Every finding on record at West Woods of Niles

This citation pertains to intake #3052734 and #3065589Based on interview and record review the facility failed to ensure quality of care and obtain physician orders to manage and monitor a JP Drain (Jackson Pratt drain- a surgical suction device that removes fluid from a wound to promote healing and reduce infection risk) and drain insertion/wound site for 1 (Resident #9) of 3 resident reviewed for quality of care resulting in a lack of managing, a lack of monitoring, and unmet care needs.Findings include:Resident #9Review of an admission Record revealed Resident #9 was a male who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: nontraumatic acute subdural hemorrhage (bleeding on the brain not caused from trauma), peripheral vascular disease (narrowing of the blood vessels in the extremities with decreased blood flow) and atherosclerotic heart disease of native coronary artery (where plaque has built up inside of the blood vessels causing narrowing).Review of a Care Plan for Resident #9 revealed .Focus/Goal/Interventions:.infection and inflammatory reaction due to internal right hip prosthesis and need for drain (JP-drain- Jackson Pratt drain- a surgical suction device that removes fluid from a wound to promote healing and reduce infection risk) .Remain in the facility for respite care (short-term relief care that allows caregivers to rest and/or take a break from ongoing care responsibilities) and return home.Hospice.clothing/dressing total dependence.physician orders: admission orders implemented as noted on the MAR and TAR (Medication/Treatment Administration Record).Skin care interventions: inspect skin with bathing and care, heels elevated in bed, report impaired skin integrity to charge nurse, protective sleeves/or long sleeved shirt as accepted by resident, apply barrier cream with incontinence care PRN (as needed) reposition frequently as accepted by resident.ADLs (activities of daily living) Dependent for ADLs.potential risk for impaired skin integrity related to history of or actual impairment, poor nutritional intake, impaired functional mobility and/or incontinence.will show improvement of impaired skin integrity as evidenced by no S/S (signs and symptoms) of infection and decreased measurements and/or prevention of avoidable impaired skin integrity.assess postural alignment, weight distribution, sitting balance and pressure redistribution on admit and prn, bridge heels in bed if indicated to protect heels, measure open areas on admission, weekly, prn, re-evaluate treatment and resident condition prn.skin inspections with am/pm care and showering report abnormal to the charge nurse. all with an initiation date of 6/17/26.Review of a Hospice Plan of Care Updates 6/2/26 for Resident #9 revealed .Most important thing: Respite.Problem: skin integrity: SN (skilled nursing) teach methods to prevent skin breakdown nutrition, mobility, friction, sheer, moisture, positioning, incontinence, declining state, preventative skin care, recognition of areas at risk for breakdown, skin assessment and use of pressure relief devices.Wound incision: Intervention- SN to perform wound care to bilateral outer ankle: cleanse with saline, apply antibiotic ointment if needed, apply mepilex (adhesive foam dressing used in wound care) frequency: PRN; Starting date 5/21/2026.Review of Census for Resident #9 revealed Admit 6/15/26 Hospice-Respite. discharge 6/19/26.In a telephone interview on 7/14/26 at 8:09 am, Family Member (FM) HH reported Resident #9 was admitted to the facility on [DATE] by hospice for respite care and was at the facility for 4 days while she was out of town. FM HH reported she was Resident #9's caregiver and she managed all of his care, including his wounds and JP drain. FM HH reported Resident #9's dressings to his ankles were due to be changed on 6/17/26 and 6/19/26 and they were not changed at all while he was at the facility. FM HH reported Resident #9 had no other pressure wounds to his skin when he arrived at the facility. FM HH reported when she arrived at the facility on 6/19/26 to pick up Resident #9, the dressings on his bilateral (both) ankles were dated 6/15, when she removed the dressings, she discovered Resident #9 had developed an additional pressure injury on the left heel, the skin was red and purple in color, and indicative of a deep tissue injury. FM HH stated I was horrified when I saw the state of his dressings and his condition.the facility failed to provide wound care during his stay.failed to prevent a pressure ulcer from developing.in general, they did not take care of him when he was there.Review of admission Assessment for Resident #9 dated 6/15/26 at 13:24 (1:24pm) revealed .Resident requires hoyer lift (a mechanical lift that supports the whole body for individuals that cannot stand) for transfers, total care for all ADLs, bed mobility and wheelchair locomotion, resident is mostly bed bound. JP drain noted to right hip, has areas to lower extremities and excoriation to peri area. Skin right ankle (outer) pressure stage II (partial thickness skin loss involving the epidermis and/or dermis) and left ankle (outer) stage III (full thickness skin loss extends through epidermis, dermis, and into the subcutaneous tissue) . No noted documentation regarding Resident #9's heel condition, nor any dressing covering the JP drain.Review of Order Summary for Resident #9 revealed . Assess skin once a day x 3 days after admission document on Skin UDA (separate assessment form to input details of a skin assessment) one time a day with a start date of 6/16/26.Healing partners (wound provider) to consult for skin and wound condition/preventions.with a start date of 6/15/26.Wound care bilateral ankles - cleanse with wound cleanser place xeroform to wound bed and cover with bordered foam. Every day shift every other day with a start date of 6/17/26.Review of Treatment Administration Record for Resident #9 for the month of June 2026, revealed . Assess skin once a day x 3 days after admission document on Skin UDA one time a day with a start date of 6/16/26. Documentation indicated completed on 6/16/26 and 6/17/26.No Skin UDA form for the dates of 6/16/26 and 6/17/26 was provided by the facility by the time of exit.No noted documented orders regarding Resident #9's JP drain nor the dressing covering his right hip at the drain site.Review of admission Orders for Resident #9 revealed no noted orders regarding any wound care, dressing changes, JP drain management or monitoring.In an interview on 7/14/26 at 1:45 pm, Certified Nurse Assistant (CNA) H and CNA M reported they did not recall any wounds or wound dressings on Resident #9 during his stay.In an interview on 7/14/26 at 2:08 pm, Licensed Practical Nurse (LPN) Z reported he was the nurse that admitted Resident #9. LPN Z reported a hospice nurse and FM HH accompanied Resident #9 when he admitted . LPN Z reported the hospice nurse told him in report that Resident #9 was only going to stay a few days and that FM HH completed his wound care before he arrived and that Resident #9 would not need wound care while he was at the facility. LPN Z reported Resident #9 had a drain in his right hip, with a dressing over it, and dressings on his ankles. LPN Z reported there were no orders to change any dressings when Resident #9 admitted to the facility. LPN Z confirmed Resident #9 did not receive any dressing changes while he was at the facility. LPN Z reported he did not document his conversation with the hospice nurse in Resident #9's medical record; and he should have. LPN Z reported former Director of Nursing Former/DON S began education after Resident #9 discharged on 6/19/26. LPN Z reported the education included making sure there were orders in place for any dressing/treatments, accurate assessments, if there was a dressing observed on assessment, find out why, and to document all dressings, and document when you are told not to complete dressing changes.Review of Resident Assistance Form completed on 6/19/26 at 13:45 (1:45pm) via telephone regarding Resident #9 by FM HH revealed .2. Dressing not changed on Rt. (right) hip resulting in macerated skin, JP stopcock (a valve that controls the flow of drainage from a wound into the suction bulb of the drain) was in off position 3. New stage 1 on Rt. Outer ankle.problem occurred 6/15/26-6/19/26. this skin injury should not have happened.Facility Response: education to nurses began 6/19/26 to always get a wound order if there were a wound present and no order given upon admission, floating heels and position education also. In a telephone interview on 7/15/26 at 9:15 am, Agency/LPN NN reported Resident #9 had a drain and a dressing to his right hip and dressings on his ankles, and when he came to the facility, he did not have orders for the dressings to be changed. Agency/LPN NN reported Resident #9 told her FM HH usually completed his wound dressing changes. Agency/LPN NN reported she was able to remove the dressings on Resident #9's ankles enough to look at the wounds and was able to determine one was the size of a dime, and the other one was the size of a quarter. Agency/LPN NN reported Resident #9 was on hospice, and hospice did not provide any orders related to his wounds, dressings, or drain at the time of admission. Agency/LPN NN reported she was educated by Former DON S regarding the admission process when a resident has wounds, there had to be an order for treatment, skin assessments, measurements, and the wound nurse needed to be notified.In an interview on 7/15/26 at 10:57 am, LPN Y reported she worked with Resident #9 the following shift after he admitted . LPN Y reported she was cleaning up admission paperwork and contacted FM HH regarding Resident #9's care. LPN Y reported FM HH informed her the dressing on Resident #9's hip was changed just before he arrived at the facility and that FM HH changed it 'every few days' and they didn't need to do anything. LPN Y reported Resident #9 came with 'bare bones' information from hospice when he arrived at the facility and she did not recall any orders related to his wounds or dressing changes. LPN Y reported she contacted hospice for treatment information and was informed FM HH completed his wound care. Review of Interdisciplinary Documentation for Resident #9 dated 6/15/26 at 22:50 (10:50 pm) revealed contacted FM HH .dressing to drain site was changed before he arrived.the dressing to bilateral lower extremities only needs to be changed QOD (every other day) .Review of Interdisciplinary Documentation for Resident #9 dated 6/16/26 at 6:57 am revealed .he has a right hip JP drain. He has small open area on left outer ankle and a quarter size open area on right outer ankle.Review of Interdisciplinary Documentation for Resident #9 dated 6/17/26 at 4:32 am revealed .JP drain on right hip.Review of Interdisciplinary Documentation for Resident #9 dated 6/17/26 at 11:47 am revealed . Spoke with Hospice nurse regarding wound care orders. Orders for xeroform and bordered foam every other day received and entered.Review of Interdisciplinary Documentation for Resident #9 dated 6/17/26 at 21:44 (9:21 pm) revealed . dressing to BLE (bilateral lower extremities) intact.Review of Progress Note for Resident #9 with a created date of 6/19/26 at15:19 (3:19 pm) and an effective date of 6/17/26 15:16 (3:16 pm) revealed .Spoke with hospice nurse regarding dressing changes. Hospice notified this writer that.FM HH .would rather the dressings be changed by her but stated the dressing to the ankle could be changed QOD if dressing were soiled or loose, Hospice nurse stated staff are not to change JP drain dressing.Review of Progress Note for Resident #9 with a creation date of 6/19/26 at 14:12 (2:12 pm) and an effective date of 6/17/26 12:10 pm revealed .upon approaching Resident #9 to change ankle dressing, I was told by him in a very irritated and raised voice that FM HH does the dressing changes. Wound dressing change documented as refused. No noted documentation regarding the condition of the dressing on Resident #9's right hip and JP drain site.In an interview on 7/15/26 at 2:13 pm, Interim Director of Nursing (IDON) B reported Resident #9 admitted to the facility for respite care and there were no orders in place for his wound care for two days. Interim DON B reported a full body assessment of skin was expected at admission, and any dressing present should be documented. Interim DON B reported elevation of heels was a standard of care and all residents were provided three pillows at admission for their heads and feet to be elevated. Interim DON B reported skin checks were part of standard care and should be completed with AM and PM care and showers. Interim DON B reviewed Resident #9's record and confirmed daily skin checks were ordered and documented in the TAR as completed on 6/16/26 and 6/17/26, but Interim DON B was unable to locate the documented skin assessments. Interim DON B reported documentation was entered late into Resident #9's record because 'the nurse did not document' and the information needed to be in Resident #9's record. Interim DON B reported her expectations were that a resident's skin was observed with cares, and if something was found it should be reported to the nurse.Review of Shower Assignment for Resident #9 revealed no noted documentation, indicated Resident #9 did not received a shower or bed bath during his stay. In an interview on 7/15/26 at 2:57 pm, Clinical Care Coordinator (CCC) Q reported there were a lot of miscommunications with Resident #9 and there were not orders for wound care. CCC Q reported they received education that included if a resident admitted with a wound there had to be an order in place from a provider. CCC Q the provider could be hospice, the in-house provider, or the wound provider.In an interview on 7/15/26 at 3:24 pm, Nursing Home Administrator (NHA) A reported she was made aware of Resident #9's care from Interim DON S when she spoke to FM HH after he discharged . NHA A reported she was informed that Resident #9's dressings were not changed while he was at the facility, and the drain was not functioning, and it was not removing fluids from the wound like it should have been. NHA A reported there was no assessment completed, there were no orders for wound care, no orders for the JP drain, and Resident #9's JP drain dressing was never changed. NHA A stated Resident #9 was here because FM HH needed a break, we were to care for him.In a telephone interview on 7/15/26 at 4:16 pm, Registered Nurse (RN) DD reported there were no orders in place for Resident #9's wound care, JP drain, or drain dressing. RN DD reported when the orders were obtained for the ankle wounds, she tried to change them and Resident #9 refused. RN DD reported she documented in the TAR the refusal but was asked later to add a progress note. RN DD confirmed she entered the note regarding Resident #9's refusal after he discharged from the facility. RN DD reported when FM HH arrived on 6/19/26 to take Resident #9 home, FM HH requested wound care supplies and changed the dressing on Resident #9's right hip/drain area before he discharged home. RN DD stated I saw the excoriation by the drain. RN DD reported she did not assess Resident #9's JP drain but did recall there were no orders in his record for it. In an interview on 7/16/26 at 11:45 am, Wound Nurse (WN) V reported she found out Resident #9 had wounds on 6/17/26, two days after he admitted to the facility. WN V reported she contacted hospice and was told FM HH did not allow for hospice to complete wound care for Resident #9. WN V reported she had been told there was a blockage with the JP drain overnight and it had leaked everywhere. WN V reported she did not address the JP drain or drain dressing with hospice when she contacted them for wound care orders. WN V reported changes have been implemented all admitted residents received a full body skin assessment by her and the wound nurse practitioner on the next day the provider was in the facility to see patients. WN V reported the wound provider saw residents twice a week. WN V confirmed the wound provider did not assess Resident #9's wounds during his stay.Attempts to contact Resident #9's hospice care provider prior to survey exit were unsuccessful.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.to assess skin on a regular basis to determine whether changes in the patient's skin condition have occurred.to provide prompt identification and intervention for resident st risk of impaired skin integrity.to limit the development of avoidable pressure ulcers.licensed nurse completes the admission assessment.pressure ulcer may develop. terminal illness.daily skin inspections with am and pm care.CNA reporting of abnormal skin inspections to charge nurse.use of pillows to bridge heels.implement standing orders for impaired skin and/or consult the physician prn for treatment and orders for impaired skin integrity.The facility was granted a Past Non-Compliance (PNC) at the time of exit due to no further like incidents had occurred, the facility re-trained pertinent staff, the wound care and physician orders policies were reviewed and deemed appropriate, new procedures were implemented for total skin assessments to be completed by wound nurse (and/or designee) and facility wound provider on the immediate next day the wound provider was available in the facility, and the facility had achieved sustained compliance. Therefore, no plan of correction will be required.

This citation pertains to intake #3052734 and #3065589Based on interview and record review the facility failed to obtain treatment orders for pressure ulcers and prevent the development of an additional pressure ulcer for 1 (Resident #9) of 3 residents reviewed for pressure ulcers resulting in Resident #9 not receiving wound care timely and the development of a stage 1/DTI (a non-blanchable redness or discoloration over intact skin/ Deep Tissue Injury). Findings include:Resident #9Review of an admission Record revealed Resident #9 was a male who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: nontraumatic acute subdural hemorrhage (bleeding on the brain not caused from trauma), peripheral vascular disease (narrowing of the blood vessels in the extremities with decreased blood flow) and atherosclerotic heart disease of native coronary artery (where plaque has built up inside of the blood vessels causing narrowing).Review of a Care Plan for Resident #9 revealed .Focus/Goal/Interventions:.infection and inflammatory reaction due to internal right hip prosthesis and need for drain (JP-drain- Jackson Pratt drain- a surgical suction device that removes fluid from a wound to promote healing and reduce infection risk) .Remain in the facility for respite care (short-term relief care that allows caregivers to rest and/or take a break from ongoing care responsibilities) and return home.Hospice.clothing/dressing total dependence.physician orders: admission orders implemented as noted on the MAR and TAR (Medication/Treatment Administration Record).Skin care interventions: inspect skin with bathing and care, heels elevated in bed, report impaired skin integrity to charge nurse, protective sleeves/or long sleeved shirt as accepted by resident, apply barrier cream with incontinence care PRN (as needed) reposition frequently as accepted by resident.ADLs (activities of daily living) Dependent for ADLs.potential risk for impaired skin integrity related to history of or actual impairment, poor nutritional intake, impaired functional mobility and/or incontinence.will show improvement of impaired skin integrity as evidenced by no S/S (signs and symptoms) of infection and decreased measurements and/or prevention of avoidable impaired skin integrity.assess postural alignment, weight distribution, sitting balance and pressure redistribution on admit and prn, bridge heels in bed if indicated to protect heels, measure open areas on admission, weekly, prn, re-evaluate treatment and resident condition prn.skin inspections with am/pm care and showering report abnormal to the charge nurse. all with an initiation date of 6/17/26.Review of a Hospice Plan of Care Updates 6/2/26 for Resident #9 revealed .Most important thing: Respite.Problem: skin integrity: SN (skilled nursing) teach methods to prevent skin breakdown nutrition, mobility, friction, sheer, moisture, positioning, incontinence, declining state, preventative skin care, recognition of areas at risk for breakdown, skin assessment and use of pressure relief devices.Wound incision: Intervention- SN to perform wound care to bilateral outer ankle: cleanse with saline, apply antibiotic ointment if needed, apply mepilex (adhesive foam dressing used in wound care) frequency: PRN; Starting date 5/21/2026.Review of Census for Resident #9 revealed Admit 6/15/26 Hospice-Respite. discharge 6/19/26.In a telephone interview on 7/14/26 at 8:09 am, Family Member (FM) HH reported Resident #9 was admitted to the facility on [DATE] by hospice for respite care and was at the facility for 4 days while she was out of town. FM HH reported she was Resident #9's caregiver and she managed all of his care, including his wounds. FM HH reported Resident #9's dressings to his ankles were due to be changed on 6/17/26 and 6/19/26 and they were not changed at all while he was at the facility. FM HH reported Resident #9 had no other pressure wounds to his skin when he arrived at the facility. FM HH reported when she arrived at the facility on 6/19/26 to pick up Resident #9, the dressings on his bilateral (both) ankles were dated 6/15, when she removed the dressings, she discovered Resident #9 had developed an additional pressure injury on the left heel, the skin was red and purple in color, and indicative of a deep tissue injury. FM HH stated I was horrified when I saw the state of his dressings and his condition.the facility failed to provide wound care during his stay.failed to prevent a pressure ulcer from developing.in general, they did not take care of him when he was there.Review of admission Assessment for Resident #9 dated 6/15/26 at 13:24 (1:24pm) revealed .Resident requires hoyer lift (a mechanical lift that supports the whole body for individuals that cannot stand) for transfers, total care for all ADLs, bed mobility and wheelchair locomotion, resident is mostly bed bound . has areas to lower extremities and excoriation to peri area. Skin right ankle (outer) pressure stage II (partial thickness skin loss involving the epidermis and/or dermis) and left ankle (outer) stage III (full thickness skin loss extends through epidermis, dermis, and into the subcutaneous tissue) . No noted documentation regarding Resident #9's heel condition.Review of Order Summary for Resident #9 revealed . Assess skin once a day x 3 days after admission document on Skin UDA (separate assessment form to input details of a skin assessment) one time a day with a start date of 6/16/26.Healing partners (wound provider) to consult for skin and wound condition/preventions.with a start date of 6/15/26.Wound care bilateral ankles - cleanse with wound cleanser place xeroform to wound bed and cover with bordered foam. Every day shift every other day with a start date of 6/17/26.Review of Treatment Administration Record for Resident #9 for the month of June 2026, revealed . Assess skin once a day x 3 days after admission document on Skin UDA one time a day with a start date of 6/16/26. Documentation indicated completed on 6/16/26 and 6/17/26.No Skin UDA form for the dates of 6/16/26 and 6/17/26 was provided by the facility by the time of exit.No noted documented orders regarding Resident #9's dressing covering his right hip at the drain site.Review of admission Orders for Resident #9 revealed no noted orders regarding any wound care, dressing changes, or monitoring.In an interview on 7/14/26 at 1:45 pm, Certified Nurse Assistant (CNA) H and CNA M reported they did not recall any wounds or wound dressings on Resident #9 during his stay.In an interview on 7/14/26 at 2:08 pm, Licensed Practical Nurse (LPN) Z reported he was the nurse that admitted Resident #9. LPN Z reported a hospice nurse and FM HH accompanied Resident #9 when he admitted . LPN Z reported the hospice nurse told him in report that Resident #9 was only going to stay a few days and that FM HH completed his wound care before he arrived and that Resident #9 would not need wound care while he was at the facility. LPN Z reported Resident #9 had a drain in his right hip, with a dressing over it, and dressings on his ankles. LPN Z reported there were no orders to change any dressings when Resident #9 admitted to the facility. LPN Z confirmed Resident #9 did not receive any dressing changes while he was at the facility. LPN Z reported he did not document his conversation with the hospice nurse in Resident #9's medical record; and he should have. LPN Z reported former Director of Nursing Former/DON S began education after Resident #9 discharged on 6/19/26. LPN Z reported the education included making sure there were orders in place for any dressing/treatments, accurate assessments, if there was a dressing observed on assessment, find out why, and to document all dressings, and document when you are told not to complete dressing changes.Review of Resident Assistance Form completed on 6/19/26 at 13:45 (1:45pm) via telephone regarding Resident #9 by FM HH revealed .2. Dressing not changed on Rt. (right) hip resulting in macerated skin, 3. New stage 1 on Rt. Outer ankle.problem occurred 6/15/26-6/19/26. this skin injury should not have happened.Facility Response: education to nurses began 6/19/26 to always get a wound order if there were a wound present and no order given upon admission, floating heels and position education also. In a telephone interview on 7/15/26 at 9:15 am, Agency/LPN NN reported Resident #9 had a drain and a dressing to his right hip and dressings on his ankles, and when he came to the facility, he did not have orders for the dressings to be changed. Agency/LPN NN reported Resident #9 told her FM HH usually completed his wound dressing changes. Agency/LPN NN reported she was able to remove the dressings on Resident #9's ankles enough to look at the wounds and was able to determine one was the size of a dime, and the other one was the size of a quarter. Agency/LPN NN reported Resident #9 was on hospice, and hospice did not provide any orders related to his wounds, dressings, or drain at the time of admission. Agency/LPN NN reported she was educated by Former DON S regarding the admission process when a resident has wounds, there had to be an order for treatment, skin assessments, measurements, and the wound nurse needed to be notified.In an interview on 7/15/26 at 10:57 am, LPN Y reported she worked with Resident #9 the following shift after he admitted . LPN Y reported she was cleaning up admission paperwork and contacted FM HH regarding Resident #9's care. LPN Y reported FM HH informed her the dressing on Resident #9's hip was changed just before he arrived at the facility and that FM HH changed it 'every few days' and they didn't need to do anything. LPN Y reported Resident #9 came with 'bare bones' information from hospice when he arrived at the facility and she did not recall any orders related to his wounds or dressing changes. LPN Y reported she contacted hospice for treatment information and was informed FM HH completed his wound care. Review of Interdisciplinary Documentation for Resident #9 dated 6/15/26 at 22:50 (10:50 pm) revealed contacted FM HH .dressing to drain site was changed before he arrived.the dressing to bilateral lower extremities only needs to be changed QOD (every other day) .Review of Interdisciplinary Documentation for Resident #9 dated 6/16/26 at 6:57 am revealed .He has small open area on left outer ankle and a quarter size open area on right outer ankle.Review of Interdisciplinary Documentation for Resident #9 dated 6/17/26 at 11:47 am revealed . Spoke with Hospice nurse regarding wound care orders. Orders for xeroform and bordered foam every other day received and entered.Review of Interdisciplinary Documentation for Resident #9 dated 6/17/26 at 21:44 (9:21 pm) revealed . dressing to BLE (bilateral lower extremities) intact.Review of Progress Note for Resident #9 with a created date of 6/19/26 at15:19 (3:19 pm) and an effective date of 6/17/26 15:16 (3:16 pm) revealed .Spoke with hospice nurse regarding dressing changes. Hospice notified this writer that.FM HH .would rather the dressings be changed by her but stated the dressing to the ankle could be changed QOD if dressing were soiled or loose, Hospice nurse stated staff are not to change JP drain dressing.Review of Progress Note for Resident #9 with a creation date of 6/19/26 at 14:12 (2:12 pm) and an effective date of 6/17/26 12:10 pm revealed .upon approaching Resident #9 to change ankle dressing, I was told by him in a very irritated and raised voice that FM HH does the dressing changes. Wound dressing change documented as refused. No noted documentation regarding the condition of the dressing on Resident #9's right hip.In an interview on 7/15/26 at 2:13 pm, Interim Director of Nursing (IDON) B reported Resident #9 admitted to the facility for respite care and there were no orders in place for his wound care for two days. Interim DON B reported a full body assessment of skin was expected at admission, and any dressing present should be documented. Interim DON B reported elevation of heels was a standard of care and all residents were provided three pillows at admission for their heads and feet to be elevated. Interim DON B reported skin checks were part of standard care and should be completed with AM and PM care and showers. Interim DON B reviewed Resident #9's record and confirmed daily skin checks were ordered and documented in the TAR as completed on 6/16/26 and 6/17/26, but Interim DON B was unable to locate the documented skin assessments. Interim DON B reported documentation was entered late into Resident #9's record because 'the nurse did not document' and the information needed to be in Resident #9's record. Interim DON B reported her expectations were that a resident's skin was observed with cares, and if something was found it should be reported to the nurse.Review of Shower Assignment for Resident #9 revealed no noted documentation, indicated Resident #9 did not received a shower or bed bath during his stay. In an interview on 7/15/26 at 2:57 pm, Clinical Care Coordinator (CCC) Q reported there was a lot of miscommunications with Resident #9 and there were not orders for wound care. CCC Q reported they received education that included if a resident admitted with a wound there had to be an order in place from a provider. CCC Q the provider could be hospice, the in-house provider, or the wound provider.In an interview on 7/15/26 at 3:24 pm, Nursing Home Administrator (NHA) A reported she was made aware of Resident #9's care from Interim DON S when she spoke to FM HH after he discharged . NHA A reported she was informed that Resident #9's dressings were not changed while he was at the facility. NHA A reported there was no assessment completed, there were no orders for wound care. NHA A stated Resident #9 was here because FM HH needed a break, we were to care for him.In a telephone interview on 7/15/26 at 4:16 pm, Registered Nurse (RN) DD reported there were no orders in place for Resident #9's wound care. RN DD reported when the orders were obtained for the ankle wounds, she tried to change them and Resident #9 refused. RN DD reported she documented in the TAR the refusal but was asked later to add a progress note. RN DD confirmed she entered the note regarding Resident #9's refusal after he discharged from the facility. In an interview on 7/16/26 at 11:45 am, Wound Nurse (WN) V reported she found out Resident #9 had wounds on 6/17/26, two days after he admitted to the facility. WN V reported she contacted hospice and was told FM HH did not allow for hospice to complete wound care for Resident #9. WN V reported changes have been implemented all admitted residents received a full body skin assessment by her and the wound nurse practitioner on the next day the provider was in the facility to see patients. WN V reported the wound provider saw residents twice a week. WN V confirmed the wound provider did not assess Resident #9's wounds during his stay.Attempts to contact Resident #9's hospice care provider prior to survey exit were unsuccessful.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.to assess skin on a regular basis to determine whether changes in the patient's skin condition have occurred.to provide prompt identification and intervention for resident st risk of impaired skin integrity.to limit the development of avoidable pressure ulcers.licensed nurse completes the admission assessment.pressure ulcer may develop. terminal illness.daily skin inspections with am and pm care.CNA reporting of abnormal skin inspections to charge nurse.use of pillows to bridge heels.implement standing orders for impaired skin and/or consult the physician prn for treatment and orders for impaired skin integrity.The facility was granted a Past Non-Compliance (PNC) at the time of exit due to no further like incidents had occurred, the facility re-trained pertinent staff, the wound care and physician orders policies were reviewed and deemed appropriate, new procedures were implemented for total skin assessments to be completed by wound nurse (and/or designee) and facility wound provider on the immediate next day the wound provider was available in the facility, and the facility had achieved sustained compliance. Therefore, no plan of correction will be required.

This citation pertains to intake # 2715364.Based on interview and record review, the facility failed to provide quality wound care to promote healing and prevent the deterioration of a pressure ulcer for 1 (Resident #121) of 3 residents reviewed for wound care resulting in an Immediate Jeopardy when on 1/8/26, Resident #121 was hospitalized with altered mental status and septic shock (life-threatening condition caused by a severe infection) from a necrotic (death of cells in tissue) sacral ulcer (pressure ulcer at the base of the spine) with osteomyelitis (infection in a bone) requiring surgical intervention and bone debridement. Findings include: Resident #121 The Immediate Jeopardy began on 12/26/25 when Resident #121 was unable to have his pressure ulcer cared for per orders and was not completed by nursing staff and was subsequently hospitalized with altered mental status and septic shock from necrotic (dead tissue) sacral ulcer with osteomyelitis requiring surgical intervention and bone debridement. Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy verbally and via email on 2/5/26 at 4:40 PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 2/5/26, but noncompliance remains at scope of isolated and severity of actual harm due to sustained compliance that has not been verified by the State Agency. Review of an admission Record revealed Resident #121 was originally admitted to the facility on [DATE] with pertinent diagnoses which included pressure ulcer of sacral region stage 4, and need for assistance with personal care. Review of Resident #121's Hospital Discharge summary dated [DATE] revealed, .Hospital Course: further examination revealed multiple deep ulcerated decubitus ulcers (pressure ulcer) and elevated CRP (lab test measures the level of C-reactive protein in your blood, indicating inflammation in the body and helping diagnose various conditions) at 8 concerning for osteomyelitis. CT (computed tomography) were reviewed . CT pelvis showed deep sacral decubitus ulcers without CT evidence of osteomyelitis . During the course of hospital stay: Patient was evaluated by surgery team, underwent debridement (medical process of removing dead, damaged, or infected tissue from a wound to promote healing and prevent infection) of the wound, clean borders achieved. Wound vac (device that uses gentle suction to promote faster and more effective wound healing), ID (Infectious Disease) recommend total of 7 days of antibiotics . He (Resident #121) is comfortable going to SNF (skilled nursing facility) with a goal for better wound care . Discharge Planning . Pressure injury, Wound clinic in 2 weeks 1/1/26 (wound care provider) in 2 weeks . Review of Resident #121's Clinical Discharge summary dated [DATE] revealed, . Follow up: Wound Clinic. When: In 2 weeks. 1/1/26 . Review of Resident #121's Documentation of Symptoms for Sacral wound indicated findings of increased drainage on the following dates: 12/29/25, 12/30/25, 12/31/25, 1/3/26, 1/4/26, and 1/8/26, findings for foul order on the following dates: 12/29/25, 12/30/25, 12/31/25, 1/3/26, 1/4/26, and 1/8/26, findings for Surrounding warmth on the following dates: 12/31/25, 1/3/26, 1/4/26, 1/8/26 and 1/8/26 and findings for Surrounding edema (swelling) on 12/31/25, 1/3/26, 1/4/26, and 1/8/26 . Review of Resident #121's Progress Note dated 1/8/26 revealed, (Resident #121) is being sent to the ER for further evaluation of altered mental status and ? infection (sic). Order received from NP MMM to send patient to the ER . Review of Resident #121's Hospital Records dated 1/8/26 revealed, . ED Course: . presents by EMS (Emergency Medical Services) for altered mental status and concern of worsening sacral wound. Per EMS, the patient is typically A&O (alert and oriented) x4 and is able to ambulate. Over the last few days patient has reportedly been more disoriented and not ambulating by himself. EMS reports that worsening facility nurses were concerned about sacral wound worsening. Reportedly SNF (Skilled Nursing Facility) nurses were concerned that sacral wound was worsening .Examination of sacral wound shows wound with VAC in place. There appears to be erythema surrounding wound with fluctuance (boggy sensation felt on palpitation, indicating a fluid filled area) present . Purulence (pus that is produced in infected tissue) noted near the tailbone . Hospital Course: . Septic shock from necrotic sacral ulcer with osteomyelitis, Bacteroides and gram positive bacilli bacteremia (presence of bacteria in the bloodstream), Pseudomonal UTI (urinary tract infection). s/p (status post) incision and drainage of sacral wound 01/09, bone biopsy shows osteomyelitis. ID (Infectious Disease) consulted . Wound Care Consult Note 1/9/26: 2. Coccyx/sacral wound 10.5 x 11 (Centimeters) x unable to assess due to necrotic tissue with bone exposed and palpable wound connect under necrotic tissue. Undermining circumferential in varies depth to uncomfortable for patient to obtain measurement. Peri wound skin erythema/nonblanchable /odor noted. Right lower leg lateral 7.6 CM x 3.9 (centimeters)x tissue purplish/black. Right anterior lower leg 3.5 x 1.1 (centimeters) x necrotic. Left lateral ankle 8 x 4 (centimeters) x Deep tissue injury Assessment: . 2. Unstageable pressure ulcer coccyx/sacral. 3. Right lower leg lateral unstageable pressure injury versus Deep tissue injury 4. Right anterior lower leg unstageable pressure injury 5. Left lateral ankle appears to be deep tissue injury evolving 6. Skin tear left arm . Infectious Disease Consultation 1/14/26: . On 01/09/2026 patient had incision and drainage and debridement of the sacral wound with bone biopsy taken that is showing acute osteomyelitis . During an interview on 2/04/2026 at 1:23 PM, Family Member (FM) FFF reported Resident #121 had been admitted to the facility on [DATE] after being hospitalized due to his coccyx wound. FM FFF reported that Resident #121 had admitted to the facility to continue receiving wound care treatments. FM FFF reported Resident #121 was typically alert and oriented, and able to ambulate in his wheelchair. FM FFF reported she first noticed that something seemed to be wrong with Resident #121 during a care conference at the facility on 12/24/25 when she noted that Resident #121 seemed to be noticeably more confused. FM FFF reported she had voiced her concern that Resident #121 seemed more confused than usual and was told that staff would get back with her regarding her concern. FM FFF reported on 12/26/25 she found Resident #121 lying in his room and that he appeared very pale and ill. FM FFF reported the nurse caring for Resident #121 had informed her that Resident #121 had not had his sacrum dressing changed because the facility was waiting on supplies to come in. FM FFF reported that she continued to voice concerns about Resident #121 condition at this time, and she felt that she felt that staff were not taking her concerns seriously. FM FFF reported she was called by LPN TT on 12/29/25 and told that Resident #121's wound looked worse, and that she was waiting for the wound doctor to look at it before putting the wound vac back on. FM FFF reported that she did not hear back from the facility about Resident #121's condition after she had talked with LPN TT on 12/29/25. FM FFF reported she went to visit Resident on 1/5/26 and noted that Resident #121 could hardly talk and seemed confused or sedated. FM FFF reported that she spoke with the nurse caring for Resident #121 and expressed her concerns that Resident #121 was declining, FM FFF reported that staff reported that they would look into it again. FM FFF reported that she called the facility's Social Worker (SW) on 1/6/26 to discuss her concerns that Resident #121 was declining, and that she received a call back from on 1/7/26 from SW XX that the facility had a call into the doctor at the facility to see Resident #121. FM FFF reported that the next day, 1/8/26, Resident #121 was transported to the emergency room where he was admitted to the hospital. FM FFF reported that Resident #121 was transferred to the Intensive Care Unit (ICU) and had to have surgery the following day on his sacrum wound. FM FFF reported that she had spoken with the facility's Nursing Home Administrator (NHA) A on 1/9/26 and expressed her concerns about Resident #121's health decline and the facility response. FM FFF' reported that she was told the facility was investigating her concerns. FM FFF reported that she received a follow up call from Clinical Support Nurse (CSN) AAA where she was informed that the facility had not provided care for Resident #121's that was up to the facility standards, and that the facility was investigating her concerns. FM FFF reported that she never heard back from the facility staff after her call with CSN AAA. During an interview on 2/05/2026 at 11:34 AM, Certified Nursing Assistant (CNA) P reported she cared for Resident #121 often. CNA P reported that when Resident #121 first came to the facility he was alert, very kind, and required assistance of 1 staff member for ADL (Activities of daily living care) and then he seemed to go downhill all of a sudden. CNA P reported that Resident #121 became combative and he became unable to feed himself. CNA P reported that it seemed like she noticed the change in Resident #121 began when the facility took his wound vac off. CNA P was not aware of the date that the facility had removed Resident #121's wound vac. During an interview on 2/05/2026 12:41 PM, CNA S reported she had cared for Resident #121 and was familiar with him. CNA S reported Resident #121 did seem to quickly decline after he was admitted to the facility. CNA S reported Resident #121 began to require more assistance, seemed more confused and was getting more combative. During an interview on 2/05/2026 at 11:40 AM, LPN TT reported that she had cared for Resident #121 multiple times since he had been admitted to the facility. LPN TT' reported Resident #121 had declined after he was admitted to the facility, and Resident #121's family member had expressed concerns related to his decline. LPN TT reported she thought that the nurses had told NP MMM about Resident #121's decline, but she was not sure what NP MMM did for Resident #121. LPN TT reported on 12/26/25 she was unable to complete Resident #121's dressing change to his sacral wound because the facility did not have the wound vac supplies. LPN TT reported she passed along to the oncoming nurse that the nurses would need to complete a wet to dry dressing change and remove Resident #121's wound vac that night if the supplies did not arrive. LPN TT reported that when she returned to the facility on [DATE], Resident #121's wound vac was still on, and the facility did not have supplies, so she was not able to confirm if the facility had changed Resident #121's dressing since 12/26/25. LPN TT reported that on 12/29/25, as she changed Resident #121's wound vac, she observed bone in Resident #121's sacral wound, and that the wound was black and the tissue was necrotizing. LPN TT reported that the wound appeared to be worsening LPN TT reported that she asked for Former Director of Nursing (F-DON) UU and LPN NN to assist her to provide treatment to Resident #121's wound. LPN TT reported that she was instructed F-DON UU to remove Resident #121's wound vac, apply a wet to dry dressing, and contact Resident #121's wound clinic. LPN TT reported that she tried to find what wound clinic Resident #121 had gone to, but she was unsuccessful. LPN TT reported that when Resident #121 was sent to the hospital on 1/8/26 she had found a wound on his right leg that she did not know was even there, and she did not think that facility had treatment orders in place for Resident #121's leg wound. During an interview on 2/05/2026 at 11:57 AM, LPN PP reported that he had cared for Resident #121, and that he recalled that Resident #121 seemed to need more assistance with care after he was admitted to the facility. LPN PP reported that he had completed wound care on 1/7/26, he had noticed that Resident #121's wound did not seem to be improving, and that there were brownish slough (dead tissue) spots across the wound. LPN PP reported that he thought that there was some issue with Resident #121's wound vac, so the facility had removed the wound vac and completed wet to dry dressings for a while, but he was not able to confirm the date that Resident #121's wound vac was removed or placed back on. When this writer queried LPN PP about Resident #121's TAR documentation on 12/21/25, where LPN PP had documented a . under the note for if Resident #121's wound care treatment had been complete, LPN PP reported that he did not know why he did not document whether the treatment was completed or not, and that he should have documented more than a period. LPN PP confirmed that his documentation did not indicate whether he had completed Resident #121's wound care treatment, and that he could not recall if he had missed any of Resident #121's wound care treatments. LPN PP reported that he could not recall if had notified the facility's provider that Resident #121's wound was worsening. During an interview on 2/05/2026 at 4:12 PM, LPN NNN reported she had cared for Resident #121 and recalled that Resident #121's wound care treatments were scheduled to completed on first shift. This writer queried about LPN NNN's documentation for Resident #121 on 12/31/25 which stated, No wound care this shift. LPN NNN reported she had documented that to remove the task from her list, and to confirm that she did not complete Resident #121's wound care treatment on that shift. LPN NNN confirmed that she had passed that information along to the oncoming nurse, but there was no way to verify if Resident #121's wound care treatment had been completed. LPN NNN reported it was common for her to skip treatments when she worked at the facility because she was struggling to manage the workload. During an interview on 2/05/2026 at 4:27 PM, LPN SS reported she was the nurse that had admitted Resident #121. LPN SS reported that Resident #121 was not admitted with his wound vac on, and she was not sure when the facility had gotten his wound vac. LPN SS reported she recalled documenting Resident #121's wounds but could not recall if she measured them or what any of his wounds looked like. LPN SS reported the admitting nurse places orders based on the hospital discharge paperwork, which is where she found the order for Resident #121's wound vac treatment. LPN SS did not recall if Resident #121 had an appointment scheduled with a wound clinic. LPN SS confirmed that she had been told by LPN TT on 12/26/25 that if the supplies did not come in for Resident #121's wound vac treatment, she would need to complete a wet to dry dressing change. LPN SS reported that on 12/26/25 during Resident #121's wound care treatment she noted that the wound looked much worse than when Resident #121 was first admitted , and it was bigger in size. LPN SS reported that there were several areas where the tissue on the wound was black. LPN SS reported she had noticed that Resident #121 had seemed to have declined, and that Resident #121's family member had also voiced concerns about his decline. LPN SS reported that Resident #121 was more confused and needed more assistance than when he was first admitted . LPN SS reported that she thought she had a left a note in the provider book for NP MMM, but she could not recall when. During an interview on 2/05/2026 at 1:06 PM, Clinical Care Coordinator (CCC) CC reported Resident #121 was admitted with a wound vac on his sacral wound, and that the dressing was supposed to be changed three times a week. CCC CC reported that she did not think that the facility was aware that Resident #121 was supposed to follow up with a wound clinic on 1/1/26. CCC CC reported that the facility submitted a referral to a wound clinic for Resident #121 on 12/31/25, and that he was scheduled for 1/14/26. CCC CC confirmed that she was aware that staff and Resident #121's family had expressed concerns that he was declining, and that she thought that NP MM was aware. CCC CC reported that she was on vacation from 12/27/25- 1/5/26, and when she returned from vacation, she discovered that two of the facility nurses had put in an order for Resident #121's sacral wound care order to be changed to a wet to dry dressing. CCC CC reported that she did not know who had given the order for the nurses to change Resident #121's wound care orders, so she instructed LPN PP to place the wound vac back on Resident #121. CCC CC reported that she did not know why the facility nurses were documenting that the facility was out of wound care supplies, because the facility was never out of supplies, and that they were in the storage room. CCC CC reviewed Resident #121's TAR with this writer and confirmed that Resident #121 had several missing and inaccurate documentation for wound care treatments. CCC CC reported that if a nurse marks a treatment as hold- see note, the nurse should document the reason the treatment was missed. CCC CC reported Medical Records (MR) ZZ would have been responsible for arranging appointments for Resident #121. During an interview on 2/05/2026 at 1:27, MR ZZ reported that she was responsible for reviewing the hospital discharge orders for residents to arrange transportation/scheduling for residents. MR ZZ reviewed Resident #121's hospital records with this writer and confirmed that she was not aware that Resident #121 was supposed to follow up with a wound clinic on 1/1/26, and that she had missed this, therefore Resident #121 had not gone to the wound clinic during his admission at the facility. During an interview on 2/05/2026 at 1:39 PM, NP MMM reported she had been made aware that nursing staff at the facility were concerned about the presence of bone on Resident #121's sacral area, and that she had told the facility staff that they were able to use an adaptic (non-adherent wound dressing) dressing to cover the wound and continue to use the wound vac as ordered. NP MMM reported that she did not recommend a change to Resident #121's wound care orders. NP MMM reported that she was alerted verbally by a nurse in the facility that Resident #121 did not have his wound vac on but she could not recall who the nurse was or what date this was. NP MMM reported that she was under the impression that Resident #121's wound vac was placed back on when she told staff it needed to be on, but she did know when staff put Resident #121's wound vac back on. In a follow up interview on 2/5/26 at 2:13 PM, NP MMM reported that she was aware of staff and family concerns that Resident #121 was declining. NP MMM reported that she had saw Resident #121 around New Years and ordered lab work which looked good with the exception of an abnormal CRP (lab test for assessing inflammation in the body and can aid in diagnosing and monitoring various health conditions) but since Resident #121 had a wound, she was not concerned. NP MMM reported when she saw Resident #121 on 1/8/26, he did not look good and he was not eating, so she ordered that Resident #121 be sent to the hospital. NP MMM reported that she had never been made aware that Resident #121's wound was hot to touch. During an interview on 2/05/2026 at 1:54 PM, F-DON UU reported Resident #121 was admitted to the facility with a wound vac on his sacral wound. F-DON UU reported at one point the facility was questioning the wound care order and trying to figure out if Resident #121 was supposed to go to a wound clinic, but she was not aware of what the facility determined for Resident #121's wound clinic referral. F-DON UU reported that she was aware that nursing staff were reporting that they did not have the supplies to treat Resident #121's wound, but that the facility did have supplies because she had found them, but she was unable to report what date she found the supplies. F-DON UU reported that she had instructed LPN TT to remove Resident #121's wound vac on 12/29/25, because the facility would typically complete a wet to dry dressing until orders were verified by a provider. F-DON UU reported that she did not notify NP MMM about the change in Resident #121's wound condition on 12/29/25, but she thought that LPN TT had. During an interview on 2/05/2026 at 2:19 PM, CSN AAA reported that she had been made aware on 1/9/26 that Resident #121's family had concerns with his care at the facility from NHA A. CSN AAA reported that she had conducted an investigation with NHA A into Resident #121's family concerns. CSN AA reported Resident #121 had been admitted to the facility and she thought that Resident #121 was not admitted with the wound vac on his sacral wound, but that Resident #121 did get a wound vac and was supposed to have the wound vac on. CSN AAA reported a nurse removed the wound vac and notified F- DON UU, who she assumed told the nurse to initiate a wet to dry dressing for Resident #121. CSN AAA confirmed that NP MMM had ordered that Resident #121's wound vac should be placed back on, and she did not want staff completing wet to dry dressing treatments. CSN AAA confirmed that nurses were supposed to notify the provider anytime that they determine a new treatment may be needed, as the wound care treatment order must come from the facility provider. CSN AA confirmed that the facility's nursing documentation did not indicate when or if a provider was notified about the change in Resident #121's wound and how long the wound vac was off for. CSN AA confirmed that there were several missing documented treatments for Resident #121's wounds, and that there was not an order for Resident #121's leg wound. CNS AA reported she was unaware that Resident #121 was supposed to follow up with a wound clinic on 1/1/26. During an interview on 2/06/2026 at 8:34 AM, LPN NN reported that she had assessed Resident #121's sacral wound with LPN TT on 12/29/25. LPN NN reported that she recalled LPN TT notifying F-DON UU and NP MMM and being instructed to complete a wet to dry dressing on Resident #121's sacral wound. LPN NN reported Resident #121's wound looked very gray, and there was a very strong odor. LPN NN reported that LPN TT was waiting for new orders from NP MMM for Resident #121's wound, and so she did not replace Resident #121's wound vac. During a follow up interview on 2/06/2026 at 8:54 AM, LPN TT confirmed that she did notify NP MMM on 12/29/25 about Resident #121's wound via text. LPN TT reviewed the text that she sent to NP MMM which indicated that she had concerns with Resident #121's wound, and that she changed his dressing to a wet to dry. NP MMM replied that she had received the text and would be in to look at Resident #121. LPN TT reported that she did not receive any follow up orders from NP MMM and she did not know when or if Resident #121 was seen by NP MMM or if his wound care orders were changed. Review of Resident #121's Care Plan revealed, (Resident #121) potential risk for impaired skin integrity related to: History of fragile skin, current sacral pressure ulcer (localized injuries to the skin and underlying tissue that occur over the sacral (tailbone) area due to prolonged pressure, Poor nutritional intake, impaired functional mobility . Date Initiated: 12/19/2025. Goal: (Resident #121) will show improvement of impaired skin integrity as evidence by no S/S (signs/symptoms) of infection and decreased measurements and/or prevention of avoidable impaired skin integrity will be achieved. Date Initiated: 12/19/2025. Interventions: Admit, quarterly, and prn (as needed) re-evaluation utilizing MDS (Minimum Data Set) based scales, Assess footwear as indicated, Assess postural alignment, weight distribution, sitting balance, & pressure redistribution on admit and prn (as needed), Assist with re-positioning with use of draw sheet as needed to prevent friction/shear, Measure open areas upon admission, weekly, prn, Pressure reducing cushion to wheelchair, Pressure reducing mattress, Re-evaluate treatment and resident condition prn with no improvement to wound appearance and/or measurements. Date Initiated: 12/19/2025. Review of Resident #121's admission assessment dated [DATE] indicated that Resident #121 was admitted with wounds on his right iliac crest (bony ridge at top of your hip bone), left inner ankle, right outer ankle, and sacrum. Noted that the assessment did not include measurements or description of the type of wound for each area. Review of Resident #121's HCP (health care provider) Visit dated 12/22/25 and documented by Nurse Practitioner (NP) MMM revealed, . Assessment and Plan: Infected decubitus ulcer-Continue Augmentin and Bactrim for total of 7 days. Wound vac, follow up with wound clinic .Review of Resident #121's Wound Measurements dated 12/24/25 revealed, .Observations: Right Anterior Leg: Length: 0.5 CM (centimeters). Width: 0.5 CM. Depth: 0.2 CM. Site: Right flank (area between the lower rib cage and top of the hip bone) Length: 0.5 CM. Width: 0.5 CM. Depth: 0.2 CM. Site: Right lateral leg: Length: 0.5 CM. Width: 1 CM. Depth: 1 CM .Site: Right buttock: Length: 6 CM. Width: 3.6 CM. Depth: 1.6 CM. Stage: IV. Site: Sacrum. Length: 8 CM. Width: 4 CM. Depth: 4 CM. Stage: IV . The documentation indicated the wound on Resident #121's Right buttock had Granulation (is reddish connective tissue that forms on the surface of a wound when the wound is healing- firm/red, moist, pebbled healthy tissue and Slough (dead tissue)- dry/or wet, loose or firmly attached, yellow to brown dead tissue present with moderate amounts of Serous- (thin, yellowish fluid) and Sanguineous (bloody fluid). The wound had a presence of odor, and the wound edges were presented as rolled (curled under). Tunneling ( a narrow passageway or tunnel extending from the wound, usually in one direction) or undermining (damage that extends beneath the wound edges in multiple directions, creating pockets or shelves beneath the skin) was also noted. Review of Resident #121's Treatment Administration Record (TAR) revealed, Wound Care; Sacrum: Cleanse area with NS (normal saline), Frame wound withtegaderm (type of wound dressing), loosely fill area with black foam, Cover with drape/tegaderm to secure seal. Cut quarter size hole into middle of drape and connect suction pad . Negative Pressure Wound Therapy (NPWT) to: 125mmhg Set vacuum at 125 mmHg Intermittent. Inspect settings and visualize dressing is intact every shift. every day shift. every Mon (Monday), Wed (Wednesday), Fri (Friday). Hold date 12/29/25-12/31/25. Noted that the treatment had not been documented to indicate if the treatment was completed or missed on 12/22/25 and 1/2/26. On 12/26/25 and 12/31/25 the TAR treatment was documented as See progress note. Review of Resident #121's TAR revealed, Wound Care: R (right) buttock with sacrum- cleanse with NS and apply wet to dry Dakins solution (wound cleanser) dressing. Change every day and PRN if dressing becomes soiled or disrupted. Everyday shift for wound management. Discontinue date: 1/10/26. It was noted that the treatment was not documented as completed or missed on 1/2/26. The treatment was documented as completed on 1/1/26, 1/3/26, 1/4/26, 1/5/26 and 1/7/26. Review of Resident #121's TAR revealed, Sodium Hypochlorite External Solution 0.25 % (wound cleanser solution). Apply to affected area topically every day and evening shift for wound. Discontinued: 1/7/26. Noted that this order did not identify which wound this treatment was indicated for.Review of Resident #121's TAR revealed, Wound location: left hip ulcer; cleanse with NS, pat dry with gauze, apply boarder foam dressing every day shift. Discontinued date 12/27/25. Noted that the treatment had not been documented to indicate if the treatment was completed or missed on 12/22/25. On 12/21/25 and 12/25/25 the TAR treatment was documented as See progress note. Review of Resident #121's TAR revealed, Wound location: Right posterior ribs, Open area x2 cleanse with NS, pat dry with gauze, apply boarder form every shift. Noted that it the treatment was not documented as completed or missed on 12/30/25 and see progress note on 12/31/25. Noted that there were no treatments orders for the right ankle or left ankle or right leg in Resident #121's TAR. Review of Resident #121's Progress notes dated 12/21/25 and 12/25/25 revealed Orders: administration note: . Noted that the nurse only documented a . (period) in the progress note and did not indicate why the treatment was missed/held. Review of Resident #121's Progress note dated 12/26/25 revealed, Orders administration record: Awaiting wound vac supplies.Review of Resident #121's Progress Note dated 12/29/25 revealed, This author attempted to change wound vac dressing today. Supplies have not arrived . Review of Resident #121's Progress Note dated 12/29/25 and documented by Licensed Practical Nurse (LPN) TT revealed, LPN attempted to change wound vac dressing. Dressing removed. LPN observed wound down to bone in right buttock wound. Left buttock wound does have some tissue left. Tissue between both wounds is necrotizing. Peri wound is red, hot to touch. DON (Former Director of Nursing) UU aware. Instructed to wet to dry (applying moist gauze to a wound, followed by dry gauze, then allowing it to dry completely and stick to dead tissue so that when it is removed the dead tissue comes with it) and call wound clinic. Wound clinic called, LPN left message on nurse line at (number redacted) for further instruction. Awaiting call back. Family aware . Review of Resident #121's Progress Note dated 12/29/25 and documented by LPN TT revealed, (wound care provider) does not see (Resident #121) for wound vac. LPN left message with Nurse Practitioner (NP) MMM for further instructions. Review of Resident #121's Progress Note dated 12/30/25 revealed, Resident recently declined, NP MMM consulted. labs to be obtained STAT .Review of Resident #121's Progress Note dated 12/30/25 revealed, Treatment completed and resident with little resistance. some drainage noted to old dressing with some odor to it .Review of Resident #121's Wound Measurements dated 12/31/25 revealed, .Observations: Site: Right buttock: Length: 6 CM. Width: 3.6 CM. Depth: 1.3 CM. Stage: IV. Site: Sacrum. Length: 8.3 CM. Width: 3.9 CM. Depth: 2 CM. Stage: IV . The documentation indicated the wound on Resident #121's Right buttock had Granulation (is reddish connective tissue that forms on the surface of a wound when the wound is healing- firm/red, moist, pebbled healthy tissue and Slough (dead tissue)- dry/or wet, loose or firmly attached, yellow to brown dead tissue present with moderate amounts of Serous- (thin, yellowish fluid) and Sanguineous (bloody fluid). The wound had a presence of odor, and the wound edges were presented as rolled (curled under). Tunneling ( a narrow passageway or tunnel extending from the wound, usually in one direction) or undermining (damage that extends beneath the wound edges in multiple directions, creating pockets or shelves beneath the skin) was also noted. Review of Resident #121S Progress Note dated 12/31/25 revealed, .Wound vac remains on hold until further wound care evaluation completed. Wound is larger, with necrotizing tissue in the middle and bone exposure observed. Wet to dry dressing maintained at this time.Review of Resident #121's Progress Note dated 12/31/25 and documented by LPN NNN revealed, No wound care this shift. Review of Resident #121's Progress Note dated 12/31/25 and documented by NP MMM revealed, Infected decubitus ulcer-Completed Augmentin and Bactrim (antibiotics) for total of 7 days. Continue wound vac, follow up with wound clinic on 1/14 .Review of Resident #121's Progress Note dated 1/6/26 revealed, . Wound care completed to buttocks, wet to dry. Wound drainage green/yellow, odor increased. Tenderness increased. Not able to participate in therapies at this time .Review of Resident #121's Wound Measurements dated 1/7/26 revealed, .Observations: Site: [TRUNCATED]

Based on interview and record review, the facility failed to ensure annual performance evaluations for certified nursing assistants were completed, resulting in the potential for the delivery of nursing and related services that does not support or maintain the residents highest practicable physical, mental, and psychosocial well-being.Findings include: Based on interview and record review, the facility failed to ensure annual performance evaluations for certified nursing assistants were completed, resulting in the potential for the delivery of nursing and related services that does not support or maintain the residents highest practicable physical, mental, and psychosocial well-being.Findings include: 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. In an interview on 02/06/2026 at 10:32 AM, Staffing & Scheduling Manager (SSM) J reported the facility had a system the staff members were placed in upon hire at the facility and this would build the staff members permanent schedules and their talent profiles. In an interview on 02/06/2026 at 3:27 PM, Human Resources (HR) JJ reported the staff members orientation included the electronic education system and the floor competency training. HR JJ reported after orientation each staff member's orientation packet was uploaded to the system the facility used to track schedules and trainings. In an interview on 02/10/2026 at 9:38 AM, Certified Nursing Assistant (CNA) P reported she had not had an annual performance review for several years. In an interview on 02/10/2026 10:22 AM CNA W reported last week the facility had asked the CNAs to sign up for annual performance evaluations and hers was scheduled for this week Thursday. Review of CNA OOOs employee file revealed the last time an annual performance evaluation was completed was on 3/21/24. In an interview on 02/10/2026 at 11:24 AM, HR JJ reported she was unable to locate an annual performance evaluation for CNA P, but she was due next month for her annual performance evaluation. HR JJ reported her QAPI (Quality Assurance & Performance Improvement) report would indicate who was due for their evaluations and then she would send the report to the Director of Nursing (DON). Then, the DON would check off who was completed in the QAPI report and in the system used to track in the talent profile section so the next time she ran the QAPI report she would have accurate dates of completion for the facility.

Based on observation, interview, and record review the facility failed to provide food and drink at a palatable temperature in 2 (R32 and R72) of 22 residents reviewed for palatability among all residents. This deficient practice has the potential to result in decreased food consumption and potential nutritional decline.Findings include: Resident #32 Review of an admission Record revealed Resident # 32 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: parkinson's disease (a progressive, incurable neurodegenerative(gradual dysfunction and death of neurons in the brain) disorder of the central nervous system primarily affecting movements, causing tremors and balance issues), muscle weakness and dementia (an umbrella term for a progressive decline in cognitive function). Review of a Minimum Data Set (MDS) assessment for Resident #32 with a reference date of 1/27/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 13/15, which indicated the resident was cognitively intact. Review of a Care Plan for Resident #32 with a reference date of 1/29/25 revealed the following focus/goal/interventions: (Resident #32) is at risk for altered nutrition due to conditions associated with dysphagia (swallowing difficulty), dementia, tremor.Goal: Reduction in risk of factors for hypo-hyperglycemic events (excessively high or how blood sugar level). Interventions: Adaptive equipment: large soup spoon.serve diet as ordered. During an observation on 2/6/26 at 1:04pm, Resident #32's room lunch tray was delivered and left on his bedside table. The plate was covered with a grey, hard plastic top. During an observation and interview on 2/6/26 at 1:07pm, Resident #32 removed the top and began to eat a piece of cauliflower. Resident #32 stated the food was lukewarm at best and too tough to eat. Resident #32 then ate a bite of the loaded baked potato and stated, It's colder than the cauliflower. Resident #32 expressed dissatisfaction with the food and reported he was not going to eat. When further queried, Resident #32 reported the palatability of the food had been a concern for several months and he purchased himself nutritional drinks to ensure he could get enough calories to avoid losing weight. Resident #72 (R72) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R72 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 9 out of 15 which indicated R72's cognition was moderately impaired. During an interview on 2/04/2026 at 10:44 AM, R72 stated that her coffee was cold and it didn't matter whether she ate in the main dining room, small dining room or her room. R72 said she liked to drink hot coffee and doesn't like it cold. R72 also stated that the food was cold when she ate in her room. During an interview on 2/05/2026 at 1:12 PM, Certified Dietary Manager (CDM) III stated that she wasn't aware about coffee being cold and food on room trays being cold. CDM III stated she would start monitoring coffee temperatures and room tray temperatures. On 2/4/26 at 11:30 AM, an interview with Certified Dietary Manager (CDM) UUU found that lunch starts at 12:00 PM On 2/4/26 at 12:46 PM, residents in the dining room, next to the kitchen, started to get served their lunch. At this time, it was noted that no heated bases or heated plates were used during service. On 2/4/26 at 12:50 PM, an interview with CDM UUU found that food on the steam table should be 165F. On 2/4/26 at 1:09 PM, a regular test tray was plated as one of the last meals coming from the steam table. The plate consisted of two, roughly two ounce, pieces of chicken, mashed potatoes, a side salad, two peanut butter cookies, a drink, and a package of salad dressing. The test tray sat in the tray line and was picked up by the surveyor when it was its turn to be delivered. On 2/4/26 at 1:17 PM, the test tray was in the conference room with the following temperatures found using a rapid read thermometer: one piece of chicken was 140F, the other piece of chicken was 118F and the mashed potatoes were 121F.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.Findings include: On 2/4/26 at 10:46 AM, an interview with Certified Dietary Manager (CDM) UUU found that staff typically date items for a three-day discard and use the day it was made or opened to label. On 2/4/26 at 10:54 AM, observation of the two-door reach in refrigeration unit found a half empty gallon of milk dated 1/26/26. When shown to CDM UUU she discarded the product. On 2/4/26 at 10:56 AM, observation of the walk-in cooler found an open package of polish sausages with no date to indicate when the item should be discarded. On 2/4/26 at 11:57 AM, observation of the Front Street refrigeration unit found two containers of cottage cheese with best by dates of 2/2/26, an open gallon of milk with a best by date of 1/28/26, and a pitcher of thickened water dated 1/28/26. According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specifiedunder S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7days. The day of preparation shall be counted as Day 1. According to the 2022 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and timecombination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) . On 2/4/26 at 10:53 AM, observation of the seals and gaskets on both of the four door freezers showed an increased accumulation of food crumb and black debris. On 2/4/26 at 11:12 AM, observation of the underside of the coffee unit found an increased accumulation of dried brown and black splatter debris. On 2/4/26 at 11:13 AM, observation of the ice scoop holder found an increased accumulation of brown and white crusted debris on the inside bottom of the holder. When shown to CDM UUU she took the ice scoop holder to the dish machine area. On 2/4/26 at 11:16 AM, an interview with [NAME] VVV found that the can opener had not been used today. Observation of the can opener found increased accumulation of debris on and around the blade with red staining on portions of the blade face of the unit. On 2/4/26 at 11:18 AM, an interview with CDM UUU found that the utensil drawers should get cleaned nightly by the PM cook. Observation of the mechanical scoop drawer found four scoops with stuck on food debris stored with clean utensils. Further observation of the drawer found increased accumulation of food crumb debris in the bottom. On 2/4/26 at 11:20 AM, observation of the clean utensil containers under the cookline found the containers dirty and dingy with accumulation of crumb debris inside the containers holding metal spoons, tongs, and spacers for the steam table. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 2/4/26 at 10:57 AM, observation in the walk-in cooler found a dozen sealed packages of single serve macaroni and cheese. Further review of the product found that it stated it should be kept frozen. When asked how many they go through, CDM UUU stated three or four each lunch and dinner service. On 2/4/26 at 11:38 AM, observation of the dry storage room found open containers of lemon juice and soy sauce sitting on a dry storage shelf. The gallon container of soy sauce was half full and the liter of lemon juice contained about 3/4 of the product. A review of both containers found their manufactures state on the label, Refrigerate After Opening. According to the 2022 FDA Food Code section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57C (135F) or above. or (2) At 5C (41F) or less. On 2/4/26 at 11:28 AM, an interview with CDM UUU found that the facility did not have any chlorine test strips to test the working order of the dish machine. According to the 2022 FDA Food Code section 4-302.14 Sanitizing Solutions, Testing Devices. A test kit or other device that accurately measures the concentration in MG/L of SANITIZING solutions shall be provided.

Based on observation, interviews, and record review, the facility failed to maintain complete and accurate medical records for 2 (Resident #121 and #19) of 22 residents reviewed for complete and accurate medical record documentation, resulting in the potential for staff and providers mismanaging care for residents. Findings include:Resident #121Review of an admission Record revealed Resident #121 was originally admitted to the facility on [DATE] with pertinent diagnoses which included pressure ulcer of sacral region stage 4, and need for assistance with personal care. Review of Resident #121's Treatment Administration Record (TAR) revealed, Wound Care; Sacrum: Cleanse area with NS (normal saline), Frame wound withtegaderm (type of wound dressing), loosely fill area with black foam, Cover with drape/tegaderm to secure seal. Cut quarter size hole into middle of drape and connect suction pad . Negative Pressure Wound Therapy (NPWT) to: 125mmhg Set vacuum at 125 mmHg Intermittent. Inspect settings and visualize dressing is intact every shift. every day shift. every Mon, Wed, Fri. Hold date 12/29/25-12/31/25. Noted that the treatment had not been documented to indicate if the treatment was completed or missed on 12/22/25 and 1/2/26. On 12/26/25 and 12/31/25 the TAR treatment was documented as See progress note. Review of Resident #121's Progress notes dated 12/21/25 and 12/25/25 revealed Orders: administration note: . Noted that the nurse only documented a . (period) in the progress note and did not indicate why the treatment was missed/held. Review of Resident #121's Progress Notes for 12/26/25 and 12/31/25 revealed no documentation related to the above wound care. Review of Resident #121's TAR revealed, Wound Care: R buttock with sacrum- cleanse with NS and apply wet to dry Dakins solution (wound cleanser) dressing. Change every day and PRN if dressing becomes soiled or disrupted. Everyday shift for wound management. Discontinue date: 1/10/26. It was noted that the treatment was not documented as completed or missed on 1/2/26. Review of Resident #121's TAR revealed, Wound location: left hip ulcer; cleanse with NS, pat dry with gauze, apply boarder foam dressing every day shift. Discontinued date 12/27/25. Noted that the treatment had not been documented to indicate if the treatment was completed or missed on 12/22/25. On 12/21/25 and 12/25/25 the TAR treatment was documented as See progress note. Review of Resident #121's TAR revealed, Wound location: Right posterior ribs, Open area x2 cleanse with NS, pat dry with gauze, apply boarder form every shift. Noted that it the treatment was not documented as completed or missed on 12/30/25 and see progress note on 12/31/25. Review of Resident #121's Progress Notes for 12/31/25 revealed no documentation related to the above wound care. During an interview on 2/05/2026 at 11:57 AM, this writer queried LPN PP about Resident #121's TAR documentation on 12/21/25, where LPN PP had documented a . under the note for if Resident #121's wound care treatment had been complete, LPN PP reported that he did not know why he did not document whether the treatment was completed or not, and that he should have documented more than a period. LPN PP confirmed that his documentation did not indicate whether he had completed Resident #121's wound care treatment, and that he could not recall if he had missed any of Resident #121's wound care treatments. During an interview on 2/05/2026 at 1:06 PM, Clinical Care Coordinator (CCC) CC reported Resident #121 was admitted with a wound vac on his sacral wound, and that the dressing was supposed to be changed three times a week. CCC CC reviewed Resident #121's TAR with this writer and confirmed that Resident #121 had several missing and inaccurate documentation for wound care treatments. CCC CC reported that if a nurse marks a treatment as hold- see note, the nurse should document the reason the treatment was missed. During an interview on 2/05/2026 at 2:19 PM, Clinical Support Nurse (CSN) AAA reported that she had been made aware on 1/9/26 that Resident #121's family had concerns with his care at the facility from NHA A. CSN AAA reported that she had conducted an investigation with Nursing Home Administrator (NHA) A into Resident #121's family concerns. CSN AA confirmed that the facility's nursing documentation did not indicate when or if a provider was notified about the change in Resident #121's wound and how long the wound vac was off for. CSN AA confirmed that there were several missing documented treatments for Resident #121's wounds, and that there was not an order for Resident #121's leg wound. CNS AA reported she was unaware that Resident #121 was supposed to follow up with a wound clinic on 1/1/26. Resident #19Review of an admission Record revealed Resident #19 was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness and major depressive disorder. Review of Resident #19's TAR revealed, WOUND CARE: Left 5th met (long bone on the outer edge of the foot that connects to the little toe) .Change 3 times a weekand as needed one time a day every Tue (Tuesday), Thu (Thursday), and Sat (Saturday) for Wound management. Noted that there was no documentation to indicate if the treatment had been completed or missed on 1/24/26 and 2/1/26. Review of Resident #19's TAR revealed, Left Great, 2nd, 3rd, 4th and 5th toe, Heel, Lateral foot and ankle . Change 3 times a week and as needed . 3 times weekly every Tue, Thu, Sat for wound care. Noted that there was no documentation to indicate if the treatment had been completed or missed on 1/24/26. Review of Resident #19's TAR revealed, Foley Cath (medical device that helps drain urine from your bladder) Care every shift for urinary retention. Empty Foley Catheter Drainage Bag Q (Every) shift & record output. Noted that there was no documentation to indicate if the treatment had been completed or missed on 1/5/26, 1/14/26, 1/15/26 and 1/25/26. During an interview on 2/10/2026 at 11:57 AM, CCC CC reviewed Resident #19's TAR with this writer and confirmed that Resident #19 was missing documentation to indicate whether his treatments had been completed or not, and that nurses were expected to complete all charting on care that residents did or did not receive.

Based on observation, interview, and record review the facility failed to maintain effective infection control practices for 6 residents (#90, #76, #32, #8, #13 and #27) of 6 sampled for infection control; as evidenced by failure to 1. Properly implement transmission-based precautions and complete testing on symptomatic residents; 2. Ensure resident shared equipment was properly cleaned; and 3. Ensure the cleanliness of a tube feeding pole/pump and the surrounding surfaces.Findings include: Review of A systematic review on the causes of the transmission and control measures of outbreaks in long-term care facilities: Back to basics of infection control. revealed The unique characteristics of long-term care facilities (LTCFs) including host factors and living conditions contribute to the spread of contagious pathogens. Control measures are essential to interrupt the transmission and to manage outbreaks effectively. This review indicates that the violation of basic infection control practice could be a major role in introducing and facilitating the spread of contagious diseases in LTCFs. It shows the need to promote compliance with basic practices of infection control to prevent outbreaks in LTCFs. https://journals.plos.org/plosone/article?id=10.1371/journal.[NAME].022991, 3/10/20. #1 Resident #90 Review of an admission Record revealed Resident #90 was originally admitted to the facility on [DATE]. In an interview on 2/4/26 at 10:00am, Nursing Home Administrator (NHA) A reported Resident #90 tested positive for Severe Acute Respiratory Syndrome Coronavirus 2 Covid 19 within the last few days. During an observation and interview on 2/4/26 at 11:24am, the signage outside Resident #90's room read Enhanced Barrier Precautions.wear gown and gloves for.high contact activities. Housekeeper (Hsk) LLL reported both Resident #90 and his roommate (Resident #76) were positive for Covid 19 infections. Resident #76 Review of an admission Record revealed Resident #76 was originally admitted to the facility on [DATE]. Review of an Interdisciplinary Progress Note for Resident #76 with a reference date of 2/3/26 revealed (Resident #76) returned to the facility at approximately 17:30 (5:30pm) .He was admitted to (name of hospital omitted) related to diagnosis of +COVID. Resident #32 Review of an admission Record revealed Resident #32 was originally admitted to the facility on [DATE]. During an observation on 2/10/26 at 9:24am, a large yellow Personal Protective Equipment (PPE) cart was noted outside Resident #32's room. Signage on Resident #32's door read Enhanced Barrier Precautions, Bed 1.wear gown and gloves for.high contact activities. Bed 1 was unoccupied. Review of an Interdisciplinary Progress Note for Resident #32 with a reference date of 2/8/26 revealed Resident was noted with cold symptoms and increased altered mental status. He was tested for COVID and noted be positive. In an interview, Certified Nursing Assistant (CNA) L reported the signage for Enhanced Barrier Precautions pertained to Resident #32's former resident who was no longer at the facility. When further queried, CNA L stated (Resident #32's name omitted) is in isolation, I think for Covid. There should be a sign that tells us what PPE we should put on before we enter the room. Resident #8 Review of an admission Record revealed Resident #8 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Chronic Obstructive Pulmonary Disease (chronic lung disease characterized by persistent, progressive airflow limitations) and Bipolar Disorder with psychotic features (severe manic or depressive episodes accompanied by breaks from reality). Review of a Minimum Data Set (MDS) assessment for Resident #8 revealed a Brief Interview for Mental Status (BIMS) assessment score of 10/15, which indicated the resident was moderately cognitively impaired. During an observation on 2/4/26 at 12:21pm, it was noted that no transmission-based precautions signage was posted outside the room that Resident #8 and Resident #13 shared. In an interview on 2/4/26 at 12:26pm, Resident #8 reported she had been feeling sick for several days and felt she needed a chest Xray due to her cough and hoarse voice. When asked if she had been tested for Covid, Resident #8 reported she had not but felt she needed to be. In an interview on 2/4/26 at 12:27pm, Licensed Practical Nurse (LPN) OO confirmed she was the nurse caring for Resident #8 and was aware of the resident's complaints of feeling ill, her cough and her hoarse voice. When queried, LPN OO reported she did not know if Resident #8 had been tested for Covid since the onset of her symptoms and no transmission-based precautions were in use during cares for Resident #8 or Resident #13. LPN OO reported Resident #8 had reported symptoms for a several days, but LPN OO thought the symptoms were more behavioral in nature. LPN OO confirmed she was aware the facility currently had a covid outbreak. Review of an Interdisciplinary Progress Note for Resident #8 with a reference date of 1/31/26 revealed Resident complained of not feeling well and was noted with a temp of 101.1 (degrees), (normal body temperature is 98.6 degrees), Resident observed with hoarse voice and congestion. MD (Doctor of Medicine) gave one time order for (cough medication) and stated resident would be assessed. Review of an Interdisciplinary Progress Note for Resident #8 with a reference date of 2/1/26 revealed . (Resident #8) noted with emesis (vomiting) x1. Review of an Interdisciplinary Progress Note for Resident #8 with a reference date of 2/4/26 revealed Resident noted to have occasional strong non-productive wet cough. Review of an Interdisciplinary Progress Note for Resident #8 with a reference date of 2/5/26 revealed .Roommate (Resident #13) noted testing positive for COVID. Tested (Resident #8) during shift and results negative at this time. Resident #13 Review of an admission Record revealed Resident #13 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: acute on chronic respiratory failure with hypercapnia (condition in which the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). Review of a Minimum Data Set (MDS) assessment for Resident #13 with a reference date of 1/28/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15/15, which indicated the resident was cognitively intact. In an interview on 2/4/26 at 12:23pm, Resident #13 reported she had been ill for the past 2 days, with symptoms that included nasal congestion, fatigue and increased shortness of breath. Resident #13 reported staff were aware of her symptoms, but she had not been tested for covid. Resident #13 stated I got whatever she had. She's been sick for a week, then gestured toward her roommate (Resident #8). In an interview on 2/4/26 at 12:27pm, LPN OO reported Resident #13 had complained of nasal congestion for the past few days and the physician had ordered a nasal allergy spray for her approximately 2 days ago. LPN OO reported she did not know if the resident had been tested for covid since the onset of her symptoms. During an observation on 2/5/26 at 10:02am, no signage for transmission-based precautions was present outside Resident #13 and Resident #8's room. Review of an Interdisciplinary Progress Note for Resident #13 with a reference date of 2/5/26 revealed (Resident #13) is A&O (alert and oriented) .observed with cough/congestion.COVID test completed that was positive.Placed on isolation at this time. In an interview on 2/6/26 at 10:45am, Infection Prevention Manager (IPM) KK confirmed that any resident with symptoms of an acute respiratory illness should be placed in transmission-based precautions immediately and tested for covid. IPM KK confirmed there was a delay in implementing isolation precautions and testing of symptomatic residents. IPM KK reported Resident #76 tested positive for covid 19 on 1/31/26 and Resident #90 tested positive on 2/1/26. When further queried, IPM KK reported she had just returned from a medical leave and the facility had not immediately implemented all of its covid 19 protocols at the onset of having symptomatic residents/an outbreak. #2 During an observation on 2/5/26 at 10:04am, a mechanical lift device that sat outside room [ROOM NUMBER] was heavily soiled with dust and debris on the blue padding that residents place their hands on during transfers. The base of the device was soiled with large areas of dried white liquid. During an observation on 2/5/26 at 10:13am, a soiled mechanical lift device sat outside room [ROOM NUMBER]. Dried white liquid coated the right side of the base of the device. During an observation on 2/5/26 at 10:24am, A mechanical lift device was stored outside room [ROOM NUMBER]. The device was heavily soiled with dust and debris across the base, the knee guard (where resident's place their knees during transfers) was soiled with dried white liquid. An unknown staff member entered the hallway and took the soiled device into room [ROOM NUMBER] and closed the door. Several minutes later, 2 staff members emerged from room [ROOM NUMBER], 1 staff member pushed the mechanical lift back into the hallway and left it. The device remained soiled as previously noted. The resident in room [ROOM NUMBER], who had been previously observed in bed, was now observed sitting in her wheelchair. In an interview on 2/6/26 at 10:45am, IP KK reported it was the expectation that shared medical equipment, including mechanical lifts be cleaned immediately after each use. IP KK reported staff members were expected to clean every surface of the device with disinfecting wipes after each use to reduce the potential for the transmission/transfer of pathogenic organisms and cross contamination. Review of a COVID 19 Testing and Screening Guidance policy with a reference date of June 2022, revealed Policy: It is the policy of this facility to follow current recommended guidance on how to assess, screen, triage and treat patients.with suspected Coronavirus. Purpose: to make informed decisions related to infection control. Procedure.2. Clinicians should use their judgement through screening and assessment to determine if a patient.has signs and symptoms compatible with COVID 19 and whether the patient should be tested.most patients with confirmed COVID 19 have developed fever and/or symptoms of acute respiratory illness (cough, difficulty breathing) . Resident #27: Review of an admission Record revealed Resident #27 was a female with pertinent diagnoses which included stroke, contractures (a permanent tightening of muscles, tendons, skin caused the joint to shorten and become very stiff) right elbow, right hand, and right ankle; contractures left elbow, hand, and ankle; abnormalities of breathing, tube feeding due to a persistent vegetative state. Review of Order dated 9/8/25, revealed, .Enteral Feed Order two times a day for Enteral Feed.Glucerna 1.5 continuous at 61ml/hr (hour) x 14hrs. On at 2pm, Off when total volume infused = 854ml Peg tube size= 22 Fr. Review of Order dated 11/12/2024 revealed, .May suction PRN (as needed) r/t (related to) increased resp. drainage. as needed for increased resp. drainage empty suction canister . Review of Order dated 11/17/24, revealed, .Change suction catheter, tubing and canister every night shift every Sun (Sunday) for infection prevention date tubing and canister. During an observation on 02/04/2026 at 12:08 PM, Resident #27 was observed lying in her bed. Behind the head of her bed on the wall were splatters of dried tan/brown liquid fanning out across the wall, there was dried tan/brown liquid material dried on the tube feeding pole and base, there was dried tan/brown liquid material on the floor under the tube feeding pole, and on Resident #27's bed frame. The suction machine on her nightstand had thick particle dust covering the whole top of the machine, the nightstand was covered in various personal items as well which were cluttered on the nightstand. During an observation on 02/05/2026 at 9:45 AM, Resident #27 was not in her room. Behind the head of her bed on the wall were splatters of dried tan/brown liquid fanning out across the wall, there was dried tan/brown liquid material dried on the tube feeding pole and base, there was dried tan/brown liquid material on the floor under the tube feeding pole, and on Resident #27's bed frame. The suction machine on her nightstand had thick particle dust covering the whole top of the machine, the nightstand was covered in various personal items as well which were cluttered on the nightstand. During an observation on 02/05/2026 at 12:28 PM, Resident #27 was in her bed. Behind the head of her bed on the wall were splatters of dried tan/brown liquid fanning out across the wall, there was dried tan/brown liquid material dried on the tube feeding pole and base, there was dried tan/brown liquid material on the floor under the tube feeding pole, and on Resident #27's bed frame. The suction machine on her nightstand had thick particle dust covering the whole top of the machine, the nightstand was covered in various personal items as well which were cluttered on the nightstand. o tube feeding observed to be running at this time, there was dried tube feeding on the pole and on the floor around the base of the pole. The suction machine did not have a date on it, and it was covered in dust and debris. The floor needed to be swept as there was dirt and debris on the floor. During an observation on 02/05/2026 2:02 PM, Resident #27 was in her bed. Behind the head of her bed on the wall were splatters of dried tan/brown liquid fanning out across the wall, there was dried tan/brown liquid material dried on the tube feeding pole and base, there was dried tan/brown liquid material on the floor under the tube feeding pole, and on Resident #27's bed frame. The suction machine on her nightstand had thick particle dust covering the whole top of the machine, the nightstand was covered in various personal items as well which were cluttered on the nightstand. o tube feeding observed to be running at this time, there was dried tube feeding on the pole and on the floor around the base of the pole. The suction machine did not have a date on it, and it was covered it dust and debris. Observed on the wall behind her bed, tube feeding pole and floor had dried tube feeding. and it was on the bed frame as well. During an observation and interview on 02/05/2026 at 1:47 PM, Licensed Practical Nurse (LPN) LL reported Resident #27 had a suction machine as a tube feeding resident all of them have one. LPN LL reported Resident #27 does become very congested with mucous during her menstrual cycle. LPN LL reported she does have a patch behind her ear for excess secretions. This writer pointed out the dried tan/brown tube feeding liquid along the wall behind her bed, the dried tube feeding liquid on the tube feeding pole and base, the floor and her bed frame. LPN LL reported housekeeping should have addressed this as they come in the room every day. LPN LL reported the nurse who had allowed the tube feeding to splatter across the wall, fall, bed, and tube feeding pole and base. Shared Equipment: During an observation on 02/04/2026 at 12:12 PM, observed a sit to stand machine between rooms , the base of the machine had dirt and debris on it, the footrests on the sides of the stem had dirt and debris on them. the knee pad area had dried whitish material on the top of it and on the right side back. During an observation on 02/04/2026 at 12:25 PM, observed a Hoyer outside room [ROOM NUMBER] which was observed to have dirt and debris on the footrest area, the blue pad which covered the fork for the hooks had dirt, debris, dried material staining the blue cover. During an observation on 02/05/2026 2:03 PM room [ROOM NUMBER] had a sit to stand outside along the wall, the footrest and the base were covered in dirt and debris, the knee pad had dried white material on the top of it, and on the right side, facing it, there was streaked white dried material running down it. there was a container with micro kill bleach wipes on the machine.

Based on observation and interview, the facility failed to ensure a safe and sanitary environment, for 2 (Resident #4 and Resident #103) including a dusty and broken oscillating fan and an unkept resident room resulting in the potential for unsafe and uncomfortable resident environment.Findings include: Resident #4 Review of an admission Record revealed Resident #4 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: vascular dementia (cognitive impairments resulting from a decrease in blood flow), hemiplegia affecting the left non-dominate side (decrease use of the left side of the body) and cerebral infarct due to occlusion (stroke due to a blocked blood vessel). Review of a Minimum Data Set (MDS) assessment for Resident #4, with a reference date of 12/23/25 revealed a Brief Interview for Mental Status (BIMS) score of 9/15 which indicated Resident #4 was moderately cognitively impaired. On 02/04/26 at 12:26 PM, 02/05/26 at 1:15 PM, and 02/06/26 at 9:15 AM, a small oscillating fan was observed on the bedside dresser in Resident #4's room. The fan was observed to be missing the cover, and the fan blades were exposed and covered in dust; the cover to the fan was observed under personal items on another bedside stand. A pedestal fan in Resident #4's room was observed to be covered in dust. On 02/06/26 at 9:15 Resident #4 was observed in bed, and a small oscillating fan was observed on the bedside dresser, on, with blades exposed and rotating and no cover in place. In an interview on 02/06/26 at 9:19 AM, Resident #4 reported the fan had been broken for a long time and she has asked for it to be fixed. Resident #4 reported she was concerned she would get her fingers in the fan when it was on. In an interview on 02/06/26 at 12:03 PM, Housekeeper (H) GG reported she was responsible for cleaning fans, and there was no set scheduled, they were cleaned as needed. In an interview on 02/06/26 at 12:31 PM, Maintenance Director (MD) EE reported fans were to be cleaned monthly and they were a part of the housekeepers' responsibilities. MD EE reported that he was usually the one that cleaned the fan covers. When MD EE was queried regarding the broken small oscillating fan on Resident #4's bedside dresser and the pedestal fan in Resident #4's room, MD EE reported the broken fan should have been replaced and the pedestal fan should be cleaned. On 02/06/26 at 12:37 PM, MD EE was observed replacing the small oscillating fan and returning the cleaned covers for the pedestal fan in Resident #4's room. Resident #103: Review of an admission Record revealed Resident #103 was a female with pertinent diagnoses which included heart failure, COPD, dementia, Alzheimer's disease (buildup of proteins as plaques and tangles in the brain, causing brain cells to die and the brain to shrink), anxiety and depression. During an observation on 02/04/26 at 11:40 AM, Observed a fall mat next to the side of the bed, which had crumbs, dirt and debris covering it. The floor around and under her bed had scattered dirt, debris, and crumbs on the floor. Resident #103's nightstand needed to be dusted as it and the items on top of it were covered in dust. During an observation on 02/05/2026 at 2:09 PM, Resident 103's room was still unkempt and needed to be dusted, swept and mopped. Using the reasonable person concept, though Resident #103 had decreased ability to verbally express her own thoughts due to her medical diagnoses, any reasonable person would likely feel a decreased sense of self-worth and frustration in the situations observed.

Based on interview and record review the facility failed to provide a Skilled Nursing Facility-Advanced Beneficiary Notice of Non-coverage (SNF-ABN) to 3 (Resident #123, Resident #124, and Resident #125) of 3 residents reviewed for proper notification related to Medicare A insurance coverage and facility care costs.Findings include:Resident #123Review of an admission Record revealed Resident #123 was a female who admitted to the facility on [DATE] and had pertinent diagnoses which included: chronic kidney disease stage 3 (mild to moderate damage to kidneys resulting in decreased ability to filter out water and fluid from the body).Review of SNF Beneficiary Protection Notification Review form for Resident #123, completed by Nursing Home Administrator (NHA) A on 02/05/26 revealed Medicare Part A Services Episode Start Date: 11/17/25 and Last covered day of Part A service: 12/19/25 and NHA A documented No, SNF ABN form was not provided to Resident #123 for Other- Resident (#123) started custodial care on 12/20/25 under Medicaid and Medicare Part B coverage.In an interview on 02/05/26 at 12:10 PM, Financial Services (FS) FF reported she was responsible for issuing SNF ABN forms to residents whose Medicare A benefits were ending. FS FF reported she did not issue the SNF ABN form to Resident #123 due to her transition to custodial care.The facility was unable to provide a documented Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage for Resident #123 prior to survey exit.Resident #124Review of an admission Record revealed Resident #124 was a female who admitted to the facility on [DATE] and had pertinent diagnoses which included: malignant neoplasm of overlapping sites of right female breast (a cancerous growth that has spread to multiple anatomical locations of the breast).Review of SNF Beneficiary Protection Notification Review form for Resident #124, completed by NHA A on 02/05/26 revealed Medicare Part A Services Episode Start Date: 10/23/25 and Last covered day of Part A service: 10/30/25 and NHA A documented No, SNF ABN form was not provided to Resident #124 for Other- Resident (#124) started hospice care on 10/31/25 under hospice - Medicaid coverage with (Name Omitted) Hospice provider.In an interview on 02/05/26 at 12:10 PM, FS FF reported she did not issue the SNF ABN form to Resident #124 due to her transition to Hospice care. The facility was unable to provide a documented Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage for Resident #124 prior to survey exit.Resident #125Review of an admission Record revealed Resident #125 was a female who admitted to the facility on [DATE] and had pertinent diagnoses which included: traumatic subdural hemorrhage without loss of consciousness (bleeding between the brain and its protective layers resulting from trauma).Review of SNF Beneficiary Protection Notification Review form for Resident #125, completed by NHA A on 02/05/26 revealed Medicare Part A Services Episode Start Date: 08/18/25 and Last covered day of Part A service: 09/09/25 and NHA A documented No, SNF ABN form was not provided to Resident #125 for The resident was discharged from the facility and did not receive non-covered services.In an interview on 02/05/26 at 12:10 PM, FS FF reported she did not issue the SNF ABN form to Resident #125 due to her choice to discharge from the facility. The facility was unable to provide a documented Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage for Resident #125 prior to survey exit.In an interview on 02/05/26 at 12:10 PM, FS FF reported she did not understand completely when SNF ABN form should be issued to residents where were transitioning from Medicare A insurance coverage.In an interview on 02/05/26 at 11:56 AM, NHA A reported she was not well versed on which forms should be issued when, but she was learning. NHA A reported she was not sure if SNF ABN forms should be issued for residents who were transitioning from Medicare A insurance services.In a telephone interview on 02/05/26 at 11:58 AM, Corporate Financial Service (CFS) JJJ reported Resident #123, Resident #124, and Resident #125 should have received a SNF ABN from when Medicare A services were being stopped and they were not issued the form. Review of facility policy Advanced Beneficiary Notice with a revision date of November 2022, revealed .to prepare and deliver to the resident or residents authorized representative an Advanced Beneficiary Notice (ABN).when utilization review entity expects that Medicare probably will not pay for or will not continue to pay for extended care items.Purpose: to ensure that beneficiaries receive adequate notice of liability to pay for services denied.the facility will utilized the CMS approved From CMS-10055 for Medicare part A stay fee-for-service care Advanced Beneficiary Notice.

This citation pertains to intake #2735016. Based on interview and record review, the facility failed to protect the resident's right to be free from sexual abuse by a staff member. Findings include: Resident #114: Review of an admission Record revealed Resident #114 was a male with pertinent diagnoses which included multiple sclerosis (the body's immune system attacks the protective covering of the nerve cells in the brain and spinal cord, disrupting signal transmission), need for assistance with personal care, suprapubic catheter (thin, flexible tube inserted through a small incision in the lower abdomen directly into the bladder to drain urine), muscle wasting and atrophy multiple sites (loss of muscle tissue characterized by decreased size, strength, and function), depression, anxiety, and chronic pain. Review of current Care Plan for Resident #114, revised on 11/28/25, revealed the focus, .Altered functional mobility and ADL's (activities of daily living) related to: MS (muscle sclerosis), obstructive and reflux chronic pain syndrome, neurogenic bladder, debility and need for assistance with personal cares with the intervention .DRESSING: One assist with cueing and encourage to do as much for self as able.EATING: Provide physical assistance to accept nutrition by mouth.LOCOMOTION: Independent in wheelchair. Review of Interdisciplinary Documentation dated 01/26/2026 at 2:15 PM, revealed, .(Resident #114) reported an allegation of having an inappropriate non-work related relationship with a staff member. Notification made to NHA (Nursing Home Administrator), DON (Director of Nursing), NP (Nurse Practitioner) and Police. He is self-determined and doesn't wish to have family notified. Review of Facility Reported Incident dated 1/26/26, revealed, .Immediate Action: (Activities Director (AD) F) notified DON (Director of Nursing B) at 1530 (3:30 PM) 1/26/2026, NHA (Nursing Home Administrator A), at 1515 (3:15 PM) 1/26/2026 of the allegation that was made by (Resident #114). (Local County) Sherrif office was called at 1630 (4:30 PM) and (Deputy Sheriff PPP) responded to building in 1700 (5:00 PM) to interview resident, (Resident #114), and file a report. Complaint number 00063310. The alleged perpetrator was sent home immediately following the reported allegation and suspended pending investigation.Witness Interview: Alleged Victim Interview: (NHA A) and (Social Worker (SW) XX) Social Worker interviewed (Resident #114) on 1/26/2026 at 1730 (5:30 PM). (Resident #114) reports that on December 19, 2025, at 1300 (1:00 PM), he left facility on an LOA (leave of absence) per (accessible public transportation) bus to (Local Hotel) in [NAME], MI to stay overnight. He stated that he paid for the room. (Infection Preventionist QQQ) at facility met him there a few minutes after his arrival as they had planned. He brought with him a few vapes (a battery powered device that heats a liquid into an aerosol) and money. He alleges they spent the night together, having unprotected sex. The next morning, they left separately at approximately 10 AM. (Infection Preventionist QQQ) had asked him not to tell anyone about them staying together and he said he promised her he would keep it to himself. A couple days later he noticed $300 missing along with his vapes. He said he contacted her and asked about it, and she denied taking the money and said she was holding his vapes for him. While on video chat with her he said he could see his vapes on her chest as she was using it while talking to him. The relationship continued over (a social media platform) between them sharing videos, and she sent him a screenshot of a picture of her buttocks wearing only a thong.Staff Interview: (CNA P) CNA was asked to give written statement regarding what (Resident #114) had reported to her by (Director of Nursing (DON) B) Director of Healthcare Services on 1/27/2026. (Resident #114) reported to me that the prostitute is what he would call the manager. When he left the facility in December, he paid for that person. We asked who he was talking about and he would not tell us the name. He bought a Nike sweater, and it went missing. I usually help him. He said the Whore took it and got lost in her garage. There was no money on his side table. The next day there was $49.00 on the nightstand, which is how much the sweater cost. He said, the whore finally paid for the sweater. He says that it has been going on with (Infection Preventionist QQQ's boyfriend), and her. I was feeding him and asked if he wanted to report it. I asked if he wanted to speak with (NHA A), NHA. He declined and wanted to speak with (Activities Director (AD) F), Life Enrichment, I reported it to (AD F), and she went to speak with him. Yesterday, he finally said he doesn't want her to take advantage of him and other people. I said, (Infection Preventionist QQQ), and he said yes. That is her. Then I left the room and he turned on the light. He pulled up the messages on the phone and showed pictures of her in her underwear. It was a phone-to-phone text message. I would see her go into his room for a while and come out with large clear trash bags. I couldn't tell what else was in the bag. I could see a sheet. I did not witness any inappropriate behavior, just what (Resident #114) reported. I have not witnessed anyone taking anything from him. Review of IDT Note dated 12/19/25 at 1:30 PM, revealed, .(Resident #114) left facility for overnight at 1300 (1:00 PM), sent with personal belongings of vape pens, knife, etc. Meds sent for the rest of today and 0800 (08:00 AM) tomorrow. Resident states he should return around 1200 tomorrow 12/20.Review of Interdisciplinary Documentation dated 12/19/2025 at 2:14 PM, .CENA (Certified Nursing Assistant) reported to this nurse that (Resident #114) stated he was taking 3,000 dollars cash with him and showed the CENA his money.Review of Interdisciplinary Documentation dated 12/20/2025 at 1:00 PM, .Resident returned from LOA (leave of absence), pleasant and denies c/o (complaints of) any discomfort and in good spirits.In an interview on 02/05/2026 12:44 PM Activities Director (AD) F reported CNA (Certified Nursing Assistant) P was one of the regular CNAs who took care of (Resident #114). AD F reported CNA P came to her to ask her to go and speak to (Resident #114) as he wanted to report someone from management. AD F reported she went to speak with Resident #114 (Resident #114). AD F reported (Resident #114) reported he had been used by (Infection Preventionist (IP) QQQ) and he proceeded to show her pictures of IP QQQ from his (a social media platform) messenger. AD F reported she was able to observe the photo and name attached to the profile and it was IP QQQs name and photo, and there were a ton of messages between them as he was scrolling his messages to show AD F the inappropriate picture IP QQQ had sent to Resident #114 of her backside wearing a thong as underwear. AD F reported Resident #114 reported when asked if it was IP QQQ, Resident #114 stated Who else it would be. AD F reported Resident #114 was scrolling fast in his phone and was unable to see any other pictures and reported he was looking for the specific photo. AD F reported Resident #114 reported the relationship started 12/4/26, as he had shown AD F several missed calls on (a social media platform)Time on that date. AD F reported Resident #114 reported it had started as IP QQQ was coming to his room and she was very friendly with him and IP QQQ started to contact him on (a social media platform) Messenger. AD F reported Resident #114 reported he rented a room, stayed with her there, and they had sexual relations. Resident #114 also reported IP QQQ had stolen his vapes, other stuff and probably took his money but he had no proof. AD F reported Resident #114 indicated to a nurse he might have a sexually transmitted disease (STD) after their sexual encounter, thought IP QQQ had given him an STD and IP QQQ had come to his room and asked him why he was asking for an STD test. AD F reported Resident #114 reported IP QQQ had come to his room another time and asked if he was going to tell anyone about their relationship. AD F reported after Resident #114 had reported to her, she asked Social Worker (SW) XX to go with her to check on Resident #114, but he was getting ready to leave the facility but Resident #114 did confirm he felt IP QQQ had used him and he asked if he was going to get in trouble for reporting her. AD F reported Resident #114 reported IP QQQ had contacted him at approximately 2:00 AM the night before she and SW XX went to speak to him and IP QQQ was crying and asked why he had reported their relationship, and she had been suspended because of it. In an interview on 02/05/2026 2:22 PM Certified Nursing Assistant (CNA) P reported she had been providing feeding assistance to Resident #114, and he reported when he went out in December, he was with a whore that worked here. CNA P reported that morning he reported he was tired of her (IP QQQ) stealing from him and he didn't want her to continue to take advantage and hurt anyone else at other facilities, so he told me her name, it was IPQQQ, who worked as the infection preventionist, when he went out in December to a hotel and it was also her who had been in and out of his room and Resident #114 reported he thought he had gotten syphilis from her that was why he wanted to get tested but then declined. CNA P reported Resident #114 had bought a Nike hoodie which ended up being too small for him and she was going to help him return it, when she asked Resident #114 where the hoodie was at, he reported the whore took it and got lost in her garage. CNA P asked Resident #114 who the person was he would not tell her but after that Resident #114 had found money on his nightstand and it had dawned on him the money had come from IP QQQ to replace the lost hoodie. CNA P reported she noticed IP QQQ had been going in and out of Resident #114's room more frequently, leaving with bags of linen and CNA P reported she was unsure why she was going to his room more frequently but thought it might be infection control related. CNA P asked Resident #114 who he would like to report his concern to and he indicated he would like to talk with AD K. CNA P reported she had left Resident #114's room and the call light turned back on, and Resident #114 needed his phone, and he needed her help with his phone, helped scroll to where he wanted her to stop and at the top of the screen was IP QQQ's name and picture and a picture of her butt in thong underwear. CNA P reported there were several other text messages between them. CNA P reported Resident #114 reported IP QQQ was still trying to contact him. CNA P reported Resident #114 reported the relationship between them started not long after she started at the facility. CNA P reported Resident #114 reported IP QQQ had reached out to him on (a social media platform) initially. CNA P reported Resident #114's (a social media platform) profile was not his first name it was his middle name, and she would have to know his middle name to find him. CNA P reported Resident #114 hid his (a social media platform) profile because of his child. Resident #114 reported IP QQQ had mentioned when he had spilled his Gatorade in his room, she had come to his room, he was always naked in his room, and she was pursuing him after that. In an interview on 02/05/2026 1:20 PM Social Worker (SW) XX reported she went with the NHA A when she interviewed Resident #114 and she wanted to make sure he felt safe and supported, asked if he needed anything. When the police arrived to take his statement, she reported she left the room so they could conduct their interview. In an interview on 02/05/26 at 5:51 PM, Deputy Sheriff (DS) PPP reported during her investigation it was determined IP QQQ had sought out Resident #114 for a relationship. DS PPP reported she was informed no sexual intercourse happened at the facility possibly some kissing only per Resident #114. DS PPP reported Resident #114 reported he had gone out on leave on December 19, 2025, and they had met at the hotel. Resident #114 had taken a ride service and IP QQQ had arrived at the hotel in her motor vehicle. Resident #114 reported they had sex, she stayed the night with him at the hotel. Resident #114 alleged he had $300.00 missing as well as some vapes which Resident #114 had observed in her possession. DS PPP reported she had interviewed IP QQQ who reported she had fallen in love with him and agreed to meet Resident #114 at the hotel. DS PPP reported IP QQQ reported there was no sexual penetration but there was sexual activity. DS PPP reported IP QQQ reported she had no financial motive to take Resident #114's money and indicated she had broken up with Resident #114. DS PPP reported she had reviewed the surveillance footage at the hotel, and both were observed in the lobby of the hotel together and it appeared to be beyond a nurse resident relationship. DS PPP indicated the report was with the prosecutor for review. This writer attempted to contact IP QQQ prior to exit. No return call was received. This writer attempted multiple times during the survey 2/4/26 - 2/10/26 to speak with Resident #114 but did not want to be interviewed. In an interview on 02/10/2026 10:49 AM NHA A reported Resident #114 reported to CNA P he was taken advantage of by a nurse, AD F went to interview him and Resident #114 reported to her, he had a relationship with IP QQQ which began on (a social media platform) Messenger with texting, sending photos and videos back of her butt and her breasts. AD F came and reported the incident to me and SW XX came with me when she went to interview Resident #114. NHA A reported Resident #114 had told her the same recount of the relationship and observed there were photos and messages. NHA A reported IP QQQ was suspended pending investigation. NHA A reported IP QQQ indicated she had been hacked, had not reported her accounts being hacked and just had deleted her accounts, and was unable to provide any documentation of reporting being hacked. NHA A reported IP QQQ reported all the messages and photos were sent by the person who hacked her accounts. NHA A reported Resident #114 reported they had stayed together at the (Local Hotel), he took $3000 with him, and she took $300 from him as well as his vapes, reported after the relationship ended Resident #114 asked for his items back and IP QQQ would not return his items. NHA A reported IP QQQ denied everything, there was no calls, texts, spending the night. NHA A reported she had attempted to contact the sheriff to obtain a copy of the final report but had not received one yet. NHA A reported she was waiting to hear from the sheriff to see if they were able to review the footage at the hotel. NHA A reported IP QQQ was terminated due to the policy of not informing the NHA of having a relationship outside of the facility.

Based on interview and record review, the facility failed to report an incident of potential neglect (elopement) to the State Agency for 1 resident (Resident #109) of 1 resident reviewed for reportable incidents resulting in the potential for additional reportable incidents to not be reported and cause a delay in the investigative process.Findings include: Resident #109 (R109)During an interview on 2/5/2026 at 3:04 PM, R109 Guardian (G) BBB stated that R109 can smoke outside with R47's daughter or a staff member but not by herself. G BBB stated R109's face sheet should show who she was able to go out with. Review of R109's face sheet revealed Special Instructions.(R109) is allowed to go outside and leave facility with (R47's daughter) or (Senior Services staff name omitted) only per her guardian. Review of the Wandering Risk assessment dated [DATE] revealed .Assessment Summary: (R109) is not a wandering risk, she does wear a wander guard (wearable electronic tag to monitor movement and can trigger alarms when a resident enters a restricted area) to alert staff if she is attempting to exit the building. She is a smoker and wants to go outdoors and smoke in unsafe undesignated areas. (R109) moves about with purpose and a destination.Review of R109's incident report dated 1/1/2026 revealed Nursing Description: (R109) exited the building at 1855 (6:55 PM). The main entrance door alarm was sounding and (R109) was outside sitting on the sidewalk between the main entrance and the office entrance. (R109) was wearing a brown winter coat backwards covering the front of her body with her arms in the sleeves, winter boots, and pajama pants. Resident Description: they let me outside when asked who let you outside, she stated I don't know I went outside and sat on the sidewalk to the right of the door, smoked my cigarette and came back in. Was this incident witnessed: N (No). Immediate Action Taken: Description: . (R109) educated. Staff educated on the door alarm procedure. Skin Assessment performed. No s/sx (signs/symptoms) of injury, bruising, redness, or skin impairments noted. (R109) exhibited no s/sx of psychosocial distress. Psychosocial needs remain at baseline. Activity Aide (AA) KKK's statement communicated to previous Director of Nursing (DON) revealed that AA KKK turned off the alarm and a resident (Resident #120) told her that R109 set off the alarm then she notified Licensed Practical Nurse (LPN) PP. LPN PP's statement communicated to previous DON revealed that he told AA KKK he would keep an eye on R109 when she was outside smoking her cigarette and then she came inside soon afterwards. LPN PP also stated to the previous DON that he was aware of (R109) going outside on previous occasions. During an interview on 2/5/2026 at 4:16 PM, R109 stated that she goes out of the building to smoke with Resident #47's (R47's) daughter when she visits. R109 said she didn't leave the building on 1/1/2026 to smoke by herself. Review of the interdisciplinary documentation progress note dated 1/2/2026 completed by Social Worker (SW) XX revealed SS (Social Services) met with resident several times this morning in regard to behaviors. SS attempted to discuss resident's continuation of exit seeking and going outside to smoke. Resident denied smoking in over a month. SS told by staff that resident was outside smoking last night. During an interview on 2/5/2026 at 12:58 PM, NHA A' stated that R109 wants to go outside unsupervised for smoking and she wasn't safe to do that. NHA A said that R109 snuck out with another resident on 1/1/2026 and was by the activity window and AA KKK saw her the whole time. During an interview on 2/5/2026 at 4:01 PM, AA KKK stated that she didn't know R109 left the building and went outside to smoke until Resident #120 told her when he came back inside from smoking. AA KKK said that when she found out that R109 was outside by herself, she yelled for LPN PP to get R109 from outside because she was doing an activity with residents. Then, AA KKK said she saw R109 coming back inside and wasn't sure how she came back in the building. AA KKK reported that she told Activity Director (AD) F about R109 leaving the building the next day on 1/2/2026. AA KKK stated that she was written up by the previous Director of Nursing (DON) for not following the policy and responding to the alarm when R109 went outside. During an interview on 2/6/2026 at 8:39 AM, LPN PP stated he was down the hall passing medications when AA KKK told him that R109 was outside smoking by herself. AA KKK told him that she couldn't leave the residents in the activity, so LPN PP said he kept an eye on her from inside. LPN 'PP reported that he continued to pass medications and could see R109 through the window smoking outside. LPN PP stated that he did not see R109 leave the building but saw her come back in. LPN PP also said that he did not report the incident to NHA A or the DON at the time because he didn't think it was a concern since she had gone out to smoke before. LPN PP reported that he wasn't written up by the previous DON, she just spoke to him about responding to alarms and following the policy. During an interview on 2/6/2026 at 12:46 PM, Housekeeper (H) HH stated on 1/1/2026 she turned off the alarm to let R109 back into the facility when R109 was done smoking. H HH said she did not see R109 leave the building. During an interview on 2/6/2026 at 8:24 AM, AD F stated that AA KKK was written up for not following the elopement policy and responding to the alarm by the previous DON. AD F said AA KKK notified her the next day on 1/2/2026 about the incident and then she (AD F) reported it to NHA A. During an interview on 2/6/2026 at 8:54 AM, Clinical Care Coordinator (CCC) CC stated that R109 had a wander guard since 7/10/2025 due to exit seeking behavior and wanting to leave the facility to smoke. CCC CC stated that R109 cannot go outside by herself. During an interview on 2/6/2026 at 9:13 AM, Social Worker (SW) XX stated that R109 can't go outside by herself to smoke and her face sheet had instructions on who can take her out to smoke. SW XX reported that staff knew she was an elopement risk since her picture was in the staff break room and in the elopement books at all the nurses' stations. Also, SW XX stated that she had a wander guard to alert staff when she tried to leave the facility. During an interview on 2/6/2026 at 12:51 PM, DON B stated she wasn't the DON when the incident occurred on 1/1/2026. DON B said that she couldn't speak to why the elopement wasn't reported on 1/1/2026 but if staff didn't see R109 leave the building it should have been considered an elopement and should have been reported. During another interview on 2/06/2026 at 12:56 PM, NHA A stated that she didn't think the elopement on 1/1/2026 needed to be reported since the corporate office was involved and said it didn't meet the criteria to be reported. NHA A said that AA KKK had eyes on R109 when she left the building and when she was outside and AA KKK saw R109 the whole time until she brought her back in from outside. NHA A stated that an elopement should be reported when staff didn't see the resident leave the building and when they didn't have eyes on them the whole time they were outside. It was discussed that staff did not see R109 leave the building and left her outside to continue smoking and NHA A said she was not aware of that. NHA A reported that that the previous DON notified her about the elopement the next day on 1/2/2026 at 12:38 PM but she did not report the incident to the State Agency.

Based on interview and record review the facility failed to ensure proper procedure for a facility-initiated discharge for 1 (Resident #120) of 1 resident reviewed for facility-initiated discharge resulting in the unapproved discharge of the resident from the facility.Findings include: Resident #120Review of an admission Record revealed Resident #120 was a male who admitted to the facility on [DATE] and had pertinent diagnoses which included: acute osteomyelitis left ankle and foot (sudden and severe bone infection, often caused by bacteria).Review of a Minimum Data Set (MDS) assessment for Resident #120, with a reference date of 10/27/25 revealed a Brief Interview for Mental Status (BIMS) score of 9/15 which indicated Resident #120 was moderately cognitively impaired.Review of Interdisciplinary Documentation for Resident #120 on 01/05/26 at 14:52 (2:52 PM) revealed .attempted to speak to Resident #120 this day in order to plan a safe D/C (discharge).This resident normally responds to discussions for D/C that he plans to leave in his van.Review of Interdisciplinary Documentation for Resident #120 on 01/06/26 at 12:29 PM, revealed .attempted to offer boxes for Resident #120 to pack up belongings and assist with D/C scheduled for today.Resident #120 became very aggressive stating that nobody is going to send him and he will just get in his van and leave.Review of Interdisciplinary Documentation for Resident #120 on 01/06/26 at 17:08 (5:08 PM) revealed .Resident #120 responded negatively to D/C scheduled for today. Resident #120 was issued a 30-day D/C on 12/04/25.Review of Notice of involuntary transfer or discharge and facility-initiated discharge for nursing homes for Resident #120 dated 12/04/25 revealed Resident (#120) did not have a guardian or resident representative.Reasons for transfer or discharge (a state and federal must be selected): state requirements- none were selected; CMS (Centers for Medicaid and Medicare Services) requirements- Resident no longer needs services provided by the facility.Has the resident had a recent level of care determination that negatively affects his or her ability to receive Medicaid covered services within the facility- answer yes; If yes, has a final determination been issued by the Michigan Department of Health and Humans Services (MDHHS), Answer- No; If no, an involuntary transfer or discharge cannot be issued to a resident until the final determination has been issued by MDHHS.Transfer or Discharge Destination- private residence- no address was provided for location of discharge, proposed date was 1/12/2026.Transfer or Discharge Timeline, Discharge Plan.If Michigan Department of Licensing and Regulatory Affairs ([NAME]) determines that a transfer or discharge is authorized, the resident shall not be required to transfer or discharge from the facility before the 34th day following receipt of the notice. prior to any involuntary transfer or discharge, a transfer or discharge plan must be prepared by the nursing home and approved by [NAME].The notice was signed by Nursing Home Administrator (NHA) A and dated 12/04/25.In an interview on 02/10/26 at 10:11 AM, NHA A reported she provided Resident #120 a 30-day notice on 12/04/25, because he no longer qualified for services. NHA A reported she filed the notice of involuntary transfer or discharge and facility-initiated discharge for nursing homes for Resident #120 on 12/04/25 with [NAME] and received confirmation of receipt. NHA A reported when she served Resident #120 with the 30-day notice he agreed to leave the facility in 30 days. NHA A stated he (Resident #120) drove his van here, had it in the parking lot, and that was his discharge plan, to live in his van.Review of electronic communication (E-mail) with [NAME]-BCHS-Involuntary Transfer on 02/10/26 at 11:11 AM, revealed Queried- regarding an approved involuntary discharge for (Name Omitted) Resident #120 submitted by the facility on 12/04/25?Review of reply E-mail communication with [NAME]-BCHS-Involuntary Transfer on 02/10/26 at 11:25 AM revealed .The involuntary discharge was never approved as the facility never submitted a discharge plan for the resident (Resident #120). The process was initiated on 12/16/25 by the facility where they stated the resident agreed to discharge to an AFC (adult foster care), was independent and owned a van that he used to come and go from the facility.In an interview on 02/10/26 at 12:15 PM, NHA A reported she did not complete the Facility involuntary transfer/discharge plan (Form IDT 101) for Resident #120 because he did not have an actual location he was to discharge to. NHA A reported she did not receive approval for Resident #120 to be discharged from the facility from [NAME]-BCHS-Involuntary Transfer.The facility was unable to provide a facility involuntary transfer/discharge plan (Form IDT 101) for Resident #120 prior to survey exit. Review of admission Record for Resident #120 revealed Date of Discharge 01/06/26 at 15:46 (3:46 PM) discharged to private home/apt. with no home health services.

Based on observation, interview, and record review, the facility failed to implement resident comprehensive care plans for 1 resident of 22 (Resident #27) reviewed for care planning resulting in a lack of service for residents to maintain their highest practicable physical, mental, and psychosocial well-being.Findings include: Resident #27: Review of an admission Record revealed Resident #27 was a female with pertinent diagnoses which included stroke, contractures (a permanent tightening of muscles, tendons, skin caused the joint to shorten and become very stiff) right elbow, right hand, and right ankle; contractures left elbow, hand, and ankle; abnormalities of breathing, epilepsy, and tube feeding due to a persistent vegetative state. Review of Care Plan for Resident #27 revised on 11/12/24 revealed the focus, . (Resident #27 is dependent on the staff for all ADL cares related to her persistent vegetative state. She has contractures to bilateral upper extremity joints and bilateral ankles. with the intervention .FALL - RISK MANAGEMENT: * Low bed in lowest position except with direct care .Comfort rounds to assess positioning and assistance to reposition. During an observation on 02/04/2026 at 12:08 PM, Resident #27 was observed lying in her bed. Her bed was not in the lowest position. Resident #27 was a taller person and took up most of the space of the length of the bed as well as the width of the bed. During an observation on 02/05/2026 at 12:28 PM, Resident #27 was in her bed, and her bed was not in the lowest position. During an observation on 02/05/2026 at 2:02 PM, Resident #27 was lying in her bed, and her bed was at transfer height, not in the lowest position. During an observation on 02/06/2026 at 12:15 PM, Resident #27 was observed in bed, supine position, arm contracted upward, bed was at transfer height, not at the lowest position. During an observation and interview on 02/05/2026 at 1:47 PM, Licensed Practical Nurse (LPN) LL reported Resident #27 had a suction machine as a tube feeding resident all of them have one as well as she does become very congested with mucous during her menstrual cycle. LPN LL reported when she does cough, she was a very active cougher as well as she had seizures, so staff checks her positioning, so she was not close to the side of the bed. In an interview on 02/10/2026 at 10:03 AM, Certified Nursing Assistant (CNA) SSS reported the CNAs can review the interventions for each resident on how to care for the residents. CNA SSS reported most of the time the CNAs care for the same residents for continuity of care and changes do get communicated to us by the nurses as well. In an interview on 02/06/2026 at 11:45 AM Clinical Care Coordinator (CCC) AA reported the CCCs were the staff responsible for maintaining the care plans for the residents. CCC AA reported the team discussed the residents and any changes. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, v1.16, Chapter 4: Care Area Assessment (CAA) Process and Care Planning, revealed .the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident 's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident 's written plan of care .

This citation pertains to intake #2715364. Based on interviews and record review, the facility failed to identify an acute change in condition for 1 (Resident #121) of a total sample of 22 residents reviewed for quality of care resulting in a delay in treatment for Resident #121 who was sent to the hospital on 1/8/26 and diagnosed with altered mental status and septic shock (life-threatening condition caused by a severe infection) from necrotic (death of cells in tissue) sacral ulcer with osteomyelitis (infection in a bone). Findings include: Resident #121Review of an admission Record revealed Resident #121 was originally admitted to the facility on [DATE] with pertinent diagnoses which included pressure ulcer of sacral region stage 4, and need for assistance with personal care. Review of Resident #121's Care Plan revealed, (Resident #121) has the potential for an acute condition change with cardiopulmonary, metabolic or infectious complicationsrelated to atrial fibrillation (irregular heart rhythm) and orthostatic hypotension (sudden drop in blood pressure when standing up, causing dizziness, lightheadedness, or fainting)Date Initiated: 12/19/2025. Goals: (Resident #121) will have early identification, management, treatment and resolution of an acute condition change. Interventions: Assess and document edema, breath sounds, circumoral (around the mouth) or nail bed cyanosis (bluish skin discoloration), Assess and intervene as indicated for chest pain, Assess heart rate and rhythm prn (as needed), Blood Sugars as Ordered, Check oxygen saturation levels SA02% (sic) ad capillary refill prn (as needed), initiate 02 (oxygen) as ordered, Conduct an assessment of the resident prior to initiating health care practitioner contact, Ensure effective communication of resident condition to members of the interdisciplinary staff, Evaluate pain with the pain assessment monitor on the MAR (Medication Administration Record, Obtain baseline labs as ordered by the physician review and compare lab value results prn; assess abnormal values as indicated, Report any significant change to the physician and appropriate responsible party as indicated prn, Review advanced directives and know residents wishes for treatment, Vital signs prn. Date Initiated: 12/19/2025 .Review of Resident #121's Documentation of Symptoms for Sacral wound indicated findings of increased drainage on the following dates: 12/29/25,12/30/25,12/31/25, 1/3/26,1/4/26, and 1/8/26, findings for foul order on the following dates: 12/29/25, 12/30/25, 12/31/25, 1/3/26, 1/4/26, and 1/8/26, findings for Surrounding warmth on the following dates: 12/31/25, 1/3/26, 1/4/26,1/8/26 and 1/8/26, and findings for Surrounding edema (swelling) on 12/31/25, 1/3/26, 1/4/26, and 1/8/26 . Noted that all findings were the indication of the wound infection. Review of Resident #121's Hospital Records dated 1/8/26 revealed, . ED Course: . presents by EMS (Emergency Medical Services) for altered mental status and concern of worsening sacral wound. Per EMS, the patient is typically A&O (alert and oriented) x4 and is able to ambulate. Over the last few days patient has had worsening mental status and is not ambulating. Reportedly SNF nurses were concerned that sacral wound was worsening. Reportedly SNF (Skilled Nursing Facility) nurses were concerned that sacral wound was worsening .Examination of sacral wound shows wound with VAC in place. There appears to be erythema surrounding wound with fluctuance (boggy sensation felt on palpitation, indicating a fluid filled area) present . Purulence (pus that is produced in infected tissue) noted near the tailbone . Hospital Course: . Septic shock from necrotic sacral ulcer with osteomyelitis, Bacteroides and gram positive bacilli bacteremia (presence of bacteria in the bloodstream), Pseudomonal UTI (urinary tract infection). s/p (status post) incision and drainage of sacral wound 01/09, bone biopsy shows osteomyelitis. ID (Infectious Disease) consulted . Wound Care Consult Note 1/9/26: 2. Coccyx/sacral wound 10.5 x 11 x unable to assess due to necrotic tissue with bone exposed and palpable wound connect under necrotic tissue. Undermining circumferential in varies depth to uncomfortable for patient to obtain measurement. Peri wound skin erythema/nonblanchable /odor noted. Right lower leg lateral 7.6 x 3.9 x tissue purplish/black. Right anterior lower leg 3.5 x 1.1 x necrotic. Left lateral ankle 8 x 4 x Deep tissue injury Assessment: . 2. Unstageable pressure ulcer coccyx/sacral. 3. Right lower leg lateral unstageable pressure injury versus Deep tissue injury 4. Right anterior lower leg unstageable pressure injury 5. Left lateral ankle appears to be deep tissue injury evolving 6. Skin tear left arm . Infectious Disease Consultation 1/14/26: . On 01/09/2026 patient had incision and drainage and debridement of the sacral wound with bone biopsy taken that is showing acute osteomyelitis . In an interview on 2/04/2026 at 1:23 PM, Family Member (FM) FFF reported Resident #121 had been admitted to the facility on [DATE] after being hospitalized due to his coccyx wound. FM FFF reported that Resident #121 had admitted to the facility to continue receiving wound care treatments. FM FFF reported Resident #121 was typically alert and oriented, and able to ambulate in his wheelchair. FM FFF reported she first noticed that something seemed to be wrong with Resident #121 during a care conference at the facility on 12/24/25 when she noted that Resident #121 seemed to be noticeably more confused. FM FFF reported she had voiced her concern that Resident #121 seemed more confused than usual and was told that staff would get back with her regarding this. FM FFF reported on 12/26/25 she found Resident #121 lying in his room and that he appeared very pale and ill. FM FFF reported the nurse caring for Resident #121 had informed her that Resident #121 had not had his sacrum dressing changed because the facility was waiting on supplies to come in. FM FFF reported she continued to voice her concerns about Resident #121 condition, but she felt that staff were not taking her concerns seriously. FM FFF reported she was called by LPN TT on 12/29/25 and told that Resident #121's wound looked worse, and that she was waiting for the wound doctor to look at it before putting the wound vac back on. FM FFF reported that she did not hear back from the facility about Resident #121's condition after she had talked with LPN TT on 12/29/25. FM FFF reported she went to visit Resident on 1/5/26 and noted that Resident #121 could hardly talk and seemed confused or sedated. FM FFF reported that she spoke with the nurse caring for Resident #121 and expressed her concerns that Resident #121 was declining, FM FFF reported that staff reported that they would look into it again. FM FFF reported that she called the facility's Social Worker (SW) on 1/6/26 to discuss her concerns that Resident #121 was declining, and that she received a call back from on 1/7/26 from SW XX that the facility had a call into the doctor at the facility to see Resident #121. FM FFF reported that the next day, 1/8/26, Resident #121 was transported to the emergency room where he was admitted to the hospital. FM FFF reported that Resident #121 was transferred to the Intensive Care Unit (ICU) and had to have surgery the following day on his sacrum wound. FM FFF reported that she had spoken with the facility's Nursing Home Administrator (NHA) A on 1/9/26 and expressed her concerns about Resident #121's health decline and the facility response. FM FFF' reported that she was told the facility was investigating her concerns. FM FFF reported that she received a follow up call from Clinical Support Nurse (CSN) AAA where she was informed that the facility had not provided care for Resident #121's up to the facility standards, and that the facility was investigating her concerns. FM FFF reported that she never heard back from the facility staff after her call with CSN AAA. During an interview on 2/05/2026 at 11:34 AM, Certified Nursing Assistant (CNA) P reported she cared for Resident #121 often. CNA P reported that when Resident #121 first came to the facility he was alert, very kind, and required assistance of 1 staff member for ADL (Activities of daily living care) and then he seemed to go downhill all of a sudden. CNA P reported that Resident #121 became combative and he became unable to feed himself. CNA P reported that it seemed like she noticed the change in Resident #121 began when the facility took his wound vac off. CNA P was not aware of the date that the facility had removed Resident #121's wound vac. During an interview on 2/05/2026 12:41 PM, CNA S reported she had cared for Resident #121 and was familiar with him. CNA S reported Resident #121 did seem to quickly decline after he was admitted to the facility. CNA S reported Resident #121 began to require more assistance, seemed more confused and was getting more combative. During an interview on 2/05/2026 at 11:40 AM, LPN TT reported that she had cared for Resident #121 multiple times since he had been admitted to the facility. LPN TT' reported Resident #121 had declined after he was admitted to the facility, and Resident #121's family member had expressed concerns related to his decline. LPN TT reported she had thought that nurses had told NP MMM about Resident #121's decline, but she was not sure what NP MMM had done for Resident #121. LPN TT reported that on 12/29/25, as she changed Resident #121's wound vac, she observed bone in Resident #121's sacral wound, and that the wound was black and the tissue was necrotizing. LPN TT reported that the wound appeared to be worsening. LPN TT reported that she was instructed by Former Director of Nursing (F-DON) UU to remove Resident #121's wound vac, apply a wet to dry dressing, and contact Resident #121's wound clinic. LPN TT reported that she had tried to find what wound clinic Resident #121 had gone to, but she was unsuccessful, and she did not know if the facility was ever able to arrange a wound clinic appointment for Resident #121. LPN TT reported that when Resident #121 was sent to the hospital on 1/8/26 she had found a wound on his right leg that she did not know was even there, and she did not think that facility had treatment orders in place for Resident #121's leg wound. During an interview on 2/05/2026 at 11:57 AM, LPN PP reported that he had cared for Resident #121, and that he recalled that Resident #121 seemed to need more assistance with care after he was admitted to the facility. LPN PP reported that he had completed wound care on 1/7/26, he had noticed that Resident #121's wound did not seem to be improving, and that there were brownish slough (dead tissue) spots across the wound. LPN PP did not recall if he had notified the facility's provider that Resident #121's wound was worsening. During an interview on 2/05/2026 at 4:27 PM, LPN SS reported on 12/26/25 during Resident #121's wound care treatment she noted that the wound looked much worse than when Resident #121 was first admitted , and it was bigger in size. LPN SS reported that there were several areas where the tissue on the wound was black. LPN SS reported she had noticed that Resident #121 had seemed to have declined, and that Resident #121's family member had also voiced concerns about his decline. LPN SS reported that Resident #121 was more confused and needed more assistance than when he was first admitted . LPN SS reported that she thought she had a left a note in the provider book for NP MMM, but she could not recall when. During an interview on 2/05/2026 at 1:06 PM, Clinical Care Coordinator (CCC) CC reported Resident #121 was admitted with a wound vac on his sacral wound, and that the dressing was supposed to be changed three times a week. CCC CC reported that she did not think that the facility was aware that Resident #121 was supposed to follow up with a wound clinic on 1/1/26. CCC CC reported that the facility submitted a referral to a wound clinic for Resident #121 on 12/31/25, and that he was scheduled for 1/14/26. CCC CC confirmed that she was aware that staff and Resident #121's family had expressed concerns that he was declining, and that she thought that NP MM was aware. During an interview on 2/5/26 at 2:13 PM, NP MMM reported that she was aware of staff and family concerns that Resident #121 was declining. NP MMM reported that she had saw Resident #121 around New Years and ordered lab work which looked good with the exception of an abnormal CRP (lab test used for assessing inflammation in the body and can aid in diagnosing and monitoring various health conditions) but since Resident #121 had a wound, she was not concerned. NP MMM reported when she saw Resident #121 on 1/8/26, he did not look good and he was not eating, so she ordered that Resident #121 be sent to the hospital. NP MMM reported that she had never been made aware that Resident #121's wound was hot to touch. During an interview on 2/05/2026 at 1:54 PM, F-DON UU reported Resident #121 was admitted to the facility with a wound vac on his sacral wound. F-DON UU reported at one point the facility was questioning the wound care order and trying to figure out if Resident #121 was supposed to go to a wound clinic, but she was not aware of what the facility determined for Resident #121's wound clinic referral. F-DON UU reported that she did not notify NP MMM about the change in Resident #121's wound condition on 12/29/25, but she thought that LPN TT had. During an interview on 2/05/2026 at 2:19 PM, CSN AAA reported that she had been made aware on 1/9/26 that Resident #121's family had concerns with his care at the facility from NHA A. CSN AAA reported that she had conducted an investigation with NHA A into Resident #121's family concerns. CSN AAA confirmed that the facility had been made aware of Resident #121's family concerns about Resident #121's potential decline on 12/24/25, and that the facility had planned to follow up with Resident #121's family with an update once they had reviewed his lab work. CSN AAA confirmed that NP MMM did not see Resident #121 until 12/31/25 and labs were not ordered for Resident #121 until 12/30/26. CSN AAA was unable to report when or if nursing staff had notified NP MMM of Resident #121's decline in function, or if NP MMM had been notified about the change in Resident #121's wound condition. CSN AAA confirmed that she had found several missing treatments and documentation of Resident #121's change in condition, and that the facility had been re-educating nursing staff on this. In a follow up interview on 2/06/2026 at 8:54 AM, LPN TT confirmed that she did notify NP MMM on 12/29/25 about Resident #121's wound via text. LPN TT reviewed the text that she sent to NP MMM which indicated that she had concerns with Resident #121's wound, and that she changed his dressing to a wet to dry. NP MMM replied that she had received the text and would be in to look at Resident #121. LPN TT reported that she did not receive any follow up orders from NP MMM and she did not know when or if Resident #121 was seen by NP MMM or if his wound care orders were changed. Review of Resident #121's Progress Note dated 12/29/25 and documented by Licensed Practical Nurse (LPN) TT revealed, LPN attempted to change wound vac (negative pressure wound therapy device that uses gentle suction to promote faster and more effective wound healing) dressing. Dressing removed. LPN observed wound down to bone in right buttock wound. Left buttock wound does have some tissue left. Tissue between both wounds is necrotizing. Peri wound is red, hot to touch. (Former Director of Nursing (F-DON) UU) aware. Instructed to wet to dry (applying moist gauze to a wound, followed by dry gauze, then allowing it to dry completely and stick to dead tissue so that when it is removed the dead tissue comes with it) and call wound clinic. Wound clinic called, LPN left message on nurse line at (number redacted) for further instruction. Awaiting call back. Family aware . Review of Resident #121's Progress Note dated 12/29/25 and documented by LPN TT revealed, (wound care provider) does not see (Resident #121) for wound vac. LPN left message with (Nurse Practitioner (NP) MMM) for further instructions. Review of Resident #121's Progress Note dated 12/30/25 revealed, Resident recently declined, (NP MMM) consulted. labs to be obtained STAT .Review of Resident #121's Progress Note dated 12/31/25 revealed, .Wound vac remains on hold until further wound care evaluation completed. Wound is larger, with necrotizing tissue in the middle and bone exposure observed. Wet to dry dressing maintained at this time.Review of Resident #121's Progress Note dated 12/31/25 and documented by NP MMM revealed, Infected decubitus ulcer-Completed Augmentin and Bactrim (antibiotics) for total of 7 days. Continue wound vac, follow up with wound clinic on 1/14 .Review of Resident #121's Progress Note dated 1/6/26 revealed, . Wound care completed to buttocks, wet to dry. Wound drainage green/yellow, odor increased. Tenderness increased. Not able to participate in therapies at this time .Review of Resident #121's Progress Note dated 1/7/26 revealed, wound vac placed without much difficulties. resident tolerated procedure well. Review of Resident #121's Progress Note dated 1/8/26 revealed, (Resident #121) is being sent to the ER for further evaluation of altered mental status and ? infection (sic). Order received from (NP MMM) to send patient to the ER . Review of the facility's Change in Resident Condition policy last reviewed January 2026 revealed, Policy: It is the policy of this facility to inform the resident; consult with the residents health care practitioner, and notify the residents authorized representative according to the minimum guidelines established in this procedure and more frequently at the discretion of the licensed nurse or member of the interdisciplinary team. Purpose: To ensure provision of the necessary care and services to meet the highest practicable physical, mental and psychosocial well-being of each resident in accordance with measurable objective assessment data. Procedure: 1. The health care practitioner will be promptly notified when . b. The resident has a significant change in physical, mental, or psychosocial status i.e., deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications. c. A resident assessment indicated the need to alter the treatment significantly i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new treatment . 6. Objective observations of changes in a resident's condition, including emotional changes as a means for analyzing and determining care required and the need for further medical evaluation and treatment shall be recorded in the resident's record.

Based on observation, interview and record review, the facility failed to adequately supervise, reduce hazards, and ensure the safety of 2 (Resident #109 and Resident #32) of 7 residents reviewed for accidents/hazards resulting in an elopement and a fall. Findings include: Resident #109 (R109) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R109's initial admission date was 5/2/2025 with pertinent diagnoses including anxiety, post-traumatic stress disorder, bipolar disorder (intense mood swings ranging from extreme highs and lows), mild cognitive impairment and depression. Brief Interview for Mental Status (BIMS) reflected a score of 10 out of 15 which indicated R109 cognition was moderately impaired. Review of R109's incident report dated 1/1/2026 revealed Nursing Description: (R109) exited the building at 1855 (6:55 PM). The main entrance door alarm was sounding and (R109) was outside sitting on the sidewalk between the main entrance and the office entrance. (R109) was wearing a brown winter coat backwards covering the front of her body with her arms in the sleeves, winter boots, and pajama pants. Resident Description: they let me outside when asked who let you outside, she stated I don't know I went outside and sat on the sidewalk to the right of the door, smoked my cigarette and came back in. Was this incident witnessed: N (No). Immediate Action Taken: Description: . (R109) educated. Staff educated on the door alarm procedure. Skin Assessment performed. No s/sx (signs/symptoms) of injury, bruising, redness, or skin impairments noted. (R109) exhibited no s/sx of psychosocial distress. Psychosocial needs remain at baseline. Activity Aide (AA) KKK's statement communicated to previous Director of Nursing (DON) revealed that AA KKK turned off the alarm and a resident (Resident #120) told her that R109 set off the alarm then she notified Licensed Practical Nurse (LPN) PP. LPN PP's statement communicated to previous DON revealed that he told AA KKK he would keep an eye on R109 when she was outside smoking her cigarette and then she came inside soon afterwards. LPN PP also stated to the previous DON that he was aware of (R109) going outside on previous occasions. During an interview on 2/5/2026 at 4:16 PM, R109 stated that she goes out of the building to smoke with Resident #47's (R47's) daughter when she visits. R109 said she didn't leave the building on 1/1/2026 to smoke by herself. During an interview on 2/5/2026 at 3:04 PM, R109 Guardian (G) BBB stated that R109 can smoke outside with R47's daughter or a staff member but not by herself. G BBB stated R109's facesheet should show who she was able to go out with. Review of R109's facesheet revealed Special Instructions.(R109) is allowed to go outside and leave facility with (R47's daughter) or (Senior Services staff name omitted) only per her guardian. Review of the interdisciplinary documentation progress note dated 10/13/2025 revealed SS attempted to provide a support visit with resident this morning. SS discussed reports of smoking in courtyard reported by other residents. SS reminded this resident that she is allowed to go with (senior services staff name omitted) . Review of the Wandering Risk assessment dated [DATE] revealed .Assessment Summary: (R109) is not a wandering risk, she does wear a wander guard (wearable electronic tag to monitor movement and can trigger alarms when a resident enters a restricted area) to alert staff if she is attempting to exit the building. She is a smoker and wants to go outdoors and smoke in unsafe undesignated areas. (R109) moves about with purpose and a destination. Review of the interdisciplinary documentation progress note dated 1/2/2026 completed by Social Worker (SW) XX revealed SS (Social Services) met with resident several times this morning in regards to behaviors. SS attempted to discuss resident's continuation of exit seeking and going outside to smoke. Resident denied smoking in over a month. SS told by staff that resident was outside smoking last night. Review of R109's active physician orders revealed Exit seeking prevention transmitter (wander guard) check placement q (every) shift. Every shift for exit seeking, placed under the seat of her wheelchair. Active 1/16/2026. Exit Seeking Transmitter Device: Check Function q afternoon shift, if no positive result; replace transmitter. every evening shift for Exit Seeking. Active 7/10/2025. Review of R109's care plan revealed .Focus: Altered functional mobility. Interventions/ Tasks.Exit Seeking Alert: Exit seeking alarm band protection device applied; follow guideline for placement and function on the treatment administration record. Placed under the seat of her wheelchair. Date initiated 7/10/2025. Revision on 1/16/2026.Psychological/Trauma Informed Care interventions: .(R109's) court appointed guardian is responsible for (R109's) safety outside of the facility and will need to approve anyone that (R109) is able to go on LOA (leave of absence) with (R109's) guardian has approved (Resident #47's daughter) as the only person that (R109) may go out of the facility or LOA with (Resident 47's daughter) must notify floor nurse and sign (R109) in and out of the kiosk every time.Date initiated 6/4/2025. Revised on 12/29/2025. During an interview on 2/5/2026 at 12:58 PM, NHA A' stated that R109 wants to go outside unsupervised for smoking and she wasn't safe to do that. NHA A said that R109 snuck out with another resident on 1/1/2026 and was by the activity window and AA KKK saw her the whole time. During an interview on 2/5/2026 at 4:01 PM, AA KKK stated that she didn't know R109 left the building and went outside to smoke until Resident #120 told her when he came back inside from smoking. AA KKK said that when she found out that R109 was outside by herself, she yelled for LPN PP to get R109 from outside because she was doing an activity with residents. AA KKK' stated that LPN PP said he would keep an eye on R109 and for her to go back to the activity. Then, AA KKK said she saw R109 coming back inside and wasn't sure how she came back in the building. AA KKK reported that she told Activity Director (AD) F about R109 leaving the building the next day on 1/2/2026. AA KKK stated that she was written up by the previous Director of Nursing (DON) for not following the policy and responding to the alarm when R109 went outside. During an interview on 2/6/2026 at 8:39 AM, LPN PP stated he was down the hall passing medications when AA KKK told him that R109 was outside smoking by herself. AA KKK told him that she couldn't leave the residents in the activity, so LPN PP said he kept an eye on her from inside. LPN 'PP reported that he continued to pass medications and could see R109 through the window smoking outside. LPN PP stated that he did not see R109 leave the building but saw her come back in. LPN PP also said that he did not report the incident to NHA A or the DON at the time because he didn't think it was a concern since she had gone out to smoke before. LPN PP reported that he wasn't written up by the previous DON, she just spoke to him about responding to alarms and following the policy. During an interview on 2/6/2026 at 12:46 PM, Housekeeper (H) HH stated on 1/1/2026 she turned off the alarm to let R109 back into the facility when R109 was done smoking. H HH said she did not see R109 leave the building. During an interview on 2/6/2026 at 8:24 AM, AD F stated that AA KKK was written up for not following the elopement policy and responding to the alarm. AD F said AA KKK notified her the next day on 1/2/2026 about the incident and then she (AD F) reported it to NHA A. During an interview on 2/6/2026 at 8:54 AM, Clinical Care Coordinator (CCC) CC stated that R109 had a wander guard since 7/10/2025 due to exit seeking behavior and wanting to leave the facility to smoke. CCCCC said they tried a wander guard on R109 but she ended up cutting them off and flushing it down the toilet so they put the wander guard under her wheelchair. CCC CC stated that R109 cannot go outside by herself. During an interview on 2/6/2026 at 9:13 AM, Social Worker (SW) XX stated that R109 can't go outside by herself to smoke and her facesheet had instructions on who can take her out to smoke. SW XX reported that staff knew she was an elopement risk since her picture was in the staff break room and in the elopement books at all the nurses' stations. Also, SW XX stated that she had a wander guard to alert staff when she tried to leave the facility. During another interview on 2/06/2026 at 12:56 PM with NHA A, it was discussed that staff did not see R109 leave the building and left her outside to continue smoking and NHA A said she was not aware of that. NHA A reported that that the previous DON notified her about the elopement the next day on 1/2/2026 at 12:38 PM. Review of the Wandering Residents Exit Seeking Management Policy with a revision date of January 2023 revealed .Elopement: The resident's leaving of the facility without staff observation or knowledge of departure.3. Response to a sounding 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. Resident #32 Review of an admission Record revealed Resident # 32 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Parkinson's disease (a progressive, incurable neurodegenerative(gradual dysfunction and death of neurons in the brain) disorder of the central nervous system primarily affecting movements, causing tremors and balance issues), muscle weakness and dementia (an umbrella term for a progressive decline in cognitive function). Review of a Minimum Data Set (MDS) assessment for Resident #32 with a reference date of 1/27/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 13/15, which indicated the resident was cognitively intact. Section GG of the MDS revealed Resident #32 required moderate assistance (helper does less than half the effort) to transfer from sitting to standing and walking 10' was not attempted due to his medical condition or safety concerns. Review of a Care Plan for Resident #32 with a reference date of 8/6/25 revealed the following focus/goal/interventions: (Resident #32) has an actual deficit in ADLs (activities of daily living). Goal: (Resident #32's) stated goal is to remain in long-term while has (sic) individualized interventions that.accentuate his functional ability. Interventions: FALL-RISK MANAGEMENT: encourage non-skid footwear.keep personal items in reach.floor mat at bedside. (nonslip material brand name omitted) to wheelchair. During an observation on 2/4/26 at 3:20pm, Resident #32 was lying on his back in bed, no fall mat was on the floor next to him. During an observation on 2/5/26 at 10:22am, Resident #32 was observed standing alone by his closet, wearing regular socks and no shoes. A staff member passed by the room but did not stop to offer Resident #32 assistance or to encourage him to put on his shoes. During an observation on 2/5/26 at 12:43pm, Resident #32 slept in his bed, no fall mat was on the floor next to his bed. No nonslip material was present on his wheelchair. During an observation on 2/6/26 at 12:33pm, Resident #32 sat partially upright in his bed with one foot off the bed. No fall mat was on the floor next to his bed. No nonslip material was present in his wheelchair. In an interview on 2/10/26 at 11:06am, Clinical Care Coordinator/Registered Nurse (CCC/RN) CC reported Resident #32 was a fall risk and should have a fall mat on the floor parallel to his bed anytime he was in bed, and non-slip material on his wheelchair seat. In an interview on 2/10/26 Licensed Practical Nurse (LPN) RRR reported on 2/7/26 at approximately 3:30am, Resident #32 was found lying face down on his floor with his head facing his closet. Resident #32 told LPN RRR he was trying to clean out his closet. LPN RRR reported Resident #32 had been more confused that night. LPN RRR reported the fall mat was appropriately placed on the floor next to his bed, the nonstick material was on the seat of his wheelchair and Resident #32 was last seen lying in his bed. LPN RRR confirmed no new interventions were implemented despite Resident #32's increased confusion that night. LPN RRR reported Resident #32 sustained a hematoma (localized collection of pooling or mostly clotted blood trapped in tissue) to his L forehead from the fall and was sent to local emergency department for further evaluation. Review of an After Visit Summary for Resident #32, (local hospital name omitted) with a reference date of 2/7/26 revealed Reason for visit: fall. Diagnoses: Ground-level fall, hematoma of frontal scalp, initial encounter, Tremor of both hands.

Based on observation, interview and record review the facility failed to maintain sufficient hydration and consistent nutritional status monitoring and re-evaluation by a nutrition professional of residents at risk for altered hydration and nutritional status for 3 of 4 residents (Resident #18, #98, #32) reviewed for hydration/nutrition resulting in the potential for dehydration, weight loss, and unmet resident needs.Findings include: Resident #18: Review of an admission Record revealed Resident #18 was a female with pertinent diagnoses which included diabetes, paralysis left side, stoke, dementia, need for assistance with personal care, and stroke. Review of Care Plan for Resident #18 revised on 1/7/25, revealed the focus, .(Resident #18) has the potential for an altered nutritional status primarily related to her diagnoses of dementia and type 2 DM (diabetes). This may lead to diminished cures of hunger or thirst and a decreased understanding of the importance of eating as well as altered blood sugars. with the intervention .Evaluate laboratory values in relation to nutritional needs prn (as needed).Nutritional Supplements per Dietary Assessment.Refer to ADL flow sheet for diet specifications.Registered Dietician evaluation prn. Review of Lab results dated 11/24/25, indicated Resident #18's sodium was high at 147, normal range 135-145 mmol/L, creatinine was high at 1.22 normal range .50-1.00 mg/dL, eGFR (estimated glomerular filtration rate) was low at 44, normal range >60 mL/min/1.73m2, Blood urea nitrogen (BUN) was high at 37, normal range 8-23 mg/dL . Note: All of these results were indicative of dehydration. Review of Interdisciplinary Documentation dated 10/28/2025 at 2:08 PM, .It was reported that (Resident #18) was having urinary complaints with burning with urination and increased noted behaviors. HCP (Health Care Provider) notified and order UA (urinalysis) with C&S (culture & sensitivity) if indication. UA completed revealed >=100,000CFU/ml E Coli meeting criteria for ABT (antibiotic) treatment. HCP notified and ordered treatment with Cephalexin 500mg TID (three times a day) x7days. Medications reviewed for any potential medication interactions. No adverse reactions noted so far throughout course of treatment. Routine toileting with proper peri care and hand hygiene continued. Increased oral fluids encouraged. STCP in place for continued staff monitoring. During an observation on 02/04/2026 at 11:35 AM, Resident #18 was in the hallway, no cup holder noted on her wheelchair, was attempting to enter another resident's room and was redirected by staff to head to the dining room for lunch. During an observation on 02/04/26 at 12:00 PM, Resident #18 was not in her room, Styrofoam cup with lid and straw was located on the nightstand, it was full. T` During an observation on 02/10/2026 at 9:42 AM, Resident #18 had water in her room, no ice in the cup. Resident #18 had not drunk any of her water. During an observation on 02/10/2026 at 9:56 AM, Resident #18 was seated in her wheelchair at a table in the dining room, she had her eyes closed and she did not have any fluids in front of her. During an observation on 02/10/2026 12:09 PM Resident #18's water was full and was the same sytrofoam cup as earlier in the day. During an observation on 02/10/2026 12:32 PM Resident #18 was seated at the dining room table and she had not touched her coffee, chicken with sauce, or her creamed corn. During an observation on 02/10/2026 at 12:43 PM Resident #18 was eating some noodles by using her hand and was trying to pick up the sauce by hand as well. No staff were observed providing encouragement to eat or drink. Utensils were under her napkin which was folded in half over the top of the utensils. During an observation on 02/10/2026 at 12:53 PM, Resident #18 had not picked up her coffee to drink, there was no water or any other juice on the table. Resident #18 picked up the chicken breast by hand and ate the sauce from it but not the chicken and then she was using her hands to eat the creamed corn in a small saucer type bowl. Review of Resident #18's medical record revealed the last Nutritional Assessment completed for her was 1/7/2025. In an interview on 02/10/2026 at 10:03 AM, CNA Z reported the CNAs would only document fluid and meal intake for certain people who were flagged to document on, and the nurse would be able to document as well. CNA Z reported fluid intake was not tracked. CNA Z reported the activities department supervised the main dining room and would log the food and fluid intake of the residents. During an observation on 02/10/2026 at 12:59 PM, Resident #18 picked up her cup of coffee, and struggled to bring it to her lips to take a drink. Resident #18's hands were shaking and the coffee was spilling from her mouth and down the front of her shirt. Resident #18 did not attempt to drink anymore coffee, did not finish her meal ate only a few bites of the chicken breast, left most of the creamed corn and half of the serving of noodles were left on her plate. In an interview on 02/10/2026 at 12:18 PM, Licensed Practical Nurse (LPN) LL reported the nurse would review the lab results, place the report in the doctor's book or if necessary, contact the provider. LPN LL reported the provider would review and initial the lab was reviewed. For Resident #18 she reviewed the lab for the urinalysis, entered the order or have us put in the order and sign off on the order for the antibiotic. LPN LL reported after review of the lab results, the provider would do a repeat of the lab. LPN LL reported that if a resident needed staff to review and document their fluid intake, the clinical care coordinator could place an order in the resident's chart for staff to complete this task in the CNA charting. Review of Dietary Orientation received on 2/6/26, revealed, .Monitoring Fluid Intake & Hydration Needs: Visually observe for fluid intake. Water is passed twice a day. Encourage residents to take sips throughout the day. The feeling of thirst decreases as we age, dehydration is a huge risk to the elderly. In an interview on 02/10/2026 at 1:01 PM, Clinical Care Coordinator (CCC) AA reported when labs were drawn, they were reviewed and discussed for what interventions would come next, if necessary. CCC AA reported the provider would review, initial and either verbally speak with the nurse or place orders themselves. CCC AA reported staff members monitor fluid intake for all residents and encourage intake for residents except those who were on fluid restriction. CCC AA reported the staff members who monitor the dining room would communicate to the nursing staff any concerns with resident intake of fluids and the nursing staff would monitor the residents output. CCC AA reported if a resident had labs with high sodium, high creatinine, low eGFR (estimated glomerular filtration rate), high Blood urea nitrogen the facility would recheck the labs to ensure the results were still abnormal. This writer requested additional lab work completed following the lab results from 11/24/25. In an interview on 02/10/2026 at 10:07 AM, Registered Dietician (RD EEE reported she was a consultant, and the facility would contact her if they had any questions on dietary needs for residents. RD EEE reported she assisted with nutritional assessments which were done at admission and annually unless there was a need to trigger one any other time, like with a significant change. RD EEE reported she did not review lab work completed on the residents in the facility, she only reviewed if she was alerted by the physician to review. RD EEE reported she depended on nursing staff to report concerns to her for a resident's intake as she was not in the facility every day, so it was the facility's responsibility to monitor and report concerns to her. RD EEE reported Resident #18 who had lab work with abnormal levels, was a diabetic, had history of urinary trach infections, and had a dementia diagnosis, the facility should be encouraging fluid intake as those factors could indicate the resident was not drinking enough and needed closer monitoring of fluid intake. Note: No other lab results were provided prior to exit from the facility. Resident # 98 (R98) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R98 admitted to the facility on [DATE] with pertinent diagnoses including dementia (decline in cognitive abilities severe enough to interfere with activities of daily life) and umbilical hernia (soft bulge near belly button caused by abdominal contents pushing through weakness in abdominal wall). Brief Interview for Mental Status (BIMS) reflected a score of 3 out of 15 which indicated R98 was severely cognitively impaired. During an observation and interview on 2/5/2026 at 9:00 AM, R98 was feeding himself in the small dining room and was unable to hold a conversation due to his cognition. Review of R98's care plan revealed Focus: Potential risk factors for nutritional concerns include: umbilical hernia, dementia with confusion which may progress and affect his ability to know hunger and thirst.Interventions/Tasks.Evaluate significant change with routine weights. Date initiated 7/22/2025. Review of R98's food acceptance record (FAR) for the last 30 days revealed no documentation between 1/20/2026 to 2/4/2026 which was 16 days. Review of R98's weight record revealed on 1/4/2026 R98 weighed 173.5 lbs (pounds). On 01/29/2026, R98 weighed 164 lbs which was a 5.48% (percent) weight loss. No other weights were obtained from 1/29/2026 until 2/5/2026 after entrance for survey. Review of R98's last nutrition assessment completed 8/10/2025 revealed (R98) is triggering for weight loss with his last weight listed above at 168# (pounds). His weight per record review in May 2025 was 146#. He was in the hospital at that time. He was homeless and may not have had adequate nutritional opportunities. Per his BMI he is at a healthy weight. He was on FAR (Food Acceptance Record) for over 30 days with 100% intake. No current open areas. He does have Dementia which could eventually be a factor with food acceptance as the disease progresses. Will continue to monitor weights for trends and intervene as applicable. MST (malnutrition nutrition screen) not completed as assess (assessment) was completed remotely. Review of Interdisciplinary Documentation completed by Registered Dietitian (RD) on 1/19/2026 revealed Review of weights for (R98) currently reflects a weight loss, however overall weight has been slowly increasing. Weight loss occurred between 10/12 and 10/26, since then weight has been slowly increasing. FAR reflects excellent intake at meals 100%. Goal is for a slow weight gain. Continue current plan of care. Review of Interdisciplinary Documentation 2/2/2026 revealed (R98) has not been eating well lately. CNA (Certified Nursing Assistant) observed decreased appetite and when questioned, (R98) did admit to having mouth pain. LPN placed order request to have patient have dental appointment and downgrade meals to mechanical soft until oral pain resolved. Review of active physician orders revealed General diet, Mechanical Soft texture, Thin consistency for new onset oral pain. Active 2/2/2026. Nutritional Supplement prn (as needed). No directions specified for order. Active 7/10/2025. Nutrition supplement 90 cc (90 ml-milliliters) tid (three times a day) and weight every day for 3 days were started on 2/6/2026 during the survey. During an interview on 2/5/2026 at 1:33 PM, Registered Dietitian (RD) EEE stated that she came to the facility every other week. When discussing weight changes with residents, RD EEE said since she wasn't in the building very often so the CNAs (Certified Nursing Assistants) and CCCs (Clinical Care Coordinators) put interventions in place for weight changes and then they call her if concerns arise. RD EEE stated that R98 had weight fluctuations since admission and wasn't on a diuretic. RD EEE also stated that they don't have anything about reweights in their policy and how often they need it get a reweight with a significant weight loss or gain. When discussing the last nutrition assessment that was completed on 8/10/2025, RD EEE reported that they are only required to do a nutrition assessment once a year as long as the MDS is completed quarterly. RD EEE stated that the CCC should monitor weights and ask for reweights and send that information to Director of Nursing (DON) B. During an interview on 2/5/2026 at 1:55 PM CCC CC stated that when there was a weight discrepancy (5 pounds), they would get a reweight for a couple of days to make sure the weight change was accurate. For weight losses, CCC CC stated a nutritional supplement would be started. During another interview on 2/6/2026 at 12:28 PM, CCC CC stated that they have weight monitoring meetings where RD EEE looked at resident weights remotely and emailed the Dietary Manager (DM) to bring any concerns to the meeting, but she said this hasn't been happening due to the turnover in the kitchen. During an interview on 2/05/2026 at 1:50 PM DON B stated that weights were taken with showers and the nurse verifies if there was a discrepancy and would ask for a reweights if there was one. DON B verified that R98 had a significant weight loss and there wasn't a reweight done from 1/29/2026 to 2/5/2026. DON B stated she wasn't sure what the policy for weights was and CCCs keep track of their units and she tries to monitor the dashboard. DON B also reported that RD EEE looks at weights remotely and sends emails with reweights and recommendations for residents. Review of the Weight Management Policy with a revision date of April 2025 revealed .5. In the event of a patterned or significant unplanned weight loss/gain the IDT (interdisciplinary team) is responsible for assessing and implementing individualized interventions. a. Parameters for evaluating significance of unplanned and undesired weight loss/gain are.5% in 30 days, 7.5% in 90 days, 10% in 180 days. Resident #32 Review of an admission Record revealed Resident # 32 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: parkinson's disease (a progressive, incurable neurodegenerative(gradual dysfunction and death of neurons in the brain) disorder of the central nervous system primarily affecting movements, causing tremors and balance issues), muscle weakness, and dementia (an umbrella term for a progressive decline in cognitive function). Review of a Minimum Data Set (MDS) assessment for Resident #32 with a reference date of 1/27/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 13/15, which indicated the resident was cognitively intact. Review of a Care Plan for Resident #32 with a reference date of 1/29/25 revealed the following focus/goal/interventions: (Resident #32) is at risk for altered nutrition due to conditions associated with dysphagia (swallowing difficulty), dementia, tremor.Goal: 1. Reduction in risk of factors for hypo-hyperglycemic events (excessively high or how blood sugar level) 2. Weights will remain stable. Appropriate interventions will be placed as needed. Interventions. Adaptive equipment: large soup spoon. evaluate significant weight change with routine weights. serve diet as ordered. Review of Physician Orders for Resident #32 revealed Weight three times weekly in the morning, every Monday, Wednesday, Friday with a start date of 11/12/25. Review of a Weight Summary record for Resident #32 revealed his weights were documented 25 of 37 opportunities during the twelve-week period of 11/12/25-2/2/26. Review of a Weights task report for Resident #32 revealed the resident had not refused being weighed in the last 30 days. A task report for the last 60 days was requested but not received at the conclusion of the survey. In an interview on 2/4/26 at 3:14pm, Resident #32 reported he was concerned about the amount of weight he had lost in the past year. Resident #32 reported he had difficulty feeding himself at times when the staff didn't provide enough set up assistance and he didn't receive the large spoons he needed to feed himself. Resident #32 stated I'm skinny compared to what I used to be. Resident #32 reported he provided his own nutritional drinks now because he felt he could not consume enough calories during meals. Review of an Interdisciplinary Progress Note for Resident #32 with a reference date of 2/1/25 revealed (Resident #32 name omitted) current body weight is 160lbs (pounds).Dietary Manager will continue to monitor weights. Review of a Nutritional Assessment for Resident #32 with a reference date of 10/29/25 revealed .most recent weight 141.0 (pounds).

Based on interview and record review, the facility failed to ensure pre-dialysis assessments were completed for 1 (Resident #19) of 4 residents reviewed for dialysis services, resulting in the potential for miscommunication, inadequate documentation of resident's clinical conditions, and unmet care needs. Findings include: Resident #19Review of an admission Record revealed Resident #19 was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness and end stage renal disease (final stage of chronic kidney disease, where the kidneys can no longer function adequately to sustain life without treatment). Review of Resident #19's Care Plan revealed, Focus: Hemodialysis required to remove urea & other toxic products from the blood: At risk for loss of vascular access; clotting, hemorrhage(bleeding), infection. At risk for exacerbation of heart failure with inadequate dialysis or increased hypervolemia (fluid overload). Date Initiated: 10/14/2025. Interventions: Assess fluid volume excess as indicated for signs and symptoms (routinely completed at dialysis as well); routine weights; JVD (Jugular vein distention-is a medical condition characterized by the bulging of the jugular veins in the neck); breath sounds; peripheral and sacral edema (swelling) assessments. Date Initiated: 10/14/2025. Assess reports of pain and or numbness distal to access site. Date Initiated: 10/14/2025. Establish communication with dialysis center process of communication is asfollows: Communication sheet sent with (Resident #19) to Dialysis center on each dialysis day, and Dialysis center should send back with (Resident #19)on his return to the facility, and then the sheet is uploaded into (Resident #19's) documents in his chart. Date Initiated: 10/14/2025 .Review of Resident #19's Hemodialysis Communication Forms revealed that nursing staff had not documented the completion of a pre-dialysis Assessment on the following dates: 11/21/25, 11/23/25, 12/1/25, 12/20/25, 1/14/26, 1/26/26, and 2/6/26. During an interview on 2/6/2026 at 1:48 PM, Licensed Practical Nurse (LPN) PP reported nursing staff were responsible for ensuring that a resident was assessed prior to leaving the facility for dialysis. LPN PP reported that the nurse should assess the resident's fistula site and obtain pre-dialysis weight and vital signs. LPN PP reported that nurses were supposed to document the pre-dialysis assessment on the hemodialysis communication form and send that form to the dialysis facility. LPN PP confirmed that the facility nursing staff primarily communicated about resident's health condition via the dialysis communication form. During an interview on 2/10/2026 at 11:57 AM, Clinical Care Coordinator (CCC) CC reported that every resident that received dialysis at the facility was supposed to be assessed prior to leaving for dialysis, and that the nurses were responsible for documenting the assessment on the hemodialysis communication form and sending the form with the resident to the dialysis facility. CCC CC reported that the communication forms needed to be completed and reviewed by nursing staff to ensure the staff were aware of any changes in Resident #19's condition or dialysis treatment orders. CCC CC reviewed Resident #19's Hemodialysis Communication Forms with this writer and confirmed that nursing staff had not documented the completion of a pre-dialysis Assessment on the following dates: 11/21/25, 11/23/25, 12/1/25, 12/20/25, and 1/26/26, and 2/6/26. CCC CC reported that she was aware that nursing staff were frequently missing pre-dialysis assessments, and that she had talked to the nurses about the importance of completing the hemodialysis forms recently. CCC CC reported that Resident #19 would sometimes refuse to go his dialysis appointments, but that nurses should document the refusal of dialysis appointments on Resident #19's Hemodialysis communication form. During an interview on 2/10/2026 at 12:12 PM, Medical Records (MR) ZZ reported she was responsible for appointment scheduling and tracking missed appointments for the residents at the facility. MR ZZ confirmed that she had record that Resident #19 had refused to go to dialysis on 1/7/26, 1/14/26, and 1/23/26 and 2/9/26. Review of the facility's Dialysis policy dated 2021 revealed, Policy: It is the policy of this facility to assist in and arrange for dialysis facility services as available for residents' requiring dialysis with a diagnosis of end-stage renal disease. Purpose: To provide general guidance for communication and continuum of care for a resident requiring dialysis services at an external dialysis facility . Procedure: 1. Arrangements with dialysis facilities for the provision of dialysis services will be established upon admission and as needed. Residents who require dialysis services will be provided care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. 2. Ongoing provision of assessment, care planning and provision of care with the dialysis facility will be in collaboration with facility services. Communication tools, short term care plans and assessment collaboration with medical and nutritional services will be ongoing for the continuum of care .

Based on interview and record review, the facility failed to ensure the physician documented review of pharmacy recommendations timely for 1 resident (Resident #5) of 6 residents reviewed for unnecessary medications resulting in the potential for medication side effects to occur and/or unnecessary medications for residents.Findings include:Resident #5 (R5)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R5's initial admission date was 10/30/2023 with pertinent diagnoses including depression, delusions (delusions are false beliefs that persist despite evidence to the contrary), bipolar disorder (intense mood swings ranging from extreme highs and lows), dementia (decline in cognitive abilities severe enough to interfere with activities of daily life) and chronic pain. Brief Interview for Mental Status (BIMS) reflected a score of 10 out of 15 which indicated R5 cognition was moderately impaired. Review of R5's active physician orders revealed Olanzapine (Zyprexa, antipsychotic medication to treat bipolar disorder) oral tablet 5 mg. Give 1 tablet by mouth one time a day for bipolar disorder.Zoloft (sertraline, antidepressant) oral tablet 50 mg tablet by mouth one time a day for major depressive disorder.Review of R5's monthly pharmacy review dated 9/10/2025 revealed .Resident is taking olanzapine and is at increased risk of weight gain and decreased effectiveness . monitor for adverse effects and adjust (dosage) accordingly.Recommendations: Please consider changing therapy to one of the listed alternatives (Paliperidone-antipsychotic drug used to treat schizophrenia, quetiapine-antipsychotic to treat schizophrenia, bipolar and other depressive disorders, , ziprasidone-antipsychotic to treat certain mental and mood disorders) to ensure resident is not having adverse effects from therapy. The recommendation was signed in agreement by the physician on 2/10/2026 (day of survey exit). Another pharmacy recommendation for R5 from 9/10/2025 revealed Resident is taking sertraline and at increased risk of side effects (nausea, diarrhea, insomnia (difficulty sleeping) and sexual dysfunction) and decreased effectiveness. Initiate therapy with recommended starting dose and consider a slower titration schedule and lower maintenance dose.monitor for clinical efficacy and adjust dose accordingly. Recommendation: Please consider changing sertraline to one of the listed alternatives (fluvoxamine-used to treat obsessive compulsive disorder, vortioxetine-antidepressant) to ensure resident is getting the most benefit and least adverse effects from therapy. The recommendation was signed in agreement by the physician on 2/10/2026 (day of survey exit). Review of R5's monthly pharmacy review dated 10/12/2025 revealed Resident has 2 orders for calcium carbonate. Please discontinue one of the orders if it is a duplicate. The recommendation was signed in agreement by the physician on 2/9/2026 (during the survey). During an interview on 2/10/2026 at 12:04 PM, Director of Nursing (DON) B stated that the pharmacist completes monthly pharmacy reviews and sends recommendations to her and then she prints them out and puts it in the physician/provider mailbox. DON B said that once the physician signs the recommendation and notes whether they agree or disagree with the pharmacy recommendations, it was returned to the DON mailbox and changes were made in the resident's chart if indicated. DON B was unsure of how the pharmacy recommendations records were maintained prior to her assuming the position of DON, and she was unable to locate R5's previous pharmacy recommendations. Corporate RN (CRN) GGG obtained copies of previous recommendations and provided them to the physician for review on 2/9/2026 and 2/10/2026. Review of the Medication Monitoring Policy with an effective date of 10/1/2018 revealed Procedure.7. For non-urgent recommendations, the Facility and Attending Physician must address the recommendations in a timely manner that meets the needs of the resident- but no later than their next routine visit to assess the resident- and the Attending Physician should document in the medical record: a. What irregularity has been reviewed. B. What action has been taken to address the issue. C. The pharmacy recommendation itself can be used as a tool to document in the medical record, or a notation may be indicated in the medical record/EHR (electronic health record) .

Based on interview and record review, the facility failed to ensure 1 (Resident #114) resident of 6 reviewed for unnecessary medications was prescribed a controlled medication, resulting in the use of a controlled addictive substance without adequate diagnosis or indications of use with potential for adverse side effects including negative physical and psychosocial side effects. Findings include: .Use of Adderall can create psychological dependence, physiological dependence, and tolerance may occur with amphetamine; dextroamphetamine therapy. Abrupt discontinuation or a significant dose reduction of CNS (central nervous system) stimulants after prolonged use may produce withdrawal symptoms that include dysphoria, depression, fatigue, vivid and unpleasant dreams, insomnia or hypersomnia, increased appetite, and psychomotor retardation or agitation. Signs and symptoms of chronic amphetamine abuse include severe dermatoses (skin defect or lesion of the skin), marked insomnia, irritability, hyperactivity, personality changes, and psychosis with features indiscriminate from schizophrenia. https://www.merckmanuals.com/professional/drug-names-generic-and-brandResident #114: Review of an admission Record revealed Resident #114 was a male with pertinent diagnoses which included multiple sclerosis (the body's immune system attacks the protective covering of the nerve cells in the brain and spinal cord, disrupting signal transmission), need for assistance with personal care, suprapubic catheter (thin, flexible tube inserted through a small incision in the lower abdomen directly into the bladder to drain urine), muscle wasting and atrophy multiple sites (loss of muscle tissue characterized by decreased size, strength, and function), depression, anxiety, and chronic pain. Review of Order dated 9/4/25 for Resident #114, revealed, .Adderall Oral Tablet 20 MG (Amphetamine-Dextroamphetamine) .Give 1 tablet by mouth two times a day for ADHD. Review of Resident #114's medical record revealed no diagnosis of ADHD (attention deficit hyperactivity disorder). Review of current Care Plan for Resident #114, revised on 12/12/25, revealed the focus, .(Resident #1140 has the potential for psychosocial distress related to: expressing sadness / anger / empty feeling over lost roles and status. with the intervention .He easily becomes frustrated and agitated and is receptive to (Behavioral Health Services Provider) services that are in place. (Resident #114) expresses himself by using profanity. He has been educated that smoking and vaping is not allowed on the facility property.Acknowledge residents mood and behavior; conveying acceptance toward the resident while rejecting negative behavior.Allow time and opportunities to express feelings.Assess feelings or behaviors that could present a danger to self or others and intervene accordingly.Behavior monitoring as identified on the individualized log; utilize log for patterning and intervention revision as indicated.Evaluate changes in mood and socialization.Identify behavioral precipitants if possible to assist with further defining effective dementia care and trauma informed care.Maintain a calm environment as able.Respond to the emotional content of what the resident is saying by utilizing distraction techniques vs reasoning which can escalate behavior. Review of HCP (Health Care Provider) Visit dated 11/6/25, revealed, .CC: Shingles rash, agitation, use of marijuana.Hoping to have a discussion on safety of using both Adderall and marijuana. 3 marijuana edibles in his bed and empty packages on the floor were found in his room by his nurse. He does admit to the nurse finding them and states that nurse Licensed Practical Nurse (LPN) PP) is an asshole for telling on me. He also explains he is unhappy about his living situation at this facility and that this place stresses me out, this is why I have this rash; I'm not talking about this with you right now, we can talk about it in court. Asked if he is unhappy and stressed why he does not work with (Community Based organization) and social work to find new care facility or AFC (Adult [NAME] Care). His response is no one will take me. He became irritated when attempting to discuss Adderall use and said, you can't even talk to me because I need higher level of care for my advanced MS (multiple sclerosis), you're just a nurse practitioner. When offered to have him see (Medical Director D) he states, he's just a nursing home doctor, I don't want him either. Explained he did have the right to find his own PCP (Primary Care Provider) and he repeated he needs a higher level of provider due to his MS but denied having a neurologist that he saw prior to coming to facility .He became increasingly agitated.GEN: agitated.Will decrease use of Adderall to once daily due to increased agitation with most staff and labile mood (rapid, intense and often uncontrollable shifts in emotional state), used in prior notes for fatigue due to MS but seems counterproductive when using in combination with Marijuana. Discussed with management that patient may find appropriate level of care he feels is better suited to manage his medical needs. MS-Recommend follow up with neurologist, was seen by (Medical Doctor) in past was on Tecfidera and Ocrevus in past. Was seen by (Medical Doctor) for 2nd opinion (1/19/2019) but note review did reveal he became agitated when (Medical Doctor) would not prescribe opiate medications and referred him back to previous neurologist. His last appointment able to view was 2/5/2019 with (Medical Doctor) .Review of Psychiatry Progress Note dated 11/12/2025, revealed, .Clinical Update -11/12/2025: The resident was reviewed during the Behavior Management Meeting with input from Social Services, MDS (Nurse who manages the Medicare/Medicaid mandated assessment process), and Nursing .He appeared mildly anxious but pleasant during observation .The resident was counseled regarding his current ADHD medications, as his presentation does not meet diagnostic criteria and behavioral therapy is more appropriate. Discussion was held regarding the need to gradually wean off stimulant medication. The resident was hesitant about this recommendation, stating that he had been diagnosed by neurology. Staff also reported that the primary care provider had already begun a gradual taper, reducing the dose to once daily. Psychotherapy was recommended to provide additional emotional support and assist with behavioral regulation. Nursing staff are advised to continue monitoring for clinically significant changes in mood and behavior, including: Depression: sadness, tearfulness, social withdrawal Anxiety: irritability, excessive worrying .Due to concerns regarding possible substance use disorder, initiation of additional psychotropic medication will be deferred. Review of Order dated 11/12/25 for Resident #114, revealed, .Adderall Oral Tablet 20 MG (Amphetamine-Dextroamphetamine) .Give 1 tablet by mouth two times a day for MS and Chronic Fatigue. Review of Interdisciplinary (IDT) Documentation dated 11/18/2025 11:47 AM, .(Resident #114) admitted to facility with Rx (prescription) of Adderall and no appropriate diagnosis. (Behavioral Health Serviced Provider) services are in place and have been unable to get an appropriate diagnosis code and attempts to reduce to D/c (discontinue) Adderall have failed due to resident's refusal to GDR (gradual dose reduction) .Resident #114 remains his own person. He has agreed to a neurology follow up and plan is for resident to follow up with Neurology and resident would prefer to see his Neurologist that he has used in the past. Scheduler attempting to schedule with his Neurologist at this time.Review of Quarterly MDS Assessment IDT Note dated 12/16/25 at 1:15 PM, .He is on Adderall which he states he has taken for at least 10 years without a proper diagnosis and adamantly refuses to decrease or stop the medication.(Resident #114) has behaviors such as anger specifically stated by him toward life and his current situation frequently lashes out at staff, requires his care to be in pairs. He receives trazadone as needed for sleep and Seroquel for depression . Review of Interdisciplinary Documentation dated 12/17/2025 at 2:42 PM, revealed, .GDR/Behavior/Psychotropic medication review with SS (social services), CCC (clinical care coordinator), DON (Director of nursing).pharmacy recommendations: Meds in review: Currently taking Seroquel, valium, gabapentin, Adderall.He has a neurology appt in January regarding Adderall use which he does not have an appropriate diagnosis. Review of BH (Behavioral Health) Progress Note dated 1/2/26, revealed, .Mental Status Exam: Depressed/Dysphoric/Sad.Anxious/Worried.Agitated.Irritable. Session Summary: In session, resident showed alert. rising and falling irritability, and cooperative.Clinician provided supportive therapy. CBT (cognitive based therapy), and neurocognitive stimulation-based techniques to help explore and promote adaptive management of negative affect.Interactive Complexity: Yes; maladaptive emotional issue that negatively impacted treatment (e.g., tearfulness, high expressed emotions).Review of Interdisciplinary Documentation dated 01/28/2026 at 3:33 PM, revealed, . (Resident #114) .This resident unsure why Adderall was started and is currently seen by (Behavioral Health Serviced Provider) and facility MD/NP. Both have recommended D/Cing the Adderall and resident refuses stating that his neurologist recommended. This residentreceptive to following up with neurologist regarding current needs and medications in order to establish appropriateness of medications and any additional/ongoing needs. (Resident #114) is scheduled for neurology follow up on 1/29/2026. (Resident #114) continues to have behaviors of frustration with his limitations, accusatory behaviors, med seeking and self-medicating outside of facility. He remains his own person and is able to leave facility independently for LOA (leave of absence) . In an interview on 02/05/2026 1:24 PM, Social Worker (SW) XX reported Resident #114 was admitted with Adderall prescribed. SW XX reported she had discussed this prescription with (Behavioral health services provider) to determine if they would be able to give him a diagnosis to continue the Adderall, he did have a neurology appointment on 1/29/26 as a follow up for the Adderall use as an agreement from the Nurse Practitioner (NP) to continue until he was able to follow up with the neurologist. SW XX reported Resident #114 was refusing to discontinue the use of the Adderall or discuss it so the agreement was he would stay on it until he was able to meet with neurology. SW XX reported she had not heard the outcome of the appointment on 1/29/26. In an interview on 02/05/2026 2:11 PM, Clinical Care Coordinator (CCC) AA reported the neurologist did not send any paperwork back with him and Medical Records (MR) ZZ sent in a request for the documentation.In an interview on 02/06/2026 11:52 AM, This writer knocked on Resident #114's door to his room and requested to enter and there was no reply even though there was obvious movement in the room. Review of Neurologist Progress Note dated 1/29/26, there was no documented support for the continued use of Adderall for Resident #114. In an interview on 02/05/2026 at 2:41 PM, Nurse Practitioner (NP) MMM reported she felt the Adderall was contributing to his irritability with staff members by the use of profanity, argumentativeness, and emotional outbursts. NP MMM reported Resident #114 did not have an appropriate diagnosis to continue the use of the Adderall and she had attempted to discontinue the Adderall last fall. NP MMM reported she had received a call from the Director of Nursing and the Nurse Manager due to discontinuing the Adderall and his resistance. NP MMM reported she was informed Resident #114 had refused to come off the medication, and he felt she was not qualified to discontinue the medication as she did not feel it was safe for him to continue the medication as he did not have an appropriate diagnosis to support the continued use of it. NP MMM reported she agreed for him to have a follow up with a neurologist to determine his continued use, but she was concerned as Resident #114 had a history of substance abuse and she thought he had developed an addiction to the Adderall. NP MMM reported she had spoken to Medical Director (MD) D, and he had agreed the medication was not appropriate for Resident #114 as well as (Behavioral health services providers) as well.

This citation pertains to intakes: 2659614 & 2661255Based on interview and record review, the facility failed to prevent significant medication errors for 1 resident (Resident #100) of 7 residents reviewed for medication errors, resulting in a change in condition, emergent transfer, and hospitalization for Resident #100. Findings include: Resident #100: Review of an admission Record revealed Resident #100 was a female with pertinent diagnoses which included dementia, dysarthria (a motor speech disorder that causes slurred or slow speech due to weak or uncoordinated speech muscles), memory deficit following a stroke, Alzheimer's disease, diabetes, metabolic encephalopathy (a brain disfunction caused by systemic metabolic problem such as liver or kidney failure, diabetes, sepsis), cognitive communication deficit (difficulty with communication caused by impairments in thinking skills like memory, attention, and problem solving). Review of Medications for Resident #100 revealed, .Resident Medications: acetaminophen (TYLENOL) 500 mg tablet Take 1 tablet by mouth every 6 hours as needed for Pain. amLODIPine (NORVASC) (calcium channel blocker for high blood pressure) 10 MG tablet Take 1 tablet by mouth every morning. aspirin 81 MG chewable tablet Chew 1 tablet daily. diclofenac sodium (VOLTAREN) (anti-inflammatory drug used to treat pain and inflammation) 1 % gel Apply 2 g (grams) to skin 4 times daily as needed for Pain. ELIQUIS (blood thinner) 5 MG tablet Take 1 tablet by mouth 2 times daily. hydroCHLOROthiazide (MICROZIDE) (used to treat high blood pressure and fluid retention, Water pill) 12.5 MG caplet Take 12.5 mg by mouth daily. Isosorbide mononitrate (used to prevent chest pain) ER(Extended Release) Take 1 tablet by mouth. Review of Incident Summary dated [DATE] at 1:10 PM, revealed, .Incident Summary: Resident was found unresponsive during morning rounds by CNA. Code blue called overhead page, nurses responded immediately, including the director of nursing (DON B). DON provided a sternal rub to arouse (Resident #100), no CPR required. VS (vitals signs) was 141/76 (blood pressure) pulse 48 o2 (oxygen saturation) 98 with a very light pulse. 911 called due to unresponsiveness. She maintained a pulse and was breathing when they arrived. Medics arrived and transported resident to hospital. At 1:30 PM the hospital notified facility that her urine drug screen came back positive for Benzodiazapam (benzodiazepine) and opioids. Per her medical record, (Resident #100) has no orders for these medications.Review of Prehospital Care Report Summary dated [DATE], Dispatched to (Facility) for a report of a 87 YOF (year old female) unconscious but breathing. Upon arrival, patient found semi-Fowlers (medical posture where a patient lies on their back with their head and upper body raised 30-45 degrees) in bed and slumped to the right, unresponsive to all stimuli, pupils fixed and constricted.Staff states that patient was at baseline yesterday evening around dinner time. She then took her meds and went to bed. Today, they are unable to wake her up. Patient is not prescribed any narcotic pain medications.06:05:32 AM, Glasgow Coma Score: 5 (Scored between 3 - 15, 3 being the worst).06:11:33 AM BP 123/61, MAP (mean arterial pressure): 82, Pulse: 49, SPO2: 86. Review of Emergency Department (ED) progress note, dated [DATE], revealed, .Diagnosis at time of disposition: 1. Unresponsive .87 y.o. female patient presenting to the ED with unresponsive state. Vital signs bradycardia (abnormally lower heart rate, defined as fewer than 60 beats per minute) and hypothermic with decreased respirations. Patient with pinpoint pupils. Narcan (medication used to reverse or reduce the effects of opioids) given without significant effect. Blood sugar okay. Withdraws to pain but moves right side more than left side. Will obtain broad laboratory workup . UA (urinalysis), UDS (urine drug screen). Patient is a do not resuscitate DNI but is currently doing okay on 2 L (liters) nasal cannula despite decreased respiratory rate.HISTORY OF PRESENT ILLNESS: 87 y.o. female presenting to the ED with unresponsive state. EMS did note constricted pupils despite no narcotic medication on her med list. No other really sedating medications on her list.Review of medical record for Resident #100 at (Local Hospital) revealed, .06:20 Medication Given naloxone (NARCAN) syringe 2 mg - Dose: 2 mg; Route: Intravenous; Line: Peripheral IV [DATE] Left Antecubital ; Scheduled Time: 0630 AM. Review of medical record for Resident #100 at (Local Hospital) revealed, .07:37:29 Drug Screen Without Confirmation, Urine.Abnormal Result Collected: [DATE] 06:52 Last updated: [DATE] at 07:37 Status: Final result Benzodiazepine Screen, Urine: Presumptive Positive.Opiate 300 screen (detected the presence of morphine and codeine at concentration of 300 ng/mL or greater), urine: Presumptive Positive.Drugs can contribute to low body temperature and decreased respiratory drive.Temperature: 35 C (95 degrees Fahrenheit) (Device Time: 08:29:38).Pulse: 47 (Device Time: 08:29:38).Respirations: 11 (Normal respiratory rate: between 12 and 20 breaths per minute) (Device Time: 08:29:38).BP: 95/58 (Device Time: 08:30:00).MAP (mmHg): 71 (Device Time: 08:30:00).AVPU (Alert, Verbal, Pain, Unresponsive) Scale: Unresponsive.Review of Progress Notes - Social Work dated [DATE] revealed, .MSW consulted for other (please specify): Patient (Pt) from the nursing home. has benzos and opioids in system. not sure if on home med list. Pt arrived per EMS sent from (Facility), unresponsive on seen, last know normal at dinner last night. RNCM (Registered Nurse Case Manager) followed up with (Facility) to confirm if any medication was given at the facility. Per pt nurse, benzos and opioids are not on pt medication list; so that is not coming from their end. (EMS) was called to confirm if any medication was administered by EMS whilst en route to the hospital. (EMS) reports to crosscheck and get back to RNCM with details. Another drug screen has been ordered to confirm lab results. Once test results shows positive for both opioid and benzos and (EMS) reports nothing was administered to pt, a report will be made to APS for further investigations. MSW to keep following.Review of Physician Discharge Summary revealed, .Brief Summary of Hospital Stay: This is a 87 y.o. female.who presented with being found unresponsive at her care facility. She is unable to give a history so obtained from the ER and records. She lives at the SNF. She was found unresponsive on 10/31 and brought in. GCS 6. RR 9. She was noted to be hypothermic. ED workup reveals.UDS (urine drug screen) + for diazepam, no prescription.APS involved due to benzo's on UDS without prescription. discharged on [DATE]. Review of Investigation Summary revealed, .Narcotic Audit was conducted and one resident who resides on (Resident #100s) unit was identified as (Resident #101) BIMs15/15 (indicated resident was cognitively intact) who has an order for Valium (benzodiazepine: central nervous system depressant that produce sedative and hypnotic effects) 10mg two tabs at 2000 (8:00 PM). Morphine ER 60mg one tab at 2100. Tizanidine 4mg one tab at 2000 and Baclofen 10mg four tabs at 2000. All medication were signed out by (Licensed Practical Nurse (LPN) C), LPN on [DATE] at 2022 (8:22 PM) as given in the medical record.In an interview on [DATE] at 09:53 AM, CNA G reported she went into Resident #100's room to wake her up as she had not gotten up to use the bathroom all night which was unlike her. CNA G reported she said her name, Resident #100 did not respond, so she tried to move her a little and she didn't respond and then she noticed she was not breathing and then while she was watching her she took a breath but then she had stopped again. CNA G reported she called a code blue, the nurses immediately responded to the room, the DON was there, and she got her breathing. Resident #100's pulse was really low, and EMS was called. CNA G reported she stayed with Resident #100 until all the staff came in the room. CNA G reported she normally ate dinner and then would go to bed and that was what she did that night as well. CNA G reported Resident #100 was checked on every two hours throughout the night. CNA G reported the nurse on the hallway was an agency nurse.Review of Resident Interview dated [DATE], .(Resident #101) was interviewed by (Director of Nursing (DON) B) and stated she doesn't think she took her medications the night of the 30th because she doesn't remember taking them. (Resident #101) states she did not have increased pain or discomfort. (DON B) asked (Resident #101), since you are on top of your pain medication do you recall asking for the medication? She stated she didn't recall. Her pain was assessed as documented in the medical record no change in her baseline was noted during this timeframe.Resident #101's orders revealed, Resident #101 was prescribed Morphine Sulfate (powerful opioid used to treat moderate to severe pain) ER Oral Tablet Extended Release 100 MG, 3x per day at 0700, 1100, 1500 (3:00 PM). Morphine Sulfate ER Oral Tablet Extended Release 60 MG, at bedtime 2100 (09:00 PM).Diazepam Oral Tablet 10 MG at bedtime 2100 every day. Review of Staff Interview dated [DATE], revealed, (Certified Nursing Assistant (CNA) D) stated, .I worked Thursday ([DATE]), 2nd shift. She was not in my section. I did see her before dinner and at dinner. She was in her room toileting before dinner when I saw her. I am pretty sure I saw her in the dining room for dinner. She was at her baseline. The day when I came back to work, I did say to one of the nurses, the nurse that was here last night from the agency (LPN C) ([DATE]). I think she mistakenly took the wrong meds to (Resident #103). The nurse came to me and asked if she (Resident #103) was taking pills with pudding. I don't think she takes her meds with pudding, and if she said those are not hers then they are probably not as she is pretty with it. She was asking about the bed numbers, and I explained to look at the bed numbers and names and ask them because they are all pretty much with it. she said OK. It was like she didn't understand the order from the report sheet. The top rooms on the report sheet are not (First Name) and (First Name) and them. She seemed a little confused and flustered. That day I did not see (Resident #100) had any visitors that day.Review of interview conducted on [DATE] by facility revealed, .To Your Knowledge has anyone given you any medications that were not yours? Resident #103 stated, Yes at 8:00 PM last night a new nurse (LPN C) brought a cup of crushed pills for me to take. I did not take them, and I told her I don't know what they were since they are crushed. She took them away. Later she brought in my normal evening medications. In an interview on [DATE] at 2:38 PM, Resident #103 reported the nurse (LPN C) did not ask her who she was, she just said she was coming in to give me my medications, looked at the cup and the medications were crushed and she told her those were not hers, those medications were my roommates medications, she got crushed medications. Review of Resident #106's admission Record revealed she was admitted to the facility on [DATE] with pertinent diagnoses of dementia, diabetes, heart failure, bipolar disorder, and COPD. Clinical Profile revealed, .Medications: May crush together and given as few bites as able. In an interview on [DATE] at 1:44 PM, Resident #102 reported her roommate had dementia and would get up and go to the bathroom by herself. Resident #102 reported there was a new nurse (LPN C) on that night, she wanted to give Resident #102 insulin and told her she didn't take insulin. Resident #102 reported she did not sleep all night that night ([DATE]) because she believed she never got her medications and Resident #100 had received them. Resident #102 reported she thought the nurse who worked ([DATE]) gave Resident #100 the wrong medication. Resident #102 reported the nurse was an agency (LPN C). In an interview on [DATE] at 9:10 AM, CNA F reported Resident #100 wasn't her normal self and the she would transfer often, so the staff had to keep a close eye on her, but she did not get up at all that night. CNA F reported she checked on Resident #100 several times and each time she was sound asleep, but during last rounds about 5:00 AM, she was unresponsive not reactive to anything. CNA G called the code blue, nurses and other CNAs responded, Resident #100 was given sternal rubs, a cold washcloth was placed on her head by DON B and she was sent out. CNA F reported Resident #102 indicated to LPN C she did not receive insulin and LPN C came and asked me and told her to ask the other nurse, the other nurse confirmed Resident #102 did not receive insulin to LPN C. CNA F reported the agency nurse appeared really confused and she didn't know the residents. In an interview on [DATE] at 11:37 AM, Licensed Practical Nurse (LPN) C reported she had to wake up Resident #100 to give her, her medication as she had gone to bed after dinner. LPN C reported Resident #100 was not talking to her. LPN C reported nurses should ask the resident who they were to verify their identity. LPN C reported there was a sheet of paper which had how each resident took their medications. LPN C reported nurses were required to follow the rights of medication administration when passing medications, which included verifying the right resident, medication, dose, time, and right route. LPN C reported nurses should verify the resident's identity by checking the name on the door, room number, asking he resident and using photos in the chart. LPN C reported she had 29 residents at dinner time and then approximately 40 after midnight and she was busy all night long and it was hard as she did not know the residents. LPN C reported she would pull medications for both residents in each room and then take the medications into the room. LPN C reported she rounded all night on all her patients and Resident #100 was breathing. LPN C reported the CNA was finishing her last round and heard a code blue was called and then realized it was a resident on the hallway she had been assigned to. LPN C reported she ran out of the hallway and when into the room. The DON was performing a sternal rub trying to get her to be responsive, she was breathing, light and light pulses, called 911, went to get vitals, pulse and put O2 on her, tried to stabilize her. LPN C reported when she was talking to the NHA she indicated she had made a med error. LPN C reported she made a mistake and this situation had never happened to her before, it was just a lot, she reported she had too many residents. LPN C stated, almost killed a lady over a mistake. LPN C reported when she spoke to the DON B she indicated she must have mixed up the medications, indicated she had charted under the wrong chart. LPN C stated, It was an accident, I didn't mean for it to happen.It was a really big mistake. In an interview on [DATE] at 2:29 PM, DON B reported she was on another hallway and heard the code blue, told the aide to get the crash cart, got there to assess the situation, on the way had another aide grab the red book for code status. DON B reported when she got there Resident #100 had a pulse, she had respirations which were irregular, two or three regular and apneic (stopped breathing) episode for approximately 30 seconds maybe and then a big breath, very irregular. DON B reported the staff reviewed the code status, verified with other nurses around, someone felt for her pulse add respirations, start on oxygen, didn't have the O2 level as the pulse oximeter was not reading it, made sure she had oxygen especially with irregular breaths, another nurse got the blood sugar, and the staff had checked all the things and they were working on sending her out, the aide stayed in there with her until EMS arrived. In an interview on [DATE] at 2:14 PM, LPN I reported pharmacy delivers the medication packets every day for the next day. LPN I reported the narcotic medication were kept in a separate drawer in the medication cart. LPN I reported there was a separate key for the narcotic medication drawer. This writer observed the narcotic medications blister packages in the drawer. LPN I reported medications were checked for resident name, room number, medication, dosage, time administered against the order/MAR in the electronic medical record against the blister package for the narcotic medication. LPN I reported for the regularly scheduled medications they come in packets with the resident's name, room, and time noted at the top and the medication and dosage on the front of the package, open the package and compare the individual packets against the order/MAR and then dispense into the medication cup. LPN I reported nurses should always address the resident or ask then to tell her their name if able to respond, compare to photo in electronic medical record prior to administering the medication. In an interview on [DATE] at 12:32 PM, Clinical Care Coordinator (CCC) H reported she had worked the first 4 hours of second shift on Resident #100's hallway. CCC H reported the off going nurse would give verbal report to the oncoming nurse. CCC H reported she and LPN C completed the count of narcotic medications prior to her leaving for the day. CCC H reported she and LPN C counted all the narcotics after she checked all the other in the fridge as well and the number was correct. CCC H reported each hallway had a sheet which tells the nurse how each resident takes their medications, and the floor nurses were responsible for updating those sheets. In an interview on [DATE] at 2:43 PM, Resident #104 stated .A few days ago the nurse had brought in my meds and left them to sit on the table as she was crocheting at the time, so when she finished, she went to take them but didn't have water so she paused and looked and there were three of the same looking pills and she reported mine are different, so she told the staff. Resident #104 asked her roommate (Resident #105) if she had gotten her pills yet and she said No. Resident #104 reported she was glad she noticed because she had high blood pressure pills, and her roommate had seizure medication.In an interview on [DATE] at 3:31 PM, Registered Nurse (RN) E reported if a resident wanted to self-administer medications the Clinical Care Coordinator (CCC) would complete an assessment. This writer and RN E reviewed Resident #104's assessments and she reported she did not have an assessment for self-administration of medication and proceeded to show me in assessments where the CCC would go to complete the self-administration assessment. Review of Resident #105's medical record revealed the Interdisciplinary Documentation dated [DATE] 17:47 (5:47 PM) .Received call from Neurology, change to current order, increase, Carbidopa-levodopa 25-100mg one tablet TID (three time per day) for Parkinson's. Review of Conclusion for investigation of Resident #100's incident dated [DATE], revealed, .Upon admission to the hospital, (Resident #100) was diagnosed with a urinary tract infection and metabolic encephalopathy. Laboratory drug screen results indicated the presence of diazepam and caffeine (metabolite).The visitor sign-in logs for the previous 30 days were reviewed, and no visitors were documented for (Resident #100) during that period. (Resident #100)'s Durable Power of Attorney (DPOA) confirmed that she does not receive visitors other than her designated representative. According to pharmacy reference data, diazepam may be detectable in the blood for approximately one to two days (up to 48 hours) following administration. Therefore, it can be determined that (Resident #100) received diazepam within that timeframe. Review of Medication Discrepancy Report dated [DATE], revealed, .What is the actual discrepancy to the resident? She ingested medications not ordered by her physician.Could the discrepancy have endangered the life or welfare of the resident? Yes.She was unresponsive and sent to the hospital. In an interview on [DATE] at 1:17 PM, Director of Nursing (DON) B reported we interviewed all the staff who had worked the last 48 hours before the event. All staff reported Resident #100 was at baseline. DON B reported LPN C was asked not to come back until a full investigation was done. DON B reported there were no conclusive answers, the investigation never revealed for certain it was LPN C who gave the medications to Resident #100. DON B reported diazepam was in her system and she had no order for that medication. In an interview on [DATE] at 12:10 PM, Nursing Home Administrator (NHA) A reported Resident #100 had a change in mental status and it was thought to be an illness, it was discovered she did have a UTI in the hospital. NHA A reported the facility received a phone call from the emergency room reporting Resident #100 had lab work completed and was tentative she was positive for opioid and benzodiazepines which were not on her medication list. NHA A reported the result indicated Resident #100 had a definitive positive for Valium (diazepam) and an investigation was completed. NHA A reported during interviews with other residents she discovered a resident did not get the right medications from LPN C, indicated the medications were crushed and she took her pills whole. A few minutes later she had brought her the correct medications. NHA A reported Resident #103 had reported LPN C had entered her room to take her blood sugar so she could administer her, her insulin. Resident #103 informed LPN C she did not get insulin and her blood sugar was not checked. NHA A reported she believed there might have been some confusion of the rooms. NHA A reported the facility interviewed all the nurses who had worked with Resident #100 leading up to the incident and they reported they gave medications to the right person. NHA A reported the nurses get distracted quite a bit and someone may have been distracted when they were pulling medications. NHA A reported the Valium was pulled from a separate drawer. When queried if Resident #100 had an order for Valium, NHA A indicated she did not and indicated an adverse medication even had occurred. Review of policy, Medication Administration by the Various Routes revised on [DATE], revealed, .1. Residents at this facility will be permitted to self-administer medications if ordered by the attending physician and approved through assessment by the inter-disciplinary team and requested by the resident.9. Medications supplied for one resident are not administered to another resident.10. To ensure accuracy in the administration of medications, staff administering the medication are responsible for checking to see if the drug and dosage schedule on the residents' administration record matches the label on the medication container.13. General Preparation: a. Review the physician order. Resolve any discrepancy before proceeding with the administration of the medication (s).b. Obtain the necessary supplies needed for the type of medications to be administered such as medication cups, proper measuring devices, cotton balls, disposable gloves, tissues, pill crusher etc.,f. Remove the medication (s) from the residents supply according to the Medication Administration Record.g. Double-check the label with the Medication Administration Record.Identify unfamiliar residents using the photo ID. The licensed nurse preparing the medication must administer it (excluding premixed and unit dose).Explain the procedure as indicated and administer the medication as ordered. Document after administering the medication and before proceeding to the next resident.o. Medication is not left unattended except as directed by a self-administration assessment.

This citation pertains to intake MI00143902 Based on interview and record review the facility failed to ensure a timely assessment for a change in condition in 1 (Resident #100) of 1 resident reviewed for timely assessment for a change in condition resulting in the delay of communication with a provider, delay of transfer to acute care setting for evaluation and a delay of treatment. Findings include: Resident #100 Review of an Admission Record revealed Resident #100 had pertinent diagnoses which included: rhabdomyolysis (muscle breakdown that causes toxins to leak into the bloodstream), abnormalities of gait (walking) and mobility, and acidosis (blood becomes too acidic due to problems related to kidneys or lungs). Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of ,d+[DATE] which indicated Resident #100 was cognitively intact. In a telephone interview on [DATE] at 3:49 PM., Family Member (FM) S reported that he had visited Resident #100 on the Friday before she was sent to the hospital, and Resident #100 was as good as she had been. FM S reported that Resident #100 was sent to the acute care hospital (Name Omitted) by the facility on the Monday after the visit. FM S reported that Resident #100 was sent to the local emergency room (Name Omitted) and was then transferred to a larger hospital (Name Omitted) in another town for further evaluation and treatment. FM S reported he received a call from the acute care hospital (Name Omitted) and the caller told him that he needed to get there pretty quickly, that Resident #100 had declined, and her condition was grave. FM S reported that Resident #100 died at the acute care hospital (Name Omitted) on Monday, [DATE]. Review of Progress Note/Alert Note for Resident #100 dated [DATE] at 22:49 PM., authored by Contract Nurse (CN) D revealed . Resident left arm observed swollen, red, and warm to touch, DR (doctor) called unable to contact, voice mail left, note put into Dr's book. Review of Progress Note/Alert Note for Resident #100 dated [DATE] at 5:04 AM., authored by CN D revealed .upon transferring resident to restroom resident stated she felt dizzy, resident was transferred back to bed, bp (blood pressure) was obtained ,d+[DATE] called MD (doctor), per dr order push fluids, lay head flat, and raise legs, recheck bp, ,d+[DATE], ,d+[DATE], ,d+[DATE]. Resident showing no signs of distress, no signs of hypotension (low blood pressure). Resident stated laying back in bed she felt better. Resident stated she cannot consume large amounts of water due to a previous surgery, writer explained to resident the urgency of drinking water to help raise her bp. Resident in bed, comfortable .will continue to monitor bp throughout the day. Review of Progress Note/Interdisciplinary Documentation for Resident #100 dated [DATE] at 9:43 AM., revealed .complains of not feeling well, color is pallor, left hand is swollen, elevated on a pillow. Noted left hand open area clean with a small amount of drainage, left hand and arm almost up to the elbow is very warm to touch and red, skin turgus (turgor- skin's ability to change shape and return to normal) return is very slow. (Name Omitted) doctor was notified, left message about pts (patients) condition. Waiting for return call . Review of Progress Note/Interdisciplinary Documentation for Resident #100 dated [DATE] at 9:45 AM., revealed .pt had 4 large episodes of diarrea (diarrhea) with a foul smell, blood pressures times 5 within 30 min period runs ,d+[DATE] p85 (pulse) . Review of Progress Note/Interdisciplinary Documentation for Resident #100 dated [DATE] at 12:35 PM., revealed . Orders received from Dr. to send Resident #100 to the hospital for further evaluation of decreased B.P., weakness and fatigue and redness and warmth to the left arm. In an interview on [DATE] at 4:10 PM., Nurse Practitioner (NP) R reported that the nurses know to contact her directly if they are unable to reach an on-call provider. NP R reported that the nurses should not let the patient suffer, there needs to be some action to resolve the situation. In an interview on [DATE] at 4:22 PM., Licensed Practical Nurse (LPN) C reported when a call was placed to the on-call provider after hours, that call was answered by the call service. The call service would take note of the resident specific information, and then the call service would transfer the nurse call to the provider to speak to them. In an interview on [DATE] at 4:33 PM., Registered Nurse (RN) G reported that non-urgent resident situations are placed into the doctor's book. RN G reported that the provider looks at the doctor's book and follows up with requests when they are in the building. RN G reported that non-urgent things like a fall without injury or a resident request to see the doctor are things to put in the doctor's book. RN G reported that a decreased blood pressure or signs of an infection were not something that should go in the doctor book, for those situations the doctor should be called. In an interview on [DATE] at 4:33 PM., Infection Preventionist (IP) F reported that if the on-call provider did not call back within 5 minutes, the nurse should call back. The nurse practitioner was here every day during the week, and you could call her 24 hours a day 7 days a week. There was an on call answering service to use during non-business hours. IP F reported that she did not recall any staff having difficulties getting ahold of a provider after hours. In an interview on [DATE] at 9:37 AM., NP Q reported that the expectation was that if the on-call provider did not respond within 15 minutes, the nurse needed to call back. NP Q stated that if the symptoms were manageable with the resources available, then do that, if not send them to the hospital. NP Q stated If their vitals are crashing then they need to be sent out. NP Q reported that she would not question a resident transfer to the emergency room in an urgent situation. NP Q reported that she would expect that she or the on-call provider were notified of the resident transfer. In an interview on [DATE] at 10:04 AM., Clinical Care Coordinator (CCC) I reported that she did not recall what happened with Resident #100 before she was sent to the hospital. CCC I accessed Resident #100's online hospital record and reported that she was admitted to the ICU (Intensive Care Unit) for septic shock, cellulitis of the left upper arm and a UTI (urinary tract infection). In an interview on [DATE] at 11:35 AM., CCC I provided this surveyor a handwritten timeline related to Resident #100's condition prior to transfer to acute care hospital (Name Omitted). CCC I reported that from the first documented sign and symptom of infection were noted in Resident #100's left arm on [DATE] at 22:49 to the documented order to transfer to the emergency roiagnom on [DATE] at 12:35 PM., was too long for the resident to wait for physician order to transfer. In an interview on [DATE] at 1:19 PM., IP F reported that Resident #100's blood pressure reading was critical, and she should have been sent out. IP F reported that the nurse would call the on-call provider through the answering service, if they didn't call back, then the nurse should call again. IP F reported that if there still was no response from the on-call provider the nurse should have called the on-call manager for guidance. In a telephone interview on [DATE] at 2:38 PM., Call Center Coordinator (CCC) W reported that the on-call answering service does not have the option for a nurse calling in to leave a voice mail message (this is in contrast to CN D's written note). CCC W reported that the operator asks the nurse calling specific questions related to the patient such as name, date of birth, and reason for the call. The operator would then put the nurse calling on hold and would then call the provider on call. If the provider answered the phone the nurse's call was transferred to the provider. If there was no answer by the provider, the operator should instruct the nurse if they had not received a call back within 15 minutes to call again. CCC W reported that the operator would continue to reach out to the on-call provider every 15 minutes. If contact was not made with the on-call provider, the operator had instructions to continue to reach out to a provider every 15 minutes until someone was reached. CCC W reported that calls related to nursing home residents were considered priority calls. In a telephone interview on [DATE] at 3:28 PM., Director of Nursing (DON) B reported that she remembered Resident #100 going to the hospital. DON B reported that she went to look at Resident #100, remembered her arm was swollen, and the nurse had gotten an order to transfer her to the hospital for treatment. DON B reported that her expectations for contacting the on-call provider was to call and speak to them. DON B reported that if the nurse had to leave a voice mail for the on-call provider her expectation was that the nurse would call back until they spoke with an on-call provider. DON B reported that if the nurse could not get ahold of the on-call provider, the nurse should call her, she was available 24 hours a day, 7 days a week. This surveyor while on the phone with DON B read the progress note entries for Resident #100 from the dates of [DATE] and [DATE] and DON B reported that her expectations were that the nurse should have continued to try to contact the on-call provider regarding Resident #100's condition. DON B reported that nurse definitely should have called back to the on-call provider after the repeated blood pressure readings were low and Resident #100 should have been sent out to the hospital long before she was sent. DON B reported that Resident #100's blood pressure readings were low enough to be emergent and the nurse should have sent he to the hospital when her blood pressure readings did not improve. In a telephone interview on [DATE] at 3:57 PM., Certified Nurse Assistant (CNA) N reported that she recalled on the day Resident #100 was sent to the hospital from the facility, Resident #100 looked very pale, and she was very nauseous. CNA N stated I remember the nurse telling me Resident #100 was being sent to the hospital. I remember I checked her vitals and got her ready for the hospital, Resident #100 had loose stools (diarrhea), her blood pressure was very low, and her heart rate was high. In a telephone interview on [DATE] at 4:18 PM., CN D reported that she worked with Resident #100 on the night shift before she was transferred to the hospital. CN D reported that she made a note in the doctor book that Resident #100's arm was swollen. CN D reported that Resident #100's blood pressure was low, and she contacted the on-call provider. CN D reported that on-call provider gave her orders to push fluids, lay her head flat, and elevate her legs. CN D reported that she felt that Resident #100 needed to go to the hospital, and that her blood pressure was too low. This surveyor asked CN D if she called any nursing managers, or Resident #100's family, or the on-call provider again and CN D stated I don't remember calling anyone else, but I spoke to the other nurses, and no one said to do anything else. CN D stated, I learned after that night, you can call the family and ask would they want their family member sent to the hospital. CN D stated I don't know if I should have called back again and again to try to convince the on-call to send her (Resident #100) to the hospital, but I just monitored her all night. Review of ED Provider Note dated [DATE] revealed . diagnosis septic shock, urinary tract infection without hematuria (blood in the urine), Cellulitis of the left upper extremity, lactic acidosis, elevated liver function tests, AKI (acute kidney injury), Sepsis with multi-organ dysfunction . Review of H&P Notes dated [DATE] at 19:55 PM., revealed .speak with patient's family who stated they saw her on Friday (,d+[DATE]) and that at that time she was able to ambulate and that her left arm had the healing wound but that it was not erythematous. They stated that she typically has some swelling in that forearm (midway) and hand that worsens with ambulating when she lets it hang down . Review of Critical Care History and Physical Exam dated [DATE] at 10:16 PM., revealed . 65 yo (year old) F (female) presented to (Name Omitted) ED (emergency department) ,d+[DATE] for generalized weakness, diarrhea, and abdominal pain. Hx (history of) L (left) forearm pressure ulcer now appearing cellulitic for the past several days. She was hypotensive on arrival, received 3L (liters) of IVF (intravenous fluids) .for septic shock. Urinalysis without a clean sample, nitrite positive however not convincing for infection, only other current source is LUE (left upper extremity) cellulitis . Review of ED to hosp-admission . dated [DATE] at 11:17 AM., revealed .patient's vitals are significant for severe hypotension of ,d+[DATE] .patient is significantly ill appearing pale .pulses are weak though 1+ .immediate concern for septic shock related to infection, likely cellulitis of the left upper extremity . patient leaving with EMS, vitals currently stable . Review of Physician Discharge as deceased Summary dated [DATE] at 6:17 AM., .admitted [DATE] .reason for admission septic shock .not long after ICU arrival pt lost pulses, PEA (pulseless electrical activity, a type of cardiac arrest that occurs when the heart stops beating due to weak electrical activity) arrest . ROSC (return of spontaneous circulation) was achieved after 10 minutes .discussed care with family member who requested that patient be made a DNR (do not resuscitate) .was noted to be in asystole again at 0611 when TOD (time of death) was called, patient without any heart tones auscultated, no central pulses .

This citation pertains to Intake MI00144494 Based on interview and record review the facility failed to prevent the worsening of a pressure ulcer in 1 (Resident #101) of 2 residents reviewed for pressure ulcers resulting in Resident #101 being sent to the hospital for evaluation and/or treatment. Findings include: Resident #101 Review of an Admission Record revealed Resident #101 had pertinent diagnoses which included: pressure ulcer of the sacral region stage 4, osteomyelitis of the vertebra, sacral and sacrococcygeal region (infection of the vertebra bone in the sacral region), and functional quadriplegia (the complete inability to move). Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 4/11/24 revealed a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated Resident #101 was cognitively intact. Review of Wound Measurement 2.2 for Resident #101 dated 4/11/24 15:32 PM., revealed .sacral wound measures 13.9 X 14.6 X 4.2 stage IV present on admission .wet to dry dressing removed and wound vac placed as per hospital orders . Review of Office Visit (Name Omitted) for Resident #101 dated 4/19/24 revealed .Physical exam .wound length 10.6 cm (lying on left side), wound width 11 cm, wound depth 4.2cm .Negative Pressure Wound Therapy (wound vac, machine to apply constant pressure to a wound to promote healing) sacrum mid wound vac placement date 4/19/24 .cycle is continuous, target pressure is 150mm/HG . no signs of infection .Negative dressing pressure machine to sacral wound: cleanse with saline .apply adaptic to exposed bone, apply santyl (nickel thickness) to wound bed and NPWT (negative pressure wound therapy) at 150 mm/HG, change 3 x (times) a week and as needed . Review of Wound Measurements 2.2 for Resident #101 dated 4/19/24 14:49 PM., revealed .sacrum to coccyx wound-measuring 10.6 X 11X 4.2 .Large amount of tan serosanguineous (tan in color) drainage noted . Review of Wound Measurements 2.2 for Resident #101 dated 4/29/24 13:50 PM., revealed . sacrum to coccyx wound - measuring 13.6 X 14.2 X 3 . large amounts of tan serosanguineous drainage noted . Review of Wound Measurements 2.2 for Resident #101 dated 5/3/24 14:56 PM., revealed .new area observed to L (left) buttock during skin check. Area measured 2 X 4.8 X 0.1, areas is superficial, no drainage . Review of Physician Orders for Resident #101 dated 5/8/24 revealed .sacrum-cleanse with normal saline pack Dakins soaked kerlix wound, cover with ABD (abdominal) and secure with tape and change daily and PRN (as needed) . dated 5/9/24 .wound consult and possible surgical consult for pt (patient) bilateral lower extremities. Pt. has swelling on both feet and blisters under great toes . Review of Office Visit (Name Omitted) for Resident #101 dated 5/10/24 revealed .Left ischial (area of the buttock that covers the pelvic bone) wound, Stage 4 Sacral ulcer, malodor (foul odor), Left plantar (bottom of the foot) blister, Right heel pressure ulcer, Blister to right D1-D5 (base of the toes on the right foot) Erythema (redness) to the base of the right great toe . Patient with worsening sacral wound with known osteomyelitis. She is c/o (complaint of) nausea, fever, chills, and sweats. I feel it is prudent to ensure patient is not becoming septic (systemic infection of the blood). Updated the ER and we will send her by non-emergent EMS (emergency medical services). Review of Physician Orders for Resident #102 revealed .5/10/24: VO/TO (voice order/telephone order) transfer to ED (emergency department) for evaluation and treatment ordered on 5/13/24 . In an interview on 7/3/24 at 8:29 AM., Certified Nurse Assistant (CNA) J reported that Resident #101 had a wound on her buttock with a wound vac. CNA J reported that the wound vac was making the wound worse because the wound vac would dislodge from the wound. CNA J reported that Resident #101 was not able to reposition herself in bed or in the wheelchair, and she could wash her face, but not much else. CNA J reported that Resident #101 was dependent for all her cares. CNA J reported that Resident #101 did not like to get out of bed and when she was in her wheelchair she didn't like to go back to bed. CNA J did not indicate where this would be documented in the medical chart. In an interview on 7/3/24 at 8:43 AM., Licensed Practical Nurse (LPN) K reported that Resident #101 had a large wound on her buttock and had a wound vac. LPN K reported that the wound vac was making her wound worse. LPN K reported that Resident #101 did not like to be turned or repositioned in bed or in her wheelchair because it hurt her to move. LPN K reported that Resident #101's lack of turning and repositioning could contribute to the wound deteriorating, and continuing to have pressure on an existing wound would continue to cause the wound to get worse. LPN J did not indicate why this was not documented in the medical chart In an interview on 7/3/24 at 9:37 AM., Nurse Practitioner (NP) Q reported that Resident #101 had a wound on her sacral region, with a wound vac, that did get worse while she was in the facility. NP Q reported that she was unaware if Resident #101 allowed staff to provide care and position her. In an interview on 7/3/24 at 10:04 AM., Clinical Care Coordinator (CCC) I reported that Resident #101 was admitted with a stage 4 sacral wound and the wound vac was applied when she admitted to the facility. CCC I reported that Resident #101's wound was getting worse. CCC I reported that Resident #101 did not like to be positioned off her wound. CCC I reported that Resident #101 would tell staff no when staff asked to reposition her off her wound area. CCC I reported that Resident #101 was not being turned or repositioned as frequently as she should have been. CCC I reported that Resident #101's wound did deteriorate while she was in the facility and that she was developing other wounds where the wound vac drape was positioned. Review of Care plan for Resident #101 initiated 4/12/24 revealed focus .potential risk for impaired skin integrity related to stated IV pressure wound to sacrum .will show improvement of impaired skin integrity as evidence by no s/s (signs and symptoms) of infection and decreased measurements and/or prevention of avoidable impaired skin integrity .Interventions .assist with re-positioning with use of draw sheet as needed .bridge heels in bed if indicated .measure open areas on admission and weekly, PRN (as needed), pressure reducing cushion to wheel chair .pressure reducing mattress . Review of Care Plan for Resident #101 revealed no noted care plan interventions related to turning scheduled, repositioning schedule, wound vac use, or resident's choices or preferences related to mobility, repositioning, and/or turning. No noted care plan intervention related to resident refusal to be turned or repositioned in bed or wheelchair. No noted care plan related to the use of a wound vac. In a telephone interview on 7/3/24 at 1:50 PM., Registered Nurse (RN) G reported that Resident #101 didn't like to be moved or repositioned, it hurt her. RN G reported that she educated Resident #101 on the benefits of moving and repositioning off her wound. When asked by this surveyor if RN G documented Resident #101 preference to not be repositioned, RN G replied I do not recall documenting refusal of care. In an interview on 7/3/24 at 1:59 PM., CCC I reported that Resident #101 didn't like to be positioned on her sides, she didn't like to be moved, it hurt her. CCC I reported that Resident #101 preferred to be on her back when in bed and/or sitting in her wheelchair. This surveyor asked CCC I if the staff documented that Resident #101 was refusing to be repositioned in bed or in her wheelchair. CCC I reported she would find out where the refusal of care was documented. In an interview on 7/3/24 at 3:00 PM Nursing Home Administrator (NHA) A and CCC I were in NHA's office, and both were unable to provide any documentation that Resident #101 refused to be repositioned by staff in her bed and/or in her wheelchair. NHA A and CCC I were unable to provide a care plan for Resident #101 that had resident specific interventions related to positioning in bed and wheelchair.

This citation pertains to intake numbers MI00143061 and MI00143279. Based on interview and record review the facility failed to ensure that staff followed care planned interventions and professional standards of care for 2 residents (Resident #1 & #3) out of 5 residents reviewed for accidents and hazards, resulting in major injuries (fractures) after avoidable falls. Findings: Resident #1 (R1) Review of an admission record reflected R1 admitted to the facility with the following pertinent diagnoses: muscle weakness, abnormalities of gait and mobility, erosive osteoarthritis, difficulty walking and a need for assistance with personal care. Review of a Care Plan initiated on 12/13/2021 reflected R1 had Altered functional mobility and ADL's (Activities of Daily Living) related to her diagnoses. The care plan specified that R1 was to ambulate with therapy only (intervention initiated 6/19/23 and resolved on 2/26/24). FALL RISK MANAGEMENT interventions included in the ADL care plan indicated R1 was to have one person assistance with transfers. The care plan also indicated Resident (R1) chooses to walk with walker or push wheelchair on occasion even with reminding her that she needs assistance in facility with walking. Review of a Care Plan initiated on 12/14/21 reflected R1 was at risk for falls or injury related to impaired mobility. The goal of the care plan was to provide individualized interventions to attain the resident's (R1's) highest practicable well-being in keeping with their preferences and assessment for independence. Interventions to meet the goal included instructions for staff to refer to the ADL care plan for fall risk interventions. Review of a Witnessed Fall incident report dated 2/19/24 reflected Registered Nurse (RN) J was called to the room by Certified Nurse Aide (CNA) after R1 had fallen. The Resident Description reflected Resident stated that she was walking to her wheelchair, and she fell as she was turning around and fall forward on her right side. Resident stated, 'I hit my head and my hip hurts'. Review of a Facility Reported Incident (FRI) dated 2/19/24 reflected (R1) had a fall that resulted in fracture. (R1) had to use the restroom and was being assisted by (CNA T). As (CNA T) was assisting (R1) back to her bed from the bathroom, she attempted to lock the wheelchair which resulted in her letting go of (R1's) hand, and (R1) then lost her balance and fell to the floor. The investigation report revealed CNA T admitted she did not review R1's care plan prior to providing assistance to R1, did not use a walker, and did not use a gait belt. R1 was diagnosed with a right femur fracture that required surgical intervention to repair. During an interview on 3/14/24 at 7:25 a.m., R1 confirmed the details of the fall that resulted in her broken leg on 2/19/24. R1 said CNA T did not use a gait belt during the transfers and said she did not have her walker with her during the trip to the bathroom on 2/19/24. Resident #3 (R3) Review of an Admission Record revealed R3 admitted to the facility with pertinent diagnoses that included: bipolar disorder, morbid (severe) obesity and dementia. Review of a Witnessed Fall incident report dated 3/1/24 reflected R3 sustained a fall from her bed when CNA K was changing R3 in the bed, rolled to her side away from her. R3 rolled off the bed and onto the floor. Investigation details included with the incident report reflected the following: Upon interview (CNA K) she stated that (R3) was in the bed and she was providing peri care. (CNA K) stated that the last time she rolled her to pull her pants up, the (R1) off the bed (sic), she tried to grab her by the back of her pants, but she (R1) kept going and landed onto the floor and onto her knees. The facility received notification from a hospital at 12:35 p.m. that R3 suffered an acute moderately displaced comminuted fracture of the distal femur (a broken leg). She (R3) also suffered a mild irregularity along the medial epicondyles may reflect acute mildly displaced fracture of the left elbow. During an interview on 3/14/24 at 2:10 p.m., the Director of Nursing (DON) reported that she was the first person to respond to CNA K's request for help after R3 rolled off the bed on 3/1/24. According to the DON, after R3 was stabilized and sent to the hospital, she interviewed CNA K who said that she rolled R3 away from her while providing peri care in the bed. When asked, the DON did not report any concerns with the technique CNA K used to care for R3 while rolling her in the bed. During an interview on 3/14/24 at 2:20 PM, Regional Nurse Consultant (RNC) V said she knew the standard of care while providing bed mobility with the assist of one staff person was to roll a resident/patient toward the caregiver and never away from the caregiver. If resident care cannot be provided while rolling the person toward that caregiver, then a second person should assist, to prevent the person from falling from the bed. RNC V said the facility reported R3's fall that resulted in fractures to the State Agency (SA) because she knew the standard of care had not been followed. RNC V and the DON both reported that facility wide education to all staff regarding the standard of care pertaining to bed mobility with one person assistance had not been started.

This citation pertains to intake MI00133951. Based on interview, and record review, the facility failed to implement fall interventions (utilize 2 staff for a 2 person transfer/assist with shower) for 1 of 3 residents (Resident #101) reviewed for accidents and hazards, resulting in a fall with a fracture of the left hip for Resident #101. Findings include: Review of an Admission Record revealed Resident #101, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: history of stroke affecting left side. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 11/28/22, revealed a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated Resident #101 was cognitively intact. In an interview on 1/31/23 at Resident #101 reported she was getting a shower last month with Certified Nurse Aide (CNA) P. Resident #101 reported she was sitting in a shower chair, and had leaned forward to dry her hair, and all of a sudden the chair must of tipped forward and she started to fall forward. Resident #101 reported (CNA P) tried to prevent the fall, but it all happened so fast. Resident #101 reported (CNA P) immediately called for help, other staff and nurses came, assessed her and got her up. Resident #101 reported it was just an accident, (CNA P) did not do anything to hurt, or harm her. Resident #101 reported she broke her hip, but is now doing well, and can bear weight on it as tolerated. Review of a Facility Reported Incident (FRI) investigation dated 12/12/2022 revealed: Investigation: Statements from staff: Licensed Practical Nurse (LPN) M Staff Interview: (LPN M) Upon interview with (LPN M), she stated that on 12/11/22 she (LPN M) heard (CNA P) yelling for help from the shower room. (LPN M) stated that she ran down the hall to the shower room and when she entered, she observed (Resident #101) on the floor of the shower room, and she was halfway still in the shower chair, the top half of her body, and the bottom half on the floor, with the shower sling still underneath her. (CNA P) stated to (LPN M) that (Resident #101) fell forward and she (CNA P) couldn't catch her. (LPN M) stated that as she had entered another CNA (CNA L), heard (CNA P) calling for help as well, and ran to the shower room to see what was needed. (LPN M) stated that she and (CNA L) pulled the shower chair from underneath (Resident #101) as it was half tipped over and (Resident #101) was hanging off it and assisted (Resident #101) to a lying position on the floor so that she could assess her. (LPN M) stated that she assessed (Resident #101) extremities. (Resident #101) complained of left knee pain upon assessment and back pain. (LPN M) instructed (CNA L) to support (Resident #101) left knee at that time for comfort. No bruising or swelling noted to the knee. (LPN M) performed ROM to the left leg, and (Resident #101) complained of pain, but only to the knee. (LPN M) stated that (Resident #101) has chronic pain to this knee per her baseline, and no signs or symptoms of fracture or dislocation were observed to her knee. She (LPN M) stated that (Resident #101) did complain of a headache, as she stated that she hit her head on the wall when she fell . (LPN M) initiated neuro checks at that time .(Resident #101) had no complaints of pain or discomfort to any other area at that time, but (LPN M) assessed her back and did observe some bruising beginning to form on her back and wrapping to her left hip (Resident #101) stated that her headache had subsided and had no further c/o knee pain. Head to toe assessment performed and there were no signs or symptoms of fracture or dislocation observed at the time of assessment (Resident #101) has chronic residual pain to her left side secondary to CVA. She (Resident #101) takes routine pain meds and receives gel (pain medication lotion/gel) topically to her left leg and knee, which are the areas she (Resident #101) has the most pain. Noted purple discoloration to left hip/buttocks. Slight swelling observed, though (Resident #101) has swelling and pain to her left side which is chronic and her baseline. (CNA P) was with resident when fall occurred and stated that (Resident #101) hit her head on the shower wall when she fell . (Resident #101) required assist x3 including mechanical lift to get up from ground and into her wheelchair Staff interview (Certified Nurse Aide-CNA P) Upon interview with (CNA P) on 12/14 she (CNA P) stated that while in the shower room, she (CNA P) had washed (Resident #101) body and washed her (Resident #101) hair as well. (CNA P) stated that she was pulling the shower chair towards her (CNA P) to get (Resident #101s) hair dried, and she (CNA P) does not know exactly what caused the chair to tilt forward, but it did, and she (CNA P) believes that the loop from the shower sling got in front of the wheel, causing the chair to tip forward, but (Resident #101) fell forward halfway out of the chair and onto the floor. (CNA P) stated that she tried to stop or lower (Resident #101) to the floor as best as she (CNA P) could to keep her (Resident #101) from falling. When asked how (Resident #101) transfers, (CNA P) stated that she (Resident #101) is a two-person mechanical lift for transfers. (CNA P) stated that (Resident #101) is a 2 person for showers as well, though she (CNA P) performed her (Resident #101) shower by herself (CNA P) . Staff Interview (CNA L) Stated she (CNA L) heard (CNA P) yelling for help and she (CNA L) immediately responded and went into the shower room. She (CNA L) observed (Resident #101) halfway on the shower chair and half on the floor. She (CNA L) stated that she (CNA L) then assisted the charge nurse (LPN M) with lying (Resident #101) on the floor and the nurse assessed her and then she (CNA L) assisted with getting the sling beneath (Resident #101) and transferring her from the floor into her (Resident #101) wheelchair and then into bed Conclusion: Despite the facility preference of having two staff members present for bathing (through staff interviews several staff members were available to assist), (CNA P) chose to bath (Resident #101) independently which resulted in a fall from the shower chair with fracture. The facility can validate the care plan was not followed and there was no willful intent to abuse or neglect the resident (Resident #101). The resident (Resident #101) does not allege abuse and states the event was an accident . In an interview on 2/1/23 at 3:15 PM., Nursing Home Administrator (NHA) A reported the incident that happened on 12/12/2022 that resulted in a fall with a fracture for (Resident #101) was due to (CNA P) not following (Resident #101's) care plan and using 2 staff to shower (Resident #101). NHA A reported a throughout investigated was completed and reported to the State Agency. NHA A reported the facility immediately held in-services, and training for all staff on the importance of following resident care plans, and making sure to ask for help when needed. NHA A reported audits, training and updating care plans is an ongoing Quality Assessment and Assurance (QAA) Quality Assurance and Performance Improvement (QAPI) discussion and plan to reduce falls, falls with injury and following the person centered resident Care Plans. The facility was granted a Past Noncompliance as they had corrected the noncompliance prior to survey entry and sustained compliance thereafter.

Based on observation, interview and record review the facility failed to ensure residents received care in accordance with physician orders [REDACTED].#12) reviewed for quality of care, resulting in Resident #12's skin condition worsening. Findings Include: Review of a facility policy Skin at Risk Assessment last revised (MONTH) (YEAR) 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 as risk of impaired skin integrity corresponding to risk factors .The following guidelines are reviewed and implemented as indicated for each individual risk factors: a. Daily skin inspections with am and pm care .5. Individualize the resident goals and interventions as documented on the plan on care. According to Fundamentals of Nursing 9th edition, The quality of patient care depends on your ability to communicate with other members of the health care team. Regardless of whether documentation is entered electronically or on paper, each member of the health care team needs to document patient information in an accurate, timely, concise, and effective manner to develop and maintain an effective, organized, and comprehensive plan of care. When a plan is not communicated to all members of the health care team, care becomes fragmented, tasks are repeated, and delays or omissions in care often occur. Potter, [NAME] [NAME]; Perry, Anne Griffin; Stockert, [NAME]; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition. Resident #12 Review of a Face Sheet revealed Resident #12 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 #12, with a reference date of 9/11/2019 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #12 was cognitively intact. Review of the Functional Status revealed that Resident #12 required extensive assistance with hygiene. Review of Care Plan date initiated 2/2/2014 last revised 4/25/2018 revealed, (Resident #12) has the potential risk for impaired skin integrity related to: History of seborrheic [MEDICAL CONDITION], psoriasis .She has chronic redness to groin area where she sees her dermatologist .Interventions: Skin inspections with am/pm care and showering report abnormal to the charge nurse Date Initiated: 02/02/2014. This care plan indicated no interventions developed for Resident #12's psoriasis that was present in her skin folds. Review of Resident #12's Written Medication Prescriptions scanned into her electronic health record dated 9/5/19 revealed, 1). [MEDICATION NAME] 0.005% topical ointment mix 1:1(equal amounts) with [MEDICATION NAME]. 2). [MEDICATION NAME] 0.025% topical ointment mix 1:1 with [MEDICATION NAME]. Review of a Dermatology Record of Consultation Services for Resident #12 dated 9/5/19 revealed, new orders were to mix [MEDICATION NAME] ointment equal amounts with [MEDICATION NAME] ointment and apply to affected areas on arms, trunk, neck, groin, etc. twice daily until clear, then use [MEDICATION NAME] ointment by itself daily and add [MEDICATION NAME] ointment as needed for flare ups of Resident #12's Inverse Psoriasis. Inverse psoriasis (also known as intertriginous psoriasis) shows up as very red [MEDICAL CONDITION] in body folds. It may appear smooth and shiny . Because the skin is thinner in areas that typically have inverse psoriasis, the risk of side effects from topically applied medicine increases. This is due to the rapid absorption of medication in thin, sensitive skin. Overuse or misuse of steroids can further thin the skin and cause stretch marks. According to the National Psoriasis Foundation https://www.psoriasis.org/about-psoriasis/types/inverse. Copyright 1996-2019 Review of Resident #12's Physician order [REDACTED]. This order indicates that the physicians written order was transcribed incorrectly as [MEDICATION NAME] (a high potency steroid) instead of instead of the correct medication [MEDICATION NAME] (a mild potency steroid). During an interview on 09/18/19 at 07:57 [NAME]M., LPN [NAME] reported that two topicals were being applied to Resident #12 for the skin condition present in her skin folds. LPN [NAME] then showed this surveyor a tube of [MEDICATION NAME] ointment 0.005% and [MEDICATION NAME] ointment 0.05% and reported that these were the topical medications that were currently being administered. Indicating that [MEDICATION NAME] ointment 0.05% was being applied topically. LPN [NAME] reported that the nurses transcribe all paper prescription medication orders that come from outside providers, into the electronic physician orders [REDACTED]. Review of Resident #12's Medication Administration Record [REDACTED]#12 only received the medication one time, due to missed P.M. doses. Indicating that Resident #12 was administered [MEDICATION NAME] (a high potency topical steroid), instead of the correct medication, [MEDICATION NAME] (a mild potency topical steroid), for 22 doses over 12 days. Review of Resident #12's Physician order [REDACTED]. (Inter Dry is a moisture-wicking fabric containing antimicrobial silver. The fabric wicks away moisture so your skin stays dry and helps eliminate skin-on-skin friction). According to Fundamentals of Nursing 9th edition, Patients with large abdominal skinfolds are at high risk for moisture within the skinfolds. This moisture promotes the growth of bacteria and fungi, which contribute to rashes and infection (Rush and Muir, 2012). Excessive moisture may cause maceration of the skin or softening of the tissues, resulting in an increased risk for breakdown (see Chapter 48). Potter, [NAME] [NAME]; Perry, Anne Griffin; Stockert, [NAME]; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition. During an observation on 09/16/19 at 11:23 [NAME]M., Resident #12 was resting in her bed. Her entire front neck fold was observed to be bright red and weeping. There was no Inter Dry cloth observed. During an observation on 09/17/19 at 07:59 [NAME]M., Resident #12 was resting in her bed. Her entire front neck fold was observed to be bright red and moist. There was no Inter Dry cloth observed. During an observation and interview on 09/17/19 at 05:16 P.M., Resident #12 observed in her room in bed. Her entire length of neck fold (approximately 6x 5) was exposed and was bright red, wet, with no Inter Dry cloth observed. Resident #12 reported that the skin on her arms was getting better, but pointed to her neck and stated That is getting worse. During an interview on 09/17/19 at 05:19 P.M., LPN D stated, (Resident #12's) neck is getting worse .we think its allergies [REDACTED].there is a new order for Inter Dry, but I don't think we have that yet. During an interview on 09/18/19 at 07:57 [NAME]M., LPN [NAME] stated, I just found out today that we should have been putting the Inter Dry cloths in (Resident #12's) neck skin fold. During an interview on 09/18/19 at 02:10 P.M. LPN [NAME] reported that Resident #12's skin was doing better for a while, then on 9/9/19 her neck fold started to worsen. Indicating that Resident #12's skin condition was noted to be worsening after 3 days of receiving the incorrect topical medication. Review of Skin assessment dated [DATE] at 1:22 P.M., indicated that the redness to neck had significantly decreased to small quarter sized areas. There were no recorded skin assessments from 8/27/19-9/1/19. Review of Skin assessment dated [DATE] at 11:50 P.M., indicated that the visible skin on assessment was normal. There were no recorded skin assessments from 9/3/19-9/15/19. Review of Skin assessment dated [DATE] at 1:10 P.M., indicated that redness remained to bilateral axilla(armpit)/ bilateral antecubital (crease where arm bends)/ abdominal folds/ breast line/ peri (genital) area/neck fold. Indicating that the skin redness had been present prior to this assessment. During an interview on 09/18/19 at 09:55 [NAME]M., Clinical Care Coordinator (CCC) I reported that the pharmacy confirmed receiving both paper and electronic prescription orders for Resident #12's topical medications on 9/5/19 and filled the order based on the electronic order. Indicating that the facility would have then received [MEDICATION NAME] instead of the correct medication [MEDICATION NAME]. During an interview on 09/18/19 at 10:00 [NAME]M., CCC I reported that the medication transcription error should have been identified by the pharmacist that filled the medication and by the pharmacist that performed the Monthly Medication Regimen Review on 9/15/19. Review of a Pharmacy Medication Regimen Review for Resident #12 dated 9/15/2019 revealed, No Irregularities. This pharmacy medication regimen review indicated that the pharmacist did not find any concerns with Resident #12's MEDICATION ORDERS FOR [REDACTED] During an interview on 09/18/19 at 10:05 [NAME]M., CCC I reported that Resident #12's dermatologist, the prescribing physician was notified of the medication order error and expressed that he wanted the resident to have [MEDICATION NAME] ointment as originally ordered and not to use the [MEDICATION NAME] ointment going forward.

This citation pertains to intake # MI 356. Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a fall with fracture in 1 of 3 residents (Resident #702) reviewed for falls, from a total sample of 3, resulting in a fall with a [MEDICAL CONDITION] and a significant change in health status. Findings include: Review of a facility policy and procedure for Accident/Incident Report Fall Management, revised 6/18, revealed .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; falls; and resident to resident altercations .To establish a standard for accident/incident completion and to evaluate the facility responsibility to make every effort to decrease the likelihood of a recurrence by investigating incidents, understand how they occur and applying appropriate action .It is recognized that not all falls can be prevented, the facility will utilize applicable elements of the systematic process of assessment, intervention, and monitoring to minimize fall risk and injury including: a. Fall risk screening b. Care plan interventions c. Evaluation of the response to interventions and balancing risk with the residents right to self-determination and independence d. Comfort Rounds and promotion of a culture of safety e. Assessment of sensory contributors f. Medication Review g. Orthostatic [MEDICAL CONDITION] h. Behavioral and [DIAGNOSES REDACTED]. Review of an Admission Record revealed Resident #702 was an [AGE] year-old female, originally admitted to the facility on [DATE] with a readmission date of [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Progress Note for Resident #702, dated 8/17/18, revealed .observed in her bathroom lying on her rt. (right) side and back. She was assessed, She has a bump noted to back of head and her rt. foot has outer external rotation out, V/s (vital signs) 98.5-18-72-156/78, sats 96%, BS 101. Physician, MDS and Family were notified and she was picked up at 17:40 by EMS and sent out .hospital called with update, she has a fx (fracture) to Rt. Femur and Hematoma to back of head and they will keep her overnight . Review of a Minimum Data Set (MDS) assessment for Resident #702, with a reference date of 5/29/18, revealed a Brief Interview for Mental Status (BIMS) score of 7, out of a total possible score of 15, which indicated severe cognitive impairment, and required supervision to limited assist with walking. Review of a MDS assessment, with a reference date of 8/27/18, revealed Resident #702 did not walk in either her room or the corridor during the entire 7-day lookback period from 8/21/18 to 8/27/18. Note Resident #702 readmitted to the facility from the hospital on [DATE]. Review of a current Care Plan for Resident #702 revealed the focus .(Resident #702) has the potential for altered mobility and ADL's (Activities of Daily Living) related to: [MEDICAL CONDITION] (the buildup of substances on the walls of arteries), Generalized muscle weakness, Hypertension (high blood pressure), [MEDICAL CONDITION] (low blood pressure), Dizziness, [MEDICAL CONDITION] (slow heart rate), Rheumatic Mitral Valve Disease (a disease of the heart), [MEDICAL CONDITION], dementia without behavioral disturbance .She is A&O (alert and oriented) x2 with intermittent confusion and forgetfulness . with interventions which included .ABLE TO LEAVE ON TOILET: No . with an initiated/revision date of 4/3/17. Review of a current Care Plan for Resident #702 revealed the focus .(Resident #702) has the potential for falls or injury related to: [MEDICATION NAME] therapy (treatment to prevent the formation of clots), disease process of [MEDICAL CONDITION], Generalized muscle weakness, Hypertension, [MEDICAL CONDITION], Dizziness, [MEDICAL CONDITION], Rheumatic Mitral Valve Disease, [MEDICAL CONDITION], dementia without behavioral disturbance, and use of medications which may increase the risk for dizziness or drowsiness, and self-determination to self transfer without staff assistance and even after education has been provided . Review of a Fall Management assessment, dated 5/29/18, revealed .(Resident #702) is alert and oriented x2 with periods of forgetfulness. She is able to voice her needs to staff. She requires assist of one for her ADL's per staff report. Ambulation via walker, SBA (stand-by assist) .(Resident #702) has self-determination to self-transfer without asking staff for help .(Resident #702) is at risk for falls . Review of an Accident/Incident Report revealed Resident #702 had an un-witnessed fall and was observed on 8/17/18 at 4:50 p.m. by Certified Nursing Assistant (CNA) I lying on the floor in the bathroom. Per the report Resident #702 .stated 'I was in the bathroom using the toilet and was going to sit back in my chair and I was next on the floor'. (Resident #702) is alert and oriented times one. She is able to voice her own needs. She is the assist of one, with transfers and adls . Review of a hospital Discharge Summary, dated 8/20/18, revealed .Patient is an [AGE] year-old woman .who presented to the emergency department following a ground level fall .At the time of presentation, she was noted to have a subdural hematoma and a right [MEDICAL CONDITION] . Review of an investigation summary for Resident #702's fall on 8/17/18 at approximately 5:00 p.m. revealed .(CNA I) went into (Resident #702's) room to see if she was ready to go to dinner. She did not see (Resident #702) in her room, so she knocked on the bathroom door and called (Resident #702's) name, and entered the bathroom to observe (Resident #702) on the floor of the bathroom, lying on her back, and lying more on her right side with legs slightly bent. She immediately went and got the charge nurse (Licensed Practical Nurse (LPN) H), who immediately responded to the room and assessed (Resident #702) .MD notified, an order obtained to send to ER for further evaluation of right leg, following fall .Hospital notified facility at 1930 (7:30 p.m.), that (Resident #702) had incurred a right femur fracture and a small subdural hematoma without midline shift .(Resident #702) was going to undergo a pinning for her hip the next morning, and per neurology orders, she was to receive no surgical intervention for the hematoma .When (Resident #702) was asked what she was doing, she stated that she was attempting to go to get back in her wheelchair after using the toilet, unassisted, when she fell to the floor. The wheelchair was observed to be unlocked upon assessment .She (Resident #702) is alert and oriented times one only and scored a 07/15 on her last BIMS. She is able to voice her own needs. She requires the assist of one with transfers and activities of daily living. She has a history of self-transfers and self-transfer attempts, secondary to her impaired cognition. (Resident #702) does not understand her safety limitations . Further review of an investigation summary for Resident #702's fall on 8/17/18 at approximately 5:00 p.m. revealed .On 8/17/18 (Resident #702) went to activities around 1430 (2:30 p.m.), which is her norm, to attend morning and afternoon activities. The activities department brought her back to her room, around 1600 (4:00 p.m.) and left her in her room up in her wheelchair, per her usual. A little while later (Resident #702) attempted to self-transfer to the bathroom, and did not place her call light on. As an intervention anti-roll backs will be added to (Resident #702's) wheelchair and resident will be encouraged to use the toilet after she returns from activities . No mention was made of the name of the activities staff member who returned Resident #702 to her room in the afternoon on 8/17/18, prior to Resident #702's fall, and no statement was documented in the Accident/Incident Report from an activity staff member as part of the investigation. In an observation on 9/6/18 at 9:02 a.m., observed Resident #702 in bed in her room wearing a hospital-style gown, with both hands holding onto her right assist bar. Resident #702 appeared restless, and was frequently shifting her position in bed. In an interview on 9/6/18 at 9:02 a.m., Resident #702 stated .I guess I fell .that's what they told me . in regard to how she injured her hip. Resident #702 was unable to provide any further details in regard to her fall with a fracture on 8/17/18. In an interview on 9/6/18 at 10:54 a.m., LPN H reported that he was notified of Resident #702's fall by CNA I. LPN H reported that he observed Resident #702 on the floor in the restroom, and that Resident #702 complained of leg pain. LPN H stated .(CNA I) said she didn't take her in there . LPN H reported that Resident #702's roommate was not in the room at the time of the fall, and stated .If she was I probably would have questioned her . LPN H reported that Resident #702 had used her wheelchair to go to the bathroom, which he noted in the bathroom near the doorway when he entered the room to assess the resident. In an interview on 9/6/18 at 11:32 a.m., Director of Nursing (DON) B reported that the activity aide who returned Resident #702 to her room on 8/17/18 was Activity Aide F. In an interview on 9/6/18 at 11:52 a.m., Activity Aide F reported that she had returned Resident #702 to her room on 8/17/18 at approximately 3:45 p.m. Activity Aide F reported that she had assisted Resident #702 to the bathroom with a gait belt and a walker. Activity Aide #702 reported that the resident stated .I'll be fine . so Activity Aide F reminded the resident to pull the call light cord in the bathroom when she was done and left the resident alone in the bathroom. Activity Aide F reported that she notified a CNA that Resident #702 was in the bathroom, but did not recall who she notified. Activity Aide F reported that at the time she assisted Resident #702 to the bathroom, the resident was safe to be in the bathroom unsupervised. In a second interview on 9/6/18 at 12:10 p.m., Activity Aide F reported that she thought the care plan stated it was safe to leave Resident #702 on the toilet unsupervised. Activity Aide F stated .apparently it never said that . and reported that she should not have left Resident #702 unsupervised on the toilet on 8/17/18. In an observation on 9/6/18 at 12:12 p.m., observed a Care Plan posted on the interior surface of Resident #702's closet door, which contained the statement .ABLE TO LEAVE ON TOILET: No . with an initiated/revision date of 4/3/17. In an interview on 9/6/18 at 12:20 p.m., DON B reported that for Resident #702's fall on 8/17/18, the wheelchair was beside the toilet, not Resident #702's walker. DON B reported that Resident #702 being left unsupervised in the bathroom by Activity Aide F on 8/17/18 at 3:45 p.m. was a .separate episode . and non-contributory to Resident #702's fall in her bathroom on 8/17/18 at 4:50 p.m. DON B reported that Resident #702 should be supervised by staff when in the bathroom. DON B reported that at the time of the investigation, Resident #702 had stated she had taken herself to the bathroom and the CNA's on the unit had reported they were unaware Resident #702 had returned from activities. DON B reported that due to this information, she did not dig deeper into the involvement Activity Aide F may have had in the incident. In an interview on 9/6/18 at 12:38 p.m., CNA I reported that on 8/17/18 at approximately 4:45 p.m. she went to Resident #702's room to take the resident down to dinner. CNA I reported that Resident #702's roommate was in the room, and that the roommate did not know where Resident #702 was. CNA I reported she heard someone calling .help, help . from in the bathroom, and when she opened the door observed Resident #702 on the floor in the bathroom. CNA I stated .She looked like she was tired and had been there for some time .what surprised me was that she had the gait belt on . CNA I reported that Resident #702's wheelchair was also in the bathroom when Resident #702 was found on the floor. CNA I reported that she came in to start her shift on 8/17/18 around 2:00 p.m. CNA I reported that she did not observe or provide care to Resident #702 prior to the fall, and stated .She was in the other section .I wasn't her assigned CNA . In an interview on 9/6/18 at 12:52 p.m., DON B reported that she completed an education with the CNA's regarding following care plans and transfers, and provided a copy of the education sign in sheets for the inservice. Review of an education sign in sheet titled Transfer Training/Care Plan Education, dated 8/6/18, revealed Activity Aide F did not receive the training that was completed between 8/6/18 and 8/18/18. In an interview on 9/6/18 at 1:12 p.m., CNA L reported that she worked on the unit where Resident #702 resides on 8/17/18 for second shift, the day that Resident #702 fell and fractured her hip. CNA L reported that she did not observe or provide care to Resident #702 prior to the fall, and reported that she was not assigned to Resident #702 that day. CNA L did not recall speaking to Activity Aide F in regard to Resident #702. In an interview on 9/6/18 at 1:26 p.m., CNA M reported that she worked second shift on 8/17/18 on the unit where Resident #702 resides, and stated she was .assigned to the other section . CNA M reported that she did not observe or provide care to Resident #702 prior to the fall. In an interview on 9/6/18 at 1:47 p.m., Administrator A reported that the Transfer Training/Care Plan Education completed between 8/6/18 and 8/18/18 was for CNA's only, and did not include Activity Aides. Administrator A reported that LPN H, CNA M, CNA L, and CNA I were the assigned staff on the unit where Resident #702 resides at the time of Resident #702's fall on 8/17/18. Administrator A reported that the staff work together as a team to provide care to the residents, but ultimately each resident has an assigned CNA. In an interview on 9/6/18 at 1:58 p.m., Administrator A reported that CNA I was the assigned CNA for Resident #702 on 8/17/18 at the time of Resident #702's fall.

BASED ON INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT A FALL IN ONE RESIDENT (#7) OUT OF 9 RESIDENTS REVIEWED FOR FALLS FROM A TOTAL RESIDENT SAMPLE OF 23 RESULTING IN A FALL WITH A REFRACTURE OF A HIP, A LENGTHENED NURSING FACILITY STAY AND A CELLULITIS (INFECTION) OF THE HIP INCISION AFTER surgery for [REDACTED]. FINDINGS INCLUDE: A FACILITY FACE SHEET (UNDATED) REFLECTED THAT RESIDENT #7 IS AN [AGE] year OLD FEMALE THAT WAS admitted to the facility on 9/16/12 WITH THE [DIAGNOSES REDACTED]. A FACILITY DOCUMENT TITLED "PROGRESS NOTE" BY DNP (DOCTORATE OF NURSE PRACTICER ) "L" DATED 1/14/13 WITHOUT A TIME REFLECTED THAT RESIDENT #7 WAS "readmitted ,[DATE]/(NO YEAR) FROM (NAME OF HOSPITAL). PATIENT SUFFERED A FALL HERE AT NURSING HOME AND HAD A RIGHT FEMUR (BONE IN THE UPPER LEG) FRACTURE. PATIENT RECEIVED AN ORIF (OPEN REDUCTION AND INTERNAL FIXATION - SURGERY TO ALIGN THE FRACTURE AND HARDWARE TO AFFIX THE BONES IN POSITION)..." A FACILITY DOCUMENT TITLED "FALL POTENTIAL ASSESSMENT" DATED 12/20/12, THE ASSESSMENT FOR RESIDENT #7 REFLECTED: COGNITIVE/BEHAVIOR STATUS: "HAS THE RESIDENT'S BEHAVIOR CHANGED IN THE LAST 90 DAYS?" THE FACILITY ANSWER WAS "YES" "HAVE ANY OF THESE BEHAVIORS BEEN DISPLAYED IN THE LAST 90 DAYS: RESTLESSNESS, LETHARGY, RESISTS CARE, CONFUSION, DOES NOT FOLLOW DIRECTIONS OR UNDERSTAND DIRECTIONS, WANDERS?" THE FACILITY ANSWER WAS "YES" BALANCE: "NOT ABLE TO ATTEMPT (MINIMUM DATA STANDING BALANCE TEST) TEST WITHOUT PHYSICAL SUPPORT" MOBILITY: "AMBULATES WITH PROBLEMS AND USES ASSISTIVE DEVICES" FALL HISTORY: "DURING THE LAST 90 DAYS THERE HAVE BEEN: NO FALLS" MEDICATION: "3 OR MORE CLASSES (TYPES) OF MEDICATION IN THE PAST SEVEN DAYS" Diagnoses: [REDACTED]. AGE: "RESIDENT IS [AGE] years OR OLDER?" THE FACILITY ANSWER WAS "YES" A FACILITY DOCUMENT TITLED, "DESCRIPTION OF INCIDENT" DATED 1/1/13 REFLECTED LICENSED PRACTICAL NURSE (LPN) "A" REPORTED AT 1:15 PM ON 1/1/13 "(LPN "A" WAS) LOOKING INTO (RESIDENT #7'S) ROOM AS (LPN "A") PASSED BY NOTING (RESIDENT #7) LYING ON HER BACK ON THE FLOOR. (LPN "A) SAID (RESIDENT #7'S) CALL LIGHT WAS WITH IN REACH BUT NOT ON....(LPN "A") SAID (RESIDENT #7) HAD BEEN ILL WITH AN UPPER RESPIRATORY INFECTION, HAD BEEN RUNNING A TEMPERATURE, WAS WEAK FROM HER (RESIDENT #7) ILLNESS AND WAS ON ANTIBIOTIC THERAPY. (LPN "A") SAID (RESIDENT #7) SEEMED A LITTLE CONFUSED AS SHE (RESIDENT #7) TOLD HER (LPN "A") SHE HAD BEEN UP WALKING AROUND HER (RESIDENT #7'S) ROOM AND TO DO THIS WAS TOTALLY OUT OF NORMAL FOR (RESIDENT #7). (LPN "A") ALSO REPORTED EARLY IN THE SHIFT (RESIDENT #7) WAS NOTED SLOUCHED AND SLIDING IN HER WHEEL CHAIR REQUIRING ASSISTANCE TO SCOOT BACK UPRIGHT INTO THE SEAT. (LPN "A") APPLIED A TAB ALARM TO (RESIDENT #7'S) WHEEL CHAIR AND BED TO ALERT STAFF OF UNSAFE ACTIVITY...(LPN "A") EDUCATED HER (RESIDENT #7) ON THE IMPORTANCE OF CALLING FOR ASSISTANCE BECAUSE SHE WAS NOW WEAK DUE TO HER (RESIDENT #7'S) ILLNESS." IN THIS DOCUMENT TITLED "DESCRIPTION OF INCIDENT" THERE WAS NO MENTION OF PLACEMENT OF THE TAB ALARM ON THE RESIDENT OR WHETHER THE ALARM WAS SOUNDING AT THE TIME OF RESIDENT #7'S FALL. DURING REVIEW OF A FACILITY DOCUMENT TITLED "INTERDISCIPLINARY NOTES" DATED 1/1/13 AT 1610 (4:10 PM) REFLECTED, "7-3 NOTES...RES (RESIDENT) CONFUSED, WEAK AND FATIGUED D/T (DUE TO) FEVER AND URI (UPPER RESPIRATORY INFECTION). TAB ALARM ADDED TO W/C (WHEELCHAIR) AND BED, SENSOR PAD ADDED TO BED FOR SAFETY. RE EDUCATED RES. ON IMPORTANCE OF CALLING FOR HELP BECAUSE SHE IS WEAK NOW D/T FEVER. RES. DID VERBALIZE UNDERSTANDING. T (TEMPERATURE) 101.4 (DEGREES F)." AN INTERVIEW ON 3/19/13 AT APPROXIMATELY 11:04 AM IN THE APPLE HALL NURSES STATION WITH LPN "A", LPN "A" WAS ASKED TO RECALL THE EVENTS OF RESIDENT #7'S FALL ON 1/1/13 AT 1:15 PM. LPN "A" REVEALED THAT RESIDENT #7 WAS UP WALKING DURING THE DAY AND THIS WAS UNUSUAL FOR RESIDENT #7. LPN "A" STATED THE INTERVENTIONS IMPLEMENTED WITH RESIDENT #7 TO PREVENT A FALL WAS A TAB ALARM OR PERSONAL ALARM. LPN "A" WAS ASKED IF THE PERSONAL ALARM WAS SOUNDING AT THE TIME OF RESIDENT #7'S FALL ON 1/1/13 AT 1:15 PM. LPN "A" STATED RESIDENT #7'S PERSONAL ALARM WAS NOT SOUNDING. LPN "A" REVEALED THE PERSONAL ALARM WAS CHECKED TO SEE IF IT WAS FUNCTIONING AFTER RESIDENT #7'S FALL AND THE PERSONAL ALARM WAS WORKING. LPN "A" REVEALED THE ALARM WAS NOT ATTACHED TO RESIDENT #7 NOR WAS RESIDENT #7'S CALL LIGHT ON WHEN RESIDENT #7 fell . LPN "A" REVEALED THAT RESIDENT #7 WAS NOT VERBALLY CALLING FOR HELP BEFORE OR AFTER THE FALL ON 1/1/13 AT 1/15 PM. A FACILITY DOCUMENT TITLED, "FALL PREVENTION PROGRAM: POLICY AND PROCEDURE" DATED REVISED JULY 2006 REFLECTED: "ROUNDS WILL BE COMPLETED TO ENSURE THAT THE ALARMS ARE IN PLACE." "BATTERIES AND FUNCTION OF ALARMS ARE ROUTINELY CHECKED." AN INTERVIEW ON 3/21/13 AT APPROXIMATELY 9:20 AM IN THE DIRECTOR OF CLINICAL CARE SERVICES OFFICE WITH THE DIRECTOR OF CLINICAL CARE AND NURSE CONSULTANT "C" REVEALED THAT THERE WAS NO CERTIFIED NURSES AID (CNA) OR NURSING DOCUMENTATION REGARDING THE APPLICATION OF A PERSONAL ALARM, CHECKS ON PLACEMENT OF A PERSONAL ALARM OR TIMES THAT RESIDENT #7 HAD BEEN TOILETED BEFORE RESIDENT #7'S FALL ON 1/1/13 AT 1:15 PM. REVIEW OF THE FACILITY CARE PLAN FOR RESIDENT #7 UPDATED INTERVENTIONS ON 1/1/13 (NO TIME WAS INDICATED) REFLECTED ON "CATEGORY: ADL FUNCTIONAL/REHABILITATION POTENTIAL. LONG TERM GOAL...(RESIDENT #7)WILL BE CLEAN, FALL RISKS MANAGED...". "SENSOR TO BED. TAB TO BED AND WHEELCHAIR. RESIDENT #7 HAD EXPERIENCED AN INCREASED WEAKNESS AND CONFUSION FROM AN UPPER RESPIRATORY ILLNESS WITH A FEVER ON 1/1/13 WITH AN INCREASE IN UNCHARACTERISTIC BEHAVIORS FOR RESIDENT #7 SUCH AS AMBULATING AND TRANSFERRING WITHOUT CALLING FOR ASSISTANCE. THERE IS NO INTERVENTION FOR AN INCREASE IN SUPERVISION OF RESIDENT #7 RELATED TO HER IMPULSIVE BEHAVIORS AND LACK OF SAFETY AWARENESS AND DECREASED PERSONAL ABILITIES WITH THE UPPER RESPIRATORY INFECTION RESULTING IN A FALL WITH A FRACTURE. ACCORDING TO THE FACILITIES "PHYSICIAN ORDERS" DATED 2/11/13, RESIDENT #7 WAS RECEIVING KEFLEX (AN ANTIBIOTIC OFTEN USED FOR SKIN INFECTIONS) 500 MG (MILLIGRAMS) ONE TAB BY MOUTH EVERY 12 HOURS FOR 7 DAYS...DIAGNOSIS "RIGHT CELLULITIS". A FACILITY DOCUMENT TITLED "PROGRESS NOTES" DATED 2/11/13 BY THE DOCTOR OF NURSE PRACTIONER (DNP) "L" REFLECTED, "RIGHT HIP CELLULITIS-START KEFLEX FOR 7 DAYS AND WOUND CARE DRESSINGS." THIS INFECTION OCCURRED ONE MONTH AFTER RESIDENT #7 WAS readmitted TO THE FACILITY FROM THE HOSPITAL. A FACILITY DOCUMENT "DESCRIPTION OF INCIDENT" DATED 1/1/13 (NO TIME) REFLECTED, "(RESIDENT #7) IS AN [AGE] year OLD FEMALE admitted to the facility on [DATE] FOR PHYSICAL THERAPY POST hospitalization FOR A PATHOLOGICAL PERIPROSTHETIC (A FRACTURE AROUND AN IMPLANT THAT POSES A UNIQUE FRACTURE FIXATION CHALLENGE) FRACTURE OF THE RIGHT FEMUR WHICH REQUIRED AN ORIF...(RESIDENT #7) WAS LIVING INDEPENDENTLY IN THE COMMUNITY PRIOR TO HER hospitalization AND WAS CURRENTLY ANTICIPATING RETURN TO THE COMMUNITY LIVING WITH DISCHARGE PLANNING UNDERWAY AT THE TIME OF THIS FALL." DURING AN INTERVIEW ON 3/18/13 AT APPROXIMATELY 4:35 PM IN RESIDENT #7'S ROOM, RESIDENT #7 REVEALED SHE WAS TO GO HOME IF SHE HADN'T FALLEN AND FRACTURED HER HIP. RESIDENT #7'S LONG TERM CARE FACILITY STAY SINCE HER FALL HAS BEEN OVER 3 MONTHS TO DATE. ( )