Every finding on record at WellBridge of Brighton

This citation pertains to Intake 2990713.Based on interview and record review, the facility failed to follow up following an outside consultation, and receive an After Visit Summer (AVS) for one resident (R700) of two reviewed for outside appointments, resulting in missed antibiotic treatments. Findings include: Family Member O was interviewed on 5/11/26 at 10:20 AM and confirmed an allegation the facility failed to deliver appropriate medical care based on R700's specific needs and follow through with R700's (AVS) from ID (Infectious Disease) on 2/25/26 that indicated R700 was to receive antibiotics through August 2026. Family 'O' said they were contacted by the facility on 4/20/26 and the facility reported that R700 had increased drainage and required an urgent visit to the wound care clinic. Family 'O' further reported R700 had not been receiving their ordered long-term antibiotic (Keflex) as recommended by ID 3/11/26. The complainant stated they contacted the Director of Nursing (DON) and after multiple conversations, the DON confirmed the facility did not have the AVS from the 2/25/26 ID visit noting the long-term use of Keflex. A review of R700's clinical record revealed they were admitted to the facility 1/30/26 after a recent hospitalization for a prosthetic joint infection with an open wound over their left patella (knee bone). Upon admission, hospital discharge records recommended conservative management and collaboration with Infectious Disease (ID) for long term antibiotic therapy. A Nursing progress note dated 2/25/26 by Licensed Practical Nurse (LPN) A documented R700 returned from their ID appointment, with no paperwork. Continued review of the note documented LPN A spoke with Staff 'P' from the ID office regarding R700's guest visit on 2/24/26 and per Staff 'P', R700 had no new orders. It was noted the progress note from LPN 'A' did not indicate Staff 'P's position at the clinic (i.e. physician, nurse, etc.) On 5/11/26 at 12:00 PM, LPN A was contacted by phone for an interview, and no return call was made by the end of the survey. On 5/11/26, A clinical record review of the March 2026 Medication Administration Record (MAR) documented Keflex 1000 milligram (mg) was last administered at 6 AM on Wednesday 3/11/26. Record review revealed on 4/21/26 at 5:17 PM the facility received a fax from ID dated 2/25/26 titled, Infectious Disease Outpatient Return Visit Clinic Note (AVS) which documented to continue Cephalexin (Keflex) started during last admission from the hospital. The recommendations were to continue oral Keflex to complete the planned 6 weeks (until 3/2/26) then decrease to 500 mg (milligrams) twice daily. The Clinic notes further read, .Since there is an opening in the patella to the outside and the infection cannot be resolved surgically that is a method to minimize infection where the risk is significant. On page six of the clinic note (AVS) it was documented medication changes, Cephalexin (KEFLEX) 500 mg capsule take 1 by mouth every 12 hours-Previously 1000mg three times a day Start Date 3/2/26 End Date 8/17/26 . On 5/11/26 at 12:20 PM, the DON was interviewed and questioned about the note authored by LPN A from 2/25/26 which documented LPN A was told there were no new orders. When asked who Staff 'P' at the ID office reported to LPN 'A' there were no changes, the DON indicated they did not know. The DON was then asked if taking a verbal confirmation from an unknown person not knowing who they were, and not having valid written documentation from the consultant was appropriate, the DON replied it was not appropriate. The DON was questioned why the ID AVS from 2/25/26 was entered into the record on 4/21/26 and they confirmed after speaking with Family O it was discovered LPN 'A' did not receive the AVS for the 2/25/26 visit to ID and it was requested by the DON and provided from ID on 4/21/26. During the interview, the DON acknowledged the facility failed to ensure outside appointment consultations were followed identifying R700's missed AVS from 2/25/26. A Past Noncompliance (PNC) from 4/20/26 was presented and the DON/Designee would review five medical records weekly for 12 weeks to ensure outside appointment consultations are followed. Compliance date April 28, 2026. Audit Week One revealed R700 had an appointment with Nephrology on 5/4/26 at 11:30 AM and had no follow up communication from the appointment in the chart. The audit was documented on 5/5/26 to have receptionist contact physician to retrieve and fax to facility. On 5/11/26 The DON was informed the Electronic Medical Record (EMR) revealed no follow up documentation from their visit. The DON stated they remembered telling Receptionist C to contact the office and have it faxed. On 5/11/26 the Nursing Home Administrator confirmed both Receptionists C and D worked Tuesday 5/5/26. On 5/11/26 at 2:08 PM, an interview with Receptionist C stated they had no recollection of being asked by the DON to contact and retrieve the AVS and have it faxed for R700. On 5/11/26 at 2:22 PM, an interview with Receptionist D said they had no knowledge of R700 needing to retrieve the AVS and have it faxed for R700. Receptionist D further stated they thought that appointment was cancelled but could not confirm. On 5/11/26 at 3:02 PM, the DON acknowledged there was nothing to be found or documented whether R700 went to the appointment on 5/4/26. The DON acknowledged they performed the audit and did not follow up ensure outside appointment consultations were followed for R700. The DON then questioned if the PNC and audit was no good.

Based on observation, interview, and record review, the facility failed to provide necessary treatment and care consistent with professional standards of practice to promote healing of a compromised skin integrity to the coccyx area (area above the buttock region) and prevent new and or worsening pressure ulcer development for one resident (R5) of one reviewed for pressure ulcers resulting in R5 developing an unstageable pressure ulcer( a severe wound characterized by full-thickness tissue loss, where the base of the wound is obscured by slough or eschar, making it difficult to assess the true extent of tissue damage) to their coccyx area.Findings include:Clinical record review revealed R5 was admitted to the facility on [DATE] for physical therapy following hospitalization for surgical repair on 12/8/25 of their right femoral (large bone in leg) fracture related to a fall at home. R5 had developed urinary retention post operative and arrived at the facility with a Foley (indwelling urinary catheter). On 1/12/26 a review of the facility matrix identified R5 had a facility acquired pressure sore.On 1/12/26 at 10:39 AM, R5 was observed asleep, and unable to be interviewed. The brother who was visiting indicated that R5 fell at their home and required surgery to fix their leg. The brother further stated the facility informed them of a very bad sore on their backside and the pain medication Norco (narcotic medication) did not work and R5 was now on morphine. The brother remarked the wound was brought to his attention by the facility and has gotten so bad R5 has just since declined.Review of an admission skin check dated 12/11/25 at 8:00 PM by Licensed Practical Nurse (LPN) C documented .skin assessment of new admit day 1. Head to toe assessment completed w/3 <sic> (with three) people.lower backside their <sic> is a cluster of raised scab markings, guest did have on a foam dressing to the coccyx area. No open areas present. Scant amount of poop observed under dressing. admission skin check documented .No skin issues identified. Braden Score (tool used to assess a person's risk for developing pressure ulcers) totaled 13 which indicated R5 was at moderate risk for developing a pressure sore.Record Review authored by Registered Nurse (RN) D Documented as a Late Entry Effective Date: 12/12/2025 13:18:00, Created 12/30/2025 17:26:18 documented .2nd skin check completed.Foam dressing in place on coccyx, dressing removed redness noted to coccyx with small open area and non-blanchable.New Skin Issue documented on 12/19/25 at 18:22 by LPN I identified: New skin Issue. Location: Coccyx. Issue type: Moisture associated skin damage (MASD). Progress: New wound. Wound acquired in-house. Length centimeters (cm) 4.74 Width (cm), 2 Depth (cm):0 Area (cm2):8.09 undermining.Nursing Progress note dated 12/26/25 at 15:37 documented skin issue .coccyx area.Deteriorating, wound acquired in-house. It is unknown how long the wound has been present. Braden Score recorded on 12/26/25 was 7 indicating very high risk for worsening of pressure ulcer development.Nursing Progress note dated 12/27/25 (Saturday) at 9:00 AM, authored by LPN K documented .guest coccyx wound decline message sent to manager to assess on Monday and change wound care order. There was no new treatment obtained or implemented for two days after identifying the worsening of the coccyx wound.Clinical Record review of a Physician Progress note dated 12/29/25 (Monday) at 13:15 Physician Progress Note documented .Patient was seen for wound evaluation. Sacral wounds were evaluated. Wound is unstageable areas of eschar noted with yellow slough. Surrounding skin with erythema and MASD. On exam, patient is guarded.wound care orders updated.pressure relieving interventions.On 1/13/26 at approximately 2:00 PM, a record review of R5's care plan was reviewed with the Director of Nursing (DON). The DON was asked why the care plan documented .The resident has.Unstageable pressure coccyx.Date Initiated: 12/11/2025. when this was not diagnosed by the Physician until 12/29/25, The DON opened a different care plan screen from their laptop which verified the author and change was done on 12/29/25 by Corporate Clinical (CC) AOn 1/13/26 at 2:30 PM, an interview with the DON and CC A regarding LPN C documentation of no open areas on 12/11/25. They both acknowledged a thorough skin assessment had not been completed. CC A was questioned who was RN D as their name was not on the facility employee roster, CC A replied RN D was Corporate and used as a Floating DON. CC A said RN D was in the facility helping on 12/12/25 and must had gotten busy. CC A figured RN D would be returning to the facility on [DATE] to document the skin assessment but must had been assigned to another facility, hence the Late Entry on 12/30/25.On 1/13/26 at 2:44 PM LPN C was attempted to be contacted by phone for an interview, but their phone indicated the caller was unable to leave a message. The facility also tried to contact LPN C and there was no response by the end of this investigation.On 1/14/26 at 8:38 AM, a telephone interview with RN D acknowledged recall of R5 and immediately reported they forgot to document their findings. RN D recalled R5 was in so much pain, that they rolled them to their side by themself, quickly assessed and redressed the coccyx area with a foam dressing. RN D admitted they are not good at measuring wounds by just looking at them, they had no measuring device, but confirmed the area was not blanchable, red, and had open skin. When questioned why they did not document Skin Assessment #2 from 12/12/25 until 12/30/25, the day after the Physician diagnosed the wound as unstageable, RN D stated they forgot to document and had left for vacation.Review of the Policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol dated 10/2010 documented: .The physician and staff will examine the skin of a new admission for ulcerations or indications of a Stage I pressure area.In addition, the nurse shall assess and document/report the following: Full assessment of pressure sores including location, stage, length, width, and depth.The physician will help the staff define the type.of an ulceration.

Based on interview and record review, the facility failed to support continuity of a previous resolved grievance for one resident (R37) of one reviewed for grievances.Findngs include:Clinical record review revealed R37 was admitted to the facility on [DATE] with impaired mobility deficits related to recent hospitalization for respiratory and congestive heart failure. R37 required wound care for a diabetic right foot ulcer and required supplemental oxygen. Brief Interview of Mental Status (BIMS) assessed on 11/14/25 scored 15/15 indicating R37 was cognitively intact.On 1/12/26 at 9:49 AM, during initial interview and introductions, R37 voiced concern they previously complained to the facility that Certified Nurse Assistant (CNA) B hurts them when they are repositioned or placed into a Hoyer lift (mechanical lift). R37 stated they can't prove there is intent, they just handle them roughly. R37 said their concern was shared with the staff and was informed that CNA B would no longer be assigned to take care of them. R37 stated that CNA B sees them in their room, and R37 must remind the staff CNA B are not to care for them.On 1/14/26 at 8:26 AM, a Resident grievance/complaint form dated 12/29/25 by the Nursing Home Administrator (NHA) for R37 documented Complain regarding transfer, not comfortable w/one <sic> (with one) aide in particular. The NHA was interviewed and confirmed the aide was CNA B. The NHA documented on the investigation summary follow up dated 12/31/25, .Removed aide from all care. The NHA assured they informed the staff CNA B was not to be assigned to that room.Clinical record review revealed CNA B had documented on the Eating Treatment Administration Record (TAR) for R37 on 12/31/25, 1/2/26, 1/5/26, 1/8/26, 1/13/26. The NHA was informed of this information and replied they had informed the scheduler, and nursing staff that CNA B was not to be scheduled to care for R37's room.On 1/14/26 at 10:18 AM, CNA B accompanied with the NHA were interviewed. CNA B acknowledged they were not to take care of R37. However, they had been scheduled to the 700 hall and care for that room because there is suitemate and must ask other CNAs to oversee the care of R37 because of the grievance. CNA B validated they charted on the R37's Eating TAR because they were assigned to the room and put down the information which another CNA reported to them.On 1/14/26 at 11:45 AM, an interview with the Facility's Scheduler/CNA/Central Supply Scheduler F was questioned why CNA B was scheduled to care for the room of R37, and responded with surprise and said, That's the room?. The Facility Scheduler F who often works as a CNA, said the CNAs should collaborate and swap out rooms in such situations and there is no documentation on the schedule what room was picked up or what room was swapped. The CNA is assigned that hall and has that room; it is their responsibility to swap it out. CNA B had confirmed this in the interview but indicated sometimes they must care for the roommate and must be in room of R37.Scheduler F provided the following documentation confirming CNA B's assignment:Friday 1/2/26- CNA B assigned set #5-entire 700 hall.Monday 1/5/26- CNA B assigned set #5-entire 700 hall and documented room for R37 as highlighted in blue.Tuesday 1/13/26- CNA B assigned set #5-entire 700 hall.Scheduler F was asked if the NHA had made arrangement for R37's room not to be assigned to CNA B, why are they scheduled to the 700 unit, Scheduler F replied the CNA's have their units (indicating preference) and provided continuity of care.

This citation pertains to intake 1220695Based on interview and record review, the facility failed to report an alleged violation to the state agency (SA) related to Injuries of Unknown Origin for one resident (R701) of one reviewed for abuse. Findings include:Clinical record review revealed R701 was a long-term resident and admitted under care of Hospice related to advanced Alzheimer dementia, psychotic and mood disturbances and anxiety. R701 was primarily nonverbal, bed/chair bound, required two-person assistance with transfers and had a BIMS (Brief Interview of Mental Status) score of 2/15 indicating severe cognitive impairment.On 7/8/25 the State Agency received a concern that R701 was observed with yellow colored bruising to their middle (sternal) chest wall, and dark red purple bruising to their right rib cage. Neither of these injuries were consistent with the care R701 received and neither was the injury reported to the Hospice Provider or Guardian.On 9/11/25 at 2:30 PM, an interview was conducted with Hospice Register Nurse (RN) D who confirmed on 7/9/25 when they arrived to care for R701, they were greeted by Certified Nurse Assistant (CNA) C who asked if they (RN D) had heard about the bruising to R701. Per RN D they replied they had not and immediately assessed. RN D observed old healing yellow bruising on R701's sternum and breast and dark purple bruising (newer bruise) on their right rib cage. RN D then contacted R701's daughter who confirmed they too were not aware nor informed of the bruising.On 9/11/25 RN B and CNA C were interviewed. Per RN B they first identified sternal yellow bruising on R701while they were at the dining room table and their shirt was lying low on their chest and was visible. RN B went to CNA C and asked what the large yellow bruise was from. During the interview, CNA C confirmed they told two other Nurses about the sternal bruising (cannot remember the names of the two Nurses) and RN B commented that because CNA C said she reported the bruising, they did not follow up further.Review of the facility policy titled Abuse, Neglect and/or Misappropriation of Resident Funds or Property dated 3/2013 documented: .Staff shall report all incidents immediately to their direct supervisors and Administrator (NHA).A licensed nurse should perform an initial assessment of the resident.When questioned who at the facility was the Abuse Coordinator, A replied the Nursing Home Administrator (NHA) and themself. Further record review documented a Change in Condition authored by Abuse Coordinator A on 7/3/25 11:37 AM that R701 had obtained bruising to their side from a two-person transfer. However, there was no further documentation of how the bright yellow sternal bruising had occurred or why a transfer would cause bruising to a resident.When Abuse Coordinator A was asked how they reached the conclusion that the rib bruising was from a two person assist transfer, they were unable to confirm who reported the incident, and they would have to see who was working that day. Abuse Coordinator A further remarked that R701 had a history of aggression with two person transfers and assumed this is how the injury to their side had occurred.Abuse Coordinator A was questioned if the family was notified of this assumption and Abuse Coordinator A was unable to recall. Record review did not reveal any documentation to the family being contacted on 7/3/25.Review of the facility policy titled Abuse, Neglect and/or Misappropriation of Resident Funds or Property dated 3/2013 documented: .The licensed nurse shall immediately contact the residents attending physician and legal representative when an incident involving suspected abuse or neglect of a resident has occurred.Record review documented not until 7/9/25 at 11:24 .spoke with daughter providing updates regarding care, skin conditions.On 9/11/25 at 1:21 PM, The NHA confirmed they were the facility's Abuse Coordinator and part of that role includes investigating injury of unknown origin. The NHA showed the documented pictures of R701's bruises and confirmed this would have been formally investigated and reported to the State Agency if they were aware of the injuries. The NHA confirmed this was just brought to their attention during this survey.

This citation pertains to intake 1220695Based on interview and record review, the facility failed to conduct a thorough investigation for one resident (R701) of one reviewed for Injuries of Unknown Origin. Findings include:Clinical record review revealed R701 was a long-term resident and admitted under care of Hospice related to advanced Alzheimer dementia, psychotic and mood disturbances and anxiety. R701 was primarily nonverbal, bed/chair bound, required two-person assistance with transfers and had a BIMS (Brief Interview of Mental Status) score of 2/15 indicating severe cognitive impairment.On 7/8/25 the State Agency received a concern that R701 was observed with yellow colored bruising to their middle (sternal) chest wall, and dark red purple bruising to their ride rib cage. Neither of these injuries were consistent with the care R701 received and neither was the injury reported to the Hospice Provider or Guardian.On 9/11/25 at 09:30 AM, a clinical record document of a wound evaluation revealed a colored photograph evaluated on 7/4/25 Labeled #8-Bruise Body location: Location not set, Age Unknown, documented length 10.42 centimeter (cm) In-house acquired.The photograph revealed a dark purple and red colored elongated oval bruise and verification of its location was unknown, or hard to determine based on the photograph angle.A clinical record document of a wound evaluation revealed a colored photograph evaluated on 7/4/25 Labeled #9-Other Body location: Location not set Age Unknown, documented length 0.0 centimeter (cm) In-house acquired.The photograph revealed a large body surface area around folded skin bruising was noted as bright yellow colored with a smaller purple bruise and verification of its location was unknown.On 9/11/25 at 10:50 AM, an interview with the Director of Nursing (DON) and Regional Clinical Director A was requested related to unidentifiable pictures of bruising on R701. Abuse Coordinator A reviewed the pictures and too could not identify the anatomy of the injuries and mentioned we would need to call Licensed Practical Nurse (LPN) E who was identified as the Nurse who took the pictures.On 9/11/25 around 11:15 AM, a telephone interview conducted with LPN E in the presence of the DON and Abuse Coordinator A informed that they were given report by Register Nurse (RN) B that R701's had new bruising and that photographs still needed to be taken.LPN E required prompting of the pictures and recalled #9-Wound- very yellow bruising was on R701's chest/sternal area and #8- Wound- dark purple bruising, was unable to recall anatomical location.On 9/11/25 RN B and CNA C were interviewed. Per RN B they first identified the sternal yellow bruising on R701while they were at the dining room table. Their shirt was lying low on their chest and questioned to CNA C what this large yellow bruise was from. During the interview, CNA C confirmed they told two other Nurses about the sternal bruising (cannot remember the names of the two Nurses) and RN B commented that because CNA C said she reported the bruising, they did not follow up further.Review of the facility policy titled Abuse, Neglect and/or Misappropriation of Resident Funds or Property dated 3/2013 documented: .Staff shall report all incidents immediately to their direct supervisors and Administrator.A licensed nurse should perform an initial assessment of the resident.When questioned who at the facility was the Abuse Coordinator, Abuse Coordinator A replied the Nursing Home Administrator (NHA) and themself. Further record review documented a Change in Condition authored by Abuse Coordinator A on 7/3/25 11:37 AM that R701 had obtained bruising to their side from a two-person transfer. However, there was no further documentation of how the bright yellow sternal bruising had occurred.When Abuse Coordinator A was asked how they reached the conclusion that the rib bruising was from a two person assist transfer, they were unable to confirm who reported the incident, and they would have to see who was working that day. Abuse Coordinator A further remarked that R701 had a history of aggression with two person transfers and assumed this is how the injury to their side had occurred.Abuse Coordinator A was questioned if the family was notified of this assumption and Abuse Coordinator A was unable to recall. Record review did not reveal any documentation to the family being contacted on 7/3/25.Abuse Coordinator A was asked if there was a soft file of this investigation, including staff interviews, and education and Abuse Coordinator A confirmed there was not.Review of the facility policy titled Abuse, Neglect and/or Misappropriation of Resident Funds or Property dated 3/2013 documented: .As part of the investigation, the Administrator, or his/her designee, shall take the following action: Interview all witnesses.Witnesses shall include anyone who (1) witnessed or heard the incident; (2) came in close contact with either the resident the day of the incident (including other residents, family members, etc.) (3) employees who worked closely with the.victim the day of the incident. To the extent possible, all interviews should be summarized into a written statement, which is signed and dated.On 9/11/25 at 1:21 PM, the NHA confirmed they were the facility's Abuse Coordinator and part of that role included investigating injury of unknown origin. The NHA showed the documented pictures of R701's bruises and confirmed this would have been formally investigated and reported to the State Agency if they were aware of the injuries. The NHA confirmed this was just brought to their attention during this survey.

Based on observation, interview and record review, the facility failed to ensure accuracy of assessments, coordination of care with a wound care clinic, and ensure recommended interventions were followed for one (R18) of four residents reviewed for pressure ulcers, resulting in R18 being sent to the hospital from the wound care clinic for surgical debridement and intravenous (IV) antibiotics of an infected Unstageable (full-thickness skin and tissue loss in which the wound bed is obscured by slough or eschar) Pressure Ulcer. Findings include: On 10/14/24 at 9:26 AM, R18 was observed sitting up in bed eating breakfast. A low air loss mattress (group 2 mattress) was observed on R18's bed and a ROHO (individual air cells) cushion was observed in R18's wheelchair. R18 was asked if they had any wounds. R18's spouse explained R18 had a bad wound on their bottom and they were going to a wound care clinic for it. Review of the clinical record revealed R18 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: acute and chronic respiratory failure, cervical disc disorder and atrial fibrillation. According to the Minimum Data Set (MDS) assessment dated [DATE], R18 had severely impaired cognition and required substantial/maximal assistance of staff for mobility in bed. The MDS assessment also indicated R18 had two facility acquired Stage 2 (partial-thickness loss of skin with exposed dermis) pressure ulcers. Review of R18's wound assessments documentation revealed: A Skin & Wound Evaluation dated 7/17/24 read in part, .Type: Pressure - Kennedy terminal ulcer (skin failure during the final weeks of life) .Stage: Stage 1: Non-blanchable erythema (redness) of intact skin .Location: Sacrum, Lateral .In-House Acquired .Exact Date: 7/17/24 . A Wound Evaluation dated 7/17/24 read in part, #18 - Pressure - Kennedy terminal ulcer - Stage 1 .Sacrum - Lateral . The evaluation also included a picture of R18's wound. A Skin & Wound Evaluation dated 8/31/24 read in part, .Type: Pressure - Kennedy terminal ulcer . Stage 2: Partial-thickness skin loss with exposed dermis .Progress: Resolved . A Wound Evaluation dated 8/31/24 read in part, .#18 - Pressure - Kennedy terminal ulcer - Stage 2 .Sacrum - Lateral . The evaluations included a picture that showed R18's wound that had an open wound, not a resolved wound. A Skin & Wound Evaluation dated 9/13/24 read in part, .Type: Pressure - Kennedy terminal ulcer .Stage: Unstageable: Obscured full-thickness skin and tissue loss . Location: Coccyx . In-House Acquired .Exact Date: (left blank) . A Wound Evaluation dated 9/13/24 read in part, .#21 - Pressure - Kennedy terminal ulcer - Unstageable .Coccyx . The picture showed the wound in the same place on R18's body as the previous sacrum evaluations. A Wound Evaluation dated 10/15/24 read in part, .#16 - Pressure - Unstageable .Coccyx . This evaluation was documented in a previously resolved wound thread however, the picture was consistent with R18's current wound. Review of R18's wound care consultation documentation available in the electronic clinical record included only two from 9/10/24 and 9/17/24, and revealed only treatment recommendations for R18's wounds. No consultation notes or description of R18's wound were included in the documentation. On 10/15/24 at 10:06 AM, the Director of Nursing (DON) was interviewed and asked about the apparent discrepancy in the documentation of R18's wounds. The DON explained she had not been at the facility when R18 acquired their wounds. The documentation and pictures of R18's wounds was reviewed with the DON. The DON agreed the wound labeled as Sacrum - Lateral and Coccyx and receiving the numbers 18, 21 and 16 were most likely the same wound. The DON was asked who had diagnosed R18's wound as a Kennedy terminal ulcer. The DON explained it is the doctor who diagnoses. When informed according to progress notes, R18's attending physician, Dr. S had last seen R18 on 7/10/24, the DON explained it must have been the Nurse Practitioner (NP R). The DON was asked about the lack of the wound care clinic's consultations and description of R18's wounds. The DON explained she would look into it. Multiple attempts beginning 10/15/24 at 12:31 PM were made to speak via phone or in person with Dr. S. No return call was made prior to the end of the survey. On 10/15/24 at 4:29 PM, a phone interview was conducted with Dr. P, the wound care clinic doctor. Dr. P was asked about R18's wounds. Dr. P explained R18's wounds had deteriorated significantly and were infected, they had sent R18 directly from the clinic to the Emergency Department (ED) from the clinic for surgical debridement and antibiotics .it had appeared the recommended interventions had not been done. Dr. P was asked if they had ever diagnoses R18's wounds as Kennedy terminal ulcers. Dr. P explained they had not. Dr. P was asked to provide the consultation notes for R18. Review of R18's wound care clinic consultation notes revealed: 9/10/24 .Note: The sacral wound cannot be examined today because the patient did not arrive seated in (their) Hoyer Lift (mechanical lift) sling. Therefore, the staff cannot safely transfer (them) for examination . 9/17/24 .Wound #4 Coccyx is a chronic Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer .The patient's wounds have worsened despite offloading on a group 2 alternating low are loss pressure reducing surface. (in bold type) (They) is a candidate for a group 3 air-fluidized bed (powered support surface that circulates air through ceramic beads to reduce pressure, friction and shear). The prognosis for healing is extremely poor unless offloading can be optimized . 10/1/24 .The coccygeal ulcer has further worsened due to suboptimal offloading .A group 3 air-fluidized bed is strongly recommended. The prognosis for healing is extremely poor unless offloading can be optimized .Offloading: .Sleep on group 2 alternating low air loss pressure reducing surface and turn q2 (every 2 hours) hours alternating between sides until group 3 air-fluidized bed procured . 10/15/24 .The coccygeal wound has further deteriorated .suggesting inconsistent adherence to the offloading directives Nor, as far as I can tell, have my strong recommendation for a group 3 air-fluidized bed been pursued. The prognosis for healing is extremely poor unless offloading can be optimized .Wound #4 (coccyx) .New circumferential undermining .Except for a narrow peripheral rim of inflamed, red subcutaneous tissue, the wound surface is entirely obscured by grossly necrotic (dead) tissue undergoing liquefactive necrosis. No viable tissue is visible .Large amount of serosanguineous (blood and serum fluid) drainage with strong malodor. The wound is grossly infected .I disagree with the classification of the ulcer as a terminal Kennedy ulcer .the patient is not imminently or actively dying; however, given the current condition of the wound, he is at high risk for sepsis and death without urgent intervention, including hospital admission, IV (intravenous) antibiotic therapy, and aggressive debridement . Review of R18's progress notes revealed a Plan of Care Note dated 10/15/24 at 8:26 PM that read in part, .wound care provider was admitting guest to (local) hospital for debridement of (their) coccyx wound . Further review of R18's progress notes revealed: A Skilled Charting note dated 9/17/24 at 3:19 PM read in part, .Guest encouraged to turn and reposition. Guest favors laying on back . A Plan of Care Note dated 9/26/24 at 7:31 PM read in part, .Staff continues to encourage guest to turn and reposition frequently, guest does decline, states 'I don't like laying on my sides.' Guest prefers laying on (their) back . *It should be noted turning and repositioning is not necessary when using a group 3 air-fluidized bed. On 10/16/24 at 10:49 AM, NP R was interviewed and asked if they had diagnosed R18's wounds as Kennedy terminal ulcers. NP R explained they had agreed with the nurse's assessment, that it was a collaboration with nursing. NP R was asked if they were monitoring R18's wounds. NP R explained since R18 went to a wound care clinic, they did not monitor the wounds, they deferred to the doctor at the clinic. On 10/16/24 at 1:33 PM, the Administrator was interviewed and asked if they had ever been notified that the doctor at R18's wound care clinic had recommended R18 have an air-fluidized bed. The Administrator explained it had never been brought to their attention. On 10/16/24 at 12:49 PM, Licensed Practical Nurse (LPN) Q, who had taken the picture of R18's wound on 10/15/24, was interviewed and asked if there had been drainage and an odor when she changed the dressing on R18's coccyx. LPN Q explained there was drainage and an odor. Further review of the Wound Evaluation of R18's coccyx dated 10/15/24 read in part, .EXUDATE (drainage): Amount: Light; Type: Serous (serum); Odor noted after cleansing: None . On 10/16/24 at 1:54 PM, the DON was informed of the findings from the wound care clinic consultation notes and asked why the consultation notes had not been requested after each visit to the wound clinic since the clinic's doctor was the one who was managing the resident's wound. The DON had no explanation. Review of a facility policy titled, Prevention of Pressure Ulcers revised 10/2010 read in part, .The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognize, evaluated, reported to the practitioner, physician, and family, and addressed .

Based on observation, interview, and record review, the facility failed to maintain the main kitchen and the south satellite kitchen in a sanitary manner. This deficient practice had the potential to affect all residents in the facility that consume food. Findings include: On 10/14/24 between 9:40 AM-10:10 AM, during an initial tour of the kitchen with Dietary Manager (DM 'D'), Culinary Specialist (CS 'B'), and the Assistant Dietary Manager (ADM 'C'), the following items were observed: In the dry food storage room, there was a package of sweet cornbread muffin mix on a metal wire shelf that was not sealed and exposed to air. In the walk-in refrigerator, there was a large package of full-size fresh carrots that were not sealed and exposed to air. In the south kitchenette, there were multiple concerns identified, including: The countertop was observed to have dried debris on the surfaces, and in the cracks. The glass enclosure was soiled with debris on the glass surfaces both inside and out. There was debris imbedded in the cracks and crevices and missing portions of the seal that connected the glass to the countertop. The walls of the kitchenette along were soiled with dried dark colored food debris and stains. The flooring underneath the sink was observed to be covered with a thick, black debris. The microwave was heavily soiled on the inside with splattered food particles. The lower countertop area directly under the steam table was observed to have a laminate bottom shelf that was chipped, worn, and the edges were swollen from water damage. There were several trays and other food equipment stored directly on the laminate shelf. CS 'B' reported that area of the shelving was going to be replaced. CS 'B' was asked to provide documentation of an invoice regarding the shelving repair. When asked about the above concerns, CS 'B' , DM 'D' confirmed and reported they would address those concerns immediately. When asked who was responsible to ensure the satellite kitchens were maintained, CS 'B' reported they had a closing night checklist and after every shift, those areas should've been cleaned. On 10/15/24 at 8:25 AM, the Administrator was requested to provide any documentation such as an invoice of repairs needed for the satellite kitchens prior to concerns identified during the survey. They were informed this was requested from CS 'B' on 10/14/24, but there was no invoice provided. The Administrator reported they would look into that further. Review of the documentation provided by the facility regarding the invoice request included a facility email request on 10/14/24 at 10:32 AM (following the concerns identified during the survey) and a document dated 9/27/24 from CS 'B' that identified a maintenance need for the south serving kitchen laminate board repair and to fix laminate underneath the main wells (on the steam table). On 10/15/24 at 1:30 PM, the Administrator confirmed there was no invoice for repairs and reported someone was coming on 10/17/24 to make repairs. According to the 2017 FDA (Food and Drug Administration) Food Code section 3-305.11 Food Storage, (A) Except as specified in (B) and (C) of this section, food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination . According to the 2017 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions, (A) Physical facilities shall be cleaned as often as necessary to keep them clean. According to the 2017 FDA Food Code section 4-602.13 Nonfood-Contact Surface, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. According to the facility's policy titled, Sanitation of Kitchen dated 8/13/2022: .All utensils, counters, shelves and equipment shall be kept clean maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use for proper cleaning. Seals, hinges and fasteners will be kept in good repair .All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions .

Based on observation, interview, and record review the facility failed to ensure medications were administered per the facility's policy and professional standards of practice for two (R's 41 & R78) of four residents observed for medication administration and provide wound care treatment and documentation of treatment changes according to professional standards of practice for one (R3) of one resident reviewed for non-pressure wounds. Findings include: The facility was previously determined to be out of compliance for concerns with administration and documentation of administration of scheduled medications according to professional standards of practice during an abbreviated survey conducted on 8/28/24 with an alleged compliance date of 9/18/24. R78 On 10/14/24 at 9:04 AM, Licensed Practical Nurse (LPN) F was observed opening the medication cabinet of R78. A clear medication cup was observed in the cabinet with three pills in the cup. When LPN F was asked what the pills were, LPN F stated they did not know. LPN F then reviewed the morning medication packets and confirmed that two of the pills inside the medication cup were identical to R78's other morning medications packets. LPN F was asked if they prepared the three medications in the clear medication cup and LPN F stated they did not. LPN F reviewed R78's medical record and noted the resident was also due for an 81 mg (milligram) Aspirin and identified that as the third pill in the medication cup. LPN F opened the Aspirin 81 mg bottle to show the surveyor that the third pill was identical to the Aspirin. LPN F then stated the night shift nurse must have prepared the three pills inside of the clear medication cup. LPN F obtained the medication cup with the three pills and administered it to R78. Review of a facility policy titled Administering Medications revised December 2012, documented in part .Medications shall be administered in a safe and timely manner, and as prescribed .The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication . LPN F was unable to follow the protocol of the facility, as the packet had been discarded and the three pills that were left in the medication cup was not prepared by LPN F, however LPN F administered the three pills to R78. R41 On 10/14/24 at 9:43 AM, LPN E was observed administering R41's morning medications. LPN E was then observed administering one spray of R41's Fluticasone Propionate Nasal Suspension allergy medication in to the right nostril (without holding down the left nostril simultaneously) and then administered one spray in to R41's left nostril (without holding down the right nostril simultaneously). Review of a facility policy titled Nasal Administration dated 9/1/23, documented in part .Purpose to administer nasal medications in a safe, accurate, and effective manner .Use a finger of your other hand to gently press and close the nostril that is not receiving medication .Press the actuator or spray tip firmly and quickly . On 10/14/24 at 12:40 PM, the Director of Nursing (DON) was interviewed and informed of the observation made of R41's nasal medication administration by LPN E and asked the facility's protocol. The DON confirmed that LPN E should have held down the opposite nostril while administering nasal medication into each nostril. The DON was then informed of the observation with LPN F and R78's medications and asked the facility's protocol on the administration of medications that were not prepared by the administering nurse. The DON replied LPN F should have not administered medications that they did not prepare. The DON stated they would check into it and follow back up. No further explanation or documentation was provided by the end of the survey. 30675 R3 On 10/15/24 at 9:29 AM, the resident was observed seated in an adaptive chair in the main lounge near the 200/300 hallways. A square foam bandage was observed to their left outer arm near the elbow that was dated 10/11/24. Review of R3's physician orders included a current order started on 10/7/24 that read, Left lateral elbow cleanse with wound cleanser pat dry apply foam dressing Q (every) 3 days and PRN (as needed) Monitor for signs of infection. At bedtime for skin protectant. Review of the Medication Administration and Treatment Administration records revealed the documentation for R3's left lateral elbow was documented with a check mark (as treatment completed) for each day from 10/7/24 through 10/14/24. Despite the order being written for every three days, Nurse 'A' and Nurse 'T' both documented treatments were being completed daily. Further review of the clinical record revealed R3 was admitted into the facility on [DATE] with diagnoses that included pneumonitis due to inhalation of food and vomit, autistic disorder, and restless leg syndrome. According to the Minimum Data Set (MDS) assessment dated [DATE], R3 had communication deficit (no speech), had severe cognitive impairment, was dependent upon staff for all aspects of care, and received hospice care. On 10/15/24 at 11:10 AM, an interview was conducted with Unit Manager (UM 'U'). When asked about the treatment to R3's left arm, UM 'U' went to R3 who was seated in a group activity, and removed the treatment with their bare hands and stated, Actually it's all healed up. When asked about the documentation that the treatment was being changed daily and most recently documented as completed on midnight shift for 10/14 when they confirmed the treatment they just removed was dated 10/11, UM 'U' reported the order had never been clarified and was unable to explain why Nurse 'A' and Nurse 'T' documented the treatment as being done, when it was not. On 10/15/24 at 11:55 AM, an interview was conducted with the Director of Nursing (DON). When asked if they had been informed of R3's concerns with documentation and treatment of their wound to the left elbow, the DON reported they were not. The DON was informed of the observation and interview and reported that should not have occurred. The DON reported they did random audits and have not identified that as an issue. On 10/15/24 at 2:05 PM, and 2:32 PM, attempts were made to contact Nurse 'A' but the voicemail was full and unable to leave a message. A SMS (Short Message Service) was left, but there was no response by the end of the survey.

Based on observation, interviews and record reviews the facility failed to ensure expired medications were discarded and medications were stored securely for three Residents (R37, R61 and R70) of four residents reviewed for medication storage. Findings include: On 10/14/24 at 8:51 AM, Licensed Practical Nurse (LPN) G was observed preparing the morning medications for R37. Included in the medications was a Docusate Sodium Capsule 100 mg (milligram) obtained from a bottle with an expiration date of 9/2024 and a Multivitamin obtained from a bottle with an expiration date of 8/2024. LPN G did not identify that the medications were expired and administered both medications to R37. LPN G was asked to open the medication cabinet of R37 and obtain the Docusate Sodium and Multivitamin bottle. LPN G was asked to review the expiration date. LPN G reviewed the date and stated they usually would check the expiration date. LPN G stated the expired medication should have not been administered to R37. LPN G stated they were removing both medications from the residents medication cabinet to discard. On 10/14/24 at 9:50 AM, LPN E was observed preparing the morning medications for R61. Included in the medications was a Multivitamin pill obtained from a bottle with an expiration date of 8/2024. LPN E did not identify that the medication was expired. LPN E was observed to administer the expired multivitamin to R61. LPN E was asked to obtain the Multivitamin bottle from R61's medication cabinet and to review the expiration date. LPN E reviewed the date and stated they were discarding the expired medication. On 10/14/24 at 11:35 AM, an observation was conducted with the Director of Nursing (DON) of the 600 & 700 medication storage room. The first five bottles observed was a b complex B-12 full medication bottle that expired on 9/2024. Additional bottles of Vitamin C, Aspirin 81 mg and Vitamin B6 were all found to be expired with dates of expiration ranging from 2/2024 to 9/2024. The DON was asked the facility's process to ensure inventory is being done on the medications in the resident's medication cabinets and the facility's medication storage rooms. The DON stated they were recently hired at the facility and planned to look into the current system and implement a more effective system. The DON obtained all of the identified expired medications and stated they would discard them from the facility's supply. Review of a facility policy titled Storage of Medications dated June 2019, documented in part . Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from inventory, dispose of according to procedures for medication disposal . The facility staff failed to follow the protocol of the facility policy. No further explanation or documentation was provided by the end of the survey. 39592 On 10/14/24 at 9:46 AM, R70 was observed lying in bed. A bottle of Systane eye drops was in it's packaging box with the top removed and observed sitting on R70's bed. R70 was asked about the eye drops. R70 explained it was supposed to be locked in the medicine cabinet on the wall, but sometimes the staff left it out. Review of the clinical record revealed R70 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: congestive heart failure, atrial fibrillation and macular degeneration. According to the Minimum Data Set Assessment (MDS) assessment dated [DATE], R70 was cognitively intact. Review of R70's physician orders revealed no order for Systane eye drops. Review of R70's September 2024 Medication Administration Record (MAR) revealed Systane eye drops had bed discontinued on 9/27/24. On 10/15/24 at 2:03 PM, R70 was observed sleeping in their bed. The bottle of Systane in it's box was observed sitting on R70's bed. On 10/16/24 at 2:58 PM, the Director of Nursing (DON) was interviewed and asked if medications should just be left on a resident's bed. The DON explained they should be locked in the medicine cabinet. The DON was informed the Systane had been discontinued on 9/27/24. The DON explained the medicine should have been removed from the cabinet when it was discontinued.

Based on observation, interview, and record review the facility failed to ensure the facility maintained proper infection control practices regarding the cleaning and disinfecting of glucometers per the facility's policy and manufacturer's instructions for two (R's 41 & 61) of four residents observed for the medication administration task. Findings include: R41 On 10/14/24 at 9:43 AM, Licensed Practical Nurse (LPN) E was observed administering R41's morning medications. Once R41 consumed their pills LPN E was then observed to obtain R41's blood glucose level via a fingerstick and glucometer. Once completed, LPN E was observed cleaning the glucometer with an alcohol prep pad and placed the glucometer in R41's medication cabinet and locked it. R61 On 10/14/24 at 9:55 AM, LPN E was observed obtaining the blood glucose level of R61 via fingerstick and the use of a glucometer. Once completed, LPN E was observed cleaning and disinfecting the glucometer with an alcohol pad and placed the glucometer in R61's medication cabinet and locked it. Review of a facility policy titled Blood Sampling revised April 2012 documented in part, . Obtain the blood sample, following the manufacturer's instructions for the device . Following the manufacturer's instructions, clean and disinfect reusable equipment, parts, and/or devices after each use . Review of the manufacturer's booklet provided by the Director of Nursing (DON) for the facility's glucometer documented in part . The disinfection procedure is needed to prevent transmission of blood-borne pathogens . The meter should be cleaned and disinfected after use . Two disposable wipes will be needed for each cleaning and disinfection procedure: one wipe for cleaning and a second wipe for disinfecting . The booklet documents multiple approved cleaning and disinfecting wipes and an alcohol prep pad was not listed. On 10/14/24 at approximately 12:43 PM, the Director of Nursing (DON) was interviewed and asked about the facility's protocol to clean the glucometers after obtaining a resident blood glucose level and the DON stated they would look into it and follow back up. The DON was informed of the observations of LPN E obtaining the blood glucose levels of R's 41 & 61 and the concern of improper infection control practices regarding the cleaning and disinfecting of the facility's glucometers and the DON stated they understood and would follow back up. At 1:05 PM the DON provided a one-step cleaner and disinfectant wipe bottle and stated the staff are supposed to use it after the resident is discharged , however staff can use alcohol swabs after each use of the glucometer. The DON was then asked about the directive in their facility policy and the manufacturer's directive regarding the cleaning and disinfecting of the glucometer device and the fact that an alcohol prep pad is not listed as an approved cleaning and/or disinfectant agent. The DON acknowledged the concern and provided no further explanation.

Based on observation, interview, and record review, the facility failed to ensure effective interventions were implemented for one (R44) of one resident reviewed for communication. Findings include: On 10/14/24 at 9:15 AM, R44 was observed sitting up in bed. When spoken to, R44 appeared to understand the questions asked, but had difficulty speaking. R44 spoke softly and speech was unclear. R44 became tearful when she was not understood. A sign was posted in R44's room that noted R44 was able to understand others. R44 said she had Parkinson's Disease. It was difficult to understand most words R44 said. On 10/14/24 at approximately 9:30 AM, an interview was conducted with a staff member who was familiar with R44 (Staff 'V'). When queried about how staff communicated with R44, Staff 'V' reported it was difficult and they could sometimes understand what she said. On 10/14/24 at 12:25 PM, a second interview was conducted with R44. R44 answered Yes, No, and Sometimes to questions regarding her care, but when further inquiry was made to get more information, it was difficult to understand the resident's speech. R44 became tearful when not understood. On 10/15/24 at 2:00 PM, R44 was observed sitting up in bed. R44 was drooling with excessive saliva pooled in her mouth. When asked questions about her care, R44 grabbed a pen and attempted to write what she wanted to say, but it was illegible. R44 tried to speak, but her voice was soft and difficult to understand. R44 became tearful. On 10/15/24 at approximately 2:10 PM, an interview was conducted with Licensed Practical Nurse (LPN) 'F'. LPN 'F' was queried about how staff communicated with R44. LPN 'F' reported R44 had intact cognition and understood what was said to her. LPN 'F' reported they just asked Yes or No questions and said sometimes staff could understand her. When queried about any additional techniques, devices, and interventions that were used to ensure staff knew what her expressed needs were, LPN 'F' reported they were not aware of anything. On 10/16/24 at approximately 12:40 PM, an interview was conducted with Speech Language Pathologist (SLP) 'W'. SLP 'W' reported working with R44 since January 2024. When queried about what recommendations were made by SLP to improve or maintain R44's verbal communication or if any alternative methods of communication were used, SLP 'W' reported they spent time training nursing staff and R44 to ensure R44's communication needs were met. SLP 'W' reported R44 was able to understand others, but had difficulty speaking clearly due to Parkinson's Disease. SLP 'W' reported she made a laminated guide with techniques for both R44 and staff to use to ensure R44 was understood. On 10/16/24 at approximately 12:45 PM, R44 was observed with family who assisted her with eating. SLP 'W' located the guide mentioned above which was located in a basket near R44 on the over bed table. A review of the guide revealed a page titled, Tips and Tricks for Others and documented the following interventions: Be patient and focus on response. If you are distracted, you may miss a lot of words. Watch/read lips. Ask for Clarification. Repeat the words you understood, ask to repeat. Remind to slow down/restart. Ask for spelling of key word that may be missed. Ask for single words to get context clues at start. Ask yes/no for clarification. Give time to collect thoughts/respond. Think about environment/sounds. At that time, the guide was reviewed with R44. When asked if staff referred to the guide and/or utilized the techniques noted to ensure adequate communication, R44 shook her head and said they did not. A review of Speech Therapy Treatment Encounter Notes for R44 revealed the following notes: On 8/16/24, .Assisted (CNA) w/(with) pt ADLs (activities of daily living). Assisted (CNA) w/ pt (patient) communication. Pt required mod cueing for repetition, utilizing loud voice, and over exaggeration of consonants for increased intelligibility . On 8/23/24, .Created visual handout personalized to pt (patient) techniques to increase intelligibility w/(with) other communication partners . 9/4/24, .Establishment of compensatory strategies/creation of external environmental aid for communication techniques for pt family members and staff to utilize to increase comprehension and socialization of speech . A review of R44's care plans revealed a care plan initiated on 1/30/24 and revised on 5/16/24 that noted, The resident has Parkinson's. Interventions initiated on 1/30/24 included, .Allow sufficient time for speech/communication. Follow ST (speech therapy) recommendation to assist resident with communication. There were no specific interventions as recommended by SLP included on the care plan, including instructions to refer to the guide made by SLP 'W' or specific techniques recommended by SLP 'W'. A review of R44's clinical record revealed R44 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Parkinson's Disease. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R44 had intact cognition, unclear speech, was able to understand others, was dependent on staff for bed mobility and transfers, and required substantial/maximum assistance for all activities of daily living (ADLs). On 10/16/24 at 2:17 PM, an interview was conducted with the Director of Nursing (DON). When queried about what was in place to ensure adequate communication with R44, the DON reported she was not sure and would have to look into it. The DON reported communication interventions should be in the care plan and Kardex (guide for CNAs).

Based on observation, interview and record review the facility failed to ensure orders were implemented for a CPAP (continuous positive airway pressure) machine for one (R231) of one resident reviewed for respiratory equipment. Findings include: On 10/24/24 at 9:16 AM, R231 was observed sitting in a wheelchair in their room. R231 was asked about the care at the facility. R231 explained they did not understand why they had to almost beg someone to put on their CPAP machine at night. R231 pointed to their CPAP machine sitting on a dresser next to the bed. R231 explained they could not put it on themselves, but no one would put it on unless he asked. Review of the clinical record revealed R231 was admitted into the facility on [DATE] with diagnoses that included: acute pyelonephritis (kidney infection), Parkinson's and obstructive sleep apnea. According to a Brief Interview for Mental Status (BIMS) exam dated 10/11/24, R231 scored 12/15 indicating moderately impaired cognition. An admission nursing assessment dated [DATE] indicated R231 required the extensive assistance of staff for activities of daily living. Review of R231's physician orders revealed no CPAP orders. Review of R231's hospital referral paperwork read in part, .Past Medical History: .OSA (obstructive sleep apnea) on CPAP . On 10/15/24 at 9:25 AM, R231 was observed in the doorway of their room. R231 was asked if they had used their CPAP during the night. R231 explained sometime in the middle of the night, they had asked someone and they had put it on for them. On 10/15/24 at 3:14 PM, the Director of Nursing (DON) was asked if a resident had their CPAP machine at the facility, and if staff were putting it on a resident, should the doctor be called and an order be obtained. The DON explained there should be a physician order for CPAP. When informed R231's hospital referral listed CPAP, and R231 wanted to use their CPAP, but there were no orders for it. The DON explained she would look into it. No further documentation was provided by the end of the survey.

Based on interview and record review, the facility failed to maintain complete and accurate medical records for one (R18) of one residents reviewed for medical records. Findings include: The facility was previously determined to be out of compliance for concerns with maintaining complete and accurate medical records during an abbreviated survey conducted on 8/28/24 with an alleged compliance date of 9/18/24. Review of the clinical record revealed R18 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: acute and chronic respiratory failure, cervical disc disorder and atrial fibrillation. According to the Minimum Data Set (MDS) assessment dated [DATE], R18 had severely impaired cognition and required substantial/maximal assistance of staff for mobility in bed. The MDS assessment also indicated R18 had two facility acquired Stage 2 (partial-thickness loss of skin with exposed dermis) pressure ulcers. Review of R18's wound assessments documentation revealed: A Wound Evaluation dated 7/17/24 read in part, #18 - Pressure - Kennedy terminal ulcer - Stage 1 . Sacrum - Lateral . The evaluation also included a picture of R18's wound. A Skin & Wound Evaluation dated 8/31/24 read in part, .Type: Pressure - Kennedy terminal ulcer . Stage 2: Partial-thickness skin loss with exposed dermis . Progress: Resolved . A Wound Evaluation dated 8/31/24 read in part, .#18 - Pressure - Kennedy terminal ulcer - Stage 2 . Sacrum - Lateral . The evaluations included picture showed R18's wound that had an open wound, not a resolved wound. A Wound Evaluation dated 9/13/24 read in part, .#21 - Pressure - Kennedy terminal ulcer - Unstageable . Coccyx . The picture showed the wound in the same place on R18's body as the previous sacrum evaluations. A Wound Evaluation dated 10/15/24 read in part, .#16 - Pressure - Unstageable . Coccyx . This evaluation was documented in a previously resolved wound thread however, the picture was consistent with R18's current wound. Review of R18's wound care consultation documentation from 9/10/24 and 9/17/24 revealed treatment recommendations for R18's wounds. No consultation notes or description of R18's wound was in the documentation. On 10/15/24 at 10:06 AM, the Director of Nursing (DON) was interviewed and asked about the apparent discrepancy in the documentation of R18's wounds. The DON explained she had not been at the facility when R18 acquired their wounds. The documentation and pictures of R18's wounds was reviewed with the DON. The DON agreed the wound labeled as Sacrum - Lateral and Coccyx and receiving the numbers 18, 21 and 16 were most likely the same wound. The DON was asked why the same wound was not consistently in the same place but in multiple places with multiple wound numbers. The DON explained they had realized the nurse had put the Wound Evaluation on 10/15/24 in the wrong place, but had no explanation for the Sacrum-Lateral and Coccyx difference. The DON was asked about the lack of the wound care clinic's consultations and description of R18's wounds. The DON explained she would look into it. On 10/15/24 at 4:29 PM, a request was made to R18's wound care clinic to provide the consultation notes for R18. Review of R18's wound care clinic consultation notes revealed: 9/10/24 .Note: The sacral wound cannot be examined today because the patient did not arrive seated in (their) Hoyer Lift (mechanical lift) sling. Therefore, the staff cannot safely transfer (them) for examination . 9/17/24 .Wound #4 Coccyx is a chronic Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer . The patient's wounds have worsened despite offloading on a group 2 alternating low are loss pressure reducing surface. (in bold type) (They) is a candidate for a group 3 air-fluidized bed. The prognosis for healing is extremely poor unless offloading can be optimized . 10/1/24 .The coccygeal ulcer has further worsened due to suboptimal offloading . A group 3 air-fluidized bed is strongly recommended. The prognosis for healing is extremely poor unless offloading can be optimized . Offloading: .Sleep on group 2 alternating low air loss pressure reducing surface and turn q2 (every 2 hours) hours alternating between sides until group 3 air-fluidized bed procured . On 10/16/24 at 12:45 PM, Unit Manager (UM) M was interviewed and asked about consultation notes. UM M explained when a resident went to an outside appointment, the assigned nurse would get the consultation report from the resident and enter the orders, then it went to the Unit Managers for review and was scanned into the clinical record. UM M was asked about R18's wound care clinic consultation from 10/1/24. UM M explained she would look for it. On 10/16/24 at 1:33 PM, the Administrator was interviewed and asked if she had ever been notified the doctor at R18's wound care clinic had recommended R18 have a air-fluidized bed. The Administrator explained it had never been brought to her attention. On 10/16/24 at 1:54 PM, the DON was informed of the recommendations from the wound care clinic consultation notes. The DON explained they had also called the clinic and received the consultation notes. When asked why when the facility had only the treatment recommendation from 9/10/24 and 9/17/24 and nothing from 10/1/24 that the consultation notes had not been requested prior, the DON had no explanation.

This citation pertains to intakes: MI00146401 and MI00146531 This citation had two Deficient Practice Statements (DPS). DPS #1 Based on observation, interview, and record review the facility failed to provide adequate supervision for one Resident (R903) of two Residents reviewed for accidents resulting in an unbeknownst exit of a cognitively impaired, wheelchair bound resident from the facility and a fall with injury. Findings include: A record review revealed that R903 was admitted to the facility on [DATE] after a hospitalization , for skilled nursing and rehabilitation services. R903 was recently hospitalized and readmitted back to the facility on [DATE]. R903's admitting diagnoses included Schizophrenia, anxiety disorder, Chronic Obstructive Pulmonary Disease (COPD), Parkinson's disease, end stage renal disease, (on hemodialysis) with history of falls and syncopal (fainting) episodes. R903 had a guardian who handled R903's medical, legal, and financial decisions. Based on the Brief Interview for Mental Status (BIMS), R903 had a score of 11/15, indicative of moderate cognitive impairment. R903 needed limited staff assistance with their Activities of Daily Living (ADLs) such as dressing, bathing etc. A complaint received by the State Agency revealed that a resident fell of their wheelchair in the middle of the road at 9 PM and the facility staff were unaware that R903 was outside of the facility. The facility's front doors were locked and resident was observed on the ground with their wheelchair by a visitor who had notified the facility staff. An initial observation was completed on 8/27/24 at approximately 11:05 AM. R903 was observed sitting in their wheelchair, in the room doorway. When this surveyor asked to meet with the R903, they were trying to back up into the room from the doorway and reported that they may need help and started backing up in their wheelchair. R903 took approximately two minutes to back into their room with verbal cues from the surveyor to back up the wheelchair. R903 had a dressing on the left lateral (outside) elbow area. R903 reported that they had pain on their left hip/groin area. When the surveyor asked how severe their pain was, R903 stated 10/10 and added I have never had this kind of pain. R903 added they were getting pain medication that was just started a few days ago. They had pain medication this morning and it was not helping and they needed something more. LPN C was notified by the surveyor. R903 was queried if the pain started after their fall, they reported that it started days after the fall and they did not remember the time frame. R903 was queried if they had seen a physician, R903 reported that a woman, not a doctor, not sure about the time frame, who was going to order an ultrasound (test) for the pain. LPN C' who was assigned to care for R903 came in; R903 reported that their pain was 10/10 and nurse reported that it was too soon to get another dose of Tramadol and they would get them a Tylenol. R903 was queried about their fall. R903 reported that they fell outside of the facility in the parking lot area. R903 confirmed that they were outside the building and there were no staff members with them. R903 stated, I scrapped my left arm, not sure if they hit their head. R903 reported that the Emergency Medical Services (EMS) came and they did not want to go to hospital. When asked about the details of the incident, R903 reported that they were in their wheelchair and thought they might have dozed off and fell . When queried further about the specifics of the fall, they reported that they did not remember. R903 added that they were not allowed to go out on their own anymore after the fall. R903 reported that they had a guardian for a few years who handled their businesses and they were able to provide the name of their guardian. R903 had asked the surveyor to check on the test that was ordered for them. Later that day a follow up observation was completed at approximately 1:40 PM. R903 was in their room and they reported that their left hip/groin pain was little better than the morning and stated it was 7/10 and they did not go to dialysis because of pain. R903 was queried about the fall time, approximately 8:30 PM (based on the visitor and staff witnesses) and how they had left through the main entrance door that was set to lock at 6 PM and if they knew the code to unlock the front door. R903 reported that they did not know the code and thought they went outside before the doors were locked (6 PM), but they were not sure. They added that they were not sure how long they were sitting outside before they fell out of their wheelchair. On 8/28/24 at approximately 10:05 AM, R903 was observed in their bed and x-ray technician was in the room. This surveyor met with R903 in their room after. R903 reported that they had an x-ray of their hip. They added that they still had left hip/pain, it was 6/10 and they had constant pain. R903 also added that they were in pain all weekend (last weekend) and they had asked the staff to get some medication for pain; they had been getting the tramadol for the last few days. R903 reported that they were not able to take their shower last night because of their pain. Review of R903's Electronic Medical Record (EMR) revealed a nursing progress note dated 8/8/24 at 20:30 read in part, At approximately 2030, guest was observed outside of the facility, on the ground. Guest stated that she was sitting in her wheelchair when she tipped over, with her wheelchair falling on top of her. Guest stated that she did hit her head on the ground. Guest has a new skin tear on the back of the left forearm writer called EMS to transport guest to hospital due to possible head injury .EMS refusing to take her to hospital stating she can make her own decisions. Director of Nursing (DON) and on call provider notified. Writer attempted to call guest's guardian but could not get in touch with her. Incoming nurse will reattempt during business hours . Further review of nursing progress note revealed a note titled skilled charting' dated 8/9/24 at 9:59 read in part, Transfer and ambulation 1-person assist (PA) with 2-wheeled walker. BIMS of 11, moderate cognitive impairment .Intervention: Offer resident to sit outside in front while waiting for dialysis. Resident can sit outside in front on patio on non-dialysis days and in the afternoon/evening. Root cause: poor trunk control. Inter Disciplinary Team (IDT) reviewed incident, root cause analysis, and new intervention and agree with plan of care. Review of R903's progress notes revealed a care transition (social services) note dated 7/26/24 that read in part, guest has a guardian named 'name of guardian omitted' .BIMS score 11/15 indicating cognition is moderately impaired .plan is for guest to remain Long Term Care (LTC) at 'name of the facility' omitted . Further review of progress notes did not reveal any evidence of follow-up evaluation by a physician or practitioner note after the fall incident on 8/8/24. There was no evidence that there were follow-up radiology/other diagnostic tests were ordered despite the nature of the incident: an unwitnessed fall incident outside of facility, with R903 reporting of hitting their head, R903's cognitive impairment and nursing observation/assessment that warranted a 911 call. Further review of the EMR revealed a physician progress note dated 7/19/24, (prior to recent admission to hospital). The surveyor confirmed with the DON on 8/27/24 that all physician documents were entered in EMR except for a practitioner visit note from 8/26/24. Review of R903's Electronic Medical Record (EMR) revealed physician orders that included: hemodialysis on Monday, Wednesday and Friday and a scheduled pick up at 11:30 AM; vital signs twice daily dated 7/25/24; acetaminophen tablet 325 milligrams (mg) - 2 tablets by mouth every 4 hours as needed for pain dated 7/25/24; and tramadol HCL 50 mg - 1 tablet every 6 hours as needed for pain. Review of R903's care plan revealed that R903 was at risk for falls due their diagnoses and co-morbidities with their physical and cognitive limitations. Review of physical therapy discharge summary dated 7/2/24 revealed that R903 needed minimal staff assistance with their wheelchair mobility in a corridor or similar space. Resident's functional wheelchair mobility on outside terrain, patios and or sidewalk were not assessed or addressed. Standing balance at discharge indicated that R903 was a high risk for falls and they needed staff supervision with their transfers. A request was sent via e-mail on 8/27/24 at 12:48 PM and verbally to the DON and Administrator to provide the incident/accident report and investigation/facility follow-up for R903's incident/accident from 8/8/24. The facility provided an incident report completed on 8/9/24 that revealed the predisposing factors for the incident were impaired memory and weakness/fainted. The section under statements read no statements. Section under agencies people notified read that R903' s guardian was notified on 8/8/24 at 20:45. There was no investigation and root cause analysis of an unbeknownst exit of a cognitively impaired, wheelchair bound resident from the facility into a secluded area of the parking lot and sustained an unwitnessed fall with skin tear that was brought to the attention of facility staff by a visitor (at 8:30 PM). On 8/27/24 at approximately 2:15 PM Regional Nurse Consultant (RC) A was queried about the investigation file for R903's incident from 8/8/24 as the DON was out of facility. RC A reported that they just found out about the incident and they would check with the DON and Administrator. On 8/27/24 at approximately, 2:35 PM facility Administrator was queried about the incident and investigation report. They reported that they were not involved in investigating the incident. They were notified of R903's fall and the DON completed the fall investigation. They did not provide any further explanation. An interview with the visitor who observed R903 in the parking lot was completed on 8/27/24 at approximately 3:45 PM. The visitor reported that they were leaving the facility with their spouse after visiting a family member it was approximately 8:45 PM. They observed R903 lying on the ground with their wheelchair on top of R903 and they were unsure if that was resident or a visitor. They reported that they had asked R903 if they had hit their head and R903 responded yes. The visitor added that R903 had gash on her arm and it was bleeding. The visitor reported the facility front door was locked when they had left. Their spouse went in and alerted the staff member while they had stayed with R903. There were two nurses who came and assisted the resident. The visitor added that staff members thanked them the next day for and bringing the incident to their attention and helping with the situation. An interview with Licensed Practical Nurse (LPN) B was completed on 8/27/24 at approximately 1:45 PM. They were queried if they remembered about R903's incident on 8/8/24. LPN B reported that they remembered the incident. They had finished their shift and they were charting on the receptionist's computer near the main entrance. A family member came to the facility between 8:30 and 8:45 PM and reported that a resident was hurt and they were on the ground and needed help. When queried how the family member had entered the facility, LPN B reported that the door was locked the family member was regular visitor and they had the code to enter and they had to use the code to exit the building. LPN C who was also at the desk, was completing their charting after their shift. They both went out and saw R903 on the ground in back. LPN B confirmed that there was no one outside and the area where R903 was not visible from the inside. LPN B stated, We assessed [R903] notified [LPN F] (who was assigned to care for R903 on that shift). When they had reported that R903 was outside on the ground LPN F was not aware that R903 was outside the facility. They had called 911. This surveyor asked LPN B to show the area where they had found R903. This surveyor walked with LPN B from the front entrance to approximately three hundred feet away towards the secluded area (West side parking). There was turn on a sidewalk with an incline closer the [NAME] end parking where R903 was located, on the road next to sidewalk. The location of incident was also confirmed by the visitor. The surveyor queried if this was safe area for a wheelchair bound resident with impaired cognition to be alone at 8:30 PM, LPN B stated, No. An interview was completed with LPN C on 8/27/24 at approximately 2 PM. LPN C also witnessed the incident and assisted LPN B on 8/8/24. LPN C was also the nurse who worked on R903's unit on the morning shift (7 AM - 7 PM). When queried if they remembered the incident and they reported that they did. It was between 8:30 - 8:45 PM a family member came in when they were at the receptionist desk charting after their shift. The family member reported that there was someone one on the ground outside in a wheelchair and they were not sure if that was resident or visitor. They went to check with LPN B and observed R903 on the road next to sidewalk walk and they had notified LPN A who was nurse assigned to R903's unit. LPN A was not aware that R903 was outside of the facility. When they had asked R903 what happened, the Resident reported that they were trying to go around the curve and their wheelchair tipped over. They had assisted with the situation, EMS was called and R903 did not want to go to hospital and the DON spoke with EMS. This surveyor queried LPN C when they had last seen R903 and they reported that R903 was in the room when they had signed off from their shift. The surveyor queried about their signoff process, LPN C reported that they were supposed to see the resident when doing the recap with the oncoming nurse. This surveyor asked if R903 was allowed to go out on their own, LPN C reported that the Resident used to sit outside in the front prior to the fall. When queried how did they monitor when they were sitting outside and what was their process, LPN C reported that they did not have any issues prior; the receptionist left around 8 PM and they would let the charge nurse know if a Resident was sitting outside. It must be noted that the area where R903 was observed was not visible from the front entrance, unless someone did a walk through to the west side of the facility or had parked on this end and walked towards their car. Calls were made to Certified Nurse Assistant (CNA) who was assigned to R903 on 8/8/24 and they were not returned prior to survey exit. An interview with Maintenance Director (DM) D was completed on 8/27/24 at approximately 2:20 PM. DM D was queried about the main door lock time frames and the process. They reported that the doors were set to lock between 6 PM - 7 AM. If anyone needed to exit outside these times frame, the instructions are posted. If they needed to exit, staff were assisting them. DM D was queried about the camera and monitoring. They reported that they had camera in the hallways, but not outside. This surveyor went to check the cameras with DM D at approximately 2:30 PM. DM D had to get the assistance from the Administrator. At approximately 2:35 PM, the Administrator came in. This surveyor explained that they wanted to check the front door camera for 8/8/24 and Administrator reported that they did not have any cameras monitoring the front (main) entrance. An interview was conducted with Receptionist (RE) E on 8/27/28 at approximately 2:50 PM. Receptionist E reported that they had worked till 5 PM and they had two other staff members who took turns to cover the weekends and afternoons, till 8 PM. They had reported that the front door locks at 6 PM to 7 AM. They were queried about the facility process on who is allowed to sit outside and how they were monitoring. RE E reported that they checked with the resident if they had let their nurse know and if they were their own person they had let them sit outside and they were not monitoring the residents. They added if they had wander guard they were not allowed. An initial interview was conducted with the DON on 8/27/24 at approximately 3 PM. The DON was queried about the incident and why they did not investigate. The DON reported that they were notified of the incident by the charge nurse, that it happened right outside the door and it did not need an investigation so they had just completed a fall investigation and did not provide any further explanation. An interview was completed with R903's guardian on 8/27/24 at approximately 3:25 PM. The guardian was queried about the incident on 8/8/24. They had checked the call notes and checked with their assistant and reported that they did not receive any calls about the incident. When explained the incident the guardian asked, What was she doing at 8:45 PM in the parking lot?. They added that residents should not be in an area where employees cannot monitor them. They added that they never gave permission and R903 was not safe to be outside unsupervised. They noted that should have been notified of this incident. If it is after hours, staff could leave a voicemail and they should receive a call back for this incident. An interview was completed with the Administrator on 8/27/24 at approximately 5 PM. The Administrator was notified of the concerns with supervision for R903, how they had exited and the unknown timeframe they were outside the facility, the fall outside the facility with no investigation, and not notifying the guardian. The Administrator reported that they understood the concerns. An interview was completed with LPN F who was assigned to R903's unit at the time of the incident on 8/28/24 at approximately 6:55 AM. LPN F was queried about R903's incident. They reported that their shift started at 7 PM and they regularly worked that unit and they were familiar with the residents. LPN F added that they received the report from LPN C that R903 was in their room, but they did not physically see the resident after their shift started. They were getting ready to gather supplies and start to pass the medications. At approximately 8:30 PM they were alerted by LPN B that R903 was observed outside the facility on the floor. It must be noted that R903 was on the front end of the unit (1st room) and LPN F failed to explain how they had not seen the Resident for over an hour and a half since the start of their shift. They added that they went outside and LPN C was with R903. They reported that they had called 911 and R903 did not want to go to hospital so EMS did not take the resident. They added that R903 had periods of confusion and had a guardian, also the resident reported that they might have hit their head and the fall was unwitnessed. They did not want to take any chances and had called EMS. They added that they had communicated with the DON and had called the guardian and left a brief message. They had notified the oncoming nurse to call the guardian during business hours. The surveyor queried if R903 was safe at the location without staff supervision/assistance at that time, LPN F' stated nobody would be safe at the location. When queried about the time frame they reported that they did not know. When this surveyor asked what could have prevented the event, LPN F reported better communication between the nursing staff, walking rounds while receiving report at the start of their shift and communication between the receptionist and nursing staff would have prevented the incident. A follow-up interview with the DON was completed on 8/28/24 at approximately 11:35 AM. The DON reported that they were notified that R903 had a fall from the wheelchair as it tipped, right outside the main entrance and that is why they had not completed any investigation. The DON was queried if they had seen where R903 was on the ground and they reported they had not. The DON agreed to see the location. This surveyor and DON went to see the area where R903 was located. This surveyor queried if that area was safe for R903 to be unsupervised at 8:30 PM? The DON agreed it was not safe. The DON was queried how the facility determined that a Resident was safe to be outside unsupervised? The DON reported that it was based on cognitive assessment and their physical functioning. This surveyor queried about R903's cognitive impairment and physical limitations and how they were safe. The DON reported that R903 usually sat at the main entrance by the door. When they were queried R903 was supervised, they reported that the receptionist and care transition staff can monitor from their desk/office. When queried further how the receptionist could visually see through the walls and vestibule in the front and what happened if they left the desk/office? No further explanation was provided. When queried further about the process, The DON reported that the best practice'' for both nurses and CNAs was to do walking rounds during shift change. They reported that they understood the concerns. Review of facility provided document titled Elopements with a revision date of December 2008 read in part, 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. 2. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the departure in a courteous manner. b. Get help from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises. 3. When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall: a. Examine the resident for injuries. b. Notify the Attending Physician. c. Notify the resident's legal representative (sponsor) of the incident. d. Complete and file Report of Incident/Accident; and e. Document the event in the resident's medical record . The facility's elopement policy that was revised approximately [AGE] years ago did not address facility process on identification and assessment of at-risk residents, facility process to provide supervision in the facility premises such sitting outside the front door, patio etc. DPS #2: Based on interview and record review the facility failed to provide a thorough root cause analysis after fall(s) and provide resident specific intervention(s)/supervision for one (R902) of two Residents reviewed for falls. Findings include: A complaint received by the State Agency reveled that R902 had multiple falls after admission to facility and the facility failed to provide appropriate interventions. A review of the medical record revealed that R902 was a long-term resident of the facility, admitted to the facility on [DATE]. R902's admitting diagnoses included: Fracture of left Femur (after fall in the hospital), sepsis, heart failure, dementia, anxiety and history of stroke. Based on the MDS (minimum data set) assessment dated [DATE], R902 had a BIMS of 6/15, indicative of severe cognitive impairment. An initial observation was completed on 8/27/24 at approximately 10:30 AM. R902 was observed sitting up in their wheelchair. A family member was in the room. The right side of the bed was against the wall. R902 had nightstand that was partially blocking the bathroom doorway. When the surveyor queried about how the family member reported that they had placed it (the night stand) the night before so R902 would not attempt to go bathroom on their own. The Family member also reported that R902 had to wait longer for assistance when they needed to be changed, especially on weekends and later in the afternoons. They added that R902 was soiled and was changed around 11 AM yesterday after they had come in and had requested the staff to assist. An interview was completed with the complainant on 8/26/24 at approximately 4 PM. The complainant reported that R902 was a high fall risk when they admitted to the facility. R902 did not have the supervision and timely assistance with toileting; had multiple falls in the last few weeks. Review of R902's hospital discharge summary dated 5/28/24 reveled that R902 had a fall in the hospital on 5/25/24 and had fracture of left femur (thigh bone) and had surgery and they were unable to bear weight on left leg and they were admitted to the facility for skilled nursing and rehabilitation services. Review of R902's Electronic Medical record (EMR) revealed that R902 had a recent room and unit change on 8/26/24. Prior to this, R902 was in a different unit in room [ROOM NUMBER], which was on the farther down, closer to the end of the hallway. Review of progress notes revealed a Care Transitions note dated 7/3/24 at 12:53, that read, reached out to family via e-mail and phone call regarding transferring guest to semi-private room on LTC (Long-Term Care) side A follow up note dated 7/3/24 at 13:06 read, Received notice from family that we can move guest to semi-private room on LTC side. No concerns at this time. Based on resident census record R902 was moved to room [ROOM NUMBER], a room closer towards the end of hallway. Facility was requested to provide the Incident & Accident (I&A) reports for R902 from July through current date and was received via e-mail. Review of I&A reports and progress notes revealed the following: R902 was high risk for falls, related to their recent fall history, co-morbidities with impaired cognition and functional mobility related to recent fracture of femur. R902 had falls on: 5/30/24, 6/14/24, 7/11/24, 7/15/24, 8/4/24, and 8/16/24. Review of I&A reports and investigative summaries revealed R902 had 3 falls between 8PM and 10:15 PM and 3 falls between 3 AM and 6 AM. R902 had 3 falls related to incontinence episodes and R902 attempting to get out of bed. Review of investigative summary for 5 out 6 falls for a resident with severe cognitive impairment revealed the root cause analysis as poor safety awareness for 5 out 6 falls and for other fall it read poor impulse control r/t (related to) cognition and an intervention dated 8/16/24 read, re-orientate resident to environment during rounds. Review of care plan included the following interventions: check for incontinence episode around 3 AM dated 5/30/24, offer toileting before and after meals dated 6/28/24, and check for incontinence episode during early morning rounds. An interview with the DON was completed on 8/28/24 at approximately 12:25 PM. The DON was queried about the falls for R902 and their root cause analysis that read poor safety awareness for R902, how that was a root cause for a resident with severe cognitive impairment and history of falls. The DON reported that R902 had multiple falls related to her restlessness due to incontinence episodes and they were working con improving their root cause analysis process with someone from corporate. The DON was queried if it was appropriate to have the high fall risk resident with recent fall and femur fracture to be farther at the end of the hallway and how re-orientation is an appropriate intervention. The DON reported that they understood the concerns and they were working on it. Review of facility provided document titled Falls and Fall Risk, Managing with a revision date of December 2007 (revised approximately [AGE] years ago) read in part, Based on previous evaluations and current data, the staff will identify interventions related to resident specific risks and causes to try to prevent resident from falling and try to minimize complications from falling.

Based on interview and record review, the facility failed to administer and/or document administration of scheduled medications according to professional standards for ten (R905, R906, R907, R908, R909, R912, R913, R914, R915, R916) of fifteen residents reviewed for medication administration. Finding include: R905 Review of R905's Medication Administration Record (MAR) revealed that the following scheduled medications were not documented as being administered: 8/6/24 1800 GenTeal Tears Severe Day/Night Ophthalmic Gel 0.4-0.3%, instill 1 drop in both eyes at bedtime 8/6/24 1800 Senna Oral Tablet 8.6mg, give 1 tablet by mouth at bedtime 8/6/24 bedtime dose Cyclosporine Emulsion 0.05%, Instill 1 drop in both eyes two times a day 8/6/24 2100 Eliquis 5mg, Give 1 tablet by mouth two times a day 8/6/24 2000 House/High Protein three times a day 8/7/24 0600 Levothyroxine Sodium Oral tablet 100 mcg, give 1 tablet by mouth one time a day every Mon, Tue, Wed, Thu, Fri, Sat 8/7/24 0600 Menthol-Zinc Oxide External Ointment 0.44-20.6%, Apply to buttock topically one time a day R906 Review of R906's Medication Administration Record (MAR) revealed that the following scheduled medications were not documented as being administered: 8/7/24 0600 Levothyroxine Sodium Oral Tablet, Give 75 mcg by mouth one time a day every Mon, Tue, Wed, Thu, Fri 8/6/24 2100 Gabapentin Oral Capsule 100mg, Give 1 capsule by mouth three times a day R907 Review of R907's Medication Administration Record (MAR) revealed that the following scheduled medications were not documented as being administered: 8/6/24 bedtime dose Senna Oral Tablet, Give 1 tablet by mouth at bedtime 8/6/24 2000 and 8/7/24 0600 Ativan 2mg, Benadryl 25mg, Haldol 2mg gel three times a day R908 Review of R908's Medication Administration Record (MAR) revealed that the following scheduled medications were not documented as being administered: 8/6/24 bedtime dose Atorvastatin Calcium 40mg, Give 1 tablet by mouth at bedtime 8/6/24 bedtime dose Citalopram Hydrobromide Oral Tablet 10mg, Give 1 tablet by mouth at bedtime 8/6/24 bedtime dose Magnesium 400mg, Give 1 tablet by mouth at bedtime 8/6/24 bedtime dose Trelegy Ellipta Inhalation Powder 100-62.5-25mcg, 1 puff inhale orally two times a day 8/7/24 0600 Pantoprazole Sodium 40mg, Give 1 tablet by mouth one time a day 8/7/24 0600 Levothyroxine Sodium 150mcg, Give 150mcg by mouth one time a day R909 Review of R909's Medication Administration Record (MAR) revealed that the following scheduled medications were not documented as being administered: 8/6/24 bedtime dose Atorvastatin Calcium Oral Tablet 40mg, Give 1 table by mouth at bedtime 8/6/24 bedtime dose Melatonin Tablet 3 mg, Give 2 tablets by mouth at bedtime 8/6/24 bedtime dose Acetaminophen Tablet 325mg, Give 2 tablets by mouth two times a day 8/6/24 bedtime dose Famotidine Oral Tablet 20mg, Give 1 tablet by mouth two times a day 8/6/24 2100 Gabapentin Oral Capsule 100mg, Give 2 capsules by mouth two times a day R912 Review of R912's Medication Administration Record (MAR) revealed that the following scheduled medications were not documented as being administered: 8/7/24 0600 Levothyroxine 50mcg, Give 50mcg by mouth one time a day R913 Review of R913's Medication Administration Record (MAR) revealed that the following scheduled medication was not documented as being administered: 8/7/24 0600 Insulin Glargine Subcutaneous Solution 100 unit/ml, Inject 15 units subcutaneously one time a day R914 Review of R914's Medication Administration Record (MAR) revealed that the following scheduled medication was not documented as being administered: 8/7/24 0600 Bumetanide Tablet 0.5mg, Give 1 tablet by mouth one time a day On 8/27/24 at 2:33 PM an interview was conducted with R914, when asked about the missing dose of Bumex, R914 reported they messed it up, it is fixed now and that the facility staff did not offer him an explanation for the missed dose. R915 Review of R915's Medication Administration Record (MAR) revealed that the following scheduled medication was not documented as being administered: 8/7/24 0600 Levothyroxine Sodium Oral Tablet 50mcg, Give 1 tablet by mouth one time a day R916 Review of R916's Medication Administration Record (MAR) revealed that the following scheduled medications were not documented as being administered: 8/6/24 2200 and 8/7/24 0600 Gabapentin Oral Tablet 800mg, Give 1 tablet by mouth every 8 hours 8/7/24 0000 and 0600 Hydrocodone-Acetaminophen (Norco) Oral Tablet 10-325mg, Give 10mg by mouth every 6 hours 8/7/24 0600 Levothyroxine Sodium Oral Tablet 137mcg, Give 137mcg by mouth one time a day On 8/28/24 at approximately 3:30 PM, an interview was conducted with R916 regarding the Norco doses that were not documented as administered on 8/7/24 (midnight and 6 AM doses). R916 reported waking up occasionally with increased pain in the morning and felt that indicated that they did not receive scheduled doses throughout the night. R916 further reported that they felt their pain was not adequately managed. A record review was completed for R905, R906, R907, R908, R909, R912, R913, R914, R915, R916 and no documentation was found in the progress notes or within the MAR's indicating an electronic medical record (EMR) outage or any late entry notes reflecting the medications that were not documented as given (as described above). On 8/27/24 at 2:16 PM an interview was conducted with Regional Nurse A (the Director of Nursing (DON) was out of the building at the time). When asked how the facility ensures medications are passed in a timely manner they reported they could pull up the policy and let me know (no policy or additional information was received prior to the conclusion of the survey). When informed that multiple medications were not passed and/or documented for several residents for the shift covering the night of 8/6/24 through the morning of 8/7/24, they stated that they did not know why but they should be administered and their policy is to notify the physician if medications are not administered as ordered. On 8/27/24 at 2:49 PM an interview was conducted with the DON. The DON reported that their EMR system was glitching on 8/6/24 and was completely down until after shift change for the nurses (on 8/7/24). When asked what their downtime policy/procedure was, the DON stated they would have to get that information and was unable to provide an answer at that time. The DON was asked if it is reasonable to expect that if the medications were not documented on the MAR that they would be documented somewhere within the EMR and they confirmed that any medications given should be documented. On 8/27/24 at 2:59 PM, the DON and Regional nurse A re-entered the conference room and reported that their downtime system was down on 8/7/24 in addition to their main EMR system. They provided conflicting information regarding whether or not the undocumented medications from 8/6/24 and 8/7/24 were given or not.The DON reported that the medications were given and Regional nurse A stated that they were unsure if the medications were given or not. On 8/28/24 at 8:41 AM an interview was conducted with LPN J (nurse assigned to several residents whose MAR's indicated they did not receive medications the night of 8/6/24 and morning of 8/7/24). When queried about the medications not documented as given on the night of 8/6/24 and the morning of 8/7/24, LPN J stated that medications were given based on the medications in the resident's medication drawers. They reported that they kept the packets from the medications that she was unable to document in the EMR, gave them to the oncoming nurse and let the DON know that they were unable to document them in the EMR. When asked what the expectation was for ensuring the medications were documented appropriately in EMR once the system was available, they reported that it wasn't discussed. They reported that they didn't go back and document them but they could have, for sure. LPN J reported that a paper chart was not available and she was not aware of what the downtime policy/procedure was for the facility. On 8/28/24 at 9:55 AM an interview was conducted with LPN F (nurse assigned to several residents whose MAR's indicated they did not receive medications the night of 8/6/24 and morning of 8/7/24). When queried about the night of 8/6/27 LPN F reported that they recalled a night when their EMR system went completely out but that she was able to administer and document all of the medications for her residents on the night in question. LPN F was unsure which day the EMR was down but reported that the DON was made aware the night it was down. On 8/28/24 at 1:46 PM a second interview was conducted with DON. The DON reported that audits of MAR's are periodically completed. When asked to clarify what their understanding is related to whether or not the undocumented medications were given or not given, the DON reported both LPN F and LPN J reported to her that the medications in question were given but not charted. When asked if it was discussed how or when the medications would be charted, the DON reported it was not discussed but reported that it should have been. The DON reported that to her knowledge the medications that were not able to be documented during the EMR downtime were not documented once the system was fully functional again. Review of the facilities policy titled DISRUPTION IN THE ELECTRONIC MEDICAL RECORD updated 8/9/24, documented in part Nexcare Health Systems and Managed Communities will have a back up plan in place for any situation that would cause a disruption in the electronic medical record longer than 2 hours .Floor staff should notify the Administrator and Director of Nursing. At this time the Administrator and Director of Nursing should start investigating to find out what is the root case of the disruption. The Administrator and/or Director of Nursing should notify their Regional team for additional assistance if needed. If the facility is still unable to find a solution to why there was a disruption in the electronic medical record the facility should call IWER (the IT company) .Call your closest facility within the company to see if they have Internet. If they have Internet then you can go to the additional facility or have that facility print your EMARs and bring them to you. Have the Administrator/DON try to access the electronic medical record on their phone. If [EMR system] is available then this is a local facility issue where you can print the EMAR from another location or contact [local] office and the EMAR can run off of a hot spot . It should be noted that the above mentioned policy was updated two days after the reported EMR outage and reported downtime system outage. Review of the facility policy titled Medication Administration General Guidelines updated 1/21, documented in part The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given. In no case should the individual who administered the medications report off-duty without first recording the administration of medications.

Based on interview and record review the facility failed to maintain complete and accurate medical records for ten (R905, R906, R907, R908, R909, R912, R913, R914, R915, R916) of fifteen residents reviewed for medication administration. Findings include: R905 Review of R905's Medication Administration Record (MAR) revealed that the following scheduled medications were not documented as being administered: 8/6/24 1800 GenTeal Tears Severe Day/Night Ophthalmic Gel 0.4-0.3%, instill 1 drop in both eyes at bedtime 8/6/24 1800 Senna Oral Tablet 8.6mg, give 1 tablet by mouth at bedtime 8/6/24 bedtime dose Cyclosporine Emulsion 0.05%, Instill 1 drop in both eyes two times a day 8/6/24 2100 Eliquis 5mg, Give 1 tablet by mouth two times a day 8/6/24 2000 House/High Protein three times a day 8/7/24 0600 Levothyroxine Sodium Oral tablet 100 mcg, give 1 tablet by mouth one time a day every Mon, Tue, Wed, Thu, Fri, Sat 8/7/24 0600 Menthol-Zinc Oxide External Ointment 0.44-20.6%, Apply to buttock topically one time a day R906 Review of R906's Medication Administration Record (MAR) revealed that the following scheduled medications were not documented as being administered: 8/6/24 2100 Gabapentin Oral Capsule 100mg, Give 1 capsule by mouth three times a day 8/6/24 1800 Senna Oral Tablet 8.6mg, give 1 tablet by mouth at bedtime 8/6/24 bedtime dose Cyclosporine Emulsion 0.05%, Instill 1 drop in both eyes two times a day 8/6/24 2100 Eliquis 5mg, Give 1 tablet by mouth two times a day 8/6/24 2000 House/High Protein three times a day 8/7/24 0600 Levothyroxine Sodium Oral Tablet, Give 75 mcg by mouth one time a day every Mon, Tue, Wed, Thu, Fri R907 Review of R907's Medication Administration Record (MAR) revealed that the following scheduled medications were not documented as being administered: 8/6/24 bedtime dose Senna Oral Tablet, Give 1 tablet by mouth at bedtime 8/6/24 2000 and 8/7/24 0600 Ativan 2mg, Benadryl 25mg, Haldol 2mg gel three times a day R908 Review of R908's Medication Administration Record (MAR) revealed that the following scheduled medications were not documented as being administered: 8/6/24 bedtime dose Atorvastatin Calcium 40mg, Give 1 tablet by mouth at bedtime 8/6/24 bedtime dose Citalopram Hydrobromide Oral Tablet 10mg, Give 1 tablet by mouth at bedtime 8/6/24 bedtime dose Trelegy Ellipta Inhalation Powder 100-62.5-25mcg, 1 puff inhale orally two times a day 8/6/24 bedtime dose Magnesium 400mg, Give 1 tablet by mouth at bedtime 8/7/24 0600 Pantoprazole Sodium 40mg, Give 1 tablet by mouth one time a day 8/7/24 0600 Levothyroxine Sodium 150mcg, Give 150mcg by mouth one time a day R909 Review of R909's Medication Administration Record (MAR) revealed that the following scheduled medications were not documented as being administered: 8/6/24 bedtime dose Atorvastatin Calcium Oral Tablet 40mg, Give 1 table by mouth at bedtime 8/6/24 bedtime dose Melatonin Tablet 3 mg, Give 2 tablets by mouth at bedtime 8/6/24 bedtime dose Acetaminophen Tablet 325mg, Give 2 tablets by mouth two times a day 8/6/24 bedtime dose Famotidine Oral Tablet 20mg, Give 1 tablet by mouth two times a day 8/6/24 2100 Gabapentin Oral Capsule 100mg, Give 2 capsules by mouth two times a day R912 Review of R912's Medication Administration Record (MAR) revealed that the following scheduled medications were not documented as being administered: 8/7/24 0600 Levothyroxine 50mcg, Give 50mcg by mouth one time a day R913 Review of R913's Medication Administration Record (MAR) revealed that the following scheduled medication was not documented as being administered: 8/7/24 0600 Insulin Glargine Subcutaneous Solution 100 unit/ml, Inject 15 units subcutaneously one time a day R914 Review of R914's Medication Administration Record (MAR) revealed that the following scheduled medication was not documented as being administered: 8/7/24 0600 Bumetanide Tablet 0.5mg, Give 1 tablet by mouth one time a day On 8/27/24 at 2:33 PM an interview was conducted with R914, when asked about the missing dose of Bumex, R914 reported they messed it up, it is fixed now and that the facility staff did not offer him an explanation for the missed dose. R915 Review of R915's Medication Administration Record (MAR) revealed that the following scheduled medication was not documented as being administered: 8/7/24 0600 Levothyroxine Sodium Oral Tablet 50mcg, Give 1 tablet by mouth one time a day R916 Review of R916's Medication Administration Record (MAR) revealed that the following scheduled medications were not documented as being administered: 8/6/24 2200 and 8/7/24 0600 Gabapentin Oral Tablet 800mg, Give 1 tablet by mouth every 8 hours 8/7/24 0000 and 0600 Hydrocodone-Acetaminophen (Norco) Oral Tablet 10-325mg, Give 10mg by mouth every 6 hours 8/7/24 0600 Levothyroxine Sodium Oral Tablet 137mcg, Give 137mcg by mouth one time a day On 8/28/24 at approximately 3:30 PM, an interview was conducted with R916 regarding the Norco doses that were not documented as administered on 8/7/24 (midnight and 6 AM doses). R916 reported waking up occasionally with increased pain in the morning and felt that indicated that they did not receive scheduled doses throughout the night. R916 further reported that they felt their pain was not adequately managed. A record review was completed for R905, R906, R907, R908, R909, R912, R913, R914, R915, R916 and no documentation was found in the progress notes or within the MAR's indicating an EMR (electronic medical record) outage or any late entry notes reflecting the medications that were not documented as given (as described above). On 8/27/24 at 2:16 PM an interview was conducted with Regional Nurse A (the DON was out of the building at the time). When asked how the facility ensures medications are passed in a timely manner they reported they could pull up the policy and let me know (no policy or additional information was received prior to the conclusion of the survey). When informed that multiple medications were not passed and/or documented for several residents for the shift covering the night of 8/6/24 through the morning of 8/7/24, they stated that they did not know why but they should be administered and their policy is to notify the physician if medications are not administered as ordered. On 8/27/24 at 2:49 PM an interview was conducted with the DON. The DON reported that [EMR system] was glitching on 8/6/24 and was completely down until after shift change for the nurses (on 8/7/24). When asked what their downtime policy/procedure was, the DON stated they would have to get that information and was unable to provide an answer at that time. The DON was asked if it is reasonable to expect that if the medications were not documented on the MAR that they would be documented somewhere within the EMR and they confirmed that any medications given should be documented within the EMR. On 8/27/24 at 2:59 PM, the DON and Regional nurse A re-entered the conference room and reported that their downtime system was down on 8/7/24 in addition to their main EMR system. They provided conflicting information regarding whether or not the undocumented medications from 8/6/24 and 8/7/24 were given or not. The DON reported that the medications were given and Regional nurse A stated that they were unsure if the medications were given or not. On 8/27/24 at 8:41 AM, an interview was conducted with LPN J (nurse assigned to several residents whose MAR's indicated they did not receive medications the night of 8/6/24 and morning of 8/7/24). When queired about the medications not documented as given on the night of 8/6/24 and the morning of 8/7/24, LPN J stated that medications were given based on the medications in the resident's medication drawers. They reported that they kept the packets from the medications that she was unable to document in the EMR, gave them to the oncoming nurse and let the DON know that they were unable to document them in the EMR. When asked what the expectation was for ensuring the medications were documented appropriately in the EMR once the system was available, they reported that it wasn't discussed. They reported that they didn't go back and document them but they could have, for sure. LPN J reported that a paper chart was not available and she was not aware of what the downtime policy/procedure was for the facility. On 8/28/24 at 9:55 AM, an interview was conducted with LPN F (nurse assigned to several residents whose MAR's indicated they did not receive medications the night of 8/6/24 and morning of 8/7/24). When queired about the night of 8/6/27, LPN F reported that they recalled a night when the EMR went completely out but that she was able to administer and document all of the medications for her residents on the night in question. LPN F was unsure which day the EMR was down but reported that the DON was made aware the night it was down. On 8/28/24 at 1:46 PM, a second interview was conducted with the DON. The DON reported that audits of MAR's are periodically completed. When asked to clarify what their understanding is related to whether or not the undocumented medications were given or not given, the DON reported both LPN F and LPN J reported to her that the medications in question were given but not charted. When asked if it was discussed how or when the medications would be charted, the DON reported it was not discussed but reported that it should have been. The DON reported that to her knowledge the medications that were not able to be documented during the downtime were not documented once the system was fully functional again. Review of the facilities policy titled DISRUPTION IN THE ELECTRONIC MEDICAL RECORD updated 8/9/24, documented in part Nexcare Health Systems and Managed Communities will have a back up plan in place for any situation that would cause a disruption in the electronic medical record longer than 2 hours .Floor staff should notify the Administrator and Director of Nursing. At this time the Administrator and Director of Nursing should start investigating to find out what is the root case of the disruption. The Administrator and/or Director of Nursing should notify their Regional team for additional assistance if needed. If the facility is still unable to find a solution to why there was a disruption in the electronic medical record the facility should call IWER (the IT company) .Call your closest facility within the company to see if they have internet. If they have internet then you can go to the additional facility or have that facility print your EMARs and bring them to you. Have the Administrator/DON try to access the electronic medical record on their phone. If [EMR system] is available then this is a local facility issue where you can print the EMAR from another location or contact [local] office and the EMAR can run off of a hot spot . It should be noted that the above mentioned policy was updated two days after the reported the (EMR) outage and reported downtime system outage. Review of the facilities policy titled Medication Administration General Guidelines updated 1/21, documented in part The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given. In no case should the individual who administered the medications report off-duty without first recording the administration of medications.

This citation pertains to Intakes: MI00146401 and MI00146565 Based on observation, interview and record review the facility failed to assess for pain and administer pain medications as ordered by the physician for two (R903 and R916) of two residents reviewed for pain, resulting in unrelieved pain, feelings of frustration, and helplessness. Findings include: R903 A record review for R903 revealed they were admitted to the facility on [DATE] after a hospitalization for skilled nursing and rehabilitation services. R903 was recently hospitalized and readmitted back to the facility on [DATE]. R903's admitting diagnoses included Schizophrenia, anxiety disorder, Chronic Obstructive Pulmonary Disease (COPD), Parkinson's disease, end stage renal disease (on hemodialysis) with history of falls and syncopal (fainting) episodes. R903 had a guardian who handled R903's medical, legal, and financial decisions. The Brief Interview for Mental Status (BIMS) revealed a score of 11/15, indicative of moderate cognitive impairment. R903 needed limited staff assistance with their Activities of Daily Living (ADLs) such as dressing and bathing. An initial observation was completed on 8/27/24 at approximately 11:05 AM. R903 was observed sitting in their wheelchair, in their room doorway. This surveyor asked to meet with R903, they were trying to back up into the room from the doorway and reported that they may need help and started backing up in their wheelchair. R903 took approximately two minutes to back into room with verbal cues from the surveyor to back into the room. R903 had a dressing on the left lateral (outside) elbow area. R903 reported they had pain on their left hip/groin area. When this surveyor asked how severe their pain was, R903 stated 10/10 and added I have never had this kind of pain. R903 added they were getting pain medication that was just started a few days ago. They had pain medication this morning and it was not helping and they needed something more. Nurse was notified. R903 was queried if the pain started after their fall, they reported that it started days after the fall and they did not remember the time frame. R903 was queried if they had seen a physician, R903 reported that they a woman, not a doctor, was not sure about the time frame, who was going to order an ultrasound (test) for the pain. LPN C who was assigned to care for R903 came in and R903 reported that their pain was 10/10. LPN C reported that it was too soon to get another dose of Tramadol as they received one 2 hours ago and they would get them a Tylenol. R903 was queried about their fall. R903 reported that they fell outside of the facility in the parking lot area. R903 stated, I scrapped my left arm, and was not sure if they hit their head. R903 had asked the surveyor to check on the test that was ordered as their pain was so severe. Later that day a follow up observation was completed at approximately 1:40 PM. R903 was in their room and they reported that their left hip/groin pain was a little better than the morning and stated it was 7/10 and they did not go to dialysis because of pain. When queried about the showers, they reported that they were able to do it minimal staff help and they were going to take a shower later that evening. On 8/28/24 at approximately 10:05 AM, R903 was observed in their bed and x-ray technician was in the room. Surveyor met with R903 in their room after. R903 reported that they had x-ray of their hip. They added that they still had left hip/pain, it was constant pain, graded the pain as 6/10. R903 also added that they were in pain all weekend (last weekend i.e. 8/24/24 - 8/25/24) and they had asked the staff to get some medication for pain. They had been getting the tramadol for the last few days. R903 reported that they were not able to take their shower last night because of their pain. R903 reported that the pain was so severe and they never had that kind of pain and did not know what it was. They were not sure if they would be able to go to dialysis on Wednesday if they continue to have this pain. Two more observations were completed later that day at approximately 11:30 AM and approximately 1 PM. R903 was observed in their bed. Review of R903's Electronic Medical Record (EMR) revealed a nursing progress note dated 8/8/24 at 20:30 read in part, At approximately 2030, guest was observed outside of the facility, on the ground. Guest stated that she was sitting in her wheelchair when she tipped over, with her wheelchair falling on top of her. Guest stated that she did hit her head on the ground. Guest has a new skin tear on the back of the left forearm writer called EMS to transport guest to hospital due to possible head injury .EMS refusing to take her to hospital stating she can make her own decisions. Director of Nursing (DON) and on call provider notified. Writer attempted to call guest's guardian but could not get in touch with her. Incoming nurse will reattempt during business hours . Review of R903's pain assessment revealed on 8/8/24 at 21:06 (9:06 PM), after the unwitnessed fall (outside the facility) 8/10. An assessment was completed on 8/9/24 at 6:40 AM. There was no further pain assessment completed after until 8/26/24 at 8:18 AM, pain level 8/10. There were no pain assessments completed for 8/24/24 and 8/25/24 when R903 had reported that they were in and had asked for staff to assist them. After the concern was brought to the facility's attention there were follow up pain assessments completed on 8/27/24 and 8/28/24. Review of R903's physician order on 8/27/24 at 12:56 PM did not reveal any physician orders for any tests related to R903's complaints of left groin/hip pain. R903 had an order that read, Acetaminophen (Tylenol) tablet 325 MG (Milligram) - Give 2 tablets by mouth every 4 hours as needed for pain dated 7/25/24 and Tramadol HCL oral tablet 50 MG - give one tablet by mouth every 6 hours as needed for pain dated 8/26/24. Review of R903's Medication Administration Record revealed that R903 did not receive any pain medication on 8/8/24 after the fall incident when they had a reported a pain level of 8/10. There was no evidence that R903 received any pain medication from 8/8/24 until 8/26/24 at 8:18 AM despite their complains of pain prior. R903 was ordered to receive tramadol on 8/26/24 and did not receive until 8/27/24 at 9:23. On 8/26/24 R903 received their first dose of Tylenol at 8:18 AM and reported a pain level of 8/10. There was no evidence of pain assessment after and there was no evidence that R903 received any pain medication later that day. On 8/27/24, R903 received one dose of tramadol at 9:23 AM and reported a pain level of 8/10, pain medication was not effective. They received their next dose of Tylenol at 11:13 AM and reported a pain level of 10/10. The next dose of pain medication (tramadol) was administered at 18:54 (6:54 PM), approximately 7 hours after. There was no evidence in R903's clinical record that a timely follow up was completed physician/mid-level providers (nurse practitioner/physician assistant) after the 8/8/24 unwitnessed fall incident and when R903 had reported had complaints of pain over the weekend. Review of R903's progress notes did not reveal any documentation after 8/12/24. There was no documentation on pain on 8/26/24 and why tramadol was ordered. Review of R903's care plan for revealed the goals that were updated on 7/5/24, that read will not have signs and symptoms of unrelieved pain; will have individualized pain medication does titration achieve adequate pain relief; and decrease pain to a tolerated level so resident can function in daily life with no interventions. There were multiple interventions listed under pain management dated 11/22/23 with no follow up/update after the recent readmission and or after the unwitnessed fall incident or after recent complaints of pain in left groin/hip area. An interview was completed with LPN F who was assigned to R903's unit at the time of incident on 8/28/24 at approximately 6:55 AM. They were just finishing up their shift and reported they had just left the facility. LPN F was queried about R903's incident and their follow-up. They reported that their shift started at 7 PM and they regularly worked that unit and they were familiar with the residents. LPN F added that they received the report from LPN C that R903 was in their room, but they did not physically see the resident after their shift started. At approximately 8:30 PM they were alerted by LPN B that R903 was observed outside the facility on the floor. LPN F explained that they had called the EMS and their follow up with the DON. LPN F did not explain why they did not administer any pain medications for R903 when they had reported a pain level of 8/10 on 8/8/24. When queried if they had worked with R903 on the night of 8/27/24 and how the resident was, LPN F reported they worked with R903 on 8/27/24. Reported that R903 was complaining of pain and stated, excruciating pain. Reported that R903 refused dialysis on Monday (8/26/24) because of her pain and they were ordered Tramadol. On 8/28/24 at approximately 11:05AM, the surveyor was outside R903's room and overheard the conversation. R903 was speaking with CNA H and reported that they were hurting and needed pain medication and CNA H reported that they would check with the nurse to find out when the next dose is due. An interview with CNA H was completed 8/28/24 at approximately 11:20 AM and they reported that R903 complained of pain and they had notified the nurse. An interview was completed with Director of Nursing (DON) on 8/28/24 at approximately 11:35 AM. The DON was queried about the facility's pain assessment and management following an incident. The DON reported that they would do an initial pain assessment every shift, twice a day (as nurses worked 12-hour shifts) for 3 days and they would follow up as needed with any new onset of symptoms. The DON was queried about the pain assessment and management for R903. The DON reviewed the clinical records and reported that they did not see any pain assessment for three days after the incident and confirmed that R903 did not receive any pain medication after fall when they had complained of pain of 8/10. The DON also confirmed that there were no physician/mid-level provider visits following the fall. The DON added if the pain medications were ineffective staff should have attempted non-pharmacologic interventions such as positioning, ice etc. and should have contacted the covering provider on after hours. The DON added that they had after hour providers available 7 days/week and they did not see any evidence in the clinical record. They reported that on 8/26/24 the nurse practitioner was at the facility and they would check on the progress note was not on R903's EMR. Later that day the DON came and reported that practitioner visit note from 8/26/24 was completed in EMR. Also, added that x-rays result for left hip and pelvis that were completed on 8/28/24 were available pending provider review and R903 did not have any acute fracture. The DON was notified of the concerns with pain assessment and management, and they reported that they understood the concerns. Review of facility provided document titled Pain Assessment and Management with a revision date of October 2010 (revised approximately [AGE] years ago) read in part, .Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established clinical goals. 49272 R916 Review of R916's Medication Administration Record (MAR) revealed an order for Norco (also known as hydrocodone-acetaminophen 10-325mg a narcotic pain medication) to be given by mouth every six hours related to aftercare following joint replacement surgery. Further review showed no documentation of administration for scheduled midnight and 6 AM doses on 8/7/24. On 8/28/24 at 9:35 AM a request was made via email for the narcotic log for R916's hydrocodone-acetaminophen 10-325mg which included midnight and 6 AM scheduled doses for 8/7/24. The NHA (nursing home administrator) provided a copy of a Narcotic log for August 6th in error. On 8/28/24 at 12:22 PM, the DON (director of nursing) reported that they were unable to locate the requested narcotic log. It was confirmed (by the NHA and DON) at the exit conference that the facility was unable to locate the requested narcotic log. On 8/28/24 at approximately 3:30 PM, an interview was conducted with R916 regarding the Norco doses that were not documented as administered on 8/7/24 (midnight and 6 AM). R916 reported waking up occasionally with increased pain in the morning and felt that indicated that they did not receive scheduled doses throughout the night. R916 further reported that they felt their pain was not adequately managed and staff have made them feel like they do not believe the level of pain being reported. Review of the clinical record for R916 revealed they were admitted into the facility on [DATE] with diagnoses that included: muscle weakness, aftercare following joint replacement surgery and difficulty walking. According to the Minimum Data Set (MDS) assessment dated [DATE], R916 scored 15/15 on the Brief Interview for Mental Status exam (which indicated intact cognition).

Based on interview, and record review, the facility failed to ensure there was thorough record keeping to accurately account for administration of controlled substances for one (R916) of one resident reviewed for pharmacy services. Findings include: Review of the clinical record for R916 revealed they were admitted into the facility on [DATE] with diagnoses that included: muscle weakness, aftercare following joint replacement surgery and difficulty walking. According to the Minimum Data Set (MDS) assessment dated [DATE], R916 scored 15/15 on the Brief Interview for Mental Status exam (which indicated intact cognition). Review of R916's Medication Administration Record (MAR) revealed an order for Norco (also known as hydrocodone-acetaminophen 10-325mg a narcotic pain medication) to be given by mouth every six hours related to aftercare following joint replacement surgery. Further review showed no documentation of administration for scheduled midnight and 6 AM doses on 8/7/24. On 8/28/24 at 9:35 AM a request was made via email for the narcotic log for R916's hydrocodone-acetaminophen 10-325mg which included midnight and 6 AM scheduled doses for 8/7/24. NHA (nursing home administrator) provided a copy of a Narcotic log for August 6th in error. On 8/28/24 at 12:22 PM it was DON (director of nursing) reported that they were unable to locate the requested narcotic log. It was confirmed (by the NHA and DON) at the exit conference that the facility was unable to locate the requested narcotic log. On 8/28/24 at 1:46 PM an interview was conducted with DON. When asked if audits are completed of the MAR's they stated that they are completed periodically and not on a scheduled basis. No explanation was given as to why the medications were not documented or what happened to the requested narcotic log. On 8/28/24 at approximately 3:30 PM, an interview was conducted with R916 regarding the Norco doses that were not documented as administered on 8/7/24 (midnight and 6 AM). R916 reported waking up occasionally with increased pain in the morning and felt that indicated that they did not receive scheduled doses throughout the night. R916 further reported that they felt their pain was not adequately managed and staff has indicated they do not believe the level of pain they are reporting.

This citation pertains to Intake Number: MI00144507. Based on interview and record review, the facility failed to ensure multiple allegations of abuse and mistreatment were reported to the Abuse Coordinator and the State Agency for one (R801) of two residents reviewed for abuse. Findings include: A review of a complaint submitted to the State Survey Agency revealed R801 alleged being sexually abused by an unnamed staff member two times. It was alleged the male staff member grabbed (R801's) penis area and played with (R801's) penis. It was noted that the abuse occurred sometime last month (April 2024) during the nighttime. On 5/20/24 at 11:33 AM, a telephone interview was conducted with R801 (who no longer resided at the facility). R801 had some difficulty getting his words out and became frustrated. R801 reported there were two sexual incidents by the same male staff member who worked the midnight shift. R801 stated, I didn't ask for abuse, but he was willing to give it to me. R801 reported the first time it happened, He played with me, my penis. I had to sit down on the floor to stop him. R801 stated, The second time, he manhandled me. I lost balance so I sat down. Then he took my shorts off and I wasn't having any of it. When queried about what he meant by manhandled, R801 stated, He molested me! He touched me sexually!. R801 explained that he gave a statement to a staff member who watched the front door immediately in the morning following the incident. R801 stated, I heard the assistant director didn't believe me. R801 further reported no police officers were involved and if they had been he would have wanted to press charges. R801 explained there were two incidents of sexual battery and one incident of the same staff member threatened to hit me. R801 reported he went to the hospital the day after he told the staff about the abuse and went to another facility to get away from that guy. R801 could not remember if he reported the abuse to anyone at the hospital. On 5/20/24 and 5/21/24, an unannounced, onsite investigation was conducted. A review of R801's clinical record revealed R801 was admitted into the facility on [DATE], readmitted on [DATE], and discharged on [DATE] with diagnoses that included: congestive heart failure, diabetes, hemiplegia affecting the right side, anxiety disorder, and major depressive disorder. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R801 had moderately impaired cognition and no behaviors. A review of R801's progress notes revealed the following: A Plan of Care Note dated 4/7/24 noted, .Guest c/o (complained of) 'No one is taking care of me. I'm sick .' Guest very upset and verbally abusive .Guest then got on his cellphone calling (emergency contact), telling (emergency contact) to call (news networks) to report 'no one is doing anything' for him .just transferred to this new room . A Plan of Care Note dated 4/9/24, written by the Director of Nursing (DON) noted, Followed up with resident regarding concerns documented. Resident denied specific incident or specific staff member. Replied to questions with 'I don't know', became irritable with writer. A review of progress notes prior to 4/7/24 revealed no documented verbally abusive or irritable behavior. It was documented R801 was cooperative and pleasant with staff. An Incident Note dated 4/30/24 revealed R801 was transferred to the hospital per his request on that date after being observed on the floor in a fetal position. On 5/20/24 at 5:09 PM, an interview was conducted with Licensed Practical Nurse (LPN) 'A'. When queried about the day R801 was transferred to the hospital (4/30/24), LPN 'A' reported he was on the floor, they assessed him, but he refused to allow staff to move him and asked to be sent to the hospital and did not tell them why. When queried about any allegations of abuse made by R801, LPN 'A' reported nothing was every directed reported to her, but remembered a vague report from LPN 'C' but LPN 'C' did not elaborate and LPN 'A' did not remember the date or what the allegation was. On 5/21/24 at 9:15 AM, an interview was conducted with LPN 'C' When queried about any abuse allegations made by R801, LPN 'C' reported one day R801 was on the phone with a friend and was making allegations. LPN 'C' reported that she confronted R801 and his story changed and he didn't give a name. When queried about what R801's allegations were, LPN 'C' reported R801 alleged one of the Certified Nursing Assistants (CNA) at night was being rough with him. LPN 'C' stated, When I confronted him about it, he didn't give me the name or the description so in my opinion it probably didn't happen. LPN 'C' further reported R801 went between saying the CNA picked me up roughly and he beat me, but that his story changed. LPN 'C' reported she notified the DON, but the DON said it was already reported to her. LPN 'C' further reported she was not sure if she reported it to the DON or the other DON (referring to Unit Manager, LPN 'E'). When queried about who the facility's Abuse Coordinator was, LPN 'C' reported she did not know and said, It's one of the three DONs and named the DON, LPN 'E', and the Administrator. On 5/21/24 at 8:30 AM, the Administrator was asked to provide all incident reports, grievance/concern forms, and any investigations conducted by the facility for R801 for the duration of his stay at the facility. A review of a Resident Grievance/Complaint Form dated 4/29/24 and completed by Receptionist 'B' revealed R801 alleged the following occurred on Sunday (4/28/24) late PM, after dinner: .'Ignored for so long' by director re: (regarding) incident aware of .'Manhandled' by aide and 'threatened' by (illegible handwriting) to roommate who is (illegible handwriting) . It was documented the other person involved was aide-male. The form was signed by the Administrator on 4/29/24 and a hand written Investigation Summary was written on the backside of the form. The handwritten investigation documented the following: ED (Executive Director - Administrator) met with patient on 4/24/24 to discuss concerns about male staff member making him remove his clothing, including socks after he was already dressed .It was identified that he had wounds that needed to be assessed and cared for. (R801) did not say that the staff member threatened him. he understood that his wound needed care and that the staff member was doing his job . .The night of 4/28/24, (R801) said that a 'mountain man' kind of white looking picked him up and he was just swinging so he lay himself down and the nurse didn't lock his chair. He said the nurse told him to 'fly right' because of his roommate. He could not say why. S/W (spoke with) the roommate who reported that the aide was (CNA 'D') who did nothing wrong . On 5/21/24 at 9:30 AM, an interview was conducted with Receptionist 'B'. When queried about how allegations of abuse were addressed in the facility, Receptionist 'B' reported an allegation of abuse or missing items is reported to her, she immediately completed the grievance form and notified the Administrator in person or by phone. Receptionist 'B' reported the grievance form was given to the Administrator. When queried about the grievance made by R801 on 4/29/24, Receptionist 'B' reported she recalled R801 was very upset and hard to redirect to get the information. R801 did not want to fill out the grievance form himself so Receptionist 'B' completed it for him the best she could. Receptionist 'B' reported she was instructed to only write down the facts without asking too many questions so she wrote down what R801 said. Receptionist 'B' did not recall what time R801 made the allegations and did not recall if the Administrator was in the building at the time. Receptionist 'B' reported she notified the Administrator and/or the DON because she definitely considered those allegations of abuse. On 5/21/24 at 9:53 AM, an interview was conducted with the DON. The DON reported she was not aware of any allegations of abuse made by R801. On 5/21/24 at 9:58 AM, an interview was conducted with the Administrator, who was the facility's Abuse Coordinator. When queried about the facility's protocol for reporting allegations of abuse, the Administrator reported once she became aware of an allegation, there was a two hour window to report to the State Agency if there was any type of injury and a 24 hour window to report to the State Agency if no injury. The Administrator reported regardless she tried to report allegations within the two hour timeframe. The Administrator reported if staff were made aware of an allegation of abuse, they were required to immediately notify her and if she was not in the building, the DON, who then would contact the Administrator. When queried about whether the allegations documented on the grievance form on 4/29/24 made by R801 and whether they were reported to the State Agency, the Administrator reported they were not because once she went to the room and talked to the roommate it was determined there was no abuse. When queried about the time the allegations were reported to her and the time she went to the room, the Administrator did not know. When queried about the handwritten statement that referred to 4/24/24, the Administrator reported she added that because of a previous allegation, but did not have it on a grievance form. The Administrator remembered being notified that R801 said someone threatened him and made him remove his clothing. The Administrator reported that allegation was not reported to the State Agency because he denied it when he was talked to about it. When queried about whether she was aware of an allegation made by R801 that a staff member was rough with him or beat him (as reported by LPN 'C' during the above documented interview), the Administrator reported she was not aware. The Administrator explained that if she would have been notified, it would have been reported to the State Agency. A review of a facility policy titled, Abuse, Neglect and/or Misappropriation of Resident Funds or Property, revised on 3/15/23, revealed, in part, the following: .For the alleged violation involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, the Center will report immediately but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .to the administrator of the facility and to other officials (including the state survey agency .

This Citation is for Intake MI00142516 and Intake MI00143475. Based on observation, interview and record review the facility failed to promptly assess, implement effective treatments and prevent the pressure ulcer (PU) development for two (R804 and R806) of three residents reviewed for pressure ulcers resulting in further clinical compromise and psychological distress. Findings include: R804 On 4/2/24, R804 was contacted and interviewed about the complaint they submitted to the state agency regarding the care they received while at the facility. R804 stated, I have lymphoedema if I get a scrap, it could weep or it could get warm and easily become infected. My legs were in so much pain and weeping, I decided to call 911. The ambulance took me to the hospital, where I was treated with several rounds of antibiotics. When the antibiotics were completed, I decided to go to this facility because I had been a resident of the corporation prior to this incident so I was comfortable. When I arrived to the facility, I was not able to walk, get out of bed or do anything for myself. I relied on the facility for pretty much everything due to my condition and the pain. I was not able to turn myself or move around much without being in pain and the staff members did not turn me as often as they should have so I ended up with a big pressure sore on my left buttock's cheek. One day while being at the facility I asked them to transport me to the hospital because of the wound on my butt, it needed to be cleaned and I also started to vomit. While in the hospital they debrided my wound three times, and I was started on antibiotics because of an infection in my wound. When it was time for me to be released from the hospital I decided to go back to the same facility and was sent back out to the hospital because the nurse thought my wound might have been infected because it was stool in it. The night before I was sent out the second time, I had pushed my call light and although the certified nursing assistant answered the light, she did not assist in cleaning me up she stated she was busy and would come back. I stayed in my stool that entire night and day shift changed me. When I was at the hospital the second time and it was time for me to be released, I did not come back to the facility because it was apparent, they did not know how to prevent or care for my wounds in the condition I was in. R804 was asked if they arrived to the facility with a wound on their sacrum, R804 stated they did not have any skin issues other than their legs. A record review revealed that on 6/6/23, the resident was admitted to facility according to progress notes . Admission wound assessment: BLE (bilateral lower extremeties) covered with thick, dark brown scales. Under abdominal folds pink. L (left) side of abdomen also has scales similar to BLE. Multiple bruises to BUE (bilateral upper extremities) . On 6/7/23 the Medical Doctor created a progress note stating that R804 had a Deep tissue injury (DTI) on their right heel. On 6/9/23, Nurse A stated there was a stage 4 present on admission on the right heel. On 6/11/23, dietary noted (backed dated from 6/15/23) that R804 had a pressure wound on their coccyx and on heels. On 6/13/23, seven days after admission, there was a wound care picture that revealed a DTI to the buttocks area. On 6/19/23 six days after the initial DTI was identified, R804 was sent to the hospital with a chief complaint of wound debridement according to hospital discharge paperwork. A further review of the hospital discharge paperwork revealed that on 6/19/23, R804 had an Unstageable pressure wound on the sacrum and it needed to be debrided. The picture taken in the emergency room showed a black wound bed with pink and red boarders. On 6/20/23 was the first surgical wound debridement. On 4/2/24 at 2:00PM, the Director of Nursing (DON) was interviewed and asked was she familiar with R804 and explained she was on (work) leave when this person was admitted to the facility. On 4/2/24 at 3:43PM, Nurse A was interviewed and asked who is responsible for wound care at the facility (putting in treatments, care plans, and progress notes). Nurse A stated the nurses are responsible for the wounds they are to put treatments in, notify the doctors if there are new areas of concern. The nurses are also to do their own treatments, and if a new area is identified, they should put in orders until the doctor can review it. Anyone can put in a progress note for wounds. Nurse A was then asked when a skin assessment should be completed, Nurse A: replied upon admission and if there is a new area identified there is an assessment tab they can use as well as create a progress note. Nurse A was then asked how and when did R804's wound (that was presented on 6/19/23) was identified. Nurse A stated she would find out and bring the information to me. On 4/3/23 at 9:36AM, Nurse A stated she had found information in regard to R804's sacrum wound, Nurse A identified that there was no documentation showing that R804 came into the facility with wounds and that there was no documentation until 6/13/23 (of the buttocks wound) and that the facility owned that new area. Nurse A stated that they applied calmoseptine ointment as a treatment on 6/13/23 and on 6/19/23. Nurse A stated that R804 did not have an infection but was started on an antibiotic for a urinary tract infection. Nurse A then proceeded to go through the hospital paperwork starting on 6/19/23 and stated that R804 had to be debrided three times in hospital so it was evident that their wound deteriorated rather quickly. Nurse A was then showed the photo that was taken by the emergency department on 6/19/23 and asked if calmoseptine an appropriate treatment for a sacrum wound with a black wound bed, Nurse A replied, Yes, we have a treatment card to let us know the appropriate treatment for the different stages of wounds. Nurse A was asked to supply a copy of the treatment card. Nurse A was then asked at what point would a sacrum wound of that nature be identified and reported, Nurse A replied, There is no way for me to know if that sacrum wound happened at the facility. Nurse A was asked if R804 was admitted to the hospital on 6/19/23 and the picture in the emergency room was taken on 6/19/23 the wound on R804's sacrum could have happened (to that extent) while waiting in the emergency room (and needed to be debrided the next day on 6/20/23). Nurse A replied, I can't say the sacrum wound happened at our facility. Nurse A was then asked if R804 was dependent on staff for activities of daily living (ADLs) which included incontinence care, should a new skin condition have been identified and reported to the nurse or doctor. Nurse A replied Yes, but (R804) left before the weekly skin assessment which is every seven days and they left on the 6th day. Nurse A was asked if skin assessments can only be done on the scheduled day even if a new skin issue was identified, Nurse A replied, No, but when we had our annual survey we created a past non-compliance but someone on your team rejected it, but we did identify that assessment of wounds was a concern for us and asked did I need the past non-compliance. Nurse A stated that the facility changed wound companies so the treatment card that was present at the time of R804 admission was obsolete. On 4/3/24 at 10:00AM the Registered Dietitian (RD) was interviewed and asked what her role in wound care was, where did she get her information about R804's sacrum wound and what made her back date her note for 6/11/23 (created on 6/15/23). RD explained that they oversee high risk guests and would go in and assess the resident, get the food preferences, go over protein rich foods and see if they like those foods then try to put those on their food trays. If the resident does not eat well, supplements would be offered. RD stated, I had a lot of residents with wounds and would keep an eye on them. I document at least once a month. But I do see them if there is a change in condition. If they are stable, the plan of care remains the same. The nursing staff will let me know if it's a new pressure wound, or I would look at the skin assessment and we also talk about it in morning meetings. I put the notes in based off the wound picture that was taken on 6/13/23. On 4/3/24 at 11:40AM, the Nurse Practitioner (NP) was interviewed and asked what orders are followed for people coming with wound care treatments.The NP replied, Whatever the hospital recommends, because I am no wound care specialist, but I know the basics and how to refer people to a wound clinic. NP was asked what she remembered about R804, when was she notified about a change in skin, and would she expect to be notified about changes in skin conditions. NP replied, Yes (R804) had a lot going on medically. I was not contacted or notified about any new or worsening wounds and yes, I expect to be contacted if there is a change in skin conditions because we can set appointments for the wound care clinic. NP was then showed a picture of R804's wound on the sacrum dated for 6/19/23 from the hospital and asked was calmoseptine an appropriate treatment for this type of wound and would she expect to be notified, the NP replied, Yes, I should be notified and no, that would require Santyl or Medi honey (debriding ointments) something to soften and slough the black wound bed. NP was asked could a wound of that degree happen in a few hours of being in the emergency room , NP replied, No, the ball was dropped somewhere. R806 On 4/2/24 at 10:36AM, an interview was conducted with Family Member(FM)D in regards to the complaint that they submitted to the State Agency(SA) and asked was there any addition information about the allegations they would like to add. FMD explained there were wounds on the heels of R806 that developed from the facility and that the facility did not carry out wound care orders as prescribed. FMD went on to state that she knew that R806 could be a challenge to care for and would refuse care at times, but she stated that R806 would not have refused wound care and that if R806 did refuse wound care, that she should be contacted in times of refusals. FM D also stated that the facility had permission to call her for any refusals as it was easier for her to redirect R806 at times. FM D stated she visited R806 on 3/10/24 and noticed a disturbing odor in the room and asked the facility could they clean the room to eliminate the odor and they told me they would, she stated she also asked them could they change the sheets that was on the recliner because that was R806's preference to sleep in the chair. FM D , stated the facility told her that they would, she then decided to write the date on the sheets placed on the recliner for 3/10/24. Further conversation revealed that the FM D purchased their own green reusable incontinent pads for R806 and when she visited there were no green pads in room. FMD stated that she was the medical power of attorney of R806, she stated he started to develop wounds on feet and that R806 called her to tell her that the Medical Doctor told R806 that there was a need for a wound care clinic appointment, however no one from the facility ever called to let me know that a new skin issue had occurred with his foot again and that there was an appointment being made for wound care specialist . FM D called the Director of Nursing (DON) to verify if the information that R806 was relaying to her was accurate, and it was curious as to why the facility did not contact her in regards to the appointment. The FM D proceeded to state that when she visited R806 on another date that she noticed that R806 was refusing care such as bathing and getting clothes changed. Which then she stated she interjected and explained to R806 that their clothes were soiled due to incontinence and weeping wounds that they needed to be changed and R806 complied, but staff gave up and left them in the wet clothing. FM D explained at the wound care appointment, the wound care specialist stated that R806 developed wounds on the bottom of their feet from being excessively moist or wet called trench foot. R806 was a diabetic and that they don't always elevate their legs so they tend to weep and that R806 has had wounds on his heels before while being admitted in the facility but FM D stated she was confused on if the facility knew he is at risk for all the skin break down complications, why did they not do anything to prevent the situation and then once they claimed to heal a wound that they allowed him to contract why didn't they still put things in place to keep it from reopening and they did nothing about it and now the wound is so bad we needed to go to a wound care specialist again. FM D continued to explain that R806 relied on the facility for activities of daily living (ADLs). A record review revealed that R806 was admitted to the facility on [DATE] with the diagnosis of type 2 diabetes, idiopathic peripheral autonomic neuropathy, and dementia with a Brief interview for mental status(BIMs) score of 15 (indicating an intact cognition) but was deemed incompetent. On 4/2/24 at 11:00AM, R806 was observed in their room laying in the bed with both feet wrapped and the legs elevated. R806 was greeted and then asked if this is how they normally laid or sat and R806 stated that the facility were making them do so today. R806's room was observed and noticed compression boots in the corner of the room.R806 confirmed the facility did not apply the boots, 806 explained that they apply the boots on themself breakfast. R806 was asked how the care was received at the facility, R806 stated, They were a pain in the ass. R806 stated, They just don't care, when I say something, they ignore me because they think I'm incompetent, so when my niece complain. I feel like they just don't treat me right. R806 was then asked about the wounds on their heels and bottom of feet and how they got there. R806 replied they did not remember but it was within the past month. R806 stated the facility changed the bandages earlier today for the first time at six this morning and the nurse told me she was changing it again until three or four PM. R806 was asked what was the facility doing for their feet prior to being seen by a wound care specialist, R806 stated, Nothing.R806 was asked do they normally change the wound care bandages on their feet daily. R806 stated, No. R806 explained that the facility does not always offer to do the treatment and are assuming they will refuse care. R806 stated, I do not like being woken up 2 or 3 AM to get my legs redressed. A review of the medical record revealed that R806 on 11/2/23 progress note showed no heel wounds or feet wounds and the wound that was on shin was stable and no new treatments needed. A further review of the record revealed that R806 had weekly skin assessments completed and identified no new skin issues and had a skin issue on the left shin dated 2/21/24. There were no assessments, care plans or progress notes to indicate a heel wound was identified as of 4/3/24. A record review also revealed that there were no prophylactic intventions inplace prior to the skin deterioration. And as of 4/3/24 there was still no documentation of the areas the facility, the R806 and FM D identified. On 4/3/24 an interview was conducted with the DON. The DON was asked if R806 admitted to the facility with heel ulcers, when did the facility identify the deterioration of the heels and what is the plan of care for the heel ulcers. The DON replied, Yes (R806) has a history with chronic venous deficiency dated back to 2022, prior to the recent visit, (R806) was going to the wound care clinic and was non-compliant with the treatments as for the current status of their heels. I do not exactly know when we identified the change in skin but I can look it up it, there should be in a progress note or an assessment, I can bring you the information. (R806) has a follow up appointment in April for their feet. (R806) did not have any skin issues this year until March when we set up wound care clinic visit. The DON was then asked if R806 refused care as the facility stated they did, if the durable power of attorney was contacted to inform of them refusals as outlined in the care plan, and the medication administration record. The DON explained that they had contacted the POA about the refusals. No additional information was provided by the exit of survey.

This citation pertains to intake: MI 980 and has two deficient practice statements (DPS). DPS #1 Based on interview and record review the facility failed to follow the care plan and properly transfer one (R73) of three residents reviewed for accidents resulting in the resident suffering a laceration that required nine sutures to the right leg. Findings include: Review of the medical record revealed R73 was admitted to the facility on [DATE] with diagnoses that included: surgical aftercare following surgery on the [CONDITION(S)] system, [CONDITION(S)] stage 3 and asthma. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, indicating intact cognition and required staff assistance for all Activities of Daily Living (ADLs). Review of a progress note dated 1/1/22 at 12:40 PM, documented in part . 2 nurses assisted the guest to the restroom. Guest use the grab bars to pull herself up from the toilet to a standing position, guest was then wiped a brief pulled up. Guest sat herself down in wheelchair and stated ouch as both nurses looked down the guest leg was bleeding. Area clean and pressure dressing applied . family and DON (Director of Nursing) notified, guest sent to E.R for further evaluation . Review of an After Visit Summary dated 1/1/22 documented in part, . Reason for Visit Laceration . Suture removal anticipated in 10-14 days . Review of a Risk for falls careplan documented the intervention, Resident transfers via 2 person assist using slide board intitiated on 12/23/2021. Review of the careplan titled, The resident has potential/actual impairment to skin integrity r/t chronic [CONDITION(S)], risk for falls revealed an intervetion of, Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Date initiated, 12/23/2021. Review of a facility incident report dated 1/1/22 at 11:58 AM, documented in part . Incident Location: Resident's Room . Person Preparing Report: (staff member name) . Nursing Description . 2 nurses assisted the guest to the restroom. Guest use the grab bars to pull herself up from the toilet to a standing position, guest was then wiped and brief pulled up. Guest sat herself down in wheelchair and stated ouch as both nursed looked down the guest leg was bleeding . Resident Description . I was doing so good using the toilet the two nurses were helping me and when I sat down in my wheelchair my leg was caught inside of the wheelchair and I was bleeding . Occurred during a 2-person transfer . Witnesses (Graduate Nurse - GN HH and Registered Nurse - RN D names) . were documented in the witness area. Review of a progress note dated 1/4/22 at 6:38 PM, documented in part, . Dressing removed to assess site under dressing noted 9 sutures no s/s of infection . Review of an Incident Note dated 1/5/22 at 6:07 PM, documented in part, . on 1/1/2022 at approx. 11:58 AM resident acquired a laceration to RLE (Right Lower Extremity) while sitting in wheelchair post toileting. Resident stated she bumped her leg on wheelchair causing the laceration . Upon returning form ER, resident now has sutures closing laceration . This note was documented by the DON. On 9/20/22 at 12:20 PM, GN HH was interviewed via telephone. When asked about the incident with R73, GN HH stated in part . I remember we were toileting her and I just heard her say ouch. We thought it was because she had trouble transferring. Her leg got caught . When asked how R73's leg got caught in their wheelchair if they had two nurses assisting with the transfer, GN HH replied they were not certain of R73's transfer status at the time and no one (that was present) knew if R73 was a one- or two-person transfer. GN HH then explained how R73 was not their resident or RN D resident but they were helping the other staff out because the facility was short staffed that day. When asked if they (GN HH' and RN D) was touching the resident at the time of the transfer, GN HH replied they (themselves and RN D) was in the restroom but they weren't physically touching the resident at the time of transfer. GN HH was then asked why they weren't physically touching the resident to help, and GN HH stated again they were unsure of R73's transfer status. GN HH then stated R73 reached for the grab bar and we kept hearing ouch, we turned and saw her leg bleeding. When asked if anyone ever followed up with them or asked for a statement regarding the incident GN HH stated No. On 9/20/22 at 1:22 PM, RN D was interviewed regarding the incident with R73. RN D was observed looking into the medical record and looking at R73's record and stated they remember vaguely. RN D explained a graduate nurse came and asked if they could help transfer (R73 name). RN D stated in part, . I was right behind the chair, she lifted up using the bar and sat down. We were there but we didn't touch her . When asked RN D stated they believed R73 was a two person assist. When asked if it was the facility's protocol to just observe a resident that required two people to assist them with a transfer, RN D then stated No, but I cannot remember. When asked if anyone followed up with them after the incident or asked for a statement, RN D stated they did not remember if anyone ever followed up with them. When asked what made the laceration to R73's leg, RN D stated the only thing we can think is the inside of the wheelchair is the foot pedal hook . When asked if the two people that are supposed to assist the resident back into their wheelchair, are supposed to make sure that all foot pedals and hooks are in the correct position prior to the resident transfer or assisting the resident back into their wheelchair safely, RN D stated they really couldn't remember. On 9/20/22 at 1:22 PM, the DON was interviewed regarding the transfer of R73 and asked to provide any additional documentation that they have regarding the incident. The DON begin to state how there were two staff members touching and assisting the resident with the transfer, but according to the facility's risk management the resident didn't give the nurses a chance to assist when R73 grabbed the bar then sat back down in their wheelchair. The DON was then asked who completed the investigation and the DON stated they did. The DON was asked if they took statements from the two nurses that was present at the time of the incident and the DON stated No. The DON was then asked to provide the investigation that they conducted for this incident for review. Shortly after the DON returned and stated they did talk to both of the nurses at the time of the incident and there was a risk investigation completed. The DON then stated the resident got up themselves without waiting for the staff. The DON was again asked to provide the statements obtained from the nurses and to provide the complete investigation. The DON then stated how could the surveyor expect for the staff to remember the incident from January (2022) and how could the investigation be based off of what they are saying from what they remember. The DON was again asked to provide for review the investigation that was completed at the time of the incident with the witness statements obtained. No further documentation was provided by the end of survey. DPS#2 Based on observation, interview and record review, the facility failed to thoroughly assess and timely investigate a laceration for one (R18) of three residents reviewed for skin conditions. Findings include: On 9/18/22 at 9:58 AM, R18 was observed lying in bed, a dressing was observed on her left lateral forearm, just below the elbow. R18 was asked why she had a dressing. R18 did not know. Review of the clinical record revealed R18 was originally admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included: [CONDITION(S)] disease, dementia, and [CONDITION(S)] disorder. According to the Minimum Data Set (MDS) assessment dated [DATE], R18 had severely impaired cognition and was totally dependent on staff for all activities of daily living (ADL's). Review of R18's September 2022 Medication Administration Record revealed an order for, Aquacell foam to LUE (left upper extremity). Change Daily, in the morning for Aquacell foam to LUE with a start date of 9/12/22 and discontinued on 9/16/22. Review of a Skin & Wound Evaluation dated 9/11/22 by Licensed Practical Nurse (LPN) M read in part, .Type: Laceration . Location: (blank) . Exact Date: 9/11/22 . Length: 1.3 cm (centimeters) . Width: 0.7 cm . Notes: (blank) . Enter name of resident/responsible party notified: (name entered was R18's family member, not R18's Guardian) . Review of R18's progress notes revealed no documentation of R18 obtaining a laceration on 9/11/22. Review of a weekly Skin & Wound Evaluation dated 9/19/22 read in part, .Type: Laceration . Location: Left Outer Forearm . On 9/19/22 at 9:36 AM, the facility was asked for investigations for R18. On 9/19/22 at 11:06 AM, Clinical Support A explained there were no investigations for R18. On 9/19/22 at 11:25 AM, LPN M was interviewed and asked about R18's laceration on her left forearm. LPN M explained no one knew how R18 got the laceration, they could not figure it out. When asked what she did, LPN M explained she cleaned the wound, took a picture, called the doctor, and got an order for a dressing, and called R18's Hospice. LPN M was asked if she had contacted R18's Guardian, LPN M explained she had called the first emergency contact, which was the family member. LPN M was asked if she had written a progress note, or started an incident report. LPN M explained she had not done either. On 9/19/22 at 4:05 PM, the Director of Nursing (DON) brought an investigation of R18 laceration. It contained two handwritten statements: One from Certified Nursing Assistant (CNA) V that read in part, I went into (R18's) room . and noticed a cut/scratch on the side of her upper right arm (bicep area). I noticed a lot of smeared and dried blood on her arm and on her blanket. She was laying on her left side and I noticed the side table very close to the bed . dated 9/11/22 and signed by CNA V. One from LPN M that read in part, CNA notified writer that resident was observed with blood on her left arm, very scant amount. Resident gets up in geri-chair daily. Resident was within arms way of the bedside table. Assessed and appears that the resident hit the bedside table and was leaning towards the left. Bedside table moved at this time . dated 9/11/22 and signed by LPN M. On 9/19/22 at 4:19 PM, LPN M was asked when she had written the statement. LPN M explained she had written the statement that day, 9/19/22. When asked why it was dated 9/11/22, LPN M explained the DON had told her to write that date.

This citation pertains to intake #MI 5676. Based on interview and record review, the facility failed to provide care and services to prevent the development of a pressure injury, and failed to accurately identify a pressure injury for one resident (#12) of three residents reviewed for pressure injuries. This deficient practice resulted in harm when Resident #12 developed a new, facility-acquired, unstageable pressure injury and contributing to infection of the wound and bone. Findings include: Review of Resident #12's Minimum Data Set (MDS) admission assessment, dated 7/14/20 revealed Resident #12 was admitted on [DATE] with [DIAGNOSES REDACTED]. Further review of the assessment revealed Resident #12 was cognitively intact, required extensive two-person assistance with bed-mobility, transfers and toileting, dressing and personal hygiene. Review of Section M of the assessment, titled, Skin Conditions, revealed the following, in part: Is this resident at risk of developing pressure ulcers/injuries? 1. Yes . Does the resident have one or more unhealed pressure ulcers/injuries? 0. No . Other Ulcers, Wounds and Skin Problems (open [MEDICAL CONDITION] other than ulcers, rashes, cuts, surgical wounds, burns, skin tears, moisture associated skin damage), Z. None of the above. A review of a progress note for Resident #12, signed and dated by registered nurse (RN) B, on 7/18/20 at 11:25 a.m., revealed the following, in part: While helping CNA (certified nurse aide) turn guest during bed bath , this writer noted that guest had a abrasion to her right mid upper back . A review of Resident #12's Wound Evaluation, dated 7/18/20 at 7:18 a.m., revealed the following: Abrasion . Body Location: Spine . Acquired: In-House Acquired . Dimensions: Area 18.15 cm (centimeters), Length 5.44 cm, Width 4.78 cm. A review of the wound photo included in the note revealed an unstageable pressure ulcer located just below Resident #12's lower, right scapula (shoulder blade), near Resident #12's spine. During an interview on 12/9/20 at 5:12 p.m., certified nurse aide (CNA) C reported upon the beginning of their shift (7:00 a.m.), on 7/18/20, they had noticed blood on Resident #12's clothing. CNA C reported they alerted RN B of the blood on Resident #12's clothing. CNA C reported RN B assisted to remove Resident #12's back brace and clothing, an upon turning the resident, they noticed a wound on Resident #12's back. CNA C confirmed Resident #12 wore an undershirt and gown underneath the back brace at all times. When asked how often the brace was removed, CNA C reported the brace was only removed on bath days, or if Resident #12's clothing was visibly soiled. A review of the point of care documentation for July 2020, titled, Bathing/Showers, revealed Resident #12 had four baths from the period of 7/7/20 through 7/18/20. Review of a physician order [REDACTED]. Frequency: two times a day. A review of Resident 12's treatment administration record (TAR) for July 2020, revealed nursing had signed off from 7/7/20 to 7/18/20, stating Resident #12's skin under the back brace had been assessed according to the physician's orders [REDACTED].>During an interview on 12/10/20 at 8:07 a.m., RN B reported she had not been aware of the wound on Resident #12's right, mid-back area until assisting CNA C on 7/18/20. RN B reported they did not know how long the wound had been present. When asked if Resident #12's skin had been monitored according to the physician's orders [REDACTED].#12's brace was not removed during assessments of resident's skin. RN B reported the brace was only removed on, shower days. When asked if Resident #12 had reported pain related to wearing the brace, RN B reported Resident #12 often reported pain. During a review of Resident #12's, Wound Evaluation, including the wound photo, dated 7/18/20, RN B reported the wound had been caused by Resident #12's back brace. When asked if the wound appeared to have happened suddenly, RN B reported the wound had happened from wearing the brace over an extended period. During an interview, on 12/10/20 at 9:30 a.m., the Director of Nursing (DON), reported they were aware of the wound on Resident #12's right, mid-back, identified on 7/18/20. During a review of Resident #12's, Wound Evaluation, including the wound photo, dated 7/18/20, the DON confirmed the wound was not an abrasion, as documented. The DON reported they were unable to assess the wound on 7/18/20, due to Resident #12's transfer to the hospital, therefore they were unable to state whether the Resident #12 had developed, was a pressure injury relating to pressure from the resident's back brace. The DON reported Resident #12 had worn the brace prior to admission on 7/7/20. When asked if skin assessments were completed upon admission to the facility to identify skin breakdown, the DON reported a risk assessment and full skin assessment were completed upon admission and any skin issues or areas of skin breakdown were documented in the resident's EHR. A review of the admission Wound Note, signed and dated 7/7/20 at 4:19 p.m., for Resident #12, revealed the following: Boney prominence areas looked dry/intact. No redness noted. Full body assessments to be done with midnights. A review of Resident #12's admission, Skin & Wound Evaluation(s), revealed the following: 7/7/20 at 20:55 (8:55 p.m.): Bruise. Right outer wrist. 7/7/20 at 20:56 (8:56 p.m.): Bruise. Right antecubital space (inner elbow). 7/7/20 at 20:57 (8:57 p.m.): Bruise. Right abdomen. 7/7/20 at 20:58 (8:58 p.m.): Bruise. Left antecubital space (inner elbow). 7/7/20 at 21:02 (9:02 p.m.): Bruise. Right dorsum (upper portion of arm, hand, leg or foot). Further review of Resident #12's EHR revealed the resident returned from the hospital on [DATE]. Review of the admission, Wound Note, signed and dated 8/4/20 at 6:46 p.m., revealed the following: Bony prominences assessed upon re-admission, all are free from redness. Guest has bruising noted to B/L arm/hands, right back with pressure ulcer, short splint to LLE r/t fracture. Full skin assessment to be completed by pm shift. A review of Resident #12's hospital, Nursing Wound Care Consult Note, signed and dated 7/22/20 at 12:51 p.m., revealed the following in part: Reason for Consult . evaluation/assessment of pressure injury on the back . from TLSO brace (back brace) . Wound Assessment . there is a device related pressure injury noted over the spine of the mid back region . patient was wearing TLSO brace . A review of Resident 12's, Plastic Surgery Consult Note, signed and dated 7/22/20 at 8:12 p.m., revealed the following, in part: (Resident #12) presented to (hospital) on 7/18 . On arrival the patient was found to have a pressure wound along her mid-back where the brace was pressing . The patient has not had any prior wounds. A review of Resident #12's hospital discharge summary, signed and dated 8/4/20 at 3:25 p.m., revealed the following, in part: Active Problems: Pressure injury of upper back, unstageable (wound covered with film, wound bed not visible for staging) . Brief Hospital Course . (Resident #12) . skin breakdown and pain related to wearing LSO brace (back brace) at all times . Wound care was consulted for brace associated skin ulcer. Plastic surgery also saw patient. They re-evaluated patient 8/4 and had low suspicion for infection or need for debridement, recommended wound recs per wound team with outpatient wound clinic follow up . A review of the policy titled, Pressure Ulcer Risk Assessment, revised 10/2010, revealed the following, in part: General Guidelines: Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or decreased blood flow to the area, which destroys the tissues . 2. The most common site of a pressure ulcer is where the bone is near the surface of the skin . including . shoulder blades, backbone . Assessment: 2. Skin Assessment. Skin will be assessed for the development of pressure ulcers on a weekly basis or more frequently, if indicated . 4. the at risk need to me identified and have interventions implemented promptly to attempt to prevent pressure ulcers. Further review of Resident #12's EHR revealed the resident was discharged from the facility on 8/9/20. Resident #12 continued to experience complications related to the pressure injury to their right, mid-back as documented in subsequent hospital documents, including the following: A Hospital Summary Note, dated 9/4/20, revealed the following, in part: Decubitus pressure ulcer of the back, now with osteo[DIAGNOSES REDACTED] (bone infection) . continue (opioid pain medication) for pain control . PICC (long term intravenous catheter) . [MEDICATION NAME] (intravenous antibiotic), initial dose . 9/4/20 . six-week course .

Based on interview and record review, the facility failed to follow manufacturer's recommendations for the administration of medication for one resident (#101) out of 2 residents reviewed for medication administration resulting in immediate jeopardy as a result of the facility administering [MEDICATION NAME] medication to Resident #101 (R #101) by not holding the medication as instructed and administering the medication in excessive dose, resulting in the resident's hospitalization and subsequent death. Findings include: Resident #101 (R #101) was an [AGE] year old female who was admitted to the facility on [DATE] for rehabilitation following surgery on 12/18/17 for a fractured left hip. In addition, R #101 had a [DIAGNOSES REDACTED]. A record review of her Brief Interview for Mental Status (BIMS) revealed a score of 15 out of a possible 15 points indicating R #101 had no impairment with cognition. On 8/2/18 at 8:30 AM, a record review of the history and physical/admission packet, a 10 page document (located on R #101's electronic medical record) from the local hospital, revealed R #101 was receiving [MEDICATION NAME] 7.5 mg (milligrams) on a weekly basis every Sunday. Further review of the admission packet revealed the following documentation: She (R #101) should resume her [MEDICATION NAME] 2 weeks after surgery date. This sentence was underlined on the admission packet. Documentation at the top of the form indicated the form was printed on 12/21/17 at 2:32:04 PM. On 8/2/18 at 8:35 AM, a record review of the physician's orders [REDACTED]. The order was dated 12/21/17 and was signed by the medical director (MD) D. On 8/2/18 at 8:45 AM, a record review of R #101's Medication Administration Record [REDACTED]. The Medication Administration Record [REDACTED]. One dose was missed on 1/1/18 due to R 101's nausea and vomiting. On 8/2/18 at 8:50 AM, a phone interview with Pharmacist C occurred. After reviewing the physician's orders [REDACTED]. Pharmacist C stated the order was verified by a pharmacist on 12/21/17 and then was automatically refilled. On 8/2/18 at 9:15 AM, a record review of lab results, drawn on 1/1/18 at the facility reflected abnormal lab results. A complete blood count (CBC) revealed R #101 had a Hemoglobin (portion of a red blood cell that contains iron) result of 7.4 and was flagged on the lab result as low. The Hemoglobin range is between 12.1 and 15.7 g/dL. The hematocrit (ratio of red blood cells to the total volume of blood) was 22.7 which was marked as low on the lab result. The normal hematocrit range is noted to be between 36 to 46 %. The white blood cell (WBC) count was 2.7 which was flagged on the lab result as low. The normal WBC count ranges of between 4.8 to 10.8 K/uL. Red blood cells (RBC) measured at 2.37 and was flagged on the lab result as low. The RBC range is between 4.00 to 5.10M/uL. The lab result documented there were no results for a platelet count due to platelet clumping. On 8/2/18 at 10:00 AM, a record review R#101's electronic medical record (EMR) was done. A progress note on 1/4/18, the date when R #101 was transferred to the local hospital, stated patient appears extremely fatigued and lethargic. Very pale and unable to hold her head up. Difficulty speaking and seems slightly confused. Due to patient's worsening condition patient was sent to hospital for evaluation for possible dehydration versus infection. On 8/2/18 at 11:55 AM, an interview with Registered Nurse (RN) N occurred. RN N entered the order for [MEDICATION NAME] into the electronic medical record for R #101 when she was admitted to the facility. RN N was asked to describe the process used at the facility for verifying medication orders when a resident is admitted to the facility. According to RN N, when a resident is admitted , it is up the the nursing staff on the units to process admission orders [REDACTED]. The floor nurse then reviews the admission packet and calls the doctor to review all medications and receives orders for the medications contained in the admission packet. RN N stated she would read each medication along with the dosage and times for administration to the physician. A second nurse would then check the admission packet's medication list against the list of medications in the electronic medical record for accuracy. According to RN N, the second review of medications may not be done prior to the administration of medications. On 8/2/18 at 12:05 PM, a copy of a blank Nursing Admission Checklist was provided as Director of Nursing (DON) B the DON B conveyed the facility did not have a policy which described how nurses were to check medications when residents were admitted to the facility. The checklist stated Physician orders [REDACTED]. Nurse MUST initial D/C (discharge) summary med (medication) section and indicate any changes made by physician in writing. The form requires initials from the initiating nurse and the verifying nurse for each action taken. On 8/2/18 at 12:15 PM, a record review of the inpatient discharge summary from the local hospital indicated two check marks next to the majority of the medications and RN N and RN M both signed off that the medications were verified with the facility physician. [MEDICATION NAME] was to be held for 2 weeks after the surgery date but was not. [MEDICATION NAME], which was listed as a stopped medication, was not checked by either nurse and a notation by RN N stated added back to order by Physician O. On 8/2/18 at 1:10 PM, a phone interview was conducted with the Medical Director (MD) D to review the dosage of [MEDICATION NAME] for [MEDICAL CONDITION] Arthritis for R101. MD D stated he did not remember R #101. On 8/3/18 at 10:00 AM, a record review of the emergency room notes from a local hospital, dated 1/4/18, revealed R #101 was admitted with blood seeping from her nose mouth and vaginal area. Progress notes from the emergency room physician on 1/4/18 note stated Of note her platelets were 20. She is also noted to be anemic ~ at baseline. With the leukopenia as well, this is concerning for pancytopenia of unknown etiology. Reticulocyte count pending. She is also oozing from her IV site her nose and her vaginal area which we noted when we did her straight cath. I did send [MEDICATION NAME], ddimer, to evaluate for DIC LDH, haptoglobin to evaluate for hemolysis. The following documentation was noted in a paragraph titled #Pancytopenia due to [MEDICATION NAME] toxicity: Acute pancytopenia on the order of days to a couple of weeks is usually due to medications or infections. In her (R #101) case, she was given daily [MEDICATION NAME] when it was supposed to be weekly. Continuous low level exposure causes severe hematological and GI (gastro-intestinal - stomach and intestines) mucosal toxicity (mouth sores, diarrhea) as it has in her case. Leucovorin (medication used to prevent side effects of [MEDICATION NAME]) can be used for [MEDICATION NAME] toxicity, particularly when [MEDICATION NAME] levels are high, but unfortunately, most of the damage has already been done and recovery may take some time. Further documentation indicated an order for [REDACTED]. On 8/3/18 at 10:15 AM, a record review of the history of present illness from the local hospital electronic record, dated 1/5/18, documented the following physician note: She (R #101) underwent intramedulary nailing on 12/18/17 for a left [MEDICAL CONDITION] and had her [MEDICATION NAME] held. Per the discharge summary, this ([MEDICATION NAME]) was to be held until 2 weeks after her surgery. She arrived at (facility name) on 12/21/17 and was ordered [MEDICATION NAME] 7.5 mg to take every night. I called (facility name) regarding her medications and confirmed she was receiving [MEDICATION NAME] 7.5 mg every night since 12/21/17. Documentation on 1/7/18 stated Per chart review and discussion with the primary team, (resident name)', care has been transitioned to a comfort/palliative approach. On 8/3/18 at 10:30 AM, a record review of the Certificate of Death for R #101 revealed the date of death was (MONTH) 8, (YEAR) and the cause of death was Complications of Pancytopenia. Nursing Home Administrator A was presented with Immediate Jeopardy notification on 8/2/18 at 1:24 PM due to the facility's inability to recognize the therapeutic dosage of [MEDICATION NAME] for [MEDICAL CONDITION] Arthritis resulting in administering of [MEDICATION NAME] in excessive dose that exceeded the manufacturers maximum dose recommendations and administering a daily dose of this medication instead of a weekly dose putting R #101 and any resident in the facility receiving [MEDICATION NAME] for [MEDICAL CONDITION] Arthritis at risk for serious harm, injury and/or death. The facility initiated the following action plan to address the immediate jeopardy: Element #l Resident #101 was admitted on [DATE] for rehabilitation following surgery for [REDACTED].#101 was administered [MEDICATION NAME] in a dosage that exceeded the manufacturer's maximum dose recommendations. Resident #10I was sent to the hospital 1/4/18 and discharged from the facility. All other residents in the building on [MEDICATION NAME] have the potential to be affected. Element #2 A one-time audit was completed on 8/2/18 of all residents currently residing at the facility to ensure that residents who were identified as being on [MEDICATION NAME] were audited to ensure that the current dose was as prescribed by the physician. Current facility census is 82 and there is currently 1 resident in the facility who is on the medication. All current residents who are on [MEDICATION NAME], (1) resident, the order was reviewed and the care plan was updated to ensure the medication and black box warnings were identified. A one-time audit was completed on 8/2/18 of all current residents in the facility to ensure that any residents who had a [DIAGNOSES REDACTED]. On 8/3/18, a education/disciplinary action was provided with the Licensed Nurse who wrote the order. Licensed Nurses were re-educated on the medication [MEDICATION NAME] and its adverse effect in regard to [MEDICAL CONDITION] Arthritis. This was initiated on 8/2/18 with Licensed Nurses who were working 7p-7am and verbal education was completed by the Regional Nurse Consultant. Staff will be educated by the Nurse Managers continuing on 8/3/18 prior to working their next scheduled shift to ensure that staff are re-educated on [MEDICATION NAME] prior to working. As of 8/3/18 at 1:08 pm 38 of 38, or 100%, of the Licensed Nurses have been re-educated. The facility reviewed their current process of medication transcription upon admission to the hospital. The current in-house residents who admitted from 7/1/18 to 8/2/18 charts were reviewed by the nurse managers to ensure that there were no transcription errors noted. This review of records were completed on 8/2/18 and by the Director of Case Management, 2 Unit Managers and the Director of Education. The Pharmacy Manager was contacted on 8/2/18 regarding the medication error and an internal investigation was initiated The responsible Pharmacist was disciplined/re-educated on 8/3/18 and the data entry tech was disciplined re-educated on 8/2/18. Element #3 An Emergency QA meeting was held on 8/2/18 to review the current in-house patient who is receiving [MEDICATION NAME] to ensure the dosage was appropriate and to review current in house residents who have a [DIAGNOSES REDACTED]. The facility policy for Medication Administration for order and receiving was reviewed with no changes needed. System change to include 2 Licensed Nurses will be responsible to check all new admission orders [REDACTED]. Element #4 Beginning 8/3/18, the Director of Nursing or designee(s) will audit 5 residents medical records who are either on [MEDICATION NAME], have a [DIAGNOSES REDACTED]. Results of the audits will be taken to QA. The result is of all monitoring will be reported to the facility's QA Committee monthly for further recommendations. The Director of Nursing is responsible for ongoing compliance. Although the Immediate Jeopardy was removed on 8/3/18 at 5:30 PM when it was verified that the facility implemented the action plan, the facility remained out of compliance at the scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, due to the fact that sustained compliance could not be verified by the State Agency.

Based on interview and record review, the facility neglected to provide treatment and medication for one sampled resident (#501) out of one resident reviewed with a [MEDICAL CONDITION] disorder [DIAGNOSES REDACTED].#501 having continuous [MEDICAL CONDITION] activity from 1:00 PM until his transfer to a local hospital at 5:00 PM without any medical assessment or intervention. Findings include: Resident #501 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. On 2/8/18 at 9:00 AM, a record review of Resident #501's progress notes indicated this resident began having [MEDICAL CONDITION] on 12/21/17 around 1:00 PM and at 16:57 (4:57 PM) documentation stated Guest continued to have [MEDICAL CONDITION] throughout the day. On 2/8/18 at 9:15 AM, a record review of the Medication Administration Record [REDACTED]. On 2/8/18 at noon, the Director of Nursing (DN) was interviewed about Resident #501. The DON stated she had been hired on 12/15/17 and was not familiar with Resident #501. The DON was asked why Resident #501 did not receive any type of medication to control or stop his [MEDICAL CONDITION] on 12/31/17. The DON stated she would research this question and return with an answer. At 1:40 PM, the DON stated there was no medication ordered for Resident #501's [MEDICAL CONDITION] because oncology was involved. On 2/8/18 at 12:50 PM, the Medical Director (MD) was interviewed. The MD could not remember when or if the facility notified him about Resident #501's [MEDICAL CONDITION] activity. On 2/8/18 at 1:00 PM, Licensed Practical Nurse (LPN) B was interviewed. LPN B took care of Resident #501 on 12/31/17 when he began having [MEDICAL CONDITION]. LPN B stated Resident #501 started to have [MEDICAL CONDITION] which lasted approximately 2 minutes per [MEDICAL CONDITION]. LPN B stated she did not give any [MEDICAL CONDITION] medication to Resident #501. LPN B stated she called the physician (MD) who told her to check with the family to see what the family wanted to do. LPN B stated she was not in the room with Resident #501 when he began to have [MEDICAL CONDITION] but would go to the room when the family told her he had [MEDICAL CONDITION]. LPN B witnessed approximately 6 to 7 [MEDICAL CONDITION]. LPN B told the family to make sure the resident was safe until LPN B returned to the room. LPN B was asked if she called anyone in management to request additional help and LPN B stated she did not as the family was in the room so I felt I could leave the room. LPN B stated she did not request any [MEDICAL CONDITION] medication for Resident #501. LPN B stated she waited for the family to tell her if they wanted Resident #501 transferred out to the local hospital. LPN B said that, around 4:50 PM, Resident #501's mother asked Resident #501 if he wanted to go to the local hospital and Resident #501 nodded his head yes. On 2/8/18 at 2:30 PM, Certified Nursing Assistant (CNA) F was interviewed. CNA F worked the day shift until 2:00 PM on 12/31/17 and cared for Resident #501. According to CNA F, Resident #501 began having [MEDICAL CONDITION] between 1:00 and 1:30 PM. At 2:00 PM, CNA F witnessed Resident #501 having a [MEDICAL CONDITION]. According to CNA F, Resident #501 began shaking, his eyes rolled back in his head and Resident #501's mother was holding the resident down by the shoulders. When queried as to what CNA F did upon witnessing the [MEDICAL CONDITION], CNA F stated he rubbed his (Resident #501's) chest but that didn't help. On 2/8/18 at 2:52 PM, on-call physician ([NAME]P) A was interviewed. She stated she recalled that Resident #501 was young and was having repeated [MEDICAL CONDITION]. [NAME]P A thought the family was deciding on hospice care versus more aggressive treatment. When asked why there was no [MEDICAL CONDITION] medication ordered to decrease [MEDICAL CONDITION] activity, [NAME]P A stated she did not think about anti-[MEDICAL CONDITION] medication. On 2/8/18 at 3:17 PM, CNA J was interviewed. CNA J worked the afternoon shift and cared for Resident #501. According to CNA J, it was very busy that night. A female resident developed chest pains and had to be sent to the hospital around 4:00 PM. CNA J stated she worked the unit with LPN B and cared for 14 residents. On 2/8/18 at 3:45 PM, a record review of the emergency room notes from the local hospital documented secondary to his [DIAGNOSES REDACTED], he'll (Resident #501) be transferred to (large, local teaching hospital) for continuous EEG (electroencephalogram - reading of brain waves) and indicated Resident #501 was in critical condition. His [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED] is a dangerous condition in which epileptic [MEDICAL CONDITION] follow one another without recovery of consciousness between them.