Every finding on record at WellBridge of Fenton

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area, resulting in the potential to spread food borne illness to all residents who consume food from the kitchen. Findings include:On 01/13/2026 at 8:25am-8:50am, during the kitchen tour with Certified Dietary Manager/Culinary Specialist A and Chef B, observed overhead spray nozzle hanging inside the sink basin near the dishwashing area. When interviewed at this time, CDM A stated there is a work order to fix the overhead spray nozzle. According to the 2022 Food Code, 5-202.13 Backflow Prevention, Air Gap, An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch).On 01/13/2026 at 8:25am-8:50am, observed yellow residue on the interior wall of the ice machine, located in the kitchen. When interviewed at this time on how often the ice machine is cleaned, CDM A stated it's cleaned every month. According to the 2022 Food Code, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, Equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations, nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. On 01/13/2026 at approximately 12:30pm, during lunch observation, observed [NAME] C remove gloves and don gloves without washing hands during food preparation in the kitchen. During interview at this time, when asked about handwashing, CDM A stated staff are supposed to wash hands after removing and putting on new gloves.According to the 2022 Food Code, 2-301.14 When to Wash, Food employees shall clean their hands and exposed portions of their arms.immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and.Before donning gloves to initiate a task that involves working with food.

Number of residents sampled: Based on observation, interview and record review, the facility failed to ensure that call lights were within reach, responded to in a timely manner, and that staff were respectful upon entering the residents' rooms and providing care for five confidential residents (#6, #35, #60, #75, #86) and a confidential group of residents.Findings include:Confidential Group of Residents On 1/13/26 at 2:00 PM, a group of Residents were assembled. The Residents were asked about any concerns they had regarding the care provided by staff at the facility. Three of the Residents answered questions and engaged in conversation. One Resident reported concerns of call lights not answered timely and reported wait times of 30 minutes at times. One Resident reported that staff would answer timely but leave to get supplies and then not come back or take a long time to return to address the Resident needs. When asked if there were concerns of staff with personal phone use while providing care, one of the Residents reported It has happened on occasion. They are talking and you don't know who it is they are talking to, and indicated during care provided, the staff was talking to someone else and indicated an earphone piece. Confidential Resident Z On 1/12/26, a Confidential Resident Z was observed in their room. The Resident was interviewed, answered questions and engaged in conversation. The Resident was asked about concerns with their care and when asked if call lights were answered timely, the Resident reported concerns. When asked if they had to wait over 30 minutes, the Resident stated, Oh yeah. When asked if there were issues at a certain time of day, the Resident stated, varies shift to shift, depends on the shortage of workers and the workers themselves. The Resident reported that, at times, the call light would be answered, the staff does not help when they answer and stated, they don't always come back. I yell out or have to call again. Confidential Resident AA On 1/12/26 at 12:30 PM, observations were made in a dining area during the dining observation task of the survey. Resident AA was asked how their food was after introductions. The Resident had engaged in conversation and reported concerns with an issue with call light response times when the call light is used. The Resident reported long call light times and when asked if over 30 minutes, the Resident stated, Oh yeah, or they shut off the light and then don't come back, and we (indicated the Resident sitting next to them) have had to sit a long time, waiting for the call light to be answered. Resident #35 (R35) On 1/12/26 at 1:46 PM, an observation was made of Resident #35 sitting in his room. An interview was conducted with the Resident who answered questions and engaged in conversation. The Resident was asked about concerns with the care received at the facility. The Resident expressed, Call lights at night is a problem. Day time they answer quick, nighttime not so much. When asked if he had to wait more than 30 minutes and Resident stated, Yes, it can be, and reported 30 minutes or longer sometimes. The Resident reported that he would call for assistance, something to eat or drink and stated, It can take a while. A review of R35's medical record revealed an admission into the facility on [DATE] and readmission on [DATE] with diagnoses that included end stage renal disease, emphysema, dementia, anxiety disorder, and stroke. A review of the Minimum Data Set assessment revealed R35 had a Brief Interview of Mental Status score of 15/15 that indicated intact cognition. On 1/13/26 at 4:59 PM, an interview was conducted with the Director of Nursing (DON) regarding call light response times. The DON was asked about call light response times and when should call lights be responded to by staff. The DON reported under ten minutes. The DON reported that they were working on a plan of correction for call light response times and reported they review call lights and anything over an hour, do a plan of correction, review at a weeks length, the Administrator reviews the call light response times, call the CNAs to see what happened and do education as needed. The DON reported that they were starting with getting two supervisors on the nightshift and reported hopefully that will remedy that if it is happening. When asked about concerns with turning off call lights before the needs are met, the DON reported that concern was not brought to my attention. Resident #75 (R75): According to R75's Electronic Medical Record (EMR), R75 was [AGE] years old admitted to the facility on [DATE] with the diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side, muscle wasting and atrophy, paralytic gait, anxiety disorders and major disorders in addition to other His Brief Interview for Mental Status (BIMS) score was 14/15 dated (11/25/25). A score of 14 means the person is cognitively intact. Minimum Data Set (MDS) assessment dated [DATE], revealed that R75 is dependent on toileting. Dependent means that the helper does all of the effort. The resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the residents to complete the activity. R75 Care Plan for Urinary Incontinence related to immobility (revised in 2/20/2024).R75's Goals were: Will have no complications due to incontinence. Will be free from skin breakdown. Will attain/maintain as clean and dignified state as possible. On 01/12/2026 at 12:28 PM, R75 was in his room watching a show on his iPad. R75 was asked how he was. Then he responded, I wet my pants a while ago, but they won't come. I think I am being ignored. When the surveyor asked what he meant and if he had activated his sensor touch alarm next to him. R75 said yes. R75 grabbed his call light (flat, rounded shape) and pressed to activate the sensor touch call light again. The surveyor observed and timed the call light after R75 activated the call button again at 12:30 PM on 01/12/26. The surveyor had noticed the nursing staff CNA Y came in at 12:48 pm (18 minutes elapsed since R75 activated his call lights). Certified Nursing Assistant (CNA) Y was interviewed on 1/12/26 at 12:58 PM, regarding R75's delayed call light response and why it took her a long time to answer his light. CNA Y explained that she was assigned to R75 and some residents in the 100 halls. She carried the pager and showed me that she knew that R75 had pressed off his call light, but he was at the dining hall feeding a resident, and that she could not leave the area. The CNA Y was asked how other staff can get notified to respond to the light when you can't? CNA Y replied, Yes, and showed where the monitor screen is located. This notifies and alerts staff in the hall when a call light is activated. The screen shows staff which call lights were activated, by room number, and the length of wait time since activation. It shows how long the call lights have been on, and it tells staff how long residents have been waiting. CNA Y confirmed that the monitor displayed the wrong time, date, and year. CNA Y recognized and confirmed that the time on the screen read 1:41 AM, while the actual time was 12:58 PM, and that the date and year were inaccurate. On 1/14/26 at 10:48 AM, R75 was observed receiving incontinence care with the nursing staff and the wound nurse. Irritation and skin impairment were observed. The wound nurse confirmed an open area that had recently developed at the coccyx area. During the assessment, the wound nurse measured the wound in the coccygeal area: L (length) 1.27 cm, W (width) 1.09 cm, Area 1.14 cm, and depth 0.1 cm. These measurements were recorded in R75's EMR on 1/14/26. Resident #3 (R3) On 01/12/2026 at 12:48 AM, R3 was interviewed and revealed issues with delayed call light response and staff failing to show respect and maintain the resident's dignity. R3's Power of Attorney (POA) F was at her bedside in R3's room. During the interview, the resident's POA F mentioned the following complaint: experiencing a longer wait after activating the call light. R3's POA stated a wait of about 45-50 minutes. POA F recalled walking down the hall to find staff. He revealed R3 had to wait a long time before staff laid wet on the bed, sometimes for a pain medication or assistance. R3's POA emphasizes that she needs pain medication and is on a Fentanyl Patch. POA F stated, The staff are never abusive nor rude, but they are neglectful with call light response. I walk to find them on their phones or computers in the hall. POA F recalled another incident and said, One time she was choking on her food, so I had to walk to the common area and found a nurse in her computer. According to the review of the Electronic Medical Record (EMR), R3 was [AGE] years old and admitted to the facility on [DATE] with the diagnosis of acute right heart failure, Dementia, Urinary Tract Infection, Chronic Kidney Disease, and polyneuropathy in addition to other diagnoses. R3's care plan (revised on 1/12/26) indicated a cognitive impairment with a Brief Interview for Mental Status (BIMS) Score of 8. A BIMS Score of 8 indicates a moderate cognitive impairment. R3's care plan revealed that R3 is on a diuretic (water pill) prescription, and the goal is for R3 to be free of any discomfort or adverse side effects of diuretic therapy. Two 2 Confidential group of residents reported: A confidential group of residents on 1/12/16 at 1:00 PM expressed: Nursing assistants are on their phones a lot while providing care. They are looking at their phones and don't care about us. Another confidential group of residents on 1/14/26 at 1:50 PM reported that staff continue to have a delayed response to call lights. This confidential resident stated, It's not quick enough, and sometimes I have to go bad. It's not as quick as I needed them to be, especially right after meals. When asked about any other concerns, he replied that one staff member is on her cell phone when helping me to the toilet. Resident 60: According to a review of R60's medical record, the resident was admitted to the facility on [DATE] for skilled nursing care related to medical diagnoses of: fracture of right great toe, cellulitis (Infection) of right toe, atherosclerosis (hardening of arteries) of right left with gangrene (infection), Proteus Mirabilis Morganii (multi-resistant drug organism – MDRO) Additional diagnoses included: diabetes mellitus, right dorsum 1st digit (Hallux) - amputation in 09/2025 including treatment of hyperbaric chamber therapy. R60's Minimum Data Set (MDS) record revealed Brief Interview of Mental Status (BIMS) score of 13/15 and indicated the resident was cognitively intact. On 01/12/2026 at 10:22AM, During a walkthrough of unit outside of R60's door was observed a sign that indicated enhanced barrier precautions (EBP) were in place for the resident, a cart of personal protective equipment was present. The infection control prevention (ICP) Nurse N was in the hall and was queried why the precautions were in place and she responded, for wounds. On 01/12/2026 at 10:22AM, An observation of R60 was made in his room, resident was sitting in his chair and was dressed wearing black and gray gloves on bilateral hands. When R60 was asked about the gloves, he said that he has neuropathy and wears those to help. R60 reports he has been at the facility for 11 months or so and that he had a wound on his right great toe and that he had part of it amputated, he reports being in hyperbaric oxygen therapy for it several times a week and that he had to put skilled services on hold until he healed. On 01/13/2026 at 08:20AM, During medication administration rounds R60's room was entered with Nurse J. Upon entrance to the room R60 stated Oh am I glad to see you this morning, I have a story to tell you. R60 proceeded to explain his concerns to Nurse J and SA. R60 expressed great concern over the many visits to his room earlier that morning and said it started at around 5:30AM. R60 reported that at least 7 staff members have been in and out of his room since that time. R60 stated I treated my inmates better and it's a level of respect; you don't just barge in someone's room/space. When R60 was asked to explain what he meant, R60 reported they barely knock and then enter my room, it is alarming and disrespectful; At least give me the dignity to answer before entering my room, and he said he did not understand why they were doing that last night or what games they are playing; I call when I need help. R60 said he doesn't sleep well and had to go to therapy offsite which was hard on him, and he needed his rest. R60 said he was upset over one of the early morning visits where he said the staff had made an attempt to clip (and clean) his toenails and he reported it was odd to him that they only completed the task on his right foot. R60 said he was concerned about his feet and said he wanted to see what the staff had done. R60 further expressed concern over the dressing and that it had been applied too tightly, he said he was worried about a setback on the progress he had made with healing. R 60 said they did not listen to him when he mentioned it this morning. R60 said they brought his breakfast too early at 7:30AM, he does not like to eat that early. R60 further complained that the breakfast was ice-cold. They (staff) don't care. R60's call light was observed wrapped around his nightstand drawer handle and knotted 3 times, R60 was unable to reach the call light when asked. Nurse J was present and responded, Oh my, that is really tied on there and she untied the call light and placed it where the resident could reach before she left the room. A record review of R60's care plan revealed: Focus: Risk for falls r/t (related to) bradycardia, OA (osteoarthritis), hx DVT (deep vein thrombosis), OSA (obstructive sleep Apnea), PVD, prediabetes, vertigo, bilateral foot drop, neuropathy, cardiac dx(diagnoses), potential medication side effects Interventions: Reinforce need to call for assistance and Transfers: 2 PA (person assist) with 2ww (2 wheeled walker); non-ambulatory Focus: The resident has potential for and actual impairment to skin integrity r/t fragile skin, obesity, CHF (congestive heart failure), gout, hx DVT, PVD, prediabetes, BLE neuropathy, bilateral foot drop, hx pressure wound, R. Great toe amputation. Interventions: Encourage good nutrition and hydration in order to promote healthier skin. Focus: Alteration in nutritional status related to Recent hospitalization s/p (status post) fracture of (R) toe. PMH (primary medical history): GERD, obesity, CHF, prediabetes, gout. Interventions: Honor food preference. Focus: ADL/Mobility deficit related to right great toe fracture, right great toe cellulitis with dry gangrene, right groin abscess s/p debridement, wound positive for proteus mirabilis, obesity, CHF, gout, HTN, HLD, bradycardia s/p pacemaker, OA, hx DVT, OSA, PVD, prediabetes, vertigo, bilateral foot drop, GERD Interventions: Assist with dressing, hygiene and toilet needs. Focus: At risk for changes in mood r/t medical condition, adjustment disorder, reaction to severe stress concern of injuring his r foot/toe and losing his leg- fears he will not be able to go home, sadness, tearfulness. Interventions: -Provide opportunities to express self; Reassure him it is normal to be afraid of not being able to go home; Offer encouragement by highlighting the progress they have already made. And Offer choices and encourage participation in healthcare decisions to enhance sense of control. Resident 86: According to a review of R86's medical record, the resident was admitted to the facility on [DATE] for skilled nursing care related to medical diagnoses of respiratory syncytial virus (RSV) pneumonia (PNA), fall, cellulitis of right lower limb (infection), bilateral lower extremity lymphedema (excessive fluid collection in lymphatic system), peripheral vascular disease (PVD) with venous insufficiency, and chronic kidney disease (CKD), stage 2 (mild kidney damage). On 01/12/2026 at 11:55AM, R86 was observed in her room, she was seated in a bariatric wheelchair with the bedside table placed in front of her. R86's call light was observed at the head of the bed hanging off the left side and, on the floor, out of reach. When R86 was asked if she was able to reach the call light, she confirmed that she was unable to reach it. Observed on R86's dresser was a tray of partially consumed food, R86 said that it was her tray from breakfast that staff had left. R86 said they should be bringing her lunch soon. Physical therapy manager H entered the resident's room with a lunch tray. Physical therapy manager H was asked to locate R86's call light, she looked and pointed at the head of the bed on the floor, when she was asked if that is where it should be she said, no it should be where the resident can reach it. Physical therapy manager H was asked about the tray on R86's dresser, and she stated Oh, that is from breakfast and should not be there. Physical therapy manager H said she was unsure why it was still there and that she was going to take it with her when she left R86's room. On 01/12/2026 at 12:34AM, An observation of Physical therapy manager H was made in the hall as she exited R86's room, there was nothing in her hands. At ~12:35PM During a follow up observation of R86's room, a dirty food tray was observed on the dresser with a meal ticket that read: 1 [NAME] sugar, 1 8-ounce spoodle Oatmeal, 1 Scrambled eggs #16 scoop, 1 Home fried potatoes with pepers#8 scoop, Cinnamon Struddle CC 2x2 square, 1 large OJ, 1 large water. R86 was eating lunch, when asked about the tray on the dresser, she said they (staff) say they are going to do things, but they don't and explained further, just like my bed is still unmade and they were supposed to clean up my room when I when to therapy this morning and as you can see they did not. She said they are too busy to stop and help. On 01/13/2026 at 1:58PM, R86 is observed resting in bed, watching television. During a follow up interview, R86 said she was upset that last night she did not eat her pie, and she asked them (staff) to leave the pie for her, and she would eat it later. R86 said when they took her tray, they took her pie and when she asked later for a piece there was no more. R86 said she does not think that staff listen to her. A record review of R86's Kardex bedside care plan revealed: Behavior/mood: Allow me time to express my feelings. A record review of R86's care plan revealed: Focus: Risk for falls r/t RLE (right lower extremity) cellulitis, BLE (bilateral lower extremity) lymphedema, falls, HTN (high blood pressure), GERD, PVD, hypothyroidism, edema, HLD (high cholesterol), neuropathy, venous insufficiency, CKD. Intervention: Educate guest wo (to) wait for assistance and use call light for toileting needs. and Transfers: 1 PA (person assist) w/ 2WW (with 2 wheeled walker); non-ambulatory. Focus: ADL/Mobility deficit related to GI bleed and anemia RLE cellulitis, BLE lymphedema, falls, HTN, GERD, PVD, hypothyroidism, edema, HLD, neuropathy, venous insufficiency, CKD. Intervention: Assist the pt with showers/bed baths and Assist with dressing, hygiene and toilet needs. Focus: Behavior r/t new environment with recent hospitalization Intervention: Allow me time to express my feelings. A record review of facilities Policy titled Quality of life- Dignity revealed: Statement: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Policy interpretation and implementation: 1. Residents shall be treated with dignity and respect at all times. 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. 6. Residents' private space and property shall be respected at all times. a. Staff will knock and request permission before entering residents' rooms. 7. Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs.

Based on interview and record review, the facility failed to provide an appropriate and timely Beneficiary Notification (NOMNC and ABN) to two (2) residents (Resident #95 and Resident #67) of 3 residents reviewed for Medicaid/Medicare Coverage/Liability Notice.Findings include:FacilityResident #95 (R95)On 1/13/26 at 12:00 PM, the surveyor requested a NOMNC and ABN Notification for 3 residents. It was noted upon review of the submitted documents that the facility did not issue Resident #95 (R95) a Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) on the resident's last covered date of 8/30/2025.A review of the Electronic Record revealed that, according to the Census Report in PCC, R95 billing status immediately switched from Medicare Part A to private pay on 8/30/25.The facility Social Worker SW was interviewed on 1/13/26 at 2:50 PM. The SW explained why no NOMNC and ABN Form were submitted for R95. She apologetically explained that they had missed issuing R95's NOMNC and ABN. The facility believed his Last Covered Day (LCD) was on September 5, 2025, but corporate billing corrected them, stating it was actually 8/30/25. By the time they were informed, the LCD had already passed, and it was too late to issue the NOMNC. When asked what policy is, SW knew that NOMNC letters are notices informing the resident or the financially responsible party of the end date of insurance coverage. The residents have the right to appeal for an extension before the last covered day. The SW admitted , It was my job to issue the NOMNC Letter to the residents. The ABN forms are issued by the [NAME] Department. I am responsible for the NOMNEC letters. I remembered, we missed giving both NOMNC and ABN notices to R95. When the SW was asked what happened as a consequence, the SW revealed that they spoke to R95 and R95 decided he wanted stay and opted to pay as a private payor for the remaining days.R95 pay status was explained by the Business Office Manager (BOM) on 1/13/26 at 4:41 PM. The BOM admitted that she missed issuing the ABN to R95 because it was too late. By the time they realized the actual LCD, R95 had already passed the cut date. R95 had exhausted his 100 days. The BOM explained that R95's payor source changed from Medicare Part A status to a full private pay right after the CD on 8/30/25. R95 opted for private pay status from September 1, 2025, until the resident was qualified and eligible for Medicaid benefits. The BOM admitted she was responsible for issuing the ABN Notices to residents, and that in case R95, they missed it. The facility's LCD was incorrect; the correct date was 8/30/25, but they thought it was 9/5/25. It was too late to issue a cut letter. The BOM further stated that because R95 opted to remain in the facility, he had to pay the full amount of his stay daily until he became Medicaid eligible. The BDM revealed that R95 was not able to appeal because the NOMNC and ABN notifications did not happen.A review of R95's Electronic Medical Record conducted on 1/13/26 at 12:00 PM revealed that R95 was admitted on [DATE] under Medicare Part A through 8/30/25. Because he opted to remain in the facility, R95 immediately switched to Private Pay status effective September 1, 2025. He currently remains on Medicaid at the facility.Resident #67 (R67)R67 was [AGE] years old and admitted to the facility on [DATE]. According to the NOMNEC, the effective date coverage of the current Skilled Nursing Services ends on 12/27/25. R67's wife was the designated Power of Attorney for both Medical and Financial Agreements/Transactions.The SW was interviewed on 1/13/26 at 2:55 PM and indicated that she issued a NOMNC to R67's wife on 12/23/25. His LCD was 12/27/25. When asked why the ABN was missing, the SW stated that the Business Office Manager (BOM) had issued it. Wife did not appeal to the NOMNEC letter.On 1/13/26 at 4:45 PM, the Business Office Manager (BOM) revealed that the ABN was issued to R67 and signed by the wife on 1/24/25. The BOM was asked to explain why the date the document entered was covered with whiteout. The BOM admitted that the wife signed the ABN 12/26/26 and stated that she had changed the date to 12/24/25. The BOM admitted that she used whiteout to change the date to an earlier one. The BOM revealed that she was unsure when or what the ABN Notification date should be, so she changed the date to 12/24/25 after the wife had signed. R6's wife was at the facility after Christmas and had signed the ABN on 12/27/25. The BOM indicated that the date was changed to 12/24/25. BOM was asked whether the wife knew and consented to the BOM changing the date to 12/24/25; the BOM did not reply.A phone call was made to R67's wife on 01/15/26 at 10:42 AM. R67 stated she was not at the facility on 12/24/25 but remembered signing papers during her visit at the facility the weekend (12/27/25) after Christmas Day.During a Quality Assurance and Performance Improvement (QAPI) Meeting with the Administrator and the Corporate Staff held on 1/14/26 at 4:00 PM, concerns were raised about the surveyor's findings regarding the Beneficiary Notices. Neither the Administrator nor Corporate had any comment.The Beneficiary Notice policy was requested and reviewed. The Form Instruction CMS 10095-NOMNC OMB Approval 0938-0910 (undated) was submitted by the facility for the NOMNC. The second Form was titled: ABN Decision Tree (undated) Beneficiary Notice Initiative Summary (Medicare FFS Beneficiaries only). Both forms submitted to the surveyor for review were not the facility policies.

Based on observation, interview and record review, the facility failed to ensure that nail care was provided, and handwashing was offered prior to dining for one resident (Resident #6), of one resident reviewed for Activities of Daily Living (ADL) care.Findings include:Resident #6 (R6):On 1/12/26 at 1:08 PM, an observation was made of R6 sitting up in bed eating lunchtime meal. The Resident expressed that he liked the food. An observation was made of the Resident eating some of his food. The Resident had chocolate on his overbed table, bed sheet, blanket, and on the bed frame. The Resident asked to have his pillow put back underneath his head that was laying on the floor underneath his bed. Staff were summoned and assisted with the pillow underneath the Resident. The Staff member did not assist with cleaning the chocolate from the items or offered to wash the Resident's hands. An observation was made of R6's hand with long fingernails on right hand with debris under the nails. Around the nails in the cuticle area, there were dried red tainted debris. The Resident did not have anything on the meal tray that had red sauce. The lunch time meal had a red sauce/soup and rice that had been observed during dining in the dining room, but the Resident did not have that item available at this time. When asked about showering or bathing, the Resident reported getting a bed bath about once a week or more. When asked if staff have offered to do nail care the Resident indicated they have not always asked and stated, It's something that can be easily overlooked. The Resident showed his left hand that he picked up with his right hand and reported he does not use that side after a stroke. An observation was made of the nails longer on his left hand but were cleaner underneath the nailbeds. The Resident reported he liked to have short nails. Closer observation of the right hand revealed a broken jagged nail. The Resident was unshaven and reported he liked it that way. On 1/13/26 at 12:32 PM, an observation was made of R6 sitting up in bed. An observation was made of R6's fingernails that remained long on both hands and debris under the nails on the right hand with red debris around the cuticle area of the nails on the right hand. After leaving the Resident's room, an observation was made outside at the Resident's doorway, two staff came in to set the lunch meal tray for the Resident. The staff did not offer to have the resident wash his hands prior to eating his lunch. A review of R6's medical record revealed an admission into the facility on 9/13/24 and readmission on [DATE] with diagnoses that included stroke affecting left non-dominant side, depression, bipolar disorder, anxiety disorder, and metabolic encephalopathy. A review of R6's Minimum Data Set assessment revealed a Brief Interview of Mental Status of 12/15 that indicated intact cognition and the Resident needed substantial/maximal assistance with bathing and personal hygiene. On 1/13/26 at 4:30 PM, an interview was conducted with the Director of Nursing (DON) regarding ADL care for Resident #6. An observation was made with the DON of R6 lying in bed. An observation was made of R6's nails that were long with debris on the right-hand nailbeds. The DON stated, Yeah, he needs some attention. The Resident reported they were too long when asked how he liked his nails and reported he wanted his nails done.A review of the medical record for R6 revealed a lack of documentation of the refusal of nail care. The DON reported they don't always document the refusals if its care planned. The Resident's care plan reflected that the Resident was known to refuse nail care. When asked how they know when nail care was provided, the DON reported that under the task when the shower or bathing is documented, then it was all encompassing to reflect that the nail care was performed at the same time. When asked if staff was then documenting nail care completed when shower was marked, the DON replied yes. The concern was brought up that the residents did not have nail care completed with the recent showers documented. The DON was asked about handwashing before meals. The DON was asked when should hand washing be accomplished prior to meals, the DON reported that if they were visibly soiled, she would help them get up and wash their hands. The DON was asked if R6's hands were visibly soiled; the DON reported yes and indicated his hands would need to be washed. A policy regarding nail care was requested but not received prior to the exit of the survey.

Based on observation, interview and record review, the facility failed to ensure that medications were securely stored for safe administration, for one resident (Resident #78 (R78)) of 12 residents, 1 medication storage room, and 4 wall-mounted medication storage units reviewed for medication storage, resulting in the potential for medication error or misappropriation.Resident #78 (R78):According to a review of R78's medical record, the resident was admitted to the facility on [DATE] for skilled nursing care related to medical diagnoses of Chondrocostal junction syndrome (inflammatory condition affecting the cartilage where the ribs in sternum meet), subsequent fall, acute with chronic respiratory failure, Myocardial infarct (heart attack), chronic obstructive pulmonary disease (COPD) and Dementia. R78's Minimum Data Set (MDS) record revealed Brief Interview of Mental Status (BIMS) assessment score of 6/15 indicating severe cognitive impairment. On 01/12/2026 at 9:45AM, R78 was observed resting in bed. R78 said she has not been at the facility long but was unable to give details.On 01/12/2026 at 10:26AM, R78's family member M approached SA in the hall and asked for assistance. Family member M was holding a small white pill in her hand and said R78 was asleep when she arrived and found this just sitting on her (R78's) over the bed tray, family member M said she was concerned about what the medication was and if R78 was supposed to take it now that she was awake or what it was and if she needed it or was supposed to have already had it. SA walked down the hall with family member M to find the nurse. Encountered on the hall was ICP Nurse N and family member M asked her the same questions. ICP Nurse N said I don't know I am not (R78's) nurse. ICP Nurse N said she would find R78's nurse to ask her and ICP Nurse N took the medication from family member M and walked away with the medication.As Family member M walked back toward R78's room she stated, I just need to know what it is and if she needs to take it and said that R78 was unable to tell her and she did not want her to take the medication without finding out what was going on first. On 01/12/2026 at 10:54AM, During a follow up interview with family member M she said R78's nurse (Nurse I) told her that she witnessed the resident take her morning medication and nothing dropped and she was not sure where the pill found had come from. Family member M said she was concerned that R78 had missed other medications, but they (family) were not able to be at the facility to observe R78 at medication times. R78 was observed resting in bed visiting with family. On 01/12/2026 at 10:56AM, During an interview with Nurse I she was asked about R78's medication, Nurse I said she had spoken with ICP Nurse N and had identified the pill as prednisone. When asked if R78 was prescribed prednisone she said yes. Nurse I further explained that she had witnessed R78 when she took her morning medication, and she had no idea where the unsecured pill came from. A record review of R78's medical orders revealed:'Prednisone oral tablet 5mg: give 1 tablet by mouth in the morning' On 01/12/2026 at 11:05AM, During a follow up interview with ICP Nurse N she was queried about the medication family member M found in R78's room, she reported that she had checked with the nurse on R78's hall Nurse I. ICP Nurse N said that Nurse I' told her, 'She (Nurse I) witnessed (R78) take her medication that morning and that she (R78) swallowed all her medication'. ICP Nurse N speculated that the pill was potentially left from yesterday but could not verify when it was left at the bedside. ICP Nurse N said the medication was identified as Prednisone. ICP Nurse N stated I am doing an on-the-spot education through the building to assure that we are confirming medications are witness and never left at the bedside. A record review of the facilities policy titled medication administration general guidelines revealed: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility patient distribution system (procurement, storage, handling and administration). The facility has sufficient staff and medication distribution system to ensure safe administration of medications without unnecessary interruptions. Medications are prepared only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to prepare and administer medications. A record review of the facilities policy titled Medication storage in the facility revealed:Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Procedure: B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access.C. All medications dispensed by the pharmacy are stored in the container with the pharmacy label.E. Except for those requiring refrigeration or freezing, medications intended for internal use are stored in a medication cart or other designated area

Based on observation, interview, and record review, the facility failed to follow enhanced barrier precautions (EBP) for residents identified with qualifying wounds and percutaneous endoscopic gastrostomy tubes (PEG - delivers nutrition and medications directly into the stomach), for two residents Resident #9 and Resident #60 (R9 and R60)) of eight residents reviewed for infection prevention. Findings include:Resident #60 (R60):According to a review of R60's medical record, the resident was admitted to the facility on [DATE] for skilled nursing care related to medical diagnoses of: fracture of right great toe, cellulitis (Infection) of right toe, atherosclerosis (hardening of arteries) of right left with gangrene (infection), Proteus Mirabilis Morganii (multi-resistant drug organism - MDRO) Additional diagnosis included: diabetes mellitus, right dorsum 1st digit (Hallux) - amputation in 09/2025 including treatment of hyperbaric chamber therapy. R60's Minimum Data Set (MDS) record revealed Brief Interview of Mental Status (BIMS) score of 13/15 and indicated the resident was cognitively intact.On 01/12/2026 at 10:22AM, During a wall through of unit outside of R60's door was observed a sign that indicated enhanced barrier precautions (EBP) were in place for the resident, a cart of personal protective equipment was present. The infection control prevention (ICP) Nurse N was in the hall and was queried why the precautions were in place and she responded, for wounds.On 01/12/2026 at 10:22AM, An observation of R60 was made in his room, resident was sitting in his chair and was dressed wearing black and gray gloves on bilateral hands. When R60 was asked about the gloves, he said that he has neuropathy and wears those to help. R60 reports he has been at the facility for 11 months or so and that he had a wound on his right great toe that he had part of it amputated, he reports being in hyperbaric oxygen therapy for it several times a week and that he had to put skilled services on hold until he heals.On 01/13/2026 at 08:20AM, During medication administration rounds R60's room was entered with Nurse J. Upon entrance to the room R60 stated Oh am I glad to see you this morning, I have a story to tell you R60 proceeded to explain his concerns to Nurse J and SA. During this time R60 expressed great concern over the many visits to his room that early morning starting at 5:30AM and reported that at least 7 staff have been in and out. R60 was concerned over the attempt staff had made that morning to clip his toenails (and reported it was only completed on his right foot). R60 was concerned and wanted to see what the staff had done as he expressed concern over that the dressing had been applied too tightly and the potential for a setback on the progress he had made with healing. R60 requested Nurse J to unwrap his feet and evaluate them and said that he also wanted to visualize them for his self.During wound care observation Nurse J was observed. During preparation of wound care supplies she placed unwrapped rolls gauze wrap directly onto R 60's bed prior to applying it to resident with no barrier used to cover the dirty linen. On 01/14/2026 at 12:02PM, During an interview with ICP Nurse N she was advised on concerns over use of proper PPE and barriers used in both wound care and medication administration via PEG tub with residents in EBP. ICP Nurse N revealed that Nurse K had come to her after the medication administration and was very upset with herself, reported that Nurse K said she was nervous and had told ICP Nurse N that she had not donned a gown until she was asked about the proper PPE needed to perform the tube feeding site and medication administration care. ICP Nurse N said We just recently had training and that it is known to staff to use barriers and PPE.A record review of R60's medical orders revealed: Dated 01/08/2026: Enhanced Barrier Precautions as directed. This includes gowns and gloves for high-contact resident care activities. Specify why: wound.Dated: 01/06/2026: WOUND CARE: Right foot wound. Cleanse with mild soap and water, pat dry completely. Cover wound bed with hydrogel and gauze. Place dry gauze between incision and between amputation site and second toe. Wrap with kerlix and do not apply tape to skin to secure in place. Monitor for increased s/sx (signs and symptoms) of infection, report spreading redness, increased drainage, streaking, fever, malaise to provider.Dated 01/02/2026 Wound Care: Left foot, great toe, second, third and fourth digit: Cleanse with betadine swab, allow to dry completely, gauze between toes. Can wrap with kerlix for comfort. Monitor for s/sx of infection, notify provider of any abnormalities.Resident #9 (R9):According to a review of R9's medical record, the resident was admitted to the facility on [DATE] for long term nursing care related to medical diagnoses of cerebral infarction (stroke), dysphasia and aphasia (difficulty or inability to speak, swallow and comprehend language), palliative care, PEG tube and obstructive uropathy. R9's Minimum Data Set (MDS) record revealed Brief Interview of Mental Status (BIMS) score of 00/15 indicating severe cognitive impairment.On 01/12/2026 at 11:00AM, During a wall through of unit outside of R60's door was observed a sign that indicated enhanced barrier precautions (EBP) were in place for the resident, a cart of personal protective equipment was present.On 01/12/2026 at 11:05AM, ICP Nurse N was in the hall and was queried why the precautions were in place and she responded, for PEG tube and wounds.On 01/12/2026 at 1:37PM, R9 is observed in her room resting in bed with eyes closed. Resident was nonverbal and had minimal physical response when spoken to, she was unable to interview. On 01/12/2026 at ~(approximately) 1:56PM, During an interview with CNA P she reported R9 is on hospice, and she was nonverbal but will nod or track with her eyes. CNA P said R9 had EBP's for wounds. Nurse T was present and when asked about wound care and PEG tube observations, she said she had already changed the wound and tube feed dressing for the day. On 01/13/2026 at 9:18AM, During an observation of R9 being repositioned by Nurse K and CNA P R9 was yelling out in pain. Nurse K stopped and said she was going to get the residents pain medication before proceeding. When Nurse K was asked what she was going to administer she replied that (R9) had an order for morphine (a narcotic pain medication) every hour as needed (PRN). Nurse K was asked to be observed during administration and the dressing care of the T-sponge to observe the ostomy site. Nurse K retrieved the narcotic medication from the Narcotic wall box on the unit and brought it to the room in an oral medication syringe the tip was placed inside a medication cup.Once back at the resident's room, Nurse K prepared the water flush and stopped the Tube feed and flushed the line. Nurse K had donned gloves and no other PPE. Nurse K pulled back R9's blanket back and lifted R9's gown and moved the residents hand out of the way of the peg tube. Nurse K was queried if the resident had any precautions and she said, yes that R9 had EBP. Nurse K was further queried if she had all the PPE she needed and she stated, oh I thought this was ok. Nurse K was asked if she had read the sign on R9's door about EBP's. Nurse K went out and looked at the door and then donned a gown got new gloves and said she said I am sorry I wasn't thinking I needed a gown. Nurse K proceeded with ostomy site care and changed the T-sponge, R9's site was unremarkable.Nurse K the prepared to administer the medication via R9's Peg tube, no barrier was used to cover the bedside table where Nurse K placed the supplies. Nurse K removed the uncapped morphine syringe from the medication cup and place it directly onto the bedside table. Nurse K connected the 60 ml syringe to the residents uncapped tube and free flushed the line, Nurse K picked up the morphine syringe and administered it to R9 via the 60 ml flush syringe. Nurse K flushed the line with water again and recapped the tube. A record review of R9's Kardex bedside care plan revealed: Resident care: enhanced barrier precautions as directed. This includes gowns and gloves for high-contact resident care activities. Eating and nutrition: Provide diet per physician order; NPO -Provide Supplement as ordered. A record review of R9's orders revealed: Enhanced Barrier Precautions as directed. This includes gowns and gloves for high-contact resident care activities. Specify why: foley, peg tube, wound. NPO (nothing by mouth) diet, NPO texture, NPO consistency. Cleanse PEG tube site once daily with NS. Pat dry and apply clean T drain sponge. Monitor for signs and symptoms of infection. Morphine Sulfate (Concentrate) Oral Solution 20MG/ML (Morphine Sulfate) Give 0.25 ml via PEG. A record review of the facilities policy titled Enhanced Barrier Precautions policy and procedure revealed: Definition: Enhanced Barrier Precautions: Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. High-Contact Resident Care Activities include: Dressing Bathing/showering Transferring Providing hygiene Changing linens Changing briefs or assisting with toileting Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator Wound care: any skin opening requiring a dressing. The policy listed Key points as: Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs.Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities.EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following:Wounds or indwelling medical devices, regardless of MDRO colonization status.Infection or colonization with a CDC targeted MDRO.Effective implementation of EBP requires staff training on the proper use of personalprotective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care. A review of the procedure reveals the facility will.: 3 a. Identify residents who may require EBPi. Residents with an indwelling medical device or wound (regardless of MDRO colonization or infection status).ii. Residents currently infected or colonized with a CDC targeted MDRO.b. Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves)c. For Enhanced Barrier Precautions, signage should also clearly indicate high contact resident care activities that require the use of gown and glovesd. Make PPE, including gowns and gloves, readily available. and g. Incorporate periodic monitoring and assessment of adherence to recommended infection prevention practices, such as hand hygiene and PPE use, to determine the need for additional training and education. A record review of the facilities policy titled medication administration general guidelines reveals: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility patient distribution system (procurement, storage, handling and administration). The facility has sufficient staff and medication distribution system to ensure safe administration of medications without unnecessary interruptions.

Based on observation, interview and record review, the facility failed to ensure dignity for 4 residents (Resident's #66, #73, #68, and #281) and 5 of 7 confidential Resident Council group meeting (held on 12/10/24) residents, regarding call lights within reach and the timely answering of the call lights. Findings Include: Resident #73: Review of the Face Sheet, care plans dated 10/29/24, nursing note's dated 11/24 through 12/10/24, and physician orders dated 12/24, revealed Resident #73 was [AGE] years-old, alert with memory deficient and confusion, and had a feeding tube; he was admitted to the facility on [DATE]. The resident was an 1 person assist with 2 persons for walker, and he has a history of falls at the facility and respiratory impairments with oxygen dependency. The resident's diagnosis includes, stroke, Aphasia (communication deficit), hemiplegia, hemiparesis with left sided weakness, Dysphagia (swallowing deficit), chronic respiratory failure, diabetes, congestive heart failure, Dementia, memory deficit, major depression, pneumonia, and dependent on oxygen. Observation was made on 12/9/24 at 11:14 a.m., of residents call light hanging over the breathing machines black tubing on the dresser next to the residents bed, When this surveyor asked him if he knew were his call light was and could he reach it, he could not find it and when location pointed out, he was not able to reach it. At the time the resident was sitting in his recliner chair. Confidential Resident Council group meeting: During the confidential Resident Council group meeting that was held on 12/10/24 at 10:07 a.m., 5 of 7 alert resident's verbally complained of staff taking an excessive amount to time to answer call lights on second shift primarily. One alert confidential resident stated I soiled myself because it took them (staff) over an hour to answer my light. Another confidential resident stated I had 2 aides this morning (on 12/20/24, first shift) come in my room and they were talking to each other and I did not get dressed, had to go to breakfast not dressed. A resident stated They (staff) talk on their phones in my room. 3 of 7 resident's revealed they had accident's because staff would not answer their call lights timely. Review of the facility Dignity policy dated 10/2009, stated Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individually. Treated with Dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Promptly responding to the resident's request for toileting assistance. Review of the facility Call Light policy dated 11/2019, stated Be sure the call light is within easy reach of the resident; answer the resident's call as soon as possible, 37668 Resident #66: On 12/10/24 at 3:11 PM, while walking down the hallway in the facility with Unit Manager Registered Nurse (RN) U, a visitor was observed standing in the center hub area of the hallway near the 600-hallway entrance. The visitor was loudly requesting staff assistance and stated, Who's (Resident #66's) aide? Several staff were observed standing on the other side of the hub area of the hallway talking to each other. The staff did not respond to the visitor. Unit Manager RN U got the staff attention and asked who (Resident #66's) aide was. One of the staff standing in the hub replied, Not me, I just got here. None of the staff who were standing in the hub area went to assist the visitor. The Visitor then loudly stated, (Resident #66's) been in the bathroom for 16 minutes and I had to help put her on the toilet. Is there no body working down here? A corporate clinical staff went to assist the visitor at this time. RN U was queried why the staff standing in the hub had not assisted the visitor/Resident and an explanation was not provided. Record review revealed Resident #66 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, dementia, cerebral infarction (stroke), and lower extremity fractures. Review of the MDS assessment dated [DATE] revealed the Resident was severely cognitively impaired and required substantial/maximum assistance to complete toileting hygiene. Review of Resident #66's Electronic Medical Record (EMR) revealed a care plan entitled, Risk for falls r/t left ankle fracture, neck muscle strain, fall . (Initiated: 1/25/24; Revised: 8/2/24) included the intervention, Transfers: 2PA (Person Assist) with 2WW (Wheeled walker) WBAT (Weight Bearing As Tolerated); Ambulation: Non-ambulatory (Initiated: 1/25/24; Revised: 8/2/24). 49944 Resident #68 (R68): R68 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include a femur fracture, falls, type two diabetes and benign prostatic hyperplasia (BPH). R68 has a brief interview for mental status (BIMS) score of 12, indicating moderate cognitive impairment. On 12/09/24 at 01:38 PM, an interview was conducted with R68. R68 was asked if their call light is in reach and if the staff answers it in a timely fashion. R68 stated the call light is in reach at all times. R68 stated that they don't use the call light a lot, but they are really slow to answer when they do use it. Resident #281 (R281): R281 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include pulmonary embolism, chronic obstructive pulmonary disease, congestive heart failure and depression. On 12/09/24 at 11:35 AM, an interview was conducted with R281. R281 was asked if their call light is in reach and if the staff answer it timely. R281 stated the call light is always in reach, sometimes they might answer in 20 minutes or it might be 12 hours. R281 stated you never really know how long it will be, but it is a long time.

Based on observation, interview and record review, the facility failed to ensure that the medication error rate was less than 5% when six medication errors were observed from a total of 29 opportunities for three residents (#'s 28, 34, and 288) of six residents reviewed. This deficient practice resulted in a medication error rate of 20.69% and the potential for adverse medication effects and decreased medication efficacy. Findings include: Resident #34: On 12/11/24 at 7:52 AM, medication pass observation for Resident #34 was completed with Licensed Practical Nurse (LPN) O. Upon entering Resident #34's room, a breakfast food tray with all food eaten was observed in the room. LPN O was observed checking the Resident's blood glucose level at the bedside. The blood glucose level result was 428. LPN O reviewed the Resident's Medication Administration Record (MAR) and verbalized the Resident needed 10 units of insulin based on the blood glucose level. The MAR showed Resident #34 had a documented blood glucose level of 254 on 12/11/24 at 5:19 AM. LPN O obtained the Resident's Insulin Aspart (short acting insulin) pen, set it to administer 10 units of insulin without priming the pen, and prepped the skin with an alcohol pad. Prior to administering the insulin, LPN O was stopped. When asked if they had primed the insulin pen, LPN O responded, No. LPN O then primed the insulin pen and reset the pen to administer 10 units of insulin. LPN O administered the insulin into the Resident's left abdomen and held the pen in place for four seconds prior to removing from the skin. Review of Resident #34's Health Care Provider Orders and MAR was completed with LPN O following medication administration. The MAR revealed: - NovoLOG Injection Solution 100 unit/mL (Insulin Aspart) Inject as per sliding scale . subcutaneously before meals and at bedtime (Start Date: 12/10/24) Resident #288: A medication pass observation for Resident #288 was completed with LPN O on 12/11/24 at 8:36 AM. LPN O was observed preparing a Lidocaine 4% and Menthol 1% topical patch for administration by writing their initials and date on the patch. When LPN O lifted the Resident's shirt to place the patch on the Resident's back, the prior patch was observed on the Resident's back. The prior patch was not fully adhered to the Resident's skin and was dated 12/11/24 with no initials. LPN O removed the prior patch and placed the new patch. LPN O was then observed handing Resident #288 a Symbicort inhaler (inhaled medication used to treat asthma and chronic obstructive pulmonary disease [COPD]) for the Resident to self-administer. After inhaling two puffs of the medication, Resident #288 handed the inhaler back to LPN O. LPN O did not assist and/or instruct the Resident to rinse their mouth following administration of Symbicort. Review of Resident #288's Health Care Provider Orders and MAR was completed with LPN O following medication administration. The MAR revealed: - Lidocaine External Patch 4% . Apply to back topically one time a day for pain and remove per schedule (Start: 12/4/24). The MAR detailed the patch was to be applied at 8:00 AM and removed at 8:00 PM. Per the MAR, the patch was removed on 12/10/24 at 8:00 PM and LPN O applied the patch on 12/11/24 during the medication pass observation. - Symbicort Inhalation Aerosol 160-4.5 mcg (micrograms)/Act (actuation) 2 puff inhale orally two times a day. Oral rinse and spit after medication administration (Start: 12/3/24) When queried regarding the patch they removed from Resident #288's back, LPN O verbalized it was a Lidocaine patch. With further inquiry, LPN O revealed the patch was supposed to have been removed the prior night. LPN O confirmed the patch was dated 12/11/24 and indicated the staff who applied the patch on the previous day must have written the wrong date on the patch. When queried why they administered a Lidocaine 4% with Menthol 1% patch when the order was for a Lidocaine 4% patch with no menthol, LPN O revealed the facility did not have plain Lidocaine 4% patches. When queried what Resident #288 was supposed to receive per their order, LPN O verbalized the Resident's order was for Lidocaine only. When queried regarding rinsing and spitting following Symbicort administration, LPN O confirmed they did not instruct/assist the Resident to rinse and spit following administration. LPN O was then queried how long an insulin pen should be held in place during administration and replied, 10 seconds. When asked if they knew how long they held the insulin pen in place during administration for Resident #34, LPN O revealed they were not sure. When asked why they only held the insulin pen in place for four seconds and did not prime the pen prior to being stopped by this surveyor, LPN O responded that they were nervous. When queried why Resident #28's blood glucose was checked and insulin administered after they already ate their breakfast, LPN O revealed they did not have an opportunity to check the Resident's blood glucose previously because they were assisting to pass breakfast trays. Resident #28: On 12/11/24 at 9:12 AM, a medication pass observation was completed with Registered Nurse (RN) P for Resident #28. RN P administered one drop of Dorzolamide HCI 2% Ophthalmic Solution (medication used to treat increased pressure in the eye) into the Resident's right eye at 9:13 AM. RN P immediately proceeded to administer one drop of Prednisolone Acetate 1% Ophthalmic (medication used to reduce inflammation in the eye) solution into the Resident's right eye at 9:13 AM. Directly after, RN P administered 1 drop of Brimonidine Tartrate 0.2% ophthalmic solution (medication used to reduce pressure in the eye) into Resident #28's right eye directly. RN P did not apply pressure to the tear duct and/or instruct the Resident to close their eyes following administration of any of the three eye drop medications. An interview was completed with RN P after exiting Resident #28's room. When queried if different medication eye drops are supposed to be administered back-to-back, RN P replied, They are all scheduled for the same time (on the MAR). RN P was queried regarding procedure and technique for eye medication administration, RN P did not provide further explanation. An interview was completed with Clinical RN F on 12/11/24 at 11:23 AM. When queried regarding administration of different eye drop medications, RN F stated, Have to wait between different eye drop medication administration. RN F verbalized they heard about that and would address with education. When queried what should occur following administration of Symbicort inhaler, RN F stated, Rinse and spit. RN F was informed of observation of Resident #288 not being instructed/assisted to rinse and spit following administration of Symbicort, RN F verbalized understanding of error. When queried if insulin pens have to be primed prior to administration, RN F confirmed they did. When asked how long insulin pens have to be held in place to ensure administration of intended dose, RN F verbalized insulin pens needed to be held in the skin for 10 seconds. When queried regarding observation of insulin pen not being primed and being held in place for four seconds, RN F verbalized understanding. RN F revealed the staff needed and would receive education. Review of facility policy/procedure entitled, Specific Medication Administration Procedures . Eye Drop Administration (Dated: 9/1/23) revealed, To administer ophthalmic solution/suspension into the eye in a safe, accurate, and effective manner . Procedures . H. Instruct resident to close eyes slowly to allow for even distribution over surface of the eye . should also refrain from blinking or squeezing eyes shut. I. While the eye is close, use one finger to compress the tear duct in the inner corner of the eye for 1-2 minutes . Alternately, the resident may keep his/her eyes closed for approximately three minutes . K. If another dop of the same or different medication is prescribed for administration in the same eye at the same time, wait 10 minutes, then repeat procedure . Upon request for a policy/procedure related to insulin pen administration, a policy/procedure entitled, Specific Medication Administration Procedures . Injectable Medication Administration (Dated: 9/1/23) did not include insulin pen administration.

Based on observation and interview, the facility failed to implement and operationalize policies and procedures to ensure appropriate labeling, storage, and disposal of medications and medical supplies, per professional standards of practice for two of two medication storage rooms in the 400 hallway and in two residents' rooms, resulting in medications left unattended and unsecured, lack of dating of medications with a shortened expiration date after opening, storage of contaminated medications and medical supplies with new medications and medical supplies. Findings include: On [DATE] at 1:45 PM, an interview was completed with Registered Nurse (RN) Q. When queried regarding storage of resident controlled and narcotic medications, RN Q revealed all controlled substances are stored in a locked cabinet at the front of the hall, near the center hub. An observation and tour of the 500-hall narcotic locked storage wall box was completed with RN Q at this time. Upon opening the wall box, two oral medication syringes were observed on the top shelf. There was a pink colored substance present in end of the syringe. When queried if the syringes had been used, RN Q responded they were, and that staff will sometimes use the oral syringe again as it is for a hospice resident who is frequently receiving liquid morphine. RN Q was asked if the facility did not have an adequate supply of oral syringes to use a new one for each medication administration and indicated they did. RN Q proceeded to dispose of the two used syringes. When queried regarding infection control considerations, due to multiple resident medications being contained in the narcotic cabinet, RN Q did not provide an explanation. A tour of the 500 and 600 Hall Medication Storage Room was completed with RN Q on [DATE] at 2:04 PM. The following items were present in the medication storage room: - A vial of CoaguChek XS PT Test strips was noted to be open - Seven Addipak 5 mL containers of 0.9% sterile saline solution, Expired ,d+[DATE] - Open 8 fluid ounce (fl. oz.) container of Iodine. The top of the container was visibly soiled with dark brown colored, crusted material. A tour of the Main (400 hall) medication room was completed with Unit Manager RN R. A box of call bells and an empty plastic container were noted in the cabinet under the sink. When queried regarding storage of items under the sink, RN R stated nothing should be stored under the sink. The following items were observed: - Open and undated vial of Tuberculin purified protein it 5 TU (Tuberculin Unit)/ 0.1 mL testing solution Multiple open and undated bottles of over-the counter medications were present in the medication room. When queried regarding facility policy/procedure related to dating and storage of over-the-counter medications, RN R revealed over the counter (OTC) medications are not dated when opened and the manufacturer expiration date is used. When asked if opened OTC medications are supposed to be stored in the medication room, RN R stated, No. They are in the in-room med cabinets. You can't but them back (in med room). That's gross. When queried regarding the open OTC medications in the medication room, RN R stated, I'm so upset because we have trained them (nursing staff) to not put med's back and to send them home with the resident. When asked about the training which had been completed, RN R revealed facility staff had received training to not return medications to the med room previously because of prior concerns. On [DATE] at 4:10 PM, RN R indicated they wanted to discuss the open medications in the medication room and an interview was completed. RN R stated, I was told they pulled them (open OTC med's) from the hall cabinets. When queried who told them that, RN R verbalized they were informed by facility corporate staff. RN R was asked what hall cabinets they were referring to and revealed there are in wall locked cabinets in each the open room/cubby on each hall which are no longer used. With further inquiry, RN R stated, We shut those down a year ago. I didn't think anyone was still using them. When asked what medications were removed from the hallway cabinets, RN R revealed they did not know. When asked if there was a list, RN R stated there was not. When queried if some of the open medications may have been from resident in room cabinets, as there was not a list and/or documentation of the medications removed from in hall cabinets, RN R confirmed but did not provide further explanation. A policy/procedure related to all medication storage including testing equipment and vaccine solutions was requested from the facility Administrator on [DATE] at 10:46 AM but not received by the conclusion of the survey. 49944 Resident #34 (R34): R34 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include acute kidney failure, major depressive disorder, paraplegia and hypertension. R34 has a brief interview for mental status (BIMS) score of 6, indicating severe cognitive impairment. On [DATE] at 11:05 AM, a bottle of iodine was observed sitting on the dresser of R34. R34 was asked if they knew why the bottle of iodine was sitting out in the room. R34 stated it didn't belong to them and they are not sure how it got there. This surveyor located the nurse that was working on the hall and had them come to R34's room. Licensed Practical Nurse (LPN) N was asked if the iodine should be locked up in a secure medicine cabinet and not left out in the room. LPN N stated, yes it should be. LPN N stated they did not know why the iodine was left out, but that the night nurse must've left it in there after wound care from the previous shift. LPN N placed the iodine in a secure medicine cabinet in the room.

Based on interview and record review, the facility failed to ensure that two resident's (Resident's #28, and #55) care plans were updated and individualized, resulting in the potential for unsupervised outdoor activity, falls, and not meeting residents' needs. Findings Include: Resident #28: Review of the Face Sheet, fall report dated 1/22/24, nurse's note's dated 6/24 through 12/10/24, and care plans dated 10/23, revealed Resident #28 was [AGE] years old, alert with confusion, admitted to the facility on [DATE], had an extensive history of falls at the facility and required staff assistance with all Activities of Daily Living, and transfers. The resident's diagnosis included vascular dementia with cognitive, cancer of breast and uterine, and undergoing treatment, intracerebral bleed, malnutrition, chronic lung disease and dependent on oxygen, cystic disease of liver, chronic pain, anemia (low iron), back fracture, osteoporosis, osteoarthritis, muscle wasting, major depression, adjustment disorder, anxiety disorder, limited activities due to disability and double vision wearing an eye patch which limited vision field. On 3/16/24, the resident tipped over her wheelchair outside while alone on the sidewalk and was hospitalized with a left hip fracture. Review of the hospital emergency room note dated 3/16/24, stated She was using her wheelchair to go outside when she caught her wheel on something resulting in her wheelchair flipping, causing her to land on her left side; at this time, she endorses left hip pain. Hip is shortened and extremely rotated. X-ray of the left hip, there is a displaced intertrochanteric femur fracture. The resident was admitted to the hospital for treatment. Review of the nursing notes, Incident Report and resident statement dated 3/16/24, revealed the resident went outside to smoke without supervision, fell on the ground in the parking lot off the curb and was found by a visitor walking in the parking lot. Review of the facility Occupational Therapy Evaluation notes dated 3/21/24, stated Functional Cognition=Needed Some Help, Mobility Performance Raw Score=4 (Poor mobility). Review of the facility Physical Therapy Evaluation notes dated 1/23/24, stated Eye patch R (right) eye due to double vision, fall risk, no ambulation due to risk for fx (fracture). During an interview done on 12/10/24 at 2:00 p.m., Occupational Therapist/Rehab Manager L stated She (Resident #28) needs to be kept an eye on; given her history of fall's she should not be outside by herself. She has poor mobility, that includes wheelchair, a very low functional mobility. During an interview done on 12/10/24 at 2:10 p.m., Administrative Assistant K who is at the front desk during first shift, stated She (Resident #28) can go outside, she is her own person. Review of all facility care plans dated 11/9/22 through 11/13/24, including the Risk for Falls (dated 11/9/22) revealed no documentation of Resident #28 requiring assistance or supervision when going outside the facility. Review of the Cognitive loss care plan dated 11/13/24, stated CVA (stroke), vascular dementia, BIMS (cognitive assessment tool) score 3/13 (decreased cognitive score). After the incident on 3/16/24, no intervention was added regarding supervision or visualization while outside the facility with no family member with her. During an interview done on 12/10/24 at 3:15 p.m., MDS Coordinator G and this surveyor went through all of the resident's care plans together and no documentation of supervision while outside was found. MDS Coordinator G stated When she came back (from the hospital after her fall outside on 3/16/24), when she was readmitted we should have caught it in the morning meeting, I am going to change the care plan. Review of the facility Comprehensive Care Plans policy dated 2001, stated As individualized comprehensive care plan that includes measurable objectives and timelines to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. 22348 Resident # 55 (R55): R55 was [AGE] years old, admitted to the facility on 4//26/24 with the diagnosis of Chronic Diastolic Congested Heart Failure (CHF), Severe Morbid Obesity, Chronic Obstructive Pulmonary Disease, Acute Respiratory Failure with hypoxia in addition to other diagnoses. R55's Minimum Data Set (MDS), dated [DATE], revealed a BIMS (Brief Interview for Mental Status) score of 13/15, which indicates that a person's cognition is intact. Section GG of the MDS, dated [DATE], revealed that R55 required Substantial/ Maximal assistance with the following activities: Toileting Hygiene, shower, and upper body dressing. However, the assessment dated [DATE] also revealed that R55 was dependent on lower body dressing, bed mobility, toilet transfers, and wheelchair ambulation. Dependent means that the helper does all of the effort to complete the task or activity. During a wound care observation on 12/10/24 at 1:45 PM, five nursing staff were inside R55's room to assist. R55 was found to have developed an excoriation on the folds that measured approximately 14 inches across her lower back from the left side to the right side of the lower lumbar area of R55's back. The area appeared extremely red, raw, raised, irritated, and tender to the touch. When NurseU was asked, he described the area as having MASD (Moisture-Associated Skin Damage) and was newly developed. Nurse U provided the standard treatment per facility skin care protocol. On 12/10/24 at approximately 2:10 PM, after the skin care observation, A review of R55's clinical record revealed no treatment, assessment, or updated care plan related to the lower back area skin impairment observed. It was a newly observed skin impairment. However, the following morning, on 12/11/24 at 10:30 AM, R55's clinical record revealed no nurse's notes indicating the skin assessment of the lower back skin excoriated MASD, no treatment entry from 12/10/24 was documented, and no physician order was documented for the lower back skin impairment. No updates in the care plan were found related to the lower back MASD. The following day, on 12/11/24 at 11:32 AM, R55's nurse's notes, skin/wound assessment, and treatment record (TAR) were reviewed. No documentation was found in the nurse's notes, and no updated skin assessments or treatment orders for the observed skin impairment were found on 12/10/24. The care plan was reviewed on 12/10/24 and 12/11/24, and no updates nor revisions of the lower back excoriation were found by the facility staff on 12/10/24. On 12/11/24 at 11:35 AM, CRN W and CRNX were queried regarding why there was no documentation of R55's lower back excoriated area observed on 12/10/24. CRN W and CRN X agreed that the observed skin impairments should have been documented. However. Both CRNW and CRN' X indicated that they thought the Nurse Manager (Nurse V) would do the documentation and stated: We will get them there. The Nurse Manager (Nurse V) was queried on 12//11/24 at 12:11 PM. She stated that I assumed Nurse U did the follow-up documentation because he did the assessment and provided the care that day. Nurse V revealed that she left the room before R55's skin evaluation on 12/10/24. Nurse U was queried on 12/22/24 at 1:30 PM. He did not explain why the assessment and treatment on 12/10/24 were not documented.

Based on observation, interview, and record review, the facility failed to ensure comprehensive skin care (assessments, treatment order, and documentation) for one resident (R#55) of 2 residents reviewed for skin and wound care of 41 total samples, resulting in the potential for severe pain, infection, and further delay in appropriate treatment. Findings include: Resident# 55 (R55): R55 was [AGE] years old, admitted to the facility on 4//26/24 with the diagnosis of Chronic Diastolic Congested Heart Failure (CHF), Severe Morbid Obesity, Chronic Obstructive Pulmonary Disease, Acute Respiratory Failure with hypoxia in addition to other diagnoses. R55's Minimum Data Set (MDS), dated [DATE], revealed a BIMS (Brief Interview for Mental Status) score of 13/15, which indicates that a person's cognition is intact. Section GG of the MDS, dated [DATE], revealed that R55 required Substantial/ Maximal assistance with the following activities: Toileting Hygiene, shower, and upper body dressing. However, the assessment dated [DATE] also revealed that R55 was dependent on lower body dressing, bed mobility, toilet transfers, and wheelchair ambulation. Dependent means that the helper does all of the effort to complete the task or activity. On 12/9/24 at approximately 12:15 PM, R55 was interviewed during an initial tour. R55 complained of pain and discomfort because her bed was too small and not comfortable. R55 indicated she had a sore but did not know how it looked because she could not see what the staff did behind her. Among her complaints was that her bed was too small, which caused her to limit her movement from side to side because she was afraid to fall out of bed. R55 explained that because of her limited movement, R55 indicated she developed a sore on her back and is currently receiving treatments. R55 revealed that she had complained about the bed being too small, but nothing had been done. She expressed difficulty with repositioning and was not comfortable. During a wound care observation on 12/10/24 at 1:45 PM, five nursing staff were inside R55's room to assist. The five staff members that were present consisted of one nurse (Nurse U), one (nursing assistant, one (1) nurse manager (NURSE V), and two (2) corporate clinical staff (CRN W and CRN X). The four positioned themselves on each side of the standard bed (42 inches), and the nurse manager (Nurse V) left the room. R55 was turned by staff from side to side to assess and provide treatment. R55 was found to have developed an excoriation on the folds that measured approximately 14 inches across her lower back from the left side to the right side of the lower lumbar area of R55's back. The area appeared extremely red, raw, raised, irritated, and tender to the touch. When NurseU was asked, he described the area as having MASD (Moisture-Associated Skin Damage) and was newly developed. Nurse U provided the standard treatment per facility skin care protocol. During the wound/skin care observation on 12/10/24 at 2:40 PM, Corporate Nurse 1 (CRN W) confirmed that R55 skin condition on the lower back was extremely red, painful, and raw that runs across her lumbar area of the back from one side to another. On 12/10/24 at approximately 2:10 PM, after the skin care observation, A review of R55's clinical record revealed no treatment, assessment, or updated care plan related to the lower back area skin impairment observed. It was a newly observed skin impairment. However, the following morning, on 12/11/24 at 10:30 AM, R55's clinical record revealed no nurse's notes indicating the skin assessment of the lower back skin excoriated MASD, no treatment entry from 12/10/24 was documented, and no physician order was documented for the lower back skin impairment. No updates in the care plan were found related to the lower back MASD. On 12/10/24 at 02:30 PM, the nurse manager was interviewed and stated a bariatric bed was available now, and we could switch it if R55 wanted it. We offered it to her before, but she refused it. When the nurse manager was queried whether she knew why R55 refused it, the nurse manager stated that she was in the smaller room and would be too tight for the bariatric bed and the Hoyer lift to fit. Now she is in a bigger room by herself. We have not offered it to her since she moved to a wider room. The following day, on 12/11/24 at 11:32 AM, R55's nurse's notes, skin/wound assessment, and treatment record (TAR) were reviewed. No documentation was found in the nurse's notes, and no updated skin assessments or treatment orders for the observed skin impairment were found on 12/10/24. The care plan was reviewed on 12/10/24 and 12/11/24, and no updates nor revisions of the lower back excoriation were found by the facility staff on 12/10/24. On 12/11/24 at 11:35 AM, CRN W and CRNX were queried regarding why there was no documentation of R55's lower back excoriated area observed on 12/10/24. CRN W and CRN X agreed that the observed skin impairments should have been documented. However. Both CRNW and CRN X indicated that they thought the Nurse Manager (Nurse V) would do the documentation and stated: We will get them there. The Nurse Manager (Nurse V) was queried on 12//11/24 at 12:11 PM. She stated that I assumed Nurse U did the follow-up documentation because he did the assessment and provided the care that day. Nurse V revealed that she left the room before R55's skin evaluation on 12/10/24. Nurse U was queried on 12/22/24 at 1:30 PM. He did not explain why the assessment and treatment on 12/10/24 were not documented. A written request sent to the administrator for the facility policy for Skin Care and Wound Management and Standing Orders on 12/11/24 at 8:57 AM. The facility did not provide the policy requested at the date and time of exit.

Based on observation, interview and record review, the facility failed to implement policies and procedures to mitigate risk of injury during wheelchair transport for one resident (Resident #45) of five residents reviewed for accidents resulting in the potential for injury. Findings include: Resident #45: On 12/11/24 at 1:30 PM, Resident #45 was observed being pushed down the hallway in a wheelchair by Certified Nursing Assistant (CNA) S. The wheelchair did not have footrests, and the Resident was attempting to hold their legs up. Resident #45's feet were observed getting closer to the floor the further they were pushed. An interview was completed with CNA S on 12/11/24 at 1:40 PM. When queried if they were pushing Resident #45 in the hallway without footrests, CNA S confirmed they were. CNA S was then asked about the facility policy/procedure related to pushing residents in wheelchairs without footrests and replied, We do. CNA S then stated, Not really supposed to but they (residents) want help and don't have footrests. With further inquiry, CNA S verbalized most residents do not have footrests available for their wheelchairs and will ask to be pushed in their wheelchair due to the size of the facility. CNA S stated they were surprised when they came to work at the facility because of the lack of wheelchair footrest availability and use when being pushed by staff. When asked why they were surprised, CNA S revealed it was a requirement at other facilities they had worked at because of resident safety. Record review revealed Resident #45 was admitted to the facility on [DATE] with diagnoses which included dementia, chronic kidney disease, hallucinations, and repeated falls. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required moderate assistance from staff to stand and transfer from a sitting position. Review of Resident #45's Electronic Medical Record (EMR) revealed the Resident fell seven times in the facility on 7/13/24, 8/11/24, 8/28/24, 9/1/24, 10/21/24, 11/4/24, and 12/5/24 and was a moderate risk for falls. Resident #45 had a care plan entitled, Risk for falls r/t (related to) dementia with behavioral disturbance . fall . (Initiated: 7/8/24; Revised: 10/24/24). The care plan included the intervention, Transfer/Ambulation: 1 PA (Person Assist) with 2ww (wheeled walker); WBAT (Weight Bearing As Tolerated) (Initiated: 7/8/24, Revised: 9/26/24). Resident #45 did not have a care plan in place pertaining to footrest use while being pushed in a wheelchair by staff. An interview was completed with Clinical Registered Nurse (RN) F on 12/11/24 at 1:55 PM. When queried regarding facility policy/procedure related to pushing residents in wheelchairs without footrests, RN F revealed the need for footrests while being pushed was based on each individual resident. When queried if the facility had a policy/procedure related to wheelchair mobility and foot pedal use, RN F replied, No. A policy/procedure pertaining to wheelchair transport of residents was requested from the facility Administrator on 12/11/24 at 1:50 PM but not received by the conclusion of the survey.

Based on interview and record review the facility failed to ensure that a physician's order was in place for indwelling catheter changes and that the indwelling catheter changes were documented for one resident (R69) of one resident reviewed for catheters, resulting in the absence of a physician's order for indwelling catheter changes and the absence of documentation of indwelling catheter changes. Findings include: Resident #69 (R69): R69 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include kidney failure, depression, hypertension and encounter for surgical aftercare following surgery on the genitourinary system. On 12/10/24 at 03:37 PM, record review revealed that there was a care plan in place for the use of the catheter, an order is present to care for the catheter every shift with the size of the catheter and catheter balloon size. There was no order present for intervals for changing the catheter. On 12/10/24 at 03:50 PM, R69 was asked when the last time their catheter had been changed. R69 stated that they believed the catheter was changed last week. R69 stated they were in the therapy gym and the staff noticed the catheter was leaking. R69 stated they were returned to their room and had the catheter changed. On 12/11/24 at 09:20 AM, record review revealed there was no documentation present in the electronic medical record (EMR) to indicate the catheter had been changed. On 12/11/24 at 09:34 AM, an interview was conducted with registered nurse (RN) F. RN F was asked if there should be a physician's order to change catheters in the EMR and should the nursing staff document when a catheter had to be changed, if it was necessary to change the catheter. RN F stated that at minimum, there should be an as needed order to change the catheter. RN F also stated, yes, there should be a progress note or an area to document that the catheter has been changed if it was needed and why it had to be changed. Review of the policy titled, Catheter Care, Urinary, revised October 2010 revealed: Changing Catheters: 1. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change the catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. Documentation: 1. The date and time that catheter care was given. 2. The name and title of the individuals giving the catheter care. 3. All assessment data obtained when giving catheter care. 4. Character of urine such as color, clarity and odor. 5. Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain. 6. Any problems or complaints made by the resident related to the procedure. 7. How the resident tolerated the procedure. 8. If the resident refused the procedure, the reason(s) why and the intervention taken. 9. The signature and titled of the person recording the data.

Based on interview and record review the facility failed to enter a physician's order timely for dialysis perma-cath care and follow a physician's order to complete dialysis documentation for one resident (R289) of one resident reviewed for dialysis care, resulting in incomplete and missing dialysis record forms and the absence of documentation of the dialysis perma-cath site being monitored. Findings include: Resident #289 (R289): R289 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include, acute kidney failure, chronic kidney disease, congestive heart failure and dependence on renal dialysis. R289 has brief interview for mental status (BIMS) score of 14, indicating that R289 is cognitively intact. On 12/09/24 at 03:27 PM, record review revealed that R289 attends dialysis at [NAME] Davita on Tuesdays, Thursdays and Saturdays with a chair time of 02:15 PM. On 12/10/24 at 01:48 PM, record review revealed a physician's order to monitor the dialysis perma-cath to the right chest wall every shift. The order was entered on 12/09/24 at 14:14 PM. R289 admitted to the facility on [DATE] and R289 attended dialysis on 12/05/24 and 12/07/24 prior to order entry. On 12/10/24 at 01:51 PM, record review revealed a physician's order to complete the Wellbridge Dialysis Assessment, the top portion of the form is to be completed and sent with the guest to Davita [NAME] Dialysis, upon returning, fill out the bottom portion under the assessment, sign and lock. The order is dated 12/04/24. On 12/10/24 at 01:54 PM, record review revealed that a Wellbridge Dialysis Assessment was started on 12/05/24 at 09:45 AM and was incomplete on the bottom of the form, not signed or locked. There was no evidence of a form from 12/07/24 when R289 would have attended dialysis as well. On 12/10/24 at 01:57 PM, an interview was conducted with Infection Control Nurse (IC) M. IC M was asked if R289 should have had the Wellbridge Dialysis Form completed for 12/05/24 and 12/07/24. IC M stated, yes, R289 should have had both been completed. IC M was asked if R289 should have had a physician's order to monitor the dialysis perma-cath site prior to 12/09/24, after already receiving dialysis. IC M stated, yes, the order should have been entered and was missed. Record review of the policy titled, End-Stage Renal Disease, Care of a Resident with, revealed: Scope of Training: 2. Education and training of staff includes, specifically: a. The nature and clinical management of End Stage Renal Disease (ESRD) (including infection prevention and nutritional needs) b. The type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis. c. Signs and symptoms of worsening condition and/or complications of ESRD. d. How to recognize and intervene in medical emergencies such as hemorrhages and septic infections. e. How to recognize and manage equipment failure or complications (according to the type of equipment used in the facility) f. Timing and administration of medications, particularly those before and after dialysis: g. The care of grafts and fistulas: and h. The handling of waste.

Based on observation, interview and record review, the facility failed to 1) Maintain food preparation and kitchen equipment in a sanitary and good working condition, and 2) Ensure proper maintenance of kitchen equipment (dishwasher), resulting in an increased likelihood for food borne illness with hospitalization , and cross contamination affecting 81 residents who consumed oral nutrition from the facility kitchen of a total census of 82 residents. Findings Include: Review of the Public Health Service 2009 Food Code, adopted by the Michigan Food Law, effective October 1, 2012, Chapter 4-501.14 directs that equipment cleaning frequency is to be throughout the day at frequency necessary to prevent recontamination of equipment and utensils. On 12/9/24 at 10:05 a.m., during the initial tour of the kitchen accompanied by Culinary Specialist H and Executive Chief I, the following was observed: -At 10:07 a.m., the inside door of the ice machine was found to have a build-up of calcium-like hard white substance coating the door gasket on the left side, directly over the ice when the door was shut. Review of the Service Invoice dated 10/25/24, revealed the facility identified the ice machine door gasket concern and had ordered new ones; however, the ice machine door gasket was still a concern on 12/9/24. -At 10:09 a.m., two clean and ready for use knifes were found in the knife rack with dried on food particles on the blades. -At 10:15 a.m., four clean and ready for use silver metal pans were found on the clean pan rack with water inside and dried food particles inside. The pans were stacked inside of one another. Chief I immediately removed them and directed staff to re-wash them and stated, they should not be wet. Review of the handwritten Employee Corrective Action sheet dated 12/9/24, stated It is expected that pans are dry before being stacked and put on shelves. Review of the facility kitchen education given on 12/9/24 at 11:45 a.m., revealed staff were inservice on wet nesting, the practice of stacking wet dishes, pots or pans on top of each other, which prevents them from drying and can lead to the growth of microorganisms. -At 10:25 a.m., in front of the dishwasher was observed an excessive amount of standing water on the floor. Culinary Specialist H took a large squeegee and push the water toward the drain under the dishwasher. When requested to turn the dishwasher on, a constant dripping/leaking was noted under the dishwasher from the drain trap. During an interview done on 12/9/24 at 10:28 a.m., Dietary Aide J stated Sometimes it leaks all over, bothers me. -At 10:35 a.m., a large silver spatula was observed in with clean silverware, and it had dried on food particles on it. During an interview done on 12/11/24 at approximately 10:15 a.m., the cooperate Infection Control Consultant A was asked if the facility Infection Control Nurse toured the kitchen and she stated, I totally trust my staff, I one hundred percent trust my staff: Infection Control Consultant A said she did have Infection Control nurse do the walk through in the kitchen. During an interview done on 12/11/24 at approximately 2:10 p.m., the facility Infection Control Nurse M was asked if she was shown or given directions on how to do a kitchen infection control tour, and she stated, I didn't get shown what to look for. Infection Control Nurse M was new to the role of Infection Control at the facility. Review of the facility Interdepartmental Infection Control Rounds sheets dated 9/24, 10/24, and 11/24, revealed no documentation (check list questions) of dishwasher, nor ice machine.

Based on observation, interview and record review, the facility failed to implement and ensure hand hygiene per professional standards of practice during medication administration for two residents (#32 and #48) of six residents reviewed during medication pass observation resulting in the potential for cross contamination and spread of microorganisms. Findings include: A medication pass observation for Resident #32 was completed with Registered Nurse (RN) Q on 12/10/24 at 1:50 PM. RN Q did not perform hand hygiene prior to entering Resident #32's room and/or preparing the Resident's medications. Following completion of medication pass administration, RN Q exited Resident #32's room without completing hand hygiene. RN Q did not complete hand hygiene prior to entering Resident #48's room at 2:00 PM on 12/10/24. RN Q was observed obtaining Resident #48's medications from the in-room medication cabinet and then administering the medications without performing hand hygiene. An interview was completed with Clinical RN F on 12/11/24 at 11:23 AM. When queried regarding hand hygiene prior to and after medication administration, RN F stated, They (staff) should do their hand hygiene. RN F was informed of observations of RN Q not performing hand hygiene and confirmed hand hygiene should have been completed. Review of facility policy/procedure entitled, Preparation and General Guidelines . Medication Administration . (Dated: 9/1/23) revealed, Procedures: A. Preparation . Handwashing and hand Sanitization. The person administering medications adheres to good hand hygiene which includes washing hands thoroughly: - before beginning a medication pass, - prior to handling any medication, - after coming into direct contact with a resident, - before and after administration .

This Citation pertains to Intake Numbers MI00146582, MI00146860, and MI00147441. Based on observation, interview and record review, the facility failed to ensure Residents were treated with respect and dignity by not ensuring call lights were in reach and answered timely, ensure respectable customer service and ensure the provision of Resident rights with care planning that included Resident representative input/awareness of resident's care, for Residents (#1, 3, 6, 7, 8, and 10) of eight reviewed for call lights, abuse, and resident rights, resulting in care needs not met timely, lack of Resident/resident representative awareness in Resident's received care, feelings of frustration and anger and the potential for unmet care needs and lack of psychosocial wellbeing. Findings include: Resident #1: A review of Resident #1's medical record revealed an admission into the facility on [DATE] with re-admission on [DATE] with diagnoses that included stroke, hemiplegia and hemiparesis following a stroke affecting the right dominant side, and gastro-esophageal reflux disease. A review of the Minimum Data Set (MDS) assessment revealed Brief Interview of Mental Status (BIMS) score of ,d+[DATE] that indicated intact cognition, and the Resident needed substantial/maximal assistance with toileting hygiene, bathing, lower body dressing, sit to stand mobility and bed to chair transfers. On [DATE] at 1:43 PM, an observation was made of Resident #1 lying in bed with the head of the bed elevated. The Resident was awake, answered questions and engaged in conversation. The Resident had a basin on the bedside table near her and inside the basin was an emesis bag. The Resident indicated she felt sick to her stomach like she was going to throw up. The Resident was asked if she had a call light in reach. The Resident stated, I can't find it. An observation was made of the call light at the top corner of the pillow with the push apparatus of the call light partially covered by the top corner of the pillow. The Resident reported she could not reach up there and could not see it. The Resident stated, It doesn't matter, they don't come to answer it. When asked to explain the Resident reported that it takes a long time or not at all and indicated she has had to wait longer than 30 minutes to have someone come or longer at times when used the call light. Resident #3: A review of Resident #3's medical record revealed an admission into the facility on [DATE] and re-admission on [DATE] with diagnoses that included heart failure, chronic respiratory failure, lymphedema and chronic pain. A review of the MDS dated [DATE] revealed the Resident had a BIMS score of ,d+[DATE] that indicated intact cognition and the Resident on admission needed partial/moderate assistance with toileting hygiene, bathing, upper and lower body dressing and with most mobility/transfers. On [DATE] at 2:50 PM, an observation was made of Resident #3 sitting in a wheelchair in his room. The Resident was asked about any issues regarding care at the facility. The Resident reported attitudes of aides. When asked to explain the Resident reported that some of the aides had bad attitudes when they come in to assist the Resident and stated, not very nice to you. The Resident reported call lights not answered timely, and indicated he could get himself to the toilet but needed help with hygiene and getting off the toilet. The Resident reported an aide came in over the weekend to answer the light and stated, she came in and said she was busy and left. The Resident said she didn't come back, and he had to put the light on again. The Resident reported he gave up on having them answer the call light quickly and reported he just started to yell out for help. The Resident stated, They leave me on the toilet too long and my legs go to sleep, legs hurt when left there and Can't stand on them then when getting off the toilet. The Resident stated, they shut it off, ask what I want, leave again and I have to put it back on. The Resident reported having to wait for 30 minutes or more when in the bathroom and ends up yelling out for help. The Resident stated, Biggest issue, damn call light not answered! A review of the document Resident Grievance/Complaint Form for Resident #3 revealed date on ,d+[DATE], Date the incident occurred: during stay, Describe the nature of the grievance/complaint (be specific): Call light times, Document the actions taken to remedy the situation. Call light answered, Investigation Summary: Cena (Certified Nursing assistant) and nurse educated on timely responses needed. Resident #6: A review of Resident #6's medical record revealed an admission into the facility on [DATE] with diagnoses that included aftercare following joint replacement surgery, erosive osteoarthritis and chronic obstructive pulmonary disease. A review of the MDS dated [DATE] revealed a BIMS score of ,d+[DATE] that indicated intact cognition, and the Resident needed partial/moderate assistance with toileting hygiene, bathing and personal hygiene, sit to stand and lying to sitting mobility and needed substantial/maximal assistance with lower body dressing, lying to sitting on side of bed and chair/bed to chair transfers. On [DATE] at 12:04 PM, an interview was conducted with Confidential Person (CP) G regarding Resident #6's care at the facility. The CP indicated the Resident had complained of the call light not answered timely, she would press the call light, and it took hours before staff would check on her or respond to her, and reported having incontinence, could not hold it, that long. The CP reported that a CNA (Certified Nursing Assistant) was verbally and physically abusive to Resident #6. The CP explained that a CNA had yelled in her face when she was getting up to the bathroom that she was taking too long and stated, She (Resident #6) had never had anyone yell at her like that before. The CP reported that the Resident had reported that a CNA had been physically abusive when she had grabbed her gown and stated, She kicked her out of her room and didn't want her touching her again. The CP reported the Resident had told her about the incident the next day. The CP reported she had tried to get a hold of someone at the Nursing home and had finally got to talk to the Social Worker, and had reported it to her. The CP reported the Resident did not want to stay there, that she didn't feel comfortable or safe. Confidential Person G reported that they had asked for a list of medications to see what the Resident was receiving, and one was not supplied. The CP reported that a care conference was held, and the family was to attend by phone due to living a distance away from the facility. The CP reported that the phone the facility was using kept dropping the call and stated, we were supposed to talk to the nurse, PT (physical therapist) and the social worker. The CP reported they missed the whole meeting and only talked to the social worker afterwards and stated, None of my questions got answered, and reported the Resident was in a lot of pain, was not progressing in therapy, and they did not know what medications were being given. The CP reported talking to the Resident about her medications who told the CP that she did not know what they were giving her and stated, She said they just tell me to take them. Confidential Person G reported that the Resident was to move to a different facility, but the new facility wanted the Resident to be evaluated at the hospital because they felt something was not right. The CP reported they requested the Resident go to the hospital where they found a fracture at the head of the femur and that was causing severe pain. The CP reported they found out at the hospital what medications the Resident was administered at the facility which included a medication the Resident had issues with bleeding when taken before. The CP reported had the facility given the list to the family or the Resident, they would have known that she had been taking the medication Celebrex (Celecoxib-a nonsteroidal anti-inflammatory drug used to treat pain) and reported the Resident had almost died before after taking that medication. The CP reported the Resident had to go for surgery to fix the fractured femur and could not take an anticoagulant due to developing GI (gastrointestinal) bleed and bleeding from the kidneys, and reported the Resident died from complications of bleeding in the bowel and a pulmonary embolism. A review of the facility document titled Resident Grievance/Complaint Form, for Resident #6, dated [DATE], revealed, Date the incident occurred: [DATE], Describe the nature of the grievance/complaint (be specific). Guest stated to SW (Social Worker) the Cena used her shirt to turn and/or reposition her in bed, Investigation Summary: Unable to educate Cena on the appropriate ways to reposition guests. Termed on [DATE] due to attendance. A review of progress notes for Resident #6 included the following: -Dated [DATE] at 7:29 PM, On [DATE] Care conference held with guest in room and teleconference with daughters. Therapy reported Wt (weight) bearing as tolerated. Mod A (moderate assistance) w(with)/transfers/bed mobility. Supervision w/UB (upper body) dressing and Mod A w/LB (lower body) dressing. SW (Social Worker) informed insurance determines length of stay and informed if not ready to dc (discharge) home options of paying privately . Family addressed some care issues and sw addressed with unit manager. Daughters at this point would like to transfer to facility in (name of town) as she was there in May ., author Social Worker F. -Dated [DATE] at 4:11 PM, Guest was discharged to9 (to) the hospital per guest request. Guest stated that her left ankle was in pain, and she needed to be sent out o (to) the hospital. Guest was scheduled to be discharged from facility today. All belongings, medications, and discharge instructions were given to guest before dismissal. On [DATE] at 11:30 AM, an interview was conducted with Social Worker F regarding concerns for Resident #6. The Resident was admitted into the facility on [DATE] and the care conference was held on [DATE]. The Social Worker reported that the initial care conferences were usually held within 48 hours after admission and depended on what was convenient with the Resident's representatives, but did not have documentation of why the care conference was set for the 28th. The Social Worker was asked what happened with the equipment failure during the care conference. The Social Worker reported issues with the phone she had been using and could not connect with the daughters for the care conference, reported she connected with them later and gave an update on what the Resident needed for assistance, managed care, determination of care, length of stay and appeal. When asked if the family requested a list of medication or if one had been given, the Social Worker did not remember giving a list of medications. Review of the medical record revealed no documentation that a list of medications had been given to the Resident or representative. The Social Worker reported they discussed the transfer to another facility. The Social Worker reported the daughter had discussed response of call light time and stated, not in a timely manner, I don't remember the length of time. The Social Worker reported the daughter reported care with how the CNA had handled her to transfer her. When asked if the daughter or Resident had talked about abuse physical and/or verbal, the Social Worked reported for the daughter it was a disappointment of the standard of care, the CNA had grabbed the top of her shirt and did not remember a discussion of verbal abuse. When asked if it was considered abuse, the Social Worker reported she was unsure and went to the Unit Manager at that time to share the information. The Social Worker reported it had upset the Resident and she did not want that CNA taking care of her. On [DATE] at 3:45 pm, an interview was conducted with Clinical Care Coordinator/Unit Manager, Nurse E regarding Resident #6. The Unit Manager reported she had talked to the guest regarding someone had grabbed her shirt to reposition her. The Unit Manager reported she had talked to the daughter who was upset, and the Unit Manager indicated she didn't think it was intentional. When asked if the daughter indicated abuse, the Unit Manager reported that she would have been on top of that, we don't hurt or disrespect people, treat them with dignity. When asked if the Resident was upset, the Unit Manager reported the Resident didn't know why the CNA had grabbed her like that. When asked if the daughter reported verbal abuse, the Unit Manager indicated she had not. Unit Manager, Nurse E was asked about call lights not answered timely. The Unit Manager reported call lights were to be answered within 10 minutes, they monitor how long call lights were on and reported that during meal pass they tend to be longer, trying to pass out food and at change of shifts and stated, I would expect no more than 15 minutes. The call lights not in reach during the initial tour of the facility was reviewed. The Unit Manager reported all call lights should be in reach for all residents. On [DATE] at 4:17 PM, an interview was conducted with the Unit Manager E regarding medication list being given to Resident #6 and to their Representative. The Unit Manager reported that they would have given the hospital discharge instructions back to the Resident that had the Celebrex listed as a new medication and reported they would reach out to the Resident of POA (power of attorney) for discrepancies if there were any. When asked how allergies were recorded, the Unit Manager reported that they would be taken from the hospital discharge records and indicated they don't ask about allergies but go off the hospital records. The Unit Manager reported the family could have reviewed the medications during the care conference, but the family was not able to be in the conference due to poor phone connection. Resident #7: A review of Resident #7's medical record revealed an admission into the facility on [DATE] with diagnoses that included stroke, dementia, anxiety disorder, contracture and gastrostomy status. A review of the MDS revealed a BIMS score of ,d+[DATE] that indicated severely impaired cognition, and the resident was dependent with activities of daily living and mobility. On [DATE] at 1:46 PM, an observation was made of Resident #7 lying in bed. The Resident was awake, moved her arms and had padding (used for contractures of the hands) inside her hands. The Resident did not engage in conversation. An observation was made of the Resident's call light hung on the bedframe of the bed with the call apparatus positioned under the mattress hanging towards the floor and not in reach for the Resident. Resident #8 A review of Resident #8's medical record revealed an admission into the facility on [DATE] and re-admission on [DATE] with diagnoses that included osteomyelitis of left ankle and foot, diabetes, chronic obstructive pulmonary disease, and anxiety disorder. A review of the Resident's MDS dated [DATE] revealed a BIMS score of ,d+[DATE] that indicated the Resident had intact cognition and the Resident needed partial/moderate assistance with toileting hygiene, upper and lower body dressing and needed substantial/maximal assistance with chair/bed to chair transfer, sit to stand and toilet transfer. A review of the facility document titled Resident Grievance/Complaint Form, for Resident #8, dated [DATE], revealed, Describe the nature of the grievance/complaint (be specific). Reported Cena enters room and says, what do you want, Document the actions taken to remedy the situation. Cena spoken to, Investigation Summary: staff termed for cursing @ (at) the ED (executive director) during conversation. On [DATE] at 9:35 AM, an observation was made of Resident #8 sitting in her wheelchair in her room. The Resident was interviewed, answered questions and engaged in conversation. The Resident was asked about the care she received. The Resident discussed some CNAs attitudes as being snotty and mean and stated, They don't have to like me, but they should be kind, and reported she had talked to the Social Worker about it. When asked about call light response times, the Resident reported having some issues with not answering the call light, having diarrhea and sitting too long with bowel movement and stated, I had skin breakdown in my lady parts. It was so painful, and reported more than 30 minutes or longer sometimes to have the call light answered. The Resident reported a Resident across the hall who yells for help, reported the resident will start screaming and people walk by and ignore her screaming, did not know if her call light was on or not, but she screams for a long time, yells her butt hurts and that she has to get off the toilet. On [DATE] at 11:30 AM, an interview was conducted with the Social Worker F regarding Resident #8's concern of how she was addressed by the CNA. The Social Worker reported Resident #8 had come to her with a few issues with some CNAs, the Resident had asked for some towels, they asked to take a minute, and she got upset with them. The Social Worker reported it was the approach, customer service. When asked if it was poor customer service, the Social Worker indicated yes and getting assistance with care. Resident #10: A review of Resident #10's medical record revealed an admission into the facility on [DATE] and re-admission on [DATE] with diagnoses that included senile degeneration of brain, dementia, anxiety disorder and repeated falls. A review the MDS dated [DATE] revealed a BIMS score of ,d+[DATE] that indicated severely impaired cognition, and the Resident was dependent with activities of daily living and mobility. On [DATE] at 1:46 PM, an observation was conducted of Resident #10 sleeping in bed. The call light cord was hanging straight down the wall between the wall and mattress and the call light apparatus was not in reach for the resident. A review of Resident #10's care plan revealed a focus for risk for falls with an intervention Clip call light to guest clothing while in bed, with revision on [DATE]. A review of facility policy titled, Resident Rights, revealed, Policy Statement: Employees shall treat all residents with kindness, respect, and dignity . 3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity . A review of facility policy titled, A review of facility policy titled, Answering the Call Light, revealed, Purpose: The purpose of this procedure is to respond to the resident's requests and needs . 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident . 8. Answer the resident's call as soon as possible. 9. Be courteous in answering the resident's call . 49944 On [DATE] at 9:46am medication administration was observed with LPN D. LPN D entered room [ROOM NUMBER]-A to administer medication. LPN D verified the resident, washed their hands, retrieved the medication and signed the medication out in the EMR (electronic medical record) LPN D then asked the resident if they would like their pills all at once or one at time. The resident stated they would take them one at a time and did so until they were done. LPN D did not explain to the resident what medications they were receiving. Review of the policy titled, Medication Administration revised ,d+[DATE], revealed: Medication Administration: 13. Explain to the resident the type of medication being administered and the procedure.

This Citation pertains to Intake Numbers MI00146860 and MI00147441. Based on interviews and record review, the facility failed to monitor and inform the physician promptly regarding the declining status post-fall for one resident (Resident #5), resulting in the delay in treatment and hospitalization for Resident #5, who sustained a brain bleed post-fall. Findings include: Resident #5 (R5): According to the review of records conducted on 1023/24 at 10:00 AM, R5 was [AGE] years old and admitted to the facility on [DATE], with the primary diagnosis of Atrial Fibrillation, Anxiety, Depression, and Chronic Respiratory Failure in addition to other diagnoses. R5 was discharged from the hospital after a fall on 8/6/24. The resident was assessed, alert, and oriented according to records on the 8/4/24 Incident Report. The list of medication orders dated August 2024 revealed that R5 was taking an anticoagulant (Eliquis) for a history of Atrial Fibrillation as a diagnosis. R5 Care plan interventions dated 8/31/2023 were noted under anticoagulant therapy: Report to the physician any signs and symptoms of anticoagulant complications: blood tinged of flank blood in urine, black, tarry stools, dark or bright red blood in stools, sudden severe headaches nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB (Shortness of breath), loss of appetite, sudden changes in mental status, and significant or sudden changes in v/s (vital signs). Date initiated on 8/31/2023. R5 Fall on 8/4/24 and 8/7/24 was reviewed on 10/23/24 at 3:00 PM. Fall #1: A Fall Incident Report, written, occurred on 8/4/24, at approx. 14:45 (2:45 PM) The nursing Description noted, R5 was found laying on the floor in room by wheelchair and chair in room. The fall was unwitnessed. However, R5 was described as alert and oriented to person and place. No injuries were observed post-incident. Fall # 2: Occurred on 8/6/24, written at approximately 06:19 AM. The incident (I/A) was described: The CENA (nursing assistant) was doing rounds when she noticed guest on the side of the bed. She immediately came to notify me . Guest stated she did not hit her head . No injuries observed at the time of the incident. However, R5's mental status: The nurse indicated that R5 was oriented, with the place was noted. Nurse Manager Z was interviewed on 10/24/24 at 10:50 AM. She stated that R5 was admitted to the facility almost a year ago and at first denied that Nurse Manager Z was not working on 8/6/24. She stated, I was not notified until I got back in. She further stated: I was not working on both falls (8/4/24 and 8/6/24). The Nurse Manager Z, after verifying the nurse's notes documentation, indicated that Nurse Manager Z had entered notes on 8/6/24 regarding the status- post fall. Nurse manager Z continued to describe that R5 fell on [DATE] and went to see R5 in the room with her daughter present in the room. She further explained it was at around 8:00 AM when she assessed and made sure R5 was ok after the fall Nurse Manager Z described what happened during the fall, reading the incident report that stated: R5 rolled out of bed, neuro checks were done, and was normal baseline during interview at that time in the morning at around 8:14 AM on 8/6/24 was when Nurse Manager z assessment was but she documented it at a later time at 15:17 (3:17 PM). From my assessment in the afternoon, compared to the morning, Nurse Manager Z felt something was not right with R5. R5 was more sluggish and lethargic and described as more tired than usual. The nurse practitioner (NP) was notified and made aware of the incident but ordered Covid testing and precautions. Nurse Manager Z denied observing any respiratory distress, coughing, or shortness of breath. However, R5 was declining for months. R5's Covid test was done and was negative. The nurse practitioner recommended a Covid test and put her on precautions for 3 days. The Nurse Manager Z denied testing R5 for UTI because it was not discussed and not recommended to be tested by the NP (Nurse Practitioner). Nurse Manager Z stated that she had assessed R5 just before she left at 3:30 PM that day on 8/6/24. The nurse Manager stated that she had talked to the daughter, who was present in the room at about 8:30 AM on 8/6/24 and discussed hospice services. The daughter said that she would discuss the recommendation with the family. The daughters were hands-on with R5. She must have gotten a call from the nurse about the fall, and she got a call from the nurse, so she immediately came at 8:00 AM. Nurse Manager Z stated she was unsure about Anticoagulant Orders: Eliquis. I observed at around 3:00 PM that something was off on her mental status. R5's family was present in the facility, and they wanted her to be sent out to the hospital. The nurse sent her on 8/6/24 at approximately 6:30 PM because the family insisted. R5 was described in the progress notes as: tired, weak, and a little confused. The family was at the bedside. Something was off, and she was not her usual. R 5 family was present. R5's family triggered her to be sent out. Nurse 2 was interviewed on 10/24/24 at 10:30 AM and stated that she was not R5's nurse but was walking by when the family approached her and asked if she could assess R5. She said she had taken care of R5 and knew R5's baseline. Nurse 2 revealed that the resident was difficult to arouse and had a one-sided weakness. Nurse 2 stated, It was very apparent and definitely not R5's usual state of self and mental state. After assessment, when the family asked if R5 needed to be treated and evaluated at the hospital, Nurse 2 stated: I did say yes after discussing with the nurse assigned to R5. Hospital records dated August 6, 2024 revealed: R5 was received nonresponsive to voice or touch but is breathing and in no acute distress. The Hospital Admission Diagnosis revealed Brain Bleed. CT Brain performed on 8/6/24 at 20:46 (8:46 PM) FINDINGS: Acute intraparenchymal hemorrhage in the left occipital and posterior parietal lobes surrounding low-attenuation edema. The intraparenchymal hemorrhage measures about 3.0 x 5.4 cm in the axial plane and about 3.7 cm in CC length. Mild mass effect in the region, effacement of sulci in the region . IMPRESSION: 3.0 x 5.4 x 3.7 cm intraparenchymal hemorrhage in the posterior left parietal and occipital lobes. Surrounding low-attenuation edema with mild regional mass effect. A posterior parafalcine hemorrhage is also present, probably a thin left parafalcine subdural . A verbal report was called to the emergency room , and the case was discussed at 2050 (8:50 PM) hours. Electronically signed on 8/6/24 at 9:04 PM EDT. Hospital Course indicated: . Patient is a [AGE] year-old female with a past medical history of atrial fibrillation maintained with Eliquis, admitted with hemorrhagic CVA after a fall at her facility. No interventions recommended by neurosurgery, and patient was transitioned to comfort measures in the emergency department 8/7 . The patient is breathing but not responding to voice. Not responsive to touch. No sternal rub as she is comfort measures. Noted notes on Hospital Discharge Summary, dated 8/7/24 at 14:07 (2:07 PM). The nurse's progress note dated 8/6/24 at 6:30 PM revealed: Guest was tired, weak, a little confused. The family was at the bedside. The nurse practitioner (NP) was interviewed on 10/24/24 at 10:35 PM, and she stated that she received a call in the morning regarding R5's fall. There was no indication of any neurological status changes at that time. The NP denied evaluating R5 in person. NP indicated that she was not present at the facility, nor was the primary physician on 8/6/24, to assess R5 post-fall. Instead, she ordered Covid Testing and Precautions for 3 days. The NP did not order her to go to the hospital because she was reported to be in her baseline. She added that regarding R5 taking Eliquis, it is not an indication to be sent to the hospital unless there are signs and symptoms. She was unaware of any changes and did not get a follow-up call. The Fall Policy entitled: Fall Reduction Program, revised on 9/25/2016, revealed the fall program's purpose: To provide a safe environment for residents, modify risk factors, and reduce risk of fall-related injury. Procedure: . 3.1 Initiate safety interventions and update care plan as applicable 3.2 Charge nurse to monitor for delayed consequences of incident utilizing the following. Physical assessment and documentation Neurological Assessment per directions, as applicable .

This Citation pertains to IntakeNumber MI00146582 Based on observation, interview and record review the facility failed to enter a physician's order for wound care and update a skin integrity care plan timely for one resident (Resident #7) of three residents reviewed for pressure ulcers, resulting in late physician's orders for wound care and late revision of a skin integrity care plan. Findings include: R7 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include cerebral infarction, contractures, dementia and age-related physical debility. R7 has a BIMS (Brief Interview for Mental Status) score of 0, indicating R7 has a severe cognitive impairment and during the survey was not observed to communicate with anyone and would occasionally moan out in pain during care. On 10/23/24 at 12:00PM, R7 was observed sleeping in bed, dressings were noted to the left and right elbows. Bilateral elbows were propped up on pillows for pressure reduction, pressure reduction mattress was in place and functioning. On 10/23/24, record review revealed that R7 has a Stage 3 pressure ulcer (full thickness loss of the skin) on the left medial elbow and a Stage 2 pressure ulcer (partial thickness loss of the skin) on the right medial elbow, both are in-house acquired and developed on 10/17/24. Record review revealed a care plan is in place that addresses the pressure ulcers on the bilateral elbows. The care plan was updated on 10/23/24. Orders were not placed for wound care on the bilateral elbows until 10/21/24. Current dressings dated 10/24 on bilateral elbows. On 10/23/24 at 01:25PM, an interview was conducted with LPN (Licensed Practical Nurse) A. LPN A was asked, if you identified a wound, when would you expect a treatment to be put in place. LPN A stated they would enter the order as quickly as possible, preferably the same day that it was identified. LPN A was asked what the process is if you were performing a skin assessment and identified a new wound. LPN A stated they would notify the unit manager, DON (Director of Nursing) and the physician, either in person or via tiger text. LPN A stated they would take pictures of the wound and get them in PCC (Point Click Care, electronic medical record), then I would expect a treatment order to be given by the physician and I would put it in place. On 10/24/24 at 01:14PM an interview was conducted with RN (Registered Nurse) B. Based on record review RN B is the nurse that identified the new pressure injuries on the bilateral elbows. RN B was asked what the steps are that you take when you identify new wounds. RN B stated there is an algorithm they follow if you identify a wound. RN B was asked when they identified the wound, if they put a treatment in place and if they notified anyone about the new pressure wounds. RN B stated it was near the end of their shift, RN B put a foam dressing in place and passed it on to the next shift and let management know there were new areas. RN B stated they took pictures of the elbows and put them into PCC. RN B was asked if they put an order for the wound care into PCC for the newly identified area. RN B stated they put a dressing on R7, but did not enter an order into PCC. RN B was asked who is responsible for updating the care plans and how quickly they should be updated. RN B stated that nurses on the floor could update the care plans and feels that 24 hours is a reasonable time to update the care plan. RN B states they don't always feel comfortable updating the care plans, so they let management know it needs to be updated. Review of the policy titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol revised October 2010, revealed: Treatment/Management: 1. The physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.) and application of topical agents. Review of the policy titled, Care Plans-Comprehensive revised October 2010, revealed: Revisions: 8. Assessments of residents are ongoing, and care plans are revised as information about the resident and the resident's condition change. Reviewing and Updating: 9. The care planning/interdisciplinary team is responsible for the review and updating of care plans: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly.

Based on observation, interview and record review the facility failed to store nebulizer equipment per facility policy and follow a physician's orders for oxygen administration for two residents (R3, R10) of three residents reviewed for nebulizer equipment, resulting in nebulizer equipment being stored on a bedside table and the medication chamber having fluid in it and not receiving the physician's ordered amount of oxygen administration. Findings include: Resident #3: R3 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include CHF (Congestive Heart Failure) chronic respiratory failure, pulmonary hypertension and major depressive disorder. R3 has a BIMS (Brief Interview for Mental Status) score of 15 indicating they are cognitively intact. On 10/23/24 at 11:30AM, R3 was observed sitting in a wheelchair in the room and watching television. R3 was observed to be receiving oxygen at 3 liters per minute via a nasal cannula and a nebulizer machine was sitting on the nightstand with liquid in the medication chamber. R3 was asked what the liquid was in the medication chamber, and they replied the nurse put it in there at 9am when they gave me my pills, it is my breathing treatment. R3 state they get nebulizer treatments 2-3 times a day. R3 was asked about using oxygen, R3 stated they only use it in the building and that is about it. R3 was asked if they use in continuously in the building and they replied yes. On 10/23/24 at 11:45AM, an interview was conducted with LPN D. LPN D was asked if they could tell me why R3 has fluid in his nebulizer chamber. LPN D stated they took over for another nurse at 9:00am and did not give morning medications to R3, LPN D stated they don't know why there would be fluid in the chamber already. This surveyor and LPN D verified there is fluid in the chamber. LPN D emptied out the chamber and went to retrieve a new nebulizer mask for R3. On 10/23/24 at 12:15PM, record review revealed a physician's order for nebulizer treatments four times a day for chronic respiratory failure. Record review also revealed a physician's order for continuous oxygen at 2 liters per minute and an at risk for respiratory impairment care plan with interventions that included O2 (oxygen) via NC (nasal cannula) at 2 Liters per minute. On 10/24/24 at 12:15PM, an interview was conducted with LPN D. LPN D was asked to verify the current rate of oxygen R3 is supposed to receive. LPN D stated they believe R3 is supposed to be receiving oxygen at 2 liters per minute. LPN D and this surveyor observed the concentrator of R3 running at 3 liters per minute. LPN D stated that sometimes residents will have orders to increase oxygen up to 5 liters per minute to maintain oxygen saturation above 90%. LPN D verified the order and adjusted the oxygen amount to 2 liters per minute. Resident #10: R10 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include pneumonia, anxiety, repeated falls and Alzheimer's disease. R10 has a BIMS score of 4, indicating severe cognitive impairment. On 10/23/24 at 01:12PM, during a tour of R10's room, a nebulizer mask setup was observed sitting on an overbed table with fluid still in the medication chamber. R10 was not present in the room at this time. On 10/23/24 at 01:15PM, an interview was conducted with LPN A. LPN A was alerted by this surveyor the nebulizer sitting on the bedside table with fluid in the medication chamber. LPN A stated you don't have to say anything, I already know what is wrong. LPN A then disposed of the nebulizer and went to retrieve a new one. On 10/23/24, record review revealed a physician's order for nebulizer treatments four times a day. Review of the October MAR (medication administration record) revealed the nebulizer had last been signed out at 0800. Review of the policy titled; Nebulizer, revised 09/25/2016 revealed: Equipment Cleaning: 10. Following medication administration, disconnect nebulizer cup/mask/mouthpiece from tubing, rinse equipment with hot water and place on paper towel to completely air dry. 11. Remove gloves and wash hands. 12. Once nebulizer cup/mask/mouthpiece is completely dried place in storage bag. Review of the policy titled; Oxygen Administration revised October 2010 revealed: Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed.

This Citation Pertains to Intake Numbers MI00131094, MI00135961, and MI00136144. Based on observation, interview and record review, the facility failed to implement and operationalize a comprehensive skin assessment and wound care program to ensure ongoing, accurate, and consistent assessment, treatment completion, treatment revision, and documentation per professional standards of practice for two residents (Resident #701 and Resident #707) reviewed, resulting in lack of assessment, treatment, and clear documentation of pressure ulcers (wounds caused by pressure), Resident #707 developing two unstageable DTI (Deep Tissue Injury) pressure ulcers, lack of treatment and assessment for Resident #701's right heel unstageable DTI pressure ulcer, gluteal and sacrum pressure ulcers worsening and infection, unnecessary pain, hospitalization , surgical intervention, and decline in overall health status. Findings include: Review of the facility provided CMS- 672 form revealed there were four Residents in the facility who had pressure ulcers. Of the four Residents with pressure ulcers, two developed at the facility. The CMS- 802 Resident Matrix form included that there were three Residents with pressure ulcers with one being facility acquired. Resident #701: Review of intake documentation, received 3/30/23, revealed Resident #701 had been transferred to the hospital due to wounds, infection, and lack of appropriate care. The intake documentation detailed, (Resident #701) had several wounds on their bottom. The facility never had a wound doctor to look at their wound . The nurses were just changing the dressing but are not trained in any wound care. The wound was starting to smell. The wound is now infected and is green. A week ago, they finally sent (Resident #701) to a wound clinic. The wound was so bad that (Resident #701) was transferred to a hospital. A second intake pertaining to Resident #701, dated as received on 4/24/23. Review of this intake documentation detailed Resident #701 presented with wounds from their waist down, including on their legs and buttocks at the hospital wound care clinic on 3/23/23. Per the intake documentation, The wounds are from neglect as if never turned at the nursing home. It was reported that (Resident #701) refused being moved; however, (Resident #701) commented that they never said this. The wounds are infected with gray ooze/pus coming the wounds. The wounds smell. (Resident #701) bones are visible in some of the wounds . The intake revealed the Resident was transferred to the hospital directly from the wound care clinic due to emergent medical concerns related to the pressure ulcers. An interview was conducted with Wound Care Registered Nurse (RN) A on 6/6/23 at 10:45 AM. When queried regarding Resident #701, RN A revealed the Resident was treated at the Wound Care Clinic three times. When asked, RN A revealed Resident #701 was first seen at the clinic on 3/23/23 and they were sent directly to the hospital ER following the visit due to wound care staff concerns of Resident #701 being neglected at the facility and not receiving appropriate wound care treatment causing the wounds to worsen and Resident #701 developed a severe infection. When queried if the Resident was treated at the wound care clinic after 3/23/23, RN A indicated the Resident was treated one other time and sent to the ER again due to their condition. Review of Resident #701's face sheet revealed the Resident was originally admitted to the facility on [DATE] with diagnoses which included Multiple Sclerosis (MS), quadriplegia (paralysis of all four extremities), lower extremity contracture, and diabetes mellitus. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact, required extensive to total assistance to complete all Activities of Daily Living (ADL) with the exception of eating, and had three pressure ulcers including one stage four (full thickness tissue loss with exposed bone, tendon, and/or muscle), one unstageable, and one DTI. Review of Resident #701's care plans revealed a care plan entitled, The resident has potential for and actual impairment to skin integrity r/t (related to) . MS, immobility, poor nutritional habits, prefers to lay in bed and resists turning and repositioning and wound care/assessments. R (Right) buttock stage 4 pressure ulcer s/p (status post) surgical closure, L buttock stage 3 ulcer s/p surgical closure, R heel UTD (Unable to Determine) pressure ulcer, DTI to sacrum, scattered scabs to lower extremity in various stages of healing. Often declines to use heel protector boots--prefers floating with pillows. Osteomyelitis of sacrum (Initiated: 1/7/23; Revised: 6/1/23). The care plan included the interventions: - Braden Scale per order (Initiated: 1/7/23) - Encourage good nutrition and hydration in order to promote healthier skin (Initiated: 1/7/23) - Encourage guest to use heel boots while in bed to prevent breakdown. Provide assistance turning as tolerated (Created/Initiated: 5/9/23) - Encourage to consult with the wound clinic (Initiated: 3/8/23) - Follow facility protocols for treatment of injury (Initiated: 1/7/23) - Identify/document potential causative factors and eliminate/resolve where possible (Initiated: 5/9/23) - Monitor for side effects of the antibiotics and over-the-counter pain medications: gastric distress, rash, or allergic reactions which could exacerbate skin injury (Initiated: 1/7/23) - Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration etc. to MD (Medical Doctor) (Initiated: 1/7/23) - Obtain blood work . and C&S (Culture and Sensitivity) of any open wounds as ordered by Physician (Initiated: 1/7/23) - Pressure reducing cushion to protect the skin while up in chair (Initiated: 1/7/23) - Resident transfers via hoyer (mechanical device to lift people) and 2 PA (Person Assist) (Initiated and Revised: 1/7/23) - Pressure reducing mattress/ air mattress to protect the skin while in bed (Initiated: 1/7/23; Revised: 4/2/23). Care Plan History detail revealed air mattress was added to care plan on 4/2/23 when it was revised. - Skin Assessments per order (Initiated: 1/7/23) - Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface (Initiated: 1/7/23) A second care plan entitled, Resistive/noncompliant with care or treatment (Turning, wound care, wound documentation) r/t (related to) guest stating does not need these interventions performed. Guest often refuses care and acknowledges risk to worsening of wounds and overall health from refusal (Initiated: 3/31/23; Revised: 5/8/23). This care plan included the interventions: - Inform of ADL that is required ahead of time (Initiated: 3/31/23; Revised: 4/25/23) - Provide education about risk of not complying with therapeutic regimen (Initiated: 3/31/23) - Reapproach at a later time (Initiated: 3/31/23) - Offer Choices (Initiated: 3/31/23) - Meet with Social Services 1:1 as needed (Initiated: 3/31/23) An interview was conducted with Resident #701 in their room on 6/7/23 at 9:45 AM. The Resident was in bed, positioned slightly on their right side with the head of their bed elevated at approximately 45 degrees. When queried regarding the level of assistance they require from facility staff, Resident #701 revealed they are unable to walk or move very much without someone helping them. When queried if they have wounds and/or pressure ulcers, Resident #701 confirmed they did. Resident #701 stated, I have drains in my wounds, getting them out today. With further inquiry, Resident #701 revealed they had a doctor appointment with a physician outside of the facility this morning related to their pressure ulcers and were hoping to have the drains removed. When asked why and how long they had drains in the wounds, Resident #701 revealed they had surgery to try to help heal the wounds and that is when the drains were placed. When asked if they had the pressure ulcers when they were admitted to the facility, Resident #701 stated, I had some when I came. Resident #701 was asked if they had developed additional pressure ulcers at the facility and revealed they were unsure as they could not see the wounds. When queried the location of their pressure ulcers, Resident #701 replied, My bottom and right heel. An alternating air mattress was present on the bed. When asked how long they have had the alternating air mattress, Resident #701 revealed they had a regular mattress when they first arrived at the facility. The Resident was unable to recall the specific date the air mattress was applied but stated, Not that long. When asked if they are able to turn and reposition themselves in bed, Resident #701 indicated they required assistance. Resident #701 was then asked how frequently staff reposition them in bed, Resident #701 revealed it was usually a couple times a shift. Resident #701 was queried regarding more frequent repositioning due to their wounds and indicated it takes two staff members reposition them which makes it more difficult for the staff. Resident #701 had black colored heel boots in place on both of their lower extremities. When asked how long they have had the heel boots, Resident #701 stated, Just got them at the hospital. Resident #701 was queried if staff had kept their heels elevated or used a different type of heel protection device prior to getting the boots from the hospital, the Resident revealed staff would sometimes elevate their legs on a but that they did not have any other boots/devices. Resident #701 was then asked when wound care treatments are typically completed and indicated they are done by the night shift nurses. When asked if the treatments are completed at the ordered frequency, Resident #701 replied, Mostly and indicated their wound care treatments are not always completed. When queried if they ever refused to have the wound dressings changed or to be repositioned in bed, Resident #701 replied, Sometimes because of pain. With further inquiry, Resident #701 revealed they hurt so bad from their wounds and there are times when they just can't take it (pain). When queried if they informed nursing staff about their pain, Resident #701 indicated they had and stated, They want to do it when they have time and that doesn't always work because they are in pain. Resident #701 revealed they wanted the wounds to heal and to get better so they can get into the chair and out of the bed. Review of Resident #701's wound documentation in the Electronic Medical Record (EMR) revealed the Resident had the following Active wounds: - #24 Right Heel: Unstageable Pressure Ulcer - #21 Sacrum: Deep Tissue Pressure - #9 Right Gluteus: Stage 4 Pressure Ulcer - #20 Right Gluteus: Surgical Sutures (9) - #22 Left Medial (inner) Thigh: Surgical Sutures (11) The wound documentation also included the multiple Resolved wounds including: - #14 Right Heel: Unstageable Pressure Ulcer- Last Evaluated on 4/23/23 - #13 Left Heel: DTI Pressure Ulcer - Last Evaluated on 4/23/23 - #12 Left Lateral (outside) Thigh: Stage 2 Pressure Ulcer from Medical Related Device- Last Evaluated on 4/15/23 - #6 Sacrum: DTI Pressure Ulcer- Last Evaluated on 4/23/23 - #23 Right Thigh (front): Open Lesion- Last Evaluated 5/17/23 - #15 Medial Right Foot: Open Lesion- Last Evaluated 4/1/23 - #4 Left Medial Thigh: Pressure Ulcer- Stage 3- Last Evaluated 4/23/23 - #7 Right Lateral Thigh: Open Lesion- Last Evaluated 5/19/23 Resident #701's wound documentation did not clearly identify which pressure ulcers/wounds were present on admission and/or if the Resident developed additional pressure ulcers at the facility. Review of census documentation for Resident #701 detailed the following: - admitted : 1/5/23 - discharged : 3/23/23 - readmitted : 3/31/23 - discharged : 4/26/23 - readmitted : 5/8/23 Review of Resident #701's Discharge- Return Anticipated MDS assessment, dated 3/23/23, detailed the Resident had three pressure ulcers including one stage two, one stage three, and one stage four. Review of Resident #701's Entry Tracking MDS assessment, dated 3/31/23, did not include any information pertaining to Skin Conditions. Review of Resident #701's 5-Day Scheduled MDS assessment, dated 4/6/23, revealed the Resident had six pressure ulcers including one stage two, one stage three, one stage four, one unstageable, and two DTIs. Review of Resident #701's Discharge- Return Anticipated MDS assessment, dated 4/26/23, detailed the Resident had three pressure ulcers including one stage three, one stage four, and one unstageable. Review of Resident #701's 5-Day Scheduled MDS assessment, dated 5/14/23, specified the Resident had one stage four, one unstageable, and DTI pressure ulcers. Review of Resident #701's Health Care Provider (HCP) orders revealed the following active orders: - Check functional status of air pressure mattress two times a day (Ordered: 5/9/23) - Guest to use heel boots while in bed to prevent breakdown. Provide assistance turning as tolerated every 2 hours (Ordered: 5/8/23) - Apply betadine-soaked gauze to right heel wound, apply non-adherent Adaptic gauze, cover with dry 4x4 gauze, ABD pad, wrap with non-compressive Kerlix and reinforce with tape at bedtime for wound care (Ordered: 5/8/23) - Chamosyn Ointment to bilateral buttocks, monitor and notify MD of acute changes two times a day for protection (Ordered: 5/25/23) - Posterior Left Thigh Incisions (with sutures): 1. Cleanse gently with wound cleanser, pat dry. 2. Leave OTA (Open to Air) unless wound has drainage or if clothing causes friction. 3. Monitor for signs of infection, notify MD of acute changes two times a day (Ordered: 5/25/23) - Clean Bilateral JP (Jackson Pratt- wound care drain) drain site with N.S (Normal Saline) pat dry. Monitor for s/s (signs/symptoms) of infection and dislodgment . Record output two times a day (Ordered: 5/8/23) - Clean sacrum with wound cleanser, pat dry, apply aquacel foam dressing as needed (Ordered: 5/25/23) - Clean sacrum with wound cleanser, pat dry, apply aquacel foam dressing in the morning every other day for pressure injury (Ordered: 5/25/23) - Left heel preventative treatment: Apply aquacell foam to left heel for pressure reduction at bedtime (Ordered: 5/8/23) - Right gluteus Incisions (near sutures) Clean with wound cleanser, pat dry, apply medihoney, cover with nonadherent dressing **Only apply medihoney to area with slough** in the morning (Ordered: 5/25/23) Review of Resident #701's Health Care Provider (HCP) orders revealed the following discontinued orders: - APM (Alternating Pressure Mattress) (Ordered and Discontinued: 1/10/23) - Silver sulfadiazine External Cream 1% . Apply to Lower legs topically at bedtime related to cellulitis of right lower . left lower limb (Ordered: 1/5/23; Discontinued: 3/31/23) - Change leg dressings Wash gently with soap and water. Apply Silvadene and Adaptic dressing, cover with gauze wrap and ace bandage at bedtime every Tue, Thu, Sat for wound care (Ordered: 1/24/23; Discontinued: 1/26/23) - Change leg dressings Wash gently with soap and water. Apply Silvadene and Adaptic dressing, cover with gauze wrap and ace bandage in the morning every Tue, Thu, Sat for wound care (Ordered: 1/26/23; Discontinued and Re-ordered: 2/28/23; Discontinued: 3/31/23) - Collagenase External Ointment (wound ointment used to remove dead tissue) (250 unit/gm (grams) Apply to Buttock topically at bedtime for Wound care (Ordered: 1/5/23; Discontinued: 3/31/23) - Wound care for wounds #7, #6 and #4 at bedtime every 3 day(s)Cleans wounds with wound cleanser, dry, cover with water-based gel, cover with mepilex (tape) (Ordered: 1/10/23; Discontinued: 2/8/23) - Wound care for wound #9 on coccyx at bedtime Clean with wound cleanser . NS gauze, cover with ABD pad and secure with tape (Ordered: 1/10/23; Discontinued: 2/8/23) - Wound care for wounds #9, #7, #6 and #4 at bedtime every 3 day(s) Cleans wounds with wound cleanser, dry, cover with water-based gel, cover with mepilex (Ordered: 2/8/23; Discontinued: 3/1/23. Re-ordered: 3/1/23; Discontinued: 3/31/23) - Coccyx wound: Cleanse with NS, pat dry, Skin Prep peri-wound Apply TRIAD paste to wound bed, Cover with Aquacel Foam padded dressing Seal edges of dressing with skin prep at bedtime every other day (Ordered: 4/1/23; Discontinued: 5/8/23) - Coccyx wound: Cleanse with NS, pat dry, Skin Prep peri-wound Apply TRIAD paste to wound bed, Cover with Aquacel Foam padded dressing Seal edges of dressing with skin prep at bedtime every 12 hours as needed for if soiled or dislodged (Ordered: 4/1/23; Discontinued: 5/8/23) - Cleanse surgical incision (Coccyx) with NS, pat dry, OTA. Monitor for s/sx of infection at bedtime for wound care (Ordered: 5/8/23; Discontinued: 5/9/23) - Left posterior thigh/buttock wound: cleanse with NS, pat dry skin prep peri-wound place Aquacel Foam dressing Seal edges of Aquacel with skin prep as needed (Ordered: 4/1/23; Discontinued: 4/20/23) - Left posterior thigh/buttock wound: cleanse with NS, pat dry skin prep peri-wound place Aquacel foam dressing Seal edges of Aquacel with skin prep at bedtime for protection (Ordered: 4/1/23; Discontinued: 4/20/23) - Left posterior thigh/buttock wound: cleanse with NS, pat dry skin prep peri-wound place Aquacel Foam dressing Seal edges of Aquacel with skin prep at bedtime every 3 day(s) for protection (Ordered: 4/20/23; Discontinued: 5/8/23) - Left posterior thigh/buttock wound: cleanse with NS, pat dry skin prep peri-wound place Aquacel Foam dressing Seal edges of Aquacel with skin prep every 12 hours as needed for if soiled or dislodged (Ordered: 4/20/23; Discontinued: 5/8/23) - Right and left heel wounds: Swab with Iodine, let dry cover with ABD pad and wrap with kerlix at bedtime . (Ordered: 4/1/28; Discontinued: 4/8/23) - Right and left heel wounds: Swab with Iodine, let dry cover with ABD pad and wrap with kerlix every 12 hours as needed for if soiled or dislodged (Ordered: 4/1/28; Discontinued: 4/8/23) - Monitor heel wounds, notify MD of acute changes two times a day (Ordered: 4/1/23; Discontinued: 5/8/23) - Right and left heel wounds: Swab with Iodine, keep open to air, elevate heels in bed two times a day . (Ordered: 4/8/23; Discontinued: 5/8/23) - Left heel: Apply non-adherent Adaptic gauze, cover with dry 4x4 gauze, ABD pad, wrap with non-compressive Kerlix and reinforce with tape at bedtime (Ordered: 5/13/23; Discontinued: 5/18/23) - Right Buttock wound: Cleanse with NS, pat dry Skin prep to peri-wound loosely pack wound with NS moistened kerlix place ABD pad two times a day (Ordered: 4/1/23; Discontinued: 4/20/23) - Right Buttock wound: Cleanse with NS, pat dry Skin prep to peri-wound loosely pack wound with NS moistened kerlix place ABD pad at bedtime every 12 hours as needed for if soiled or dislodged (Ordered: 4/1/23; Discontinued: 5/8/23) - Right Buttock wound: Cleanse with NS, pat dry Skin prep to peri-wound loosely pack wound with NS moistened kerlix place ABD pad at bedtime every 3 day(s) for wound care (Ordered: 4/20/23; Discontinued: 4/20/23) - Right Buttock and Posterior Left Thigh Incisions (with sutures): 1. Cleanse gently with wound cleanser, pat dry. 2. Leave OTA unless wound has drainage or if clothing causes friction. 3. Monitor for signs of infection, notify MD of acute changes two times a day (Ordered: 5/9/23; Discontinued: 5/25/23) - Right Buttock Incisions (near sutures) Clean with wound cleanser, pat dry, apply medihoney, cover with nonadherent dressing **Only apply to area with slough** in the morning (Ordered and Discontinued: 5/25/23) Review of Resident #701's EMR revealed the following documentation: - 1/5/23 at 9:27 PM: Skin & Wound - Total Body Skin Assessment . Number of New Wounds . Five . The assessment did not identify the location of the wounds. - 1/7/23 at 1:56 AM: Wound Evaluation . #9 Pressure- Stage 3 . Location Not Set .Length: 5.62 cm, Width 4.11 cm . Wound Bed . Epithelial: Yes . Granulation: Yes . Slough: Yes . Eschar: Yes . Evidence of Infection: None . The evaluation included an image of the wound. The wound had visible depth but measurement of the depth of the wound was not included in the evaluation. Note: Wound #9 was later identified as being on the Resident's right gluteus and right buttocks - 1/30/23 at 11:09 AM: Skilled Charting . Dx (diagnoses) cellulitis of right lower limb . - 2/4/23: Wound Evaluation . #9 Pressure- Stage 3 . Right Gluteus . Length: 6.85 cm, Width 5.22 cm . Wound depth not documented. - 3/18/23 at 11:52 PM: Wound Evaluation . #9 Pressure- Stage 3 . Right Buttocks . Length: 7.0 cm; Width: 3.5 cm . Wound Bed . Granulation: Yes . Slough: Yes . Hypergranulated . Exudate: Light . Sanguineous/Bloody . Odor after Cleansing: Moderate . Periwound . Rolled Edges . The image of the wound included on the evaluation showed significant depth to the wound bed, but depth measurements were not included. - 3/21/23 at 11:22 AM: Weight Change Note . Continues to trigger for decrease in weight . Skin: Stage II (L) thigh, Stage III (R) buttock, Deep tissue injury Sacrum, Open Lesion (R) thigh . Will attend wound care clinic weekly . - 4/1/23: Wound Evaluation . #9 Pressure- Stage 3 . Right Gluteus . Length: 5.81 cm, Width 5.81 cm . No depth measurements were included. - 4/1/23 at 7:39 PM: Skilled Charting . readmit . Wound care rendered, bed bath given, family in to visit. - 4/8/23: Wound Evaluation . #9 Pressure- Stage 4 . Right Gluteus . Length: 4.97 cm, Width 4.12 cm, Depth: 1 cm . - 4/11/23 at 7:46 AM: Skilled Charting . Writer contacted provider regarding Resident's wounds d/t (due to) moderate - large, green purulent drainage from the Right buttocks. Per provider order (laboratory blood tests) and place resident in book to be seen by the provider. Resident has several areas of very dry skin on BLE (Bilateral Lower Extremities) that is creating red/irritated and open areas that this writer has requested the provider also evaluate. Writer also informed day shift during report. - 4/13/23 at 10:12 AM: Lab . reviewed and no new orders. - 4/15/23: Wound Evaluation . #9 Pressure- Stage 4 . Right Gluteus . Length: 5.72 cm, Width 3.77 cm, Depth: 2.2 cm . - 4/16/23 at 3:07 PM: eMar - Medication Administration Note . Right and left heel wounds: Swab with Iodine, keep open to air, elevate heels in bed two times a day for protection. Sock stuck to Rt heel. NS (Normal Saline) used to soak sock off. Iodine applied and Rt heel covered with gauze to protect from sock but allow air to heel. - 4/16/23 at 3:09 PM: eMar - Medication Administration Note . Right Buttock wound . Large amt (amount) of sanguineous drainage with small amounts of green purulent drainage noted . - 4/21/23 at 1:36 AM: eMar - Medication Administration Note . Right Buttock wound .Dressing loose and soaked with drainage. Drainage noted to be green tinted with foul odor . - 4/21/23 at 1:38 AM: eMar - Medication Administration Note . Left posterior thigh/buttock wound . Dressing saturated with serosanguinous drainage. Wound cleansed per orders and new dressing applied. - 4/23/23 at 9:22 PM: Wound Evaluation . #14 - Pressure - Unstageable (Slough and/or eschar) . Right Heel . Length 3.64 cm; Width 4.94 cm . Wound Bed . Eschar . Scab . Progress: Resolved. Notes: Edge of eschar loosening and bleeding coming from edge of eschar that is loose. Note: The wound was documented as resolved but the image in the evaluation clearly showed a non-healed unstageable pressure ulcer. - 4/23/23 at 9:26 PM: Wound Evaluation . #6 - Pressure Deep Tissue Injury . Sacrum. Resolved- 4 months ago . Length 4.2 cm . Width 1.28 cm . Wound Age: 1 week . Exudate . Light . Serous . Treatment: Turning/repositioning program . Progress: Resolved . The image attached to the evaluation showed two distinct open wounds with apparent depth over Resident #701's sacrum and the surrounding skin was reddened and excoriated. The wounds were notably larger than 4.2 cm by 1.28 cm and it is unclear what was measured from the evaluation documentation. Additionally, the evaluation did not include wound depth measurements. - 5/8/23 at 2:24 PM: Wound Evaluation . #21 - Pressure- Deep Tissue Injury . Sacrum . Length 8.39 cm; Width 7.48 cm . Wound Bed . Epithelial: Yes . Granulation: Yes . No dressing applied . The wound image revealed the pressure ulcer was in the same place as wound #6 had been documented previously and per the image, the pressure ulcer appeared to be improved and healing in comparison to the documentation and image on 4/23/23. - 5/8/23 at 2:25 PM: Wound Evaluation . #22 -Surgical - Sutures (11) . Left Thigh Medial .Length 6.61 cm; Width 0.96 cm . New . - 5/8/23 at 3:15 PM: Skilled Charting . Guest admitted from Hospital post-surgical debridement and closure of coccyx wound, placement of JP (Jackson Pratt - type of wound drain) drains x 2, and colostomy. Guest has PICC (Peripherally Inserted Central line - used for longer term IV therapy) line in place for IV antibiotics. Guest oriented to room and cleaned with the assistance of nurse aid. JP drains have minimal drainage noted to be bright red per report. Foley catheter in place . - 5/8/23 at 4:15 PM: Wound Evaluation . #24 Pressure- Unstageable . Right heel . New . Length: 4.97 cm . Width . 1.74 cm . Wound Bed . Epithelial . Eschar . Progress: New . - 5/9/23 at 11:52 AM: Physician Progress Note . s/p (status post) hospitalization for osteomyelitis (infection in the bone) of sacrum due to pressure injuries. Pt with functional quadriplegia . Pt reports pain is not well controlled with current oxy dose at this time. Requesting oxycodone (narcotic pain medication) to be increased; discussed options of pain management . discussed risk of dependence and side effects. Will schedule pain management at this time . Continues on IV abx for osteomyelitis . Skin: Inspection and palpation: Multiple surgical incisions to bil (bilateral) buttocks, + JP drains to surgical sites, + serosanguinous drainage. Pt with bil. Heel wounds, Unstageable . Patient with pressure ulcer closure on 5/5; monitor surgical incisions, monitor drains. Follow up with surgeon. Continue wound care to incisions and bil. Heel wounds. Monitor for s/sx of infection . - 5/13/23 at 3:22 AM: Skilled Charting . During wound care, left hip surgical wound with JP drain: noted drain to still be in place and suture remains intact. Also noted that tip of the white internal part of drain is visible at the puncture site. This was not visible during wound care last night. Drain continues to produce output and Guest denies any changes in pain to area. On call provider notified. - 5/18/23 at 3:01 PM: Physician Progress Note . pt seen and examined . Multiple surgical incisions to bil buttocks. + JP drains to surgical sites, + serosanguinous drainage. Pt with bil. Heel wounds, Unstageable . Note: There was no documentation of a current left heel pressure ulcer in Resident #701's wound evaluations/assessments. - 5/19/23 at 6:27 AM: Skilled Charting . Guest continues on IV abx for osteomyelitis . Surgical incisions to right and left buttock areas both well approximated with stitches intact. Scant amt of serosanguinous drainage noted when cleansing incisions. JP drains to both areas intact. Left side JP drain continues to have minimal output 5mL (milliliters) or less of dark brownish red fluid . Right side JP drain continues to have decreasing drainage approx. 10-15 mL per shift of dark brownish red fluid . continues to have excoriated periwound skin and also open pressure area to sacrum . Clear yellow drainage noted at times on bed pad, unable to determine source, as when cleansing wounds, no yellow drainage noted to any of the wounds . Wounds to bilateral heels remain dry and without drainage. Guest tolerating all dressing changes well. This nurse timing dressing changes to coincide with administration of scheduled analgesic. Reassurance given often of wound conditions. Guest expresses many concerns r/t the healing of wounds . - 5/19/23 at 7:47 AM: eMar - Medication Administration Note . Guest to use heel boots while in bed to prevent breakdown. Provide assistance turning as tolerated every 2 hours. - 5/19/23 at 7:47 AM: eMar - Medication Administration Note . Chamosyn Ointment (non-prescription moisture barrier cream) to Sacrum DTI . two times a day for protection - 5/19/23 at 1:40 PM: Skilled Charting . had a scheduled follow up appointment with Infectious Disease physician for evaluation of wounds, treatment orders, and continuation of IV antibiotics. Upon transportation arrival stated . would not like to go today due to the fact that would be in too much pain during the transportation . - 5/23/23 at 11:36 AM: Skin & Wound Evaluation . Pressure . Deep Tissue Injury . Sacrum . Present on Admission . How long has the wound been present? New . Length: 6.7 cm . Width: 4.7 cm . Depth: 0.1 cm . Wound Bed . Eschar . 10% of wound filled . Image included with evaluation displayed a large, irregularly shaped, open wound. The wound bed was beefy red in color with minimal eschar. The tissue surrounding the wound was not intact, excoriated, and discolored. - 5/23/23: Wound Evaluation . Pressure . Stage 4 . Right Gluteus . Length: 2.08 cm . Width: 2.09 cm . Width: 1.24 cm . - 5/23/23 at 11:50 AM: Skin & Wound Evaluation . Surgical . Sutures . 11 . Left Thigh Medial . Present on Admission . New . Length: 5.1 cm . Width: 3.5 cm . - 5/23/23 at 5:32 PM: eMar - Shift Level Administration Note . Updated buttock wound assessment, noted changes. Educated and encouraged guest to turn and reposition from side to side to offload pressure and promote healing with verbalized understanding. Educated guest on the repercussions of pressure injury since just had surgery at the wound clinic. Assisted this afternoon with wound care and positioned guest to right side . - 5/24/23 at 3:38 PM: Skin & Wound Evaluation . Pressure . Unstageable . Right Heel . Present on Admission . New . Length: 4.8 cm . Width: 3.1 cm . Wound Bed . Eschar . 100% . Edges . Attached . The attached image of the heel pressure ulcer showed a necrotic cap covering the Resident's heel with areas of separation along the edge of the necrotic tissue. - 5/24/23 at 3:51 PM: Skin & Wound Evaluation . Surgical . Sutures . 9 . Right Gluteus . Present on Admission . New . Length: 3.8 cm . Width: 2.6 cm . Slough . 70% . - 5/26/23 at 9:38 AM: Physician Progress Note . Resident has the following wounds: Unstageable pressure right heel; Left thigh surgical; Sacral pressure- DT(I); Right gluteus surgical; right gluteus pressure. Currently being seen outpatient through consulting Infectious Disease physician . Meeting held with resident, nursing staff, and DON and discussed the importance of cooperating with care, participating in turning regimen, allowing wound care to be completed. Pain regimen discussed and guest expressed . doesn't believe that the Tramadol (pain medication) is assisting in pain. Guest is currently on scheduled oxycodone (narcotic pain medication) and tramadol, discuss [TRUNCATED]

This Citation Pertains to Intake Numbers MI00133898 and MI00134745. Based on observation, interview and record review, the facility failed to operationalize policies and procedures for fall prevention including analysis for two residents (Resident #703 and Resident #708) of three residents reviewed resulting in lack of implementation of meaningful and planned implementation of interventions, lack of thorough analysis of falls to determine root cause, Resident #703 experiencing fractured ribs from a fall, Resident # 708 falling and suffering a fracture of their right humeral neck (bone in upper arm), emergency medical treatment/care, unnecessary pain, and the likelihood for decline in overall health and well-being. Findings include: Resident #703: An interview was completed with Witness I on 6/6/23 at 11:18 AM. When queried, Witness I revealed Resident #703 had a fall with injury in February 2023 at the facility. Witness I revealed the Resident suffered two broken ribs from the fall. When asked what occurred, Witness I responded, (Resident #703) was getting up to go to the bathroom and their walker wasn't in reach. With further inquiry, Witness I revealed the Resident is very unsteady without their walker and facility staff do not put it next to them when they are in bed. When asked if that had spoke to staff about the walker not being next to the Resident, Witness I revealed they spoke to staff multiple times, but the walker was still not next to the Resident when they visited. Witness I was queried regarding staff response when they spoke to them regarding their concern and replied, They say it's (walker) in the way. Witness I then stated, (Resident #703) ended up there (facility) because they fall and broke their hip at home and the staff were aware the Resident was at risk for falls. When queried what interventions were in place to prevent falls prior to the Resident falling and fracturing their ribs, Witness I replied that the walker was supposed to be next to them. When queried what interventions were implemented following the Resident's fall in February, Witness I stated, They put up signs in the room about the walker. Record review revealed Resident #703 was most recently admitted to the facility on [DATE] with diagnoses which included macular degeneration, left eye glaucoma, hypotension (low blood pressure), Chronic Obstructive Pulmonary Disease (COPD), diabetes mellitus, and falls. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required limited to extensive, one-person assistance for all Activities of Daily Living (ADLs) with the exception of eating. The MDS specified the Resident had zero falls since admission, reentry, or prior assessment. On 6/6/23 at 4:12 PM, Resident #703's room door was closed. This Surveyor knocked on the door and heard sounds but was unable to discern what the Resident was saying. Upon opening the door slightly, Resident #703 stated they were in the bathroom. When asked if there was a staff member in the room, Resident #703 replied, No. When queried if they needed staff assistance, Resident #703 indicated they were okay and just in the bathroom. There were no facility staff present in the hallway. Review of Resident #703's care plans revealed a care plan entitled, Risk for falls r/t related to x (diagnoses) of Right femur fracture . HX (history): Falls, incontinence, weakness, impaired mobility (Initiated: 6/14/21; Revised: 5/23/23). The care plan included the interventions: - Ambulation order: 1 PA (person assistance) using a walker (Initiated: 6/14/21; Revised: 9/3/21) - Evaluate lab tests (Initiated: 2/2/21) - Evaluate X-rays (Initiated: 2/2/21) - Keep walker next to bed in front of med cabinet (Initiated: 2/2/23) - Orders made to make sure guest has walker next to bed at all times (Initiated: 2/1/23) - Reinforce need to call for assistance (Initiated: 2/2/21) - Resident transfers via 1 PA (Initiated: 8/21/21; Revised: 2/1/23) - Weight Bearing Status: WBAT (Weight Bearing As Tolerated) (Initiated: 2/2/21) On 6/8/23 at 8:40 AM, Resident #703 room door was closed. After knocking and entering the room, Resident #703 was observed in bed, positioned on their back with the room lights off. The TV was off, and the room was quiet and dim. Resident #703's walker was positioned approximately three to four feet away from their bed, directly against the wall next to the bathroom door. Their push pad call light was clipped to the sheet, positioned above their head, and not within the Resident's line of sight and/or feel. An interview was completed at this time. Resident #703 was pleasantly forgetful. When queried where their call light is if they need help from staff, Resident #703 began looking and feeling all around their bed and stated, I can't find it, never can find it. I don't know where they put it. Resident #703 then stated, Will you help me find it? When asked if staff assist them to get up to go to the bathroom, Resident #703 replied, No. I don't know where they are. They aren't coming in here. When queried if they had fallen at the facility, Resident #703 revealed they don't remember. Review of progress note documentation in Resident #703's Electronic Medical Record (EMR) revealed: - 2/1/23 at 1:56 PM: Skilled Charting . Guest was found on the floor by a nurse bringing lunch to room. Guest was sitting on the floor, leaning up against the bed with feet out in front of them. (Resident #703) said tripped and fell and did not hit head. Guest is complaining of right hip pain 5 out of 10, I notified provider and recommended a STAT x ray of the right hip. Guest was wearing appropriate footwear and non-slip socks. Room was free of clutter and well lit. Notified family of incident. Vital signs right after fall . 154/99 (1230 PM [elevated]) with pulse of 70 . (Authored by Registered Nurse [RN] L) - 2/1/23 at 3:08 PM: eINTERACT SBAR Summary for Providers . Situation . Falls . Outcomes of Physical Assessment . Functional Status Evaluation: Fall . Pain Status Evaluation: Does the resident/patient have pain? Yes . Neurological Status Evaluation: (Blank) . Nursing observations, evaluation, and recommendations are: (Blank) . Primary Care Provider responded with the following . Recommendations: Complete x-ray, family insisted on resident going to ED . Out to ED . (Authored by RN K) - 2/1/23 at 4:17 PM: Skilled Charting . Investigation Summary Note: Guest had a noted fall on 2/1/23. Nurse description of the event is reported as: Guest was found on the floor by a nurse bringing lunch to room. Guest was sitting on the floor, leaning up against the bed with feet out in front of them. (Resident #703) said they tripped and fell and did not hit head. Guest is complaining of right hip pain 5 out of 10, I notified provider . recommended a STAT x-ray of the right hip. Guest was wearing appropriate footwear and non-slip socks. Room was free of clutter and well lit. Notified family of incident. Vital signs right after fall . 154/99 (12:30 PM- elevated) with pulse of 70, not her vital signs are 117/71 (1400- 2:00 PM) with pulse of 68 . After hip x-ray guest complained of rib pain and the family wanted to resident to be evaluated at (hospital) ED. Guest was sent to ED. Root cause has been determined to be transferring without assistance/misunderstanding of limitations. IDT met and care plan has been reviewed. New intervention added to keep walker next to bed and a sign on the medication cabinet to keep walker there. - 2/3/23 at 6:33 PM: eMar - Shift Level Administration Note . Guest expresses is experiencing pain, post fall. A review of facility provided employee list revealed neither RN K nor RN L were listed as facility employees. Upon request of Incident and Accident (I and A) report and any related investigation document to Resident #703's fall in the facility on 2/1/23, the Administrator provided the following: - I and A form, dated 2/1/23, which detailed, Fall . Nursing Description: Guest was found on the floor by a nurse bringing lunch to room. Guest was sitting on the floor, leaning . feet out in front of them. (Resident #703) said tripped and fell and did not hit head. Guest was wearing . non-slip socks. Room was free of clutter and well lit . Resident Description: (Resident #703) said tripped and fell and did not hit head . complaining of right hip pain 5 out of (10) . Resident Taken to Hospital: Y (Yes) . Injuries Observed at Time of Incident . Unable to determine . Right trochanter (hip) . Level of Pain . 5 (out of 10) . Mobility: Ambulatory with Assistance . Mental Status: Orientated to Person . Injuries Report Post Incident . No Injuries Observed Post Incident . Predisposing Physiological Factors: Confused . Weakness . Gait Imbalance . Impaired Memory . Predisposing Situational Factors . Ambulating without Assist . Predisposing Situational Factors . Using [NAME] . (Authored by RN K) Review of Resident #703's Hospital diagnostic testing reports dated 2/1/23 revealed: - 2/1/23: CT Chest/Abd (abdomen) Pelvis . Impression: Acute fractures of the lateral right 11th and 12th ribs . - 2/1/23 XR (x-ray) Hip Right . Impression: Partially healed incomplete nondisplaced periprosthetic fracture proximal right femur. No evidence of acute injury . An interview was completed with Certified Nursing Assistant (CNA) J on 6/8/23 at 1:24 PM. When queried regarding Resident #703's required level of assistance for ambulation and to use the bathroom, CNA J indicated the Resident requires one assist but gets up on their own. When queried if the Resident ever uses their call light for assistance, CNA J replied, Sometimes. When queried if the Resident is confused, CNA J revealed they were. When asked if the Resident was cognitively able to utilize the call light when it is within their reach, CNA J stated, Yes and continued that the Resident's family is usually present and assists with care. CNA J was queried regarding the signs in Resident #703's room specifying their walker needed to be next to the bed and the reason for the signs. CNA J replied the [NAME] needed to be by their bed was so they could use it when they get up. When queried why they were getting up without one person assist if that is what they require, CNA J did not provide an explanation. When queried regarding the call light not being in reach and the walker not being next to the bed during observation on 6/8/23 at 8:40 AM, a reasonable justification was not provided. When asked if the Resident is able to be left unattended in the bathroom, CNA J reiterated the Resident will get up on their own. When queried regarding observations of Resident #703's room door being closed and the reason the door is closed when care is not being provided, CNA J disclosed resident doors are closed for privacy and to maintain a home-like feel. When queried regarding Resident #703 getting up on their own, risk for falls, and how staff observe the Resident when they are in the room with their door closed, CNA J did not provide an explanation. Additional review of Resident #703's care plans revealed the following care plans revealed the following: - Alteration/at risk for musculoskeletal problems r/t HX (history) of right femur fracture (Initiated: 6/14/21; Revised: 5/23/23). The care plan included the intervention, Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance (Initiated: 2/2/21). - Actual ADL/Mobility deficit, hx of Right femur fracture, Alzheimer's dementia . HX: Falls, incontinence, weakness, impaired mobility . Guest unable to utilize call light related severe cognition impairments. Staff to anticipate needs (Initiated: 8/30/21; Revised: 5/23/23). Review of Resident #703's EMR revealed the current active order, Hydrocodone-Acetaminophen (Norco- narcotic pain medication for severe pain) Oral Tablet 5-325 mg (milligram) . Give 1 tablet by mouth every 6 hours for pain due to recent FX (fracture) of ribs (Start Date: 2/20/23). Per the Resident's Medication Administration Record (MAR) for June 2023, they were still receiving the medication for rib pain from their fall with fracture. An interview and review of Resident #703's fall was completed with the Director of Nursing (DON) on 6/9/23 at 11:55 AM. When queried what intervention was implemented following the fall with subsequent rib fracture, the DON replied, Keep walker next to bed. When asked where the Resident's walker was in the room when they fell on [DATE], the DON was unable to provide a response. When queried the last time the Resident had been observed by staff prior to finding them on the floor, the DON was unable to provide a time. When queried if Resident #703 is supposed to have assistance from staff to transfer and ambulate, per their orders/care plan, the DON confirmed they are. The DON was then queried regarding the root cause of the fall, per the investigation summary note, being transferring without assistance, and how the intervention was going to ensure the Resident received the required staff assistance, the DON did not elaborate. When queried regarding observation of the Resident, in bed with the door closed, call light not in reach, and walker not next to them, the DON denoted they were unaware. When queried if the facility had any additional investigation information pertaining to the Resident's fall, the DON revealed they would check. Resident #708: Record review revealed Resident #708 was most recently readmitted to the facility on [DATE] with diagnoses which included dementia, kidney disease, intracerebral hemorrhage (brain bleed), stroke, weakness, difficulty walking. Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively intact and required limited one person assistance for transferring, dressing, and toileting. The MDS further indicated the Resident had one with no injury and one fall with major injury. On 6/8/23 at 11:15 AM, Resident #708 was observed sitting in a wheelchair at an empty table in the dining room of the facility. When spoke to, Resident #708 was pleasantly confused and unable to provide meaningful responses to questions asked regarding falls in the facility. At 1:15 PM on 6/8/23, Resident #708 was observed sitting at the same table as previously observed in the dining room. The Resident was eating their lunch at this time. Review of Resident #708's care plans revealed a care plan entitled, Risk for falls r/t dementia, intracerebral hemorrhage . poor safety awareness (Initiated: 4/13/22; Revised: 2/2/23). The care plan included the interventions: - During transfers, remind/encourage guest to change positions slowly 1/31/23 (Initiated: 2/2/23) - Frequent rounds on resident when in room to make sure needs are met (Initiated: 2/2/23) - Neuro checks per protocol (Initiated: 4/13/22) - Reinforce need to call for assistance (Initiated: 4/13/22) - Resident transfers via 1pa ambulation with 1pa 2WW (two wheeled walker) (Revised: 2/1/23) - Set Guest on dining table while sitting on wheelchair when in dining room for meals (Initiated: 8/23/22) - Use shower chair when giving a shower (Initiated: 2/3/23) - Wear gripper socks at all times as resident allows (Initiated: 10/17/22) The care plan also included the discontinued intervention, Resolved: Requires 2PA for ambulation (Initiated: 4/13/22; Revised and Resolved: 2/1/23) A second care plan entitled, Actual ADL/Mobility deficit d/t . RUE (Right Upper Extremity) fx (fracture) (Initiated: 4/13/22; Revised: 2/2/23) was noted in the Resident's EMR. This care plan included the Resolved intervention, Sling to RUE at all times (Initiated: 2/2/23; Resolved: 3/26/23). Review of Resident #708's progress note documentation in the EMR revealed the following: - 8/23/22 at 6:29 PM: Skilled Charting .Resident observed sitting on floor near table in dining room, no injuries. Resident states . was trying to get out of chair back into wheelchair. Assist off floor with 2-person assist . Will continue with plan of care . - 8/23/22 at 7:05 PM: Skilled Charting . Observed on floor in dining room near table. Resident states . was trying to get out of chair to get back into wheelchair. Assist off floor with 2-person assist . Will continue with plan of care. - 8/23/22 at 9:14 PM: Incident Note . Investigative Summary r/t incident on 8/23/22. Nurse was called by staff to dining room, upon arrival, nurse observed Guest on floor in dining room near table. Resident states was trying to get out of chair to get back into wheelchair. Nurse assist Guest off floor with 2-person assist . Root cause: guest self-transferred from dining chair to w/c (wheelchair) without assistance. Intervention: Guest will be assisted on dining table on w/c ensuring no dining chair is closed to guest. - 10/14/22 at 8:15 AM: Skilled Charting . LATE ENTRY . (CNA) notified nurse that guest was found on the left side of the bed (bed in lowest position) sitting on the floor . was wearing socks and shoes and the room was free of clutter. Guest was helped into bed and relaxed for a little while before being assisted into chair . Guest was found to have high blood pressure and I notified provider on call, they recommended giving guest scheduled blood pressure medications and to recheck blood pressure in an hour. Blood pressure was rechecked in an hour and blood pressure in now WNL (Within Normal Limits) . Guest is resting in chair . Guest said . slipped out of bed and hit head but is only complaining of 3 out of 10 left shoulder pain. Remind guest to call for help for assistance. - 10/17/22 at 11:28 AM: Skilled Charting . Investigation Summary . Resident was found next to bed with regular socks on, care plan updated to have the resident wear gripper socks at all times as allowed. - 1/31/23 at 7:08 PM: Incident Note . Certified Nursing Assistant [CNA] N) called for help, and (Licensed Practical Nurse [LPN) O] went in to help . asked for more assistance. All the nurses went in to assist. Guest was laying in the shower on the floor on belly and left side. The CNA stated that (Resident #708) stood up from the shower bench to transfer to wheelchair and fell slowly down as (CNA) tried to brace them. The CNA stated that (Resident #708) did not hit their head. (Resident #708) said . did hit head. Neuros were started and a complete head to toe assessment was completed . had minor scratches to Left thigh and knee . complaining of left hip and right shoulder pain. 8/10 . no bruising or swelling to area. Guest has active ROM. Guest able to squeeze nurse's fingers and hold when nurse pushes back and forth. VS taken. BP: 78/48 (low), HR: 95, RR: 15. Guest complains it hurts more with movement. All nurses safely assisted guest to wheelchair. Once in wheelchair guest vomited and had a BM . safely assisted back to bed. On-call (Provider) called and notified . said to continue neuros and get an x-ray of right shoulder and left hip . - 2/1/23 at 12:15 AM: Skilled Charting . Nurse called x-ray and they stated that it was dispatched out so someone would come out and do it before 6am. Tylenol was given earlier for pain . (Resident #708) is able to squeeze my fingers and hold steady while I push and pull. Complaining more of pain with movement. No swelling or bruising to area . - 2/1/23 at 6:53 AM: Skilled Charting . X-Ray still has not showed up. Called them and they said they pushed it to morning. (Resident #708) is able to squeeze my fingers and hold steady while I push and pull. Complaining more of pain with movement. No swelling or bruising to area . On call (Provider) aware . - 2/1/23 at 8:34 AM: Skilled Charting . Waiting on x-ray to arrived (sic) around 9:40AM to Xray R shoulder and L hip. Doctor is aware that we are waiting until x-ray gets here to x-ray patient. once results are in, will notify on call provider for further instruction. - 2/1/23 at 9:00 AM: Skilled Charting . Incident notes: Guest is still complaining of pain. We got the results back from x ray . sending guest to the hospital . - 2/1/23 at 10:50 AM: Skilled Charting . Results came in for right shoulder x ray and relayed results to on call provider. Guest will be transferred to the hospital per doctor . - 2/1/23 at 9:41 PM: Skilled Charting . Guest returned tonight from Hospital via an ambulance with a fractured right humerus post fall wearing a sling. Guest needs to wear the sling at all times for good healing and only take a sponge bath until seen by the doctor . - 2/3/23 at 2:01 PM: Skilled Charting . Investigation Summary Note: Guest had a noted fall on 1/31/23. Nurse description of the event is reported as: (CNA N) called for help, and LPN (LPN) O went in to help. (LPN O) then asked for more assistance. All the nurses went in to assist. Guest was laying in the shower on the floor on belly and left side. The CNA stated that (Resident #708) stood up from the shower bench to transfer to wheelchair and fell slowly down as (CNA) tried to brace them. The CNA stated that (Resident #708) did not hit their head. (Resident #708) said . did hit head. Neuros were started and a complete head to toe assessment was completed . had minor scratches to Left thigh and knee was complaining of left hip and right shoulder pain. 8/10. There was no bruising or swelling to area. Guest has active ROM. Guest able to squeeze nurses fingers and hold when nurse pushes back and forth. VS (Vital signs) taken. BP: 78/48, HR: 95, RR: 15. Guest complains it hurts more with movement. All nurses safely assisted guest to wheelchair. Once in wheelchair guest vomited and had a BM . assisted back to bed. On-call called and notified . said to continue neuros and get an x ray of right shoulder and left hip . X-ray later showed a hairline fracture non-displaced, resident sent to (Hospital) ED. Guest was given a sling and to attend a follow up appointment with orthopedics. Root cause has been determined to be transferring without assistance/misunderstanding of limitations. IDT met and care plan has been reviewed. New intervention added to use shower chair when giving a shower . - 2/3/23 at 12:14 AM: Skilled Charting . Incident notes . Guest rated pain 5/10 - 2/3/23 at 6:30 PM: eMar - Shift Level Administration Note . Guest is not getting up out the bed like normal, states is in pain. - 2/4/23 at 3:00 PM: Nursing Progress Note . Subjective: Fall from bed . Objective: Patient had a fall from bed, patient was lying in bed prior to the fall, no room clutter noted, patient had nonslip socks on, provider and family to be notified, no new orders at this time. Assessment: No apparent injury noted, and patient has full ROM. Plan: No new orders at this time. - 2/4/23 at 4:40 PM: Physician Progress Note . Pt (patient) sp (status post) left (sic) up (upper) ext (extremity) fracture . Pt instructed needs to ask for help when trying to transfer. ER paperwork reviewed. X Ray reviewed. Ortho consult ordered by ER . - 2/7/23 1:14 PM: Skilled Charting . Investigation Summary Note: Guest had a noted fall on 2/4/23. Nurse description of the event is reported as: Patient rolled out of bed and landed on knees with no apparent injury and no hitting of head, patient has no change to range of motion . placed back into bed and updated care plan. Neuros WNL PERRLA, vitals WNL, ROM WNL with fracture shoulder. Patient had a fall from bed, patient was lying in bed prior to the fall, no room clutter noted, and patient had nonslip socks on . Assessment: No apparent injury noted, and patient has full ROM. Root cause has been determined to be transferring without assistance/misunderstanding of limitations. IDT met and care plan has been reviewed. New intervention added to keep bed in lowest position . - 2/7/23 at 10:11 PM: Skilled Charting . Incident note . Guest is complaining of 5/10 pain in shoulder . Resident #708's care plans were reviewed again. No active and/or resolved care plan and/or intervention were present related to maintaining the Resident's bed in the lowest position. Review of Resident #708's Health care provider orders revealed the following active and discontinued orders: - Discontinued . Transfers 2PA with walker Ambulation therapy only (Discontinued: 2/1/23) - Transfers 1 PA Ambulation 1 PA with 2WW (Ordered: 2/1/23) Review of Neuro Assessment documentation for Resident #708 revealed the form contained a section titled, Neurological Assessment . A1. Which Neurological Schedule is being performed? 1) Q (every) 15 min. x 1 hour 2) Q hour x 4 hours 3) Q 2 hours x 4 hours 4) Q shift x 24 hours . Neuro assessment documentation following their fall on 1/31/23 revealed neuro assessments were not completed four times for the first hour following the fall. Neurological assessments were completed on 1/31/23 at 7:20 PM, 7:35 PM, 7:50 PM, 8:50 PM, 9:50 PM, 10:50 PM, and 11:50 PM and 2/1/23 at 1:50 AM, 3:50 AM, 8:30 AM, and 9:55 PM. Review of Resident #708's Fall Risk Assess documentation dated 2/1/23 detailed, Reason for Assessment Request . Recent Falls . History of Falls within last six month . 1-2 times . Memory and Recall Ability: In the last 7 days: recalls three out of four of the following: current season, that he/she is in a nursing home, location of room, staff names/faces . Sometimes . Confined to a Chair: If resident cannot walk even when assisted by staff are they . Confined to a chair and oriented . Gait Analysis . Requires hands-on assistance to move from place to place . Uses an assistive device . Intervention/Comment: Remind guest to call for help for assistance . Upon request for all I and A forms and documentation for Resident #708 since the last annual, the Administrator provided the following: - 10/14/22, I and A form: Fall . Nursing Description: CNA notified nurse that gues was found on the left side of the bed . wearing socks and shoes . Resident Description . slipped out of bed and hit head but is only complaining of 3 out of 10 left shoulder (pain) . Injuries Observed at time of Incident: No injury Left shoulder (rear) . Level of Pain: 3 . Mental Status: Orientated to Person .Orientated to Situation . Notes: Guest claims . has 3 out of 10 pain in left shoulder, no visible injury, ROM (Range of Motion) intact . Predisposing environmental Factors . Other . Predisposing Physiological Factors . Weakness . Guest said slipped out of bed, bed was in lowest position . No Witnesses . - 1/31/23, I and A form: Fall . Nursing Description: CNA N called for help, and LPN O went in to help . then asked for more assistance . Guest was laying in the shower on the floor on belly and left side . fell slowly down as (CNA) tried to brace them. Resident Description: I tried to move over by myself and I fell . Immediate Action Taken: Neuros started . guest found at baseline . minor scratches Complaining of left hip and right shoulder pain 8/10 . no bruising or swelling to area . Taken to Hospital: N (No) . Injuries Observed at time of Incident: Abrasion: Left thigh . Abrasion: Left knee . Level of Pain: 8 . Mobility: Wheelchair bound . Mental Status: Orientated to Person . No Injuries Observed Post Incident . Predisposing environmental Factors . Wet floor . Predisposing Physiological Factors . Weakness . Gait Imbalance . Impaired Memory . Predisposing Situational Factors . Ambulating without Assist . During Transfer . - 2/4/23 at 2:15 PM, I and A form: Fall . Nursing Description: Guest found on knees next to bed with no apparent injury and denies hitting head . Resident Unable to give Description . Immediate Action Taken . Guest assessed for signs of injury and denies any pain at this time . assisted safely into bed. ROM intact . updated care plan . Injuries Observed at time of Incident: No injury . Mental Status: Orientated to Person . Predisposing Physiological Factors . Weakness . Impaired Memory . Predisposing Situational Factors . Ambulating without Assist . No Witnesses Review of Resident #708's Radiology Results Report dated 2/1/23 at 10:23 AM and reviewed 2/1/23 at 1:51 PM detailed, Shoulder Complete . 2V (2 View) . Reason for Study . Pain in Right Shoulder . Findings . There is a hairline, nondisplaced surgical neck fracture of the right humerus . Visualized right hemithorax (collection of blood between the chest wall and lung) is clear . Conclusion: Acute surgical neck fracture right humerus . On 6/9/23 at 7:55 AM, Resident #708's room door was closed. Upon knocking and entering, Resident #708 was observed on their back in their bed with their eyes closed. The right side of the bed was positioned directly against the wall and their overbed table was positioned next to the left side of the bed. The bed was approximately waist high and not in low position. An interview and review of Resident #708's falls was completed with the Director of Nursing (DON) on 6/9/23 at 11:55 AM. The DON was queried regarding Resident #708's fall on 10/14/22 and interventions implemented following the fall. The DON reviewed the Resident's EMR and stated the intervention implemented following the fall was, Gripper socks. The DON was asked if the Resident was wearing socks and shoes when they fell and confirmed they were. When queried how gripper socks were different than shoes for fall prevention, the DON was unable to provide an explanation. When asked the rationale and appropriateness of that intervention related to the fall, given the Resident was wearing shoes, the DON replied, I agree. It doesn't make sense. When asked why the IDT Investigation note following the fall indicated the Resident was wearing regular socks when the nurses note and I and A specified the Resident was wearing shoes and socks, the DON was unable to explain the discrepancy. When queried if wearing non-slip footwear including gripper socks and/or shoes was a standard intervention for fall prevention, the DON confirmed it was. When queried if the Resident was at risk for falls prior to falling, the DON verified they were. The DON was then asked why the intervention was not already in place, the DON did not elaborate. The DON was then asked to clarify what time Resident #701 fell on [DATE], the DON was unable to provide a specific time. When queried what occurred when Resident #708 fell on [DATE] and fractured their humerus, the DON revealed the Resident had just finished receiving a shower when the fall occurred. When asked if the CNA was present when the Resident fell , the DON replied, Yes. The DON was then asked what they determined had occurred from the investigation and stated, From what I was told, (CNA V) had just turned their back for a minute to get something and the Resident stood up and fell . When asked where the wheelchair was in the bathroom when other staff entered the room, the DON replied, I don't know. The DON was then asked how CNA V braced the Resident during their fall and the DON indicated they believed the CNA turned around, saw the Resident, and then assisted/lowered them to the floor. When queried how Resident #708 fell hard enough to fracture their humerus (large bone in upper arm) while being lowered to the ground, the DON was unable to provide an explanation. The DON was then asked what intervention was implemented following the fall and replied, Shower chair. When queried what was being used for the Resident's shower on 1/31/23, the DON revealed the Resident was sitting on the bench in the shower. The DON was queried regarding the difference between sitting on the bench vs. a shower chair, the DON replied, Two handra [TRUNCATED]

This Citation pertains to Intake Number MI 687. Based on interview, and record review, the facility was placed in Immediate Jeopardy (IJ) when Licensed Practical Nurse (LPN) F failed to respond and/or address concerns regarding a deterioration or change in condition (Respiratory Distress) for one resident (Resident #400) on two occasions at approximately 3:00 PM, and 3:30 PM, respectively, on [DATE], when prompted by Resident Care Aid (RCA) C. RCA C observed Resident #400 excessively drooling down one side of his face and observed him to be in respiratory distress. LPN F failed to respond when notified and perform an adequate assessment and monitoring, obtain vital signs and/or a pulse, or assess respiratory status when informed by RCA C that Resident #400 had a drastic change in his condition. LPN F failed to assess Resident #400 at any time during the afternoon hours of [DATE], failed to provide treatment, failed to perform Cardio-Pulmonary Resuscitation when Resident #400 was found unresponsive, and failed to summon emergency services and have Resident #400 taken to an acute care facility. out of 9 residents' care reviewed, resulting in a delay in emergency medical treatment, transfer out of the facility for emergency services, lack of an adequate assessment for change in condition, and a delay in the initiation of CPR, for Resident #400 who went into [CONDITION(S)] resulting in his death in the facility on [DATE]. These deficient practices place 58 residents at significant risk to not receive competent care during a serious deterioration of condition or an emergency situation and to not receive life-sustaining measures in a timely manner. Immediate Jeopardy: The Immediate Jeopardy began on Thursday, [DATE]. The Immediate Jeopardy (IJ) F-684 was identified [DATE] at 3:00 PM, upon review of the Emergency Medical Services (EMS) Run Report, dated [DATE], review of clinical record and other pertinent documents. The Administrator was notified of the Immediate Jeopardy on ,d+[DATE]//21 at 3:30 PM, and was instructed to provide an Abatement Plan to remove the immediacy. The facility also needs to operationalize their CPR protocol and policy to include the determination of the Code Status of each resident and the initiation of CPR in a timely manner, if a resident is deemed to be Full Code status. The Immediate Jeopardy was removed on [DATE], based on the facility's implementation of the Removal Plan as verified onsite on [DATE], The Immediate Jeopardy was changed to F-600 on [DATE], and the facility was notified of the change and a notification was provided to the Administrator for signature as received on [DATE] at 3:30 PM The Removal Plan from [DATE] remained in effect with a Removal Date of [DATE]. Findings include: Resident #400: A review of Resident #400's medical record, revealed Resident #400 was a [AGE] year old male with an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) dated [DATE], Resident #400 scored a 15 out of 15 on the cognition assessment, indicating no cognition impairment. Further review of the MDS revealed the Resident #400 needed extensive two-person assist with bed mobility, transfers, dressing and toilet use. Review of Resident #400's clinical record, documented on [DATE] at 10:35 AM, under vital signs, an entry made by LPN F as a Blood Pressure of ,d+[DATE], and a warning listed 'Systolic low of 90 exceeded' generated in the computer system of Point Click Care. Further review of the clinical record reflected the blood pressure entry made by LPN F was not struck out as incorrect, or another blood pressure re-entered. Review of progress notes for documentation around 10:35 AM, on [DATE], reflected no entry made in the record by LPN F related to the condition of Resident #400 for blood pressure monitoring. Review of Progress notes, in the clinical record, reflected an entry made by LPN F under skilled charting [DATE] at 18:04 (6:04 PM). The documentation entered was Around 17:05 (5:05 PM) CENA alerted writer that guest was unresponsive. Writer entered room to assess guest and noted guest had no pulse. Writer alerted staff there was a code blue, verified guest was a CPR and began compressions. 911 was called at 17:09 (5:09 PM) and EMS arrived at 17:18 (5:18 PM) and took over compressions. At 17:24 (5:24 PM) EMS called MD to call time of death. Time of death called by (DR.) at 17:34 (5:34 PM). DON, MD, and Admin. aware. CENA was in the room at 1600 and guest was sitting up in bed, guest was responsive at that time. CENA went back to room around 1700 to complete rounds and noted guest was unresponsive and alerted writer. There were no s/s of distress noted throughout shift. Code status was followed per medical record. ME (medical examiner) notified and waiting on medical examiner number. The next entry was made [DATE], at 19:30 (7:30 PM) by LPN F, as ME was here to pronounce. Number ,d+[DATE]. The next entry was made on [DATE] at 23:32 (11:32 PM) by a different nurse, who came onto the next shift, and documented Resident was taken by medical examiner at 19:37. (7:37 PM). Review of Resident #400's Code Status, as documented in the medical record, reflected a Code Status Form for Full Code, as noted by an X in the Full Code box, signed by Resident #400 on admission, dated [DATE]. Further review of the form, reflected under a box for Do Not Resuscitate, a blank box not verified with an X, however, the form documentation reflected an entry This do-not-resuscitate order is issued by attending physician name printed, who was the attending physician for Resident #400. At the bottom of the form, Under Attestation of Witnesses's, documented 2 witnesses's names printed, signed, and dated for [DATE]. Corporate Compliance Office O was shown the form and was asked to clarify Code Status for Resident #400, and indicated the form was documented inaccurate, that Resident #400 had chosen Full Code Status. She verbalized someone made a mistake on the form, and also there did not need two witness signatures for verification of Full Code, as Resident #400 was alert, oriented, and his own responsible party. Corporate Officer O indicating upon review of the form an audit was being done to verify correct Code Status reflected in medical records. An interview was conducted on [DATE], with Registered Nurse A at 9:37 AM. RN A indicated she remembered the events that occurred on [DATE], with Resident #400. RN A verbalized she was near the 600 hall, in a sitting area, talking to the Director of Nursing (DON), who was working the floor that day, caring for residents on the 600 hall. RN A indicated she remembered LPN F walking over to her and the DON, and witnessed LPN F verbalize to the DON, I need you to come and look at my patient. Something is wrong. RN A was asked what time did LPN F summons help, and indicated it was around 5 PM, Supper time. RN A verbalized the DON sent RN A over to assist LPN F as DON was working a cart and caring for residents on the 600 hall. RN A was asked if LPN F had came up running and verbalized, No, she was walking. RN A was asked if she knew what area LPN F was working, and indicated on the 300 hallway, across the hall, on the other side of the building. RN A indicated she asked LPN F what was going on, and LPN F had not identified the concerns were with Resident #400 at that time. LPN F verbalized to RN A I don't know, he don't seem right. RN A was then informed it was Resident #400. RN A indicated she asked LPN F Did you assess him. Does he have a pulse. RN A said LPN F remained silent when she asked her twice and did not answer both times. RN A verbalized again that LPN F did not respond when asked if she checked for a pulse. RN A verbalized that when she walked into Resident #400's room, and looked at Resident #400, he was 'discolored, not pink, gray/ ashen color' and not responding. I checked for a pulse and could not verify that he had a pulse. RN A asked LPN F when the last time she seen Resident #400. LPN F indicated it was around lunch time (noon) and that he had an increase in congestion and sputum. RN A indicated she asked LPN F what the Code Status was for Resident #400, and LPN F verbalized she did not know and would have to go check the clinical record. RN A indicated that LPN F left the room and walked down the 300 hall toward the area where the computer was located, and checked the Code Status. RN A verbalized that a Resident Care Aid C came into the room and asked her if she knew Resident #400's code status. RCA C verbalized she did not know. RN A indicated she was waiting for LPN F to return with Code Status verification and had opened Resident #400's gown. RN A verbalized another Aid came to the room during that time from the 100 hall. RN A verbalized again she knew something was wrong with Resident #400. RN A indicated that LPN F returned several minutes later and verbalized Resident #400 was a Full Code. RN A was asked if she attempted to assess Resident #400 by listening for lung sounds, respirations, or obtain oxygen saturation levels, blood pressure, or any vital signs during that time. RN A indicated just a pulse, and it was absent. RN A verbalized she directed someone to call 911, (AID she thinks) and someone to bring the crash cart, and at that time began compressions on Resident #400. RN A said she thought it was less than 5 minutes for LPN F to come back, but was not sure how long. RN A was asked if LPN F ever announced Code Blue at any time, and verbalized she did not. RN A verbalized an RN, who was working the floor on the next hall over (400 hall), showed up, who was a Corporate RN, came to assist her with CPR. RN A was asked how that RN knew to come, and replied that an Aid went and got her. RN A indicated the other RN placed an AED device on Resident #400 and was advised not to defibrillate, and then took over doing compressions. RN A indicated she then got an Oxygen mask with the Ambu bag and began ventilation and CPR with the other RN. RN A verbalized they continued the compressions until EMS arrived. RN A indicated that an Aid went back to the 600 hall and got the DON to come over. When the DON came in the room, We switched doing compressions for maybe 10 minutes. RN A was asked what LPN F was doing during the code, and indicated LPN F did not do any compressions, and was standing back in the room, appearing to be frustrated and flustered. RN A verbalized someone was taking notes, but could not recall who was documenting the code. RN A verbalized that she and RCA C helped place a back board under Resident #400 at some point, because the bed was soft. RN A went on to say that EMS arrived, and there were 3 of them. RN A said that one of the EMS personnel hooked Resident #400 up to telemetry unit, and the heart rhythm detected was 'Asystole' (no rhythm). RN A indicated that one of the EMS girls took over and assisted with compressions, and the third girl called dispatch to speak to the Physician, who called the time of death. RN A verbalized that compressions and ventilation had been stopped at the time the Physician declared the time of death. RN A indicated she wrote down a timeline of the events and gave all the notes to LPN F and indicated These are your notes and times to be entered in the medical record. RN A was asked if there were any notes or documents related to the event available, and said they were all given to LPN F. RN A was asked if she thought anything different could have been done for Resident #400, and verbalized that LPN F could have called for help instead of leaving the room, and walking across the building, all the way to the other side. RN A verbalized that LPN F could have got the RN on the 400 hall, who was right next to her on the next hall over, and also paged overhead for Code or for help. RN A verbalized LPN F could have told her if she had assessed Resident #400, or attempted to get vital signs or a pulse at anytime, and at noon when she indicated he was congested. RN A also verbalized that LPN F could have ran instead of walking. RN A verbalized again, she could have gotten someone closer and faster. RN A said, She should have assessed him and known if he was breathing or had a pulse. RN A verbalized We did what we could. RN A became tearful during the interview, and discussed the information related to informing the family of the events that took place with family member of Resident #400's passing. An interview was conducted on [DATE] at 11:13 AM, with LPN F. LPN F was asked if she was the nurse in care on 1st shift, of Resident #400 on [DATE], and said yes. LPN F was asked if she remembered Resident #400, and said, He was the over-dose Resident with [CONDITION(S)]. He was alert and oriented, dependant on staff for Activities of Daily Living Care. LPN F was asked to clarify what she meant about Resident #400 being the over-dose resident and said, Oh, never mind. I might be mixing him up with someone else. LPN F was asked if she remembered the day that Resident #400 passed away, and indicated she did and said, What do you want to know. LPN F verbalized she gave him (Resident #400) meds at ,d+[DATE] AM. He ate breakfast and was talking. He had a blanket over his head. His Family came in and visited that day around 11ish or so, two ladies, I think. I seen him again around 11 AM and gave him meds. He still had the blanket over his head and said he was ok. I went in at 2 PM, he had no issues. I went in at 4 PM, he was sleeping. LPN F said around 5 ish, during Supper time, the Aid, with reddish hair, (said she couldn't remember her name) came and got me. After I checked my other resident's, I went to the room. The blanket was off his head. He was Ghostly colored/Pale. I ran to the 600 hall, from the 300 hall, to get the DON. I had to go past the dinning room to get to the 600 hall. It is on the other side of the building. The DON and ADON were both there sitting and charting. I said, I need you both to come immediately. The DON sent the ADON. She (DON) stayed on the 600 hall, because she was working a cart. We went into Resident #400's room. She (ADON) looked at him and checked for a pulse. She did not get one. I did not assess him, she did. I did not check for a pulse. The ADON asked me his code status. I did not know. She stayed with the resident and told me to go check for Code Status. I went up the 300 hall, to the open area, where the computer was located and checked his Code Status. I came back and told her he was a Full Code, and we started CPR. LPN F verbalized that she had not assessed Resident #400, before she went and summoned help, or checked his pulse or perform any other assessment, when Surveyor asked. LPN F was asked if she ever called Code Blue, or yelled for help at any time and verbalized that No one called Code Blue, or yelled for help. LPN F indicated the ADON said go get the crash cart. LPN F said I helped put the back board under Resident #400. The Corporate Nurse who was working the 400 hall, arrived to help. I don't know how she knew to come. Someone must have went and got her. The DON showed up a short time later. I called 911. LPN F was asked how long it took to check a code status in the computer and indicated maybe 1 to 2 minutes, not very long. LPN F was asked how long it took to go across the hall and get the DON, and said maybe 3 or 4 minutes. LPN F said she called the medical examiner to fill out the paper work and release the body. LPN F verbalized the medical examiner indicated not to touch anything and leave everything as is. LPN F was asked if she had any notes from the event and indicated she did not. I got rid of all of that. I charted and did not need that anymore. I got rid of all of that stuff. LPN F was asked about her inconsistencies with documentation in the medical record, entered on [DATE], at 17:05. LPN F was also shown the medical record documentation and that it did not reflect her interview and an accurate recall of the events. LPN F had documented Writer assessed for pulse . and verbalized again, I did not assess him, the ADON did. LPN F was asked if she paged 'Code Blue' at anytime and said No. LPN F was asked why she went all the way across the building to get help. LPN F did not respond to the question. LPN F was asked if she obtained any vital signs for Resident #400 on [DATE], and verbalized 'I am sure I did. LPN F was asked if Resident #400 had an increase in sputum/congestion, and said Not that I can remember. LPN F was shown the documented Blood Pressure of ,d+[DATE], documented on [DATE] at 10:35 AM, and did not offer an explanation. An interview was conducted with the Director of Nursing (DON) on [DATE] at 11:00 AM. The DON was asked about the events on [DATE]. The DON verbalized she remembered that day as she was working a floor/cart, taking care of several residents residing on the 600 hall. DON said, Around 5 PM, I was talking to the ADON [NAME] wowing over issues and following up with Infection Control things. It was getting late in the day. I remember LPN F walking over and asked for assistance. She said Can you come over and look at him. I don't remember her giving a name at that time. The DON was asked if LPN F paged for emergency assistance or Code Blue at any point. The DON indicated They don't use overhead paging here. I sent the ADON over to assist with what she needed, because I did not want to leave my residents alone on the 600 hall. I sent her. I stayed with my cart and my residents. Several minutes later, and Aide from the another hall, came and waved me to come on. I ran and followed the Aid to Resident #400's room. I entered the room and observed CPR in progress. I seen the crash cart, the AED was hooked up, the pads were correct. I observed my ADON and the Corporate RN, from the 400 hall performing compressions and ventilation. I verified if anyone called 911 and was told yes, and they were in route. I am not sure who was documenting notes. EMS showed up. It was 3 girls. The EMS people did not take over the code, but one of the girls helped do cycles of CPR. One set her bag down and adjusted some wires. The other assisted with compressions. I did one cycle of compressions. The other EMS girl called the Physician at the hospital and relayed information and a time of death was called. The DON was asked if she seen LPN F or the ADON walking or running and verbalized she did not see either one running. Paper work was provided to EMS. I did not see them start a line or give any meds. I was only there for ,d+[DATE] minutes, not very long, and had to go back to my cart and the resident's on the 600 hall. The DON was asked to provide notes or any documentation related to the event, and indicated all the notes were provided to LPN F for her charting. The DON verbalized she did not have any notes, timeline, documentation, or an investigation from the event on [DATE], and that an investigation had not been completed. The DON did not provide the Surveyor any documentation upon request related to events involving Resident #400 on [DATE], and his death. An interview was conducted on [DATE] at 11:34 AM, with Administrator. The Administrator was asked about Resident #400's Code on the day of [DATE]. The Administrator verbalized she was not in the building during the incident, and that the DON had called her and told what had happened. She kept me informed about Resident #400 and all the events. She also said that other people had phone her, and was not specific who those other people were. She also indicated she fed him at lunch, around 12 and he was responsive. Family was in to see his Dad. They said Resident #400 had a blanket over his head. No one reported to me any thing about his condition. Administrator was asked if she started an investigation after the events and Resident #400 expiring, and said there was no investigation. I did not do one. I was informed the nurse went and got help, but did not say where she got help. CPR was attempted. Three EMS people came and were in the room. I did not do an investigation. Nothing was out of the ordinary. It was a basic Code. An interview was conducted on [DATE] at 1:36 PM, with Resident Care Aid (RCA) C who indicated she started her shift a little before 2 PM on [DATE], and was the Waiver Aid assigned to care for Resident #400, on 2nd shift. (Time clock verification indicated 1:54 PM started her shift). RCA C was asked if she remembered what happened on [DATE], the day Resident #400 passed away. RCA C indicated she did. RCA C indicated it was Strange what happened to Resident #400. RCA C was asked why she thought it was strange. RCA C indicated she got report from the off going shift, and began to pass water to her residents. I am coming down the hall and his family (Resident #400) stopped me. They had been in visiting Resident #400's dad, who is a resident in the facility too. It was 2 ladies. They asked me if I would go check on Resident #400, that something was wrong. RCA C was asked what time she went in and looked at Resident #400. RCA C verbalized it was around 3ish, per family request. I walked in He had a blanket over his face. I asked if he was ok. He brought the blanket down off of his face. He looked pale. He was slurring his words. He said he was cold. I noticed he was drooling down one side of his face. (did not indicate left or right side of face). I left the room. I went directly to the nurse. (LPN F). I asked her to go in and check on the Resident, that something was wrong with him. She never did go in and check. I went back in his room a second time, to check on him, around 3:30 PM. I seen him breathing very hard (blowing air), and he was foaming at the mouth at this time. I went to the nurse again, for a 2nd time. I asked her to please go check on Resident #400. I told her he was breathing funny and had drool/foam on his face. He had a lot of it. The nurse did not go in and check him again. I asked her during that time, Is this normal for him to be drooling down the side of his face so much. She said to me, This is normal. He did this to himself. They upped his Narc's yesterday. He foams out the sides of his mouth. RCA C said, The nurse never went in to check on him both times that I alerted her, that something was wrong. RCA C indicated the 1st and 2nd time I checked him, was long before 5 PM. I continued rounding on my other residents and providing care. RCA C went on to say We were getting close to Supper time. The trays come out around 5 ish. I thought I would go check on him again, before I passed a tray to his room. The third time I went into his room, around 5 PM, he did not look right. I walked over and touched him. He was cold. He was dead. I am not a nurse, but I have seen enough dead people to know when they are dead. RCA C was asked to clarify why she thought he was dead, and verbalized I was a Certified Aid for ,d+[DATE] years. I let my Certification lapse. I came to the facility to work as a Waiver Aid, do the training, and get it (Certification) back. I am not a nurse, but I know if something is wrong. Like I said, He was dead and cold. I left the room. I ran to find the nurse, who was down near room [ROOM NUMBER]. I told her You NEED to come now. It don't look good. The nurse walked into the room and looked at the Resident. She never tried to get a pulse, or take any vital signs or anything. She just looked at him. She left the room and walked across the building to the 600 hall, all the way to the other side of the building, to find the DON. The DON then sent the ADON into see what was up. The ADON came back with the nurse. The ADON tried to get a pulse and couldn't get one. The ADON was asking the nurse what his Code Status was. The nurse said she did not know and would have to check. The nurse left the room. I stayed with the ADON, and she was asking me if I knew the Code Status. I said, I don't know. The ADON was saying out loud, It should not take this long to find out a Code Status. She asked me again, if I knew the Code Status. I said, I don't know, for a second time. I didn't know. RCA C was asked how long the nurse was gone, and indicated it was longer than 6 minutes but less than 10. RCA C verbalized The nurse came back and said he was a Full Code. The ADON then started CPR. Another Aid got the crash cart. I helped place the back board under Resident #400, with the ADON. The nurse (LPN F) stood back and did not know what to do. She was just standing there watching what was happening. The Corporate RN, on the next hall, showed up to help. 911 was called. He had been long dead by the time CPR was started. No one ever checked his vital signs. EMS came and worked with him for just few minutes. He was pronounced dead. I asked that nurse to come 3 times. If she would have came on the 1st or 2nd time. He might still be alive or she could have got him out. Review of EMS Run Report was done on [DATE]. The report incident #,d+[DATE], documented Dispatch Information: Response Urgency: Lights and Sirens, dated as [DATE]. Time received 17:13. Time responded: 17:13. On scene: 17:18. Patient Contact: 17:22. Complaint reported: [CONDITION(S)]/Death. Medical information: [CONDITION(S)], Other: (Substance Abuse) History of Present Illness, under Primary Complaint documented: DOA Under symptom: Death. Last Time seen Normal: Time [DATE]. 13:00 hour. Under CPR information: Yes, prior to EMS arrival. Witnessed: Not witnessed. CPR prior to EMS arrival: Yes. AED used prior to arrival: Yes-no defibrillation advised. by Healthcare Professional. EMS: initiated chest compressions. Type of CPR: Compressions intermittent with ventilation. First monitored rhythm: Asystole. Circulation: No. Time CPR discontinued: 17:24 Reason CPR or resuscitation efforts discontinued: Obvious signs of death. Estimated time of arrest: > than 20 minutes. Initial CPR time: 17:09. Narrative: A 557 was dispatched PRI 1 to Above location for a [AGE] year old male in [CONDITION(S)], crew arrived on scene and brought all equipment (stretcher, Monitor, Jump Bag, IV Kit, Drug Box, Intubation Kit, Suction). Pt in room [ROOM NUMBER]. Multiple staff members were w/the Pt. and compressions and ventilation being performed on the Pt. who was laying supine. Staff had the AED attached to the Pt. with pads in proper position. Staff stated the pt was last seen alive around 1300, found unresponsive at 1700, and CPR started at 1709. Staff advised the AED had not advised that any defibrillation was needed. EMT (gave name) continued compressions to relieve on-scene RN. EMT (gave name) placed the pads on the Pt. and noted Asystole on the cardiac monitor. Pulse/breathing check completed and found the Pt Pulseless and Apneic during pulse check. Pt was found cool to the touch and with Rigor Mortis present in pt's jaw. Compressions were stopped at this time and pt was rolled slightly onto his side, crew noted Lividity (pooling of blood) beginning in the Pt's lower back. Hospital contacted via radio and given the crew findings. [NAME] [Time of Death] was given at 17:34 per Dr (gave name). Crew clarified last seen time with RN and RN confirmed 1300. Staff denied any complaints from the Pt, or distress when he was last seen. Local PD (gave name) was requested to the scene as was the [NAME]. Local PD arrived on scene spoke to Crew and Staff. At this time, Staff stated the Pt. was seen normal at 1300, approx 1400, and approx 1600. Crew waited on scene with PD for [NAME] (medical examiner investigator). When the ME arrived, Crew advised of our findings and the inconsistencies in the last known well time from staff. Crew cleared the scene. End of report. Under Treatment: Primary: [CONDITION(S)] Secondary: Obvious death. Protocol Used: General-Universal Patient Care/Initial Patient Contact: General Time: 17:22 Treatment: Cardiopulmonary resuscitation: success: Yes. Complications: None. Response: unchanged. Performed by (gave name of EMT) 17:22: Patient Contact. 17:23: Vitals Taken: BP: NA/NA Manual. Pulse: 0; Absent. Respiration Rate: 0; Apneic; ECG Rate: 0/Asystole; Pads; GCS Eye: 1. Verbal: 1, GCS Motor: 1, GCS Score: 3, AVPU: U, Position: Laying. Under Disposition: Patient Disposition: Patient Dead at Scene-Resuscitation Attempted (Without transport). (According to Science ABC. com, Rigor Mortis starts 2 to 6 hours after death.) (According to www.sciencedirect.com, Lividity (Livor Mortis) is the settling of blood in the body due to gravity. The pooling of blood in dependant parts which is associated with 4 stages of death: Pallor Mortis, Algor Mortis, Rigor Mortis, and Livor Mortis. Livor Mortis starts in ,d+[DATE] minutes after death, but is usually not observable by the human eye until 2 hours after death. The size of the patches increase in the next ,d+[DATE] hours, with maximum Lividity occurring between 8 and 12 hours after death). An interview was conducted on [DATE] at about 1:00 PM, with The Administrator, DON and Corporate Compliance Officer O, in the presence of another Surveyor, inquiring if the local Police showed up on [DATE], to the facility. All three staff were asked if there had been a police report made. Both Surveyors were informed by the three staff that they could not recall or remember if the police were ever onsite, or if a police report had been generated. Surveyor asked if an investigation had been conducted related to the events surrounding Resident #400's death, and were told No by all three staff listed above. The DON commented that she didn't know that the police were there at all. Corporate Compliance Officer O was interviewed, a short time later on [DATE], who was asked if the nurse had completed a transfer sheet, or any documentation related to change in condition, for Resident #400. Corporate Compliance Officer O verbalized, No and went on to indicate that the nurse did not know it was a code, at the time he was found unresponsive. Surveyor verbalized the nurse would have known it was a code if she had checked for a pulse, listen for respirations/lung sounds, or performed any type of an assessment upon the time of finding Resident #400, before leaving, to get help on the other side of the building. Review of LPN F's Nursing Orientation/Annual Competency Checklist, reflected she had completed one on [DATE], checked off as competent, signed by a former RN. Review of the checklist covered the Topics of : Vital signs, Documentation, (nursing assessments), Medicare charting (always include an assessment based on their primary diagnosis), and several other topics covered. Review of facility Policy 'Abuse, Neglect, and/or Misappropriation of Resident Property' dated [DATE], documented Facility (name) will not tolerate verbal, sexual, physical, or mental abuse, involuntary seclusion and/or neglect of its residents or misappropriation of resident's funds or property by anyone .Center staff should report any incident or suspicion of abuse, neglect, misappropriation of property to the administrator immediately . Under Purpose, To assure each resident in the center is free from abuse, neglect . Under definitions: Neglect--means the intentional or reckless failure to provide a resident with any treatment, care goods or service necessary to maintain the health or safety of the resident when its failure results in serious physical harm to the resident . Review of facility Policy 'Death of a Resident', dated [DATE], documented All resident's deaths, whether expected or unexpected, must be treated in the same manner. All resident's must be treated with dignity and respect at all times, including at the time of death. Under 'Procedure': In the event that a resident is found without a pulse or heartbeat or not

This Citation pertains to Intake Number MI 687. Based on interview and record review, the facility failed to immediately operationalize or initiate emergency life-sustaining measures, Cardiopulmonary Resuscitation (CPR), for approximately 9 minutes for one resident (Resident #400) out of 9 residents' care reviewed. Resident #400 was found with change in condition, absent of pulse, respirations, and vital signs. Resident #400 was designated as a Full Code for life saving measures. CPR was delayed and not initiated for approximately 9 minutes. Resident #400 died in the facility. Findings include: Review of facility Policy Cardiopulmonary Resuscitation (CPR) & Emergency Cardiovascular Care (ECC), dated [DATE], documented To respect each resident's individual informed decision regarding advance directives and code status. To initiate Cardiopulmonary Resuscitation (CPR) & Emergency Cardiovascular Care (ECC), using an AED when necessary, for resident's with full-code statuses and residents who have not declared code status in the event of cardiopulmonary arrest . Under 'Procedure' to complete the following steps if the resident has been declared a full-code: -If thorough circulatory, airway, breathing (CAB) assessment determines there is no pulse or respiratory activity, a licensed staff member will: -Call for help to initiate a 911 call and page code according to the facility protocol, including location .Simultaneously with the initiation of CPR/ECC, direct staff member to obtain emergency cart/AED device. Start chest compressions according to the American Heart Association recommendation for the use of AED .Direct a member of the response team to contact the attending physician and responsible party/DPOA/guardian. This staff member shall also complete a hospital transfer sheet, including the advance directives/code status and make these documents available to Emergency Response Personnel. Defer all resuscitation efforts to the Emergency Response Personnel one they arrive and declare they will assume responsibility of maintaining life support interventions. Resident #400: A review of Resident #400's medical record, revealed Resident #400 was a [AGE] year-old male with an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS), dated [DATE], Resident #400 scored a 15 out of 15 on the cognition assessment, indicating no cognition impairment. Further review of the MDS revealed the Resident #400 needed an extensive two-person assist with bed mobility, transfers, dressing and toilet use. Review of Resident #400's clinical record, documented on [DATE] at 10:35 AM, revealed under vital signs, an entry made by LPN F of a Blood Pressure of ,d+[DATE], and a warning listed 'Systolic low of 90 exceeded' generated in the computer system of Point Click Care. Further review of the clinical record reflected that the blood pressure entry made by LPN F was not struck out as incorrect, nor was another blood pressure re-entered. Review of progress notes for documentation around 10:35 AM, on [DATE], reflected no entry made in the record by LPN F related to the condition of Resident #400 for blood pressure monitoring. Review of Progress notes, in the clinical record, reflected an entry made by LPN F under skilled charting [DATE] at 18:04 (6:04 PM). The documentation entered was Around 17:05 (5:05 PM) CENA alerted writer that guest was unresponsive. Writer entered room to assess guest and noted guest had no pulse. Writer alerted staff there was a code blue, verified guest was a CPR and began compressions. 911 was called at 17:09 (5:09 PM) and EMS arrived at 17:18 (5:18 PM) and took over compressions. At 17:24 (5:24 PM) EMS called MD to call time of death. Time of death called by (DR.) at 17:34 (5:34 PM). DON, MD, and Admin. aware. CENA was in the room at 1600 and guest was sitting up in bed, guest was responsive at that time. CENA went back to room around 1700 to complete rounds and noted guest was unresponsive and alerted writer. There were no s/s of distress noted throughout shift. Code status was followed per medical record. ME (medical examiner) notified and waiting on medical examiner number. The next entry was made on [DATE], at 19:30 (7:30 PM) by LPN F, as ME was here to pronounce. Number ,d+[DATE]. The next entry was made on [DATE] at 23:32 (11:32 PM) by a different nurse, who came onto the next shift, and documented Resident was taken by medical examiner at 19:37. (7:37 PM). Review of Resident #400's Code Status, as documented in the medical record, reflected a Code Status Form for Full Code, as noted by an X in the Full Code box and signed by Resident #400 upon admission, dated [DATE]. Further review of the form, reflected under a box for Do Not Resuscitate, a blank box not verified with an X, however, the form documentation reflected an entry This do-not-resuscitate order is issued by and attending physician name printed, who was the attending physician for (gave Resident #400's name). At the bottom of the form, Under Attestation of Witnesses's, documented 2 witnesses's names printed, signed, and dated for [DATE]. Corporate Compliance Office O was shown the form and was asked to clarify Code Status for Resident #400, and indicated the form was documented inaccurately, that Resident #400 had chosen Full Code Status, and that someone made a mistake on the form. She also verbalized there did not need to be two witness signatures for verification of Full Code, because Resident #400 was alert, oriented, and his own responsible party. Corporate Officer O indicated upon review of the form, that an audit was being done to verify the correct Code Status reflected in medical records. Review of EMS Run Report was done on [DATE]. The report incident #,d+[DATE], documented Dispatch Information: Response Urgency: Lights and Sirens, dated as [DATE]. Time received 17:13. Time responded: 17:13. On scene: 17:18. Patient Contact: 17:22. Complaint reported: Cardiac Arrest/Death. Medical information: [CONDITION(S)], Other: (Substance Abuse) History of Present Illness, under Primary Complaint documented: DOA Under symptom: Death. Last Time seen Normal: Time [DATE]. 13:00 hour. Under CPR information: Yes, prior to EMS arrival. Witnessed: Not witnessed. CPR prior to EMS arrival: Yes. AED used prior to arrival: Yes-no defibrillation advised. by Healthcare Professional. EMS: initiated chest compressions. Type of CPR: Compressions intermittent with ventilation. First monitored rhythm: Asystole. Circulation: No. Time CPR discontinued: 17:24 Reason CPR or resuscitation efforts discontinued: Obvious signs of death. Estimated time of arrest: > than 20 minutes. Initial CPR time: 17:09. Narrative: A 557 was dispatched PRI 1 to Above location for a [AGE] year old male in cardiac arrest, crew arrived on scene and brought all equipment (stretcher, Monitor, Jump Bag, IV Kit, Drug Box, Intubation Kit, Suction). Pt in room [ROOM NUMBER]. Multiple staff members were w/the Pt. and compressions and ventilation being performed on the Pt. who was laying supine. Staff had the AED attached to the Pt. with pads in proper position. Staff stated the pt was last seen alive around 1300, found unresponsive at 1700, and CPR started at 1709. Staff advised the AED had not advised that any defibrillation was needed. EMT (gave name) continued compressions to relieve on-scene RN. EMT (gave name) placed the pads on the Pt. and noted Asystole on the cardiac monitor. Pulse/breathing check completed and found the Pt Pulseless and Apneic during pulse check. Pt was found cool to the touch and with Rigor Mortis present in pt's jaw. Compressions were stopped at this time and pt was rolled slightly onto his side, crew noted Lividity (pooling of blood) beginning in the Pt's lower back. Hospital contacted via radio and given the crew findings. [NAME] [Time of Death] was given at 17:34 per Dr (gave name). Crew clarified last seen time with RN and RN confirmed 1300. Staff denied any complaints from the Pt, or distress when he was last seen. Local PD (gave name) was requested to the scene as was the [NAME]. Local PD arrived on scene spoke to Crew and Staff. At this time, Staff stated the Pt. was seen normal at 1300, approx 1400, and approx 1600. Crew waited on scene with PD for [NAME] (medical examiner investigator). When the ME arrived, Crew advised of our findings and the inconsistencies in the last known well time from staff. Crew cleared the scene. End of report. Under Treatment: Primary: Cardiac Arrest Secondary: Obvious death. Protocol Used: General-Universal Patient Care/Initial Patient Contact: General Time: 17:22 Treatment: Cardiopulmonary resuscitation: success: Yes. Complications: None. Response: unchanged. Performed by (gave name of EMT) 17:22: Patient Contact. 17:23: Vitals Taken: BP: NA/NA Manual. Pulse: 0; Absent. Respiration Rate: 0; Apneic; ECG Rate: 0/Asystole; Pads; GCS Eye: 1. Verbal: 1, GCS Motor: 1, GCS Score: 3, AVPU: U, Position: Laying. Under Disposition: Patient Disposition: Patient Dead at Scene-Resuscitation Attempted (Without transport). An interview was conducted on [DATE], with Registered Nurse A at 9:37 AM. RN A indicated she remembered the events that occurred on [DATE], with Resident #400. RN A verbalized she was near the 600 hall, in a sitting area, talking to the Director of Nursing (DON), who was working the floor that day, caring for residents on the 600 hall. RN A indicated that she remembered LPN F walking over to her and the DON, and witnessed LPN F verbalize to the DON, I need you to come and look at my patient. Something is wrong. RN A was asked what time did LPN F summon help, and indicated it was around 5 PM, Supper time. RN A verbalized the DON sent RN A over to assist LPN F as the DON was working a cart and caring for residents on the 600 hall. RN A was asked if LPN F had came up running and verbalized, No, she was walking. RN A was asked if she knew what area LPN F was working, and indicated on the 300 hallway, across the hall, on the other side of the building. RN A indicated that she asked LPN F what was going on, because LPN F had not identified what the concerns were with Resident #400 at that time. LPN F verbalized to RN A I don't know, he don't seem right. RN A was then informed it was Resident #400. RN A indicated she asked LPN F Did you assess him. Does he have a pulse. RN A said LPN F remained silent when she asked her twice and did not answer both times. RN A verbalized again that LPN F did not respond when asked if she checked for a pulse. RN A verbalized that when she walked into Resident #400's room, and looked at Resident #400, he was 'discolored, not pink, gray/ ashen color' and not responding. I checked for a pulse and could not verify that he had a pulse. RN A asked LPN F when the last time she seen Resident #400. LPN F indicated it was around lunch time (noon) and that he had an increase in congestion and sputum. RN A indicated she asked LPN F what the Code Status was for Resident #400, and LPN F verbalized she did not know and would have to go check the clinical record. RN A indicated that LPN F left the room and walked down the 300 hall toward the area where the computer was located, and checked the Code Status. RN A verbalized that a Resident Care Aide C came into the room and asked her if she knew Resident #400's code status. RCA C verbalized she did not know. RN A indicated she was waiting for LPN F to return with Code Status verification and had opened Resident #400's gown. RN A verbalized another Aid came to the room during that time from the 100 hall. RN A verbalized again she knew something was wrong with Resident #400. RN A indicated that LPN F returned several minutes later and verbalized Resident #400 was a Full Code. RN A was asked if she attempted to assess Resident #400 by listening for lung sounds, respirations, or obtain oxygen saturation levels, blood pressure, or any vital signs during that time. RN A indicated just a pulse, and it was absent. RN A verbalized she directed someone to call 911, (AID she thinks) and someone to bring the crash cart, and at that time began compressions on Resident #400. RN A said she thought it was less than 5 minutes for LPN F to come back, but was not sure how long. RN A was asked if LPN F ever announced Code Blue at any time, and verbalized she did not. RN A verbalized an RN, who was working the floor on the next hall over (400 hall), showed up, who was a Corporate RN, came to assist her with CPR. RN A was asked how that RN knew to come, and replied that an Aid went and got her. RN A indicated the other RN placed an AED device on Resident #400 and was advised not to defibrillate, and then took over doing compressions. RN A indicated she then got an Oxygen mask with the Ambu bag and began ventilation and CPR with the other RN. RN A verbalized they continued the compressions until EMS arrived. RN A indicated that an Aid went back to the 600 hall and got the DON to come over. When the DON came in the room, We switched doing compressions for maybe 10 minutes. RN A was asked what LPN F was doing during the code, and indicated LPN F did not do any compressions, and was standing back in the room, appearing to be frustrated and flustered. RN A verbalized someone was taking notes, but could not recall who was documenting the code. RN A verbalized that she and RCA C helped place a back board under Resident #400 at some point, because the bed was soft. RN A went on to say that EMS arrived, and there were 3 of them. RN A said that one of the EMS personnel hooked Resident #400 up to telemetry unit, and the heart rhythm detected was 'Asystole' (no rhythm). RN A indicated that one of the EMS girls took over and assisted with compressions, and the third girl called dispatch to speak to the Physician, who called the time of death. RN A verbalized that compressions and ventilation had been stopped at the time the Physician declared the time of death. RN A indicated she wrote down a timeline of the events and gave all the notes to LPN F and indicated These are your notes and times to be entered in the medical record. RN A was asked if there were any notes or documents related to the event available, and said they were all given to LPN F. RN A was asked if she thought anything different could have been done for Resident #400, and verbalized that LPN F could have called for help instead of leaving the room, and walking across the building, all the way to the other side. RN A verbalized that LPN F could have got the RN on the 400 hall, who was right next to her on the next hall over, and also paged overhead for Code or for help. RN A verbalized LPN F could have told her if she had assessed Resident #400, or attempted to get vital signs or a pulse at anytime, and at noon when she indicated he was congested. RN A also verbalized that LPN F could have ran instead of walking. RN A verbalized again, she could have gotten someone closer and faster. RN A said, She should have assessed him and known if he was breathing or had a pulse. RN A verbalized We did what we could. RN A became tearful during the interview, and discussed the information related to informing the family of the events that took place with family member of Resident #400's passing. An interview was conducted on [DATE] at 11:13 AM, with LPN F. LPN F was asked if she was the nurse in care on 1st shift, of Resident #400 on [DATE], and said yes. LPN F was asked if she remembered Resident #400, and said, He was the over-dose Resident with [CONDITION(S)]. He was alert and oriented, dependant on staff for Activities of Daily Living Care. LPN F was asked to clarify what she meant about Resident #400 being the over-dose resident and said, Oh, never mind. I might be mixing him up with someone else. LPN F was asked if she remembered the day that Resident #400 passed away, and indicated she did and said, What do you want to know. LPN F verbalized she gave him (Resident #400) meds at ,d+[DATE] AM. He ate breakfast and was talking. He had a blanket over his head. His Family came in and visited that day around 11ish or so, two ladies, I think. I seen him again around 11 AM and gave him meds. He still had the blanket over his head and said he was ok. I went in at 2 PM, he had no issues. I went in at 4 PM, he was sleeping. LPN F said around 5 ish, during Supper time, the Aid, with reddish hair, (said she couldn't remember her name) came and got me. After I checked my other resident's, I went to the room. The blanket was off his head. He was Ghostly colored/Pale. I ran to the 600 hall, from the 300 hall, to get the DON. I had to go past the dinning room to get to the 600 hall. It is on the other side of the building. The DON and ADON were both there sitting and charting. I said, I need you both to come immediately. The DON sent the ADON. She (DON) stayed on the 600 hall, because she was working a cart. We went into Resident #400's room. She (ADON) looked at him and checked for a pulse. She did not get one. I did not assess him, she did. I did not check for a pulse. The ADON asked me his code status. I did not know. She stayed with the resident and told me to go check for Code Status. I went up the 300 hall, to the open area, where the computer was located and checked his Code Status. I came back and told her he was a Full Code, and we started CPR. LPN F verbalized that she had not assessed Resident #400, before she went and summons help, or checked his pulse or perform any other assessment, when Surveyor asked. LPN F was asked if she ever called Code Blue, or yelled for help at any time and verbalized that No one called Code Blue, or yelled for help. LPN F indicated the ADON said go get the crash cart. LPN F said I helped put the back board under Resident #400. The Corporate Nurse who was working the 400 hall, arrived to help. I don't know how she knew to come. Someone must have went and got her. The DON showed up a short time later. I called 911. LPN F was asked how long it took to check a code status in the computer and indicated maybe 1 to 2 minutes, not very long. LPN F was asked how long it took to go across the hall and get the DON, and said maybe 3 or 4 minutes. LPN F said she called the medical examiner to fill out the paper work and release the body. LPN F verbalized the medical examiner indicated not to touch anything and leave everything as is. LPN F was asked if she had any notes from the event and indicated she did not. I got rid of all of that. I charted and did not need that anymore. I got rid of all of that stuff. LPN F was asked about her inconsistencies with documentation in the medical record, entered on [DATE], at 17:05. LPN F was also shown the medical record documentation and that it did not reflect her interview and an accurate recall of the events. LPN F had documented Writer assessed for pulse . and verbalized again, I did not assess him, the ADON did. LPN F was asked if she paged 'Code Blue' at anytime and said No. LPN F was asked why she went all the way across the building to get help. LPN F did not respond to the question. LPN F was asked if she obtained any vital signs for Resident #400 on [DATE], and verbalized 'I am sure I did. LPN F was asked if Resident #400 had an increase in sputum/congestion, and said Not that I can remember. LPN F was shown the documented Blood Pressure of ,d+[DATE], documented on [DATE] at 10:35 AM, and did not offer an explanation. An interview was conducted with the Director of Nursing (DON) on [DATE], at 11:00 AM. The DON was asked about the events on [DATE]. The DON verbalized she remembered that day as she was working a floor/cart, taking care of several residents residing on the 600 hall. DON said, Around 5 PM, I was talking to the ADON [NAME] wowing over issues and following up with Infection Control things. It was getting late in the day. I remember LPN F walking over and asked for assistance. She said Can you come over and look at him. I don't remember her giving a name at that time. The DON was asked if LPN F paged for emergency assistance or Code Blue at any point. The DON indicated They don't use overhead paging here. I sent the ADON over to assist with what she needed, because I did not want to leave my residents alone on the 600 hall. I sent her. I stayed with my cart and my residents. Several minutes later, and Aid from the another hall, came and waved me to come on. I ran and followed the Aid to Resident #400's room. I entered the room and observed CPR in progress. I seen the crash cart, the AED was hooked up, the pads were correct. I observed my ADON and the Corporate RN, from the 400 hall performing compressions and ventilation. I verified if anyone called 911 and was told yes, and they were in route. I am not sure who was documenting notes. EMS showed up. It was 3 girls. The EMS people did not take over the code, but one of the girls helped do cycles of CPR. One set her bag down and adjusted some wires. The other assisted with compressions. I did one cycle of compressions. The other EMS girl called the Physician at the hospital and relayed information and a time of death was called. The DON was asked if she seen LPN F or the ADON walking or running and verbalized she did not see either one running. Paper work was provided to EMS. I did not see them start a line or give any meds. I was only there for ,d+[DATE] minutes, not very long, and had to go back to my cart and the resident's on the 600 hall. The DON was asked to provide notes or any documentation related to the event, and indicated all the notes were provided to LPN F for her charting. The DON verbalized she did not have any notes, timeline, documentation, or an investigation from the event on [DATE], and that an investigation had not been completed. The DON did not provide the Surveyor any documentation upon request related to events involving Resident #400 on [DATE], and his death. An interview was conducted on [DATE] at 1:36 PM, with Resident Care Aid (RCA) C who indicated she started her shift a little before 2 PM on [DATE], and was the Waiver Aid assigned to care for Resident #400, on 2nd shift. (Time clock verification indicated 1:54 PM started her shift). RCA C was asked if she remembered what happened on [DATE], the day Resident #400 passed away. RCA C indicated she did. RCA C indicated it was Strange what happened to Resident #400. RCA C was asked why she thought it was strange. RCA C indicated she got report from the off going shift, and began to pass water to her residents. I am coming down the hall and his family (Resident #400) stopped me. They had been in visiting Resident #400's dad, who is a resident in the facility too. It was 2 ladies. They asked me if I would go check on Resident #400, that something was wrong. RCA C was asked what time she went in and looked at Resident #400. RCA C verbalized it was around 3ish, per family request. I walked in He had a blanket over his face. I asked if he was ok. He brought the blanket down off of his face. He looked pale. He was slurring his words. He said he was cold. I noticed he was drooling down one side of his face. (did not indicate left or right side of face). I left the room. I went directly to the nurse. (LPN F). I asked her to go in and check on the Resident, that something was wrong with him. She never did go in and check. I went back in his room a second time, to check on him, around 3:30 PM. I seen him breathing very hard (blowing air), and he was foaming at the mouth at this time. I went to the nurse again, for a 2nd time. I asked her to please go check on Resident #400. I told her he was breathing funny and had drool/foam on his face. He had a lot of it. The nurse did not go in and check him again. I asked her during that time, Is this normal for him to be drooling down the side of his face so much. She said to me, This is normal. He did this to himself. They upped his Narc's yesterday. He foams out the sides of his mouth. RCA C said, The nurse never went in to check on him both times that I alerted her, that something was wrong. RCA C indicated the 1st and 2nd time I checked him, was long before 5 PM. I continued rounding on my other residents and providing care. RCA C went on to say We were getting close to Supper time. The trays come out around 5 ish. I thought I would go check on him again, before I passed a tray to his room. The third time I went into his room, around 5 PM, he did not look right. I walked over and touched him. He was cold. He was dead. I am not a nurse, but I have seen enough dead people to know when they are dead. RCA C was asked to clarify why she thought he was dead, and verbalized I was a Certified Aid for ,d+[DATE] years. I let my Certification lapse. I came to the facility to work as a Waiver Aid, do the training, and get it (Certification) back. I am not a nurse, but I know if something is wrong. Like I said, He was dead and cold. I left the room. I ran to find the nurse, who was down near room [ROOM NUMBER]. I told her You NEED to come now. It don't look good. The nurse walked into the room and looked at the Resident. She never tried to get a pulse, or take any vital signs or anything. She just looked at him. She left the room and walked across the building to the 600 hall, all the way to the other side of the building, to find the DON. The DON then sent the ADON into see what was up. The ADON came back with the nurse. The ADON tried to get a pulse and couldn't get one. The ADON was asking the nurse what his Code Status was. The nurse said she did not know and would have to check. The nurse left the room. I stayed with the ADON, and she was asking me if I knew the Code Status. I said, I don't know. The ADON was saying out loud, It should not take this long to find out a Code Status. She asked me again, if I knew the Code Status. I said, I don't know, for a second time. I didn't know. RCA C was asked how long the nurse was gone, and indicated it was longer than 6 minutes but less than 10. RCA C verbalized The nurse came back and said he was a Full Code. The ADON then started CPR. Another Aid got the crash cart. I helped place the back board under Resident #400, with the ADON. The nurse (LPN F) stood back and did not know what to do. She was just standing there watching what was happening. The Corporate RN, on the next hall, showed up to help. 911 was called. He had been long dead by the time CPR was started. No one ever checked his vital signs. EMS came and worked with him for just few minutes. He was pronounced dead. I asked that nurse to come 3 times. If she would have came on the 1st or 2nd time. He might still be alive or she could have got him out. Review of facility Policy 'Death of a Resident' dated [DATE] documented All resident's deaths, whether expected or unexpected, must be treated in the same manner. All resident's must be treated with dignity and respect at all times, including at the time of death. Under 'Procedure': In the event that a resident is found without a pulse or heartbeat or not breathing, a licensed nurse will be notified immediately. If resident is Full Code status or code status has not been established or resident is found is suspicious position .Follow CPR policy and procedure, Notify the in-house supervisor or nurse on-call, Follow procedure for Post-Mortem Care, Notify the physician, Notify the family or responsible party, Document the following: The time of absence of vital signs, Description of the resident when found, Physician time and notification, Time the body was removed from the facility and where the body was taken, what valuables and belongings accompanied the resident. Document the residents death on a 24 hour report. Contact agencies as necessary per coroner's office policies. Review of facility Policy Change of Condition-Resident Physician/NP Notification, dated [DATE], documented The attending physician/physician extender or on-call physician/physician extender will be notified with changes in a resident's condition or health status .Under Procedure: Seven (7) days a week, the attending physician is to be called/notified of all condition or health status changes . Acute symptoms: temperature of 101 .change in vital signs, continuous nausea and vomiting, unconsciousness .The SBAR is to be completed before physician notification unless emergent need to transfer to the hospital. Document the time of call, physician or nurse practitioner or other person spoken to; reason for call and result or orders received .

This Citation pertains to Intake Number MI 687. Based on interview and record review, the facility failed to properly assess, monitor, and document (including vital signs) a change in condition for 2 residents (Resident #400, Resident #402), out of 9 residents' care reviewed for assessment with change in condition, resulting in Resident #400 and #402 expiring in the facility without a documented assessment. Findings include: Review of facility Policy and Procedure 'Resident Examination and Assessment' dated as revised December, 2011, documented : The purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides the basis for the care plan. Review the resident's admission assessment and/or preliminary care plan to assess for any special situation's regarding the resident's care . Resident #400: According to Resident #400's medical record, Resident #400 was a [AGE] year old male with an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) dated [DATE], Resident #400 scored a 15 out of 15 on the cognition assessment, indicating no cognition impairment. Further review of the MDS revealed the Resident #400 needed extensive two person assist with bed mobility, transfers, dressing and toilet use. Review of Resident #400's clinical record, documented on [DATE] at 10:35 AM, under vital signs, an entry made by LPN F as a Blood Pressure of ,d+[DATE], and a warning listed 'Systolic low of 90 exceeded' generated in the computer system of Point Click Care. Further review of the clinical record reflected the blood pressure entry made by LPN F was not struck out as incorrect, or another blood pressure re-entered. Review of progress notes for documentation around 10:35 AM, on [DATE], reflected no entry made in the record by LPN F related to the condition of Resident #400 for blood pressure monitoring. Review of Progress notes, in the clinical record, reflected an entry made by LPN F under skilled charting [DATE] at 18:04 (6:04 PM). The documentation entered was Around 17:05 (5:05 PM) CENA alerted writer that guest was unresponsive. Writer entered room to assess guest and noted guest had no pulse. Writer alerted staff there was a code blue, verified guest was a CPR and began compressions. 911 was called at 17:09 (5:09 PM) and EMS arrived at 17:18 (5:18 PM) and took over compressions. At 17:24 (5:24 PM) EMS called MD to call time of death. Time of death called by (DR.) at 17:34 (5:34 PM). DON, MD, and Admin. aware. CENA was in the room at 1600 and guest was sitting up in bed, guest was responsive at that time. CENA went back to room around 1700 to complete rounds and noted guest was unresponsive and alerted writer. There were no s/s of distress noted throughout shift. Code status was followed per medical record. ME (medical examiner) notified and waiting on medical examiner number. The next entry was made [DATE], at 19:30 (7:30 PM) by LPN F, as ME was here to pronounce. Number ,d+[DATE]. The next entry was made on [DATE] at 23:32 (11:32 PM) by a different nurse, who came onto the next shift, and documented Resident was taken by medical examiner at 19:37. (7:37 PM). An interview was conducted on [DATE], with Registered Nurse A at 9:37 AM. RN A indicated she remembered the events that occurred on [DATE], with Resident #400. RN A verbalized she was near the 600 hall, in a sitting area, talking to the Director of Nursing (DON), who was working the floor that day, caring for residents on the 600 hall. RN A indicated she remembered LPN F walking over to her and the DON, and witnessed LPN F verbalize to the DON, I need you to come and look at my patient. Something is wrong. RN A was asked what time did LPN F summons help, and indicated it was around 5 PM, Supper time. RN A verbalized the DON sent RN A over to assist LPN F as DON was working a cart and caring for residents on the 600 hall. RN A was asked if LPN F had came up running and verbalized, No, she was walking. RN A was asked if she knew what area LPN F was working, and indicated on the 300 hallway, across the hall, on the other side of the building. RN A indicated she asked LPN F what was going on, and LPN F had not identified the concerns were with Resident #400 at that time. LPN F verbalized to RN A I don't know, he don't seem right. RN A was then informed it was Resident #400. RN A indicated she asked LPN F Did you assess him. Does he have a pulse. RN A said LPN F remained silent when she asked her twice and did not answer both times. RN A verbalized again that LPN F did not respond when asked if she checked for a pulse. RN A verbalized that when she walked into Resident #400's room, and looked at Resident #400, he was 'discolored, not pink, gray/ ashen color' and not responding. I checked for a pulse and could not verify that he had a pulse. RN A asked LPN F when the last time she seen Resident #400. LPN F indicated it was around lunch time (noon) and that he had an increase in congestion and sputum. RN A indicated she asked LPN F what the Code Status was for Resident #400, and LPN F verbalized she did not know and would have to go check the clinical record. RN A indicated that LPN F left the room and walked down the 300 hall toward the area where the computer was located, and checked the Code Status. RN A verbalized that a Resident Care Aid C came into the room and asked her if she knew Resident #400's code status. RCA C verbalized she did not know. RN A indicated she was waiting for LPN F to return with Code Status verification and had opened Resident #400's gown. RN A verbalized another Aid came to the room during that time from the 100 hall. RN A verbalized again she knew something was wrong with Resident #400. RN A indicated that LPN F returned several minutes later and verbalized Resident #400 was a Full Code. RN A was asked if she attempted to assess Resident #400 by listening for lung sounds, respirations, or obtain oxygen saturation levels, blood pressure, or any vital signs during that time. RN A indicated just a pulse, and it was absent. RN A verbalized she directed someone to call 911, (AID she thinks) and someone to bring the crash cart, and at that time began compressions on Resident #400. RN A said she thought it was less than 5 minutes for LPN F to come back, but was not sure how long. RN A was asked if LPN F ever announced Code Blue at any time, and verbalized she did not. RN A verbalized an RN, who was working the floor on the next hall over (400 hall), showed up, who was a Corporate RN, came to assist her with CPR. RN A was asked how that RN knew to come, and replied that an Aid went and got her. RN A indicated the other RN placed an AED device on Resident #400 and was advised not to defibrillate, and then took over doing compressions. RN A indicated she then got an Oxygen mask with the Ambu bag and began ventilation and CPR with the other RN. RN A verbalized they continued the compressions until EMS arrived. RN A indicated that an Aid went back to the 600 hall and got the DON to come over. When the DON came in the room, We switched doing compressions for maybe 10 minutes. RN A was asked what LPN F was doing during the code, and indicated LPN F did not do any compressions, and was standing back in the room, appearing to be frustrated and flustered. RN A verbalized someone was taking notes, but could not recall who was documenting the code. RN A verbalized that she and RCA C helped place a back board under Resident #400 at some point, because the bed was soft. RN A went on to say that EMS arrived, and there were 3 of them. RN A said that one of the EMS personnel hooked Resident #400 up to telemetry unit, and the heart rhythm detected was 'Asystole' (no rhythm). RN A indicated that one of the EMS girls took over and assisted with compressions, and the third girl called dispatch to speak to the Physician, who called the time of death. RN A verbalized that compressions and ventilation had been stopped at the time the Physician declared the time of death. RN A indicated she wrote down a timeline of the events and gave all the notes to LPN F and indicated These are your notes and times to be entered in the medical record. RN A was asked if there were any notes or documents related to the event available, and said they were all given to LPN F. RN A was asked if she thought anything different could have been done for Resident #400, and verbalized that LPN F could have called for help instead of leaving the room, and walking across the building, all the way to the other side. RN A verbalized that LPN F could have got the RN on the 400 hall, who was right next to her on the next hall over, and also paged overhead for Code or for help. RN A verbalized LPN F could have told her if she had assessed Resident #400, or attempted to get vital signs or a pulse at anytime, and at noon when she indicated he was congested. RN A also verbalized that LPN F could have ran instead of walking. RN A verbalized again, she could have gotten someone closer and faster. RN A said, She should have assessed him and known if he was breathing or had a pulse. RN A verbalized We did what we could. RN A became tearful during the interview, and discussed the information related to informing the family of the events that took place with family member of Resident #400's passing. An interview was conducted on [DATE] at 11:13 AM, with LPN F. LPN F was asked if she was the nurse in care on 1st shift, of Resident #400 on [DATE], and said yes. LPN F was asked if she remembered Resident #400, and said, He was the over-dose Resident with [CONDITION(S)]. He was alert and oriented, dependant on staff for Activities of Daily Living Care. LPN F was asked to clarify what she meant about Resident #400 being the over-dose resident and said, Oh, never mind. I might be mixing him up with someone else. LPN F was asked if she remembered the day that Resident #400 passed away, and indicated she did and said, What do you want to know. LPN F verbalized she gave him (Resident #400) meds at ,d+[DATE] AM. He ate breakfast and was talking. He had a blanket over his head. His Family came in and visited that day around 11ish or so, two ladies, I think. I seen him again around 11 AM and gave him meds. He still had the blanket over his head and said he was ok. I went in at 2 PM, he had no issues. I went in at 4 PM, he was sleeping. LPN F said around 5 ish, during Supper time, the Aid, with reddish hair, (said she couldn't remember her name) came and got me. After I checked my other resident's, I went to the room. The blanket was off his head. He was Ghostly colored/Pale. I ran to the 600 hall, from the 300 hall, to get the DON. I had to go past the dinning room to get to the 600 hall. It is on the other side of the building. The DON and ADON were both there sitting and charting. I said, I need you both to come immediately. The DON sent the ADON. She (DON) stayed on the 600 hall, because she was working a cart. We went into Resident #400's room. She (ADON) looked at him and checked for a pulse. She did not get one. I did not assess him, she did. I did not check for a pulse. The ADON asked me his code status. I did not know. She stayed with the resident and told me to go check for Code Status. I went up the 300 hall, to the open area, where the computer was located and checked his Code Status. I came back and told her he was a Full Code, and we started CPR. LPN F verbalized that she had not assessed Resident #400, before she went and summons help, or checked his pulse or perform any other assessment, when Surveyor asked. LPN F was asked if she ever called Code Blue, or yelled for help at any time and verbalized that No one called Code Blue, or yelled for help. LPN F indicated the ADON said go get the crash cart. LPN F said I helped put the back board under Resident #400. The Corporate Nurse who was working the 400 hall, arrived to help. I don't know how she knew to come. Someone must have went and got her. The DON showed up a short time later. I called 911. LPN F was asked how long it took to check a code status in the computer and indicated maybe 1 to 2 minutes, not very long. LPN F was asked how long it took to go across the hall and get the DON, and said maybe 3 or 4 minutes. LPN F said she called the medical examiner to fill out the paper work and release the body. LPN F verbalized the medical examiner indicated not to touch anything and leave everything as is. LPN F was asked if she had any notes from the event and indicated she did not. I got rid of all of that. I charted and did not need that anymore. I got rid of all of that stuff. LPN F was asked about her inconsistencies with documentation in the medical record, entered on [DATE], at 17:05. LPN F was also shown the medical record documentation and that it did not reflect her interview and an accurate recall of the events. LPN F had documented Writer assessed for pulse . and verbalized again, I did not assess him, the ADON did. LPN F was asked if she paged 'Code Blue' at anytime and said No. LPN F was asked why she went all the way across the building to get help. LPN F did not respond to the question. LPN F was asked if she obtained any vital signs for Resident #400 on [DATE], and verbalized 'I am sure I did. LPN F was asked if Resident #400 had an increase in sputum/congestion, and said Not that I can remember. LPN F was shown the documented Blood Pressure of ,d+[DATE], documented on [DATE] at 10:35 AM, and did not offer an explanation. An interview was conducted on [DATE] at 1:36 PM, with Resident Care Aide (RCA) C who indicated she started her shift a little before 2 PM on [DATE], and was the Waiver Aid assigned to care for Resident #400, on 2nd shift. (Time clock verification indicated 1:54 PM started her shift). RCA C was asked if she remembered what happened on [DATE], the day Resident #400 passed away. RCA C indicated she did. RCA C indicated it was Strange what happened to Resident #400. RCA C was asked why she thought it was strange. RCA C indicated she got report from the off going shift, and began to pass water to her residents. I am coming down the hall and his family (Resident #400) stopped me. They had been in visiting Resident #400's dad, who is a resident in the facility too. It was 2 ladies. They asked me if I would go check on Resident #400, that something was wrong. RCA C was asked what time she went in and looked at Resident #400. RCA C verbalized it was around 3ish, per family request. I walked in He had a blanket over his face. I asked if he was ok. He brought the blanket down off of his face. He looked pale. He was slurring his words. He said he was cold. I noticed he was drooling down one side of his face. (did not indicate left or right side of face). I left the room. I went directly to the nurse. (LPN F). I asked her to go in and check on the Resident, that something was wrong with him. She never did go in and check. I went back in his room a second time, to check on him, around 3:30 PM. I seen him breathing very hard (blowing air), and he was foaming at the mouth at this time. I went to the nurse again, for a 2nd time. I asked her to please go check on Resident #400. I told her he was breathing funny and had drool/foam on his face. He had a lot of it. The nurse did not go in and check him again. I asked her during that time, Is this normal for him to be drooling down the side of his face so much. She said to me, This is normal. He did this to himself. They upped his Narc's yesterday. He foams out the sides of his mouth. RCA C said, The nurse never went in to check on him both times that I alerted her, that something was wrong. RCA C indicated the 1st and 2nd time I checked him, was long before 5 PM. I continued rounding on my other residents and providing care. RCA C went on to say We were getting close to Supper time. The trays come out around 5 ish. I thought I would go check on him again, before I passed a tray to his room. The third time I went into his room, around 5 PM, he did not look right. I walked over and touched him. He was cold. He was dead. I am not a nurse, but I have seen enough dead people to know when they are dead. RCA C was asked to clarify why she thought he was dead, and verbalized I was a Certified Aide for ,d+[DATE] years. I let my Certification lapse. I came to the facility to work as a Waiver Aid, do the training, and get it (Certification) back. I am not a nurse, but I know if something is wrong. Like I said, He was dead and cold. I left the room. I ran to find the nurse, who was down near room [ROOM NUMBER]. I told her You NEED to come now. It don't look good. The nurse walked into the room and looked at the Resident. She never tried to get a pulse, or take any vital signs or anything. She just looked at him. She left the room and walked across the building to the 600 hall, all the way to the other side of the building, to find the DON. The DON then sent the ADON into see what was up. The ADON came back with the nurse. The ADON tried to get a pulse and couldn't get one. The ADON was asking the nurse what his Code Status was. The nurse said she did not know and would have to check. The nurse left the room. I stayed with the ADON, and she was asking me if I knew the Code Status. I said, I don't know. The ADON was saying out loud, It should not take this long to find out a Code Status. She asked me again, if I knew the Code Status. I said, I don't know, for a second time. I didn't know. RCA C was asked how long the nurse was gone, and indicated it was longer than 6 minutes but less than 10. RCA C verbalized The nurse came back and said he was a Full Code. The ADON then started CPR. Another Aid got the crash cart. I helped place the back board under Resident #400, with the ADON. The nurse (LPN F) stood back and did not know what to do. She was just standing there watching what was happening. The Corporate RN, on the next hall, showed up to help. 911 was called. He had been long dead by the time CPR was started. No one ever checked his vital signs. EMS came and worked with him for just few minutes. He was pronounced dead. I asked that nurse to come 3 times. If she would have came on the 1st or 2nd time. He might still be alive or she could have got him out. Review of facility Policy Change of Condition-Resident Physician/NP Notification, dated [DATE], documented The attending physician/physician extender or on-call physician/physician extender will be notified with changes in a resident's condition or health status .Under Procedure: Seven (7) days a week, the attending physician is to be called/notified of all condition or health status changes . Acute symptoms: temperature of 101 .change in vital signs, continuous nausea and vomiting, unconsciousness .The SBAR is to be completed before physician notification unless emergent need to transfer to the hospital. Document the time of call, physician or nurse practitioner or other person spoken to; reason for call and result or orders received . Licensed Practical Nurse (LPN) F failed to respond to and address a Resident Care Aide's (RCA) C concerns regarding the deterioration of one resident's (Resident #400) condition on two occasions at approximately 3:00 PM and 3:30 PM on the afternoon of Thursday, [DATE], and around 5 PM found resident unresponsive. LPN F did not check on the resident nor make any effort to obtain vital signs, check for a pulse, check for respirations or call 911 to transfer Resident #400 to an emergency room , after being informed on two occasions that Resident #400 was having respiratory issues and foaming at the mouth. Resident #402: According to admission face sheet, Resident #402 was an [AGE] year old female with an re-admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) dated [DATE], Resident #402 received no score on the cognition assessment, indicating severe cognition impairment. Further review of the MDS revealed the Resident #402 needed extensive two person assist with bed mobility, transfers, dressing and toilet use. Resident #402 expired in the facility on [DATE]. Review of Resident #402 Weights and Vitals, reflected the last entry for vital signs were made on [DATE]. Nothing was entered for [DATE]. There was nothing documented under assessments as well. Review of Progress notes in the medical record , reflected an entry under skilled charting, on [DATE] at 13:59 (1:59 PM) made by Licensed Practical Nurse F : [NAME] (sic) is resting at this time. Turned 2 q hours.(sic) All meds given per DR order. Call light within reach. Will try to call Family for update. The next entry was made by Social Worker R at 14:23 (2:23 PM), The writer called the nephew of Guest and notified him of the death. The nephew asked that he be contacted before the funeral home comes. (24 minutes after LPN F documented). The next entry was made by LPN F at 18:03 (6:03 PM) as Called the M.E. (medical examiner) for the county and informed of [NAME] [SIC] pronounced by RN in building. M.E. here and did her report. Face sheet was filled out and placed in chart. There was no additional documentation reflecting an assessment for change in condition, or vital signs or anything documented in the medical record. There was not an assessment or documentation by the RN who pronounced Resident #402, or a description of how resident was found . An interview was conducted on [DATE] at 11:13 AM, with LPN F who was asked about Resident #402. LPN F was asked if she remembered Resident #402 and verbalized I can remember her face. LPN F was asked if she remembered the day she died . I don't remember the day she died . It has been six months ago. LPN F went on to verbalize what she could recall and said Resident was confused all the time and out in left field. Surveyor asked for clarification on last statement. LPN F verbalized She would see people that were not there. She was nice. Not compliant. LPN F was asked about the charting in the medical record related to 'going to call family with an update', and to clarify what was going on. Oh, I don't recall, just an update on her condition. LPN F was asked about the entry 24 minutes after she documented that meds were given and call light in reach, and was asked what happened to Resident #402 in between time of documentation by her and then made by Social Worker R that resident was dead. LPN F was asked why there was with no description of how resident was observed, vital signs, or anything else in the medical record about the condition of Resident #402 or anything related to the death of Resident #402. LPN F was asked again if she remembered the day that Resident #402 died on [DATE]. LPN F said, Not really. Like I said, It has been 6 months ago. LPN F was asked who the RN was in the building that pronounced death, and said she couldn't recall. (According to the release of information, it was A Corporate RN.) LPN F was asked why she did not document anything such as lack of vital signs, a nursing assessment, or anything in the medical record from 1:59 PM to 2:23 PM, when Resident #402 died . LPN F did not respond. Review of facility Policy 'Death of a Resident' dated [DATE] documented All resident's deaths, whether expected or unexpected, must be treated in the same manner. All resident's must be treated with dignity and respect at all times, including at the time of death. Under 'Procedure': In the event that a resident is found without a pulse or heartbeat or not breathing, a licensed nurse will be notified immediately. If resident is Full Code status or code status has not been established or resident is found is suspicious position .Follow CPR policy and procedure, Notify the in-house supervisor or nurse on-call, Follow procedure for Post-Mortem Care, Notify the physician, Notify the family or responsible party, Document the following: The time of absence of vital signs, Description of the resident when found, Physician time and notification, Time the body was removed from the facility and where the body was taken, what valuables and belongings accompanied the resident. Document the residents death on a 24 hour report. Contact agencies as necessary per coroner's office policies.

This Citation pertains to Intake Number MI 136. Based on observation, interview, and record review, the facility failed to safely transfer one resident (Resident #10) out of two residents reviewed for transfers, resulting in a bone fracture with resultant pain and immobility and the potential for clots and embolisms. Findings include: According to the Seventh Edition of Medical-Surgical Nursing textbook by Mosby, complications of fractures can include venous [CONDITION(S)], fat embolism, [CONDITION(S)], and muscle spasms. These complications can be life threatening or long [MEDICATION(S)]. Resident #10: According to the Admission Record, printed on 5/20/2021, Resident #10 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)], type 2 Diabetes Mellitus, anxiety, high blood pressure, and asthma. On 5/20/2021 at 10:30 AM, Resident #10 was visited in her room. Resident #10 reported that her knee had been broken by a Certified Nursing Assistant (CNA) I when she transferred her using a mechanical lift by herself in February 2021. Resident #10 stated that she was still having pain related to the fracture. According to the facility report of the incident, dated 2/23/2021, the incident occurred at about 10:30 AM on 2/23/2021. Resident #10 had a brief interview for mental status on 1/25/2021 where she scored 15 of 15, indicating she was cognitively intact. The report indicated that Resident #10 was a two-person assist for transfers with the mechanical lift. However, Resident #10 had been taken to a shower on the date of 2/23/2021, with one CNA to assist with the transfers into the shower and then back to bed. The CNA was identified as CNA I who was interviewed by the facility staff and confirmed that she had used the lift to transfer Resident #10 by herself. On 2/25/2021, CNA I was given an Employee Corrective Action for not following the Kardex for a two assist with the mechanical transfer and she was given the violation of safety rules for improper operation of equipment. CNA I notified the nurse of the resident complaining of pain on 2/23/2021 and the nurse assisted to transfer Resident #10 back into her wheel chair, then she was put to bed following increasing complaints of knee pain. The nurse had applied ice and notified the provider who ordered x-rays of the knee. According to the notes, the x-ray was suspicious for a non-displaced fracture of the right knee cap. Resident #10 was transferred to an acute care facility for follow up of a CAT scan. the results of the CAT scan were suspicious for minimally displaced [MEDICATION(S)] fracture through the superior portion of the patella. Resident #10 returned to the facility with a knee brace and was to follow-up with a specialist. On 5/20/2021 at 12:45 PM, CNA I was interviewed. CNA I stated that Resident #10 started to complain of knee pain after the shower and she had put her back to bed and gotten the nurse to check her. She had gotten her up by herself because she couldn't find anyone to help her. According to the policy for Lifting Machine, Using a Portable, dated 10/2010, The portable lift can be used by one nursing assistant if the resident can participate in the lifting procedures, If not, two nursing assistants will be required to perform the procedure. According to the care plan for Resident #10, Risk for falls, initiated on 5/5/2021, Resident #10 required two for physical assistance with the mechanical lift. The Kardex, printed on 5/20/2021, also indicated two persons to assist with the mechanical lift transfer. On 5/21/2021 at 8:40 AM, Resident #10 was observed as she was bathed by Licensed Practical Nurse (LPN) G and CNA N. A brace was in place on her right knee, it was removed for her bath. There was a small imprint of the outline of the brace and a red area just below her knee cap, these areas faded with time. Resident #10 continued to complain of pain in her right knee, rating it an 8 of 10 on a scale of one to ten with ten being the worst. Resident #10 continued to receive pain medication [MEDICATION(S)]-acetaminophen 10-325 every six hours for pain in her knee.

This Citation pertains to Intake Number MI 555. Based on interview and record review, the facility failed to prevent the development of pressure ulcers for 2 residents (Resident #9 and Resident #12) and failed to ensure that wound treatments were completed as ordered for 2 residents (Resident #5 and Resident #12), resulting in Resident #9 and Resident #12 being admitted to the facility with no pressure ulcers or areas of concern and acquiring facility-acquired pressure ulcers/injuries that required treatments and dressing changes. Resident #9 acquired a Stage III pressure ulcer, while residing at the facility. Resident #5 did not receive skin treatments for pressure areas as ordered. Findings include: Record review of facility 'Pressure Ulcer Prevention' Word document provided by facility, undated, revealed Pressure ulcers (decubitus ulcers) are localized ulcerations of the skin or deeper structures. They most commonly result from prolonged periods of bed rest in acute- or long-term care facilities; however, they can develop within hours in the compromised individual. International NPUAP/EPUAP pressure injury stages. (A) Stage I-nonblanchable [CONDITION(S)]. (B) Stage II-partial thickness skin loss with exposed dermis. (C) Stage III-full-thickness skin loss. (D) Stage IV-full-thickness skin and tissue loss. (E) Unstageable pressure injury-obscured full thickness skin and tissue loss. (F) Deep tissue pressure injury-persistent non-blanchable deep red, maroon, or purple discoloration. (2016 NPUAP Pressure Injury Staging Illustrations from http://www.npuap.org/resources/educational-and-clinical-resources/pressure-injury-staging-illustrations/. Used with permission of the National Pressure Ulcer Advisory Panel March 2018. © NPUAP.) Nursing and Patient Care Considerations: Prevent Pressure Ulcer Development-1. Provide meticulous care and positioning for immobile patients. (a.) Inspect skin several times daily. (b.) Wash skin with mild soap, rinse, and pat dry with a soft towel. (c.) Lubricate skin with a bland lotion to keep skin soft and pliable. (d.) Avoid poorly ventilated mattress that is covered with plastic or impermeable material. (e.) Employ bowel and bladder programs to prevent incontinence.(f.) Encourage ambulation and exercise. (g.) Promote nutritious diet with optimal protein, vitamins, and iron. Record review of facility 'Pressure Ulcer Treatment' policy, dated 10/2010 at the bottom of each page, revealed the pressure ulcer staging description: Stage II Pressure ulcer: Partial thickness loss of dermis presenting as a shallow open ulcer with red, pink wound bed, without slough. May also present as an intact or open serum-filled blister. Unstageable Pressure Ulcer: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray green or brown) and or eschar (tan, brown or black) in the wound bed. Pressure ulcer treatment requires a comprehensive approach, including: (1.) Debridement. (2.) Managing infection. (3.) Managing systemic issues. (4.) Maximizing the potential for healing. (5.) Pain Control. Stage III Pressure Ulcer: Full thickness tissue loss. Record review of facility 'Wound Management' Policy, dated 3/2017, revealed that the purpose of the policy was to eliminate, modify or minimize factors that place residents at risk for skin breakdown. To ensure residents, who acquire wounds, receive treatment and services to promote healing, prevent complications and prevent new skin conditions from developing. Resident #9: Record review of Resident #9's admission Skin Assessment, dated 11/25/21, revealed good elasticity, skin color normal for ethnic group, temperature was normal (warm), moisture was normal, condition normal, one new wound was noted. Record review of Resident #9's nursing wound progress notes, dated 11/25/20 at 7:00 PM, revealed there was no redness over bony prominence's. Lower back incision is open to the air, no redness or drainage, staples are intact, edges are well approximated. Record review of Resident #9's nursing progress note, dated 11/25/20 at 23:05 PM, revealed the skin assessment and Braden scale completed as ordered. Resident #9 was noted to have staples intact to mid back, well approximated with no drainage noted. Resident does have scattered bruising to left forearm and small scab to right forearm. Resident's buttocks and coccyx area are free from skin breakdown and has no redness. Bilateral heels had no redness and floated on pillow per resident request for comfort. In a telephone interview on 2/11/2021 at 3:55 PM, Registered Nurse (RN) C revealed that the Resident #9's name sounded familiar, but that she picks up extra shifts all over the facility. The surveyor reviewed RN C's charting over the phone to RN C on Resident #9. RN C stated that if she documented that must be what she assessed. Record review of Resident #9's Care plans, pages 1-18, dated 11/25/20, revealed resident had potential/actual impairment to skin integrity related to fragile skin, surgical incision related to laminectomy, loss of feeling/sensation, history of skin cancer, [CONDITION(S)]. Revision of 12/6/20 added a blister to the left heel. Revision on 12/9/20 added Moisture Associated Skin Damage (MASD) to the sacrum. Record review of Resident #9's nursing skilled charting note, dated 11/30/2020 at 1:29 AM, noted Resident #9 was a one (person) assist with toileting and 1-2 (person) assist with bed mobility. Resident #9 was noted as continent of bowel and intermitting catheterization for bladder. Record review of Resident #9's admission Minimum Data Set (MDS), completed 12/1/2020, revealed under Section M: Skin, that the resident was at risk for pressure ulcers but that there were no unhealed pressure ulcers or injuries. A surgical wound was identified. Section M Skin: skin and ulcer/injury treatments were pressure reducing device for chair, pressure reducing device for bed. The turning/repositioning program was not selected. Record review of Resident #9's physician's progress note, dated 12/6/2020 at 10:14 AM, revealed: Notified by nursing staff regarding resident MASD (Moisture Associated Skin Damage) to bottom, facility to initiate house stock barrier cream for resident. Nursing staff educated on turning and repositioning. Resident has low [MEDICATION(S)] and protein. Record review of Resident #9's Skin/Wound Assessment, dated 12/8/20, revealed facility-acquired left heel blister; measurement area of 4.69 centimeters, Length: 2.55 cm by Width 1.91 cm. (Stage II pressure ulcer as fluid filled blister as described in the policy) Record review of Resident #9's Skin/Wound Evaluation form, dated 12/15/20, revealed in-house acquired new left heel blister measurement area of 2.1 centimeters, Length: 1.3 cm by Width 2.1 cm. Wound bed with Eschar (dead black tissue) of 100%. Record review of Resident #9's Skin/Wound Evaluation form, dated 12/15/20, revealed MASD (Moisture Associated Skin Damage) to the sacrum noted as in-house acquired. How long has the wound been present: Unknown. Wound measurements: Length 4.6 cm by width 4.1 cm with 60%v slough and 7.40% eschar filled wound. Exudate (drainage) Serosanguinous (blood and serum). Treatment: Enzymatic debridement. (Stage II pressure ulcer- with debridement treatment as described in the policy) Record review of Resident #9's November 2020 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply skin prep every six hours. Record review of Resident #9's December 2020 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/10/20 new order to cleanse sacrum with normal saline and pat dry. Apply [MEDICATION(S)] and cover with dressing in the morning for Moisture Associated Skin Damage (MASD). On 12/15/2020 new order of: Santyl ointment 250 unit/GM (collagenase) apply to sacrum topically at bedtime, for sacral wound cleanse sacrum wound with normal saline, pat dry. Apply nickel thick layer of Santyl to wound bed, cover with [MEDICATION(S)] foam. Record review of Resident #9's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Continue to monitor. Record review of Resident #9's 12/21/20 discharge instruction included: Sacral wound: cleanse with normal saline, pat dry. [MEDICATION(S)] AG is fabric pack into wound bed and cover with [MEDICATION(S)] foam. Change every 3 days or if soiled. Facility provided EVIDENCE BASE Ayello, E. A., & [NAME], R. G. (2016). Nursing standard of practice protocol: Pressure ulcer prevention & skin tear prevention. In M. [NAME], E. Capezuti, T. [NAME], & D. [NAME] (Eds.), Evidence-based geriatric nursing protocols for best practice (5th ed.). New York, NY: Springer Publishing Company. Pressure ulcers (decubitus ulcers) are localized ulcerations of the skin or deeper structures. They most commonly result from prolonged periods of bed rest in acute- or long-term care facilities; however, they can develop within hours in the compromised individual (see Figure 9-2) Stage III-full-thickness tissue loss, with subcutaneous fat that may be visible but bone, tendon, or muscle is not exposed; may include undermining and tunneling. Slough may be present but does not obscure the depth of tissue loss. Record review of facility 'Pressure Ulcer Treatment' policy, dated 10/2010 at the bottom of each page, revealed that Stage III pressure ulcer interventions or treatments included to fill dead space (in the wound which is Packing of the wound) with treatment material such as described on the Resident #9's discharge instructions. Resident #12 According to medical record, Resident #12 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to Minimum Data Set (MDS) dated [DATE], Resident #12 scores 14/15 indicating intact cognition, and also required 2 person assistance with Activities of Daily (ADL) care to include bed mobility, toileting and transfers. Resident #12 skin was intact on admission. Resident #12 discharged from the facility on 2/17/21. The following observation was made on 2/11/21 at 3:00 PM, in Resident #12's room. Upon entering resident's #12's room to observe treatment to Resident #12's heels, Resident #12 was resting in bed with heels up on a pillow. Resident #12 was asked how long at the facility and indicated a few weeks. Resident #12 was asked if he came into the facility with sores on both heels and said, No, I got them after I was here for a little while. Resident #12 was asked if the sores were painful and said Oh Yes, the left one hurts the worst. The right one not so bad any more. Registered Nurse B entered the room to perform treatments to Resident #12's heels. RN B entered the room and put on gloves with out washing her hands or using hand sanitizer. RNB donned gloves and then removed the sock to Resident #12's left heel. RN B was asked what was the treatment was Resident #12 was going to receive for the deep tissue injury (pressure ulcer) on the left heel and verbalized it was skin prep. RN B then verbalized she had not done the treatment to both heels on the day shift as ordered by the physician. RN B was asked why and indicated she did not have the supplies needed to do the treatments. RN B then proceeded to leave the room after removing Resident #12's sock, and removing gloves. On the way out of the room RN B verbalized she did not have the supplies needed to do the treatment so it did not get done on the day shift. I was supposed to do it this morning but I did not. Observation made of Left heel revealed a blackened area approximately the size of a quarter on the back of Resident !2's heel with dry, flaky, peeling skin noted to surrounding area. Skin prep was applied to area after cleansing with normal saline. Resident #12 verbalized it hurt when RN B was cleaning the heel. RN B was asked if Resident #12 received any pain medications before treatment to the hell and verbalized she wasn't sure. RN B asked Resident 12 to rate his pain on scale of 0 - 10 and he verbalized a 9. RN B said she would get him something. RN B then removed the sock of the right heel and it was noted a small pink area that was not opened. RN B verbalized the right heel was open but closed now. Review of current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12 was admitted on [DATE]. Review of wound/ skin assessment dated [DATE], documented no to pressure ulcers.(No new wounds) Review of skin/wound assessment dated [DATE], documented no to pressure ulcers. (No new wounds) Review of skin/wound assessment dated [DATE], documented no to pressure ulcers. (No new wounds) Review of skin/wound assessment dated [DATE], documented no to pressure ulcers. (No new wounds) Review of skin/wound assessment dated [DATE], documented no new wounds. (No new wounds) Review of skin/wound assessment dated [DATE], documented Pressure Ulcer Right Heel that started on 1/25/21. Review of skin/wound assessment dated [DATE], documented Pressure Ulcer Left Heel, DTI (Deep Tissue Injury) that started on 1/25/21 with measurements of 1.4 cm (centimeters) x 1.3 cm with eschar (black necrotic tissue) noted, 100 percent of wound bed filled. Resident #12 also had an area on right buttock documented as MASD. (Moisture Associated Skin Damage). Review of Minimum Data Set, dated dated dated [DATE], under 'Skin' documented Resident #12 having no Pressure Ulcer on admission. Review of Braden score on 1/12/21, documented a score of 18 indicating Resident #12 was 'At Risk' for the development for Pressure Ulcers. Review of Braden score on 1/19/21, documented a lower score of 16. Review of Braden score on 1/26/21, documented a score of 16. Review of Braden score on 2/1/21, documented a score of 17. Review of POC (Plan of Care) response history, on the Nursing Assistants task list, has a question to check either Yes or No that Pressure Reducing device placed in the bed. Out of a time frame of 1/20/21 through 2/17/21, there were approximately 34 check 'No' responses that Pressure Reducing devices were placed in the bed. There was also an area to check for Resident refusals and it was blank, There were no areas checked that Resident #12 was not available and was also blank. Review of Resident 12's skin care plan documented The resident has potential/actual impairment to skin integrity r/t fragile skin, guest is non-compliant with turning and repositioning, when staff approach encourage turning and repositioning if he refuses, guest prefers to lay in bed all day, which puts guest at risk for skin breakdown, guest declines to float heels while in bed, refuses to wear soft blue boots, MASD to right buttock. Couple of Interventions documented were: May have pressure reducing cushion to protect skin while up in chair .float heels while in bed as tolerated .monitor, document location, size, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .to MD (Medical Director). An interview was conducted with the Administrator on 2/11/21, related to Pressure Ulcers for Resident #12 who verbalized Resident #12 was just non-compliant. The Administrator was informed at that time the RN doing the treatment admitted not being able to do the day shift treatment because of lack of sufficient supplies during the observation of wound care. Resident #5 According to medical record, Resident #5 was a [AGE] year old female with an admitted [DATE],readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to Minimum Data Set (MDS) dated [DATE] (Significant Change) , Resident #5 scored 0/15 indicating severe impaired cognition, and also required 2 person assistance with Activities of Daily (ADL) are to include bed mobility, toileting and transfers. Review of Resident #5's Treatment Acceptance Record (TAR) documented for the month of August 2020 treatments for: Treatment to ensure heels are up while in bed at all times as tolerate, to be completed at 0900 and 2100 (9 AM/9 PM). Review of the TAR reflected the treatment was not completed by nursing on 8/17/20, 8/18/20, 8/24/20, 8/25/20, at 0900 hour, and at 2100 hour not completed on 8/31/20. (As manifested by wholes in the TAR not checked, initialed as completed). treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of TAR for September 2020 reflected wholes for same treatments as above on the days of: 9/2/20, 9/10/20, 9/14/20, 9/17/20, 9/28/20, 9/29/20, 9/30/20, for the 0900 hour, and the same dates for skin prep to the spine as not completed. Review of TAR for October 2020, same treatments listed above reflected wholes on the dates of 10/2/20., 10/7/20, 10/19/20, 10/21/20, as not completed. The same dates of whole were noted for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER]

This Citation Pertains to Intake Numbers MI 333 and MI 431. Based on interview and record review, the facility failed to ensure interventions, including closer monitoring with a change of wound condition, documentation of changes and timely notification of physician and responsible parties, were enacted to prevent the development and worsening of wounds and pressure ulcers/injury for 2 residents (Resident #2 and Resident #3 ) of 3 residents reviewed for wounds, resulting in Resident #2 developing a skin tear from shear on the spine (when the skin is pulled across another object) that progressed into a Stage 3 Pressure Injury (NPIAP-Full thickness loss of skin, in which adipose (fat tissue) is visible in the ulcer .granulation tissue, rolled wound edges, slough (tough, stringy yellow/brown tissue) and eschar (black dead tissue) may also be present) and, Resident #3's lumbar surgical incision dehisced (opened up) and became infected. Findings Include: Resident #2: During a tour of the facility on 9/2/20 at 2:40 PM with the Administrator and Infection Control (IC) Nurse A all residents in the building were observed to have Droplet precautions signs on their doors. Some of the doors were closed and some were not. Some residents were sitting in their doorways, restless and anticipating coming out of their rooms. The Administrator and IC Nurse said all of the residents were in Droplet precautions and their doors were supposed to be closed, because there was a resident identified positive for Covid-19 on the 700 hall (on the other side of the building) and several staff members had positive Covid-19 tests from a recent facility testing. Resident #2's door was closed. A record review of the Face Sheet and Minimum Data Set (MDS) Assessment indicated Resident #2 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. On 4/23/20 the resident was diagnosed with [REDACTED]. The MDS assessment dated [DATE] revealed the resident had severe memory loss with a Brief Interview for Mental Status (BIMS) score of 3/15 and needed extensive 1-person assistance with all care including hygiene and bathing. The resident began receiving Hospice services on 10/1/18. A Skilled Charting note dated 7/28/20 at 3:29 PM provided, Guest wound pictured today and is now . a stage 3 pressure ulcer. Area started out on 4/21/20 as a skin tear due to shearing on bed linens. Guest frail stature A Progress Note titled Encounter by Nurse Practitioner Q dated 7/28/20 at 12:00 AM (midnight) said, Patient is seen today regarding her back wound . Wound will most likely not heal . Wound care will continue as the same . Patient reports back pain 10/10 (0 is no pain and 10 is the worst pain) . Stage 3 pressure ulcer of back . approximately 80% fibrogen tissue and 20% granulation tissue . currently takes MS ER ([MEDICATION NAME] Extended Release) and prn (as needed) [MEDICATION NAME] . A review of a Wound Note dated 7/6/20 at 10:06 AM revealed, Guest has open wound to spine. Wound originally started out as a skin tear and has since progressed into open lesion. Wound bed is 33% granulation tissue 66% slough at this time. Current measurements (1.66 (cm length) x 1.55 (cm width) x 0.2 (cm depth) . Wound not anticipated to heal . Guest reports pain at this time . Patient does have Stage III (3) pressure ulcer on back contributing to her pain . A Provider Encounter note dated 6/25/20 at 12:00 midnight, . Chief Complaint . Wound .Patient also has wound on her back which started in the skin tear . small amount of drainage was noted on her wound dressing A Progress note dated 4/21/20 at 11:50 PM, Guest was noted to have skin tear to mid spine . she is unable to tell how it was acquired . A review of the progress notes did not indicate that the responsible party was notified of Resident #2's initial skin tear on her spine or deteriorating wound to a Stage 3 pressure ulcer. A Late Entry progress note dated for 7/17/20 provided, Guest daughter contacted regarding concern form left at desk, message left for daughter to return call to the DON or Admin. This was greater than 3 weeks after the pressure ulcer was identified. On 9/8/20 at 4:21 PM, an interview with Unit Manager B about Resident #2 provided, She has a wound on her back (mid-back area/spine). It started off as a skin tear. It changed into a pressure injury over time. The wound was identified as a skin tear due to shear. An interview with the Director of Nursing (DON) on 9/8/2020 at 4:30 PM related to Resident #2, She received a skin tear from shearing with positioning, around April (2020). She started to decline. We are unsure of the date or who was caring for her at the time. The wound declined to a Stage 2 pressure ulcer. There was a period of time that slough was present. (Slough is defined as yellow devitalized tissue, that can be stringy or thick and adherent on the tissue bed . Skilled wound care.com 2019). The progress is up and down; it has gotten larger. The DON said the resident was provided with a low air loss/alternating pressure mattress to relieve pressure from her back on 7/21/20. The DON was asked if the resident's responsible party was notified of the skin tear and decline of the wound to a Stage 2 and then Stage 3 pressure ulcer and stated, We told the hospice nurse. She would have told them. The DON was asked if it was the facilities responsibility to ensure the resident's responsible party was made aware of the skin injury and decline and he stated, We told hospice. We assumed they told them. On 9/9/20 at 9:50 AM, during an interview with Confidential Person I she stated, In the 2nd week of July (2020), I talked to the visiting nurse; she told me she (Resident #2) had a pressure sore. She said (Resident #2) had it since April (2020). I don't know why they didn't tell me about it. I took pictures of it. I've written 2 grievances with the facility related to her care. She fell in April (2020) and broke her hip in 2 spots. They notified me of the fall, but not the bedsore. She is now bedridden and has a bedsore. She now has back pain because of the bedsore. I found out when he went to the window, at that timed they opened the window. She winced and said, It's my back. That's when I found out. I asked the visiting nurse and she told me. On 9/14/20 at 11:30 AM, the DON was interviewed about Resident #2's spinal/back wound and said Nurse P notified the Hospice nurse on 4/21/20 of the wound but did not contact the resident's responsible person. The DON said he did not locate a note in the medical record to indicate the date the pressure ulcer was identified or that the resident's responsible party had been notified when the wound worsened to a Stage 3 pressure ulcer. A returned call and interview with Hospice Nurse R on 9/21/20 at 12:25 PM about Resident #2's spinal wound, I see the (Resident #2) 3 times a week. I don't normally do wound care; the facility does assessment and wound care. They see her every day. We discuss the plan of care, but they ultimately have the say because they are treating it. I was told what their protocol was. Usually, they notify the responsible person. I communicate with the daughter every week, but not about the wound on her back. She broke her pelvic bone (from a fall at the facility prior to the wound) and has pain from that and pain from the wound. She would just say her back hurts. She is now on MS ([MEDICATION NAME])[MEDICATION NAME] a day. She had [MEDICATION NAME] (a narcotic pain medication) but it wasn't holding her. She also has [MEDICATION NAME] (liquid [MEDICATION NAME]) as needed and takes it about twice a week. Pressure Injury, National Pressure Injury Advisory Panel -NPIAP Definition, April 2016: A pressure injury is a localized damage to the skin and underlying soft tissue usually over a bony prominence .the injury can present as intact skin or an open ulcer and may be painful. The Injury occurs as a result of intense and/or prolonged pressure or in combination with pressure and shear .may also be affected by microclimate (moisture to the skin . AANAC (American Association of Nurse Assessment Coordination), How to Identify Wound Etiology . May 15, 2018, . Shearing . pressure injury can also be caused by shearing forces in combination with pressure. Shearing forces are caused when the skin stays in one position due to pressure and the bones and underlying tissue roll in the opposite direction . By causing trauma and cutting off the blood supply, shearing forces can lead to rapid tissue breakdown . A review of the resident's Wound Assessments revealed the following: 9/8/2020, Pressure- Stage 2- Spine . 5 months old, Acquired: In-House Acquired, Area 2.37 cm 2- Measurement: 1.38 cm length x 2.4 cm width x (no measurement depth). 9/1/2020, Area 5.66 cm 2- Measurement: 2.65 cm length x 3.18 cm width x 0.1 cm depth. 8/25/2020, Measurement: Area 3.66 cm 2- 2.56 cm length x 2.02 cm width x (no measurement depth). 8/18/2020, Measurement: Area 2.97 cm 2- 1.58 cm length x 2.42 cm width x, 0.1 cm depth. 8/11/2020, Measurement: Area 0.8 cm 2- 1.03 cm length x 0.98 cm width x 0.1 cm depth. 8/4/2020, Measurement: Area 1.24 cm 2- 1.2 cm length x 1.27 cm width x (no measurement depth). 7/28/2020, Measurement: Area 1.24 cm 2- 1.24 cm length x 1.24 cm width x 0.1 cm depth. 7/21/2020, Measurement: Area 1.69 cm 2- 1.57 cm length x 1.28 cm width x 0.1 cm depth. 7/15/2020, Measurement: Area 1.8 cm 2- 1.58 cm length x 1.42 cm width x 0.2 cm depth. 7/8/2020, Measurement: Area 3.33 cm 2- 2.23 cm length x 1.89 cm width x 0.1 cm depth. 7/1/2020, Measurement: Area 1.61 cm 2- 1.66 cm length x 1.55 cm width x 0.1 cm depth. 6/24/2020, Measurement: Total area 2.15 cm 2. A review of the documentation indicated a discrepancy on what stage the pressure ulcer was on Resident #2's spine was. The Wound Assessments document a Stage 2 and the progress notes and Physician/NP notes say Stage 3. The wound size/area fluctuated frequently. A review of the Physician orders [REDACTED]. Orders for weekly skin assessments did not occur until 7/21/20 and routine [MEDICATION NAME] was initiated on 8/12/20 related to increased back pain. A review of the Care Plan titled, Alteration in pain secondary to: .aging joints, muscle weakness . wound on lower mid- back . date initiated 7/21/17 and revised 8/2/20 with no updated interventions since 11/15/19 and Care Plan titled, Pain medication therapy, date initiated 7/25/17 and revised 2/2/18 with last updated intervention 7/25/17. A review of a Skin Care Plan titled, The resident has potential for impairment to skin integrity . related to fragile skin, impaired mobility . history of skin tears . pressure injury . mid back, dated 7/21/17 and revised 8/5/20 with Interventions: Follow facility protocols for treatment of [REDACTED]. The resident did not have an intervention for frequent repositioning until 8/11/20, several months after an injury due to shear and development of a pressure ulcer on her spine. There was no intervention that identified how to correctly reposition the resident to prevent shear and development of a skin injury or exacerbation of the existing wound. A specialty low air loss mattress was not provided to the resident until 7/27/20; several months after development of the skin tear on her back and after the wound became a Stage 3 pressure ulcer. Resident #3: On 9/9/20 at 10:35 AM, an interview with Confidential Person J related to Resident #3's surgical incision on her spine- The doctor/surgeon told me he sent specific information, get her off her back, get her up as soon as possible, other hospitals put a wedge under her so she was strong enough to sit. They all of a sudden said they were going to discharge her and then they said her wound was opening. The DON said it did not look infected. (Physician G) said, My 2-year-old son could tell it was infected, oozing pus, green. He said if you send her back there you have no other options. That was on July 8th. (Physician G) said it was open much longer than a week. She (Resident #3) was sent (to the hospital from the facility) on July 7th (2020). The facility kept saying, 'Don't worry we're taking really good care of her.' They did not tell her or me, there was a problem until July 7th the day she went to the hospital. They cleaned it out and did another surgery and she had a wound VAC. She was so weak from not eating; she was in a unit like an ICU to monitor her closely then she was discharged to (another hospital) now she's at another facility. Her back wound is still open but progressing. (The facility) would never tell me the wound measurements. They said it was (their) property. I am her Power of Attorney. I was the person to give information to. During the interview, Confidential Person J said the facility had a Care Conference with her on 6/11/20 and 6/30/20 and the wound was not discussed. Then July 7th, they said 'She's being discharged today.' I said what and where? They called back and said she's going to the hospital today for her wound. A review of the facility Team Conference form dated 6/11/20 with a Lock Date of 7/9/20, two days after the resident was discharged said Guest's daughter voiced concerns about skin. Daughter was informed that facility ordered guest a APM (alternating pressure mattress) as well as facility's protocol for tracking wounds. Daughter and guest satisfied with wound care . The note was initiated 3 days after admission. A review of the Face Sheet and MDS assessment for Resident #3 indicated she was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment dated [DATE] revealed the resident had a BIMS score of 13/15 with mild cognitive loss and needed 2-person assistance for all care, except for eating and was able to feed self with set up. A review of the Wound Evaluation notes/each with a picture of the wound, revealed the following: 6/9/2020: Surgical, Spine, Area 4.32 cm 2, Length 16.23 cm, Width 0.65 cm, Evidence of Infection none, Exudate (drainage) none, Surrounding tissue [DIAGNOSES REDACTED] (redness),Pain: None, Dressing: None, Goal of Care: Healable, Progress: Monitor. (Staples were observed intact.) 6/16/20: Surgical, Spine, Area 3.31 cm 2, Length 11.15 cm, Width 0.45 cm, Wound Bed: [MEDICATION NAME] 80%, Granulation 20%, Other Bleeding, Scab, Exudate: amount/light, Type/sanguinous/bloody, Surrounding Tissue (blank), Pain: 4 (0-10 with 10 the worst pain), Goal of Care: Healable, Progress: Stable. 6/23/20: Surgical, Spine, Area 9.01 cm 2, Length 18.16 cm, Width 0.74 cm, [MEDICATION NAME] 100%, Evidence of Infection: None, Exudate: Amount light, Type Serous (yellow/clear), Surrounding Tissue: Normal in color, Pain: 5, Pain Frequency: Intermittent, Dressing: Composite Dressing, Goal of Care Healable, Progress: Monitoring. (A small round area near the distal/lower left area of the incision was observed, in the wound picture, with a pink border and yellow center. It was the approximate size of the blue dot held next to it by the nurse for measurement. There was also a raised pink area with slight yellow tissue in the upper area of the incision. The incision edges were not well approximated.) 6/30/20 at 5:59 AM: Surgical, Spine, Area 1.45 cm 2, Length 4.39 cm, Width 0.43 cm, Slough: 100%,Evidence of Infection: None, Exudate: light, serous, Surrounding Tissue: Fragile, Pain: 5, at dressing, Dressing: Calcium Alginate, Goal of Care: Healable, Progress: Monitoring, Notification: Practitioner Notified, Resident/Responsible Party Notified, Practitioner: Nurse Practitioner (NP) Q, Responsible Party: Daughter. (The incision was greater than 50% open with yellow slough covered tissue inside the raised edges. Two areas of the wound were round, and the incision was no longer linear. The upper portion of the incision appeared healed.) 6/30/20 at 6:00 AM: Surgical, Spine, Area 18.06 cm 2, Length 17.03 cm 2, Width 1.52 cm 2, Granulation: 20%, [MEDICATION NAME], Pain: 4, at dressing, Primary Dressing: Foam, Goal: Healable, Progress: Stable There were two conflicting assessments for 6/30/20. 7/7/20 at 4:54 AM: Surgical, Spine, Area 6.9 cm 2, Length 6.82 cm, Width 1.44 cm, Granulation: 10%, Slough 90%, Evidence of Infection (blank), Exudate: moderate, purulent (with pus), Pain: 5, intermittent, Dressing: No dressing applied. Goal of Care: Healable, Progress: Deteriorating (Approximately 30-40% of the incision was completely open (dehisced) and deep, with visible bloody drainage and slough.) A review of the Progress notes indicated the facility physician was notified of the resident's opening wound, but no one contacted the surgeon who transferred the resident to the facility. Every week, on the wound note, as the wound continued to deteriorate the facility documented Monitoring or Stable on the wound note, until 7/7/20 when they said it was deteriorating. A Provider Progress note by NP Q dated 6/9/20 at 1:32 PM revealed, . admitted following hospitalization for a fall at home . sustained a T12 burst fracture . surgical repair of her T12 Fracture . surgical incision has some minor redness on the surrounding edges, however wound edges are well approximated. Staples intact. Per her discharge instructions patient is to follow-up with neurosurgery in 1 to 2 weeks . No signs of infection . An EMAR Medication note dated 6/16/20 at 6:15 PM, Remove Spinal incision staples on 6/16/20 . Scant amount of bloody drainage on dressing . Some redness noted to incision. NP at bedside to observe incision. Staples removed . A review of a Provider Encounter note by NP Q dated and signed 6/16/20 at 2:19 PM, Patient seen today to remove staples at nursing staff request. [MEDICATION NAME]/lumbar surgical incision . minor surrounding redness she has had since admission. Small scabs are present . A Provider note by NP Q dated 7/1/20 at 12:13 PM revealed, . Kin: Surgical incision on spine, staples removed, minor surrounding redness, wound edges well approximated . There was no mention of the deterioration in the resident's surgical wound on her spine or that it was no longer approximated. It was opening with round areas and the wound had slough, as noted on the 6/30/20 Wound Evaluation. A progress note dated 7/6/20 at 11:15 AM provided, Met with IDT (Interdisciplinary Team) to discuss patient's progress . Family contacted regarding patient status and requested transfer to another SNF (skilled nursing facility) . There was no mention of the condition of the resident's wound. A Skilled Charting note dated 7/7/20 at 5:27 AM, by Nurse S provided, Guest's wound care completed. Wound to back had notable purulent drainage oozing from wound bed. Approximately 100 cc of drainage collected during wound care and still currently draining. Wound is currently packed with gauze . A Skilled Charting note dated 7/7/20 at 1:17 PM written by the DON revealed, Guest back wound assessed this am upon request from nursing staff . wound found to have abnormal drainage characteristics and an increase in depth. Guest was admitted with surgical incision and seems to have dehissed (dehisced). Family contacted and gave recommendation to call surgeon for further direction . A Discharge Summary dated 7/7/20 at 2:16 PM, Guests [MEDICATION NAME] wound assessed by provider and nursing staff this AM and determined to have dehisced . Collaboration with guest's surgeon regarding unstable wound bed resulted in guest's surgeon arranging for guest to be seen (at the hospital) for further assessment and possible surgical repair . A review of the physician orders [REDACTED]. 6/8/20: Weekly assessment, measurement, and document of wounds, at bedtime every 7 days. 6/8/20: Skin assessment, every 7 days during stay, at bedtime every 7 days. 6/9/20: Rinse spinal incision with Normal Saline, cover with ABD and secure, at bedtime for post-op care. There were no updated orders for wound dressings to the spinal incision as the wound declined. A review of the Medication Administration Record [REDACTED] The 6/8/20 orders for Skin assessment were on the TAR as was the 6/9/20 order for a normal saline rinse and ABD pad to the spinal incision. 6/16/20: Remove Spinal incision staples on 6/16/20 per neurosurgery one time only, Start date 6/16/20. An undated entry on the July TAR stated, Neurosurgery would like to be called by nursing for a spinal incision wound check up one time only until 7/20/20. There was no corresponding progress note to explain the entry on the TAR. There were no updated wound dressings to the spinal incision on the June or July MAR's or TAR's related to the deteriorating incision. There was no indication that the Neurosurgeon had been contacted prior to 7/7/20 to inform him of the change in the wound that had been declining for weeks. The nursing staff were initialing completion of the normal saline and ABD treatment to Resident #3's spinal wound, but they did not document any changes or findings. The wound documentation was provided weekly by the Unit Manager or Director of Nursing. A review of the Care Plan titled, The resident has potential/actual impairment to skin integrity related to surgical wound on back . date initiated and revised 6/9/20, with Interventions: Identify/document potential causative factors and eliminate/resolve where possible, dated 6/9/20; Low air loss mattress to protect the skin while in bed, date initiated 6/9/20 and revised 6/19/20; Monitor/document location, size and treatment of [REDACTED]. to MD, date initiated 6/9/20. There was no mention of the APM (alternating pressure mattress) as mentioned in the Team Conference note dated 6/11/20. A review of the Care Plan titled, Potential for Infection related to surgical wound, date initiated 6/9/20 and revised 7/8/20 (after discharge) with Interventions: Monitor for infections, date initiated 6/9/20. There were no updated interventions. A review of the Hospital progress notes for Resident #3 from 7/7/20-7/14/20 revealed the following: ED (Emergency Department) Visit, 7/7/20 at 4:16 PM, . presents to the ED for evaluation for concerns of wound dehiscence at the site of the [MEDICATION NAME] region surgery .Skin: . open wound midline in the [MEDICATION NAME] lower region, 4 cm in length approximately, approximately 2 cm in width and approximately about 2-3 cm in depth . patient requires admission . consult with (Physician G) . admitted [DATE]. 7/8/20 at 9:16 am, Infectious Disease Hospital Consult with Physician She (Resident #3) presents with a fairly large posterior thorax wound dehiscence with 6 cm of undermining. (Journal of Wound Care and [MEDICATION NAME][MEDICATION NAME] Therapy (WCET), Wound terms and definitions, January/March 2015, Undermining: The destruction of tissue or ulceration extending under the skin edges (margins) so that the pressure ulcer is larger at its base than at the skin surface.) The case was discussed with neurosurgery and the patient will be taken back to the OR for wound debridement and washout with Wound VAC placement . The superficial wound culture is with numerous PMN's (polymorphonuclear leukocytes (white blood cells)), gram-positive cocci and gram-positive bacilli . will continue empiric treatment with [MEDICATION NAME] and [MEDICATION NAME] (antibiotics). Please encourage offloading of the wound (to relieve pressure) . 7/9/20: Date of Surgery 7/9/20, Preoperative Diagnosis: [REDACTED]. Findings: A lot of purulent discharge . it was deemed appropriate and urgent to take her to the operating room . There was a small dehiscence above and a large dehiscence below . The wound was investigated. It was 15 cm long, 4 cm wide and 3 cm deep . we irrigated with 3 liters of fluid . then debrided the wound . 7/11/20 an ICU Consultation: (Resident #3) presented to the hospital on [DATE] complaining of fever and wound dehiscence . Post-operative [MEDICATION NAME] wound dehiscence . Intraoperative cultures showed: [MEDICATION NAME] cloacae complex, [DIAGNOSES REDACTED] pneumoniae, pseudomonas aeruginosa, [MEDICATION NAME] faecalis . continue [MEDICATION NAME] and [MEDICATION NAME] . 7/14/20 Discharge Summary: . presented to (hospital) complaining of wound dehiscence . She did have a temperature of 100.9 and states that she had a head ache and was tired .When she arrived she was hypokalemic (low potassium level) . Neurology was consulted . incision and drainage . Wound VAC 7/9/2020 . the wound culture during surgery only grew [MEDICATION NAME] cloacae . discharged [DATE] (to Long Term Acute Care) . Resident #3 was admitted to the facility on [DATE] with a surgical incision on her back. The wound was pictured and measured, but not identified as being in the process of opening (dehiscence). The process for caring for the wound was not changed to aid in healing and the Neurosurgeon was not contacted to inform him of the changing wound until the daughter called him on 7/7/20, after the facility told her it looked infected. The resident then had another hospital stay and surgery. A review of the facility policies included the following: Change in a Resident's Condition or Status, dated revised September 2013 revealed, Our facility shall promptly notify the resident, his or her Attending physician and representative of changes in the resident's medical/mental condition . Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated revised October 2010 indicated . the physician will authorize pertinent orders related to wound treatments . the physician will help identify medical interventions related to wound management . the physician will evaluate and document the progress of wound healing- especially for those with complicated, extensive, or non-healing wounds . the physician will help staff review and modify the care plan . Surveillance of Infections, dated revised December 2012 provided, Nursing Staff will monitor residents for signs and symptoms that may suggest infection, according to current criteria and definitions of infections and will document and report suspected infections to the Charge Nurse as soon as possible . When infection or colonization with epidemiologically important organisms is suspected, cultures may be sent . The Charge Nurse will notify the attending physician and Infection Preventionist . Surveillance should include a review of any or all of the following information to help identify indicators of infections . Laboratory reports, Skin care sheets, Infection control rounds or interviews, verbal reports from staff . Analyze the data .

This Citation pertains to intake MI 526. Based on interview, and record review, the facility failed to maintain the safety of one Resident (#204) resulting in two falls with injury, failed to maintain safety by following safety care planned interventions, failed to perform an assessment timely post fall, failed to follow standards of practice for positioning and bed mobility, failed to thoroughly and accurately complete and investigate Incident/Accident for one Resident (#204) out of three reviewed for safety/accidents, resulting in Resident #204 rolling out of bed and sustaining serious injuries. Findings include: According to admission face sheet dated [DATE], Resident #204 was [AGE] year old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to Brief Interview for Mental Status assessment dated [DATE], Resident #204 scored 15 on the Cognition Assessment, indicating no Cognition Impairment. According to Discharge Minimum Data Set ((MDS) dated [DATE], Resident #204 required Extensive assistance with Activities of Daily (ADL) care to include bed mobility, transfers, and toileting. Review of hospital discharge notes, dated [DATE], documented under History and Physical Problem 1: [MEDICAL CONDITION] (Passing out) secondary to [MEDICAL CONDITION] (iron deficient). Under 'Chief Complaint' documented [AGE] year old African-American with PMH (past medical history) significant for A-Fib (cardiac abnormality), chronic [MEDICAL CONDITION], hypertension (high blood pressure), chronic debility (weak) and other complications, who is known to our service. According to patient while at a rehab facility, she was having light headedness during positional changes, and was also feeling weak. According to son, resident was feeling light headed and passed out, [MEDICATION NAME] 5 to 10 minutes, and then able to regain consciousness. Son had brought her to the emergency room (ER) for evaluation. Resident #204 discharged to facility on [DATE]. During an interview conducted on [DATE] at 9:47 AM, Resident #204's family member indicated they were upset at how Resident #204 was cared for while residing in the facility from a time frame of [DATE] through [DATE]. Family member indicated Resident #204 had called on several occasions indicating staff did not respond to her call light needs, and Resident #204 had to wait from 30 minutes to over an hour to get staff in to help her to the bathroom, or respond when she needed assistance. Family member verbalized that Resident #204 indicated she had falls and had self transferred to the bathroom early on [DATE], to keep from soiling herself. Family member also verbalized she had contacted the facility and was informed that Resident #204 had a fall on [DATE], and [DATE], but indicated she was not sure what events took place and no one would give her any answers to events that occurred in the facility. Resident #204's family member indicated that after a fall on [DATE], Resident #204 called indicated her leg was hurt and required medication for pain relief. Family member verbalized Emergency Contact person, listed in the medical record, was in touch with her and informed her that Resident #204 had another fall on [DATE], which resulted in Resident #204 being sent to the emergency room . The family member indicated that a nurse from the facility contacted the family indicating Resident #204 was sent to the ER and the family needed to go to ER due to a change in Resident #204's Level of Consciousness, and that Resident #204 had been down (on the floor) for at least 20 minutes. Family member verbalized that Resident #204 came to the facility as a fall risk and that the facility should have kept a closer eye and better supervision for Resident #204. Family member also indicated the family had some difficulty obtaining Resident #204's belongings and could not get any answers from the facility timely. Family member indicated the hospital physican indicated to her that in order to have [DIAGNOSES REDACTED]. Review of Progress notes dated [DATE], by physician documented: Pt (patient) seen today for follow up on fall. Found early this morning lying on her stomach at the side of her bed. She states she rolled out of bed. Pt notes left ankle pain following her fall, x-ray was ordered and negative for acute fracture or dislocations. Resident did also sustain an abrasion on her right upper arm. Will order 50 milligrams of [MEDICATION NAME] every 8 hours for pain management for 5 days. Review of Progress notes dated [DATE] through [DATE], documented on [DATE] at 09:36 AM that a fall occurred on [DATE], indicating CNA alerted nurse of guest fall at 1942. Guest was on floor next to bed, supine (on back) unresponsive. No apical pulse was noted and no respirations were noted. CPR (cardio-pulmonary resuscitation) was then started at 1945 (7:45 PM). 911 was called at 1946. AED (automatic external defibrillator) applied, no shocks were required. CPR continued till EMS (emergency medical services) arrived and took over at 1951. Family notified at 2000. DON notified at 1949. Stat EMS left building with guest at 2015. Guest son called the facility at 2025, and was instructed to follow up with Emergency Department for further updates, documented by a Licensed Practical Nurse. (There were no additional progress notes documented by the Registered Nurse who was in care of Resident #204 for the occurrence on [DATE]. There was no incident report documentation entry made for the occurrence on [DATE]). On [DATE], Regional Interim Director of Nursing was asked for Incident/Accident reports for any falls Resident #204 had during her eight day stay at the facility, and provided two incident reports dated [DATE], and [DATE]. Review of Incident/Accident Report dated [DATE] at 6:50 AM, documented 'Fall in Resident #204's room' and described the incident Upon entering Guest's room, to administer [MEDICATION NAME], guest's feet were seen at the end of the bed on the floor. Guest observed to be laying on stomach with head lifted up and wearing [MEDICAL CONDITION] (Bilevel Positive Airway Pressure). Guest was noted to be resting on elbows. Guest stated she rolled out of bed and doesn't remember doing it until she was jolted awake on the floor. Guest denies hitting head and states increased pain in left ankle. Guest states SOB (shortness of breath) with [MEDICAL CONDITION] off. Under Immediate Action: Guest assessed while on the floor and assisted to seating position to help breathing ability. Guest assisted onto hoyer pad and lifted with hoyer machine back to bed by staff. Guest educated on importance of having bed in low position during H.S. (at bedtime). Guest re-assessed on ability to use bed control, demonstration was appropriate and successful. Under injuries: No injuries observed at the time of incident. Under 'other info' documented 'Guest rolled during sleep and rolled off the bed. (physician progress notes [REDACTED]. Resident #204 used [MEDICAL CONDITION] not [MEDICAL CONDITION]. ([MEDICAL CONDITION] is continuous positive airway pressure. [MEDICAL CONDITION] is Bilevel positive airway pressure and has 2 pressure settings. One for inhalation and one for exhalation). Review of Incident/Accident report dated [DATE] at 7:45 PM, with a revision date of [DATE] at 8:07 AM, listed as prepared by the Regional Interim Director of Nursing documented a Fall. Location of Incident was Residents' room. Under Nursing description At 1942 (7:42 PM), this writer was called by nurse on the hall that guest had rolled off the edge of the bed during a check and change. CENA (Certified Nursing Assistant) ensured that guest was ok. Guest observed alert and responsive and left the room to get the nurse. Nurse and CENA entered guest's room less than 3 minutes after incident and observed guest unresponsive in Cardiac and respiratory assessed (SIC). Resident unable to give a description. Under the heading of 'Description' CPR (Cardiopulmonary Resuscitation) initiated at 1945 (7:45 PM), EMS/911 called at 1945, AED (automated external defibrillator) applied, no shock was advised, but advised to continue CPR. CPR continued. Nurses rotated CPR until EMS arrived and took over at 1951. [MEDICAL CONDITION] (continuous positive airway pressure) and O2 (oxygen) had been on patient. Patient has BIMS ,[DATE] and applies [MEDICAL CONDITION] or [MEDICAL CONDITION] mask herself with supervision of nursing. EMS obtained pulse and guest left the facility via emergency stretcher at 2015 (8:15 PM), per nursing documentation. Nurse attempted to get a hold of son and left voicemail. Son returned call and instructed to go to ER. This writer notified medical director and NP (Nurse Practitioner). Under the listing of 'Resident taken to the hospital' was documented an 'N' indicating No. Under injuries documented no injuries observed. Under 'Predisposing Physiological Factors' documented as 'Weakness/Fainted'. Under the heading of 'Witnesses' documented No witnesses's found. This entry was in contradiction to the above documentation from the same incident report that described the incident as having happened while she was under care from the CNA. During an interview on [DATE], with Regional Interim DON (RIDON), related to the two incidents that occurred for Resident #204, The RIDON indicated she had completed an investigation related to the two falls for Resident #204. RIDON was asked what interventions were implemented for the roll out of bed on [DATE], and verbalized pillows were to be put in place to prevent Resident #204 from rolling out of bed. Review of the report provided by the RIDON, documented an investigation completed dated [DATE]. The RIDON was asked why she completed an investigation for Resident #204, and verbalized because Resident #204 had left the facility unresponsive. Review of the report documented that Resident #204 was admitted to the facility on [DATE], after she was admitted to the hospital after multiple episodes of vasovagal like [MEDICAL CONDITION] episodes ([MEDICAL CONDITION] or passing out) at home and [MEDICAL CONDITION] (slow heart rate). Guest had recent stay at another SNF (skilled nursing facility) and reported having multiple episodes of light headedness during positional changes, and was discharged from SNF and went home to have [MEDICAL CONDITION] episodes and then returned to the hospital. Patient has an extensive cardiovascular history including [MEDICAL CONDITION] with acute exacerbation, [MEDICAL CONDITIONS] hypertension and [MEDICAL CONDITION]. Guest also has extensive respiratory history including [MEDICAL CONDITIONS], sleep apnea, acute and chronic [MEDICAL CONDITION] with [MEDICAL CONDITION] (insufficient oxygen in the body). Patient also morbidly obese. The report revealed on [DATE], This writer was called by floor nurse, (name listed), that guest was observed in cardiac and respiratory arrest and that CPR had been initiated. Time line as follows: 1940 (approximation) CENA (name listed) entered room to complete a check and change on guest due to incontinence. CENA gathered supplies and entered room. Guest observed with [MEDICAL CONDITION]/oxygen on. Guest transferred 1 person assist and had been previously been easily check and changed in bed without incident. CENA had turned guest onto her side, guest had been positioned in the middle of the bed. CENA reported that all of the sudden it appeared that guest had a slight change in consciousness and rolled off the edge of the bed per her statement. CENA attempted to correct the movement, guest is morbidly obese with a weight of 371.8 lbs and CENA unable to correct move independently. CENA immediately went to check on guest who was alert and responsive after rolling off the edge of the bed. Guest reported that she was ok, and CENA left the room to notify nurse. 1942 Nurse was notified that guest had fallen off the edge of the bed. Nurse and 2 CENA's re-entered room. Guest observed in a Supine position (on her back), guest unresponsive and in cardiac and respiratory arrest. 1945 CPR initiated by nurse, other nurses in facility notified that guest was undergoing a code blue. At 1946, 911/EMS called. AED applied, no shock advised, but AED advised to continue CPR. Nurses continued CPR and ventilation via ambu bag in rotation until EMS arrived. 1951 EMS arrived and took over CPR. 200 nurse attempted to call guest's son and left voicemail to call facility as soon as possible. 2005 (8:05 PM), this writer notified the Medical Director, Nurse Practitioner and updated on guest's status. 2005, after obtaining a pulse, EMS took guest from facility via stretcher. 2025, Guest's son called facility and was updated and directed to ER. Review of Physical Therapy evaluation completed by Physical Therapist (PT) F who provided an evaluation for Resident #204 dated [DATE]. Under current illness documented pt is being evaluated s/p (status [REDACTED]. Currently she presents with functional regression in terms of bed mobility, transfer, and functional ambulation. She exhibits decrease in muscle strength, of B/L (bilateral) LE (lower extremity), decrease in dynamic standing balance and increased risk of falls. Under bed mobility 'Roll left and right' was documented as 'Partial/moderate assistance.' An interview was conducted on [DATE] at 2:31 PM, with Certified Nursing Assistant C related to what happened on [DATE]. CNA C verbalized she had been working on the back of 300 hallway and remembered very well what happened that night. CNA C indicated CNA B was working on the 100 hall where Resident #204 was residing in room [ROOM NUMBER]. CNA C indicated CNA B came to get some help from her, and indicated she needed help getting Resident #204 off the floor from a fall that occurred when she was changing Resident #204's brief, and that she had Resident #204 rolled over on her left side facing the window, and then Resident #204 rolled off the bed onto the floor. She verbalized that the nurse in care of Resident #204 was working a wrap assignment, working the 100 hall and 300 hall that night, and was down on the 300 hall. CNA C indicated she made sure that Registered Nurse D was informed that Resident #204 was on the floor and in need of assistance. CNA C indicated that she found RN D down passing medications on the 300 hall and RN D verbalized I'm coming. CNA C indicated her and CNA B left and went down to room [ROOM NUMBER], after stopping on the 100 hallway linen closet, to get a hoyer lift pad. Upon entering the room, Resident #204 was observed on the floor next to the bed, laying on her stomach, face down, not talking, and not responsive. We rolled her over before the nurse got there, onto her back. CNA C said that Resident #204 was unresponsive and not breathing, and she tried to wake her up. CNA C indicated that she did a sternal rub with no response, and the RN still had not come. CNA C verbalized at least 5 minutes had passed maybe longer, and she wanted to start CPR and was CPR certified. CNA C indicated RN D showed up and said Resident was a Full Code and to go ahead with CPR. CNA C indicated she started CPR on Resident #204 with 3 other nurses who had arrived, taking turns for about 10 to 15 minutes until EMS arrived. CNA C was asked if she observed the call light or staff assist button on and activated upon entering the room, and verbalized it had not been activated by CNA B. CNA C verbalized that RN D got there and other nurses showed up as well. One nurse brought the crash cart, and ambu bag that was used to deliver breaths. An AED was applied, with no shocks delivered. CNA C indicated they took turns rotating with compressions and ventilation device until EMS arrived. CNA C indicated she stayed and helped with CPR the whole time until the EMS's took over, and then left and went back to her rooms with other nurses. CNA C verbalized that RN D had her write a statement, and provided one. CNA C was asked if Resident #204 had a [MEDICAL CONDITION] mask on and indicated it was not observed on Resident #204 or lying any where near her. I was at her feet area and covered her bottom with a gown, and the other CNA was at her head area and it was very difficult to roll Resident #204 over due to her size. I was asked to provide my CPR card to the DON after the incident, and I did. (The investigation completed after the event documented [MEDICAL CONDITION] on). On [DATE] at 10:18 AM, an interview was conducted with PT F inquiring about the bed mobility status for Resident #204. PT F indicated he was aware that Resident #204 could pass out during positional changes, but she had not had any episodes while he was working with her. PT F was asked if he was aware of Resident #204's weight up near 400 lbs and verbalized he was. PT F was asked what moderate assist was for bed mobility and indicated it was one person assist, as Resident #204 was able to roll with assist from side to side. PT F was asked if he should have made Resident #204 a two person assist due to her weight. PT F indicated again 'No' as Resident is able to help staff with movement in bed. PT F was asked if he let the nurses and CNA's know that with positional changes, Resident #204 could pass out. PT F indicated he did not share that with nursing, that it was nursing's responsibility to get that information from the medical record and documents and share it with the CNA's. Review of Nursing Assistant Care guide (Kardex) for Resident #204, dated [DATE], printed [DATE], documented under 'Safety' to offer guest pillows to be tucked under sides at night that are easily removed to maintain bed positioning. Provide safety razor/electric shaver for shaving. Reinforce need to call for assistance. Under 'Mobility' to ambulate with therapy, Non-pharmacological intervention, exercise-encourage to prevent muscle stiffness, ROM (range of motion) with care daily. (Nothing was documented for one person assist with bed mobility or any mobility status for positioning in bed). For transferring, was documented as 'Resident transfers via 1 PA (person assist). After the interview with CNA C that occurred on [DATE], Regional Vice President of Nursing A and Regional Interim Director of Nursing asked to speak to Surveyor on [DATE], at 2:58 PM, to clarify 'minor misunderstandings' related to the investigation that was completed for Resident #204. The RIDON indicated she was under the impression thru her investigation that RN D, CNA B, and CNA C all entered the room at the same time. She verbalized that she was unaware that the two CNA's entered the room before the nurse and rolled her over. RIDON verbalized that Resident #204 has no [MEDICAL CONDITION] episodes since being in the hospital or [MEDICAL CONDITION], and assumed that Resident #204 was stable, and the condition of [MEDICAL CONDITION] was related to the [DIAGNOSES REDACTED].#204 was on her back (supine), not face down, and was alert and responding when the aid left the resident alone. RIDON was asked if CNA B pushed the call light or assist button to summons help, and indicated she did not. CNA B thought it would be faster to go get help and left Resident #204 alone in her room. CNA B came back to find Resident #204 unresponsive and in [MEDICAL CONDITION]. RIDON was asked why the RN in care of Resident #204 did not complete any progress notes or an Incident/Accident report. RIDON verbalized the RN involved with care for Resident #204 was leaving and did not document the event or fill out the Incident/Accident report. The next oncoming nurse who had come to help documented some notes at the end of her shift the next day. RIDON indicated she, herself, completed the Incident/Accident report for [DATE] on [DATE]. The RIDON was asked if she thought it was ok to leave Resident #204 alone in her room, and indicated it was probably faster to leave the resident alone and go get help. I don't think we could have done or would have done anything different. RIDON was asked if she obtained written statements from the Nurse and CNA's involved and provided two hand written statements, one from CNA B and one from CNA C. RIDON did not provide any written statements from RN D who was in care of Resident #204 on the night of [DATE], by the end of the survey. RIDON was asked to provide a hospital transfer sheet, and all documents that were given to EMS and hospital. RIDON did not provide the documents by the end of the survey. Review of written statement from CNA C dated [DATE], documented On [DATE], I was asked by CNA B to come assist with a guest in room [ROOM NUMBER]. We needed a hoyer sling first, so we went and retrieved the sling first in the linen closet. Upon opening the door to room [ROOM NUMBER], I walked into guest lying face down on the floor, on the right side of her bed and her [MEDICAL CONDITION] mask was to the left of her face. As I approached Resident, I asked CNA B what happened. I was notified she (Resident #204) rolled off the side of the bed while being changed. I cleaned the guests back end and covered her, tried to get her to respond. CNA B and I rolled her over onto her back, and I instructed CNA B to check for pulse. I was going to get a nurse. I informed a 200 hall nurse (this was at shift change), that we needed help. We arrived back in the room, and as they assessed her. RN D said go ahead on CPR and we started CPR. EMS was in route. Once EMS arrived, we stepped out, after I made sure I was clear to go. I returned back to 300 hall. At the top of the form listed a phone number for any questions. (According to this written statement, Resident #204 was left alone again for 2nd time by both CNA's to go get help, as CNA B originally left resident to get CNA C and nurse). CNA B was attempted to be contacted several times from [DATE], and [DATE], and RIDON indicated CNA B worked another job and was hard to contact. Review of hand written statement provided to RIDON by CNA B dated [DATE], documented I went into change 112, (not 100% of what time). I gathered all supplies I would need then proceeded with patient care. I rolled 112 on her side and began cleaning her bottom. She was facing the window. Resident was secure in the middle of the bed. While cleaning resident, I felt and noticed her body start to roll. I tried to prevent the fall but was unable to. I immediately went to notify the nurse and a 2nd aid for help. Resident was alert and talking when I left to retrieve help, but was not when we returned. I would say I was gone for 30 sec to a minute. Myself and second aid noticed resident not responding to verbal prompts, noticed she was unconscious. Went to alert the other staff and nurses. All nurses came. CPR & AED was performed. Emergency Services had to be started. The statement was signed and dated [DATE], by CNA B An interview was conducted on [DATE] at 1:27 PM, with RN D. RN D was asked if she was in care of Resident #204 on the evening of [DATE], and indicated she was the nurse working the hall 100 and 300 called a wrap from 7 AM to 7 PM. She indicated she had residents to care for on both halls. RN D indicated she was working down on the 300 hall around rooms ,[DATE], when CNA B came and said We had a fall in room [ROOM NUMBER]. RN D verbalized to get another aid as resident is a large woman and got CNA C to assist. I was right behind them. I entered the room with the CNA's and observed Resident #204 on her back next to the bed. They (two CNA's) said that resident had gone unresponsive. When I got in there, resident was unresponsive. I checked for a pulse. I initiated CPR. CNA C and another nurse came to help. I yelled to another nurse to call 911. CNA B was standing back in the corner pretty upset. One nurse was using the Ambu bag, another nurse brought the crash cart, and we hooked up the AED. We took turns with CPR. EMS came and took over, and got Resident #204 out. The EMS and Sheriff started asking questions as to what happened. I heard CNA B verbalized she had got Resident #204's right leg up over the left leg, and the next thing was Resident #204 rolled out of bed onto the floor. During the code, I called the RIDON and explained what had happened. This event occurred at shift change 7 to 7:30 PM. The next nurse came onto shift in the middle of the code. RN D was asked if she documented an Incident/Accident report and Progress notes and verbalized she did not. I don't know why I didn't. I just did not. I wrote out a statement of what happened (which was not received). RN D was asked if she was aware of the roll out of bed on [DATE], and verbalized she did not know. RN D was asked if she was aware of [MEDICAL CONDITION] episodes with positional changes and indicated she was not aware. I knew she had Cardiac issues, but I did not exactly know what it involved. I only cared for this resident a couple of times. No one shared that information with me. RN D was asked if CNA C initiated CPR and said No, us nurses performed CPR. RN D was asked if CNA C helped at all during the code and said No. (CNA C indicated she initiated CPR). A telephone interview was conducted on [DATE] at 11:56 AM, with CNA B related to the event on [DATE]. CNA B indicated she had worked with Resident #204 only one day, and was not familiar with her. CNA B was asked if she had received report that day from nurse or off going CNA and indicated she did from the CNA, but not the nurse. CNA B was asked what information was relayed to her, and verbalized that it was just about the emotional state of Resident #204, and if she had a good or bad day, and that Resident #204 transferred with one person assist, and could move in the bed with help. CNA B was asked if she looked at the Kardex and said yes. CNA B was asked if she was aware of the roll out of bed on [DATE], and said No, I was not told about that. CNA B was asked if she was informed that Resident #204 had a recent history of passing out/[MEDICAL CONDITION] with positional changes and said, No. No one told me that. I had no idea. That would be important to know. CNA B indicated that she responded to call light around 7 to 7:30 PM, and the first shift nurse was getting ready to leave. She indicated that Resident #204 said she was wet, and needed a dry brief. CNA B was asked if there were any pillows placed on either side of Resident #204, or on the floor, chair, or near by, and said, No, there was only one pillow and her head was on it. CNA B indicated she gathered all her supplies for a brief change. She said Resident #204 was laying in the middle of the bed. CNA B was asked if she tried to move or position Resident #204 toward her in bed before rolling her over, and said, No, she was a large lady almost 400 lbs. I did not move her toward me before rolling her. CNA B was asked if she rolled Resident #204 toward her body or away from her body and said away from her body. CNA B went on to say that she crossed Resident #204's right leg over the left leg and rolled her onto her left side, and started care, cleaning her bottom. CNA B indicated her and Resident #204 was having general conversation, and then Resident #204 got quiet. CNA B was asked if Resident #204 was wearing her [MEDICAL CONDITION] or [MEDICAL CONDITION] mask and said No, she had oxygen on with the plastic things in her nose, not the [MEDICAL CONDITION] or [MEDICAL CONDITION]. CNA B said she felt Resident #204 start to roll and by the time she noticed the movement, Resident #204 rolled off the edge of the bed onto the floor landing face down. CNA B said Resident #204 was on the floor down on her stomach, face down, not on her back. CNA B was asked if Resident #204 was talking to her after being down on the floor and indicated she could not remember Resident #204 talking to her. CNA B verbalized she could not remember if Resident #204 was alert and responsive at that time. CNA B was asked if Resident #204 ever became responsive from the time of rolling out of bed and the time she left Resident #204 alone and said she could not remember Resident #204 ever talking to her again. CNA B said she tried to roll Resident #204 over by herself while she was down on the floor, but could not because of her size. CNA B was asked if Resident #204 was responsive enough to help roll over and indicated she could not remember. CNA B verbalized she pulled on Resident #204's gown to try and move her onto her right side, but was unsuccessful. CNA B was asked if she activated the call light or staff assist button and said, No, I left the room and went to find a nurse. I went to the 300 hall from the 100 hall to find a nurse. I was the only aid on the 100 hall. CNA B indicated she found RN D in a sitting area on the 300 hall, and said, 'we had a fall in room [ROOM NUMBER], can you help'. RN D said 'Yes', I am on my way, go get another aid because Resident #204 is large lady. So I walked further down the 300 hall, and found another aid coming out of a room. I asked her if she could help me. We went to the 100 hall linen closet and got a hoyer sling pad to lift her up off the floor first, before going to room [ROOM NUMBER]. When we (Me and other aid) entered the room, Resident #204 was not talking or responding, and still face down on the floor. The other aid was near her feet. I was near her head. We rolled her toward the right side. Resident was still not responding. RN D came in after we rolled her over. RN D checked for a pulse and respirations. There were none. Another nurse came with the crash cart and CPR was started. I was panicking at first and had my back to what was going on and not watching, but could hear everything. I called 911 from my personal cell phone in my pocket. I heard them taking turns doing CPR until EMS arrived. The nurses put an AED on Resident, and then the EMS took over and got Resident #204 out of the building. A Cop took my statement. I answered questions. RIDON instructed staff to get my statement. I wrote out a statement and gave it to a nurse. CNA B was asked again if she activated the call light, and said No, I thought it would be faster to go get help. So I left the room. CNA B was asked how long it took her to go to another hall, talk to the nurse, get another aid, get a sling and go back to the room, and said maybe ,[DATE] minutes maybe 5 minutes. I don't really know for sure. CNA B was asked if she was running thru the halls and first replied 'Yes', then said 'No, I was walking fast or brisk. I was freaked out. This was my first experience with anything like this. CNA B was asked if she typically leaves a resident alone after a fall, while face down on the floor, and indicated that she thought it was faster to go get help. CNA B was asked again if Resident #204 ever became responsive enough to say she was ok, and said, I don't remember. Certified Nursing Assistant (CNA) B, hired on [DATE] according to the undated Employee List, had a CNA Orientation/Annual Competency form dated [DATE] where the column designated for the Reviewers Initial had been initialed by herself. The skills listed were vital signs & weight, transfers, ambulation, documentation, activities of daily living, positioning, dining room, skin care, equipment, bowel and bladder, communication, supplies, oxygen, shower, and abuse. When the scheduler, Staff K was asked about why CNA B may have initialed all of the entries on [DATE] at 9:45 AM, she stated that CNA B had probably done that to indicate she was familiar with the procedures listed. The signature line at the bottom on the back of the form for the Reviewer Signature, was signed illegibly, although the last two letters, RN, were legible. According to the employee list, undated, CNA B was hired on [DATE]. According to the Course Results Report of the computer training for CNA B, dated [DATE], the lessons under the sections of Activities of Daily Living and Fall and Restraint Reduction had not been attempted or completed by CNA B. The CNA Orientation/Annual Competency checklist for CNA B did not include a section for the CNA role/responsibility when a resident fell . Review of hospital notes,

This Citation Pertains to Intake # MI 060 Based on interview and record review, the facility failed to assess, monitor, and update pain management interventions in a timely manner to prevent lethargy and over sedation for one (#701) of three Residents reviewed for pain management assessment and monitoring, from a total sample of three, resulting in the need for emergency treatment and hospitalization . Findings include: Record Review on 6/21/17 at 9:45 AM revealed Resident #701 was originally admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #701 had moderately impaired cognition and required supervision to extensive assistance to perform Activities of Daily Living (ADL's). Additional review revealed the Resident had recently been treated for [REDACTED]. Review of Resident #701's medical record on 6/21/17 at 10:10 AM revealed documentation that the Resident had been discharged from the facility to the hospital emergency department by ambulance on 5/2/17. A Skilled Charting note authored by Nurse C on 5/2/17 at 12:32 PM revealed the following documentation, This nurse called (Resident's family member) to update about Resident's current condition. Resident is lethargic, not wanting to get out of bed and appetite has declined. (Resident's family member) stated that they would like us to talk to doctor about discontinuing the [MEDICATION NAME] ([MEDICATION NAME] - medication to treat nerve pain) and [MEDICATION NAME] (narcotic pain medication) orders because they feel they (medications) are causing the lethargy. Currently have a note in for the doctor for these concerns. Another Skilled Charting note written by Nurse C on 5/2/17 at 2:46 PM indicated Resident #701 was transferred to the hospital emergency department at approximately 2:30 PM. Documentation further indicated that Resident #701's family member called the ambulance for transfer due to concern related to the Resident's condition. On 6/21/17 at 11:40 AM, an interview was conducted with Nurse C. When queried regarding the situation that occurred when Resident #701 left the faciity on [DATE], Nurse C replied, Oh my God, it was a mess. I hadn't taken care of the Resident in a couple of weeks because I went on vacation. The family was always very involved in (the Resident's care). I called the family that morning because (Resident #701) seemed a little off to me. The family member wanted pain medications discontinued. I was trying to talk to the Doctor about it when a family member came in to visit the Resident. They were talking to another family member on video chat. I really didn't know what was going on. We discontinued some of the meds that the family member wanted discontinued (from phone conversation). Anyway, we are a facility that likes to try to treat here if possible and only send out (Residents) if needed. The family member ended up calling the ambulance themselves and (the Resident) was sent to the hospital and didn't come back. When queried if Resident #701 had complained of pain and the location of the pain, Nurse C replied, I don't think I gave anything for pain and I didn't notice any pain until the ambulance staff moved her. Additional review of Resident #701's medical record on 6/21/17 at 1:00 PM did not reveal a documented acceptable pain level for the Resident but did reveal the Resident had the following orders for pain medications: [REDACTED] [MEDICATION NAME] (narcotic pain medication) 5-325 milligrams (mg) every six hours as needed (started 4/18/17) [MEDICATION NAME] (used to treat nerve pain) 100 mg three times a day (started 4/26/17, discontinued 5/1/17) [MEDICATION NAME] 200 mg three times a day (started 5/1/17) Review of Resident #701's Medication Administration Record [REDACTED] 4/21/17: [MEDICATION NAME] 5-325 mg at 6:45 PM (Pain level 6) 4/24/17: [MEDICATION NAME] 5-325 mg at 10:30 PM (Pain level 8) 4/25/17: [MEDICATION NAME] 5-325 mg at 6:45 PM (Pain level 9) [MEDICATION NAME] 5-325 mg at 8:10 PM (Pain level 4) 4/26/17: [MEDICATION NAME] 5-325 mg at 5:35 AM (Pain level 10) [MEDICATION NAME] 100 mg at 2:00 PM (No documented pain level) [MEDICATION NAME] 5-325 mg at 4:39 PM (Pain level 10) 4/27/17: [MEDICATION NAME] 5-325 mg at 4:19 AM (Pain level 8) [MEDICATION NAME] 100 mg at 9:00 AM (No documented pain level) [MEDICATION NAME] 5-325 mg at 11:56 AM (Pain level 9) [MEDICATION NAME] 100 mg at 2:00 PM (No documented pain level) [MEDICATION NAME] 5-325 mg at 6:25 PM (Pain level 6) [MEDICATION NAME] 100 mg at 9:00 PM (No documented pain level) 4/28/17: [MEDICATION NAME] 100 mg at 9:00 AM (No documented pain level) [MEDICATION NAME] 5-325 mg at 4:49 PM (Pain level 6) [MEDICATION NAME] 5-325 mg at 11:30 PM (Pain level 8) [MEDICATION NAME] 100 mg at 2:00 PM (No documented pain level) [MEDICATION NAME] 100 mg at 9:00 PM (No documented pain level) 4/29/17: [MEDICATION NAME] 100 mg at 9:00 AM (No documented pain level) [MEDICATION NAME] 5-325 mg at 1:15 PM (Pain level 8) [MEDICATION NAME] 100 mg at 2:00 PM (No documented pain level) [MEDICATION NAME] 100 mg at 9:00 PM (No documented pain level) [MEDICATION NAME] 5-325 mg at 11:00 PM (Pain level 7) 4/30/17: [MEDICATION NAME] 5-325 mg at 8:20 AM (Pain level 7) [MEDICATION NAME] 100 mg at 9:00 AM (No documented pain level) [MEDICATION NAME] 100 mg at 2:00 PM (No documented pain level) [MEDICATION NAME] 5-325 mg at 3:40 PM (Pain level 7) [MEDICATION NAME] 5-325 mg at 9:00 PM (Pain level 8) [MEDICATION NAME] 100 mg at 9:00 PM (No documented pain level) 5/1/17 [MEDICATION NAME] 5-325 mg at 8:25 AM (Pain level 8) [MEDICATION NAME] 100 mg at 9:00 AM (No documented pain level) [MEDICATION NAME] 200 mg at 2:00 PM (No documented pain level) [MEDICATION NAME] 5-325 mg at 2:45 PM (Pain level 4) [MEDICATION NAME] 200 mg at 9:00 PM (No documented pain level) 5/2/17 [MEDICATION NAME] 5-325 mg at 4:49 AM (Pain level 5) [MEDICATION NAME] 200 mg at 9:00 AM (No documented pain level) Record review of Resident #701's final care plans prior to discharge from the facility revealed the Resident did not have a care plan pertaining to pain management associated with Shingles. Review of documentation for Resident #701 completed by Provider B at this time revealed the following documentation: 4/24/17- Alert, clear speech, baseline forgetful. 4/26/17- Drowsy with slightly slurred speech at this time . Altered mental status: suspect related to recent [MEDICATION NAME] doses. Change neuropathic pain controlled to low-dose [MEDICATION NAME] . Use sedating medications with care as Resident appears to have some increased confusion now with [MEDICATION NAME] use. 4/27/17- Resident remains quite lethargic and blood pressure is now running low at 89/50 . Started on [MEDICATION NAME] 100 mg three times daily to help with complaints of burning pain in left arm. This reduced need for [MEDICATION NAME] which may have been contributing to increased confusion . Drowsy appearing, alert . Left arm pain appears to be improved. [MEDICATION NAME] 100 mg three times daily continued and will try to withhold [MEDICATION NAME] as needed for acute pain. 5/1/2017- Today Resident remains weak and lethargic. (Resident) continue to complain of burning pain affecting left upper arm despite [MEDICATION NAME] 100 mg three times daily, nurses are giving her as needed [MEDICATION NAME] doses frequently.Lethargic, chronically confused. An interview was completed with Provider B and the Director of Nursing (DON) on 6/21/17 at 1:55 PM. When queried regarding pain management for Resident #701, Provider B replied, (Resident #701) was being treated for [REDACTED]. Documentation by Provider B for Resident #701 and Medication Administration Records (MAR) were reviewed with Provider B at this time. When queried why [MEDICATION NAME] dosage was not decreased when [MEDICATION NAME] was added and why provider documentation indicated to reduce [MEDICATION NAME] utilization, Provider B replied, Wishful thinking I guess. Upon inquiry why alternative medications and treatments were not attempted due to Resident #701's documented lethargy from [MEDICATION NAME] and continued use of [MEDICATION NAME] after addition of [MEDICATION NAME], Provider B did not provide a response. When asked if any non-pharmacological or other non-narcotic interventions were attempted to treat Resident #701's pain that would not create lethargy and over-sedation, Provider B replied, We added [MEDICATION NAME] that is non-narcotic. With additional inquiry if any non-pharmacological pain management techniques were utilized for Resident #701, Provider B and the DON did not provide a response or documentation. On 6/21/17 at 5:00 PM, review of facility policy titled Pain- Clinical Protocol (Revised October 2010) revealed, Nursing staff will assess each individual for pain . The physician will order appropriate non-pharmacologic and medication interventions to address the individual's pain. Review of facility policy titled Pain Assessment and Management (Revised October 2010) on 6/21/17 at 5:10 PM revealed, If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated. The policy further revealed, Report the following information to the physician or practitioner: . Adverse effects from pain medications, such as . anorexia, confusion, lethargy .