Every finding on record at West Woods of Bridgman

This citation pertains to intake #3045701Based on observation, interview, and record review the facility failed to monitor and prevent the worsening of a pressure ulcer for 1 (Resident #5) and prevent the development of a pressure injury/ulcer in 1 (Resident #7) of 3 residents reviewed for pressure injuries/ulcers resulting in Resident #5 stage IV pressure wound (most severe, deep open wound that extends through the skin, underlying tissue, muscle and bone) worsening, and Resident #7 developing a stage II pressure injury (shallow, wound that affects both top layers of skin, and park of the under layer, appearing red, pink sore or blister).Findings include: Resident #5Review of an admission Record revealed Resident #5 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: osteomyelitis of the sacral region (an infection of the bone in the sacral- low back / upper buttock area of the body), a stage IV pressure wound, and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #5, with a reference date of 5/5/26 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated Resident #5 was cognitively intact.On 6/26/26 at 1:30 pm, Resident #5 was observed positioned on her back in bed. No additional devices were used to assist her positioning. Resident #5 was noted to have a wound vac present; a large brown stain was noted on the gown she was wearing and she was sleeping.Review of admission Assessment for Resident #5 dated 4/28/26 at 17:08 (5:08 pm) revealed .sent to hospital.for sacral wound.here for IV (intravenous) ATB (antibiotic) and wound vac (vacuum- assisted closure; a medical device that uses negative pressure to promote wound healing) to area r/t (related to) osteomyelitis.Review of Care Plan for Resident #5 revealed .Focus: potential risk for impaired skin integrity related to: history of actual impairment admitted with stage 4 to sacrum, NPWT (negative pressure wound therapy) in place.Goal: will show improvement in skin integrity as evidenced by.decreased measurements.Interventions: assess postural alignment, weight distribution.assist with repositioning with use of draw sheet as needed to prevent friction/shear.measure open areas upon admission, weekly, and prn, pressure reducing mattress, re-evaluate treatment and resident condition with no improvement to wound appearance, skin inspections with am/pm (morning and night) care and showers.Focus: skilled nursing care.intervention: bathing one assist, encourage resident to do as much for herself as able, skin care interventions, inspect skin with bathing and care, heels elevate in bed, reposition frequently, as accepted. all with an initiation date of 4/28/26 and 4/29/26.In an observation and interview on 6/26/26 at 2:44 pm, Resident #5 was lying supine (on her back) in bed, and had no additional devices used to assist her positioning or relieve pressure points. Resident #5 was noted to have a wound vac present on the foot of her bed, and an IV ball attached to the PICC (peripherally inserted central catheter; a long tube inserted into a large vein for long term antibiotic administration use) in her right arm. A large brown stain was noted on the gown she was wearing. Resident #5 reported she spilled her coffee at lunch and no one had changed her yet. When queried, Resident #5 said she was unsure if her bed was wet, but denied the coffee being hot when she spilled it. Resident #5 reported the staff didn't move her around too much in bed because of her wound vac. Resident #5 further reported she didn't know too much about the wound vac, but she knew her wound got worse when she first came to the facility and it was now starting to improve. Resident #5 reported the staff had had difficulty managing the wound vac, and at times the way the staff made it stop alarming was by turning it off. Review of Treatment Administration Record (TAR) for Resident #5 for May 2026 revealed .Sacrum: cleanse with wound cleanser, apply skin prep to peri-wound. Protect any exposed bone with contact layer with silver. Fill wound bed with black foam, cover with clear drape, cut small hole and cover with suction disk. Run machine at continuous 125 mmHg (millimeters of mercury) If seal cannot be maintained, cover with NS, moistened gauze and secure with tape daily until NPWT can be reapplied every shift Tues, Thru, Sat. with a start date of 4/30/26.Review of TAR for Resident #5 for May 2026 revealed .Sacrum: cleanse with wound cleanser, apply skin prep to peri-wound. Protect any exposed bone with contact layer with silver. Fill wound bed with black foam, cover with clear drape, cut small hole and cover with suction disk. Run machine at continuous 125 mmHg (millimeters of mercury) If seal cannot be maintained, cover with NS, moistened gauze and secure with tape daily until NPWT can be reapplied every shift Mon, Wed, Fri. with a start date of 5/11/26.Review of TAR for Resident #5 for May 2026 revealed 5/9/26 entry was blank, no documentation for wound vac dressing change was noted. In an interview on 6/26/26 at 2:58 pm, Infection Preventionist (IP) Q reported Resident #5's wound was deteriorating. IP Q reported Resident #5's wound vac was to be changed three times a week, and the days were changed when she first arrived at the facility. IP Q reported the order was for Tuesday, Thursday, and Saturday wound vac change and then it was changed to Monday, Wednesday, and Friday, the following week. IP Q reported an outside homecare nurse followed Resident #5 and her wound vac dressing was changed by her once a week, on Monday, and Resident #5 went to the wound clinic once a week, on Tuesday, and they changed the wound vac as well. IP Q reported the facility staff was scheduled only once a week to change Resident #5's wound vac dressing. IP Q reported the facility staff would change Resident #5's wound vac dressing on an as needed basis too.Review of Wound Treatment Clinic notes for Resident #5 dated 5/12/26 revealed .with a sacral pressure ulcer complicated by osteomyelitis status post debridement (removal of damaged tissue from a wound bed) with wound vac. is accompanied by Family Member (FM) II. she is concerned about when the wound will improve.on arrival her caregiver found the VAC unit off with no suction. Duration of disconnection is unknown. She notes fluid collecting on her back and is concerned about possible green drainage.wound bed red; necrotic; yellow/white; pink; slough (dead non-viable tissue).surrounding skin macerated (softening and breakdown of skin caused by prolonged exposure to moisture).length 7.6 cm (centimeters) x width 3.4 cm x depth 2.1 cm.wound vac not reapplied to allow skin to rest.Hold wound vac for 1 week due to skin irritation and malfunction.continue turning and reposition schedule.Review of Resident #5's record revealed no documented turning or repositioning schedule.In a telephone interview on 6/26/26 at 3:47 pm FM II reported he had attended the wound clinic appointment with on 5/12/26 with Resident #5 and reported she had a wound vac that was to be on at all times. FM II reported when Resident #5 arrived at the wound clinic appointment on 5/12/26 the wound vac was powered off, and when the wound clinic staff asked him how long the wound vac had been powered down, FM II stated .I had no answer for them I didn't know. I met Resident #5 at the appointment, and she didn't know how long it had been powered off either. FM II reported he was educated that when a wound vac was in place on a wound, but not suctioning, it could cause more harm to the wound; and it had caused damage to Resident #5's wound. FM II reported the staff at the wound clinic decided to leave the wound vac off due to the surrounding tissue being swollen and red to let the skin rest. FM II reported he attended most wound clinic appointments with Resident #5, and the wound did get worse in the beginning. FM II reported he was not sure the facility was following the orders that were being given by the wound clinic and he had been informed that the facility had run out of supplies for Resident #5's wound dressing change, and on one appointment, the facility did not send the wound vac with Resident #5 to be re-applied to the wound.Review of Resident Assistance Form (facility concern form) for Resident #5 completed via telephone for FM II revealed .5/12 wound clinic appt (appointment) he was present arrived with NPWT device on her but not function.how can we address your issue.please make sure the wound is changed daily per provider orders.Review of Wound Treatment Clinic notes for Resident #5 dated 5/19/26 revealed .wound check.wound bed slough; yellow/white; red; necrotic.surrounding skin dry; excoriated (outer layers of skin have been scraped, scratched, or picked away resulting in abrasions or open wounds).length 7.5 cm x width 5 cm x depth 1.2 cm.chronic large lower limb ulcer with persistent but improving cutaneous candidiasis peri-wound rash (a fungal infection of the skin caused by an over growth of yeast) remained incompletely resolved, so wound vac held. continue daily dressings.maintain current wound regimen.turn and reposition every 2 hours.increase protein intake at least twice daily.In an observation and interview on 6/26/26 at 4:07 pm, Resident #5 was receiving care. Resident #5 gown was changed by Certified Nurse Assistant (CNA) M and Resident #5 was positioned supine in bed, with no assistive devices for positioning. Resident #5 reported sometimes she was put on her side, but today, she has just been on her back. During 3 observations on 6/26/26 Resident #5 was positioned on her back in bed.In an observation on 6/30/26 at 10:03 am, Resident #5 was positioned on her back in bed, no assistive devices were noted to assist with position maintenance.In an interview on 6/30/26 at 10:14 am, IP Q reported the nurse's responsibility was to change the wound vac dressing as ordered and monitor the wound vac functioning. When queried how that was documented, IP Q reported it wasn't unless the nurse documented it in a progress noted. In an interview on 6/30/26 at 10:50 am, Licensed Practical Nurse (LPN) Y reported she cared for Resident #5 a couple of times, and she did care for her when she went to the wound clinic. LPN Y reported she remembered, Resident #5's wound vac was to be left off on the day she goes to the wound clinic; LPN Y stated they put it on for the week. LPN Y reported Resident #5's wound vac dressing was removed when she had a shower, which she did that day, and the wound vac was beeping, and she had shut it off.In a telephone interview on 6/30/26 at 11:02 am Registered Nurse (RN) W reported the nurses needed to make sure Resident #5's wound vac was patent (working) and functioning and not beeping and that the wound dressing was not saturated. RN W reported there was no order to monitor Resident #5's wound vac, and there was no expected documentation of the wound vac. When queried if she was the assigned nurse when Resident #5 went to the wound clinic on 5/12/26, RN W replied that as LPN Y.In a follow-up interview on 6/30/26 at 12:16 pm, LPN Y reported she had sent Resident #5's wound vac with her to her wound clinic appointment on 5/12/26 so the wound clinic could re-apply the wound vac. LPN Y reported she that she had not done a thing with the wound vac, she did not know if it was running or not. LPN Y reported she hung the wound vac on Resident #5's wheelchair, told the transport driver it was there, and when Resident #5 returned to the facility, the wound vac was still hanging from her wheelchair in the same position. LPN Y reported she documented everything in Resident #5's record in a progress note.In an interview on 6/30/26 at 2:00 pm, Director of Nursing (DON) B and Regional Clinical Support (RCS) C reported their expectations were that Resident #5's wound vac was to be monitored at least each shift, and it should be documented in her record. RCS C confirmed there was no order in place for the monitoring of Resident #5's wound vac and there was no required documentation for monitoring her wound vac. RCS C reported an order had been created to monitor a wound vac and had been added to Resident #5's record.In an interview on 6/30/26 at 2:30 pm, IP Q reported she assisted with getting Resident #5 ready for the wound clinic appointment on 5/12/26 around lunch time and IP Q reported she did not look at Resident #5's wound vac and had no idea if it was functioning or not that day. When queried, IP Q reported Resident #5's wound vac dressing was never to be removed before going to the wound clinic.Review of interdisciplinary Documentation for Resident #5 on 5/12/26 at 5:08 am revealed .continues on wound vac for sacral wound and wound vac is in place and functioning.No further documentation was noted in Resident #5's record for 5/12/26 regarding her wound vac.Further review of Resident #5's progress notes revealed between 4/28/26 and 5/12/26 documentation regarding Resident #5's wound vac was noted 5 times, 4/28/26, 5/4/26, 5/8/26, 5/11/26 and 5/12/26.In an interview on 6/30/26 at 2:55 pm, CNA M and CNA H reported resident should be repositioned or turned every 2 hour or so, if they will allow. CNA H reported there was no place to document if a resident refused to be turned. CNA M reported that they used wedges (triangle shaped pillows) to help a resident maintain their position. On 6/30/26 at 3:00 pm a tour of Resident #5's room revealed a wedge noted on the top shelf of the closet.In a telephone interview on 6/30/26 at 4:37 pm, LPN R reported her responsibility was to monitor Resident #5's wound vac and change the dressing if ordered. When queried, LPN R reported, there was no place to documents the monitoring of her wound vac other than in a progress note.Resident #7 Review of an admission Record revealed Resident #7 was a male who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: acquired absence of the right leg above the knee, acquired absence of the left leg above the knee, and progressive multiple sclerosis (a progressive autoimmune disease that affects the central nervous system that results in a range of physical and cognitive symptoms).Review of a Minimum Data Set (MDS) assessment for Resident #7, with a reference date of 6/23/26 revealed a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated Resident #7 was cognitively intact. Section M Skin conditions: indicated Resident #7 had 1 stage II pressure injury that was not present on admission.During observations on 6/26/26 at 1:25 pm, 3:05 pm, and 4:15 pm, and 6/30/26 at 9:45 am, 11:30 am, and 2:55 pm, Resident #7 was positioned supine in bed, with no assistive devices to offload pressure or maintain positioning.Review of a Care Plan for Resident #7 revealed Focus.There is a potential for alteration in comfort: Resident #7 requires assistance with repositioning due to comorbidities. He has no skin breakdown at this time. Assist with repositioning frequently, as tolerated.initiated 6/17/26.Impaired skin integrity related to impaired mobility, dependence for repositioning and transfers, poor nutritional status.decreased ability to relieve pressure independently , as evidenced by stage 2 pressure ulcer to the sacral region developed from excoriation noted at admission.Goal: will show improvement of impaired skin integrity.Interventions: assess postural alignment, weight distribution, sitting balance, and pressure redistribution on admit and prn (as needed) assist with re-positioning with use of draw sheet as needed to prevent friction/shear, pressure recuing mattress. all initiated on 6/17/26 and revised on 6/24/26.Review of admission Assessment for Resident #7 dated 6/16/26 revealed .noted healed sacrum. and the skin section was blank.Review of Skin Assessment dated 6/16/26 revealed .noted excoriation multiple areas on buttock cream applied, some scarring noted to upper back area.Review of Skin Assessment dated 6/17/26 revealed .buttock excoriated.Review of Wound Measurement for Resident #7 dated 6/22/26 revealed .site- rt buttock (right buttock) type pressure length 12 cm x width 12 cm x depth 0 Stage II.Review of Hp skin and wound noted for Resident #7 dated 6/22/26 revealed .the resident has.Stage 2 PU (pressure ulcer) right buttock, and has bene present for less than 30 days.Assessment: location right buttock.present on admission.Review of Interdisciplinary Note for Resident #7 dated 6/24/26 revealed .buttock with MASD (moisture associated skin damage) partial thickness wound noted to right buttock, he has multiple areas of scarring to his sacrum and buttock. Cleft of buttocks with white maceration and without open areal bilateral amputation of LE (lower extremities) .Review of an Order Summary for Resident #7 revealed .Cleanser open area to right buttock with wound cleanser. Apply barrier cream to base of the wound, leave open to air. Complete every shift, every shift for stage II sacrum with a start date of 6/24/26.In an interview on 6/30/26 at 2:30 pm, IP Q reported Resident #7 looked to us at admission that he did not have a pressure injury, was seen by the wound provider a week later and she classified it as a stage II pressure ulcer. IP Q reported Resident #7 was waiting for a specialty mattress to be delivered, and he would be seen by the wound doctor weekly, barrier cream and reposition him frequently would be some interventions. IP Q reported she had not seen Resident #7 out of bed and she did not think he had gotten out of bed at all since he admitted . When queried regarding the meaning of frequently, IP Q replied no set time.In an interview on 6/30/26 at 2:55 pm, CNA M and CNA H reported resident should be repositioned or turned every 2 hour or so, if they will allow. CNA H reported there was no place to document if a resident refused to be turned. CNA M reported that they used wedges to help a resident maintain their position and CNA M entered Resident #7's room and was heard saying I think he has a couple we use. CNA M did not produce any wedges or additional devices for positioning of Resident #7.During an observation of Resident #7's room on 6/30/26 at 2:57 pm, no wedges, additional pillows, or other devices for positioning were noted. Resident #7 was observed supine, on his back, in bed with only a pillow behind his head.In a telephone interview on 6/30/26 at 4:37 pm, LPN R reported that Resident #7 had some excoriation on his bottom and that standards of care were to turn residents every 2 hours. LPN R reported Resident #7's buttock was breaking down due to him being in bed all the time.Review of facility policy Skin at Risk Assessment, Documentation, Staging & Treatment with a revision date of 1/2020 revealed .to assess resident risk factors for the development of impaired skin integrity and intervene as indicated utilizing the admission assessment, plan of care, and Minimum Data Set as formal assessment tools.to limit the development of avoidable pressure ulcers.the following guidelines are reviewed and implemented as indicated for each individual risk factor: daily skin inspections with am and pm care.limitation of skin injury due to friction or shearing through proper positioning.use of pressure relieving devices.shower twice weekly as accepted and desired and prn including skin inspections.change the residetns positions every 2 hours and more frequently if redness or irritation of the skin develops.assessment of individualized need for pressure redistribution support surfaces.individualize the resident goals and interventions as documented on the plan of care.

Based on observation, interview, and record review the facility failed to maintain activities of daily living (ADLs) specifically showers for 1 (Resident #5) of 8 sampled residents, resulting in an unkempt appearance and the potential for unmet care need.Findings include:Resident #5Review of an admission Record revealed Resident #5 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: osteomyelitis of the sacral region (an infection of the bone in the sacral- low back upper buttock area of the body), a stage IV pressure wound, and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #5, with a reference date of 5/5/26 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated Resident #5 was cognitively intact.On 6/26/26 at 1:30 pm, Resident #5 was observed positioned on her back in bed a large brown stain was noted on the gown she was wearing and she appeared disheveled and unkept. In an observation and interview on 6/26/26 at 2:44 pm, Resident #5 was lying supine (on her back) in bed, and a large brown stain was noted on the gown she was wearing. Resident #5 reported she spilled her coffee at lunch and no one had changed her yet. When queried, Resident #5 said she was supposed to get showers twice a week on Thursday and Sunday, and she was lucky if she got one a week. Resident #5 reported she loved getting showers, they made her feel so good.In an interview on 6/26/26 at 3:06 pm, Registered Nurse (RN) W reported there was no reason Resident #5 could not get in the shower.In a telephone interview on 6/26/26 at 3:47 pm, Family Member (FM) II reported Resident #5 was not getting showers or baths at the facility and stated She (Resident #5) would love a bath or shower, she was always a 'clean fanatic'. In an interview on 6/26/26 at 4:05 pm, Certified Nurse Assistant (CNA) L reported Resident #5 preferred bed baths and did not like to get in the shower.Review of Task for Resident #5 revealed .Shower assignment Thurs & Sun AM (Thursday and Sunday morning). Documentation for the previous 30 days, 6/4/26 to 6/30/26, of 8 possible shower days, documentation indicated Resident #5 received only 4 showers during that time, and 1 bed bath. 3 additional days were undocumented.In an interview on 6/30/26 at 11:20 am, Licensed Practical Nurse (LPN) T reported Resident #5 had no reason she could not get in the shower. LPN T reported she thought Resident #5 enjoyed getting showers.In an interview on 6/30/26 at 2:37 pm, Infection Preventionist (IP) Q reported Resident #5 had a wound, but that didn't restrict her from getting in the shower.In an interview on 6/30/26 at 3:55 pm, CNA P reported Resident #5 really enjoyed her showers.In a telephone interview on 6/30/26 at 4:37 pm, LPN R reported Resident #5 should have a shower or bath twice a week and there was no reason Resident #5 could not have a shower. LPN R stated .Resident #5 loves her baths, I think it's the highlight of her stay.Request for shower documentation for Resident #5 from admission to present, additionally any refused shower documentation, and none was provided by the facility by the time of survey exit.

This citation pertains to intakes 3056471 and 3056531.Based on interview and record review facility staff failed to notify a nurse and ensure a post-fall assessment was completed timely for 1 (Resident #6) of 3 residents reviewed for falls resulting in a delay in an assessment following a staff assisted fall and the potential for an injury and/or an increase in pain to go unaddressed. Findings include: Review of Resident #6 (R#6)'s Facility Reported Incident investigation report, dated 6/6/26, indicated R#6 had pertinent diagnoses that included dementia (decline in mental abilities) with other behavioral disturbances, genetic intellectual disability (affects brain development and impacts intelligence, learning, and life skills), and osteoporosis (disease that makes bones weak). R#6's brief interview for mental status score was noted to be .8 indicating moderate cognitive impairment. The report stated, .On June 4th (6/4/26; estimated to be approximately 11:00 AM/lunch time), an assisted event (staff intervened/assisted resident) occurred when resident (R#6)'s right leg gave out while being escorted back to her room from activities.The staff member (Certified Nurse Aide (CNA) D) lowered her safely to the floor without impact but this incident was not reported to nursing at the time.failure to report the initial assisted lowering to the floor.Action (facility's corrective action).Facility-wide education for all departments regarding.Immediate reporting of all incidents/accidents.Reinforcement of expectations regarding timely communication with nursing staff. (Note: If a resident lost his/her balance and would have fallen, if not for another person or didn't catch him/herself, this would be considered a fall). The report indicated, on 6/6/26 at approximately 6 AM, Licensed Practical Nurse (LPN) R was the first nurse to discover R#6 had fell on 6/4/26. Witness Interview statements in the report stated:- .(CNA D).I was assisting resident (R#6) back from activities on 6/4/26 when her right leg gave out from under her.I was able to stop her before her knees hit the ground. I slowly let her down the rest of the way (onto the floor).- .(CNA L).the activity aide (CNA D) asked me to assist (R#6) back to her room. I asked what was wrong. The activity aide said her leg gave out, but she (R#6) didn't hit the floor.- .(LPN R).I came in Saturday morning at 6 AM, 6/6/2026.She (R#6) said my hip is hurt.I assessed her. - .(CNA JJ).observed (R#6) on one knee (one knee on the ground) while passing in the hall during mealtime on June 4th.stated she believed the staff member (CNA D) assisting (R#6) was reporting it to the nurse and had no further knowledge of the incident.Review of R#6's Fall During Staff Assist incident report, started on 6/6/26, stated, .Date: 6/4/2026.(R#6's) right leg gave out while she was ambulating and the Activities (sic) aide (CNA D) assisted (R#6) down to the floor on her knees.No evaluation (post-fall assessment) was performed with this incident by a nurse at this time.Notes.This incident was not reported to nursing.During an interview on 6/30/26 at 11:46 AM, CNA D reported, on 6/4/26 at approximately 11:00 AM, R#6 was walking down the hallway from the activities room to the North dining room, her right leg gave out, she slowly lowered R#6 to the floor, and R#6 came to rest in a kneeling position with her left knee and hand on the floor. CNA D confirmed after the fall she didn't notify a nurse and had not considered it a fall at the time. During a telephone interview on 6/30/26 at 2:44 PM, LPN R reported working the morning of 6/6/26 when R#6 reported right hip pain, completed an assessment, began an investigation, and discovered R#6 was lowered to the floor by staff (CNA D) on 6/4/26. LPN R reported she then immediately called the doctor and R#6 was sent to the hospital. LPN R confirmed she had worked on 6/4/26 but had not been notified that R#6 fell.Review of R#6's hospital record, dated 6/6/2026, stated, .XR (x-ray) Right Hip with Pelvis.Exam Date: 6/6/2026 at 1:34 PM.Indication: GLF (ground level fall), Pain.There is an acute right femoral neck (part of the thigh bone) fracture.Review of the facility's Accident/Incident Report Fall Management policy, revised 6/18, stated, .It is the policy of this facility to complete an accident incident report for.accidents or incidents where there is injury or the potential to result in injury; falls.When witnessing a resident fall.assessment that includes a minimum of the following will be completed by the Licensed Nurse.Full body inspection for any obvious deformity, bleeding, bruising, laceration or other signs of traumatic injury.Assessment for pain.Assessment for.Range of Motion.Vital signs (measurements of body's basic functions).Evaluation of indication for emergency medical treatment.During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included comprehensively assessing the affected resident (R#6), identified and assessed other residents who had the potential to be affected to ensure appropriate interventions/monitoring were in place, reviewed and updated residents' care plans as appropriate, facility-wide all staff education (included, but not limited to, post-fall policy and procedures, required notifications, and required follow up assessments; the education was started on 6/8/26 and completed on 6/19/26), initiated audits of all fall incidents to ensure proper post-fall procedures took place, and would review the audit findings at the facility's quality assurance meeting. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to intake #3045701Based on interview and record review the facility failed to ensure complete and accurate medical records of 3 (Resident #5, Resident #7, and Resident #6) of 8 sampled residents resulting in incomplete and inaccurate documentation and the potential for a diminished medical outcome.Findings include: Resident #5 Review of an admission Record revealed Resident #5 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: osteomyelitis of the sacral region (an infection of the bone in the sacral- low back upper buttock area of the body), a stage IV pressure wound, and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #5, with a reference date of 5/5/26 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated Resident #5 was cognitively intact. Review of Resident #5's medical record revealed no noted order for monitoring her wound vac. Review of Treatment Administration Record (TAR) for Resident #5 for April 2026 revealed .Daily weight x 3 days post admission every day shift for 3 days. Documentation for 4/29/26 and 4/30/26 were blank. Review of TAR for Resident #5 for April 2026 revealed .Lidocaine External Gel 2% Apply to sacrum topically every day shift every Tue, Thu, Sat (Tuesday, Thursday, Saturday) for wound care. 4/30/26 was blank. Review of TAR for Resident #5 for April 2026 revealed .Sacrum: cleanse with wound cleanser, apply skin prep to peri-wound. Protect any exposed bone with contact layer with silver. Fill wound bed with black foam, cover with clear drape, cut small hole and cover with suction disk. Run machine at continuous 125 mmHg (millimeters of mercury) If seal cannot be maintained, cover with NS, moistened gauze and secure with tape daily until NPWT can be reapplied every shift Tues, Thru, Sat. with a start date of 4/30/26.4/30/26 was blank. Review of TAR for Resident #5 for May 2026 revealed .Lidocaine External Gel 2% Apply to sacrum topically every day shift every Tue, Thu, Sat (Tuesday, Thursday, Saturday) for wound care. 5/9/26, 5/22/26, 5/25/26, and 5/27/26 were all blank. Review of TAR for Resident #5 for May 2026 revealed .PICC (peripherally inserted central catheter; a long tube inserted into a large vein for long term antibiotic administration use) Line transparent dressing and needleless connectors changes of every seven days and as needed.5/4/26, 5/11/26, and 5/25/26 were all blank. Review of TAR for Resident #5 for May 2026 revealed .Sacrum: cleanse with wound cleanser, apply hydrofera blue and cover with dry dressing every other day. 5/18/26 was left blank. Review of TAR for Resident #5 for May 2026 revealed .Sacrum: cleanse with wound cleanser, apply remedy clinical antifungal ointment (Miconazole 2.0%) and triad (a cream wound dressing designed to adhere to damaged skin) to peri wound (area around wound) apply vashe gel then calcium alginate to wound bed, cover with ABD/bordered foam dressing every day shift. 5/22/26 and 5/27/26 were blank. Review of TAR for Resident #5 for May 2026 revealed .Sacrum: cleanse with wound cleanser, apply skin prep to peri-wound. Protect any exposed bone with contact layer with silver. Fill wound bed with black foam, cover with clear drape, cut small hole and cover with suction disk. Run machine at continuous 125 mmHg (millimeters of mercury) If seal cannot be maintained, cover with NS, moistened gauze and secure with tape daily until NPWT can be reapplied every shift Mon, Wed, Fri. 5/13/26 was blank. In a telephone interview on 6/30/26 at 11:02 am Registered Nurse (RN) W reported blank documentation indicated something wasn't done. RN W reported there was no order to monitor Resident #5's wound vac, and there was no expected documentation of the wound vac. In an interview on 6/30/26 at 2:00 pm, Director of Nursing (DON) B and Regional Clinical Support (RCS) C reported their expectations were that Resident #5's wound vac was to be monitored at least each shift, and it should be documented in her record. RCS C reported documentation should be completed each shift. RCS C confirmed there was no order in place for the monitoring of Resident #5's wound vac and there was no required documentation for monitoring her wound vac. Further review of Resident #5's progress notes revealed between 4/28/26 and 5/12/26 documentation regarding Resident #5's wound vac was noted 5 times, 4/28/26, 5/4/26, 5/8/26, 5/11/26 and 5/12/26. In a telephone interview on 6/30/26 at 4:37 pm, Licensed Practical Nurse (LPN) R reported her responsibility was to monitor Resident #5's wound vac and change the dressing if ordered. When queried, LPN R reported, there was no place to document the monitoring of her wound vac other than in a progress note. Resident #7 Review of an admission Record revealed Resident #7 was a male who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: acquired absence of the right leg above the knee, acquired absence of the left leg above the knee, and progressive multiple sclerosis (a progressive autoimmune disease that affects the central nervous system that results in a range of physical and cognitive symptoms). Review of a Minimum Data Set (MDS) assessment for Resident #7, with a reference date of 6/23/26 revealed a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated Resident #7 was cognitively intact. Section M Skin conditions: indicated Resident #7 had 1 stage II pressure injury that was not present on admission. Review of TAR for Resident #7 for June 2026 revealed .Daily weight x 3 days post admission every day shift for 3 days. Documentation for 6/18/26 and 6/19/26 were blank. Review of TAR for Resident #7 for June 2026 revealed .Cleanse open area to right buttock with wound cleanser, apply barrier cream to base of the wound, leave open to air complete every shift. 6/25/26, 6/26/26, and 6/27/26 all had blank documentation. Review of TAR for Resident #7 for June 2026 revealed . Suprapubic cath care, (a catheter inserted directly into the bladder through the skin) every shift, empty foley catheter drainage bag Q (every shift) . Documentation was missing from 6/16/26, 6/17/26, 6/18/26, 6/19/26, 6/24/26, 6/25/26, 6/26/26, and twice on 6/27/26. In an interview on 6/30/26 at 2:00 pm, RCS C reported her expectations were that nurses documented in the resident's medical record to reflect the care given to residents. In a telephone interview on 6/30/26 at 4:37 pm, LPN R reported her responsibility was to document what she completed in the resident's medical records. LPN R reported .if it wasn't documented, it wasn't done. Resident #6 (R#6):Review of R#6's pain care plan, dated 8/26/25, stated, .Focus.(R#6) has a potential for alteration in comfort: swelling with arthritic joints (inflammation or swelling of one or more joints), dementia (decline in mental abilities), cognitive communication deficit (impaired ability to communicate).Interventions.Evaluate the effectiveness of the medication provided.Provide medication as ordered. During an interview on 6/30/26 at 3:20 PM, Licensed Practical Nurse (LPN) Y reported on 6/5/26 at an unknown time, R#6 was walking the halls independently as she normally had done, showed no signs or symptoms of pain, but R#6 informed her she had some pain. LPN Y reported upon further questioning, R#6 was unable to describe the pain or location at that time. LPN Y confirmed she gave R#6 a PRN dose of acetaminophen but forgot to document it in the medication administration record (MAR). Review of R#6's MAR, dated 6/1-6/30/26, stated, .Acetaminophen (medication used to relieve mild to moderate pain) Oral Tablet 500 MG (milligrams) Give 1 tablet by mouth every 4 hours as needed for Pain. The administration record for acetaminophen on 6/5/26 was blank (empty). The sections, Pain Level (numerical pain value; 0 (no pain) - 10 (highest pain level)) and PRN (as needed), were empty which reflected no documentation for pain level, which nurse gave the medication, time of medication administration, or effectiveness.

This citation pertains to intake #2698524Based on interview and record review the facility failed to adequately assess and treat a resident experiencing an acute change of condition timely for 1 (Resident #1) of 3 residents reviewed for quality of care, resulting in an immediate jeopardy when, on [DATE], Resident #1 was found unresponsive, lethargic, hypotensive (low blood pressure) and 911 EMS (emergency medical services) were not immediately contacted. Resident #1 subsequently died.Findings include:The immediate jeopardy began on [DATE] and was identified on [DATE] due to the facilities failure to assess for an acute change in condition, follow physician orders for medical laboratory testing, and notify 911 EMS when Resident #1 was found unresponsive, lethargic, hypotensive and subsequently died.On [DATE] at 4:55 PM, the Nursing Home Administrator was verbally notified and received written notification of the immediate jeopardy. The surveyor confirmed by observation, interview, and record review the immediate jeopardy was removed on [DATE], but noncompliance remains at scope of isolated and severity of actual harm due to not all staff receiving the education and sustained compliance that has not been verified by the State Agency. Resident #1Review of an admission Record revealed Resident #1 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: bipolar disorder (a mental health disorder characterized by significant mood swings), dementia (a syndrome characterized by a decline in cognitive function affecting memory, thinking, behavior, and the ability to perform everyday activities) and delusional disorder (serious mental health condition characterized by persistent, false beliefs that are not based in reality, often leading to significant distress and impairment in functioning).Review of Interdisciplinary Documentation for Resident #1 dated [DATE] at 03:16 AM (3:16 am) and authored by Registered Nurse (RN) V at 8:19 am on [DATE] revealed .PA (physician assistant) notified of patient's change in condition, including hypotension (83/56 BP Blood pressure).lethargy, cool skin, significant bilateral lower-extremity edema, and blue-to purplish fluid-filled blisters on posterior heels bilaterally. After discussion, PA agreed patient requires hospital evaluation. Hospital notified and report given. Preparation initiated for transfer to hospital. Focus at this time is on facilitating transport and maintain patient safety while awaiting transfer.Review of Interdisciplinary Documentation for Resident #1 dated [DATE] at 08:19 AM (8:19 am) revealed .Patient transferred to hospital for further evaluation per provider recommendation. Report given to receiving hospital staff and transport personnel. Patient departed facility via ambulance in stable condition at time of departure. Facility notified as appropriate. Documentation completed.In a telephone interview on [DATE] at 9:54 AM, EMS [NAME] Specialist (EMS/BS) Z reported on [DATE], the (Name Omitted) local emergency room contacted (Name Omitted) local EMS ambulance services, reported the facility was unable to contact 911 due to a telephone issue, and needed a patient transported from the facility that (Name Omitted) local emergency room had received report on, but did not receive the patient.In a telephone interview on [DATE] at 10:08 AM, 911- Service Specialist (SS) AA reported 911 EMS received two calls for the facility on [DATE], one at 3:20 AM the call was for an ambulance at (Name Omitted), and (Name Omitted) ambulance service was dispatched at 3:25 AM, the call was clear at 5:01 AM. When queried, SS AA reported a call being clear meant the patient that was transported was in the care of the hospital and the ambulance was back in service, available for another call. SS AA reported an abandoned call was received at 5:24 AM from the facility. When queried, SS AA reported an abandoned call indicated a call was made but was disconnected for some reason and no conversation occurred. SS AA reported 911 returned the abandoned call and was informed there was no emergency at the location. SS AA reported 911 received a call at 5:29 AM from the local emergency department and a call at 5:30 AM from the ambulance service, advising they had received a call from the local emergency department, indicating that they had received a call from the facility providing report on a patient and had not received the patient yet. Review on Call for Service Detail Report - CFS 2334 dated [DATE] at 5:29:55 AM revealed .5:30:16 AM (Name Omitted) ambulance service also calling in - advising they got a call from the hospital that THEY got a call from (Name Omitted) facility of an unresponsive male over an hour ago. 5:30:26 AM now getting an [NAME] (abandoned) from (Name Omitted) facility.5:33:04 AM Spoke with (Name Omitted) staff (Name Omitted) Facility who confirmed no emergency.5:33:13 AM close call.5:34:17 AM call reactivated. 5:37:46 AM (Name Omitted) ambulance service just called back- 77 y/o year old female hypertensive, unresponsive- (Name Omitted) Facility said they couldn't get thru to 911- in cardiac arrest - (Name Omitted) ambulance service contact at the hospital is (Name Omitted) at (Name Omitted) local emergency department- .5:39:08 AM ambulance dispatched (unit 4010). 5:41:03 AM per (Name Omitted) ambulance service no police or mfr's (medical first responders) needed.7:39:16 AM call cleared, close call.Review of Incident Detail Report dated [DATE] at 5:36:12 AM revealed .XXX[DATE] 05:36:58 AM, 77 yo (year old) female called in by (Name Omitted) ER (emergency room), (Name Omitted) facility staff said they were unable to get ahold of (Name Omitted) 911 due to phone issues.Review on Prehospital Care Report Summary for Resident #1 dated [DATE] revealed . call received 05:36:12 (5:36 am), dispatched at 05:37:05 (5:37 am).Initial patient acuity: Emergent (yellow).Lights and sirens, destination.Dispatch reason: 9 cardiac or respiratory arrest/death.Provider impression. unconscious. Vitals. 5:49:32 (5:49 am) BP 136/108 (normal value - 110/75 to 130/85 with 120/80 being standard normal reading), Pulse 79 (normal value - 60 to 100 beats per minute), Resp (respirations, normal value - 12 to 20 per minute) 24, SpO2 62 (normal value - 90 to 100 with readings below 90 requiring immediate medical attention). 05:57 am BP 161/122, Pulse 95, SpO2 85. 5:59 am, 177/144, Pulse 114, Resp 23, SpO2 89. 6:03 am BP 192/155, Pulse 100, Resp 31, SpO2 78.6:11 am, 197/166, Pulse 67, Resp 25. Narrative History Text: was dispatched to (Name Omitted) facility for a reported full cardiac arrest. Upon arrival, the crew was met at the entrance by facility staff.Two staff members were present in the room. No CPR or ventilations were in progress. when asked for the latest status update, staff stated the patient was breathing now and has a pulse and then exited the room to retrieve paperwork. The patient was found unconscious, breathing spontaneously, with a palpable pulse. The patient was warm to the touch and was receiving oxygen via nasal cannula (a medical device used to deliver oxygen to a patient through their nostrils) at 3 LPM (liters per minute). initial heart rate and pulse oximetry (SpO2- measure oxygen saturation of the blood) were obtained, SpO2 was noted low. oxygen was increased to 6 LPM vial nasal cannula.Once loaded. patient remained minimally responsive. Due to continued hypoxia (low levels of oxygen in the body tissues) and mental status, oxygen delivery was upgraded to a non-rebreather mask at 15 LPM.ETCO monitoring (End Tidal Carbon Dioxide monitoring used to assess a patient's respiratory status and overall health. Measure the concentration of carbon dioxide in exhaled are at the end of a respiration) was applied, revealing tachypnea (rapid respirations) with low CO2 values (inadequate amounts of carbon dioxide being expelled from the body) The patient remained unresponsive to verbal stimuli and responsive only to painful stimuli (sternal rub).radio report was given and acknowledged to (Name Omitted) local emergency department. care was documented as transferred to emergency department at 06:21:42 (6:21 AM).Review of ED to Hosp-admission (Discharge) in (Name Omitted) critical care Discharge Note for Resident #1 revealed .XXX[AGE] year old lady with dementia with psychotic features, major depressive disorder, atrial fibrillation (irregular heart rhythm) on Eliquis (blood thinner medication).was brought in on [DATE] from her health care facility (Name Omitted) where she was found unresponsive. On EMS arrival patient was hypotensive (low blood pressure), tachycardic, (fast heart rate). cool and cyanotic (blue in color indicated poor blood circulation) extremities (arms and legs). Upon arrival to the ER patient continued to be comatose.and was intubated for airway protection. Notably during intubations, provider noted crushed pill remnants in the back of the throat with concern for polypharmacy versus aspiration of medication. infectious workup. urinalysis concerning for UTI.Hospital course complicated by recurrent hemodynamically unstable (the body's circulatory system cannot maintain adequate blood flow often leading to shock) SVT (Supraventricular tachycardia, a fast or erratic heart rhythm) requiring multiple synchronized cardioversions (quick low-energy shocks to a patient's heart to restore a regular rhythm) . furthermore patient's blood pressure continued to plummet despite escalating doses of vasopressor (medications used to raise blood pressures). concerns for cardiogenic shock (a life-threatening condition characterized by the heart's inability to pump enough blood to meet the body's needs leading to severe symptoms and potential organ failure) on top of sepsis (a life-threatening condition caused by the body's extreme response to an infection) .Patient's condition continued to worsen and blood started oozing out of from all IV (intravenous) access points and repeat labs were concerning for DIC (Disseminated intravascular Coagulation is a rare blood clotting disorder that can cause organ damage and uncontrollable bleeding and can occur as a complication of a very serious medical condition such as an infection). ICU (Intensive Care Unit) team had multiple discussions with patient's family and POA about her worsening medical condition, guarded prognosis, and ultimately family decided to proceed with comfort measures in keeping with patient's wishes. Patient was pronounced deceased at 2319 on [DATE].In a telephone interview on [DATE] at 3:03 PM, Certified Nurse Assistant (CNA) W reported she was assigned to the back unit but not directly to Resident #1 during the overnight shift on [DATE] to [DATE] and that Resident #1 was her usual self at the beginning of the shift, and then, all of the sudden, in the middle of the shift she was out of it. CNA W reported she informed the nurse, Registered Nurse (RN) V that something was wrong with Resident #1. CNA W reported that night Resident #1 could not keep her eyes open and she was very out of it. CNA W reported that herself, RN V and RN P checked on Resident #1 frequently, took her vital signs several times, and both nurses made several phone calls that night. CNA W reported there was more than one resident that went to the hospital that night, and that Resident #1 was the second resident to go to the hospital. CNA W reported she could only recall RN V and RN P working that night, she could not recall a third nurse.In a telephone interview on [DATE] at 4:15 PM, CNA T reported she worked the night shift from [DATE] to [DATE] and remembered that RN V wanted to send Resident #1 to the hospital. CNA T reported RN V was completing the steps, notifying chain of command, completing paperwork and working with her partner, RN P to send Resident #1 to the hospital. CNA T reported she recalled RN P was not as convinced as RN V that Resident #1 needed to be transported to the emergency department for evaluation. CNA T reported she could not recall if there was a third nurse that worked that night.In a telephone interview on [DATE] at 4:43 PM, CNA F reported Resident #1 was fine at the beginning of the overnight shift on [DATE] to [DATE], and sometime in the middle of the shift Resident #1 became completely unresponsive. CNA F reported RN V did everything she possibly could do to get her sent out to the hospital. CNA F reported RN V made lots of phone calls and it seems like she could not get ahold of the people in the chain of command to get permission to send her out.In a telephone interview on [DATE] at 4:51 PM, CNA K reported she worked the night shift from [DATE] to [DATE], was not assigned to the unit Resident #1 resided on but did recall that she went out to the hospital that night. CNA K reported there were two nurses working that night, RN V and RN P. CNA K reported she did not recall a third nurse that night. In a telephone interview on [DATE] at 5:13 PM, RN V reported she and RN P were the only two nurses working on [DATE] to [DATE] night shift. RN V reported RN P was assisting her to complete her orientation check list including transferring a resident to the hospital, as she had not yet competed that part of her training. RN V reported everything happened at about 3 AM that night, and there were only the two of us nurses in the building. RN V reported both her and RN P assessed Resident #1, and they noticed that her vital signs were fluctuating, she appeared to be in pain, and she was not responding. RN V reported Resident #1 was not responding, but when they did a sternal rub, she flinched and that was not her baseline. RN V reported RN P told her that Resident #1 did not need to be transported to the hospital yet, her vitals were stable. RN V reported when she would take Resident #1's vitals she would get one reading and when RN P would take them they were completely different. RN V reported Resident #1's vitals were wonky, and she knew that wasn't right. RN V reported Resident #1's hands were cold, and the pulse oximetry wasn't working correctly, and she couldn't get a reading. RN V reported she contacted the on-call provider, received a verbal order to transfer to the emergency department. RN V stated I remember talking to the provider and he asked me what my recommendations were and I said send her to the hospital. RN V reported RN P was assisting her with completing the paperwork for a transfer to the hospital, the steps to take, the check list to be completed, and the packet that had to be filled out. RN V stated I asked (RN P) should we just call 911 and RN P told me to finish up the packet, paperwork, she was going to go eat something, and then she would help me again when she was done. RN V reported she had transferred another resident to the hospital that night, and she stated I learned that 911 comes really fast and if you don't have the paperwork filled out, they won't wait for you, and then they don't have what they need. RN V reported the packet needs to be filled out and the transfer sheet, call the family, call report to the hospital and then call 911. RN V reported she went through the transfer paperwork and the program prompts line by line to answer the questions and then the sections turn green when they are completed. RN V reported she had more questions, but RN P wasn't available, so she continued completing the form. RN V reported at the bottom of the transfer form was a section where it asks who you called report to and RN V reported when she got to that line in the transfer form, I called the hospital and provided report to a nurse in the local emergency department. RN V reported she recalled that she did not complete the paperwork correctly for the first resident she transferred from the facility this shift, so the second time she took her time to make sure all the paperwork and transfer forms were completed before the ambulance arrived to transport the patient. When queried, if RN V recalled when she called 911 for Resident #1 to be transported to the hospital, RN V replied No, I didn't call 911, I thought RN P called them. I remember 911 called the facility after 5 AM, RN P spoke to them, and Resident #1 was picked up after that.Review of SNF/NF (skilled nursing facility/nursing facility) to Hospital Transfer Form for Resident #1 dated [DATE] 04:00 am revealed .last vital signs were 124/70, pulse 70, respiration 18, temp 98.4, and SpO2 95%, all recorded on [DATE].reported called to (Name Omitted) Registered Nurse on [DATE] at 04:00 AM.In a telephone interview on [DATE] at 9:42 AM, Physician Assistant (PA) BB reported it is not standard that on-call providers document a call received when providing on call support to the facility. PA BB reported he did not know what time he was contacted by the facility regarding Resident #1 but review of the notes from RN V indicated she spoke with him before 3 am. PA BB reviewed RN Vs documentation in Resident #1's record, and stated the facility should have sent her (Resident #1) to the hospital right after we spoke, I certainly wouldn't have told them to wait for transfer.In an interview on [DATE] at 3:30 PM, Nurse Practitioner (NP) CC reported on the Thursday ([DATE]) Resident #1`s roommate stopped her in the hallway and told her Resident #1 was not feeling good. NP CC stated she (Resident #1) was sick on Thursday when I saw her. NP CC reported she assessed Resident #1 and noticed she had right flank pain (refers to the area on the right side of the body specifically between the last rib and the hip. This area contains organs such as kidney and liver), some confusion, and she did not eat her breakfast. NP CC stated when I tapped on her back it was noticeably painful. NP 'CC stated I suspected she (Resident #1) had a UTI (urinary tract infection) and I ordered labs (CBC complete blood count; a blood test that measures components of the blood assessing overall health including infection and CMP complete metabolic panel; a blood test measuring overall health, kidney and liver function, blood sugar, electrolyte and fluid balance) and a UA with C&S if indicated (UA- urinalysis examines urine to assess overall health and can diagnosis a urinary tract infection; C & S - culture and sensitivity test is a laboratory test used to identify the microorganism causing an infection and to determine the most effective medications to treat it.) and the facility never did them. NP CC reported she hand wrote the orders on the doctor's order sheet, and she would give that sheet to the clinical care coordinators to enter the orders into the electronic medical records of residents in the facility. NP CC reported a UTI could have been treated in house (in the facility), and it was preventable, and it was possible Resident #1's infection would not have turned into sepsis (a life-threatening condition that arises when the body's response to an infection causes widespread inflammation and can lead to tissue damage, organ failure, and death).Review of HCP Visit for Resident #1 dated [DATE] authored by NP CC revealed .Progress Note CC (Chief complaint) fatigue, pain.she is seen today. increased fatigue, not eating well today, and reports of low back pain. = (positive) for fatigue, poor appetite. 12/16 (date) 118/72 (blood pressure), 66 (pulse), 97.4 (temperature), and 96 % RA (pulse ox, percent amount of oxygen in the blood on room air). ABD (abdomen). mild tenderness in lower abdomen. Decline/low back pain/poor appetite-check labs and urinalysis.In an interview on [DATE] at 3:42PM, Infection Prevention Manager/Registered Nurse (IPM/RN) L reported NP CC used a paper form titled Doctor's Orders where she hand-wrote out orders and provided them to her or Clinical Care Coordinator/Registered Nurse (CCC/RN) EE to be entered into resident medical records. IPM/RN L reported Resident #1 did not reside in the part of the building that she was assigned, and NP CC did not provide her with Resident #1's orders on [DATE]. IPM/RN L reported she maintained a file of the Doctor Order forms that NP CC hand wrote, and IPM/RN L provided the handwritten Doctor's Order sheet completed by NP CC on [DATE].Review of Doctor's Order sheet on [DATE] at 3:50 PM, dated [DATE] and provided by IPM/RN L revealed . Resident #1[check] CBC, CMP U/A C&S if urine dip + (positive). When queried, IPM/RN L reviewed Resident #1's record and confirmed she was unable to locate any order for labs, CBC, CMP, UA with C & S if indicated from [DATE]. IPM/RN L further accessed the online laboratory website and confirmed the labs or UA were not completed as there were no results available.In an interview on [DATE] at 11:42 AM, IPM/RN L reported she and CCC EE were responsible for certain parts of a resident admissions; they would verify orders, create care plans. IPM/RN L reported that resident orders went through a triple check; the orders should be entered by the clinical managers, herself and CCC EE and then the nurses would confirm/verify orders, and then Director of Nursing (DON) B would be the third and final check.In an interview on [DATE] at 12:08 PM, DON B reported there were two clinical care coordinators, and one was out on a medical leave as of last week. DON B reported the nurses on the unit can input orders and the CCCs can verify them or vice versa. DON B reported providers were writing the orders on Doctor Order sheets and providing them to the CCCs for them to be inputted into the resident records. DON B reported CCC EE was assigned to Resident #1.CCC EE was unavailable for interview during the survey.In an interview on [DATE] at 08:00 AM, Director of Nursing (DON) B reported staffing on the night shift was to try for 3 nurses, but they could work with only 2 nurses. DON B reported there were always 3 nurses for the evening medication pass in the building; if there was a nurse call in then the staffing manager tries to cover the shift, otherwise a clinical care coordinator or the DON B would cover the open shift. DON B reported when covering a shift, the nurse covering only had to stay through completion of the evening medication pass. DON B stated .I have been in the building after 10 (PM) and there isn't much to do other than a few PRN's (as needed medications) and dressing changes, you don't need 3 nurses.In an interview on [DATE] at 12:33 PM, Director of Nursing (DON) B reported if a resident had a change in condition her expectations were that the nurse was to call the on-call provider, and the nurses will make the decision if the resident needs to be transferred to the hospital. DON B reported an assessment should be done, call to on call provider, complete the transfer form on the computer, the transfer packet, and call 911-EMS for transport. DON B reported her expectations were that the other nurses in the building helped where needed. DON B reported if a resident was assessed and the change was more serious, then the resident needs to be transferred quicker than someone who wasn't as serious. When queried, DON B reported her expectations for a resident was unresponsive would be for transfer to happen immediately. DON B reported the telephone system in the building was a voice over IP internet service and they did go down at times. DON B reported there is a second Wi-Fi access that can be used, and the expectations are that the staff switch to their personal cell phones when calls need to be made. DON B reported she was on vacation when Resident #1 was transferred to the hospital on [DATE]. DON B reported the at about 3:00 am on [DATE], facility staff did notify her that Resident #1 was being sent to the hospital for evaluation, and she instructed them to notify IPM/RN L as she was on call that night.In an interview on [DATE] at 12:57 PM, Infection Prevention Manager/Registered Nurse (IPM/RN) L reported she did not receive any call from the facility during the overnight hours on [DATE] to [DATE]. IPM/RN L reported she was walking in the front door when Resident #1 was exiting the building with EMS on a stretcher headed to the ambulance for transport. IPM/RN L reported she punched in on [DATE] at 5:48 AM.In an interview on [DATE] at 12:52 PM, Nursing Home Administrator (NHA) A reported there was no phone outage on [DATE] or [DATE]. NHA A reported the phones do go down and can be reconnected to a different Wi-Fi connection.The immediate jeopardy began on [DATE] and was removed on [DATE] when the facility took the following actions to remove the immediacy.On [DATE] all licensed nurses were immediately re-educated that 911 EMS must be called without delay for any resident exhibiting signs of an acute decline, including but not limited to unresponsiveness, hypotension, altered mental status, respiratory distress, or other emergent conditions.Staff were instructed that contacting the emergency department or hospital does not replace activation of 911 EMS.An emergency response protocol reeducation requiring immediate activation of 911 followed by notification of the supervisor or administrator on call. The monthly on call schedule was posted on the back wall at the nurse's station.The Director of Nursing or designee are available 24 hours a day, 7 days a week to support clinical decision-making during all shifts.Re-education began on [DATE] and will be completed in person or by telephone prior to their next scheduled shift being worked.No licensed staff will be allowed to start a shift or give care until education is completed.Medical director was notified on [DATE].A verbal conversation followed by agreement indicated facility health care providers as of [DATE] will enter their own orders into the electronic medical record. As of [DATE] 100% of facility health care providers' orders are electronic.A facility wide review of all current residents was initiated on [DATE] and will continue until complete to identify those at risk for acute clinical decline.On [DATE] all residents exhibiting signs of deterioration were immediately assessed and transferred via EMS and the emergency response protocol.On [DATE] a licensed nurse will conduct a chart review of all current residents for change in condition and follow through with the health care practitioner orders this audit will continue until complete.As of [DATE], 6 of 10 registered nurses were educated; 3 of 7 Licensed practical nurses were educated, and 2 of 4 agency nurses were educated. As of [DATE], 10 licensed nurses have not been re-educated with 3 licensed nurses on a leave of absence. All licensed nurses will receive education prior to their next worked shift.Agency licensed nurses will be educated and will complete a competency test prior to their shift worked. The facility change in condition policy was reviewed on [DATE] by the interdisciplinary team and updates made to clearly require the activation of 911.On [DATE] emergency condition decision-support tools were implemented at the nurse's station.On [DATE] leadership oversight implemented to review all emergency transfers.

This citation pertains to Intake # 2698524Based on interview and record review the facility failed to ensure sufficient staffing to meet the needs and maintain the highest practicable well-being of 1 (Resident #1) of 1 resident reviewed for sufficient staffing, resulting in a delay in treatment for Resident #1, who experienced an acute change in condition and was not transported timely to an acute care facility and subsequently died.Findings include: Review of an admission Record revealed Resident #1 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: bipolar disorder (a mental health disorder characterized by significant mood swings), dementia (a syndrome characterized by a decline in cognitive function affecting memory, thinking, behavior, and the ability to perform everyday activities) and delusional disorder (serious mental health condition characterized by persistent, false beliefs that are not based in reality, often leading to significant distress and impairment in functioning).In an interview on [DATE] at 12:53 PM, Staffing Manager (SM) E reported staffing was directed by a staffing matrix from corporate and the matrix was based on census. SM E reported when census was above 74 resident there should be 3 nurses working on day shift and 3 nurses working on night shift, working 12-hour shifts. SM E reported when the census was 73 staffing for nurses should be 3 working on day shift and 2 working on night shift. SM E reported if there was a call in for the night shift, a day shift nurse was required to stay over and complete the evening medication pass, no longer than 4 extra hours. SM E reported she tried to staff 3 nurses on the night shift, but if there was a call in or a hole in the schedule, a day shift nurse had to stay over, and there may not be other coverage when the day shift nurse left at 11 PM. SM E reported on the night shift starting on [DATE] and ending on [DATE] there were three nurses scheduled but one called in. SM E reported only one clinical care coordinator, and the director of nursing could help fill an open shift on the floor.Review of the Clinical Time Punches revealed . Registered Nurse (RN) V and RN P were the only two nurses clocked in for the entire overnight shift [DATE].Review of Daily Census Report for [DATE] revealed .census was 75.Review of Staffing Matrix provided by SM E revealed for a .census count of 75 residents the nurse supervisors on both the day and night shift should be 3 each. No noted indication for the use of resident acuity (severity of a person's illness) was listed.Review of Facility Assessment with a reviewed date of 10/2025 provided by Nursing Home Administrator (NHA) A revealed .How did the facility determine resident staffing level.the facility identified minimum staffing with evaluation of acuity and diagnosis which will ensure the needs of the residents are met while providing overall safety. The staffing level planned is reflective of current staffing with tasks considered. Clinical leadership. will be utilized during staffing needs.Licensed Nurses (LN): RN, LPN, LVN providing direct care . RN or LPN charge nurse: 3-4 on day and evening shift and 3 on night shift.In a telephone interview on [DATE] at 4:43 PM, CNA F reported on [DATE] to [DATE] on the night shift there were only two nurses working when Resident #1 and another resident had to be transported to the hospital. CNA F reported RN V was the nurse responsible for both residents that shift. CNA F reported . once you're in the back on the east or south unit, you're back there; You do not go to other parts of the building; the acuity and the need of the residents was too high in those units.In a telephone interview on [DATE] at 3:45 PM, CNA S reported staffing could be better. CNA S reported she made it a point to get the tasks done for the residents, but some CNAs only work 8-hour shifts and leave in the middle of a 12-hours shift. CNA S reported if a CNA leaves at 10:30 PM, the remaining CNA's have 15-16 residents to care for overnight. CNA S reported half of the residents she usually cares for on the south and east wings (the back unit hallways) require two staff members for some of their care. CNA S reported when there were scheduled showers to do, the other residents had to wait until the shower was done before their call lights would be answered. CNA S reported sometimes residents had to wait for a long time, 20 minute or more.Review of Facility data, for the date of [DATE] provided by Nursing Home Administrator NHA A included . census was 75 residents in the facility, of those 75 residents, 35 residents required two or more staff members when assisting with cares such as a transfer.In a telephone interview on [DATE] at 4:15 PM, CNA T reported the nurses work short a lot on night shift. CNA T reported that there were not enough nurses to cover the night shifts. CNA T reported that sometimes there are only 2 nurses scheduled on the night shift. CNA T reported that staffing on night shift can be 5 CNAs and 2 nurses, and when that happens, showers are not always done, Residents may get a quick wash up and most shifts were like that, we don't get our lunch breaks. CNA T reported the back unit (south and east halls) was a very hard unit, the residents on those two units have a higher acuity and more needs to be met. CNA T reported she worked the night Resident #1 was sent to the hospital and Resident #1 was on the east unit.In a telephone interview on [DATE] at 5:13 PM, RN V reported she and RN P were the only two nurses working on [DATE] to [DATE] night shift. RN V reported RN P was assisting her to complete her orientation check list including transferring a resident to the hospital, as she had not yet competed that part of her training. RN V reported everything stared to happened at about 3 AM, and two residents (one of which was Resident #1) had to be transported to the hospital. RN V reported RN P was providing direction to complete the paperwork for a transfer to the hospital. RN V stated I asked (RN P) should we just call 911 and RN P told me to finish up the paperwork, she was going to go eat something, and then she would help me again when she was done. RN V reported she had transferred another resident to the hospital that night, and she stated I learned that 911 comes really fast and if you don't have the paperwork filled out, they won't wait for you, and then they don't have what they need. RN V reported she recalled that she did not complete the paperwork correctly for the first resident she transferred from the facility this shift, so the second time she took her time to make sure all the paperwork and transfer forms were completed before the ambulance arrived to transport the patient. When queried, if RN V recalled when she called 911 for Resident #1 to be transported to the hospital, RN V replied No, I didn't call 911, I thought RN P called them. I remember 911 called the facility after 5 AM, RN P spoke to them, and Resident #1 was picked up after that.In a telephone interview on [DATE] at 9:31 AM, RN P reported that her and RN V were the only two nurses who worked on [DATE] to [DATE], the night that RN V transferred two residents to the hospital. RN P reported she assisted RN V with the paperwork for Resident #1, but she did not call 911. RN P said wait, did I call 911 or did she call 911, yes, yes, I did not call, she did.Review of Interdisciplinary Documentation for Resident #1 dated [DATE] at 03:16 AM (3:16 am) and authored by Registered Nurse (RN) V at 8:19 am on [DATE] revealed .PA (physician assistant) notified of patient's change in condition, including hypotension (83/56 BP Blood pressure).lethargy, cool skin, significant bilateral lower-extremity edema, and blue-to purplish fluid-filled blisters on posterior heels bilaterally. After discussion, PA agreed patient requires hospital evaluation. Hospital notified and report given. Preparation initiated for transfer to hospital. Focus at this time is on facilitating transport and maintain patient safety while awaiting transfer.Review of Interdisciplinary Documentation for Resident #1 dated [DATE] at 08:19 AM (8:19 am) revealed .Patient transferred to hospital for further evaluation per provider recommendation. Report given to receiving hospital staff and transport personnel. Patient departed facility via ambulance in stable condition at time of departure. Facility notified as appropriate. Documentation completed.In a telephone interview on [DATE] at 9:54 AM, EMS [NAME] Specialist (EMS/BS) Z reported on [DATE], the (Name Omitted) local emergency room contacted (Name Omitted) local EMS ambulance services, reported the facility was unable to contact 911 due to a telephone issue, and needed a patient transported from the facility that (Name Omitted) local emergency room had received report on, but did not receive the patient.In a telephone interview on [DATE] at 10:08 AM, 911- Service Specialist (SS) AA reported 911 EMS received two calls for the facility on [DATE], one at 3:20 AM the call was for an ambulance at (Name Omitted), and (Name Omitted) ambulance service was dispatched at 3:25 AM, the call was clear at 5:01 AM. When queried, SS AA reported a call being clear meant the patient that was transported was in the care of the hospital and the ambulance was back in service, available for another call. SS AA reported an abandoned call was received at 5:24 AM from the facility. When queried, SS AA reported an abandoned call indicated a call was made but was disconnected for some reason and no conversation occurred. SS AA reported 911 returned the abandoned call and was informed there was no emergency at the location. SS AA reported 911 received a call at 5:29 AM from the local emergency department and a call at 5:30 AM from the ambulance service, advising they had received a call from the local emergency department, indicating that they had received a call from the facility providing report on a patient and had not received the patient yet. Review on Call for Service Detail Report - CFS 2334 dated [DATE] at 5:29:55 AM revealed .5:30:16 AM (Name Omitted) ambulance service also calling in - advising they got a call from the hospital that THEY got a call from (Name Omitted) facility of an unresponsive male over an hour ago. 5:30:26 AM now getting an [NAME] (abandoned) from (Name Omitted) facility.5:33:04 AM Spoke with (Name Omitted) staff (Name Omitted) Facility who confirmed no emergency.5:33:13 AM close call.5:34:17 AM call reactivated. 5:37:46 AM (Name Omitted) ambulance service just called back- 77 y/o year old female hypertensive, unresponsive- (Name Omitted) Facility said they couldn't get thru to 911- in cardiac arrest - (Name Omitted) ambulance service contact at the hospital is (Name Omitted) at (Name Omitted) local emergency department- .5:39:08 AM ambulance dispatched (unit 4010). 5:41:03 AM per (Name Omitted) ambulance service no police or mfr's (medical first responders) needed.7:39:16 AM call cleared, close call.Review of Incident Detail Report dated [DATE] at 5:36:12 AM revealed .XXX[DATE] 05:36:58 AM, 77 yo (year old) female called in by (Name Omitted) ER (emergency room), (Name Omitted) facility staff said they were unable to get ahold of (Name Omitted) 911 due to phone issues.Review on Prehospital Care Report Summary for Resident #1 dated [DATE] revealed . call received 05:36:12 (5:36 am), dispatched at 05:37:05 (5:37 am).Initial patient acuity: Emergent (yellow).Lights and sirens, destination.Dispatch reason: 9 cardiac or respiratory arrest/death.Provider impression. unconscious. Vitals. 5:49:32 (5:49 am) BP 136/108 (normal value - 110/75 to 130/85 with 120/80 being standard normal reading), Pulse 79 (normal value - 60 to 100 beats per minute), Resp (respirations, normal value - 12 to 20 per minute) 24, SpO2 62 (normal value - 90 to 100 with readings below 90 requiring immediate medical attention). 05:57 am BP 161/122, Pulse 95, SpO2 85. 5:59 am, 177/144, Pulse 114, Resp 23, SpO2 89. 6:03 am BP 192/155, Pulse 100, Resp 31, SpO2 78.6:11 am, 197/166, Pulse 67, Resp 25. Narrative History Text: was dispatched to (Name Omitted) facility for a reported full cardiac arrest. Upon arrival, the crew was met at the entrance by facility staff.Two staff members were present in the room. No CPR or ventilations were in progress. when asked for the latest status update, staff stated the patient was breathing now and has a pulse and then exited the room to retrieve paperwork. The patient was found unconscious, breathing spontaneously, with a palpable pulse. The patient was warm to the touch and was receiving oxygen via nasal cannula (a medical device used to deliver oxygen to a patient through their nostrils) at 3 LPM (liters per minute). initial heart rate and pulse oximetry (SpO2- measure oxygen saturation of the blood) were obtained, SpO2 was noted low. oxygen was increased to 6 LPM vial nasal cannula.Once loaded. patient remained minimally responsive. Due to continued hypoxia (low levels of oxygen in the body tissues) and mental status, oxygen delivery was upgraded to a non-rebreather mask at 15 LPM.ETCO monitoring (End Tidal Carbon Dioxide monitoring used to assess a patient's respiratory status and overall health. Measure the concentration of carbon dioxide in exhaled are at the end of a respiration) was applied, revealing tachypnea (rapid respirations) with low CO2 values (inadequate amounts of carbon dioxide being expelled from the body) The patient remained unresponsive to verbal stimuli and responsive only to painful stimuli (sternal rub).radio report was given and acknowledged to (Name Omitted) local emergency department. care was documented as transferred to emergency department at 06:21:42 (6:21 AM).Review of ED to Hosp-admission (Discharge) in (Name Omitted) critical care Discharge Note for Resident #1 revealed .XXX[AGE] year old lady with dementia with psychotic features, major depressive disorder, atrial fibrillation (irregular heart rhythm) on Eliquis (blood thinner medication).was brought in on [DATE] from her health care facility (Name Omitted) where she was found unresponsive. On EMS arrival patient was hypotensive (low blood pressure), tachycardic, (fast heart rate). cool and cyanotic (blue in color indicated poor blood circulation) extremities (arms and legs). Upon arrival to the ER patient continued to be comatose.and was intubated for airway protection. Notably during intubations, provider noted crushed pill remnants in the back of the throat with concern for polypharmacy versus aspiration of medication. infectious workup. urinalysis concerning for UTI.Hospital course complicated by recurrent hemodynamically unstable (the body's circulatory system cannot maintain adequate blood flow often leading to shock) SVT (Supraventricular tachycardia, a fast or erratic heart rhythm) requiring multiple synchronized cardioversions (quick low-energy shocks to a patient's heart to restore a regular rhythm) . furthermore patient's blood pressure continued to plummet despite escalating doses of vasopressor (medications used to raise blood pressures). concerns for cardiogenic shock (a life-threatening condition characterized by the heart's inability to pump enough blood to meet the body's needs leading to severe symptoms and potential organ failure) on top of sepsis (a life-threatening condition caused by the body's extreme response to an infection) .Patient's condition continued to worsen and blood started oozing out of from all IV (intravenous) access points and repeat labs were concerning for DIC (Disseminated intravascular Coagulation is a rare blood clotting disorder that can cause organ damage and uncontrollable bleeding and can occur as a complication of a very serious medical condition such as an infection). ICU (Intensive Care Unit) team had multiple discussions with patient's family and POA about her worsening medical condition, guarded prognosis, and ultimately family decided to proceed with comfort measures in keeping with patient's wishes. Patient was pronounced deceased at 2319 on [DATE].In an interview on [DATE] at 08:00 AM, Director of Nursing (DON) B reported staffing on the night shift was to try for 3 nurses, but they could work with only 2 nurses. DON B reported there were always 3 nurses for the evening medication pass in the building; if there was a nurse call in then the staffing manager would try to cover the shift, otherwise a clinical care coordinator or DON B would cover the open shift. The covering nurse only had to stay until the evening medication pass was complete. DON B stated .I have been in the building after 10 (PM) and there isn't much to do other than a few PRN's (as needed medications) and dressing changes, you don't need 3 nurses.Review of Clinical Time Punches revealed . Clinical Care Coordinator/Registered Nurse (CCC/RN) EE punched in at 4:55 pm and punched out at 8:21 pm.In an interview on [DATE] at 10:30 AM, Licensed Practical Nurse (LPN) M reported she was mandated to stay over to complete the evening medication pass on [DATE] due to a nurse call in. LPN G reported she left as soon as the evening medication pass was complete because she was scheduled to return the next morning. LPN M reported CCC/RN EE did not take the cart from her or complete a medication pass. Review of Clinical Time Punches revealed .LPN M punched out at 7:19 PM.In an interview on [DATE] at 12:08 PM, DON B reported there were two clinical care coordinators that could assigned to cover an open shift on the floor. DON B reported that CCC/RN EE was one of them but did not cover shifts working on the floor.In an interview on [DATE] at 12:42 PM Infection Prevention Manager/Registered Nurse (IPM/RN) L reported CCC EE was in the building on [DATE] to provide educational trainings to employees, she did not work the floor during that shift.CCC/RN EE was not available during the survey.

Based on interview and record review the facility failed to ensure that an effective training program for newly hired nurses was provided and monitored for all newly hired nurses in 1 of 1 resident (Resident #1) reviewed for training, resulting in a delay in treatment and emergent hospital transfer for Resident #1. Findings include:Resident #1Review of Interdisciplinary Documentation for Resident #1 dated [DATE] at 03:16 AM (3:16 am) and authored by Registered Nurse (RN) V at 8:19 am on [DATE] revealed .PA (physician assistant) notified of patient's change in condition, including hypotension (83/56 BP Blood pressure).lethargy, cool skin, significant bilateral lower-extremity edema, and blue-to purplish fluid-filled blisters on posterior heels bilaterally. After discussion, PA agreed patient requires hospital evaluation. Hospital notified and report given. Preparation initiated for transfer to hospital. Focus at this time is on facilitating transport and maintain patient safety while awaiting transfer.Review of Interdisciplinary Documentation for Resident #1 dated [DATE] at 08:19 AM (8:19 am) revealed .Patient transferred to hospital for further evaluation per provider recommendation. Report given to receiving hospital staff and transport personnel. Patient departed facility via ambulance in stable condition at time of departure. Facility notified as appropriate. Documentation completed.In a telephone interview on [DATE] at 5:13 PM, Registered Nurse (RN) V reported on [DATE] she had to transfer two residents to an acute care hospital for changes in condition and she had never done it before. RN V reported RN P was assisting her to complete her orientation training check list that night, which included training on transferring a resident to an acute care hospital, which she had not done yet. RN V stated I started at the end of [DATE], and I have not yet completed all my training. RN V reported RN P was assisting her with completing the paperwork for a transfer to the hospital, the steps to take, the check list to be completed, and the packet that had to be filled out. RN V stated I asked (RN P) should we just call 911 (for Resident #1) and RN P told me to finish up the paperwork, she was going to go eat something, and then she would help me again when she was done. RN V stated when she transferred the first resident to the hospital that night I learned that 911 comes really fast and if you don't have the paperwork filled out, they won't wait for you, and then they don't have what they need. RN V reported she recalled that she did not complete the paperwork correctly for the first resident she transferred from the facility this shift.In a telephone interview on [DATE] at 9:54 AM, EMS [NAME] Specialist (EMS/BS) Z reported on [DATE], the (Name Omitted) local emergency room contacted (Name Omitted) local EMS ambulance services, reported the facility was unable to contact 911 due to a telephone issue, and needed a patient transported from the facility that (Name Omitted) local emergency room had received report on, but did not receive the patient.In a telephone interview on [DATE] at 10:08 AM, 911- Service Specialist (SS) AA reported 911 EMS received two calls for the facility on [DATE], one at 3:20 AM the call was for an ambulance at (Name Omitted), and (Name Omitted) ambulance service was dispatched at 3:25 AM, the call was clear at 5:01 AM. When queried, SS AA reported a call being clear meant the patient that was transported was in the care of the hospital and the ambulance was back in service, available for another call. SS AA reported an abandoned call was received at 5:24 AM from the facility. When queried, SS AA reported an abandoned call indicated a call was made but was disconnected for some reason and no conversation occurred. SS AA reported 911 returned the abandoned call and was informed there was no emergency at the location. SS AA reported 911 received a call at 5:29 AM from the local emergency department and a call at 5:30 AM from the ambulance service, advising they had received a call from the local emergency department, indicating that they had received a call from the facility providing report on a patient and had not received the patient yet. Review on Call for Service Detail Report - CFS 2334 dated [DATE] at 5:29:55 AM revealed .5:30:16 AM (Name Omitted) ambulance service also calling in - advising they got a call from the hospital that THEY got a call from (Name Omitted) facility of an unresponsive male over an hour ago. 5:30:26 AM now getting an [NAME] (abandoned) from (Name Omitted) facility.5:33:04 AM Spoke with (Name Omitted) staff (Name Omitted) Facility who confirmed no emergency.5:33:13 AM close call.5:34:17 AM call reactivated. 5:37:46 AM (Name Omitted) ambulance service just called back- 77 y/o year old female hypertensive, unresponsive- (Name Omitted) Facility said they couldn't get thru to 911- in cardiac arrest - (Name Omitted) ambulance service contact at the hospital is (Name Omitted) at (Name Omitted) local emergency department- .5:39:08 AM ambulance dispatched (unit 4010). 5:41:03 AM per (Name Omitted) ambulance service no police or mfr's (medical first responders) needed.7:39:16 AM call cleared, close call.Review of Incident Detail Report dated [DATE] at 5:36:12 AM revealed .XXX[DATE] 05:36:58 AM, 77 yo (year old) female called in by (Name Omitted) ER (emergency room), (Name Omitted) facility staff said they were unable to get ahold of (Name Omitted) 911 due to phone issues.Review on Prehospital Care Report Summary for Resident #1 dated [DATE] revealed . call received 05:36:12 (5:36 am), dispatched at 05:37:05 (5:37 am).Initial patient acuity: Emergent (yellow).Lights and sirens, destination.Dispatch reason: 9 cardiac or respiratory arrest/death.Provider impression. unconscious. Vitals. 5:49:32 (5:49 am) BP 136/108 (normal value - 110/75 to 130/85 with 120/80 being standard normal reading), Pulse 79 (normal value - 60 to 100 beats per minute), Resp (respirations, normal value - 12 to 20 per minute) 24, SpO2 62 (normal value - 90 to 100 with readings below 90 requiring immediate medical attention). 05:57 am BP 161/122, Pulse 95, SpO2 85. 5:59 am, 177/144, Pulse 114, Resp 23, SpO2 89. 6:03 am BP 192/155, Pulse 100, Resp 31, SpO2 78.6:11 am, 197/166, Pulse 67, Resp 25. Narrative History Text: was dispatched to (Name Omitted) facility for a reported full cardiac arrest. Upon arrival, the crew was met at the entrance by facility staff.Two staff members were present in the room. No CPR or ventilations were in progress. when asked for the latest status update, staff stated the patient was breathing now and has a pulse and then exited the room to retrieve paperwork. The patient was found unconscious, breathing spontaneously, with a palpable pulse. The patient was warm to the touch and was receiving oxygen via nasal cannula (a medical device used to deliver oxygen to a patient through their nostrils) at 3 LPM (liters per minute). initial heart rate and pulse oximetry (SpO2- measure oxygen saturation of the blood) were obtained, SpO2 was noted low. oxygen was increased to 6 LPM vial nasal cannula.Once loaded. patient remained minimally responsive. Due to continued hypoxia (low levels of oxygen in the body tissues) and mental status, oxygen delivery was upgraded to a non-rebreather mask at 15 LPM.ETCO monitoring (End Tidal Carbon Dioxide monitoring used to assess a patient's respiratory status and overall health. Measure the concentration of carbon dioxide in exhaled are at the end of a respiration) was applied, revealing tachypnea (rapid respirations) with low CO2 values (inadequate amounts of carbon dioxide being expelled from the body) The patient remained unresponsive to verbal stimuli and responsive only to painful stimuli (sternal rub).radio report was given and acknowledged to (Name Omitted) local emergency department. care was documented as transferred to emergency department at 06:21:42 (6:21 AM).Review of ED to Hosp-admission (Discharge) in (Name Omitted) critical care Discharge Note for Resident #1 revealed .XXX[AGE] year old lady with dementia with psychotic features, major depressive disorder, atrial fibrillation (irregular heart rhythm) on Eliquis (blood thinner medication).was brought in on [DATE] from her health care facility (Name Omitted) where she was found unresponsive. On EMS arrival patient was hypotensive (low blood pressure), tachycardic, (fast heart rate). cool and cyanotic (blue in color indicated poor blood circulation) extremities (arms and legs). Upon arrival to the ER patient continued to be comatose.and was intubated for airway protection. Notably during intubations, provider noted crushed pill remnants in the back of the throat with concern for polypharmacy versus aspiration of medication. infectious workup. urinalysis concerning for UTI.Hospital course complicated by recurrent hemodynamically unstable (the body's circulatory system cannot maintain adequate blood flow often leading to shock) SVT (Supraventricular tachycardia, a fast or erratic heart rhythm) requiring multiple synchronized cardioversions (quick low-energy shocks to a patient's heart to restore a regular rhythm) . furthermore patient's blood pressure continued to plummet despite escalating doses of vasopressor (medications used to raise blood pressures). concerns for cardiogenic shock (a life-threatening condition characterized by the heart's inability to pump enough blood to meet the body's needs leading to severe symptoms and potential organ failure) on top of sepsis (a life-threatening condition caused by the body's extreme response to an infection) .Patient's condition continued to worsen and blood started oozing out of from all IV (intravenous) access points and repeat labs were concerning for DIC (Disseminated intravascular Coagulation is a rare blood clotting disorder that can cause organ damage and uncontrollable bleeding and can occur as a complication of a very serious medical condition such as an infection). ICU (Intensive Care Unit) team had multiple discussions with patient's family and POA about her worsening medical condition, guarded prognosis, and ultimately family decided to proceed with comfort measures in keeping with patient's wishes. Patient was pronounced deceased at 2319 on [DATE].In an interview on [DATE] at 9:31 AM, RN P reported on the night of [DATE], when RN V had more than one resident who was transferred to the hospital, RN V was overwhelmed and RN P reported she tried to help her with the paperwork required to transfer a resident to the hospital. RN P reported she did not think RN V had ever had to transfer someone to the hospital and was not familiar with the process.In an interview on [DATE] at 3:45 PM, DON B and Nursing Home Administrator (NHA) A reported each new nurse was given 5 days of training when they were hired. DON B reported a nurse could have more days of training if they asked for them. DON B reported each nurse was given a checklist to complete addressing training items. DON B reported the check list does not have to be completed for the check list to be returned to DON B.Review of Licensed Nurse - Orientation and Skill Check. revealed .Emergency Procedures.Director of Health Care Services.Hospitalization.Transfer form from electronic record.Emergency access for Rapid Transport.In an interview on [DATE] at 3:50 PM, DON B reported RN V had not turned in her orientation training checklist, and she was not aware what was complete and what wasn't.The orientation checklist for RN V was not provided by the time of exit.

Based on interview and record review the facility failed to develop and implement a person-centered care plan for 1 (Resident #2) of 3 residents reviewed for person centered care planning resulting in the potential for injury and unmet care needs.Findings include:Resident #2Review of an admission Record revealed Resident #2 was a male who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: other displaced fracture of sixth cervical vertebra (fracture of the 6th vertebra in the neck area), syncope (fainting) and collapse, and weakness.Review of History and Physical dated 12/6/25 revealed .had a syncopal (passing out) episode this morning.On standing he lost consciousness, fell and struck his head.has neck pain.a scalp laceration (cut) was sutured (stitches).MRI (magnetic resonance imaging an non-invasive technique that produces detailed images of the internal structures of the body) showed an anterior superior vertebral body fracture (a type of compression fracture occurring at the front upper part of a vertebra, often caused by trauma). he is stabilized in an Aspen collar.recommended Aspen collar and f/u (follow up) Xray in 4 weeks .Review of After Visit Summary (AVS) for Resident #2 dated 12/12/25 revealed .discharge instructions (specific in comments) continue to wear Aspen collar splint designed to provide firm yet comfortable immobilization of the neck (prevents movement of the neck)) at all times. Review of Health Care Provider Note for Resident #2 dated 12/15/25 revealed .sustained a C6 (6th cervical vertebra fracture) cervical fracture.Assessment and plan.C6 cervical fracture-Aspen collar.seen heading to therapy in C-collar (Aspen collar).Review of Care Plan for Resident #2 revealed no noted documented care plan related to a cervical fracture or the use of an Aspen collar.Review of Interdisciplinary Documentation for Resident #2 dated 12/16/25 at 10:27 (am) revealed .is alert and oriented with some confusion. Continuously removed aspen collar despite education to keep it in place per provider orders. He is unsteady and requires assistance of 2 for bed mobility, transfers, and ambulation.In an interview on 1/16/26 at 11:42 AM, Infection Prevention Manager/Registered Nurse (IPM/RN) L reviewed Resident #2's record and confirmed there was no care plan in place for a C6 fracture or the use of an Aspen collar. IPM/RN L reported there should be a care plan in place. IPM/RN L reported clinical care coordinators were responsible for creating care plans, and that Clinical Care Coordinator/Registered Nurse (CCC/RN) EE was assigned to Resident #2 and should have created the care plan for his C6 fracture and his Aspen collar.In an interview on 1/16/26 at 12:08 PM, Director of Nursing (DON) B reported the clinical care coordinators were responsible for the development of resident centered care plans. DON B reported Resident #2 had an Aspen collar he was to wear at all times, but he would play with it more than he wore it. DON B reported there should have been a care plan in place related to Resident #2's C6 fracture and Aspen collar. DON B reported CCC/RN EE was responsible for the unit Resident #2 resided on and should have created his care plan at admission.CCC/RN EE was not available for interview during the survey.

Based on interview and record review the facility failed to ensure that residents were free from significant medication errors in 1 (Resident #1) of 1 resident reviewed for significant medication error resulting in the potential for Resident #1 to experience lethargy (decreased alertness and response), dizziness, and an increased risk for falls.Findings include:Resident #1 Review of an admission Record revealed Resident #1 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: bipolar disorder (a mental health disorder characterized by significant mood swings), dementia (a syndrome characterized by a decline in cognitive function affecting memory, thinking, behavior, and the ability to perform everyday activities) and delusional disorder (serious mental health condition characterized by persistent, false beliefs that are not based in reality, often leading to significant distress and impairment in functioning).Review of Physician Order for Resident #1 revealed Metoprolol Succinate ER (extended release) Oral tablet extended release 24 hour 25 mg (milligram) give 25 mg by mouth one time a day for htn (hypertension- high blood pressure), hold if systolic (top number in a blood pressure reading) is <110 (less than) or pulse < 60 (less than) and notify the MD (doctor).with a start date of 10/7/25 and no noted revisions during Resident #1's stay.Review of Medication Administration Record (MAR) for Resident #1 for the month of October, 2025 revealed .on 10/9/25 BP (blood pressure) documented was 107/64, on 10/12/25 BP documented was 102/56, On 10/15/25 BP documented was 106/53, on 10/24/25 BP documented was 107/63, on 10/26/25 BP documented was 94/76, on 10/19/25 BP documented was 107/58. all dates were documented that the medication was administered to Resident #1.Review of Medication Administration Record (MAR) for Resident #1 for the month of November, 2025 revealed . on 11/2/25 BP documented was 103/61, on 11/3/25 BP documented was 106/64, on 11/6/25 and 11/7/25 BP documented was 100/61, on 11/8/25 BP documented was 108/72, on 11/18/25, BP documented was 105/59, and on 11/27/25 BP documented was 109/27. all dates were documented that the medication was administered to Resident #1.Review of Medication Administration Record (MAR) for Resident #1 for the month of December, 2025 revealed .on 12/3/25 BP documented was 103/68, on 12/6/25 and 12/7/25 BP documented was 104/62, 12/9/25 BP documented was 106/60, on 12/11/25 BP documented was 109/66, on 12/13/25 BP documented was 104/62. all dates were documented that the medication was administered to Resident #1.Review of Resident #1's medical record revealed no noted documentation of any provider being notified of blood pressure reading outside of ordered parameters.In an interview on 1/14/26 at 10:19 AM Licensed Practical Nurse (LPN) G reported if a medication has parameters such as holding for a specific blood pressure or pulse, you check the vital sign and if it's outside of the parameter, you should not give it.In a telephone interview on 1/14/26 at 9:42 AM Physician Assistant (PA) BB reported per the way the metoprolol succinate order for Resident #1 was written it should have been held, not given to the resident on the dates the BP reading had a systolic number less than 110. PA BB reported he only covers the facility occasionally when on call and would not be the provider who would receive any notification if or when the medication was held.In a telephone interview on 1/14/26 at 11:31 AM, Nurse Practitioner (NP) CC reported a physician order should be followed, and she does not recall ever getting notified that Resident #1's metoprolol succinate was held. NP CC reported Resident #1's metoprolol succinate should have been held every time her systolic BP reading was below 110.In an interview on 1/14/26 at 12:33 PM, Director of Nursing (DON) B reported her expectations were that medications were given per the physician order. When queried, regarding Resident #1's MARs for October, November, and December 2025, DON B reported Resident #1's metoprolol succinate should only be given if the provider was contacted when Resident #1's BP was outside of the parameters. DON B reported if the provider was not contacted, and the medication was given it was a mediation error.

Based on interview, and record review, the facility failed to complete an annual performance review for 2 Certified Nursing Assistants (CNAs) (CNA's F and DD) of 5 CNA's reviewed for annual performance evaluations, resulting in the potential for unidentified CNA performance concerns, a lack of training related to staff performance review outcomes, and the potential for unmet care needs.Findings include:In an email on 1/16/26 at 1:47 PM, Nursing Home Administrator (NHA) A provided information indicating CNA F was hired on 8/24/24 and no performance evaluation had been completed; and CNA DD was hired on 3/9/15 and the last documented performance evaluation was completed on 3/19/24.In an interview on 1/16/26 at 1:50 PM, NHA A reported CNA F and CNA DD did not have completed performance reviews. NHA A reported Director of Nursing (DON) B was responsible for completing performance evaluations, and Human Resource (HR) KK was responsible for maintaining a list of when performance evaluations needed to be completed.In an interview on 1/16/26 at 1:55 PM, DON B reported she was unaware she was responsible for completing performance evaluations for CNA's and she had never completed one since she began working for the company about 5 months ago.In an interview on 1/16/26 at 1:55 PM, Regional Clinical Support (RCS) GG reported performance evaluations should be completed annually on the employee's anniversary date of hire.HR KK was unavailable during the survey.No performance evaluations for CNA F and CNA DD were available for review by the end of survey.Review of The Essentials Guide to Healthcare Performance Reviews, www.hrforhealth.com , 2024, revealed The benefits of healthcare performance reviews go beyond creating a better experience for your team.the most important (benefit) is performance reviews lead to improved performance.greater productivity and better overall experience for your patients.

Based on interview and record review the facility failed to ensure Certified Nurse Assistants (CNA's) completed the required 12 hours of in-service training to ensure continued competency in 1 of 5 CNA's reviewed for in-service training, resulting in the potential for a decrease in resident safety.Findings include:In an email on 1/16/26 at 1:47 PM, Nursing Home Administrator (NHA) A provided information indicating CNA F was hired on 8/24/24 and had completed 0 hours of in-service training.Review of a list provided by NHA A for CNA F with the assigned in-service trainings, revealed documentation that CNA F had Not Attempted to complete any assigned in-service trainings.In an interview on 1/16/26 at 1:50 PM, NHA A reported CNA F did not have 12 hours of completed in-service trainings. NHA A reported the in-services were assigned at the beginning of the year and monthly. CNAs were notified when new training has been assigned electronically. NHA A reported Human Resource (HR) KK was responsible for maintaining a list of employees and training completions. HR KK was unavailable during the survey.

Based on observation, interview and record review, the facility failed to provide adequate supervision and implement interventions to prevent falls for 2 residents (Resident #1 and Resident #16) of 7 sampled residents reviewed for accidents, resulting in Resident #1 falling and sustaining a pelvic fracture, along with severe pain, and Resident #16 falling and hitting his head during an improper transfer.Findings include: Resident #1 Review of an admission Record revealed Resident #1 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Alzheimer's disease (a progressive disease that primarily affects memory, thinking and behavior). Review of a Minimum Data Set (MDS) assessment for Resident #1 with a reference date of 6/11/25, revealed a Brief Interview for Mental Status (BIMS) score of 6/15 which indicated Resident #1 was severely cognitively impaired. Section E of the MDS revealed Resident #1 exhibited wandering behavior daily during the 14-day assessment period. Section GG revealed Resident #1 required moderate assistance (helper does less than half effort) to safely transfer self from sitting to standing, from bed to wheelchair. Review of a Care Plan for Resident #1 with a reference date of 8/22/24, revealed the focus/goal/interventions of: 1. Focus: altered functional mobility.She is alert and confused.Goal: (Resident #1) is here for convalescent care. Interventions: .Staff to anticipate needs and give physical and verbal cues for tasks.AMBULATION: Non-Ambulatory, BED MOBILITY: Assist of 1.FALL-RISK MANAGEMENT: encourage non-skid footwear, maintain personal items in reach.bed in lowest position. 2. Focus: (Resident #1) is predisposed to.impaired judgement due to diagnosis of dementia. She has a history of attempting independent surface-to-surface transfers.she has a history of repeated falls.may exercise her self determination without realizing that her movements exceed her functional capacity. Goal: (Resident #1) will be free from falls and injury through her next review. Interventions: .review and modify environmental factors as indicated.see ADL (Activities of Daily Living) plan of care for fall risk interventions. In an interview on 8/18/25 at 2:48pm, Family Member (FM) SS reported Resident #1 had suffered a pelvic fracture during a fall at the facility. FM SS reported the resident was not receiving 1:1 supervision on 2/12/25 when she fell and subsequently fractured her pelvis. Review of an Incident Report for Resident #1 with a reference date of 2/12/25 at 2:00am, revealed Resident was observed laying on her right hip. Resident stated, It's broken. Resident sent to hospital.not moved due to severe pain.Staff interview: The nurse providing care to (Resident #1) described (Resident #1) as anxious/restless and agitated.(Resident #1) refused attempts to assist her to bed around 8-10pm.at the Nurses station until approximately 1:30am when staff noticed that (Resident #1) was falling asleep.staff assisted her into bed at 1:40am.at approximately 2:00am.heard a bang and immediately went to investigate finding (Resident #1) in the doorway of her room on the floor crying out in pain it's broken.imagining confirmed pelvic fracture as a result of fall.spoke with CNA (Certified Nursing Assistant) who was providing care to (Resident #1).describes (Resident #1's) behavior as abnormal, stating she.was feisty and on a roll.not interested in going to sleep last night.began nodding off.at around 1:45(am) staff assisted (Resident #1) into bed and she reportedly fell shortly after.this writer met with (Resident #1) in her room.(Resident #1) has been experienced (sic) acute pain related to this fracture.treated with oxycodone 10mg (milligrams) every 2 hours as needed.(Resident #1) placed on 1:1 observations at all times as (Resident #1) is impulsive and her ability to have insight into her functional limitations is skewed by her cognitive impairment. In an interview on 8/19/25, at 1:36pm, Registered Nurse (RN) RR reported Resident #1 was restless and very busy throughout the evening of 2/11/25 and into the early morning hours of 2/12/25. RN RR reported she had concerns for Resident #1's safety and tried to supervise Resident #1 by keeping her near the nurse's station, but the resident self-propelled her wheelchair all over the building that night. RN RR reported Resident #1 had no awareness of her own physical limitations and would attempt to stand up and walk without assistance. RN RR reported Resident #1 began to fall asleep while at the nurse's station around 1:40am and staff transferred her to bed. Approximately 15 minutes later, RN RR heard a bang and responded to Resident #1's room, where she found the resident on the floor in severe pain, after a fall. RN RR described Resident #1 as experiencing severe pain as she laid on the floor of her room. When further queried, RN RR reported Resident #1 was not on 1:1 supervision on 2/12/25 and would not have fallen if she'd been on 1:1. RN RR reported providing Resident #1 with 1:1 supervision on 2/12/25 was probably an option but it had not pursued that night. RN RR reported she did not know how the facility determined if a resident needed 1:1 supervision. Review of a Diagnoses List for Resident #1 with a reference date of 2/12/25 revealed fracture of right pubis (break in the right pubic bone which typically causes pain, swelling and difficulty walking), initial encounter for closed fracture (bone break where the skin remains intact. Review of a Resident Visual Observation Assessment for Resident #1 with a reference date of 2/11-2/12/25 revealed the resident was agitated and self-propelling her wheelchair from 10pm-1:30am on this night. In an interview on 8/19/25 at 1:33pm, CNA R reported when Resident #1 was restless and agitated, staff could not turn their back on her for a second because she got up constantly and needed someone right next to her. In an interview on 8/19/25 at 1:38pm, CNA T reported sometimes Resident #1 required 1:1 supervision to remain safe during the night. CNA T reported when Resident #1 was restless, she needed staff to be at her side to keep her safe. In an interview on 8/19/25 at 3:51pm, RN TT reported the nurse responsible for caring for Resident #1 was responsible to assess the resident's needs for supervision. RN TT reported if Resident #1 was restless and agitated during the night, the nurse should call the Director of Nursing (DON) for approval to implement 1:1 supervision. RN TT reported they had called the DON a few times prior to the fall on 2/12/25 to get approval for 1:1 supervision of Resident #1 and each time it had been approved. Review of a Census Report with a reference date of 2/12/25 revealed Resident #1 resided in room [ROOM NUMBER] bed 2 at the time of her fall. During an observation on 8/18/25 at 10:21am, room [ROOM NUMBER] bed 2 was noted to be approximately 40' from the nurses' station. Activity within the room was not viewable from the nurse's station. Review of a 1:1 Supervision Timeline for Resident #1, provided by Nursing Home Administrator (NHA) A revealed 10/16/24 IDT (Interdisciplinary Team) met to review high fall risk residents. (Resident #1) remains at risk for falls. Her most recent fall management assessment revealed a fall risk score of 10. (Resident #1) has a history of falls with injury at the facility. Currently (Resident #1) remains on 1:1 supervision at all times to mitigate risk of injury.11/5/24 (Resident #1) placed on 1:1 supervision last evening due to increased restlessness and exit seeking. (Resident #1) was observed by staff to attempt ambulation from her chair and her bed.she has poor insight into her functional limitations and as such.redirection is not effective in managing (Resident #1's) risk for falls.1/13/25 1:1 supervision 8am-8pm. Review of all fall incident reports for Resident #1 from 9/25/24-8/20/25, revealed the resident fell on 9/25/24 at 2:30am, on 10/2/24 at 4:06am, and on 2/12/25 at 2:00am. Each fall occurred during early morning hours, prior to 8am when Resident #1 was scheduled to have 1:1 supervision. In an interview on 8/19/25 at 2:28pm, Clinical Support Nurse (CSN) LL reported the provision of 1:1 supervision for a resident was not reflected in the physician orders but would be reflected in a resident's plan of care. CSN LL confirmed she would provide the facility's rationale and clinical process for the provision and discontinuation of 1:1 supervision for Resident #1. Documentation of the clinical process for 1:1 implementation and discontinuation was not provided by the conclusion of the survey. In an interview on 8/20/25 at 9:38am, Clinical Psychologist (CP) KK reported she used her expertise to assess resident needs for effective behavior management but was not consistently involved in the decision-making process for the provision of 1:1 supervision for Resident #1. CP KK confirmed she regularly assessed and monitored Resident #1's behavioral care needs. CP KK reported Resident #1 was very impulsive and unsafe and could not remain seated more than 90 seconds at a time when she was agitated. In an email on 8/20/25 at 10:34am, NHA A reported the facility did not provide staff with any training specifically related to the provision of 1:1 resident supervision. In an interview on 8/20/25 at 1:41pm, NHA A reported the facility did not have a policy related to the provision of 1:1 supervision for residents. When queried regarding the rationale for the use/discontinuation of 1:1 supervision for Resident #1, NHA A reported he thought the facility may have provided 1:1 supervision due to her exit-seeking behaviors, rather than her fall risk. NHA A reported he provided all the documentation available regarding the clinical process for the provision/discontinuation of 1:1 supervision for Resident #1. Resident #16: Review of an admission Record revealed Resident #16 was a male with pertinent diagnoses which included muscle weakness, and cognitive communication deficit (communication impairment stemming from difficulties with thinking processes like attention, memory, and reasoning, and problem solving). Review of Care Plan for Resident #16 initiated on 4/17/25, revealed the focus, .Altered functional mobility and ADL's (activities of daily living) related to:. with the intervention .Dependent for ADL's.AMBULATION: Non-Ambulatory.Bed Mobility: assist of two. Review of Incident Report dated 4/19/25 at 12:00 PM, revealed, .Nursing Description: Informed by the CNA that while she was transferring the resident by herself because was not care plan available. CNA, was ready to transfer the resident into his wheelchair, the resident could not stand long enough to transfer, and CNA assisted the resident to the floor. He did bump his head on the floor, blister and bruise noted on the L (left)/side of the resident's eye.Immediate Action Taken: The resident moved upper extremities, and he is stiff on his legs, he stated to hit his head on the floor but he denies pain at this time. Transferred the resident to his wheelchair using the hoyer lift machine.Intervention: Reeducated staff to follow care plan, if one is not present, have nurse print one PRIOR to transferring.Notes: Hx (history) of osteoarthritis, cognitive communication deficit and a history of falls.(Resident #3) is non-ambulatory, requires max assistance for ADLs (activities of daily living) including bathing, transfers, and bed mobility.A quarter size bruise is noted to the left of (Resident #3's) eye.Root Cause: (Resident #3's) care plan was not followed by staff. As a result, education was provided to the staff members involved in his care. The nurse spoke with the CNA prior to this incident and asked her to wait to provide care for him until the nurse could evaluate him for his care plan needs. The CNA did not wait stating that she felt she could transfer him with one assist. (Resident #3) is care planned for a max assist 2-person transfer.Immediate Action: Staff education was completed and (Resident #3's) care plan was updated and placed in his closet by his nurse. Review of Interdisciplinary Documentation dated 4/19/2025 at 1:18 PM, revealed, .Informed by the CNA (Certified Nursing Assistant) that while she was transferring the resident by herself because was not care plan available. CNA was ready to transfer the resident into his wheelchair, the resident could not stand long enough to transfer, and CNA assisted the resident to the floor. He did bump his head on the floor, blister and bruise noted on the L (left)/side of the resident's eye.The resident is on blood thinners and NP (Nurse Practitioner) is aware, but she said not to send the resident to the hospital, just monitor for changes. In an interview on 08/19/2025 3:20 PM, Certified Nursing Assistant (CNA) M reported the nurse wanted her to get Resident #16's weight. CNA M reported she looked in the closet and there was no care plan guide there for her to refer to for his transport needs. When queried, CNA M reported there was nothing in the medical record she was able to observe for his transfer status. CNA M reported she asked Resident #16 if he was able to stand and he indicated he was able to stand. CNA M explained she had the wheelchair on the side of the bed, and he would only need to stand at the side of the bed and pivot to be seated in the wheelchair. CNA M reported Resident #16 was unable to stand and he went down onto the floor. In an interview on 08/19/2025 at 12:49 PM, Licensed Practical Nurse (LPN) D reported the care plan was usually in the closet for the CNAs to reference. Resident #16 was a new admit and his care plan was not in the closet. LPN D reported CNA M was informed not to transfer the resident if they were unsure of a resident's transfer status until she had spoken to the nurse as the incident created a safety issue for Resident #16 and he could have been hurt badly. Review of Fall Management assessment completed on 4/16/25 at 7:30 PM, revealed, .Balance: Not able to attempt without physical support .Resident presented to facility in wheelchair and told staff that he could not walk or stand. When staff insisted that he tried, resident and wife were stern that patient could not do it. Nurse used sit to stand to transfer patient from wheelchair to bed.

This citation pertains to Intake 1210578.Based on interview and record review, the facility failed to provide care and services to promote dignity and respect in 4 of 5 residents (Resident #31, #3, #17, #16) reviewed for dignity/respect, and 7 of 12 residents from the confidential group meeting, resulting in the potential for unmet care needs and feelings of diminished self-worth, sadness, and frustration.Findings include:Resident #31 Review of an “admission Record” revealed Resident #31 was a male, with pertinent diagnoses which included: need for assistance with personal care; major depressive disorder, recurrent severe without psychotic features; difficulty walking, not elsewhere classified; and muscle weakness (generalized). Review of a Minimum Data Set (MDS) assessment for Resident #31, with a reference date of 6/17/25 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #31 was cognitively intact. Further review of said MDS revealed Resident #31 was “always incontinent of bowel and bladder” and required “substantial/maximal assistance” (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.) for “toileting hygiene” (The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement…) In an interview on 8/18/25 at 2:10 PM Resident #31 reported call light wait time was at least a half hour and sometimes the wait had been up to 2-3 hours. Resident #31 reported he has had to wait extended periods for staff to change his brief after having a bowel movement and “it is uncomfortable to say the least.” In an interview on 8/19/25 at 11:59 AM, “Licensed Practical Nurse” (LPN) “D” reported residents have complained to her about long call light wait times. In an interview on 8/20/25 at 9:01 AM, “Certified Nurse Aide” (CNA) “X” reported residents complained to her about long call light wait times. In an interview on 8/20/25 at 9:02 AM, CNA “FF” reported residents sometimes complained about long call light wait times. According to https://journals.lww.com/ regarding call light use, “It is one of the few means by which patients can exercise control over their care on the unit. When patients use the call light, it is usually to summon the nurse…Patients expect that when they push the call light button, a nursing staff member will answer or come to them.” Resident #3: Review of an admission Record revealed Resident #3 was a female with pertinent diagnoses which included paralysis affecting right dominant side, need for assistance with personal care, weakness, and difficulty in walking. In an interview on 08/18/2025 at 12:11 PM, Resident #3 reported “things haven’t changed.” Resident #3 reported over the weekend she had to wait from 6:15 PM to 8:00 PM for them to come and answer the call light. Resident #3 reported she knew the times because the long call light waits happened “quite a bit” and she wanted to make sure she had the time down on how long it took Resident #17: Review of an admission Record revealed Resident #17 was a male with pertinent diagnoses which included paraplegia (affects all or part of the trunk area, legs, and pelvic organs), and need for assistance with personal care. In an interview on 08/18/2025 at 3:59 PM, Resident #17 reported he had concerns with call lights times being usually 45 minutes to an hour. Resident #17 reported he had the most issues with his call light being answered during the evening and nighttime shifts. Resident #17 reported at night the staff were not emptying his urinal. Resident #17 reported a few nights ago the urinal was not emptied from 10:00 PM until 4:30 AM and it was full. Resident #17 reported he had [NAME] his concerns with call light wait times to the previous two nursing home administrators and he felt they tried to placate him and nothing changed. Resident #16: Review of an admission Record revealed Resident #16 was a male with pertinent diagnoses which included muscle weakness, and cognitive communication deficit (communication impairment stemming from difficulties with thinking processes like attention, memory, and reasoning, and problem solving). In an interview on 08/18/2025 at 1:45 PM, Family Member (FM) “OO” reported waiting long periods of time for call lights to be answered and when staff do respond, the staff would turn off the call light prior to completing the request. FM “OO” reported sometimes the staff would forget to come back. FM “OO” reported the call light had been turned on at 1:20 PM today, the CNA came in and turned it off and reported she would be back with someone to assist. FM “OO” reported Resident #16 had a bowel movement and had been sitting in it since then (25 minutes upon my entry to the room, no staff entered the room when this writer was present approximately 10 minutes). FM “Betty” expressed worry the staff would return as the door was closed and she wanted to ensure Resident #3 would get his brief changed. In an interview on 08/20/2025 at 1:57 PM, Certified Nursing Assistant (CNA) K reported she attempted to answer the call light as soon as possible. CNA K reported if unable to complete the requested task she would tell the resident she would return to assist them. CNA K reported she does turn off the light but does return to the resident as soon as she was able to. u In an interview on 08/20/2025 at 2:01 PM, [NAME] President of Clinical Services JJ reported the staff were educated during orientation to leave the light on until the need was met. Review of “Call Lights” received on 08/20/25 from employee orientation, revealed, “…Response to Call Lights: If you see an activated red light in the hall, you are expected to answer the call light…Assist with the need if it is within your scope or to advise the resident you will get assistance, do not turn off the call light unless you have met the resident’s need…”

Based on interview and record review, the facility failed to employ an Activity Director with the required qualifications resulting in the potential for unmet met psychosocial needs, feelings of boredom and a lack of person-centered activities. This citation has the potential to impact the residents who choose to participate in structured activities and/or are dependent for their leisure needs.Findings include:Review of certification standards of the National Certification Council for Activity Professionals revealed ADC (Activity Director Certified) Certification ensures an individual has the knowledge and skills to lead and direct an activities and life enrichment department. ADC Certification validates the competencies necessary to be an Activity Director including leadership, management, advocacy, care planning and documentation.Review of Leisure engagement in older adults is related to objective and subjective experiences in aging, [NAME] K. Bone, Feifei Bu, [NAME] K. Sonke, [NAME] Fancourt (2024), revealed Leisure engagement has potential to slow health and functional decline in older age.there is extensive evidence linking leisure engagement to physical and mental health across the life course.Older adults should be supported and encouraged to incorporate physical and creative activities into their everyday lives.In an interview on 08/18/2025 at 11:43am, NHA A stated The Activities Director is working on her certification. She is about 30-40% completed (with the required training). I do not know how much experience she has.In an interview on 8/20/25 at 2:22pm, Activity Director (AD) P reported she was enrolled but had not completed an Activities Director training course and did not have 2 years' experience in social or recreational programming. AD P reported she had worked at the facility for a little over a year and had completed about 30% of an activity professional certification course. AD P reported she struggled to provide activities that would meet the needs of residents with severe cognitive impairments and often found those residents could not focus on the group activities that were being provided. When further queried, AD P reported she was not supervised by a qualified Activities Director at this time and felt she needed support and guidance to ensure the residents were provided with activities that met their needs.Review of the facility's Activity Calendars with reference dates of 6/2025, 7/2025 and 8/2025, revealed no activity opportunities in the evenings, no structured opportunities to participate in physical activity 2-3 times per week, and no specialized programs for residents with severe cognitive impairments.Review of the facility's Activities Director Job Description, with no reference date, revealed Qualifications.Those who don't currently have a certification, must, at a minimum, begin an Activity Professional Certification Course within 90 days of employment and be certified within 12 months of employment.primary functions and responsibilities of this position are as follows: 1. Plan, schedule and implement a program of individual and group activities based on residents' schedule, needs and desires.5. Identify and document in the resident's care plan, the activity interests and needs.11. Plan and implement evening functions.29. Review the activity plan.for residents with little or no activity.determine if there is a problem or concern that can be resolved, improved or addressed.to improve the resident's Quality of Life.

Based on observation, interview, and record review, the facility failed to provide adequate infection control practices that included 1.) proper hand hygiene during medication administration for 4 (R27, R6, R52, and R3) residents observed during medication administration, 2.) resident-shared equipment not being cleaned prior to use for 1 (R6) of 18 residents and, 3.) adequate Enhanced Barrier Precautions (EBP) for 2 (R3, R5) of 2 residents observed for infection control practices, resulting in the potential of cross-contamination and the harborage of pathogens leading to infection among a vulnerable population.Findings include: R27 According to R27's Minimum Date Set (MDS) dated [DATE], diagnoses included coronary artery disease, hypertension, Alzheimer's disease, dementia, anxiety disorder, and depression. During an observation, interview, and record review on 8/20/2025 at 7:05 AM with Registered Nurse (RN) L at the South Medication cart, a small clear plastic cup held multiple pills, tablets, and capsules was in the cart's top drawer. RN L poured the medications out of the cup onto a piece of paper that had numbers written on it. RN L, using her bare hands counted 15 various types of medications and put them back into the cup then went to R27's room to administer them. R6 According to R6's Diagnoses, the resident had methicillin susceptible staphylococcus aureus infection, intraspinal abscess and granuloma, and other bacterial agents as the cause of diseases classified elsewhere. During an observation and interview on 8/20/25 at 7:18 AM, RN L was removing R6's medications from their packages with her bare hands and placing them into a medication cup. After all medications were prepared, RN L administered them to R6. R6 stated, I found out recently I am receiving an antibiotic to keep me clean, so I don't catch anything. RN L reported the resident had been ill with some type of respiratory infection. R52 According to R52's MDS dated [DATE], R52 diagnoses included cancer, heart failure, diabetes mellitus, hyperlipidemia, thyroid disorder, arthritis, anxiety disorder, depression, and chronic lung disease. During an observation on 8/20/2025 at 7:32 AM, RN L was removing R52's medications from their packages with her bare hands and placing them into a medication cup. After all the medications were prepared, RN L administered them to R52. R3 According to R3's MDS dated [DATE], diagnoses included coronary artery disease, heart failure, hypertension, diabetes mellitus, stroke, hemiplegia, and depression. During an observation and interview on 8/20/2025 at 8:02 AM, RN L was removing R3's medications from their packages with her bare hands and placing them into a medication cup. After all the medications were prepared, RN L administered the medications to R3. RN L stated, I used hand sanitizer before I touched each pill so I should be able to use my bare hands. Resident-Shared Equipment During an observation on 8/20/2025 at 7:05 AM Registered Nurse (RN) L took R27's blood pressure using a blood pressure cuff and checked level of oxygen using a pulse oximeter then placed both into a resident-shared equipment basket for storage. Neither piece of resident-shared equipment was cleaned after use. One other blood pressure cuff was in the basket and the cuff used on R27 was placed on top of it after use. No disinfecting wipes were seen on the cart. During an interview on 8/20/2025 at 10:50 AM Corporate Infection Control (IC) JJ stated, For infection control prevention, resident-shared equipment should be cleaned between each resident. (Name of disinfectant) wipes are kept on each piece of equipment or cart that is used regularly on rotation with residents. Bare hands should not be used to take pills out of their package for infection control purposes either. Review of Centers for Disease Control and Prevention (CDC) dated March 20,2024, revealed, .Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities .EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .EBP are indicated for residents with any of the following: o Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or o Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO .Effective Date: April 1, 2024 . Resident #3: Review of an admission Record revealed Resident #3 was a female with pertinent diagnoses which included diabetes, paralysis affecting right dominant side, difficulty in walking, weakness, joint inflammation, and need for assistance with personal care. During an observation and interview on 08/18/2025 at 12:11 PM, Resident #3 was observed lying in her bed, she was dressed, she had on non-slip socks. Resident #3 reported the provider came in on Monday last week (8/11/25) and Resident #3 reported she informed them of the wound on her right heel. Resident #3 reported the wound provider came on Friday (8/15/25) and she had debrided the wound. Resident #3 reported she had asked the nurse multiple times on Saturday (8/16/25) about changing her dressing but she never got it changed until 4:00 PM and then it was not done again. Resident #3 reported she had only one dressing change on Saturday, it was freshly debrided wound (removed damaged tissue) and Resident #3 reported how important it was for her to get her dressing changes. Resident #3 reported she had only one dressing change on Sunday as well. Resident #3 reported she had asked about a dressing change around 10:00 AM on Sunday and it was not done until 6:00 PM. Resident #3 reported she had asked the nurse today prior to her shower at 09:30 AM and the dressing still had not been changed. Review of HCP Visit dated 8/11/25 at 11:56 AM, revealed, .Report of new wound to her R (right) ankle.R medial (middle) ankle wound discussed with nursing staff.wound specialist to be seen this week. Recommend Medi-honey application daily until evaluation. Review of the order for the dressing change dated 8/15/25 revealed the dressing was to be changed during the day (6 AM to 2 PM) and evening shifts (2 PM to 10PM). During an observation on 08/19/2025 at 2:03 PM, Resident #3 did not have an enhanced barrier precautions (EBP) sign on the wall or door to her room to indicate she had a diagnosis which required the staff to utilize personal protective equipment (PPE) during high contact resident care, such as showering, transferring, wound dressing changes, etc. Resident #5: Review of an admission Record revealed Resident #5 was a male with pertinent diagnoses which included dementia, paralysis left side and right side, stroke, and tube feeding. During an observation on 08/18/2025 11:14 AM Resident #5 was observed in his room seated in his wheelchair, he had a gown on still, enhanced barrier precautions (EBP) sign on the door to his room. During an observation and interview on 08/18/2025 at 2:03 PM, Resident #5's Family Member (FM) UU reported his water flush was leaking over his brief and down the front of him. CNAs BB and U entered the room donned with gloves and no gowns to assist in preparing Resident #5 to be transferred to his bed for a brief change and clothing change. Resident #5 was coughing up his phlegm and the wife suctioned him . CNA R entered the room and she did not don a gown only gloves. LPN E ensured the resident's flush and tube feeding tubes were capped off at the juncture. LPN E was observed to not have gloves or a gown on as well as had approximately 2 inches long painted fake fingernails. LPN E removed the bags of tube feeding and the fluid and disposed of them. Resident #5's left leg was up and straight out, supported on his foot pedals, which had padding on each side of his lower leg and foot area. LPN E lowered his wheelchair left leg footrest. CNA BB and CNA R hooked him up to the back side of the hoyer and CNA U hooked him up to the front side, slowly raised him up to lower him to the bed, he cried out and resident replied he was a little stiff. CNA U removed his call light and oxygen prior to transferring him to his bed. Resident #5 was slowly lowered to the bed, his body was unparallel to the bed and had to be adjusted as he was slowly lowered to the mattress. CNA U assisted his head and neck to the pillow, CNA R supported his legs. In an interview 08/20/2025 at 2:13 PM, CNA R reported the EBP sign on the door indicated the staff would wear a gown and mask when hands on care were provided to the resident. In an interview on 08/20/2025 at 2:16 PM, CNA G reported EBP were used when providing hands on care to a resident. CNA G reported if I went into the room to give him his lunch or bring him water, PPE was not required. CNA G reported if he were to raise him up in the bed or transfer him he would have to don PPE. In an interview on 08/20/2025 at 9:43 AM, Corporate Infection Preventionist (CIFP) JJ reported if a resident had a chronic wound the resident would be placed on EBP but if it was a small shearing or superficial the resident would not be placed on EBP. CIFP JJ reported typically a resident was placed on EBP when a pressure ulcer or ulcer wound was discovered. CIFP JJ reported Resident #3 should have been placed on EBP on 8/11/25 when the ulcer was discovered. In an interview on 08/20/2025 at 9:53 AM, CIFP JJ reported when direct contact care was to take place, a gown and gloves would be donned prior to providing care. CIFP JJ reported the last time staff was educated on EBP was in July 2025.

Based on observation and interviews, the facility failed to maintain a safe, functional, sanitary, and comfortable environment. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living.Findings Include:On 8/18/25 at 10:59 AM, observation of the kitchen hand sink, near the dish machine area, found that the soap and the paper towel dispenser for the hand sink are on the opposite wall as the hand sink. Further observation found the paper towel dispenser over an area used for drying clean pots, pans, and utensils.On 8/18/25 at 1:25 PM, An interview with Maintenance Director (MD) I found that the facility is in good repair, however there are a few roof leaks that pop up when the rain gets heavy. MD I has been bidding out the repairs to get them complete, but they have not been finalized and no timeline for the complete repairs have been set. On 8/18/25 at 1:47 PM, Observation of the Clean Utility storage found clean and sanitary items stored on the floor. When asked how items get on the floor. The MD I stated that staff get in a hurry and end up dropping items as they grab what they need. On 8/18/25 at 1:50 PM, Observation of the South Hall spa room found an accumulation of debris under the mat of the shower bed. Further review found what looked like flakes of skin, with paper and plastic debris. An interview with MD I found that staff do not use the shower bed often.On 8/18/25 at 2:15 PM, Observation the East Hall Clean linen room found items stored on the floor, MD I stated the room would get cleaned nightly. On 8/18/25 at 2:35 PM, Observation of the Mechanical Room door, in the boiler room, found a gap underneath the door that would allow for pest entry. On 8/19/25 at 9:45 AM, A revisit to both Spa rooms on the South Hall found clean and sanitary linens and briefs stored on the short shower wall that separates the shower and the sink area, leaving them open and exposed to contamination. On 8/19/25 at 9:47 AM, observation of the hall near resident room [ROOM NUMBER], found a large trash container in the middle of the hall catching dripping water from the ceiling. Further observation found multiple tiles wet with a few tiles that had started falling apart due to excess moisture. On 8/19/25 at 10:55 AM, observation of the love seat near the courtyard entrance found an increased accumulation of debris and trash under the cushions. A dirty folded up dollar bill, a used band-aid, and a dirty wadded up Kleenex was among the dirt debris. On 8/19/25 at 11:00 AM, observation of the Spa room on the North Hall found clean and sanitary linens stored on the half shower wall, leaving them open and exposed for contamination. On 8/19/25 at 11:05 AM, Observation of the double doors used for deliveries and a employee entrance, found a visible gap and space where the doors meet at the bottom middle, allowing pests to freely enter the building.On 8/19/25 at 11:31 AM, An interview with MD I found that with all the heavy rain last night he has been attending to the roof leaks that have been occurring and trying his best to stay on top of them while waiting for needed repairs. MD I stated he was able to get the leak to stop near resident room [ROOM NUMBER], but it will still need a solid repair to last.On 8/19/25 at 1:55 PM, Observation of the therapy room found that the parallel bars were loose in the brackets that bring the bars closer together or further apart. The surveyor was able to move them back and forth with no way to steadily hold them in place. An interview with Therapy Program Manager NN found that staff and residents generally just use the outside of the bar, but that the screws holding the bars width from each other are stripped and do not tighten well. Further review of therapy equipment found that the right pedal of the arm bike slowly comes off as residents use it and staff must keep trying to retighten the pedal so that residents can use it properly over the course of the day.

Based on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) Level II Exemption Form 3878 (Mental Illness/Intellectual Disability/Related Condition Exemption Criteria Certification Level II Screening) was completed timely for 1 resident (Resident #2) of 3 residents reviewed for PASARR, resulting in the lack of the local Community Mental Health Services Program (CMHSP) to have a complete picture of the resident status.Findings include:Resident #2Review of an admission Record revealed Resident #2 was a female, with pertinent diagnoses which included: unspecified dementia (a group of symptoms that affect memory, thinking, and problem solving that interfere with daily life), unspecified severity, with other behavioral disturbance; major depressive disorder, recurrent, unspecified; delusional disorders; and generalized anxiety disorder.Review of Resident #2's Preadmission Screening (PAS)/Annual Resident Review (ARR) Level I Screening form dated 1/31/25 revealed, .Section II Screening Criteria.1. X Yes The person has a current diagnoses of X Mental Illness or X Dementia 2. X Yes The person has received treatment for X Mental Illness or X Dementia 3. X Yes The person has routinely received one or more prescribed antipsychotic or antidepressant medications within the last 14 days.DISTRIBUTION: If any answer to items 1 - 6 in SECTION II is Yes, send ONE copy to the local Community Mental Health Services Program (CMHSP), with a copy of form DCH-3878 if an exemption is requested.A review of Resident #2's medical record on 8/19/25 at 10:13 AM revealed no form DCH-3878 exemption was found.In an interview on 8/20/25 at 8:41 AM, [NAME] President of Clinical Services (VPCS) JJ was requested to provide evidence that a Level II Exemption Form 3878 was completed for Resident #2.In an interview on 8/20/25 at 1:36 PM, VPCS JJ reported the Level II Exemption Form 3878 was not completed by the physician when it was due because the form hadn't pulled over in the computer for him to sign it at that time. VPCS JJ reported it was the responsibility of the Social Worker to make sure the correct forms were in place. VPCS JJ reported she did not know what happened with Resident #2's form. VPCS JJ reported Resident #2's Level II Exemption Form 3878 was completed on 8/20/25.The Social Worker was not available for interview during the survey period of 8/18/25 - 8/20/25.

Based on observation, interview, and record review the facility failed to provide ADL (activities of daily living) care, to include nail care, to a dependent resident in 1 (Resident #36) of 4 residents reviewed for ADL care, resulting in the potential for Resident #36 to experience feelings of embarrassment and diminished self-esteem.Findings include:Resident #36Review of an admission Record revealed Resident #36 was a male, with pertinent diagnoses which included: spastic quadriplegic cerebral palsy (a severe form of cerebral palsy, a movement disorder, that affects movement in all limbs) and unspecified intellectual disabilities.Review of a Minimum Data Set (MDS) assessment for Resident #36, with a reference date of 6/10/25 revealed a Staff Assessment for Mental Status indicating Resident #36 had a problem with both short-term and long-term memory. Further review of said MDS revealed Resident #36 was dependent on staff for Shower/Bathe self (The ability to bathe self, including washing, rinsing, and drying self.), and Personal hygiene (The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands.)Review of Resident #36's Care Plan revealed a focus of (Resident #36) has altered functional mobility and ADL's related to: he (sic) diagnosis of Spastic Cerebral Palsy.He can be combative with care and has episodes of restlessness and agitation and has hx (history) of placing hands in brief when incontinent. with care planned interventions which included ADL's: Dependent for ADL's with a date initiated of 2/17/22.During an observation on 8/18/25 at 11:26 AM, noted Resident #36 was seated in his room in his specialized wheelchair. Resident #36's fingernails, specifically the thumb and index finger on the right hand, were caked with a black substance underneath the nails.During an observation on 8/19/25 at 8:26 AM, Resident #36 was seated in his specialized wheelchair across from the nurses' station. Resident #36's fingernails, specifically the thumb and index finger on the right hand, remained caked with a black substance underneath the nails.During an observation and interview on 8/19/25 at 3:00 PM, Licensed Practical Nurse (LPN) D observed Resident #36's fingernails with this surveyor. LPN D confirmed that Resident #36's fingernails, specifically the thumb and index finger on the right hand, were caked with a black substance underneath the nails.During an observation and interview on 8/20/25 at 8:58 AM, LPN D observed Resident #36's fingernails with this surveyor. LPN D confirmed that Resident #36's fingernails, specifically the thumb and index finger on the right hand, were caked with a black substance underneath the nails. LPN D reported it was embarrassing to her that Resident #36's nails were still dirty.Review of Resident #36's Shower Assignment Task report revealed Resident #36 received a shower on 8/20/25 documented at 3:06 AM.In an interview on 8/19/25 at 8:42 AM, Family Member (FM) GG reported Resident #36 did not refuse cares (referring to ADL cares).In an interview on 8/19/25 at 10:42 AM, Certified Nurse Aide (CNA) M reported it was important to clean Resident #36's nails because he would dig in his brief with his hands. CNA M reported cleaning of fingernails was part of giving a resident a shower.In an interview on 8/19/25 at 12:47 PM, CNA AA reported nail cleaning and clipping, if needed, was part of what was done when a resident received a shower. CNA AA reported nails should also be cleaned in between shower time if they are dirty. In an interview on 8/19/25 at 3:16 PM, Registered Nurse (RN) EE reported Resident #36 did not refuse ADL cares.

Based on observation, interview and record review, the facility failed to provide individualized activities designed to support the psychosocial well-being of 1 of 18 Residents (Resident #1) reviewed for activities, resulting in a potential for feelings of social isolation, loneliness, anxiety and boredom.Findings include: Review of Revolutionizing the Experience of Home by Bringing Well-Being to Life: The [NAME] Alternative Domains of Well-Being, Copyright 2012, Rev. 2020, revealed The [NAME] Alternative defined one domain of wellness as Connectedness- the state of being connected; alive .engaged, involved . without meaningful interactions the individual can become disconnected .develop loneliness, helplessness, and boredom.Resident #1Review of an admission Record revealed Resident #1 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Alzheimer's disease (a progressive disease that primarily affects memory, thinking and behavior), major depressive disorder (persistent sad mood that impacts daily life) and adjustment disorder (mental disorder defined by maladaptive response to psychosocial stressor).Review of a Minimum Data Set (MDS) assessment for Resident #1 with a reference date of 6/11/25, revealed a Brief Interview for Mental Status (BIMS) score of 6/15 which indicated Resident #1 was severely cognitively impaired. The MDS reflected Resident #1 experienced wandering daily during the 14-day assessment period and her family member expressed it was somewhat important to the resident that she do things in groups of people, pursued her favorite activities, listen to music, participated in religious activities, go outdoors, and spent time around pets. Further review of this assessment revealed Resident #1was easily distractible and experienced disorganized thoughts.Review of a Care Plan for Resident # 1 with a reference date of 9/9/24, revealed a focuses/goals/interventions of: 1. Focus: At Risk for decreased Activity pursuits related to: anticipated dementia worsening. (Resident #1) enjoys listening to music and being outside. She will participate in some activities with coaxing but loses interest quickly and leaves. Goal: Will participate in activities of their choice which include: (sic) relaxing outside and listening to music, some social activities like bingo and birthday parties. Interventions: .Assist to and from activities of choice.Assist with reminiscing items, books and music.Provide assistance with outdoor patio activities weather permitting.record activity attendance and analyze as needed to continue to evaluate a change in need. 2. Focus: Resident has the potential for psychosocial distress.Goal: Adjustment to nursing home placement as evidenced by participation in daily routine and socialization with peers.Interventions.with presentation of behavioral and psychological symptoms of dementia, attempt to use social interventions such as tactile stimulation, sorting objects, appropriate touch, music and sounds to increase stimulation of the senses and to decrease negative behaviors. Review of Recreational Engagement records for Resident #1 with a reference date of 5/1/25-8/19/25 revealed Resident #1 was recorded as participating in 1 outdoor activity and 6 religious activities during the 15-week period. No pet visits or involvement in music activities were documented for Resident #1. The record also contained no documentation of Resident #1 participating in tactile stimulation or sorting activities. Conflicting information was noted in Resident #1's Recreation Engagement records, including documentation of refusal and simultaneous documentation of participation in the same activity (same date/time), duplicate entries of participation in the same activity at the same time, and participation in group activities that were not offered on those days per the Activity Calendar.In an interview on 8/19/25 at 1:38pm, Certified Nursing Assistant (CNA) T reported Resident #1 wandered through the halls of the building throughout the entire day. CNA T stated she's on the move from the moment she gets up. CNA T reported she assisted Resident #1 to group activities, but she usually could not focus her attention on the activity.In an interview on 8/20/25 at 9:38am, Clinical Psychologist (CN) KK reported Resident #1 was very impulsive and could not focus her attention on tasks of interest for more than 90 seconds, as a result, Resident #1 needed personalized interventions to optimize her ability to engage in activities.During serial observations on 8/19/25, Resident #1 self-propelled her wheelchair through the halls of the facility at 9:23am, 10:13am, 11:36am, 1:57pm, 2:41pm and 4:16pm. It was noted that Resident #1 did not have dementia sensory items as she attempted to engage in her surroundings.During serial observations on 8/20/25, Resident #1 self-propelled her wheelchair through the halls of the facility at 9:52am, 1:46pm, 2:21pm, 2:59pm, and 4:02pm. It was noted that Resident #1 did not have access to tactile sensory items or music of her choosing as she attempted to engage in her surroundings.No social interactions between Resident #1 and staff, residents or visitors were observed as she propelled her wheelchair around the building on 8/18, 8/19, and 8/20/25.In an interview on 8/20/25 at 2:22pm, Activity Director (AD) P reported Resident #1 was not able to consistently maintain her attention on most group activities and was not scheduled to receive 1:1 activity visits on a regular basis. AD P confirmed that if Resident #1 was present in a group activity for any length of time, it was recorded in her Recreational Engagement Record, but she usually only stayed a minute or two. AD P reported she had not received training related to activity programming for residents with severe cognitive impairments and it was difficult to ensure their activity needs were met. AD P stated we offer her group activities but who knows if she likes them. AD P reported she provided Resident #1 a baby once, thinking she could carry it with her as she wandered around the facility. When queried about Resident #1's response to the baby, AD P stated she held it for a minute but then gave it back, so I guess she didn't like it. AD P reported Resident #1 spent most of her time just self-propelling her wheelchair around the facility, making her rounds. AD P reported she had not completed the training to become a certified activity professional, was new to the profession, and needed support as she learned how to meet the needs of residents with dementia.

Based on observation, interview, and record review, the facility failed to ensure adequate care and appropriate treatment for 2 residents (Resident #3 and Resident #16) of 18 sampled residents reviewed for quality of care, resulting in the potential for development of new wounds and infection. Findings include: Resident #3: Review of an admission Record revealed Resident #3 was a female with pertinent diagnoses which included diabetes, paralysis affecting right dominant side, difficulty in walking, weakness, joint inflammation, and need for assistance with personal care. Review of current Care Plan for Resident #3, revised on 3/26/24, revealed the focus, .Impaired skin integrity related to: She had a diagnosis that delay wound healing: Stage 3 kidney disease (kidney damage where the kidneys are not functioning optimally); congested heart failure; coronary artery disease; irregular heart rate; high blood pressure, and diabetes.admitted with a diabetic ulcer to her right heel that has closed and remains at risk to resurface - tx (treatment) order in place for protection only. with the intervention .Skin inspections with am/pm care and showering report abnormal to the charge nurse.SKIN: Heels elevated in bed as tolerated; Inspect heels with care and report to charge nurse as indicated; Sage boots on when in bed.During an observation and interview on 08/18/2025 at 12:11 PM, Resident #3 was observed lying in her bed, she was dressed, she had on non-slip socks. Resident #3 reported the provider came in on Monday last week (8/11/25) and Resident #3 reported she informed them of the wound on her right heel. Resident #3 reported the wound provider came on Friday (8/15/25) and she had debrided the wound. Resident #3 reported she had asked the nurse multiple times on Saturday (8/16/25) about changing her dressing but she never got it changed until 4:00 PM and then it was not done again. Resident #3 reported she had only one dressing change on Saturday, it was freshly debrided wound (removed damaged tissue) and Resident #3 reported how important it was for her to get her dressing changes. Resident #3 reported she had only one dressing change on Sunday as well. Resident #3 reported she had asked about a dressing change around 10:00 AM on Sunday and it was not done until 6:00 PM. Resident #3 reported she had asked the nurse today prior to her shower at 09:30 AM and the dressing still had not been changed. Note: no sage boots noted out in the room or on Resident #3. Review of the order for the dressing change dated 8/15/25 revealed the dressing was to be changed during the day (6 AM to 2 PM) and evening shifts (2 PM to 10PM). Review of Treatment Administration Record (TAR) dated August 2025, revealed, .Rt (Right) Heel: Cleanse with NS (normal saline) apply honey and calcium alginate (high absorbency wound dressing) cover every day and evening shift for Diabetic ulcer on heel. Review of documentation of treatment revealed the first treatment documented on 8/16/25 Day and documented twice a day each day on Saturday 8/16, Sunday 8/17, Monday 8/18. Note: No dressing change was noted as completed on the administration record prior to 8/15/25. Review of HCP Visit dated 8/11/25 at 11:56 AM, revealed, .Report of new wound to her R (right) ankle.R medial (middle) ankle wound discussed with nursing staff.wound specialist to be seen this week. Recommend Medi-honey application daily until evaluation. During an observation and record review on 08/19/2025 at 1:23 PM, Resident #3 had one sage boot on the seat of her wheeled walker over by the entry door and one on top of her bed. During an observation and interview on 08/19/2025 at 1:50 PM, Registered Nurse (RN) L reported she had a wound about half dollar size on her inner heel. When Resident #3 was queried, she reported the nursing staff had not put any sage boots on her feet since she discovered the wound on 8/11/25 during her shower. Resident #3 reported she had seen the podiatrist today and he had informed her she should have something in place to keep her heel off the bed. Resident #3 was looking in her closet and remembered she had a pair of sage boots in her closet, and she took them out and put the one on her right heel today. Resident #3 reported she doesn't have any pain with the wound due to her neuropathy but when it was debrided on Friday it did hurt. Resident #3 reported she received her dressing change last night at approximately 1:00 AM. Resident #3 reported she was not happy to be woken up at that time but was happy the dressing was changed. This writer observed the cleaning and dressing application performed by RN L. The wound was cleaned, treated with Medi honey (medical grade manuka honey product that promotes healing by drawing fluid from the surrounding tissue, helps to liquefy and remove non-viable tissue and helps to control bacteria and reduce inflammation), and calcium alginate pad, and covered with a foam dressing dated and initialed as 8/19/25. Resident #3 reported she asked the nurse on Sunday how many times it was ordered to be changed because she knew it was to be changed twice a day, and she was informed there was no order and she didn't change it until 6:00 PM. Resident #3 reported the provider came in on Monday 8/11/25 and looked at the wound on her right heel but there was no order for treatment until after the wound provider came in on Friday (8/15/25) as she had no treatment and/or dressings applied from 8/11/25 until 8/16/25. In an interview on 08/19/2025 at 1:50 PM, RN L reported the nurse documented a yes, no or refused when they go in to document for the treatment. RN L reported the nurse had to put an answer in there in order to move on. RN L reported the CNAs (certified nursing assistants) did not complete shower sheets for resident skin observations when assisted the resident with a shower. RN L reported if something was discovered, the CNAs verbally informed the nurses of any issues. RN L reviewed the order for the wound treatment and indicated the wound dressing change was to be completed during the Day-- 6 AM to 2 PM, and Night - 2 PM to 10 PM.Review of Kardex for Resident #3 reviewed on 08/20/2025 at 10:33 AM, there was no intervention for sage boots on the Kardex. In an interview on 08/20/2025 at 10:38 AM, RN L reported skin assessments were to be done every week, changes with the care plan can be done by the nurse such as adding new interventions and focus for the resident. RN L reported there was a binder at the nurse's station which had guides on what to do if had a certain thing like a new skin wound. RN L reported the guide helped the nurse completed the required tasks for the new concern like modifying the care plan, assessments, etc. Review of Skin Assessments revealed Resident #3 had her last one completed on 8/5/2025. Note no skin assessment was completed on 8/11/2025 when Resident #3 reported she discovered the wound on her right heel. No Skin Assessment was completed on 8/18/25. Resident #16: Review of an admission Record revealed Resident #16 was a male with pertinent diagnoses which included muscle weakness, and cognitive communication deficit (communication impairment stemming from difficulties with thinking processes like attention, memory, and reasoning, and problem solving). Review of Care Plan for Resident #16 initiated on 4/17/25, revealed the focus, .Altered functional mobility and ADL's (activities of daily living) . with the intervention .Dependent for ADL's.AMBULATION: Non-Ambulatory.Bed Mobility: assist of two.Review of Interdisciplinary Documentation dated 7/23/25 at 3:32 PM, revealed, .A review of MDS based skin risk assessment scales, reveal the following risk factors are present for the development of skin impairment: GG-(Resident #16) has bilat impairment of legs and 1side of upper extremities.Dependent for toileting and transfers via mechanical lift. He is non ambulatory and is not able to propel self in wheelchair. H- Always incontinent of bowel and bladder, wears briefs for dignity and containment.M- Has thin and fragile skin that can bruise and tear easily. Currently has MASD (moisture associated skin damage) to buttock and groin. Interventions in place to mitigate risk of skin impairment include Pressure relieving mattress, pressure relieving wheelchair pad, skin inspections with bathing and daily cares, skin barrier cream with incontinence care. During an observation and interview on 8/20/25 at 9:05 AM, Resident #16 was in bed awake. Resident agreed to have brief change and observation for abnormal skin issue(s). Certified Nursing Assistant (CNA) K donned appropriate PPE provided care necessary for a brief change. Observation of Resident #16's penis and foreskin did not reveal any outward visible signs of infection as evb (evidence by) no discharge, odor, redness, raw or open skin. The foreskin was pulled back and cleaned by CNA K appropriately. Resident #16 was rolled onto his right side for observation of his buttocks, coccyx, and sacrum. CNA K spread the resident's buttock cheeks apart to clean the area and exposed an open area approximately the size of a quarter between the cheeks. The open area was red within the opening and covered in a sticky white cream-like substance. CNA K stated, That looks like a sore. You have to spread his buttock cheeks apart to find it.In an interview on 08/20/2025 at 2:12 PM, Corporate Infection Preventionist JJ reported Resident #16 had an abrasion on his upper left butt cheek /split. Corporate Infection Preventionist JJ reported a skin assessment was not completed, a progress note was not entered for it from a nurse. Corporate Infection Preventionist JJ reported the CNA would verbally tell the nurse and the facility did not have the CNAs complete shower skin sheets for residents. Corporate Infection Preventionist JJ confirmed the last skin assessment was completed on 8/5/25.In an interview on 08/20/2025 at 2:15 PM, RN L reported she received report the nurse this morning noticed the open area on his bottom when she observed care for Resident #16. In an interview on 08/18/2025 at 1:45 PM, Family Member (FM) OO reported Resident #16 had messy pants and had been waiting for staff to come change him since 1:20 PM, FM OO reported the staff member had told her they had to get another staff member to transfer him from his wheelchair to the bed. FM OO reported he had loose stools earlier when he was changed to get up out of bed. FM OO reported when the CNAs come into his room and check him, they check the front of his brief and it would be dry because when he was lying down it runs to the back and the back would be soaked on him, like it was earlier, but they don't check the back of the brief when they check him. FM OO reported a few days ago, green pus was observed coming out of Resident #16's penis. FM OO reported he had a urinary trach infection recently and got antibiotics for it, but FM OO wondered if it was back or never left.

This citation pertains to intake MI00134009, MI00136319, and MI00132467. Based on interview, and record review, the facility failed to provide an environment free from verbal abuse from staff two residents (R38 and R73) and to protect a vulnerable resident from non-consensual sexual act by a resident (R226) who had documented inappropriate sexual behaviors for one resident (R11) of three residents reviewed for abuse, resulting in abuse, continued fear, humiliation, and the likelihood of mental anguish. Findings include: According to the Minimum Data Set (MDS) 6/5/2023, R38 scored 15/15 (cognitively intact) on her BIMS (Brief Interview Mental Status) and required a wheelchair for mobility. The resident did not exhibit behaviors including verbal/communicated outbursts. Diagnoses included cancer, stroke, anxiety, and depression. During an interview on 6/28/23 at 9:53 AM, Licensed Practical Nurse (LPN) NN stated, I did not do anything wrong. I just opened my mouth. It happened the end of December (2022). (R38) parked in front of my medication cart and argued with me about the number of pills I gave her. I told the CNAs (Certified Nursing Assistant) at the desk to get off their butts and do something. I was angry because the CNAs were on their phones and not doing anything. I told the CNAs if they did not do something to help me, I would punch (R38) in the face but i would not do that. (R38) has a lot of mental issues being the youngest in with elderly. This happened at 10 (PM) at night at the end of my shift. I did not say anything to the Administrator (Nursing Home Administrator (NHA) A). I worked half my shift the next day with (R38) before I was suspended. I knew I had spouted off my mouth to (R38). During an interview on 6/28/23 at 11:19 AM, CNA CC stated, I witnessed (R38) was upset. (LPN NN) kept pushing (R38) away. (R38) kept ramming her wheelchair into the medication cart. At first (LPN NN) was calm. The CNAs kept taking (R38) to her room, but she kept coming back to the medication cart. (LPN NN) told us CNAs to get (R38) away from her before she hit her in the face. I wrote a witness note. I forgot who the abuse coordinator is. I would report abuse right away. I reported this incident to the DON (Director of Nursing) that night who was agency. During an interview on 6/28/23 at 11:27 AM, CNA EE stated, I was working that night the incident happened. (R38) was coming up to the station asking about medications. She was upset, kicking the medication cart. The nurse finally exploded. The nurse cussed at (R38). During an interview on 6/28/23 at 11:40 AM, CNA M stated, During my rounds, (R38) was telling (LPN NN) about her medications. (LPN NN) told her she got three pills, not four. (R38) refused to leave. (LPN NN) started calling (R38) a B**** (curse word) and acting liking a F****** (curse word) 2-year-old. The LPN shoved (R38) in her wheelchair into the door. (R38) looked shook up. That is when I told (LPN NN) she could not do that. I grabbed (R38's) chair and felt she was in danger. The facility let (LPN NN) finish her shift that night and then back the next morning to work part of her shift with (R38). During an interview on 6/28/2023 at 12:28 PM, NHA A stated, I am not the abuse coordinator, the DON is. For the incident between (R38 and LPN NN) it occurred on 12/29 (2022). (LPN NN). The nurse was a good nurse, she just said and did some things she should not have. During an interview on 6/28/2023 at 1:48 PM, R38 communicated that on the day of the incident, (LPN NN) called her names and pushed her into a door. She stated, It made me feel bad. I told her she was stubborn and so was I. 41424 Resident #11: Review of an Admission Record revealed Resident #11 was a female with pertinent diagnoses which included unsteadiness on feet, mood disorder with depressive features, difficulty walking, muscle weakness, dementia without behavior disturbance, cognitive communication deficit (impairment in organization/thought, sequencing, attention, memory, planning, problem solving and safety awareness), dysphagia (impaired ability to understand or use the spoken word), depression, and stiffness in right hand. Review of current Care Plan for Resident #11, revised on 4/27/22, revealed the focus, .(Resident #11) has the potential for psychosocial distress related to anticipated dementia progression. She will look for and ask for her mother as she walks about, (Resident #11 is pleasantly confused yet agreeable to suggestions to participate in activities .She requires cueing and reminding of why she needs things or where things are .Followed by (Psychiatry Service Provider) .(Resident #11) often exposes her breasts and will touch and lick them in public areas, she will also rub items on her breasts. (Resident #11)'s husband passed away recently . with the intervention .Allow time and opportunities to express feelings. (Resident #11) will repeatedly ask staff what she should do or where to go, often looking for someone to talk to although she does not interact much with other residents as she walks around .Behavior monitoring as identified on the individualized log; utilize log for patterning and intervention revision as indicated . Review of the 5 Day Investigation Summary for facility reported incident on 10/9/22, revealed, .On 10/9/22: At approximately 9:10 AM, CNA (CNA C) observed (Resident #226), with his hand on top of (Resident #11)'s clothing. Touching, and squeezing her left breast. (Resident #11)'s eyes were closed and she did not have any grimacing on her face and was not making any noise. (CNA C) immediately told him to stop. Once she separated them she assisted him in his wheelchair to his room. (CNA C) notified (RN TT) of what she had observed. CNA C also went back to (Resident #11) to assure that she was ok .Staff interviews: (CNA C), CNA: I was working on North Hall the day of the incident. (Resident #226) was sitting in his wheelchair, (Resident #11) was sitting in a chair in the breezeway, outside of the dining room. (Resident #226) had his hand on her breast (left) on the outside of her clothing squeezing her breast. She appeared to be sleeping as her eyes were closed. She had no expression on her face, and was making no sound, she was quiet. I told (Resident #226) to get his hands off her boobs, he said OK, I then took him to his room and told the nurse, (RN TT). I also told (Housekeeper UU) about it, she headed to the other hall to tell the other nurse (LPN VV). I did not speak to (Resident #226) about it after that. When I took him to his room via wheelchair, (Resident #11) was still sitting in the chair in the breezeway. When I came back, I asked (Resident #11) if she was okay and she said yes .(Director of Nursing B), LPN CCC .:I was present at the facility at the time of the incident. (LPN VV) came to my office and stated that (Resident #226) was inappropriate with (Resident #11), the residents were separated, (Resident #11) was sitting in the chair outside the dining room, and I was told that (CNA C) had observed (Resident #226) touching (Resident #11)'s boobs .I know that the police were called, and he interviewed CNA C and (Resident #11). He also spoke to (Resident #226) whom told the police officer that (Resident #11) made him do it. I informed (LPN VV) to place (Resident #226) on 15-minute checks .Resident Interviews: On 10/10/22 (Resident #226) was interviewed by (Corporate Clinical Nurse (CCN) SS), RN (Resident #226) said that he did not recall the incident at all. He then asked (CCN SS) why she was asking about the incident since an officer had already come to speak with him regarding the incident. (CCN SS) asked if he remembered that, then did he remember touching the other resident. (Resident #226) said, I don't know why I did it, I think I just blacked out. He then became agitated and told her that he did not want to talk about it. (CCN SS) let him know that the IDT is suggesting that he be assisted back to his room after meals in an effort to reduce the risk of another incident such as this one from happening again, he did agree with this. It was suggested that he attend activities and he said he would not do that and only wants to watch TV in his room. (Resident #11) has difficulty in communicating, had appeared to have been sleeping while the incident occurred .Immediate Action: (Resident #11) and (Resident #226) were immediately separated from each other. Notifications were made to the appropriate parties and the residents were each placed on 15-minute checks. (Resident #11)'s skin was assessed with no marking or bruising noted. On 10/10/22 after an investigation was completed .(Resident #226) and (Resident #11) were removed from 15-minute checks and it was added to (Resident #226)'s plan of care that he be assisted by a staff member to his room after meals from the dining room. (Resident #226) was evaluated by Psych Services on 10/11/22, and they recommend that his antidepressant be changed to Zoloft and that it may help to alleviate his inappropriate sexual behaviors. The provider agreed and an order was obtained to initiate Zoloft. (Resident #226) was a agreeable to this change .Conclusion: This event was determined to be an isolated event. Both residents continue to function at their baseline psychosocially and physically. A complete investigation was conducted and with staff direct supervision, this event could not have been predicted .(Family Member LL), son of (Resident #11) requested that we send a referral to another facility to mitigate the ability for this incident to be repeated. Social services will continue to follow up with each resident weekly x 2 weeks to assess for psychosocial changes from baseline . Review of Interdisciplinary Documentation dated 10/10/2022 at 12:17 PM, revealed, .(Resident #11) continues on q15min checks. She went to the dining room for breakfast with staff direction .She was then assisted to her room where she is currently resting in her chair. CNA just reported to this nurse, that when she went to check on (Resident #11), she had her shirt lifted up and was licking her breast. (Resident #11) has done this in the past, but has not been observed doing it in some time. She was redirected and her shirt tucked into her pants. Skin check completed this shift and charted under assessment tab. (Resident #11) denies pain when asked . Review of Interdisciplinary Documentation dated 10/10/2022 at 3:18 PM, revealed, .I met with (Resident #11) in her room today and asked how she was and she would not engage in conversation or eye contact, which is not abnormal for her given her confusion and altered cognition as she has advanced dementia. She was mumbling nonsensical things. I re-approached later and she did smile at me and when I asked how she was she said fine. No pain based on behavioral pain score and no reason to believe she has any recall of yesterday's incident when another resident touched her inappropriately. post incident yesterday 15 minute checks were started and have since been resolved . Review of Interdisciplinary Documentation dated 10/11/2022 at 11:52 AM, revealed, .I met with (Resident #11) today in her room as she was eating breakfast on her own and she was alert and not able to answer questions appropriately . Review of Interdisciplinary Documentation dated 10/11/2022 at 1:43 PM, revealed, .(Resident #11)'s son and POA, along with his wife and daughter came into the facility today to visit (Resident #11) .he was concerned that (Resident #11) had another resident touch her and wanted to know what we were doing to prevent it from happening again. I let him know we had interventions in place to mitigate the risk of another resident to resident interaction, and that we did notify the police as well as the state .I also let him know that I could not divulge too much information about another resident but that other residents here are here for a reason and may not all be cognitively intact and aware as others. The fact that I informed him that we notified the Police and (Survey Authority), did seem to ease his mind some but he did request that a referral be sent to another facility in the area (Local LTC/long term care). SSD aware and a referral will be sent. He and his wife then asked what if we want to press charges and we let them know that they have that right to do so. He voiced some frustration that a message was left regarding the concern and he called back to the facility to determine what all happened and that a return call with full details was not provided, we told him we understood his concern and would address it. No other questions at that time . Resident #226: Review of an Admission Record revealed Resident #226 was a male with pertinent diagnoses which included dementia with behavioral disturbance, Alzheimer's disease, sleep disorders, alcoholic cirrhosis of liver, depression, difficulty in walking, heart failure, muscle weakness, and kidney disease. Review of a Minimum Data Set (MDS) assessment for Resident #226, with a reference date of 2/20/23 revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated Resident #226 was moderately cognitively impaired. Review of current Care Plan for Resident #226, initiated on 3/12/19, revealed the focus, .Has a history of inappropriate sexual comments towards staff. History of unwanted touching interactions with others requiring education and reminders of maintaining appropriate boundaries .He recently has an interaction with a female resident and requires frequent education and reminders of appropriate boundaries (10/5/20) .When wife visits he often requests to see her breasts - staff to provide privacy with their visits (6/3/21) . with the intervention .Increased supervision while out of his room (11/23/22) .PSYCHOSOCIAL: Refer to and document on the resident individualized behavior log (11/19/19) .Redirect if expressing inappropriate conversation or if escalating agitated; redirecting to his room to relax and watch TV .Supervise while out of his room per nursing discretion (10/10/22) . Review of Interdisciplinary Documentation dated 10/10/2022 at 3:12 PM, revealed, .I met with (Resident #226) in his room today related to the incident he had yesterday where he initiated contact in a sexual nature with another female resident. He said he did not recall the incident at all. He has a BIMS of 13/15 and diagnosis of dementia. He is able to verbalize his needs and preferences and is independent in his w/c with mobility. He then asked me why I was speaking to him about it as the Police officer came to his room yesterday after it happened and spoke with him about it. I asked if he remembered that then did and he maybe remember touching another resident and he again said no and then said to me I don't know why I did it, I think I just blacked out He then became agitated and told me he did not want to talk anymore and I let him know that the IDT is suggesting we assist to get him to his room from the DR in an effort to reduce the risk of another incident such as this one from happening again, he did agree with this. I suggested he attend activities and he said he would not do that and only wants to watch TV in his room. His care plan was revised with this preference and that staff will assist him to his room from the DR(dining room) . Review of Interdisciplinary Documentation dated 10/10/2022 at 3:21 PM, revealed, .Per IDT review of incident from yesterday 15-minute checks have been resolved . Review of Interdisciplinary Documentation 10/11/2022 13:52, revealed, .Psych services came into the facility to meet with (Resident #226) and we did inform her of his recent resident to resident interaction. She met with (Resident #226) today and stated she will send her report to the facility of the interaction . Review of Interdisciplinary Documentation dated 10/11/2022 at 1:54 PM, revealed, .I met with (Resident #226) in his room today after 1741 son met with him in his room. 1741 son came in to meet with 1741 and then went to (Resident #226)'s room. Staff noticed that he was not family of (Resident #226) and entered the room and he did leave the room. No specific words were identified at that time by staff, nor were there loud voices. I asked (Resident #226) what was said and he said they were just talking. I asked if he touched him or said anything mean or threatening to him and he said no not at all. I asked if he felt safe here and he said oh yes, I am fine here (Resident #226) is alert and orientated with a BIMS of 13/15. I asked what was said and he said nothing just small talk I then asked (Resident #226) about the incident he had on Sunday with 1741 and he responded with I thought we were done with this, why are you asking me again today I let him know that it was an incident that happened, and we need to review it. He said it was an accident; I didn't mean to I asked what was an accident and he would not respond. I asked if he remembered touching her and he said he did, and that it was wrong I will keep my hands to myself I asked how it went with psych services today and he would not respond. He then asked if he was in trouble with the police and I reminded him that the police were here and met with him already and he said he knew that . Review of Interdisciplinary Documentation dated 10/12/2022 at 09:21 AM, revealed, .Reviewed (Psychiatry Service Agency) recommendations regarding residents' sexual inappropriate behaviors with (Doctor). New orders to reduce lexapro to 5mg daily and start zoloft 25mg daily . Review of Interdisciplinary Documentation dated 10/20/2022 1:49 PM, revealed, .I met with (Resident #226) today to discuss the sexual interaction he had with another resident. I asked him how he was feeling about it and he stated that he would not do it again and does not know why he did it at all. (Resident #226) is escorted by staff to and from the dining room for meals as he enjoys eating in the dining room. Will follow up next week . Review of Interdisciplinary Documentation dated 10/24/2022 2:18 PM, revealed, .Met with (Resident #226) today regarding the sexually inappropriate incident that occurred with another resident. I asked (Resident #226) if he felt like what he did was appropriate and he replied no I should have never done that and I do not know why I did that. I asked him if he would do it again and he relied with a no answer. (Resident #226) wanted to end the conversation and said that he is fine and it will not happen again . Review of Police report dated 10/9/22 at 10:06 AM revealed, SUSPECT'S STATEMENT: R/O made contact with (RESIDENT #226) in his room .(RESIDENT #226) did make the comment that R/O looked familiar. R/O advised (RESIDENT #226) that R/O spoke to him years ago in regards to him inappropriately touching people. R/O ended the conversation with (RESIDENT #226) at that time .CONTACT WITH (FAMILY MEMBER LL) R/O made contact with (FAMILY MEMBER LL) over the phone. (FAMILY MEMBER LL) is (RESIDENT #11)'S son and emergency contact. R/O advised (FAMILY MEMBER LL) of the situation and that R/O would be sending a report to the prosecutor's office for review. (FAMILY MEMBER LL) was frustrated knowing that this is the second time that (RESIDENT #226) had assaulted her (sic) mother and nothing was done the first time by (Facility) or the prosecutor's office. CONTACT WITH (FAMILY MEMBER XX)R/O made contact with (FAMILY MEMBER XX) over the phone. (FAMILY MEMBER XX) is (RESIDENT #226)'S wife and emergency contact. R/O advised (FAMILY MEMBER XX) of the situation and that R/O would be sending the report to the prosecutor's office for review. R/O recommended to (FAMILY MEMBER XX) due to it being the second time (RESIDENT #226) had assaulted someone to possibly find better living accommodations for him. (FAMILY MEMBER XX) stated that she had nowhere to put him . Review of Interdisciplinary Documentation dated 11/23/2022 at 10:47 AM, revealed, .IDT met and reviewed past incidents that he has had at the facility. He has had recently had a resident to resident interaction that was sexual in nature. (Resident #226) is alert and orientated and his own person with a BIMS of 13/15. He is able to communicate his needs and is independent in his w/c with mobility. He spends the majority of his time in his room in his w/c but does attend the DR for meals and staff assist him to return to his room. His care plan was reviewed and revised to add that he have increased supervision while out of his room. DC (discharge) was discussed as well to home with his wife or a possible AFC (adult foster care). SSD will contact the wife and request a care conference and AAA (County agency for older adults) for assistance with DC to the community . In an interview on 6/28/23 at 10:17 AM, CNA C reported (Resident #11) was seated by (Resident #226) he was observed to be ambulating closer to her. CNA C reported she was aware of his history of inappropriately sexually touching other residents, and she reported she was assisting another resident but when she came back, he was seated next to Resident #11 with his hand placed on her breast. CNA C reported she directed Resident #226 to remove his hand from Resident #11's breast, separated them, and took him back to [NAME] hall (which was located at the back of the facility) and informed the nurse. CNA C reported Resident 11's room was down at the left end of the 100 hallway and she has always been down there. In an interview on 06/28/23 at 02:45 PM, Family member (FM) LL reported the recent incident was with the same person who had sexually assaulted his mother previously. FM LL reported his mother, (Resident #11) was taken to the hospital in 2020 for a rape kit to be performed on her because (Resident #226) had made sexual contact with her but his dad decided not to have the test done as she didn't remember and didn't want her to go through that. FM LL reported This absolutely devastated my dad, and the police were contacted. FM LL reported his mother was a very reserved person her whole life, would not be accepting of that happening to her and she started to flip her shirt up more, that was not something she did prior to all this happening. Review of Facility Reported Incident Report dated 10/2/2020, revealed, .Incident Summary: Review of statement from Previous Administrator RR revealed, .Writter (sic) walked into the day room and saw (Resident #226) looking up (Resident #11)'s dress while her brief was down to her ankles .Incident Description: On 10/02/2020 at 6:30 PM, Administrator walked past day room and saw (Resident #11) and (Resident #226) really close together. (Resident #226) was in his powered wheelchair sideways next to (Resident #11) who was sitting in a recliner in the day room with her walker in front of her. Administrator entered the room from the opposite side of the room and began to call out for (Resident #226) to back away from (Resident #11). As Administrator continued to call out to (Resident #226) he ignored and stayed put so Administrator continued to walk over to the two of them. When Administrator made his way to the 2 of them, Administrator saw (Resident #11) with her brief down to her ankles and (Resident #226) sitting next to her, and his arms extended towards her. Once next to them Administrator called for (Resident #226) to remove himself from the area again. (Resident #226) became startled and ran over (Resident #11)'s walker as he tried to remove himself. No contact was visualized at that time but based on the positioning of him and his arms, and how he became startled, and that her brief was off, and peri area exposed it is probable that contact was made at that time. Administrator then called for the staff 's assistance to dress (Resident #11) and take her back to her room. As staff took (Resident #11) back to her room, she told Administrator .that (Resident #226) just wanted to see her boobies. (Resident #11) was immediately placed on a one on one with the CNA .Administrator called the police and all responsible parties were notified. After talking to (Resident #11)'s husband about the incident, it was explained that no actual contact was visualized but based on scenario it was probable. He then asked that we send her out to the ER (emergency room ) to be examined. When (Resident #11) arrived at the hospital., the hospital and family called the administrator to verbalize (Resident #11) didn't remember the incident. The hospital had contacted her husband and he informed the ER staff that he didn't want her put through the exam since she couldn't recall the incident .Resident #226 went out to (Local Hospital) for a pysch eval .Nothing could be done and set-up transportation for the AM .Both residents were placed on one to one when they returned from the hospital . Review of Interdisciplinary Documentation dated 10/3/20 at 8:07 AM, revealed, .On 10/2020 (10/2/2020) as the evening progressed after he had a verbal altercation with another resident he was later observed with a female resident in the TV room touching her in an inappropriate sexual way, they were immediately separated and he was placed on 1:1 supervision and sent to the ER for eval. And was placed in his own room on the COVID new admission/re-admission unit. 1:1 supervision will continue and was added to his plan of care . Review of Interdisciplinary Documentation dated 10/6/20 at 1:50 PM, revealed, .He then sat at the nurses station and called his friend. They exchanged some small talk, then (Resident #226) said to his friend I had some real fun the other day with one of the ladies I guess I was not supposed to though, I know that now, but she came onto me They then proceeded to discuss other items. (Resident #226) recently had an incident where he had made contact with another female resident .After he completed his phone call I asked him if I could talk in his room and he agreed, I then told him I wanted to talk about the incident he had with the female resident the other day and he stated, yes I know that was bad, I am really sorry I asked him why he said it was fun with his friend, and he apologized and said he knew that was wrong too, then has (sic) asked me if I thought he was a womanizer and I said no. I just wanted to make sure he was aware hat (sic) touching other residents is not acceptable and he verbalized understanding. He has a BIMS of 13 . Review of Interdisciplinary Documentation dated 3/11/21 at 1:05 PM, revealed, .(Resident #226) has a hx (history of) a resident to resident that was sexual in manner and the spouse of the other residents has stated that he wasn't to be around his wife and that he will press charges if he is. I let the wife know this [NAME] (sic) and she stated that was mean of us and the other residents husband to press charges on his as he is an old man in a nursing home I let her know that he has a BIMS of 13 and 9, and that he is alert and orientated (sic) and cognitively not confused . In an interview on 06/28/23 at 03:02 PM, Corporate Clinical Nurse (CCN) SS reported she was present for the previous incident in 2020, the prosecuting attorney was involved in that incident. CCN SS reported room moves were conducted, he was removed off the unit and we did put interventions into place. When queried as to the knowledge of Resident #226's previous incident with Resident #11, how was Resident #226 permitted access to Resident #11 to commit another incident of inappropriate sexual touching? CCN SS was unable to provide a reply as to how this was able to happen again other than it was reviewed, and interventions were put in place. CCN SS reported Resident #11 did not present with any adverse actions and her dementia had progressed. CCN SS stated, .(Resident #11) pulls them out (her breasts) and plays with them .she licks her nipples often . Note: This writer did not observe Resident #11 exposing her breasts or playing with her breasts during the multiple observations of her in the hallway by the nurse's station, in activities, or in the dining room. Review of progress notes revealed no recent documentation of exposing her breasts. Review of Minimum Data Set (MDS) dated [DATE], revealed, .Section E: Behaviors: C. Other behavioral symptoms not directed towards others .( .public sexual acts, disrobing in public .) .0. Behavior not exhibited . Resident #73: Review of an Admission Record revealed Resident #73 was a male with pertinent diagnoses which included diabetes, surgical procedure for ulcers, depression, chronic pain, vascular disease, lymphedema, muscle weakness, difficulty walking, and arthritis. Review of a Minimum Data Set (MDS) assessment for Resident #73, with a reference date of 3/21/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated Resident #73 was cognitively intact. MDS Section G: revealed, Resident #73 had lower extremity impairment on side. Review of Intake dated 4/16/23, revealed, .Date of Alleged Event: 04/15/23 at 11:30 PM .Incident Summary: At 1130, (Resident #73) was sleeping and (CNA OO) came into his room and turned on his light. It woke him up and he told her to get out of his room. She was not his CNA. She told him that he needs to treat staff better and was threatening him. He stated he repeatedly asked her to leave his room and she kept yelling at him. After a few minutes she then stated, I am a police officer and I will hurt you. Then left the room. (Resident #73) got up and went to the south dining room in the dark for a few hours as he was afraid to go back to his room. He eventually returned to his room and went back to sleep. Police were called and spoke with him. (CNA OO) is suspended until further notice. (Resident #73) did not want to press charges . Review of 5 Day Summary Investigation Report revealed, .Statement from (LPN J): I was not there, I heard talking. (CNA OO) went in and turned the light on, and he was angry. He came out to ask, 'who the ass was that woke me up'. (CNA L) and (CNA M) were there. He then went in the dining room . Statement from (CNA M), CNA: I saw (CNA OO) and (CNA L) coming towards the nurse's station. (CNA L) told (CNA OO) not to go in his room. I asked who's room as I was charting at the nurse's station. (CNA OO) said (Resident #226). I told her not to go in there. She went in and poked her head out about his IV, then turned on the light. (Resident #226) told her to get out. She said to be nicer to the staff. I couldn't hear nothing else. She then left. I saw him in the South dining hall, and he was upset so I told him to report it. I also told (LPN J). This writer attempted to speak to CNA M prior to exit from the facility. .Statement from (CNA OO), CNA: I went in there, I said if he could be more respectful to the staff because he swears at them. He told me to get the hell out. I then asked him again and then I left. They were telling me about him, so I went in there to talk to him for a second. He got upset and then I left .When asked, (CNA OO) denies telling (R73) that she is a police officer and would hurt him . .Statement from(CNA L), CNA: I was up front .(CNA OO) said she was going in there. I repeatedly told (CNA OO) not to go in there. I walked back with (CNA OO). (CNA M) and I told her not to go in .Root Cause Analysis: Staff were upset with the way (Resident #73) was speaking to them and (CNA OO) thought she could talk to (Resident #73) about this. (CNA OO) approached (Resident #73) in his room and the conversation was not productive. (CNA OO) was previously a corrections officer, and it is believed she did state this with an attempt to deescalate the situation and assist in correcting his behavior . .Summary: Through interview and investigation, it was concluded (Resident #73) and (CNA OO) had a conversation initia [TRUNCATED]

Based on observation, interview, and record review the facility failed to follow Local Health Department (LHD), Center for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guidance to mitigate the spread of COVID-19 when the facility failed to: 1.) place residents that had been exposed to COVID-19 positive roommates into isolation precautions for 4 of 6 (Resident #101, #103, #106, and #107) reviewed for infection control; 2.) properly use PPE (personal protective equipment); 3.) ensure that proper signage indicating when isolation precautions are in place and 4.) effectively screen and monitor staff for signs and symptoms of COVID-19, resulting in an immediate jeopardy when, beginning on 10/11/20 facility staff did not implement nationally established infection control standard interventions to prevent the likelihood of the spread of COVID-19 in a community with a positivity rate at or above 3% to staff members and residents in the facility. This deficient practice placed all residents at risk for serious harm and/or death. Findings include: On 10/16/20, Nursing Home Administrator (NHA) A, Director of Nursing (DON) B and Regional Clinical Support (RCS) C were notified of an Immediate Jeopardy that began on 10/11/20 when Transmission Based Precautions (TBP) were not in place for Resident #103 after her roommate Resident #111 tested positive for COVID-19. On 10/23/20, this surveyor verified the facility completed the following to remove the Immediate Jeopardy: 1. On 10-16-2020 Residents # 101, 103, 106 and 108 were immediately placed in Transmission-Based Precautions with appropriate utilization of PPE. Observation Unit (since inception 03-2020) and COVID + Unit (since 10-15-2020) are in Transmission-Based Precautions. Residents in the remaining units have the potential to be affected with a known exposure and will be place on Transmission-Based Precautions with identified exposure. Residents in the observation unit and the COVID+ unit are in full Transmission -Based Precautions with extended use of N95s facemasks or at a minimum KN95s if N95s are unavailable, face shields for eye protection, gowns and gloves. (Since 10-15-2020) 2. The Health Department was contacted on 10-17-2020 and they scheduled an on-site visit on 10-19-2020 with approval of care and services and use of PPE on each of these units. The medical director and if indicated, in consultation with the health department epidemiologist will be consulted with presentation of signs and symptoms for indicated treatment. 3. Beginning on 10/17/20, the Director of Health Care Services and /or designees will audit adherence to implementation of Transmission-Based Precautions daily with audits varying shifts and staff. The Clinical Support Nurse/Director of Health Care Services is serving as the infection prevention manager. She assumes responsibility, with the support of clinical care coordinators, for monitoring documented signs and symptoms of Covid -19, resident cohorting, new admission placement, and signage placement. The Director of Health Care Service will initiate immediate education and correction with any identified non-compliance with CDC guidance. The Director of Health Care Service/Designee will assume responsibility and be supported with monitoring the CDC website for changes in guidance a minimum of weekly. Re-education included information on CDC website, AADNS training and QSEP training materials was conducted on 10-22 for staff working, and all staff prior to their next shift worked. 4. Beginning 10/15/20 and reeducation on 10/22/20, the facility will ensure adoption of CDC guidance for residents exposed to COVID-19 which includes: (italics direct from CDC) Ensure appropriate patient placement: Residents who are found to show s/sx. of COVID 19 will be tested and isolated per facility policy and procedure-and upon positive test will be relocated to isolation COVID 19. Use personal protective equipment (PPE) appropriately. Staff have been educated and had return demonstration education for proper PPE usage-per facility policy, proper storage and disposal as of 10/22/2020. All staff working at that time, prior to their next shift and those at home were called and provided verbal education. 5. Beginning 10/17/20, the facility is using and FDA approved disinfectant. The staff have been trained on contact time and where to locate disinfectants and wipes for cleaning equipment and PPE as needed-per facility policy. Staff were educated on appropriate cleaning of high touch surfaces, equipment and items in resident rooms per facility infection control process and policy. All staff working in the building on 10/17/2020 and again on 10/23/2020 were educated during their work hours, before coming into the building for their next scheduled shift. 6. On 10-22-2020, the facility immediately place appropriate signage on each unit to identify precautions that are in place. 7. All residents are assessed for signs and symptoms 2x daily since March, 2020. Advanced respiratory assessments, breath sounds, was completed by 10-16-2020. In addition to 2x daily screen of resident's temperature and SP02%, facility staff will complete a respiratory assessment on each resident (census of 53, with no new symptomology presenting) to establish baseline symptomology by 10-17-2020. 8. Beginning 10/22/20, facility staff will record each VS and assessment to depict the time of assessment and recorded in the medical record. Although the Immediate Jeopardy was removed on 10/22/20, the facility remained out of compliance at a scope of widespread and severity of no actual harm with the potential for minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency. Review of the Centers for Disease Control and Prevention (CDC) guidance Responding to Coronavirus (COVID-19) in Nursing Homes, updated 4/30/20, revealed Response to Newly Identified [DIAGNOSES REDACTED]-CoV-2-infected HCP or Residents. HCP who worked with symptoms consistent with COVID-19 or in the 48 hours prior to symptom onset. Prioritize these HCP for [DIAGNOSES REDACTED]-CoV-2 testing. Exclude HCP with COVID-19 from work until they have met all return to work criteria. Determine which residents received direct care from and which HCP had unprotected exposure to HCP who worked with symptoms consistent with COVID-19 or in the 48 hours prior to symptom onset. Residents who were cared for by these HCP should be restricted to their room and be cared for using all recommended COVID-19 PPE until results of HCP COVID-19 testing are known. If the HCP is diagnosed with [REDACTED]. Resident with new-onset suspected or confirmed COVID-19. Ensure the resident is isolated and cared for using all recommended COVID-19 PPE. Place the resident in a single room if possible pending results of [DIAGNOSES REDACTED]-CoV-2 testing. Cohorting residents on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected residents (e.g., residents who have fever, for example, due to a non-COVID-19 illness could be put at risk if moved to a COVID-19 unit) .Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [DIAGNOSES REDACTED]-CoV-2 14 days after their last exposure . HCP should use all recommended COVID-19 PPE for the care of all residents on affected units (or facility-wide if cases are widespread); this includes both symptomatic and asymptomatic residents .Notify HCP, residents, and families and reinforce basic infection control practices within the facility (e.g., hand hygiene, PPE use, environmental cleaning). Promptly (within 12 hours) notify HCP, residents, and families about identification of COVID-19 in the facility pdf icon(164 KB, 3 pages)external icon: Provide educational sessions or handouts for HCP, residents, and families. Maintain ongoing, frequent communication with residents, families, and HCP with updates on the situation and facility actions. Monitor hand hygiene and PPE use in affected areas. Maintain all interventions while assessing for new clinical cases (symptomatic residents): Maintain Transmission-Based Precautions for all residents on the unit at least until there are no additional clinical cases for 14 days after implementation of all recommended interventions. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html Review of the Centers for Disease Control and Prevention (CDC) guidance Criteria for Return to Work for Healthcare Personnel with [DIAGNOSES REDACTED]-CoV-2 Infection (Interim Guidance) Updated Aug. 10, 2020 revealed, Symptom-based strategy for determining when HCP can return to work. HCP with mild to moderate illness who are not severely immunocompromised: At least 10 days have passed since symptoms first appeared and at least 24 hours have passed since last fever without the use of fever-reducing medications and Symptoms (e.g., cough, shortness of breath) have improved. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/return-to-work.html Review of a facility policy COVID19 Testing Guidance last revised August 2020 revealed, 3. The facility will continue to screen staff (each shift) and each resident a minimum of daily and all persons entering the facility . 11. Symptomatic staff will be encouraged to stay home .12. If you identify a person under investigation (PUI) place the patient in a private room or cohort if available. a. Practice airborne precautions (N 95 respirator preferred, but at a minimum surgical mask and contact precautions plus eye protection (goggles or face shield) .13. Documentation of testing: a. For symptomatic residents and staff, document the dates and times of the identification of signs or symptoms, when testing was conducted, when results were obtained, and the action the facility took based on the results. b. Upon identification of a new COVID-19 case in the facility (i.e., outbreak), document the date the case was identified, the date that all other residents and staff are tested , the dates that staff and residents who tested negative are retested , and the results of all tests . Review of a facility policy Management of Infection Control Outbreaks last revised August 2020 revealed, 2. Surveillance procedures account for a record of all resident cases of potential infection noting the time of onset of symptoms in each case .5. The infection control practitioner leads the outbreak management including considerations for: .c. Removing staff from duty; consistent assignment of staff to limit potential unit to unit transfer . During an interview on 10/16/20 at 12:16 P.M., Local Health Department (LHD) XX reported that the facility has been in close contact and stated, .a resident that has been exposed to a COVID-19 positive roommate should not be moved, but be placed under isolation precautions for 14 days .the same as community isolation .these residents at minimum have a common source exposure due to sharing CNA's (Certified Nursing Assistants) and nurses . LHD XX reported that when a staff member becomes positive, the facility should then identify which residents the staff member worked with and quarantine those residents. LHD XX reported that the facility must utilize signs indicating isolation precautions and stated, .this physical reminder is very important .staff need these reminders . Resident #101 Review of an Admission Record revealed Resident #101 was a [AGE] year-old female, originally admitted to the facility on [DATE]. Resident #101 had pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 10/5/2020 revealed a Brief Interview for Mental Status (BIMS) score of 2, out of a total possible score of 15, which indicated Resident #101 was cognitively impaired. Review of the Functional Status revealed that Resident #101 was independent with locomotion in her wheelchair on and off the unit. During an observation and interview on 10/15/20 at 11:30 A.M., Resident #101 was observed in her room on west hall, lying in her bed with her room door open and no visible signage indicating isolation precautions present. This surveyor entered the room, and began to interview Resident #101. At 11:35 A.M., Certified Nursing Assistant (CNA) M came into the room and stated, you have to stay back from (Resident #101) her temperature is going up .she is refusing to get up because she doesn't feel good . This surveyor exited the room promptly. CNA M reported that Resident #101 was not feeling well this morning and stated, .so I took her temperature again and it was 100 .I don't remember what time that was . During an observation on 10/15/20 at 11:41 A.M. RCS C, CNA M and Licensed Practical Nurse (LPN) H entered Resident #101's room, to provide care, donned K-N95 masks, faceshields and gloves, no gowns observed being used by staff. CNA M observed to then exit the room with a plastic bag of soiled linen. LPN H stated, .(RCS C) is going to test (Resident #101) for COVID-19 because she is running a fever .they are just popping up all over . During an observation on 10/15/20 at 11:45 A.M., Director of Nursing (DON) B was observed to don full PPE and performed a COVID-19 test on Resident #101. DON B then exited Resident #101's room, the door was observed left open and no signage indicating isolation precautions were in place. During an interview on 10/15/20 at 11:50 A.M., CNA M reported that Resident #101 would be moved to the COVID hall if she tested positive for COVID. CNA M then proceeded to show this surveyor where the COVID hall is located. CNA M walked through the double doors at the end of west hall and entered south hall and stated, .this area of south hall is considered the transition hall and then down there on the other side of the nurses station .past the other double doors .that's where the COVID positive residents are . It was noted that this information was incorrect, as RCS C had reported previously that the entire south hall was designated as the COVID unit and that east hall was designated as the transition unit. It was noted that there was no signage indication isolation precautions on the double doors between west hall and south hall to indicate that staff or visitors were entering an isolation unit. During an interview on 10/15/20 at 11:56 A.M., LPN H reported that the COVID unit is on south hall and stated, .mainly in the back corner .some on the front side, but also some residents that aren't positive for COVID too .the transition unit is the one off of the COVID unit near the employee entrance . It was noted that this information was not completely accurate. During an interview on 10/15/20 at 12:00 P.M., to clarify which halls are designated for COVID and transition residents and require transmission based precautions (TBP), RCS C reported that as she had stated earlier, all of south hall is designated for COVID positive residents and all of east hall is designated for transition residents. RCS C stated, .if staff go through the double doors to the south hall they should don full PPE (personal protective equipment) .all of those resident are COVID positive . During an interview on 10/15/20 at 12:47 P.M., RCS C reported that they are in the process of moving Resident #101 to the COVID unit, even though her rapid COVID test was negative and stated, .I think she has COVID but it may be too early to test positive .her roommate was positive and a resident across the hall was positive yesterday . During an interview on 10/15/20 at 8:45 A.M., Regional Clinical Support (RCS) C reported that facility currently had 11 residents in-house that were positive for COVID-19 and that they were all residing in a COVID-19 designated unit on south hall, which is located at the back of the facility. RCS C reported that staff were wearing full PPE inlcuding a gown, K-N95 mask and a face shield while working on the COVID-19 unit and that staff did not change PPE between residents, unless it became soiled and stated, .all the residents have the [MEDICAL CONDITION], so we don't have to be concerned with cross-contamination . During an observation on 10/15/20 at 1:26 P.M., Resident #101 was observed sitting in her wheelchair, in her room on west hall with the door open. There was no observation of signage on Resident #101's door to indicate isolation precautions were in place. During an observation on 10/15/20 at 1:30 P.M., the double doors at the entrance of the COVID unit were observed to have no signage indicating isolation precautions were in place. During an observation on 10/15/20 at 2:56 P.M., Resident #101 was observed sans a mask sitting in her wheelchair at the nurses station on south hall (COVID unit). Resident #109, whom was known to be COVID positive, was observed wandering around the nurses station sans a mask. In was noted that there was no staff in the area supervising these residents. During an interview on 10/16/20 at 2:42 P.M., RCS C reported that Resident #101's roommate (Resident #109) was tested for COVID-19 on 10/12/20 which revealed a positive result and stated, .(Resident #101) was not placed in isolation precautions at that time . Review of Resident #101's COVID-19 results dated performed on 10/16/20 and a report date of 10/19/20 revealed, Custom COVID-19 test Positive. Resident #103 Review of an Admission Record revealed Resident #103 was a [AGE] year-old female, originally admitted to the facility on [DATE]. Resident #103 had pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 9/14/20 revealed a Brief Interview for Mental Status (BIMS) score of 4, out of a total possible score of 15, which indicated Resident #103 was cognitively impaired. Review of the Functional Status revealed that Resident # 103 required extensive assistance of 2 staff members for bed mobility and was totally dependent on 2 staff members to transfer. During an interview on 10/16/20 at 2:42 P.M., RCS C reported that Resident #103's roommate (Resident #111) was tested for COVID-19 on 10/11/20 which revealed a positive result and stated, .(Resident #101) was not placed in isolation precautions at that time . RCS C reported that Resident #103 tested positive for COVID-19 on 10/12/20. Resident #106 Review of an Admission Record revealed Resident #106 was a [AGE] year-old female, originally admitted to the facility on [DATE]. Resident #106 had pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #106, with a reference date of 7/27/20 revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated Resident #106 was cognitively impaired. During an observation on 10/15/20 at 1:58 P.M., Emergency Medical Services (EMS) were observed entering Resident #106's room, along side DON B, LPN H and CNA M. During an interview on 10/15/20 at 1:59 P.M., LPN H reported Resident #106 had a temperature of 101 degrees, shortness of breath and stated, .her roommate (Resident #107) tested positive for COVID and was moved to the COVID unit yesterday . During an interview on 10/15/20 at 2:07 P.M., DON B reported that Resident #106 has been ill with pneumonia and today was running a fever and had increased shortness of breath. DON B reported that she had tested positive for COVID twice today at about 1:07 P.M. and 1:29 P.M. DON B reported that Resident #106 has been lethargic and having an increased in shortness of breath recently and stated, .we had moved her to the transition unit because we thought that she would test positive .but moved her back to west hall yesterday . DON B reported that she was not sure of what time Resident #106's vitals were taken today or when her fever was identified, because the time is not documented and stated, .we try to get all the vitals done by 10:00 A.M. and then again between 8:00-9:00 P.M During an interview on 10/16/20 at 2:42 P.M., RCS C reported that Resident #106's roommate (Resident #107) tested positive for COVID-19 on 10/12/20 and stated, .(Resident #106) was not placed in isolation precautions at that time . RCS C reported that Resident #106 tested positive for COVID-19 on 10/15/20. Resident #107 Review of an Admission Record revealed Resident #107 was a [AGE] year-old female, originally admitted to the facility on [DATE]. Resident #107 had pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #107, with a reference date of 10/12/20 revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated Resident #107 was cognitively impaired. During an interview on 10/16/20 at 2:42 P.M., RCS C reported that Resident #107 tested positive for COVID-19 on 10/12/20. Resident #108 Review of an Admission Record revealed Resident #108 was a [AGE] year-old male, originally admitted to the facility on [DATE]. Resident #108 had pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #108, with a reference date of 7/13/20 revealed a Brief Interview for Mental Status (BIMS) score of 10, out of a total possible score of 15, which indicated Resident #108 was cognitively impaired. During an interview on 10/16/20 at 2:42 P.M., RCS C reported that Resident #108's roommate (Resident #112) tested positive for COVID-19 on 10/12/20 and stated, .(Resident #108) was not placed in isolation precautions at that time . RCS C reported that Resident #108 tested positive for COVID-19 on 10/14/20. During an observation on 10/21/20 at 1:20 P.M., LPN H was observed to enter Resident #108's room with medication in a cup. LPN H was observed to hand Resident #108 the cup and ask him to talk the medication. LPN H was then observed to exit the room and enter a different resident's room to answer a call light. There was no observation of gloves used or hand hygiene performed. LPN H then walked to the medication cart, used her keys to open the cart and began preparing medication for another resident. LPN H was then observed to enter Resident #109's room and use a spoon the administer medications to Resident #109. LPN H was observed to enter Resident #109's bathroom, and walk out approximately 10 seconds later while wiping her hands with a paper towel and walking back to the medication cart at the nurses station. There was no observation of gloves used or hand sanitizer used by LPN H. During an observation and interview on 10/22/20 at 3:19 P.M., LPN H was observed on the COVID unit walking fast down the hall and entering Resident #108's room. There was no observation of LPN H donning gloves or carrying anything in her hands when she entered Resident #108's room. LPN H was observed talking to Resident #108 and asking him to take his medications. LPN H was then observed to exit Resident #108's room with a cup of pills in her hand. LPNH reported that she had Resident #108's medications in her pocket when she entered the room and stated, .I don't wear gloves to pass meds .I didn't wash my hands between residents . Resident #109 Review of an Admission Record revealed Resident #109 was a [AGE] year-old female, originally admitted to the facility on [DATE]. Resident #109 had pertinent [DIAGNOSES REDACTED]. It was noted that Resident #109's [DIAGNOSES REDACTED]. During an observation on 10/15/20 at 2:55 P.M. Resident #109 was observed wandering on south hall near the nurses station sans mask. No observation of staff supervision or encouraging resident to wear a mask. During an interview on 10/16/20 at 2:42 P.M., RCS C reported that Resident #109 tested positive for COVID-19 on 10/12/20. Resident #111 Review of an Admission Record revealed Resident #111 was a [AGE] year-old female, originally admitted to the facility on [DATE]. Resident #111 had pertinent [DIAGNOSES REDACTED]. It was noted that the record did not include COVID-19 diagnosis. During an interview on 10/16/20 at 2:42 P.M., RCS C reported that Resident #111 tested positive for COVID-19 on 10/11/20. Review of Resident #111's Progress Note dated 10/11/20 at 9:21 A.M. revealed, On 10/10/20 aide came to this nurse and said resident had a temp of 100.6. This nurse went into room, room was very warm blankets were removed. This nurse rechecked her temp at that time and it was 100.0. One hour later her temp was rechecked again and it was 100.8. DON was called and she was moved per staff to south hall. She had no s/s of cough or shortness of breath at that time. Review of Progress Note dated 10/11/2020 at 09:21 A.M. revealed, This nurse entered resident room to swab for COVID test, resident coughing, has a runny nose/ sniffles. Pale in color, not eating. Tolerated swab without difficulty. Review of Resident #111's COVID-19 results dated performed on 10/11/20 and a report date of 10/16/20 revealed, COVID-19 test Positive. Review of Progress Note dated 10/11/2020 at 09:22 A.M. revealed (Resident #111) was running a fever yesterday evening, and now has a cough, lethargic, she was moved to isolation room yesterday at time of fever, and poc (point of care) rapid COVID test completed in facility, positive, 2nd one completed and was also positive. Clinical support nurse and Administrator notified. Resident #112 Review of an Admission Record revealed Resident #112 was a [AGE] year-old male, originally admitted to the facility on [DATE]. Resident #112 had pertinent [DIAGNOSES REDACTED]. It was noted that the record did not include COVID-19 diagnosis. During an interview on 10/16/20 at 2:42 P.M., RCS C reported that Resident #112 tested positive for COVID-19 on 10/12/20. Review of COVID-19 POC (point of care) testing worksheet provided by RCS C, indicated that Resident #112 was tested twice on 10/12/20 using a rapid POC (point of care) test, and that both tests were positive. It was noted that this worksheet is a resident census list with results written on the document. Review of a facility document COVID-19 Outbreak Reporting Form indicated that Resident #112 tested positive for COVID-19 on 10/14/20. Indicating that this documentaion was inaccurate. During an observation and interview on 10/15/20 at 9:15 A.M., Maintenance Assistant (MA) F observed walking in the hall near the entrance of the facility wearing a gown. RCS C was observed advising MA F to remove his gown prior to leaving resident rooms or isolation halls. MAF reported that he had been working in resident rooms on east hall (the transition unit). RCS C reported that MA F was new to the facility and stated, .he has not been trained yet . During an observation on 10/15/20 at 11:05 A.M. MA F was observed walking in the hall near the entrance of the facility wearing a gown. RCS C was observed educating MA F about why the double doors are closed to the south and east halls and also the proper use of PPE. During an observation on 10/15/20 at 12:51 P.M., it was observed that the double doors between the employee entrance hall and the transition unit on east hall did not have signage indicating that you were entering an isolation area. At 12:54 it was observed that none of the rooms on the transition hall had signage posted on the doors to alert staff of the TBP that were in place. During an observation on 10/15/20 at 12:57 P.M., located on east hall (transition hall) CNA K was observed to exit a residents room on in full PPE, then sans gown and discard into a trash bin in the hall. There was no observation of hand hygiene performed by CNA K. CNA K then donned a clean gown and entered another residents room to assist with putting that residents glasses on, then walked out into the hall, donned gloves and walked down the hall to the meal cart. CNA K was observed to deliver and set up lunch trays to 5 residents that were in their rooms, touching food containers and adjusting resident's tray tables. There was no observation of hand hygiene performed by CNA K before or after contact between residents and CNA K did not change her gown between residents. There was no observation of CNA K offering or performing hand hygiene to any residents prior to meals. During an observation and interview on 10/15/20 at 1:18 P.M., MA F was observed wearing black disposable gloves, K-N95 mask and a face shield on east hall (transition unit.) MA F reported that he had a few things to take care of in resident rooms. MA F was observed to go in and out of 3 separate resident rooms, talking to residents, touching a resident bed, a TV remote and a tray table. MA F was not observed changing his gloves, donning a gown or performing hand hygiene at any time during these observations. MA F was then observed exiting east hall (transition unit) and headed toward the front of the facility, all while wearing the same disposable gloves, mask and face shield. During an observation on 10/15/20 at 2:36 P.M. east hall (transition unit) was observed with no signage on double doors or anywhere visible prior to entrance onto the unit and no signage on resident room doors indicating isolation precautions were in place. During an observation and interview on 10/15/20 at 2:44 P.M. LPN G observed exiting a resident's room on east hall (transition unit) walking toward south hall (COVID unit) and stated, .I am assigned to the transition unit and the COVID unit today . Observation of the double doors between east hall and south hall did not reveal any signage indicating isolation precautions were in place. During an observation and interview on 10/15/20 at 3:03 P.M., Housekeeper (HSK) HH was observed wearing a gown, gloves, mask and face shield, pushing a large cart and collecting trash from the bins in the hallway on south hall (COVID unit). HSK HH was then observed to exit the hall and proceed down east hall (transition unit) where she then collected all of the trash from the bins in that hallway. HSK HH was not observed removing any PPE prior to leaving the COVID unit. It was observed that HSK HH wore the same PPE until she was finished collecting the trash and exited the transition unit. During an observation and interview on 10/16/20 at 12:40 P.M., CNA P located on east hall (transition unit) reported that all residents on the hall are on isolation precautions. CNA P reported that the hoyer lift and the portable machine used to obtain vital signs are not disinfected between residents. CNA P reported that she used (TRUNCATED)

Based on observation, interview, and record review the facility failed to ensure that residents who had a pressure ulcer received the necessary treatment to prevent the worsening of a pressure ulcer for 2 of 14 residents (Resident #103 and #101) reviewed for skin integrity, resulting in the worsening of pressure ulcers and a delay in wound healing with the potential for infection and overall deterioration in health status. Findings include: Review of the facility policy Skin at Risk Assessment last revised March 2015 revealed, Policy: It is the policy of this facility to assess resident risk factors for impaired skin integrity and intervene as indicated utilizing the admission plan of care and Minimum Data Set as formal assessment tools. Purpose: To ensure prompt identification and intervention for residents as risk of impaired skin integrity corresponding to risk factors. Procedure: 1. The licensed nurse completes the admission assessment to determine the need and application of immediate interventions. 2. Resident's ongoing risk factors for development of impaired skin integrity are determined and monitored with each minimum data assessment. 3. With completion of each assessment-Quarterly, and with change of condition applicable areas are reviewed to determine risk factors. Section G for determination of mobility, friction and shear factors, H incontinence for moisture, K for Nutrition (may be combined with review of FAR (Food Acceptance Record) if applicable for further determination of nutritional factors), I Diagnosis, M Skin Assessment, C cognitive/sensory, D & E for mood and behavior (i.e., depression may impact) J Health Conditions and O Treatment and Procedures. 4. The following guidelines are reviewed and implemented as indicated for each individual risk factors: a. Daily skin inspections with am and pm care b. C.N.A. reporting of abnormal skin inspections to the charge nurse c. Application of skin barrier ointment with incontinence care to form a protective coating to prevent skin maceration (occurs when skin is in contact with moisture for too long) d. Prevention of skin injury due to friction or shearing through proper positioning e. Rehabilitation consultation to improve mobility, promote movement and receive recommendations for positioning support. F. Use of pressure relieving devices, i.e., chair cushions, pressure reduction mattresses, air mattresses g. Shower twice weekly as accepted and desired and prn (as needed) including skin inspections h. Communication of skin concerns to other team members on the 24 hour report summary .k. Change the residents position every 2 hours and more frequently if redness or irritation of skin develops l. Use of pillows or devices to bridge heels as indicated .p. Consult the physician prn for treatment and orders for actual impaired skin integrity. 5. Individualize the resident goals and interventions as documented on the plan of care. Review of the Fundamentals of Nursing revealed, The health care provider (physician or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care providers' orders unless they believe that the orders are in error, violate agency policy, or are harmful to the patient. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition. Resident #103 Review of a Face Sheet revealed Resident #103 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 11/26/20 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #103 was cognitively intact. Review of the Functional Status revealed that Resident #103 required extensive 2 person assistance with bed mobility, transferring, dressing, toileting, and eating. Review of Section M Skin Conditions revealed Resident has a pressure ulcer/injury, a scar over a bony prominence, or a non-removable dressing/device-Yes .Is this resident at risk of developing pressure ulcers/injuries? 1. Yes .Does this resident have one or more unhealed pressure ulcers/injuries? 1. Yes .Number of Stage 4 pressure ulcers-1 .Turning/repositioning program-Yes .Pressure ulcer/injury care-Yes. Review of Resident #103's Wound Clinic Note dated 12/9/20 revealed, .PLEASE REPOSITION PT (patient) EVERY 1 ½-2 HR (hours) TO RELIEVE PRESSURE ON COCCYX PRESSURE WOUND; USE WEDGES OR PILLOWS TO KEEP PT ON SIDE. Limit 3 hours In (sic) wheelchair . Review of Resident #103's Wound Clinic Note dated 12/23/20 revealed, .Coccyx wound: Hold wound vac due to breakdown of peri skin .PLEASE REPOSITION PT (patient) EVERY 1 ½-2 HR (hours) TO RELIEVE PRESSURE ON COCCYX PRESSURE WOUND; USE WEDGES OR PILLOWS TO KEEP PT ON SIDE. Limit 3 hours in wheelchair. Please send a documented turning schedule with patient to next wound clinic appointment . Review of Resident #103's Care Plan revealed, Potential risk for impaired skin integrity related to: History of fragile skin, History of or actual impairment, Poor nutritional intake, impaired functional mobility and bowel incontinence . Measure open areas upon admission, weekly, prn Date Initiated: 08/22/2020. Review of Resident #103's Care Plan revealed no intervention that resident was to be repositioned every 1 ½-2 hours. Resident #103's electronic health record Care Plan was not updated when the wound vac was placed on hold from the wound clinic.Wound vac to sacral region, if it alarm (sic) sounds please inform charge nurse. Place on sides only not on her back, reposition often, and limit amount of time she is up in her w/c (wheelchair) air mattress Date Initiated: 08/24/2020 Revision on: 11/26/2020. Review of Resident #103's Skin Assessments revealed a Skin Assessment was completed on 11/22/20 (admission assessment), 12/13/20, 12/9/20, and 1/8/20. (Indicating weekly skin assessments were not completed per intervention on care plan.) Review of Resident #103's Wound Tracking Note dated 12/10/2020 revealed, Location: Coccyx measurements from wound clinic appointment on 12/9/20. She had debridement (removal of dead tissue) of area at wound clinic. Length: 1.5cm (centimeters) Width: 4.0cm Depth: 1.5cm Stage: 4 Treatment: Cleanse with normal saline, apply (wound vac-draws fluid of ouf wound and increases blood flow to area) wound vac sponge, and dressing, with wound vac set at -125mmhg every (Monday), (Wednesday), and (Friday). Other: Per wound clinic notes- area has no odor, moderate serosanguinous drainage. 60% granulation tissue, 30% slough and 10% fascia. Review of Resident #103's Wound Tracking Note dated 12/18/2020 revealed, Location: Coccyx Length: 5.0cm Width: 4.0cm Depth: 2.0cm Stage: 4 Treatment: Apply wound vac foam, cover with wound vac dressing every Mon, Wed, and Fri, with wound vac setting at -125mmhg. Other: ARea is red wound base, minimal serosanguinous drainage, no odor or s/sx of infection. periwound is dry, red, but blancheable. (sic) Review of Resident #103's Wound Tracking Note dated 01/07/2021 revealed, Location: Wound progress note from 12/24/20 Coccyx Length: 5.0cm Width: 4.0cm Depth: 2.0cm Stage: 4 Treatment: Cleanse with normal saline, apply [MEDICATION NAME] blue to wound, cover with dry dressing three times weekly. Other: Documentation from wound clinic from 12/23 was reviewed on 12/24/20- measurements and description per wound clinic. (Resident #103) has undermining at 1 o'clock of 2.8cm. Wound bed is 70% granulation, 20% slough, and 10% bone. No odor. Large amount of serosanguinous drainage. No s/sx (signs or symptoms) of infection. She continues on antibiotic therapy for wound infection. Review of Resident #103's Wound Tracking Note dated 01/08/2021 revealed, Location: Reviewed Wound clinic notes Coccyx Length: 6.0cm Width: 4.0cm Depth: 1.6cm Stage: 4 Treatment: Cleanse with normal saline, apply moistened [MEDICATION NAME] blue, and cover with dry dressing every Monday, Wednesday and Fri. Other: Area is 70% pink, and 30% slough. Serosanguinous drainage. No odor or s/sx of infection. Review of Resident #103's Wound Clinic Note dated 12/09/20 revealed, Procedure Orders-Debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue). Post-procedure [DIAGNOSES REDACTED].Irritant contact [MEDICAL CONDITION] due to body fluid .Pressure Injury of coccygeal region, stage 4 .Patient presents for a follow up visit for (stage) IV (4) sacral decubitus .Reports that they have not been turning her often enough especially on night shift .Pt (patient) claims she is not being repositioned. Review of Resident #103's Wound Clinic Note dated 12/23/20 revealed, (Resident #103) is seen today as a FU (follow up) for stage 4 pressure injury to sacrum. Pt is not sure if wound is getting better She acknowledges that she is on a LAL (low air loss) mattress and turn schedule she does say often at night she is not turned .Reports that they have not been turning her often enough especially on night shift .decline is noted with increased wound measurements to undermining and denuded (loss of the epidermis, caused by exposure to urine, feces, body fluids, wound exudate or friction) skin is noted to surrounding skin. Will hold NPWT (Negative Pressure Wound Therapy) . During an interview on 01/07/2021 at 9:39 A.M., Resident #103 reported that she would like to be repositioned frequently and that her wound doctor told her she should be repositioned every 1.5 hours. Resident #103 reported she does not refuse to be repositioned. Resident #103 reported she does not believe her weekly skin assessments are completed. During an observation on 01/07/2021 at 9:39 A.M., Resident # 103 was in bed, on her back, with no offloading devices placed behind her (as recommended by wound clinic). During an observation and interview on 01/07/2021 at 11:58 A.M., Resident #103 was in bed, on her back, with no offloading devices placed behind her (as recommended by wound clinic) Resident #103 verified that she had not been repositioned since the previous interview. During an interview on 01/07/2021 at 3:25 P.M., CNA K reported that Resident #103 does not refuse care or repositioning. Review of Resident #103's Behavior Log from the last 30 days revealed no documentation of refusal of care. During an interview on 01/07/2021 at 2:12 P.M., Interim Director of Nursing (IDON) B reported that interventions for skin breakdown are put in place when it is identified that the resident is at risk on admission and on the weekly skin assessments. IDON B reported that Resident #103's care plan was updated from the (wound clinic) visit she had yesterday (1/6/21) with increased turning. During an interview on 01/07/2021 at 12:30 P.M., CNA G reported that Resident #101 and Resident #103 do not refuse care and allow staff to reposition them. During an interview on 01/06/2021 at 10:08 A.M., CNA F reported that it is difficult to reposition residents as needed because of staffing concerns. CNA F reported that most of the residents on the unit require 2 person assistance. CNA F stated, We can't reposition people like we are supposed to because I can't do it by myself. Therapy can't do it all either. If the nurse is busy, residents have to wait up to an hour because I can't do hoyer transfer by myself. During an interview on 01/07/2021 at 11:44 A.M. Certified Nursing Assistant (CNA) F reported that facility staff follow the resident care plan to provide care. CNA F reported that she was notified an hour ago that Resident #103 should be repositioned every hour. During an interview on 01/08/2021 at 2:43 A.M., Clinical Care Coordinator (CCC) D reported that the nursing staff are responsible for completing Weekly Skin Assessments. CCC D reported that the nursing staff are prompted to complete Weekly Skin Assessments in the residents Treatment Administration Record (TAR) in the Electronic Health Record (EHR). Resident #101 Review of a Face Sheet revealed Resident #101 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 11/2/20 revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, which indicated Resident #101 was moderately cognitively impaired. Review of the Functional Status revealed that Resident #101 required extensive 2 person assistance with bed mobility, transferring, dressing, toileting, and personal hygiene. Review of Section M Skin Conditions revealed Is this resident at risk of developing pressure ulcers/injuries? 1. Yes .Does this resident have one or more unhealed pressure ulcers/injuries? 0. No .Turning/repositioning program-No. Review of Resident #101's Care Plan revealed, Altered functional mobility and ADL's (activities of daily living) related to: (Resident #101) has T7 T8 fracture (vertebral fractures) with generalized weakness, moribid (sic) obesity, requires assistance with ADL's (Activities of Daily Living). Goal is long term care . o ADL's: assist of one for ADL's, allow to do as much for self as able. Date Initiated: 01/29/2020 Revision on: 03/09/2020 .AMBULATION: One Assist with FWW (4 wheeled walker) Date Initiated: 01/29/2020 Revision on: 03/09/2020 .BATHING: One person assist with bathing, encouraging the resident to do as much for self as able Date Initiated: 01/29/2020 Revision on: 01/29/2020o BED MOBILITY: assist of one Date Initiated: 01/29/2020 Revision on: 03/09/2020 . o DRESSING: One assist with cueing and encourage to do as much for self as able. Date Initiated: 01/29/2020 Revision on: 01/29/2020 . o SKIN: Apply barrier cream with incontinence care prn; inspect skin with bathing and care; report impaired skin integrity to charge nurse . Date Initiated: 01/29/2020 Revision on: 11/06/2020. Review of Resident #101's Wound Clinic Note dated 12/2/20 revealed, .Offloading every 2 hours off right hip. Continue bilateral sage boots. Review of Resident #101's Wound Clinic Note dated 12/16/20 revealed, .Offloading: Turning every two hours while in bed, continue to wear sage boots to bilateral heels. Review of Resident #101's Wound Clinic Note dated 12/29/20 revealed, .Offloading: Turning every two hours while in bed, continue to wear sage boots to bilateral heels. Review of Resident #101's Care Plan revealed, (Resident #101) has actual skin integrity impairment. Her predisposing factors include impaired bed mobility and decreased functional ability, preference to remain in her wheelchair for extended periods of time; comorbid conditions of [MEDICAL CONDITIONS] with impaired diffuse blood flow, diabetes mellitus with potential for delayed wound healing, obesity, [MEDICAL CONDITIONS] with fluctuating [MEDICAL CONDITION], cognitive communication deficit, cognitive impairment; functional urinary and fecal incontinence, thin fragile skin; use of diuretic medication that could contribute to hydration deficits and anticoagulant with risk for bruising and bleeding; and history of skin impairment .Measure open areas upon admission, weekly, prn (as needed) Date Initiated: 01/29/2020 Revision on: 01/29/2020. Review of Resident #101's care plan revealed no intervention for repositioning Resident #101 every 2 hours while in bed or to wear sage boots. Review of Resident #101's Skin Assessments revealed a Skin Assessment was completed on 10/9/20, 11/1/20, 11/13/20, 11/22/20, 12/5/20, and 12/16/20. (Indicating weekly skin assessments were not completed weekly per intervention on care plan.) Review of Resident #101's Wound Clinic Note dated 12/29/20 revealed, Wound: Right Ischial Tuberosity: open to air. (Discontinuation of the wound treatment). Review of Resident #101's Wound Tracking Note dated 01/08/2021 revealed, Charting for 12/29/20 wound clinic notes right buttock .Area is closed. Review of Resident #101's Wound Tracking Note dated 01/08/2021 revealed, Location: Right buttock Length: 0.6cm Width: 0.6cm Depth: 0.1cm Stage: healing stage 3. Treatment: Cleanse with normal saline, apply [MEDICATION NAME] blue (type of wound treatment) and cover with dry dressing three times weekly. Other: Area is re-opened (was closed at wound clinic last week per notes). Pink, scant drainage. No odor or s/sx (signs or symptoms) of infection. Review of Resident #101's January Medication Administration Record [REDACTED]. change three times a week and PRN at bedtime every Mon, Wed, Fri (Monday, Wednesday, Friday) for wounds. On 01/01/21 and 01/06/21 there was a checkmark in the boxes indicating the treatment had been completed despite the wound clinic note indicating the area was closed. During an observation on 01/07/2021 at 11:58 A.M., Resident #101 was in bed, on her back, with a pillow under her knees. During an observation on 01/07/2021 at 3:03 P.M., Resident #101 was in bed, on her back, with a pillow under her knees. Resident #101 was incontinent of stool and staff entered room to perform incontinence care. Resident #101 had a deep purple/red area on her left buttocks the size of a D battery and a deep purple/red area on her right buttocks the size of a D battery. Under her right buttock (right ischial tuberosity) there was a healed pressure ulcer. There was no dressing over the healed pressure ulcer. After the completion of incontinence care, barrier cream was not applied to Resident #101's buttocks (per care planned intervention) Resident #101 was then placed on her back with a pillow under her knees. Resident #101 was not repositioned to her left or her right side (per wound clinic instructions). During an interview on 01/07/2021 at 3:03 P.M., Certified Nursing Assistant (CNA) J reported that the area on Resident #101's left buttock and right buttock were new. During an observation on 01/08/2021 at 11:23 A.M., Resident #101 was in bed, on her back, with a pillow under her knees. Resident #101 was incontinent of stool. Director of Nursing (DON) C assisted with her incontinence care. There was no dressing observed on Resident #101's buttocks. Resident #101 had a deep purple/red area on her right buttocks the size of a D battery. Under her right buttock (right ischial tuberosity) there was an open area approximately the size of 2 pencil erasers. Review of Resident #101's Behavior Log revealed a documentation of refusal of care on 12/11/20 at 01:41 A.M. and a documentation of refusal of care on 01/06/21 at 11:07 A.M. Review of Resident #101's Progress Notes revealed no documentation of refusal of care. No other refusal of care documented in the last 30 days. During an interview on 01/07/2021 at 12:53 P.M., Physical Therapy Assistant (PTA) V reported that Resident #101 does not refuse care.

This pertains to intake MI 928. Based on observation, interview and record review the facility failed to prevent an elopement and ensure safety in 1 of 6 residents (Resident #10) reviewed for safety/supervision, resulting in an Immediate Jeopardy when on 12/16/19 at approximately 7:00 P.M., Resident #10 (with a known elopement risk) exited the facility unattended through an emergency exit door, and was found outside of the facility in her wheelchair by a visitor at approximately 7:20 P.M. This deficient practice placed 6 residents, identified as at risk for elopement, at risk for serious harm, injury, and/or death. Findings include: Review of a facility policy Wandering Resident Exit Seeking Management last revised 11/2017 revealed, It is the policy of this facility to assess residents and plan their care to prevent foreseeable accidents related to wandering and exit seeking behavior which has the potential to lead to elopement .1. Assessment and identification of wandering residents .2. Residents identified with risk for elopement .3. Response to a sounding door alarm: a. Check the alarm panel to determine which door has been triggered. Do not assume someone else has already done this. b. Check the exit door for any exiting resident by means of a visual check. A visual check means observing the area around the exit, and may require leaving the building and checking the grounds. c. If an exit door alarm is triggered, the cause is evaluated and reset after the resident is redirected and their safety is assured. Consider the applicability of conducting a census count with an activated alarm. d. If unable to locate a resident, or in the event of an elopement drill, a building search is conducted. The charge nurse or designee shall announce resident alert, room______. Available employees are to report to their stations for assignments in this regard . Resident #10 Review of a Face Sheet revealed Resident #10 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #10, with a reference date of 12/24/19 revealed a Brief Interview for Mental Status (BIMS) score of 5, out of a total possible score of 15, which indicated Resident #10 was cognitively severely impaired. Review of Behavior revealed that Resident #10 had wandering behavior on 4-6 days out of the 7 day assessment period. Review of Functional Status revealed that Resident #10 required only supervision for locomotion on and off the unit. Review of Care Plan revealed, Focus: (Resident #10) is at risk for altered functional mobility and ADLs related to: advanced dementia. (Resident #10) is alert and oriented times one, self only. She receives limited assist with a walker, and independent in her wheelchair .She often propels her wheelchair quickly through the facility. Had a recent elopement from facility without injury and is on increased supervision. Date initiated 9/20/19, Revision on: 12/17/19 .INTERVENTIONS: Exit seeking alert: exit seeking alarm band protection device applied; follow guidelines for placement and function on the treatment administration record 12/31/19. (Resident #10) has been observed removing her wander guard from her ankle wander guard also applied to wheelchair .12/31/19 (Resident#10) has been observed removing her wander guard from her ankle, wander guard also applied to wheelchair. Date initiated 9/25/19. Revision on: 12/31/19. Fall-Risk Management: .Resident to be laid in bed after dinner. 11-8-19. Date initiated: 10/30/19. Revision on: 11/22/19 .Locomotion: independent with wheelchair mobility. Date Initiated: 9/26/19. Revision on: 12/17/19 . F[NAME]US: (Resident #10) has the potential risk for falls or injury related to: recent falls within the past 30 days. Date initiated: 9/26/19. Revision on: 9/26/19. INTERVENTIONS: Fall risk management: assist resident to bed after meals or place in high visible area of facility. Date initiated: 11/8/19. Revision on: 11/11/19 . With history of exit seeking and mobility independence apply interventions as indicated and reassess PRN (as needed) Date initiated: 9/26/19. Review of Facility Reported Incident (FRI) reported 12/17/19 at 12:29 P.M. revealed, Date of Alleged Event: 12/16/2019 Time: 07:20 PM. Incident Summary Abuse has been ruled out. The resident exited the facility through an emergency door with alarm sounding, staff responded to alarm, resident search initiated. Resident was escorted through front door by a visitor. Skin assessment completed with no injury noted and no complaints of pain or any concerns. Family & provider notified. 15-minute checks initiated. Care plan revised. Investigation Summary (Resident #10) is a long-term care resident who had been previously identified as a wander risk. An exit seeking transmitter was initiated on 10-26-19. When staff heard the alarming door they responded appropriately with a resident search. While in the process of searching the facility and locating each resident, a few minutes later a visitor brought (Resident #10) into the front entrance of the facility. (Resident #10) did not have any injuries and was joking with staff upon assessment. Her wander guard was checked at that time and it was functioning as it should be. She had on appropriate foot wear (shoes) and a thick sweat shirt. Her skin was not cold to touch and she did not say she was cold, she was not shivering or shaking at the time, indicating that she may be cold. The temperature that day was 34 degrees and it was not snowing, and no high wind conditions. At that time she was evaluated by the nurse and no injury was identified and she denied pain. Post incident she was placed on 15 minute checks, and her urine was dipped and was positive for a suspected infection. A UA was later completed and indicated an active UTI. Oral antibiotics were initiated for treatment of [REDACTED]. The plan of care is reflective of the device, and was prior to the elopement. On 12-17-19 (NHA A) and (RN-RCS B), (DOHCS C) re-enacted and timed the amount of time it would have taken (Resident #10) to travel from the exit door by Human Resources to get to the front sidewalk. This took 2.5 minutes to travel, as we were ambulating at a pace comparable to how she self-propels her wheelchair. The door she exited through to the left has a paved side walk and is lit well with outdoor lights. The sidewalk passes around back corner of the facility along the employee entrance and parking lot to the front of the facility where there is another side walk that runs perpendicular to the parking lot. The side walk and parking lot are paved well and have no concerns relating to the integrity of the cement and asphalt. There was no debris noted during the re-enactment. IDT met and reviewed her plan of care and it was revised with new interventions to encourage her to attend activities and indicating staff that she enjoys magazines as well as socializing with others. While on the antibiotic she has remained on 15 minute checks and has had no other instances of elopement. Staff education has been provided post incident that when an exit door is alarming in addition to initiating a resident search staff immediately exit the alarming door and walk the perimeter of the facility. At the time of the elopement (LPN D) exited the facility, took a few steps outside of the door and searched for someone, he did not hear or see her. At the time he exited the door she was likely along the side of the facility, on the corner of the building where he would not have been able to see her unless he walked several more steps around the corner of the facility. As the resident search was in progress (RN F) did get her coat and was going to exit the facility to search but (Resident #10) had entered the facility at that time. Resident search drills have been, and will continue to be completed, in an effort to educate staff of the new process to exit the alarming door and search outside at the time the alarm sounds. The exit doors are monitored and audited daily to ensure they are functioning. Wander guard devices will continue to be monitored daily to ensure they are functioning and every shift staff will validate placement of the device. These processes were in place prior to the elopement and will remain in place. In conclusion staff responded to the alarm at the exit door and a resident search was completed, the resident entered the facility post incident, without harm, and her plan of care has been revised to encourage her to attend activities and increased supervision has been provided. She has oral antibiotics for an active infection that likely contributed to her increased confusion and her exiting the facility. Through our re-enactment of ambulating the perimeter of the facility, which took 2.5 minutes, and through elopement drills conducted on every shift, that are cleared in 5-7 minutes, it has been concluded that she was not outside any longer than 5-7 minutes. According to the alarm panel with corresponding map located at the south nurses station, the exit door by Human Resources is labled #5. Review of a facility Incident Report dated 12/16/19 at 17:40 (5:40 P.M.) revealed, Resident #10 .Exit Seeking .Emergency exit door was sounding and 2 nurses approached the door that was sounding. 1 nurse exited the door and took a few steps to the left of door and yelled hello with no response, and then did the same to the right side of the door. Nurse then entered the building and initiated a resident search. While a resident search was in progress this nurse approached north Station and a staff notified me that (Resident #10) was back in the building safely after being observed outside in front of the building in her wc (wheelchair) on the sidewalk. During an observation on 01/07/20 at 01:23 P.M., Resident #10 self-ambulating in her wheelchair down west hall. Resident #10 stated I am looking for my room and continued down the hall towards her room on north hall. During an observation on 01/07/20 at 02:16 P.M., Resident #10 observed quickly exiting her room by self-ambulating in her wheelchair down the hall. During an interview on 01/08/20 at 08:34 [NAME]M., Social Services (SS) AA sitting at south nurses station, reported that the nurse's stations all have a panel of lights and when a door is exited by a resident, the panel lights up and sounds an alarm, alerting staff to which door has been exited. SS AA reported that Resident #10 is sometimes sitting at the nurses station one minute and the next she is out of sight. During an interview on 01/08/20 at 08:39 [NAME]M., Nursing Home Administrator (NHA) A reported that on 12/16/19 Resident #10 exited the door by the Human Resource (HR) office and was discovered near the front entrance of the building by a visitor. NHA A reported that after a reenactment of the elopement, it was determined that it would have taken Resident #10 approximately 2 1/2 minutes to ambulate in her wheelchair from the door that she exited to the front of the building. NHA A reported that the location of the door that Resident #10 exited would only allow her to ambulate to the left, as the right was heavily wooded. During an interview on 01/08/20 at 10:44 [NAME]M., Nursing Home Administrator (NHA) A reported that she was unsure of the exact time that Resident #10 eloped on 12/16/19. NHA A reported that the nurse that completed the incident report for Resident #10's elopement, did not revised the time stamp to reflect the actual time of the incident or indicate a time in the description of events. NHA A reported that Licensed Practical Nurse (LPN) D notified her by phone of the incident at approximately 7:20 P.M. on 12/16/19 and that Resident #10 had been returned to the facility unharmed. During an observation and interview on 01/08/20 at 08:44 [NAME]M., Environmental Services Manager (ESM) L reported that if a resident was attempting to exit the facility, the emergency exit doors would start to beep and then open after 15 seconds of holding down the handle, at which time the beep becomes steady and an additional alarm sounds at the nurses station. ESM L reported that the wanderguard system is not linked to the emergency exit doors, but only to the front and back entrances of the building. ESM L reported that he has considered adding a screamer to the door alarms so that staff would be alerted sooner. Observation of the beeping of the exit door, and the alarm that sounded at the nurses station. This surveyor observed no staff response to the door alarm, but multiple staff responding to the alarm at the nurses station by coming out of rooms and looking down the halls. During an interview on 01/08/20 at 09:45 [NAME]M., Housekeeper (HK) S reported that in response to a door alarm she would go to the door, possibly open and look out the door, and if she did not see a resident she would probably let the nurse know. HK S reported that she was recently educated to do a 2 man resident search if instructed by a nurse. During an interview on 01/08/20 at 10:00 [NAME]M., Certified Nursing Assistant (CNA) I reported that in response to a door alarm, her responsibility would be to go to the door and look out the window to see if anyone was out there, and then see that all of her assigned residents were accounted for. CNA I reported that she would not go outside at that time unless it was determined that a resident was missing. During an interview on 01/08/20 at 10:00 [NAME]M., CNA I reported that Resident #10 is very anxious and gets her mind set, so if you are her aide you have to watch her close. CNA I reported that Resident #10 is the first resident to look for in a resident search, because she is fast and if she was adamant to get home, she could get to the road very quickly. During an interview on 01/08/20 at 10:53 [NAME]M., Health Information Manager (HIM) V reported that on 12/16/19 she was assigned as the night manager and was at the front entrance when Resident #10 was brought back in by a visitor. HIM V reported that Resident #10 eloped at approximately 7:00 P.M., as it was between the time she left the dining room around 6:30 P.M. and when she left work for the night at 7:30 P.M. HIM V reported that there were 2 resident searches called back to back that night and she stayed at the nurses station while other staff accounted for the residents in the facility, so that she could clear the alert. When Resident #10 was brought back in HIM V reported that staff wasn't even aware that she was missing yet. HIM V reported that Resident #10 should be one of the first residents located due to her being a flight risk. HIM V reported that LPN D looked outside near the door that Resident #10 exited, but did not see her possibly because it was too dark and Resident #10 was too fast. During an interview on 01/08/20 at 11:20 [NAME]M., CNA J reported that if a door alarm sounded, she would go and check the door that the alarm is coming from and make sure it is closed, then count residents to be sure no one has gone outside. During an interview on 01/08/20 at 05:17 P.M. LPN D reported that on the day Resident #10 eloped, he was at South nurses station giving report to RN F between 6:30-7:00 P.M., when they thought to have heard a sound coming from the emergency exit door by the HR office. LPN D reported that he didn't see any residents near the door, so he opened the door and walked out onto the sidewalk and called out, but didn't hear or see anyone. LPN D reported that there were woods to the right and a parking lot and garage to the left. LPN D stated that he looked only as far as he could see from where he was standing by the door, and did not search the facility grounds. LPN D reported that approximately 10-15 minutes later he was notified that Resident #10 had been found in the parking lot by a visitor. During an interview on 01/09/20 at 09:06 [NAME]M., RN F reported that on the day that Resident #10 eloped, there was a lot going on around the nurses station on south hall. RN F reported that she was sitting at the nurses station receiving report from LPN D between 6:30-7:00 P.M. and did not recall seeing Resident #10 in the area at that time. RN F and LPN D stood up and walked around to the medication cart located on the hall where Resident #10 had exited the building, where they then both stopped and listened because they thought that they had heard an alarm, but were not sure of where it was coming from, that is when they walked down by the emergency exit door #5 at the end of the hall and could tell that the door was alarming. RN F could not be sure how long that the alarm had been sounding. RN F reported that in the past when a emergency exit door was opened the alarm had been loud at the nurses station. RN F reported that LPN D exited door #5 and walked straight out and when he didn't see anyone, he came back in the facility and called a resident search. RN F reported that is was very cold and windy that night and she was on her way to get her coat, when she heard that Resident #10 had been found in the parking lot and brought back inside by a visitor. During an interview on 01/10/20 at 09:37 [NAME]M., Certified Occupational Therapy Assistant-Therapy Manager CC reported she would have to go to the nurses station to verify which exit door is alarming based on which light is lit and the corresponding map. During an interview on 01/10/20 at 09:29 [NAME]M. CNA I reported that she can only hear the exit door alarms when she is in the hall near the alarming door, otherwise she would need to look at the light panel behind the nurses station to verify which door is alarming. During an interview on 01/09/20 at 09:53 [NAME]M., Environmental Services Manager (ESM) L reported that on 12/17/19, during a reenactment of Resident #10's elopement it was discovered that the audible alarm for door #5 by the HR office was not sending a signal and alarming at the alarm panel located at the nurses station. ESM L reported that the alarm was accidentally disconnected during maintenance that was performed on the call light system a couple of days prior to the elopement, but went unnoticed until the reenactment of Resident #10's elopement. ESM L reported that the door alarm was reconnected to the alarm panel at the nurses station and was functioning properly at approximately 10:00 [NAME]M. on 12/17/19. ESM L reported that the work was completed by himself and Corporate Project Manager (CPM) FF. ESM L was not able to provide documentation or a work order to confirm a date and time of the maintenance. During an interview on 01/09/20 at 10:02 [NAME]M., Nursing Home Administrator (NHA) A reported that on 12/17/19 during the reenactment of the elopement it was discovered that door #5 was alarming only at the exit and not at the alarm panel at the nurses station as it was designed to do. During an interview on 01/09/20 at 10:02 [NAME]M., Registered Nurse Regional Clinical Support (RN-RCS) B reported that she was aware that on 12/17/19 door #5 was found to be disconnected from the alarm panel at the nurses station and did not function properly on 12/16/19 by sending a loud alarm to the nurses station when Resident #10 eloped from the facility. During an interview on 01/09/20 at 11:02 [NAME]M., RN-RCS B reported that staff would expect to hear a loud alarm coming from the nurses station to alert them to a resident exiting the facility through door #5. According to Wunderground.com the local weather on 12/16/2019 at 6:54 PM was the following: temperature was 29 Fahrenheit, wind out of the North at 5 miles per hour. During an observation on 01/09/20 at 12:13 P.M., this surveyor observed the speed limit on the road directly in front of the facility to be 35 mph (miles per hour). The walking distance outside from emergency exit door #5 to the front entrance of the building was approximately 963 feet. Approximately 75% of this distance was a parking lot. The road was observed to be approximately 81 feet from the path where Resident #10 was assumed to have ambulated in her wheelchair during her elopement on 12/16/19. On 1/08/20 at 01:40 P.M., NHA A and RN-RCS were notified and received written notification of the immediate jeopardy that began on 12/16/19 due to the facility's failure to implement safety measures to prevent the elopement of and ensure a resident at risk for elopement (Resident #10) was safely returned to the facility after an elopement. On 1/10/20, this surveyor verified the facility completed the following to remove the Immediate Jeopardy: ELEMENT #1: Action Taken: A wandering risk assessment was completed on 12-17-2019 and outdoor safety assessment was completed on 12-27-2019 for Resident #10. An exit seeking alarm is in place for resident #10. Updates to the plan of care were completed as indicated by these assessments. IDT reviewed these items on 1-8-2020 and no changes were made to her plan of care. ELEMENT #2: Identification of Other residents: To identify other residents with the potential for wandering and exit seeking conditions we utilized an examination of residents with MDS (Minimum Data Set) responses for wandering tendencies at Section E0900. The 8 Identified residents at risk had a review of wandering and exit seeking potential through review of their wandering risk assessment, with care plans updated in accordance with the review, as applicable, on 1-8-2020. ELEMENT #3: Systemic Changes: Education initiated at the time of the event will be re-introduced and includes the initiation of care planned interventions for wandering and exit seeking potential as well as the standard for a response to a sounding door alarm and perimeter grounds inspection. The education will also include a review of the facility Wandering Resident Elopement Prevention Policy. Education will be completed for all staff including; Nursing, Dietary, Laundry/Housekeeping, Maintenance, Recreational Services, Social Services, Financial Services, Admissions, Human Resources, medical records, and all department heads. This will be completed shift to shift prior to the employees next day worked. This education began on 1-8-2020, and 25 of 77 employees have received the education as of 1-8-2020 at 1715. The 8 Residents exhibiting wandering and exit seeking potential were assessed on1-8-2020 by members of the IDT for appropriate interventions and their care plans were updated accordingly, as applicable. The Clinical Care Coordinators and / or designees are responsible for an ongoing review and analysis of the assessments for wandering and outdoor safety. Updates to these assessments and plans of care are completed with significant change of status. Contributing risk analysis completed on 12-17-2019 revealed the door at this exit alarmed audibly at the door, however it did not sound at the panel located at the nursing station 100 feet away. Root cause of this occurrence is during contracted work on the call light system on 12-12-2019 the supply power to the low voltage transmitter was incidentally disconnected. This was corrected on 12-17-2019. Although the immediate jeopardy was removed on 1/9/20, the facility remained out of compliance with a scope of isolated and severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to all staff had not received the inservice education and sustained compliance had not yet been verified by the state agency.

Based on interview and record review, the facility failed to prevent facility acquired pressure ulcers for 1 (Resident #59) of 16 residents reviewed for pressure ulcers, resulting in the development of one unstageable pressure ulcer and one deep tissue injury and the potential for the overall deterioration in health status. Findings include: Review of Skin at Risk Assessment Policy and Procedure dated revised (MONTH) (YEAR), revealed Policy It is the policy of this facility to assess resident risk factors for impaired skin integrity and intervene as indicated utilizing the admission plan of care and Minimum Data Set as formal assessment tools. Purpose: To ensure prompt identification and intervention for residents at risk of impaired skin integrity corresponding to risk factors. Procedure: 4. The following guidelines are reviewed and implemented as indicated for each individual risk factors: a. Daily skin inspections with am and pm care. b. Certified Nursing Assistant reporting of abnormal skin inspections to the charge nurse. c. Application of skin barrier ointment with incontinence care to form a protective coating to prevent skin maceration. d. Prevention of skin injury due to friction or shearing through proper positioning. e. Rehabilitation consultation to improve mobility, promote movement and receive recommendations for positioning support. f. Use of pressure relieving devices, i.e., chair cushions, pressure reduction mattresses, air mattresses. g. Shower twice weekly as accepted and desired and prn including skin inspections. h. Communications of skin concerns to other team members on the 24 hour report summary. i. Consultation with dietary services for assessment of adequate dietary intake of proteins calories and fluids. j. Nutritional support is offered and encouraged. k. Change the residents position every 2 hours and more frequently if redness or irritation of the skin develops. l. Use of pillows of devices to bridge heels as indicated o. Provide education to the resident and family regarding skin breakdown prevention as indicated 5. Individualize the resident goals and interventions as documented on the plan of care. Review of the Admission Record revealed Resident #59 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a MDS assessment for Resident #59, with a reference date of 12/3/19 revealed a Brief Interview for Mental Status (BIMS) score of 11, out of a total possible score of 15, which indicated Resident #59's cognitive skills for daily decision making were moderately intact. Review of Activities of Daily Living (ADL) Care Plan dated 6/11/18 revised 11/14/19, revealed (Name of resident) is dependent for her ADL's and has double incontinence Edentulous but has no problems eating a regular diet. (name of resident) is alert to self only related to [DIAGNOSES REDACTED]. Her (family member) .visits (name of resident) often. (MONTH) likes to wear pajamas for clothes instead of day clothes. Often prefers to remain up daily in her w/c, encourage to lay down. Encourage her to reposition self while in w/c. Date Initiated: 06/11/2018. Goal: · (Name of resident) will be clean, well groomed and meet her highest practicable level of independence, pain will be managed. Revision on: 04/17/2019 Interventions: ·SKIN: Apply barrier cream with incontinence care prn; inspect skin with bathing and care; report impaired skin integrity to charge nurse Revision on: 04/16/2019 ·Skin: 11/6/19-Lay (Name of resident) down in her room after meals as she will tolerate. Encourage her to lay on her sides to remove pressure off her coccyx. Air mattress to bed Date Initiated: 11/06/2019 Revision on: 11/11/2019 ·COMFORT INTERVENTIONS: Reposition in bed and w/c as she allows. Air mattress to bed. Rojo cushion in w/c. Revision on: 12/03/2019 (SIC) Review of the Short Term Care Plan Wound and Skin date 12/6/19, revealed 1. Deep Tissue Injury to coccyx continued, 2. 12/18/19 deep tissue injury to left foot (lateral aspect), 3. blanchable boggy bilateral heels, 4. antibiotic, Approach: elevate heels as tolerates, air mattress applied, wound care clinic referral sent, hospice, activated charcoal in room as wound has odor, [MEDICATION NAME] wound bed. (SIC) Review of the Impaired Skin Care Plan dated 10/15/18 revision 12/13/19, revealed Focus (Name of resident) ·has potential risk for impaired skin integrity related to: thin fragile skin decreased mobility, incontinence and cognitive impairments. She often prefers to remain in her w/c throughout the day and often propels self throughout the facility. Wound on her coccyx that is necrotic and emits an odor, activated charcoal is in her room to eliminate odor. Date revision 12/13/19 Goal- ·Will show improvement of impaired skin integrity as evidence by no S/S of infection and decreased measurements and/or prevention of avoidable impaired skin integrity will be achieved. Date Initiated: 10/15/2018 Interventions- ·Assess footwear as indicated Date Initiated: 10/27/2019 ·Assess postural alignment, weight distribution, sitting balance, & pressure redistribution on admit and prn Date Initiated: 10/15/2018 ·Pressure reducing mattress Date Initiated: 11/06/2018 ·Pressure reducing cushion to wheelchair. Date Initiated: 11/06/2018 ·Skin inspections with am/pm care and showering report abnormal to the charge nurse Date Initiated: 10/15/2018. (SIC) Review of the Interdisciplinary Nursing Note dated 10/18/19 at 2:34 PM, revealed (Name of resident) quarterly MDS was completed yesterday. She is alert to self and place and is independent with mobility in her w/c, and requires assist of 1 for transfers and is stable on her feet. No recent falls. She denies pain and is able to verbalize her needs. Edentulous but tolerates a regular diet and eats well at meals as her weight has been stable. No area of pressure. Double incontinence and requires assistance of 1 in the bathroom. some days she prefers to wear her pajamas during the day and often wears only socks no shoes. She often naps in her w/c and will decline wanting to be laid down. (SIC) Review of the Wound Nursing Notes dated 11/6/19 at 9:33 AM, revealed Tracking Location: Coccyx Length: 5 cm Width: 5 cm Depth: 0 Stage: Deep tissue injury Treatment: padded sacral dressing to cushion coccyx, Resident to be laid down after meals & prn as she will tolerate. Encourage to lay on her side as she will tolerate. (SIC) Review of the Skin Assessment Nursing Note dated 11/6/19 at 1:43 AM, . raised and open area noted to buttocks and Clinical Care Coordinator (CCC) and physician notified and area covered. (SIC) Review of the Interdisciplinary Nursing Notes dated 11/8/19 at 1:32 PM, revealed Called and placed order for resident with (name of store) for air mattresses as well as a gel cushion for wheelchair. (SIC) Review of Interdisciplinary Nursing Note dated 11/10/19 at 1:18 AM, revealed the only refusal of care noted Resident had c/o pain to buttocks/coccyx, declined repeated offers of repositioning to reduce pressure. PRN (as needed) APAP given. Resident continues to lay on back, declines any offers of repositioning and turning. Education provided r/t (related to) wound and promoted healing and comfort with no change in outcome. (SIC) Review of Interdisciplinary Nursing Note dated 11/19/19 at 11:39 AM, revealed Completed wound care as ordered. Cleansed with medi-honey and dressing. (name of resident) is on an air mattress, she has some recent weight loss although still 25+ pounds above usual and admitting weight. Her (family member) provides comfort foods which are snack type foods, prostat ordered and evaluated by RD (registered dietitian) related to increased protein needs and little nutritional protein intake from diet. (Family member) reports frequent recurring history of pressure ulcer development. (Name of resident) is well-known to us, having been admitted on hospice respite back in (YEAR) and with stabilization was DC'ed from hospice ~1 year ago. Call placed to the wound clinic, have not had response from our call for an appointment. Message left. Risk factors for development and barriers to wound healing continue: Glycemic control with POA (power of attorney) preference for comfort food over nutritional recommendations; Inadequate fluid intake to support blood flow for healing; Elevated BUN/CR ([MEDICAL CONDITION] stage III) resistance of care and repositioning - when asked if there was anything I could do for her following wound care she replied just stop moving me. She did express comfort with final position on her side with heels elevated. (SIC) Review of the Interdisciplinary Nursing Note dated 11/14/19 at 2:32 PM, revealed She has an area of pressure facility acquired to her coccyx that is covered with slough. Tx in place is medi-honey to debride the area. She does have pain to the wound bed and during our assessment she was able to use her feet to lift her buttocks off of the bed and can roll independently in her bed. She has occasional incontinence and prefers to remain in w/c throughout the day. Since the development of the wound she has been laying down after meals. She has an air mattress as well. (SIC) Review of the Wound Clinic Note dated 11/21/19, revealed length 4.5 cm x width 2 cm x depth unable due to necrotic tissue and pain, moderate yellow drainage, foul odor, mild pitting slight indentation. Cleanse wound with normal saline only then apply Santyl (nickel thickness) to wound bed then cover with calcium alginate, gauze and an ABD. Change daily. Prescription for Santyl sent with patient, Please limit patient being out of bed to meals only. offload and reposition in bed every 2 hours. SIC) Review of Hospice Admission Note dated 11/27/19, revealed Decline: Patient has new sacral decubitus with necrotic tissue, malodorous, very painful to patient, per (family member) wound to the bone per (family member) patient has been unable to pull self up to move to w/c, has increased confusion and difficulty locating feet to move them over past 6 weeks. , .patient in bed w/c bound, increasingly bedbound. Patient was able to get into w/c on own, now a 2 person assist. (SIC) Review of the Skin assessment dated [DATE] at 6:38 PM, revealed Late Entry: .Resident alert oriented x2 currently in bed for assessment residents eyes are clear without drainage scalp is clean hair is clean. Resident skin is wnl clean and warm to touch unable to see nail beds they are polished. No redness/bruising or open areas onback/trunk/abdominal fold/under breast. Currently has coccyx wound and is seen by wound clinic. Heals are red treatment in place. (SIC) Review of the Wound Tracking Note dated 12/18/19 at 12:59 PM, Location: Left lateral foot Length: 1.5 cm Width: 1.5 cm Depth: 0 100% purple nonblanchable Stage: DTI Treatment: skin prep every shift. cover with a 2x2 Allevyn to protect. Prevelon boots while in bed as (name of resident) will allow Other: DTI is 100% dark purple, non-blanchable. (Name of resident) rates it as 5/10 for pain. No drainage or odor noted. (SIC) Review of the Interdisciplinary Nursing Note dated 12/23/19 at 9:53 PM, revealed (Name of resident) continues with significant weight loss of 7.9% over the last month with a current weight of 149.6 lbs. Her coccyx wound has decreased in size this month and has also improved in tissue type. She did however, develop an additional wound to her left outer foot. Please see wound tracking notes for details. Reviewed MAR for acceptance of Mighty Shakes which she receives BID for pm and HS snacks. She rarely drinks more than 25% at the HS time. Will d/c (discontinue) the HS shake and replace with Gelatein. A high protein jello-type supplement. Name of resident) continues to be at risk for weight loss and impaired healing. (SIC) Review of the Treatment Administration Record dated (MONTH) 2019, revealed Resident #59 was receiving mighty shake supplement BID until 12/23/19, she was consuming 75-100% would occasionally refuse at 1500 and 0-25% would occasionally take 50 % at 2000. Review of the Wound Tracking Note dated 12/31/19 at 3:59 PM, revealed Location: Left lateral foot Length: 1.4 cm Width: 1.8 cm Depth: 0 Stage: DTI Treatment: skin prep q shift and prevelon boot as she will allow. (SIC) During an observation and interview on 01/07/20 at 11:22 AM, Resident #59 was laying in bed on her right side she stated my hips and legs are killing me she gives me [MEDICATION NAME] once in awhile, resident was (dressed for the day) brace to left palm bed low, right side with pad to floor on left side of low bed. Resident #59 fell asleep right after telling me she was in pain. No pillow under heels or between knees, no boots noted on feet, no pillow noted supporting resident behind her back. During an observation on 01/07/2020 at 3:50 PM, Resident #59 laying in bed on left side appeared to be sleeping legs pulls up together, no pillow under heels, no pillow between knees, no boots on feet. During an observation on 01/08/20 at 8:27 AM, Resident #59 laying in bed on right side appeared to be sleeping legs pulls up together, no pillow under heels, no pillow between knees, no boots on feet. During an observation on 01/08/20 at 12:29 PM, Resident #59 laying in bed on right side awake head of bed at 30 degrees, refusing lunch did not have any complaints about care or pain, staff did not ask if they could reposition her or offer to place a pillow under her heels or between her knees, just took her tray (did ask if she would like something else prior to leaving the room) During an interview on 01/09/20 at 8:26 AM, Clinical Care Coordinator (CCC) H reported that Resident #59's pressure ulcer started as a deep tissue injury on 11/6/19, then opened and the base could not even be seen due to slough and eschar. CCC H reported that Resident #59 was placed on Hospice on 11/27/19, she could not recall any trauma to cause the deep tissue injury, Resident #59 was just starting to stay in bed more. CCC H reported that at the time the deep tissue injury was found Resident #59 was using a pressure relieving mattress on her bed and in her wheelchair and before her decline she was up in her wheelchair more during the day and had to be encouraged to lay down. CCCH reported that a specialized mattress and a gel cushions for her wheelchair were ordered after the pressure ulcer was found. During an observation and interview on 01/09/20 at 11:25 AM, Registered Nurse (RN) F reported that she had given Resident #59 her [MEDICATION NAME] about an hour ago, over-the-bed table covered with paper towels with [MEDICATION NAME] (antibiotic) for odor control, 4x4's, normal saline (NS), and Hy[DATE].25 % and a Allevyn (padded adhesive foam dressing). Resident #59 was able to move self very slowly in bed, she was dressed in a nightgown and brief, CCC H and RN F went in to bathroom to wash hand, CCC H with clean gloves on opened closet door to get wash cloths out and RN H went into the bathroom to get (2) washcloths wet, stated she put a little soap on (1), noted a wound (deep tissue injury) to left outer side of foot by small toe dark brown in color not open size of a dime (1.7 cm square approximately) dry, Perineal care completed by RN F, CCC H removed dirty dressing that was saturated with brown liquid, slight odor noted, hands cleaned with hand sanitizer, new gloves applied, NS put in wound and 4x4's used to catch NS, gloves changed and hands cleaned, wound edges clean 2.4 cm x 1.2 cm x 1.3 cm straight 11:00 o'clock 3 cm 1:00 o'clock 2 cm, frank blood noted when measurement of tunneling taken, gloves changed and hands cleaned gauze soaked with [MEDICATION NAME] and Hy[DATE] placed in tunneling and covered Allevyn with resident complaining of burning with insertion of gauze. Resident #59 continued to cry with reposition, RN F stated I think we should place something between her knees and was placing a pillow between her knees and CCC H stated if she lets you Resident #59 allowed positioning and laid quietly after RN F covered her up. Resident #59 was positioned on her left side and no attempt to get her heels off the bed was done or offered. During an interview on 01/09/20 at 12:00 PM, Resident # 59 reported that she did not recall the last time pillows were under heels, and/or could not recall the last time blue boots were put on her feet, she did say her pain was all right. During an interview and observation on 01/09/20 at 2:05 PM, Resident #59 was laying on back no blue boots were noted in room, Hospice Care GG and CCC H looked all over shelves and in the closets and stated the blue boots were not in the room. During an interview and observation 01/09/20 at 2:55 PM, Certified Nursing Assistant Hospice Care GG were completing personal care placed resident on left side put pillow between legs did not see grimacing or hear verbal complaints of pain when resident was positioned. Hospice Care GG reported the residents pain was under control better, she tolerated the turn both times and did not swear at me, her pain management was best it has ever been. Hospice Care GG reported that she has not seen the blue boots for her feet for a long time, and that she ask the resident where they were and she said she had not seen them in awhile either. Hospice Care GG reported that she comes to see the resident twice a week. During an interview on 01/09/20 at 3:42 PM, CCC H reported that Resident #59 can have as needed pain medication every 2 hours it just depends on how often we move her, and she will very rarely use the call light so when staff are in the room they will ask her if she needs pain medication. CCC H reported that Resident #59 sleeps most of the time, and staff turn her every couple of hours. CCC H reported that they believe the wound on the foot happened by it being on the bed, we are putting skin prep on it and trying to keep it up on a pillow as much as she will allow us to, to heal it, the wound has never been open. During an observation on 01/10/20 at 8:54 AM, Resident #59 up in wheelchair in the area by the nursing station having a coke and ice cream staff encouraging to eat resident alert and has no complaints, dressed for the day socks to feet.

Based on observation, interview, and record review the facility failed to prevent the development and worsening of pressure ulcers for 1 of 4 residents (Resident #100), reviewed for skin integrity, resulting in two facility acquire pressure ulcers, worsening of pressure ulcer,[MEDICAL CONDITION] related to pressure ulcer, subsequent hospitalization , and surgical intervention. Findings include: Review of the facility's policy and procedure, revised April, 2010, revealed .It is the policy of this facility to assess resident risk factors for impaired skin integrity and intervene as indicated .To ensure prompt identification and intervention for residents at risk of impaired skin integrity .The following guidelines are reviewed and implemented as indicated for each individual risk factors: .Communication of skin concerns to other team members .change the residents position every 2 hours and more frequently if redness or irritation of the skin develops .Consult the physician prn (as needed) for treatment and orders for actual impaired skin integrity .Individualize the resident goals and interventions as documented on the plan of care . Review of the Face Sheet revealed Resident #100 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, completed on 9/4/19, revealed Resident #100 required extensive assistance of 2 staff for transfers, hygiene, bathing, dressing, and toileting; and assistance of 1 staff for eating. Review of Resident #100's Minimum Data Set ((MDS) dated [DATE], revealed Resident #100 was severely cognitively impaired. Review of MDS 3.0 Section M - Skin Conditions, dated 7/18/19, an evaluation of Resident #100's condition upon his 7/10/19 return to the facility from a rehabilitation hospital, revealed no (skin impairments noted). Review of Resident #100's Progress Note: Skin Assessment, dated 7/30/19 at 2:35 PM, revealed Resident has two open areas on his coccyx, both measuring at 3 inches in length and 1 1/2 inches in width. Coccyx area reddened, surrounding tissue pink ., electronically signed Licensed Practical Nurse C (LPN). In an interview on 9/10/19 at 2:10 PM, LPN C indicated began working at the facility on 7/22/19 and has frequently worked with Resident #100. LPN C indicated first noted Resident #100's skin impairment when assisting an aide with care. Resident #100's coccyx was reddened and very concerning. LPN C indicated reported Resident #100's impaired skin to former Clinical Care Coordinator O (CCC). LPN C indicated returned to work one to two days later, 7/30/19, and assisted with Resident #100's care again and the wound to his coccyx had worsened rapidly. It was now open in two areas and was sloughy (dead tissue separating from live tissue indicating a progression in wound stage). LPN C indicated reported to former CCC O and had former CCC O look at Resident #100's wound. LPN C indicated continued to work two or three shifts after 7/30/19 and there was not a dressing change order on the task bar of the Treatment Administration Record (TAR) until 8/7/19 when the wound worsened again. LPN C indicated there was a standing order to treat a Stage II pressure ulcer and used that order to dress Resident #100's wound. Review of Resident #100's Order Summary Report revealed standing orders (preordered set of orders that could be implemented without consultation of the physician) WOUND CARE STAGE II - Cleanse the area with soap and water or saline and dry. Apply [MEDICATION NAME] or wound gel with dressing - change according to product specification and PRN . WOUND CARE: STAGE III and IV - notify health care practitioner . Review of Resident #100's Progress Notes from 7/31/19 to 8/6/19, revealed no skin assessments, wound assessments, or wound treatments were documented. The medical record is a legal document and is used to protect the patient as well as the professional practice of those in healthcare. Documentation of the care you give is proof of the care you provide .Charting is objective, not subjective. This means chart only what you see, hear, feel, measure, and count - not what you infer or assume. All nurses know that if it wasn't charted, it wasn't done the patient's complete and accurate medical record the most reliable source of information on the care of that patient. Proper nursing documentation prevents errors and facilitates continuity of care. https://www.asrn.org/journal-chronicle-nursing/341-charting-and-documentation.html Review of Resident #100's (MONTH) and (MONTH) TAR, revealed no treatment for [REDACTED]. Review of Resident #100's Care Plan for his identified pressure ulcer risks factors revealed, focuses on risk for impaired skin integrity, mobility, comfort, and nutrition. Interventions for these identified focus areas were not reassessed or revised until 8/7/19, over a week after LPN C discovered the first sign of Resident #100's skin impairment and reported the impairment to CCC O. Review of Resident #100's Progress Note: Wound Assessment, dated 8/7/19 at 9:46 AM, revealed Location: Coccyx, Length: 4.2, Width: 7.5, Depth: 0.2, Stage: unstageable, slough noted to wound bed, Treatment: Medi honey, Other: see progress note ., electronically signed by Regional Clinical Consultant P (RCC). Review of Resident #100's Progress Note: Wound Assessment, dated 8/7/19 at 9:44 AM, revealed Location: Left heel, Length: 3.8, Width: 8.4, Depth: 0.0, Stage: unstageable, Treatment: skin prep q shift, Other: see progress note ., electronically signed by RCC P. Review of Resident #100's Progress Note: Interdisciplinary Documentation, dated 8/7/19 at 9:51 AM, revealed On 7/30/2019 wound to bilateral buttocks was noted. Today he has an area of pressure, facility acquired, unstageable to his coccyx where the open areas on bilateral buttocks has opened together ., electronically signed by RCC P. In an interview on 9/10/10 at 2:45 PM, RCC P indicated LPN C discovered and reported to CCC O Resident #100's initial skin impairment to his coccyx on 7/30. CCC O should have measured/assessed the wound, documented the assessment, made the wound treatment available on the task bar for the nurses to document the treatment was being done, and assessed and update his care plan interventions. RCC P indicated was requested by Nursing Home Administrator A (NHA) to examine Resident #100's skin on 8/7/19. RRC P indicated the standing order for a Stage II wound was no longer applicable due to the wound being unstageable. We also discovered Resident #100's had developed a second unstageable pressure ulcer to his heel. Review of Resident #100's (MONTH) TAR, revealed an active treatment from 8/8/19 to 8/14/19, Cleanse coccyx with NS, pat dry, apply honey alginate to wound bed, skin prep to peri wound, cover with dry dressing change daily and prn one time a day for wound care . On 8/11, 8/12, 8/13 no dressing change was documented. Review of Resident #100's Care Plan after Resident #100's coccyx pressure ulcer worsened on 8/7/19, revealed the revision to the focus (Resident #100) has the potential for impaired skin integrity related to: .currently has skin impairments .Revision on 08/07/2019. There were no new care plan interventions related to the coccyx skin impairment found. No intervention for weight redistribution while in a wheelchair found. No intervention for frequency of repositioning (until 8/29/19, return from hospital stay for [MEDICAL CONDITION]) found. In an interview on 9/11/19 at 12:20 PM, LPN C indicated prior to the discovery of Resident #100's coccyx wound, he would routinely get up into his Broda (specialized wheelchair) for approximately 1.5 hours, 1-2 times a day. At that time the facility was attempting to discontinue his tube feedings and we took him to the dinning hall for at least 2 meals every day. The day before or the same day Resident #100's coccyx wound was discovered (7/30/19), the attempt to discontinue his tube feeding was abandoned because of significant weight loss and poor consumption. After discovery of Resident #100's coccyx wound he was still getting up in his Broda for approximately 1.5 hours, 1-2 times a day. Resident #100's has used the same Broda and seat cushion since his return from the rehabilitation hospital until today. In an interview on 9/11/19 at 12:30 PM, Certified Nursing Assistance D (CNA) indicated had assisted many times with Resident #100's care since his return from the rehabilitation hospital. CNA D indicated has always positioned Resident #100 in his Broda chair the same way whether before his coccyx wound and after. CNA D indicated would occasionally place a pillow on either side of his trunk, so he did not lean but nothing under his bottom to keep him off his wound. CNA D indicated he would sit him up right or recline in his chair dependent on what was happening and sometimes would put a pillow under his knees for comfort. In an interview on 9/11/19 at 1:32 PM, CNA L indicated had worked frequently with Resident #100 before and after the discovery and worsening of his coccyx wound. CNA L indicated at first his coccyx did not look that bad; it was red and intact. A couple of days later it was worse and open. During that time his routine was up for meals, into his Broda. When we positioned him in the chair for approximately 2 hours, we did not use anything to keep him off his wound; it would have been a good idea. We would sometimes use a pillow under knees with his feet lying on the footrest. In an interview on 9/11/19 at 2:45 PM, CNA N indicated had worked frequently with Resident #100 before and after the discovery and worsening of his coccyx wound. CNA N indicated Resident #100's routine was to get into his Broda for lunch and dinner every day. CNA N indicated would position him sitting straight up in his chair and he would stay in his chair for approximately 2 hours. CNA N indicated did not use pillows or wedges to relieve the pressure on Resident #100's coccyx wound. Review of Resident #100's Nurse Practitioner's (NP) Progress Note, dated 8/16/19, revealed .Coccyx wound, black heel. Wound smelling worse. No fever until today Assessment .Pressure injury of buttock, Stage 3 .significant slough, odor, Bactrim, Keflex, to wound clinic . Review of Resident #100's Wound Clinic Progress Note, dated 8/21/19, revealed .He has a wound on his left heel and a sacral wound. Left heel wound is a stage 3 with eschar (dark, hard, dead tissue) removed today .The sacral wound is leathery eschar with fluctuance (movement within a swelling signaling contains fluid). I debrided off a portion of the eschar that revealed a deep cavernas (cavernous) wound with undermining (larger wound beneath the opening). There is significant odor as well .Pt (patient) is in need of surgical debridement in an OR (operating room) with a subsequent wound vac application to optimize outcome .Plan .Off-Loading .Keep pressure of wound sites .Avoid directing pressure to Wound site . sic Review of Resident #100's Progress Note, dated 8/22/19 at 12:44 PM, revealed Elevated temp reported to NP orders received to send ER Stat eval and treat. Administrator notified POA . Review of Resident #100's hospital Resident Admission History & Physical, dated 8/22/19, revealed .presented to ED (emergency department0 for fevers, chills, and sacral wound .this morning had fevers of 102 .Assessment .Sepsis secondary to Sacral decubitus ulcer .Sacral wound is significantly malodorous. It is unstageable ulcer with central necrosis, pustular exudates (drainage with pus), undermining and some tunneling (tract below wound to surrounding tissue) at the right lateral aspect .resident with surround [MEDICAL CONDITION] (skin infection) . Review of Resident #100's hospital Operative Report, dated 8/22/19, revealed .excisional debridement of sacral ulcer, 7.5 x 6 x 3 cm .There was a large amount of necrotic (dead) skin, subcutaneous fat, and muscle .The deepest tissue layer encountered was muscle .

Based on interview and record review the facility failed to revise care plan interventions to prevent pressure ulcers for 1 of 4 residents (Resident #100), reviewed of care plans, resulting in the development of two new pressure ulcers and worsening of one of the pressure ulcers. Findings include; Review of the Face Sheet revealed Resident #100 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, completed on 9/4/19, revealed Resident #100 required extensive assistance of 2 staff for transfers, hygiene, bathing, dressing, and toileting; and assistance of 1 staff for eating. Review of Resident #100's Minimum Data Set ((MDS) dated [DATE], revealed Resident #100 was severely cognitively impaired. Review of MDS 3.0 Section M - Skin Conditions, dated 7/18/19, an evaluation of Resident #100's condition upon his 7/10/19 return to the facility from a rehabilitation hospital, revealed no (skin impairments noted). Review of Resident #100's Progress Note: Skin Assessment, dated 7/30/19 at 2:35 PM, revealed Resident has two open areas on his coccyx, both measuring at 3 inches in length and 1 1/2 inches in width. Coccyx area reddened, surrounding tissue pink ., electronically signed Licensed Practical Nurse C (LPN). Review of Resident #100's Care Plan dated 7/10/19 for his identified pressure ulcer risks factors revealed, focused on risk for impaired skin integrity, mobility, comfort, and nutrition. Interventions for these identified focus areas were not reassessed or revised after the discovery of Resident #100's coccyx wound on 7/30/19. Review of Resident #100's Progress Note: Wound Assessment, dated 8/7/19 at 9:46 AM, revealed Location: Coccyx, Length: 4.2, Width: 7.5, Depth: 0.2, Stage: unstageable, slough noted to wound bed, Treatment: Medi honey, Other: see progress note ., electronically signed by Regional Clinical Consultant P (RCC). Review of Resident #100's Progress Note: Wound Assessment, dated 8/7/19 at 9:44 AM, revealed Location: Left heel, Length: 3.8, Width: 8.4, Depth: 0.0, Stage: unstageable, Treatment: skin prep q shift, Other: see progress note ., electronically signed by RCC P. Review of Resident #100's Progress Note: Interdisciplinary Documentation, dated 8/7/19 at 9:51 AM, revealed On 7/30/2019 wound to bilateral buttocks was noted. Today he has an area of pressure, facility acquired, unstageable to his coccyx where the open areas on bilateral buttocks has opened together ., electronically signed by RCC P. Review of Resident #100's Care Plan after Resident #100's coccyx pressure ulcer worsened on 8/7/19, revealed the revision to the focus (Resident #100) has the potential for impaired skin integrity related to: .currently has skin impairments .Revision on 08/07/2019. There were no new care plan interventions related to the coccyx skin impairment found. No intervention for weight redistribution while in a wheelchair found. No intervention for frequency of repositioning (until 8/29/19, return from hospital stay for [MEDICAL CONDITION]) found. Review of Resident #100's hospital Resident Admission History & Physical, dated 8/22/19, revealed .presented to ED (emergency department) for fevers, chills, and sacral wound .this morning had fevers of 102 .Assessment .Sepsis secondary to Sacral decubitus ulcer .Sacral wound is significantly malodorous. It is unstageable ulcer with central necrosis, pustular exudates (drainage with pus), undermining and some tunneling (tract below wound to surrounding tissue) at the right lateral aspect .resident with surround [MEDICAL CONDITION] (skin infection) . In an interview on 9/10/10 at 2:45 PM, RCC P indicated LPN C discovered and reported to Clinical Care Coordinator O (CCC) Resident #100's initial skin impairment to his coccyx on 7/30. CCC O should have re-evaluated Resident #100's skin integrity risk factors and updated his care plan interventions accordingly on 7/30 to prevent new pressure ulcers occurring and to prevent the worsening of his coccyx wound. RCC P indicated there were not any care plan interventions for Resident #100 after 8/7/19 that addressed repositioning in his wheelchair.

Based on observation, interview and record review the facility failed to: 1.) prevent the development of facility aquired pressure ulcers in 2 of 17 residents (Resident #18 and Resident #28) and 2.) consistently provide care and monitor for skin breakdown in residents at risk for skin breakdown in 9 of 17 residents (Resident #'s 18, 23, 68, 28, 24, 22, 43, 66, and 4) reviewed for the prevention of pressure ulcer development, resulting in facility acquired pressure ulcers for Resident #18 and Resident #28 and the potential for skin breakdown for all residents at risk for skin breakdown. Findings include: Review of facility policy for Skin at Risk Assessment revealed, It is the policy of this facility to assess resident risk factors for impaired skin integrity and intervene as indicated utilizing the admission plan of care and Minimum Date Set (MDS) as formal assessment tools Individualize the resident goals and interventions as documented on the plan of care. Review of the facility's policy and procedure Skin at Risk Assessment, revised 3/2015, revealed .Purpose: To ensure prompt identification and intervention for residents at risk of impaired skin integrity corresponding to risk factors. Procedure: .The licensed nurse completes the admission assessment to determine the need and application of immediate interventions .Daily skin inspections with am and pm care .C.N.A. reporting of abnormal skin inspections to charge nurse .Shower twice weekly as accepted and desired and prn including skin inspections . Resident #18 Review of Face Sheet and MDS dated [DATE] revealed that Resident #18 was an [AGE] year-old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), reflected a score of 3 out of 15 which indicated Resident #18 was severely cognitively impaired. Resident #18 needs extensive assistance while in bed and total dependence transferring, toileting, and activities of daily living (ADL's). The MDS indicate Resident #18 was incontinent of bowel and bladder and was at risk for developing pressure ulcers. Review of Resident #18's skin inspection to be performed weekly, revealed only 2 skin inspections were documented from admission on 07/20/18 to the date of exit (10/11/18). Review of a wound tracking note dated 08/20/18 at 02:21 PM by RN, L, revealed a facility acquired pressure ulcer had been identified, Location: coccyx Length: 1.1 Width: 0.4 Depth: Stage: (not documented) Treatment: cleansed with saline, allevyne (wound dressing) applied Other: wound bed pink, no drainage or odor. Review of a wound tracking note dated 08/23/18 (3 days after the wound was identified) at 12:51 PM by Clinical Nurse Consultant G revealed, Location: Coccyx Length: 2.5 Width: 1.5 Depth: 0.3 Stage: 3-facility acquired. Treatment: cleanse with NS, pat dry, apply calcium alginate (wound dressing), cover with dry dressing, change daily and prn Other: see progress note. Review of a wound tracking note dated 10/04/18 at 14:51 PM by Clinical Nurse Consultant G revealed Resident #18 had a second facility acquired pressure ulcer identified 1.5 months after the first one. Clinical Nurse Consultant G wrote, Location: Right buttocks Length: 5.0 Width: 7.0 Depth: 0.0 Stage: unstageable-facility acquired Treatment: solosite (gel wound dressing) ordered to debride the site. Other: The entire area measures 5.0x7.0 and there is a black necrotic area in the center that is 4.0 x 4.0. In an interview on 10/11/18 at 12:0 PM, Clinical Nurse Consultant G indicated that skin assessments had not been completed as ordered. Clinical Nurse Consultant G stated, .I have looked and we don't have them. Resident #23 Review of a Face Sheet revealed Resident #23 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #23, with a reference date of 7/10/18, revealed a Brief Interview for Mental Status (BIMS) score of 1, out of a total possible score of 15, which indicated Resident #23 was severely cognitively impaired. The MDS indicated Resident #23 was totally dependent on facility staff for bed mobility, activities of daily living (ADL's) and personal hygiene. The MDS indicated Resident #23 was at risk of developing a pressure ulcer. Review of Resident #23's care plan revealed, Potential risk for impaired Skin Integrity, revealed, Focus: .potential risk for impaired skin integrity related to: History of actual impairment, Poor nutritional intake, impaired functional mobility and or incontinence. History of fragile skin. (Resident #23) had shearing on her spinal column upon admission (resolved, she has very thin and frail skin. Date Initiated: 05/09/16 Revision on: 08/04/16 Goal: (Resident #23) will show improvement of impaired skin integrity as evidence by no S/S (sign or symptoms) of infection and decreased measurements and/or prevention of avoidable impaired skin integrity will be achieved. Date Initiated: 05/09/16 Revision on: 07/19/18 Target Date: 11/12/18. Intervention: Daily skin inspections 5 days post admit, weekly and prn Date Initiated: 05/09/16 . The date initiated for weekly and PRN skin inspections should be ongoing from 05/09/2016 through current date as the target was 11/12/18. Review of Resident #23's Progress Notes: Skin Assessment revealed from 05/06/16 through 10/11/18, the facility missed of 117 of 126 weekly opportunities to perform skin inspections. Resident #68 Review of a Face Sheet revealed Resident #68 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #68, with a reference date of 10/02/18, revealed a Staff Assessment for Mental Status score of 3, which indicated Resident 68 was severely cognitively impaired. The MDS also indicated Resident #68 required extensive assistance for bed mobility activities of daily living (ADL's) and personal hygiene. Resident #23 was also identified as at risk of developing a pressure ulcer. Review of Resident #68's care plan revealed, Potential risk for impaired Skin Integrity, revealed, Focus: .potential risk for impaired skin integrity or at risk for complications of current skin impairment related to dependence with care. She can be non-cooperative with attempts to reposition in bed. (Resident #68) is at risk of skin breakdown from eyeglasses related to refusal to remove while sleeping. She is incontinent of bowel and bladder. Date Initiated: 05/05/14 Revision on: 03/07/18 Goal: (Resident #68) will show improvement of impaired skin integrity as evidence by no S/S (sign or symptoms) of infection and decreased measurements and/or prevention of unavoidable impaired skin integrity will be achieved. Date Initiated: 05/05/14 Revision on: 07/19/18 Target Date: 12/30/18. Intervention: Daily skin inspections 7 days post admit, weekly and prn Date Initiated: 05/09/16 . The date initiated for weekly and PRN skin inspections should be ongoing from 05/05/2014 through the date of exit. Review of Resident #68's Progress Notes: Skin Assessment revealed from 04/07/12 through 10/11/18, the facility failied to document over 5 years of weekly opportunities to perform skin inspections. In an interview on 10/11/18 at 1:32 PM, DON B indicated that CNA's should be looking at the resident's skin during the resident's shower and should be notifying the nurse of any abnormal findings. DON B also indicated that skin assessments should be done on a weekly basis and that it has not been done. Resident #28 Review of a facility Admissions Record revealed Resident #28 was a [AGE] year-old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, completed on 8/7/18, revealed Resident #28 required extensive assistance with 1 staff for dressing and hygiene and was independent for transfers, ambulation and eating. Brief Interview for Mental Status (BIMS), on 8/7/18, revealed Resident #28 was moderately cognitively impaired. Review of Resident #28's care plan revealed the focus (Resident #18) has the potential for impaired skin integrity .related to .11/5/15 partial thickness open area .on right buttock ., revised 2/26/18. Care plan revealed the interventions .Daily skin inspections 7 days post admit, weekly and prn ., date initiated 6/25/14. Review of Resident #18's weekly skin inspections revealed, no skin inspections have been documented since 8/20/18. Review of Resident #28's progress notes revealed Resident #28 went out to the emergency room for evaluation of respiratory distress on 10/1/18. She was treated for [REDACTED]. Review of Resident #28's electronic medical record revealed no admission assessment or skin assessment was done after returning from her hospital stay. Review of Resident #28's physician's orders [REDACTED]. Apply [MEDICATION NAME] or wound gel with dressing - change according to product specification and PRN electronically signed by Nurse Practitioner P (NP). Review of Resident #28's wound care notes from 10/8/18 to present, revealed no wound care inspections or dressing changes have been documented regarding 10/8/18 physician's orders [REDACTED].>In an interview on 10/10/18, Director of Nursing B (DON) indicated only 2 residents on Resident #28's hall have wounds and Resident #28 was not named. Review of the only note addressing Resident 28's wound, found in progress notes, dated 10/11/18 at 6:00 AM, revealed .this nurse attempted several times to assess and re-dress resident's wound to coccyx . In an interview and observation on 10/11/18 at 2:00 PM, Clinical Nurse Consultant G (CNC) indicated read Resident #28's 10/11/18 nursing note that morning and neither DON B or CNC G were aware of any kind of coccyx wound. CNC G indicated there are no skin assessments documented prior to Resident #28 going to the hospital on [DATE] and no admission assessment documenting skin condition since readmitting from the hospital on [DATE]. CNC G indicated would assess Resident #28's coccyx now. CNC G inspected Resident #28's coccyx. Resident #28 did not have a dressing on her coccyx and it was covered with a white paste like residue. Beneath the paste Resident #28's coccyx was red, with an excoriated area approximately pencil eraser size. CNC G indicated Resident #28 has an area of impaired skin integrity to the coccyx and should have treatment orders and wound tracking. CNC G indicated was unaware of the 10/8/18 treatment order for a Stage II coccyx wound dressing change written by NP P. In an interview on 10/11/18 at 4:00 PM, NP P indicated does not know when or how was notified of a skin integrity issue for Resident #28. NP P indicated could not find any progress notes documenting or addressing the 10/8/18, coccyx wound treatment order. NP P does not remember this visit and was unsure if simply did not document the visit or never visited at all. Resident #24 Review of a facility Admissions Record revealed Resident #24 was an [AGE] year-old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, completed on 8/6/18, revealed Resident #24 required extensive assistance with 1 staff for transfers, dressing, and hygiene and was setup assistance ambulation and eating. Brief Interview for Mental Status (BIMS), on 8/6/18, revealed Resident #24 was severely cognitively impaired. Review of Resident #24's care plan revealed the focus (Resident #24) has the potential risk for impaired skin integrity .related to decreased mobility, incontinence, revised 2/27/18. Care plan revealed the interventions .Daily skin inspections 5 days post admit, weekly and prn ., date initiated 2/27/18. Review of Resident #24's weekly skin inspections revealed, sporadic skin inspection, averaging 2 skin inspections (instead of 4) per month for the last 6 months. Dates of skin inspections for the last 6 months were 10/10/18, 9/26/18, 9/2/18, 8/22/18, 8/8/18, 718/18, 7/11/18, and 6/27/18. Resident #22 Review of an Admission Record revealed Resident # 22 was a [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment with a reference date of 7/31/18 revealed a Brief Interview of Mental Status (BIMS) score of 99, which indicated Resident #22 was severely cognitively impaired and was unable to complete the interview. Review of Section G: Functional Status revealed Resident #22 was totally dependent on 2 staff members for bed mobility, personal hygiene, and transfers. Review of the current care plan (undated) for Resident #22 revealed, Problem: (Resident #22) has the potential risk for impaired skin integrity related to impaired mobility, incontinence of bowel and bladder and severe [MEDICAL CONDITION]. (Resident #22) is dependent on staff for all ADL'S and has minimal response to verbal and tactile stimuli. She has a PEG tube. Increased risk of pressure areas related to need for elevation of head of bed related to tube feeding. These risk factors lead to an unavoidable pressure ulcer to sacrum that is recurrent. Goal: (Resident #22) will show improvement of impaired skin integrity as evidenced by no s/s of infection and decreased measurements and/or prevention of avoidable impaired skin integrity will be achieved. Interventions: .Daily skin inspections 5 days post admit, weekly, and prn . Review of all Skin assessments provided by the facility revealed the facility completed 5 of the 26 required opportunities in the last 6 months as outlined in Resident #22's care plan. The dates of the skin assessments completed were documented on 5/10/18, 8/2/18, 9/2/18, 9/6/18, 10/11/18. Resident #43 Review of an Admission Record revealed Resident # 43 was an [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment with a reference date of 9/10/18 revealed a Brief Interview of Mental Status (BIMS) score of 99, which indicated Resident #43 was severely cognitively impaired and she couldn't complete the interview. Review of Section G: Functional Status revealed Resident #43 needed extensive assistance for bed mobility, transfers, and personal hygiene with one staff member. Review of a care plan dated 9/13/18, signed by DON B revealed, (Resident #43) is at potential risk for impaired skin integrity related to: poor nutritional intake, impaired functional mobility and incontinence. She does not realize at times her special relation while in wc and can bump up against the railings in hallway. Goal: (Resident #43) will show improvement of impaired skin integrity as evidence by no s/s of infection and decreased measurements and/or prevention of avoidable impaired skin integrity will be achieved. Interventions: .Daily skin inspections 5 days post admit, weekly and prn . Review of all Skin assessments provided by the facility revealed the facility completed 18 of the 26 required opportunities in the last 6 months as outlined in Resident #43's care plan. The dates of the skin assessments completed were documented on 5/22/18, 5/25/18, 5/26/18, 6/5/18, 6/12/18, 6/19/18, 6/26/18, 6/27/18, 7/4/18, 7/10/18, 7/17/18, 7/24/18, 7/31/18, 9/2/18, 9/6/18, 9/7/18, 10/1/18. Resident #66 Review of an Admission Record revealed Resident # 66 was a [AGE] year old male originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment with a reference date of 10/1/18 revealed a Brief Interview of Mental Status (BIMS) score of 5 out of a total possible score of 15, which indicated Resident #66 was severely cognitively impaired. Review of Section G: Functional Status revealed Resident #66 needed extensive assistance for bed mobility and personal hygiene with one staff memember, and was totally dependent for transfers with 2 staff members. Review of Section M: Skin revealed, Resident #66 admitted with one stage 2 pressure ulcer. Reviewed the initial nursing assessment dated [DATE] revealed L. Skin: site: Coccyx. Type: Other (specify) Length/Width/Depth/Stage: Superficial. Review of care plan dated 7/12/18 revealed Focus: Potential risk for impaired skin integrity related to: History of fragile skin, poor nutritional intake, impaired functional mobility and incontinence. signed Director of Nursing (DON) B. Goal: (Resident #66) will show improvement of impaired skin integrity as evidenced by no s/s of infection and decreased measurements and/or prevention of avoidable impaired skin integrity will be achieved. Interventions: . Consult RD/CDM prn to evaluate nutritional approaches . Daily skin inspections 5 days post admit, weekly and prn, Measure open areas upon admission, weekly, prn . Review of all Skin assessments provided by the facility revealed the facility completed 7 of the 17 required opportunities as outlined in Resident #66's care plan, based on his admission date of [DATE]. The dates of the skin assessments that were completed were documented on 7/6/18- initial assessment, 7/8/18, 7/9/18, 8/2/18, 8/23/18, 9/5/18, and 10/11/18. Resident #4 Review of a Face Sheet revealed Resident #4 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #4, with a reference date of 7/10/18, revealed a Brief Interview for Mental Status (BIMS) score of 7, out of a total possible score of 15, which indicated Resident #4 was severely cognitively impaired. The MDS also indicated Resident #4 required supervision and set-up for bathing and was at risk of developing a pressure ulcer. Review of Resident #4's care plan, Skin Integrity, revealed, Focus: .potential risk for impaired skin integrity related to: History of fragile skin, Poor nutritional intake, impaired functional mobility Date Initiated: 10/26/2016 Revision on: 02/14/2017 Goal: Name (referring to Resident #4) will show improvement of impaired skin integrity as evidence by no S/S (sign or symptoms) of infection and decreased measurements and/or prevention of avoidable impaired skin integrity will be achieved. Date Initiated: 10/26/2016 Revision on: 07/24/2018 Target Date: 10/15/2018. Intervention: Skin inspections with am/pm care and showering report abnormal to the charge nurse Date Initiated: 10/26/2016 .Daily skin inspections 5 days post admit, weekly and prn Date Initiated: 10/26/2016 . The date initiated for weekly and PRN skin inspections should be ongoing from 10/26/2016 through current date as there was no target or revision date indicated. Review of Resident #4's Progress Notes: Skin Assessment revealed from 9/1/2017 through 10/11/2018, the facility missed of 45 of 58 weekly opportunities to perform skin inspections.

This citation pertains to intake number MI 223. Based on interview and record review, the facility failed to ensure a functional and/or care planned safety device was in place in 1 out of 3 residents (Resident #502) reviewed for falls, out of a total sample of 3, resulting in facility staff not being alerted to Resident #502 getting up from his wheelchair, which resulted in a fall and a right hip fracture. In addition, a facility failure to provide adequate supervision in addition to a facility failure to ensure a functional and/or care planned safety device was in place. Findings included: Per the Face Sheet, Resident #502 was an [AGE] year old male admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a Minimum Data Set ((MDS) dated [DATE] revealed Resident #502 had a Brief Assessment for Mental Status (BIMS) score of 6 out of 15, which indicated Resident #502 had an impairment in cognitive function. The MDS revealed Resident #502 required extensive assistance with transfers (bed to chair, chair to bed and/or toilet), and did not ambulate. Review of a facility incident report and investigation, not dated, revealed Resident #502 was found on the floor of the bathroom in Resident #502's room. The report indicated Resident #502 was lying on his right side, on the bathroom floor with his head towards the doorway, and his feet towards the toilet. The report revealed Resident #502's pants were pulled down and around his ankles with his brief partially off, and a small amount of stool was noted. The report also revealed a fall alarm (did not reveal what type of alarm) was in place, but was not sounding (alarming) when Resident #502 was found on the floor. The report revealed the alarm string (clip that attached to Resident #502's shirt and then connected to the alarm box via a magnet) was on but detached and lying next to Resident #502. The report revealed Resident #502's right leg was observed to be rotated, and Resident #502 was transferred to the hospital. Review of an CT scan dated 3/25/2017 revealed Resident #502 had a fracture of the right femoral (large leg bone) neck, and also a fracture at the greater trochanter (top of the hip bone). Review of a Fall care plan dated 3/15/2017 revealed Resident #502 was to have a Sensor alarm (a pad that lies underneath a person, and alarms when the person's weight is removed) on his bed and wheelchair. Review of a Certified Nurse Aid (CNA) care guide, that was kept in Resident #502's room hanging on the wall, dated 3/15/2017, revealed Resident #502 was to have a personal alarm (tab alarm that clipped on the person via a string and attached to the alarm box via a magnet) on his bed and wheelchair. In an interview on 4/10/2017 at 2:02 PM, CNA C stated when Resident #502 had fallen a tab alarm was clipped to his shirt, and stated the alarm never sounded at the time Resident #502 got up out of his wheelchair in the bathroom and fell . CNA C stated she had transferred Resident #502 from his bed to his wheelchair that morning before he went to the cafeteria for breakfast. CNA C said there was a pressure alarm on Resident #502's bed, and a tab alarm was on his wheelchair so she clipped the tab alarm to his shirt. CNA C said, although she had checked the placement and functioning of Resident #502's tab alarm at shift change with the off-going CNA, she did not check to assure the tab alarm was working, upon clipping the alarm onto Resident #502's clothing. CNA C stated she did not look at the alarm box when she clipped the alarm string onto Resident #502. In an interview on 4/11/2017 at 10:00 AM, Registered Nurse (RN) D, who was the manager of the hall where Resident #502 had resided, stated the breakfast meal was over, and walking in the hall she had heard Resident #502 yell, Help me, and then went into Resident #502's room to find him lying on the bathroom floor, on his right side. RN D said Resident #502 had a tab alarm that was still clipped to Resident #502, but separated from the alarm box, which would cause the alarm to sound, but RN D said the tab alarm was not sounding when she found Resident #502 on the bathroom floor. RN D said the back of the alarm box, the compartment where the batteries were, did not have a screw in it to keep the cover over the batteries closed, and stated that the batteries were slightly popped out, therefore the alarm would not sound when required to do so. RN D said the CNA care guide that was in Resident #502's room still reflected Resident #502 was to have a tab alarm on his person and while in bed. RN D stated the care plan revealed Resident #502 was to have a pressure alarm on his bed and wheelchair. RN D said this was a recent change in Resident #502's care plan; from a tab alarm to a pressure alarm on his wheelchair. RN D said she did not know what type of alarm Resident #502 was to have on his bed. RN D also said she was not made aware of the alarm , nor why the alarm was changed for Resident #502. RN D stated Resident #502 had made attempts to self transfer without the assistance of staff on the day of his fall. RN D said Resident #502 was scheduled to go home in 3 days. RN D said the paperwork (CNA care guide) never was changed (updated) to reflect the change (update) in Resident #502's care plan, and also said the actual alarm was not changed to a pressure alarm (whenever he was up in his wheelchair) from the tab alarm for Resident #502 , when Resident #502's care plan was updated. RN D said when she found the discrepancy she turned the investigation over to Director of Nursing (DON) B. In an interview on 4/11/2017 at 11:34 AM, Licensed Practical Nurse (LPN) E said she had admitted Resident #502 on 3/14/2017 and said she had put a pressure alarm on Resident #502's bed, but stated she could not recall if she had put an alarm on his wheelchair. LPN E said she had no plan on getting Resident #502 out of bed until therapy could assess him for his ability to stand. LPN E said she worked 6:00 PM to 6:00 AM, and Resident #502 was admitted late into the evening. LPN E said she updated Resident #502's care plan on 3/15/2017, and changed the fall alarm from a tab alarm to a pressure alarm while Resident #502 was up in his wheelchair. LPN E said she could not answer as to why the changes she had made on Resident #502's care plan were not followed through, and changed on the CNA care guide and the actual alarm changed from a tab alarm to a pressure alarm on Resident #502's wheelchair. LPN E said she could not remember if she had made Resident #502's CNA aware that he/she needed to change the alarm on Resident #502's wheelchair. LPN E said she should have made Resident #502's CNA aware of the changes she had made. LPN E said she thought DON B or RN D were supposed to make sure the nursing care plans and the CNA care guides all matched. In an interview on 4/11/2017 at 1:30 PM, DON B said when a nurse made a change on a resident's care plan the nurse was responsible for making all changes to a resident's care plan and CNA care guide. and when a nurse made a change(s) to a resident's care plan, the nurse was responsible to immediately print out the updated care plan and replace the CNA care guide with the new updated care plan. In an interview on 4/11/2017 at 12:45 PM, supplemental Resident #503, who had a BIMS score of 14 out of 15, said he always sat with Resident #502 in the dining room for meals. Resident #503 said on 3/25/2017, the morning of Resident #502's fall, while in the dining room for breakfast, Resident #502 had attempted at least 6 times to get up out of his wheelchair. Resident #503 said staff had to intervene to get Resident #502 to sit back down in his wheelchair. Resident #503 said Resident #502 told him that he was going to his room because he had to use the bathroom. Resident #503 said he had told staff twice that they better go help Resident #502, but stated that staff did not leave the dining room to go assist Resident #502 to use the bathroom. Review of a Shift to Shift Safety Comfort Rounds record dated 3/15/2017 revealed Resident #502 was to have a Sensor (pressure) alarm on bed and chair (wheelchair) The record revealed that the off-going third shift CNA confirmed (via their initials) with the on-coming first shift CNA, and the first shift nurse that the sensor alarm was in place on Resident #502's bed and chair. The record also revealed the first shift CNA, upon ending their shift confirmed with the second shift CNA the sensor alarms were in place on Resident #502's bed and chair. The second shift nurse did not initial confirmation that the alarms were in place. The record revealed for the third shift no initials for either the off-going second shift CNA, the on-coming third shift CNA, nor the third shift nurse. Review of a Shift to Shift Safety Comfort Rounds record dated 3/25/2017 revealed Resident #502 was to have a sensor alarm on his bed and chair (wheelchair). The record revealed, for the first shift, the off-going third shift CNA and the on-coming first shift CNA initialed that the sensor pad was in place on Resident #502's chair, and the first shift nurse also initialed that the sensor pad was in place. Furthermore, the record indicated the off-going first shift and on-coming second shift CNA initialed Resident #502's alarms to his bed and chair were in place. The record indicated the second shift off-going CNA and the third shift on-coming nurse initialed that Resident #502's alarms were in place. Review of nurses' notes dated 3/25/2017, and timed at 8:25 AM, revealed documentation of Resident #502's fall, and revealed an ambulance was called and Resident #502 was transferred to the hospital. Therefore, Resident #502 was not at the facility at the end of the first shift on 3/25/2017 and beyond.

This citation pertains to MI 424. Based on interview and record review, the facility failed to assess and monitor pressure ulcers, in 1 of 2 residents reviewed with pressure ulcers (Resident #91), in a total sample of 4 residents, resulting in the development and worsening of pressure ulcers. Findings include: The Admission assessment dated [DATE] indicated Resident #91 had the [DIAGNOSES REDACTED]. The same assessment revealed Resident #91 was alert and orientated to person, place and time and was admitted to the facility with a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough) on the right buttock, measured as 3 centimeters (cm) by 1 cm with 0 depth. The Admission Assessment was completed by Clinical Consultant I. Prior to facility admission, Resident #91 had a consultation during a hospital stay dated [DATE] that indicated she was a [AGE] year old admitted following a fall requiring cervical decompression with fusion on [DATE]. The same consultation indicated a past medical history that included Friedreich's ataxia (disease that causes nervous system damage and movement problems), and left sided [MEDICAL CONDITION] (weakness caused from a stoke). The same consultation revealed pressure ulcers on gluteal region. The Progress Notes dated [DATE] at 9:45 PM revealed Resident #91's dressing was intact on the right buttock. Progress Notes dated [DATE] at 2:50 PM indicated right buttock has wound that remains. On [DATE] at 10:35 AM, the Director of Nursing (DON) B stated Resident #91 was admitted with a pressure ulcer on the left buttock not the right buttock as 3 other nurses had documented in the residents medical record above. There was no clarification in Resident #91's medical record of the error in the documentation regarding Resident #91's pressure ulcer. Progress Notes dated [DATE] at 7:32 AM, indicated skin is clean and dry and intact except for stage II on left buttocks noted on admission. (The Admission assessment dated [DATE] did not indicate an open area on the left buttock.) Progress Notes dated [DATE] revealed Resident #91 had a Stage II pressure ulcer on the left buttock that re-opened and measured 2 cm by 1.2 cm by 0.1 cm depth and a Stage II pressure ulcer on the coccyx measuring 5 cm by 4.5 cm and had a superficial depth. On [DATE] at 3:00 PM, DON B and Nurse Consultant I confirmed Resident #91 did not have wounds measured including assessment documentation from [DATE] to [DATE]; 15 days there was no documentation in the record reflecting the improvement or decline in Resident #91's pressure ulcers. On [DATE] at 9:00 AM, DON B stated the facility did not complete any formal risk assessments for pressure ulcer risk. Progress Notes dated [DATE] reflected Resident #91's coccyx pressure ulcer was 4.8 cm by 4.5 cm with an increased depth of 2 cm. The same Progress Notes indicated the wound bed had 100% slough with a large amount of purulent drainage. The Same Progress Notes revealed Resident #91 was .compliant with repositioning and minimizing amount of time spent in wheelchair. According to the Admission assessment dated [DATE], under skin issues/definitions, a stage II pressure ulcer did not have slough (yellow [MEDICATION NAME] tissue that consists of [MEDICATION NAME], pus, and proteinaceous material), but a stage III may have slough present. Resident #91's skin impairment care plan dated [DATE] indicated to inspect skin 5 days post admit, weekly and as needed. According to the comprehensive metabolic panel drawn on [DATE], Resident #91's protein levels were low with the Total Protein at 5.3 grams/deciliter (g/dl) (normal 6XXX,[DATE].2 g/dL) and [MEDICATION NAME] (plasma protein) was 3.0 g/dL (normal 3.4 -5.0 g/dL). According to Resident #91's Progress Notes, protein supplements, to aid in wound healing and weight loss, were not implemented until [DATE]. According to the National Pressure Ulcer Advisory Panel at www.npuap.org; adequate calories, protein, fluids, vitamins and minerals are required by the body for maintaining tissue integrity and preventing tissue breakdown. The same source indicated Protein is responsible for the synthesis of enzymes involved in pressure ulcer healing, cell multiplication, and collagen and connective tissue synthesis. All stages of healing require adequate protein. The same source revealed that the recommended range of protein associated with healing currently was between 1.2 to 1.5 grams per kilogram of body weight per day. Review of the Nutritional Services Review dated [DATE] indicated no laboratory values regarding previous [MEDICATION NAME] and protein levels. The same assessment revealed Resident #91 was admitted with a stage II pressure ulcer on the right buttock and estimated protein needs were between ,[DATE] grams needed daily and estimated fluid needs were 2220 cubic centimeters (cc) a day. The same assessment indicated Resident #91 was admitted with a mechanical soft diet and thin liquids and that Resident #91's Food Acceptance was ,[DATE]% at meals. The Weight Management policy and procedure dated [DATE], revealed suggestions to improve intake via wholesome foods such as fortification of foods and offering smaller more frequent meals. On [DATE] at 8:30 AM, DON B stated that enhanced foods, intake and output assessments or a calorie count were not considered for Resident #91's deceased food and fluid acceptance. Resident #91's weight as documented on the Weights and Vitals Summary, indicated on [DATE] her weight was 161 pounds. The same source, on [DATE] indicated a 6 pound weight loss and on [DATE] reflected a 9.8 percent weight loss in less than 30 days. There were no further weights found in Resident #91's medical record from [DATE] until [DATE]. On [DATE], Resident #91's Weights and Vitals Summary reflected her weight had dropped again to 120 pounds. ( )

This citation pertains to MI 424. Based on observation, interview, and record review, the facility failed to implement and evaluate nutritional interventions to ensure prevention of weight loss in 2 of 2 residents reviewed with pressure ulcers (Resident #91 & Resident #93), in a total sample of 4 residents, resulting in avoidable weight loss. Findings include: Resident #93 Resident #93 was observed sitting in his room eating lunch independently on 7/13/16 at 12:05 PM. According to the Progress Notes dated 6/14/16 at 1:15 PM, the Registered Dietician indicated Resident #93 had a weight loss and had a poor appetite. The same note indicated Resident #93 acknowledged he wanted to regain lost weight. Review of the Progress Notes dated 6/14/16 at 1:54 PM, revealed the dietician recommended Prostat 30 milliliters (ml) three times daily for supplement to improve intake of calories and protein. Review of Resident #93's electronic Progress Notes indicated the [DIAGNOSES REDACTED]. On 7/13/16 at approximately 10:50 AM, Registered Nurse (RN) H stated there was not any supplements ordered for Resident #93. The Nutritional Services Quarterly Review dated 7/11/16, indicated Resident #93 had lost 5 percent (%) of his weight in 30 days, 7.5 % in 90 days and 10% in 180 days. The same assessment indicated Resident #93 Food Acceptance ranged from 25-100% and fluid acceptance was 50-100%. No new interventions were implemented. There was no mention of Prostat supplement that was recommended on 6/14/16. Resident #93's Weights and Vitals Summary revealed on 6/7/16 he weighed 162.2 pounds and on 7/7/16 his weight had decreased to 146.2 pounds. This weight loss was severe at a loss of 9.8 % in 30 days. In an interview on 7/14/16 at 11:30 AM, Director of Nursing (DON) B confirmed that the Prostat that was recommended on 6/14/16 for Resident #93 was not implemented because of the Dietitian was not clear in where to place recommendations. DON B stated that no new interventions to prevent additional weight loss were implemented until the week of the abbreviated survey on 7/13/16. ( ) Resident #91 The Admission assessment dated [DATE] indicated Resident #91 had the [DIAGNOSES REDACTED]. The same assessment revealed Resident #91 was alert and orientated to person, place and time and was admitted to the facility with a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough) on the her buttock. Prior to facility admission, Resident #91 had a consultation during a hospital stay dated 3/3/16 that indicated she was a [AGE] year old admitted following a fall requiring cervical decompression with fusion on 2/19/16. The same consultation indicated a past medical history that included Friedreich's ataxia (disease that causes nervous system damage and movement problems), and left sided [MEDICAL CONDITION] (weakness caused from a stoke). The same consultation revealed pressure ulcers on gluteal region. Progress Notes dated 4/25/16 reflected Resident #91's coccyx pressure ulcer had increased in size to 4.8 cm by 4.5 cm and a depth of 2 cm. The same Progress Notes indicated the wound bed had 100% slough with a large amount of purulent drainage. The Same Progress Notes revealed Resident #91 was .compliant with repositioning and minimizing amount of time spent in wheelchair. According to the Admission assessment dated [DATE], under skin issues/definitions, a stage II pressure ulcer did not have slough (yellow [MEDICATION NAME] tissue that consists of [MEDICATION NAME], pus, and proteinaceous material), but a stage III may have slough present. Nutritional Services Review dated 3/14/16 indicated no laboratory values regarding previous [MEDICATION NAME] and protein levels. The same assessment revealed Resident #91 was admitted with a stage II pressure ulcer on the right buttock and estimated protein needs were between 89-111 grams needed daily and estimated fluid needs were 2220 cubic centimeters (cc) a day. The same assessment indicated Resident #91 was admitted with a mechanical soft diet and thin liquids. The same assessment indicated Resident #91's Food Acceptance was 25-75% at meals. According to the comprehensive metabolic panel drawn on 3/15/16, Resident #91's protein levels were low with the Total Protein at 5.3 grams/deciliter (g/dl) (normal 6.4-8.2 g/dL) and [MEDICATION NAME] (plasma protein) was 3.0 g/dL (normal 3.4 -5.0 g/dL). According to Resident #91's Progress Notes, protein supplements, to aid in wound healing and weight loss, were not implemented until 4/20/16. According to the National Pressure Ulcer Advisory Panel at www.npuap.org; adequate calories, protein, fluids, vitamins and minerals are required by the body for maintaining tissue integrity and preventing tissue breakdown. The same source indicated Protein is responsible for the synthesis of enzymes involved in pressure ulcer healing, cell multiplication, and collagen and connective tissue synthesis. All stages of healing require adequate protein. The same source revealed the recommended range of protein associated with healing currently was between 1.2 to 1.5 grams per kilogram of body weight per day. The Weight Management policy and procedure dated April 2015, revealed suggestions to improving intake via wholesome foods such as fortification of foods and offering smaller more frequent meals. In an interview on 7/14/16 at 8:30 AM, Director of Nursing (DON) B stated that enhanced foods, intake and output assessments or a calorie count were not considered for Resident #91's decreased food and fluid acceptance. Resident #91's weight as documented on the Weights and Vitals Summary, indicated on 3/11/16 her weight was 161 pounds. The same source, on 3/16/16 indicated a 6 pound weight loss and on 3/23/16 reflected a 9.8 percent weight loss in less than 30 days. There were no further weights found in Resident #91's medical record from 3/23/16 until 4/28/16. On 4/28/16, Resident #91's Weights and Vitals Summary reflected her weight had dropped again to 120 pounds. On 7/14/16 at 10:35 AM, The DON stated the facility did not have a Restorative Dining Program. ( )

This citation pertains to intake number MI 177 Based on observation, interview, and record review the facility failed to provide adequate supervision for safety to prevent falls with major injury in 1 of 3 sampled residents (#101) reviewed for falls, out of a total sample of 4 residents, resulting in a Resident #101 being found on the floor in a storage room with a displaced left hip fracture. Findings include: According to the the facility, Wandering Resident Elopement Precautions Policy and Procedure last revised July, 2013, under, Policy: It is the policy of this facility to assess residents and plan their care to limit injury from foreseeable accidents related to wandering and exit seeking behavior which has the potential to lead to elopement. Definition: Wandering: Aimless or purposeful motor activity that causes a social problem such as becoming lost, leaving a safe environment, or intruding in an inappropriate place .Procedure: a. The history of behaviors, including wandering and exit seeking, will be obtained prior to or upon admission .c. The MDS process; Section E 0900 (wandering), along with Section B (cognitive) will be utilized to continue to assess and evaluate the risk quarterly and post significant change in status .e. Each resident's level of supervision and elopement prevention interventions will modified according to these assessments. The plan of care will be updated accordingly. According to the facility, Accident/Incident Reports Policy and Procedure, last revised 2/15, under, Policy: It is the policy of this facility to complete an accident/incident report for unexplained bruises or abrasions; accidents or incidents where there is injury or the potential to result in injury; and resident to resident altercations .Definition: An accident is defined as any happening not consistent with the routine operation of the facility that does or has the potential to result in bodily injury or property damage .Procedure .4. When witnessing a resident fall or when a resident is observed on the floor and presumed to have fallen, and initial sequential assessment that includes a minimum of the following will be completed by the Licensed Nurse. a. Full body inspection for any obvious deformity, bleeding, bruising, laceration or other signs of traumatic injury. b. Assessment for pain. c. Assessment for active followed by passive Range of Motion. d. Assessment of head injury with initial neurological evaluation if indicated. e. Vital signs. f. Evaluation of indication for emergency medical treatment .6. Notify the family and health care practitioner as soon as possible wit assessment findings .8. Documentation in the ID Notes should include a description of the unusual occurrence, results of the assessment, confirmation of family and physician notification, and remedial measures or treatments .10. The resident will be assessed closely for any changes from baseline habits that could be an indication that there is an injury. 11. Changes in the resident's status will be reported to authorized representatives and the health care practitioner . Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected Resident #101 was a [AGE] year old female with [DIAGNOSES REDACTED]. The MDS reflected Resident #101's ability to make daily decisions was severely cognitively impaired with behaviors that occur 1-3 days a week that impact others including privacy, care or living environment. The MDS reflected Resident #101 had daily behaviors of wandering that placed Resident #101 at significant risk of getting to a potentially dangerous place. The MDS reflected Resident #101 was independent with transferring and ambulation and required one person physical assist with dressing, eating, hygiene and bathing. Review of the Altered Mobility and Activities of Daily Living (ADL) Care Plan dated 8/5/2014, revealed intervention that included, Ambulation: Independent with supervision, wanders, can be difficult to redirect .Behavior: Refer to and document on the resident individualized behavior log .Fall Intervention: Direct away from high traffic areas and keep environment clutter free as (Resident #101) allows .Fall Interventions: Encourage to wear non-skid footwear .Transfer: Independent. Review of the Psychosocial Distress Care Plan dated 8/8/14 and revised 2/24/15, revealed interventions that included, Evaluate changes in mood and socialization. (Resident #101) is normally smiling and fairly pleasant so we would look for any changes such as negative behaviors or less walking in the halls .Gently redirect (Resident #101) if she begins to go somewhere she is not supposed to such as another residents room .Identify behavioral precipitant with use of the behavior log .Support and reward positive behavior through acknowledging her and saying hello to her as you pass her in the hallway as she wanders. Review of the Fall Care Plan dated 8/5/14, revealed Resident #101 had a potential risk for falls or injury related to Resident #101 desire to ambulate through the building and her memory problems. The Care Plan revealed Resident #101 is not able to express her needs verbally and the staff had to rely on non-verbal cues to assist in meting her needs. Interventions included, See ADL plan of care for fall risk interventions .With history of exit seeking and mobility independence apply interventions as indicated and reassess prn. Review of the facility Incident/Accident report dated, 9/6/15 at 10:40 a.m. reflected Resident #101 had an un-witnessed fall in an unlocked storage room. The report reflected, Immediate action taken: T 98.5, B/P 136/72, R 22, P 85. Passive ROM assessed and was WNL, neurological assessment performed and WNL, head to toe assessment and no injuries noted, q 15 min. checks initiated. Key pad locked applied to storage door on 09/08/2015 .Injury Type: No injuries observed post incident. Report completed by Registered Nurse (RN) L (assigned to Resident #101). In a telephone interview on 9/24/15 at 10:39 a.m. CNA J reported that on 9/6/15 Resident #101 was found on the floor in the west storage room. CNA J reported another resident informed CNA J that Resident #101 was on the floor in the storage room. CNA J reported she entered the west hall storage room and the door was open and saw Resident #101 on the floor and called for assistance. CNA J reported that CNA F arrived as well as RN E. CNA J reported prior to the fall on 9/6/15 Resident #101 had been known to wander in facility and open doors and enter rooms. In an interview on 9/23/15 at 1:55 p.m. RN E (first nurse responder to fall) verified her witness statement from 9/8/15 related to Resident #101 fall on 9/6/15 at 10:40 a.m. was correct. RN E reported she was called to the storage room on the west hall by Certified Nurse Aid (CNA) F. RN E reported that Resident #101 was laying flat on her back with knees bent in the middle of the storage room with her head towards the window and feet towards the door. RN E reported she asked Resident #101 what happened and Resident #101 responded, no, no, no. RN E reported that Resident #101 was trying to to get up while RN E was doing neurological check and head to toe assessment. RN E reported she did not do a skin assessment and did not rotate Resident #101's hips at that time. RN E reported one of the CNA's assisted RN E stand Resident #101 with the use of a gait belt and Resident #101 started to back step and was unsteady. RN E reported Resident did not demonstrate any signs of pain at that time. RN E reported Resident #101 was placed in a wheelchair close by and RN L arrived and transported Resident #101 out of the storage room and back towards Resident #101's hall. In a telephone interview on 9/24/15 at 12:10 p.m. RN L reported she was Resident #101's nurse on 9/6/15 when Resident #101 was found on the floor of the west storage room. RN L reported an unnamed CNA had come to get her related to Resident #101. RN L reported RN E was with Resident #101 upon arrival to the west storage room and Resident #101 was on her back on the floor laughing in no distress. RN L reported she did a neurological assessment and range of motion and skin assessment and Resident #101 had no guarding, crying or facial grimacing. RN L reported Resident #101 was assisted off the floor to the wheelchair and she transported Resident #101 back to the Nurses Station #2. RN L reported she completed the Incident/Accident reported and called Resident #101's husband, DON B, the Administrator (ADM) Aand notified Doctor P via fax of Resident #101's fall. This surveyor asked RN L if she called the doctor and RN L reported, No, if obvious injury I would of called on call doctor. RN L reported she documented on the 24 hour report and started short term Care Plan. In an observation and interview on 9/23/15 at 2:10 p.m. RN E demonstrated the west hall storage room. The room was large with a window and appeared to look similar to an old resident room and had an automatic closing door noted with large equipment noted in storage room that included wheelchairs, recliners, and large furniture. RN E reported that when Resident #101 was found in the storage room on the floor there was a wheelchair by her right side, head area, and left lower leg area. In an interview on 9/23/15 at 2:20 p.m. CNA F reported that on 9/6/15 she was called to the west storage room by CNA J. CNA F reported when she entered the storage room Resident #101 was laying on her back in the middle of the floor trying to get up. CNA F reported she left the storage room to get RN E while CNA J stayed with Resident #101. CNA F reported Resident #101 normally would ambulate independently in halls. Review of the Radiology Report dated 9/7/15 at 4:27 p.m. revealed Resident #101 has an acute left subcapital hip fracture. The report indicated the report was faxed to the facility at 4:29 pm. Review of the Interdisciplinary Progress Notes dated 9/7/15 at 8:10 p.m. for Resident #101 revealed, X-ray performed at 1530 (3:30 pm). X-ray results received at 1950 (7:50 pm). Physician notified of X-ray results and order obtained to send resident to E.R. for evaluation and treament at 2000 (8:00pm). Husband notified at 2002 (8:02pm). Ambulance called at 2003 (8:03pm) and arrived at 2010 (8:10pm) to transport resident to E.R. Report called into (named hospital) at 2012 (8:12pm). In an observation on 9/23/15 at 3:50 p.m. Resident #101 was in her room in bed positioned on her back with no pillow noted between legs. Resident was awake with eyes open and was non-verbal. In an interview on 9/24/15 at 9:40 a.m. CNA G reported that Resident #101's baseline prior to the fall on 9/6/15 was that she would walk independently in the halls all day. In an interview on 9/24/15 at 10:05 a.m. CNA H reported she was familiar with Resident #101 and reported that prior to the fall on 9/6/15 Resident #101 would typically walk independently in halls and open doors at times. In an interview on 9/24/15 at 10:10 a.m. CNA I reported she was familiar with Resident #101 because CNA I would see Resident #101 walking in the halls routinely and open doors and enter other resident rooms. CNA I reported the facility uses stop signs on some resident doors to prevent wandering residents from entering. CNA I reported she did not work on 9/6/15 but reported when CNA I returned to work there was a lock on the west hall storage room door that was not there before. In an interview on 9/24/15 at 2:30 p.m. Environmental Service Manager (ESM) N reported he did not have a work order for the door lock that was placed on the west storage room door recently. ESM N reported with the help of ADM A they identified several doors that needed locks and an order was placed. ESM N reported he did not keep track what day each lock was placed on each door. ADM A reported the lock was placed on the west hall storage room door on 9/8/15. ( )

This citation pertains to intake number MI 663 and MI 854. Based on interview and record review, the facility failure to prevent resident to resident abuse in 1 of 6 sampled residents (Resident #501) reviewed for abuse, from a total sample of 6 residents, resulting in an Immediate Jeopardy when, on [DATE], Resident #500, who was independently mobile and had recent prior history of aggressive and assaultive behaviors while at the facility, forcefully threw Resident #501 to the floor and hit him five times about the face with a shoe, causing a bilateral traumatic subarachnoid hemorrhage (bleeding around the brain), an intraparenchymal brain contusion (bruising of the brain), and a left frontal linear skull fracture. Resident #501 subsequently died on [DATE] as a result of severe, traumatic head injury. This deficient practice placed all 74 residents who resided at the facility, at risk for serious harm/injury and/or death. Findings include: Per the Face Sheet, Resident #500 was a [AGE] year old male admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a "Physician Determination of Decision Making Capability" dated [DATE] revealed that Resident #500 was deemed, by two physicians, to not be capable of, "understanding the Bill of Rights and participate in Medical Treatment Decisions." Review of a "Minimum Data Set" ((MDS) dated [DATE] revealed Resident #500 scored a 5 out of 15 on his "Brief Interview for Mental Status" (BIMS) which indicated he was severely cognitively impaired. Review of an MDS dated [DATE] revealed Resident #500 score decreased to a "1" on his BIMS score. The MDS dated [DATE] revealed Resident #500 exhibited, "Physical behavioral symptoms directed towards others". Review of the Nurses' Notes, dated [DATE] at 9:55 PM revealed, Resident #500 approached the nurses' station and "slammed fists on counter" and then "slammed" his door. Review of the Incident report dated [DATE] at 2:18 PM, revealed that Resident #500 had approached Certified Nurse Aid (CNA) #4 while CNA #4 was approaching the nurses' station and said "You!" then "punched" CNA #4 in the chest, and then Resident #500 attempted to punch CNA #4 in the face but CNA #4 blocked the punch. The "Immediate Interventions Taken" were, "He (Resident #500) calmed down, sat him in the chair and he went to his room. A little while later he (Resident #500) came back out apologizing and crying saying, (I am sorry my people have died .) He hugged me (CNA #4) twice and repeated apologizing while he cried." Review of the Incident report dated [DATE] at 5:30 PM, revealed Resident #500 "suddenly" emerged from his chair and approached CNA #5 and "grabbed" the right side of CNA #5's neck. The "Immediate Interventions Taken" were, "Separation". The incident report did not reveal separated from whom, what, or to where. No further interventions to prevent Resident #500 from harming any other person (resident or staff) at the facility were noted to have been implemented. Review of a care plan titled, "(Resident #500) has the potential for psychosocial distress ..." dated [DATE], revealed an intervention dated [DATE], "Behavior monitoring as identified on the individualized log; utilize log for patterning and intervention revision as indicated", and dated [DATE], "Identify behavioral precipitant with use of the behavioral log." There were no new interventions added to the care plan in response to the [DATE], [DATE], or [DATE] incidents. All behavioral logs for Resident #500 were requested from Administrator #1 on [DATE] at 8:50 AM. On [DATE] at 9:50 AM one "Behavioral Tracking Log" for the month of [DATE] was received. No other behavioral logs for the months of September, October, November or [DATE] for Resident #500 were received as of [DATE] at 3:10 PM. The [DATE] behavioral log, under "Behaviors/Mood" in box #1, revealed, "Aggression towards others." The log did not have any documentation of a behavior for Resident #500 for the month of [DATE]. The log was noted to have a tracking section for behaviors that included documentation of the date, time, behavior, precipitating event, intervention, response, and signature of the staff member. The log also revealed a section for, "End of the Month Analysis" for behaviors, which was also blank. Review of the "Behavioral Monitoring/Management Program" policy and procedure dated [DATE] revealed, under Procedure #1, "The following criteria may be used to identify residents placed on the behavior management/monitoring program". Following Procedure #1 the policy revealed, Procedure #1e, "Physically abusive where others were hit, shoved, scratched." Under #2, "Residents with behaviors will be monitored utilizing the behavior logs, monthly psychoactive monitoring note summaries from the behavioral log, ID (Interdisciplinary Team, Should read IDT) notes, social work, and community mental health or other documentation." Under #3, "The IDT will review collected data." Under #4, "The interdisciplinary team will establish individualized interventions for each targeted behavior. The team will qualitatively and quantitatively determine the resident's response to these interventions. "And under #5, "Recommendations and a plan of care will be determined and documented in the resident's medical record." Review of "Resident Visual Observation Assessment" revealed Resident #500 was placed in 15 minute observation, but the dates were sporadic and did not consistently have staff documentation of the 15 minute checks, there were many empty spaces where facility staff should have put their initials of preforming a 15 minute observation of Resident #500. The first observation assessment was dated [DATE] and the latest one was dated [DATE]. The observation assessment had a section for documenting the time of the observation, the location, the residents behavior, and staff initials. The assessment record did not have any sections of what interventions were added and/or the outcome of the interventions. Review of the Incident report for Resident #501 dated [DATE] at 8:10 PM revealed, Resident #500 was standing at that the nurses' station speaking to Licensed Practical Nurse (LPN) #2, when Resident #501 approached the nurses' station. The incident report revealed Resident #500 turned to Resident #501 and stated, "Stop it, just stop it". Resident #500 then put his left hand on Resident #501's chest and his right hand to Resident #501's back and pushed Resident #501, with force, to the ground. The report revealed Resident #500 had a shoe in his hand and began hitting Resident #501 in the face with the shoe. The report also revealed that LPN #2 did not observe Resident #501 hit or touch Resident #500 in anyway prior to the occurrence. The report indicated LPN #2 was unsure if Resident #501 hit his head on the wall first, then the floor, or the floor only. The report revealed Resident #501 complained of pain when staff turned him to his right side to assess the back of his head. Resident #501 also complained of nausea and his eyes shifted to the left and right, back and forth. The report revealed Resident #501 had a cut to his right upper lip, two skin tears to his right upper forearm near his elbow. Resident #501 was transferred to the hospital and the local police agency was notified. Review of the Incident report dated [DATE] at 8:10 PM for Resident #500 revealed he was listening to a conversation between the nurse and Resident #501 then turned and stated, "'Stop it, just stop it' with agitation in his voice while placing his left hand on the upper chest/neck region of (Resident #501) and his right hand on his left rib/back region, pushing him backward." After the residents were separated, the nurse asked Resident #500 if he remembered what had happened. Resident #500 responded, "The one who got pushed? Yeah I did it". When asked why, Resident #500 responded, "Well, you see. He just, he just was in that position. He was in that position where, where I didn't like it. I just didn't want anymore fighting. No more fighting, fighting, fighting. He hit me first, so I got him back." Review of the hospital records dated [DATE] revealed a CAT scan result that showed Resident #501 received from the resident to resident incident a "Left frontal parietal skull fracture" (the front of the skull) and a "Subarachnoid hemorrhage (bleeding in the brain). Review of the hospital "Admitting History and Physical", dated [DATE] revealed, "Patient (Resident #501) was the victim of an assault and suffered fracture of parietal bone (skull bone that makes up each side of the skull) of skull leading to subarachnoid hemorrhage following injury, no loss of consciousness. He also had abrasion to right elbow and occiput (back of head)...The patient is a resident of a nursing (home) and was reportedly assaulted by another resident who slammed the patient against the wall and then threw him down to the ground." The report revealed Resident #501 had to receive platelets (blood component) due to excessive bleeding on his brain. Review of a "Consultation Report" dated [DATE] (no time), revealed that a repeat CAT scan was performed which revealed Resident #501 had a bilateral (both sides) subarachnoid hemorrhage and intraparenchymal brain contusion (bruise on the brain tissue), along with a left frontal skull fracture. The consult revealed Resident #501's brain had shifted and there was compression (worsening of the bleeding on the brain) on the left side of his brain. The consult revealed there was no appropriate neurosurgical intervention for Resident #501 and a poor outcome was suspected. Review of a "Hospital Course" dated [DATE] (no time) revealed that Resident #501's family requested for comfort measure only and no attempts to prolong Resident #501's life. Review of the hospital Nurses' Notes revealed on [DATE] at 1:17 PM, Resident #501 had ceased breathing and was pronounced dead on [DATE] at 1:17 PM. In interviews conducted on [DATE] at 12:32 PM and [DATE] at 10:00 AM, LPN #2 stated that Resident #501 had approached the nurses' station and asked to see his wife (who also resided at the facility). LPN #2 said she was sitting behind the nurses' station talking with Resident #500 who was happy and joking prior to Resident #501 walking up the nurses' station. LPN #2 said she told Resident #501 that his wife was sleeping at the time. LPN #2 said Resident #501 would not accept the answer and asked two more times, and that Resident #501's voice got louder each time he asked about his wife. LPN #2 said Resident #501 stated that he did not see why he could not see her (his wife). LPN #2 said the third time that Resident #501 asked about seeing his wife was when Resident #500 turned and "pushed" him. LPN #2 said she saw Resident #500 put his left hand on Resident #501's neck/chest area, and his right hand on Resident #501's back and then "forced" Resident #501 to the floor. LPN #2 said it was at approximately the half-way point of falling backwards when Resident #500 let go of Resident #501. LPN #2 stated that Resident #500 "took" Resident #501 down to the floor with force and said "it was intentional". LPN #2 said she heard a "thud" and upon going around the nurses' station she saw Resident #501's head approximately 1 inch from the brick wall, and said when she got to Resident #501, Resident #500 was hitting Resident #501 with a shoe, and that Resident #500 hit Resident #501 five times in the face with the shoe. LPN #2 said she put her arms around Resident #500 and told him that it was "ok". LPN #2 reported Resident #500 said, "No, it's not." LPN #2 said two other staff members came to assist. LPN #2 also stated that when Resident #500 was hitting Resident #501 in the face with a shoe, Resident # 501 did not try to stop Resident #500 from hitting him, and that Resident #501 was not responsive during the time Resident #500 hit him in the face with a shoe. LPN #2 said Resident #501 was transferred to the hospital. LPN #2 said Resident #500 and #501 had not interacted with, nor looked at each other, while standing at the nurses' station prior to the incident. LPN #2 said she had not been made aware of any previous spontaneous physical aggression from Resident #500. In an interview on [DATE] at 2:46 PM, LPN #6 stated that she responded to the incident on [DATE] between Resident #500 & 501. LPN #6 said she was in room [ROOM NUMBER] when she heard noise that sounded "panicky". LPN #6 said she first saw Resident #500 hitting something, but stated that she could not tell what he was hitting until she went around the nurses' station and saw Resident #500 hitting Resident #501 with a shoe. LPN #6 said she put her arms around Resident #500 and got him away from Resident #501. LPN #6 said she could see blood on Resident #501's right upper lip and when she turned her attention to Resident #501, he was talking and said that he had a headache. LPN #6 said she did not know where Resident #500 got the shoe from. LPN #6 said she had seen Resident #500 on a 1:1 observation before, but did not know why and thought it was approximately 3 months ago. LPN #6 said there was a "baseball" size blood spot on the floor where Resident #501's head was. In an interview on [DATE] at 3:14 PM, LPN #7 said she assisted Resident #500 back to the nurses' station, in the other hall. LPN #7 said Resident #500 was crying, and stated that he did not mean to (hurt Resident #501). LPN #7 said when the police approached Resident #500 he stood up and crossed his arms to the police, and the police told Resident #500 that they were not taking him to jail, but stated that he was to keep his hands to his self. In a second interview on [DATE] at 10:10 AM, LPN #7 stated that Administrator #1 had told her that Resident #500 had a "problem" with Certified Nurse Aids (CNA) #9 &10. LPN #7 said she did not know what the problem was, but that the problem was with black males, but females were not a problem. LPN #7 said she was instructed that CNAs #9 &10 were not to care for Resident #500. LPN #7 said she did not write this instruction on Resident #500's care plan and stated that she did not know if Administrator #1 had either. LPN #7 said no other interventions were put into place for Resident #500 (regarding his previous physically aggressive behaviors). In an interview on [DATE] at 10:15 AM, LPN #11 stated that she recalled the incident on [DATE] when Resident #500 punched CNA #9 on the chest. LPN #11 stated that she did not write anything (problems, goals, interventions) on Resident #500's care plan in regards to the [DATE] incident. LPN #11 said she "left that up to the Director of Nursing (DON) to make changes on resident's care plans and add interventions." Upon departure from the facility on [DATE] at 1:00 PM, Administrator #1 stated that she had written on Resident #500's care plan (did not state which care plan) that Resident #500 was to have no males caring for him (stated she did not want to single out black males so she put all males on the care plan). Administrator #1 was informed that this surveyor did not see the stated intervention on any of Resident #500's care plans. Administrator #1 then stated that the care plan she had written the intervention on was resolved (care plan was no longer active). In another interview on [DATE] at 3:40 PM, Administrator #1 stated that she "figured" Resident #500 did not like black men, because CNA #9 &10 were black men. Administrator #1 stated that she discontinued the care plan that included Resident #500 was not to have any male caregivers because Resident #500 did not have any more behaviors. Administrator #1 said Resident #501 was a white male. In an interview on [DATE] at 10:41 AM, Social Worker (SW) #8 stated thatout of concern for Resident #500 she had instituted a "sitter" (staff member who sits with resident at all times), but stated that she had not documented anything about the sitter anywhere in Resident #500's medical record. SW #8 said she was not aware that Resident #500 was a "red flag" (for aggression), but that Resident #500 was mostly tearful. SW #8 said she guessed she did not document anything on Resident #500, but stated that in "hind-sight" she should have. SW #8 said she was not made aware Resident #500 had any circumstances, behaviors, or aggression towards any staff members. SW #8 said when a resident behavioral type of incident occurred she would discuss the incident with the appropriate charge nurse and start a behavioral log. SW #8 said the unit Clinical Care Coordinator (CCC) or herself would update the appropriate care plan. SW #8 said she would document her interventions in the IDT notes. SW #8 stated that she documented every quarter in resident IDT notes unless the resident had an occurrence of behavioral incidents, and stated that then she would document more often. SW #8 stated that a antipsychotic medication meeting was held every month, and stated that she would take the Behavioral Tracking Logs to the meeting. SW #8 said that resident care plan were not brought to the meeting for updates, and/or review. Review of Resident #500's IDT notes dated [DATE] through [DATE] revealed no documentation from SW #8 in regards to Resident #500's aggression or behaviors. Review of IDT notes dated [DATE] at 4:40 PM, revealed that Resident #500 had become more frustrated, wanting to leave the facility in a staff member's vehicle. The notes revealed Resident #500 had an increase in difficulty with re-direction and was angry with his wife for leaving him at the facility. The notes revealed that Resident #500's behaviors had become more frequent. Review of an IDT note dated [DATE] at 7:49 PM, revealed Resident #500 was observed going in and out of other resident's rooms and taking items out of the rooms. Review of IDT notes dated [DATE] at 11:10 AM & 10:00 PM, and [DATE] at 2:00 AM revealed Resident #500 was up ambulating throughout the facility, "as usual". The notes did not reveal any documentation from SW #8 in regards to Resident #500 being mostly tearful. Review of Resident #500's current active care plans revealed no interventions prohibiting male staff members caring for Resident #500. Review of Resident #500's care plans for falls dated [DATE], psychosocial distress dated [DATE], and mobility and activities of daily living dated [DATE], including Resident #500's care plan that were not relevant to behaviors and ambulation were reviewed. None of the care plans revealed any initial or updated interventions for Resident #500's increased frustration and anger with his wife, wanting to leave the facility, increase difficulty with re-direction, and Resident #500's wandering in and out of other resident's rooms and taking items out of other resident rooms. On [DATE] at 3:00 PM, Administrator #1 was notified of an Immediate Jeopardy due to the facility ' s failure to prevent the abuse, assault and injury to Resident #501 by Resident #500 on [DATE] and the failure to provide an assessment and interventions for Resident #500 after two recent prior incidents of aggressive assaultive behavior. Resident #501 subsequently died of the injuries sustained at the facility on [DATE]. On [DATE], this surveyor verified that the facility implemented the following to remove the Immediate Jeopardy: 1). On [DATE], Resident #500 was sent for an emergency room visit with the request for a psychiatric evaluation following the incident. The resident was sent again on [DATE] to the emergency room for a psychiatric evaluation and was admitted under a petition. 2). On [DATE],5 like residents include residents with MDS responses of a, b, or c under EO200 were reviewed for psychiatric care plans and updated as indicated 74 out of 74 residents were reviewed. Two like residents were verified and care plans updated and reviewed. Care plan interventions added include 1:1 observation in the event of escalating behaviors. A behavior book verified to be at each of the two nurses' stations for staff reference. The CNA's will continue to document behaviors and the social service and or designees will review this log daily. 3). On [DATE], the "Behavior Monitoring and Management Program policy was reviewed and deemed congruent with regulation and standard of practice. 4). Beginning [DATE], education had begun for 55 nursing staff on documentation and intervention expectations. Staff will receive the education at the start of their shift. Beginning [DATE] all staff will receive education regarding therapeutic interventions for behaviors, 2 of 39 staff members had been completed as of [DATE]. The remaining staff will be educated prior to working their next shift. 5). Beginning [DATE], all residents exhibiting aggressive behaviors will immediately be assessed for appropriate interventions and care plans updated accordingly. 6). On [DATE], the Social Worker/designee will continue to be responsible for reviewing and analyzing behavior logs or other documentation reflecting resident's behavior. 7). On [DATE], the Clinical Care Coordinators (CCC) were informed that they are responsible to manage resident behaviors in the event the Social Worker is absent, 3 out of 3 CCC's had been informed. 8). On [DATE], it was confirmed that licensed staff have all emergency numbers of department head at immediate reference to make appropriate notifications in the event of off duty situations. 9). Beginning [DATE], behavioral management is reviewed weekly with the IDT members. 10). Beginning [DATE], the physician will be notified when significant behaviors occur to review the possibility of additional psychiatric intervention. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of pattern and severity of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy due to the fact that not all facility staff had been educated and sustained compliance had not yet been verified by the State Agency. ( )

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROTECT 1 OF 4 (#18) SAMPLED RESIDENTS REVIEWED FOR ABUSE FROM A TOTAL SAMPLE OF 17 RESULTING IN PSYCHOSOCIAL HARM IN THE FORM OF GENERALIZED FEAR, ANXIOUSNESS AND FEAR OF RETALIATION, AND SLEEPLESSNESS. FINDINGS INCLUDE: A GROUP MEETING WITH 11 RESIDENTS TOOK PLACE ON 5/30/2013 AT 10:00 AM IN THE WEST DAY ROOM. DURING THE DISCUSSION OF STAFF TREATMENT AND RESIDENT ABUSE, RESIDENT #18 REVEALED THAT A STAFF MEMBER HAD YELLED AT HER DURING THE NIGHT SHORTLY AFTER HER ADMISSION (4/7/2013) AND CAUSED HER A TO SUFFER "TREMENDOUS AMOUNT OF FEAR". RESIDENT #18 CONFIRMED THAT SHE REPORTED THE STAFF PERSON YELLING AT HER TO THE EVENING NURSE (STAFF "Q") RIGHT AWAY. RESIDENT #18 THEN REQUESTED A PRIVATE MEETING AFTER THE GROUP MEETING. ACCORDING TO THE ADMISSION MINIMUM DATA SET ((MDS) dated [DATE], RESIDENT #18 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #18 WAS ALSO IDENTIFIED AS NOT HAVING ANY BEHAVIOR ISSUES. DURING AN INTERVIEW ON 5/31/2013 AT 8:45 AM, RESIDENT #18 IDENTIFIED HERSELF AS A LICENSED PRACTICAL NURSE WITH [AGE] years EXPERIENCE AS A PSYCHIATRIC NURSE AND WAS ONLY IN THE FACILITY FOR A SHORT TIME FOR REHABILITATION FOLLOWING FOOT RECONSTRUCTION SURGERY. A REVIEW OF THE CARE PLAN FOR RESIDENT #18 REVEALED DISCHARGE PLANNING WAS IN PLACE FOR A RETURN TO THE COMMUNITY AND THAT STAFF WERE ASSISTINGTHE RESIDENT WITH ALL ACTIVITIES OF DAILY LIVING RELATED TO HER FOOT SURGERY AND NON-WEIGHT BEARING STATUS. AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) TOOK PLACE ON 5/30/2013 AT 1:15 PM IN HER OFFICE. A REQUEST WAS MADE FOR THE INVESTIGATION REPORT OF THE ABOVE INCIDENT FOR RESIDENT #18. THE DON STATED THAT SHE DID NOT HAVE ANY "WRITTEN" INVESTIGATION. THE DON ALSO STATED THAT SHE DID NOT CONSIDER THE ABOVE INCIDENT AN ALLEGATION OF ABUSETHE DON STATED THAT SHE TALKED WITH THE CERTIFIED NURSING ASSISTANT (CNA), STAFF "V" ABOUT THE INCIDENT AND STAFF "V" STATED THAT SHE HAD THROAT SURGERY AND THAT HER VOICE SOUNDED LOUDER THAN WHAT SHE INTENDED IT TO. THE DON VERIFIED THAT STAFF "V" CONTINUED TO WORK AT THE FACILITY, WAS NEVER REMOVED FROM DUTY AND CONTINUED TO CARE FOR OTHER RESIDENTS, FOLLOWING THE ALLEGATION OF VERBAL ABUSE. THE DON CONFIRMED THAT THE INCIDENT WAS NEVER REPORTED TO THE STATE AGENCY. ON 5-30-2013 APPROXIMATELY 15 MINUTES AFTER THE ABOVE INTERVIEW WITH THE DON, LICENSED PRACTICAL NURSE, AND STAFF "Q" CAME TO THE SURVEYOR'S CONFERENCE ROOM AND PROVIDED THE SURVEYORS WITH A "COMPLAINT FORM" DATED 4/20/2013. THE FORM INDICATED THE DATE OF THE INCIDENT WAS 4/18 - 19, (2013). STAFF "Q" VERIFIED THAT THE "COMPLAINT FORM" WAS USED ANY TIME A RESIDENT MADE A COMPLAINT TO THE FACILITY. THE "COMPLAINT FORM" REFLECTED, "SEE ATTACHED FORM. RESIDENT (RESIDENT #18) C/O (COMPLAINED OF) CNA (STAFF "V") NOT MEETING NEEDS, COLD, IMPERSONAL, RUDE, DOESN'T ACKNOWLEDGE YOU, YELLED AT HER." THE "COMPLAINT FORM" ALSO IDENTIFIED THAT THE DON WAS IMMEDIATELY NOTIFIED AND STAFF "V" WAS REMOVED FROM THE CARE OF RESIDENT #18. STAFF "Q" VERIFIED THAT STAFF "V" WAS NOT REMOVED FROM THE FACILITY BUT MOVED TO ANOTHER HALL. STAFF "Q" WAS ASKED IF SHE FELT THERE WAS A POSSIBILITY THAT STAFF "V" COULD ABUSE OTHER RESIDENTS AND STAFF "Q" RESPONDED, "PROBABLY. I SEE WHAT YOU MEAN." A REVIEW OF THE "NOTES" (ATTACHED FORM MENTIONED IN THE "COMPLAINT FORM" ABOVE) DOCUMENTED BY STAFF "Q" ON 4/20/2013 INDICATED THAT ON 4/18/2013, RESIDENT #18 HAD SOILED HERSELF WITH STOOL BECAUSE "SHE HAD TO WAIT A LONG TIME FOR SOMEONE TO ANSWER HER CALL LIGHT." WHEN STAFF "V" CAME INTO HER ROOM, RESIDENT #18 SAID "HI" TO HER AND TOLD STAFF "V" WHERE HER BED PAN WAS LOCATED. (STAFF "V") YELLED AT HER "SETTLE DOWN, SETTLE DOWN, I'M GETTING IT." THE "COMPLAINT FORM" ATTACHMENT INDICATED THAT THE NEXT NIGHT 4/19/2013, STAFF "V" CAME INTO RESIDENT #18 ' S ROOM AGAIN BECAUSE RESIDENT #18 WAS HAVING A MUSCLE SPASM. RESIDENT #18 ASKED STAFF "V" IF SHE HAD HEARD HER WHEN SHE STATED THAT SHE NEEDED THE NURSE, AND STAFF "V" REPLIED "MEANLY", " I SAID I WOULD GET THE NURSE." ACCORDING TO STAFF "Q'S" NOTES, SHE ASKED RESIDENT #18 HOW SHE FELT ABOUT STAFF "V" TALKING TO HER THAT WAY AND RESIDENT #18 REPLIED, "FELT HELPLESS, SHE (STAFF "V") WAS NON-TALKING, MEAN, DOESN'T TALK". RESIDENT #18 ALSO STATED IN THE "COMPLAINT FORM ATTACHMENT" THAT SHE WAS "AFRAID (OF STAFF "V") AND OF RETALIATION." STAFF "Q" VERIFIED THAT THE "COMPLAINT REPORT" DATED 4/20/2013 AND THE "COMPLAINT REPORT ATTACHMENT" WERE GIVEN TO THE DON. THE "COMPLAINT REPORT" REVEALED THE DON AND THE ADMINISTRATOR'S SIGNATURE AT THE BOTTOM OF THE FORM. AN INTERVIEW WITH THE DON TOOK PLACE AT 3:00 PM ON 5/30/2013. THE DON VERIFIED THAT STAFF " V " CAME BACK TO WORK THE NEXT NIGHT BUT WAS NOT ASSIGNED TO CARE FOR RESIDENT #18 NOR WAS SHE ALLOWED TO GO INTO RESIDENT #18 ' S ROOM. THE DON ALSO VERIFIED THAT STAFF " V " HAS CONTINUED TO WORK WITH ALL OTHER RESIDENTS UNTIL YESTERDAY (4/29/2013) WHEN SHE LEFT FOR PERSONAL REASONS TO ANOTHER COUNTRY. THE DON VERIFIED THAT THE CNA INVOLVED IN THE INCIDENT WITH RESIDENT #18 CONTINUED TO BE EMPLOYED BY THE FACILITY AND HAS NOT BEEN PUT ON ANY TYPE OF ADMINISTRATIVE LEAVE OR TERMINATION. AN INTERVIEW TOOK PLACE ON 5/31/2013 AT 8:45 AM IN RESIDENT #18'S ROOM. RESIDENT #18 RE-TOLD THE INCIDENT OF 4/18 AND 4/19/2013. RESIDENT #18 STATED THAT STAFF "V" WAS "STONE FACED AND JUST STARRED AT ME. SHE HAD THE LOOK OF HORRIBLE ANGER AND LOOKED LIKE A PRESSURE COOKER THAT WAS READY TO BLOW. IN ALL MY [AGE] years IN PSYCHIATRIC NURSING, I HAVE NEVER BEEN TREATED LIKE THIS AND HAVE NEVER HAD THIS MUCH FEAR EVEN FROM PATIENTS WITH MENTAL CONDITIONS AND I HAVE SEEN A LOT." RESIDENT #18 ALSO STATED "IT WAS TOTALLY UNPROVOKED." RESIDENT #18 STATED THAT SHE CONTINUED TO HAVE A CERTAIN AMOUNT OF ANXIETY EVERY DAY IN FEAR THAT (STAFF "V") WILL COME INTO HER ROOM. RESIDENT #18 STATED THAT FOR THE FIRST TWO WEEKS AFTER THE INCIDENT SHE WAS UNABLE TO SLEEP AND NOW SHE MUST SLEEP WITH HER ROOM DOOR OPEN, THE BATHROOM DOOR OPEN AND THE LIGHT ON IN THE BATHROOM TO FALL ASLEEP. WHEN ASKED WHAT SHE WAS AFRAID OF, RESIDENT #18 STATED THAT HER WORST FEAR WAS THAT STAFF "V" WOULD COME INTO HER ROOM DURING THE NIGHT. RESIDENT #18 ALSO STATED THAT SHE "WAS AFRAID OF RETALIATION FROM (STAFF "V") OR THAT SHE WOULDN'T BE ABLE TO RUN FROM STAFF "V", (DUE TO HER FOOT SURGERY) IF SHE NEEDED TO. WHEN ASKED IF SHE HAD SEEN STAFF "V" SINCE THE INCIDENT, RESIDENT #18 STATED THAT SHE "SEES HER SOMETIMES WALKING BY. (STAFF "V" ) HAS ALSO "PEEKED INTO MY ROOM FROM AROUND THE SIDE OF THE DOOR." WHEN ASKED IF STAFF "V" HAS BEEN IN HER ROOM, RESIDENT #18 STATED, "JUST A FEW DAYS AGO, SHE (STAFF "V") CAME INTO MY ROOM TO DROP OFF LINEN." RESIDENT #18 WAS ASKED IF THE DON HAD TALKED TO HER ABOUT THE INCIDENT AND RESIDENT #18 STATED THAT SHORTLY AFTER THE INCIDENT, THE DON DID COME IN AND ASKED A LOT OF QUESTIONS AND WROTE IT ALL DOWN. RESIDENT #18 STATED THAT NEITHER THE DON, THE ADMINISTRATOR NOR THE SOCIAL WORKER HAD FOLLOWED UP WITH HER TO ASSURE HER OF HER SAFETY OR TO ASSESS FOR ANY LONG TERM EFFECTS RELATED TO THE WAY SHE WAS TREATED BY STAFF "V". A REVIEW OF THE FACILITY POLICY "ABUSE PROHIBITION AND RESIDENT'S RIGHTS POLICY AND PROCEDURE" UPDATED 4/23/2013 REVEALED ON PAGE 9 AT THE BOTTOM OF THE PAGE, "STAFF MEMBERS, VOLUNTEERS, FAMILY MEMBERS, AND OTHERS SHOULD BE ENCOURAGED TO REPORT UNUSUAL OCCURRENCES OF ABUSE AND SUSPECTED ABUSE, AND SHOULD BE ASSURED THAT THEY WILL BE PROTECTED AGAINST REPERCUSSIONS." FOLLOWING THIS STATEMENT WAS A PROCEDURE STATEMENT: 1. "ANY ALLEGED VIOLATION INVOLVING MISTREATMENT, MISAPPROPRIATION OF PROPERTY, ABUSE, EXPLOITATION, OR NEGLECT OF A RESIDENT SHALL BE REPORTED TO THE ADMINISTRATOR OR DESIGNEE IMMEDIATELY. 2. THE ADMINISTRATOR OR DESIGNEE SHALL THOROUGHLY INVESTIGATE ALL ALLEGATIONS. 3. THE ADMINISTRATOR OR DESIGNEE WILL NOTIFY RESIDENT ' S REPRESENTATIVE, AND ANY STATE OR FEDERAL AGENCIES OF ALLEGATIONS AND INVESTIGATION WITHIN 24 HOURS 4. THE ADMINISTRATOR OR DESIGNEE WILL TAKE STEPS TO ENSURE AND PREVENT FURTHER POTENTIAL ABUSE WHILE INVESTIGATION IS IN PROCESS. 5. IF THE ACCUSED IS AN EMPLOYEE OF THE FACILITY, HE/SHE WILL BE SUSPENDED UNTIL THE INVESTIGATION HAS BEEN COMPLETED... 6. THE DIRECTOR OF NURSING OR DESIGNEE WILL COMPLETE AN ASSESSMENT OF THE RESIDENT OR RESIDENTS AND DOCUMENT FINDINGS IN THE MEDICAL RECORD... 7. AN UNUSUAL OCCURRENCE REPORT WILL BE COMPLETED." DURING THE INTERVIEW WITH THE DON ON 5/30/2013 AT 3:00 PM, THE DON STATED THAT SHE NOW UNDERSTANDS WHY THIS WAS CONSIDERED AN ALLEGATION OF ABUSE AND THAT SHE KNOWS NOW THAT SHE SHOULD HAVE REPORTED IT TO THE STATE AGENCY AND REMOVED STAFF "V"FROM DUTY PENDING THE INVESTIGATION TO PROTECT OTHER RESIDENTS. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT THE DEVELOPMENT OF PRESSURE ULCER IN 1 OF 4 RESIDENTS (#15) WITH PRESSURE ULCERS FROM A TOTAL SAMPLE OF 20 RESIDENTS, RESULTING IN AN UNSTAGEABLE (COVERING OF ESCHAR OR NECROTIC TISSUE) LEFT LOWER BACK PRESSURE ULCER WITH REPEATED WOUND INFECTIONS. FINDINGS INCLUDE: RESIDENT #15 WAS AN [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. ON 7/20/11 AT 12:30 P.M., RESIDENT #15 WAS OBSERVED PROPELLING HERSELF IN A WHEEL CHAIR IN THE HALL WAY NEAR THE "STATION ONE" NURSING UNIT. SHE WAS USING HER LEFT HAND ONLY TO PUSH THE WHEEL, LEANING EXTREMELY TOWARD HER LEFT SIDE. AS THE RESIDENT WAS OBSERVED SELF PROPELLING HERSELF SHE WAS NEARLY STUCK TO THE HAND RAILS AND CEMENT CINDER BLOCK WALL. SHE KEPT PUSHING HERSELF BY WHEELING WITH HER LEFT HAND TO GO FORWARD. HOWEVER, SHE WAS NOT MAKING ANY PROGRESS. IN FACT THE RESIDENT LOOKED LIKE SHE COULD SCRAPE HER ARM AGAINST THE WALL AT ANY TIME. THE HOUSEKEEPING STAFF, (STAFF "K") WHO HAPPENED TO BE WORKING IN THE HALL WAY PULLED THE RESIDENT AWAY FROM THE WALL SAYING, " ...(RESIDENT'S NAME)...YOU ARE GOING TO HURT YOUR ARM... " STAFF "K" THEN PUT BOTH OF THE RESIDENT'S FEET ON FOOT PEDALS AND WHEELED HER DOWN TO THE MIDDLE OF HALL. THE "OCCUPATIONAL THERAPY DISCHARGE" NOTE DATED 2/9/11 REFLECTED RESIDENT #15 HAD BEEN IDENTIFIED AS HAVING LEFT LEANING WHEEL CHAIR POSITION AND PROVIDED TECHNIQUES AND DEVICES SUCH AS "RIGHT HIP BOLSTER" WEDGE CUSHION WITH DYCEM (CLOTH TO PREVENT SLIP) TO PROPEL WHEEL CHAIR AND MAINTAIN MIDLINE POSITION. THE OCCUPATIONAL THERAPY DISCHARGE NOTE ALSO INCLUDED PROVIDING EDUCATION TO RESTORATIVE STAFF TO PROVIDE AN EXERCISE PROGRAM TO THE RESIDENT TO INCREASE TRUNK STRENGTH AND MIDLINE SITTING AND TO DECREASE LEFT LATERAL FLEXION. THE QUARTERLY MINIMUM DATA SET (MDS) SUMMARY STATEMENT DATED 4/25/11 REFLECTED RESIDENT #15 WAS AT HIGH RISK OF FALLS AND MILD RISK FOR PRESSURE ULCERS. SHE HAD BEEN RECEIVING HOSPICE CARE BETWEEN 1/8/10 THROUGH 11/3/10 FOR PAIN MANAGEMENT, BUT IT WAS DISCONTINUED DUE TO HER STABILITY AND NO LONGER MEETING HOSPICE CRITERIA. THE SKIN CARE PLAN, INITIATED 2/22/10, STATED THE RESIDENT HAD A SCABBED AREA NOTED TO HER LEFT LOWER BACK ON 3/5/11 AND THE SCAB CAME OFF REVEALING A STAGE 2 PRESSURE ULCER (PARTIAL THICKNESS LOSS OF SKIN INVOLVING EPIDERMIS, DERMIS, OR BOTH) ON 5/2/11. THE WOUND DEVELOPMENT WAS BEING RELATED TO THE RESIDENT'S LEFT SIDED LEANING POSITION. THE WOUND PROGRESS NOTE DATED 3/7/11 REFLECTED, " ... THE RESIDENT HAD A SMALL SCABBED AREA ON HER LEFT LOWER BACK... THERE WAS A SIMILAR AREA ON THE LEFT LOWER BACK ABOVE IT WHICH IS NOW HEALED, BUT PINK...SHE LEANS TO THE LEFT IN HER CHAIR AND USES HER LEFT ARM TO PROPEL THE CHAIR SO THE AREA COULD BE DUE TO PRESSURE... " THE WOUND PROGRESS NOTES DATED 4/28/11 REFLECTED THE WOUND WAS DETERMINED AS UNSTAGEABLE DUE TO LARGE SCABBED AREA. THE RESIDENT WAS RECOMMENDED HAVING THERAPY TO ASSESS WHEEL CHAIR AND PROVIDE FOAM PILLOW/PADDING TO LEFT SIDE AND BACK. THE "WOUND EVALUATION FLOW SHEET" DATED 3/5/11 REFLECTED THE LEFT LOWER BACK SCABBED WOUND MEASURED 0.5 CM LONG AND 0.5 CM WIDE. THE WOUND INCREASED IN SIZE ON 3/28/11 TO 0.7 X 0.7 CM BUT IT STILL REMAINED A SCAB. HOWEVER, A WEEK LATER ON 4/4/11 THE WOUND WAS CLASSIFIED AS AN UNSTAGEABLE PRESSURE SORE WITH MEASUREMENT OF 0.9 X 0.8 CM. THE "WOUND EVALUATION FLOW SHEET' DATED 4/11/11 THROUGH 4/29/11 REFLECTED THE LEFT LOWER BACK REMAINED AS AN UNSTAGEABLE PRESSURE ULCER WITH WOUND BED AS A SCABBED AREA WITH PINK SURROUNDING TISSUE. THE WOUND EVALUATION FLOW SHEET DATED 5/3/11 REFLECTED THE WOUND WAS NOW A STAGE 2, HAVING MODERATE AMOUNT OF THICK DRAINAGE AND MEASURED 1.5 X 1.0 X 0.5 CM. THE SIZE OF THE WOUND WAS INCREASED TO 2.0 X 1.2 X 0.5 CM ON 5/30/11. THE WOUND EVALUATION FLOW SHEET DATED 6/9/11 REFLECTED THE LEFT LOWER BACK PRESSURE ULCER WAS ASSESSED AS A STAGE 3 WITH MODERATE AMOUNT OF THICK TAN COLOR DRAINAGE AND THE SURROUNDING TISSUE WAS DESCRIBED AS MACERATED. THE TREATMENT INCLUDED APPLYING ENZYMATIC DEBRIDEMENT WITH "SANTYL." THE WOUND PROGRESS NOTES DATED 5/19/11 REFLECTED, " ... THE RESIDENT'S WOUND IS COVERED WITH BLACK ESCHAR (DEAD TISSUE)... APPLY FOAM DRESSING...HAVE PHYSICAL THERAPY (PT) TO EVALUATE WHEEL CHAIR FOR PROPER FIT...NEEDS A CHAIR TO ACCOMMODATE WITHOUT CAUSING PRESSURE INJURY AS SOON AS POSSIBLE... " THE RESIDENT WAS PRESCRIBED [MEDICATION NAME] (ANTIBIOTIC) ON 5/3/11 FOR WOUND INFECTION. ON 7/21/11 AT 10:15 A.M., THE DIRECTOR OF NURSING (DON) WAS INTERVIEWED REGARDING RESIDENT #15'S PT EVALUATION, CHAIR MODIFICATION AND OTHER ASSISTIVE DEVICES UTILIZED TO PROMOTE PRESSURE ULCER HEALING. THE DON STATED THE RESIDENT TRIED A DIFFERENT WHEEL CHAIR THAT HER FAMILY PROVIDED BUT SHE DID NOT LIKE IT. THE RESIDENT WAS ALSO PROVIDED A SPECIAL AIR MATTRESS AND ATTEMPTED TO REPOSITION AS MUCH AS POSSIBLE. THE DON ADDED THAT THE RESIDENT WAS UP ALMOST ALL DAY (8-10 HOURS) AND SHE WOULD SOMETIMES LET THE STAFF TO REPOSITION HER IN CHAIR BUT SOMETIMES SHE DID NOT. HOWEVER, THE NURSING NOTES DATED 8/4/10 THROUGH 6/30/11 REFLECTED NO DOCUMENTATION OF ATTEMPTS TO REPOSITION THE RESIDENT. THE WOUND PROGRESS NOTES DATED 6/9/11 REFLECTED THE ESCHAR FROM THE RESIDENT'S LEFT LOWER BACK HAD BEEN DETACHED, REVEALING A STAGE 3 (FULL THICKNESS TISSUE LOSS INVOLVING DAMAGE OR NECROSIS OR SUBCUTANEOUS TISSUE THAT MAY EXTEND DOWN TO, BUT NOT THROUGH, UNDERLYING FASCIA) 2.0 X 2.0 X 0.5 CM OPEN AREA. THE WOUND WAS COVERED WITH 95 % MOIST YELLOW SLOUGH. EXUDATE (DRAINAGE) WAS TAN AND PURULENT WITH FOULD ODOR AFTER CLEANING. THE RESIDENT WAS PRESCRIBED KEFLEX (ANTIBIOTIC) FOR WOUND INFECTION. SHE WAS AGAIN PRESCRIBED 10 DAY COURSE OF [MEDICATION NAME] (ANTIBIOTIC) FOR CONTINUED PURULENT EXUDATE ON 6/24/11. THE WOUND PROGRESS NOTES DATED 7/14/11 REFLECTED THE WOUND WAS STILL AT STAGE 3 WITH THE WOUND BED COVERING WITH 80 % YELLOW SLOUGH BUT THE EDGES WERE FILLING IN AND SHOWED [MEDICATION NAME] (NEW TISSUE GROWTH). ON 7/21/11 AT 1:30 P.M., THE DRESSING CHANGE WAS OBSERVED IN THE RESIDENT'S ROOM WITH THE UNIT NURSE (STAFF "F"). THE LEFT LOWER BACK WOUND HAD A DARK CIRCLE AROUND WITH RED SKIN SURFACE. THE WOUND BED COVERED WITH YELLOW SLOUGH AND MEASURED APPROXIMATELY 1.0 CM LONG AND 1.2 CM WIDE WITH UNKNOWN DEPTH. AS STAFF "F" WAS CHANGING THE DRESSING, STAFF "F" STATED THAT THE WOUND WAS GETTING MUCH BETTER AND SHE THOUGHT THE WOUND STARTED FROM PRESSURE BY THE METAL POST OF WHEEL CHAIR BACKING WHENEVER THE RESIDENT LEANED TO THE LEFT SIDE. ON 7/21/11 AT 8:30 A.M., RESIDENT #15 WAS OBSERVED PROPELLING HERSELF, WHILE LEANING EXTREMELY TO THE LEFT SIDE AGAIN, HOLDING THE WHEEL OF THE WHEELCHAIR WITH HER LEFT HAND. THERE WAS A BACK CUSHION THAT EXTENDED TO BOTH SIDES. HOWEVER, THE CUSHION DID NOT PREVENT THE RESIDENT FROM LEANING STRONGLY LEFT AND THERE WAS NO PILLOW TO PROTECT HER FROM INJURY. ( )