Every finding on record at WellBridge of Romeo

Based on observation and interview, the facility failed to provide access to past survey results, affecting 117 residents residing in the facility.Findings include: On 12/15/25 at 9:45 AM, during a tour of the facility, a table was noted with a sign on it saying, previous state survey results book can be found at this location. At 2:00 pm and 3:30 PM there was no book observed on the table. On 12/16/25 at 9:00 AM, 12:00 PM and 3:00 PM, there was no book observed on the table. On 12/17/25 at 9:00 am and 10:00 AM, there was no survey book available on table. On 12/17/25 at 10:05 AM, R9 was observed sitting up in wheelchair watching television. R9 was asked about the survey book and where it was located. R9 could not recall seeing a survey book or knowing where it was located. A review of the medical record revealed R9 admitted into the facility on 7/22/2025 with the following medical diagnoses, Infection of Amputation Stump and Congestive Heart Failure. A review of the most recent Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating intact cognition. On 12/17/25 at 10:30 AM, during an interview with the Nursing Home Administrator (NHA) regarding the accessibility of the survey results, they said the survey results book was in their office. NHA confirmed the survey book was being updated for the current survey but had not been put back out on the table. A review of the facility policy titled, Resident Rights Handbook revealed that 'a resident has the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. The facility must make the results available for examination in a place readily accessible to residents and must post a notice of their availability.' .

Based on observation, interview, and record review, the facility failed to apply heel boots per physician's order for one resident (R61) out of two reviewed for skin conditions. Findings include:On 12/17/2025 at 9:11 AM, R61 was observed in bed with socks on their feet and their heels resting on the bed.A review of the medical record revealed R61 admitted into the facility on 6/8/2024 with the following medical diagnoses, Encephalopathy and Pain in Right Hip. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 3/15 indicating an impaired cognition. R61 also required staff assistance with bed mobility and transfers.A review of the physician orders revealed the following, Bilateral heel lift boots on while in bed every shift. Start Date: 7/1/2024. Status: Active.A review of the December (2025) Treatment Administration Record (TAR) revealed a check (indicating boots applied) on the night shift on 12/16/2025 and day shift on 12/17/2025.On 12/17/2025 at 9:15 AM, an interview was conducted with Certified Nursing Assistant (CNA) B. CNA B was asked if they saw R903's heel boots. CNA B reported they did not see the boots in the room, and they are usually kept in the closet, unless they need to be cleaned. On 12/17/2025 at 9:47 AM, an interview was conducted with Unit Manager (UM) A. UM A observed R903 did not have on heel boots. UM A confirmed heel boots are usually kept in the resident's room, unless they need to be cleaned. UM A reported they would have to check as to why the heel boots were checked as being applied on the TAR, On 12/17/2025 at 12:18 PM, an interview was conducted with the Director of Nursing (DON). The DON reported they were informed R903 refused the heel boots, and they were going to do education regarding heel boots and proper documentation when someone is non-compliant or refuses.A review of a facility policy titled, Physicians Orders did not address following physicians' orders and documentation.

Based on observation, interview, and record review, the facility failed to ensure interventions for repositioning were implemented for care of a pressure injury (skin impairment) for one resident (R35) of three reviewed for pressure ulcer care. Findings include: On 10/08/24 at 10:38 AM, R35 was observed to be on their back in bed with the head of the bed elevated around thirty degrees; their lower legs were elevated on a pillow and an active low air loss mattress was in place. On 10/08/24 at 12:07 PM, R35 was observed to be in bed as before, legs elevated, and the head of the bed elevated around thirty degrees. At 12:43 PM, R35 appeared positioned in bed as before. Licensed Practical Nurse (LPN) D nurse raised the bed a little higher to around 45 degrees and stood next the bed to assist R35 to eat. On 10/08/24 at 1:33 PM, resident observed to be awake, eyes open with the TV on. R35 was observed to be in bed on their back with the head of the bed elevated around 30 to 45 degrees. The legs appeared elevated. R35 reported they were generally not feeling well. At 4:21 PM and 4:40 PM, R35 was observed to be in bed on their backside with the legs elevated. R35 appeared positoned in bed as before. A review of the progress notes revealed no documented refusal to be repostioned. On 10/09/24 at 8:35 AM, 9:06 AM, 10:36 AM, 10:48 AM, and 11:29 AM, R35 was turned toward they're right side with a pillow on the left side behind the torso. R35 appeared asleep with their head toward the right side of pillow. At 10:48 AM and 11:29 AM the heels were on the bed surface. Review of the record for R35 revealed R35 was admitted into the facility on [DATE]. Diagnoses included Falls and Stroke with weakness and paralysis which affected the left side. The Minimum Data Set (MDS) assessment dated [DATE] indicated impaired cognition and the need for partial/moderate assistance for toileting hygiene and total dependence for transfer, toilet transfer, sit to stand, and walking. The nursing care plan Actual skin impairment (related to) terminal pressure injury on sacrum (buttocks) and DTI (deep tissue injury) left heel. Revised 10/06/24 indicated, .turn side to side to stay off sacral wound as tolerated . Also indicated were PRAFO (Pressure Relief Ankle Foot Orthosis) boots while in bed A review of the October 2024 Treatment Administration Record (TAR) and Medication Administration Record (MAR) documented, Turn side to side to stay off sacral wound as tolerated and use positioning device if needed for support as tolerated two times a day. A review of a physician note dated 09/30/24 documented, .Pressure induced deep tissue damage left heel, Patient with noted DTI (non-blanchable deep red, purple, or maroon areas of intact skin) of left heel and stage I pressure ulcer (non-blanchable reddened areas of intact skin) right heel also sacral [NAME] (non healing) ulcer. Patient has declined significantly under hospice care, patient with end-stage skin breakdown/failure. Continue with the frequent position change and also try to keep pressure off of both heels by floating. On 10/10/24 at 8:31 AM, Licensed Practical Nurse (LPN) G indicated R35's sacral area appeared to have improved and did not feel R35 would reposition independently. On 10/10/24 at 11:40 AM, the Director of Physical Therapy reviewed the most recent therapy notes and reported R35 was max assist for transfer, walking and bed mobility. On 10/10/24 at 3:25 PM, the identified concerns were reviewed with the Director of Nursing (DON). The wound pictures of the sacral area were reviewed and indicated the wound had been open and closed but the purple discoloration remained. The DON reported the aide should attempt to reposition the resident on rounds which should be at least every two hours. A review of the Pressure Ulcer Risk Assessment policy revised October 2010 revealed, .Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time .Pressure ulcers are often made worse by continual pressure .

This citation pertains to Intake MI00146218. Based on observation, interview, and record review, the facility failed to document targeted behavior and non-pharmacological intervention attempts and prior to use of a psychotropic medication (ativan/lorazepam) for one resident (R35) of three reviewed for medication use. Findings include: On 10/08/24 at 10:38 AM, R35 was observed to be awake and alert and easily answered yes and no questions and provided detail to answers. At 1:33 PM, R35 was observed to be awake, eyes open with the TV on. R35 reported they were generally not feeling well but was awake and alert. At 4:21 PM and 4:40 PM, R35 was observed to be in bed. At 4:40 PM, R35 had two visitors and was engaged in a conversation. On 10/09/24 at 4:50 PM, R35 appeared asleep on each encounter and did not remain awake or with eyes open after query. On 10/10/24 R35 appeared asleep and did not open their eyes to a knock on the door or a call of their name. At 11:24 PM, the visitor indicated R35 did not awaken to their voice. R35 did not awaken to a knock on the door or a call of their name. R35 appeared to remain asleep and did they open their eyes nor move during the conversation with the visitor. A review of the physician orders for R35 revealed: An order dated 09/05/24 which documented, Lorazepam Oral Tablet 0.5 (milligrams) MG (Lorazepam) Give 1 tablet by mouth every 4 hours as needed for anxiety. The order did not have a 14 day stop date. An order with start date of 09/23/24 for Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 4 hours as needed for anxiety for 6 Months. Document 3 non-pharm interventions prior to giving. An order with start date of 10/07/24 documented, Ativan oral tablet, 0.5 MG Lorazepam, Give one tablet four times daily for anxiety. A review of the September 2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed: The Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 4 hours as needed for anxiety did not have a 14 day stop date. The progress notes indicated upon a pharmacy review dated 09/23/24 the order was discontinued on 09/23/24. No as needed administrations were documented during this time. The Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 4 hours as needed for anxiety for 6 Months Document 3 non-pharm interventions prior to giving was documented as given two times on 09/29/24. A review of the progress notes and September 2024 MAR and TAR revealed no indications of anxiety or non-pharmacological interventions attempted. Further review of the September 2024 MAR documented, (Ativan) Lorazepam Tablet 0.5 MG Give 1 tablet by mouth at bedtime related to Anxiety Disorder was last given 09/16/24. A review of the October 2024 MAR revealed, Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 4 hours as needed for anxiety for 6 Months Document 3 non-pharm interventions prior to giving was documented as given on 10/03/24 and 10/07/24. A review of the progress notes and October 2024 MAR and TAR revealed no indications of anxiety or non-pharmacological interventions attempted. A physician note was dated 09/30/24 and did not indicate increased episodes of anxiety. A nurse note dated 10/07/24 documented weight warning and the request to have the ativan scheduled. It was was further documented the Ativan scheduled four times a day was given on 10/07/24 and had continued four times a day on 10/08/24 and 10/09/24 and had been given at midnight and six AM on 10/10/24. A progress note date 10/07/2024 at 10:44 AM by Licensed Practical Nurse (LPN) E revealed, .Family requesting Ativan to be ordered scheduled as well as (as needed) PRN due to guests recent agitation. Hospice aware. Order ok by (Nurse Practitioner) NP and (doctor) Dr. and hospice. Placing order at this time . The prior note was a weight change warning note dated 10/03/24. No indication of restlessness or anxiety was noted. A review of the hospice note dated 09/26/24 documented, has been more awake and talking since reducing meds .speech has been easier for (R35) . Further review of the Nurse Practitioner and Physician notes dated 07/11/24, 08/02/24 and 08/07/24 documented the chief complaint as fatigue. The 08/07/24 visit note documented a daughter's concern for medication related sedation. A review of the record for R35 revealed R35 was admitted into the facility on [DATE]. Diagnoses included Anxiety Disorder, Bipolar Disorder, Falls and Stroke. The Minimum Data Set (MDS) assessment dated [DATE] indicated impaired cognition and the need for partial/moderate assistance for toileting hygiene and total dependence for transfer. The nursing care plan At risk for changes in mood (related to) r/t Adjustment (Disorder) d/o with anxiety and depressed mood initiated 09/24/21, revised 08/21/24 revealed, .Observe for potential side effects of psychotropic medication prescribed for anxiety, such as drowsiness, fatigue, headache, dizziness, and weight changes. On 10/10/24 at 3:25 PM, the identified concerns were reviewed with the Director of Nursing (DON). The DON was asked about the ativan scheduled four times a day when the as needed had only been used three times and indicated it was related hospice care and the family concerns. The DON was also asked about the missing documentation for the indication for use of a psychotropic medication and documentation of non pharmacological interventions prior to as needed administration of the ativan. The DON indicated they would look into it. No further documentation or information was provided prior to exit. On 10/10/24 at 3:52 PM, the observed sedation of R35 was noted to the Hospice Registered Nurse (RN) F. RN F was asked about the scheduled ativan four times a day and the indications for administration of the as needed Ativan as only three Ativan administrations had been documented. RN F noted the recent discontinuation of many of R35's psych medications and they try to consider resident and family requests to provide comfort for the resident. A review of the policy titled, Palliative/End of Life Care - Clinical Protocol revised October 2010 revealed, .The hospice and facility will communicate with each other when any changes are indicated or made to the plan of care .

Based on interview, and record review, the facility failed to ensure a responsible party (RP)/family member/Durable Power of Attorney (DPOA) was notified when a resident left the facility against medical advice (AMA) for one resident (R111) of one reviewed for notification of changes. Findings include: A record review of R111's electronic medical record revealed the following progress note, 8/13/24 02:53 AM: 8/12/24, around 20:40 (8:40 PM) [R111] stated to writer that [they] [were] leaving [Nursing Home] tonight with [their two friends]. [R111] stated that [they] [were] going to the [Upper Peninsula] and [they] will not be returning to [nursing home]. Conversation had with [R111] encouraging [them] to stay at facility and [they] continued to refuse. [R111] asked plans for transportation, where [they] will be staying once [they] left the facility as well as who is going to provide care for [them] when needed. [R111] stated that [their] friend [had] transportation, provides shelter and her two friends will help care for [R111] DON (Director of Nursing) contacted regarding situation and spoke directly with [R111] about [their] decision to leave AMA. DON suggested to [R111] that [they] stay tonight so our team can speak with [them] in the morning, make proper arrangements for possible homecare and provide all available resources to guest before leaving against medical advice and [R111} continued to refuse. [R111] made aware of the importance of medication compliance and that [they] [had] prescription medications that will need to be filled by a doctor. [R111] made aware that [they] need a physician overseeing [their] care and also made aware that [they] need someone to help provide care for [their] basic needs and medical needs. [R111] claimed [that their] pain medications [they] received here do not work for [them] anyway's and [that they] do not need a doctor. [R111] also claims that [they] have [their] two friends that can help with [their] care and [they] can also provide [their] own care for [themselves], as [they] [have] always done so before. [R111] continued to refuse to stay at [nursing home] despite multiple attempts and conversations with writer and DON. MD (Medical Doctor) contacted by DON, notified of situation and said 'Okay it is AMA.' [R111] signed face sheet stating [they were] leaving against medical advice on 8/12/2024 at 21:20. Further record review revealed the following email sent to R111's designated responsible party (RP) C by Social Services Director (SSD) A on 8/13/24 at 9:39 AM, Wanted to let you know that to my surprise, found out this morning that [R111] is no longer at the facility. I'm not sure if you were aware of that. [R111] checked [them self] out last night, stated [they] [were] going to live with friends. Several staff members had discussions with [R111] but [R111] [insisted] on leaving . Further review of R111's progress notes revealed the following, On 8/16/24 1421 (2:21 PM) Phone call received from [Social Worker] from an [out of state hospital] stating that [R111] had arrived at the emergency room (ER), 'caked in urine and feces' with [their] [friend]. [Friend] stated that [R111] was unable to transfer from vehicle to the restroom and [that they] [were] unable to transfer [R111]. [R111] had not exited vehicle since leaving [nursing home] [Social Worker] stated that [R111] provided phone number for [RP/Family member] and requested writer to confirm phone number. [Social Worker] also requested rx (prescription) list and DPOA (durable power of attorney) papers to assist w (with)/ initiation of care and discharge planning. Writer sent information to [Social Worker]. Continued review of R111's EMR revealed family member C was indicated in R111's record to be the responsible party and DPOA. A document titled, .DPOA For Healthcare was signed by family member C and dated 7/19/22. Per review of R111's EMR, R111 was originally admitted to the facility on [DATE] with diagnoses that included Multiple sclerosis (autoimmune disease) and Chronic obstructive pulmonary disease (COPD) (lung disease). R111's most recent quarterly minimum data set assessment (MDS) dated [DATE] revealed that R111 had a moderately impaired cognition, was dependent for toileting, and required assistance with showering, bathing, and dressing. On 10/9/24 at 4:04 PM, Registered Nurse (RN) B was interviewed by phone and asked about the discharge of R111 from the facility on 8/12/24. RN B indicated that R111 made the decision to leave the facility and discharge with a friend on, the spur of the moment. RN B was asked if R111's RP/DPOA/Family member C was contacted regarding R111's discharge from the facility. RN B' was not able to provide an answer to this question. On 10/10/24 at 12:12 PM, R111's RP/DPOA/Family member C was contacted by phone and asked about R111's discharging from the facility on 8/12/24. Family member C stated, This is a messed up situation. They shouldn't have let [R111] go without notifying me. [R111] left with someone I consider to be a stranger. Family member C indicated that they had not spoken to [R111] in over three weeks and were unaware of [R111's] current whereabouts. Family member C indicated that [R111] was incontinent and dependent upon others for their care. Family member C stated, I'm very upset that the [nursing home] let [R111] leave their facility without notifying me. On 10/10/24 at 12:47 PM, The Social Service Director (SSD) A was interviewed about R111 leaving the facility AMA and asked if the RP/Family Member/DPOA should have been contacted upon R111 leaving the facility. SSD A stated, [R111] was her own RP when they left the facility. The business office changed it, I had nothing to do with it. SSD A was further interviewed and asked if they had any documentation to provide which indicated that R111 was their own RP on 8/12/24 when they left the facility AMA. SSD A was unable to provide any documentation to the surveyor regarding this issue. On 10/10/24 at 1:16 PM, the Director of Nursing (DON) was interviewed about R111 leaving the facility AMA and asked if the RP/Family Member/DPOA should have been contacted upon R111 leaving the facility. The DON stated, [R111] was cognitively intact. The DON further indicated that they felt that it was unnecessary to contact [R111's] RP/Family Member/DPOA regarding [R111] leaving the facility AMA. A facility policy titled, Discharge or Transfer of Resident Effective: 10/24/17 was reviewed and revealed the following, Purpose: To provide safe departure from the center .To provide guidelines to ensure the proper steps are taken should a resident .request to be discharged from the center against medical advice (AMA). Discharge Against Medical Advice: 1. The resident/guest/and/or family legal representative should be informed of the risk involved, the benefits of staying at the facility and alternatives to do both .2. Document in the Medical Record regarding the information was presented to .the family responsible party if needed. 3. Notify Adult Protective Services .if self-neglect is suspected and document as needed. A facility policy titled, Change of Condition Resident Family/Responsible Party Notification Revision Date: 4/12/16 was reviewed and revealed the following, Purpose: Family and/or responsible party are notified anytime there is a change in the resident's condition or plan of care. Procedure: 1. Notification of any change in the resident's condition will be done in a timely manner .Check the medical record for specific family/responsible party instructions regarding notification. 2. Notify appropriate party and record in resident's medical record.

This citation pertains to Intakes MI00143027, MI00143206, and MI00142945. Based on observation, interview, and record review the facility failed to protect and report an allegation of abuse to the abuse coordinator in a timely manner, for one resident (R902) of three residents reviewed for abuse. Findings include: A review of the Intake revealed, It was alleged the resident was physically and verbally abused by an employee. A review of R902's medical record revealed, R902 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Acute and Chronic Respiratory Failure with Hypoxia. A review of R902's Minimum Data Set (MDS) assessment dated [DATE] noted, R902 with an intact cognition and dependent of staff to complete activities of daily living. On [DATE] at 10:50 AM, R902 was observed sitting on the side of the bed. R902's face was observed with bruising around both of their eyes. R902 was asked how their eyes became bruised. R902 explained that they didn't know, but it was not related to this incident (physical abuse) and that they bruise easily. R902 was asked about the incident with Certified Nursing Assistant (CNA A). R902 explained that CNA A punched them in their left arm and grabbed them hard. R902 continued and stated that this was the first time something like this had happened. R902 explained, that they were up that night and couldn't sleep and that they pressed their call light, and it seemed that CNA A had a problem with them pressing the light. R902 was asked the time the incident occurred and explained they couldn't remember but it was late around 1:00 AM on [DATE]. R902 was asked if they reported the incident right away and stated, Yes. R902 explained they reported the incident to their nurse. R902 added that they always offer the CNAs candy after the care, but they did not offer CNA A any after this incident. On [DATE] at 12:24 PM, CNA A was interviewed via phone and was asked about the incident with R902. CNA A explained that the incident was on a Friday night. They were short staffed and that they had been in (R902's) room one time for care. CNA A stated, Because we were so short (staffed), I had two hallways. When you go in R902's room [R902] is always at the bottom of the bed. I pulled [R902] up and changed them. After I was done [R902] asked me to turn off their decorative lights and to hand them a heart frame picture that had their deceased family in it with them. CNA A stated, [R902] had said they [family member] had just passed away. I said I was so sorry and after I was done [R902] offered me a (chocolate) kiss, but I declined. CNA A was asked around what time did this interaction occur, CNA A stated, around 1:45 AM. CNA A explained that sometime after that R902 put the light on and requested a pain pill. CNA A said they told Nurse B and they replied that R902 had to wait 30 minutes before they could get the pain pill. CNA A stated they think they went back and told R902 what Nurse B said about the pill. CNA A stated, Around 1:55 AM, I reminded Nurse B to give R902 the pain pill. After Nurse B came out, Nurse B told me [R902] said I punched [them]. CNA A then explained that Nurse B implied that they didn't believe R902, but to not go back to R902's room. CNA A further explained that next day they received a call from them Director of Nursing (DON) around 1:00 PM, about the allegations and that they were suspended because of the allegations. CNA A was asked if they worked the rest of their shift after Nurse B reported the allegation to them. CNA A stated, I worked 7pm-7am the entire shift. I was just told not to go back to that room. CNA A was asked if they went back into R902's room. CNA A stated, Yes, to check on the roommate. On [DATE] at 12:06 PM, Nurse B was called for an interview, a voice message was left for a return call. A review of the facility's investigation statement by Nurse B revealed, On the night of [DATE] going into [DATE] writer was nurse on shift on 200 hall. On [DATE] a few hours into the shift, the [CNA A], came to writer and said [R902] wanted to speak to nurse. Writer went into guest's bedroom, guest was lying in bed, vitals were taken and blood pressure was slightly elevated ., writer asked guest if [R902] was okay because a few hours earlier, guest blood pressure was lower ., guest informed writer [R902] did not feel safe with that aide. And guest expressed how at times [CNA A] will refuse to change guests brief, and when [CNA A] does change guests brief, guest states she is too rough with me, these bruises are probably from her. Guest expressed to writer that any time aide works 200 hall , aide is rude to guest, rough with care with guest ., she says she has too many people to change.Writer informed guest that she would speak with aide and make sure aide did not enter guests' room to perform care for the rest of the shift. Writer went into hallway after departure from guest's room to find CNA, CNA was sitting in chair in the hallway, on her laptop, head down. Writer told CNA that if a call light for [R902' room] goes off, to inform writer or the other CNA on shift and care will be provided from writer or other CNA, writer told CNA that guest does not want CNA back in room . Writer arrived for night shift on [DATE], writer was getting report from off going nurse . Nurse expressed to writer that this morning, the guest in [R902's room] informed her that after the writer left the guests room last night, CNA went back in guests' room, after the writer spoke with the CNA instructed her to not to enter guests' room . On [DATE] at 1:20 PM, the DON was asked the facility's procedure after an allegation of abuse from staff is made by a resident. The DON explained that the staff is sent home and that the allegation is reported to the abuse coordinator, which is the Nursing Home Administrator (NHA). The DON further explained that they didn't get the report of abuse until the next day. The DON was asked if Nurse B followed the facility's procedure with this allegation. The DON explained that Nurse B did not and that they were educated on the abuse policy and procedure. On [DATE], at 2:12 PM., the NHA was asked the facility's expectation regarding reporting allegations of abuse. The NHA explained, the Nurse should have called us right away. She had both of our personal numbers. A review of the facility's investigation documentation noted, a timeline by the NHA that revealed, [DATE] 12:44 PM, Notified of an allegation of abuse by the DON. DON stated she initiated investigation, suspended CNA and will interview resident for her statement . [DATE] 3:38 PM Reported to [local police department] and asked for an officer to be sent to the facility . A review of the facility's policy titled ABUSE, NEGLECT AND/OR MISAPPROPRIATION OF RESIDENT FUNDS OR PROPERTY dated, [DATE] revealed, . d) PROTECTION & IDENTIFICATION i) The Administrator and/or Director of Nursing (DON) must be notified of all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown origin and misappropriation of resident property immediately. If the events that cause the allegation involve abuse or result in serious bodily injury, the facility administrator or DON will report to appropriate licensing agencies and local officials immediately but not later than 2 hours and not later than twenty four (24) hours if the events that cause the allegation does not involve abuse and did not result in serious bodily injury. ii) . Managed Communities will take all action necessary to prevent the abuse, neglect, or misappropriation of the resident ' s funds or property from occurring while it is conducting its investigation of the incident, and will also take appropriate action to attempt to prevent similar incidents in the future. (1) Protect the Resident. (a) If the resident is injured as a result of the alleged or suspected abuse or neglect, the center shall take immediate action to treat the resident. If appropriate, the center shall send the resident to the hospital for an examination. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. Protection from retaliation; and -Providing emotional support and counseling to the resident during and after the investigation, as needed .

Based on observation, interview, and record review, the facility failed to provide assistance during meals for one sampled resident (R68) of three reviewed for activities of daily living (ADLs), resulting in difficulty eating and the potential for discomfort. Findings include: On 8/14/23 at 8:43 AM, R68 was observed in bed sitting in a fowler's position (semi-sitting position at a 45-60 degree angle) with a cushion device underneath their knees. Two call lights were clipped/hanging behind the resident's bed and out of reach. R68 was attempting to eat breakfast and had spilled a cup of fruit onto the table in front of them. R68 struggled to pick up pieces of spilled fruit to try and eat. No staff were present to assist the resident. When queried if they were comfortable, R68 stated, Not in this position, no. R68 was somewhat confused but was oriented to person and place when queried throughout the interview. A review of R68's record revealed that the resident was initially admitted into the facility on [DATE] and readmitted on [DATE]. R68 started receiving hospice services on 6/15/23. A review of R68's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident is moderately cognitively impaired with medical diagnoses of Arthritis, Dementia, Seizures, and Anxiety. A review of R68's care plan revealed: -Goal: Will receive assist with meals, as needed. Date Initiated: 02/01/2021 Revision on: 07/20/2023. -Intervention: Staff providing set up, encouragement, total assist with meals, as needed. Date Initiated: 02/01/2021. Further review of R68's record revealed the following progress notes: -8/8/2023 14:20 (2:20 PM) Skilled Charting Note Text: guest states I'm having a harder time using my hand, I can't grip things like I use to, referral to therapy. -8/8/2023 14:34 (2:34 PM) Skilled Charting Note Text: Guest on hospice, guest to be a assist feed. On 8/14/23 at 12:52 PM, R68 remained in bed in a semi-sitting position with a cushion under their knees. R68 was observed eating lunch with no staff assistance. R68 had successfully eaten some lunch on their own but was unable to reach some of the cups placed at the back of their lunch tray. On 8/14/23 at 1:01 PM, R68 was observed struggling to feed themselves a red-colored food item from a cup and remained unable to reach the items at the back of the tray. No staff were present or observed rounding to assist the resident. On 8/15/23 at 8:15 AM, R68 was observed lying in bed in a semi-upright position with their heels on the mattress. R68 had some eggs left on their adaptive plate, but was observed to have a dropped both a full piece and half piece of toast and other food debris onto themselves (onto their sheet in bed). R68's adaptive cup was also lying on its side in their bed next to them. R68 was asked if someone had helped them eat breakfast this morning. R68 indicated that no one had helped them and asked if this surveyor would help them finish eating. On 8/15/23 at 8:29 AM, staff was observed taking R68's breakfast tray away without the resident receiving assistance to finish their meal. On 8/15/23 at 12:12 PM, R68 was observed sitting upright in their wheelchair in the dining room. R68 sat at a table and was observed feeding themselves lunch without much difficulty. Staff was observed walking by periodically to check on R68 and the other residents in the dining room. On 8/15/23 at 1:16 PM, Certified Nursing Assistant (CNA) D was interviewed and queried regarding R68's level of assistance required during meals. CNA D stated that R68 has some good days and some bad days, i.e. days they need more assistance than others. CNA D pointed out that today seemed like a better day for R68 in terms of being able to feed themselves. CNA D stated that sometimes R68 does not want to get up out of bed for meals and that if R68 is eating a meal while in bed, the resident has to be sitting completely upright with nothing underneath their legs. On 8/16/23 at 10:22 AM, the Director of Nursing (DON) was interviewed and queried regarding R68's level of assistance required during meals. The DON indicated that there are days the resident can feed themselves and staff tries to encourage that. The DON added that she expects staff to set up R68's tray and make rounds to check on the resident and others who may require assistance eating, and offer assistance if needed. A review of the facility's policy/procedure titled, Assisting the Nurse in Examining and Assessing the Resident, revised October 2010, revealed, .During your daily contact with the resident, be observant of the resident's level of independence in performing ADL. As you observe the resident, note if the resident performs activities of daily living a. With assistance, b. With some assistance, or c. With total assistance; .Eating: As you serve the resident his or her meals, you should note: a. assistance needed with eating .b. The amount and types of food eaten; and c. Any changes in the resident's eating habits . 46956 Based upon observation, interview and record review, the facility failed to provide timely nail care for one (R67) of five residents reviewed, resulting in the nails of the contracted left hand embedding into the skin of the palm and the potential for skin breakdown. Findings include: Review of the facility record for R67 revealed an initial admitted [DATE] with the most recent admission being 03/03/23 with diagnoses that included Respiratory Failure with Hypoxia, Heart Failure, Rheumatoid Arthritis and Hand [left] Contracture. The Minimum Data Set (MDS) assessment dated [DATE] indicated R67 required moderate/maximum assistance with most self care activities. The Brief Interview for Mental Status (BIMS) assessment score of 15/15 indicated intact cognition. On 08/14/23 at 11:54 AM, R67 was observed to be wearing a left hand palm protector. R67 demonstrated that their fingers did not open on that hand and they reported that they were able to take the palm protector on and off independently. On 08/15/23 at 11:59 AM, R67 was observed laying in bed without the left hand palm protector on. R67 was able to hold the left hand up and manually open the fingers to allow observation of the palm which was significantly red and had nail indentations from digits four and five (ring and pinky fingers). R67 reported that their nails were digging into the palm and stated I like to have the nails on that hand kept shorter but they haven't been cut in awhile. The nails were observed to be approximately one half inch beyond the finger tips and with sharp corners. The hand and nails did appear clean and there was no foul odor. On 08/16/23 at 8:57 AM, R67 was observed sitting up at the edge of the bed eating breakfast. R67 reported that their nails on the left hand had been cut yesterday afternoon after they asked the nurse about it. The palm protector was not on and the hand could be observed to see that the nails had been cut and that the palm continued to have residual nail indentations from digits four and five. Review of R67's facility Care Plan dated 05/26/23 revealed, in the ADL (activities of daily living) focus area, inclusion of the goal [resident]Will be neat, clean and well groomed daily and the related intervention of Provide nailcare as needed. Review of R67's facility Kardex revealed, under the Resident Care category, inclusion of the statement Keep fingernails short. On 08/16/23 at 11:50 AM, the facility Director of Nursing (DON) reported that R67's daughters often assist with their nail care however they hadn't been visiting as often during the summer. Review of the facility policy provided to address ADL care which is titled Quality of Life - Dignity and is undated, includes the statement 3. Residents shall be groomed as they wish to be groomed (hairstyles, nails, facial hair, etc.). On 08/16/23 at 12:59 PM, the facility DON was asked if they would expect that R67's nails would be kept short enough to not imbed into the palm and they stated Yes, as long as the resident is compliant with the nail care. Sometimes residents are resistive to having the nail care and if that's the case we use a non-compliance care plan.

Based on observation, interview, and record review, the facility failed to administer intravenous (IV) medication per professional standards of nursing practice for one resident (R278) of five reviewed for medications, resulting in the potential for error and/or adverse reactions. Findings include: On 8/14/23 at 10:47 AM, R278 gave this surveyor their name during initial tour screening. R278 was noted to have an intravenous (IV) medication infusing through a PICC (peripherally inserted central catheter) line in their left arm. Closer observation of the label on the medication bag revealed an almost empty bag of Daptomycin (antibiotic) - 1000 milligrams (mg) per 50 milliliters (mL). The full patient name written on the bag did not match the name of R278. (same first name as R278; different last name). The medication was administered through dial-flow tubing. Registered Nurse (RN) A was nearby and was asked to enter the room at this time. RN A confirmed that the name on the IV medication bag did not match R278's name. A review of R278's record revealed that the resident was admitted on [DATE] with diagnoses of Local Skin and Subcutaneous Tissue Infection, Acute Embolism and Thrombosis of Left Femoral Vein, and Hypertension. Further review revealed the following medication order: Daptomycin Intravenous Solution Reconstituted - Use 900 mg intravenously in the morning for Left knee periprosthetic infection until 09/11/2023 .Active .Start Date: 8/11/2023 07:00 . On 8/14/23 at 10:53 AM, R278's assigned nurse, Licensed Practical Nurse (LPN) C, was interviewed and confirmed that the name on the IV medication bag did not match R278's name. LPN C claimed she had reconstituted the medication correctly per R278's order and added that she must have only looked at the first name listed on the bag. When queried regarding how nurses are supposed to identify they have the right patient before administering a medication, LPN C stated that there are photos in the residents' electronic medical records (EMRs). On 8/16/23 at 10:22 AM, the Director of Nursing (DON) was interviewed and indicated that RN A had done an immediate 1:1 education on 8/14/23 with LPN C regarding the rights of medication administration (right patient, right drug, right dose, right route, right time, right documentation) and labeling. The DON added that starting on 8/14/23, all staff nurses were receiving in-service education on medication administration. A review of the facility's policy/procedure titled, Medication Administration General Guidelines, dated 01/21, revealed, Policy: Medications are administered as prescribed in accordance with .good nursing principles and practices .Residents are identified before medication is administered using at least two resident identifiers .Medications supplied for one resident are never administered to another resident .

Based on observation, interview and record review, the facility failed to develop a care plan to address the feeding assistance requirements and interventions for one (R92) of five residents reviewed for plans of care, resulting in the potential for unmet care needs. Findings include: Review of the facility record for R92 revealed an initial admitted [DATE] with the most recent admission being 03/25/23 with diagnoses that included Vascular Dementia, Osteomyelitis of the Ankle/Foot and Diabetes Mellitus. The Minimum Data Set (MDS) assessment dated [DATE] (Significant Change in Status Assessment) indicated R92 required partial/moderate assistance for eating. The Brief Interview for Mental Status (BIMS) assessment score of 0/15 indicated severe cognitive impairment. On 08/14/23 at 9:21 AM, R92 was observed receiving assistance for eating breakfast. They required consistent cueing for alertness and appeared to be very minimally able to participate. On 08/15/23 at 4:02 PM, R92 was observed sitting up in the wheelchair in their room alone. R92 was intermittently responsive to voice and was leaning to the left side against the armrest. There was spilled food, a napkin and a spilled water cup laying on the floor near their feet. On 08/16/23 at 9:00 AM, R92 was observed laying in bed with the head of the bed elevated approximately 45 degrees. The breakfast tray was set up on the over-bed table and was uneaten. The coffee cup was empty and the tray was covered with coffee. The serving dishes, bowls and utensils were sitting in the spilled coffee. At 9:26 AM, R92 remained directly observed and had not been checked on or assisted since 9AM. At 9:29 AM, an unkown staff entered/exited R92's room without any interaction/assistance provided to R92. At 9:45 AM, R92 was observed in the previous position with the food tray unchanged. When asked if they were hungry R92 stated You're damn right I am. When asked if they could try to eat some food R92 was not able to respond clearly. At 9:49 AM, Licensed Practical Nurse (LPN) G and a Certified Nurse Assistant (CNA) entered R92's room together. At 9:59 AM, LPN G exited R92's room with the breakfast tray. During interview with LPN G it was observed that the breakfast remained uneaten. LPN G was asked if R92 required or was care planned for feeding assistance and LPN G stated Yes and reported that R92 sometimes accepts the feeding assistance and sometimes they do not. LPN G was asked if assistance had been attempted with this meal and they stated Yes, but it didn't go too well. Review of R92's Activites of Daily Living (ADL) Care Plan dated 07/28/23 revealed no interventions that addressed eating/feeding assistance. Review of R92's Dietary Profile dated 07/30/23 indicates that R92 requires Partial assistance with eating consistent with the MDS assessment. On 08/16/23 at 12:09 PM, the facility Director of Nursing (DON) reviewed R92's care plan and agreed that feeding assistance was not directly addressed on the care plan. Review of the undated facility policy titled Care Planning - Interdisciplinary Team revealed the following Policy Statement: Our facility's care planning interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident.

Based on observation, interview, and record review, the facility failed to obtain a physician order for oxygen use and store oxygen equipment in a sanitary manner for one resident (R70) of one reviewed for oxygen use, resulting in the potential for equipment contamination and unmonitored oxygen utilization. Findings include: On 8/14/23 at 11:10 AM, R70 was interviewed and indicated they were drowsy but having some pain. R70 was noted to be receiving hospice services. Nasal cannula oxygen tubing was noted lying on the residents bed and connected to a concentrator at two liters per minute (2L). R70 complained of a scab in their nose that is irritated by the oxygen. R70's CPAP (continuous positive airway pressure machine for sleep apnea) mask was observed hanging over their bedside dresser without a storage barrier. R70 repeated that they were feeling drowsy and indicated they wanted their oxygen applied. A review of R70's record did not reveal a physician's order for oxygen administration. Further review revealed that the resident is cognitively intact and was admitted into the facility on [DATE] with medical diagnoses of Malignant Cancer, Anxiety, Mild Intermittent Asthma, and Obstructive Sleep Apnea. On 8/14/23 at 2:29 PM, R70 was observed sleeping in bed. The resident now had their oxygen applied. On 8/15/23 at 9:30 AM, R70 was observed sitting up in their wheelchair in their room. R70 continued to talk about the irritation in their nostril and stated they believe it is from the oxygen tubing. R70 confirmed that they do require the application of supplemental oxygen via nasal cannula at times. The resident's CPAP mask was observed hanging on their bedside dresser with the left side of the mask touching the dresser without a barrier. R70's oxygen tubing was observed curled up and directly touching the carpeted floor. When the tubing being on the floor was mentioned to the resident, they replied, That's probably how you pick up things (germs), it's probably not supposed to be on the floor. An clear empty storage bag was observed hanging on the concentrator. On 8/15/23 at 9:46 AM, Licensed Practical Nurse (LPN) E was interviewed and confirmed the observations of R70's oxygen tubing and CPAP mask. LPN E stated she didn't think anything was wrong with the mask storage but stated that the oxygen tubing should not be on the floor. When queried if supplemental oxygen use requires a physician order, LPN E replied, Yes, I believe so. A review of the facility's policy/procedure titled, Departmental (Respiratory Therapy) - Prevention of Infection, revised August 2012, revealed, .8. Keep the oxygen cannulae and tubing used PRN in a plastic bag when not in use .

Based on interview and record review, the facility failed to consistently implement effective fall prevention interventions and adequately supervise one (R125) of three closed record residents reviewed, resulting in multiple falls. Findings include: A review of R125's census information revealed that the resident was originally admitted into the facility on [DATE] and transferred to the hospital less than 24 hours later. The resident was then readmitted on [DATE] and transferred to the hospital on 7/4/23. R125 was again readmitted on [DATE] and passed away in the facility on 7/22/23. An initial record review revealed that R125 experienced five falls during their admission on the following dates: 5/25/23 (unwitnessed), 6/3/23 (unwitnessed), 6/13/23 (witnessed), 6/20/23 (unwitnessed), and 6/22/23 (witnessed). The resident's diagnoses while in the facility included Traumatic Subdural Hemorrhage With Loss Of Consciousness Of 6 Hours To 24 Hours, Subsequent Encounter, Muscle Weakness, Dementia, Altered Mental Status, and Anemia. A review of R125's admission fall risk assessment dated [DATE] categorized the resident as being at High Risk for falls with the following details noted: -History of Falls within the last six months: Multiple Falls . -Memory and Recall Ability: In the last 7 days: recalls three out of the four of the following; current season, that he/she is in a nursing home, location of room, staff names/faces: Never . -Gait Analysis: Exhibits loss of balance while standing, Decrease in muscle coordination .Intervention/Comment: Guest educated to use call light when assistance is needed . A review of R125's progress notes revealed the following: -5/18/2023 22:56 (11:56 PM) Admission Summary .Guest is here with a primary diagnosis of fall, weakness from hospital. Guest has wound in the top of her head with 6 staple from prior fall . -5/25/2023 11:00 (AM) Skilled Charting Late Entry: Note Text: Patient was in her room with her husband. At some point, the patients husband left to return home and the patient was left sleeping in bed. The RN (Registered Nurse) and Aide were unaware that the patients husband had left. Upon walking past the room, the aide noticed the patient sitting on the floor directly beside the bed on her bottom. Aide called nurse into room. The nurse assessed patient for injury. No signs of injury present. Patient unable to state if she was injured or lost consciousness. Vital signs were taken and within normal limitations. Skin assessment performed with no new wounds noted. Nurse and aide assisted patient into wheelchair and brought out of room to sit with nurse/aide for further supervision. Patient husband notified. DON (Director of Nursing) notified. MD (Physician) notified. Received orders for PRN (as needed) Xanax (antianxiety). -5/26/2023 11:44 (AM) Physician Progress Note .[Resident with] past medical history of hypertension, atrial fibrillation and dementia initially was hospitalized with fall and subdural hematoma. Patient was at SAR (sub acute rehab-facility) sent back to the hospital same night with possible seizure-like activity. Patient now is back .for rehab. Patient is being seen today to follow-up on a fall that occurred yesterday evening as well as noted increased anxiety. On assessment patient is resting sitting upright in her wheelchair and appears comfortable. She remains confused her baseline cognitive status and is pleasant and cooperative on assessment this morning. Nursing staff is reported that patient has had intermittent anxiety, restlessness and occasional combative behavior. Assessment/plan: .Contusion of right lower leg- Patient with small area of contusion to right lower extremity on shin. No pain or tenderness with palpation. Uncertain if related to fall or if patient may have come in contact with furniture in her room while self-propelling in her wheelchair. Discussed with nursing staff to monitor site . -6/3/2023 14:45 (2:45 PM) Incident Note .Writer noticed guest on floor on buttocks at table near nurses' station at approximately 1300 (1 PM). Writer assessed guest for any major or minor injuries, vitals taken. Staff assisted guest off floor into wheelchair. Guest Vitals stable .No major or minor injuries noted. Guest unable to verbalize if she hit her head. Neuro checks initiated. Guest husband .on call physician, and DON notified. Guest currently in chair near nurse station with no noticeable concerns from normal baseline . -6/6/2023 21:01 (9:01 PM) Incident Note .Investigation Summary: On 5/25/23 at approximately 15:58 (3:58 PM), guest was in her room with her husband. At some point, guest's husband left to return home and the guest was left sleeping in bed. The RN and Aide were unaware that the guest's husband had left. Upon walking past the room, the aide noticed the guest sitting on the floor directly beside the bed on her bottom. Aide called nurse into room. When asked what happened, guest was unable to answer, guest historically with marked confusion. The nurse assessed guest for injury. No signs of injury present. Guest unable to state if she was injured or lost consciousness. Vital signs were taken and within normal limitations. Skin assessment performed with no new wounds noted. Neuro checks started and was within baseline .Range of motion (ROM) assessed and was within baseline .Nurse and aide then 2PA (two person assist) assisted guest into wheelchair and brought out of room to sit with nurse/aide for further supervision and safety .Received orders for PRN Xanax. Orders placed for Post Fall charting x 3 days. Care plan updated, intervention is to keep guest in common area for safety when family is not visiting to monitor guest -6/6/2023 16:28 (4:28 PM) .Investigation Summary- On 06/03/2023 at approximately 1300 the nurse observed the guest on the floor near the nurse cart. The guest was sitting on her buttocks with her legs fully extended in front of her. The nurse assessed for immediate injury and no injury was noted. The guest was unable to recall what happened. The nurse asked the guest if she had pain and the guest did not verbalize pain. ROM to bilateral upper and lower extremities performed with no c/o (complaints of) pain voiced. Neuro checks initiated and were within the guest baseline. The guest was assisted off of the floor and into the wheelchair. The physician was notified and no new orders were given. The guest spouse was notified. Interventions in placed and care plan updated. Intervention is to encourage and offer guest activities while in common area . -6/13/2023 23:01 (11:01 PM) Skilled Charting Note Text: Writer was notified by staff that guest had fall in common area. Guest was assessed for ROM and skin assessment performed. Guest has small skin tear to left forearm with treatment order in place. Guest was assisted back into wheelchair and remains out in common area with staff .Fall was witnessed by staff and guest did not hit head. VSS (Vital signs stable). -6/14/2023 10:20 (AM) Physician Progress Note .Patient with a witnessed fall in commons area yesterday evening. Sustained small skin tear to left forearm but no other evidence of injury. Patient with underlying Alzheimer's dementia and significant baseline confusion. Patient with very poor safety awareness and frequent impulsive behavior which places patient at increased risk for falls. Continue frequent reminders to patient utilize call button to request staff assistance. Fall precautions reviewed with both patient as well as nursing staff . -6/20/2023 11:08 (AM) .Investigation Summary: On 6/13/23 at approximately 2253 (10:53 PM), guest was witnessed by another nurse stand up and fall in the common area as she was sitting in front of 200 Hall, charting. Staff immediately alerted nurse and the nurse went to assess guest. Guest had a small skin tear to L (left) elbow. Witness stated that guest did not hit her head. Guest was then assessed for further injuries, no other injuries noted. Guest with severe confusion and was unable to answer when asked why she stood up and fell . Guest was 1PA (one person) assisted back to wheelchair and guest to remain in common area in front of 300 Hall. VSS. Neuro checks initiated and were (normal) .ROM assessed and were within baseline .Skin tear to L elbow was cleaned .On call MD .notified, orders received to continue neuro checks and monitor guest at this time. DON notified. Husband .called and notified of situation. Orders placed for Post Fall charting x 3 days. Care plan updated, intervention is to ensure that guest is wearing proper non-skin footwear while in wheelchair and to ensure that guest stay in the common area for closer monitoring . -6/20/2023 13:20 (1:20 PM) Skilled Charting Note Text: Guest was seen by writer at 1300 (1 PM) sitting on her right hip sitting up on floor near dining room area/Nurses' area. Guests' feet were curled up underneath her. Guest sitting up with no signs of hitting head. Nothing near guest. Guest sitting near window. Immediately PROM completed with no S/S of pain. Guests Vitals checked on floor and (normal). Guest was 2pa assisted into chair where she was further evaluated. Guests Nueros (sic) completed and at this time normal. MD notified. Guests Husband calleld (sic) . -6/21/2023 10:12 (AM) Skilled Charting .s/p (status post) fall - neuro check WNL (within normal limits) for guest. VSS. No new obvious injuries noted. Guest still attempts to get out of wheelchair with no supervision. Guest currently sitting in common area with writer. -6/22/2023 23:01 (11:01 PM) Skilled Charting Note Text: At approx. 2050 (8:50 PM) CNA (Certified Nursing Assistant) alerted writer that guest had fallen out of wheelchair. CNA stated they brought guest in wheel chair to 400 hall to check out the food and guest leaned forward to reach her feet and fell forward onto her knees and then on to her side. Guest was assessed for injury/pain. ROM completed and guest was assisted back into wheelchair. On-call notified and husband .Guest has no injuries and shows no s/s (signs/symptoms) of pain or discomfort. Guest is now out in common area with staff . Further review of R125's progress notes revealed that the resident continued to be anxious with continued attempts at standing and self-transferring. Additional review revealed: -6/27/2023 13:38 (1:38 PM) .Investigation Summary: On 6/20/23 at approximately 1300 (1 PM), guest was observed by staff sitting on the floor near the dining table in the common area. Staff alerted nurse and nurse came immediately and observed the guest sitting on right hip near dining room table with legs curled under bottom. Guest was sitting near the window prior to time of fall. Guest sitting up, wheelchair in locked position right beside guest. Guest was unable to give statement as to what happened due to guest's severe confusion. Guest was immediately assessed for injuries, no injuries noted Care plan updated, intervention is to encourage and provide guest activities and distractions while guest is sitting in common area for safety . -6/28/2023 16:45 (4:45 PM) .Investigation Summary: On 6/22/23 at approximately 2050, CNA was walking towards 400 hall to investigate refreshments arranged for CNA week, pushing guest while she was on her wheelchair. CNA stated that while she was pushing the wheelchair, guest leaned forward to reach for her feet and fell forward off of the wheelchair and then on to her knees and to her right side. CNA immediately alerted the nurse and the nurse came to assess guest right away. Guest with marked confusion and is unable to give an answer as to why she was reaching for her feet. Guest was 1PA assisted back to her chair. VS obtained and were WNLs. ROM assessed and were within guest's baseline, able to move all extremities without complaints of pain .orders received to continue monitoring guest at this time intervention is to apply non skid wheelchair mat as guest tolerates to prevent sliding . -7/4/2023 13:42 (1:42 PM) Skilled Charting Note Text: Guest was noted at 1330 sitting in wheelchair in nurses' area with head dangling laying back in chair .Sternal rubs given to guest and guest continues to be nonverbal nonresponsive. MD requested guest to be sent out ASAP. 911 called. Guest with staff at entire time .(Sent to hospital) . -7/15/2023 18:59 (6:59 PM) Skilled Charting Note Text: Guest arrived via stretcher @ (at) approximately 1615 (4:15 PM .s/p (status-post) hospital stay r/t (related to) L femur Fx (left femur fracture) . -7/16/2023 00:42 (12:42 AM) Skilled Charting Note Text: Resident is alert with confusion. Admitting DX (diagnoses) of Left Femur Fx, Acute cystitis .mental status altered .Resident has 17 staples to left hip, and thigh open to air, 0 drainage noted, 0 redness to area. Small skin tear to right forearm allevyn placed . -7/17/2023 14:30 (2:30 PM) .Physician Progress Note .Patient's records from recent hospitalization reviewed, patient resting in bed does not seem in distress but does not follow any verbal commands. According nursing staff patient being very lethargic with minimal oral intake now. Unclear etiology, patient has been declining rapidly has very poor prognosis .Patient is more appropriate for hospice/palliative care . -7/18/2023 07:50 (AM) Skilled Charting Note Text: Guest noted with Temp 101.4, R34, spo2 84% while on 5 lpm (liters per minute) (all vital signs outside of normal limits) via N/C (nasal cannula). Husband .was notified and husband request that (resident) not be sent to (hospital) and to make guest comfortable . -7/22/2023 04:15 (AM) Skilled Charting Note Text: Guest passed peacefully at 0400 (AM) . On 8/15/23 at 1:11 PM, the Medical Director was interviewed and queried regarding the etiology of R125's left femur fracture. The Medical Director reviewed the hospital documentation scanned by the facility into R125's record upon the resident's readmission. An indication of how the fracture occurred was not found at this time. R125's hospital records from 7/4/23 - discharge were obtained and reviewed. The hospital records did not indicate R125 sustained a fall or trauma after arriving at the hospital. Consultation notes after the resident's arrival indicated that the resident was guarding her left hip. An X-Ray of the resident's left hip was performed in the hospital on 7/5/23 at 10:51 PM and found the following: Imaging: Hip Left 2-3 Views with Pelvis: 7/5/23 10:51 PM Indication: .Hip pain, left Comparison: Pelvis radiograph dated 5/12/2023 Findings: There is a comminuted fracture involving the left femur neck and intratrochanteric region with associated soft tissue swelling. There is superior displacement of the distal fracture fragment. Mild diffuse osteopenia. Mild degenerative changes of both hip articulations with mild narrowing of the joint spaces. There are degenerative changes of the sacroiliac articulations. Assessment and Recommendations: Left displaced IT (intertrochanteric) hip fracture. Secondary to the debility associated with non-operative care, surgical treatment is recommended. I would recommend an intramedullary nail . Per Cleveland Clinic and [NAME] Hopkins, A comminuted fracture is a type of broken bone. The bone is broken into more than two pieces. It takes a lot of force for someone to get a comminuted fracture. A car accident or serious fall, for instance, can cause this type of break. Someone with a comminuted fracture will probably need surgery. On 8/15/23 at 1:55 PM, Licensed Practical Nurse (LPN) H, who frequently cared for R125, was interviewed. LPN H was queried regarding fall precautions for R125. LPN H described the resident as being very anxious and at times aggressive. LPN H stated that the resident was often placed in a common area where many staff walk through and could monitor her. LPN H added that the resident made frequent attempts to stand up even when staff attempted to redirect. LPN H stated, As soon as we walked away she would stand back up again. LPN H added that staff tried to give the resident fidget toys or other items, but the resident would sometimes just throw the items at the staff. LPN H indicated through interview that the resident did receive visits from her husband and attend activities, typically in the morning. When queried regarding other options for increased supervision of R125, LPN H stated that the facility's staffing did not allow for assigned 1:1 supervision. On 8/15/23 at 2:19 PM, CNA B was called for interview, however, this surveyor was unable to leave a voicemail. CNA B was identified by the facility as being the CNA with R125 on 6/22/23. On 8/16/23 at 9:40 AM, CNA B was called for interview and a voicemail was left for call back. No return call received prior to survey exit. On 8/16/23 at 10:22 AM, the Director of Nursing (DON) was interviewed. When queried regarding R125 experiencing multiple falls at the facility, the DON stated that she felt the facility did everything they could to prevent them. The DON stated that staff could be sitting next to the resident and there would be no indication of when she was going to try to stand up. The DON stated that the staff tried to give the resident things to distract her, and tried to keep her somewhat near a table so if she stood up, she would at least have the table as support for her hands. When queried regarding leg rests on R125's wheelchair when the resident fell forward on 6/22/23, the DON stated that leg rests were not present due to being an environmental hazard to the resident since she constantly tried to stand up. The DON stated that the CNA took the resident with her to an event and that R125 leaned forward and toppled over, and added that the resident was very thin. On 8/16/23 at 11:35 AM, the Nursing Home Administrator (NHA) and DON were interviewed during the Quality Assurance Performance Improvement (QAPI) task review. They were asked how the facility determines that fall prevention interventions are effective. The DON replied that the facility monitors whether falls are continuing and if they are, what additional interventions are needed; The results of the interventions are monitored and addressed in the QAPI meeting. The DON stated that they are not able to provide 1:1, so if that is the indication the facility offers for the family to assist or to hire a private sitter. The NHA and DON were then asked what facility process to is address a resident who experiencing multiple falls. The DON stated they follow the protocol for increased fall prevention and leading to the 1:1 described above which they do not provide. A review of R125's care plan revealed: Goal: Minimize risk for falls Date Initiated: 05/18/2023. Interventions: -2PA for transfers, ambulation with therapy only. Date Initiated: 07/15/2023 -Administer medications as ordered by physician Date Initiated: 05/18/2023 -Apply Non Skid wheelchair mat as guest tolerates Date Initiated: 06/20/2023 -Encourage and offer guest activities while in common area Date Initiated: 06/03/2023 -Ensure guest is wearing nonslip footwear when up out of bed Date Initiated: 06/13/2023 -May use w/c (wheelchair) for mobility Date Initiated: 05/19/2023 -Neuro checks per protocol Date Initiated: 05/18/2023 -Reinforce need to call for assistance Date Initiated: 05/18/2023 -Sit in common area Date Initiated: 06/03/2023 -Use leg rests at all times when transporting guest Date Initiated: 06/22/2023 -Weight Bearing Status: WBAT (weight-bearing as tolerated) Date Initiated: 05/18/2023. A review of the facility's policy/procedure titled, Falls Reduction Program, revised 9/25/2016, revealed, Purpose: To provide a safe environment for residents, modify risk factors, and reduce risk of fall-related injury .2. Implement and indicate individualized interventions on Care Plan/Kardex .

This citation pertains to intake #MI 096. Based on interview and record review, the facility failed to implement appropriate interventions to prevent falls, injury from falls, and perform an accurate, thorough root cause analysis and investigation after a fall for one resident (R390), of three residents reviewed for falls, resulting in a fall with major injury. Findings include: Review of a complaint submitted to the State Agency on 6/13/22 revealed, .that complainant states the resident (R390) fell so hard that he sustained a bad cut on his head and had a brain bleed . A review of a facility policy titled, FALLS REDUCTION PROGRAM revised on 9/25/16 was conducted and read, PURPOSE: To provide a safe environment for residents, modify risk factors, and reduce risk of fall-related injury .PROCEDURE: 1. Identify/analyze resident risk for fall 1.1 Review the following: Admission Assessment .Observation of resident's mobility and/or behavior, Communication from family and/or others. 2. Implement and indicate individualized interventions on Care Plan .3.3 IDT (Interdisciplinary Team) to review each incident to complete root cause analysis . On 6/14/22 at 2:40 PM, an interview was conducted with the complainant and they said they felt the facility did not implement appropriate interventions to prevent falls, or injury from falls for their loved one. They went on to say R390 had multiple falls at home, had went to the hospital and was transferred to the facility for rehabilitation. They further explained they informed facility nursing staff R390 was a high risk for falls, got confused at night, and probably wouldn't be able to use the call light related to his confusion. They then reported R390 was continent but had an enlarged prostate and needed to urinate frequently. They said facility staff told them they would watch him. The complainant then said on 5/16/22 around 8:45 AM they received a phone call from the facility telling them R390 had sustained a fall and was being transferred to the hospital. The complainant said because of the fall, R390 suffered a laceration to their head and a brain bleed. The complainant said they did not know what caused R390's fall or what he hit his head on to cause the laceration and bleed. They then explained that due to R390's advanced age, they moved him home with palliative care and he passed away on 5/31/22. On 6/14/22, a review of R390's clinical record was conducted and revealed an admitted [DATE] and a discharge to the hospital on 5/16/22. R390's diagnoses included: unspecified fall, multiple fractures of ribs, fracture of clavicle, urinary tract infection, and unspecified dementia without behaviors. A review of R390's admission fall assessment dated [DATE] at 1:15 AM, indicated they were a High Risk for falls. Section 5. on the fall risk assessment indicated R390 never recalled three out of the four following: current season, that they were in a nursing home, location of their room, or staff names/faces. The assessment further documented R390 exhibited loss of balance while standing, and it was noted Section 12. on the fall risk assessment that read, Intervention/Comment was left blank. A review of R390's orders indicated they were placed on transmission-based precautions for COVID-19 r/t their unvaccinated status. A review of R390's progress notes was conducted and revealed the following: A nursing note from Licensed Practical Nurse (LPN) 'K' dated 5/13/22 at 7:26 PM that read, . Guest is admitted for skilled nursing and therapy after hosp (hospital) stay r/t (related to) falls. Guest is .difficult to redirect. Guest is stating that he is not staying here and needs to go home .Daughter reports hx (history) of sundowning (restlessness, agitation, irritability, or confusion that can begin or worsen as daylight begins to fade) .Guest reports he is cont (continent) of B&B (bowels and bladder) and has requested urinal .Guest was oriented to room and use of call light however guest is yelling out and not using light . A nursing note from LPN 'L' dated 5/14/22 at 1:38 AM that read, .Guest is A&Ox1 (alert and oriented to self only) with confusion and behaviors. Guest has been seen multiple times by the writer self transferring. When educated guest states It'll be okay . A physician's progress note from Dr. 'F' dated 5/14/22 at 10:49 AM that read, . Chief complaint: Debility .past medical history of hypertension, [CONDITION(S)], and dementia present to hospital with multiple falls. Patient was diagnosed with left-sided ribs fracture, orthopedics recommended conservative treatment .patient forgetful not able to give a good history .History of multiple falls . Assessment/plan: .Repeated falls .Patient was hospitalized , had multiple falls .Fall precautions . A nursing note from LPN 'L' dated 5/16/22 at 12:03 AM that read, .Guest is A&Ox1 with confusion and behaviors . A nursing note from LPN 'H' on 5/16/22 at 8:11 AM that read, .0745 (7:45 AM) Guest was found on floor by speech therapist. RN notified, guest picked up and placed in w/c (wheelchair) . Guest oriented to baseline. Top of head bleeding .Guest had no account of what happened, denies LOC (loss of consciousness) .Guest sent to (Hospital name) via ambulance . An incident note from LPN 'A' on 6/1/22 at 6:57 PM that read, .Investigation Summary- On 05/16/22 at approximately 0745 the nurse was notified by the speech therapist that the guest was on the floor. Upon entering the room, the nurse observed the guest on the floor. The guest was assisted off the floor and into his wheelchair. The nurse assessed for injury and noted the top of the guest head was bleeding and an old skin tear to the left elbow reopened. The nurse asked the guest what happened and the guest had no account of what happened. The guest denied loss of consciousness .Physician notified and gave orders to send to the ER (emergency room ) for treatment and evaluation . On 6/14/22 a review of R390's care plans was conducted and revealed a care plan for falls dated 5/14/22 that read, Focus: Risk for falls r/t pneumonia, multiple falls with rib fractures .and cognitive impairment Dementia .Interventions: 2 PA (person assist) until therapy eval (evaluation) Administer medications as ordered by physician .may use wheelchair for mobility .Reinforce need to call for assistance . It was noted the care plan did not address any additional interventions such as a low bed, increased supervision, scheduled rounding for assistance, or fall mats, despite the resident's high fall risk assessment, history of frequent falls, and most recent admission to the hospital for falls that resulted in rib and clavicle fractures. On 6/14/22 at 3:39 PM, the facility's Administrator was asked via e-mail for any incident reports or investigation documents related to R390's fall on 5/16/22. On 6/15/22 at 9:00 AM, an interview as conducted with LPN 'N', R390's assigned nurse upon admission on 5/13/22. LPN 'N' was asked what type of fall interventions were in place for R390 and said he was under, Close Supervision. When asked what that mean, LPN 'N' said, staff, Kept an eye on him. LPN 'N' said R390 was getting up unassisted frequently and they constantly reminded him to use his call light. LPN 'N' was then asked if reminding R390 to use their call light was an appropriate or effective intervention given his cognitive status and said, Probably not. LPN 'N' was also asked about R390's room location and whether they were on transmission-based precautions. LPN 'N' said his room was at the end of the hall and they were not sure if he had been on transmission-based precautions. On 6/15/22 at 9:28 AM, an interview was conducted with LPN/Unit Manager 'A' regarding their note dated 6/1/22 in R390's record regarding the fall on 5/16/22. Unit Manager 'A' said RN 'H' documented form in Risk Management that described the details surrounding the fall and they used that form to write their incident note. They were asked why their note was put in more than two weeks after the fall and said they did not have an answer. At that time, LPN 'A' was requested to provide a copy of the form from Risk Management On 6/15/22 at 9:45 AM, a review of the Risk Management form dated 5/16/22 at 10:47 AM completed by RN 'H' for R390's fall was conducted and read, .Nursing Description: Unwitnessed fall brought to RN attention by speech therapist. Guest was found on butt on floor, bleeding form <sic> head .Resident Description: guest states he was using his walker to go to rr (restroom) and fell . It was noted this form contradicted RN 'H's progress note on 5/16/22 and Unit Manager 'A's incident note on 6/1/22 that both documented, .Guest had no account of what happened . Continued review of the form read, Immediate Action Taken .911 called to transfer guest to ER . but the next question on the form read, Resident Taken to Hospital? and it was documented 'N' (no). The form further indicated R390 sustained and Abrasion to the Top of Scalp, was oriented only to person, had predisposing physiological factors check marked for: confused, incontinent, recent illness, weakness/fainted, gait imbalance, and impaired memory, had predisposing situational factors check marked for: admitted within the last 72 hours and ambulating without assist. The section on the form that read Other Info read, Guest did not call for assistance to transfer to toilet. It was unclear how it was determined R390 did not call for assistance to transfer to the toilet, considering the contradicting progress notes in the record that documented R390 not having any recollection of the fall. It was further noted the form did not indicate where in the room R390 was found, or whether they fell ambulating, or possibly rolled out of bed, or whether the bed was in a low position, or the last time staff had observed R390 prior to the fall. On 6/15/22 at approximately 10:00 AM, the facility's Administrator reported she had a soft file regarding R390's fall. At that time, it was requested to review the documents in the soft file. On 6/15/22 at approximately 10:20 AM, a review of the additional documents in the soft file provided by the facility's Administrator was conducted. It was noted the documents provided did not include any statements from Speech Language Pathologist (SLP) 'M' who had discovered R390 on the floor, no statements from any other assigned caregivers, no interventions in place at the time of the fall, the last time they had been assisted to the bathroom, or any additional evidence a thorough root/cause analysis into R390's fall had been conducted. On 6/15/22 at 10:11 AM, a phone call was placed to RN 'H' (R390's assigned nurse on the day of the fall and transfer to the emergency room ) and a voicemail was left, however; no return call was received by the end of the survey. On 6/15/22 at 10:25 AM, an interview was conducted with SLP 'M'. SLP 'M' said they were at the end of the hallway retrieving a meal tray from the meal cart parked in front of R390's room. SLP 'M' said they noticed R390 was on the floor in their room. SLP 'M' said they alerted the nurse and assisted RN 'H' to get R390 back in bed. SLP 'M' reported R390 had blood coming from the top of his head. SLP 'M' was asked about the resident's positioning and said he was on the floor at the end of the bed. SLPN 'M' was asked if R390 had been incontinent and said they did not know because he was wearing dark colored sweat pants. On 6/15/22 at 11:19 AM, an interview was conducted with the facility's Director of Nursing (DON) regarding falls. The DON was asked if R390 should have had any additional fall precautions other than: 2 person assist, administer medications, use a wheelchair for mobility, and reinforce call light use; given his history of falls, cognitive status, and admission fall assessment that indicated he was a high risk for falls. The DON reported staff should have care planned, provided, and documented supervision. The DON also indicated an option for residents with a high risk for falls would be to have them in common areas and place them in rooms closer to the front of the hallway to ensure increased supervision. At that time, they were asked about R390 being on transmission-based precautions and being at the end of the hallway and said they were not aware R390 had been on transmission-based precautions. The DON was then asked about the appropriateness and documentation by staff of reminding R390 to use the call light as an intervention to prevent falls. The DON said staff always put that intervention in place and documented it in the progress notes even if it was not appropriate. During the interview, the DON was asked about the facility's investigation into the fall, the root cause analysis, and the contradicting documentation regarding whether R390 had no recollection of the fall, or whether he reported he was trying to use the restroom. The DON had no explanation, and said they were off the week it occurred. The DON acknowledged the concern and said they would need to look more closely at the investigations in the future. A review of R390's hospital records received on 6/15/22 was conducted and read, Date of Service 5/16/22 9:15 AM .CHIEF COMPLAINT: Head injury .Patient presents to the Emergency Center today with a chief complaint of a head injury with onset of 7:30 AM this morning .Skin tear on the scalp . R390's Computerized tomography (CT) scan of his head conducted on 5/16/22 at 10:07 AM was reviewed and read, FINDINGS: .There is a hyperdense extra-axial fluid collection overlying the right cerebral convexity measuring up to 5 mm (millimeters) causing approximately 4 mm right to left ventricular midline shift . A review of R390's death certificate was conducted on 6/15/22 and read, .4. date of death : May 31 2022 .36 .PART I ENTER the chain of events .Cranio-Cerebral Trauma and Complications Thereof .

Based on observation, interview and record review, the facility failed to accurately assess/identify pressure injuries and consistently utilize preventative measure prevent the development and/or worsening of pressure ulcers for three (R88, R82 and R85) of three residents reviewed for pressure ulcers, resulting in R88 having a misidentified Unstageable (full-thickness skin and tissue loss .obscured by eschar - devitalized tissue . usually black . may appear scab-like) sacrum pressure ulcer. Findings include: R88 On 6/13/22 at 9:47 AM, R88 was observed lying in bed. Protective foam boots were noted on the floor next to the dresser. R88 was asked if he had any wounds or sores. R88 explained he had wounds on his bottom and both his feet. When asked if the foam boots were ever used when he was in bed, R88 explained the boots were used sometimes. R88 was asked if his heels were elevated on a pillow. R88 explained there was not pillow under his legs. When the covers were pulled aside, R88's heels were observed in direct contact with the mattress. Review of the clinical record revealed R88 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) assessment dated [DATE], R88 was cognitively intact and required the extensive to total assistance of staff for activities of daily living (ADL's). The MDS assessment also indicated R88 was admitted with one Stage 2 (partial-thickness skin loss with exposed dermis) pressure ulcer, one Stage 3 (full-thickness loss of skin . slough - non-viable yellow, tan, gray, green or brown tissue - and/or eschar may be visible but does not obscure the depth of tissue loss), and one DTI (Deep Tissue Injury - intact skin with persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue). Review of R88's skin integrity care plan revised 6/3/22 revealed a focus that read, The resident has actual impairment to skin integrity r/t (related to) surgical wound right leg, DTI right buttock, stage 2 right heel, stage 3 left heel. An intervention initiated 5/31/22 read, PRAFO (Pressure Relief Ankle Foot Orthosis) boots to bilateral heels while in bed. Review of Skin & Wound Evaluations for R88 revealed: 5/26/22 read in part, .Pressure . Stage 2 . Right Buttock . Length: 2.3 cm (centimeters) . Width: 1.2 cm . Slough: 20% of wound filled . Goal of Care: Healable . Review of a picture of the wound revealed an open area on the right buttock. 6/2/22 read in part, .Pressure . Deep Tissue Injury . Right Buttock . Length: 4.8 cm . Width: 6.2 cm . Goal of Care: Healable . Review of a picture of the wound revealed an open area on the right buttock, an open area on the left buttock and an area of discoloration on the coccyx. 6/9/22 read in part, .Pressure . Deep Tissue Injury . Right Buttock . Length: 7.0 cm, Width: 7.4 cm . Goal of Care: Healable . Progress: Deteriorating . Review of a picture of the wound revealed a large open area encompassing the right buttock, left buttock and coccyx area. Review of R88's May 2022 Treatment Administration Record (TAR) revealed: An order dated 5/27/22 and discontinued 6/1/22 that read, Apply barrier cream to buttocks BID (two times a day) and PRN (as needed). An order dated 5/30/22 and discontinued 6/10/22 read, magic butt cream bid and prn two times a day for skin care . Review of R88's June 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/14/22 at 2:09 PM, Licensed Practical Nurse (LPN) C, R88's assigned nurse, was asked about R88's wounds. LPN C explained R88's order for Magic Butt Cream had been discontinued, so she did not know if he had a wound on his bottom or not. An observation of R88's wound revealed no dressing covering the wound when LPN C removed R88's brief. LPN C explained the wound needed a dressing on it. The wound opening appeared approximately 4 inches long by 4-5 inches wide, black eschar completely covering the wound. The surrounding skin was red with necrotic tissue present. LPN C reviewed R88's orders and explained there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked why there was no dressing on the wound, LPN C explained it must have been removed when R88 had been taken to the bathroom earlier that day. On 6/14/22 at 3:16 PM, the Director of Nursing (DON) was interviewed and asked who oversaw wounds at the facility. The DON explained she did along with the Medical Director, Dr. F. When asked why R88's wound was classified as a DTI when it appeared to be an Unstageable pressure ulcer, the DON explained she thought it had changed from DTI the last time it had been evaluated. Review of progress notes revealed a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . F that read in part, .Patient noted to have DTI of sacral area withsmall [sic] open area now . Review of a Skin & Wound Evaluation for R88 dated 6/14/22 at 3:59 PM read in part, .Pressure . Unstageable . Sacrum . Length: 8.8 cm . Width 9.1 cm . Eschar: 100% of wound filled . surrounding Tissue: Dark reddish brown . Goal of Care: Slow to Heal . Progress: Deteriorating . Notes: Wound was staged as a DTI on last assessment but with the open blacked area, it should have been staged as an unstageable. Description adjusted for this assessment . Review of a picture revealed black eschar completely obscuring the wound with reddened and necrotic tissue surrounding the wound. On 6/15/22 at 9:47 AM, Registered Nurse (RN) D was interviewed by phone and asked about R88's wound assessments. RN D explained he took the pictures and filled out the assessments, but the DON staged the wounds. When asked if he had notified the doctor when R88's wound had deteriorated, RN D explained he could not remember if he had put it in the Doctor's Log Book or not. On 6/15/22 at 10:08 AM, the DON was interviewed and asked about R88's wound assessments. The DON explained the picture taken on 5/26/22 was of a Stage 2 on the right buttock, but there was also a DTI on the coccyx area. When asked if there should have been a separate assessment for both wounds, the DON agreed. On 6/2/22 the assessment only stated DTI when the picture showed two open wounds and a discolored area. The DON explained she had added a note to the assessment that read, .there are actually 3 areas. 2 are stage 2 and one is an DTI. Pictures will be taken separately. When asked why separate pictures were not taken, and why three separate wounds continued to be assessed as one wound, the DON did not answer. The DON was asked why the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON explained she felt the Magic Butt Cream was an effective treatment until it was changed on 6/9/22. When asked if a wound deteriorated with a specific treatment, should that treatment be changed. The DON had no answer. On 6/15/22 at 12:49 PM, Dr. F was interviewed and asked about his progress note on 6/7/22 that said a DTI with small open area. Dr. F explained he did not know how else to phrase the open area with a DTI. When asked if once a DTI opened, if it could still be considered a DTI, Dr. F explained DTI's were always closed. R82 On 6/13/22 at 10:38 AM, R82 was observed lying in bed sleeping. An low air loss mattress was observed with the setting on AutoFirm . level 5. It should be noted, that was the highest/firmest level. Review of the clinical record revealed R82 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS assessment dated [DATE], R82 had moderately impaired cognition and required the extensive to total assistance of staff for ADL's. Review of R82's skin integrity care plan revealed an intervention initiated 2/21/22 that read, Air mattress to reduce pressure. Review of Skin & Wound Evaluations for R82 revealed: 6/9/22 read in part, .Skin Tear . Category I: Flap - Flap type (partial thickness) . Left Calf (Lateral) . In-House Acquired . Length: 1.7 cm . Width 1.5 cm . 6/10/22 read in part, .Pressure . Deep Tissue Injury . Left Calf . In-House Acquired . Length: 1.6 cm . Width: 0.9 cm . On 6/14/22 at 2:28 PM, R82's left lateral calf wounds were observed with LPN C. No dressing was observed on wounds. The bottom wound appeared to be approximately 1/2-3/4 inch circular with black eschar obscuring the wound. The top wound appeared linear approximately 1 inch long and was dark reddish purple in color with no open area. The low air mattress was observed to still be on the AutoFirm level 5 setting. Review of Skin & Wound Evaluations for R82 revealed: On 6/15/22 at 2:34 AM, read in part, . Skin Tear . Category I . Left Calf (Lateral) . Length: 2.0 cm . Width: 1.0 cm . On 6/15/22 at 2:35 AM read in part, .Pressure . Deep Tissue Injury . Length: 2.3 cm . Width: 1.2 cm On 6/15/22 at 10:38 AM, the DON was interviewed and asked about the wounds on R82's lateral left calf. An observation with the DON was conducted. The DON explained the bottom wound was an Unstageable Pressure Ulcer and the top wound was a DTI. When asked why it had been assessed as a skin tear, the DON had no answer. The DON was informed the low air loss mattress had been set at AutoFirm level 5 since 6/13/22. The DON explained it should be on alternating pressure. R85 On 6/13/22 at 9:51 AM, R85 was observed lying in bed. R85's left heel was wrapped in a bandage. Both heels were in direct contact with the mattress. Foam boots were noted on the floor by the dresser. R85 was asked if he had any wounds. R85 explained he had a wound on his left foot. Review of the clinical record revealed R85 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS assessment dated [DATE], R85 had moderately impaired cognition and required the extensive to total assistance for ADL's. Review of R85's skin integrity care plan revealed an intervention initiated 5/31/22 that read, PRAFO boots to bilateral heels while in bed. On 6/14/22 at 2:58 PM, R85 was observed lying in bed with both heels in direct contact with the mattress. The foam boots were noted on a chair by the window. On 6/15/22 at 12:25 PM, R85 was observed sitting in a wheelchair in his room. The foam boots were in the chair by the window. R85 was asked if the foam boots were put on his feet when he was in bed. R85 explained it was very rare when they did. Review of a facility policy titled, Pressure Ulcer Risk Assessment revised October 2010 read in part, .Review the resident's care plan to assess for any special needs of the resident . the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers .

Based on observation, interview and record review, the facility failed to ensure infection control standards and practices were consistently followed throughout the facility for seven of seven residents (R3, R10, R13, R14, R31, R63, and R77) reviewed for transmission-based precautions related to suspected COVID-19 exposure. Findings include: According to the facility's Pandemic Response Plan updated 3/9/22: .Manage Residents with Suspected or Confirmed [CONDITION(S)]-CoV-2 Infection - HCP (Health Care Personnel) caring for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator) .Ideally, a resident with suspected [CONDITION(S)]-CoV-2 infection should be moved to a single-person room with a private bathroom while test results are pending .In general, it is recommended that the door to the room remain closed to reduce transmission of [CONDITION(S)]-CoV-2. This is especially important for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection being cared for outside of the COVID-19 care unit .If limited single rooms are available, or if numerous residents are simultaneously identified to have known [CONDITION(S)]-CoV-2 exposures or symptoms concerning for COVID-19, residents should remain in their current location pending return of test results .Roommates of residents with [CONDITION(S)]-CoV-2 infection should be managed as described in Section: Manage Residents who have had Close Contact with Someone with [CONDITION(S)]-CoV-2 Infection .Manage Residents with Close Contact Manage Residents who had Close Contact with Someone with [CONDITION(S)]-CoV-2 Infection .Residents who are not up to date with all recommended COVID-19 vaccine doses and who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should be placed in quarantine after their exposure, even if [CONDITION(S)] testing is negative. HCP caring for them should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator) .Quarantine might also be considered if the resident is moderately to severely immunocompromised .Symptomatic residents, regardless of vaccination status, should be restricted to their rooms and cared for by HCP using a NIOSH-approved N95 or equivalent or higher-level respirator, eye protection (goggles or a face shield that covers the front and sides of the face) gloves, and a gown pending evaluation for [CONDITION(S)]-CoV-2 infection . Review of an alert initiated by the Director of Nursing (DON) to staff on 6/6/22 via the facility's electronic medical record system identified the facility had a resident that was positive for COVID-19 and also had a total of eight staff that were positive for COVID-19 and encouraged them to wear their mask, wash hands, and also to wear goggles/face shields. On 6/13/22 at 10:00 AM, R63's room was observed to have a sign on the door which indicated they were on contact and droplet TBP. There was personal protective equipment (PPE) available in storage containers outside of the room. Upon further review, this room was shared by R31 who was not on TBP and in order to gain access to R31, staff had to enter and go past R63's room. R63 was observed seated in a wheelchair in the room, not wearing any PPE. On 6/13/22 at 10:08 AM, R63 was observed to self-propel via the wheelchair out of their room, into the hallway and going up to another resident in the hallway. R63 was not wearing any facemask while in the hallway. Additionally, there were no staff present in the hallway at this time to redirect the resident back to their room or encourage to wear a face mask. On 6/13/22 at 10:14 AM, Staff 'O' approached R63 in the hallway and stated to R63 that the choir group was there, then placed a surgical mask on R63 (who did not appear upset or attempt to remove when placed) and the resident was brought to the group activity located on another hallway in the facility's common lounge area with several other residents and visitors. On 6/13/22 at 10:52 AM, R63 was observed in the hallway with a surgical mask pulled down under their nose. There were several staff observed in the hallway (from various departments), that interacted with R63, however no one identified any concerns that R63 was in the hallway, not properly wearing PPE, or encourage the resident to return to their room. On 6/13/22 at 10:04 AM, Certified Nursing Assistant (CNA 'Q') was observed at the bedside of R31 (roommate of R63 who was on TBP for COVID-19) wearing goggles, gloves and a surgical mask that was below their nose. CNA 'Q' was observed to be providing care to R31 from behind the privacy curtain, but also went back and forth from the resident's closet and opening the curtains. At 10:14 AM, upon CNA 'Q's exit from the room, they were asked about the room and to explain what specific TBP were in place and if they knew the specific reason. CNA 'Q' reported that only R63 was on TBP's and stated they didn't know what they were for since they (facility) don't give that information. When asked about having to pass through R63's room to access R31 that was not on TBP, CNA 'Q' stated sometimes it was like that where you had to go by someone on precautions to get to someone that was not. When asked about whether their mask should be under their nose, or covering, they indicated Above and when they went to touch their mask stated they didn't know it was down. On 6/13/22 at 10:21 AM, R63 was observed seated directly in between two other residents, and several visitors and other residents were also in attendance. On 6/13/22 at 10:36 AM, Staff 'O' was observed walking with R77 who was overheard voicing to Staff 'O' that they were chilled and had a runny nose. Staff 'O' continued to encourage R77 to walk with them to the choir activity and stated, It's allergy season. On 6/13/22 at 10:38 AM, an interview was conducted with Staff 'O'. When asked about whether or not they were aware R63 was on TBP for suspected COVID-19, Staff 'O' reported they were not aware and that the resident was in the hallway and tending to go to those types of group activities and doesn't usually stay in their room. On 6/13/22 at 10:45 AM, Staff 'O' was observed taking R63 to their room and upon entering the room, did not don/doff any additional PPE. Staff 'O' was then observed to pull their surgical mask down and offer the resident some chocolates, ice cream and water to drink. Staff 'O' was not observed to use hand sanitizer, or wash hands upon exiting the room to head back towards the group activity. On 6/13/22 at 12:10 PM, R77 was observed seated at a table eating lunch. R63 was observed seated at the table, just to the left of R77. R63 had not been served yet, but their surgical mask was off and placed on top of the table. There were five other residents eating in the common dining area. On 6/13/22 at 12:25 PM, R63 asked various staff about when they were going to get their meal and no staff were observed to identify any concerns that R63 was seated in common area. On 6/13/22 at 12:33 PM, a dietary staff was observed to enter the room of R10 who was identified as being on TBP for COVID-19 exposure. Although the proper PPE was donned, upon exiting the room, staff was observed to carry a silver covered plate and cup of juice out of the room, place on the chair just behind R77 and was not observed to wash hands or use hand sanitizer upon exit from the room. On 6/13/22 at approximately 1:30 PM, R63 was observed self-propelling throughout their hallway without a mask. There were no staff in the area, but there were several other residents. On 6/13/22 at approximately 1:35 PM, an interview was conducted with the Infection Control Preventionist (Nurse 'A') who reported they had been in that role for about four years. When asked about how the facility handled residents on TBP, Nurse 'A' reported residents that were being monitored for suspected COVID-19 due to exposure would have two signs which identified what was required for donning prior to providing care which included N95 masks, gowns, glove, goggle, or face shield. When asked if residents on TBP for suspected COVID-19 came out of their room, what PPE would they be expected to wear, Nurse 'A' reported the residents should be encouraged to wear an N95. When asked if resident's on TBP for suspected COVID-19 should be encouraged to come to communal dining or group activities, Nurse 'A' reported they might have dementia and might not understand, so should be encouraged to stay in room as much as they can. On 6/14/22 at 9:27 AM, an interview was conducted with Nurse 'A'. When asked why R63 was on TBP, they reported it was for possible exposure from a staff that tested positive for COVID-19. When asked why they were allowed to remain in the same room with R31 (who was not placed on TBP), Nurse 'A' reported they could remain in the same room but the curtain had to be closed. When asked about having to pass by R63 who was on TBP to get to R31 who was not, Nurse 'A' reported as long as the curtain was pulled, that would be ok. At that time, Nurse 'A' was informed of the multiple observations of concerns with infection control practices. Nurse 'A' was asked to provide any documentation for R77 that indicated staff had been notified of their complaint of being chilled and runny nose, and upon viewing the clinical record they indicated there was no documentation. When asked what should have occurred, Nurse 'A' reported they would follow up and the nurse should've been notified immediately. Nurse 'A' was asked how staff became aware of changes such as residents that needed to be on TBP, and reported they do education with orientation and post on the dashboard which CNAs have access to. When informed that CNA 'Q' reported they were not aware, Nurse 'A' reported they would follow up. On 6/14/22 at 11:17 AM, observations of the same hallway on 6/13/22 now had TBPs removed for R10 and R63, but now had droplet and contact TBPs for suspected COVID-19 for R77 who shared a room with R14 (not on TBP) and R13 and R3. These rooms were identified via signage and PPE bins outside the room. On 6/14/22 11:19 AM, CNA 'R' was approached by Vendor 'S' who was pushing a cart which contained clean oxygen supplies who asked if it was ok to go into the room. CNA 'R' proceeded to enter the room of R13 and R3 without donning/doffing any PPE, exited the room and informed Vendor 'S' there was no patient care being provided and would be ok for them to go in. At that time, Vendor 'S' entered the room while bringing their entire cart of oxygen supplies and did not don/doff any PPE. At that time, when CNA 'R' (who was just outside of the room) was asked about why they entered the room without PPE and also why they did not address Vendor 'S' going into the room without PPE, CNA 'R' reported they should've put on PPE and reported Vendor 'S' had only asked if any patient care was going on and told them no. CNA 'R' proceeded to re-enter R13 and R3's room without donning/doffing PPE and stated, we were supposed to tell you that you had to get a gown to go in and put on. Vendor 'S' proceeded to exit the room and don PPE, but when queried about the oxygen supplies on the cart and why they brought it into the room with them, Vendor 'S' only reported they were cleaning the machines and making sure the filters were wiped down. On 6/14/22 at 11:24 AM, an interview was conducted with Nurse 'A'. When asked about the change to the TBPs for Rs: 3, 10, 13, 14, 31, 63 and 77, Nurse 'A' reported R10 and R63 were finished with their precautions so those were discontinued. Nurse 'A' further reported that R13 had a fever, and R77 was due to the complaints of chills and runny nose yesterday. When asked if the roommates for R13 and R77 were also placed on precautions, Nurse 'A' reported there was only one of the residents in each of the rooms because they were double vaxxed. On 6/14/22 at 11:57 AM, an email request was sent to the Administrator, Director of Nursing (DON) and Nurse 'A' to provide the guidance the facility used to determine placing residents on TBPs. On 6/14/22 at 4:20 PM, during a discussion with the Corporate Clinical Staff (Staff 'T'), when informed that the request for what guidance was used for choosing to cohort residents that were and were not on TBP for suspected COVID-19 exposure was not provided yet, Staff 'T' reported that unless there were no additional beds available, the residents should not be kept in the same room as this was also in their policy and had provided education to the facility staff and that R77 was moved to a room by themselves and the decision was made to keep R13 and R3 together since R3 began showing symptoms of oxygen desaturation and were unsure if due to clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] On 6/15/22 at 10:28 AM, an emailed response from Nurse 'A' deferred to their Pandemic Response Plan as what should be followed. Record Reviews: R3: Review of the clinical record revealed R3 was admitted into the facility on [DATE], readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] STAT CBC and BMP STAT for elevated Temp on 6/14/22 at 10:22 AM. Transmission Based Precautions Includes: Contact, Droplet and Airborne Precautions. In addition, you must wear an N-95 in the patient's room . were started on 6/14/22 at 2:00 PM. R10: Review of the clinical record revealed R10 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Transmission Based Precautions Includes: Contact, Droplet and Airborne Precautions. In addition, you must wear an N-95 in the patient's room . were started on 6/8/22 and discontinued (d/c'd) on 6/14/22). F13: Review of the clinical record revealed R13 was admitted into the facility on [DATE], readmitted on [DATE] with hospice services with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Transmission Based Precautions Includes: Contact, Droplet and Airborne Precautions. In addition you must wear an N-95 in the patient's room . were started on 6/14/22 at 2:00 PM. R14: Review of the clinical record revealed R14 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] R31: Review of the clinical record revealed R31 was admitted into the facility on [DATE] and readmitted on [DATE] with hospice services. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] R63: Review of the clinical record revealed R63 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Transmission Based Precautions Includes: Contact, Droplet and Airborne Precautions. In addition you must wear an N-95 in the patient's room . were started on 6/8/22 and d/c'd on 6/14/22. R77: Review of the clinical record revealed R77 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Transmission Based Precautions Includes: Contact, Droplet and Airborne Precautions. In addition you must wear an N-95 in the patient's room . were started on 6/14/22 at 2:00 PM.

Based on observation, interview and record review the facility failed to ensure one resident (R#61) of one residents reviewed for self-administration, was assessed for the safe self-administration of medication. Findings include: On 6/13/22 at approximately 10:50 a.m., R61 was observed in their room, lying on their bed. R61 was observed to have a bottle of Vicks Vapor Rub ([MEDICATION(S)] 4.8% (Cough Suppressant and Topical Analgesic), Eucalyptus Oil 1.2% (Cough Suppressant), Menthol 2.6% (Cough Suppressant and Topical Analgesic)) and Thera Tears (Sodium [MEDICATION(S)]) on their bedside table. R61 was queried regarding the medications and indicated that they use the eye drops so the Nurses do not have to do it and use the vapor rub when they get a stuffy nose. On 6/14/22 at approximately 10:35 a.m., R61 was still observed with the Vicks vapor rub and the Thera tears on their bedside table in the same spot as 6/13/22. R61 was queried if they Nursing staff knew they had the medications and they indicated they did and have had them for weeks. R61 was queried when the last time they had used the medications and they indicated that their memory is not good and did not remember. On 6/14/22 at approximately 10:38 a.m., Nurse B was queried regarding the Vicks vapor rub and Thera tears observed on R61's bedside table and Indicated they would have to go in and address the medications. On 6/14/22 at approximately 1:45 p.m., Nurse B was queried regarding the disposition of the Vicks vapor rub and Thera tears that had been observed on R61's bedside table. Nurse B indicated they had confiscated the medications and had locked them in R61's medication cabinet. Nurse B indicated that the medications needed to be locked up and had written a message for the Physician to get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse B was queried regarding the ability for R61 to self-administer both the medications and indicated that R61 had dementia and would not be able to administer them correctly. Nurse B indicated the medications needed to be locked up due to R61's dementia and other residents that may come into the room and see them. Nurse B was queried if R61 had been assessed for self-administration of the medicine and they indicated they had not. On 6/14/22 the medical record was reviewed and revealed that R61 was initially admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R61's minimum data set with an assessment reference date of 5/5/22 revealed R61 needed extensive assistance with most of their activities of daily living. R61's BIMS score (brief interview of mental status) of 12 indicating moderately impaired cognition. A progress note dated 6/14/22 at 2:04 p.m., revealed the following: Guest had several over the counter medications at bedside. Writer explained to guest that all medications need to be locked up. She was educated about potential interactions with other medications ordered. Physician gave order for over the counter eye drops which writer entered. Guest had Vicks vapo rub at bedside (writer locked up with medications) and writer explained that if guest is feeling congested or not feeling well it would be harder for her nurses and doctor to know if she was using the Vicks vapo rub . A review of R61's Physician orders did not reveal any orders for the Self-Administration of R61's vapor rub or eye drops. A review of R61's care plan did not reveal any documentation that the self-administration of vapor rub or eye drops was part of their plan of care. On 6/15/22 at approximately 11:14 a.m., Staff Development/Nurse Manger A (SD/NM A) was queried regarding the Nursing expectations/procedures for the self-administration of medications at the bedside. SD/NM A indicated that residents should not have medications at the bedside and that the Nurses should have had them locked up and obtained an order from the Physician to self-administer. SD/NM A was queried regarding the observations of R61 having the Vicks Vapor Rub and Thera tears on the bedside table and they indicated that an investigation should be done to determine how they got the medications and they should be locked up. They were queried if R61 had the ability to self administer the medications and they shook their head no and indicated that R61 would have had to have been assessed to self administer them. On 6/15/22 a facility document titled Medication Administration (Self-Administration) was reviewed and revealed the following: POLICY: Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe. PROCEDURES l . If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility, during the care planning process. 2, The interdisciplinary team determines the resident's ability to self-administer medications by means of a skill assessment conducted as part of the care plan process. The nursing care center may use the following as a guideline or establish an alternate procedure: a. The resident is instructed in the use of the package, purpose of the medication, of reading of the label, and scheduling of medication doses. b. The resident is then requested to read the label on each package and indicate at what time the medication should be taken and any other special instructions for use. c. The resident is asked to demonstrate the removal of the medication from the package and, in the case of nonsolid dosage forms such as an inhaler, to verbalize the steps involved in administration. d. The resident is asked to complete a bedside record indicating the administration of the medication. 3. The results of the interdisciplinary team assessment are recorded on the Medication Self Administration Assessment, which is placed in the resident's medical record. 4. If the resident demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage is conducted .

Based on observation, interview, and record review, the facility failed to monitor a low air loss mattress for one ( R34) of one resident sampled for equipment, resulting in the potential for skin breakdown. Findings include: On 10/21/19 at 1:30 PM, an observation was made in R34's room that the lights on the control unit on their low air loss mattress which indicated the pressure settings and if the unit was activated, were off. On 10/22/19 at 12:55 PM, at 2:28 PM, and at 4:21 PM, observations was made in R34's room that the lights on the control unit on R34's low air loss mattress were off. On 10/23/19 at 8:50 AM, R34 was met in their room and queried about their low air loss mattress and stated, I know nothing about my mattress. It is new. It was observed that the lights on the control unit were on. On 10/23/19 at 9:12 AM, Nurse [NAME] was queried on the operation of R34's low air loss mattress and asked if the lights on the control unit on the mattress should be on. Nurse [NAME] stated, They should be on everyday or the mattress will deflate. On 10/23/19 at 9:25 AM, the Director of Nursing (DON) was queried about R34's lights on the control unit on their low air loss mattress observed to not be on consistently. The DON stated, If the mattress was not on it would be totally deflated. The lights might not be working properly. I can put a maintenance request into the Maintenance Director. On 10/23/19 at 10:52 AM, the Maintenance Director (MD) F was queried about the maintenance protocol and monitoring of residents low air loss mattresses at the facility. MD F stated, If there is a problem with a mattress, staff will contact me and/or put in a work order. MD F was queried about the low air loss mattress in R34's room and stated, The mattress was inflating but the lights were not working. I switched out the air hose on the mattress. On 10/23/19 at 12:39 PM, the Administrator was queried on their expectations for staff if they notice that the lights on a resident's low air loss mattress are off. The Administrator stated, Staff should let maintenance know and a work order should be put in. On 10/23/19 a review of R34's medical record indicated an admission to the facility on [DATE] and a readmission to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/23/19 a review of R34's Braden Scale Assessment (Scale For Predicting Pressure Sore Risk) dated 8/15/19, revealed a score of 16, which indicated that the resident was At risk for developing a pressure sore. On 10/23/19 a review of R34's skin care plan indicated the following, Focus: The resident has potential impairment to skin integrity .Date Initiated: 4/3/19. Goal: Guest will be free from skin breakdown/pressure ulcer. Date Initiated: 4/5/19. Interventions: Pressure reducing mattress to protect the skin while in bed. Date Initiated: 5/7/19. On 10/23/19 at 2:00 PM, a policy was requested from the facility regarding maintenance and monitoring of low air loss mattresses. The facility indicated that they had no policy which addressed this issue.

Based on interview and record review, the facility failed to ensure a bed hold notice was given to a long term care resident (R1) of one reviewed for receipt of bed hold notices, resulting in the resident or representative not being fully informed of their rights and the potential for the resident not being able to return to the facility and or to their same room on readmission to the facility. Findings include: On 10/22/19 a review of the facility records for R1 revealed: R1 was admitted into the facility on [DATE] and discharged for an acute transfer to the hospital on [DATE]. The Minimum Data Set (MDS) assessment dated [DATE] indicated intact cognition with a Brief Interview for Mental Status score of 13 out of 15. A review of the progress notes did not indicate a bed hold notice was sent. A review of the Facility Admission Packet revealed: Bed Hold Policy-Medicaid: Michigan's bed hold policy is the bed may be held up to 10 days per leave and there is no limit per year when you are hospitalized . The policy further indicated the Director of the Business Office would contact private pay residents. The policy did not indicate who was responsible for long term care or Medicaid residents. Presenting a bed hold notice allows the resident or representative the chance to pay to hold a bed if Medicaid coverage of the bed hold does not apply. On 10/22/19 at 8:20 AM, R1 was asked about their recent stay at the hospital and reported they had spent two weeks in the hospital and it was not fun, but was glad to be back. On 10/22/19 at 2:33 PM, the Administrator was asked where staff documented a bed hold notice was sent and stated, The bed hold should be documented by the nurse in the progress notes. On 10/22/19 at 2:49 PM, Nurse A was asked what was sent with a resident upon transfer to the hospital and stated, A face sheet, medication sheet, any relevant paper or progress notes, vital signs. Nurse A was not aware of who sent the bed hold or if the nurse needed to document the notice was given. On 10/22/19 at 2:54 PM, Unit Manager Nurse B was asked to locate documentation that a bed hold notice was sent with R1 upon transfer to the hospital. No documentation was presented by Nurse B. On 10/22/19 at 4:22 PM, the Admission Coordinator Staff C was asked about sending a notice of the bed hold policy with resident on transfer to the hospital and stated, I take care of the rehab. I send notice to the business office who documents it. Staff C was asked who ensured bed hold notices were sent for the long term care resident and reported it was the Administrator. On 10/23/19 at 11:04 AM, during the Quality Assurance interview the Administrator was asked about bed hold notices and reported that there was a problem with bed hold notices for long term care residents related to confusion over who was responsible for sending them. The Administrator confirmed there was no documentation of a bed hold notice sent for R1. On 10/23/19 at 1:40 PM, the Administrator reported the facility policy for bed hold notification was what was included in the admission packet and that nursing is responsible.

Based on observation, interview, and record review, the facility IDT failed to assess one (# 343) of two sampled residents for self administration of an inhaler, resulting in the potential for accidental over use of medication and multiple administrations of the inhaler. Findings include: On 10/21/19 at 9:43 AM, during initial tour Resident #343 was observed sitting in their room in a chair. A blue inhaler was observed on the bed side table. Resident #343 was asked what it was and stated, That's my inhaler. Resident #343 was asked if they were allowed to keep it in the room. Resident #343 stated, No. Resident #343 was asked why and the resident stated, Because it's a medication that I brought from home. Resident #343 was asked if the facility was aware that it was in the room. The resident, Yes, they know. Resident #343 was asked if the facility did a self-administration assessment. Resident #343 stated, Yes. On 10/23/19 at 9:21 AM, Resident #343's door to their room was open. The bed side table was observed placed at the foot of the bed with the inhaler, book, and remote. Resident #343 was not in the room at the time. On 10/23/19 at 9:23 AM, Nurse D was asked for Resident #343's self-administration assessment. Nurse D stated, Let me check into that and talk to the Director of Nursing (DON). On 10/23/19 at 9:31 AM, a review of Resident #343's medical record revealed, Order: [MEDICATION NAME] Aerosol Powder Breath Activated 108 (90 Base). 2 puff inhale orally every 6 hours as needed for SOB (Shortness of Breath) related to [MEDICAL CONDITION], UNSPECIFIED. Start date: 10/9/19 End date: Indefinite. On 10/23/19 at 9:36 AM, the Director of Nursing (DON) was asked if the facility was aware of Resident #343 having an inhaler in their room. The DON stated, No we didn't know (Resident #343) had one until now. We didn't do an assessment because we did not know (Resident #343) had it. The DON further explained that Resident #343 has the same medication in the medication cart. Further review of Resident #343's medical record revealed, Resident #343 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The record also noted Resident #343 had some cognitive confusion. A review of the following progress notes revealed; Admission note: 10/9/2019 13:40 Skilled Charting Note Text: Guest was admitted with primary ([MEDICAL CONDITION]). PMH (past medical history) includes syncopy/collapse, pancytopenia, myelodysplasti[DIAGNOSES REDACTED], panlobular [MEDICAL CONDITIONS], weakness,[MEDICAL CONDITION](hypertension), spondylosis, [MEDICAL CONDITION], arthropathy, low back pain, gout, TIA ([MEDICAL CONDITION]) and cerebral infarction, varicose veins, ulcerative [MEDICAL CONDITIONS] disc disease/lumbarsacral, and [MEDICAL CONDITION]. (Resident #343) arrived via car/husband to transport from (local hospital) and admitted to room . (Resident #343) is awake alert and orient x3 (person, place, and time). Speech is clear . 10/10/2019 02:45 Skilled Charting Note Text: Guest complained of (Resident #343) in (unidentified resident's) room. Writer went to check on guest in (their) room and guest was slightly confused, pacing back and forth, Guest had on T-shirt and undergarments only and stated (they) was in the wrong room and (their) husband wouldn't like (them) sleeping with another man. Writer calmed guest down and explained where (Resident #343) was and that (Resident #343) was in (their) correct room and if (Resident #343) needs any help to use the call light . 10/15/2019 14:46 Skilled Charting . (Resident #343) is alert and orient x2-3 with some confusion/forgetfulness at times . 10/16/2019 18:54 Skilled Charting Note Text: Guest A&Ox2 (alert and orient to person, place). forgetful. Reports that guest self amb (ambulate) into another guests room during night. Poor safety awareness as guest will self ambulate without use of assistive device. Requires frequent Reminders to use call light. Guest is 1 PA (patient assist. Guest transferred to room. On 10/23/19 at 11:04 AM, the Administrator was interviewed about the medication being left on the bedside table and reported it was brought in by the residents family. When asked if the nurse should have noticed the medication and removed it, the Administrator indicated the nurse should have removed it. On 10/23/19 at 1:21 PM, a review of the facility's policy titled, Self-Administration of Medications dated, (MONTH) 2012, noted, Residents in our facility who wish to self-administer their medications may do so, if it is determined that they are capable of doing so. Policy Interpretation and Implementation. 1. As part of their overall evaluation the staff and practitioner will assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering medications .

Based on interview and record review, the facility failed to review lab results and obtain a stool sample in a timely manner for one sampled resident (R900) of three residents reviewed for monitoring and assessment, resulting in a delay in treatment for [REDACTED]. Findings include: On 8/14/19 at 8:29 AM, an interview was conducted with Confidential Family Member A who stated that the facility had a record of excessive bowel movements (loose diarrhea) multiple times within a 2 day period for R900. Confidential Family Member A explained that concerns were expressed to the facility doctor and unit manager on 7/23/19 regarding the amount of bowel movements, and (R900) being tired and lethargic. On 7/24/19 the physician ordered a stool sample. Confidential Family Member A further stated, The nurses did not follow protocol and put a hat in the toilet to catch a sample. The stool sample was needed to check for possible [MEDICAL CONDITION]. It wasn't until 7/30/19 that a hat was put in the toilet to get a sample. A sample was obtained on 7/31/19 and sent to the lab in which (R900) tested positive for [MEDICAL CONDITION]. Confidential Family Member A also explained that lab results for a UTI were received by the facility on 7/3/19 for R900. They reported that the lab work results indicated that R900 tested positive for a UTI, and the results were not read or looked at by anyone at the facility until 7/5/19 when R900 was being sent to the hospital. A review of R900's medical record revealed that they were initially admitted into the facility on [DATE], and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. R900's recent Minimum Data Set (MDS) assessment dated [DATE] revealed that R900 is severely cognitively impaired and required extensive assistance with all Activities of Daily Living. On 8/14/19 at 1:06 PM, The Director of Nursing (DON) was asked to explain the dates located on the urinalysis report that stated: Collection Date: 6/30/2019, Received Date: 7/01/2019, Reported Date: 7/03/2019. The DON explained that the collection date is when the urine was collected, the received date is when the lab received the collection, and the reported date is when the results were provided to the physician. The DON was queried on the process for notifying the physician of lab results. The DON explained the scheduling and coverage for how physicians are notified which includes being notified by tiger text (communication between facility staff), placed in their log, or contacted by phone. They also explained that if the results are critical, the lab will contact the facility. A review of R900's urinalysis results dated 7/3/19 revealed that R900's urine, tested positive for a UTI. Further review of R900's progress notes revealed the following: physician progress notes [REDACTED]. Chief Complaint: Vomiting, constipation, multiple concerns by daughter .Patient's oral intakes been declining. Also according to daughter patient vomited twice but patient unable to give me any history .Assessments/Plans: Vomiting without nausea .According (to) daughter patient vomited twice couple days ago . physician progress notes [REDACTED]. Patient has underlying dementia and unable to give a good history, according to caregiver who is bedside patient vomited one time today. Also had to (two) loose bowel movements this morning. Patient also complained of abdominal discomfort and a headache .patient will be transferred to emergency room for further work-up and treatment. A review of the hospital physical revealed the following: Complicated UTI to be mostly cause of abdominal pain .urinalysis for infection .Plan: Continue IV (intravenous) [MEDICATION NAME] (antibiotic to treat infections). On 8/14/19 at 3:03 PM, the DON was queried in regards to the date the physician was notified of the positive urinalysis for R900's UTI, as the urinalysis report indicated that it wasn't reviewed until 7/8/19 by facility staff. The DON brought in Unit Manager B who indicated that the physician had not been notified of the positive urinalysis until the resident was in the process of being transferred to the hospital on [DATE]. The DON and Unit Manager B were asked if it was typical for a physician to be notified two days after a positive urinalysis is received, in which they both stated, No. Unit Manager B further explained that All nurses received one-on-one education. A review of R900's medical record revealed that R900 was readmitted into the facility following their hospital stay on 7/10/19. Progress notes reveal the following upon readmission: Skilled Charting Note. Effective Date: 7/22/2019. [AGE] year old guest,on a pureed food diet and thin liquids. medications were crushed in (and) put in pudding today. Senna and [MEDICATION NAME] (medications to treat constipation) held this shift r/t (related to) loose bowel movement on the oliet (toilet) this am . physician progress notes [REDACTED]. Chief Complaint: Questionable diarrhea .Patient was recently started on [MEDICATION NAME] and senna, patient had loose stool last night and this morning. Patient senna and [MEDICATION NAME] was held. Skilled Charting Note. Effective Date: 7/24/2019 02:47 (2:47am). Anti-constipation medications are currently being held for guest because of episodes of diarrhea . Skilled Charting Note. Effective Date: 7/24/2019 14:33 (2:33pm). Guest is feeling lethargic this shift, has had one large loose bowel movement this morning . Skilled Charting Note. Effective Date: 7/24/2019 15:35 (3:35pm).This nurse spoke with guest's POA (power of attorney) .MD (medical doctor) ordered stool sample for CDIFF . physician progress notes [REDACTED]. Chief Complaint: Diarrhea .According to staff patient had 11 loose stools yesterday also patient was looking more tired and lethargic. Patient was started on IV fluids yesterday . Skilled Nursing Note. Effective Date: 7/29/2019 18:41 (6:41pm). Guest had two loose bowel movements this shift. (DPOA-durable power of attorney) notified, all anti-constipation meds held. No behaviors noted this shift. Skilled Charting Note. Effective Date: 7/30/2019 11:26 (11:26am). Guest had small loose stool with mucus this morning. DPOA notified, NP (nurse practioner) notified who ordered stool sample w (with) C&S (culture and sensitivity), [MEDICAL CONDITION] toxin . Skilled Charting Note. Effective Date: 8/2/2019 13:56 (1:56pm). Waiting for results from lab r/t (related to) possible [MEDICAL CONDITION]. Isolation cart outside of guests room for precautions. Private caregiver arrived this morning and this nurse informed her that we do not have results back yet,but are taking precautions to prevent possible spread. Skilled Charting Note. Effective Date: 8/2/2019 18:21 (6:21pm). Stool specimen received, positive for [MEDICAL CONDITION]. MD started guest on vanco (antibiotic) 250mg (milligram) QIDx14 days (4 times a day for 14 days). On 8/14/19 at 1:13 PM, the DON was queried as to why a physician's orders [REDACTED]. The DON explained that the loose stools in R900's brief were too small, and other times they were too loose and soaked into the brief.They also stated that a CNA (certified nursing assistant) forgot to put the hat in the toilet in order to receive the sample, and that CNA received a one on one education. On 8/14/19 at 1:17 PM, a policy related to communication with the physician regarding lab results was requested however, this was not received by the end of this survey. A review of a policy titled 'Medication and Treatment Orders did not address the timeliness of when a order should be implemented.

This citation pertains to intake # 8 Based on observation, interview and record review, the facility failed to prevent verbal and mental abuse that occurred with one Resident (#702) of three residents sampled for abuse, resulting in mental anguish and aggravation. Findings include: On 12/28/18 at 9:30 AM, Resident #702 was observed sitting up in their wheelchair eating breakfast in the dining room. Resident #702 was dressed and groomed. A record review of an investigation involving Resident #702 revealed the following: On 12/5/18 at 11:00 PM, Two Certified Nursing Assistants (CNA) called Licensed Practical Nurse (LPN) C in Resident #702's room because the resident was refusing to go to bed. LPN C was verbally inappropriate. The CNA's reported the nurse. The nurse was fired. The facility substantiated the allegations and reported the incident to the police. On 12/28/18 at 9:47 AM, an interview was attempted via phone with LPN C, however, the nurse did not return the phone call. A review of the face sheet and Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #702 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed that the resident had a Brief Interview of Mental Status (BIMS) score of 13, indicating and intact cognition and had a history of [REDACTED]. On 12/28/18 at 11:15 AM, Resident #702 was up in a wheelchair in their room and was asked if they remembered the incident with LPN C and to describe what happened. Resident #702 stated, Yes, I remember it. The nurse (LPN C) said that she was going to get her husband to kick my ass. Resident #702 could not remember what exactly led up to LPN C stating that but stated, It was over a document, and then stated, I had a package that I wouldn't give up. Resident #702 was asked if they had any issues with LPN C prior to the above incident and stated, No, I like her. I even complimented her before. A review of the Progress Notes for Resident #702 revealed the following: 11/11/18 - refused shower. 11/21/18 - increased agitation. 11/27/18 - refused wound care. 12/5/18 - refused to go to bed, refused shower, cursing at staff. 12/15/18 - attempting to stand up at bars in the bathroom after told not to. A review of the statements from the investigation revealed the following: 12/6/18 CNA B- .(LPN C) told (Resident #702) 'It's time to go to (explicit) bed'. (Resident #702) then said, 'This is my house, I don't have to go to (explicit) bed!' .the nurse then made (CNA A) help and try to transfer them (LPN C) said, 'It's not going to work so get the dam (sic) sit to stand.' .(CNA A and CNA B) both said that wasn't going to work .The nurse then said to (Resident #702), 'If you don't want to go to bed then you are going to have to sit out here.' .the nurse then attempted to push the resident via wheelchair out of the room .the guest then resisted and grabbed at the doorway . 12/6/18 CNA A-I asked the resident if they wanted to get to bed into bed and the guest refused multiple times .the resident was upset and began yelling at me and (CNA B) because they could not stand on their own .the resident swung at me .then I told them I was getting the nurse .the (LPN C) walked into the room and began to yell at this resident stating we don't have time for these 'games' .The nurse snapped and stated, 'We don't have time for this[***]we've got to get this done' .the resident would not stand so the nurse and I tried to put the sling around them and the resident grabbed the nurses' arm and the nurse stated, 'You leave a mark on me and my husband will be up here to get you real quick. A review of resident 702 care plan revealed the following: Focus-At risk for behavior symptoms r/t (related to) dementia, progression of disease .displays a demanding demeanor toward staff and exhibits very little patience, frequently yelling out for help . On 12/28/18 at 12:50 PM, the Administrator was interviewed regarding the incident between Resident #702 and LPN C. The Administrator stated, We never had any problems before with her. She had been here almost a year. It was reported to me and we investigated it and determined it happened. We called the police and the police interviewed her. We did terminate her and reported her license to the board. On 12/28/18 at 1:24 PM, an interview was completed with CNA A via phone. CNA A stated, It was my first time working with (Resident #702) and the nurse. (Resident #702) would not go to bed so I stayed over to help the other shift get them to bed. I went to get the nurse to help. The nurse came in (the resident's room) and was swearing, she escalated the situation, I just kept looking at her in disbelief. The resident said he was going to call the police and he kept yelling. The nurse finally said to leave (Resident #702) alone and if they fell , they fell . A review of the Progress Note authored by LPN C revealed the following: 12/6/18 5:09 AM-(Resident #702) has refused staff attempts multiple times this shift to assist with care and place in bed . A review of the facility's policy titled, Abuse, Neglect and/or Misappropriation of Resident Funds or Property, revised 12/10/18 revealed, (Facility) will not tolerate verbal .or mental abuse. Purpose-To assure each resident in the center is free from abuse, neglect and exploitation.

Based on observation, interview, and record review, the facility failed to turn and reposition every two hours (at a minimum) for (#65) of one sampled resident, who was reviewed for pressure ulcers, out of a total sample of 32, resulting in an unstageable facility acquired pressure ulcer (PU) to the sacrum/coccyx area. Findings include: On 1/23/18 at 9:00 a.m., during initial rounds, Resident #65 reported having a wound on his bottom near the rectal area. Resident #65 stated, Everyone has been looking at it and taking pictures. It was no big deal at first. They didn't do much. Now it's being treated. Everyone is looking at it . On 1/24/18 at 2:48 p.m., Resident #65 was observed sitting in his wheelchair next to bed while awaiting for two CNAs to assist him back to bed using a Hoyer lift. Resident #65 was noted sitting on a wheelchair cushion. While waiting to be transferred to bed, Resident #65 was queried regarding his care while residing in the facility. The resident denied any concerns. Resident #65 refused a wound care observation when requested. Resident #65 stated, Everyone has looked at it already. All I can tell you is that it has gotten better. A specialty mattress was noted to Resident #65's bed. On 1/24/18 3:04 p.m., review of Resident #65's clinical record revealed the following: The face sheet indicated an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #65's admission Minimum Data Set (MDS) assessment, dated 1/5/18, indicated an intact cognition and the requirement of the assistance of two persons for bed mobility/repositioning and all activities of daily living (ADLs), with the exception of eating. The admission MDS assessment indicated that Resident #65 did not have any pressure ulcers (PU) at the time of admission into the facility. A Skilled Charting Note, dated 1/13/2018 at 14:09 (2:09 p.m.), revealed the following documentation: Guest is A&O x3 (alert to person, place, and time) able to make needs known. Guest is admitted with ileus and gastritis with bleed. No current s/sx of bleeding. Guest requires hoyer lift and 2 PA (person assistance) with transfers. 2PA with bed mobility. Guest is incontinent of bowel . On 1/13/18 it was pictured. Showed a picture of a wound with a huge necrotic area. The Skin & Wound - Wound Assessment, dated 1/13/18, indicated that Resident #65 had a facility acquired, newly developed pressure ulcer (PU); Deep Tissue Injury (DTI) covered with 100% [MEDICATION NAME]. The edges of the wound was described as attached: Edge appears flush with wound bed or as a sloping edge. The PU/DTI total area measured 15.7 centimeters (cm). The length was 6.1 cm and the width was 4.1 cm. The DTI was on his sacrum. The most current Skin & Wound - Wound Assessment, dated 1/23/18, indicated the area is unstageable due to slough/eschar (black dead tissue). The total area now measured 4.8 cm. The length was 2.9 cm and the width was 2.0 cm. The wound bed was described as 100% eschar. The wound edges were the same. 01/24/18 at 4:06 p.m., the Director of Nursing (DON) confirmed the PU was noted on 1/13/18 by the facility. 01/24/18 4:55 p.m., review of the Wound Note Late Entry, dated 1/16/2018 18:35 (6:35 p.m.) revealed the following: Wound assess to left buttock and sacrum. Left buttock MASD (moisture associated skin damage)/excoriation with islands of slough. Tissue bright red and has mild bleeding after cleansing. Guest has no c/o pain even with cleansing as per guest, he has no feeling from waist down. Sacrum has excoriation with island of slough with necrotic tissue at center of slough. excoriated/ MASD area of wound appears to be mostly superficial at this time. Heavy Chamosyn (incontinence skin protectant) applied to bilateral buttocks and coccyx area. Guest educated on hydration and wound healing in addition to increasing protein and starting the new med Pro-Stat. New air mattress has been placed on bed to aide in pressure relief. Guest also placed on a turning schedule and has agreed to allow staff to turn and reposition him more frequently. On 1/25/18 09:48 a.m., an interview and record reviews were conducted with the DON and the facility's Regional Nurse Consultant regarding Resident #65's facility acquired pressure ulcer. The DON stated, He was identified at risk for pressure ulcer on admission, 12/28/17. The resident had an At Risk care plan for PU, dated 12/29/17. The care plan included the following interventions: - Braden Scale per order - Encourage good nutrition and hydration . - Keep skin clean and dry. Use lotion on dry skin - Pressure reducing mattress to protect the skin while in bed - Pressure reducing cushion to protect the skin while up in chair - Skin assessments per order - Use caution during transfers and bed mobility The following interventions were added after the development of Resident #65's pressure ulcer: - 1/23/18: Continue to educate guest on repositioning as guest frequently refuses turning/repositioning - 1/15/18: Encourage turn and reposition every two hours while awake and prn (as necessary), check for incontinence of stool with each turn and change. At hour of sleep to adhere to guest request of every 4 hours during HS (at bedtime). The DON and Nurse Consultant reported that Resident #65 refused to turn and reposition every two hours. The documentation of the refusals by the resident was requested. Upon record review by the DON and the Nurse Consultant, no such documentation was located, nor was there a care plan in place for non-compliance. When queried about Resident #65's bed mobility status, both, the DON and Nurse Consultant were unable to answer. Resident #65's admission Minimum Data Assessment (MDS) assessment indicated the requirement of two persons for bed mobility. When the DON and Nurse Consultant were queried why the intervention to turn and reposition every two hours and as needed was not added to the care plan until 1/15/18, after the development of the pressure ulcer, neither one of the two provided an explanation. Review of the Treatment Administration Record (TAR) with the DON and Nurse Consultant revealed the interventions to turn and reposition every two hours, check for incont. of stool with each turn and change, apply chalmosyn with each change every two hours, were started 1/18/18. This was indicated by documentation completed every two hours by the nurses. Previously, there was no such documentation for turning and repositioning the resident with the exception of the Certified Nursing Assistants' (CNAs) documentation of turning and repositioning the resident sporadically, and not at a minimum of every two hours. Per the Nurse Consultant, the turning and repositioning was documented as being done per the TAR. A physician's orders [REDACTED]. Two times a day for skin care BID (twice a day). Resident #65's current physician's orders [REDACTED]. Again, this was after the development of the facility acquired pressure ulcer on 1/13/18. The physician's treatment for [REDACTED]. The order read: Cleanse coccyx wounds with normal saline and apply [MEDICATION NAME] (wound debridement treatment) to dark areas, apply chalmosyn around dark areas daily and as needed. This order was modified on 1/23/18 to increase the frequency of the treatment to twice a day. On 1/25/18 at 1:14 PM, review of the physician progress notes [REDACTED]. Encounter Date: 01-22-2018 Chief Complaint: Sacral decub HPI: This is a [AGE] year-old white male with a past medical history significant for CAD, diabetes and spinal stenosis had L2-S1 bilateral hemi laminectomy done . Patient's hospital course was also complicated with the development of paraparesis (paralysis below the waist) and [MEDICAL CONDITION] . Patient is seen again for his and family's request for sacral decub .Admit Dx: status [REDACTED].>Objective: Exam: Constitutional: Skin: Unstageable pressure ulcer in the sacral area noted Assessments/Plans: Pressure ulcer of sacral region, unstageable - L89.150 Patient noted to have some unstageable sacral pressure ulcer. Patient started local wound care with the med honey and also on high-protein diet. Continue local wound care and frequent position changing. 01/25/18 1:24 PM, when queried if at any time he refused to be turned and or repositioned by the staff, Resident #65 stated, I never refused to be turned and repositioned. I wanted to be turned and repositioned. Why would I refuse something that would benefit me? When they turn me, I am checked for stool back there. I get cleaned up more the more they turn me. On 1/25/18 at 1:50 p.m., review of facility's policy titled Wound Management Program, revised 3/15/17, revealed the following documentation: Place initial interventions for residents at risk for development of skin breakdown in Care Plan/Kardex as applicable. Monitor any acute illness or change in condition. Update Care Plan to reflect new risks and interventions

Based on observation, interview and record review, the facility failed to provide interventions and monitor residents to prevent falls and serious injury for 2 (#'s 1014 and 1017) of 10 residents reviewed for safety and falls, from a total sample of 22 residents, resulting in Residents # 1014 and 1016 falling and sustaining hip fractures and Resident #1007, falling and sustaining a head injury. All 3 residents were hospitalized for [REDACTED]. On 2/27/17 at 9:50 AM Resident #1014 was observed in her room, sleeping in bed. On 2/27/17 at 9:51 am, Registered Nurse (RN) F was queried on what measures were in place to prevent resident falls and stated, It's hard, we do our best, we try communication (with the resident) and placing them in common areas (for observation). A record review on 2/28/17 at 3:30 PM indicated, Resident #1014 was initially admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data set assessment dated [DATE] indicated the resident had severe cognitive deficits and received extensive assistance for all care and 2 person assistance with transfers. The resident received the following medications: [REDACTED]. Further review of the medical record, on 2/28/17 at 3:45 PM provided the following: Resident #1014 had fallen 3 times, while at the facility: 2/21/16, 4/9/16 and 5/21/16. The resident was hospitalized after falling on 5/21/16, with a fractured left hip. At the time of the falls the resident received 1 assist with transfers and walked with a walker. The resident suffered a stroke on 2/14/17 and was no longer able to walk. The Fall Care Plan dated 2/14/16 had a Goal: Minimize risk of falls, Interventions: reinforce need to call for assistance (2/14/16), staff will remain with guest while toileting (2/29/16), staff to offer guest frequent turning and repositioning (4/11/16), Guest will receive frequent checks with offer to toilet to decrease risk for falls (2/29/16), bed at lowest position at all times (5/27/16), ambulation therapy only (11/9/16), 2 PA (person assist) for transfers (11/9/16), 1 (person assist) bed mobility . A progress note dated 2/21/16 at 7:08 AM noted, Self transferred to the bathroom, was found by RN. Did not use (the) walker .will continue to monitor closely. A progress note dated 4/9/16 at 2:45 PM noted, Guest stated, I was getting out of this chair to get into my w/c(wheelchair), Heard guest say, Ohh. Nurse rushed into room. Guest legs gave out and (the resident) lowered self to the floor . A progress note dated 5/21/16 at 2:00 PM noted, At 1250 staff heard (the resident) yell for help. Guest was observed laying on floor of bedroom .Unable to move left leg, light touch to hip results in increase pain to that area EMS was called . On 3/1/17 at 12:50 PM, the resident was observed receiving assistance with eating from Confidential Person H, who stated, I am afraid to leave (the resident) alone here. That is why I come up everyday and stay for about 8 hours to make sure (the resident) gets the proper care. There is not enough staff here. That is why (the resident) fell . They don't answer the call lights and (the resident) tried to get to the bathroom by (themselves). On 2/28/17 at 4:15 PM, a record review revealed Resident #1017 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] indicated the resident had no cognitive impairment and received extensive assistance with transfers, dressing and toileting and limited assistance with ambulation and hygiene, all with 1 person assistance. The resident received the following medications: [REDACTED]. On 3/1/17 at 9:30 AM review of a progress note dated 11/16/16 at 4:06 AM noted, Cena (Certified nursing assistant) heard guest call out for help. Cena noted guest laying on the floor at the foot of the bed .Cena states guest told her (the resident) was going to use the bathroom .did not want to bother the Cena .complains of pain to left hip left leg, which was tucked under right calf .grimaced in pain .A stat Xray of guest bilateral hips and pelvic area was ordered . A progress note date 11/17/16 at 9:37 AM noted, .The guest was transferred out to hospital .positive left hip fracture transfers via 1 person assistance and ambulates with a rolling walker . A review of the Fall Care plan on 3/1/17 at 1:30 PM indicated, the Care plan was initiated on 1/6/16 and had a revision date of 12/5/16, Risk for falls related to impaired mobility s/p (status [REDACTED]. (4/4/16), ambulate with therapy only (11/21/16), clutter free room and bathroom, call light within reach (1/6/16), It is safe for guest to sit in the recliner chair (5/23/16), Reinforce need to call for assistance (1/6/16), weight bearing precautions 25% weight bearing to left lower extremity (1/23/17). On 2/27/17 at 9:20 AM, the Director of Nursing was interviewed regarding fall prevention measures and stated, We don't use alarms or floor mats, the bed may be placed up against the wall, if the family or resident requests it, we may use low beds. When queried on how the facility is aware that a resident, at risk for falls, is trying to get up on their own, the Director of Nursing stated, We monitor the best we can. The Director of Nursing was queried on 2/28/17 at 4:20 PM, regarding the number of resident's who had fallen and received serious injuries, The nurses and CNA's all assist the residents. When queried if there are enough staff to safely care for the resident's and prevent injury, the Director of Nursing did not respond. On 3/1/17 at 11:30 AM, the Administrator was interviewed and stated, Falls are one of our focus areas. Of course, staffing is a focus. It is hard to find staff. The Administrator said the facility is trying to hire more staff and partnered with a nurse aide training program in December of 2016, stating, We hired 3 new CNA's. The facility was asked for a Fall Prevention Policy on 2/27/17 at 8:30 am. A policy was provided titled, Assessing Falls and Their Causes, and it indicated, Falls are a leading cause of morbidity (illness/injury) and mortality (death) among the elderly in nursing homes. No Fall Prevention policy identifying measures to prevent falls was provided prior to exit.

Based on observation, interview and record review, the facility failed to provide interventions, including completion of weekly skin checks, to prevent pressure ulcers ( bed sores, localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or pressure with shear and /or friction) for 2 ( #'s 1002 and 1003) of 4 residents reviewed for pressure ulcers from a total sample of 22 residents, resulting in Resident #1002 obtaining a stage 2 pressure ulcer (a superficial open sore in the upper layer of skin) on the coccyx (tailbone area) and Resident # 1003 obtaining 2 pressure ulcers, 1 stage 4 (full thickness tissue loss exposing bone, tendon or muscle) on the coccyx and 1 stage 2 on the ischium (lower back part of the hip bone) and further resulted in resident pain and suffering. Findings include: On 2/27/17 at 9:15 am during the initial tour, the Director of Nursing identified Resident #1002, as having a facility acquired pressure ulcer on the coccyx. On 2/27/17 at 10:00 am, Resident #1002 was observed in the resident's room, sitting in a wheelchair, watching television. On 2/27/17 at 10:03 am during the initial tour, Nurse F stated, (The resident) has a pressure ulcer on the coccyx that was acquired here. A record review on 2/27/17 at 11:30 am indicated, Resident #1002 was initially admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] indicated, the resident had no cognitive impairment and received extensive assistance with eating, hygiene and dressing and total assistance with 2 persons for transfers, toileting and bathing. The resident did not walk and received the following medications: [REDACTED]. An interview with the resident on 2/27/17 at 2:50 PM provided, The call light is not always answered. I go to the dining room if I need help. A review of the medical record on 2/28/17 at 10:30 am indicated the following: Resident #1002 had redness to the buttocks area on 1/5/17, per a Braden scale ( a risk tool for identifying pressure ulcers), with a score of 15 (indicating low risk) and stated, Continue POC (plan of care). A wound note written on 1/20/17 by Nurse L indicated, Allevyn ( a wound dressing) to coccyx times 3 days, 1 inch wide open area-coccyx. A wound note for Resident #1002, written on 2/1/17 by Nurse M provided, Coccyx slightly reddened. A wound note written on 2/16/17 by Nurse E, noted the resident's wound had increased in size with measurements: 3 centimeters in length by 1.6 centimeters in width by 0.1 centimeters in depth. The note further described the wound as facility acquired, stage 2 (on a 1 to 4 scale) and the resident was experiencing pain rated as an 8 on a scale of 0-10 ( with 0 indicating no pain and 10 indicating the worst pain possible), the Braden score for risk was rated at 13, indicating Moderate Risk for pressure ulcer development. The section titled Current plan and comments, was not completed. The physician was not notified. A wound note written on 2/23/17, by Nurse E, indicated the resident's wound measured 2.75 centimeters in length by 1.5 centimeters in width by 0.1 centimeters in depth, facility acquired, stage 2 and the resident was experiencing pain rated as an 8 on a 0-10 scale, the Braden score for risk was rated at 13 for Moderate risk. The Current plan and comments section was blank. The physician was not notified. On 2/28/17 at 3: 25 PM, a review of the resident's Care plan revealed, The resident has potential impairment to skin integrity r/t (related to) fragile skin, impaired mobility and incontinence, diabetes, stage 2 to coccyx, MASD (moisture associated skin damage) to left gluteal fold, date initiated on 4/21/15 and revised on 2/17/17, Goal: The resident's skin injury to coccyx and left gluteal fold will be healed by review date (Target date: 4/19/17). The Skin integrity care plan for Resident #1002 was not updated with new preventive interventions, after redness to the coccyx was first identified on 1/5/17, or after an open area to the coccyx was identified on 1/20/17. The care plan was not updated with additional preventive interventions until the wound was noted to be a stage 2 pressure ulcer on 2/16/17. The care plan was then updated to include a low air loss mattress, monitor/document the wound, offer to reposition guest in wheelchair every hour, treatments as ordered, on 2/17/17. On 2/27/17 at 9:15 am during the initial tour, the Director of Nursing identified Resident #1003, as having a facility acquired pressure ulcer on the coccyx. On 2/27/17 at 9:50 am, the resident was observed laying in bed. A low air loss mattress was in use. An interview with Nurse F, on 2/27/17 at 9:50 am revealed, (The resident) has a stage 4 pressure ulcer on the coccyx and is Hospice now. On 2/27/17 at 5:10 PM a record review revealed Resident # 1003 was admitted to the facility on [DATE] with Diagnosis: [REDACTED]. The Minimum Data Set assessment indicated the resident had severe cognitive deficits and received extensive 1 person assistance with eating via a feeding (stomach) tube, extensive, 2 person assistance with transfers, dressing and hygiene and total 2 person assistance with bathing and toileting. The resident received the following medications: [REDACTED]. Further review of the medical record, on 2/28/17 at 10:40 am indicated the following: Resident #1003 developed a facility acquired pressure ulcer on 8/10/16: coccyx wound. A wound note dated 8/31/16 indicated, coccyx 1.6 (centimeters length) by 1 (centimeters width) by 0.2 (centimeters depth), left buttock 2 centimeters (length) by 2.5 centimeters (width) by 0.1 centimeters (depth). A wound note dated 9/14/16 revealed, stage 4 coccyx, stage 2 sacrum ( bony area at the base of the spine), left buttock area. On 2/28/17 at 12:15 PM, a review of the medical record, indicated the following: A wound note dated 12/27/16, closed area coccyx. No further wound notes or skin assessments documented from 12/28/16- 2/15/17. A 2/16/17 wound note, coccyx 2.0 centimeter (length) by 1.6 centimeter (width) by 0.8 centimeter (depth), ischium 4.0 centimeter (length) by 3.0 centimeter (width) by 0.1 centimeter (depth). A wound note dated 2/24/17 revealed, stage 4 coccyx, 2 centimeters (length) by 1.3 centimeters (width) by 0.8 centimeters (depth), 50% slough ( thick fibrous yellow or black tissue), 50% pink tissue, scant drainage, stage 2 ischium, A&D (ointment), low air loss mattress. On 3/1/17 at 2:15 PM, a review of the Hospice records indicated, Resident #1003 was admitted to Hospice services on 6/27/16 with, Establish upon admission the care and services needed to meet the personal care, nutritional, mobility, DME (durable medical equipment), elimination and skin integrity needs. Patient's care is coordinated with facility and hospice staff. On 3/1/17 at 2:30 PM, a review of the Skin Care plans for Resident #1003 provided the following: The resident has potential impairment to skin integrity, r/t (related to) previous wounds/scars, decreased mobility, and cachetic appearance stage 4 to coccyx, stage 2 to right ischial tuberosity, date initiated 2/17/17, revision 2/17/17. Goal: The resident's skin injury will decrease in size to the coccyx and right ischial tuberosity by 1 centimeter, date initiated 2/17/17, revision 2/17/17. There was no indication of a prior Skin Care plan Focus. The Skin Care plan was not updated for preventive measures, or treatments, from the time the resident's coccyx wound was first observed on 8/10/16 until 8/25/16, provided, reposition in gerichair every hour. The Skin Care plan was not updated for preventive measures, or treatments again, from 9/14/16, when Resident #1003's wounds were first documented as a stage 4 pressure ulcer to the coccyx and stage 2 pressure ulcer to the sacrum, until 10/4/16, when low air loss mattress, was added. The Skin Care plan for Resident #1003 was updated on 2/7/17 with, treatments as ordered. An interview with the facility Administrator on 3/1/17 at 11:35 am provided, The DON (Director of Nursing) monitors that, when asked about measures to prevent pressure ulcers. An interview with the Director of Nursing on 3/1/17 at 3:10 PM indicated, Hospice coordinates the resident's care with our staff. An interview with Nurse E on 3/1/17 at 3:30 PM provided, Hospice is supposed to provide weekly notes, but we don't always get those. We are supposed to complete weekly skin assessments, usually on a wound care note or Braden scale. On 3/1/17 at 3:45 PM, a review of the Hospice Notes and assessments for Resident #1003 indicated, there were 4 notes from 6/27/16 until 2/22/17. None indicated specific interventions to prevent skin breakdown or pressure ulcers. On 3/1/17 a review of the facility wound documentation for Resident #1003 revealed there were 12 documented wound notes from 8/10/16 until 3/1/17. They were completed less than weekly. On 3/1/17 at 3:45 PM, a review of the facility policy, Prevention of Pressure Ulcers, dated 10/2010, provided, The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family and addressed. For a person in bed: Determine if resident needs a special mattress. For a person in a chair, change position at least every hour. Neither of these measure were enacted in time to prevent further increase in the size of the resident's pressure ulcer for Resident's #1002 or 1003.

Based on observation, interview and record review, the facility failed to provide a two person assist during resident care for one ( #102) sampled resident out of three sampled residents assessed for falls out of a total sample of three residents, resulting in the resident falling out of bed, hitting her head and bleeding from a laceration. Findings include: Record review revealed that Resident #102 was an eighty-five year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Coli (bacteria found in the colon), gastric reflux disease and Alzheimer's dementia. Resident #102 was taking Xarelto (a blood thinner) 20 milligrams at HS (hour of sleep) for chronic embolism (blood clot) of a vein. On 3/17/2016 at 9:30 AM, a record review of the quarterly Minimum Data Set (MDS) indicated Resident #102 was a two person extensive assist for transfers, ambulation, dressing, hygiene, and bathing. Resident #102 had a Brief Interview for Mental Status (BIMS) score of 0 which indicated severe cognitive impairment. On 3/17/2016 at 9:30 AM, a record review of a mobility assessment by the therapy department, dated 2/24/2016, indicated Resident #102 had poor muscle strength, poor mobility and balance, and transitional movements (between bed and chair or wheelchair) were not steady and only able to stabilize with staff assistance. On 3/17/2016 at 10:15 AM, a phone interview was done with the complainant. She stated she had concerns with the care at the facility because she observed Resident #102 in the emergency room of the local hospital. She said Resident #102 had a hematoma (bruise) to the left eye and a puncture wound to the left temple. She stated Resident #102 was bleeding heavily from her head. The complainant indicated Resident #102 was admitted to the surgical intensive care unit at the local hospital. On 3/17/2016 at 11:00 AM, a record review of the accident and incident (A & I) report for Resident #102's fall was done. According to the form, the data in the form was completed by LPN E. It was noted that the form was revised on 3/17/2016 at 10:38 AM prior to the Director of Nursing presenting the form to the surveyor. Under the topic Mobility, it was documented Resident #102 was ambulatory without assistance. However, documentation in the MDS, nursing notes and physician orders [REDACTED]. On 3/17/2016 at 1:00 PM, an interview was conducted with certified nursing assistant (CNA) B. She said that Resident #102 was totally dependent for everything. CNA B stated Resident #102 was totally dependent when dressing or transferring or changing her brief. CNA Bsaid Resident #102 had contractures to both arms which made it difficult to put deodorant on her. In addition, Resident #102 had stiff knees that were hard to bend. CNA B said Resident #102 did not make any voluntary movements on her own. CNA B was asked if she knew anything about Resident #102's fall. CNA B said on the morning of 3/15/2016 at approximately 6:30 AM, she went to Resident #102's room. Resident 3102 was lying in the bed, which was in the low position. CNA B said Resident #102 had her head wrapped in gauze, an ice pack to the left temple and her face was purple. CNA B noted a large spot of blood on the floor near the wall. CNA B was asked what part of Resident #102's face was purple and she stated her face was purple from the left eyebrow to the bottom of her left cheek with a large lump by the left cheekbone. On 3/17/2016 at 1:20 PM, an interview was conducted with Registered Nurse (RN) C who worked the day shift the morning after Resident #102 fell . RN C said, when she heard that Resident #102 had fallen the night before, she went to the resident's room to assess her. She stated Resident 3102 was sitting up in bed with an ice pack to her face. RN C said Resident #102 was actively bleeding through the dressing over the left eye and there was blood on the pillow and on the ice pack. RN C said Resident #102 had a large black and purple hematoma (bruise) to the left side of the face, the left eye was swollen shut and there was bruising and swelling over the left eyebrow. After her assessment, RN C wanted to send Resident #102 to the hospital. On 3/17/2016 at 2:00 PM, an interview was conducted with Licensed Practical Nurse (LPN) E who was on duty when Resident #102 fell out of bed. LPN E said he became aware of the situation with Resident #102 when CNA D came to get him. LPN E said found Resident #102 on the floor between the bed and the wall. He noted there was bleeding from the forehead from a laceration and there was swelling to the face. LPN E stated resident #102 does not have a lot of control over her body. If you rolled her away from you, the resident could not catch herself and stop the roll but would keep rolling. LPN E stated CNA D was changing the resident's brief by herself. LPN E was asked if he had notified the physician that Resident #102 was taking Xarelto after Resident #102 has sustained a laceration to her left eyebrow and LPN E said he did not do so. On 3/17/2016 at 2:30 PM, an interview was conducted with CNA F who stated the resident couldn't catch (stop) herself if she was rolled away from you. On 3/17/2016 at 3:00 PM, an interview was conducted with CNA D. According to CNA D, Resident #102 was easy to care for. She stated, on 3/14/2016, she started her final rounds at 10:30 PM. When she came to Resident #102, CNA D noted that Resident #102 was incontinent and needed her brief changed. CNA D assembled all her supplies and raised the bed up to waist level for ease in care. CNA D said she unstrapped Resident #102's brief and turned Resident #102 on her right side positioning her in the middle of the bed facing the window. CNA D began to pull wipes from the dispenser to wipe Resident #102 in her perineal area. CNA D said she had her right hand on Resident #102's waist and was using a wipe to clean the resident with her left hand. The wipes got caught in the box so CNA D removed her right hand from Resident #102's waist and placed it on the wipe dispenser to unstick the wipes. According to CNA D, Resident #102 twitched a little and fell off the bed. CNA D said she wasn't aware that Resident #102 was a two person assist with her care, just a two person assist when using the Hoyer lift. According to CNA D, she had changed Resident #102 by herself in the past. On 3/17/2016 at 3:20 PM, a re-enactment of the fall by CNA D was observed in the presence of the Administrator and the Director of Nursing. CNA Ddescribed how she positioned the resident, how CNA D removed her supporting hand from Resident #102's waist and how Resident #102 fell from the bed. A large blood stain was noted on the carpet next to the wall. The Housekeeping Manager measured the stain and it was 14 inches by 11 inches. On 3/17/2016 at 3:30 PM, in an interview with the Director of Nursing, she denied that Resident #102 was a two person assist while changing her brief. According to the State Operations Manual, the facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. ( )