Every finding on record at Westland, A Villa Center

Based on observation, interview, and record review, the facility failed to honor a resident's right to smoke for one resident (R167) of three reviewed for self-determination. Findings include: On 05/13/2026 at 11:00 AM, R167 was observed walking in the hallway fully dressed, wearing a winter coat. At 11:08 AM, R167 reported the facility was not allowing them to smoke saying, they had been told it was because they had been caught smoking in their room, which they denied. R167 stated the facility had taken or thrown away the two packs of cigarettes a friend had just purchased for them. On 05/13/2026 at 11:17 AM, R167 walked down the hall toward the smoking area to introduce the activities person (Activity Aide-AA L) who was often out with the smokers. AA L reported R167's smoking privileges had been taken away per the smoking contract and would have to ask the supervisor about any additional information. On 05/13/26 at 11:20 AM, the Activities Director (AD E) reported R167 was their own responsible party and had signed the smoking contract upon admission. AD E reported R167's smoking privileges were taken away as they had been caught smoking in their room. Staff E confirmed R167 had smoked all the cigarettes that someone had purchased for them and could not confirm if anyone had actually seen R167 smoking in their room. On 05/13/26 at 11:28 AM, the Director of Nursing (DON) reported R167 was not actually seen smoking in their room. On 05/13/2026 3:23 PM, a progress note dated 05/10/26 at 2:08 PM, by Licensed Practical Nurse (LPN) F was reviewed and documented (patient) pt found smoking in bathroom. During a phone interview at 2:15 PM, with LPN F they reported they were instructed by their manager, LPN A, to put in a (progress) note because R167 was smoking in their room but confirmed they did not see R167 smoking in their room. On 05/13/26 at 3:43 PM, during an interview with LPN A they reported they were informed R167 was found smoking in the bathroom and told LPN F to write a progress note. LPN A went on to say, R167 was found in the bathroom with an unlit cigarette butt, and no lighter and no one actually saw R167 smoking. On 05/13/2026 at 3:53 PM, the Director of Nursing, (DON), reported R167 did not have any cigarettes to smoke. The DON was asked about R167 going outside at the same time (as the smokers), to just go outside and the DON reported they (R167) just wanted to smoke. The DON confirmed the resident has refused a nicotine patch. On 05/13/2026 at 4:18 PM, AD E reported, R167 could go outside after the smokers came in. AD E reported they would reach out to family to provide additional cigarettes. A review of the progress notes documented only once instance of 04/10/26 at 2:08 PM, (two days after admission) in which R167 was refused a cigarette and proceeded out to the courtyard to ask other residents. No additional instances were noted in the progress notes. On 05/14/26 at 6:16 AM, R167 was observed to be fully dressed and seated on the edge of the bed in their room. The resident was tearful and crying, not understanding why the facility would not let them smoke, had no cigarettes to smoke confirming they had not been smoking in their room. On follow up with AD E, it was noted follow up with family for additional cigarettes had not occurred. The visit notes by the psychiatric nurse practitioner (NP I) dated 05/14/26 at 1:45 PM, documented, .The patient was initially observed pacing the hallway before returning to (their) room .appeared visibly anxious and tearful at times . speech was rapid at times but soft in tone . also endorses ongoing depression and anxiety . A review of the facility medical records for R167 revealed R167 was admitted into the facility on [DATE]. Diagnoses included, Nicotine Dependence, Tobacco Use, Anxiety, Bipolar Disorder and Malnutrition. The active care plan initiated 04/10/26 documented, .resident is new to the facility, has diagnosis of anxiety, intellectual impairment and poor impulse control . A care plan initiated 05/10/26 documented, .has a diagnosis of anxiety and sometimes expresses feeling of fear and excessive worry . A review of the Minimum Data Set (MDS) dated [DATE] documented moderately impaired cognition with an 11/15 Brief Interview for Mental Status (BIMS) score and the need for partial/moderate assistance with personal hygiene and supervision for mobility. A review of the facility Smoking Guideline date 11/28/17 revealed, resident who want to smoke are evaluated and assessed for smoking safety. Each facility establishes its own smoking policy that addresses how when and where to allow smoking. Each resident will be informed prior to or upon admission, residents shall be informed about any limitations on smoking including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences .

This citation pertains to Intake 3012716.Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse for one resident (R57) by another resident (R102). Findings include:On 05/13/2026 at 2:12 PM, along with the facility's administrator, a review of video footage from an incident which occurred on 5/3/2026 at approximately 9:50pm between R57 and R102 was performed. The video revealed the two residents appearing to be arguing and engaging in an angry confrontation. R57 visually (angry facial expression and moving arms about) became agitated by the conversation with R102 and subsequently grabbed R102's phone which was on their lap. R57 then started walking away from R102. R102 was then noted to follow R57, running into them with their electric wheelchair, making contact causing R57's pants to fall down. R57 then struck out at R102 with the back of their hand. The residents were then separated by staff. , an interview was conducted with the facility administrator while viewing the video footage noted above. The administrator described the situation they saw on the video; that R102 ran into R57 with their electric wheelchair, which tangled R57's pants and caused them to fall down while R57 attempted to swat R102 away. On 05/13/2026 at 11:00 AM, an interview was conducted with R57. They stated that during the incident, R102 tried to run them over with their wheelchair so R102 got slapped. R57 further stated that R102 was verbally insulting and egging them on for two hours, and said that R102 goes around bothering everybody, they were just the first that slapped R102. R57 stated they were insulted again by R102 in the hallway when going to the vending machine yesterday, but there was no physical contact. When asked if they felt safe from having further problems with R102, R57 nodded yes. A review of R57's electronic medical record (EMR) revealed they were admitted into the facility on 4/8/2026 with diagnoses of hemiplegia and hemiparesis (one-sided muscle weakness or paralysis) following cerebral infarction (stroke), Type 2 Diabetes, and muscle wasting/atrophy. A review of R57's most recent Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Further review of R57's EMR did not reveal any care plans for behavioral issues.On 05/13/2026 at 11:09 AM, an interview was conducted with Licensed Practical Nurse (LPN) Unit Manager (UM) H. LPN UM H stated they have not witnessed R57 display any aggressive behavior towards staff or other residents.On 05/12/2026 at 9:09 AM, R102 was observed exhibiting loud cursing and derogatory language directed towards the surveyor and facility staff in the hallway near R102's room. As R102 moved past the surveyor in their electric wheelchair, they struck the surveyor's laptop with their hand. They were also observed to be playing loud music in a disruptive manner on a portable speaker.On 05/13/2026 at 11:42 AM, an interview was conducted with R102. When asked about the altercation with R57 on 5/3/2026, they stated that R57 punched them in the face and threatened to kill them. R102 said that during the incident, they were questioning R57 about their health problems, as R102 stated they did not believe R57 had really had a stroke and said R57 was upset because it was like I was busting their game. R102 said they were being followed and threatened by R57, and that R57 was behind them and hit them. R102 stated they then tried to get away but couldn't move fast enough and tried to push R57 away. R102 said they shut off their wheelchair to prevent hurting anyone, and that's when they were struck by R57 and choked.Review of the video footage from the incident noted above did not support the statements of R102 being hit from behind or choked by R57.A review of R102's EMR revealed they were admitted into the facility on 6/21/2024 with diagnoses of quadriplegia (paralysis of body and limbs) C-1 through C-4 (first four vertebrae of the spine) incomplete, unspecified psychosis, and generalized anxiety disorder. A review of R102's most recent MDS dated [DATE] revealed a BIMS score of 13, indicating intact cognition.A review of R102's care plan revealed The resident has a behavior problem cursing, screaming, and other unpredictable behaviors r/t schizoaffective and depressive disorders, with interventions including Psychiatric/Psychogeriatric consults as indicated, Evaluate resident for changes in pain levels and if appropriate request a scheduled pain medication from Physician, If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident, and Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes.A psychiatry encounter note dated 5/7/2026 revealed Behavioral concerns remain significant. Additional reports indicate ongoing agitation and impulsive behaviors, including a recent altercation in the dining room where the patient threw a drink at another resident. [R102] has also made threatening statements toward peers, including comments about physically harming another individual with a baseball bat.On 05/13/2026 at 11:23 AM, an interview was conducted with LPN J. LPN J stated they have witnessed R102 showing verbal aggression towards staff and other residents all the time. They further stated that R102 will sometimes follow other residents and insult them even after the targeted resident tries to walk away. LPN J said that staff attempt to redirect R102 and walk alongside them when they start displaying these behaviors.On 05/13/2026 at 11:38 AM, an interview was conducted with Certified Nursing Assistant (CNA) K. CNA K stated R102 is on one-on-one supervision, and they follow people and constantly insult and nitpick other staff and residents. When this behavior occurs, CNA K said that staff will redirect the resident, take them for a walk, or offer them to get something to eat. CNA K stated other residents in the building have complained about R102's behavior.On 05/14/2026 at 9:50 AM, an interview was conducted with LPN UM H. LPN UM H stated the expectation for managing R102's behaviors was one-on-one monitoring, especially in the hallways. Staff should encourage R102 and their targeted resident to be separated, and if R102 continues to follow them, that resident should be removed from the situation and administration should be notified. On 05/14/2026 at 10:43 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that staff are to deescalate and separate residents who are having a verbal altercation for safety, and to report to management what happened so next steps like psychiatric consults and behavior plans can be assessed. On 5/14/2026 at 11:21 AM, CNA R, who was assigned as the one-on-one aide for R102 during the time of the incident, was called for an interview but did not answer or have a voicemail set up.On 05/14/2026 at 10:01 AM, residents that attended the resident council meeting reported a patient at the facility that was going around harassing others by recording from the outside window into their bedrooms, saying all kinds of things to people, and trying to run over others with their electronic wheelchair. The patient was later identified as R102 by the residents. Review of a facility policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property with an effective date of 11/28/2017 revealed It is the policy of the Facility that each resident will be free from Abuse . Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for Protection.

Based on observation, interview, and record review, the facility failed to develop comprehensive care plans for Post-Traumatic Stress Disorder (PTSD) and discharge planning care plans for three residents (R5, R112 and R223) out of three reviewed for care plans. Findings include: R5 On 5/12/2026 at 10:00 AM, R5 was observed sitting in their wheelchair. R5 stated they do not have any problems in the facility; however, they sometimes get depressed. R5 reported they do speak to psychiatric services inside the facility. A review of the medical record revealed R5 admitted into the facility on 9/2/2020 with the following medical diagnoses Post-Traumatic Stress Disorder and Major Depressive Disorder. A review of the Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status score of 14/15 indicating an intact cognition. R5 was also coded on the MDS as having PTSD as an active diagnosis. Further review of R5's did not reveal a care plan for PTSD. On 05/14/2026 at 12:00 PM, an interview was conducted with Social Worker (SW) B. SW B reported they have only been in the facility for four weeks. Upon medical record review, SW B confirmed they did not see a developed care plan with goals and interventions addressing R5's PTSD. R223 A review of the facility electronic medical records revealed, R223 was admitted in the facility on 01/12/26 and discharged on 02/17/26. Diagnoses included Debility, Muscle Wasting and High Blood Pressure. The Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition and substantial/maximal or dependence on staff assistance for most activities of daily living. R223 was a one-person assist and was alert and oriented. A review of the care plans initiated 01/13/26 revealed no care plan for discharge planning. On 05/13/2026 at 4:00 PM, Licensed Practical Nurse (LPN) N reported they recalled R223 discharged to home and had been at the facility for intravenous (IV) antibiotics. R112 On 05/13/2026 at 8:34 AM, R112 reported a concern for a delay in their discharge to an apartment and their discharge had been cancelled four times. On 05/13/2026 at 12:00 PM, the Corporate Social Worker reported there was a plan in place to discharge R112 on 05/15/26 pending final details for care post discharge. A review of the facility electronic medical record revealed R112 was admitted into the facility 03/23/26. Diagnoses included Heart Failure and Dialysis. The Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition and setup or partial/moderate staff assistance for most activities of daily living. A review of the care plans initiated 03/24/26 revealed no care plan for discharge planning. On 05/14/2026 at 1:59 PM, the discharge process and the care plan records for R112 and R223 were reviewed with the Director of Nursing (DON) who reported the Social Worker was the person who initiated the discharge care plan, and it was generally completed at admission and updated as needed. The DON confirmed no discharge care plan had been initiated for R112 nor R223. A review of the facility Transfer and Discharge Guideline dated 11/28/27, revealed, .the facility staff will reevaluate the resident's care plan to determine if changes to the care plan will help meet the resident's needs .

Based on observation, interview, and record review, the facility failed to provide adequate grooming care for one (R76) of three residents reviewed for activities of daily living (ADL) care. Findings include: On 05/12/2026 at 12:29 PM, R76 was interviewed at bedside. They were observed to have lengthy hair stubble on their chin and upper lip and reported they prefer to keep their face shaved regularly and is able to do it themself, but they have trouble getting assistance and supplies to shave with. A review of the facility medical records for R76 revealed they were admitted into the facility on [DATE] with diagnoses that included Muscle Wasting and Atrophy, Abnormal Posture, and Unspecified Visual Disturbance (visual impairment). The Minimum Data Set (MDS) assessment dated [DATE] indicated R76's cognition was intact and they required Supervision/Touching Assistance to Total Assistance for completion of self-care activities. R76's Care Plan included a Focus area which addressed the resident's impaired vision and included an intervention of, Assist with all ADLs that resident is unable to self-perform. On 05/13/2026 at 1:15 PM, R76 was interviewed at bedside, and the facial hair was observed to remain unshaved. On 05/14/2026 at 10:56 AM, R76 was interviewed at bedside, and their facial was observed to remain unshaved. When asked how they feel when the facial hair is grown out, they stated, It looks bad and it's embarrassing. On 05/14/2026 at 2:04 PM, Certified Nursing Assistant (CNA) C was interviewed and reported they shave residents either on shower days or during daily ADLs on non-shower days if they notice it needs to be done. CNA C reported they are expected to complete the shaving question on the shower sheet identifies male or female and Yes or No whether the task was completed or not. A review of the eight shower sheets dated 4/18, 4/22, 4/25, 4/29, 5/5, 5/6, 5/9, and 5/13/26 for R76 documented the shaving completion question had not been completed on any of them and no additional notes were present on the sheets addressing shaving. Review of the ADL items in the resident's Kardex Task tab (a task completion checklist in the electronic medical record) revealed no resident refusals or completion of shaving. On 05/14/2026 at 2:34 PM, the facility Director of Nursing (DON) was interviewed and made aware of the concern related to R76's facial hair and reported resident shaving should be maintained according to resident preference and should be documented including any resident refusals. The DON indicated that due to R76's visual impairment, the resident would require shaving assistance and would not be able to use a razor unassisted. A facility policy addressing ADL care was requested on 5/14/26 at 10:39 AM but not received by the time of survey exit.

Based on observation, interview, and record review, the facility failed to apply heel protectors per physician orders for one resident (R16) out of two reviewed for skin conditions. Findings include:On 5/12/2026 at 12:18 PM, R16 was observed lying in bed. No heel boots were in use and R16's heels were resting on the mattress. On 5/13/2026 at 9:27 AM, R16 was observed lying in bed. No heel boots were in use and R16's heels were resting on the mattress. On 05/14/2026 at 9:58 AM, R16 was observed lying in bed. No heel boots were in use and R16's heels were resting on the mattress. A review of the medical record revealed R16 re-admitted into the facility on 5/21/2023 with the following medical diagnoses, Muscle Weakness and Adult Failure to Thrive. A review of the Minimum Data Set assessment (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3/15 indicating an impaired cognition. R16 also required staff assistance with bed mobility and transfers. Further review of the physician's orders noted the following, Ordered: 4/27/2026 .heel lift off loading protective boots, bilateral .Status: Active .On 5/14/2026 at 10:00 AM, an interview was conducted with Licensed Practical Nurse (LPN) A. LPN A was asked if R16 should have on bilateral heel protectors. LPN A reported they are unsure but would look into it. On 05/14/2026 at 11:41 AM, R16 was observed lying in bed. No heel boots were in use and R16's heels were resting on the mattress. On 5/14/2026 at 11:50 AM, an interview was conducted with the Director of Nursing (DON). The DON stated they would look into if R16 still needed the heel boots, because they did not have anything on their heels at the time. Neither LPN A or the DON followed back up with information regarding R16's heel boot order.A request for a policy related to following physician orders was requested on 5/14/26 at 10:39 AM but not received by the end of survey.

Based on interview, and record review, the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS-an assessment to detect involuntary movement) assessment for one resident (R27) out of five reviewed for unnecessary medications. Findings include: A review of the medical record revealed R27 admitted into the facility on 4/3/2026 with the following medical diagnoses, Wernicke's Encephalopathy (acute neurological emergency caused by thiamine (vitamin B1) deficiency, often associated with alcohol misuse, and can progress to irreversible brain damage if untreated) and Major Depressive Disorder. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating R27 was unable to complete the assessment and required staff assistance with bed mobility and transfers. Further review of the medical record noted R27 was prescribed Risperdal (an antipsychotic) three times a day. The medical record did not reveal an AIMS assessment completed for R27. On 5/14/2026 at 12:02 PM, an email was received from the Nursing Home Administrator (NHA) indicating they reached out to the psychiatry group to determine why an AIMS was not completed for R27. A review of a facility policy titled, Psychotropic Medications Guideline did not address completion of AIMS assessments.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent (medication rate 6.67%) for two residents (R6 and R23) of eight resident observed during the medication pass observation. Findings include:R6 On 05/14/26 at 5:24 AM, Licensed Practical Nurse (LPN) P and Q were observed to prepare a 5% menthol pain patch at the medication cart for R6. LPN P and Q then entered the room of R6 and applied the patch onto the skin of the lower back of R6. Upon return to the cart the medication physician order was reviewed with LPN P. The active order dated 04/15/25 was documented as Pain Relieving Ultra St (strength) External Patch 5% Apply to right knee, lower back topically in the morning for pain. LPN P acknowledged they had not asked R6 about the need for a pain patch on the right knee. LPN P reported there were four patches in the package. LPN P reentered the room and asked R6 if they desired a pain patch for the right knee and R6 accepted. A review of the electronic medical record for R6 revealed R6 was admitted into the facility on [DATE]. Diagnoses included Dementia and Stroke. R23On 05/14/2026 at 5:51 AM, LPN O was observed to prepare a Guaifenesin 400 milligram (MG) immediate release tablet at the medication cart for R23. LPN O then entered the room of R23 and administered the medication to R23. Upon return to the cart the medication bottle and physician order were reviewed with LPN O. The active order dated 02/25/26 was documented as Mucinex (guaifenesin) Oral Tablet Extended Release 12 Hour Give 1 tablet by mouth every 24 hours as needed for cough. LPN O reported the 400 mg immediate release tablet was what was available from supply. A review of the electronic medical records (EMR) for R23 revealed R23 was admitted into the facility on [DATE]. Diagnoses included Acute Cough and Epilepsy. A review of the facility's policy titled, Medication Administration-Guidelines dated May 2022, revealed, .Medications are administered as prescribed in accordance with good nursing principles and practices .

Based on observation, interview, and record review, the facility failed to maintain an accurate medical record for one resident (R210) out of two reviewed for medical records. Findings include:On 5/12/2026 at 9:38 AM, R210 was observed lying in bed with their blanket over their head and was nonreviewable. An Enhanced Barrier Precaution (EBP) sign was on the door, as well as a cart in front of the door. A review of the medical record revealed R210 admitted into the facility on [DATE] with the following medical diagnoses, Severe Sepsis with Septic Shock and Failure to Thrive. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 0/15, indicating an impaired cognition and required staff assistance with bed mobility and transfers. Further review of the medical record revealed the following physicians' orders, (Name of) Cath (Catheter) DX (Diagnosis): BPH (Benign Prostatic Hyperplasia) neuromuscular dysfunction of the bladder.Status: Active. Enhanced Barrier Precautions (EBP) r/t (related to) (name of) catheter.A review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], also coded R210 as having an indwelling catheter device. Further review of R210's active care plans noted the following, Focus: Resident requires EBP r/t foley catheter.Date Initiated: 1/21/2026. Focus: (Name of): Resident requires use of an indwelling catheter r/t obstruction 2/2 BPH.Date Initiated: 3/16/2026.On 5/13/2026 at 8:47 AM, R210 was observed lying in bed and noted to be free from any catheter devices. Further review of the progress notes revealed the following, Date: 2/4/2026 13:48 (1:48 PM) Nurses Note.: Resident complained of pain from cath, upon removal and reinsertion of cath moderate amount of blood noted at the urethral site and in urine return. Resident verbalized increased pain and discomfort throughout procedure. Procedure paused and hospice Notified. New orders given . Date: 2/5/2026 15:01(3:01 PM) Nurses Note.: Writer contacted hospice regarding catheter reinsertion for (R210). Hospice advised to allow bladder to rest for additional 24 hrs. Continue to monitor bladder output. Hospice will follow up and reassess tomorrow.On 5/14/2026 at 10:35 AM, an interview was conducted with MDS Nurse S. MDS Nurse S' reported that it may be a coding error. MDS nurse S confirmed R210 no longer has an indwelling catheter. On 5/14/2026 at 10:47 AM, an interview was completed with the Assistant Director of Nursing (ADON). The ADON reported the catheter and EBP orders and care plan should have been discontinued and resolved when the catheter was discontinued by hospice. On 5/14/2026 at 11:35 AM, an interview was conducted with the Director of Nursing (DON) and they reported it is a collective team effort to ensure the information in the medical record remains accurate. A request for a facility policy related to accurate medical records was requested, but not received by end of survey.

This citation pertains to Intake 2978833.Based on interview and record review, the facility failed to permit one resident (R700) out of three residents reviewed for discharges, to return to the facility after a hospitalization. Findings Include: A review of documentation submitted to the State Agency (SA) revealed the following, Complainant states the facility called the police and had [them] sent to the hospital for a psych (psychiatric) evaluation on the evening of 04/07/2026.The complainant states [they the hospital] cleared his evaluation and is ready to be sent back to the facility, but [facility] staff told the hospital they won't accept [them] back . On 4/16/26 at 10:32 AM, R700 remained hospitalized and was interviewed via phone. They explained they were transported to the local hospital and evaluated by psychiatric services. They explained they were cleared to return to the facility; however, they were informed by the hospital social worker the facility was not willing to take them back, rather they would be transferred to another facility located in a different city. R700 explained they wanted to return back to the facility as it has been their home for almost two years, and they were still at the hospital and are ready for discharge. R700 further explained they were also informed their personal belongings had been moved to the other facility and was concerned their belongings were missing.A review of R700's medical record revealed they were admitted into the facility on 6/21/24 and discharged from the facility on 4/7/26 with diagnoses which included, Quadriplegia, Depression, and schizoaffective disorder. Further review revealed the resident was cognitively intact and required assistance with activities of daily living (ADLs). On 4/14/26 at 11:18 AM, an interview was complete with the Nursing Home Administrator (NHA), and explained R700 behaviors began to appear manic within the last 3-4 weeks, where they were making accusations about employees and residents, stalking and causing havoc to the point the police had to be called three times as they were becoming a threat to other residents. The NHA further explained the resident was going to be transferred to the facility's sister facility as they could better manage the resident's behaviors, and their belongings had already been transferred there. The NHA was asked if there had been a discussion with the resident about this transfer, and indicated between the hospital liaison, corporate, and the resident's physician, this discussion was held and the resident agreed. On 4/14/26 at 2:51 PM, the Director of Nursing (DON) was asked about R700's discharge from the facility, and explained the resident began displaying symptoms of a psychotic break and was petitioned to the hospital. Regarding R700 returning to the facility, the DON explained the resident's physician thought the resident would receive better psychiatric care at their sister facility and the conversation regarding this was between the physician and the resident as the resident indicated they wanted to be transferred elsewhere. A review of the resident' progress notes did not note any arrests by the local police, documentation of the resident's agreeance to transfer to another facility or a change in the resident's ability to go out of the building for leave of absences alone due to their mental health. A review of local hospital documentation dated 4/8/26 revealed the social worker spoke to the DON who informed them the resident's physician wanted the resident transferred to their sister facility. The progress notes revealed the following, PSW (psychiatric social worker) spoke with patient who is refusing to go to [sister facility]. [R700] states that [they] will return to [home facility].Further review of hospital documentation dated, 4/14/26 revealed the following, SW (social worker) met with pt (patient) at bedside this morning to discuss dc (discharge) plan, [sister facility] can accept the pt. Pt is refusing to go to this facility, [they] report [they] only want to go back to [home facility]. Per chart review they are not allowing [R700] to return .A review of the facility's Transfer and Discharge policy revealed the following, .The resident and representative will receive timely notification, adequate preparation, orientation and information to make the transfer as orderly and safe as possible. The notice contains information about the transfer and information about the resident's appeal rights If the transfer is due to an emergency, the notice will be issued as soon as practicable .

This citation pertains to Intake 2978833.Based on observation, interview, and record review, the facility failed to implement supervision interventions after an incident of alleged inappropriate touching for two residents (R705 and R706) of two reviewed for adequate supervision.Findings include: A review of documentation submitted to the State Agency (SA) revealed the following, Complainant states an unknown male resident on Unit 3 gave resident [R706] a bag of candies in exchange for allowing him to touch her inappropriately. The complainant states [they] witnessed the male resident's hand up [R706's] dress and [R706's] hand was on the outside of the male resident's pants near his genitals. On 4/14/26 at 11:18 AM, a request for documentation related to any incidents regarding R706 was requested and was provided with an investigation regarding inappropriate touching between two residents, R705 and R706 in exchange for candy. The conclusion of the facility's investigation was inconclusive.On 4/14/26 at 12:50 PM, R705 was interviewed regarding allegations that he touched R706 inappropriately in exchange for candy. R706 became defensive and explained they were in their room when R706 wheeled themselves into their room and started touching their snacks. R705 indicated he attempted to stop R706 because he was aware the resident isn't supposed to eat anything by mouth. He denied touching R706 anywhere on their body. A review of R705's medical record revealed they were admitted into the facility on 3/19/22 with diagnoses which included, Schizoaffective Disorder, Bi-Polar Disorder and Anxiety. Further review revealed the resident was cognitively intact and required assistance with activities of daily living.On 4/14/26 at 12:59 PM, R706 was interviewed and was able to communicate through the use of nodding their head and the use of hand gestures regarding the allegations of inappropriate touching, due to their speech impairment. R706 was able to communicate that she did touch R705 in his groin area, and that he also touched her in her groin area in exchange for candy. R706 was also able to communicate this type of incident occurred twice by holding up two fingers, and she did not feel safe in the facility because of R705. A review of R706's medical record was reviewed and revealed they were admitted into the facility on 9/8/14 with diagnoses which include, Vascular Dementia, Anxiety and Depression. Further review revealed the resident was cognitively intact and required assistance for activities of daily living. On 4/14/26 at 2:31 PM, an interview was completed with the NHA regarding the alleged incident between R705 and R706. The NHA explained the investigation was inconclusive as R705 stated it didn't occur, while R706 indicated that it did. Regarding interventions, the NHA indicated that facility staff are aware of the need to monitor both residents. On 4/24/26 at 2:40 PM, a phone interview was completed with the Director of Nursing (DON) regarding R705 and R706 and explained R705 stated touching didn't occur while R706 stated it did. Regarding interventions, the DON explained, the residents were both informed to stay out of each other's rooms.A review of both R705 and R706's current plans of care did not address increased supervision for either resident.A review of the facility's Care Plan Standard Guideline policy revealed the following, .Comprehensive Care plan. The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: 1. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being .

This citation pertains to intake 2588154.Based on observation, interview, and record review, the facility failed to maintain clean and sanitary shower beds affecting two residents (R900 and R902) out of three residents reviewed for infection control. Findings include: R900On 9/4/2025 at 10:02 AM, an interview was conducted with R900. R900 reported they had just been given a bed bath and dressed for the day. R900 reported they would love to take a shower, but the bed baths and shower rooms are not clean at all. R902On 9/4/2025 at 12:00 PM, an interview was conducted with R902. R902 reported they would love to take a shower, however the shower beds that they use are disgusting. R902 proceeded to show pictures in their phone of the shower bed on various days. R902 reported they have just been doing bed baths because no one will clean the shower beds. On 9/4/2025 at 12:20 PM, shower room [ROOM NUMBER] was observed with Certified Nursing Assistant (CNA) C. A shower bed was observed in the shower room. The shower bed had a blue covering on it and was noted to have standing brown water in the crevices. The shower bed was observed to have white residue on it, and brown flakes on the covering, as well as the white plastic frame poles. CNA C was asked who was responsible for cleaning the shower beds. CNA C reported staff are supposed to clean the shower beds after each resident use. At 12:43 PM, an observation of shower room [ROOM NUMBER] was completed with Infection Control Preventionist (ICP) B. ICP B reported the shower beds should be cleaned in between patient use, and then a deep clean on midnights. ICP B reported there are scrub brushes and disinfectant in every shower room to clean the shower beds and chairs, and it should be getting completed. A review of a facility policy titled, Medical Equipment Management noted the following, .Clean equipment surfaces in accordance with instructions from both the equipment manufacturer and the chemical manufacturer.

This citation pertains to Intake: MI00153897 Based on interview and record review, the facility failed to ensure an allegation of abuse was reported to the State Agency for one resident (R901) of one reviewed for staff to resident abuse. Findings include: A review of documentation submitted to the State Agency revealed the following, At nighttime a nurse put [R901] in a chair and tied a belt [restraint] around [them]. [R901] was screaming to get out and the nurse told [them] to 'shut up'. On 6/30/25 at 9:47 AM, R901 was observed resident sitting in their wheelchair. Attempts to interview the resident were to no avail. A review of R901's medical record revealed they were admitted into the facility on 3/27/25 with diagnoses which included, other abnormalities of gait and mobility, Dysphagia, and Difficulty in Walking. Further review revealed the resident was severely cognitively impaired and required extensive assistance for Activities of Daily Living. On 6/20/25 at 11:00 AM, a request for all Facility Reported Incidents (FRIs) submitted to the SA regarding R901 were requested from the Nursing Home Administrator (NHA), and they responded there were no FRIs submitted for R901. On 6/30/25 at 11:09 AM, an interview was completed with the Director of Nursing (DON) regarding allegations of abuse and physical restraints for R901. The DON confirmed there was an investigation concerning allegations that R901 had been physically restrained to their wheelchair but was unable to confirm it happened. The DON also acknowledged there was a training for staff following the alleged incident regarding abuse and physical restraints. On 6/30/25 at 1:49 PM, an interview was completed with the NHA regarding the SA not being notified of alleged allegations regarding R901. The NHA explained the internal investigation was completed immediately, but the allegations could not be confirmed. The NHA also acknowledged training was held on abuse and restraints, and a past non-compliance was completed. A review of the facility's Abuse policy revealed, .Initial reporting of allegations: If an incident or allegation is considered reportable, the Administrator or designee will make an initial (immediate not to exceed within 24 hours) report to the State Agency. A follow up investigation will be submitted to the State Agency within five (5) working days .

This citation pertains to Intake number: MI00153419. Based on observation, interview, and record review, the facility failed to thoroughly assess and determine the root cause of a skin impairment for one (R801) of one resident reviewed for skin management. Findings include: A review of a complaint submitted to the State Survey Agency (SSA) revealed an allegation that staff were rough when transferring them to the wheelchair and have caused injury to their arms and legs. An unannounced, onsite investigation was conducted on 6/10/25 and 6/11/25. On 6/10/25 at 9:25 AM, R801 was observed lying flat on their back in bed. R801 sat up in bed and the left hand was observed to be held tightly against their chest. It was unknown if they were able to straighten their arm. R801 was able to move the right arm freely. At that time R801 was interviewed about the care in the facility. R801 reported they wanted to get out of the facility and said they hated it there. R801 reported staff were rough with them when they put them in the wheelchair and sometimes it hurt their arms. R801 reported they did not report it to anyone because it made them feel anxious was afraid they would get in trouble. At that time, R801's arms were visible and did not appear bruised or with any skin impairments. A review of R801's clinical record revealed R801 was admitted into the facility on 3/12/24 and readmitted on [DATE] with diagnoses that included: hemiplegia and bipolar disorder. A review of R801's Minimum Data Set (MDS) assesment dated 3/14/25 revealed R801 had intact cognition, no behaviors, and was dependent on staff assistance for chair to bed and bed to chair transfers.

This citation pertains to Intake number: MI00153419. Based on observation, interview, and record review, the facility failed to provide medically related social services for one (R801) of one resident reviewed for mood and behaviors who had a history of self harm and repeatedly contacted 911(emergency medical services). Findings include: A review of a complaint submitted to the State Agency revealed allegations of being treated badly by the staff at the facility and as a result had thoughts of suicide and thoughts of homicide towards the staff. On 6/10/25 at 9:10 AM, an interview was conducted with the Administrator who reported they were not aware of any suicidal or homicidal ideations expressed by R801. On 6/10/25 at 9:25 AM, R801 was observed lying flat on their back in bed. R801 had a long, scruffy beard and wore a hospital gown. When queried about the care in the facility, R801 reported they hated it at the facility and wanted to get out of there. R801 reported the staff were rough when they provided care and did not like to talk to people about their concerns because they did not want to get in trouble. R801 reported they called 911 often, was on a waiting list for housing for Veterans, and wanted to go outside to smoke. R801 stated, I would rather be dead, than be here! R801 reported they had not talked to anyone from the social services department in a while. A review of R801's clinical record revealed R801 was admitted into the facility on 3/12/24 and readmitted on [DATE] with diagnoses that included: hemiplegia, hemiparesis, and bipolar disorder. A review of a Minimum Data Set Assessment (MDS) assessment dated [DATE] revealed R801 had intact cognition and no behaviors. A review of R801's Social Service Notes revealed the last note was dated 3/18/25 and read, Writer met with resident due to increased behaviors, resident explained they get agitated but don't now why, resident agreed to be seen by psych (Psychiatrist). Psych to follow. A review of R801's progress notes from 2/2025 through 3/18/25 revealed R801 had multiple incidents of resisting care, screaming at staff, and agitation. Further review of R801's progress notes after 3/18/25 revealed the following: R801 had a psychiatric evaluation on 3/31/25. At that time R801 had feelings of anxiety and depression and exhibits moments of irritability and impulsivity .via verbal outbursts in (nursing home) when making requests from staff .reports frequent sleep disturbance on most nights . R801 called 911 on: -4/9/25 because felt like he was having a stroke/heart attack, -5/6/25 because they were in pain, -5/22/25 due to shoulder pain, -5/31/25 due to chest pain, and -6/2/25 for groin and arm pain. R801 was transferred to the hospital on most of those dates and returned to the facility the same day besides the on 5/6/25 when they were admitted to the hospital until 5/11/25. There was no documentation of any discussion with R801 to determine why they kept calling 911. A review of R801's psychiatric evaluation notes revealed they were seen by psychiatric services on 4/9/25 and 5/9/25 but there was no mention of R801 calling 911 and going to the hospital. On 5/22/25, prior to R801 calling 911, it was documented that R801 continued to scream even after staff did every task (R801 demanded, changed, water, snack, repositioned, calling 911 several times, very agitated, using vulgar language to staff) . On 6/2/25, it was documented in a Health Status Note the physician was notified of R801's call to 911 to be transferred to the hospital. The physician ordered a Full Psych Eval from the hospital prior to returning to the facility for possible guardianship. R801 returned to the facility the same day. R801 called 911 on 6/3/25 for chest pain and the physician (MD) ordered R801 to be sent to a specific hospital. R801 returned the same day. On 6/3/25 at 2:25 PM, approximately four hours after R801 returned to the facility from the hospital, the following was documented, Writer called 911 to get transferred to the hospital due to abdominal pain. Resident was observed by staff member hitting themself in the stomach . R801 returned to the facility on 6/3/25 at 8:00 PM. On 6/6/25, it was documented in a progress note R801 asked to be changed, during peri care residents bottom sheet was wet. They did not want their bottom sheet changed and started to yell and bang their head against the wall .MD notified ordered to transfer resident to ER (Emergency Room) for Psych Eval (evaluation) . It was documented in a Transfer to Hospital . note on the same date that R801 was being transferred for psych eval due to self harm. Further review of R801's progress notes revealed continued documentation of R801 calling 911 to be transferred to the hospital. A review of a psychiatric evaluation note dated 6/9/25 revealed no documentation of R801's continued 911 calls and hospital transfers or the incidents of self harm on 6/3/25 (punching self in the stomach) and 6/6/25 (banging head on the wall). Further review of R801's Social Service Notes revealed no additional follow up from social services since 3/28/25 when it was identified R801 had increased behaviors. There were no notes from social services that addressed R801's incidents of self harm. A review of R801's care plans revealed the following: A care plan initiated on 4/30/24 that noted, The resident is resistive to care .chooses to call 911 for shoulder pain .verbally aggressive with staff . No additional interventions were implemented since 7/19/24. No care plan was developed or implemented after R801 exhibited self harming behaviors (hitting self in stomach and hitting head on the wall). On 6/10/25 at 10:04 AM, an interview was conducted with the Director of Nursing (DON). When queried about any behaviors exhibited by R801, the DON stated, They just call 911 all the time. It is becoming an issue for the doctor. When queried about why R801 called 911, the DON stated, They don't say why they are calling, they just call. The DON reported staff could be in the room and as soon as they leave, EMS showed up. The DON reported Physician 'D' wanted R801 to have a cognitive test because they can't make their own decisions. When queried about any assessment from social services or nursing, psych services, or the physician that documented any discussion about the root cause of why R801 called 911 all the time, the DON reported R801 did not give a reason. No documentation was provided to show that was discussed with R801. On 6/10/25 at 12:28 PM, an interview was conducted with Social Services Director (SSD 'B'). SSD 'B' reported they started working in the facility a little over one month ago. When queried about how the social services department was involved in developing and implementing interventions for behaviors, SSD 'B' reported they started a new behavior management program recently. When queried about how the social services department was notified of any new or increased behaviors from residents, SSD 'B' reported they look at nursing documentation or was verbally notified by nursing staff. When queried about knowledge of any suicidal ideations or self harming behaviors, SSD 'B' reported they were not aware of those things, only that the resident called 911 a lot and had frequent yelling. On 6/10/25 at approximately 1:00 PM, an interview was conducted with the Administrator who was over the social services department. The Administrator reported he was not aware of any self harming behaviors exhibited by R801 and there should have been documented follow up and interventions in place after he returned to the facility from the hospital.

This citation pertains to intake M100152760: Based on observation, interview, and record review, the facility failed to prevent the misappropriation of medication for one (R703) of three residents reviewed for misappropriation of property. Findings include: Review of the identified intake revealed the facility reported to the State Agency (SA) that R703 had missing medication and their investigation determined that the medication had been diverted by Licensed Practical Nurse (LPN) A resulting in reports to the SA and local law enforcement. On 05/27/25 at 10:40 AM, R703 was interviewed in their room. They reported they had no concerns regarding missing any pain medication doses or being able to get their medication when they needed it. R703 was observed to demonstrate no overt signs of pain. R703 indicated no specific knowledge of their medication being missing at any point. On 05/27/25 at 12:01 PM, a call was placed to LPN A and a message requesting a return call was left. No return call was received by completion of the survey. On 05/27/25 at 12:45 PM, the facility Director of Nursing (DON) was interviewed and asked their understanding of how the medication diversion took place. The DON reported the alleged perpetrator had started a new Controlled Substance Shift Inventory and recorded a false number of medication blister packs so that when LPN A and LPN B completed the shift change medication count no discrepancy was initially identified. The DON reported that approximately two hours after the shift change R703 requested their pain medication and when LPN B attempted to retrieve it, the absence of the medication was identified. The DON reported the ensuing investigation revealed the Controlled Substance Shift Inventory which proceeded the new one that LPN A completed was missing as were the pharmacy controlled substance sheets that pertain to the missing medication. The DON reported the missing inventory sheet was found intact in the shred box and it did reveal a discrepancy in the number of controlled substance blister packs when compared to the new inventory made by LPN A. On 05/27/25 at 2:05 PM, the DON was interviewed and asked their expectation for comparing a new controlled substance inventory sheet to the previous inventory to confirm the transfer of accurate information and the DON reported that the oncoming nurse should verify the previous inventory against the new one when a new inventory is presented and acknowledged that in this case the oncoming nurse did not do so. On 05/27/25 at 2:50 PM, LPN B was interviewed via phone. LPN B reported they did recall the shift change with LPN A and stated they did complete a med count together. LPN B reported they did realize that a new controlled substance inventory had been started and that they asked LPN A about the previous inventory and LPN A told them they had put it in the nursing box. LPN B was asked if putting the previous inventory in the nurses box was normal procedure and they stated No, we normally only do that at the end of the month. LPN B acknowledged that this incident did not occur at the end of the month and therefore the previous inventory should have been available with the new inventory for review, however they did not pursue it further at that time. Review of the facility policy Controlled Substance Accountability Guideline revealed the following statement under Change of Shift Reconciliation: Two licensed nurses (the nurse arriving on duty and the nurse departing from duty) are required to conduct reconciliation (i.e., change of shift count) of controlled substances and sign a signature log attesting to the completion and accuracy of the count. The reconciliation process should include: - A count comparing the Controlled Substance Count Sheet Inventory Log (the master list of the individual count sheets) with the actual individual count sheets. Review of the facility policy Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property dated 11/28/17 revealed the statement It is the policy of this facility to prevent abuse by providing residents, families and staff information and education on how and to whom to report concerns, incidents and grievances without the fear of reprisal or retribution. The Definitions portion of the policy included Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident ' s belongings or money without the resident ' s consent.

Based on interview and record review, the facility failed to ensure the residents' right to receive unopened and private mail delivery was maintained for two of eight confidential residents who attended a resident group interview. Findings include: On 3/19/25 at 9:48 AM, during the Resident Council interview meeting, the residents reported, their mail is delivered opened at times. One resident explained they had a personal letter from their sister that was opened, and they didn't understand why this happened. The group explained if the facility staff felt the mail might be a check, they will open it. On 3/19/25 at 2:18 PM, the Activities Director was asked about the delivery of mail. The Activities Director (AD) explained the mail is given to them by the business office and they deliver the mail to the residents. The AD was asked if they opened resident mail, the AD explained the activities department does not open resident's mail. The AD further explained the business office has opened mail and has given it to the activities department for us to deliver it to the resident. The AD explained they did not feel comfortable with delivering mail that had been opened because it is against the law to open other people's mail. The AD explained when open mail is given to the activities department they return it back to the business office, for them to deliver to the resident. On 3/20/25 at 9:02 AM, the Business Office Manager was asked about the opening of resident's mail. The manager explained they open resident's mail if the facility's name is also on the mail, along with the resident's name. A review of the facility's policy titled, Resident Rights dated 1/28/2017, revealed, Purpose: It is the practice of this facility to provide for an environment in which residents may exercise their rights, each day. Our residents have certain rights and protections under Federal law. Our facility meets and provides these rights through care and related services at all times. Guideline: Our residents have certain rights and protections under Federal law that help ensure appropriate care and services are provided. Our facility will provide residents with a written description of their legal rights . Privacy and Confidentiality The right to send and receive mail and packages Facility staff should never open your mail unless a resident allows it .

This citation pertains to Intake number MI00150524 and MI00150867. This citation has two Deficiant Practice Statements (DPS). DPS #1 Based on observation, interview, and record review, the facility failed to maintain a clean, homelike, and odorless environment for all 194 residents residing at the facility. Findings include: On 3/17/25 at 6:38 PM, an observation was made of a toilet in the bathroom located in the hallway by nurse station one being plugged with toilet paper, feces, and urine. The odor in the bathroom smelled of feces and urine. On 3/17/25 at 6:45 PM, a fan in room [ROOM NUMBER] was observed to be covered in dust. On 3/18/25 at 9:12 AM, a observation was made of a toilet in the bathroom located in the hallway by nurse station one being plugged with toilet paper, feces, and urine. The odor in the bathroom smelled of feces and urine. A review of resident council meeting notes for the months of December 2024 through February 2025 revealed multiple resident concerns indicated in the notes regarding resident rooms not being cleaned daily. On 3/18/25 at 2:30 PM, Environmental Services Assistant (ESA) Q was interviewed regarding who was responsible for unclogging toilets at the facility. ESA Q indicated that maintenance was responsible for unclogging toilets and repairing them as needed. On 3/18/25 at 2:35 PM, Corporate Maintenance Director (CMD) R was interviewed about the plugged toilet by nurse station one and indicated that the toilet was currently broken and needed new bolts to attach it securely to the floor. On 3/21/25 at 11:21 AM, the Administrator (NHA) was interviewed regarding their expectations for maintenance of the facility. The NHA indicated that maintenance issues should be reported and followed up on as needed. 22960 On 03/18/25 at 2:20 PM, room [ROOM NUMBER] was observed. The flooring was soiled with stains, and was sticky and dull in appearance. The bathroom flooring was also soiled with a buildup of grime. The over-bed table in the room was observed with the plastic edging pulling away from the surface, leaving rough, exposed particle board underneath. The surface was no longer smooth and easily cleanable. On 03/18/25 at 2:25 PM, the flooring in room [ROOM NUMBER] was observed with a black, gummy substance surrounding 7-8 floor tiles. On 03/18/25 at 2:30 PM, the flooring in room [ROOM NUMBER] was observed with a black, gummy substance surrounding several floor tiles. When queried about the black substance, Regional Housekeeping Supervisor stated, It looks like built up glue. Resident (R92), who resided in room [ROOM NUMBER] was queried about the room. R92 complained of old urine on the floor in the corner of her room, and stated it was from a previous resident. R92 also complained of urine odors in the bathroom. R92 stated the man that was in this room before her, peed everywhere and they didn't clean it up and stated, I can smell the pee when I'm trying to eat, and it makes me sick! Upon observation, in addition to the black, gummy substance on the floor, there was a yellow stain on the flooring in the corner of the room. In the bathroom, there was a strong, pungent urine odor. Review of the undated policy Quality of Life-Homelike Environment noted: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible .2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment .f. Pleasant, neutral scents . 44750 DPS #2 Based on interview and record review, the facility failed to protect two residents' (R3 and R47) personal property from loss, out of two reviewed for personal property. Findings include: R3 On 3/18/2025 at 2:59 PM, an interview was conducted with R3. R3 indicated that laundry brought up their clothing for the day, but did not bring back any of their socks. R3 reported they marked all their socks and that someone brought them some socks to the room, but they did not belong to them and indicated this has happened more times than they can count. A review of the medical record revealed that R3 admitted into the facility on [DATE] with the following diagnoses, Bipolar Disorder and Weakness. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. R3 also required staff assistance with bed mobility and transfer. On 3/19/2025, a personal inventory sheet was requested but not received by end of survey. R47 On 3/17/2025 at 8:40 PM, an interview was conducted with R47. R47 indicated their socks were missing. R47 reported they were unsure if they were stolen, or missing in laundry. R47 indicated they labeled their socks and that their sister had just brought the socks to the facility and reported they informed their nurse and certified nursing assistant about the missing socks. A review of the medical record revealed that R47 admitted into the facility on [DATE] with the following diagnoses, Unsteadiness on Feet and Anxiety Disorder. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. R47 also required staff assistance with bed mobility and transfers. On 3/19/2025, a personal inventory sheet was request but not received by end of survey. On 3/20/2025 ta 10:59 AM, an interview was conducted with Environmental Services Director (EVS) V. EVS V was queried about the process when there is a missing item and reported if they are unable to find the item, then they ask for a receipt and replace the item. EVS V reported if they do not have a receipt for the item, then they can go by the personal inventory sheet. A review of a facility policy titled, Quality of Life-Homelike Environment noted the following, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.

Based on interview, and record review, the facility failed to complete in-service education performance reviews for five Certified Nurse Aides (CNA's Z, AA, BB, CC, and DD) of five reviewed for an annual performance review. Findings include: On 3/20/25 at 11:54 AM, a request was made for the required 12 hours annual resident care in-service education performance reviews for CNA's Z, AA, BB, CC, and DD. On 3/20/25 at 1:56 PM, the Director of Nursing (DON) reported they were contacting the third party education company for the staff education records. At 2:42 PM, the DON reported she did not have an estimate time that the company will be able to provide the education in-services. The request for the CNA's 12 hours of education was not provided by the end of the survey. A review of the facility's policy titled, Training Requirements Guideline dated 5/29/2020, revealed, Purpose: To inform and guide center leadership about training requirements and their role in the training development, implementation, and maintenance of an effective training program for all new and existing staff. 1 . At a minimum, training topics for all center staff must include: a. Effective communication b. Resident rights c. Activities which constitute abuse, neglect, and exploitation d. Procedures for reporting abuse, neglect, and exploitation e. Dementia management and resident abuse prevention f. Conflict resolution and anger management g. QAPI program h. Infection control i. Compliance and ethics training j. Behavioral health training. The following additional training requirements are outlined for all nurse aides: a. Must ensure the continuing competence .

Based on observation, interview, and record review, the facility failed to maintain the exterior dumpster area in a clean manner. This deficient practice had the potential to affect all residents, staff and visitors. Findings include: On 3/8/25 at 9:30 AM, during an observation of the 2 exterior dumpsters with Dietary Manager (DM) O, there were several bags of trash observed on the ground in front of the dumpsters, a bag of trash on the side of the dumpster and a bag of trash behind the dumpsters. There was an accumulation of loose trash items in between the 2 dumpsters and along the sides of the dumpsters. DM O stated Maintenance is responsible for cleaning up the dumpster area. Review of the undated policy Food-Related Garbage and Rubbish Disposal noted: Outside dumpsters provided by garbage pick up services will be kept closed and free of surrounding litter.

Based on observation, interview, and record review, the facility failed to ensure appropriate infection control practices, storage of nebulizer mask for two residents (R32, R655), clean blood pressure cuffs, and elements of the infection control program were completed potentially affecting all 194 residents that reside in the facility. Findings include: On 03/20/25 at 10:10 AM, a review of the infection control program was conducted with the Director of Nursing (DON) who was acting as the interim Infection Preventionist. The DON noted that during a recent outbreak of the flu multiple residents were treated prophylactically. Education related to the outbreak was requested but not provided prior to survey exit. A review of the monthly summaries revealed: In January 2024, 21 facility acquired infections were documented and based on a census of 200 the infection control rate was: -In February 2024 the rate was 14.5%; -In March 2024 the rate was 11%; -In April 2024 the rate was 11%; -In May 2024 the rate was 7%; -In June 2024 the rate was 10.5%; -In July 2024 the rate was 12.5%; No staff call in log was found; -In August 2024 the rate was 9%; -In September 2024 the rate was 12% and -In October 2024 the rate was 9.5%. The monthly summaries for November and December 2024 were not found. The DON was asked about the infection control rate being about a 5% threshold rate and if staff education had been completed. The only staff education was in May of 2024 related to enhanced barrier precautions. Mapping related to the line listings for January and February if 2025 was also requested but not received prior to survey exit. Additional documentation of staff education for 2024 was not provided prior to survey exit. On 03/20/25 at 11:30 AM, the DON reported a resident on dialysis should be Enhanced Barrier Precautions (EBP) and signs should be in place on the door and personal protective equipment (PPE) available. The DON was also asked about the storage of a nebulizer mask and reported it should be kept in a plastic bag in a suitable location in the resident's room. 40384 R32 On 3/18/25 at 9:20 AM, R32 was observed in their room. Observed in the room was the resident's unused oxygen concentrator in addition to their nebulizer mask which was uncovered, and lying on the resident's cluttered nightstand. On 3/18/25 at 2:18 PM, R32's nebulizer mask was observed uncovered and lying on the floor. On 3/19/25 at 9:38 AM, R32 was observed sitting on their bed and asked about their nebulizer treatments, and they explained that the used to get a breathing treatment nightly because they would get wheezy at night. The nebulizer mask was observed sitting inside R32's nightstand. On 3/20/25 at 2:31 PM, the Director of Nursing (DON) was made aware of the observations of R32's nebulizer mask and explained her expectation is once the treatment is completed, it should be stored in plastic. 44750 R655 On 3/17/2025 at 7:00 PM, R655 was observed in their room. Their nebulizer was observed on the nightstand, it not stored in bag or placed on a barrier. On 3/19/25 at 10:40 AM, R655's nebulizer mask was observed not stored in a bag or placed on a barrier and sitting on nightstand. On 03/20/25 at 10:15 AM, R655's nebulizer mask was observed not stored in bag and sitting on nightstand. R655 was queired as to often they used their nebulizer and they reported they use it everyday. A review of the medical record revealed that R655 admitted into the facility on [DATE] with the following diagnoses, Human Immunodeficiency Virus and Asthma. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 15/15. R655 also required staff assistance with bed mobility and transfers. On 03/20/25 at 11:10 AM an interview was conducted with the Director of Nursing (DON) who also served as the Infection Control Preventionist (ICP). The DON/ICP indicated the nebulizer mask should be stored in a a bag. The expectation is when they are done using it, then it should be put in a plastic bag. 49699 On 3/19/2025 at 08:30 AM, Licensed Practical Nurse (LPN) M during medication pass was observed taking vital signs of three residents without cleaning before or after use. On 03/19/2025 upon completion of medication pass, LPN M was queried about when reusable medical equipment should be cleaned. LPN M revealed equipment should be cleaned with the bleach wipes between residents with a 3 minute wet time. LPN M did not clean the equipment before resuming medication pass. On 3/19/2025 at 09:10 AM took a resident blood pressure. Upon returning to the medication cart, LPN N did not clean the blood pressure cuff. When queried what should occur after using a blood pressure cuff, LPN N revealed the reusable medical equipment should be cleaned with a bleach wipe when task is completed. On 3/20/25 the Director of Nursing (DON) was queried regarding the expectation for cleaning reusable medical equipment and they indicated the expectation is cleaning should occur between each resident. A review of the Policy titled, Infection Prevention and Control Guideline dated 11/28/2017, revealed the following: Equipment or items in the patient environment . must be handled in a manner to prevent transmission of infectious agents (properly clean and disinfect or sterilize reusable equipment before use on another patient.).

This citation refers to Intake MI00146945. Based on interview and record review, the facility failed to protect the resident's right to be free from resident to resident physical abuse for one resident (R904) out of two residents reviewed for abuse resulting in hospitalization for right eye fracture. Findings include: A review of a complaint called into the State Agency incident revealed the following: (R903) sold clothes to (R904) but (R904) didn't pay for the clothes and claims that (R903) took them back. On 9/5/24 (R904) hit (R903) in the arm and (R903) swung back hitting (R904) in the face causing (them) to fall. The residents were separated, and the police were called. (R904) injuries were assessed and treated without further incident. R904 A review of R904's record revealed they were admitted to the facility on [DATE] with the following diagnosis; end stage renal disease. A review of R904's Brief Interview for Mental Status revealed a score of 15 indicating intact cognition. Further review of R904's record revealed they were hospitalized following the physical altercation from 9/5/24 to 9/17/24. A hospital discharge note dated 9/17/24 revealed the following: (R904) reports (they) started the altercation with another resident due to the resident stealing jerseys from (their) room. (R904) ended up being punched and kicked in the face multiple times .Right eye hematoma (bruising), subconjunctival hemorrhage. There is a moderate acute fracture of the medial right orbital wall. On 9/25/24 at 9:31 AM, a call was placed to R904 and a voicemail was left. Call was not returned by the completion of the survey. R903 A review of R903's record revealed they were admitted to the facility on [DATE], discharged on [DATE] and readmitted on [DATE] with the following pertinent diagnosis: schizophrenia, and PTSD (post traumatic stress disorder). A review of R903's Brief Interview for Mental status revealed a score of 15 indicating intact cognition. A visit note from psychiatry for R903 dated 8/15/24 revealed the following: Pt was referred to therapist for psychotherapy following a self report of hallucinations and delusions. Pt reported that the aliens came and cloned his family. Pt has a history of facility treatment, IP treatment and incarceration. Pt is also diagnosed with Schizophrenia (unspecified type). Currently, pt endorses mild depression. Pt. has a history of suicide attempt in 2022. Pt also endorses multiple triggers to anger tied to perceived criticism from family members due to his substance misuse history. Pt currently denies suicidal thoughts and intent. Pt voiced concerns over frustration with family members, past trauma and his plans for the future. Pt agreed to psychotherapy to address the above issues. A review of R903's care plans revealed no mention of psychiatric diagnosis, behaviors, or suicidal ideation. Further review of R903's electronic medical record revealed a behavior monitoring task list revealed the following: -On 9/1/24 at 5:08 AM: cursing at others, express frustration/anger at others, screaming at others, threatening others. -On 9/2/24 at 9:35PM documented by CNA O, accusing of others, cursing at others, express frustration/anger at others, screaming at others, threatening others, disruptive sounds, disrobing in public, public sexual acts, rummaging A psychiatry visit note dated 9/3/24 revealed the following: Pt (patient) appears to be becoming restless at the facility. Thp (therapist) and pt discussed coping skills that (they) can do to remain calm and to control (their) triggers. On 9/25/24 at 10:43 AM, during an interview with R909, they confirmed they had witnessed the altercation involving R903 and R904. R909 stated, (R903) got hit in the arm then (R903) knocked (R904) to the ground and stomped on (their) face twice. (R904) eyes became blood shot and the back of (their) head was bloody. It was brutal. On 9/25/24 at 10:45 AM, during an interview with R908 they confirmed they had witnessed the altercation between R903 and R904. R908 explained that (R904) was their neighbor so they knew them well and would get agitated regarding an issue with clothing. R908 stated, (R903) and (R904) were exchanging un-niceties and (R904) wouldn't calm down and kept getting more and more agitated and charged at (R903). Then (R903) let (R904) have it. It wasn't much of an equal fight. (R903) really assaulted him. While (R904) was on the ground (R903) was on (them) punching and then kicked (R904) twice. (R904's) head and eye were badly injured. R908 explained that R903 maintained a violent attitude and that they were glad they were now discharged . On 9/25/24 at 11:35 AM, during an interview with the Director of Nursing (DON) they explained they did not see the altercation between R903 and R904 when it happened but they saw everyone running outside afterward and when they got outside to the courtyard someone was taking R903 away and R904 was lying on the ground and R904's eye was red. The DON explained they called the police and initially R904 did not want to go to the hospital, but later that day R904's condition changed and was sent to the hospital via Emergency Medical Services (EMS). On 9/25/24 at 11:56 AM, during an interview, the Assistant Nursing Home Administrator (ANHA) they explained R903 and R904 got into a disagreement about clothing. The AHNA explained the altercation was witnessed by other residents and one of the other residents came inside to tell staff. The ANHA confirmed, Abuse was substantiated. (R904) admitted to throwing the first punch and took the blame. On 9/25/24 at 12:45pm, during an interview with Certified Nurse Assistant (CNA) V they explained about 25-30 minutes prior to the physical altercation, (R903) told CNA V that (R904) stood up out of (their) wheelchair and confronted (R903) about some stolen clothing and was advised to avoid the other resident. .On 9/25/24 at 1:06 PM, during a phone interview with CNA O they said R903 became angry, got out of bed and started screaming obscenities and racial slurs. CNA O explained they reported the behaviors to Licensed Practical Nurse (LPN) P and R903 was moved to a different room after that incident. On 9/25/24 at 1:27 PM, LPN P was called for an interview and a voicemail was left with no return call by the completion of the survey. On 9/25/24 at 3:14 PM, The DON was shown the documentation of behaviors on the task list. The DON confirmed there was no progress note or incident report of the behaviors for 9/1/24 or 9/2/24 and confirmed the nurse the behaviors was reported to should have entered a progress note and filled out an incident report so protective interventions could be put in to placed. The facility's policy titled Abuse revealed the following: C. Prevention. Abuse Policy requirements: It is the policy of this facility to prevent abuse by providing residents, families and staff information and education on how and to whom to report concerns, incidents and grievances without the fear of reprisal or retribution. The facility will provide feedback regarding complaints and concerns. The facility leadership will assess the needs of the residents in the facility to be able to identify concerns in order to prevent potential abuse. Procedure: 1. Resident assessment .Every resident is unique and may be subject to abuse based on a variety of circumstances including facility physical plant, environment, the resident's health, behavior, or cognitive level. A. Before admission, the prospective residents will be screened to help determine suitable placement within the facility. B. Upon admission and periodically after that, each resident will have a safety or vulnerability assessment completed which identifies potential vulnerabilities such as cognitive, physical, psychosocial, environment and communication concerns. C. The interdisciplinary team will identify the vulnerabilities and interventions on the resident care plan .4. Population. A. The facility's population presents the following factors, (May include, but not limited to ) which could result in maltreatment of residents: The assessment, planning of care and services, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of cognitive deficits, sensory deficits, aggressive behaviors, residents who have behaviors such as entering other residents rooms, wandering behaviors, verbal outbursts .

This citation pertains to intake #'s: MI 741, M 487, MI 557 and MI 579. Based on observation, interview and record review, the facility failed to implement interventions and/or accurately assess and treat a wound appropriately for two Residents (Resident #702 and #703) of three reviewed for wound care, resulting in a delay in wound healing, pain, and hospitalization requiring surgery. Findings include: Resident #703 (R703) On 04/20/2022 at 09:54 AM, Resident #703 was observed awake in bed. The Resident had clear speech and was able to answer questions appropriately. Resident #703 explained that they had recently gotten back from the hospital, stating, They had to do surgery on my wound. Resident #703 was queried on how the wound was acquired and stated, I don't know, I think it is a bed sore. A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #703 did not have any wounds, had an intact cognition, and needed extensive assistance with bed mobility, toileting needs and personal hygiene. Further review of the medical record revealed the resident was readmitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the care plan for Resident #703 revealed the following: Focus-BED MOBILITY: Bed Mobility - Resident has a self care deficit in bed mobility related to SELECT ONE (decrease ability to position or re-position self in bed, turn from side to side, push self up in bed, moves from lying to sitting position .requires assist for bed mobility. Date Initiated: 04/12/2022. Focus-(Resident #703) has actual impairment to skin integrity-declines to position off back .prefers to sit up in wheelchair for extended periods of time .has MASD (Moisture Acquired Skin Damage) to buttocks .has wound to coccyx. Date Initiated: 08/26/2018. A record review of the Progress Notes for Resident #703 revealed the following: 03/15/2022 02:00 PM- .As she gave perineal care to resident, CENA (Certified Educated Nurse Assistant) brought to the attention of writer (Licensed Practical Nurse/LPN F) an open area on the inner right buttock. Wound care notified. 03/16/2022 08:08 AM- .With assistance of pillows. Writer attempted to turn and reposition resident to face the wall. Resident slowly rolled back to position on back .states I can't help it. Writer repositioned .again rolled back on .back. 03/18/2022 11:02 AM- .Writer notified that resident was having buttocks pain and wanted to go to the hospital. writer into asses (sic) resident. Writer observed area no new changes to skin area. Writer explained to resident that there is no changes. Writer repositioned and gave PRN (prescribed as needed) Tylenol and applied a comfort form to area. Resident stated 'This is not going to help, when I go to [CONDITION(S)] I will have them send me to the hospital.' Writer notified shift nurse of interventions applied. Will continue to monitor resident . 03/21/2022 08:07 PM-Skin/Wound Note .seeing pt (patient) re: buttock wound .has had recent loose stools resulting in skin breakdown. Topical Tx (treatment) had been implemented. Pt refusing to lay/turn on sides. When positioned on .side .will push .self onto .back .Skin: buttocks significant MASD (moisture associated skin damage) and [MEDICATION(S)] (yeast) with scattered open areas and [MEDICATION(S)] sloughing (skin pealing off), scant drng (drainage), no [CONDITION(S)] (skin infection). Recommend Tx: apply layer of Antifungal cream followed by layer of ZnOx (zinc) cream to entire area QS (every shift). Continue pressure downloading interventions. Encourage turning/repositioning . Authored by Wound Nurse Practitioner/NP G. 03/28/2022 06:36 PM-Writer received called from [[CONDITION(S)] center] that resident complained of pain in .buttock and has been transferred to [local hospital] . 03/29/2022 06:59 AM-[local hospital] called that they want resident's medication list be fax to them. And that resident is being admitted . 04/6/2022 05:50 PM- .was seen after readmission from hospital for sacral ulceration, debridement (surgical removal of nonviable dead tissue to allow for healthy tissue growth), and hypovolemic shock (an emergent condition related to blood loss) .required ICU (Intensive Care Unit) monitoring .went to the hospital for worsening lower back pain, and was found to have sacral ulceration. (Resident #703) underwent debridement and was started on ABX (antibiotics) .was on ASA (aspirin), [MEDICATION(S)], and [MEDICATION(S)] (both medications commonly known as blood thinners), and had significant bleeding post procedure. (Resident #703)developed hypovolemic shock, and did require pressors and transfusion. (Resident #703) had to undergo second surgical procedure .(Resident #703) did improve, and completed antibiotics. (Resident #703) was sent back to [Skilled Nursing Facility] .(Resident #703) is having pain with movement, due to ulceration .will continue local wound care .Plan Note .Pressure ulcer (a wound caused from prolonged pressure over a bony prominence) of sacral (lower buttock) region, stage 3 (pressure ulcers are staged according to wound damage depth, stage 3 indicated wound damage that extends beyond all layers of skin into the fatty and/or muscle tissue. Continue local wound care . 04/06/2022 09:02 PM-Skin/Wound Note .seeing pt re: buttock wound .I was seeing .for significant MASD. (Resident #703) had ongoing noncompliant issues: refusing to lay/turn on sides. When positioned on .side .will push .self onto .back, refusal to limit time in chair. Recently hospitalized d/t (due to) c/o (complaints of) back/buttock pain. Found to have stg 3 ulcer, General Surgery with surgical debridement .soft tissue infection Tx with Abt (antibiotics). Not readmitted on Abt. Tx and advanced pressure downloading interventions were re-implemented .Skin: sacrum stg 3 ulcer, 3.5 x 5.3 (centimeters/cm), minimal drng, no clinical evidence of infection, base necrotic (black nonviable tissue) slough (nonviable tissue, often yellow, white or gray in color). Recommend Tx: santyl (a topical medication used to remove nonviable tissue from wounds) cover with ABD QD (every day). LAL (low air loss)mattress, W/C (wheelchair) ROHO cushion. Encourage turning/repositioning, limiting time up in chair. Document refusals. Hemodialysis to reposition Pt. Continue pressure downloading interventions. Encourage turning/repositioning . 04/14/2022 11:54 (AM)-Physician/NP .Reason: Following up on a patient with the compliant of pain on .buttocks, less than post 30 days re-admission .complaint of buttocks pain due to coccyx wound. wound nurse and NP on board, dressing change per ordered, specialty bed ordered, reposition q 2 hrs, stay off .buttocks as possible .Problem/Diagnosis 1, Pressure ulcer of sacral region, stage 3 Wound care per ordered, wound nurse and NP continue to follow, reposition patient q 2 hrs, notify provider with s/s of infection, change in mental status change. 2, Pain associated with wound on [MEDICATION(S)] (a narcotic pain medication) HCl Tablet 50 MG Give 1 tablet by mouth every 6 hours as needed which patient preferred also on [MEDICATION(S)]-Acetaminophen (a narcotic pain medication) Tablet 10-325 MG Give 1 tablet by mouth every 6 hours as needed. notify provider with increased or unrelieved pain .Comments or Notes - discussed plan of care and the important of repositioning and staying off .buttocks to the patient . 04/18/2022 08:04 (AM)-Skin/Wound Note .I was seeing .for significant MASD .had ongoing noncompliant issues: refusing to lay/turn on sides. When positioned on .side .will push .self onto .back, refusal to limit time in chair. Recently hospitalized d/t c/o back/buttock pain. Found to have stg 3 ulcer, General Surgery with surgical debridement. No OM (osteo [CONDITION(S)]/bone infection) noted, soft tissue infection Tx with Abt. Not readmitted on Abt. Tx and advanced pressure downloading interventions were re-implemented .Skin: sacrum stg 3 ulcer, minimal drng, no clinical evidence of infection, base granular with scant necrotic slough. Recommend Tx: santyl cover with ABD QD, LAL mattress, W/C ROHO cushion. Encourage turning/repositioning, limiting time up in chair. Document refusals .Continue pressure downloading interventions. Encourage turning/repositioning . A record review of the hospital notes for Resident #703 revealed the following: 03/28/2022- .Per [Emergency Medical Services], patient is coming from [CONDITION(S)] after completion for complaints of bed sore. Patient has bedsore located on coccyx that is stage 3 pressure ulcer .was seen today at bedside .is undergoing [CONDITION(S)] .Blood cultures show enterococcus faecalis (a bacteria found in stool) in wound. Debridement completed .Sacral decubitus ulceration: This is likely due to increase pressure due to inability to change positions. General surgery consultation in place. Antibiotics in place . A review of the Braden Scales (a scale utilized to determine the risk of developing a pressure ulcer wound) for Resident #703 revealed the following: 01/07/2022- 15, indicating a mild risk. 04/14/2022 and 04/19/2022-14, indicating a moderate risk. A review of the Skin/Wound Observations for Resident #703 revealed the following: 03/17/2022- no skin issues. 03/24/2022- Right gluteal fold-treatment in progress 04/07/2022 and 04/14/2022- Sacrum wound-treatment in progress 04/18/2022- Pressure stage 3 present on admission, new 3 x 1.8 (cm) A review of the wound observations (pictures of wounds in electronic medical record/EMR) and measurements for Resident #703 revealed the following: 03/15/2022-A round open area noted on buttocks, in the crack (intergluteal cleft). The wound was not measured, but looked to be the size of a nickel. The wound base was red and moist, with yellow slough tissue at the 9 o'clock position. The surrounding skin was dark in color and appeared mushy. The picture was labeled as new MASD. Treatment listed-Normal Saline, Soap & Water and Other. No dressing listed. Authored by Wound Nurse D. 03/22/2022-This picture revealed a much more scattered wound. There were multiple scattered irregular edged wounds revealing pink, read and black skin tissue. The area in between the buttocks crack was larger, revealing gray and white slough/necrotic tissue covering the whole wound base. The notation next to the picture stated, Deteriorating MASD 7.98 cm x 7.39 cm. Treatment listed-Normal Saline, Antifungal and Other. Authored by Wound Nurse D. 04/06/2022-The picture was labeled as New, revealing a smaller area as the previous picture. The wound had pink, irregular borders and appeared dry. The wound in the inner buttocks this time had a visible wound bed revealing a deep wound with red and yellow tissue around a black center. The wound was identified as Pressure Stage 3 with the new measurements of 3.56 cm x 5.31 cm. Treatment listed-Normal Saline, Antimicrobial (Santyl). Authored by Wound Nurse D. 04/14/2022-The picture was labeled as Improving and revealed a moist, pink wound base with yellow slough tissue. There was no black or necrotic tissue noted. The measurements were: 3.27 cm x 3.14 cm. Treatment listed-Normal Saline, Antimicrobial. Authored by Wound Nurse D. 04/18/2022-This was the most recent picture, revealing a wound with a clean, pink and moist wound bed. No necrotic tissue observed. The peri wound was irregular. The measurements were at this time 2.97 cm x 1.81 cm. Authored by Wound Nurse D. On 04/21/2022 at 09:47 AM, this Surveyor requested the Nursing Home Administrator (NHA) to observe wound care on Resident #703. The NHA agreed, however the staff had completed the wound care treatment and gotten Resident #703 up in their wheelchair. At that time, the resident did not want to be laid back down to do wound care again. A review of the wound care orders for Resident #703 revealed the following: Before hospitalization - Triad Hydrophilic Wound Dress Paste (a thick barrier paste) Apply to buttock topically every day shift for MASD thin layer. Order date: 03/16/2022-03/21/2022. Layer of house (over the counter) antifungal cream to buttocks followed by layer of zinc oxide cream (similar to diaper rash ointment) every day shift for MASD. Order date: 03/21/2022-03/31/2022. After hospitalization - Cleanse coccyx with normal saline, apply manuka honey (a topical medication used to pull nonviable tissue from wounds) and cover with gauze and border gauze daily and prn every day shift for wound care for two days. Order date: 04/06/2022-04/08/2022. Santyl Ointment .Apply to sacrum topically every day shift for wound care cleanse with normal saline, apply nickel thick layer, cover with 4 x 4 and secure with border gauze daily and prn. Ordered 04/08/2022. On 04/21/2022 at 09:55 AM, Wound Care Nurse D was interviewed. Wound Care Nurse D was asked what the process was for newly identified skin breakdown. She explained that when a nurse comes to her with a concern, she will go and assess the wound, and then typically apply a wet to dry dressing or something until the Wound Care NP assesses the wound. At this time, the pictures of the wounds were reviewed with Wound Care Nurse D. Wound Care Nurse D explained that the facility was utilizing a new system for wounds, and that they had a team working together. While reviewing the 03/15/2022 picture, Wound Care Nurse D was asked what was being utilized for wound care and stated, We did basic pericare. When asked to elaborate what basic pericare was, she stated, Basically a zinc ointment, because (Resident #703) had MASD. Wound Care Nurse D was asked if they thought zinc ointment was appropriate for an open wound and stated, Yes, because it was MASD, see all the soft skin around it? It is soft and lumpy. Wound Care Nurse D was asked to review the wound picture dated 03/22/2022, which noted gray slough, and was much larger, and stated, We did triad cream at that time. Wound Care Nurse D was asked why a more aggressive treatment was not utilized given the deterioration of the wound but did not provide an explanation. On 04/21/2022 at 10:40 AM, LPN F was interviewed in regard to her initial assessment of Resident #703's wound on 03/15/2022. LPN F stated, Yes, I remember it. It was barely a stage 2. I think it was bigger than a nickel but smaller than a quarter. I told the wound care nurse and they came in and ordered a treatment. On 04/21/2022 at 11:11 AM, the Wound Care Director E was interviewed in regard to Resident #703's wound. Wound Care Director E explained that the floor staff reported the wound to LPN R who took a picture of it (the wound). Wound Care Director E stated, We contacted the Doctor, got a treatment initiated by the NP, the Doctor (eventually) approves it. With (Resident #703), it started out as moisture, so we used the triad cream to dry it up, then the Wound Nurse Practitioner (G) came in and switched it over to antifungal cream and zinc. (Resident #703) ended up going to the hospital by then, [Wound Nurse Practitioner G] would have seen (Resident #703) again, but couldn't because they were hospitalized . We typically give it (the treatment) a week before we change anything. At this time, the wound pictures were reviewed with Wound Care Director E. While reviewing the 03/15/2022 picture, Wound Care Director E stated, All that surrounding skin was lumpy from moisture. While reviewing the 03/21/2022 picture, which reflected a deteriorating wound, Wound Care Director E was asked if they felt the treatment to put an antifungal cream was appropriate for the wound type. Wound Care Director E stated, I think [Wound NP G] was concentrating on the surrounding tissue first. She did not provide any further explanation. On 04/21/2022 at 11:55 AM, the NHA was interviewed in regard to Resident #703 acquiring a wound while in the facility, and only applying pericare initially, then Triad cream and then an antifungal cream. The NHA stated, Typically we don't have problems with [Wound NP G], she usually is pretty aggressive, she will use other treatment types to heal wounds. On 04/21/2022 at 01:29 PM, Wound NP G was interviewed via phone in regard to Resident #703's facility acquired wound. Wound NP G explained that at the time, Resident #703 had a Urinary Tract Infection ([CONDITION(S)]) and was constipated and then had loose stool contributing to the MASD. Wound NP G further stated, Plus, (Resident #703) does not want to turn and reposition. The first time I saw it was on 03/21/2022. Based on how it presented, I ordered the treatment. Wound NP G was asked about the open area and if she felt putting an antifungal cream would be effective and stated, I felt it was responding favorably. (Resident #703) did complain of butt pain and went to the hospital and then came back with a debrided wound, I was shocked. Wound NP G stated that she comes in to do rounds in the facility weekly and can do telehealth if needed. Wound NP G was asked if she was aware that Wound Care Nurse D had documented the wound as Deteriorating on 03/21/2022 and stated, It may have deteriorated, I would have seen (Resident #703) on 03/28/2022. No one told me it deteriorated. On 04/21/2022 at 01:38 PM, the Director of Nursing (DON) was interviewed in regard to the wound on Resident #703. The DON was asked if she felt the wound treatment was appropriate for the type of wound Resident #703 had and stated, We go by [Wound NP]'s recommendations. She is the wound doctor. She comes in on Mondays. The DON was asked how she was informed of Resident #703's wound progression and stated, We do discuss wounds in our weekly meeting (but do not actually look at them). [Wound Director E] just basically updates us on new issues. When (Resident #703) went to the hospital, it was a (very small) wound, then when they came back, it was huge and opened. We don't think that wound needed to be debrided, no way. On 04/21/2022 at 01:57 PM, Resident #703 was observed to be up in their wheelchair. Resident #703 was asked if the facility was making an effort to reposition them. Resident #703 pointed to their specialty air bed and stated, See that bed, they (unknown staff) told me they don't have to position me because that bed does it for me, so I don't know. A review of the facility policy titled Skin Protection Guideline, effective: 07/07/202, revealed the following: .Purpose: To provide evidenced based practice standards for the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .Interventions for prevention, removing and reducing predicting factors and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Or, for residents that have diminished sensory perceptions of the lower extremities that may affect an independent ability to turn, reposition and off load pressure .Monitoring of Skin Integrity .if a skin concern or change is observed .The plan of care will be modified based upon root cause analysis investigation findings for additional prevention and healing approaches . Resident #702 (R702) Review of the medical record revealed R702 was admitted to the facility on [DATE] and discharged on [DATE]. The Minimum Data Set (MDS) assessment dated [DATE] revealed, Determination of PU (pressure ulcer)/Injury Risk Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. Yes., Unhealed PU Yes. Stage 3 PU 1., Number of these stage 3 PU that were present upon admission/entry 1., Number of unstageable slough and or eschar 1., Number of these unstageable pressure ulcers that were present upon admission/entry or reentry 1., Number of unstageable pressure injuries presenting as deep tissue injury (DTI) 1., Number of these unstageable pressure injuries that were present upon admission/entry or reentry 1. A review of R702's medical record revealed, 4/14/21 ADMISSION NURSING ASSESSMENT: . 14) abdomen scar on lower abdomen, 23) Coccyx 3 open wounds on buttock area, Other left arm bruising and bump. Other dry skin in various parts of body. Skin assessment: Site Left buttock UTD (Unable To Determine). Right buttock Stage 3, Left heel DTI. Skin Wound 4/15/21, . Wound Care Assessment is performed on resident. Writer observes skin concerns on right and left buttock. Discoloration present on left heel. No other areas of concern at this time. Skin Wound Note: 5/4/21, Resident is a readmit. Areas of concern present on Right buttock, left buttock, and a DTI on left heel. ORDER: Order Summary: Apply skin prep to L (left) heel cover with ABD and secure with [MEDICATION(S)] three times a week and prn (as needed). every day shift every Tue (Tuesday), Thu (Thursday), Sun (Sunday) for wound care. 4/20/21. A review of the treatment administration record (TAR) revealed, treatments were not documented as completed for some dates in the month of April 2021. Order: Apply skin prep to L (left) heel cover with ABD (absorbent dressing) and secure with [MEDICATION(S)] three times a week and prn every day shift every Tue, Thu, Sun for wound care - Order Date 04/15/2021 - D/C Date 04/22/2021. Documentation was missing for Thursday 15th, Sunday 18th. Order: Cleanse L buttock with normal saline, apply [MEDICATION(S)] and cover with border foam three times a week and prn every day shift every Tue, Thu, Sun for wound care - Order Date 04/15/2021 - D/C Date 04/22/2021. Documentation was missing for Thursday 15th, Sunday 18th. Order: Apply skin prep to L (left) heel cover with ABD (absorbent dressing) and secure with [MEDICATION(S)] three times a week and prn (as needed) every day shift every Tue, Thu, Sun for wound care - Order Date 04/15/2021 - D/C Date 04/22/2021. Documentation was missing for Thursday 15th and Sunday 18th on the TAR. A review of R702's care plan noted interventions to address R702's wound on the buttock, but did not address the DTI on the left heel. On 4/21/22 at 10:00 AM, Wound Nurse E was asked about the missing treatments/documentation and about the care plan interventions to address R702's heel. Wound Nurse E stated, I'm not sure why [R702] didn't get done on the Sunday. Normally we give heel boots when they come in. Normally would be care plan heel boots as tolerated. On 4/21/22 at 1:38 PM, the Director of Nursing (DON) was asked if there is a treatment order, is it also to be care planned. The DON explained, that it should have been care planned so that it could have went on to the kardex (to alert the aides to float heels).

Based on observation, interview, and record review the facility failed to ensure the safety and supervision of six Residents (R509, R532, R533, R534, R535 and R538) who smoked, two confused Residents (R536 and R537) who were observed in the smoking area with smokers, and failed to prevent smoking residents from keeping their own cigarette lighters, and possessing smoking materials, including around Residents (R528 and R538) who received oxygen treatment, of eight residents reviewed for smoking, resulting in Immediate Jeopardy due to the likelihood of serious injury, harm or death from resident [CONDITION(S)] or fire related accidents. Findings include: Resident #533 and Resident #534 On 09/07/2021 at 1:50 PM, R533 was observed in the courtyard socializing and smoking cigarettes with R534. An interview was conducted with R534 regarding smoking at the facility and R534 stated, Staffing is bad, we're out here all day and no one comes to check on us. R533 was asked where their cigarettes and lighters were stored and stated, I don't have cigarettes, my cigarettes are gifts. I have two lighters; one doesn't work and I keep the other one in my wheelchair. R533 then lifted the pad on the wheelchair to show the lighter. Record review of R533's Electronic Health Record (EHR) revealed R533 was admitted into the facility on [DATE] with diagnoses that included, [CONDITION(S)] Disorder, Unspecified Dementia, and a Fractured Right Femur (thigh bone). The most recent Minimum Data Set (MDS) assessment dated , 06/03/2021 revealed R533 had a Brief Interview for Mental Status (BIMS) score of 10 indicating a moderately impaired cognition and needed supervision with Activities of Daily Living (ADLs). Review of R533's Smoking Risk Evaluation dated 6/29/2021, revealed R533 had a score of 1 indicating R533 was a Potentially Unsafe Smoker - follow facility policy. Review of R533's care plan revealed, Focus - Resident is an independent safe smoker and chooses to smoke cigarettes. Date Initiated: 06/29/2021. Goals - Resident will follow facility guideline and will continue to be a safe smoker till review date. Date Initiated: 06/29/2021 Target Date: 11/21/2021. Interventions - Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. Date Initiated: 06/29/2021 - Review guidelines with resident as needed. Date Initiated 06/29/2021. On 09/08/2021 at 12:06 PM, an interview was conducted with Nurse L regarding the residents keeping their cigarettes and lighters and Nurse L stated, Residents that smoke are not allowed to keep their lighters on them. On 09/08/2021 at 12:12 PM, an interview was conducted with Nurse K regarding residents keeping their cigarettes and lighters and stated, They are not allowed to keep their cigarettes or lighters. Resident #509 On 09/08/2021 at 2:54 PM, R509 was observed in the courtyard smoking. An interview was conducted with R509 regarding smoking at the facility and stated, I keep my cigarettes and lighter. R509 showed a small cloth cigarette case. We're not supposed to, but I have them. There are supposed to have smoking times, I stay up late and the door is never locked. You can ask someone (staff) to come with you, but you have to find them first. Review of R509's EHR revealed, R509 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included, [CONDITION(S)], Type-2 Diabetes, and Chronic Obstructive Pulmonary Disease. The most recent MDS dated , 06/28/2021 revealed R509 had an intact cognition and needed supervision with ADLs. Review of R509's Smoking Risk Evaluation dated, 04/14/2021 reflected R509 had a score of 0.0 indicating R509 was a Non-Smoker or Safe Smoker (follow facility policy). Smoker? No. Review of R509's care plan reflected, Focus - Resident is an independent safe smoker and chooses to smoke cigarettes. Date Initiated: 06/29/2021. Goals - Resident will follow facility guideline and will continue to be a safe smoker till review date. Date Initiated: 06/29/2021 Target Date: 09/28/2021. Interventions - Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. Date Initiated: 06/29/2021. Observe clothing and skin for signs of cigarette [CONDITION(S)] as needed. Date Initiated: 06/29/2021 - Review guidelines with resident as needed. Date Initiated 06/29/2021. On 08/09/2021 at 1:45 PM, an interview was conducted with Certified Nurse Aide (CNA M) regarding the residents that smoke and stated, This is supposed to be a no smoking facility. They used to have smoking time on the patio by the front door a long time ago. Resident #534 On 9/7/21 at 12:20 PM, R534 was observed in their room asleep in their wheelchair. An empty cigarette box was observed on the side table next to their bed, and a full box of cigarettes were observed on the floor in front of R534's wheelchair. Upon entering R534's room, they aroused and noticed that the cigarettes were on the floor, grabbed them and stuck them in their shirt. R534 was asked if they were able to always keep their smoking items and explained that they were. R534 was asked if they were able to go out and smoke whenever they chose to, and stated, Yes. A review of R534's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included, [CONDITION(S)] and [CONDITION(S)] following Cerebral Infarction, Diabetes, Weakness, and Hypertension. A review of R534's Minimum Data Set assessment dated [DATE], revealed that the resident had a Brief Interview for Mental Status score of 7/15 indicating a severely impaired cognition, and required moderate assistance for toileting, personal hygiene, and wheelchair mobility. Further review of R534's medical record revealed the following smoking assessment progress note, 7/7/2021 19:18 (7:19pm) Smoking Risk Obs (observation) Note Text: Resident is a smoker. Resident smokes cigarettes. Resident smokes less than hourly. Resident has Extrapyramidal Symptoms, History of [CONDITION(S)] (stroke), [CONDITION(S)] or other diagnosed syndrome or disease that would limit the safe physical act of smoking. Resident Risk Score is 2.0, Potentially Unsafe Smoker-follow facility policy. Further review of R534's medical record revealed a comprehensive care plan however, the care plan did not address R534 being a smoker. Residents: #533, #534, #535, #536, #537 and Unsampled Resident #1 On 9/7/21 at 1:28 PM, seven residents were observed sitting in an enclosed courtyard, which also served as the designated smoking area for residents. Of the seven residents, three were observed smoking (R534, R533, and unsampled resident (UR1)). R535 was observed with a personal bag strapped to their person that contained a clear view of a pack of cigarettes, and a lighter. In addition, there were two cognitively impaired residents in the courtyard (R536 and R537) sitting between the smokers. There were no facility staff observed in the courtyard providing supervision, nor were any of the residents observed wearing smoking aprons or protectors. Resident #534 and Resident #528 On 9/8/21 at 11:35 PM, 12:01 PM, and 12:16 PM, R534 was observed in bed asleep. A pack of cigarettes and a lighter were observed sitting on their side table. R534's roommate, R528 was observed in bed asleep with their oxygen concentrator running. There was a sign observed on the outside of the residents' door that indicated, No smoking oxygen in use. A review of R528's medical record revealed that they were ordered the following physician order on 6/15/21, RESPIRATORY: Administer Oxygen at 2L (liters)/min (minute) per nasal cannula. Every shift. In addition, R528's care plan revealed the following, Focus: The resident has oxygen therapy r/t (related to) Ineffective gas exchange. Date Initiated: 02/04/2020. Interventions: OXYGEN SETTINGS: O2 (oxygen) AS ORDERD VIA NC (nasal cannula). Date Initiated: 08/27/2021. Position resident to facilitate ventilation/perfusion matching: Use upright, high-Fowlers position whenever possible to allow for optimal diaphragm, When on side, the good side should be down (e.g., damaged lung should be up). Date Initiated: 02/04/2020 . Resident #532 On 9/7/21 at 2:15 PM, R532 was observed coming back into the facility from the smoking area. R532 was observed to have a pack of cigarettes and a lighter in their possession. No facility staff was observed to be present in the smoking area. R532 was interviewed and asked if staff supervised residents when they are smoking. R532 responded, No never. R532 also indicated that they were allowed to retain their lighter and cigarettes in their possession. On 9/7/21 at 2:45 PM, a review of R532's electronic health record (EHR) revealed an admission to the facility on [DATE] with diagnoses that included Diabetes and Chronic Obstructive Pulmonary Disease ([CONDITION(S)]). R532's most recent minimum data set assessment (MDS) dated [DATE] revealed that R532 had a moderately impaired cognition. Resident #538 On 9/8/21 at 3:23 PM, R538 was observed sitting under a gazebo with their oxygen tank and tubing on a chair next to them. R538 was observed with a lit cigarette in their hand smoking. No staff was observed to be outside monitoring R538. On 9/8/21 at 3:30 PM, the Director of Nursing (DON) went outside and observed R538 smoking under the gazebo. The DON stated, Lord have mercy Jesus we about to get blown up here. The DON acknowledged that R538 had an oxygen tank while smoking. The DON was interviewed about the residents smoking and indicated if the resident smokes independently, they need to sign a contract. The DON was interviewed about other residents who come out to the smoking area with the smoking residents and the DON indicated that other residents come out into the smoking area but they do not smoke. The DON acknowledged that there was currently no staff present outside to monitor the residents. The DON was interviewed and asked if confused residents should be wandering out into the smoking area with residents who smoke. The DON acknowledged that confused residents should not be with the smoking residents. On 9/8/21 at 3:40 PM, R538's EHR was reviewed and indicated that R538 was admitted to the facility on [DATE] with a diagnosis that included, Acute [CONDITION(S)] with hypercapnia. On 9/8/21 at 3:45 PM a facility policy titled Smoking Guideline Revised: 6/1/21 was reviewed and stated the following, Purpose: Residents who want to smoke are evaluated and assessed for smoking safety. Each resident will be informed prior to or upon admission .about any limitations on smoking, including designated smoking areas, and the extent to which the facility can accommodate their smoking .preferences. Procedure: 6. Interventions for safe smoking .will be included in resident individualized smoking care plan. 8. Smoking materials that are flammable (lighters and matches) will be securely stored . On 9/9/21 at 3:21 PM, the Administrator (NHA) was interviewed regarding the lack of monitoring of resident smokers and resident smokers having lighters in their possession including in their rooms. The NHA stated, They should not have lighters on them. Safe smokers can smoke independently, unsafe smokers should be monitored. The NHA was notified of the Immediate Jeopardy on 9/8/21 at 4:07 PM, and a plan of correction (POC) was requested to remove the immediacy which began on 9/8/21. The facility provided the following removal plan on 9/9/21. The Immediate Jeopardy was removed on 9/9/21 as validated by the team on 9/9/21. Removal Plan: Element 1: Resident # 538- was assessed for injuries. The lighter was immediately seized, and the resident was transferred to the hospital for psychiatric evaluation due to non-compliance and potential threat to himself and others. Resident # 509- was assessed with no injuries. The lighter was immediately seized and safely stored. Resident # 532- was assessed with no injuries. The lighter was immediately seized and safely stored. Resident # 533- was assessed with no injuries. The lighter was immediately seized and safely stored. Resident #534-. was assessed with no injuries. The lighter was immediately seized and safely stored. Resident #535-. was assessed with no injuries. The lighter was immediately seized and safely stored. Resident #536- was assessed with no injuries. The lighter was immediately seized and safely stored. Resident #537- was assessed with no injuries. The lighter was immediately seized and safely stored. Resident #528- was assessed with no injuries. The oxygen order was discontinued on 1.22.2021 and uses Bi-pap at night. Oxygen was not being delivered at that time. Element 2 Residents who currently resident in the facility have the potential to be affected. A full in-house audit was completed on each residents' room and person for lighters. Found lighters were immediately removed and safely stored. Residents who smoke had a smoking evaluation updated and care plan updated as necessary. The smoking area will be monitored by a staff member 24 hours a day in the designated courtyard until facility can transition to non-smoking. Element 3 Smoking rules have been reviewed by the Administrator, Director of Nursing, and the Medical Director. Employees who are in the facility have been educated on the smoking rules. Employees will be educated prior to working. The facility determined that the root cause analysis was due to lack of employee supervision and routine checks for smoking materials. Element 4 The NHA/Designee will be responsible for conducting daily audits of lighters and supervision of the courtyard. The Vice President of Clinical Operations will be responsible to monitor the process weekly for continued compliance. The facility alleges date of compliance 9.9.2021. The Administrator is responsible for compliance. Although the immediacy was removed on 9/9/21, the deficient practice was not corrected by the facility and remained a pattern with the potential for actual harm that was not Immediate Jeopardy, as sustained compliance could not be verified by the state agency.

This citation pertains to intake MI 705. Based on interview and record review, the facility failed to effectively assess, monitor, and initiate wound treatment in a timely manner for one sampled Resident (R531) of five reviewed for pressure ulcers, resulting in a lack of treatment and development/worsening of an unstageable pressure ulcer, as well as the potential for infection and development of additional wounds. Findings include: The Minimum Data Set (MDS) 3.0 describes an unstageable pressure ulcer as a full-thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough and/or eschar (non-viable tissue) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth cannot be determined but it will be either a Stage III or IV pressure ulcer (full-thickness tissue loss extending to subcutaneous fat or down to muscle, tendon, or bone). A review of intake MI 705 revealed: It was alleged facility staff failed to provide adequate and appropriate care to prevent and/or treat pressure sores. On 9/2/21 at 8:54 AM, Confidential Witness O was interviewed regarding R531's stay at the facility. Witness O explained that R531 had been admitted to the facility from the hospital. Witness O stated they were not aware of R531 having a bedsore (pressure ulcer) at the hospital. Witness O claimed they had obtained R531's medical records from the facility and Didn't even see that [R531] was assessed for anything at all when [they] initially got [there] . and added, I was speaking to multiple people there but the wound was never, ever mentioned. I spoke to people on a regular basis. A review of R531's medical record and MDS assessment dated [DATE] revealed that the resident was admitted to the facility on [DATE] and discharged on [DATE]. R531's medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R531's MDS dated [DATE] included the following under Section M - Skin conditions: Is this resident at risk of developing pressure ulcers/injuries? Yes. Does this resident have one or more unhealed pressure ulcers/injuries? No. R531's MDS dated [DATE] also indicated that the resident was severely cognitively impaired and required extensive assistance from two or more staff for bed mobility and toilet use, and extensive assistance from one staff for dressing, eating, and personal hygiene. Review of Section M on R531's discharge MDS dated [DATE] reflected that Licensed Practical Nurse Wound Care Director (LPN WCN) E documented the following: Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar: 1. Number of these unstageable pressure ulcers that were present upon admission/entry or reentry: 1. A review of R531's admission nursing assessment (including skin) dated 12/22/2020 (6:11 PM) revealed: Skin Integrity: Facial color is normal. Skin color L (left) upper extremities are normal. Skin color R (right) upper extremities are normal. Skin color L Lower extremities are normal. Skin color R Lower extremities are normal. Skin temperature upper extremities warm. Skin temperature equal on upper both sides. Upper extremity skin is moist. Skin temperature of lower extremities are warm. Skin temperature of lower extremities are equal on both sides. Lower extremity skin is moist. The resident does not have skin integrity concerns. The following nursing note for R531 included the following: 12/23/2020 07:44 (AM) *Health Status Note (nurses note) Note Text: Writer received [R531 from hospital] at about 5.15pm in a stretcher by three paramedic. Resident alert times one. Writer obtained vitals, vitals within normal, skin assessed, resident has ulcer on the coccyx . No corresponding wound assessment was present for this noted ulcer on or around the date of this documentation. No documentation of family notification of the wound was found. A review of R531's, Order Summary Report, which included all ordered medications and treatments for the duration of R531's stay, revealed only one wound care-related order of, Barrier Cream, apply after incontinent episodes as needed (PRN) per nursing judgement as needed for skin protective ointment, Start Date: 12/23/2020. A review of R531's medication administration records (MARs) and treatment administration records (TARs) for December 2020 and January 2021 revealed no documented administrations of the barrier cream order. No additional wound care orders or administrations of wound care treatments were found. A review of R531's skin assessments dated 12/26/2020 revealed: Date: 12/26/2020 14:32 (2:32 PM) - Does the Resident have ANY Skin Issues Observed? Yes .Site: Coccyx, Description: wound with tx (treatment) in place. Site: Other (specify), Description: BLE (bilateral lower extremities) skin discoloration .New Wound, Wound Team Evaluation Needed: No. Date: 12/26/2020 14:48 (2:48 PM) - Does the Resident have ANY Skin Issues Observed? Yes .Site: Coccyx, Description: open area to coccyx .New Wound, Wound Team Evaluation Needed: Yes. No further wound assessment, measurement, wound care consult, or wound care documentation was found related to the above skin assessments from 12/26/2020. R531's progress notes on 12/27/2020, 12/28/2020, and 12/29/2020 were reviewed and did not mention any wounds, wound assessments/measurements, or wound treatments for R531. A Physician/PA (Physician Assistant/Associate)/NP (Nurse Practitioner) progress note dated 12/28/2020 at 11:10 AM did not address the resident's skin/wound. A progress note dated 12/30/2020 at 19:18 (7:18 PM) included, Resident had bed bath. No new changes reported regarding skin condition. R531's remaining skin assessments were reviewed and revealed: -1/2/2021 at 14:48 (2:48 PM): Does the Resident have ANY Skin Issues Observed? Yes .Site: Coccyx, Description: TX (treatment) in progress . -1/6/2021 at 19:09 (7:09 PM): Does the Resident have ANY Skin Issues Observed? Yes .Site: Coccyx, Description: Affected area--Treatment in progress . No further wound assessment, measurement, wound care consult, or wound care documentation was found related to the above skin assessments dated 1/2/21 and 1/6/21. A review of R531's remaining progress notes after 12/30/2020 did not address R531's wound(s) until the following note: -1/7/2021 14:39 (2:39 PM) *Skin/Wound Note (Narrative) Late Entry: Note Text: Wound Consult. Seeing pt (patient) via telemedicine with nurse assistance due to covid-19 pandemic I was referred by [physician] to consult re: sacral/heel wounds. [R531] was sent to the hospital .stabilized and discharged to this facility for rehabilitation .At time of admission noted to have scar tissue on sacral region. Since admission .has had a continual overall decline .Found to have rapid developing sacral and heel wounds .Skin: sacrum Kennedy appearing ulcer, central dark extending to b/l (bilateral) buttocks, currently no drng (drainage) .Recommend Tx: Foam dressing QOD (every other day) Heels now dark nonblanching .Recommend Tx: Dry dressing change QOD .Acute overall decline .Wounds/further breakdown expected and unavoidable . A review of R531's orders revealed that the recommended wound care treatments were not ordered/documented as implemented prior to the resident's discharge on 1/8/21. Remaining progress notes for R531 were reviewed and included: 1/8/2021 15:07 *Pressure Ulcer Unavoidability Note Text: Coccyx - Pressure: Length = 5, Width = 4, - Stage Unstageable, 12/23/2020 Resident has .Continuous or Chronic Urinary Incontinence, Chronic Bowel Incontinence, LAL (low air loss) mattress, heel float boots .Acute overall decline, acute pneumonia. Pt hospice appropriate. Wounds/further breakdown expected and unavoidable . [Written by Licensed Practical Nurse (LPN) E - Wound Care Director]. -1/8/2021 15:37 (3:37 PM) *Health Status Note (nurses note) .during bed bath writer noticed skin tear on the resident buttock, wound nurse notified . -1/8/2021 23:44 (11:44 PM) *Health Status Note (nurses note) .Writer called [hospital] and was informed .that Resident is admitted . Family notified. Upon requesting all wound care documentation for R531 from the facility, only one, Wound Assessment Details Report, dated 1/8/2021 at 2:07 PM was found and included the following: Wound: Coccyx, Assessment Date: 1/8/2021 2:07 PM .Status: Active, Type: Pressure, Classification: Ulceration, Source: Facility-acquired, Date Identified: 1/08/2021, Identified by: [Licensed Practical Nurse (LPN) LPN F] .Clinical stage: Unstageable .Tissue Types: Bright Beefy Red=50%, Slough Non-adherent=50% .Size (cm) (centimeters) 5.00 x 4.00 x Unknown (Length x Width x Depth), Area 20.00 cm² .Family or Designee Notified [box not checked, no notification time/date present] . No information was present regarding R531's heels as noted on the 1/7/2021 Skin/Wound progress note. A review of R531's care plan was reviewed and revealed the following: [R531] has potential for impairment to skin integrity r/t (related to) incontinence, limited mobility, fragile skin, [CONDITION(S)], [CONDITION(S)] (hypertension), [CONDITION(S)], CHF (congestive heart failure), Depression, Gout, [CONDITION(S)], Dementia, [CONDITION(S)] Date Initiated: 12/23/2020. Apply barrier cream per facility protocol to help protect skin from excess moisture. Date Initiated: 12/23/2020. Change bedding/clothing if moist. Date Initiated: 12/23/2020. Monitor skin when providing cares, notify nurse of any changes in skin appearance. Date Initiated: 12/23/2020. Assist me to reposition frequently as tolerated. Date Initiated. 12/23/2020. Encourage me to float heels, use heel boots in bed as tolerated. Date Initiated: 12/23/2020. No changes/updates/additions to R531's skin management care plan were noted to be made after 12/23/2020. On 9/9/21 at 1:00 PM, Licensed Practical Nurse Wound Care Director (LPN WCN) E was interviewed regarding R531's wound documentation and treatment while in the facility. When queried regarding the discrepancy between R531's admission and discharge MDS assessments under Section M, LPN E stated, I'd have to see who did the MDS. When informed that she had documented on Section M on R531's discharge MDS, LPN E replied, Oh, I did. No, [R531] did not have one (pressure ulcer) on admission, [R531] acquired one before [they] left. When queried regarding what the treatment order was for R531's coccyx wound and where it was located in the record, LPN E stated, I don't know if they got the treatment order, they found the wound the same day [R531] discharged . Let me look. LPN E proceeded to review R531's medical record and stated, Yeah, it looks like they had just found it and they contacted the doctor. I was home [sick] when this all happened so I have to look in the chart and see .I'm looking for their notes, they normally see everyone when they first come in and do an assessment. It looks like they did their assessment when [R531] first came in and there wasn't anything (wounds). LPN E was then queried regarding the note dated 12/23/2020 that mentioned a pressure ulcer on the resident's coccyx. LPN E replied, I do see that and I don't .[The] treatment team (took photos of) [R531's] feet on 12/23 but they normally do a head-to-toe within 24 hours of admission. But [R531's] coccyx is not in the pictures. I would have to ask [LPN F] who did the assessment. On wound rounds there is only the assessment for the coccyx dated 1/8. When asked if the only documented measurements for R531's coccyx wound were the ones from 1/8/21, LPN E stated, Yes, just the one set. LPN E was then asked to review R531's skin assessments completed on 12/26/20, 1/2/21, and 1/6/21. LPN E was queried regarding the treatment in place mentioned in the skin assessments, and what was ordered. LPN E stated, The only treatment that would be there would be the barrier cream which is the standard. But let me double check .Yep, that's the only order I see, is for the barrier cream. On 9/9/21 at 2:21 PM, the Director of Nursing (DON) was interviewed interview and asked, after a wound is noted how soon a treatment order should be implemented. The DON responded, Immediately, the nurse can put the basic treatment in and let the wound care nurse know, [so the] appropriate treatment [gets put] in. The DON was asked when should measurements/full wound assessment take place and be documented in the medical record to which he replied, Wound care takes care of that when they are consulted by whoever sees the wound. The DON was asked if he was able to speak to [R531's] wound(s) specifically, however, indicated he was unable to and responded, Generally speaking, if a nurse on the floor sees a wound, they would let the wound care nurse know. Nine times out of 10 a wound care nurse may go in and there's nothing there. But the first step for the nurse would be to put in a wound care consult. A review of the facility's policy/procedure titled, Skin Management Guideline, effective 11/28/17, revealed, It is the practice of this facility to properly identify and evaluate residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care .All residents admitted to the facility will be evaluated for actual and potential skin integrity issues .The Pressure Injury Notice will be completed and provided for the resident and/or resident representative providing notice of predicting factors and baseline care plan interventions to support prevention, treatment and healing .A comprehensive individual evaluation guides the: .Identification of residents at risk and factors predicting the risk for breakdown, Identification of the presence of skin impairment, Provides an ability for the facility to develop and implement a care plan that reflects each resident's identified needs, Identify interventions to stabilize, reduce or remove underlying risk factors, Evaluate the effectiveness of interventions, Modify the interventions as appropriate .An individualized plan of care will be developed upon admission, reviewed and updated quarterly and with a change in condition as needed. The plan of care will identify impairment and predicting factors .Interventions for prevention, removing and reducing predicting factors and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . If any skin concerns are noted, they are to be reported to the licensed nurse. Weekly skin observation on the bath/shower day will be performed by a Licensed Nurse. If a skin concern is noted, refer to the skin and wound formulary. The Care plan for Skin Integrity is to be evaluated and revised based on response, outcomes, and needs of the resident. The physician will be consulted with changes suggesting impairment in skin integrity .If a resident is admitted with or there is a new development of a pressure ulcer .the following procedure is to be implemented: 1. Review the wound formulary for guidance, 2. Consult with the Physician/NP and Resident Representative, 3. Notify Supervisor/Designee as assigned, 4. Notify Dietary for nutritional interventions, 5. Notify therapy department for seating surface evaluation and possible treatment interventions and other interdisciplinary team members as appropriate, 6. Re-evaluate turning and repositioning interventions, 7. Initiate Braden Scale and initiate investigation process if new onset, 8. Evaluate interventions per risk factors identified and re-evaluate and modify the plan of care based on root cause analysis for new skin alterations ., 9. Update the Care Plan for Skin Integrity and nursing assistant care cards with skin concern, appropriate risk factors, turning intervals and interventions as appropriate, 10. Initiate the Wound Initial Documentation Observation in PCC which will include: type of wound, location, date, stage (pressure ulcers only) or indicate partial or full-thickness .length, width, and depth, wound base description, wound edge description and if present: drainage, odor, undermining, tunneling, and/or pain .11. When a pressure ulcer is present, daily wound monitoring should include: An evaluation of the ulcer, if no drainage is present, An evaluation of the status of the dressing, if present, The status of the area surrounding the ulcer (that can be observed without removing the dressing), The presence of the possible complications, such as signs of infections, Whether pain, if present, is being adequately controlled .Document on any changes or concerns in the nurses notes and re-evaluate prior steps 1-9 as appropriate .

This citation pertains to Intake number MI 037. Based on observation, interview, and record review the facility failed to prevent a hot liquid burn affecting one resident (R505) of two residents reviewed for accidents and hazards resulting in a painful injury by a hot liquid. Findings include Review of R505's anonymous complainant's allegation revealed, On 05/09/2021, the facility staff served a hot liquid to a resident resulting in a burn. On 05/18/2021 at 10:50 AM, R505 was interviewed regarding the burn injury and stated, I asked the Aide (Certified Nurses Aide, CNA K) for some hot water so I could make some soup (brand name noodles) and she brought me a cup and put it there on the table. Then [CNA K] went over there and got me a package of noodles and was reaching over to hand me the noodles. I don't know what [CNA K] hit, but whatever, it knocked the hot water over and burned me. It did hurt, but at first it was just two small blisters. I've gone through a case of noodles and this never happened before. It was an accident. But they (the burns) opened up and now they have to change the dressing every day. R505 displayed the wounds. The lower right abdomen and upper right thigh were observed. R505 was asked where CNA K obtained the hot water from and stated, I don't know. But now they have to get the water from the kitchen and take it to the desk and put the noodles in it and wait until the water puffs up the noodles. When the noodles are done, there isn't that much water left. Then they bring it to me. Record review of R505's Electronic Health Record (EHR) revealed R505 was admitted into the facility on [DATE] with diagnoses that included, [CONDITION(S)] (pain syndrome), Covid-19, and [CONDITION(S)] (poor circulation). The most recent Minimum Data Set (MDS) assessment dated , 03/03/2021 revealed R505 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating an intact cognition and needed extensive assistance with Activities of Daily Living (ADLs) and supervision with eating. Further record review revealed a wound assessment dated , 5/17/2021 10:58 AM, .upper abdomen Partial Thickness (second degree) 20.00 x 4.0 x 0.10 (centimeters). upper thigh Partial Thickness 18.0 x 6.0 x 0.00. length, width, depth) . R505's care plan revealed, Focus - Resident prefers to have extra hot water to make noodles. Goal - Staff to provide hot water for noodles. Interventions - Educate resident to be safe when using hot liquids. R505's care plan for hot liquids was initiated on 03/10/2021 and not reviewed or revised after the burn injury on 05/09/2021. On 05/18/2021 at 1:55 PM, the Nutritional Services Director (NSD G) was interviewed regarding the serving of hot liquids to R505 and stated, We now prepare the noodles for her. I don't know where the water came from. There are microwaves in the employee lounge and in the (personal name of the conference room) room. We are open at 6:00 AM. Maybe it was one of the agency gals that didn't know where to get it. NSD G demonstrated that the source of hot water is on the coffee urn which was set to HOLD, NSD G turned the coffee urn's temperature dial to BREW and poured a cup of hot water and stated, When it is done brewing, we turn it back to hold. NSD G was asked to take the temperature of the water served from the coffee urn and the temperature of the water was 180 degrees Fahrenheit. NSD G then stated, We hold it and serve it around 140 (degrees). On 05/18/2021 at 2:40 PM, the facility's Corporate Advisor approached and stated, We did a corporate-wide QAPI (Quality Assurance (QA) and Performance Improvement (PI) plan on it. We educated staff on temperatures, reheating food, and made it clear that the microwave in the employee lounge is for employee food only. The staff weren't allowed to come back unless they were in-serviced. On 05/19/2021 at 9:27 AM, an interview was conducted with CNA B regarding a resident's request for hot water or to have food reheated and stated, I would turn the microwave on for two seconds and check it. If the kitchen is serving I would get it from them. On 5/19/2021 at 9:37 AM, CNA K was called on the phone but the phone was not in service. On 05/19/2021 at 9:42 AM, Nurse T, the nurse that documented the incident was called on the phone and a voice mail requesting a return call was left. On 05/19/2021 at 9:48 AM, an interview was conducted with Nurse P regarding caring for R505 the morning R505 was burned by a hot liquid. Nurse P stated, I got report on the incident that morning. CNA K got the water from the kitchen. Usually when [R505] asked for hot water, it's with a meal. So they (the kitchen) prepare it and let it sit until it's ready. In this case it was early in the morning, so [CNA K] got it from the kitchen and unfortunately immediately gave it to the resident. Nurse P was asked if it was facility practice to take the temperature of hot liquids before serving them to the residents and stated, No. On 05/19/2021 at 2:00 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were asked about the facility's policy and procedure regarding the serving of hot liquids to residents and the NHA stated, They all have been in-serviced. Review of the facility's policy and procedure titled, Personal Food Guidelines dated as, Effective 3. 12. 2018 reflected. If using the microwave oven, reheated foods will be covered, rotated or stirred midway during cooking, heated to a temperature of 165 [degrees] F, and allowed to stand covered for two minutes. The policy and procedure did not address the serving of hot liquids directly for the coffee urn.

This Citation Pertains to Intake Numbers MI 603 and MI 665. Based on observation, interview and record review, the facility failed to ensure a thorough and comprehensive investigation related to abuse for one (#701) of two Residents reviewed for abuse, resulting in lack of comprehensive interviews of all potential witnesses, no investigation of verbal abuse concerns, lack of comprehensive assessment of Resident psychosocial status following abuse allegation, and Resident verbalization of feelings of fear. Findings include: Review of intake documentation revealed an allegation of physical abuse occurred within the facility on 7/25/20. The intake documentation included, Allegations . (Resident #701) is bed-bound and does not ambulate on their own. On 7/25/20, (Resident #701) had a bowel movement in the bed. A nurse aide (Nursing Assistant A) cleaned (Resident #701) up; however, doing so roughly. (Resident #701) informed (Nursing Assistant A) that they were being rough . (Nursing Assistant A) then made a fist and struck (Resident #701) on their outer thigh of left leg. Law enforcement was involved . An interview was conducted with the facility Administrator on 7/30/20 at 10:20 AM. When queried regarding the occurrences involving Resident #701, the Administrator stated, Over last weekend we had a concern that staff was rough with (the Resident) when providing care. When asked about the facility investigation pertaining to the incident, the Administrator replied, The CNA (Certified Nursing Assistant A) was in the room providing care following the Resident having a BM (Bowel Movement). The Administrator was then asked what time the incident occurred and stated, Day shift. The Administrator then stated, Early afternoon shift, the Resident made a complaint to the afternoon nurse and we suspended (Nursing Assistant A). When queried if the Nursing Assistant had returned to work, the Administrator replied, Yes. On 7/30/20 at 11:05 AM, Resident #701 was observed in their room, positioned on their back in bed. An interview was conducted at this time. When asked how they are treated by staff in the facility, Resident #701 replied, They are rude. With further inquiry, Resident #701 disclosed a recent interaction with staff. Resident #701 stated, I had diarrhea and asked the Aide (Nursing Assistant) to come in and change me. (The Nursing Assistant) wiped me really hard and I told them. (The Nursing Assistant) told me to quit being a baby. When asked what happened after that, Resident #701 indicated they semi rolled back and stated, (The Nursing Assistant) hit me with their right hand. When asked when the Nursing Assistant hit them, Resident #701 pointed to their left leg, directly above the thigh. Resident #701 was asked if they had a mark or bruise on their skin following the incident and replied, No. When asked the Nursing Assistant's name, Resident #701 replied, I don't know and revealed they were unaware of most of the staff members names because their name tags are flipped around and the staff do not tell them. When queried what the Staff member looked like, Resident #701 indicated they were female and stated, They were black and had an accent. They are hard to understand. Resident #701 was then asked if there were any other staff present in the room at the time of the incident and replied, No. When asked if other staff came into their room later, Resident #701 replied, Yes but were unaware of the nurse's name. Resident #701 then stated, I'm just scared to be here. I don't sleep good at night anymore since it happened. Resident #701 was asked if they had spoken to their Physician and/or the facility Social Worker regarding the incident and how they were feeling. Resident #701 replied, They came in but there was really no discussion. When asked for clarification, Resident #701 revealed facility staff came in the room and asked questions but did not have a discussion with them. When queried, Resident #701 revealed the Nursing Assistant had cared for them in the past but had never physically hurt them prior to this incident but revealed the Nursing Assistant had been rude and rushed in the past. When queried regarding treatment by other staff in the facility, Resident #701 indicated some staff are nice and a lot are rude and rush. Record review of Resident #701's medical record revealed the Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required extensive to total assistance to perform Activities of Daily Living (ADLs). Additional review of Resident #701's medical record revealed they were seen by a behavioral health care provider on 6/3/20 and 6/18/20. Documentation from both dates revealed the Resident's demeanor was Cooperative, pleasant and engaging and they were Oriented to person, place, time and situation with intact insight and judgement and organized thought processes. The documentation also revealed the Resident was not experiencing any behaviors and was not experiencing any delusions/hallucinations but was experiencing signs and symptoms of depression. Review of progress note documentation in Resident #701's medical record revealed the following: -7/29/20: Psychosocial Note . Writer followed up with resident and provided psychosocial support. Resident indicates . doing okay and feels safe in the facility . -7/28/20: Psychosocial Note . Writer followed up with resident today to provide psychosocial support. Resident stated . doing okay and feel safe in the facility. Resident was alert and pleasant while talking to the writer. Psychosocial support was provided to resident. -7/27/20: Psychosocial Note . Writer followed up with resident to provide psychosocial support regarding resident's allegation. Resident stated . doing okay and feel safe in the facility. The resident was laying in bed while writer walked into residents room. This writer provided psychosocial support. -7/25/20: Psychosocial Note . Writer followed up with resident to provide psychosocial support regarding resident's allegation. Resident was laying in bed watching TV when writer walked into residents room. Resident stated . doing okay and feel safe in the facility. This writer provided psychosocial support . -7/25/20: Health Status Note (nurses note) . Resident Reported at 3:18 PM that a day shift aide had hit (them) on the left leg . Resident has skin intact with no redness swelling or pain . No assessment documentation related to the Resident's psychosocial status and well-being was noted in the medical record other than a Brief Interview Mental Status (BIMS) assessment to assess the Resident's cognition. Review of facility provided Investigation Folder related to the incident included: -Multiple Like Resident interview forms. The forms included the following closed-ended questions with areas to check Yes or No or N/A as the response. Did you have any concerns how staff provider care for you over the weekend? and Did you report it to anyone? -Staff statements including a statement from Nursing Assistant A which was signed by the Director of Nursing (DON) but not by Nursing Assistant A and a Statement by Licensed Practical Nurse (LPN) C -A skin and pain assessment for Resident #701 The investigation documentation did not contain documentation and/or a psychosocial assessment, a staffing schedule showing who was assigned to care for Resident #701, and a statement from the Resident describing what had occurred. The staffing assignment sheets for 7/25/20 were requested from the Administrator on 7/30/20 at 1:03 PM. A phone interview was conducted with Nursing Assistant A on 7/30/20 at 1:05 PM. Nursing Assistant A was asked what shift they normally work at the facility and replied, Morning, day shift. Nursing Assistant A was then queried if they had worked on 7/25/20 and indicated they had. When asked if they were assigned to work on the 300 unit/hall, Nursing Assistant A replied, Normally work on Station Three (three hundred hall) but not that day. When asked if they were assigned to care for Resident #701 on 7/25/20, Nursing Assistant A indicated they were. When queried how they were assigned to care for Resident #701 who residing on the 300 hall (Station Three) if they were not assigned to work there on 7/25/20, Nursing Assistant A indicated they normally work in the front part of the hall. When asked if they were saying they were assigned a different set of Residents than they typically are on 7/25/20, Nursing Assistant A indicated that was correct and that they were assigned a different set of Residents. When queried regarding Resident #701 on 7/25/20 and if anything unusual occurred during care, Nursing Assistant A stated, I went there three or four times. Nursing Assistant A then revealed they noticed two call lights on in the hall around 2:50 PM and answered Resident #701's call light last. Nursing Assistant A stated, When I went in, (Resident #701) told me they had a BM. They told me the water was cold in the middle of care. I changed (the Resident's) brief and linen. when I was cleaning (Resident #701) they told me they weren't clean enough but there wasn't any BM so I went out in the hall to find someone to validate that (Resident #701) was clean. (Licensed Practical Nurse (LPN) C) was walking by. I called out to validate. I opened (Resident #701's) brief and showed no BM. (LPN C) said they looked clean. When asked if the Resident told them they were being rough when cleaning them, Nursing Assistant A replied, No. When queried if anything else unusual occurred while providing care to the Resident, Nursing Assistant A indicated it had not. When asked if they had hit the Resident during care, Nursing Assistant A replied, Not me, no. An interview was conducted with Social Services Director D on 7/30/20 at 1:30 PM. When queried if they were the Social Services staff member assigned to Resident #701, Social Services Director D indicated they were. When queried regarding the Resident, Social Services Director D stated, (Resident #701) is a nice person to talk to. When asked about the Resident's psychosocial history and current concerns, Social Services Director D replied, Yes, depression. Social Services Director D was then asked if Resident #701 was followed by psychiatric services and replied, Yes. When queried if they interviewed the Resident following the abuse allegation on 7/25/20, Social Services Director replied, Yes. When queried why their interview was not included in the provided facility investigation, Social Services Director D was unable to provide an explanation. Social Services D then reviewed the facility provided investigation documentation and confirmed the investigation did not include a statement from Resident #701 detailing the incident. Social Services Director D then stated, I was just there with the Resident when the police interviewed them. When asked about the interview, Social Services Director D stated, (Resident #701) said they told the CNA to wipe them and they didn't feel they were wiped well. (Resident #701) said the CNA hit them on their left thigh. When queried if they conducted an assessment of the Resident's psychosocial status and well-being following the incident, Social Services Director D indicated they had. When asked why there was not an assessment in Resident #701's Electronic Medical Record (EMR), Social Services Director D indicated they documented under Psychosocial Notes. Social Services Director D was then asked if they found any concerns during their assessment and replied, No. When queried regarding Resident #701's verbalization of fear related to being in the facility following the incident, Social Services Director D revealed they were unaware Resident #701 was fearful. At 1:40 PM on 7/30/20, an interview was conducted with Resident #701 and Social Services Director D in the Resident's room. When asked, Resident #701 indicated they knew who Social Services Director D was but was unable to recall their name. Resident #701 was then asked if they told Social Services Director D that they did not feel safe within the facility and Resident #701 stated, Yes. Social Services Director D stated to the Resident, No, you did not and Resident #701 replied, Well then it was the DON (Director of Nursing). I told someone. Social Services Director D did not ask Resident #701 any further questions regarding their concerns prior to exiting the room. After exiting the room, Social Services Director D was interviewed further regarding Resident #701 on 7/30/20 at 1:50 PM. Social Services Director D's EMR documentation was reviewed at this time. When asked what psychosocial support was provided as described in the documentation, Social Services Director D did not provide a response. Social Services Director D was then asked what questions they asked Resident #701 to determine the Resident was doing okay and that they felt safe in the facility as documented in the EMR and Social Services Director D replied, I asked them how they were doing. No further explanation was provided. When queried if they had completed any type of formalized assessment with Resident #701 following the incident, Social Services Director D replied, No. When asked if completion of an assessment is included in facility policy/procedure, Social Services Director D indicated it was not. An interview was completed with Police Officer B on 7/30/20 at 3:00 PM. When queried regarding the incident concerning Resident #701 on 7/25/20, Police Officer B revealed they responded to the facility. When asked what had occurred, Police Office B stated, It sounded like the Nursing Assistant was rough with (Resident #701) when providing care. With further inquiry, Police Officer B revealed Resident #701 had told (Nursing Assistant A) they were being rough and then (Nursing Assistant A) got mad and hit (the Resident) in the leg. An interview was conducted with LPN C on 7/30/20 at 3:10 PM. When queried if they were working on the 300 hall of the facility on 7/25/20, LPN C stated, No. When asked if they were involved with Resident #701's care on that day, LPN C stated, I was walking in the hallway when the CNA asked me to come into the room. When queried what occurred in the room, LPN C replied, The Resident was upset and screaming. (Nursing Assistant A) opened (Resident #701's) brief to show me (the Resident) was clean. Even though (Resident #701) was clean, (Nursing Assistant A) wiped (the Resident) again. When asked what occurred next, LPN C revealed they left the Resident's room. When asked if Nursing Assistant A was still in the room when they exited the room, LPN C stated, Yes. LPN C was asked how long Nursing Assistant A was in the Resident's room after they left the room and stated, Shortly after. LPN C was unable to provide an estimated length of time. On 7/30/20 at 3:32 PM, the Administrator was queried regarding the provided investigation documentation not including a statement from Resident #701. The Administrator provided a statement at this time and indicated it was in their office. Resident #701's statement was provided at this time. The statement was not signed by the Resident. An interview was conducted with Nurse J on 7/30/20 at 4:10 PM. When queried if they were aware of an incident involving Resident #701 on 7/25/20, Nurse J revealed they had worked on that date but were not involved in the Resident's care. When asked if anything out of the usual had occurred, Nurse J stated, We were really short staffed. There were only two aides for 45 Residents. With further inquiry, Nurse J revealed the Residents on the Third Bay of the facility are high acuity and require additional staff to meet their needs. When asked how many Nursing Assistants and nurses typically work on the unit, Nurse J replied, Should be at least three but four is optimal. When queried if they worked with and observed Nursing Assistant A provide care to Residents, Nurse J indicated they had. When queried regarding their observations of Nursing Assistant A's interactions with Residents and stated, I have noticed (Nursing Assistant A) can be short and abrupt. Rude- not the ideal bedside manner. When asked what they meant, Nurse J stated, Kind of witchy, impatient, rushed. Seems irritated when they have to do the care. I don't understand that- that is what we are here for. When queried if they were interviewed regarding the incident by the facility, Nurse J indicated they were. When asked if they had disclosed their observations of Nursing Assistant A during the interview, Nurse J revealed they did not because they were not asked about the Nursing Assistant and/or Resident #701. An interview was conducted with the Director of Nursing (DON) on 7/30/20 at 4:45 PM. When queried about Resident #701's allegation and the investigation completed by the facility, the DON indicated the allegation was unable to be substantiated. When queried regarding the length of time Nursing Assistant A was in the room with Resident #701, the DON revealed they did not know a time frame. When asked if there were cameras present in the facility and if the camera footage was reviewed, the DON replied, No cameras. When queried regarding assessment of Resident #701's emotional and psychosocial well-being following the incident including the Resident's statement of being fearful and interview with the facility Social Services Director, the DON indicated they did see a concern with the investigation. When queried regarding staff statements pertaining to observations of Nursing Assistant A, the DON stated, I have not seen that. When asked if verbal abuse concerns were addressed in the investigation, the DON indicated the allegation was related to physical abuse. When queried if concerns would have been uncovered with additional investigation and open-ended questions, the DON did not provide further explanation. When queried if staffing levels on 7/25/20 were sufficient to provide care, the DON indicated there were four staff (two nursing assistants and two nurses) for 45 Residents. When asked about facility staff rushing while providing care, the DON stated, It (incident involving Resident #701) was right at the end of the shift. They were probably trying to get out of there. When asked if staffing levels were considered in the facility investigation, the DON revealed they were not. When asked, the DON denied a potential correlation with staffing levels, rushed care, and Resident perception of care. Review of Nursing Assistant A's personnel file revealed the employee had received an Employee Discipline Form on 7/16/20. The form revealed, Job Performance/Behavior Deficiency: On the date of 7/16/20, staff had double briefed residents . Specific Results Required for Acceptable Improvement: Staff are to check/change Residents every two hours or as needed . An interview was conducted with the Administrator at 17:05 PM on 7/30/20. When queried regarding Resident #701's and staff statements related to observations of care by Nursing Assistant A, the Administrator indicated they were unaware of any concerns. Review of facility policy/procedure entitled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property (Dated 11/28/17) revealed, It is the practice of the facility to encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse . Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Abuse includes verbal abuse . physical abuse and mental abuse . Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Investigation of abuse: When an incident or suspected incident of abuse is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include: i. Who was involved ii. Residents' statements a. For non-verbal residents, cognitively impaired residents or residents who refuse to be interviewed, attempt to interview resident first. If unable, observe resident, complete an evaluation of resident behavior, affect and response to interaction, and document findings. iii. Resident's roommate statements (if applicable) iv. Involved staff and witness statements of events v. A description of the resident's behavior and environment at the time of the incident vi. Injuries present including a resident assessment vii. Observation of resident and staff behaviors during the investigation viii. Environmental considerations .

This citation pertains to intake numbers: 7 and 0. Based on observation, interview and record review, the facility failed to secure the back delivery door, allowing one resident (#702) of six residents reviewed for elopement, to exit the building unbeknownst to staff at approximately 9:47 PM on 7/4/2020, resulting in the likelihood of serious injury or death from being outside, unsupervised for an extended period of time. Resident #702 was returned to the facility, escorted by two police officers on 7/10/2020 at approximately 10:05 PM. Findings include: The Immediate Jeopardy (IJ) started on 7/4/2020 and was identified on 7/15/2020. The Administrator was notified of the Immediate Jeopardy on 7/15/2020 at 3:00 PM and was asked for a plan to remove the immediacy. The IJ was removed on 7/05/2020, based on the facility's implementation of the removal plan as verified onsite on 7/16/2020. Although the immediacy was removed, the facility's deficient practice was not corrected and remained isolated with actual harm that is not immediate jeopardy. On 7/15/2020 at 12:10 PM, an interview was conducted with the Nursing Home Administrator (NHA) in regard to a facility reported incident. The NHA stated, (Resident #702) was discharged to another facility yesterday. They were alert and oriented and had a Brief Interview for Mental Status (BIMS) of 15. (Resident #702) wants to smoke cigarettes. (Resident #702) left and stayed out for a week, then came back on Friday. (Resident #702) didn't tell anyone where they were going, they just left out the back door. The NHA explained that when the resident did come back, Resident #702 was unable to say where they went. On 7/15/2020 at 12:30 PM, an observation was made with the NHA of the door that Resident #702 exited. The NHA went through a double doorway that was wide open. There was a sign just above the doorway that referenced the corridor was for staff only. The NHA was asked if the doors always remained open and stated, No, not really. Upon entering the corridor, there was an open door that entered into the employee break room Around the corner from the break room, there was the kitchen, and then another corridor that lead to an exit door (delivery door). The NHA explained that Resident #702 went in the employee break room, looked out the doorway and then walked passed the kitchen and out the delivery door. Upon inspection of the delivery door, there was a key pad next to the door. The NHA was queried on whether or not the door locks. The NHA explained that the door was working earlier on 7/4/2020 when staff checked it but, at the time of Resident #702's exit, the door had not locked or had the alarm sounded. The NHA explained that normally the door would not open without keying in a code, and would sound an alarm if a resident with a wanderguard (a bracelet normally placed on the ankle to trigger an alarm response when near certain doors) when trying to exit through the door. The NHA explained that the door was fixed on 7/5/2020. A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #702 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED].#702 had a BIMS score of 15 out of 15, indicating an intact cognition and needed supervision for ambulation and transfers. On 7/15/2020 at 2:30 PM, an observation was made of the camera footage dated 7/4/2020 with the NHA. At 9:47PM, Resident #702 was observed in the staff break room door way. A staff member had walked out of the break room and then Resident #702 exited the break room, walked down the service hallway near the kitchen, turned and walked out of the back delivery door. There was no staff present at the time. A record review of the Progress Notes for Resident #702 revealed the following: 4/1/2020 14:26 (2:26 PM) .Resident chooses not to comply with quarantine. Resident aimlessly wanders unit. Resident was seen knocking on glass window to library wanting to go outside to court yard. Resident was asked to go back to room. Resident chose not to. Doctor notified. Will continue to redirect. 6/25/2020 20:48 (8:48 PM) . Social Service Note . Social worker tried calling resident guardian and case worker to discuss transferring resident to a smoking facility . 7/5/2020 02:35 (2:35 AM) . At approximately 0040 (12:40 AM) CENA (Certified Educated Nurse Assistant) reported that (Resident #702) was not in their room. Room to room search began, then Code White (missing person) called, DON (Director of Nursing) and Administrator called . Police called . CENA walked the perimeter . Authored by Licensed Practical Nurse (LPN) A. 7/5/2020 1:00 PM (nurses note) . Writer finally got a hold of Guardian at about 9:30 am to inform (them) of incident . (Guardian) stated that (they) are not surprised because resident has done that before (eloped). Writer also spoke to (family member) multiple times to see if (they) had any information or any possible area where resident may be but (family member) stated, (family member) doesn't have any ideas, that (family member) was also searching. Police was also informed and police went to (family members) house. Search around the neighborhoods but resident was not found. Search in progress. Let it be noted that Resident #702 was missing from the facility for 6 days. 7/10/2020 22:05 (10:05 PM) .Res (Resident) returned to facility with 2 police officers. Res A&Ox3 (alert and oriented to person, place and time). [MEDICAL CONDITION] (a communication deficit that limits speech and expression) noted. Res still able to make needs known to staff .Res oriented to Station 1. Staff maintaining frequent visual checks to establish a baseline for resident. Call light within reach. A record review of the initial Wander/Elopement Risk Evaluation dated 6/21/2019 indicated a high score of 17, related to Resident #702 being cognitively impaired, independent with ambulation and having a history of attempted elopements. A record review of the care plan dated 7/12/2020 for Resident #702 revealed the following: Focus: (Resident #702) has a hx (history) of elopement risk as they went AWOL from the group home that they previously resided in. Goal: (Resident #702)'s safety will be maintained . Interventions: Frequent monitoring Photo on wander list Staff aware of residents wander history Distract resident from wandering . Identify pattern of wandering . Monitor location . On 7/16/2020 at 11:49 AM, the DON was interviewed in regard to Resident #702 exiting the building on 7/4/2020. The DON stated, Staff called me, they said (Resident #702) was missing and gone for awhile. They did call the police. (Resident #702) was aphasic . had a stroke . They (the staff) did not know where (Resident #702) went or how they got out. We reviewed the cameras .and then gave that information to the police. We walked around and checked the doors. The door was working on and off. We called the hospitals every single day. We walked to the (family member's) house. (Family member) was looking .too. The police found (Resident #702) at a Coney Island (restaurant) in Wayne. On 7/16/2020 at 12:16 PM, Maintenance Director B was interviewed in regard to checking the doors to be sure they are working properly. Maintenance Director B explained that he has staff in the building daily to do the checks and that the door was checked earlier that day and it did work. The Maintenance Director was asked if he had to fix the door and he stated, I had to call to get the door fixed, they (door company) came in the next day. On 7/16/2020 at 2:00 PM, LPN A was interviewed via phone in regard to Resident #702 exiting the building on 7/4/2020. LPN A explained that she was the nurse on duty from 7:00 PM (7/4/2020) through 7:00 AM (7/5/2020). LPN A did not recall the last time she had seen the resident that evening but did explain that when she discovered (Resident #702) as missing she searched the premises, called a Code White and called the police. An attempt was made to contact three CENA's that were in charge of the care for Resident #702 during the night of 7/4/2020 and morning of 7/5/2020, however there were no return phone calls by the end of the survey. A record review of the communication (via email form) between the facility and door alarm repair company revealed the following: (Dated 7/5/2020) .I went out today after I received a call that the mag lock was not working to the freight door. I discovered that the mag lock was not getting proper power. I restored power to it and tested the door several times. It is now working fine. Loss of power to the mag lock in (sic) unknown at this time. A review of the facility policy titled Wandering and Elopement Guideline, dated 3/16/2017 revealed the following: The Facility will provide .safe environment for wandering residents at risk for elopement. Facility procedures-the facility will have a process to evaluate door alarm functioning every day . Door Alarms-Any suspected or confirmed malfunctioning of any door alarm will have an immediate 1:1 supervision of the exit until repairs can be made or alternate alarm accommodations can be applied. Door alarm function will be checked daily by maintenance personnel and weekends and/or holidays designated personnel. IJ Abatement Plan - F689 Element # 1 Resident # 702 returned to the facility on 7.10.2020, a physical assessment was immediately performed with no injury noted. Vital signs stable. Denied pain or discomfort. Resident # 702 was placed on continuous one on one supervision until appropriate discharge planning could occur. Resident # 702 was discharged from the facility on 7.14.2020 to a more appropriate setting. The delivery entrance door was serviced on the same day that Resident # 702 was noted to be out of the facility, July 5, 2020. The delivery entrance door is in full working order and is tested daily for proper functioning. A secondary alarm that is not connected to the same electrical circuit was also engaged at the delivery entrance door. Element # 2 Residents who currently reside in the facility have the potential to be affected. Updated Elopement Assessments were completed on all residents who reside in the facility on July 5, 2020. Residents deemed at risk for elopement had a care-plan review to ensure appropriate interventions were in place. Each Resident room window was audited to ensure the security screw was in place on July 5, 2020 by the Maintenance Director. Facility exit doors were checked to ensure alarms were in place and functioning properly on July 5, 2020 by the Maintenance Director or designee. An audit of the Elopement Binder was conducted by the Corporate Compliance Officer on July 5, 2020 for accuracy. Element#3 The facility administrator and Corporate Compliance Officer hosted an Ad-Hoc QAPI committee meeting with the Medical Director to review the Past Non-Compliance and associated staff education. Facility staff have been educated on the Wandering and Elopement Guidelines with 100% completion. Element # 4 Daily door alarm checks will be conducted by the Maintenance Director or designee. Any alarm failures will immediately be reported to the Administrator and the door will be properly secured until the malfunction is rectified. Audit findings will be reported at the facility monthly QAPI (Quality Assurance Process Improvement) Committee meeting for a period of 6 weeks then as needed moving forward, Twice weekly a window security audit will be conducted by the Maintenance Director or designee Any security discrepancies will immediately be reported to the Administrator and the window will be properly secured until the discrepancy is rectified. Audit findings will be reported at the facility monthly QAPI Committee meeting for a period of 6 weeks then as needed moving forward. Random weekly staff inquiries are in place to ensure staff have an understanding of the Wandering and Elopement Guidelines for a period of 6 week then as needed moving forward. These audits will be reviewed and discussed at the facility monthly QAPI Committee. The Administrator is responsible for sustained compliance.

This Citation Pertains to Intakes: MI 406 and MI 272. Based on interview and record review, the facility failed to ensure comprehensive assessment and documentation for one (Resident #701) of three Residents reviewed for change in condition, resulting in lack of timely and comprehensive assessment, including temperature monitoring, and documentation of a change in condition, need for emergency medical treatment, decline in overall health status, and hypothermia (body temperature less than 95 degrees Fahrenheit- F). Findings include: Record review of intake documentation from Confidential Witness A revealed the following, On [DATE] we received a called from the hospital saying that (Resident #701) was admitted to the hospital . The ER doctor told me that they strongly believe(d) that (Resident #701) was left unattended for several hours (the Resident) was cold, confused, little clothing and temperature was very low. Review of intake documentation, submitted by Emergency Department (ED) Registered Nurse (RN) B revealed the following, (Resident #701) resides in a nursing home. (Resident #701) is bedridden and has Dementia . sometimes non-verbal. On [DATE], (Resident #701) was admitted into the hospital. When (Resident #701) arrived, their temperature was 86 degrees (F) rectal (normal body temperature is 98.6 F). The (Physician) was concerned . unlikely for someone to get that cold without being near an open window or in a cold room with no clothes on. If (Resident #701) would have been another degree or two colder, (they) would be dead. It is unknown exactly how they became so cold. If (Resident #701) was septic (infection throughout body) or had an infection, (Resident #701) would still take a long time to become that cold . (Resident #701) was not being properly checked on at the nursing home . An interview was attempted to be completed with ED RN B on [DATE] at 9:08 AM. However, ED RN B was not working. A message was left with a return number. An interview was conducted with Confidential Witness A on [DATE] at 9:21 AM. When queried regarding Resident #701, Witness A stated, (Resident #701) died on [DATE]th (2020). When asked about events prior to the Resident's death, Witness A revealed they had received a call on [DATE]th (2020) from the facility. During the call, facility staff informed them that Resident #701 was acting funny and they were going to give (Resident #701) some IV (intravenous) fluids. With further inquiry regarding the Resident acting funny, Confidential Witness A revealed they were told the Resident was dehydrated and the (facility) nurse told them they thought the Resident would perk up with some fluids and indicated they would let them know if anything changed. Confidential Witness A proceeded to state, Then the hospital called and said (Resident #701) was admitted . When queried, Witness A stated, The Doctor at the hospital talked to me. They were really upset. They (Doctor) said (Resident #701's) temperature was 86 (degrees Fahrenheit- F) and that (Resident #701) had pneumonia, was very dehydrated, and that their body was shutting down. Witness A then stated, The ER Doctor told me they strongly believed (Resident #701) was left unattended and not checked on because of their temperature. They said (Resident #701) was cold and confused. Record review revealed Resident #701 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set Assessment ((MDS) dated [DATE] did not include a cognitive assessment but did indicate the Resident required supervision to perform Activities of Daily Living (ADLs) at that time. Review of Resident #701's medical record revealed the following progress note documentation: -[DATE] at 6:23 AM: Health Status Note (nurses note) . Received in bed . alert and verbal . Resident seems to be failing to get well . -[DATE] at 7:09 AM: Health Status Note (nurses note) . Resident was received in bed during shift change, alert, but barely talk. Resting in bed . Fluids offered and accepted . -[DATE] at 2:42 PM: Health Status Note (nurses note) . Resident is alert and verbal, oriented to name only. resident has graduated off of Covid status. has increase weakness and is being seen by therapy . -[DATE] at 11:25 AM: (Health Status Note (nurses note) . Writer spoke with (Physician) and (Physician Assistant) in house this morning regarding resident declining status. Resident is a feeder with meals, sleeps with eyes closed, easy to arouse at times but only for few minutes. Increase weakness. New orders were written . STAT labs . Writer will notify (family). -[DATE] at 11:30 AM: Respiratory Therapy Note . Resident seen awake in bed on room air continues with congested cough BRS (Bilateral Respiratory Sounds) bilaterally diminished with scattered rhonchi . appears tired with weakness . -[DATE] at 12:11 PM: Physician/PA/NP Progress Note . Altered mental status . Patient was seen in room . sleepy and not getting up for breakfast which is not like them. Nurse made aware. CNA was having a hard time getting (Resident #701) to eat drink this morning as well . vitals were reviewed. Will get stat labs and start IVF's (Intravenous Fluids) now. Nurse to check glucose. No [MEDICAL CONDITION] activity noted . Vitals . BP (Blood Pressure): ,[DATE] (Normal is ,[DATE]), HR (Heart Rate): 52 (Normal range is 60 to 100) . Temp: 96.8 (F) . General Appearance . appears lethargic . moist mucus membranes (normal- dry in dehydration) . [MEDICAL CONDITION]: diminished (abnormal) . -[DATE] at 1:43 PM: Health Status Note (nurses note) . IV Access in to start IV line and draw blood for lab work. -[DATE] at 3:22 PM: Health Status Note (nurses note) . Writer called (family) updated them resident was started on IV fluids and blood work completed and sent for pick up. -[DATE] at 1:25 AM: Health Status Note (nurses note) . Resident received in bed at the beginning of the shift with IV infusing . not easily arousable and not verbal. About an hour to the start of the shift, critical lab results were received and (Doctor) was notified. No new order at this time but will come in the morning to see resident. Writer continued to monitor resident but (Resident #701) condition was not getting better and vitals abnormal. Writer called Dr. to get order to send resident to hospital but (Doctor) didn't answer or return call. Then writer called on call manager to get resident sent to hospital. -[DATE] at 2:04 AM: SBAR-General Situation: Background: Vitals: BP ,[DATE] - [DATE] 02:06; P 43 -[DATE] 02:07 Pulse Type: Irregular - new onset; R 16.0 -[DATE] 09:23 (AM); T 96.8 - [DATE] 09:23 (AM) Route: Oral ; O2 93 % - [DATE] 02:08 (AM) Method: Room Air ; BS 122.0 - [DATE] 12:24 (PM) . Signs and Symptoms: Has fatigue . Resident not easily arousable and weakness . Assessment: Has facial droop. Has confusion. Has signs of dehydration . Review of vital sign documentation in the medical record revealed Resident #701's last assessed and documented respiratory rate and temperature in the facility occurred on [DATE] at 9:23 AM. Review of Resident #701's health care provider orders in the medical record revealed an order, Vitals: BP/Pulse/Resp/Temp/02 Sats one time a day. Reason: vitals done every shift every day. (Start Date: [DATE]). On [DATE] at 11:40 AM, an interview was conducted with Licensed Practical Nurse (LPN) D. When queried if they had provided care to Resident #701 prior to being transferred to the hospital, LPN D revealed they had cared for the Resident but were not the Resident's nurse when they were transferred to the hospital. LPN D further revealed Resident #701 was in the Covid Unit of the facility when they provided care to them and when they were discharged . When queried regarding Resident #701's clinical condition and documentation in the medical record indicating the Resident's medical condition was not improving and/or declining beginning on [DATE], LPN D reviewed the Resident's medical record and stated, The change and decline really started on ,[DATE]. (Resident #701) wasn't talking and then declined further on ,[DATE]. When asked if Resident #701 was normally verbal, LPN D replied, Yes and indicated the Resident not talking was a definite change. When queried regarding the Physician order [REDACTED]. When queried regarding facility policy/procedure pertaining to frequency of vital sign monitoring for Residents on the Covid-19 unit, LPN D indicated temperatures were supposed to be taken twice a day. LPN D was then queried where temperatures are documented per facility policy/procedure and indicated that vital signs are documented in the vital signs tab in the medical record. LPN D was then asked about facility policy/ procedure pertaining to Resident transfers to the hospital and documentation and replied, We get an order (from Health Care Provider), notify the DON (Director of Nursing), have a full set of vitals, send a copy of most recent labs, meds, face sheet and orders. With further inquiry regarding documentation completed in Resident medical records at the facility, LPN D stated, Do an SBAR assessment and then a Transition to Hospital Assessment (SNF to ED Handoff Form). When asked if a full set of vitals included temperature, LPN D indicated it did. Resident #701's medical record was reviewed with LPN D at this time. When queried regarding Resident #701's temperature at the time of their discharge, LPN D reviewed the medical record and stated, The last temperature documented was on [DATE] at 9:23 AM. When asked if a temperature should be assessed, prior to the Resident being transferred per facility policy/procedure, LPN D indicated it should be. LPN D was then asked if the nursing staff on that unit worked eight or 12 hour shifts and revealed nurses at the facility work both eight and 12 hour shifts. LPN D further revealed the the nurses on the unit that Resident #701 had been on were supposed to work 12 hour shifts but often ended up having to utilize a nurse who works eight hour shifts to provide coverage and stated, It ends up being a mix. An interview was attempted to be completed with Nursing Assistant G on [DATE] at 1:24 PM. The phone number provided for Nursing Assistant G was no longer in service. An interview was attempted to be completed with Nursing Assistant E on [DATE] at 1:27 PM. A voicemail message was left with a return number, but a return call was not received by the conclusion of the survey. An interview was conducted with Licensed Practical Nurse (LPN) C on [DATE] at 12:10 PM. When asked if they recalled Resident #701, LPN C indicated they did. When queried what occurred when the Resident was transferred to the Emergency Department on [DATE], LPN C stated they don't remember exactly what happened. When asked if they take Resident's temperatures, as part of their vital signs (vital signs include but are not limited to: pulse rate, temperature, respiration rate, and blood pressure), and if Resident vital signs and temperatures are assessed prior to transferring a Resident, LPN C replied, No, not always take a temperature. It depends on the vital signs. When asked if they recalled if Resident #701's skin felt warm or cold when they were transferred, LPN C replied, I don't remember. When asked about the temperature of Resident #701's room, LPN C replied, I don't remember. When queried approximately how often staff, including themself and other facility staff checked on Resident #701 throughout the shift, LPN C stated, I don't remember. LPN C was then queried regarding facility policy/procedure pertaining to obtaining Resident vital signs including frequency of monitoring and stated, Sometimes at the beginning of the shift, sometimes at the end. It depends on the Resident. When asked if they obtained Resident #701's vital signs prior to transferring them, LPN C indicated vital signs would be documented in the Resident medical record. When queried why the temperature documented on the transfer information was from 12 hours prior to the time of the transfer, LPN C did not provide an explanation. An interview was conducted with the Director of Nursing (DON) on [DATE] at 2:45 PM. When queried regarding Resident #701's transfer to the hospital and lack of comprehensive vital sign documentation, the DON replied, It was a 911 call. I would just worry about getting the Resident stable and transferring them out. When queried why vital signs were not obtained and documented during the shift, prior to the Resident requiring an emergency transfer to the hospital, the DON indicated vital signs only needed to be measured once per shift. When asked if vital signs should be monitored more frequently than once a shift when the Resident is having a decline in condition, the DON reiterated that vital sign assessment was only required once per shift. When queried regarding documentation of Resident #701 having a progressive decline in condition, including facial droop, the DON replied, Facial droop was (Resident #701's) baseline. When asked why nursing would document facial droop if the facility documents by exception (documentation in medical record occurs only when there is a deviation from the baseline or expected outcome) in the medical record, the DON did not provide an explanation. A policy/procedure pertaining to vital sign monitoring and assessment including documentation was requested from the facility Administrator on [DATE] at 12:34 PM via email. The Administrator replied, We do not have a policy on vital signs via email on [DATE] at 1:01 PM. Review of facility policy/procedure entitled, Notification of Changes Guideline (Revised [DATE]) revealed, Purpose: It is the practice of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative . and reported to the attending physician or delegate (hereafter designated as the physician). The resident and/or their representative will be educated about treatment options and supported to make an informed choice about care . All pertinent information will be made available to the provider by the facility staff. Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative, and the resident's physician, to ensure best outcomes of care for the resident .1. In addition to a change in the resident's condition, the resident and/or representative(s) shall be notified promptly if there is: a. A decision to transfer or discharge the resident from the facility (only for a discharge prompted by the facility). Notice must be given before the discharge occurs . Review of facility policy/procedure entitled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property (Effective [DATE]) revealed, e. Mistreatment means inappropriate treatment or exploitation of a Resident . f. Neglect is the failure of a the facility, itls employees or service providers to provide goods and services to a Resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .Resident Assessment . Every Resident is unique and may be subject to 'abuse' based on a variety of circumstances, including facility physical plant, environment, the Resident's health behavior, or cognitive level .

This Citation Pertains to Intake MI 640. Based on observation, interview and record review, the facility failed to operationalize policies and procedures for pressure ulcer (wounds caused by pressure) care and prevention for five (#'s 8, 26, 63, 179, and 192) of 12 Residents reviewed for pressure ulcers, resulting in lack of the provision of incontinence and repositioning per professional standards of practice, lack of infection control techniques during wound care, development of new and recurring pressure ulcers and the likelihood for delayed healing, infection, and decline in overall health status. Findings include: Resident #26 On 1/26/20 at 6:25 AM, an interview was conducted with Nursing Assistant Y. When queried regarding work load within the facility, Nursing Assistant Y revealed they frequently are assigned to care for over twenty Residents during their shift. When asked about Resident's who have pressure ulcers, Nursing Assistant Y indicated multiple Residents have pressure ulcers. When asked the frequency Resident's with pressure ulcers are repositioned when they are assigned over 20 Residents, Nursing Assistant Y revealed they do the best they can but are not able to get to every Resident every two hours especially when multiple Residents require assistance of two staff for care. On 1/26/20 at 10:04 AM, Resident #26 was observed in bed, positioned on their right side with their eyes closed. The Resident did not respond verbally or non-verbally when spoke to. The Resident had wound dressings in place on both of their feet. The dressings were dated, 1/22. An interview was conducted with Nurse D on 1/26/20 at 10:08 AM. When queried regarding Resident #26, Nurse D revealed the Resident had multiple pressure ulcers (wounds created by pressure) including Stage four (full thickness tissue loss with exposed bone, tendon or muscle) and Unstageable (full thickness tissue loss with unknown depth) pressure ulcers. With further inquiry regarding the Resident's pressure ulcers, Nurse D revealed they were aware the wound dressings on (Resident #26's) feet were dated 1/22 and that the dressings were in place for prevention. Nurse D then stated, I talked to wound care to find out about it. Record review revealed Resident #26 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated , 10/30/19, revealed the Resident was severely cognitively impaired, required extensive to total assistance to perform Activities of Daily Living (ADLs), had multiple pressure ulcers, and required a feeding tube for nutrition. Further review of Resident #26's medical record revealed the Resident was admitted to Hospice services on 1/13/20. Review of Resident #26's wounds listed in the Wound Rounds section of the medical record revealed the Resident had the following unhealed pressure ulcers: -Coccyx . Date Identified: 10/25/19 . Unstageable (full thickness tissue loss with unknown depth) . Exudate: Serosanguineous .Length: 11 (centimeters- cm), Width: 7 cm . -Left trochanter (hip) . Date Identified: 10/25/19 . Stage 3 (full thickness tissue loss) . Exudate: Bloody . Length: 5 cm, Width: 3.5 cm, Depth: 0.2 cm . -Sacrum . Date Identified: 10/25/19 . Stage 4 (full thickness tissue loss with exposed bone, tendon or muscle) . Exudate: Serosanguineous .Length: 2.5 cm, Width: 1.5 cm, Depth: 0.5 cm . Review of Resident #26's medical record documentation did not include additional measurements of the Residents pressure ulcers. Documentation pertaining to Resident #26's pressure ulcers included the following notes: -10/25/19: Skin/Wound Note: Admissions Skin Assessment . Resident has open area to sacrum . open area to coccyx . open area to left hip .open area to left shoulder . dark non blanching area to left outer ankle .resident is unable to turn and reposition without assistance. -10/30/19: Physician/PA/NP Progress Note . Wound rounds . admitted [DATE] . stage 4 ulcer to the left of midline in line with upper sacral area. With clean base and margins. + sero-sanguineous drainage . stage 4 ulcer to the coccyx. With clean base and margins. + sero-sanguineous drainage . stage 4 ulcer to the left hip. With clean base and margins. + sero-sanguineous drainage . dark discoloration to the left lateral malleolus related to DTPI . stage 3 ulcer to the left shoulder . -11/29/19: Admission Summary .Re-admission from Hospital; pt (patient) is post debridement right ischial site; wounds noted at coccyx, left heel and ankle, and left shoulder . -12/31/19: Physician/PA/NP Progress Note . Wound rounds .Stage 4 ulcer to the left of midline in line with upper sacral area . yellow slough . Serosanguineous drainage . Stage 4 ulcer to the coccyx. With clean base and margins . Serosanguineous drainage . Stage 4 ulcer to the left hip. Yellow slough. Appears worst . odor . Serosanguineous drainage . Dark discoloration to the left lateral malleolus related to DTPI (Deep Tissue Pressure Injury) Unchanged . [MEDICATION NAME] stage 3 ulcer to the left shoulder . -1/13/20 at 11:49 PM: Nursing Evaluation (Admit/Readmit): The resident has skin integrity concerns. Sacrum - stage 1 wound, Left gluteal fold - stage 1 wound . 1/15/20: Physician/PA/NP Progress Note . Wound rounds .Stage 4 ulcer to the left of midline in line with upper sacral area. With yellow necrotic slough. + Serosanguineous drainage . Stage 4 ulcer to the coccyx. Appears worst. Now with yellow necrotic slough and with clearing slough. + Odor + Serosanguineous drainage . Stage 4 ulcer to the left hip. Appears worst. Yellow slough. + odor. + Serosanguineous drainage . Dark discoloration to the left lateral malleolus related to DTPI . [MEDICATION NAME] stage 3 ulcer to the left shoulder. Hypo-pigmented. Continue Rx (prescription) with bordered foam dressing . LAL (Low Air Loss) mattress ordered . On 1/27/20 at 1:55 PM, observation occurred of Resident #26. The Resident wearing a hospital gown and positioned on their right side in bed. Resident #26's lips were very dry in appearance with visible cracks and chucks of dry peeling tissue noted. The Resident's eyes were open, but they did not make eye contact when spoke to. On 1/28/20 at 9:18 AM, Resident #26 was observed in their room in bed. The Resident was positioned on their right side. The Resident did not respond verbally when asked questions but made purposeful eye contact when spoke to. Wound care observation of Resident #26's pressure ulcers occurred on 1/28/20 at 10:03 AM with Wound Care Nurse B, Nurse C and Nurse I. Prior to entering the Resident's room, staff were queried regarding the number of pressure ulcers the Resident had. Nurse B stated, Three areas. Upon entering Resident #26's room, the Resident was observed in bed, positioned on their right side. The first wound addressed was the pressure ulcer on the Resident's left hip. Nurse B removed the dressing in place on the Resident's left hip and cleansed the wound bed. At this time, Resident #26 began yelling and moaning loudly and facial grimacing was observed on the Resident's face. The removed dressing had a moderate amount of drainage on it. The wound was roughly circular shaped and slightly larger than a gulf ball. The wound bed was primarily white in color with some red tissue noted. The wound edges were unattached and rolled with visible undermining and tunneling. After cleansing the wound bed, Nurse B placed a new dressing over the wound. Nurse B did not perform hand hygiene and/or change their gloves after removing the soiled dressing and cleansing the wound bed. When staff removed the blanket covering the Resident to reposition the Resident, the toes and pad of the Resident's left foot were observed to be positioned directly on the mattress. When queried, Nurse C lifted the Resident's left foot. The areas of the Resident's toes and foot which had been directly on the mattress were dark purple in color. When queried regarding the Resident's positioning, an explanation was not provided. After the Resident was repositioned, the wounds on the Resident's coccyx and sacrum did not have dressings covering them. When queried regarding the wound being open and uncovered, Nurse B indicated the Resident had a bowel movement earlier and staff had removed the dressing due to it being soiled. When asked what time the dressing was removed, Nurse B, Nurse C and Nurse I were unable to provide an answer. Stool remained in-between the Resident's legs and on their peri-area. When queried regarding the observed stool, Nurse A stated, I want the aide (Nursing Assistant) to come do incontinence care. The coccyx wound bed was larger than a softball and irregularly shaped with significant, evident depth. The wound bed was red and white in color with dark red/brown colored tissue noted on the proximal edge of the wound. The wound edges were unattached with substantial undermining and an obvious area of tunneling. The sacrum wound was slightly larger than a half dollar and circular in shape. The wound bed was white and red in color where visible due to substantial depth. Tunneling observed at approximately the 2 o'clock position. Nurse A washed both wounds and covered with one dressing. When queried regarding the wounds being treated as one wound and covered with the same dressing if they were considered two separate wounds, Nurse I indicated the wounds are separate areas. No further explanation was provided. Nurse A and Nurse B proceeded to perform care to restore the Resident's hygiene at this time. While observing care, the stool on Resident #26's skin was observed to be dry. When asked if the stool was dry and stuck to the Resident's skin, Nurse C replied, Some is dried and some is fresh. During hygiene care, a dressing with dark colored shadowing was observed on the Resident's left shoulder. The dressing was dated 2/7/20. When queried regarding the dressing, Nurse B and Nurse C indicated they were not aware of Resident #26 having an alteration to their skin in that area. When asked about the date on the dressing, Nurse B confirmed the dressing was dated 2/7/20. Nurse B then removed the dressing. The dressing was saturated with a large amount of extremely foul smelling, dark colored, copious drainage. The rancid odor from the dressing and wound permeated the area. After removing the dressing, Nurse B wiped the wound bed with a disposable peri-wipe in a rubbing motion and the wound bed began to bleed. The wound was located directly over the Resident's left scapula. The wound bed was irregularly shaped and approximately the size of a quarter with evident tissue loss. Nurse B covered the wound with a dressing. Following wound care, Resident #26 was positioned on their right side. An interview was completed with Nurses B, C and I following wound care completion. When queried regarding measurements of Resident #26's wounds not being accessible in the medical record, Nurse I indicated they would provide paper printouts of the Resident's wound measurements. When asked about the An interview was conducted with Nurse [NAME] on 1/28/20 at 11:09 AM. When queried regarding Resident #26 getting out of bed, Nurse [NAME] replied, Never gets out of bed. When asked how often the Resident is repositioned in bed, Nurse [NAME] revealed staff do the best they can to reposition the Resident. When asked if the Resident is repositioned every two hours, Nurse [NAME] did not provide a response. Review of Resident #26's Treatment Administration Record (TAR) revealed Resident #26's left shoulder pressure ulcer treatment was documented as completed and discontinued on 1/7/20. A treatment order was not in place for the Resident's sacral wound on the TAR. The TAR did include documentation of wound care treatment for [REDACTED]. A treatment order, dated 1/16/20, for the Resident's left hip pressure ulcer specified, Left hip- cleanse with normal saline/ apply No sting barrier to the peri-ulcer skin and let dry. Apply a damp to dry using Dakins Solution 1/4 strength and gauze/cover with a comfort foam sacral border and change daily and prn (as needed) . No wound care treatments were documented on 1/16/20, 1/17/20, 1/18/20, 1/19/20, 1/20/20, 1/21/20, 1/21/20, and 1/22/20. Review of Resident #26's care plan revealed a care plan entitled, The Resident has actual impairment to skin integrity coccyx, left trochanter, sacrum r/t (related to) disease process, dementia, generalized weakness and cerebral infarction . healed area to left shoulder (Initiated: 10/24/19). The care plan included the interventions: -Evaluate and treat per physicians orders (Initiated: 10/24/19) -Evaluate Resident for s/sx (signs/symptoms) of possible infections (Initiated: 10/24/19) -Heels off the bed as tolerated (Initiated: 1/15/20) -Low air loss mattress (Initiated: 12/15/19) -Turn and reposition frequently as tolerated (Initiated: 12/15/19) -Utilize pillows for positioning and protection as tolerated (Initiated: 12/15/19) Review of facility provided Wound Assessment Detail reports for Resident #26's Left Trochanter (hip) pressure ulcer detailed the following: -10/30/19: Stage 3 . Length: 2.5 cm; Width: 2.5 cm; Depth: 0.3 cm . Exudate: Light . Bloody . Wound Edge: Separate from base . -12/31/19: Stage 3 . Length: 3.5 cm; Width: 3.5 cm; Depth: 0.2 cm . Exudate: Light . Bloody . Wound Edge: Separate from base . -1/21/20: Stage 3 . Length: 5 cm; Width: 3.5 cm; Depth: 0.2 cm . Exudate: Light . Bloody . Wound Edge: Separate from base . Review of Wound Assessment Detail reports for Resident #26's coccyx pressure ulcer detailed the following: -10/30/19: Stage 4 . Length: 2.5 cm; Width: 3 cm; Depth: 0.5 cm . Exudate: Scant . Bloody . Wound Edge: Separate from base . -1/21/20: Unstageable . Length: 11 cm; Width: 7 cm; Depth: Unknown . Exudate: Moderate . Serosanguineous . Wound Edge: Separate from base . Review of Wound Assessment Detail reports for Resident #26's sacrum pressure ulcer detailed the following: -10/25/19: Stage 4 . Length: 3.5 cm; Width: 1.8 cm; Depth: 0.1 cm . Exudate: Moderate .Bloody . Wound Edge: Separate from base . Tunneling: 1 o'clock/2 cm . -1/21/20: Stage 4 . Length: 2.5 cm; Width: 1.5 cm; Depth: 0.5 . Exudate: Light . Serosanguineous . Wound Edge: Separate from base . Undermining: Present . Review of Wound Assessment Detail reports for Resident #26's left shoulder pressure ulcer detailed the following: -10/25/19: Stage 1 . Length: 1 cm; Width: 1.5 cm; Depth: 0.1 cm . Exudate: None . Wound Edge: Separate from base . -1/21/20: Healed Stage 3 . Resident #63 On 1/26/20 at 8:40 AM, Resident #63 was observed in their room. The Resident was in bed, positioned on their back. An alternating air mattress was in place on the Resident's bed. The mattress was set at 310 pounds. An interview was conducted with the Resident at this time. The Resident was pleasantly confused but answered specific questions appropriately. When asked if they had pain, Resident #63 replied, In heaps. With further inquiry regarding their pain, Resident #63 revealed they get medication. When asked if they had any sores on their skin, Resident #63 stated, Well, I got bandages. Record review revealed Resident #63 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required extensive assistance to perform all Activities of Daily Living (ADLs) with the exception of eating. The MDS further revealed the Resident was at risk for pressure ulcer development but did not have any pressure ulcers. Additional record review revealed Resident #63 had a Facility acquired, stage three pressure ulcer on their coccyx. The medical record further revealed the Resident #63's most recent weight was 191 pounds. At 8:09 AM on 1/27/20, Resident #63 was observed in bed, positioned on their back with their eyes closed. The Resident's alternating air mattress was set at 310 pounds. Review of Resident #63's care plans at this time revealed a care plan entitled, (Resident #63) has actual skin integrity impairment r/t incontinence, limited mobility (Initiated: 7/12/18). The care plan included the interventions: -Encourage/assist Resident reposition when in wheelchair freq (Initiated: 7/12/18) -Encourage/assist with turning and repositioning freq as tolerated (Initiated: 7/12/18) -Wheelchair pressure reduction cushion (Initiated: 7/12/18) -Low Air Loss Mattress (Initiated: 7/12/18) Resident #63 had another care plan, The Resident has actual impairment to skin integrity unstageable pressure ulcer to the sacrum . (Initiated: 12/23/19). The care plan included the interventions: -Evaluate and treat per physicians orders (Initiated: 12/23/19) -Evaluate Resident for s/sx of infections (Initiated: 12/23/19) -Encourage good nutrition and hydration in order to promote healthier skin (Initiated: 12/23/19) On 1/28/11 at 11:00 AM, Resident #63 was in their room. The Resident was in bed, positioned on their back. The alternating air mattress in place on the Resident's bed remained set at 310 pounds. A wound care treatment observation for Resident #63's pressure ulcer took place on 1/28/20 at 11:32 AM with Wound Care Nurse B, Nurse C and Nurse I. Upon entering the room, Resident #63 was observed in bed on their back. The alternating air mattress was set at 310 pounds. After repositioning the Resident, a dressing, with a large amount of dark shadowing, was noted on the Resident's coccyx. At this time, Nurse I removed the dressing. The removed dressing had a large amount of dark colored, malodorous drainage. The wound was circular in shape and very deep. The bed of the wound was unable to be visualized due to depth. The wound edges were unattached. The wound was noted to have a strong, foul odor which became increasing potent in closer proximity to the wound bed. Nurse I cleansed the wound and applied a new dressing. Resident #63 was then repositioned on their back. Following wound care completion, wound care staff were queried if the pound setting on the alternating air mattress was supposed to be set at the Resident's weight and Nurse I replied, Yes. When queried regarding Resident #63's mattress settings, Nurse I reviewed the current settings on the mattress and stated, I don't know what (Resident #63) weighs. Documentation of Resident #63's last recorded weight was reviewed with staff at this time. Nurse I was then observed changing the settings on the Resident's alternating air mattress. When asked if the mattress was effective for pressure reduction when not set at the correct weight, Nurse I stated, No. When queried who initiates and monitors the settings, Nurse I stated, The floor nurse. When asked, Nurse I indicated alternating air mattress setting monitoring should be documented on the Resident's Medication Administration Record [REDACTED]. Review of Resident 63's TAR also revealed no documentation of monitoring. When queried, Nurses B and C were unable to provide an explanation. Nurse I then stated, We do not have a system to monitor that (air mattress settings). When asked how the facility was ensuring the effectiveness of pressure reduction interventions without a system in place to monitor the interventions, Nurse I reiterated, If it's not at the right setting, not going to be effective but did not provide elaborate further. Additional review of Resident #63's TAR with Nurses B and C at this time further revealed, no documentation of wound care treatment completion on 1/9/20, 1/20/20, and 1/23/20. When asked about the blank areas on the TAR, Staff were unable to provide an explanation. When asked what interventions were in place at the time the pressure ulcer developed and what interventions were implemented following the development of the pressure ulcer, Nurse I indicated they would have to pull the interventions. An interview was completed with Nurse R on 1/28/20 at 12:15 PM. When queried who monitors the alternating air mattress settings on Resident beds, Nurse R replied, Wound care does that. Review of facility provided paper wound documentation for Resident #63 revealed the coccyx pressure was identified on 12/20/19. Review of Wound Assessment Documentation revealed the following: -12/23/19: Pressure . Facility acquired . (Length) 3 cm X (Width) 2 cm X (Depth) unknown . Exudate: Scant . Serosanguineous . Wound Edge: Separate from base . -1/21/20: Pressure . Facility acquired . Stage 3 . (Length) 2.5 (cm) X (Width) 2 cm X (Depth) unknown . Exudate: Light . Serosanguineous . Wound Edge: Separate from base . Review of Progress Note documentation in Resident #63's medical record revealed the following: -1/24/20: Physician/PA/NP . Wound rounds . Unable to turn self. Unstageable ulcer to the sacrum. Now with clearing slough. Scant drainage . -12/24/19: Physician/PA/NP . Wound rounds . Unable to turn self. Developed an unstageable ulcer to the sacrum. Covered with yellow slough. Scant drainage . Resident #192 On 1/26/20 at 8:54 AM, Resident #192 was observed in their room. The Resident was in bed, positioned on their back. An interview was completed at this time. When asked if they had pain, Resident #192 replied, Yeah, in my butt. With further inquiry regarding their pain, Resident #192 explained that they have open wounds which causes them a great deal of pain. When queried their current level of pain, on a scale of zero to 10 (with zero being no pain and 10 being the worst imaginable pain), Resident #192 revealed their pain was a 6 or 7. When queried if they are able to reposition themselves in bed, Resident #192 revealed they were not able to move on their own. When asked how often staff reposition them in bed, Resident #192 revealed they are repositioned when they are changed from incontinence. With further inquiry regarding the frequency of incontinence care, Resident #192 revealed they typically receive care twice a shift. An air mattress controller was observed on the floor at the foot of the Resident's bed. The air mattress setting was on soft. Record review revealed Resident #192 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 1/12/20, revealed the Resident was cognitively intact and required extensive assistance to perform Activities of Daily Living (ADLs) with the exception of eating. On 1/27/20 at 8:12 AM, Resident #192 was observed in in bed, positioned on their back. When asked how they were feeling and if they were having any pain, Resident #192 revealed they were having pain in their back and butt. When asked to rate their pain on a numeric scale, Resident #192 stated their current pain level was a 7. The air mattress controller remained on the floor in the room, set on soft. On 1/27/20 at 2:36 PM, Resident #192 was observed in their room, positioned on their back in a Geri-chair (reclining, wheeled chair). The Geri- chair was reclined and almost flat. A pressure reduction cushion was not present in the Geri-chair. An interview was completed with the Resident at this time. When queried, Resident #192 replied, I'm sore and I'm wet. With further questions, Resident #192 revealed they had been wet (incontinent of urine) and had notified staff 45 minutes to an hour previously. When asked how long they had been sitting in the chair, Resident #192 revealed staff got them up right after breakfast. When queried if staff had repositioned them in the chair or if they had been back to bed since getting in the chair, Resident #192 replied they had not. On 1/27/20 at 2:40 PM, an interview was completed with Nurse T. When queried how long Resident #192 had been sitting up in the Geri-Chair, Nurse T replied, Right after breakfast. An interview was conducted with Nursing Assistant S on 1/27/20 at 2:48 PM. Nursing Assistant S was asked if Resident #192 had received incontinence care, been repositioned, or went back to bed since having been transferred into the Geri-chair and Nursing Assistant S replied, No. An observation of wound care was completed with Wound Care Nurse B, Wound Care Nurse C, and Nurse I on 1/27/20 at 3:10 PM. The Resident was in bed, positioned on their back upon entering the room When the Resident was repositioned to complete wound care, they began crying out, Oww, oww, oww. The dressing in place covering the Resident's buttocks was saturated with drainage. The dressing removed by Nurse I had a foul odor and significant amount of gray colored drainage. The primarily area was located slightly left of the Resident's sacral-coccyx area and extended over the midline and towards the Resident's head. The primary wound was open with notable depth and tunneling. The wound bed was pink with white tissue around the wound borders. The wound area proximal and to the right was dark in color with unattached edges. When asked, Nurse B measured the wound and stated, It's 14 (cm) by 12 (cm) by 0.2 (cm). When asked about the wound tunneling, Nurse B replied, It's 2 cm at about four o'clock. Nurse B cleansed the wound area, packed the area with visible depth, and applied a dressing. The air mattress controller remained on the floor in the room, set on soft. Throughout the treatment, Resident #192 continued to yell out Oww, oww, oww repeatedly. When asked their pain level, Resident #192 stated, Eight (out of 10). When queried regarding pain management during wound care for Resident #192, Nurse B replied, (Resident #192) gets scheduled [MEDICATION NAME] ([MEDICATION NAME]-medication frequently used to treat nerve pain). (Resident #192) doesn't get anything else. Review of facility provided Wound Assessment Detail reports for Resident #192's revealed the following documentation completed by Nurse B and Nurse C: -10/4/19: Left upper buttock . Stage 4 . Exudate Light . Serosanguineous . Wound Edge: Separate from base . Size (cm): 14 X 12 X 0.2 (L X W X D) . Undermining: None . Tunneling: Present . 4 o'clock/ 2 cm . -1/21/20: Left upper buttock . Stage 4 . Exudate Light . Serosanguineous . Wound Edge: Separate from base . Size (cm): 3.5 X 2.5 X 0.5 (L X W X D) . Undermining: None . Tunneling: None . -10/4/19: Right upper buttock . Unstageable . Exudate Light . Serosanguineous . Wound Edge: Separate from base . Size (cm): 4 X 1.5 X Unknown (L X W X D) . Undermining: None . Tunneling: None . -1/21/20: Right upper buttock . Stage 4 . Exudate Light . Serosanguineous . Wound Edge: Separate from base . Size (cm): 2.5 X 1 X Unknown (L X W X D) . Undermining: None . Tunneling: None . On 1/28/20 at 7:59 AM, Resident #192 was observed in their bed, positioned on their back. An interview was conducted with the Director of Nursing (DON) on 1/28/20 at 3:43 PM. When queried how often Residents who have pressure ulcers should be repositioned, the DON stated, Should be turned every two hours. With further inquiry regarding observations of Resident #'s 26, 63, and 192 as well as Resident #192's statements of not being repositioned frequently, the DON indicated Resident's should be turned/repositioned Unless they request not to be. When asked if they should be documentation of Resident refusal, the DON replied, Should be documented unless there is a care plan. The DON was then asked what blank areas on Resident TAR's indicated. The DON replied, Blank means it wasn't documented or they (staff) didn't do it. When queried regarding Resident #26's pressure ulcers including the wound identified during wound care observation with a dressing dated 2/7/20 on the Residents left shoulder and wound care observations, the DON did not provide an explanation. When queried if Resident #192 should have a pressure reduction pad in place when sitting in the Geri-chair, the DON replied, Yes, it is on their care plan. When queried how frequently the Resident should be turned and repositioned, the DON stated, More frequently. When asked about Resident #63 developing a facility acquired pressure ulcer, alternating air mattress settings, and lack of monitoring by staff, the DON did not provide an explanation. Resident #8 On 1/26/20 at 9:07 AM, R#8 was observed in bed, sitting up and eating breakfast. R#8 was asked if they currently have any wounds. R#8 stated, Yes on my buttock. When asked if they had developed the wound here, R#8 stated, Yes. They ain't been cleaning me or my bed up right. Oh my goodness does it ever hurt. I feel like I can't sit on it sometimes. On 1/27/20 at 9:41 AM, incontinence care for R#8 was observed with agency Certified Nursing Assistant (CNA) [NAME] Upon pulling back the sheet, R#8's brief was observed to have two blue lines on the front, indicating it was wet. The resident did not have any foam/prafo boots on, and the boots were observed to be in the resident's closet. CNA A was asked when she changed R#8 last and responded that this was the first time she was changing the resident on her shift. Stool was noted to be dried and caked between R#8's legs and in their groin area. R#8 was asked when the last time staffed changed them and responded, Last night. About 10 PM. Not after that. CNA A was asked if she received report from midnight shift that they had changed R#8 before they left. CNA A stated midnight shift was gone before she was on the floor and received no information about her assigned residents. Wound Care Nurse (WCN) B entered the room to help change R#8. R#8 was moaning when being turned and stated that their bottom hurt. A dressing was present on R#8's coccyx dated 1/25 and was observed to be saturated with urine. R#8 had stool caked on their bottom as well as in the brief, and the brief was visibly saturated with urine with a strong urine odor. WCN B indicated the resident's dressing is changed every other day. R#8's coccyx/upper buttock area had pink scar tissue present with a red, opened area in the middle. When queried, WCN B indicated the wound was facility-acquired, but did not know the stage (severity of tissue loss) when it developed. When queried how often R#8 should be checked and changed for incontinence care, CNA A stated, It should be every two hours or when needed. R#8 was noted to have pink scar tissue to the outer right heel area. When queried regarding the heel, WCN B stated it was a healed pressure area. CNA A removed the draw sheet and fitted sheet from under R#8 which were observed to have a large area of brownish/yellow discoloration. When queried if the draw sheet and fitted sheet were wet with urine that had soaked through, CNA A and WCN B both felt the linen and stated, Yes. WCN B indicated that R#8 sitting in a wet brief for an extended period was not conducive to wound healing. A review of R#8's medical record revealed that the resident developed the wound on their coccyx on 11/20/2018, and it was assessed as a Stage II pressure ulcer with surrounding Moisture Associated Skin Damage (MASD). A wound care assessment and progress note dated 1/8/19 noted the pressure ulcer as, 1.5cm (centimeters) length by 1cm width (w(TRUNCATED)

This citation has three Deficient Practice Statements. Deficient Practice Statement One: Based on observation, interview and record review, the facility failed to ensure enteral tube feeding (liquid nourishment provided directly into the stomach through a feeding tube) administration and Percutaneous Endoscopic Gastrostomy (PEG- surgically placed tube into the stomach through the abdominal wall) tube management was completed timely, per Health Care Provider orders, and professional standards of practice for one (#26) of five Residents reviewed for tube feeding, resulting in the complete lack of provision of hydration and nutrition for approximately 35 hours to a severely cognitively impaired, non-verbal, nutritionally compromised Resident with the likelihood of dehydration, nutritional impairment, psychosocial distress utilizing the reasonable person concept, and decline in overall health and well-being. Findings include: On 1/26/20 at 10:04 AM, Resident #26 was observed in bed, positioned on their right side with their eyes closed. The Resident did not respond when spoke to. A tube feeding pole and pump was noted in the room with a 1000 milliliter (mL) bottle of Glucerna 1.5 calorie (tube feeding solution) and tubing. The solution tubing was connected through the pump but not being administered to the Resident. The Glucerna bottle was noted to be almost full, with approximately 950 mL of tube feeding solution. The bottle of Glucerna was dated, 1/25/20, 5 PM. A pistol syringe and container were hanging in a clear plastic bag on the pole. The syringe was visibly soiled with a light brown colored substance visible in the tip of the syringe. An interview was conducted with Nurse D on 1/26/20 at 10:08 AM. When queried regarding Resident #26's tube feeding, Nurse D stated, The midnight nurse reported to me that (Resident #26's) PEG tube came out last night. When asked what time the Resident's PEG tube was noted to be dislodged, Nurse D replied, The night nurse said it happened at 6:00 (AM). When asked if the Resident was able to have any oral intake, Nurse D replied, No and revealed the Resident was completely dependent upon the tube feeding for their hydration and nutritional needs. When questioned regarding the plan of care for Resident #26, Nurse D revealed they were told in report, by the night shift nurse, that they were instructed by the Physician to schedule an appointment on Monday (1/27/20) to have it (PEG tube) replaced. When queried if the Resident was not going to receive any hydration and/or nutrition until an appointment was able to be scheduled, Nurse D stated, I don't understand why we don't send (Resident #26) to the ER (emergency room ) to have the PEG replaced. Nurse D further revealed they were going to contact the Resident's Physician to obtain clarification due to the Resident's need for hydration and nutrition and ensure the Resident received treatment. With further inquiry regarding the Resident, Nurse D revealed the Resident had multiple pressure ulcers (wounds created by pressure) including Stage four (full thickness tissue loss with exposed bone, tendon or muscle) and Unstageable (full thickness tissue loss with unknown depth) pressure ulcers. When asked what typically occurs, per facility policy/procedure, when a PEG tube becomes dislodged, Nurse D revealed Residents are sent to the ER to have the PEG tube reinserted. Record review revealed Resident #26 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated , 10/30/19, revealed the Resident was severely cognitively impaired, required extensive to total assistance to perform Activities of Daily Living (ADLs), had multiple pressure ulcers, and required a feeding tube for nutrition. Further review of Resident #26's medical record revealed the Resident was admitted to Hospice services on 1/13/20. Review of Resident #26's progress note documentation within the medical record revealed the following: -1/26/20 at 8:15 AM: Health Status Note .Peg tube noted to be under resident's left arm with drainage on the outside of the gauze . dislodged with balloon intact. Writer received order to place T/F and meds on hold until peg tube is replaced by per (Physician G) . -1/26/20 at 11:49 AM: Health Status Note . Per MD, STAT abdominal x-ray ordered. -1/27/20 at 2:16 PM: Health Status Note . This morning (Physician H) okayed meds and feedings to be held while Foley catheter (peg) is switched to a real peg tube .ordered to get an x-ray STAT to verify placement . On 1/27/20 at 1:55 PM, observation occurred of Resident #26. The Resident wearing a hospital gown and positioned on their right side in bed. Resident #26's lips were very dry in appearance with visible cracks and chunks of dry peeling tissue noted. Their eyes appeared sunken, their oral cavity appeared dry, and the sclera (white part of eye) were slightly red in color. The Resident's eyes were open, but they did not make eye contact when spoke to. An interview was completed with Nurse [NAME] on 1/27/20 at 1:58 PM. When queried regarding Resident #26's tube feeding, Nurse [NAME] stated, It came out yesterday and they (staff) replaced it with a Foley. When queried why a Foley was utilized, Nurse [NAME] indicated Nurse L had inserted the Foley catheter they were not sure why a Foley Catheter was inserted in place of a PEG tube catheter. With further inquiry regarding the Foley catheter insertion and use for hydration and tube feeding, Nurse [NAME] revealed the placement of the catheter had been verified via X-ray but had not received tube feeding nutrition. When queried regarding the observation of the Resident's lips, eyes, and oral cavity, Nurse [NAME] revealed they had concerns regarding the Resident not receiving any nutrition and/or hydration. Nurse [NAME] further disclosed the Foley Catheter had been removed and replaced with a PEG tube catheter. Nurse [NAME] stated, The DON (Director of Nursing) put another one in today. We are waiting for the placement x-ray. Review of Resident #26's two view abdominal x-ray obtained 1/26/20 revealed the catheter tip Overlies the the region of the stomach. The x-ray results were signed by the Radiologist on 1/29/20 at 2:13 PM. On 1/27/20 at 2:05 PM, an interview was conducted with the DON. When queried what occurred with Resident #26's tube feeding when the tube became dislodged, the DON replied, They put in a Foley and did an X-Ray for placement. With further inquiry, the DON revealed PEG tube catheters were available in the facility and they had inserted one about two hours ago. On 1/28/20 at 9:18 AM, Resident #26 was observed in their room in bed. The Resident was positioned on their right side. The Resident did not respond verbally when asked questions but made purposeful eye contact when spoke to. Glucerna 1.5 calorie tube feeding solution was being administered via pump at 70 mL per hour. Review of Resident #26's Tube Feeding and hydration orders and Medication Administration Record [REDACTED] -Enteral Feed Order one time a day Provide Auto Flush 1000 cc (cubic centimeters) H2O (water) at 70 cc per hour, while pump is running (Order Date: 1/21/20; Discontinued: 1/26/20 at 2:59 PM). The MAR indicated [REDACTED]. -Enteral Feed Order one time a day Start at: 5 PM. Glucerna 1.5 per TF (Tube Feed) via: 1080 mL/ 1620 calories at 70 cc per hour to start at 5 PM until dose is complete (Order Date: 1/21/20; Discontinued: 1/26/20 at 2:59 PM). The MAR indicated [REDACTED]. -Enteral Feed Order every shift T/F (Tube Feed) on hold until peg tube is replaced (Order Date: 1/26/20 at 8:20 AM). Review of the MAR indicated [REDACTED]. The Chart Code/Follow Code for 09 documentation indicated Other/See Nurse Note. No nursing note documentation was present in the Resident's medical record during the night shift hours on 1/26/20. -Enteral Feed Order every shift Meds on hold until peg tube is replaced (Order Date: 1/26/20 at 8:25 AM). Review of the MAR indicated [REDACTED]. The Chart Code/Follow Code for 05 documentation indicated Hold/See Nurses Notes. No nursing note documentation was present in the Resident's medical record on 1/27/20 during night shift. -Enteral Feed Order one time only for 1 Day Replace peg tube at bedside (Order Date: 1/26/20 at 8:42 AM). Review of the MAR indicated [REDACTED]. No nursing note documentation was present in the Resident's medical record on 1/27/20 around 2:09 AM. -Enteral Feed Order one time a day Provide Auto Flush 1000 cc H2O at 70 cc per hour, while pump is running (Order Date: 1/26/20 at 2:59 PM). The MAR indicated [REDACTED]. No nursing note documentation was present in the Resident's medical record during the night shift hours on 1/26/20. -Enteral Feed Order one time a day Start at: 5 PM Glucerna 1.5 per TF via: 1080 mL/1620 calories at 70 cc per hour to start at 5 PM until dose is complete. Planned weight gain (Order Date: 1/26/20 at 2:59 PM). The MAR indicated [REDACTED]. No nursing note documentation was present in the Resident's medical record during the night shift hours on 1/26/20. Record review revealed no documentation indicating Hospice had been notified of Resident #26's PEG tube dislodgement. Review of Resident #26's care plans revealed the following care plans and interventions. -The Resident had dehydration or potential fluid deficit r/t (related to) oropharyngeal dysphagia, NPO status (nothing by mouth), and dependence on tube feeding for all fluids . (Initiated: 10/25/19). The care plan included the intervention, Provide tube feeding and water bolus as ordered (Initiated: 10/30/19). -The Resident requires tube feeding . (Initiated: 10/25/19). The care plan included the intervention, The Resident is dependent with tube feeding and water flushes . (Initiated: 10/30/19). An interview was conducted with the Director of Nursing (DON) on 1/28/20 at 12:33 PM. When queried regarding Resident #26's PEG tube becoming dislodged and actions taken to ensure the Resident received nutrition and hydration, the DON replied, They told me they put a Foley in right away (in PEG tube site). When asked if facility staff should document insertion of the Foley catheter in the Residents' PEG tube stoma per facility policy/procedure, the DON revealed nursing staff should document a progress note. When queried why there was no note in the medical record, the DON reviewed the documentation but was unable to provide an explanation. When questioned what day and time the Foley Catheter was inserted, the DON was unable locate documentation in the Resident's medical record. When asked if the Resident received nutrition, hydration, and/or medications via the Foley catheter inserted in the PEG stoma, the DON revealed an X-Ray was obtained which verified the placement of the Foley catheter in the Resident's stomach and that the catheter could be utilized. When asked if the Resident received nutrition and/or hydration through the catheter, the DON indicated they were unsure. Resident #26's medical record and MAR indicated [REDACTED]. When queried regarding the last administration prior to tube dislodgement, the DON stated, It looks like it was the 25th (1/25/20). Documentation on the MAR indicated [REDACTED]. When queried how much tube feeding and hydration the Resident received prior to the PEG tube becoming dislodged, the DON replied, I cannot tell how much they got. The nurses don't document (volume administered). When asked what time the PEG tube became dislodged due to Nurse D stating the Resident's PEG tube became dislodged during the night shift on 1/26/20 at 6:00 AM, nursing documentation related to the dislodgement dated at 1/26/20 at 8:15 AM, and observation of the feeding solution container volume on 1/26/20. The DON revealed they were not aware of the time the PEG tube became dislodged. The DON was then asked what date and time the Resident first received tube feeding and hydration after dislodgement of the PEG tube in the early morning of 1/26/20. After review of Resident #26's MAR, the DON stated, 1/27 at 5:00 PM. When queried how long the Resident went without any nutrition and hydration, the DON did not provide a response. When asked for clarification, regarding Resident #26 not receiving any nutrition and hydration from between 6:00 AM to 8:00 AM on 1/26/20 until 1/27/20 at 5:00 PM, for approximately 35 hours, the DON replied, The Doctor said to hold it. When queried regarding the risks of dehydration and clinical decline to Resident #26 related to lack of any nutrition and hydration for approximately 35 hours, the DON replied, Well, (Resident #26) is hospice. When asked if the Resident is supposed to receive nutrition and hydration, regardless of receiving Hospice services, the DON revealed they were. When queried why the catheter was inserted and placement verified with an X-ray but not utilized, the DON did not provide an explanation. When asked about visible changes in the Resident from 1/26/20 to 1/28/20, including the Resident's lips, mucous membranes, and level of alertness, a meaningful explanation was not provided. A phone interview was conducted with Physician G on 1/28/20 at 1:11 PM. Upon introduction, Physician G revealed they had just received a phone call from the facility DON regarding Resident #26. When queried regarding the Resident's PEG tube becoming dislodged, Physician G disclosed they were contacted by facility staff on Sunday (1/26/20) regarding the Resident's PEG tube dislodgement and informed a Foley catheter could be inserted due unavailability of PEG tubes within the facility. Physician G further revealed they ordered an abdominal X-ray to confirm placement of the catheter prior to use. When asked if they were aware Resident #26 did not receive any hydration or nutrition for approximately 35 hours, from the time the PEG tube became dislodged in the AM on 1/26/20 until 1/27/20 at 5:00 PM, Physician G replied they were not aware and stated, I'm not happy about it. When queried regarding the DON stating the Physician ordered the tube feeding to be held, Physician G stated, I did not give an order for [REDACTED]. When queried regarding clinical risks to the Resident as a result of not receiving nutrition and hydration for approximately 35 hours and observations of the Resident, Physician G disclosed dehydration is a significant concern. With further inquiry, Physician G stated, I thought they (facility staff) were giving (Resident #26) fluids. I would have sent (Resident #26) out (to the hospital) if I would have known they weren't going to feed them (utilizing Foley catheter). An interview was conducted with Physician H on 1/28/20 at 1:19 PM. When queried regarding Resident #26 and their PEG tube being dislodged, Physician H indicated they were aware the PEG tube had become dislodged and a Foley catheter had been inserted. When asked if they were aware the Resident did not receive any hydration and/or nutrition for approximately 35 hours, from the early morning on 1/26/20 until 5:00 PM on 1/27/20, Physician H responded, No. Deficient Practice Statement Two: Based on observation, interview and record review, the facility failed to ensure administration of enteral tube feeding and equipment maintenance was completed per professional standards of practice for two (#'s 131 and 192) of five Residents reviewed for tube feeding, resulting in tube feeding equipment being maintained in an unsanitary manner, inadequate Head of Bed (HOB) elevation during feeding, and the potential for contamination, infection, and aspiration. Findings include: Resident #192 On 1/26/20 at 8:54 AM, Resident #192 was observed in their room in bed. The Resident was on their back with the head of their bed elevated approximately 20 degrees. Glucerna 1.2 calorie tube feeding solution was being administered at 70 mL per hour via pump. The tube feeding solution was dated as began, 1/25/20, 6 AM. A piston syringe and container dated 1/24/20, 6 AM, were present on the tube feeding pump pole in a clear plastic bag. Record review revealed Resident #192 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 1/12/20, revealed the Resident was cognitively intact and required extensive assistance to perform Activities of Daily Living (ADLs) with the exception of eating. On 1/27/20 at 8:12 AM, Resident #192 was observed in their room. The Resident was in bed, positioned on their back with the head of the Resident's bed elevated at 20 degrees. The Resident was receiving tube feeding, Glucerna 1.5 calorie solution, via pump at 70 mL per hour. The tube feeding solution was dated as began, 1/26/20, 6 AM. The pump indicated, Total Volume Delivered 488 (mL). A piston syringe and container dated 1/24/20, 6 AM, were hanging on the tube feeding pump pole in a clear plastic bag. The pump and pole were visibly soiled with a light brown colored substance noted on the front of the pump and unknown dark colored substances on the base of the pole that were built up and think in appearance. An interview was conducted at this time. The Resident was asked when the tube feeding was started and replied, Last night. When queried regarding how often the tube feeding pump and pole are cleaned by facility staff, Resident #192 revealed they were not aware of staff cleaning the pump. Review of Resident #192's Health Care Provider orders revealed the following order, dated 10/4/19, Enteral Feed Order, one time a day for dysphagia. Start: 5 PM. Glucerna 1.5 per TF (tube feed) via pump: Rate: 70 cc/hr (hour) until Total dose of 1260 mL/1890 calories completed. Review of Resident #192's care plan revealed a care plan entitled, The Resident requires tube feeding r/t (related to) dysphagia/suboptimal oral nutrition intake . (Initiated: 10/3/19). The care plan included the intervention, The Resident needs the HOB (Head of Bed) elevated 45 degrees during and thirty minutes after tube feed (Initiated: 10/7/19). On 1/27/20 at 3:08 PM, Resident #192 was observed in their room. The Resident was in bed, positioned on their back. An unknown light-colored substance and unknown dark colored substances remained easily discernible on the Resident's tube feeding pump and pole. The piston syringe and container dated 1/24/20, 6 AM, remained in a clear bag hanging on the tube feeding pump. An interview and observation of Resident #192 was completed with Nurse I on 1/27/20 at 3:27 PM. When queried regarding facility policy/procedure and the piston syringe and container, dated 1/24/20, 6 AM in place on the Resident's tube feeding pole, Nurse I stated, Well that should be thrown away. When asked about the pump and tube being overtly unclean tube feeding pump and pole, Nurse I indicated it looked as though tube feeding had been spilled on the pump. No further explanation was provided. On 1/28/20 at 7:59 AM, an observation occurred of Resident #192 in their room. The Resident was positioned on their back in bed. The Resident's tube feed pump was infusing at 70 mL/ hour and the head of their bed was noted to be elevated at approximately 20 degrees. The tube feed pump and pole remained visibly soiled with same unknown substances observed on 1/27/20. At 8:30 AM on 1/28/20, Resident #192 was observed in their room in bed. The head of their bed remained elevated at 20 degrees and the tube feeding pump and pole remained soiled. An interview was conducted with Nurse R on 1/28/20 at 8:36 AM. When queried how high the head of a Resident's is supposed to be when they are receiving tube feeding, Nurse R replied, Head of bed is supposed to be 45 degrees. An observation of Resident #192 occurred with Nurse R at this time. When queried regarding Resident #192's head of bed elevation, Nurse R replied, It's not high enough. Nurse R was then observed raising the head of the bed. When queried regarding the unknown substances on the Resident's feeding tube pump and pole, Nurse R indicated they were not sure what the substances were but would make sure the pump and pole were cleaned. A facility policy/procedure pertaining to tube feeding within the facility, including dislodgement and replacement, was requested from the facility Administrator on 1/27/2020 3:13 PM but not received by the conclusion of the survey. On 1/28/20 at 1:13 PM, the Administrator revealed, via email communication that the facility did not have a policy/procedure pertaining to dislodgement/replacement of tube feedings. Deficient practice statement #3. Based on observation, interview, and record review the facility failed to maintain a tube feeding pole in a sanitary manner for one sample resident (#131) of five reviewed for tube feeding, resulting an unsanitary environment and the potential of the spread of infection. Resident #131 On 1/26/20 at 6:20 AM, during the initial tour Resident #131 was observed in bed sleeping with the head of the bed at approximately 25 degrees. On the left side of Resident #131's bed the mattress was observed to have dried drips of tube feeding formula on it. Resident #131's tube feeding pole was observed infusing and with dried drips down the pole and with the base covered with large drips of dried formula. On 1/27/20 at 9:10 AM, Resident #131's mattress and pole were in the same condition. On 1/28/20 at 10:11 AM, Resident #131's mattress and pole were in the same condition. Further review of Resident #131's medical record revealed, Resident #131 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/28/20 at 10:01 AM, during the infection control task the Nurse was asked about dirty tube feeding poles and explained that housekeeping was responsible and for infection control they should be wiped down when they are dirty. On 1/28/20 at 10:50 AM, the Director of Nursing (DON) verified the observation in Resident #131's room and was asked the facility's expectation for cleaning tube feeding formula that waste. The DON stated, I will get someone to clean it. The DON was asked what the risk for dried formula to be on the pole and mattress. The DON said it was a risk for infection. On 1/28/20 at 3:22 PM, during the quality assurance task, the Administrator was asked the facility's expectation for cleaning tube feeding poles. The Administrator explained that housekeeping is responsible for cleaning poles and curtains. A review of the facility's policy titled, Daily Cleaning Procedures undated, noted .5. Disinfect. Work your way clockwise around the room and disinfect flat surfaces and high-touch items. This includes, but not limited to: . bed frame . 6. Spot Clean Walls and Inspect Privacy Curtains . spot cleaning walls and vertical surfaces that are visibly soiled .

This investigation pertains to intaked 4 Based on interview and record review, the facility failed to assess for change in condition and provide the necessary treatment related to change in neurological status in accordance with professional standards of practice for one sampled resident (R300) resulting in resident hospitalization . Findings include: On [DATE] at 9:27 AM, the Family Member A of R300 was interviewede and queried regarding status of resident. Family Member A said, They (the facility) called me and said (R300) was sent to the hospital because (R300) was not doing well. The doctor from the hospital called me and said (R300) was in bed shape. I was so confused because I talked to (R300) a few days ago. (R300) does not say much, but (R300) kept calling my name asking me to come help. The hospital called me back and said (R300) died . On [DATE] at 10:07 AM, Doctor B was interviewed and queried regarding the condition of (R300). Doctor B said, I remember this patient. (R300) had bruises all over. (R300) was dirty, teeth looked like they had not been brushed in a while. (R300) had abrasions on the palette. It looked like (R300) was forced fed. (R300's) mouth was so dry. There was blood in (R300's) stool. (R300) has a CT scan that showed a brain bleed. (R300) was not doing good. I did not expect (R300) to live. I talked to the family and they decided to place (R300) on hospice. On [DATE] at 10:43 AM, Nurse C was interviewed and queried regarding R300's condition on [DATE]. Nurse C said, I was giving (R300) their medication. (R300) would not open their eyes and did not swallow the medications. I put a glove on to scoop the medications out of their mouth. (R300's) mouth was a little dry and white. I gave (R300) oral care with a swab. The Certified Nurse Assistant (CNA) D fed (R300). On [DATE] at 11:05 AM, CNA D was interviewed and queried regarding the condition of R'300 on [DATE]. CNA D said, I did the morning care and dressed (R300). I cleaned (R300's) mouth with a green swab. (R300) did not eat good that day. (R300) does not eat a lot, but (R300) did not eat good my whole shift. CNA D was queried about shift report from the previous CN[NAME] CNA D said, We don't give report to each other. Only the nurses give report. On [DATE] at 12:43 PM, Nurse [NAME] was interviewed regarding the status of R300. Nurse [NAME] said, My notes are in the resident's chart. That's what happen. Nurse [NAME] was asked to discuss R300's condition at the beginning of their shift. Nurse [NAME] said, Oh, you want me to talk about the resident. I received report that (R300) did not eat that day. I work the 7pm-7am shift. At around 2AM, the CNA said that the resident had blood in their brief. I checked (R300's) vitals, called the doctor, and sent (R300) to the hospital because (their) blood pressure was low. Nurse [NAME] was queried about R300's condition prior to 2AM. Nurse [NAME] said, Nothing, all that happened was when the CNA said (R300) had blood in the brief. I documented what happened in the chart. On [DATE] at 11:30 AM, a review of the electronic medical record noted R300 was admitted on [DATE]. R300's medical [DIAGNOSES REDACTED]. R300 had a Brief Interview for Mental Status (BIMS) score of ,[DATE]. The care plan initiated on [DATE] noted the following: Anticipate and meet needs, Discuss with resident/family concerns or feelings regarding communication difficulty .Monitor/document/report and changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty, expressing self, difficult understanding others, level of consciousness, mental status. Monitor /document/report as needed any s/sx (signs and symptoms) of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion. A review of the hospital Admission record on [DATE] noted the following: Per staff, patient had been altered and unresponsive for one hour prior to arrival to ED (emergency department). Attempt was made to reach nursing home staff, however, no one was available .patient was responsive only to pain. Vitals demonstrated [MEDICAL CONDITION] 99 (fast heart rate) and tachypnea to 25 (breaths) .Patient had fixed right lateral gaze. Labs showed NA 185 (sodium , normal range 135 to 145), CL 155 (chloride, normal range 96 to 106), WBC15.8 (white blood cell count, normal 4 to 11), with [DIAGNOSES REDACTED] level of 89.3 (normal range 1.5 to 8.0), PO2 160 (Partial pressure of oxygen, normal range 75 to 100) . Preliminary head CT demonstrated Right and Lift posterior parietal-occipital hemorrhages .Hospital [DIAGNOSES REDACTED].Per discussion with ED team who spoke with family, patient is DNR (Do Not Resuscitate). Per facility progress note dated [DATE] at 2:20 AM by Nurse [NAME] noted: Writer alerted by CNA that resident had dark clay color blood in (their) brief. Writer went in to assess resident. Resident not responsive to touch and verbal stimuli. BP via manual ,[DATE], P 105, R 21 .Writer called to notified MD. Nurse B documented in the medical record as a Late Entry on [DATE] at 7:21 AM for date [DATE] at 5:20 PM noted: Late Entry: Note Text: This writer observed while giving (R300) medication crushed in applesauce that (R300) was not swallowing or chewing and pocketing in their jaw after several attempts of this writer trying to get resident to swallow her medication with no success this writer cleaned resident mouth out and physically swept all applesauce out of resident mouth and completed oral care, and also had the Cena complete oral care later on in the shift, resident was observed lying in bed with the head of the bed raised with eyes closed and the chest rising and falling. Call light and all necessary items within reach, will continue to monitor.There was no documentation of vital signs, neurological assessments, or nursing assessment documented for this time. On [DATE] at 2:30 PM, the Director of Nursing (DON) was interviewed regarding the status of R300 and queried about the late documentation, three days after the resident was sent to the hospital. The DON stated, (Nurse B) told me, but forgot to document in the medical record. The DON was queried on the expectation of nurses documenting the condition and changes in conditions of residents. The DON states, Well, they should document when it happened, but (Nurse B) told me. A review of the Notification of Changes Guideline policy dated [DATE] noted the following: Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative, and the resident's physician, to ensure best outcomes of care for the resident .Notification is provided to the physician to facilitate continuity of care and obtain input from the physician about changes, additions to or discontinuation of treatment Notification is provided to residents and/or the resident representative(s) to promote the resident's right to make choices about care and treatment and to keep them informed of the resident's current health status .The nurse will immediately notify the resident, resident's physician and the resident representative(s) for the following (list is not all inclusive). If the residents physician is not available contact the Medical Director. a. An accident involving the resident, which results in injury and has the potential for requiring physician intervention. b. A significant change in the resident's physical, mental, or psychosocial status that is a deterioration in the health, mental or psychosocial status in either life threatening conditions or clinical complication.

This citation refers in part to MI 342. Based on interview and record review, the facility failed to provide timely hospitalization and or care for one sampled resident (R901) of three reviewed for changes in condition, resulting in multiple episodes of vomiting positive for blood, an acute change in condition and hospitalization . Findings include: On 09/24/19 a review of the facility record for R901 revealed: A review of the facility record for R901 revealed: R901 was admitted into the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. A care plan to address the history of GI bleed was not found. The Minimum Data Set (MDS) assessment dated [DATE] indicated, moderately impaired cognition and the need for extensive assistance of one person for bed mobility, dressing and hygiene. The supervision of one was required for locomotion in a wheelchair. 12/6/2018 09:10 (AM) Health Status Note (nurses note) Note Text: Resident had episode of large projectile coffee ground emesis (potential evidence for blood or [MEDICAL CONDITION]). Then, continue(d) eating breakfast. (vital signs) V/S-172/92-100- (temperature) 98.1 (oral)- (oxygen saturation) Sa02 98% (room air) R[NAME] Rectal check was negative. STAT Abdominal x-ray ordered. 12/7/2018 19:41(7:41 PM) Health Status Note (nurses note) Note Text: Resident had x1 emesis with no fever/afebrile with temp of 98.6 oral. Constipated per x-ray result with Milk of magnesia given for constipation at this time as ordered. Vital(s) stable 1/14/2019 18:53 (6:53 PM) Health Status Note (nurses note) Note Text: At lunch time resident had a projectile vomiting, medium amount, (positive for blood) + for gastroccult. (bowel sounds) BS + (4 quadrants) 4Q, (abdomen) abd soft, non tender, non distended. Dr. (A) notified ordered STAT abdominal flat plate. Obtained blood specimen on the right hand, resident tolerated the procedure. At dinner time resident had very small emesis. X-Ray result-developing constipation, Gastric obstruction is not excluded. Dr. (A ordered) [MEDICATION NAME] 100 mg PO BID. 1/14/2019 00:18 (12:18 AM) Physician/PA/NP - Progress Note Late Entry: Subjective: Asked to evaluate patient per nursing request. (R901) vomited earlier. No distress noted. No chest pain or abdominal pain. No shortness of breath. Plan: Discussed case with nursing. Will obtain an abdominal x-ray and check labs. Monitor closely. A lab result dated received 01/18/19 revealed: Hemoglobin (Hgb)8.6 (protein which carries oxygen in the blood-normal range indicated as 13.6-17.6); Hematocrit (Hct) 24.8 (ratio of Hgb to total blood volume-normal is 40-50). Red blood cell count (RBC) 2.83 (normal is 4.3-5.9); White Blood Cell count (WBC) 5.1 (indicator of infection-normal is 4.0-11.3). 2/10/2019 13:36 (1:36 PM) Health Status Note (nurses note) Note Text: Resident projectile vomiting X 4 coffee ground emesis. Positive for gastro occult blood. Dr. (A) phoned new order for stat (complete blood count, comprehensive metabolic panel) CBC,CMP and [MEDICATION NAME] 4 (milligram) mg (intramuscularly) IM stat, clear liquid diet X 24 hours. Continue to monitor. A lab report dated received 02/10/19 revealed: Hemoglobin 11.4; Hematocrit 34.7; RBC 4.07; WBC 15.2 (abnormal high-no new orders noted per report). 2/13/2019 15:20 (3:20 PM) Appointments Note Text: patient has appt (appointment) with Gastro([MEDICATION NAME]-stomach/intestine specialist) on 4-30-19 @1:30. 2/14/2019 13:24 (1:24 PM) Physician/PA/NP - Progress Note Late Entry: Subjective: Events noted. on 2/10/19 patient had episode of emesis which was dark. had some blood work done which was stable. doing better. has not had anymore vomiting for the past couple days. No abdominal pain or rectal bleeding. No fevers. Assessment: 1- S/P Coffee ground emesis?? A lab result dated received 02/15/19 revealed: Hemoglobin 9.6; Hematocrit 28.8; RBC 3.40; WBC 6.0. (Hgb has decreased from 11.4 to 9.6.) 3/21/2019 16:27 (4:27 PM) Physician/PA/NP - Progress Note Note Text: S: Pt was seen for monthly f/u visit. No distress noted. No fever/chills. Assessment: Recurrent emesis- resolved. 3/28/2019 07:38 (AM) Health Status Note (nurses note) Note Text: At approximately 0630 resident yelled out , when writer approached resident it was noted that resident had coffee ground like emesis on himself and bedding. gastro - occult test was performed and was positive (for blood). while resident was being cleaned resident vomited again vitals taken (blood pressure) bp 118/68 (heart rate) hr 88 (temperature) t97. (respirations) r-20. supervisor was notified, along with (Director of Nursing) DON. writer called Dr. (A) call back. stat order for cbc placed (per DON). A lab result dated received 03/28/19 revealed: Hemoglobin 9.5; Hematocrit 29.1; RBC 3.67; WBC 16.3 (abnormal high-possible infection). 3/29/2019 06:18 (AM) Health Status Note (nurses note) Note Text: writer went into resident room to obtain vitals sign and observed coffee ground emesis on resident gown. vs 110/68, 97,101.1. writer informed supervisor and physician. new orders to obtain stat CBC and hemoglobin and start iv infusion of normal saline . 3/29/2019 10:28 AM Health Status Note (nurses note) Note Text: writer attempt to call Dr. (A) x3, no answer and no call back, voicemail box is full, unable to leave message. (endorsed) to oncoming day shift nurse. 4/22/2019 01:36 (1:36 AM) Physician/PA/NP - Progress Note Late Entry: Subjective: Seen for monthly follow up visit. Assessment 11- [MEDICAL CONDITION]. Plan: Long term resident. Resume current treatment. Monitor blood pressure. Medications were reviewed. Discussed with nursing. Monitor labs. This is the first Physician note which indicates a [DIAGNOSES REDACTED]. Subsequent visits on 5/20/19, 06/19/19, 07/23/19 and 8/20/19 indicate [MEDICAL CONDITION]. 4/24/2019 14:05 (2:05 PM) Appointments Note Text: appt. and transportation for 4-30-19 has been canceled. This was for a [MEDICATION NAME] (Stomach/Intestine Specialist) Consult. A lab result dated received 04/25/19 revealed: Hemoglobin 10.1; Hematocrit 30.2; RBC 3.85; WBC 7.7. A lab result dated received 07/25/19 revealed: Hemoglobin 11.4; Hematocrit 36.6; RBC 4.24; WBC 6.6. 5/20/2019 15:26 (3:26 PM) Physician/PA/NP - Progress Note Note Text: S: Monthly follow up visit. He is a poor historian at baseline. No distress noted. No recent concerns from nursing staff. Assessment: 11- [MEDICAL CONDITION] Plan: Medications reviewed. Resume current (treatment) tmt plan. Long term resident. 8/20/2019 15:41 (3:41 PM) Physician/PA/NP - Progress Note (Narrative) Note Text: S: Monthly f/u visit. BP running on the lower side. No signs of distress. No fever/chills. Lungs: Clear (cardiovascular regular rate and rhythm) CVS: RRR S1 S2 Abd: Soft, ND NT Ext: No [MEDICAL CONDITION] Assessment: 11- [MEDICAL CONDITION] Plan: Medications reviewed. DC(discontinue) [MEDICATION NAME] and cont(inue) on [MEDICATION NAME] for BP control with parameters. Cont with tmt plan. 8/28/2019 09:46 (AM) Physician/PA/NP - Progress Note Note Text: Resident alert and verbal. Emesis x3 this morning. Writer notified Dr. (A). Order to administer [MEDICATION NAME] 2ml(milliter vs milligram). Writer also placed resident on 24hr clear liquid diet. (Vital signs) VSS 135/78- 97-16-97.3-98%R[NAME] Resident denies pain, staff will continue to monitor. This note was per Nurse B. 8/29/2019 12:52 (PM) Health Status Note (nurses note) Late Entry: Note Text: Writer called to resident room by (central suppy) CSR manager. Resident noted in bed lethargic with basin in bed with him. Writer called nurse to room who came with a b/p machine. vitals assessed resident vitals noted at 65/53 B/P, 123 P, BS 423. Assigned nurse left room to call physician to obtain stat IV orders and blood work. Dr. order to transfer resident 911 to ER. (assistant director of nursing) ADON at bedside, assisting writer and staff nurse with assessment and interventions. 911 arrived within 5 min approximately and Resident transferred to (hospital). With (diagnosis) DX: (severe)-serve septic shock and (gastrointestinal) GI bleed. Will continue to monitor. This note was written by unit manager Nurse D. A discharge Handoff note dated 08/29/19 at 13:17 (1:17 PM) indicated Discharge. Reason for discharge: Resident slow to respond, Low B/P 63/39 P(ulse) 126. 3a. Most Recent Blood Pressure: Blood Pressure: 135 / 78 (mmHg) Date: 8/28/2019 09:30. This note was completed by Nurse C. On 09/24/19 at 12:25 PM, Nurse B was asked about the care of R901 and stated, I took care of (R901) the day before (they) went out. (R901) did have some emesis (vomiting) that morning. It was dark meat chunks and corn. I gave [MEDICATION NAME] (anti-nausea medication) IM (intramuscularly), towards end of the day (R901) was a little more normal but still not the same. On 09/24/19 at 3:39 PM Nurse D was asked about the discharge of R901 to the hospital and stated, I termed (terminated) that particular nurse (nurse C) that day. (R901), didn't look (themselves). (R901) was quiet that morning. The blood pressure was 65/53 at the time. (R901) did respond to (their) name and said did not feel good. (R901) had low blood pressure the night prior and had emesis on the midnight shift. My CSR manager said (nurse C never went to assess (R901). I felt there was no way (R901) could have been fine prior to my observation. Nurse D was asked about the last emesis of R901 and what happens when it tests positive for blood and stated, It was not reported as coffee ground emesis. We will do gastro occult test (for blood) and if positive, we used to transfer to the hospital. They (facility) look at rehospitalization rates so it is not an automatic to transfer to the hospital anymore. If there is a positive gastro occult tested here, the nurse will tell the doctor and will try to insist on hospitalization . It could go up to the (Director of Nursing) DON to make the call. Nurse D was also asked why the gastro consult appointment was canceled and stated, I want to say it was an insurance reason, sometimes we run into that. Nurse D was also asked why the note from 08/29/19 written by them was a late entry and reported they had noticed Nurse Chad not written a note in regard to the discharge. On 09/24/19 at 4:10 PM, the CSR manager was asked about the condition of R901 prior to discharge and stated, (R901) didn't look right so I told the nurse (nurse C). The next thing I know (R901) is going out the door. I visited (R901) frequently because I was (R901's)ambassador. (Nurse C) did go into the room and come out. I had no concerns the day before on my visit. On 09/24/19 at 4:34 PM the DON was asked about the discharge of R901 to the hospital and sending out for a positive occult blood test and a change of condition policy and stated, There is not a set policy on sending out, unless there is respiratory distress. If the occult test was positive the nurse would still call doctor to get orders. The (DON) would not override the doctor. If you can reach the doctor, the doctor's orders come first., On 09/24/19 at 5:29 PM, a return call from Dr. A was received. Dr. A was asked about the what was done for a positive occult blood test and a nurse assessment of coffee ground emesis and stated, It is dependant on how the patient is doing. It would be based on their clinical condition at the time. If their was a drastic change in their hemoglobin then would send out. You want to give a little bit of time, check the vitals. I doubted if may not be real coffee ground emesis. If really bleeding you would send out. I am not sure I would send out for occult positive test. You would look at the clinical correlation. If continuously vomiting you would send out. You hate to send out if they don't need to go. Potentially you would send out for coffee ground emesis, but I was not necessarily sure that is what it was. I felt (R901) was generally stable. A review of the facility policy Change in Condition or Status (not dated) revealed it did not specifically address when to transfer a resident to the hospital.

This citation pertains to Intake number MI 864. Based on observation, interview, and record review the facility failed to prevent the elopement of 1 (R#1) of 1 sampled resident reviewed for elopement, resulting in the resident leaving the facility through locked and/or alarmed exit doors unobserved with the likelihood of serious harm, injury, or death. Findings include: On 10/30/18 at 9:26 AM, an interview with R#1 was conducted. R#1 was asked about leaving the facility and getting lost outside R#1 stated, I had a [MEDICAL CONDITION] and they said I didn't. Then asked if the exit door was locked or made any alarms while it was opened R#1 stated, No, I don't think so. Then asked If the staff were told of the plan to go outside R#1 stated, I think so. R#1 then became impatient with the questions and stated, All I need is a hot breakfast. I just walked out, I don't remember what door, it was cold out so the ambulance driver gave me 10 blankets. On 10/30/18 at 9:53 AM, an interview with R#1's staff was conducted. Certified Nurses Aide (CNA) Z was asked if R#1 has exhibited any exiting behavior and stated, No, not for me. All she ever asks for is pop. Nurse O was asked if R#1 ever stated she wanted to leave and stated, I wasn't here that day, but (R#1) never said anything like that to me. Her family is here a lot and seems OK. On 10/30/18 at 10:15 AM, review of R#1's medical records was conducted. R#1 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] was the entry assessment and did not include a Brief Interview for Mental Status (BIMS) or mobility data. Review of the Nursing progress notes dated, 10/24/2018 04:21 *Health Status Note (nurses note) Note Text: At 03:45 am, checking on resident, resident was not on bed, checked bathroom, not there. Writer and other staffs checked resident every units and could not find the resident. Informed supervisor. Called police and they said they admitted this resident to Garden city hospital and they saw her outside of the building. Spoke to ER doctor who stated that the resident is doing well, ready to transfer her to our facility. Supervisor called rapid response and waiting for resident's return. Informed Director of Nursing (DON) and Administrator. On 10/30/18 at 1:15 PM, telephone interviews with the midnight shift staff on duty the night R#1 eloped were conducted. CNA L was asked to recall the events leading up to R#1's elopement and stated, I can't remember the exact time but it was around 2:00 AM. (R#1) was in the bathroom, I heard the water running. Nurse M was asked to recall the events leading up to R#1's elopement and stated, I gave the resident's medications at 10:30 PM, (10/23/18). (R#1's) family was there. (R#1) liked the door closed while sleeping. On 10/30/18 at 1:45 PM, an interview was conducted with the Administrator and the Director of Nursing (DON). When asked about the elopement the DON stated, The CNA said she heard the resident in the bathroom around two, at 3:45 the resident was not in the room. She notified the nurse and started a search and called the police. We came in and tested all the doors and they all worked. We found no open windows. The DON asked when the door alarms were tested and stated, Around 4:40. (R#1) has a wanderguard on now. The Administrator was asked if the elopement was reported to the state agency and stated, We looked up the definition of elopement, (R#1) gave no indications that (R#1) was going to leave. (R#1) put on a sweatshirt and had a destination. We do not know what door (R#1) left from. On 10/30/18 at 2:15 PM, a tour of the facility's exit doors and windows was conducted with the Maintenance Director. All six of the emergency exits were alarmed and the alarms sounded when opened. Doorways to the facility's two courtyards were locked but not alarmed. The courtyards provided no access off of the facility's property. The main entrance, back entrance and loading dock doors were code locked and could not be opened without a code. A window in a resident's room was opened. The window opened eight inches and was stopped by a bolt. A screen with a two inch frame was securely in place. The windows in random rooms throughout the building were inspected with the same results. On 10/31/18 at 9:15 AM, the Administrator and a corporate advisor presented video recordings of the hallway where R#1's room was. Using the date and time stamp of the video, On 10/24/18 at 02:22 (2:22 AM) two CNAs were observed making rounds in the rooms next to and across from R#1's room. On 10/24/18 at 02:32, R#1 was observed to open the door of the room, look around the hall and walk away from the camera. The Administrator was asked to provide video recordings taken by the cameras at the main entrance door and the loading dock door. On 10/31/18 at 10:45 AM, record review was conducted. The police report dated, 10/24/18 03:08 AT ENTRANCE TO THE (apartment complex next door to the facility) - (description of R#1), GRY SWEATER, AND BLUE PAJAMA PANTS SITTING ON THE GROUND, APPEARS CONFUSED AND LOST .HAS BEEN IN THE COLD FOR AT LEAST AN HOUR .WAS NOT WEARING SHOES .APPEARS TO BE DISORIENTED AND COULD NOT PROVIDE AN ADDRESS OF HOW (R#1) GOT TO THE AREA. (city EMS) RESPONDED AND TRANSFERRED (R#1) TO THE HOSPITAL FOR FURTHER TREATMENT AND EVALUATION. Review of the audits of the exit doors the week of the elopement revealed that all alarms and code locks functioned as designed from 10/22/18 to 10/26/18. Review of the Incident and Accident (I&A) investigation and Plan of Correction revealed, R#1's background and co-morbidities were documented, staff interviews were documented, Upon return to the facility R#1 received a full body assessment and was safe and uninjured and placed on 1:1 supervision. R#1 received a BIMS score of 14 (Intact cognition). R#1's elopement assessment was reviewed and an elopement risk care plan was implemented. A wanderguard was placed on the resident. A QAPI (Quality Assurance/Performance Improvement) Plan for Resident Exiting Facility was formulated. And staff education was conducted, including sign in sheets. On 11/1/18 at 10:00 AM, An interview with the Receptionist, Staff BB at the back door lobby was conducted. Staff BB was asked how long the back door is monitored by staff and stated, Until 8:00 PM. But the door is code locked 24/7. There is no way anyone could get out without the code. On 11/1/18 at 12:50 PM, The Administrator stated, Video recordings of the main entrance door and loading dock door are just not available. On 11/1/18 at 1:30 PM, a tour of the exterior of the facility was conducted. All of the exit doors had exterior cameras mounted over them except the loading dock door. Back inside the building the loading dock door was observed to have an interior camera pointed at it. The Certified Dietary Manager (CDM) was asked what time the dietary staff take the garbage out for the evening and stated, The last staff leave at 8:00 PM. The CDM was asked to open the loading dock door and entered a code on the lock's keypad. The door opened and closed on its own and would not open without the code entry. Another test of the door revealed that the door could only be opened with the code, however the door did not close fully and could be opened by pushing on it, the CDM had to pull on the door to engage the lock. Two more tests of the door were conducted and the door closed and locked each time. On 11/1/18 at 2:00 PM review of the facility's policy and procedure was conducted. The Document titled, Wandering and Elopement Guidelines, dated (MONTH) 16, (YEAR)., review of the document revealed the unobserved elopement of a resident was not addressed.

This Citation Pertains to Intake Numbers: MI 806 and MI 893 Based on observation, interview and record review, the facility failed to implement planned interventions to prevent the development and worsening of facility acquired pressure ulcers for two (#'s 802 and 803) of four Residents reviewed for pressure ulcers, of a total sample of 10, resulting in the development and deterioration of stage three (wound involving full thickness tissue loss) and stage four (wound involving full thickness tissue loss with exposed bone, tendon and/or muscle) pressure ulcers, unnecessary pain, and the potential for delayed healing and decline in overall health status. Findings include: Resident #802 Record review on 2/21/18 at 10:20 AM revealed Resident #802 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact, had and indwelling urinary catheter, and required extensive assistance to perform activities of daily living. Resident #802's care plans were reviewed on 2/21/18 at 10:20 AM. Review revealed a care plan entitled, Impaired Skin Integrity Actual, as evidenced by: Stage 4 Pressure Injury to sacrococcyx/bilateral buttocks; h/o (history of Stage 3 Pressure Injury to sacral/(L) buttock; Decreased mobility; h/o moist skin; incontinence; unwillingness to get out of bed; unwillingness to allow staff to turn & reposition as indicated; Braden Scale Score 15 (Edited: 2/5/18). Care plan interventions included: -Foley catheter for aggressive wound healing (Created: 12/19/17) -Provide measures to decrease pressure/irritation to skin: Low air loss mattress, Barrier cream after each incontinent episode, float heels while in bed (Edited: 10/11/17) -Turn and reposition every 2 hours & prn (as needed). Nursing to document refusals (Edited: 12/30/17) -Up in chair as tolerated (Created: 4/23/16) On 2/21/18 at 10:55 AM, Resident #802 was observed in their bed, positioned on their back. The head of the Resident's bed was elevated, at approximately a 35 degree angle. The Resident was positioned low in the bed with their neck at the point the head of the bed began to elevate and their feet at the end of the bed. An interview was completed with the Resident at this time. When queried regarding pain, the Resident stated, Yes, in my legs and back where the sore is. With further inquiry regarding pain on a scale of zero to 10 with zero being no pain and 10 being the worst pain imaginable, Resident #802 stated, It's (pain) a 10. When asked where the pain was the worst, Resident #802 stated, The sore. When queried regarding staff repositioning in bed, Resident #802 stated, They don't do that. With additional inquiry regarding refusing repositioning, Resident #802 stated, They don't ask. Resident #802 further indicated they have refused care in the past due to pain. On 2/21/18 at 11:00 AM, Nurse B was observed entering Resident #802's room with wound care supplies. When queried, Nurse B indicated they were going to complete the Resident's dressing change. An interview was completed with Wound Care Nurse B. When queried regarding the Resident's pain levels, Nurse B stated, (The Resident) has a lot of pain with it. At this time, Nurse B spoke to the Resident and indicated they would complete the dressing change after the Resident received pain medication. When queried regarding Resident #802's pressure ulcers, Nurse B stated, They're not showing much progress. When asked if the pressure ulcers were facility acquired, Nurse B replied, I'm not sure. At this time, wound care observation for Resident #802 was attempted to be scheduled. Nurse B indicated they would complete the dressing change approximately 20 minutes after the pain medication was administered. Contact information was provided to Nurse B at this time. At 12:05 PM on 2/21/18, an interview was completed with Nurse B. Nurse B stated, I had to do it (wound care). Observation of the Resident's wounds and wound care was unable to be completed. On 2/21/18 at 12:15 PM, Resident #802 was observed in their room in their bed. The Resident was positioned on their back. An interview was completed with Confidential Witness C and Resident #802 at this time. When queried, Witness C stated, (Resident #802) got it (pressure ulcer) here. Witness C further stated, (The Resident) was walking before. They had to use a quad cane but they were walking. Now (Resident #802) doesn't even get up. (Resident #802) just got out of the hospital about three weeks ago, they (facility) sent (the Resident) to the hospital. (Resident #802) had flu and pneumonia. With further inquiry, Witness C stated, When (the Resident) was discharged from the hospital, I didn't know where they were so I didn't get here until around 11:00 PM. When I got here, (Resident #802's) call light and bed controller were on the floor. (Resident #802) couldn't even call for help and (the Resident) was back for six hours before I even got here. Review of Resident #802's medical record on 2/21/18 at 1:10 PM revealed the pressure ulcer was acquired at the facility. The following documentation related to the pressure ulcer were noted within the medical record: - 10/18/17 at 4:24 PM: Partial thickness open area to (L) buttock r/t (related to) equipment failure/electrically issue . Guest to be turned & repositioned every 2 hours & prn (as needed). Writer educated guest on importance, guest ok with P[NAME] (Plan Of Care). Physician made aware. -11/29/17 at 1:37 PM: Changed wound care tx (treatment) to coccyx/bilateral buttock . -12/05/17 at 1:22 AM: Body assessment completed, no new skin issues noted. Tx (Treatment) continues on coccyx area. -12/14/17 at 2:38 PM: CNA (nursing assistant) approach writer regarding patient coccyx. Pin point open area to coccyx, yellow base, irregular edges, scant seroganious fluid . -12/29/17 at 1:17 PM: .Wound to left buttock. Wound beds are scattered with irregular edges. Moderate serosanguinous drainage noted. Periwound fragile. Site measured at 5 x 7. no depth . -1/2/18 at 3:15 PM: Coccyx 9.6 x 8 x 0.6. Depth only noted at approx. 1 o ' clock. Wound bed is granulated with active moderate sanguineous drainage . Patient tolerated but narrator did note discomfort . -1/9/18 at 8:25 PM: Sacral/(L) buttock Stage 3 Pressure Injury, 8.0 x 8.0 x 0.5 cm. Yellow necrotic base. Moderate serous drainage. Irregular edges. Periwound [DIAGNOSES REDACTED]. Treatment changed . -1/16/18 at 7:02 PM: Sacral/(L) buttock Stage 3 Pressure Injury changed to Sacral/Bilateral buttocks Stage 4 Pressure Injury, 11.0 x 14.0 x 0.5 cm. Necrotic base. Bone is exposed. Moderate serosang drainage. Mild odor. Irregular edges. Treatment changed . 1/16/18 at 9:41 PM: (Resident Family) in facility at this time. Writer notified resident & (family) of decline in wound. Resident stated I ' m doing everything they tell me to do! Writer asked resident if he has been eating, resident stated yeah. Brother states resident not eating good, only eating significant amounts when brother in facility and assisting resident. Writer educated resident at length about importance of proper oral consumption to promote proper wound healing. Resident stated understanding. Brother & resident ok with P[NAME] (Plan of Care). -2/5/18 at 5:56 PM: . New orders in place for low air loss mattress. -02/13/18 at 7:33 PM: Sacral/Bilateral buttocks Stage 4 Pressure Injury, 13.5 x 13.6 x 1.8 cm (centimeter). Pink base. Scattered yellow necrosis. Bone is exposed. Large serosang drainage. Necrosis to midcore. Irregular edges. Treatment changed . -2/20/18, Physician Wound Progress Note: Sacrococcyx bilateral buttocks is a Stage 4 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 12 cm length X 14 cm width X 1 cm depth . Bone is exposed . large amount of serosanguinous drainage noted . mid odor. Wound bed has pink base [MEDICATION NAME] . Scattered necrosis irregular edges. Additional review revealed progress note documentation of Resident refusal to reposition on 12/16/17 and 11/17/17. Review of the Resident's current medications revealed the following orders for pain medications: [REDACTED] -[MEDICATION NAME] (used to treat moderate to severe pain) 7.5-325 milligram (mg), one tablet every four hours as needed -[MEDICATION NAME] (used to treat minor pain), 400 mg, every six hours as needed On 2/21/18 at 1:50 PM, an interview was completed with Nurse J. When queried regarding interventions related to Resident #802's pressure ulcer, Nurse J stated, (Resident #802) has the air mattress. With further inquiry, Nurse J stated, (Resident #802) barely gets up. Resident #803 Record review on 2/21/17 at 10:30 AM revealed Resident #803 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required extensive assistance to perform Activities of Daily Living (ADL's). The MDS further revealed the Resident had one stage three pressure ulcer and two stage four pressure ulcers. On 2/21/18 at 11:05 AM, an interview was completed with Wound Nurse D. When queried regarding wound care treatment for [REDACTED]. With further inquiry, Nurse D stated, (Resident #803) has three open areas. When asked if the pressure ulcers were facility acquired, Nurse D replied, I'm not sure. On 2/21/18 at 11:10 AM, Resident # 803 was observed lay in bed in their room. The Resident was positioned on their back. An interview was completed with the Resident at this time. When queried, Resident #803 stated, The pressure ulcers are stage four. When queried if they developed the pressure ulcers at the facility, Resident #803 stated, I had some but the worst one I developed here. When asked about pain, Resident #802 stated, Oh yes. They hurt. I get [MEDICATION NAME] and every other darn thing. Resident #803's care plans were reviewed on 2/21/18 at 12:50 PM. Review revealed a care plan entitled, Actual Impaired Skin Integrity as evidenced by: Left buttock (stage IV), Left hip (stage IV), h/o (history of) Sacral Stage 3 Pressure Injury; parascaral Stage III Pressure injury h/o Right lower leg (stage II) -resolve 1-3-17. Treatment to areas in progress r/t [MEDICAL CONDITION], decreased mobility; noncompliance with positioning & pericare; noncompliance with prn treatment changes; h/o open area to lower back; skin tear to R buttock. (Edited: 10/13/17). Care plan interventions included: -Bari low air loss mattress . (Created: 10/13/17) -Educated on importance of turning/reposition & timely pericare/ADL care to relieve pressure & prevent further skin breakdown (Created: 1/4/17) -Provide measures to decrease pressure/irritation to skin: bilateral Heel Boots, Low air loss mattress, turn & reposition every 2 hours & prn (Edited: 10/11/17) -Wound care/dressing change as ordered: (Edited: 10/21/16) The Resident also had a care plan entitled, Noncompliance with wound care treatment as ordered. Resident refuses treatment frequently. 2/9/2016-Resident verbalize does not like to be turned to right side. Resident is willing to reposition onto left side and back onto back two times per shift (every 2-3 hours). States will forget to alert staff with call light. Wants staff to come and reposition even if asleep . (Edited: 7/17/17). The care plan included the intervention, Approach every 2-3 hours or twice per shift to alternate repositioning from left side to back only. Per resident request states to wake if sleeping (Edited: 10/21/16). Record review of Resident #803's wound care documentation on 2/21/17 at 1:25 PM revealed the following: -2/6/18, physician progress notes [REDACTED].>Wound #2 Left Buttocks is a Stage 4 Pressure Injury Pressure Ulcer . Wound encounter measurements are 3.5 cm length X 5 cm width X 0.4 cm depth . moderate amount of sero-sanguineous drainage noted . Two wounds, irregular edges. Wound # 5 Left hip . Chronic Stage 4 Pressure Injury Pressure Ulcer . Wound encounter measurements are 6.5 cm length X 6.5 cm width X 1 cm depth .Bone is exposed . large amount of sero-sanguineous drainage noted . Minimal yellow slough . Ligament noted to wound bed, irregular edges. Wound # 6 Left Parascral is a Stage 3 Pressure Injury Pressure Ulcer .Subsequent wound encounter measurement are 2 cm length X 0.9 cm width X 0.2 cm depth .moderate amount of sero-sanguineous drainage noted . irregular edges. -2/20/18, physician progress notes [REDACTED].>Wound #2 Left Buttocks is a Stage 4 Pressure Injury Pressure Ulcer . Wound encounter measurements are 5 cm length X 3 cm width X 0.5 cm depth . moderate amount of sero-sanguineous drainage noted . Moderate yellow slough . irregular edges . Wound # 5 Left hip . Chronic Stage 4 Pressure Injury Pressure Ulcer . Wound encounter measurements are 6.5 cm length X 6 cm width X 1 cm depth .Bone is exposed . large amount of sero-sanguineous drainage noted . Minimal yellow slough . Irregular edges, ligament noted to wound bed . Wound # 6 Left Parascral is a Stage 3 Pressure Injury Pressure Ulcer .Subsequent wound encounter measurement are 1 cm length X 4.5 cm width X 0.5 cm depth .moderate amount of sero-sanguineous drainage noted . Two wounds irregular edges. Wound #7 Left, Lateral Hip is a Stage 3 Pressure Injury Pressure Ulcer. Measurements are 4 cm length by 4.5 cm width X 0.5 cm depth . moderate amount of sero-sanguineous drainage noted . Necrosis proximally irregular edges . On 2/21/18 at 2:10 PM, Resident #803 was observed lying in bed in their room. The Resident was positioned on their back. An interview was completed at this time. When queried regarding repositioning in bed, Resident #803 indicated they were unable to reposition themselves. When asked the frequency that staff assist the Resident to reposition, Resident #803 stated, Once a day when I get my wound care done. With further inquiry, Resident #803 stated, I want them to turn me more but they don't. I don't think they have enough people (staff). When queried if they refused to be turned or repositioned in bed, Resident #803 stated, No, I even told them to turn me when I was sleeping. When asked if they got out of bed, Resident #803 stated, No. An interview was completed with Nursing Assistant I on 2/21/18 at 2:30 PM. When queried regarding turning and repositioning Resident #803, Nursing Assistant I stated, I try to go in there (Resident room) when wound care is in there. With further inquiry, Nursing Assistant I stated, The thing about (Resident #803) is that she don't say anything (about needing to be repositioned) so we do miss her. When asked if Resident's are expected to request to be repositioned, Nursing Assistant I did not provide further explanation. When queried further regarding staff availability to reposition Residents, Nursing Assistant I stated, One day, I was the only CNA (Nursing Assistant) for like an hour and a half. There is like 50 Residents. We have been short staffed for a while which affects care for everybody. Nursing Assistant I further stated, I have 15 or 16 Residents today. An interview was completed with the Director of Nursing (DON) on 2/21/18 at 2:40 PM. When queried regarding the onset date of Resident #802's pressure ulcer, the DON revealed the Resident's medical record and stated, It looks as though (MONTH) 14, (YEAR). When asked if the pressure ulcer was facility acquired, the DON stated, Yes. When queried regarding interventions to prevent pressure ulcer development and worsening, the DON indicated the Resident had been in the hospital from 12/19/17 to 12/27/17 and from 1/25/18 to 2/5/18. With further inquiry, the DON stated, A Foley was inserted on 12/19/17, the treatment was changed on 1/9, 1/16, 1/23, and 2/5. When queried regarding the implementation date of the alternating air mattress, the DON stated, That was on 4/23/17. When asked about turning and repositioning the Resident, Resident statements, observations of Resident in the same position, and lack of documentation of Resident refusal to reposition as indicated in the care plan, the DON did not provide and explanation. When queried regarding Resident #803's pressure ulcers and documentation of a forth pressure ulcer developing between 2/6/18 and 2/20/18, the DON indicated the Resident was being followed by wound care. When queried regarding turning and repositioning the Resident including Resident and staff statements of not being repositioned, the DON stated, They said that. I can't say anything else. No further explanation was provided. Record review on 2/21/18 at 7:00 PM of facility entitled, Preventative Skin Care Policy (November (YEAR)) revealed, All Residents will receive necessary assessments and treatments to prevent pressure ulcers, promote healing, and prevent infection by the licensed nursing staff. The policy further revealed, Weekly skin assessments will be completed . Nurse will chart in the progress notes any skin new changed skin issues and sign in eMAR (electronic Medication Administration Record) that assessment was completed . Ulcers/Wound Measurements, and Documentation, the licensed nurse will follow the Skin Protocol Section III . Record review of facility policy entitled, Skin Protocol (11/27/17) on 2/21/18 at 7:10 PM revealed, Pressure ulcers . are to be inspected by the licensed nurse, measured and documented in the treatment record weekly . Monitoring .d. Whether pain, if present is being adequately controlled .

This citation pertains to Intake/FRI #MI . Based on interview and record review, the facility failed to protect a vulnerable resident from an unconsentual sexual act by a resident who had documented sexually risky behaviors and a confirmed [DIAGNOSES REDACTED].#505) out of a sample of five reviewed for abuse out of a total sample of eight residents resulting in the sexual assault and risk for contracting a [MEDICAL CONDITION]. The Immediate Jeopardy was identified on 10/31/17 at 9:15 am. The Immediate Jeopardy began on 10/31/17 at 9:15 am when a staff person observed the sexual act occuring. The Administrator was notified of the Immediate Jeopardy on 12/01/17, at 4:00 pm. The immediacy was removed on 10/31/17 at 3:30 pm when one to one staff supervision was implemented on resident #504. Surveyors verified the removal of the immediacy on site by record review and interview on 12/1/17. Although the immediacy was removed, the facility's deficient practice was not corrected and remained isolated with harm that is not immediate jeopardy. Findings include: On 12/1/17 at 9:00 a.m., the facility submitted a facility investigation and other pertinent documentation regarding a facility reported incident (FRI) that occurred on 10/31/17. It was reported R#505 was involved in a sexual resident to resident incident with R#504 without consent. R#504 also had a [MEDICAL CONDITION] ,[MEDICAL CONDITION]. R#504 was discharged from the facility on 11/3/17 subsequent to the incident occurring. On 12/1/17 at 4:00 p.m., R#505 was observed in the room, sitting in a wheelchair at the bedside watching television. R#505 was asked if able to recall the incident with R#504. R#505 was unable to recall the incident stating, I haven't had no problems with no one. Everything has been ok. On 12/1/17 at 11:30 a.m., review of R#505's clinical record documented the Resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment dated [DATE], R#505 was moderately cognitively impaired (BIM score of 10), and required extensive assistance with most activities of daily living (ADLs). R#505 also has a court appointed legal guardian to assist with decision making. Review of R#504's clinical record documented the Resident was admitted into the facility on [DATE] and discharged from the facility on 11/3/17 with [DIAGNOSES REDACTED]. According to the MDS assessment dated [DATE], R#504 was moderately cognitively impaired (BIM score of 10), and required limited assistance with ADLs. R#504 is able to propel self independently while in a wheelchair. R#504 does not have a legal representative to assist with decision making. Review of the Incident and Accident Report (Usual Occurrence) dated 10/31/17, documented the incident occurred in the R#505's room, at 9:15 a.m. The incident was witnessed a CENA (CENA B). According to the report completed by the nurse on shift, Description of occurrence documented, CNA witnessed another resident (R#504) performing oral sex on this resident (R#505). When CNA walked into room, (resident's name, R#504) was sitting on this resident (R#505) bed with over bed tray with breakfast tray on it moved over. (Resident's name, R#504) had this resident (#505) penis in mouth. 1:1 provided for (Resident's name, R#504). On 12/1/17 at 1:00 p.m., CENA B was on confirmed as the CENA that witnessed the incident. CENA B was then asked to recall the incident. CENA B stated, At 9:15 a.m., after feeding someone, I went to collect the trays. I went into (Resident's name, R#505) room. The door was shut. The resident's bed was close to the door. The curtain was not closed. (Resident's name, R#504) was sitting on the edge of the bed. (Resident's name, R#505) was supine. (Resident's name, R#505) brief was peeled back and (Resident's name, R#504) had (Resident's name, R#505) penis in his (R#504) right hand with the top of his penis (R#505) in his (R#504) mouth. I told (Resident's name, R#504), You can't be in here. (Resident's name, R#504) started to get up. He stood up from the bed and got into the wheelchair and wheeled toward the door. I went and reported the incident to the nurse and unit manager immediately. CENA B was then asked what the reaction from R #505 was. CENA B stated, (Resident's name, R#505) had a look of confusion on his face. CENA B was asked if R#505 seemed aware of what happened. CENA B stated, He's not always aware of what's going on. CENA B was then asked if R#504 was aware of what occurred. CENA B stated, (Resident's name, R#504) would be aware and able to understand. CENA B was asked if R#505 would be able to give consent. CENA B stated, I don't feel (Resident's name, R#505) is in his right mind to consent. CENA B was asked if R#504 exhibited any similar behaviors or other inappropriate behaviors towards staff or residents prior to this incident. CENA B stated, (Resident's name, R#504) would say inappropriate things about staff's body sizes and what they were wearing and other inappropriate things. On 12/1/17 at 3:46 p.m., Nurse A was interviewed. Nurse A confirmed being a consistent nurse for R#504. Nurse A was asked if R#504 exhibited any behaviors prior to the incident occurring. Nurse A stated, (Resident's name, R#504) was known to talk about people like what they wore or how they wore their hair. The Resident had stated to me, I'm in here (the facility) because of being out in the streets being a hoe. On 12/1/17 at 9:00 a.m., the facility also provided another Incident and Accident (Unusual Occurrence) report involving R #504, which alleged R#504 performed oral sex on a staff member. The report documented the incident occurred on 10/18/17 in the resident's room, at 3:30 a.m. According to the report completed by the nurse on shift, Description of occurrence documented, Alleges fell atio was performed on staff member by resident. Resident stated to this writer a male CENA came in his room at 3:30 a.m., pulled his dick out and said suck it till I come and I'll fix your light. Resident stated he did what he said. The incident was investigated by the facility and found the incident did not occur. As an intervention to the incident, the facility implemented the resident not to be assigned male CENAs. Review of a witness statement dated 10/22/17 regarding the incident on 10/18/17 which was submitted by a nurse working on the unit documented, documented, Early Wednesday (October 18) morning, I observed patient (Resident's name, R#504) out in the hallway in his wheelchair. Resident stated, I'd love to suck his dick. I bet it smells like soap. Resident was laughing to himself and then stated, Let me quit before I get somebody fired up in here. On October 25, 2017, R#504 was seen by psychiatric services provided by the facility. The psychiatric documentation included, On 10/1- This worker met with resident. He admitted to stealing snacks from his roommate .very confused and expressing delusional thoughts. On 12/1/17 at 1:30 p.m., the behavior monitoring log was reviewed in the electronic record. There were no documented behaviors. Review of admission into the facility documentation dated 9/7/17, R#504 was transferred into the facility from another skilled nursing facility with a primary [DIAGNOSES REDACTED].#504 exhibited inappropriate behavior. According to the physical therapy note dated 8/17/17, Pt refused to get out of bed . Pt conversation very inappropriate. Pt kept talking about sex and drugs. PT (physical therapist) would redirect conversation but Pt would redirect back. On 8/22/17, another physical therapy note revealed, Pt is very easily distracted. Pt made inappropriate comments throughout the session, constant redirections with very poor follow up. Review of the facility's dated 1/31/17, Abuse, Neglect, and Exploitation policy included: Residents must not be subject to abuse by anyone, including but not facility staff, other residents .Assess, monitor, and develop appropriate plans of care for residents with inappropriate sexual behavior, whether towards staff or other residents.

This citation pertains to intake MI 244. Deficient Practice #1 Based on interview and record review the facility failed to provide transfer support in accordance with the assessed resident need for one sampled resident (# 627) out of three residents reviewed for care and treatment needs from a total sample of 27, resulting in a transfer injury, fractured right lower leg. Findings include: On 9/20/17 at 3:30 PM, a record review revealed that Resident #627 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE]. Based on the Annual Minimum Data Set ( MDS) assessment dated [DATE] resident #627 was a [AGE] year severely cognitively impaired female whose [DIAGNOSES REDACTED]. The resident's Brief Interview for Mental Status ( BIMS) score for the above MDS was 3/15 indicating severe cognitive (thought processes) impairment. The MDS assessment on the above date indicated the resident required 2 person assistance with transfers. On 9/21/17 at 10 am, an interview with CNA X regarding resident #627 was conducted. CNA stated she is usually assigned to resident # 627. Stated she arrived to the facility on the morning of Saturday, 9-16-17, and was on the unit at 7 am. When she went into resident's 627 room she found the resident in bed receiving a dressing change to the right calf of her leg. Stated the dressing on her leg was new for her. CNA X stated that after resident # 627 dressing change, she got her out of the bed. She stated when she moved the resident she screamed in pain from her right leg. The CNA stated, she is usually not in pain that bad. I let the nurse know about the resident's pain. When I came back to the facility on Sunday, (September 17), the resident was gone, they told me she went to the hospital. When asked did she receive assistance getting the resident out of the bed on Saturday, September 16th, CNA X stated, yes another CNA helped me get her up she is a two-person assist. Review of a document titled, Verification of Investigation, dated 9/15/17, documented, when a CNA was providing care to resident # 627 on 9/15/17 at about 3 am the resident complained of pain in her right leg/calf area. The CNA observed a bruise on the resident's right calf. The CNA immediately notified the nurse and the nurse assessed the resident and the nurse noted the resident complaining of pain in addition to the bruise on her right calf area. The nurse administered pain medication per the physician's verbal orders and received an additional verbal order to obtain a stat x-ray of the right femur ( thigh bone) and right lower extremities. The x-ray was completed the morning of 9/16/17 at the facility and the results were suspected fracture of lateral tibial break in the bone affecting the knee joint, stability and motion) plateau. The physician was notified of the x-ray results and was ordered resident # 627 to be sent to the hospital for further review of the fracture. Resident #627 returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the hospital emergency room x-ray dated 9-17-17 revealed, There is a depressed [MEDICAL CONDITION] tibial plateau. There is no evidence of any other fracture, dislocation or significant skeletal abnormality. Review of a document titled, Verification of Investigation, dated 9/15/17, revealed the assigned CNA did not follow the Care Guide and transferred the resident alone. The assigned CNA was re-educated on transfers, and the Zero tolerance lift policy. She was given a final written warning. Review of the care plan for the resident with an approach start date of 9-1-17 indicated resident # 627 was a 2 person assist for all transfers. Review of a document titled, Work Performance Corrective Action Record, dated 9/20/17 with the CNA's signature, documented, the CNA did not follow the Patient Care Guide, the resident was unintentional injured and this will never happen again. A document, titled, Zero Tolerance Lift Policy, with an effective date of May, 15, 2014, documented, it is the policy of this facility to reposition, transfer, and/or lift patients/residents safely and according to the care plan. The facility has a zero tolerance for employees that do not follow the patient/resident's care plan/care guide. Employees who do not follow the patient/resident's care plan/care guide related to repositioning, transfers, and/or lifting will be subject to disciplinary action up to and including termination. The determination for termination will be made by the Regional Manager and Administration. Deficient Practice #2 Based on observation, interview, and record review, the facility failed to reposition a resident in bed in accordance with the assessed resident need for one sampled resident (# 627) out of three residents reviewed for care and treatment needs from a total sample of 27, resulting in an increased risk for skin breakdown/pressure ulcer development. Findings include: On 9/19/17 at 2:00pm ,record review of revealed that Resident # 610 was originally admitted to the facility with [DIAGNOSES REDACTED]. According to the most recent Minimum Data Set (MDS) assessment (significant change) with an assessment reference date of 8/20/17, Resident # 627 was severely cognitively impaired (scored 3/15 on a brief mental status exam ( BIMS). Resident # 627 required extensive assistance of two persons for all activities of daily living, and a hoyer lift for transfers. Review of a document titled, Physician order [REDACTED].#627 to be turned and repositioned every 2 hours and PRN. Every shift: Days 07:00 AM- 3:00pm- Afternoons 3:00pm-11:0opm- Midnights 11:00pm- 07:00am. Review of a document titled. CENA DAILY CARE PLAN, with a review date of 8/31/17 revealed Resident #627 was to be turned and repositioned every 2 hours and as needed. Observed resident # 627 on 9/19/17 at 3:00pm sleeping, positioned on her back with a neck brace on, foot boots noted and her legs were elevated on a pillow. CNA sitter Y at her bedside, when asked why the resident had a sitter, the CNA responded the resident is a falls risk. Observed resident # 627 on 9/19/17 at 5:15pm. The resident was sleeping positioned on her back with the CNA sitter Y at her bedside. Observed resident #627 on 9/20/17 at 8:45am. The resident was sleeping positioned on her back with the CNA sitter at the bedside. Observed resident #627 on 9/20/17 at 11:00 am. The resident was sleeping positioned on her back with the CNA sitter at the bedside. Observed resident # 627 on 9/20/17 at 5:20pm. lying on her back sleeping with sitter at the bedside. When sitter Y was questioned as to why the resident is always on her back, the sitter 'Y had no response. When asked if she knew the resident should be repositioned every 2 hours, sitter Y said yes. Sitter Y was asked how she knew, sitter Y stated it is on her care plan. Sitter, Y stated she did not know why she was not repositioning the resident. Observed resident #627 on 9/21/17 at 9:11am. The resident was sleeping positioned on her back, with CNA sitter Z at her bedside. CNA sitter, Z was asked about repositioning resident # 627, she stated I try to reposition her every 1-2 hours. When asked if she was familiar with resident #627 plan of care for turning her she said, no, but me an another aide just moved her pillow from one side of her to another. CNA sitter Z was asked to pull back the covers of resident # 627 and show where the pillows were now in relation to her body. CNA sitter, Z pulled back the covers of resident #627 and there were no pillows on either side of her and she was positioned on her back. Deficient Practice #3 Based on observation, interview and record review the facility failed to ensure pain medications were available and administered timely for one (#608) of 26 sampled residents reviewed for pain, resulting in the resident experiencing excruciating, prolonged pain and discomfort. Findings Include: On 9/19/17 at approximately 11:10 A.M., resident #608 was observed in her room with a visitor (identified as the resident's sister). R#608 during interview stated, I am in pain. The resident's sister interrupted, stating, I came to the facility on [DATE] and talked to several nurses about her pain medications and today they say they do not have her pain medications. R#608 explained, (Nurse F) gave me extra strength Tylenol around 6:00 A.M., but I am supposed to get some other pain medications. During the interview R#608 displayed facial grimacing with her eyes closed and legs shaking due to pain. The resident was asked to assess her pain level on a scale from 1 to 10 with 10 being the worse pain. The resident responded, My pain is a 10 out of 10. The Resident's sister explained, I got here around 9:30 (A.M.), since then (Nurse C) just keeps saying they are working on the prescription. On 9/19/17 at 12:10 P.M., Nurse C was interviewed concerning R#608's pain medications. Nurse C reported that Unit Manager D had just talked to the Nurse Practitioner (NP) about an order for [REDACTED].M., Nurse Y reported she was going to try and help obtain the medication after being informed of the resident's level of pain and distress. At 12:26 P.M., R#608 was observed crying as Unit Manager D informed her that she had to first get the NP to write a prescription in order to get authorization from the pharmacy to take the medication out of the drug back up supply box. R#608 repeatedly stated, I am in pain. Why is it taking so long? At 12:35 P.M., Nurse C was observed at the medication Cart and at this time indicated R#608's pain medication had been given approximately 10 minutes prior. On 9/19/17 at approximately 1:00 P.M., review of the Facility's Authorization Form for one [MEDICATION NAME] tablet documented the medication was pulled from the back up medication box at 12:38 P.M. However the resident's Medication Administration Record [REDACTED].M. Review of the Nurse's Notes for 9/19/17, revealed no documentation that [MEDICATION NAME] was administered late. On 9/21/17 at 8:00 A.M., R#608 reported that again, her pain medication was not administered by the previous Midnight shift staff as ordered. The resident commented that she put her call light on three times within one hour and then had to go to the Nursing station, without a back brace on, to inquire about her pain medication. Review of the MAR for 9/20/17-9/21/17 during the Midnight shift, documented the medication was administered two hours late. On 9/21/17 at 8:30 AM, the Director of Nursing (DON) and midnight shift Nurse F were interviewed. The resident had had arrived to the facility on [DATE] at 3 PM. Nurse F, who reported to duty at 7 PM on 9/18/17, went into the resident's room at 8:30 PM and she was crying and said her pain was at a 10 and I gave her two, extra strength Tylenol. At 10 (PM), she still had pain and was crying. At 10:30 (PM), I gave her [MEDICATION NAME] (narcotic scheduled every 6 hours as needed for breakthrough pain). I came back in a half hour and she still had pain. I came back in another half hour (11:30 PM). She was not crying, but still had pain. I went back in the room a few more times. She still had pain and was agitated. I went back in the room at 4 AM and she was crying and said her pain level was at a 9, so I gave her [MEDICATION NAME] (narcotic scheduled for pain every 6 hours). When asked, nurse F did not explain why she did not go back to the room until 4 AM and why the physician was not called regarding the resident's uncontrolled pain during the night. At 9 AM and 9:30 AM, DON and nurse unit manager 'D' were queried regarding why the resident had received a scheduled [MEDICATION NAME] tablet from nurse F at 4 AM on 9/19/17, had requested a pain pill at 10 AM (from day shift nurse C), but still had not received it that day by 12:30 PM, in spite of the order for [MEDICATION NAME] that she could have received between doses of [MEDICATION NAME]. They said that the delay was due to a mix up with the orders, in which an electronic order was entered in the computer on 9/18/17 by nurse 'C' for one of the medications, but not for the other as she should have. The pharmacy then received a prescription directly from the prescriber for one of the medications in order for the pharmacy to authorize dispensing it, but no prescription for the other as intended. Nurse 'D' provided a slip from the drug back-up supply box noting that a dose of [MEDICATION NAME] was pulled from the box at 12:38 PM on 9/19/17, once the orders were straightened out, resulting in the resident crying in pain and ending up waiting 8½ hours after the 4 AM dose was given, to receive any further pain medication. On 9/21/17 at 3:00 P.M., review of the Admission Record for R#608 documented the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. admission orders [REDACTED]. On 9/21/17 at 6:00 P.M., review of the Facility's Policy Titled: New Orders for Scheduled 11 Controlled Substance revised date of 1/1/13, stated under subsection 3 Schedule 11 controlled substances may be provided only after a hard copy prescription has been received by Pharmacy and is limited to a 5 day supply of medication. If the controlled substance is needed before the Pharmacy can make arrangements for a timely delivery, Facility must fax a request to remove a controlled substance from the emergency drug supply to the pharmacy. Deficient Practice #4. Based on observations, interview and record review the facility failed to administer [MEDICATION NAME] cream (cream for the treatment of [REDACTED].#154) resulting in the potential for ineffective treatment regimen. Findings include: On 9/19/17 at 8:45 a.m., observation was made of R#154 in her private room, lying in bed. Noted hanging on the door was an isolation sign and a red bucket with personal protective equipment (PPE) was observed just inside the residents room. On 9/20/17 at 9:00 a.m., during a review of the facility's infection control program with Nurse T she was asked about the isolation precautions for R#154. Nurse T stated the resident was in isolation for scabies and that she had received the first treatment of [REDACTED]. Nurse T said that a second treatment should have been applied on 9/15/17 per the physicians orders, but the [MEDICATION NAME] was not available from pharmacy at that time. At this time the Medication Administration Records (MAR) dated 9/1/17 through 9/30/17 for R#154 were reviewed with Nurse T. The MAR indicated [REDACTED]. Amount to administer: as directed; topical, the medicated cream was signed out by the nurse as given. The MAR further revealed and entry for the [MEDICATION NAME] cream for 9/15/17 signed out by the nurse as not given, Not administered: Drug/Item unavailable. The MAR indicated [REDACTED]. Nurse T said Yes. It was a delay in treatment. Pharmacy did not send the cream and the nurses didn't follow up on the re-ordering of the cream. Per the manuafctures guidelines [MEDICATION NAME] is the drug of choice for the treament of scabies. Two (or more) applications, each about a week apart, may be necessary to eliminate all mites. On 9/20/17 at 10:30 a.m., record review revealed that R#154 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set Assessment ((MDS) dated [DATE] indicated the residents cognition was intact and required extensive assistance for activities of daily living (ADL's). On 9/21/17 at 11:00 a.m., during an interview with the Director of Nursing (DON-Nurse U) she was asked about medication availability. Nurse U sated, I have no rational as to why the second dose of [MEDICATION NAME] cream did not come from the pharmacy. The nurses should not just document Not administered: Drug/Item unavailable and then do nothing, they should contact the physician and the pharmacy and check on the medication. Review of the facility's policy tilted, Medication Not Available dated 6/15/15 documented, When a medication order(s) is not received or unavailable, the licensed nurse will immediately initiate action in cooperation with the attending physician and the pharmacy provider.

This citation pertains to intake numbers MI 132. Based on interview and record review the facility failed to provide adequate supervision and transfer support to prevent falls for one sampled resident (#804) out of two residents reviewed for falls from a total sample of five resulting in a fall sustaining injury (skin tear, haed abrasion,eyebrow laceration and bruising on hip). Findings include: On 8/10/17 at 1:00 p.m., record review revealed that R#804 was originally admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set Assessment ((MDS) dated [DATE] indicated the resident's cognition was moderately impaired and required extensive two person assistance with toilet transfers. Review of the facility provided Unusual Occurrence reports from 6/19/17 through 7/7/17 ( four falls in 19 days) revealed the following: 6/19/17-Observed on floor. One to One (1:1-close supervision by staff for the resident) monitoring put into place. No injuries noted. 6/26/17-Observed on floor. Pain assessment done and Non-skid pad placed in wheelchair. No injuries noted. There was no documented evidence that R#804 was on a 1:1 at the time of the fall. 7/5/17-Observed on floor. Floor mat down. Low bed. Hip protectors (brief with padded hips). Scratch on right elbow. There was no documented evidence that R#804 was on a 1:1 at the time of the fall. 7/7/17-Fall on to bathroom floor. Resident not to be left alone while toileting. Right forearm skin tear, right eyebrow laceration, right hip imprint bathroom tile. Transferred to the hospital (for a five day hospital stay). There was no documented evidence that R#804 was on a 1:1 at the time of the fall. Review of a physician's note dated 7/5/17 documented, Noted increased lethargy .Nursing says he (R#804) takes his feet off the wheelchair foot pedals and drags them along the floor .not lifting his right leg-leaning to the right. On 7/6/17 review of a Nurse Practitioner's progress note dated 7/6/17 documented, (Resident #804's) wife is very concerned with his increased amount of falls recently .she stated that since he has been off the 1:1, he has been falling more frequently .and that is why she put him in a nursing home because she was unable to care for him at home .discussed wife's concerns with nursing. Review of the care plan titled Falls dated 5/18/16 had an intervention of Assigned 1:1 staff to sit directly beside resident, no bedside table to be placed between resident and staff member with a start date of 1/30/17. There was no evidence of when the 1:1 supervision was discontinued for R#804. Review of the Certified Nurse Assistant (CENA) Daily Care Plan guide (a guide to assist the CENA on individualized resident care) documented on 2/1/17 R#804 was 2 person assist with toilting transfers. On 8/10/17 at 1:30 p.m., CENA A was interviewed regarding the fall that occurred on 7/7/17. CENA A said that she was assigned to the resident that day and had got the resident up and put him on the toilet. The CENA was asked if she had any assistance putting R#804 on the toilet that morning, to which she responded No. The CENA was asked if she looked at the care guide which indicated that the resident required two persons to assist with transfers to the toilet to which she responded, I had just returned from vacation and don't remember looking at the care guide. CENA A went on to say that after putting R#804 on the toilet she then proceeded into the resident room to go make his bed (leaving R#804 unattended on the toilet). The CENA said that is when he fell . I called for the nurse and she came right away. The nurse told me I should have stayed with (Resident #804) while he was on the toilet. On 8/10/17 at 1:45 p.m., Staff Nurse B was interviewed regarding the fall on 7/7/17 for R#804. Nurse B said she heard CENA A call out for help and went to the residents room. She said that upon entering the room, the resident was observed laying on the bathroom floor with an abrasion noted on the top of his head, a bleeding laceration above the right eyebrow, a skin tear on the right arm and the imprint of the bathroom floor tile on the residents right hip. Nurse B stated, I cleaned him up and provided first aide. When the wife came in she wanted him sent out to the hospital, so I got the order to sent him. Nurse B was asked about supervision for R#804. Nurse B stated, he is a two person transfer to and from the toilet and should have not been left unsupervised. On 8/10/17 at 3:00 p.m., the Director of Nursing (DON) was queried regarding the falls for R#804. The DON was asked why a resident with a history of recent falls, documented evidence of lethargy, not lifting his leg and leaning to the right was left unattended on the toilet (putting him a risk for falls) to which she responded We weren't aggressive enough with supervision. On 8/10/17 at 3:30 p.m., review of the Fall Prevention Program dated 7/02 reviewed 12/16 documented, The facility will identify hazards and resident risk factors and implement interventions to minimize resident falls. Each resident is assisted in attaining/maintaining his her highest practical level of function by providing the resident adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the risk for falls.

This citation pertains to intake #MI 857. Based on observation, interview and record review, the facility failed to care plan and implement appropriate, timely interventions for three (#702, #707, #708) of 10 sampled residents reviewed for pressure sores from a total of 27, resulting in the development of pressure sores. Findings include: Resident #702 Observations of Resident #702 were conducted on 12/12/16 at 8:45 a.m., 12:25 p.m., 4:43 p.m., 12/13/16 at 7:35 a.m., and 10:55 a.m. At each of observation, the Resident was in the bedroom, seated in a wheelchair wearing pink and white backless slippers, with both feet directly touching the hard linoleum floor. (Direct pressure on the bottom of the feet.) On 12/13/16 at 10:55 a.m., Resident #702 declined observation of the wound care. On 12/12/16 at 9:45 a.m., Nurse Manager J was asked to identify any Residents on Unit 1 with pressure ulcers. At that time, it was reported that Resident #702 had a pressure ulcer to the left heel. On 12/12/16 at 11:00 a.m., review of the facility's documentation of pressure ulcers identified that Resident #702's current left heel pressure ulcer had developed at the facility. Review of the clinical record identified Resident #702 was initially admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the 5 day admission Minimum Data Set (MDS) assessment dated [DATE], cognition/mood/behavior were not assessed, the Resident required extensive assistance of two persons for bed mobility and transfers, had no weight loss/gain, and was ad risk for pressure ulcer development. Review of the Nursing Weekly (Head-to-Toe) Skin Assessment included: 11/12/16 .L (left) anterior foot .resolved 11/19/16 .A new skin issues, Followed by wound care TX (treatment) L heel. Review of the current physician orders [REDACTED].>11/23/16 .Santyl 250 unit/gram prn to L (left) heel with NS (normal saline) - wrap with Kerlix QD and prn (daily and as needed) Special Instructions: Cleanse (l) medial heel with NS pat dry, apply Santyl to wound bed, cover with dry bulky dressing, wrap with Kerlix QD and prn. 11/23/16 .Heel float boots while in bed. Nursing to remove Qshift and prn to assess skin integrity. There were no treatment orders identified or implemented upon the initial change in the Resident's skin condition to the left heel on 11/19/16, until four days later on 11/23/16. Review of the interdisciplinary progress notes included: On 11/12/16 at 1:59 p.m., (L) anterior foot .resolved. BLE (bilateral lower extremities) and feet dry and scaly. Dermaphor applied ordered QD and prn. On 11/19/16 at 3:36 p.m., Shower given .No skin change noted. This was inaccurate as it had been identified on the aforementioned weekly skin assessment on 11/19/16 as new skin issues. Review of the Resident's Wound Care consultations included two consults, the first which occurred on 12/1/16 (11 days after the identification of the change in skin condition) and the second on 12/13/16. The documentation included: On 12/1/1/6, .Wound #1 Left Medial Heel is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Measurements are 1 cm length x 0.6 cm width x 0.01 cm depth, with an area of 0.6 sq cm and a volume of 0.006 cubic cm. There is a small amount of serosanguinous drainage noted which has no odor. Wound bed is Pale Pink base [MEDICATION NAME] .necrotic tissue mid-core, irregular edges .Treatment Recommendations: Santyl daily and prn - L heel Pressure relief/offloading - Float Heels. (Stage III pressure ulcer is full thickness tissue loss involving damage to or necrosis of subcutaneous tissue.) On 12/13/16, .Wound #1 Left Medial Heel is a Stage 3 Pressure Injury Pressure Ulcer .Measurements are 0.6 cm length x 0.5 cm width x 0.01 cm depth, with an area of 0.3 cm sq cm and a volume of 0.0003 cubic cm .Treatment Recommendations: Santyl daily and prn - L heel Pressure relief/offloading - Float Heels. Review of the Resident's documented Braden Scale Assessments (assessments to determine the Resident's risk of developing skin breakdown) included the following scores (At risk is a score of 15-18; Not at risk is a score of 19 or greater): 9/8/16 (on admission) = 17; 9/20/16 = 20; 10/18/16 = 18; 11/1/16 = 18; 11/14/16 = 16; 11/15/16 = 21; 11/21/16 = 21; 11/23/16 = 19. There were no further Braden Scale assessments completed after 11/23/16. Review of the Resident's skin care plan initiated 9/19/16 and revised 11/23/16 (four days after the observation of the change in skin condition) documented: Problem: Impaired skin integrity x Actual as evidenced by: open area (L) medial heel, h/o (history of) open blister to (L) anterior foot . Interventions included: As of 9/19/16, Turn and reposition frequently As of 9/19/16, Provide measures to decrease pressure/irritation to skin . As of 11/23/16, Heels float boots while in bed. Nursing to remove heel boots Q Shift and inspect skin. Although the pressure ulcer was initially identified by Nurse I on 11/19/16, the intervention to float the heels while in bed was not implemented until 11/23/16 (four days later), and there were no interventions implemented to address the pressure on the heel while the Resident was out of bed and seated in the wheelchair. There was no documentation or care plan implemented which identified the Resident was non-compliant with treatments. On 12/13/16 at 10:15 a.m., Social Worker F was asked about Resident #702's behaviors and denied being aware of any concerns such as refusal or resistance to care. On 12/13/16 at 10:50 a.m., Certified Nursing Assistant (CNA H) was asked about Resident #702's behaviors and reported, She wants to be independent and when she first got here she had them on, but she's non-compliant. CNA H further reported that Resident #702 has been up in the wheelchair upon starting the day shift and spends most of the day up, seated in the wheelchair. On 12/13/16 at 1:55 p.m., the Director of Nursing (DON) was interviewed about the Resident's pressure ulcer. At that time, the DON reported On admit she had a blister to the left heel. When asked about the inconsistent Braden Scale assessments, the DON reported the facility had identified a concern with those as well and had in serviced the nurses. When asked if Resident #702's Braden Scale had been redone after 11/23 (most recent assessment available) since the facility had identified a concern with the completion and accuracy of the assessments, the DON reported she would investigate. When asked about the development of the pressure ulcer to the Resident's left heel, the DON deferred to Wound Care Nurse E. There was no additional Braden Scale assessments provided by the facility by the end of the survey. On 12/13/16 at 2:05 p.m., an interview was conducted with Wound Care Nurse E. When asked about the delay in notification of the identified change in skin condition on 11/19/16, Wound Care Nurse E stated, I was not made aware until 11/23. At that time, when informed of the multiple observations of the Resident seated in the wheelchair with both feet touching the floor with feet donned with slippers, and when asked if the slippers were considered a pressure relieving device, Wound Care Nurse E stated No. When asked if she would consider the placement of the feet in the slippers directly touching the floor (hard linoleum) as additional pressure to the area, Wound Care Nurse E shook her head Yes. When asked if the Resident was known to refuse care or treatments, Wound Care Nurse E reported, She gets up at times alone. She gets dermaphor (lotion for dry, scaly feet) at night that at times doesn't allow, and when she first came in she was but she has no problems with me doing the treatments. When asked how the Resident developed the pressure ulcer if adequate interventions had been in place, given the history of and risk of skin breakdown, Wound Care Nurse E reported, I was surprised myself when I was made aware of it. I'd love to know what happened. At that time, Wound Care Nurse E reported, We just made a referral to therapy to obtain a pressure relieving boot (today). When asked why that hadn't been considered earlier, given the amount of time the Resident spends out of bed and seated in the wheelchair with both feet touching the floor, Wound Care Nurse E offered no further explanation. On 12/14/16 at 2:30 p.m., review of the facility's Skin Protocol dated 4/10/2014 included: .A skin assessment will be completed utilizing the .NURSING WEEKLY (HEAD-TO-TOE) SKIN ASSESSMENT) .Pressure Ulcer: Localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear .Pressure redistribution refers to the function or ability to distribute a load over a surface or contact area .Residents scoring 18 or less on the Braden Skin Risk Assessment, and/or have existing alterations in skin integrity will be provided with (on an individualized basis) pressure redistribution devices for heels . ( ) Resident #707- On 12/12/16 at 9 AM, resident #707 was observed asleep in bed with his head raised all the way up. His arms were folded across the chest and elbows on the mattress. At 1 PM, the resident was asleep in the same position with elbows on the mattress, waiting to be fed. At 3:50 PM, the resident was asleep with his elbows on the mattress. On 12/13/16 at 11:30 AM, the resident's skin was observed with the wound care physician and wound care nurse 'E'. The resident was totally immobile and remained asleep. The resident had large deep purple areas on both heels, developed at the facility that the specialist said were vascular in nature due to poor circulation. The areas were assessed, measured, re-dressed and the specialist stepped out of the room to prepare to see other residents. Nurse 'E' was asked to lift the resident's arms to observe the elbows. The right elbow had a large, deep purple, non-blanchable skin area. When asked, nurse 'E' said that the area was new and she was unaware of it. She called the specialist back into the room to observe the area. The specialist measured the area as 3.2 cm by 6 cm in diameter and said that the area was a deep tissue injury pressure sore. Nurse 'E' told another nurse, Let's get some elbows protectors (pads to relieve pressure) and did not explain why the pads, pillows, etc. were not already in use to relieve pressure. On 12/13/16 at 2 PM, per review of the clinical record for resident #707: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Minimum data sets ((MDS) dated [DATE] and 10/18/16 noted that the resident had moderate to severe cognitive impairment, was non-ambulatory, required extensive assistance for bed mobility and had one stage II (partial thickness skin loss) pressure sore. An Impaired Skin Integrity care plan dated 5/10/16 and on-going, did not include pressure relief interventions specific for elbows. Resident #708- On 12/12/16 at 9 AM, during a tour of the facility, nurse unit manager 'D' said that resident #708 had pressure sores on her legs. When asked how they developed on the legs, she said, She used to keep her legs crossed. The resident was observed to be asleep on a low air loss specialty pressure relief mattress, with lower legs elevated, legs uncrossed and was very thin and frail in appearance. On 12/13/16 at 11:45 AM, the resident's skin was observed with the wound care physician and wound care nurse 'E'. The resident was alert and had immobile lower extremities. The resident had a purple, closed pressure area on the right heel and a necrotic (black, dead tissue) pressure area on the left lateral heel. Dressings were removed from the resident's legs. The specialist said that a pressure sore on the right leg was resolved (healed). The left lateral leg had a long, linear shaped pressure sore measuring 15 cm by 2.5 cm with necrotic tissue. Nurse 'E' said that the wounds had developed at the facility. The resident's wound records were requested. On 12/13/16 at 2:30 PM, the clinical record for the resident was reviewed. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. MDS' dated 6/28/16 and 9/20/16 noted that the resident had severe cognitive impairment, was non-ambulatory, incontinent of bowel/bladder, required extensive assistance for bed mobility, had limited movement to lower extremities and had stage II pressure sores and an unstageable (depth unable to be visualized) pressure sore. Braden (pressure ulcer risk) Scales dated 7/6/16 and 9/27/16 noted that the resident was at high risk. A Braden scale dated 10/7/16 noted moderate risk and on 10/30/16, was again at high risk. Wound notes revealed the following: 8/17/16-open area on right lateral leg measuring 1.8 cm x 1 cm with moderate drainage. (No further documentation prior to 10/29/16 provided regarding the right lateral leg.) 10/29/16-Right lateral leg noted with stage III (full thickness skin loss) pressure ulcer that measured 3 cm in length by the specialist on 11/1/16. Recommendation: Pressure relief/off loading, elevate bilateral lower extremities. Per review of a Risk for Skin Breakdown care plan dated 7/6/16 and on-going, there was no documented intervention to elevate bilateral lower extremities. 11/8/16-right lateral leg stage III, left lateral lower leg stage III measuring 3 cm by .6 cm. 11/15/16-pressure sore remained to the right lateral lower leg. The left lateral lower leg sore increased to 5.5 cm by 1.5 cm at stage III. 11/22/16-left leg sore increased to 10 cm x 2 cm. There were two Unavoidable Pressure Ulcer Assessment forms for resident #708. One form dated 2/26/16 noted that pressure sores were unavoidable. The form was not signed by a physician until 11/22/16. The second form was signed and dated 11/22/16 by another physician. The forms however, did not indicate that if sores developed, they were incapable of healing, even with proper care planning and timely, consistent implementation of appropriate interventions, as evidenced by the right leg sore that was resolved during the wound observation. Wound records noted that on 6/28/16, 7/26/16 and 10/4/16, a right medial leg abrasion (stage II pressure sore), a left buttock stage III pressure sore and a left heel pressure sore had all resolved. On 12/14/16 at 12 noon, when asked about pressure sore development for residents #707 and 708, the Director of Quality Improvement said, We had a change over of wound care nurses in October (2016) and did audits and hired two more nurses. One has not started yet. She said that on 12/5/16, a new program was implemented to signal staff by overhead announcement, to turn and reposition residents to decrease the number of pressure sores. On 12/15/16 at 8 AM, per review of the facility's Skin Protocol dated 4/10/2014: Write an individualized plan of care outlining the preventive program developed specific to resident's risk factors Realizing that even residents with low risk for pressure ulcer development can still be at risk ; For residents requiring pressure redistribution, document use of pressure relief devices and interventions on the care plan. ( )

This citation pertains to intake #MI 807 and #MI 831. Based on interview and record review, the facility failed to provide proper supervision to prevent an elopement from the facility, resulting in an immediate jeopardy (IJ) for one (# 601) of two sampled residents reviewed for elopement risks from a total of four, resulting in the potential for harm related to the resident, who was confused and had exit seeking behavior, leaving the facility unaccompanied and without the facility's knowledge. The IJ was identified on 10/31/16 at 8:30 AM. The IJ began on 8/5/16 at 9:30 AM when resident #601, who was wearing a wander guard (door alarm trigger device), exited the building, past a receptionist, setting off a door alarm that the receptionist thought was triggered by another passing resident. The receptionist then re-set the door alarm without looking at a picture of resident #601 that was prominently posted to alert staff of the resident being at risk for elopement. The Administrator was notified of the IJ on 10/31/16 at 12:15 PM. The IJ was abated on 10/31/16 at 5:30 PM, when the Administrator did a plan of action consisting of termination of the receptionist, staff education, door alarm audits, door breach audits and staff door breach drills. The surveyor confirmed removal by interview and record review. Although the IJ was removed, the facility's deficient practice was not corrected and remained isolated with no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Findings include: On 10/31/16 at 9 AM, the clinical record and hospital record were reviewed for resident #601. The hospital record noted that the resident was admitted into the hospital on [DATE] and presented with increased confusion and memory loss. Hospital therapists noted: Decreased safety awareness, insight and impulsivity and poor cognition. The resident required frequent redirection and verbal/tactile cues to maintain safety, had impaired motor control and confusion. The resident stated that he had no children, however according to his daughter, he suffered from dementia for the past 8 months. Per the admission face sheet, resident #601 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum (MDS) data set [DATE] noted that the resident had severe cognitive impairment, wandering behavior and exhibited physical behavior toward others. On admission, the resident was prescribed Seroquel (antipsychotic) twice daily. An Elopement Risk Assessment completed 8/4/16 by nurse 'A' noted: The resident was disoriented occasionally, wandered in the facility and had a wander guard placed on the right ankle. The elopement risk score was 10. A score of 10 or greater meant At High Risk. Per nursing notes dated 8/5/16 at 2:10 AM, written by nurse 'A': Resident walked to nurses station and stated 'I want to go to my house. How do I get out of here?' Per resident #601's History and Physical dated 8/5/16: The resident was alert and oriented x 1-2, confused, had memory loss due to dementia, poor cognition, forgetfulness and poor insight and judgement. Per a note by the mental health specialist dated 8/5/16: The resident was oriented to person, but not to place and time, recent memory was impaired, had depressed mood and anxiety and was diagnosed with [REDACTED]. The resident's care plans for Falls and Wandering dated 8/5/16 noted: The resident had behavioral concerns, such as noncompliance with requesting assistance and experienced wandering (moves with no rational purpose, seemingly oblivious to needs or safety). The goal: Resident will wander safely within specified boundaries. Interventions included: wander guard to right ankle. Per a nursing note by nurse 'B' dated 8/6/16 at 1:44 AM: Writer made aware by assigned (nurse aide 'G') that she was unable to locate resident in facility at 9:30 PM (on 8/5/16). A search was begun. A nurse on another unit told nurse 'B' that she may have witnessed the resident trying to leave the facility around 8 PM. The receptionist stated that the resident was last seen walking around the facility at about 8:45 PM to 9 PM. Staff searched in and around the outside of the facility and a nurse searched around the resident's home, which was a few miles away. Nurse 'B' called the resident's daughter about the elopement and while on the phone with the daughter, the police called to inform nurse 'B' that they had taken the resident to a local hospital. He was found wandering around with confusion at the local (electronic department store), (opposite a local shopping mall 0.6 miles away) and staff at (the electronic store) contacted the (local) police Daughter told writer that she was afraid that this would happen because one week prior to resident's arrival at facility found resident (who lived alone) sitting in front lawn in his underwear she stated to writer that 'he's determined to get out side because he loves the outdoors and was concerned about his truck' Resident returned to facility with family with elopement bracelet (wander guard) working and signaling alarm upon entrance. (When asked, nurse 'B' said that the resident returned from the hospital about 12:30 to 1 AM on 8/6/16.) At 10 AM, an unusual occurrence investigation for resident #601 was reviewed with the Administrator and the Director of Nursing (DON). The investigation summary noted: On 8/5/16 at 9:50 PM, the receptionist was questioned by nursing staff with the resident's picture present and asked if the resident had been seen by the door or had exited the door. The receptionist recalled seeing the resident leave the facility around 7 PM with (unrelated) visitors and did not believe he was the one who had triggered the alarm, as another exit seeking resident was near the door at the same time. The Administrator said that resident #601 left out of the building among other people. His wander guard triggered the alarm, but a resident, who had a wander guard discontinued a week prior, was passing by in a wheelchair at that time and the receptionist thought this resident triggered the alarm. The DON pointed to the desk by the main door where the receptionist sat and pointed to an area in front of the receptionist where the resident's picture was posted. She said that the picture was posted in clear view because the resident was so new to the facility, rather than keeping it in a binder behind the desk with pictures of other wandering residents. The Administrator said that the receptionist re-set the alarm and did not make note of resident #601's picture. She said that the receptionist was immediately suspended and then terminated following the investigation because of a zero tolerance policy. The resident was placed on one to one supervision until discharge on [DATE]. On 11/1/16 at 8 AM, per review of the facility's Elopement Risk/Secure care policy dated 3/16/16: The licensed nurse assures each resident is identified as elopement risk by placing his/her picture in the book at the nursing stations The licensed nurse places a secure care bracelet (wander guard) on all those residents at risk for elopement When the door alarms, the nearest staff from any location immediately checks the security door, look inside and proceed out the door to the surrounding areas on all sides, go around the corner and be sure no resident exited the building. If no one is in sight, thoroughly check the perimeter (walk around the entire building checking surrounding perimeter). The facility submitted the following plan to remove the immediacy on 10/31/16: Westland Healthcare Center Abatement Plan o Identified resident returned to the facility at 1 am on 8/6/2016 transported by daughter from Garden City Hospital. Physician was notified and physical assessment was completed with vital signs within normal limits, no injuries noted, and in no acute distress. Resident was placed on 1:1 supervision with care plan and care guide updated. Identified resident no longer resides in the facility. o Door alarms were checked for functionality on the evening of 8/5/2016 and were found to be in proper working order and continue to be checked daily. o 14 residents that were identified with wandering and exit seeking behavior were re-evaluated. Secure Care bracelets were immediately checked for placement and functionality. Secure Care bracelets continue to be checked daily by the Charge Nurse. o Photographs of high risk patients were reassessed for placement in the elopement book. Photographs are updated as needed. o Missing resident policy was reviewed and deemed appropriate. Re-education of staff began immediately on the evening of 8/5/2016 with: 17 of 17 receptionist/Business office/ admissions/nursing clerical 65 of 70 nurses have been re-educated 104 of 108 CENA ' s have been re-educated 25 of 25 dietary employees have been re-educated 4 of 4 Maintenance 24 of 25 housekeeping and laundry employees have been re-educated 3 of 3 Social Services 18 of 21 Therapy 1 of 1 Administrator o The elopement risk/secure care policy was reviewed and revised on 8/5/2016, and re-education of the policy has also been implemented. o The Administrator/designee audited employee response time to breach of alarmed doors 2x weekly times two weeks, weekly x4 weeks, then monthly x two months. Information will continue to be brought to the QAPI committee for further review and response as needed. ( )

This deficient practice pertains to Intake number: MI 656 Based on observation, interview, and record review, the facility failed to ensure that a resident who was at risk for falls was provided adequate equipment (sling) during transfer from a mechanical lift from bed to wheelchair for one (#201) of three sampled residents reviewed for falls from a total sample of three, resulting in the the sling straps breaking in two places causing the resident to fall sustaining a left femur (knee) fracture. Findings include: On 5-17-16, during the entrance conference the facility reported incident and five day investigation was reviewed with the administrator. The administrator identified that the resident was being assisted by two aides per the facility's policy for mechanical lift transfers. The sling was checked for good repair and was attached appropriately to the lift. The medium sized sling (purple) was used. Further interview with the administrator at 1:30 p.m. identified that the sling sizes vary significantly depending on the resident size, weight and girth. Upon obtaining additional information from the manufacture it was noted that the resident's most recent weight was within three pounds (196.8 pounds) of the manufactures suggested weight capacity (200 pounds). The administrator felt that the straps were checked and that there were no visible signs of defects. However, we have now established new guidelines and the sling used with this resident (purple) is being used on individuals up to 175 pounds. A review of the residents weight for past 90 days (April 19-197 pounds, March 15-198 pounds, February 13-200 pounds). On 5-17-16 at 10:00 a.m., Resident #201's clinical record was reviewed. The resident was admitted [DATE]. diagnosed included: Dementia, Essential hypertension, Depression and Muscle weakness. Review of Minimum Data Set (MDS and assessments, dated 3-15-16 revealed that the resident had cognitive patterns that were moderately impaired. The resident required extensive one person physical assist with bed mobility and a two person physical assistance with transfers. The care plan dated 9-30-15 indicated that the resident was at risk for injury due to history of falls, impairments in functional mobility .etc. The Care plan approaches included: The use of (mechanical) lift with transfers. A review of the resident progress noted dated 4-22-2016 at 4:28 p.m. states, Resident admitted to hospital, with fracture to left lower extremity .above her knee. At 12:00 p.m., employee 'A', nurse was interviewed. The nurse stated, I had been outside in hallway setting up medication cart when the incident occurred. The aide (employee B) came out the room and informed me that the resident fell from the (mechanical lift). I entered room to assess. The resident was observed sitting on the floor with both legs sitting right and left with complaint of knee pain. I gave her pain medication and left on the floor. The physician and 911 was called, arriving within minutes they immobilized the resident's left leg and transported her to the emergency room . The facility's unusual occurrence report dated 4-22-16 at 10:15 a.m., (completed by employee 'A') was reviewed. The following was documented: Location of incident: resident room next to bed. Type of occurrence: Fall. Equipment involved: 'mechanical' lift pad. Physical assessment: Internally rotated left hip and knee. At 12:20 p.m., employee 'B', the certified nurse aide (cna) assigned was interviewed. She stated, I placed the (mechanical lift) pad under the resident .I used the purple pad for her it was not to big or to small .I checked the sling before use to ensure it was find it had no rips or tears. It broke while lowering the resident into the chair. The resident fell over the lower right strap had broken. The cna was asked what did she feel contributed to the fall? The cna stated, I think the sling was faulty. Afterward I was shown the material on the sling and how it was worn, which would suggest old, brittle and dry material. It should have been replaced. The sling used (in administrators' office) was observed (1:00 p.m.). The sling appeared worn (coloring faded). The strap on right lower side was split in two places, with noted frayed areas along the edges of the strap and loose threads. At 1:15 p.m., the employee 'D' Director of Laundry was interviewed. Employee 'D stated, all slings are washed (not bleached) at temperatures not to exceed 180 degrees (per manufactures recommendation). In laundry we check for tears in mesh/fabric, stiffness in loops/straps and get rid of any damaged slings and exchange for new ones available in central supply. At 3:00 p.m., employee 'C', the certified nurse aide (cna) was interviewed by phone. She stated, Upon entering the room to assist the sling was already in place. I lifted the resident using the (mechanical) lift, I turned it facing the wheelchair while in the air (over the floor). The assigned cna was behind the wheelchair and got it in position. As I began to lower the sling it snapped. I held out my hand, trying to brace her fall, but the resident (#201) fell downward quickly onto the floor. Both cna's were asked during their interview if they followed the facility's protocol related to slightly raising the resident off bed then checking that all loops on the sling are secure prior to moving. It was identified that the loops were checked upon attaching the straps to the mechanical lift, but neither cna identified performing the safety checks before initiating the transfer. The facility policy and procedure for Hoyer Lift transfer written/revised dated 12-16-14 was reviewed. Policy: Residents who require a mechanical lift transfer may be transferred safely by two nursing staff using a . mechanical lift .Procedure: 10. Attach straps to the mechanical lift) securely making sure same loop is used on both sides at top and bottom. 11. Before transferring a patient from the stationary object (wheelchair, commode, or bed) slightly raise the patient off the chair, commode or bed and check that all loops are secure. 12. If any loops are not properly secure, lower the resident/patient back to the chair, commode or bed and correct the problem .etc. ( )

Based on observation, interview, and record review the facility failed to implement interventions to prevent the development of a Stage IV pressure ulcer (full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures) and failed to adequately reposition and provide the appropriate mattress to promote wound healing for one (Resident #703) of two residents reviewed for new or worsened pressure ulcers from a total of 30 sampled residents resulting in the development of an avoidable Stage IV pressure ulcer and the potential for delayed healing. Findings include: On 1/12/16 at 12:00 pm, Resident #703 was observed on his back with the head of the bed positioned at approximately a 30 degree angle. Resident #703 had to remain at a minimum of 30 degree angle due to the presence of a feeding tube to prevent the accidental inhalation of formula. A pillow was observed positioned behind the left side of his back with minimal pressure observed to be off loaded from the coccyx and buttocks. Minimal to no pressure was observed to be offloaded because the resident's buttocks remained rested against the overlay. An Alternating Pressure Pump (APP, a mattress overlay with a firm, waffle shaped exterior) was observed underneath the fitted sheet. On 1/12/16 at 1:30 pm, clinical record review revealed that Resident #703 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set ((MDS) dated [DATE] Resident #703 had severely impaired cognition, and required extensive to total physical assistance with all activities of daily living (ADLs). The assessment noted that Resident #703 was at risk for the development of pressure ulcers, however Resident #703 did not have any pressure ulcers or skin issues. Per the dietary notes dated 9/25/15, Resident #703 had no open areas on his skin. Review of the medical record revealed no initial or interim care plan to prevent the development of a pressure ulcer upon admission. There was no documented evidence that upon admission, Resident #703 was turned or repositioned every two hours or that he was provided off-loading for pressure relief to his coccyx are or buttocks. Review of a Braden Assessment (an assessment used to determine the likelihood of pressure ulcer development) dated 9/24/15, noted that Resident #703 was a new admit with a very high risk of developing a pressure ulcer. There were no interventions documented as being in place at the time of the time of the assessment and there were no documented other measures taken. Further review of the assessment revealed that the plan was to continue with the current plan of care. However, there was no plan of care to prevent the development of pressure ulcers in place at the time of admission on 9/24/15 through 10/7/15. Review of clinical record progress notes documented that on 10/3/15 at 4:17 pm, During brief change resident observed with small (no measurements were documented) opening between buttocks. On 10/4/15 the following was documented, Coccyx 4.0 cm x 1.5 cm pink base, moderate serosanguinous (bloody fluid) drainage, irregular edges. According to the clinical record orders a LAL (low air loss) mattress (not an APP overlay) was ordered on [DATE]. According to the MDS dated [DATE], Resident #703 required total physical assistance with all activities of daily living and had developed a pressure ulcer that measured 9.6 centimeters (cm) x 4.2 centimeters x 3.0 centimeters with slough (rotting tissue) at the time of the assessment. A Pressure Ulcer Care Plan dated 12/30/15 noted to reposition Resident #703 every two hours and use pressure relieving device to bed. Low air loss mattress. Review of the physician wound care notes dated 10/13/15, 11/10/15, 11/17/15, 11/24/15, 12/8/15, 12/15/15, 12/22/15, 12/29/15 and 1/12/16 recommended frequent repositioning (off-loading to promote pressure relief to the coccyx area and buttocks). On 1/12/16 at 2:30 pm, Resident #703 was observed on his back with the head of the bed positioned approximately at a 30 degree angle. A pillow was observed positioned behind the right side of his back. However, there was minimal pressure off loaded (pressure relief) to Resident #703's coccyx area and both buttocks. On 1/13/16 at 10:10 am, Resident #703 was observed on his back with the head of the bed positioned at approximately a 30 degree angle. A pillow was positioned onto the right side of Resident #703's back. When removed by Nurse 'P' to perform [MEDICAL CONDITION] care, only Resident #703's torso was observed to move while the Resident's buttocks remained unchanged. There was little to no offloading of pressure to Resident #703's coccyx area and buttocks. On 1/13/16 at 4:40 pm, Resident #703 was observed on his back with the head of the bed positioned approximately at a 30 degree angle. A pillow was positioned behind Resident #703's back on the left side. There was no off-loading or pressure relief observed to Resident #703's buttocks or coccyx area. On 1/14/16 at 8:40 am, Resident #703's wound care was observed with Wound Care Nurses 'N' and 'O.' Nurse 'O' removed the pillow from behind Resident #703's back and it was observed that Resident #703 received no pressure relief (off-loading) from his buttocks. When this was brought to the attention of Wound Care Nurses 'N' and 'O' no explanation was offered to explain why Resident #703 was not repositioned in a manner to relieve pressure off of the coccyx and buttocks. According to the National Pressure Ulcer Advisory Panel (NPUAP) residents with a high risk of developing a pressure ulcer require positioning that prevents prolonged pressure on body surfaces. On 1/14/15 at 8:50 am, Nurse 'O' and 'N' repositioned Resident #703 onto his right side, Nurse 'O' removed the soiled bandage, and described the wound drainage as moderate amount of serosanguinous drainage. Nurse 'O' described the wound as a Stage IV pressure ulcer that Started from pressure. (Resident #703) was only here for a week before we got a referral regarding his pressure ulcer. Nurse 'O' measured the sacrococcyx wound that extended to both sides of Resident #703's buttocks as 7.4 centimeters in length (cm) x 5.0 cms in width x 1.8 cm deep. The wound also had 3.3 cm of undermining. Both Wound Care Nurses were asked what interventions were in place before the onset of the pressure ulcer, and were unable to identify or explain interventions that were in place to prevent the development of the Stage IV pressure ulcer at the time of Resident #703's admission. Both Wound Care Nurses 'N' and 'O' explained that they would have to review the clinical record to obtain the care plan at the time of admission. Nurse 'N' was asked why Resident #703 was on an APP (Alternating Pressure Pump) overlay instead of the LAL (Low Air Loss) mattress as noted on Resident #703's care plan. Nurse 'N' explained that before the development of the pressure ulcer Resident #703 did not need the LAL mattress but was unable to explain why the LAL mattress was not implemented after Resident #703 developed the Stage IV pressure ulcer. When asked why Resident #703 given the complications such as a [MEDICAL CONDITION] which makes it difficult to reposition the resident and with a gastrostomy tube where Resident #703 has to maintain an upright position placing pressure on the coccyx and buttocks area would not have an LAL mattress Nurse 'N' stated, I will have to look at the clinical record. On 1/14/16 at 10:20 am, Wound Care Nurses 'N' and 'O' were again interviewed and explained that upon admission Resident #703 was on a regular mattress (not an APP overlay or LAL mattress). When asked if a regular mattress was appropriate for a resident at very high risk for the development of a pressure ulcer, Nurse 'N' did not provide a verbal explanation. When asked why Resident #703 who had a Braden score upon admission as being a Very high risk for the development of pressure ulcers and with a number of complications did not have interventions in place at the time of admission to prevent the development of a pressure ulcer neither nurse was able to explain. When asked to explain the difference between an APP overlay and a LAL mattress, Nurse 'N' stated, An APP overlay is used more for prevention and an LAL mattress is more wound driven. When asked why Resident #703 remained on an APP overlay after developing a Stage IV pressure ulcer, Nurse 'N' explained that the facility thought that Resident #703 had a terminal ulcer and that maybe they didn't order the LAL in the beginning because they thought Resident #703 was terminal (going to die). When asked why Resident #703 remained on an APP overlay even though the care plan stated LAL mattress and the physician wound care notes recommended an LAL mattress on 11/10/15, 11/17/15, 11/24/15, and 1/12/16, neither Nurse 'N' nor 'O' provided a verbal explanation. According to the National Pressure Ulcer Advisory Panel (NPUAP) residents with a high risk of developing a pressure ulcer staff are to minimize the time lag between identification of Pressure Ulcer risk and placing the patient on the correct surface. On 1/14/16 at 10:45 am, Unit Manager Nurse 'C' was queried regarding the interventions used to prevent the development of Resident #703's avoidable Stage IV pressure ulcer upon admission and interventions to promote its healing. When asked how she ensured that offloading (providing pressure relief for Resident #703's coccyx and buttocks) occurred during turning and repositioning, Nurse 'C' was unable to provide a verbal explanation. According to the National Pressure Ulcer Advisory Panel (NPUAP) residents with a high risk of developing a pressure ulcer require effective repositioning and turning. When queried further, Nurse 'C' was unable to recall interventions that were in place to prevent the development of the Stage IV pressure ulcer upon Resident #703's admission and stated that when it comes to wound care, I leave it up to the Wound Team. When asked why Resident #703 remained on an APP overlay instead of the LAL mattress that was listed on the care plan as intervention on 10/7/15, Nurse 'C' stated, I know it has something to do with insurance. On 1/14/16 at 4:00 pm, the facility policy titled, Skin Management Policy/Procedure with a review date of 9/2014 revealed, Review the resident's care plan to assess for any special needs of the resident. For a person in bed: Change position at least every two hours or more frequently if needed; Determine if resident needs a special mattress, devices or pillow to raise heels; Raise the head of the bed as little and for as short a time as possible (due to increased pressure placed on coccyx area and buttocks when is a sitting positing) and only as necessary for meals, treatments and medical necessity. The care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate. On 1/14/16 at 5:00 pm, no care plans regarding Resident #703's pressure ulcer prevention at the time of admission were provided by the end of survey. ( )

This citation pertains to intake MI 665. Based on interview and record review, the facility failed to prevent a fecal impaction in one (#501) of one sampled resident reviewed for bowel and bladder concerns from a total sample of four, when Resident #501 displayed symptoms including lack of bowel activity, depressed appetite with weight loss, and abdominal distention, resulting in hospitalization for a fecal impaction and [MEDICAL CONDITION]. Findings include: According to a complaint on file with the department, the facility did not assess or monitor Resident #501 when she lost her appetite, experienced abdominal distention and lower extremity [MEDICAL CONDITION] and was constipated. Resident #501 was transferred to a local acute care hospital on [DATE], where, according to the hospital History & Physical, Resident #501 "...was (found to be) in acute [MEDICAL CONDITION] with the severe [DIAGNOSES REDACTED]. There was a concern for abdominal mass. After having placed a Foley (indwelling urinary catheter), 5 liters of urine came out. She was severely constipated and has received enemas in the emergency room and has been disimpacted. She was severely constipated with impaction...4+ [MEDICAL CONDITION] large...retention of urine may be secondary to fecal impaction?" On 02/25/2014 at 12:00 p.m., Family Member J reported that Resident #501 was hospitalized on [DATE], "impacted with feces and bloated two times her normal size. After she (#501) went to the hospital, they put a catheter in her and drew off 4 liters of urine, and she was so impacted with feces that her abdomen was distended way out. She hadn't been eating. We had care conferences with the facility but it didn't seem like they were doing anything for her." On 02/25/2014 at 10:00 a.m., record review revealed that Resident #501 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #501 was diagnosed with [REDACTED]. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #501 had moderately impaired cognition, was immobile and required extensive assistance with activities of daily living including bed mobility, dressing, eating, toileting and hygiene. Review of Resident #501's bowel records for the months of January and February 2014 revealed that monitoring for bowel activity was only document three days during the month of January 2014 and one day in February 2014: on January 10, 2014 (3:13 a.m.), Bowel Movement (BM): Medium; on January 24, 2014 (10:51 p.m.), BM: Medium; on January 27 (8:18 a.m.), BM: Medium; and, on February 1 (9:40 a.m.) BM: Small. Review of nurses' notes for Resident #501 revealed the following: On 01/25/2014 at 10:58 p.m., "...increased [MEDICAL CONDITION] noted, logged for physician..." On 01/30/2014 at 3:08 p.m., "...Case conference...family wants CBC (complete blood count) to be ordered and liver function tests for resident...information logged for physician..." On 01/30/2014 at 3:14 p.m., "Case conference held with staff and family. Family doesn't want resident to have a peg tube at this time...she was noted to have some swallowing difficulty on a puree diet per SLP (Speech Language Pathologist)...family is concerned about the resident's increased BLE (bilateral lower extremity) swelling...CBW (current body weight) is 158# which has increased by 13# within the past two weeks..." On 01/31/2014 at 10:29 a.m., "...Patient with increased [MEDICAL CONDITION] Bilateral extremities...3+ (noticeably deep pitting) BLE [MEDICAL CONDITION]" On 02/03/2014 at 10:17 p.m., Licensed Practical Nurse (LPN) C documented,"...left side of abdomen is firm...rectal check negative..." On 2/25/14 at 1:47 p.m., LPN C stated, "she (#501) had a slight distended abdomen, it looked uneven ...if anyone (resident) has a distended abdomen, I do a rectal check. I didn't feel anything when I did (#501's) rectal exam, but there was a little amount of soft BM noted." When queried about the facility's policy regarding residents who go multiple days without having a BM, LPN C stated, "My practice is, if I don't see a BM, I do a rectal exam." When asked, LPN C was unsure of the facility's bowel protocol policy. On 02/04/2014 at 10:54 a.m., the nurse's note documented, "...seen in evaluation ...Density left side of abdomen...abdomen slightly distended and firm...no recorded BM in matrix..." On 2/25/2014 at 1:20 p.m., the 200 Unit Manager, Nurse D stated, "we had taken an x-ray (of Resident #501 on 2/4/14) and it showed a pelvic mass and fecal impaction." When queried about the documentation on the bowel records for Resident #501, Unit Manager D stated, "CNAs (Certified Nurse Aides) should have informed us (licensed nursing staff) that she (#501) did not have BMs." According to the Radiological Report completed in the facility, dated 02/04/2014, "...there is a severe fecal impaction in the rectum. Multiple densities are also noted in the rectum..." On 02/25/2014 at 3:30 p.m., when queried about the facility's bowel protocol, the Director of Nurses (DON) explained "when residents go three days without having a bowel movement, the computer automatically issues an alert to the nurses." When asked what was done for Resident #501 when she went multiple days without having a bowel movement, the DON stated, "I can't find it in the documentation. If they addressed it, it should have been documented." On 2/26/2014 at 12:35 p.m., LPN F explained that she was assigned to provide care for Resident #501 on 2/3/14, 2/4/14 and 2/5/14. LPN F stated that "her (#501) abdomen was very large" but LPN F reported that she was more concerned that Resident #501 was not eating. LPN F said, "I asked if they considered getting a peg tube for her (#501)." LPN F said that she had not seen a computer alert related to a lack of BM for Resident #501. On 02/26/14 at 2:45 p.m., LPN F provided a list of weights that were recorded for Resident #501. This list of weights documented that Resident #501's weight in August 2013 was 156 pounds. By 12/11/13, she weighed 139.5 pounds. Her weight decreased to 132.5 by 12/25/14. In January 2014, Resident #501's weight began to increase. The recorded weight for (#501) was 158 on 01/22/2014. According to LPN F, Resident #501 became [MEDICAL CONDITION]. It was unclear why the facility did not initiate the bowel regimen interventions to Resident #501, during the month of January when Resident #501 had almost no bowel activity, no appetite, [MEDICAL CONDITION] and weight gain. Review of care plans for Resident #501, did not reveal a care plan for constipation. According to the facility policy entitled "Preventive Bowel Regimen" dated 11/17/05, "...if no bowel movement in 48 hours stool softener and stimulant, and or [MEDICATION NAME] no bowel movement in 72 hours perform rectal examination to rule out impaction. If not impacted, [MEDICATION NAME] if not already administered, or [MEDICATION NAME] suppository or Magnesium [MEDICATION NAME], or Fleet Phospho-Soda Enema...If impacted and stool is soft, manually remove impaction. Or, if impacted and stool is hard, administer Fleet Oil Retention Enema followed by Saline enema until impaction is resolved..." Review of physicians' orders revealed that Resident #501 was not on a laxative until 02/04/2014 when an order for [REDACTED]. ( ) ( )

Refer to intake MI 691. Based on interview and closed record review, facility staff failed to adequately monitor the amount of feeding consistent with the physician's orders [REDACTED]. Findings: Resident #106, [AGE] years old, was initially admitted to the facility on [DATE], per the Admission Record. Resident #106, per [DIAGNOSES REDACTED]. An MDS (Minimum Data Set) report, dated 7/25/13, documented that Resident #106 required extensive assistance with all ADL's (activities of daily living). A care plan addressing the Resident's nonverbal status stated that the Resident "may respond to simple yes/no questions". CNA (certified nursing assistant) "G", interviewed on 10/1/13 at 4 p.m., stated that Resident #106 would smile to acknowledge staff, shake his head yes/no to answer simple questions, and point with a finger on his left hand to indicate that he wanted something. The CNA said the Resident did not use a call light to summon assistance and had no other way to call for staff if he needed help. Licensed Practical Nurse (L.P.N.) "C", interviewed on 10/2/13 at 2:30 p.m., said that she had never seen Resident #106 use his call light. On 9/10/13, Resident #106, had a physician's orders [REDACTED]. During administration of the feeding on 9/10/13, the Resident accidentally received 1400 ml of formula between 5 p.m. and 9 p.m., per the Administrator, interviewed on 10/1/13 at 2:30 p.m. The Administrator said E.M.S. was called at approximately 10:30 p.m. The resident was transferred to the hospital. Hospital records for Resident #106 were reviewed on 10/3/13 at 9:00 a.m. E.R. Physician Notes documented that the Resident was in respiratory distress on admission, "most likely due to aspiration pneumonitis (enteral feeding in the airway causing pneumonia)" . Residual tube feeding was observed while intubating (insertion of a breathing tube into the airway to allow for drainage or to maintain an open airway) the resident, and there was a return of 400 ml of tube feeding while initially suctioning the resident. A History & Physical report, dated 9/11/13, indicated that the Resident had been transferred to the Intensive Care Unit. A Discharge Summary, dated 9/16/13, stated that Resident #106 had been discharged to inpatient hospice, " . . . as he is actively dying " . The Administrator, interviewed on 10/1/13 at 2:30 p.m., said she reviewed a video which documented all persons who entered Resident #106's room on 9/10/13 between 5:20 p.m. when L.P.N. (Licensed Practical Nurse) "C" hung the enteral feeding for Resident #106 and 10:30 p.m. when E.M.S. was called. According to the video, a laundry employee entered the room at 5:33 p.m. An activities employee entered the room at 5:44 p.m. Podiatry (a specialist in foot care) entered the room at 6:14 p.m. C.N.A. (Certified Nursing Assistant) "G" entered the room at 6:06 p.m., 6:09 p.m., 6:10 p.m., 6:35 p.m., and 7:12 p.m. L.P.N. "C" entered the Resident's room at 9:15 p.m. and several times thereafter. The Administrator, in the 10/1/13 interview, said she checked the feeding tube pump used with Resident #106 on 9/10/13. She said the machine ran appropriately with alarms sounding when indicated. The Administrator said two different types of tubing , used for tube feeding in the facility, were tested running free flow off the pump. One type of tubing took 1 hour and 45 minutes for 1530 ml to infuse. The second type of tubing took 2 hours and 15 minutes to infuse the 1530 ml. The Administrator said L.P.N. "C" was competency tested for administration of enteral feedings, and she performed adequately. CNA "G" was interviewed on 10/1/13 at 4 p.m. He said he had cared for Resident #106 many times prior to 9/10/13. CNA "G" said he changed the Resident's brief twice on 9/10/13 at approximately 5:30 p.m. and at approximately 7:00 p.m. The CNA said he did not press "hold" to temporarily stop the feeding while he provided care because the feeding pump was not "on" either time he changed the resident's brief. The CNA said he did not tell the nurse about the pump not running because he didn't know her schedule or the schedule of the tube feeding infusion. He said, "That night I never saw the pump running." The CNA said his job was only to put the pump on hold when providing care and to place the resident back in an upright position when he finished providing care. L.P.N. "C" was interviewed on 10/2/13 at 2:30 p.m. L.P.N. "C" said she followed the procedure for initiating the tube feeding with Resident #106 on 9/10/13 between 5:15 p.m.-5:30 p.m. She said she connected the tubing to the pump and then waited a few minutes to assure everything was o.k. The next time she visited the Resident was between 9:00 p.m. and 9:30 p.m. Nurse "C" said she entered the room and saw that the Resident's bed was almost completely flat (10 degrees). The Resident had tube feeding on his chin, and it was trickling down to his neck. The Resident's feeding tube was still connected to the tubing from the formula bag, but the tubing was not attached to the pump. Nurse "C" said she did not remember whether there was a clamp on the tubing. Nurse "C" said she disconnected the feeding tube from the formula. She said the bag of formula was almost empty. Nurse "C" said she heard "wetness" and "congestion" when listening to the lungs with her stethoscope. At that time, per Nurse "C", the Resident responded to the nurse with eye contact and did not appear in any distress. Nurse "C" said she placed a telephone call to the physician and described the incident and the Resident's condition. The physician gave orders to hold feedings until the next day and monitor the Resident. Nurse "C" said she continued her medication pass before checking Resident #106 again. When she returned to the room, the Resident had labored breathing, and he did not respond when she called his name. The Resident's abdomen was firm and distended. Nurse "C" called L.P.N. ''D" and L.P.N. "E" for assistance. Oxygen was placed on the Resident. The physician and EMS were called. A crash cart was moved to the Resident's room in case it was needed. EMS responded timely and transported the Resident to the hospital. The Director of Nursing (DON) was interviewed on 10/3/13 at 9:30 a.m. She said the nurse's responsibility regarding tube feeding administration was to assure proper positioning of the resident, to turn the tube feeding on, and to make sure it functioned appropriately until completed. The CNA's responsibility was to make sure that the head of the bed was up and to push the hold button if the resident was receiving a tube feeding during the administration of care. According to the DON, the CNA does not stop or start an infusion. The DON said residents are to be checked at least every two hours, but it is not the nurse's responsibility to check a tube feeding administration every two hours. The DON said CNA's or a nurse could be the one to check a resident every two hours.. When questioned whether Resident #106's inability to call for assistance required any change in care, the DON said that the Resident had received tube feedings for a while and there had never been a problem. ( )

THIS CITATION PERTAINS TO INTAKE MI 817 BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT ACCIDENTS FOR 1 (#102) OF 5 SAMPLED RESIDENTS, ALL REVIEWED FOR SAFE ENVIRONMENT FROM A TOTAL SAMPLE OF 5, WHEN STAFF FAILED TO ENSURE THAT THE BED SENSOR ALARM WAS FUNCTIONAL, RESULTING IN A FALL WITH INJURY (FRACTURED LEFT FEMUR). FINDINGS INCLUDE: REVIEW OF THE CLINICAL RECORD FOR RESIDENT #102 INDICATED ON THE ADMISSION FACE SHEET, DATED 11/2/11, THAT THE RESIDENT HAD [DIAGNOSES REDACTED]. THE COMPREHENSIVE assessment dated [DATE], INDICATED THAT RESIDENT #102 HAD MODERATELY IMPAIRED COGNITION AND BOTH SHORT AND LONG TERM MEMORY LOSS. THE COMPREHENSIVE ASSESSMENT INDICATED THAT RESIDENT #102 WAS NON AMBULATORY AND REQUIRED EXTENSIVE ASSISTANCE WITH TRANSFERS AND SELF-CARE ACTIVITIES. REVIEW OF THE COMPREHENSIVE CARE PLAN DATED 5/16/12, INDICATED THAT RESIDENT #102 WAS AT RISK FOR FALLS WITH INTERVENTIONS TO INCLUDE BOTH WHEELCHAIR AND BED SENSOR PAD ALARMS TO ALERT STAFF WHEN THE RESIDENT ATTEMPTED UNASSISTED AMBULATION. REVIEW OF AN "INCIDENT/ACCIDENT REPORT" DATED 7/08/12, INDICATED THAT RESIDENT #102 fell TO THE FLOOR WHEN SELF-TRANSFERRING FROM BED TO WHEELCHAIR. THE INCIDENT REPORT INDICATED THAT THE FALL OCCURRED AT APPROXIMATELY 5:00 P.M., AND WAS WITNESSED BY EMPLOYEE #1, A LICENSED PRACTICAL NURSE. THE INCIDENT REPORT FURTHER INDICATED THAT THE RESIDENT WAS TRANSFERRED TO AN AREA HOSPITAL WHERE AN X-RAY REPORT REVEALED A "LEFT HIP FRACTURE." ON 8/15/12, AT 11:00 A.M., INTERVIEW WITH THE ASSISTANT DIRECTOR OF NURSING KNOWN AS EMPLOYEE #2, REVEALED THAT AN INTERNAL FACILITY INVESTIGATION HAD BEEN COMPLETED AND RESIDENT #102 HAD GOTTEN OUT OF BED AND ATTEMPTED TO TRANSFER INTO HER WHEELCHAIR WITHOUT STAFF ASSISTANCE. EMPLOYEE #2 STATED THAT THE INCIDENT WAS WITNESSED BY EMPLOYEE #1, A LICENSED PRACTICAL NURSE. ON 8/15/12, AT 1:30 P.M., INTERVIEW WITH EMPLOYEE #1 VERIFIED THAT SHE WAS PRESENT IN THE RESIDENT'S ROOM AT THE TIME OF THE INCIDENT. EMPLOYEE #1 STATED THAT SHE OBSERVED RESIDENT #102 GET OUT OF HER BED, ATTEMPT TO TRANSFER INTO HER WHEELCHAIR, AND FALL TO THE FLOOR. EMPLOYEE #1 STATED THAT AT THE TIME OF THE INCIDENT SHE WAS PROVIDING CARE TO THE RESIDENT'S ROOMMATE. WHEN QUERIED IF THE RESIDENT'S BED SENSOR PAD ALARM HAD SOUNDED WHEN SHE GOT OFF THE BED, EMPLOYEE #1 REPLIED, "NO, I DID NOT HEAR ANY ALARM SOUND." EMPLOYEE #1 FURTHER STATED THAT SHE WAS UNCERTAIN OF THE TYPE OF BED SENSOR ALARM USED FOR RESIDENT #102 AND WAS NOT ABLE TO VERIFY THAT A BED SENSOR PAD WAS EVEN ON THE RESIDENT BED. EMPLOYEE #1 STATED THAT SHE IMMEDIATELY ASSESSED RESIDENT #102 FOR INJURIES AND THE RESIDENT COMPLAINED OF PAIN IN HER GROIN. EMPLOYEE #1 STATED THAT THE PHYSICIAN WAS IMMEDIATELY NOTIFIED AND THE RESIDENT WAS TRANSFERRED BY AMBULANCE TO AN AREA HOSPITAL WHERE SHE RECEIVED treatment for [REDACTED]. REVIEW OF THE HOSPITAL emergency room RECORD INDICATED THAT RESIDENT #102 WAS admitted on [DATE], WITH A PRIMARY [DIAGNOSES REDACTED]." SUBSEQUENT TO THE hospitalization , RESIDENT #102 WAS REadmitted to the facility on [DATE]. THE FALL INCIDENT THAT OCCURRED ON 7/8/12, FOR RESIDENT #102 WAS AVOIDABLE AND RESULTED IN HARM DUE TO THE FAILURE BY THE FACILITY TO ENSURE THAT THE BED SENSOR PAD ALARM WAS FUNCTIONAL AS A PRECAUTIONARY AND PREVENTATIVE INTERVENTION TO ALERT STAFF WHEN THE RESIDENT ATTEMPTED SELF-TRANSFERS AND/OR AMBULATION.

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO CONSISTENTLY ASSESS, MONITOR AND IMPLEMENT MEASURES TO PREVENT THE DEVELOPMENT OF A NEW PRESSURE SORE FOR ONE ( # 708) OF 7 SEVEN RESIDENTS REVIEWED FOR PRESSURE SORES OUT OF A TOTAL SAMPLE OF 30 RESIDENTS, RESULTING IN THE DEVELOPMENT OF AN AVOIDABLE PRESSURE SORE. FINDINGS INCLUDE: ON 4/26/11 AT 9:40 AM, AND AT 11:30 AM RESIDENT #708 WAS OBSERVED ASLEEP SITTING SLUMPED BACKED AND SCOOTED DOWN IN HIS RECLINED GERICHAIR WITH A LAP TRAY IN THE HALLWAY NEAR HIS ROOM. AT 2:00 PM, RESIDENT #708 WAS OBSERVED IN HIS ROOM SLEEPING IN HIS RECLINED GERICHAIR. ON 4/27/11 AT 9:30 AM, AND 11:30 AM. IN THE SAME POSITION. RESIDENT #708 WAS OBSERVED SITTING SLUMPED BACK IN HIS RECLINED GERICHAIR, LAP TRAY INTACT, IN THE HALLWAY NEAR HIS ROOM. ON 4/28/11 AT 10:30 AM, RESIDENT # 708 WAS OBSERVED IN BED ON HIS BACK SLEEPING. ON 4/27/11 AT 9:40 AM, A REVIEW OF THE ADMISSION FACE SHEET AND CLINICAL RECORD REVEALED RESIDENT #708 WAS admitted INto the facility on [DATE], WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET (MDS), WITH AN ASSESSMENT REFERENCE DATE OF 2/18/11, IDENTIFIED THE RESIDENT AS COGNITIVELY INDEPENDENT AND REQUIRING EXTENSIVE ASSISTANCE WITH DRESSING, BATHING, AND TRANSFERS (TWO PERSON PHYSICAL ASSIST). THE MDS ALSO INDICATED RESIDENT #708 WAS "AT RISK" FOR DEVELOPING PRESSURE SORES. REVIEW OF RESIDENT # 708 BRADEN SCALE (PRESSURE ULCER RISK ASSESSMENT TOOL) DATED 2/11/11, DOCUMENTED A SCORE OF 17, WHICH INDICATED RESIDENT #708 WAS A MILD RISK FOR PRESSURE SORES. FURTHER REVIEW OF THE RESIDENT'S CLINICAL RECORD REVEALED NO FURTHER BRADEN SCALE AFTER 3/9/11 UNTIL 4/26/11. REVIEW OF THE ADMISSION NURSING HISTORY AND ASSESSMENT SHEET DATED 2/11/11, REVEALED NO DOCUMENTED EVIDENCE THAT RESIDENT # 708 WAS admitted INTO THE FACILITY WITH PRESSURE SORES. THE SKIN WAS INTACT AND DESCRIBED MULTIPLE BRUISES TO THE RESIDENT'S EXTREMITIES. THERE WAS NO FURTHER DOCUMENTATION OF THE RESIDENT'S SKIN FROM 2/11/11 UNTIL 4/12/11. FURTHER REVIEW OF THE NURSING NOTES REVEALED THE FOLLOWING: 1. ON 4/12/11 AT 5:50 PM: "STAFF NOTIFIED OF REDNESS AND A SORE AT COCCYX AREA, STAGE TWO (II) APPROXIMATELY ? INCHES CIRCULAR WITH YELLOWISH MOIST CENTER." 2. ON 4/13/11 AT 6:10 PM: " SACROCOCCYX AREA INVOLVING BUTTOCKS DEEP TISSUE INJURY WITH THREE OPEN AREAS WITH SCATTERED YELLOW SLOUGH PERI WOUND FRAGILE WITH [DIAGNOSES REDACTED]. REVIEW OF THE WOUND CARE PROVIDER NOTES REVEALED THE FOLLOWING: 1. ON 4/19/11, "UNSTAGEABLE PRESSURE ULCER SACRAL. THE SACRAL ULCER MEASURED 1.4 CENTIMETER (CM) BY (X) 1.0 CM X 0.1 CM WITH A YELLOW NECROTIC BASE WITH MINIMAL SEROSANGUINOUS DRAINAGE OVER A BONY PROMINENCE." THE WOUND CARE PROVIDER'S RECOMMENDATIONS INCLUDED SANTYL AND ALLEVYN EVERY DAY AND AS NEEDED, FREQUENT REPOSITIONING, PRESSURE REDUCTION MATTRESS. 2. ON 4/26/11, "UNSTAGEABLE PRESSURE ULCER SACRAL. THE SACRAL ULCER MEASURED 1.5 CM X 1.0 CM X 0.3 CM, AND MINIMAL SEROUS DRAINAGE." THE WOUND CARE PROVIDER'S RECOMMENDATIONS INCLUDED SANTYL AND ALLEVYN EVERY DAY AND AS NEEDED. ON 4/27/11 AT 2:15 PM, AFTER WOUND CARE OBSERVATION WAS COMPLETED, TREATMENT NURSE "B" WAS INTERVIEWED REGARDING RESIDENT #708 ' S PRESSURE REDUCTION MATTRESS RECOMMENDED BY THE WOUND CARE PROVIDER. NURSE "B" STATED, "A WAFFLE OVERLAY WAS ORDERED BUT HE HAS A FOAM MATTRESS FOR SAFETY FROM FALLS". NURSE 'B" WAS UNABLE TO EXPLAIN HOW THE FOAM MATTRESS REDUCES PRESSURE SORE. ON 4/28/11 AT 2:00 PM THE UNIT MANAGER "N" WAS INTERVIEWED REGARDING BATH AND SKIN SHEETS, AND STATED, "I KEEP AND REVIEW THOSE." HOWEVER, THERE WERE NO BATH AND SKIN SHEETS AVAILABLE FOR 4/1/11 UNTIL 4/11/11, AND UNIT MANAGER "N" WAS UNABLE TO EXPLAIN WHY THEY WERE NOT AVAILABLE. THROUGHOUT THE SURVEY FROM 4/26/11 THROUGH 4/28/11, RESIDENT #708 WAS NOT REPOSITIONED WITH ANY REGULARITY AS RECOMMENDED BY THE WOUND CARE PROVIDER, NOR WAS THE WAFFLE OVERLAY MATTRESS OBSERVED ON RESIDENT #708'S BED AS INDICATED. ON 4/28/11 AT 3:00 PM, REVIEW OF THE FACILITY'S SKIN PROTOCOL PROCEDURE DATED 5/17/10 STATED: "A SKIN ASSESSMENT WILL BE COMPLETED WEEKLY UTILIZING THE BATH AND SKIN REPORT. "A BRADEN SCALE WILL BE PERFORMED UPON THE DEVELOPMENT OF A PRESSURE ULCER." REVIEW OF THE CLINICAL RECORD REVEALED WEEKLY SKIN ASSESSMENTS WAS NOT PERFORMED, NOR THE BRADEN SCALE PERFORMED AFTER THE ONSET OF THE PRESSURE SORE, AS PER THE FACILITY'S POLICY. ( )

THIS CITATION PERTAINS TO INTAKE MI 551. BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW THE FACILITY FAILED TO ENSURE THE SAFETY OF 1 OF 6 SAMPLED RESIDENTS (#501) RESULTING IN AN IMMEDIATE JEOPARDY WHEN RESIDENT #501 fell WHILE BEING TRANSFERRED IN A SEATED POSITION WITH A MECHANICAL LIFT SLING, AND THE TOP STRAP SUPPORTING RESIDENT #501'S HEAD CAME UNHOOKED CAUSING HIM TO STRIKE HIS HEAD ON THE LEG OF A MECHANICAL LIFT, RESULTING IN A SUBDURAL AND SUBARACHNOID BLEED (BLEEDING INTO THE SPACE BETWEEN THE OUTER AND INNER LAYERS COVERING THE BRAIN), A FRACTURED SKULL, AND SUBSEQUENT DEATH AND PLACED 39 ADDITIONAL RESIDENTS, WHO REQUIRED TRANSFERS WITH A MECHANICAL LIFT, AT HIGH RISK FOR SERIOUS HARM, INJURY, AND/OR DEATH. FINDINGS INCLUDE: REVIEW OF A FACILITY "UNUSUAL OCCURRENCE STATEMENT FORM" DATED 2/13/11 AT 12:45 PM DISCLOSED: "STAFF MEMBER 310 ATTEMPTING TO TRANSFER PER HOYER - STATES RESIDENT BECAME RESTLESS WHILE IN HOYER - RES(IDENT) LOWERED FLOOR - AND BUMPED BACK OF HEAD - APPROX(IMATE) SIZE QUARTER. ICE PACK APPLIED WITH PRESSURE DRESSING...". ACCORDING TO THE FORM THE RESIDENT WHO WAS LOWERED TO THE FLOOR FROM THE HOYER LIFT AND HIT HIS HEAD WAS RESIDENT #501. REVIEW OF THE NURSES NOTES WRITTEN BY NURSE #3 DATED 2/13/11 AT 12:45 PM, REVEALED NURSE #3 WAS CALLED TO RESIDENT #501'S ROOM AND FOUND RESIDENT #501 LYING ON THE FLOOR. NURSE #3 DOCUMENTED THE CERTIFIED NURSING ASSISTANT (CNA) TOLD NURSE #3 THAT RESIDENT #501 "HAD INCREASED RESTLESSNESS ON MOVING IN HOYER SLING WHILE TRANSFERRING FROM BED TO WHEELCHAIR WHEN THE TOP HEAD OF THE HOYER PAD CAME OFF BEFORE CNA COULD CATCH. RESIDENTS (RESIDENT #501) HEAD CONNECTED WITH BACK OF HOYER MACHINE ... OTHER STAFF NURSE APPLIED ICE PACK AND PRESSURE DRESSING TO BACK OF HIS HEAD - SHE NOTED COPIOUS BLEEDING". REVIEW OF THE NURSES NOTES DATED 2/13/11 AT 1:45 PM REVEALED RESIDENT #501 WAS TRANSFERRED TO THE HOSPITAL. REVIEW OF THE HOSPITAL "EMERGENCY DEPARTMENT PHYSICIAN NOTES" DATED 2/13/11 REVEALED RESIDENT #501 WAS diagnosed AS HAVING "ACUTE SUBDURAL BLEED AND SUBARACHNOID BLEED AND ACUTE FRACTURED SKULL". REVIEW OF THE HOSPITAL physician progress notes [REDACTED]. REVIEW OF THE FACE SHEET OF THE MEDICAL RECORD REVEALED THAT RESIDENT #501 WAS A [AGE] year OLD MAN admitted to the facility on [DATE]. THE PHYSICIAN ORDER [REDACTED]. REVIEW OF THE NURSES NOTES DATED 2/10/11 REVEALED RESIDENT #501 WAS ALERT AND VERBAL WITH SOME CONFUSION, WAS INCONTINENT OF BOWEL AND BLADDER, AND WAS TRANSFERRED FROM SURFACE TO SURFACE BY WAY OF A HOYER LIFT (MECHANICAL LIFT WHERE RESIDENTS ARE PLACED IN A SLING AND TRANSFERRED TO ANOTHER SURFACE BY MECHANICAL MEANS). IN AN INTERVIEW ON 3/11/11 AT 10:55 AM CNA # 6 SAID SHE AND CNA # 4 WERE TRANSFERRING RESIDENT #501 BY MECHANICAL LIFT FROM THE BED TO THE WHEELCHAIR AND THAT RESIDENT #501 WAS IN THE MECHANICAL LIFT SLING IN A SITTING POSITION. CNA #6 STATED RESIDENT #501 WAS AGITATED AND WAS PULLING AT THE STRAPS ON THE SLING THAT HELPED HOLD HIM IN POSITION CAUSING THE SLING TO SWING AND ROCK. CNA #6 SAID SHE AND CNA #4 WERE LOWERING RESIDENT #501 DOWN TO PLACE HIM IN HIS WHEELCHAIR WHEN ONE OF THE STRAPS CAME LOOSE FROM THE HOOK AND HIS HEAD WENT BACK, HITTING THE LEG OF THE MECHANICAL LIFT. CNA # 6 SAID RESIDENT #501 WAS ABOUT 12 INCHES OFF THE FLOOR WHEN HE SLID FROM THE SLING, HEAD FIRST, ONTO THE LEG OF THE MECHANICAL LIFT. CNA #6 SAID RESIDENT #501 HAD SLIPPED SO THAT, WHEN HE CAME TO REST ON THE FLOOR, THE TOP EDGE OF THE SLING WAS AT THE TOP OF HIS HIPS. CNA #6 SAID SHE HAD GRABBED THE LOOSE END OF THE SLING AND TRIED TO SUPPORT HIS HEAD AND BREAK THE FALL, BUT SHE WAS UNABLE TO KEEP HOLDING IT. AFTER THE FALL CNA # 6 SENT ANOTHER CNA (CNA #4) OUT OF THE ROOM TO GET A NURSE. IN AN OBSERVATION AND INTERVIEW ON 3/11/11 AT 1: 40 PM CNA'S #6 AND #4 REENACTED RESIDENT #501'S MECHANICAL LIFT TRANSFER AND FALL IN AN EMPTY RESIDENT ROOM USING A NURSE MANAGER IN LIEU OF RESIDENT #501. THE "RESIDENT" WAS PLACED IN THE SLING BY CNA #6. CNA # 4 THEN ENTERED TO ASSIST. NO FURTHER CHECKS WERE DONE BY EITHER CNA OF THE SLING STRAPS TO ENSURE THEY WERE SECURELY ATTACHED TO THE HOOKS OF THE MECHANICAL LIFT. CNA # 6 STATED THAT, AFTER RESIDENT #501 HAD BEEN LOWERED SO HIS BOTTOM WAS BELOW THE TOP OF THE MATTRESS, THE LOW BATTERY ALARM OF THE MECHANICAL LIFT BEGAN TO BEEP. CNA #6 REPORTED THAT WHEN THAT HAPPENED, THE RAISING AND LOWERING OF THE MECHANICAL LIFT BOOM SLOWED WAY DOWN. IN A SECOND INTERVIEW ON 3/16/11 AT 12:00 PM, CNA # 6 SAID THEY PROBABLY COULD HAVE ELEVATED THE RESIDENT VIA THE MECHANICAL LIFT AND PLACED HIM ON THE BED, HAD THE MACHINE NOT BEEN IN SLOW MOTION DUE TO THE BATTERY BEING LOW. CNA # 6 DEMONSTRATED, BY USE OF HER HANDS, HOW FAR RESIDENT #501 WAS OFF THE FLOOR WHEN HE SLID OUT OF THE SLING, IT MEASURED 18 INCHES USING A SURVEYOR TAPE MEASURE. REVIEW OF THE MANUFACTURER'S "OWNERS' MANUAL" FOR THE MECHANICAL LIFT USED IN THE TRANSFER OF RESIDENT #501, RETRIEVED FROM THE INTERNET ON 3/17/11, REVEALED THAT "BEFORE LIFTING A PATIENT FROM A STATIONARY OBJECT (WHEELCHAIR, COMMODE OR BED) SLIGHTLY RAISE THE PATIENT OFF THE STATIONARY OBJECT AND CHECK THAT ALL SLING ATTACHMENTS ARE SECURE. IF ANY ATTACHMENT IS NOT CORRECT, LOWER THE PATIENT AND CORRECT THE PROBLEM , THEN RAISE THE PATIENT AND CHECK AGAIN". THAT STEP WAS NOT DONE, EITHER DURING THE REENACTMENT, OR VERBALIZED DURING THE INTERVIEWS WITH CNA # 6 AND CNA #4 REGARDING RESIDENT #501'S FALL. ALSO, THE CHECKING OF THE MECHANICAL LIFT STRAPS HAD NOT BEEN ADDRESSED IN THE FACILITY "HOYER (MECHANICAL) LIFT TRANSFER" POLICY DATED 3/20/08. REVIEW OF THE FACILITY "CLEANING AND INSPECTION OF MECHANICAL LIFTS" POLICY DATED 5/16/08 REVEALED THAT "NURSING WILL CHANGE THE BATTERIES DAILY". IN AN INTERVIEW ON 3/16/11 AT 11:30 AM THE DIRECTOR OF NURSING (DON) SAID A FRESH BATTERY FOR EACH LIFT WAS SUPPOSED TO BE PUT IN EACH LIFT EVERY MORNING. WHEN ASKED HOW SHE KNEW IT WAS DONE THE DON SAID THERE WAS "NO SURE WAY TO KNOW" AS THERE WAS NO TRACKING LOGS TO MONITOR THIS. THE ADMINISTRATOR AND DON WERE NOTIFIED ON 3/21/11 AT 11:13 AM OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 2/13/11 AT 12:45 PM WHEN RESIDENT #501 fell WHILE BEING TRANSFERRED IN A SEATED POSITION WITH A MECHANICAL LIFT SLING, AND THE TOP STRAP SUPPORTING RESIDENT #501'S HEAD CAME UNHOOKED CAUSING HIM TO STRIKE HIS HEAD ON THE LEG OF A MECHANICAL LIFT, RESULTING IN A SUBDURAL AND SUBARACHNOID BLEED (BLEEDING INTO THE SPACE BETWEEN THE OUTER AND INNER LAYERS COVERING THE BRAIN), A FRACTURED SKULL, AND SUBSEQUENT DEATH AND PLACED 39 ADDITIONAL RESIDENTS, WHO REQUIRED TRANSFERS WITH A MECHANICAL LIFT, AT HIGH RISK FOR SERIOUS HARM, INJURY, AND/OR DEATH. ON 3/22/11 THE SURVEYOR VERIFIED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON 3/21/11 THE "HOYER LIFT TRANSFER" POLICY WAS REVISED. 2. ON 3/21/11, 66 OF 141 EMPLOYEES WERE EDUCATED ON THE HOYER LIFT TRANSFER POLICY INCLUDING, A LICENSED NURSE WILL BE PRESENT DURING ALL MECHANICAL LIFT TRANSFERS, PLACING A NEW BATTERY IN THE MECHANICAL LIFT AT THE START OF EACH SHIFT, AND THE LOGGING OF THE BATTERY EXCHANGE ON THE "BATTERY EXCHANGE LOG" WHICH IS ATTACHED TO EACH MECHANICAL LIFT WITH THE DATE, TIME, AND SIGNATURE OF THE STAFF MEMBER. EDUCATION WILL CONTINUE UNTIL ALL NURSING STAFF HAVE BEEN EDUCATED. NO NURSING STAFF WILL BE ALLOWED TO WORK UNTIL EDUCATION ON THE NEW POLICY AND PROCEDURE HAS OCCURRED. 3. BEGINNING 3/21/11 STAFF USING A MECHANICAL LIFT WERE TO ENSURE THAT A FRESH BATTERY IS PLACED IN EACH LIFT AT THE BEGINNING OF EACH SHIFT WITH THE DATE, TIME AND SIGNATURE PLACED ON THE "BATTERY EXCHANGE LOG" WHICH IS ATTACHED TO EACH LIFT. 4. ON 3/21/11, THE REVISED "HOYER LIFT TRANSFER" POLICY WAS ADDED TO THE GENERAL ORIENTATION FOR ALL EMPLOYEES. WHILE THE IMMEDIATE JEOPARDY WAS REMOVED ON 3/21/11 AT 4:44 PM THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF ISOLATED AND SEVERITY OF HARM THAT IS NOT IMMEDIATE JEOPARDY DUE TO ALL STAFF HAD NOT BEEN EDUCATED AND SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY. ( )