheduled for 3:00 pm on 4/20/2023 with . pulmonologist . Schedule appointments with . surgeon assessment of trach and . for respiratory assessment and possible removal of trach . Resident #101: On 4/19/23, at 8:30 AM, an observation of Resident #101 who was in their bed. Their tracheostomy tubing looped under the bed. Approximately 3 feet of the tubing was resting on the floor. On 4/19/23, at 8:44 AM, an observation of Resident #101's tracheostomy supplies was conducted along with Nurse AA. Nurse AA was asked to located the emergency tracheostomy supplies for Resident #101. Nurse AA looked in all the drawers and looked on all the shelves on the rolling cart that was draped closed with a blue flap. Nurse AA pulled out her phone and alerted the nurse manager there was no emergency tracheostomy supplies in Resident #101's room. Nurse AA left the room. On 4/19/23, at 8:51 AM, Infection Control Nurse (IC Nurse) B entered Resident #101's room with a box in their hand. IC Nurse B was asked what they had in their hand and IC Nurse B stated, 6.5 is his size. IC Nurse B placed the box with the emergency tracheostomy tube on the bedside tray. On 4/19/2023, at 9:45 AM, a record review of Resident #101's electronic medical record revealed a readmission on 3/24/23 with diagnoses that included Acute Disseminated Demyelination, Tracheostomy status and quadriplegia. Resident #101 required extensive assistance with all Activities of Daily Living and had severely impaired cognition. On 4/19/23, at 1:38 PM, Nurse M was interviewed via a phone call regarding Resident #101's emergency with the tracheostomy tube coming out of his neck on 3/19/2023. Nurse M explained that Resident #101 was on the edge of the bed. Their tracheostomy tube was hanging out of their neck and when they rolled him over it completely fell out. Nurse M explained that they attempted to put the tracheostomy tube back in although was unable to, so they called 911 sent the resident to the hospital. 37771 Resident #48: A review of Resident #48's medical record revealed an admission into the facility on [DATE] and re-admission on 4/7/23 with diagnoses that included chronic obstructive pulmonary disease with exacerbation, diabetes, obesity, acute and chronic respiratory failure, epilepsy, hypoxemia, cellulitis, nicotine dependence, stroke, and tracheostomy status. A review of the Minimum Data Set assessment, dated 2/28/23, revealed a Brief Interview of Mental Status score of 13/15 that indicated intact cognition and needed extensive assistance with activities of daily living in transfers, bed mobility, dressing, toilet use and personal hygiene. Further review of the medical record revealed the Resident had a tracheostomy and required tracheostomy care. A review of Resident #48's care plan revealed a Focus: I have Tracheostomy r/t (related to) impaired breathing mechanics, date initiated 11/11/22, and an intervention of: Keep extra trach tube and obturator at bedside, date initiated 11/11/22 and Shiley size 4 MM, revision on 4/20/23. A review of Resident #48's medical record, dated 4/7/23 at 7:49 AM, Nursing Progress Note, Resident observed in her bathroom with trach in her hand, and bright red blood in toilet. Emergency trach was observed to be opened as well. SpO2-89%. 911 called for respiratory distress and trach removal. The Resident was transferred to a nearby hospital and returned to the facility the same day. On 4/18/23 at 4:27 PM, an observation was made of Resident #48's room. The Resident had equipment for oxygen connection to a tracheostomy (trach) tube and cleaning supplies for cleaning of the tracheostomy tube at the bedside. The oxygen concentrator was functioning and the tubing that connects to the tracheostomy tube was sitting in a chair. The Resident was not in the room at the time. Nurse N was asked where the Resident was and indicated that she goes outside to smoke and removes herself off the oxygen. The Nurse was asked where the emergency tracheostomy tube was to be located in the room and indicated they usually keep it at the bedside or taped on the wall above the Resident's bed. The Nurse searched the room and was not able to find any spare emergency tracheostomy tube that would be used for dislodgement of the trach tube. On 4/18/23 at 4:41 PM, Nurse P who was the other nurse on the 200 hall, came to the hallway were Resident #48 resided. The Nurse was asked about emergency equipment for dislodgement of the trach tube for Resident #48. The Nurse indicated that it was on the wall last week and she took it out and I replaced it. Nurse N indicated that she usually checks for the spare trach equipment but that today she had not checked for the emergency spare trach. Nurse N was asked about the size of tracheostomy tube the Resident had. The Nurse indicated that the Resident had decannulated herself about a week and a half ago and came back from the hospital with a size 4 trach tube and reported prior to that the Resident was a size 6. Nurse N indicated they should have the spare size 4 trach tube at the bedside. On 4/18/23 at 4:45 PM, an observation was made with Nurse N of the supply room for the 200 hall floor. Staff W Healthcare Coordinator who indicated she took care of central supply and stocking the floors with equipment was in the supply room where Nurse N reported extra trach equipment was stored. Staff W was asked about trach equipment and a size 4 trach tube for Resident #48. The Staff reported she had taken trach supplies down and was not aware they needed a size 4 for Resident #48. The Staff indicated they would be back with the equipment. On 4/18/23 at 5:01 PM, Staff W had not returned to the 200 hall. The Director of Nursing (DON) was in the area and an interview was conducted. The lack of available emergency tracheostomy tube for Resident #48, with the equipment not at the bedside or on the 200 hall and history of recent dislodgement of the tube and emergency transfer to the hospital of Resident #48 was reviewed with the DON. The DON indicated they should have the equipment at the bedside. The DON indicated she would check on the status of the size 4 trach tube for Resident #48. On 4/18/23 at 5:05 PM, the DON returned to the 200 hall and reported they did not have any size 4 tracheostomy tubes in-house. The DON indicated that the Resident had dislodged her cannula recently and returned with a size 4 and the facility had not gotten any trach tubes that size in. The DON indicated they were calling around to nearby hospitals and nursing homes to get a size 4 tracheostomy tube in-house. On 4/18/23 at 5:25 PM, the Administrator was aware of the need for the emergency tracheostomy tube for Resident #48 and the DON reported that a nearby hospital had the supplies and they would pick it up. On 4/18/23 at 5:49 PM, the Administrator sent confirmation that the emergency tracheostomy tube size 4DCFS was in the facility for Resident #48. On 4/19/23 at 8:50 AM, an observation was made of Resident #48 lying in bed sleeping with oxygen collar overtop the Resident's tracheostomy tube. The trach dressing was clean and dry. The emergency supplies of the size 4 tracheostomy tube was present and taped above the Resident's head of bed on the wall. There was also an ambu bag and suction equipment in the room. On 4/19/23 at 11:56 AM, an observation was made of Resident #48 lying in bed and was awake. The Resident was interviewed, was able to answer questions by plugging her trach tube and conversed in simple conversation. The Resident had her left thumb and hand wrapped kerlix but was able to plug her trach tube to make her voice heard. The Resident was asked about the recent dislodgement of the tracheostomy tube. The Resident indicated the whole tube had come out and she tried to place it back in herself, but the nurse came and helped her get the tube back in. The Resident indicated that dislodgment had happened multiple times. The Resident indicated she had blood around the trach area and had difficulty breathing, she had gone to the emergency room of a nearby hospital, and they had placed another trach tube in. On 4/20/23 at 12:24 PM, the Immediate Jeopardy was presented to the facility Administrator. The facility-provided an abatement plan that was reviewed and accepted on 4/20/23 by State Agency Survey Manager. The Immediate Jeopardy was abated on 4/20/23, based on the facility's implementation of the removal plan as verified onsite. The Abatement Plan was as follows: Identification of Residents Affected or Likely to be Affected: -Residents #37, #48, #101 are the affected residents and any current resident with a tracheostomy have the potential to be affected. The facility currently has 3 residents with tracheostomy as identified above. -The availability of replacement tracheostomy tubes for the three residents was verified by the Regional Director of Clinical Operations on 4/20/23. -On 4/20/23, the 3 identified resident were assessed by the DON/designee for an acute change in condition. No potentially relatable issue identified at this time. -On 4/20/23, the facility leadership determined the root cause analysis of the event is the licensed nurse's lack of policy knowledge. Actions to Prevent Occurrence/Recurrence: -On 4/20/23, the Tracheostomy Care Policy was reviewed. -The Medical Director was notified of the facility Immediate Jeopardy event and the removal plan on 4/20/23. -On 4/20/23, the DON received education of facility Tracheostomy Care Policy, including the need to ensure the availability of replacement tracheostomy tubes. -Beginning on 4/20/23, the DON/designee reeducated the licensed nurses, including contracted nurses, on the Tracheostomy Care Policy and the need to ensure the availability of replacement tracheostomy tubes. Any licensed nurse who has not received education by the end of the day 4/20/23 will be educated prior to their next shift. -On 4/20/23, the facility Quality Assurance & Performance Improvement Committee held an ad hoc meeting to discuss the root cause analysis, the plan to remove immediacy, and plan to sustain policy compliance. -A systemic measure the facility will initiate on this date is the utilization of standing tracheostomy order sets. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 04/20/2023. 37666 Deficient Practice Statement #2: Based on observation, interview and record review the facility failed to ensure sanitary storage of respiratory equipment for 2 residents (Resident #30 and Resident #38)) and ensure that oxygen was ordered and care planned for 1 resident (Resident #38) of 5 residents reviewed for respiratory care, resulting in the potential for exposure to infectious organisms for Resident #30 and Resident #38 and inappropriate treatment with respiratory decline for Resident #38. Findings Include: Resident #38: Respiratory Care A record review of the Face Sheet and Minimum Data Set (MDS) assessment for Resident #38 indicated an admission to the facility on [DATE] with Diagnoses: Diabetes, heart failure, depression , history of kidney failure, COPD, hypertension and peripheral vascular disease. The MDS assessment dated [DATE] identified a mild cognitive loss with a Brief Interview for Mental Status (BIMS) score of 12/15. The resident also needed some assistance with all care. On 4/18/23 at 2:35 PM, during a tour of the facility, Resident #38 was observed lying in bed in her room. She was receiving oxygen via an oxygen concentrator at 4 liters/minute. The oxygen tubing did not have a date that indicated when it was last replaced. Upon asking the resident when the tubing was last changed, she said it had not been changed recently, I've never seen them change it. A review of the physician orders for Resident #38 revealed the following: Oxygen at 4 l/nc (4 liters/nasal cannula), No directions specified . date revised 1/14/2023. Change 02 tubing and bag weekly. Do not date the tubing or bag, document on the MAR (medication administration record), in the afternoon every Thursday, start date 10/13/2022. A review of the Medication Administration Record and Treatment Administration Record (MAR/TAR) for April 2023 for Resident #38, identified two separate entries for changing the oxygen tubing. One entry was dated 10/13/2022, Change 02 tubing and bag weekly. Do not date the tubing or bag, document on the MAR. In the afternoon every Thursday for Prophylaxis. The other entry was dated 2/12/2023, Change oxygen tubing weekly and prn if damaged or soiled. Every night shift every Sunday related to Chronic Obstructive Pulmonary Disease with Acute Exacerbation. A review of the resident's care plan titled, I have Emphysema/COPD r/t Physiological atrophy, date initiated 3/2/2022 with Interventions: Give oxygen therapy as ordered by the physician, date initiated 3/2/2022. On 4/25/23 at 8:10 AM, met with the Director of Nursing/DON and reviewed the conflicting oxygen orders. She said the oxygen tubing is supposed to be dated- reviewed the 2 different orders on the MAR/TAR related to changing the oxygen tubing. She said she would check into it. No further clarification. A review of the facility policy titled, Oxygen Administration and Concentrator Policy, dated implemented 05/06 and reviewed/revised 12/20, provided, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences . Oxygen is administered under orders of a physician . The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders: The type of oxygen delivery system; When to administer, such as continuous or intermittent and/or when to discontinue; equipment setting for the prescribed flow rates; Monitoring of (oxygen saturation) levels and/or vital signs, as ordered; Monitoring for complications . Change oxygen tubing and mask/cannula weekly and as needed . Resident #30: On 4/18/23, at 12:15 PM, Resident #30 was lying in their bed. Their CPAP/BiPap mask was lying face down on their bedside table. On 4/19/23, at 11:30 AM, Resident #30 was lying in their bed, Their mask was lying on top of the bedside table with the face side up. The mask was uncovered. Resident #30 stated, Yes, when asked if they wear it at night. On 4/20/23, at 12:31 PM, a record review of Resident #30's electronic medical record revealed an admission on 3/27/23 with diagnoses that included Congestive Heart Failure, Stroke, urinary tract infection and Sleep apnea. Resident #30 was alert and orientated with some confusion and required assistance with all Activities of Daily Living. A review of the physician orders revealed no order to maintain, clean or manage all the components of the CPAP/BiPap machine including the mask and tubing. A review of the progress notes revealed 3/30/23 . Admission . Note Text: Late entry . Resident arrived via stretcher . BiPap was delivered for bedtime .

Based on observation, interview and record review the facility failed to initiate pressure relief interventions prior to wound development and timely assess skin/wound for one resident (Resident #81), resulting in Resident 81 developing a left heel, Stage III wound (sore that has broken through the top two layers of skin and into the fatty tissue below) at the facility and the potential for worsening of pressure ulcers, pain and delayed wound healing. Findings include: Resident #81: Resident #81 was observed during initial tour on 4/19/2023, the resident was in good spirits as she was visiting with her sister and preparing to be transported to dialysis. On 4/20/2023 at approximately 9:15 AM, a review was completed of Resident #81's medical records and it revealed the resident was admitted to the facility on [DATE] with diagnoses that included Hyperkalemia, Pressure Ulcer of Left Heel Stage 3, Major Depressive, Heart Failure, Diabetes and Kidney Disease. Resident #81 is cognitively intact and able to make her needs known to staff but she is dependent on staff for Activities of Daily Living (ADL). Further review of Resident #81's records showed the following: Care Plan: .I am at risk for impaired skin integrity r/t risk for immobility. Stage III Unstageable to left heel . Assist me to position body with pillows/support devices, protect bony prominences, as I allow .Assist/encourage me to elevate my heels off the bed .Bed mobility- I need extensive 2 person assist .Bed mobility-I require weight bearing assistance, lifter sheet, trapeze to turn and reposition . Resident #81's care plan as it related to her Stage III pressure ulcer was initiated on 4/11/2023. TAR (Treatment Administration Record) March 2023: Resident #81 wound care treatment was not completed for five days in March 2023 and she was hospitalized on [DATE] Hospital Discharge Records: .Pressure injury of left heel stage 3 present upon admission .wound location: left heel. Cleanse/irrigate with NS (normal saline). Apply skin prep periwound. Apply Triad cream to wound bed. Wipe off only soiled area then reapply Triad paste, do not Scrub off all Triad if not soiled. Cover with NS moistened gauze 4x4's and secure with kerlix and tape . Physician Notes: 12/30/2022 at 3:57 PM: .Seen regarding left leg edema . there is much less edema of both feet but much more on the left foot and more than usual . 2/5/2023 at 3:27 PM: .There is much less edema of both feet but much more on the left foot and more than usual .left sided weakness mainly the left lower extremity .She now has wound of the left heel that is being treated and improving . 3/7/2023 at 6:10 PM: .Seen regarding left leg edema . left sided weakness mainly the left lower extremity. She now has wound of the left heel that is being treated and improving . 4/15/2023 at 4:01 PM: .She has another ulcer on the left leg. It is stable . Progress Notes: 12/28/2022 at 12:36 PM: .Skin injury to left heel and sacrum per last skin sheet . 1/19/2023 at 6:17 AM: resident states Can you look at my heel, its hurting, observed medium size hard black raise area, left heel, up on pillow. 1/20/2023 at 4:38 PM: Notified by staff resident has a wound on left heel. resident assessed. Unstageable pressure wound noted. Measurements: 13cm x 5.5cm x 0, with 95% eschar noted with scant amt of s/s (signs and symptoms) drainage noted. Cleansed with n.s (normal saline)., pat dried, betadine gauze to area, covered with abd. and wrapped with kerlix . The first mention of left heel skin injury was on 12/28/2023 and there was no assessment or interventions put in place to address it. About 3 weeks later Resident #81 complained of pain and staff observed an unstageable pressure wound to her left heel. Wound Care Physician Notes: 1/25/2023: .Patient has developed an wound which was noted during skin assessment. The wound is located on left heel .large ruptured blister appreciated to the heel. There is necrotic tissue appreciated which is easily removed revealing pale pink granulation tissue .There is serous exudate appreciated to scant to moderate .No sign of infection or deep tissue injuries at this time .Dimensions: 4 x 5 cm (centimeters) x 4.3 cm . 2/1/2023: .patient has a ruptured blister appreciated to the heel. There is necrotic tissue appreciated which is easily removed revealing pale pink granulation tissue . There is serous exudate appreciated to scant to moderate .No sign of infection or deep tissue injuries at this time .Dimensions: 4.0 cm x 3.5 cm . 2/8/2023: .patient has a ruptured blister appreciated to the heel. There is necrotic tissue appreciated which is easily removed revealing pale pink granulation tissue .There is now dry without exudate .no sign of infection or deep tissue injuries at this time. Essentially however the area is mildly indurated and a darker red-pink hue is appreciated. Dimensions: Wound status improved; 3.5 cm x 3.5 cm . 2/15/2023: .patient has a ruptured blister appreciated to the heel. There is necrotic tissue appreciated which is easily removed revealing pale pink granulation tissue .There is now dry without exudate .no sign of infection or deep tissue injuries at this time .Dimensions; 3.0 cm x 3.0 cm . 2/22/2023: .patient has a ruptured blister appreciated to the heel. There is necrotic tissue appreciated which is easily removed revealing pale pink granulation tissue .Dimensions; 3.0 cm x 3.0 cm by dry stable eschar. No tunneling or undermining . 3/8/2023: .Wound base is now developed a new mature thickened eschar. The area is nontender. The area remains dry without exudate. There is no odor .Dimensions: 2.5 cm x 3.0 cm . 3/15/2023: .Wound base is now developed a new mature thickened eschar. The area is nontender .no sign of infection or deep tissue injuries at this time . 3/22/2023: .The eschar noted showing signs of serous exudate without odor at the edges of eschar. The edges are slightly lifted. Use sharp dissection without discomfort to the patient there is partially removed (70%) without discomfort to the patient. Underneath the eschar there is granular tissue red in color .There was moderate serosanguineous exudate post dissection . 4/12/2023: .She was last seen 2 weeks ago. In the interim the patient had been hospitalized due to renal dialysis access .While in the hospital the wound was once again debrided. Hospital wound care described this wound as stage III .Wound base shows early formation of soft eschar. Wound edges are partially attached. There is no odor of exudate .Dimensions: 3.0 cm x 3.2 cm . 4/18/2023: .stage III .wound base shows early formation of soft eschar. Wound edges are partially attached. There is no odor or exudate. There is also a heterogenous mixture of fax and granulation tissue at the wound bed. There are no signs of abscess or infections .Dimensions: 2.5 cm x 4.1 cm . On 4/21/2023 at 12:03 PM, an interview was held with Unit Manager/Infection Preventionist B regarding Resident #81's left heel wound. Manager B stated upon Resident #81's readmission to the facility the hospital classified her wound at Stage III, but their wound physician noted DTI (Deep Tissue Injury). Nurse stated the wound was facility acquired as the resident had dialysis for long periods of time with no offloading. On 4/21/2023 at 12:30 PM, this writer observed Resident #81's left heel wound in the presence of Unit Manager B and AA. Resident #81 reported prior to wound development her heels were not being floated, and she was in bed most of the time or at dialysis. Unit Manager B and AA, reported they took over wounds about a month ago after their wound care nurse did not return. The wound was observed on the left outer aspect of her foot, there was no odor, drainage or infection noted. The heel had an area approximately 3.5 cm wide and appeared to be 1 to 1.5 cm deep. On 12/28/2022 a progress note indicated skin injury to the left heel, on 1/19/2023, Resident #81 complained of pain and on 1/20/2023 the resident was assessed by the facility wound nurse and wound treatments put in place. There was a two-week gap between development and when the facility enacted a treatment. Resident #81 is dependent upon staff and indicated they were no interventions in place to prevent development of wounds on her heel.

This Citation pertains to Intake Number MI00133669. Based on observation, interview and record review, the facility 1) Failed to provide a safe, monitored environment to prevent falls with serious injury for two residents (Residents #630 and Resident #638), 2) Failed to assess and monitor for serious injury after a fall for Resident #638, and 3) Failed to ensure that neurological assessments (neuro checks) were completed per Standards of Practice after unwitnessed resident falls or with a head injury for Resident #630 and Resident #638 of 2 residents reviewed for falls, resulting in Resident #630 falling and hitting their head with no documented neurological assessment and Resident #638 falling and sustaining a left hip fracture with a delay in evaluation/treatment, pain and surgery. Findings Include: Resident #630: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #630 was admitted to the facility on [DATE] with diagnoses: history of a stroke, left lower extremity deep vein thrombosis, Dementia, encephalopathy, depression, anxiety, and hypertension. The MDS assessment dated [DATE] revealed the resident had severe cognitive decline with a Brief Interview for Mental Status (BIMS) score of 6/15. The MDS assessment also identified the resident needing one-person supervised assistance with bed mobility, transfers, walking in her room and hallway, and eating. The resident needed on-person extensive assistance with dressing toileting and personal hygiene and total on-person assistance with bathing. On 1/11/2023 at 10:45 AM, Resident #630 was observed sitting on a chair behind the nurses desk with a drink. No staff were in attendance. After several minutes staff arrived and sat with the resident. They said the resident enjoyed being with the staff. A review of the electronic medical record progress notes indicated Resident #630 fell 4 times between 10/1/2022 and 12/1/2022- 10/4/2022, 10/9/2022, 10/10/2022, and 11/16/2022: 10/4/22 at 6:57 PM, a nurses note provided, Resident was found on floor. Vital sign stable . Denies any pain. Will continue to monitor . 10/4/22 at 7:01 PM, a nurses note provided, Event occurred on 10/4/2022 10:51 AM. Resident found on floor by housekeeping staff. Resident was found at the side of bed on her buttocks sitting straight up . 10/5/2022 at 10:51 AM, a nurses note, Resident has had a fall documented. Please monitor closely for changes/additional falls . 10/9/2022 at 4:50 PM, Event occurred on 10/9/2022 at 1:30 PM, Was reported to writer that resident appeared to be relaxed and comfortable just laying on floor . Staff will monitor closely . 10/9/2022 at 4:57 PM, an SBAR Summary for Providers, Situation: The change in condition reported on this CIC Evaluation are/were: 'Tired, weak, confused or Drowsy'. At the time of evaluation resident/patient vital signs, weight and blood sugar were: 'Blood Pressure: BP 147/88 10/9/2022 10:57 AM; Position: Sitting/left arm; Pulse: 'P 61-10/9/2022 10:57 AM; Pulse type: Regular'; RR (respiratory rate) 'R 18.0- 10/8/2022 2:54 PM'; Temp: 'T 98.1- 10/8/2022 2:54 PM, Route: Forehead'; . Pulse Oximetry: 'O2 98%- 10/8/2022 2:54 PM, Method: Room Air'; Blood Glucose assessment/blank . Mental Status Evaluation: 'Increased Confusion'; Pain status evaluation: blank; Neurological Status Evaluation: blank; Nursing observations, evaluation and recommendations are: 'Resident seems to be confused due to dementia. Resident will be closely monitored . Resident vital signs stable and no injuries noted . Recommendations: Hospice team will take note . and follow-up. The resident's vital signs included in the assessment were not taken at the time of the fall on 10/9/2022 at 1:30 PM. The Blood pressure and pulse were obtained on 10/9/2022 at 10:57 AM and the respiratory rate, temperature and Pulse Oximetry (oxygen saturation rate) were obtain the day prior to the incident on 10/8/2022 at 2:54 PM. The facility did not provide an assessment of the resident immediately after the resident fell . The resident's fall on 10/9/2022 at 1:30 PM, was not observed when it occurred. The resident was found on the floor after the incident. There was no neurological assessment completed after the fall, but per the SBAR report dated 10/9/2022 at 4:57 PM, the resident had increased confusion. 10/10/2022 at 6:20 PM, a nurses note, Event occurred on 10/10/2022 6:20 PM. Resident was sitting in the dining room eating . when resident attempted to stand up the resident slipped and fell on to the ground . 10/10/2022 7:29 PM, SBAR Summary for Providers, . Evaluation are/were: Tired, weak, Confused or Drowsy. At the time of evaluation resident/patient vital signs, weight and blood sugar were: 'Blood Pressure: BP 134/88- 10/10/2022 6:53 PM, Position: Sitting/left arm . Pulse Oximetry: O2 98%-10/8/2022 2:54 PM, Method: Room Air; Blood glucose: blank . Mental Status Evaluation: 'Increased confusion'; Neurological Evaluation: blank; Nursing observations, evaluation, and recommendations are: 'Recommend one on one care between busy hours, 1-8 PM; closely monitor . Hospice will send nurse out . After the first 2 falls closely together, the facility had not obtained a blood pressure in the standing position (sitting only): orthostatic blood pressures were not mentioned. The oxygen saturation rate for the 10/10/2022 SBAR assessment did not have a current oxygen saturation rate; The 02 saturation rate was from 10/8/2022 at 2:54 PM. There was no current assessment after the fall on 10/9/2022 or 10/10/2022. There was no neurological assessment. 11/16/2022 11:21 AM, a nurses note Observed resident standing at nursing station, resident fell back and hit her head on the ground. Resident was lying flat on her back with her legs outstretched. Attempted to talk to resident, resident mumbled but did not respond using words, resident did respond to pain. Observed the back of resident head and there was a laceration and a bump on the back of her head. Resident vitals were obtained, and vitals were within normal limits. EMS (emergency medical services) contacted . 11/17/2022 5:53 AM, a nurses note Resident had a fall 11/16/22. Transported to ER due to her injuries. Return with sutures to the back of head . blood stains on pillow coming from wound . Spoke with doctor he instructed for pressure to get applied to wound . A review of the Post-fall/Fall Risk Assessment V2, forms for 10/4/2022. 10/9/2022, 10/10/2022 and 11/16/2022 revealed the following: 10/4/2022 7:01 PM, Resident found on floor by housekeeping staff. Resident was found at the side of the bed on her buttocks. Date & Time of incident: 10/4/2022 10:51 AM; Was the Fall witnessed: No. 'Unwitnessed fall or head Injury, Initiate Neuro checks' .Orthostatic Blood Pressures: (lying and sitting blood pressures were listed/ there was no standing blood pressure) . Intervention: State immediate intervention (new or revised) implemented to help prevent additional accidents: 'Rt. (resident) was assessed and assisted back in bed after evaluation skin, pain. Responsible parties notified,' Placed intervention in the Fall Risk Care Plan/Kardex. Nurse Now add the intervention to the communication board for all to see.' (This was unchecked) . The residents fall on 10/4/2022 was unwitnessed and there were no neuro checks completed; There was no mention of an intervention to prevent future falls. 10/9/2022 Dated 10/9/2022 4:50 PM with a Lock date of 12/22/2022 (2 months after the incident), Was reported to writer that Resident appeared to be relaxed and comfortable just laying on floor . Was the Fall witnessed: No. 'Unwitnessed fall or head Injury, Initiate Neuro checks' .Interventions put in place. Staff will monitor closely and check residents vitals. Date and time of incident 10/9/2022 (1:30 PM) . Orthostatic Blood Pressures: (lying and sitting blood pressures were listed/there was no standing blood pressure) . Check any care planned safety devices that were in place at the time of the fall: Close monitoring and redirect . State immediate intervention (new or revised) implemented to help prevent additional accidents: 'Resident pain, skin, vitals assessed and redirected to room. Responsible parties notified' . Placed intervention in the Fall Risk Care Plan/Kardex. Nurse: Now add the intervention to the communication board for all to see .' The resident's fall on 10/9/2022 was unwitnessed and there were no neuro checks completed. There was no intervention mentioned to prevent additional falls and there was no checkmark to indicate an intervention was placed on the Fall Risk Care Plan, Kardex or Communication board. 10/10/2022 6:20 PM, Resident was sitting in the dining room eating cheese balls . when resident attempted to stand up the resident slipped and fell on to the ground Date and time of incident: 10/10/2022 6:20 PM . Was the Fall witnessed: Yes. 'Unwitnessed fall or head Injury, Initiate Neuro checks' . Orthostatic Blood Pressures: (Lying, sitting, standing blood pressures and pulse were taken with no abnormalities) . Last time resident was toileted: '10/10/2022 11:00 AM' (over 7 hours before the resident fell ) . State immediate intervention (new or revised) implemented to help prevent additional accidents: (there were no interventions listed). Placed intervention in the Fall Risk Care Plan/Kardex. Nurse: Now add the intervention to the Communication Board for all to see: (this was blank) . 11/16/2022 (Date) 12:01 PM and Locked 12/9/2022 3:58 PM, Resident standing at nursing station, resident fell back and hit her head on the ground. Resident was lying flat on her back with her legs outstretched . resident mumbled but did not respond using words, resident did respond to pain. Observed the back of resident head and there was a laceration, and a bump on the back of her head . Date and time of incident: 11/16/2022 4:00 PM. Was the fall witnessed: 'Yes'. Unwitnessed Fall or Head Injury, Initiate Neuro Checks. Was the resident injured: 'Yes'. Site: 'Top of scalp, sent to ER' . When was the last time the resident was toileted: 11/16/2022 11:00 AM . State immediate intervention (new or revised) implemented to help prevent additional accidents: 'Resident will be redirected if drowsy/sleepy to room/comfortable place'. Placed intervention in the Fall Risk Care Plan/Kardex. Nurse: Now add the intervention to the Communication Board for all to see . This was blank. A review of the Care Plans for Resident #630 revealed the following: I am at an increased risk for falls related to: Wandering, antipsychotic medication; I had a fall without injury on 10/4/2022; I had a fall without injury on 10/9/2022; I had a fall without injury on 10/10/2022, Date initiated 6/21/2022 and revised 11/4/2022. There was no mention on the Care Plan of the resident's fall with a head laceration on 11/16/2022. Per nursing notes and the Fall Risk Assessment Resident #630 was standing at the nurse's desk when she fell backwards and hit her head. The Care Plan had an updated intervention on 11/17/2022 To consult with Hospice for medication for terminal restlessness. The resident was already receiving medications that could cause sedation when taken in combination. A review of the October 2022 Medication Administration Record (MAR) identified the following medications: Mirtazapine for depression, Celexa for depression, Quetiapine and antipsychotic medication, Depakote an anticonvulsant medication for mood. A review of the November 2022 MAR identified the following medications: Celexa, Mirtazapine, Quetiapine, and Depakote. The 11/17/2022 Care Plan intervention for Resident #630 was requesting an additional medication that could further predispose the resident to falling. There were no additional interventions after the 11/17/2022 fall to aid in preventing future falls for Resident #630. On 1/10/2023 at 2:00 PM, the Administrator was asked for all Incident and Accident (I&A) reports for Resident #630 for October 2022 to the time of survey 1/10/2023. The facility provided I&A reports for 10/4/2022, 10/10/2022 and 11/16/2022. After review of the documents, the facility was asked if there was an I&A report/investigation for 10/9/2022, as a nurses note indicated Resident #630 had fallen that day. On 1/13/2023 an I&A report for 10/9/2022 was received from the facility. On 1/13/2023 the Administrator and Interim Director of Nursing (DON) were asked if there were Neuro check assessments after Resident #630 had unwitnessed falls and a fall with head injury. Reviewed with the Administrator and DON there were no Neuro checks in the medical record. No Neuro check assessments were received from the facility prior to exit on 1/13/2023 at 1:00 PM. A review of the facility policy titled, Incident Reporting-Accidents and Supervision, date implemented 06/2002 and last revised 12/20 revealed, Policy: The resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazards and risks; 2. Evaluating and analyzing hazards and risks; 3. Implementing interventions to reduce hazards and risks; 4 Monitoring for effectiveness and modifying interventions when necessary . Documentation- The purpose of the Incident/Accident report is to provide a standardized, systematic process to ensure that all accidents and incidents are promptly identified, reported and investigated, and that measures addressing causes are implemented to reduce recurrence . 37771 Resident #638: A review of Resident #638's medical record, revealed an admission into the facility on [DATE] with a readmission on 8/29/22 with diagnoses that included encephalopathy, osteoarthritis, alcohol abuse, cirrhosis of liver, atrial fibrillation, thrombocytopenia, anxiety disorder, hallucinations, and fracture of left femur. A review of the Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status of 12/15, which indicated moderately impaired cognition. Further review of the MDS revealed the Resident needed extensive assistance for bed mobility, transfer, dressing, eating, toilet use and personal hygiene. A review of Resident #638's facility 5 Day Investigation Report: Injury of Unknown Origin, revealed the following Allegation and Interviews/Investigation: -Allegation: On 8/22/22 it was reported to the administrator that (Resident #638) was displaying signs and symptoms of pain. A Doppler and x-ray was ordered. Doppler was negative, while X-ray revealed angulated displaced sub capital left hip fracture. -(Resident #638): stated that she recalls being on her floor mat but doesn't recall falling. She reported to the physician that she walked without her walker. -(CNA KK) stated that while doing walking rounds she observed (Resident #638) on the floor next to the window. The patient had both feet still up on the bed and had all of her blankets wrapped around her. The aide called her name, but she didn't respond, she just looked at me. I informed the nurse and after the nurse assessed her, we used the mechanical lift to place the patient back in the bed. -(Nurse HH) (stated) (CNA KK) notified me that (Resident #638) was on the floor. I observed the patient lying on her right side on the floor mat next to her bed. I completed the assessment and observed a skin tear to her right upper extremity. I cleaned the skin tear and applied a dressing. Resident denied pain. We used the Hoyer to transfer the patient back into bed. -Conclusion: Based on the Interviews conducted, (facility name) does not substantiate that any form of abuse occurred nor is the injury of unknown origin. The patient had a fall which resulted in her displaced hip. Upon readmission to the facility, the IDP will review the patient's status and update care plans accordingly . -Text message from CNA GG, .On August 21, 2022 Sunday morning . Resident pain was still the same from Saturday. I told the nurse that she was in pain . -Interview with Nurse II on 8/22/2022, Did the patient complain of pain-No; Did the patient display signs of pain-No; Do you know if the patient received a shower that day-I don't think so; Did the patient receive care that day? I would assume I was not in the room with anyone; Does patient use her call light-I've never seen her use her call light; Do you think if the patient would have fallen, she could get herself back up-I don't think so; How was the patient's demeanor that day-Sleepy; Worked Saturday and cared for patients on this day from 7a-7p; Are you aware of her having a fall-No . signed by the Nurse. -Written statement from CNA KK, While doing walking rounds I observed (Resident #638) on the floor next to the window. She had both feet still up on the bed. She had all her blankets wrapped around. I called her name 3x (three times) and she didn't respond just looked at me. I came down got the blood pressure cuff and informed the nurse. Grabbed the lift and sling with the nurses help went back into the room. The nurse looked her over while still on the floor. She had a skin tear on her right lower arm . signed on 8/23/22. -Typed statement that was not dated or signed. (CNA FF) states he had the resident during 3rd shift. He states the resident had a skin tear on her R forearm and a bruise on her L lower leg between the knee and ankle. He states the resident was yelling out with care and he asked her was she in pin and she said no -Typed statement, not dated when the statement was written or who typed the statement, On 8/20/22 at 2315 (11:15 PM), (CNA KK) had this nurse check on (Resident #638). Resident observed laying on her right side on the floor mat next to her bed. Assessment done. Sin tear to RUE (right upper extremity). RUE cleaned and tegaderm applied. Resident denies pain. 2 person assist with Hoyer lift transfer back into bed, signed by Nurse HH but was not dated. -Document titled 1:1 (one to one) Education Record, dated 8/23/22, Employee (Nurse HH), Topic: All falls must be reported and documentation must be completed at the time of fall. A review of the Incident report, date unable to be read from the document sent by the facility, revealed Nurse Description: (CNA KK) reported to this nurse resident observed laying on her back fall mat on floor next to bed, resident laying on her right side on fall mat next to her low bed. Further review of the document revealed the Resident was Alert with mental status Oriented to Person, injuries of No Injuries Observed Post Incident and predisposing physiological factors of the Resident Confused. The document revealed the Witnesses documented as No Witnesses found, and Agencies/People Notified No Notifications found. Review of Resident #638's X-Ray, dated 8/22/22, revealed the following: -History: Pain in left hip, Pain in left knee, Pain in left leg. -Impression: 3 view left hip: There is an angulated displaced subcapital left hip fracture. A review of Resident #638's progress note revealed the following: -Nursing Progress Note by Nurse HH: Created Date: 8/23/2022 at 7:06 AM, Effective Date: 8/20/2022 at 11:15 PM, Event occurred on 8/20/2022 at 11:15 PM. (CNA KK) reported to this nurse resident observed laying on her back fall mat on floor next to bed. This nurse observed resident laying on her right side on fall mat next to her low bed Physician and responsible party notified. The Post-fall/Fall Risk Assessment document in the medical record revealed the same documentation in the Information section. The document in the Information section in red capital letters revealed, UNWITNESSED FALL OR HEAD INJURY, INITIATE NEURO CHECKS. There were no neuro checks found in the medical record and when asked for the neurological assessment, the facility did not present the assessments. -Nursing Progress Note by Nurse HH: Created Date: 8/23/2022 at 7:12 AM, Effective Date: 8/20/22 at 11:15 AM, (CNA KK), reported to this nurse resident observed laying on her back fall mat on floor next to bed. This nurse observed resident laying on her right side on fall mat next to her low bed Responsible party notified, Physician notified, Administrator notified, DON notified -Provider Follow Up Note with date of service 8/22/2022 9:48 AM, .Patient is evaluated today . at the request of the attending physician for ongoing rehabilitation needs . Pt (patient) c/o (complains of) L (left) LE (lower extremity) pain-biofreeze applied, Pt has a bruise on her L leg just below the knee and has difficulty moving the leg today 2/2 pain . -Practitioner Progress Notes, dated 8/22/2022 at 4:09 PM, .Upon speaking with the patient, patient explained in a very slow response that she had attempted to walk without a walker. Patient reporting having left leg pain and weakness. Pain that was radiating from her hip down. Patient was unable to move her left leg but was able to feel sensation in her leg. Patient denied any kind of loss of consciousness or hitting her head. Patient has been getting her Eliquis (anticoagulant medication) but mentioned that she did not have any kind of increased bleeding besides the bruising on her left lower leg and some on her arm region . Speaking with the pt's nurse, pt had received a Doppler US (ultrasound) of the lower extremities which was negative for any acute issue. Pt also had multiple x-rays pending at the time we evaluated pt. Pt complained of increasing pain as well as difficulty ambulating which was worse than before. Pt was agreeable to going to the hospital for further evaluation of possible left hip fracture . On further review of results pt's x-ray which resulted later in the day, showed an angulated, displaced sub capital left hip fracture . Discussed with patient's nurse. Patient will benefit with hospital admission for worsening weakness along with left hip fracture . -Nursing Progress Note, dated 8/22/22 at 4:46 PM, Nurse summon to room by therapist who states resident is yelling in pain. Resident assessed and told therapist not to do any PT (physical therapy) with resident today. Resident has bruising to shin and skin tear on right arm. Resident physician in building and order received for Stat x-ray to left hip tibia and fib and Doppler study. Resident given Tylenol to relieve discomfort. Residents pain is observed on movement. Will continue to monitor. Review of the Post-fall/Fall Risk Assessment document, Date: 8/20/2022 23:15 (11:15 PM) and Lock Date: 8/23/2022 07:06 (7:06 AM) in the medical record revealed the same documentation in the Information section as the Nursing Progress Note: Created Date: 8/23/2022 at 7:06 AM, Effective Date: 8/20/2022 at 11:15 PM, Event occurred on 8/20/2022 at 11:15 PM. (CNA KK) reported to this nurse resident observed laying on her back fall mat on floor next to bed. This nurse observed resident laying on her right side on fall mat next to her low bed Physician and responsible party notified. The incident was documented as unwitnessed. The document in the Information section in red capital letters revealed, UNWITNESSED FALL OR HEAD INJURY, INITIATE NEURO CHECKS. There were no neuro checks found in the medical record and when asked for the neurological assessment, the facility did not present the assessments. The Post-fall/Fall Risk Assessment revealed date and time physician notified, 8/22/2022 at 1800 (6:00 PM) and responsible party notified 8/22/2022 at 1850 (6:50 PM). Further review of Resident #638's medical record revealed no documentation of assessments of range of motion to extremities after the fall occurred on 8/20/22 or on 8/21/22. A review of the Medication Administration Record revealed the scheduled Pain Assessment every shift revealed no pain documented on 8/21/22 on the 7A-7P shift or on the 7P-7A shift. The medical record revealed no documentation of neuro checks. On 1/11/23 at 8:50 AM and 4:50 PM, a phone call was made to Nurse HH regarding Resident #638's fall on 8/20/22. The Nurse did not answer and a message was left to return the call. The Nurse was called again multiple times on 1/12/23, with no answer and no return phone call. The facility had indicated that the Nurse no longer worked at the facility. On 1/11/23 at 9:44 AM, an interview was conducted with CNA GG regarding Resident #638's fall on 8/20/22. The CNA indicated she was assigned care of Resident #638 on 8/21/22 on the day shift. The CNA indicated that the CNA she got report from indicated the Resident had fallen and was found on the side of the bed. When asked if the Resident had complained of pain on 8/21/22, the CNA reported the Resident had pain in her hip and complained of pain every time I turned her, and she yelled out in pain that was at her hip. The CNA stated, I told the Nurse. When asked about the Resident's activity that day, the CNA indicated the Resident did not get up because she was in too much pain and reported the Resident usually got up and went out to smoke. The CNA indicated that was out of the Resident's normal activity routine. When asked if the Resident was alert and oriented, the CNA indicated she remembered the Resident knew her name but that she was acting confused and stated, she was back and forth with it (confusion). On 1/12/23 at 10:38 AM, Nurse EE was called regarding assigned care of Resident #638 on 8/21/22, but there was no answer, a message was left and there was no return call. On 1/12/23 at 11:45 AM, an interview was conducted with the Director of Nursing (DON) and the Regional Clinical Director (RCD) A regarding Resident #638's fracture to the left hip. The DON reported she was not the Director of Nursing at the time of the incident and the Administrator was also new to the facility. Review of the investigation report revealed the investigation was initiated for the complaints of pain from the resident. When asked when they were notified of the fall, the RCD stated, We can't determine that. When asked if the Nurse had not documented the fall until 8/23/22, the RCD reported that they couldn't determine that. After going into the computer system with the DON and RCD, it was determined that the date on the Post-fall/Fall Risk Assessment document was changeable to a date put in and that the lock date was when the note would be transferred to the progress note section of the electronic medical record. The RCD indicated there was no way to tell what time the Risk assessment had actually been opened. Further review of the investigation report revealed the education provided to Nurse HH for: Topic: All falls must be reported and documentation must be completed at the time of fall. When asked if the Nurse had not reported the fall to the oncoming shift and had not documented the fall, how would the oncoming nurse be aware to do a post fall assessment and how would the staff be aware of a potential injury? The RCD indicated that they were not able to determine that after review of the investigation report. When asked about facility policy for assessments after a fall, the RCD indicated the nurse would do three days of post assessments. When asked if any of the three day post assessments were completed, the RCD stated, Well she goes out to the hospital. Review of the medical record revealed a lack of nursing assessment post fall. Review of documented physician notification of the fall on 8/22/22 was reviewed with the DON and the RCD. The DON indicated that the DON and the Physician should be notified of a resident falling at the time of the fall when able to after assessment of the resident. When asked why the physician was not notified at the time of the fall the RCD indicated that was not able to be determined when the Nursing note did not indicate a time that the physician was notified. When asked if per facility policy, were neuro checks needed to be completed, the RCD indicated they should be completed and further review of the medical record revealed a lack of documented neuro checks. The lack of pain documentation in the MAR on 8/21/22 was reviewed with the DON and RCD. When asked if the Nurses should have done an assessment when CNA FF had indicated in the statement that the Resident was yelling out with care and CNA GG had indicated in her interview that the Resident had pain and she had notified the Nurse. The RCD and the DON indicated that Residents with pain should be assessed by the nurse. Further review of the investigation report revealed a lack of documented interviews from the Nurse that had passed medications to the Resident on 8/21/22. The RCD was unable to ascertain through the investigation report and assignment sheets of the Nurse assigned care and reported that the Nurse passing the medication is usually the one assigned care. There was no documented interviews from the Nurse EE who passed medication to the Resident on 8/21/22. On 1/12/23 at 1:50 PM, an interview was conducted with the Administrator (NHA) regarding the concerns with Resident #638's fall, lack of reporting of the fall on 8/20/22 and follow-up assessments to monitor for changes, the Resident complaining of pain, x-rays completed on 8/22/20 with results of a dislocated fracture in the left hip with a delay in treatment when the Resident was transferred to the hospital on 8/22/22 resulting in surgery. A review of the facility policy titled, Fall Reduction Policy, reviewed 8/2021, revealed, Policy: Our residents have the right to be free from falls, or to sustain no or minimal injury from falls . 5. When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment, c. Complete an incident report. d. Notify physician and family, e. IDT review of the resident's care plan and update as indicated, f. Document assessments and actions, g. Obtain witness statements as needed .

This Citation pertains to Intake Number MI00131037. Based on observation, interview and record review, the facility failed to develop, implement, and operationalize policies and procedures to ensure that eight residents (Resident #701, Resident #702, Resident #703, Resident #704, Resident #705, Resident #706, Resident #707, and Resident #708) of eight residents reviewed and 32 additional Residents residing on the third floor of the facility were assessed for appropriate placement in a locked unit of the facility and provided immediate access for visitation. This deficient practice resulted in the third floor of the facility being converted to a locked unit without Resident/representative involvement in care planning, assessment and documentation of appropriate clinical justification or criteria, including procurement of a Health Care Provider (HCP) order, means for independent egress, involuntary seclusion, psychosocial distress, and residents' verbalizations of feelings of discontentment, loss of freedom, fear, and frustration and anxiety, including feeling they are in jail. Findings include: Review of intake documentation detailed, The 3rd floor of the facility is on lock down because (Resident #701) tried to escape the facility on 9/6/22 and 9/7/22 . residents are now required to have an aide (Certified Nursing Assistant [CNA]) accompany them to the elevator and swipe the key access card to get the elevator to work, but the aides are busy doing care and don't have time to take residents to the elevator to go downstairs or outside . On 11/28/22 at 1:30 PM, an interview was completed with the facility Administrator. When queried if there were any locked units and/or codes required to enter units in the facility, the Administrator stated, The third floor. You have to have a card to go up and down the elevator. The Administrator was queried if the card system to access the third floor of the facility was new and replied, No. When queried regarding a card not being required to reach the third floor during previous surveys, the Administrator did not provide an explanation. Resident #701: Record review revealed Resident #701 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included diabetes mellitus, hypertension, and dementia without behavioral disturbance. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required supervision to extensive assistance to complete all Activities of Daily Living (ADL) with exception of eating. The MDS further revealed the Resident displayed inattention, disorganized thinking, wandering every one to three days, and daily verbal behaviors directed towards others. Review of Resident #701's Active, Completed, Discontinued, On hold, Pending Clinical Review, Pending Confirmation, Struck out HCP orders in the Electronic Medical Record (EMR) revealed the Resident did not have an order for placement on a locked/secured unit of the facility. Resident #701 did have the following active order dated 11/9/22, Wander guard . Please check daily every shift for functioning and placement Located on walker every shift for safety. Review of Resident #701's care plans revealed a care plan entitled, I exhibit Exit seeking behavior r/t (related to) dementia with behavior disturbance. Resident is to be escorted by staff when leaving off the unit (Initiated: 12/20/21; Revised: 10/9/22). The care plan included the interventions: - Distract me from wandering by offering pleasant diversions; I prefer group activities (Initiated: 4/8/22) - Document any behaviors or attempts to leave the facility and attempted diversional interventions on my POC (Plan Of Care), including statements regarding attempting or threatening to leave (Initiated: 4/8/22) - I need direct supervision while outside the facility (Initiated: 4/8/22) - Need to be escorted and supervised when leaving the unit (Initiated: 8/16/22) A second care plan entitled, I use anti-psychotic medications r/t Behavior management (Initiated: 1/3/22) was noted in Resident #701's EMR. This care plan included the interventions: - Monitor me and record occurrence of target behaviors and attempted nonpharmacological interventions on the POC (Initiated: 1/3/22; Revised: 6/7/22) - Related to behaviors resident will be on 15-minute checks (Initiated: 8/8/22) Resident #701 did not have a care plan and/or care plan intervention including wander guard use and/or monitoring. On 11/28/22 at 3:42 PM, Resident #701 was observed in their room. A wander guard was not observed on the Resident's person and/or walker. An interview was completed at this time. Resident #701 was pleasantly confused and shifted topics randomly during the interview. When queried if the facility staff had placed a bracelet (wander guard) on their ankle or walker, Resident #701 replied, I took it off because it was cutting into me. With further inquiry regarding the wander guard, Resident #701 stated, They (staff) told me I have to put it on when I am downstairs. I said no and came back upstairs. When asked about the elevator, Resident #701 stated, It's a hazard to be here because the elevator don't move when you get on it. Resident #701 then stated, They need to be investigating themselves in this damn place. I don't want to be here. I just want to leave. During the interview, Resident #701 revealed they smoke. The Resident indicated they used to allowed to go outside to smoke but are not allowed to anymore. An interview was completed with Licensed Practice Nurse (LPN) G on 11/28/22 at 4:00 PM. When asked, LPN G revealed they were not Resident #701's assigned nurse but were familiar with the Resident. When queried regarding Resident #701 including behaviors, LPN G revealed the Resident is confused, does not want to be at the facility, and exhibits exit seeking behaviors. LPN G was queried regarding the elevator being inaccessible to all Residents on the third floor without staff assistance and revealed the prior Administrator had maintenance staff enable the swipe card functionality a couple months ago. When asked the reason, LPN G indicated it was related to Resident #701's behaviors. On 11/28/22 at 4:24 PM, an interview was conducted with LPN F. When queried, LPN F revealed they were Resident #701's assigned nurse. When queried regarding Resident #701 not having a wander guard in place, LPN F stated, I don't know when but (Resident #701) threw it away and wouldn't let me put it back on. When queried regarding the elevator requiring a staff member badge for all residents on the third floor to leave the floor, LPN F stated, Before (elevator required staff badge access), (Resident #701) would hold up the elevator because they would get in with the wander guard and no one could use the elevator. When asked to explain, LPN F revealed Resident #701 had a wander guard and before the elevator was changed to card swipe for everyone for the third floor, staff had to enter a code for the elevator to move when a Resident with a wander guard got on the elevator. When queried why facility staff did not enter the elevator code and accompany Resident #701 on the elevator if that was the reason the floor was secured and elevator changed for all Residents, LPN F was unable to provide an explanation. An interview was completed with Social Worker B on 11/28/22 at 4:30 PM. When queried the date the third-floor elevator was secured and only accessible with a staff badge, Social Worker B stated, Active since September. When queried the reason the elevator was changed and the third floor was secured, Social Worker B indicated it was due to Resident #701's exit seeking behaviors. Review of Resident #701's progress notes in the EMR revealed the following: - 1/2/22 at 6:51 PM: Nursing Progress Note . Refusing to get off elevator. Sitting on elevator with walker. Instructed that only one elevator is in use. Eventually went downstairs. 3/2/22 at 5:45 PM: Nursing Progress Note . Resident petitioned out for psych eval after going outside for a supervised smoking break and refusing to come back into the building. Unit manager and social work intervened and were unable to get resident to return to the building. Resident is stating that wants to go home, and wants the 'band' off leg, which is wander guard. Resident is visibly agitated and hostile. Physician and guardian company has been notified - 3/7/22 at 9:46 PM: Nursing Progress Note . Resident continues to get on elevator. Wander guard in place and working. Redirection ineffective. Safety measures in place . - 3/18/22 at 11:45 AM: Nursing Progress Note . Patient attempted to get onto elevator twice within the last ten minutes. Resident was not easily redirected. Staff was able to assist resident off of the elevator. Resident provided with education. - 3/18/22 at 2:17 PM: Nursing Progress Note . Pt (patient_ began kicking the trash can near the elevator. Staff redirected patient. Patient went on the elevator and began pressing the emergency elevator button. Staff unable to assist resident off of the elevator . - 4/24/22 at 5:07 PM: Nursing Progress Note . Resident was observed getting onto the elevator. Nurse informed patient that it was not time to go outside. Nurse also informed resident that they needed staff to assist them outside. Resident became combative and started to yell . attempted to hit staff with walker. Resident was redirected by activities staff off the elevator. Activity staff informed resident that it was not time to go outside. Resident apologized and stated, '(they) had times mixed up' . - 6/1/22 at 3:39 AM: Nursing Progress Note . Patient stated to CNA that was sick and needed to have nurse check BS (Blood Sugar) . Checked BS 59 (low) . Gave patient orange juice and a yogurt . rechecked BS after 15 minutes BS 79, CNA gave patient a sandwich due to patient stating that they still felt sick and needed something to eat. Patient became very aggressive and calling nurse names attempting to go downstairs to get something from the vending machine. Nurse advised patient per note at nurse desk patient can't leave floor alone. Patient placed their foot in doorway of elevator stating wasn't going to let elevator alarm go off and wake everyone up. This went on from 3- 3:30 AM until 6:00 AM. Patient then apologized nurse and went to room after taking 6 AM medication . - 6/29/22 at 4:36 PM: Medication Administration Note . Pt upset about not being able to go outside for a smoke break at 4pm because refused to come in after the last smoke break. Pt was yelling at staff, being disrespectful to nurse, using profanity, threatening the nurse, getting in the elevator trying to go downstairs multiple times, causing disruption and refused her medications, redirection unsuccessful - 8/10/22: Psychiatric Service Progress Note . LATE ENTRY . Complaint: Medication review, follow up physically aggressive behavior, recent incident, and evaluation per social worker request . last assessed in July 2022. Resident is seen today for follow up of medication review, use of antipsychotics, follow up recent physically aggressive behavior. Resident is up in her chair . exhibits some irritability as well as confusion throughout the evaluation. Resident indicates to me that is very angry and down about being here in a nursing home . 'just wants to leave.' With regard to recent incident, resident relates that another resident was in the elevator with them, and the elevator bumped their leg. Subsequently they hit the resident . - 8/26/22 at 3:16 PM: Social Service Progress Note . SW (Social Work) met with resident this afternoon as displayed eloping behaviors. Resident was not redirectable while hollering on the elevator. Staff was unable to accommodate needs. SW shared with resident that due to behaviors, it is not safe for staff to let them outside for smoking times. SW agreed with resident that once behaviors subside, they would be able to begin going back outside. This is to protect themselves and the facility against any danger associated with them going outside and possibly not returning. SW left a message with guardian re this matter. - 8/29/22 at 2:13 PM: Nursing Progress Note . Resident experienced tantrum. Attempted to open door to stairwell while yelling and cursing. She tried to hit her walker against door stating, 'I need to go to my doctor's appt.' Reoriented resident away from door. Educated resident cannot leave the floor by staircase. - 8/30/22 at 9:30 AM: Social Service Progress Note . SW (Social Work) met with resident this morning re: elopement activity . SW informed resident that would not be permitted outside until behaviors could subside. SW explained the risk and barriers to being outside and practiced some coping skills to smoking. Resident was reluctant but receptive to information given. - 9/8/22 at 8:11 PM: Nursing Progress Note . Resident in hallway screaming I'm going to be a DOA (Dead On Arrival). I'm going to kill myself. (Doctor) present for behavior. Resident cussing at staff, screaming profanities. Received new order for Ativan (antianxiety medication) IM (intramuscular injection). Injection administered. Spoke with MD regarding resident suicidal thoughts. States no need to send to hospital tonight due to recent hospital stay for same behaviors. Will follow up with (social services) on 9/9 so resident can be seen by (Behavioral Health Services Provider) . -9/8/22 at 10:54 PM: Nursing Progress Notes . Upon arrival resident was agitated and stated to the unit manager that . would jumped out the window and the dead body would be on them. Doctor was in visiting residents and heard resident. A order was put in for IM Ativan and administered. Resident did calm down after 45 mins . There was no documentation of Social Services and/ Psychiatric Service follow up. - 9/19/22 at 2:34 PM: Behavior Notes . Upon returning from lunch, cart 1 nurse said that resident was trying to elope by turning doorknob to stairwell waiting for the door to unlock. When writer went to check on resident, (Resident #701) was yelling and cursing at social worker. This went on for approximately 20 minutes. What was happening before the behavior occurred? Resident wanted to go outside but was told by unit manager and social worker that could not . then wanted to call daughters and neither daughter answered. - 9/19/22 at 2:43 PM: Social Service Progress Note . sw approached resident this afternoon as attempted to elope the floor. nurse stood in front of exit as resident ranted on about leaving the facility. resident was not redirectable and began to speak derogatory in front of other residents. SW shared that leaving the floor is not safe for resident at this time. SW left a VM with guardian re: sustaining from smoking to promote safety for resident. - 9/26/22 at 9:10 AM: Activity Participation Summary . Resident will occasionally attend bingo and exercise and food activities. Resident will go outdoors with staff and refuse to come back in. Resident is verbal and able to make needs known . - 10/14/22 at 10:30 PM: Behavior Notes . Resident was smoking in bathroom . What non-pharmacological Interventions were attempted? This writer asked the resident to stop smoking, then resident place the tip of cigarette in the toilet to turn it off then drops it in the trash can. This writer asked for the cigarettes box and lighter that resident was holding but resident refused . - 10/20/22 at 1:07 AM: Nursing Progress Note . Patient exhibit mood disturbance threatening to leave out of facility via elevator staff could not redirect resident. Client proceed toward exit on unit pulling fire alarm and attempting to leave down back stairs. Resident threatened bodily harm to staff nurse while assisting patient to safety. Physician DON (Director of Nursing), guardian notified (via voicemail) of status. Order in place to transfer to hospital. Client transport to hospital via stretcher . An interview was completed with the facility Administrator on 11/29/22 at 9:00 AM. The Administrator provided Resident #701's Incident and Accident (I and A) forms. There were no I and A forms related to elopement and/or exit seeking behaviors provided. When queried if an I and A form should be completed if Resident exhibits exit seeking and/or disruptive behaviors, the Administrator indicated an I and A would not be completed unless an actual elopement occurred. An interview was conducted with Social Worker B on 11/29/22 at 10:52 AM. When queried regarding Resident #701, Social Worker B stated, (Resident #701) is an angry, demented person. (The Resident) yells a lot and curses out staff. Social Worker B was then asked about interventions implemented related to Resident #701's behaviors including exit seeking and revealed that the elevator was card access only due to Resident #701's behaviors. When queried what other interventions had been implemented and/or attempted, Social Worker B reviewed the care plan and stated, Have to go through the building with staff. There is a note at the nurses' station that they are not to go off the unit. Social Worker B was asked when the intervention was implemented and stated, 10/9/22 after reviewing the care plan. When queried regarding the note they authored in Resident #701's EMR on 8/30/22 and if the Resident had eloped from the facility, Social Worker B stated, No, someone had eyes on (Resident #701) the entire time. When asked what had occurred, Social Worker B stated, (Resident #701) tried to take off down the street. When asked the date and/or who was working or with the Resident at the time of the occurrence due to lack of documentation in the EMR, Social Worker B replied, I think I was here, but I don't remember. I don't remember, (Resident #701) try to elope so many times. When asked about their note detailing that they told Resident #701 that they would not be permitted outside until their behaviors ceased, Social Worker B replied, I let (Resident #701) know they couldn't go outside alone. When queried why their note stated Resident #701 was not permitted outside, regardless of whether or not they were accompanied by staff, Social Worker B did not provide an explanation. When asked if the Resident went outside without staff prior to 8/30/22, Social Worker B replied, (Resident #701) was allowed to go outside before. Social Worker B did not provide clarification when asked. When asked why their note stated Resident #701 was not permitted outside, regardless of whether or not they were accompanied by staff, Social Worker B did not provide an explanation. Social Worker B was then queried regarding Behavioral Health Services and recommendations regarding interventions and stated, Med changes but nothing non-pharmacologic. When asked what non-pharmacological interventions were attempted prior to changing the elevator to badge access, Social Worker B replied, Offer activities. Social Worker B was then asked if Resident #701 needed to be a locked unit and if this was the best setting for the Resident and replied that the facility does offer a locked unit. When queried Social Worker B confirmed they were referring the third floor being converted to a locked unit. When queried how many Residents resided on the third floor of the facility, Social Worker B stated, 39 total. When asked how many of the 39 Residents were cognitively intact, Social Worker B reviewed the facility census and stated, 19. An interview was completed with Activities Director C on 11/29/22 at 1:46 PM. When queried regarding Resident #701's activity participation, Director C revealed Resident #701 will typically come to special events. When asked the location of special events for activities, Director C revealed they are typically held in the first-floor dining room. Director C was then asked about participation in regular events and stated, Used to come to bingo but don't not come no more. When asked why the Resident stopped attending bingo, Director C was unable to provide an explanation. Resident #702: Record review revealed Resident #702 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included heart failure, depression, chronic pain, and dementia. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required extensive to total assistance to complete ADL with the exception of supervision with eating. The MDS further revealed the Resident did not display any behaviors. On 11/28/22 at 4:35 PM, an interview was completed with Resident #702 in their room. The Resident was asked if they had any concerns related to the facility and/or the care they receive and stated, Can't get down the elevator because of one person (Resident #701). When asked what they meant, Resident #702 explained that Resident #701 had tried to elope and drove the staff nuts sitting on the elevator so they (facility staff) locked the elevator so no one can get on it without a staff member swiping their badge card. With further inquiry, Resident #702 revealed Resident #701 had a wander guard and would take it off. Resident #702 continued, I think it should go back to the way it was. When queried how the elevator functioned prior to the change, Resident #702 replied, Used to be able to go up and down whenever you wanted. Resident #702 elaborated that if a resident had a bracelet (wander guard) the staff would have to enter a code for the elevator to move but indicated that occurred infrequently. Resident #702 was asked when the facility locked the elevator and replied, Changed about two to three months ago. (Prior Administrator) had them put the key card up here. Resident #702 then stated, Don't none of the smokers like it. Someone gotta swipe it again once inside. Resident #702 was queried what they meant and revealed a staff member has to swipe their badge for the elevator to open when they are on the third floor and a badge also has to swiped to access the third floor. When queried how that effects their daily life, Resident #702 revealed they miss things including activities because there is no one to let them on the elevator and it is like being in jail. With further inquiry, Resident #702 stated, If all the aides and nurses is busy then we gotta wait to go. I always need someone to take me. It effects everybody. The Aides don't like it either. When asked if they had expressed their concerns to facility staff, Resident #702 stated, I talked to the Social Worker, and they are the one who told me to call the State. Resident #702 then stated, It ain't right that we (third floor residents) are being punished for one person. Review of Resident #702's Elopement Risk Assessment documentation in the EMR from April 2021 to November 2022 revealed the Resident was not at risk for elopement. Review of Resident #702's documentation in the EMR revealed no documentation, including HCP documentation, of clinical criteria and need to be placed in a locked/secured unit of the facility. Review of Resident #702's care plans revealed the Resident did not have a care plan pertaining to being on a locked unit in the facility. An interview was conducted with Social Worker B on 11/29/22 at 10:45 AM. When queried regarding Resident #702, Social Worker B indicated they did not understand the question. Social Worker B was then asked if Resident #702 had verbalized concerns to them related to the third floor being locked and not being able to get on the elevator to go to a different floor and/or move throughout the facility as they previously had. Social Worker B replied, (Resident #702) just said we should be able to come up and down the elevator. Social Worker B continued, (Resident #702) ranted on in the hall and I gave them the number to the State. With further inquiry, Social Worker B stated, I actually just walked into the rant. When asked what they meant when they said the Resident was ranting, Social Worker B indicated the Resident was having a fit and going on and on about it. When queried if they asked if there was anything they could do to help Resident #702 and/or address their concerns, Social Worker B stated, I did not. I let my patients do what my patients do. When queried if they documented their interaction and Resident #702's verbalization of concerns in the EMR, Social Worker B indicated they did not recall. Social Worker B was asked to review the EMR at this time. After review of Resident #702's EMR, Social Worker B stated, There is no note in there for that. When queried if any other residents had verbalized concerns and/or talked to them about not being able to access the elevator freely, Social Worker B replied, I don't understand the question. When queried if they had heard anything about the elevator from any other residents, Social Worker B replied, I don't remember. An interview was conducted with Resident #702 on 11/30/22 at 10:05 AM. When queried regarding the elevator no longer requiring a staff badge for access, Resident #702 stated, Thank you Jesus! Resident #702 revealed facility staff had not informed them that the elevator required a staff member badge to enable movement. When queried if they had spoke to the Administrator regarding their concerns about the floor being locked and not being able to use the elevator, Resident #702 revealed they had only talked to Social Worker B. When asked why they did not speak to the Administrator, Resident #702 replied, Don't think they do nothing about it. Resident #703: Record review revealed Resident #703 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke) with resulting dysphagia (difficulty swallowing). Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required supervision to extensive assistance to perform ADL. The MDS further revealed the Resident did not display any behaviors including but not limited to wandering. Review of Resident #702's documentation in the EMR revealed no documentation, including HCP documentation, of clinical criteria and need to be placed in a locked/secured unit of the facility. Review of Resident #703's Active, Completed, Discontinued, On hold, Pending Clinical Review, Pending Confirmation, Struck out HCP orders in the Electronic Medical Record (EMR) revealed the Resident did not have an order for placement on a locked/secured unit of the facility. The Resident did have an active order, dated 4/22/22, for a wander guard. Review of Resident #703's Elopement Risk Assessments dated 7/22/22 and 10/22/22 revealed the Resident was not at risk for elopement. Resident #704: Record review revealed Resident #704 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus, hypertension, and right great toe amputation. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact, required supervision to perform all ADL, and displayed no behaviors including wandering. Review of Resident #704's Elopement Risk Assessment documentation since admission to the facility revealed the Resident was not a risk for elopement. Review of Resident #704's documentation in the EMR revealed no documentation, including HCP documentation, of clinical criteria and need to be placed in a locked/secured unit of the facility. The Resident also did not have a HCP order for placement in a locked/secured unit. An interview was conducted with Resident #703 and Resident #704 in their room (on the third floor) on 11/29/22 at 1:59 PM. When queried if they had any concerns related the elevator, both Residents verbalized concerns pertaining to not being able to get on the elevator and leave the floor without asking for staff assistance. Resident #703 stated they have had to wait 20 minutes for a staff member to swipe their badge so they could get on the elevator. Resident #704 added, It's hard because we gotta catch people and have them swipe it (badge). It's made it bad on us (residents). Resident #703 verbalized agreement and then stated, Some of the nurse aides say it's an inconvenience and Resident #704 added, A real inconvenience. When queried if it bothered them, both Residents stated, Yes, Resident #704 then stated, We are being punished because of other people. When asked, Resident #703 indicated they also felt as though they were being punished. When asked if having to have a staff member in order to operate the elevators limited their mobility in the facility, Resident #703 replied, Very much. Resident #704 added, Make it real bad for us. You would think they would move the person who caused the problem but not punish us. At this time Resident #703 stated, Its real inconvenient for visitors too. When asked what they meant, Resident #703 revealed they were supposed to be able to have visitors but the people who visit can't get to or off the floor without a staff member. Resident #703 revealed their visitors have had to wait and it is delayed/reduced the time they get to spend with the family as well as disrupted their visitors' schedules. Resident #704 then verbalized concerns about an emergency or a fire and not being able to utilize the elevators. Resident #704 stated, What are we supposed to do, just die up here? Resident #703 then stated, I feel completely trapped up here. Resident #704 stated, I do feel like that (trapped). When asked if they had verbalized their concerns to staff, both Residents indicated they had spoke to facility CNA's and nursing staff about their concerns but were unable to recall names. Resident #704 then stated, We brought it up at the council and they said they are working on it but nothing ever happens. The Resident's were then asked about the location of the dining and activities were in the facility and both revealed the dining room was on the first floor and that was also the location of the majority of activities. When asked if not being able to utilize the elevator without staff assistance effected dining and/or activities and both Residents replied, Yes. Both Residents revealed they have missed times to go outside and activities because they could not get off the floor. Resident #703 revealed they feel like they are in jail. Resident #705: On 11/30/22 at 10:00 AM, Resident #705 was observed in their room (on third floor) in the facility. When queried regarding their ability to move throughout the facility, Resident #705 replied I wanna get out of here. When asked what they meant, Resident #705 stated, Cant. No way out. Resident #705 was asked what they meant but revealed it did not matter what they say because nobody cares. Record review revealed Resident #705 was most recently admitted to the facility on [DATE] with diagnoses which included dementia and diabetes mellitus. Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively impaired with disorganized thinking and required supervision to extensive assistance to complete ADL. The MDS further revealed the Resident did not display any wandering behaviors. Review of Resident #705's documentation in the EMR revealed no documentation, including HCP documentation, of clinical criteria and need to be placed in a locked/secured unit of the facility. Review of Resident #705's Active, Completed, Discontinued, On hold, Pending Clinical Review, Pending Confirmation, Struck out HCP orders in the Electronic Medical Record (EMR) revealed the Resident did not have an order for placement on a locked/secured unit of the facility. The Resident did have an active order, dated 10/25/22, for a wander guard. Resident #706: An interview was completed with Resident #706 in their room (third floor) on 11/30/22. When queried regarding their [TRUNCATED]

This Citation pertains to Intake Number MI 488. Based on observation, interview and record review, the facility failed to properly identify and treat a skin condition for one resident (Resident #20) of three residents reviewed for pressure injury, resulting in Resident #20 developing a Stage 3 pressure injury and suffering pain and hospitalization . Findings include: Resident #20: According to admission face sheet, Resident #20 was a [AGE] year-old female, admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to Minimum Data Set (MDS) dated [DATE], Resident #20 was scored 9 on the Cognition Assessment, indicating moderate Cognition Impairment. According to the MDS, Resident #20 required two staff assistance with transfer, and toileting, and one staff assistance with bed mobility. On 5/24/22 at 2:50 PM observation was made in a facility of two residents with stage 4 sacral pressure injuries. Both residents were in bed positioned on their backs. No wedge pillows in use for sacral area. A second observation was made on 5/25/22 at 12:00 PM of the same two residents. Both were seen in their beds positioned on their backs. No wedge pillows were noted for sacral area. Third observation was made on 5/31/22 at 10:00 AM and same two residents appeared to be in the same position as observed previous two times. On 5/24/22 at 5:23 PM a phone interview was conducted with a family member of Resident#20. They stated that Resident #20 was admitted to facility for a rehabilitation after she suffered a fall at her residence and a subsequent hospitalization . Family shared that Resident #20 was ambulatory with a walker prior to fall and could perform majority of her own care. After hospitalization and while in a facility Resident #20 suffered major decline. She was not able to ambulate and was staying in her bed. Family expressed their worries that Resident #20 was not provided regular bed position changes (every 2 hours) or helped up in a wheelchair. She developed stage 3 sacral pressure wound after staying in a facility for three months and was hospitalized by her close relative to facilitate proper wound care. Review of Resident #20 electronic medical records revealed following wound assessments for the period of her stay in a facility (from 2/15/22 to 5/16/22): 2/15/22 coccyx excoriation 2.0 x 0.4 x 0.1 cm - present on admission 2/24/22 coccyx excoriation 3.6 x 4.5 x 0.1 cm (bridging, healable) 3/8/22 coccyx excoriation 6.0 x 4.5 cm (healable) 3/10/22 coccyx excoriation 4.0 x 4.7 cm, slough 100% (slow to heal: wound healing is slow or stalled, but stable) 3/24/22 coccyx excoriation 3.0 x 2.8 cm, slough 70% (healable) 4/4/22 coccyx excoriation 3.0 x 2.2 cm, slough 50% (healable) 4/7/22 no wound description or measurements noted, slough 35% (healable) 4/14/22 coccyx excoriation 2.7 x 1.6 x 0.1 cm, granulation 100% (healable) 4/28/22 coccyx excoriation 2.7 x 1.5 x 0.1 cm (healable) 5/5/22 coccyx excoriation 2.3 x 1.6 x 0.2 cm, granulation 100% (healable) 5/12/22 coccyx excoriation 2.5 x 1.8 x 0.2 cm, granulation 100% (healable) Wound care orders for Resident #20 were as following: 1) Cleanse buttocks, intragluteal fold, coccyx, and sacrum with soap and water, pat dry, apply barrier cream and leave open to air. Every day and night shift for preventive measures. Start date- 2/16/22. Discontinue date- 2/18/22 2) Cleanse coccyx with wound cleanser, pat dry, apply 50% antifungal and 50% barrier cream, apply border foam gauze. Every day shift for preventive measures. Start date- 2/19/22. Discontinue date-3/14/22 3) Clean coccyx with wound cleanser or N/S (normal saline), pat dry, apply santyl to wound surface and cover with N/S or dakins soaked gauze and cover with bordered gauze. Every night shift for wound care, Start date- 3/14/22. Discontinue date- 4/14/22. 4) Santyl Ointment 250 Unit/gm ([MEDICATION(S)]). Apply to coccyx topically every night shift for wound care. Start date- 3/14/22. Discontinue date- 4/20/22. 5) Clean sacrum with wound cleanser, pat dry, apply silver collagen gel, and apply boarder gauze daily and as needed. Every night shift for wound care. Start date- 4/15/22. Discontinue date- 5/17/22. Further medical record review revealed Kardex for Resident #20: Mobility: Bed Mobility- I need Extensive 2 person assist. Encourage resident to allow staff to turn and reposition for comfort and pressure reduction and educate on risk for skin impairment. Resident Care: Change resident's position every 2 hours to facilitate lung secretion movement and drainage. Review of bed mobility tasks for Resident #20 did not reflect position changes every 2 hours. Care plan for Resident #20 initiated on 2/15/22 was reviewed. In a Focus section there was a note: I am at risk for impaired skin integrity r/t (related to): incontinence and refuses to be turned and repositioned. In a Goal section there was a note: I will have no further breakdown through the review date. In Interventions/Tasks section there were following interventions outlined: -Assist me to moisturize my skin as needed, -Encourage resident to allow staff to turn and reposition for comfort and pressure reduction, and educate on risk for skin impairment, -Incontinent: Cleanse area and apply barrier cream to buttocks/peri area after incontinence episodes, per my preference and as I permit, -Licensed nurse skin assessment per protocol, -Please lift, do not slide me. Utilize an assistive device as applicable to decrease friction. No revisions in Resident #20's care plan regarding pressure wound prevention were noted. In the next Focus section, there was a note: I have actual impairment to skin integrity r/t: -area on coccyx. (Initiated on admission on 2/15/22 and revised on 2/24/22). In a Goal section there was a note: I will experience progressive signs of healing by the next review date. Section for Interventions/Tasks had following interventions: -Keep skin clean and dry. Use lotion on dry skin, -Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. No interventions/tasks were noted for frequent repositioning (every 2 hours) to prevent pressure injury. No revisions/updates in Resident #20's care plan was noted after 2/24/22. Braden scores for Resident #20 were assessed as followed: On 3/3/22- Moderate risk (14.0) On 3/17/22- Very High risk (9.0) On 3/24/22- Very High risk (9.0) During an interview with Nurse, LPN B on 5/25/22 at 3:10 PM, she stated that she remembers Resident #20 and her wound assessments. She stated that physician and herself are doing skin assessments every Thursday and she records the findings and measurements, that physician provides after their rounds, in electronic medical records. Nurse B' stated that she trusted physician's skin assessment and was following his orders for treatments. Regarding Resident #20's wound care she recalled that resident was resistant to care, screamed when she was moved and refusing to change position in bed. Nurse B said Resident #20 liked her head of the bed up, to be in a sitting position, and not on her side, and with her left hand prepped on the pillow. Physical therapy was working with Resident #20 as well, and pain medications were adjusted per physician order, nurse B added. On 05/31/22 at 1:04 PM during interview with physician responsible for wound care he recalled that Resident #20 did not like to be touched and repositioned. In his professional opinion, considering that Resident #20 was incontinent and had a poor bed mobility, he diagnosed her wound as coccyx excoriation and prescribed appropriate treatments. Further review of the Resident #20's progress notes in electronic medical record revealed a nursing progress note dated 4/19/22 at 7:04 PM Spoke with son regarding wounds and setting up a time to speak with the physician. Son stated that he feels wounds should have healed by this time, explained to son that wound healing is impeded due to resident refusing to be repositioned and resistance to care. Resident also has poor appetite and does not like to get out of bed. There was a nursing progress note date dated 5/14/22 at 10:44 AM Nurse offered to reposition resident to lay on side resident declined to be repositioned at this time. No additional nursing notes were found about Resident #20 refusals to be repositioned during her stay in a facility from 2/15/22 to 5/16/22. On 5/25/22 at 3:52 PM during interview with occupational therapist C she stated that she remembers Resident #20 case and recalled several discussions regarding her (Resident #20) care with family. Therapist C said she did Resident #20's second assessment prior to hospitalization on [DATE]. Therapy notes were provided and reviewed on 5/25/22. Resident #20 response to Physical therapy treatments was documented as followed: On 2/23/22- actively participates with skilled interventions and compliant with skilled interventions. On 2/24/22- minimum participation with skilled interventions. On 2/25/22- actively participates with skilled interventions. On 2/28/22- compliant with skilled interventions. On 3/1/22- compliant with skilled interventions. On 3/2/22- compliant with skilled interventions. On 3/3/22- compliant with skilled interventions. On 3/4/22- compliant with skilled interventions. Resident #20's response to Occupational therapy was as followed: On 2/23/22- compliant with skilled interventions. On 2/24/22- compliant with skilled interventions. On 2/25/22- actively participates with skilled interventions. On 2/28/22- compliant with skilled interventions, exhibits improvement with structured tasks and exhibited carryover of skills to untrained tasks. On 3/1/22- actively participates with skilled interventions. On 3/3/22- actively participates with skilled interventions. On 3/4/22- compliant with skilled interventions. Occupational therapy assessment notes dated 5/16/22 revealed the following: Pain at rest=5/10; Frequency= Constant; Location: buttocks; Pain description/Type: aching distressing. Pain with movement= 10/10 (reports 12/10); Frequency= Intermittent; Location: buttocks; Pain Description/Type: distressing with movement. On 5/16/22 Resident #20 was hospitalized . Review of hospital records revealed wound care note dated 5/17/22 Stage 3 pressure injury to coccyx. 50% pink, 50% yellow wound base. Peri wound with new epithelium. No local s/s (signs/symptoms) of infection. Present on admission. Wound measurements were recorded on 5/17/22 as 3.2 x 1.2 x 0.2 cm. Hospital admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Emergency department note on admission on 5/16/22 had following pain assessment Positive for back pain. Review of facility provided Policy for Skin and Pressure Injury Risk Assessment and Prevention revised on 7/21 revealed the following: 9. Residents determined as at risk for developing pressure injuries will have interventions documented in plan of care based on specific factors identified in the risk assessment. 10. Interventions for Prevention and to Promote Healing a. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. b. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to: i. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.); ii. Minimize exposure to moisture and keep skin clean, especially of fecal contamination; iii. Provide appropriate, pressure-redistributing, support surfaces; iv. Maintain or improve nutrition and hydration status, where feasible. d. Evidence-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present. i. Pressure injuries will be differentiated from non-pressure injuries, such as arterial, venous, diabetic, moisture or incontinence related skin damage. ii. Treatment decisions will be based on the characteristics of the wound, including the stage, size, amount of exudate, and presence of pain, infection, or non-viable tissue. 11. Modifications of Interventions a. Interventions on a resident's plan of care will be modified as needed. Considerations for needed modifications include: i. Changes in resident's degree of risk for developing a pressure injury. ii. New onset or recurrent pressure ulcer development. iii. Lack of progression towards healing. iv. Resident non-compliance. v. Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights. According to International NPUAP/EPUAP (National Pressure Ulcer Advisory Panel/ European Pressure Ulcer Advisory Panel; a group of experts who serve as the authoritative voice in pressure injuries) defined pressure injury stages. (A) Stage I-nonblanchable [CONDITION(S)]. (B) Stage II-partial thickness skin loss with exposed dermis. (C) Stage III-full-thickness skin loss. (D) Stage IV-full-thickness skin and tissue loss. (E) Unstageable pressure injury-obscured full thickness skin and tissue loss. (F) Deep tissue pressure injury-persistent non-blanchable deep red, maroon, or purple discoloration. (2016 NPUAP Pressure Injury Staging Illustrations from http://www.npuap.org/resources/educational-and-clinical-resources/pressure-injurystagingillustrations/. Used with permission of the National Pressure Ulcer Advisory Panel March 2018. © NPUAP.) Nursing and Patient Care Considerations: Prevent Pressure Ulcer Development- 1. Provide meticulous care and positioning for immobile patients. (a.) Inspect skin several times daily. (b.) Wash skin with mild soap, rinse, and pat dry with a soft towel. (c.) Lubricate skin with a bland lotion to keep skin soft and pliable. (d.) Avoid poorly ventilated mattress that is covered with plastic or impermeable material. (e.) Employ bowel and bladder programs to prevent incontinence. (f.) Encourage ambulation and exercise. (g.) Promote nutritious diet with optimal protein, vitamins, and iron.

This Citation pertains to Intake Numbers MI 060 and MI 153. Based on observation, interview and record review, the facility neglected to ensure proper monitoring and to implement interventions to avoid harm for 1 of 3 confused residents reviewed (Resident #10) with increased agitation, anxiety, and impulsive behaviors, resulting in a delayed transfer to acute care, urinary tract infection, extensive vaginal bleeding with bruising, decreased hemoglobin (red blood cells) with increased distress and anxiety and an extended stay at the hospital. Findings Include: Resident #10: Review of the facility Resident Rights policy dated 8/21, stated The resident has a right to a safe, clean, comfortable, and home-like environment. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in federal regulation. Review of the residents Fall care plan dated 5/10/19, stated Staff is to monitor and observe for periods of restlessness or anxiety and offer assistance with toileting or snacks to provide comfort. Review of the resident's Cognitive care plan dated 2/11/22, stated Observe/document/report PRN (as needed) any changes in cognitive function, specifically changes in : decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental statue. Review of the Face Sheet, Minimum Data Set (dated 2/22, resident assessment), Nursing, Social Worker and Physician notes dated 3/9/22 through 3/10/22, revealed Resident #10 was [AGE] years-old, severely cognitively impaired alert to self only, required assist of one with all Activities of Daily Living, who had behaviors and wandered frequently with a history of falls and elopement. The resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility video done on 3/16/22 at approximately 12:15 p.m., of the third floor Northeast and West Hall (including the room Resident #10 was sleeping in), revealed Nurse, LPN F was in the resident's room (cleaning her up and changing the bed linen) at 4:09 p.m. Nurse F left the resident's room at 4:14 a.m., no one entered her room until 6:35 a.m. (2 hours and 21 minutes), when Nurse F and Nursing Assistant/CNA G (coming in for day shift on 3/10/22) both walked into her room together. The resident was found bloody in her bathroom at 6:35 a.m. by Nurse F and CNA G. The ambulance entered the resident's room at 7:14 a.m., when the resident was transferred to the hospital for vaginal bleeding and extensive vaginal bruising of unknown source. There was blood on the floor and on the resident in the bathroom. The resident was not able to tell staff what happened due to severe decreased cognition. Review of the Ambulance report dated 3/10/22, stated 0700 (at 7:00 a.m.) in bathroom with a pool of bright red blood. Blood appeared to come from vaginal area. On 3/17/22 at approximately 3:40 p.m., observation of the facility third floor room where the resident was sleeping on 3/9/22 through 3/10/22, revealed a private bathroom; there was only one door to the room, which was visualized from the facility video camera. In the bathroom was a hard seat toilet and a white metal bathtub next to the toilet. The resident was not properly monitored and no interventions for increased anxiety, behaviors or wandering were put in place per care plan; she was put back in her room by herself each time she came out of the room on 3/9/22 through 3/10/22. The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility Door log (a record of each time an alarmed door is opened) dated 3/9/22 at 8:40 p.m., through 3/10/22 at 6:26 a.m., revealed the stairwell door on 3rd floor (right next to the room the resident was sleeping in) was opened on 3/9/22 at 11:07 p.m. and not again until 3/10/22 at 7:12 a.m. The door was not opened by anyone after 11:07 p.m. to 7:12 a.m.; no one came from that stairwell door and went into the resident's room during the time staff had left her alone in the room (4:14 a.m.) to the time she was found in her bathroom bleeding (6:35 a,m.). Review of the residents Behavioral (dated 10/5/21), Mood (dated 7/31/20), Elopement (dated 3/29/21), and Communication (dated 7/31/20) care plans revealed, the resident had periods of increased agitation, aggression, wondering with elopement (she had a wander guard placed with a history of elopement) with increased confusion and behaviors. Staff were to monitor increased behaviors and agitation along with providing aroma therapy, calm environment, diversional activities (TV, puzzle book, coloring, and her teddy bear) and provide her with snacks during periods of increased anxiety. On 3/16/22, observation of the facility video dated 3/9/22 at 10:20 p.m. through 3/10/22 at 7:14 a.m., revealed no food or snacks were brought to Resident #10, nor was the resident put on a one-on-one staff with resident or taken up to the nurse's station or put in the Day Room for continued observation due to increased agitation and behaviors exhibited on the video (wandering, picking things off the floor that were not there, and taking off her clothes and walking into another residents' room naked). Nurse F kept taking the resident back to the room she was sleeping in and leaving her alone in the room. Nursing Assistant/CNA E was not observed in the resident's room, nor down the hall she was assigned on the night of 3/9/22 through the morning of 3/10/22, other than at the beginning of the third shift, she put her in her room. Review of the Nursing notes dated 3/9/22 through 3/10/22, revealed no documentation done by Nurse F on 3/9/22 or 3/10/22, third shift when the resident was found bloody in her bathroom. Review of the hospital Patient/Examiner Information dated 3/10/22 at 8:30 p.m., revealed the resident had fresh blood in the vaginal area and black and dark purple bruising with a egg sized bulge/swelling on the right vaginal labia. No documentation of any bruising was found on the resident's inner thighs, legs nor arms. Review of the Hospital records dated 3/10/22, stated [AGE] year-old female, history of [CONDITION(S)] disorder, [CONDITION(S)], anxiety, depression, hypertension (high blood pressure), [CONDITION(S)] (high blood lipids) resides at an extended care facility presented to the emergency department with vaginal bleeding of unclear etiology. The patient had presented with vaginal bleeding. It was difficult to assess her given her [CONDITION(S)] and dementia. She did have some mid lower abdominal tenderness and had blood per vagina. Active Problem: Contusion of labia majora, urinary tract infection. Pelvis US (ultrasound) limited study due to patient's condition. Thickened endometrium (inside lining of the uterus). The hospital records had documented the resident had episodes of combativeness and had to be restrained with soft wrist restraints. Review of the hospital History dated 3/10/22, stated presented to the emergency department with vaginal bleeding of unclear etiology. Patient reportedly found in the bathroom with large amounts of blood on the floor and vaginal bleeding. Examination revealed extensive bruising to the patient's labia, again of unknown origin. Work up revealed a [CONDITION(S)] (urinary tract infection) as well as [CONDITION(S)] (low iron) with a hgb of now 8 (normal hemoglobin for women is 12 to 15). Review of the hospital US (ultrasound) of the pelvis dated 3/10/22, revealed thickened endometrium lining of the uterus). Review of the hospital lab dated 3/12/22, revealed the residents hgb on 3/11/22, was 3.80 and on 3/21/22, was 3.42 (normal red blood cells/hgb for 75 and above female is 12 to 15gm/dl). Observation of Resident #10 at the acute care setting was done on 3/17/22 at 8:20 a.m. The resident was awake in her bed. She had severe confusion and was not able to be interviewed. The resident was not observed to have bruising on her face, hands or lower arms. At this time there was no planned placement for the resident. During an interview done on 3/17/22 at 10:29 a.m., Certified Nursing Assistant/CNA E said she had personal problems and she was not with it on 3/9/22, so she did not go in resident's rooms to check on or monitor any of her assigned residents during her shift. CNA E said she took the resident to her room at approximately 12:30 p.m. (from the Day Room) at the start of her third shift and never went back in her room during the night. CNA E stated, I should of gone back and looked at her. CNA E said she knew the resident had increased agitation and confusion, along with increased behaviors including wandering the night of 3/9/22 through the morning of 3/10/22 and said she put her in her room knowing she had these behaviors. CNA E did not do any of the increased agitation or behavioral interventions listed on the resident's care plans. When this surveyor asked CNA E why she did not go home, she stated I called in the night before, I needed the money. When this surveyor asked CNA E how many residents she was assigned to the night of 3/9/22, she stated about 15. Review of the facility Employee Counseling Notice dated 3/15/22, revealed CNA E was given a final suspension due to not checking on her resident's during her shift, lying to the facility Administrator and changing her story of events on 3/9/22 through 3/10/22 regarding Resident #10. During an interview done on 3/16/22 at approximately 11:00 a.m., Nurse, LPN F was asked by this surveyor if she had been aware resident #10 had increased behaviors, wondering and agitation on 3/9/22 through 3/10/22, on third shift and she stated, yes. When asked by this surveyor if she had taken her to the Day Room, instructed CNA E to monitored her or implemented any interventions on her care plans regarding increased agitation, behaviors or wandering, she stated no. No one increased the monitoring of Resident #10 on 3/9/22 through 3/10/22, due to increased agitation and behaviors of wandering. Nurse, LPN F said she freaked out when she saw resident #10 in her bathroom all bloody and an excessive amount of blood on the floor. She said she wanted to clean up the blood before the ambulance got there. Nurse F got a mop and bucket and cleaned the blood up before the ambulance got to the facility to take her to the emergency room . Nurse F said she took vital signs and that is it. She did not know where the blood was coming from, she was not sure what to do because she had never been in that situation before. She left the CNA (CNA G) in the room with the resident while she asked the other nurse (Nurse, LPN D) what to do and cleaned the blood up. Nurse F stated, I should of stayed in the room with her, I got excited, I did not know what to do. No, I did not tell the CNA (CNA E) to monitor her during the shift, I knew she was having problems and I felt bad for her. During an interview done on 3/17/22 at 10:55 a.m., Nurse, LPN D (working 3/9/22 third shift on same unit as Resident #10 was on) stated I was coming from my hall; I was getting my meds (medications) ready. I had half the rooms down her hall (Resident #10). I did see her naked in the hall that night. I tried to talk to her, but she would not listen; I went and got her nurse (Nurse F). I did ask (Nurse F) where the CNA (CNA E) was. I did get some clean linen when her bed was wet, this was about 4:00 to 4:30 (a.m. on 3/10/22). Nothing was seen at that time; there was no blood, and nobody was in the room. During an interview done on 3/17/22 at 3:40 p.m., the facility Administrator stated she (Nurse F) was terminated, due to her actions on 3/9/22 through 3/10/22 regarding Resident #10. Time Line of Facility Video dated 3/9/22 through 3/10/22, on third floor, Northeast, and West Hall: Review of the facility video done on 3/16/22 at approximately 12:17 p.m., of the third floor Northeast and West Hall (including room the resident was sleeping in) and per staff interviews done on 3/16/22 and 3/17/22, revealed at 12:16 p.m., CNA E took Resident #10 from the Day Room to the room where she was sleeping (her friend's room, they had switched rooms for the night) and at 12:17 p.m., she came out of the residents room. That is the only time CNA E was observed with the resident the night of 3/9/22. The video showed the resident coming out of her room at 1:47 a.m. on 3/10/22, with only a brief on, walking down the hallway toward the nurse's station. She stopped opened another resident's room door and picked something off the floor (nothing was observed on the floor), then she kept walking towards the station. At this time, Nurse, LPN F saw the resident and walked her back to her room. The resident did not want to go back in the room. No blood was observed on the resident at this time. Nurse F changed her bed linens and put a gown on her. Again at 4:06 a.m. (on 3/10/22), the resident walked out of her room, this time completely naked. At this time the resident walked into a male resident's room alone naked (directly across from her room) . At 4:09 a.m., Nurse's F and D saw her naked in the hallway and took her back to her room. Nurse's F and D both changed the linen on the resident's bed and then left her alone in her room. No one took her to the nurse's station or Day Room for increased monitoring, brought her snacks or any diversional activity due to increased confusion and anxiety at this time. No blood was observed on the resident herself (she had no clothes on) at 1:47 a.m., or 4:06 a.m. At 6:35 a.m., Nurse F and CNA G (CNA was coming on for day shift) both walked into the resident's room and found her with blood on her and on the bathroom floor where she was found. Between 4:09 a.m. and 6:35 a.m., the resident was left in her room alone. At 6:36 a.m., Nurse F left the resident's room, at 6:38 a.m., Nurse F went back in the resident's room with another nursing staff member (management). At 6:40 a.m., Nurse F again left the resident's room. At 6:43 a.m., Nurse F came back in the resident's room with a mop and bucket to clean up the blood from the bathroom floor. At 6:49 a.m., Nurse F came out of the resident's room with two soiled linen bags and took them down the hall, at 6:50 a.m., she went back in the resident's room to do vital signs. At 6:54 a.m., Nurse F left CNA G alone in the room with the resident while she took the bucket and mop out of the room. The resident was bleeding and was left alone with a CNA by Nurse F. At 7:15 a.m., the Ambulance and Nurse E were observed entering the resident's room. Nurse F did not stay with Resident #10 after finding her on 3/10/22 at 6:35 a.m., bloody with extensive blood on the bathroom floor; CNA G took care of the resident in her room until the ambulance arrived. During an interview done on 3/16/22 at 8:20 a.m., Housekeeper H said she was working on 3/10/22, and she was asked to disinfect the room Resident #10 was in. She denied seeing any blood in the room nor the bathroom. During an interview done on 3/17/22 at 11:09 a.m., CNA C stated Some nights she (Resident #10) walks around, I did not go in her room that night (third shift 3/9/22). I did not see any male or anyone that should not be there on the unit that night. I have seen her take her clothes off. I have seen her take her clothes off. CNA C said if someone was in the resident's room, she would of screamed out; she had behaviors including screaming and yelling when anyone touched her or did personal care. Review of the facility Abuse, Neglect, and Exploitation policy dated 12/20, stated Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

This Citation pertains to Intake Number MI 988. Based on interview and record review, the facility failed to: 1) Follow up falls with neurological monitoring for two residents (Residents #14 and Resident #79 and 2) Failed to prevent a fall from an electric wheelchair for Resident #405, resulting in the likelihood of missed early signs of neurological changes for Resident #14 and Resident #79 post fall, and a fracture of the spine for Resident #405. Findings include: Record review of the facility 'Fall Reduction Policy' dated 8/2021 revealed residents have the right to be free from falls, or to sustain no or minimal injury from falls. A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force. The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere. (1.) The facility utilizes a standardized risk assessment for determining a resident's fall risk. (3.) The nurse will initiate interventions on the resident's baseline care plan, in accordance with the resident's identified risks. (4.) Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. (a.) Interventions will be monitored for effectiveness. (b.) The plan of care will be revised as needed. Resident #405: Record review of Resident #405's medical diagnoses list revealed diabetes, left sided cerebral infarction affecting left side, [CONDITION(S)], hypertension, peripheral vascular disease, [CONDITION(S)] heart disease, amputation at level between knee and ankle of left lower leg, end stage renal disease, heart failure, depression, asthma and dependence on renal [CONDITION(S)]. Record review of Resident #405's fall incident report, dated 1/9/2022 at 8:00 PM, revealed that the charge nurse heard a crash, and someone yell out from inside the room. When the nurse entered the resident's room, the nurse observed Resident #405 on the floor and stated the straps from the resident's [CONDITION(S)] bag were caught in the wheels of the chair. The nurse asked what happened and was informed that the resident was trying to help workers by taking off her bra and shirt. According to the resident this is when she fell out of her wheelchair. The charge nurse notified the brother of the incident and the charge nurse said that her brother was concerned because she had a safety belt on her wheelchair. Record review of facility five-day investigation for Resident #405's fall on 1/9/2022, revealed increased complaints of pain/discomfort post fall and a request to be sent to hospital on 1/11/2022. Record review of Resident #405's Minimum Data Set (MDS) 5-day admission assessment, dated 12/19/2021, revealed a Brief Interview of Mental Status (BIMS) score of 12 out of 15, some cognitive deficits. Medical diagnoses included: diabetes, left sided cerebral infarction affecting left side, [CONDITION(S)], hypertension, peripheral vascular disease, [CONDITION(S)] heart disease, amputation at level between knee and ankle of left lower leg, end stage renal disease, heart failure, depression, asthma, and dependence on renal [CONDITION(S)]. Section G: Functional status- bed mobility 3/3 extensive assist with two persons assist, Transfers 4/3 total dependence on staff with two persons assist, ambulation activity did not occur, dressing 3/2 extensive assist with one person assist. Functional limitation of upper and lower extremity. In an interview on 02/01/22 at 01:25 PM, the Therapy Services Director J, revealed that the resident #405 had a manual WC on 11/23/2021 and then the brother brought in an electric tilt in place wheelchair on 11/25/2021 for the resident's use. Record review of R#405's therapy notes revealed that the electric wheelchair was used in a therapy session on 11/25/2021 and that the resident had poor skills with the chair. The therapy notes did not document that there was a wheelchair seat belt or not, or if it was to be used for safety, or if the resident was able to self-release seat belt. There was no documentation about a seat belt found in the therapy notes or and evaluation for use of the electric wheelchair. In an interview on 02/01/22 at 01:30 PM, Physical Therapy Assistant (PTA) I revealed that she worked with Resident #405 only 2 times with the electric wheelchair on navigation, and that Resident #405 needed a lot of redirections to task. In an interview on 02/01/22 at 01:40 PM, Certified Occupational Therapy Assistant (COTA) EE revealed that they worked on navigation skills with the electric wheelchair and that the resident's brother brought it in for her use after she was admitted . Record review of Resident #405's Occupational therapy note, dated 11/25/2021, revealed that the brother brought in a power chair. Resident participated with wheelchair training, required maximum verbal cues. Resident demonstrates with left side neglect with processing instructions. Resident would not react to commands, such as, stop when driving into the wall or turning into drinking fountain. She has difficulty clearing doorways. Trained her to pull in front of the doorway with at least two feet of room, rotate chair to face doorway entry, then proceed forward through the door. Power char set on slowest mode. She needs to continue training with power chair. Record review of Resident #405's Physical Therapy evaluation & plan of care, certification period date 11/23/2021 through 12/22/2021, revealed clinical impression of [AGE] year-old above knee [CONDITION(S)] left, history of cerebral vascular accident left sided weakness presents with generalized weakness, decreased trunk strength, decreased functional activity tolerance contributing to decreased functional mobility. Record review of Resident #405's skilled care nursing assessment, dated 1/9/2022 at 6:23 PM, revealed that the resident was assessed as unable to bear weight, had an unsteady gait, impaired balance and weakness were noted. There were no safety devices or seat belt documented on the form. Record review of Resident #405's progress note, dated 1/9/2022, (the event occurred on 1/9/2022) at 8:45 PM, revealed that the writer heard a loud sound followed by resident screaming for help. The writer and several (aides) went into resident's room and found her on the floor laying on her left side against the wall, where she had fallen out of her wheelchair. The aides used the Hoyer lift to get (the resident) back on the bed. Physician and responsible party notified. There was no mention of a physical assessment for neck/head or hip areas noted. Record review of Resident #405's neurological record, dated 1/9/2022 starting at 9:00 PM, revealed the resident was noted to have confused conversation. Record review of Resident #405's Occupational Therapy treatment encounter note, dated 1/10/2022, revealed that while rolling, the resident complained of her head hurting. Resident explained that she had fallen out of her wheelchair the night prior and hurt her left shoulder and back of her head. Record review of Resident #405's skilled care nursing assessment, dated 1/10/2022 at 4:23 PM, revealed resident was assessed as having impaired decision-making skills, unable to bear weight, unsteady gait, impaired balance and weakness were noted. There were no safety devices or seat belt documented on form. Record review of Resident #405's Post-fall Risk Assessment form, dated 1/9/2022, revealed fall involved electric wheelchair and that no restraint used. The seat belt on the wheel chair was not used. Record review of Resident #405's progress note, dated 1/11/2022 at 9:29 AM, revealed that the resident requested to be sent to local hospital related to the fall from wheelchair. Record review of Resident #405's hospital radiology CT scan of cervical spine reports, dated 1/11/2022 at 10:47 AM, revealed a nondisplaced fracture to the right lateral mass of C2. Record review of Resident #405's care plans, pages 1-19, revealed that the resident had left upper extremity weakness, above-the-knee amputation of the left leg, end stage renal disease (ERSD), dependence on hemodialysis, diabetes, [CONDITION(S)] (CPOD) and heart disease. There was no care plan found to address the assessment, training, seat belt use and safety concerns with the use of the electric powered wheelchair for Resident #405. Record review of facility 'Baseline Care Planning', dated 2/2022, revealed that the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. (4.) In the event that the comprehensive assessment and comprehensive care plan identified a change in the resident's goals, or physical, mental, or psychosocial functioning, which was otherwise not identified in the baseline care plan, those changes shall be incorporated into an updated summary provided to the resident and his or her representative, if applicable. (5.) The comprehensive care plan is developed from the RAI (Resident Assessment Instrument) scheduled and is reviewed and revised by the IDT (Inter Departmental Team) as necessary. Resident #14: A review of Resident #14's medical record, revealed an admission into the facility on [DATE] with a readmission on 7/14/20 with diagnoses that included diabetes, dysphagia, [CONDITION(S)], [CONDITION(S)] disease, anxiety disorder, depression, paranoid [CONDITION(S)], delusional disorder and dementia. A review of the Minimum Data Set assessment revealed the Resident had severely impaired cognition and needed supervision-oversight, encouragement or cueing for transfer, walk in room and corridor, locomotion on and off the unit, needed limited assistance with dressing and toilet use and extensive assistance with personal hygiene. On 1/26/22 at 12:03 PM, an observation was made of Resident #14 wandering in the hall and in and out of other Resident's rooms. Resident was observed to have bruising to the chin area and a healing wound to her forehead. The Resident was asked questions but did not respond. A review of Incident and Accident reports obtained from the facility for Resident #14 included the following: -Dated 10/23/21 at 3:41 AM, Nursing Description resident was observed on the floor in her bed room; Resident Description Resident unable to give description; Immediate Action Taken: Description: message left with DR (doctor) neuro taken; . Injuries Observed at Time of Incident: Injury Type: Abrasion; Injury Location: 5)Back of head . -Dated 1/20/22 at 5:46 PM, Nursing Description Resident fall in room; Resident Description don't know; Immediate Action Taken: Description: redirect resident. send to hospital. Call Dr. Resident Taken to Hospital? N (no); Injury Type: No injuries observed at time of incident. There was not an Incident and Accident report for 1/18/22. A review of Resident #14's progress notes revealed the following: -Dated 10/23/21 at 9:11 AM, Resident returned from ER (emergency room ) with via EMS (ambulance) with the attendant wearing face mask with discharge paperwork. Will continue neuro's -Dated 1/18/22 at 7:13 AM, Resident was found 645 (6:45 AM) in chair with blood coming from resident head found by cna (certified nursing assistant). Assess resident open area upper right forehead blood coming from area applied pressure. Obtain resident vitals b/p (blood pressure) 170/90, p (pulse) 86, t (temperature) 98.6 O2 (oxygen saturation) 98 (%). Resident is confused alert x 1 with confusion said she did not no what happen. Patriot call at 652 (6:52 AM) dr (doctor) (name) call at 721 (7:21) am pick resident up at 720 (7:20) am guardian (Name) was called at 729 (7:29) am don (Director of Nursing) notify. -Dated 1/18/22 at 12:03 PM, Pt (patient) returned via ambulance on stretcher. Pt. has laceration on the face. Sutures in place. Discharge instructions to follow up with PCP (primary care physician) in 5-7 days. Pt. is shaky and unsteady gait. Pt. is anxious and is assigned a one-on-one aide for observation. Doctor notified of return. -Dated 1/19/22 at 5:56 PM, Pt. sent out R/T (related to) resident found on floor. Therapy concerned about shoulder due to bruising and pain. Doctor notified and X-ray of shoulder ordered. Pt. sent (hospital name) via ambulance on stretcher. Pt. was stable and Vital signs WNL (within normal limits). Responsible party aware. Further review of the medical record lacked documentation of neurological assessment (neuro checks) for the fall on 10/23/21 and 1/18/22. The neurological assessments were requested but were not received prior to the exit of the survey. On 2/1/22 at 10:26 AM, an interview was conducted with the Administrator (NHA) regarding Resident #14's history of unwitnessed falls and head injury. The NHA was queried regarding facility policy for neurological assessments. The Administrator stated, Unwitnessed falls for a confused resident, I would think the neuros (neuro checks) would be done. On 2/1/22 at 1:09 PM, an interview was conducted with the Director of Nursing (DON) A regarding Resident #14's fall on 1/18/22. The DON was unsure if there had been two falls or if the Resident was sent out to the hospital on 1/19/22 after the fall on 1/18/22 and hospitalization . When asked about the Incident and Accident (I and A) report for 1/18/22, the DON reported that the I and A was not completed on 1/18/22. When questioned about the lack of neurological checks for Resident #14 with head injuries, the DON stated, All the neuro checks are what I gave you. They seen one for that time she hit her head, but were unable to locate the documentation for the neuro checks. The DON indicated that there was documentation that had not been uploaded into medical records and the facility was working on that process. Resident #79: A review of Resident #79's medical record, revealed an admission into the facility on [DATE] with a readmission on 12/8/21 with diagnoses that included arthritis, [CONDITION(S)], muscle weakness, dementia, [CONDITION(S)], difficulty in walking, lack of coordination, anxiety disorder, mood disorder, [CONDITION(S)] and [CONDITION(S)]. A review of Resident #79's Minimum Data Set assessment revealed the Resident had severely impaired cognition and needed limited assistance with transfer, walking in room and dressing, needed extensive assistance with personal hygiene and was dependent on staff for toileting. On 1/26/22 at 2:32 PM, an observation was made of Resident #79 lying on the bed sideways with his feet on the wheelchair that was near the bed. The Resident did not converse with conversation when questions were asked. An observation was made of the floor in the Resident's room to be sticky and had debris on the floor and a puddle of liquid by the bedside table that was across the room. A review of the Incident and Accident reports for Resident #79 included the following: -Dated 12/30/21 at 3:43 PM, Nursing Description: was notified that resident was observed in his room on the floor. When I entered the room, resident was on floor stating he fell out of his chair; Resident Description: resident stated that he bumped his head when he fell out of his chair; Immediate Action Taken: Description: vital signs take Dr and DON and guardian notified. Shin assessment complete. Bruise and swelling above residents right eye. -Dated 1/2/22 at 6:31 AM, Nursing Description: resident was heard yelling for help. Resident was observed on the bathroom floor face down by the toilet. He stated that he hit his head and is in a lot of pain; Resident Description: fell while transferring to toilet; Immediate Action Taken: Description: vital signs taken. Dr. notified, don notified, guardian notified. Resident requested to go to hospital; Resident Taken to Hospital? Y (yes). Further review of Resident #79's medical record revealed a lack of neurological assessment for the fall on 12/30/21 and 1/2/22 or documentation in the progress notes of the falls or post fall assessment. On 2/1/22 at 1:05 PM, Resident #79's falls at the facility was reviewed with Director of Nursing A. After review of the fall on 1/2/22, the DON indicated the Resident had been transferred to the hospital and then came right back. When inquired about follow up neurological assessments, the DON stated, No neuro checks when he came back. When asked about neuro checks for the fall on 12/30/21, the DON indicated that all the neuro checks that were found were given. A review of neuro checks provided by the facility revealed a lack of neuro check documentation for the Resident's falls on 12/30/21 and 1/2/22. The DON indicated that Therapy was currently working with the Resident after a fall on 1/14/22. The DON was asked about facility policy for neurological assessments after an unwitnessed fall for a cognitively impaired Resident. The DON stated, Our policy is not to do neuro checks every time, just when determined by the nurse that it is needed or if they have a head injury. A review of the facility document titled, Neurological Record, revealed, .Frequency: every 30 min. (minutes) x (times) 4, every 1 hour x 4 hours, every 4 hours x 24 hours, every 8 hours x for remaining 72 hours or as ordered by physician. A review of the facility policy titled, Fall Reduction Policy, reviewed/revised on 8/21, revealed, . 5. When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. E. IDT review of the resident's care plan and update as indicated. f. Document assessments and actions .

This Citation pertains to Intake Number MI 959 Based on interview and record review the facility is placed in Immediate Jeopardy for its failure to comprehensively assess, treat and monitor the circulation and skin conditions of Resident #13's right leg, including not having a Wound Care Physician assess the resident's leg for 2 1/2 months, which resulted in Resident #13 requiring a right leg, above-the-knee amputation. This deficient practice placed 107 residents at significant risk of not being comprehensively and competently assessed, monitored, and treated by facility staff for their skin issues, which could result in loss of limb or other life-threatening health conditions. Immediate Jeopardy: Resident #13 admitted to the facility on [DATE] with assessed dark areas on her right knee (0.5cm (centimeters) x 0.5cm), two darkened areas on the right ankle (1cm x 2 cm and 1 cm x 1 cm), a blister on her right heel (3.5 cm x 5 cm) and darkened bunion (1 cm x 3.5 cm). On 12/9/21 Wound Care Physician A was consulted for the first time for Resident #13 and documented acute critical limb Ischemia to the right lower extremity, with shin-to-toe wounds, which could develop into wet gangrene and result in amputation, if not assessed and treated urgently. Wound Care Physician A documented the following description of measurements of Resident #13's wounds: right, anterior foot and shin is an eschar covered Arterial Ulcer (27.5cm x 8.1cm), 95% ischemic eschar and wound consist of at least 4 areas from the anterior shin down to the anterior foot and including the right big toe. Right, medial foot is full thickness Arterial ulcer (1.2cm x 1.2cm). Right, medial malleolus (boney prominence on side of ankle) is full thickness Arterial Ulcer (1.5cm x 1.5cm). Right, lateral lower leg skin to foot including heel is an Eschar covered arterial ulcer (28cm x 15cm width), 90% ischemic eschar.Wound is too large and multiple areas to measure all as separate as are from the same pathological condition of arterial occlusion. Entire right foot is cold to touch and edematous and no pedal pulses are palpable. Wedge defect noted from anterior foot to big toe concerning for critical limb ischemia . Resident #13 was transported to an acute care hospital and subsequently had a right-above the knee amputation on 01/02/2022 due to severe [CONDITION(S)] (PVD) as the hospital was unable to [NAME] the infected and gangrenous right foot. The Immediate Jeopardy began on 09/24/2021. The Immediate Jeopardy was identified on 01/07/2022. The Administrator was notified of the Immediate Jeopardy on 01/07/2022 at 3:46 PM and instructed to provide a plan of correction to remove the immediacy. The Immediate Jeopardy was abated or removed on 01/07/2022. Findings include: On 1/4/2022 at 12:20 PM, an interview was conducted with Family Member AA regrading Resident #13. The family member expressed the resident was admitted to the facility in September 2021 and once she was able to see the resident there were two wounds on Resident #13's heels. Family Member AA explained she saw the wounds as therapy was taking off her socks and her socks were sticking to the wounds, as there was no dressing on them. Family Member AA reported the heels wounds worsened during her time at the facility due to her them not being elevated, the staff not getting her out the bed and her blood flow. Family Member AA further reported she saw Resident #13 a few days before she was admitted to the hospital and the wounds were worsening but there was still no dressing or treatment being performed on them. The family member stated the facility was not assessing and monitoring Resident #13's wounds which resulted in Resident #13's leg being amputated on 1/2/2022. On 1/5/22 at approximately 9:45 AM, an interview was held with Rehab Director Z regarding Resident #13. Director Z reported they were working with Resident #13 on upper extremity ROM (Range of Motion), positioning and left sided weakness. Physical Therapy worked on her lower extremities and there was some progress. Director Z stated there were multidisciplinary meetings with Resident #13's daughter and there were expressed concerns with the overall care Resident #13 received at the facility. During one of Resident #13's physical therapy sessions, the therapist found breakdown on both of the residents' heels and a communication form was completed and provided to nursing staff. On 1/5/2022 at 10:15 AM, an interview was conducted with the Director of Nursing (DON) regarding Resident #13. This writer and the DON reviewed Resident #13's admission assessment (completed on 9/24/21) that indicated the resident had discolored areas on the right and left ankle, darkened bunion and blister on the right heel. The DON reported on 10/15/21 an order was placed for skin prep for the resident's heels. Resident #13's skin assessment from 12/5/21 was reviewed with the DON and the only noted area of concern identified was on the left buttock (there were no measurements or description documented). Resident #13's skin assessment from 12/8/2021 was reviewed and the following areas were documented as concerns: 1. Coccyx- right buttock small areas of peeling/dryness 2. Left buttock-open areas 3. Right heel-blister area 4. Left heel-blister, dark area hard 5. Right toes-right great toe discolored/cool to touch 6. Left toe- left 2nd toe is crossed over great toe dark area 7. Left toe- left baby toe at joints upper and lower joints dark 8. Anterior right foot dark area 2 other dark areas above and below 9. Left bunion area small dark area also top of foot has small dark area 10. Left lateral foot dark areas 2 spots feet are dry 11. Right bunion area raised loose tissue discolored loose tissue/loose scab 12. Side of right foot dark area also blister area dark and hard 13. Under leg right side peeling area lower leg Discussion was held with DON regarding their documentation, as Resident #13's identified skin issues went from one concern to 13 concerns in a matter of three days. The DON agreed the skin conditions identified on the 12/8/2021 did not all open in three days and their staff did not document appropriately. On 1/5/22 at approximately 3:00 PM, a review was completed of Resident #13's medical records and it revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review was completed, and it was found the resident was admitted with dark areas on her right knee (0.5cm x 0.5cm), two darkened areas on the right ankle (1cm x 2 cm and 1 cm x 1 cm), a blister on her right heel (3.5 cm x 5 cm) and right darkened bunion (1 cm x 3.5 cm). Dark area on left knee (1 cm x 1 cm), left outer ankle (1 cm x 0.5 cm), and left outer ankle (1 cm x 1 cm). Further review was completed, and the following was noted: Showering/Bathing: In November 2021, Resident #13 had three showers. The last scheduled November shower was on 11/26/21 but was not given. On 12/3/2021 the resident was scheduled for a shower, but facility documented had the notation 97, which means not applicable. Care Area Assessment (CAA): Resident is dependent on the staff to meet all ADL's secondary to: [CONDITION(S)], limited mobility of limbs, dysphagia, incontinence, the need for G-tube for nourishment, dementia, [CONDITION(S)]. Resident is at risk for falls related to limited mobility and dementia. Will be evaluated by therapy, labs will be monitored as ordered, skin assessments preformed per policy and the physician will be notified of any breakdown. There were several missed opportunities for facility staff to assess Resident #13 wounds and implement appropriate interventions. On 1/5/2022 at 4:00 PM, an interview was conducted with Nurse T regarding Resident #13. The nurse reported she had recently returned from leave and was directed to complete a skin assessment on Resident #13. Nurse T stated upon admission the resident had spots on her feet that were intact. Nurse T continued upon assessment on 12/8/21 they found one of the resident's feet had loose tissue that appeared to be dead, and she knew her leg issues were vascular in nature. Nurse T continued the residents' toes were black in color but upon admission Resident #13's toes were not black. The nurse continued before she went on leave in the beginning of November Resident #13's legs had some spots, but they were intact, and not in the condition that she observed during this skin assessment on 12/8/2021. Nurse T explained the only treatment being administered was skin prep for the resident's heels. On 1/6/22 at 4:35 PM, an interview was conducted with CNA (Certified Nursing Assistant) F regarding Resident #13's skin. The CNA reported in November as the resident was receiving a shower it was noticed her bilateral heels were black in color and very soft. Additionally, the back of the residents' ankles, both heels, side of her foot and toes were black in color. CNA T expressed Resident #13 also complained of pain in her legs. The CNA was questioned if the nurse was alerted to these skin concerns and the CNA stated the nurse was alerted 2-3 times regarding these areas of concerns. On 1/6/22 at 2:10 PM, an interview was conducted with OTA (Occupational Therapy Assistant) CC regarding their sessions with Resident #13. OTA CC stated she had Resident #13 for about 11 days and then finished up with her in November 2021. She reported there was a time she recalls when Resident #13's daughter was in the facility as she was changing the resident's socks and the resident was flinching as she was removing the socks. OTA CC reported the residents' heels looked like the beginning a pressure sore. OTA CC stated she changed the resident's socks often and darkness was noted on the lateral outside of the foot. She continued her foot was always sensitive anytime they would take off or put socks on and Resident #13 would pull her knee up during the encounters (which indicated she was experiencing pain/discomfort). In those instances, OTA CC would communicate this to the resident's nurse. On 1/6/2022 at approximately 2:50 PM, further review was completed of Resident #13's medical records: Therapy Documentation: 10/14/21: Therapist preformed skin check upon changing pt (patient) socks and noticed pressure sore on bil (bilateral) heel/ankles. Nurse notified of this immediately with communication form filled out by their therapist . Therapy/Nursing Communication: 10/14/2021: Upon therapist arrival and changing pt socks, notice bilateral wounds on pt heels/ankles. Also, when Pt is positioned from lying to sitting position presents with dizziness with [CONDITION(S)] of bilateral eyes .Floor nurse was notified of both conditions. 10/26/21: Change in condition- Pt presents with pitting [CONDITION(S)] to L (left) food and reports pain during PROM of the ankle joint. Progress Notes: 12/9/2021 at 14:06: (Medical Director B notified that resident was sent out for evaluation of wound on RLE (right lower extremity). There were no other progress notes located regarding Resident #13's deteriorating wounds. Care Plan: Focus: I am at risk for impaired skin integrity r/t (related to) incontinence and limited mobility. Interventions/Tasks: Assist/encourage me to elevate my heels off the bed .Inspect skin daily with care-report concerns to nurse .Wound physician to follow . Initiated on 10/19/2021. Focus: I have altered cardiovascular status r/t CHF (Congestive Heart Failure), Hypertension. Interventions/Tasks: Assess fingers and toes for warmth and color. Report decrease in temperature or change in color to physician . Weekly Skin Sweep: 10/1/2021: None-Skin intact 10/10/2021: None-skin intact 10/21/21: Left and right buttock open areas. 10/28/2021: Right and left heel. 11/4/2021: Right heel, left heel and coccyx. 11/6/2021: Coccyx, right and left heel 11/16/2021: Bilateral heels, left buttocks treatment in place. 11/26/2021: Left buttock 12/5/2021: Left buttock 12/8/2021: 1. Coccyx- right buttock small areas of peeling/dryness 2. Left buttock-open areas 3. Right heel-blister area 4. Left heel-blister, dark area hard 5. Right toes-right great toe discolored/cool to touch 6. Left toe- left 2nd toe is crossed over great toe dark area 7. Left toe- left baby toe at joints upper and lower joints dark 8. Anterior right foot dark area 2 other dark areas above and below 9. Left bunion area small dark area also top of foot has small dark area 10. Left lateral foot dark areas 2 spots feet are dry 11. Right bunion area raised loose tissue discolored loose tissue/loose scab 12. Side of right foot dark area also blister area dark and hard 13. Under leg right side peeling area lower leg Wound Assessments: 10/14/2021: The assessment is blank 10/19/2021: Right heel- blister/purple area 10/28/2021: 1. Coccyx 2. Left heel-discoloration 3. Right heel- discoloration 11/4/2021: 1. Sacrum-Pressure 2. Left heel- Pressure 3. Right heel-Pressure It can be noted the facility completed weekly skin sweeps and wound assessments that were inaccurate (Resident #13 was admitted with skin concerns that were not carried over from week to week) and failed to provide detailed descriptions and measurements of the wounds. There documentation does not show the progression of Resident #13's wounds and subsequent need for amputation. Although, the Care Plan stated, Wound Physician to follow (initiated on 10/19/21), Wound Care Physician A was not consulted until 12/9/21. On 1/7/22 at 9:00 AM, an interview was conducted with Wound Care Physician A regarding their assessment of Resident #13's legs/feet on 12/9/21. Physician A reported this was the first time they were consulted to assess Resident #13 and upon observation of the wounds, the Physician questioned the facility on why this was the first time they were consulted. Physician A stated Resident #13's left leg/foot was assessed first and there was observed pressure on the left heel, the eschar on the heel was unstable and falling off. Physician A removed what was falling off and debrided the left heel wound. Physician A then moved to Resident #13's right leg/foot (that was covered while treating the left foot). Physician A reported upon assessing the foot, critical limb ischemic and wet gangrene was a major concern. The physician explained they observed where the occlusion (blockage) was in the resident's limb. Physician A explained the occlusion did not occur overnight and it would have been signs prior to full occlusion. Physician A explained the resident complaining of pain in her legs was a sign that should have warranted further assessment. The physician stated Resident #13's daughter expressed the resident was complaining of leg pain and Physician A was informed therapy and other facility staff expressed the resident complained of pain in her legs as well. Physician A stated it's a slow roll to get to an occlusion but, if wound care had been consulted, they could have assessed, monitored, and sent out for evaluation and treatment at an earlier stage. Physician A stated at the time of assessment there were no treatments or dressing in place to the multiple wounds on Resident #13. Physician A stated she was unsure why the facility had not consulted them earlier. At conclusion of the assessment Physician A informed the facility Resident #13 needed to evaluated swiftly at the hospital or she could lose her leg. Wound Care Physician A reported pictures of the wounds were provided to the DON. The Physician was able to provide the pictures to this writer, as when the DON was asked about the pictures it was stated the Surveyor would need to request them from Physician A as they did not have them. The pictures from the wound assessment on 12-9-21 were labeled and the wounds were circled and numbered. The numbers coincide to the Physician A wound assessment and description. Resident #13 right and left foot/leg had multiple open wounds in varying shapes and sizes. The boney prominence of right big toe was discolored, and a large flap of skin was hanging off. It is unclear how the facility staff could have missed such wounds and discoloration during the residents' showers, daily cares, and weekly skin assessments. On 1/7/22 at approximately 9:10 AM, a review was completed of Resident #13's medical records from the acute care hospital that she was transferred too. The medical records revealed the following: .Over the past few weeks they (wounds) have begun to drain and have a foul odor. No noted previous evaluation by vascular surgeon .bilateral lower extremity arterial ulcers .Plan #1: Significant gangrenous changes to right foot in the setting of significant PAD ([CONDITION(S)]) .Arterial Doppler: Aortoiliac disease nearly absent flow below knee BLE .Podiatry agrees with vascular surgery assessment that patient would benefit from amputation. Right foot non-salvageable .(Right)- Significant gangrenous changes about the right foot extending to darkened discoloration to the anterior aspect of the ankle. Multiple areas of ulceration about the right foot varying in size about the digits, dorsal-medial and dorsum of the foot, posterior heel, anterior and posterior ankle. Diffuse peri-wound [CONDITION(S)] about the right foot and anterior ankle . On 1/7/22 at 1:22 PM, an interview was conducted with Medical Director B, regarding Resident #13. Medical Director B reported he vaguely remembers Resident #13 and when questioned about assessment of her wounds and other skin conditions, Medical Director B stated she was being followed by wound care. Medical Director B was informed the resident was not being followed by wound care and he stated he thought she was. Medical Director B reported he does not recall receiving any calls from the facility regarding her wounds or change in condition related to her skin but would expect the facility to call and alert him to any concerns. He stated he does remember Resident #13 being send out to the hospital as the facility contacted him. Review was completed of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] 9/30/2021: .assess for wound .cont (continue) wound care. 10/8/2021: No mention of Resident #13's wounds 11/4/2021: No mention of Resident #13's wounds 12/8/2021 (day before Resident #13 was sent out to the hospital for her leg wounds): No mention of Resident #13's skin. It can be noted from the interview with Medical Director B and subsequent progress notes that Resident #13 was not being assessed or monitored for her leg wounds by her in house Physician (Medical Director B). On 1/7/22 at 1:35 PM, an interview was conducted with PTA (Physical Therapy Assistant) BB regarding Resident #13. PTA BB reported they were completing a session with Resident #13 and the family was also in the room. They completed incontinence care on the resident as she was soiled. As the PTA was going to put lotion on the resident's feet, they noticed both heels, medial-lateral side of the right foot and boney prominence of right big toe were all black in color. PTA BB reported this was new for the resident, as they have observed her feet prior to this encounter and they were not in that condition. PTA BB stated she verbally alerted the nurse to what she observed but also completed a communication form. PTA BB reported the nurse informed her she was going to call the physician and mentioned having wound care consulted. PTA BB expressed prior to this, Resident #13 had little scratches on the top of her foot, but her skin was intact. She reported there was no dressing or treatment in place that was observable on Resident #13's feet when she discovered the discoloration. The PTA further explained when the resident was lying in a supine position as they were completing ROM (Range of Motion) the resident expressed paint in her feet and most of the time it was the right foot that caused her the most pain. On 1/7/2021 at approximately 1:50 PM, a review was completed of Wound Care Physician A's assessment of Resident #13 on 12/09/21, the assessment showed the following: .Today (12/9/21) is the first time (Wound Care) has been consulted to assess wounds on patient. After assessment spoke to patient's daughter over the phone who stated mother was complaining to her of pain in her right leg. Discussed with daughter my concerns for critical limb ischemia and concern for potential development of wet gangrene which could result in amputation if not assessed and treated urgently .Wound #2 Left Heel is a Stage 4 Pressure Injury Ulcer .measurements are 5cm length x 4.5cm width .with an area of 22.5 sq (square) cm .Eschar present is unstable with edges already uplifting upon exam. Hyperkeratotic peri wound present, dead skin patches present .Wound #3 Right, Anterior Foot and shin is an eschar covered Arterial Ulcer .measurements are 27.5cm length x 8.1cm width .222.75 sq cm sq cm .95% ischemic eschar .Wound consist of at least 4 areas from the anterior shin down to the anterior foot and including the right big toe all being measured as one wound today .Wound #4 Right, Medial Foot is full thickness Arterial ulcer .measurements are 1.2cm length x 1.2 cm width x 0.2 depth, with an area of 1.44 sq cm .Wound bed has 100% pale grey granulation Wound #5 Right, Medial Malleolus is full thickness Arterial Ulcer .measurements 1.5cm length x 1.5cm width x 0.3cm depth .Wound bed is 100% pale grey, pink granulation .Periwound is painful .Wound #6 Right, lateral lower leg skin to foot including heel is an Eschar covered Arterial Ulcer .measurements are 28cm length x 15cm width .with an area of 420 sq cm .90% ischemic eschar. Wound is too large and multiple areas to measure all as separate as all from the same pathological condition of arterial occlusion. Wound consists of at least 4 areas from shin down to the heel and including part of the foot all being measured as one wound . Entire right foot is cold to touch and edematous and no pedal pulses are palpable. Wedge defect noted from anterior foot to big toe concerning for critical limb ischemia. Debridement for this wound is not safe at this time due to concern for significant arterial insufficiency. Concerns for wet gangrene presence or near future development .Refer to Vascular Surgery- recommend hospitalization for concern for wet gangrene .Concern for acute ischemic limb ischemia needing urgent assessment and treatment and management by as vascular surgeon which is best achieved by sending patients to the hospital urgently. On 1/7/22 at 2:15 PM, an interview was conducted with the DON. The DON reported the practice at the facility is to consult their wound care team for pressure, non-pressure such as toes, venous and arterial skin issues. The DON reported wound care evaluates everyone on their caseload on a weekly basis. The DON was queried if the facility has a designated wound nurse from their in-house nursing staff. The DON reported they do not. The DON was further queried regarding expectations for resident's skin assessments. The DON reported at a minimal, nursing staff should describe and measure (if they felt comfortable) any new wounds and/or skin concerns. The DON further stated any new change with wounds they would expect the staff to inform the doctor. The DON was questioned as to why Resident #13 was not being followed by wound care. The DON reported resident had a treatment in place for her coccyx wound and there was a consistent treatment in place for her right and left heels (skin prep). The DON reported the resident had a blistered dark area on the right heel and was not certain as the measurements (as there were none documented in Resident #13's chart since her admission in September 2021). The DON was queried if there were any open areas on Resident #13's shin area and the DON reported there was not. The DON further explained she was with the nurse who completed the 12/8/2021 skin assessment on the Resident and saw the resident skin concerns. The DON was not able to ascertain why the facility's past skin assessments on Resident #13 were vastly different from week to week and did not capture all her skin concerns. The DON reported comprehensive skin assessments and measurements should be completed and documented weekly. The Immediate Jeopardy was identified on 01/07/2022. On 1/7/2022 at 3:46 PM, the Immediate Jeopardy Notification was presented to the Administrator. The facility provided an Abatement Plan that was reviewed and accepted on 1/7/2022 by State Agency Survey Manager. The Immediate Jeopardy was abated or removed on 1/7/22, based on onsite interviews and record review that occurred on 1/7/2022 and 1/10/2022. The abatement plan was as follows: Element #1: IDENTIFYING OTHER RESIDENTS AT RISK o Beginning 1/7/22 Residents have comprehensive, accurate skin assessments completed o Beginning 1/7/22 A facility-wide sweep is being conducted to identify new skin impairments. o Beginning 1/7/22 The facility has Identified residents with a Braden scale of 11-12 (High risk) who have the potential to be affected o Beginning 1/7/22 New admissions will be reviewed to ensure those identified with skin impairments have accurate assessments of the wounds, interventions, monitoring, including notification of the clinical prescriber as indicated. Element #2: PROCESSES IMPLEMENTED TO PREVENT FURTHER OCCURRENCE 1. Beginning 1/7/22 The facility medical director has been notified and has received the components of the plan to correction for approval. 2. The resident remains in the hospital, unable to complete a follow-up assessment. 3. Beginning 1/7/22, The Director of Nursing and Administrator reviewed the skin and pressure injury risk assessment and prevention policy and deemed it meets clinical and regulatory requirements. 4. Beginning 1/7/22, The Director of Nursing/Designee has re-educated the Licensed Nurses on the importance of completing weekly skin assessments and following up with the clinician prescribers to ensure interventions and care plans are revised as needed. Nurse aides have been educated on completing skin assessments during showers and notification to charge nurses regarding changes in condition. Nursing Staff not educated by the end of the day (1/7/2022) will receive education before starting their shift on 1/8/2022. Element #3: MONITORING 1. Beginning 1/7/22 The Director of Nursing/designee will review new admissions to ensure those identified with compromised skin integrity (non -pressure and pressure) have treatment interventions, monitoring, and notification of the clinical prescriber as indicated. The audit will be completed three times a week for two weeks, then two times a week for two weeks, then weekly for four weeks. Any concerns will be addressed accordingly and reported to the administrator. 2 . Beginning 1/7/22 Results will be reported to the QA committee for monitoring and follow-up. 3. Beginning 1/7/22 The administrator is responsible for substantial compliance with this Plan of Action. The facility alleges the removal of the immediacy of these discrepancies 1/7/2022. On 1/11/22 at 3:00 PM, a review was completed of the facility policy entitled, Skin and Pressure Injury Risk Assessment and Prevention, revised 7/21. The policy stated, It is our policy to perform a skin assessment and pressure injury risk assessment as part of our systematic approach to injury prevention and management .A skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter 4. Documentation of skin assessment: a. Document observations; b. Document type of wound; c. Describe the wound (measurements, color, type of tissue in wound bed, drainage, odor, pain); d. Document if resident declined the assessment and why; e. Document other information as indicated or appropriate . On 1/11/22 at 3:15 PM, a review was completed of the facility policy entitled, Wound Treatment Management and Documentation, revised 07/21. The policy stated, .Wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates. Wound treatments are documented at the time of each treatment. The following elements are documented as part of a completed wound assessment: a. Type of wound and anatomical location; b. Stage of wound, if pressure injury ( stage 1, 2, 3, 4, 5, deep tissue); c. Measurements, height, width, tunneling; d. Description of the wound characteristics: i. Color of wound bed; ii. Type of tissue in the wound bed; iii. Condition of the peri-wound skin; iv. Presence, amount, and characteristics of wound drainage/exudate; v. Presence or absence of odor; vi: Presence or absence of pain.

This Citation pertains to Intake Number MI 523. Based on interviews and record reviews, the facility is placed in Immediate Jeopardy as a result of the facility's failure to promote healing and prevent the worsening of a Stage III pressure ulcer by not implementing professional standards of practice and physician-ordered, care planned interventions in a timely manner for one resident (Resident #117) that included the following: a) The facility failed to have an assessment and evaluation of Resident #117's dietary and hydration needs, and care planned interventions to promote wound healing upon admission and with the subsequent deterioration of the coccyx pressure ulcer. b) The facility failed to identify and evaluate potential alternatives to counteract the resident's refusal for positioning. c) The facility failed to follow wound treatment recommendations from the wound care provider when on [DATE] the treatment was recommended for Santyl (a wound treatment used for debridement of necrotic tissue) to the Stage III pressure wound to the coccyx area and not instituted until [DATE] and an additional order, on [DATE], for a low air loss mattress that was not instituted until [DATE]. d) The facility failed to follow recommendations made on [DATE] from the wound care provider, for [MEDICATION NAME] and [MEDICATION NAME] to the periwound of the coccyx pressure ulcer (area around the wound). e) The facility failed to follow recommendations made on [DATE], from the wound care provider, for the treatment of [REDACTED]. f) The facility failed to have documented physician assessment and evaluation in the Resident's medical record of the Stage III pressure wound to the coccyx upon admission into the facility and with the worsening of the wound. As a result of this deficient practice, Resident #117's Stage III pressure ulcer of the coccyx worsened to a Stage IV pressure ulcer with exposed bone, sero-sanguineous drainage, and scattered necrosis. Resident #117 was hospitalized for [REDACTED]. Resident #117 also suffered subsequent septic shock, metabolic acidosis, acute osteo[DIAGNOSES REDACTED], [MEDICAL CONDITION] requiring blood [MEDICAL CONDITION], and placement in the Intensive Care Unit (ICU) of a local hospital. The Immediate Jeopardy started on [DATE]. The Immediate Jeopardy was identified on [DATE]. The facility was notified of the Immediate Jeopardy in writing on [DATE] at 3:05 PM. The Immediate Jeopardy was removed on [DATE]. Findings include: Resident #117: Resident #117 was admitted to the facility on [DATE] with a Stage III pressure ulcer (full thickness tissue loss) to the coccyx measuring 3 cm x 3 cm x 0.7 cm. The wound increased in size and worsened to a Stage IV ( full thickness tissue loss with exposed bone and underlying structure) by [DATE], when the measurements of the coccyx wound were 3.0 cm x 5.5 cm x 1.5 cm, with an area of 16.5 sq cm and a volume of 24.75 cubic cm with bone exposed, a moderate amount of sero-sanguineous drainage, scattered necrosis, irregular edges and a fragile periwound. This deficient practice resulted in serious harm by the worsening of a Stage III pressure ulcer of the coccyx to a Stage IV pressure ulcer with exposed bone, a moderate amount of sero-sanguineous drainage, scattered necrosis (dead tissue), and hospitalization [MEDICAL CONDITION] (infection throughout the body). Resident #117 required surgery for [REDACTED]. Resident #117 also suffered subsequent septic shock (organ shutdown from infection), metabolic acidosis, acute osteo[DIAGNOSES REDACTED] (bone infection) and [MEDICAL CONDITION] requiring blood [MEDICAL CONDITION]. The resident was in the Intensive Care Unit of a local hospital and later died at the hospital. A review, of Resident #117's medical record, revealed an admission into the facility on [DATE], with [DIAGNOSES REDACTED]. The Resident was transferred to the hospital on [DATE]. A review of the Minimum Data Set assessment revealed the Resident had intact cognition and needed extensive assistance of 2+ person physical assistance with bed mobility, dressing and personal hygiene and was total dependent of 2+ person physical assist for transfers, toilet use and bathing. A review, of Wound Care Clinic A's visit report for Resident #117 revealed the following for the wound care visit on [DATE]: -Physician/Extender: Nurse Practitioner B -Chief Complaint: .This patient was seen today as a consultation for evaluation of the patient's wounds. -Wound Assessment: Wound #1 Coccyx is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 3.5 cm (centimeters) length x (by) 2.5 cm width x 1 cm depth, with an area of 8.75 sq (square) cm and a volume of 8.75 cubic cm. There is a moderate amount of sero-sanguineous drainage noted. Wound bed has Pink Base [MEDICATION NAME]. The periwound skin texture is normal. The periwound skin moisture is normal. The periwound skin color is normal. General notes: Scattered necrosis irregular edges. -Diagnosis: [REDACTED]. -Plan: Wound Orders: Wound #1 Coccyx. Treatment Recommendations: SANTYL DAILY AND PRN (as needed) -Additional Orders: Pressure Relief/Offloading, LOW AIR LOSS MATTRESS OR LOW AIR LOSS BED, FREQUENTLY REPOSITION. A review, of Wound Care Clinic A's visit report for Resident #117 revealed the following for the wound care visit on [DATE]: -Physician/Extender: Nurse Practitioner B -Chief Complaint: .This patient was seen today for follow up and management of the patient's wound(s). -Wound Assessment: Wound #1 Coccyx is a Stage 4 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 3 cm length x 5.5 cm width x 1.5 cm depth, with an area of 16.5 sq cm and a volume of 24.75 cubic cm. Bone is exposed. There is a moderate amount of sero-sanguineous drainage noted. Wound bed has Pale Pink Base [MEDICATION NAME]. The periwound skin texture is normal. The periwound skin color is normal. The periwound skin exhibited: Moist. General Notes: Scattered necrosis irregular edges fragile periwound. -Diagnosis: [REDACTED]. -Plan: Wound Orders: Wound #1 Coccyx. Treatment Recommendations: [MEDICATION NAME] + [MEDICATION NAME] CREAM ,[DATE] QSHIFT (every shift) AND PRN-To periwound. SANTYL + CALCIUM ALGINATE QD (every day) AND PRN -Additional Orders: Pressure Relief/Offloading, LOW AIR LOSS MATTRESS OR LOW AIR LOSS BED, FREQUENTLY REPOSITION. A review, of Resident #117's Treatment Administration Record (TAR) in the medical record revealed the following treatment orders: -Cleanse open area to coccyx with NS (normal saline), apply Therahoney to wound bed, cover with boarder gauze dressing daily and PRN loose/soiled every day shift for wound care, Order Date [DATE] 1615 (4:15 PM), D/C (discontinued) Date [DATE]. Scheduled at 0700 (7:00 AM). First dressing documented as completed on [DATE]. -Cleanse open area to coccyx with NS, apply Therahoney to wound bed, cover with boarder gauze dressing daily and PRN loose/soiled every night shift for wound care, Order Date [DATE] 1642 (4:42 PM), D/C Date [DATE]. Scheduled at 2300 (11:00 PM). There was no order for the recommended treatment for [REDACTED]. There was no order for the recommended treatment made on [DATE] for the Santyl daily and PRN. A review, of Resident #117's medical record of orders on the Medication Administration Record [REDACTED]. The order for the recommended Santyl and Calcium Alginate daily and PRN dressing made on [DATE] was not ordered until [DATE]. A review, of Resident #117's orders revealed an order, dated [DATE] at 14:10 (2:10 PM), for Facility Low Air Loss mattress to be applied to bed. The audit details of the order revealed the order was Created by: (Wound Care Nurse F). Created Date: [DATE] at 14:10 (2:10 PM). A review, of Resident #117's orders revealed an order, dated [DATE], for Pro STAT (supplement) liquid by mouth 30 ml (milliliters) twice daily for increased wound healing and decreased PO intake. A review, of Resident #117's Admission Data Collection documentation revealed the following: -Description: Admission -Date: [DATE] -Lock Date: [DATE] -Section 7. Physical Examination: Skin Integrity. A. Skin Condition 1. Is resident's skin intact, No; 2. Does the resident have pressure ulcer(s) if so, be sure care plan has been included, No; 3. Does the resident have non-pressure area/other skin conditions? Yes. The listed areas had a type of skin condition listed as Pressure at the site of the crack of buttocks, and the Stage documented as N/A (not applicable). -The Section 7, Physical Examination: Skin Integrity, was signed by Nurse C and dated [DATE]. Sections ,[DATE] and ,[DATE] were signed by Nurse D and dated [DATE], with Section 1, Admission Details/Vitals Signs/General Appearance, signed on [DATE] and Section 4, Physical Examination: Cardiovascular/Circulation/GI/GU, signed on [DATE]. A review, of Resident #117's Nutrition Data Collection documentation, dated [DATE], revealed the Skin Status documented as Skin Intact, with comments of bruising to extremities. The Summary/Plan/Progress note revealed, .Resident disagreeable and refusing more than a few bites of food. Alternative foods offered . No wounds. Skin at risk for breakdown with LE (lower extremity) [MEDICAL CONDITION] and bruising to extremities, incontinence and limited mobility A review, of Resident #117's care plan for nutrition, revealed the following: -Focus: Nutrition: I am at risk for compromised nutritional status r/t (related to) CKD4 ([MEDICAL CONDITION] stage 4), and AMS ,[DATE] UTI (urinary tract infection). I receive a regular texture diet. I have my own teeth. My weight is acceptable. I like Pepsi and prefers cold cereal for breakfast. *Noted decrease in PO (oral) intake*, Date Initiated: [DATE], Revision on: [DATE]. -Interventions/Tasks: Monitor weight per facility policy. Monitor labs and medications for nutritional significance and intervene as needed. Provide diet as ordered: Regular texture, monitor for tolerance. Please offer an alternative food if I am not eating. Please offer assistance as needed. Obtain and honor food preferences as able. I like Pepsi and prefer cold cereal. A review, of Resident #117's care plan for skin impairment, revealed the following: -Goal: (Resident's name) has increased potential for skin impairment r/t: Respiratory impairment, Personal Hx (history) of Fall, Shingles, Decreased mobility, Decreased PO intake, Pres (presence) of indwelling catheter, Preference to lay on back, repositions self to back. *Known Skin Impairment* Shingles [MEDICAL CONDITION] to left torso, front and back, pres on admit with skin tears present from scratching. Pressure wound to coccyx, pes on admit. Scattered discoloration to bilateral forearms with skin tears, pres on admit. Indwelling catheter, pres on admit. [DATE] Active Shingles [MEDICAL CONDITION] to left lateral back, observation of intact blisters. -Interventions/Tasks included: --Encourage good nutrition and hydration in order to promote healthier skin. Provide diet as ordered. Facility RD (Registered Dietician) consult as needed. Supplements in place Date Initiated: [DATE], Revision on [DATE]. --Encourage/assist (Resident's name) to turn and reposition from side to side while in bed. May use soft positional device to assist with repositioning. *Resident wiggles away from positioning device to reposition self on back.* Date Initiated: [DATE], Revision on [DATE]. --Low air loss facility mattress applied to bed, Date Initiated: [DATE], Revision on [DATE]. A review, of Resident #117's medical record revealed no documentation from the Attending Physician L. A review, of Resident #117's progress notes, included the following: -Dated [DATE] at 6:18 PM, Admission Note, Resident arrived into room [ROOM NUMBER] via EMS on a stretcher .Resident is A&Ox ,[DATE] (alert and oriented to person, place and time) . Admission is endorsed to PM (afternoon shift) nurse, author Nurse E. -Late Entry, Effective Date: [DATE] at 11:22 AM, Skin/Wound Note, Assessment of resident's skin r/t admission to facility . Stomach with dry, shingles rash present, multiple scattered pink bases, no active drainage or crusting visible. Left lateral back with 2 boarder gauze dressings in place, area reddened, no active shingles lesion drainage or crusting, moderate frank bleeding with removal of dressings due to thin fragile skin. Coccyx with stage 3 pressure area observed, 3 cm x 3 cm x 0.7 cm, pink wound base with scattered yellow necrosis present, periwound area with [DIAGNOSES REDACTED], increased moisture, exhibits scarring, moderate sero-sang drainage without odor. Right of wound is a small yellowed irregular round lesion, no active drainage observed. Wound care provided to coccyx area, cleanse with NS, apply Therahoney gel to wound bed, cover with boarder gauze daily and PRN loose/soiled. Leave area of shingle [MEDICAL CONDITION] open to air to lateral left back and stomach, author Wound Care Nurse (WCN) F. -Dated [DATE] at 10:29 AM, Physician Note, . She is oriented to baseline and denies any pain at this time .There are some healing skin tears and ecchymosis (bruising) on both hands, no other skin issues noted. She is wearing a brief. Discussed orders with RN, no needs at this time other than pain medication . author Nurse Practitioner G. -Dated [DATE] at 10:39 AM, Nursing Note, IDT (interdisciplinary team) RISK meeting held. Resident followed for new admission and skin. Resident admitted for skilled nursing and therapy following falls at home. Seen in hospital for UTI, dehydration, shingles. Resident's goal is to return home following therapy. Resident has dried Shingles [MEDICAL CONDITION] on left side of torso, front and back. Resident admitted with stage 3 to her coccyx. Wound bed yellow and necrotic. Abnormal lab values noted. Decreased appetite with refusals to eat noted. Resident continues on oral antibiotic. Wound care treatment in place and will be followed weekly by wound care. RD to assess need for supplements to promote healing . author Social Services H. -Dated [DATE] at 10:53, Nursing Note, IDT RISK meeting held. RD, MDS, Nursing, Wound Nurse, SW present. Resident followed for skin. Resident has stage 3 to coccyx present upon admit; shingles rash left torso front and back. Treatments in place: cream to rash; wound care orders in place for wound to coccyx. POI (oral intake) poor. Resident recently completed abt (antibiotic), which may have had an effect on her POI. RD assessed and ProStat BID (twice a day) added for supplement, author Social Services H. -Dated [DATE] at 2:06 PM, Skin/Wound Note, Consult with (Wound Care Service A) for placement of Low Air Loss mattress. No new Shingles [MEDICAL CONDITION] noted at this time. Resident noted to wiggle away from soft positioning device and reposition self on back. Facility Low Air Loss mattress to be applied to resident's bed to assist in comfort and wound healing. Author WCN F. -Dated [DATE] at 12:37 PM, Care Plan Note, IDT Risk Meeting held. Resident followed for skin and weight. Resident followed by facility RD for weight with supplements in place. Resident noted with wounds deteriorating. Low air loss mattress ordered. No further Shingles eruption. Refuses repositioning. Continues to be followed by Wound Kair. Treatments in place, author Social Services H. -Dated [DATE] at 4:24 PM, Skin/Wound Note, Writer received new order for resident's wound, order updated to eTAR and Unit Coordinator notified of change. Order for Santyl ointment to wound bed, cover with Calcium Alginate and boarder gauze daily and PRN loose/soiled. Order faxed to pharmacy with expected delivery of Santyl ointment tonight, author WCN F. -Dated [DATE] at 3:22 PM, SBAR (situation, background, assessment, recommendation) Summary, . RN Assessment/LPN Appearance of resident-What I think is going on with the resident is: [MEDICAL CONDITION], 400 ml of Frank red blood. Denies any pain, dizziness, or shortness of breath. Alert and orientated to person, place, time, and situation. Had [MEDICAL CONDITION] episode on [DATE] . author Director of Nursing. -Dated [DATE] at 3:13 AM, Nursing Note, writer notified on [DATE] at 2200 (10:00 PM) pt (patient) admitted into hospital in room [ROOM NUMBER] for poss (possible)[MEDICAL CONDITION] . author Nurse I. A review of Resident #117's wound measurements, revealed the following: -Dated [DATE], Late Note documented on [DATE] by WCN F of a progress note, Coccyx with stage 3 pressure area observed, 3 cm x 3 cm x 0.7 cm. -Dated [DATE], Wound Care Services A, Wound #1 Coccyx is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 3.5 cm (centimeters) length x (by) 2.5 cm width x 1 cm depth, with an area of 8.75 sq (square) cm and a volume of 8.75 cubic cm. -Dated [DATE], Skin-Weekly Non-Pressure Condition Record, Site: Coccyx; Type: Pressure; 3.5 cm length, 2.5 cm Width, 1 cm Depth, Stage III. -Dated [DATE], Wound Care Services A, Wound #1 Coccyx is a Stage 4 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 3 cm length x 5.5 cm width x 1.5 cm depth, with an area of 16.5 sq cm and a volume of 24.75 cubic cm. A review, of Resident #117's medical record from the hospital, included the following: -Date of service, [DATE], Surgeon progress note, Indications for procedure: . presented to the hospital with worsening sacral decubitus ulcer. The ulcer was noted to be stage IV with multiple areas of devitalized necrotic tissue. It was determined that the best procedure to proceed would be debridement and then a diverting [MEDICAL CONDITION] to prevent contamination into the newly-debrided wound. -Date of service, [DATE], Progress Note Infectious Disease, History of present illness: Patient . presented to the ED (emergency department) for altered mental status and urinary tract infection . Also, patient has large sacral decubitus ulcer down to the bone. When our service saw the patient last month, sacral wound was quite small and shallow. -Date of service, [DATE], Progress Note Critical Care, History of present illness: . Patient was also found to have a large sacral decubitus ulcer down to the bone (small on previous admission) on admission for which she was started on aztreonam (due to her extensive allergies [REDACTED]. Patient was successfully extubated after the procedure but became hypotensive with SBP (systolic blood pressure) in the 70's and had to be started on [MEDICATION NAME] . She was transferred to ICU (intensive care unit) for further management . Assessment: #Acute [MEDICAL CONDITION] ,[DATE] (secondary to) GI (gastrointestinal) bleed vs (versus) retroperitoneal bleed s/p (status [REDACTED].>5.2>4.9> 2 U (units) PRBC (packed red blood cells) .; #Shock ,[DATE][MEDICAL CONDITION] .; #Acute osteo[DIAGNOSES REDACTED] ,[DATE] sacral decubitus ulcer s/p surgery .; #Metabolic acidosis ,[DATE][MEDICAL CONDITION] vs shock . On [DATE] at 2:15 PM, an interview was conducted with Wound Care Nurse (WCN) F regarding Resident #117's pressure ulcer care. A review, of the measurements, was conducted with the WCN and also reviewed measurements documented on the Skin-Weekly Non-Pressure Condition Record, dated [DATE], completed by Nurse D, of measurements of the coccyx pressure wound of 3.5 cm x 2.5 cm x 1 cm, Stage III. The measurements were the same that were documented by the wound care services on [DATE] and did not reflect the worsening of the wound as documented on [DATE] by the wound care services. The WCN explained, the floor care nurses are not to do the measurements of the wounds and reported the nightshift nurse had documented on the wrong document. The WCN stated, They know they are not to do this document for this reason. You get conflicting data. I don't know how she got that measurement, same as the one on ,[DATE] and ,[DATE]. Further review, of the measurements, was conducted with the WCN. The WCN explained that after admission on [DATE] she had completed a head to toe assessment the next day ([DATE]) and reported that a note had been put in the progress notes for the coccyx wound measurements of 3 cm x 3 cm x 0.7 cm, Stage III. When queried if the note was the late entry put in on [DATE] with an effective date on [DATE], the WCN indicated she had done the assessment on ,[DATE] but did not document it until ,[DATE]. The WCN was queried regarding the admission assessment with the skin condition listed as Pressure at the site of the crack of buttocks, and the Stage documented as N/A (not applicable). The WCN indicated the wound needed to be assessed on admission and stated, There needs to be education on that. They are used to putting in a note and me doing the rest, indicating the measurements and Staging. The WCN indicated the Resident had been admitted into the facility with the pressure ulcer to her coccyx. When queried regarding the start of treatment, the WCN reported she had received an order to cleanse the wound with normal saline and apply a dressing with [MEDICATION NAME] (Therahoney) and indicated she had documented the dressing in the progress note. When queried regarding the treatment change with the deterioration of the wound, the WCN indicated the dressing had been changed to Santyl ointment with calcium alginate daily and as needed. The intervention of repositioning the Resident onto her side was reviewed. The WCN indicated the Resident did not like to be reposition and would wiggle back onto her back as indicated with the review of the care planned intervention. When queried if that was a refusal for positioning and documentation of the refusals, the WCN indicated the nurses should be documenting the refusals and was unsure why they were not. When queried regarding other interventions attempted for repositioning, the WCN reported that the issue with repositioning had been an issue at home. The WCN was queried why the air mattress was not completed as an intervention until [DATE] when the recommendations of the Wound Care Service A had ordered the air mattress on [DATE]. The WCN reported the air mattress was not applied until the shingles were no longer active. The WCN indicated the air mattress would cradle her sides and cause an issue with sweating and stated, When we seen no more active shingles, then we started the air mattress. The nutritional interventions and dietary aspect of care in the medical record was reviewed with the WCN. The WCN reported there was not a dietary note and was unsure why the dietary assessment did not indicate the pressure wound for Resident #117. The WCN, after review of the baseline care plan, indicated the care plan did not address the pressure ulcer wound on admission. When queried regarding supplements, the WCN indicated that Pro-STAT (dietary supplement) was added, on [DATE], after a discussion with the Dietician and was unsure why nutritional supplements were not implemented prior to [DATE]. After further review, of the nutritional care plan, the WCN reported there was no updates made with the Pro-STAT or other interventions and was unsure why other interventions were not addressed with the Dietician and indicated that the intervention on the skin impairment care plan included to encourage good nutrition and hydration in order to promote healthier skin, provide diet as ordered, facility RD consult as needed and supplements in place, that were initiated on [DATE]. On [DATE] at 2:35 PM, an interview was conducted with Confidential Person J regarding Resident #117's care at the facility. The Confidential Person reported that Resident #117 had come into the facility for rehab therapy and had a small bedsore about the size of a dime, she had blood in her urine and was sent to the emergency room where they discovered a bedsore the size of a large vegetable can. The Confidential Person continued to explain the Resident had to have surgery, as soon as possible, and they had the surgery on Sunday, [DATE], where they cleaned out the wound of necrotic tissue and had to do a [MEDICAL CONDITION] to make sure the pressure sore healed. The Confidential Person relayed a concern that she laid in bed all the time, and reported they had been visiting on Saturday and Sunday. Saturday ([DATE]), the Confidential Person reported they were at the facility from about 2:00 PM to 8:00 PM and stated, They checked on her and brought her food, but they did not turn her the whole time I was there. The Confidential Person indicated that they were visiting on Sunday ([DATE]), form approximately 9:00 AM to 1:00 PM, and reported the Resident was in bed the entire time, was not repositioned, laid on her back and denied positioning equipment to keep her off her back, not on Saturday or Sunday. The Confidential Person indicated that the Resident had a caregiver at home, and they would come to visit. The caregiver was concerned that the Resident was in bed, not repositioned and that the wound was smelling. The Confidential Person reported the Resident had made it through the surgery but was having a difficult time with recovery. On [DATE] at 4:25 PM, an interview was conducted with the WCN F regarding dietary notes for Resident #117 related to the pressure ulcer to the coccyx. The WCN reported they were unable to locate progress notes or other dietary evaluations with the worsening of the wound. The WCN reported that Magic Cup (dietary supplement) was on her tray and stated, It might have been on her meal ticket but I don't know how to pull those up, and indicated the Dietician was not in the facility this day. On [DATE] at 11:18 AM, an interview was conducted with Nurse Practitioner, (NP) B, from the Wound Care Services A, who had assessed Resident #117's pressure ulcer to the coccyx area. The NP was queried regarding when the facility is notified of the wound recommendations. The NP reported that they see the Residents' wounds and write the recommendations prior to leaving the facility and stated, they would have them the same day as the visit. When queried regarding the procedure if the facility elected not to following the Wound Care Services' recommendations, the NP indicated the wound care nurse would contact her with the physician orders [REDACTED]. A review of Resident #117's recommendations for the wound treatment of [REDACTED]. The NP indicated the [MEDICATION NAME] was no longer to be used and that Santyl was ordered instead and stated, It's (Santyl) an agent to help to remove the necrosis with more effective results. The NP reported no one had contacted her regarding not following the recommendations and was not aware the recommendations were not followed. The NP indicated they had not been aware that the Santyl was not being used and reported they expected recommendations for Santyl to be followed within 24 hours for pharmacy to get the Santyl to the facility. The NP stated, Santyl is not an issue on getting it, within 24 hours it is in the facility. The periwound treatment of [REDACTED]. The NP reported she had not had any communication of their recommendations not followed for Resident #117. The NP was queried regarding not following the recommendation of the air mattress due to an active care of shingles and stated, Clinically there is no correlation, she can have an air mattress with shingles. The NP indicated they had noticed the Resident had not been on the air mattress on [DATE] and stated, I discussed with the wound care nurse about getting the mattress as soon as possible, and indicated it had not been brought to their attention that the air mattress was not started because of the shingles. On [DATE] at 12:20 PM, an interview was conducted with Registered Dietician (RD) K regarding Resident #117's dietary evaluation. When queried regarding the Nutritional Data Collection document, dated [DATE], with the skin status documented as intact, the RD stated, When I did the assessment, the skin assessment was not done yet so I was unaware she had an ulcer. The RD reported she could not recall if staff had let her know the Resident had a pressure ulcer. The RD was queried regarding nutritional interventions upon admission in the baseline care plan to promote wound healing and reported that at the time of the admission evaluation, they were unaware the Resident had a pressure ulcer wound. The RD reported had she been aware, then she would have put interventions in the care plan to promote wound healing. When queried regarding further deterioration of the wound on [DATE], the RD reported they were unaware of the deterioration of the wound and reported a communication issue between dietary services and nursing staff. The RD was queried what would take place had they been aware and reported that an evaluation, assessment, data collection, recalculate the nutritional needs with the wound deterioration, if refusing the supplements they would reassess and try something different and stated, We would have done more things, that included look at what she is eating, evaluate what she is taking in, watch her intake. The RD indicated that when there was a wound that was not improving, I would be in constant communication with the wound care nurse, and document the interventions that are appropriate and again indicated she was not aware of the wound. The RD reported the nutritional care plan would reflect there was a wound and if it was improving or not improving and if there were supplements in place. The RD stated, We like to have the nutritional care have all those things in the care plan. On [DATE] at 12:43 PM, an interview was conducted with the Director of Nursing regarding the lack of Physician notes/assessments regarding Resident #117's pressure ulcer to the coccyx area. The Director of Nursing (DON) indicated she called and texted Physician L, the Physician had not answered, and it went to voice mail but indicated the Nurse Practitioner reported the Physician had done the notes. The DON stated, We don't have them available. The issue of the lack of Physician assessment of the Resident's wounds and that there was no available documentation that the attending Physician was overseeing wound care and evaluated the worsening of the wound was discussed with the DON. The DON was queried regarding the admission assessment and lack of documentation of the pressure ulcer, for Resident #117, and indicated on admission the nurse was to measure and assess the wound but the Staging was done by the Wound Care Nurse either on the admission day or the next day. The DON reported the admission nurse, or the next shift nurse, if admitted near the change of the shift, was to complete the skin assessment of the Admission Data Collection. A review, of Resident #117's medical record, with the DON, revealed no assessment and measurements of the wound on the day of admission, [DATE], and a progress note, on [DATE]

This Citation pertains to Intake Number MI 979. Based on observation, interview and record review the facility failed to assess and manage pain for one resident (Resident #469) out of one resident reviewed for pain, resulting in unmanaged pain and hospitalization . Findings include: Resident #469: According to Admission Record printed 2/19/2020, Resident #469 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #469's Brief Interview for Mental Status (BIMS score) on 2/16/2020 was 9/15 indicating her cognition was moderately impaired. During an interview with Resident #469 on 02/18/2020 at 09:23 AM she said she had not received her [MEDICATION NAME] (pain medication) for two days. Resident #469 stated, They are out of [MEDICATION NAME] and have to order more. They said they don't know when they will get it. Resident #469 said they are giving her Tylenol instead of [MEDICATION NAME] for pain until the [MEDICATION NAME] is available. When asked to rate her pain on a 0-10 Likert Pain Scale, Resident #479 said her pain level was a 6/10 in her legs and back. She described the pain as aching and burning. She said the only thing that helps make the pain better was [MEDICATION NAME]. Resident #469 said she is always in pain and has had the pain for six years. Resident #469 was observed grimacing and rubbing her legs pointing to the location of her pain. Review of Resident #469's Pain Level Summary printed 2/19/2020, Resident #469's pain level was documented as 4 on 2/17/2020 at 06:00 AM, 0 on 2/17/2020 at 12:30 PM, 12:32 PM, and 5:10 PM, 0 on 2/18/2020 at 00:04 AM,1:27 PM, 1:30 PM, and 5:07 PM. Upon review of Resident #469's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Review of Resident #469's physician orders [REDACTED]. Review of Resident #469's progress notes revealed the following notes related to her [MEDICATION NAME] pain medication being unavailable: 2/17/2020 at 12:32 PM, written by Nurse C: [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Give 1 tablet by mouth every 6 hours for Pain Medication unavailable. On order with pharmacy. 2/17/2020 at 17:10 PM, written by Nurse C: [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Give 1 tablet by mouth every 6 hours for Pain Waiting delivery of medication from pharmacy. 2/17/2020 at 23:24 PM: [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Give 1 tablet by mouth every 6 hours for Pain Spoke with (name) from pharmacy new script needed will contact DR and follow up. 2/18/2020 at 13:30 PM, written by Nurse C: [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Give 1 tablet by mouth every 6 hours for Pain Medication unavailable. Waiting delivery. 2/18/2020 at 10:39 AM, written by Nurse Manager R: New CII sent to Dr. (Doctor's Name) to sign and fax to pharmacy. Pharmacy received order and Authorization to pull for [MEDICATION NAME] was obtained. Medication to be delivered. 2/18/2020 at 05:25 AM: [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG Give 1 tablet by mouth every 6 hours for Pain Script faxed to Dr waiting for signature. Upon further review of Resident #469's progress notes, no mention of physician notification related to missed doses of pain medication or alternate pain management intervention while awaiting [MEDICATION NAME] were documented. Resident #469's baseline care plan (initiated 2/8/2020; signed and locked 2/11/2020), documented that Resident #469 did not have pain present. Resident #469 did not have a comprehensive care plan specific to management of her chronic pain [DIAGNOSES REDACTED]. Resident #469 did not have pharmacological or non-pharmacological interventions for pain management on her baseline or comprehensive care plan. During an interview with the Director of Nursing on 02/20/2020 at 09:18 AM she confirmed that the [MEDICATION NAME] dosage prescribed to Resident #469 was available in their back up medication supply. The DON stated, They should have followed the process to get it out of back up and They should have notified the doctor and obtained an order so they could get a prescribed medication to treat her pain. During a follow up interview with Resident #469 on 02/20/2020 at 10:17 AM, she stated a pain level of 4/10 was uncomfortable but tolerable for her. Resident #469 said her pain level got up to a 7/10 while her [MEDICATION NAME] was unavailable and stated, 7 was pretty uncomfortable. Resident #469 stated she had her [MEDICATION NAME] today and her pain level at the time of interview was 4/10. A phone call was place to Nurse C on 02/20/20 at 10:56 AM for interview. Nurse C did not answer. A voicemail for Nurse C to return call to surveyor was left. Nurse C did not return call. Review of Pain Evaluation for an Acute Episode dated 2/20/2020 at 3:10 PM, revealed Resident #469 was complaining of a left arm strain. The document asked, have you had pain or hurting at any time in the last 5 days? Resident #469 answered yes. Then document asked, How much of time have you experienced pain or hurting over the last 5 days? Resident #469 answered, almost constantly. The document said Resident #469 was unable to say whether the pain made it hard for her to sleep at night or if it limited her day-day activities. The potential underlying cause of the pain and timing and contributing factors were left blank. At the time of the evaluation, Resident #469 vocalized a pain level of 10, worst possible pain (unbearable, crushing, devastating, excruciating). The evaluation said, resident pain is not subsiding, resident transferring out to hospital. The evaluation said Resident #469 was grimacing, groaning, screaming and had expressions of anger/agitation and restlessness. The evaluation also said that Resident #469 was experiencing increased anxiety/fear related to the pain. The evaluation comment box under Prior Interventions Attempted was left blank. In the box labeled Pain Management Plan it said, Continue current plan of care. According to facility policy titled, Pain Management (revised (MONTH) (YEAR)), The facility recognized the inter-relationship between uncontrolled pain and the decline in functional abilities, leading to an impaired quality of life. The facility will evaluate and identify residents experiencing pain; evaluate the existing pain and the cause (s); determine the type and severity of the pain; and develop a care plan for pain management consistent with the comprehensive care plan and the resident's goals and preferences. The Care Plan is implemented and evaluated for its effectiveness. The staff monitors and documents the resident's response to pain management interventions The goal of the pain management system is to effectively and consistently identify and treat pain. The policy said pain is defined as .whatever the experiencing person says it is, existing whenever he says it does. The policy also included a definition of chronic pain that said, A pain state which is persistent and in which the underlying cause of the pain cannot be removed or otherwise treated. Chronic pain may be associated with a long-term incurable or intractable medical condition or disease. The facilities pain management system included assessing for pain upon admission and change of condition, notifying the physician or practitioner, developing, implementing or updating a care pain care plan, initiate pain observation, communicate pain to the interdisciplinary team (IDT), the IDT reviews resident for pain management, IDT updates/reviews care plan, staff implements care plan, the nurse administers the pain medication and observes for pain and documents.

This Citation pertains to Intake Number MI 979. Based on observation, interview and record review, the facility failed to assess/monitor pressure ulcers and ensure interventions and treatments were enacted to prevent/assist with healing of pressure ulcers for two residents (Resident #60 and Resident #100) of three residents reviewed for pressure wounds, resulting in the reopening and worsening of a Stage IV pressure wound for Resident #100 and the development and worsening of a Stage III pressure wound for Resident #60. Findings Include: Resident #100: A review, of Resident #100's medical record, revealed an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. Depression, anxiety and systemic [MEDICAL CONDITION] response syndrome (SIRS). A review of the Minimum Data Set assessment revealed the Resident had severe cognitive impairment and was dependent on staff for bed mobility, transfers, dressing, toilet use and personal hygiene. A review of Resident #100's medical record revealed the Resident had a pressure wound on the left gluteal fold. A review of the Skin-Weekly Pressure Ulcer Records of the wound measurements included the following: -Date 1/10/20, Date of Onset 1/5/20. Type: skin tear, 1.3 cm (centimeters) length x (by) 1.5 cm width x 0.3 cm depth, Stage not applicable. Description of Site: Left gluteal fold, site of previous stage 4 ulceration with new open area, moderate sero-sang drainage without odor, wound bed with pink tissue exposure via edges, irregular with yellow necrosis to center, periwound exhibits scarring, normal color and moisture. -Date 1/17/20, Date of Onset 1/10/20. Type: pressure, 1.5 cm x 1.7 cm x 0.3 cm, Stage II. Description of Site: Left gluteal fold with ski tear at site of previously resolved stage 4 pressure area, now stage 2. Moderate serous drainage without odor, pale pink base [MEDICATION NAME], irregular edges, periwound color, moisture are normal, exhibits scarring, no s/sx (signs or symptoms) of infection. Resident noted to continue with weight trending downward, hospice services in place with expected decline. Decreased appetite ongoing. -Date 1/24/20, Date of Onset 1/10/20. Type: pressure, 1.7 cm x 1.7 cm x 0.3 cm, Stage II. Description of Site: Left gluteal fold, stage 2 pressure ulceration. Small amount of serous drainage without odor, pale pink base [MEDICATION NAME], irregular edges, periwound color, moisture are normal, exhibits scarring, no s/sx of infection . -Date 1/31/20, Date of Onset 1/10/20. Type: pressure, 1.7 cm x 1.7 cm x 0.3 cm, Stage II. Description of Site: Left gluteal fold, stage 2 pressure ulceration. Small amount of serous drainage without odor, pale pink base [MEDICATION NAME], irregular edges, periwound color, moisture are normal, exhibits scarring, no s/sx of infection . -Date 2/14/20, Date of Onset 1/10/20. Type: pressure, 3 cm x 4 cm x 1 cm, Stage II. Description of Site: Stage 2 to left gluteal fold, moderate sero-sang drainage without odor, wound with pink base [MEDICATION NAME], moderate yellow slough, periwound with normal color, moisture, exhibits scarring. No s/sx of infection. Resident noted to be incontinent at time of assessment. A review of Resident #100's wound clinic note revealed the following: -Date 1/10/20 - Wound Assessment: Wound #2 Left Gluteal fold is a Stage 4 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 1.3 cm length x 1.5 cm width x 0.3 cm depth, with an area of 1.95 sq cm and a volume of 0.585 cubic cm. There is a moderate amount of sero-sanguineous drainage noted. Wound bed has Yellow Necrotic Base [MEDICATION NAME]. -Diagnoses: [REDACTED]. -Treatment Recommendations: [MEDICATION NAME] Gel Daily and PRN - L gluteal. On 2/19/20 at 3:03 PM, a review of Resident #100's pressure ulcer care, treatments and measurements were conducted with the Wound Care Nurse (WCN) N. When queried regarding the origination of the wound first documented as 1/5/20, the WCN was unsure but indicated the initiation of the wound was on 1/10/20 and she might have documented the wrong date. The WCN reported the wound was a recurrent Stage 4 pressure ulcer that had reopened. The WCN was queried regarding the measurements from 1/31/20 then not until 2/14/20. The WCN indicated the measurements should have been done weekly and that she had been working the floor as direct care staff and did not do the measurements that week. When queried regarding when they were to be done the WCN stated, When I become available again as the wound care nurse, and stated she missed a week, and indicated the measurements should have been completed on 2/7/20. A review of the treatments to the Resident's pressure ulcer was reviewed with a treatment change on 2/4/20 for therahoney with a border gauze. The WCN reported she had been working the floor and when she did the Resident's dressing, she realized the wound had worsened and that the dressing had been a folded gauze with a dressing on top causing pressure to the site. The WCN denied taking measurements of the wound at that time indicating she was working as a floor care Nurse and not as a Wound Care Nurse and the measurements were done when she worked as the Wound Care Nurse. When queried that the wound had worsened on 2/4/20 but measurements were not completed until 2/14/20, the WCN stated, Correct. When queried if the dressing to the pressure wound was to be folded, the WCN stated, No, it was to be a single layer. The WCN explained the therahoney was used with a border gauze instead of the gauze placed on the wound then put the dressing over top, it gets rid of the extra gauze that was causing pressure. Resident #60: According to admission face sheet, Resident #60 was a [AGE] year old female admitted to the facility with the following [DIAGNOSES REDACTED]. Resident #60 was non-verbal, but could nod yes or shake head no with simple questions, and required extensive assistance with all Activities of Daily Living (ADL) care. Resident #60 was receiving all nutrition through Enteral feeding via peg tube. An observation was made during initial screening on 2/18/20, at 10:00 AM, of several wedge shaped Blue position pads stacked up on chair at foot of bed in room, and resident lying on her back with her head leaning to her left side, heels down on the bed. A second observation on 2/18/20 at 2:00 PM, with the blue pads still stacked up on the chair, and Resident #60 lying in the same position on her back heels down on the bed. No pillows or positioning devices in place. Also observed was dry flaky skin to mouth and lips. Resident had dried saliva running and dried on the right side of her mouth extending down her chin. Resident #60 had dried peeling skin to her lips, yellowish in color. Review of Minimum Data Set ((MDS) dated [DATE], section 'M' for skin documented 'No' to Pressure Ulcers, and checked a box for Moisture Associated damage (MASD), and checked the box for ointments/medications other than to feet. There was nothing checked for Pressure Ulcer or surgical wounds. Review of MDS dated [DATE], documented in section 'M' for skin 'No' to Pressure Ulcers. Review of MDS dated [DATE], documented in section 'M for skin 'No' to Pressure Ulcers, and checked the box for applications of ointments/medications other than to feet. Review of MDS dated [DATE], documented in section 'M' for skin 'No' to Pressure Ulcers. During an observation of a Activities of Daily Living (ADL) care on 2/20/20 at 9:00 AM, an open area was observed to coccyx, that had a pink wound base with approximately 20 percent of yellow scattered slough observed to the wound base. There was no dressing to coccyx area observed during ADL care with 2 Resident Care Specialists. Resident #60 was observed to be lying on a specialty mattress called 'Wound Kair'. The Blue Wedge Pads were stacked on the chair at the end of the bed. The RCS were asked what the Blue Wedge pads were for and indicated to help reposition Resident #60 and verbalized Resident #60 did not like the Pads, or pillows and would throw them on the floor at times. Review of Skin/Wound Progress notes dated 8/1/19, documented Assessment completed of reported open area. Recurrent open area to sacrum with treatment order in place, irregular round with approximate measurement of 1 cm x 1.5 cm, depth 0.1 cm, pink base [MEDICATION NAME], moderate sero-sang drainage noted to dressing, no odor, no s/sx of infection, peri wound texture, color and moisture are normal, cicatrix noted to same area. Review of Skin/Wound noted dated 8/30/19, documented area to coccyx with measurements of 0.3 cm x 0.3 cm, scant amount of sero-sang drainage noted, previous order discontinued with new order for [MEDICATION NAME] cream twice daily and PRN (as needed) in place for 10 days. There was no additional documentation for the coccyx area until 1/10/20. Review of Skin- Head to Toe Skin checks dated 1/7/20, under 'Skin Integrity' identified an area as 'New Other Issue'. Under #3: For areas identified above, document the site and description of the site and the description including progress as appropriate. There was nothing described for the new identified area. The rest of the skin assessment was blank. Review of an SBAR Communication Form dated 1/7/20, documented under 'Assessment or Appearance' under 1a: Open area to buttocks, and dry echar to pinky toe. Review of 'Skin-Head to Toe Skin Checks' dated 1/10/20, under heading 'Skin Integrity' checked the box for 'New Other Issue' and there was nothing described or measured or documented on the form. Review of 'Skin -Weekly Non-Pressure Condition' record dated 1/10/20, documented under site as 'Coccyx' on Page 1. Page 2 1b: documented as date of onset as 1/7/20, 1c: Is this a new or existing Non-Pressure skin condition with a box checked for 'existing'. 1d: Was the resident admitted with this Non-Pressure Ulcer or was it acquired while in the facility and a box was checked for 'Acquired in the facility.' Under Site Details: Location/Description: Coccyx, Other, length as 0.2 cm, width as 0.7 cm, depth as 0.5 cm and N/A under stage, and described the site as 'excoriation'. Review of Admission Data Collection dated 2/7/20, under the heading for 'Physical Examination: Skin Integrity' documented under question 1: Is the resident's skin intact and the answer was left blank for yes or no response. Question 2: Does the resident have Pressure Ulcer and the answer was left blank for yes or no response. Question 3: Does resident have non-pressure area/or other skin assessments was left blank for yes or no response. Review of 'Skin-Head To Toe Skin Checks' dated 2/14/20, documented 'Coccyx' as Pressure. Review of 'Weekly Pressure Ulcer Record' dated 2/14/20, documented site 'Coccyx' as existing and admitted with and described 'Coccyx' type as Pressure: length as 3 cm x 3 cm width, and 0.7 cm depth and staged as III. Review of Wound Notes documented by Wound Nurse Practitioner, dated 1/10/20, documented under HPI as This information was obtained from caregiver, the following HPI elements were documented for the patient's wound as Location Wound is located on the Coccyx and is Pressure Ulcer. Under 'Wound Assessment' Wound #2 Coccyx is a Stage III Pressure Injury Pressure Ulcer and has received status of not healed. Subsequent wound encounter measurements are 0.2 cm length x 0.7 cm width, 0.5 cm depth with an area of 0.14 sq cm and a volume of 0.07 cubic cm. There is small amount of sero-sanguineous drainage noted. Wound bed has pink base [MEDICATION NAME]. Periwound with scarring exhibited. An interview was conducted with the Licensed Practical Nurse N on 2/20/20 at 11:55 AM, related to skin concerns for Resident #60. LPN N verbalized a skin sweep was done in the facility on 1/7/20, and a nurse identified an open area on Resident #60's coccyx area. LPN N verified that the nurse who identified the open area on 1/7/20, did not describe the area or document what was observed. LPN N also verbalized that Resident #60 skin was identified as a Pressure Ulcer by the Wound Nurse Practitioner, and the previous Physician had described as excoriation. LPN N indicated that Resident #60 was having fluctuations in Blood Sugars and was sent out of the facility a couple of time on 1/15/20 until 1/28/20, back on 1/28/20 until 1/31/20, and sent out again and back to the facility on [DATE]. LPN N discussed a time line of the wound for Resident #60 and verbalized that on 1/7/20, a whole house skin sweep was conducted with Head to Toe Assessments completed, and SBAR was reviewed in morning meeting with a treatment initiated to sacrum, and revised on 1/8/20, to reflect that correct area was coccyx. LPN N indicated the Wound NP seen the area on 1/10/20 and classified the area as Pressure Ulcer. The treatment continued until 1/15/20, until the Resident was sent to the hospital. Resident #60 returned on 1/28/20, and was to be seen by the Wound NP on 1/31/20, but was sent out again early before NP seen the wound. Resident was back in facility 2/7/20, and indicated the skin assessment on admission on 2/7/20, was incomplete with no description of skin areas, wound areas or measurements. Wound NP seen the wound on 2/14/20, with measurements of 3 cm x 3 cm x 0.70 cm with some slough (yellow tissue) noted to wound base. LPN N was asked what the current measurements for the wound to coccyx area was and indicated they were to be measured on 2/21/20. LPN N verbalized that the Pressure Ulcer was Facility Acquired, but had gotten worse while out of the facility, and that with the nurse not completing the skin assessments and the admission assessments, We own it. LPN N also indicated that Resident #60 had a history of [REDACTED]. LPN N was asked what interventions are in place to promote the healing of the wound to the coccyx area and indicated Resident #60 was on specialty mattress, had Blue Wedge Pads to help with repositioning, and barrier cream, [MEDICATION NAME] cream, Registered Dietician involved, soft pillows, Skin checks weekly, and the current treatment is to Cleanse the area with normal saline, apply [MEDICATION NAME] to wound base, cover with border foam, and keep clean and dry. LPN N was asked if the dressing comes off to the area, are the nurses supposed to place a clean one on and verbalized yes. LPN N was asked if she ever checks to see if Resident #60 is repositioned frequently and if the Blue Wedge Pillows in place and verbalized 'I do when I can. Review of Resident #60's Skin Care Plan documented 'Known Skin Impairment' Pressure Ulcer to coccyx, date as initiated 1/31/2020. Interventions listed as: Followed by Wound care, diet as ordered, Tube Feed formula changed to meet increased nutritional needs, Float feet off mattress with soft positioning devices as resident allows, Wound Kair Air parameter mattress, Assist resident to turn and reposition side to side on routine rounds, and PRN for comfort, care and decreased risk of skin impairment, may use pillow or other soft devices to assist. Keep soft positioning devices between knees to decrease risk of pressure.

This citation pertains to Intake Numbers MI 214, MI 206, MI 595 and MI 152. Based on observation, interview and record review the facility failed to supervise one Resident (#208) of 5 residents reviewed for elopement, supervision and wandering into 2 identified residents' rooms (#212 and #213) and several other unidentified residents' rooms, resulting in Resident #208 leaving the facility unsupervised without knowledge of the staff, walking towards a busy highway and wandering in other residents' rooms without supervision causing injury and frustration to himself other residents. Findings include: The Immediate Jeopardy started on 11/25/19. The Immediate Jeopardy was identified on 1/14/19. The facility was notified of the Immediate Jeopardy on 1/14/20 at 5:15 PM The Immediate Jeopardy was removed on 12/31/19. A review, of the facility policy Elopement Management, dated, July 2017, revealed, Unsafe Wandering or Elopement. According to the Centers for Medicare & Medicaid Services, Wandering is random or repetitive locomotion. This movement may be goal-directed (e.g., the person appears to be searching for something such as an exit) or may be non-goal-directed or aimless. Non-goal-directed wandering requires a response in manner that addresses both safety issues and an evaluation to identify root causes to the degree possible. Moving about the facility aimlessly may indicate that the resident is frustrated, anxious, bored, hungry, or depressed. Unsafe wandering and elopement may be associated with falls and related injuries. Unsafe wandering may occur when the resident at risk enters an area that is physically hazardous or that contains potential safety hazards (e.g., chemicals, tools and equipment, etc.). Entering into another resident's room may lead to an altercation or contact with hazardous items. A review, of the facility Elopement Management, Practice Guidelines, dated July 2017, revealed, 10. Notices should be provided to residents and residents' representatives, and/or family members in newsletters or posted in the facility to inform residents and families not to assist a resident out of the facility. a. If a resident who is at risk for elopement exhibits exit-seeking behavior, the behavior must be documented on the 24-Hour Report and the resident must be assessed for the need for additional interventions. b. If a resident is determined to be missing and cannot be located in the facility, staff is to immediately notify the Administrator and Director of Nursing (DON) and initiate the Missing Resident Guideline located in the Resident Elopement policy (OP .04). 11. Facility staff reports all missing residents to the resident's attending physician and representative. The licensed nurse and documents notification of the physician and resident's attending physician and representative on a SBAR (situation, background, assessment, recommendation) communication Form and Progress Note (UDA). 12. In addition to the required notifications in the Resident Elopement policy (OP2 0401.04, the Administrator or DON/designee will notify the District Director of Operations (DDO) and/or District Director of Clinical Services (DDC) and the Chief Operations Counsel of any episode of a resident at risk for elopement that is missing from the facility. A review, of the facility policy Resident Elopement (OP .04), dated, August 2012, revealed, It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the Director of Nursing and the Administrator and to document the occurrence.b. If a resident is observed attempting to elope, follow the steps outlined below for Attempted Elopement; c. If no resident is found to be exiting the facility, the employee should i. Exit the facility, walk around the building, and ensure that a resident has not already exited the facility; ii. Notify the Director of Nursing and the Administrator immediately; and iii. Complete a head count to ensure that all residents are accounted for. Attempted Elopement. 1 . 2. Upon return of the resident the facility, the Director of Nursing and the Administrator should: a. Examine the resident for injuries (Director of Nursing); b. Contact the attending physician, report what happened, and follow the physician's orders [REDACTED]. Complete and file and Incident/Accident Report, (Briggs); e. Make appropriate notations in the resident's medical record (Director of Nursing); f. Investigate how the resident attempted to elope and make recommendations regarding safety measures to the Quality Assurance and Performance Improvement Committee; and g. Update the resident's care plan with preventive interventions for elopement (Director of Nursing). Missing Resident - 1. Should an employee discover that a resident is missing from the facility, he or she should: a. Determine if the resident is out on an authorized leave or pass. If not; b. Notify the Administrator and the Director of Nursing services; c. Make a thorough search of the building(s) and premises. If the resident is not located; 2. The administrator, Director of Nursing, or a designee will: a. Notify the resident's legal representative; b. Notify the attending physician; c. Notify the Sheriff and the Police Department; d. Notify the state agency, if required . 3. Upon return of the resident to the facility, the Director of Nursing and the Administrator should: a. Examine the resident for injuries (Director of Nursing); b. Contact the attending physician, report findings and conditions of the resident, and follow the physician's orders [REDACTED]. Notify search teams that the resident has been located; e. Complete and file an Incident/Accident Report, (Briggs); f. Make appropriate entries into the resident's medical record (Director of Nursing); g. Investigate how the resident eloped and make recommendations regarding safety measures to the Quality Assurance and Performance Improvement (QAPI) Committee and or the Safety Team Committee (as necessary); and h. Update the resident's care plan with interventions for elopement prevention (Director of Nursing). Resident #208: A review, of Resident #208's electronic medical record that included physician progress notes [REDACTED]. A review, of Resident #208's Nurse Progress note, dated 11/25/19, revealed, Note text: Resident was downstairs on own and did not let staff know wander guard applied to resident's right ankle. A review, of Resident #208's Physician Progress, note dated 11/25/19, revealed, .Resident found awake, sitting in day room. He was alert and oriented x 1 and was confused. He was able to verbalize his needs and wants without prompting. (Resident) stated, I wanna get out of this place. Resident was in no distress and denied pain during visit. Per unit nurse-the resident has been restless and more confused. A wander guard was placed on resident after he was found outside. He requires more redirecting and often becomes irritable with staff . A review, of Resident #208's physician progress notes [REDACTED]. He was alert and oriented x 1 and appeared more confused . A review, of Resident #208's physician progress notes [REDACTED].He was alert and oriented x 2-3 with confusion . A review, of Resident #208's physician progress notes [REDACTED].Resident found lying in bed, awake watching television. He is alert and oriented x 1-2 and requires frequent reorientation . A review, of Resident #208's physician progress notes [REDACTED]. He is alert and oriented x 1-2 with confusion . A review, of Resident #208's Skin - Head to Toe Skin Check (SSC v.1.5) - V3 revealed the assessment was not completed until 11/29/19. This was 4 days after the incident of the elopement. A review, of the facility sign out sheets for leave of absence revealed, Resident #208 had not signed out of the facility on 11/25/19. According to the facility policy, Resident Elopement (OP .04) , dated, August 2012. A review, of the facility incident reports revealed, there was no incident report for Resident #208 for 11/25/19 related to resident leaving the facility unsupervised. A review, of the facility policy, Elopement Management, Practice Guidelines, dated, July 2017, revealed, there was no documentation of an SBAR (situation, background, assessment, recommendation) for Resident #208 on 11/25/19 that included notification to the physician and responsible party/guardian and there was no documentation in the nurse progress notes related to Resident #208 leaving the facility and there was no documentation that Resident #208 was examined by nursing for injuries at the time of the incident. A review of the facility investigation revealed, an incident report was not completed, and elopement drill was not completed at the time of the incident on 11/25/19 to ensure the safety of the other residents. A review, of Resident #208's Admission Elopement Risk assessment dated [DATE], revealed a score of 10 which indicated resident was a low risk for elopement. The evaluation was inaccurate. The assessment was not checked for resident as Cognitively impaired (decreased safety awareness, disturbances in judgement, wandering) which would have scored resident as 3 points instead of 1 point. Making the score at 12 not a 10 as indicated. Which indicated resident was at risk for elopement according to the facility form. Resident #208 had a [DIAGNOSES REDACTED]. A review, of Resident #208's Elopement Risk dated 11/25/19, revealed a score of 12, which indicated at risk. The evaluation was incomplete and inaccurate and not completed until Resident #208 left the facility. Resident #208 had an episode of attempting to exit and wandering into multiple resident rooms. The score should have been a 21 according to Resident #208's electronic medical records. Ambulatory scored (2) points, Verbalizes desire to leave facility (10), Dementia (2), Cognitively impaired, wanderer (3), length of stay (1), history of elopement (3) for a total of 21 which would have indicated Resident #208 was a high risk for elopement and wandering. A review, of Resident #208's electronic medical record and investigation revealed there were no 1:1 monitoring form or 15-minute monitoring forms from 11/15/19 through 12/27/19 available. A review of Resident #208's monitoring forms revealed there was no consistent documentation that 1:1 was being monitored or provided for Resident #208. In an interview, on 1/14/20 at 9:34 AM, Assistant Director of Nursing (ADON) D reported was acting as interim Director of Nursing at the time of the incident on 11/25/19, and stated, He (Resident #208) was still on the premises, did not consider the incident an elopement. ADON D reported there was no incident report for the elopement for Resident #208 dated 11/25/19. ADON D agreed there was not an elopement drill completed at the time of Resident #208's return to the facility on [DATE]. ADON D agreed an investigation was not initiated following Resident #208's return to the facility on [DATE]. A review of the facility investigation with ADON D revealed there were no facility in-services or elopement drills until 12/30/19. ADON D agreed there was no documentation of Receptionist C's education on 11/25/19 related to the incident. ADON D provided a copy of Receptionist C's education for resident elopement on 1/14/20. In an interview, on 1/14/20 at 10:23 AM, the Director of Nursing (DON) reported she was reviewing Resident #208's chart, noted in the progress note that Resident #208 was out of the building (on 11/25/19), and initiated an investigation on 12/27/19 (over a month later). The DON reported Resident #208 was found by CNA A, not too far off a main road. In an interview, on 1/14/20 at 10:57 AM, the Administrator, reported was informed on 11/25/19 by ADON D that Resident #208 went out in the parking lot and was returned to the facility. The Administrator reported on 12/30/19 that he was informed of the gravity of the incident, by the DON and was given education. The Administrator stated, the incident was not reported (to the state agency), it is not like he left the premises, and returned with another person. The Administrator stated, On that day he had not signed out. Administrator reported due to behaviors Resident #208 was placed on 1:1 on 11/25/19 then taken off but was unsure of that date, then had another altercation on 12/27/19 and was placed back on 1:1. The Administrator agreed he had not questioned CNA A about how far Resident #208 had gone out of the facility and around the parking lot. The Administrator reported he had been provided pictures from the facility surveillance tape from 11/25/19 from Maintenance Director BB and could only visualize Resident #208 in the hallway of the facility from the pictures and reported he had not reviewed the facility surveillance tape. The Administrator reported he was not sure if the receptionists had received education at the time of the incident, how the resident had left the facility at the time of the incident or discussed the incident with the receptionist at the time of the incident. In an interview, on 1/14/20 at 11:43 AM, Receptionist C, explained it was the receptionist' responsibility to monitor the door and ensure residents did not leave the facility. The door was always locked, and a button had to be activated to release the lock, to open the door, unlock the door and allow residents, visitors or staff to enter or exit the facility entrance door. Receptionist C reported Residents were to sign out when they go outside and sign in when they return. Receptionist C stated, I do not recall letting him (Resident #208) out. He (Resident #208) never signed out (on 11/25/19). Therapy always took him out. He did not go out often, I just noticed it was therapy that was taking him out. I would not have let him out intentionally. I would have called upstairs, before I let him out. Receptionist C reported she had not recalled previously to 11/25/19, that resident had gone outside. Receptionist C reported there is a list of residents that are approved to leave the facility unsupervised. Receptionist C could not explain how Resident #208 got out of the facility. In an interview, on 1/13/20 at 11:35 AM, Certified Nurse Aide (CNA) A reported she was at lunch on 11/25/19 at approximately 1:00 PM, had observed Resident #208 outside of the building, on the west side of the facility, near the employee entrance. CNA A stated, I was outside on my break, in my car and I saw him (Resident#208) in my mirror behind my car, walking in the parking lot, and I knew he was one of the residents from the 200 hall. He was confused and should not be outside by himself. CNA A reported she had upon returning to the facility, immediately informed ADON D Resident #208 was outside unsupervised and was instructed to return him (Resident #208) to his unit. During an observation, on 1/14/20 at 12:05 PM, the Administrator, DON and CNA A, with surveyor went outside of the facility to the parking lot. CNA A explained the location that Resident #208 was observed on 11/25/19 behind her car near the employee entrance, at the time he was outside the facility, and walking towards the road unsupervised. The Administrator voiced at that time he had not realized Resident #208 had gone that far. The DON was queried about the concern of the elopement risk factors and with Resident #208's frequent wandering prior to the elopement why had resident not been reassessed for a change of condition and DON responded, He (Resident #208) was not considered at admission a risk for elopement and was assessed as a low risk. The DON reported she had reviewed the risk assessments and had not identified any concerns or changes. The DON was queried about the concern for his dementia and wondering in resident rooms and facility and denied that it would change Resident #208's Risk elopement score or concerns. (The risk assessment scores were in accurate and Resident #208 was at risk. (See above.) During an observation, on 1/14/19 at 12:30 PM, the Administrator with surveyor, measured the distance from the area behind a parked car (location of CNA A's car) near the employee entrance, where Resident #208 was reported to have been found by CNA A, to the road. The distance was measured to be 152.5 feet. The driveway behind the parked car was in a busy exit driveway leading out of the facility, on to the roadway. The road was noted to be a busy main 4 lane highway with many cars going by, at the end of the driveway. In an interview and observation, on 1/15/19 at 2:45 PM, Resident #208 was observed in his room watching a mystery murder program on TV. Resident stated, Nobody wants to kill a kid. Resident #208 kept repeating the statement. Charge nurse was notified and requested to monitor the programs resident was watching. The request was met with a dismissal. A review, of Resident #208's care plan revealed, Please have sports on my television when it's on, unless I ask otherwise, initiated on 12/31/19. The facility was not following Resident #208's care plan and resident was notably distressed by the thought of a child being killed from watching an inappropriate program on the TV. During an observation, on 1/16/20 at approximately 9:15 AM, Resident #208 was observed walking in the hall near the front entrance with therapy staff. Resident #208 was trying to walk towards the exit door. Resident #208 was being redirected by therapy staff. A review, of Resident #208's Behavior Progress note, dated 10/16/19 at 7:20 AM, revealed, Around 1 am noticed the resident coming in the hall yelling for his roommate to get out of his room. He stated that his roommate has mental issues and he does not want him in his room. he stated that they had a physical altercation, but it was not witnessed. The roommate was yelling just for him to leave him alone I relocated the roommate to another room no issues after that. A review, of Resident #208's Nurse Progress note, dated 11/19/19, revealed, Resident wandering into other resident room, when asked to return to his end of the hall, he became louder and making false statements in regards to staff being wrong for not allowing him to do his job. Redirection did work but resident not happy with staff. A review, of Resident #208's Social Service Behavior note, dated 11/20/19, revealed, Resident was in another resident's room. Resident was easily redirected to his own room. He stated he was tired, and he wanted to lie down to rest. Show the resident his room and the number with his name. Showed resident the items in his room that has his name on them. Resident reassured that he was in the right room. A review, of Resident #208's Nurse Progress note, dated 12/2/19, revealed, Resident has been going in other resident rooms . Resident in 205-1 has stated he scares him because he has awoke with this resident standing over him on many occasions . A review, of Resident #208's Nurse Progress note, dated 12/3/19, revealed, when passing HS (bedtime) medication resident was going into another resident's room, writer asked him to step back out and only go into his own room due to giving each other privacy. Resident started talking loud at writer said I was not to talk to him as he clinched his fist closed and stated, I can show you how much I dislike your ass I explained to him I had no dislike of him and he just needed to allow each resident privacy. He then stated just stay the hell out of my room you ignorant ass. He then returned into his room. A review, of Resident #208's Nurse Progress note, dated 12/5/19, revealed, during HS medication pass Resident #208 had repeated attempts to go into room [ROOM NUMBER] (females) and was then observed in the room with the door closed and was verbally aggressive. A review, of Resident #208's Nurse progress note, dated 12/11/19, revealed, Resident was wandering in other residents' room when asked to come out resident began calling the nurse a [***] . resident then proceeded to push the nurse and refused to leave the other residents' room. A review, of Resident #208's Nurse Progress note, dated 12/12/19, revealed, resident pacing in halls most of third shift as well as going into other residents' rooms. Been redirected each time and has become more verbally aggressive. Resident has verbally told a staff member he is going to jump out a window, as he assessed the height, he asked which window is lower to the ground. He has set off stairwell door alarm and continues to go back to the same door to exit. He has stated he needs to go home to (town) . A review, of Resident #208's Social Services Behavior note, dated 12/12/19, revealed, Resident continues with behaviors of wandering/pacing, entering others' rooms, verbal aggression, exit-seeking. Resident is not redirectable and becomes verbally aggressive with staff when redirection is attempted. When writer meets with resident, he appears to have no recollection of behaviors. Resident does talk about wanting to go home and needing to get out of here. Writer provided encouragement and reassurance to resident. Resident indicated that he feels safe at facility (name) psych (Psychiatric) PA (Physician Assistant)notified of resident's increase in behaviors; nursing and Psych PA to collaborate on resident's medications and behaviors. CP updated. A review, of Resident #208's Nurse Progress note, dated 12/16/19, revealed, Resident took staff coat and put it on, staff asked for coat back and he stated its mine. She stated look in the pockets its mine, he did and then raised his voice stating you think your somebody as he handed coat over then he began to follow her saying you are not[***] and I mean it, I smell a rat all the time having fist clinched. Staff left area resident then sat down quietly. Resident went to bed and needed to be directed to his room due to confusion. A review, of Resident #208's IDT (Interdisciplinary Team) Progress note, dated 12/16/19, at 9:30 AM, revealed, Late Entry: IDT met regarding resident and reviewed whether or not there is continued need for 1:1 and documentation from the weekend and or any s/ss (signs and symptoms) of aggressive verbal/physical behaviors. Upon review, resident did not show any outward behaviors over the weekend toward staff or other residents. IDT has determined that 1:1 can be discontinued at this time. A review, of Resident #208's Nurse Progress notes, from 11/25/19 through 12/12/19, revealed, no documentation of 1:1 supervision. A review, of Resident #208's Nurse progress notes from 12/12/19 through 12/29/19, revealed documentation that resident was a 1:1 on 12/12/19 and 12/14/19. A review, of Resident #208's care plan revealed that the care plan was not updated following the incident on 11/25/19 through 12/12/19 when 1:1 was restarted. The care plan was then not revised from 12/12/19 -12/16/19 according to the IDT note when the 1:1 was again restarted and discontinued. A review, of Resident #208's electronic medical record and investigation revealed there were no 1:1 monitoring form or 15-minute monitoring forms from 11/15/19 through 12/27/19 available. A review, of Resident #208's care plans revealed, (I am at risk for elopement r/t to my -impaired safety awareness - independently ambulatory - Dementia, initiated 11/25/19, with interventions that included observe my location at regular and frequent intervals. Document wandering behavior and attempted diversional interventions and orientate me to environment. (Resident) has behavior problems r/t (related to) -Dementia with behaviors -Impaired safety awareness Known behaviors include: -Verbal aggression - physical aggression -pacing - wandering -exit seeking, dated 12/12/19, with interventions that included 1 on 1 at all times 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 12/12/19. Please have sports on my television when it's on, unless I ask otherwise initiated on 12/31/19. Provide meaningful activities to reduce behaviors (Resident) enjoys using his hand; (Resident) enjoys watching football, American Pickers, American Pawn on TV. (Resident) likes fishing, Bingo, Music (especially enjoys saxophone). Provide (Resident) with activities such as Jenga, building blocks, memory/busy box to allow for use of hands. Provide supervision during activity. I don't always respond well to nonpharmacological interventions. If, I am not receptive to activities, please re-approach later. Date initiated: 1/3/2020. A review, of IDT (Interdisciplinary Team) Progress note, dated 12/26/19, revealed, .Increased instances of sundowners noted with episodic confusion during the day. (Resident) is alert and oriented X 2, speech is clear, able to answer questions without delay, STM (Short Term Memory) impairment present with supportive Dx (diagnosis) of Dementia . A review, of Resident #208's SBAR (situation, background, assessment, recommendation), dated 12/27/19, (completed by DON) revealed, .Scratches noted to resident's face . A review, of Resident #208's physician progress notes [REDACTED]. Resident has exhibited increased verbal and physical aggression. No recent falls or somnolence reported. Symptoms have been ongoing and have not responded .Will consider addition of [MEDICATION NAME] or antipsychotic if resident continues to exhibit physically aggressive behavior. Resident was recently hospitalized for [REDACTED]. He is currently on [MEDICATION NAME] and [MEDICATION NAME]. Recently [MEDICATION NAME] was increased . Resident was recently hospitalized for [REDACTED]. Will monitor closely for worsening status, ongoing mood instability. Recommend competency evaluation for guardianship appointment. There was no documentation of a revision of Resident #208's care plan following the elopement on 11/25/19 until 1/7/20. There is no clear understanding of when resident received 1:1 supervision with multiple episodes of the resident entering multiple other residents' rooms and an increased documentation of resident's behaviors. IDT has not addressed these concerns. The abatement plan was accepted on 1/15/20 at 2:01 PM for the date of 12/30/19. Element 1: The resident 208 was found in the facility premises by a staff member and was safely returned to the facility at approximately 1:00 PM on 11/25/2019. The resident was out of the building for 3 minutes 20 seconds. The resident was identified by a staff member on the premises 152 feet away from the road. The weather on 11/25/2019 was a high of 50 degrees Fahrenheit. The resident's attire included a zip up jacket and a baseball hat. An elopement assessment was done. A wander guard device was implemented. Resident's elopement risk assessment and care plan were updated. Resident had no other incidents of exit seeking. Element 2: Elopement risk assessments for all residents were reviewed and updated accordingly. Residents' individual care plans were updated to reflect the current assessments initiated on 12/30/2019. The roam alert devices for the like residents were checked for placement and function. Element 3: All staff was reeducated on the facility elopement policy and procedure initiated on 12/30/2019. The facility elopement policy was reviewed on 12/30/2019. The receptionists were educated on the identification of at-risk residents from the elopement risk binders initiated on 12/30/2019. All doors were checked for proper closure and locking by Maintenance supervisor or designee on 11/25/2019. Elopement risk binders which contain pictures and detailed descriptions of all residents listed as elopement risks have been placed at every unit and the front desk. Social services updated binders and with changes to elopement risk assessments initiated on 12/30/2019. Nursing staff is checking for proper placement of all roam alert devices every shift and recording findings on the residents' medication administration record. Resident 208 was placed on roam alert on 11/25/2019 and the roam alert device checked daily. Placement and functioning of devices are also checked and logged daily by nurses or designee. Maintenance personnel check and log the proper closure and locking of all doors daily. Any noted concerns will be addressed and corrected immediately. Element 4: To ensure compliance, the DON or Designee is responsible for completion of an audit of the MAR for placement and function of roam alert devices weekly times 4 weeks, bimonthly times 2 months and then quarterly to encompass all shifts until continued compliance is maintained for 2 consecutive quarters. The results of these audits will be reviewed by the QAPI committee. If the threshold of 95% is not achieved an action plan will be developed to ensure compliance. The maintenance supervisor or designee will be responsible for auditing all doors for proper closure and locking daily. Any identified concerns will be addressed immediately, and corrective action taken. Element 5: Date of compliance: 12/30/2019. A review, of the facility reported incident dated, 12/27/19 revealed, Resident #208 went into (Resident #213's) and (Resident #212's) room and made physical contact with each resident. (Resident #212) made physical contact with (Resident #208). All residents currently safe. Facility is continuing investigation. According to the facility reported incident report (5 day investigation) (late) dated 1/7/20 (4 business days late) at 3:02 PM Summary of Investigation/Statements: On December 27, 2019 the facility became aware of a physical assault involving (Resident #208). After a review of the chart and condition of investigation the following was identified: 12/27/19 Staff immediately notified DON of scratches to (Resident #208's) face. DON immediately returned to facility to start investigation. Upon investigating it was noted that physical aggression occurred, involving (Resident #208), (Resident #212), and (Resident #213). Physical assessment and pain assessments were completed immediately. First Aid provided to the scratch on the face of (Resident #208), no first aid needed for (Resident #212), or (Resident #213). Bruise to forearm was noted for (Resident #212). No injury noted for (Resident #213). (Resident #213) was able to describe the event in full and a statement was taken. The other two residents were unable to give a description of the events due to cognitive impairment. (Resident #212) did provide verbal confirmation through various random statements (during initial follow up of reported incident) that he did hit someone stating, Yea, I hit that mother*****. That B**** came in here snooping around. Due to resident's visual and cognitive impairment he was unable to describe the aggressor. (Resid

This citation pertains to Intake Numbers MI 153, MI 769, and MI 436. Based on observation, interview, and record review, the facility failed to protect one resident from neglect (#210) regarding an untreated, unassessed, unstageable pressure ulcer, and one resident (#204) from verbal and emotional abuse, failed to protect Resident (#219) from staff to staff verbal abuse on at least two occasions, and ensure that residents were treated with dignity, respect, and remain free from verbal abuse, resulting in hospitalization , fear, humiliation, embarrassment, and lack of care needs. Findings include: Resident #210: According to the Admission Record, printed on 1/14/2020, Resident #210 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Nursing Monthly Summary, dated 12/10/2019, Resident #210 had no skin issues at that time. A Communication Form and Progress Note completed for a Change in Status was completed on 12/20/2019 at 6:26 AM that indicated Resident #210 had developed two open areas on the bilateral upper inner buttocks near his coccyx. The area on the left buttock was measured at 3 centimeters (cm) in length and 1.5 cm in width with some tunneling. The open area on the right was measured as 2.2 cm by 1.5 cm. The depth of both areas was not indicated. The area of tunneling was not measured. No stage was given for either area. The nurse who completed the form recommended that Resident #210 needed to be turned every two hours and shouldn't be up in the chair for more than one hour at a time. On 1/15/2020 at 12:44 PM, the Licensed Practical Nurse (LPN), staff Z, who had authored the communication form on 12/20/2019 was interviewed. LPN Z stated that when an aide had told her about the open wounds on Resident #210 she had gone to his room to assess and measure the wounds, had notified the physician and wife of Resident #210, and put in an order for [REDACTED]. LPN Z stated that she had checked the box at the bottom of the computerized Communication Form and Progress Note to be included on the 24 hour report. There were no care plan interventions added to the care plan of Resident #210 when the pressure ulcers were first observed on 12/20/2019. The Treatment Administration Record for December 2019 indicated a treatment to be done twice a day beginning on 12/20/2019. On 12/28/2019 and 12/29/2019 the spaces for the nurse to initial completion of the treatment were blank for 6:00 PM. On 1/14/2020 at 8:50 AM, LPN K was interviewed. LPN K stated that she had the overall responsibility for the wound care program. LPN K stated that there was a wound care consultant group that came in to the facility on Fridays and did the wound weekly measurements. The wound consultant group did not have access to the electronic medical record system used at the facility so she kept the notes that were made in a binder in her office. She transposed the measurements into her weekly notes for each resident and discussed with the attending physician the recommendations made by the wound consultant. LPN K stated that she was unaware of the wounds that Resident #210 had developed on 12/20/2019 until 12/30/2019. LPN K stated that she could smell the wound as she entered the room on 12/30/2019. LPN K had completed a Communication Form and Progress Note at 2:43 PM on 12/30/2019. In the note, LPN K had documented that Resident #210 had abnormal labs values with infective process present to wound sacrococcyx area. LPN K documented that the Things that make the condition or symptom worse are sitting in wheel chair for prolonged periods of time and incontinence of bowel and bladder. LPN K notified the physician of Resident #210 having a wound odor and assisted in the transfer of Resident #210 to a local hospital. No wound measurements were noted on the Communication Form and Progress Note dated 12/30/2019. A progress note done 12/30/2019 indicated that resident had bilateral open areas to buttocks with the top layer of skin present and rolled. The Open area to Sacrum with measurement of 2 cm X 2 cm X 1 cm, dark discolored wound base, mild odor. LPN K stated that the consultant from the wound group had not seen or measured the open areas. The area of tunneling was not noted or measured. The wounds were not staged, however, the note indicated a dark discolored wound base which would have been consistent with an unstageable wound as the wound base was not visible. A Skin = Head to Toe Skin Checks form completed on 12/29/2019 indicated that Resident #210 had existing Other Issue , described as Pressure ulcers in buttock/coccyx area and open area on right elbow. In section 3 of the form were the sites of right buttock, left buttock, coccyx, sacrum, and right elbow. No type was identified and no measurements of the lengths, widths, depths of the areas were listed, and none of the areas were given a stage. Section 4 was for further description of skin issues and stated, one of the pressure ulcers (at the top) is beginning to tunnel. The area is worsening; treatment in place, may need to changed to another kind of treatment that could help this wound as it has worsened. No where in the electronic medical record was a measurement of the depth of the wounds or the tunneling and the wound stages were not identified. The record also did not indicate if the physician had been informed of the worsening condition and increasing numbers of pressure ulcers. There was also no indication that the nutritionist had been consulted at any time for input of dietary expertise. The most recent Nutrition Note found in the electronic medical record was 11/18/2019, prior to the development of the pressure ulcers. The Registered Dietician noted that Resident #210 was on a mechanically altered diet with excellent intake recorded. There was no identification of additional supplements to boost protein stores for healing. Resident #210 developed two pressure ulcers documented on 12/20/2019. No care plan interventions were initiated to prevent worsening. The interdisciplinary team did not meet to discuss the new pressure ulcers. The registered dietician did not assess the nutritional needs of Resident #210 with regard to the development of pressure ulcers. On 12/29/2019, five pressure ulcers were noted on the skin check, one with tunneling, and worsening in condition. The facility wound nurse did not evaluate the wounds until 12/30/2019, at that time, she noted an odorous, unstageable wound and assisted to transfer Resident #210 to the local hospital. This citation pertains to Intake Numbers MI 153, and MI 769. Resident #204: According to admission face sheet, Resident #204 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to Minimum data Set ((MDS) dated [DATE], Resident #204 scored a 14 on his Cognition Assessment, and also required assistance with Activities of Daily (ADL) care. Review of facility's 5 day investigation dated 11/4/19, documented Resident #204 is a [AGE] year old male admitted to the facility on [DATE], and BIMS scored 14/cognitively intact. Under summary of investigation: On 11/14/19, Resident #204 voiced a concern to social service assistant that a Licensed Practical Nurse Z was informed by him that he hit his leg on the wheel chair and was bleeding, and her response was that she was not dealing with it. The investigation continues under 'Immediate Action': On 11/14/19, Resident was interviewed and reported that the incident happened on 11/12/19 around 11:30 PM, in the hallway out side of his room. He said he indicated to the nurse he hit his (left) ankle on the foot rest of his wheel chair and it began bleeding. He stated nurse LPN Z said I don't have time for this[***] I don't need this[***] and said the nurse had no bed side manners. The report documents the nurse was interviewed on 11/14/19, and did not recall having an interaction with the resident, but was suspended pending an investigation. Conclusion of the investigation: the allegation of Abuse was not substantiated. Review of the investigation documented a 1:1 education given on 11/18/19, a verbal education, on the topic of 'Effective Communication' signed by LPN Z. Review of Social Worker AA documented statement written 11/14/19, documented Met with Resident regarding reported incident with nurse. Resident stated on 11/12/19, at 11:30 PM, he hit his left ankle on the foot rest of his wheel chair and began bleeding. Resident said He told his nurse and she said, I don't have time for this[***] I don't need this[***] An interview was conducted with Resident #204 on 1/13/20. Resident #204 was asked how he was being treated while residing at the facility and indicated It depends on who is working. Resident #204 was asked if he had complaints with the care he was receiving. Resident #204 went on to say he has not been getting his showers regularly for months, and on some shifts, it takes up to an hour or longer to get help. Resident #204 also said that he was swore at by a nurse recently and he told staff about that. Resident #204 indicated that 3rd shift was worse then the other shifts about getting help. They have attitudes a lot and don't want to work. I also hear them yelling at each other and swearing too. The women are mean to each other, and swear at each other and loud too. I hear it and they don't know that I am paying attention. When I have to wait too long to get my call light answered, I get fed up and go down the hall to get an aid or nurse. Then they say 'What do you need now.' I don't like it, and it makes feel bad and angry and frustrated. I try not to bother anyone, but sometimes I just need something. I don't like being here and I wish I did not have to stay. They just are not nice here to each other or me. Resident #204 was asked about the nurse who swore at him if he could recall what happened and said Yes, It was on 3rd shift in November. I bumped my left ankle and it was bleeding. I asked for the nurse to come. I told her my ankle was bleeding and she said, I don't need this[***] I can't deal with this[***]right now. Resident #204 was asked how it made him feel and said, It made me pissed off. That is why I am here. They are supposed to take care of me when I am hurt. I don't think that nurse likes me very much any way. This Surveyor asked why. Resident #204 said, She has terrible bedside manners or none at all. She is short with how she talks to me, with an attitude all the time. I try not to ask for too much, but sometimes I need help. Resident #204 was asked if he remembered the nurse who swore at him and said Yes and identified LPN Z. An interview was conducted with LPN Z on 1/15/20 at 12:09 PM, who indicated she had worked at the facility for 2-3 yrs and was usually working the 3rd floor on 3rd shift 7 PM -7 AM. LPN Z was asked if she was familiar with Resident #204 and said she was. LPN Z was asked if Resident #204 was alert and oriented and said Yes. LPN Z was asked if she received Abuse training at the facility and indicated she had. LPN Z was able to verbalize the different types of Abuse. LPN Z was asked to give an example of what verbal abuse was. LPN Z said it involved cursing, yelling, disrespect in front of residents, putting a patient down with derogatory remarks LPN Z was asked if she remember an incident when Resident #204 bumped his ankle and was bleeding. LPN Z indicated she could recall an incident when Resident #204 bumped his ankle at night awhile back. LPN Z was asked what happened. LPN Z verbalized Resident #204 called her to his room and showed her his ankle that it was bleeding. LPN Z indicated she cleansed the area with normal saline, applied triple antibiotic ointment, and left it open to air. LPN Z was asked if she said, I don't have time for this[***]or I can't deal with this[***]and said She couldn't recall what was said. LPN Z then said I would never say that in front of my residents. Then LPN Z recanted her statement and indicated I said, I don't have time for this crap as I was walking down the hall to get supplies to treat Resident #204. LPN Z said It was a stupid mistake, and I should never had said it. LPN Z was asked if being in charge of care for Resident #204 and treating a bleeding wound was 'crap'. LPN Z said again, I can't recall what I said, I don't think I said[***] but I think I said I don't have time for this crap as I was walking away down the hall. LPN Z was asked again if she thought caring for Resident #204's bleeding wound was 'crap' and said No. LPN Z went on to say she had been overwhelmed that night, but could not give an example of what was happening or why she was overwhelmed. LPN Z was asked if she called any other nurse, or on call nurse that night and said No. LPN Z indicated she had been suspended pending the investigation and received a 1:1 education when she returned to work. LPN Z said, I never said it in front of Resident #204, but I said it walking down the hall to my treatment cart. LPN Z was asked if other residents on the hall could have heard her, and said Its possible, there is always residents in the hall. I don't know who or how many, but there is always someone up. This interview was witnessed by another Surveyor present during the interview. Review of Facility Policy 'Abuse & Neglect Prohibition' dated July 2018, documented Each Resident has the right to be free from abuse, neglect, mistreatment, injuries of unknown origin, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and physical/chemical restraint not required to treat the resident's medical symptoms. Any allegations of abuse, neglect, or mistreatment must be reported immediately to the Administrator. The Facility Administrator is the Abuse Prevention Coordinator. Abuse means: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also means deprivation by an individual, including a caretaker, of goods and services that are necessary to maintain physical, mental, and psychosocial well-being. It includes verbal abuse, sexual abuse, physical abuse, and 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 to others regarding the resident, or within resident's hearing distance regardless of their age or ability to comprehend, or disability. Willful: means the individual must have acted deliberately, not that the individual must have intended to inflict harm. An anonymous complaint was made to the State Agency related to Staff to Staff altercation in front of Residents around the date of 12/22/19. During the investigation several residents voiced concerns that staff were yelling loudly at each other, and swearing at each other in front of residents and were mean, disrespectful, loud, and did not care what resident's were around or staff. An interview took place with RCS (Resident Care Specialist) H on 1/14/20 at 3:00 PM, related to Staff members yelling in front of residents and other staff. RCS H was asked if she was aware of any instances of staff yelling in front of residents and verbalized an incident that occurred on 12/22/19, up on the 4th floor. RCS H indicated Staff G was yelling and cursing at her at the nurse station, near the elevators, with several resident sitting in the hallway. RCS H gave the names of a couple of resident's that were present in the hall at the time of the altercation, but those resident were not able to recall the details. RCS H indicated she had printed off her schedule and went to find out why she was marked as a No Call No Show (NCNS) on two occasions. RCS H indicated she had called the facility and spoke with the Director of Nursing and explained that she would be a little late due to babysitting problems, but would be at the facility as soon as she could. RCS H indicated she went to find Staff G who was standing at the nurse station. RCS H said Staff G looked at her and said What do you need. Do you need something. RCS H said I asked why am I down for a NCNS on these days. RCS H verbalized that Staff G started to yell at her and indicated that RCS H pick up extra days but did not show up for them, and was marked as a NCNS. RCS H said she pulled off her printed schedule and those 2 days that were marked as a NCNS were not on her printed schedule, that they were added at a later time with out her knowledge. RCS H said that Staff G had a love hate relationship with staff. If you do her favors, she loves you. If you don't do her favors she hates you. RCS H indicated another staff member was present and heard everything that went on. This interview was witnessed by another Surveyor present during the interview. An interview was conducted on 1/14/20, with Staff G related to the incidence on 12/22/19. Staff G was asked if she received Abuse training and verbalized she had received training several times during the year, and was knowledgeable about the different types of abuse. Staff G asked if there was ever an instance when she had a verbal altercation in front of residents and said No. An interview was conducted on 1/15/20 at 11:28 AM, with Staff R. Staff R was asked if she was aware of a verbal altercation that took place on the 4th floor around 12/22/19, and indicated she could recall an instance on the 4th floor with Staff G and RCS H. Staff R said she witnessed Staff G yelling at RCS H very loudly and disrespectfully, in front of several residents that were in the hall way and by the elevator on the 4th floor. Staff R indicated No one knew or was paying attention that I was there on the floor at the time. Staff R said she heard Staff G yell at RCS H yelling, Don't be disrespectful to me and was being rude with her tone of voice to RCS H. Staff R said that RCS H was not yelling and said I am just trying to talk to you. Staff R verbalized that Staff G is very rude to other staff all the time and has heard it before. Staff R said that RCS H was crying and asked her if she heard everything and said Yes and told RCS H she would tell what she heard if it came to that, and indicated that Staff G was not liked by some of the staff because she yells, swears at them, and is very rude, and does not care who hears it. An interview was conducted on 1/15/20 at 3:46 PM, with LPN M who was being interviewed by another Surveyor. During the interview, LPN M was asked if she ever witnessed staff to staff altercation or heard staff yelling and swearing in front of residents and indicated she had, and was involved in an altercation on 1/11/20, with another nurse LPN N at 7:30 AM on the 2nd floor. LPN M indicated there was video footage to support the interaction. LPN M verbalized that she showed up to work on Saturday 1/11/20, which was her regular day to work, and proceeded to go to the med cart/hall she normally is assigned to. LPN M said that LPN N came to the floor at around 7:30 AM, and was late that day, and indicated she was promised the med cart, and wanted the med cart that she had just received report from 3rd shift nurse, and had counted the narcotics. LPN M said that LPN N indicated she could not take care of Resident #219 because he does not want her taking care of him. LPN M said, I will take Resident #219 and you could still take the other cart. LPN N said No. I asked her to get the manager. LPN N left the floor and returned a few minutes later with the manager LPN P. LPN P said that LPN N was promised the med cart when she agreed to pick up that day. LPN M indicated she gave the keys to LPN N at that point. LPN M indicated she asked LPN N that when she left the floor or the unit, could she let her know when she leaves, and said you are gone for a long time and other residents are asking me for things you are responsible for. LPN M said that LPN N put her finger in her face and said Who the [***] do you think you are talking too. Shut the [***] up. LPN M said that Unit Manager LPN P stepped in between them and pushed them apart. LPN M indicated they never spoke to each other the rest of the shift and Unit Manager LPN P stayed and watched us re-count the narcs. There were several resident present, but the one closest to the med cart near the clean utility room was Resident #219 who witnessed the altercation and heard every thing. I know he did, because he came and told me so. There were also several staff who heard too. Video footage was observed on 1/16/20 at around 9 AM, with Maintenance, Director of Nursing, and two other Surveyors. There was no audio noted, but video footage supported what the nurse had indicated above with the interaction and body language. Several staff were observed present, there were no visible residents observed. Resident #219: According to admission face sheet, Resident #219 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to Minimum (MDS) data set [DATE], Resident #219 scored a 15 on the Cognition Assessment indicating no cognitive impairment, and Resident #219 also required assistance with Activities of Daily Living (ADL) care. During an interview that was conducted on 1/16/20 at 10:15 AM, with Resident #219, it was reported that some of the staff do not treat Resident #219 very well. Resident #219 indicated he had a problem with one of the nurses that had been ongoing for some time. He indicated the Licensed Practical Nurse N had been giving him some problems and had been very rude to him on several occasions, and in front of him with other staff, that began when she changed his medication times that he had worked with the nurses to adjust according to specific reasons and ok by the physician. He also indicated she did it when she was not on duty or working on his floor or assigned to him. Resident #219 went on to verbalize that he recently witnessed a verbal altercation with LPN N and LPN M on 1st shift 1/11/20, at 7 AM, on the 2nd floor. Resident #219 indicated he was in eye and ear shot of the altercation, and was sitting by the Clean Utility room out of video camera shot, and not observed on camera from being around the corner on the hall Resident #219 indicated that LPN M had showed up for her shift as her normal scheduled day and went to the medication cart that she normally works from, and proceeded to get report from 3rd shift nurse around 7 AM. Resident #219 indicated LPN N came to the floor at around 7:30 AM, indicating the nurse was late that day. Resident #219 also verbalized that LPN N was frequently late showing up for work, and that he constantly heard complaints from other residents and staff that LPN N would disappear for long periods of time with out telling anyone where she was going or for how long she would be off the unit. Resident #219 verbalized that LPN N came to the floor, exiting the elevator, and observed LPN M at the medication cart she had just counted and got report from the off going nurse. Resident #219 indicated he over heard LPN N verbalize They are not doing this to me and was in a(NAME)and then left the floor and went back into the elevator. Resident #219 indicated LPN N returned a few minutes later with a Unit Manager LPN P and both went to the medication cart where LPN M was standing. LPN P told LPN M that she had to take the other medication cart, and LPN M asked why and verbalized that was her normal cart/hall she works on, and also that she was there first before LPN N. LPN P indicated that LPN N could not work that other cart because of a resident on the hall LPN N could not be in charge of. Resident #219 said, It was because of me, and the problems I had with LPN N related to the way she talked to me, treated me, and the medication issues. I just did not trust her, or want her caring for me, she intimidates me. She is always rude and nasty to me, and makes me feel like she don't like me. Resident #219 went on to say he over heard LPN M say she would be in care of Resident #219 and they wouldn't need to switch carts or halls. LPN N then said that she was promised the cart when she agreed to pick up that day. Resident #219 verbalized that LPN M agreed to switch carts and accept the other medication cart. Resident #219 indicated that LPN M verbalized to LPN N Can you let me know when you are going to leave the unit, or be off the floor for a long time, because you are always gone for a long time, and I have resident's asking me for things you are responsible for. Resident #219 indicated LPN N 'got angry, yelled and swore at LPN M and and stuck her finger in the face of LPN M as she stepped toward her Who the [***] are you talking to. Shut the [***] up. Resident #219 indicated that LPN P stepped in between the nurses at that point and put her hands up in between the nurses. Resident #219 indicated LPN M never swore or yelled, it was LPN N that was yelling loudly and swearing. Resident #219 indicated I was dumb-founded that I heard that nurse swear at the other nurse. I can't believe that just happened. She was very unprofessional and rude. I put it in my phone in case someone asked me about it. Resident #219 indicated he left the floor and stayed off the floor all day while LPN N was present. I only came back to the floor twice during that day to receive my medications and lunch. I stayed off the floor until I knew staff or the Unit Manger was present. I was trying to stay away from LPN N because I don't trust her. She is mean to me, and others. I don't want to be around her because she is very rude, unprofessional, and intimidating. I just couldn't believe what I heard. An interview was conducted with the Director of Nursing on 1/16/20 at 2 PM, related to the altercation between LPN N and LPN M on 1/11/20, who indicated both nurses received disciplines related to the verbal altercation. The DON indicated video footage did not reveal any residents in ear shot of the altercation. The DON was not aware of any other verbal altercations when asked.

This citation pertains to Intake Numbers MI 736 and MI 436. Based on interview and record review, the facility failed to assess, monitor, and treat one resident (#210) for a pressure ulcer out of three residents reviewed for pressure ulcers resulting in an odorous, unstageable pressure ulcer requiring hospitalization . Findings include: According to the facility policy for Skin Management, dated as revised July 2017, residents were to receive care to aid in the prevention or worsening of wounds and/or pressure ulcers. Ongoing monitoring and evaluation were to be provided for optimal resident outcomes. The fundamental information of the policy was a pressure ulcer is defined as any [MEDICAL CONDITION] caused by unrelieved pressure resulting in damage of underlying tissue. An unavoidable pressure ulcer was described as one that the resident developed even though the facility had evaluated the resident's clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with resident needs, goals and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate. All of this was to be clearly documented in the medical record. Pressure ulcers are usually over bony prominence's and are staged to determine the degree of tissue damage observed. Unstageable pressure ulcers were described as one in which the extent of tissue damage within the ulcer cannot be confirmed because the depth is obscured with darkened tissue of slough or eschar. A nutritional evaluation was to be completed within seven days for residents with compromised skin integrity. Pressure ulcers were to be measured and staged in accordance with the practice guidelines. Measurements were to include the length, width, and depth as well as measurement of any areas of tunneling. The Skin Management policy, dated July 2017, instructed that wounds were to be measured and evaluated weekly by a nurse. When a new area was discovered, the care plan was to be updated to reflect the new area and interventions. Suggested interventions included pressure reduction surfaces; mobility and exercise, avoidance of pressure on the area; assessment for pain during turning, positioning, and dressing changes; referral to therapy for evaluation of positioning, both in bed and seated; implementation of an individualized turning and positioning schedule; use of a turn sheet to prevent injury from shearing; and consultation with an expert in wound care. Resident #210: According to the Admission Record, printed on 1/14/2020, Resident #210 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Nursing Monthly Summary, dated 12/10/2019, Resident #210 had no skin issues at that time. The care plan for Resident #210, initiated on 9/13/2018, indicated that he required extensive assistance with two staff members to turn and position in bed. Resident #210's care plan identified a risk for skin impairment due to decreased mobility, a history of pressure ulcers, generalized weakness, [MEDICAL CONDITION], abnormal laboratory values, medication use, and a heart impairment, initiated on 9/18/2018. The care plan, initiated 9/13/2018, stated, Resident #210 had an unavoidable in place by my physician due to abnormal labs and underlying medical conditions. There was no explanation as to what an unavoidable was. The care plan focus indicated that Resident #210 had a Sacral ulcer with shearing to bilateral buttocks, initiated on 9/13/2018, in direct contradiction to the Nursing Monthly Summary dated 12/10/2019 that indicated he had no skin issues at that time and the Skin - Head to Toe Skin Checks form completed 12/15/2019 that indicated an existing rash, but was not checked for pressure ulcers. The care plan interventions included assist to reposition and/or turn side to side after care was completed, on routine rounds, and as needed to decrease the risk of skin impairment, initiated on 5/20/2019, to complete a full check of his body weekly, initiated on 5/20/2019, to encourage him to lay down at intervals and try to avoid prolonged periods in his wheel chair, initiated on 7/25/2019, to observe his nutritional status, initiated on 5/20/2019, to report and document any changes in his skin status, initiated on 1/13/2020, and to provide incontinence care as needed, initiated on 5/20/2019. A Communication Form and Progress Note completed for a Change in Status was completed on 12/20/2019 at 6:26 AM that indicated Resident #210 had developed two open areas on the bilateral upper inner buttocks near his coccyx. The area on the left buttock was measured at 3 centimeters (cm) in length and 1.5 cm in width with some tunneling. The open area on the right was measured as 2.2 cm by 1.5 cm. The depth of both areas was not indicated. The area of tunneling was not measured. No stage was given for either area. The nurse who completed the form recommended that Resident #210 needed to be turned every two hours and shouldn't be up in the chair for more than one hour at a time. On 1/15/2020 at 12:44 PM, the Licensed Practical Nurse (LPN), staff Z, who had authored the communication form on 12/20/2019 was interviewed. LPN Z stated that when an aide had told her about the open wounds on Resident #210 she had gone to his room to assess and measure the wounds, had notified the physician and wife of Resident #210, and put in an order for [REDACTED]. LPN Z stated that she had checked the box at the bottom of the computerized Communication Form and Progress Note to be included on the 24 hour report. There were no care plan interventions added to the care plan of Resident #210 when the pressure ulcers were first observed on 12/20/2019. The Treatment Administration Record for December 2019 indicated a treatment to be done twice a day beginning on 12/20/2019. On 12/28/2019 and 12/29/2019 the spaces for the nurse to initial completion of the treatment were blank for 6:00 PM. On 1/14/2020 at 8:50 AM, LPN K was interviewed. LPN K stated that she had the overall responsibility for the wound care program. LPN K stated that there was a wound care consultant group that came in to the facility on Fridays and did the wound weekly measurements. The wound consultant group did not have access to the electronic medical record system used at the facility so she kept the notes that were made in a binder in her office. She transposed the measurements into her weekly notes for each resident and discussed with the attending physician the recommendations made by the wound consultant. LPN K stated that she was unaware of the wounds that Resident #210 had developed on 12/20/2019 until 12/30/2019. LPN K stated that she could smell the wound as she entered the room on 12/30/2019. LPN K had completed a Communication Form and Progress Note at 2:43 PM on 12/30/2019. In the note, LPN K had documented that Resident #210 had abnormal labs values with infective process present to wound sacrococcyx area. LPN K documented that the Things that make the condition or symptom worse are sitting in wheel chair for prolonged periods of time and incontinence of bowel and bladder. LPN K notified the physician of Resident #210 having a wound odor and assisted in the transfer of Resident #210 to a local hospital. No wound measurements were noted on the Communication Form and Progress Note dated 12/30/2019. A progress note done 12/30/2019 indicated that resident had bilateral open areas to buttocks with the top layer of skin present and rolled. The Open area to Sacrum with measurement of 2 cm X 2 cm X 1 cm, dark discolored wound base, mild odor. LPN K stated that the consultant from the wound group had not seen or measured the open areas. The area of tunneling was not noted or measured. The wounds were not staged, however, the note indicated a dark discolored wound base which would have been consistent with an unstageable wound as the wound base was not visible. A Skin = Head to Toe Skin Checks form completed on 12/29/2019 indicated that Resident #210 had existing Other Issue , described as Pressure ulcers in buttock/coccyx area and open area on right elbow. In section 3 of the form were the sites of right buttock, left buttock, coccyx, sacrum, and right elbow. No type was identified and no measurements of the lengths, widths, depths of the areas were listed, and none of the areas were given a stage. Section 4 was for further description of skin issues and stated, one of the pressure ulcers (at the top) is beginning to tunnel. The area is worsening; treatment in place, may need to changed to another kind of treatment that could help this wound as it has worsened. No where in the electronic medical record was a measurement of the depth of the wounds or the tunneling and the wound stages were not identified. The record also did not indicate if the physician had been informed of the worsening condition and increasing numbers of pressure ulcers. There was also no indication that the nutritionist had been consulted at any time for input of dietary expertise. The most recent Nutrition Note found in the electronic medical record was 11/18/2019, prior to the development of the pressure ulcers. The Registered Dietician noted that Resident #210 was on a mechanically altered diet with excellent intake recorded. There was no identification of additional supplements to boost protein stores for healing.

This citation pertains to Intake Number MI 326. Based on observation, interview and record review, the facility is placed in Immediate Jeopardy due to the facility's 1) failure to ensure that residents with tracheostomies (artificial opening in neck for breathing) were assessed for type and size of [MEDICAL CONDITION] (trach) tube; 2) failure to ensure that physician's orders [REDACTED]. needs for 4 residents (Resident #605, Resident #607, Resident #608, Resident #609) of 4 residents reviewed for [MEDICAL CONDITION] care. These deficient practices resulted in, 1) Residents #605, #607 and #609 dislodging their tracheostomies which led to respiratory distress and subsequent transfer to the hospital, 2) Resident #608's Care Plan not being followed and, 3) Resident #608 not being assessed, as ordered, which resulted in low oxygen saturation levels, increased secretions, fever and respiratory distress. This deficient practice caused serious harm to all four residents with tracheostomies, who resided at the facility between 04/30/2019-5/30/2019, and is likely to cause serious harm, serious impairment and/or death to any resident with a [MEDICAL CONDITION]. This Immediate Jeopardy began on 04/30/2019 at 4:27 PM when, according to Resident #605's Census List, Resident #605 was admitted to the facility. Upon the admission of Resident #605, the facility failed to implement a baseline care plan identifying individualized [MEDICAL CONDITION] care needs and failed to obtain physician's orders [REDACTED]. The Immediate Jeopardy was identified on 5/23/2019. The Administrator and Director of Nursing were notified on 5/30/2019 at 2:01 PM of the Immediate Jeopardy that began on 4/30/2019 at 4:27 PM, due to 1) the facility's failure to ensure that tracheotomy care needs were met for four residents, and 2) the facility's failure to develop and implement comprehensive care plans identifying [MEDICAL CONDITION] individualized care needs for four residents. This led to Resident's #605, #607, and #609 being transferred to the emergency room and/or being hospitalized , Resident's #605 and #607 experiencing decannulation, and incorrect [MEDICAL CONDITION] supplies were at the bedside for Resident's #607 and #609. These deficient practices placed a total of two residents with tracheostomies, out of a census of 133 residents, at risk for serious harm, including infections, severe pain, hospitalization and/or death. Findings Include: Resident #605: According to the Admission Record, printed on 05/23/2019, Resident #605 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to Census List, Resident #605 was transferred out of the facility to the hospital on [DATE] at 02:29 AM. According to Section G of Resident #605's admission Minimum Data Set (MDS), completed 05/10/2019 (Assessment Reference Date 05/06/2019), Resident #605 required full staff performance with a two-person assist for bed mobility, transfer, dressing, toilet use and personal hygiene. According to Section J of the same MDS assessment, Resident #605 received PRN (as needed) pain medications. Section J also noted that Resident #605 was assessed as having shortness of breath with exertion, at rest and when lying flat. Resident #605's fall history was unable to be determined at the time the MDS was completed. Section O of the same admission MDS assessment indicated that Resident #605 received oxygen therapy, suctioning, and [MEDICAL CONDITION] care and isolation for active infectious disease at the facility, but did not receive any Respiratory Therapy days or minutes. According to the MDS, Resident #605's cognition and behavior were not assessed on the admission MDS completed 05/10/2019 due to his persistent vegetative state and no discernable consciousness. Upon review of Resident #605's Baseline Care Plan, dated 5/2/2019, it was noted that there was not a plan of care for oxygen therapy, suctioning, and [MEDICAL CONDITION] care. Under therapy services being received, Respiratory Therapy was not marked. In section one of the baseline care plan for Resident #605, No is marked for Does the resident have a pressure ulcer? and Does the resident have a surgical site?. Resident #605 was admitted with surgical sites and a pressure ulcer. In section two of Resident #605's baseline care plan, the question Is pain present? is marked No. The baseline care plan was not discussed with the resident's representative according to the baseline care plan summary. The summary indicates that focuses, goals and interventions were discussed with the resident. The resident was comatose. Upon review of Resident #605's comprehensive care plan, it was noted that Resident #605 did not have a plan of care related to oxygen therapy, suctioning, [MEDICAL CONDITION] care, isolation for active infectious disease, pain or agitation and behaviors (pulling at [MEDICAL CONDITION]). Resident #605's comprehensive care plan included, .resident is non-verbal (initiated 5/2/2019), .has increased potential for skin impairment related to vegetative state, immobility, restless, decerebrate posturing (initiated 5/8/2019), Known skin impairment .left chest surgical puncture wounds .(chest tube and drain placement), left buttocks stage 2 pressure ulceration present upon admit, coccyx stage 3 pressure ulceration present upon admission (initiated 5/8/2019). Care plans related to respiratory treatment and care, possible complications, advance directives, equipment functioning and cleaning, and procedures for emergencies were not implemented for Resident #605. Resident #605's care plan did not identify his respiratory care needs and other needs, that may have been impacted by respiratory care requirements, measurable goals, resident involvement, preferences, and choices. Resident #605's care plan record did not reflect resident-specific monitoring of respiratory status, including type and size of airway and care of the artificial airway. Resident #605's care plan record did not address the resident's specific risks for complications such as: Unplanned extubation; Aspiration and the potential for respiratory infection; and Airway complications such as tracheal infections and mucous plugging. Resident #605's care plan record did not reflect respiratory complications that he had experienced during his stay at the facility such as Resident #605's agitation, episodes of pulling at his [MEDICAL CONDITION], increased and discolored sputum, and decannulation. Upon review of Resident #605's physician's orders [REDACTED]. Resident #605 had an order for [REDACTED]. Resident #605 had an order to observe for changes in skin integrity of stoma site, redness, excoriation, and signs/symptoms of infection every shift during care (ordered 5/1/2019-5/16/2019). Resident #605 had an order to suction his [MEDICAL CONDITION] as needed to clear the airway and document the results in PN every day and night shift [MEDICAL CONDITION] (ordered 5/1/2019-5/16/2019). A review of progress notes revealed three documented instances of [MEDICAL CONDITION] suctioning for Resident #605: 5/2/2019, 5/8/2019 and 5/15/2019. In an interview on 5/30/2019 at 1:53 PM, the Director of Nursing (DON) stated that PN was an abbreviation for progress notes. Resident #605 also had an order for [REDACTED]. The progress note was written on 5/2/2019 by Nurse AA at 00:55. It read, Inner cannula cannot be removed for cleaning per respiratory. Cleaning around cannula and site. Review of progress notes revealed no other progress notes that discussed cannula cleaning/changes or suctioning. In an interview on 5/30/2019 at 1:53 PM, the DON admitted that Resident #605 had not been seen by Respiratory Therapy. In an interview on 5/31/2019 at 12:20 PM, Registered Respiratory Therapist DD stated that their company had not collaborated with the facility for Resident #605's respiratory therapy, only for Resident #609. Upon review of Resident #605's Respiration Summary, it was noted that his respiratory rate was documented only three times during his stay at the facility (4/30/2019-5/15/2019): once on 4/30/2019 (rate of 22), once on 5/5/2019 (rate of 20) and once on 5/10/2019 (rate of 20). According to Resident #605's heart rate summary, temperature summary and blood pressure summary, his heart rate, temperature and blood pressure were documented a total of three times during his stay at the facility (once on 4/30/2019, once on 5/5/2019 and once on 5/10/2019). When asked if there was additional vital sign documentation anywhere else, the DON and Assistant Director of Nursing (ADON) said, No. In an interview on 5/24/2019 at 11:53 AM, DON stated that the standard of practice for vital sign assessment for a resident with a [MEDICAL CONDITION] is that it should be done at least daily. According to Resident #605's Oxygen Sats Summary, on 5/5/2019 (day of decannulation) his oxygen level was 96% with oxygen via nasal cannula, on 5/7/2019 it was 94% with oxygen [MEDICAL CONDITION] and the day before hospitalization (5/14/2019) his oxygen level was documented between 95-96% on room air and on oxygen [MEDICAL CONDITION]. Review of Progress Note written by Nurse Z on 5/5/2019 at 18:29 AM noted, upon arrival in resident room to [MEDICAL CONDITION]. Resident was found [MEDICAL CONDITION] out called for transport to the hospital. Review of Progress Note written by Nurse BB on 5/5/2019 at 20:00 PM, noted, resident restless, pulling covers off, [MEDICAL CONDITION] (sic) off, frequent room checks .awaiting for (Doctor X) to order [MEDICATION NAME] for restless . Review of Progress Note written by Nurse BB on 5/6/2019 at 03:48 AM noted, resident has hand around the top of [MEDICAL CONDITION] times hands was taken away and instructed to leave along . Progress Note written by Nurse BB on 5/6/2019 at 06:48 AM noted, resident restless between [MEDICATION NAME], yet somewhat restless, pulls covers, sttemp the pulling of trach, yet has not pulled out, non verbal, yet obeys some commands. Review of final lab results for a sputum culture, obtained on 5/8/2019, noted heavy growth of Citrobacter koseri. Citrobacter koseri is a bacteria known to cause infection in people with chronic diseases and conditions. This bacteria type is also known to cause abscesses. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 41/ Review of Progress Note written by Nurse CC on 5/11/2019 at 18:19 PM noted, Resident appeared agitated during whole shift, grabs and pulls on anything, ([MEDICAL CONDITION], PEG tube, o2 mask, cloth, briefs), multiple attempt of getting off bed, needs close monitoring. In a review of SBAR (situation, background, assessment, response) Communication Form and Progress Note ., dated 5/15/2019 at 01:39 AM, it was documented that Resident #605 was .coughing up a lot of yellow mucus out [MEDICAL CONDITION] this breathing is shallow at 01:30 am and vital sign bp 106/56 and p 100 and spo 96 and tep 98.3 . call Dr . (doctor) I suction resident 01:35am. Resident still coughing up yellow mucus. Resident mental status change of unresponsive noted. The LPN completing the document wrote don't know. Short of breath and shallow breathing, in response to the resident's appearance and suggested monitoring vital signs and lab work. Hospital transfer was marked no. Review of hospital medical records revealed that Resident #605 was sent to the hospital from the facility on 5/15/2019 and presented to the emergency room with an elevated respiratory rate of 28 breaths per minute and an elevated heart rate of 121 beats per minutes, and heavy amounts of sputum coming from his [MEDICAL CONDITION]. Hospital records described Resident #605's sputum as foul smelling and green, indicating infection. Resident #605 was started on antibiotics in the emergency room . Hospital records also indicated that Resident #605 had been having difficulty with increasing agitation as another reason for transfer from the facility to the hospital emergency room . Review of a lung doctor's consult in Resident #605's medical record, noted aspiration pneumonia and lung abscess were suspected. Review of hospital records revealed Resident #605 had three Stage 3 pressure ulcers upon admission to the hospital on [DATE]. Pressure ulcers documented upon admission to the hospital from the facility included, one stage three pressure ulcer located left anterior neck, one stage three pressure ulcer located right anterior neck and one stage three pressure ulcer located neck inferior to the [MEDICAL CONDITION] plate. In Resident #605's Head to Toe Skin Checks assessment, dated 5/1/2019 (one day after admission), Resident #605 was noted to have a 1-centimeter (cm) X 1 cm round open wound and skin tear on left buttock measuring 2 cm. Upon interview with Wound Care Nurse T, she stated that Resident #605 had a pressure ulcer on his coccyx and a pressure ulcer on his buttock. Wound Care Nurse T did not have knowledge of any pressure ulcers to Resident #605's neck/[MEDICAL CONDITION] device site. Additional record review of Resident #605's Head to Toe Skin Checks assessment dated [DATE], 5/8/2019, 5/13/2019 and 5/14/2019 along with Resident #605's Weekly Pressure Ulcer Record dated 5/3/2019 and 5/10/2019 did not document any pressure ulcers to Resident #605's neck/[MEDICAL CONDITION] device site. Upon record review it was noted at the time of survey that there were no physician's progress notes in Resident #605's hard chart. There was one physician's progress note in the Electronic Medical Record (EMR) at the time of review. The note was dated 5/14/2019. During an interview with the DON regarding doctor visits and the physician progress notes [REDACTED].#605's admission history and physical. Resident #605 admitted to the facility on [DATE]. When asked if Resident #605's doctor had seen Resident #605 only once, she stated, his notes must not have been transferred to our medical record yet, I will look into that. In an interview on 5/23/2019 at 3:06 PM with Resident #605's Doctor X, he stated that he had seen Resident #605 more than once and would get his notes transferred to the electronic medical record by the end of the day. Upon review of updated physician progress notes [REDACTED].#605 pulled his [MEDICAL CONDITION] out and was sent to the hospital [MEDICAL CONDITION]. Doctor X saw Resident #605 on 5/6/2019 and noted that Resident #605 continued to be anxious and agitated and ordered [MEDICATION NAME] 0.25 mg every eight hours for anxiety/agitation. On 5/11/2019, Doctor X noted that he was informed on 5/10/2019 that Resident #605 was found on the floor mat near the bed. On 5/12/2019 Doctor X noted he seen Resident #605 and he continued to be anxious and agitated and had increased need [MEDICAL CONDITION]. Doctor X increased Resident #605's [MEDICATION NAME] to four times daily and recommended continuing [MEDICATION NAME] pain medication as scheduled. On 5/15/2019 Doctor X noted that he was called by nursing staff and notified of Resident #605 experiencing shortness of breath and a lot [MEDICAL CONDITION]. Doctor X wrote, blood pressure is dropping down, patient is critical, and patient was transferred to the hospital. Resident #607: According to the Admission Record, printed on 05/29/2019, Resident #607 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to section C of Resident #607's admission MDS assessment, completed 05/24/2019 (Assessment Reference Date 05/14/2019), his cognition was intact, evidenced by a Brief Interview for Mental Status (BIMS) score of 15. According to Section G of the same MDS, Resident #607 required extensive assistance of a two-person physical assist for bed mobility, dressing, and toilet use, total assistance of a two-person physical assist for transfer and needed set up help with supervision to complete personal hygiene. According to Section J of the same MDS assessment, Resident #607 was assessed as having shortness of breath with exertion, at rest and when lying flat. Section O of the same admission MDS assessment indicated that Resident #607 received oxygen therapy, suctioning, and [MEDICAL CONDITION] care at the facility, but did not receive any Respiratory Therapy days or minutes. Upon review of resident #607's Baseline Care Plan, dated 5/10/2019, it was noted that there was not a plan of care for oxygen therapy, suctioning, and [MEDICAL CONDITION] care. In section three of the baseline care plan under, therapy services being received, Respiratory Therapy was not marked. Upon review of Resident #607's comprehensive care plan it was noted that Resident #607 had [MEDICAL CONDITION]/respiratory care plan initiated 5/9/2019 (revised 5/27/2019). Resident #607's respiratory interventions included: document oxygen level and respiratory rate every day and night shift (date initiated: 05/29/2019), ensure [MEDICAL CONDITION] are secured at all times (date initiated: 05/09/2019), observe/document for increased heart rate and [MEDICAL CONDITION] (date initiated: 5/9/2019), observe/document respiratory rate, depth and quality, check and document every shift/as ordered (date initiated: 5/9/2019, resolved 5/24/2019), Oxygen (O2) settings: 02 mist as ordered by physician (date initiated: 5/9/2019, revised 5/24/2019), [MEDICAL CONDITION] care every day and night shift and as needed. Clean or change inner cannula when needed (date initiated: 5/24/2019), Tube out procedures: keep [MEDICAL CONDITION] and obturator at bedside (Shiley#5). If tube is coughed out, open stoma with hemostat. If tube cannot be reinserted, observe/document for signs of respiratory distress. If able to breathe spontaneously, elevate HOB (head of bed) 45 degrees and stay with resident. Obtain help immediately (date initiated: 5/9/2019, revision on 5/29/2019). Resident #607's code status care plan was initiated on 5/25/2019 (revised 5/27/2019). Resident #607's behavior care plan included, .Known behaviors .I loosen [MEDICAL CONDITION] at times because they are uncomfortable and I do not want to have [MEDICAL CONDITION](date initiated: 5/27/2019). Resident #605's care plan did not identify his involvement, preferences, and choices such as self-suctioning, which he admitted to doing during an interview on 5/30/2019 at 11:15 A.M. Critical individualized [MEDICAL CONDITION], respiratory and emergency interventions were not initiated or individualized until three weeks after admission at the time of survey. In an interview on 5/30/2019 at 12:18 PM, MDS Nurse T admitted that she had just revised Resident #607's care plan on 5/24/2019 and 5/29/2019 to reflect his equipment size. Nurse T stated, I had to review his care plan, it still [MEDICAL CONDITION] and size, so I filled in the blanks. His care plan has to match his orders. Resident #607 had an order to suction his [MEDICAL CONDITION] as needed to clear the airway and document the results in PN on every day and night shift [MEDICAL CONDITION] (ordered 5/9/2019). Review of Resident #607's (MONTH) 2019 Treatment Administration Record (TAR), printed 5/29/2019, revealed no documented instances of suctioning. Review of Resident #607's progress notes revealed no documented suctioning or self suctioning. Resident #607 had an active order that read clean or change inner cannula Q (every) day. (specify cannula type and size), ordered 5/9/2019 with no specific directions. Review of (MONTH) 2019 TAR, printed 5/29/2019, revealed no documented instances of the inner cannula being cleaned or changed between 5/9/2019 and the time of survey. Review of Resident #607's [MEDICAL CONDITION] care ordered revealed some changes had recently been made. From 5/9/2019-5/24/2019, Resident #607 had an order for [REDACTED]. On 5/25/2019 it changed to say, [MEDICAL CONDITION] Care every day and night shift and PRN. Clean or change inner cannula when needed (specify:[MEDICAL CONDITION] type and size), and document SPo2(oxygen level) and respiratory rate, ordered 5/25/2019. It was unclear what type and size [MEDICAL CONDITION] for Resident #607 had been ordered. It was unclear if Resident #607's inner cannula was disposable or non-disposable. A disposable inner cannula is changed, and a non-disposable inner cannula is cleaned during [MEDICAL CONDITION] care. It was also unclear whether the inner cannula should be cleaned or changed every day or if it should be cleaned or changed when needed. Review of (MONTH) 2019 TAR, revealed no documented vital signs until 5/25/2019 when order was changed to include document SPo2. Resident #607 had an order for [REDACTED]. On 5/29/19 at 4:25 PM, Nurse S explained Someone changed his order, and no one told me! Nurse S stated, It was once a day and as needed and now it is twice a day and as needed. Upon review of Resident #607's orders, a change was noted on 5/29/2019 for [MEDICAL CONDITION] Care every day and night shift and PRN. Clean or change inner cannula when needed (Shiley #5), and document SPo2 and respiratory rate. When interviewed, MDS Nurse T stated, I only clarified the size of the trach, the frequency of the treatment did not change. Review of Resident #607's progress notes revealed one physician's note dated 5/14/2019 at 17:53 PM (six days after admission). No other physician progress notes [REDACTED]. On 5/30/2019 at 11:15 AM, Nurse S was observed performing [MEDICAL CONDITION] care for Resident #607. Nurse S put on clean gloves for the procedure. Nurse S then opened the sterile [MEDICAL CONDITION] care kit and laid out the sterile drape. Nurse S then emptied contents of sterile kit one at a time onto the sterile drape by picking up each item, contaminating the sterile field and contents. Nurse S removed [MEDICAL CONDITION] mask and hung it from the dresser drawer next to Resident #607's bed. Nurse S removed the old dressing, removed a non-disposable inner cannula and placed the inner cannula in the sterile tray to soak. Nurse S did not replace the oxygen near the outer cannula to supply Resident #607 with oxygen during the procedure. Using the same gloves Nurse S cleansed [MEDICAL CONDITION] with a cotton tipped applicator then cleansed with gauze and sterile water then patted dry. Nurse S scrubbed the inner cannula with pipe cleaner and set aside on sterile drape after drying it. Next, Nurse S removed the clean gloves and donned sterile gloves. Nurse S did not perform hand hygiene after removing gloves. Once sterile gloves were donned, Nurse S replaced the inner cannula. Resident #607 was observed grunting and gasping while speaking to Nurse S. Resident #607's respiratory rate of 24 breaths per minute was observed post procedure. Nurse S noticed Resident #607'[MEDICAL CONDITION] mask was soiled with food. Nurse S looked for a [MEDICAL CONDITION] mask in the bedside supply drawer but could not locate one. Nurse S stated, I'm going to get this one cleaned up. Nurse S went to wash her hands and [MEDICAL CONDITION]. Resident #607 continued without oxygen until she returned. According to the [MEDICAL CONDITION] cannula and stoma care skills checklist, dated 7/25/2018, that evaluated Nurse S's competency in the skill, it lists put on sterile gloves as the first step when cleaning a non disposable inner cannula and put on clean gloves as the first step when cleaning a disposable inner cannula. The skills checklist indicates place the .oxygen device .over or near the outer cannula, after removing the inner cannula. During a follow up interview with Nurse S at 12:30 PM she stated that Resident #607 had a disposable inner cannula, but admitted that she had never changed it, only cleaned it and replaced it. When asked how often Resident #607 needed suctioning, Nurse S stated, I have never had to suction him . I have heard he suctions himself, but I have never seen him do it. In an interview on 5/30/2019 at 12:20 PM following the procedure, Resident #607 stated that the staff have never changed his inner cannula. Resident #607 stated that he sometimes has had to wait 30 minutes to four hours for staff, so he suctions himself. the supply cart at Resident #607's bedside was inspected in the presence of Nurse S. Size 6 disposable inner cannula's were supplied in the drawer. Upon review of Resident #607's respiration, oxygen sats, temperature, pulse, and blood pressure summaries, printed 5/29/2019, it was noted that his vital signs were documented a total of three times each between 5/8/2019 and 5/25/2019. Once on 5/8/2019 and twice on 5/17/2019. According to SBAR Communication Form and Progress Note . dated 5/17/2019 at 09:56 AM, it was documented, Resident'[MEDICAL CONDITION] out [MEDICAL CONDITION] site is actively bleeding . The form indicated Resident #607 was sent to the hospital. According to SBAR Communication Form and Progress Note . dated 5/23/2019 at 10:57 AM, it was documented, [MEDICAL CONDITION] out, due to Resident #607 [MEDICAL CONDITION]. The form indicated that Resident #607 was sent to the hospital. Vital signs documented on the form and progress notes were dated 5/17/2019. Vital Signs taken at the time of the decannulation are not documented. Resident #609: According to the Admission Record, printed on 05/29/2019, Resident #609 was a [AGE] year-old male admitted to the facility on [DATE] (original admission date of [DATE]) with [DIAGNOSES REDACTED]. According to section C of Resident #609's most recent (quarterly) MDS, completed 03/21/2019 (Assessment Reference Date 03/1/2019), his cognition was not intact and the brief interview for mental status could not be completed. According to Section G of the same MDS, Resident #609 required full staff performance with a two-person assist for bed mobility, transfer, dressing, toilet use and personal hygiene. Section J of the same MDS assessment indicated that Resident #609 did not have shortness of breath with exertion, at rest or when lying flat. Section O of the same MDS assessment indicated that Resident #609 received oxygen therapy, suctioning, and [MEDICAL CONDITION] care at the facility but did not receive any Respiratory Therapy days or minutes. Upon review of orders for Resident #609, it was noted that he had an order to change shiley size [MEDICAL CONDITION] daily and PRN every day shift [MEDICAL CONDITION], ordered 3/4/2019. During an observation on 5/29/2019 a Shiley size 6 was noted at bedside. Upon review of progress notes for Resident #609, a Size 6 Shiley was mentioned on 11/9/18, 11/11/18, 5/12/18, and 2/24/19. Upon review of completed/discontinued orders, Resident #609 was noted to have a previous order for a size 6 Shiley that was discontinued on 3/3/2019. Upon further inspection, in the presence of Nurse Q on 5/30/2019 at 4:00 PM, Resident #609 had two different sized [MEDICAL CONDITION] supplies at bedside. He had a 6.0 mm Shiley in his drawer, a size 8 disposable inner cannula in his drawer and a size 8 [MEDICAL CONDITION] with disposable inner cannula at bedside. A clear plastic bag was observed hanging on Resident #609's wall with an object inside. The bag was unlabeled and undated. When questioned about the bag and the contents, Nurse Q, stated, Oh that is a device to use in case of an emergency. I guess since we don't know when it was opened, I'll just throw it away. Nurse Q was observed as she removed the bag from the wall and put it in the garbage. Upon review of Resident #609's comprehensive care plan, printed 5/29/2019, a care planned intervention read, Change inner cannula #6 shiley every shift, (initiated 2/11/2016) was resolved on 5/27/2019. A new intervention was initiated on 5/27/2019 that read, Change Shiley size [MEDICAL CONDITION] daily and PRN every day shift [MEDICAL CONDITION]. Another care planned intervention read, Observe/document respiratory rate, depth and quality, Check and document q (every) shift/as ordered, was initiated 9/24/2015 and resolved 5/24/2019. Upon review of Resident #609's Respiration Summary, printed 5/29/2019 it was noted that Resident #609's respiratory rate was documented three times in the month of (MONTH) 2019: twice on 5/13/2019 and once on 5/19/2019. In an interview, the DON provided a copy of hospital paperwork that documented a [MEDICAL CONDITION] change on 5/13/2019 indicating [MEDICAL CONDITION] of 8.0. DON could not explain or provide documentation [MEDICAL CONDITION] order changing from 6.0 to 8.0 on 3/4/2019. DON stated, some of the old supplies must have been left in the room, when made aware of the size 6 Shiley at Resident #609's bedside. [MEDICAL CONDITION] Management Policy According to the [MEDICAL CONDITION] Management policy dated (MONTH) (YEAR), Residents are admitted based on the needs of the resident and the facility's ability to meet those needs .There is a licensed nurse with additional training on [MEDICAL CONDITION] care and management, or respiratory therapist on schedule at all times .The following items are kept at bedside for emergency [MEDICAL CONDITION] care: .replaceable [MEDICAL CONDITION] (with minimum one size down) with obturator . [MEDICAL CONDITION] Training/Competence During an interview with the Assistant Director of Nursing (ADON), she stated they use Lippincott Procedures (nursing resource) for [MEDICAL CONDITION] patient assessment and respiratory assessment guidelines. The ADON also said they have had their Respiratory Therapists educate staff as well. In an interview, Division Manager EE (for the respiratory therapy services company the facility utilizes) stated, I did a training for a group of mostly DON's and ADON's back on (MONTH) 7th. It was arranged through one of the corporate girls as a train-the-trainer training, which are not a good idea in my opinion. EE explained, train-the-trainer training doesn't usually carry through to the nurses that are providing the respiratory care to the patients. EE said she was not aware of any other [MEDICAL CONDITION] training provided to the facility by her company. According to the [MEDICAL CONDITION] patient assessment, respiratory therapy documented dated 8/17/18, .a patient with a [MEDICAL CONDITION] can experience sudden life-threatening emergencies. Clinical staff must know these complications and understand how to conduct a thorough assessment of a patient with a [MEDICAL CONDITION]. The document also notes, Staff must understand the different types of cannulas to know how to assess for obstructions while also making sure not to dispose of a permanent inner cannula. Th

This citation pertains to Intake Numbers MI 359, and MI 372. Based on interview and record review, the facility is placed in Immediate Jeopardy due to the facility's 1) failure to ensure residents were free from the use of physical restraints for one resident (Resident #605), and 2) failure to contact the physician regarding the use of a restraint. This deficient practice resulted in, 1) the limitation of the resident's movement, 2) the likelihood for entanglement and entrapment with the restraint, 3) the likelihood of decreased circulation, infection and skin breakdown related to improper application, and 4) the likelihood of increased agitation and anxiety. This deficient practice is likely to cause serious injury, serious harm, and/or death to any resident of the facility, who is subjected to a physical restraint, that is not ordered by a physician and monitored accordingly. This Immediate Jeopardy began on the evening of 5/7/2019 at 01:30-02:00 AM, when, per interview done on 5/23/19 at 7:27 AM, CNA FF stated Resident #605 was observed to be physically restrained. The Immediate Jeopardy was identified on 5/23/2019. The Administrator and Director of Nursing were notified on 5/30/2019 at 2:01 PM of the Immediate Jeopardy that began on 5/7/2019 at 01:30-02:00 AM, due to the facility's failure to ensure that residents were free from the use of physical restraints, without notification to a physician and a physician's orders [REDACTED].>Findings include: According to the Admission Record, printed on 05/23/2019, Resident #605 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to Census List, Resident #605 was transferred out to the hospital on [DATE] at 02:29 AM. According to Resident #605's admission Minimal Data Set (MDS), completed 05/10/2019 (Assessment Reference Date 05/06/2019), Resident #605 required full staff performance with a two-person assist for bed mobility, transfers, dressing, toilet use and personal hygiene. According to section J of the same MDS assessment, fall history was unable to be determined at the time the MDS was completed. Section P, of the same MDS, indicated that physical restraints were not used. Resident #605's cognition and behavior were not assessed on the admission MDS completed 05/10/2019 due to his persistent vegetative state and no discernable consciousness. During an interview, the Nursing Home Administrator (NHA) stated that he received an anonymous letter on the morning of 05/07/2019. The letter stated, Upon enter Resident Room (Resident #605 room number given) I notice that there was a rope made of what appeared to be glaze around his arm, connecting him to the bed. Was told it was to prevent the resident from pulling his tube out of neck. Thank you a concern worker. A review of the schedule for third shift for the night of 5/6/2019 into 5/7/2019, revealed the names of two certified nursing assistants (CNA J and CNA FF) and one nurse (Nurse AA) assigned to the floor Resident #605 resided on. A review of time card punches verified this. A statement obtained from CNA FF on 5/7/2019 read, When I came on it was wrapped around his bed and it was wrapped around his right arm. I was told he had pulled [MEDICAL CONDITION] and was sent out prior. (Nurse AA) gave me scissors to cut him loose. During an interview on 5/23/19 at 7:27 AM, CNA FF stated, When we did walk throughs about 11:15 PM, I saw what looked like gauze, wrapped around the bed. I saw the gauze around his wrist between 1:30 AM-2:00 AM and I took it off. CNA FF explained that Resident #605 was on his back with palms up, the gauze was wrapped around his right wrist to keep his arm from coming up. CNA FF stated that Nurse AA said to her You didn't see anything; you didn't see anything. CNA FF said, When I saw the gauze around his wrist, I took it off. CNA FF said CNA J was with her when she saw the gauze the first time. CNA FF said the second time she saw the gauze wrapped around Resident #605's right wrist was after Nurse AA went to do his tube feed. CNA FF stated, I saw the gauze on his right wrist again about 4:00 AM and I took it off. The nurse put it back on because she didn't want to send him back to the hospital because he had just gone to the hospital for pulling [MEDICAL CONDITION]. I went in periodically every 30-40 minutes. CNA FF explained that she told Nurse AA that she would do frequent checks on Resident #605 but Nurse AA said You don't need to, he is not a one-on-one. CNA FF stated that Nurse AA gave her scissors towards the end of the shift and said, If management comes up on the floor, cut it off. CNA FF said that as soon as Nurse AA gave her scissors, she went to Resident #605's room and cut the gauze off the bed frame and put the gauze in the garbage. CNA FF said, The gauze was knotted, and it was wrapped at least twice around the bed frame. I could slip his hand out, but I needed scissors to cut it off the bed. A statement obtained from CNA J on 5/15/2019 read, I saw a white gauze tied to the bed frame and wrapped around his wrist. We took his arm out of there by sliding his arm out and later on the nurse gave scissors to cut the thing off. In an interview on 5/23/2019 at 8:09 AM, CNA J said that on the midnight shift the night of 5/6/2019 into 5/7/2019 it was herself, CNA FF and Nurse AA assigned to the floor Resident #605 resided on. CNA J stated, I first noticed the gauze on (Resident #605's) bed at 11:20 PM on 5/6/2019. We removed gauze from his wrist twice that night. CNA J explained that she came into Resident #605's room and overheard Nurse AA tell CNA FF, You don't see nothing. CNA J said that is when she saw gauze tied around Resident #605's bed frame and wrapped around his right arm. CNA J explained that Resident #605 often used his right arm to yank at his tubes and that he could not move his left arm. I saw it on his arm between 1:30 AM -2:00 AM. CNA J said that CNA FF removed Resident #605's arm from the gauze. CNA J also stated that close to 7:00 AM we finally got scissors. (Nurse AA) told (CNA FF) I'm about to run downstairs. If management comes cut it off, and gave (CNA FF) her scissors. I observed it. CNA J said CNA FF went right in and cut the gauze off Resident #605's bed frame immediately. CNA J stated that she heard CNA FF tell Nurse AA that she would sit in Resident #605's room but Nurse AA told her No because he was not a one-on-one. CNA J stated, We had been asking for him to be a one-on-one because he kept getting out of his bed and pulling at his tubes. He would slide out of bed and sit on the mats. We asked our afternoon supervisor if we could get a one-on-one for him and they just care planned him to be able to be on the floor. CNA J stated, Resident #605 cannot speak for himself and it's not right that (Nurse AA) was kept as his nurse and not removed from his care. Nurse AA was not removed from the schedule during the investigation or after. CNA J stated, she was still caring for the resident every day until he went to the hospital. Review of time clock punches for Nurse AA between 5/6/2019 and 5/15/2019 it revealed that Nurse AA punched in for twelve-hour shifts on the nights of 5/6/2019 (6:53 PM to 8:38 AM), 5/7/2019 (6:51 PM to 7:33 AM), 5/12/2019 (6:53 PM-10:10 AM) and 5/13/2019 (6:53 AM to 8:23 AM). During an interview on 5/23/2019 at 3:06 PM, Resident #605's Doctor, X stated that he had not discussed the use of restraints for Resident #605 with anyone and stated, What! No, we don't use restraints at the nursing home, there are guidelines. Doctor X said he was never made aware of Resident #605 having gauze wrapped around his wrist and tied to his bed frame on 5/6/2019-5/7/2019. Resident #605 was at the hospital at the time of survey. Resident #605's Resident Representative was called three times but did not return phone call for interview. Nurse AA, was call three times but did not return the phone call for an interview and was at the facility at the time of survey. Upon review of Resident #605's orders, it was noted that he was not prescribed any type of physical restraints, therefore there were no orders for frequency of releasing the restraint, documentation of specific medical symptoms justifying the use of the restraint and no documented risk vs. benefits analysis for the use of the restraint. Upon further review of Resident #605's orders, it was noted that his physician prescribed [MEDICATION NAME] tablet 0.25 milligrams (mg) give 1 tablet via PE[DEVICE] (feeding tube) every 8 hours for anxiety on 5/6/2019 (discontinued 5/9/2019). Resident #605's [MEDICATION NAME] order was modified multiple times between 5/8/2019 and 5/14/2019. On 5/8/2019, [MEDICATION NAME] tablet 0.50 mg give 1 tablet via PE[DEVICE] three times a day for anxiety was prescribed (discontinued 5/9/2019). On 5/9/2019, [MEDICATION NAME] tablet 0.25 mg give 2 tablets via PE[DEVICE] every 8 hours for anxiety was prescribed (discontinued 5/10/2019). On 5/10/2019, [MEDICATION NAME] tablet 0.25 mg give 2 tablets via [DEVICE] four times a day related to traumatic subdural hemorrhage with loss of consciousness was prescribed (discontinued 5/14/2019). On 5/14/2019, [MEDICATION NAME] 0.5 mg give 1 tablet via PE[DEVICE] four times a day for anxiety was prescribed. Resident #605 was also prescribed, Levetiracetam solution 500 mg /5 milliliters (ml), use 10 ml intravenously two times a day for [MEDICAL CONDITION]. It was noted that this order was changed on 05/01/2019 to give Levetiracetam solution via PE[DEVICE] instead of intravenously. Upon review of Resident #605's (MONTH) 2019 Medication Administration Record [REDACTED]. On the MAR indicated [REDACTED]. Review of Resident #605's progress notes did not reveal why the medication was not administered until 5/2/2019. Nurse AA did not return phone calls three times. Upon review of resident #605's Baseline Care Plan it was noted in Section One that No is marked for does the resident use restraints. The baseline care plan was not discussed with the resident's representative according to the baseline care plan summary. The summary indicates that focuses, goals and interventions were discussed with the resident. The resident was comatose. Upon review of Resident #605's comprehensive care plan, it was noted that Resident #605 did not have a plan of care related to pain, agitation and behaviors (pulling at [MEDICAL CONDITION] and feeding tubes) or the use of physical restraints. Resident #605's care plan did not include interventions according to standards of practice for the use of a physical restraint. Resident #605's care plan did not provide interventions for the ongoing monitoring and evaluation for the use of a physical restraint. Resident #605's comprehensive care plan did include, resident will place self on mats at bedside (initiated 5/13/19), at risk for falls (initiated 5/2/2019, revised 5/16/2019), .resident is non-verbal (initiated 5/2/2019), .has increased potential for skin impairment related to vegetative state, immobility, restless, decerebrate posturing (initiated 5/8/2019), Known skin impairment .left chest surgical puncture wounds X 2 (chest tube and drain placement), left buttocks stage 2 pressure ulceration present upon admit, coccyx stage 3 pressure ulceration present upon admission (initiated 5/8/2019). Review of progress notes and hospital medical records indicated that Resident #605 experienced agitation that progressed through to his hospital transfer on 5/15/2019, increased episodes of falls, expression of wanting to be on the floor, and threatening behaviors towards staff. Progress Note written by Nurse Z on 5/5/2019 at 18:29 AM noted, upon arrival in resident room to [MEDICAL CONDITION]. Resident was found [MEDICAL CONDITION] out called for transport to the hospital. Progress Note written by Nurse BB on 5/5/2019 at 20:00 PM, noted, resident restless, pulling covers off, [MEDICAL CONDITION] off, frequent room checks .awaiting for (Doctor X) to order [MEDICATION NAME] for restless . Progress Note written by Nurse BB on 5/6/2019 at 03:48 AM noted, resident has hand around the top of [MEDICAL CONDITION] times hands was taken away and instructed to leave along . Progress Note written by Nurse BB on 5/6/2019 at 06:48 AM noted, resident restless between [MEDICATION NAME], yet somewhat restless, pulls covers, sttemp (sic) the pulling of trach, yet has not pulled out, non verbal, yet obeys some commands. SBAR (situation, background, assessment, response) Communication Form and Progress note, dated 5/10/2019 at 17:26 PM, documented that Resident #605 had rolled out of bed and onto fall mat. SBAR Communication Form and Progress note, dated 5/10/2019 at 22:57 PM, documented that Resident #605 had .rolled out of bed and onto fall. The nurse documented better pain med would make the condition or symptom better, indicated it had happened before and that [MEDICATION NAME] was used to treat the last episode. It was noted that Resident #605 was moving more. Progress Note written by Nurse CC on 5/11/2019 at 18:19 noted, Resident appeared agitated during whole shift, grabs and pulls on anything, ([MEDICAL CONDITION], PEG tube, O2 mask, cloth, briefs), multiple attempt of getting off bed, needs close monitoring. On 5/13/2019 at 00:34 AM Nurse AA wrote, Writer and staff monitoring resident every 30 minutes or less if possible. Resident continues to throw legs over side of the bed trying to put himself on the floor. Resident stated, I want to be on the floor. I am going to shoot someone if you don't let me get on the floor. Staff has been continuously going into resident room and positioning legs back into bed. Resident needs to become a one on one or care plan needs to be changed to allow resident to crawl onto the floor . SBAR Communication Form and Progress note, dated 5/13/2019 at 07:09 AM, documented that Resident #605 .begun to attempt to talk. Resident has also been moving legs off the bed and putting himself on the mat next to his bed. The nurse documented .medications for anxiety and pain would make the condition or symptom better. Hospital records from 5/15/2019 hospitalization also indicated that Resident #605 had been having difficulty with increasing agitation as another reason for transfer from the facility to the hospital emergency room . Resident #605's risk for falls, non-verbal status, known skin impairment, restlessness, and documented [MEDICAL CONDITION] disorder placed Resident #605 at high risk for the likelihood of serious harm and/or serious injury due to complications from the use of physical restraints due to the risk of entanglement, entrapment, skin breakdown and death associated with the use of restraints. Consent for the use of restraints was not located in the medical record. Review of Restraint Management policy (revised (MONTH) (YEAR)) defines a physical restraint as any manual method, physical or mechanical device, material, or equipment attached or adjacent to the residents body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. The policy also stated, Restraints are implemented in accordance with State and Federal regulations .Restraints are not used as a disciplinary action or for the convenience of the facility to control behavior. The policy defines convenience as any action taken by the facility to control a resident's behavior of manage a resident's behavior with a lesser amount of effort by the facility .: The policy says that any resident requiring a restraint will have a current order .If the restraint must be tied, a quick release knot is used .during the time a restraint is in place, it is periodically removed and the resident is assisted with change of position, range of motion and/or stretching .If the resident and/or resident's representative agree to the use of a physical restraint, a Physical Restraint Consent form is completed . The Immediate Jeopardy was abated on 5/30/19, based on confirmation that the facility had implemented the following to remove the Immediate Jeopardy: 1. On 5/30/2019, Resident #605 no longer resided in the facility. 2. On 5/30/2019, all 133 residents residing at the facility were identified as having the potential to be affected by the alleged deficient practice. All residents were assessed to have no restraints, that were not specifically ordered, and care planned by the physician. No restraints were identified on 5/30/19. 3. On 5/30/2019, education for all licensed nurses on the restraint policy was initiated. Education to include the need to use proper assessment, physician notification, physician order, and device monitoring to avoid potential harm. Although the Immediate Jeopardy was removed on 5/30/19, the facility remained out of compliance at a scope and severity of no actual harm with potential for more than minimum harm that is not immediate jeopardy, pending the completion of inservice training of all staff and pending confirmation of the facility's ability to maintain sustained compliance, as verified by the State Agency (SA).

This Citation Pertains to Intake Number MI 372. Based on observation, interview and record review, the facility failed to assess, monitor and ensure medications were given timely and as ordered by the physician for 1 resident (Resident #604) of 6 residents reviewed for assessment and medications, resulting in Resident #604 not receiving medications as ordered, having a [MEDICAL CONDITION] the next morning after readmission, a change of condition, a lack of assessment and monitoring, and readmission back to the hospital. Findings Include: A review of the Face Sheet and Minimum Data Set Assessment (MDS) indicated Resident #604 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS, dated [DATE], revealed that the resident needed total assistance with all care and had mild cognitive dysfunction. Resident #604 had multiple discharges to the hospital with a recent readmission on 5/22/19 and discharge back to the hospital on [DATE] after experiencing a [MEDICAL CONDITION]. The resident was readmitted to the facility again on 5/29/19. A review of the hospital discharge instructions revealed that the resident received morning medications at the hospital and was to receive evening medications at the facility on 5/22/19, but the facility did not order the medications to begin until the next day. A review of the physician's orders for Resident #604 identified the following medications were to be given at 9:00 PM on the evening of readmission, 5/22/19. However, the medications were not ordered until 5/23/19 and the resident did not receive them. The medications that were not given were [MEDICATION NAME] 0.5 mg at bedtime (anxiety), Insulin [MEDICATION NAME] 15 Units inject subcutaneously at bedtime (diabetes), [MEDICATION NAME] Extended Release 60 mg (high blood pressure), [MEDICATION NAME] 50 mg (for [MEDICAL CONDITION]), Eliquis 2.5 mg tablet (blood thinner), Levetiracetam 750 mg tablet ([MEDICAL CONDITION]), and [MEDICATION NAME] 50 mg (high blood pressure). The resident only received 2 medications after readmission- Atorvastatin at 9:00 PM on 5/22/19 for high cholesterol and [MEDICATION NAME] for depression at 6:00 AM the next day (5/23/19). None of the medications scheduled for 9:00 AM (5/23/19) were given because the resident was transferred back to the hospital prior to that time. The resident had two as needed pain medications ordered: Tylenol and [MEDICATION NAME]. There was no documentation that either was given to the resident. A review of the Nursing Daily Skilled Charting, indicated there was no assessment for 5/22/19-the day of readmission; only an assessment for 5/23/19 and it was incomplete and missing assessment information in all sections. A review of the Weights & Vitals, for the resident showed the following from readmission on 5/22/19 to discharge on 5/23/19: 5/22/19 at 7:09 PM Blood Pressure 112/68 (Within normal limits (WNL)), Pulse- 77 beats/per/minute ( WNL), Temperature 99.7 (slightly elevated), Respirations 19 (slightly elevated for the resident), Blood Sugar (there were no documented blood sugars), Oxygen saturation level (identifies adequate oxygenation in the blood (there were none)). There was no weight recorded from admission on 5/22/19 through discharge on 5/23/19. A review of the progress notes for Resident #604 revealed that there were no nursing or physician's notes from 5/22/19-5/23/19. The only note was a Nutrition Note, written by the Registered Dietitian (RD) dated 5/23/19 at 10:50 AM, reading RD review on 5/14/19, resident sent out to hosp (hospital), returned 5/22 and sent out to hosp again on 5/23. Resident with diet order and tube feeding orders in place. A nursing SBAR (Situation, Background, Assessment, Recommendation) assessment, dated 5/23/19, stated that the resident had a change of condition and [MEDICAL CONDITION] and was transferred to the hospital. A review of the Care Plans for Resident #604 indicated the following: [MEDICAL CONDITION] Disorder, date initiated 4/30/19, revision on 4/30/19 with Interventions: Give medication as ordered. Observe/document for effectiveness and side effects (4/30/19,) [MEDICAL CONDITION] Documentation: Location of [MEDICAL CONDITION] activity, type of [MEDICAL CONDITION] activity, duration . (4/30/19). Hyper/[DIAGNOSES REDACTED] (high/low blood sugar), Diabetes, date initiated 4/03/19, revision on 4/03/19 with Interventions: Diabetes medication as ordered by doctor .observe document for side effects and effectiveness (4/4/19), Observe/document/report as needed any signs/symptoms of [MEDICAL CONDITION] .Observe/document/report as needed any signs/symptoms of [DIAGNOSES REDACTED] .4/4/19. Cardiovascular Impairment, date initiated 4/24/19, revision date 4/24/19 with Interventions: Assess for shortness of breath and cyanosis (bluish color) as needed, observe/document/report as needed any changes in lung sounds on auscultation (listening with the stethoscope), [MEDICAL CONDITION] (swelling) and changes in weight, Obtain a full set of vital signs each shift, Notify nursing/MD of significant abnormalities, all dated 4/24/19. Pain, dated 4/3/19 with Interventions: Anticipate the resident's need for pain relief and respond immediately . 4/3/19. In an interview on 5/29/19 at 4:00 PM, the Director of Nursing stated, Vital signs should be taken every shift if the resident is skilled and every shift for 72 hours after admission and documented. The Director of Nursing was asked why Resident #604 did not receive her necessary medications as recommended by the hospital and said They should have been ordered and given. Some of them are in back-up and anything we don't have, we can call the pharmacy and have them sent. A policy on Medication Administration was requested and not received prior to exit. A policy titled Medication Management, was reviewed but not pertinent to the identified issues. A policy for assessment was requested and not received prior to exit. A review of the facility policy titled, Changes in Resident Condition, revised (MONTH) (YEAR) revealed .The SBAR Communication Form and the Progress Notes are used to assess and document changes in condition .

This Citation Pertains to Intake Number MI 372 Based on observation, interview and record review, the facility failed to document changes for pressure ulcers, provide skin assessments per professional standards, and implement treatments to prevent skin breakdown or further worsening of wounds for 2 residents (Resident #107 and Resident #605) of 4 residents reviewed for pressure ulcers, resulting in Resident #107 developing a Stage IV left gluteal pressure ulcer with missing documentation that wound care was provided, and Resident #605 developing 3 Stage III facility-acquired pressure ulcers at the [MEDICAL CONDITION] site while residing at the facility, with no documentation of assessment or treatment. Findings Include: Resident #107: On 5/23/19 at 2:30 PM, Resident #107 was observed awake and lying in bed on her right side with the TV on. The resident was able to slowly and quietly respond to questions. A record review of the Face Sheet and Minimum Data Set (MDS) assessment for Resident #107 revealed that the resident was readmitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS, dated [DATE], indicated that the resident needed extensive 1-2-person assistance with all care. A review of the physician orders for Resident #107 revealed the following: Cleanse wound to left gluteal fold with NS (normal saline), apply Dakins solution soaked rolled gauze to entire wound bed, cover with large border gauze dressing, revision date 5/27/19. Cleanse wound to left hip with NS, apply [MEDICATION NAME] calcium sheet to wound bed, cover with border gauze daily, revision date 5/22/19. A review of the prior orders identified: Cleanse wound to left hip with wound cleanser, apply [MEDICATION NAME] calcium sheet to wound bed, cover with border gauze, daily every day shift for wound care, order date 1/16/19 and discontinued 5/22/19 and Dakins Solution 0.5%. Apply to kerlix gauze left gluteal topically every day shift for wound care. Cleanse wound to left gluteal fold with NS, saturate rolled gauze with Dakins solution, lightly pack saturated gauze to entire wound bed of left gluteal fold, cover with ABD (thick gauze pad) secure with mediflex tape, daily and as needed, order date 4/25/19 to 5/7/19 and 5/7/19 to 5/23/19. Changed mediflex tape to border gauze. The left gluteal fold pressure ulcer is not referenced upon readmission on 1/13/19. The resident also had Bilateral heel boots on resident while in bed. Every day and night shift for skin/wound care, order date 2/26/19 and Resident to have house stock skin moisturizer applied to feet and legs twice daily every morning and at bedtime for skin care, order date 3/4/19 to 5/27/19. The Treatment Administration Record (TAR) for (MONTH) 2019 identified multiple instances of the resident not receiving the treatments: Left gluteal fold- missed treatments on 5/9/19, 5/13/19 and 5/28/19. Left Hip- missed treatment on 5/9/19 and 5/28/19. Bilateral Heel boots- not applied 5/9/19 at 7:00 AM, 5/23/19 at 11:00 PM and 5/28/19 at 7:00 AM. House stock moisturizer to feet and legs- not applied 5/2/19 at 9:00 PM, 5/7/19 at 9:00 PM, 5/9/19 at 7:00 AM, 5/11/19 at 9:00 PM, 5/12/19 at 9:00 PM and 5/20/19 at 9:00 PM. A review of the Wound Assessments revealed the most recent assessment provided by the facility was dated 5/17/19 and revealed Left gluteal wound measurement: 6 cm length x 5 cm width and 2 cm depth with a moderate amount of serosanguinous drainage and Left Hip wound measurement of 2.7 cm length x 1.2 cm width and 1 cm depth with a large amount of serosanguinous drainage. A review of the Resident's Skin Care Plan titled, Increased potential for Skin Impairment related to: Admit with Stage 3 pressure ulceration to left hip, personal history of multiple pressure ulcers decreased mobility, left [MEDICAL CONDITION] (weakness) .Recurrent ulceration open to left gluteal fold 2/2019, date initiated 1/7/19 and revision on 3/5/19 with Interventions: Provide treatment as ordered by physician, date initiated 1/7/19 with revision on 4/3/19. During an interview on 5/30/19 at 4:00 PM, the Director of Nursing (DON) was asked about the missing wound care documentation and stated, That should be completed. A review of the facility policy titled, Skin Management, revision dated (MONTH) (YEAR), provided Residents receive care to aid in the prevention or worsening of wounds and/or pressure ulcers. Individuals identified, assessed and provided treatment to promote healing, prevent infection, and prevent new ulcers from developing. Ongoing monitoring and evaluation are provided for optimal resident outcomes. Resident #605: According to the Admission Record, printed on 05/23/2019, Resident #605 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to Census List, Resident #605 was transferred out of the facility to the hospital on [DATE] at 02:29 AM. According to section G of Resident #605's admission MDS (Minimum Data Set), completed 05/10/2019 (Assessment Reference Date 05/06/2019), Resident #605 required full staff performance with a two-person assist for bed mobility, transfers, dressing, toilet use and personal hygiene. Section O of the same admission MDS assessment indicated that Resident #605 received [MEDICAL CONDITION] care According to the MDS, Resident #605's cognition was not assessed on the admission MDS, completed 05/10/2019, due to his persistent vegetative state and no discernable consciousness. Upon review of Resident #605's Baseline Care Plan, dated 5/2/2019, it was noted in section one that No was marked for does the resident have a pressure ulcer and does the resident have a surgical site. Resident #605 admitted with surgical sites and a pressure ulcer. The baseline care plan was not discussed with the resident's representative according to the baseline care plan summary. The summary indicates that focuses, goals and interventions were discussed with the resident. The resident was comatose. Upon review of Resident #605's comprehensive care plan it was noted that Resident #605 did not have a plan of care related to [MEDICAL CONDITION] care. Resident #605's comprehensive care plan included, .resident is non-verbal (initiated 5/2/2019), .has increased potential for skin impairment related to vegetative state, immobility, restless, decerebrate posturing (initiated 5/8/2019), Known skin impairment .left chest surgical puncture wounds .(chest tube and drain placement), left buttocks stage 2 pressure ulceration present upon admit, coccyx stage 3 pressure ulceration present upon admission (initiated 5/8/2019). Resident #605's Head to Toe Skin Checks assessment, dated 5/1/2019 (one day after admission), revealed that Resident #605 was noted to have a 1-centimeter (cm) X 1 cm round open wound and skin tear on left buttock measuring 2 cm. The Head to Toe skin check on 5/1/2019 upon admission did not document a pressure ulcer to the coccyx. The pressure ulcer on Resident #605's coccyx was first documented on 5/3/2019 (three days after admission) as a Stage II pressure ulcer measuring 2 cm X 1 cm X 0.2 cm. The Head to Toe Skin check, dated 5/3/2019, noted that Resident #605's physician was notified of his pressure ulcer to the coccyx on 5/3/2019 (three days after admission). According to the Head to Toe Skin Checks, referenced above, Resident #605 did not have a Stage II pressure ulcer on his coccyx on 5/1/2019 (upon admission). Review of Resident #605's hospital records (from hospitalization on [DATE]) revealed that Resident #605 had three Stage III pressure ulcers on his neck/[MEDICAL CONDITION] site upon admission to the hospital on [DATE]. Hospital records indicated that the three pressure ulcers were first assessed in the emergency roiagnom on [DATE]. Pressure ulcers documented upon admission to the hospital (from the facility) included, one Stage III pressure ulcer located left anterior neck, one Stage III pressure ulcer located right anterior neck and one Stage III pressure ulcer located neck inferior to the [MEDICAL CONDITION] plate. The three stage III pressure ulcers were undocumented at the facility during Resident #605's time at the facility (4/30/2019-5/15/2019). In a interview, Wound Care Nurse T stated that Resident #605 had a pressure ulcer on his coccyx and a pressure ulcer on his buttock. Wound Care Nurse T did not have knowledge of any pressure ulcers to Resident #605's neck/[MEDICAL CONDITION] device site. Additional record review of Resident #605's Head to Toe Skin Checks assessment dated [DATE], 5/8/2019, 5/13/2019 and 5/14/2019 along with Resident #605's Weekly Pressure Ulcer Record dated 5/3/2019 and 5/10/2019 did not document any pressure ulcers to Resident #605's neck/[MEDICAL CONDITION] device site. Review of Skin Management policy, revised (MONTH) (YEAR), noted, resident received care to aid in the prevention or worsening of wounds and/or pressure ulcers. Individuals at risk for skin compromise are identified, assessed and provided treatment . The Skin Management policy defines a Stage III pressure ulcer as, full-thickness loss of skin, in which adipose tissue (fat) is visible in the wound

This Citation pertains to Intake Numbers MI 326, MI 359, and MI 372 Based on observation, interview and record review the facility failed to ensure there was adequate staff to meet the needs of the residents, including appropriate care and management of residents with tracheostomies for 4 residents (# 605, #607, #608, #609) of 9 residents reviewed for staffing and 4 residents reviewed for tracheostomies, resulting in staff verbalizations of being unable to adequately provide care and prevent the residents from harm. Resident #605 and Resident #607 dislodging their tracheal tubes, leading to respiratory distress and hospitalization and the staff for Resident #608 and Resident #609 did not follow the physician's orders [REDACTED]. Findings Include: Resident #608: A record review of the Face Sheet and Minimum Data Set (MDS) assessment for Resident #608 indicated the resident was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment was not yet completed and there was no Care Plan for the amount of assistance that the resident needed with care. On 5/26/19 Resident #608 was hospitalized after he experienced a fever with increased thick tracheal secretions and [MEDICAL CONDITION]. At the time of exit on 5/31/19, the resident had not returned to the facility. The following facility staff were interviewed about staffing assignments and resident care for the 3 nursing floors- 200 (about 55 residents), 300 (about 60 residents) and 400 (about 20-25 residents): 5/22/19 at 12:00 PM, Certified Nursing Assistant (CNA) B stated, We don't have enough staff with call in's. That gives us about 14 residents apiece on day shift. 5/22/19 at 2:15 PM, CNA M replied, I feel like we could have more staff. There are 2 CNA's for about 20 residents (on dayshift and the afternoon shift). 5/22/19 at 2:34 PM, CNA N stated, Someday's we have call in's and we have 4 aides. We have 14 residents apiece. It's difficult to do the right kind of care. 5/22/19 at 2:58 PM, CNA H commented, I'm not gonna lie. Sometimes there aren't enough staff; People were quitting. I don't feel like I'm doing my true job. 5/29/19 at 11:00 AM, Nurse U stated, There is no Manager for 3 (3rd Floor). We all try to keep an eye on it. Nurse U was queried about Resident #608's transfer to the hospital and stated, The nurses were asking about his oxygen saturation. It was getting down to 80-83% (90-100% normal range). We tried everything on the oxygen pathway. We didn't do anything with the trach. He wasn't gurgling. We were concerned about the oxygen and there were no secretions that we needed to suction a that time. Nurse U was asked if the nurses attempted to suction the resident'[MEDICAL CONDITION] she said, No. A review of the facility Staffing Schedules for 4/29/19-5/2/19, 5/6/19-5/7/19 and 5/23/19-5/24/19 revealed there were multiple days when the 3rd floor had 4 nurse aides and an additional nurse aide providing 1:1 or 2:1 care for residents on the 3rd floor, during the day and afternoon shifts for approximately 60 residents. The 1:1 nurse aide had to be relieved for breaks and lunch, which would then leave 3 nurse aides on the floor. There were 2 instances when there were 4 nurse aides or less on the 200 hall on the day shift. On 5/6/19 on the day shift, there were 3.5 nurse aides on the 200 hall and 4 nurse aides on the 300 hall with an additional 1:1 aide. On most nights there was 1 nurse for the 400 Hall with 2 nurse aides and 3 nurse aides on both the 200 and 300 halls for 50-60 residents each. Residents with tracheostomies had resided on each floor. During an interview on 5/23/19 at 7:27 AM, CNA FF related an incident that occurred on third shift the night of 5/6/2019 to 5/7/2019. CNA FFstated, I saw the gauze on his (Resident #605) right wrist .and I took it off. The nurse put it back on because she didn't want to send him back to the hospital because he had just gone to the hospital for pulling [MEDICAL CONDITION]. CNA FF explained that she told Nurse AA that she would do frequent checks on Resident #605, but Nurse AA said You don't need to, he is not a one-on-one. CNA FF stated that Nurse AA gave her scissors towards the end of the shift and said, If management comes up on the floor cut it off. CNA FF also stated that when the Director of Nursing interviewed her regarding the incident, the DON stated to her that she couldn't afford to lose a nurse In an interview on 5/23/2019 at 8:09 AM, CNA J stated, We asked our afternoon supervisor if we could get a one-on-one for him (Resident #605) and they just care planned him to be able to be on the floor. In a review of a progress note, dated 5/13/2019 at 00:34, AM Nurse AA wrote, Writer and staff monitoring resident every 30 minutes or less if possible. Resident continues to throw legs over side of the bed trying to put himself on the floor. Resident stated, I want to be on the floor. I am going to shoot someone if you don't let me get on the floor. Staff has been continuously going into resident room and positioning legs back into bed. Resident needs to become a one on one or care plan needs to be changed to allow resident to crawl onto the floor . In an interview on 5/30/2019 at 12:20 PM, Resident #607 stated that sometimes he has had to wait 30 minutes to four hours for staff, so he suctions himself.

Based on observation, interview, and record review, the facility 1. failed to ensure/maintain the safety of 1 Resident (#36) out of 3 residents reviewed for safety/accidents and 2. failed to perform Neurological Assessments post unwitnessed falls, resulting in Resident #36 sustaining serious injuries of a fractured left hip, skin tears, head injury, and pain. Findings include: According to admission face sheet, Resident #36 was a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. According to Minimum Data Set (MDS), dated [DATE], Resident 36's cognition assessment was scored a four indicating severe cognitive impairment and required assistance with Activities of Daily (ADL) care to include transfers, mobility, and ambulation. Review of incident report, dated [DATE] at 02:55 (2:55 AM), documented Resident was on the floor lying on his stomach with his head on the pillow, on the left side of bed. Noted Skin Tear 1 x 1 cm (centimeter) on his left knee. Resident is alert and oriented times 2. Under notes: Leg cleansed with normal saline and Band-Aid applied. Interventions documented as: Fall mats to bilateral bedside. On the report, it was documented as Unattended/no witnesses found. Review of incident report, dated [DATE] at 06:57 (6:57 AM), documented Observed trying to get on his wheel chair, slipped, landed on the floor on his back. Under injuries: Abrasion left shoulder. The report also had documented resident as confused, ambulating without assist. Under notes: Encourage to use call light/ask for assistance. Review of incident report dated [DATE], at 03:35 (3:35 AM), documented Loud noise heard, upon investigation, resident was found on the floor by the restroom, he fell out of wheel chair. It was documented as unattended. Under action taken: Resident was helped off the ground. Vital signs taken and cleaned up all of feces that was on the resident and his w/c. Under injuries: Abrasion left knee, Head injury, Skin Tear right elbow. Also documented on the report was Oriented to Situation, not person, place, or time. Also documented was Fatigue, confusion, impaired cognitive status, drowsy, incontinent, and weakness. Under other information: Resident was attempting to ambulate to the restroom in w/c without assistance. Resident had BM (bowel movement) before or during the incident. There was no intervention documented for this unwitnessed fall. Review of incident report dated [DATE], at 06:29 (6:29 AM), documented Resident on floor in doorway of bathroom after ambulating without assistance. Under injuries: no injuries observed. Under mental status: Oriented to person. The report also had documentation of: Gait imbalance, Ambulating without assistance, and Unattended. Under Notes: toilet upon rising.' Review of incident report dated [DATE], at 08:29 (8:29 AM), documented Resident was trying to walk over to his roommate's bed and fell . Under injuries: Fracture, left thigh, front and rear. Under mental status: Oriented to person. The report also had documentation of Gait imbalance, Ambulating without assistance, Impaired cognitive status, weakness, and no witnesses's found. Action taken: had x-rays done of left leg and hip. Sent to hospital. Review of 'Nursing Admission Data Collection', dated [DATE], listed under Admission Details, 'left [MEDICAL CONDITION]' on the admission document, and under Item Summary, documented c/o (complaints of) pain when moving left side. During an interview with the Director of Nursing (DON) on [DATE], the DON was asked to provide Neurological Assessments for the four unwitnessed falls. The DON indicated it was the expectation for all unwitnessed falls that Neuro checks be completed, and also for witnessed falls with head injury. The DON provided only one Neurological assessment for the fall on [DATE], and was not able to provide any other Neurological Assessments for the other unwitnessed falls by the end of survey. Review of the Neurological Record had instructions at the top of the form as to the frequency to perform the Neurological Assessment as: every 30 minutes times 4, every 1 hour times 4 hours, every 4 hours times 24 hours, every 8 hours for remaining 72 hours, or as ordered by physician. Post [MEDICAL CONDITION] every 15 minutes times 8. According to www.ncbi.nlm.nih.gov 'The clinical practice guideline for falls and fall risk' documented Falling is a significant cause of injury and death in frail older adults. Residents in long-term care (LTC) facilities fall for a variety of reasons and are more likely to endure injuries after a Fall. According to www.hcpro.com 'Neurological checks for head injuries LTC Clinical Pearls: Powered by HCPRO's Long Term Care Nursing Library, (MONTH) 8, 2013, documented Assess the resident for changes in level of consciousness, which is a cardinal sign of untoward pathology. Assess resident immediately after the fall, then frequently throughout the shift. Assessment should continue for minimum of 72 hours. Perform frequent neurological exam: every 15 minutes for 2 hours, every 30 minutes for 2 hours, every 60 minutes for four hours, every 8 hours for 16 hours, every 8 hours for at least 72 hours have elapsed, and the resident is stable. The neurological assessment includes: pulse, respirations, blood pressure measurements, assessment of pupil size, equality of hand grasps, which helps keep the findings objective. The neurological exam is the assessment of sensory neuron and motor responses, reflexes to determine whether the nervous system is impaired. Review of Resident #36's Neuro checks revealed Neuro's were completed [DATE], at 2:30 AM, 3 AM, 3:30 AM, and then on [DATE], at 4 AM, 5 AM, 6 AM, 7 AM. There were no other entries, dates, or assessment past [DATE], at 7 AM. (What was missing was every 1 hour times four, and every 8 hours for 72 hours). Observation of Resident #36 was done on [DATE], during the final tour and at lunch time, Resident #36 was observed sitting up in dining room in w/c and was observed to be leaning forward. Staff had to remind Resident #36 to sit back in his chair several times. An additional observation was made on [DATE], and Resident #36 was observed in his room in bed sleeping at 9:00 AM. On [DATE], at 10:00 AM, an observation was attempted and Resident #36 was not in his room, or the dining room. An interview with staff verbalized that Resident #36 had been sent back to the hospital for pulling his dressing off to the incision site on his left hip multiple times and picking at his staples which caused a small area of the incision to open, and the surgeon requested him back to the hospital for evaluation. Resident #36 was out of the facility. Review of Fall risk assessment, dated [DATE], documented Fall risk score at an 8 indicating Resident #36 was at low risk for falls with intermittent confusion and as ambulatory and balance problem with standing and walking. On [DATE], Fall risk score was documented as a 12 and High risk for falls, alert and oriented, Chair bound, and Not applicable for Gait/Balance issues. An additional fall risk assessment had been completed on [DATE], and documented Resident #36 as 9 and at low risk for falls and Alert and oriented, one to two falls, chair bound, balance problems with standing and ambulating, and 2 or more disease boxes checked. On [DATE], Resident #36 was documented as 13 and High risk for falls with intermittent confusion, ,[DATE] falls, chair bound, balance problem with walking and standing, and use of assistive devices. The box for 2 or more disease was left unchecked, as previously marked. Review of Resident #36's initial Falls care plans, initiated [DATE], documented 'Potential for falls due to disease process. One of the interventions listed ensure call light in reach, encourage to use it. There were also several other safety interventions documented. Review of an additional fall care plan documented I have an increased potential for Fall r/t (related to) Personal history of falls related to Disease Process, psych history, impaired cognition, generalized weakness, impulsive, medication side effects, poor safety awareness. The goal documented My risk for falls or fall related injury will be minimized thru next review and review date of [DATE]. Review of Activities of Daily Living Care Plan, dated [DATE], and review date of [DATE], documented encourage Resident to use Call light/wait for assistance. An interview was conducted over the phone with Certified Nursing Assistant M who works on 2nd shift and sometimes third shift. CNA M was asked about Resident #36 and multiple falls. CNA M indicated Resident #36 was very impulsive, tries to walk all the time, and can't. He is not supposed to walk unassisted, but he still gets up and tries all the time. He has had so many falls, what us CNA's have done is put him on 30 minute checks. It is not ordered and their is no documentation we fill out, but we did it on our own. Not all of the other staff do that, but they should because he is always falling. It is not on the Kardex, but we just do it. He needs to be 1 on 1, but no one has made him that. But they should. He is impulsive and is constantly trying to get up. This last fall was a bad one. During an interview conducted on [DATE], the DON was asked why Resident #36 was not a 1 to 1 because of all of his recent falls, and indicated she was not sure why. The DON was asked if she investigated the root cause of all of Resident #36's falls and verbalized this resident was very impulsive. She also indicated she did not want to implement all of the interventions at once and have nothing to put in place and that he would not listen or wait for help. Review of 'Fall Management' Policy, dated July, (YEAR), documented The facility assists each resident in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices, and/or functional programs, as appropriate, to minimize the risk for falls. The Interdisciplinary Team (IDT) evaluates each resident's fall risks. A Care Plan is developed and implemented, based on this evaluation, with ongoing review. The Fall Policy that was provided by the facility did not address Neurological Assessments to be completed for unwitnessed falls, however, the DON indicated it was Standard of Practice to complete Neurological assessments with every unwitnessed fall and for those witnessed Falls with head injuries or hitting of heads. Resident #36 suffered 5 falls from a time frame of [DATE], through [DATE], resulting in Resident #36 sustaining a left [MEDICAL CONDITION], head injury, pain, skin tears and other injuries. The facility failed to complete/perform neurological assessments for several unwitnessed falls per standards of practice, and the Director of Nursing's expectation.

This citation pertains to Intake MI 633. Based on observation, interview, and record review, the facility failed to ensure/maintain the safety of 3 Residents (#400, #401, #402), out of 3 residents reviewed for safety/accidents; resulting in Resident #400 being struck by an motor vehicle in facility parking lot and sustaining discomfort with the potential for serious injuries; failure to prevent a fall and perform neurological assessment post-fall for Resident (#401 and failure to prevent Resident #402 from obtaining a disposable razor and causing self-harm/mutilation and hospitalization . Findings include: Resident #402: According to admission face sheet, Resident #402 was an [AGE] year old male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], documented Resident #401's cognitive assessment at a 15 indicating no cognition impairment, or requiring assistance from staff for Activities of Daily Living (ADL) care. Review of an Incident/Accident report dated [DATE], documented under findings Resident (#402) was sitting in his w/c (wheel chair) naked in his room with blood on his penis, floor, and on his hands. The Incident report was undated at the top of the report, and documented the time as 10:00 AM. Under cognitive status was checked as normal. Under the section of 'Equipment Used' was left blank. Under the section 'Resident Outcome' listed as checked 'bleeding/laceration and self-inflicted injury.' Under the heading of 'hospitalization ' was checked as 'yes' dated [DATE], at 10:30 AM. The report was documented as an unwitnessed incident. The Incident report was signed by Licensed Practical Nurse P. Review of clinical record and Comprehensive Level II evaluation, dated [DATE], documented under Diagnostic and Statistical Manual for Mental Disorders (DSM) Diagnoses: [REDACTED]. Under 'History and Presenting Problems' documented that in 1977, Resident #402 was admitted to a psychiatric hospital. In 1978, readmitted to psychiatric hospital for attempting to burn two residents and home owner of a group facility with lighter fluid, and diagnosed with [REDACTED].#402 readmitted to a psychiatric hospital from 1981 until 1988. In (MONTH) of 1989, admitted to hospital with foreign body insertion of an open safety pin into his urethra (tube that drains urine from the bladder). In (MONTH) of 1989, admitted to the hospital with [REDACTED]. In 1991, readmitted to the hospital with [REDACTED]. Resident #402 was readmitted to a psychiatric hospital from [DATE], through [DATE]. Resident #402 was admitted to current facility on [DATE], and receiving psych services. In (MONTH) of (YEAR), while residing in the facility, Resident #402 attempted to remove his/her penis with a plastic knife, with a documented discussion regarding 'being a woman', thought to be delusional and evidence of further [MEDICAL CONDITION]. According to the report, Resident #402 begun to inquire about transitioning to a woman. Under 'Presenting Problems' documented In (MONTH) of 1977, a pencil was deeply inserted into the urethra and required surgical repair of bladder. There was documentation of suicide attempt at age 17, and attacking his/her mother and sister, asking neighbor kids to pull his/her teeth out, scratching his/her face until it bled. Under the heading 'Behavior' listed the comments as 1: 'delusional thinking', under 'frequency' documented as 'constant' and under 'Intensity' documented as 'moderate to severe.' 2: Under heading 'Behavior' documented 'Requesting to have surgery to transition to female' and under 'Frequency' as 'episodic.' 3: Under 'Impaired judgement and Insight' documented under the heading of 'Frequency' as 'constant/chronic'. Under 'intensity' documented 'severe.' 'Affective Development' documented Resident #402 Has remarkable vocabulary, thought it is often used to express his/her delusional thinking. The report also documents Resident #402 was admitted to the hospital from [DATE] through [DATE], for Self-injurious behaviors with a butter knife, and an attempt again on [DATE], to cut himself again using a plastic knife. Under 'Clinical Symptoms' by history as Decreased sleep,weight gain, delusions, attempts at self-harm involving inserting objects into his urethra, auditory hallucinations, and severe [MEDICAL CONDITION] requiring many years of hospitalization . An interview was conducted on [DATE], at 1:27 PM, with Social Worker Q related to Resident #402 obtaining a disposable razor and cutting his penis. SW Q was asked to provide this Surveyor behavioral monitoring related to self-injury attempts and interventions in preventing self-harm for Resident #402. SW Q indicated she was monitoring him, but did not document anything, and that it would be the nurse or nursing assistants who were supposed to be documenting any behavior's. SW Q was unable to provide any behavioral monitoring being done by any staff in the facility for Resident #402. SW Q was asked if Resident #402 was supposed to have a razor, and indicated No, someone had to have left one in his room, or given him one. SW Q was asked what interventions were in place to keep Resident #402 safe. SW Q said, Resident #402 was not supposed to have any sharps objects (pins, pencils, silverware, in his room and could only have a spoon on his meal tray after the last incident. SW Q was asked about the last incident and indicated Resident #402 attempted to cut his penis off with a butter knife on [DATE]. SW Q indicated Psych Services were managing Resident #402. SW Q provided an Incident/Accident report dated [DATE]. An interview was conducted on [DATE] at 3:00 PM, with Licensed Practical Nurse P who was caring for Resident #402 on [DATE]. LPN P indicated that Resident #402 must have had a razor in his drawer, and was found naked in his room by staff with a razor and cut his penis. I knew he had a psych history related to wanting to be a woman, and having painted nails, etc, but I did not know about the self-harm until he was sent to the hospital this time. I was told at that time he had cut himself before, but it was after the incident this time. I only heard that he tried to cut himself a few months ago after this incident. Review of Incident/Accident report, dated [DATE], at 10:00 AM, documented 'self-inflicted injury' due to penis cut with knife, causing bleeding and laceration. Review of the I/A 'Follow Up' documented Resident #402 attempted to cut his penis off with a butter knife. He was able to make a 2-centimeter L shaped laceration on the right inner aspect of penile meatus. Under 'New Interventions' documented All silverware is not to be placed on his food tray. He is not to be alone in his room during the day. He is to be in the dinning room and under observation at all times. An interview was conducted on [DATE] at 9:58 AM, with Certified Nursing Assistant U who had been caring for Resident #402 on [DATE]. CNA U indicated she had performed Activities of Daily Living Care to include shaving Resident #402 and placed him in the day room when finished. CNA U was asked if she left a razor in his room and indicated at first, she could not remember if she disposed of the razor when finished, but verbalized it was a one time use razor and should be disposed in the sharp's container in the bathroom. CNA U verbalized that a fire extinguisher had been knocked off the wall and was spraying white substances all over and staff was instructed by upper management to place all residents in their room and close the doors. CNA U verbalized she placed Resident #402 in his room and closed the door. CNA U was asked if anyone stayed with him and indicated No. She said she went to check on other residents and when she returned to check on Resident #402, she saw blood on his hands, penis, and in his drawer. CNA U said she got the nurse. CNA U was asked if she knew Resident #402 was not supposed to be left alone or have any sharps in his room. CNA U said, After the fact, I found out. No one told me about this before it happened. The nurse did not tell me in report, nor did the other staff, until after he hurt himself and went to the hospital. I knew he only had a spoon on his meal trays, but I did not know why. CNA U indicated she was not sure how Resident #402 obtained a razor. An interview was conducted on [DATE], at 11:40 AM, with Assistant Director of Nursing D about where razors are kept. ADON D verbalized they are stored in central supply room behind a lock door, and in the shower room behind a locked door, and in the clean utility room. ADON D indicated that residents can't get to them. Staff bring them out as needed. An interview was conducted on [DATE], with Minimum Data Set Nurse L about who updates interventions on behavioral care plans and she indicated that the Social Worker would be the one to update the behavioral care plan with interventions and changes. MDS L was asked about the extensive psych history for Resident #402 and said, I am not familiar with his psych history or with sharp objects or any interventions related to not having access to sharps, razors, or anything else about self-injuries. An observation made on [DATE] at 12:00 PM, in Resident #402's room, while he was at the hospital. In the room was observed to have one loose stick pin laying on the over bed table, next to the bed. On a bulletin board located on a wall at the end of the bed were more than 20 stick pins in the bulletin board with pinned mail items, and various other letters, mail and papers pinned to documents on the bulletin board. Director of Nursing B was made aware of the observation about sharp objects located in Resident #402's room and indicated after this past incident, those items should not be in there, and should never have been placed in there. We will get them out right away. DON B was asked about the long psych history for Resident #402 and indicated she had no knowledge of his history of self harm. No one had shared that information with her. Review of Resident #402's facility paper care plans documented a Behavior Care Plan, dated as initiated [DATE], with a revision date [DATE], and [DATE], and indicated as 'Focus' documenting Exhibition of Behavioral Symptoms as evidenced by: Socially inappropriate, disruptive, resists care, disorganized thinking and Delusions, hallucinations, self-injurious behaviors, HX (history) of inserting a pencil deep into his urethra 1977. Under interventions documented: Modify environment, situations, and treatment to minimize external stressors. Not to have knives on my tray on the Nutrition care plan. Under Hygiene staff is to shave me. There were no documented interventions on the Care Plans to reflect No Sharps ( razors, stick pins, safety pins, paper clips, pencils, or any other objects) documented that could potentially cause self- harm or monitoring and removal of, listed as interventions on any facility care plans. The facility failed to maintain safety and provide supervision to prevent Resident #402 from obtaining a razor and harming himself, with several documented attempts at self-harm and a recent self-inflicted injury months prior to this recent incident. Resident #401: According to admission face sheet, Resident #401 was an [AGE] year-old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to Minimum Data Set ((MDS) dated [DATE], documented Resident #401 cognitive assessment at a 3 indicating severe cognition impairment, and required assistance from staff for Activities of Daily Living (ADL) care to include supervision with ambulation and one person assist. Review of (Name) County Probate Court Guardianship Division document dated [DATE], documented To whom it may concern (Resident #401) was admitted to hospital [DATE], with [DIAGNOSES REDACTED]. Warrants a guardian, lacks the capacity to provide informed consent. Does not have sufficient mind to reasonably understand her condition. Is not capable of understanding the nature and effect of treatment choices. Is unaware of the consequences associated with these choices. Is unable to make an informed choice that is voluntary. Review of Incident/Accident report dated [DATE], dated 2:30 PM, documented Resident (#401) stated she fell while talking to roommate. Under 'outcome' documented Pain, Bruise/Hematoma and a picture indicating bruising to the right mid back, stretching around slightly to front of the abdomen, and right biceps. Under witnessed, the box was checked as 'yes' and listed 'room mate' as a witness. Signed by Licensed Practical Nurse O. An interview was conducted on [DATE] at 12:30 PM, and again on [DATE], at 11:59 PM, with Resident #401's room mate, who was alert and oriented and able to verbalize what had happened on [DATE]. Resident #401's room mate indicated she was having a conversation with Resident #401, who was trying to reach her tray and slipped and fell on the floor hitting her head on the floor and her back on the overbed table. Roommate indicated there was actually 2 falls that day [DATE], for Resident #401 and verbalized Resident #401 hit her head both times. She hit her head hard. Roommate indicated the second fall occurred while Resident #401 was attempting to ambulate to the bathroom. I called the nurse in and told her she fell twice, but she did not ask me any questions. The next day my roommate passed away and they all came into work on her. They couldn't revive her. On [DATE], roommate to Resident #401 was interviewed again and said that Resident #401 fell two times on the same day. One while reaching for her tray and the other while attempting to go to the bathroom. Roommate was asked if anyone interviewed her about the fall and said No one spoke to me until they were in working on her, and asked me what happened. I told them she hit her head, and that she had two falls. Resident #401 indicated the day after the two falls Resident #401 appeared to be her normal self, but more tired, and complained of hurting her back and side. An interview was conducted on [DATE] at 12:50 PM, with LPN O related to the falls for Resident #401. LPN O was asked if she completed Neurological Assessment post-fall for Resident #401. LPN O indicated she did not, due to roommate witnessing the fall and Resident #401 saying she did not hit her head. LPN O was asked if Resident #401 was alert and oriented, and said I guess so. LPN O was informed that the most current cognition assessment indicated that Resident #401 had severe cognitive impairment, documented a cognition assessment at a '3' dated [DATE]. LPN O indicated she was not aware. LPN O also indicated Resident #401 was unsteady on her feet at times and was not sure if she was supposed to be up ambulating without staff assistance. LPN O was asked if Resident #401 had a second fall on [DATE], and indicated she was not positive if there was a second fall. LPN O was asked 'Why' and said, I did not find out until a day later when I came to work, and heard Resident #401 had passed away. I was talking to her roommate about what had happened. Roommate told me Resident #401 had a second fall. I did not think she was accurate about the second fall. I thought she must have been confused. LPN O was asked if she told her Director of Nursing or anyone else about the possibility of a second fall. LPN O said, No, I did not really think it happened, and could not be positive it happened, so I never told anyone. LPN O was asked why she did not initiate 'Neurological Assessment' with the first fall, and said she took Roommate's word about not hitting her head. LPN O was asked how could she be positive on one day the Roommate was accurate, but not positive the very next day about the second fall. LPN O said, she mostly went by what Resident #401 told her. LPN O was reminded that Resident #401 had 'impaired cognition' and then said, I guess I should have done Neuro Checks and told someone there could have been a second fall. I did not think it was important because she had passed by the time I came to work. LPN O indicated Resident #401 was complaining of pain and she had observed the 2 large purple areas to right mid back and right bicep when she was passing her medications later on her shift on [DATE]. LPN O was asked what should be done for an unwitnessed fall, or if potential for hitting their heads. I should initiate Neuro Checks. Review of Head to Toe Skin Check dated [DATE], documented 'New Bruise' Right Illiac Crest (Rear) Bruising 3.5(L) Length in Centimeters, 11 Cm as width. Right Gluteal Fold as 0.7 Cm in Length, and 2 Cm in width. Other (right side) as 0.5 Cm Length and 2.5 Cm in width. Report signed electronically by LPN O. An interview was conducted on [DATE] at 9:10 AM, with Vice President of Ambulance services that had responded on scene [DATE], at 13:29 (1:29 PM), and provided a report of what was documented on [DATE]. Review of report documented Dispatched to the scene. Pt. (patient) in full arrest. Pt. placed on cardiac monitor showing Asystole (no heart rhythm), IV access was attempted with out success. IO (intraosseous) established in left tibia without incident. [MEDICATION NAME] 1 MG (milligram) 1: was administer. No carotid pulse. LUCAS Device (mechanical chest compression device) was place on resident to continue chest compressions. No Carotid Pulse Palpated. CPR continued. Vocal cords visualized during intubation. V-Tach (Ventricular Tach[DIAGNOSES REDACTED], which is abnormal heart rhythm) noted on monitor. Pt. had a weak Carotid pulse. Pt. was defibrillated at 150 Joules. V-Fib (Ventricular Fibrillation, an abnormal heart rhythm) was noted on the monitor, 300 Milligrams of [MEDICATION NAME] (cardiac drug) was administered. Asystole noted on monitor. [MEDICATION NAME] 1: MG administered. Pulse check revealed asystole and no palpable pulse. Hospital contacted for a TOD (Time of death) documented at 13:54 PM, given by a Physician. County notified Medical Examiner needed on scene. Crew waited for MEI and report was given, and crew cleared scene. An interview was conducted with Director of Nursing B on [DATE] at 1:13 PM, related to #401 falling. DON B was asked if there were 2 falls and said, I am only aware of one. DON B was asked what happened and she indicated that on [DATE], she was attempting to go and speak to Resident #401 a little before 1:00 PM, when she heard All available nurses come to room [ROOM NUMBER]. When I entered the room, Cardio [MEDICAL CONDITION] Resuscitation (CPR) was being performed by my Assistant Director of Nursing and several other nurses. The crash cart was in the room, someone had activated 911. Staff continued performing CPR until Emergency Medical Technicians arrived, two of them, then a short time later 2 Paramedics (The County) and a sheriff arrived. DON B indicated that a IV line was established, External Defibrillator device was used, and Resident #401 had been intubated by the Medical Team, who had taken over the Code. CPR went on for almost 30 minutes before a Hospital Doctor had been contacted with information by the EMT's/Paramedics and called the time of death. DON B was asked if she thought Neurological (neuro) checks should have been initiated for the fall on [DATE]. DON B indicated in light of the injuries, and unwitnessed by staff, we don't really know what happened and Neuro checks should have been initiated. DON B was asked if she knew the cause of Resident #401's death, and indicated she was informed later from cardiac event/natural causes, not associated with the fall. Contact was made with the Medical Examiners office on [DATE] at 2:00 PM, for cause of death for Resident #401. Surveyor spoke with Autopsy Assistant and was informed the cause of death was listed as Hypertensive/Athersclerotic [MEDICAL CONDITION]/Cardiovascular Disease, and Significant change in Diabetes. Review of facility Fall Management Policy dated July, (YEAR), documented The facility assists each resident in attaining his/her highest practicable level of function by providing the resident adequate supervision, assistive devices, and or functional programs as appropriate, to minimize the risk for falls. The IDT evaluates each residents fall risks. A Care Plan is developed and implemented based on this evaluation, with ongoing review. Under the heading 'Resident with Potential Head Injury' documented In the event a Resident has a fall and it has been determined they hit their head, it is obvious they hit their head, or it cannot be determined they hit their head, (fall unwitnessed or pt. cannot verbalize they hit their head) the nurse initiates the following actions: All items under Fall event, and Neurological checks are completed and documented per instructions. Review of Resident #401's Fall Care Plan documented I am at risk for falls and under interventions documented Make sure my call light in reach, encourage me to use it for assistance as needed. I need prompt response to all requests for assistance. (dated as initiated [DATE], 3 days after Resident #401 expired.) Make sure I have safe environment that has even floors, free from spills, and clutter, a working and reachable call light, and my personal items within reach. Anticipate my needs. Dated as initiated [DATE]. This citation pertains to intake MI 633. Resident #400: Resident #400's Face sheet, care plan, Minimum (MDS) data set [DATE], revealed resident was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #400's Nurse aide Kardex, dated [DATE], revealed, The resident requires SUPERVISION while smoking. Review of Resident #400's Incident Report, dated [DATE], revealed Resident states, as she was crossing the parking lot in the cross walk in her wheel chair, a white SUV backed up from a parking space and bumped her arm and now she has (L) (left) shoulder pain. Description of incident: (Resident) was in the crosswalk of the parking lot and a white SUV was witnessed to back in the (resident) wheel chair, bumping her left arm (shoulder area) resident states arm pain is 8 out of 10 following incident. On [DATE] at 1:30 PM, a review of the facility video dated [DATE] at 18:42:24 with facility staff that included Administrator (NHA), Maintenance Director K, and Scheduler I revealed, limited visibility of the front entrance of the building. The edge of the canopy and a part of the first handicap parking space to the west of the building can be visualized. A white van was observed sitting in front of the facility in the handicap space, was observed backing out of the handicap space and directly into the cross walk leading to the gazebo and then leaving the parking lot. At 18:43:15 an African American female identified by Scheduler I as CNA G was observed assisting Resident #400 sitting in a wheel chair up the front walk under the canopy of the facility and into the facility. CNA G turned around and was observed gesturing/pointing toward the location of where the white van had been sitting in the parking lot. Following review of the video of the incident and during an interview NHA stated, he had not observed the video until surveyor requested to review the video for the investigation. He stated had looked at Resident #400's wheel chair and there were no marks on the chair, and the resident was sent to the ER with no findings, resident had a history of [REDACTED].#400 did not request to contact the police so, police were not contacted. Staff were supervising the smokers. On [DATE] at 1:55 PM, during an interview, CNA G reported on [DATE] for the last smoking break around 6:,[DATE]:45 PM, Resident #400 was on her way back in to the facility was assisted toward the building then she was left to wheel herself part way, CNA G had turned around to assist another resident. CNA G stated Resident #403 stated, 'that white van just hit that resident (Resident #400).' CNA G reported she had then wheeled Resident #400 the rest of the way into the facility. CNA G reported, after everyone was in the facility, she had notified LPN L of the incident . CNA G reported no one had discussed the incident with her until surveyor inquired of the incident. On [DATE] at 3:51 PM, during an interview, CNA H reported on [DATE] she was on the third floor in the dining room at about 7:00 PM. Residents were observed returning from their smoking break. Resident #400 wheeled across the cross walk coming in from the gazebo, was struck by a white van, her left arm near shoulder flew up and wheel chair starting sliding/moving backwards several feet. CNA G was observed to have assisted Resident #400 into the facility. CNA H reported Family Member T was observed putting another resident into the white van and identified and driving the vehicle. CNA reportedly had immediately informed LPN L of the incident. CNA H reportedly had written a statement but no one had discussed the incident with her until surveyor inquired of the incident. On [DATE] and on [DATE] during observations of the facility parking lot from the conference room, it was observed on multiple occasions that cars pulling in to the facility were not stopping at the cross walk with residents in the cross walk leading to the gazebo, resulting in a potential resident /vehicle accidents and potential resident injury. Vehicles were observed sitting in the handicap parking spaces and backing out into the cross walk when residents were crossing the cross walk, potentially causing an resident/vehicle accident and potential injury. Ambulances were observed sitting near the facility blocking the view as residents were unable to see around the vehicles as they were crossing the cross walk leading to the gazebo resulting in a potential vehicle accident and potential resident injury. On [DATE] at 2:30 PM, during an interview, Administrator reported that he had identified a concern with the parking lot as residents go across the cross walk leading to the gazebo. Cars are reported to not not slow down and stop for residents as they are crossing the cross walk, and the cars pulling out of the handicap parking spaces, back across the cross walk leading to the gazebo directly into residents on the cross walk. NHA reported that several parking spaces (handicap) were discussed to be removed or relocated to prevent further accidents. Stop signs were discussed to be placed in several areas in the parking lot, and stop (in big letters) signs were discussed to be placed on the pavement to slow cars down. NHA reported Ambulance space on the east end of the facility was discussed to be removed also as residents crossing are also unable to see around the ambulance making it difficult for residents to go across the cross walk to the gazebo without getting into traffic. During the discussion NHA reported the area near the entrance was monitored by a camera for safety, but the parking lot cross walk and gazebo was not monitored by a camera for safety.

Based on observation, interview and record review the facility failed to 1) prevent a fall with injury, 2) Complete a post-fall nursing assessment, 3) implement the facility fall policy, 4) notify Physician #1 of a fall in a timely manner and 5) follow the Fall Prevention care plan for 1 resident (#603) of 3 residents reviewed for falls, resulting in a [MEDICAL CONDITION] femur, pain with the potential for decreased mobility and repeated falls. Findings include: According to Resident #603's face sheet, physician orders [REDACTED].#603 was a [AGE] year-old female admitted to the facility on [DATE], confused and not able to make her own healthcare decisions, poor safety awareness with an extensive history of falls prior to admission and required total assistance with her ADL's (Activities of Daily Living). The resident's [DIAGNOSES REDACTED]. Resident #603 was transferred from the facility to the hospital on [DATE], due to a fall with injury ([MEDICAL CONDITION] femur) and readmitted on [DATE]. Review of the BIMS (Brief Interview for Mental Status) dated 6/25/18, revealed Resident #603 was moderately impaired cognitively. Review of the Incident/Accident Report dated 6/24/18, revealed on 6/24/18 at 9:30 p.m., Resident #603 was observed on the floor lying on right side by CNA (Nursing Assistant). On 6/24/18, Resident #603 had an unwitnessed fall in her room from her bed to the floor. Attending Physician was notified of the fall on 6/25/18 at 5:15 a.m. (a total of 8 hours and 15 minutes after the resident had fallen). Review of the Incident/Accident Report (dated 6/24/18), revealed no documentation under sections, predisposing diseases, (diseases, medical conditions that would increase the risk of falling), environmental factors, (wet floor and room lighting) and footwear/assistive devices, (bed height, bedside table location and call light placement). Recommendations documented on the Incident/Accident Report (dated 6/24/18) were to keep call light within reach, and resident re-educate about call light use for help and safety. On 7/25/18 at 3:00 p.m., during an interview, CNA J said when she found Resident #603 on the floor in her room (on 6/24/18 at 9:30 p.m.), her head was on the floor against the dresser. Review of Resident #603's x-ray report of the right femur dated 6/25/18 at 1:54 PM revealed Conclusion : There is a possible non-displaced [MEDICAL CONDITION] right femur. Correlate with site of pain. Consider follow-up radiograph or CT . Review of Resident #603's CT of the right hip due to pain, dated 6/25/18 at 23:13 (11:13 PM) revealed, Nondisplaced intertrochanteric fracture right proximal femur. On 7/25/18 at 3:00 p.m., during an interview, CNA J revealed on 6/24/18 at approximately 7:30 p.m., she had changed Resident #603's brief. She said she entered the residents room (on 6/24/18) at 9:30 p.m. and found her yelling on the floor on her left side lying partly on her back and her head was on the floor against her bedside dresser. CNA J said she had informed Nurse, RN X that the resident was on the floor and assisted with transferring her back to bed where she was found to have a wet brief. Review of the Nurse progress notes dated 6/23/18 through 6/25/18, revealed no documentation of an assessment of Resident #603 related to the fall. On 7/24/18 at 3:28 p.m., during an interview, Nurse Consultant RN P stated, Documentation for Resident #603's fall was under a behavior note, because she has a history of sliding out of the bed. Review of Resident #603's Behavior note dated 6/25/18 at 5:10 AM, stated Resident crying states has pain in that right side (after her fall), 2 views of right hip ordered (2 X-rays of the resident's right hip ordered by physician). Review of Resident #603's Electronic Medical Record (EMAR) revealed there were no neurological assessments completed on 6/24/18 (the day she fell ). Review of Resident #603's EMAR revealed a Pain assessment was initiated on 6/25/18 (a day after her fall on 6/24/18), however it was blank. Review of Resident #603's Fall Care plan dated 2/12/16, revised on 7/24/18, stated FALLS: (Resident #603) is at risk for falls related to mobility limits, cognitive limits, poor safety awareness, [MEDICAL CONDITION] and hx (history) of fall, with an intervention to keep bed in lowest position and keep call light within reach and keep frequently used items within reach to unaffected side (right). On 7/24/18 at 11:30 a.m., during an observation, Resident #603 was in her bed which was observed to be at a waist level. CNA AA stated, It (the residents bed) can't be lowered much, she has a specialty mattress (therapeutic mattress) with an attached box on the bottom of it. During the interview done on 7/24/18 at 11:40 a.m., this surveyor observed Nurse D LPN lower the residents specialty mattress within 6 inches of the floor without difficulty. During this observation (done on 7/24/18), the residents soft touch call light was observed sitting on the right side of her pillow; the resident had a contracture of the right hand and elbow, she would not have been able to reach her call light. On 7/25/18 at 8:35 am, during an observation, Resident #603 was observed weighed and the bed was noted at waist level at the completion of the task. Restorative CNA M stated, the bed will go until it stops when lowering the bed to the floor and stated it is in the lowest position. Restorative CNA M then lowered the resident's bed approximately another 4 inches so the bed was within 6 inches from the floor. Resident #602's bed was noted to have stopped lowering at that time and the wheels of the bed were observed to have lifted at that time. On 7/25/18 at 8:45 a.m., during an interview, Nurse RN DD said she instructed staff that Resident #603's bed was to be in low position and stated, the wheels (bed wheels) are to be lifted when in appropriate position. Nurse RN DD said she had provided training for staff on the unit Resident #603 was on regarding the appropriate position her bed should be in for safety. On 7/24/18 at 1:55 p.m., during an interview, Assistant Director of Nursing (ADON) M said the residents incident report (dated 6/24/18), should have been thoroughly and accurately completed, a progress note including a complete assessment regarding the resident's fall should have been documented (in the nurse's notes dated 6/24/18) and stated, there are a lot of unanswered assessment questions and information missing, such as the x-ray results are not in the progress notes. The ADON M stated re-education on the use of the call light as a post-fall intervention for this resident that was probably not an appropriate recommendation, I would not have put that as a recommendation. On 7/24/18 at 3:28 p.m., during an interview, Nurse Consultant RN P said Resident #603's fall care plan did not address that the resident threw herself out of bed at times. Nurse Consultant P said according to the Incident report (dated 6/24/18), (Physician #1) was not notified of the fall (on 6/24/18 at 9:30 p.m.) until 6/25/18 at 5:10 a.m., and stated, there was a delay in the physician being notified. Nurse Consultant P further stated, the facility needs to do everything such as: access the resident, do everything that needs to be done per facility policy and every assessment that needs to be done, vitals, assessments and check for injury, head to toe assessment, skin assessment and check for bruising, neuro checks. Nurse Consultant P said the facility post-fall documentation for resident #603 was incomplete. On 7/24/18 at 1:55 p.m., during an interview, the Assistant Director of Nursing (ADON) RN M, reviewed Resident #603's Incident Report (dated 6/24/18), and verbalized to this surveyor the following identified concerns she had regarding the uncompleted facility Incident/Accident report dated 6/24/18 were as follows: -The transported to acute care section was not checked. -Neuro checks were not found. -A skin assessment was not found. -A pain assessment was not found. -Numerous boxes were found incomplete. -Due to the resident's fall being unwitnessed, it should have been reported to the State Agency. On 7/25/18 at 11:35 a.m., during an interview, the Director of Nursing/DON B stated, following a resident fall staff are to complete an Incident report, fall assessment (and) pain assessment. I thought we discussed this fall (on 6/24/18) during morning meeting. I do not put any preventive interventions in place to prevent a fall. What would be left if I put them all in place before a fall; I would not have anything left to choose after a fall. During the investigation (7/24/18), this surveyor was unable to interview Nurse RN X (the nurse assigned to Resident #603 when she fell on [DATE]), several phone attempts were made with no return calls. Review of the facility Fall Management, policy dated 11/2107, revealed in the event of a fall event staff should: -Assess the resident for injury -The Nurse will, enter the event information in the Risk Consult if necessary, complete an Incident Report if necessary, complete the SBAR (Situation, Background, Assessment, Recommendation) communication form and progress note, add the fall event to the 24-hour-report and initiate the Interdisciplinary Post-Fall Review. -The nurse communicates resident falls to the attending physician and the resident's representative and document the notification on the SBAR Communication Form, Progress notes and Interdisciplinary Post-Fall review. -For residents with potential head injuries, all items listed under Fall Event on the Incident Report are to be completed; neurological checks are completed and documented. Review of the facility fall policy Fall Management dated (MONTH) (YEAR), revealed When a resident is found on the floor, the facility is obligated to investigate to determine how the resident got there and put into place an intervention to minimize it from recurring.

This citation pertains to Intake MI 816. Based on observation, interview and record review the facility failed to provide prevent pressure ulcers in 1 (Resident #4) of a total sample of 7 residents reviewed for pressure ulcers, resulting in Resident #4 being who was admitted on [DATE] and found by facility staff on 3/9/18 to have acquired 10 pressure ulcers or skin areas of concern while residing at the facility. Findings: Record review of facility 'Skin Management' policy revision dated 7/2017, revealed residents receive care to aid in the prevention or worsening of wounds and/or pressure ulcers. Individuals at risk for skin compromise are identified, assessed and provided treatment to promote healing, prevent infection, and prevent new ulcers from developing. Ongoing monitoring and evaluation are provided for optimal resident outcomes. Unavoidable pressure ulcers mean the resident develop a pressure ulcer even though the facility had evaluated the residents clinical condition and pressure ulcer risk factors: defined and implemented interventions that are consistent with resident needs, goals and recognized standards of practice; monitored and evaluated the impact of the interventions and revised the approaches as appropriate. All of this must be clearly documented in the resident's medical record .Pressure ulcer staging classifications: Stage 2: Partial-thickness loss of skin with exposed dermis is present. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Stage 3: Full-thickness loss of skin, in which adipose tissue (fat) is visible in the wound and granulation tissue and epibole (rolled wound edges) are often present. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds The Stage 3 pressure ulcer presents clinically as a deep crater with or without undermining or adjacent tissue. Stage 4: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer are present. Epibole (rolled edges), undermining and/or tunneling beneath the surface of the ulcer often occur. Depth varies by anatomical location. Even id slough or eschar is visible in the wound, if there is fascia, muscle, tendon, ligament, cartilage and/or bone exposed or palpable, this ulcer is still classified as a Stage 4 pressure ulcer. Stage Deep Tissue Injury (DTI): intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood-filled blister is present. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This wound results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. Record review of the facility 'Abuse & Neglect Prohibition' policy revision dated 8/2017, revealed each resident has the right to be free from abuse, neglect, mistreatment, injuries of unknown origin Any observations of abuse, neglect or mistreatment must be immediately reported to the administrator. Injuries of unknown origin may occur as a result of abuse. Neglect means a failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Injuries of unknown origin may occur as a result of neglect. Resident #4: Record review of Resident #4's Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year-old female with moderately impaired cognitive abilities. Medical [DIAGNOSES REDACTED]. Under the MDS section 'M' there were no skin or unhealed pressure ulcers at stage 1 or higher noted. Observation on 3/14/18 at 11:25 AM with the floor nurse Registered Nurse (RN) F when the surveyor requested the nurse assistance to review Resident #4's wounds revealed: Resident #4 was laying on her right side in bed with the only pillow in the room under her head. RN F was asked to review all of Resident #4's wounds. (1.) Right heel and outer right great toe area with dark purple/black discoloration noted. (2.) Left outer ankle with dressing dated 3/10/18, dressing lifted to reveal a stage IV with white substance attached to dressing. (3.) Left heel with dark purple/black discoloration noted. There were no dressings or padding to heels. (4.) Left gluteal fold stage III area with dressing dated 3/12/18. (5.) Left mid shin open stage II dressing dated 3/11/18. (6.) Sacrum area stage III with no dressing in place. All dressings if in place, were noted to be dated for 4 days prior to the observation. There were no pillows or devices used to position or elevate resident injuries. On 3/14/18 at 11:45 AM with RN F, Resident #4's medical record was reviewed and revealed that there were no physician orders for treatments or dressing changes for Resident #4's pressure ulcers. Record review of Resident #4's Medication Administration Record [REDACTED]. Record review of resident #4's 'Re-Admission Braden Scale for Predicting Pressure Sore Risk' dated 2/14/18, revealed a risk score of 9: Very high risk (9 or below) Record review of resident #4's 'Potential Skin Issues' care plan revision date 1/31/18, revealed potential skin issues related to refusal of showering or bathing. Resident #4 was being treated for [REDACTED].?). Interventions included: notify physician of changes in wound or emerging wounds 10/25/2016. Offer showers or bed baths several times notify nurse of refusals 2/13/17. Shin checks weekly per facility protocol, document findings 10/25/2016. Wound care to left heel as ordered 10/19/2017. Record review of Resident #4's total care plans, revealed that there were no updated interventions related to the facility's finding of multiple pressure ulcer wounds, treatment for [REDACTED]. In an interview on 3/14/18 at 3:00 PM, Licensed Practical Nurse (LPN)/MDS Assessment Nurse D, stated that she had performed the Minimum Data Set (MDS) assessment on Resident #4 on 2/26/18 and that there were no pressure ulcers or skin conditions that she found. LPN/MDS nurse D was asked about the condition of resident #4's bilateral heels of her feet and LPN/MDS nurse D stated that there were no deep tissue injury's or eschar to the heels or ankles when she assessed the resident on 2/26/18. Record review of Resident #4's 'Skin-Head to Toe Skin Checks' form dated 3/9/18 revealed new abrasions and new other issues. Sacrum 1cm X 0.02cm stage III, Left Lateral ankle 2.1cm X 1.3cm stage IV, Left gluteal fold 3.2cm X 5.5cm not staged, Deep tissue injury (DTI) (site unspecified) 5.5cm X 3.7cm not staged, Right heel DTI 12cm X 12.5cm not staged, Left heel DTI 7cm X 10cm not staged, Left lateral foot 3cm X 4.1cm not staged, Left medial calf 2.3cm X 1cm stage III, Left knee scab #1 0.9cm X 0.9cm not staged, Left knee scab #2 3.3cm X 1.6cm not staged, Left knee scab #3 3.1cm X 1.5cm not staged. No narrative note documented on the form. Record review Resident #4's Wound Care services notes dated 3/9/18 revealed, Resident #4's wound were assessed and treatment recommendations: Calmoseptin + [MEDICATION NAME] cream 50/50 every shift and PRN (as needed), Dry dressing every two days and PRN to right heel, Foam dressing every three days and PRN left hip, [MEDICATION NAME] calcium every 2 days and PRN left ankle. Pressure relief/Offloading recommendations: Low air mattress or low air loss bed, frequently reposition, elevate bilateral extremities, float right heel. Record review of resident #4's physician orders in the medical record revealed there were no wound treatment or dressing change orders in place. Record review of Resident #4's Medication Administration Record [REDACTED]. During an observation on 3/15/18 at 7:25 AM Resident #4 was laying in bed. Resident #4 was laying on her left hip wound and left ankle stage IV wound with no pillows for positioning or elevation of heels. In an interview on 3/15/18 at 7:35 AM with the Unit Manager, Registered Nurse (RN) E stated that she was told on 3/8/18 by a nursing assistant that she need to see something and that they went to Resident #4's room. The RN E stated that the nursing assistant showed her the right inner thigh wound/sore of Resident #4. RN E stated that she assessed Resident #4 and found 7 wounds total. RN E stated that she assessed, measured, cleansed and put dressings on the wounds. On 3/15/18 at 7:35 AM, the state surveyor took the RN E to Resident #4's room to review wounds. RN E stated that when she saw the left lateral ankle wound it was already a stage IV necrotic and that she did not know how long it had been there because there was no documentation of wounds. RN E stated that she assessed the wounds and did dressings and measurements and wrote them on a piece of paper and gave it to another nurse and did not document any of it in Resident #4's medical record and neither did the other nurse. RN E stated that she did not call the physician nor did the other nurse. The facility submitted an 'Unavoidable Pressure Ulcer Assessment' form dated 3/14/18 at 12:34 PM faxed by a physician. The form did not address the lack of treatment orders, poor dressing wound care or positioning by the facility.

This citation pertains to Intake MI 816. Based on observation, interview and record review, the facility failed to provide quality of care services to provide physician orders [REDACTED].#28) of 7 total sampled residents reviewed for quality of care, resulting in Resident #28 being observed by state surveyor with 3 and 4-day old dressing changes in place to pressure ulcer wounds and the increase risk for infection and delayed healing. Findings: Record review of facility 'Physician Orders' policy revision date 11/2017, revealed physician orders [REDACTED]. Orders given by a physician or State permitted health care professional must be accepted by a licensed nurse and documented in the resident's medical record. Orders must be cosigned and dated by hand by the ordering physician or State permitted health care professional Written orders must be maintained in chronological order. Record review of facility 'Clean Dressing Change' policy revised date 12/2009, revealed the licensed nurse or therapist applies dressings using clean technique to promote wound healing and prevent cross-contamination among and between residents and caregivers. Record review of the facility 'Abuse & Neglect Prohibition' policy revision dated 8/2017, revealed each resident has the right to be free from abuse, neglect, mistreatment, injuries of unknown origin Any observations of abuse, neglect or mistreatment must be immediately reported to the administrator. Neglect means a failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Injuries of unknown origin may occur as a result of neglect. Resident #4: Record review of Resident #4's Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year-old female with moderately impaired cognitive abilities. Medical [DIAGNOSES REDACTED]. Under the MDS section 'M' there were no skin or unhealed pressure ulcers at stage 1 or higher noted. Observation on 3/14/18 at 11:25 AM with the floor nurse, Registered Nurse (RN) F, when the surveyor requested the nurse assistance to review Resident #4's wounds revealed: Resident #4 was laying on her right side in bed with the only pillow in the room under her head. RN F was asked to review all of Resident #4's wounds. (1.) Right heel and outer right great toe area with dark purple/black discoloration noted. (2.) Left outer ankle with dressing dated 3/10/18, dressing lifted to reveal a stage IV with white substance attached to dressing. (3.) Left heel with dark purple/black discoloration noted. There were no dressings in place or padding to heels. (4.) Left gluteal fold stage III pressure ulcer with dressing dated 3/12/18. (5.) Left mid shin open stage II, dressing dated 3/11/18. (6.) Sacrum area stage III with no dressing in place. All dressings, if in place, were noted to be dated for 3 or 4 days prior to the observation. There were no pillows or devices used to position or elevate resident injuries. Record review Resident #4's Wound Care services notes dated 3/9/18 revealed, Resident #4's wound were assessed and treatment recommendations: Calmoseptin + [MEDICATION NAME] cream 50/50 every shift and PRN (as needed), Dry dressing every two days and PRN to right heel, Foam dressing every three days and PRN left hip, [MEDICATION NAME] calcium every 2 days and PRN left ankle. Pressure relief/Offloading recommendations: Low air mattress or low air loss bed, frequently reposition, elevate bilateral extremities, float right heel. Record review of resident #4's physician orders [REDACTED]. Record review of Resident #4's Medication Administration Record [REDACTED]. During an observation on 3/15/18 at 7:25 AM Resident #4 was laying in bed. Resident #4 was laying on her left hip wound and left ankle stage IV wound with no pillows for positioning or elevation of heels. In an interview on 3/15/18 at 7:35 AM with the Unit Manager, Registered Nurse (RN) E stated that she was told on 3/8/18 by a nursing assistant that she need to see something and that they went to Resident #4's room. The RN E stated that the nursing assistant showed her the right inner thigh wound/sore of Resident #4. RN E stated that she assessed Resident #4 and found 7 wounds total. RN E stated that she assessed, measured, cleansed and put dressings on the wounds. On 3/15/18 at 7:35 AM, the state surveyor took the RN E to Resident #4's room to review wounds. RN E stated that when she saw the left lateral ankle wound it was already a stage IV necrotic and that she did not know how long it had been there because there was no documentation of wounds. RN E stated that she assessed the wounds and did dressings and measurements and wrote them on a piece of paper and gave it to another nurse and did not document any of it in Resident #4's medical record and neither did the other nurse. RN E stated that she did not call the physician nor did the other nurse. Record review of facility 'Wound Measurement' policy revised date 12/2005, revealed a licensed nurse or therapist measures wounds to assist with wound healing assessment and treatment. Wound measurements must be precise, consistent, and completely documented. In an interview on 3/14/18 at 4:50 PM with the Medical Director when asked how a resident could go from no skin issues to a stage II or stage IV pressure ulcer in in 24 hours the Medical Director acknowledged that was not likely.

This Citation pertains to Intake Number MI 450. Based on interview and record review, the facility failed to assess, monitor, provide, and document appropriate and timely diabetic care and interventions for 1 (#703) of 2 sampled resident's reviewed for assessment and monitoring, from a total sample of five, resulting in a Resident experiencing [DIAGNOSES REDACTED] (low blood sugar levels) and a change in condition requiring resuscitation efforts and the potential contribution to the Resident's death. Findings include: Record review of intake documentation on [DATE] at 5:00 AM entitled, State of Michigan Department of Community Health Certificate of Death, revealed Resident #703 was pronounced dead within the facility on [DATE] at 12:24 AM. Review of Flint Township Police Department report dated [DATE] at 10:52 AM indicated Police Officer Witness I and Police Officer Witness J were dispatched to the facility on [DATE] at 11:53 PM for a Resident in full arrest. Upon arrival, (EMS personnel) were providing medical attention for the (resident) later identified as (Resident #703) . After several minutes of medical attention (EMS personnel) advised that (resident #703) was deceased . (EMS personnel) advised that (resident #703) as actually [AGE] years old. The report indicated the facility nurse caring for Resident #703 at the time of their death was Nurse K. On [DATE] at 7:15 AM, facility incident and accident reports for Resident #703 were requested from the facility Administrator. On [DATE] at 7:45 AM, an interview was conducted with Nurse K. When queried regarding Resident #703, Nurse K stated, I don't remember (that Resident). With further inquiry, Nurse K stated, Oh, the CNA (nursing assistant) came to me and said '(the Resident) went out.' So I went into the room and took (Resident #703's) blood sugar. Nurse K proceeded to state, It should be in my documentation. I think (the Resident's) sugar was low. (Resident #703's) roommate had cookies and they (Resident #703's roommate) gave me cookies to give to (the Resident). When queried regarding the time that Resident #703's blood glucose was checked, Nurse K stated, I would have charted it. When queried further regarding providing the Resident their roommates cookies as treatment for [REDACTED]. When asked if the Resident's blood glucose level was rechecked following the cookies, Nurse K stated, I can't remember. When asked if Resident #703 had requested to be transferred to the hospital for treatment, Nurse K replied, They may have. With further inquiry regarding why the Resident was not transferred to the hospital upon request, Nurse K stated, I remember. They (Resident #703) didn't want to go earlier after [MEDICAL TREATMENT]. With additional inquiry, no further explanation was provided. Record review on [DATE] at 0930 revealed Resident #703 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required limited to extensive assistance to perform Activities of Daily Living (ADL's). Additional review revealed the Resident was a full code (wanted all life saving measures completed). The Resident died within the facility on [DATE]. On [DATE] at 10:25 AM, an interview was completed with Police Officer Witness I. When queried regarding Resident #703, Police Officer Witness I stated, We were called out the facility for a full code. I really remember this because (Resident #703) was so young and had asked to go to the hospital but the nurse (Nurse K) didn't send (the Resident) because they had not wanted to go earlier in the day. I interviewed (Nurse K), and they did not seem to know what was going on. Police Officer Witness I then stated, (Witness P), (Resident #703's roommate) was really upset about it all. They said the CNA (nursing assistant) had been trying to get the nurse to come. Police Officer Witness I indicated Witness P was alert and oriented and able to answer their questions at the time of the incident. Police Officer Witness I further stated, I also interviewed the nursing assistant that was there and they said they had to yell for (Nurse K). It should all be in the report. Additional review of Flint Township Police Department report dated [DATE] at 10:52 AM occurred on [DATE] at 10:35 AM. Review included the following documentation: (Nurse K) advised that they had last saw (Resident #703) prior to calling 911 at approximately 11:30 PM when they took (the Resident's) blood sugar. (Resident #703's) blood sugar was at 58, which is low . At this time (Nurse K) advised that (Resident #703) asked to go to the hospital, but (Nurse K) would not send (the Resident) to the hospital. I asked (Nurse K) why they wouldn't not allow (Resident #703) to go to the hospital when they asked. (Nurse K) advised me that on today's date, (Resident #703) had gone to [MEDICAL TREATMENT] and had complained of chest pain and had been offered to go to the hospital then at approximately 3:30 PM and (Resident #703) refused stating, 'just take me to my room.' This was the only reason (Nurse K) gave as to why they would not allow (Resident #703) to go to the hospital when they asked at approximately 11:30 PM. (Nurse K) stated that to fix the sugar problem, they gave (Resident #703) two cookies. (Nurse K) stated they returned to (Resident #703's) room at approximately 11:50 PM due to the fact that a CNA (Nursing Assistant L) had been in (Resident #703's) room . (Nursing Assistant L) had advised (Nurse K) several times that (Resident #703) was 'going in and out'. I asked (Nurse K) what 'going in and out' meant. (Nurse K) stated that (Resident #703) was breathing but was not responsive. At this time, (Nurse K) went to the room and gave (Resident #703) a [MEDICATION NAME] (medication to increase blood glucose levels) shot in an attempt to fix their sugar level; however it did not work and (Resident #703) stopped breathing. At this time, CPR was started on (Resident #703). The report further indicated an interview was completed with Nursing Assistant L. During the interview, Nursing L stated They went into change and clean up (Resident #703) after they had a bowel movement at an unknown time . (The Resident) was awake and asked for some water . and then (Resident #703) began acting funny . (Nursing Assistant L) informed (Nurse K) that they needed to come into the room . (Nursing Assistant L) indicated they had asked (Nurse K) to several times to come to the room to address (Resident #703's) condition. When (Nurse K) finally did come, they started CPR as (Resident #703) had stopped breathing and was unresponsive. The report further indicated Witness P told (Nursing Assistant L) that Resident #703 had wanted to go to the hospital earlier and (Nurse K) refused to send the Resident. The report also included an interview with Witness P. The report revealed, (Witness P) was visually upset and crying . (Witness P) stated (Resident #703) woke them up at approximately 10:00 PM to call for a nurse . and that (Resident #703) wanted to go to the hospital. (Witness P) advised that it took approximately one hour for the nurse to respond. At that point (Nurse K) arrived at the room and took (Resident #703's) blood sugar and stated it was at 58. (Witness P) stated (Nurse K) wanted to give (Resident #703) insulin; however (Witness P) was well aware of an incident that had occurred where (Resident #703) had received insulin when there sugar was low . (Witness P) reminded (Nurse K) of this and instead (Nurse K) asked (Witness P) if they could have two of (Witness P's) personal cookies to give to (Resident #703) . While (Nurse K) was in the room, (Witness P) advised (Nurse K) several times that (Resident #703) wanted to go to the hospital. (Nurse K) did not allow (Resident #703) to the hospital and did not call for an ambulance at this time and left the room. The report then indicated, Nursing Assistant L entered the room shortly after the incident to provide care to Resident #703. Witness P stated, they could hear (Nursing Assistant L) calling and yelling (Resident #703's) name and there was no answer. (Witness P stated at this time they heard gurgling coming from (Resident #703). (Witness P) stated that they had asked (Nursing Assistant L) to several times to get an RN (Registered Nurse) to which (Nursing Assistant L) had attempted to call for (Nurse K) several times that (Nurse K) did not come. When Nurse K) did come, they looked at (Resident #703) and then left the room. (Witness P) stated they assumed that (Nurse K) had went to call 911 and came back to do CPR. The report further indicated, (Witness P) stated it was at least an hour as they remembered looking at the clock at 10:00 PM when they hit the (call) button and did not remember seeing (Nurse K) come into the room until approximately 11:00 PM. Review of Resident #703's [MEDICAL TREATMENT] Communication Record dated [DATE] on [DATE] at 1:45 PM revealed documentation from the facility to the [MEDICAL TREATMENT] center indicating, Condition alert: Has not been eating. The [MEDICAL TREATMENT] communication form included documentation by [MEDICAL TREATMENT] Nurse O to the facility which indicated concerns were observed during treated and stated, (Resident #703) complain of chest pain at 3:30 PM . Gave O2 (oxygen) and repositioned . Recommendations/Follow-up: Leave with a temp (temperature) 99.8. Arrived 97.6. Offered the hospital- Refused- Please watch . Record review on [DATE] at 2:10 PM of documentation in Resident #703's medical record did not reveal documentation of follow up nursing assessment and monitoring. Additional documentation of Resident vital signs including temperature were not present in the record. Review of vital sign measurements, under Weights and Vitals in the medical record, revealed the most recent documentation of vital signs occurred on [DATE] at 4:46 PM. The following progress note documentation was present in the medical record for [DATE] and [DATE]. [DATE] at 11:40 PM, SBAR Communication Form and Progress Note: Resident Blood Sugar 58. resident responding,stating. I want to go to the hospital, cookie given. The SBAR form further indicated Resident #703's condition had gotten worse. [DATE] at 12:26 AM, Nursing Note authored by Nurse M: Writer in to assist nurse with assessment of Resident who has a BS of 58, 2 units of [MEDICATION NAME] was administered to Resident, and Resident is unresponsive at this time, no pulse, warm to touch, CPR was initiated, 911 en-route, CPR continuing, No pulse, Paramedic to take over CPR . [DATE] at 12:35 AM, Nursing Note authored by Nurse K: Resident blood sugar 58. answer questions, States 'I want to go to the hospital' insulin maintenance dose not given ,cookie given obtain from roommate, cna (nursing assistant) went in to clean resident from incontinent [DATE] at 1:48 AM, Care Plan Note authored by Staff N: Writer called regarding change of condition with resident. States resident noted to have a low blood sugar was initially responsive and was given a cookie to eat. Resident's blood sugar did not improve despite interventions and staff called to initiate CPR. EMS was notified and was on scene . Per HD ([MEDICAL TREATMENT]) group resident noted to have temp and chest pains at HD and refused paramedics to transfer to hospital and wanted to return home to facility . Review of Resident #703's documented blood glucose levels at this time revealed the following: [DATE] 6:24 PM: 123.0 mg/dL (milligrams per deciliter) [DATE] 7:37 PM and 7:41 PM: 253 mg/dL [DATE] 10:54 PM: 123 mg/dL [DATE] at 11:07 PM: 58 mg/dL On [DATE] at 2:05 PM, an interview was completed with Nurse E. When queried regarding Resident #703's blood glucose monitoring on [DATE] not being completed until 10:54 PM and 11:07 PM when it was ordered to be completed at 9:00 PM, Nurse E stated, I don't know. Resident #703's medical record was reviewed with Nurse E at this time. When queried regarding appropriate treatment for [REDACTED]. With further inquiry regarding why Resident #703 was not transferred to the hospital when they requested to be transferred, Nurse E stated, I don't know. It they asked to go to the hospital, they should have went to the hospital. The doctor should have been called at least and I don't see any documentation (that the physician was notified). When queried regarding blood glucose monitoring, Nurse E stated, The last documented (blood glucose) level is 58. There is nothing about it being rechecked. When asked the last time Resident #703 received insulin (medication to lower blood glucose levels), Nurse E reviewed the medical record and medication administration record (MAR), and stated, (The Resident) did not get their 9:00 PM insulin dose. Review of the MAR and facility provided Medication Administration Audit Report at this time revealed, Resident #703 received their 4:30 PM dose (6 units) of Insulin [MEDICATION NAME] ([MEDICATION NAME]) at 7:37 PM. The medication order indicated to administer subcutaneously (injection into subcutaneous tissue) before meals . When queried if the insulin injection was administered before Resident #703 ate, Nurse E was unable to provide an answer. Review of the MAR did not reveal documentation of [MEDICATION NAME] administration to Resident #703. On [DATE] at 2:50 PM, an interview was completed with Nursing Assistant L. When queried regarding Resident #703, Nursing Assistant L stated, When I went into change (Resident #703), they weren't really responding. The way (the Resident) was responding wasn't okay with me. With further inquiry, Nursing Assistant L replied, It was like (Resident #703) was weak and not really with it. Nursing Assistant L then stated, I called then nurse and I went into the hall and told the nurse. Then I called the nurse again. They didn't come so I went out (in the hall) and called the nurse again. When queried how many times they attempted to get the nurse to come into the Resident's room, Nursing Assistant L replied, Three times. Nursing Assistant L proceeded to state, I think (the nurse) was getting med's. They were in the hall. When they came in and saw (Resident #703), left and came back with other people. (Resident #703) was out then. When queried who the nurse was, Nursing Assistant L replied, (Nurse K). When asked what occurred after Nurse K returned with other staff, Nursing Assistant L stated, They (staff) started working on (Resident #703). I am not sure. I stayed out of the room, I am not a nurse. I know the ambulance came. On [DATE] at 3:00 PM, an interview was completed with the Director of Nursing (DON). When queried, the DON stated, We don't have any incident and accident reports for (Resident #703). When asked about events leading up Resident #703's death within the facility, the DON stated, I was not here at that time. I will have to review the record. When queried if an incident and accident report should be completed per facility policy for a death that occurs within the facility, the DON replied, It would depend on the situation. When asked if incident and accident reports are supposed to be completed for unexpected deaths that occur within the facility, the DON replied, Yes. When queried if they would consider Resident #703's death unusual or unexpected, the DON stated, I am not a doctor. I don't make that determination. When asked if they would anticipated an incident and accident report be completed, the DON replied, I was not here at that time, I cannot speak for the prior DON's expectations. Resident #703's clinical record was reviewed with the DON at this time. When queried why Nurse K did not send the Resident to hospital per the Resident's request, the DON was unable to provide an explanation. When queried regarding Nurse K not responding immediately to Resident #703's change in condition and Nursing Assistant L's requests for assistance, the DON was unable to provide an explanation. Record review of facility policy entitled Diabetic Management (Revised [DATE]) revealed, Diabetic Management involves both preventative measures and treatment of [REDACTED]. Results outside of ordered parameters are communicated to the physician immediately. Anti-diabetic agents are administered per physician order. Residents are monitored for signs/symptoms of complications. The policy further revealed, [DIAGNOSES REDACTED]- Low Blood Sugar Levels . 1. If the Resident is unconscious or vital signs are absent, give [MEDICATION NAME] 1 mg (milligram) IM (intramuscular) and call 911; 2. Test the Resident's blood glucose with a glucose monitoring device; 3. If blood glucose is below 70 mg/dl and the Resident is presenting with signs/symptoms of [DIAGNOSES REDACTED] and can swallow, administer: four ounces of fruit juice, or Administer three (3) 5 gm (gram) oral glucose tablets . 4. Reassess blood glucose level in 15 minutes. The policy further revealed, Stay with the Resident to ensure all the food is eaten and the Resident does not fall back to sleep. Feed the Resident if he or she is disorientated or lethargic . Repeat blood glucose level ,[DATE] minutes after food is consumed to ensure maintenance of acceptable range . Documentation: For acute complications, the clinical record should include the following information: notification of physician and any new orders, Residents signs and symptoms, Results of blood testing, Interventions implemented, Resident's response to treatment . Record review of facility policy entitled Incident/Accident Reporting for Residents (Revised February 2017) revealed, All incidents, accidents, and unusual occurrences involving are Resident are investigated, documented, and reported . Adverse Event (Significant or Serious Incidents): An adverse event is an untoward, undesirable and usually unanticipated event that causes death or serous injury or the risk or thereof. Adverse events include, but are not limited to . Unusual or unexplained death.

Based on observation, interview and record review, the facility failed to ensure adequate monitoring and documentation of [MEDICAL CONDITION] medications for one (#702) of one Residents reviewed for [MEDICAL CONDITION] medications, of a total sample of five, resulting in lack of monitoring and documentation of [MEDICAL CONDITION] medications, lack of routine therapeutic laboratory monitoring of medication levels, and Resident side effects of excessive drowsiness, somnolence, lack of participation in daily activities, and the potential for increased adverse medication effects and decline in overall health status. Findings include: On 10/16/17 at 6:55 AM, Resident #702 was observed lying in bed in their room. The Resident was positioned on their back and their eyes were closed. The Resident was unshaven and their hair did not appear to be combed. Record review on 10/16/17 at 8:45 AM, revealed Resident #702 was most recently admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the Resident was severely cognitively impaired and required limited to total assistance to perform Activities of Daily Living (ADL's). On 10/16/17 at 9:15 AM, Resident #702 was observed in their room. The Resident was lying in bed with their eyes closed, positioned on their back. The Resident was unshaven and their hair was uncombed with a greasy appearance. On 10/16/17 at 11:30 AM, Resident #702 was observed lying in bed in their room. The Resident was positioned on their back with their eyes closed. The Resident was unshaven and their hair was uncombed with a greasy appearance. On 10/16/17 at 1:30 PM, an interview was completed with Nursing Assistant C. When queried regarding Resident #702, Nursing Assistant C stated, (The Resident) sleeps a lot now. Observation of Resident #702 occurred with Nursing Assistant C at this time. Resident #702 was in their room, lying in bed on their back with their eyes closed. Nursing Assistant C pulled down Resident #702's blanket. Under the blanket, Resident #702 was wearing only a disposable brief. The Resident also had an abdominal binder in a place. Nursing Assistant C proceeded to undo the Velcro abdominal binder to expose the Resident's gastrostomy tube. Nursing Assistant C then re-applied the Velcro abdominal binder. The Resident did not move or open their eyes at any time when Nursing Assistant C removed the blanket, removed and reapplied the abdominal binder. When queried regarding the Resident not responding or waking, Nursing Assistant C did not provide further explanation. On 10/16/17 at 1:40 PM, record review of Resident #702's medical record revealed the following Mental Healthcare Provider documentation authored by Physician Assistant D: -8/4/17: Current medications: [REDACTED]. Disposition: Duplicate therapy with unresolved psychotic sx (symptoms), begin GDR (Gradual Dose Reduction) of [MEDICATION NAME] d/t (due to) weight loss, will continue scheduled and PRN anxiolytics short term, continue Trazadone . No GDR of [MEDICATION NAME]. -9/20/17: Current medications: [REDACTED].HPI: (Resident #702) last seen in August, seen today for follow up of multiple medication changes, medication review, use of [MEDICATION NAME], GDR of [MEDICATION NAME]. Staff reports . some increased somnolence noted over past few weeks. Recent decrease in Trazadone dose well tolerated . (Resident #702) noted in bed. (Resident) is quiet, minimally interactive, somnolent . Disposition: Discontinue Trazadone due to acute somnolence. Consider GDR of [MEDICATION NAME] pending response to medications changes and mood stability. Long-standing history of mood instability, psychotic symptoms with social interactions, care noncompliance. Continue with [MEDICATION NAME]. Continue [MEDICATION NAME], Continue [MEDICATION NAME]. No GDR of these medications. Benefits of medications are greater than risks. Additional review of Progress Note documentation within Resident #702's medical record at this time revealed the following documentation: -8/30/17 at 11:34 AM, Care Plan Note authored by Physical Therapist F indicated, Therapist attempted to evaluate the Resident on 8/28/17 and 8/29/17. Resident is in deep sleep and unable to wake up. Resident to be reassessed once condition improves. -9/28/2017 at 7:10 AM, SBAR Summary authored by Nurse G indicated, What I think is going on with the Resident is: drowsy. Review of Physician order [REDACTED]. -8/25/17 at 5:50 PM, Physician order [REDACTED]. Has triggered the following drug protocol alerts/warning(s): Drug to Drug Interaction Severity: Moderate. Interaction: [MEDICATION NAME] HCl Tablet 50 mg may increase pharmacologic effects and plasma concentrations of [MEDICATION NAME] ([MEDICATION NAME]) Suspension 125 mg/5 mL. [MEDICATION NAME] Suspension 125 mg/5 mL may decrease plasma concentrations of [MEDICATION NAME] HCl Tablet 50 mg. -8/25/17 at 6:08 PM, Physician order [REDACTED]. Has triggered the following drug protocol alerts/warning(s): Drug to Drug Interaction. The system has identified a possible drug interaction with the following orders: [MEDICATION NAME] ([MEDICATION NAME]) Suspension 125 mg/5 mL .Severity: Moderate. Interaction: [MEDICATION NAME] Suspension 125 mg/5 mL and [MEDICATION NAME] Suspension 300 mg/5 mL are frequently used together. Plasma concentrations and clinical outcome may not be as anticipated when they are used concurrently. -8/25/17 at 6:12 PM, Physician order [REDACTED]. Has triggered the following drug protocol alerts/warning(s): Drug to Drug Interaction. The system has identified a possible drug interaction with the following orders: [MEDICATION NAME] Suspension 125 mg/5 mL .Severity: Moderate. Interaction: The pharmacologic effects of [MEDICATION NAME] Suspension 125 mg/5 mL may be increased by [MEDICATION NAME] Capsule Delayed Release 20 mg. -8/25/17 at 6:12 PM, Physician order [REDACTED].Has triggered the following drug protocol alerts/warning(s): Drug to Drug Interaction. The system has identified a possible drug interaction with the following orders: [MEDICATION NAME] Suspension 125 mg/5 mL Severity: Moderate. Interaction: Plasma concentrations and therapeutic effects of Quetiapine [MEDICATION NAME] Tablet 200 mg may be decreased by [MEDICATION NAME] Suspension 125 mg/5 mL. [MEDICATION NAME] Acid ([MEDICATION NAME]) Liquid . Severity: Moderate. Interaction: Co-administration of [MEDICATION NAME] Acid Liquid and Quetiapine [MEDICATION NAME] Tablet 200 mg may increase the risk for [DIAGNOSES REDACTED] and leukopenia (decreased white blood cells and ability to fight infection) compared to either agent alone. On 10/16/17 at 1:55 PM, an interview and record review of Resident #702's medical record was completed with Nurse E. A review of Resident #702's current psychoactive/[MEDICAL CONDITION] medications revealed the Resident was currently receiving the following the medications: [REDACTED] -[MEDICATION NAME] Tablet 3 mg at bedtime (Order Date: 8/25/17) (Supplement for sleep) -[MEDICATION NAME] 25 mg IM (Intermuscular) q 14 days(Order Date: 8/25/17) (Medication for [MEDICAL CONDITION] and [MEDICAL CONDITION]) -[MEDICATION NAME] 50 mg a day (Order Date: 8/25/17) (Medication to treat depression and anxiety disorders) -[MEDICATION NAME] 10 mg twice a day (Order Date: 8/25/17) (Medication often used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] disorders) -[MEDICATION NAME] 200 mg twice a day (Order Date: 8/25/17) (Medication for [MEDICAL CONDITIONS], and depression) -[MEDICATION NAME] 1 mg three times a day (Order Date: 8/25/17) (Benzodiazepines medication to treat anxiety) -[MEDICATION NAME] 125 mg/5 mL, give 6 ml three times a day (Order Date: 08/25/2017) (Medication to treat [MEDICAL CONDITION]) -[MEDICATION NAME] Acid Liquid ([MEDICATION NAME]), 15 ml three times a day (Order Date: 8/25/17) (Medication to treat [MEDICAL CONDITION]) -[MEDICATION NAME] 2 mg IM every 4 hours as needed (Order Date: 9/14/17) When queried regarding the discrepancies between the psychoactive medications Resident #702 had been taking since 8/25/17 and the Current Medications listed on documentation authored by Physician Assistant D on 9/20/17, Nurse E reviewed documentation in the medical record and stated, I don't know. They don't match up. When queried how the Resident's psychoactive medications are assessed, managed, and dose adjustments made if the Mental Health Provider, Physician Assistant D, is not aware of what medications Resident #702 is currently taking, Nurse E stated, I don't know how they can. When queried regarding the Resident not waking, opening their eyes, or moving with tactile and verbal stimulation and the amount of psychoactive medications they were taking, Nurse E replied, I know that is not normal for (Resident #702). When queried how often Resident #702 had gotten out of bed, Activity documentation for Resident #702 was reviewed. Review revealed Resident #702 had participated in Locomotion off Unit and Locomotion on Unit activities twice during the month of October, on 10/3/17 and 10/5/17. Documentation did not indicate what activity was completed by the Resident. When asked is a GDR of [MEDICATION NAME] was completed as recommenced on Physician Assistant D documentation dated 9/20/17, Nurse E reviewed Resident #702's medical record and stated, I don't see a GDR (for [MEDICATION NAME]). When queried regarding therapeutic laboratory level monitoring of medications, Nurse E reviewed the medical record and stated, Levels were done on 7/10/17. Record review of laboratory results at this time revealed a [MEDICATION NAME] level and a [MEDICATION NAME] acid were completed on 7/10/17. Additional review revealed handwritten documentation, signed by the Physician indicating to increase the dosage of both medications. When queried, Nurse E replied The levels haven't been drawn since then. When asked how often therapeutic blood levels should be completed per facility policy/procedure for Resident #702, Nurse E replied, I would think every month or two at least until it's stable (doses are not being adjusted). On 10/16/17 at 2:05 PM, an interview was completed with the Director of Nursing (DON) and Nurse E. When queried regarding psychoactive medication management for Resident #702, the Director of Nursing (DON) reviewed documentation in the Resident's medical record and stated, I will have to look into it. With further inquiry, the DON stated, They (Mental Health Care Physician Assistant) should know what medications Residents are taking to make recommendations. When queried regarding laboratory monitoring of therapeutic medication levels, the DON stated, Let me see if we can find anything. On 10/16/17 at 3:30 PM, an interview was completed with the DON. When queried regarding Resident #702, the DON stated, I spoke to (Mental Health Care Physician Assistant D) and they faxed over an addendum to their last note (dated 9/20/17). Review of provided addendum revealed the following documentation, Med error noted in note done 9-20. current med list [MEDICATION NAME] should be listed as [MEDICATION NAME] 25 mg IM (by (Physician Assistant D) on 2:20 PM, [DATE]). When queried regarding why the documentation addendum did not include all psychoactive medications that Resident #702 was taking, the DON was unable to provide an explanation. The DON then stated, We are going to get labs (therapeutic laboratory monitoring levels) done for (Resident #702). When queried facility policy/procedure regarding frequency of monitoring of therapeutic medication levels, the DON replied, That is up to the Doctor. On 10/16/17 at 3:35 PM, an interview was completed with Nurse E. When queried regarding Resident #702's medications and the provided medication addendum, Nurse E was unable to provide an explanation pertaining to why the addendum did not contain all the Resident's psychoactive medications. On 10/16/17 at 3:40 PM, an interview was completed with Mental Health Care Physician Assistant D. When queried Resident #702's medications listed on provider note dated 9/20/17, Physician Assistant D replied, I just did an addendum to that note today. With further inquiry, Physician Assistant D stated, They (facility) called me and I sent over the addendum. When asked why the addendum did not include all the psychoactive medications Resident #702 was receiving including scheduled doses of [MEDICATION NAME], and [MEDICATION NAME], Physician Assistant D replied, I personally don't prescribe [MEDICATION NAME]. I am just the consultant for the facility. When queried why as needed [MEDICATION NAME] was included on documented Current Medications list but the scheduled [MEDICATION NAME] dosage was not included and why the as needed [MEDICATION NAME] medication dosage was listed as every six hours when Resident #702 is receiving the medication every four hours, Physician Assistant D did not provide an explanation. When asked if they were making medication recommendations/ordering medications as a consultant for the facility, Physician Assistant D replied, Yes. When queried further, Physician Assistant D stated, Sometimes the attending Doctor will order meds if the nursing staff call them with a concern. When queried regarding recommendations for psychoactive medication management without being aware of all the mediations the Resident was receiving, Physician Assistant D stated, My med list is not always accurate. When I come in, the nurses let me know if there have been any changes (in medications) or an increase in behaviors. When queried regarding observations of Resident #702 not opening their eyes or moving with both verbal or tactile stimulation and if the Resident's level of lethargy could be related to psychoactive medications, Physician Assistant D stated, Yes. That should not be. I will contact the nursing staff. With further inquiry, Physician Assistant D stated, The nurses (at the facility) are able to contact me if there is a concern with a Resident. Record review on 10/16/17 at 5:00 PM of facility policy entitled [MEDICAL CONDITION] Management (July 2017) revealed, The facility will use [MEDICAL CONDITION] medication therapy only when clinically indicated to enhance the quality of life, while maximizing functional potential and well-being of the Resident . [MEDICAL CONDITION] medication is any medication that affects brain activities associated with mental processes and behavior. These medications include the following categories: anti-psychotic; anti-depressant; anti-anxiety; and sedative/hypnotic. The policy further revealed, [MEDICAL CONDITION] medications can also be considered chemical restraints . when dose reduction is never considered . Each Resident's medication regiment must be free from unnecessary medications. An unnecessary medication is any medication when used: In excessive dose; For excessive duration; Without adequate indications for its use; In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or Any combination of the above.

This Citation Pertains to Intake #: Based on observation, interview, and record review, the facility failed to provide necessary services, individualized care, and a homelike like environment for one ( #701) of three Residents reviewed and failed to ensure that a Resident Representative was in place for one ( #701) of one Residents reviewed, who were unable to make medical and financial decisions independently, from a total sample of three Residents, resulting in care being provided that did not meet individual resident needs and the resident not having a representative to act on their behalf. Findings include: Record review on 3/8/17 at 1:40 PM revealed that Resident #701 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the 14 Day MDS (Minimum Data Set) assessment dated [DATE] revealed that Resident #701 was cognitively impaired, required total assistance to complete Activities of Daily Living (ADL's), and experienced difficultly communicating with others. On 3/8/17 at 1:00 PM, personal protection equipment (PPE) for isolation (equipment utilized by healthcare providers to prevent the spread of illness or infection) was observed hanging on the door to resident #701's room that contained disposable gloves, an empty disposable gown container, and red and yellow colored bags. No sign was present on the door to indicate type of isolation precautions. On 3/8/17 at 1:30 PM, an interview was conducted with Nurse A. When queried regarding the isolation equipment hanging on Resident #701's door without a sign, Nurse A stated, (Resident #701) had [MEDICAL CONDITION] ([MEDICAL CONDITION], a contagious spore-forming bacterium) but the hospital said it was clear. I haven't had time to look into it yet. Nurse A further stated that Resident #701 requires 2 people for all care, takes off wound dressings, and has ended up on the floor because (Resident #701) is always moving around. On 3/8/17 at 2:05 PM, Resident #701's paper medical record was reviewed. No documentation of legal guardianship or Durable Power of Attorney documentation was located within the chart. Only one Skin Monitoring: Comprehensive Certified Nurse Assistant (CNA) Shower Review sheet was noted in the Residents record and the department's shower book. Unit Coordinator C was asked if additional sheets for Resident #701 were located elsewhere. Unit Coordinator C responded let me look. On 3/8/17 at 2:20 PM, observation of wound care for Resident #701 occurred with Nurse A and Nurse Assistant B. Upon entering the room, it was noted that the window blinds were closed and the lightening in the room was very dim. There was no sounds heard in the room. The Resident was observed lying in bed lying in bed on their back covered by a sheet. The walls in the room were bare, without any pictures, color, art, or decor. There was no television or radio within the room. The only items observed within Resident #701's room included the bed, a fall mat on the floor next to the bed, a container for soiled linen, a container for garbage, and a cork style board that had a clock on it. The clock indicated the time of 8:37. Nurse A and Nurse Assistant B proceeded to remove the sheet that was covering Resident #701. After removing the sheet, it was observed that Resident #701 was wearing a disposable adult diaper. No other clothing was observed within the room. The Resident appeared un-groomed. The Residents hair had a greasy appearance, a visible white colored substance was observed in the Residents facial hair, and the Residents fingernails were long and jagged with visible dark red/brown colored substance noted under their nails. During an interview with Nurse A on 3/8/17 at 2:45 PM, when queried regarding Resident #701's room. Nurse A stated, They took everything out so that (Resident #701) wouldn't hurt themselves if they got out of bed. When queried if the Resident is taken out of their room or gotten out of bed, Nurse A replied, no, we tried that once but (Resident #701) got out of the wheelchair, tried to walk, and fell . (Resident #701) would need one to one care and we don't have the staff for that. When queried if other interventions have been attempted, Nurse A replied, Not that I know of. When asked if Resident #701 has visitors that come to the facility, Nurse A stated, No. When queried if Resident #701 lays in bed all day with no stimulation or interaction, Nurse A stated, I never thought about it that way. (Resident #701) is not an easy patient. There is one nursing assistant that does really good with (the Resident) though. She is the best with him. An interview with conducted with the facility Administrator and Director of Nursing (DON) on 3/8/17 at 3:40 PM. When queried regarding Resident #701's room, the DON stated, We took everything out of the room so that (Resident #701) did not hurt themselves. (Resident #701) has no safety awareness and (Resident #701) gets out of bed and moves around on the floor. When queried regarding sensory deprivation within the room due to lack of light, noise, and human interaction, the DON stated, I can see what you're saying. The Administrator stated, I don't know why the shades are closed. On 3/8/17 at 4:10 PM, an interview was conducted with Activities Staff D. When queried regarding activities, interaction, and sensory stimulation for Resident #701, Staff D stated, We do individual activities. When queried regarding the frequency and length of time that individual activities are completed with Resident #701, Staff D replied, two to three times a week for five to 15 minutes at a time. When queried if activities are provided at the same time of day and by consistent staff members, Staff D stated No. I haven't been able to pay attention or narrow down the time of day that is better for (Resident #701). When asked if Resident #701 is brought out of the room for activities, Staff D replied, I haven't really tried that. (Resident #701) tries to walk and can't When asked if avenues other than individual in-room activities have been attempted for Resident #701, Staff D stated No, not really. When queried regarding the lack of decor in Resident #701's room, Staff D replied, I get you, I see what you're saying. We should be doing more for (Resident #701) but we just don't have the time to give (Resident #701) what (the Resident) needs. We only have two staff members in the Activities department to provide Activities for 154 Residents. Quite a few of the Residents receive individual activities and (Resident #701) really has special needs. Resident #701's Activity care plan was reviewed with Staff D at this time. The activities care plan listed the intervention, Invite the Resident to scheduled activities. When queried this intervention, Staff D stated, I don't know if that if really happening. Another intervention on Resident #701's activity care plan indicated provide the Resident with materials for individual activities as desired. The Resident likes the following independent activities: (SPECIFY). When asked what the specific individual activities included for Resident #701, Staff D replied, We don't have anything. (Resident #701) is really slipping between the cracks. I am trying but (Resident #701) really needs more individualized attention to meet (the Residents) needs. On 3/8/17 at 4:55 PM, an interview was conducted with Social Worker E and Admissions Staff F. When queried if Resident #701 had a legal guardian, representative, or power of attorney, Social Worker E stated, No. When asked who facility staff members contacted to assist with decisions pertaining to Resident #701, Social Worker E stated, Well, there were two people listed on paperwork that we had received from the facility that the Resident came from. I didn't get any documents of who or if the Resident had a guardian when they were admitted . I don't know if Admissions did or not. That was two Admissions people ago. When queried, Admissions Staff F stated, We usually do get guardianship papers so no, it is not normal (to not obtain guardianship papers for new admissions) especially when someone can't communicate with us. When queried if any actions had been taken by the facility pertaining to guardianship for Resident #701, Social Worker E replied, I contacted the county probate count where guardianship petition had been filed by the facility that Resident #701 was in before coming here. When asked when the call was made, Social Worker E stated today. When queried why the process had not been started prior to today, Social Worker E was unable to provide an explanation. On 3/9/17 at 8:00 AM, a record review of facility provided documentation pertaining to legal guardianship, representation, and/or power of attorney for Resident # 701 occurred. Record review revealed on 12/12/16, Social Worker H (Social Worker at facility that Resident #701 was at prior to current facility in the State of Indiana) had completed and submitted a Petition for Appointment of Guardian of Incapacitated Individual Form to a Probate court in the State of Michigan. Attached to the petition was a letter written by Physiatrist G that indicated, In Patient's current clinical state, (Resident #701) does not possess the capacity to make appropriate decisions regarding medical, financial, and housing affairs. It would be in (the Resident's) best interest if a guardian was appointed to provide decision making and care in these areas. Additional review revealed that the Probate Court in the State of Michigan was unable to assign a guardian to Resident #701 as the Resident was not residing within the State of Michigan at the time of the petition. Upon request of a facility policy/procedure pertaining to Advance Directives for Residents, a document entitled What You Need To Know Before Filing a Petition To Appoint A Guardian For An Incapacitated Adult (Dated 2/14) was provided. This document was reviewed on 3/9/17 at 11:00 AM and did not address facility procedures related to Residents residing within the facility. A policy pertaining to facility Activities was requested but not received by the conclusion of the survey.

This Citation Pertains to Intake #: Based on observation, interview, and record review, the facility failed to provide an environment free from involuntary seclusion and neglect for two ( #'s 701 and 702) of three Residents reviewed, of a total sample of three, resulting in the imposition of involuntary seclusion, sensory deprivation, lack of personal hygiene care, and Resident feelings of frustration and anger. Findings include: Resident #701 Record review on 3/8/17 at 1:40 PM revealed that Resident #701 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the 14 Day MDS (Minimum Data Set) assessment dated [DATE] revealed that Resident #701 was cognitively impaired, required total assistance to complete Activities of Daily Living (ADL's), and experienced difficultly communicating with others. On 3/8/17 at 1:00 PM, personal protection equipment (PPE) for isolation (equipment utilized by healthcare providers to prevent the spread of illness or infection) was observed hanging on the door to Resident #701's room. PPE equipment included disposable gloves, an empty disposable gown container, and red and yellow colored bags. No sign was present on the door to indicate type of isolation precautions. On 3/8/17 at 1:30 PM, an interview was conducted with Nurse A. When queried regarding the isolation equipment hanging on Resident #701's door without a sign, Nurse A stated, (Resident #701) had [MEDICAL CONDITION] ([MEDICAL CONDITION], a contagious spore-forming bacterium) but the hospital said it was clear (Resident no longer had infection). I haven't had time to look into it yet. When queried if the Resident had been having loose bowel movements, Nurse A stated, Not that I know of. On 3/8/17 at 2:20 PM, observation of care for Resident #701 occurred with Nurse A and Nurse Assistant B. Upon entering the room, it was noted that the window blinds were closed and the lightening in the room was very dim. There was no sounds heard in the room. The Resident was observed lying in bed lying in bed on their back covered only by a sheet. The walls in the room were bare, without any pictures, color, art, or decor. There was no television or radio within the room. The only items observed within Resident #701's room included the Resident's bed which was positioned alongside the wall in the room, a fall mat on the floor next to the bed, a container for soiled linen, a container for garbage, and a cork style board that had a clock on it. The clock indicated the time was 8:37. Nurse A and Nurse Assistant B proceeded to remove the sheet that was covering Resident #701. After removing the sheet, it was observed that Resident #701 was wearing was only wearing a disposable adult diaper. No other clothing was observed within the room. The Resident appeared un-groomed. The Residents hair had a greasy appearance, a visible white colored substance was observed in the Residents facial hair, and the Residents fingernails were long and jagged with visible dark red/brown colored substance noted under their nails. During an interview with Nurse A on 3/8/17 at 2:45 PM, when queried regarding Resident #701's room. Nurse A stated, They took everything out so that (Resident #701) wouldn't hurt themselves if they got out of bed. When queried if the Resident is taken out of their room or gotten out of bed, Nurse A replied, no, we tried that once but (Resident #701) got out of the wheelchair, tried to walk, and fell . (Resident #701) would need one to one care and we don't have the staff for that. When queried if other interventions have been attempted, Nurse A replied, Not that I know of. When asked if Resident #701 has visitors that come to the facility, Nurse A stated, No. When queried if Resident #701 lays in bed all day with no stimulation or interaction, Nurse A stated, I never thought about it that way. (Resident #701) is not an easy patient. On 3/8/17 at 3:00 PM, all provided Skin Monitoring: Comprehensive CNA Shower Review sheets for Resident #701 were reviewed. The provided shower sheets revealed the following: 1/31/17 -Refused care. No skin abnormalities documented. Signed by nursing assistant and nurse. No documentation was present that care was re-attempted. 2/7/17- Documented skin tear (knees) and decubitus (buttocks). Signed by nursing assistant and nurse. 2/14/17- Bed Bath given. No skin abnormalities documented. Signed by nursing assistant and nurse. 2/18/17- Bed Bath given. No skin abnormalities documented. Signed by nursing assistant and nurse. 3/4/17- Bed Bath given. No skin abnormalities documented. Signed by nursing assistant and nurse. Record review of documentation from the Michigan Wound Care + Hyperbaric Institute for Resident #701 revealed the following: 1/27/17- Pressure Ulcers and open areas on skin included: Sacrococcyx/Right Buttocks, Left Buttocks, and Right Heel 2/3/17 - Pressure Ulcers and open areas on skin included: Sacrococcyx/Right Buttocks, Left Buttocks, Right Heel, and Left Lateral Heel Record review of Resident #701's medical record on 3/8/17 at 3:30 PM revealed that there was not a Physician order [REDACTED].>An interview with conducted with the facility Administrator and Director of Nursing (DON) on 3/8/17 at 3:40 PM. When queried regarding the PPE equipment hanging on Resident #701's door, the Administrator stated, (The Resident) was positive for [MEDICAL CONDITION]. When queried why a Physician order [REDACTED].#701's room, the DON stated, We took everything out of the room so that (Resident #701) did not hurt themselves. (Resident #701) has no safety awareness and (Resident #701) gets out of bed and moves around on the floor. When queried regarding sensory deprivation within the room due to lack of light, noise, and human interaction, the DON stated, I can see what you're saying. The Administrator stated, I don't know why the shades are closed. When queried regarding Resident #701 leaving their room, the DON stated, We tried that but it did not work. When questioned further if additional attempts or methods to assist the Resident to leave their room and participate in social interaction had been attempted, the Administrator and DON were unable to provide documentation. When queried regarding why the Resident had not had a shower since admission to the facility and why the skin abnormality documentation was not consistent with documentation from the wound care center, the Administrator stated, Since we (DON and Administrator) came here, we have been working on improving the documentation. They (staff) should be documenting abnormalities every time but we are working on that. The DON stated, (Resident #701) has been in and out of the hospital since admission here and (Resident #701) is not always cooperative with care. When queried if additional attempts are made to provide care if a Resident refuses, the Administrator stated, Staff always try more than once. When asked where staff document when multiple attempts are made to provide care, the Administrator stated, Don't document if retry. I can understand how that could be important. Review of Resident #701's profile census in the medical record on 3/8/17 at 3:50 PM revealed that Resident #701 was not in the facility from 1/14/17 to 1/24/17, 2/21/17 to 3/1/17, and from 3/5/17 to 3/7/17. On 3/8/17 at 4:10 PM, an interview was conducted with Activities Staff D. When queried regarding activities, interaction, and sensory stimulation for Resident #701, Staff D stated, We do individual activities. When queried regarding the frequency and length of time that individual activities are completed with Resident #701, Staff D replied, two to three times a week for five to 15 minutes at a time. When queried if activities are provided at the same time of day and by consistent staff members, Staff D stated No. I haven't been able to pay attention or narrow down the time of day that is better for (Resident #701). When asked if Resident #701 is brought out of the room for activities, Staff D replied, I haven't really tried that. (Resident #701) tries to walk and cant. When asked if avenues other than individual in-room activities have been attempted for Resident #701, Staff D stated No, not really. When queried regarding the lack of decor in Resident #701's room, Staff D replied, I get you, I see what you're saying. We should be doing more for (Resident #701) but we just don't have the time to give (Resident #701) what (the Resident) needs. We only have two staff members in the Activities department to provide Activities for 154 Residents. Quite a few of the Residents receive individual activities and (Resident #701) really has special needs. Resident #701's Activity care plan was reviewed with Staff D at this time. The activities care plan listed the intervention, Invite the Resident to scheduled activities. When queried this intervention, Staff D stated, I don't know if that if really happening. Another intervention on Resident #701's activity care plan indicated provide the Resident with materials for individual activities as desired. The Resident likes the following independent activities: (SPECIFY). When asked what the specific individual activities included for Resident #701, Staff D replied, We don't have anything. (Resident #701) is really slipping between the cracks. I am trying but (Resident #701) really needs more individualized attention to meet (the Residents) needs. Resident #702 Resident #702 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Nursing Admission Assessment (Dated 2/27/17) revealed that Resident #702 was cognitively intact and required supervision to minimal assistance complete Activities of Daily Living (ADL's) and had an indwelling urinary catheter. On 3/8/17 at 2:35 PM, personal protection equipment (PPE) for isolation (equipment utilized by healthcare providers to prevent the spread of illness or infection) was observed hanging on the door to Resident #702's room. No sign was present on the door to indicate type of isolation precautions. On 3/8/17 at 2:40 PM, an interview was conducted with Nurse I. When queried regarding the PPE hanging on the door to Resident #702's room, Nurse I stated, (Resident #702) has a urine bacteria infection and [MEDICAL CONDITION]. The Resident wants to come out of the room but we told (the Resident) that they have to stay in there. When queried regarding the length of time that the Resident had been in isolation precautions, Nurse I relied, Since (the Resident) got here. When queried regarding when the precautions would be discontinued, Nurse I stated, I don't know, not sure we have any results back. On 3/8/17 at 2:45 PM, Resident #702 was observed in their room lying in bed. Resident #702 appeared unkept and groomed. The Resident's hair appeared greasy and un-brushed, there was unidentifiable particles noted on the front of the Residents shirt. The Resident's feet were bare and a dark colored substance was noted on all areas of the Residents feet. The indwelling urinary catheter drainage tube was noted coming up through the top of the waistband of the Residents pants and the indwelling catheter drainage bag was lying on the floor exposed and not in a dignity bag. A dignity bag was not observed within the room. The urine within the drainage bag was a dark amber color with sediment noted in the tubing and drainage bag. An interview was conducted with the Resident at this time. When queried regarding their room, Resident #702 stated, I guess it's fine, but I would like to be able to leave it every once and a while. I didn't realize that I was coming here so that I could be a prisoner. I don't even know what the hell they are talking about, said they need a stool sample of diarrhea. I haven't had diarrhea the whole time I been here. When queried further Resident #702 stated, (Nurse I) told me she's the new sheriff in town so I gotta do what she says and I can't leave my room until they get a stool sample. So I went (had a bowel movement) and put it in a cup for her. It was normal but that was what she wanted so she can have it. When asked what the date of the occurrence was, Resident #702 replied, I don't really remember. It all kind of blends together when you are stuck somewhere. The whole thing really pisses me off and upsets me, they treat me like I'm a leper or something. When queried regarding staff supervision and assistance with personal hygiene, Resident #702 laughed and replied, What assistance? I have to do it myself. I been using this wipes (Resident held up a package of moist body wipes) to get myself cleaned up. I haven't had a shower since I got here. When queried further, Resident #702 stated, They offered once but I had already washed myself up and gotten dressed. Nobody bothered to ask me when I wanna take one. During an interview with Nurse I on 3/8/17 at 3:10 PM, when queried regarding a dignity bag for Resident #702's indwelling urinary catheter drainage bag, Nurse I stated, It should have one. When queried regarding the catheter bag on the floor, Nurse I replied, Shouldn't be. When queried if they had told Resident #702 that there was a new sheriff in town, Nurse I did not respond. An interview with conducted with the facility Administrator and Director of Nursing (DON) on 3/8/17 at 3:40 PM. Wen queried who is the infection preventionalist for the facility, the Administrator stated, The DON and I are covering that role for now, we have someone hired that will be starting soon though. When queried regarding the lack of an order for [REDACTED]. Record review of Resident #702's medical record on 3/9/17 at 11:45 AM revealed that Resident #702 did not have a Physician order [REDACTED].#702 had not had loose or liquid bowel movement since admission to the facility. Review of facility provided Skin Monitoring: Comprehensive CNA Shower Review form revealed that Resident was offered and refused a shower on 3/6/17 (seven days after admission to facility) and on 3/8/17. During an interview with the facility Administrator and DON on 3/9/17 at 12:10 PM, when queried regarding the lack of an order for [REDACTED]. The Administrator further stated, We are working on the infection control program here, we know that it needs improvement. Record Review of facility policy entitled Routine Resident Care (Revised September 2011) on 3/9/17 at 1:00 PM revealed Residents receive the necessary assistance to maintain good grooming and personal/oral hygiene. Showers, tub baths, and/or shampoos are scheduled at least twice weekly and more often as needed.Daily personal hygiene minimally included assisting or encouraging Residents with washing their faces and hands, combing their hair each morning, and brushing their teeth and/or providing denture care. Record Review of facility policy entitled Indwelling Catheter Care (Daily Cleaning) (Revised December 2009) on 3/9/17 at 1:05 PM revealed, Care and maintenance of indwelling catheters is essential to prevent infection and/or complications. A policy was requested pertaining to facility use of dignity bags for urinary catheters and positioning of catheter bags off the floor but not received by the conclusion of the survey. Record review of facility provided infection control policies/procedures entitled Infection Prevention Manual for Long Term Care: Infection Prevention Plan, pages 8, 16, and 17 (Dated 2012, ICP Associates, Inc.) on 3/9/17 at 1:10 PM did not reveal facility procedures pertaining to isolation and precautions. No further policies and/or procedures where provided by the conclusion of the survey. Facility policy pertaining to isolation of Residents was requested but not received by survey conclusion.

This citation pertains to MI intakes: , , , , , and Based on observation, interview and record review, the facility failed to implement new fall interventions and safely supervise five (#'s 702, 706, 710, 711 and 713) residents who are at risk for falls from a total of 10 residents sampled for falls from a total sample of 14 residents, resulting in potential or actual falls causing injuries. Findings include: Resident # 702 On 1/3/17 at 8:30 a.m., a record review was completed on Resident #702. According to the MDS assessment dated [DATE], Resident #702 was admitted to the facility on [DATE] and then readmitted on [DATE] with the following Diagnoses: [REDACTED]. Resident #702 needed extensive assist with bed mobility and personal hygiene and was moderately cognitively impaired. On 1/3/17 at 10:20 a.m.-2:50 p.m., Resident #702 was observed in a reclined back gerichair with his legs flexed at the knees and his neck and head extended so that it was not resting on the back of the gerichair. He was in his room alone until Visitor H arrived around 1430. On 1/3/17 at 3:40 p.m., an interview was completed with Certified Nurse Assistant (CNA) J. CNA J stated, He is all over the place, he walks sometimes, he is also combative sometimes .In my opinion he needs 1:1 care because he falls all the time, but we don't have the staff for it. On 1/4/17 at 8:50 a.m. a review of Resident #702's incident and accident reports were completed. The following was revealed: 7/11/16-Lost balance while trying to kick a CNA. No new interventions. 8/21/16-Crawling on floor in hallway. No intervention provided. 9/14/16-Observed on floor in hallway. Intervention: appropriate footwear. 10/1/16-Observed on floor at nurses station. Intervention: Observe frequently. 10/27/16-Observed on floor in front of bed; bed in high position. Intervention: Mat on floor in bed. 11/2/16-Observed on floor in front of nurses station. Intervention: Lay down after dinner. 11/5/16-Lying on floor in front of nurses station. Intervention: No intervention provided, hospice referred. 11/28/16-fell out of stationary chair; hit forehead, small laceration. Intervention: Provide diversional activities. On 1/4/17 at 10:10 a.m., a record review of the fall risks assessments revealed: 7/7/16 (10), 10/27/16 (16) and 11/6/16 (17) - all revealing a progressively higher risk for falls each time completed. On 1/3/17 at 8:30 a.m. a record review of the care plan revealed a care plan created for Resident #702 stating, A potential Fall Risk related to wandering, poor cognition, poor safety awareness and unable to follow safety precautions. On 1/4/17 at 2:50 p.m., Resident #702 observed in bed with Visitor H at his bedside. Visitor H stated, He hasn't fallen in a long time now since they put him in this chair (gerichair). I really think they put him in this chair just so he can't get out of it. I have been asking them over and over to let him sit in a wheel chair. Resident #710 On 1/3/17 at 1:30 p.m., a record review was completed on Resident #710. According to the MDS assessment dated [DATE], Resident #710 was admitted to the facility with the following Diagnosis: [REDACTED]. Resident #710 was incontinent of bowel and bladder and had a moderately impaired cognition. On 1/3/17 at 10:30 a.m., Resident #710 was observed naked sitting on his room mate's bed. Resident #710 was confused and did not verbalize anything at the time. On 1/3/17 at 12:05 p.m., Resident #710 was observed wandering in the dining room with no staff in the room. Resident appeared to have an unsteady, slow gait with poor posture. On 1/3/17 at 2:35 p.m., Resident #710 was observed sleeping in the dining room in a wheelchair with no staff in the room. On 1/4/17 at 11:00 a.m., 11:35 a.m. and 3:00 p.m., Resident #710 was observed in the dining room with no staff observing him. On 1/4/17 8:10 a.m., a review of the paper chart revealed a facility communication form dated 12/14/16 stating, Fall on Tuesday and Wednesday, Please assess. On 1035 reviewed Fall Risks assessments and the following was revealed: 9/23/16 (23), 12/22/16 (13), 12/27/16 (14), indicating Resident #710 is a high risk for falls. On 1/4/17 11:25 a.m., a record review of the incident and accidents reports was completed for Resident #710 revealing the following: 9/23/16-Observed lying on back in doorway. Intervention: Appropriate footwear. 12/14/16-fell on floor, hit head on wall, sent to hospital. Intervention: Physical Therapy to evaluate. 1/4/17-Sitting on buttocks. Intervention: Observe frequently. Resident #711 On 1/4/17 at 10:00 a.m., a record review of Resident #711 was completed. According to the MDS assessment dated [DATE], Resident #711 was admitted on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. Resident #711 needed extensive assist with bed mobility, toileting and was moderately cognitively impaired. A record review of the Activity of Daily Living care plan revealed that Resident #711 needed extensive assist with transfers. Further review of the Fall Risk Assessments revealed that on 8/18/16 and 11/8/16 Resident #711 was a high risk for falls, scoring a 16. On 1/4/17 at 11:20 a.m., A review of the nursing progress notes revealed that Resident #711 had a witnessed fall and slid from chair and was sent to the hospital. Resident #711 also had a fall on 11/2/16, but did not state any details or interventions put into place for fall. The Administrator stated, I can't find the incident report for that fall. Resident #713 On 1/4/17 at 8:00 a.m., a record review of Resident #713 was completed. According to the MDS assessment dated [DATE], Resident #713 was admitted to the facility on [DATE] and then readmitted on [DATE] with the following Diagnoses: [REDACTED]. Resident #713 needed extensive assist with personal hygiene, bed mobility and was incontinent of bowel and bladder. Resident #713 had a moderately impaired cognition. On 1/4/17 at 4:00 p.m., a record review of Resident #713's Fall Risk Assessment was completed on 2/15/16 and revealed she was a high risk for falls with a score of 18. A record review of the Fall Care plan created 8/19/15 revealed under the interventions: Bedside Mat on floor. The following observations were made of Resident #713: 1/3/17 at 10:15 a.m., 12:10 p.m., 2:40 p.m., and 4:35 p.m., Resident #713 was lying on her back in bed with her HOB up 60 degrees. 1/4/17 at 0935, 11:05 a.m. and 11:45 a.m., Resident #713 was lying on her back in bed with her HOB up 30 degrees. On each of those observations, there was not a mat on the floor beside the bed. On 1/4/17 at 11:00 a.m., an interview was completed with CNA C and L in regards to fall interventions for Resident #713 specifically the mat not being on the floor, CNA C stated, I didn't know there was a mat that was supposed to be on the floor. When further queried in regards to how CNA's are aware of residents who may be a fall risk and what interventions are in place, CNA L stated, Usually the nurse tells us. CNA L further explained that there is no direct communication to tell them what interventions are in place, they used to look at the care plans in the paper chart but there no longer are paper care plans. On 1/4/17 at 11:45 a.m., an interview was completed with the Director of Nursing (DON) regarding the implementation of the fall mat for Resident #713. The DON stated, I didn't know there was supposed to be a fall mat, I will look into it. On 1/4/17 at 4:00 p.m., an interview with the Administrator was completed regarding the fall program and what is done with information assessed from the Fall Risk assessments. The Administrator did not provide an explanation but stated, We look at that, we have work to do on it all yet. On 1/4/16 at 4:10 p.m., a record review of the policy titled, Fall Management revised August 2012 revealed the following: Under Fall Event, #7. The IDT (interdisciplinary team) modifies and implements a Care Plan and treatment approach to minimize repeat falls. The Care Plan will be reviewed/revised as indicated. The RCS (CNA) Assignment Sheets/Care Kardexes are updated as appropriate. ( ) Resident #706 A record review on 1/4/17 at 9:00 am revealed Resident #706 was admitted to the facility on [DATE], discharged on [DATE], readmitted on [DATE] at and discharged on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data set assessment ((MDS) dated [DATE] was the most recent MDS and indicated the resident had mild cognitive impairment, and required 2 person assistance with transfers. An interview on 1/3/17 at 0910 with Confidential person O revealed, the resident informed them on 12/10/16 at approximately 6:30 PM that she had fallen at the facility after admission on 12/9/16. The facility did not notify the family that the resident had fallen on 12/9/16 at approximately 8:30 PM. The resident was transferred to the hospital on [DATE] per the families request where the resident was assessed to have 3 fractures resulting from the fall. On 1/4/17 at 9:10 am a review of the admission assessment dated [DATE] and timed 10:23 PM does not indicate the resident fell . There was no nurses note or assessment on 12/9/16 in the medical record that indicated the resident had fallen or if she was injured. There was no documentation the physician was notified or the resident was assessed by the physician. There was no current Fall Risk Assessment. The resident had a history of [REDACTED]. There was no Fall Risk Assessment from 5/19/16 -12/10/16. On 1/4/17 at 9:12 am, the Care Plans for Resident #706, dated 8/31/16 were reviewed and revealed a Fall Care Plan related to, Gait/Balance problems. Keep call light in reach. There were no additional interventions. An ADL (activities of daily living) Care Plan dated 6/16/16, indicated the resident required extensive assistance with bed mobility, dressing, toileting and bathing. There was no current Care Plan from the 12/9/16 admission. On 1/4/17 at 9:15 am, a review of the nurses notes indicated the following: A nurses note written by Licensed Practical Nurse (LPN) P on 12/10/16 at 2:53 PM, states, When entering room ., to meet new resident, she reported that she fell trying to get out of wheel chair. Resident's daughter asks to send resident out to ER(emergency room ). Mobile X tech(technician) here for x-rays and cancelled. Resident sent to ER. An entry dated 12/11/16 at 8:30 am was entered and deleted and stated, When entering room ., to meet new admit, I was told by daughter that they (her and her sister) were going to transfer the resident to the hospital because she fell . When asked what happened the resident stated that she fell trying to get out of wheel chair. Doctor call, Administrator call, and informed of the irate behavior of the family and the statement that resident made. Resident sent to ER per family request. There were no additional interventions in the resident's chart to promote safety or address the results of her fall. An incident report dated 12/9/16, 8:30 PM and completed by the Director of Nursing(DON) and LPN Q stated, Resident states, Attempting to transfer self without assistance. I was trying to get into my chair. She was observed on floor by resident he reported fall to staff. The resident was unidentified. The DON completed an investigation between 12/10/16-12/13/16. On 1/4/17 at 3:45 PM the facilities Fall Management policy was reviewed: Newly admitted Residents-Facilities will take a proactive approach for new residents and will consider new admissions at risk for falls until the resident is reviewed by the IDT(interdisciplinary team). Upon admission the nurse will complete the Fall Risk Assessment the Initial Care Plan and address risk factors . and implement appropriate interventions . All residents will be assessed for risk using the Fall Risk Assessment, quarterly, annually and with significant change . Fall Event- When a fall occurs assess the resident for injury. An interview with the DON and Administrator on 1/4/17 at 4:15 PM revealed they were both new to the facility and their first day at the facility was 1/3/17. When asked why there was no assessment in the medical record following the resident's fall or documentation of notification of the physician or family at the time of the fall, there was no answer. When queried why a fall resulting in a serious injury requiring immediate medical treatment was not assessed or reported, there was no answer. ( )

This citation refers to intake # MI 625. Based on interview and record review, the facility failed to provide proper assessment, evaluation and monitoring for bowel elimination and implement a physician ordered bowel protocol for one (#701) of three residents reviewed for bowel elimination patterns, from a total sample of three, resulting in multiple bowel impactions, abdominal distention, physical distress, and pain. Findings include: On [DATE] at 4:30 P.M., the complainant was contacted and reported that on several occasions in August, Resident #701 experienced impacted bowels (accumulation of solid, hardened stool in the rectum that prevents further defecation) and required disimpaction (manual removal of stool from the rectum). The complainant stated, The hospice nurse removed three to four cups of feces on more than one occasion. She would give instructions to the nurse and they would not follow up. They had no bowel records or documentation of his (Resident #701) last bowel movement. On [DATE] at 10:55 A.M., the clinical record for Resident #701 was reviewed and revealed the following: Resident #701 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #701 was had severely impaired cognition and required extensive physical assistance with all activities of daily living including toileting, and that he had not been transferred out of bed during the seven day assessment period. Resident #701 was receiving hospice services through a contracted hospice agency and expired on [DATE] at the facility. physician's orders [REDACTED]. Milk of Magnesia (MOM) concentrate, give 30 ml (milliliters) by mouth as needed for constipation, give ,[DATE] hours after no bm (bowel movement) [MEDICATION NAME] 10 mg (milligram) suppository, Insert 1 suppository rectally as needed for constipation. Give 8 hours after giving MOM if no results. Fleet enema ,[DATE] gm (gram)/118 ml. Insert 1 unit rectally as needed for constipation. Give 8 hours after suppository if no results. If still no results call physician. A PRN (as needed) Administration Record dated [DATE] through [DATE] for Resident #701 was reviewed and documented that no doses of MOM, [MEDICATION NAME], or enema were administered to Resident #701 in the month of [DATE] The Director of Nursing (DON) was interviewed about where bowel movements were documented on [DATE] at 11:30 A.M. and indicated that the Certified Nursing Assistants (CNAs) would document in their electronic charting system. Bowel elimination records were requested for Resident #701 for July and [DATE] at this time. Documentation Survey Report v2 for Bowel Elimination for July and [DATE] were received on [DATE] at 12:15 P.M. and reviewed with the DON. The bowel elimination record documented the following: From [DATE] through [DATE], there was no documentation that Resident #701 had a bowel movement. The report documented 0s (which according to the key and the DON indicated the resident did not have a bowel movement) or blanks. The DON was asked when Resident #701 last had a bowel movement based on the CNA documentation and stated, According to this, he did not have one in August. The DON indicated that bowel movements were expected to be documented by the CNAs. Progress notes were reviewed with the DON at this time for [DATE] and revealed one progress note on [DATE] that documented, Fleet enema given with a moderate BM result. Abdomen still slightly distended with hypoactive BS (bowel sound). There were no other progress notes regarding Resident #701's bowels. Hospice Nursing Clinical Notes were reviewed on [DATE] at 1:30 P.M. for Resident #701 for the month of [DATE] and documented the following: On [DATE] (from 2:10 P.M. to 3:05 P.M.), Hospice Nurse Z documented that Resident #701 was constipated, did not have bowel sounds present, and his abdomen was firmly distended. The additional comments section documented, .Seems a little disoriented today. Patient has developed a new cough. Is frequent .Says has been coughing like this for three and a half days. Says that his stomach has been upset for that long too .Feels like he's going to throw up. Found that patient's abdomen is firmly distended. Bowel sounds very hypoactive. Went out to nurse's station and found charge nurse (Nurse E) at desk. Informed her that patient was in distress and told her his symptoms. Asked her when his last BM was. She got on the computer .she perused the computer and couldn't see anywhere where it had been charted that he had a BM. She called over one of the aides and asked her if she could find where the patient's BM's were charted. (CNA G) looked for about 10 minutes and could not find where his BM's were charted. No one able to tell me. Informed charge nurse that I needed to give patient an enema. She gave me a Fleet's enema. Administered to patient. Waited for about 10 minutes. Most of the enema leaked back out. Checked patient for impaction and found that patient had a large amount of firm stool in the rectal vault .Got approximately 3 cups of very firm stool from rectal vault, with probably that much more still there. Patient hurting so didn't try to remove any further. Went back to nurse's station and told the nurse, (Nurse E), the results of the enema and manual disimpaction, and that they would need to give another enema later tonight and remove the rest of the impaction. (Nurse E) acted busy and disinterested, but said she'd let someone know .At 8:30 P.M .Spoke with floor nurse (Nurse F), and asked her how patient was doing. She said, 'Oh, he's doing great.' I informed her of what had occurred earlier, and she said she had no idea .Told her that he really needed another enema and probable manual disimpaction . The Coordination/Plan section documented, .Patient in distress today. Unknown how long it's been since last BM. Abdomen firmly distended .Verbal instruction to charge nurse (Nurse E) and staff nurse (Nurse F) as stated above . On [DATE] (from 5:20 P.M. to 6:15 P.M.), Hospice Nurse Z documented, .Asked him (Resident #701) if he had a BM since I was here on Monday and he said no. Patient's abdomen is still moderately distended and moderately firm .Asked him if he was passing any gas, and he said no. Patient is very sleepy .Call placed to (Nurse Proactivation I) to inform her of what happened on Monday and failure of facility staff to follow through on rechecking patient on Monday evening. I informed her that floor nurse today says that patient had a BM yesterday. Patient said it was very small. [MEDICATION NAME] ordered as stated above. Instructed staff that [MEDICATION NAME] has been ordered and that BM's need to be documented and followed up on. Attempted to reach (Director of Social Services, SW E), the head social worker x 2 this week regarding lack of care by staff on follow through. Left two detailed messaged on her voicemail with no call back received. It was documented that there was an order for [REDACTED]. On [DATE] (from 2:30 P.M. to 3:50 P.M.), Hospice Nurse Z documented that Resident #701 experienced constipation. Additional comments documented, Arrived at facility, and before going down to patient's room, I stopped and asked two aides if they could tell me if patient has had a BM since I was here last Friday. The first aide said that she has no idea how to look it up. The other aide said there was nothing charted. Asked to speak with (SW E) the head of social work. SW C, the floor social worker, came into the room and introduced herself. I informed her of what had occurred on [DATE] .I told (SW E) that on my way to patient's room, I stopped and asked if patient has had a BM since I was here on Friday. Again no one able to tell me if he had a BM. (SW E) brought the nurse manager of the 3rd floor (Nurse B) down and I repeated the story to her. She states that this is a priority, and she will look into it. Checked patient's abdomen today and is still firm and distended. Hypoactive bowel sounds. Orders given to staff, specifically, to give patient an enema today and check digitally for need for disimpaction . On [DATE] (from 5:30 P.M. to 6:35 P.M.), Hospice Nurse Z documented, Patient in bed, drowsy. States his bowels still aren't moving .Informed aide that we need to coordinate care between facility and hospice staff. (Nurse H) came down to room and I informed her of everything that patient has been through since [DATE]. Asked her if she knew when patient had last BM. States she's not sure, because she usually doesn't work this wing. Asked her how she knows when patient had his last BM and she said the aide writes it on a bowel and bladder log. She went back up to the desk and asked the aide how they know when a patient has had a BM. Aide told (Nurse H) to look it up on the computer. She logged into the computer and found that patient had an enema on ,[DATE] with moderate results. I instructed (Nurse H) and the two aides of the importance of following the bowel regimen and to follow closely due to narcotic use by patient. Instructed that the rectal vault can perforate, and then the contents of the bowels enter the abdominal cavity and cause pain and infection, and possible death. Informed patient that I needed to check him for stool. Found large amount of firm stool in the rectal vault. Disimpacted him of, again, about ,[DATE] cups of stool. Stool was felt higher up, but unable to reach to remove. Patient's abdomen remains distended and firm .bowel sounds are hypoactive .Staff still not following up appropriately to assure that patient's bowel are moving . Nursing progress notes were reviewed at 1:40 P.M. for the dates mentioned above. There were no progress notes documented by the facility regarding Resident #701's bowel movements, instructions given by Hospice Nurse Z, or need for disimpaction. SW D was interviewed via the telephone on [DATE] at 1:53 P.M. SW D explained that she was no longer the social worker at the facility, but that she recalled Resident #701. SW D reported that when she worked at the facility, she was the Director of Social Services. When queried about any contact she had with the hospice staff assigned to Resident #701, SW D stated, I wasn't assigned to him (Resident #701). (SW C) was assigned. They would have contacted (SWC). SW D was queried about the note written by Hospice Nurse Z on [DATE] that documented she left multiple messages for SW D and did not receive a response. SW D stated, I don't remember. I think I was off on [DATE]. SW C was interviewed on [DATE] at 1:55 P.M. regarding Resident #701. SW C indicated that she was the assigned social worker. SW C was asked about any concerns expressed by the hospice staff. SW C stated, I remember it was within the last month, the nurse (hospice) had some concerns and wanted to talk to the nurse manager (Nurse B). They were nursing concerns so I just pulled (Nurse B) to talk to her and left. SW C was queried about the content of the concerns expressed by the hospice nurse and stated, I don't remember. She seemed frustrated. Something about his stomach being distended and his bowel movements. Nurse B (Unit Manager) was interviewed on [DATE] at 2:15 P.M. regarding Resident #701. Nurse B was asked about any concerns expressed to her by the hospice staff. Nurse B stated, The social worker came and got me because it was a nursing issue. Apparently she assessed him (Resident #701) and his abdomen was distended and she disimpacted him. She said she told the staff at the previous visit that this happened and told the charge nurse on the floor and asked them to continue to assess him and continue treatment. She wanted to know if they were following up on his BM's. Nurse B was asked what she did to follow up on the above and stated, I asked (the DON) on that day how to find it (bowel movements) in the computer. The documentation of Resident #701's bowel elimination was reviewed with Nurse B at this time. Nurse B was asked how bowel movements were monitored to know when to implement the bowel protocol. Nurse B stated, It would be triggered by documentation, so there would have to be correct documentation in order for it to trigger. Nurse B was asked if she reported any of the hospice nurse's concerns to the DON or if Resident #701 was assessed after talking to the hospice nurse and stated, She just said he was having some problems. I didn't document anything. I just went to (the DON) to ask how to find the bowel movement documentation and asked if there was a report because we needed to know when his last bowel movement was. The DON was interviewed on [DATE] at 2:30 P.M. regarding the concerns with staff not following up with recommendations from the hospice nurse regarding Resident #701 experiencing impacted bowels. The DON was asked how the concerns were addressed. The DON stated, I don't remember anyone reporting anything to me. The DON was asked if she reviewed the documentation by Hospice Nurse Z and indicated that she had not. The hospice documentation mentioned above from [DATE], [DATE], [DATE] and [DATE], as well as facility progress notes were reviewed with the DON at this time. The DON stated, Based on this documentation it appears that there was no follow up. Resident #701's clinical record was further reviewed on [DATE] at 2:40 P.M. and the following was revealed: A Doctor's Progress Note written by NP , dated [DATE] (five days after hospice contacted) documented, (positive for) distention with history of constipation. Pt on polyethylene [MEDICATION NAME] .no distention noted, on bowel protocol . A physician's orders [REDACTED]. There was no care plan for bowel elimination management or constipation. The facility's policy, titled, Bowel and Bladder Management, dated [DATE], was reviewed on [DATE] at 3:30 P.M., however, it did not address monitoring bowel movements or what to do when a resident was not having bowel movements. ( )

Based on observation, interview and record review, the facility failed to prevent the development of a pressure ulcer for 1 (# 311) sampled resident and failed to ensure weekly skin assessments were completed for 3 (#'s 302, 311 and 314) of 3 sampled residents reviewed for pressure ulcers from a total sample of 24 residents, resulting in the development of avoidable pressure ulcers and the potential for development of new pressure ulcers. Findings include: Resident #311 On 7/19/16 at 3:05 p.m., record review revealed that Resident #311 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the initial Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #311 required extensive assistance with bed mobility and eating. Resident # 311 had a minimally impaired cognition. According to the MDS dated [DATE], there were no pressure ulcers present on admission. On 7/20/16 at 7:45 a.m. review of the skin assessments revealed that on 2/20/16, 2/27/16, 3/8/16, 3/10/16, 3/15/16, 3/21/16, 3/28/16, and 4/7/16 there were no skin issues identified. There were no other skin assessments until 5/18/16 which identified a 4 centimeters (cm) by 5 cm existing pressure area noted on the right heel and a 3 cm by 2.5 cm area noted on the left heel. Review of the initial Braden Scale (an assessment used to determine the risk for pressure ulcer formation) dated 2/19/16 revealed, upon admission, that Resident #311 was at risk to develop pressure ulcers because of the potential for friction or sheer during bed mobility. On 7/20/16 at 11:40 a.m., observation of resident # 311 wounds with Nurse D revealed a stage three pressure ulcer on the right heel. The wound bed was red with some yellow slough tissue present and minimum drainage was present. Nurse D was interviewed regarding the development of resident's # 311 pressure ulcers and stated, It (the pressure ulcer) started out as a blister. Resident #311 was interviewed regarding the development of the pressure ulcers and stated, I had a blister on both of my heels. They hurt in the beginning. On 7/21/16 at 11:30 a.m., review of the Wound Care notes revealed the following: 5/21/16 . 1.5 cm x 1.5 cm stage 3 pressure ulcer 6/10/16 . 2 cm x 1 cm stage 3 pressure ulcer 6/17/16 .1.5 cm x 1 cm stage 3 pressure ulcer 7/15/16 .1 cm x 0.7 cm stage 3 pressure ulcer On 7/21/16 at 2:00 p.m., the Director of Nursing (DON) was interviewed regarding the development of Resident #311's pressure ulcer and skin assessments. The DON offered no verbal explanation. On 7/21/16 at 2:30 p.m., review of the facility's policy, titled Skin Management, dated 2012, revealed Skin assessments findings will be documented weekly on the Head to Toe Skin Check form. The nurse will assure treatments, interventions, Care Plan and the appropriate skin documentation records are initiated in a timely manner . ( ) Resident #314 Clinical record review on 7/19/16 at 2:00 PM, revealed that Resident #314 was originally admitted into the facility on [DATE], and was readmitted on [DATE], with [DIAGNOSES REDACTED]. According to the most recent quarterly Minimum Data Set, dated dated [DATE], Resident #314 was cognitively intact. Review of a Braden scale assessment for Resident #314, dated 1/3/16, noted that the Resident had a score of 13, which indicated that the Resident was at moderate risk for skin breakdown. Review of the care plans for Resident #314 revealed a Skin care plan, dated 9/24/15, and revised 6/30/16, which noted: (Resident #314) is at risk for pressure ulcer development related to disease process, decreased activity, impaired mobility, co-morbid conditions .Complete a full body check weekly and document . Review of the Weekly skin checks for Resident #314, noted that the most recent, documented skin assessment for Resident #314 was dated 6/24/16, and noted: Existing Other Issue located on buttocks/coccyx area. On 7/21/16 at 3:00 PM, the Director of Nursing (DON) was queried as to why Resident #314 had not received a weekly skin assessment since 6/24/16. The DON was unable to provide an explanation, and stated, I'm having them do one right now. Review of the facility's policy, Skin Management, dated August 2012, noted: 16. Skin assessments: a. Weekly skin check will be transcribed onto the Treatment Record including the day and shift on which the check will be conducted. b. Completion of the weekly skin assessment will be noted on the Treatment Administration Record with the Licensed Nurse's initials. c. Skin assessment findings will be documented weekly on the Head to Toe Skin Check form . ( ) Resident 302: At 3:35 p.m. on 7/19/16 a review of Resident 302's clinical record revealed Resident 302 was originally admitted into the facility 10/27/2005 and readmitted [DATE]. [DIAGNOSES REDACTED]. A recent Minimum Data Set assessment ((MDS) dated [DATE] documented Resident 302 required extensive staff assist with bed mobility and hygiene. The most recent Braden Scale for Predicting Pressure Sore Risk in Resident 302's clinical record, dated 1/1/16, documented Resident 302 was Very High Risk for skin breakdown A review of Resident 302's Skin care plan, updated 1/30/16, conducted on 7/19/16 at approximately 1:00 p.m., revealed the following: Actual Skin Issues related to: Pressure Ulcer .history (hx) of pressure ulcers on multiple sites. Current pressure ulcer: left buttock area, right thigh upper, right thigh, 5/18/16 right foot on top. Interventions: Skin checks weekly per facility protocol, document findings Review of Skin-Head to Toe Skin Checks for Resident 302, conducted 7/20/16 revealed Resident 302's most recent skin assessment was completed 5/19/16. Prior to 5/19/16, skin assessments were conducted on the following dates in 2016: April 7 th and 19 th; March 10 th and 21 st; January 1st and 9 th. On the 5/19/16 skin check a newly developed pressure ulcer was documented, 1l. New Pressure Ulcer .Top of right foot 3 centimeters (cm) by 2.5 cm Stage II (partial thickness skin loss) .open area observed to top of right foot . A nursing progress note dated 5/18/16 at 3:47 p.m., reviewed on 7/20/16, revealed, Resident has skin breakdown related to immobility, new area observed top of right foot which is prone to lying down on mattress . A review of the facilities Skin Management policy revised August 2012 was reviewed on 7/21/16 and revealed, 16. Skin assessments: c. Skin assessment findings will be documented weekly on the Head to Toe Skin Check form The Director of Nursing was interviewed on 7/21/16 at approximately 3:00 p.m. regarding the facilities policy on skin assessment and was unable to offer an explanation. ( )

Based on observation, interview, and record review, the facility failed to: 1. assess a resident's pain upon admission 2. obtain physician's orders and administer pain medication in a timely manner for one (#315) out of 18 residents reviewed for pain from a total sample of 24, resulting in feelings of pain, discomfort, and frustration. Findings include: Resident 315 was observed on 7/20/16 at 8:00 a.m. lying in bed on his right side. Resident 815 was calling out, Nurse, I need Tylenol .I hurt, I hurt. Nurse J was queried immediately after the observation of Resident 315 was made and stated, He came from the hospital last night with no orders .the Doctor (Dr.) was called several times but hasn't called back. On 7/20/16 at 10:38 a.m. record review revealed that Resident 315 was admitted into the facility at 5:50 p.m. on 7/19/16 with [DIAGNOSES REDACTED]. There was no admission assessment or pain assessment noted in Resident 315's clinical record. A review of the hospital discharge documentation revealed, (Resident 315) is mostly bed bound due to severe low back pain and spinal stenosis .unable to care for himself due to debilitating back pain At 11:45 a.m. on 7/20/16, Resident 315 was interviewed regarding his back pain. Resident 315 stated, I was in pain all night .they never gave me no pain med's .I was screaming in pain all night .I was even crying .I didn't sleep all night due to the pain. They (nurses') told me that I didn't have any order for pain med's and they didn't know why. I was crying. I was in super bad pain, more pain than I ever had at home. On 7/21/16 at approximately 11:00 a.m., Nurse P who was assigned to Resident 315's care during the midnight shift 7/19/16 to 7/20/16, was interviewed over the phone regarding Resident 315's admission into the facility and reports of pain. Nurse P stated, He did a lot of tossing and turning that night but I didn't know he was in pain .I didn't assess him for any pain, the Certified Nurse Assistant (CNA) didn't tell me anything until about 6 a.m. (7/20/16). The CNA told me he was hollering out for pain med's .I called the Doctor (Dr)but when he called back the call was lost .Nurse J (name) ended up getting an order from him (Dr) later in the morning. At 8:30 a.m. on 7/20/16, Nurse J obtained a physician's order for [MEDICATION NAME] 800 milligrams (mg) every 6 hours as needed. Nurse J stated, This is all the Doctor will give until he assess's him (Resident 315). Nurse J was observed administering the [MEDICATION NAME] to Resident 315. Resident 315 stated his pain was a 10 out of 10 (Scale of 1 to 10 with 10 being the worst pain). On 7/21/16 at 12:15 PM review of the facility's policy, titled, Pain Management, revised August 2012 , stated, The facility recognizes the inter-relationship between uncontrolled pain and the decline in functional abilities, leading to an impaired quality of life The goal of the Pain Management program is that pain is identified and treated effectively and consistently .Practice Guidelines: 1. Upon admission, residents will be assessed for pain . The Director of Nursing (DON) was queried regarding Resident 315's delay in pain management and offered no verbal explanation. ( )

This citation pertains to MI 871 and MI 166. Based on observation, interview, and record review, the facility failed to 1) prevent the development of pressure ulcers for 2 (Resident #71, #72) and 2) perform daily dressing changes as ordered for 1 (Resident #70) of 3 reviewed for pressure ulcers from a total sample of 4, resulting in worsening, development of multiple stage I and stage II (partial thickness skin loss) pressure ulcers, recurrent stage II pressure ulcers, and the potential for infection and worsening of pressure ulcers. Findings include: Review of the Facility's Skin Management Policy revised ,[DATE], revealed .16. Skin assessments: a. 'Weekly Skin Check' will be transcribed onto the Treatment Record including the day and shift on which the check will be conducted. b. Completion of the weekly skin assessment will be noted on the Treatment Administration Record (TAR) with the Licensed Nurse's initials. c. Skin assessment findings will be documented weekly on the Head to Toe Skin Check form .17. The nurse will assure treatments, interventions, Care Plan, and the appropriate skin documentation records are initiated in a timely manner according to Practice Guidelines. The section titled Practice Guidelines Newly admitted Residents revealed 1. Upon admission, all residents are assessed for skin integrity by completing a head to toe physical assessment of skin condition and completing the Braden Scale-For Predicting Pressure Sore Risk. 2. Following admission, the Braden Scale-For Predicting Pressure Sore Risk will be completed weekly for 3 additional weeks (for a total of 4 weeks including admission), quarterly, annually, and with a significant change of status for their risk for development of pressure ulcers. The section titled Bed Bound Resident, revealed 1. Avoid positioning a resident directly on a pressure ulcer whenever possible. 2. Use positioning devices. Devices (pillows, blanket rolls, etc.) should be used to completely raise the pressure sore area, i.e., heel and back of the head, completely off the support surface. Use of these devices may reduce the need for a pressure reducing mattress or overlay .3. Establish an individualized turning schedule based on the resident's clinical condition. Review of the Face Sheet and significant Minimum Data Set ((MDS) dated [DATE], revealed Resident #72 was [AGE] years old, admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #72 had moderate cognitive impairments and totally dependent for all activities of daily living (ADLs). The MDS revealed Resident #72 did not transfer from bed, had a stage III pressure ulcer on her prior MDS assessment and was not on a turning/repositioning program. Review of the discharge MDS dated [DATE], revealed Resident #72 had four stage II pressure ulcers present that were not on her prior MDS assessment, indicating Resident #72 developed these pressure ulcers while in the facility. Review of the quarterly MDS dated [DATE], revealed Resident #72 did not have any unhealed pressure ulcers, but was at risk for pressure ulcers. The MDS revealed Resident #72 was not on a turning/repositioning program and did not have nutrition or hydration interventions to manage skin problems. Review of the Braden Scale for Predicting Pressure Sore Risk dated [DATE], revealed Resident #72 scored 11 (high Risk for pressure ulcers). Review of the Braden Scale dated [DATE], revealed Resident #72 scored 9 (very high risk). Review of Resident #72's Skin-Weekly Pressure Ulcer Record dated [DATE], revealed she had a stage II pressure ulcer on her coccyx that measured 0.7 cm long x 1.2 cm wide x 0.1 cm deep. This pressure ulcer healed on [DATE]. The Skin/Wound Note dated [DATE] revealed Resident #72 also had an open area on her elbow. Review of the Nursing Note dated [DATE], revealed When doing rounds, resident was found left soaked in urine. Was dried and 5 inches away from her on either side. Very large circle. The room smelled extremely strong of urine. Old urine smell is hard to miss. No way of not knowing that resident was not wet. Review of the Nursing Note dated [DATE], revealed Resident #72 had open skin area observed on coccyx. Review of the Skin/Wound Notes dated [DATE], revealed Resident #72 had an open area on her left buttock and her right buttock is swollen and indurated . On [DATE] at 11:30 am, Resident #72's weekly skin assessments from [DATE] through February 2016 were requested from Director of Nursing (DON) B. The surveyor was provided with Skin-Head to Toe Skin Checks dated [DATE], [DATE] and [DATE]. There were no skin assessments for [DATE], [DATE] or [DATE] (Resident #72 was in the hospital from [DATE] through [DATE]). The skin assessment dated [DATE], revealed Resident #72's skin was intact. The skin assessment dated [DATE], revealed Resident #72 had a scab/blister located on her right inner knee and left hip. No other impairments were listed. An observation on [DATE] at 11:34 am with Registered Nurse (RN)/wound nurse D, revealed Resident #72 was lying in bed, all 4 extremities contracted. Resident #72 had an air mattress with settings on low air loss and the firmness set to level 8 out of possible 10 (1 being the softest and 10 being the firmest). There was a piece of masking tape on the mattress control that read 4 with an arrow pointing to level 4 of firmness. Resident #72 was lying on her back with her legs to her right with a wedge cushion on her right side and pillows between her knees and under her feet. Boots were observed in the chair in her room. RN D reported Resident #72 should have her boots on her feet at all times. RN D did not know what Resident #72's mattress settings should be. RN D reported staff had informed her of a new skin impairment on Resident #72. The following observations were made with RN D measuring the areas: 1) left hip bruise with an open area measuring 3 cm x 5.5 cm (this is the area RN D identified as staff notifying her of) 2) red, non-blanchable area on right lateral foot measuring 3 cm x 2 cm 3) intact dressing to right knee 4) right buttock redness measuring 1.2 cm x 1.5 cm 5) Resident #72 was incontinent of a large amount of loose stool and had an open area on her coccyx measuring 5.5 cm x 3.5 cm Review of RN/wound nurse D's documentation of the pressure ulcers identified on [DATE], revealed: 1) left hip suspected deep tissue injury measuring 3 cm x 5.5 cm x 0.1 cm 2) right food stage I (intact skin with noblanchable redness) pressure ulcer measuring 3 cm x 2 cm x 0 cm 3) right knee stage II pressure ulcer measuring 2 cm x 2 cm x 0.1 cm 4) right buttock stage I pressure ulcer measuring 1.2 cm x 1.5 cm x 0 cm 5) coccyx stage II pressure ulcer measuring 5.5 cm x 3.5 cm x 0.1 cm An observation on [DATE] at 8:38 am, revealed Resident #72's mattress settings set at mode alternation 10 minutes (this option was set on low air loss on [DATE]). The firmness was set at level 8 out of 10. In an interview on [DATE] at 8:40 am, Licensed Practical Nurse (LPN) F reported she was caring for Resident #72 that day. LPN F did not know what the mattress settings should be. LPN F asked another nurse on the floor who reported not knowing and then asked Unit Manager (UM) E who reported the settings should be on the end of Resident #72's bed. LPN F was unable to find an order in Resident #72's chart regarding the mattress and settings. UM E looked at Resident #72's bed and stated I will have to find out (the settings). At this time, Resident #72 was observed lying on her back, with only 1 boot on her right foot. The other boot was not in her room. UM E reported she did not know where the other boot was. Review of Resident #72's skin care plan initiated [DATE], revealed the following interventions: -encourage good nutrition and hydration in order to promote healthier skin (Resident #72 was actually NPO and received water and food through her feeding tube) -follow facility protocols for treatment of [REDACTED].>-identify/document potential causative factors and eliminate/resolve where possible -keep skin clean and dry. Use lotion on dry skin. Do not apply on (specify: site of injury). -The resident needs (pressure relieving/reducing mattress) to protect the skin while in bed -The resident needs (pressure relieving/reducing mattress) to protect the skin while up in chair -use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. The care plan did not mention positioning, boots, wedge cushions, or mattress settings. The care plan also did not mention that Resident #72 had a history of [REDACTED]. Review of Resident #72's Visual/Bedside Kardex Report (Certified Nursing Assistant care guide) printed [DATE], revealed no mention of Resident #72's skin or any interventions to prevent the development of recurring and new pressure ulcers. In an interview on [DATE] at 8:53 am, when queried about Resident #72's turning and repositioning, Certified Nursing Assistant (CNA) G reported she tries to get in there every 2 hours, but sometimes not because we have so many people to care for. CNA G reported that sometimes Resident #72 is left in the same position for 3 hours. CNA G reported that she removed Resident #72's boots for a couple hours at a time so her feet can breathe. Review of the medical record did not reveal an order to remove Resident #72's boots to let her feet breathe. In a telephone interview on [DATE] at 11:51 am, mattress company representative K reported the facility should determine the firmness of the mattress. Mattress company representative K emailed this surveyor instructions on setting firmness. The instructions revealed To set firmness: A common method is to check to see if suitable pressure is selected by sliding one hand between the air mattress and the air/foam base under the resident's buttocks with the acceptable range being ,[DATE]mm (1i to 1-,[DATE]i). This hand check procedure is issued by AHCPR (Agency for Health Care Policy and Research). In an interview on [DATE] at 12:25 pm, DON B reported mattresses were placed onto beds by housekeeping. DON B reported none of the mattresses in the building were rentals and she did not realize mattresses had different settings. DON B was unsure who determined the settings on the mattresses and how the settings were determined. DON B reported she was unaware of the mattress company's instructions on setting firmness. In an interview on [DATE] at 1:35 pm, RN/wound nurse D reported she did not have any guidelines for mattress settings. RN D reported that if Resident #72's mattress was too firm, the pressure would be higher than needed which could result in pressure ulcers, but she was not sure what the settings should be. When queried if Resident #72 not having her boots on at all times could have contributed to her new pressure ulcer on her foot, RN D stated yeah I think that's possible. It could definitely be a contributing factor. RN D reported the pillows between Resident #72's legs was a new intervention as of [DATE], but agreed this was not documented anywhere and reported it might have been verbal communication. When queried if Resident #72's new pressure ulcers identified on [DATE] were avoidable or unavoidable, RN D stated some of each. RN D reported the pressure ulcers on the foot, knee, and hip could have been avoided. RN D reported that Resident #72 should be turned and repositioned every 2 hours. RN D reported the CNA care guides were lacking information, but the CNAs know who they should be doing more care for. In another interview on [DATE] at 9:20 am, RN D reported that the CNAs should not remove Resident #72's boots so that her feet can breathe and only remove the boots during bathing. Review of Resident #72's medical record and physician's orders [REDACTED]. an order for [REDACTED]. Review of Resident #72's weight record, revealed she weighed 114.8# on [DATE] and 109# on [DATE] (loss of 5.8#/significant loss of 5%). Review of the physician's orders [REDACTED].#72 had Med Pass in place until she was hospitalized on [DATE]. Med Pass was not reordered upon readmission on [DATE]. ( ) This citation portion is related to Intake #'s MI 908 and MI 871. According to the Electronic Medical Record (EMR) Resident #70 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DATE] Medication Administration Record [REDACTED]. The admission Minimum Data Set (MDS) completed on [DATE] reflected Resident #70 was cognitively intact, required extensive assistance of 2 people for dressing, hygiene, bathing, bowel assistance, and bed mobility. The Nursing Admission Data Collection dated [DATE] reflected Resident #70 was admitted with 5 pressure ulcers: 1. Right buttock stage 1: 4 (Length) x 5 (Width) centimeters (cm). 2. Left buttock stage 1: 5 x 3.5 cm 3. Right heel unstageable 3 x 3 cm 4. Left heel unstageable 2 x 1 cm 5. Sacrum unstageable 2 x 1 x 0.5 (Depth) The sheet reflected the following for staging: Stage 1- Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Unstageable- Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Additional notes reflected: The sacrum pressure ulcer area had 100% slough on top portion of wound, small amount of serosanguinous drainage. Normal surround tissue/black necrotic to right side of wound. The right and left heel areas were black and necrotic. According to the [DATE] Treatment Administration Record (TAR), Resident #70 was ordered to receive the following treatments: -Wound care for sacrum: Cleanse with normal saline (NS), apply santyl to wound bed, cover with adhesive foam dressing, change daily and as needed (PRN). Every night shift related to pressure ulcer of sacral region, unstageable. Order date [DATE] at 2:17 PM. The MAR indicated [REDACTED]. There were no Progress/Nursing notes with the missing treatment dates to reflect treatment was given to the sacral region. -Wound care for heels: apply adhesive foam dressing, assess skin, keep heels floated. Every night shift every 2 days. Order date [DATE] at 2:18 PM. Yet, the MAR indicated [REDACTED]. There were no Progress/Nursing notes with the missing treatment dates to reflect treatment was given to the heels. According to the [DATE] Treatment Administration Record (TAR), Resident #70 was ordered to receive the following treatments: -Wound care for sacrum: Cleanse with normal saline (NS), apply santyl to wound bed, cover with adhesive foam dressing, change daily and as needed (PRN). Every night shift related to pressure ulcer of sacral region, unstageable. Order date [DATE] at 2:17 PM. The MAR indicated [REDACTED]. There were no Progress/Nursing notes with the missing treatment dates to reflect treatment was given to the sacral region. -Wound care for heels: apply adhesive foam dressing, assess skin, keep heels floated. Every night shift every 2 days. Order date [DATE] at 2:18 PM. The MAR indicated [REDACTED]. There were no Progress/Nursing notes with the missing treatment dates to reflect treatment was given to the heels. The facility's Skin-Weekly Pressure Ulcer Record reflected the following measurements for the sacrum/coccyx unstageable pressure ulcer: [DATE]: Type pressure 3.5 x 4.5 x unknown unstageable. [DATE]: Type pressure 5 x 3 x unknown unstageable. [DATE]: Type pressure 5 x 3 x 2.5 unstageable. [DATE]: Type pressure 5 x 3 x 2 stage 3. The changes in wound size and stage reflected treatment to the sacral area was needed. Right heel: [DATE]: Type pressure 2 x 4 x 0 suspected deep tissue injury. [DATE]: Type pressure 4 x 4 x unknown suspected deep tissue injury. [DATE]: Type pressure 3 x 6 x 0 suspected deep tissue injury. [DATE]: Type pressure 3 x 6 x unknown suspected deep tissue injury. [DATE]: Type pressure 5 x 7 x 0 suspected deep tissue injury. The changes in wound size reflected treatment to the sacral area was needed. Left heel: [DATE]: Type pressure 3 x 5.2 x unknown suspected deep tissue injury. [DATE]: Type pressure 4 x 5 x unknown suspected deep tissue injury. [DATE]: Type pressure 3 x 4.2 x 0 suspected deep tissue injury. [DATE]: Type pressure 3 x 5 x 0 suspected deep tissue injury. The changes in wound size and stage reflected treatment to the sacral area was needed. Resident #70's PRESSURE ULCER/SKIN care plan was initiated on [DATE], 11 days after admission with 3 unstageable and 2 stage 1 pressure ulcers. The care plan was revised on [DATE], but still did not reflect locations of pressure ulcers. There was no documentation in the EMR or hard chart to reflect a plan of care had been initiated and implemented related to Resident #70's (5) pressure ulcers prior to [DATE]. On [DATE] at 9:24 AM the Wound Registered Nurse (D) was shown the MAR indicated [REDACTED]. Nurse D stated, she did not know why they were not done. The facility's Skin Management policy revised on [DATE] reflected: Overview: Residents who are at risk or with wounds and/or pressure ulcers and those at risk for skin compromise are identified, assesses and provided appropriate treatment to encourage healing and/or integrity .11. The licensed nurse will record his/her initials on the TAR to reflect the monitoring of each wound regardless of the findings .17. The nurse will assure treatments, interventions, care plan, and the appropriate skin documentation records are initiated in a timely manner according to practice guidelines . ( )

This citation pertains to intake number MI 657 Based on observation, interview, and record review, the facility failed to prevent the development and worsening of pressure ulcers in 1 (#4) of 6 sampled residents reviewed for pressure ulcers, from a total sample of 22 residents, resulting in skin breakdown and the potential [MEDICAL CONDITION]. Findings include: According to Resident #4's Quarterly Minimum Data Set (MDS) assessment dated [DATE] Resident #4 was a [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. On 9/16/15 at 5:00 PM, Certified Nurse Aide (CNA) JJ was requested to Resident #4's room. Resident #4 was observed in a regular bed, with an overwhelming smell of urine and feces. CNA JJ pulled the top sheet back and discovered resident was laying on top of a dry pad that was placed over a bottom sheet that was soaked with urine from shoulder to knees. CNA JJ removed Resident #4's soiled wedge cushion. Resident #4's brief was checked by CNA JJ, and discovered to be urine soaked and covered with feces including the pressure ulcer dressing. CNA JJ stated she came on at 3:00 PM, had not checked Resident #4 at that time, and was not sure the last time resident had been reposition or checked. CNA JJ stated, I would have checked him after I completed a couple more residents on the other side of the hall. I was working my way around, but then dinner was scheduled to be served at any time so the resident (#4) may have not been cleaned until after dinner. Resident #4 resided in the last room at the end of the hall. CNA JJ was observed to have been the only CNA on the hall at the time. According to the daily staff schedule CNA JJ was the only CNA on the hall at that time for 26 residents. Review of Resident #4's Care plan dated 8/15/15, revealed Stage III on the right and left Sacral area bridged with interventions that included weekly skin checks, frequent turning and repositioning, diet as ordered and wound care as ordered. According to Resident #4's physician order [REDACTED]. According to Resident # 4's treatment record this treatment was not completed on 9/2, 9/4, 9/5 or 9/6/2015. According to Resident #4's Wound Care physician documentation dated 9/15/15, Resident #4 had 2 separate pressure ulcer areas numbered #4 and #6; #4 - Right Sacral Stage 2 measured 3 x 1 x .5 (centimeters)(Length x width x depth) and #6 - Sacral Mid Necrotic Unstageable measured 3.1 x 2.5 x 2.5 On 9/16/15 at 5:25 PM, Licensed Practical Nurse (LPN) Y and LPN/Unit Manager D were observed to have changed Resident #4's pressure ulcer dressing. Resident #4's (#4) Right sacral Stage 2 pressure ulcer open (quarter size) approximately area surrounding with a 6.5 x 5 cm area of dark pink / gray skin (#6) Sacral Mid upon removal of the packing had a very strong foul odor. Packing noted to have serous drainage, no slough noted at the base of the wound at this time, beefy red and measured 2 x 6.5 x 3.4 centimeters. According to Resident #4's physician order [REDACTED]. Cleanse with normal saline pat dry, moisten 4 x 4 with Dakins Solution and apply to coccyx. Apply Xeroform to Sacral and cover with ABD and secure every evening and night shift. Dakins solution was not available until 9/17/15 at 2:45 PM per unit Manager D. Review of Resident #4's nurse progress notes dated 9/16/15-9/17/15 revealed there was no mention of notification to the physician that Dakins solution was not available, or that the wound had a foul odor. Review of Resident #4's Weekly skin assessments identified one wound, on the following dates 8/28/15 R/L sacral comb 5.5 x 7 x 0.4 -8/27/15 sacrum 2.5 1.5 0.1 un-stageable. -9/1/15 sacrum 5.5 x 7 x 0.3 un-stageable. -9/8/15 sacrum 5 x 6.5 x 0.3 Stage 2 bases seen small serosanguinous drainage. -9/8/14 describe new or existing other issues. Pressure ulcer coccyx stage (2) 4 cm by 6 cm edges and surrounding skin drak (sp) pink in color gluteal fold. -9/15/15 Stage IV beefy red tissue with tunneling near gluteal fold 3 x 2 x 3. Director of Nursing (DOB) B was not available during the week of the survey to clarify the discrepancies of the wound measurements, clarify documentation of more than one pressure ulcer. On 9/17/15 at 12:15 PM, Physician KK reported the Dakins solutions would help with slough, granulation tissue and healing of the wound, was aware it was not in on 9/16/15 but was informed it would be in on 9/16/15 at night. Physician KK stated, Had I been informed it (Dakins solution) would have been longer, I could have ordered something else. Physician KK reported she was not aware Resident #4 was not on a specialty bed to promote healing of the wound and was not aware of the wound had developed an odor. On 9/18/15 at 2:15 PM, Wound Nurse LL reported she was hired 2 weeks ago as the wound care nurse, had rounded with the Wound Physician on 9/15/15, agreed Resident #4 had 2 separate wounds #4 on the sacral area (right upper buttock area) and #6 mid sacral (top of gluteal fold). Wound Nurse LL reported there was a small amount of slough present in the base of the wound bed, there had not been any odor at that time on 9/15/15. Wound Nurse LL reviewed the treatment records and agreed the records were very confusing, with inconsistent measurements, clinical records did not specify which wound was measured, and clinical records appeared the wounds had worsened. At 3:30 PM, Wound Nurse LL reported she had contacted the physician due to Resident (#4) temperature of 99.4 and a foul odor to the wound, and that the physician had ordered a culture of the wound following antibiotics of [MEDICATION NAME] and [MEDICATION NAME]. According to the facility's Wound Care/Treatment Guidelines, I. A weekly assessment should be done on all wounds requiring treatment. This should include measurement and description. Preferably, this will be done on an assessment sheet and placed near the nurse's note on the chart so nurses will be aware of the progress .XIII. Documentation of the treatment should be done immediately after the treatment. According to information provided by the facility, Lippincott Procedures-Pressure ulcer management, long term care, Stage III A stage III pressure ulcer is characterized by full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, and muscle aren't exposed. Slough may be present but doesn't obscure the depth of tissue loss. Undermining and tunneling may be present. The depth of a Stage III ulcer varies by anatomic location. Stage IV- A stage IV pressure involves a full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present in some parts of the wound bed. Undermining and tunneling are also common. The depth of a stage IV ulcer varies by anatomic location. ( )

This citation pertains to intake MI 522. Based on interview and record review the facility failed to apply a specialty leg brace on one (#717) of seven sampled residents reviewed for range of motion from a total sample of 20, resulting in a decrease in range of motion. Findings include: On 8/19/14 at 12:30 pm and on 8/25/14 at 10:00 am, Resident #717 who no longer lived in the facility was interviewed by telephone. Resident #717 explained that she was fitted for a brace in the hospital that she was supposed to wear to prevent any further contracture in her right knee. Resident #717 further explained that before she entered the facility, she could transfer herself on and off the bedside commode and get back and forth into her wheelchair and now, "I (#717) need help with everything. Now my leg is so contracted I can kick myself in the butt. They may even have to cut it off if they can't get it straighten out." Resident #717 described that when she left the hospital, she had been able to place both feet flat on the floor, when seated in a chair; but, now, her right knee was so contracted that in order to put the right foot on the floor when seated, she would have to be sitting on the edge of the seat and lean all the way over to her right side to get the top of her foot to the floor. She went on to say that "I went there (facility) to get better not worse! They were supposed to give me therapy on my knee and they didn't do that the first two weeks I was there. They put me on the Dementia Unit and when my husband showed up, they (staff members) asked him what did I want to eat and if they should get me up. When my husband raised hell, that's when they put me on the rehab (rehabilitation) floor and that's when I got some therapy. They didn't put my brace on until then (when moved onto the rehabilitation floor). (Company name) came and fitted me for the brace while I was in the hospital. I expected to wear it (the Jax Brace) four hours in the morning and in the evening because I had surgery on my knee. They (facility staff members) didn't even try to put it (brace) on. It just sat in closet and when they put it on, it (brace application) would hurt and I would holler. I expected some pain, they prepared me for that (pain) in the hospital. Some man from physical therapy would come in and lift my leg up and as soon as I hollered he would put it back down. That ain't no therapy!! Then there was a female (CNA 'G') that would come in and she act like she didn't know what she was doing. I had to tell her how to put it on. I kept showing her the picture that the (Company name) left. I only refused to wear the brace one time because I was coming down with something. Sometimes they didn't even have enough staff. There were many days when there was only two staff for 26 residents. How are two staff gonna help all of us? I need that many just to help move me in the bed. They didn't give me therapy, didn't put my brace on right and when I got discharged my right leg was so contracted that right now I can kick my own butt!!!!" On 8/20/14 at 10:30 am, clinical record review revealed that Resident #717 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE], revealed that Resident had intact cognition, was able to make her needs known and had no documented behaviors that impeded care. Resident #717 required extensive two-person physical assistance with bed mobility and transfers. During the assessment period Resident #717 did not ambulate in the room or outside of the room and there was limited Range of Motion to one lower extremity. Further record review revealed the following: The "Initial Plan of Care" dated 5/22/14, did not address Resident #717's right knee contracture nor did it address the Jax Brace that she was admitted with. The "Physician History and Physical" dated 5/23/14 noted that Resident #717 had a total right knee replacement and was "coming for rehabilitation." An admission nursing note dated 5/23/14 indicated that Resident #717 had bilateral leg and feet contractures. Physical Therapy (PT) notes signed on 5/30/14 noted the plan of treatment to improve range of motion to left hip, improve muscle strength to left hip and improve bed mobility. There was no plan of care for the right knee contracture nor did the PT notes address the use of the Jax Brace. The Assessment summary noted "patient had knee arthroplasty right, have knee flexion contracture." Review of the facility "Rehab to Restorative Transition Record" for Resident #717 did not include any goals or intervention to "maintain/improve passive range of motion right knee" until 6/2/14. Activities to be performed with resident included "On and off knee brace two hours as tolerated in morning and evening." The problems that were documented included "pain/contracture." There was no physician order that specified use of the Jax Brace until 6/5/14. The physician order dated 6/5/14 indicated Resident #717 was to have "Jax brace to right knee on at all times may remove for bathing. Physical Therapy for Range of Motion and strengthening to right knee." According to a "Report of Consultation" dated 6/4/14 noted a healing right knee arthroplasty and the Jax Brace on right knee to worn at all times (off for bathing only.) Physical Therapy for Range of Motion and strengthening to the right knee. There was no "Rehabilitation/Restorative Service Delivery Record" to review for May 22 - 31, 2014. Review of the "Rehabilitation/Restorative Service Delivery Record" for June 2014 revealed that Resident #717 was not offered application of the Jax Brace until 6/4/14. There was no care plan related to Restorative Nursing or application of the Jax Brace. On 8/21/14 at 2:40 pm, the Rehabilitation Director (Physical Therapist 'T') was interviewed regarding Resident #717's progress with Physical Therapy. Physical Therapist 'T' reviewed Resident #717's therapy notes and revealed that measurements of the right knee were taken upon admission but not at discharge and therefore was unable to determine if the knee joint had improved or declined. Also, there were no intermediate measurements taken. The Rehabilitation Director was unable to explain why therapy to the knee was not included in the goals or why the Physical Therapy plan of care did not address use of the Jax Brace on admission since Resident #717 was admitted for physical therapy. The Rehabilitation Director was also unable to determine if Resident #717's brace was applied between the dates of 5/22/14 through 6/4/14 and referred any further questions to Physical Therapist 'R'. On 8/22/14 at 10:00 am, Physical Therapist (PT) 'R' was queried and stated that Physical Therapy and Restorative Nursing had been combined. PT 'R' then reviewed Resident #717's Physical Therapy notes and was queried. PT 'R' was unable to explain why there was no Physical Therapy goal related to Resident #717's right knee contracture or why use of the Jax Brace was not addressed or included in the plan of care. PT 'R' was unable to explain if the Jax Brace was placed on Resident #717 between 5/22/14 (admission) through 6/5/14 nor was PT 'R' able to confirm if the application of the Jax Brace was consistently applied by Restorative Nursing Staff. On 8/22/14 at 10:30 am, Restorative Certified Nurse Assistant (CNA) 'G' stated that Resident #717 came from the hospital with the Jax Brace. CNA 'G' explained the brace was one "that I ('G') am unfamiliar with. (PT 'R') showed me how to apply it. It took a couple of times for me to get used to putting it on." When asked about the order of how long Resident #717 was to wear the brace, CNA 'G' said that there was on order written on 6/5/14 for Resident #717 to wear it at all times but she didn't get the order until a week later. CNA 'G' was unable to say if Resident #717 wore the brace or was assisted with applying the brace prior to 6/5/14. CNA 'G' added, "sometimes, (Resident #717) would say that the brace was hurting her and sometimes she would tell me stop." CNA 'G' confirmed that there was no "Rehabilitation/Restorative Service Delivery Record" for the month of May 2014. CNA 'G' reviewed the "Rehabilitation/Restorative Service Delivery Record" for June 2014 and was asked what the blanks indicated. CNA 'G' explained that blanks meant that there was no staff available to put the splints on and off and that there was no staff present on the weekends to put the splints on. The letter 'h' meant that the brace was held for "some reason" and that there are only two shifts (am and pm) for restorative nursing. "We do have off days. I don't know what happens when we are off. There is no restorative on the night shift either." On 8/22/14 at 11:55 am, Nurse 'K' was queried and stated, "(Resident #717) refused to wear the brace probably because of pain." When queried if the brace was placed on consistently Nurse 'K' stated "I wasn't familiar with the brace. It should have already been applied by the time the Midnight shift started." On 8/22/14 at 12:30 pm, Restorative CNA 'Q' was queried regarding Restorative Nursing and stated that "I (CNA 'Q') haven't worked in Restorative for the last six months. There has been no Restorative Aides scheduled on the weekends. And they (managers) don't understand that you need two to three people to perform Range of Motion on (Resident #717) because she was large, the bed was small and you have to do a lot a stretching which takes up a lot of time to get the brace on." On 8/22/14 at 1:15 pm, during an interview with the Director of Nursing (DON) regarding the Restorative Nursing Program, the DON explained that the Physical Therapy Department was given oversight of the Restorative Nursing Program and was unable to explain why Resident #717's contracture or knee brace was not addressed in a care plan, why the knee brace was not applied as ordered when Resident #717 was admitted into the facility for therapy, or why Resident #717 did not receive interventions to prevent an increase in contractures. The DON then stated, "You and I both know that ultimately I am responsible for the (restorative nursing) program." The DON when asked, explained that there was Restorative Certified Nursing Assistants scheduled on each shift and that if staff were not available to apply the Jax Brace any nursing staff would be able to do it. When asked if nursing staff had to be trained to apply the Jax Brace like Restorative CNA 'G', the DON stated, "I expect all nursing staff to be able to put on a brace. I am certain that even if it were a specialty item, the nurses could put it on." When asked if she was aware that staff believed it was necessary for at least two staff to be present to apply the Jax Brace the DON stated, "I was not aware that (Resident #717) required two people to apply the Jax Brace." During the interview a policy regarding Restorative Nursing was requested but was not made available for review by the end of survey. ( )

This citation pertains to intake MI 522. Based on interview and record review, the facility failed to implement interventions to prevent a pressure ulcer and failed to implement the necessary treatment and services to promote healing and prevent infection for one resident (#717) of seven reviewed for pressure ulcers from a total sample of twenty resulting in an avoidable unstageable (full thickness tissue loss where the base of the pressure ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) right heel pressure ulcer which subsequently led to a bone infection and the potential for right foot amputation. Findings include: On 8/19/14 at 12:30 pm and again on 8/25/14 at 10:00 am, Resident #717, who no longer lived in the facility, was interviewed by telephone. Resident #717 explained that her right knee was bent (contracted) at an angle which caused her right heel to press into the mattress. According to Resident #717, "That facility gave me a foot infection!! I got a pressure ulcer in the facility and they never even told me about it! I saw a doctor (who came in) every week the last few weeks and (doctor) looked at my right foot. They put a boot (Allevyn heel foam, a soft, cup-shaped dressing placed on wounds that are difficult to dress and used to collect wound drainage) on it and never told me anything. The boot was too big anyway and it never stayed on. It was always falling off! My right foot was always on the bed." When Resident #717 was asked if the facility tried to position her foot so that it was not pressing into the bed, Resident #717 said, "No!! They didn't tell me about the bed sore. They didn't do anything! They didn't give me a pillow or nothing. Just that boot (according to the manufacturer, the heel foam only comes in one size) that kept coming off because my heel was always pressing into the bed (mattress). When I got home after they (facility) discharged me, the next day the home health care nurse took the dressing off my foot and asked me how did I get a pressure sore that bad on my foot. The next thing I knew they told me it was infected down to the bone and if the antibiotics don't work they are going to amputate my foot off at the ankle. I have diabetes and my foot is slow to heal." Resident #717 could be heard audibly crying, sobbing and attempting to catch her breath as she explained what the facility failed to do for her. On 8/20/14 at 10:30 am, clinical record review revealed that Resident #717 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE], revealed that Resident had intact cognition, was able to make her needs known and had no documented behaviors that impeded care. Resident #717 required extensive two-person physical assistance with bed mobility and transfers. During the assessment period Resident #717 did not ambulate in the room or outside of the room and there was limited Range of Motion to one lower extremity. According to the MDS assessment Resident #717 was at risk for pressure ulcer development. However, Resident #717 did not have any unhealed pressure ulcers prior to admittance. Further clinical record review revealed the following: The "Initial Plan of Care" dated 5/22/14 did not indicate that any goals or interventions were initiated to assess, monitor or prevent Resident #717's potential for the development of pressure ulcers. Physician History and Physical dated 5/23/14 noted that Resident #717 had no documented evidence of pressure ulcers noted to either heel. Resident #717 was at the facility 13 days before a care plan for pressure ulcer prevention was developed. The form titled "Care Plan - Pressure Ulcers" dated 6/4/14 for Resident #717 noted a Braden Score of "15", which according to the Braden Scale Assessment, "a score of 15 to 16 indicates low risk" for the development of a pressure ulcers. The Care Plan did not address the potential for the development of pressure ulcer development to the heel. According to the facility form titled, "Head to Toe Skin Checks" dated 6/7/14, a "dark area" on Resident #717's right foot was observed. There was no change or intervention implemented at the time that Resident #717's "dark area" on the right foot was noted. A physician's order dated 6/9/14 documented "Wound care consult." A "Wound Care Services" note dated 6/10/14 documented a suspected deep tissue injury pressure ulcer that was purple in color and measured 5.5 cm (centimeters) in length x 4.5 cm. The treatment at that time was to leave wound open to air and monitor for drainage. There was no intervention noted to offload or reposition (to decrease pressure) Resident #717's right foot to promote healing. A "Wound Care Services" note dated 6/17/14 documented an unstageable pressure ulcer that measured 3.5 cm x 5.0 cm developed in the facility "two weeks" ago (6/3/14) as a result of a right knee contracture and "the staff was unable to offload pressure." The suggested treatment at that time was to apply Allevyn foam to right heel and change dressing every four to five days and as needed. A physician's order dated 6/17/14 noted, "Allevyn heel foam (boot) to right heel every four days." According to the June 2014 Treatment Administration Record (TAR), the Allevyn heel foam was ordered, however was not applied until 6/20/14. In addition, there was no evidence that the facility staff assessed, monitored or implemented interventions to treat the "dark area" to Resident #717's right heel. Another physician's order dated 6/25/14 noted to apply Allevyn to the right heel, to change every four days and to perform a weekly skin assessment. A "Wound Care Services" note dated 7/1/14 documented that Resident #717 had a right heel wound that was black and elliptical in shape. "The patient is at moderate risk for developing complications. Prognosis for healing is uncertain. Wound #1 right heel is necrotic tissue (unstageable) pressure ulcer, measurements are 3 cm (centimeters) in length and 4.5 cm in width. The wound bed is 75-100% eschar (dead skin tissue)." On 8/22/14 at 1:15 pm, during an interview with the Director of Nursing (DON) regarding Resident #717's development of a pressure ulcer the DON reviewed the clinical record and noted that Resident #717's developed an avoidable unstageable pressure ulcer. The DON was asked why Resident #717 had no initial care plan that addressed the prevention of a right heel pressure ulcer; why Resident #717 did not have interventions in place to prevent a right heel pressure when Resident #717 was admitted with a right knee contracture; why no interventions to alleviate pressure were initiated after Resident #717 developed an avoidable unstageable pressure ulcer to the right heel; why the care plan did not reflect the presence of a right heel pressure ulcer; why there was no wound assessment by the facility other than that by the Wound Care Specialist; why there was no treatment documentation by the facility other than application of the Allevyn heel foam; and why there was no evidence that the facility implemented interventions to prevent the right heel pressure ulcer before and after discovery of Resident #717's right heel pressure ulcer. The DON did not have any explanation. On 8/27/14 at 11:40 am, Nurse 'S' who was the nurse manager at the time of Resident #717's admission was queried. Nurse 'S' stated that she was aware of the pressure ulcer to the right heel but was unable to explain why there was no care plan that addressed interventions nor was she able to explain why no other interventions other than the Allevyn heel cover was implemented. On 8/27/14 at 12:00 pm, review of the facility policy titled "Skin Management" revised on 2/2010, noted that an unstageable pressure ulcer is "when eschar is present, accurate staging is not possible until the eschar has sloughed or the wound has been debrided" at this point the depth and stage of the pressure ulcer is unable to be determined. The policy defined suspected deep tissue injury as "purple or maroon localized area of discolored intact skin or blood-filled blister due to damage to underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is firm, mushy, boggy, or warmer or cooler as compared to adjacent tissue. May open and deteriorate rapidly even with optimal treatment." The policy also noted that for bed bound residents, tissue loads could be managed through positioning: "position off of an ulcer. Avoid positioning a resident directly on a pressure ulcer whenever possible. Use positioning devices (pillows, blanket rolls) should be used to completely raise the pressure sore area (i.e. heel and back of head, completely off of the support surface. Use of these devices may reduce the need for a pressure reducing mattress or overlay. 3. Establish an individualized turning schedule based on the resident's clinical condition. 4. Totally relieve heel pressure by elevation of the heel completely off of the bed surface (or use of heel protectors)." The Skin Management Policy did not address interventions specifically related to Suspected Deep Tissue Injury or Unstageable Pressure Ulcer Management. ( )

This citation pertains to intake number MI 443 Based on interview and record review the facility failed to provide consistent interventions to promote healing and follow the recommended orders for pressure ulcer treatment in a timely manner for one (#501) of three residents reviewed for altered skin integrity from a sample of three residents resulting in the development of a stage IV pressure wound that was acquired in the facility. Findings include: 04/16/14 at 10:45 a.m., the 2nd floor unit manager (A) was queried about wound treatment in the facility and the unit manager reported that the facility did not currently have a treatment nurse, but they were in the process of hiring one. When asked about resident #501's pressure wounds, Unit manager (A) explained that Resident #501 no longer resided in the facility, but she (#501) did reside on the 2nd floor when she (501) was there. Unit manager (A) further explained that #501 developed a blister on each heel and had been followed by Nurse Practitioner (C). The blister on the left heel resolved, but one month later the right heel blister became progressively worsen and developed into an unstageable pressure ulcer. Review of medical record on 04/16/2014 at 11:15 a.m. revealed that #501 was [AGE] years old and was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS (Minimum Data Set) assessment dated [DATE], resident #501 required extensive assistance with activities of daily living including bed mobility and transfers. The MDS also indicated that Resident#501 had no pressure ulcers as of 10/24/2013. The Braden scale assessment dated [DATE] and 3/1/14 documented a score of 17 and 12 respectively. The score of 12 indicated a high risk for the development of pressure sores. On 04/16/14 at 10:45 a.m., an interview was conducted with the unit manager (A) who explained that resident wound got progressively worse. "It was being treated with Santyl. I kept asking if she (#501) should go to the hospital to have the wound debrided, but the wound consultant said that the Santyl served the same purpose and would provide enzymatic debridement." The unit manager further explained that resident #501 was supposed to have heel protectors on at all times, but there were times when she did not have them on. The unit manager reported that wound specialist became angry because she observed the heel protectors not being used multiple times. Review of the Pressure Ulcer care plan revealed that heel protectors were to be worn while up in cair. According to the clinical record, Resident #501 was initially seen by the wound consultant on 11/20/2014 for blisters on both her right and left heels. Review of nurse practitioners wound report revealed the following: On 11/20/13 "I am seeing (#501) for left and right heel wounds ...has a blood blister on her right heel. The cap is measuring 4.0 x 3.0 cm.(centimeters) It is about three-quarters desiccated (dried out) ...there is another blister on her left heel that has desiccated. The cap measures 4.8x 3.2 cm. There is no drainage...we are going to continue with the pressure offloading to these areas. I want this to be while she is in bed and while she is up in the chair. We will allow the left heel cap to autolytically separate. We will allow the right heel to continue to desiccate." Further review of the wound consultants reports revealed that Resident #501was seen by the consultant on 11/27/13,12/04/13 and 12/11/13. The wound consultant documented the following: On 12/11/13 "...I am seeing (#501) again for her left and right heel desiccated blister caps. right heel is essentially resolved. It is a dry cap that is probably going to be some time before it peels off. The left heel.is now resolved ... " On 01/13/14 "...I am seeing (#501) today for an unstageable right heel wound ...The last time I saw (#501) the left heel we peeled off the blister cap and there was intact [MEDICATION NAME] tissue. The right heel still had a small stable cap that just needed to autolytically separate. Since that time her heel has further developed into a wound It is now measuring 3.0x 6.5 cm with an undeterminable base length. There is a scant to minimal amount of serosanguineous drainage..the base are blackened with some necrotic slough ...I am going to have Santyl applied for enzymatic debridement. We are going to cover the right heel with a foam dressing to help pad the region. To the left heel, we are also going to add a foam dressing to help protect the area ..." On 01/20/14 "...Plan: I would like to continue the Santyl for ongoing enzymatic debridement ... " On 04/16/2014 at 12:15 p.m. in the presence of the Unit Manager (A), the treatment administration records for January 2014 were reviewed and revealed that the recommended treatment of [REDACTED].#501 until 01/25/2014. The treatment that was administered to #501's right heel was "xeroform and bulky dry dressing" and even then, it had not been provided daily. The TAR indicated that there was no treatment provided to #501 on 01/14/14, 01/15/2014, 01/16/2014, 01/20/14, or 01/21/14. The facility began the Santyl treatment to the right heel on 01/25/14, but #501 did not receive treatments on 01/28/14 or 01/30/14. The TAR also indicated that resident #501 did not receive the Santyl treatment to her right heel on 02/1/14 through 02/04/14, 02/07/14, 02/11/14, 02/15/14, 02/16/14, and 02/25/14. The unit manager was queried about the inconsistent wound treatment, and the lack of providing the recommended treatment by the wound consultant. The unit manager stated, "I was present when the wound consultant said that Santyl should be used on the resident's right heel, but the order was not written and the nurses continued to treat the right heel would with the previous order. The order wasn't written until 01/25/14. The wound consultant (C) mentioned to me that the Santyl treatment was not being administered, so I spoke to the floor nurse (D) who explained that the order for Santyl was not on the TAR or on the physician order sheet." Review of the Physicians orders dated 01/25/14 revealed, "Santyl ointment to the right heel, cover with foam dressing and bulky wrap daily, and Left heel foam dressing with bulky dressing change every three days. " The unit manager further explained that the order was transcribed incorrectly onto the TAR, as it indicated that the right heel wound was to be changed every three days when in fact it was to be treated daily. A telephone interview with NP (C) was conducted on 04/16/14 at 2:18 p.m. NP (C) explained that she recommended the use of Santyl once the wound became unstageable. There were times when the dressings were old which indicated that they had not been changed consistently. There was some confusion on how they would process my orders. it wasn't clear if I would make the recommendation and they would write the order, or if I would write the order. When queried about the Santyl treatment for [REDACTED]. The NP said that the Santyl treatment was supposed to have been daily. The NP further stated that "An every three day order is an inappropriate order." On 04/16/13 at 3:00 p.m. an interview was conducted with restorative aide (G) who explained that she walked with the resident (#501) daily for the restorative porgram and she walked very well. Restorative aide (G) said that she stopped walking with (#501) when she began to complain that her foot was hurting and she was required to stay in bed most of the time. Resident #501 lost her ability to walk independently as a result of the heel wound. Further review of the wound consultant reports revealed the following: On 03/03/14 "...we continued the Santyl for ongoing enzymatic debridement. Unfortunately, this week the wound has markedly deteriorated so now has an area on her coccyx...right heel is measuring 8.0x55.8 cm..I have ordered an x-ray to rule out osteo[DIAGNOSES REDACTED] ... " On 03/10/14 "...her right heel wound is now measuring 9.5 x 6.1...we are going to continue limiting her time in the chair" On 03/17/14 "...right heel wound is measuring 9.5 x 6.5 cm ...she is going to have an MRI of her right calcaneus. Additionally she is going to go to vascular surgery, and they are going to decide whether they can do debridement or amputation. " On 03/24/14 "... right heel wound is now measuring 9.1 x 7.5 cm with undeterminable base depth ...she did go out for an MRI recently to rule out an acute osteo[DIAGNOSES REDACTED] ...she is going out to a vascular surgeon over the next week. He is going to decide about amputation. Review of Radiology report dated 03/24/14 revealed "...No evidence of osteo[DIAGNOSES REDACTED] left heel. " Review of the physician orders dated 3/14/14 revealed " Vascular surgery consult ...MRI left heel for osteo[DIAGNOSES REDACTED] ... " It was unclear why the facility ordered for the MRI to be done on resident #501's left foot, when the right foot had the unstageable wound. The unit manager was unable to explain why the MRI was done on the wrong foot or why consistent use of the recommended treatment was not administered to resident #501. On 4/16/14 at 3:20 p.m., review of the facility policy entitled "skin management" dated August 2012 revealed, "...the nurse will document daily monitoring of all pressure ulcers on the Treatment Administration Record ...the nurse will assure treatments, interventions, care plan, and the appropriate skin documentation records are initiated in a timely manner ..." ( )

THIS REGULATION HAS THREE DEFICIENT PRACTICES. DEFICIENT PRACTICE #1. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO CLEAN AND SANITIZE THE KITCHEN AND KITCHEN EQUIPMENT USING AN APPROPRIATE SOLUTION THAT REDUCES MICRO-ORGANISMS TO A SAFE LEVEL FOLLOWING A BACK UP OF RAW SEWAGE INTO THE KITCHEN RESULTING IN THE POTENTIAL FOR 135 RESIDENTS BEING SERVED FOODS FROM CONTAMINATED FOOD CONTACT SURFACES AND KITCHEN EQUIPMENT THAT WERE NOT WASHED, RINSED AND SANITIZED FROM A TOTAL CENSUS OF 144 RESIDENTS , RESULTING IN AN IMMEDIATE JEOPARDY TO THE HEALTH AND SAFETY OF THE RESIDENTS. THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON 8/8/12 AT 11:55 A.M., WHEN RESIDENTS WERE OBSERVED BEING SERVED FOODS WHICH WERE PREPARED FROM THE KITCHEN. THE FACILITY ADMINISTRATOR WAS NOTIFIED ON 8/8/12 AT 2:15 P.M., AND A PLAN OF CORRECTION WAS REQUESTED TO REMOVE THE IMMEDIATE JEOPARDY. THE IMMEDIATE JEOPARDY WAS REMOVED ON 8/8/12 BASED ON THE FACILITY'S IMPLEMENTATION OF CORRECTIVE ACTIONS AS VERIFIED ONSITE BY THE SURVEY TEAM ON 8/8/12. ALTHOUGH THE IJ WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE WAS NOT CORRECTED AND REMAINED AS WIDESPREAD, WITH NO ACTUAL HARM, WITH A POTENTIAL FOR MORE THAN MINIMAL HARM THAT WAS NOT IMMEDIATE JEOPARDY. FINDINGS INCLUDE: ON 8/8/12 AT 9:45 A.M., DURING OBSERVATIONS OF THE FACILITY'S KITCHEN A FOUL, SEWER LIKE SMELL WAS NOTED. DIETARY MANAGER, "D" WAS QUERIED AS TO WHAT THE SMELL WAS AND STATED, "THE DRAINS BACKED UP." THE FLOOR DRAIN IN FRONT OF THE OVEN WAS BEING SNAKED BY AN OUTSIDE CONTRACTOR. THE FLOOR SURROUNDING THE DRAIN HAD PIECES OF BROWNISH BLACK DEBRIS. THE CONTRACTOR WAS OBSERVED TO BE REMOVING WHAT APPEARED TO BE A LARGE BALL OF LATEX GLOVES WITH REMNANTS OF BROWNISH SEWER DEBRIS. THE CONTRACTOR STATED, "I FOUND SOME GLOVES," AND DISPOSED OF THEM IN THE GARBAGE CAN. THERE WAS A SECOND DRAIN IN FRONT OF THE DISH MACHINE, THE FLOOR MATTS HAD BEEN PULLED AWAY FROM THE AREA, IT WAS ALSO OBSERVED THAT THE DRAIN IN FRONT OF THE DISH MACHINE HAD PIECES OF BROWNISH BLACK DEBRIS ON THE FLOOR SURROUNDING THE DRAIN. THE ACTING HOUSEKEEPING SUPERVISOR, EMPLOYEE "H" WAS VACUUMING UP SEWER OVERFLOW THAT HAD POOLED OUT THE SIDE DOOR OF THE KITCHEN FROM THE DISH MACHINE AREA SEWER DRAIN. THERE WAS AN AREA AT LEAST 2 FEET WIDE AND SIX TO SEVEN FEET LONG COVERED WITH SEWER OVERFLOW. ON 8/8/12 AT 10:45 A.M., AN OBSERVATION WAS MADE OF THE KITCHEN. DIETARY MANAGER "D" WAS MOPPING THE FLOOR BY THE FOOD PRODUCTION COUNTER. THE FLOOR STILL HAD BITS OF FOOD DEBRIS AND DIRT UNDERNEATH THE COUNTER AND STEAM TABLE. DISHES WERE BEING RAN THROUGH THE DISH MACHINE, THE COOK WAS PREPPING SAUSAGE FOR THE LUNCH MEAL. DIETITIAN "E" STATED, "ALL EQUIPMENT HAS BEEN SANITIZED." AT 10:50 A.M., DIETITIAN "E" WAS OBSERVED WIPING DOWN THE COOKS PREPARATION TABLE WITH A RAG THAT WAS DIPPED IN A RED SANITIZING BUCKET SITTING ON THE MIXER TABLE WHILE DIETARY MANAGER "D" CONTINUED TO MOP THE SURROUNDING FLOOR. DIETITIAN "E" WAS QUERIED REGARDING THE SANITIZING SOLUTION IN THE BUCKET AND REVEALED THAT IT WAS THE SANITIZING SOLUTION BEING USED TO CLEAN THE EQUIPMENT AND THAT SHE "TOOK IT FROM THE 3 BIN SINK THAT WAS BEING USED TO WASH THE DISHES." DIETITIAN "E" WAS ASKED TO CHECK THE SANITIZING SOLUTION WITH THE APPROPRIATE TEST STRIP. DIETITIAN "E" tested THE SANITIZING SOLUTION OF THE BUCKET AND VERIFIED THAT IT DID NOT REGISTER THE REQUIRED 150-400 PPM (PARTS PER MILLION) NECESSARY FOR ADEQUATE SANITIZATION ACCORDING TO THE MULT-QUAT SANITIZER PRODUCT INFORMATION. EMPLOYEE "F" WAS QUERIED AS TO HOW SHE CLEANED THE LARGE EQUIPMENT AND STATIONARY EQUIPMENT AND REVEALED, "I WIPED THEM DOWN WITH A RAG FROM THE SANITIZING SOLUTION BUCKET THAT WAS TAKEN FROM THE 3 BIN SINK." EMPLOYEE "G" WAS QUERIED AS TO HOW SHE CLEANED THE LARGE EQUIPMENT AND STATIONARY EQUIPMENT AND REVEALED THAT SHE WIPED THEM DOWN WITH THE "BUCKET OF SANITIZER." BOTH EMPLOYEE'S REFERRING TO THE SAME SANITIZING BUCKET THAT DID NOT REGISTER THE APPROPRIATE AMOUNT OF SANITIZING AGENT. DIETITIAN "E" STATED, "THAT IS HOW WE ALWAYS DID IT (BY DIPPING A BUCKET INTO THE SANITIZING SOLUTION COMPARTMENT OF THE THREE BIN SINK). WHEN QUERIED NEITHER EMPLOYEE "F," "G," OR DIETITIAN "E" REVEALED THAT THE EQUIPMENT HAD BEEN FIRST WASHED, THEN RINSED AND PROPERLY SANITIZED. DIETARY MANAGER "D" WAS QUERIED AS TO WHAT WAS IN THE MOP BUCKET SHE WAS EMPTYING. SHE REVEALED, "IT IS BLEACH WATER." WHEN QUERIED AS TO HOW MUCH BLEACH WAS IN THE SOLUTION, SHE REVEALED, "ONE TABLESPOON PER GALLON OF HOT WATER." THIS DILUTION WOULD EQUAL ONE HALF OF AN OUNCE OF BLEACH PER GALLON OF WATER WHICH IS WELL BELOW THE RECOMMENDATIONS OF 1.6 OUNCES OF BLEACH PER GALLON OF WATER FOR CLEANING OF FLOORS AFTER A SEWER BACKUP ACCORDING TO THE "EMERGENCY ACTION PLANS FOR RETAIL FOOD ESTABLISHMENTS," IN MICHIGAN, NO DATE, PAGE 37. ON 8/8/12 AT 11:55 AM, THE STEAM TABLE WAS OBSERVED SET UP IN THE MAIN DINING ROOM WITH PANS OF FOOD THAT HAD BEEN PREPARED IN THE KITCHEN. RESTORATIVE AIDE 'W' APPROACHED THE REGISTERED DIETITIAN (RD 'E'), WHO WAS STANDING BEHIND THE STEAM TABLE, AND REQUESTED A PLATE OF FOOD FOR RESIDENT #515, WHO WAS SEATED IN THE DINING ROOM. RD 'E' PLACED POLISH SAUSAGE, CORN, AND BAKED BEANS ON A PLATE. AIDE 'W' WAS OBSERVED CARRYING THE PLATE OF FOOD AND PLACING IT ON THE TABLE IN FRONT OF RESIDENT #515 IN AN ATTEMPT TO SERVE IT TO THE RESIDENT. ON 8/8/12 AT 11:55 A.M., THE MEAL SERVICE WAS STOPPED. ON 8/8/12 AT 12 NOON, DIETITIAN "E" WAS QUERIED REGARDING WHAT THE NORMAL PROCEDURES SHOULD BE IF A BACKUP OF A DRAIN OCCURRED AND DIETITIAN "E" STATED, "CLEAR THE AREA, CLEAN AND SANITIZE EVERYTHING." REVIEW OF THE FACILITY'S POLICY AND PROCEDURE TITLED "DIETARY CLEANING," NO DATE, REVEALED THE FOLLOWING: "PROPER CLEANING AND SANITATION OF EQUIPMENT ENSURES REMOVAL OF RESIDUAL FOOD, CHEMICALS, AND BACTERIA. ALL FOOD CONTACT SURFACES MUST BE WASHED, RINSED AND SANITIZED." A REVIEW OF THE MATERIAL SAFETY DATA SHEET AND PRODUCT INFORMATION FOR THE FACILITY'S MULTI-QUAT SANITIZER USED IN THE THREE BIN SINK REVEALED THE FOLLOWING: "EFFICACY RANGE 150-400 PPM. DIRECTIONS FOR USE: APPLY MULTI-QUAT SANITIZER AT PROPER USE SOLUTION. EXPOSE ALL SURFACES OF EQUIPMENT, WARE OR UTENSILS TO THE SANITIZING SOLUTION FOR A PERIOD OF NOT LESS THAN ONE MINUTE. AIR DRY." INDICATING THAT IF USED FOR FREE STANDING EQUIPMENT OR FOOD CONTACT SURFACES, THE EQUIPMENT OR SURFACE WOULD NEED TO BE COMPLETELY COVERED IN THE PROPERLY DILUTED SANITIZING SOLUTION AND LET SIT FOR NOT LESS THAN ONE MINUTE TO BE PROPERLY SANITIZED. ACCORDING TO THE "EMERGENCY ACTION PLANS (EAP) FOR RETAIL FOOD ESTABLISHMENTS IN MICHIGAN," NO DATE, PAGE 3, "IN THE EVENT OF AN IMMINENT HEALTH HAZARD INVOLVING...SEWAGE BACK-UP AT (A FACILITY) THE (FACILITY) SHALL IMMEDIATELY DISCONTINUE OPERATION IF A SAFE OPERATION CANNOT BE MAINTAINED USING AND ALTERNATIVE PROCEDURE. 2. NOTIFY THE REGULATORY AUTHORITY OF THE IMMINENT HEALTH HAZARD AND DISCUSS ALTERNATE PROCEDURES TO BE USED. 3. FOLLOW THE APPROPRIATE EMERGENCY PROCEDURES IF APPROVED BY THE REGULATORY AUTHORITY OR REMAIN CLOSED UNTIL GRANTED APPROVAL TO RE-OPEN BY THE REGULATORY AUTHORITY." PAGE 36, "AFFECTED WALLS, FLOORS, AND EQUIPMENT SURFACES MUST BE CLEANED WITH SOAP AND WATER, RINSED, AND SANITIZED. USE A DETERGENT SOLUTION TO CLEAN FLOORS, EQUIPMENT, AND OTHER AFFECTED AREAS FOLLOWED BY A CLEAN WATER RINSE. SANITIZE THE FLOOR AND ANY OTHER AFFECTED AREAS USING A CLEAR WATER SANITIZER SOLUTION (EIGHT OUNCES OF BLEACH PER FIVE GALLONS OF WATER=500 PARTS PER MILLON CHLORINE SOLUTION (OR 1.6 OUNCES PER GALLON OF WATER). ALTERNATIVE MEASURE: HIRE A JANITORIAL SERVICE HAVING EXPERTISE IN CLEANING FOOD ESTABLISHMENTS EXPOSED TO SEWAGE BACKUPS." ON 8/10/12 AT 1:30 P.M., THE ADMINISTRATOR WAS INTERVIEWED REGARDING THE SEWER BACKUP IN THE KITCHEN. THE ADMINISTRATOR WAS QUERIED REGARDING WHY THE FACILITY CONTINUED TO PREPARE AND SERVE FOOD BEFORE THE KITCHEN WAS COMPLETELY SANITIZED FOLLOWING THE SEWER BACK-UP. THE ADMINISTRATOR STATED, "I WAS TOLD BY THE CORPORATE DIETITIAN TO SERVE THE MEAL (LUNCH). I DIDN'T WANT TO OPEN THAT KITCHEN." THE IMMEDIATE JEOPARDY WAS REMOVED ON 8/8/12 WHEN THE FOLLOWING PLAN OF CORRECTION WAS ACCEPTED: ON 8.8.12 AT APPROXIMATELY 9:00 A.M., IT WAS OBSERVED THAT A SMALL AMOUNT OF WATER WAS LEAKING INTO THE BASE OF 1 ELEVATOR PIT. THE ELEVATOR IN QUESTION WAS TURNED OFF, DETROIT ELEVATOR COMPANY CONTACTED. AT APPROXIMATELY 9:15AM NO WATER WAS LEAKING INTO THE ELEVATOR PIT. THE MAINTENANCE PERSONAL IN THE FACILITY ENTERED THE ELEVATOR PIT TO INSPECT AND WATER WAS IDENTIFIED WITHOUT ODOR OR DEBRIS, HOWEVER IT DID CONTAIN OIL. DETROIT ELEVATOR ADVISED MAINTENANCE DIRECTOR TO ADD ONE GALLON OF BLEACH TO THE PIT AREA AND THEY WOULD BE AT THE FACILITY ON 8/9/12 AT 6 PM TO PUMP ANY WATER THAT WAS IN THE PIT AREA. HOWEVER, DUE TO A MALFUNCTION OF THEIR PUMP TRUCK, THEY DID NOT ARRIVE AS SCHEDULED AND DID NOT NOTIFY THE FACILITY UNTIL 8 AM ON 8/10/12. HOWEVER, THEY ARE SCHEDULED FOR ARRIVAL ON 8.10.12 AT 1:00 PM TO CLEAN PIT RELATED TO THE OIL CONTINENTS SECONDARY TO EPA REGULATIONS. ON 8.8.12 AT APPROXIMATELY 12:00PM, THE NHA DIRECTED KITCHEN PERSONAL NOT TO SERVE FOOD FROM THE STEAM TABLE DURING LUNCH. THE STEAM TABLE WAS UNPLUGGED AND REMOVED FROM AREA. SERVING TABLES WERE SET UP AND SANITIZED IN THE BACK OF THE DINING ROOM. PROVISIONS AND SUPPLIES FOR COLD LUNCH SERVICE WERE OBTAINED FROM THE COOLER AND STORAGE ROOM AND BROUGHT THOUGH THE SERVICE HALLWAY TO AVOID THE KITCHEN AREA. THE KITCHEN WAS CLOSED AND REMAINED CLOSED UNTIL THE HIRED CLEANING COMPANY COMPLETED THROUGH KITCHEN CLEANSING AND SANITATION (SEE OUTLINED SCHEDULE BELOW) COLD FOOD WAS PREPARED BY KITCHEN PERSONAL IN THE SANITIZED AREA AND SERVED TO THE DINING ROOM ATTENDEES FIRST, THEN TO THE 2ND FLOOR RESIDENTS, 4TH FLOOR RESIDENTS AND 3RD FLOOR RESIDENTS UNTIL ALL RESIDENTS RECEIVED THE NOON MEAL. ALL FOOD THAT WAS COOKING FOR THE NOON MEAL WAS DISPOSED OF IMMEDIATELY. THE KITCHEN REMAINED CLOSED FOR DINNER ON 8.8.12, BREAKFAST AND LUNCH ON 8.9.12. DINNER ON 8.8.12 WAS PREPARED AT A SISTER FACILITY 20 MINUTES AWAY AND TRANSPORTED TO HERITAGE MANOR VIA HERITAGE CURRIERS. RESIDENTS RECEIVED THEIR DINNER MEAL AT APPROX 5:15PM AND TEMPERATURES OF FOOD WAS TAKEN AND LOGGED. ALL FOODS WERE AT ACCEPTABLE TEMPERATURE RANGE BETWEEN 38-40 DEGREES. BREAKFAST ON 8.9.12 AND LUNCH ON 8.912 WERE PREPARED IN A SANITIZED ARE IN THE DINING ROOM, AND TRANSPORTED TO RESIDENT DINING AREAS AND ROOMS IN THE FACILITY ON THE 2ND, 3RD, AND 4TH FLOOR. DURING MEAL DISTRIBUTION ON 8.8.12 & 8.9.12, EACH RESIDENT WAS ASKED IF THEY LIKE THE MEAL SERVED OR PREFER AND ALTERNATE. THOSE RESIDENTS THAT REQUESTED AN ALTERNATE WERE PROVIDED WITH ONE. THE REMAINING RESIDENTS EXPRESSED SATISFACTION WITH MEAL SERVED. THE DIETARY STAFF CLEANSED AND SANITIZED THE CONVENTIONAL OVEN, CONVECTION OVEN, STEAMER, REACHING REFRIGERATOR AND FREEZER HAD ALL OUTSIDE SURFACE AREAS USING 50/100 RATIO OF BLEACH AND WATER IN ACCORDANCE WITH THE FACILITY POLICY. THE SURFACE PREPARATION AREAS, TABLE AND SHELVES, WERE CLEANSED AND SANITIZED IN ACCORDANCE WITH FACILITY POLICY. THE KITCHEN PERSONAL WILL CONTINUE CLEANSING AND SANITIZING UNTIL ALL EQUIPMENT IS COMPLETED. THIS WILL INCLUDE WALLS, FLOOR AND CEILING TILES. ITEMS IN THE KITCHEN THAT COULD NOT BE SANITIZED WERE DISCARDED BY KITCHEN PERSONNEL. THE LIST OF DISCARDED ITEMS INCLUDES: FILM WRAP ALUMINUM FOIL ALCOHOL SWABS GLOVES TRAY PAN LINERS ZIP LOCK BAGS PUREE BREAD MIX POURED MILK FOR FOOD TRAYS PREPARED SNACKS PREPARED SNACK BEVERAGES FOOD THICKENER THE REGISTERED DIETICIAN CONTACTED CISCO FOODS ON 8.8.12 FOR FOOD REPLACEMENT DELIVERIES. A PROFESSIONAL CLEANING COMPANY, ' MOE CLEANING COMPANY ' WAS CONTACTED ON 8.8.12 TO THOROUGHLY DEEP CLEAN AND SANITIZE KITCHEN AND IS SCHEDULED TO IN THE EVENING ON 8.8.12. THE TEAM ARRIVED AT 8PM AND CLEANED/SANITIZED CONSISTENTLY UNTIL COMPLETION AT 5AM ON 8.9.12 CONVENTIONAL OVEN, CONVECTION OVEN, STEAMER, REACHING REFRIGERATOR AND FREEZER, ICE MACHINE, HAD ALL OUTSIDE SURFACE AREAS CLEANSED AND SANITIZED AND AS WELL AS INSIDE. THE SURFACE PREPARATION AREAS, TABLE AND SHELVES, WERE CLEANSED AND SANITIZED. THIS INCLUDED THE ENTIRE KITCHEN FROM CEILING TO FLOOR ALL PREPARATION SURFACE AREAS AND STORAGE SHELVES AND RACKS. ALL KITCHEN EQUIPMENT WAS CLEANED/SANITIZED. ARRANGEMENTS HAVE BEEN MADE TO RECEIVE SUBSEQUENT MEALS FROM AN OUTSIDE SOURCE UNTIL THE KITCHEN HAS BEEN COMPLETELY CLEANSED AND SANITIZED, STARTING WITH DINNER ON 8.8.12 AND CONTINUING UNTIL THE PROFESSIONAL CLEANING COMPANY HAS COMPLETED ENTIRE KITCHEN SANITIZATION. REGISTERED DIETITIAN WAS RE-EDUCATED ON POLICY AND PROCEDURE REGARDING INFECTION CONTROL AND KITCHEN SANITIZATION. DIETARY PERSONAL HAS BEEN RE-EDUCATED BY THE REGISTERED DIETICIAN ON 8.8.12 REGARDING THE FACILITY ' S ' DIETARY CLEANING POLICY ' AND CLEANSING AND SANITATION OF KITCHEN SURFACES. DIETARY PERSONAL THAT HAVE NOT BEEN RE-EDUCATION WILL NOT RESUME WORK RESPONSIBILITY UNTIL ALL EDUCATION IS COMPLETED. ALL FACILITY STAFF HAS BEEN EDUCATED BY THE NHA OR DESIGNEE BEGINNING ON 8/9/12 REGARDING THE POLICY TITLED ' EMERGENCY PREPAREDNESS ' INCLUDING SECTION E III TITLED ' NUTRITIONAL SERVICES ' . ANY FLUID COMING UP FROM A FLOOR DRAIN SHOULD BE TREATED AS POSSIBLE CONTAMINANT UNTIL DETERMINE OTHERWISE. EDUCATION WILL CONTINUE UNTIL ALL STAFF HAS RECEIVED THE EDUCATION, AND STAFF MEMBERS WHO HAVE NOT RECEIVED EDUCATION WILL NOT BE ALLOWED TO RESUME WORK RESPONSIBILITIES UNTIL EDUCATION HAS BEEN COMPLETED. ON 8.8.12 AN AD HOC SUBCOMMITTEE OF THE QUALITY ASSURANCE AND ASSESSMENT COMMITTEE MET TO DISCUSS AND APPROVE THIS PLAN. THE MEDICAL DIRECTOR WAS INFORMED AND APPROVED THE PLAN ON 8.8.12. THE COMMITTEE WILL MEET DAILY UNTIL THE FINDINGS OF IMMEDIATE JEOPARDY ARE LIFTED. THE COMMITTEE WILL MEET MONTHLY THEREAFTER. FINDING FROM THE RESULTS OF AUDITS AND OVERSIGHT WILL BE REPORTED TO COMMITTEE ON A MONTHLY BASIS. THE COMMITTEE WILL MAKE RECOMMENDATIONS FOR POLICY CHANGES OR FURTHER EDUCATION WHERE NECESSARY. ( , , , , , ) DEFICIENT PRACTICE #2 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO MAINTAIN SANITARY CONDITIONS IN THE KITCHEN, MAINTAIN APPROPRIATE REFRIGERATOR TEMPERATURES, STORE FOOD AT LEAST 18 INCHES FROM THE CEILING, AND LABEL AND DATE OPENED AND UNOPENED FOOD ITEMS, RESULTING IN THE POTENTIAL FOR FOOD BORNE ILLNESS, POTENTIALLY AFFECTING 135 OF 135 RESIDENTS IN THE FACILITY WHO CONSUME MEALS FROM THE FACILITY KITCHEN. FINDINGS INCLUDE: ON 8/7/12 AT 9:15 A.M., THE FACILITY'S KITCHEN WAS OBSERVED WITH DIETITIAN "E." THE FOLLOWING WERE OBSERVED: -THE VENTS IN THE HOOD OVER THE STOVE WERE DUSTY. THE FOLLOWING ITEMS HAD NO OPEN OR USE BY DATE: -THERE WAS AN OPENED CONTAINER OF INSTANT PUREE PASTA MIX WITH A SCOOP INSIDE -ONE OPENED 48 OUNCE CONTAINER OF DEHYDRATED CHOPPED ONIONS -ONE OPENED 24 OUNCE BOX OF GRITS -ONE OPENED BAG OF BISCUIT GRAVY MIX. DIETITIAN "E" THREW ALL OF THE ITEMS IN THE TRASH AND REVEALED, "THEY SHOULD OF HAD AN OPENED DATE." -THE SINGLE DOOR COOKS REFRIGERATOR WAS DUSTY ON TOP AND DIRTY WITH DIRT AND DEBRIS ON THE BOTTOM OF THE FLOOR OF THE COOLER. THE GASKET WAS CAKED WITH DEBRIS AND RIPPED. -THE TWO DOOR REACH IN FREEZER EXTERIOR WAS DUSTY AND THE INTERIOR HAD BITS OF DEBRIS SCATTERED THROUGHOUT THE BOTTOM OF THE COOLER. THE GASKETS WERE CAKED WITH DEBRIS AND RIPPED. -THE STEAM TABLE HAD A DRIED OFF WHITE COLORED SUBSTANCE ON THE SIDE OF THE UNIT. -THE PLATE WARMER WAS DIRTY AROUND THE BUMPERS AND HAD A OFF WHITE COLORED DEBRIS STUCK TO IT. -THE REACH IN 2 DOOR REFRIGERATOR THERMOMETER READ 50 DEGREES. THE TEMPERATURE OF A HALF PINT OF CHOCOLATE MILK THAT WAS IN THE COOLER WAS TAKEN AND REVEALED A TEMPERATURE OF 48.9 DEGREES. DIETITIAN "E" TOLD THE STAFF TO GET RID OF EVERYTHING IN THE COOLER. -THE SINGLE DOOR DESSERT PREP REFRIGERATOR HAD A DIRTY SMUDGED EXTERIOR. THE INTERIOR TEMPERATURE WAS WARM, THE FACILITY'S THERMOMETER REVEALED A TEMPERATURE OF 70 DEGREES. THERE WAS A RACK OF DISHED UP FRUIT AND PUDDING, DIETITIAN "E" TOLD HER STAFF "GET RID OF ALL OF THE PROTEIN ITEMS." DIETITIAN "E" CALLED THE MAINTENANCE DIRECTOR AND ASKED THAT HE LOOK AT THE REFRIGERATOR WHILE DIETARY MANAGER "D" CONTINUED WITH THE KITCHEN TOUR. THE WALK-IN FREEZER REVEALED THE FOLLOWING UNDATED FOOD ITEMS. -FIVE POUND BAG OF TATER TOTS -TWO THREE POUND BAGS OF BATTERED ZUCCHINI -ONE THREE POUND BAG OF YELLOW SQUASH -ONE FOUR POUND BAG OF MIXED VEGETABLES -TWO TWO AND A HALF POUND BAGS OF LIMA BEANS -ONE OPENED BAG OF SALISBURY STEAKS DIETARY MANAGER "D" WAS QUERIED REGARDING THE FACILITY'S POLICY FOR DATING OF FOOD ITEMS AND STATED, "THE POLICY IS TO DATE EVERYTHING AFTER IT IS OPENED, FOR THE BAGS OF VEGETABLES THEY (STAFF) SHOULD KEEP IT IN THE BOX UNTIL EMPTIED BECAUSE THE BOX IS DATED." THE MAINTENANCE DIRECTOR WAS OBSERVED LOOKING OVER THE SINGLE DOOR DESSERT COOLER AND REVEALED, "THE TEMPERATURE IS FINE." A THERMOMETER IN THE COOLER WAS OBSERVED THAT WAS PLACED BY THE FAN OF THE UNIT, THE INTERIOR OF THE COOLER FELT WARM. THE TEMPERATURE OF THE UNIT WAS TAKEN AND REVEALED A TEMPERATURE OF 64.5 DEGREES. TEMPERATURE LOGS WERE REVIEWED AND REVEALED THAT THE TEMPERATURES OF THE TWO UNITS WERE TAKEN IN THE MORNING AND BOTH TEMPERATURES READ 40 DEGREES. ON THE BOTTOM OF THE "RECORD OF REFRIGERATOR TEMPERATURES" LOG, THE FOLLOWING WAS REVEALED, "OPTIMAL REFRIGERATOR TEMPERATURE 33-38 DEGREES. (CONTACT SUPERVISOR FOR TEMPERATURES OUTSIDE THIS RANGE). DIETITIAN "E" REVEALED THAT NO ONE HAD INDICATED THAT THE TWO UNITS WERE NOT FUNCTIONING PROPERLY. THE SINGLE DESSERT REFRIGERATOR WAS SHUT DOWN. THE DRY STORAGE AREA WAS OBSERVED AND REVEALED NUMEROUS BOXES OF DISPOSABLE PLATES, CUPS AND SILVERWARE WERE STORED LESS THAN 18 INCHES FROM THE CEILING. DIETITIAN "E" STATED THAT THEY WOULD BE TAKEN DOWN. THE FACILITY'S POLICY TITLED "COLD STORAGE AREAS," NO DATE, REVEALED THE FOLLOWING: "2. REPORT PROBLEMS/CONCERNS...6. DATE AND LABEL ALL PRODUCTS REMOVED FROM ORIGINAL CONTAINERS. " THE FACILITY'S POLICY TITLED "STORING DRY FOODS," NO DATE, REVEALED THE FOLLOWING: " 2. STORE FOODS AT LEAST 6 INCHES OFF THE FLOOR AND 18 INCHES FROM THE CEILING." A POLICY FOR LABELING AND DATING OF FOOD WAS REQUESTED BUT NOT PROVIDED BY END OF SURVEY. ( ) DEFICIENT PRACTICE #3. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO MAINTAIN PROPER FOOD TEMPERATURES RESULTING IN THE POTENTIAL FOR FOOD BORNE ILLNESS POTENTIALLY AFFECTING 135 OF 135 RESIDENTS WHO CONSUMED MEALS IN THE FACILITY AND COLD FOOD. FINDINGS INCLUDE: ON 8/7/12 AT 11:25 A.M., A DINING SERVICE OBSERVATION WAS MADE AND REVEALED THAT THE FIRST CART OF MEAL TRAYS FOR RESIDENTS EATING ON THE SECOND FLOOR WAS ALREADY AT THE DESK. SOME MEALS WERE PASSED TO RESIDENTS EATING IN THEIR ROOMS. THE SECOND MEAL CART CAME TO THE UNIT AT 11:40 A.M. SOME OF THE TRAYS FROM THE FIRST CART WERE PUT ON THE SECOND CART. AT 11:50 A.M., RESIDENTS IN THE DINING ROOM WERE STARTING TO GET SERVED. AT 12:03 P.M., A MEAL TRAY TEMPERATURE WAS TAKEN FROM A TRAY THAT CAME UP ON THE FIRST MEAL CART. THE TRAY WAS A PUREE MEAL AND THE FOLLOWING TEMPERATURES WERE OBSERVED: FOOD TEMPERATURE MEAT 126.5 DEGREES POTATO 129 DEGREES VEGETABLE 122 DEGREES BREAD 122.9 DEGREES PUDDING 51.2 DEGREES MILK 49.6 DEGREES JUICE 53.6 DEGREES ON 8/10/12 AT 10:50 A.M., DIETARY MANAGER "D" AND DIETITIAN "E" WERE QUERIED REGARDING THE MEAL SERVICE TO THE UNITS. DIETITIAN "E" REVEALED THAT THE NURSING ASSISTANTS HAD TO WAIT FOR A NURSE TO BE IN THE DINING ROOM BEFORE THE MEALS WERE SERVED TO THE RESIDENTS BECAUSE OF A PAST ISSUE WITH SUPERVISION. WHEN QUERIED AS TO PROPER TEMPERATURES DIETARY MANAGER "D" REVEALED THAT THE GOAL FOR THE HOT FOOD WAS "160-200 DEGREES LEAVING THE KITCHEN FOR HOT FOODS AND 35-38 DEGREES FOR COLD" BUT NO GOAL WERE SET FOR SERVING TEMPERATURE. DIETARY MANAGER "D" REVEALED THAT THE TEMPERATURE DANGER ZONE WAS BETWEEN 41-135 DEGREES FARENHEIT. ON 8/10/12 AT 11:48 A.M., THE DIRECTOR OF NURSES WAS QUERIED REGARDING THE PASSING OF TRAYS ON THE UNITS AND OFFERED NO COMMENT. THE FACILITY'S POLICY TITLED "SERVING FOODS, NO DATE, REVEALED THE FOLLOWING "SERVE FOODS AT THE PROPER TEMPERATURES, ATTRACTIVELY, AND UNDER SANITARY CONDITIONS." THE POLICY DID NOT DISCUSS THE APPROPRIATE SERVING TEMPERATURES OF HOT AND COLD FOOD TO PREVENT FOOD BORNE ILLNESS. ( )

THIS CITATION PERTAINS TO INTAKE # MI 585 AND MI 650. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO IMMEDIATELY REPORT TO THE STATE SURVEY AND CERTIFICATION AGENCY AN ALLEGATION OF NEGLECT FOR 1 RESIDENT (#102) OF 5 RESIDENTS REVIEWED FOR ABUSE AND NEGLECT FROM A TOTAL SAMPLE OF 7 RESIDENTS, RESULTING IN AN IMMEDIATE JEOPARDY FOR RESIDENT #102 WHO WAS EATING UNSUPERVISED AND HAD A CHOKING EPISODE FROM A FOOD ITEM THAT WAS NOT APPROPRIATE FOR HIM. RESIDENT #102 SUBSEQUENTLY died . THE POTENTIAL REMAINS FOR SERIOUS INJURY, HARM, IMPAIRMENT OR DEATH TO ANY RESIDENT WHO REQUIRES SUPERVISION WHILE EATING. FINDINGS INCLUDE: RESIDENT #102 ACCORDING TO THE FACESHEET DATED [DATE], RESIDENT #102 WAS A [AGE] year OLD MALE WHO WAS admitted to the facility on [DATE]. THE MINIMUM (MDS) data set [DATE], INDICATED THAT RESIDENT #102 REQUIRED SUPERVISION AND THE PHYSICAL ASSISTANCE OF ONE STAFF MEMBER WITH EATING. HE HAD SEVERAL [DIAGNOSES REDACTED]. CARE PLAN DATED [DATE] IDENTIFIED RESIDENT #102'S RISK OF ASPIRATION (THE DRAWING OF A FOREIGN SUBSTANCE, SUCH AS THE [MEDICAL CONDITION] CONTENTS OR FOOD, INTO THE RESPIRATORY TRACT) AND IMPLEMENTED SEVERAL INTERVENTIONS INCLUDING "MECHANICAL SOFT DIET WITH THIN LIQUIDS" AND "MONITOR FOR COUGHING, WHEEZING AND NOTIFY MD." ON [DATE] AT 12:30 PM THE SPEECH THERAPIST WAS INTERVIEWED REGARDING RESIDENT #102. ACCORDING TO THE SPEECH THERAPIST, WHEN SHE ASSESSED RESIDENT #102 ON [DATE], SHE (THE SPEECH THERAPIST) FOUND RESIDENT #102 TO BE IMPULSIVE AND COULD NOT UNDERSTAND HIS LIMITATIONS. THE RESIDENT WAS ABLE TO FEED HIMSELF AND CONSUMED A REGULAR CONSISTENCY DIET BEFORE HE WAS admitted TO THE HOSPITAL. THE SPEECH THERAPIST WENT ON TO SAY THAT RESIDENT #102 WOULD TRY TO EAT ANYTHING HE COULD GET ACCESS TO, DESPITE HIS SWALLOWING DIFFICULTIES. THE SPEECH THERAPIST THEN SAID SHE IMPLEMENTED CHOKING AND SAFETY PRECAUTIONS, WHICH REQUIRED SOMEONE TO BE PHYSICALLY PRESENT AT THE TABLE SUPERVISING RESIDENT #102 TO ENSURE HE DID NOT EAT SOMETHING THAT WAS UNSAFE. ACCORDING TO THE SPEECH THERAPIST, RESIDENT #102 NEEDED TO BE PROTECTED BECAUSE IT WAS LIKELY THAT HE WOULD HAVE "SOME SORT OF PROBLEM" IF HE ATE WITHOUT SUPERVISION. ACCORDING TO A SURVEILLANCE VIDEO, RECORDED ON [DATE], AT 11:38 A.M., AND VIEWED ON [DATE] AT 11:10. AM, ON [DATE] AT APPROXIMATELY 11:38 AM, RESIDENT #102 BEGAN CHOKING. REGISTERED NURSE (RN) #1 WAS OBSERVED WALKING FROM DOWN THE HALLWAY AND WENT INTO THE DAY ROOM TO ASSESS RESIDENT #102. SOON AFTER RN #2 FOLLOWED. ACCORDING TO THE NURSE'S NOTES DATED [DATE] AT AN UNDOCUMENTED TIME RESIDENT #102 WAS TRANSPORTED TO A LOCAL AREA HOSPITAL WHERE ACCORDING TO THE EMERGENCY DEPARTMENT CHART RESIDENT #102 HAD "...ABOUT A 4 OUNCE CHUNCK OF CHICKEN [MEDICATION NAME] REMOVED FROM (HIS) AIRWAY WITH FORCEPS ..." RESIDENT #102'S PRIMARY [DIAGNOSES REDACTED]. (PATIENT ' S) AIRWAY..." RESIDENT #102 expired on [DATE] AT 12:47 PM. ON [DATE] AT 12:21 PM RN #1 SAID THAT ON [DATE], SHE HAD BEEN ASSIGNED TO BE IN THE DAY ROOM WHERE RESIDENT #102 ATE, SUPERVISING RESIDENT MEALS. RN #1 THEN admitted THAT SHE HAD NOT BEEN IN THAT DAY ROOM SUPERVISING THE RESIDENTS DURING THE MEAL. ON [DATE] AT 1:45 PM THE DIRECTOR OF NURSING (DON) SAID THAT ACCORDING TO FACILITY PRACTICE AND POLICY A REGISTERED NURSE SHOULD HAVE BEEN WITH RESIDENT #102. THE DON SAID THAT DURING THE FACILITIY'S OWN INTERNAL INVESTIGATION, CONDUCTED ON [DATE], THE VIDEO RECORD FOR RESIDENT # 102'S CHOKING EPISODE WAS VIEWED AND THE FACILITY FOUND THAT NO STAFF WAS SUPERVISING RESIDENT #102 AT THE TIME HE WAS EATING ON [DATE] AND CHOKED. ON [DATE] AT 1:53 PM THE ADMINISTRATOR SAID THAT THE FACILITY NEGLECTED TO SUPERVISE RESIDENT #102 ADEQUATELY ON [DATE] WHICH RESULTED IN RESIDENT #102 ' S DEATH, BUT THE FACILITY FAILED TO REPORT THE INCIDENT. THE ADMINISTRATOR SAID FACILITY POLICY DOES NOT DEFINE WHAT IS REPORTABLE. THE ADMINISTRATOR SAID SHE DISAGREED WITH THE DECISION, BUT "...WE WERE ADVISED BY OUR LEGAL TEAM..." NOT TO REPORT THE INCIDENT TO THE STATE. THE ADMINISTRATOR WAS INFORMED ON [DATE], AT 11:05 A.M. OF THE IMMEDIATE JEOPARDY THAT BEGAN ON [DATE] WHEN THE FACILITY FAILED TO REPORT AN INCIDENT INVOLVING POSSIBLE NEGLECT, OR ABUSE TO THE STATE SURVEY AND CERTIFICATION AGENCY. ON [DATE], THE SURVEYOR CONFIRMED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. RESIDENT #102 NO LONGER RESIDES IN THE FACILITY. THE FACILITY SUBMITTED THE APPROPRIATE NOTIFICATION TO THE STATE SURVEY AND CERTIFICATION AGENCY ON [DATE]. 2. ON, [DATE], THE SURVEYOR CONFIRMED THE FACILITY'S ACTION TO REVIEW ALL INCIDENT AND ACCIDENT REPORTS DATED [DATE] THROUGH [DATE]. THE SURVEYOR CONFIRMED THAT THERE WERE NO INCIDENTS THAT MET THE CRITERIA OF STATE REPORTABLE INCIDENTS, THAT WERE NOT REPORTED TO THE STATE SURVEY AND CERTIFICATION AGENCY. 3. ON [DATE], THE SURVEYOR CONFIRMED THE FACILITY'S REVIEW OF THE FACILITY'S "INCIDENT AND ACCIDENT REPORTING" POLICY ON [DATE]. 4. ON [DATE], THE SURVEYOR CONFIRMED THAT AS OF [DATE], 196 OUT OF 202 STAFF WERE IN SERVICED ON THE FACILITY'S " INCIDENT AND ACCIDENT REPORTING" POLICY. 5. ON [DATE], THE SURVEYOR CONFIRMED THE DAILY REVIEW OF ALL INCIDENTS AT THE MORNING STAND-UP MEETING. 6. ON [DATE], THE SURVEYOR CONFIRMED THAT THE REGIONAL CLINICAL DIRECTOR PROVIDED EDUCATION TO THE FACILITY ADMINISTRATOR AND DIRECTOR ON NURSING RELATED TO THE STATE REPORTING GUIDELINES. WHILE THE IMMEDIATE JEOPARDY WAS REMOVED ON [DATE], 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 BECAUSE NOT ALL STAFF HAS BEEN EDUCATED IN THE PERTINENT POLICIES AND BECAUSE THE FACILITY'S SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY. ( )

THIS CITATION PERTAINS TO INTAKE # MI 585 AND MI 650. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT 1 RESIDENT (#102) OUT OF 5 RESIDENTS REVIEWED FOR SUPERVISION DURING MEALS TO ENSURE SAFE SWALLOWING, FROM A TOTAL SAMPLE OF 7 RESIDENTS, RESULTING IN AN IMMEDIATE JEOPARDY FOR RESIDENT #102 WHO WAS EATING UNSUPERVISED AND HAD A CHOKING EPISODE FROM A FOOD ITEM THAT WAS NOT APPROPRIATE FOR HIM. RESIDENT #102 SUBSEQUENTLY died . THE POTENTIAL REMAINS FOR SERIOUS INJURY, HARM, IMPAIRMENT OR DEATH TO ANY RESIDENT WHO REQUIRES SUPERVISION WHILE EATING. FINDINGS INCLUDE: RESIDENT #102 ACCORDING TO THE FACESHEET DATED [DATE], RESIDENT # 102 WAS A [AGE] year OLD MALE WHO WAS admitted to the facility on [DATE]. THE MINIMUM (MDS) data set [DATE], INDICATED THAT RESIDENT # 102 REQUIRED SUPERVISION AND THE PHYSICAL ASSISTANCE OF ONE STAFF MEMBER WITH EATING. HE HAD SEVERAL [DIAGNOSES REDACTED]. THE RESIDENT HAD A physician's orders [REDACTED]. CARE PLAN DATED [DATE] IDENTIFIED RESIDENT #102'S RISK OF ASPIRATION (THE DRAWING OF A FOREIGN SUBSTANCE, SUCH AS THE GASTRIC CONTENTS OR FOOD, INTO THE RESPIRATORY TRACT) AND IMPLEMENTED SEVERAL INTERVENTIONS INCLUDING "MECHANICAL SOFT DIET WITH THIN LIQUIDS" AND "MONITOR FOR COUGHING, WHEEZING AND NOTIFY MD." THE SPEECH THERAPY EVALUATION DATED [DATE], SAID THAT RESIDENT #102 HAD MILD TO MODERATE DYSFUNCTION WITH FOOD BOLUS MANAGEMENT AND MODERATE DYSFUNCTION WITH ORAL SENSATION. COGNITIVE ASSESSMENTS RELATED TO EATING SAID RESIDENT #102 SUFFERED FROM MODERATE TO SEVERE DYSFUNCTION WITH DECISION MAKING AND PROBLEM SOLVING. THE SPEECH THERAPY EVALUATION IDENTIFIED RESIDENT #102 TO HAVE ORAL DYSPHAGIA (THE MEDICAL TERM FOR DIFFICULTY SWALLOWING) AND REQUIRED CHOKING AND SAFETY PRECAUTIONS TO BE IMPLEMENTED FOR RESIDENT #102. ON [DATE] AT 12:30 PM THE SPEECH THERAPIST WAS INTERVIEWED REGARDING RESIDENT #102. ACCORDING TO THE SPEECH THERAPIST, WHEN SHE ASSESSED RESIDENT #102 ON [DATE], SHE (THE SPEECH THERAPIST) FOUND RESIDENT #102 TO BE IMPULSIVE AND COULD NOT UNDERSTAND HIS LIMITATIONS. THE RESIDENT WAS ABLE TO FEED HIMSELF AND CONSUMED A REGULAR CONSISTENCY DIET BEFORE HE WAS admitted TO THE HOSPITAL. THE SPEECH THERAPIST WENT ON TO SAY THAT RESIDENT #102 WOULD TRY TO EAT ANYTHING HE COULD GET ACCESS TO, DESPITE HIS SWALLOWING DIFFICULTIES. THE SPEECH THERAPIST THEN SAID SHE IMPLEMENTED CHOKING AND SAFETY PRECAUTIONS, WHICH REQUIRED SOMEONE TO BE PHYSICALLY PRESENT AT THE TABLE SUPERVISING RESIDENT #102 TO ENSURE HE DID NOT EAT SOMETHING THAT WAS UNSAFE. ACCORDING TO THE SPEECH THERAPIST, RESIDENT #102 NEEDED TO BE PROTECTED BECAUSE IT WAS LIKELY THAT HE WOULD HAVE "SOME SORT OF PROBLEM" IF HE ATE WITHOUT SUPERVISION. ACCORDING TO A VIDEO VIEWED ON [DATE] AT 11:10 AM, ON [DATE] AT APPROXIMATELY 11:38 AM RESIDENT #102 BEGAN CHOKING. REGISTERED NURSE (RN) #1 WAS OBSERVED WALKING FROM DOWN THE HALLWAY AND WENT INTO THE DAY ROOM TO ASSESS RESIDENT #102. SOON AFTER RN #2 FOLLOWED. ACCORDING TO THE NURSE'S NOTES DATED [DATE] AT AN UNDOCUMENTED TIME, RESIDENT #102 WAS TRANSPORTED TO A LOCAL AREA HOSPITAL WHERE ACCORDING TO THE EMERGENCY DEPARTMENT CHART RESIDENT #102 HAD "...ABOUT A 4 OUNCE CHUNK OF CHICKEN BOLUS REMOVED FROM (HIS) AIRWAY WITH FORCEPS..." RESIDENT #102'S PRIMARY [DIAGNOSES REDACTED]. (PATIENT'S) AIRWAY..." RESIDENT #102 expired on [DATE] AT 12:47 PM. ON [DATE] AT 2:00 PM THE CERTIFIED NURSE ASSISTANT (CNA) #5 WAS INTERVIEWED REGARDING THE INCIDENT. ACCORDING TO CNA #5, ON [DATE] AT APPROXIMATELY 11:00 AM, SHE (CNA #5) SERVED A MECHANICALLY SOFT MEAL TRAY TO RESIDENT #102 IN THE DAY ROOM OF THE FACILITY. CNA #5 SAID SHE ALSO PROVIDED SEVERAL OTHER RESIDENTS IN THE SAME DAY ROOM WITH MEAL TRAYS THAT WERE NOT MECHANICALLY ALTERED. "HE (RESIDENT #102) COULD HAVE EASILY TAKEN SOMEONE ELSE'S FOOD, OR COULD HAVE BEEN GIVEN SOMEONE ELSE'S FOOD." CNA #5 STATED THAT AFTER PASSING OUT THE TRAYS, SHE LEFT THE DAY ROOM UNSUPERVISED. CNA #5 STATED, "(RN #1) WAS SUPPOSED TO BE IN THE ROOM WATCHING THE, THERE SHOULD ALWAYS BE SOME SUPERVISING IN THE DINING ROOM." ACCORDING TO THE "DINING MANAGEMENT" POLICY, DATED FEBRUARY 2011, "...A LICENSED NURSE IS PRESENT AT ALL MEALS ANS SUPERVISES RESIDENTS DURING THE MEAL PERIOD..." ON [DATE] AT 12:21 PM, RN #1 SAID SHE HEARD RESIDENT #102 CHOKING FROM DOWN THE HALLWAY AND WENT INTO THE DAY ROOM TO ASSESS HIM (RESIDENT #102). RN #1 SAID THAT ON [DATE], SHE HAD BEEN ASSIGNED TO BE IN THE DAY ROOM WHERE RESIDENT #102 ATE, SUPERVISING RESIDENT MEALS. RN #1 THEN admitted THAT SHE HAD NOT BEEN IN THAT DAY ROOM SUPERVISING RESIDENT #102 OR ANY OF THE RESIDENTS DURING THE NOON MEAL ON [DATE]. ON [DATE] AT 1:31 PM RN #2 SAID THAT ON [DATE] DURING THE NOON MEAL, SHE RESPONDED TO THE DAY ROOM WHEN RN #1 CALLED FOR HELP. RN #2 SAID THAT RN #1 WAS THE ONLY STAFF MEMBER IN THE DAY ROOM WHEN SHE ENTERED. ON [DATE] AT 1:45 PM THE DIRECTOR OF NURSING (DON) SAID THAT ACCORDING TO FACILITY PRACTICE AND POLICY A REGISTERED NURSE SHOULD HAVE BEEN WITH RESIDENT #102. THE DON SAID ACCORDING TO HER INVESTIGATION NO STAFF MEMBER WAS SUPERVISING RESIDENT #102 AT THE TIME HE WAS EATING ON [DATE] AND CHOKED. THE DON SAID THAT SINCE NO ONE WAS SUPERVISING RESIDENT #102, THE FACILITY HAS "NO WAY TO KNOW WHERE (RESIDENT #102) GOT THE CHICKEN" WHICH CAUSED HIM TO CHOKE. ON [DATE] AT 1:53 PM THE ADMINISTRATOR SAID, THE "...RN NEGLECTED TO PERFORM HER JOB DUTIES..." WHICH RESULTED IN RESIDENT #102'S CHOKING. THE ADMINISTRATOR WAS INFORMED ON [DATE], AT 11:05 A.M. OF THE IMMEDIATE JEOPARDY THAT BEGAN ON [DATE] WHEN THE FACILITY FAILED TO ADEQUATELY SUPERVISE A RESIDENT WHO REQUIRED SUPERVISION AND ASSISTANCE WITH EATING. ON [DATE], THE SURVEYOR CONFIRMED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. RESIDENT #102 NO LONGER RESIDES IN THE FACILITY. 2. ON [DATE], THE SURVEYOR CONFIRMED THE FACILITY REVIEWED AND UPDATED THE CARE PLANS OF 34 OF 34 RESIDENTS THAT RECEIVE A MECHANICALLY ALTERED DIET ON [DATE]. 3. ON [DATE], THE SURVEYOR CONFIRMED THAT SCHEDULE OF NURSES FOR DINING ROOM OVERSIGHT WAS REVIEWED AND REVISED ON [DATE] AND AGAIN ON [DATE]. 4. ON [DATE], THE SURVEYOR CONFIRMED THE FACILITY'S AUDIT AND COMPARISON OF MEALS ORDERED VS MEALS SERVED WHICH BEGAN ON [DATE]. 5. ON [DATE], THE SURVEYOR CONFIRMED THAT AS OF [DATE], 49 OUT OF 53 NURSES WERE IN-SERVICED ON THEIR RESPONSIBILITIES WHEN ASSIGNED TO THE DINING ROOM. 6. ON [DATE], THE SURVEYOR CONFIRMED FOR ALL DINING AREAS THE FACILITY'S DINING ROOM CALENDAR VERIFICATION OF NURSING PRESENCE IN THE DINING ROOM WHICH BEGAN ON [DATE]. 7. ON [DATE], THE SURVEYOR CONFIRMED THE TERMINATION OF RN #1. 8. ON, [DATE], THE SURVEYOR CONFIRMED THE FACILITY REFERRED 34 OF 34 RESIDENTS THAT RECEIVE A MECHANICALLY ALTERED DIET TO SPEECH THERAPY FOR EVALUATION. 9. ON [DATE], THE SURVEYOR CONFIRMED THAT THE QA&A COMMITTEE REVIEWED THE FACILITY'S REHABILITATION POLICY ON [DATE]. 10. ON [DATE], THE SURVEYOR CONFIRMED THE RE-EDUCATION OF THE SPEECH THERAPIST ON [DATE]. 11. AS OF [DATE], THE SURVEYOR CONFIRMED THAT 42 OUT OF 53 NURSES WERE IN-SERVICED ON THEIR RESPONSIBILITIES RELATED TO REFERRING RESIDENTS THAT RECEIVE A MECHANICALLY ALTERED DIET TO SPEECH THERAPY FOR EVALUATION AND IN-SERVICED THAT RESIDENTS WITH MECHANICALLY ALTERED DIETS ARE REQUIRED TO BE SUPERVISED DURING MEAL TIMES. 12. ON [DATE], THE SURVEYOR CONFIRMED THAT A LIST OF RESIDENTS WHO REQUIRE SUPERVISION HAD BEEN DEVELOPED. 13. ON [DATE], THE SURVEYOR CONFIRMED THAT 53 OF 53 LICENSED NURSES WERE CPR CERTIFIED. 14. ON [DATE], THE SURVEYOR CONFIRMED THAT 45 OF 53 LICENSED NURSES WERE REEDUCATED ON PROPER HEIMLICH MANEUVER TECHNIQUE. 15. ON [DATE], THE SURVEYOR CONFIRMED THAT AS OF [DATE], 196 OUT OF 202 STAFF WERE IN SERVICED ON THE FACILITY'S "INCIDENT AND ACCIDENT REPORTING" POLICY. 16. ON [DATE], THE SURVEYOR CONFIRMED THAT EMERGENCY EQUIPMENT WAS AVAILABLE FOR USE IN ALL DINING AREAS, AND THAT THE FACILITY STAFF VALIDATE THE PRESENCE OF ALL ITEMS WITH A DAILY CHECKLIST WHILE THE IMMEDIATE JEOPARDY WAS REMOVED ON [DATE], 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 BECAUSE NOT ALL STAFF HAS BEEN EDUCATED IN THE PERTINENT POLICIES AND BECAUSE THE FACILITY'S SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY. ( )

THIS CITATION PERTAINS TO INTAKE # MI 585 AND MI 650. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT 1 (#102) OF 5 RESIDENTS REVIEWED FOR QUALITY OF NURSING CARE FROM A TOTAL SAMPLE OF 7 RECEIVED NURSING SERVICES THAT MET PROFESSIONAL STANDARDS OF QUALITY IN RESPECT TO EMERGENCY LIFE SAVING PROCEDURES AND THE [MEDICATION NAME] MANEUVER, RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #102 WHO EXPERIENCED A CHOKING EPISODE, AND HAD THE [MEDICATION NAME] MANEUVER PERFORMED INCORRECTLY. RESIDENT #102 SUBSEQUENTLY died . THE POTENTIAL REMAINS FOR SERIOUS INJURY, HARM, IMPAIRMENT, OR DEATH TO ALL RESIDENTS IN THE EVENT OF A CHOKING EPISODE. FINDINGS INCLUDE: ACCORDING TO THE [MEDICATION NAME] MANEUVER: BEST TECHNIQUE FOR SAVING ANY CHOKING VICTIM'S LIFE. (1990) HENRY J. [MEDICATION NAME], MD, SCD EDWARD A. PATRICK, MD, PHD, POSTGRADUATE MEDICINE, 87:6,,[DATE], [DATE], THE RESCUER SHOULD NEVER PROBE THE MOUTH, AND SHOULD NEVER HIT THE CHOKING VICTIM ON THE BACK. THE REPORT CONCLUDED THAT "A BLOW ON THE BACK" AND AN "ATTEMPT TO REMOVE THE FOREIGN BODY WITH THE FINGER" CAN FORCE A FOREIGN BODY INTO THE AIRWAY FURTHER. "...THE [MEDICATION NAME] MANEUVER SHOULD BE THE ONLY METHOD USED TO RELIEVE AN AIRWAY OBSTRUCTION BY A FOREIGN BODY...IMPROVISATION COULD BE EXTREMELY DANGEROUS OR LETHAL..." RESIDENT #102 ACCORDING TO THE FACESHEET DATED [DATE], RESIDENT #102 WAS A [AGE] year OLD MALE WHO WAS admitted to the facility on [DATE]. THE MINIMUM (MDS) data set [DATE], INDICATED THAT RESIDENT # 102 REQUIRED SUPERVISION AND THE PHYSICAL ASSISTANCE OF ONE STAFF MEMBER WITH EATING. HE HAD SEVERAL [DIAGNOSES REDACTED]. THE RESIDENT HAD A physician's orders [REDACTED]. CARE PLAN DATED [DATE] IDENTIFIED RESIDENT #102'S RISK OF ASPIRATION (THE DRAWING OF A FOREIGN SUBSTANCE, SUCH AS THE [MEDICAL CONDITION] CONTENTS OR FOOD, INTO THE RESPIRATORY TRACT) AND IMPLEMENTED SEVERAL INTERVENTIONS INCLUDING "...MONITOR FOR COUGHING, WHEEZING AND NOTIFY MD..." ACCORDING TO A SURVEILLANCE VIDEO, RECORDED ON [DATE], AT 11:38 A.M., AND VIEWED ON [DATE] AT 11:10. AM, ON [DATE] AT APPROXIMATELY 11:38 AM, RESIDENT #102 BEGAN CHOKING. REGISTERED NURSE (RN) #1 WAS OBSERVED WALKING FROM DOWN THE HALLWAY AND WENT INTO THE DAY ROOM TO ASSESS RESIDENT #102. SOON AFTER RN #2 FOLLOWED ACCORDING TO THE NURSE'S NOTES DATED [DATE] AT 11:45 AM RESIDENT #102 WAS OBSERVED IN THE DAY ROOM AND APPEARED TO BE CHOKING. ACCORDING TO THE NURSE'S NOTES THE REGISTERED NURSE (RN #1) "...PROCEEDED TO SIT RESIDENT FORWARD IN (THE) CHAIR AND PERCUSS (TO STRIKE FIRMLY) HIS UPPER BACK..." ACCORDING TO THE NURSE'S NOTES DATED [DATE] AT AN UNDOCUMENTED TIME, RN #2 DOCUMENTED "AUDIBLE WHEEZE WITH STRIDOR (HIGH PITCHED NOISES WHILE BREATHING) HEARD...FINGER SWEEP (AN ATTEMPT TO REMOVE THE FOREIGN BODY WITH THE FINGER) PERFORMED..." ACCORDING TO THE NURSE'S NOTES RESIDENT #102 THEN BECAME CYANOTIC, UNABLE TO FOCUS, AND LOST BALANCE. ACCORDING TO THE NURSE'S NOTES DATED [DATE] AT AN UNDOCUMENTED, TIME RESIDENT #102 WAS TRANSPORTED TO A LOCAL AREA HOSPITAL WHERE ACCORDING TO THE EMERGENCY DEPARTMENT CHART, RESIDENT #102 HAD "...ABOUT A 4 OUNCE CHUNCK OF CHICKEN [MEDICATION NAME] REMOVED FROM (HIS) AIRWAY WITH FORCEPS..." RESIDENT #102'S PRIMARY [DIAGNOSES REDACTED]. (PATIENT'S) AIRWAY..." RESIDENT #102 expired on [DATE] AT 12:47 PM. ON [DATE] AT 12:21 PM, RN #1 SAID SHE HEARD RESIDENT #102 CHOKING FROM DOWN THE HALLWAY AND WENT INTO THE DAY ROOM TO ASSESS HIM. RN #1 SAID RESIDENT #102'S CHOKING BEGAN AS A WEAK BUT NOISY COUGH. RN #1 SAID SHE THEN STRUCK HIM ON THE BACK WITH HER HAND SEVERAL TIMES. ON [DATE] AT 1:31 PM RN #2 SAID SHE AND RN #1 STRUCK RESIDENT #102 ON THE BACK WITH THEIR HANDS SEVERAL TIMES IN AN ATTEMPT TO RESOLVE RESIDENT #102'S CHOKING. RN #2 SAID SHE THEN PERFORMED BLIND FINGER SWEEPS ON RESIDENT #102 AND "...THE COUGH CHANGED..." RN #2 SAID RESIDENT #102 THEN LOST CONSCIOUSNESS AND STOPPED BREATHING COMPLETELY. ON [DATE] AT 1:20 PM THE CERTIFIED NURSE ASSISTANT (CNA) #5 SAID HE WITNESSED RN #1 AND RN #2 HITTING RESIDENT #102 ON THE BACK SEVERAL TIMES. CNA #5 SAID HE ALSO WITNESSED RN #2 PERFORMING FINGER SWEEPS OF RESIDENT #102'S MOUTH BEFORE HE (RESIDENT #102) STOPPED COUGHING AND BREATHING. ON [DATE] AT 1:53 PM THE ADMINISTRATOR AND DIRECTOR OF NURSING EXPLAINED THAT DURING THE COURSE OF THE FACILITY'S INVESTIGATION IT WAS DISCOVERED THAT RN #1 AND RN #2 HAD BOTH STRUCK RESIDENT #102 ON THE BACK WITH THEIR HANDS SEVERAL TIMES IN AN ATTEMPT TO RESOLVE RESIDENT #102'S CHOKING. ON [DATE] AT 2:00 PM THE ADMINISTRATOR SAID THAT ACCORDING TO THE [MEDICATION NAME] INSTITUTE, BACK BLOWS AND FINGER SWEEPS SHOULD NEVER BE PERFORMED ON A CHOKING VICTIM EHO IS COUGHING, BREATHING OR CONSCIOUS, BECAUSE IT COULD "MAKE THINGS WORSE." THE ADMINISTRATOR WAS INFORMED ON [DATE], AT 11:05 A.M. OF THE IMMEDIATE JEOPARDY THAT BEGAN ON [DATE] AT 11:45 AM WHEN THE FACILITY STAFF PERFORMED THE [MEDICATION NAME] MANEUVER IN A MANNER THAT WAS INCONSISTENT WITH PROFESSIONAL STANDARDS BY IMPLEMENTING BACK BLOWS AND FINGER SWEEPS ON A COUGHING, BREATHING, CONSCIOUS RESIDENT. ON [DATE], THE SURVEYOR CONFIRMED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. RESIDENT #102 NO LONGER RESIDES IN THE FACILITY. 2. ON, [DATE], THE SURVEYOR CONFIRMED THE FACILITY REVIEWED AND UPDATED THE CARE PLANS OF 34 OF 34 RESIDENTS THAT RECEIVE A MECHANICALLY ALTERED DIET ON [DATE]. 3. ON, [DATE], THE SURVEYOR CONFIRMED THAT SCHEDULE OF NURSES FOR DINING ROOM OVERSIGHT WAS REVIEWED AND REVISED ON [DATE] AND AGAIN ON [DATE]. 4. ON [DATE], THE SURVEYOR CONFIRMED THE FACILITY'S AUDIT AND COMPARISON OF MEALS ORDERED VS MEALS SERVED WHICH BEGAN ON [DATE]. 5. ON [DATE], THE SURVEYOR CONFIRMED THAT AS OF [DATE], 49 OUT OF 53 NURSES WERE INSERVICED ON THEIR RESPONSIBILITIES WHEN ASSIGNED TO THE DINING ROOM. 6. ON [DATE], THE SURVEYOR CONFIRMED FOR ALL DINING AREAS THE FACILITY'S DINING ROOM CALENDAR VERIFICATION OF NURSING PRESENCE IN THE DINING ROOM WHICH BEGAN ON [DATE]. 7. ON [DATE], THE SURVEYOR CONFIRMED THE TERMINATION OF RN #1. 8. ON [DATE], THE SURVEYOR CONFIRMED THAT AS OF [DATE], THE FACILITY REFERRED 34 OF 34 RESIDENTS THAT RECEIVE A MECHANICALLY ALTERED DIET TO SPEECH THERAPY FOR EVALUATION. 9. ON [DATE], THE SURVEYOR CONFIRMED THAT THE QA & A COMMITTEE REVIEWED THE FACILITY ' S REHABILITATION POLICY ON [DATE]. 10. ON [DATE], THE SURVEYOR CONFIRMED THE RE-EDUCATION OF THE SPEECH THERAPIST ON [DATE]. 11. AS OF [DATE], THE SURVEYOR CONFIRMED THAT 42 OUT OF 53 NURSES WERE INSERVICED ON THEIR RESPONSIBILITIES RELATED TO REFERRING RESIDENTS THAT RECEIVE A MECHANICALLY ALTERED DIET TO SPEECH THERAPY FOR EVALUATION. 12. ON [DATE], THE SURVEYOR CONFIRMED THAT 53 OF 53 LICENSED NURSES WERE CPR CERTIFIED. 13. ON [DATE], THE SURVEYOR CONFIRMED THAT 45 OF 53 LICENSED NURSES WERE REEDUCATED ON PROPER [MEDICATION NAME] MANEUVER TECHNIQUE. 14. ON [DATE], THE SURVEYOR CONFIRMED THAT AS OF [DATE], 196 OUT OF 202 STAFF WERE INSERVICED ON THE FACILITY'S "INCIDENT AND ACCIDENT REPORTING" POLICY. 15. ON [DATE], THE SURVEYOR CONFIRMED THAT EMERGENCY EQUIPMENT WAS AVAILABLE FOR USE IN ALL DINING AREAS, AND THAT THE FACILITY STAFF VALIDATE THE PRESENCE OF ALL ITEMS WITH A DAILY CHECKLIST. WHILE THE IMMEDIATE JEOPARDY WAS REMOVED ON [DATE], 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 BECAUSE NOT ALL STAFF HAS BEEN EDUCATED IN THE PERTINENT POLICIES AND BECAUSE THE FACILITY'S SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY. ( )

Applies to MI 010 Based on interviews and records review, the facility failed to monitor skin as indicated in policy/procedure for 1 of 5 sampled residents (Resident #104) who was at risk for skin breakdown resulting in the development of pressure ulcers. Findings include: Review of Resident #104 ' s closed medical record file MDS (Minimum Data Set) dated 8/26/10 revealed [DIAGNOSES REDACTED]. The MDS revealed no pressure, no stasis ulcers. Review of " Nutritional Recommendation to Physician " dated 8/18/10 revealed 26 pound weight loss from 5/10 to 8/15/10. Note revealed Resident #104 ' s oral intake down from 75% to 25%-50% of meal. Noted Resident #104 " does little self initiation of feeding " ; Resident #104 says " not hungry " . Review of " Care plan for Skin / Preventative Care " dated 5/26/10 revealed intervention " weekly skin audits " . Review of " Skin Management " policy/procedure dated 2/2010 revealed, " Weekly skin check will be transcribed onto treatment record ...completion of weekly skin assessment will be noted on the TAR (Treatment Administration Record) ... Review of nurses notes dated 10/6/10, written by nurse Staff # 3 revealed the following: " ( ...called to resident ' s room by family ...observed open areas on Resident #104 ' s coccyx ...and dark abrasion on both heels ...) " sic Staff #3 was interviewed on 3/7/11 at 9:45 am by telephone. Said , " ...on the bottom, open areas ...basically skin tears on buttocks ...they were open ...(both heels)sic were black, not open ...I started a new treatment. I didn ' t see any treatment orders. " LPN (Licensed Practical Nurse) Staff #5 was interviewed on 3/1/11 at 3:00 pm in a conference room. Said she applied treatments to Resident #104 ' s wounds. Said, " ( ...there were no treatment orders at that time ...the coccyx had an old healed wound that I had seen before .... I put a dressing on the coccyx and a preventive bulk dressing on the heels. The coccyx looked like a healed wound, there was no open area ...) " sic Review of " Doctor ' s Progress Note " dated 10/6/10 (transcribed by Director of Nurses Staff # 8) revealed the following: " ...Bilateral heel sores, skin break between buttocks ...Bilateral heel pressure [DIAGNOSES REDACTED], no skin break and no blister formation ...back ulceration between buttocks ... " Review of " Non-Pressure Skin Condition Record " reports revealed last skin observation prior to 10/6/10 was 9/27/10. Report dated 9/27/10 revealed, " 0 (zero) abnormalities noted. Review of TAR dated 9/1 through 9/30/10 and 10/1 through 10/31/10 revealed no indication of weekly skin assessment as described in policy/procedure until 10/6/10. Review of " Non-Pressure Skin Condition Record " dated 10/7/10 revealed bilateral buttocks wounds were described as " partial thickness " measuring 2 cm (centimeter) x 2 cm. Review of " Weekly Pressure Ulcer report " dated 10/7/10 revealed left heel stage 2 (Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.) measuring 2.5 cm x 2.5 cm. Right heel was described as stage 2 measuring 4.0 cm x 4.0 cm.