Every finding on record at WellBridge of Grand Blanc

This citation pertains to Intake Number 2698891.Based on observation, interview, and record review, the facility failed to ensure adequate staff supervision in the common area and that appropriate assistance to the bathroom was provided to prevent falls or accidents for one resident (Resident #303) of 3 residents reviewed for falls, resulting in a fall requiring a transfer to the emergency room for evaluation and treatment of bleeding coming from a laceration of the scalp requiring six (6) staples (stitches) and a hematoma to the left side of the head Findings include:Resident #303 (R303): On 1/6/26 at 3:30 PM, R303 was observed in the hallway heading towards her room. R303 appeared confused as she approached the surveyor and asked where she should go. Another staff member was two doors away, yelling to R303 to go to her room (yelling out the room number). R303 was very confused, teary-eyed, while self-ambulating in her own wheelchair. The surveyor asked her for her name and her room number, but R303 was unable to answer. R303 was observed to have an obvious bruise on both sides of the temple and head (left and right) and a healing scalp laceration. The Director of Nursing (DON) came to her, led her into her room, and shut the door. R303's Fall Incident Report was requested on 1/7/26 at 10:30 PM, it revealed that on 12/20/25 at 13:05 PM, R303 fell in the common area bathroom by herself and without any staff witnessing the fall. The report had indicated:Nursing Description: Resident was found down on the bathroom floor in the common area. She was alert and talkative. The resident was noted to have a laceration on the top of the head (right-sided) with blood oozing out of the wound. Pressure was immediately applied to the site. The resident also noted a hematoma on the left side of the forehead. No other injuries noted.Resident Description: Resident said she was using the bathroom and attempted to get back into her wheelchair and fell on the floor.Was the incident witnessed? NoInjury Type:1. Hematoma. Location: Face2. Laceration. Location: Top of Scalp This Fall Incident Report, dated 12/20/25, indicated that R303 was sent to the nearby Emergency Center for further evaluation and treatment of a laceration to the head. An interview with Registered Nurse A (RN A) was conducted on 1/7/26 at 12:32 PM. RN A stated that she was the nurse assigned and responded to R303 during the fall on 12/20/25. She indicated that she found R303 alone in the common area bathroom (by the common dining room). R303 was sitting with other residents after lunch.RN A' was asked how she was alerted about R303's Fall?RN A replied: I just got done with her 12 o'clock med pass and was going into the nurses' working area when a CNA (CNA B) hurriedly approached me and said that a resident was on the floor inside the common area bathroom.RN A was asked if the CNA who found R303 witnessed the fall?RN A replied: No. No one witnessed the fall. CNA B happened to pass by the common area and heard R303 screaming for help, and was alone in the bathroom. The bathroom door was wide open, but I did not find any other staff with the resident nor in the common area. Just a group of residents. So CNA B went to the nurses' working area to find a nurse and found me. I immediately responded. RN A further described that she found R303 lying with her face down next to her wheelchair. Blood was all over the floor. There was a [NAME] of blood on top of her head, but we could not tell how or where she hit her head. R303 sustained a cut requiring six (6) staples on her scalp. RN A recalled that she immediately assessed her and called the Nurse Practitioner, Nurse Manager, and the guardian.RN A was asked to describe the R303's cognition status and her transfer status on 12/20/25.RN A replied: R303 was alert to herself and often forgot that she needed assistance in going to the bathroom. She has Dementia as her diagnosis.RN A was asked whether any staff were assigned or present who put her in the common-area bathroom?RN A replied: No. RN A was asked: Are you sure the fall was unwitnessed by staff?RN A replied: Yes.RN A was asked: Was R303 supposed to be going to the bathroom and left by herself unattended?RN A replied: Staff generally sit out there with residents during activities, but we did not find any staff at that time. R303 was noted to be impulsive and forgets that she needed assistance to go to the bathroom. Her Care plan was to make sure she needed to be watched and therefore should not have been left there without staff in the common area. An attempt to interview the nurse aide (CNA B) who found R303 on the floor covered with blood in the common area bathroom, either in person or by phone. But CNA B was unavailable on 1/7/26 at 1:12 PM. A call was made, and the surveyor left a voicemail to call back with a callback number, but no call was returned. The Facility Social Worker (SW C) was interviewed by phone on 1/7/26 at 3:14 pm. SW C had access to R303's EMR at the time of the interview. SW C indicated that she was no longer assigned to the facility; however, she revealed that she performed the Brief Interview for Mental Status (BIMS) assessment for R303 on 11/24/25. SW C described R303's BIMS Score as a 5/15. SW C had indicated that R303 was observed to be more confused in the afternoon. SW C reported that the assessment also revealed that R303 required one-person assistance during transfers and 2-person assistance with a rolling walker. She commented that R303 should not have gone to the bathroom on her own without assistance. The BIMS assessment dated [DATE] was reviewed, and it was confirmed that there was no acute mental status change at the time of the assessment. However, R303 had behaviors present that come and go and change in severity. SW C further explained, R303 can be very impulsive to get up and out of bed and most often forgets that she needs assistance during transfers and walking. She needed assistance to go to the bathroom. R303 according to the review of the Electronic Medical Record (EMR) conducted on 1/7/25 at 10:35 PM, revealed that R303 was [AGE] years old, admitted to the facility on [DATE], with the diagnosis of Senile degeneration of the brain, Intracapsular Fracture of the Right Femur (status/post fall in October 23, 2025 at the facility), Aftercare Following Joint Replacement, repeated falls, Alzheimer's Disease, Cognitive and Communication Deficit, General Anxiety Disorders, Mood Disorder, Psychophysical Visual Disturbances, Psychotic Disorder with Delusions due to known physiological condition, in addition to other diagnoses. R303's Brief Interview for Mental Status Score was 5/15, assessed on 11/24/25. A score of 5/15 indicates severe cognitive impairment. Minimum Data Set (MDS) Assessment Section GG dated December 2, 2025, revealed: one-sided impairment on the upper extremity(shoulder, elbow, wrist, and hand), and no impairment on the lower extremities (hip, knee, ankle, foot). R303 uses mobility devices, including a walker and a manual wheelchair. Although R303 was assessed as independent with eating and oral hygiene, she requires substantial maximal assistance with toileting, hygiene, shower/bathing, and lower-body dressing. R303's transfer ability was assessed and required partial/moderate assistance with the following activities:(D.) Sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed),(E.) Chair/bed-to-chair transfer (The ability to transfer to and from a bed to a chair or wheelchair), (F.) Toilet transfer (the ability to get on and off a toilet and commode) and(FF). Tub/Shower transfer (the ability to get in and out of the tub/shower).(I.) Walk 10 feet: (once standing, the ability to walk at least 10 feet in a room, corridor, or similar space), and lastly(J.) Walk 50 feet with 2 turns: (once standing, the ability to walk at least 50 feet and make two turns).The above ADLs were assessed, and these specific activities of daily living (ADL) required partial to moderate assistance for R303. R303's MD Orders included: Transfer 1PA/Ambulation status, 2PA with walker, order date 10/29/2025, and Plavix Oral Tablet 75 mg (Clopidogrel Bisulfate once daily by mouth ordered on 11/8/2025. Plavix is a type of blood thinner that may cause bleeding , black or tar-like stools, red dark urine and vomiting blood. R303's Fall Incidents Report 2025 was reviewed:10/23/25. R303 had a Fall and sustained a right Femoral neck fracture and underwent surgical repair. Unwitnessed Fall12/20/25. R303 had a Fall and sustained a hematoma and laceration and was transferred to the ER for 6 staples to her scalp laceration. Unwitnessed Fall.12/25/25 R303 was found on her knees next to the bed. No injuries or transfer to the ER noted. Unwitnessed Fall. A review of the R303 Care Plan was conducted on 1/7/26 at 10:35 AM.It revealed:R303 was a care plan for incontinence: Provide assistive devices as needed was part of the incontinence intervention care plan dated 7/24/2024, which was not updated or revised. There was nothing written about assisting the R303 to and from the bathroom, as required for the one-person assist transfer in the GG assessment dated [DATE].R303 will experience no decline in the Range of Motion (ROM) or Ambulation. (Date initiated: 07/24/2024. Revision on 10/28/2025. Interventions: (A.) Encourage active ROM to the bilateral shoulders, elbows, and wrists. Date initiated: 7/23/25, Revision on 9/23/25. (B.) Encourage and assist with ambulation using a walker as tolerated. (Date initiated: 07/23/24, Revision on 07/03/2025.R303's care plan interventions were updated related to R303's fall at the facility on 1023/25, resulting in a hip fracture, and R303 underwent a hip replacement after a fall. R303 returned to the facility on [DATE]. The care plan is specified as follows:Reinforce the need to call for assistance.Transfer assistance status: 1 PA (Person Assist) Ambulation was 2PA (2-person assistance) with a walker (Date 7/13/2024, Revised on 10/29/2025).Weight Bearing status: WBAT (Weight Bearing as Tolerated) (Date initiated: 7/13/24, Revised on 10/29/25)R303's fall, dated 12/20/25, description indicated that the fall was unwitnessed, and there was no staff who assisted R303 in going to the common area bathroom. There were no staff members monitoring the residents in the common area at that time. The activity occurred simultaneously after lunch at 1:05 PM, after lunch time, and most residents' urge to use the bathroom may have been anticipated, although there was no call light access and no staff were present in the common area when R303 went to the common area bathroom by herself. Although the Hospital record dated 10/23/25 noted that R303 was in Hospice status due to a Dementia diagnosis, no hospice category was found in R303's Care Plan Report during the review of records held on 1/7/2026 at 4:00 PM. There was no Care Plan found reflecting that she was receiving Hospice Care ServicesAccording to the review of the facility's Interact SBAR Communication Form dated 12/20/2025 at 1315 (1:15 PM) for R303, the nurse noted, Appearance: (Summarize your observations and evaluation): Guest fell and requires sutures/staples for cranial laceration closure. The Facility's SNF/NF to Hospital Transfer Form described the following:Usual Functional Status before the acute change in Condition:Mobility: R303 Ambulates only with human assistance.ADLs: Needs Assistance with Bathing, dressing, toileting, and transfers. Independent with eating.Sensory Impairment: VisionBladder and Bowel Function: INCONTINENTUsual Mental Status/ Cognitive Function before the Acute Change in Condition:Alert, disoriented, but can follow simple instructionsA review of the Emergency Department ED Patient Discharge summary dated [DATE] revealed, admit date and Time: 12/20/25 Time 1400 and discharge date and Time: 12/20/25 at 14:44. Discharge Instruction: Head Injury, Adult and Laceration Care, Adult. Follow-up Instructions: Follow up with the Primary Care Provider or Specialist within 5 days. Staples will need to come out in approximately 1 week. Return to Emergency Department for persistent, worsening or new symptoms. During the discussion with the Director of Nursing (DON) and the Administrator regarding R303's Fall on 12/20/25, the Director of Nursing (DON) immediately responded on 1/7/26 at 4:15 PM, stating that every resident has the right to use the bathroom on their own at any time. The DON further stated that, it is R303's right to go when she needs to go. She was not under one-on-one supervision. When the surveyor asked who was with the residents in the common area on 12/20/25 at 1:05 PM? The DON did not answer. The surveyor also asked whether they were supposed to be left with no staff during a group activity. The DON did not answer. Who was supposed to assist residents at the common area when they needed to go? Since R303 fell in the common area bathroom, who took her to the toilet? The DON answered, Residents can go to the bathroom on their own. We cannot stop them. R303 was not a one-on-one supervision. Then the DON said, That's fine! We are going to IDR (Independent Dispute Resolution) the citation anyway. Administrator on 1/7/25 at 4:20 PM, agreed on R303's right to go independently to the bathroom when she wants to. The Administrator stated, We can't stop residents if they want to go to the bathroom on their own when they choose to, while in their own room, and should not be restricted. She reiterated that it is the resident's right and they honor that. When the Administrator was asked whether she was aware of the 12/20/25 incident in the common-area bathroom, she insisted that it occurred in R303's own bathroom. The fall on 12/20/25, sustaining 6 staples and a head laceration and left-sided hematoma, occurred at the common area bathroom, not in the resident's room.The incident occurred in the common-area bathroom, not in the resident's room. She was unaware of this particular incident and stated, I thought she fell in her bathroom. The Facility's Fall Reduction Program (revised date of 9/25/2016), was reviewed on (1/7/25 at 4:00 PM).Purpose: To provide a safe environment for residents, modify risk factors, and reduce risk

Based on observation, interview and record review, the facility failed to ensure that residents were treated with dignity and respect, failing to follow the care plan for a visually impaired resident by failing to describe meals when served, and failing to ensure that call lights were in reach or respond to resident call lights in a timely manner and not provide explanations when resident asked questions about their medications, identified for six residents (R72, R76, R86, R98, R128, R143) of seven residents reviewed for dignity, and a confidential group of residents. Resident #86 (R86): During the observation tour conducted on 09/23/25 at 11:00 AM, R86 was lying in bed and asked for some water. When surveyor ask if he had asked and if he was using his call light? He said he was not able to find them. R86 further explained that he was partially blind and that he was not able to find his call light. R86 indicated that he needed some water to drink and he thought I came to bring some fresh water pointing out that two cups were empty by his bedside. While searching for his call light button, R86 call light was found on the floor under his bed. He revealed he was blind on one eye and couldn't see very well. The Director of Nursing (DON) was in the hallway on 9/23/25, at 11:05 AM, and was asked if staff can get R86 some fresh water (if R86 did not have fluid restrictions) and that his water cups were empty, and the call button was found on the floor. The DON confirmed that R86 did not have fluid restrictions. R68 was observed sipping fresh water after DON prompted the staff on 9/23/25 at 11:07 and said Thank you to the surveyor. R68 was noted positioned at bedside within reached by R68. A review of Electronic Medical Record conducted on 9/23/25 at 1:57 PM revealed, R86 was [AGE] years old, admitted to the facility since 12/02/22 with the diagnosis of Major Depressive Disorder, Alzheimer's Disease, Type 2 Diabetes Mellitus and Generalized Anxiety Disorders in addition to other diagnoses. R86 Brief Interview of Mental Status (BIMS) Score was 07/15 assessed on 7/22/25. A score of seven means severe cognitive impairment. Minimum Data Set Section GG assessed on August 5, 2025, revealed R86 was dependent on staff with toileting, and required a two-person transfer assistance. R86 Care plan was reviewed and revealed that R86 was legally blind in his left eye and had hearing loss. Some interventions were to encouraged fluid intake for R68 as ordered and reinforce the need to call for assistance to prevent/minimize the risk for falls or accidents. Resident #128 (R128) A review of R128's medical record revealed an admission on [DATE] with diagnoses that included dementia, diabetes, respiratory failure, and stroke. A review of the Minimum Data Set assessment revealed a Brief Interview of Mental Status score of 9/15 that indicated moderately impaired cognition and the Resident needed substantial/maximal assistance with bathing, upper body dressing, personal hygiene, roll left and right and was dependent on a helper for toileting hygiene, lying to sitting, and transfers. On 9/23/25 at 10:49, an observation was made of Resident #128 lying in bed. The head of the bed was elevated slightly. The Resident had a meal tray on an overbed table in front of her. The meal had been eaten. The Resident was interviewed, answered questions and engaged in conversation. The Resident was asked about the care she received at the facility and if she had any concerns. The Resident reported she had been waiting to get checked and changed this morning. The Resident was asked if she had been changed before breakfast was brought in and the Resident reported the breakfast came before they checked and changed for incontinence. The Resident indicated she thought she had a bowel movement. The Resident reported that she was waiting for staff to come back to get the breakfast tray and get changed but no one had been in. The Resident was asked what time her breakfast tray had been received and the Resident stated, 8:45 I think. It doesn't take me that long to eat. The Resident was asked where her call light was and if she had used it. The Resident reported she did not have her call light and thought it might be up at the top of the bed. An observation was made of the call light clipped to the fitted bedsheet at the corner of the mattress on the side of the mattress and not in reach for the Resident. The Resident reported she had pulled her pillow from underneath her head hoping the call light was attached to the pillow, but reported it was not on her pillow. An observation was made of the Resident without a pillow, the Resident reported it had fallen to the floor when she was trying to see if the call light was attached to the pillow. When asked if she had issues with the call light not being placed in reach, the Resident reported it has happened before, sometimes it has been attached to the pillow or where she can't find it and stated, I like it right here on this pocket, that's where it is supposed to be clipped. The Resident reported that she had rolled off the bed before and hurt her knee. She reported she could not reach up to the top of the mattress with her left hand because she could not move it well and if she were to reach over to try to find it with her right hand, she reported being afraid of rolling off the bed. The Resident stated, I have been waiting for someone, I can't get my light. The Resident reported she had finished her breakfast around 9:00 AM. On 9/23/25 at 11:13 AM, an interview was conducted with Nurse EE who had gone to find the CNA who was taking care of R128. The Nurse was unable to find the CNA and came into the room. The Nurse was asked about the call light not in reach for the Resident. The Nurse reported the call light should be placed in reach for the Resident, unclipped the call light from the upper side corner of the fitted sheet and placed it where the Resident described she wanted it, which was on the chest pocket of the Resident's gown. The Nurse indicated that the breakfast trays should have been picked up out of the Resident's room and indicated trays come for breakfast about 8 to 8:30 in the morning. The Resident requested that she get changed. On 09/23/2025 at 11:56 AM until ~(approximately)12:28 PM During dining observation, CNA BB was observed standing at the front of the staff line near the kitchen service area. CNA BB paced back and forth in front of the dining area toward the service line while yelling out, 608, 609, 604, and then a resident's name toward the service line. Staff were not addressing residents in a dignified respectful manner. According to a review of R72's medical record, the resident was admitted to the facility 08/26/2025 for skilled nursing care related to a fracture of the left femur, diabetes mellitis type 2 (insulin resistance causing elevated blood sugar) and chronic obstructive pulmonary disease. A review of R72's Minimum Data Set (MDS) record revealed a Brief Interview of Mental Status (BIMS) score of 14 out of 15, indicating the resident was cognitively intact. Additional medical diagnoses included glaucoma (impaired vision) and anxiety. On 09/23/2025 at 11:56 AM until ~12:28 during dining observation, R72 was served her meal from the opposite side of the table by CNA I. CNA I initially attempted to serve the meal to a different resident and, after being redirected by several dining residents to R72's location, CNA I reached over the top of a resident and placed the meal plate down in front of R72 before walking away toward the serving line. R72 picked up a piece of bread form the tray, and held it in her hand, and stated, Oh bread; do I have any butter? while turning to her left and right. The resident seated next to her replied, You do not, but I have some and handed butter to R72. CNA I was approached as they crossed the dining room and was asked for R72's meal ticket. When this surveyor reapproached R72's table, R72 asked several times, What am I eating? I cannot see, can someone tell me what I have?. No staff were observed identifying the resident's food items on her plate. A review of R72's lunch ticket (#349) showed the alert Blind- describe meal to resident., which was highlighted in yellow. A review of section GG in R72's Minimum Data Set (MDS) assessment revealed a functional status, Eating; code 05. Indicating Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. A review of R72's care plan revealed: Focus: Alteration in nutritional status related to weakness and debility . Guest at risk for weight changes related to fluid status shifts, edema, and diuretic therapy prefers to eat with her hands & wears her own clothing protector; Date Initiated: 09/04/2025 with an Intervention: Provide diet per physician order; Regular diet, regular texture, thin liquids, low sodium/DM (diabetes) modified, guest blind- describe meal to guest; Date Initiated: 08/26/2025 Revision on: 08/29/2025. A review of R72's Kardex (resident care guide) revealed: Eating and Nutrition: Provide diet per physician order; Regular diet, regular texture, thin liquids low sodium/DM modified; guest blind- describe meal to guest. According to a review of R98's medical record, the resident was admitted to the facility on [DATE] for skilled nursing care related to a displaced fracture of the left femur, orthopedic after care and diabetes mellitis type 2. A review of R98's Minimum Data Set (MDS) record revealed a Brief Interview of Mental Status (BIMS) score of 14 out of 15, indicating the resident was cognitively intact. Additional medical diagnosis included depression, dementia and hypertension. On 09/23/2025 at 11:43 AM, R98 was observed in his room lying in bed watching tv and agreed to an interview regarding his care at the facility. R98 said that he had waited up to 30 minutes on multiple occasions for his call light to be answered, which he expressed was concerning to him because he had experienced 3-4 sugar drops since he has been here, (which indicated a drop in blood glucose). R 98 further said that late one night a nurse came in and handed him a bunch of pills, including a small blue pill, which he had never taken before. When R98 asked the nurse about the pill, the resident reported that the nurse responded, I am not here to tell you what it is, I am here to make sure you take it. R98 said that upset him, because I did not know what it was. R98 said he was hesitant to take it without being informed and asked, don't I have a right to know? Staff did not respond to resident's request for informed care. A review of R98's Kardex revealed: Transferring: Bed mobility: 1PA, Transfer status: 1PA, Ambulation status: non ambulatory, Weight bearing status: 25% to left leg, increasing to as tolerated over next 6 weeks (through October 27,2025). (PA=Person Assist, meaning the number of people required to assist resident for activity listed). Personal hygiene/oral care: Assist the pt with showers/bed baths. and under Resident care: Assist with dressing, hygiene and toilet needs. A record review of R98's care plan revealed: Focus: Risk for falls r/t (related to) weakness and debility, fall. Date Initiated: 08/12/2025; Revision on: 08/14/2025, with Interventions: .Administer medications as ordered by physician; Reinforce need to call for assistance; Ambulation status: non ambulatory . Focus: Actual ADL (activities of daily living) /Mobility deficit r/t weakness and debility, fall. L distal femur fx (fracture) s/p ORIF (open reduction internal fixation - surgery); Date Initiated: 08/12/2025; Revision on: 08/14/2025, with Interventions: . Assist the pt with showers/bed bath; Assist with dressing, hygiene and toilet needs; Explain all procedures; Date Initiated: 08/12/2025. Focus: At risk for changes in mood r/t Depression; Date Initiated: 08/14/2025, with Interventions: .Offer choices to enhance sense of control. According to a review of R143's medical record, the resident was admitted to the facility on [DATE] for skilled nursing care related to left knee replacement surgery. A review of R143's Minimum Data Set (MDS) record revealed a Brief Interview of Mental Status (BIMs) score of 14 out of 15, indicating the resident was cognitively intact. Medical diagnosis included diabetes mellitis type 2, hypertension, unspecified heart failure, and chronic kidney disease stage 3 (mild to moderate damage to kidneys). On 09/23/2025 at 10:20 AM, an observation was made of R143 sitting in her wheelchair in her room, her call light was on the floor behind her wheelchair. She reported she had been in the facility for about one week. R143 said she was there because she needed rehabilitation after she had a knee replacement. She said she had the ability to care for herself independently before but cannot since her surgery. R143 explained she had limited to no mobility with her knee and was dependent on help with daily care. She said she had waited 45 minutes for a call light to be answered. R143 explained, I came here from the hospital where they had given me medication for my stomach, you know to make me go to the bathroom, but it never kicked in before I left there she continued, I got here, and was not here but maybe a day, and that medicine must have kicked in. She stated, I put my call light on and waited and waited, no one came; So, I started yelling out and even began crying; I had to go to the bathroom so bad. R143 said it was about 30-40 minutes without anyone coming to answer her calls and that she had a bowel movement all over myself because she could no longer hold it. She said the nurse came in after that happened and said, I don't know where the aide is, and that the nurse offered little to no help with getting her cleaned up. She stated, It was absolutely humiliating and I have never been through anything like that, and I am (stated age) old. Staff did not respond to resident's needs in a timely manner, leading to resident reported humiliation. On 09/24/2025 at 1:14 PM, during an interview with R143 she reported that yesterday (09/23/2025) she had to wait over a half hour for staff to respond to the call light. She stated, I don't typically turn on my light if I don't need something and I understand it takes time; but that's a little too long without any communication to me about what's going on. A record review of R143's care plan revealed: Focus: Risk for falls r/t weakness and debility . with Interventions: .Bed mobility: 1PA; Immobilizer to LLE (left lower extremity); Reinforce need to call for assistance; Transfer status: 2PA with slide board; Ambulation status: non-ambulatory. Focus: Actual ADL/Mobility deficit r/t weakness and debility. with Interventions: Assist the pt (patient) with showers/bed baths; Assist with dressing, hygiene and toilet needs; Explain all procedures. On 09/24/2025 at 2:20 PM, during an interview with a confidential group of residents it was revealed, a consensus that call light response was long, reported averages of half an hour or longer on the weekends, citing there was often just one CNA per hallway and indicated not enough staff to answer call lights timely and assist with resident needs. The group expressed concern with They (the staff) will come in shut the light off and not help you or return. and the wait being up to 45 minutes. On 09/25/2025 at 10:00 AM, during an interview with Nurse J about call lights and how staff got alerted since there was no light or sounds in the hallways, she said they used a pager system. She was asked if she had a pager, and she said she had no pager and that only the CNA's carried pagers, and nurses did not. When asked if nurses answered call lights, she stated If I am aware of them I will, but I do not get a pager. On 09/25/2025 at 3:20 PM, during an interview with Kitchen Manager A and Culinary Specialist B it was said the staff serves the dining room first then the residents dining in their rooms. The staff should be checking the meal tickets for residents as a final check of accuracy and needs. According to a record review of the facility's Quality of life – dignity policy statement, Each resident shall be cared for in a manner that promotes and enhances quality of life dignity and respect and individuality. Listed under Interpretation and Implementation, was written: 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. 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. 8 Staff shall keep the resident informed and oriented to their environment. Procedures shall be explained before they are performed . 11 Demeaning practices and standards of care that compromise dignity are prohibited; Staff shall promote dignity and assist residents as needed by: .(B) promptly responding to the resident's request for toileting assistance. According to a record review of the facility's policy on, Answering a call light the purpose was listed as This procedure is to respond to the resident's request and needs. Listed under General guidelines, was written: 5 When the resident is in bed or confined to a chair be sure the caller is within easy reach of the resident. 8 Answer the residents call light as soon as possible. 9 Be courteous in answering the resident's call. Listed Under Steps in procedure, was written: 3 Listen to the resident's request. 5 If you promise the resident you will return with an item or information do so promptly Resident #76 Dignity On 9/23/2025 at 11:13 AM, Resident #76 was observed lying in bed, awake. His call light was observed hanging on the wall. It was not near the resident or in reach. When asked about it the resident did not respond. During the observation, Nurse Aide Z entered the resident's room and when asked about the call light hanging on the wall, he said he had asked the Nurse about it and was told the resident had a care plan for the call light to be hanging out of reach on the wall. The Nurse Aide was asked how the resident called for help and stated, He doesn't really talk that much; there was no alternative call device in place. A review of a nurses note dated 9/23/2025 at 11:22 AM provided, Family interviewed. Family verbalized wanting to keep call light out of guest's reach and frequent rounding to continue. The note was written after the observation that Resident #76 did not have a means to communicate for assistance. A record review of the Face sheet and Minimum Data Set/MDS assessment for Resident #76 indicated an admission to the facility on 7/28/2023 with diagnoses: history of a stroke, depression, heart disease, diabetes, gout and history of seizures. The MDS assessment dated [DATE] revealed the resident had moderate cognitive impairment with a Brief Interview for Mental Status/BIMS score of 12/15 and the resident needed assistance with all care. On 9/25/2025 at 12:30 PM, the resident was observed lying in bed. A visitor was present and said she was his fiancé. She was asked about the resident's call light as it was again observed hanging on the wall and not in reach of the resident. She said she had asked him not to have it because he didn't know what to do with it and in the past and had tangled it on himself. She said if he had the call light, he would just push the button and not know why. The resident's fiancé was asked how he could call for help, and she stated, He can't. There was no alternative method for calling for assistance in the room and there was a sign on the wall to keep the door closed. A record review of the Care Plans identified the following: Actual ADL (activities of daily living)/Mobility deficit related to CVA (stroke), head injury, skull/orbital fracture, diabetes, anemia, seizures, Gout, dysphagia, Dyslexia, history of MI (heart attack), hypertension, muscle weakness and debility, date initiated 7/28/2023 and revised 7/3/2024 with Interventions including: Family prefers for call light not to be within reach, dated initiated 9/23/2025; Frequent checks related to family not wanting call light within reach, date initiated 9/23/2025; Guest prefers to have door closed at all times with note on door, date initiated 7/17/2024. There was no identified alternative to the call light for Resident #76. With his door closed it would be difficult to know if he needed help. A review of the progress notes for Resident #76 revealed a note dated 3/5/2025 at 12:47 PM, Guest fiancé requesting to not give guest call light because he just plays with it. Fiancé educated on the importance of having call light within reach, she verbalized understanding fidget [NAME] given to guests to assist with the need to move fingers. On 9/25/2025 at 3:40 PM, during an interview with the Administrator, she said the resident's fiancé had requested for the resident not to have a call light and in the past, they had tried a Fidget [NAME] at the fiancé's request but it didn't work. When asked if other alternative methods of requesting help had been attempted, the Administrator said the staff perform frequent rounding. When asked how often that was, she said there was no specific timeframe. A review of the Kardex for Resident #76 revealed the following: Safety: Reinforce need to call for assistance; Family prefers for call light to not be within reach; Frequent checks related to family not wanting call light within reach: bell at bedside. There was no bell observed at the bedside. A review of the physician orders did not identify any alternate means of communicating need for assistance for Resident #76.

Based on observation, interview, and record review, the facility failed to ensure that a resident received necessary care and services to maintain the highest practicable level of health by not providing timely IV (intravenous) antibiotic therapy or alternative treatment during a peripherally inserted central catheter (PICC) line occlusion, for one resident (R24) of 2 residents reviewed for IV therapy, resulting in R24 missing five consecutive doses of prescribed IV antibiotic vancomycin (an antimicrobial medication used to treat resistant bacteria) over two days, placing the resident at risk for a delay in resolution of infection and increased risk for further antibiotic resistance and clinical decline.Resident #24 (R24):According to a review of R24's medical record, the resident was admitted to the facility on [DATE] for skilled nursing care related to diabetic ketoacidosis (DKA) (a buildup of ketones in the blood caused by elevated blood sugar making the blood acidic), weakness and IV Vancomycin infusion (42 days remaining on IV). R24's Minimum Data Set (MDS) record revealed Brief Interview of Mental Status (BIMS) score of 12/15 indicated the resident had moderately impaired cognition. Medical diagnosis included: Sepsis (the bodies extreme response to infection), Methicillin Resistant Staphylococcus Aureus (MRSA) infection (bacteria that is resistant to many antibiotics, including methicillin), diabetes mellitis type 2, calculus of kidney (kidney stones), Heart failure, acute and sub-acute infective endocarditis (inflammation of the hearts lining).On 09/23/2025 at 1:23 PM, an observation was made outside R24's room, to the left of the door on the wall was a pink butterfly note that indicated R24 had enhanced barrier precautions (EBP) (gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a multidrug resistant organism/MDRO). R24 was sitting in his wheelchair in his room, agreed to an interview regarding his care at the facility. During the interview he reveals that he went 3 1/2 days without getting his IV antibiotics and when he was asked why that happened, he replied, My IV line was clogged and apparently no one here was qualified to fix it he continued with It took them 2-3 days to get someone out here who could fix it. R24 said missing the IV antibiotics for that long was concerning to him because he Just wanted to get stronger so I can return home. He was glad that it was finally taken care of but wondered why it took so long. A record review of R24 medical records revealed the following under progress notes: 9/20/2025 (at) 06:04 Skilled Charting: . PICC line dressing was change and circumference was measured. 9/20/2025 (at)16:51 Medication Administration Note: Vancomycin HCl Intravenous Solution 1000 MG/200ML Use 1 gram intravenously two times a day for infection until 10/04/2025. Held r/t awaiting picc line flush/replacement at this time. 9/20/2025 (at) 21:14 Medication Administration Note: Vancomycin HCl Intravenous Solution 1000 MG/200ML Use1 gram intravenously two times a day for infection. Unable to flush to PICC line. Waiting on (the contracted mobile medical) to de-clot/replace RUE PICC line. Physician notified. 9/21/2025 (at) 06:45 Skilled Charting . Guest has a clogged PICC line, (the contracted mobile medical) was scheduled to come out and declog, (the contracted mobile medical) did not make an arrival. Physician was notified of (the contracted mobile medical) not arriving to the facility. c/o pain and asked for prn pain medication. Staff did not receive an order for or initiate an alternative access site to administer IV Vancomycin that was on hand at facility, following a delay in PICC line access. 9/21/2025 (at) 12:24 Medication Administration Note: (the contracted mobile medical) representative stated they will not be willing to come out until Cathflo (used to restore function of catheter lines) medication is on hand in facility. Medication was ordered via provider, pharmacy was contacted and notified, pharmacist stated it will be here this evening. 9/21/2025 (at) 15:49 Skilled Charting: Yesterday (9/20/25) morning, nurse noted that picc line was difficult to flush, and unable to run gravity Vanco drip effectively. On-call provider was notified and ordered (the contracted mobile medical) to try to de-clot or replace picc line. (the contracted mobile medical) was contacted that morning for de-clotting/picc replacement, and order was entered. Provider ordered hold for Vanco morning dose. (the contracted mobile medical) nurse . contacted facility and stated that she would not be willing to visit facility until additional measures such as another flush attempt, filter attachment removal, or use of Cathflo was attempted by facility nurse first. Provider was made aware, cathflo was not available in backup, so heparin dwell flush was ordered by provider. It was unsuccessful. Filter attachment was removed, and another saline flush was attempted, and it was still unsuccessful. Provider was notified, and (the contracted mobile medical) was notified. Representative stated the previous replacement order was not cancelled, and that it was labeled as 'dispatched', and that a nurse should be there that afternoon or evening. (the contracted mobile medical) nurse. contacted facility this morning 9/21/25, stating she never received a call back and asked about status of picc line. Facility nurse stated that they were unaware of the need for a return call. measures she requested were not successful. Nurse . stated that she would be unwilling to visit facility until Cathflo medication was on hand in facility, and needed to be ordered from out pharmacy. She provided the following contact. notify her when the pharmacy order was confirmed. Provider was notified.order was entered. Pharmacy was contacted, and stated the Cathflo medication should be delivered this evening alongside regular pharmacy delivery. Pharmacy was also notified of 3 total missed Vancomycin IV doses due to inaccessible picc, and they states they would note that down. (the contracted mobile medical) nurse.was contacted at the provided number, and notified of (pharmacy) order confirmation. (contracted nurse) requested to be contacted at the same phone number to be noticed of when medication arrives. Provider and management aware of situation. 9/21/2025 (at) 23:25 Medication Administration Note: Guest picc line not working, been waiting for cathflow to arrive now it arrived (the contracted mobile medical) nurse. stated that she cannot come out and the morning nurse would have to come out. 9/22/2025 (at) 00:35 Skilled Charting: . Guest picc line is clogged and (the contracted mobile medical) nurse was waiting for cathflo to arrive from pharmacy. (the contracted mobile medical) Nurse. was called and she stated that she can not come out because she is off work and the morning (the contracted mobile medical) nurse comes on shift about 9am and she will be here to fix picc line. On call provider aware with no new orders, continued with Picc line was flushed but it was hard to do. 9/22/2025 (at) 09:48 Skilled Charting: This writer was informed that guests PICC Line had been difficult to flush and antibiotics not given for 2 days, 4 doses. Discussed with NP, gave verbal order to extend antibiotic treatment two days. 9/22/2025 (at) 12:45 Skilled Charting: Discussed worsening BLE edema since Wednesday, now 3+ up to knees. Per NP change lasix (diuretic medication) order. Aware (the contracted mobile medical) here for PICC troubleshooting at this time. 9/22/2025 (at) 14:36 Skilled Charting: Spoke to guest and significant other to touch base and address any concerns or complaints that they may have. Guest stated his only concerns was his picc. According to a record review of R24's orders revealed the following: Dated 09/22/2025 Vancomycin HCl Intravenous Solution 1000MG/200ML (Vancomycin HCl) Use 1 gram intravenously two times a day for infection until 10/06/2025. According to R24's medication administration record (MAR), the Vancomycin IV order was scheduled as upon and HS-Li (hour of sleep/liberal), as clarified by staff Interview Nurse G who reported the at liberal times are medication orders that are scheduled to be given anytime between 07:00 AM-10:00 AM & 18:00 PM-21:00 PM (06:00 PM - 09:00 PM). This was confirmed by the time frame listed in the scheduled medications administration time.According to a review of Food and Drug administration (FDA) Vancomycin prescribing information/FDA label related that, the usual daily dose IV dosage of Vancomycin injection is 2 grams divided either as 500mg every 6 hours or 1 gram every 12 hours. A record review of R24's medical administration records (MAR) revealed the following: Vancomycin HCl Intravenous Solution 1000 MG/200ML (Vancomycin HCl) Use 1 gram intravenously two times a day for infection.The following dates for the Upon (at liberal time 07:00 AM - 10:00 AM) dose not given are noted as: 09/20/2025; 09/21/2025; 09/22/2025The HS dose (at liberal time 06:00 PM - 09:00 PM) not given are noted as: 09/20/2025; 09/21/2025A total of 5 consecutive doses of Vancomycin were not given.Each missing dose was reason noted as being 5 and 9 (5 being= to hold/see nurses notes and 9 being = to other/see nurses notes) per key on MAR. On 09/24/2025 at 1:38 PM, R24 was observed sitting in his wheelchair in his room, the PICC line dressing film on his right upper arm was dated 09/22/2025. The resident confirmed that 09/22/2025 was the date on the dressing and he stated, That is the day the special nurse came out to fix my IV; she changed it. R24 reported that he was supposed to get his IV antibiotics two times a day. He confirmed that he had received his morning dose on the day of the survey (09/24/2025).On 09/25/2025 at 8:16 AM, an observation of R24 sitting in his bed identified he had just completed his breakfast and ate about 75%. When asked, he reported he had not received his morning dose of IV antibiotic yet and stated, They bring it when they bring it, it's never at the same time. On 09/25/2025 at 8:35 AM, during an interview with Nurse G it was revealed that R24 had not yet received his morning dose of IV Antibiotics. Nurse G was asked when it would be administered and she stated, It's an at liberal time, asked nurse G what that meant and she replied, It can be given between 7-10 in the morning., It was further discovered the night dose was scheduled as at liberal also with a window administration time of 1800-2100 (which is 6:00 PM-9:00 PM). When asked if that was normally scheduling for an antibiotic such as Vancomycin, Nurse G replied, It is a twice a day medication; that is how it was scheduled.On 09/25/2025 at 4:04PM, an interview with Nurse G about R24's PICC line revealed that she was working for several shifts when the IV antibiotics were unable to be administered. Nurse G was asked about it and she stated, I was working with the resident over the weekend, I was unable to flush or run the Vancomycin because the PICC line was clotted. She said she let the provider know she had to hold the medication and that they ordered for (the contracted mobile company) to come in to assess and de-clot or replace the line. Nurse G cited several delays that happened and summarized the following: Prior to coming to the facility, the contracted vascular access nurse said she requested measures that were necessary to be taken on the part of the facility nurses (1) attempt to flush the PICC line (2) Change the filter (3) attempt to dwell/flush with Cathflo (a medication used to restore function of catheter lines).The facility did not have Cathflo on hand.There was a delay in the pharmacy delivery of Cathflo for an undetermined reason; An unwillingness for the contracted nurse to come in without the medication available at the facility; and a delay from the contracted company.Nurse G reported that the issue was not resolved until sometime on Monday (09/22/2025). When asked how many doses of the IV vancomycin the resident missed because of all of this she replied, 2 days so, 4 doses at least. On 09/26/2025 at 12:52PM to ~1:12PM during an interview with Corporate Clinical Nurse F, he was asked about the order correspondence and consultation notes form the contracted mobile company that came out for R24's PICC line. He stated, they did not complete the order and on that Monday morning one of the nurses that was previously an ICU nurse fixed the PICC line. When Corporate clinical nurse F was asked what the staff nurse did to fix the PICC and he stated, They just have the skills, they know tricks they are from the ICU. Corporate clinical nurse F was asked if all the nurses working with PICC lines should have the necessary skills to care for them and he stated, Yes, they should. He then exited and came back later and said that the former ICU did not fix the PICC and it was done by (the contracted company). A record review of R24's medical records revealed the following (mobile contracted company) documentation labeled: Peripheral intravenous catheter insertion CVC care/ Maintenance document dated 09/22/2025 had a noted arrival time at 09:50 AM with departure time of 11:10 AM. The note section on the document revealed: .Dressing (medical symbol used) change done. line discovered to be kinked under Biopatch (type of medical cover/dressing) . length consistent with baseline, has not been dislodged and continued Line redressed, '(unkinked line)' line, now flushes with ease but sluggish blood return. Instilled 2 mg Cathflo. after dwell the line with brisk blood return. According to a record review of the facilities nursing skills and competencies assessment for Nurse G, in the IV Therapy section: Date (signed off on as competent in skill) 8/13/2025; Competence indicator (skill competent to perform): IV insertion, IV administration, IV documentation, IV dressing change.There was no documentation on PICC line care, maintenance or assessment listed in competencies. According to a review of the facilities Infusion maintenance table, reads: under site maintenance for PICC section titled, transparent dressing change, PICC listed 24 hours post insertion, then Q week (every week) and as needed (PRN) - measure upper arm, circumference and external length catheter. According to a record review of the (Mobile contracted company) Standard terms and conditions contract: Under services it read, For vascular access services, Provider shall provide registered nurses (RN's) qualified in infusion therapy administration that administer placement of vascular access devices and follow up nursing care if required. The nurse's responsibility at the location is as follows (1) assessment of the patient's pick or midline PIV line insertion (2) inform consent for pick or midline procedure (3) verification of physician's order number (4) ultrasound guidance for PC insertion; and (5) documentation related to insertion.Section 1.2.2 non-stat (non-urgent) imaging exams, read, Every effort will be made to complete services within the day of when services are ordered. In the event the provider is unable to complete services within a day of when services are ordered, customer will be notified in the exam will be performed as scheduled.Section 1.3 special services / on-call emergency provider services read, If requested by customer and where available, provider shall be available 24 hours a day, seven (7) days a week for stat emergency requests. According to a record review of R24's lab results, the following Vancomycin Trough levels were included in the resident's chart: 09/22/2025 collected at 03:40 AM: (test) VANCOMYCIN, TROUGH (result) 6.6 (units) ug/mL (Reference range) 10.00-20.00 (flag) L (low). 09/17/2025 collected at 05:50 AM: (test) VANCOMYCIN, TROUGH (result) 16.5 (units) ug/mL (Reference range) 10.00-20.00. 09/10/2025 collected at 13:45 PM (01:45 PM) : (test) VANCOMYCIN, TROUGH (result) 10.6 (units) ug/mL (Reference range) 10.00-20.00.According to a review of Food and Drug administration (FDA) Vancomycin prescribing information/FDA label related that, the usual daily dose IV dosage of Vancomycin injection is 2 grams divided either as 500mg every 6 hours or 1 gram every 12 hours. According to the Infectious Disease Society of America (IDSA) Vancomycin guidelines 2020 Update, The guidelines recommend an AUC/MIC (Area Under Curve/Minimum Inhibitory Concentration) ratio (parameter to assess effectiveness of an antibiotic) of 400-600 mg*hour/L to achieve clinical efficacy and ensure safety for patients being treated for serious methicillin-resistant Staphylococcus aureus infections and according to the IDSA clinical practice guideline recommendation achieving a trough (parameter to assess effectiveness of an antibiotic) concentration of 15-20 mg/L (milligram per liter) for complicated infections. These guidelines emphasize the importance of consistent and timely administration of vancomycin to maintain therapeutic exposure and endorsed Interruptions in therapy can lead to suboptimal drug exposure and potential therapeutic failure. According to the Centers for Disease Control and Prevention (CDC), Healthcare Infection Control Practices Advisory Committee (HICPAC) guidelines, they said delays in the administration of critical antibiotics, such as vancomycin, can compromise treatment efficacy and patient outcomes.A review of Infusion Nurses Society (INS) standards of practice (2021), concluded that when the access or functionality of a vascular access device (VAD) site was compromised, healthcare providers must have acted promptly to ensure the continuation of necessary treatments, this included the use of alternative venous access routes or the administration of medications via different modalities to prevent critical treatment interruptions.

Based on interview and record review, the facility failed to ensure completion of yearly Performance reviews and competencies for 6 of 6 Certified Nursing Assistants reviewed for yearly education, resulting in the potential for the nurse aides to not be able to safely provide the needed care and services for the residents.Facility Sufficient and Competent Nurse Staffing On 9/24/2025 at 2:30 PM, during an interview with Staff Education Nurse M she said the nurses and nurse aides had a 2-day classroom orientation where they completed online computer training and then they were assigned to a preceptor on the nursing units and were to complete competencies. Nurse M was asked if the staff completed hands on competencies and she said she went over Personal Protection Equipment/PPE's and Hand Hygiene with them.On 9/24/2025 at 3:00 PM, Human Resources/HR Manager X was asked for education files for Certified Nursing Assistants/Nurse Aide N, O, P, Q, R, S. A record review of the education files for Certified Nursing Assistants N, O, P, Q, R, S revealed the CENA Orientation & Annual Competency Checklist had 74 competency check off items listed. Each Nurse aide placed their initials next to the boxes they completed, and each one said they completed all of the items in one day. The Nurse Aide signed that they completed all the items in one day and the Staff Educator M signed that they were completed on the same day. Some of the check off competencies did not have an initial next to it, but a line was drawn through the item for almost 100% of the items.On further review of the Nurse Aide competencies the following was identified: Nurse Aide O had a straight line dragged through all competency entries and the form was signed as completed on 11/19/2024 by Nurse Aide O and Nurse Y. Nurse Aide P did not have a last page to the competency. There was no identified completion date.Nurse Aide R had a straight line dragged through all of the competency entries. The competency was signed as completed by Nurse Aide R and Nurse Y on 1/28/2025.There were no entries for PPE or Hand Hygiene on the CENA Orientation & Annual Competency Checklist and there was no document confirming an in-person hands on competency for each had been completed.On 9/25/2025 at 11:28 AM, Assistant Director of Nursing AA was interviewed about nurse and nurse aide orientation. She said it started with a 2-day computer training and then they would be assigned to the floor to complete competencies. On 9/25/2025 at 11:40 AM, the Administrator and Corporate Nurse E were interviewed related to the Certified Nursing Assistants checking themselves off on their competencies. The Competency forms were reviewed for Nurse Aides N, O, P, Q, R and S. They Nurse Aides initialed they completed the competencies and then signed and dated it was done. There were no specific dates when each item was completed; only when the entire competency was completed and then the Staff Education Nurse signed the form. There was an entry for Preceptor CENA Signature, but 3 out of 6 were blank, one said NA, and one had no signature page. It was unclear who was observing the Nurse Aides to ensure they completed each competency appropriately. The Administrator and Corporate Nurse E were asked to review the yearly Performance evaluation for each nurse aid (N, O, P, Q, R, S) and they said they did not do that. They said they had the yearly competency check offs. The Administrator and Corporate Nurse E were asked how they determined which areas of improvement were needed for the Nurse aides if there was no evaluation and they said they no longer did that. On 9/26/2025 at 9:30 AM, the Director of Nursing said there was no staffing policy. A review of the Facility Assessment dated revised 7/1/2025 by the Administrator identified the following: Purpose: The Facility assessment is a complete review of internal human and physical resources required by the facility to care for residents competently during day to day and emergency operations. There are three components to the review: 1. Resident profile. 2. Services and care offered. 3. Facility resources needed to provide competent care for residents, including staff, staffing plan, staff training/education and competencies, education and training. Nursing Services: The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. A facility must develop, implement, and maintain an effective training program for all new and existing staff. Required in-service training for nurse aides: In-service training must- address areas of weakness as determined in nurse aides performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff. Training, Competencies: As needed and monthly and annually using Health care academy (online training).

Based on observation, interview, and record review, the facility failed to maintain best practices in the kitchen resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings include:Resident interview On 9/24/25 at 10:10 AM, an interview was conducted with a Confidential Resident II regarding issues with their care at the facility. The Resident answered questions and engaged in conversation. The Resident expressed a concern that she had witnessed while eating. The Resident reported that a Resident that she ate meals with was eating lunch and had most of her meal eaten with a spoon. The Resident reported that she had two spoons stuck together and the spoons were dirty that was stuck to the other spoon. The Resident reported being upset that the spoons had been wrapped in a napkin by staff and that the spoons had not been detected as being dirty and stated, you could get sick from that. On 09/23/2025 between 9:00AM - 9:30AM during the initial kitchen tour with the culinary Specialist B and the Kitchen Manager A, observed dessert plates stored upwards so that the interior was exposed with one of the bowls visibly soiled with a yellow liquid substance, located in the clean dish area. When interviewed on whether these dishes were supposed to be clean, the Culinary Specialist B confirmed these were clean dishes and proceeded to take the soiled dish back to the dishwashing area. On 09/23/2025 at 12:40 PM during lunch service, meatballs were temped using Thermapen at 130 and then 122 degrees Fahrenheit on two separate meatballs held on the steam table located in the northside kitchen. When interviewed, the Kitchen Manager A stated they try to keep the hot holding temperature at 135 degrees Fahrenheit. According to the 2022 Food Code, 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, Cleaned equipment and utensils, laundered linens, and single-service and single-use articles shall be stored: in a clean, dry location; where they are not exposed to splash, dust, or other contamination; and at least 15 cm (6 inches) above the floor. and Clean equipment and utensils shall be stored: in a self-draining position that allows air drying; and covered or inverted. According to the 2022 Food Code, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding, Except during preparation, cooking, or cooling, or when time is used as the public health control, time/temperature control for safety food shall be maintained . at 57 degrees C (135 degrees F) or above. According to the facility's policy on hot holding, All hot foods must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees Fahrenheit . hot food items may not fall below 135 degrees Fahrenheit after cooking, unless it is an item which is to be rapidly cooled to below 41 degrees Fahrenheit and reheated to at least 165 degrees Fahrenheit prior to serving.

Based on observation, interview, and record review, the facility failed to properly dispose of waste and maintain the dumpster area to mitigate the presence of insects and rodents, potentially affecting all residents, staff, and visitors in the facility.Findings include:On 09/24/2025 at 8:50AM - 9:46 AM during the environmental tour with the Maintenance Director C, observed a strong odor in the dumpster area and plastic lids, plastic cups, a chip bag, and dark residue surrounding the area behind the dumpster. When interviewed, the Maintenance Director C stated that they do rounds every so often.According to the 2022 Food Code, 5-501.115 Maintaining Refuse Areas and Enclosures A storage area and enclosure for refuse, recyclables, or returnable items shall be maintained free of unnecessary items.

Based on observation, interview and record review, the facility failed to 1) Properly store clean linen, sanitary supplies and Personal Protective Equipment (PPE), 2) Ensure distilled water for respiratory care was replaced properly for Residents #8, 3) Ensure appropriately associated precaution signage was posted, 4) Use/disposal of PPE was provided and consistent for Residents #24 (R24) and #153 (R153), and 5) Failed to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing, resulting in an increased potential for contamination and a possible decrease in the satisfaction of living, affecting residents in following areas: 800, 600, and 100 hallways. Findings include: Resident 24 (R24) According to a review of R24's medical record, the resident was admitted to the facility on [DATE] for skilled nursing care related to diabetic ketoacidosis (DKA) (a buildup of ketones in the blood caused by elevated blood sugar making the blood acidic), weakness and IV Vancomycin infusion (42 days remaining on IV). R24's Minimum Data Set (MDS) record revealed Brief Interview of Mental Status (BIMS) score of 12/15 that indicated the resident had moderately impaired cognition. Medical diagnosis included: Sepsis (the bodies extreme response to infection), Methicillin Resistant Staphylococcus Aureus (MRSA) infection (bacteria that is resistant to many antibiotics, including methicillin), diabetes mellitis type 2, calculus of kidney (kidney stones), Heart failure, acute and sub-acute infective endocarditis (inflammation of the hearts lining). On 09/23/2025 at 1:23 PM, an observation was made outside R24's room, to the left of the door on the wall was a pink butterfly note that indicated R24 had enhanced barrier precautions (EBP) (gown and glove use during high-contact resident care activities) R24 was sitting in his wheelchair in his room, agreed to an interview regarding his care at the facility. R24 explained, he was here for rehabilitation and that he was also receiving IV antibiotics for an infection, his goal was to get stronger so I can return home. When R24 was queried about the EBP status and when he was being provided care, he said they always wear gloves, rarely a gown and could not recall ever seeing a mask used during his care. On 09/24/2025 at 1:38 PM, R24 was observed sitting in his wheelchair in his room, the PICC line dressing film on his right upper arm was dated 09/22/2025. During an interview, R24 remarked, they (staff) are wearing gloves and gowns more today, are they supposed wear them (gowns) all the time? They normally just wear gloves. On 09/25/2025 at 8:15 AM, An observation of R24's door was made and there was a contact precaution (requires PPE of gloves and gown, to minimize transmission of infectious organisms through direct or indirect contact with a person or their environment) sign on the residents door, the EBP sign was located on the wall to the left of the door with a plastic drawer cart containing PPE (personal protective equipment) under it, and a wooden slatted hamper to the right of the door that had yellow gowns in it. The Director of Nursing (DON) was on the hall and was asked about the contact precautions sign, she replied it has always been there, he has been in contact since he has been here. On 09/25/2025 at 8:16 AM, R24 was observed sitting on his bed and identified he had just completed his breakfast. While verifying with R24 staff's use of PPE, he was asked if they wore gowns when entering and before when performing care, he said just yesterday and today. R 24 confirmed it was not a consistent practice prior to that. On 09/25/2025 at ~(approximately) 8:20 AM, upon exiting R24's room, gown was disposed into the wooden slatted hamper that was observed in the hall by R24's door. Nurse L said the hamper was for clean gowns. She confirmed there was no sign to identify if the gowns were clean or dirty. According to a review of the CDC recommendations for contact precautions: Everyone must: clean their hands, including before in entering and when leaving the room. Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. #2 put on gown before entering room. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. #3 use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. A review of R24's Kardex (resident care guide) revealed: Resident care: .enhanced barrier precautions as directed. This includes gowns and gloves for high-contact resident care activities. A review of R24's physician orders revealed: Start date: 08/22/2025; Enhanced Barrier Precautions as directed. This includes gowns and gloves for high-contact resident care activities. Specify why: PICC Line and wounds. Start date: 08/22/2025; Contact Precautions: Gown and Gloves. Start date: 09/19/2025; Wound Care: Cleanse stage 2 pressure injury to sacrum. Resident 153 (R153) According to a review of R153's medical record, the resident was admitted to the facility on [DATE] for skilled nursing care related to vascular surgery, stomach ulcers, gastritis and feeding tube placed on 09/11/2025. R153's Minimum Data Set (MDS) record revealed Brief Interview of Mental Status (BIMS) score of 06/15 indicated the resident had severely impaired cognition. Medical diagnoses included dysphasia (moderate language impairment), diabetes mellitis type 2 and debility. On 09/23/2025 at 11:15 AM, an observation was made outside R153's room, to the right of the door on the wall was a pink butterfly note that indicated R153 had enhanced barrier precautions (EBP). When attempted to meet resident, It was reported by staff that R153 and his family were having a care conference. On 09/24/2025 at 8:44 AM, an observation was made outside R153's room, to the right of the door on the wall was a pink butterfly note that indicated R153 had enhanced barrier precautions (EBP), no PPE cart or bin present at room. R153 is resting in bed with tube feed up and running. He said he has not been here long; he was unable to give details about his reason for being here, but confirmed he attends therapy. There is a garbage can bin labeled dirty gowns inside R153, no trash nearby. On 09/25/2025 at 8:35AM, an observation was made outside R153's room, to the right of the door on the wall was a pink butterfly note that indicated R153 had enhanced barrier precautions (EBP), no PPE cart or bin present at room. CNA K that provides care for R153 was asked, where she would obtain PPE to provide R153's care and she looked around then stated, I would have to go down the hallway to see if I could find it. CNA K was asked if she could identify a PPE bin near R153's room and she stated, No, there should be one outside the room, CNA K confirmed that there was none present outside R153's door. On 09/25/2025 at 12:10 PM, an observation was made of Nurse J, she pulled out a gown from the clean bin and attempted to untie a knot that was in the neck ties, she was unable to get then un-knotted. She stated, I don't think I am going to get that out. Nurse J rolled the knotted gown into a ball and placed it back into the clean bin and grabbed another clean gown out and put it on. Nurse J entered R153's room to take down R153's tube feeding and change the dressing, she discovered it still needed to run, and said to come back in about 30-40 minutes. On 09/25/2025 at 1:05PM, an observed was made of Nurse J donned a gown, enter the room, and prepare to take down R153's tube feeding and change the PEG tube (surgically placed tube placed for nutrition) dressing. Nurse J did not close the resident's door prior to starting care, when her attention was called to it, she stated, Oh sorry, I should have done that. Nurse J changed the dressing and discovered she did not have a pen to date the dressing; she left the room and observed her lift the clean gown bin and place the gown in the bin and then grab it back out and place it in the dirty bin inside the resident's room. She put on a new gown and returned inside the room, she dated the residents dressing and then reached under her gown to her clothes and placed the pen in her pants pocket. A record review of R153's orders revealed: Enhanced Barrier Precautions as directed. This includes gowns and gloves for high-contact resident care activities. Specify why: Peg tube (feeding tube) A record review of R153's care plan revealed: Focus: Actual ADL/Mobility deficit; interventions: Assist the pt with showers/bed baths; Assist with dressing, hygiene and toilet needs; ROM with care daily. Focus: Alteration in nutritional status related to Enteral/parenteral nutrition (via Peg tube) , Recent hospitalization, Swallowing difficulty.; Interventions: . There was no documentation on of residents enhanced barrier precautions in the care plan. A review of the facilities Enhanced Barrier Precaution - Policy – Policy – Procedures revealed: 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. Key points included: 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: 1. Wounds or indwelling medical devices, regardless of MDRO colonization status 2. Infection or colonization with a CDC targeted MDRO. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care. Procedure: included The facility will: a. Identify residents who may require EBP i. 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 the high contact resident care activities that require the use of gown and gloves d. Make PPE, including gowns and gloves, readily available. e. Ensure access to alcohol-based hand rub in every resident room. f. Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room 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 h. Provide education to residents and visitors According to a review of the CDC recommendations for enhanced barrier precautions: Everyone must: clean their hands, including before in entering and when leaving the room. Providers and staff must also: wear gloves and a gown for the following high contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs as assisting with toileting; device care or use: central line, urinary catheter, feeding tube, tracheostomy; Wound care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more than one person. Resident 8 (R8): A review of Resident 8's medical record revealed an admission on [DATE] and readmission on [DATE] with diagnoses that included heart failure, dementia, chronic obstructive pulmonary disease (COPD) with exacerbation, acute respiratory failure with hypercapnia and hypoxia and obstructive sleep apnea. A review of the Minimum Data Set assessment revealed a Brief Interview of Mental Status score of 5/15 that indicated severely impaired cognition. Further review of the medical record revealed the Resident had a Bi-PAP (bilevel positive airway pressure-a device that helps with breathing by supplying pressurized air through a mask or nasal plugs often used for patients who have difficulty breathing due to conditions such as sleep apnea, COPD or respiratory failure) machine. Review of Resident 8's orders revealed order dated 8/19/24, Nurse to sanitize BiPap machine. Nurse to sanitize BiPap machine in the morning every Thu (Thursday). On 9/23/25 at 11:57 AM, an observation was made in Resident 8's room of a Bi-Pap machine. The humidification chamber was filled with water. At the bedside was a gallon container of distilled water. The gallon container of distilled water had a small amount of water left. The handwritten date on the gallon read 3/29. On 9/25/25 at 12:50 PM, an observation was made in Resident 8's room. Staff were assisting the Resident to eat while he was in bed. An observation was made of the opened gallon container of distilled water with the handwritten date of 3/29. On 9/25/25 at 11:59 AM, an interview was conducted with the Assistant Director of Nursing (ADON) AA regarding the distilled water for C-PAP and Bi-PAP machines. The ADON was asked how long the distilled water was good for once opened. The ADON indicated they should be changing it out every week. An observation was made of Resident 8's distilled water with the date 3/29. The ADON indicated the date would be the open date of when the distilled water was opened, the date would be written on the container. The Nurse reported that the water was outdated and needed to be replaced. Resident 131: An observation of Resident 131's room with the ADON revealed an opened container of distilled water that was not dated. The ADON indicated it should be dated when opened and emptied the remaining water and disposed of the container. A review of the facility policy for C-PAP/Bi-PAP machines was requested but did not give guidance on use and storage of the distilled water to maintain good infection control standards or condition over time once opened to prevent contamination of infectious organisms. Facility: The laundry room observation was conducted with the facility's infection control nurse (ICP Nurse M) and corporate infection control nurses (Corporate ICP HH') on September 25, 2025, at 12:00 PM. The laundry staff were unavailable in the soiled linen room and the wash & dry rooms at the beginning of the observation. Later, two laundry staff members were found in the clean linen room. The two laundry staff indicated they were there preparing and folding clothes and linen, but no clothes or linen were found nearby. On September 25, 2025, at 12:05 PM, it was observed that one of the three dryer machines, #3, was in use and actively in a drying cycle. Two dryers (Dryer #1 and Dryer #2) were not in use, and the machine was cool to the touch. The surveyor asked the laundry personnel, FF, to open the dryer lint door for dryers #1 and #2. Both dryers (#1 and #2) were observed to have an obvious visible accumulation of fibers, fuzz, and fluff on the lint trap after use, which had not been cleaned of debris. Accumulated debris was found on both the lint screen and its surrounding area. When Laundry staff FF was asked about the protocol, the laundry staff FF stated they were supposed to clean the lint trap and clear the surrounding area after every load but did not get to it. On 9/25/25 at 12:05 PM, the laundry staff member FF was asked to describe the process of washing the non-disposable yellow gowns staff use for PPE. Laundry staff member FF revealed that the process involves placing the washed and dried yellow gowns directly into the transport carts and delivering them to the Personal Protective Equipment (PPE) bin/ in each unit. Laundry staff FF specifically described that they don't fold the yellow gowns individually. From the dryer, they drop them into the blue transport cart and deliver them to the units. Laundry staff FF was explaining the process to the surveyor while next to the blue transport cart. The Laundry staff member FF uncovered the blue transport bin and noticed that the contents included personal clothing, trash, and empty trash bags. Laundry staff member FF indicated that there shouldn't be items there and was unsure if the items found were clean or dirty. She was uncertain how often they are washed, cleaned, or sanitized, and who is responsible for cleaning the bins before clean clothes and linens are put in. The Laundry Staff FF was asked if they use the same carts that handle the dirty soiled linen and transport clean linens, clothes, and PPE gowns as well? Laundry Staff FF had no answer. When three laundry staff members in the clean linen room were asked who washes and how often they disinfect the blue bins that transport the soiled and clean laundry. They did not answer. One of the staff members said, once a day, but when asked who is responsible or how they get assigned to wash them, they did not answer. When asked what the process is for washing the bins? Sprayed with bleach water? Soap and water? Or wipe down with a disinfectant. How do they dry the bins? No one can answer., A policy for Lint Trap Maintenance and Cleaning of Laundry transport bins was requested from the ICP Nurse. No policies were received for review. However, an in-service education on 9/25/25, following the above observations, was conducted for the four laundry staff members. Topic: Must remove all garbage from soiled linens before washing—clean Linen Carts and dry lint trap cleaning responsibilities. There was no policy received as requested related to Cleaning/Maintenance scheduled on Dryer Lint traps. However, the Lint Trap Cleaning Log Form with a revised date 8/19/2025, noted in the form as a reminder: Lint Traps are to be cleaned after every use. On September 25, 2025, at 12:43 PM, the Director of Nursing (DON) was informed of the observation. The ICP Nurse M, on 09/25/2025 at 1:16 PM, returned to the surveyor and revealed that the process for the bins is that they are cleaned daily, but no log is kept. The ICP Nurse M stated, Moving forward, we will keep a log. On 09/23/2025 at 1:46- 2:20 PM during the housekeeping tour with the Housekeeping Manager D, observed two packaged catheters, a urinary drain bag and bandages on the floor located in the supply room in 800 hallways. When interviewed, the Housekeeping Manager D stated that the supply rooms are cleaned daily. On 09/23/2025 at 1:46- 2:20 PM observed clean linen on the floor located in the 600 hallways. On 09/23/2025 at 1:46- 2:20 PM observed an unused brief, towels, and plastic cups on the floor located in the supply rooms in the 100 hallways. On 09/24/2025 at 8:50AM - 9:46AM during the environmental tour with the Maintenance Director C, when interviewed on testing for chlorine residual in the water system, he stated that chlorine is not tested at the facility. On 09/24/2025 at 10:00AM interviewed the Administrator and the Coporate Nurse E on testing chlorine residual and they were both unfamiliar with testing chlorine residual at the facility. On 09/25/2025 at 1:00 PM this surveyor was notified that the facility bought a chlorine test kit and tested the water after the interview and review of the water management plan the day prior, after this surveyor had exited. Record review of the facility's Water Management Plan (WMP), on the monitoring for control measures diagram, it indicates the facility is checking disinfectant level before the water softener and at laundry. On the control measures and corrective action diagram, it shows how the facility plans to act when control measures aren't being met. According to the State Operations Manual, Facilities must be able to demonstrate its measures to minimize the risk of Legionella and other opportunistic pathogens in building water systems such as by having a documented water management program. Water management must be based on nationally accepted standards (e.g., ASHRAE (formerly the American Society of Heating, Refrigerating, and Air Conditioning Engineers), CDC, U.S. Environmental Protection Agency or EPA) and include: an assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g., Pseudomonas, Acinetobacter) could grow and spread; and measures to prevent the growth of opportunistic waterborne pathogens (also known as control measures), and how to monitor them. According to the Centers for Disease and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Ensure disinfectant residual is detectable throughout the potable water system.

Based on observation, interview and record review, the facility failed to ensure that bathroom doors and blinds in residents' rooms were in good working order for two residents (61 and 128) of four residents reviewed for a clean, comfortable, homelike environment.Findings include:Resident #61 (R61):A review of R61's medical record revealed an admission into the facility on 9/2/25 with diagnoses that included cystitis, heart failure, diabetes, and heart disease. A review of R61's Minimum Data Set assessment revealed a Brief Interview of Mental Status score of 9/15 that indicated moderately impaired cognition, and the Resident used a wheelchair for mobility. On 9/24/25 at 9:46 AM, Resident 61 was observed in his room, seated in a wheelchair. The Resident was interviewed, answered questions and engaged in conversation. The Resident was asked about any concerns he had about his care at the facility and was asked about any issues with his room. The Resident reported that the sliding bathroom door would not open, he could close it with difficulty but reported he could not get it back open. The Resident was able to propel himself around in the room and went to the partially open bathroom door and was unable to push it open. The door was observed and pushed on but would not open further. The Resident reports that with the door partially closed, Now I can't get in there. The door was able to be closed a little further with difficulty but when pushed on by the Resident, the door would not open for him. The Resident reported that being seated in the wheelchair, he did not have the momentum to open the door and reported he was afraid of getting shut in the bathroom and not being able to get himself out. The Resident reported that he would have to close his bedroom door if he were to use the bathroom and hopes that no one walks in to the room. When asked how long the issue with his door had been going on, the Resident reported that the door had problems since he had been there. When asked if staff were aware, he indicated yes because they sometimes go in there and they were aware how hard it is to open the door. The Resident stated, I showed some guy who I thought was from maintenance, that he could not close the door. Resident #128 (R128):A review of R128's medical record revealed an admission on [DATE] with diagnoses that included dementia, diabetes, respiratory failure, and stroke. A review of the Minimum Data Set assessment revealed a Brief Interview of Mental Status score of 9/15 that indicated moderately impaired cognition and the Resident needed substantial/maximal assistance with bathing, upper body dressing, personal hygiene, roll left and right and was dependent on a helper for toileting hygiene, lying to sitting, and transfers. On 9/23/25 at 10:49, an observation was made of Resident #128 lying in bed. The head of the bed was elevated slightly. The Resident had a meal tray on an overbed table in front of her. The meal had been eaten. The Resident was interviewed, answered questions and engaged in conversation. The Resident was asked about the care she received at the facility and if she had any concerns. A concern the Resident reported was that the bathroom sliding door was too difficult to get open and that staff would kick at it to try to open it. The Resident said that the issue with the door was recurring, and they had fixed it before, but it happened again. The Resident reported the blinds did not work and they could not adjust the slats how the Resident wanted in opened or closed or partially opened. The Resident reported the blinds have been an issue for a couple months or longer. On 9/23/25 at 11:13 AM, an interview was conducted with Nurse EE, while in the room with the Nurse, the Resident expressed concern of the blinds not working and the bathroom door not working properly. The Resident stated that there was no way to move the slats of the blinds up and down. Nurse EE reported that the twist rod to adjust the slats of the blinds was broken and needed to be replaced. The Nurse reported the blinds had been an issue for two or three months and it had been conveyed to Maintenance personnel. The Resident complained of the bathroom door was not opening. The Nurse tried to open the door, but it was very difficult to open and reported they had fixed it once already. Out in the hall, the Nurse was asked if there was a way to make a work order, the Nurse reported that they changed the screen on the computer, and they did not have a way to make a maintenance work order and that only housekeeping could do that with an app on their phone. On 9/25/25 at 11:01 AM, an interview was conducted with Maintenance Director (MD) C regarding Resident 61 and 128's blinds and bathroom doors. The MD was asked about the bathroom door and reported that Resident 128's door was fixed yesterday, was an ongoing issue and had been adjusted to keep the problem from recurring. The blinds were observed, and it was reported by the MD that they were unaware that the blinds were an issue for Resident 128. The MD reported that they would have it fixed or replace the blinds.An observation was made in Resident 61's room of the bathroom door that was very difficult to open. The MD reported to the Resident that they would get it fixed for him and explained to the Resident that he should be able to open the door with a light push.The MD was asked about the system for staff to put in a work order for the doors and blinds. The MD reported that they can tell us, but they also need to put a work order on the computer. It was reviewed that the Nurse indicated that there was no longer a way to put the work order on the computer and that housekeeping were the ones to put in the work orders. The MD reported that the computer should have the app on the computer, or they can use the phone app by putting their phone camera to the bar code. An observation was made with the MD of the code that was hung in the hallway by a computer and showed how the phone would take a picture of the code, and it goes to the system used by maintenance department to be aware of maintenance issues. The computer in the hall where Resident 61 and 128 resided was observed with the MD and the Nurse in the hallway. The computer did have the app on the screen. The MD stated, They should be using the system and if they tell us, they should also put it in the system so we can follow up on it.

Past Non-Compliance (PNC) was identified during investigation of the deficient practice and was accepted by the survey team upon exit from the facility for this citation. Following discussion with the State Manager, Past Non-Compliance was accepted with a Compliance Date of 6/25/25. Based on observation, interview and record review, the facility failed to ensure Resident safety when care-planned interventions were not followed for bed mobility for one resident (#128) of three reviewed for falls and accidents, resulting in Resident 128 falling from the bed, pain to the knee and need for x-rays.Findings include:Resident #128 (R128): A review of R128's medical record revealed an admission on [DATE] with diagnoses that included dementia, diabetes, respiratory failure, and stroke. A review of the Minimum Data Set assessment revealed a Brief Interview of Mental Status score of 9/15 that indicated moderately impaired cognition and the Resident needed substantial/maximal assistance with bathing, upper body dressing, personal hygiene, roll left and right and was dependent on a helper for toileting hygiene, lying to sitting, and transfers. On 9/23/25 at 10:49, an observation was made of Resident #128 lying in bed. The head of the bed was elevated slightly. The Resident was interviewed, answered questions and engaged in conversation. The Resident did not have her call light in reach. When asked if she could reach it where it was observed positioned on the upper corner on the side of the mattress fitted sheet, the Resident reported that if she tried to roll over, she was afraid she would roll off the bed again. When queried about rolling off the bed, the Resident reported that staff had pushed her over when assisting the Resident with turning in bed and stated, She said I rolled over, I was trying to lay on my side, but she pushed me over, I was reaching for the handle of the chair and she pushed me. The Resident reported that they were to use two people to turn me and the CNA repositioned her by herself and stated, Did x-rays, no broken bones but it affected my right knee, and complained of having pain in her right knee since the fall off the bed. A review of Resident 128's incident documentation revealed the following:-Date of fall, 5/22/25 at 11:15 AM, Incident Description: This nurse was called to the room by hospice RN. Hospice CENA was doing care on guest. Guest likes to hang on to the chair. She was on her right side. Her right side and slipped off the bed and she landed on it and rolled to her back. Guest denies pain. All extremities move at baseline. Guest's 3rd, 4th, and 5th toenails were removed in the fall. -Dated 5/23/25 Fall Assess revealed, .Root cause: Guest was receiving care by 1PA (one person physical assist) and slipped off bed on the right side of bed. Intervention: Care plan updated and changed bed mobility to 2PA. IDT (interdisciplinary team) met and care plan updated.-Date of incident 6/18/25 at 8:15 PM, Nursing Description: CNA was assisting guest in brief change, guest was reaching for the chair and pulling and working against CNA during incident. Guest pulled herself off the right side of the bed and onto the floor. Witnessed and guest did not hit her head. She is painful, has skinned her right knee and the ball of her right toe.-Dated 6/19/25 Fall Assess revealed, .Guest had complaints of pain to her right knee and right 1st foot digit. Xray of right knee was ordered and negative for fracture, but shows moderate osteoarthritis of the right knee. Root cause: Guest was receiving care by 1PA and pulled herself off bed on the right side of bed. Intervention: Care plan reviewed and updated to educate staff of guests bed mobility requires 2PA. A review of Resident 128's care plan report revealed a focus for Risk for falls r/t (related to) unsteady gait, . with interventions that included Bed Mobility: 2PA, revision on 5/22/25. On 9/25/25 at 2:35 PM, an interview was conducted with the Director of Nursing (DON) regarding Resident 128's falls from the bed. The Resident's fall from the bed during care with the Hospice CNA, care plan had been updated to two person assist with bed mobility on 5/22/25, then on 6/18/25 CNA DD was assisting with bed mobility and the Resident fell from the bed, the CNA did not have two people to assist with bed mobility was reviewed with the DON. The care plan had not been followed by the CNA during bed mobility. The DON reported that they completed education with the CNA for not following the care plan and then completed education with all the CNAs. The DON reported they did a sweep of all residents bed mobility and care plans reviewed and updated as needed. The DON reported that CNAs do a room to room report between shifts and update on any changes and stated, The need to look at the care plan for any changes, it could change at any time. The DON reported they had another resident with a fall and stated, The CNA did follow care (plan) and stated, We did audits and made sure we were compliant with it. The Administrator presented the corrective action plan regarding Resident 128's fall on 6/18/25 when the care plan had not been followed during bed mobility with two persons assist. The facility attained and maintained compliance for F689 with a compliance date on 6/25/25.1.) Resident A (R128) was assessed by the nurse manager on 6/19 and no acute injuries were noted. All residents have the potential to be affected.2.) A one time review of residents bed mobility and fall care plans were reviewed on 6/19 by the nurse managers to ensure they were appropriate and were updated as needed. Nursing staff were re-educated on bed mobility. All residents reviewed for bed mobility as one time audit on 6/19/25.Education completed on 6/20/25 with the Topic: Please read and follow careplans for all residents. Follow bed mobility careplans and Kardexs (care guides), with signed signatures of CNAs and Performance Education for CNA DD on 6/20/25.3.) System change: Bed mobility will be reviewed for all new admissions and quarterly with MDS and quarterly as needed.4.) DON/Designee will review 5 residents weekly x 6 to ensure that bed mobility is appropriate and followed per care plan. Any nonadherence will result in 1:1 education. All audits will be reviewed with the QA committee. Audits completed on 7/3/25, 7/10/25, 7/17/25, 7/24/25, 7/31/25 and 8/7/25.Date of compliance of the plan of correction: 6/25/25. The State Surveyor verified the documentation provided by the facility and conducted interviews with facility staff regarding following care planned interventions and staff were knowledgeable about the facility policies. Other Residents were reviewed for falls and noncompliance was not identified with F-689.

Based on interview and record review the facility failed to ensure nurses completed yearly competencies and training for 3 of 5 nurses, reviewed for education and competencies, resulting in the potential for nurses to lack the necessary skills and qualifications to adequately care for the needs of the residentsFacility Sufficient and Competent Nurse Staffing On 9/24/2025 at 2:30 PM, during an interview with Staff Education Nurse M she said the nurses had a 2-day classroom orientation where they completed online computer training and then they were assigned to a preceptor on the nursing units and were to complete competencies. Nurse M was asked if the staff completed hands on competencies and she said she went over Personal Protection Equipment/PPE's, Hand Hygiene, electronic medical record/emr documentation, blood glucose checks, bladder scanner, and the Ekg machine. She said IVs were reviewed with the Nurse and they verbalized back the process. On 9/24/2025 at 3:00 PM, Human Resources/HR Manager X was asked for education files for Nurses V and W. A record review of the education files for Nurses V and W revealed the Nurse Skill/Competencies Assessment form revised 3/25, had 58 competency check off items listed. It did not specify whether a nurse was an RN or LPN. There was a category for Assessment and under Assessment Satisfactory and Unsatisfactory were listed. Each Nurse V and W placed their initials next to the items completed under the Satisfactory category. There was no indication another nurse observed their competency and deemed them competent.Nurse V's Nurse skills/Competencies Assessment was checked in the Annual box. She initialed and signed that she completed all of her orientation hands on competency skills on 6/10/2025 except for Trach care, Suctioning- trach/oral/pharyngeal, C-Pap/BiPap, and Insertion of G-tube, they were not checked off. Staff Education Nurse E signed the document on 6/10/2025, but the Evaluator signature box was empty.Nurse W's Nurse skills/Competencies Assessment was not identified as Initial/New hire, Annual, or Other; each box was blank. Nurse W initialed and signed that she completed all of the hands-on competency training in one day on 5/30/2025, except for Trach care, it was left blank. Nurse E signed the document on 6/2/2025 as the Evaluator 2 days later.On further review of the Nurse Skills/Competencies Assessment form it was noted there was an entry for IV medication, IV Insertion (RN), IV administration- label, hang, IVP, IV documentation, and IV dressing change. There was no competency for maintenance of the IV line. There was no competency for Central Lines including PICC/Peripherally Inserted Central Catheter's.The entries for PPE and Hand Hygiene were marked as completed by Nurses V and W; and there was no document confirming an in-person hands on competency for each had been completed. On 9/25/2025 at 11:28 AM, Assistant Director of Nursing AA was interviewed about nursing orientation. She said it started with a 2-day computer training and then they would be assigned to the floor to complete competencies. At this time, competencies for Nurses T, U and G were requested. On 9/25/2025 at 11:40 AM, the Administrator and Corporate Nurse E were interviewed related to the nurses V and W checking themselves off as Satisfactory on their competencies. The Competency forms were reviewed for Nurses V, and W. The Nurses initialed they satisfactorily completed the competencies and then signed and dated it was done. There were no specific dates when each item was completed; only when the entire competency was completed and then the Staff Education Nurse signed the form. The Administrator and Corporate Nurse E were asked how it was possible for a Nurse to say they performed a skill/task Satisfactory and also to complete all of the skills in one day. They were asked if orientation was one day on the floor and they said it was not. There was no explanation as to why the nurses were checking themselves off as Satisfactory on their competencies. On 9/25/2025 at 1:50 PM, Human Resources/HR Manager X was observed in her office with Nurse G who was sitting at the HR Manager's desk. The Human Resources Manager was heard asking Nurse G to complete and sign her yearly competency because HR X couldn't find one in the Nurses education file. Nurse G was observed to have a blank copy of a Nurse Skills/Competencies Assessment form in front of her. Upon entering the room, this Surveyor asked Nurse G how long she had worked at the facility and she said 3 years. HR X was asked if there were any competencies in Nurse G's file and she stated, No. The Administrator entered the office and said they were also looking in the Staff development/education office for more competencies. On 9/25/2025 at 3:45 PM a competency for Nurse G was identified as being located by the Administrator. On 9/26/2025 at 9:30 AM, the Director of Nursing said there was no staffing policy. A review of the Facility Assessment dated revised 7/1/2025 by the Administrator identified the following: Purpose: The Facility assessment is a complete review of internal human and physical resources required by the facility to care for residents competently during day to day and emergency operations. There are three components to the review: 1. Resident profile. 2. Services and care offered. 3. Facility resources needed to provide competent care for residents, including staff, staffing plan, staff training/education and competencies, education and training. Nursing Services: The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. A facility must develop, implement, and maintain an effective training program for all new and existing staff.

Based on observation, interview and record review the facility failed to store and handle medications in accordance with acceptable pharmaceutical standards of practice: 1) for 2 of 3 medication rooms 2) ensure medication refrigerators were clean, and 3) ensure medications were stored to professional standards of practice, including vaccinations, resulting in the potential for contamination of medications, incorrect administration of medications, a lack of therapeutic benefits necessary to promote healing for residents, increase the potential for adverse effects. Facility Medication Storage and Labeling: On [DATE] at 9:28 AM, during a review of the South over-the-counter medication and supplies storage room with Assistant Director of Nursing/ADON AA, several expired items were identified: Multiple packets of A&D ointment, triple antibiotic and bacitracin all dated 5/2025. In addition, there were gauze dressings dated 12/2024. Nurse AA said she would remove and discard the items. Observed on several different shelves and supply bins were lancet devices mixed with unrelated items. It appeared they spilled into multiple different boxes and bins. Nurse AA said they should not have been there and needed to be picked up. On [DATE] at 9:43 AM a review of the South medication room for prescription medications with ADON AA identified a medication refrigerator under the counter. The refrigerator was observed to have spilled items on the top edge and inside bottom areas. In addition, the refrigerator was stacked full inside with a majority of vaccinations (Influenza, Pneumonia and several others). Upon touching the outside box of an Influenza vaccination, it felt slightly damp. The refrigerator was 40 degrees Fahrenheit, but it was unclear what the temperature inside the large stacks of vaccinations were. The refrigerator was very full. On [DATE] at 10:05 AM, a review of the North medication room with ADON AA it was observed the countertop under the cabinets and over the refrigerator was covered in sanding dust. It appeared holes in the wall were filled and sanded and debris was left on the counter covering items on the counter; ADON AA said she would make sure it was cleaned up. Upon review of the refrigerator, it was noted to have only a few items stored there. ADON AA said they might store some of the vaccinations in the refrigerator to alleviate the amount in the South hall medication room refrigerator. On [DATE] at 10:51 AM, Corporate Clinical Nurse E was interviewed related to the medication storage issues, including the South hall medication room refrigerator that was full with vaccinations, she said they needed another refrigerator. On [DATE] at 2:45 PM, ADON AA said some of the vaccinations had been moved from the South Hall medication room refrigerator to the North Hall medication refrigerator, but they were still looking at obtaining a new refrigerator. On [DATE] at 11:30 AM, Maintenance Director C was interviewed and said, he had corrected the issue with construction dust on the surfaces in the North Medication room and it should not have happened. On [DATE] at 9:47 AM, an observation was made during medication administration observation with Nurse GG giving Resident 144 their medication. An observation was made of two boxes with a prescription label and a small container with a prescription label on it. The items were on a shelf next to the Resident's bed. The Nurse was asked about the items. Upon inspection the Nurse indicated it was lidocaine gel and nystatin powder for Resident 144. The Nurse reported that it should not be left out of the medication cupboard and had opened the medication cabinet in the room with a key and then locked the medication in. On [DATE] at 11:40 AM, an interview was conducted with the Assistant Director of Nursing (ADON) AA regarding medication storage. The ADON was asked about storage of topical creams, ointments and treatments stored with oral medication. The ADON reported topical medication can be stored in a separate box, on a separate shelf, or in the original box/bag, the medication could then be stored with the oral medication. The ADON reported that a box or bag would be a barrier between the oral medication and the other routes. An observation was made with the ADON of Resident 144's medication cupboard in the room. The nystatin powder was not in a bag or box and was positioned next to oral medication. The ADON reported the nystatin powder should not be next to the oral medication. When asked about the medication at the bedside, the ADON reported that medication was to be stored in the locked area. On [DATE] at 12:15 PM, an observation was made in Resident 24's room with ADON AA. An observation was made of Voltaren gel (a topical nonsteroidal anti-inflammatory drug often used to relieve joint pain associated with osteoarthritis) on the counter of the sink near the Resident's bed, two containers, and one container across the room on a counter space. The ADON stated, We can't have medication that is not locked, and explained to the Resident, who was in the room at the time and expressed it was his own personal gel, that they would get him a lock box to keep it safe. On [DATE] at 3:09 PM, the concern of storage of medication was reviewed with the Director of Nursing (DON). The DON indicated that the medication cannot be left out and the plan for Resident 24 was to care plan for it (Voltaren gel), get a lock box and assessment to do the gel himself.

Based on observation, interview, and record review, the facility failed to provide palatable food products and meet residents' food preferences, for 7 residents (24, 61, 72, 74, 89, 121 and 143) of 7 residents reviewed for food and choices and a Confidential Group of Residents, resulting in residents' feelings of frustration and anger. Resident #61 (R61) A review of R61's medical record revealed an admission into the facility on 9/2/25 with diagnoses that included cystitis, heart failure, diabetes, and heart disease. A review of R61's Minimum Data Set assessment revealed a Brief Interview of Mental Status score of 9/15 that indicated moderately impaired cognition, and the Resident used a wheelchair for mobility. On 9/24/25 at 9:46 AM, Resident 61 was observed in his room, seated in a wheelchair. The Resident was interviewed, answered questions and engaged in conversation. The Resident was asked about any concerns he had about his care at the facility and was asked about any issues with the food served. The Resident stated, Breakfast this morning was not cooked all the way through with the sausages. It was cooked on one side; it was half cooked. It was obviously not cooked all the way, and reported his wife had the same issue. When asked if the sausage was warm, the Resident indicated it was warm, but it was pink on the inside and expressed concern about getting sick from eating undercooked meat. On 09/23/2025 at 11:56 AM until ~(approximately)12:28 PM During dining observation, R24 was served his meal without silverware and had to request the staff to supply some. A review of R24's meal ticket (#309) revealed, 1 Cottage cheese (#8 scoop) was to be served and was observed to be missing from the meal. When R24 was asked about his meal and the cottage cheese he stated, I guess I just don't get that. According to a review of R24's medical record, the resident was admitted to the facility on [DATE] for skilled nursing care related to diabetic ketoacidosis (DKA) (a buildup of ketones in the blood caused by elevated blood sugar making the blood acidic), weakness and IV Vancomycin infusion (42 days remaining on IV). R24's minimum data set (MDS) record revealed Brief Interview of Mental status (BIMs) score of 12/15 indicated the resident had moderately impaired cognition. Medical diagnosis included: Sepsis (the bodies extreme response to infection), Methicillin Resistant Staphylococcus Aureus (MRSA) infection (bacteria that is resistant to many antibiotics, including methicillin), diabetes mellitis type 2, calculus of kidney (kidney stones), Heart failure, acute and sub-acute infective endocarditis. A review of R24's Kardex (resident care guide) revealed, Provide diet per physician order; regular diet, regular texture, thin liquids; high protein food items added to meal ticket to promote wound healing; low sodium/DM modified diet; supplements as ordered to promote wound healing. On 09/23/2025 at 11:56 AM until ~12:28 during dining observation, R72 was served her meal from the opposite side of the table by CNA I. R72 picked up a piece of bread form the tray, and held it in her hand, and stated, Oh bread; do I have any butter? while turning to her left and right. The resident seated next to her replied, You do not, but I have some and handed butter to R72. A review of R72's lunch ticket (#349) revealed, 1 French Fries (1/2 cup) and 1 butter (1 each) were to be served, and the ticket listed an alert: Blind- describe meal to resident., which was highlighted in yellow. Observed on R72's plate was rice (not listed on ticket) and missing butter. According to a review of R72's medical record, the resident was admitted to the facility 08/26/2025 for skilled nursing care related to a fracture of the left femur, diabetes mellitis type 2 (insulin resistance causing elevated blood sugar) and chronic obstructive pulmonary disease. A review of R72's Minimum Data Set (MDS) record revealed a Brief Interview of Mental Status (BIMS) score of 14 out of 15, indicating the resident was cognitively intact. Additional medical diagnoses included glaucoma (impaired vision) and anxiety. A review of R72's care plan revealed: Focus: Alteration in nutritional status related to weakness and debility . Guest at risk for weight changes related to fluid status shifts, edema, and diuretic therapy prefers to eat with her hands & wears her own clothing protector; Date Initiated: 09/04/2025 with an Intervention: Provide diet per physician order; Regular diet, regular texture, thin liquids, low sodium/DM (diabetes) modified, guest blind- describe meal to guest; Date Initiated: 08/26/2025 Revision on: 08/29/2025. A review of R72's Kardex (resident care guide) revealed: Eating and Nutrition: Provide diet per physician order; Regular diet, regular texture, thin liquids low sodium/DM modified; guest blind- describe meal to guest. On 09/23/2025 at 11:56 AM until ~12:28 during dining observation, R89 was served a meal that included her entrée' and 2 bowls, one with broccoli and cheese and one with tomato soup. A review of R89's meal ticket (#40) revealed, neither requested soup. R 89's meal ticket further revealed, 1 Cottage cheese (#8 scoop) was to be served and was observed to be missing from the meal. When R89 was asked about her meal she stated, I don't know why I got two different soups and said that she did not know where her cottage cheese was, she stated I guess this is what I am getting. According to a review of R89's medical record, the resident was admitted to the facility on [DATE] for nursing care. R89's Brief Interview of Mental status (BIMs) score of 6/15 indicated the resident was severely cognitively impaired, needed some assistance with care and was independent with eating. Medical diagnosis included: Atherosclerotic heart disease (ASHD), Atrial Fibrillation (irregular heart rhythm), non-Alzheimer's dementia, and depression. A review of the physician orders for Resident #89 revealed an order for a Regular diet, Regular Texture, thin consistency (fluids). On 09/24/2025 at 1:48 PM, during an interview with R121 she said her lunch was good but explained it was not hot. She said she eats in her room and does not go to the dining area. On 09/24/2025 at 8:27 AM, during a follow up interview with R121 about how breakfast was on this day, she said it tasted ok, but it was lukewarm. R121 further explained that at least half her meals are served that way. She reports that she has let the staff know and that it is still 50 % of the time. According to a review of R121's medical record, the resident was admitted to the facility on [DATE] for nursing care related to a fracture of her right humerous (arm), fracture of T11-T12 spine. R121's Brief Interview of Mental status (BIMs) score of 9/15 indicated the resident was moderately cognitively impaired. Medical diagnosis included: chronic obstructive pulmonary disease (COPD), diabetes mellitis type 2, Aphasia related to cerebral infarct. A review of R121's Kardex revealed, Eating and nutrition. Provide diet per physician order; regular diet, regular texture, thin liquids; DM/low sodium modified. A review of R121's care plan revealed: Focus: Risk for falls r/t weakness and debility; interventions: Encourage good nutrition and hydration in order to promote healthier skin. Focus: Alteration in nutritional status related to weakness and debility; interventions: Honor advance directives related to nutrition/hydration; Honor food preference. On 09/24/2025 at 1:14 PM, during an interview with R143 she reported that she had just vomited. R 143 explained that she had not felt well since breakfast and reported I had under cooked sausage, she said it was not done all the way and that she had eaten half of it when she noted the middle was not cooked all the way. R143 further explained that she had told this to CNA H. R143 reported that when she had shown CNA H the sausage, that CNA H agreed the sausage did not look fully cooked. R143 continued to explain that she attempted to eat lunch and had hoped that might calm her nausea. R143 reported that when she uncovered her fruit there were fruit flies present, and she was unable to eat after that. R143 further reported that last week, she received her meal tray and that she found a paper clip, in her fruit cup. R143 said that she was in food service before, so she knew the challenges. She stated, I asked to talk to the kitchen manager and said that Kitchen Managers (2) came and talked to her. She said she explained to them that, If the paperclip got into the disposal of the kitchen, it could cause a lot of damage, and think what it could do to my body. R143 said that they apologized to her. According to a review of R143's medical record, the resident was admitted to the facility on [DATE] for skilled nursing care related to left knee replacement surgery. A review of R143's Minimum Data Set (MDS) record revealed a Brief Interview of Mental Status (BIMs) score of 14 out of 15, indicating the resident was cognitively intact. Medical diagnosis included diabetes mellitis type 2, hypertension, unspecified heart failure, and chronic kidney disease stage 3 (mild to moderate damage to kidneys). On 09/24/2025 at 1:27 PM, CNA H was asked about R143's breakfast tray (on 09/24/2025) and if she observed the sausage that was served, and she agreed that she had. CNA H was asked if she had agreed with R143 that her sausage was underdone, and she replied, yes. CNA H further stated, all of my residents sausage looked that way at breakfast. A review of R143's care plan revealed: Focus: .has impairment to skin integrity r/t fragile integument impaired mobility. ; intervention: Encourage good nutrition and hydration in order to promote healthier skin. Focus: Alteration in nutritional status related to weakness and debility.; intervention: Honor advance directives related to nutrition/hydration; Honor food preference; Provide diet per physician order; regular diet, regular texture, thin liquids DM modified. On 09/24/2025 at ~2:30 PM, during a meeting with confidential group of residents, it was revealed that there was a consensus of the residents present that meals being served to residents that dine in their rooms are being served colder than was desired. Residents reporting that, Breakfast is the worst, with the consensus that most residents eat breakfast in their rooms and not the dining room. Other resident concerns that were related to food and service included: My oatmeal is like soup before I ever put anything in it. The print is small on the menus given out. Not enough variety in the menu On 9/25/2025 at 3:07 PM to ~(approximately) 03:30 PM, during an interview with Kitchen Manager A and Culinary Specialist B, they were asked if residents had concerns about the temperature of the food. Kitchen Manager A said they did at times and if a resident had concerns, they would talk to the resident. The Kitchen Manager A said there was a food committee once a month and usually 10-15 residents attended and sometimes, they mentioned cold food. When asked specifically about resident concerns about the sausage served on 09/24/2025 during breakfast service, Culinary Specialist B stated, it temped in the kitchen. Kitchen Manager A and Culinary Specialist B were asked about the resident reported concern over finding a paperclip in her fruit last week, Culinary Specialist B responded, we talked to a resident, I don't recall which one or what was in the food she further explained, we did talk to them and they were ok. When Culinary Specialist B was asked how a paper clip would get into a resident's food from the kitchen service, she stated, we use paper clips on meal tickets. Both Kitchen Manager A and Culinary Specialist B report after speaking with the resident that they no longer used paper clips on meal tickets. According to a review of facilities resident council meeting minutes from May 29th, 2025: Dietary: guests asked to have dietary management present to discuss their food concerns in general. 'the chicken is overcooked. The potatoes in the potato salad were hard. The eggs are cooled too' . According to a review of facilities resident council meeting minutes from June 27th, 2025: Dietary: guests are still having concerns about dietary issues. The issues are that chicken is still being served overcooked, and eggs during breakfast are still being served cold. According to a review of facilities resident council meeting minutes from July 15th, 2025: . Resident states she must go to the kitchen to receive her breakfast tray if she wants to receive it at a decent time. According to a review of facilities resident council meeting minutes from August 29th, 2025: Dietary: No grievances needed to be filed with dietary, .ran food committee after council, she was able to answer questions and concerns. On 09/23/2025 at 11:56 AM until ~(approximately)12:28 PM During dining observation, R24 was served his meal without silverware and had to request the staff to supply some. A review of R24's meal ticket (#309) revealed, 1 Cottage cheese (#8 scoop) was to be served and was observed to be missing from the meal. When R24 was asked about his meal and the cottage cheese he stated, I guess I just don't get that. According to a review of R24's medical record, the resident was admitted to the facility on [DATE] for skilled nursing care related to diabetic ketoacidosis (DKA) (a buildup of ketones in the blood caused by elevated blood sugar making the blood acidic), weakness and IV Vancomycin infusion (42 days remaining on IV). R24's minimum data set (MDS) record revealed Brief Interview of Mental status (BIMs) score of 12/15 indicated the resident had moderately impaired cognition. Medical diagnosis included: Sepsis (the bodies extreme response to infection), Methicillin Resistant Staphylococcus Aureus (MRSA) infection (bacteria that is resistant to many antibiotics, including methicillin), diabetes mellitis type 2, calculus of kidney (kidney stones), Heart failure, acute and sub-acute infective endocarditis. A review of R24's Kardex (resident care guide) revealed, Provide diet per physician order; regular diet, regular texture, thin liquids; high protein food items added to meal ticket to promote wound healing; low sodium/DM modified diet; supplements as ordered to promote wound healing. On 09/23/2025 at 11:56 AM until ~12:28 during dining observation, R72 was served her meal from the opposite side of the table by CNA I. R72 picked up a piece of bread form the tray, and held it in her hand, and stated, Oh bread; do I have any butter? while turning to her left and right. The resident seated next to her replied, You do not, but I have some and handed butter to R72. A review of R72's lunch ticket (#349) revealed, 1 French Fries (1/2 cup) and 1 butter (1 each) were to be served, and the ticket listed an alert: Blind- describe meal to resident., which was highlighted in yellow. Observed on R72's plate was rice (not listed on ticket) and missing butter. According to a review of R72's medical record, the resident was admitted to the facility 08/26/2025 for skilled nursing care related to a fracture of the left femur, diabetes mellitis type 2 (insulin resistance causing elevated blood sugar) and chronic obstructive pulmonary disease. A review of R72's Minimum Data Set (MDS) record revealed a Brief Interview of Mental Status (BIMS) score of 14 out of 15, indicating the resident was cognitively intact. Additional medical diagnoses included glaucoma (impaired vision) and anxiety. A review of R72's care plan revealed: Focus: Alteration in nutritional status related to weakness and debility . Guest at risk for weight changes related to fluid status shifts, edema, and diuretic therapy prefers to eat with her hands & wears her own clothing protector; Date Initiated: 09/04/2025 with an Intervention: Provide diet per physician order; Regular diet, regular texture, thin liquids, low sodium/DM (diabetes) modified, guest blind- describe meal to guest; Date Initiated: 08/26/2025 Revision on: 08/29/2025. A review of R72's Kardex (resident care guide) revealed: Eating and Nutrition: Provide diet per physician order; Regular diet, regular texture, thin liquids low sodium/DM modified; guest blind- describe meal to guest. On 09/23/2025 at 11:56 AM until ~12:28 during dining observation, R89 was served a meal that included her entrée' and 2 bowls, one with broccoli and cheese and one with tomato soup. A review of R89's meal ticket (#40) revealed, neither requested soup. R 89's meal ticket further revealed, 1 Cottage cheese (#8 scoop) was to be served and was observed to be missing from the meal. When R89 was asked about her meal she stated, I don't know why I got two different soups and said that she did not know where her cottage cheese was, she stated I guess this is what I am getting. According to a review of R89's medical record, the resident was admitted to the facility on [DATE] for nursing care. R89's Brief Interview of Mental status (BIMs) score of 6/15 indicated the resident was severely cognitively impaired, needed some assistance with care and was independent with eating. Medical diagnosis included: Atherosclerotic heart disease (ASHD), Atrial Fibrillation (irregular heart rhythm), non-Alzheimer's dementia, and depression. A review of the physician orders for Resident #89 revealed an order for a Regular diet, Regular Texture, thin consistency (fluids). On 09/24/2025 at 1:48 PM, during an interview with R121 she said her lunch was good but explained it was not hot. She said she eats in her room and does not go to the dining area. On 09/24/2025 at 8:27 AM, during a follow up interview with R121 about how breakfast was on this day, she said it tasted ok, but it was lukewarm. R121 further explained that at least half her meals are served that way. She reports that she has let the staff know and that it is still 50 % of the time. According to a review of R121's medical record, the resident was admitted to the facility on [DATE] for nursing care related to a fracture of her right humerous (arm), fracture of T11-T12 spine. R121's Brief Interview of Mental status (BIMs) score of 9/15 indicated the resident was moderately cognitively impaired. Medical diagnosis included: chronic obstructive pulmonary disease (COPD), diabetes mellitis type 2, Aphasia related to cerebral infarct. A review of R121's Kardex revealed, Eating and nutrition. Provide diet per physician order; regular diet, regular texture, thin liquids; DM/low sodium modified. A review of R121's care plan revealed: Focus: Risk for falls r/t weakness and debility; interventions: Encourage good nutrition and hydration in order to promote healthier skin. Focus: Alteration in nutritional status related to weakness and debility; interventions: Honor advance directives related to nutrition/hydration; Honor food preference. On 09/24/2025 at 1:14 PM, during an interview with R143 she reported that she had just vomited. R 143 explained that she had not felt well since breakfast and reported I had under cooked sausage, she said it was not done all the way and that she had eaten half of it when she noted the middle was not cooked all the way. R143 further explained that she had told this to CNA H. R143 reported that when she had shown CNA H the sausage, that CNA H agreed the sausage did not look fully cooked. R143 continued to explain that she attempted to eat lunch and had hoped that might calm her nausea. R143 reported that when she uncovered her fruit there were fruit flies present, and she was unable to eat after that. R143 further reported that last week, she received her meal tray and that she found a paper clip, in her fruit cup. R143 said that she was in food service before, so she knew the challenges. She stated, I asked to talk to the kitchen manager and said that Kitchen Managers (2) came and talked to her. She said she explained to them that, If the paperclip got into the disposal of the kitchen, it could cause a lot of damage, and think what it could do to my body. R143 said that they apologized to her. According to a review of R143's medical record, the resident was admitted to the facility on [DATE] for skilled nursing care related to left knee replacement surgery. A review of R143's Minimum Data Set (MDS) record revealed a Brief Interview of Mental Status (BIMs) score of 14 out of 15, indicating the resident was cognitively intact. Medical diagnosis included diabetes mellitis type 2, hypertension, unspecified heart failure, and chronic kidney disease stage 3 (mild to moderate damage to kidneys). On 09/24/2025 at 1:27 PM, CNA H was asked about R143's breakfast tray (on 09/24/2025) and if she observed the sausage that was served, and she agreed that she had. CNA H was asked if she had agreed with R143 that her sausage was underdone, and she replied, yes. CNA H further stated, all of my residents sausage looked that way at breakfast. A review of R143's care plan revealed: Focus: .has impairment to skin integrity r/t fragile integument impaired mobility. ; intervention: Encourage good nutrition and hydration in order to promote healthier skin. Focus: Alteration in nutritional status related to weakness and debility.; intervention: Honor advance directives related to nutrition/hydration; Honor food preference; Provide diet per physician order; regular diet, regular texture, thin liquids DM modified. On 09/24/2025 at ~2:30 PM, during a meeting with confidential group of residents, it was revealed that there was a consensus of the residents present that meals being served to residents that dine in their rooms are being served colder than was desired. Residents reporting that, Breakfast is the worst, with the consensus that most residents eat breakfast in their rooms and not the dining room. Other resident concerns that were related to food and service included: My oatmeal is like soup before I ever put anything in it. The print is small on the menus given out. Not enough variety in the menu On 9/25/2025 at 3:07 PM to ~(approximately) 03:30 PM, during an interview with Kitchen Manager A and Culinary Specialist B, they were asked if residents had concerns about the temperature of the food. Kitchen Manager A said they did at times and if a resident had concerns, they would talk to the resident. The Kitchen Manager A said there was a food committee once a month and usually 10-15 residents attended and sometimes, they mentioned cold food. When asked specifically about resident concerns about the sausage served on 09/24/2025 during breakfast service, Culinary Specialist B stated, it temped in the kitchen. Kitchen Manager A and Culinary Specialist B were asked about the resident reported concern over finding a paperclip in her fruit last week, Culinary Specialist B responded, we talked to a resident, I don't recall which one or what was in the food she further explained, we did talk to them and they were ok. When Culinary Specialist B was asked how a paper clip would get into a resident's food from the kitchen service, she stated, we use paper clips on meal tickets. Both Kitchen Manager A and Culinary Specialist B report after speaking with the resident that they no longer used paper clips on meal tickets. According to a review of facilities resident council meeting minutes from May 29th, 2025: Dietary: guests asked to have dietary management present to discuss their food concerns in general. 'the chicken is overcooked. The potatoes in the potato salad were hard. The eggs are cooled too' . According to a review of facilities resident council meeting minutes from June 27th, 2025: Dietary: guests are still having concerns about dietary issues. The issues are that chicken is still being served overcooked, and eggs during breakfast are still being served cold. According to a review of facilities resident council meeting minutes from July 15th, 2025: . Resident states she must go to the kitchen to receive her breakfast tray if she wants to receive it at a decent time. According to a review of facilities resident council meeting minutes from August 29th, 2025: Dietary: No grievances needed to be filed with dietary, .ran food committee after council, she was able to answer questions and concerns. Resident #74 Food On 9/23/2025 at 10:57 AM, Resident #74 was observed sitting in her room and stated, This morning I got my breakfast, and it was cold. When asked how the resident's other meals were she stated, They serve soup and it's not bad, but some of the meals are bad. I bought peanut butter yesterday so I could eat something. A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #74 was admitted to the facility on [DATE] with diagnoses: Heart disease, COPD, anxiety, depression, and GERD (gastroesophageal reflux disease). The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 14/15 and the resident needed some assistance with care and was independent with eating. A review of the physician orders for Resident #74 revealed an order for a Regular diet, Regular Texture, thin consistency (fluids), start date 9/22/2025 and revised 9/23/2025. A review of the Care Plans for Resident #74 identified the following: Alteration in nutritional status related to co-morbidities. date initiated 1/19/2025 and revised 9/15/2025 with Interventions including: Honor food preference, date initiated 1/19/2024. On 9/25/2025 at 3:07 PM, during an interview with Kitchen Manager A and Culinary Specialist B, they were asked if residents had concerns about the temperature of the food. Kitchen Manager A said they did at times and if a resident had concerns they would talk to the resident. The Kitchen Manager A said there was a food committee once a month and usually 10-15 residents attended and sometimes they mentioned cold food.

Based on observation, interview, and record review, the facility failed to ensure that appropriate communication between the hospice agency and the facility was accessible in a timely manner for one resident (Resident #39) of the three sampled residents reviewed for hospice care.Findings include: Resident #39 (R39): On 09/23/25 at approximately 11:45 AM, during the initial tour, the surveyor observed R39 with a caregiver and verified that she was the hospice nurse caring for R39 today. However, upon entering the facility at 10:00 AM, the CMS Form 802 submitted to the surveyors indicated that Resident R39 was not coded as receiving hospice care services. A review of records on 9/24/25 at 11:30 AM revealed that R39 was [AGE] years old, admitted to the facility on [DATE] with the diagnosis of Senile Degeneration of Brain, Transient Ischemic Attack (TIA), Vascular Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety in addition to other diagnoses. R39' Brief interview of Mental Status BIMS Score dated 6/26/25 was 5/15. A score of 5 means the person's cognition is severely impaired. R39's Minimum Data Set (MDS) Section GG dated 6/18/25 revealed that R39 required assistance to perform most of the Activities of Daily Living (ADLs), particularly incontinence care, toileting, bed mobility, and transfers.On 9/24/25 at 1:08 PM, an interview with the Social Service staff (Staff CC) was conducted. The Staff CC confirmed that R39 enrolled in hospice care services on 9/19/25. When Staff CC was asked why R39 was not coded in the 802, it reflected R39's hospice status. Staff CC indicated it was the MDS Nurse's responsibility to make changes in the CMS-802 Form. Staff CC explained she sends the referral to the Hospice agency via email, and usually the rest is taken care of by the facility. She does not follow up with the rest. Staff CC verified that there was no hospice agreement, no initial hospice evaluation or care guide in the EMR, and no hospice visit notes or schedule for hospice care were found in R39's current record. The Administrator admitted that it was an error on their part and that #39 was enrolled in hospice care on 9/19/25. When queried on what happened to the assessments, visitation notes, and the enrollment form from hospice?During the survey on 9/23/25 until 09/25/2025 at 1:36 PM, R39's clinical record was reviewed. It was verified and validated that no hospice agreement/contract in Resident#39, the EMR (Electronic Medical Record), no initial assessment/Hospice evaluation, no hospice progress notes, and no record of care services provided for R39 was found. There was no schedule of hospice visits by the nurse, hospice aide, or chaplain. Confirmed by the social services (Staff CC) on 09/24/25 at 1:08 PM, the Staff CC revealed that the hospice record would be found in the Electronic Medical Record (EMR). That's the only place to put the hospice visits, assessment, and the enrollment packet. On September 25, 2025, at 1:40 PM, the Director of Nursing (DON) was queried about why there are no hospice contract agreement notes scanned or recorded in the resident's file. The DON said to the surveyor, I will find out for you. On 9/25/25 at 1:40 PM, after R39's record review, no hospice service notes, no hospice plan of care and services from the hospice agency, and no schedule of hospice visits were found on record.On 9/25/25, the surveyor requested a facility binder for all residents listed as receiving hospice care services but was reminded by a staff member that they don't keep a hospice binder or post a hospice calendar. Everything is electronically scanned or entered in each of the residents' records. An attempt to verify with the Facility Minimum Data Set (MDS) staff on 9/26/25 at 1:30 PM. No Facility MDS was available to query regarding the error in coding R39 as hospice in Form 802. The Fcility MDS staff were available to explain why R39 was not accurately coded as receiving Hospice Care.On 9/26/25 at 12:04 PM, a call was made to the Hospice Agency to verify the absence of a contract on file, as well as the lack of progress notes and a service record in R39's chart. However, there was no reply at the time the survey exited.The Administrator validated on 9/26/25 at 11:00 AM that it was an error on their part and that R39 was enrolled in hospice care on 9/19/25. When queried, what happened to the assessments, visitation notes, and the enrollment form from hospice? It was not in R39's clinical record in the EMR, but the surveyors were assured that all the hospice visits and progress notes had been scanned and entered on 9/26/26 at 11:30 AM, including the signed Hospice Agreement.All of R39's hospice visit notes dated 9/19/25, 9/20/25, 9/22/25, 9/23/25, 9/24/25, and 9/25//25 were scanned and uploaded into R39's EMR on 9/26/25 at approximately 11:30 AM, The Administrator notified the surveyor that the Hospice Service Agreement dated 9/19/25 was scanned and uploaded, along with other pertinent hospice visit notes.The Palliative/ End of Care Policy was reviewed on 9/26/25 at 1:45 PM. It specified: . The physician will order a hospice evaluation as indicated: for example , by resident or family request. If hospice becomes involved in the care of the resident:a. The facility and hospice will establish a coordinated plan of care that reflects and supports the hospice policy,b. The plan of care will include directives for managing pain and will be revised and updated as the resident's status changes.c. The facility and hospice will identify the specific services that will be provided by each entity, and this information will be communicated in the plan of care.d. The hospice retains overall responsibility for directing and coordinating the plan of care related to the terminal illnesses and related conditions f. The hospice and facility will communicate with each other when any changes are indicated or made to the plan of care .5 Nursing staff will implement comfort measures identified in the comprehensive care plan .

This Citation pertains to Intake Number MI00152519. Based on interviews and record review, the facility failed to ensure that the GLP-1 (Glucagon-like peptide-1) injection medication was protected from staff misappropriation for one resident (Resident #601) of three residents reviewed for misappropriation of medication. Findings include: According to Cleveland Clinic, myclevelandclinic.org, dated 7/3/23, the prescribed GLP-1 medication states, GLP Agonists are medications that help lower blood sugar levels and promote weight loss .They mainly help manage blood sugar levels in people with Type 2 diabetes. Some GLP-1 agonists can help treat obesity. Resident #601 (R601): A review of R601's medical record conducted on 4/29/25 at 11:30 AM revealed an admission into the facility on [DATE], with the diagnosis of Type 2 Diabetes Mellitus, Chronic Kidney Failure, Heart Failure, and Obesity in addition to other diagnoses. R601 Physician's order for R601's Type 2 diabetes regimen revealed: Insulin Lispro Injection Solution-Humalog Injection Solution 100 units/ML inject 30 units subcutaneously three times a day (Injected as per sliding scale), Ozempic (1mg dose) subcutaneous solution pen-Injector 4mg/3 ml (Semaglutide) inject subcutaneously in the morning every Monday, Insulin Glargine Solution, 100 unit per ML (Inject 30 unit subcutaneously at bedtime). R601's daily blood sugar readings from 3/15/25 to 4/29/25 indicated that R601 remains stable and on her baseline. A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental Status (BIMS) score assessed on 3/25/2025, indicating a BIMS score of 11/15. A score of 11 indicates moderate impairment. This suggests the individual may need extra assistance with daily tasks and activities and may be experiencing cognitive decline. R601 Blood Sugar (BS) on 4/14/25 when the injection was found missing, R602 's Blood Sugar testing remained in her baseline, and the Medication Administration Record (MAR) revealed that R601 received Ozempic at 1700 (at 5:00 PM) instead of the order to be administered every Monday morning as ordered. R601 was interviewed on 4/29/25 at 2:00 PM. She was well groomed and in good affect, interacting with her husband in her room. She stated she was receiving excellent care at the facility, and she believed that her medications were given too soon and more than what she needed. She did not recall missing any of her medications and had no blood sugar complications during her stay. R601's Family interview on 4/29/25 at 2:05 PM revealed that he disagreed with R601's opinion regarding her insulin medication regimen. He expressed that as a caregiver at home, she was not receiving the same prescriptions that R601 had at home. He stated that She is getting less here. R601 's husband presented the surveyor with his home medication orders and gave the surveyor a copy to evaluate. The surveyor explained that the Physician's orders at the facility are the ones followed because he is the current attending Physician. The list you submit will be given to the Director of Nursing for reconciliation. R601's husband indicated that R601 is getting the care she needs and is looking forward to her returning home. The Director of Nursing (DON) was interviewed on 4/29/25 at 11:22 AM. She revealed that they went back to the staff who gave the last dose, and the video was installed in the secured med room, and found suspicious activity with one of the RNs who was not the nurse responsible for the insulin administration that day, taking the Ozempic Pens from the supplies. On the day of 4/7/25, the RN W was seen on video taking the two Ozempic pens. RN W at first denied taking them, but when the DON mentioned the video, Nurse W sobbed and admitted taking them. Nurse W admitted and returned the pens. She was terminated instantly by phone. We reported the incident to the local authorities and reported the incident to the state. The Facility Administrator was interviewed on 4/29/25 at 10:15 AM During the interview, she revealed that on 4/14/25, the nurse on duty could not locate R601's Ozempic inj due to the secured medication room refrigerator. She immediately reported after knowledge of the missing GLP-1 and search and investigation started. After a full investigation and a review of the video installed in the medication room, the administrator revealed that they reported the incident to the local police department, reported the case to the State of Michigan, and the Bureau of Health Professionals to report her actions. RN W took the Ozempic medication, admitted taking the Ozempic Pens, wrote a statement, and returned the pens to the facility. A review of the investigation report for R601 revealed the summary of the incident, which revealed the following: Facility Incident Report Incident Summary on April 14, 2025, the nurse supervisor was notified that missing medication from a guest's (R601) prescribed GLP-1 agonist medication, Ozempic (Semaglutide), from the secured medication refrigeration unit located in the North Team Room of the facility. The medication in question was ordered and stored per protocol in the team room's refrigeration unit designated for injectable, multi-use, and temperature-sensitive medications. A discrepancy was noted when the medication could not be located in the designated storage area during routine preparation for administration. Verification of medication administration record (MAR) and narcotic log entries related to the Ozempic pen in question. Interview with the last administering nurse, who affirmed that she had administered the medication per MAR on her assigned shift and returned the Ozempic pen to the medication refrigerator in accordance with facility protocol. Subsequent interview with a night shift RN who reported that the Ozempic was present in the refrigerator as of the early morning hours of Wednesday, April 9, narrowing the timeframe of disappearance. Video surveillance review security surveillance footage from the North Team Room camera was reviewed covering the timeframe from Monday, April 7, 2025, at 08:00 hours through Thursday, April 10, 2025, at 17:07 hours. The following actions were captured on camera: On Thursday, April 10, 2025, between 17:04 and 17:07, RN JW (Full name mentioned) is visibly observed entering the North Team Room and proceeding to the medication refrigeration unit. At approximately 17:04, RN JW is seen opening the refrigerator and removing two manufacturer-labeled Ozempic boxes. She is then observed withdrawing the injectable pen device from one of the boxes, obtaining corresponding injection needles, and placing the empty cardboard packaging back into the refrigerator, a behavior inconsistent with standard disposal procedures. Immediately thereafter, she removed the second Ozempic box from the refrigerator and exited the medication room with it in her possession at precisely 17:07. These actions were not contemporaneously documented in any medication administration record or shift count sheet. No corresponding guest MARs indicated a need for administration of the second dose, nor was there documentation of a medication return or disposal consistent with policy. Based on the findings of the internal review, which included: Video evidence demonstrating unauthorized removal of controlled medication; Lack of MAR or narcotic log entries justifying the dual removal the facility concludes that there is substantial and substantiated evidence suggesting diversion or misappropriation of a controlled injectable pharmaceutical by RN [NAME] Wartella on April 10, 2025. Immediate actions were taken to: Remove RN JW from active duty pending further investigation; call the local police department. Husband and resident notified. Initiate this mandatory report to [NAME] pursuant to regulatory obligations regarding suspected drug diversion by a licensed healthcare provider. Investigation Summary and Plan On April 14, 2025, the nurse supervisor was notified that missing medication from a guest's (R601) prescribed GLP-1 agonist, Ozempic (Semaglutide), from the secured medication refrigeration unit in the facility's North Med Room. After reviewing video surveillance that viewed RN JW removing medication, a call to RN JW took place in which she admitted to taking medication. > Police authorities were notified and arrived at the facility for investigation. > On 4/14/2025, RN JW admitted to taking medication and also arrived at the facility to return the medication. > The police officer NL (Fullname mentioned) arrested RN JW. > On April 14, 2025, the facility completed a one-time audit of guests prescribed GLP-1 agonist medication, Ozempic (Semaglutide), including antidiabetic medications, to ensure no other medications were missing. We also checked the blood sugar levels for the last seven days to ensure no abnormalities were noted. > On 4/14/25 and 4/15/25, a facility-wide education on System change: Ozempic and Like Medications will be locked and counted like narcotics and treated was conducted. The education was delivered by phone or live to all licensed and registered nurses. > A process change was implemented effective 4/14/2025: All GLP-1 agonist medications will follow the narcotic double lock protocol and sign-out process. > On April 17, 2025, RN JW was terminated. > The date of completion of the plan of correction was dated 4/17/2025. On 4/29/2025, the State Surveyor verified the documentation provided by the facility and conducted interviews with facility staff. During the interviews, staff reported that they had been educated on the facility's policy for abuse and misappropriation of medications, including reporting, and were knowledgeable about the facility's policies. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included the Investigation Summary and Plan, listed above. The facility was able to demonstrate monitoring of the corrective action and maintained compliance. The Compliance Date is 04/17/2025.

This Citation pertains to Intake Number MI00145400. Based on observation, interview and record review, the facility failed to provide a safe and monitored environment to prevent falls with injuries and fractures for one resident (Resident #30) of 2 residents reviewed for falls, resulting in Resident #30 having three falls with injuries and sustaining fractures with two of the falls. Findings Include: Resident #30: Accidents On 9/30/2024 at 11:01 AM, Resident #30 was observed in his room, lying in a low bed. The call light was in his hand. The resident said he fell in the hallway and once in the bathroom. He said he had hurt his arm and leg. A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #30 was initially admitted to the facility on [DATE] with diagnoses: Parkinsonism, arthritis, peripheral vascular disease, heart disease. The MDS Admission assessment dated [DATE] revealed the resident had severe cognitive decline with a Brief Interview for Mental Status (BIMS) score of 6/10 and had no upper or lower extremity limitation in range of motion. Resident #30 needed substantial-to-maximal assistance with all mobility. Fall on 06/07/2024: An Incident and Accident report dated 6/7/2024 said Resident #30 said, I walked into the hallway and fell in front of a door. A review of a Facility Reported Incident, dated 6/8/2024-6/17/2024, indicated that Resident #30 fell on [DATE] and reported that he was having pain in his right elbow. The resident said he had a fall and thought he broke his arm; his arm was assessed by the nurse to be slightly swollen and spongy. An x-ray was obtained and identified an acute fracture of the right olecranon (a bony prominence of the elbow). The resident was transferred to the emergency room and returned to the facility with a cast on his right arm. Per the facility investigation the incident was not witnessed by a staff member, but was witnessed by a visitor. A review of a Significant Change MDS assessment, dated 6/13/2024, indicated that the resident had fallen at the facility and suffered an injury. MDS section GG identified the resident to have Functional Limitation to one side of the upper extremity and both sides of the lower extremities. A review of the Care Plans for Resident #30 identified the following: Risk for falls (related to) Parkinson's, dementia, (osteoarthritis) of bilateral hips, atrial fibrillation, unsteady gait, and muscle weakness. Fall with hip (fracture) (status post hip surgical repair), date initiated 5/1/2024 and revised 9/17/2024 with Interventions: Geri chair in upright position, date initiated 6/8/2024 and revised 6/10/2024; Scoop mattress to bed, date initiated 6/8/2024. The interventions did not address that the resident was walking on his own in the hallway. Fall on 06/29/2024: A review of an Incident and Accident report for Resident #30, dated 6/29/2024, revealed the following: Another guest (resident's) family came to me in the hall and explained that (Resident #30) was on the floor. Guest was on the floor on his bottom in front of the easy chair. Leg of over-the-bed-table was wedged under the heating unit. Guest states he was getting up to answer the door. CENA (nurse aide) explained to him that he doesn't walk anymore. Guest replied 'Oh, yeah' . Guest is very confused . A review of the Care Plans for Resident #30 identified the following: Risk for falls (related to) Parkinson's, dementia, (osteoarthritis) of bilateral hips, atrial fibrillation, unsteady gait, and muscle weakness. Fall with hip (fracture) (status post hip surgical repair), date initiated 5/1/2024 and revised 9/17/2024 with Interventions: Leave room door open, date initiated 7/1/2024 and updated 8/29/2024. Fall on 09/13/2024: A review of the Progress Notes for Resident #30 identified the following: 9/13/2024 at 4:32 PM, . Guest observed on floor at the foot of his bed. Sitting on his right side . abrasion/carpet burn to right elbow area. Recommends that staff continues to place guest bed in lowest position. 9/13/2024 at 4:59 PM, Guest observed on floor at foot of his bed. Guest has a carpet burn to right anterior arm . 9/14/2024 at 10:57 AM Incident Note, . Guest had no complaints of pain at time of fall but later (complained) of left hip pain Left hip x-ray, results show positive for acute fracture, dr made aware of results and gave order to send to ER for further evaluation . Root Cause: guest observed prior to fall safely in wheelchair in room . Guest stood independently and was unable to maintain balance and had a fall . 9/17/2024 at 5:50 PM, Admission Summary, Guest arrived to facility by (ambulance) . via stretcher. Guest has a 16 fr patent foley (urinary catheter) . Guest has an auacel dressing to left hip surgical site . small red area to left knee . (complains of) pain when moving (left lower extremity) . A review of the Care Plans for Resident #30 identified the following: Risk for falls (related to) Parkinson's, dementia, (osteoarthritis) of bilateral hips, atrial fibrillation, unsteady gait, and muscle weakness. Fall with hip (fracture) (status post hip surgical repair), date initiated 5/1/2024 and revised 9/17/2024 with Interventions including: Encourage guest to participate in group activities, date initiated 9/13/2024. 1:1 activities, date initiated 9/182024; Bed in lowest position, date initiated 9/14/2024; Encourage family visits, 9/18/2024. Resident #30 was admitted to the facility on [DATE]. The basic interventions were not mentioned until the resident had fallen and injured himself numerous times. On 09/30/2024 at 11:08 AM, Nurse H was interviewed about Resident #30 and said she didn't normally work on his hall, but was today. When asked about fall prevention measures for Resident #30, she said she would have to check on it. On 10/1/2024 at 10:00 AM, Confidential Person O was interviewed about Resident #30 falling and suffering multiple injuries and fractures and said that the resident had a different chair previously and seemed to sit in it better. The Confidential Person said the resident looks uncomfortable at times. On 10/01/2024 at 10:26 AM, the Director of Nursing/DON was interviewed related to Resident #30's falls and reviewed the multiple incident reports of falls on 6/7/2024 when he fractured his right elbow; 6/29/2024 when he obtained an abrasion to the right arm that he previously injured and 9/13/2024 when he fractured his left hip. The DON was asked about the interventions to aid in preventing the resident from falling. Supervision of the resident was not identified as an intervention or an updated intervention. The DON said the facility had increased nursing staff overall in the building, as the Resident census had continuously increased throughout the year, but specific supervision and monitoring for Resident #30 was not addressed. The DON said the staffing on the resident's hall had not changed from prior to his falling. Reviewed the Care Plans for Resident #30 as several of the updated interventions after the 3rd fall on 9/13/2024, such as encourage group activities, were addressed in prior activities assessments after the resident was admitted on [DATE]. The interventions reviewed were not necessarily specific to the resident's falls. None of the falls were witnessed by staff and he was identified as at risk for falls and continued to fall and sustain serious injuries. A review of the facility Policy titled, Falls Reduction Program, origination date July 1, 2008 and revision date 9/25/2016, provided, Purpose: To provide a safe environment for residents, modify risk factors, and reduce risk of fall-related injury . Identify/analyze resident risk for fall .Implement and indicate individualized interventions on Care Plan/Kardex . Initiate safety interventions . Determine the need for ongoing assessments/interventions .

Based on interview and record review, the facility failed to employ a qualified social worker on a full-time basis to meet the psychosocial, mental, and behavioral health care needs of the residents. This deficient practice had the potential to affect all 124 residents that reside within the facility. Findings Include: On 10/1/2024 at 12:05 PM, an interview was conducted with Transitional Care Coordinator D regarding her role at the facility. Coordinator D explained while she does assist with social work roles, she is not a qualified Social Worker but is currently enrolled in a Bachelor of Social Work program. She shared a Social Worker from a sister facility does review assessments she completes and sends edits if needed. On 10/1/2024 at 1:15 PM, an interview was conducted with the Administrator regarding fulfilling their social worker position. The Administrator stated their Social Worker resigned with no notice on December 21, 2023. On August 29, 2024, a new social worker was hired with the start date of September 23, 2024, but she never showed up for orientation and informed the facility she accepted another position elsewhere. As of September 26, 2024, two social workers from sister facilities began splitting the full-time status at the facility and are in the building Monday to Thursday. On 10/1/2024 at approximately 4:40 PM, a review was completed of the facility's license which indicated they were certified for 128 beds. Review was completed of the job description for Director of Care Transitions it stated, .Education: Bachelor's degree in a human services field including, but not limited to: social work, sociology, special education, rehabilitation counseling, and psychology. Master's Degree Preferred . On 10/2/2024 at 11:50 AM, the Administrator shared they received a Medicaid Bed Count waiver beginning January 1, 2024, and ending June 30, 2024, which decreased their bed count to 116. The administrator provided the document for this writer to review that indicated on July 1, 2024 their bed count was back to 128 from 116.

Based on interview and record review, the facility failed to ensure that a comprehensive person-centered care plan was established for two residents (Resident #32, Resident #41) of twenty-five residents reviewed for care planning, resulting in Resident #32, a hemodialysis resident, to continue to gain weight with no updated care plan interventions and the likelihood for unmet care needs. Findings include: Record review of the facility 'Care Plans-Comprehensive' 2001 MED-PASS, Inc. (revised October 2010) policy revealed an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs is developed for each resident. Policy Interpretation and Implementation: 3.) Each resident's comprehensive care plan is designed to: incorporate identified problem areas, incorporate risk factors associated with identified problems. #5.) Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes Record review of the facility 'Policy: Obtaining Weights and Re-weight Policy' undated, revealed each individual's weight will be determined and documented upon admission to the facility. Procedure: 1.) Nursing will be responsible for the initial determination of each individual's weight. Subsequent measurements for weight will be documented on the appropriate designated form or tracker in the computer database. Weight will be documented on the individual assessment instrument (MDS) for nursing facilities), and in the medical nutrition therapy (MNT) assessment. Weight will be obtained weekly for 4 weeks after admission. Subsequent weights will be obtained monthly. unless physician orders or individual condition warrants frequent determinations. Re-weights will be done for a weight change of +/- (gain/loss) of 3# (pounds) for anyone under 100# pounds and for +/- (gain/loss) of 5# (pounds) for anyone 100 pounds and over. (2.) The Registered Dietitian (RD) or designee will be responsible for determining the desirable weight range Resident #32: Observation and interview on 09/30/24 at 10:03 AM with Resident #32, while the resident was seated at the edge of her bed, revealed a left upper arm hemodialysis graft with dressing in place. Resident #32 stated that she had been getting hemodialysis treatments for 3 years and goes to dialysis on Tuesdays-Thursdays and Saturdays. Observation of bedside table noted two glasses of beverages. Observation of Resident #32's lower extremities noted skin tightness and possible edema. Record review of Resident #32's medical diagnosis list revealed: acute and chronic Respiratory failure with hypoxia, hypertension, metabolic encephalopathy, falls, seizures, end stage renal disease, cerebral infarction, heart failure, type 2 diabetes, chronic obstructive pulmonary disease, anxiety, Gastrostomy tube, muscle wasting, dysphagia, cognitive communication deficit, mild cognitive impairment, insomnia, dependence on renal dialysis, pneumonia, and anemia. Record review of Resident #32's electronic medical record weight log revealed inconsistent weight monitoring: 9/5/2024 weight 160.8 Lbs. 9/10/2024 weight 166.3 Lbs. that was a gain of 5.5 pounds, no care plan intervention added. 9/12/2024 weight 166.1 Lbs. 9/14/2024 weight 172.9 that was a gain of 6.8 pounds, no care plan intervention added. 9/17/2024 weight 178.9 Lbs. was a gain of 6.0 pounds, no care plan intervention added. 9/19/2024 weight 182.8 Lbs. that was a gain of 3.9 pounds, no care plan intervention added. 9/21/2024 weight 189.9 Lbs. was a gain of 7.1 pounds, no care plan intervention added. The total weight gain in a 17-day period for Resident #32 who received hemodialysis treatment for renal failure was a total of 29.1 pounds. Record review of Resident #32's care plans, pages 1-18, revealed that the 'Alteration in nutritional status related to recent hospitalization , diabetes, heart failure, end stage renal disease and peg tube' initiated on 7/29/2024, with a revision on 7/30/2024 and 9/20/2024 of offer evening snack and then revised after the state surveyor inquired about weight gain on 10/2/2024 with updated intervention of 'No PM/HS (bedtime) water. An interview and record review on 10/02/24 at 08:44 AM with Registered Dietitian (RD) M of Resident #32's weight log revealed that Resident #32 was a hemodialysis resident that received treatment 3 days a week. The state surveyor inquired about Resident #32's estimated weight gain of about 6 pounds weekly, and her fluid status, how much was the resident drinking. The state surveyor and RD M discussed possible health crisis of fluid overload. The RD M stated that she did make the care provider (NP) aware, and each week notify the NP. Discussion of follow-up to the notifications and possible treatments were discussed. RD M stated weights for Resident #32 were taken from her post dialysis weights sent from the dialysis center and documented those in the medical record. RD M agreed that Resident #32 does have around a 6-pound gain weekly. In an interview on 10/02/24 at 10:39 AM, Registered Dietitian (RD) M stated that Resident #32 was aware of the fluid restrictions and that she is gaining weight. RD M stated that she spoke with the Resident #32 in regard to more account ability by the bedside water, we are just going to limit the water amounts and update her care plans. RD M stated that she did put a note in yesterday (10/1/2024) about the weight gain, the re-weigh we don't do because of the dialysis weights. Resident #41: Observation and interview on 10/01/24 at 08:17 AM with Resident #41 revealed that he had his gall bladder out and lost weight, but he thought that he should be gaining weight back. Observation of Resident #41 was noted to be lying in bed with a breakfast tray still at the bedside with most of the meal left on the plate. Record review of Resident #41's admission Minimum Data Set (MDS), date 6/25/2024, revealed an elderly male cognitively intact. Medical diagnoses: Medically complex conditions, anemia, coronary artery disease, hypertension, gastroesophageal reflux disease (GERD), benign prostatic hyperplasia (BPH), renal insufficiency, pneumonia, septicemia, diabetes, thyroid disorder, anxiety and depression. Section K: Swallowing/Nutritional Status- Weight 185, mechanically altered diet and therapeutic diet were noted. Record review of Resident #41's care plans, pages 1-24, revealed that the 'Alteration in nutritional status related to recent hospitalization , dysphagia, C. diff, pneumonia, diabetes, coronary artery disease, hypertension, chronic kidney disease stage 4, and anemia' initiated on 5/11/2024, with a revision on 8/29/2024 interventions added included: Provide diet as ordered 6/21/2024, Provide diet per physician order; mechanical soft texture, thin liquids, supplements as ordered 8/29/2024. Record review on 10/01/24 at 01:55 PM of Resident #41's weight log electronic medical record weight log revealed inconsistent weight monitoring: 6/4/2024 weight 192.4 Lbs. 6/9/2024 weight 180.6 Lbs. that was a loss of 11.6 pounds, no care plan intervention added. 7/2/2024 weight 169.0 Lbs. that was a loss of 16.2 pounds, no care plan intervention added. There was no re-weight for a week. 7/8/2024 weight 165.9 Lbs. that was a loss of 3.1 pounds, no care plan intervention added. Record review on 10/02/24 at 08:22 AM of the facility re-weigh policy identified that a resident with weight loss of 5 pounds or more would be re-weighed. In an interview and record review on 10/02/24 at 08:41 AM with Registered Dietitian (RD) M of the facility 'weight /Re-weight policy' revealed that Re-weigh policy did not have a time frame for re-weights to be performed. RD M stated that the re-weights should be performed within 48 hours, is what the RD would prefer. Facility Policy states that a re-weight of -/+5 (loss/gain) we should re-weigh. The State surveyor asked why not weighed more than once weekly? RD M stated that after Resident #41's weight went down to 175 pounds, the facility was only going by his weekly weight. An interview and record review on 10/02/24 at 10:43 AM with Registered Dietitian (RD) M of Resident #41's electronic medical records and weight log revealed that in June 2024 weight of 192.6 dropped on July 165.6 with a loss of 27 pounds with an -14.02% percent loss. RD M stated that Resident #41 has been in and out of the hospital and the last time he lost weight. RD M stated that the re-weight was not performed to verify actual resident weights.

Based on observation, interview and record review the facility failed to complete timely comprehensive activity assessments and ongoing programming to meet the interests of one resident (Resident #77) one resident reviewed for activities, resulting in, Resident #77's activity assessments not being completed since 03/2023 and a lack of activity programming to meet the resident's independent leisure pursuits. Findings Include: Resident #77: During initial tour on 10/1/2024 at 8:33 AM, Resident #77 was observed resting quietly in her room. When asked about activities she participates in, she stated many of the activities she physically cannot complete due to limited mobility in her hands. Resident #77 expressed prior to being admitted she was very active and always on the go and now she just lays in bed everyday with nothing to do. Resident #77 stated they have asked her to come to activities and watch the others participate as there would have been no adaptations made so she could fully participate. On 10/1/2024 at approximately 3:30 PM, a review was completed of Resident #77's medical records and it indicated she was admitted to the facility on [DATE] with diagnoses that included, Peripheral Vascular Disease, Tinea Unguium, Diabetes, Major Depressive Disorder, Anxiety and Polyneuropathy. Resident #77 is cognitively intact and able to make her needs known. Further review was completed of Resident #77's record and it yielded the following: Care Plan: (Resident #77) will initiate independent leisure activities of interest daily, attend group programs as interested and be provided/offered 1:1 room visits throughout the week until next quarter for increased opportunities of personal enjoyment and socialization . Activities Assessments: Resident #77 only had one Activity Assessment that was completed on 3/3/2023, which was her admission assessment. There were no other documented assessments completed for the resident. On 10/2/2024 at 9:20 AM, an interview was conducted with Activities Director N regarding Resident #77 lack of Activity Assessments and activities offered/adapted for the resident. Director N and this writer reviewed the activity assessments for Resident #77 and saw only one assessment from 3/2023. Director N stated the assessments should be completed every three months. She further explained she initially completes the assessment on paper and will input it into their respective charts within a week. Director N stated there should be assessments documented in the chart from her at this juncture. Director N was further asked what efforts were being made to adapt activities to meet her needs. She explained they spend extra time with her when delivering her meal tray. The director was asked if they have adapted any activities so she can participate fully with the group and she stated they had not. Director N was asked if there is any documentation of leisure purists attempted with the residents, rather its music in her room, an iPad to browse or making more efforts to get her out of bed maybe once a week. The Director state they did not have any documentation of this type. It can be noted Resident #77 did not have any activity assessment in over one year and there was nothing found indicating how they maintained her engagement or found alternative ways to entice and include her in programming at the facility. Review was completed of the facility policy entitled, Life Enrichment Programs, revised 5/23/2013. The policy stated, Activity program designed to meet the needs of each resident are available on a daily basis .individualized and group activities .reflect cultural and religious interests, hobbies, life experiences and personal preferences of the residents .

Based on observation, interview and record review, the facility failed to ensure that a urinary drainage bag and tubing was properly placed off the floor for one resident (Resident #46) of two residents reviewed for urinary catheters, resulting in the likelihood of cross-contamination and infection. Finding include: Resident #46: On 10/01/24, at 9:34 AM, Resident #46 was resting in their bed. Their urine drainage bag was hooked to bed frame and resting on the floor. A loop of the catheter tubing was on floor as well. On 10/01/24, at 9:40 AM, an observation along with CNA J of Resident #46's drainage bag and tubing was conducted. CNA J was asked if the bag and tubing was supposed to be on the floor and CNA J stated, no. On 10/01/24, at 9:45 AM, CNA J was observed placing a basin under the drainage bag and tubing. On 10/01/24, at 3:30 PM, a record review of Resident #46's electronic medical record revealed an admission on 4/25/2024 with diagnoses that included Dementia, Quadriplegia and stroke. Resident #46 required extensive assistance with all Activities of Daily Living and was severely cognitively impaired. A review of the (the resident) has 16 French indwelling foley catheter with 10 ml retention balloon related to urinary retention . Check catheter system every shift for pateny and integrity Date Initiated: 04/11/2024 . There was no intervention to ensure urine drainage bag and tubing was kept up off the floor. On 10/02/24, at 10:29 AM. Resident #46 was resting in their bed. Their urine drainage bag was hooked to bed resting inside a basin protecting it from the floor. According to the Healthcare Infection Control Practices Advisory Committee GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009 . Maintain unobstructed urine flow . Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor .

Based on observation, interview and record review, the facility failed to ensure timely re-weighs for weight loss or weight gain for two residents (Residents #32, Resident#41), resulting in a lack of weight monitoring completion, follow-up of abnormal weights, and the potential for unidentified nutritional deficiencies and a decline in overall health. Findings include: Record review of the facility 'Policy: Obtaining Weights and Re-weight Policy' undated, revealed each individual's weight will be determined and documented upon admission to the facility. Procedure: 1.) Nursing will be responsible for the initial determination of each individual's weight. Subsequent measurements for weight will be documented on the appropriate designated form or tracker in the computer database. Weight will be documented on the individual assessment instrument (MDS for nursing facilities), and in the medical nutrition therapy (MNT) assessment. Weight will be obtained weekly for 4 weeks after admission. Subsequent weights will be obtained monthly. unless physician orders or individual condition warrants frequent determinations. Re-weights will be done for a weight change of +/- (gain/loss) of 3# (pounds) for anyone under 100# pounds and for +/- (gain/loss) of 5# (pounds) for anyone 100 pounds and over. (2.) The Registered Dietitian (RD) or designee will be responsible for determining the desirable weight range Resident #32: Observation and interview on 09/30/24 at 10:03 AM with Resident #32 while the resident was seated at the edge of her bed revealed a left upper arm hemodialysis graft with dressing in place. Resident #32 stated that she had been getting hemodialysis treatments for 3 years and goes to dialysis on Tuesdays-Thursdays and Saturdays. Observation of bedside table noted two glasses of beverages. Observation of Resident #32's lower extremities noted skin tightness and possible edema. Record review of Resident #32's medical diagnosis list revealed: acute and chronic Respiratory failure with hypoxia, hypertension, metabolic encephalopathy, falls, seizures, end stage renal disease, cerebral infarction, heart failure, type 2 diabetes, chronic obstructive pulmonary disease, anxiety, Gastrostomy tube, muscle wasting, dysphagia, cognitive communication deficit, mild cognitive impairment, insomnia, dependence on renal dialysis, pneumonia, and anemia. Record review of Resident #32's electronic medical record weight log revealed inconsistent weight monitoring: 9/5/2024 weight 160.8 Lbs. 9/10/2024 weight 166.3 Lbs. that was a gain of 5.5 pounds, no care plan intervention added. 9/12/2024 weight 166.1 Lbs. 9/14/2024 weight 172.9 that was a gain of 6.8 pounds, no care plan intervention added. 9/17/2024 weight 178.9 Lbs. was a gain of 6.0 pounds, no care plan intervention added. 9/19/2024 weight 182.8 Lbs. that was a gain of 3.9 pounds, no care plan intervention added. 9/21/2024 weight 189.9 Lbs. was a gain of 7.1 pounds, no care plan intervention added. The total weight gain in a 17-day period for Resident #32 who received hemodialysis treatment for renal failure was a total of 29.1 pounds. Record review of Resident #32's care plans pages 1-18 revealed that the 'Alteration in nutritional status related to recent hospitalization , diabetes, heart failure, end stage renal disease and peg tube' initiated on 7/29/2024, with a revision on 7/30/2024 and 9/20/2024 of offer evening snack and then revised after the state surveyor inquired about weight gain on 10/2/2024 with updated intervention of 'No pm/HS (bedtime) water. Record review of Resident #32's care guide Kardex dated 10/2/2024 revealed eating/nutrition: No pm/HS water, offer evening snacks, provide diet per physician order; Regular, thin liquids- Renal low sodium, diabetic modifications. In an interview and record review on 10/02/24 at 08:44 AM with the Registered Dietitian (RD) M of Resident #32's weight log revealed that Resident #32 was a hemodialysis resident that received treatment 3 days a week. The state surveyor inquired about Resident #32's estimated weight gain of about 6 pounds weekly, and her fluid status, how much was the resident drinking. The state surveyor and RD M discussed possible health crisis of fluid overload. The RD M stated that she did make the care provider (NP) aware, and each week notify the NP. Discussion of follow-up to the notifications and possible treatments were discussed. RD M stated weights for Resident #32 were taken from her post dialysis weights sent from the dialysis center and documented those in the medical record. RD M agreed that Resident #32 does have around a 6-pound gain weekly. In an interview on 10/02/24 at 10:39 AM with Registered Dietitian (RD) M stated that Resident #32 was aware of the fluid restrictions and that she is gaining weight. RD M stated that she spoke with the Resident #32 in regard to more account ability by the bedside water, we are just going to limit the water amounts and update her care plans. RD M stated that she did put a note in yesterday (10/1/2024) about the weight gain, the re-weigh we don't do because of the dialysis weights. Record review of Resident #32's Nurse Practitioner (NP) note dated 9/9/2024 at 1:17 PM noted resident eating most meals and sometimes more, discussion with dietitian, will discontinue bolus (tube feedings) feeds at this time There were no other care provider notes regarding weight gains. Resident #41: Observation and interview on 10/01/24 at 08:17 AM with Resident #41 revealed that he had his gall bladder out and lost weight, but he thought that he should be gaining weight back. Observation of Resident #41 was noted to be lying in bed with a breakfast tray still at the bedside with most of the meal left on the plate. Record review of Resident #41's admission Minimum Data Set (MDS) date 6/25/2024 revealed and elderly male cognitively intact. Medical diagnosis: Medically complex conditions, anemia, coronary artery disease, hypertension, gastroesophageal reflux disease (GERD), benign prostatic hyperplasia (BPH), renal insufficiency, pneumonia, septicemia, diabetes, thyroid disorder, anxiety and depression. Section K: Swallowing/Nutritional Status- Weight 185, mechanically altered diet and therapeutic diet were noted. Record review on 10/01/24 at 01:55 PM of Resident #41's weight log electronic medical record weight log revealed inconsistent weight monitoring: 6/4/2024 weight 192.4 Lbs. 6/9/2024 weight 180.6 Lbs. that was a loss of 11.6 pounds, no care plan intervention added. 7/2/2024 weight 169.0 Lbs. that was a loss of 16.2 pounds, no care plan intervention added. There was no re-weight for a week. 7/8/2024 weight 165.9 Lbs. that was a loss of 3.1 pounds, no care plan intervention added. Record review on 10/02/24 at 08:22 AM of the facility re-weigh policy identified that a resident with weight loss of 5 pounds or more would be re-weighed. In an interview and record review on 10/02/24 at 08:41 AM with Registered Dietitian (RD) M of the facility 'weight /Re-weight policy' revealed that Re-weigh policy did not have a time frame for re-weights to be performed. RD M stated that the re-weights should be performed within 48 hours, is what the RD would prefer. Facility Policy states that a re-weight of -/+5 (loss/gain) we should re-weigh. The State surveyor asked why not weighed more than once weekly? RD M stated that after Resident #41's weight went down to 175 pounds, the facility was only going by his weekly weight. In an interview and record review on 10/02/24 at 10:43 AM with Registered Dietitian (RD) M of Resident #41's electronic medical records and weight log revealed that in June 2024 weight of 192.6 dropped on July 165.6 with a loss of 27 pounds with an -14.02% percent loss. RD M stated that Resident #41 has been in and out of the hospital and the last time he lost weight. RD M stated that the re-weight was not performed to verify actual resident weights.

Based on observation, interview and record review, the facility is placed in Immediate Jeopardy because it 1) Failed to implement and operationalize policies and procedures to prevent the development and worsening of pressure ulcers (wounds caused by pressure), 2) Failed to ensure comprehensive pressure ulcer care and assessment, per professional standards of practice, including risk identification, 3) Failed to implement interventions to prevent pressure ulcer development, 4) Failed to perform ongoing monitoring, and 5) Failed to complete and document treatments as ordered for two residents (Resident #17 and Resident #62) of four residents reviewed. This deficient practice resulted in 1) Resident #62 developing three facility-acquired Deep Tissue Injury (DTI- Purple or maroon colored area of intact skin resulting from intense and/or prolonged pressure/shear forces with unknown depth which may rapidly evolve and open) pressure ulcers, and 2) Resident #17 developing two facility-acquired Unstageable (pressure ulcer with full-thickness skin, tissue loss, and unknown depth) pressure ulcers, infection development, delay in care, unnecessary pain, and surgical amputation of their phalange (toe). Immediate Jeopardy (IJ): The Immediate Jeopardy began on 03/11/2022 as outlined in the IJ Notification. The Immediate Jeopardy was identified by the survey team on 04/28/2022. The Administrator was notified of the Immediate Jeopardy on 05/02/2022 at 3:30 PM. A plan to remove the immediacy was requested. The Immediate Jeopardy was removed on 05/02/2022 based on the facility's implementation of the Removal Plan as verified onsite on 05/02/2022. Although the immediacy was removed on 05/02/2022, the facility remained out of compliance at a Scope of Isolated and a Severity of No actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: Resident # 17: An observation of Resident #17 occurred on 4/26/22 at 10:03 AM in their room. The Resident was sitting in a wheelchair, facing the doorway of the room, with a rolling, overbed table in front of them. Resident #17 had an open toe, Velcro closure surgical shoe with a sock on their right foot and a slipper on their left foot. The Resident's right foot was directly on the floor and was not elevated. No pressure reduction heel boots were noted in the Resident's room. An interview was completed at this time. Resident #17 was pleasantly confused and unable to provide detailed responses when asked questions. When queried regarding their right foot, Resident #17 replied, I had to have my feet wrapped because they hurt. With further discussion, Resident #17 revealed they had surgery on their foot. Resident #17 stated, The Doctor did that thing when they go to the bone and the skin. Resident #17's call light was observed on the other side of the room on the floor. When asked how they call staff for assistance, Resident #17 provided a response unrelated to the question. On 4/26/22 at 2:32 PM, Resident #17 was observed sitting in the wheelchair in the same place and position as during the prior observation. Record review revealed Resident #17 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 2/23/22, revealed the Resident was severely cognitively impaired and required limited assistance with ambulation, dressing, toileting, and personal hygiene. The MDS assessment further revealed the Resident had no limitations in Range of Motion (ROM), was at risk for pressure ulcer development, and had intact skin. Review of Resident #17's Electronic Medical Record (EMR) revealed the following progress note documentation: - 12/10/20: Encounter . Date of Service: 12/11/2020 . Chief Complaint / Nature of Presenting Problem: Patient has baseline dementia (Resident #17) complaining of mild bilateral toe pain . has arthritic changes noted to toes with deformities . Physical Exam . Extrem (Extremities): Patient has no significant noted lower extremity [CONDITION(S)] however has some changes noted on physical exam regarding (Blank) . Diagnosis, Assessment and Plan: (Blank) . - 1/30/22 at 2:08 PM: Skilled Charting . Guest's daughter came in to give a shower. Noted . hammer toe (common deformity in the second joint of the toe which causes the toe to be contracted and bent at the joint due to muscle and tendon imbalances) is quite red and was oozy through sock .LLE (Left Lower Extremity) is also swollen a bit . - 2/18/22 at 8:49 PM: Wound Note: All boney prominences intact at this time - 3/8/22 at 10:59 AM: Skilled Charting . This nurse notified the PCP (Primary Care Provider) and podiatrist to complaints of discomfort to the second toe on the right foot. The toe is warm, edematous and has a fluid-filled blister to the dorsal side of the toe. [MEDICATION(S)] to be applied q HS (at bedtime), xeroform to wound bed, dry dressing. [MEDICATION(S)] (antibiotic) 100mg (milligrams) BID (twice a day) for 10 days ordered . - 3/11/22 at 10:43 AM: Wound Note . Unstageable pressure noted on right foot 2nd digit. Picture taken and treatment initiated . - 3/20/22 at 12:40 PM: Skilled Charting . After daughter gave shower, called nurse in to look at toe right foot. Guest is being treated with [MEDICATION(S)]. Toe is reddened and has slight amount of whitish fluid coming from small opening on top of toe. Daughter wanted to loosely cover area so sock would not be soiled and to protect toe. (Resident) has return appointment on Wed. with podiatrist to reassess. Text sent to on call and note written in Dr. book to please eval - 3/31/22: RD (Registered Dietician) Note . Guest reviewed for pressure injury . severely impaired cognition with BIMS (Brief Interview Mental Status) score of 3. Per skin assessment, guest has an unstageable pressure injury to R 2nd toe . measuring 0.76 x 0.61cm . - 4/13/22 at 7:02 PM: Skilled Charting . Staff took meal tray into guest room. Yelled for nurse. Guest . non-responsive . to name, easy stimulation, but will grimace with sternal rub . carried to the bed by 3 staff. Got vitals. 138/104, 109, 18, 81% on RA. BS was 107 .Guest's heart beats 3 times with each beat. Trying to open guest's eyes to get pupil response, the eyeball rolled upward . Dr. said to send guest to hospital. - 4/15/22 at 6:15 AM: Skilled Charting . (Resident #17) left facility this morning at 06:10 (AM) via transportation with daughter . going to (hospital) for surgical amputation of second toe to right foot . has been NPO (nothing to eat or drink) since midnight with sips of water as needed per surgeon's request . - 4/18/22 at 11:00 AM: Skilled Charting . nurse spoke with (Resident #17's) daughter regarding follow up appt. with surgeon s/t (status post [MEDICAL RECORD OR PHYSICIAN ORDER] - 4/18/22 at 11:15 AM: Wound Note . nurse assessed amputation site to 2nd digit of right foot. Dressing in place at time of incision site had moderate amount of sanguineous drainage. Incision site cleansed with NS (Normal Saline) and patted dry. Incision is well approximated with 5 sutures and no drainage during cleanse. Surrounding skin intact and free of s/sx of infection. Nonadherent dressing applied to site with secured with cling gauze wrap. - 4/18/22 at 3:53 PM: Care Transition Note . Room visit / follow up after toe surgery. (Social) Worker met with guest and their daughter in room. Guest continues to present with significant cognitive impairments . Review of Resident #17's Health Care Provider Orders, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - Place [MEDICATION(S)] loosely over toes right foot to help protect top of hammertoe. Apply one time daily in am. Replace if becomes wet or soiled. One time a day for to help protect hammertoe . Start Date: 3/21/22 . Discontinued: 3/20/22 (sic) . Note: The order was never implemented and/or completed. - [MEDICATION(S)] . 100 mg . 1 capsule by mouth two times a day for Right dorsal 2nd toe infection (Start: 3/8/22; Discontinued: 3/11/22) - [MEDICATION(S)] (antibiotic) Tablet 500-125 milligram (mg) . 1 tablet by mouth two times a day for toe infection for 10 Days . (Start: 3/11/22) - Resident to remain NPO (nothing by mouth) after midnight (evening of 3/29-3/30) except for clear liquids (water, coffee/tea with nothing added, cola, apple/cranberry juice-no milk or orange juice) up to two hours before noon on 3/30; may take all a.m. medications with sips of water two times a day until 03/30/2022 23:59 (11:59 PM) (Start: 3/29/22 at 9:00 PM) - Apply [MEDICATION(S)] to Right 2nd toe blister. Apply xeroform and dry dressing. Change daily and as needed for soiled dressing at bedtime (Start Date: 3/8/22; Discontinued: 4/20/22). TAR documentation was blank on 3/24/22 indicating the treatment was not completed. Review of Resident #17's Health Care Provider Orders, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - Apply [MEDICATION(S)] to Right 2nd toe blister. Apply xeroform and dry dressing. Change daily and as needed for soiled dressing at bedtime (Start Date: 3/8/22; Hold from 4/14/22 at 4:22 AM to 4/14/22 at 1:23 PM; Discontinued: 4/20/22). TAR documentation was blank on 4/7/22, 4/7/22, and 4/13/22 indicating the treatment was not completed. The code 9 indicating Other / See Nurse Notes was documented on 3/19/22. - Monitor dressing room (sic) right foot for drainage; change as needed in the morning (Start Date: 4/16/22; Discontinued: 4/25/22) Documentation was blank indicating the task was not completed on 4/23/22 and 4/24/22. - Monitor right 2nd toe for s/s (signs/symptoms) infection and/or change in condition and notify physician if present until healed two times a day (Start Date: 3/8/22; Hold from 4/14/22 at 4:22 AM to 4/14/22 at 1:23 PM). Documentation was blank, indicating the task was not completed on 4/7/22 at 9:00 PM, 4/8/22 at 9:00 PM, 4/23/22 at 9:00 AM, and 4/24/22 at 9:00 AM. - Apply [MEDICATION(S)] to Right 2nd toe blister. Apply xeroform and dry dressing. Change daily and as needed for soiled dressing at bedtime (Start Date: 3/8/22; Discontinued: 4/20/22). The code 5 indicating Hold/See Nurses Notes was documented on 4/15/22 and 4/18/22. The code 7 indicating Sleeping and not completed was documented on 4/17/22 and code 9-Other / See Nurse Notes was documented on 4/19/22. Note: Review of progress notes in the EMR revealed no corresponding documentation related to documentation of code 9 on the MAR for March 2022 and April 2022. Additional review of Resident #17's EMR revealed no medication and/or treatment orders pertaining to Resident #17's toes in January and/or February 2022. Review of Resident #17's care plans revealed the following care plans and interventions: Care plan: (Resident #17) has impairment to skin integrity r/t (related to) impaired mobility, fragility . history of fall with fracture. Surgical amputation of R (Right) second toe (Initiated: 5/22/20; Revised: 4/15/22). The care plan included the interventions: - Encourage and assist guest to turn and reposition as tolerated (Initiated: 4/11/22) - Keep skin clean and dry. Use lotion on dry skin. (Initiated and Revised: 5/20/20) - Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface (Initiated: 5/22/20) Care plan: (Resident #17) has an alteration in pain secondary to . u/s (Unstageable) R foot 2nd toe . (Initiated: 5/22/20; Revised: 4/11/22) was present in Resident #17's EMR. This care plan included the following interventions: - Non-pharmacological Intervention. Environmental-Adjust the room temperature, smoothing the linens, providing a pressure-reducing mattress, repositioning (Initiated: 5/22/20) - Non-pharmacological Intervention Physical-Ice packs, cool or warm compresses, bath, massage (Initiated: 5/22/20) - Non-pharmacological Intervention Exercise-Encourage to prevent muscle stiffness (Initiated: 5/22/20) - Monitor and record effectiveness, side effects of medication PRN (as needed) (Initiated: 5/22/20) - Administer pain meds as ordered (Initiated: 5/22/20) - Non-pharmacological Intervention Cognitive or Behavioral-relaxation, music, diversions, activities etc. (Initiated: 5/22/20) Care plan: (Resident #17) is at risk for an alteration in nutritional status related to . dx (diagnosis) dementia . pressure injury to toe . (Initiated: 5/22/20; Revised: 3/31/22) was noted in Resident #17's EMR. Review of Resident #17's discontinued/resolved care plans exposed that the Resident had been treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The following discontinued/resolved care plans were present in the EMR: - RESOLVED: Antibiotic Therapy r/t R 2nd toe infection (Initiated: 3/9/22; Revised and Resolved: 3/22/22). - RESOLVED: Infection of Wound/skin (Initiated: 3/9/22; Revised: 3/22/22). A current and/or resolved (discontinued) care plan was not present in Resident #17's EMR which addressed and/or included applicable interventions related to feet/toe pressure reduction/prevention including but not limited to specialty footwear and/or cushioning. On 4/27/22 at 10:02 AM, Resident #17 was observed in their room. The Resident was sitting in their wheelchair facing the entryway of the door. The Resident's feet were both on the floor in front of them with the surgical shoe in place on their right foot. The surgical shoe was incorrectly positioned on the Resident's foot. The back (heel) part of the shoe was bent forward over the sole/footbed of the surgical shoe. When queried if facility staff assisted them to put on their shoe, Resident #17 revealed staff did not provide assistance with putting on their shoes. No pressure reduction heel boots and/or customized shoes were present in the Resident's room and/or closet. Further review of Resident #17's medical record revealed the following Wound Evaluation assessment documentation: - Evaluated on [DATE] - 22:33 (10:33 PM) . #4 -Pressure - Unstageable (Slough and/or eschar) . Body Location: Right Foot, 2nd Digit (Second Toe) . Minutes old . Acquired: In-House Acquired . Length: 0.72 cm (centimeters) . Width 0.53 cm . Wound Bed: Slough . Yes . 100% . Exudate . Light . Serosanguineous . Periwound . Edges . Non-Attached . Surrounding Tissue . Fragile . Extent (cm- centimeter) 1 (cm) . No swelling or [CONDITION(S)] . Pain: 3 . Additional Care: Foam Mattress; Heel Suspension/Protection device; Nutrition/Dietary; supplementation; Positioning Wedge; Repositioning device(s); Turning/repositioning program . A picture of the wound was included with the evaluation. The wound was circular, and the bed of the wound was white in color. The second toe was visibly red in comparison to the Resident's other skin and the skin on the top of the foot, proximal to the wound was also notably reddened in the picture. The Resident's left foot was also present in the image and a darkened wound area was present on the second toe of the left foot. - Evaluated on [DATE] - 21:19 (9:19 PM) . #4- Pressure - Unstageable (Slough and/or eschar) . Right Foot, 2nd Digit (Second Toe) . Age Unknown . Acquired: In-House Acquired . Length: 0.85 cm . Width: 0.56 cm . - Evaluated on [DATE] - 06:43 (6:43 AM) . #4 - Pressure - Unstageable (Slough and/or eschar) . Right Foot, 2nd Digit (Second Toe) . Age Unknown . Acquired: In-House Acquired . Additional Care: Customized shoe wear; Foam Mattress; Heel Suspension/Protection device; Positioning Wedge; Repositioning device(s); Turning/repositioning program . - Evaluated on [DATE] - 02:00 (2:00 AM) . #4 - Pressure - Unstageable (Slough and/or eschar) . Right Foot, 2nd Digit (Second Toe) . Age Unknown . Acquired: In-House Acquired . - Evaluated on [DATE] - 15:43 (3:43 PM) . #4 - Pressure - Unstageable (Slough and/or eschar) . Right Foot, 2nd Digit (Second Toe) . Age Unknown . Acquired: In-House Acquired . Length: 0.6 cm . Width: 0.51 cm . Exudate . Light . Serosanguineous . Edges . Non-Attached . Surrounding Tissue . [CONDITION(S)] . 1 (cm) . Pain: 5 (out of 10) . Additional Care: Customized shoe wear; Heel Suspension/Protection device; Positioning Wedge; Repositioning device(s); Turning/repositioning program . - Evaluated on [DATE] - 01:12 (1:12 AM) . #4 - Surgical - Sutures, Incision Approximated . Right Foot, 2nd Digit (Second Toe) . New - 1 month old . Acquired: In-House Acquired . Review of Resident #17's PCC Skin & Wound - Total Body Skin Assessment historical assessment data for number of new wounds detailed zero new wounds were documented on 3/4/22, 3/18/22, 3/26/22, 4/1/22, 4/11/22, and 4/12/22. On 4/20/22, one new wound was documented. Review of Physician Visit Assessment documentation in Resident #17's EMR detailed: - 5/5/21: Physical Examination . Skin: Warm and Dry . Extremities: Decreased range of motion of the right hip . Diagnostic Impression: 1. Right hip pain/femur fracture . The note did not contain any documentation of abnormal assessment findings of Resident #17's feet and/or toes. - 8/10/21: Physical Examination . Skin: Warm and Dry . Extremities: Decreased range of motion of the right hip . The note did not contain any documentation of abnormal assessment findings of Resident #17's feet and/or toes. - 9/13/21: Physical Examination . Skin: Warm and Dry . Extremities: Decreased range of motion of the right hip . The note did not contain any documentation of abnormal assessment findings of Resident #17's feet and/or toes. - 10/5/21: Physical Examination . Skin: Warm and Dry . Extremities: Decreased range of motion of the right hip . The note did not contain any documentation of abnormal assessment findings of Resident #17's feet and/or toes. - 11/5/21: Physical Examination . Skin: Warm and Dry . Extremities: Decreased range of motion of the right hip . The note did not contain any documentation of abnormal assessment findings of Resident #17's feet and/or toes. - 1/24/22: Physical Examination . Skin: Warm and Dry . Extremities: Decreased range of motion of the right hip . The note did not contain any documentation of abnormal assessment findings of Resident #17's feet and/or toes. - 1/31/22: Physical Examination . Skin: Warm and Dry . Extremities: Right foot hammertoe . Diagnostic Impression: 1. Right foot pain . Plan: 1. Podiatry consult for right hammertoe . - 3/8/22: Physical Examination . Skin: Warm and Dry . Extremities: Cellulitic changes (usually occurs after an injury and/or wound to the skin) of right foot . Diagnostic Impression: Right foot [CONDITION(S)] (bacterial infection) . - 4/22/22: Physical Examination . Skin: Warm and Dry . Extremities: status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Right foot pain, status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Monitor wound care for toe . Additional documentation in Resident #17's EMR included the following: - Fax Face Sheet from External Surgical Center dated 3/24/22. The Fax Face Sheet detailed, (Resident #17) will be having foot surgery here 3/30 . Please send list of medication (Resident) is taking and medical problem list. We will fax back instructions per anesthesia guidelines re: medication administration/pre-op . - Hospital Discharge Instructions dated 4/14/22 at 9:21 AM. The discharge instructions revealed the Resident was admitted to the hospital on 4/13/22 and discharged with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . - Surgical Center Discharge Instructions dated 4/15/22 at 8:25 AM which included instructions for post operative pain management with [MEDICATION(S)] (narcotic pain medication). An interview was completed with the Director of Nursing (DON) on 4/27/22 at 4:26 PM. When queried regarding Resident #17, the DON indicated they were aware of Resident #17's recent surgical toe amputation. The DON was then asked if they were familiar with the pressure ulcer on Resident #17's right second toe prior to the surgical amputation. The DON indicated they were unable to recall specific clinical information. A review of Resident #17's EMR wound assessment documentation, including wound pictures, was completed with the DON at this time. After review of wound assessment documentation, the DON was queried regarding the etiology of Resident #17's right toe pressure ulcer and confirmed the pressure ulcer was facility acquired. The DON was then queried regarding the reason Resident #17's toe was amputated following development of a facility-acquired pressure ulcer and infection but was unable to provide further explanation. At 8:15 PM on 4/27/22 PM, an interview was completed with Family Member Witness AK. When queried regarding Resident #17's toe, Witness AK revealed Resident #17 has hammer toes on both of their feet and a wound had developed on their right toe which was the reason their toe had to be amputated. When asked the date the pressure ulcer wound on Resident #17's toe was first identified, Witness AK disclosed they were uncertain of the specific date. With further inquiry, Witness AK revealed they had brought the wound up to facility nursing staff multiple times before it was addressed. Witness AK specified they were concerned when they saw Resident #17's toe and lower extremity, so they went to the nurses' station to let them know. When queried what the nursing staff did after being informed of the wound, Witness AK revealed only one nurse at the facility responds to concerns in a timely manner and the other nurses just want to sit on their butts and don't do anything. When asked what happened, Witness AK stated, Another week went by, and (Resident #17's) toe was dripping pus and there was redness on their foot and up their leg. Witness AK revealed they informed Resident #17's nurse about their toe and leg again because the wound/redness looked worse. Witness AK was queried regarding what happened then and stated, The next week it (wound) was super bad. Witness AK revealed the Resident was assigned a different nurse that day. Witness AK stated, (Registered Nurse [RN] AM) said yes something needs to be done. Witness AK indicated RN AM is one of the only nurses at the facility who responds to concerns. Witness AK stated, I made an appointment outside of (the facility) and that Doctor ordered antibiotic. Witness AK revealed the external Physician was concerned the infection from the toe pressure ulcer had spread to the bone and stated they were going to do a biopsy of tissue from Resident #17's amputation. Witness AK was then asked how many times they had spoken to facility nursing staff regarding Resident #17's toe wound prior making an appointment with a Physician not associated with the facility and replied, I can't tell you how many times I've told them about it. When asked, Witness AK was unable to recall the names of the multiple nursing staff they had informed about the wound on Resident #17's toe. Witness AK was queried regarding Resident #17's footwear and revealed the Resident always wears some sort of shoe. When asked if Resident #17's shoes had been rubbing on the bony part of their hammer toe, Witness AK replied, Yes. Witness AK continued, Rubbing got worse when Resident #17's toe became infected and swollen. Witness AK was asked if facility nursing staff had contacted them regarding the Resident's shoes and/or if the facility had requested/recommended a different style or a customized shoe and replied, No. When queried if the facility had implemented any other interventions to prevent pressure, rubbing, and/or skin breakdown on the bony prominence of Resident #17's hammer toe such as padding, etc., Witness AK replied, No. Witness AK disclosed they had mistakenly assumed the facility would provide care and make necessary recommendations to ensure Resident #17 did not develop pressure wounds and infection. When queried regarding the date of the amputation related to conflicted information in Resident #17's EMR, Witness AK specified Resident #17 was scheduled to have the surgery in March, but the facility did not follow the pre-operative instructions from the surgeon and the surgery had to be canceled. Witness AK revealed they went to the facility to pick up the Resident for their surgery when they walked into the room and said (Resident #17) is supposed to have surgery. Witness AK revealed the Resident had eaten a meal tray. Witness AK stated, It doesn't seem like anyone gives a[OBSCENITY]about (Resident #17) there. I feel like nobody listens. Witness AK stated, I really feel that if the nurses would have listened to me that it wouldn't have gotten so bad. After the surgery, the (external) Doctor told me no (regular) shoes. Witness AK revealed Resident #17 had to wear a surgical shoe until the amputation was healed and they brought them a slipper for their other foot. Witness AK continued, A nurse came in on Sunday and was crappy with me because they asked where (Resident #17's) shoes were and I told them, (Resident #17) couldn't wear them. Witness AK indicated communication seemed to be an ongoing issue at the facility. An interview was completed with Unit Manager RN E on 4/28/22 at 8:25 AM. When queried regarding Resident #17's pressure ulcer on their right toe, RN E stated, (Resident #17) has had a hammer toe deformity, it's gotten worse over time. RN E was asked about the frequency in which Resident #17 wears shoes in the facility and revealed the Resident wears shoes all day. When queried regarding the type of shoes the Resident wears, RN E indicated the Resident has regular tennis shoes. RN E was queried if the pressure ulcer on their toe was caused from their shoes but did not provide a response. When asked if Resident #17's shoes were evaluated by facility staff to ensure appropriate fit with the Resident's known hammer toe and increased risk of pressure ulcer development due to the bony prominence created by the hammer toe, RN E stated, No. When asked why the facility did not evaluate Resident #17's shoes and/or recommend different/customized footwear due to the increased risk of pressure ulcer development, RN E was unable to provide an explanation. RN E was then asked who had referred Resident #17 to an external physician and surgeon regarding their toe and replied, Might have been their daughter. When queried regarding scanned external healthcare provider documentation in Resident #17's medical record not including documentation prior to the fax face sheet for the surgical amputation of the Resident's toe, RN E revealed they were not aware of any other documentation. RN E was then asked if the antibiotic for the infection in Resident #17's toe was originally ordered by the external physician or the facility physician and revealed they were unsure because all EMR orders are ordered/entered under the facility physician. When asked if the facility-maintained paper documentation and/or audits related to medication orders, RN E revealed all paper documentation is scanned into the EMR. When queried regarding scanned documentation in Resident #17's EMR indicating the Resident was supposed to have surgery on 3/30/22 and why the Resident did not have surgery until 4/15/22, RN E stated, It had to be rescheduled because (Resident #17) got their (food) tray. With further inquiry regarding the delay in care, RN E provided no additional explanation other than the food tray had been mistakenly given to the Resident. When queried regarding the first wound assessment of Resident #17's facility acquired right second toe pressure ulcer being dated 3/11/22, the short timeframe between the initial assessment and scheduled and canceled surgical amputation on 3/30/22, and the family statements indicating staff responsiveness to the wound, RN E was unable to provide an explanation. When queried what interventions were in place to prevent and/or reduce the risk of Resident #17 developing a pressure ulcer on their toe, RN E reviewed the Resident's care plans and revealed there were no interventions in place pertinent to the Resident's toes. On 4/28/22 at 8:56 AM, Resident #17 was observed sitting in their wheelchair in their room. The wheelchair was in the same place in the room as on prior day observations with an overbed table in from on them. The Resident's feet were directly on the floor with the surgical shoe in place on their right foot and a slipper on their left foot. An observation of Resident #17's closet revealed a pair of boots and a Sketchers Relaxed Fit: Air -Cooled Memory Foam shoe box on the top shelf. No pressure reduction heel boots were present in the closet and/or elsewhere in the Resident's room. On 4/28/22 at 9:05 AM, a wound care and skin observation of Resident #17 in regard to bilateral feet and distal lower extremities was completed with Licensed Practical Nurse (LPN) AF. Upon entering the room, Resident #17 was positioned in the same position in their wheelchair. LPN AF did not perform hand hygiene and then removed the surgical shoe and sock in place on Resident #17's right foot and the slipper and sock on Resident #17's left foot. [CONDITION(S)] was noted in both of Resident #17's lower extremities. When queried, LPN AF palpated the Resident's legs and indicated it was 1+ pitting [CONDITION(S)]. When queried regarding pulses, LPN AF palpated Resident #17's dorsal and tibial pulses. LPN AF indicated the pulses were not easy to locate but once they were found were 2+ (normal pulses). The right foot/toe incision was OTA. Sutures were present on the proximal (top) side of the right foot, in between the big and third toe. New tissue was forming around the suture sites and the suture appeared to be grown into the skin. When queried regarding the type of sutures and removal, LPN AF revealed they were unsure when the sutures needed to be removed but indicated it would most likely be completed when the Resident went back to see the surgeon. When asked, both Resident #17 and LPN AF were unaware of a follow up appointment date. The skin both of Resident #17's feet was visibly dry and peeling. A contracted hammer toe was present on Resident #17's left foot second toe. The toe was bent upward at the second joint creating a point and the pad of the toe was resting over the big toe. A wound was observed over the bony prominence left foot second toe. The wound was circular in shape with dark red tissue at the distal end, a dark brown, black semicircular area in the center, and bright reddened and white area toward the proximal end of the wound bed. LPN AF was asked if the wound bed was blanchable. LPN AF proceeded to press on areas of the wound bed. No blanching was noted. When asked if the wound was pressure related, LPN AF revealed it was. When queried regarding the skin under the second toe on the left foot, LPN AF lifted the toe. Visible chunks of a malodorous, brown/gray colored unknown substance were present under the second toe on Resident #17's left foot. When asked what the substance was, LPN AF began removing large chunks with their fingers. LPN AF then obtained a washcloth and began to wash Resident #17's left foot without performing hand hygiene. LPN AF proceeded to begin to wipe Resident #17's right (surgical) foot without performing hand hygiene and with the same washcloth. L [TRUNCATED]

Based on observation interview and record review, the facility failed to implement and operationalize a Restorative Nursing Program for one resident (Resident #15) of four residents reviewed, resulting in a lack of the provision and documentation of ROM/Restorative Nursing services, lack of treatment and services to accurately monitor, measure, maintain, increase and/or prevent reduction in Range of Motion (ROM), increased limitations in ROM, resulting in Resident #15 developing contractures within the facility, and the likelihood for further functional decline, diminished mobility, and unnecessary, increased pain. Findings include: Resident #15: On 4/25/22 at 2:50 PM, an observation and interview with Resident #15 was completed in their room. Upon entering the room, a lingering, stale, foul odor was noted. A Hoyer lift (mechanical lift for transferring dependent individuals) was present in the foyer/entry area of the room. The Resident was observed in bed, positioned on their back wearing a hospital style gown. Their call light was not observed. The Resident's right hand was in the shape of a fist with a visibly soiled palm guard in place. Resident #15's bedding on the right side was noticeably soiled with a wet, light brown colored unknown substance. An interview was completed at this time. Resident #15 was asked where their call light was and indicated they did not know. When asked questions, Resident #15 was pleasant and responded in a slow and meaningful manner. With further inspection, the call light was observed on the floor, behind the head of the bed, and not within reach of the Resident. When queried how they get help when they need it, Resident #15 replied, I don't know. Resident #15 was queried regarding the palm guard on their right hand and indicated they had a stoke and were unable to use their right hand. When asked if they were able to move their right arm, Resident #15 picked up their right wrist with their left hand. When queried regarding mobility and getting out of bed, Resident #15 stated they don't get up much. When asked why not, the Resident proceeded to pull up the sheet covering their feet. Resident #15's left heel was positioned directly on the mattress. A pillow was in place under their right lower extremity with half of their right heel pressing into the pillow. The skin on both of their legs were extremely dry with a scaly appearance and visibly flakes of skin on the bedding around their legs. The Resident's feet were in a straight line with their legs with their toes were pointed away from their head. When asked if they were able to point their toes upward and move their ankles, Resident #15 lifted their legs slightly at the hip joint and revealed they were unable to move their ankles. An observation of the Resident's room revealed no positioning boots and/or devices for their lower extremities and/or feet. When asked if they had/wore positioning boots/devices on their lower extremities, Resident #15 indicated they only had the palm guard for their hand. Resident #15 was queried regarding the frequency staff remove the palm guard to clean their hand and to clean the guard. Resident #15 indicated staff rarely ever remove the guard and was unable to state when it was last cleaned. Record review revealed Resident #15 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired, required extensive to total assistance to perform Activities of Daily Living (ADLs), and had one sided impaired ROM in both their upper and lower extremities. The MDS further indicated the Resident was receiving Restorative Nursing services including both Active ROM (AROM) and Passive ROM (PROM) for at least 15 minutes per day. Review of Resident #15's care plans revealed a care plan entitled, (Resident #15) will experience no decline in Range of motion, ADLs (Initiated: 4/6/21; Revised: 4/8/21). The care plan included the interventions: - Encourage active range of motion left sided extremities/passive ROM to Right Side (Initiated: 1/21/22) - Encourage guest to actively participate in ADL care twice daily (Initiated: 2/5/19; Revised: 4/21/20) Another care plan titled, (Resident #15) has an actual ADL/Mobility deficit R/T (Related To) . [CONDITION(S)] (Urinary Tract Infection) . Complete heart black, [CONDITION(S)] . debility . dementia, weakness . Guest has impaired vision following [CONDITION(S)] and wears glasses. Guest sometimes chooses to stay in bed (Initiated: 4/6/21; Revised: 4/8/21) was present in Resident #15's Electronic Medical Record (EMR). Care plan interventions included: - ROM with care daily (Initiated: 7/9/18; Revised: 9/6/18) - Right hand palm guard to be worn when . in bed up to 6 hours (Initiated: 4/5/22; Revised: 4/18/22) Review of Resident #15's Health Care provider orders and Order Summary Report of Active, Completed, Discontinued, On hold, Pending Clinical Review, Pending Confirmation, Struck out and Administrative orders revealed the following active order: - Right hand palm guard to be donned when in bed up to 6 hours (Order Date: 3/29/22). Review of Resident #15's Treatment Administration Record (TAR) for April 2022 revealed the treatment, Monitor skin integrity of right hand due to wearing a splint on right hand. two times a day (Start Date: 4/18/22). Review of Resident #15's EMR documentation revealed the most recent Restorative Nursing Assessment documentation was dated 2/5/19. The documentation detailed, Restorative Nursing Note . Assessment: No decline with range of motion or ADLs noted at this time. Guest currently participates with AROM to LUE (Left Upper Extremity) and LLE (Left Lower Extremity), PROM to RUE (Right Upper Extremity) and RLE (Right Lower Extremity) as tolerated. Plan: Continue with plan of care and assess monthly and prn (as needed) . Review of Resident #15's EMR Progress Note documentation revealed no documentation related to assessment and/or management of palm guard device since order date. Review of Resident #15's available EMR therapy documentation revealed the Resident began Occupational Therapy on 3/29/22 with treatment diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Task documentation in Resident #15's EMR for the previous 30 days revealed the following: - Task: Nursing Rehab: Right hand palm guard to be donned when in bed up to 6 hours . Amount of minutes spent providing splint or brace assistance. Documentation of task completion details included the following: - 4/5/22: 15 minutes - 4/6/22: 15 minutes - 4/7/22: 15 minutes - 4/8/22: 15 minutes - 4/10/22: 15 minutes - 4/11/22: 15 minutes - 4/12/22: 15 minutes - 4/13/22: 15 minutes - 4/14/22: 15 minutes - 4/15/22: 0 minutes - 4/16/22: Total 14 minutes - 4/17/22: 15 minutes - 4/18/22: 15 minutes - 4/19/22: 15 minutes - 4/20/22: 15 minutes - 4/21/22: 15 minutes - 4/22/22: 5 minutes - 4/23/22 15 minutes - 4/24/22: 15 minutes - 4/25/22: 10 minutes -4/26/22: 15 minutes - 4/27/22: 15 minutes - Task: Nursing Rehab: Encourage active range of motion to left sided extremities twice daily as tolerated. There was no documentation of completion on 4/2/22, 4/3/22, and 4/9/22. The task was only completed twice daily once during the prior month on 4/16/22. - Task: Nursing Rehab: Assist with passive range of motion to right sided extremities twice daily as tolerated. There was no documentation of completion on 4/2/22, 4/3/22, and 4/9/22. The task was only completed twice daily once during the prior month on 4/16/22. On 4/27/22 at 8:24 AM, Resident #15 was observed in their room in bed, positioned on their back. The room continued to have a detectable foul odor upon entering. The visibly soiled palm guard remained in place on the Resident's right hand. When asked the last time the palm guard had been removed and their hand cleaned, Resident #15 indicated the guard was never fully removed by nursing staff. The Resident's sheets remained discernibly soiled with an unknown light brown colored substance on the right side of the Resident. The lateral side of Resident #15's RLE and heel were positioned directly on the mattress. A pillow was in place under their LLE but their heel was pressing into the pillow. The Residents ankles and toes remained pointed downward, away from the Resident's head. An interview was completed with CNA AR on 4/27/22 at 8:30 AM. When queried who the facility Restorative Nurse was CNA AR replied, I can't even tell you. When asked to clarify, CNA AR revealed they were unaware of the facility having a Restorative nurse. CNA AR was then queried regarding PROM and AROM activity completion with Residents by CNA staff as part of a Restorative Nursing program. CNA AR replied, No, that is therapy. CNA AR was asked to clarify and replied, We (facility CNAs) don't do that. We can tell them (residents) to move, but that (PROM and AROM/Restorative) is therapy. When asked about documentation of ROM in the task section of the EMR, CNA AR revealed they document it as completed if they provide any ADL care to residents, including incontinence care, as the resident moved. No further explanation was provided. An observation of ADL care including completion of a bed bath and hygiene restoration for Resident #15 was completed on 4/27/22 at 10:28 AM with Certified Nursing Assistant (CNA) AO. Upon entering Resident #15's room, the Resident was observed in the same position previously observed on 4/27/22 at 8:24 AM. During ADL care completion, CNA AO did not remove Resident #15's right hand palm guard nor did they clean the Residents hand. CNA AO did not assist the Resident to complete PROM nor did they encourage the Resident to perform AROM to any of their extremities. An interview was conducted with CNA AO following ADL care observation on 4/27/22 at 11:06 AM. When queried why they did not remove Resident #15's right palm guard and clean the Resident's hand, CNA AO stated, I don't. CNA AO was asked if they have ever removed the Resident's right palm guard and stated, No. CNA AO then stated, Maybe the nurses do. When asked to clarify, CNA AO revealed CNA staff do not remove nor apply splint or guards of any kind at the facility. On 4/27/22 at 2:29 PM, an interview was completed with the Director of Nursing (DON), When queried who the facility Restorative Nurse is, the DON stated, The MDS nurse is the restorative nurse. When queried if the facility had dedicated Restorative CNAs for restorative activities and/or exercises, the DON replied, All aides (CNAs) document ROM. Resident #15's The DON was the queried regarding documentation of Resident #15's Right hand palm guard . task documentation was reviewed with the DON at this time. The DON was asked what documentation of Amount of minutes spent providing splint or brace application meant when the Resident was supposed to wear the guard for up to six hours at a time when up in bed per the order, the DON stated, I don't understand that either. The DON was then queried how the facility monitored the length of time the palm guard was in place. The DON did not provide a response. When queried regarding observation of Resident #15's palm guard not being removed during ADL care, the guard being visibly dirty, Resident #15's statements that it is not removed by staff, the DON validated that the Resident's palm guard should be removed and cleaned. When queried regarding CNA statements that they do not remove the palm guard and do not complete PROM and/or AROM exercises, the DON reiterated that the CNA staff complete ROM/Restorative and document completion. When asked why CNA staff would state they do not and that therapy completes, the DON replied, I don't know. An interview was conducted with Physical Therapist (PT) AP on 4/27/22 at 2:49 PM. When queried regarding the facility Restorative Nursing program process, PT AP stated, We (therapy services) have a form that we fill out and give to nursing. When queried if therapy services complete AROM and/or PROM exercises for Residents referred to/receiving Restorative Nursing, PT AP revealed they did not. When queried regarding Resident #15, PT AP stated, I think OT eval-ed (Resident #15) on 3/29/22 and they are waiting for authorization from the insurance (to treat). PT AP was queried regarding the OT evaluation. PT AP reviewed Resident #15's therapy documentation and stated, It says education hand hygiene and they use of carrots. PT AP indicated the evaluation also included education related to appropriate application of a palm guard. A copy of the OT evaluation was requested at this time. PT AP was then asked when the Resident was last seen/evaluated by PT, PT AP reviewed therapy documentation and revealed they were unable to locate a previous PT evaluation. When queried regarding observations of the Residents BLE and feet, PT AP stated, Sounds like (Resident #15) should definitely have Prafos (boots used for positioning and pressure reduction). PT AP was then asked when Resident #15 was evaluated by therapy services prior to March 2022. After reviewing the Resident's medical record, PT AP stated, Seen by OT and Speech in 2019. When queried if Resident #15 had contractures when they were evaluated in 2019, PT AP reviewed OT documentation from 2019 and stated, (Resident #15) had impaired (ROM) but was not contracted. When asked if Resident #15's evaluation from 2022, PT AP revealed Resident #15's right hand was contracted. PT AP was then asked if the contracture developed while the Resident was in the facility and stated, Yeah, developed here. An interview was conducted with Physical Therapist (PT) AP and Occupational Therapist (OT) AQ on 4/27/22 at 3:18 PM. When queried regarding Resident #15, OT AQ revealed they were asked to eval the Resident by nursing staff but were waiting for insurance authorization to begin treatment. OT AQ revealed they implemented a carrot and/or palm guard to prevent worsening of Resident #15's hand contracture until authorization was obtained. OT AQ was asked how frequently the palm guard should be worn by the Resident and replied, On at all times except for hygiene/daily care. With further inquiry about Resident #15's OT evaluation, OT AQ revealed they were able to get it (right hand) partially open enough to get the carrot in and stated, It (hand) smelled. When asked to clarify, OT AQ revealed the Resident's right hand was dirty and hand a foul odor as though it had not been cleaned in a long time when they completed the eval. OT AQ was asked about the facility Restorative Nursing program and revealed there was not really a program. OT AQ stated Therapy staff just give (Restorative/ROM) to the Unit Manager to enter in (the EMR). Resident #15's task documentation of Amount of minutes spent providing splint or brace assistance was reviewed with OT AQ at this time. OT AQ stated, (Resident #15) doesn't have a splint, they have a palm guard. No further explanation was provided. Review of OT therapy Evaluation documentation for Resident #15 detailed the following: - OT Evaluation & Plan of Treatment . Certification Period: 1/15/19 - 2/4/19 . Reason for Referral: Patient exhibits new onset of decrease in strength, function mobility . UE ROM . RUE (Right Upper Extremity) ROM = Impaired (h/o [history of] R [right] hemi); LUE (Left Upper Extremity) ROM = WFL (Within Functional Limits) . The evaluation revealed the Resident did not have any contractures. - OT Evaluation & Plan of Treatment . Certification Period: 3/29/22 - 4/25/22 . Musculoskeletal System Assessment . LUE . Shoulder - Impaired; Elbow/Forearm = Impaired; Wrist = WFL . Contracture: Functional Limitations Present due to Contracture= Yes . R hand- decreased had hygiene (moist skin with increased odor), increased tightness in digits and in ability to assist with own care . Location of Contracture R hand contracture with digit 3-4 Swan neck deformity (5 with risk of developing Swan Neck deformity) . An interview was completed with RN AI on 4/29/22 at 2:12 PM. When queried regarding the facility Restorative Nursing program, RN AI revealed the facility was deficient in the provision of ROM and Restorative. RN AI stated, It is important, and we are really lacking. When asked to elaborate, RN AI stated, We really don't have a program and it (Restorative/ROM) doesn't get done. RN AI was asked why it does not get done and replied, There isn't time. When asked what staff are responsible to complete Restorative Nursing/ROM activities, RN AI replied, CNAs. When queried regarding Resident #15 including Restorative Nursing/ROM activities and monitoring/cleanliness of the Resident's skin under the palm guard, RN AI indicated the tasks do not get completed. An interview was completed with the DON on 4/27/22 at 3:18 PM. When queried regarding the facility Restorative Nursing Program/ROM, Resident #15 contracture development in the facility, staff interview statements, and lack of the provision of ROM/Restorative, the DON stated, All Residents should have [NAME] completed. When asked if lifting a Resident's arm to wash them and/or change their clothing was purposeful ROM, the DON stated, No, it is not. No further explanation was provided. Upon request for a Restorative Nursing policy/procedure, the facility provided a policy/procedure entitled, Functional Impairment - Clinical Protocol (No Date). Review of the policy/procedure revealed, If a potential to benefit form rehabilitation therapies (either skilled or unskilled) is identified, the attending physician will order a relevant therapy evaluation . In conjunction with the physician and staff, therapists will propose a rehabilitation or restorative care plan that provides an appropriate intensity, frequency and duration of interventions to help achieve anticipated goals and expected outcomes .

Based on observation, interview and record review, the facility 1) Failed to provide a safe and monitored environment to prevent falls with serious injuries for two residents (Residents #12, Resident #30), 2) Failed to ensure that neurological assessments (neuro checks) were completed per Standards of Practice after unwitnessed resident falls for 2 residents (Resident #16, Resident #44) of 5 residents reviewed for falls, and 3) Failed to ensure that staff provided care for a 2-person assist with bed mobility for Resident #32, resulting in Resident #12 being transferred to the hospital for an arm fracture and head injury; Resident #30 having multiple falls and Resident #16 and Resident #44 to have the potential for head injury without necessary Neuro assessments that could further lead to serious complications and death. Findings Include: Resident #12: Accidents: On 4/26/22 at 9:42 AM, during a tour of the facility Resident #12 was observed awake and alert, lying in bed, when asked about her mobility she stated, I have fallen once in this room- I fell and hurt myself. It was really painful. A record review of the Face Sheet and Minimum Data Set (MDS) assessment indicated Resident #12 was admitted to the facility on [DATE] with diagnoses: Dementia, Diabetes, [CONDITION(S)], history of mini-strokes, weakness, [CONDITION(S)], [CONDITION(S)], anxiety, history of falls, hypertension, diabetic [CONDITION(S)], [CONDITION(S)] of liver, history of kidney failure. The MDS assessment dated [DATE] indicated the resident had cognitive loss with a Brief Interview for Mental Status (BIMS) score of 7/15 and needed 2-person assistance with bed mobility and transfers and 1-person assistance with all other care. A review of the incident and accident reports revealed Resident #12 fell 3 times: 4/26/21, 5/13/21 and 9/27/21. Incident and Accident Report 4/26/21 at 4:16 PM in the dining room: Stood up to switch from armchair to wheelchair and fell on floor. fell to left side and hit left side of head, left ribs, and nose. Later she voiced right knee pain. Fall was witnessed . Resident Description: I fell and hurt myself. My ribs and nose and knee hurt . Voices pain left side of head, left ribs, nose and right knee . Predisposing Physiological Factors: Gait Imbalance Incident and Accident Report 5/13/21 at 7:30 AM in the resident's room: Found Patient . in room on floor sitting and leaning against TV wall . left arm was unaligned wrist to arm, right arm pain, rib pain . Resident Description: I fell . Patient was asked if she broke her fall forward by putting her hands down in front of her and she said, Yes . Patient said both arms hurt . obtained order to send to ER for evaluation . Injury location: Right elbow . Level of Pain: 9 (scale of 0-10) . Predisposing Physiological Factors: Confused, Gait Imbalance . No witnesses . Review of a Skilled Charting note dated 5/13/2021 at 7:39 AM and created 1 day later on 5/14/2021 at 6:45 PM: Guest was previously assessed by other staff nurses and placed in wheelchair, noted that right wrist was dislocated and splinted and placed ice on wrist until ambulance arrived. Doctor was texted by other nurse . There was no documentation of assessment or that Resident #12 fell , in the medical record at the time of the incident. The next Progress note was dated 5/13/2021 at 5:01 PM: Note text: Guest arrive via stretcher . at 1618 (4:18 PM) new orders for RUE (right upper extremity) cast and [CONDITION(S)] ABT (antibiotic) . On 5/19/2021 at 9:48 AM, 6 days after Resident #12 had fallen, a Skilled Charting progress note provided, Note text: Guest has been using her left arm since her fall, but today she can't use it. She wouldn't even feed herself. I tried to reposition her arm and heard a pop. Left note for doctor to visit today. 5/19/2021 at 4:50 PM, a Progress note/Discharge Summary revealed, Note text: This a.m. (resident) was noted to have decreased mobility to LUE (left upper extremity) joint. Area edematous with aged yellow bruising to the lateral aspect . asked (resident) to perform active range of motion . she experience 9/10 pain . new order for STAT 2 view LUE x-rays to include humerus, elbow and forearm (radius/ulna) . results establishing an acute fracture to left distal humerus . denied any other incidents (related to) falling or other trauma since 5/13/21 and that she had intermittent pain since the incident . left via EMS transport . The resident returned to the facility 2 days later on 5/21/21. 5/21/2021 at 6:06 PM, Skilled Charting Note text: Guest was readmitted with fracture left arm. Left arm is in a sling and she says that she cannot move her shoulder. Staff attempted to feed her, but she refused food at this time. She has cast right arm . says she cannot use the call light because, I broke both my arms. I can't do anything. Incident and Accident Report: 9/27/21 at 4:59 AM in the resident's room: Observed sitting on buttocks next to bed in bedroom about 4:50 am, unassisted ambulation . bleeding from front hairline . Resident unable to give description . Immediate Action Taken: (This was blank) . Injuries observed at time of Incident: No injuries observed at time of incident . Predisposing Physiological Factors: Gait Imbalance . Predisposing Situation Factors: Ambulating without Assist . No witnesses . A review of a Progress Note/Incident Note dated 9/27/2021 at 5:32 AM: Note text: Televisit completed post fall. Resident states she lost consciousness in the bathroom and hit her head on the cement. Bleeding from the forehead . A Progress Note dated 9/27/2021 at 5:47 AM: Note Text: Transported to (ER) to receive CT Scan due to fall. There was no additional documentation of the resident's return from ER or results. A review of the Fall Risk Assessment indicated the resident was reassessed for Fall risk after falling on 4/26/21 and 9/27/21. There was no Fall Risk Assessment completed after the resident fell on [DATE] and fractured both arms. A Fall Risk Assessment completed on 3/1/2021 for Resident #12 indicated a Fall risk score of 10.0 Moderate Risk. In the Intervention/Comment section, there was nothing documented. A Fall Risk Assessment completed on 4/26/21 after Resident #12 fall indicated a Fall risk score of 16, High Risk. The Intervention/Comment was listed as Care Plan reviewed. There was no documented intervention. A Fall Risk Assessment initiated on 8/23/21 prior to the Resident's next fall on 9/27/21 and locked on 10/5/21 after the resident fell indicated a Fall risk of 17 High Risk. The Intervention/Comment section was blank. A Fall Risk assessment dated [DATE] after Resident #12 fell again had no Intervention or comments in the Intervention/comment box. A review of Resident #12's Care Plan titled, Risk for falls . date initiated 8/26/2020 and revised 1/21/22 indicated there was no updated intervention to the care plan after the resident fell and injured her head on 9/27/21; The interventions were updated on 4/26/21 Assist with transfer to dining room chair during meal services related to fall on 4/26/21. This intervention was documented as Resolved and removed from the care plan; On 5/13/21 the care plan was updated with, Assist guest with toileting in a.m., after meals, and before bed related to fall on 5/13/21. This intervention is Standard nursing practice and was not enacted on the care plan until the resident had multiple serious injuries. On 4/27/22 at 2:25 PM, the Director of Nursing was interviewed related to the resident's falls and lack of interventions. She provided no comment. Resident #30: Accidents: On 4/26/22 at 10:45 AM, during a tour of the facility, Resident #30 was observed lying in bed and stated, It takes a long time for someone to take care of me. I have to wait a long time. A record review of the Face sheet and MDS assessment indicated Resident #30 was admitted to the facility on [DATE] with diagnoses: Dementia, history of a stroke, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], depression, anxiety, weakness, [CONDITION(S)] bilateral, peripheral vascular disease, hypertension, chronic pain, GERD, [CONDITION(S)] and [CONDITION(S)]. The MDS assessment dated [DATE] indicated mild cognitive loss with a BIMS score of 12/15 and the need for assistance with all care: 1-person extensive assistance with bed mobility, toileting, dressing and personal hygiene and 2-person total assistance with transfers. A review of the Incident and Accident reports for Resident #30 indicated the resident had multiple falls while in the facility: 11/7/21, 1/15/22, 2/24/22, 4/24/22. Incident and Accident Report 11/7/2021 at 4:45 PM: At 1645 (4:45 PM), this nurse was summoned to guests' room by CENA (nurse aide) who stated guest was on the floor . noted guest laying on her back beside the left side of her bed . Resident Description: When asked what happened, guest stated she was laying on the bed and decided to sit up on the side of the bed, but she slid off and landed on her buttocks . Other info: . Guest does have difficulty in repositioning and is weak . No witnesses . An Incident note dated 11/7/2021 at 5:04 PM: Patient was evaluated via Telemed visit for fall . Another note dated 11/7/2021 at 7:03 PM reviewed the Incident and Accident Report findings. No additional assessment until 11/11/2021 at 8:01 AM related to Patient's blood sugar was 78 at 0500 (5:00 AM). Snack given and patient stated feeling better . There was no mention of the resident's fall or measures to prevent future falls. Incident and Accident Report 1/15/2022 at 5:15 PM: This nurse was walking past guests doorway to room when I glanced in and noted [NAME] was sitting on the floor with her back against the side of her bed . She saw me and motioned with her hand for me to come in . Guest states she feels some mild discomfort on her buttocks and near should blades . Other info: Guest was too close to the edge of the bed when she went from laying on bed to sitting up and slid off the edge to the floor on her buttocks . No witnesses . An Incident Note dated 1/15/2022 at 7:29 PM: Note Text: At 1715 (5:15 PM ) . checking hallway rooms when I glanced into 404 and noted guest was sitting on the floor . saw me and was waving her hand for me to come in . guest stated she knew it was close to supper time and had been laying on the bed. She decided to sit up on the side of her bed for the meal but was too close to the edge and she slid off onto the floor . call placed . to (family) and he stated she did this not long ago . No further notes/assessments related to the fall. Incident and Accident Report 2/24/2022 at 11:25 AM: Resident observed on floor . Resident Description: . my legs went out . Level of Pain: 5 (of 0-10 scale) . No witnesses . A Progress Note dated 2/24/2022 at 12:21 PM: . writer approached room 404 to administer noon medications and was met by CNA (nurse aide) opening the room door reporting she needed help after lowering resident to floor . entered room and observed resident on floor in front of toilet . sitting flat leaning on right side . assisted in Hoyer lift by writer and 2 CENA's . resident (complained of) some generalized discomfort in right knee . resident stated, feels achy . care plan reviewed and updated. Another Progress note dated dated 2/24/2022 at 4:25 PM: Resident had a change of plane today and was lowered to the floor . had an issue with feeling lightheaded the day prior as well . BP 105/74 . after reviewing medications, [MEDICATION(S)] (for hypertension) was decreased . Incident and Accident Report 4/24/2022 at 4:20 AM: Patient observed on floor on the left side of her bed . Resident Description: I rolled out of bed . Other Info: Patient will frequently hang her left leg over the side of the bed . No witnesses found . A Skilled charting note dated 4:38 AM: Note Text: Guest observed laying left side on floor beside bed . 96/65 (BP low), 58 (Pulse low) . An Incident Note dated 4/24/2022 at 6:44 AM: Telemed completed post fall . no injures . There was no further assessment related to the fall. A review of the Fall Risk Assessments indicated the resident was reassessed for Fall risk after 3 of the 4 falls: 11/7/21, 1/16/22 and 4/24/22. The Fall on 2/24/2022 was not reassessed. A Fall Risk assessment dated [DATE] indicated a Fall Risk score of 14- Moderate Risk . Intervention/Comment was blank. A Fall Risk assessment dated [DATE] with a Fall Risk score of 14- Moderate Risk . Intervention/Comment: Staff to try and get guest to sit up in w/c (wheelchair) for her meals instead of on the side of the bed. A Fall Risk assessment dated [DATE] with a Fall Risk score of 18- High Risk . Intervention/Comment was blank. A review of the Care plans for Resident #30 provided, At risk for falls related to history of falls . date initiated 7/9/2918 and revised 1/15/2022. The Fall Care plan had not been updated with new interventions to aid in the prevention of future falls after the resident fell on [DATE] and 1/15/22. The intervention on 3/3/2022, 7 days after the 2/24/22 fall was Transfer status: 2-person assist with Hoyer. The 4/24/22 care plan update was Encourage patient to lay in the center of the bed and not hang her left leg off the bed. On 4/25/2022 at 2:50 PM Confidential Person X was interviewed about staffing on the resident halls and said usually nurses had 2-3 halls and nurse aides were assigned 12-14 residents on day shift. The Confidential Person was asked if they were able to provide the resident's care needs and monitor them for safety and said there wasn't enough time to do all of that, especially when many of the residents needed 2-person assistance and there was usually only 1 nurse aide on the hall. A review of the facility policy titled, Falls-Clinical Protocol, dated revised October 2010 provided, . the staff and physician should document in the medical record a history of one or more recent falls . In addition, the nurse shall assess and document/report the following: Vital signs; recent injury, especially fracture or head injury . Musculoskeletal function . change in condition or level of consciousness; Neurological status; Pain, frequency and number of falls since last physician visit; Precipitating factors, details on how fall occurred; All current medications, especially those associated with dizziness or lethargy; all active diagnoses . The staff will document risk factors for falling in the resident's record and discuss the resident's fall risk . Risk factors for subsequent falling include lightheadedness or dizziness, multiple medications, musculoskeletal abnormalities, peripheral [CONDITION(S)], gait and balance disorders, cognitive impairment, weakness, environmental hazards, confusion, visual impairment, and illnesses affecting the central nervous system and blood pressure . The physician will identify medical conditions affecting fall risk . the staff will evaluate and document falls that occur while the individual is in the facility . For an individual who has fallen , staff will attempt to define possible causes within 24 hours of the fall . the staff and physician will continue to collect and evaluate information . Based on the preceding assessment, the staff and physician will identify pertinent interventions . the staff with the physician's guidance, will follow up on any fall with associated injury until the resident is stable . the staff and physician will monitor and document the individual's response to interventions intended to reduce falling . If the individual continues to fall the staff and physician will re-evaluate the situation and consider other possible reasons . Resident #44: On 4/25/55 at 3:31 PM, Resident #44 was observed in their room. An overwhelming foul odor and increase in temperature was instantly noted upon entering the room. The Resident was positioned on their back in bed with a sheet and comforter over them. Resident #44's hair was visibly wet, and perspiration was observed on their forehead and the sides of their face. The closer in proximity to the Resident, the foul odor of bowel and body odor became increasingly prevalent and unendurable. When spoke to, Resident #44 made eye contact but did not provide meaningful responses when asked questions. On 4/26/22 at 9:57 AM, Resident #44 was observed in their room in bed. An overbed table was in place over the bed. The foul odor remained in the room but was less pungent throughout the room. The Resident had a disheveled appearance, and a greasy film was present on their hair. When spoke to Resident #44 made eye contact but did not provide meaningful responses. Record review revealed Resident #44 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis which included Covid-19, pressure ulcer (wound caused by pressure) and [CONDITION(S)]. Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively impaired, required extensive to total assistance to complete all ADLs with the exception of eating, and have no falls since their last assessment completion. Review of Resident #44's progress notes in the Electronic Medical Record (EMR) revealed the following: -1/27/22 at 1:23 PM: Skilled Charting . At 11:45 CNA called nurse to room . Upon entering guest's room, nurse found that upper body was on the floor parallel to the bed while the lower half of body was in the bed . was on tummy. Lowered bed closer to floor and laid guest on back . voiced no pain during ROM or when asked . said that didn't hit head. Neurochecks were started. - 2/22/22 at 4:56 PM: Resident observed to be lying on floor beside bed near window. Resident assessed for Pain . Neuro checks initiated . denies hitting head. No visible injuries noted. Resident assisted back to bed via 5PA (5 person assist) assist and Hoyer sling. Resident Alert and oriented 3-4. Foley bag observed to be leaking from bag . Review of neurological assessment (neuro check) documentation following the falls in Resident #44's EMR revealed assessments were completed on the following dates/times: - 1/27/22 at 12:00 PM - 1/27/22 at 12:15 PM - 1/27/22 at 12:30 PM - 1/27/22 at 1:30 PM - 1/27/22 at 2:30 PM - 1/27/22 at 3:30 PM - 1/27/22 at 4:30 PM - 1/28/22 at 11:04 PM - 2/22/22 at 8:00 PM - 2/22/22 at 8:10 PM Review of Resident #44's care plans revealed a care plan entitled, Risk for falls r/t (related to) Covid 19 recovery . Falls, Autism . Muscle weakness (Initiated: 11/1/21). The care plan included the following interventions: - Administer medications as ordered by physician (Initiated: 11/1/21) - Ambulation: Non-ambulatory (Initiated: 11/1/21; Revised: 1/21/22) - Reinforce need to call for assistance (Initiated: 11/1/21) - Resident transfers via 2 PA Hoyer (Initiated: 11/1/21; Revised: 12/4/21) - Weight Bearing Status: WBAT (Weight Bearing As Tolerated) (Initiated and Revised: 11/1/21) On 4/26/22 at 9:57 AM, Resident #44 was observed in their room in bed. An overbed table was in place over the bed. The foul odor remained in the room but was less pungent throughout the room. The Resident had a disheveled appearance, and a greasy film was present on their hair. When spoke to Resident #44 made eye contact but did not provide meaningful responses. Review of Incident and Accident Reports for Resident #44 detailed the following: - 1/27/22 at 12:40 PM: Fall . Resident's Room . CNA came to alert nurse that guest was part way on the floor. When nurse entered room . saw guest with part of upper body on the floor parallel to the bed, with legs and feet in the bed. Lowered bed and laid guest on the floor on back . Lifted guest with 2-person assist back into bed . Resident Description: 'I slid out of bed.' . 'I don't know how I slid out. Immediate Action Taken: ROM (Range of Motion) was done and is Ok. No pain voiced . Mental Status: Orientated to Person . No Witnesses . - 2/22/22 at 3:30 PM: Fall . Resident's Room . Resident observed lying on the floor beside bed on window side of the bed . Resident states I rolled out of bed . Vital signs assessed. ROM assessed. Pain assessed. Resident assisted back to bed via 5 PA assist and Hoyer sling . Level of Consciousness: Alert . Mobility: Bedridden . Mental Status: Orientated to Person . Place . Situation . Time . Predisposing Physiological Factors . Confused . Predisposing Situational Factors . Other . Other Info: (Blank) . No Witnesses . The Incident and Accident Report did not include any potential causes of the falls, interventions implemented to prevent further falls, and/or investigation related to what had occurred. An interview was completed with the Director of Nursing (DON) on 4/2/22 at 2:39 PM. When queried regarding facility policy/procedure related to completion of neuro checks for unwitnessed falls, the DON revealed neuro checks should be completed for all falls that are not witnessed by staff. The DON was then asked what the frequency of neuro check completion following an unwitnessed fall is and revealed neuro checks should be completed every 15 minutes for the first hour, then every 30 minutes, then hourly, then every hour fours, eight hours, and 24 hours but was unable to recall the specific frequency and indicated they would need to review the policy/procedure to confirm. Resident #44's neuro check documentation was reviewed with the DON at this time. When asked if the neuro checks were comprehensively completed per protocol, the DON stated, I can verify they weren't completed. Resident #44's Incident and Accidents forms and care plans were reviewed with the DON at this time. When queried if the facility completed any additional investigation of the falls and if any staff education was provided, the DON indicated they were not aware of any. When asked what interventions were implemented following the falls to prevent further falls and potential injury, the DON reviewed Resident #44's care plans and stated they were no interventions implemented. Resident #16: According to admission face sheet, Resident #16 was admitted to the facility on [DATE], with diagnoses that included: [CONDITION(S)] Disease, Dementia, Depression, Anxiety, and other complications. According to the Minimum Data Set (MDS) dated [DATE], Resident #16 scored a 15 on the Cognition Assessment indicating no cognition impairment, and was also coded as requiring limited assist (supervision) with Activities of Daily Living (ADL) care to include toileting, ambulation, and dressing. Resident #16 was also coded as 'no' to [CONDITION(S)] and 'no' to behaviors. Review of medical record reflected that Resident #16 had falls on 1/25/22, and 4/26/22. The Director of Nursing was asked to provide Accident/Incident reports for both falls. According to the Accident/Incident report dated 1/25/22 at 21:50, the description on the report was: Guest observed in bedroom 1/25/22 at about 9:50 PM, in bathroom sitting on buttocks in front of toilet with clothing on, resident could not verbalize incident, no apparent injury . Under 'Immediate Action' documented monitoring Neuro's, notified on call provider, telemed. Under Mobility: Ambulatory without assistance .Gait imbalance .no witness found and the name of the nurse preparing the report. The Director of Nursing verbalized for unwitnessed falls, staff are to do Neuro checks (Neurological Assessment). The Director of Nursing was asked to provide Neurological Assessment for the unwitnessed fall for 1/25/22. The DON returned a short time later and verbalized she could only find a partially completed Neurological Assessments. The DON was asked when the Neuro check assessment is supposed to be performed, and verbalized: Every 15 minutes times one hour, then every 1 hour times 4 hours, then every 2 hours times 4 hours, and then every shift times 24 hours, for a total of 12 completed Neurological Assessments. The DON indicated it is specified on the forms. Review of the form specifies to check: Level of Consciousness, Pupil response, Hand grasps, Extremities, Pain, Blood Pressure, Respirations, and Pulse as part of the assessment. Review of Neurological assessment dated [DATE], reflected Neuro's completed at: - 9:50 PM -10:05 PM -10:30 PM -10:45 PM (Every 15 minutes times one hour). The next assessment was completed: -11:45 PM -12:45 PM There were no other documented Neurological Assessment as completed after 12:45 PM. (There should have been 12 assessments completed and only 6 were done.) Resident #32: According to admission face sheet, Resident #32 was admitted to the facility on [DATE], readmitted [DATE], with diagnoses that included: Palliative Care, Vascular Dementia, Diabetes, Diabetic Foot Ulcer, [CONDITION(S)], High Blood Pressure, and other complications. According to the Minimum Data Set (MDS) dated [DATE], Resident #32 scored a an 8 on the Cognition Assessment indicating moderate cognition impairment, and was also coded as requiring total assist with 2 person assist for Bed Mobility, Transfers, Dressing, Toileting, and Personal hygiene. The following observation of Activities of daily Living (ADL) care was done on 4/28/22, 8:47 AM, with Nursing Assistant D. NA D was in Resident #32's room when Surveyor entered. NA D was performing a bed bath and person hygiene and Bed Mobility for Resident #32. NA D was the only staff present in the room. NA D was wearing gloves and had water running in the sink, and verbalized it takes the water a few minutes to get warm, so I let it run. NAD washed Resident #32's face, and began to wash down the chest area, working down the body. NAD verbalized Resident is assessed for a 2 person assist, but he moves well, so I do this with out a second person. He is supposed to have 2 person for moving him in bed. I take care of him a lot I just do it and get it done. NA D was asked if he often takes care of 2 person assist by him self, and indicated Yes, I have to sometimes, if there are call offs. I do 2 person assists by myself. Most of the time you can't find anyone to help. I was late today, so I am behind and trying to catch up with all I have to do. I did this to myself The care continued, and NA D began to wash the frontal perineal area including the scrotal area. NA D then rolled Resident #32 on his right side, away from NA D, and washed his back. (Resident is coded as extensive 2 person assist for Bed Mobility in the MDS assessment). NA D performed 2 person assist with Bed Mobility by himself and was fully aware the Resident was assessed for 2 person assist with Bed Mobility, several times during ADL care, and also did not perform proper hand hygiene during care. (Resident #32 was assessed per the MDS for 2 person assist with Bed Mobility.) The DON was asked for Policy related to Bed Mobility and verbalized they did not have a specific Policy and provided a transfer policy. Review of facility 'Transfer Policy' The facility will determine the guest's transfer status and level of assistance needed by utilizing an IDT approach. This approach will include consideration of hospital paperwork, therapy consultation/assessment, nursing and physician assessment and the guest's preference, as applicable. The facility believes in person centered-care and will honor the guest's preference to the extent practicable. However, the facility reserves the right to refuse to honor a guest's specific request/preference if a determination is made that the guest's request/preference poses a risk of harm to guest or staff. Once a determination is made as to the level of assistance needed it will be added to the plan of care. CENA's and licensed nurses will be responsible to ensure they are following the care plan/Kardex.

This Citation pertains to Intake Numbers MI 611 and MI 657. Based on interview and record review, the facility failed to assess, treat, and monitor pressure ulcers for one resident (Resident #1) out of three residents reviewed for pressure ulcers resulting in the worsening condition of the wounds, the development of new wounds, and hospitalization . Findings include: According to the Admission Record, Resident #1 was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 had been a previous resident of the facility on 12/29/2019 and 3/6/2020; according to the electronic medical record (EMR) following those stays he had discharged to home. According to John Hopkins Medicine, Pressure injuries have 4 stages, ranging from an early warning signal to the most severe: Stage 1. A red, blue, or purplish area first appears on the skin like a bruise. It may feel warm to the touch and burn or itch. Stage 2. The bruise becomes an open sore that looks like an abrasion or blister. The skin around the wound can be discolored and the area is painful. Stage 3. The sore deepens and looks like a crater, often with dark patches of skin around the edges. Stage 4. The damage extends to the muscle, bone, or joints and can cause a serious infection of the bone, known as osteo[DIAGNOSES REDACTED]. It can also lead to a potentially life-threatening infection of the blood [MEDICAL CONDITION]. Unstageable pressure ulcers are also hard to diagnose because the bottom of the sore is covered by slough or eschar. The ulcer may be yellow, green, brown, or black from slough or eschar. According to the notes, for Resident #1, from the local hospital's emergency department physician on 6/3/2020, Ultimately, the significant worsening of the wounds (compared to pictures from last admission) is very concerning. According to the hospital record, dated 6/4/2020, the wounds had last been assessed at the hospital on 5/5, was noted to have a Stage 2 pressure injury of Left ear, Stage 3 pressure injury to Right heel, Stage 3 pressure injury to Sacrum/coccyx, and a Stage 2 pressure injury to lumbar spine. On 6/4/2020, the hospital records revealed that the Stage 3 wound on the sacrum/coccyx had evolved into a non-healing Stage 4 with bone and tendon exposed and had increased in size and depth with undermining present, (according to Woundeducators.com Wound undermining occurs when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound's edge.) In addition, the hospital record, dated 6/4/2020 for Resident #1, the record revealed, the stage 2 pressure injury of the lumbar spine had become a stage 3 wound and had increased in size. The left heel pressure injury had become blackened, with defined edges, and had become larger in size. A new pressure injury had developed on Resident #1's right hip that was new and now an unstageable wound. In addition, there were multiple new ischemic skin changes/wounds to bilateral lower legs and feet that were not present on 5/5/20. The note continued that Resident #1 was cachectic, that is, defined as loss of weight, wasting of muscles and body fat, and that he had lost weight in the last 4 weeks. A note from the social worker in the hospital revealed that a complaint for potential medical neglect had been filed with the State of Michigan at the request of the treating emergency room physician, Dr. J. During a telephone interview with Dr H on 9/1/2020 at 9:00 AM, Dr H stated that Resident #1 had been seen and treated at the hospital during the admission in May 2020 and on 6/3/2020 and that she felt that Resident #1 had been neglected at the facility, due to the worsening of his wounds and the development of new wounds. According to the facility electronic medical record (EMR), although Resident #1 had been admitted on [DATE], no wound assessment or treatment of [REDACTED]. According to the May 2020 Treatment Administration Record (TAR), no treatment to any wound occurred until 5/11/2020, and the wound treatment for [REDACTED]. The code 9 was for other/see nurses notes, however, there was no associated nurses note for that day. There was another entry for a treatment to the spine to cleanse the pressure injury with normal saline, pat dry, and apply an allevyn dressing to pressure relief every three days and as needed if soiled or dislodged at bedtime every three days, initiated on 5/12/20, with no initial indicating it had been performed on 5/15/20. The order to treat the coccyx wound with a wash with normal saline, apply Triad paste, cover with four by four gauze and secure at bedtime starting on 5/11/2020, not initialed as performed on 5/15/2020 and discontinued on 5/21/2020 and restarted on 5/21/2020 as twice a day but not initialed as performed on the mornings of 5/22/2020, 5/24/2020, 5/28/2020, and 5/29/2020 or on the afternoon of 5/28/2020 and coded with a 9 on 5/31/2020 with no corresponding nurses note. During a telephone interview with Registered Nurse (RN) D on 9/2/2020 at 2:18 PM, she stated that she had been the wound nurse and focused on wounds earlier in the year, but when Covid-19 hit she was moved to a unit manager position and the responsibility for wound assessments and weekly measurement of wounds fell to the floor nurses with the unit managers overseeing the wounds to assure that the required weekly measurements were recorded. The Skin & Wound Evaluation assessments, that included taking measurements and pictures, occurred on 5/11/2020, three days after his admission, 5/22/2020, eleven days later, 5/31/2020, nine days later, and 6/1/2020 for Resident #1. These dates were confirmed by RN D, as well as Resident #1's admission date of [DATE]. On 5/8/2020, RN D had entered a Wound Note in the EMR which revealed the presence of bruising in various stages of healing, multiple areas of pressure injuries including right buttock, coccyx, spine, and bilateral heels. No further measurements were found in the EMR. Resident #1's Admission/Re-Admission nursing assessment did not contain a section for description of the wounds. The admission progress note indicated that Resident #1 had arrived at the facility at 2:21 PM on 5/8/2020. A nursing progress note on 5/8/2020 at 7:48 PM identified that Resident #1 had scattered bruising in various stages of healing and multiple areas of pressure injuries including right buttock, coccyx, spine, and bilateral heels. On 5/11/2020 Dr B noted that Resident #1 had extensive bruising present he had multiple sores in his sacral and coccygeal area .skin shows extensive bruising involving the right flank. He has stage 2 pressure ulcer located on the coccyx He is got stage 2 pressure ulcer all located on the spine he is got multiple bruising throughout all extremities. He is got some right heel stage 2 pressure ulcer On 5/11/2020, three days after admission, the pressure ulcer on Resident #1's spine was photographed, assessed, and measured. The pressure area was identified as a stage 2. The area of the wound was measured as 0.63 squared centimeters (cm). The pictures showed two specific reddened areas on the spine with crater-like centers. On June 1, 2020, the area was re-photographed and measured, still identified as a stage 2, now the area was 11.33 squared cm and was one large area reddened with peeled skin on the outside and a large, blackened open area in the center. The progress of the wound was documented as stable. On 5/11/2020, three days after admission, the pressure ulcer on Resident #1's right hip was photographed, assessed, and measured. The area was identified as a stage 2. The area was closed, dark red/purple skin. The area was measured as 16.64 squared cm. On June 1, 2020, the area was re-photographed and measured, now identified as a Deep Tissue Injury (DTI), with an area of 7.11 squared cm. In the photograph, the skin appeared black in the center with surrounding redness and dark red or brown drainage from the wound on the dressing which was peeled back. The drainage was not identified or described in the assessment on 6/1/2020. The progress of the wound was documented as stable. On 5/11/2020, three days after admission, the pressure ulcer on Resident #1's left heel was photographed and assessed. The area was identified as a DTI. The area was closed, dark red/purple skin. The area was not measured. On June 1, 2020, the area was re-photographed and measured, still identified as a DTI, with an area of 8.83 squared cm. In the photograph, the skin appeared black in the center with the surrounding skin peeling. The progress of the wound was documented as stable. On 5/11/2020, three days after admission, the pressure ulcer on Resident #1's right heel was photographed, assessed, and measured. The area was identified as a DTI. The area was closed, dark red/purple skin. The area was measured as 0.53 squared cm. On June 1, 2020, the area was re-photographed and measured, now identified as a stage 2 pressure ulcer, with an area of 13.56 squared cm. In the photograph, the skin appeared black in the center with surrounding peeling skin. The drainage was not identified in the assessment on 6/1/2020. The progress of the wound was documented as stable. On June 1, 2020, the area on the coccyx of Resident #1 was re-photographed, assessed, and measured. The area was identified as unstageable. The surrounding area was reddened with a black or slough area in the center. The area was measured as 57.9 squared cm, an increase of 216%. This area was also documented as stable. The Minimum Data Set Resident Assessment (MDS), for Resident #1, with an assessment reference date of 5/14/2020, identified that there were 3 stage 2 pressure ulcers and 2 DTI's. The associated, undated, Care Area Assessment (CAA) identified five pressure injuries, three at a stage 2 on the coccyx, spine, and right heel and 2 DTI's, one on the right gluteus (hip) and one on the left heel. The section for wound description read see skin and wound notes. The section for Extrinsic risk factors had boxes checked for Pressure and Needs special mattress or seat cushion to reduce or relieve pressure. Left unchecked were the boxes for Requires staff assistance to move sufficiently to relieve pressure over any one site, Confined to a bed or chair all or most of the time, Requires regular schedule of turning, and Friction and shear, and Maceration. Although the Section G for Functional Status indicated that Resident #1 required extensive assistance of two staff members for bed mobility. Under the section for [DIAGNOSES REDACTED].#1 had a Cerebral Infarction (stroke), and Dyspnea (difficulty breathing). In the box below on the CAA, for writing in Describe impact of this problem/need on the resident and your rationale for care plan decision, had been entered a history of [MEDICAL CONDITION]. In the Functional Status section of the MDS, Resident #1 had been coded as having a one-sided limitation of his range of motion on an upper extremity. According to the weight section of the EMR, Resident #1 had weighed 173 pounds in December 2019 and 144.6 pounds on 5/10/2020, a loss of 16% in six months. Other pressure injuries for Resident #1 that were identified on 5/30/2020 included the top of the right foot, identified as a DTI, acquired in-house, that measured an area of 11.77 squared cm, the photograph showed an irregular shaped, shiny, red/deep purple area of skin. On 6/1/2020, the same area was measured as 15.9 squared cm, an increase in size of 35%, with the progress reported as stable. Other pressure injuries on Resident #1 that were identified on 5/30/2020 included the middle of the right foot, identified as a DTI, acquired in-house, that was not measured. The photograph showed an irregular circular shaped, shiny, red/deep purple area of skin. Other pressure injuries on Resident #1 that were identified on 5/30/2020 included the side of the right calf, identified as a DTI, acquired in-house, that was not measured, the photograph showed an irregular shaped, shiny, red/deep purple area of skin that took up a large portion of the calf, with some peeling skin toward the bottom. On 6/1/2020, the same area was measured as 25.04 squared cm, with an open area in the center and peeling skin from the bottom side of the calf. The progress reported as stable. On 6/1/2020, additional pressure injuries were identified for Resident #1 on the middle of his left foot, identified as acquired in-house, two days previous, with an area that measured 8.42 squared cm, the photograph showed an irregular shaped, closed, deep purple/red area of skin. There was no documented assessment or measurement of the wound which had been identified two days earlier. On 6/1/2020, additional pressure injuries were identified for Resident #1 on the side of his left calf, identified as acquired in-house, two days previous, with an area that measured 3.91 squared cm, the photograph showed an irregular shaped, deep purple/red area of skin with peeling skin at the bottom and upper sides. There was no documented assessment or measurement of the wound which had been identified two days earlier. On 6/1/2020, additional pressure injuries were identified for Resident #1 on the middle side of his left foot, identified as acquired in-house, two days previous, with an area that measured 1.69 squared cm, an increase in size of 37%, the photograph showed an irregular shaped, closed, deep purple/red area of skin. There was no documented assessment or measurement of the wound which had been identified two days earlier. On 6/1/2020, additional pressure injuries were identified for Resident #1 on the tip of his great toe of his left foot, identified as acquired in-house, with an area that measured 2.27 squared cm, the photograph showed a circular shaped, closed, deep red area of skin. On 9/3/2020 at 8:10 AM, a telephone interview was conducted with Physician B. Dr B stated that he had cared for Resident #1 while he was at the facility. He stated that he did in-person visits alternating with the Physician's Assistant C who was certified in wound care. Dr. B stated that Resident #1 had several comorbidities that were impeding the ability for his wounds to heal. These included his dementia, lack of mobility, poor circulation, and emaciation (defined as loss of weight, thin appearance). Dr B noted that he would have expected nutritional support and an assessment by a dietician for a decreased appetite. On 5/12/2020 Dr. B had noted in the EMR that Resident #1 had an unstageable pressure ulcer of his left heel, a Stage 2 pressure ulcer on his right heel, a Stage 2 pressure ulcer on the coccyx, a Stage 2 pressure ulcer of the spine, and multiple bruising on his right side and throughout all of the extremities. On 9/3/2020 at 11:50 AM, a telephone interview was conducted with the Physician's Assistant (PA) C. PA C recalled that she had seen Resident #1 on a few occasions when he was last a resident at the facility. She had first seen him on 5/18/20, then again on 5/21/2020 to observe his wounds. Resident #1 was bedridden as she recalled, and the facility was trying to encourage nutrition. When asked if she had referred him to the dietician, PA C stated, there is a dietician on staff. PA C stated that from the medical aspect, we are cognizant of wounds. And that Resident #1 had a vascular component (poor circulation) to his wounds that was concerning related to wound healing. PA C stated she had ordered a Doppler exam to verify his circulation. The result of the bilateral Doppler exam of both lower feet, performed on 6/2/2020, was moderate bilateral [MEDICAL CONDITION] with possible occlusions of both arteries on the top of his feet. The facility policy for Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated as revised October 2010, directed that a full assessment of the pressure sore would include location, stage, length, width and depth, presence of drainage or necrotic tissue. The admission assessment may identify pre-existing signs, such as a purple or dark area that is surrounded by profound redness, swelling, or induration that might suggest that deep tissue damage has already occurred. The comprehensive assessment, MDS, evaluates the resident's risk factors, skin condition, and other factors which may place the resident at risk for developing pressure ulcers. The assessment should identify which risk factors can be removed or modified. According to John Hopkins Medicine, nutrition plays an essential role in pressure injury healing. The body needs enough calories, protein, and nutrients such as vitamin C and zinc to heal properly. On 9/3/2020 at 2:43 PM a telephone interview was conducted with the Registered Dietician (RD), E. RD E when she was asked about the Minimum Data Set Resident Assessment, with an assessment reference date of 5/14/2020, which she had completed for Resident #1 where she had coded weight loss as No, or unknown. RD E explained that the weight loss was only coded as yes if there had been a 5% weight loss in one month or a 10% weight loss in six months. When reviewing the weights of Resident #1 in the EMR, he had weighed 173 pounds in December of 2019 and 144.6 pounds on 5/10/2020, which represented a weight loss of 16% in six months. The weight loss was not noted in the dietary assessment performed on 5/12/2020, the MDS Care Area Assessment completed on 5/15/2020, or in the plan of care in the focus area of alteration in nutritional status, initiated on 5/8/2020 with updates added 5/9/2020, 5/11/2020, 5/12/2020, and 5/14/2020. RD E stated that she had noted the weight loss during Resident #1's previous admission in March 2020, but didn't know why she didn't code that weight loss again. RD E had completed the Dietary Profile for Resident #1's admission on 5/9/2020, and had entered under the section for the Current Diet Order, regular/pureed Texture with honey thick liquids per Speech Therapist, there were no comments in the box for Resident/family concerns about diet order. In the section for Current texture of food, RD E had entered pureed Texture/honey thick liquids, and again in the box for comments for Resident/family concerns about texture of food had made no entry, although the Speech Therapist had documented on the therapy treatment notes for 5/11/2020 to 6/3/2020 that Resident #1 had stated a preference for mechanical soft foods. RD E had checked the box for Total Assistance as a response to the question about eating assistance required. In the final box for Comments RD E had entered that Resident #1 weighed 144.6 pounds, and was at risk for weight loss, not that he had lost weight. In that box she noted that Resident #1 was independently eating with someone needed to set up his tray. His appetite was noted as 50 to 75% of his meals. The wounds were mentioned with a need for extra protein for healing. RD E stated that she had recommended a supplement of Medpass four ounces once a day and one serving of yogurt daily to provide more protein for wound healing. The CAA worksheet for Nutritional Status listed Functional problems that affect ability to eat, where boxes were checked from pre-filled items, the boxes for Swallowing problem, Need for special diet or altered consistency which might not appeal to resident, Functional limitation in range of motion, and [MEDICAL CONDITION]/[MEDICAL CONDITION] were left blank. According to the Speech Therapy notes for 5/11/2020 to 6/3/2020, the Therapist was treating Resident #1 for dysphagia following cerebral infarction. In the section Other diseases and condition that can affect appetite or nutritional needs, left un-checked were Cardiovascular disease, [MEDICAL CONDITION], Gastrointestinal problem, and weight loss. Resident #1 had [DIAGNOSES REDACTED]. In the section for Medications, Cardiac drugs was left unchecked. Resident #1 had orders for [MEDICATION NAME] (for irregular heart beat), [MEDICATION NAME] (for heart failure), and [MEDICATION NAME] (also for heart failure). In the section for a referral to another discipline warranted? the question was answered No, even though Resident #1 was being seen by the Speech therapist. On 6/3/2020, Resident #1 was sent to the hospital at the family's request for further evaluation of the wounds.

Based on interview and record review, the facility failed to begin cardiopulmonary resuscitation (CPR) and call 911 per standards of practice for one (#902) resident of two residents reviewed for cardiopulmonary resuscitation resulting in the untimely initiation of CPR, delayed emergency response help and the subsequent death of the resident. A review of the American Heart Association; Basic Life Support Healthcare Provider Adult [MEDICAL CONDITION] Algorithm revealed the following steps: victim is unresponsive, shout for nearby help, activate emergency response system via mobile device (if appropriate) Get AED and emergency equipment . (YEAR) update guidelines for healthcare workers. On [DATE], at 10:00 AM, a record review of Resident #902's order summary report . active orders as of [DATE], an admission on [DATE] with [DIAGNOSES REDACTED]. Resident #902 had an active order for CPR. A review of Resident #902's Minimal Data Set assessment dated , [DATE], revealed that Resident #902 had intact cognition. On [DATE], at 11:00 AM, a record review of the Facility Summary of Investigation was conducted which revealed: Summary of Investigation: . EMS had already been to the facility and had left already when DON arrived. The Grand Blanc Police were at the bedroom door of the guest and were waiting for the Medical Examiner to arrive. Administrator was contacted regarding guest passing away and entered facility at approximately 6:40 PM . At approximately 7:30 PM, Medical Examiner arrived at the facility. The Medical Examiner asked if (the resident) had received any guests that day and was told yes, (the resident's) brother had visited earlier in the day. Medical Examiner then said they would be doing an autopsy. A typed statement, that was signed by Nurse H and dated [DATE], revealed At 4:30 PM I went into (the roommates) side of the room and after (the roommate) took her med's I went over to (Resident #902's) side and said hello. I was unlocking the med cabinet, I had my back towards (the resident). (The resident) did not answer me. I turned around and looked at (Resident #902) and approached her. She was laying on her back in the bed with the head of the bed slightly up and the foot of her bed slightly up. I said hello again and began to shake her and picked up her arm. She was flaccid. I did the sternal rub and then checked her pulse. Her skin was cool and I did not find a pulse. I locked the cabinet door and ran out of the room and saw (cena) over on the 500 hall next to the satellite kitchen. I said I need help right now in room . I ran back down and grabbed the crash cart and went to room . I put the head of the bed down and started chest compressions, ambu (artificial manual breathing unit) bag and then (Nurse W) entered the room. (Nurse V) then came into the room less than a minute after . Who was the first to do chest compressions and when? I was and I started them when I re-entered the room with the crash cart. A typed statement, that was signed by Nurse V and dated [DATE], revealed I was on 200 hall and one of the cena's . came to me and said something like there is an emergency on 400 hall and they need you. I turned the corner and saw the crash cart was gone so I took off running. Got into the room and the door was shut, opened the door. (Nurse W) was to the left of the door on the phone and I went around the corner and (Nurse H) was up on the guest's left side head of the bed trying to get the ambu bag on and there was an aide in there . I went around to the side of (Nurse H) and asked if she was a full code. They said yeah so I jumped on the bed and began compressions. I asked why compressions hadn't started and I don't remember if I even got a response. While I was doing compressions (Nurse H) and the aide were trying to figure out how to get the ambu bag to function. I asked for the AED to be started, but it didn't happen. I then asked about the back board and told them to look on the side or back of the crash cart. The back board was then put under (the resident). Chest compressions resumed and then I asked for the AED again ( I think about 4 times). I was giving chest compressions and then we got the AED hooked up and proceeded with that. When the police came they asked who contacted 911. No one answered right away and then finally the officer said that it was called in as a DOA (dead on arrival) and they didn't understand it was an emergency situation. On [DATE], at 11:30 AM, a record review of Resident #902's progress notes revealed a skilled charting noted by Nurse H, that stated, [DATE] 19:46 (7:46 PM) . @ (at) 4:30 pm this nurse entered guest's room and called out hello and opened medication cabinet when guest did not answer this nurse noted guest head of bed slightly up and foot of bed slightly up. Guest non-responsive eyes closed when this nurse touched guest's arm cool to touch and right arm was flaccid and no response when sternal rub done. This nurse then went out to get help and informed cena to get nurse to room and this nurse grabbed crash cart. This nurse lowered feet and head of bed and began chest compressions and then obtained ambu bag and gave two breaths. (Nurse W) then came into room and was instructed to call 911 followed closely by (Nurse V) who assisted with placing back board under guest and began chest compressions AED (automatic external defibrillator) pads were then placed on guest and ambu bag then hooked to oxygen . On [DATE], at 1:40 PM, Nurse Consultant J was asked again to provide a copy of the death certificate or autopsy, Resident #902's face sheet, [DIAGNOSES REDACTED]. On [DATE], at 2:01 PM, a phone interview with Office Manager P, at the Genesee County Medical Examiners office revealed the doctor sent toxicology to the crime lab because of the prior opioid abuse and will not have a final (death certificate) for approximately 60 to 90 days. On [DATE], at 2:40 PM, a phone interview with the Director of Nurses (DON) B was conducted regarding Resident #902. The DON B was asked why Nurse H left Resident #902 knowing she didn't have a pulse and did not start CPR immediately and the DON B responded, the nurse would call for help rather it would be yelling help help! I guess if she needed, she could pull the call light. There is a staff assist button. On [DATE], at 3:24 PM, an interview with the Administrator A was conducted regarding Resident #902. The Administrator A was asked if Nurse H followed standards of practice for initiating CPR and the Administrator A stated, Her roommate could've got help, she is very mobile. Yes. Absolutely (Nurse H) could've yelled. (Nurse H) should've called for help while she started CPR. On [DATE], at 3:44 PM, a phone interview with Nurse H was conducted regarding Resident #902. Nurse H stated, I did a sternal rub. No pulse. Skin was cold. I went in the hallway to get help. I went towards the dining room grabbed someone there. I need nurses in room . I have a code. I did not even think to push the call light. I literally said hello I need help but I couldn't find anyone. I don't think I could've yelled loud enough but I think I would have started chest compressions and pulled the light. I hate to say that. On [DATE], at 8:46 AM, Nurse Consultant J was again asked to provide the documents asked for on the previous day. Nurse Consultant J was asked if they were aware that Nurse H admitted to not doing CPR correctly and Nurse Consultant J responded, Yeah. She's been with us for [AGE] years and she is really upset. On [DATE], at 11:00 AM, a record review of the facility policy Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) . revision date (MONTH) 16, 2012 revealed: If thorough circulatory, airway, breathing (C-A-B) 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 facility protocol, including location. Simultaneously with initiation of CPR/ECC, direct a staff member to obtain an emergency cart/and AED device. Start chest compression according to the America Heart Association recommendations and follow manufactures recommendations when AED device arrives. Continue to follow American Heart Association recommendation for use of AED and CPR/ECC .

Based on interview and record review, the facility failed to assess and monitor behavior changes after family visits, notify the physician and implement care plan interventions for one (#902) resident of one resident reviewed for quality of care resulting in the potential for the family supplying drugs to a resident with known history of opioid abuse and an overdose that may have resulted in a drug overdose death. On 12/18/2018, at 10:00 AM, a record review of Resident #902's order summary report . active orders as of 7/09/2018, an admission on 4/16/2018 with [DIAGNOSES REDACTED]. A review of Resident #902's Minimal Data Set assessment, dated 10-04-2018, revealed that Resident #902 had intact cognition. On 12/18/2018, at 11:00 AM, a record review of Resident #902's electronic medical record revealed the following; History and Physical, dated and e-signed 07/09/2018 by Physician K, that stated, respiratory arrest after narcotic overdose Nov (YEAR). A physician's visit note, dated 5/22/2018 and e-signed by Physician O, stated, (the resident) has a history of narcotic dependence. A review of a progress note, effective date 6/5/2018 and author Social Worker M, stated, Met with (VAAA 'Valley area agency on aging' representative) . states (they) spoke with (Resident #902) and has decided not to go back from where (Resident #902) came. (The resident) is unsure where (the resident) wants to live . VAAA is requiring (the resident) to attend NA (narcotic anonymous) meetings due to (the resident's) past risky behavior and drug abuse. A progress note, dated 9/13/2018 11:38, revealed, discussed issue of (the residents) last two family visits, where (the resident) seemed under the influence of something. Explained that (their) medications can and will be withheld with physician order [REDACTED]. reminded (the resident) of social worker support . discussed family will need to start visiting only in public places. (the resident) was agreeable. Discussed that we can reevaluate on (the residents) quarterly review. (The resident) agreed . DON left and social work offered support . Social work explained impaired cognition and why (their) medications can be held with physician order. The progress note did not have an author listed. There was no mention that the doctor was notified. A progress note, dated 9/13/2018 with author Director of Nursing (DON) B, stated, This writer in with social work to discuss recent events of change of mental status following family visits. Guest verbalized What I did was wrong. Guest did not elaborate on what she did that was wrong. This writer explained to guest that any drug use is not allowed in the facility. Education provided to guest that dr could hold pain medication based on nursing judgement for her safety . The Social Worker nor the DON documented notification to the physician of Resident #902's behavior changes after family visits. A progress note, team conference effective date 10/03/2018, revealed nursing conference held no concerns at this time. A progress note, quarterly review dated 10/9/2018 with author Director of Nursing DON B, revealed . res (the resident) reports her family remains partially involved and they can be observed visiting monthly . staff will cont (continue) to monitor for changes in mood and behavior. There was no assessment to behavior changes after family visits and no mention of family visiting in public places. On 12/18/2018, at 2:01 PM, a phone interview with Office Manager P, at the Genesee County Medical Examiner's office revealed the doctor sent toxicology to the crime lab because of the prior opioid abuse and will not have a final for approximately 60 to 90 days. On 12/18/2018, at 2:30 PM, in an interview CNA C stated, (Resident #902) bragged to me (Resident #902) was an alcoholic and was using. (The resident) had slurring a little bit, acting a little bit funny. On 12/18/2018, at 2:35 PM, in an interview anonymous interviewee Q, stated, I'm not surprised she OD'd (overdosed) because (Resident #902's) brother brought stuff in . I went to the DON a couple months ago about (the resident's) brother bringing in drugs. On 12/18/2018, at 2:40 PM, a phone interview with the Director of Nursing DON B was conducted regarding Resident #902's progress note, dated 9/13/2018, that the DON B wrote. The DON stated, I didn't think we were able to do supervised visits and I did talk to the dr about it. The DON B was unable to provide documentation proving that the physician was alerted. The DON B was unable to offer an explanation as to why Resident #902's behavior care plan was not updated. On 12/18/2018, at 3:24 PM, the Administrator A was interviewed regarding Resident #902's lack of care planning of a history of opioid abuse, overdose, behavior changes after family visits, possibility of doing drugs or alcohol while in the facility. The Administrator A stated, Yes. It should be on the care plan. On 12/19/2018, at 9:50 AM, Nurse Consultant J was asked to provide the facility behavior monitoring policy, nursing assessment and notification of changes policy. A facility policy of nursing assessment and notification of changes was not received. On 12/19/18 at 10:15 AM, an interview with Certified Nursing Assistant CNA E regarding Resident #902's behavior changes after family visits and needing to meet with family in public places was conducted. CNA E stated, (Resident #902) was very moody verbally. He (the brother) came in probably 2:30 PM He went down to (the residents) room . (the resident) was happy to see him (brother). The nurse did say they should meet at the table near the 400 Hall possibly a couple months ago, but I only seen it twice. On 12/19/18, at 11:00 AM, an interview was conducted with Charge Nurse G regarding Resident #902's history of opioid abuse, overdose and that (the resident) had behavior changes after family visits. Charge Nurse G stated, I knew she had substance abuse issues but I was under the impression it was just alcohol. Charge Nurse G was shown a physician's visit note, dated 11/22/2018 and e-signed by Physician K, which stated, Pain med seeking with hx (history) of overdose: limit opioids . and stated, Yes that's an issue and agreed it should be part of the plan of care. Charge Nurse G further offered that she was unaware family visits were to be in a public area. On 12/19/2018, at 12:00 PM, a record review of Resident #902's care plans revealed (the resident) is at risk for changes in mood r/t (related to) anxiety and depression, [MEDICAL CONDITION], date initiated: 04/17/2018 and revision on 04/24/2018, had no interventions in place to monitor family visits. A second copy of at risk for changes in mood r/t anxiety, depression, [MEDICAL CONDITION], date initiated 07/09/2018, revealed interventions . encourage family support-friends and family bring (the resident) coke and other comfort food . revision 09/06/2018. There were no other interventions in place to monitor behavior after family visits or to have family visits in public areas. On 12/19/2018, at 1:00 PM, a record review of facility policy Behavior assessment and monitoring, dated 2001, revealed . the nursing staff will identify, document, and inform the physician about an individual's mental status, behavior, and cognition, including: onset, duration and frequency of problematic behaviors or changes in behavior, cognition or mood. Any precipitating or relevant factors . On 12/19/2018, at 1:10 PM, a record review of facility policy Care Plans - Comprehensive, dated 2001, revealed an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Our facility's care planning/interdisciplinary team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain.

Based on observation, interview and record review, the facility failed to ensure interventions, including weekly skin assessments, were enacted to prevent the development and worsening of wounds and pressure ulcers/injury for 3 (#2, 11, 13) of 7 residents reviewed for wounds from a total of 19 sampled residents, resulting in Resident #2 developing a peeling, open area on the left buttock that was unstaged and not measured, Resident #11 obtaining a Stage 3 Pressure Injury and Resident #13 developed a darkened, unmeasured area on the left buttock. Findings Include: According to the National Pressure Ulcer Advisory Panel (NPUAP) Definition, (MONTH) (YEAR): 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) . A stage 3 pressure injury is defined as 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). A review of the facility policy, Prevention of Pressure Ulcers, dated (MONTH) 2010, Review the resident's care plan to assess for any special needs of the resident .the most common site of a pressure ulcer is where the bone is near the surface of the body .If pressure ulcer are not treated when discovered, they quickly get larger, become very painful for the resident and often become infected .the facility should have a system to ensure assessments are timely . Resident #2 On 3/28/18 at 10:30 am, A review of the face sheet, progress notes, skin/wound assessments, physician notes, orders, treatment records and care plans for Resident #2 revealed the following: The face sheet indicated Resident #2 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The Minimum Data Set (MDS) assessment, dated 12/15/17, indicated the resident had cognitive impairment and needed extensive to total assistance with most care. On 3/29/18 at 9:42 am, wound care for Resident #2 was observed performed by Nurses X and D, to the left buttock open area; The wound was red with peeling skin. When the nurses were queried about the measurement of the wound, Nurse X stated, We don't measure it. It is from moisture. A Nurses note, dated 3/10/18 and written by Nurse AA, said Cena (Certified Nursing Assistant) reported open area to buttock area. Resident continues to receive barrier cream as ordered every shift . The Skin Care Plan, dated 5/10/16 and revised on 3/12/18 revealed, .actual impairment to skin integrity related to decreased mobility, rash to left calf, blister to bilateral feet, hands, and under breast .Monitor/document location, size and treatment of [REDACTED]. It did not mention an open area on the resident's buttock. A review of the physician's orders, revealed the resident was to receive a Skin Assessment weekly, on Tuesdays, beginning 10/18/16. The Skin Assessments were not completed weekly. The medical record listed 6 Skin/Wound Notes from (MONTH) (YEAR) to (MONTH) (YEAR) dated: 6/13/17, 7/5/17, 2/13/18, 3/14/18 x2 and 3/27/18. A Skin/Wound Note, on 3/14/18 stated, Guest continues with MASD (Moisture associated skin [MEDICAL CONDITION]) noted to buttocks, moisture barrier cream in place as ordered, staff continues to turn and reposition Q2 hours and PRN. Will continue to monitor and make changes as deemed necessary and 3/14/2018 4:04 am, Guest has no new areas of concern at this time. Guest remains with a reddened/open area on left buttock. A review of the Treatment Administration Record (TAR) for (MONTH) (YEAR), indicated the resident was supposed to receive a treatment Apply moisture barrier cream to buttocks each shift, beginning 3/3/18. The treatment was not administered as ordered twice on 3/4/18 and once on 3/18/18, 3/22/18 and 3/24/18. The open area on the left buttock was noted on 3/10/18. On 3/16/18 the treatment was changed to include, Cleanse left buttock with normal saline and apply a ([MEDICATION NAME] protective) dressing each day. There was no documentation of the size of Resident #2's wound found in the medical record. A review of the seven physician progress notes [REDACTED]. The area on the left buttock was positioned over a bony prominence and was about 1 centimeter (cm) in length and width. When asked how the nurses would evaluate that the wound was improving or declining, Nurse X stated, I saw it 2 days ago. I can tell it is getting better. Resident #11 On 3/27/18 at 11:30 am, a review of the face sheet, progress notes, physician notes, orders, treatment records, medication administration records, MDS, skin/wound assessments, notes and care plans revealed the following: Resident #11 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS indicated the resident had severe cognitive impairment and needed extensive to total assistance with all care. During the initial tour on 3/26/18 at 10:50 am, a strong foul odor was noted near and in the room of Resident #11. The resident was noticed lying on an air mattress and positioned on the right side with eyes closed. 3/28/18 at 1:30 pm, wound care for Resident #11 was observed with Nurses J and BB. The resident had a very large, foul smelling sacral wound, with multiple areas of yellow and brown wet stringy slough, eschar. Resident #11 was moaning with repositioning and wound care. [MEDICATION NAME] was given 1 hour prior to wound care. A dressing with iodosorb ointment, to slough/eschar, ointment to granulating tissue, packed with foam gauze and a [MEDICATION NAME] dressing was applied by the nurses The Skin Care Plan, dated 2/7/18 and updated 3/6/18, revealed, .actual skin impairment related to impaired mobility, fragile skin integrity, incontinence, pressure ulcer to right buttock .Follow facility protocols for treatment of [REDACTED]. Review of the physician note dated 9/27/17 revealed that Skin/wound Assessments were to be completed weekly. Review of Resident #11's Skin/Wound Notes between (MONTH) (YEAR) and (MONTH) 11, (YEAR) revealed that there were only 3 notes. On 3/27/18 at 3:30 pm, Director of Nursing (DON) B was queried regarding the skin assessments from 9/27/17-current and was asked why weekly skin assessments did not begin until after the sacral wound was identified. DON B responded, I identified there was a problem when I came here. They were not being completed. (weekly skin assessments). I printed what they had. It is a problem. Review of the Weekly Wound assessment dated [DATE] and revealed that Resident #11 had a STDI (Suspected Deep Tissue Injury) on the right buttock, 'First Observation,' measuring 30 millimeters (mm) length, by 20 mm width, by 0 mm depth, with no drainage or odor. Interventions: Weekly assessment, measurement, documentation of wounds, special mattress, turn sheet, positioning device. Review of the Weekly Wound assessment dated [DATE] revealed, Worsening, Necrotic tissue, moist, purulent drainage, undermining, foul odor, 85 mm length, by 60 mm width, by 25 mm depth, infection suspected .orders updated. Further review of the assessment revealed that the wound was not staged, and it was documented as a STDI and the wound was open and draining. Further review revealed, Until 2/7/18, the resident's appetite and fluid intake had been the 'same' .It was noted 'declining' on 2/7/18, when the wound appeared infected. Review of the Weekly Wound assessment dated [DATE] revealed, Stage 3, with slough, granulation tissue and necrotic tissue, moist, odor, 85 mm length, by 70 mm width, by 15 mm depth, Appetite Better. Review of the Weekly Wound assessment dated [DATE] revealed ,Stage 3, granulation, slough, necrotic tissue, 70 mm length, by 5 mm width by 10 mm depth, with 2 cm undermining, moist with no odor. Appetite Better . Review of the medical record revealed that a note for 3/27/18 with measurements was not available and there were measurements taken on 3/28/18. Resident #13 On 3/28/18 at 9:00 am, a review of the face sheet, progress notes, skin/wound notes, physician order, treatment records and care plans, indicated, Resident #13 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. Wound care for Resident #13 was observed on 3/29/18 at 9:55 am, with Nurses X and Y. The resident had dark intact areas on the right buttock, barrier cream was the treatment. Nurse X said the cause of the wound was moisture and stated, No, it is not measured. The physician orders dated 3/15/18, on readmission, stated, Skin assessment every 7 days, every Thursday. The order was renewed from the original admission and readmissions, including 1/2018 and 2/13/17. Review of the medical record revealed that the last documented Skin/Wound Note, was 2/22/18. Further review of the medical record revealed that The Skin Care Plan for Resident #13 had not been updated since 10/13/16 and stated, Skin Assessments as ordered.

This citation pertains to intake # 515 Based on observation, interview and record review, the facility failed to place a wander guard on 1 (#701) sampled resident who was assessed to be cognitively impaired and an elopement and wandering risk, out of five residents sampled for elopement risk, from a total sample of five. An Immediate Jeopardy (IJ) arose when the facility identified that Resident #701 had eloped on 8/11/17 and the staff was unaware of the whereabouts of the Resident, who was last seen at approximately 9:30 a.m., and returned to the facility at 10:51 a.m. via ambulance, resulting in the potential for serious harm, injury, or death. The Administrator was notified of the IJ at 8/17/17 at 2:06 p.m. and a plan of correction to remove the immediacy was requested. The IJ was removed on 8/17/17 based on the facility's implementation of the plan removal as verified onsite. The facility's deficient practice remains at isolated. No actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: On 8/17/17 at 9:00 a.m., a review of the face sheet revealed that Resident #701 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The BIMS assessment dated [DATE] revealed that Resident #701 had a score of 07 indicating moderate cognitive impairment. On 8/17/17 at 9:30 a.m., Resident #701 was observed in his room with an ankle bracelet with a wanderguard device (causes an alarm sound if exits the building with doors that are armed with the wanderguard system) was observed around the left ankle. Resident #701 was ambulatory without an assistive device, but confused. Resident #701 was asked about leaving the facility unattended and stated, I don't remember ever getting out. On 8/17/17 at 9:45 AM, an interview was completed with the Administrator and Director of Nursing (DON) outside where Resident #701 had walked around and had been found. According to the DON, He (Resident #701) got out just outside our perimeter. He had only been here for 12-14 hours, he was a late admission. The housekeeper (Staff Member B) seen him around 10:00 a.m., to her he looked like a visitor. He must have gotten out through this door (a door that does have a wanderguard alarm on it and has no key pad that would prevent access through it with a code and leads into the staff hallway) then out this door (a second door that leads outside to the back of the building). The DON stated, We think he walked around the facility into another parking lot where the ambulance drivers sit. The ambulance driver said that he (Resident #701) had said he was going to church. The ambulance driver called his church, then the pastor called his (Resident #701's) wife (Family Member D) who came to the facility. The Administrator stated, The ambulance drivers brought him (Resident #701) back. He was pleasant, not aggressive. The Administrator was asked if the cameras that were present in the hallway and outside the facility back door had been able to capture the footage of Resident #701 getting outside. The Administrator stated, No, I tried to view the tape but our system was down that day. The parking lot just outside the door that Resident #701 had exited was large, paved and designated to staff for parking. The parking lot wrapped around the building to the front of the building which had more parking spaces for visitors. There were several other parking areas that eventually connected to each other that led to other office buildings and parking areas. The parking lot was connected to a driveway area that lead to a busy, high traffic road. On 8/17/17 at 10:50 a.m., a record review of the Admission/Re-admission assessment dated [DATE] completed by Unit Manager A revealed that Resident #701 had been admitted to the facility for short term rehab following a hospitalization for pneumonia. Under the section titled Risk for wandering it states the following: Does have a history of wandering or is independent with ambulation and has confusion or a history of exit seeking behavior. Under the question that asks if the resident is a wandering risk, it is answered yes. Under comments it states, The resident is confused at times;has a history of Dementia and Alzheimer's Disease. Under the Mobility title, the following was revealed: Walking in room independently. It also states, Walks in corridor with supervision. On 8/17/17 at 11:15 a.m., an interview was completed with Unit Manager A in regards to the Admission/Re-admission assessment that she had completed that had Resident #701 assessed as a risk for wandering upon admission. Unit Manager A was asked why if she felt that he was a high risk she did not place a wanderguard on him at that time. Unit Manager A stated, Because he (Resident #701) stated that he wanted to go home. I had to talk to him and explain to him that he was here for physical therapy and that his wife knew where he was. At that point, I felt he was okay. He mostly stayed in his room. On 8/17/17 at 11:30 a.m., an interview was completed over the phone with the nurse that was taking care of Resident #701 that morning. Registered Nurse (RN C) stated, It was my last day there. That morning I felt like he (Resident #701) was at risk for an elopement because he was confused and ambulatory. My DON told me to put a wanderguard on him. I did not know how to put those on and neither did my coworkers. I asked the Unit Manager how to put it on but she told me to wait and she would reassess him (Resident #701) after the morning meeting. I had last seen him at 9:30 a.m. On 8/17/17 at 11:50 a.m., an interview was completed with Staff Member B who had seen Resident #701 outside. Staff Member B stated, I went outside on my break. I went in my car and drove up to a different parking lot. I noticed him (Resident #701) walking by the road. I thought it was kind of strange because he was just kind of standing there. He was dressed and had his shoes on and didn't have a wheelchair so I didn't think he was a Resident. I then came inside and then RN C had asked me if I had seen the Resident. I asked her to describe him to me and then I realized it was him. I told her (RN C) that I had seen him outside. She started freaking out and I immediately got in my car and went back out looking for him. On 8/17/17 at 11:55 a.m., a record review of the progress notes was completed. On 8/11/17 at 12:27 p.m., an entry was written by RN C. The entry stated, Pt (Resident #701) eloped this a.m., and was last seen around 9:15 a.m .RN (C) unable to locate (Resident #701) at 10:10 a.m. when RN (C) went to give his medications .Pt (Resident #701) was picked up from (a theater) and safely returned by EMS (Emergency Medical System) around 10:30 a.m. Prior to Pt (Resident #701) leaving facility, CNA (certified nursing assistant) advocated for pt. (Resident #701) to have wanderguard and were told to wait until the Unit Manager (A) finished the morning meeting. Wanderguard placed upon return to the facility. On 8/17/17 at 12:15 p.m., a record review of the written statement completed by Unit Manager A stated, RN (Unit Manager A) obtained a wanderguard to place on (Resident #701) after reports of him wandering off the hall for long periods. When I entered his room, he was not there. On 8/17/17 at 12:25 p.m., an interview was completed with the DON. The DON stated, I came in (on 8/11/17) to do inservices at 6 a.m., and got report from the nurse (RN C) on the new admit (Resident #701). I told her to go ahead and put a wanderguard on him. Then I asked the Unit Manager A to follow up that the wanderguard was placed on the Resident (#701). After the morning meeting I was told that he was missing. I had asked if the wanderguard had been placed on the Resident (#701) and was told 'no' because the nurse did not know how to put the wanderguard on. The DON also stated, I went out looking for him and received a text at 10:51 a.m., to come back to the building because he was back. On 8/17/17 at 1:20 p.m., an interview was completed with the Administrator. According to the Administrator he was notified that Resident #701 was missing from the facility right after the morning meeting. On 8/17/17 at 2:10 p.m., an interview was completed with Family Member D who was the wife and responsible party for Resident #701. Family Member D stated, I was upset (that Resident #701 had gotten out). He (Resident #701) wanders at home. We had to move into an apartment because it was safer for him. On 8/17/17 at 2:35 p.m., a record review of the incident report created by the DON dated 8/11/17 stated that Resident #701 had gotten out and upon return to the facility had gotten a head to toe skin assessment to assess for injury. On 8/17/17 at 3:00 p.m., a record review of the Wandering assessment dated [DATE] stated the following: Forgetful and history of wandering. On 8/17/17 at 3:10 p.m., a record review of the At risk for wandering care plan dated 8/11/17 states that Resident #701 is at risk for wandering due to his confusion and independent ambulatory status. Interventions include: Allow for safe wandering Check wanderguard every shift Picture added to Medication Record Encourage family/caregiver participation/support. On 8/17/17 at 3:30 p.m., a record review of the facility policy titled, Wandering, Unsafe Resident (revised December 2008) was completed and revealed the following: The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). 6. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. The facility submitted the following plan of removal of immediacy: Element 1: On August 11, 2017 the following were initiated and implemented after Resident # 98 exited the premises of the facility that occurred on 8/11/17 approximately between 9 am-10:30 am. The resident had ambulated out the back door and went through parking lots that there were connected to each other and adjoining businesses. Resident # 98 resided on B-Hall. The resident exited out of the back door of the building. A complete head count of all residents in the facility was done on 8/11/17 revealed 72 residents accounted for including resident # 98 on 8/11/17 between 10:15 -10:32 am by the NHA & DON. When Resident # 98 was returned to the facility the guest had a complete head to toe assessment completed by the Director of Nursing with no impairments, injuries noted. MD and family were notified. Element 2: All residents were accounted for on 8/11/17 during the head count by the Director of Nursing, & NHA. All residents who reside at the facility were re-assessed and wandering risk assessments, care plans were reviewed and updated as necessary including the elopement book. This process was started and achieved on 8/11/17 by the Director of Nursing. The facility identified 6 residents that display elopement or exit seeking behavior Care plans and risk assessments were reviewed and revised as necessary for all 6 residents identified as wandering/elopement risk. This assessment was completed by the Director of Nursing. Element 3: On August 11, 2017 the facility began in-servicing licensed nurses on policy and procedure of elopement and exit seeking management and for missing residents. The total number of licensed nurses employed at the center is 18. The education of this change will be completed on the first day the employee returns to work. The employees have been verbally educated and a physical signature will be completed on their next scheduled shift. If an employee does not complete this they will be unable to work. An Emergency Quality Assurance Committee was held on 8/11/17 by the Administrator, Director of Nursing, and Medical Director. During this meeting the Elopements, Wandering Unsafe Resident policies were reviewed and no revisions were needed. System change to include: Licensed nurses are responsible to ensure that wandering risk is assessed and patients will receive wander guard/code alert as necessary. The next business day the Director of Nursing/Designee will be responsible to check each new admission to ensure that they have been assessed appropriately for elopement risk. This was initiated on 8/11/17. This will be ongoing until directed otherwise by the QAPI Committee. Element 4: As of August 11, 2017 thru August 14, 2017 the facility conducted random wandering risk assessments of 7 residents daily for the next 7 day, then 7 residents biweekly x 2 weeks, the monthly x 3 months, and quarterly thereafter. This audit will include elopement risk assessments, care plans were updated as necessary. Results will be brought by the Maintenance Director or Designee to the Quality Assurance Process Improvement Committee monthly for review and recommendations. Any abnormal findings will be immediately corrected. Element 5: The administrator will be responsible for sustained compliance

Based on interview and record review, the facility failed to operationalize and effectively implement the facility's abuse policies and procedures, and ensure staff had knowledge and education to identify, thoroughly investigate, and report instances of actual resident abuse for seven (#s 704, 706, 716, 717, 718, 719 and 724) of 28 sampled residents reviewed for abuse from a total of 30 sampled residents and a potential for abuse for 115 of 115 residents who lived in the facility, resulting in an Immediate Jeopardy (IJ) to the health and safety of all residents and the potential for harm, serious injury, and/or death due to abuse. The Immediate Jeopardy was identified on 5/07/14. The Administrator was notified of the IJ on 5/8/14 at 11:55 a.m. A plan of correction to remove the IJ was requested at this time. The Immediate Jeopardy (IJ) was removed on 5/9/2014, based on the provider's implementation of corrective actions on 5/9/2014, as verified by review of documented evidence submitted on 5/9/14. Although the Immediate Jeopardy (IJ) was removed, the facility's deficient practice remained as widespread with no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: On 5/01/14 at 1:45 p.m., the Director of Nursing (DON) explained during interview that he had been the Abuse Coordinator since January 2013. The DON further explained that it was the facility's practice to investigate and report abuse situations in accordance with LARA (Licensing and Regulatory Affairs) guidelines and the algorithm for investigating and reporting possible incidents of suspected abuse including mistreatment, neglect, misappropriation, and injuries of unknown origin. The DON went on to explain that the facility's "Abuse Prevention and Reporting Manual" was maintained in the business office and accessible to the Clinical Nurse Managers at all times. He further stated that staff were trained to report any witnessed or alleged incident of abuse immediately and were required to attend no less than 2 abuse training programs annually as scheduled by Nurse "O". The DON stated that the last abuse training that he received was in June 2013. The DON stated that all abuse investigations were conducted by the Clinical Nurse Managers who were required to notify him and the Administrator of abuse allegations in accordance with the facility's abuse policies. The DON further explained that he had been notified of only one abuse investigation since he became the Abuse Coordinator in January 2013. The DON said that on 2/17/14, Nurse "K" informed him that she was investigating multiple allegations of abuse voiced by various residents and resident family perpetrated by certified nurse assistant (CNA) "I". The DON stated that resident #s 704, 706, 716, 717, 718, 719 and 724 were identified in the abuse investigation. The facility's abuse investigation was reviewed at 10:00 a.m., on 4/30/14. According to the facility's investigation report dated 2/19/14, Resident #704 stated that CNA "I" was mean, yelled at her, and made her cry. At the time of the survey Resident #704 was visibly upset when talking about CNA "I". Review of the Quarterly Minimum Data Set ((MDS) dated [DATE], indicated that Resident #704 had a BIMS (Brief Inventory Mental Status) score of 10 which indicated that the resident had moderately impaired cognition. On 4/30/14, at 4:50 p.m., the DON stated that the allegation of abuse by Resident #704 was not thoroughly investigated or reported to the State Agency. According to the facility's investigation report dated 2/19/14, Resident #706 stated that she felt threatened by CNA "I" and had witnessed CNA "I" being mean to her roommate Resident #704. At the time of the survey, Resident #706 reported these concerns during the Resident Group Interview. Review of the, Quarterly MDS dated [DATE], indicated that Resident #706 had a BIMS score of 9 which indicated that the resident had moderately impaired cognition. On 4/30/14, at 4:50 p.m., the DON stated that the allegation of abuse by Resident #706 was not thoroughly investigated or reported to the State Agency. According to the facility's investigation report dated 2/19/14, CNA "H" witnessed Resident #716 in the shower room with CNA "I". Resident #716 was screaming that he was being beaten, visibly afraid, and vomiting. Review of the Quarterly MDS dated [DATE], indicated that Resident #704 and had severely impaired cognition (BIMS score of 4). On 4/30/14, at 4:50 p.m., the DON stated that the allegation of abuse by Resident #716 was not thoroughly investigated or reported to the State Agency. According to the facility's investigation report dated 2/19/14, the daughter of Resident #717 requested that CNA "I" be taken off duty as caregiver. On 5/2/14, at 2:20 p.m., during an interview with Resident 717's daughter, it was reported that CNA "I" had snatched her mother and threw her into bed causing a skin tear on her leg. Review of the MDS dated [DATE], indicated that Resident #717 had moderately impaired cognition (BIMS score of 9). On 4/30/14, at 4:50 p.m., the DON stated that the allegation of abuse by Resident #717 was not thoroughly investigated or reported to the State Agency. According to the facility's investigation report dated 2/19/14, the daughter for Resident #718 requested that CNA "I" be taken off duty as caregiver. On 5/5/14, at 2:50 p.m., during an interview with Resident 718's daughter, it was reported she had observed scratches all over the face and a bruise on Resident #718's nose. The daughter stated that she questioned CNA "I" about the scratches and bruise, and CNA "I" said that Resident #718 was fighting her. Review of a Social Service progress dated 4/22/13, noted that Resident #718 had significant cognitive and physical limitations. On 4/30/14, at 4:50 p.m., the DON stated that the allegation of abuse by Resident #718 was not thoroughly investigated or reported to the State Agency. According to the facility's investigation report dated 2/19/14, indicated that CNA "I" was observed by CNA "H" and Nurse "K" verbally abuse Resident #719 on 2/19/14. On 5/1/14 at 10:20 a.m., during interview with Resident #719 he described CNA "I" as speaking in a a harsh and gruff manner and stated that she had an abrasive personality. Resident #719 also stated he had witnessed CNA "I" scold his roommate Resident #727. Review of the Quarterly MDS dated [DATE], indicated that Resident #704 had a BIMS score of 15 which indicated he was cognitively intact. On 4/30/14, at 4:50 p.m., the DON stated that the abuse witnessed by CNA "H" and Nurse "K" perpetrated by CNA "I" toward Resident #719 was not thoroughly investigated or reported to the State Agency. According to the facility's investigation report dated 2/19/14, indicated that Resident #724 described CNA "I" as being a little rough around the edges. On 5/01/14, at 12:20 p.m., during interview Resident #724 described CNA "I" as acting like a dictator with residents and stated that he had kept his distance to keep in her good graces so there wasn't any trouble. Review of the Annual MDS dated [DATE], indicated that Resident #724 had a BIMS score of 14 which indicated he was cognitively intact. On 4/30/14, at 4:50 p.m., the DON stated that the allegation of abuse by Resident #724 was not thoroughly investigated or reported to the State Agency. On 4/30/14 at 4:30 p.m., review of the facility's abuse policy "Investigating and Reporting Possible Incidents of Suspected Abuse" dated 2014, indicated "any incident witnessed or suspected of having occurred shall be reported immediately to the Administrator (either the Administrator or Director of Nursing) verbally and in written form (using the Unusual Occurrence, Resident Incident, Problem-Concern-Complaint, and/or Employee Problem forms, depending on whether an injury has occurred or not." The DON stated that "we did not handle things the way they should have been handled." When the DON was asked about previous disciplinary actions against CNA "I" he replied, "to my understanding in October 2013, she (CNA "I") received a written warning because a family member complained on 10/28/13, that the CNA (CNA "I") exhibited an irritable and rushed approach with Resident #717 that resulted in a skin tear. The DON stated that the abuse allegations had not been reported timely nor thoroughly investigated. The DON further explained that despite the fact that on 2/17/14, when resident abuse was alleged, CNA "I" worked a full day on 2/19/14. When asked why CNA "I" was not immediately suspended, the DON replied, "because she is a member of the union and we had to make sure our investigation was tight before we suspend anyone." On 4/30/14, at 4:30 p.m., review of the facility's abuse policy "Investigating and Reporting Possible Incidents of Suspected Abuse" dated 2014, indicated "if an employee is suspected of being the abuser, he/she shall be suspended indefinitely at that time, pending further investigation. The employee shall be clocked out and escorted from the building." On 5/1/14, at 2:00 p.m., review the form entitled "Corrective Bargaining Notice" indicated that CNA "I" was terminated for violations of witnessed and verified evidence that she "forcefully fed residents; made a resident sit/lay in urine; verbally abusive toward residents; and inappropriate touched staff." On 4/30/14/ at 4:30 p.m., review of the facility's abuse policy "Investigating and Reporting Possible Incidents of Suspected Abuse" dated 2014, indicated "should it be determined that the incident of abuse (physical or sexual) caused by an employee was severe enough to warrant discharge, the employee will be terminated, and notification to the proper State of Michigan authorities and the Nurse Aid Registry." The DON stated that he chose not to report the abuse incidents to the State Agency or notify the Nurse Aid Registry regarding the termination of CNA "I" and stated, "I used poor judgment." When the DON was queried if Resident #'s 716, 704, 724, 706, 717, 718, and 719 who were identified in the abuse investigation had been provided psychosocial services, he replied, "no." On 4/30/14 at 4:30 p.m., review of the facility's abuse policy "Identification of Abuse" dated 2014 indicated, "the Social Services staff is readily available to counsel a resident or family members and to assist in filing a complaint with the Center or State as needed." On 5/02/14, at 2:10 p.m., interview with the Administrator revealed that she supported the decision to not report the abuse incident that involved CNA "I" to the State Agency or Nurse Aid Registry. The Administrator stated, "we didn't want to jeopardize her (CNA"I") career and we felt by removing her (from identified residents) we removed the risk of further abuse." Review of the facility's abuse policy "Investigating and Reporting Possible Incidents of Suspected Abuse" dated 2014, indicated "the administrator or his/her designees is responsible for reporting any abuse to the proper authorities, filing all necessary reports, overseeing the investigation and the administration of any corrective action if necessary; a nursing home administrator or nursing director is expected to immediately conduct a thorough in-house investigation or abuse to determine what happened; complete a detailed incident report with the investigation findings and retain it at the facility; notify the Bureau of the investigative findings within the timeframe's required by the State and appropriate State officials in accordance with applicable State law. On 5/2/14 at 9:30 a.m., interview with Nurse "D" who identified herself as a Clinical Nurse Manager revealed that she had been employed in her position 2 years. Nurse "D" reported that she could not recall her last abuse training, however stated it was "sometime in the summer of 2013." Nurse "D" further stated that she had no recollection of receiving any Resident Incident, Problem-Concern-Complaint, and/or Employee Problem forms regarding alleged abuse. Furthermore, Nurse "D" stated that she had not conducted any investigations pertaining to allegations of abuse since she became a Clinical Nurse Manager two years ago. Nurse "D" further stated that she had not determined that abuse was a factor upon her review of "Unusual Occurrence" forms. On 5/2/14 at 10:10 a.m., interview with Nurse "A" who identified herself as a Clinical Nurse Manager revealed that she has been employed in her position since February 2013. Nurse "A" reported that she could not recall her last abuse training and stated "I think last year." Nurse "A" further stated that she had no recollection of receiving any Resident Incident, Problem-Concern-Complaint, and/or Employee Problem forms regarding alleged abuse. Nurse "A" further stated that she had not determined that abuse was a factor upon her review of "Unusual Occurrence" forms. Furthermore, Nurse "A" stated that she had not conducted any investigations pertaining to allegations of abuse since she became a Clinical Nurse Manager in February 2013. When Nurse "A" was queried regarding the facility's abuse prohibition policies and procedures she replied, "I am not aware if there are specific procedures for me to follow regarding conducting my investigations." On 5/1/14, at 3:00 p.m., interview with Nurse "O" revealed that all facility staff were provided training on the "Patient Protection and Affordable Care Act (Elder Justice Act). Nurse "O" stated that formal in-service on the Elder Justice Act was provided in March 2013. Nurse "O" further explained that "on line" instruction regarding the Elder Justice Act was offered to staff starting in January 2014. She further explained that "at least 20 percent of our staff still need this training." On 5/02/14, at 9:30 a.m., interview with Nurse "D" revealed that she was unfamiliar with the Elder Justice Act and the reporting requirements. Nurse "D" further stated, "I think my last abuse training was sometime last year." On 5/02/14, at 10:10 a.m., interview with Nurse "A" revealed that she had no knowledge of the Elder Justice Act. Nurse "A" further stated, "I think my last abuse training was sometime last year. I don't recall the exact date." On 4/30/14, at 7:15 a.m., during an interview, CNA "R" commented, "I'm drawing a blank" when asked about the Elder Justice Act. CNA "R" further stated her last abuse in-service training was "last month". On 5/01/14, at 8:45 a.m., CNA "D" stated that she had no knowledge of the Elder Justice Act. CNA "T" also stated, "I can't remember when I had my last abuse in-service training. On 5/1/14, at 12:50 p.m., CNA "S" stated, "I have no idea what it (Elder Justice Act) means. I have no recollection of any training about it." On 5/2/14 at 11:40 a.m., CNA "Q" stated, "I have no idea" when asked about the Elder Justice Act. CNA "Q" stated, "I believe that my last abuse training was sometime last year." According to the "Center for Medicaid, CHIP, and Survey and Certification/Survey and Certification Group" letter dated 6/17/14, (REF: S&C 11-3-NH, Revised 01/20/12) for "reporting reasonable suspicion of a crime in a Long Term Care Facility (LTC) "effective implementation of Section 1150 B of the Act may promote a timely response to potential crimes, thereby protecting residents of such facilities. The statute required that: "covered individuals (employees) timely report any reasonable suspicion of a crime against a resident of, or who is receiving care from a LTC, if the events that cause the reasonable suspicion result in serious bodily injury, the report must be made immediately after forming the suspicion (but not later that two hours after forming the suspicion). Otherwise, the report must be made not later than 24 hours after forming the suspicion. The LTC facility's responsibilities under existing CMA (Centers for Medicare and Medicaid Services) conditions and requirements are to report incidents, prevent abuse or neglect, provide quality care and a safe environment, train staff, and similar duties of direct relevance to safety and quality of care." The facility submitted a plan of correction (POC) dated 5/9/2014 that indicated: Deficits identified 1. Facility failed to operationalize and effectively implement the facility ' s abuse policies and procedures and ensure staff had knowledge and education to identify, thoroughly investigate, and report instances of suspected abuse. 2. Thoroughly investigate and report instances of actual resident abuse for seven residents 3. Potential for abuse for 115 of 115 residents and health and safety of all residents. Element #1 - Corrective Actions: 05/08/14 Social worker Laura Rawlings interviewed #704, #706, #716, #717, #719, and #724. PHQ-9 Mood interview for MDS 3.0 was completed to ensure that no further emotional effects existed. One resident scored a five (mild depression), #706. The remaining residents scored in the category of minimal depression. Comparison of previous PHQ-9 screening results were reviewed and indicates no worsening for the residents identified. Resident #718 passed 03/20/2014. 05/07/14 Review and updating of abuse prevention & reporting policies and procedures started. 05/09/14 Abuse & abuse reporting training modules and materials updated. 05/09/14 Mandatory abuse & abuse reporting education begins for all employees. All employees working first shift must read the abuse training materials, take the abuse test, and sign the sign in sheet as proof of the education. Starting with second shift and all shifts over the weekend, the employees must read the abuse materials, take the abuse test, and sign the sign in sheet as proof of the education before they begin their shift. All employees scheduled to work the weekend are being called to let them know about the mandatory education and are encouraged to come to the facility on first shift 05/09/14 to complete the education prior to their scheduled shift. There are 192 GCC employees; 83 part time, 94 full time, 6 casuals, 4 leave of absence, and 5 contracted. We will be educating 101 employees on first and second shift today and 36 over the weekend for a total of 137. Any employee that has not had the abuse training by 05/12/14 will be contacted and notified they must complete the training prior to their shift. Any employee who has not completed the abuse & reporting education will not be allowed to work their scheduled shift until the education is completed. 05/09/14 The DON will educate the managers on the Abuse Questionnaire. Element #2 - Identify Residents at Risk: All residents within Genesys Convalescent Center are at risk if the facility fails to operationalize and effectively implement the facility ' s abuse policies and procedures and ensure staff has knowledge and education to identify, thoroughly investigate and report instances of abuse. Element #3 - Prevent Recurrence: 05/08/14 GCC will follow the policy Investigating and Reporting Possible Incidents of Suspected Abuse Including Mistreatment, Neglect, Misappropriation, and Injuries of Unknown Origin. GHS Human Resources and/or Risk Management personnel will be consulted as needed. 05/08/14 GCC Administrator will follow the LARA Investigation Guide for Abuse, Neglect, Mistreatment, Misappropriation and Injury of Unknown Origin and report any allegation or suspicion of abuse, neglect, or misappropriation of resident property to LARA as identified in the LARA document. 05/08/14 In addition to the quarterly PHQ-9 completed by social workers, the clinical managers will interview and document on the Abuse Questionnaire, at a minimum, bi-weekly for the next 90 days on these residents to ensure no residual emotional effects or concerns. The standardized tool will include, 1) How well have we been taking care of you?, 2) Has anyone hurt you or yelled at you or have you witnessed anyone else being hurt or yelled at?, 3) Do you feel safe here? If any of these residents' voice concerns related to potential for harm, serious injury, an/or death due to abuse, managers will immediately investigate and notify the DON and the Administrator. The facility will report a allegation or suspicion of abuse, neglect or misappropropriation of resident property to LARA immediately. Appropriate social service resources will be initiated if indicated. All findings as reported on Resident Accident/Incident/Near-Miss Reports will be tracked and trended for commonalities by Quality Assurance Coordinator and will be reported to the QAPI Committee bi-monthly. Additional improvement plans will be initiated as needed. 05/08/14 Starting 05/09/14, in addition to the scheduled PHQ-9 required assessments, we will interview all GCC residents using The Abuse Questionnaire stated above. The interviews will be completed by 05/16/14. If any of these residents ' voice concerns related to abuse, neglect, mistreatment, misappropriation, injury of unknown origin, potential for harm, serious injury, an/or death due to abuse, managers will immediately investigate and notify the DON and the Administrator. The facility will report an allegation or suspicion of abuse, neglect, or misappropriation of resident property to LARA immediately. Appropriate social service resources will be initiated if indicated. All findings as reported on Resident Accident/Incident/Near-Miss Reports will be tracked and trended for commonalities by Quality Assurance Coordinator and will be reported to the QAPI Committee bi-monthly. Additional improvement plans will be initiated as needed. Element #4 - Monitoring: 05/09/14 All new residents receive the Nursing Home Patient Rights and Responsibilities and the GCC admission packet with information pertaining to abuse and reporting avenues. All employees are educated on abuse and reporting on hire and annually. Any of the elements of the action plans identified in this plan of correction will be included in new employee orientation. We will continue to request any abuse concerns at monthly Resident Council. 05/09/14 At Morning Meeting an Abuse agenda item was added to the agenda. Attendees include; Administrator, DON, Clinical Managers, Departmental Managers (Maintenance, Activity/Social Work), social workers, MDS Coordinator, Admissions Coordinator, Billing Coordinator, Dietician, Medical Records, and Therapy Manager. If there are any concerns related to abuse, neglect, mistreatment, misappropriation, injury of unknown origin, potential for farm, serious injury, and/or death due to abuse, managers will immediately investigate and notify the DON and the Administrator. The facility will report an allegation or suspicion of abuse, neglect or misappropriation of resident property to LARA immediately. Appropriate social service resources will be initiated if indicated. All findings as reported on Resident Accident/Incident/Near-Miss Reports will be tracked and trended for commonalities by Quality Assurance Coordinator and will be reported to the QAPI Committee bi-monthly. Additional improvement plans will be initiated as needed. 05/12/14 Daily Morning Meeting will include review and discussion of all open incident reports which include abuse and reporting. 05/12/14 Facility Huddle Board, located by employee time clock, will be utilized to reinforce abuse educational materials and will be updated every two weeks for the next 90 days. A special focus will be on the immediate reporting of any allegation or suspected abuse. 05/12/14 Administrator and DON will educate managers on interviewing employees related to " What to report and when to report " . (See next item below) 05/12/14 In addition to the post abuse test from the mandatory abuse education beginning 05/09/14, all employees will be interviewed by management to ensure comprehension and understanding of abuse prevention and reporting policies. Interviewing will be completed by 05/16/14. Focus on " What do you report and when do you report " . 05/08/14 All substantiated findings as reported on Resident Accident/Incident/Near-Miss Reports will be tracked and trended for commonalities by Quality Assurance Coordinator and will be reported to the QAPI Committee bi-monthly. Additional improvement plans will be initiated as needed. 05/09/14 Options to include elements; abuse, neglect into the current occurrence report are being investigated. Modifications to this process will be complete by 05/09/14. Education on the occurrence report will be included in the mandatory education on 05/14/14 and all related education as stated above apply to this policy. ( ) ( ) ( ) ( )

Based on observation, interview and record review, the facility failed to prevent an employee from verbally, physically, and mentally abusing 6 of 28 residents (#704, 706, 716, 717, 719, and 724) reviewed for abuse from a total sample of 30, resulting in 1) verbal/emotional abuse that caused fear, crying and physical reaction (vomiting); and, 2) physical abuse, including taking a resident who was known to become combative during showers into the shower, force-feeding and excessive roughness while providing care, that caused anxiousness, emotional distress and a skin tear. Findings include: During the Group Interview on 4/29/14 at 2:30 p.m., Resident #706 stated that she witnessed abuse when Certified Nursing Assistant (CNA) "I" was "mean and hateful" toward her roommate, Resident #704. Resident #706 stated she witnessed this abuse several months ago. On 4/30/14 at 9:30 a.m., the investigation of abuse allegations against CNA "I" was requested from the facility's abuse coordinator, the Director of Nursing (DON). The facility's investigation of abuse allegations against CNA "I" dated 2/19/14, was reviewed on 4/30/14 at 10:00 a.m. The facility's investigation noted, "On February 17, 2014, it was brought to my (Nurse "K") attention concerns regarding (CNA "I"). The concerns are serious in nature..." The facility's investigation revealed numerous alleged incidents of abuse perpetrated by CNA "I", involving Resident #s 704, 706, 716, 717, 718, 719, and 724. Resident #716 The facility's written investigation of abuse allegations against CNA "I" dated 2/19/14, detailed the following incidents involving Resident #716: 1. "(CNA "H") began to tell us about on February 10, 2014, she witnessed loud yelling coming from the shower room. She knew (CNA "I") had just taken (Resident #716) into the room. When she entered the shower room and pulled back the curtain...(Resident #716) stated, "she's beating the (expletive) out of me!" This situation was verified by the nurse (Nurse "J"). The resident (Resident #716) was so upset that he vomited." 2. "During this conversation it was revealed, (CNA "I") was feeding (Resident #716), which is to have small bites. It was witnessed (CNA "I") forcefully putting full spoons of food into his (Resident #716) mouth. (Resident #716) stated the food was "too hot." (CNA "I") replied, "I don't have all day" and pushed another spoonful in his mouth...The nurse (Nurse "J") verified that this was reported to her." On 4/30/14 at 10:00 a.m., the DON stated that he became aware of the alleged incidents of abuse involving CNA "I" and Resident #716 on 2/17/14. The DON stated that Nurse "K" had conducted the investigation, but that Nurse "K" was currently on stress leave, and was unavailable for interview. The DON stated that CNA "I" had lost her husband suddenly in early fall of 2013, and that "we (facility staff) noticed a change in her behavior, and we had to coach her (CNA "I") on her approach with the residents." The DON stated that in October 2013, CNA "I" had been given a written warning regarding her performance, but that he was unaware of any further allegations regarding CNA "I". When queried as to whether the 2/10/14 incident regarding Resident #716 was reported to him by Nurse "J", the DON stated, "I was not aware of that incident until 2/17/14". The DON further stated that Nurse "J" was on a medical leave. When queried as to whether CNA "I" was suspended pending an investigation, after he became aware of the alleged abuse on 2/17/14, the DON stated, "No." It was further revealed that CNA "I" continued to work in the facility on 2/19/14, after the DON (the abuse coordinator) had become aware of the alleged abuse incidents involving CNA "I". The DON stated that because the employees of the facility belong to a union, "we have to make sure our investigation is tight before we suspend anyone." On 4/30/14 at 1:30 p.m., a phone interview was attempted with Nurse "J"; however, the phone number provided by the facility for Nurse "J" was disconnected. On 4/30/14 at 2:00 p.m., CNA "H" was queried regarding the allegations against CNA "I" involving Resident #716. CNA "H" stated that she had worked as a CNA in the facility for [AGE] years. CNA "H" stated that on the morning of 2/10/14, she heard screaming coming from the shower room. CNA "H" stated that she knew (Resident #716) was in the shower room with CNA "I", and that he (Resident #716) was usually "soft spoken." CNA "H" stated, "As soon as I walked in the shower room, I knew something was wrong. The look that he (Resident #716) had on his face, he was terrified. He (Resident #716) looked at me and said, "she's beating the (expletive) out of me!" He was so upset that he was throwing up violently. I stayed in the shower room with him and CNA "I" until he was dressed. I brought him out of the shower room, and I immediately told my nurse (Nurse "J") about what I had witnessed. Then at lunch time, she (CNA "I") was feeding (Resident #716). She (CNA "I") was shoving the food into his (Resident #716) mouth. He kept saying, "it's too hot," but she just kept shoving it in. I said, "that's enough," but she (CNA "I") wouldn't stop." Review of the admission face sheet on 5/1/14 at 9:30 a.m., revealed that Resident #716 was originally admitted into the facility on [DATE], and was readmitted on [DATE], with [DIAGNOSES REDACTED]. According to a quarterly Minimum Data Set (MDS), dated [DATE], Resident #716 had severely impaired cognition, and was totally dependent on staff for eating and personal care needs. Review of an "Activities of Daily Living" care plan for Resident #716, initiated on 10/15/12 and updated 4/25/14, noted: Problem: (Resident #716) has self care deficit r/t (related to) dementia. He is dependent on staff for his bathing, dressing and hygiene. Approach: "Bed baths." Review of an "Accident/Incident" report for Resident #716, dated 7/3/13, noted: "CNA...discovered a skin tear...on a large bruised area, top of left forearm..." Under "corrective measures," it was noted: "Bed baths instead of showers". Under the section for "findings," it was noted: "Resident has very fragile skin and is combative. Family agrees to try bed baths instead of showers. Showers are very traumatic to resident." On 5/1/14 at 11:00 a.m., Nurse "D" stated that she was unaware of the 2/10/14 incident where Resident #716 was observed in the shower room with CNA "I", screaming, visibly afraid, and vomiting. Nurse "D" was queried as to why Resident #716 had received a shower instead of a bed bath on 2/10/14, when it was assessed that showers were very "traumatic" to Resident #716. Nurse "D" was unable to provide an explanation. ( ) Resident #706 Review of the admission face sheet on 5/1/14 at 3:00 p.m., revealed that Resident #706 was originally admitted into the facility on [DATE], with [DIAGNOSES REDACTED]. According to the annual Minimum Data Set, dated dated [DATE], Resident #706 had intact cognition. The facility's investigation of abuse allegations against CNA "I" dated 2/19/14 documented the following regarding Resident #706: "On 2/20/2014, I (Nurse "K") received a call to come to room [ROOM NUMBER] to talk with Family members "AA" and "BB", the daughters of (Resident #706). When I got to the room, I could see they were physically upset...Family member "AA" stated, "Mom you need to tell what was said to you." (Resident #706) is alert and oriented, stated, "(CNA "I") said if my daughters and I don't watch it, I'm going to be in trouble." I asked what she felt was meant by that statement. (Resident #706) stated, "We are always telling her not to be so mean to (Resident #704). You (Nurse "K") know she (CNA "I") makes her (Resident #704) cry. I felt she (CNA "I") was threatening me." During an interview on 5/2/14 at 1:30 p.m., Resident #706 restated that she had witnessed CNA "I" being mean to her roommate (Resident #704), and making her cry. Resident #706 further confirmed that CNA "I" had "threatened" her and her daughters, because they had told her (CNA "I") not to be mean to Resident #704. Resident #706 expressed feelings of "relief" that CNA "I" no longer worked in the facility. ( ) Resident #704 On 4/30/14, at 4:30 p.m., review of a facility investigation of abuse allegations against CNA "I" dated 2/19/14, revealed that Nurse "K" interviewed Resident #704 who alleged that CNA "I" was "mean to her." The report indicated that when Resident #704 was questioned about CNA "I", "her eyes became wide, and she stated, "I'm afraid to say anything." The report indicated that Resident #704 said that CNA "I" would "yell at me and make me cry." On 4/30/14, at 2:30 p.m., review of Resident #704's medical record face sheet printed 5/1/14, revealed an original admission date of [DATE], and listed [DIAGNOSES REDACTED]. The MDS dated [DATE], documented that Resident #704 had some short and long term memory impairment and required extensive assistance with her personal care activities. On 5/01/14, at 9:30 a.m., interview with Resident #704 revealed, "I'm glad that (CNA "I") isn't here anymore. She (CNA "I") liked to quarrel at me and that would upset me." Resident #704 stated that she recalled being interviewed about how she was treated by CNA "I" and said "I told the truth. She (CNA "I") was mean." Resident #704 appeared visibly upset when discussing CNA "I" and added, "I really don't like talking about this because it was unfair of her (CNA "I")." Resident #704 further said that "She (CNA "I") got me so mad once I told her that you'll be sorry if I get out of this bed. She (CNA "I") laughed at me and thought I was being funny." Resident #719 On 5/1/14, at 9:30 a.m., review of Resident #719's medical record face sheet printed 5/1/14, revealed an original admission date of [DATE], and listed [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE], indicated that Resident #719 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated he had intact cognition. On 5/01/14, at 10:20 a.m., during an interview, Resident #719 described CNA "I" as "speaking in a harsh and gruff manner, with an abrasive personality." Resident #719 stated that it wasn't unusual for CNA "I" to "complain in front of patients" and "tell us that she was too busy and (residents) had to wait when we needed to be helped." Resident #719 further explained that CNA "I" "wasn't very nice to my roommate," who was Resident #727. Resident #719 stated that he often witnessed CNA "I" "scold him (Resident #727) like a child, telling him that he was too demanding and needed to learn to wait his turn." Resident #719 further explained that his roommate, Resident #727, wasn't able to defend himself because he was "confused." On 4/30/14, at 2:30 p.m., review of the facility investigation of abuse allegations against CNA "I" dated 2/19/14, revealed that on 2/19/14, both Nurse "K" and CNA "H" witnessed CNA "I" being verbally abusive to Resident #719, when he was in the bathroom. The report indicated that at approximately 2:20 p.m., on 2/19/14, Nurse "K" heard loud voices and upon entering the room the bathroom door was open. CNA "I" was heard speaking to Resident #719 in a harsh and angry tone, and had an angry look on her face. Resident #724 On 5/1/14, at 10:45 a.m., review of Resident #724's medical record face sheet printed 5/1/14, revealed an original admission date of [DATE], and listed [DIAGNOSES REDACTED]. Review of Resident #724's MDS dated [DATE], revealed that Resident #724 had intact cognition without evidence of memory impairment. On 5/01/14, at 12:20 p.m., interview with Resident #724 revealed that he would call CNA "I" "Sargent" because "she (CNA "I") acted like a dictator with residents." Resident #724 further stated, "I heard she had problems, so I kept my distance, and tried to keep in her good graces so there wasn't any trouble for me." On 5/01/14, at 2:30 p.m., review of the facility investigation of abuse allegations against CNA "I" dated 2/19/14, indicated Resident #724 was interviewed by Nurse "K" on 2/18/14. The report indicated that Resident #724 reluctantly described CNA "I" as being "a little rough around the edges." ( ) Resident #717 On 5/1/2014 at 1:00 p.m., a record review of the facility's resident "Accident/Incident/Near-Miss Report" for resident #717 dated 10/27/2013 at 1:00 p.m. revealed, "While resident was being transferred, right leg brushed against side of bed resulting in skin tear approximately 1.0 cm (centimeter) by 1.5 cm...Corrective measure to avoid repetition of incident: transfer with two persons ...The resident asked to go to the bathroom but the resident is placed in bed on bedpan. During the transfer into the bed the resident hit her leg causing a small skin tear." The report further revealed the incident was witnessed by Resident #717's daughter, but did not identify the name of the staff member who was involved. On 5/2/2014 at 2:20 p.m., Resident #717's daughter was queried regarding the facility ' s CNAs and their ability to provide care to residents in the facility. Resident #717's daughter was hesitant to answer at first, but then stated she had problems with only one CNA in the facility. Resident #717's daughter identified the CNA as CNA "I". When queried regarding Resident #717's accident/incident report dated 10/27/2013 at 1:00 p.m., Resident #717's daughter stated, "I was there when it happened to Mom (#717). Mom wasn't feeling well and she wanted to lay down. This CNA (CNA "I") snatched mom up and she threw my mom in bed. That's how my mom hurt her leg. Mom's leg was cut pretty bad. She still has a scar from that...I told them, I do not want this girl touching her (Resident #717) again...My mom has dementia and will say things over and over, but you don't treat her like that...I've seen this CNA (CNA "I") treat other residents wrong, but I'm not at liberty to talk about them." On 5/2/2014 at 2:30 p.m., observations of Resident #717's right leg revealed a resolved [MEDICATION NAME] area with a faded scar approximately 1.0 by 1.5 cm. On 5/2/2014 at 3:00 p.m., review of Resident #717's medical record face sheet revealed a 4/27/2009 original admitted in the facility with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #717 had moderately impaired cognition and required extensive two person assistance with transfers. ( )

Based on interview and record review, the facility failed to identify, thoroughly investigate, and report allegations of abuse incidents for seven of 28 residents (#s 704, 706, 711, 716, 717, 718, and 719) reviewed for abuse from a total sample of 30, resulting in the potential for ongoing and/or reoccurrence of abuse, neglect, or mistreatment. Findings include: On [DATE], at 1:45 p.m., the Director of Nursing (DON) explained that all abuse investigations were conducted by the Clinical Nurse Managers who were require to notify him and the Administrator of abuse allegations in accordance with the facility's abuse policies. The DON further explained that he had been notified of only one abuse investigation since he became the Abuse Coordinator in [DATE]. The DON said that on [DATE], Nurse "K" informed him that she was investigating allegations of abuse against multiple residents perpetrated by certified nurse assistant (CNA) "I". On [DATE] at 9:30 a.m., review of the investigation of abuse allegations against CNA "I" revealed that Resident #s 704, 706, 716, 717, 718, and 719 were named in the investigation. Resident #716 According to the facility's investigation report dated [DATE], CNA "H" witnessed Resident #716 in the shower room with CNA "I". Resident #716 was screaming that he was being beaten, visibly afraid, and vomiting. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE], indicated that Resident #704 and had severely impaired cognition. On [DATE], at 4:50 p.m., the DON stated that the allegation of abuse by Resident #716 was not thoroughly investigated or reported to the State Agency. On [DATE] at 2:00 p.m., CNA "H" was queried regarding the allegations against CNA "I" involving Resident #716. CNA "H" stated that on the morning of [DATE], she heard screaming coming from the shower room. CNA "H" stated, "As soon as I walked in the shower room, I knew something was wrong. He was so upset that he was throwing up violently. I stayed in the shower room with him and CNA "I" until he was dressed. I brought him out of the shower room, and I immediately told my nurse (Nurse "J") about what I had witnessed. Then at lunch time, she (CNA "I") was feeding (Resident #716). She (CNA "I") was shoving the food into his (Resident #716) mouth. I said, "that's enough," but she (CNA "I") wouldn't stop. I told my nurse (Nurse "J") what I had seen, but by the time she went into his (Resident #716) room, she (CNA "I") was finished feeding him. She (CNA "I") has done so many things that have been reported, and reported, and reported, but nothing is done. I slipped a note under the previous DON's door, and never heard back about it. I tried to find the number to call the State, but I couldn't find where it was posted. I'm worried about saying anything because there is no confidentiality." On [DATE] at 2:30 p.m., a family member of Resident #716 was queried regarding the quality of care provided to Resident #716. During the course of the interview, it was determined that the family of Resident #716 was unaware of the alleged incidents of abuse involving CNA "I". On [DATE] at 10:30 a.m., the DON (the facility's abuse coordinator) was queried regarding the investigation of CNA "I", and the alleged incidents of abuse. The DON stated that he became aware of the alleged incidents of abuse involving CNA "I" and Resident #716 on [DATE]. When queried as to whether the [DATE] incident regarding Resident #716 was reported to him by nurse "J", the DON stated, "I was not aware of that incident until [DATE]." ( ) Resident #704 According to the facility's investigation report dated [DATE], Resident #704 stated that CNA "I" was mean, yelled at her, and made her cry. At the time of the survey, Resident #704 was visibly upset when talking about CNA "I". Review of the Quarterly Minimum Data Set ((MDS) dated [DATE], indicated that Resident #704 had a BIMS (Brief Inventory Mental Status) score of 10 which indicated that the resident had moderately impaired cognition. On [DATE], at 1:45 p.m., when the DON was asked if there was an incident report for Residents #704 regarding the allegation of abuse he replied, "no, not to my knowledge". The DON further explained that the allegation of abuse by Resident #704 was not thoroughly investigated or reported to the State Agency. Resident #719 According to the facility's investigation report dated [DATE], indicated that CNA "I" was observed by CNA "H" and Nurse "K" verbally abuse Resident #719 on [DATE]. On [DATE] at 10:20 a.m., during interview with Resident #719 he described CNA "I" as speaking in a a harsh and gruff manner and stated that she had an abrasive personality. Resident #719 also stated he had witnessed CNA "I" scold his roommate Resident #727. Review of the Quarterly MDS dated [DATE], indicated that Resident #704 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated he had intact cognition. On [DATE], at 1:45 p.m., when the DON was asked if there was an incident report pertaining to the incident witnessed by Nurse "K" and CNA "H" when CNA "I" was abusive to Residents #719 and he replied, "no, not to my knowledge". The DON further explained that the allegation of abuse by Resident #719 was not thoroughly investigated or reported to the State Agency. On [DATE], at 4:50 p.m., both the DON and Administrator revealed that the decision to not report the abuse incident to the State Agency or report CNA "I" to the Nurse Aid Registry, was because "we didn't want to jeopardize her (CNA"I") career and we felt by removing her we removed the risk of further abuse." The DON stated that "we did not handle things the way they should have been handled." The DON further stated, "I used poor judgment." ( ) Resident #706 According to the facility's investigation report dated [DATE], Resident #706 stated that she felt threatened by CNA "I" and had witnessed CNA "I" being mean to her roommate Resident #704. At the time of the survey, Resident #706 reported these concerns during the Resident Group Interview. Review of the, Quarterly MDS dated [DATE], indicated that Resident #706 had a BIMS score of 9 which indicated that the resident had moderately impaired cognition. During an interview on [DATE] at 10:30 a.m., the DON stated that the incident where Resident #706 had alleged that she was threatened by CNA "I", had not been reported to the State Agency. No further explanation was provided. ( ) Resident #717 According to the facility's investigation report dated [DATE], the daughter of Resident #717 requested that CNA "I" be taken off duty as caregiver. On [DATE] at 1:00 p.m., a record review of the facility's resident "Accident/Incident/Near-Miss Report" for resident #717 dated [DATE] at 1:00 p.m. revealed, "While resident was being transferred, right leg brushed against side of bed resulting in skin tear approximately 1.0 cm (centimeter) by 1.5 cm...Corrective measure to avoid repetition of incident: transfer with two persons ...The resident asked to go to the bathroom but the resident is placed in bed on bedpan. During the transfer into the bed the resident hit her leg causing a small skin tear." The report further noted the incident was witnessed by Resident #717's daughter. The report did not have witness statements attached and did not identify the name of the staff was present. On [DATE] at 1:00 p.m., during the Quality Assurance Review with the facility, the Abuse Coordinator/Director of Nursing (DON) was queried regarding the incident. The Abuse Coordinated/DON was not able to identify the CNA (Certified Nursing Assistant) involved in the incident and stated "we don't take witness statements. We don't complete a incident and accident form for abuse allegations." The Abuse Coordinated/DON offered no further information related to the incident and stated, "all I know is what written there." On [DATE] at 2:20 p.m., Resident #717's daughter was queried regarding the skin tear sustained by Resident #717 on [DATE]. Resident #717's daughter stated, "I was there when it happened to mom. Mom wasn't feeling well and she wanted to lay down. This CNA (identified as CNA "I") snatched mom up and she threw my mom in bed. That's how my mom hurt her leg. Mom's leg was cut pretty bad. She still has a scar from that...I told them, I do not want this girl touching her (Resident #717) again...My mom has dementia and will say things over and over, but you don't treat her like that." On [DATE] at 3:00 p.m., Review of the facility "Corrective Bargaining Notice" written warning for CNA "I" dated [DATE] revealed "reason for this action: standards of conduct, policy or procedure violated)-work performance...explanation of facts; On [DATE] a family filed a complaint regarding CNA "I's" "approach and care...The family felt CNA's ("I") approach to the resident was...rushed and irritable causing a skin tear to the resident. CNA ("I") was talked to on [DATE]..." The corrective action was signed by The Abuse Coordinated/DON. When queried regarding knowledge of the event, The Abuse Coordinated/DON stated "I take full responsibility. I missed it. We dropped the ball." ( ) Resident #718 Resident #718, [AGE] years old, was admitted to the facility on [DATE], per an Admission Record, dated [DATE]. The resident expired, according to a nurse's note, dated [DATE]. According to the facility's investigation report dated [DATE], the family of Resident #718 requested that CNA "I" be taken off duty as caregiver. A physician's History & Physical, dated [DATE], identified Resident #718's [DIAGNOSES REDACTED]. A social worker's progress note indicated that Resident #718 had "significant cognitive and physical limitations." Unsuccessful attempts were made to contact Resident #718's responsible party (Family Member "L"), but Family Member "L" contacted the surveyor on [DATE] at 2:50 p.m., and was interviewed at that time. Family Member "L" stated that she visited Resident #718 frequently. Family Member "L" indicated that scratches were often noted on Resident #718's face and arms. When the family member questioned CNA "I", the response was always "She (Resident #718) did it, she (#718) was fighting me (CNA "I")." Family Member "L" said Resident #718 could not talk and was unable to protect herself. One day, when Family Member "L" came to visit, there were scratches all over Resident #718's face, and there was a bruise on her nose. The family member said she was "livid" to see the resident like that. Family Member "L" stated that she took Resident #718 out of the unit to show the facial scratches and the bruise to an unidentified staff member on another unit. The staff member said the marks looked like dead skin and did not acknowledge that Resident #718 had been scratched. Family member "L" said that to her knowledge, no investigation was ever done to look into her concerns about the rough care provided Resident #718 and the scratches found on the resident's body. The DON (director of nursing) provided no incident reports or facility investigations regarding scratches on Resident #718 which were requested during the annual survey. No report of abuse regarding Resident #718 was received by the state agency. ( ) Resident #711 Review of Resident #711's clinical record on [DATE] at 2 p.m. revealed the following: Resident #711, [AGE] years old, was initially admitted to the facility on [DATE], per the [DATE] Admission Record. A physician's Progress Note, dated [DATE], noted the following diagnoses; status [REDACTED]." The mental status examination dated [DATE] indicated that Resident #711 had severe cognitive impairment. The resident was slow to respond and had difficulty verbalizing. A social service progress note, dated [DATE] noted that Resident #711 required two person assistance with transfers and other activities of daily living. Resident #711 was observed during the initial tour of the facility with Clinical Case Manager Registered Nurse (R.N.) "A" on [DATE] at 10:15 a.m. The entire back of Resident #711's right hand along with the fingers of the right hand were observed to be bruised (black and blue). There was a large hematoma, approximately 1 cm to 1.5 cm elevation above the skin, noted on the back of the hand. The resident said, "Don't touch my hand." as soon as she was approached. Resident #711 said she did not know what had happened to her hand. The resident guarded her hand. The Clinical Care Manager said she did not know what had happened to Resident #711's right hand. The manager left the room. On return, the manager said the bruising was the result of a blood draw on [DATE]. Licensed Practical Nurse (L.P.N.) "E" was interviewed on [DATE] at 10 a.m. She said she came into work on [DATE] for the day shift and was informed by the midnight nurse (Nurse "F") that Resident #711 was found during the night with a bruise on her hand. Nurse "E" documented the bruise in a nurse's note on [DATE] at 9:50 a.m. "Resident has raised hematoma top of (R) hand had blood draw on [DATE] probably hematoma from blood draw. . . hematoma measures 2.5 cm x 2.5 cm." The note documented that the physician and the responsible party were notified. Physician orders [REDACTED]. Nurse "E" said she did not write an incident report regarding the bruise. Registered Nurse (R.N.) "F" was interviewed by telephone on [DATE] at 12:56 p.m. She said CNA "G" reported Resident #711's bruised hand to her during the night shift on [DATE] (11:00 p.m. on [DATE] through 7:00 a.m. on [DATE]). R.N. "F" said she looked at the bruise which involved only the back of the right hand as well as a hematoma on the back of the right hand. Nurse "F" said she looked in the chart and saw that a blood draw was done on [DATE] and assumed that was the cause of the bruise. R.N. "F" said she did not initiate an incident report because it was caused by a blood draw. "If I couldn't explain what had caused the bruised hand, I would do an incident report." Nurse "F" said she did not notify the physician or the responsible party on her shift. Nurse "F" said she reported the bruised hand to the oncoming day nurse, L.P.N. "E". There was no nurse's note documenting the bruise. CNA "G" was interviewed on [DATE] at 9:30 a.m. She said she first noticed Resident #711's bruised hand during the midnight shift on [DATE] and reported it to R.N. "F". The CNA said she thought the resident had bumped her hand. CNA "G" said she cared for the resident on [DATE] during the midnight shift and did not notice any bruise at that time. Clinical Care Manager "A" was interviewed again on [DATE] at 3 p.m. about Resident #711's bruised hand. She said an incident report had not been completed regarding the bruise. When questioned about whether there had been any discussion with the laboratory, the clinical care manager said, "No, do you want me to call them?" On [DATE] at approximately 1:30 p.m. L.P.N. "E" said the physician had just looked at Resident #711's bruised hand and said it was due to a blood draw. The Director of Nursing was interviewed on [DATE] at 8 a.m. He said he did not know that Resident #711 had sustained a bruise on her hand. Sometime during the day on [DATE], an incident report for Resident #711 regarding her bruised hand was placed on a table in the room used by the surveyors. ( ) Resident #711 also sustained a left [MEDICAL CONDITION] on [DATE], per a hospital History & Physical report, reviewed on [DATE]. According to the report, the resident required surgical intervention to repair the [MEDICAL CONDITION]. An incident report for #711's fall on [DATE] indicated that the fall was not observed by any staff member and alarms which were in place were not functioning. In an interview with Clinical Care Manager "A" on [DATE] at 2:30 p.m., Clinical Care Manager "A" stated the pressure sensor bed alarm was not functioning and an alarm on the bathroom door was not mounted correctly and did not function. The state agency did not receive any report regarding Resident #711's fall with injury which occurred on [DATE]. ( )

This citation has three deficient practice statements. Deficient practice statement #1 Based on observation, interview, and record review, the facility failed to ensure that alarms, used to alert staff of unsafe transfer and ambulation, were operational and in use to prevent falls for two (#705, and #711) of eight sampled residents reviewed for supervision/falls in a total of 30 sampled residents resulting in a fall with a hip fracture and a decline in activities of daily living for Resident #711; and, a fall with minor injury for Resident #705. Findings include: Resident #711 was initially admitted to the facility on [DATE], per the 2/26/14 Admission Record. A physician's Progress Note, dated 4/22/14, noted the following diagnoses; status [REDACTED]." According to an Incident Report, dated 2/13/14, Resident #711 sustained a fall on 2/13/14 at 1:35 a.m. which was not observed by any staff member. Staff, per the incident investigation report, dated 2/18/14, heard "a loud 'thud' sound and a voice call for help." Staff found the bathroom door open and Resident #711 lying on her left side in front of the toilet. According to the Incident Report the pressure sensor bed alarm was not functioning properly. A facility investigation, dated 2/18/14, stated, "Although it was appropriately attached to the pressure sensor alarm and said alarm exhibited a red blinking light, indicating activation, the alarm did not sound upon pressure relief. Closer observation revealed the cord proximal to the sensor pad to have been sheared away from the plastic, likely causing its malfunction." The investigation report indicated that Resident #711 also had a bathroom door alarm placed on 2/3/14 due to repeated attempts of the resident to self-transfer to the toilet. The alarm, per the investigation report, had been positioned to the bathroom door using the hand sanitization holder rather than having it securely mounted on the wall. The bathroom door alarm did not function at the time of the fall. The investigation report for Resident #711's fall on 2/13/14 indicated that staff on the day shift and the afternoon shift had checked the bed pressure alarm and reported it working. Staff did not report that the bathroom door alarm did not function. Clinical Care Manager "A", interviewed on 5/2/14 at 2:30 p.m., presented a form on which staff documented when alarms were checked. The midnight staff on the date of the fall had not documented that the alarms were checked to determine whether they were functioning. A toileting care plan, dated 2/28/2012, stated that Resident #711 was toileted with assistance and remained at risk for urinary tract infections. One intervention, dated 2/28/2012, indicated that staff were to offer the toilet "routinely" with one person assistance. Clinical Care Manager "A", during the 5/2/14 interview, could not say when resident #711 was last toileted prior to the fall on 2/13/14. A falls care plan, updated on 3/12/14, indicated that Resident #711 was not ambulatory and required two person assistance for transfers using a mechanical lift. Interventions included a sensor alarm in bed and in the wheelchair, a bathroom door alarm, a floor mat next to the bed, and the bed in the low position. Resident #711 was observed in her bed on 5/1/14 at 1 p.m. with licensed practical nurse (L.P.N.) "E". The bed sensor alarm and the bathroom door alarm were functioning. The mat was on the floor. However, the bed was not in the lowest position. CNA (certified nursing assistant) "G", when interviewed on 5/2/14 at 2 p.m., said she placed Resident #711 back to bed after lunch and thought she had placed the bed in the lowest position. Comparison of Minimum Data Set (MDS) assessments for Resident #711, dated 10/15/13 and 2/24/14 respectively, indicated that Resident #711's ability to perform activities of daily living declined following her fractured hip on 2/13/14: Bed mobility from independent to extensive 2 person assistance. Transfer from extensive 1 person assistance to totally dependent. Walk in corridor from extensive 1 person assistance to unable to perform. Dressing from limited 1 person assistance to extensive 1 person assistance. Eating from independent with supervision to extensive 1 person assistance. Toileting from extensive 1 person assistance to totally dependent. Hygiene from limited 1 person assistance to extensive 1 person assistance. Bathing from extensive 1 person assistance to totally dependent. ( ) On 4/29/14, at 10:20 a.m., during the facility tour on the ARD (Alzheimer Related Dementia) Unit, Resident #705 was observed sitting in the dining room. Resident #705 had a bruised area surrounding her right eye that was purple and red. There was also a steri-strip (bandage) applied to a skin tear located above her right eyebrow that appeared to be approximately 1/2 centimeter in length. On 4/29/14, at 10:22 a.m., interview with Nurse "X" revealed that Resident #705 had a fall on 4/26/14. Nurse "X" further stated that Resident #705 was impulsive and tried to walk without assistance. Nurse "X" further explained that Resident #705 had poor balance, but was able to ambulate with staff assistance and the use of a gait belt. Review of a form entitled, "Resident Accident/Incident Report" dated 4/26/14, indicated that at 6:30 p.m., on 4/26/14, Resident #705 was found in the hallway on the floor. The report indicated "CNA (certified nursing assistant) saw resident after fall. Resident was face first on the floor resting on elbows and knee. A skin tear is present above the right eyebrow measuring 1/2 cm in length. Bruising is noted above the right eye and below the right eye. Resident went into hallway while nurse and 3 CNA's were assisting residents in the dining room during dinner. Skin tear was cleaned with normal saline, steri-strip applied, ice pack applied to bruising and neuro-checks performed." On 4/29/14, a 11:30 a.m., review of the clinical record for Resident #705 revealed the Minimum Data Set ((MDS) dated [DATE]. This MDS documented that Resident #705 was ambulatory with assistance. Review of the Comprehensive Care Plan dated 3/01/14, indicated that Resident #705 had a fall assessment completed on 3/26/14, and interventions to decrease her risk for accidents included a chair sensor pad alarm and bed sensor pad alarm. On 5/01/14, at 4:10 p.m., interview with Nurse "Y" revealed that she understood that at the time of the incident there was no chair sensor pad alarm applied to the chair to alert staff if Resident #705 attempted to transfer independently. Nurse "Y" stated that, "the CNA was new and the licensed nurse on the day of the accident was part time and neither knew that (Resident #705) needed a chair senor pad alarm." On 5/01/14, at 4:40 p.m., review of the facility's policy on "Restraint Free Alarms" dated 1/6/11, indicated that "it is the policy of the nursing department to assess and assign a restraint free alarm to those residents in need of such a system. The purpose of the system is to notify staff that a resident who requires assistance to stand and balance is attempting to transfer independently." On 5/01/14, at 4:55 p.m., review of the facility's policy on "Fall Assessment and Prevention" revised 3/2013 indicated that, "the need for continued or additional safety devices is determined by the interdisciplinary team and will be posted for staff on the care plans." ( ) Deficient practice statement #2 Based on observation, interview, and record review, the facility failed to ensure that one (#716) of eight sampled residents reviewed for supervision/falls in a total of 30 sampled residents was not left unattended in an elevated bed during care, resulting in a fall with minor injury and the potential for serious injury. Findings include: Review of the admission face sheet on 5/1/14 at 9:30 a.m., revealed that Resident #716 was originally admitted into the facility on [DATE], and was readmitted on [DATE], with [DIAGNOSES REDACTED]. According to a significant change Minimum Data Set, dated dated [DATE], Resident #716 had severely impaired cognition, and required extensive assistance of two staff members for bed mobility. Review of a "Fall Risk Assessment" for Resident #716, dated 10/25/13, noted a fall risk score of 16, with a score of 10 or more indicating high fall risk. Further clinical record review for Resident #716 revealed the following falls care plan: Problem: (Resident #716) is at risk for falls related to his [DIAGNOSES REDACTED]. Approach: (7) Bed in lowest position. Review of a "Resident Accident/Incident/Near-Miss Report" for Resident #716 noted: Date of Incident: 11/15/13 Describe the situation: Patient was being bathed by CENA (competency evaluated nurse assistant). Patient was on left side, reached for the window curtain and pulled himself out of bed, landed on floor between bed and window. Very large bump/bruise on right forehead, small cut beside right eye, red area on right cheek below eye, 2 small skin tears on right elbow. If resident was in bed, bed height: Elevated/Care Level Clinical Manager/Nursing findings: Resident was being cleaned. CNA (certified nurse assistant) went to reach for another wash cloth and resident grabbed curtain and rolled onto floor. Resident hit forehead on sill. Review of a "Witness Statement" for CNA "Z", dated 11/15/13, noted: "I (CNA "Z") was...taking care of (Resident #716). He was on his side and had a bm (bowel movement). I was cleaning him up and went to grab another wash cloth and while I was grabbing the wash cloth, he grabbed onto the curtains in the window and pulled himself off the bed. He fell on the floor..." Review of the nurse's notes for Resident #716 noted: On 11/15/13 at 3:45 p.m., "CENA called nurse to room, stated while he was bathing patient and had him on his left side patient reached for window curtain and pulled himself out of bed. Patient was on floor between bed and window. Large bump on right forehead, small cut by right eye, reddened area on right cheek, 2 skin tears on right elbow...When asked if anything hurt, he stated "my head". Ice pack placed on forehead..." On 11/16/13 at 6:00 a.m., "Resident...continues to have minor swelling on right side of forehead...also slight bruising on right cheek." On11/16/13 at 9:00 a.m., "Resident's pupils uneven right pupil larger than left, pupils sluggish to light reaction. Resident complains of mild pain on right forehead...(Physician) stated to get a STAT CAT scan..." Review of a physician's orders [REDACTED]. Diagnosis/Reason: Fall, pupils uneven." Review of the "Discharge Instructions" from the emergency room , revealed that Resident #716 had been evaluated for "head injury, and contusion to the scalp." On 5/2/14 at 2:00 p.m., clinical nurse manager "D" was unable to provide an explanation as to why Resident #716 had been left unattended in an elevated bed during care, resulting in the resident falling out of bed and sustaining a head injury, a cut beside the right eye, and 2 skin tears on the right elbow. ( ) Deficient practice statement #3 Based on observation, interview and record review, the facility failed to provide supervision to one supplemental sampled resident (#80), who displayed wandering behaviors, resulting in the potential for accidents. Findings include Resident #80's record was reviewed on 5/2/14 at 10:30 a.m. A hospital physician's History & Physical (H&P) report dated 1/24/14 documented that the resident had recently been very confused at home, pouring gasoline on trash and then moving towards a gas stove while covered in gasoline. He was found at home eating a raw hamburger smeared with butter. He was observed at home covered in feces. Resident #80 was admitted to the facility on [DATE], per the Admission Record, dated 2/10/14. A nursing home H&P documented a [DIAGNOSES REDACTED]. During the initial tour of the facility on 4/29/14, Resident #80 was observed moving up and down the hallways of DE and DW in his wheelchair. He was noted to be in a pleasant mood, greeting everyone who passed by. Conversations with staff were often nonsensical, unrelated to the conversation initiated by staff. Resident #80 was observed continuously wandering in the hallways on 4/30/14, 5/1/14, and 5/2/14, moving up and down the hallways of DE and DW in his wheelchair. On 5/1/14 between 9:15 a.m. and 9:30 a.m. Resident #80 twice attempted to exit a locked door into the dementia unit. Staff were not in the area. Between 9:15 a.m. and 10:30 a.m. Resident #80 was observed three times in a short hallway attempting to enter the clean utility room and the dirty utility room. The resident also went into the nurse's station during this time until Licensed Practical Nurse (L.P.N.) "E" moved the chart rack at the entry to the nurse's station making it more difficult for a wheelchair to enter the area. L.P.N. "E" said Resident #80 got into her papers when he went behind the desk because no staff were there to monitor his behavior. On 5/1/14 at 3:30 p.m. Resident #80 was observed at the housekeeping cart in the hallway, going through the trash receptacle. Staff saw the resident and removed him from the cart. On 5/2/14 at 11:50 a.m. Resident #80 was observed entering the shower room at the end of the hallway DE. He was observed entering into the shower stall. No staff were in the area. The surveyor notified nursing staff who removed Resident #80 from the shower room. A social service note dated 2/3/14 indicated that Resident #80 had daily confusion and disorientation to time, place, and happenings around him. He needed daily reminders and orientation from staff. It was documented that the resident was up at night wandering around and was often difficult to redirect. Resident #80 had an undated care plan addressing his wandering. The care plan included interventions for a transmitting device to be worn by the resident that alarmed when approaching specially designed doors. Another intervention was to assess the possible cause when the resident "begins to wander or when wandering increases." However, Resident #80 spent most of his day wandering. Specific behaviors were not identified on the care plan. The only intervention addressing staff supervision was to "redirect resident when he propels w/c (wheelchair) into other rooms." A behavior summary, dated 3/20/14, documented that Resident #80's behaviors were noted primarily during early evening and night shifts. Frequent behaviors identified during the afternoon shift included "restlessness, profane gesturing to staff members, wandering into other patient rooms, and inappropriate touching of nursing staff." On the 3/20/14 tracking tool for Resident #80, behaviors were noted on 3/24/14, 3/25/14, 3/28/14, and twice on 4/4/14. On four dates, the behaviors continued, meaning the interventions were not effective. On one occasion the interventions were effective. These behaviors were not addressed in the wandering care plan or in an undated care plan addressing mood and cognitive problems. Social Worker (SW)/Activities Director (AD) "M" was interviewed on 5/2/14. She stated that the care plans for Resident #80 were not complete and "needed work." She said stop signs (cloth signs which attached to the doorframe with Velcro) were being used to deter Resident #80 from entering rooms of other residents, but CNA "G", sitting nearby, said that she had only seen one resident using the stop sign. During the initial tour units DW and DE on 4/29/14, beginning at 9:15 a.m., no stop signs were observed. ( )

This citation refers to intake # MI 844. Based on interview and record review, the facility failed to provide the necessary care and services to attain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care, for 1 of 5 (Resident #101) sampled residents, from a total sample of 5 residents with swallowing problems, resulting in an Immediate Jeopardy when Resident #101, who was identified with a swallowing problem (dysphagia), was not given a swallow evaluation by Speech Therapy, had no care plan or interventions in place for his dysphagia, choked on sausage and eggs at breakfast on [DATE] at approximately 9:00 AM and subsequently died on [DATE] at 9:31 AM. Findings include: Resident #101 was a [AGE] year old male admitted to the facility on [DATE] after transferring from another facility with [DIAGNOSES REDACTED]. On [DATE] at 9:30 AM, a record review of Resident #101's admission Minimum Data Set ((MDS) dated [DATE], indicated that the MDS for Resident #101 had not been completed and did not contain any clinical information regarding Resident #101. On [DATE] at 9:30 AM, a record review of Resident #101's medical record revealed there were no care plans and no identified interventions in regards to Resident #101's swallowing problems. In an interview with RN Clinical Manager #10, she stated that one of her responsibilities was to complete resident care plans. When asked why there was no care plan for dysphagia, RN Clinical Manager #10 said "dysphagia should have been care planned". In an interview on [DATE] at 12:50 PM, Attending Physician #5 described Resident #101 as very difficult to control because Resident #101 refused to take any oral medications. Attending Physician #5 reported that he observed Resident #101 while eating and that Resident #101 would "pick up food in his hands and stuff the food in his mouth." Attending Physician #5 stated Resident #101 was "unhygienic" and he "wouldn't use utensils" to eat. Attending Physician #5 reported he was aware of Resident #101's [DIAGNOSES REDACTED]. Attending physician #5 said he questioned if Resident #101's dysphagia was "related to the texture of the food" and concluded that the dysphagia was "more mechanical" (related to the chewing of the food as opposed to the ability to swallow) so he did order a regular diet. Attending Physician #5 stated he did not order a swallow evaluation to assess Resident #101's swallowing problem because he was afraid the speech therapist would be "hit or hurt" by Resident #101 due to a past history of Resident #101 being aggressive towards staff. Attending Physician #5 stated he didn't remember being contacted during the weekend of [DATE] and [DATE] by the nursing staff and being told that Resident #101 was observed "coughing and gurgling" while eating. Resident refused to eat in the dining room. Review of the facility's "physician progress notes [REDACTED]. He choked on his eggs and sausage. He is a fast eater and usually takes large amounts of volume in his mouth without chewing and then swallows". In an interview on [DATE] at 2:40 PM, Certified Nursing Assistant (CNA) #7 reported Resident #101 "had double portions and a regular diet" at mealtimes. CNA #7 stated Resident #101 "just shoved food in his mouth while he continued to talk and yell." CNA #7 said Resident #101 always ate in his room. On [DATE] at 9:30 AM, a record review of the Resuscitate Options and Organ Donation Wishes Form indicated that Resident #101 signed the "Do Not Resuscitate" option on [DATE]. In an interview on [DATE] at 10:45 AM, Licensed Practical Nurse (LPN) #3 stated she observed Resident #101 all weekend ([DATE]- [DATE]) and noted that Resident #101 was "coughing and gurgling" while eating his food. LPN #3 said she reminded Resident #101 to "slow down" because Resident #101 was "stuffing food in his mouth". LPN #3 stated she did not contact Attending Physician #5 to report the "coughing and gurgling" because Attending Physician #5 "was in the house and was aware" of this behavior because Attending Physician #5 "observed the coughing and gurgling". LPN #3 stated that, on [DATE] (approximate time 9:00 AM), Resident #101 was yelling so she went to his room to check on him. LPN #3 stated Resident #101 requested that a pillow be placed behind his head and LPN #3 stated she "would be right back". LPN #3 reported she did not put the pillow behind Resident #101's head because she had to wash her hands. A few minutes later, LPN #3 reported she heard Resident #101 ringing his bell and thought to herself "I forgot his pillow". LPN #3 reported that as she went to Resident #101's room and she heard the call bell fall to the floor. LPN #3 stated she walked in Resident #101's room and observed "food was pouring out of the side of his (Resident #101's) mouth" and Resident #101 "was gurgling". LPN #3 stated she ran out of the room and yelled to Registered Nurse (RN) #4 "Is (Resident #101) a full code?" and told RN #4 "You need to come now!" LPN #3 stated she went back into Resident #101's room and saw that he was "blue around his face and lips". LPN #3 reported she left the room, went to the dementia unit, called for RN #4 to come and help and then went across the hall from Resident #101's room to an alcove and paged the DON #2 overhead at approximately 9:17 AM for assistance. LPN #3 stated she then went back to the room, and was joined by RN #4 and DON #2. LPN #3 reported that when DON #2 entered the room, Resident #101 was sitting up at a 90 degree angle. LPN #3 stated DON #2 put the head of the bed down, rolled Resident #101 on his right side and gave Resident #101 a blow to the back. LPN #3 applied oxygen to Resident #101. LPN #3 reported she suctioned Resident #101 and removed some partially chewed meat and egg from Resident #101's mouth. LPN #3 stated she looked in Resident #101's mouth, completed a finger sweep and removed a half dollar sized piece of egg from the back of Resident #101's mouth. LPN #3 said that Resident #101's pulse ox (pulse oximetry reading) was 23%. (According to the book "Fundamentals of Nursing: The Art and Science of Nursing Care, Sixth Edition", a pulse oximeter is a device that measures the amount of oxygen present in red blood cells and is reported as a percentage. The accepted parameter for a pulse oximeter reading is 95% or greater.) LPN #3 also said that no abdominal thrusts were done on Resident #101. LPN #3 stated Resident #101 "died in a matter of minutes". Cardiopulmonary Resuscitation (CPR) was not initiated. In an interview on [DATE] at 3:30 PM, DON #2 reported at approximately 9:17 AM on [DATE], she was paged overhead to go to Resident #101's room. DON #2 stated when she entered the room, Resident #101 had no normal respirations, his pupils were dilated, and he was taking "agonal breaths" (irregular breathing characterized as shallow with irregular pauses). DON #2 stated Resident #101's "pulse (heart rate) was 20 (normal pulse is between 60 and 100 beats per minute) and weak". DON #2 stated she lowered the head of the bed, turned Resident #101 to his right side and gave Resident #101 a blow to the back. DON #2 reported Resident #101 was turned onto his back and LPN #3 opened his mouth and saw a piece of egg at the right side of his cheek. DON #2 stated LPN #3 did a finger sweep of Resident #101's mouth and removed egg from his mouth and then suctioned Resident #101's mouth. DON #2 said that no abdominal thrusts were performed on Resident #101. DON #2 stated the Attending Physician #5 was notified and came to the facility. DON #2 reported that Attending physician #5 pronounced Resident #101 dead at 9:31 AM on [DATE]. The Police Department was notified of the unexpected death, came to the facility, interviewed staff and notified the medical examiner of the death. On [DATE] at 9:30 AM, a record review of nurse's record documentation dated [DATE] at 9:35 AM indicated that the [MEDICATION NAME] maneuver was performed on Resident #101 after Resident #101 was turned on his right side. However, in separate interviews with DON #2 (on [DATE] at 3:30 PM) and LPN #3 ([DATE] at 10:45 AM), both denied that the [MEDICATION NAME] maneuver (abdominal thrusts) was done on Resident #101. Both stated that, after Resident #101 was turned to his right side, Resident #101 received a blow to the back by the DON #2 and not the [MEDICATION NAME] maneuver. On [DATE] at 9:30 AM, a record review of the nurse's record indicated no documented evidence that the respirations, heart rate and pulse ox were monitored for Resident #101 while Resident #101 was choking. Cardiopulmonary resuscitation (CPR) was not performed on Resident #101 as he was considered a Do Not Resuscitate (DNR) according to the Resuscitate Options and Organ Donation Wishes form signed by Resident #101 on [DATE]. The Administrator and the DON were notified on [DATE] at 10:00 AM of the immediate jeopardy that began on [DATE] and was identified on [DATE] when Resident #101 began choking on food and subsequently died . On [DATE] at 3:30 PM, the surveyor confirmed that the facility implemented the following to remove the immediate jeopardy: 1. Beginning on [DATE], twenty-seven nurses (27) and ninety-eight (98) CNA's were scheduled to receive face to face inservices about caring for residents at risk for aspiration. As of [DATE], fourteen (14) nurses and sixty-six (66) CNAs completed the inservice. The face to face inservice topics reviewed with staff included: policies and procedures, care for residents at risk for aspiration, definition of aspiration, identifying who is at risk for aspiration, signs of aspiration, prevention of aspiration and managing aspiration. Nurses and CNA's on personal time off (PTO) or on extended leave of absence (LOA) will complete face to face training before returning to work at the facility. Agency staff will receive face to face training prior to working at the facility. 2. On [DATE], the DON reviewed the policies and procedures for choking, airway obstruction, dysphagia assessment (including the [MEDICATION NAME] maneuver) and made no changes to these policies. 3. Beginning [DATE], nursing staff at the facility began assessing all residents during meal times for swallowing issues. All residents identified with a potential swallowing issue will have a swallow evaluation ordered to be done by speech therapy. 4. On [DATE], four (4) residents were identified by management staff with swallowing difficulties. The medical record of each of these residents was reviewed to determine if an assessment for swallowing issues was completed and if their swallowing difficulty was addressed in their care plan. Care plans were updated to include interventions for swallowing difficulties for each of these residents. 5. On [DATE], a mealtime audit tool was implemented in the facility. The audit tool was used by nursing staff to evaluate residents during meals to identify residents with swallowing issues. This tool was to be used by nursing staff for the ten days following implementation and randomly thereafter. Although the Immediate Jeopardy was removed on [DATE] at 3:30 PM, the facility remained out of compliance at a scope of isolated and severity of no actual harm but potential for more than minimal harm that is not immediate jeopardy due to the fact that all staff had not been inserviced and sustained compliance had not been verified by the state agency.

THIS CITATION PERTAINS TO INTAKE MI 513. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE NECESSARY CARE AND SERVICES TO MAINTAIN THE HIGHEST PRACTICABLE PHYSICAL WELL BEING FOR 2 (#101, #102) OF 4 SAMPLED RESIDENTS, OUT OF A TOTAL SAMPLE OF 4, WHEN THE FACILITY FAILED TO PROVIDE ADEQUATE PAIN CONTROL FOR RESIDENT #101, WHO HAD SUSTAINED A 100% DISPLACED FRACTURE OF HER LEFT UPPER ARM, AND CANCELLED A FOLLOW UP APPOINTMENT WITH AN ORTHOPEDIC (BONE) SPECIALIST WHICH WAS ORDERED BY THE HOSPITAL PHYSICIAN, AND WHEN RESIDENT #102 SUSTAINED A FRACTURE OF BOTH LOWER LEG BONES OF HER RIGHT LEG, WHEN HER LEG WAS CAUGHT UNDER HER WHEELCHAIR WHICH WAS BEING PUSHED WITHOUT FOOT RESTS BY CNA #9 ON 5/19/11, AND WENT UNdiagnosed UNTIL 5/24/11 WHEN AN XRAY WAS ORDERED; RESULTING IN SEVERE PAIN, AND LACK OF HOSPITAL ORDERED ORTHOPEDIC SPECIALTY CARE FOR RESIDENT #101, AND UNTREATED FRACTURES OF BOTH BONES IN THE LOWER RIGHT LEG FOR RESIDENT #102 FROM 5/19/11 TO 5/24/11. FINDINGS INCLUDE: RESIDENT #101: REVIEW OF RESIDENT #101'S MEDICAL RECORD REVEALED A [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. HER MINIMUM DATA SET ((MDS) dated [DATE] DOCUMENTED THAT SHE HAD SEVERE COGNITIVE IMPAIRMENT, REQUIRED EXTENSIVE ASSISTANCE OF ONE PERSON FOR BED MOBILITY, TRANSFERS AND DRESSING, AND DENIED HAVING PAIN. FACILITY INCIDENT REPORT DATED 6/16/11 FOR RESIDENT #101 DOCUMENTED RESIDENT YELLING WHEN HER LEFT ARM MOVED AND A "BUMP" WAS OBSERVED ON HER LEFT UPPER ARM, PHYSICIAN NOTIFIED, AND XRAY ORDERED OF LEFT UPPER ARM. THE INCIDENT REPORT ALSO DOCUMENTED XRAY RESULTS RECEIVED ON 6/16/11 OF ACUTE DISTAL LEFT HUMORAL FRACTURE. FACILITY NURSE'S NOTES FOR RESIDENT #101 DATED 6/16/11 DOCUMENTED THAT WHILE CNA (CERTIFIED NURSE AIDE) WAS BATHING RESIDENT #101, THE CNA NOTICED A LARGE BUMP ON HER UPPER LEFT ARM, AND "WHEN WE LIFT HER ARM STARTS SCREAMING". NURSE'S NOTES THE SAME DAY AT 11:35 PM DOCUMENTED XRAY RESULTS OF ACUTE DISTAL LEFT HUMORAL(BONE IN THE UPPER ARM) FRACTURE AND THAT AN ORDER WAS RECEIVED BY THE PHYSICIAN TO SEND RESIDENT #101 TO THE HOSPITAL. HOSPITAL XRAY RESULTS DATED 6/17/11 DOCUMENTED 1. OBLIQUE [MEDICATION NAME] (SLANTED, THROUGH ENTIRE BONE FROM ONE SIDE TO THE OTHER) FRACTURE THROUGH THE LEFT HUMERUS AT THE JUNCTION OF THE MIDDLE AND DISTAL 3RD. AND 2. THERE IS DISPLACEMENT LATERALLY OF THE DISTAL FRACTURE FRAGMENT OF APPROXIMATELY 2 CENTIMETERS WITH OVERLAP OF THE FRACTURE FRAGMENTS OF APPROXIMATELY 3 CENTIMETERS AND ANGULATION. HOSPITAL emergency room PHYSICIAN ORDERS [REDACTED]. FACILITY NURSE'S NOTES DATED 6/17/11 DOCUMENTED RESIDENT #101 RETURNED FROM THE HOSPITAL WITH ORDERS TO NOT REMOVE SLING OR SPLINT AND MAKE APPOINTMENT MONDAY MORNING WITH ORTHOPEDIC DOCTOR. FACILITY NURSE'S NOTES DATED 6/18/11 AT 4:15 PM, DOCUMENTED THAT RESIDENT #101 WAS GRIMACING AND HOLDING ARM AND MAKING GRUNTING NOISES AND INFORMED THE NURSE, "YES" SHE WAS IN PAIN AND , "MY ARM HURTS". NURSE'S NOTES FOR THAT SAME DAY AND TIME, DOCUMENT THAT RESIDENT #101'S PHYSICIAN WAS CONTACTED AND ASKED FOR PAIN MEDICATION STRONGER THAN TYLENOL(USED FOR MILD TO MODERATE PAIN), WITH NEW ORDER RECEIVED TO INCREASE TYLENOL. NURSE'S NOTES FOR THAT SAME DAY AT 8:00 PM DOCUMENTED THAT RESIDENT #101 CRIES OUT WHEN MOVED TO BE GIVEN CARE AND ATE POORLY. NURSE'S NOTES DATED 6/20/11 DOCUMENTED RESIDENT #101 STILL HAVING PAIN AND DISCOMFORT AND TYLENOL BEING GIVEN AROUND THE CLOCK. NURSE'S NOTES DATED 6/22/11 DOCUMENTED THAT RESIDENT #101'S RINGS HAD TO BE REMOVED DUE TO INCREASED SWELLING RELATED TO THE FRACTURE. PHYSICIAN ORDER [REDACTED]. NURSE'S NOTES DATED 7/1/11 DOCUMENTED THAT RESIDENT #101'S LEFT EXTREMITY WAS VERY PAINFUL WHEN IT WAS MOVED AND SHE NEEDED STRONGER PAIN MEDICATION. IN AN INTERVIEW ON 7/5/11 AT 12:45 PM, RN #6 STATED ON 6/16/11, SHE WAS CALLED TO RESIDENT #101'S ROOM TO LOOK AT HER. RN #6 STATED SHE OBSERVED A LARGE LUMP ON HER LEFT UPPER ARM, "LIKE BONE STICKING OUT". RN#6 STATED THAT RESIDENT #101 HAD NOT EXPERIENCED ANY FALLS THAT DAY. IN AN INTERVIEW ON 7/5/11 AT 1:40 PM, RN #3 STATED ON 6/16/11, SHE WAS CALLED TO RESIDENT #101'S ROOM TO LOOK AT HER ARM, BY RN #6. RN #3 STATED WHEN RESIDENT #101 MOVED HER LEFT ARM, SHE (RN #3) OBSERVED A "BIG BULGE COMING OUT UNDER THE SKIN, LIKE BONE PUSHING OUT". RN #3 STATED THAT RESIDENT #101 YELLED IN PAIN EVERY TIME SOMEONE CAME NEAR HER. IN AN INTERVIEW ON 7/5/11 AT 10:00 AM, RESIDENT #101 WAS ASKED BY THE SURVEYOR HOW SHE WAS DOING. RESIDENT #101 STATED, "I'M HURTING". WHEN ASKED WHERE SHE WAS HURTING, RESIDENT #101 STATED, "MY ARM" AND POINTED TO HER LEFT UPPER ARM. THE SURVEYOR ASKED RESIDENT HOW MUCH PAIN SHE WAS IN, AND RESIDENT #101 STATED, "A LOT". DURING AN OBSERVATION ON 7/5/11, IN RESIDENT #101'S ROOM, THE SURVEYOR OBSERVED CARE BEING PROVIDED TO RESIDENT #101 BEING TRANSFERRED FROM HER BED TO HER WHEELCHAIR BY STAFF RN #12 AND CNA #13. DURING THE TRANSFER RESIDENT #101 SCREAMED AND STATED, "IT HURTS, IT HURTS, MY ARM". CNA #13 STATED THAT RESIDENT #101 DOES COMPLAIN OF PAIN IN HER LEFT ARM REGULARLY. RN #12 STATED SHE WOULD CHECK TO SEE WHAT SHE COULD GIVE RESIDENT #101 FOR PAIN, AND THE SURVEYOR WALKED OUT OF THE ROOM WITH RN #12 TO THE MEDICATION CART. RN #12 REVIEWED THE PHYSICIAN ORDERED MEDICATION FOR RESIDENT #101 AND THEN STATED THERE WAS NO ORDERED PAIN MEDICATION TO BE GIVEN AS NEEDED, ONLY THE TYLENOL EVERY 6 HOURS. IN AN INTERVIEW ON 7/5/11 AT 10:40 AM, PHYSICIAN #10 STATED HE WAS THE PRIMARY PHYSICIAN FOR RESIDENT #101. PHYSICIAN #10 STATED HE WAS AWARE OF THE FRACTURE SUSTAINED BY RESIDENT #101 AND THAT IS WAS A SPIRAL FRACTURE. THE SURVEYOR ASKED PHYSICIAN #10 IF TYLENOL WAS THE ONLY PAIN MEDICATION HE HAD ORDERED FOR RESIDENT #101'S PAIN, AND PHYSICIAN #10 STATED YES, SHE WAS DOING FINE AND WAS PAIN FREE. THE SURVEYOR THEN ASKED PHYSICIAN #10 IF HE HAD CANCELLED THE APPOINTMENT THAT RESIDENT #101 HAD WITH AN ORTHOPEDIC SPECIALIST ON 6/20/11, WHICH HAD BEEN ORDERED BY THE HOSPITAL PHYSICIAN. PHYSICIAN #10 STATED HE DID ORDER THAT THE APPOINTMENT BE CANCELLED BECAUSE SHE DIDN'T NEED IT. PHYSICIAN #10 STATED HE HAD SPOKEN WITH THE SON OF RESIDENT #101, AND THE SON HAD AGREED TO CANCEL THE APPOINTMENT WITH THE ORTHOPEDIC SPECIALIST. IN AN INTERVIEW ON 7/5/11 AT 10:55 AM, RESIDENT #101'S SON STATED HE WAS AT THE HOSPITAL WITH HIS MOTHER AND THE ORTHOPEDIC DOCTOR SHOWED HIM THE XRAY. RESIDENT #101'S SON STATED HIS MOTHER'S ARM WAS BROKE IN TWO AND MOVED APART. THE SURVEYOR ASKED RESIDENT #101'S SON IF HE KNEW THAT HIS MOTHER HAD A FOLLOW UP APPOINTMENT ON 6/20/11 WITH THAT SAME ORTHOPEDIC SPECIALIST THAT HE HAD MET IN THE HOSPITAL. RESIDENT #101'S SON STATED HE DIDN'T KNOW THAT HIS MOTHER HAD A FOLLOW UP APPOINTMENT. THE SURVEYOR ASKED RESIDENT #101'S SON IF HE KNEW THAT PHYSICIAN #10 HAD CANCELLED THE FOLLOW UP APPOINTMENT ON 6/20/11 AND THE SON STATED HE NEVER KNEW THERE WAS AN APPOINTMENT. THE SURVEYOR THEN ASKED RESIDENT #101'S SON IF HE HAD GIVEN PERMISSION TO PHYSICIAN #10 TO CANCEL HIS MOTHER'S FOLLOW UP ORTHOPEDIC APPOINTMENT, AND THE RESIDENT'S SON STATED ABSOLUTELY NOT AND THAT HE WASN'T EVEN AWARE THAT HIS MOTHER HAD A FOLLOW UP APPOINTMENT. RESIDENT #102: REVIEW OF RESIDENT #102'S MEDICAL RECORD REVEALED A [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. HER MINIMUM DATA SET ((MDS) dated [DATE] DOCUMENTED THAT SHE WAS MODERATELY IMPAIRED WITH COGNITIVE SKILLS, REQUIRED EXTENSIVE ASSISTANCE OF TWO PERSONS FOR TRANSFERS AND DRESSING. FACILITY INCIDENT REPORT DATED 5/19/11 DOCUMENTED RESIDENT #102 HAD TWO LARGE BRUISES APPROXIMATELY 3 INCHES ROUND ON HER SHIN BELOW THE RIGHT KNEE, WARM TO TOUCH WIT HER RIGHT ANKLE SWOLLEN ON THE RIGHT SIDE AND REDDENED, AND RESIDENT #102 STATED IS WAS SORE TO TOUCH. THE INCIDENT REPORT ALSO DOCUMENTED THAT PHYSICIAN #11 WAS NOTIFIED. PAGE 2 OF THE INCIDENT REPORT DOCUMENTED THAT UPON INVESTIGATION FOUND THAT WHILE TRANSPORTING RESIDENT TO THE DINING ROOM, THERE WERE NO FOOT PEDALS ON THE WHEELCHAIR AND WHEN RESIDENT #102 PUT HER FOOT DOWN, HER LEG WAS BENT UNDERNEATH THE WHEELCHAIR CAUSING INJURY. FACILITY NURSE'S NOTES DATED 5/19/11 AT 11:30 PM, DOCUMENTED BRUISING AND PAIN TO RESIDENT #102'S RIGHT LOWER LEG, BELOW THE KNEE, THE RESIDENT'S PHYSICIAN WAS NOTIFIED AND NEW ORDERS WERE RECEIVED. PHYSICIAN ORDERS [REDACTED]. FACILITY NURSE'S NOTE DATED 5/20/11 AT 10:00 AM DOCUMENTED THAT PHYSICIAN #11 WAS IN TO EXAMINE RESIDENT #102'S LEG, AND DID NOT GIVE ANY NEW ORDERS. FACILITY NURSE'S NOTES DATED 5/20/11 AT 11:00 PM DOCUMENTED THAT PHYSICIAN #11 WAS NOTIFIED OF RESIDENT #102 CRYING DUE TO AN INCREASE IN PAIN WITH RIGHT LEG AND WORSENED BRUISING, WITH NEW PHYSICIAN ORDERS [REDACTED]. PHYSICIAN ORDERS [REDACTED]. FACILITY NURSE'S NOTES DATED 5/21/11 DOCUMENTED THAT RESIDENT #102 COMPLAINED OF PAIN IN HER RIGHT LEG AND WAS GIVEN PAIN MEDICATION. NURSE'S NOTES DATED 5/22/11 AT 2:15 PM, DOCUMENTED THAT THE NURSE SPOKE WITH PHYSICIAN #11 AND ORDERS WERE RECEIVED FOR STRONGER PAIN MEDICATION. PHYSICIAN ORDERS [REDACTED].#102 UP FOR DINNER AND ICE PACK TO RIGHT SHIN EVERY SHIFT. NURSE'S NOTES DATED 5/22/11 AT 5:00 PM, DOCUMENTED RESIDENT #102 WAS UP IN WHEELCHAIR FOR SUPPER WITH RIGHT LEG BLACK AND BLUE AND COMPLAINTS OF PAIN FROM RESIDENT #102. NURSE'S NOTES ON 5/24/11 AT 11:30 PM DOCUMENTED PHYSICIAN #11 WAS IN TO SEE RESIDENT #102 REGARDING HER RIGHT LEG AND NEW ORDERS WERE RECEIVED. PHYSICIAN ORDERS [REDACTED].#102 WAS TO STAY IN BED UNTIL XRAY WAS READ. XRAY RESULTS DATED 5/24/11 DOCUMENTED ACUTE OBLIQUE MINIMALLY DISPLACED FRACTURE THROUGH THE RIGHT PROXIMAL TIBIAL METAPHYSIS AND THROUGH THE RIGHT PROXIMAL FIBULAR METAPHYSIS (FRACTURE THROUGH BOTH BONES IN THE LOWER LEG, JUST BELOW THE KNEE). IN AN INTERVIEW ON 7/5/11 AT 1:30 PM, PHYSICIAN #11 STATED SHE WAS MADE AWARE, BY THE NURSING STAFF, THAT RESIDENT #102 HAD BUMPED HER RIGHT LEG, AND IT WAS BRUISED AND SWOLLEN ON 5/19/11. PHYSICIAN #11 STATED SHE DID NOT ORDER AN XRAY OF RESIDENT #102'S RIGHT LEG UNTIL 5/24/11, BECAUSE SHE DIDN'T THINK IS WAS FRACTURED. WHEN ASKED BY THE SURVEYOR WHY SHE DIDN'T THINK IT WAS FRACTURED, PHYSICIAN #11 STATED BECAUSE RESIDENT #102 DID NOT HAVE ANY PAIN. WHEN ASKED BY THE SURVEYOR WHY SHE ORDERED THE XRAY ON 5/24/11, PHYSICIAN #11 STATED BECAUSE RESIDENT #102 WAS HAVING INCREASED PAIN. DURING AN INTERVIEW ON 7/5/11 AT 12:15 PM, IN THE DINING ROOM, RESIDENT #102 WAS OBSERVED IN HER WHEELCHAIR WITH A FULL LEG SPLINT ON HER RIGHT LEG. RESIDENT #102 STATED SHE COULDN'T REMEMBER HOW THE INJURY TO HER LEG HAPPENED, BUT THAT IS DID HURT SOMETIMES. IN AN INTERVIEW ON 7/5/11 AT 12:35 PM, NURSE #8 STATED SHE WAS CALLED TO RESIDENT #102'S ROOM BECAUSE OF AN ISSUE WITH HER RIGHT LEG. NURSE #8 STATED THERE WAS BRUISING, SWELLING AND REDNESS BELOW RESIDENT #102'S RIGHT KNEE AND AROUND HER RIGHT ANKLE, AND IT WAS WARM TO THE TOUCH. NURSE #8 STATED SHE CALLED THE DOCTOR WHO ASKED HER TO DESCRIBE THE INJURY, AND THE PHYSICIAN DIDN'T ORDER ANYTHING. NURSE #8 STATED THE NEXT DAY SHE WAS CONCERNED BECAUSE RESIDENT #102'S RIGHT LEG LOOKED WORSE, SO SHE CALLED PHYSICIAN #11 AGAIN AND ASKED, "PLEASE CAN I GET AN XRAY?" NURSE #8 STATED PHYSICIAN #11 SAID SHE HAD ALREADY SEEN RESIDENT #102 THAT MORNING. NURSE #8 STATED THAT RESIDENT #102 WAS CRYING IN PAIN, AND THAT SHE DID GET PHYSICIAN #11 TO ORDER [MEDICATION NAME] FOR THE PAIN. IN AN INTERVIEW ON 7/5/11 AT 12:25 PM, CNA #9 STATED ON 5/19/11 SHE WAS PUSHING RESIDENT #102 TO THE DINING ROOM WITH OUT FOOT PEDALS ON HER WHEELCHAIR, WHEN SUDDENLY RESIDENT #102 SAID TO WAIT A MINUTE, SO SHE STOPPED. CNA #9 STATED RESIDENT #103 STATED, "MY LEG", AND SHE ASKED RESIDENT #102 IF SHE WAS OK, AND THE RESIDENT STATED YES. CNA #9 admitted SHE DID NOT TELL THE NURSE THAT RESIDENT #102 COMPLAINED ABOUT HER LEG. CNA#9 STATED THAT RESIDENT #102 DID GET HER LEG STUCK UNDER THE WHEELCHAIR WHILE SHE (CNA #9) WAS PUSHING HER TO THE DINING ROOM. #

THIS CITATION PERTAINS TO INTAKE MI 513. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ASSISTIVE DEVICES TO ENSURE THE SAFETY FOR 1 (#102) OF 4 SAMPLED RESIDENTS OUT OF A TOTAL SAMPLE OF 4, RESULTING IN RESIDENT #102 HAVING HER FOOT CAUGHT UNDER HER WHEELCHAIR WHILE BEING TRANSPORTED, CAUSING A RESULTING FRACTURE OF BOTH BONES IN HER LOWER RIGHT LEG. FINDINGS INCLUDE: REVIEW OF RESIDENT #102'S MEDICAL RECORD REVEALED A [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. HER MINIMUM DATA SET ((MDS) dated [DATE] DOCUMENTED THAT SHE WAS MODERATELY IMPAIRED WITH COGNITIVE SKILLS, REQUIRED EXTENSIVE ASSISTANCE OF TWO PERSONS FOR TRANSFERS AND DRESSING. FACILITY INCIDENT REPORT DATED 5/19/11 DOCUMENTED RESIDENT #102 HAD TWO LARGE BRUISES APPROXIMATELY 3 INCHES ROUND ON HER SHIN BELOW THE RIGHT KNEE, WARM TO TOUCH WIT HER RIGHT ANKLE SWOLLEN ON THE RIGHT SIDE AND REDDENED, AND RESIDENT #102 STATED IS WAS SORE TO TOUCH. THE INCIDENT REPORT ALSO DOCUMENTED THAT PHYSICIAN #11 WAS NOTIFIED. PAGE 2 OF THE INCIDENT REPORT DOCUMENTED THAT UPON INVESTIGATION FOUND THAT WHILE TRANSPORTING RESIDENT TO THE DINING ROOM, THERE WERE NO FOOT PEDALS ON THE WHEELCHAIR AND WHEN RESIDENT #102 PUT HER FOOT DOWN, HER LEG WAS BENT UNDERNEATH THE WHEELCHAIR CAUSING INJURY. FACILITY NURSE'S NOTES DATED 5/19/11 AT 11:30 PM, DOCUMENTED BRUISING AND PAIN TO RESIDENT #102'S RIGHT LOWER LEG, BELOW THE KNEE, THE RESIDENT'S PHYSICIAN WAS NOTIFIED AND NEW ORDERS WERE RECEIVED. PHYSICIAN ORDERS [REDACTED]. FACILITY NURSE'S NOTES DATED 5/20/11 AT 10:00 AM DOCUMENTED THAT PHYSICIAN #11 WAS IN TO EXAMINE RESIDENT #102'S LEG, AND DID NOT GIVE ANY NEW ORDERS. FACILITY NURSE'S NOTES DATED 5/20/11 AT 11:00 PM DOCUMENTED THAT PHYSICIAN #11 WAS NOTIFIED OF RESIDENT #102 CRYING DUE TO AN INCREASE IN PAIN WITH RIGHT LEG AND WORSENED BRUISING, WITH NEW PHYSICIAN ORDERS [REDACTED]. PHYSICIAN ORDERS [REDACTED]. FACILITY NURSE'S NOTES DATED 5/21/11 DOCUMENTED THAT RESIDENT #102 COMPLAINED OF PAIN IN HER RIGHT LEG AND WAS GIVEN PAIN MEDICATION. NURSE'S NOTES DATED 5/22/11 AT 2:15 PM, DOCUMENTED THAT THE NURSE SPOKE WITH PHYSICIAN #11 AND ORDERS WERE RECEIVED FOR STRONGER PAIN MEDICATION. PHYSICIAN ORDERS [REDACTED].#102 UP FOR DINNER AND ICE PACK TO RIGHT SHIN EVERY SHIFT. NURSE'S NOTES DATED 5/22/11 AT 5:00 PM, DOCUMENTED RESIDENT #102 WAS UP IN WHEELCHAIR FOR SUPPER WITH RIGHT LEG BLACK AND BLUE AND COMPLAINTS OF PAIN FORM RESIDENT #102. NURSE'S NOTES ON 5/24/11 AT 11:30 PM DOCUMENTED PHYSICIAN #11 WAS IN TO SEE RESIDENT #102 REGARDING HER RIGHT LEG AND NEW ORDERS WERE RECEIVED. PHYSICIAN ORDERS [REDACTED].#102 WAS TO STAY IN BED UNTIL XRAY WAS READ. XRAY RESULTS DATED 5/24/11 DOCUMENTED ACUTE OBLIQUE MINIMALLY DISPLACED FRACTURE THROUGH THE RIGHT PROXIMAL TIBIAL METAPHYSIS AND THROUGH THE RIGHT PROXIMAL FIBULAR METAPHYSIS (FRACTURE THROUGH BOTH BONES IN THE LOWER LEG, JUST BELOW THE KNEE). IN AN INTERVIEW ON 7/5/11 AT 1:30 PM, PHYSICIAN #11 STATED SHE WAS MADE AWARE, BY THE NURSING STAFF, THAT RESIDENT #102 HAD BUMPED HER RIGHT LEG, AND IT WAS BRUISED AND SWOLLEN ON 5/19/11. PHYSICIAN #11 STATED SHE DID NOT ORDER AN XRAY OF RESIDENT #102'S RIGHT LEG UNTIL 5/24/11, BECAUSE SHE DIDN'T THINK IS WAS FRACTURED. WHEN ASKED BY THE SURVEYOR WHY SHE DIDN'T THINK IT WAS FRACTURED, PHYSICIAN #11 STATED BECAUSE RESIDENT #102 DID NOT HAVE ANY PAIN. WHEN ASKED BY THE SURVEYOR WHY SHE ORDERED THE XRAY ON 5/24/11, PHYSICIAN #11 STATED BECAUSE RESIDENT #102 WAS HAVING INCREASED PAIN. DURING AN INTERVIEW ON 7/5/11 AT 12:15 PM, IN THE DINING ROOM, RESIDENT #102 WAS OBSERVED IN HER WHEELCHAIR WITH A FULL LEG SPLINT ON HER RIGHT LEG. RESIDENT #102 STATED SHE COULDN'T REMEMBER HOW THE INJURY TO HER LEG HAPPENED, BUT THAT IS DID HURT SOMETIMES. IN AN INTERVIEW ON 7/5/11 AT 12:35 PM, NURSE #8 STATED SHE WAS CALLED TO RESIDENT #102'S ROOM BECAUSE OF AN ISSUE WITH HER RIGHT LEG. NURSE #8 STATED THERE WAS BRUISING, SWELLING AND REDNESS BELOW RESIDENT #102'S RIGHT KNEE AND AROUND HER RIGHT ANKLE, AND IT WAS WARM TO THE TOUCH. NURSE #8 STATED SHE CALLED THE DOCTOR WHO ASKED HER TO DESCRIBE THE INJURY, AND THE PHYSICIAN DIDN'T ORDER ANYTHING. NURSE #8 STATED THE NEXT DAY SHE WAS CONCERNED BECAUSE RESIDENT #102'S RIGHT LEG LOOKED WORSE, SO SHE CALLED PHYSICIAN #11 AGAIN AND ASKED, "PLEASE CAN I GET AN XRAY?" NURSE #8 STATED PHYSICIAN #11 SAID SHE HAD ALREADY SEEN RESIDENT #102 THAT MORNING. NURSE #8 STATED THAT RESIDENT #102 WAS CRYING IN PAIN, AND THAT SHE DID GET PHYSICIAN #11 TO ORDER VICODIN FOR THE PAIN. IN AN INTERVIEW ON 7/5/11 AT 12:25 PM, CNA #9 STATED ON 5/19/11 SHE WAS PUSHING RESIDENT #102 TO THE DINING ROOM WITH OUT FOOT PEDALS ON HER WHEELCHAIR, WHEN SUDDENLY RESIDENT #102 SAID TO WAIT A MINUTE, SO SHE STOPPED. CNA #9 STATED RESIDENT #103 STATED, "MY LEG", AND SHE ASKED RESIDENT #102 IF SHE WAS OK, AND THE RESIDENT STATED YES. CNA #9 admitted SHE DID NOT TELL THE NURSE THAT RESIDENT #102 COMPLAINED ABOUT HER LEG. CNA#9 STATED THAT RESIDENT #102 DID GET HER LEG STUCK UNDER THE WHEELCHAIR WHILE SHE (CNA #9) WAS PUSHING HER TO THE DINING ROOM. IN AN INTERVIEW ON 7/5/11 AT 12:05 PM, THE FACILITY ADMINISTRATOR STATED THAT AN INVESTIGATION WAS COMPLETED REGARDING RESIDENT #102'S FRACTURED LEG. WHEN ASKED BY THE SURVEYOR WHAT THE FACILITY HAD CONCLUDED WITH THERE INVESTIGATION, HE STATED THAT HER LEG GOT CAUGHT UNDER HER WHEELCHAIR WHILE SHE WAS BEING PUSHED BY A STAFF MEMBER WITH OUT FOOT PEDALS. #

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY IGNORED THE REQUEST OF ONE ( #209) OF 24 SAMPLED RESIDENTS REQUEST TO GO TO BED AND BE TOILETED, RESULTING IN NEGLECT, INCREASED COMBATIVENESS, AGITATION, AND PSYCHOSOCIAL DISTRESS. FINDINGS INCLUDE: ON 3/16/11 AT 9:30 A.M. RESIDENT #209 WAS OBSERVED IN THE DEMENTIA UNIT DINING ROOM, SEATED IN A CHAIR WITH A PERSONAL SAFETY ALARM PAD. RESIDENT #209 WAS ALERT WITH CONFUSION AND RESPONDED TO SIMPLE QUESTIONS. AT 9:55 A.M., RESIDENT #209 AMBULATED (WALKED) TO THE RESTROOM USING A ROLLING WALKER. SHE WAS ASSISTED BY CERTIFIED NURSING ASSISTANT (CNA)"E" USING A GAIT BELT. RESIDENT #209 WALKED WITH A SLOW UNSTEADY GAIT WITH HER UPPER BODY BENT FORWARD. CNA "E" REPORTED THAT RESIDENT #209 HAD RECENTLY BROKEN HER HIP DURING A FALL IN THE FACILITY. RESIDENT #209 COMPLAINED OF BEING TIRED AND ASKED REPEATEDLY TO BE ALLOWED BACK TO HER ROOM TO LIE DOWN. CNA "E" ASSISTED RESIDENT #209 TO SIT IN A GERI CHAIR (WHEELED RECLINING CHAIR) IN THE HALLWAY. AT 11:50 A.M., RESIDENT #209 COMPLAINED OF BEING TIRED AND STATED REPEATEDLY "I WANT TO GO HOME AND GO TO BED" AND "I WISH YOU'D LET ME GET UP AND GO BACK, OR I'LL HAVE TO GO BY MYSELF." ON 3/16/11 AT 1:30 P.M., CNA "E" AMBULATED RESIDENT #209 TO THE GERI CHAIR IN THE HALLWAY AND ASSISTED HER TO SIT DOWN. RESIDENT #209 REPEATEDLY ASKED CNA "E" TO PUT HER TO BED, STATING SHE WAS TIRED AND WANTED TO SLEEP. CNA "E" SPOKE TO RESIDENT #209 WITH A HARSH VOICE, IN AN ABRUPT MANNER, STATING, "YOU HAVE TO SIT IN THE CHAIR." RESIDENT #209 BECAME AGITATED AND ATTEMPTED TO STRUGGLE UP FROM THE CHAIR, YELLING, "I WANT TO GO TO BED." CNA "E" STATED ABRUPTLY AND FORCEFULLY, "YOU HAVE TO STAY HERE." RESIDENT #209 CONTINUED TO YELL THAT SHE WANTED TO GO TO BED. ON 3/16/11 AT 1:32 P.M., WHEN QUERIED, CNA "E" STATED THAT RESIDENT #209 NEEDED TO STAY IN THE GERI CHAIR IN THE HALLWAY WHERE SHE COULD BE WATCHED BECAUSE SHE WAS A "FALL RISK". ON 3/16/11 AT 1:35 P.M., NURSE "C" WAS INTERVIEWED REGARDING RESIDENT #209. WHEN ASKED WHY RESIDENT #209 WAS NOT ALLOWED TO GO TO BED FOR A NAP AFTER LUNCH, AS SHE HAD BEEN OUT OF THE ROOM SINCE 9:30 A.M., NURSE "C" STATED, "WE'LL PUT HER TO BED NOW." ON 3/16/11 AT 1:45 P.M., OBSERVATION REVEALED RESIDENT #209 WAS ASLEEP IN BED IN HER ROOM. THE BED WAS IN THE LOWEST POSITION WITH A PERSONAL SAFETY MAT ON THE FLOOR NEXT TO BED. A PRESSURE PAD SAFETY ALARM WAS ON THE MATTRESS AND A MOTION SENSOR ALARM WAS ON THE MAT BY THE BED. ON 3/17/11 AT 11:20 A.M., RESIDENT #209 WAS OBSERVED SEATED IN A GERI CHAIR IN THE HALLWAY. RESIDENT #209 WAS AGITATED AND ATTEMPTED TO EXIT THE GERI CHAIR, WHILE YELLING, "I HAVE TO GO TO THE BATHROOM... I HAVE TO GO WEE WEE." CNA "H" STRUGGLED WITH RESIDENT #209 AND ATTEMPTED TO PLACE A GAIT BELT AROUND THE RESIDENT'S WAIST AS SHE YELLED AND TRIED TO GRAB AT CNA "H"'S ARMS AND GET OUT OF THE CHAIR. CNA "H" CALLED FOR ASSISTANCE, BUT NO OTHER STAFF WERE AVAILABLE TO ASSIST. CNA "H" ASSISTED RESIDENT #209 TO WALK INTO THE DINING ROOM. THE RESIDENT CONTINUED TO ASK TO BE TAKEN TO THE BATHROOM UNTIL HER LUNCH TRAY WAS PLACED IN FRONT OF HER. ON 3/17/11 AT 12:00 P.M., CNA "H" REPORTED THAT RESIDENT #209 COULD NOT BE TOILETED AT THIS TIME AS THE NURSE AND ONE CNA WERE ON LUNCH BREAK, AND THE OTHER CNA WAS TOILETING ANOTHER RESIDENT. CNA "H" EXPLAINED SHE NEEDED TO REMAIN IN THE DINING ROOM TO SUPERVISE THE OTHER RESIDENTS. RESIDENT #209 REMAINED IN THE DINING ROOM UNTIL 1:30 P.M., WITH HER EYES CLOSED AND HER HEAD RESTING ON THE TABLE. ON 3/17/11 AT 1:30 P.M., CNA "E" APPROACHED RESIDENT #209 AND TOLD HER TO WAKE UP AS IT WAS TIME TO GO TO THE BATHROOM. RESIDENT #209 STATED, "THAT'S GOOD. I HAVE TO GO TO THE BATHROOM. I GOT TO GO WEE WEE." WHEN QUERIED AT THIS TIME, CNA "E" STATED THAT RESIDENT #209 WAS CONTINENT OF BOWEL AND BLADDER DURING THE DAY. OBSERVATION OF RESIDENT #209'S BRIEF AT 1:35 P.M., REVEALED THAT RESIDENT #209'S HAD BEEN INCONTINENT OF URINE. ON 3/17/11 AT 1:40 P.M., IN RESPONSE TO QUERY, NURSE "C" STATED THAT RESIDENT #209 WAS USUALLY CONTINENT OF BOWEL AND BLADDER DURING THE DAY, AND SHOULD BE TOILETED BEFORE AND AFTER MEALS AND UPON REQUEST. ON 3/16/11 AT 1:45 P.M., REVIEW OF RESIDENT #209'S CLINICAL RECORD REVEALED A FACE SHEET THAT DOCUMENTED ADMISSION ON 6/6/09, WITH READMISSION ON 1/17/11 AFTER A HIP REPLACEMENT FOR A TRAUMATIC [MEDICAL CONDITION]. [DIAGNOSES REDACTED]. REVIEW OF A MINIMUM DATA SET ASSESSMENT (MDS), dated [DATE], REVEALED RESIDENT #209 HAD SEVERE COGNITIVE IMPAIRMENT, EXHIBITED BOTH VERBAL AND PHYSICAL COMBATIVE BEHAVIORS, AND WAS RESISTANT TO CARE. THE MDS ALSO DOCUMENTED THAT RESIDENT #209 HAD POOR BALANCE DURING TRANSITIONS AND WALKING AND REQUIRED EXTENSIVE STAFF ASSISTANCE FOR TRANSFERS TO AND FROM THE WHEELCHAIR AND TOILETING. ON 3/16/11 AT 1:45 P.M., REVIEW OF RESIDENT #209'S CLINICAL RECORD ALSO REVEALED BEHAVIOR MANAGEMENT SUMMARY FORMS DATED 12/6/10, AND 11/18/10 DOCUMENTING RESIDENT #209 EXHIBITED THE FOLLOWING BEHAVIORS, "YELLING, RESTLESS, KICKING, ARGUMENTATIVE." ON 3/16/11 AT 1:45 P.M., REVIEW OF RESIDENT #209'S CLINICAL RECORD ALSO REVEALED THE FOLLOWING NURSING CARE PLANS AND INTERVENTIONS: 1. TOILETING CARE PLAN DATED 8/11/09, REVIEWED 5/28/10 NOTING, "CONTINENT OF BOWEL AND BLADDER. OFTEN WHEN SHE ATTEMPTS TO STAND IT INDICATES THAT SHE NEEDS TO USE THE BATHROOM" AND, "OFFER TOILET BEFORE AND AFTER MEALS" AND "TOILET UPON REQUEST WHEN IS ATTEMPTING TO STAND UP." ON 3/18/11 AT 1:00 P.M., THE DIRECTOR OF NURSING (DON) WAS INTERVIEWED REGARDING STAFF TRAINING ON DEALING WITH RESIDENTS WITH DEMENTIA, AND HANDLING COMBATIVE BEHAVIORS AND RESIDENTS WHO WERE RESISTANT TO CARE. THE DON REPORTED THAT CNA "H" HAD RECENTLY TRANSFERRED TO THE DEMENTIA UNIT, AND HAD NOT RECEIVED TRAINING ON DEMENTIA OR HANDLING RESISTIVE AND COMBATIVE BEHAVIORS. THE DON ALSO STATED THAT RESIDENTS SHOULD BE ADDRESSED RESPECTFULLY AND TREATED LIKE ADULTS. THE DON ALSO STATED THAT A REFUSAL TO TOILET A CONTINENT RESIDENT WAS NEGLECT, AND IF STAFF WERE UNAVAILABLE, THE RESIDENT SHOULD HAVE BEEN TOILETED AS SOON AS POSSIBLE, AND SHOULD NOT HAVE HAD TO WAIT FOR TWO HOURS AFTER A REQUEST TO BE TOILETED. ON 3/21/11 AT 1;00 P.M., REVIEW OF THE FACILITY POLICY ENTITLED "IDENTIFICATION OF ABUSE", DATED 5/07 REVEALED THE FOLLOWING STATEMENTS: 1. "ABUSE MAY TAKE THE FORM OF ......MALTREATMENT (SUCH AS IGNORING THEIR NEEDS.)" 2. "BY LAW, THE RESIDENT HAS A RIGHT TO APPROPRIATE TREATMENT, MEANING FREEDOM FORM ALL ABUSE AND TO RECEIVE ADEQUATE AND APPROPRIATE CARE WHICH CANNOT BE DENIED BASED ON ANY CRITERIA." 3. "SITUATIONS THAT MAY LEAD TO SOME FORM OF ABUSE INCLUDE THE FOLLOWING, LACK OF TRAINING OF EMPLOYEES." ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND ASSISTIVE DEVICES (GAIT BELT AND CHAIR ALARM) FOR TWO (# 209 AND #216) OF 24 SAMPLED RESIDENTS, RESULTING IN A FALL WITH A FRACTURE AND A RESIDENT TO RESIDENT ALTERCATION WITH AN INJURY. IN ADDITION, THE FACILITY FAILED TO ENSURE THAT AN UNATTENDED, UNSUPERVISED MEDICATION CART WAS LOCKED, AND THAT CONTROLLED DRUGS WERE DOUBLE LOCKED, RESULTING IN THE POTENTIAL FOR ACCIDENTAL INGESTION OF MEDICATIONS. FINDINGS INCLUDE: ON 3/16/11 AT 9:30 A.M. RESIDENT #209 WAS OBSERVED IN THE DEMENTIA UNIT DINING ROOM, SEATED IN A CHAIR WITH A PERSONAL SAFETY ALARM PAD. RESIDENT #209 WAS ALERT WITH CONFUSION, AND RESPONDED TO SIMPLE QUESTIONS. AT 9:55 A.M., RESIDENT #209 AMBULATED (WALKED) TO THE RESTROOM USING A ROLLING WALKER, ASSISTED BY CERTIFIED NURSING ASSISTANT (CNA)"E" USING A GAIT BELT. RESIDENT #209 WALKED WITH A SLOW UNSTEADY GAIT WITH HER UPPER BODY BENT FORWARD. CNA "E" REPORTED THAT RESIDENT #209 HAD RECENTLY BROKEN HER HIP DURING A FALL IN THE FACILITY. ON 3/16/11 AT 1:45 P.M., REVIEW OF RESIDENT #209'S CLINICAL RECORD REVEALED A FACE SHEET DOCUMENTING ADMISSION ON 6/6/09, WITH READMISSION ON 1/17/11 AFTER A HIP REPLACEMENT AFTER A TRAUMATIC HIP FRACTURE. [DIAGNOSES REDACTED]. REVIEW OF A MINIMUM DATA SET ASSESSMENT (MDS), dated [DATE], REVEALED RESIDENT #209 HAD SEVERE COGNITIVE IMPAIRMENT, EXHIBITED BOTH VERBAL AND PHYSICAL COMBATIVE BEHAVIORS, AND WAS RESISTANT TO CARE. THE MDS ALSO DOCUMENTED THAT RESIDENT #209 HAD POOR BALANCE DURING TRANSITIONS AND WALKING AND REQUIRED EXTENSIVE STAFF ASSISTANCE FOR TRANSFERS TO AND FROM THE WHEELCHAIR AND TOILETING. ON 3/17/11 AT 11:00 A.M., REVIEW OF FACILITY INCIDENT AND ACCIDENT REPORTS FOR RESIDENT #209 REVEALED THE FOLLOWING: 1. ON 5/24/10 AT 4:30 A.M., RESIDENT #209 HAD FALLEN ONTO THE TOILET AND BUMPED HER ARM ON THE GRAB BAR DURING A TRANSFER TO THE TOILET ASSISTED BY CNA "N". ON 3/17/11 AT 11:30 A.M. STAFF NURSE "C" WAS INTERVIEWED AND WAS UNCERTAIN WHETHER OR NOT CNA "N" HAD BEEN RETRAINED ON RESIDENT TRANSFERS AND CHECKED FOR COMPETENCY AFTER THE INCIDENT. THERE WAS NO DOCUMENTATION OF WHETHER A GAIT BELT HAD BEEN USED. 2. ON 5/30/10 AT 2:10 P.M., RESIDENT #209 HAD FALLEN WHILE AMBULATING TO THE DAYROOM WITH CNA "E" ON 5/30/10. CNA "E" WAS INTERVIEWED ON 3/17/11 AT 11:30 A.M. AND REPORTED THAT RESIDENT #209 HAD BECOME AGITATED AND COMBATIVE AND HAD FALLEN TO THE FLOOR AS A RESULT. CNA "E" REPORTED SHE SHOULD HAVE TRANSFERRED RESIDENT #209 BY WHEELCHAIR INSTEAD OF TRYING TO HAVE HER WALK WHEN SHE WAS AGITATED, AS RESIDENT #209 had a history of [REDACTED]. CNA "E" STATED THAT THE FALL MIGHT HAVE BEEN PREVENTED IF SHE WAITED TO TAKE RESIDENT #209 TO THE DAYROOM AFTER SHE HAD CALMED DOWN. 3. ON 7/19/10 AT 3:00 P.M., RESIDENT #209 WAS FOUND ON THE FLOOR BY THE RECLINER IN THE UNIT "ALCOVE". THE INVESTIGATION DOCUMENTED "SENSOR PAD WAS NOT ON AND DID NOT ACTIVATE." 4. ON 11/18/10 AT 11:10 A.M., RESIDENT #209 SUFFERED A 0.5 CENTIMETER (CM) LACERATION (CUT) TO THE UPPER LIP DURING AN EPISODE OF COMBATIVENESS DURING TOILETING BY CNA "E". THE REPORT DOCUMENTED "WHILE TOILETING RESIDENT SHE BECAME AGITATED, ATTEMPTED TO PUNCH CNA, MISSED AND PUNCHED HERSELF IN THE FACE CAUSING A 0.5 CM CUT TO UPPER LIP. CUT CLOSED WITH STERI-STRIP." ON 3/17/11 AT 11:30 A.M., CNA "E" WAS INTERVIEWED AND STATED THE RESIDENT WAS REFUSING TO ALLOW CNA "E" TO ASSIST HER. CNA "E" STATED THAT INSTEAD OF CALMING THE RESIDENT DOWN AND TRYING AGAIN LATER, OR SEEING IF RESIDENT #209 WOULD COOPERATE WITH A DIFFERENT STAFF MEMBER, SHE HAD ARGUED AND STRUGGLED WITH THE RESIDENT. WHEN QUERIED ABOUT THIS, CNA "E" STATED SHE KNEW IN THEORY WHAT SHE SHOULD HAVE DONE, BUT "EVERYONE ELSE WAS BUSY" AND SHE (CNA "E") "HAD GOTTEN STUCK IN THE OLD WAYS OF DOING THINGS." CNA "E" STATED THAT ANOTHER CNA HAD COME IN TO ASSIST A FEW MINUTES LATER, AND HAD CALMED RESIDENT #209 DOWN TOILETED HER WITHOUT ANY FURTHER AGITATION OR COMBATIVENESS. 5. ON 12/12/10 AT 12:45 A.M., RESIDENT #209 WAS FOUND ON THE FLOOR IN HER ROOM. RESIDENT SUFFERED "TWO SMALL ABRASIONS ON MID BACK." THE REPORT NOTED "REPLACED MOTION ALARM. HERS WAS SLOW TO GO OFF WHEN WE tested IT AND DIDN'T GO OFF EACH TIME AS IT SHOULD HAVE. OFFER TO TOILET IF AWAKE." 6. ON 1/11/11 AT 2:00 P.M., RESIDENT #209 SUFFERED A FALL RESULTING IN A BROKEN LEFT HIP WHILE AMBULATING IN THE DAYROOM WITH CNA "H". RESIDENT #209 WAS SUBSEQUENTLY TRANSFERRED TO ACUTE CARE (HOSPITAL) WHERE SHE UNDERWENT surgery for [REDACTED]. CNA "H" WAS ALSO INSTRUCTED THAT WHEN A RESIDENT IS RESISTIVE OR AGITATED OR ANXIOUS, THE AIDE SHOULD BACK OFF AND TRY WHATEVER ACTIVITY IT IS LATER, WHEN THE RESIDENT IS MORE CALM." ON 3/17/11 AT 11:30 A.M., CNA "H" WAS INTERVIEWED AND STATED THAT SHE SHOULD HAVE USED A GAIT BELT WHILE AMBULATING RESIDENT #209, BUT DID NOT AS RESIDENT #209 DID NOT HAVE A GAIT BELT ON AT THE TIME. CNA "H" ALSO REPORTED THAT SHE HAD RECENTLY BEEN REASSIGNED TO THE DEMENTIA UNIT FROM ANOTHER UNIT, AND HAD HAD NO TRAINING ON DEMENTIA. CNA "H" STATED THAT SHE KNEW NOW THAT CNA'S SHOULD NEVER STRUGGLE OR ARGUE WITH A COMBATIVE OR AGITATED RESIDENT, BUT HAD NOT KNOWN THAT AT THE TIME. ON 3/18/11 AT 1:00 P.M., THE DIRECTOR OF NURSING (DON) WAS INTERVIEWED AND WAS UNABLE TO PROVIDE DOCUMENTATION THAT CNA "N" WAS RETRAINED ON RESIDENT TRANSFER TECHNIQUES AFTER BANGING RESIDENT #209'S ARM DURING TRANSFER ON 5/24/10. THERE WAS NO EVIDENCE CNA "E" WAS RETRAINED FOLLOWING THE FALL ON 5/30/10 WAS DUE TO STAFF TRYING TO STRUGGLE WITH RESIDENT #209 WHILE AGITATED. THE DON FURTHER REPORTED THAT SHE WAS UNAWARE THAT RESIDENT #209'S 'S FALL ON 1/11/11 RESULTED IN A FRACTURE. WHEN QUERIED, THE DON STATED THAT RESIDENT #209 REQUIRED A GAIT BELT FOR AMBULATION ASSISTANCE AT THE TIME OF THE FALL WITH FRACTURE ON 1/11/11, AND NOTED THIS HAD NOT BEEN USED. ON 3/21/11 AT 2:30 P.M., THE FACILITY POLICY ENTITLED, "GAIT BELT" DATED 8/97 WAS REVIEWED AND REVEALED THE FOLLOWING STATEMENT, "THE GAIT BELT WILL BE USED ON ALL RESIDENTS FOR AMBULATION AND TRANSFERS PER FACILITY POLICY." (THIS PERTAINS TO MI 153) ON 3/17/11 AT 9:30 A.M., REVIEW OF A FACILITY REPORTED INVESTIGATION (FRI), DATED 2/3/11, REVEALED RESIDENT #216, WHO WAS DESCRIBED AS A CONFUSED RESIDENT, HAD SUFFERED A 1.4 CENTIMETER (CM) LACERATION TO THE SCALP ON 1/29/11 AS A RESULT OF AN ALTERCATION WITH RESIDENT #127. RESIDENT #127 HIT RESIDENT #216 WHEN SHE WANDERED INTO HIS ROOM. RESIDENT #216 WAS NOT SUPERVISED AT THE TIME SHE WANDERED INTO RESIDENT #127'S ROOM. ON 3/17/11 AT 9:30 A.M., REVIEW OF RESIDENT #216'S CLINICAL RECORD REVEALED THE FOLLOWING: 1. A FACE SHEET DOCUMENTING ADMISSION ON 3/20 O6, WITH [DIAGNOSES REDACTED]. 2. A MINIMUM DATA SET ASSESSMENT ((MDS) dated [DATE] REVEALEDRESIDENT #216 SUFFERED FROM SEVERE COGNITIVE IMPAIRMENT, EXHIBITED WANDERING BEHAVIORS, AND WAS INDEPENDENTLY MOBILE ON THE UNIT WHEN IN A WHEELCHAIR. 3. A WANDER RISK ASSESSMENT FORM, DATED 12/7/10 DOCUMENTED RESIDENT #216 WAS AT RISK FOR WANDERING. 4. A NURSING CARE PLAN ENTITLED, "AT RISK FOR WANDERING", DATED 2/1/10, UPDATED ON 12/7/10 AND 1/29/11 CONTAINED NO SAFETY INTERVENTIONS PRIOR TO 1/29/11 TO PREVENT RESIDENT #216 FROM WANDERING INTO OTHER RESIDENT'S ROOMS. 5. A "BEHAVIOR MANAGEMENT SUMMARY FORM" DATED 11/30/10 DOCUMENTED RESIDENT #216 WAS BEING MONITORED FOR THE FOLLOWING BEHAVIORS: "AGITATED/YELLING", "PHYSICALLY ABUSIVE", "GOING IN OTHER'S ROOMS AND TRYING TO PUT RESIDENT TO BED", AND "USING OTHERS' RESTROOMS." RESIDENT #216 WAS DOCUMENTED AS "GOING IN OTHER'S ROOMS" ON SEVEN OCCASIONS IN NOVEMBER 2010. 6. A "BEHAVIOR MANAGEMENT SUMMARY FORM" DATED 12//10 DOCUMENTED RESIDENT #216 WAS BEING MONITORED FOR THE FOLLOWING BEHAVIORS: "TAKING OTHER'S THINGS" AND "GOING INTO OTHER 'S ROOMS". THE LOG NOTED THAT RESIDENT #216 WAS OBSERVED TAKING OTHER'S BELONGINGS SEVEN TIMES BETWEEN 11/29/10 AND 12/29/10, AND WAS OBSERVED GOING INTO OTHER'S ROOMS ON SIXTEEN OCCASIONS DURING THE SAME TIME PERIOD. 7. FACILITY "RESIDENT CARE CONFERENCE SUMMARIES" FOR RESIDENT #216, DATED 12/01/09 AT 10 A.M., AND 11/23/10 AT 10:30 A.M., CONTAINED NO DOCUMENTATION OF CARE PLANNING COMMITTEE DISCUSSION OF ACCIDENT PREVENTION RELATED TO WANDERING BEHAVIORS. ON 3/18/11 AT 10:10 A.M., THE DIRECTOR OF NURSING (DON) WAS INTERVIEWED REGARDING SAFETY MEASURES IN PLACE TO PREVENT INJURIES DUE TO WANDERING BEHAVIORS FOR RESIDENT #216 AT THE TIME OF THE INCIDENT ON 1/29/11. THE DON REPORTED THAT RESIDENT #216 HAD NOT BEEN PLACED ON THE DEMENTIA UNIT, DUE TO A LACK OF AVAILABLE BEDS. THE DON ALSO STATED THAT RESIDENT #216 SHOULD HAVE BEEN SUERVISED TO PREVENT WANDERING INTO OTHER RESIDENT'S ROOMS, AND INTERVENTIONS SUCH AS VELCRO STOP SIGNS ACROSS ROOM DOORS COULD ALSO HAVE BEEN USED TO STOP WANDERING RESIDENTS FROM ENTERING OTHER'S ROOMS. ( ) ON 3/18/11 AT 8:38 A.M., DURING GENERAL OBSERVATION ON THE FACILITY'S "B" HALL, IT WAS OBSERVED THAT AN UNATTENDED AND UNLOCKED MEDICATION CART WAS LOCATED ADJACENT TO RESIDENT ROOM #21. THE HALL WAS ACCESSIBLE TO NON-CLINICAL STAFF, RESIDENTS AND VISITORS. THE CART WAS OUT OF VIEW OF THE UNIT NURSE. THE CART CONTAINED CONTROLLED SUBSTANCES LOCKED WITH A SINGLE LOCK. AT 8:40 A.M., UNIT NURSE "I" WAS QUERIED AND STATED " IT SHOULD BE LOCKED, I ONLY STEPPED AWAY FOR A MINUTE. " ON 3/18/11 AT 12:30 P.M., REVIEW OF THE FACILITY'S POLICY ENTITLED "MEDICATION ADMINISTRATION", UPDATED 6/09, ITEM # III. C, READ AS FOLLOWS: "THE MEDICATION CART IS TO BE LOCKED WHENEVER IT IS OUT OF THE NURSES'S LINE OF VISION." ITEM #III, B, DOCUMENTED: "CONTROLLED SUBSTANCES (SCHEDULED II DRUGS) ARE ACCOUNTED FOR EVERY SHIFT AND ARE STORED BEHIND DOUBLE LOCKS." ( )