Every finding on record at Westgate Nursing & Rehabilitation Community

Based on observation, interview and record review, the facility failed to prepare food in accordance with professional standards for food service safety resulting in the potential to spread food borne illness among all residents that consume food from the kitchen. Findings include:On 12/2/2025 at 2:15 PM, during a kitchen tour with the Certified Dietary Manager (CDM) F it was noted that the drain line from the three-compartment sink extends down into the bowl drain causing an improper air gap. This drain line and the receiving bowl drain were noted soiled with excess food debris. When asked, CDM F stated that all dirty kitchen utensils that do not go through the dish machine are washed, rinsed and sanitized in this three-compartment sink. At 2:17 PM on 12/2/2025 it was noted the drain line on the vegetable wash sink was also indirectly connected to the bowl drain below it. CDM F stated that this sink was used for washing the facilities' vegetables before food preparation. At this time, it was also noted that the drain line for the facility ice machine located beside the vegetable wash sink extended down into the same bowl drain below the vegetable wash sink.According to the 2022 FDA Food Code section 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed.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.

Based on observation, interview, and record review, the facility failed to ensure a correct therapeutic diet was prescribed for two Residents (#26 & #51) of eight residents reviewed for nutritional concerns. This deficient practice resulted in the potential for unmet nutritional needs and associated health complications. Findings include:(All times are recorded in Eastern Standard Time unless otherwise indicated.)Resident #26 (R26)R26 was admitted to the facility 10/2/2025 with diagnoses including failure to thrive, diabetes mellitus (DM), hypertension, and chronic kidney disease. A review of R26's Electronic Medical Record (EMR) revealed the physician had ordered a diet on 10/2/25 of Regular texture, No salt added, No Sugar added, Regular fluids.On 12/03/2025 at 9:20 AM, the breakfast tray for R26 was observed and included a tray with a salt packet despite the card which included the restriction of No Added Salt. Resident #51 (R51)R51 was admitted to the facility 11/7/2025 with diagnoses including congestive heart failure (CHF), chronic kidney disease and diabetes mellitus. A review of R51's EMR revealed the physician had ordered a diet on 11/9/25 of Reg/Reg Thin liquids (consistent carb [carbohydrate] and 2 g [gram] sodium). The care plan for R51 included a focus of Problem Start Date: 11/10/2025 Category: Nutritional Status (R51) is at Nutritional/Hydration risk due to history of CHF and DM . Approaches include: Approach Start Date: 11/10/2025 Diet per doctors order.On 12/3/2025 at 9:15 AM, the breakfast tray for R51 included 2 packets of regular sugar, salt and pepper, and had a tray card indicating a diet of Regular, SS (Sugar Substitute) but no indication of the sodium restriction ordered by the physician.Several other tray cards included SS on the diet order and the Certified Nurse Aides (CNAs) passing trays were questioned on the meaning of the term SS. The three CNAs passing the trays (CNA H, CNA I, and CNA J) all could not explain the notation. The Certified Dietary Manager (CDM F) was on the unit and explained SS indicated Sugar Substitute should be served rather than regular sugar packets.During an interview on 12/03/2025 at 4:49 PM, CDM F stated the facility did not serve a consistent carb or a 2 gram sodium diet. CDM F explained they offered an SS diet and an NAS (no added salt) diet as the facility had a liberalized diet policy. CDM F said that R51's tray card should have been changed and stated, I am surprised that the nursing staff did not know what the term SS meant. The online diet manual did not include a definition of a 2 gram sodium diet (a diet in which salt is severely restricted).During an interview on 12/3/2025 at 4:45 PM, Licensed Practical Nurse (LPN L) was asked the meaning of SS on the diet tray card and replied it meant soft diet.During an interview on 12/3/2025 at 4:54 PM, CNA K was asked the meaning of SS on the diet tray card and replied it meant soft diet.During a telephone interview on 12/4/2025 at 2:45 PM, the Registered Dietitian (RD M) stated the 2 gram sodium diet was not a diet we provide. RD M agreed the facility should follow the physician's orders.

Based on observation and interview, the facility failed to securely store medications in two of two medication carts reviewed for medication storage. (All times are recorded in Eastern Standard Time unless otherwise indicated.) Findings include: On 12/3/25 at 6:20 AM, an unattended pill cup was left on the South medication cart with one chewable 81 milligrams (mg) tablet of Aspirin. Licensed Practical Nurse (LPN) D was asked about the medication after she returned to the cart after the observation and stated she made a mistake and should have locked it up or taken it with her when she went to get the doorbell alarm.On 12/3/25 at 7:00 AM, an observation was made of the South medication cart for medication storage, and the following was observed:a. Various debris of paper and medication powder in the second drawer.b. One loose oblong capsule identified as gabapentin 300 mg with marking (IP 102) and beige in color.c. One loose round tablet identified as torsemide 10 mg with marking (PA 916) and white in color. d. One loose oblong tablet identified as valsartan and sacubitril 26 mg / 24 mg with marking (71) and white in color.e. One loose round tablet identified as quetiapine fumarate 25 mg with marking (U 25) and peach in color. On 12/3/25 at 8:20 AM, an observation was made of the North medication cart for medication storage, and the following was observed:a. Various debris of paper and medication granules of polyethylene glycol (over the counter laxative) and spilled liquid potassium in the second drawer.b. One loose round tablet identified as acetaminophen 325 mg with marking (GC 101) and white in color.c. One loose capsule identified as tamsulosin hydrochloride 0.4 mg with marking (D 53) and green/orange in color.d. One loose capsule identified as gabapentin 100 mg with marking (IP 101) and white in color. e. Two loose oval shaped tablets identified as metoprolol succinate extended release 25 mg with marking (M scored 1) and white in color.f. One loose round tablet identified as rivaroxaban 10 mg with marking (Xa, triangle on top of 10) and red in color.g. One loose round tablet identified as furosemide 40 mg with marking (3170 and V) and white in color. h. One loose round tablet identified as quetiapine fumarate 25 mg with marking (U 25) and peach in color. i. One loose round tablet identified as sitagliptin 25 mg with marking (221) and pink in color. j. One loose oval tablet identified as levocetirizine dihydrochloride 5 mg with marking (SG and 1-36) and white in color.k. One loose oval tablet identified as norethindrone acetate 5 mg with marking (AN and 475) and white in color. l. One loose oval tablet identified as apixaban 5 mg with marking (894 and 5) and pink in color. On 12/3/25 at 8:30 AM, an interview was conducted with LPN P who stated that carts should have been cleaned last night because the night nurses knew we were having a survey.On 12/3/25 at 8:35 AM, an interview was conducted with the Director of Nursing (DON), who was asked about medication storage and replied, Medications are not to be left unattended, and carts are to be cleaned regularly. On 12/3/25 at 8:45 AM, an interview was conducted with the unit manager Registered Nurse (RN) E who stated, I asked the night shift nurses to clean both medication carts out two days ago and obviously they did not. RN E verified that there was no official check off sheet that indicated the task for cleaning medication carts was completed and that cleaning was done with a vacuum. An interview was conducted on 12/3/25 at 9:00 AM, with LPN P who was asked about cleaning medication carts and accounting for all the loose pills in North cart and replied, Some nurses pop the pills over the open drawer and that makes me wonder if the resident is actually getting the medication or it is getting lost when replacing it back into the cart from the back of the pill blister pack. Either way there should not be any loose pills and night shift should have cleaned it last night.Review of policy titled, Maintenance of Medication Storage Areas, dated 4/2020, read in part A. CART: 1. Clean inside and out, including crushing devices.3. No medications on top of cart unless cart is under direct supervision.

Based on interview and record review, the facility failed to monitor and record the amount of tube feeding administered to one Resident (#45) of one resident reviewed for tube feeding management. (All times are recorded in Eastern Standard Time unless otherwise indicated.) Findings include: Resident #45 (R45) Review of R45's face sheet revealed an admission to the facility on 9/23/25 with diagnoses including malignant neoplasm of esophagus (cancer in the throat), protein-calorie malnutrition, dysphasia (difficulty swallowing), and failure to thrive. Review of R45's admission Minimum Data Set (MDS) assessment dated [DATE] revealed R45's brief interview for mental status (BIMS) assessment was indicative of moderate cognitive impairment. On 12/02/2025 at 4:06 PM, an interview was conducted with R45 in their room. R45 stated he has a history of cancer and has a tube feed (G-tube) for enteral (anything involving the gut) feedings and is scheduled for the evening for feedings. Review of R45's physician order, dated 12/1/25, read in part (brand name enteral feeding) 1.5 via pump: nighttime feeding at 150 ml (milliliters) x 10 hours. No recorded total amount of tube feeding was recorded in the electronic medical record to ensure R45 was tolerating or receiving the amount prescribed by the physician or dietitian.Review of R45's progress note, dated 11/10/25 read in part .returns to the facility today.has a new G-tube due to inability to consume adequate kcal(kilocalorie)/protein intakes since admit last month.has lost 8% since admit 5-6 weeks -ago, which is considered to be a significant change. Current weight 150.4#. Wt (weight) from initial admit on 9/23 was 163.4# (pounds). Expect weight gain, which is desired.Will monitor tolerance to increase of tube feeding.Will continue to monitor tolerance to tube feeding, weight, labs, etc.R45's care plan dated 11/12/25 disclosed a problem in part .is at risk of complications D/T (due to) use of feeding tube.goal.will have all nutritional and hydration needs met.approach.Record and monitor intake and output every shift.Review of R45's intake dated 11/10/25 through 12/3/25 had no shift to shift intake recorded. R45's weights were reviewed:admission Weight 9/23/25- 163.4 pounds Weight 11/17/25- 147.6 pounds Between 9/23/25 and 11/17/25 a -9.67 weight loss in two months and between 9/23/25 and 10/20/25 a weight loss of -7.22 pounds in one month was discovered during the review of weights in the EMR for R45.Review of R45's progress note, dated 11/26/25 read in part .Weight does continue to trend down, no new weight this week. Last weight 147.6#. If weight continues to trend down, will increase enteral nutrition. Will continue to monitor. On 12/3/25 at 2:20 PM, an interview was conducted with unit manager Registered Nurse (RN) E who was asked about recording the amount of total volume tube feed delivered and water with medication flushes and replied, I do not know I have never had to record an amount before. I just sign it out on the MAR (medication administration record) that it was given. RN E was asked what if the pump gets turned off or there is residual and replied, I guess I never thought of that. RN E agreed that the total tube feed volume should be recorded to ensure R45 was tolerating and receiving the correct amount.On 12/3/25 at 2:25 PM, an interview was conducted with Assistant Director of Nursing (ADON) Licensed Practical Nurse (LPN) C who was asked if there was any documentation to show the nurses were recording the total volume of tube feed administered and water during medication passes for R45 and replied, I do not see any documentation of total volume recorded for tube feedings or water. It should be recorded so we know how much fluid they are getting. On 12/3/25 at 3:40 PM, the Certified Dietary Manager (CDM) F was asked if the total volume of tube feeding administered to R45 should be recorded so the dietitian would be aware of how much they are actually receiving and replied, Yes, that will assist the dietitian with determining if they are tolerating the amount of tube feeding and if it needs to be increased related to weight loss or decreased related to weight gain.Review of policy titled, Tube Feeding dated 01/2025, read in part .Purpose.When a resident requires special feeding techniques as ordered by the physician, the nursing and dietary department are responsible for the adequate intake of nutritional support. Proficient management of tube feeders assures fewer complications and improved general health status.The dietitian's responsibilities include evaluation of tube feeding volume and strength, total fluid intake.to ensure adequate nutrition.

Based on observation, interview and record review, the facility failed to ensure implementation of enhanced barrier precautions (EBP) during high contact care activities was performed per standards of practice for one Resident (#6) of one resident reviewed for EBP.Findings include: All times recorded in Eastern Standard Time (EST), unless otherwise noted.Resident #6 (R6)Review of the Minimum Data Set (MDS) assessment, dated 10/17/2025, revealed R6 was admitted to the facility on [DATE] and had diagnoses including paraplegia (paralysis affecting lower half of body), heart failure and chronic obstructive pulmonary disease (COPD). Further review of the MDS assessment revealed R6 required substantial/maximal assistance from staff for bed mobility, lower body dressing and putting on/taking off footwear.An observation on 12/2/2025 at 2:50 p.m. revealed a sign attached to the entryway of R6's room indicating the use of Enhanced Barrier Precautions (EBP) during high contact care activities. The sign indicated staff were to wear gloves and a gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, wound care: any skin opening requiring a dressing.On 12/2/2025 at 2:54 p.m., R6 was observed lying in bed with the head of the bead at approximately 70 degrees and his left leg bent at the knee and folded underneath his extended right leg. Indwelling catheter tubing was observed leading from R6 to a dependent drainage bag hanging on the left lower frame of the bed. R6 reported he was waiting for staff to assist him in repositioning his legs as he was unable to move his lower body unassisted. There was a sign observed posted on the wall behind R6's bed indicating the use of EBP during high contact care activities. During the observation, Certified Nursing Assistant (CNA) B entered R6's room, performed hand hygiene and donned protective gloves. CNA B then unhooked the catheter bag from the bed frame and placed it on the bed next to the resident. CNA B proceeded to lean over R6's bed to reposition the Resident's lower body so both legs were extended. CNA B then leaned over the resident lying in bed to assist him with plugging a phone charger into the outlet on the opposite side of R6's bed. CNA B did not wear a protective gown during the observed care provision which required close contact with R6.On 12/3/2025 at 1:35 p.m., CNA B and CNA A were observed in R6's room providing incontinence care to the Resident. CNA A was observed cleansing R6's buttocks of fecal matter with gloved hands while CNA B stood on the opposite side of the bed to assist R6 with maintaining a side-lying position during care. CNA A's clothing was observed in direct contact with R6 and the bed linens. CNA A assisted R6 with changing his shirt and then assisted CNA B with transferring R6 to their wheelchair using a total mechanical lift. CNA A then removed the soiled linens from R6's bed. The sign alerting staff to use EBP during high-contact care activities remained posted behind R6's bed. Neither CNA B or CNA A wore protective gowns while providing assistance with incontinence care, changing clothing and linens, or for transfer for R6.During an interview immediately following the observation, CNA A and CNA B were queried regarding the use of EBP during care of R6. Both CNAs acknowledged there were signs posted both on the door entering the room and on the wall behind R6's bed. CNA A and CNA B acknowledged protective gowns should be worn while providing care to R6.Review of R5's comprehensive care plan revealed the following: Start Date: 3/31/2025. Enhanced Barrier Precautions. Resident requires enhanced barrier precautions related to: Urinary catheter, PI [pressure injury] to bilateral thighs .Review of R6's physician orders revealed the following: Start Date: 11/04/2025. End Date: Open ended. Enhanced Barrier Precautions (targeted gown and glove use) during high contact resident care activities, foley catheter, bilateral stage 2 PI [pressure injuries] to posterior thighs.Review of the facility policy titled, Enhanced Barrier Precautions, reviewed 1/2025, revealed the following: Enhanced barrier precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities . An order of enhanced barrier precautions will be obtained for resident with any of the following . wounds . and/or indwelling medical devices (. urinary catheters .) .

This deficiency pertains to Intake MI00152867. Based on interview, and record review, the facility failed to ensure licensed nursing staff maintained complete and accurate progress notes based on acceptable standards of practice for 1 Resident (R1) of 4 residents reviewed for complete medical records. This deficient practice resulted in lack of documentation in the medical record of the provision of wound care without a physician order, timely wound identification and documentation, and failure to provide notification and documentation of such to the physician and responsible party upon initial discovery of the R1's pressure injury wound. All times noted are Eastern Daylight Savings Time (ESDT) unless otherwise noted. Findings include: A review of intake information MI00152867, received 5/7/25 at 11:29 a.m., which alleged, in part: Complainant states that [Assistant Director of Nursing (ADON) A] and [the Director of Nursing (DON)] have directed staff not to open any more skin events because they do not want this information reported to the [State Agency] . staff put a patch on the wound (pressure injury on left iliac crest) but it is unknown if they are doing anything else to treat it (pressure injury) . family is not aware that she has this wound . Review of R1's Face Sheet, retrieved by the facility on 6/10/25 at 9:55 a.m., revealed R1 was initially admitted to the facility on [DATE] with diagnoses that included the following, in part: dementia, pressure ulcer of unspecified part of back, unstageable and abnormal posture (contractures). R1 had a Power of Attorney for Health Care and was unable to make independent medical decisions. Review of R1's Care Plans revealed a care plan problem initiated 5/15/2025, which read as: Resident has a [NAME] Terminal ulcer to lower left back/iliac crest. All interventions were initiated on 5/15/25, with the last review of the care plan performed on 6/6/25 at 21:16 [9:16 p.m. Central Standard Time (CST)]. R1 also have a Pressure Ulcer/Injury care plan initiated on 4/4/23 following initial admission. Interventions included the following, in part: 4/4/23 - Report signs of skin breakdown (sore, tender, red, or broken areas). 4/4/23 - Conduct a systematic skin inspection Q (every) week by LN (licensed nurse). Pay particular attention to the bony prominences. Review of R1's Progress Notes retrieved 6/11/25 at 10:27 a.m., revealed the first progress note entry documentation of R1's pressure injury: 5/16/25 - POA (Power of Attorney) updated r/t (related to) res (resident) with PI (pressure injury) . Documented by ADON A. Review of R1's Weekly Skin Body Assessments revealed the following, in part: 5/15/25 - Determination of Unavoidable Pressure Wound . Res with an unstageable PI to left lower back that measures 4.5 cm x 3.5 cm covered in slough ., completed by ADON A on 5/15/25 at 19:07 (7:07 p.m. CST). 5/15/25 - Nursing Fax Order to PCP, in part: Res with an unstageable PI to lower left back, possible iliac crest. Area covered with slough 4.5 cm x 3.5 cm. TX initiated to cleanse with wound cleanser, dry well, apply skin prep to peri (skin surrounding wound) wound. Place piece of calcium alginate to wound bed and cover with border foam M-W-F + PRN (as needed) . Any new orders? PCP replied: NNO (no new orders) Cont (continue) RX (prescription) for unavoidable DT (deep tissue) injury. Form was completed by ADON A on 5/15/25 and signed by the physician on 5/19/25. Review of R1's May 2025 Treatment Administration Record (TAR) revealed a documented physician order for R1's iliac crest pressure injury began on 5/15/25 with Cleanse wound to right (wound was on left lower back) lower back with wound cleanser, dry well. Apply skin prep to peri-wound. Cut piece of calcium alginate and place over slough. Cover with boarder (sic) foam. Change M-W-F and PRN. The physician order was changed on 5/20/25 to Cleanse wound to right (wound was on left lower back) lower back with wound cleanser, dry well. Apply skin prep to peri-wound. Cut piece of Aquacel (Dressing type) AG (Silver) and place over slough. Cover with adhesive foam. Change M-W-F and PRN. Review of R1's April 2025 TAR revealed no physician order was present and no documentation of a wound or wound care was entered by licensed nursing staff. Weekly Skin check by Licensed Nurse, once a Day on Tuesday was documented as completed by LPN C on 4/8, 4/15, 4/22, 4/29/2025. Review of Weekly Skin Body Assessments) revealed the following, in part: 4/15/25 - No Areas of Skin Impairment. 4/22/25 - No Areas of Skin Impairment. 4/29/25 - No Areas of Skin Impairment. 5/6/25 - No Areas of Skin Impairment. 5/13/25 - No Areas of Skin Impairment. 5/20/25 - Areas of Skin Impairment, describe below . continues with dressing to hip area as scheduled. During an interview on 6/10/25 at 1:53 p.m., when asked if a pressure injury had been identified and treated prior to 5/15/25, when the wound was first documented, Confidential Nurse N stated, The ADON (ADON A) told me not to chart it . I questioned it (lack of documentation on the wound and wound treatment without a physician order) - if something (a skin event) was going to be opened up on it . The ADON just told us what to put on it (the wound) and we were told not to document it. Confidential Nurse N tearfully continued and said she had seen the wound when it first developed, and it was small. Nurse N positioned her thumb and index finger into a small circle showing the size of the wound upon initial identification to be approximately the size of a nickel. Nurse N said she was instructed to use wound cleanser, apply Aqua (something), which killed all the bad organisms in the slough away, and apply a border foam dressing to the wound. Nurse N said slough was present in the wound prior to May 15th, when ADON A opened up the skin event. Nurse N stated, I questioned [the DON] as well, because I wasn't comfortable (with no documentation of wound assessment or wound treatment of R1's PI) . I probably treated (R1's PI for a month with no physician order and no documentation of the wound . I complained constantly about the lack of charting and no physician order. During an interview on 6/10/25 at 2:10 p.m., Confidential Nurse O confirmed R1 had developed a pressure injury prior to being documented in the medical record on 5/15/25. Nurse O, with tears in her eyes, stated, It could have been the end of April 2025, or the first week of May that I saw the wound . When we seen (sic) it there was slough on it. It was not intact. It was small, on [R1's] left hip. I didn't document or open any skin event because I was told the family is so particular about her care. Even though R1 is declining they (family) want us to go above and beyond . Both of them (ADON A and DON) told me not to document the care because there was no physician order. We all didn't want to do it (omit documentation and family and physician notification of the wound) and were voicing our opinions, and they said no . We were told - we did not ask - to not document in progress notes and we were told to not open up a skin event. Nurse O said R1's left iliac crest wound was treated with Aquacel and a border foam dressing. Nurse O acknowledged she had seen R1's PI wound prior to 5/15/25, treated the wound per ADON A's direction prior to 5/15/25, and failed to document anything about the wound in the medical record because she was told not to do so. During an interview on 6/10/25 at 2:55 p.m., when asked about R1 having a PI prior to the initial documentation of the wound on 5/15/25, Confidential Nurse P stated, I had to do some digging and found out they had not updated the doctor or received a physician order (for R1's left iliac crest PI). There was nothing in the physician orders for me to know how to change the dressing. They (Nurse N and Nurse O) told me what they had been doing for dressing the wound . I asked if the family knew, and they said family was not aware . I told Nurse N, 'How does it look when you say there is nothing wrong (on the weekly skin reports) and then you have a Stage IV pressure injury when you are saying there isn't one.' I knew right away this was very wrong. They (Nurse N and Nurse O) were very afraid. During an interview on 6/11/25 at 7:30 a.m., the DON was asked about instructing staff to not document R1's PI wound in the Residents progress notes, failure to open up a skin event, and the failure to notify the physician and family of the presence of a new pressure injury for R1 that was found approximately a month prior to the 5/15/25 documentation of the new wound. The DON acknowledged LPN (Licensed Practical Nurse) C had asked her about it (documentation for R1's wound). The DON stated, I didn't realize it was such a huge thing, because she was the only one who came and asked me about it. I don't remember what she came and asked me . She did not tell me she had already talked to [ADON A]. I didn't go to [ADON A] either. I asked LPN C to go to [ADON A]. During an interview on 6/11/25 at 8:53 a.m., ADON A was asked about the lack of documentation of the initial discovery of R1's left iliac crest pressure injury. ADON A denied that any staff informed her of R1's PI and denied she had ever instructed nursing staff not to open a skin event, not to inform the physician and/or family of the wound, and to perform wound treatments without a physician order. When asked when a skin event is routinely opened, ADON A stated, Immediately. When asked when family should be notified of a change in condition, such as a new pressure injury, ADON A stated, Immediately, or as soon as something is found. The physician is notified the same day. I did call the physician immediately (on 5/15/25). When asked for documentation of that telephone notification, ADON A reviewed the medication record and said there was no documentation of a call to the physician on 5/15/25. During an interview on 6/11/25 at 10:15 a.m., with the Nursing Home Administrator (NHA), Corporate Consultant L, and the DON concerns related to the absence of documentation in progress notes, skin events, notification to the POA and PCP, and wound treatments performed without a physician order or documentation in the medical record were discussed. The DON acknowledged she did not go and make inquiry to the ADON regarding the issue with the earlier discovery of a wound on R1 in late April 2025, and therefore did not know what the outcome of the event was. Review of the Pressure Injury Prevention and Care policy, reviewed 1/2025, revealed the following, in part: . ^. Pressure injuries will be assessed and documented upon admission, readmission, upon discovery, and weekly thereafter. Assessment may include the size, location, category/stage, odor (if any), drainage (if any), peri-wound condition, wound edges, undermining, tunneling, exudate, pain, and current treatment order. 7. Physicians and responsible parties will be notified of pressure injury upon identification and with change in status of pressure injury. 8. Physician/provider will be notified . for further evaluation and recommendations regarding treatment and interventions. 9. Potential/suggested procedure with pressure injury identification: A. Notify the physician/provider and the resident's responsible party. B. Initiated treatment in accordance with facility protocols, standing orders, or physician orders. C. Document the appearance of the pressure injury . D. Implement pressure-reliving or pressure-reducing interventions as appropriate. E. Notify the Director of Nursing. F. Update the resident care plan to address the area of pressure injury, and approaches initiated .

Based on observation, interview and record review, the facility failed to implement measures to prevent additional pressure wound and/or prevent the development and worsening of pressure injuries for two Residents (R108 & R7) of five reviewed, resulting in harm for R108 with the development of a stage III pressure wound which worsened, required hospitalization , antibiotics, and wound debridement. Findings Include: (All times are recorded in Eastern Daylight Time.) This citation is related to intake #MI00145848. Resident 108 (R108) Reivew of the complaint intake information from the State Agency, dated 7/23/24, read in part, .They stated he (R108) was doing fine .While driving up to see him on 4/19/24, [Licensed Practical Nurse] (LPN) D] called and said that dad wasn't doing well .She also told us that he has (sic) a pressure wound and she thought it was a Kennedy ulcer, which meant death was imminent within a few days to weeks. When we got there, (LPN D) met us at the door and said that 'we could move him to comfort care so he's comfortable'. I advised that we would be doing everything we can to get him better and rehabilitated .I scheduled a medical transport from [facility name] to (out of state facility) . Between the time I left on 4/27/24 and when he arrived in the out of state facility on 5/13/24, the wound grew in depth, and became extremely infected. It appears they [skilled nursing facility] did nothing to the wound after I left. A wound care Registered Nurse (RN) from (out of state facility) came to assess his pressure wound on 5/15/24 and she immediately called the ambulance because the wound was so badly infected, and she was afraid he was septic. In the emergency department (ED) out of state, they started intravenous (IV) antibiotics immediately. He was admitted and stayed in the out of state hospital until 6/10/24 . R108 was hospitalized for 28 days because of the severity of the infected pressure wound. A Kennedy ulcer, also known as Kennedy terminal ulcer, is a specific type of pressure ulcer that manifests in terminally ill patients. A Kennedy ulcer is a distinct type of pressure ulcer that primarily affects individuals in the terminal stages of illness or nearing the end of life. It is characterized by its sudden onset and rapid progression, often appearing as a sharply defined, irregularly shaped lesion with a dark maroon or purple hue. Kennedy ulcers typically develop on the sacral or coccygeal area but can also occur on other pressure points, such as the heels, hips, or elbows. Kennedy ulcers are painful, non-blanchable lesions with surrounding tissue exhibiting signs of impending necrosis. Unlike traditional pressure ulcers, Kennedy ulcers may not exhibit the typical signs of tissue breakdown, such as erythema (redness) or inflammation. Instead, they often appear deep, crater-like wounds with minimal surrounding tissue trauma. On 9/5/24 at 4:54 PM, an interview was conducted with the complainant. The complainant stated, On three different occasions the wound care nurse told me that he (R108) had a Kennedy ulcer. I did not know any different and so I just did not think it was that bad and I thought the wound care nurse and the practitioner were providing the correct treatment and knew what they were doing. When we got to the hospital out of state the pressure wound was open (worse in depth visible with flesh, size, and odorous). I know that even with the wound he was not on a turn schedule at the facility prior to transfer. When we went to visit him in state name, they kept him up in his wheelchair for extensive periods of time and no one came in and turned him. We would visit for hours and hours at a time only briefly leaving to get something to eat. The medical transport van had two emergency medical technicians and a RN in the back riding with him and ensured he was being turned and repositioned every one to two hours and they stopped to get dad something to eat. The complainant stated, After my dad arrived in out of state facility I went to see him, and he said, 'Is that me that smells?' 'Is that my a**?' I replied, 'Yes dad. That is your a** that stinks.' On 9/5/24 at 5:47 PM, Complainant I emailed photos of R108's pressure wound including one photo dated 5/8/24, which was taken while R108 was under the care of the facility. A request was made to an out of state hospital for R108's medical records on 9/6/24 via fax. On 9/6/24 at 1:11 PM, an interview was conducted with Family Member (FM) H, who stated, I can picture it just like it happened. On 5/8/24 I went to visit my dad and LPN D used their phone to take a picture of my dad's pressure wound. FM H stated, I had no idea it looked that bad. It got progressively worse. I could put my whole fist inside the wound he had. It was so bad. I swear on a stack of Bible's that the doctor was never there at the facility. They did not turn and reposition him and he was up in his chair 60% of the time. I went to see him three or four times while I was in the area. He was not on any antibiotics for the wound. I was not happy at all with what went on at the facility. They were shooting from the hip providing care for dad. We had a meeting with the nurse, physical therapist, and others to develop a treatment plan and the very next day they had it screwed up because they were not turning and repositioning him or changing the gauze on the dressing for the wound. They were making a plan because we had complained they were not doing their job turning and repositioning, so he was not on his right side. They called the wound a Kennedy ulcer. The dressing was a couple piece of gauze with some tape. On 5/8/24 they were putting A & D ointment on it. The wound care Nurse Practitioner (NP) spent ten minutes with him and never asked my dad a thing. He was not eating, was losing weight, and was losing his strength. My dad told me that the wound hurt, and he has a high pain tolerance. They just could not get their act together. I am so glad we had him transported elsewhere and now he is doing much better after receiving the treatment he should have gotten at the facility. Review of R108's Admission Record, revealed an original admission to the facility on [DATE], with medical diagnoses including polymyalgia rheumatica (inflammatory disorder causing muscle pain and stiffness around the shoulders and hips), benign prostatic hyperplasia (age-associated prostate gland enlargement), hyperlipidemia (elevated blood cholesterol), and hypertension (elevated blood pressure). R108's admission Minimum Data Set (MDS) assessment, dated 4/15/24, revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating R108 had moderately impaired cognition. Review of an Admission Skin Assessment, dated 4/10/24, revealed areas of skin impairment described as follows: right lateral inside toe scab, right side coccyx red area, left lower side back (lacked description), left hand (lacked description), left lateral outer arm near elbow bruise, right top of arm scab, and right shin old scar. No open areas of skin were documented in the initial skin assessment on admission. Review of the Braden scale for prediction of pressure wound risk, dated 4/10/24, revealed a score of 16 which indicated R108 was a high risk for developing pressure wounds. Review of a progress note, dated 4/11/24, read in part, Resd (resident) is being monitored for falls and weakness .Skin id (sic) dry and intact .Resd is Ax2 (assistance of two staff) with walker and Ax1 (assistance of one staff) for ADLs (activities of daily living) . An MDS assessment, dated 4/15/24, section E0800, read in part, .Did the resident reject evaluation or care that is necessary to achieve the resident's goals for health and well-being? .Behavior not exhibited .section M Skin Conditions, revealed R108 was at risk for developing pressure ulcers and had no unhealed pressure ulcers . Review of a progress note, dated 4/18/24, read in part, Resd (resident) DTI (deep tissue injury)/blister to coccyx has opened. Red beefy tissue showing at wound bed, skin still partially attached. Will pas (sic) along to wound nurse for assessment . No mention of blister prior to this progress note. Review of R108's skin integrity event incident report, dated 4/19/24, revealed R108 developed an in house acquired pressure injury on their buttocks that measured 10 (length) cm (centimeters) x 8 (width) cm x 0.4 (depth) cm. Review of R108's Wound Management Detail report, dated 4/19/24 through 5/10/24 revealed the following: a.) 4/19/24 - Wound type: Unspecified Ulcer, wound location: Right buttocks/coccyx, date identified: 4/19/24 at 12:30 PM, date created: 4/19/24 at 8:42 PM, present on admission: No, measured 6.0 cm, L (length) x 4.0 cm, W (width) x 0.3 cm, D (depth) cm. Wound comments: Res was found to have a blister-like area that opened on 4/18/24 with beefy red tissue showing to (sic) the wound bed. When doing skin assessments today, res presents with an unstageable wound that is likely a Kennedy ulcer to the right glut/coccyx area that is surrounded by a DTI (deep tissue injury) .DTI surrounding is dark maroon/red/purple and extends 5 cm. b.) 4/26/24 - Wound comments: Res with an unstageable ulcer to the right glut/coccyx area that is surrounded by DTI. Necrotic tissue to entire wound measuring 5 cm x 3.7 cm with irregular edges and an area of slough to lateral side measuring 5 cm x 0.1 cm. DTI surrounding is dark maroon/red/purple and extends 4.7 cm from necrotic tissue in an irregular shaped circle pattern. Treatment changed. Light serosanguinous drainage noted. c.) 5/3/24 - Wound comments: Res with an unstageable ulcer to the right glut/coccyx area that is surrounded by DTI. Necrotic tissue to entire wound measuring 5 cm x 3.5 cm x 0.1 cm with irregular edges and an area of slough to lateral side measuring 4 cm x 0.1 cm. DTI surrounding is dark maroon/red/purple and extends 4.0 cm from necrotic tissue in an irregular shaped circle pattern. Light serosanguinous drainage noted. d.) 5/10/24 - Wound comments: Res with an unstageable ulcer to the right glut/coccyx area. Wound measures 5 cm x 3.5 cm x 0.2 cm with slough and granulation tissue scattered throughout the wound. Necrotic tissue that is 3 cm x 3 cm x 0.1 cm with irregular edges that is in the middle of the wound. DTI surrounding is dark maroon/red/purple and extends 3.5 cm from necrotic tissue in an irregular shaped circle pattern .Res with no s/s (signs or symptoms) of infection to area with light serosanguinous drainage noted . Observation of the photo of R108's pressure wound, dated 5/8/24, revealed a Stage III pressure wound to the right sacral region, round in shape, dressing pulled down away from the wound revealing a completely saturated dressing with serosanguineous drainage; red/yellow in color. No 1/4 inch packing was observed as physician ordered. There was one piece of folded 2 inches (in.) x 2 in. gauze lying on top of the center of the padded dressing entirely saturated with serous drainage; clear and bloody in color and some yellow purulent exudate. The surrounding peri area of the wound was reddened and swollen all the way around the wound extending out approximately two inches. The wound had some purulent appearing drainage, undermining, mucus, stringy tissue, a brown and yellow piece of tissue in the center that appeared to be hanging off underlying tissue below that had some granulation. The dressing appeared to be an adhesive island wound dressing (porous) approximately 4 in. x 5 in. and in the center a pad measuring 2 in. x 2.5 in In the photo the wound appears to be larger than the dressing. R108's wound showed signs of infection in the photo dated 5/8/24 as described above. Review of R108's physician order, dated 4/23/24 through 4/26/24, revealed an order to apply A & D ointment to right buttocks wound four times a day and as needed to keep wound protected. Review of a progress note for R108, dated 4/23/24, read in part, .Side to side positioning every two hours and air mattress overlay. Wound healing supplement per facility . R108's physician orders lacked any order for an air mattress or for to check for settings and functioning. Review of R108's care plan, dated 4/24/24, read in part, Problem: Urinary incontinence .provide incontinence care after each incontinent episode. Use moisture barrier product to peri area .Problem: Resident is at risk for skin breakdown .report any signs of skin breakdown (sore, tender, red, or broken areas.) .Problem Start Date: 04/19/24. Category: Pressure ulcer/injury. Resident has a pressure ulcer, DTI, R (right) buttocks, suspected Kennedy ulcer .Assess the pressure ulcer for stage, size, presence of granulation tissue and epithelization, and condition of surrounding skin 7 days .apply dressings per MD (medical doctor) order . Progress note for R108, dated 5/7/24, read in part, Weight/wound review: current weight 194.8 pounds, down 7% in last 30 days triggers for significant loss, oral intake has dropped off recently to 0-25%, had been fair 50-75% .Recommend increasing oral supplement to 120 cc (cubic centimeters/4 ounces) three times a day . Review of Recap of Stay, dated 5/13/24, revealed, R108 was transferred to another facility out of state to out of state. R108's pressure injury wound was not measured prior to his discharge. Skin condition note was described as: areas of skin impairment and described as declining unstageable pressure injury right glut (gluteal/buttocks). The discharge MDS assessment, dated 5/13/24, section M skin conditions, revealed R108 had no unhealed pressure ulcers . From review of R108's complete medical record it appeared the discharged MDS, dated [DATE], was inaccurate related to the related to the Wound Management detail reports. Review of progress note, dated 5/13/24, read in part, .He (R108) does continue with declining unstage (sic) pressure injury to right glut. Does have occasional c/o (complaint of) pain to same .,Prior to leaving an order was given for prn (as needed) tramadol (pain medication) .Resident happy about transfer .Res. discharged at 4:05 PM (central time zone). An interview was conducted on 9/11/24 at 10:02 AM, with LPN D. When asked if she recalled R108 and replied, Yes, I remember him well unfortunately. He was a nice guy. LPN D was asked if R108 had any open areas on admission and replied, No, but he did have a few scabs, a couple of bruises, and a small, reddened area to his right side near his coccyx. LPN D stated, R108 was at risk for developing pressure wounds. LPN D was asked what the initial treatment was and replied, Side to side repositioning and barrier cream. LPN D was asked when R108's pressure wound first opened and replied, It first opened up on 4/18/24 and was described as red, beefy tissue underneath. LPN D stated, I opened up wound management for R108 and I had the DON look at the wound on 4/18/24 and we called it a Kennedy ulcer. LPN D was asked if R108's wound was opened why she classified it as an unspecified ulcer. LPN D stated, Because I am not always sure what they are, but then I detail them in the notes section. So, in the notes is where I reflect what they are classified as. LPN D was asked if she could explain what a Kennedy ulcer was and replied, A terminal ulcer that is dark in color, opens fast, and has irregular boarders. LPN D was asked when the physician first seen R108's pressure wound and replied, The nurse practitioner came in to see his wound on 4/30/24 for the first time. LPN D was asked if pictures are ever taken of wounds and replied, No. LPN D was shown the photo of R108's wound dated 5/8/24 and replied, I did not take that the daughter did with her phone. That is R108's wound and yes it has redness surrounding the peri area. LPN D was asked if R108's pressure wound had any drainage and if it was ever cultured and replied, Yes, it had drainage, but just a light drainage and no it was never cultured. LPN D was asked if she was wound care certified and replied, No. I consult with the wound care representative and the nurse practitioner. An interview was conducted on 9/11/24 at 10:58 AM, with the DON and was asked if R108 had an air mattress and replied, Maintenance would know when it was implemented because they keep a log of when air mattresses are added to resident rooms. The DON was asked if she could run a report for R108's turning and repositioning and replied, We do not keep track of that because it is a standard of care. The DON was asked how she would classify a pressure wound that appeared to be red, beefy to the wound bed and replied, A stage three. Well, it depends on depth so possibly a stage two depending on depth. The DON was asked what a Kennedy ulcer was and replied, It is an ulcer people generally get near the end of life and it is generally unstageable. An interview was conducted on 9/11/24 at 1:01 PM, with the DON who was asked if air mattresses needed a physician order and replied, Not necessarily. The DON was asked if there should be a system to check off that the air mattresses are working properly and replied, We may or may not put an order in to check off that an air mattress is working properly, but it should be on the care plan too. On 9/11/24 at 1:15 PM, an interview was conducted with RN E who was asked if an air mattress needed a physician order and replied, Yes. RN E was asked if there is a system to check off if the air mattress is working properly and replied, Yes, usually an order and also on the care plan. On 9/11/24 at 1:20 PM, an interview was conducted with RN F who was asked if an air mattress needed a physician order and replied, Yes. RN F was asked if there is a system to check off if the air mattress is working properly and replied, Yes, I know another resident has it where I check it off that it is working and has the setting in an order. Review of R108's out of state hospital admission documentation, dated 5/15/24 through 6/10/24, revealed the following: a.) .admitted to ED 5/15/24 reason for visit buttocks wound. Diagnoses: Sacral wound and cellulitis. Presenting problem: Infected decubitus ulcer. EMS states that the wound is odorous . b.) Decubitus wound culture obtained in ED, labs drawn, IV inserted, and two different antibiotics started via IV. [NAME] blood cell count was elevated at 13.8 indicating infection was present in (R108) . c.) ED basic information: Patient reports noticing the wound becoming more sore and has a mal odor to it. Assessment and plan: Sacral wound - open wound of lower back and cellulitis . d.) ED Physical Exam: Right sacral wound about 4 cm x 6 cm, undermining a little 1 cm circumferentially, some purulent appearing drainage and a necrotic area of the skin on a pedunculated stalk . e.) Medical decision making: . here for concern of an infected sacral wound. Patient reports he has discomfort and pain at the area of the wound . f.) Transferred to inpatient at (out of state hospital) for further treatment . g.) Wound care consultation note: Sacral wound on admission, unstageable sacral pressure injury. Upon debridement, the wound is likely to be a stage IV given the current depth that is visible. Concern about the amount of odor, necrosis, and cellulitis. Have requested evaluation by general surgery . h.) Surgical consult note dated 5/16/24 read in part, Stage III right buttock/sacral pressure injury. Wound has become increasingly painful and malodorous over the last month. Wound debrided at bedside .Large amount of necrotic slough tissue within the wound bed was debrided .Wound cultures so far reveal heavy gram-negative bacilli . i.) Progress noted dated 5/18/24, read in part, .The following day surgery came back and performed a more extensive bedside debridement as well . j.) Progress note dated 5/21/24, read in part, .Assessment/Plan .Stage 4 skin ulcer of sacral region .Team saw the patient and suggested a wound VAC (a treatment that uses suction to help wounds heal) and that was placed on the 20th (May 2024) . k.) Progress note dated 6/9/24, read in part, .Assessment/Plan: 1.) Stage 4 skin ulcer of sacral region. The patient has a wound VAC in place. Medically stable for discharge. Awaiting insurance authorization .2.) Cellulitis of sacral region. On oral amoxicillin and clavulanate (antibiotic) . l.) R108 was discharge out of the hospital on 6/10/24 .Discharge Diagnosis: Stage 4 skin ulcer of sacral region .Recent wound care assessment last week: Infected stage IV sacral ulcer, status post bedside debridement on May 15 (2024), status post surgical debridement on May 17 (2024) .wound VAC started on May 24 (2024) .Per last wound care assessment last week: Significant (sic) improved (evidence of a pressure wound and not a Kennedy ulcer) .Wound care team will follow-up in clinic in 1 to 2 weeks . Review of R108's photo of the right sacral pressure wound, dated 6/14/24, revealed no infection surrounding the wound, significant reduction in size, and granulation tissue in the wound bed that appeared healthy. Resident 7 (R7) A quarterly MDS assessment, dated 8/13/24, section E0800, read in part, .Did the resident reject evaluation or care that is necessary to achieve the resident's goals for health and well-being .Behavior not exhibited .section M skin conditions, revealed R7 was at risk for developing pressure ulcers and had one unhealed pressure ulcer stage II . On 9/9/24 at 3:10 PM, an observation was made of R7 in his room, lying in bed. R7 had an air mattress that was set at 250 and static (not alternating pressure). R7's heel protector for his left foot was not on and his heel was touching the bed. On 9/10/24 at 8:30 AM, an observation was made of R7 lying in his bed, on his back, in his room. R7's air mattress was set at 250 and static. R7's heel protectors were both off and were in his wheelchair. R7's left heel was overlapping a pillow and resting on the bed and R7's right heel was also touching the bed off a pillow. On 9/10/24 at 8:35 AM, an interview was conducted with the DON, who was asked if R7's air mattress was at the correct setting and if their heel boot protectors should be on and heels off the bed and replied, I would have to check the orders for the air mattress settings to verify and the boots should be on and that the heels are to be floated. After reviewing the orders for R7 the DON returned and replied, The air mattress settings are incorrect. On 9/10/24 at 11:05 AM, an observation was made of R7 lying in his bed, on his back, in his room in the same position from the previous observation. On 9/10/24 at 2:00 PM, an observation was made with LPN D of R7's skin on their buttocks and peri area. R7's coccyx wound was healed, and their peri area was reddened with excoriation surrounding their peri area. LPN D stated, R7 was readmitted from a short hospital stay with a stage II (pressure wound) on their coccyx area. This area is known to open from time to time. Review of R7's physician order, dated 7/13/23, revealed an order for a pressure relief air mattress with setting 320. Review of R7's physician order, dated 10/3/23, revealed an order to check air mattress placement and functioning every shift. Review of R7's care plan, dated 1/2/21, read in part, Category: Pressure ulcer/injury. Resident is at risk for skin breakdown . is also dependent on staff for repositioning and incontinence care .Approach .Heel float boot while in bed and wheelchair .Float heels while in bed .low air loss alternating pressure relieving mattress setting at 320 .turn and reposition every 1-2 hours while in bed . Review of policy titled, New or Worsening Pressure Wounds, dated 1/2024, read in part, .Standard of Care: A resident who enters the facility without pressure wounds does not develop pressure wounds unless the individual's clinical condition demonstrates that they were unavoidable and a resident having pressure wounds receives the necessary treatment and services to promote healing, prevent infection, and prevent occurrence of additional wounds and worsening of existing wounds .

Based on observation, interview, and record review the facility failed to ensure weights were monitored and nutrition interventions implemented for one Resident #41 (R41) of four residents reviewed for weight loss. This deficient resulted in a significant weight loss for R41. Findings include: (All times are recorded in Eastern Daylight Time unless otherwise noted). Resident #41 (R41) Review of R41's Minimum Data Set (MDS) assessment, dated 6/5/24 revealed admission to the facility on [DATE] with active diagnoses which included: dementia, hypertension, fracture, and anemia. R41 scored a 4 of 15 on the Brief interview for Mental Status (BIMS) reflective of severe cognitive impairment. During an observation of R41 on 9/9/24 at 2:52 p.m., R41's clothes appeared large and hung loosely on the Resident. Review of the MDS assessment dated [DATE] revealed R41 weighed 95 pounds. Review of monthly weights revealed R41 weighed 93.7 pounds on 6/1/24 and R41 weighed 86.4 pounds on 7/1/24. This was calculated to be a 7.79% weight loss in one month. Review of R41's Electronic Medical Record (EMR) found no dietary progress notes completed by Certified Dietary Manager (CDM) A or Dietician regarding R41's weight loss. Review of R41's care plan titled Nutritional Status revealed, approach start date of 6/13/23 house supplement 90ml (milliliters) three times a day (TID) and 9/15/23 may have tray table with all meals .goal no significant weight loss. During an interview on 9/11/24 at 10:32 a.m., the Director of Nursing (DON) stated every resident is weighed monthly .if we identify them as an unplanned weight loss then re-weighs are done .if there is a 5% weight loss in 30 days then we would re-weigh a resident .the physician and dietician would be notified as soon as we identify a weight loss . the dietician would request an order to add supplements and then the doctor would give an order for supplements . we didn't have a dietician at the time of the weight loss for R41 . the Certified Dietary Manager (CDM) A would have more information. During an interview on 9/11/24 at 10:46 a.m., the Certified Dietary Manager A reviewed R41's weights and stated, I see where I needed a reweigh but one was not done . I don't see a progress note by the Dietician regarding the weight loss . the physician didn't order anything different for (R41) .interventions for the Resident experiencing a weight loss would be added to the care plan by the Registered Nurse (RN) doing the MDS assessments or the Registered Dietician (RD) .there was no supplement added for (R41) and no interventions were added to R41's diet or added to the care plan. No documentation could be provided by the facility showed dietician/physician was informed and/or involved with assessing and treating the weight loss. There was not evidence of additional nursing interventions once the weight loss was documented. Review of the facility policy titled Weight and Height Records Policy last revised 8/23, read in part . The facility staff will obtain and monitor resident weights as follows .residents will have their weight obtained .at monthly intervals unless more frequent monitoring is needed as determined by . a weight loss or gain of 3 pounds for those residents who weigh less then 100 pounds will result in a re-weigh .weight orders will be placed in the Electronic Medical Record (EMR) if more frequent monitoring is needed .those residents that trigger for a significant weight loss of greater then 5% from the previous month will be placed on weekly weights .and appropriate interventions will be put into place .weekly weights will be monitored . Review of the facility policy titled Residents at Nutritional Risk Policy last revised 8/23, read in part . the following criteria will be used to identify nutritionally at risk residents .weight loss .of 3 pounds if [Resident] is under 100 pounds .in one month . once a problem has been identified .the primary nurse should work with the Dietician . in identifying approaches to be used . Review of the facility policy titled Nutritional Assessment last revised 8/23, read in part . analyze weight pattern .compare current weight to weight 30, 90, 180 days .assess general downward .trend in weight .identify nutritional risk factors .weight below 100 pounds, weight loss of 3 pounds a month if below 100 pounds .document nutrition related problems and approaches .identify problems, goals, and approaches . evaluate effectiveness of interventions.

Based on interview and record review, the facility failed to provide a complete Notice of Medicare Non-Coverage (NOMNC) and the Advanced Beneficiary Notice of Non-Coverage (SNF ABN) for two of four residents reviewed for Beneficiary Notice, resulting in resident and/or a resident representative not being informed of the right to appeal and the potential for undue emotional and financial hardships: Findings include: A SNF (Skilled Nursing Facility) Beneficiary Notification Review form was provided to the facility for Residents R209, R210, R211, and R28 to be filled out by facility staff and returned for beneficiary notification review. During an interview on 9/10/24 at 1:30 p.m., the Nursing Home Administrator (NHA) stated there was a problem with the form and asked this surveyor to meet with Corporate-Area Director of Utilization B and Minimum Data Set (MDS)/Registered Nurse (RN) C. During an interview on 9/10/24 at 1:33 p.m., Corporate-Area Director of Utilization B and MDS/RN C revealed the facility had not completed the necessary NOMNC/ABN forms for the residents selected and requested Past Non-Compliance (PNC). Corporate-Area Director of Utilization B indicated noncompliance was found during internal audits of Beneficiary Notification Review. Corporate-Area Director of Utilization B educated MDS/RN C regarding completion of the form and the facility had conducted weekly audits since 8/13/24. The facility PNC form revealed the alleged compliance was 8/20/24. Review of facility PNC documentation revealed that MDS/RN B was educated, weekly audits had been conducted, and no additional residents were affected. During an interview on 9/11/24 at 1:20 p.m., the NHA stated, the identified PNC and audits would be brought to the Quality Assurance Performance Improvement (QAPI) committee during their next meeting in September of 2024 for resolution. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included . education provided to MDS/RN C regarding NOMNC and ABN forms and audits were completed weekly since PNC was identified. This facility was able to demonstrate monitoring of the correction action and maintained compliance.

This citation pertains to intake MI00139217. All observations and interviews are recorded in Eastern Standard Time (EST). Based on observation, interview and record review, the facility failed to safely transfer one Resident (R56) of three residents reviewed for accidents. This deficient practice resulted in actual harm when R56 fell to the floor and sustained a right hip fracture with subsequent hospitalization , and surgical intervention. Findings include: A review of R56's Narrative and Impression Report, dated 8/29/2023, revealed the following result: 1. Mildly displaced right hip intertrochanteric fracture A review of R56's Emergency Department (ED) Note, dated 8/29/2023 at 12:19 p.m , revealed the following: .Patient has a great deal of chronic debility, lives in a local skilled nursing facility. She had some type of fall 4 days ago. Was seen in the ER by myself 3 days ago, but at times complaining of pain in her right ribs and right knee. X-rays of the right knee were negative for any sign of fracture. Per mother, since then she has developed pain in her right hip and is unwilling to try to bear weight on the leg .X-rays of the right hip show minimally displaced right intertrochanteric hip fracture. No orthopedic surgeon is available. Patient has had surgery previously at [Hospital Name]. Spoke with the orthopedic team there, they are willing to accept the case. Will transfer via EMS (Emergency Medical Services). On 9/12/23 at approximately 12:00 p.m., R56 was observed sitting in her wheelchair near the nurse's station. R56 was beginning to be agitated with staff members attempting to assist her to the main dining room for her meals. An interview was conducted with Registered Nurse (RN) S who was also R56's guardian who stated that R56 was currently have symptoms of a UTI (urinary tract infection) and was normally not so agitated. An interview was conducted with RN S who confirmed R56 had fallen due to an improper transfer and fractured her right hip. R56 was transferred to the local hospital, but they were unable to perform the surgery, so she was transferred again to a hospital where her hip was able to be repaired and sent back to the facility. RN S stated R56 still was upset with the staff who did the improper transfer. R56 was admitted to the facility on [DATE] and had diagnoses including benign neoplasm of cerebral meninges, hemiplegia affecting left nondominant side, and congenital malformation syndromes predominantly associated with short stature. A review of R56's Minimum Data Set (MDS) assessment, dated 6/29/23, revealed she required extensive, two people assist for bed mobility, transfers, and toileting. Further review revealed R56 scored a 99 on the Brief Interview for Mental Status (BIMS), and staff noted R56 had severely impaired cognition. A review of R56's electronic medical record (EMR) revealed the following: 8/25/23 21:40 (9:40 p.m.) written by Licensed Practical Nurse (LPN) N. Resident was lowered to the floor by writer and another CNA (Certified Nurse Aide). Resident was unsteady during transferring. CNA called writer, writer went into room immediately and gently lowered resident to the floor with no injuries. Writer than called charge nurse into the room and resident was lifted back into her chair with no issues. Vital signs revealed to be unremarkable, Resident also denies any pain or discomfort, Resident is sitting in the hallway eating a snack and chatting with other residents at this time. Will continue to carefully monitor and assist. 8/26/23 5:14 Resident stated her leg feels sore. Writer asked if resident would want to take some Tylenol and she said, 'No I just want to sleep.' Resident VSS (Vital Signs Stable). Resident slept well throughout the night. 8/26/23 8:00 Res (Resident) with a noted right leg external rotation and on a pillow. Writer asked res to try and move leg, and res unable to do so. Res with swelling to right knee and dark area around knee cap. Res with c/o (complaints of) pain and shaking noted. Ice pack applied, and on-call paged with V.O. (Verbal Order) from (Physician T) to send res via (transport name) for eval (evaluation) and Tx (treatment) to ER (emergency room ) . 8/26/23 10:44 Res returned via private vehicle with POA (Power of Attorney). Res with no issues r/t (related to) being lowered to the floor. Res with some c/o pain to knee that was relieved with PRN (as needed) Tylenol. WCTM (will continue to monitor). 8/26/23 21:12 (9:12 p.m.) Resident being monitored after being lowered to floor on 8/25. Writer asked if res has any pain to right leg and res stated a little bit. Res was slow to lift right leg up and writer asked if it was pain that made it difficult to raise leg, res stated 'no, I'm just scared. Writer asked again if she has any pain to the right leg and she shook her head no but stated 'just a little bit. PRN Tylenol was given to help with any pain, scattered redness noted to R (right) knee with no defined edges, size difficult to determine. Res had no c/o pain with writer touching knee. Per CENA, res did fine with transferring this shift, however when res was toileting, she had an episode of shaking. After taking a few deep breaths resident stopped shaking. 8/27/23 23:23 (11:23 p.m.) Resident with some c/o left leg pain. PRN Tylenol given with some relief. 8/28/23 11:24 slight bruising to R knee, c/o pain in knee, not wanting to walk on leg with PT (physical therapy) WCTM. 8/28/23 15:27 (3:27 p.m.) IDT (interdisciplinary team) met during morning meeting to discuss resident's fall over the weekend. Witnessed fall and resident was lowered to the floor in the bathroom after her knees buckled. No injuries although later did have c/o pain and had an ER visit r/t same. No apparent fx (fracture) or other injury noted at the ER> Investigation revealed resident was being transferred onto toilet with 1 CNA, Therapy has been recommending transfer Ax2 (assist times two). Staff education to CNA. 8/29/23 4:20 Staff reported to nurse that res was combative with last rounds and requesting pain medication. Writer entered room and asked res if she was experiencing any pain. Res replied 'Just my leg, just my leg' . 8/29/23 8:08 PCP (Primary Care Provider) gave verbal order to send resident out to [Hospital Name] for evaluation. POA aware and is in agreement. 8/29/23 11:25 Writer notified per POA that res had fractured right hip and is surgical. Res to be sent to [Hospital] for surgery. DON (Director of Nursing) and administrator notified. Resident with continued c/o of right hip/leg pain. Post fall from 8/25/23. Is combative with cares, crying out with movement. POA would like resident sent out for evaluation r/t same. 9/1/23 14:47 (2:47 p.m.) IDT met with discussion of res who was being transferred, her knee buckled, and she was lowered to the floor by staff. Initially appeared to have no injuries, did get sent toER on ,d+[DATE] as she was offering complaints of pain to right knee and ribs, X-rays done which indicated no fractures and she was transferred back to the facility. She did have mild complaints of pain on Sunday and Monday. She started to complain of increased pain to her right hip early Tuesday morning. She was sent back to the ER r/t these complaints, and it was noted that she had a fracture. She then went to [hospital Name] where she underwent surgery to her hip. She returned to the facility post this hospital stay a short time ago. Intervention was for staff education. Care plans reviewed and are appropriate. An attempted phone interview was conducted with LPN N on 9/14/23 at approximately 9:10 a.m. A message was left with no return call prior to the exit of the survey. Review of LPN N's witness statement dated and signed on 8/30/23 read, in part, . (LPN N reports she was at her med cart outside the door of room where (R56) resides. At approximately 2100 (9:00 p.m.) (LPN N heard CNA U call out for help from the bathroom . (LPN N immediately entered the bathroom and observed (R56) on the floor and (CNA U) stated to (LPN N) that (R56's) knees buckled and she had to be lowered to the floor . Further review showed that this witness statement was different than the nurse progress wrote LPN N wrote on 8/25/23 where she stated she helped lower R56 to the floor. An attempted phone interview was conducted with CNA U on 9/14/23 at approximately 9:15 a.m. A message was left with no return call prior to the exit of the survey. Review of CNA U's witness statement dated and signed on 8/29/23 read, in part, .At approximately 2100 (9:00 p.m.) (CNA U) asked resident (R56) if she would like to get her pajamas and get ready for bed. (R56) agreed so (CNA U) brought (R56) in her wheelchair into the resident's bathroom. (CNA U) and (R56) prepared for the transfer. (R56) reached for the grab bar in her bathroom and (CNA U) was beside her. (R56) then used the grab bar to rise out of her chair and stood up. (CNA U) then was assisting (R56) to pivot to the toilet and at that time (R56's) knees buckled. (CNA U) was unable to keep (R56) from falling, she assisted her to the floor in the bathroom as safely as she could . A review of R56's Physical Therapy PT Evaluation & Plan of Treatment dated 6/30/23 revealed the following: .Reason for Therapy .(R56) presents with significant functional decline after prolonged, complicated hospital stays for brain tumor resection. She demonstrates decreased LE/core (Lower Extremity/core) strength impacting ability to perform transfers. She is unable to ambulate and requires assistance from 2 caregivers currently for safety . A review of R56's care plans read, in part, Problem Start Date: 6/30/23 AT RISK FOR FALLS .Approach Start Date: 8/25/23 Increased assistance with transfers .

This deficiency pertains to Complaint Intake #MI00138936 & #MI00137644. Based on observation, interview, and record review, the facility failed to provide necessary treatment and services to promote healing and prevent the development of pressure ulcers for four Residents (R1, R6, R30 and R51) of four residents reviewed for pressure ulcer care, out of a total sample of 15 residents. This deficient practice resulted in harm with the development of a facility acquired stage 3 pressure ulcer, the potential for delayed wound healing, infection, and deterioration of condition. Findings include: All times documented are Eastern Daylight Savings Time (EDST) unless otherwise noted. Resident #6 (R6) Review of R6's hospital admission documentation, dated 2/1/23, read in part, .visiting diagnoses list pressure injury of left buttocks stage 3 and pressure injury of right buttocks stage 3 - primary diagnosis bilateral pneumonia, sepsis abdominal pain . * Pictures from hospital show a stage three pressure injury to right buttocks circular in shape and bleeding. Surrounding tissue is purplish in color and scar tissue noted around the open area. Review of R6's hospital discharge instructions, dated 2/6/23, read in part, .for pressure ulcer on right and left buttocks: Calazime to area of concern with avoidance of open wounds. A sacral foam to cover the area due to the patient's immobility. The patient was encouraged to offload pressure to the right and left gluteal regions with rotating his position every hour. The patient will need assistance from nursing facility and or staff. When seated, a Roho cushion is recommended to assist an offloading pressure. Please assure that the patient's buttocks is clean and dry from urine and feces as he is wearing a brief. On 9/14/23 at 8:52 AM, an interview was conducted with Certified Nurse Aide (CNA) X. CNA X was asked if she could provide further information regarding the complaint which involved R6 and replied, Yes. R6 had a dressing on his right second toe. It was like a boarder gauze with adhesive around the edges to make it stick. CNA X was asked if she recalled seeing a date or telling anyone about the dressing and replied, Yes. The date on the dressing was 5/22/23 and I told the nurse on shift about it and told the oncoming CNA to keep a watch on R6 because I was worried about his toe. CNA X was asked why she was worried and replied, Well the dressing had been on for about two months. No one had changed it and the toe was red and oozing green pus. The nurse cleaned it and changed it that afternoon. The new dressing for R6's toe stayed on for about two weeks and then I did not see it anymore. I think it fell off and no one put a new one on. R6 also had a wound on his back side that was open and near his tailbone on the right and was red and had purplish coloring on the outer edges which almost looked like a bruise or deep tissue type wound. CNA X was asked if R6 had ever been difficult to provide care for and replied, I never had any problems with him. He was incontinent and needed incontinence care. I do not feel he was being changed as much as he needed to be, or he would not have open areas. On 9/14/23 at 3:20 PM, an interview was conducted with Registered Nurse (RN) G who was responsible for MDS documentation. RN G was asked about R6's wounds and replied, The stage 3 pressure ulcer was facility acquired and the stage 2 pressure ulcer was there prior to his last admission on 2/6/23. Review of R6's Face Sheet, revealed the Resident was admitted to the facility on [DATE] with admitting diagnoses including hemiplegia and hemiparesis (paralysis of one side of the body) affecting right dominate side, kidney disease, diabetes mellitus, and dementia. R6's census sheet, revealed R6 was discharged on [DATE] and returned on 12/2/20 from a hospital stay. R6 had another discharge on 2/1/23 and returned on 2/6/23 from a hospital stay. The most recent discharge for R6 was on 7/30/23 and returned on 8/10/23 after a hospital stay. Review of R6's Minimum Data Set (MDS) annual assessment, dated 12/1/2022, revealed in section - M under skin conditions that R6 was at risk for developing pressure ulcers and had no unhealed or existing pressure ulcers. On 9/12/23 at 1:50 PM, an observation was made of R6 in his room. R6 was lying in bed with a foot boot protector on the right foot, a small bandage on the right second toe area, heels were resting directly on the bed, and no other dressings to the right foot. R6 had an air mattress that was set between 320 and 350 pounds per square inch (psi). R6 had a PICC (peripherally inserted central catheter) to his left upper arm with a dressing applied over the PICC and lacked a dressing date last changed. On 9/12/23 at 1:55 PM, an interview was conducted with the ADON F who was asked if R6's PICC dressing had a date on it and if the dressing should have a date on it. ADON F replied, No, it does not have a date. Yes, it should have a date on it to indicate when it was last changed. Review of R6's physician order, dated 1/25/23, read in part, Right lateral foot: Adhesive foam change once a week, as needed if loose, soiled, or saturated. Remove when showering and alleviate pressure at all times. Review of R6's electronic medical record (EMR) progress note, dated 9/2/22, read in part, Intra Disciplinary Team (IDT) met with discussion of resident who continues to have wound to his right gluteal. No change noted this week .Care plans reviewed and are appropriate. Review of R6's weekly skin assessment, dated 9/7/22, read in part, Continues with wound on buttocks near coccyx. *Documentation lacked wound measurements. Review of R6's EMR progress note, dated 9/30/22, read in part, IDT review of resident who continues with a stage II to his sacrum. He has not had improvement in wound status in the last two weeks .Care plans are reviewed and are appropriate. Review of R6's weekly skin assessment, dated 10/12/22, read in part, Right glute open sore / right foot blister. *Documentation lacked wound measurements. Review of the EMR, revealed an order scanned and dated 10/19/22 with ICD-10 code L89.313, which is code for; pressure ulcer of right buttock, stage 3, size 1 x 0.5 x <0.2 cm and debridement - autolytic. Review of R6's weekly skin assessment, dated 11/2/22, read in part, Right buttocks sore. *Documentation lacked wound measurements. Review of R6's weekly skin assessment, dated 11/9/22, read in part, Open sore inner glute. *Documentation lacked wound measurements. Review of R6's weekly skin assessment, dated 11/16/22, read in part, Open sore on right buttocks. *Documentation lacked wound measurements. *R6's right buttock/gluteal wound lacked wound observations and measurements from 9/7/22 through 12/30/22 by facility licensed nurses. Review of R6's wound observation, dated 12/30/22, revealed, a right buttock, pressure ulcer that measured - 2 x 2 x 0.4 cm - comments: Depth has increased, and NP CC is staging it as a stage 3 pressure ulcer. New orders given for calcium alginate and border foam 2 times a week. Review of R6's EMR progress note, dated 1/13/23, read in part, IDT a stage 3 to his R glute, previously this wound was considered a composite wound, but when wound Nurse Practitioner CC was in house this week she changed it to a stage 3. *R6's EMR lacked any wound observation documentation between 12/31/22 through 1/17/23. R6 should have had wound assessments completed on 1/6/23 and 1/13/23 for weekly wound measurements. Review of R6's MDS discharge assessment, dated 2/1/2023, revealed in section - M under skin conditions that R6 was at risk for developing pressure ulcers and had an unhealed or existing pressure ulcer stage 3, and under section E behavior - rejection of care - behavior not exhibited. Review of R6's Care plan history and review, dates 11/1/22 through 9/14/23, revealed, problem started date 1/2/21 - read in part, Problem: Resident is at risk for skin breakdown .Goal: Resident's skin will remain intact. Approach start date: 1/2/2021, conduct a systemic skin inspection every week by licensed nurse. Pay particular attention to the bony prominences. Low air loss alternating pressure relieving mattress setting at 320. Report any signs of skin breakdown (sore, tender, red, or broken areas). Provide incontinence care after each incontinent episode and as needed. Approach start date 11/28/22, Enhanced barrier precautions related to open wound (discontinued on 6/7/23). *Note - no documentation of open wound measurements in wound observations or healed wound for this approach. Problem: start date 12/30/22: Resident has a pressure ulcer .and history of pressure ulcers .approach start date 12/30/22, conduct a skin inspection every week by licensed nurse. Report signs of further skin breakdown (Sore, tender, red, or broken areas). *R6's EMR lack any documentation of a wound and lacked orders for wound care on R6's right foot 2nd toe. Review of R6's EMR, revealed a progress note, dated 7/7/23, read in part, Forwarded to primary care physician (PCP), as well as blood sugars from last week and medication list .Returned with the following abnormals: WBC (white blood cell count) 12.80 [elevated and out of normal range] . *Physician address blood sugars and did not address abnormal lab results. Review of progress note, dated 7/27/23, read in part, CNA informed writer that resident has redness and swelling to 2nd phalange on right foot. Fax sent to PCP for culture and is pending. Review of R6's census, revealed an admission to the hospital on 7/30/23 for cellulitis and osteomyelitis of the right foot second toe and later on 8/4/23 resulted in the right foot second toe amputation. On 9/14/23 at 11:00 AM an interview was conducted with Assistant Director of Nursing (ADON) F who was asked why R6 did not have any wound measurements prior to 12/30/22. ADON F replied, If R6 had an open area the floor nurses should have been documenting and measuring weekly under skin assessments and brought it to my attention. ADON F was asked how she was not aware of the open area if the progress notes indicated there was an open area on R6's skin of concern documented in the IDT notes in September 2022. ADON F replied, Well there were some things that we were missing in documenting the last time the Regional Director of Operations came and did a visit here. On 9/14/23 at 11:40 AM, ADON F was asked if the result of the culture mentioned in the progress note from 7/27/23 was resulted or obtain and replied, I would have to check. ADON F stated later that the culture was never obtained related to the fax being sent to the PCP on the next day and the PCP would have been out of the office then. ADON F was asked why the PCP was not phone verbally and replied, I am not sure, but R6 was sent out on 7/30/23 before the PCP could see him. ADON F was asked if the WBC was elevated on 7/7/23 and then the toe was being cultured on 7/27/23 why the PCP would not address the WBC being elevated and replied, That's the PCP for you. 35103 Resident R1 During an interview on 9/14/23 at 8:06 a.m., when asked if R1 had a dressing applied to their Stage IV pressure injury, Registered Nurse (RN) G said R1 had only cream applied to their pressure ulcer wounds and that no dressings were applied to the skin of R1. Review of R1's Face Sheet retrieved from the Electronic Medical Record (EMR) on 9/12/23 at 1:30 p.m., revealed R1 was admitted to the facility on [DATE], and had diagnoses that included: multiple sclerosis, pressure ulcer of right buttock, stage 4 (present on admission), dementia, and paraplegia. Review of R1's MDS assessment, dated 5/2/23, revealed R1 scored 9 of 15 on the BIMS, reflective of moderately impaired cognition. The MDS also revealed R1 had one Stage IV pressure injury that was present on admission. Review of R1's Physician Order Summary, retrieved 9/14/23 at 2:18 p.m., revealed the following, in part: Pressure relief air mattress. No settings. (On & Off), Start Date 7/13/2023 - Open Ended, and Cleanse wound to right ischium with wound cleanser. Apply 50/50 zinc/Lantiseptic ointment to areas in a thin layer. Ensure being changed BID and prn with incontinent episodes. Twice A Day, 5/10/23 - Open Ended. Observation of R1's stage IV wound care occurred on 9/14/23 at 10:33 a.m. RN G, assisted by Certified Nurse Aide (CNA) H donned gowns and gloves prior to beginning wound care. R1's feet/heels were observed resting directly on the bed mattress. CNA H washed the zinc/[NAME] septic cream from the outside of the wound dried to the buttocks and the outside surface of R1's stage IV wound. CNA H did not doff his dirty gloves or perform hand hygiene prior to assisting with positioning R1 in the bed. CNA H held their dirty gloves up in the air, while supporting R1's body with his upper arms. RN G applied wound cleanser to wound with a spray bottle. The interior of the wound was not held open and was not fully cleansed. RN G touched the top of the garbage clan lid with their gloved hand and then picked up a clean 4 x 4 gauze to dry the surface of the wound with the same hand used to touch the garbage can. CNA H's dirty gloves were observed to touch the back of the resident's shirt and R1's thighs. RN G put a very thin layer of the zinc/[NAME] septic cream on the outside of the wound using her gloved fingers, with nothing applied to the interior of the stage IV pressure injury. RN G used her dirty, gloved hands to pick up the zinc/[NAME] septic bottle and the bottle of wound cleanser, contaminating the outside of both bottles with cream applied directly to R1's skin. RN G exited the room, leaving the dirty wound cleanser bottle and wound cream bottle in R1's room. During an interview on 9/14/23 at approximately 10:45 a.m., CNA H was asked if his hands were clean or dirty as he touched R1 during wound care. CNA H confirmed he continued assisting with wound care with dirty gloves. CNA H said he should have washed his hands and donned clean gloves after completion of peri care for R1. RN G was asked if she had partially opened the stage IV pressure injury to cleanse the interior of the wound. RN G stated, No I don't open the wound and look inside. All I know is that there is a thin layer (of Lantiseptic cream) to the exterior of the wound. RN G was unaware of any dressing being required for the wound. The pressure relief air mattress machine at the end of the bed was observed with the button in the off position upon entry to the room with facility staff during the wound care observation on 9/14/23 at 10:33 a.m. The pressure relief air mattress remained off during the entire procedure. RN G and CNA H were in the process of exiting the room when this Surveyor asked RN G if the pressure relief air mattress was supposed to be off for R1. RN G then examined the pressure relief air mattress controls on the footboard of R1's bed on 9/14/23 at 10:58 a.m., confirmed the machine was off, and turn the air mattress back on. A sign on wall by R1's bed revealed the following instructions: Make sure mattress pump is on. During an interview on 9/14/23 at 12:54 p.m., the DON was asked how the interior of R1's stage IV pressure injury should be cleaned. The DON stated, I would use a sterile Q-tip to clean the interior of the wound with wound cleanser. I would attempt to open that wound so that the wound cleanser could get inside. (It is) not acceptable to not go inside the wound (to clean the wound). The DON was informed of the observation details related to R1's pressure injury and confirmed there was a potential for both wound and environmental contamination. Resident R30 During a telephone interview on 9/8/23 at 2:03 p.m., Complainant V expressed concern with skin concerns identified during an emergency room Visit on 6/1/2023. Complainant V stated, [R30] had open wounds. Complainant V said photographs were available that documented the skin concerns. Review of R30's Face Sheet revealed the Resident was admitted to the facility on [DATE] with diagnoses that included the following, in part: functional quadriplegia, congestive heart failure, anxiety disorder, and impaired vision in the left eye. Review of R30's Minimum Data Set (MDS) assessment, reference date of 6/16/23, revealed a Brief Interview for Mental Status (BIMS) score of 15/15 reflective of intact cognition. Record review on 9/13/23 at 9:14 a.m., found no facility documentation in the electronic medical record showing R30 had a sacral/buttock pressure injury prior to transfer to the emergency department on 6/1/23. Observation on 9/12/23 at 11:30 a.m., found R30 lying flat on her back in bed. Bilateral feet were without foot coverings and were positioned directly on the bed mattress. R30 did not respond to verbal communication with this Surveyor. R30's family member answered all questions related to R30's care in the facility. Review of R30's weekly Skin Body Assessments beginning 4/2/23 through 9/10/23, revealed the following, in part: 5/21/23: Areas of Skin Impairment, describe below (was checked) . sore on right anterior shin, redness to abd (abdomen) and breast folds, (and) sore on bottom. No location of the sore on the bottom of R30 or measurements were documented in the facility EMR for R30 prior to emergency room visit on 6/1/23. The area of impairment for R30 was only documented on this Skin Assessment. No other documentation was present in the EMR to record or detail the sore on bottom for R30. 5/28/23: No Areas of Skin Impairment. 6/4/23 and 6/11/23 . Out to Hospital. 6/12/23: Areas of Skin Impairment . open reddened area to the upper left gluteal cheek measuring 1 cm (centimeter) x (by) 3.25 cm. Review of skin photographs documented with the 6/1/23 admission to the emergency department showed purplish/red bruising to both buttock cheeks, with a larger pressure injury, with serosanguinous (blood mixed with clear drainage) exudate (wound drainage) on the left buttock, and a smaller open area on the right buttock cheek. The photograph showed a barrier cream had been applied to the wound area. During a telephone interview on 9/14/23 at 9:36 a.m., RN W was asked about Skin Body Assessments that did not detail all wounds present on R30. RN W stated, If it was not a new opening (wound), sometimes they (facility nursing staff) did not document the open areas. If the wound was previous identified in a Skin Body Assessment staff may not document the wound again on following skin assessments. Resident R51 During an interview on 9/14/23 at 8:06 a.m., RN G said R51 only had a cream applied to her pressure injury, and that no dressings were applied to the skin of R51. Review of R51's Face Sheet revealed Resident R51, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: dementia and need for assistance with personal care. Review of R51's MDS assessment, with a reference date of 7/7/23, revealed a BIMS score of 3 of 15, reflective of severe cognitive impairment. R51 was receiving Hospice care. During wound care observation on 9/14/23 at 11:18 a.m., R51 was observed lying in bed slightly on her right side. R51 winced in apparent pain as they removed her pants. R51 was positioned onto her right hip, and a pressure injury was observed on the inside of the right buttock cheek near the coccyx. Wound cleanser was applied, and the area dried with sterile 4x4 gauze. A small, sealed package of periguard ointment was placed directly on R51's over bed table. RN G used her clean gloves to pick up the Periguard Ointment. RN G opened the potentially contaminated package and used the now dirty gloves to apply the periguard directly onto the entire wound bed on R51's buttock/coccyx pressure injury. During an interview on 9/14/23 at 11:29 a.m., when asked if the surface of the bedside table had been disinfected, RN G acknowledged it had not been cleaned. Placement of clean supplies on a Resident's dirty over bed table was discussed. CNA H, also present during wound care nodded his head up and down in understanding. RN G confirmed the potential environmental contamination to the gloves used to apply the periguard cream directly onto R51's wound had the potential for contamination of R51's wound. No wound dressing was applied to the stage II pressure injury to R51's inner right buttock cheek. Review of the hospice visit documentation provided by the Hospice agency to the facility on [DATE], revealed the following electronic discussion related to R51's pressure injury on the interior right buttock cheek near the coccyx, in part: - Hospice Licensed Practical Nurse (LPN) I, 8/15/23 at 1:28 p.m. (CDST), .Assisted the CNA to change the patient' brief and look at her bottom. It is open to air with only her brief over it. CNA states she has many diarrhea-like stools in a day so the nurses do not put the foam on it because they can't change it frequently due to case load. Spoke directly to the nurse and she states the same. This nurse questioned if they need an MD order for something to be put on her wound to help heal it and not cause more breakdown . - Hospice LPN I, 8/30/23 11:20 a.m. (CDST), Patient continues to have the open area to the coccyx area. CNA (Certified Nurse Aide) in nursing home states they are using the barrier cream that was ordered 2 weeks ago but she has not had a foam to that area ever since. The area is not any better and looking at it, looks very sore. Can we get an order for the foam to that area, or do you have another suggestion? Please advise. Thank you. - Hospice LPN I to Hospice RN J, 8/30/23 at 3:41 p.m. (CDST), Can you call this order to [Name of Facility] The wound looks terrible, and they aren't doing anything for pressure relief . During an interview on 9/14/23 at 12:25 p.m., Hospice Supervisor RN J agreed the hospice visit documentation should be available to the facility floor nurses. When asked about the current order for R51's right buttock/coccyx pressure injury, RN J stated, The order said sacral foam daily and PRN (as needed) for Stage II pressure relief. That is the order I believe is in place now. RN J said the order was sent to the facility on [DATE] at 9:34 a.m. and said that is the treatment that should be done to R51's coccyx pressure injury currently. RN J stated, I am not aware that they have not been doing the sacral dressing . During an interview on 9/14/23 at 12:47 p.m., the DON was asked to verify the current physician order for R51's coccyx pressure injury. The DON said the current order for R51's coccyx wound was barrier cream. The DON confirmed Hospice had faxed an order to the facility for a foam dressing on 8/31/23 but said an unidentified hospice nurse verbally said the facility could go back to just barrier cream on the wound. When asked for the new physician order for just application of barrier cream to R51's wound, the DON stated, I probably don't have it. I changed the order when the nurse told me, because we could not keep the patches on anyways. When asked if the DON had a physician order for the change to barrier cream, the DON stated, Not right in front of me. The DON acknowledged she had changed the physician order for a foam dressing to be applied to R51's coccyx pressure injury based on the verbal comments of a hospice nurse, not on a new physician order. No physician order was provided to show a change in treatment for R51's coccyx pressure injury. Review of the Pressure Injury Prevention and Care policy, revised 03/2023, revealed the following, in part: Pressure injuries will be assessed and documented upon admission, readmission, upon discovery, and weekly thereafter. Assessment may include the size, location, category/stage, odor (if any), drainage (if any), peri-wound condition, wound edges, undermining, tunneling, exudate, pain, and current treatment order . 7. Physician/provider will be notified if pressure injury shows signs of deterioration, infection, or no improvement for further evaluation and recommendations regarding treatment and interventions. 8. Potential/suggested procedure with pressure injury identification: A. Notify the physician/provider and the resident's responsible party. B. Initiate treatment in accordance with facility protocols, standing orders, or physician orders. C. Document the appearance of the pressure injury (e.g.: size, location, appearance, odor (if any), drainage (if any), condition of peri-wound, wound edges, stage, etc.) D. Implement pressure-relieving or pressure-reducing interventions as appropriate E. Notify the Director of Nursing Review of the undated Dressing Change Competency revealed the following, in part: Establish a clean field: A barrier (paper towels, dressing kit wrapper, etc.) is used. Supplies are opened using clean technique. Indicated ointment/solutions are poured over gauze . Review of the Hand Washing/Hand Hygiene policy, reviewed 04/2023, revealed the following, in part: Practicing Hand Hygiene is a simple effective way to prevent infections by preventing the spread of germs. Wash hands and other skin surfaces when: 1. After immediate contamination with blood, other body fluids or potentially contaminated articles. 2. After removing gloves or other personal protective equipment. 3. After care of each resident. 4. Before and after nursing treatments or procedures (dressing changes, catheter insertion, eye drop instillation, etc.). 5. After handling urinals, bedpans, catheters, sputum, or any other body fluid .

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: 1. Failing to ensure potentially hazardous foods (milk) were stored at proper temperature while waiting to be served. 2. Failing to demonstrate the proper cooling of potentially hazardous foods which were destined to be served at a later date. 3. Failing to properly wash and clean melons prior to slicing through the rind and cutting into sections. These deficient practices have the potential to result in food borne illness among any and all 57 residents of the facility. Findings include: All times are reported in EDT. 1. On 9/13/23 at approximately 8:27 AM, observations were made during the morning meal service. A tray of cups with poured milk was observed sitting on a counter, waiting to be placed on residents' trays. Using a metal stem probe thermocouple thermometer, the temperature of one cup of milk was measured to be 56 F. Five additional cups of milk were measured and found to range from 52 F to 57 F. Cook B was asked to use a facility thermometer to measure the temperature of the milk, which was done and reported to be about 60 F. An interview with Cook B was conducted, who stated the tray of milk had been removed from the refrigerator within the last 10 minutes An interview with Certified Dietary Manager (CDM) A was conducted, who stated the refrigerator being used to hold the milk was not working properly and needs to be replaced. The FDA Food Code 2017 states: 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 57 C (135 F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54 C (130 F) or above;P or (2) At 5 C (41 F) or less. 2. On 9/12/23 at approximately 2:20 PM, a pan was observed in the walk in freezer. The top of the pan was labeled with the date 9/11/23. An interview was conducted with CDM A at this time and requested evidence the food had been properly cooled on the previous day. A Cooling Log sheet was located and reviewed adjacent to the walk in cooler. The log sheet had three entries. One from 9/10 identified Chicken as the product and a starting temperature of 110 F. No final temperature was recorded. For 9/11, Pork Roast was identified with a starting temperature of 182 F. Again there was not a final temperature. The facility could not provide evidence that food was being properly cooled from 135 F to 41 F in the appropriate time frame. An interview with CDM A confirmed this missing information. The facility provided a non-facility specific, generic policy titled: Dietary Manual, Cooling foods log ' Chapter 5.12; 1 of 1 Revised 4/21. which states: Policy: Ensure potentially hazardous foods are cooked, cooled correctly, and stored to eliminate Food Borne Illness. Under the heading of Process the policy identifies: Total time cooling, Within 4 hours Cooled from 135 F Cooled to 41 degrees F degrees (sic) Not to exceed 6 hours to 41 degrees F. The FDA Food Code 2017 states: 3-501.14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); P and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. 3. On 9/12/23 at approximately 2:45 PM, Cook C was observed cutting cantaloupe melon, and placing the fruit chunks in a Lexan container. An interview was conducted with Cook C at this time and learned the facility did not employ any procedures which would ensure the exterior of the melon had been properly cleaned prior to slicing through the rind into the fruit. Cook C stated that the melons, including watermelon and cantaloupe, when being prepped for slicing, were only run under water before cutting. The FDA Food Code 2017 states: 3-302.15 Washing Fruits and Vegetables. (A) Except as specified in (B) of this section and except for whole, raw fruits and vegetables that are intended for washing by the CONSUMER before consumption, raw fruits and vegetables shall be thoroughly washed in water to remove soil and other contaminants before being cut, combined with other ingredients, cooked, served, or offered for human consumption in READY-TO-EAT form. (B) Fruits and vegetables may be washed by using chemicals as specified under S 7-204.12.

Based on interview and record review, the facility failed to provide dementia-specific care training for employees before assigning them to work independently with residents. This deficient practice resulted in the potential for inappropriate staff-to-resident interactions and unmet resident care needs, potentially effecting facility residents with dementia. Findings include: All time are recorded in Eastern Standard Time (EST) A request was made on 9/13/23 at 12:02 p.m. to the Nursing Home Administrator (NHA) for staffing information for Certified Nurse Aide (CNA) M, CNA P, CNA Q and CNA R which included their criminal background checks, clinical performance evaluations, dementia, and abuse training. On 9/14/23 at approximately 9:00 a.m., documentation for CNA M, CNA P, CNA Q and CNA R was reviewed and revealed the following: CNA M who's hire date was 6/27/23 had a New Hire Dementia Training Post Test which was not signed or dated. CNA P who's hire date was 6/8/23 had a New Hire Dementia Training Post Test which was not signed or dated. CNA Q who's hire date was 6/22/23 had a New Hire Dementia Training Post Test which was not signed or dated. CNA R who's hire date was 5/17/23 had a New Hire Dementia Training Post Test which was not signed but dated on 10/29/22. An interview was conducted with Human Resources/Staff O on 9/14/23 at approximately 11:00 a.m. who stated she was with all four staff members on their orientation date but could not provide further documentation to prove that staff members completed their dementia training. When asked about CNA R, Staff O stated this staff member was hired initially on the assisted living section of the facility and was transferred over to the long-term care side, but then left a short while later and returned back to employment in May of 2023. Staff O could not provide more current dementia training for CNA R. Review of the facility's Abuse Prevention Program Policy & Procedure revised 9/22 read, in part, .Training: the facility will ensure that all staff, new and existing are trained and knowledgeable of facility's Abuse Prevention Program, with additional in-service for nursing assistants. These topics include: Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond. These symptoms, include, but are not limited to, the following: .dementia training for staff to educate on choosing the appropriate response for the Behavior using person-centered care strategies .

Based on observation, interview, and record review, the facility failed to ensure the provision of ongoing collaboration and communication between the facility and hospice providers for two Residents (R51 and R54) of two residents reviewed for hospice services. This deficient practice resulted in the potential for gaps in coordination of care, and the potential for unmet needs during the dying process. Findings include: All times are Eastern Daylight Savings Time (EDST) unless otherwise noted. R51 Review of R51's Face Sheet revealed an original admitted to the facility on [DATE] with pertinent diagnoses which included: unspecified dementia, need for assistance with personal care, dysphagia, altered mental status, and personal history of malignant neoplasm of breast. Review of a Minimum Data Set (MDS) assessment for Resident R51, with a reference date of 7/7/23 revealed a Brief Interview for Mental Status (BIMS) score of 3 of 15, reflective of severe cognitive impairment. During an interview on 9/13/23 at 8:37 a.m., Registered Nurse (RN)/Assistant Director of Nursing (ADON) F was asked to provide R51's hospice care plan and hospice visit notes for review. ADON F looked through several binders at the nurses' station and was unable to find any hospice visit documentation for hospice services provided to R51. ADON F said she would have to ask the Director of Nursing (DON) for the location of the hospice care plan and hospice visit notes for R51. During an interview with the DON on 9/14/23 at 8:32 a.m., R51's hospice visit documentation was provided to this Surveyor. The DON confirmed the hospice documentation had been faxed to the facility, based on facility request, on 9/13/23, which was noted on the top of all pages. The DON agreed the hospice documentation should have been present in the building for review by facility staff to facilitate a collaborative provision of care for R51. Review of the hospice visit documentation provided by the Hospice agency to the facility on [DATE], revealed the following electronic discussion related to R51's pressure injury on the interior right buttock cheek near the coccyx, in part: - Hospice Licensed Practical Nurse (LPN) I, 8/15/23 at 1:28 p.m. (CDST), .Assisted the CNA (Certified Nurse Aide) to change the patient' brief and look at her bottom. It is open to air with only her brief over it. CNA states she has many diarrhea-like stools in a day so the nurses do not put the foam on it because they can't change it frequently due to case load. Spoke directly to the nurse and she states the same. This nurse questioned if they need an MD order for something to be put on her wound to help heal it and not cause more breakdown . - Hospice LPN I, 8/30/23 11:20 a.m. (CDST), Patient continues to have the open area to the coccyx area. CNA (Certified Nurse Aide) in nursing home states they are using the barrier cream that was ordered 2 weeks ago but she has not had a foam to that area ever since. The area is not any better and looking at it, looks very sore. Can we get an order for the foam to that area, or do you have another suggestion? Please advise. Thank you. - Hospice LPN I to Hospice RN J, 8/30/23 at 3:41 p.m. (CDST), Can you call this order to [Name of Facility] The wound looks terrible, and they aren't doing anything for pressure relief . During an interview on 9/14/23 at 12:25 p.m., Hospice Supervisor RN J agreed the hospice visit documentation should be available to the facility floor nurses. When asked about the current order for R51's right buttock/coccyx pressure injury, RN J stated, The order said sacral foam daily and PRN (as needed) for Stage II pressure relief. That is the order I believe is in place now. RN J said the order was sent to the facility on [DATE] at 9:34 a.m. and said that is the treatment that should be done to R51's coccyx pressure injury currently. When this Surveyor informed RN J, the facility was not placing any dressing on the wound, RN J stated, I am not aware that they have not been doing the sacral dressing . During an interview on 9/14/23 at 12:47 p.m., the DON was asked to verify the current physician order for R51's coccyx pressure injury. The DON said the current order for R51's coccyx wound was barrier cream. The DON confirmed Hospice has faxed an order to the facility for a foam dressing on 8/31/23 but said an unidentified hospice nurse verbally said the facility could go back to just barrier cream on the wound. When asked for the new physician order for just application of barrier cream to R51's wound, the DON stated, I probably don't have it. I changed the order when the nurse told me, because we could not keep the patches on anyways. When asked if the DON had a physician order for the change to barrier cream, the DON stated, Not right in front of me. The DON acknowledged she had changed the physician order for a foam dressing to be applied to R51's coccyx pressure injury based on the verbal comments of a hospice nurse, not on a new physician order. No physician order was provided to show a change in treatment for R51's coccyx pressure injury. 34568 Resident #54 (R54) Review of R54's EMR revealed an admission to the facility on [DATE] with a primary diagnosis of amyotrophic lateral sclerosis (ALS) and indicated R54 was admitted on hospice services. Review of R54's physician orders for September 2023 read, in part, .the resident requires hospice services. [name of hospice company] ALS Visits per hospice communication binder .Date 3/14/23 .Open Ended . On 9/13/23 at 3:37 p.m. a request was made for all of R54's hospice visits documentation to the facility. During an interview on 9/14/23 at 12:25 p.m., The DON confirmed documentation from hospice for R54 from June 2023 until September 2023 had not been present in the facility. The DON stated the hospice organization was contacted during the annual survey and documentation had been sent to the facility for review and follow-up. The DON agreed the information from the hospice provider should have been readily available at the facility for nursing staff to review and to ensure collaboration of care between the facility and the hospice provider. Review of the Nursing Facility Services Agreement between the [Hospice Agency] and the facility, signed 10/21/2023, revealed the following, in part: Hospice Services means those services provided to a Hospice patient that are reasonable and necessary for the palliation and management of such Hospice patient's terminal illness and are specified in a Hospice patient's Plan of Care. Hospice Services include: (i) nursing care and services by or under the supervision of a registered nurse; (ii) medical social services provided by a qualified social worker under the direction of a physician; (iii) physician services to the extent that these services are not provided by the attending physician; .(vii) medical supplies; (viii) drugs and biologicals: (ix) use of medical appliances; and (x) medical direction and management of the Hospice Patient . Coordination of Care. (i) General. Facility shall participate in any meetings, when requested, for the coordination, supervision, and evaluation by Hospice of the provision of Facility Services. Hospice and Facility shall communicate with one another regularly and as needed for each particular Hospice Patient. Each party is responsible for documenting such communications in its respective clinical records to ensure that the needs of Hospice Patients are met 24 hours per day .Hospice retains primary responsibility for development of the Plan of Care .Facility will not make any modifications to the Plan of Care without first consulting with Hospice. Hospice retains the sole authority for determining the appropriate level of hospice care provided to each Hospice Patient . Physician Orders. If there are physician orders that are inconsistent with the Plan of Care or Hospice protocols, a registered nurse with Facility shall notify Hospice. An authorized representative of Hospice shall resolve differences directly with the physician and secure the necessary orders .

Based on interview and record review, the facility failed to ensure PRN (as needed) orders for psychotropic drugs were limited to 14 days and/or rationale was documented in the resident's medical record to indicate the rationale for an extended duration for PRN psychotropic medication orders for one Resident (R30) of five residents reviewed for unnecessary medications. This deficient practice resulted in the potential for continued use of medications unnecessary to treat R30 and the potential for undesirable side effects associated with prolonged use of psychotropic medications. All times are Eastern Daylight Savings Time (EDST) unless otherwise noted. Findings include: R30 Review of R30's Face Sheet revealed R30 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: altered mental status, anxiety disorder, and chronic respiratory failure. Review of R30's Minimum Data Set (MDS) assessment, reference date of 6/16/23, revealed a Brief Interview for Mental Status (BIMS) score of 15/15 reflective of intact cognition. Review of R30's Physician Order Summary Report, retrieved 9/13/23, revealed the following orders, in part: Lorazepam (anti-anxiety-benzodiazepine-controlled medication) concentrate, 2 mg (milligrams)/mL (milliliter); amt (amount): 0.25ml-0.5ml (1mg) by oral route every 2 hour as needed for anxiety/agitation. Every 2 Hours .Start Date 8/25/2023 - Open Ended . During an interview on 9/14/23 at 1:01 p.m., the Director of Nursing (DON) acknowledged she was aware PRN psychotropic medications were to be prescribed for a duration of 14 days, unless there was justification documented by the prescribing physician for a longer duration. The DON reviewed R30's Physician Orders and confirmed there was no specified end date for the Lorazepam, nor was their justification for the extended PRN usage by the physician. Review of the Psychotropic Medication Use policy, updated 3/2023, revealed the following in part: PRN orders for all psychotropic medications will be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration, not to exceed 14 days. a. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she will document the rationale in the resident's medical record and indicate the duration for the PRN order.

Based on observation, interview, and record review the facility failed to provide pain medication as ordered for one Resident (R212) of two residents reviewed for pain. This deficient practice resulted in unrelieved pain for R212 and the potential for other residents to experience unrelieved pain. Findings include: All times documented are Eastern Daylight Savings Time (EDST) unless otherwise noted. Resident #212 (R212) Review of R212's face sheet, revealed admission to the facility on [DATE], with medical diagnoses of fracture of upper end of left humerus (subsequent encounter for fracture with routine healing), diabetes mellitus, fall, and chronic pain. On 9/12/23 at 11:15 AM, an observation was made of R212 resting in her bed with an arm sling on her left arm watching TV. On 9/12/23 at 11:25 AM, an interview was conducted with R212 in her room. R212 stated she was receiving hydrocodone 10/325 mg (milligrams) for pain relief every four hours as needed. R212 also stated the facility had run out of her hydrocodone 10/325 mg tabs on Sunday night into Monday morning (9/11/23) and she had experienced increased pain in her left arm because of running out of her medication prescribed to her. Review of physician orders, dated 8/21/23, revealed an order for hydrocodone 10/325 mg, one tab every four hours, as needed, orally with special instructions: Pain 4 - 10 and acetaminophen 325 mg; amount 650 mg every four hours; orally with special instructions: Pain of 0 - 3 or fever. Review of R212's medication administration record (MAR), dated 8/21/23 through 9/12/23, revealed an average usage of her hydrocodone 10/325 mg tabs were provided about four to five times in a 24-hour period. Review of R212's MAR, dated 8/21/23 through 9/12/23, revealed R212 lacked receiving acetaminophen 650 mg on 9/11/23. Further review of R212's controlled substance record, dated 9/4/23 through 9/11/23, revealed the last dose of hydrocodone 10/325 mg given on 9/11/23 at 12:30 AM. On 9/13/23 at 9:57 AM, an interview was conducted with R212, who was asked how her pain was today and replied, It is about a 6 or 7. R212 was asked if she received any pain medication or told her nurse what kind of pain she was having and replied, Yes, I told my nurse and she brought me in some hydrocodone this morning. On 9/13/23 at 10:00 AM, an interview was conducted with Registered Nurse (RN) S. RN S was asked if R212 should have run out of her hydrocodone to help control her pain related to her left arm fracture and replied, No. She has about three hundred on order from pharmacy remaining in her original order. RN S stated that in shift to shift report she was not made aware R212 had run out of her hydrocodone, and subsequently discovered this when she went to administer the medication and the medication card was empty. RN S stated she was unsure why the medication was not requested to be refilled and the sticker for a refill was removed. RN S stated the medication should have been here when R212 needed it. Review of R212's controlled substance record, dated 9/2/23, for R212's hydrocodone 10/325 mg, revealed a quantity remaining of 300 pills, and 30 dispensed on 9/2/23. Review of R212's MAR, dated 8/21/23 through 9/12/23, revealed a pain assessment every shift as follows: 8/21/23 shift 2 - pain 10/10, 8/29/23 shift 1 - 1/10, 9/8/23 shift 1 - 1/10, 9/11/23 shift 1 - 2/10, and All other shifts pain 0/10. Further review of R212's electronic medical record vital signs lack any pain results charted from 8/21/23 through 9/12/23. Review of R212's progress notes, dated 9/2/23 through 9/12/23, lacked any communication to pharmacy or physician that R212's hydrocodone needed a refill. On 9/13/23 at 10:15 AM, an interview wit RN S was conducted. RN S was asked what R212's normal pain level was and replied, She usually has a pain level of 2 - 3 out of ten. RN S was asked if she was aware that the order for R212's hydrocodone had special instructions that the medication was for a pain level of 4 - 10 and replied, R212 is a nurse, and she knows what she wants so we just give it to her. RN S was asked if she had ever consulted with the physician to have the special instructions lifted and replied, No. Not that I am aware of. I did not. RN S was asked if there was a pain assessment that went hand in hand with the administration of the as needed hydrocodone and replied, I am not aware. RN S was asked to review R212's pain assessments and replied, I do not feel that afternoons and nights has an accurate assessment of R212's pain, but I did ask R212 what her pain level was today. On 9/13/23 at 10:26 AM, an interview was conducted with R212. R212 was asked if all shift nurses do a pain assessment on her and replied, Some afternoon nurses ask me about pain but nights doesn't. On 9/13/23 at 10:35 AM, an interview was conducted with Assistant Director of Nursing (ADON) F who was asked if a pre and post pain assessment should be completed by nursing after administering an as needed narcotic pain medication. ADON F replied, Yes. ADON F was asked if orders indicated special instructions for levels of pain should be considered and followed by nursing and replied, Yes. ADON F was asked if nursing should be administering hydrocodone 10/325 mg for special instructions for pain levels of 4 - 10 if the residents pain assessment does not reflect 4-10 and replied, No. ADON F was asked if a resident with both hydrocodone orders and acetaminophen orders should have an acetaminophen limit and replied, Yes. ADON F was asked if she was aware R212 did not have an acetaminophen limit and replied, No. I will add one and I will call the physician and get the hydrocodone order special instructions updated. R212 should have never run out of hydrocodone. Review of policy titled, Pain Management, dated 3/2023, read in part, Purpose: to provide an approach to pain management that provided the resident with optimal comfort, dignity and quality of life .Procedure: .2. Nurses will routinely assess residents for pain .6. Pain will be reassessed after interventions to evaluate the effectiveness of the intervention and to recognize undesirable side effects and documented in the medical record .

Based on observation, interview, and record review the facility failed to ensure that weights were obtained and monitored timely and accurately for one Resident (R17) of four residents reviewed for nutrition and hydration. This deficient practice resulted in an undetermined baseline weight, significant weight loss and compromised health conditions. Findings include: All times documented are Eastern Daylight Savings Time (EDST) unless otherwise noted. Resident #17 (R17) A review of R17's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses including Barrettes esophagus (growth of abnormal cells in the lower esophagus/throat), diabetes mellitus, adult failure to thrive, and malnutrition. A review of R17's 4/18/23 Admission Minimum Data Set (MDS) assessment revealed she scored a 15/15 on the Brief Interview of Mental Status (BIMS) assessment indicating intact cognition. On 9/12/23 at 1:43 PM, and observation was made of R17 in her room. R17 had her lunch tray on her bedside table, which included mashed potatoes and gravy, mixed vegetables, and some ground meat with gravy. R17 had only eat a bite of her mashed potatoes and gravy. R17 two drinks on her bedside table one appeared to be juice and the other was a med pass supplement. R17 had drank a half of glass of her juice and the glass of med pass supplement was left untouched, and the lid remained on top of the glass. Further review of R17's record revealed that she had been weighed on 4/12/23 with a result of 93.9 pounds and not weighed again until 5/4/23 with a result of 77.3 pounds. On 5/12/23 R17's weight was recorded at 77.2 pounds reflecting a significant weight loss of 17.7 percent in one month. No weights obtained on 4/13/23 and 4/14/23. A review of R17's physician orders revealed, an order for weekly weights dated 4/12/23. No weekly weights obtained on 4/19/23 and 4/26/23. R17's medical record lacked any documentation of weight refusals on these dates. A progress note, dated 4/13/23, revealed, Certified Dietary Manager (CDM) A note, read in part, Resident updated on Covid positive status. A progress note, dated 4/14/23, revealed, Registered Dietician (RD) W note, Dietitian Assessment .Diagnoses include- Diabetes, Hypothyroidism, Barrett's Esophagus, Epilepsy, Heart Disease, history of brain cancer. Height- 59 inches, Weight- 93.9# (pounds). BMI- 19 kg (kilgrams)/m2 (meter sqared). IBW (ideal body weight)-97.5# +/-10%. Diet- Regular, mechanical soft meats .Diet averages 2200-2500 kcal (kilocalories), 100-105 grams protein. Has her own teeth, some missing. Screened as at risk for spills .3-4+ (moderate to severe) edema is noted. Total Energy Expenditure- 1144 kcal, Protein need- 42 grams, fluid need- 1142 ml (milliliters). Screened as at nutrition risk with a mini nutrition risk assessment score of 11 . A progress note, dated 4/18/23, revealed, CDM A note, read in part, Resident updated on current Covid status. Review of R17's progress noted dated 4/27/23 at 10:50 AM, revealed, CDM A note, read in part, Dietary note: .It takes res a very longtime to finish her meals . Review of R17's progress note dated 4/27/23 at 6:02 PM, revealed, RD W note, read in part, Dietitian updated on current approaches .Eating very slowly with foods removed well before 4-hour limits within temperature danger zone. CDM is giving significant attention to [R17] to respect her ability to manage some aspects of her day. A review of a 4/29/23 Physician V note revealed, .Patient's chart was reviewed . *The physicians progress notes lacked any assessment or plan regarding failure to thrive, review of weights, and/or malnutrition diagnoses. A review of the hospital records for R17, revealed the following weight log: 4/2/23 - weight 85 pounds, and 4/10/23 - weight 83 pounds 6.4 ounces. *R17 was transferred to the facility on [DATE]. A review of R17's hospital lab record, dated 3/28/23, revealed, .Total protein - 6.2 (normal range 6.2 - 8.5 g/dL [grams/deciliter]) and Albumin 3.5 (normal range 3.5 - 5.2 g/dL). Review of Physician V communication for R17, dated 5/8/23, revealed, weight loss of 17.7% on 5/5/23 and physician signed and agreed to adding supplement on 5/8/23. Orders not placed until 5/10/23 adding a supplement for R17 and indicated no direction to provide documentation to track acceptance. On 9/13/23 at 9:45 AM, an interview was conducted with R17. When asked about weight refusals and dietary supplements, R17 stated, I would not and have not refused any weights. I get full quickly and I would prefer my supplements to be given in between meals and not with my regular meals. On 9/13/23 at 10:30 AM, an interview was conducted with the Assistant Director of Nursing (ADON) F. When asked about obtaining weights on new admissions to establish a baseline weight in the medical record, ADON F stated, The staff are to obtain a weight on the first day of admission and then the next two days to have a total of three weights in three days to establish a baseline weight. When asked about R17 and her weights, ADON F stated, She should have been weighed on day two and day three. I do not know why she was not weighed after the first day. I would have to check with the dietary manager. On 9/13/23 at 11:00 AM, an interview was conducted with the CDM A. When asked if she felt R17 weights could give her a good baseline weight, CDM A stated, No. When asked if she was aware of R17's weight when she was transferred from the hospital to the facility, CDM A stated, I would have to look. When asked if R17's significant weight loss could have been detected sooner and interventions added sooner, CDM A stated, Yes. I should have gone out to the nurses and ensured admission weights were obtained. When asked if the amount of additional supplement should be recorded for acceptance, CDM A stated, Yes. CDM A agreed weights were missed and R17 should have been followed more closely related to her nutritional status and diagnoses. A review of the facility new admission checklist for nurses, no date, revealed admission weight: weight to be obtained first 3 days of admission. Admit day, give to dietary manager, place 3 more weekly weights .Standing orders that must be added at time of admission: .Weight weekly x 4 weeks following admission (add on weekly weight list please) . A review of the policy titled Monthly and Weekly Weights, dated 1/2022, read in part, .Weekly weights conducted on residents that: a. Have experienced a significant weight loss/gain as indicated by the weight variance report. b. Are newly admitted to the facility .Risk factors for malnutrition .Slow eating pace resulting in food becoming unpalatable .Nutritional Plan for Weight Loss .Provide a high calorie/high protein snack between meals .Food enhancement: Some residents may benefit from protein powder being added to their beverage and/or food .(NOTE: All interventions must be monitored through meal observation, specific snack times and intake of meal and supplement percentage .

Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse for one Resident (R30) of 15 sample residents reviewed for abuse. This deficient practice resulted in the potential for undetected and continued abuse within the facility. Findings include: All times documented are Eastern Daylight Savings Time (EDST) unless otherwise noted. R30 Review of R30's Face Sheet revealed R30 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: altered mental status, anxiety disorder, functional quadriplegia (complete immobility due to severe disability), retinal artery branch occlusion in left eye (sudden painless loss of vision), and chronic respiratory failure. Review of R30's Minimum Data Set (MDS) assessment, reference date of 6/16/23, revealed a Brief Interview for Mental Status (BIMS) score of 15/15 reflective of intact cognition. Review of R30's Progress Notes, dated 9/9/23 at 1:46 a.m. Central Daylight Savings Time (CDST), revealed the following nursing progress note, in part: During nightly rounds, resident reported to CNA at 0030 (12:30 a.m. CDST) that they think they were inappropriately touched. Writer entered residents' room to inquire further about inappropriate touching and resident reported that they were raped. Writer asked resident when this happened and by whom, to which resident responded, 'by a guy and gal, they fingered my anus about three nights back.' Writer then asked if they know who it was exactly to which resident replied, 'I do not know. It was a guy and a girl. They said they were going to do me up good' . During an interview on 9/13/23 at 8:16 a.m., the Director of Nursing (DON) said there was no way that (allegation of sexual abuse to R30) had happened. When asked for an investigation file, the DON said she did not have an investigation file, because she did not work that weekend (of the sexual abuse allegation) and when she (DON) came back into the facility they had talked to the resident again and determined it did not happen. The DON confirmed no incident report, witness statements, or investigation summary were available for review. Review of the facility Abuse Prevention Program Policy & Procedure, revised 09/2022, revealed the following, in part: 1. The Administrator and or Director of Nursing are to initiate and coordinate completion of a thorough investigation. Investigations must be initiated immediately and concluded as soon as possible not to exceed (5) days . The investigation must include, but not limited to: - Identify alleged perpetrator, remove from resident care area immediately, suspend pending investigation conclusion, obtain statement; - Caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); - Identify and begin investigating different types of alleged violations; - Identify and interview (witness statements) all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s) such as roommate - Interviews with co-workers or other supervisors in regard to the alleged perpetrator's work performance. - Review of alleged perpetrator's employee file to confirm background checks, reference checks and to review any possible past performance issues. - Determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause. - Body assessment and psychosocial status of the resident. Signs of catastrophic reaction. - Methods of treatment and interventions. (i.e.: psychological services, hospital transfer, first aide, medication, staff staying with resident for comfort, etc.) - Providing complete/thorough documentation of the investigation findings (timeline of events), summary or conclusion - Follow-up actions to correct and prevent potential reoccurrence - State and local agencies notified facility reportable incident, (FRI) 2. The Administrator, the Director of Nursing, or designee will then coordinate the activities required for completion Resident Abuse Investigation Summary and Conclusion. 3. In order to complete the Resident Abuse Investigation, all information must be gathered and reviewed, with a final summary analysis with an action plan to prevent reoccurrence . 6. The Administrator will document the final disposition for each incident and will presented to and reviewed with the QAPI Committee. 7. A file for all data obtained, will be retained with the Administrator's or Director of Nursing office .

Based on interview and record review, the facility failed to report an allegation of sexual abuse to the State Agency within the required time frame for one Resident (R30) of 15 sample residents reviewed for abuse. This deficient practice resulted in the potential for undetected and/or continuation of abuse for R30. All times documented are Eastern Daylight Savings Time (EDST) unless otherwise noted. Findings include: R30 Review of R30's Face Sheet revealed R30 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: altered mental status, anxiety disorder, chronic respiratory failure, and impaired vision. Review of R30's Minimum Data Set (MDS) assessment, reference date of 6/16/23, revealed a Brief Interview for Mental Status (BIMS) score of 15/15 reflective of intact cognition. Review of R30's Progress Notes, dated 9/9/23 at 1:46 a.m. Central Daylight Savings Time (CDST), revealed the following nursing progress note, in part: During nightly rounds, resident reported to CNA at 0030 (12:30 a.m. CDST) that they think they were inappropriately touched. Writer entered residents' room to inquire further about inappropriate touching and resident reported that they were raped. Writer asked resident when this happened and by whom, to which resident responded, 'by a guy and gal, they fingered my anus about three nights back.' Writer then asked if they know who it was exactly to which resident replied, 'I do not know. It was a guy and a girl. They said they were going to do me up good.' Writer encouraged resident to disclose any further details to which resident was unable to describe any additional information. Writer asked again how long ago it happened to which resident responded, 'It was about 3 nights back and I'm pretty sure it was at night' .Writer notified on call ADON (Assistant Director of Nursing) and will follow-up with resident in the morning with day shift nurse. A Late Entry progress note was entered by the Director of Nursing (DON) on 9/12/23 at 8:28 a.m. CDST regarding her follow-up discussion with R30. No incident report was completed, and no report of potential sexual abuse was submitted to the State Agency. During an interview on 9/13/23 at 8:16 a.m., the DON confirmed the allegation of sexual abuse was initially reported by the nurse who was told not to put R30's allegation of sexual abuse in the nursing progress notes. The DON reviewed the progress notes and confirmed the sexual abuse allegation had been documented on 9/9/23 by [Registered Nurse (RN) E]. The DON said there was no way that had happened, and they (facility staff) investigated and determined it was not an accurate allegation and therefore did not report the allegation to the state agency. When asked for an investigation file, the DON said she did not have an investigation file, because she did not work that weekend (of the sexual abuse allegation) and when she (DON) came back into the facility they had talked to the resident again and determined it did not happen. The DON confirmed R30's allegation of sexual abuse was not reported to the State Agency. Review of the facility Abuse Prevention Program Policy & Procedure, revised 09/2022, revealed the following, in part: .'Sexual abuse,' is defined as 'non-consensual sexual contact of any type with a resident' . All alleged or suspected violations are to be reported immediately to the Administrator or Director of Nursing, which are responsible to notify required officials, including to the State Survey Agency, Adult Protective Services, Local Public Safety . and any other agencies in accordance with State law through established procedures. All alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown source . are reported immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury .

Based on interview and record review, the facility failed to ensure pre-employment screening that included fingerprinting was conducted for two staff members. This deficient practice resulted in the potential for the facility to employ staff who have a past history of abuse and could have subjected the entire facility population to various types of abuse. Findings include: All time are recorded in Eastern Standard Time (EST) A request was made on 9/13/23 at 12:02 p.m. to the Nursing Home Administrator for staffing information for Certified Nurse Aide (CNA) M and Licensed Practical Nurse (LPN) N which included their criminal background checks, clinical performance evaluations, dementia, and abuse training. On 9/14/23 at approximately 9:00 a.m., documentation from employee files for CNA M and LPN N were reviewed and revealed the following: CNA M was hired on 6/27/23 and did not have her criminal background check approved by the State until 8/2/23. An interview was conducted with Human Resources/Staff O on 9/14/23 at approximately 11:00 a.m. who stated CNA M did not work on the floor until her background check was approved. A request for documentation including time punches was made from June 2023 until August 2023, was made for CNA M. On 9/14/23 at 12:52 p.m., an interview was conducted with the NHA who confirmed that CNA M did work from 6/27/23 through 8/2/23, despite her background check not being approved. LPN N was hired on 6/9/22 and did not have her criminal background check approved by the State. Documentation requested for LPN N revealed that on 5/25/22, a payment was received to run a background check, but results had not been submitted since 9/13/23. An interview was conducted with Staff O on 9/14/23 at approximately 11:00 a.m. who stated LPN N had submitted her own background check to a third-party company. Staff O confirmed the results had not been submitted to the facility and that the facility had not conducted their own background check through their normal process. Review of the facility's Abuse Prevention Program Policy & Procedure revised 9/22 read, in part, .The facility will conduct thorough investigations of histories of prospective staff, in addition to inquiry of the state, nurse aide registry or licensing authorities prior to employment .The facility will ensure specific additional State requirement for criminal background checks and State law be followed that may prevent certain convicted crimes from working in a long-term care facility .Prior to employment: Applicants will submit to finger printing and/or criminal background checks to facility to ensure compliance with the Federal/State regulations. Offer for employment remains contingent upon results received from the Criminal Back-ground check .

This citation pertains to intake MI 021. All times are recorded in Eastern Daylight Time (EDT). Based on observation, interview, and record review, the facility failed to prevent a fall with fracture resulting in harm for one Resident (#29) of two residents reviewed for falls. This deficient practice resulted in decreased mobility, hospitalization , and pain. Findings include: Resident #29 Resident #29's facility incident report, dated 6/14/22, revealed she had an unwitnessed fall on 6/14/22. Orders were received for x-rays from the physician on that same day. Resident #29 expressed discomfort and complaints of pain and was sent to the local hospital. The local hospital contacted the facility and notified the facility of the x-ray results, which indicated that Resident #29 had sustained a right hip fracture. Resident #29's facility incident summary, dated 6/14/22, revealed during a shift-to-shift report the resident had increased pain in her right hip and she was unable to reposition. Resident #29's facility event report, dated 6/14/22, revealed the resident was observed sitting on the floor, weeping, with complaints of pain in the right hip. Pain level 10/10 and described as excruciating pain, worst possible, and interferes with ability to carry on with daily routines, socialization, or sleep. Pain with range of motion in the right hip and inability to move right hip. Facility event report, dated 6/14/22, revealed risk factors to medications as antipsychotic, antidepressant, narcotic, cardiovascular, and diuretic. The electronic medical record (EMR), revealed medical diagnoses that included: dementia, altered mental status, mixed obsessional thoughts and acts, and need for assistance with personal care and difficulty in walking. The Minimum Data Set (MDS) assessment, dated 5/27/22, revealed a Brief Interview for Mental Status (BIMS) for Resident #29 which indicated severe cognitive impairment. Resident #29's progress note, dated 1/29/22, read in part, An unwitnessed fall in the evening where she was found on the floor .Certified Nurse Assistant (CNA) instructed to check on frequently and assist with transfers for the next 24 hours. After this fall there was no new fall risk assessment completed. Review of Resident #29's progress notes revealed the following: 6/5/22 .She does request assistance with ADL's (Activities of daily living). The tasks she does performs on her own are slow process for her and she does stop or not complete them . 6/7/22 .OT (Occupational Therapist) had called writer into the room to talk about the resident confusion / speaking being odd . 6/14/22 - Resident [#29] had uncontrollable pain to right hip after fall .Resident unable to bend right leg and refusing to reposition. 6/14/22 .Local emergency room called with update that resident has a right hip fracture and that they would be transferring her to another facility as they do not have ortho in house right now . 6/17/22 .Resident returned from out of state hospital via wheelchair .Transferred on to her bed with assist of four . 6/17/22 .She expressed discomfort in her right hip .she came back to the facility for a right hip fracture that cannot be surgically repaired .hospital recommended hospice . Resident #29's local hospital records, dated 6/14/22, revealed an x-ray report with findings of acute, displaced intertrochanteric fracture of the right femur (area where the top of the thigh bone meets the pelvic bone). Resident #29's out of state hospital records, dated 6/15/22, revealed medication administered for pain management was given intravenously (medication added directly to the blood stream) [MEDICATION(S)] (an opioid) one milligram (a scheduled two class drug) and was given on 6/15/22 twice and on 6/16/22 twice to manage Resident #29's pain caused by her hip fracture. Resident #29's out of state hospital records, dated 6/17/22, revealed orthopedic discharge patient instructions to be non-weight bearing on her right lower extremity. Review of facility CNA Care Sheet, dated 8/1/22, revealed that Resident #29 required a mechanical lift for transfers. Resident #29's quarterly fall risk assessments, revealed no quarterly fall risk assessments were completed between 1/4/21 and 6/17/22 on Resident #29. Resident #29's quarterly fall risk assessment, dated 1/17/21, revealed a fall risk score of 3 (A score of 5 or greater = High Risk. Score of 4 or less = Not a High Risk). Three months later another quarterly fall risk assessment was completed on 3/30/21 and revealed an increased fall risk score of 11. After the quarterly fall risk assessment was completed on 3/30/21, Resident #29's care plan did not include any added interventions to ensure she remained free of injury. Resident #29's fall risk assessment, dated 6/18/22, from the critical admission assessment, revealed a fall risk score of 18. Resident #29's Care Plan, date printed 8/3/22, read in part, Problem: Resident at risk for falling related to fall at home .Goal: Resident will remain free from injury. Approach: Grip strips next to bed. (dated 6/14/22), Provide increased assistance with transfers x 24 hours (dated 1/29/22), Assure resident is wearing eye glasses .(dated 1/21/20), Encourage resident to assume a standing position slowly (dated 1/21/20), Encourage resident to use environmental devices . (dated 1/21/20), Provide proper, well-maintained footwear (dated 1/21/20), and Provide toileting assistance every 2-3 hours and PRN (as needed) (dated 1/21/20). Note fall mat not indicated on care plan, bed rail on right side of bed not present but on care plan, Resident #29 now a Hoyer lift and not indicated, and grip strips on care plan and not on the floor next to bed as indicated per care plan. Review of Resident #29's MDS, section G functional status, dated 5/27/22, revealed a functional status for ADL's for walking in room - score 8 indicating the activity did not occur during a seven-day period. Walk in corridor - score 3 indicating extensive assistance. Mobility devices walker and wheelchair. Functional limitation in range of motion - no impairment. Review of Resident #29's MDS, section G functional status, dated 6/28/22, revealed a functional status for ADL's for walking in room - score 8 indicating the activity did not occur during a seven-day period. Toileting use - score 3 indicating extensive assistance. Walk in corridor 8 - indicating the activity did not occur during a seven-day period. Mobility devices wheelchair. Functional limitation in range of motion - score one = impairment on one side. On 8/3/22, an observation was made of Resident #29, at approximately 7:30 AM, resting in bed, with a fall mat on the floor next to bed. There were no grip strips noted under fall mat as indicated by the care plan. On 8/2/22, at 5:15 PM, an interview was conducted with Resident #29's Family Member K. Resident #29's Family Member K was asked if she had any concerns regarding the care Resident #29 was receiving at the facility and responded, The only concern I have is her falls. She has had a decline since her fall in June. On 8/3/22, at 7:30 AM, an interview was conducted with CNA J. CNA J was asked if Resident #29 was care planned for a floor mat and a right-sided enabler bar and responded, I'm not sure. CNA J was asked how long Resident #29 has had her urinary catheter and responded, She has had it ever since she came back from the hospital after she fell in June. On 8/3/22 at 7:40 AM, an interview was conducted with Licensed Practical Nurse (LPN) C. LPN C was asked if Resident #29 was care planned for a floor mat and if she had grip strips on the floor next to her bed and responded, I would have to look at the plan of care. On 8/3/22 at 9:00 AM, an interview was conducted with the Director of Nursing (DON). The DON was asked how often fall risk assessments were to be conducted on residents and responded, Quarterly and if a fall occurs as needed. The DON was then asked when Resident #29 had her last fall risk assessment completed and responded, I have to check. It was last done on 11/4/21. The Don was asked if she was able to identify an increase in a fall risk or a decrease in a fall risk if the quarterly assessments were not being completed on Resident #29 and responded, No. I do not think so. The DON was asked if she knew what Resident #29's real fall risks were and responded, No. The DON was then asked if she felt that the interventions in Resident #29's care plan prior to her fall on 6/14/22 were adequate for being a high fall risk and responded, No. The DON was asked if the grip floor strips were applied to Resident #29's floor next to her bed to prevent further falls and responded, Probably not. On 8/3/22, an interview was conducted with Occupational Therapist Assistant (OTA) I, at 10:30 AM. OTA I was asked what kind of assistance Resident #29 needed prior to her fall on 6/14/22 and responded, She was a standby assistance / supervision, used the front two wheeled walker, and with a gait belt and one staff. OTA I was then asked what kind of assistance she needed after her fall on 6/14/22 and responded, She is wheelchair dependent and non-weight bearing on her right hip related to her fall with a fracture and non-surgical repair. Review of facility policy titled Fall Prevention and Management, date revised 2/20/2020, read in part, Purpose: to assess resident risk for falls and implement interventions to reduce the incidence of falls and / or mitigate the risk of injury related to falls. Procedure: 1.) Licensed nurses will complete fall risk assessments on residents upon admission, quarterly, and prn (as needed), 2.) When a fall event occurs .4.) The Director of Nursing or clinical leader will review the fall, events surrounding the fall, intervention, and post-fall documentation with the IDT (Interdisciplinary Team) during morning clinical meeting to elicit IDT input and recommendations and determine if additional investigation is needed.

Based on observation, interview, and record review, the facility failed to: 1) implement an ongoing system of communicable disease surveillance, 2) implement appropriate transmission based precautions, 3) timely report a communicable disease outbreak (Norovirus), and 4) utilize EPA (Environmental Protection Agency) approved environmental cleaning products approved for Norovirus following a disease outbreak, resulting in harm to 23 Residents (#1, #2, #3, #4, #7, #12, #13, #21, #23, #32, #37, #38, #42, #43, #44, #48, #54, #56, #57, #60, #61, #162, & #212) and the potential for harm for three Residents (#8, #10, -) out of a total of 56 vulnerable residents residing in the facility. This deficient practice resulted in a Norovirus outbreak with nausea, vomiting, diarrhea, the potential for dehydration, worsening of condition, and psychosocial distress when group dining and activities were cancelled. Findings include: All time noted is Eastern Standard Time (EST). On 6/24/19 at 2:47 p.m. a Contact Precaution information sheet was observed posted on the outside of Resident #45's room door. Certified Nurse Aide (CNA) J, present at the time stated, That sign isn't even supposed to still be there. You can take it down. (Resident #45) was on contact precautions because of nausea, but I don't even know if she threw up this weekend. No sign, directing visitors to see a nurse, was present on the door. On 6/26/19 at 8:03 a.m. the Director of Nursing (DON) was asked about the Contact Precautions information sheet observed on Resident #45's room door. The DON stated, (Resident #45) had some vomiting . we are still monitoring for Norovirus. When asked about the following information on the Contact Precautions information sheet: What to do: .10. Place a sign stating, See Nurse Prior to Entering on the resident's door, the DON stated, The (item number) 10 is directions for the nurse to place a sign on the door. The DON agreed the staff may have failed to place the See Nurse Prior to Entering sign on Resident #45's door. On 6/26/19 at 11:40 a.m., when asked when the (Name Brand) formulated bleach product was added to facility cleaning products, Environmental Services (Staff) K stated, We just started using it - maybe a couple of weeks (ago). When asked what environmental cleaning product was used prior to the (Name Brand) formulated bleach product, Staff K stated, It was called germicide. I am not sure I have any. When asked if bleach and water were ever mixed together by housekeeping staff, Staff K stated, No, we never hand-mixed bleach in bottles. Staff K provided a spray bottle of (Name Brand) Germicidal Cleaner & Disinfectant, and stated, During the flu (May and June), for most of the flu we were using this (Name Brand) Germicidal Cleaner & Disinfectant. Review of the (Name Brand) Germicidal Cleaner & Disinfectant gallon container, provided by Environmental Services Director E, revealed no label information showing effectiveness against Norovirus. On 6/26/19 at 2:00 p.m. Environmental Services Director (Staff) E, DON, and the Nursing Home Administrator (NHA) were interviewed in the presence of the survey team. After review of facility infection control line maps, and type-written surveillance documentation the DON said Norovirus, within the facility, would have been considered an outbreak starting Probably the 26th (of May). When asked when the local public Health Department was first contacted regarding the Norovirus outbreak in the facility, the DON stated, I called on 6/4/19 and she (health department staff) called me back in the morning (of 6/5/19) . We had 10 residents (who had contracted Norovirus) before we called. (Staff) [NAME] was asked if the (Name Brand) Germicidal Cleaner & Disinfectant was used to clean within the facility prior to contact with the Health Department. Staff [NAME] stated, That is our 'go to' germicide - that is what is on our cart (cleaning carts) .I don't believe that product handles Norovirus . I was surprised that it didn't (kill Norovirus). When asked if there was written documentation of staff education regarding the proper mixing and use of bleach and water, Staff [NAME] stated, Probably not . can't make sure everyone was educated regarding the use of water and bleach . It was verbal . I said, we have to do some extra sanitizing due to the flu. I am not sure exactly who was told . three staff (were told) . I believe that would have been (MONTH) 5th. The DON confirmed 23 residents were involved in the Norovirus outbreak. The DON stated, It (Norovirus) spreads very easily, (by) surface contact(s), coming in close contact .It (Norovirus) would have went away faster if we used the right products. Review of the facility Outbreak Management Checklist (May and (MONTH) 2019) completed by the DON, revealed the following, in part: Norovirus Outbreak Interventions: 1. Communication 1.1 Facility administration & regional team notified, (dated) 6/4. 1.2 Facility infection control team notified, (dated) 5/24. 1.3 Outbreak defined as more than one confirmed or suspected case of like symptoms affecting residents and or staff. Date of initiation of line listing. (dated) 5/25. 1.4 Outbreak reported to local health Department (County) dates of communication, (dated) 6/4 + (and) 6/5. 1.5 Resident responsible parties & visitors notified, (dated) 5/28. 1.6 Date & time of suspended resident congregate activities: meal service, group activities. (dated) 5/30 1.7 Posting of limiting visitors to resident & facility (dated) 5/28. 1.8 Resident isolation PPE (personal protection equipment) supplies in place, review procedures with staff (clinical & non clinical) (dated) 5/28 2. Investigation and Monitoring 2.1 Symptomatic health care workers removed from work, (dated) 5/26 . 3. Specimen Collection 3.1 Stool specimens collected within 48-72 hours after onset and kept refrigerated at 39 ° (degrees) for lab confirmation. (dated) 6/5/19 . 6. Education 6.1 Training provided to all staff on the signs and symptoms of norovirus . (dated) 6/4/19 . 6.3 Infection Control Manual: Policy compliance reviewed (dated) 6/4/19. Review of a typed Norovirus timeline, submitted by the facility, revealed the following: 5/23/19 - (room [ROOM NUMBER]x-3) starts with symptoms - emesis and one loose stool . 5/24/19 - (room [ROOM NUMBER]x-2) starts symptoms in the late evening with emesis and nausea (room [ROOM NUMBER]x-3) starts with symptoms - emesis and loose stools . 5/25/19 - (room [ROOM NUMBER]x-3) - start of symptoms with emesis . 5/26/19 - (room [ROOM NUMBER]x-2) starts with symptoms emesis and loose stools . 5/27/19 - residents on South hall begin to show symptoms. Medical Director notified via phone and in agreement with contact precautions and not having group activities and serving meals in rooms. All meals to be served to residents in their rooms and group activities are cancelled . (room [ROOM NUMBER]x-2) - starts with symptoms of loose stool . 5/29/19 - (room [ROOM NUMBER]x-1) starts with symptoms of emesis . (room [ROOM NUMBER]x-1) starts with symptoms of emesis . (room [ROOM NUMBER]x-2) starts with symptoms of emesis . 5/30/19 - (room [ROOM NUMBER]x-2) starts with symptoms of emesis and loose stools . 6/2/19 - (room [ROOM NUMBER]x-2) starts with symptoms of emesis . (room [ROOM NUMBER]x-2) starts with symptoms of emesis . 6/4/19 - (room [ROOM NUMBER]x-1) starts with symptoms of emesis . Norovirus inservice with information provided via health department. Message left with county nurse at (County) Health Department. 6/5/19 - Spoke with nurse . with Health Department . 6/5/19 - 10:10 (a.m.) (Central Standard Time) Spoke with . District Health Department and updated her with number of cases of employees and resident and when symptoms started . 10:45 (a.m. CST) (Health Department Nurse) called me back at facility and advised their medical director . recommends obtaining a few stool samples and sending to local hospital to test for norovirus and bacteria. She said she is waiting to see if she can get state approval for us to send some samples to the state laboratory . emailed me information about Norovirus education. 14:30 (2:30 p.m. CST) I called (Health Department Nurse) back to see if she had heard regarding the samples to be sent to state lab. She let me know that she will be stopping at the facility to drop off kits and then will be here to pick them up when they are ready . Review of the Acute Gastroenteritis/Norovirus Case Report Worksheet, received 6/26/19 at 2:39 p.m. from the DON, revealed a list of 23 facility residents, ranging in age between 70 and [AGE] years old, that had contracted Norovirus in the facility between 5/23/19 and 6/21/19. Five stool specimens were collected: three submitted to the state laboratory, and three submitted to the local hospital. One specimen was submitted to both state laboratory and local hospital, resulting in a total of five residents sampled, with confirmation of Norovirus in all samples submitted to both state and hospital labs. Review of the facility Norovirus Prevention and Control policy, dated 12/2015, revealed the following, in part: . Transmission: Norovirus is highly contagious and can infect anyone . People are most contagious when they are sick with norovirus illness and during the first two to three days after recovering from the symptoms . Procedure: 1. Place residents with symptoms of norovirus gastroenteritis on Contact Precautions in a private room. If a private room cannot be accommodated efforts must be attempted to separate symptomatic residents from asymptomatic residents . 6. Perform additional cleaning and disinfection of frequently touched environmental surfaces and equipment in resident care areas, resident with isolation and cohorted areas, as well as high-traffic clinical areas . Clean and disinfect shared equipment between residents using EPA-registered products with label claims for use in healthcare which lists activity against norovirus . Resident #12 According to Face Sheet, Resident #12 was admitted [DATE] with the following major Diagnoses: [REDACTED]. Review of Resident #12's Progress Notes revealed the following: 6/21/19 at 1:59 (a.m.) Res(ident) reported feeling nauseous and was diaphoretic. Res with a few episodes of emesis-was immediately placed on contact precautions . 6/22/19 at 23:01 (11:01 p.m.) Res. Is being monitored related to emesis on 6/21/19; Res. Had a large emesis after supper of brite (sic) yellow liquid .Res. Is on contact precautions . 6/23/19 at 22:28 (10:28 p.m.) Res. Continues on precaution related to emesis on 6/21 . On 6/24/19 at 11:02 a.m., during an observation, Resident #12's bed was positioned in the middle of two other beds, Resident #10's bed was closest to the door, and Resident #8's bed was closest to the window. A sign Pathway To Infection Precautions was taped to the opened door. The sign did not identify which of the three Residents required contact precautions. CNAs O and P were observed in the room assisting Resident #8 and not wearing any type of Personal Protective Equipment (PPE). Both CNAs were asked why contact precautions were in place. CNA O responded, respiratory and CNA P responded, GI (gastrointestinal). Outside the residents' door, a plastic three drawer bin with PPE supplies was found, which included: one box of large sized disposable gloves, a full drawer of blue, plastic disposable gowns, one can of odor eliminator spray, one canister of (brand name) cleaning/disinfecting wipes (without bleach), red biohazardous garbage bags, and one box of disposable masks. During an interview on 6/24/19 at 11:41 a.m., Infection Control, Registered Nurse (RN A) clarified (Resident #12) required Contact Precautions due to symptoms of nausea and vomiting beginning on 6/21/19. RN A confirmed PPE of gowns and gloves were required with cares and immediate environment. RN A stated, Some staff are sometimes wearing masks because they're paranoid. During an interview on 6/25/19 at 4:14 p.m., Maintenance, Housekeeping, Laundry Supervisor /Staff [NAME] said the facility recently acquired, within the last two weeks, a (brand name) disinfectant cleaner with bleach. Staff [NAME] was asked what the product's contact time for proper surface disinfection. Staff [NAME] responded, ten minutes. Review of the (brand name) product label reads, .CONTACT TIME: Wet surface and let stand 2 minutes . Staff [NAME] said he had not participated in any environmental cleaning monitoring during the outbreak. During an interview on 6/26/19 at 8:10 a.m., the Director of Nursing (DON) confirmed Resident #12's contact isolation was implemented for nausea, vomiting and diarrhea. The DON stated the facility suspected Resident #12 had contracted Norovirus. Review of 2007 Guidelines for Isolation Precautions: Preventing Transmission for Infectious Agents in Healthcare Settings Centers for Disease Control and Prevention (CDC) page 28-29 read, .Noroviruses .are transmitted via contaminated food or water and from person-to-person, causing [MEDICAL CONDITION] of gastrointestinal disease. Environmental contamination also has been documented as a contributing factor in ongoing transmission during outbreaks .The epidemiology of norovirus outbreaks shows that even though primary cases may result from exposure to a fecally-contaminated food or water, secondary and tertiary cases often result from person-to-person transmission that is facilitated by contamination of fomites and dissemination of infectious particles, especially during the process of vomiting. Widepread, persistant and inapperant contamination of the environment and fomites can make outbreaks extremely difficult to control . During a review of the infection control surveillance data, on 6/25/19 at 1:59 p.m., Registered Nurse, (RN) A confirmed she was the infection control coordinator. During review of the (MONTH) 2019 line list, cluster map and summary of analysis, the following was revealed: The line list did not correlate with the cluster map. For example, Resident #60 was listed on the line list in one room, but not shown on the cluster map. RN A stated, Well, that's not even his room. RN A marked the Resident on the cluster map in the correct room. Resident #41 was listed on the line list, but not reflected on the cluster map. Resident #6 was listed on the (MONTH) line list for an infection started on 3/21/19. The (MONTH) summary of analysis of data provided rates of infection compared with the previous month, without providing the statistics to evidence the data. The Infection Control Committee Meeting Minutes, dated 4/24/19, revealed, .Decreases in the Number of Infections Compared to Last Month .Yes, #4 . The column over the #4 revealed, .if Yes, refer to QAA (Quality assessment and assurance) Action Plan # When asked what Action Plan #4 was, RN A could not explain. RN A signed the meeting minutes. The Employee Infection Control Monthly Reporting Period: 4/1/2019 To 4/30/2019, revealed, .Res(ident with) trend/patterns (with) influenza A .Employees (with) pattern cold (symptoms), influenza (symptoms) .Trend/pattern (with) res(idents and) employees .Based on Analysis of Findings the following corrective action will be implemented: Education .Nursing monitored .Was it effective? Yes . When asked if there was any evidence of the effectiveness of the education, provided to staff, such as audits, RN A confirmed there was not. The (MONTH) 2019 surveillance documents revealed the following: The cluster map had a yellow dot in one room, with no key explaining what the dot meant. RN A stated, I don't even know what that one is. The (MONTH) 2019 cluster map revealed 20 cases of Norovirus, but the line list revealed only 10 cases. When asked about the difference, RN A said the other ten cases began in June, but, provided no explanation for why they were on the (MONTH) cluster map. The Employee Infection Control Monthly Reporting Period: 5/1/2019 To 5/31/2019, revealed, . Based on Analysis of Findings the following corrective action will be implemented: Education: Hand Hygiene (with residents)/Employees Monitoring Compliance (Nursing) monitor .Was it effective? Yes . When asked how she knew the education was effective, RN A could not provide evidence. The document showed a trend with residents and staff related to gastroenteritis. RN A agreed, the surveillance documents were difficult to understand, and could not provide an explanation. When asked if the line list should correlate with the cluster map, RN A stated, Yes, there should be one (a dot on the cluster map) for every person on the line list. The policy Infection Control Program, Chapter 1, dated 11/2016, revealed, .Infections are among the most frequent and significant problems facing nursing facility residents today Because of changing requirements and circumstances, this Infection Control Program Manual should be considered a dynamic, not static, process. Its usefulness and effectiveness will be re-evaluated periodically .It (the infection control program) should not just be seen as a way to meet paperwork requirements but as a way to analyze and use information effectively to improve care and prevent problems.

Based on interview and record review, the facility failed to ensure a full body mechanical lift was operated properly in accordance with manufacturer's instructions for one (Resident #103) of eight residents reviewed for full body mechanical lifts in a total facility population of 62 residents. This deficient practice resulted in Resident #103 sustaining right intertrochanteric femoral neck fracture and interhemispheric subdural hematoma, and requiring admission into an acute care hospital for orthopedic and neurosurgical services. Findings include: An abbreviated survey was conducted on 6/3/14 through 6/5/14 in response to an anonymous complaint (received on 6/3/13), which alleged Resident #103 fell from a lift during a transfer on 5/22/14, and suffered a broken hip and a "bleed in his brain". A medical record document titled "Inter Hospital Transfer Form" dated 5/22/14, reflected Resident #103 was emergently transferred to a trauma center via helicopter for trauma surgery services. According to the undated "Resident Admission Record" from the electronic medical record (EMR), Resident #103 was a [AGE] year old male admitted to the facility 1/20/12 and readmitted [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #103 scored 1/15 on the Brief Interview for Mental Status indicative of severe cognitive impairment. The MDS assessment showed Resident #103 as "total dependence" with assist of two (staff) for transfer between surfaces including to or from bed, chair and wheelchair. Resident #103's care plan for falls dated 11/9/13, read in part: "Criss cross legs of sling through inner thighs and secure to mechanical lift." The current Certified Nurse Aide (CNA) care sheet for 5/22/14 indicated "Mechanical lift for all transfer assist of 2" and "assure sling comes through inner thighs and is criss crossed." The manufacturer guidelines for "Patient Lifting Instructions and Sling" dated 1/16/04, read in part: "1) Run the right leg strap under the patient's right leg, up between the patient's legs, and attach to the left front hook; 2) Run the left leg strap under the patient's left leg, up between the patients legs, and attach to the right front hook". (Figure 6 shows a picture with the sling straps criss crossed between the legs.) The document "Incident/Accident Report" regarding Resident #103, dated 5/22/14 and signed by RN "A", included a description of the incident as follows: "Res (resident) (with) fall at 1500 (3:00 p.m.) while being transferred via (mechanical lift)(with) 2 staff...Res observed lying on the floor on R (right) side...res stated he was having pain to R side of head, R leg (and) R rib. Hematoma (bruise/swelling) observed to R forehead, golf ball size..." An interview was conducted with Registered Nurse (RN) "A" on 6/4/14 at 12:22 p.m. RN "A" reported, "Certified Nurse Aide (CNA "B") came to me and said (Resident #103) just fell out of the (mechanical lift) through the hole. When I went down there I was concerned about a hip, rib and obviously head injuries. We stabilized his body...(Resident #103) was alert and talking. He looked scared. He was able to say his head hurt...I assessed him and called (the ambulance)...(CNA "B") said he fell through the hole...she heard his head crack when he hit the floor. (CNA "D") didn't say a word and (RN "C") kind of took over from there." In an interview with CNA "B" on 6/4/14 at 12:34 p.m., she reported, "It actually started out as a completely normal day...I don't know what happened, I just don't know...I just made a mistake, I guess." An interview was conducted with CNA "D" on 6/4/14 at 2:18 p.m. CNA "D" reported, "We hooked him up to the (mechanical lift). (CNA "B") operated the (lift) and I was behind (Resident #103's) wheelchair. I didn't see the fall itself...it happened so quick...I looked up and (Resident #103) was on the floor and the pad (sling) was hanging there..." CNA "D" stated, "The left strap was hooked on the right side and the right strap was hooked on the left side and it (the straps) was under him." ( ) An interview with Registered Nurse (RN) "C" on 6/5/14 at 11:10 a.m., revealed at the time of the transfer of Resident #103 on 5/22/14, it was determined the sling straps were not criss crossed between Resident #103's legs resulting in him falling to the floor. According to the final radiology report from the hospital dated 5/22/14, Resident #103 sustained interhemispheric subdural hematoma and fracture of the right intertochanteric femoral neck. Thus, by not utilizing the proper sling size and criss crossing the sling through Resident #103 legs, the fall with injury could have been avoided. ( ) ( ) --

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE DIRECT SUPERVISION, FOLLOWING THE REMOVAL OF AN ASSISTANCE DEVICE (ALARMED SAFETY BELT) USED TO PREVENT FALLS FOR ONE (#1) OF SEVEN SAMPLED RESIDENTS IDENTIFIED BY THE FACILITY AS BEING AT RISK FOR FALLS FROM A TOTAL SAMPLE OF 14 RESIDENTS. THIS FAILURE RESULTED IN HARM TO RESIDENT #1 WHEN SHE STOOD UP UNASSISTED AND fell , RECEIVING A FEMUR FRACTURE UPON IMPACT. FINDINGS INCLUDE: ALL OF THE TIMES RECORDED ARE CENTRAL STANDARD TIME (CST). DURING THE INITIAL TOUR OF THE FACILITY ON 11/29/11 AT 9:20 A.M. WITH THE DIRECTOR OF NURSING (DON), RESIDENT #1 WAS POINTED OUT AS A RESIDENT WHO HAD FALLEN AND RECEIVED A FRACTURE IN THE FACILITY. A REVIEW WAS PERFORMED OF THE FACILITY "INCIDENT/ACCIDENT REPORT" DATED 11/12/11 FOR RESIDENT #1. THE REPORT REVEALED RESIDENT #1 STOOD UP FROM HER WHEELCHAIR AND fell on TO THE FLOOR AT 6:15 P.M. ON 11/12/11. THE "RESIDENT SAFETY REPORT" DATED 11/12/11 REVEALED RESIDENT #1 WAS SITTING IN THE DINING ROOM AND WAS IDENTIFIED AT RISK FOR FALLS. A REVIEW OF THE "POST DISCHARGE INVESTIGATION SUMMARY", DATED 11/12/11, WRITTEN BY THE DON, REVEALED RESIDENT #1 "HAD (AN) UNWITNESSED FALL IN THE DR (DINING ROOM)... CNAS (CERTIFIED NURSE AIDES) IN DR DID NOT SEE HER FALL, BUT HEARD A LOUD THUMP... X-RAY OBTAINED REVEALING FX (FRACTURE) TO NECK OF (RIGHT) FEMUR." THE FACE SHEET FOR RESIDENT #1 REVEALED SHE IS A [AGE] year-old FEMALE WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. A REVIEW OF RESIDENT #1'S MINIMUM DATA SET ((MDS) dated [DATE] REVEALED SHE EXHIBITED SEVERE COGNITIVE IMPAIRMENT, INATTENTION AND DISORGANIZED THINKING. AN INTERVIEW WAS ATTEMPTED WITH RESIDENT #1 ON 11/29/11 AT 11:00 A.M. RESIDENT #1 WAS UNABLE TO ANSWER SIMPLE QUESTIONS. A REVIEW OF RESIDENT #1'S FALLS CARE PLAN, INITIATED ON 8/02/11, REVEALED RESIDENT #1 HAD FALLEN ON 8/18/11, AND 10/06/11. RESIDENT #1'S INCIDENT/ ACCIDENT REPORTS, REVIEWED FOR THE PAST 3 MONTHS, REVEALED SHE HAD ALSO FALLEN ON 8/05/11. ACCORDING TO THE INCIDENT REPORTS, STAFF RESPONDED TO ALL THREE FALLS WHEN THE RESIDENT'S ALARMS SOUNDED AND NO INJURY OCCURRED TO THE RESIDENT ON THOSE OCCASIONS. THE RESIDENT'S CARE PLAN SHOWED APPROPRIATE INTERVENTIONS WERE PUT IN PLACE FOLLOWING THE 10/06/11 FALL, WITH AN "ALARMED SELF-RELEASE SEATBELT TO BE WORN WHEN (RESIDENT #1) WAS UP IN HER WHEELCHAIR." RESIDENT #1'S CURRENT FALL CARE PLAN ALSO REVEALED, FOLLOWING THE FALL ON 11/12/11 RESULTING IN A FEMUR FRACTURE, RESIDENT #1 HAD IN PLACE A "SENSOR ALARM (TO BE) ON AT ALL TIMES". THIS TYPE ALARM WOULD SOUND IF THE RESIDENT BEGAN LIFTING HERSELF FROM THE WHEELCHAIR. ON 11/29/11 AT 3:45 P.M., AN INTERVIEW WAS HELD WITH CNA "G" PERTAINING TO RESIDENT #1'S FALL WITH FRACTURE ON 11/12/11. CNA "G" STATED, "I WAS IN THE DINING ROOM WHEN SHE (RESIDENT #1) fell , BUT DID NOT SEE HER FALL ...HER (RESIDENT #1'S) ALARMING SEATBELT WAS NOT ON HER ...THAT LADY (RESIDENT #1) IS FAST... REALLY FAST... REALLY NEED TO WATCH HER." CNA "G" WENT ON TO SAY SHE WAS FEEDING ANOTHER RESIDENT AT A DIFFERENT TABLE AND HAD HER BACK TURNED AWAY FROM RESIDENT #1. WHEN CNA "G" WAS ASKED WHY RESIDENT #1'S ALARMING SEATBELT WAS UNFASTENED, SHE RESPONDED, "WE ALWAYS UNDO THE SEATBELTS WHEN RESIDENTS ARE EATING." WHEN CNA "G" WAS ASKED IF RESIDENT #1 COULD HAVE RELEASED THE ALARMING SEATBELT, CNA "G" SAID "NO, IT WOULD HAVE ALARMED WHEN SHE UNHOOKED IT." WHEN CNA "G" WAS ASKED IF ANY STAFF WERE SITTING AT RESIDENT #1'S TABLE, SHE SAID, "NO." ON 11/30/11, INDIVIDUAL INTERVIEWS WERE HELD WITH CNAS "I" AND "F" AT APPROXIMATELY 3:00 P.M. AND 4:30 P.M. RESPECTIVELY. THEY EACH PROVIDED WRITTEN STATEMENTS, DATED 11/30/11, REGARDING THE INCIDENT WITH RESIDENT #1 RESULTING IN A FRACTURED FEMUR. BOTH CNAS STATED THEY WERE IN THE DINING ROOM WHEN RESIDENT #1 fell , WERE SITTING AT DIFFERENT TABLES AND DID NOT SEE HER STAND UP AND FALL. CNAS "I" AND "F" DENIED REMOVING THE RESIDENT'S ALARMING SEATBELT. CNA "F" SAID, "SHE (RESIDENT #1) WAS REALLY QUICK (AT STANDING UP AND MOVING)." AN OBSERVATION OF RESIDENT #1 ON 11/29/11 AT 9:30 A.M. IN HER WHEELCHAIR IN THE HALLWAY, REVEALED A SENSOR ALARM WAS IN PLACE IN THE CHAIR. ON 11/29/11 AT 12:20 P.M., RESIDENT #1 WAS IN THE DINING ROOM WITH A STAFF MEMBER SITTING NEXT TO HER AT THE SAME TABLE WITH A SENSOR ALARM IN PLACE. AN OBSERVATION WAS MADE OF RESIDENT #1 ON 11/30/11 AT 9:50 A.M. IN HER WHEELCHAIR WITH HER ALARMING SEATBELT ON. AT THAT TIME, RESIDENT #1 EASILY UNHOOKED THE BELT. THE SEATBELT ALARMED, AND AS SHE STARTED TO STAND UP, THE SEAT SENSOR ALARMED AND TWO STAFF IMMEDIATELY HELPED HER BACK INTO HER SEAT AND FASTENED HER SEATBELT. ( ) --