Every finding on record at WellBridge of Novi

This citation pertains to intake 3055863 Based on observation, interview and record review, the facility failed to include resident focused and personalized interventions for incontinence care in the comprehensive plan of care for one resident (R55) of two residents reviewed for bowel and bladder programs. Findings include:On 7/13/26 a concern submitted to the State Agency was reviewed which alleged R55 was incontinent and left wet and soiled for an extended period of time. On 07/13/2026 at approximately 11:34 AM R55 was observed in the main dining room up in their wheelchair with a family member sitting next to them. R55 was asked if they had any concerns regarding their care and they were observed to have confusion when attempting to answer the inquiry. On 7/14/26 at approximately 8:00 a.m., R55 was observed in their room, laying in their bed. R55 presented with some noted confusion. R55 was asked if they knew when they had to use the bathroom and they reported they were not sure. On 7/14/26 the medical record for R55 was reviewed and revealed the following: R55 was initially admitted to the facility on [DATE] and had diagnoses including Malignant neoplasm of left breast and Dementia. A review of R55's MDS (minimum data set) with an Assessment Reference Date of 6/10/26 revealed R55 needed assistance from facility staff with most of their activities of daily living. R55's BIMS score (brief interview for mental status) was two, indicating severely impaired cognition. Further review of the MDS in section H (bowel and bladder) revealed R55 was occasionally incontinent with bowel and bladder. A review of section V (Care Area Assessment (CAA) Summary) in the MDS revealed the following: Urinary Incontinence and Indwelling Catheter - Care Area Triggered (V0200A06A) 1 - Checked (Yes) .Urinary Incontinence and Indwelling Catheter - Care Planning Decision (V0200A06B) 1 - Checked (Yes) .A review of R55's CAA worksheet revealed the following: Triggering conditions-6. Urinary Incontinence and Indwelling Catheter Problem Definition Triggering Conditions (any of the following)1-ADL assistance for toileting was needed as indicated by: Toileting Hygiene: The ability to maintain perineal hygiene, adjust clothes before and after using the toilet, commode, bedpan, or urinal. If managing an ostomy, include wiping the opening but not managing equipment. - admission Performance (GGOI 30C1) = Substantial/maximal assistance (02) ORToilet transfer: The ability to safely get on and off a toilet or commode. - admission Performance (GGOI 70F1) = Substantial/maximal assistance (02)Urinary incontinence has a value of 1 through 3 as indicated by: 5-Urinary continence - Select the one category that best describes the resident (H0300) = Occasionally incontinent (1 ) .Analysis of Findings-Is this problem/need: Actual (checked) .Care plan considerations-Will urinary incontinence and indwelling catheter be addressed in the care plan: Yes (checked) . A review of R55's comprehensive care plan was conducted and did not reveal any person-centered focus or interventions for R55's documented urinary incontinence in the MDS. A review of R55's Kardex (a description of care provided to the resident for the direct care staff) did not reveal any documentation that R55 was incontinent and needed incontinence care/interventions. On 7/14/26 at approximately 10:01 a.m., Certified Nursing Assistant F (CNA F) was queried regarding the incontinence interventions for R55. CNA F was observed reviewing the Kardex and indicated R55 did not have any indication that they were incontinent on it. CNA F was queried if R55 was incontinent, and they indicated they were and did not know why it was not indicated on the Kardex. CNA F was asked how a new CNA who did not know R55 would be able to identify what kind of incontinence care needed to be provided to them and reported it should be on the Kardex for review. On 7/14/26 at approximately 10:18 a.m., Minimum Data Set Nurse Coordinator G (MDSC G) was interviewed regarding R55's incontinence program that was documented via section H and V indicating R55 was occasionally incontinent in both bladder and bowel and needed a plan of care. MDSC G indicated that R55 should have a care plan to address incontinence and that they did not know why R55 did not have one and that it was missed. MDSC was asked how staff would know R55 was incontinent and had to do brief checks and changes and they indicated they would have to ask the floor Nurse. MDSC G was queried where the CNA's would find that information in the record, and they indicated it would be on the Kardex but R55 did not have it on there. MDSC G indicated they would review the care plan to see if incontinence interventions needed to be added to it. On 7/14/26 at approximately 10:35 a.m., during a follow up conversation with MDSC G, they reported that they had to update R55's care plan to include R55 incontinence problem and interventions. A facility document titled Care Plans-Comprehensive was reviewed and revealed the following: Policy Statement-An individualized comprehensive care plan that includes measurable objectives and to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Policy Interpretation and Implementation-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. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. Each resident's comprehensive care plan is designed to; A. Incorporate identified problem areas; B. Incorporate risk factors associated with identified problems; C. build on the resident's strengths; D. Reflect the resident's expressed wishes regarding care and treatment goals; E. Reflect treatment goals, timetables and objectives in measurable outcomes; F. Identify the professional services that are responsible for each element of care; G. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; H. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and I. Reflect currently recognized standards of practice for problem areas and conditions. Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools (including Care Area Assessments) before interventions are added to the care plan. Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers .

This citation pertains to intake 2990676.Based on interview and record review, the facility failed to ensure appropriate documentation of controlled substance removal, administration and accountability for one (R78) of six residents reviewed for unnecessary medications. Findings include:Review of complaints reported to the State Agency included an allegation that R78's pain medications were not given on time or at all.Review of the clinical record revealed R78 was admitted into the facility on 4/16/26 and discharged home on 4/21/26 with diagnoses that included: concussion with loss of consciousness of unspecified duration, postural orthostatic tachycardia syndrome (POTS), conversion disorder with motor symptom or deficit, type 2 diabetes mellitus without complications, epilepsy, [NAME]-Danlos syndrome, post-traumatic stress disorder, and Arnold Chiari Syndrome without spina bifida or hydrocephalus.According to the Minimum Data Set (MDS) assessment dated [DATE], R78 had intact cognition and received both scheduled and as needed (PRN) pain medication.Review of R78's physician orders included Oxycodone HCl (Hydrochloride) (a narcotic pain medication) Oral Tablet 5 MG (Milligrams) Give 1 tablet by mouth every 4 hours as needed (PRN) for Pain. This order had a start date of 4/16/26 and a discontinued date of 4/21/26.Review of R78's Medication Administration Record (MAR) revealed there were 11 PRN administrations of oxycodone HCl documented on:4/16 at 8:43 PM Pain level 5;4/17 at 12:24 AM Pain level 4;4/17 at 9:20 AM Pain level 5;4/17 at 3:52 PM Pain level 4;4/17 at 9:47 PM Pain level 8;4/18 at 2:43 PM Pain level 9;4/19 at 12:38 PM Pain level 7;4/19 at 9:58 PM Pain level 3;4/20 at 6:21 AM Pain level 2;4/20 at 9:55 AM Pain level 6;4/21 at 8:33 AM Pain level 6.Review of the miscellaneous tab in the electronic health record (EHR - the location in which additional documents were scanned in) revealed there was no controlled substance record (CSR) for the oxycodone HCl, there was only one for an anti-anxiety medication.On 7/13/26 at 4:47 PM, the facility was requested to provide the CSR for R78's oxycodone HCl.On 7/14/26 at 8:30 AM, review of the additional CSR for oxycodone HCl revealed a total of 13 medication removals. There were two additional removals that did not correspond with and were not documented on the MAR by Nurse 'D' on 4/18 at 8:00 PM and on 4/19 at 3:00 AM.Further review of the interdisciplinary progress notes (which included the electronic/eMAR nursing notes) revealed there was no documentation that reflected Nurse 'D' administered the additional oxycodone HCl even though it was documented as removed on the CSR, or whether there was any follow-up if the medication had been administered and if it had been effective or not.An entry on 4/18/26 at 2:43 PM by Nurse 'E' documented, oxyCODONE HCl Oral Tablet 5 MG Give 1 tablet by mouth every 4 hours as needed for Pain.The next entry was on 4/19/26 at 6:51 AM by Nurse 'D' which documented, .This note is a follow up to: 4/18/20[Author: (Nurse 'E'] .PRN Administration was: Effective Follow-up Pain Scale was: 0. There was no documentation that Nurse 'D' administered the oxycodone HCl to R78 on 4/18 at 8:00 PM and 4/19 at 3:00 AM.On 7/14/26 at 8:55 AM, Nurse 'D' was attempted to be contacted at the number provided by the facility, but it was not a working number.On 7/14/26 at 8:57 AM, the Director of Nursing (DON) was requested to provide another phone number for Nurse 'D'.On 7/14/26 at 9:03 AM, the DON provided the same phone number and reported they would see if there was any other contact information. The DON was requested to see if they were able to contact Nurse 'D' to inform them of a request for an interview as well and the DON reported they would follow-up.On 7/14/26 at 9:09 AM, a phone interview was attempted with Nurse 'D' at the new number provided, however there was no answer, and a detailed message was left to return the call. There was no further response from Nurse 'D' by the end of the survey.On 7/14/26 at 10:00 AM, an interview was conducted with the DON. When asked about the facility's process for administration of a controlled substance such as the oxycodone HCl, the DON reported Nurses should document the removal on the CSR, the administration on the MAR, and follow-up in the progress note. The DON reviewed R78's CSR for the oxycodone HCl and when the discrepancies for the oxycodone HCl for 4/18 and 4/19 were reviewed, the DON reported they were disappointed with that and would need to follow-up with Nurse 'D'. When asked if the facility had previously identified any concerns with controlled substances, the DON reported they had not until today. The DON was requested to provide a policy that addressed controlled substance administration/documentation.According to the facility's policy titled, Controlled Substance Medication Orders dated 1/2020, this policy did not include the process of documenting removal/administration of controlled substances.According to the facility's LPN Job Description: .the Licensed Practical Nurse Supervisor performs as a licensed practical nurse and assumes the overall supervision, direction, and clinical services provided for their group of patients.Ensures their unit maintains compliance with federal, state and local regulations.Completes assigned charting each shift.

This citation pertains to Intake #2634191Based on interview and record review the facility failed to ensure a resident's safety to prevent a fall and ensure x-rays pertaining to the fall were completed timely for one (R702) of one resident reviewed for falls resulting in R702 falling out of bed, sustaining a fracture to the right femur that required hospitalization, surgery and led to their death. Findings include:Complaints were filed with the State Agency (SA) that alleged R702 fell out of their bed trying to attempt to grab their food tray and feed themselves. The complainant reported R702 required 1:1 feeding assistance for all meals/snacks as they suffered from severe Rheumatoid Arthritis (an inflammation that causes swollen joints causing difficult performing daily activities) and Osteoarthritis (joint disease that causes pain, stiffness and loss of function). The complainant noted that a full lunch tray was placed out of reach of R702 on or about 5/13/25. The resident was sitting on the side of their bed and allegedly tried to reach for their meal tray and fell out of bed. R702 was sent to the Hospital the next evening (5/14/25). It was determined the resident had sustained a fracture on their left femur that required surgery. Continued review of the complaint noted that despite the surgery, R702's death certificate noted that the resident died due to Left femur fracture with complications on 5/27/25.A review of R702's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: urinary tract infection, morbid obesity, rheumatoid arthritis and congestive heart failure. A review of the resident's Minimum Data Set (MDS) dated [DATE] noted R701 had a Brief Interview for Mental Status (BIMS) score of 13/15 (cognitively intact). However, additional record reviews noted that R702 had a decline in cognition after 4/26/25.Continued review of R702's record revealed the following:4/18/25: Hospital Assessment OT(Occupational Therapy): .DC (discharge) recommendations:.Patient requires extra time and encouragement to participate, with mod (moderate) x2 assist with ADLs (activities of daily living) secondary to pain.Patient is easily distracted.Precautions to Rehabilitation Treatment: falls.Functional Mobility: Roll-Right: Max PA (Patient Assist)=Maximal Assist.Supine to Sit: Max PA.Sit to Stand=Moderate 2 Person Assist.Stand to Sit: Moderate 2 Person Assist.OT Problem List: Balance deficits.decreased functional ability.Fall risk.Assessment details.Patient requires extra time and encouragement to participate with mod x2 assist with ADLs.4/20/25: admission Summary: .Patient has pain all over her body due to arthritis. Patient is a one-to-one feed hydration.4/21/25: Physician Progress Note:.Patient presented to ED (emergency department) for SOB (shortness of breath) and BLE (bilateral lower extremities).PT (patient) has acute metabolic encephalopathy due to pain medication. Palliative care was consulted.Physical Exam:.Chronically ill appearing weak, obese.Plan:.PT (Physical Therapy)/OT.Fall precautions.Rehab Potential: Fair.4/23/25: Skilled Charting: .Guest resting in bed. Ax0x1-2 (alert and oriented) to name and date.4/25/25: Skilled Charting: .Resident stated she was having chest pain.whole body is hurting.She then began to ask where daughter is.stated that she is lost. This appears to be resident's baseline.4/26/25: Skilled Charting: .Resident calls out for daughter and stating she wants to die.Assisted with transfers as needed, 2 PA.non-ambulatory.4/29/25: Order: .Regular texture, thin consistency, 1:1 assistance at meals. Created by Nurse E.5/2/25: Physician Progress Note: .Patient seen.somewhat increased anxiety today. Does not know why she can't walk.Tolerating Keflex (antibiotic) for suspected UTI (urinary tract infection).5/8/25: Skilled Charting: .Resident a/o x 1-2.5/12/25: Order Note: .Late entry.Follow-up UTI.chronically ill, weak.5/13/25 (12:54 PM): INTERACT SBAR (Situation, Background, Assessment, Recommendations): .Evaluation: Fall.Does resident have pain: Yes.Nursing observations.was charting when writer heard a faint help me from room (number redacted). Writer then went to assist resident when writer enter room resident was on floor by the bed with upper body against the bed, resident stated she [sic] slip out of bed trying [sic] get her food tray close to her as she set [sic] on the side of the bed.resident stated her left knee was in pain.Manager came and assist resident back on bed with writer.5/13/25 (2:38 PM): Nursing Note: .Writer was charting when writer heard a faint help me from room.Writer then went to assist resident, when writer enter room resident was on floor by the bed with her upper body against the bed, resident stated she slip out <sic> out of bed trying to get her food tray close to her as she set on the side of the bed.Manager came and assist resident back on bed with writer. *It should be noted that the writer was Nurse D and is no longer is employed at the facility.5/13/25 (2:50 PM): (Facility) Fall Assess: .R702.History of Fall. doing unusual activity 7.Reaching up or reaching down.Contributing Factors: 1. Difficulty maintaining sitting balance.3. Gait Problem , such as unsteady gait.Intervention/Comment: Resident should always be in bed fully if no one is in room to assist her w/adjusting herself in bed.5/14/25: Order Note (6:11 AM): .Pt had a fall currently awaiting xray services (emphasis added). Pt has increased pain, on call physician contacted and ordered one time order for ibuprofen.5/14/25 (10:29 AM): Physician Progress Note: .Patient was reported to have a fall in which she slipped off the bed onto the floor while seated at the side of the bed. Patient reports pain to her entire left extremity.she states do not touch my leg it hurts too much.Plan.Check STAT knee, hip/pelvis x-ray. *It should be noted that there was no STAT X-ray for the knee, hip/pelvis x-ray to Check at the time the resident was seen by physician services.5/14/25: Skilled Charting: Investigation.Date of incident: 5/13/25.Guest transfer and ambulation status is 2 PA with 2 WW, non-ambulatory.Root Cause Analysis.guest incident: occurred despite a fall prevention plan in place. *It should be noted that the Fall Prevention plan was reviewed and documented: Focus: Risk for Falls (date initiated 4/20/25).Interventions: Administer medications as ordered (4/20/25).Evaluate lab tests and xray (4/20/25).Neuro checks per protocol (4/20/25).Transfer 2 PA with 2 WW, non-ambulatory (4/20/25).The only additional intervention added was on 5/13/25 that noted: Encourage and offer guest to be in wheelchair and in dining room for meals.(This intervention was entered after the R702's fall on 5/13/25). 5/14/25 (6:57 PM) Radiology Report: .Conclusion: Acute comminuted fracture to left distal femur with moderate displacement and angulation. *It should be noted that the report was received approximately 30 hours after the fall.5/14/25 (7:32 PM): Guest C/O (complains of) excruciating to her knee r/t fall on 5/13/25.Approximately 6 PM x-ray tech came in and she performed the x-ray procedure.Guest is positive for fracture/dislocation.Advised to transfer guest to the hospital.An Incident/Accident (IA) dated 5/13/25 report was reviewed and documented the following: Fall Scene Investigation Report:.Resident slipped out of bed when trying to sit at edge of bed.Fall Summary: Found on floor (unwitnessed).Fall Location: Resident Room.What type of assistance was resident receiving at time of fall? Alone and unattended.Describe resident's mental status prior to fall: Alert with periods of confusion. Impulsive.Creation of Last 3 hours before fall: resident was in bed resting.Resident checked on by nursing manager at 12 PM during rounding.What appears to be the root cause of the fall? Guest wanted to sit on side of bed to eat food, guest slid out of the bed.Describe initial interventions to prevent .offer assistance to chair for meals or to have meals in dining room.Additional Care Plan.x-ray ordered to send guest to ED (emergency department). *It should be noted that a drawing was attached to the report. It contained a drawing of R702's bed. An X was placed in the middle of the bed on the side, indicating where R702 was allegedly sitting .a drawing of the tray table was made and it appeared not to be directly near their bed. There were no measurements included in the drawing to actually determine how far items were from the resident's bed. A review of R702's care plan and Kardex was conducted to determine their mobility/transfer status and to confirm 1:1 assistance for eating. The only documentation noted in R702's Kardex noted: Transferring: Transfers 2 PA (person assist) with 2 WW (wheel walker), non-ambulatory. There was no additional information as to bed mobility or 1:1 assistance. R702's care plan noted that the only interventions for ADL care were: Assist with showers.Assist with dressing, hygiene and toilet needs, Explain all procedures, PT/OT/ST (physical, occupational, speech therapy). dated 4/20/25On 10/7/25 at approximately 10:27 AM, an interview and record review were conducted with Physical Therapy Manager (PTM) B . PTM B reported that they were not directly employed by the facility but worked via a contracted company. PTM B was queried about R702 and their status as to balance/sitting on the side of the bed. PTM B reported that R702 required assistance for all ADLs and noted that R702 could not sit up longer than 30 seconds. PTM B was asked if in general residents, similar to R702 should sit on the side of their bed to eat, they noted generally residents who eat in their rooms should not be sitting on the side of their bed if they cannot sit for a lengthy period of time. When asked about R702's 1:1 order for feeding and general protocol on 1:1 feeding orders, PTM B noted that often those requiring 1:1 either need assistance as they cannot utilize utensils, needed queuing to eat, and staff available to ensure that food is consumed in appropriate portions. *It should be noted that there were no staff in R702's room assisting with meals at the time of the fall despite having a food tray in their room.On 10/7/25 at approximately 1:26 PM, an interview was conducted with Unit (UM) Nurse C . UM C was queried as to R702 and the incident that led to their fall with fracture. UM C noted that they were in the building the day of the fall, but they were not in the resident's room. They reported that R702 did require 1:1 assistance with meals. They noted that on 5/13/25 (date of fall), R702 was sitting on the side of their bed and believed they reached out and scooted to get their meal tray and slipped out of bed. UM C further reported that they assisted in getting the resident back to bed. They were uncertain but believed a Hoyer lift was used. UM C noted that R702 suffered from chronic pain however, the next day R702 was still in pain and a STAT X-ray was ordered. UM C reported that generally STAT-X-rays usually are completed five to six hours after being ordered.On 10/7/25 at approximately 2:30 PM, an interview was conducted with the MDS coordinator (hereinafter Nurse E). Nurse E was queried as to the 1:1 order that was created by them on 4/29/25 and signed by the physician on 4/30/25. MDS E noted that they completed it based on the dietary recommendation. MDS E was asked what is the facility 1:1 feeding assist protocol, they reported that a staff member should always be present when the resident is eating to either ensure food is consumed/not consumed and/or directly assist the resident.On 10/7/25 at approximately 3:14 PM a phone interview was conducted with Nurse D. Nurse D reported that they are no longer employed by the facility. Nurse D was asked about the incident/fall that occurred on 5/13/25. Nurse D reported that on 5/13/25 they heard R702 yelling from their room. They went to the room and saw R702 half on the ground and half on the bed. They called a CNA to help get the resident off the floor. Nurse D did not recall how they got the resident off the floor and if they used a Hoyer lift but believed they lifted the resident under their arms. Nurse D was asked if they recalled where the food tray was and they noted that it was not near the resident and noted there was no 1:1 staff in the room assisting with meals after she was heard yelling. The facility policy titled, Falls and Fall Risk, Managing was reviewed and documented, in part: Based of previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .Prioritizing Approaches to Managing Falls and Fall Risk.The staff.will identify appropriate interventions to reduce the risk of falls.Examples of Interventions:.examples.rearrangement of room furniture.The facility policy titled, Assistance with Meals was reviewed and documented, in part: .Residents shall receive assistance with meals that meets the individual needs of each resident.All residents shall be encouraged to eat in the dining room.Residents confined to bed.nursing staff will prepare residents for eating.Nursing staff and/or Feeding Assistants will feed those residents needing full assistance within _____ (*It should be noted that a blank line was in the policy, no time was noted).Resident who cannot feed themselves will be fed with attention to safety.

This citation pertains to intake: 2634191.Based on interview and record reviews the facility failed to ensure a STAT (immediate) chest x-ray was ordered and completed as noted by the physician assistant for one (R702) of one resident reviewed for radiology services. Findings include:A review of the medical record revealed R702 was re-admitted to the facility on [DATE] with a primary diagnosis of acute on chronic diastolic (congestive) heart failure and additional diagnoses of edema, paroxysmal atrial fibrillation and acute embolism and thrombosis of unspecified deep veins of lower bilateral extremity. A Minimum Data Set (MDS) assessment dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. A review of a Physician progress note dated 4/28/25 at 1:57 PM, documented in part . Reason for visit: request by patient/family/nurse regarding weakness, fatigue, pain. Patient seen and examined. C/O (complaints of) increased weakness and fatigue. Also C/o generalized joint pain. States she is feeling weakness than when she was admitted . C/o dysuria (pain with urination), urgency, urinary frequency. Also c/o SOB (shortness of breath). chronically ill appearing, weak. Diminished BS (breath sounds) with crackles at bases. + (positive) trace BLE (bilateral lower extremities) edema. Assessment SOB, suspect secondary to CHF (congestive heart failure). decompensated CHF, Fatigue, Urinary . UTI, Persistent atrial fibrillation with RVR (rapid ventricular response), BLE edema. Plan. check UA (urinalysis), C&S (culture & sensitivity), CHF - with SOB. Check CXR (chest x-ray) PA (posterior - anterior)/lat (lateral) STAT (immediate). Give extra 20 mg (milligram) Lasix QD (every day) x3 days-1st dose today. Begin duoneb (nebulizer treatment) QID (four times a day). Continue Lasix. A review of the physician orders revealed no order implemented for the STAT chest x-ray until 5/6/25, more than a week later. On 10/7/25 at 1:37 PM, the Unit Nurse Manager (UNM) A (the nurse manager for the unit R702 resided on) was interviewed and asked the facility's practices when a nurse practitioner, physician assistant or physician examines a resident and orders new medications and test to be completed whose responsibility was it to put in the orders for the new medications and tests. UNM A stated the provider would tell the floor nurse to put in the order or they would usually tell them (the unit manager) and they would put in the orders. When asked why R702's STAT chest x-ray was ordered more than a week after the provider examined and noted to have the STAT chest x-ray completed, UNM A stated the ordered probably did not hit the board (electronic medical system notification) delaying the implementation. UNM A stated they would look into the concern and follow back up. At 2:41 PM, UNM A stated they reviewed the medical record and they were unable to provide further information or documentation on why the STAT chest x-ray order was not implemented and completed timely. No further explanation or documentation was provided by the end of the survey.

This citation pertains to intake: 2634191.Based on interview and record reviews the facility failed to timely implement orders as directed by the Provider for one (R702) of one resident reviewed for a change of condition. Findings include:A review of the medical record revealed R702 was re-admitted to the facility on [DATE] with a primary diagnosis of acute on chronic diastolic (congestive) heart failure and additional diagnoses of edema, paroxysmal atrial fibrillation and acute embolism and thrombosis of unspecified deep veins of lower bilateral extremity. A Minimum Data Set (MDS) assessment dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. A review of the progress notes revealed the following: A nursing note dated 4/25/25 at 6:15 AM, documented . Resident stated she was having chest pain. Given Nitroglycerin x3. She then stated that her whole body is hurting . given.pain medication. She then began to ask where her daughter is & where is she at. Stated that she is lost. Resident is now stating that pain is decreasing.A review of a Physician progress note dated 4/28/25 at 1:57 PM, documented in part . Reason for visit: request by patient/family/nurse regarding weakness, fatigue, pain. Patient seen and examined. C/O (complaints of) increased weakness and fatigue. Also C/o generalized joint pain. States she is feeling weakness than when she was admitted . C/o dysuria (pain with urination), urgency, urinary frequency. Also c/o SOB (shortness of breath). chronically ill appearing, weak. Diminished BS (breath sounds) with crackles at bases. + (positive) trace BLE (bilateral lower extremities) edema. Assessment SOB, suspect secondary to CHF (congestive heart failure). decompensated CHF, Fatigue, Urinary . UTI, Persistent atrial fibrillation with RVR (rapid ventricular response), BLE edema. Plan. check UA (urinalysis), C&S (culture & sensitivity), CHF - with SOB. Check CXR (chest x-ray) PA (posterior - anterior)/lat (lateral) STAT (immediate). Give extra 20 mg (milligram) Lasix QD (every day) x3 days-1st dose today. Begin duoneb (Ipratropium-Albuterol Solution via nebulizer) QID (four times a day). Continue Lasix. A review of the Physician orders and medical record revealed the extra 20 mg of Lasix to be administered once a day for three days was not implemented as directed for the first dose to be administered on 4/28/25. The duoneb nebulizer treatment was implemented incorrectly and ordered three times a day instead of four times a day.Further review of the Physician orders revealed on 5/7/25, more than a week later the extra 20 mg of Lasix was administered as initially directed by the Provider on 4/28/25. The duoneb (Ipratropium-Albuterol nebulizer treatment) was implemented four times a day as initially directed by the Provider on 5/7/25, more than a week after the directive.On 10/7/25 at 1:37 PM, the Unit Manager (UM) A was interviewed and asked about the facility's practices when a nurse practitioner, physician assistant or physician (Provider) examines a resident and orders new medications to be implemented whose responsibility it was to ensure the orders are implemented in the electronic medical system and administered. UNM A replied the provider would inform the floor nurse to put in the orders or the Provider would usually tell them (the unit manager) and they would ensure the orders are put in the system. UNM A was then asked why R702's extra 20 mg of Lasix x3 days was not implemented and administered timely and why the nebulizer treatment was not implemented correctly initially causing a delay in the correct administration/dose of the treatment. UNM A stated they would look into it and follow back up. At 2:41 PM, UNM A stated they reviewed the medical record and they were unable to provide further information or documentation on why the extra 20 mg of Lasix was not implemented/administered timely or why the nebulizer treatment was not implemented as ordered by the Provider. No further explanation or documentation was provided by the end of the survey.

This citation pertains to intake: MI00153179. Based on interview and record reviews the facility failed to adequately assess/monitor a resident with an identified change of condition, notify the Physician of continued decline and transfer the resident to a higher level of care in a timely manner, for one of six residents reviewed for a change in condition, resulting in an approximately 12 hour delay in identifying and treating the resident for an acute stroke contributing to the resident's death. The deficient practice resulted in the increased likelihood of serious harm, serious injury and/or death to occur. Findings include: The Immediate Jeopardy (IJ) began on [DATE] when the facility staff failed to adequately assess/monitor R802 who had an identified change of condition and notify the Physician of the continued decline. The IJ was identified on [DATE] and the Administrator was notified of the Immediate Jeopardy on [DATE] at 4:08 PM. A plan of removal was requested at that time to remove the immediacy. The surveyor team confirmed by Observation, Interview and Record review that the Immediate Jeopardy was removed on [DATE] based on the facility's implementation of an acceptable plan of removal. The noncompliance remains at an isolated event with the potential for more then minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency (SA). A review of a complaint submitted to the SA documented allegations of the facility's failure to timely address a change in condition and the delayed transfer to the hospital for R802 that resulted in death . An Emergency Documentation ED Triage report dated [DATE] at 7:40 AM, documented in part . pt (patient) to ed (emergency department) via EMS (emergency medical services) pt was found unresponsive low 02 (oxygen level) upon arrival pt AOx0 (alert and oriented times zero) . Transferred From: Skilled nursing facility . Glasgow coma Scale (measures the extent of impaired consciousness and severity of brain injury)- Eye Opening Response Glasgow: To pain . Best Verbal Response Glasgow: None . Best Motor Response Glasgow: Flaccid . Glasgow Coma Score: 4 (indicates a severe level of impaired consciousness and suggests serious neurological impairment) . Temperature Rectal . 100.0 . Pulse Rate: 114 . Respiratory Rate: 24 . Systolic Blood Pressure 170 . Diastolic Blood Pressure 93 . Oxygen Saturation: 84% . Oxygen Therapy: Non rebreather . Tracking Acuity: 1 - Immediate . Diagnosis . unresponsive . Level of Consciousness . unresponsive . intubated . A review of the medical record revealed R802 was admitted to the facility on [DATE], with the primary diagnosis of aftercare following joint replacement surgery. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R802 was mostly Independent with some limited assistance needed for Activities of Daily Living (ADLs). The resident was their own responsible party and signed to be a Full Code status. An Admission nursing assessment dated [DATE], documented R802 to be oriented to person, place, time, situation and noted to be verbally appropriate. Further review of the assessment documented breath sounds to be clear and heart sounds to be regular. The assessment documented the admission vitals as follows: Temperature 97.6. Pulse 94, Respirations 18 and Blood Pressure 125/75. A review of the complaint submitted to the SA documented on [DATE], . the resident was throwing up non-stop. The complainant states the resident had to use a garbage can to throw up in because staff weren't around to give him an appropriate container . A review of the medical record and progress notes, revealed no documentation of R802's emesis episodes, however a Zofran 4 MG (milligram) tablet was ordered on [DATE]. The order noted . Give 1 tablet by mouth one time only for Nausea and Vomiting for 1 Day Nausea and Vomiting . A review of the [DATE] Medication Administration Record (MAR) documented the Zofran medication to have been administered on [DATE] at 1:36 PM. A review of the blood pressure summary documented on [DATE] at 8:30 AM, R802's blood pressure was 167/101 mmHg (millimeters of mercury). A review of the medical record revealed no progress notes on [DATE], however a Physician order for hydralazine HCl 25 mg tablet was ordered on [DATE], that noted . one time only for elevated bp (blood pressure) for 1 Day . This medication was documented as administered on [DATE] at 6:26 PM. A review of the Blood Pressure Summary documented the following on [DATE]: At 9:55 AM- 177/109 mmHg At 10:04 AM- 172/106 mmHg At 10:30 AM- 167/101 mmHg A review of the [DATE] MAR documented Metoprolol Tartrate 50 mg by mouth one time only for HTN (hypertension- high blood pressure) for 1 Day. This medication was documented as administered on [DATE] at 10:16 AM. A review of the progress notes revealed the following: On [DATE] at 11:42 AM, a Physician Assistant (PA)- later identified as PA D note documented in part . Reason for visit . Request by patient/family/nurse regarding cough, Urianry <sic> sx (symptoms) . Patient seen and examined. Resting comfably <sic> in bed. Awake, alert, in no acute distress. No <sic> as respisnvei <sic> to answering questions as usual. Afebrile, non-toxic. C/o (complaints of) cough. Not eating or drinking much per nurse. Pt (patient) had N/V (nausea/vomiting) over the weekend- resoled <sic>. BP elevated over the weekend and this AM (morning). Received hydralazine over the weekend. Per nurse, pt requesting melatonin to be discontinue due to nausea from it. Also, C/o dysuria (painful urination), urgency, urianru <sic> frequency. +generalized weakness. C/O pain, worse with movement and better with rest and meds (medications). Denies fevers, chills. Denies CP, SOB (shortness of breath) , N/V, abd (abdominal) pain. Tolerating PT (physical therapy)/OT (occupational therapy) . Physical Exam BP 169/99 P (pulse) 99 R (respirations) 22 T (temperature) 98.6 02 (oxygen saturation) 90% . chronically ill appearing, appears weak . PERRLA (pupils equal, round, reactive to light and accommodation), EOMI (extraocular movements intact), MMM (moist mucous membranes), + HOH (hard of hearing), CV (cardiovascular): RRR (regular rate and rhythm), S1 S2 (first and second heart sounds), Resp (respiratory): CTAB (clear to auscultation bilaterally), no wheezes, no rales . Alert, awake, some confusion, appropriate mood and affect. Assessment N/V- resolved, Urianry <sic> sx, Dehydration, HTN (hypertension) Insomnia, S/P (status post) fall Left femoral neck fracture s/p anterior THA (total hip arthroplasty) . DVT (deep vein thrombosis) ppx (prophylactically) per ortho (orthopedics) . Plan . Dehydration: check CBC (complete blood count) BMP (basic metabolic disorder) stat (immediately). Begin IV (intravenous) fluids as patient not eating/drinking much today per nurse. Cough: Check labs, check CXR (chest x-ray) and covid. Urianry <sic> sx: check labs, check UA (urinalysis) C&S (culture & sensitivity). HTN: Metoprolol 50mg x1 this AM with improvement. Pt (patient) not on meds. Monitor for persistent elevations . d/w (discussed with) patient at length and pt verbalized an understanding of all risks and instructions. All questions answered. Pt verbalized an understanding of all instructions. D/W staff at length . A Nursing note dated [DATE] at 1:25 PM, documented in part . The Change in Condition/s reported . Altered mental status . Guest is less responsive than baseline. Not eating or drinking. Irregular movement of arms. High BP (blood pressure)/ P (pulse) . Primary Care Provider responded with the following feedback . stat labs, stat CXR, IV (intravenous) fluids . Blood Tests Urinalysis or culture X-ray . New Intervention Orders: IV or subcutaneous fluids . This note was documented by Licensed Practical Nurse (LPN) A. A Physician note dated [DATE] at 10:49 PM, documented in part . labs reviewed- leukocytosis (elevated white blood cell count) noted. Pt with Urianry <sic> sx and dark, cloudy urine per nurse. Will begin IV Rocephin (antibiotic) 1 gm (gram) QD (every day) x7 days- 1sr <sic> dose today . Further review of the complaint submitted to the SA and interviews conducted with the complainant noted that on [DATE] the family visited the resident and found them . laying in bed with his tongue hanging out of his mouth and his breathing was shallow . female nurse on the afternoon shift told (the family) the resident was getting a Covid test and could possibly have pneumonia because he hadn't been responsive and was unable to be woken from his sleep . A review of the [DATE] MAR revealed the following medications were not administered on [DATE] for the HS (hour of sleep) doses: Apixaban 2.5 mg for DVT (deep vein thrombosis/blood clot) prophylaxis, Aspirin 81 mg for DVT prophylaxis, Calcium Carbonate 500 mg, Metformin 500 mg, Senna-Docusate Sodium 8.6-50mg, and Sodium Chloride solution 0.9% intravenously for dehydration. There was no documentation in the medical record of the Physician to have been notified of the omitted medications. A Nursing note dated [DATE] at 6:54 AM, documented . Chest x-ray reviewed, unremarkable. Resident has remain in the same condition throughout the shift. Resident is stable, yet unarousable . This note was documented by LPN B who worked the midnight shift on [DATE] from 7:00 PM on [DATE] to 7:00 Am on [DATE]. Review of the medical record revealed no documentation of any additional assessment of the resident on the midnight shift despite LPN B to have documented that the resident remained unarousable all shift. A review of a facility policy titled Acute Condition Changes revised [DATE], documented in part . Before contacting a physician about someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the Physician . Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident's current symptoms and status . The nursing staff will contact the Physician based on the urgency of the situation. For emergencies, they will call or page the Physician and request a prompt response . A review of the medical record revealed on [DATE] at 9:24 PM, R802's vital signs were documented as: BP 169/99 mmHg, Temperature 98.6, Pulse 99, Respirations 22, and 02 Sats 90% on room air. (Note this is the same vitals documented in the Physician Assistant - PA D note from 11:42 AM on [DATE]. The medical record revealed no adequate monitoring of the resident from [DATE] at 9:24 PM to [DATE] at 7:14 AM. On [DATE] at 7:14 AM a pulse was noted at 115 beats per minute. At 7:15 AM R802's temperature was noted as 100.5 F (Fahrenheit) and 02 Sat was noted at 79% on room air (normal readings would be 90% or above). There was no documentation of a blood pressure obtained at this time. A review of a Nursing note dated [DATE] at 7:22 AM, documented . Per provider, resident is being sent out to hospital 911 . This note was documented by LPN B. A review of the hospital records revealed the following: A History & Physical dated [DATE], documented in part . comes to the emergency room with acute hypoxic respiratory failure, sepsis secondary to UTI (urinary tract infection), acute toxic encephalopathy. He has been also intubated. Right now, he is in ICU (intensive care unit). Management per ICU team . An Admit/Progress Note dated [DATE], documented in part . ICU team at bedside to round at 0900. Patient is off sedation, does not follow commands. Pending CT (computerized tomography scan) Head . seen and examined . breathing over vent, withdrawing to pain but no response to commands pupils equal but non reactive . The patient does have cerebral edema (swelling of the brain) (Addendum [DATE]) . A Neurosurgery Consultation note dated [DATE], documented in part . Patient . with recent history of left hip fracture s/p (status post) THA (total hip arthroplasty) on [DATE], reportedly on Eliquis for DVT prophylaxis who presented to hospital from rehab facility on [DATE] . Patient was discharged to rehab facility in good condition was awake alert and oriented and answering questions appropriately. At some point on . [DATE], patient became unresponsive not answering questions. For unknown reasons, patient was not brought to the ER (emergency room) for evaluation until the morning of [DATE]. This morning ([DATE]) CT head was obtained which demonstrated bilateral cerebellar infarcts (stroke) with mass effect on the fourth ventricle and obstructive hydrocephalus (the flow of cerebrospinal fluid is blocked along one or more passages connecting the ventricles). Neurosurgery was consulted in this regard. At the time of evaluation, patient intubated off sedation. Does not open eyes pupils 4 mm (millimeters) nonreactive, absent cough/gag/oculocephalic (neurological test used to assess the brainstem function) reflexes . Recommendations: Long discussion was had with patient's brother and sister at bedside. CT findings and patient's clinical status and neuroexam were described in depth to family. We explained that given his poor neurological exam, his prognosis is extremely guarded and his likelihood of functional recovery is quite low. He has likely suffered some irreversible damage to his brain/brainstem based on neuroexam . Ultimately given the patient's poor prognosis, his brother and sister agreed that patient would not want to undergo surgery and elected for comfort measures . Review of a Discharge Documentation dated [DATE], noted the resident was pronounced deceased at 2:01 AM. A review of the Certificate of Death documented the only cause of death noted as . Acute Stroke . Approximate Interval Between Onset and Death four to five Days . On [DATE] at 12:16 PM, LPN B was interviewed via telephone and was asked where they document the residents vitals that are obtained, LPN B replied they document it in the (Electronic Medical Record) chart. LPN B was asked about the vitals not being obtained for R802 on the nightshift of [DATE] into [DATE]. LPN B stated they were unsure why there was no vitals documented. LPN B could not recall the values obtained. LPN B then stated in part . It was alarming to me (R802's presentation/status). I had been off two or three days. Dayshift said he (R802) was already like that (unresponsive) and the Physician had been notified. Based on what I was told we were not able to send him (R802) to the hospital . When asked why they were not allowed to send R802 to the hospital, LPN B replied that the dayshift nurse (LPN A) had informed them of that in their verbal shift report at the change of shift. LPN B then stated in part . The same thing the unit manager (Unit Manager- UM, later identified as UM G) told me as well and I blew up on him. I tried advocating for him (R802) throughout the night . When asked who they contacted in attempts to advocate for R802, LPN B stated the provider that was on call, they were unsure of who it was. LPN B stated in part . I told him (UM G) No, you need to come and look at him and he needs to go to the hospital. I was pissed off the entire night and I begged them to send him and they told me I cannot . LPN B was asked why R802's medications had not been administered for the evening of [DATE] and stated in part . No, he couldn't take nothing. He (previously) was A&O x4 (alert and oriented times four) which is why I was so upset. He would get up on his own and do his own personal care. He would talk to me (in the past), but he couldn't do any of that when I came on shift. He was not responding to me at all. When I went in there (R802's room) I was shocked that they would not let me send him to the hospital. It was upsetting they would not allow me to send him to the hospital. The IV and antibiotics was not enough for me, but they would not allow us to send him out. I had to wait until the morning to talk to (UM G name). I blew up on him. I went off and told (UM G) it was unsafe and this is my license and he (R802) needed to go to the hospital . It was very disheartening because I wanted to send him out when I got to work (at the beginning of their shift) but they told me that I could not . LPN B then stated . Please talk to (LPN A name) first because they (Administration team) have a habit of trying to cover their stuff up. (LPN A) was upset too because they wouldn't let her send him out before on dayshift . When asked who is they that they keep referring to, LPN B kept referencing the report given to them by LPN A of not being able to send the resident to the hospital. On [DATE] at 12:31 PM, a message was left on LPN A voicemail to return the call. On [DATE] at 1:05 PM, an interview was conducted with UM G. When asked how often a resident with an identified change of condition should be assessed and monitored, UM G replied in part . it depends on the change of condition, very frequently the nurse should be spending a lot of time with that patient if they were responsive and now unresponsive. At least hourly . UM G was then asked about R802 and UM G stated they remembered the resident had a change from their baseline and the Nurse and PA was in there (R802's room). UM G stated they didn't have a chance to see the resident that day. UM G stated they were approached by the Nurse the next day who said (R802) was not doing well and they did not like the way that (R802) was presenting. UM G stated . I told the PA he didn't look good and ensured I had a fresh set of vitals . UM G stated they were instructed to send R802 to the hospital. On [DATE] at 1:18 PM, a message was left on PA D's voicemail to return the call. At 1:24 PM, a text message was sent to the Medical Doctor (MD) C who was the Physician assigned to R802. A reply was not received that day. At 1:37 PM, LPN A returned the surveyor's call. When asked about R802 on the day of [DATE], LPN A replied when they came on duty R802's blood pressure was way up. LPN A stated they called to get an order for something and kept checking on R802 because . he was not responding normally . LPN A stated R802 was very hard of hearing and had speaker things that they would utilize. LPN A stated R802 was not eating and . he wasn't very responsive . LPN A stated R802 would respond by groaning but . he was getting worse responsive wise . LPN A stated they notified (PA D) and the PA ordered a few things. LPN A stated they then talked to UM G (their supervisor) who was sitting with (Unit Nurse Manager- UNM J) and . they would not get off their butts and I was pissed . LPN A stated they talked to R802's brother and stated they really thought R802 needed to go to the hospital. LPN A stated . (UM G name) told me no, you already have orders for him (R802) . LPN A stated I told (UM G name) to go down there and look at (R802) and LPN A stated UM G told them they were busy. LPN A stated . I was so scared . I was like please come and look at him and set eyes on him all the CNAs (Certified Nursing Assistants) said this is not him (R802's presentation) . The Nurse (LPN B) sent him out because she had enough . LPN A then stated in part . I am an LPN but I have been doing this for a million years and I asked (UM G name) to come and see him and he wouldn't. It was not a good situation and the managers put a stop to it and wouldn't allow us to send him out. I was pissed about it. This has happened before, there have been other incidents. There is a lot of things that they do there, they don't let us chart the truth . It was disturbing and the fact that we got no support and I couldn't do what I wanted to do and send him to the hospital because I had no manager support . Despite to have verbalized that R802 needed to go to the hospital, neither LPN A or LPN B called emergency services timely. At 1:58 PM, PA D returned the surveyor's call. When asked if they were notified of the change in condition of the resident becoming unresponsive, PA D stated in part . I was notified in the morning and prior to leaving the shift he (R802) was stable. He was able to talk to me when I assessed him and I ordered labs and he was awake and alert. No, I wasn't aware until they reported to me the next morning . On [DATE] at 3:35 PM, the Administrator and Director of Nursing (DON) was interviewed and asked if they were familiar with R802. The DON stated they believed he came to the facility after he had a fall. The DON remembered the resident was hard of hearing and had a headset that looked like a Walkman (assisted him with hearing). The DON stated they remember the resident would always come down to the community room to eat. The DON stated they remember the resident told them their story (on what happened that caused them to be at the facility) but they couldn't remember it. At this time the Administrator and DON were both interviewed on the concerns of the facility staff inadequately assessing/monitoring a resident with an identified change of condition, the failure to notify the Physician of continued decline and the delay in transferring the resident to a higher level of care, both acknowledged the concerns and offered no additional explanation at that time. At 5:57 PM, a second phone call was received from LPN A who stated the facility Administration team were repeatedly calling them. LPN A stated . They told me that I couldn't tell the nurse (LPN B) not to call the doctor for the resident with a change in condition. I told them I didn't tell the nurse (LPN B) not to . They kept trying to blame me and I hung up on them . On [DATE] at 9:07 AM, the [NAME] President of Operations (VPO) H, Medical Doctor (MD) C and Regional Nurse Consultant (RNC) I requested to provide additional information. MD C reported they had information that they felt would be useful for the investigation. MD C went on to verbalize that they talked to their PA (PA D) who had examined R802 on [DATE] and the resident didn't have any signs/symptoms of a stroke. MD C stated the stroke was identified the day after the resident went into the hospital and the resident was moving his limbs in the ER. MD C stated the resident was on a blood thinner and aspirin and they don't believe that they could have change the direction of how the incident played out. The findings of inadequate assessment/monitoring, lack of notification to the Physician of the continued decline and the delay in transferring the resident to the hospital was discussed. MD C was asked if they were notified by the nursing staff of the continued decline of R802 and MD C stated they were not notified. RNC I stated the medical team was not aware of a continued decline and believed there was a glitch in the facility's EMR as to the reason a blood pressure was not documented on the morning of [DATE]. It was discussed with VPO H, MD C and RNC I that if they had any additional information they could provide it for further review. On [DATE] at approximately 10:00 AM, UM G and the DON was recalled together for a second interview. UM G was asked about being informed multiple times by the nursing staff of the concern of R802'si ws condition declining, the request for them to set eyes on R802 and to send R802 to the hospital. UM G replied they recalled being asked about the patient and informing the nurse that if it was any change of condition with the resident to notify the provider. When asked if they told the nursing staff that R802 was not going to the hospital, UM G stated they did not say that (R802) was not going to the hospital and remembered telling the staff to contact the provider for changes. UM G was asked to recall [DATE] the morning R802 was transferred to the hospital. UM G stated the nurse said (R802) wasn't presenting well. UM G stated they remember going into the room with the nurse and they could not recall who obtained the vitals that morning, but they remembered they called PA D who instructed the resident to be sent out. UM G stated they remember the resident only responded to painful stimuli. When asked what was different about R802 from the evaluation completed the day before by PA D and (R802) not presenting well on the morning of [DATE], if there was no alleged changes for R802 throughout the night and UM G stated in part . with the new vitals that we just obtained which is the new change of condition and we sent him out . The DON was asked if they felt it was acceptable practice for a resident to have an identified change of condition and not be closely monitored or have vitals obtained from [DATE] at 9:24 PM until [DATE] at 7:14 AM, especially considering the one time doses of blood pressure medications that were given in attempts to control R802's blood pressure. The DON replied . I expect them to follow the physician orders . The DON was asked if there needed to be an order for the nurse to monitor and obtain the vitals of a resident with an identified change of condition and the DON repeated that they expected the nurses to follow the Physician orders. On [DATE] at 11:30 AM, RNC I entered into the conference room and stated that Unit Nurse Manager (UNM) J seen R802 on [DATE]. Shortly after UNM J entered the conference room and stated LPN A was believed to be irritated with their assignment on [DATE] because they were normally assigned to another part of the facility. UNM J stated they remember (R802)'s vitals to be fine and beautiful. UNM J stated they remembered that R802 was responsive when they saw them just slow to respond. UNM J stated they were in the room with LPN A. When asked where their documentation was of their assessment from R802, UNM J stated they did not document the assessment. UNM J was asked what time they went off duty on [DATE] and stated they leave the facility by 4 or 4:30 PM. On [DATE] at 10:14 AM, a voicemail was left on the surveyors phone from LPN A which noted in part, . He (R802) would move you know moan and and <sic> and kind of push away . he (R802) wasn't unresponsive on my shift. He responded to movement to. He would mumble and try and talk . he was the same . he didn't get worse on my shift . No additional information was provided to the survey team before the end of the survey. The Immediate Jeopardy that began on [DATE] was removed on [DATE] wen the facility took the following actions to remove the immediacy, including the following: Resident 802 no longer resides at the facility. Root cause: The physician was not notified by LPN A and LPN B of the resident's continued decline (unresponsive, not alert, not responding, and unable to take medications), leading to the resident being transferred to the hospital. A one-time audit was completed for the last 14 days of nurses notes and change of conditions to ensure appropriate MD notification and follow-up was completed. There are no concerns noted. Licensed Nurses were re-educated on [DATE] on the change of condition policy, including appropriate assessment, and timely notification of the physician to prevent serious injury, harm, and or death. SYSTEM CHANGE: The facility nurse leadership team did a one-time visual assessment of all current residents to ensure no change in condition is noted and required physician notification is completed timely. No concerns were noted. The policy on change in condition was reviewed and deemed appropriate. DON/designee will review 5 charts weekly x 12 weeks to ensure appropriate MD notification and change of conditions have been completed timely. Non- compliance will be addressed immediately. Audits will be forwarded to QAPI (Quality Assurance Process Improvement) committee for review and recommendations. COMPLIANCE DATE: [DATE]

This citation pertains to Intake Number(s): MI00153132. Based on interview and record review, the facility failed to accurately reconcile and implement physician's orders from the hospital upon admission into the facility for one (R803) of two residents reviewed for admission orders, resulting in increased psychiatric symptoms including agitation, throwing objects, and combativeness. Findings include: A review of a complaint submitted to the State Agency revealed an allegation of R803 not receiving appropriate care by the facility. On 5/27/25 at 11:18 AM, an interview was conducted with the complainant. The complainant reported concerns about how R803 presented when she visited her in the facility prior to being discharged . The complainant reported R803 had a diagnosis of bipolar disorder and had a recent psychiatric hospitalization where she was started on a new medication (Abilify) in addition to the medications she took previously, including Lithium (a mood stabilizer that treats or prevents manic episodes of bipolar disorder). The complainant explained she was concerned when she saw R803 in the facility because she had developed slurred speech and other symptoms such as difficulty swallowing. On 5/29/25 and 5/30/25, an unannounced, onsite investigation was conducted. A review of R803's clinical record revealed R803 was admitted into the facility on 5/9/25 and discharged home on 5/18/25 with diagnoses that included: bipolar disorder. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R803 had moderately impaired cognition and no behaviors during the assessment period. A review of R803's Discharge Summary from the hospital provided to the facility upon admission into the facility on 5/9/25 revealed the following orders with instructions to continue the medications and when the next dose was due: Lithium 300 milligrams (mg) once a day with the next dose due 5/10/25 in the morning. Lithium 600 mg once a day (in the evening) due 5/9/25 in the evening. A review of R803's Physician's Orders and Medication Administration Record (MAR) revealed the following: An order dated 5/9/25 for Lithium Carbonate ER (extended release) 300 mg give 2 tablet by mouth at bedtime for Bipolar. (It should be noted the hospital discharge instructions did not note the order to be an ER tablet. There was no order for the 300 mg dose of Lithium that R803 was supposed to get in the morning daily. A review of R803's MAR revealed she received the 300 mg ER dose of Lithium at bed time on all days she resided in the facility, 5/10/25 through 5/17/25. R803 did not receive the dose on the evening of 5/9/25 as the medication was not on hand or in backup. A review of R803's progress notes revealed the following: On 5/10/25 at 5:04 PM it was documented R803 was throwing things at 7:00 AM, was yelling that she wanted to go home. R803 yelled and threw things throughout the day, and banged on a cabinet at 5:10 PM. On 5/11/25 at 6:09 AM it was documented R803 was awake during the whole shift, was very combative and uncooperative with care, continuously banged on cabinets, and screamed during the night. On 5/11/25 at 6:20 PM, it was documented R803 was very combative, threw everything in her room in the trash after visitors left because she wanted to go home, kept getting in and out of bed on her own without a wheelchair, and threw all her meals. On 5/12/25 at 6:48 AM it was documented R803 was very confused and uncooperative with care, continuously banged on cabinet doors while screaming about wanting to go home, spit up food into trash, threw personal items at staff, was aggressive with staff, and remained awake and agitated all night. On 5/12/25 at 11:45 AM, R803 was seen by Physician 'C' who documented R803 was confused, but did not note any behaviors. It was documented R803's medications were reviewed at that time. However, there was nothing noted that R803's Lithium dose should be changed from what it was in the hospital discharge instructions. On 5/12/25 at 4:49 PM it was documented R803 was very confused and uncooperative with care, continuously spit up food into hands and floor, threw personal items at staff, and was aggressive when redirected. On 5/13/25 at 6:25 AM it was documented R803 spit medication out at bedside, slammed the closet door repeatedly throughout the night and continued to do so until 7:00 AM. On 5/13/25, the following was documented in a Pharmacy Recommendation, RE: Lithium Extended-Release - Resident currently receiving 600 mg PO (by mouth) QPM (at night). Hospital discharge order indicate that resident was receiving 300 mg PO QAM (every morning) AND 600 mg PO QPM. Please clarify appropriate dosing. Further review of R803's progress notes and Physician's Orders revealed no changes to R803's Lithium orders after the pharmacy recommendation was made. R803 was seen by Physician 'C' on 5/14/25 after a fall and it was documented R803's bipolar disorder was stable. On 5/15/25 at 7:11 AM it was documented R803 was very uncooperative and combative, banged on cabinets, continuously spit and threw objects at staff, constantly got out of bed and wheelchair without assistance, did not sleep all night, and was disruptive. On 5/16/25 at 6:21 AM it was documented R803 was up and awake all night, very restless, and hyperverbal. On 5/16/25 at 9:40 AM, the following was documented in a discharge management note written by the Nurse Practitioner (NP): R803 appeared at her baseline mental status, was confused, had agitation at times secondary to bipolar disorder which was stable. On 5/16/25 at 10:10 AM it was documented R803 screamed, asked for applesauce and then threw it at the wall, screamed, and pulled her hair. R803 was discharged on 5/18/25 without any changes to her Lithium per hospital discharge instructions. On 5/29/25 at 10:04 AM, an interview was conducted with the Director of Nursing (DON). When queried about who was responsible for entering the physician's orders when a resident was admitted into the facility, the DON reported it was a collaboration between the floor nurses and the unit managers. When queried about who ensured the admission orders were accurate, the DON reported the unit managers did a second check for accuracy. When asked why R803's Lithium order did not get implemented upon admission according to the hospital discharge instructions, the DON reported she would look into it. On 5/29/25 at 10:45 AM, an interview was conducted with Physician 'C' via the telephone. When queried about what could happen if a resident with bipolar disorder treated with Lithium was given too small of a dose too quickly, Physician 'C' said it would not be dangerous, but the resident could certainly become very hyper (manic). When queried about whether he reviewed R803's medication when he saw her on 5/12/25 and if he was aware of the behaviors she was having, Physician 'C' reported he recalled the resident being calm when he evaluated her, knew she had falls throughout her stay, but could not recall any behaviors. Physician 'C' reported the staff call him whenever there is an issue but did not recall being notified of anything being wrong behaviorally. When queried about how it was ensured that the orders on the hospital discharge summary were accurately reconciled and ordered for the resident at the facility, Physician 'C' reported there were multiple layers of people who reviewed the order, including nurses and pharmacy. Physician 'C' said R803 should have received her full dose of Lithium during her stay and stated, We missed it. On 5/29/25 at 10:55 AM, Physician 'C' called back and reported he spoke with the DON who told him nursing did not contact him because R803's behaviors were because she wanted to go home. When asked if it could be a result of not receiving her full dose of Lithium, Physician 'C' reported he understood the concern, but wanted to give all the information he could. On 5/29/25 at approximately 1:45 PM, a follow up interview was conducted with the DON. When queried about whether she found any additional information to justify why R803's Lithium order was not entered according to the hospital discharge instructions, the DON stated, We are all human and said they go through second and third checks to ensure accuracy and said the orders should have been entered accurately on admission. The DON then said pharmacy did not catch the error. When queried about the Pharmacy Recommendation documented on 5/13/25, the DON did not offer a response. A review of a facility policy titled, Reconciliation of Medications on Admission (undated) revealed, in part, the following, .The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility .Gather the information needed to reconcile the medication list .list all medications from the medication history, discharge summary, the previous MAR (if applicable), and the admission orders (sources) .Review the list carefully to determine if there are discrepancies/conflicts .If there is a discrepancy or conflict in medications, dose, route or frequency, determine the most appropriate action to resolve the discrepancy .Document findings and actions .

Based on interview and record review, the facility failed to obtain neurology consult documentation and implement recommendations to start medication for multiple sclerosis (MS) and ensure timely follow-up evaluation was coordinated per recommendation for one (R47) of one resident reviewed for quality of care. Findings include: On 4/15/25 at 9:17 AM, R47 was observed lying in bed, eating their breakfast meal. When asked about whether they had any concerns with the care at the facility, R47 reported they were concerned they were not receiving medication like they should and at times felt weaker. Review of the clinical record revealed R47 was initially admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: multiple sclerosis, pneumonia, acute and chronic respiratory failure with hypoxia, and interstitial pulmonary disease. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], R47 had intact cognition. Review of a neurology consultation document dated 12/13/24 with Neurologist (Physician 'Q') read, .is seen for multiple sclerosis .was last seen way back in July and missed her last two appointments .has been on Aubagio in the past and would like to go back on the Aubagio .Assessment & Plan .Started teriflnomide 7 mg (milligrams) tablet, 1 (one) tablet daily, #30, 30 days starting 12/13/2024, Ref. (Refill) x1 .IMPRESSION: Multiple sclerosis. PLAN: We will restart Aubagio. I have asked the patient to return for reevaluation in three months and have follow-up blood work before her next visit. Further review of the interdisciplinary team documentation in the clinical record revealed there was no further follow-up appointments with Physician 'Q' completed or scheduled as of this review. Review of R47's facility physician (Physician 'L' who also functioned as the Medical Director) and extender documentation revealed no entries which addressed the neurologist's recommendation to restart the MS medication as recommended on 12/13/24, or issues with not being able to coordinate follow-up appointment with neurology. Review of the incident reports provided by the facility indicated R47 had multiple falls from December 2024 to March 2025 which identified the resident feeling weak during attempts to self-transfer. Review of a single grievance form from R47 dated 3/7/25 documented, in part: .Frustrated medication from neurologist never started .Explained process for starting medication. Daughter called to get order faxed .Faxed medication received - provided to nursing and order place <sic> after physician review . Review of the physician order history revealed R47 was prescribed Teriflunomide (Aubagio) Oral Tablet 7 MG Give 1 tablet by mouth in the morning for MS for 30 Days. This order was received on 3/7/25, had a start Date of 3/8/25 and ended on 4/7/25. There was no documentation from the provider as to the clinical rationale for why this medication was only prescribed for 30 days, or plan for follow-up. On 4/16/25 at 10:50 AM, a phone interview was conducted with R47's Neurology office. When asked to confirm scheduled visits since July 2024, the scheduler confirmed R47 had not been seen since 12/13/24, but did have an appointment scheduled for 5/2/25 (two months beyond Physician 'Q's recommendation for follow-up.). They further reported there were several appointments that had been canceled but was unable to provide any further details. On 4/16/25 at 11:11 AM, the facility was requested to provide policies for coordination of outside appointments and follow-up of implementing recommendations from these appointments. (There was no documentation that addressed this request provided by the end of the survey.) On 4/16/25 at 11:03 AM, an interview was conducted with the Social Services Coordinator (SSC 'K') who confirmed their Care Transitions department was responsible for coordinating outside referral appointments for the residents, including R47's neurology appointment. SSC 'K' was asked to provide any documentation of arrangements made or if there were any issues with not being able to make arrangements as recommended and they reported they would follow-up. SSC 'K' reported that although they began working at the facility in February 2025, they would look to see what other documentation might be available for review. On 4/16/25 at 12:55 PM, SSC 'K' provided consultations for R47's appointments since 2024 which revealed there were two for the neurologist from 12/13/24 and 2/19/24. They further reported they just confirmed today (after the concern was identified during the survey) that R47 had an appointment scheduled for 5/2/25 and they would work on obtaining transportation. When asked why the resident had not been scheduled prior to 5/2/25 as the recommendation was for follow-up in three months, SSC 'K' reported they were not able to answer that question and also confirmed there was no documentation they could find in regard to if appointments were previously scheduled and canceled. On 4/16/25 at 1:35 PM, an in-person interview was conducted with Physician 'L'. When asked to explain the process when residents saw outside physician's and recommendations were made, how they became aware and what follow-up was done, Physician 'L' reported they see a letter and note from the physician and usually follow-up if they come back with instructions. If they don't come back with anything, then we will just review but don't always make a note in our notes. Physician 'L' further reported they should document in their progress notes and if they agree with the recommendation would be glad to honor that. When asked why the medication such as the one prescribed for R47's MS was ordered for only 30 days, Physician 'L' reported they thought that because the pharmacy only allowed 30 days. When asked why other medications that were ordered for R47 were not just limited to 30 days, Physician 'L' reported they were not able to answer that question, but would follow-up. When asked once a resident was started on an MS medication, should that medication be taken consistently and they reported it's an MS medication and they should stay on. When asked if they were aware R47's initial recommendation from 12/13/24 was to start the MS medication, and the resident had not received it until R47 brought it up as a concern on 3/7/25, and had not been receiving the medication now since 4/7, they reported they were not aware and would have to follow-up. On 4/16/25 at 2:02 PM, Physician 'L' reported the facility didn't have any update from neurology until March (when R47 complained) and the Administrator talked to the daughter and we got the letter and they (neurology) wanted it for 30 days. When asked why the facility did not follow-up in December 2024 if they didn't receive paper work timely, Physician 'L' reported the primary neurology office was supposed to fax the order and someone from here should've followed-up. Physician 'L' further acknowledged their documentation should reflect clinical rationale and did not. On 4/16/25 at 2:05 PM, an interview was conducted with the Director of Nursing (DON). When asked about the facility's process if the resident consults with an outside specialist and returned without documentation, what should happen, the DON reported the nurse of the resident or the Unit Manager should follow-up. They were informed of the concerns with the lack of timely follow-up for R47 and they reported they would be further investigating to see what happened.

Based on observation, interview and record reviews the facility failed to ensure all expired medications were removed from the residents medication storage units for one (R31) of five residents observed for the medication administration observation. Findings include: On 4/16/25 at 8:41 AM, LPN A was observed preparing the morning medications for R31. Included in the morning medications was a senna-plus pill. The expiration date on the senna-plus bottle was observed to be 12/2024. LPN A and LPN B failed to check the expiration date of the senna-plus medication. LPN A then gave LPN B the cup containing R31's morning medications to administer and LPN B administered the morning medications to R31. After the medication observation, LPN A and LPN B were both asked to check the expiration date of the senna-plus bottle and LPN A and LPN B stated the medication should have not been administered and removed the medication from R31's medication storage cabinet. A review of a facility policy titled Storage of Medications dated June 2019 documented in part, . The nurse will check the expiration date of each medication before administering it . No expired medication will be administered to a resident . All expired medications will be removed from the active supply and destroyed in the facility or returned to the pharmacy for destruction, regardless of amount remaining . On 4/16/25 at 9:33 AM, the Director of Nursing (DON) was interviewed and informed of the expired medication that was administered to R31 during the medication administration observation with LPN A and LPN B. The DON stated they had been informed of the error and completed additional education with both nurses. No further explanation or documentation was provided.

Based on observation, interview and record review, the facility failed to ensure enhanced barrier precautions (EBP) policies and protocols were followed and maintained for one (R64) of seven residents reviewed for infection control. Findings include: On 4/15/25 at 9:00 AM, R64's door was observed closed. Signage on the hallway wall near the doorframe indicated the resident was on EBP and a storage bin contained various PPE (Personal Protective Equipment) which included disposable face masks, gloves, and gowns. The EBP signage further read, STOP ENHANCED BARRIER PRECAUTIONS EVERYONE MUST: Clean their hands, including before 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 or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound care: any skin opening requiring a dressing . On 4/15/25 at 9:40 AM, R64 was observed lying in bed. At 9:42 AM, R64 reported they needed someone to help me change my diaper and pressed the call light button on the wall. On 4/15/25 at 9:43 AM, Certified Nursing Assistant (CNA 'C') was observed entering the room in response to the call light, but did not use hand sanitizer upon entry into the room. CNA 'C' was then observed to close the door to the room, without donning/doffing any PPE. On 4/15/25 at 9:51 AM, CNA 'C' exited the room and returned with a hospital gown. They were not observed to use hand sanitizer upon re-entering the room, or donning any PPE. On 4/15/25 at 9:55 AM, CNA 'C' exited the room carrying a bag with soiled linens. On 4/15/25 at 9:58 AM, an interview was conducted with CNA 'C'. When asked about what type of care they had just provided to R64, CNA 'C' reported the resident had a bowel movement and they had changed their gown too. When asked about whether they should've put on any PPE, CNA 'C' reported they didn't think (R64) had anything that they needed to use that for. When informed of the details on the signage, CNA 'C' reported they never did that for him and no one else did either. On 4/15/25 at 3:07 PM, Corporate Infection Preventionist (Nurse 'F') who was covering for the facility's Infection Preventionist (Nurse 'M') was informed of the concern with lack of infection control protocol for R64 and informed of the earlier observation and interview. They reported that should not have occurred and staff had repeatedly been in-serviced about EBP. Review of the clinical record revealed R64 was initially admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: anoxic brain damage, acute metabolic acidosis, type 2 Diabetes mellitus with ketoacidosis without coma, dysphagia, gastrostomy status, esophageal obstruction, diaphragmatic hernia without obstruction or gangrene, acute kidney failure, hematemesis, functional quadriplegia, unspecified severe protein-calorie malnutrition, bipolar disorder, and chronic respiratory failure unspecified whether with hypoxia or hypercapnia. According to the MDS assessment dated [DATE], R64 had intact cognition, had impairment on both sides of their upper extremities, had impairment to one side of the lower extremity, received nutrition via tube feeding and oral food and was dependent upon most aspects of care. According to the facility's policy titled, Enhanced Barrier Precaution - Policy - Procedures dated 4/1/2024: .Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce the transmission of resistant organisms that employs targeted gown and glove use during high contact resident care services .The facility will implement EBP, effective 4/1/2024, following CDC (Centers for Disease Control) and CMS (Centers for Medicare & Medicaid Services) guidance .For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves .

Based on interview, and record review the facility failed to ensure an antibiotic medication was administered within the prescribed parameters and not in excessive dose for one (R2) of five reviewed for unnecessary medication. Findings include: Review of the clinical record revealed R2 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included: urinary tract infection, extended spectrum beta-lactamase (ESBL - a bacteria resistant to some antibiotics). According to the Minimum Data Set (MDS) assessment dated [DATE], R2 had severe cognitive impairment, did not receive antibiotic medication during this review period of seven days. Review of R2's urine culture results collected 4/1/25, reported on 4/6/25 documented a result of SOURCE URINE, ORGANISM 1 10,000 CFU (Colony Forming Unit)/ML (Milliliters) PROTEUS MIRABILIS, ESBL. Review of the physician orders included two orders for an antibiotic medication which included: Start Date - 4/7/25 at 7:00 AM, Discontinue Date 4/9/25 at 12:02 PM, LevoFLOXacin Tablet 500 MG (Milligrams) Give 1 tablet by mouth in the morning for Infection for 7 Days. Start Date - On 4/10/25 at 7:00 AM, LevoFLOXacin Tablet 500 MG Give 1 tablet via PEG-Tube (Percutaneous endoscopic gastrostomy - the placement of a feeding tube through the skin and the stomach wall) in the morning for infection for 7 Days. Further review of R2's Medication Administration Record (MAR) revealed the resident received this medication for a total of 9 doses from 4/7/25 to 4/15/25. There was no other documentation in the electronic medical record that identified the Physician/Extenders rationale for the additional two doses as documented as administered on the MAR, or the reason for the change in orders on 4/9/25. On 4/15/25 at 4:01 PM, an interview was conducted with the Corporate Infection Preventionist (Nurse 'F' who reported the current Infection Preventionist (Nurse 'M') was on vacation. When asked about R2's recent orders for antibiotic and precautions for ESBL, Nurse 'F' reported R2 had started on the antibiotic on 4/7/25 and the order changed on 4/10/25 but they were not sure why or who changed the order. Nurse 'F' reported just this morning Nurse 'M' had notified the facility remotely to pull the contact precaution signage for the ESBL. Nurse 'F' reported they would attempt to find out why the order was changed between 4/9 and 4/10 and confirmed there was currently no documentation in the clinical record to clarify this. On 4/15/25 at 4:15 PM, Nurse 'F' provided a phone text message from Nurse 'M' on 4/15/25 at 9:03 AM to remove the contact precaution signage. When asked to confirm the total dose of antibiotic R2 received, Nurse 'F' confirmed documentation reflected the resident received a total of nine doses. When asked about lack of documentation of physician justification/clinical rationale for two additional doses, Nurse 'F' confirmed there was no documentation but was looking into that further with the nursing staff. There was no further follow-up from Nurse 'F' by the end of the survey. On 4/16/25 at 9:15 AM, an interview was conducted with the Director of Nursing (DON). The DON was informed of the concern that R2 received two additional days of antibiotic and no clinical rationale from the provider or facility staff regarding the change in orders the DON reported they were aware of that and further reported the resident had initially been ordered the antibiotic to be given orally, but following a recent swallow study, the order was changed back to administer via peg and when the order was put in the system it automatically calculated seven days and should have been adjusted at that time.

Based on observation, interview, and record review, the facility failed to ensure a physician documented an assessment for a competency evaluation for one resident, (R84) of one resident reviewed for competency. Findings include: On 4/15/25 at 9:25 AM, R84 was observed in their room sitting at the bedside. An interview was conducted with R84 and they said they were no longer receiving rehab and were not sure why they were still residing in the facility. They had no complaints but did express their desire to no longer reside in a long term care setting. R84 was asked what precipitated their admission to the facility and said in September 2024 they were living alone, independently in the community where they sustained a fall, broke numerous bones and admitted to the facility for rehab after hospitalization . On 4/15/25 at 3:04 PM, a review of R84's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: tibia, fibula, and radius fractures, osteoarthritis, diabetes, adjustment disorder and mood disorder. R84's admission Brief Interview for Mental Status (BIMS) score was a 10 indicating moderately impaired cognition. Continued review of R84's clinical record revealed a document titled DETERMINATION OF INABILITY TO PARTICIPATE IN HEALTHCARE DECISIONS signed by Psychologist 'R' ON 12/23/24 and Dr. 'L' on 12/24/24 that indicated R84 was, .unable to participate in medical or mental health treatment decisions . The form continued to read, .This determination is based on examination and by the facts and circumstances noted in the patient's medical record . The form indicated indicated R84's Power of Attorney had been activated and they were no longer their own responsible party. R84's record did not include any documentation regarding why R84 underwent a competency evaluation at that time, three months after their admission to the facility. Furthermore, the record did not include any assessment data from either Psychologist 'R' or Dr. 'L' that indicated R84 was not capable of making their own decisions. On 4/16/25 at 10:42 AM, a second interview was conducted with R84. They were asked if they were aware they underwent a competency evaluation and based on the evaluation their Power of Attorney had been activated. They said they were not aware. They said they had suffered from some memory loss after their hospitalization but they said they felt they had returned to their baseline and believed their memory to be, very good. R84 then went on to say they would like to make their own decisions regarding their care. On 4/16/25 at 11:49 AM, an interview was conducted with Social Worker 'K' regarding the facility's process for competency evaluations. Social Worker 'K' said they would start with a BIMS score and if it was between ten and twelve, further evaluation for memory and decision making would be done by psychiatric services and the attending physician. They were asked if psychiatric services would document in the record and said they would. They were then asked if the attending physician would perform an assessment prior to being the second required signature on the competency evaluation. They said they did not think the attending physician did and assessment and they signed the form based on the psychiatric service provider's assessment. At that time, documentation of any assessments done for R84's competency evaluation was requested. On 4/16/25 12:53 PM, Social Worker 'K' followed up with a document signed by Psychologist 'R' on 12/23/24 that read, .Evaluation of cognitive ability to participate in medical decision-making .She knew where she was and the current date/season .Mental status guided by the SPMSQ (Short portable mental status questionnaire) was normal .It is recommended that the patient may benefit from having support with significant decisions .Psychology Exam .Orientation: +Person; +Place +Inconsistent/Variable; .Memory/Immediate: +Grossly intact; Memory/Recent: +Grossly intact; Memory/Remote: +Grossly intact; .Assessment & Plan: Adjustment disorder with anxiety . It was noted the document signed by Psychologist 'R' did not indicate R84 was not competent to make their own decisions. On 4/16/25 at 1:47 PM, an interview was conducted with Dr. 'L' regarding their role with competency evaluations and whether they documented any assessments when making a determination. They said they did not, but they should document an assessment to justify their decision when evaluating competency. A review of a facility provided policy titled, Physician Services was reviewed and read, .The resident's Attending Physician participates in the resident's assessment and care planning, monitoring changes in resident's medical status, and providing consultation or treatment when called by the facility .

Based on observation, interview, and record review, the facility failed to ensure one (R87) of one resident reviewed for bowel and bladder, who was continent of bladder and bowel, received assistance to maintain continence. Findings include: On 4/15/25 at 9:50 AM, R87 was observed sitting up in bed. Family members were present in the room and R87 was getting ready to go to an appointment. An interview was conducted with R87 and his family members. R87 reported having to wait a long time for his call light to be answered at times. When asked what he needed assistance with, R87 reported he had to wait for his brief to be changed after urinating or having a bowel movement. R87 reported he did not use the toilet in the bathroom. R87's family member reported they were working on getting a bedside commode so R87 could use that instead of going to the bathroom in a brief. A review of R87's clinical record revealed R87 was admitted into the facility on [DATE] with diagnoses that included: right femur fracture. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R87 had intact cognition, no behaviors, was dependent for toileting hygiene, dependent for transfers, including a toilet transfer, and was always continent of urine and stool. A review of R87's Admission/Re-Admission assessment form dated 3/3/25 revealed R87 was continent of urine and stool. On 4/15/25 at 3:55 PM, R87 was further interviewed. R87 reported that at times he was not asked if he needed help or needed his incontinence brief changed and other times staff were not available to change him right away if he activated the call light. When queried about whether he was able to tell when he had to urinate or have a bowel movement, R87 reported he could tell. When queried about whether he was able to sit on the toilet, R87 reported he was physically able to sit up, but required some assistance transferring from the bed to the wheelchair and needed some assistance getting to the toilet. R87 reported the staff did not take him to the toilet and that he went to the bathroom in a brief and then they cleaned him and changed him. When queried when the last time staff assisted him to the toilet was, R87 reported they never put him on the toilet. When asked if he would prefer to use the toilet if he had assistance to get there, R87 reported he would prefer the toilet. R87 reported he did not express a concern to anyone because the staff usually just change me. On 4/15/25 at 4:09 PM, Certified Nursing Assistant (CNA) 'T' was interviewed. When queried about how the CNAs knew if a resident was continent or incontinent, CNA 'T' reported they talked to the nurses or asked the resident, but often put briefs on residents because sometimes they were continent and sometimes they were not. When queried about whether R87 utilized incontinence briefs or the toilet, CNA 'T' stated, I put a brief on him. I do not take him to the toilet. When asked how she knew that was appropriate for R87, CNA 'T' stated, I don't usually work over here but acknowledged working with R87 in the past and always used a brief. On 4/15/25 at 4:12 PM, an interview was conducted with Licensed Practical Nurse (LPN) 'U'.When queried about how residents were assessed for continence or incontinence, LPN 'U' explained they were assessed when they were admitted into the facility from the hospital and also they reviewed the hospital records. When queried about how the CNAs would know whether a resident was continent or incontinent of urine or stool, LPN 'U' reported it would be on the care plan and also on the Kardex (care guide used by CNAs) for the CNA and the nurses would let the CNAs know. When queried about R87's continence status, LPN 'U' stated, He's incontinent and uses briefs. When queried about where she got that information from, LPN 'U' reported it was on the care plan. When queried about the Admission Assessment and MDS assessment that identified R87 as continent of urine and stool, LPN 'U' stated, We have to follow what is in place from therapy. When queried about whether there were any instructions from therapy to not assist R87 to the toilet, LPN 'U' reported it would be documented on the care plan. On 4/15/25 at approximately 4:30 PM, a review of R87's care plans revealed a care plan initiated on 3/3/25 that read, Risk for Urinary retention or Incontinence related to BPH (benign prostatic hyperplasia). Interventions included, Provide incontinent care/products as needed. There were no care plans that addressed R87's urinary or bowel continence and interventions to prevent incontinence. On 4/16/25 at 8:44 AM, an interview was conducted with the Director of Nursing (DON). When queried about whether a care plan should be developed with interventions for residents who were assessed to be continent of urine and stool and whether those interventions would be added to the Kardex for the CNAs, the DON reported she was not sure and would look into it. Additional documentation was provided including: An Admission Summary dated 3/3/25 that highlighted a sentence that noted R87 had a urinal but had problems with urination. The note did not indicate R87 was incontinent or that he should not be taken to the toilet. A Skilled Charting note dated 3/28/25 with a highlighted section that noted R87 did not have any concerns. However, R87 reported during the interview on 4/14/25 that he had not expressed a concern to anyone because the staff change his brief and have not offered to take him to the toilet. A Skilled Charting note dated 3/30/25 with a highlighted section that noted, Continent of b/b (bowel and bladder), with episodes of incontinence. The note did not indicate R87 should not be taken to the toilet and instead use a brief. A Occupational Therapy (OT) Treatment Encounter Note dated 4/2/25 with a highlighted section that noted R87 required partial/moderate assistance for toileting and Toilet/Commode Transfers. There was no documentation that indicated R87 was not supposed to be assisted to the toilet. An OT Therapy Progress Report dated 4/8/25 with a highlighted section that noted R87 was dependent on staff for toilet transfers on 3/4/25 and required partial/moderate assistance on 4/1/25 and 4/8/25. There was no documentation that indicated R87 was not able to be assisted to the toilet. An Occupational Therapy Treatment Encounter Note dated 4/4/25 with a highlighted section that noted, Toilet transfer training onto commode. There was no documentation provided or follow up received by the end of the survey regarding why R87 did not have care planned interventions in place to help maintain continence or documentation that provided evidence of staff transferring R87 to the toilet instead of the resident urinating or having a bowel movement in a brief.

Based on observation, interview and record review, the facility failed to ensure an environment free from accident hazards for one (R64) of four residents reviewed for accidents. Findings include: On 4/15/25 at 9:40 AM, R64 was observed lying in bed. The entire left side of the bed was against the wall and the wall outlet which had two white and two red outlets was observed to have the entire right portion of the outlet cover broken off and missing. The mattress was observed directly touching the outlet. R64 was also observed to have a breakfast tray on the overbed tray table that was within three feet of the outlet. Additionally, next to the head of the bed was a tall metal pole used to hang tube feeding that was observed broken and leaning to the left. On 4/15/25 at 9:42 AM, R64 pressed their call light and stated they needed someone to help change my diaper. On 4/15/25 at 9:43 AM, Certified Nursing Assistant (CNA 'C') was observed to respond to the call light. On 4/15/25 at 3:00 PM, Nurse 'G' was asked to observe R64. Upon entry to the room, they confirmed the same observations as observed at 9:40 AM. Nurse 'G' reported they would contact maintenance staff right away. On 4/15/25 at 3:03 PM, Maintenance Staff 'E' came to the room with another maintenance staff and confirmed the broken outlet. When asked if the broken outlet was protected by GFCI (Ground Fault Circuit Interrupter - A safety device that shut off electrical power when they detect ground faults to prevent electrocution, electric shocks and burns.), Maintenance Staff 'E' reported they weren't sure but another outlet a few feet to the right of the broken outlet might be connected and would get a tool to check and confirm. On 4/15/25 at 3:07 PM, Corporate Infection Preventionist (Nurse 'F' was asked about the broken tube feeding pole and reported they had been aware the pole was leaning and had recently been fixed. Upon entering R64's room, they confirmed it was broken and would be replaced. On 4/15/25 at 3:10 PM, Maintenance Staff 'E' returned ro R64's room and upon checking the outlets, confirmed the broken outlet was not connected to the GFCI. When asked if they were notified about the broken outlet before now, they reported they were not. Review of the facility's work order report documentation since March 2025 revealed no concerns identified/reported for R64's tube feeding pole or broken outlet. Review of the clinical record revealed R64 was initially admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: anoxic brain damage, acute metabolic acidosis, type 2 Diabetes mellitus with ketoacidosis without coma, dysphagia, gastrostomy status, esophageal obstruction, diaphragmatic hernia without obstruction or gangrene, acute kidney failure, hematemesis, functional quadriplegia, unspecified severe protein-calorie malnutrition, bipolar disorder, and chronic respiratory failure unspecified whether with hypoxia or hypercapnia. According to the Minimum Data Set (MDS) assessment dated [DATE], R64 had intact cognition, had impairment on both sides of their upper extremities, had impairment to one side of the lower extremity, and was dependent upon most aspects of care. Care plans identified R64 frequently scooted in bed, received tube feeding and an oral diet and fluids. According to the facility's policy titled, Fire Safety and Prevention dated October 2012: .Whoever identifies a fire hazard, or other conditions that could develop into a fire hazard, must report the situation to the department director or Maintenance Director as soon as practical .The following fire safety precautions must be followed in the facility at all times: Electrical Precautions .Never touch an electrical appliance when you are wet .Do no use defective equipment .Do not use gasoline, benzene, etc., inside .Store chemicals, cleaners, etc., as instructed on the containers .

Based on observation, interview, and record review, the facility failed to address grievances for two residents (R#'s 29 and 81) of two residents reviewed for grievances, resulting in verbalized complaints and frustration between roommates. Findings include: On 4/15/25 at 9:30 AM, R81 was up in their room seated in their wheelchair. They were asked if they had any concerns and said they do not get along with their roommate, R29. On 4/15/25 at 9:32 AM, R29 was observed in their bed. They were asked if they had any concerns and agreed with R81 saying they did not get along. R29 was asked if facility staff were aware they didn't get along and they said staff were aware and they requested a room change about a month ago. They were asked if they filed a grievance and if the facility had followed up with them and they said they didn't know they could file a form and no one had followed up regarding their concerns. On 4/16/25 at 9:59 AM, grievances for R81 and R29 were requested, and it was reported by the Administrator neither resident had any grievances on file. 4/16/25 at 10:29 AM, a review of a progress note entered into R29's record by Social Worker 'K' on 4/3/25 was conducted and read, Note Text: Discussion held at bedside with guest regarding interpersonal interactions with roommate. Reviewed expectations for navigating shared spaces. Guest amenable to the discussion .All concerns addressed, no questions or issues at this time. SW will continue to follow and support as needed. On 4/16/25 at 10:35 AM, a review of a progress note entered into R81's record by Social Worker 'K' on 4/3/25 was conducted and read, Note Text: Discussion held with guest regarding interpersonal interactions with roommate. Reviewed expectations for navigating shared spaces and encouraged guest to request assistance from staff as needed. Guest amenable to the discussion. All concerns addressed, no questions or issues at this time. SW will continue to follow and support as needed. On 4/16/25 at 11:09 AM, an interview was conducted with Social Worker 'K' regarding R29 and R81. They were asked if they filled out a grievance form regarding them not getting along and requesting room changes and they said they did not. A review of a facility provided policy titled, RESIDENT CONCERN POLICY was conducted and read, Step 1. Tell your grievance(s) to one of the individuals listed below: Director of Nursing, Administrator, Social Service Director .Step 2. If you are not satisfied with the staff person's response please complete our Resident's Assistance Form/Grievance Form. Let us know if you need help in completing the form. Step 3. Submit the form to our Administrator or Director of Nursing. Step 4. If you are not satisfied with the center ' s written response, complete a request for the administrator to review the investigation findings .3. We will give you a written response as soon as possible but not later than 10 business days following completion of the investigation. 4. We will follow-up to ensure your grievance has been addressed satisfactorily and use findings of our investigation as part of our Quality Improvement Program .

Based on interview, and record review, the facility failed to ensure Minimum Data Set (MDS) Assessments were completed accurately for one (R2) of 20 reviewed. Findings include: According to the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual. Link to the LTCF RAI User's Manual: https://www.cms.gov/files/document/finalmds-30-rai-manual-v1191october2024.pdf: .an accurate assessment requires collecting information from multiple sources .Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician . Review of the clinical record revealed R2 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included: gastrostomy status, aphasia, altered mental status, other seizures, acute kidney failure, type 2 diabetes mellitus with hyperglycemia, moderate protein-calorie malnutrition, adult failure to thrive, myelopathy, unspecified dementia, and malignant neoplasm of thyroid gland. Review of R2's physician orders for nutritional/dietary needs included: Enteral Feed three times a day 240 mL (milliliters) bolus free water via PEG (Percutanous Endoscopic Gastronomy - the placement of a feeding tube through the skin and the stomach wall) TID (three times a day), total 720 mL daily. Enteral Feed in the morning Bolus 60 mL free water via PEG pre- and post EN (enteral nutrition) administration. Enteral Feed in the morning Glucerna 1.5 (1 can- 237 mL) bolus via PEG QD (once daily) to provide 356 kcal (kilocalories); 19.6 g (grams) protein; 180 mL free water. Regular diet, Pureed texture, Honey consistency; Cueing at meals, Double protein portions, DM (Diabetes Mellitus) modifications, spoon sips only, Supplement mighty shake BID (twice a day) and at activities as appropriate, or magic cup in place of ice cream at activities. Review of the Minimum Data Set (MDS) assessments identified the following inaccuracies: The MDS dated [DATE] documented section (K0520 B. Feeding Tube) was not marked (left blank) and only section C. Mechanically altered diet and D. Therapeutic diet were check marked. This section of the assessment was completed by Staff 'J'. The MDS assessment dated [DATE], also incorrectly coded section K0520 B. Feeding Tube (left blank). This was completed by MDS Nurse 'H'. On 4/16/25 at 11:55 AM, an interview was conducted with MDS Nurse 'H'. When asked about why R2 was documented as not having tube feeding on the MDS assessment from 3/7/25, when they were, MDS Nurse 'H' reported they weren't sure that person worked at the facility anymore. They were requested to have the MDS Coordinator (MDS Nurse 'I') come for an interview. When MDS Nurse 'H' was asked about their documentation on the MDS dated [DATE] that incorrectly marked no for tube feeding, MDS Nurse 'H' reported they were not able to offer any further explanation. On 4/16/25 a 12:23 PM, and interview was conducted with the Corporate Registered Dietician (RD 'S') and MDS Nurse 'I'. When asked about the MDS inaccuracies, RD 'S' reported Staff 'I' was a former MDS nurse that worked remotely to assist with completing assessments. When asked how that was missed if visual assessment and review of orders revealed tube feeding was in use at the time of both of these assessments, MDS Nurse 'I' reported the remote worker would use the information from assessments that were completed with facility staff and they were unable to offer any further explanation as to the inaccuracies, but would have to submit modifications.

Based on observation, interview and record review the facility failed to ensure consistent professional standards of practice were utilized by two nurses (Licensed Practical Nurse- LPN) LPN A and LPN B of four nurses reviewed for medication administration observation for one resident (R31). Findings include: On 4/16/25 at 8:41 AM, LPN A was observed preparing the morning medications for R31. LPN A completed their medications checks and instructed LPN B (a newly hired nurse in training) to obtain clonazepam from the controlled medication cabinet in the hallway. At 8:46 AM LPN B returned and gave LPN A the pill in a medication cup. LPN A added the pill to the rest of R31's morning medications. LPN A then gave LPN B the cup containing R31's morning medications to administer. LPN B administered the morning medications to R31. LPN A then signed off on the medications as administered. A review of a facility policy titled Medication Administration dated 9/1/23, documented in part . Right resident, right drug, right dose, right route, right reason, right documentation and right time, are applied for each medication being administered. A triple check of these Rights is recommended at three steps in the process of preparation of a medication . The person who prepares the dose for administration is the person who administers the dose .The individual who administers the medication dose records the administration on the resident's MAR/eMAR(medication administration record) directly after the medication is given . The resident's MAR/eMAR is initialed by the person administering the medication . LPN A prepared the medications and failed to administer the medications to R31. LPN B administered the medications and failed to complete the rights and checks prior to the medication administration and LPN A signed off for the medications they did not administer. On 4/16/25 at 9:33 AM, the Director of Nursing (DON) was informed of the medication observation with LPN A and LPN B and stated the nurse that pulled the medications should have administered the medications. The DON acknowledged LPN A and LPN B did not follow protocol. No further explanation or documentation was provided by the end of the survey.

This citation pertains to intake #MI00149107. Based on interview and record review the facility failed to involve a court appointed-legal guardian in the discharge process for one resident (R502) of three residents reviewed for discharge planning, resulting in R502 signing themselves out of the facility without the legal guardian's knowledge. Findings include: On 1/9/25 a complaint submitted to the State Agency was reviewed and alleged R502 had signed themselves out of the facility against medical advice (AMA) without the legal guardian being involved in the decision on 11/17/24. On 1/9/25 the medical record for R502 was reviewed and revealed the following: R502 was initially admitted to the facility on [DATE] and had diagnoses including Adult failure to thrive, Cognitive communication deficit and Heart failure. A patient demographics hospital document from R502's initial admission in June 2024 was reviewed and revealed R502 had a legal guardian. A letters of guardianship document signed by the [NAME] County probate court Judge on 9/30/24 indicated R502 had a court appointed legal guardian. A PASARR (Preadmission screening and resident review) dated 10/15/24 completed by the hospital Social Worker was reviewed and indicated R502 had a public guardian and had a history of major depression and psychosis A review of R502's facility census revealed they were discharged on [DATE] and was readmitted on [DATE]. A progress note dated 11/17/2024 at 15:05 revealed the following: Writer entered residence room resident was up in bed watching TV, Vitals were assessed , medication was administered. At 1504 Resident became very agitated saying that he wanted to go home, resident called his friend, friend came resident started to get dressed. Writer educated him on the importance of staying and also informed him that he was leaving AMA. Resident still decided to leave , he got in a red car with his friend. On call NP (Nurse Practitioner) notified along with on call manager . A progress note dated 11/19/24 revealed the following: guest admitted back to facility, .guest admitted with cell phone no charger and clothing. guest was offered lunch and snacks upon arrival. guest consumed meal with no concerns. guest is currently in bed with call light and fluids with in reach. A progress note dated 11/20/24 revealed the following: Spoke with guardian; guardian wanted to make sure resident is not to have any contact with [name of neighbor]-his neighbor; they are pressing charges against him; resident is allowed to speak with [name of brother], his brother, but [brother] can not make any decisions regarding resident ' s care. On 1/9/25 at approximately 10:56 a.m., during a conversation with R502's legal guardian D (LG D), LG D indicated that they were never contacted before R502 signed themselves out on 11/17/24. LG D reported that they were not involved in the discharge planning process until after R502 had been brought back to the facility and reported that it was dangerous that the facility let R502 leave without consulting them to ensure R502 was safe in the community and had an appropriate discharge plan. On 1/9/25 at approximately 1:56 p.m., during a conversation with the facility Administrator, the Administrator was asked why R502 was permitted to leave the facility without notifying the legal guardian and discussing the discharge plan with them. The Administrator indicated that there was little information in the record that identified R502 had a legal guardian and that after they were brought back, they reviewed the PASARR form which gave some information that R502 had a legal guardian. The Administrator indicated they completed a past non-compliance as a result of failing to contact R502's guardian before the discharge and had audited all the PASARR forms to ensure residents that had guardians had updated guardianship information and audits were ongoing. The Administrator indicated that the Social Worker at that time was educated on completing thorough reviews of PASARR forms upon admission and that the facility's compliance date to be back in compliance was 11/28/24.

This citation pertains to intake: MI00144138. Based on interviews and record review, facility failed to implement interventions and or provide adequate supervision to prevent injuries/falls for one (R901) of two Residents reviewed for falls, resulting in hospitalization for left hip fracture, preceded by emergency room visits, with subsequent decline in overall condition, pain (per the reasonable person concept) and death. Findings include: Review of the complaint received by the State Agency read in part, (relationship omitted) has had multiple falls, with the most previous breaking (gender omitted) hip. A review of R901's death certificate dated 3/6/24 read manner of death Accident; Describe how the injury occurred Fall; place of injury nursing home. R901 was admitted to the facility for skilled nursing care and rehabilitation after hospitalization . R901's admitting diagnoses included respiratory failure, heart failure, acute urinary tract infection, anxiety, and depression. R901 had dysphagia (difficulty with swallowing) and they were receiving their nutrition and hydration through a Percutaneous Endoscopic Gastrostomy (PEG) tube. Based on the Minimum Data Set (MDS) assessment dated [DATE], R901 had severe cognitive impairments. R901 was transferred to the hospital on 2/11/24 after a fall at the facility and they were admitted to the hospital with a hip fracture. A nursing progress note dated 2/11/24 at 8:12 read, New order in place to transfer resident to ER (emergency room ) for further evaluation due to SPO2 (oxygen level) desaturations, increased confusion, and restlessness. Transferred a resident to ER via 911 at 6:40. DON (Director of Nursing) notified. Further review of the nursing progress note dated 2/11/24 at 5:04 read in part, At approx 0030, 2/11/24, CNA (Certified Nursing Assistant) assigned to 500 hall alerted writer into the room. Writer noted resident in sitting position on the floor with back against the bed, legs extended to full length, CNA states that resident was lying in prone position when she entered the room at first, she assisted him in sitting position for comfort prior to alerting writer. Resident assessed for injuries; Discomfort observed with ROM (range of motion) assessment. Assisted back in bed with the help of CNA New orders for stat-x-ray and PRN (as needed) pain medication in place. PRN Ativan 0.5 mg given r/t (related to) restlessness. Review of R901's discharge summary from the hospital dated 1/30/24 (prior to admission to facility), revealed R901 was nonverbal and they were receiving intra-venous (IV) antibiotics for a urinary tract infection and they had altered mentation. The History & Physical note by the attending physician at the facility dated 1/31/24 revealed an assessment section that included R901 had gait instability and ataxia (unsteady walking) and they were under fall precautions. Further review of R901's Electronic Medical Record (EMR) revealed a Speech Language Pathology (SLP) evaluation dated 1/31/24. Cognitive-communicative skills section of SLP evaluation read in part: Ability to understand others = rarely/never understands; follows 1-step direction= usually, with prompts/cues; ability to express ideas/wants=rarely/never understood clearly indicating that the R901 had poor insight about their current physical and medical condition with severely impaired safety awareness primarily due to their cognitive impairments that was exacerbated by their communication deficits. SLP evaluation assessment summary section read, Barriers likely to impact discharge to next level = Exacerbation of cognitive impairment; Patient characteristics that may impact treatment = lacks insight into condition and risk factors. Review of R901's admission fall risk assessment dated [DATE] revealed a score of 13, indicative of moderate risk for falls. A care transition/social services progress note dated 1/31/24 also revealed that R901 was alert and oriented x1, indicting severe cognitive impairment and they were non-verbal. A review of R901's fall care plan initiated on admission, dated 1/30/24, revealed the following interventions: Administer medications, encourage and assist to bed after therapy, evaluate lab tests, evaluate x-rays, neuro checks per protocol, reinforce need to call for assistance. R901's care plan did not have any safety interventions based on their cognitive impairments, communication deficits and their overall functional impairments/health condition during the admission to the facility. A nursing progress note dated 2/1/24 at 07:18 read, Resident AxOx0, unable to express concerns. PICC (Peripherally Inserted Central Catheter) was placed around 19:00. Patient was combative and pulling at PEG tube and trying to get out of bed. PEG tube was secured. Safety measures, patient bed was lowered to ground and call light within reach. Review of Kardex (electronic patient care information sheet) for Certified Nursing Assistants (CNA) had the following interventions under safety section: Encourage and assist resident into bed after therapy and Reinforce need to call for assistance. There were no other resident specific safety interventions that were in place for R901 from admission to discharge. A nursing progress note dated 2/1/24 at 15:30 read, Writer was notified of patient noted on the floor.patient was assisted to bed .patient unable to state why he was on the floor. A change of condition progress note dated 2/1/24 at 10:40 revealed that R901 had a fall (approximately 3 hours) after the initial observation of R901's combative behavior/restlessness. Further review of the note revealed a section that read nursing observation, evaluation, and recommendation and the section was blank. The section that read Primary care Provider Feedback was blank. Review of R901's incident/accident report received via e-mail from the facility administrator revealed the following information: R901 had an unwitnessed fall on 2/1/24 and predisposing physiological factors were confusion and unsteady gait. The note read patient unable to state why he was on the floor. It must be noted that R901 was non-verbal and had severe cognitive deficits. Further review of the incident and accident report did not reveal a thorough follow-up and root cause analysis of the fall with an appropriate/resident specific post fall intervention to prevent any further falls/injuries on R901's care plan. A nursing progress on 2/2/24 at 7:09 read in part, unable to express concerns or communicate needs Resident continues making effort to dislodge PEG tube and attempts to get out of bed. CNA assigned to Resident found him in the bathroom at approx 03:25. No evidence of fall . There was no evidence of any interventions based on EMR and timeline of interventions document provided by the facility despite resident making attempts for unassisted and unsafe transfers. A nursing progress note on 2/2/24 at 10:07 (approximately 3 hours later) revealed R901 had a fall. The note read Writer notified by staff that resident was on the floor. Writer went to the room and noticed the patient was on the floor on the side of his bed sitting on his bottom. Patient had a skin tear on each arm that was bleeding and a small gash in the back of his head. Patient is nonverbal and unable to express if he was in any pain. Patient went to hospital at 9:20 for further evaluation . R901 returned from the emergency roiagnom on [DATE]. Review of R901's fall risk assessment dated ,d+[DATE] at 17:14 revealed a score of 20, (increase by 7 points from the previous score), indicative of high risk for falls. There was no change in R901's care plan despite the increase in risk with a recent fall and injury. There were no nursing progress notes for 2/2/24 and 2/3/24 after R901 had returned from the emergency room . A progress note dated 2/4/24 at 18:35 revealed that R901 was attempting to ambulate unassisted and had a fall. The note read Skin laceration and bleeding noted on left forearm. Resident appeared to be alert after hitting his head .NP (name omitted) ordered writer to send resident for further evaluation for PICC line insertion due resident current medical status. The night nurse informed the writer that PICC line was pulled out by the resident earlier this morning . A change in condition note dated 2/4/24 at 18:15 revealed that R901 had fall and altered level of consciousness. Nursing observation, evaluation and recommendations read Resident has chronic confusion with poor safety awareness. R901 was sent to ER for further evaluation. R901 returned from the ER the same day. Discharge summary from the ER read, you have a head injury. It does not appear serious this time. But, symptoms of more serious problem, such as a mild brain injury (concussion) or bruising or bleeding in the brain may appear later. For this reason, you or someone caring for you will need to watch for the symptoms listed . An investigative summary note dated 2/5/24 at 10:10 read, Root cause analysis was completed and identified that guest incident occurred despite a fall plan in place and followed. Contributing safety factors for this guest for this guest included: anxiety, depression, malnutrition .The root cause of this event was guest attempting to self-transfer. Conclusion: Follow-up assessments support that guest did not experience any functional decline in his conditions. Safety measures are in place per plan of care .There were no lasting effects from the incidents and resolved without complications. No changes in neuro status. It must be noted that R901 had multiple staff observations of attempts for unassisted transfers/ambulation with 3 falls. Review of R901's fall care plan revealed a note under the focus regarding the fall incident on 2/4/24. There were no additional fall preventions/supervision measures implemented despite 3 falls since admission and 2 ER visits, in less than 72 hours. The fall prevention intervention under fall care plan that was added after admission was transfers/ambulates with 2-person assist with assistive device on 1/31/24. A progress note dated 2/6/24 at 3:46 read, During start of shift patient was agitated. Patient was pulling at his PEG tube, trying to get out of bed. Patient's son was called and advised to come and sit with son due to his behaviors and was told no 'That is our f .g job' .Patient would benefit with one-on-one care. A progress note dated 2/7/24 at 00:13 read in part, Resident received on shift fully naked standing without assistance .Resident constantly up without assistance and reminded to use walker . Resident appears to be confused . There was no evidence that R901 received the supervision/additional interventions they needed after multiple falls. R901 was in their room during all the fall events based on the medical records. Nursing progress notes revealed that R901 was agitated on 2/8/24 and 2/9/24. R901 was transferred out to the hospital on 2/8/24 for a dislodged PEG tube and PICC line. The nursing progress note read Resident very agitated tonight. He was constantly trying to get out of bed . R901 was seen by the practitioner on 2/9/24 due to anxiety, restlessness and agitation and they were ordered to have Ativan (a narcotic anti-anxiety) medication as needed. On 2/11/24, R901 sustained another unwitnessed incident in the room when they were observed in the prone position by the CNA. R901 was transferred to hospital and admitted with a hip fracture. An e-mail request was sent to the facility administrator to provide the fall prevention/supervision intervention that were provided for R901. The document received had the following details: Fall: 2/1/2024 - 10:40am - unwitnessed fall in room - no injury noted - offer and assist with transfer back to bed after therapy. Fall: 2/2/2024 - 17:07 - unwitnessed fall in room - abrasion and 2 skin tears - sent to ED for further evaluation. Fall: 2/4/2024 - 11:40 - witnessed fall in room - laceration - sent to ED for further evaluation Fall: 2/11/2024 - :30 - unwitnessed fall in room - left hip pain - sent to ED for further evaluation. During an interview with the complainant on 4/29/24 at approximately 4:50 PM, they reported that R901 had multiple falls during the stay at the facility. The complainant reported that R901 did not have the staff supervision they needed during their stay and they had expressed their concerns, and that after the last fall R901, was admitted to hospital. R901 had a hip fracture and they had hip surgery. The complainant added that R901 went home with family. Their condition had worsened and they had passed away on 3/6/24. An interview was completed with staff member A on 4/30/24 at approximately 9:45 AM. Staff member A was queried how they had received information on the resident care and staff member Areported that they had received information from their electronic medical record (EMR). An interview was completed with the DON on 4/30/24 at approximately 3:55 PM. During the interview the DON was queried what was facility protocol if a resident were a high fall risk. The DON reported that they would order fall prevention interventions like: make sure that wheelchair brakes were locked, low bed, fall mat etc. The DON was queried specifically on R901's fall prevention interventions who had severe cognitive impairment and a communication deficit. The DON reported that R901 was weak when they were admitted . When queried about the multiple falls and ER visits why R901 and the intervention/supervision the facility had in place after every incident, the Administrater and DON provided a copy of the care plan that was in the EMR under mood and activity sections for leisure activities, family support etc. No further information was provided prior to the exit of the survey. A facility provided document titled Falls and Fall Risk, managing with a revision date of December 2007 read in part, Based on previous evaluations and current data the staff will identify interventions related to residents' specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Prioritizing approaches to managing falls and fall risk: 1. Staff with the input of the attending physician will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident form risk identifies several possible interventions the staff may choose to prioritize interventions. (i.e. to try one or a few at a time rather than many at once). 2. Examples of initial approaches might include exercise and balance training or a rearrangement of room furniture. If a medication is suspected as a possible cause of a residence falling the initial intervention might be to taper or stop that medication. 3. In conjunction with the consultant pharmacist and nursing staff the attending physician will identify and adjust medications that may be associated with an increased risk of falling or indicate why those medications could not be tapered or stopped even for a trial period. 4. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. 5. If underlying causes cannot be readily identified or corrected staff will try various interventions. Based on the assessment and of the nature or category of falling until falling is reduced or stopped or until the reason for the continuation of the falling is identified as unavoidable .

Based on observation, interview, and record review, the facility failed to ensure appropriate infection control practices during medication administration observation for three residents (R284, R59, R20) of four resulting in the increased likelihood for the spread of infection. Findings include: On 3/19/24 at 8:22 AM, medication administration was conducted with Licensed Practical Nurse (LPN) N for R284. Medications were identified to be administered without observing hand hygiene. LPN N confirmed when asked if hand hygiene was performed and acknowledged it was not. As this surveyor exited the room, LPN N removed the blood pressure equipment from the room that was used on R284 and left it in the hallway. It was observed that no sanitation of the equipment was provided. LPN N was asked if there was a process of handling the equipment in between residents. After this surveyor questioned if it was cleaned, LPN N stated Oh yes, it should be cleaned, let me go get the stuff to wipe it down. On 3/19/24 at 8:47 AM, medication administration was conducted with LPN O for R59. As medication was being retrieved from the cabinet, LPN O began instruction of identifying the medications and was observed to prepare to open the medication. This surveyor interjected and questioned if hand hygiene was performed. LPN stated it was not. On 3/19/24 at 8:55 AM, LPN O was observed for another medication observation for R20. As medication was being retrieved from the cabinet, LPN O began instruction of identifying the medications and was observed as preparing to open them. This surveyor interjected and questioned if hand hygiene was performed. LPN O stated it was not. On 3/19/24 at 10:55 AM, this surveyor identified the rolling desks on units 200, 400, 600 used by nursing for medication preparation and administration, having strips of tape adhered on the sides of the desks, black colored tape residue on the back of the desks, and an overall unsanitary appearance was observed. It was observed the tops of these desks were not sanitized in between resident medication administration. On 3/19/24 at 12:45 PM, the Director of Nursing (DON) was informed concerns of hand hygiene during medication administration and the sanitation of medical equipment and equipment used for medication preparation and administration. The DON agreed hand hygiene should have been performed without this surveyor prompting and was provided the location of the units where the desks were identified as looking unsanitary. Review of the facilities Hand Washing and Hand Hygiene Policy (Policy # NRS-182D, revised 4/29/2020) .Hand hygiene for each facility will follow the CDC definition of cleaning your hands by using handwashing with soap and water or alcohol-based hand sanitizer, essential in reducing the risk of transmission of infection . Review of the facilities Medication Administration General Guidelines (01/21) states .Hands are washed with soap and water before administration, hands are washed with soap and water again after administration and with any resident contact . Review of the facilities Cleaning and Disinfection of Resident-Care Items and Equipment #3 .Resident-care equipment, will be cleaned and disinfected before reuse by another resident .

This citation pertains to intake #MI00135770. Based on observation, interview and record review the facility failed to ensure appropriate supervision was provided for two residents (R901 and R902) of two residents reviewed for elopement resulting in R901 and R902 having unauthorized exits from the building and R902 sustaining injuries that required an acute transfer to the hospital. Findings include: Review of multiple complaints reported to the State Agency included allegations that R902 got out of the facility unsupervised, fell and received a head injury and R901 got out of the building at night while unsupervised. Resident #902 On 5/16/23 the medical record was reviewed and revealed the following: R902 was initially admitted to the facility on [DATE] and had diagnoses including Anxiety and Altered Mental status. A review of R902's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/10/23 revealed R902 needed extensive assistance from staff with most of their activities of daily living. R902 needed supervision from staff with walking. R902's BIMS score (brief interview for mental status) was 12 indicating moderately impaired cognition. A Physician's order dated 2/12/23 revealed the following: Wanderguard check every shift for placement, function, and expiration date two times a day A review of R902's careplan revealed the following: Focus-Resident at risk for wandering or elopement r/t (related to) altered mental state, exit seeking behavior-Date Initiated: 02/12/2023 . An incident note dated 3/11/23 revealed the following: Writer was informed by another staff member that resident was observed in the staff parking lot sitting on the curb. When writer approached resident and staff, writer observed blood on the ground and a large, raised area located on the left side of her eye, head and blood on face and ground. Writer and other staff assisted with getting resident up into chair and returning resident inside the facility. When writer returned resident into room writer preformed a complete skin assessment and then observed an abrasion on resident Left knee. Resident pupils were equal and reactive to light however resident began to c/o (complain of) of being able to hold eye open and writer trying to assist. Resident is A&O x 1 (alert to person only) and speech became slow to response to question asked by writer. Resident was able to move all extremities although resident had c/o pain with movement. Writer attempted to ask resident what occurred, and resident was unable to informed writer of what occurred R/T (related to) orientation. Writer contacted on call [Nurse Practitioner] and an order was given to transfer to hospital. Resident BP (blood pressure) 155/95 P (pulse) 88 SPO2 (oxygen saturation rate) 96% RA (room air), resp. (respirations)18, Temp (temperature) 97.1 forehead non-contact. The last time writer observed resident was 6:15pm in the north DR (dining room) sitting her chair eating dinner. An incident report dated 3/11/23 revealed the following: Incident Description Date:3/11/202318:52 (6:52 PM.) Resident Location: 600 Corridor .Nursing Description: Approximately 6:52 PM. Writer was informed by another staff member that resident was observed in the staff parking lot sitting on the curb. When writer approached resident and staff writer observed blood on the ground and a large, raised area located on the left side of her eye, head and blood on face and ground. The last time writer observed resident was 6:15pm in the north DR sitting her chair eating dinner .Resident Description: Resident Unable to give Description .Immediate Action Taken Description: Writer and other staff assisted with getting resident up into chair and returning resident inside the facility. When writer returned resident into room writer preformed a complete skin assessment and then observed an abrasion on resident Left knee. Resident pupils were equal and reactive to light however resident began to c/o of being able to hold eye open and writer trying to assist. Resident is A&O x 1 and speech became slow to response to question asked by writer. Resident was able to move all extremities although resident had c/o pain with movement. Writer attempted to ask resident what occurred, and resident was unable to informed <sic> writer of what occurred R/T (related to) orientation. Writer contacted on call [Nurse Practitioner]and an order was given to transfer to hospital .Resident Taken to Hospital? Y .injuries Observed at Time of Incident .Injury Type: Unable to determine .Injury Location 38) Left knee (front) Injury Type: Unable to determine . Injury Location 4) Face . A Physician progress note dated 3/13/23 revealed the following: Reason for visit: - Request by patient/family/nurse regarding agitation. S (systems): Patient seen and examined. Sitting comfortably in chair. Pt (patient) with fall over the weekend and went to ER (emergency room ) and returned back to facility. Pt is calm and cooperative during exam. In no acute distress. + generalized weakness. Denies constipation or diarrhea. Pt is pleasantly confused,forgetful, a poor historian .ROS (range of systems) 6 systems reviewed/2pt each negative- unable to obtain from patient due to dementia Physical Exam BP 146/76 P 74 R 17 T 98.3 O2 99% . non-toxic,chronically ill appearing, appears weak Skin: No gross rashes. Left periorbial ecchymosis and abrasion left side of face/cheek . On 5/16/23 at approximately 10:04 a.m., Nurse U was queried regarding R902's elopement from the facility on 3/11/23. Nurse U reported they were made aware of the elopement by Certified Nursing Assistant K (CNA K) and that when they went outside they observed R902 sitting on the curb of the back staff parking lot with blood on their forehead and knees and blood on the cement. Nurse U was queried if they were aware that R902 had been outside and had fallen and they reported they had not been aware until CNA K had informed them of it. Nurse U indicated that R902 was with Nurse V when they went outside to get them. Nurse U reported they assisted R902 back into the building, assessed them and notified the Nurse Practitioner of the injuries who ordered R902 to be sent out to the hospital because they had an unwitnessed fall outside. Nurse U was queried if R902 had presented with wandering behaviors and they indicated that they did and that R902 needed supervision from staff. Nurse U was queried how R902 made it outside without anyone knowing and reported that they were watching them the best they could that day but that they have more than one resident they were responsible for. Nurse U reported they had last seen R902 about 6:15 p.m., eating dinner in the dining room. Nurse U was queried if R902 should have been outside without supervision and they reported they should not have been outside and nobody had heard the alarms from the emergency exit door. On 5/16/23 at approximately 10:46 am., Maintenance Director E (MD E) was queried regarding the checking of alarms on the emergency exit door that R902 went out of. MD E Stated that there had been a few elopements out of the specific door and that the alarms were functioning but indicated that their administrator at the time had instructed them to increase the pitch of the alarm. On 5/16/23 at an undocumented time, Nurse V was queried regarding R902's elopement from the building on 3/11/23. Nurse V reported they were walking to their car for a break and had seen R902 already sitting alone on the curb with blood on their knees and forehead and No other staff members present. Nurse V reported that as they were trying to talk to R902 who was confused and Nurse U came outside a few minutes later to take her into the building. On 5/16/23 at approximately 1:26 p.m., during a conversation with the Director of Nursing (DON), the DON was queired regarding elopement of R902. The DON indicated they were in training at that time, but had reviewed the incident. The DON reported that the alarm for the emergency door was working but the facility had inserviced the Nursing staff on being more vigilant with residents who had wandering behaviors which included not being in the office and being present in the hallways with their computers. On 5/16/23 at approximately 2:36 p.m., CNA K was queried how they became aware that R902 had eloped from the facility and they reported that they had looked out the window and saw Nurse V talking with R902 who was observed sitting on the curb in the back parking lot. CNA K indicated that it appeared Nurse V looked like they needed help with R902 so they went to R902's Nurse (Nurse U) and informed them that R902 was outside. 30675 R901 The Administrator at the time of the survey had been in their position since 5/8/23. The [NAME] President of Operations (Staff 'M') was in the role of interim Administrator from 2/24/23 to 5/7/23. The Director of Nursing (DON) was in their role since 3/22/23. The Corporate Clinical Staff (Nurse 'A') had been in the DON role from 2/25/23 to 3/21/23. It should be noted that the facility reported Nurse 'A' was unavailable for an interview due to travel. The facility was informed that any interviews would need to be conducted by the end of the survey. Review of the clinical record revealed R901 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Parkinson's disease, unspecified dementia, unspecified severity, with other behavioral disturbance (onset date 1/22/2021), wandering in diseases classified elsewhere (onset date 4/12/23), anxiety disorder, depression, insomnia, and cognitive communication deficit (onset date 1/22/21). According to the MDS assessment dated [DATE], R901 had no communication concerns, and scored 12/15 on BIMS (Brief Interview for Mental Status exam) which indicated moderately impaired cognition. On 5/16/23 at 10:39 AM, R901 was observed seated in the common area talking to two staff members. A wanderguard device was secured to their left ankle. At 3:25 PM, Nursing staff reported the resident was picked up by his wife around 11:00 AM and would not return until after dinner. Review of the resident's elopement risk assessments included three since their initial admission which included: On 1/22/21, Low risk for wandering (score 4.0). On 3/8/23, Low risk for wandering (score 4.0). (The portion of this assessment that asked if the resident was a Known wanderer/hx (history) of wandering was left blank, despite an elopement on 3/7/23.) On 4/12/23, Moderate Risk for Wandering (score 7.0). Review of the care plans included: A care plan for Resident at risk for wandering or elopement r/t (related to) altered mental state due to dementia. was initiated on 4/12/23, revised last on 4/27/23 and included the following interventions: Allow for safe wandering within the facility. Check Wanderguard bracelet for placement q (every) shift. Encourage family/caregiver participation and support. Initiate Wander Alert System. Reassure if resident feels lost, abandoned or disoriented. Remind resident that they are in the right place. Remove objects that are reminder of leaving. Another care plan for, At risk for behavior symptoms r/t dementia, Anxiety, Parkinson's Disease, Cerebral Infarction, Cognitive Communication deficit, Depression, Insomnia. Behavior of sitting himself on floor, sleeping on floor. States if he has enough falls, his wife will take him home. History of urinating in cups and in inappropriate places (attempting to urinate in areas other than bathroom ie. dining room., was initiated on 8/23/2022, reviewed last on 4/12/23. There were no interventions that identified any wandering/exit seeking behaviors. Neither of these care plans had been reviewed/revised following an elopement incident on 3/7/23 and behaviors of wanting to leave on 3/19/23, until 4/12/23. Review of the progress notes included: An entry on 3/7/23 at 11:44 AM with a Created Date: 3/8/2023 05:45:08 by Nurse 'G' read, Incident occurrence: resident was found outside of 500 hall emergency exit doors by CNA (Certified Nursing Assistant). Banging on the doors to get in. elopement precautions initiated, with frequent rounds performed by staff to ensure residents safety. Supervisor notified via CNA and requested written statements from nursing staff. resident is alert and orient x3 and he has full ROM (Range of Motion) of limbs, no injuries or complaints. monitoring continues .supervisor (Staff 'O') text per CNA. written statements from Nurse writer and attending CNA. and submitted under supervisor door. A second entry on 3/7/23 at 11:40 AM with a Created Date: 3/8/2023 05:45:28 by Nurse 'G' read, Incident occurrence: resident was found outside of 500 hall emergency exit doors by CNA. Banging on the doors to get in. elopement precautions initiated, with frequent rounds performed by staff to ensure residents safety. Supervisor notified via CNA and requested written statements from nursing staff. resident is alert and orient x3 and he has full ROM of limbs, no injuries or complaints. monitoring continues. wife .called and notified, and Np (Nurse Practitioner)/Dr on call. and supervisor (Staff 'O') text per CNA. written statements from Nurse writer and attending CNA. An entry on 3/8/23 at 6:09 AM by Nurse 'G' read, please evaluate for wandergard <sic> for safety, (name of Physician 'Q') made aware of request. An entry on 3/13/23 at 2:05 PM by Nurse 'R' read, wife in to visit today and is reporting confusion, stated that pt (patient) called her in the middle of the night last night wanting his brothers phone numbers, but they have been dead for over [AGE] years, writer notified her that pt is having labs drawn tomorrow, and when psych services come in he is on the list to be seen. An entry on 3/18/23 at 11:11 AM by Nurse 'R' read, pt is alert with confusion noted, pt is aggressive and screaming at staff trying to redirect pt, writer attempted to call wife .but her phone is disconnected, staff was able to redirect pt to his room where he has calmed down some, safety maintained and call light in reach. An entry on 3/19/23 at 4:01 PM by Nurse 'R' read, pt alert with confusion noted, behaviors noted today were just talking about wanting to leave, but did not actively head towards the exit, his wife .came in to visit today, incontinent, pt needs reminders to keep a pull up on, safety maintained and call light in reach. An entry on 4/12/23 at 1:16 PM by Nurse 'J' read, Guest has baseline intermittent confusion. Trying or wanting to 'go home'. Restless, pacing or making repetitive movements and moving with wheelchair aimlessly at times. Placed guest on wanderguard. NP (Nurse Practitioner and family member notified. An entry on 4/29/23 at 9:15 PM by Nurse 'T' read, CNA on 800 hall heard door alarm sounding. She immediately walked to door and observed resident exiting the door in his wheelchair. CNA alerted staff nurse while she stayed with resident while trying to reason with resident to go back in the building. Writer then came outside where resident was trying to persuade CNA to help him to a car in the parking lot where he thought someone was waiting on him. Resident agreed to go back into the building .10 minute checks were put in place per DON. Snacks and drinks were provided while resident was in room. Resident fell asleep shortly after he ate his snacks. An entry on 4/29/23 at 9:29 PM by Nurse 'C' read, Resident exhibiting signs of increased anxiety, staff tried to calm resident with redirection and were unsuccessful, resident attempted to leave the building. Call made to on call provider, one time order for 0.5 Ativan given. A Late Entry on 5/3/23 at 9:03 PM for 4/29/23 at 9:01 PM by Nurse Practitioner (NP 'S') read, Writer notified of patient's increased agitation and elopement attempt. Order given for one time ativan 0.5 mg (milligram) dose. Patient with occasional anxiety with agitation related to wanting to return home. Benefit of medications outweighs risk. Wanderguard in place for safety. Continue to monitor behaviors and need for medications adjustment. Review of the physician orders, and administration records included an order started on 4/12/23 and was scheduled to be completed daily at 7:30 AM and 7:00 PM which read, Wanderguard check every shift for placement, function, and expiration date. Placed on LLE (Left Lower Extremity) - Exp (Expires): January 2026. Two times a day related to WANDERING IN DISEASES CLASSIFIED ELSEWHERE. On 5/16/23 at 10:33 AM, an interview was conducted with Receptionist (Staff 'F'). When asked if there was any documentation such as a binder or anything of who the facility's identified residents at risk for elopement were, Staff 'F' reported they didn't have anything written like a list or anything but they knew who the residents were and deferred to speak with the Director of Nursing (DON). On 5/16/23 at 10:45 AM, an interview was conducted with Nurse 'H' who was assigned to R901. When asked about where they would document R901's behaviors, such as in a progress notes or log, Nurse 'H' reported they were normally able to calm him down and so they didn't document that. They did report they were aware of an incident last week where he became aggressive but hasn't done that with them. When asked if family visited, they reported the wife visits daily and is usually what triggers his exit seeking behaviors. When asked about the facility's process for monitoring residents that were elopement/wandering risk, such as checking to make sure the wanderguard bracelet was functioning, Nurse 'H' reported, We just make sure it's on his leg. Nobody told me about anything like that. His works because it set off the alarm last week. On 5/16/23 at 11:40 AM, a phone interview was conducted with Nurse 'J'. When asked about R901's exit seeking behaviors, their note on 4/12/23, and the reason for placing the wanderguard bracelet, they reported it was for a precautionary reason and there were times when he'd push on the door and say he wanted to go home. Nurse 'J' further reported, He's pleasantly confused and at times unpredictable. Just put safety measures. When asked what they did to check the functioning of the wanderguard bracelet, Nurse 'J' reported We need to check expiration date and if it's attached. We will push near door if have time. When asked if the door alarm sounds, Nurse 'J' stated, It will sound, especially in front door and will lock .Wife visits for about an hour and when she leaves, he asks Where's my wife. On 5/1/23 at 11:58 AM, an interview was conducted with Nurse 'G'. When asked to recall the elopement incident from 3/7/23, Nurse 'G' reported they had been passing medications on the 600 hall when Staff 'K' reported they found (R901) outside. They immediately went over to the 500 hall and reported it was a little distance but didn't hear the door alarming or anything. Staff 'G' reported Staff 'K' told them they already got the resident back in their room. Staff 'G' reported when they asked Staff 'K' how they found the resident, Staff 'K' reported to them that they didn't find the resident, the resident was outside and banging on the door by the time they got up to check on the noise. Staff 'G' also reported that Staff 'K' had seen R901 outside and banging on the door to get back in when they responded to a call light in a room which was right next to the exit door and that the resident had put on their call light due to concerns about the banging noise. Staff 'G' reported when they went down the hallway to the resident at the end, they asked the resident (that had their call light on next to the exit door) if they heard or saw R901 walk by and they reported they didn't hear or see anything. Staff 'G' further reported concern that it was in the middle of the night and it was very scary for them as it was cold outside that day too. (According to the website www.timeanddate.com, the weather at the time and location where R901 was found on 3/7/23 between 6:00 PM - 12:00 AM was clear and 36/34 degrees F (Fahrenheit). Staff 'G' further reported approximately two days later, another resident got out the same door. Staff 'G' reported R901 had no injuries and wasn't likely out there long cause they weren't cold and their body temp didn't dip, but the resident had dementia and thankfully knew enough to bang on the door to get back in. When asked to recall the staff that found R901, Staff 'G' reported that was Staff 'K. When asked who would place the wanderguard bracelet if it was determined a resident needed one, or if they had done that for R901 and they reported, they were not sure but thought that might be maintenance. Nurse 'G' reported they Tiger texted the physician their information about wanting the wanderguard and that's how the ball gets rolling. Nurse 'G' further reported when they came in the next night, they were concerned and looked for a wanderguard but didn't see one, so they told R901 they didn't want any issue with the door tonight. Nurse 'G' also reported they made the resident raise their leg to confirm if the bracelet was there or not and there wasn't one on. Nurse 'G' then reported they only worked a few times a week and later on they noticed he had one on, but wasn't sure how long after that. When asked about the order to verify function of the wanderguard and to explain how that was done and who was responsible for the 7:00 PM checks, Nurse 'G' stated they weren't sure if the days shift did that, or if they should but reported, Probably should be night shift, but I don't always do that. When asked how it would be checked, they reported, they didn't know and haven't seen any device to check it like they used at other facilities. Nurse 'G' further reported that although they didn't check it, it was on him when last looked and they had been assigned to the resident last night, they knew to keep a closer eye on R901. On 5/16/23 at 12:17 PM, an interview was conducted with the Maintenance Director (Staff 'E') and Administrator. When asked about what they could explain as far as the door alarms not sounding, or were too low, Staff 'E' reported they had gone to check around the time of R901's elopement on 3/7/23 and it was working. They further reported they did turn the pitch up the next day as the panel defaulted to a default pitch, but they didn't have any documentation of that, only that the doors were checked for functioning. When asked if a resident had a wanderguard bracelet, how would the door alarm if the resident got close (and Staff 'E' reported the doors are always locked but able to be opened within 15 seconds), if the resident were to walk by the door, it would lock down and the alarm sound was different than the 15 second delay egress sound. When asked if they recalled staff reporting they couldn't hear the alarm, Staff 'E' reported they did and that's when we (Former Non-Licensed Administrator Staff 'L') proceeded to change the pitch. When asked how the nurses would check the wanderguard device to ensure they were functioning, as indicated in the physician orders, Staff 'E' reported they would bring the resident up to the door to check it, there wasn't a device that checks while secured on the resident. On 5/16/23 at 1:43 PM, the DON was asked who was responsible for placing the wanderguard device on a resident that was identified as elopement risk, and reported that would be the nurses and those were available in the medication rooms. When asked how the nurses would check the function of the wanderguard devices, the DON reported there was a controller device. At that time, observation of the two facility medication rooms revealed there were no wanderguard devices available. The DON reported they did have one in their office and showed they had one device available. The DON was informed of the concern with the conflicting documentation of the events surrounding R901's first elopement on 3/7/23, the lack of nurses actually verifying the device was functioning, the inaccurate elopement risk assessment on 3/8/23, and the lack of review of any care plans/interventions until 4/12/23. They offered no further explanation or clarification and indicated they would have to re-educate their staff. On 5/16/23 at 2:31 PM, attempted to contact Staff 'L' and a message was left to return the call. On at 5/16/23 at 2:45 PM, Staff 'L' returned the call and reported they had spoken to Staff 'M' who informed them that the State might be calling. Staff 'L' reported their last day working at the facility was 5/1/23. When asked to recall the elopement incident from 3/7/23, Staff 'L' reported they were going off memory but they recalled R901 walked out and stopped into roommate's room. They further reported R901 told another resident they were going to the the movies and exited the door. Staff 'L' reported one of their staff watched R901 walk out the door and he turned right back around and started knocking on the door. Staff 'L' was informed that the concern was that the staff interviewed that were present at the time of the elopement incident both recalled the exact same account of incidents which did not match what they were saying. Staff 'L' reported they were not able to offer any further explanation about that. Staff 'L' did report that the door alarm was very quiet, so they had maintenance raise the level of the alarm on that door. When asked if that was after R901's, or R902's elopement, the reported they weren't sure. When asked about whether the facility had discussed implementation of a wanderguard device following the elopement incident on 3/7/23, Staff 'L' reported they had and realized R901's BIMS score was too high to do that and there was a cut-off where that was appropriate or not. Staff 'L' was informed that the documented BIMS prior to and just after the elopement incident on 3/7/23 both indicated the resident had moderately impaired cognition and multiple documentation that reflected increased confusion and agitated behaviors. Staff 'L' offered no further explanation. Review of the facility's documentation provided for wandering/exit-seeking included an undated policy that referenced former federal regulations. The document read, .The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) .The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering .The resident's care plan will indicate the resident is at risk for elopement or other safety issues .Interventions to try to maintain safety will be included in the resident's care plan .Nursing staff will document circumstances related to unsafe actions, including wandering, by a resident .Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have high risk of elopement or other unsafe behavior .Staff will notify the Administrator and Director of Nursing immediately, and will institute appropriate measures (including searching) for any resident who his discovered to be missing from the unit or facility.

This citation pertains to Intake Number(s): MI00130570, MI00130946, MI00128064, MI00133318. Based on observation, interview, and record review, the facility failed to ensure there was sufficient nursing staff to care for all 84 residents in the facility. This resulted in extended call light response times, delay in incontinence care for R188, and delay in medication administration for R190 and R189 who was tearful due to pain and expressed feeling like they were going to have a panic attack when they did not receive their morning medications until several hours after they were due to be given. Findings include: On 2/12/23 at 8:54 AM, an observation of the call light monitor located on the unit revealed several call lights were activated, including R188's since 7:56 AM (58 minutes earlier) and another resident on the 100 hallway since 8:19 AM (35 minutes earlier). On 2/12/23 at 9:00 AM, R188 was observed in their room with a visitor. When queried about the care in the facility, R188's family member reported there was not enough staff at the facility. They explained they arrived approximately 45 minutes prior and had to change R188's brief and bed linens. R188's family member reported that occurred often and there were not enough certified nursing assistants (CNAs) to care for the residents. When asked when the call light was activated, R188's family member stated, It doesn't even matter because they don't come anyway. I already changed her. According to the call light monitor, R188's call light was activated at 7:56 AM, 58 minutes earlier. On 2/12/23 at approximately 8:56 a.m. Nurse N was queried regarding the staffing level at that time. Nurse N reported their was only one Certified Nursing Assistant (CNA) for the 100, 200, and 300 hallways. Nurse N reported they were trying to assist the CNA with passing trays for breakfast and would not be able to pass their medications on time and were unable to assist in getting residents out of bed and up in their wheelchairs. Nurse N reported that lots of call lights were going off and were late to being answered because of the lack of CNA's present on the unit. Nurse N reported there were three to four CNAs typically assigned to the unit on a day shift and there was only one currently working since the start of the shift. On 2/12/23 at approximately 9:02 a.m. CNA S was queried regarding the staffing level in the facility. CNA S reported they were the only CNA for three of the halls and that they had not been able to answer any call lights (resident request for assistance) because they were the only CNA and had been busy passing breakfast trays. CNA S reported they had been the only CNA on the unit since 7:00 AM and that other aides calling off of work had been a problem. CNA S was queried if they had sufficient staff to meet the resident needs at that time and they reported they did not. On 2/12/23 at approximately 9:08 a.m., Nurse T was queried regarding the staffing level in the facility. Nurse T reported there was only one CNA (CNA S) for three hallways and that was not enough to meet resident needs. Nurse T was queried how only one CNA affected resident care and they reported that call lights were late and that residents could not get up for the day because CNA S had been passing breakfast trays. On 2/12/23 at 10:36 AM, R189 was observed lying on their bed. When asked about the care they received in the facility, R189 reported there was not enough staff. R189 explained they experienced call light response times as long as two and half hours. R189 became tearful and reported they put their call light on a half hour prior because they had not received their morning medications. While tearful, R189 stated, They just forget about you. There's only me and one other person on this hall and they just forget about you. R189 reported they were in pain at that time and the pain was located in their hip. R189 stated, It's killing me! R189 stated, I feel neglected and ignored! At that time (10:40 AM), an observation was made of the call light monitor which indicated R189 activated their call light 31 minutes prior at 10:09 AM. When queried about whether anyone had come in to answer their call light, R189 reported nobody came so they went into the hallway where they told Staff 'R' (an administrator from a sister facility). R189 reported Staff 'R' said he would find R189's nurse and nobody ever came back to help her. When queried about the level of pain they had, R189 stated, The worst! 10 out of 10 because I have been waiting so long. If I get it on time, my pain is managed. R189 explained they were supposed to receive a pain medication at 6:00 AM that they received every six hours for breakthrough pain and another pain medication that was supposed to be administered with their 9:00 AM medications. R189 reported they did not receive the dose at 6:00 AM or any 9:00 AM medications. At approximately 10:42 AM, Staff 'R' was asked who was supposed to pass R189's medications. Staff 'R' said he would go get the nurse. At that time, Nurse 'N' told R189 that she had to put a pain patch on another resident and then she would come right back. At 10:44 AM, Staff 'R' reported he texted another staff member to see if they could give R189's medications right away. R189 stated, My 6AM med is also due at 12pm and it's almost 11:00 AM and I haven't had it yet! My hip is hurting so bad but I had to walk on it to come out here to see what was going on. At 10:51 AM, Nurse 'N' had not came back to R189. Nurse 'N' was observed on the 200 hall going in and out of multiple residents' rooms. On 2/12/23 at 10:54 AM, Regional Clinical Director (RCD) 'M' entered R189, spoke with R189 and left the room. On 2/12/23 at 10:59 AM, RCD 'M' told R189 she would get their nurse right then to give them their medication. On 2/12/23 at 11:00 AM, Nurse 'N' arrived on the 400 unit to pass R189's medications. At that time, Nurse 'T' came to the 400 unit and Nurse 'N' asked Nurse 'T' if they were assigned to R190 (the only other resident on the 400 unit). Nurse 'T' reported they were not sure if they were assigned to any residents on the 400 hallway. It was determined Nurse 'N' was assigned to R189 and Nurse 'T' was assigned to R190. Both nurses reported they had not yet administered medications to R189 and R190. On 2/12/23 at approximately 11:00 AM, an interview was conducted with R190. R190 reported they had not yet received their morning medications. R190 explained they usually received them right after the breakfast tray was delivered, but they did not. At 11:46 AM, R190 reported they had not yet received their medication. Review of R190's Medication Administrator Record (MAR) revealed no electronic signature from the nurse that indicated R190's morning medications had been administered. On 2/12/23 at 11:10 AM, Nurse 'N' was observed to pass R189's medications. R189 stated, I feel like I'm having a panic attack! During the medication pass observation, R189 was observed to know the names, spelling, and dosage of each medication and what each medication was for. Prior to administration of a oxymorphone HCL extended release (a narcotic pain medication used to treat severe pain) 40 milligram (mg) tablet, R189 reported a pain level of seven out of 10 with 10 being the highest level of pain. At that time, R189 received 0.25 mg of alprozalam (a medication used to treat anxiety). R189 reported to Nurse 'N' that they did not receive their 6:00 AM dose of oxycodone 20 mg which they said helped with breakthrough pain. R189 expressed concern that they did not receive the previous dose, but it was time for the next dose at 12:00 PM. R189 asked Nurse 'N' if she could take the 40 mg and 20 mg together and Nurse 'N' reported she had to contact the physician. At that time, Nurse passed the following medications to R189 and explained they were due at 9:00 AM: sucralafate (used to treat gastric ulcers - Nurse 'N' explained she gave the 12:00 PM dose because the 9:00 AM dose was missed), latuda (an antipsychotic medication), loratadine (an allergy medication), oxybutynin (used to treat urinary urgency) , verapamil HCL ER (a medication used to treat high blood pressure), divalproex DR (a mood stabilizer), and potassium chloride (a supplement used to treat low potassium levels). At approximately 11:30 AM, Nurse 'N' removed 20 mg of oxycodone from the narcotic box and administered it to R189. When Nurse 'N' asked R189 their level of pain, R189 stated, 12 out of 10! and explained that was the most important pain medication because it treated breakthrough pain. Nurse 'N' was not observed to contact the physician about administering the 40 mg oxymorphone and 20 mg oxycodone at the same time. On 2/12/23 at approximately 11:40 AM, Nurse 'N' was interviewed. When queried about why R189's medications were given late, Nurse 'N' reported there was only one CNA covering three hallways and therefore the nurses had to help with other tasks such as answering call lights and was not able to get the medications passed timely. Nurse 'N' reported she did not know she had a resident on the 400 hallway. On 2/12/23 at 11:46 AM, review of R189 and R190's clinical records revealed no progress notes that indicated their physicians were contacted regarding late medication administration. On 2/12/23 at 1:00 PM, review of R189's progress notes revealed a note written by the Director of Nursing (DON) at 12:14 PM and designated as a late entry effective at 9:13 AM noted the physician was contacted and approved for meds to be administered late. Also confirmed and approved of administering oxycodone 20 mg and oxymorphone ER 40 mg at same time per guest request. It should be noted that Nurse 'N' did not indicate the physician was contacted during the medication administration observation and stated she needed to contact him, but was not observed to. According to interview with Nurse 'N' between the times of 11:00 AM and 11:40 AM, they were not aware they were assigned to R189 on the 400 unit. On 2/13/23 at 11:00 AM, a confidential interview was conducted with members of the resident council. When asked about any concerns they had about their care in the facility, all ten residents indicated they felt the facility was short of nursing staff. One resident reported medications often came late and that it was worse on the weekends. Another resident reported on 2/12/23 they activated their call light because they wanted to get up to go eat in the dining room for breakfast. The resident explained they resided on the 100 hallway and nobody came and their call light was on for 30 to 40 minutes. The same resident reported they were admitted to the facility on ly four days prior and they rang it all night before and nobody answered it. Another resident reported they had to wait two hours before to have their call light answered. 38271 On 2/14/23 at approximately 4:04 p.m., The Director of Nursing (DON) was queried regarding the staffing level for the morning of 2/12/23. The DON reported that they had worked the floor on the night shift of 2/11/23 and had multiple staff members call off for the day shift that started at 7:00 AM. The DON reported they had thought they had one CNA coming in to help but they also ended up not showing up. The DON reported that three or four CNA's are normally required for the unit to operate efficiently. On 2/14/23 a facility document titled Staffing was reviewed and revealed the following: Policy Statement-Our facility provides adequate to meet needed care and services for our resident population .

This citation pertains to Intake Number(s): MI00134357. Based on interview and record review, the facility failed to discharge one (R88) of three residents reviewed for discharge, with physician ordered oxygen, resulting in an emergent hospital transfer for acute respiratory failure with hypoxia (low blood oxygen levels) and hypercapnia (high levels of carbon dioxide in the blood) and an admission to the intensive care unit (ICU). Findings include: Review of a complaint submitted to the State Agency on 1/17/23 revealed it was alleged R88 was discharged home without oxygen and was admitted to the hospital in intensive care. On 2/10/23 at 3:56 PM, the complainant reported R88 was started on oxygen while a resident at the facility and discharged without it even though their oxygen was low when not using it. The complainant reported the home health care (HHC) nurse attempted to contact the facility and eventually R88 was sent to the hospital and admitted into intensive care. On 2/14/23 at 11:14 AM, during a conversation with the complainant, it was clarified that R88 was not sent home with any oxygen or supplies to treat their wound on their foot. It was further reported that the HHC nurse (HHC Nurse 'Q') attempted to contact the facility and did not receive a response. The complainant explained that R88's oxygen levels were so low the home health nurse called emergency. The complainant reported oxygen arrived at their home five days after R88 was discharged , but they were already admitted to the hospital in intensive care. Review of R88's hospital records revealed R88 was admitted into the hospital on 1/14/23 and discharged on [DATE]. Review of ED (emergency department) Provider Notes dated 1/14/23 revealed, .Patient presents with Shortness of Breath .Patient presents emergency department with noted increased dyspnea (shortness of breath) .Patient states being with hypoxia as she does not use oxygen at home .Shortness of Breath Severity: Severe .Timing: Constant .Relieved by: Oxygen .Worsened by: Deep breathing .Ineffective treatments: Rest .Physical Exam .Resp (respiratory rate) 32 (a respiratory rate over 25 is considered abnormal) .Patient noted to having increased oxygen requirements and to have further interventions, along with nitro drip and bipap. ICU notified as will further escalate oxygen requirement . Review of a hospital Discharge Summary for R88 revealed a diagnosis of acute respiratory failure with hypoxia and hypercapnia which was resolved in the hospital. Review of R88's facility clinical record revealed R88 was admitted into the facility on [DATE] and discharged on [DATE] with diagnoses that included: congestive heart failure (CHF). Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R88 had intact cognition, required extensive assistance for bed mobility, total assistance with transfers, and used oxygen while a resident. Review of R88's progress notes on 2/12/23 revealed the following: A Skilled Charting note dated 12/24/22 noted, .Started on oxygen at 2 liters per NC (nasal cannula) as pt.'s (patient's) pulse ox (oximetry) is 85 (percent) is 89 % (percent) on RA (room air). Pulse ox is 84 (percent) on oxygen . A Skilled Charting note dated 12/25/22 noted, .Using oxygen at 2 liters per NC . A Radiology note dated 12/27/22 revealed a diagnosis of CHF. A Skilled Charting note dated 1/3/23 noted, .Oxygen at at all times at 2 liters per NC, pulse ox maintained above 90%. A Physician Progress Note dated 1/3/23 noted, .on O2 (oxygen) supplementation . A Skilled Charting note dated 1/4/23 noted, .Oxygen at at <sic> all times at 2 liters per NC, pulse ox maintained above 90% . An Order Note dated 1/5/23 noted, .on O2 supplementation .continue O2 supplementation as instructed . A Care Transition Note dated 1/9/23, written by Care Transitions Coordinator (CTC) 'J', noted, This writer provided guest with Medicare non-coverage paperwork. This writer explained to guest NOMNC (Notice of Medicare Non-Coverage) per guest understood and will not appeal. Will discharge home on 01/12/23 with home health services. This writer also provided a copy to guest . A Care Transition Note dated 1/9/23, written by CTC 'J', noted, This writer sent referral to (HHC agency) per family request for continuity of care for DC (discharge) on 1/12/23, per guest request. A Physician Progress Note dated 1/11/23 documented, .Discharge management .O2 98% .NC in place .continue current rx (prescription) plan . Review of R88's Physicians Orders revealed the following orders: 1. D/C with home health services, nurse, nurse aide, PT (physical therapy) dated 1/9/23. 2. Oxygen at 2 LPM via nasal cannula continuously with a start date of 12/27/22 and was active at the time of R88's discharge on 1/12/23. Review of R88's Treatment Administration Records for January 2023 revealed R88 received 2LPM of oxygen continuously from 1/1/23 through 1/12/23 (the day of discharge) as indicated by electronic signatures by the nurses each shift daily. Review of R88's Discharge Review dated 1/11/23 revealed the following documentation: Recap of Stay .Special treatments or procedures .PT/OT (occupational therapy), Skilled nursing care, dietary, wound care, pain management . The form did not mention R88 required oxygen. Review of R88's Discharge Instruction Form dated 1/11/23 (and locked the same day) revealed R88 was referred for HHC services. In the section for Current Treatments and Therapies oxygen therapy was not included. It was documented that R88's family/guest received discharge instructions and acknowledged understanding of information on 1/12/23 (the day after the form was completed) and did not include a signature from the family or guest. Review of a Team Conference form dated 1/11/23 (locked on 2/7/23) revealed no date and time of the meeting. It was documented the social worker and recreation therapy attended the meeting. In the nursing section meds reviewed was documented. There was no documentation of R88's oxygen needs. On 2/13/23 at 4:24 PM, an interview was conducted with CTC 'J'. When queried about the facility's discharge process, CTC 'J' reported they conducted a team conference for residents who were ready to be discharged and the meeting typically included CTC 'J' and therapy staff. CTC 'J' explained if the guest or family requested other departments to attend, CTC 'J' asked them to come. CTC 'J' reported the DON did not attend the discharge conference unless the resident or family requested it. When queried about why R88 was not discharged home with oxygen, CTC 'J' stated, I went in there to talk to her and she wasn't using oxygen. When queried about the active physician's order that was in place since 12/27/22 that indicated R88 required 2 LPM of continuous oxygen therapy, CTC 'J' reported they did not review the physician's orders and went by what was observed or if the resident requested something. When queried about how it was ensured resident's were sent home with the required medical equipment such as oxygen, CTC 'J' reported nursing ordered oxygen and it was the responsibility of the DON. CTC 'J' reported they only set up HHC or private care duty. On 2/13/23 at 4:57 PM, the Director of Nursing (DON) was interviewed. When queried about the facility's discharge process and how it was ensured that residents were discharged home with the required medical equipment, the DON reported there were interdisciplinary team (IDT) meetings where residents' needs were discussed. The DON explained that she did not always attend those meetings and that they were facilitated by CTC 'J' and therapy. The DON reported that any medical equipment needed would be discussed at the IDT meeting for discharge. When queried about who was responsible to order oxygen for a resident being discharged , the DON reported she was responsible. When queried about why R88 did not go home with oxygen, the DON reported she ordered oxygen for her and it was delivered to her house. At that time, any evidence that oxygen was provided to R88 at the time of discharge was requested. The DON logged into the software the facility used to order medical equipment from (not available in R88's electronic medical record). The following was documented: Encounter: 01/12/2023 .Face-to-Face Oxygen .(R88) is .currently diagnosed with chronic diastolic (congestive) heart failure .The face-to-face encounter occurred on 01/12/2023 for oxygen therapy. Her chronic hypoxia-related symptoms include shortness of breath (dyspnea), coughing, rapid breathing, fast heart rate, and use of accessory muscles when breathing Although patient's condition improved with this treatment, she remains hypoxic. Oxygen therapy is now required .An oximetry test was performed during an outpatient visit on 01/12/2023. The patient was tested at rest and in a chronic stable state. During the rest test, the patient's SpO2 (pulse ox) was 85% .She will use home oxygen at a flow rate of 2 LPM 24 hours a day via nasal cannula. The patient's oxygen saturation is expected to improve with oxygen therapy. The patient will use gaseous portable oxygen because she is mobile in the home .Products: Home Oxygen Concentrator .Portable O2 Option. The document was digitally signed by Physician Assistant (PA) 'S' on 1/14/23 at 10:56 PM (two days after R88 was discharged from the facility). The DON provided evidence from the medical equipment ordering software that oxygen was delivered to R88's home on 1/18/23, six days after R88 was discharged from the facility. At that time, the DON was queried about whether oxygen would have been available prior to the PA signing it on 1/14/23. The DON reported it would not have been delivered until the order was signed by the practitioner and that was likely why it was not delivered prior to R88's discharge. The DON reported she sent an oxygen concentrator home with R88 and R88's daughter. At that time, evidence that oxygen was sent home with the resident was requested. On 2/13/23 at 5:19 PM, the DON followed up and reported R88 was sent home without oxygen because it was supposed to be delivered. The DON further explained that R88's daughter called up to the facility because oxygen had not been delivered. The DON reported the daughter came back to the facility to get the oxygen concentrator. The DON reported it was not ordered prior to 1/12/23 because the family was deciding if they wanted to keep R88 in the facility. There was no documentation in R88's medical record that indicated oxygen was included in the discharge planning conference and instructions. There was no documentation in R88's medical record that indicated they were sent home with oxygen until it could be delivered. There was no documentation that indicated R88 or their family requested R88 to stay in the facility past the planned discharge date . On 2/15/23 at 9:45 AM, a phone interview was conducted with HHC Nurse 'Q' who was the HHC nurse who saw R88 after they were discharged from the facility on 1/12/23. HHC 'Q' reported she reviewed R88's discharge information and saw R88 experienced oxygen saturation levels way below 90 percent and that R88 was supposed to be set up with oxygen supplies. HHC Nurse 'Q' reported she contacted the facility and talked to the DON and a social worker and expressed concern about the lack of oxygen provided and it was difficult to get any information. HHC 'Q' reported she made sure to see R88 back to back (days) and had to send her to the hospital because she was hypoxic. When queried about whether there was an oxygen concentrator available during her visit at R88's home, HHC 'Q' reported there was no oxygen available. HHC Nurse 'Q' explained oxygen was eventually delivered four to five days later but R88 had already been transferred and admitted to the hospital. Review of a Resident Grievance/Complaint Form provided by the DON on 2/14/23 revealed R88's daughter called on 1/12/23 at 12:00 PM to say when she got home w/ (with) mom after discharge, oxygen had not been delivered yet as promised. Told daughter if needed to bring mom back up to get tanks/concentrator from our supply. Told to take her to hospital if SOB (short of breath) or in distress but denied any distress .Daughter came back to facility and obtained a blue concentrator and agreed to return it when (oxygen supplier) delivered the home oxygen supply. DON brought concentrator to front and instructed receptionist to give to daughter upon arrival. Apologized to daughter - oxygen was ordered late because daughter kept telling us they were appealing. Instructed daughter to take mom to hospital if in resp. (respiratory) distress .1/18/(23) (software for ordering medical equipment) updated order as completed and delivered . The grievance was signed by the DON. Additional documentation was made by the scheduler on 1/23/(23) that noted, Family returned concentrator. Notified housekeeping. In the section to document the actions taken to remedy the situation, the DON documented, Orders were confirmed submitted to (oxygen supplier) via (software) - (PA 'S') signed orders on 1/16/23 (four days after R88 was discharged home). It should be noted that the facility was aware that R88 did not have oxygen delivered to their home at the time of discharge on 1/12/23, as evidenced by the order not yet being signed by a medical practitioner. There was no documented evidence in the medical record or discharge paperwork that indicated R88 came back to the facility and was provided with oxygen. Review of a facility policy titled, Discharge or Transfer of Resident, revised 8/5/21, revealed, in part, the following: .PROCEDURE: Discharge to Home or Lesser Level of Care .Obtain discharge order from attending physician .Complete Post-Discharge Plan of Care: .Include instruction for post discharge care .Document in the Medical Record whom the information was reviewed with .

This citation pertains to Intake #MI 511 Based on interview and record review the facility failed to provide 1:1 feeding assistance recommended by Hospice services for one hospice resident (R707) out of one resident reviewed for Hospice services, resulting in R707 sustaining second and third degree [CONDITION(S)] from hot coffee. Findings include: Review of a complaint filed with the State Agency (SA) on 1/10/22 revealed, On 12/24/2021 (R707) fell and fractured her arm .On 12/31/2021 (R707) was drinking hot coffee without a lid and it spilled on her, burning her legs . During a phone interview on 2/2/22 at 12:15 pm, the Complainant reported that R707 was a Hospice patient and had been showing signs of decline that increased following a fall causing a fracture to the arm on 12/24/21. The Complainant alleged that on or about 12/31/21, R707 who was supposed to receive 1:1 feeding assistance, was served hot coffee in a paper-like cup without a lid, could not hold the cup with one hand and it spilled causing second and third degree [CONDITION(S)] to their legs and abdomen. The complainant indicated that the resident passed away approximately one week after receiving the [CONDITION(S)]. A review of the facility policy titled, Hospice Program' (revised December 2011) revealed, in part: .When a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. The care plan shall be revised and updated as necessary . A review of the R707's clinical record revealed the resident was admitted to the facility on [DATE]with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent Minimum Data Set (MDS) dated [DATE], indicated the resident was severely cognitively impaired, a hospice patient and needed limited one person assistance with feeding. R707's Care Plan was reviewed and documented, in part, the following: Focus: Cognitive loss related to dx of dementia .Resident does not have capacity for medical .decision making .(initiated 7/18/19) Focus: Alternation in nutritional status .Interventions: Provide diet per physician order .1:1 feeding assistance with meals (Revision on 12/17/2021) Focus: .resident under (name redacted) Hospice (date initiated 11/11/2020) .Interventions: .contact them for change in condition, new orders or any questions/concerns . Review of an Incident Note dated 12/31/21 at 12:40 PM revealed, Guest was up in w/c participating in activities in the main dining room writer was charting at the computer and the activities assistance notified writer that guest had spilled hot coffee all over herself . Wound Evaluations with photographs were reviewed and revealed, in part the following: Evaluation on [DATE], .Burn-Second Degree .Body Location: Left thigh .New .In-House Acquired. Evaluation on [DATE] .Burn-Third Degree .Body Location: Location not set .New: Minutes old .Acquired: In house .Area 45.83, Length 11.74 cm . Width.9cm . Evaluation on [DATE] .Burn Second Degree .Body Location: Lower Left Abdomen .New-6 days ago. Acquired: In house .Area 5.05 cm, Length 2.88 cm, Width 2.48 cm . Evaluation on [DATE] .Burn - Second Degree .Body Location: Right Thigh Medial .New-6 days ago. Acquired: In house .Area 14.99cm, Length 11.16 cm, Width 3.73cm . An Incident and Accident (I/A) and accompanying investigation documentation were reviewed and revealed, in part: Friday morning (12/31/21) a little after 11 AM we gathered at Group in the dining room. There were several residents there for morning coffee hour .I used our brown disposable cups to serve coffee to everyone. The large carafes the <sic> kitchen had just finished brewing and by the time I passed the coffee out, it was probably about 2 minutes from the time I poured it to the time I sat it in front of (R707). I proceeded to get paper towels . I was passing out the paper towels and my back was turned for only a few seconds; I turned around to find out (R707) spilled her coffee .ran to get nurse .asked if I witnessed it to which I replied no .and then took R707 to her room, changed her pants and brought her back out to group . (Recreational Therapy Assistant (RTA) L). Investigation (undated): (R707) .On 12/31/21 @ 11:30 am guest was up for activities .Guest is able to feed herself meals and consumes liquids herself. Family requested on 12/17 that she is changed to 1:1 assistance as they wanted to ensure staff provided cueing with meals .Guest has a cast on left arm and is right hand dominant .The guest picked up cup and spilled it on top of her thighs .Conclusion: This was an isolated occurrence of someone spilling their coffee. The guest was changed on 12/17 to have 1:1 meals to provide supervision & cueing (*it should be noted that the updated care plan dated 12/17/21 documented: 1:1 assistance for feeding the word cueing was not noted). Guest was in the dining room under supervision and cueing .The facility added sippy cups to help avoid future occurrences . (unsigned). On 2/2/22 at approximately 1:20 PM, an interview was conducted with Dietary Manager (DM) B. DM B was queried as to the facility's policy regarding hot liquids, specifically coffee. DM B indicated that coffee temperatures were taken and kept in a log. When asked as to view the temperature taken for the coffee served on 1/31/21 at or around 11:00 AM, DM B noted that there was no temperature documented on that date/time. DM B was asked to provide the disposable cups used by R707 on 1/31/21, DM B stated that they did not have any and that the facility will not be using them again. DM B further stated that following the incident staff were educated on the use of a sippy cup. On 2/2/22 at approximately 1:50 PM, an interview was conducted with Recreation Therapy Assistant (RTA) 'C. RTA C reported that on 1/31/21, they arranged a group coffee activity in the main dining room. RTA C stated that she used brown disposable cups and filled each cup from the large coffee maker brewed by the kitchen. She then placed a cup on the table in front of R707. RTA C reported that she did not put a lid on the cup. RTA C noted that after placing the cup on the table in front of R707, she went to get some paper towel. When she turned around, she saw that R707 had spilled coffee all over herself. When queried as to whether she was aware the resident was to receive 1:1 assist for feeding, RTA C reported she did not believe it meant for coffee. On 2/2/22 at approximately 2:00 PM, an interview was conducted with Physical Therapy Manager (PTM) M. PTM M was asked if they had completed any assessments following R707's change in condition/fall with fracture on 12/24/21 that would address any decrease strength and/or ability. PTM M reported that as R707 was a Hospice patient, no assessment was completed. PTM M suggested reviewing Hospice documentation. Further review of R707 clinical record was conducted. There were no Hospice documents in the record for December 2021 and January 2022. On 2/3/22 at approximately 9:30 PM, the facility was asked to provide Hospice documentation for the months of December 2021 and January 2022. Hospice documents titled Hospice Comprehensive Assessment and Plan of Care Update Report were provided. The documents had a fax date of 2/3/2022 (10:14 AM) at the top. It should be noted that documents provided had dates at the top documenting IDG (interdisciplinary group) dates of 12/22/21 and 1/5/22. The notes were difficult to interpret any date specific as to the plan of care. The documents identified Hospice Nurse N as part of the IDG team. A phone call was made to Hospice Nurse N on 2/3/22 at approximately 11:32 AM. Hospice Nurse N reported that she was aware of R707 receiving 2nd and 3rd degree [CONDITION(S)] and had been providing Hospice Nurse services for the Resident. When queried as whether she had visited and assessed R707 after the fall on 12/24/21 and prior to the incident resulting in [CONDITION(S)] on 12/31/21, Hospice Nurse N reported that she had and noted that she found that the resident had had a significant decrease in strength and comprehension and recommended changes to the facility. Hospice Nurse N noted that she had visited the resident on 12/28/21 and was able to provide documentation dated 12/28/21. Review of the Visit Note Report from (name redacted) Hospice Services was reviewed and documented, in part, the following: Visit Date: 12/28/21 .Agent (Hospice Nurse N) .Began .12:13 PM .Completed 1:14 PM .Summary of Today's Visit Findings: Documentation Head-to-Toe Assessment .Writer arrived to PT (patient) sitting in wheelchair .PT is alert to self and place. PT is often confused and unable to make needs know. PT is sleeping more 20+hours a day, staff report sometimes even sleeping 24 hours .PT requires max assist for transfers from bed to wheelchair, PT is dependent for all ADLs, .Writer spoke with staff and daughter about making sure someone is with her to help her eat .All questions answered of daughter .and staff .contact information reviewed and instructed to call with any questions or concerns . (Electronically signed by Nurse N 12/28/21 1:14 PM). *It should be noted that the rep Visit Note Report provided was not included in the documentations provided by the Facility A second phone interview and record review were conducted with Hospice Nurse N on 2/3/22 at approximately 12:01 PM. After reviewing the Visit Note Report dated 12/28/21, Hospice Nurse N was asked about her note that indicated speaking with staff. Hospice Nurse N reported that the resident had been showing a decline prior to the fall with fracture on 12/24/21 and showed further decline after the fall as discussed with staff on 12/28/21. When asked if R707 would have been able to hold, lift and drink hot coffee from a disposable cup without a lid on their own, Hospice Nurse N reported as a resident with decline in strength and instructions of 1:1 eating assistance she would consider it crucial that a staff person be with her for food/drink assistance and a stable coffee cup be provided. On 2/3/22 at approximately 1:00 PM an interview was conducted with Corporate Director of Nurse (CDON) A. CDON A was asked as to the communication between facility staff and Hospice and the lack of Hospice documentation in R707's record. CDON A reported that there should be communication between Hospice and documentation should be in the resident's record. With respect to the Hospice Visit Note dated 12/28/21, CDON A asked the Surveyor if they could provide the document to them for review. The document requested was later obtained by CDON A and when discussed, CDON A reported that a 1:1 set up for feeding had been established on or about 12/17/21, after a request by family and was meant for cueing only.

Based on observation, interview, and record review, the facility failed to implement physician ordered fall interventions and perform root-cause analysis investigations into repeated falls with one resulting in major injury for one resident (R162), of one resident reviewed for falls. Findings include: A review of a facility provided document titled, FALLS REDUCTION PROGRAM revised 9/25/16 was conducted and read, .3.3 IDT (Interdisciplinary Team) to review each incident to complete root cause analysis 3.4.1 Complete physical review of environment 3.4.2 Complete/review Fall assessment. Discuss and determine root cause. Summarize IDT analysis in the incident report. 4. Determine the need for ongoing assessments/interventions based on MDS reviews, fall risk history, and IDT member recommendation On 12/5/21 at 8:47 AM, R162 was observed awake, and alert in their bed. There were no visitors or guests in their room at that time. It was observed a large blue mat was in place only on the left side of the bed. At that time, R162 was asked if they had any falls in the facility and said, Last week I fell backwards and busted my head open. R162 was asked what they were doing when they fell and said the bed was too high, they prefer it low, and they were trying to get out of bed when they fell . R162 was asked if any staff were present when they fell and said as soon as they fell the nurse came into the room. A review of R162's clinical record was conducted on 12/5/21 and revealed R162 admitted to the facility on [DATE] with diagnoses that included: falls, [CONDITION(S)] disease of the nervous system, unspecified head injury, and dementia. A review of R162's Minimum Data Set assessment dated [DATE] revealed R162 had moderately impaired cognition, was non-ambulatory, and required extensive assistance from one to two staff members for activities of daily living. A review of R162's fall assessment dated [DATE] indicated they were a moderate risk for falls. R162's care plans for falls was conducted and multiple interventions on the care plan were undated as well as it was noted the care plan did not reveal any interventions that mentioned the bed height, or increased supervision. A review R162's orders included an order dated 12/3/21 that indicated R162 was to have floor mats to both sides of the bed, but that order was discontinued on 12/5/21 at approximately 1:30 PM and no new order had been put in for fall mats. It was further noted a new care plan intervention initiated by a sister facility's Director of Nursing (DON) 'G' on 12/5/21 read, Floor mats to left side of bed as visitors sit to right side. May remove if family at bedside. Remind family to let staff know if they are leaving for the day so mat can be placed if removed . On 12/6/21 at approximately 9:30 AM, a review of facility provided Incident & Accident (I&A) reports that have written on the bottom of the page Privileged and Confidential-Not part of the Medical Record for R162 were reviewed and revealed the following: An I&A report dated 11/29/21 by Licensed Practical Nurse (LPN) 'J' that indicated R162 was observed seated on the floor in their room next to their window. The I&A read, .Resident Description: I did not fall .I just sat on the floor. I did not fall .Description: .Bed placed in low position . It was noted there were no statements from LPN 'J' or any other staff regarding any details into the fall including the height of the bed at the time R162 was found on the floor, any assessment of what R162 was trying to do prior to being found seated on the floor near the window, or who and how they were returned to their bed. An accompanying note for the incident documented by LPN 'J' on 11/30/21 at 12:30 PM that read, Patient was observed seated on the floor .Bed returned to lowest low position . An INVESTIGATIVE SUMMARY note entered into R162's record by the facility's DON was reviewed and read, Patient was observed seated on the floor next to the window. I did not fall .I just sat on the floor. I did not fall .Guest observed on floor .Guest assisted to bed without issue .Guest asked about fall and insisted he was seated on the floor intentionally. Guest encouraged to request assistance with repositioning and elevation changes . An I&A report dated 11/30/21 by LPN 'K' that read, .Nursing Description: Writer was called to resident room by a staff member, upon entering resident's room writer observed resident on the floor lying on his back on the right side of his bed . It was noted there no statements from LPN 'K', the staff member (who found R162), or R162 regarding any details into the fall including whether the fall was witnessed, or any assessment of what R162 was trying to do prior to the fall. It was further noted there was no progress note from LPN 'K' in the clinical record that documented R162's fall. An INVESTIGATIVE SUMMARY note entered into R162's record on 12/1/21 by the facility's DON was reviewed and read, Writer was called to resident room by a staff member, upon entering residents <sic> room writer observed resident on the floor lying on his back .Guest observed on floor. Guest asked about fall and indicated he'd rolled intentionally and accidentally <sic> ended up on floor .Guest reminded to call for assistance whenever repositioning for staff to assist with bed mobility . An I&A report dated 12/2/21 by Registered Nurse (RN) 'L' that read, .Nursing Description: was called to resident's room, PT (Physical Therapy) heard resident fall and he was placed back in wheelchair. When writer first saw resident he was sitting in wheelchair, noted 1 to 1 1/2 inch lac (laceration) to back of head .Resident is complaining of headache. Resident Description: resident only says 'I fell ' mo <sic> other description given .Immediate Action Taken: .Resident was sent to hospital per EMS (Emergency Medical Service) .Injury Type: Laceration Injury Location: 1) Top of Scalp . It was noted the I&A report did not include any statements from RN 'L', the therapist who heard the fall, or any other staff members involved with assisting in R162's care during the time of the fall. It was further noted the I&A did not include any assessment of what R162 was trying to do prior to the fall, where in the room the fall occurred, or what R162 hit their head on that caused the laceration and transfer to the hospital where it was documented in a progress note on 12/3/21 they received two staples to the back of their head. An INVESTIGATIVE SUMMARY note entered into R162's record on 12/5/21 at 2:40 PM by the facility's DON was reviewed and read, was called to resident's room, PT heard resident fall and he was placed back in wheelchair. When writer first saw resident he was sitting in wheelchair, noted 1 to 1 1/2 inch lac to back of head .Resident is complaining of headache .Guest observed on floor by therapy staff. Guest unable to recall reason as to what lead to fall accident .It was decided to send guest to hospital per provider . On 12/6/21 at 10:14 AM, an interview was conducted with the facility's DON regarding R162's I&A reports. The DON was asked if there was any other documentation to provide for the reports such as interviews with staff. The DON indicated there was no additional documentation. At that time, the DON was asked about their process for addressing resident falls and said that when a fall occurs the nurse initiates an I&A report, does a change in condition assessment, a fall assessment, a pain assessment, a skin assessment, and initiates neurological checks if needed. The DON said they reviewed the documentation and made changes to the care plan. The DON was asked specifically about R162's falls and the assessment into the root causes of the falls such as what the resident was trying to do when the falls occurred, the disposition of the resident prior to the fall, the locations in the room where the resident was discovered, and any interviews with other staff involved such as who found the resident on 11/30/21, who was the therapist that heard the fall on 12/2/21, and other staff members involved in caring for the resident during the times of the falls. The DON reported that each time they talked to R162 after a fall, R162 did not give any information about why they had fallen because of their cognitive status. The DON was then asked about the appropriateness of the intervention to remind the resident to call for assistance if cognitively it would not be appropriate, at that time, the DON said they would follow-up. On 12/6/21 at 10:50 AM, an interview was conducted with the facility's Corporate Nurse Consultant regarding thorough root-cause analysis investigations into R162's falls, specifically regarding interviews with staff members involved, disposition and assessment of the resident, and appropriateness of interventions implemented. It was brought to the Nurse Consultant's attention the bilateral floor mat physician order had been discontinued on 12/5/21 and a new care plan intervention to only have a floor mat on the left side of the bed had been implemented. It was further pointed out that on 12/1/21, R162 was found on the floor on the right side of the bed. The Nurse consultant acknowledged the concerns and indicated they were going to be working with the DON to perform more thorough root-cause analysis investigations to ensure appropriate fall prevention interventions were implemented. The Nurse Consultant was then asked if the IDT team met and discussed falls and said they did every morning. When asked if they documented or summarized their findings and outcomes they said they did not.

Based on observation, interview, and record review, the facility failed to perform appropriate bed mobility for a resident with a history of stroke with right sided weakness for one Resident (R#20) of three residents reviewed for accidents, resulting in a fall out of bed where R#20 sustained a bleeding head contusion, a bruise above the eye, multiple bleeding abrasions, and a transfer to the emergency room . Findings include: On 12/9/19 at approximately 9:30 AM, R#20 was observed in bed eating their breakfast. R#20 was not able to verbally respond to questions related to [MEDICAL CONDITION], but appeared to smile and nod appropriately during conversation. An observation of the room layout was conducted and revealed that on the right side of R#20's bed was a wooden storage closet and the entrance to the bathroom. On 12/9/19 at approximately 12:45 PM, R#20 was observed up in their wheelchair being assisted to the dining room. R#20's wheelchair was observed to be specially adapted so they could propel themselves with a left sided hand pump attached to the rear wheel of the chair that propelled the wheelchair forward. R#20's right arm appeared flaccid. On 12/9/19 at 4:00 PM, an interview with R#20's family member was conducted. During the interview, R#20's family member stated, A while ago, one aide was changing him and she rolled him away from her and he rolled out of bed. She shouldn't have been alone, there should have been someone on on his other side. I think she was a new aide. He had to go to the hospital for that. A review of R#20's clinical record was conducted and revealed an admission date of [DATE] and re-admission date of [DATE] with [DIAGNOSES REDACTED]. A review of R#20's Minimum Data Set (MDS) assessment dated [DATE] (prior to R#20's fall out of bed) indicated R#20 required extensive assistance of two staff members for bed mobility and transferring, was non-ambulatory, and had range of motion impairments for one upper and one lower extremity. A review of R#20's CNA (Certified Nursing Assistant) Kardex (guide for care requirements) and care plans was conducted and neither indicated what level of assistance or by how many staff members R#20 required for bed mobility. On 12/10/19 at 11:27 AM, a review of a facility provided document regarding the incident was conducted. The document prepared by Registered Nurse (RN) 'D', dated 8/4/19 at 5:45 AM read, Witnessed Fall .Nursing Description: At about 545 am a CENA (Certified Nursing Assistant) .called out from room (room number redacted) to me .to assist her in an emergency. She reported pt. (patient) rolling out of bed while she was rendering care. I found pt. sitting on bedroom floor, alongside his bed, between the bed and bathroom. His back was against the brown wood cabinet between the sink and bed. His legs extended in front of him. he was sitting on his buttocks and thighs on the carpet. I noted blood stains on the carpet, blood dripping from the left side of his forehead blood on his left arm, left knee, and dripping from one of his great toes. he had a large contusion, swelling above his left eye, on his forehead. I noted the bed was elevated to above my waist area, (the waist area of a 5 foot 2 inch tall person). When I brought this elevation to the attention of (CNA 'B'). She told me she left the bed up so I could better examine (R#20's) skin and injuries .Immediate Action Taken. Description: I summoned the assistance of 1 other RN (RN 'G'), who helped (CNA 'B') and me transfer (R#20) to his bed. Prior to the transfer, one of us lowered the bed to the lowest point so we could better perform the transfer .Other Info: Bed in a rather high position when nurse initially entered room. (CNA 'B') disputed that pt. did not fall from that high position, that she raised the bed after the fall so the nurse could assess the pt .who at that time remained on the floor and was in need of a transfer to the bed .Witnesses: .Statement: The CNA assigned to the (hall number redacted), (CNA 'B') was in the room at the time the resident fell to the floor. She stated the bed was at the height between her knees and her waist, she should <sic> me with her hand. She said she was changing the patient's brief, he was lying in bed on his right side which is his weak side. She said his strong side was up. She said he was not in the middle of the bed, but closer to the side of the bed that is nearer to the bathroom. She was not precise in her description of how close to the side of the bed he was, except to say he was not in the middle. She said she didn't know if he became drowsy and rolled out of the bed during the brief change. I was across the hall .and I went immediately to (R#20's room). It was unclear to me why the bed was at least at my waist level, maybe a little higher when I walked across the hall. She said after (R#20) fell she rolled the bed up so I could assess him better, however, he was clearly on the floor and if I were to assess him at that point, I would have to moved <sic>down, not upward. We had to move the bed down in order to transfer (R#20) off the floor . On 12/10/19 at 11:30 AM, a review of R#20's progress notes was conducted and revealed the following: A physician's progress note dated 8/4/2019 at 6:22 AM that read, Note Text: Received a call from nursing staff that guest was being changed and rolled out of bed onto the floor. He suffered a left forehead contusion with bleeding. He is a stroke patient on (brandname blood thinning medication). I advised staff to send for stat head CT (diagnostic head scan). An Incident note from RN 'D' dated 8/4/19 at 8:54 AM that read, Note Text: S (Subjective): Resident has [MEDICAL CONDITION], unable to describe his fall. CENA summoned nurse to room at about 545 am stating guest rolled onto the floor while she was changing his brief. O (objective): Nurse observed resident sitting on floor between bed and room sink, on buttocks, with back against the brown cabinet, his legs extended. He had multiple abrasions and what appeared to be a large bruise above his left eye with an abrasion. Resident was bleeding from his abrasions . On 12/10/19 at 11:50 AM, an interview with Therapy Program Manager 'I' was conducted regarding R#20's functional status at the time of the fall. Program Manager 'I' stated, He should have been a 2 person assist. He has an old stroke and it affects his right side. He does not know where his center is. On 12/10/19 at 12:00 PM, an interview with CNA 'A', R#20's assigned CNA was conducted. During the interview, CNA 'A' was asked about R#20's functional status. CNA 'A' stated, He is a two person assist, but I can do it by myself because I am strong enough. I know when he's weak, when he's weak I will go get help. He's only a one person assist for rolling from side to side. When asked where they look to obtain the functional status of a resident, CNA 'A' indicated they check the CNA Kardex. When asked what they tell the next shift during report regarding R#20's functional status, CNA 'A' said, I report off that he is a two person extensive assist. On 12/10/19 at 1:58 PM, a telephone interview was conducted with RN 'D'. During the interview, RN 'D' stated, I remember the fall. I was across the hall. The aide came across the hall and asked me to come over, she said she had an emergency and 'I need you now'. When I go there he was on the floor between the bed and the cabinets. She said he rolled out of bed. At the time, I noticed the bed was in the high position, I asked her about it. She said it was in the low position and she put the bed up so I could assess him, but he was still on the floor. At the time of the interview, RN 'D' was asked if CNA 'B' had been providing care for R#20 by herself. RN 'D' indicated CNA 'B' was changing R#20's brief by herself. RN 'D' stated, At that time their duties are to check and change the residents and that's probably what she was doing. She was by herself. She didn't ask me to come in to help her before hand. After the incident my suggestion was to have two people present when changing his brief. RN 'D' was then queried about her knowledge of R#20's physical abilities. RN 'D' stated, I know for a fact it's really hard for him to move, he couldn't roll himself out of bed. I have never seen him roll in bed. It would be very doubtful that he rolled himself out of the bed .I don't think he had the capability to push himself out of bed and I don't think he would do that, push himself over the edge. He's very oriented even though he can't speak. I know I discussed it thoroughly with management. A second review of R#20's clinical record was conducted on 12/10/19. A review of the CNA bed mobility task documentation for the month of (MONTH) was conducted and revealed that the CNA's were documenting that R#20 was an extensive assist with bed mobility, however some CNA's documented R#20 needed one person assistance and other CNA's documented R#20 required two person assistance. A review of CNA 'B's documentation for R#20's transfer status on 8/4/19 (the day R#20 fell from bed) was conducted and revealed that CNA 'B' documented R#20 required extensive two person assistance for bed mobility, but had been changing R#20's brief alone when the incident occurred. On 12/11/19 at 10:00 AM, an interview with Corporate Nurse Consultant 'H' was conducted. During the interview, Nurse Consultant 'H' indicated the facility was in between Directors of Nursing and she looked into R#20's fall. During the interview, it was brought to the Nurse Consultant's attention that neither R#20's Kardex or care plan indicated how many staff members R#20 required for bed mobility at the time of the fall. It was further pointed out that CNA's were documenting that R#20 required both one and two person assistance for bed mobility both before the fall and even after the fall when it had been added to the Kardex and care plan that R#20 required extensive assistance of two people for bed mobility and brief changes. The Corporate Consultant indicated the Kardex and care plans should have indicated the number of staff required for bed mobility at the time of the fall and CNA's should always be using the required amount of staff members when providing care. A review of the facility provided admission packet that included the rights of residents was conducted and read, .You have a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely . The facility was asked if they had any additional information to provide regarding the concern; none was received by the end of the survey.

This citation refers to Intake # M 6932 Based on interview and record review the Facility failed to adequately assess, monitor and provide necessary care to one Resident (#916) with a history of diabetes out of four residents reviewed for coordination of care out of total sample of 18, resulting in Resident #916 being transferred to the Hospital emergency room with an altered mental status. Findings include: On [DATE] at 11:40 a.m. and 2:30 p.m., a phone interview was conducted with the Complainant. The Complainant reported that Resident #916 was admitted for a second time to the facility on [DATE] for gallbladder issues. During her second stay at the Facility the Complainant expressed concerns that Resident #916 was not receiving the care and treatment she needed. The Complainant stated that she had expressed her concerns with Facility staff and requested to speak with the Facility's treating physician. The Complainant further reported that prior to visiting the Resident on [DATE], she was informed that Resident #916 had been taken to the Hospital via ambulance. The Complainant reported that the Resident expired approximately seven hours later. The Complainant was queried as to the Resident's medical history including, diabetes. The Complainant stated that the Resident was diabetic and had been monitoring and taking diabetic medication to treat her diabetes prior to entry. On [DATE] at 9:00 p.m., a Review of Resident #916's clinical record revealed that the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Resident's Minimum Data Set ((MDS) dated [DATE] revealed that the Resident had a Brief Interview for Mental Status (BIMS) score of 14 (cognitively intact). Continued review of Resident #916's electronic medical record, documented a H&P Referral Documentation (history and physical information provided by the Hospital to the Facility) dated [DATE] that revealed, in part, the following: Name: Resident #916 medications: [REDACTED]. Nutritional Pertinent Past Medical History: .diabetes Discharge to: .structured rehab setting. Home equipment:blood glucose monitor. Review of the Resident's clinical record revealed the following: Progress Note (effective date 1//17) Type: Admission Summary Diagnoses: [REDACTED]. Note Text: HPI (history of present illness) .Resident admitted on [DATE] from Hospital (name redacted) with DC (discharge) Dx (diagnosis) of dehydration and cholelithiasis with [MEDICATION NAME] (gallstones) . PMH (past medical history) .diabetes . Note Text (authored by Physician K) Late Entry ([DATE]): History of patient illness: This is elderly lady was admitted to the Hospital for generalized weakness. After work-up she was diagnosed with [REDACTED]. I discussed with primary care physician her condition as well as reviewed all records from the Hospital, reviewed medication discussed with nurse on call. * No indication of history of diabetes was mentioned in the physician notes. Lab Results Report (received date [DATE]): Basic Metabolic Panel: TEST: GLUCOSE (the main type of sugar in the blood and source of energy in the blood cells) RESULT: 132 mg/dl (milligrams of glucose per decliter of blood) FLAG: H (high) ( Indicates a number is above the normal range) REF RANGE: ,[DATE] (Numbers below 70 and above 120 indicates that the range is abnormal.) Reviewed by Name/Signature/Date: BLANK Results sent to: NOT, specified Lab Results Report (received date [DATE]): Basic Metabolic Panel: TEST: GLUCOSE RESULT: 246 mg/dl (milligrams of glucose per decliter of blood) FLAG: H (high) ( Indicates a number is above the normal range) REF RANGE: ,[DATE] (Numbers below 70 and above 120 indicates that the range is abnormal.) Reviewed by Name/Signature/Date: BLANK Results sent to: Physician K Lab Results Report (received date [DATE]): Basic Metabolic Panel: TEST: GLUCOSE RESULT: 339 mg/dl (milligrams of glucose per decliter of blood) FLAG: H (high) ( Indicates a number is above the normal range) REF RANGE: ,[DATE] (Numbers below 70 and above 120 indicates that the range is abnormal.) Reviewed by Name/Signature/Date: BLANK Results sent to: Physician K A review of the Resident's Medication Administration Record [REDACTED] Ensure glucose test strips & control solution bottles are dated when opened and initiated qhs at bedtime related to Type 2 Diabetes Mellitus without complications) Start Date: [DATE] - D/C (discontinue) [DATE]. Accuchecks BID Start date: [DATE]- D/C date: [DATE]. A progress note (authored by Nurse A) dated [DATE] documented: Lab reviewed, elevated glucose level. NP (nurse practitioner) requesting RN to obtain accucheck, RN (registered nurse) obtained blood sugar levels, approx 2 hours after lunch. Blood sugar =450. RN asked Resident if she had elevated blood sugar in the past and resident told RN that her PCP (primary care physician) said she was pre-diabetic and was put on [MEDICATION NAME]. RN notified NP of Acucheck sugar and that resident was stating she takes [MEDICATION NAME]. Awaiting new orders. A progress note (authored by Nurse L) dated [DATE] documented: .went into resident's room to recheck blood sugar after OJ and crackers ., resident noted to be slumped in chair, hard candy on floor in front of resident. Resident was difficult to arouse, BS(blood sugar) checked and noted to be 42 verbal order to send to (name redacted) Hospital for evaluation. On [DATE] at 1:15 p.m., an interview and record review was conducted with the Director of Nursing (DON) regarding Resident #916. The DON was queried as to why Resident #916 was not receiving treatment, including accuchecks, insulin, other medication for her diabetes upon admission and through [DATE]. The DON responded, Not all diabetics need treatment, it is up to the physician to order. When further queried as to the Facility's policy regarding admitting patient protocol, including the review of Resident #916's H & P documents that contained information pertaining to Resident #916 diabetes and treatment, the DON responded, Generally, Nurses do not review the H & P documents, it is a tool used by the physician and the MDS coordinator. During a continued interview, the DON was queried as to the Facility's policy regarding the Lab Report (dated [DATE]) that indicated that Resident #701's Glucose level of 246 was flagged as H (high) and out of normal range. The DON responded, It is up to the treating physician to make decisions based on the lab reports. On [DATE] at 2:30 p.m., a telephone interview and record review was conducted with Physician K. Physician K was queried as to Resident #916's H&P documentation's pertaining to her history of diabetes and treatment. Physician K stated, Usually I will see a patient first and then I will dig into the hospital records, including the H&P and discharge records. When queried as to why no insulin treatments/orders were made for Resident #916 pertaining to her diabetes, Physician K replied, It probably wasn't on her discharge papers, but sometimes things can just get messed up. A review of the Resident's medical documents obtained from Hospital X were reviewed and documented as follows: EMS (emergency medical services) Patient Care Report ([DATE]): Received: 11:45 a.m. Call Type: ALS (advanced life support) Response Priority: Immediate Nature of Call: Diabetic Problems Narrative:ALS arrived to find (Resident#916) in bed with snoring respirations .staff reported pt had low blood glucose and was fed and rechecked without improvement . Final Report ([DATE] 12:32 -authored by Hospital Physician): .female brought in by EMS from rehabilitation facility. On Thursday she was diagnosed with [REDACTED]. On [DATE], at 2:35 p.m., the Administrator was asked to provide a Facility Policy pertaining to a Physician(s) responsiblility for reviewing hospital documentation upon entry to determine patient history. The Facility reported that they did not have a specific policy that detailed the request. A Policy titled Medication Utilization and Prescribing -Clinical Protocol (revised [DATE]) was provided and documented, in part, the following: 5. the physician will explain/and or document the rationale for not modifying a medication in a situation where an adverse medication consequense is likely.

This citation has two deficient practices. Deficient practice #1 Based on observation, interview and record review, the facility failed to: assess, monitor and perform wound care to prevent infection for a surgical incision on the thigh; perform wound care in a manner to protect healthy skin on the shin and document treatment was provided for surgical wounds on the calf per physician's orders [REDACTED].#905) of two sampled residents observed for wound care, from a total sample of 14, resulting in an infected wound to the resident's thigh, the potential for damage to healthy skin on the shin and the potential for worsening of two surgical wounds on the calf. Findings include: On 7/14/15 at 10:00 A.M., Resident #905 was observed lying in bed. Resident #905 had an uncovered open wound on his right thigh that appeared pink in color with grey substance inside of the wound. A wound vac (a device that promotes wound healing through negative pressure) was observed to Resident #905's right lateral (outer) and medial (inner) calf. Resident #905 reported that he liked to air out the wound to his right thigh and stated, It used to have staples it in. My doctor wanted them left in and it got really infected. I had to go get them removed. It was so bad, they were pulling all this stuff out and my daughter passed out. Resident #905's clinical record was reviewed on 7/15/15 at 9:30 A.M. and revealed the following: Resident #905 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A minimum data set (MDS) assessment dated [DATE] documented that Resident #905 had intact cognition and required extensive physical assistance for bed mobility, transfers, and activities of daily living, except for eating. Hospital discharge paperwork, dated 4/30/15, documented that Resident #905 had a thrombectomy (surgical removal of a blood clot from a vein or artery) and core compartment fasciotomy (surgical procedure to remove the connective tissue covering the muscle to relieve pressure and inflammation related to an injury to prevent the tissue from dying). The hospital discharge orders for Incision/wound/pressure ulcer/abnormality documented, Leg, right lower .surgical, wound vac, assess .12 centimeters (cm) x 12 cm .Thigh, right anterior, upper .surgical, staples, assess . A Nursing Admission Assessment, dated 5/1/15, documented surgical wounds measuring 13 centimeters (cm) by 4 cm and 15.5 cm by 6 cm on Resident #905's right lower leg. There was no documentation on the skin assessment about the surgical wound with staples on Resident #905's right anterior upper thigh. physician's orders [REDACTED].#905's admission (4/30/15) through 7/15/15 and documented the following orders: 6/21/15 - Clean wound on upper right thigh with NS (normal saline), leave open to air. 7/2/15 - Bactrim DS (an antibiotic) .Daily for infection/wound 7/2/15 - NPWT (negative pressure wound therapy) to RLE (right lower extremity) MWF (Monday, Wednesday, Friday) 7/3/15 - Clean wound on upper right thigh with NS (normal saline), cover with hydrogel (wound dressing gel) and abd (abdominal) pad BID (twice a day) Prior to 6/21/15, there were no orders related to the surgical incision on Resident #905's right thigh. Progress Notes were reviewed from 4/30/15 through 7/15/15 and revealed the following Nurse's Notes: On 5/3/15, the nurse's note documented, (Resident #905's) wound vac changed this shift as he states it has been on for several days .wounds are beefy red granular tissue with small amount of slough on edges. Tendon exposed in medial and lateral wounds .Right medial thigh surgical incision staples intact, eschar over wound, edges approximated . The nurse's notes from 5/4/15 through 6/16/15 documented that Resident #905 was complaining of severe pain in his right leg that was not relieved with current pain medications. On 6/16/15, Nurse I documented, .C/o (complained of) feeling sick. (Resident #905) does not look well and very lethargic . On 6/20/15, Nurse I documented, .Surgical incision on upper right thigh appears infected, red around edges, clear and yellow drainage. Cleaned with wound cleaner and left open to air. Notified DON (director of nursing) to contact Dr. On 6/22/15, the DON documented, .has an appointment with (vascular doctor) July 2, 10:45 A.M . Weekly skin assessments were reviewed from 4/30/15 through 7/16/15 and did not document the surgical incision with staples on Resident #905's right thigh until 6/19/15. On 7/15/15 at 12:40 P.M., Resident #905 was interviewed about the wound on his right thigh. Resident #905 reported that he was admitted into the facility after major surgery to his right leg to remove a blood clot. Resident #905 reported that he had staples in his right thigh when he was admitted and the surgeon wanted them kept in. When queried about what kind of treatment or care the facility was providing to his right thigh, Resident #905 stated, They were letting me take care of it and it got real bad. It hurt and it smelled really bad. The next day when I went to my doctor (vascular doctor), they pulled out four staples and pulled out all this infection. It was so bad it made my daughter pass out. Resident #905 reported that he had been in the facility for about two months prior to seeing his vascular doctor. On 7/15/15 at 1:40 P.M., an observation was made of Nurse C and Nurse F providing wound care to Resident #905's right calf wounds and right thigh wound. Upon entry to Resident #905's room, the wound on the right medial thigh was open to air. Nurse C stated, He (Resident #905) took the bandage off. Resident #905 stated, It was twice as big as it is now. Nurse C stated, When it got infected, they took him to the doctor and pulled a huge goop out and it made his daughter pass out. The wound on Resident #905's right thigh was observed to have a pink base on the upper half and was filled with gray, white, yellow gel-like slough, as in a bottom of a bowl, on the lower half. Nurse C was queried about the gray, white, yellow substance and stated, I was told that is new skin tissue. Nurse C took a measurement of the wound and reported it to be 1.75 inches in length by 1.0 inch wide by 0.5 inches in depth. Nurse C was observed wiping around the wound on Resident #905's thigh with a gloved hand, then proceeded to place wound gel into the wound with the gloved finger without changing gloves or using a wood tongue blade. A NWPT was observed at this time for the two wounds on the lower leg. There were two irregulary shaped oval wounds on the lower leg. The surgical wound to Resident #905's right lower inner leg was observed to be beefy red with two blackish brown areas toward the edge of the wound that appeared necrotic (dead tissue) and measured 5 inches by 1 inch as reported by Nurse C. The wound on the outer leg, measured 5 inch by 0.7 inch as reported by Nurse C and appeared beefy red. The wounds were seperated by a strip of intact skin. Nurse C and Nurse F placed a rectangular plastic drape over the entire inner and outer leg wounds. The drape did not cover the strip of intact skin between the wounds. Scissors were used to cut the drape around the perimeter of the wounds. Nurse C then cut out a foam pad to fit the shape of the inner wound and a narrow (1 inch) rectangular strip of foam to connect or bridge the two wounds together. (The bridge allows one NWPT machine to service both wounds.) The foam to cover the wound and the bridge were then placed over the inner leg wound. The bridge extended from the inner leg wound foam over the unprotected intact skin between the two wounds. The second nurse, Nurse F cut out a second piece of foam to fit the outer wound, placed the foam onto the wound and began to cover the wound and bridge with a second piece of rectangular plastic drape. Immediately before Nurse F was about to place the outer drape, wound care was stopped and she was asked about the gap between the base drape on the medial and lateral wounds. Nurse C stated, I didn't see that. I thought it was covered. On 7/15/15 at 3:00 P.M., Nurse C was interviewed about the wound on Resident #905's right thigh. Nurse C was asked when the wound was first identified. Nurse C reported that when Resident #905 was admitted , he had a surgical incision on his right thigh that was due to the surgery he had on his lower leg. Nurse C reported that Resident #905 had staples in his right thigh when he was admitted into the facility. Nurse C was asked what kind of monitoring or treatment was in place for the surgical incision on Resident #905's thigh when he was admitted . Nurse C stated, We were cleaning and caring for it. The DON was in communication with his doctor (vascular) and he said he wanted to keep them in (the staples). It started to look horrible and was starting to split apart. He went to the doctor two weeks ago, I think. Nurse C was queried about where the thigh wound would be documented along with any treatment or monitoring that was provided. Nurse C stated, In the weekly skin assessments and the wound logs. In the wound log I would measure once or twice a week and it would say where and what is going on. An interview was conducted with the DON on 7/15/15 at 3:40 P.M. regarding Resident #905 and the wound on his right thigh. The DON reported that Resident #905 came into the facility with a surgical thigh wound with staples. The DON was queried about where the wound would be documented upon admission. The DON stated, On the admission skin assessment typically. The admission skin assessment, dated 5/1/15, was reviewed with the DON. The DON stated, They identified two on the right lower with a wound vac. I do not see anything for the thigh. The DON reported that all wounds would be documented on the wound log. The wound log for Resident #905 was reviewed with the DON. The wound log documented a surgical wound on admission to the right medial calf that measured 15.6 cm by 5.3 cm and to the right lateral calf that measured 13.6 cm by 3.8 cm with wound vac treatment. There was no mention of the surgical incision to the right thigh until 7/3/15 that documented, Right medial thigh .L (length) 4.5 cm, W (width) 2 cm, Depth 0.5 cm . There was no description of the wound. The DON was queried about what was in place for the surgical incision and staples for Resident #905 on admission on 4/30/15. The DON stated, The resident said his doctor wanted the staples left in until he went back to see the doctor. He was sent back (on 7/3/15) because it started opening up. The DON was asked when Resident #905 was supposed to follow up with the vascular physician. The DON reviewed the hospital discharge paperwork and stated, one to two weeks after discharge. When queried about when Resident #905 followed up with the vascular physician, the DON stated, He only went on 7/2/15 (approximately 2 months after his admission to the facility) after it started opening up (the thigh wound). He is particular about his appointments and wanted his family member to take him. We tried to make appointments with his doctor but he never returned our calls. (Resident #905) said he's like that (the vascular doctor, about not returning calls). The DON was queried about the dates and times attempts were made to contact the vascular surgeon's office to schedule an appointment for follow up. The DON reported that she did not document when contact was made. The DON was asked what was in place for monitoring the surgical wound on Resident #905's thigh prior to the infection and complications on 6/21/15. The DON reviewed the Medication and Treatment Administration Records (MAR and TAR) for May 2015, June 2015 and July 2015 and stated, It does not appear there was any other treatment or order until the doctor opened up the wound. Documentation from the vascular surgeon appointment on 7/2/15 was requested. The DON stated, I thought we scanned it in, but it's not in there. I do not have any documentation from that appointment. The DON was asked if the attending physician at the facility was contacted regarding Resident #905 when his vascular surgeon could not be reached for follow up. The DON reported that she did not contact the facility's physician. TARS were reviewed on 7/16/15 at 11:00 A.M. for May 2015, June 2015, and July 2015. The May 2015 TAR revealed no nurse's signature for NPWT to RLE on 5/8/15 and 5/28/15. The June 2015 TAR revealed no nurse's signature for NPWT to RLE on 6/13/15, 6/16/15, and 6/20/15. On 7/16/15 at 2:00 P.M., the DON was further interviewed. The TARs for Resident #905 were reviewed with the DON for May 2015 and June 2015. The DON was shown the missing signatures for the NPWT for Resident #905. The DON stated, In the nursing world, if it's not documented, it's not done. The DON was queried regarding the proper technique for NPWT and the gap that was observed between the drapes of the wounds on Resident #905's calves. The DON explained there should be no intact skin exposed between the drapes, especially when bridging the wounds. The DON was queried about the proper technique for adding wound gel to a wound. The DON explained that the nurse should put the gel into a cup and use a tongue depressor or put the gel directly on the gauze. When queried about the observation made of Nurse C using her finger in a non-sterile glove to place the wound gel into the wound on Resident #905's thigh, the DON said it should not have been done that way. Resident #905's clinical record was further reviewed on 7/16/15 at 2:30 P.M. and revealed the following: Physician Notes from 4/30/15 through 7/16/15 did not document anything about the surgical wound on Resident #905's right thigh. Nurse Practioner Notes dated 5/6/15, documented, .The patient c/o severe pain to right lower limb .States does not have scheduled follow up with surgeon .Incision to right upper leg with staples intact and dried blood present . There was no care plan for the surgical wound on Resident #905's thigh in the clinical record. The facility's policy titled, Surgical Incisions (undated) was reviewed on 7/16/15 at 2:40 P.M. and documented the following: .Possible complications of Surgical Incisions: Wound dehiscence is a separation of the surgical incision .signs of infection include: a yellow or green discharge .a change in odor .redness or hardness of the surrounding area .increasing or unusual pain .Follow up: Assess and document incision characteristics (i.e. drainage, color, inflammation, approximation) in nurses notes initially and at every dressing change. Document surgical incisions and characteristics in the virtual body and within: for new skin alterations .for weekly skin measurements .for daily wound care .Follow physician's instructions . ( ) Deficient Practice #2 Based on interview and record review, the facility failed to ensure there was a coordinated plan of care and communication between the facility and the hospice agency for one (#909) of one sampled resident reviewed for hospice, from a total sample of 14, resulting in the potential for unmet psychosocial and physical care needs at the end of life. Findings include: A review of Resident #909's clinical record was conducted on 7/16/15 at 10:00 A.M. The record revealed that Resident #909 was on hospice and admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] documented that Resident #909 had intact cognition and required limited physical assistance for bed mobility, transfers and ambulation; and extensive assistance with bathing and toileting. A Care plan dated 7/6/15, documented, .has a terminal prognosis r/.[MEDICAL CONDITION] (stomach) .She is under hospice care .Interventions: .Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met . The DON was interviewed on 7/16/15 at 2:00 P.M. regarding coordination between the hospice agency and the facility for Resident #909. The DON stated, If there are any changes, the nurses let the nurse practicioner know and they will contact the physician. When queried about the hospice schedule, the plan of care, and what dates the hospice agency has been to the facility to see Resident #909, the DON stated, I don't know the answer to that. The clinical record was reviewed for Resident #909 and revealed a contract between the facility and the hospice agency, but no contract or individualized plan of care for Resident #909. Nurse H was interviewed on 7/16/15 at 3:30 P.M. regarding the frequency of hopice visits for Resident #909 and how the care is communicated and coordinated between the facility and the hospice agency. Nurse H stated, I think they (hospice) come once a week, but I work afternoons. I have only seen the nurse (hospice) twice since (Resident #909) has been here. Nurse H was asked if the hospice agency left any documentation or communication when they came to the facility. Nurse H stated, Not that I know of. If there's an emergency we would call her physician or nurse practicioner. A policy for hospice coordination was requested from the DON on 7/16/15 at 2:30 P.M., however, the DON reported that they facility did not have one. ( )