Every finding on record at Woodward Hills Health and Rehabilitation Center

This citation pertains to intake: 3063575.Based on interview and record reviews the facility failed to provide timely and comprehensive wound care, including timely wound consultation, dietitian involvement and the identification of wound deterioration for one (R704) of two residents reviewed for wounds, resulting in a transfer to a higher level of care, the need for intravenous antibiotics and surgical wound debridement (removal of devitalized/necrotic tissue from a wound to improve/facilitate healing). Findings include:A review of a complaint submitted to the State Agency (SA) documented in part, . An aide asked a family member to leave during a change, but the family member insisted on staying and discovered two ulcers on. right buttock and sacrum. The nurse promised appropriate treatment, but a week later, the wounds remained unexamined by a wound care nurse, nurse practitioner, or physician. On April 2, 2026 we demanded her transfer to (hospital name) for evaluation, threatening to call 911.A review of the medical record revealed R704 was admitted to the facility on [DATE], with diagnoses that included dementia and hemiplegia and hemiparesis following cerebral infarction affecting the right and left side. R704 was dependent on staff assistance for all Activities of Daily Living (ADLs).A review of a Nursing admission evaluation dated 1/28/26 at 2:04 PM, documented the following in part for the admission skin assessment . Left gluteal fold - moist redness. Right gluteal fold - moist redness. Coccyx - Redness blanchable. Left buttock - redness. Right buttock - redness.A review of a clinical tool that predict the risk of developing pressure injuries assessment dated [DATE] noted a score of 11.0 - High Risk. A review of the Physician orders revealed a skin protectant (antiseptic barrier cream) started on 1/28/26 to be applied to the coccyx and buttocks every shift for . Redness, skin protectant.A review of a care plan titled Resident has MASD (moisture associated skin damage) under breasts, abdominal folds, and groin, red blanchable buttock and coccyx implemented on 1/28/26 noted one intervention provide incontinence care q (every) shift and as needed. Additional interventions were added on 2/3/26 to monitor and document location, size, and treatment to skin injury. Report abnormalities, report evidence of infection such as purulent drainage, swelling, localized heat, increased pain, etc.A review of a Physician order dated 2/18/26 noted to place a low air loss mattress on bed for pressure reduction.A review of the Physician orders, Medication Administration Record (MAR) and Treatment Administration Record (TAR) for March 2026 documented the following:Start date 3/4/26 - Cleanse wound with normal saline, pat [NAME] with gauze, apply Chamosyn (a moisture barrier skin protectant) and leave open to air. Site: Right gluteal. Every day shift for wound care.A review of the medical record revealed no documentation on why the treatment changed on 3/4/26.A review of a progress note created on 4/1/26 and back dated to 3/18/26 at 10:24 PM, noted in part . Skin assessment completed and noted new area of concern to L (left) gluteal fold. WC (Wound Care) consult placed and WC team notified of new areas of concern. Temp (temporary) Tx (treatment) placed until seen by WC. Patient was on an air mattress already. Physician and family notified. Care plan reviewed and updated.A review of the Physician orders, MAR and TAR for March 2026 documented the following: Consult Wound Care: buttocks/coccyx on 3/18/26.Cleanse wound with normal saline, pat dry with gauze, apply medihoney (a medical-grade wound gel), cover with 6x6 boarded gauze, tape and date ever day shift for wound care- Site- coccyx/buttocks. Start date 3/19/26, this order was discontinued on the same day and never signed off as applied.Further review of the March 2026 MAR & TAR revealed the facility staff continued to apply the skin protectant (antiseptic barrier cream) that was initially implemented on 1/28/26 (and continued until transferred to the hospital) and in addition continued to apply the normal saline and chamosyn (a moisture barrier skin protectant) to the right gluteal fold and was discontinued on 3/26/26.A Skin Issue note dated 3/25/26 at 11:03 AM, documented in part . Right Gluteal Fold. Pressure ulcer. new wound. Stage 3 Pressure ulcer. Wound acquired in-house. Staged by: Health care provider. Length (cm- centimeters): 2.01 Width (cm): 3.33 Depth (cm): 0.1 Area (cm2): 5.18. Granulation: 50%, Slough: 50% . mixture of serous and sanguineous fluid.A review of the Physician orders and March 2026 MAR & TAR noted the following order with a start date of 3/25/26- Cleanse wound with normal saline, pat dry with gauze, apply medihoney and cover with silicone absorbent border dressing every day shift for wound care.A review of the medical record revealed no documentation of the staff to have identified the worsening of the wound prior to the right gluteal fold being diagnosed as a stage 3 pressure ulcer.A review of the first documented Wound consultation dated 3/30/26 at 9:50 AM, documented in part . Chief Complaint: Wound care consulted for stage III pressure ulcer to the right gluteal fold. New treatment implemented. Stage III pressure ulcer in the right gluteal fold, current measurement 2.53 cm x 1.42 cm x 0.1 cm, surrounding tissue fragile, no odor, no signs or symptoms of infection or cellulitis, based granular with some necrotic slough present, minimal serosanguineous drainage. Clean wound with wound cleaner, pat dry with gauze, apply Medihoney, cover with silicone absorbent border dressing, change daily and as needed.A review of a care plan implemented on 3/31/26 titled Resident has pressure ulcer UTD (unable to determine) right gluteal area noted the following interventions: Administer treatment per physician orders, monitor and document location, size and treatment of skin injury. Report abnormalities, report evidence of infection such as purulent drainage, swelling, localized heat, increased pain, etc. and notify physician, diet and supplements per order, Wound Care Order- cleanse wound with normal saline, pat dry with gauze, apply medihoney and cover with silicone absorbent border dressing every day shift for wound care.A review of the medical record revealed no documentation of the dietician to have been informed of the wound for a collaborative interdisciplinary approach.A review of a Nurse Practitioner (NP) note dated 4/2/26 at 12:29 PM, documented in part . Son reveals images of right gluteal wound from last night-noted to be worse from prior w (with) surrounding erythema, d/w (discussed with) unit manager-wound care provider/team unable to see patient again until Monday. D/w family-will transfer to ER (emergency room) for urgent evaluation and treatment. Hospital team notified.A review of the hospital medical record revealed the following:An Internal Medicine note dated 4/2/26 at 3:43 PM, . Chief Complaint Patient presents with Wound Check. Presented to ED (emergency department) with complaints of evaluation of wound on her right buttocks. patient received 1 dose of ceftriazone and vancomycin (intravenous antibiotics), 2.4 L (liters) fluid bolus was given and 15 mcg (microgram) fentanyl (synthetic opioid used to treat severe pain) was given as a one time dose. Indwelling catheter was placed in ED. Fatigue, right hip wound. Right buttock pressure ulcer, with discharge. Right-sided gluteal fold pressure wound with surrounding cellulitus. IV (intravenous) fluid LR (lactated ringers) cc/HR (cubic centimeters per hour) x 12 hrs. (hours). Wound/MRSA (methicillin-resistant staphylococcus aureus) culture ordered. Wound care ordered. Blood cultures ordered. General Surgery consulted for possible debridement.A General Surgery consult note dated 4/3/26 at 12:50 AM, documented in part . sent to the emergency department for evaluation of a wound on her right buttock.Patient was discharged from (hospital name) in January of this year after suffering a right vertebral artery thrombosis. She was discharged to a nursing facility. However, her son recently noticed this wound and became concerned that they were unable to care for her appropriately at the facility. Plan for buttock debridement at bedside once consent from family obtained. Pt (patient) admitted under medicine. Multimodal pain control. IV (intravenous) abx (antibiotic).A General Surgery note dated 4/3/26 at 10:33 AM, documented in part . PREOPERATIVE DIAGNOSIS: Right buttock necrotic wound. debride devitalized tissue of the right necrotic buttock wound, including surrounding skin, subcutaneous, and fascia. A healthy bleeding surface of viable tissue was obtained. Following the debridement, the wound measured 4 cm x 4 cm x 4 cm.An Infectious Disease consultation dated 4/3/26 at 11:45 AM, . presented to the hospital for evaluation of wound involving her right gluteal area. She come back from extended-care facility and she has developed significant right gluteal wound. Patient was started empirically on IV vancomycin and IV ceftriazone (intravenous antibiotics). She just underwent debridement of right buttock ulcer by surgery team which involved full-thickness of skin and subcutaneous tissue. IMPRESSION: Infected right gluteal ulcer status post surgical debridement. PLAN: Continue IV vancomycin, Continue IV ceftriaxone.On 8/12/26 at 11:19 AM, Registered Dietician (RD) N was interviewed and asked how they are informed of residents that have a skin impairment or development of a wound. RD N replied they are usually informed at the morning meetings or notified by the wound care nurse. RD N was asked if they were ever informed of R704's wound and RD N stated they would look into the medical record and review the Dietary notes and follow back up. At 11:42 AM, RD N returned and stated they could not find documentation that Dietary was notified.On the day of this survey 8/12/26, the Director of Nursing (DON) was not present in the facility. Covering for the DON was the Administrator.On 8/12/26 at 10:49 AM, the facility's Wound Nurse (WN) I was interviewed and asked how often the Wound Clinician consulted in their facility. WN I replied the Wound Clinician comes to the facility weekly, every Monday. WN I was asked about wound orders and how they are implemented in the residents medical record and WN I replied they would usually change the wound orders after the Wound Clinician examines the resident and change the orders. WN I reported they had recently been hired in July 2026 as the facility's Wound Nurse. WN I confirmed the previous wound nurse was no longer employed with the facility. WN I was asked to look into the medical record of R704 regarding the following concerns- the delay of appropriate preventative wound interventions, the reason for the change in treatment on 3/4/26, the lack of the wound assessment identified wound on 3/18/26, the Medihoney treatment ordered and discontinued on 3/19/26 then restarted days later, the delay in the wound consultation, the staff failure to identify the worsening of the wound and the failure to notify the Dietician and ensure an interdisciplinary collaborative approach. WN I stated they would review the record and follow back up.On 8/12/26 at 12:32 PM, the Administrator was asked about the delay of appropriate preventative wound interventions, the reason for the change in treatment on 3/4/26, the lack of the wound assessment identified wound on 3/18/26, the Medihoney treatment ordered and discontinued on 3/19/26 then restarted days later, the delay in the wound consultation, the staff failure to identify the worsening of the wound and why the failure to notify the Dietician and ensure an interdisciplinary collaborative approach. The Administrator stated they would review the record and follow back up.On 8/12/26 at approximately 1 PM, the Administrator followed back up and provided copies of the Chamosyn order implemented on 3/4/26 and the Medihoney order placed on 3/25/26.On 8/12/26 at 1:17 PM, WN I returned with the same orders that were provided by the Administrator. WN I confirmed the only wound consultation was noted as 3/30/26 and confirmed they were unable to find any documentation of the identification by staff regarding the deterioration of the wound that resulted in the Stage III right gluteal wound.No further explanation or documentation was provided by the end of the survey.

This citation pertains to intake 3096655.Based on observation,interview and record review, the facility failed to provide emergency medical transportation services for an acute change in condition for one (R702) of one reviewed for a change of condition and failed to implement physician ordered daily wound dressing changes for one (R706) of three reviewed for wound care. Findings include: R702Medical record review revealed R702 had a history of diabetes and hypertension and was admitted to the facility on [DATE] for physical rehabilitation secondary for surgical intervention for a right hip fracture from a fall. R702's brief interview of mental status assessed on 6/29/26 documented R702 was cognitively intact.The State Agency received a concern alleging the facility failed to properly transfer R702 to the emergency department after identifying a mental status change in condition.On 8/11/26 at 10:14 AM, the complainant, R702's mother, was interviewed and confirmed on 7/6/26 R702 was to be discharged from the facility and would be transported via non-emergent transportation service. The mother stated they received a call from the facility nurse on 7/6/26 at 11:40 AM. The mother was informed that R702 was lethargic, unresponsive, and remarked maybe it was their blood sugar and were being transported to the hospital. Per the mother, R702 was taken to the emergency department (ED) by non-emergent transportation and just dropped off, despite R702's unstable condition. The mother said once they arrived at the hospital, the hospital staff were unclear what was going on, had administered two doses of naloxone (medication to reverse opioid medication) in the ED, and was later admitted to the Intensive Care Unit (ICU) and required a naloxone drip.On 8/11/26 at 2:59 PM, R702 was interviewed and said on 7/6/26, they had no recollection of what happened. Per R702 they woke up in hospital days later; and were told they had overdosed. R702 said their mom had told them they were taken from the facility by a strange man in a car and dropped off at the door of the hospital. R702 said they were .so out of it.how do I know this guy didn't do something to me?Record review of the nursing progress note dated 7/6/26 at 12:18 PM, by Registered Nurse (RN) D documented .Resident received in bed with eyes closed, writer went into room to take morning blood sugar, vitals, and introduce myself. Resident answered by name but could not answer further cognition questions. attempted to feed resident breakfast and provide orange juice, but resident continued to fall asleep. I attempted to wake resident up to discuss discharge and get documents signed but resident continued to fall asleep. Called UM [sic] (Unit Manager) to come and examine resident, The transport company driver (later identified as driver K) entered during examination in regard to taking resident to an ortho [sic] (orthopedic) appt (appointment) then home. Called MD (Medical Doctor) explain [sic] resident current state and agreed to send resident to hospital.On 8/11/26 at 11:10 AM, RN D was interviewed and confirmed they were not familiar with R702 as a patient and upon initial assessment, R702 appeared, lethargic, drowsy, and would answer to name only. Per RN D, they were so out of it, something was just not right. Per RN D, R702 was to be discharged later that morning, and RN D did not feel comfortable with R702's mentation and contacted Doctor (Dr.) F. Dr. F, informed RN D they saw R702 earlier that morning, that was not their baseline, and to send them to the ED. RN D observed Driver K had arrived to pick up R702 for an appointment/discharge and RN D inquired if they could transport R702 to the ED instead. Per RN D they observed Driver K call their supervisor and authorized the change in destination. Per RN D R702 left the facility very lethargic with Driver K.On 8/11/26 at 11:43 AM, Licensed Practical Nurse (LPN) Unit Manager E said they were called by RN D to look at R702 because there was a concern and wanted to know if they should contact the doctor. Per LPN E, they were not familiar with R702 but saw they were lethargic and appeared there was a problem. LPN E concurred the doctor should be contacted and were later informed the doctor identified a change in condition and ordered R702 to be transferred to hospital. When asked if they knew the mode of transportation R702 was taken to the hospital, LPN E said they did not. Per LPN E it would be expected residents going to the hospital for a change in condition would go on a stretcher with Emergency Medical Service (EMS).On 8/11/26 at 11:50 AM, during an interview and record review of R702's Electronic Medical Record (EMR) with Dr. F, record review documented on 7/6/26 R702 is being seen on the morning of 7/6/2026 for discharge summary.physical medicine and rehab [sic] consult.it seems to have gone so well.leaving a little sooner than expected.At the present time.is quite stable.will be here until later this afternoon.and then appropriate discharge PHYSCIAL EXAMINIATION: alert and orientated.in no acute distress at the present time. Dr. F was interviewed and said they could not recall the actual details of the conversation with the nurse but indicated if their orders were documented as such, then that is what was ordered. Per Dr. F they were not aware of how the resident was transferred to the hospital, that would be nursing judgment but would assume a change in condition, would be transported by EMS.Record review order 7/6/26 at 12:43 PM from Dr. F .Transfer to hospital for lethargy.On 8/11/26 at 12:06 PM, Driver K and Owner of the transportation company M were interviewed. Per Driver K, they arrived at the facility to pick up R702 and was asked by a nurse if they could take them to the ED instead. When questioned if there was explanation of why the change in destination Driver K said none was given. Per Driver K they said R702 seemed stable because they were able to state their name, but had no knowledge of their medical history, baseline mental status, or informed there was a change in condition. Per Driver K, they drove R702 to the ED, went to security desk and dropped them off, and further remarked I did my part. Owner M was questioned if their drivers had any medical training such as Basic Life Support (BLS) and Owner M said most drivers do not and confirmed Driver K was not BLS trained, and their company caters to non-emergency transportation services.On 8/12/26 at approximately 12:45 PM, the Nursing Home Administrator (NHA) was interviewed and according to the NHA, R702's mother had come up to the facility in the evening of 7/6/26, confronted RN D and was very upset about how R702 was transferred to the hospital. RN D had called the NHA and informed them of the concern and then asked if how they sent R702 to the ED was okay. Per the NHA, it was identified that any resident who has a change in condition and requires an elevation in care, are to be sent via EMS. Per the NHA, the Director of Nursing (DON) had followed up with R702's mother the following day and was informed R702 was in the ICU and placed on a naloxone drip. This was confirmed with the DON on 8/11/26 at the start of this investigation. The NHA acknowledged the deficient practice and provided documentation of their investigation noted in part .Due to the resident's failure to respond to cognition questions, the attending physician was contacted, informed of the change, and gave order to transfer the resident to the hospital. The resident was transported to the hospital using a routine, non-emergency wheelchair transport vendor that was already on-site for the planned discharge, rather than being sent via EMS.On 8/12/26 around 1:00 PM, Assistant Director of Nursing (ADON) was interviewed and confirmed education was developed and conveyed to the nursing staff. This included an updated hospital transfer list developed by the DON and stressed the importance that any acute changes in mental status require 911/EMS transport, regardless of routine transport availability. R706Medical record review revealed R706 was admitted to the facility on [DATE] following hospitalization with bilateral lower leg infected cellulitis with blistering and required wound and skin care treatments.On 8/12/26 at 8:22 AM, R706 was observed sitting at the side of bed, both lower legs were wrapped in gauze dressings and dated in black marker 8/9. When questioned how their care at the facility was, R706 had voiced concern their wound dressing had not been changed in a few days.Record review revealed wound orders, documented: Wound Care Order Site: BLE (bilateral lower extremities) 1) Cleanse wound with NS (Normal Saline) 2) Pat Dry with Gauze 3) Apply sterile, non-adherent wound dressing made of petrolatum-impregnated gauze with 3% bismuth tribromophenate (antibacterial dressing used to protect wounds and promote healing) 4) Cover with ABD (padding) 5) Wrap in gauze if indicated 6) Tape every day-shift for wound care-Start Date 07/23/2026.Record review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not document the wounds on the legs were cleansed or dressed on, 8/9/26, 8/10/26, 8/11/26. The dressing on R706 was observed dated 8/9 but was not documented on the medical record.On 8/12/26 at 9:48 AM, R706's assigned Registered Nurse (RN) G was interviewed and during a record review of the MAR/TAR, RN G acknowledged nursing had not documented the dressing changes since 8/8/26. An observation was made of RN G looking at R702's lower leg dressings and confirmed they were last changed according to the date on 8/9. R702 was observed telling RN G these dressings need to be changed. Nobody had changed them in a few days.On 8/12/26 at 10:19 AM, Nurse Practitioner (NP) H was contacted and confirmed the wound care orders for R702's legs were to be done daily and mentioned R702 had brought to their attention that they were not being changed enough. When informed the last dressing on R702 was dated 8/9, NP H replied with frustration, that they had just informed the wound care nurse recently that the leg dressings had be changed daily. When asked if there was any contact from nursing why the dressing was not changed, NP H replied there was no communication.On 8/12/26 at 10:50 AM, Licensed Practical Nurse (LPN) Wound Care I confirmed R702's dressing changes to their lower legs was to be done by their assigned floor nurse. LPN I was made aware of the dressings not being changed, and R702 had voiced concern with them not being done. LPN I confirmed the dressing changes were to be done daily and acknowledged not being cleansed and changed daily was not appropriate and would follow-up.On 8/12/26 around 1:00 PM, the Nursing Home Administrator (NHA) acknowledged that nursing had brought the attention to them that R702 voiced concern and nursing did not perform and document dressing changes as ordered. No further documentation or explanation was provided by the end of the survey.

This citation relates to Intake 3003663. Based on interview and record review, the facility failed to prevent an avoidable fall for one Resident (R903) of two residents reviewed for falls. This resulted in R903 sustaining a brain bleed, a fractured humerus, and a fractured femur, which required surgery and resulted in increased pain and a functional decline. Findings include:A complaint was received by the State Agency on 5/05/26, which revealed R903 was admitted to the facility during April 2026, had a prior traumatic brain injury, and wore a yellow bracelet showing they were at high risk for falls. The report alleged R903 had a fall at the facility on 4/09/26 which resulted in fractured ribs, and a second fall on 4/19/26, which resulted in a brain bleed, fractured left hip, and a fractured left distal (lower) radius (wrist fracture). It was reported R903 was wandering in and out of residents' rooms on the night of their fall, in the early morning (on 4/19/26), which contributed to the major injuries. The complainant reported R903 was in extreme pain at the time of the fall and the nurses said they had to call the physician first, so the family called an ambulance themselves. It was alleged the nurse delayed sending R903 to the hospital which concerned them. It was further reported that the facility did not place R903's sensor alarm consistently and there was no alarm observed in R903's room after their fall. The complainant said R903 underwent hip surgery at the hospital due to their new fracture. Another concern noted was R903's family said they attempted to obtain more specific details about R903's fall from the facility however no additional information was provided. Review of R903's accident and incident report, dated 4/19/26 at 5:00 a.m., revealed, Patient son stated to nurse that his dad reported to him that he had a fall during the night shift. Patient was never found on the floor by staff during the night. Staff reported that he was only seen wondering (sic) during the night shift. Staff also reported to son that patient (R903) has had multiple behaviors including yelling out and hitting the walls and skin in room.Son called 911 prior to full evaluation being completed by nursing staff. Patient sent to hospital for evaluation. The report showed R903 was confused and had memory impairment. Review of the facility census showed R903 had been discharged from the facility on 4/19/26. Review of R903's Minimum Data Set (MDS) assessment, dated 4/08/26, revealed R903 was admitted to the facility on [DATE], with diagnoses including sepsis (severe systemic infection), urinary tract infection, kidney disease, osteoporosis (weak or fragile bones), dementia, rheumatoid arthritis (inflammatory arthritis), lupus (an autoimmune disorder), anxiety, and depression. The assessment revealed R903 was able to eat with set up, required moderate assistance with bed mobility and transfers, and they used a walker for mobility. The Brief Interview for Mental Status (BIMS) assessment showed a score of 8/15, which showed severe cognitive impairment. Review of R903's hospital neurosurgical consult, dated 4/19/26, revealed they were consulted because R903 had a head injury as was on a blood thinner with an intracranial hemorrhage (brain bleed). The report showed R903 was admitted to the hospital on [DATE] after an unwitnessed fall around 5:30 a.m., which required two staff to assist R903 back up. The report revealed R903 had a left distal radial fracture which was casted and a displaced femoral neck fracture (hip fracture). The report showed the bleed was not present on prior imaging at the hospital on 4/09/26 with no surgery indicated. Review of R903's trauma surgery consult, dated 4/19/26, revealed R903 presented with pain after a presumed fall, and per reports from family and facility R903 was confused overnight and was walking around knocking hard on doors, and patient remembered falling at some point and requiring assistance to get up and called his son and complained of pain. This prompted his son to go him, and he presented with left hip and left wrist pain, with the left wrist, left hip, and brain bleed diagnosed at hospital. Review of R903's physical therapy hospital document, dated 4/22/26, revealed R903 required max assistance of two people for bed mobility and was unable to transfer, showing a decline in function prior to second fall. On 6/15/26 at 11:47 a.m. Family Member (FM) G was asked about R903's care at the facility during a phone interview. FM G shared about a week after R903 arrived at the facility he fell in the bathroom and hit his neck, which was bruised, went to the hospital and afterwards R903 complained of pain in his chest and rib, which was discovered a few days later to be rib fractures. FM G reported on 4/19/26, R903 called them just before 6:30 a.m., and said he was in tremendous pain after falling while sitting in a chair. R903 explained R903 said they called for staff and said, Girls; come help me., and no staff came. FM G told R903's spouse to call the facility, who said they could not reach anyone and so FM G headed over to the facility themselves. FM G said they found R903 in his room alone and clarified they had visited R903 the night before and R903's bed was still made, and it appeared R903 was not in bed all night. FM G reported feeling distressed because they had purchased a bed alarm for R903's bed and said they could not find it in the room or underneath R903 in their chair, a green padded reclining chair. FM G believed if the sensor alarm had been in place, it may have alerted staff to R903's fall. FM G said R903 was in too much pain to move and they saw R903's wrist was swollen and Certified Nurse Aide (CNA) F came into R903's room at that point to assist. FM G said they had not seen any staff prior. FM G stated staff were not aware R903 fell and learned from staff R903 was up all night wandering to other residents' rooms. FM G said CNA F could also not move R903 as he was in tremendous pain. FM G said they went to the nurses and said, You need to do an assessment (on R903 urgently), and the nurse (unnamed) said she had to finish her rounds on her beds and then they would call the physician to send R903 if needed. FM G told the nurse R903 was in extreme pain and said R903's wrist was very swollen. FM G said they called their family who agreed with them R903 was in acute distress and needed to go out as soon as possible, so after attempts at nursing intervention they called the ambulance themselves, as they were concerned as nursing staff declined to assess R903, declined to administer pain medications, and declined to call the doctor when R903 he was in 9 - 10/ 10 pain (with 10 the highest pain) on his entire left side. FM G said they were present when EMS (Emergency Medical Services) arrived and the EMS staff had a horrible time trying to get R903 on the stretcher. FM G reported the hospital found R903 had a left hip fracture, a wrist fracture, and a brain bleed. FM G said they let the Nursing Home Administrator (NHA) and facility know about the findings afterwards and requested video footage of what occurred that night, which was not received, and denied receiving a reply. FM G said the staff told them on 4/19/26 R903 was found wandering around and banging on people's doors when they asked further but received no formal explanation. On 6/15/26 at 2:21 p.m., LPN B was asked about any incident on 4/19/26 with R903 when they were working. LPN B said R903's family said he fell and confirmed R903 was wandering on the unit during their shift at night and early morning. LPN B described they and an aide heard R903 yelling and pushing the call light, and said they repositioned R903 in his room, as he was found seated on the footrest of the recliner instead of on the seat, and said he was not positioned well, between 5:00 and 6:00 a.m. LPN B said due to R903's behaviors and steady wandering that night, they had called the Unit manager and asked for a 1:1 sitter (staff for supervision) of R903. LPN B reported they were told, No, as the facility did not do 1:1 sitters and they could not assist, as they were training a new nurse. LPN B stated, I felt like (R903) needed a 1:1 (for safety and supervision due to behaviors). LPN B said R903's unit held up to 20 residents but they were uncertain of how many were there that night. It was unclear with R903's ongoing wandering behaviors at night why he was in his room alone, since he was in their positional chair, which could have been moved outside the room in nursing line of sight, given their wandering behaviors, agitation, and need for increased supervision. On 6/15/26 at 2:36 p.m., Certified Nurse Aide (CNA) F reported during a phone interview there was only one nurse on shift and one nurse acting as an aide the night before when they arrived for the day shift. CNA F said by the time they got there with another aide, they understood why R903's family needed to call an ambulance themselves, because R903's wrist and leg looked broken and they could not move him, around 7:00 a.m. CNA F said they told the nurse and didn't know what the nurse did but R903's family called because no nurse came and assessed R903 for an urgent situation. CNA F said the midnight nurse wasn't doing anything and they and the other aide were concerned. CNA F said the situation happened on the night shift, not on the day shift when they arrived. On 6/15/26 at 2:56 p.m., Registered Nurse (RN) C said on 4/19/26 at shift change they went to assist another resident when R903's family member came out of R903's room and said, Did (R903) have a fall? . RN C clarified they did not receive information about a fall. RN C said many residents were having behaviors that night and they were short staffed. RN C explained there was one aide and one nurse on the unit where R903 resided, and there was supposed to be one nurse and two aides. RN C said this occurred at about 7:10 a.m. and they left at 7:30 a.m., and the facility called them and asked what had occurred. RN C said there was not adequate staff when R903 fell and due to R903's behaviors reported to them R903 could have fallen and needed increased supervision. RN C said it was not possible to get a 1:1 supervision for R903 as there were many residents with behaviors and no extra staff were available. On 6/15/26 at 3:20 p.m. Physician D was asked about R903's falls with injury during their stay. Physician D acknowledged R903 had two falls with injury, and reported R903's first fall was when they fell walking out of the bathroom which resulted in bruising on their left side. Physician D explained initially R903's hospital x-ray showed no fracture but it was redone (a few days later) due to ongoing discomfort and showed fractures (of the ribs). Physician D said R903 had many behaviors when they were in the facility, and R903's family had asked them about R903's medications, especially at night since they were confused and agitated most at night. Physician D said R903's family had asked about adding an antipsychotic medication however they did not want to put R903 on one due to his earlier fall and put R903 on Melatonin ( a natural sleep aide) at night, which was safer. Physician D indicated R903 was on a steroid and had an appointment the day before his fall (which the medical record confirmed on 4/17/26) which might have contributed by causing an acute mental status change, which they believed contributed to the fall on 4/19/26 however earlier acknowledged R903 had behaviors at night during their stay. Physician D clarified they believed R903 must have fallen, as they sustained a hip fracture, and noted R903 had a diagnosis of osteoporosis (weak and fragile bones). On 6/15/26 at 3:39 p.m., LPN E said during a phone interview they were told when they arrived for their shift on 4/19/26 by LPN B that R903 had wandered all night and said he fell and explained they did not know what the earlier shift had done. LPN E said they learned from LPN B that R903 was found hanging off their (positional) chair and an aide and nurse had pulled R903 back into the chair. LPN E said R903 was complaining of pain, said he fell, and CNA F said R903's wrist was swollen and said they had mentioned it to several nurses. LPN E acknowledged they did not do a nursing assessment as R903 was injured on the night shift, and their expectation would have been for the prior nurse to complete an assessment. LPN E explained the typical process would be when a resident went to the hospital a transfer assessment form would have been completed. LPN E clarified 20 minutes after their arrival on shift EMS services came to pick up R903, who FM G called, and explained had not been made fully aware of what occurred by the prior shift nurse, LPN B. LPN E said LPN B had told them R903's sensor alarm was missing at the time of their fall, and they knew R903 had a sensor alarm during their stay for safety. On 6/15/26 at approximately 3:46 p.m., LPN E was asked about staffing. LPN E reported on the night shifts there was typically only one nurse and one aide working, and there were typically supposed to be two nurses working on the unit. LPN E said on the morning of 4/19/26 they needed more staff, as when they arrived they were tossed everything from the previous shift which should have been done, such as completing the risk management report related to R903's fall, which the former DON (Director of Nursing) asked them in a phone call to complete. LPN E explained they respectfully declined, as they were not comfortable completing. LPN E said R903's unit had a higher acuity with many residents who were at risk for falls and higher skilled care needs, and with one nurse it was difficult to give the medications timely, take vitals, and complete wound care. LPN E said this caused the medications to be passed late and wound care was not completed at times and they had told management. It was clarified any missed wound treatments may have been rescheduled. Review of R903's, Summary of Investigation, dated 4/24/26, received from the NHA (Nursing Home Administrator), revealed, Patient Name: (R903). Date: 4/24/26 (of investigation report), BIMS: 11. Date of stay: 4/02/26 to 4/19/26. (R903) is an [AGE] year-old male who admitted to (facility) s/p (status post) hospital stay related to cystitis (bladder infection) with left pyelonephritis (kidney infection) .During the morning hours of 4/19/26, (R903) was showing many behaviors. As can been (sic) seen on the facility camera he was up and wondering (sic) in and out of other patient rooms on multiple occasions with continuous redirection by the staff. The staff also report that the patient was yelling out, (female name) is evil, while striking his arm on the wall in his room. On the morning of 4/19/26, the patient reported to his son that he had had a fall the (sic) recently around 5 a.m. and was having some leg pain. To this point, the family wanted the patient sent out to the hospital for evaluation. The facility received the ER (Emergency Room) records from the patient on 4/19/26 showing that the patient had a left distal (lower) radial (large forearm bone) fracture, a displaced fracture to the femoral neck (femur - large leg bone) of the left hip, as well as trace dependent intraventricular bleep (sic) within both occipital horns (brain bleed in back of brain). The facility staff on the night in question reported no falls. Investigation began immediately. Investigation:.Review of camera footage in the report revealed. A review on the security camera footage (from the investigation report) showed: 4/19/26: 0028: patient (R903) was seen walking out of his room (room [ROOM NUMBER]) across the hall to another patient's room. 0030: patient (R903) was seen walking back to his room at this time.0036: patient (R903) see wandering again down the hall from his room down to room [ROOM NUMBER]. 0055: Staff called down to come redirect patient (R903) from room. (R903) was taken back to his room without issue.0237: Three staff members observed walking towards room, however when writer questioned staff it was determined they went into room [ROOM NUMBER] (another resident's room). 0605: Staff was seen going (sic) patients room. 0652: (Family member) was seen coming into facility and speaking with nurse.0821: EMS arrived to take patient to hospital. A review of facility camera footage report revealed a timeline of observations on R903's hall on the night of 4/19/26. It was noted R903 was redirected back to his room at 0055, and there was no other observation documented until staff went to his room at 6:05 a.m. From the description, no staff were with R903 or in his room from 0055 (12:55 a.m.) to 6:05 a.m. thus a fall could have occurred. R903 was not out on the unit or in their positional chair supervised per description or in visual line of sight, and there was no documentation or evidence of a 1:1 (sitter) provided. This Surveyor was unable to observe camera footage per verbal and email request during the survey, and R903's room itself would not have likely been in camera view. R903's investigation report next summarized witness statements, by LPN B, LPN E and CNA H. Review of LPN Bs witness statement revealed R903 followed them down to another resident's room, and many residents were complaining about R903 wandering during the night. R903 was reportedly in their chair and staff continued to try to reposition him and tried to get him into bed multiple times and he continuously refused. LPN B said they had to go back to R903's room several times to take medicine, and said they saw him hitting his arm off the wall several times during the night. No increased supervision or placing R903 in their chair in the hallway in visual line of sight occurred; from available documentation it appeared R903 slept little. Review of CNA H's witness statement showed R903 was reported as wandering and yelling during the night, and staff had to put R903 back into his recliner, as he was halfway out, per staff report, and put him back in between 4:00 and 5:00 a.m. CNA H said they had to adjust R903's chair as it was tilted forward and in a high position. The camera timeline did not show staff entering R903's room between these times, so it was unclear if the timeline included full camera footage, since the video was not provided upon request. Further review of the investigation revealed conclusions were as follows: .Investigation conclusion: When reviewing therapy notes for this patient as well as witness statements and camera footage showing the patient had independent mobility. Patient has a history of behaviors as noted in his H & P (History and Physical) prior to admission. These items all point to the fact that the patient would be able to get himself up s/p (status post) unwitnessed fall in the room. It is believed this writer that when the patient was found sliding in his chair that this is when he was attempting to get himself back up, as the patient reported to the son that the fall occurred around 5:30 a.m. Patient did not report any pain from his hip or arm to the staff when staff were in the room repositioning the patient. It was validated that all the patient care plan interventions were in place at the time of his reported fall. Signed by the NHA. Review of R903's fall risk evaluation, dated 4/09/26, showed fall risk factors including incontinence, history of recent falls, occasional incontinence, minimal unsteadiness, requiring supervision or steadying assistance, attempts to self-transfer, impulsivity, lack of understanding of physical and cognitive limitations, the use of at-risk for falls medications, and forgetting or not always using their assistive device, as well as predisposing medical conditions. There was no documentation of ongoing behaviors being a fall risk factor. Review of R903's Accident and Incident report, dated 4/09/26, revealed they had a fall on 4/09/26 and were sent out emergently on 4/09/26, with wearing improper footwear listed as one of the contributing factors. The improper footwear was not clarified further. Review of R903's progress note, dated 4/16/26, revealed R903 went to the hospital on 4/16/26, and returned with a diagnoses of rib fractures, which may have been attributable to the fall on 4/09/26, as they remained in pain after the fall on 4/09/26. Review of R903's physical restraint evaluation, dated 4/10/26, revealed R903 had a bed (sensor) alarm in place, which was not considered as a restraint. This may be used on a bed or in a positional chair, to alert staff when a resident attempted to stand up. Review of R903's nursing progress note, dated 4/19/26 at 8:20 a.m., LPN B, revealed, (R903) was wandering around throughout the night into other pts (residents) rooms. (R903) was redirected many times but continued to wander. Pt (R903) was also in room hitting on room walls, yelling and screaming, '(female name) is evil'. This was not reported in the camera footage description. Review of R903's nursing progress note, by LPN E, dated 4/19/26 at 7:50 a.m., revealed, Upon arriving on shift, previous nurse notified writer that resident (R903) had been up throughout the night wandering down the hallway and into patient rooms. She (nurse) stated that the resident told her he had fallen. She stated that when she went into the room herself, and the aide, (they) had seen him practically out of the chair and they lifted him back into the seat. She (nurse) also stated that he had been banging on the walls. When writer observed patient (R903), he was sitting in his recliner calmly with son in the room. The son had asked the morning aide if there was a physician on duty and the aide asked the writer (nurse). Writer stated that there aren't typically physicians (available) over the weekend. He (R903's son) then asked about getting an x-ray for his father because his wrist was swollen and how long it would be. He also asked to have his father (R903) sent to the hospital because he was in pain. Writer notified son that I would have to contact the physician and I would be in to assess the resident's (R903's) status. The son had called 911 to transport his father himself. At this point, the first responders were walking down the hallway before the writer could assess the patient. Resident was transferred to (name of hospital) at approx. 8:15 a.m. with son at bedside. Wife and (Physician D) notified of transfer. Review of R903's nursing progress note, dated 4/17/26 at 15:16 (4:16 p.m.), revealed, Patient (R903) returned from appointment alert and verbal. Consult report, x-ray show severe RA (Rheumatoid arthritis) Rt (right) shoulder. Cortisone injection given. Follow up as needed. Pain assessment endorsed to another nurse on the unit. Review of R903's nursing progress note, dated 4/16/26 at 00:48, revealed, R (right) rib 5th and 8th rib has nondisplaced fracture. MD (physician) is notified and aware. Orders for pain relief already in place. Will continue to monitor for safety. Review of R903's physician team progress note, by the Medical Director, Physician D, dated 4/15/26 at 11:36 (a.m.) revealed, (R903) is an [AGE] year old gentlemen with a history of hypertension, (elevated blood pressure), rheumatoid arthritis, lupus., atrial fibrillation (heart rhythm disorder) not on anticoagulation.and vascular dementia.(R903) sustained a fall getting out of bed and going to the bathroom; (R903) lost his balance and fell on his right side, had a hematoma right forehead and right parietal area, also complain of pain right shoulder in right ribcage on April 9, he was transferred to hospital where CT (Computed Tomography) scan of the brain revealed no fractures, was transferred back to the facility. (R903) is seen again today for continued pain in right shoulder with movement and right lower chest wall pain with movement, denies having much pain if he is still, family concerned about having an injury from fall although CT scan of brain and cervical spine were negative for any injury the same with right shoulder x-ray and right ribcage x-ray; he is currently only on Tylenol 650 mg (milligrams) 4 times a day. Also, family concerned about (R903) having intermittent confusion in the evening compatible with sundowning (condition where residents with dementia become more confused and disoriented in the evening and at night). (R903) is making slow progress in therapy; oral intake is marginal.(R903) is alert, oriented to year and month, able to name the president, does not appear to be in distress.Urinalysis was essentially unremarkable with white blood count 6-10 and negative bacteria. Assessment and plan: 1. Status post fall with right shoulder and right ribcage pain. (R903) continues to complain of pain especially with movement, will continue Lidoderm patch to right lower ribcage however will obtain a right ribcage x-ray to rule out a hairline fracture that was not seen on previous x-ray. (R903) does not have good range of movement in his right shoulder with no deformities or bruising seen; continue ketoprofen gel to right shoulder and continue scheduled Tylenol 650 mg 4 times a day; will add tramadol (controlled pain medication) 25 mg every 6 hours as needed for severe pain only. 2. Critical illness myopathy; (R903) is making slow progress in therapy, continued to have intermittent confusion and element of depression and poor participation.3. History of traumatic brain injury status post metabolic encephalopathy during recent hospitalization, continue frequent reorientation and encourage family involvement and support as above to try to avoid narcotic treatment. Review of R903's behavioral care provider note, dated 4/13/26, showed R903 was alert and oriented x 3, however expressed concerns about AMS (altered mental status) at that time, and the provider did not recommend a GDR (Gradual Dose Reduction) of their psychoactive medication which was deemed appropriate at that time for Zoloft (an antidepressant) and Melatonin (a natural sleep aide medication). On this assessment, R903's BIMS score was noted as improved to 11/30 (moderate cognitive impairment and was diagnosed with an adjustment disorder. Review of Physician's I's visit progress note, dated 4/13/26 at 13:57 (1:57 p.m.) showed R903 was seen for Right shoulder and Right rib pain from the fall on 4/09/26, which was addressed with Tylenol 650 mg four times a day. Narcotics were not prescribed at that time due to risk of delirium. Review of R903's skilled nursing home to hospital transfer form, dated 4/09/26, revealed R903 was at high risk for falls, and had an admitted diagnoses of repeated falls. Review of R903's assessment page showed there was no hospital transfer form dated 4/19/26 or after, when they went to the hospital emergently, so their status at time of discharge was unclear, including pain level, skin concerns, etc. Additionally, there were no separate skin or pain assessments, and the vitals page also had no notation of pain status. On 6/17/26 at 1:46 p.m., an email was received from the Nursing Home Administrator (NHA), indicating camera footage was no longer available for the night of R903's fall with injury, which lead to the emergent transfer and subsequent hospitalization. Review of R903's behavioral logs, received from the NHA via email on 4/15/26 at 3:10 p.m., revealed 17 blank entries where no behavior observations were documented. The entries present showed no behaviors. Review of R903's Care Plan showed they were at high risk for falls, with no increased supervision noted. On 6/15/26 at approximately 4:20 p.m., the NHA was made aware of the concerns related to the need for increased supervision for R903 on 4/19/26, given staff reported they needed additional assistance, R903's ongoing and increased behaviors on 4/19/26, lack of complete resident assessment, including pain and their presentation. The NHA explained they verified via camera footage there were three staff on the unit that night (4/19/26) and three were scheduled however denied having camera footage available when asked for review. The NHA respectfully disagreed with the supervision concerns respective to R903's ongoing and increased behaviors on and prior to 4/19/26, which resulted in two avoidable falls with injury. Review of the policy, Fall Management Guidelines, revised 2/03/26, revealed, The purpose of this policy is to provide guidelines to assist with fall risk identification and fall management of residents in the facility. Policy overview: .To provide guidelines to assist with fall risk identification and fall management of residents in the facility.General guidelines.Intrinsic factors that may increase the risk of falls include but are not limited to:.cognitive impairment, delirium.Extrinsic factors that may increase the risk of falls include, but are not limited to: assistive devices,.personal clothing or footwear.the MDS (assessment) identifies several possible indicators for falls or fall risk, including: fell in the past 30 days,.wandering.

This citation relates to Intake 2962105. Based on interview and record review, the facility failed to ensure a change in condition was addressed timely for one Resident (R901) of three residents reviewed for change in condition. Findings include:On 3/20/26 at 8:35 a.m., a complaint was received by the State Agency, which alleged the facility failed to respond timely to a change in condition, when R901 experienced a significant medical decline on 5/16/25 in the middle of the night. The complainant described R901 was rushed to the hospital by the daytime nurse (on 5/17/25) after they received a phone call from the night nurse, who reported R901's breathing was fluctuating, their blood pressure had fallen, and they were not responding as normal. The complainant reported they received a phone call from the daytime nurse who told them they were rushing R901 to the hospital, as when they walked into R901's room they could tell that something was wrong with him, with his eyes rolling in the back of his head and called for the ambulance immediately. The complainant alleged the nighttime nurse should have sent R901 to the hospital when the nighttime nurse called them, as all the signs were there that something was off and wrong with (R901). Review of R901's Minimum Data Set (MDS) assessment, dated 4/28/25, revealed R901 was admitted to the facility on [DATE], with diagnoses including coronary artery disease (plaque in the heart arteries), hypertension (high blood pressure), deep vein thrombosis (blood clot in deep veins of leg), kidney disease, diabetes, dementia, seizure disorder, depression, metabolic encephalopathy (brain dysfunction caused by metabolic disturbances), sepsis (severe life-threatening infection), lung disease, sarcopenia (loss of muscle mass), and cystitis with hematuria (inflammation of the bladder with blood in the urine, often after a urinary tract infection). The assessment showed R901 required supervision with eating, and maximal assistance for bed mobility and transfers. The cognitive assessment showed R901 had cognitive impairment and was sometimes able to understand others and make themselves understood, with no hearing or vision impairment. The assessment revealed R901 was on an anti-depressant medication, an anti-coagulant (blood thinner to treat/prevent blood clots), insulin (for diabetic management), and a seizure medication. The bladder section of the assessment showed R901 had a urinary catheter and was frequently incontinent of bowel. Review of R901's vitals page for pulse (heart rate) showed elevated pulses as follows: 5/17/2025 3:18 (a.m.): 123 bpm (beats per minute) - irregular - new onset.5/17/2025 3:00 (a.m.): 133 bpm - irregular - new onset.5/17/2025 at 2:34 (a.m.): 120 bpm - irregular - new onset. It was noted since admission, R901's pulses ranged from 51 to 85 bpm, so this was atypical for them, and beyond the clinically acceptable range (typically 60 to 100 bpm for a resting pulse, per professional standards of practice). Review of R901's vitals chart for blood sugar showed elevated blood sugars as follows: 5/16/2025 21:36 (9:35 p.m.): 356.05/16/2025 21:52 (9:52 p.m.): 356.0 It was noted during the week prior (back to 5/10/25), R901's blood sugar ranged from 140 at lowest to 280 at highest (with a typical range of 100 to 200 for persons with complex health, per professional standards of practice). Review of R901's assessment page showed a sepsis screening was done on 4/27/25 and 4/29/25, however no sepsis screening was done at the time of these findings. Review of R901's nursing progress note, dated 5/17/25 at 2:34 (a.m.), revealed, Writer called into residents room by CNA (unnamed), res (resident) appeared to not be at normal baseline; VS (vital signs) obtained: 96/64 (blood pressure - in low normal range), 120 P (pulse - elevated), 20 RR (20 respiration rate of breaths per minute - high normal range), 184 BS (blood sugar). Pt (R901) responds to painful stimuli but would not vocalize any discomfort, res had a large BM (bowel movement) at this time. 0600 midodrine given (generic name of medication to increase blood pressure) and BP rechecked: 0300 (3:00 a.m.) bp 111/75 (increased). Pulse still tachycardic at 128 (pulse increased) and respiration rate increased to 28 (higher than typical range of 12 to 20 respirations (breaths), per professional standards of practice). Updraft given (breathing treatment). 0318 (a.m.). res continues to have increased RR (respiratory rate), BP 111/81, 126 P (highly elevated pulse). Left a voicemail for (name of) Nurse practitioner and on call staffing #, awaiting call back. It was unclear why midodrine was given about 3 hours before the next scheduled dose at 6:00 a.m. Review of R901's May (2025) Medication Administration Record (MAR) revealed their midodrine with 10 mg (milligram) dosing was scheduled three times a day, at 0600 (6:00 a.m.), 1100, and 1600. And to hold for systolic blood pressure of 140 or above (top number). There was no physician order found of an extra dose ordered on 5/16/25 or 5/17/25 or an additional dose added. Further review of R901's progress notes showed no documentation of any follow-up with R901, or a provider, until 5/17/25 at 6:29 a.m., which showed, NP called (back), order for CBC (complete blood count - lab)/CMP (complete metabolic profile - lab) and CXR (chest x-ray). There was no documentation of any observation of R901 at that time, or their clinical presentation. Continued review of R901's progress notes sequentially revealed no new progress note until 5/17/25 at 14:23 (1:23 p.m.), by Licensed Practical Nurse (LPN) A, which showed R901 had a marked decline: Writer went into resident's room to check his BS (blood sugar) for the morning med pass; upon going into the room, writer observed the resident lying in bed but unresponsive to commands. Resident was in bed with his eyes opened and mouth breathing. Writer got a full set of VS (vital signs) on (R901). BP (blood pressure) was 105/70, P42/125 (ranging from low of 42 to high of 125 - erratic pulse) resident pulse was going up and down when get patient. VS O2 (oxygen saturation) 92% on room air (range 92% to 100% clinically acceptable per professional standards of practice) and temperature 100.5 (fever, as 97.0 Fahrenheit to 99 F is the clinically acceptable range per professional standards of practice). Writer reached out to DR (doctor - unnamed) and supervisor on shift. Resident sent out to (name of hospital). Family was also notified of resident status. R901's next nursing progress note in chronological sequenced noted on 5/17/25 at 14:46 (p.m.): Physician team discharge note. Late entry: pt (patient) transferred to ED (Emergency Department) for unresponsiveness. R901's subsequent progress notes and census page showed they did not return to the facility. Review of R901's progress notes on 5/16/25 (the day prior to their hospitalization) showed R901 was alert and able to answer general questions during their rehab practitioner visit at 13:26 (1:26 p.m.), revealing, .Pt (R901) seen lying in bed. He stated that he is participating in therapy. He denies concerns. Denies pain. Denies SOB (shortness of breath), chest pain, and abdominal pain. Foley (catheter) is intact, but hematuria (blood in urine) is noted. Later in the day, pt was examined again. Foley is clearing up. D/w (discussed with) nursing. General: Well-developed, well-nourished (patient), who appears the stated age. Patient in no acute distress.Catheter intact with yellow urine.Neurological: Alert and oriented x 2 (name and place) with cues.Comprehension: No word finding difficulty. Following simple commands. Poor safety awareness noted.Psychiatric: Calm and cooperative. This progress note revealed R901's discharge plan was to return home and revealed R901 had a fall on 5/07/25 with no injury or hitting their head. Review of R901's next progress note, dated 5/16/25 at 19:59 p.m. (7:59 p.m.), showed, Small amount of blood observed to foley cath (urinary catheter). Writer attempted to apply securement; resident was agitated at the moment and refused. NP (name) aware of blood. Writer observed throughout shift and blood subsided. No complaints of pain during shift). There was no notation of R901's catheter being removed, or further concerns with their catheter. The next progress note was dated 5/17/25 at 2:34 a.m., earlier referenced, which showed no catheter concerns. Review of R901's progress notes showed no practitioner or physician visit during the time of R901's decline (5/17/25) before R901 was sent out to ED emergently. Review of R901's SNF (Skilled Nursing Facility)/ NF (Nursing Facility) to Hospital Transfer Form, by LPN B, revealed R901 was full code (full resuscitation life wishes). The date of transfer showed: 5/17/2025 13:00 (1:00 p.m.). The reason for their emergent transfer was marked, Change in mental status. There was no mention of change of fluctuating vital signs, including pulse, respirations, or fever, or their unresponsiveness documented on this emergent transfer document. On 4/22/26 at 12:50 p.m., the Medical Director, Physician C, was asked about R901's incident when they were sent out emergently on 5/17/25. Physician C said they reviewed R901's medical record prior to the interview and based on the clinical judgment of what they were seeing, they would have sent R901 out earlier due to a change in condition. Physician C indicated they had not been contacted, as it was the facility protocol for an on-call provider to be contacted on the weekends (5/17/25 was a Saturday). Surveyor reviewed R901's progress notes and vitals of concern with them as well. Physician C clarified based on the clinical judgment of what they were seeing, R901 needed to go to the hospital sooner, after reviewing the nursing progress note dated 5/17/25 at 2:34 a.m., by a former nursing staff. Physician C reviewed R901's May (2025) MAR with Surveyor and concurred midodrine should have not been given early. Physician C was asked if there was anything the facility could do going forward to prevent a recurrence of a similar incident, and responded, Staff education. Upon further review, Physician C indicated it was unclear why R901 was not sent out sooner when the practitioner on call ordered a medical work up, and why there was a gap of time on 5/17/25, from 2:34 a.m. until 1:00 p.m. (per EMR), with no additional clinical presentation or reattempts to contact a provider documented. When asked about the midodrine being administered three hours earlier than the morning dose, Physician C said the former LPN probably did not have to give it (early). Physician C understood there was no documentation which showed it should have been given earlier. On 4/22/26 at 1:09 p.m., LPN A, was asked during a phone interview about the incident which occurred on 5/17/25 at 1:43 p.m., when they sent R901 to ED emergently. R901's progress notes were reviewed with them, per request, because they initially did not recall the incident. After the review, LPN A stated based on what occurred prior to them coming on shift, R901 should likely have been sent out sooner, because the nurse documented a change in condition. LPN A' said with a high heart rate, they could have had sepsis going on, or something they could not treat, and noted R901 was responding only to painful stimuli. LPN A did not recall the prior nurse giving them this information at shift change and clarified they saw R901 in the morning, not in the afternoon, per their note, but they did not know a time and said they should have documented a late entry note. LPN A explained when they walked in R901's room they went out quickly to get their vitals machine, and R901's heart was going everywhere, from the 40s to the 120s (pulse 40 bpm to 120 bpm range). LPN A said they were calling R901's name and R901 was not responding to them and was staring into space. LPN A clarified they couldn't get anything out of them (a response) and immediately called 911. LPN A said they didn't reach the physician until afterwards and were not sure of the exact time. LPN A said they should have written their progress note in the morning. LPN A denied any catheter concerns and said they would have documented if removed. On 4/22/26 at 1:25 p.m., LPN B was asked about their transfer form and to explain the detail of R901's emergent hospital transfer, and their observations. LPN B said they could not recall the incident or writing the note or the timing and details. LPN B believed they were only assisting LPN A with the documentation. On 4/22/26 at 1:37 p.m., R901's EMR related to the incident, including R901's vitals, progress notes (since 5/16/25), and transfer note were reviewed with the Director of Nursing (interim DON). Based on their review, the DON acknowledged R901 should have been sent out emergently sooner, when R901 was found responsive only to pain in the 2:34 a.m. progress note, with a change of condition documented. The DON was asked to review R901's May (2025) MAR and about the early dosing of midodrine for high blood pressure, as there was no documentation of the physician being contacted or any additional as needed order. The DON concurred the midodrine was administered 3 hours early with no clinical reason, or provider contact documented and said they had concerns based on what they read had occurred. On 4/22/26 at 11:47 a.m., the complainant was left a voicemail, which was not returned during the survey. On 4/22/26 at 2:10 p.m., the Administrator was asked regarding the results of the investigation, however did not wish to respond. Review of the policy, Change in Condition Notification, issued 8/09/23, revised 2/02/26, revealed, It is the policy of the facility to notify the resident, his or her attending physician/practitioner, and the resident's designated representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident, the resident's physician/ practitioner, and the resident's designated representative when there is.a significant change in the resident's physical, mental, or psychosocial status, such as deterioration which includes life-threatening conditions or clinical complications. A need to alter the resident's medical treatment significantly, such as a new treatment, discontinuation of current treatment due to adverse consequences, an acute condition, or exacerbation of a chronic condition. A need to transfer or discharge the resident from the facility, including discharge against medical advice. A room change or roommate change. A change in resident rights. Death of a resident. The nurse will document in the resident's medical record information relative to the resident's change in medical/mental condition or status (i.e. assessment, notifications, interventions, and response). If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted.Definitions: Significant change of condition: Means that the condition will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions and that it impacts more than one area of the president's health status, and required interdisciplinary review and/or revision to the care plan. Immediately: For purposes of notification, immediately is determined to be as soon as practicable after the resident has been adequately assessed, necessary emergent care or treatment is rendered, and the resident's safety has been secured. (For example, if a resident receives a laceration, the nurse should assess the resident, control the breathing, and manage the resident's pain before (they) would be required to contact the physician.) Review of the policy, Standards of Practice, revised 2/03/26, revealed, Residents at the facility will receive services, treatment, and care in accordance with professional standards of practice. Residents care policies are developed, revised, and updated as needed, to ensure they are consistent with current professional standards of care and implemented within the facility. Facility symptoms, guidelines, policies, and procedures are developed, revised, and updated as needed, to ensure they are consistent with professional standards of care and implemented within the facility. Facility staff education, training, and skills checklists are developed, revised, and updated as needed, to ensure they are consistent with current professional standards of care and implemented within the facility.

Based on observation and interview, the facility failed to ensure the storage of medications were labeled with name of medication and resident specific identifiers in three of five medication carts reviewed for medication storage.Findings Include:On 3/3/26 at 8:36 AM, the 600-hallway medication cart was observed for medication storage with Registered Nurse (RN) C and the Director of Nursing (DON) and revealed on the bottom of drawer two, nine loose medications and bottom of drawer three observed two medications loose with no medication or patient identifiers. Five vials of albuterol (medication for breathing treatments) were observed lying on base of drawer with no patient identifiers. RN C and the DON acknowledged loose medications are not proper storage in the medication cart and disposed per protocol.On 3/3/26 at 9:05 AM, the 100-hallway medication cart was observed for medication storage with Licensed Practical Nurse (LPN) B and revealed on the bottom of drawer two, four unidentifiable medications and no resident identifiers and drawer three was observed with four unidentifiable medications and no resident identifiers. LPN B acknowledged the loose medications and commented they would dispose of them.On 3/3/26 at 9:55 AM, the 200-hallway medication cart was observed for medication storage with LPN E and revealed the bottom of drawer two, nine unidentifiable medications and no resident identifiers. The last bottom drawer had one vial of an unknown medication, stated by LPN E it was a respiratory medication and had no resident identifier.On 3/3/26, the DON was informed observations detected on the 600-hallway medication cart had similar findings on the 100 and 200 medications carts.Review of the facility policy titled Medication and Treatment Storage dated 2/3/2026 documented: It is the policy of this facility to ensure accurate labeling and dating of medications and treatments for safe administration and safe and secure storage.

Based on observation and interview, the facility failed to maintain general cleanliness and repair of a cabinet surface, laundry equipment, and plumbing fixture resulting in an increased potential for contamination affecting all residents. Findings include: On 03/02/2026 at 10:10 AM in the laundry soiled linen room observed 2 plastic carts for transport of soiled linens that had debris and soil (used gloves, food wrappers, sticky brown substance) covering the interior bottom of the carts beneath the false fabric bottom. The same 2 carts were cracked and not smooth and easily cleanable around the top perimeter. The metal attachments (attached near the 4 corners of each bin) for the false bottom were worn and difficult to remove for cleaning of the bin and had worn to have sharp edges. During this observation when staff L was asked about these carts he said that some new carts had been purchased and were in use for clean linen transport and that more were needed. He indicated that the expectation was that the carts were cleaned daily at the end of the shift. On 03/02/2026 at 2:50 PM observed in 1st floor Cranbrook pantry room that the floor of the cabinet under the sink was water damaged and the surface was peeling and no longer smooth and cleanable. During the observation when interviewed about the damaged surface, staff I said he was not aware of this and would add it to the task list. On 03/02/2026 at 2:55 PM observed in 2nd floor [NAME] pantry room that the drain tubing from the ice bin was submerged below the rim of the drain line and not properly protected with an air gap. During the observation when interviewed about the required air gap, staff I said he was not aware of this and will make the needed adjustment to the drain line.

Based on observation, interview and record review, the facility failed to ensure residents were assessed for safe self-administration of medication for three residents (R27, R134 and R138) of three residents reviewed for self-administration. Findings include: R134 On 3/02/2026 at approximately 11:26 a.m., R134 was observed in their room, sitting in their wheelchair. R134 was observed to have two antacid tablets in a medication cup on their bedside table. R134 was queried regarding the medications, and they indicated the Nurse had left them there for them after they received their morning medications. R134 was asked if the Nursing staff had left medications for them to take before and they reported they had. On 3/2/26 the medical record for R134 was reviewed and revealed the following: R134 was initially admitted to the facility on [DATE] and had diagnoses including Congestive heart failure and Dysphagia. A review of R134's medications revealed the following: Calcium Carbonate Tablet Chewable 500 MG (milligrams) Give 2 tablet by mouth three times a day for Indigestion; Upset Stomach before meals Further review of R134's medical record did not reveal any Physician orders to self-administer medications. R134's careplan did not indicate that self-administration was part of their plan of care or that R134 had been assessed for safe self-administration of medication. R27 On 3/2/26 at 10:50 AM R27 was observed in their room in bed. It was further observed a medication cup containing seven pills was placed at the corner of their bedside table. At that time, R27 was asked about the pills and had no response. They were then more specifically asked if staff entered their room with the pills and left them on the table without them taking them and replied, I guess so. On 3/2/26 at 10:53 AM, a review of R27's electronic medication administration record was conducted and revealed Nurse 'V' documented seven medications scheduled for 9 AM as given. On 3/2/26 at 11:02 AM, an interview was conducted with Nurse 'V'. They were asked about the pills observed on R27's bedside table and said R27 told them they were going to take them. They were then asked if they remained in the room and observed R27 take their medications and had no response. On 3/3/26 at 11:27 AM, a review of R27's clinical record revealed they had no assessment, physician's order, or care plan for self-administration of medications. On 3/3/26 at 11:42 AM, an interview was conducted with the facility's Director of Nursing (DON). They were asked about the process to determine whether a resident was appropriate for self-administration of medications and said residents would be assessed, physician's orders would be written, and a care plan would be in place. They were then asked if a resident was not appropriate or assessed for self-administration, should the nurse administering the medications remain with the resident and said they should. Finally, the DON was asked to provide a list of residents in the facility who self-administered medications and said they could run a report and would provide it. On 3/4/26 at 9:16 AM, a review of facility provided report for residents where were assessed and deemed appropriate for self-administration of medications was conducted, however; R27 was not on the list. R138 On 3/2/26 at 9:30 AM, R138 was observed in their room eating their breakfast. An observation of the sink and countertop in the room revealed four bottles of various supplements including a supplement for sleep, a multivitamin, a bottle of protein supplements and a bottle of magnesium supplements. On 3/3/26 at 11:25 AM, a second observation of R138's room continued to reveal the four bottles of supplements on the sink countertop. On 3/3/26 at 11:48 AM a review of R138's clinical record revealed they had no assessment, physician's order, or care plan for self-administration of medications. On 3/4/26 at 9:16 AM a review of a facility provided report for residents where were assessed and deemed appropriate for self-administration of medications was conducted, however; R138 was not on the list. A review of a facility provided policy titled, Medication-Self Administration reviewed 2/2026 was conducted and read, .Each resident is offered the opportunity to self-administer medications. If the resident requests to do so, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident .The Medication Self-Administration Safety Screen in (electronic medical record name) will be completed by the licensed nurse .If it is deemed safe and appropriate for a resident to self-administer medications this is documented in the physician orders, medical record, and the care plan .

Based on interview and record review, the facility failed to ensure the resident rights of one Resident (R127) of three residents reviewed for resident rights, related to privacy with opening their own mail. Findings include:On 3/03/26 at 11:03 a.m., a group meeting was held with facility residents to review the facility resident council process. On 3/03/26 at approximately 12:00 p.m., R127 reported two weeks prior they received their mail opened, which upset them. R127 clarified the mail opened by facility staff was a statement from their insurance company, Medicaid or Medicare. R127 said, It (the letter) was addressed to me. It was a statement about payments. R127 explained they had only been made aware by a surveyor there was a resident council meeting and concern review process. R127 said they were grateful to be heard. R127 was interviewable and oriented to themselves, their situation, place, and could tell time. Review of R127's profile revealed they were their own responsible party, with bills marked. Review of R127's Minimum Data Set (MDS) assessment, dated 1/21/26, revealed R127 was admitted to the facility on [DATE], with diagnoses including diabetes, heart failure, lung disease, depression, and malnutrition. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 11/15, which showed R127 had moderate cognitive impairment. On 3/04/26 at 1:41 p.m., the Business Office Manager, Staff G, was asked if they had opened any of R127's mail, with the Director of Nursing (DON) present. Staff G acknowledged they had opened R127's application for Medicaid and said they had been authorized by R127's attorney. Staff G reported R127 had let them know this bothered them afterwards when R127 had received the letter opened. Staff G said they and R127 had a conversation regarding their concern. Staff G and the DON reported they understood the concern related to residents' rights to open their own mail. Review of the policy, Resident Council Meetings, revised 3/03/26, revealed, This facility supports the rights of the residents to organize and participate in resident groups in the facility. Resident group is defined as a group of residents that meets regularly to discuss and offer suggestions about facility policies and procedures affecting resident care, treatment, and quality of life, support each other, plan resident and family activities, participate in educational activities, or for any other purpose.8.Examples of meeting topics: Resident rights.Resident mail procedures. Review of the Resident Information Handbook, viewed in the general admission contract documents provided to residents upon admission, revealed on Page 31: . Our facility. Just as you value your choices, we value respecting them. (Facility) person-centered care focus allows for individuality, preferences, and dignity coupled with a sense of community. Our philosophy of person-centered care means that you will receive the help and support you need to reach your health care goals without losing choice and autonomy. The handbook further revealed on Page 34, .Mail: Mail and other deliveries will be brought to your room.

Based on observation, interview and record review, the facility failed to ensure routine bathing was provided for two residents (R186 and R197) of five residents reviewed for activities of daily living (ADL's). Findings include:R186 Clinical record review revealed R186 was admitted to the facility on [DATE] and had significant complications with diabetes including peripheral neuropathy (nerve damage causing lack of feeling) and resulted in a Left Below Knee Amputation (LBKA). R183 had declined in Activities of Daily Living (ADL's) related to mild cognitive impairment, but was alert, orientated and able to make their needs known. The Minimum Data Set (MDS) assessed on 2/9/26 revealed a Brief Interview Mental Status (BIMS) score of 12/15, indicating cognitive impairment. On 3/02/2026 at 10:10 AM, initial introduction and observation with R186 revealed them alone in room in their wheelchair. Their hair was disheveled; all fingernails were observed long and dirty. A strong odor of urine was noted which became more intense closer to R186. A clothing protector was observed heavily soiled with dried food, liquid matter that covered them from neck to waist and the navy-blue t-shirt sleeves and pants were observed stained with dried food and crumbs. Food and crumbs were also observed amongst the wheelchair seat. R186 spoke of their left leg prosthetic and wanted to share how their right foot was healing. R186 voluntarily removed their right sock, revealed very dry skin flaking off onto the floor and a strong pungent odor was immediately noticed. A shower sign posted above their bed read shower days were Monday and Thursday between 3:00 and 11:00 PM. When questioned when their last shower was, R186 stated showers are an issue and could not recall the last time they had one. On 3/02/2026 at 11:36 AM, R186 was observed in same clothes with dirty clothing protector self-propelling down the common hall. R186 had a table tray and a box of microwaveable lasagna. As they passed by, R186 was observed interacting with another resident, and the smell of urine odor was very apparent and became stronger the closer contact with R186. On 3/2/26 at 1:23 PM, a review from the last 30 days (February 2026) for R186 documented Task Shower/Bath: 2/2/26 at 21:55 charted Not applicable. No reference to meaning. 2/9/226 at 22:09 a shower was performed. 2/23/26 at 21:44 residents refused. On 3/3/26 at 2:30 PM, R186 were observed in room sitting in their wheelchair entertained with their electronics. Upon entrance the notable smell of urine was identified and became stronger the closer contact. R186 was observed wearing the same soiled navy-blue colored t-shirt with soiled pants as observed on 3/2/26. When asked if a shower was provided the night before, R186 replied no. When asked if they refused, they replied no, they .just never got it. On 3/3/2026 at 2:30 PM, an interview with the Unit Manager Registered Nurse (RN) D was asked to aid to locate where the Certified Nurse Assistants (CNA's) would document progress notes regarding showers for R186. RN D was observed looking into R186's electronic medical record (EMR) and indicated they could not locate where the CNA's document in the Task area and would have to ask the Director of Nursing (DON). When questioned if there was any documentation elsewhere, such as a progress note, RN D replied there was nothing in the progress note, but there might be a completed a shower sheet. RN D explained the process for shower sheets that once completed, the CNA places into a bin at the nurse's station and then medical records picks them up the following day. RN D said CNAs can document on the shower sheet if a resident refuses. On 3/3/26 at 2:40 PM, Medical Records Coordinator U retrieved the last 30 days of shower sheets for R186 and revealed only one shower sheet was archived. The sheet was dated for 2/23/26 and was checked resident refused .resident stated he will take it on Thursday. On 3/3/26 at 3:30 PM, a clinical record review of R183's progress notes authored by RN D documented an effective date of 3/2/26 19:45 Nursing Progress note Resident offered shower by assigned CNA refused scheduled on 3 separate attempts. Writer will follow-up on 03-03-2026. On 3/3/26 around 4:00 PM, The DON and RN D were asked to come to the conference for an interview. When inquired how previous requested documentation that they claimed was unavailable was now in R186's progress, RN D said they had learned how to chart in the Task area and called the CNA from 3/2/26 and back dated the progress note that R186 had refused. RN D remarked that when a resident refuses three times, the CNA tells the assigned nurse, and sometimes they as the unit manager must assist if there are three refusals. When questioned if this was the case on 3/2/26, then why was this not communicated during the interview, RN D did not provide an explanation. Final record review revealed for the month of February 2026, a total of eight opportunities for a shower, R186 was documented have been only offered only three showers. Record review of R186's care [lan documented resident has an ADL self-care performance deficit r/t <sic> generalized weakness and fatigue, left BKA. Initiated on 8/20/25. Interventions for R186 included Bathing/Showering: Check nail length and trim and clean on bath day. Continue to offer showers on shower day. R197 On 3/02/2026 at approximately 9:44 a.m., R197 was observed in their room, lying in their bed. R197 was asked if they had any concerns regarding their care in the facility and they reported they were only being offered bathing once a week and the schedule was supposed to be twice a week. R197 reported that they ask staff about their shower days they receive a blank stare. R197 was asked if they have refused showers/bathing and they reported they had not. On 3/3/26 at approximately 11:06 a.m., R197 was queried if they have been offered any bathing and the indicated that nobody has told them about their showers. R197 reported that the staff dodge the question. On 3/2/26 the medical record for R197 was reviewed and revealed the following: R197 was initially admitted to the facility on [DATE] and had diagnoses including Infection and Inflammatory reaction due to due to internal right knee prosthesis. A review of R197's MDS (minimum data set) with an ARD (assessment reference date) of 2/6/26 revealed R197 needed substantial assistance from facility staff with bathing. A review of R197's careplan revealed the following: Focus-ADL self-care deficit related to generalized weakness, impaired mobility 2/2 (secondary)R (right) knee PJI (prosthetic joint infection) Date Initiated: 01/31/2026 .Interventions-Assist to bath / shower as preferred per shower schedule and as needed. Date Initiated: 01/31/2026 . A review of R197's documentation of being offered bathing for the prior 30 days revealed the following: Certified Nursing Assistant (CNA) Task documentation revealed R197 was provided shower on 2/5/26. One bathing refusal was noted on 3/3/26. A review of R197's shower sheets revealed one shower sheet in which R197 received a shower on 2/20/26. A review of R197's skin assessments reveled R197 received a shower on 2/24/26. On 3/4/26 at approximately 1:31 p.m., the Director of Nursing (DON) was queried regarding the provision of routine bathing, and they reported that bathing should be offered twice a week. The DON was informed of the lack of documentation that R197 was being offered bathing twice a week and they repeated that bathing should be offered twice a week. At that time, the DON was asked to provide any additional documentation for R197's bathing and none was received before the end of the survey.

This citation pertains to intake 2745432. Based on interview and record review, the facility failed to ensure medications were available for administration and Physician orders were clarified with the Physician/pharmacy for one resident (R204) of one resident reviewed for medication administration, resulting in R204 having missed doses of their Physician-ordered medications. Findings include:On 3/2/26 a concern submitted to the State Agency was reviewed which alleged R204 was not administered their medications according to the Physician's orders. On 3/3/26 the medical record for R204 was reviewed and revealed the following: R204 was initially admitted to the facility on [DATE] and had diagnoses including Malignant neoplasm of brain and Malignant neoplasm of lymph nodes of multiple regions. A progress note dated 8/21/25 revealed the following: A progress note revealed the following: 8/21/2025 16:34Nursing - Progress Note-Note Text: Radiologist ordered Namenda titration pack for 1 month, then 10 mg (milligrams) daily for 5 months. writer reviewed correct dosing with pharmacist from .pharmacy A Physician order dated 8/21/25 with a start date of 8/22/25 revealed the following: Namenda Titration Pak Oral Tablet (Memantine HCl) Give 5 mg by mouth one time a day for dementia for 7 Days -Start Date- 08/22/2025 0900 -D/C Date 09/05/2025 A second Physician order with a start date of 8/30/25 revealed the following: Namenda Titration Pak Oral Tablet (Memantine HCl) Give 5 mg by mouth two times a day for dementia for 7 Days -Start Date- 08/30/2025 2100 -D/C Date- 09/05/2025A review of R204's August and September 2025 medication administration record (MAR) revealed R204 was not administered doses of their namenda on 8/23, 8/24, 8/25, 8/30, 8/31, 9/1 and 9/2. A review of R204's electronic medication administration (eMAR) notes pertaining to their nameda administration (EMAR) revealed the following: 08/22/2025 14:24 Type: Physical Medicine and Rehabilitation: 8/22: Pt (patient) was started on a namenda titration pak by radiation/oncology .08/23/2025 10:14 Type: eMAR - Administration Note: Namenda Titration Pak Oral Tablet Give 5 mg by mouth one time a day for dementia for 7 Days patient medication is not available contacted pharmacy, medication needs clarification and has to be broken differently contacted supervisor on staff writer was told to put a note in mar and supervisor would contact D.O.N.(Director of Nursing) There are no further concerns at this time.08/24/2025 09:11 Type: eMAR - Administration Note: Namenda Titration Pak Oral Tablet Give 5 mg by mouth one time a day for dementia for 7 Days pt medication is not available and needs to be clarified per pharmacy08/25/2025 08:42 Type: eMAR - Administration Note: Namenda Titration Pak Oral Tablet Give 5 mg by mouth one time a day for dementia for 7 Days not in back up box08/30/2025 22:08 Type: eMAR - Administration Note: Namenda Titration Pak Oral Tablet Give 5 mg by mouth two times a day for dementia for 7 Days unavailable08/31/2025 22:05 Type: eMAR - Administration Note: Namenda Titration Pak Oral Tablet Give 5 mg by mouth two times a day for dementia for 7 Days unavailable09/01/2025 08:46 Type: eMAR - Administration Note: Give 5 mg by mouth two times a day for dementia for 7 Days pt medication is not available and needs to be clarified per pharmacy09/02/2025 08:10 Type: eMAR - Administration Note Namenda Titration Pak Oral Tablet Give 5 mg by mouth two times a day for dementia for 7 Days patient medication is not available09/02/2025 21:08 Type: eMAR - Administration Note Namenda Titration Pak Oral Tablet Give 5 mg by mouth two times a day for dementia for 7 Days na (not available)09/13/2025 17:27 Type: Physician Team - Progress Note: Patient has all the medications reviewed as following; Namenda 10 mg 1 p.o. (by mouth) daily .Plan of care; Patient's all the medications reviewed and continued Further review of the September 2025 MAR and Physician orders revealed R204 did not receive any namenda after 9/5/25. On 3/4/26 at approximately 1:31 p.m., R204's medical record was reviewed with the DON, who reported they were not the DON during the period R204 was in the facility and that R204's namenda medication orders should have been clarified with the pharmacy and the Physician to ensure the medication would be delivered and available to be administered. On 3/4/26 a facility document titled Medication Administration was reviewed and revealed the following: Policy overview-To safely and accurately prepare and administer medication according to physician order, professional standards of practice, and resident needs Administer medication in accordance with frequency prescribed by physician and standards of practice If a pharmacy supplied medication is not available, refer to the pharmacy policy and procedures related to emergency pharmacy delivery and emergency supply kit usage .

Based on observation, interview, and record review, the facility failed to prevent two accidents with a mechanical lift and remove a malfunctioning lift from circulation for one Resident (R171) of two residents reviewed for accidents. Findings include: On 3/02/26 at approximately 10:17 a.m., R171 was observed in their room dressed, standing in a standing wheelchair, with a laptop on a tray table. On 3/02/26 at 10:20 a.m., R171 stated, .Their (lift) machines are not operating well to get me up; their lift machines are broken. Some days I am getting stuck in bed and it started since last Tuesday (2/24/26) and they keep me in bed. I should always have two people to position me. For example, this morning the lift didn't work so they transferred me into the wheelchair with two-person (assistance). The lift would be ideal. R171 reported their nurse said if they haven't fixed the (Brand name stand) lift by tonight, they were not getting them up (out of bed) tomorrow. R171 said this made them feel anxious and guilty, like they did something wrong. R171 added, It made me feel helpless. R171 clarified they had to wait longer to get out of bed when this happened. R171 continued, I wasn't going to report it. but said it was upsetting them and they did not want to get stuck in bed, because this was not good for their legs as they had a multiple sclerosis (MS) and standing was important to them and they didn't want to get weaker. R171 denied any injury from the sit-to-stand lift not working correctly in the past week however reported they were injured in the lift another time, when staff did not operate the lift correctly. R171 said they wanted to be in bed by 8:30 p.m., however sometimes waited one to one and a half hours to be transferred back to bed with the lift problems. On 3/02/26 at 10:25 a.m., R171 described the accident which occurred when staff were transferring them with the facility sit-to-stand mechanical lift a few months before. R171 said their foot became caught under the sit to stand platform during a transfer. R171 said the aide did not move their foot correctly and their foot hit the lift platform and spasmed so hard that their toenail came off. R171 explained this became an open wound and took some time to heal. R171 said they believed the cause was their aide was rushing their care, which occurred sometimes, and was upsetting as they had to deal with an open wound. R171 clarified they felt safest being transferred with the sit-to-stand lift due to their leg weakness, given their MS diagnosis, and this was their preference and was designated for their care. On 3/02/26 at 10:46 a.m., R171 showed Surveyor a paper posted on their bulletin board, which showed R171's transfer status. The post read in handwriting, .Transfers: x 2 (Name brand) stand (lift).Toileting: x 1 (Name brand) stand (lift). R171 was designated to use the sit-to-stand lift for all transfers per the care note in their room. On 3/02/26 at approximately 3:30 p.m., the floor staff were asked to show the sit-to-stand lift to this Surveyor. All reported they were unable to locate the sit-to-stand lift, including the unit manager. Review of R171's Care Plan, accessed 3/04/26, revealed R171 required a (Name brand) sit-to-stand mechanical lift or two-person (adapted) assistance for transfers. Review of R171's Minimum Data Set (MDS) assessment, dated 1/05/26, revealed R171 was admitted to the facility on [DATE], with diagnoses including multiple sclerosis, depression, and anxiety. The assessment showed R171 required maximal assistance for bed mobility, was dependent for transfers and was frequently incontinent for toileting. R171 was not marked for any behaviors. The assessment showed choices and preferences being honored was very important to R171. Review of the Brief Interview for Mental Status (BIMS) assessment revealed a score of 15/15, which showed R171 was cognitively intact. On 3/02/26 at approximately 3:41 p.m., the Director of Nursing (DON) arrived and acknowledged the sit-to-stand lifts in the building did not work and were removed from circulation on 3/02/26, after they were made aware of the concern. The DON explained R171 had already been reevaluated by physical and occupational therapy, and it was determined they were safe to transfer with two-person assistance until a new sit-to-stand rental lift arrived. The DON explained that the floor staff and nursing management had not made them aware the sit-to-stand lift in use was not working and was unsafe for residents' use per their own observation. The DON clarified the maintenance staff had confirmed the sit-to-stand lift in use was not functional and had tagged the lift and removed it from use. The DON confirmed there were no accidents or incidents from the lift when it began to malfunction recently. The DON acknowledged they understood the concern and reported at that time they believed no other residents used the sit-to-stand lift, from staff interviews. On 3/02/26 at 4:36 p.m., the Maintenance Director, Staff I, also reported no staff had brought any concerns about the sit-to-stand mechanical lift to their attention. Staff I confirmed they only knew of one sit-to-stand lift in the facility, which the DON confirmed. Both said the lift in the building was unsafe for resident use, and there was no other lift. The DON said the lift was stuck in the wrong position when it was turned on and could not be used safely, which Staff I confirmed. The DON confirmed they had not received a concern or grievance form related to R171's lift not working either. On 3/02/26 at approximately, 4:40 p.m., Certified Nurse Aide (CNA) J was asked how many sit-to-stand lifts were available for resident transfers. CNA J reported they only knew of one sit-to-stand life for resident use, however said they had not used it recently. On 3/02/26 at approximately 4:37 p.m., the sit-to-stand lift was observed with Staff I and the DON, with a paper note attached taped to the lift which showed, Not working. On 3/02/26 at 4:57 p.m., Physical Therapist (PT) K confirmed they had reevaluated R171 on this date, and R171 demonstrated the ability to complete a slide lateral scoot transfer with them, and their technique was safe for staff to complete two-person transfers with R171 until the new sit-to-stand lift was received. PT K understood the sit-to-stand lift was not working only on this date and had not been made aware prior. On 3/02/26 at approximately 5:00 p.m., R171 was interviewed with the DON present, and confirmed they had not been injured in the past week when the sit-to-stand lift was not working. R171 described the incident when operator error caused their toe to get caught under the lift, when staff moved the lift too quickly towards them without lifting their foot, resulting in an injury to their toe. R171 reported that incident occurred this summer but did not know of the date. R171 described the lift battery was not always charged and said sometimes the lift did not work as the battery would run out. It was unclear if there was a backup battery, or if this was a malfunction of the lift itself. R171 shared they felt comfortable completing two-person scoot transfers temporarily but said they felt safest in the lift for their daily transfers and for toileting needs. Review of R171's progress note, dated 8/31/25 at 23:04 (11:04 p.m.), by Licensed Practical Nurse (LPN) H, revealed, Writer was notified by CNA (unnamed) that the resident foot was caught under the sit-to-stand (lift) and that her left great toenail had got caught under it and was bleeding. Upon assessment of the resident toe, writer observed the resident toenail was coming off of her toe. Resident stated that the CNA came into the room with the sit to stand and had pushed it up to her and the CNA had placed one of her feet on the sit-to-stand (lift) and the other one was still on the floor Resident stated that she had ask the CNA if she could open the legs of the sit-to-stand (lift) a little more before trying to move her other foot resident (sic) said that the CNA told her to hold on, she knows what she is doing and that when the CNA tried to move the sit-to-stand (lift) her left foot had started to spasm and her toe had got caught under the bottom of the sit-to-stand (lift) causing her toenail to come off. Writer cleaned the resident toe and contacted the DR (physician). After writer reached out to the DR, he stated to clean the wound with warm water and soap and apply triple antibiotic ointment and wrapped with gauze and kerlix; there was no other bleeding noted after wound care was done. Writer also put in a wound consult and a temporary wound order. On 3/04/26 at 12:19 p.m., LPN H was asked about the incident with R171 and the sit-to-stand lift when they were assigned to care for R171 on 8/31/25. LPN H explained they were trying to assist the resident getting back into the bed and her foot got caught under the sit-to-stand (lift) and she started to spasm and her foot went up and her toenail got caught. LPN H said they assessed R171 and her toenail was still intact and then her toenail ultimately fell off. LPN H said they didn't understand how the incident occurred and they were trying to visualize how the foot could go underneath under the sit to stand. LPN H said they believed the aide took R171's foot off the (lift) platform but her foot was caught under platform. LPN H concluded R171's foot should not have been under the platform. LPN H said, I keep educating (staff) on the safety of the sit-to-stand. LPN H concluded this was an avoidable incident when asked. LPN H said they worked with R171 regularly and their foot had healed. LPN H said R171 would only transfer with the sit-to-stand lift and declined all other transfers. Review of R171's progress note (after the incident), dated 9/05/25, showed they were seen by wound care for their left great toe, as they had begun to develop cellulitis with an exudated (missing) toenail, which occurred after their injury on the lift. The note showed R171 was in a lot of pain however the wound was healing as they were on an antibiotic. The noted further revealed R171 was being followed by both wound care and podiatry closely after the incident. Further review of R171's nursing progress note, dated 9/14/15 at 2:34 (a.m.), revealed another incident with the sit-to-stand lift during transfers. The progress note revealed, Writer called to room due to conflict with resident (R171) and CNA (their aide). (R171) stated she needs to have a bowel movement and is constipated and would like to sit on the toilet. CENA (aide) unable to transfer resident at this time due to malfunctioning equipment (lift). Resident (R171) insists on getting up, other options were presented such as bedpan, turning resident on her side, and putting bed in sitting position. Review of the policy, Transferring Residents Using a Mechanical Lift Machine, revised 2/04/26, revealed, Policy Overview: The purpose of this procedure is to provide guidelines for the safe lifting using a mechanical lifting machine. It is not a substitute for manufacturer's training or instructions. General guidelines: Follow manufacturers' guidelines for the number of nursing assistants (or other licensed and trained staff) that are needed to safely move a resident with a mechanical lift. Mechanical lifts may be used for tasks that require: lifting a resident from the floor, transferring a resident from bed to chair (or vice versa), lateral transfers, toileting or bathing, repositioning. Types of lifts that may be available in the facility are: Floor-based full body sling lifts, overhead full body sling lifts, sit-to-stand lifts.Lift design and operation varies across manufacturers. Staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility.Prepare the environment: Clear an unobstructed path for the mechanical lift, ensure there is enough room to pivot the mechanical lift, position the lift and the surface the resident is transferring from or to at the correct height. Move the mechanical lift base legs near or around the resident's transferring surface (i.e. bed or wheelchair). Base legs are usually more stable in full open position. Prepare the equipment: Make the battery is charged. Test the lift controls. Ensure the emergency release feature works. Make sure the lift and surface the resident is transferring from and to is stable and locked. Make sure that all necessary equipment (slings, hooks, chains, straps, and supports) are available, appropriate, and correctly sized. Examine sling and attachment areas for tears, holes, and frayed seams. Do not use sling with any signs of wear.Perform Safety Check: Before the resident is lifted, double check the security by examining that all hooks, clips, fasteners, and sling straps are securely fastened and will not unhook during use

This citation pertains to intake 2745432.Based on observation, interview and record review, the facility failed to implement timely care and monitoring of a resident's suprapubic urinary catheter (flexible tube surgically inserted into the bladder through the skin of the abdominal wall) which included physician orders and nursing assessment for one (R214) of four residents reviewed for urinary catheters. Findings include:Review of a complaint reported to the State Agency (SA) included allegations that the facility was not properly caring for a resident with a urinary catheter.On 3/2/26 at 11:35 AM, R214 was observed in their room and a urinary catheter drainage bag was observed secured to the side of the bed and the urine appeared very dark. At that time, R214 reported there was blood in their urine and they were upset about the catheter site hurting and just wanted it out.On 3/4/26 at 10:20 AM, R214 was observed in their room, seated in a wheelchair. When asked about what the facility had done to follow up on their concerns from 3/2/26, R214 reported they were due to go to a urology appointment today because they were told the facility staff were not able to change the suprapubic tubing and now, they had to see a urologist. The resident further reported they really didn't want to go out to see them and asked why they couldn't do that here. When asked if the nursing staff had assessed their urine output since their admission, they reported no. R214 reported they've had the suprapubic for about six months and was recently on antibiotics for Urinary Tract Infection (UTI) at the hospital and was worried because it hurt so much about every 45 minutes or so.Review of the clinical record revealed R214 was admitted into the facility on 2/26/26 with diagnoses that included: other fracture of left femur, other nondisplaced fracture of upper end of left humerus, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, type 2 diabetes mellitus with diabetic nephropathy, kidney transplant status, end stage renal disease, and other neuromuscular dysfunction of bladder.There was no Minimum Data Set (MDS) assessment to review at this time due to the resident's new admission status.Review of the physician orders since admission revealed there were no orders for the care, monitoring, or assessment of the resident's suprapubic catheter. Additionally, review of the medication and treatment administration records revealed there was no documentation of any monitoring or care for R214's suprapubic urinary catheter.Review of the care plans included:Use of indwelling urinary catheter needed due to Neurogenic bladder. This care plan and interventions were initiated on 2/27/26 and as of this review (3/3/26) there were no new interventions added since.Interventions included:Catheter Care. (There were no specific details identified.)Change catheter per physician's order. (There was no physician's order.)Change urinary collection bag as needed. (There was no documentation this was completed in the electronic medical records/EMR since admission.)Maintain drainage bag below bladder level.Report any changes in amount and color, or odor of urine.Report to physician signs of UTI such as blood, cloudy urine, fever, increased restlessness, lethargy, c/o (complaints of) pain/burning, acute change in mental status, functional decline in ADLs (Activities of Daily Living).Resident requires enhanced barrier precautions related to: Foley. This was initiated on 2/27/26 and was incomplete. There was no identification of the specific urinary catheter utilized by R214.Review of R214's hospital documentation prior to admission included: .Has hx (history) of suprapubic catheter which is currently plugged as he is trying to be weaned off of it .Patient is a [AGE] year old male with hx of ESRD (End Stage Renal Disease) now s/p (status post) renal transplant in 5/2025, chronic urinary retention due to neurogenic bladder from basal ganglion stroke s/p (status post) suprapubic catheter placement in October 2025 .Urology consulted for SP tube management and hematuria in SP tube 2/23/2026: 20 Fr (French) SP tube exchanged without difficulty .SP tube exchanged today without incident. He reports burning has resolved .Hematuria has resolved . Review of the nursing admission evaluation dated 2/26/26 documentation revealed there was no identification of the specific suprapubic urinary catheter and read, in part: .Urinary Characteristics .Amber .External catheter (condom catheter.) .b. Yes .Indwelling Catheter Care Plan .Review of the progress notes included several entries of R214's complaints of pain and discomfort with the suprapubic catheter since 2/27/26, but did not include any specific orders for the care of and monitoring of the suprapubic catheter until it was identified as a concern during the survey. As of 3/2/26 approximately 5:00 PM, there was no evidence of any provider evaluation of R214's catheter site.Documentation of the progress notes included:An entry on 2/27/26 at 5:30 AM by Nurse 'M' read, Resident arrived to facility on 2/26/26 at approximately 2230,from [name of local hospital].Resident AOX4 (alert and oriented to person, place, time and situation) able to make needs Known.Resident is diabetic, with indwelling foley catheter. This assessment did not identify R214's use of a suprapubic urinary catheter, or identify need for specific orders to provide care.An entry on 2/27/26 at 6:42 PM by Nurse 'P' read, Change Foley Catheter Catheter [sic] Size/French: (left blank) Balloon CC (Cubic Centimeters): (left blank) one time only for Hematuria until 02/27/2026 23:59 unable to change due to being suprapubic catheter.An entry on 2/27/26 at 6:47 PM by Nurse 'P' read, Writer unable to administer new foley due to catheter being a suprapubic catheter. Physician informed of situation. Per physician orders bedtime dose of enoxaparin and morning aspirin chewable placed on hold for hematuria.An entry on 2/28/26 at 12:03 PM read, Patient alert and verbal able to make needs known. Patient verbalized he was told a couple days ago that he will have an appointment to have his suprapubic catheter changed today and will be transported by stretcher to [name of local hospital]. No order listed and no paperwork available about any appointment. Observed dark yellow blood-tinged urine in foley bag, also observed urine in brief. Patient complains of burning while urinating. (Nurse Practitioner/NP 'N') on call for (Physician) notified and made aware, noted new order for UA C&S (Urinalysis with Culture and Sensitivity),Pyridium Oral Tablet 100 MG (Milligrams) Give 1 tablet by mouth three times a day for Dysuria (pain, discomfort, or burning sensation during urination) for 2 Days. There was no orders implemented for the monitoring and/or care of the suprapubic catheter.As of 3/2/26, there was no further documentation available in the EMR for review that nursing staff and providers had assessed/evaluated the resident's urinary catheter status, including any urine output.On 3/3/26 at 10:33 AM, an interview was conducted with R214's Nurse (Nurse 'Q'). When asked about R214's suprapubic catheter and whether they had assessed that yet today, or if they could give any additional information, Nurse 'Q' reported they hadn't been down this hallway in a while and further reported R214 had an appointment for the catheter today but they were not sure what was going on with it and acknowledged they did see the redness in the tubing. When asked if they assessed the suprapubic catheter site, or urine output, Nurse 'Q' reported they don't typically deal with suprapubic catheters but orders should be in the TAR (Treatment Administration Record) and he said he has the appointment.At that time, Nurse 'Q' was asked to review the EMR and confirmed there were no orders for R214's suprapubic catheter. Nurse 'Q' further reported there should be an order to monitor output but confirmed there was not.On 3/3/26 at 10:37 AM, an interview was conducted with Nurse Manager (NM 'R') who reported they had been in that role since April 2025. When asked about the facility's process for implementing care for residents that were admitted with indwelling urinary catheters, NM 'R' reported when residents came into the facility, either they or the other NM review the record the next morning. NM 'R' further reported that was a second check to see if the nurse missed something and if residents came after hours, they would review it the next morning. NM 'R' reported R214's day after admission was on 2/27 and they were not available and acknowledged that got missed. NM 'R' further reported they were not able to see that any practitioners had assessed R214 to address the suprapubic catheter but had given orders for a urine test and medication to help with the burning. NM 'R' reviewed the urine results and reported they were negative for an infection. When asked about the nursing documentation of any assessment monitoring following the initial complaints of burning and pain, NM 'R' reported there should have been ongoing evaluation by the nurses and confirmed that was not documented in the EMR.When asked about if there should be specific orders for the care and monitoring of suprapubic urinary catheters, NM 'R' reported yes that should've been put on at the time of admission and was missed by multiple nurses.Further review of the clinical record revealed orders for the suprapubic catheter were not implemented until after the discussion with NM 'R'. Additionally, an entry created on 3/3/26 at 11:49 AM for effective date 3/2/26 at 12:48 PM (four days after complaints were voiced by R214) by NP 'S' documented, in part: .The pt (patient) was seen and examined, sitting up in bed, reports he is uncomfortable due to burning at the catheter site.D/w (Discussed with) staff and nurse plan of care and need for f/u (follow up) appts (appointments) .Medication List .Methenamine Hippurate Oral Tablet 1 GM (Gram) Give 1 tablet by mouth one time a day for Antibiotic until 03/20/2026 08:59 .Neurogenic bladder SP catheter exchange q32 (every) weeks and as needed Requested f/u (follow up) appt with urology .According to the facility's policy titled, Catheter Care dated 2/2/2026: .It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use .Catheter care will be performed every shift and as needed by nursing personnel .Observe the resident for complications associated with urinary catheters. Report unusual findings to the nurse supervisor (or if nurse to the physician) .if the resident indicates that his or her bladder is full or that he or she needs to void (urinate) .if urine has an unusual appearance (i.e., color, blood, etc.) .in the event of bleeding, or if the catheter is accidently removed .if the resident complains of burning, tenderness, or pain in the urethral area .if signs and symptoms of urinary tract infection or urinary retention occur .According to the facility's policy titled, Physician and Practitioner Orders dated 2/3/2026: .admission Orders will be obtained for the residents' immediate care and needs. The orders should allow facility staff to provide essential care to the resident consistent with the resident's mental and physical status on admission and will include at a minimum: An order for the resident to be admitted to the facility .Routine care orders .The licensed nurse is responsible for physician notification per physician parameters for a resident's refusal of medications, treatments, and cares .

Based on observation, interview and record review, the facility failed to ensure appropriate PICC line (Peripherally Inserted Central Catheter) care was provided for one resident (R197) of one resident reviewed for Parenteral/IV fluids. Findings include:On 3/2/2026 at approximately 9:44 a.m., R197 was observed in their room, lying in their bed. R197 was observed to have a PICC line in their upper right arm with the dressing dated 2/25/26 (Wednesday). R197 was queried if Nursing staff are changing and assessing the dressing and they indicated that it needed to be changed. At that time, the med tape securing the dressing to the arm was observed to be losing its adhesiveness. On 3/3/26 at approximately 11:06 a.m., R197 was observed in their room, lying in their bed. R197 was observed to have a PICC line in their upper right arm with the dressing dated 2/25/26 and the tape holding the dressing to be coming apart. On 3/3/26 at approximately 11:38 a.m., R197's PICC line dressing was observed with Nurse Manager R (NM R) and verified that the date on the dressing was 2/25/26. At approximately 11:40 a.m., the TAR (treatment administration record) for March 2026 was reviewed with NM R and it was observed that R197 was documentation in the TAR as having had the dressing change completed on 3/1/26. NM R indicated they would have to talk with the Nurse regarding appropriate documentation on treatments that were not completed. On 3/2/26 the medical record for R197 was reviewed and revealed the following: R197 was initially admitted to the facility on [DATE] and had diagnoses including Infection and Inflammatory reaction due to due to internal right knee prosthesis. A review of R197's carelans revealed the following: Focus- Potential for complications at IV (intravenous) insertion site. PICC inserted at right arm. Date Initiated: 01/31/2026 .Interventions-Dressing change by physician order and prn if soiled or wet. Date Initiated: 01/31/2026 . A Physician's order dated 1/31/26 revealed the following: Change PICC Line Dressing (location): RUE (right upper extremity) every day shift every Sun (Sunday) for safety monitoring AND as needed for safety monitoring On 3/3/26 at approximately 11:51 a.m., the Director of Nursing (DON) was informed of the Physician's order that indicated it should have been done every Sunday, according to the Physician's order with the last change scheduled have been done on (3/1/26) and they reported that it should have been done that Sunday and would have to address the issue of documentation error with the Nurse who documented the treatment had been completed when it had not.

Based on interview and record review, the facility failed to ensure Physician ordered laboratory diagnostics (labs) were completed and reported to the Physician in a timely manner for one resident (R52) of one resident reviewed for laboratory diagnostics. Findings include: On 3/2/26 the medical record for R52 was reviewed and revealed the following: R52 was initially admitted to the facility on [DATE] and had diagnoses including Pneumonia and Sepsis. A Physician's order dated 2/20/26 revealed the following: CBC (complete blood count) and CMP (comprehensive metabolic panel) Dx (diagnosis): New Admit A review of R52's laboratory results in the electronic medical record did not reveal any lab results for R52's labs ordered on 2/20/26. On 3/4/26 at approximately 11:54 a.m., Nurse Manger R (NM R) was queried regarding the lab results for 2/20/26. NM R reported that new admission residents have baseline labs ordered and drawn upon admission, and that they would check for the results. On 3/4/26 at approximately 12:02 p.m., NM R reported the facility did not have the results from the labs ordered on 2/20/26 because they were never drawn, because the Nurse who completed R52's admission orders failed to place the request in the laboratory book for lab technician to complete the order. NM R reported the facility had to recently reorder the labs to get some baseline results. A review of R52's lab results from the re-order of labs that was completed on 3/2/25 revealed R52 had multiple values that were indicated to be outside of normal reference ranges. On 3/4/26 at approximately 1:31 p.m., during a conversation with the Director of Nursing (DON), the DON was queried regarding the expectation of Physician ordered labs to be completed, and they indicated it should be competed when the order is received. On 3/4/26 a facility document titled Laboratory Results was reviewed and revealed the following: Policy Overview-The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law .The facility must provide or obtain laboratory services to meet the needs of its residents. The facility will assist the resident in making transportation arrangements to and from the laboratory if necessary. Labs not drawn as ordered are reported to the attending physician for further direction. STAT lab results are received according to timeframes established in the contract. Laboratory results will be dated and contain the name and address of the testing laboratory .The staff will process test requisitions and arrange for tests. The laboratory or other testing source will report test results to the facility. The laboratory will notify the facility of critical or panic laboratory results. The laboratory will notify the facility of stat laboratory results. For facilities and laboratories integrated with the electronic health record ., laboratory results will display in [EMR] under the resident's results tab, and unreviewed laboratory results can also be accessed under the Clinical Dashboard and under the Clinical Lab/Rx Results Dashboard in [EMR]. For facilities and laboratories not integrated with electronic health record [EMR], laboratory results may be faxed to the facility or retrieved from the laboratory's website. Those results will be uploaded into the resident's electronic health record. Laboratory results will be classified as Critical/Panic, Abnormal, or Normal, according to the lab parameters. Critical or Panic and Abnormal laboratory result notifications: Promptly notify physician or physician extender with lab result and resident current condition. If results are integrated with [EMR], click [NAME] as Reviewed on the laboratory result and document response and any new orders as applicable. If results are not integrated with [EMR], document notification, response, and any new orders as applicable. Notify and document notifications to resident or resident representative, as applicable. Implement new orders, as applicable. If the physician fails to respond to the Critical or Panic laboratory results within 2 hours, place another call to the physician and/or the Medical Director . No laboratory diagnostics results for the lab diagnostics ordered on 2/20/26 were provided for review by the end of the survey.

Based on observation and interview, the facility failed to provide proper hand hygiene procedures during medication administration for three (R128, R53, R215) residents of four reviewed for medication administration.Findings include:On 3/3/26 at 8:12 AM, a medication administration observation was conducted with Registered Nurse (RN) C for R128. RN C donned a pair of clear gloves at the 600-hallway cart without cleaning their hands. RN C proceeded to touch items on top of cart including a stack of clear plastic cups, poured a brown liquid supplement into a plastic cup, retrieved a pen from the top of cart, and opened the top drawer, donned with the same gloves, RN C proceeded to remove the medicine cup of opened medications and liquid supplement for R128 and proceeded to administer at bedside.On 3/3/26 at 8:58 AM, a medication administration observation was conducted with Licensed Practical Nurse (LPN) B for R53 and was observed not performing hand hygiene prior to medication preparation and not performing hand hygiene prior to medication administration to R53.On 3/3/26 at 9:09 AM, a medication administration observation was conducted with LPN B for R215 and was observed in front of the room not performing hand hygiene prior to donning Personal Protective Equipment (PPE). LPN B proceeded to walk back to the cart, touch the prepared medications, open the door to the room, move the bedside side table and proceeded to administer the medications to R215.Review of the facility titled Hand Hygiene dated 4/14/2023 documented.guidelines to staff for proper hand hygiene techniques that will aid in the prevention and transmission of infection.Included but not limited to: Before applying and after removing personal protective equipment (PPE), including gloves.Before preparing or handling medications.

This citation is or complaint # 2573833Based on observations, interviews, and record reviews, the facility failed to follow a transfer status and fall protocol for one resident (R303) of three residents reviewed for falls, resulting in R303 obtaining a serious injury.Findings include:A record review revealed that on 7/8/25 R303 fell from bed while being changed and sustained a head injury and required a higher level of care. According to the incident report R303 was being changed by one certified Nursing assistant (CNA) and rolled out of bed and hit their head. R302 care planned as a two person assist for actives of daily living (ADLs). On 8/5/25 at 10:40 AM, R303 was interviewed, and asked did they remembered how they fell from the bed. R303, report that they rolled out of bed and remembered hitting their head but that was it, R303 could not recall the staff that was around. A record review revealed that R303 was re-admitted to the facility on [DATE] with the medical diagnosis of Traumatic Subarachnoid Hemorrhage without loss of consciousness, contusion of eyeball and orbital tissues, left eye and fall. A further review of the record showed that R303 was a two person assist with ADLs.On 8/5/25 at 12:22 PM, the administrator was interviewed and asked about the fall for R303, and reported that it happened and the CNA who was involved was terminated for that reason, the CNA had been educated on proper transfer status of residents. The administrator was then asked about the facilities fall protocol, the Administrator reported that staff is supposed to follow the policy and complete all required documentation. The administrator was then asked for the incident and accident reports for R303 and R302, and agreed that required documentation was missing from the report. A review of the Employees file who was terminated revealed that the CNA had dropped three different residents and all were improper transfers. No additional information was provided by the exit of survey.

This citation pertains to intake #2577284.Based on observation, interview, and record review, the facility failed to provide a safe, clean, homelike environment, in multiple resident rooms and throughout the hallways on the 100, 400, 500, 600, and 700 units. Findings include:Review of concerns reported to the State Agency on 7/31/25 included: the building smells like mildew, the facility is dirty, rain is coming down from the second-floor ceiling, which was not a new issue and happened every time it rains, and there was black mold on the pipes and in the ceiling.On 8/5/25 between 8:30 AM - 10:05 AM, observations of the facility revealed the following environmental concerns:At 8:30 AM, upon entry into the facility's main lobby, there was a strong mildew odor present, as well as in hallway towards the conference room.At 9:11 AM, there were three ceiling tiles off the main dining room towards the long-term care side of the facility that were heavily stained with water damage.At 9:15 AM, the end of the 500 hallway had a build-up of cobwebs in the corner of the window ledge under the window, with the surrounding walls had peeling wallpaper; the fabric window valance was stained in darker brownish color (water damage) and five ceiling tiles along the ceiling directly in front of the window valance were observed to have brown stains (water damage) and the area to the right of the window valance had a ceiling tile with dark brown and black colored mold-like substance on the tile and surrounding tile grid. Throughout this hallway and in the window area, there was a strong musty/mildew-like odor.At 9:20 AM, the main elevator to access the second floor did not work. There was no signage to indicate this was not in working order, or where to go to access a secondary elevator. When staff were asked, they reported the elevator had not been working for several days and thought there used to be a sign indicating it was out of order but wasn't sure what happened to it.At 9:21 AM, upon exiting the service elevator to the second floor 600 hallway, there was a very strong musty/mildew-like and urine odor.At 9:23 AM, an interview was conducted with Nurse ‘A'. When asked about the elevator, Nurse ‘A' reported that had not been working for about three weeks or so. When asked how visitors and residents knew it was out of order and/or where to access the other elevator since there was no sign posted, Nurse ‘A' reported there used to be a sign, but confirmed there was none now.At 9:24 AM, the ceiling tile outside the elevator on the 700 hall was heavily water damaged with brown/colored stains.At 9:25 AM, while walking throughout the 500 hallway, there was a significant musty, mildew-like odor throughout most of the hallway. The ceiling tiles in the hallway across from room [ROOM NUMBER] had a large area of water damage (brown colored stain) and was observed to be sagging down in the center of the ceiling tile.At 9:27 AM, the 600-hall lounge/dining area was observed to have four ceiling tiles with water damage (varying brown colored stains) and a broken wall outlet cover with cracked/sharp plastic edges.At 9:28 AM, room [ROOM NUMBER] was observed to have one ceiling tile in the center of the ceiling between the two occupied beds with a water damage (round brownish colored water stain).At 9:29 AM, the 600 hall was observed to have five ceiling tiles missing outside of rooms [ROOM NUMBER]. The carpet was significantly stained darker in color in several areas and there was a very significant musty/mildew-like odor present. The surrounding walls had peeling wallpaper directly under the area of the removed ceiling tiles and extended down past room [ROOM NUMBER].At 9:31 AM, room [ROOM NUMBER] was observed to have a ceiling tile in the center of the room with a large area of water damage (brown colored stain).At 9:32 AM, room [ROOM NUMBER] was observed to have a ceiling tile directly over the end of their bed that was occupied with a large area of water damage and the center of the ceiling tile was sagging down.At 9:33 AM, room [ROOM NUMBER] was observed to have a ceiling tile directly above the head of the bed with a small circular water stain. On 8/5/25 at 9:31 AM, a Resident was observed seated in a wheelchair next to their bed, eating breakfast. When asked about their room and if there were any concerns, the resident pointed to the bathroom door and above their bed. The ceiling tile located just above the resident's bed was observed to have an area of small water damage (brown colored stain). Upon opening the door to the bathroom, there were three ceiling tiles missing and there was a strong musty/mildew-like odor present. Additionally, there was a toilet commode with bilateral arm rests that was placed on top of the toilet. The left arm rest was observed broken with cracked plastic and had sharp, jagged edges on the top portion of the arm rest. The resident pointed to the bathroom ceiling and stated, That's pretty bad huh?.At 9:40 AM, Nurse ‘A' was asked about the missing ceiling tiles at the end of the 600 hallway and reported the issue had been going on for a long time and further reported, Whenever it rains really hard, the ceiling leaks terribly and it smells like mold and mildew. We had to move a resident a couple weeks ago because the tile came down in their room, luckily they weren't in the room at the time. That carpet is discolored from the rain.At 9:41 AM, two ceiling tiles outside room [ROOM NUMBER] were observed with significant water damage (brown colored stains).The hallway carpeting observed on the 400, 500, 600, and 700 hallways were observed very worn, with significant darker colored stains.At 9:43 AM, the carpet in the center of the hallway near the emergency exit between 300 and 400 unit was approximately two feet long with a visible ripple (accident/trip hazard).At 9:45 AM, the 100 hall (non-long-term area of the facility) carpet was observed to be heavily worn and stained in several spots throughout the hallway.On 8/5/25 at 9:50 AM, an interview was conducted with the Administrator. They reported the Maintenance Director was currently on the roof with the mechanical company for AC (Air Conditioner) repairs for three units. When asked about the elevator that was out of order on the long-term side of the facility, the Administrator reported it recently had been out for two days and before that was closed for several weeks last year for repairs. They further reported a part needed to be replaced and should be here this week. When asked how would residents and visitors know it was not in working order and/or where to access another elevator, the Administrator reported there should be a sign up and was informed there were none during earlier observations. At that time, the Administrator was requested to observe the same areas as identified above. Upon accessing the alternate elevator, a door was propped open that had signage that indicated that was for employee access only. When asked about how visitors or residents would know it was ok to access if signage indicated otherwise, the Administrator acknowledge the concern and reported there should also be a sign that indicated that as well.During the observations with the Administrator, when asked about the water damage and missing ceiling tiles, the Administrator reported the facility had issues with leaks on the long-term care side and the roofers were out last Thursday to assess. When asked about the concerns with water damage observed in several resident rooms, and other hallways, the Administrator reported they were not aware of the concerns at the end of the 500 hall and acknowledged they also smelled the same musty/mildew-like odor and thought the smell was coming from the carpet. They further reported they had similar concerns with the carpet and roof leaks when they began working at the facility (January 2023).When asked about the worn and soiled carpets, the Administrator reported the carpets are on capital budgets to be replaced this year, and were hopeful for September 2025. However, they had to replace the three AC units and didn't sign a formal contract yet, but would reach out to try to get documentation from their Corporate Maintenance Director.When asked to observe the bathroom in room [ROOM NUMBER], the Administrator reported they were not aware of that (missing ceiling tiles, mildew-like odor and cracked commode arm rest) and would have to follow-up. The Administrator was requested to provide any documentation of facility audits, logs, or quotes for the areas of concern observed.On 8/5/25 at 10:52 AM, the Administrator emailed a quote from their corporate Maintenance Coordinator for the flooring where the areas (carpet) were torn.On 8/5/25 at 11:10 AM, the Administrator reported they were still waiting on the quote from the roofers who were out last week to assess the areas of concern.Review of the flooring quotes provided revealed there were only two quotes. One for the kitchen service hallway dated 6/27/25 and one for the area from the courtyard to Cranbrook dated 7/9/25. There was no evidence that any plan was in place for the flooring for the other affected hallways (100, 400, 500, 600, and 700) other than the kitchen service hallway and main corridor towards the long-term care side of the facility. The short-term care portion of the facility mostly consisted of rooms that had been renovated.According to the facility's policy titled, Homelike Environment dated 9/21/2023: .The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include.clean, sanitary, and orderly environment, pleasant, neutral scents, The facility staff and management minimizes, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. These characteristics include.institutional odors.Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment.Staff may assist in providing a safe and homelike environment by.Reporting any unresolved environmental concerns to the administrator.

This citation pertains to intake: MI00151510. Based on interview and record reviews the facility failed to address the concerns reported to the facility for one (R202) of three residents reviewed for grievances. Review of a complaint submitted to the State Agency (SA) documented multiple concerns that the complainant attempted to get resolved with the facility staff unsuccessfully. The complainant noted the facility's failure to follow up and the lack of communication to resolve any of their concerns. A review of R202's medical record revealed the resident was admitted to the facility on [DATE] and transferred out to the hospital on 3/27/25. R202 admitted with the primary diagnosis of hypokalemia and required staff assistance with all Activities of Daily Living (ADLs). A review of the progress notes revealed the following: On 3/26/25 at 9:35 AM, a Social Worker (SW) note documented in part . CM (case manager) had some concerns regarding the resident. SW asked appropriate parties to follow up . This note was documented by SW K. A review of a facility policy titled Grievance Policy And Procedure revised November 2023, documented in part . Grievances made to the Facility may be oral or in writing . The grievant may request assistance from the facility's social worker when completing a written grievance . all grievances will be investigated and reported back to the grievant within fifteen 15 days from the receipt of the grievance . On 5/28/25 at approximately 9:07 AM, the Administrator was asked to provide all grievances and concerns filed on the behalf of R202. Shortly after the Administrator stated they had no grievances for R202. On 5/28/25 at 10:50 AM, an interview was conducted with SW K. SW K was asked about the concerns reported to them by R202's CM on 3/26/25. SW K stated they could not recall. SW K was asked if they completed a grievance form regarding the concerns reported to them and SW K stated they did not. SW K stated they would look into it and see if they could find what the concerns were and follow back up. At 11:18 AM, SW K returned and stated the believed the concerns were regarding the discharge planning for R202. When asked how they came to that conclusion and what documentation they reviewed to remind them, SW K stated they had notes on their desk. SW K was asked to provide any additional documentation for review. No further explanation or documentation was provided by the end of the survey.

This citation relates to Intake #MI00151329. Based on observation, interview, and record review, the facility failed to protect the resident's rights to be free from physical abuse during two resident-to-resident incidents for two Residents (R205, R206) of three residents reviewed for abuse. Findings include: R206 Review of R206's Minimum Data Set (MDS) assessment, dated 12/13/25, revealed R206 was admitted to the facility on [DATE], with diagnoses including heart failure, lung disease, and arthritis. R206 required set up with eating, and maximal assistance with toileting and transfers. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 15/15, which showed R206 was cognitively intact. On 5/27/25 at 12:54 p.m., R206 was observed dressed, seated in a bariatric wheelchair. On 5/27/25 at 12:56 p.m., R206 reported they had a concern with another resident. R206 reported they transferred to R205's room from another facility room a couple months ago, and the room was torn apart (messy) .so bad (unorganized) . R206 reported the facility staff turned their roommate's bed to fit their (R206's) large bariatric bed with extenders in the room, which made their new roommate (R205) angry. R206 explained their new roommate gave them dirty looks. R206 continued, The next thing I knew, (R206) was yelling and screaming .and (R205) got up and pointed at (R206) with their reacher (metal item retrieval device). (R205) had it in their hand, and (R205) got over there (to their bed) and (R205) hit my right leg and knee, and the woman in the next room heard and got everyone (staff) over here and the patient was (R205) .I said, Get the cops (police), do something, and someone (staff) came in and got (R205) . I was in shock .It (the incident) was inappropriate .Why is (R205) so nasty when I didn't say anything to (R206) .It didn't make me feel happy .(R205) reported the strikes hurt their knee at the time, and there were two small bruises, but they could not be certain they were from the incident. Review of the facility investigation report, received from the Nursing Home Administrator (NHA) on 5/27/25, revealed on 3/10/25 at 4:51 a.m., .Allegation: Assault: Substantiated . The report showed on 3/10/25 nursing staff witnessed an argument between R205 and R206, when R205 threatened R206 who turned their room light off (with assistance). The report further revealed on 3/11/25 at 9:10 p.m., R205 ambulated to their roommate's side of the room and began yelling at R206 and struck them in their legs with reaching device. R205 was reportedly loud and out of control, with their room messy, with clothing, food, and personal items thrown around their room. 911 was called and the police arrived and moved R205 out of the room into another resident room. R206 reportedly declined to press charges. The report revealed the police declined to have R205 sent to the hospital. Afterwards, R205 acknowledged the incident, expressed no remorse and felt their roommate was in the wrong. R205 clarified they did not want to have any roommates. Review of R205's Accident and Incident report, dated 3/11/25 at 8:00 p.m., (R206) was lying in bed when roommate (R205) in Bed A ambulated over and hit (R206) in the leg with a reacher. (R206) began to yell for staff and immediately staff came in the room and intervened . (R206 stated) (R205) hit me in the leg once or twice . The report showed staff intervened, (R205) to another resident room in the facility, and R206 had no injury. Review of Registered Nurse (RN) B's witness statement, dated 3/11/25, revealed, Writer (RN B) was at the nurse's station .Yelling was heard from down the hall in patient's room. When writer arrived, second nurse (unnamed) was in the room .as (R206) was standing at foot of roommates (R206's) bed, striking (R206) and bed with reaching device .Second nurse removed reacher from (R206's) hands. Both nurses escorted (R205) to her side of the room .(R205) was still upset, yelling .The violence was deescalated but (R205) was still yelling and upset about a room change. When writer asked (R206) if (they) were hit (R206) stated 'yes', in the right leg near the knee .911 was called and (police) arrived .(R205) was removed from room and taken to new room by head nurse (unnamed). Review of R206's full skin assessment, dated 3/14/25 (three days after the physical abuse incident), revealed no pain and no new skin concerns. Review of R206's Care Plan, accessed 5/27/25, revealed no interventions to protect R206 from approaching R205 them in their room or in facility common areas. R205 Review of R205's MDS assessment, dated 1/10/25, revealed R205 was admitted to the facility on [DATE], with diagnoses including heart failure, stroke, anxiety, and depression. The assessment revealed R205 required supervision or contact guard assistance (touching assistance with or without cues) for toileting, transfers, and walking room distances. The BIMS assessment revealed a score of 13/15, which showed R205 was cognitively intact. The sensory assessment revealed corrective lenses (glasses) were used by R205 at the time of the assessment. On 5/27/25 at 1:31 p.m., R205 was observed in their room, seated on the edge of their bed, dressed. R205 was not wearing eyeglasses. On 5/27/25 at 1:33 p.m., R205 reported they were having a problem with their roommate in their former room, and staff packed up their (R205's) personal items up and moved them out of the room. When asked why, R205 stated staff cut the lights off and I need the lights on, as they said their eyeglasses got lost and the staff never found them. R205 clarified, I didn't have nothing (any glasses) to see. R205 explained they told their roommate (R206), Don't you see me trying to do something? and R206 started cussing and turned the lights off again. R205 continued, I told the young lady (aide) I'm going to kick (their) butt, and I fell twice trying to get to (R206). I hit (R206) two to three times with the reacher, and it didn't hardly touch (them). They (staff) had me in a hold, and took me out of the room, and the police came and asked me why I was so angry .It made me feel scared . R205 had a metal reacher next to them on their bed, in a private room. R205's nurse, Licensed Practical Nurse (LPN) A, entered their room during the interview, and R205 became verbally escalated (speaking loudly and aggressively) with LPN A about finding their belongings in their room, and declined to speak with Surveyor further. On 5/27/25 at approximately 1:45 p.m., the Unit Manager, LPN A, confirmed there were no other resident-to-resident incidences for R205 and R206. LPN A clarified neither resident had a medical, psychosocial, or functional decline since the incident, and R206 was not injured. Review of R205's social work progress note, dated 3/07/25 at 10:14 a.m. (four days prior to the resident-to-resident incident on 3/11/25), R205 had behavioral episodes including calling 911 r/t (related to) having a roommate (R206). (R205) made it clear (they did) not want a roommate .(R205) has had issues with past roommates and continues to call the family upset (about having a roommate) . Review of R205's behavioral progress note, dated 3/10/25 at 4:51 a.m., revealed R205 was upset R206 wanted to turn the room lights off when they (R206) were attempting to sleep. The writer entered the room when R205 was yelling, and stated, I can't see (vision) . Writer explained to R205 how R206 had a right to sleep with the room lights off so they could fall sleep. In response R205 reportedly became aggressive, and stated, How come it's all about that b@tch? and I don't care what (R206) says; I was in this room first. Writer also heard R205 threaten R206 if they attempted to turn the lights off. The note showed they intervened and notified their supervisor on duty who reported they would contact the Director of Nursing (DON). Review of R205's census form showed R205 was in room [ROOM NUMBER], Bed A, from 1/03/25 to 3/11/25. Review of R206's census form showed R206 was in room [ROOM NUMBER], Bed B, from 3/06/25 to 3/14/25. On 5/27/25 at approximately 3:25 p.m., Social Worker (SW) D reported they were aware there had been verbal allegations by R205 towards R206 prior to the physical abuse incident on 3/11/25. SW D reported they spoke to both residents, who were both their own responsible parties, and neither resident would change (relocate) rooms. SW D said they reported this to the NHA and DON, as they had concerns about both residents remaining in the shared room prior to the resident-to-resident incident on 3/11/25. SW D explained they were concerned as nursing staff had reported R205 threatening words to R206. SW D reported the concerns were R205 wanted their room lights to remain on, and R206 wanted the lights off, and they did not know why. SW D confirmed the resident-to-resident incident occurred on 3/11/25 when R206 reported R205 hit them with their reacher, and confirmed the police were called. SW D reported they and nursing management believed R205 should have been taken to the hospital emergently, however, the police declined, and assisted staff to relocate R205 to another resident room on the other side of the facility. SW D confirmed this was a physical abuse resident-to-resident incident, as when interviewed R205 reported they attempted to hit R206 and expressed no remorse. SW D reported they were not aware R205 had glasses, or had reported they could not see to them or staff and said they would follow-up. Review of the Electronic Medical Record (EMR) including R206's progress notes with SW D revealed no progress note describing the incident itself. SW D reported their expectation would be there would be a progress note describing the resident-to-resident physical abuse incident on 3/11/25 would be in R206's medical record. Review of the incident investigation file revealed a verbal reeducation in service with LPN C, dated 3/11/25, signed by the NHA. The document revealed LPN C had not reported the alleged verbal abuse in a timely manner to the NHA or DON, when floor staff reported to their supervisor, LPN C, R205 made a verbal threat to their roommate (R206). The abuse policy was reportedly reviewed with LPN C at that time. On 5/27/25 at 3:44 p.m., the afternoon supervisor, (LPN) C, confirmed the resident-to-resident physical abuse incident between R205 and R206 occurred, as they were working. LPN C reported they were sitting at the desk when they heard the nurse and aide yelling and they observed R205 standing over R206. LPN C described they had not known R205 stood and walked, as they had only seen them using their manual wheelchair. LPN C reported RN B was standing there when R205 struck R206 on their shin with their reacher, and since R206 was physically assaulted, they called the police. LPN C stated the DON wanted R205 sent out to the hospital, and the police declined. LPN C explained R205 admitted to the police they hit R206, and R206 declined to press charges. LPN C confirmed this was physical abuse. LPN C reported they got an Xray of R206's knee and clarified R206 was not injured. On 5/27/25 at 3:50 p.m., the verbal review in service education form dated 3/11/25 was reviewed with LPN C, who denied recalling a phone in service or reeducation by the NHA regarding not reporting verbal abuse prior, and said they only learned of this when the 3/11/25 incident occurred. On 5/28/25 at 10:04 a.m., during a phone interview, Registered Nurse (RN) B stated on 3/11/25 they observed R205 hit R206 on their legs with a reacher, using it as a weapon, and they and another nurse had to intervene. RN B reported R206 was not upset or fearful after the incident. RN B reported the police were called and called this a violent incident. On 5/28/25 at 11:48 a.m., the Medical Director, Physician F, reported they had been made aware resident-to-resident incidents occurred between R205 and R206, and they were reviewing the incidents in their QAPI (Quality Assurance and Performance) program. Physician F conveyed they understood the residents declined to change rooms prior to the incident, and deferred documentation expectations to the NHA. Physician F reported R206 was under their care, and they had not been made aware of any reported vision concerns for R205. On 5/28/25 at 12:21 p.m., room [ROOM NUMBER] (R205 and R206's former room) was observed, where the incident occurred. It was noted when the room light switch was activated, a circle overhead ceiling light lit above both Bed A and Bed B simultaneously. It was further observed each bed had a bright fluorescent light over the head of bed, and the room ceiling lights activated in tandem, making the room well-lit when the room light switch was on. On 5/28/25, the police report, dated 3/11/25, received from the NHA, was reviewed. The police report showed simple, non-aggravated assault and battery occurred by R205 towards R206. The report described how R206 reported R205 was complaining because they wanted their room lights turned off to sleep, while R205 wanted them on. R205 reportedly became angry about the lights being turned off, and whacked R206's legs with an extended grab claw reacher. R206 denied any injuries, and said they only wanted R205 removed from the room, and did not want to press charges. The report further revealed R205 reported they wanted the lights on as they were having difficulty seeing when they were awake and walked over to R206's bed to yell them but denied hitting R206. The report described R205 was relocated to room [ROOM NUMBER] (a different facility room) with no further issues. On 5/18/25 at approximately 1:10 p.m., the NHA confirmed the resident-to-resident incident on 3/11/25 was a physical abuse assault incident between R205 and R206. The NHA confirmed there was a delay in staff reporting the alleged verbal abuse incident on 3/10/25 to them and the DON, and clarified the incident was reported and investigated upon discovery. The NHA understood the concern there was no progress note for R206 regarding the resident-to resident incident on 3/11/25 in the EMR. The NHA confirmed R206 was not injured right after, and no injuries were found a few days after the incident. The NHA reported they explained their staff had not been found aware of R205 reporting their vision was impacting their perceived ability to feel comfortable with the lights off in their room, and they had already begun follow-up. This Surveyor shared with the NHA R205's progress notes showed R205 was reporting vision concerns to their staff, law enforcement noted a concern in their report, and R205's MDS assessment on 1/10/25 showed they corrective lenses were used. Review of the policy, Abuse, dated 4/13/25, revealed, Residents have the right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of resident property The facility will develop and implement policies that include: Screening potential employees and prospective residents, training new and existing staff on prohibiting, preventing, and identifying abuse, neglect, exploitation, mistreatment, and misappropriation of resident property, reporting procedures, dementia, and behavior management. Prohibiting, preventing, and identifying abuse, neglect, mistreatment, exploitation, and misappropriation of resident property. Reporting all allegations of abuse, neglect, mistreatment, exploitation, and misappropriation of resident property including reporting a reasonable suspicion of a crime to the State Survey Agency and other officials in accordance with State law. Investigating allegations of abuse, neglect, misappropriation, mistreatment, and exploitation to include protecting residents during the investigation, and taking necessary actions as a result of the investigation. Establishing coordination with the QAPI (Quality Assurance Process Improvement) program. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written .

This citation pertains to intake #: MI00152670 Based on interview and record review facility failed to investigate (and follow-up) on an injury (skin tear) of unknown origin for one (R207) of three Residents reviewed for abuse resulting in the potential for further unidentified instances of injuries of unknown origin. Findings include: Review of the complaint received to the State Agency revealed that a family member/emergency contact regularly visited R207 during their stay at the facility. On 4/28/25 the family member discovered that R207 had a bandage on their arm when they removed the resident's jacket. When they removed the bandage they found bruises and a gash. They reported they were handling and assisting R207 with all their affairs. They did not receive any calls from the from the facility on how R207 sustained this injury. Record review revealed R207 was admitted to the facility on [DATE] for short-term skilled rehabilitation and nursing care. R207's admitting diagnoses included atrial fibrillation (irregular heartbeat), stroke, urinary tract infection, hearing loss, and dementia. Based on Minimum Data Set (MDS) assessment dated [DATE], R207 had a Brief Interview for Mental Status (BIMS) score of 8/12, indicative of moderate cognitive impairment. Review of R207's Electronic Medical Record revealed that R207 was admitted to the facility on [DATE] and they were discharged home with family on 5/20/25. Review of admission nursing progress notes dated 4/4/25 read that R207 had healed scratch marks on both thighs and skin tags to back and chest. Note read Resident has no wounds . Review of R207's admission nursing assessment did not reveal any open injuries/skin tear on their arms. Review of skin assessments dated 4/9/25, 4/16/25, and 4/23/25 did not reveal any skin tear/lesions. Further review of skin assessment dated [DATE] revealed a note that read right ante-cubital (area of forearm in front of the elbow joint), healing skin tear to right forearm'. Skin assessment dated [DATE] also had the same note as above. Further review of R207's nursing, practitioner and physician progress notes did not reveal any documentation of any incidents and or injuries/lesions. Review of R207's physician orders did not reveal any orders for treatment for any injuries/skin tear. Review of the discharge summary and order did not reveal any documentation on the skin tear on the the forearm. Review of R207's MDS (discharge) assessment dated [DATE] did not reveal documentation of any skin tear. A request was sent via email to the facility administrator on 5/28/25 at 9:02 AM requesting all incident/accident reports and facility investigations for R207 throughout their stay at the facility. The Administrator replied and noted that they did not have any incident and accident reports and or any investigations for R207. Review of R207's shower sheets were completed with Unit Manager H on 5/28/25 at approximately 1:10 PM. The shower sheets dated 4/26/25, 4/30/25, 5/7/25, 5/14/25 and 5/17/25 signed by the Certified Nursing Assistants (CNA) and nurse (s) did not indicate any skin tears. An interview with the complainant was completed on 5/28/25 at approximately 11:10 AM. The complainant reported that they came in to visit R207 and they were sitting on the courtyard and they had removed R207's jacket and observed the bandage on their forearm. They reported that R207 was not able to explain what happened. They had approached the facility staff at the desk. One staff member had mentioned that it might have happened in the shower room and did not provide any further details. They were notified that someone from the facility would contact and follow-up with them. The facility did not provide any further details. Prior to the review of R207's shower sheets (at approximately 12:45 PM), an interview was completed with Unit Manager H. They were asked about R207. UM H reported that they remembered the resident. When queried if they recall R207 having incidents and they reported R207 having a skin tear on their arm and might have been the right arm and they need to check the EMR. When queried further about what facility investigation process and what happened, UM H reported that the nurses completed an incident report and it was under their risk management and they added that the physician and responsible party were notified as part of their process. They added that treatment orders would be placed and it would also reflect in nursing progress notes and they would notify the facility's wound care team. They were asked to check R207's EMR to provide documentation/additional information. UM H reviewed the EMR and reported that they did not find any incident/accident report or progress notes and or treatment orders related to the right forearm skin tear. They were notified of the concern and they agreed on the concern and did not provide any further explanation. They reported that they would follow with the staff. An interview with facility Administrator was completed on 5/28/25 at approximately 1:35 PM. During the interview Regional Clinical Services Director (RCD) I was present in the office. The Administrator was asked about the facility process on investigation of skin tears. The Administrator reported that they would complete a nursing assessment, incident and accident report/risk management report and completed an investigation. They added that the physician and responsible parties were notified and treatment orders were implemented. They were queried about R207 and skin tear investigation and follow up, that were noted on skin assessment dated [DATE]. The Administrator reviewed the EMR and reported that they would check further and report back. The Administrator was notified of the follow up with Unit Manager H and notified of the concern. Prior to exit, the Administrator replied via e-mail and notified that they did not have any additional information or investigation for the skin tear on R207's right forearm. Review of the facility provided document titled Abuse - Policy and Procedure with a revision date on 5/24/23 read in part, Key to investigating abuse allegations is an environment that facilitates the reporting of such allegations. Once reported, the center conducts a timely, thorough, and objective investigation of any allegation of abuse. It is the Center's policy to investigate all alleged violations involving Abuse, Neglect, Misappropriation of Resident Property, Exploitation or Mistreatment, including Injuries of Unknown Source to ensure that all individuals who report such incidents and allegations are free from retaliation or reprisal for reporting the incident. Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. Report the results of all investigations to the administrator or designee and to the State Agency in accordance with State law. The investigation process includes: • Identifying staff responsible for the investigation. • Determining the purpose of the investigation and issue(s) to be investigated, whether or not the alleged violation has occurred, the extent, and cause. • Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations (such as other residents, family members, staff who worked closely with the alleged perpetrator and/or alleged victim). • Conducting observations of the alleged victim, including identification of any injuries as appropriate, the location where the alleged situation occurred, interactions and relationships between staff and the alleged victim and/or other residents, and interactions/relationships between resident to other residents as applicable. • Identifying and reviewing all relevant medical records and facility documentation as applicable. o If the alleged perpetrator is a staff member, review their employment records. • Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence). o Providing complete and thorough documentation of the investigation .

Based on observation, interview and record review the facility failed to prevent a facility acquired pressure ulcer for one (R59) out of four residents reviewed for pressure ulcers, resulting in the development of an unstageable pressure ulcer (full thickness skin and tissue loss with obscured wound bed) to the left heel and sepsis infection from tight fitting shoes. Findings include: On 12/2/24 at approximately 8:55 AM, R59 was observed lying in bed. The resident was alert but confused and not able to answer questions asked. The resident was not wearing shoes and had yellow skid socks on. A review of R59's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Dementia, type II diabetes and atrial fibrillation. A review of the resident Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 1/15 (severely cognitively impaired). Continued review of the MDS (7/5/24) noted the resident had no physical and/or verbal behaviors directed towards others. Continued review of R59's clinical record revealed, in part, the following: Care Plan: Focus: Risk for Pressure Ulcer Formation related to generalized debility and weakness as evidenced by decreased mobility in bed and wheelchair .Resident need staff assistance with incontinence care, turning and repositioning, Braden score <17 .10/4/23-no pressure ulcers noted .7/8/24 - no pressure ulcer noted .9/3/24: LEFT HEEL UNSTAGEABLE PRESSURE ULCER .Date initiated: 10/2/22 .Interventions: Encourage resident to float heels and/or wear heel boots (10/2/22) . Skin and Wound Evaluation (date 8/19/24- lock date: 8/29/24): .Describe: Type: Pressure .Stage: Unstageable (obscured full-thickness skin and tissue loss) .Location: Left medial calf .acquired: In house Acquired .Wound measurements .length 2.6 cm .width 1.0 cm .Notes on pain: Patient complained of pain during dressing change .Goal of care: Slow to heal .Education: Patient educated on the importance of not wearing shoes while in bed, or that they are too tight, as the wound was caused by her shoe . 8/17/24: Note Test: assisted cna (certified nursing assistant) with changing the patient and notice a swollen ankle and bleeding heel. Pt (patient) refused to let me examine further but did say she would allow an x-ray. The patient states it hurts, I can't stand, and the pain started yesterday. 8/19/24: Physician Team: R59 .has history of significant Alzheimer's dementia, atrial fibrillation .and diabetes mellitus .is seen today for left ankle pain and bleeding .she apparently keeps her shoes on while in bed and that is rubbing against her left Achilles area and left heel she started having a wound with intermittent bleeding and swelling of the left heel .she has refused to allow staff to dress her left heel and ankle .Impression and plan: Left ankle wound likely from her shoes that she refuses to remove while lying in bed, we will have patient seen by wound care services, she appears that she has secondary cellulitis she will be started on Augmentin (antibiotic) every 8 hours for 5 days, apply TAO (triple antibiotic ointment) and wrap with Kerlix and removed shoe when she is in bed keep he <sic>is floated while in bed 8/19/24: Nursing Skin/Wound Note: Late Entry: Wound care consulted for left ankle wound. Wound care able to remove shoes from residents' feet. Observed by wound care left ankle and top of foot is swollen, left Achilles has an area of eschar tender to touch. Area has some moisture damage from edema. Resident being treated for cellulitis. Will apply adaptic <sic> with dry dressing. Wound care to follow. No shoes. Supplied grip socks for resident to wear. Will encourage elevation of heels while in bed . 8/31/24: Wound Rounds: Patient (R59) .is being seen for the management of a wound that she has acquired on the left heel close to the Achilles. It is trauma induced, as she was wearing tight shoe and refusing to take it off .has history of advanced Alzheimer's type dementia The examination was focused on left foot . During the record review that included facility staff notes, care plans, Task/Kardex interventions there were no documents as to the resident either wearing shoes in bed prior to 8/19/24, refusing to take off their shoes, or attempts to remove the resident's shoes while in bed. On 12/4/24 at approximately 9:30 AM, an interview was conducted with Wound Nurse Coordinator P and Nurse Q who reported they were working with Nurse P. Both were asked as to the protocol for preventing and treating wounds. Wound Nurse P reported that they do not work with residents until they receive a report of a concern with skin. When asked about R59, Nurse P reported that they received information about R59 on 8/19/24 and noted it was the first time they had seen the resident. When asked about the facility acquired wound on R59's heel, they noted that they believed the root cause was due to R59 refusing to remove their shoes that were too tight. However, they indicated again that they had never seen the resident for wound care prior to 8/19/24. On 12/4/24 at approximately 9:41AM, an interview was conducted with both the Director of Nursing (DON) and Former DON/Administrator in Training (AIT)A. Both were asked about R59's facility acquired unstageable wound to the left heel. AIT A reported that it was determined the wound stemmed from the resident's shoe and their refusal to have staff remove them while lying in bed. AIT A was asked to provide any documentation that attempts were made to remove the resident's shoe(s) and their refusal to have it removed. In addition, AIT A was asked to provide any interventions initiated regarding shoe removal. On 12/4/24 at approximately 10:01 AM, R59 was observed attempting to get out of their bed. The resident had yellow gripper socks on, was alert, non-combative, but confused as to where they were and where they wanted to go. Their call light was out of reach. CNA S was asked to come assist the resident who appeared confused. CNA S reported they had worked at the facility for over [AGE] years and was familiar with the resident. When asked if they were aware that R59 refused to have her shoes removed during care. CNA S noted that they did not recall that the resident refused. On 12/4/24 at approximately 11:16 AM, an interview was conducted with Medical Director (MD) U. MD U was asked about R59's facility acquired unstageable wound to the left heel and noted that he saw the resident right after the wound was found and noted that they remember removing the resident's shoe to view the wound. MD U was not certain as to interventions that were tried prior to discovering the wound. Prior to the end of the Survey, the facility provided documentation regarding R59's wound however, the documentation provided did not contain any evidence that attempts were made to remove the resident's shoes while in bed and/or documentation that the resident refused prior to 8/19/24. There was also no documentation as to whether the resident feet were floated and/or heel boots were provided as noted in the resident's care plan.( 10/2/22).

This citation pertains to Intake Number(s): MI00148148 and MI00147901 Based on observation, interview, and record review, the facility failed to transfer a resident in a safe manner, provide adequate supervision, and implement effective interventions to prevent falls for three (R7, R129, R59) of four residents reviewed for accidents, resulting in R7 falling and sustaining a right oblique humerus fracture (broken at an angle) and right fifth digit (finger) fracture which caused a decline with additional assistance needed (substantial to dependent). Findings include: R7 On 12/2/24 at 9:50 AM, R7 was observed seated in a wheelchair in their room. At that time, an interview was conducted with R7 regarding the care in the facility. R7 reported they fell multiple times due to not being able to stand like they used to. R7 reported the worst fall was several months ago and occurred when a Certified Nursing Assistant (CNA) did not assist them to get back into the bed after using the bathroom. R7 reported when they asked the CNA to help get back in bed, the CNA told R7, You can do it yourself. It's only 2 or 3 steps. According to R7, their legs gave out and they fell to the floor and broke the big bone in my arm and some fingers. R7 stated, My arm still bothers me sometimes. A review of R7's progress notes revealed the following: On 2/26/24, it was documented in a Physician Team - Progress Note that R7 had cough, congestion, body aches, hypoxia (low oxygen levels) with fatigue. On 2/27/24 at 10:42 PM, it was documented in a Nursing-Progress Note that the on-call doctor ordered a complete x-ray for the right arm. It was documented Writer and care team placed resident back in wheelchair then placed in bed and R7 had small bruising on right arm. On 2/28/24 at 7:36 AM, it was documented in a Nursing-Progress Note that it was one day status post a witnessed fall and R7 complained of pain to the right arm. It was documented an x-ray was pending. On 2/28/24 at 1:13 PM, it was documented in a Physician Team-Progress Note that R7 was seen for follow-up after a witnessed fall the previous night while being assisted from a transfer into bed from the wheelchair. It was documented R7's legs became weak and they landed on the floor. R7 had pain in her right arm, an x-ray was ordered, and they were unable to move their arm due to pain. On 2/28/24 at 7:27 PM, it was documented in a Nursing-Progress Note that R7 was transferred to the hospital due to an oblique fracture involving the humeral neck. On 3/2/24, it was documented in a Nursing-Admission Note that R7 was readmitted into the facility from the hospital with acute pain/fx (fracture) to right arm from recent fall. On 3/4/24, it was documented in a Physician Team - H&P (History and Physical) that R7 returned from the hospital with a right proximal humerus fracture. R7's arm was placed in a sling and due to pain in their right hand, an x-ray was done at the hospital which revealed a nondisplaced fracture of the base of the proximal base of the right fifth digit and was placed in a special brace and non-weightbearing in the right upper extremity. On 12/3/24 at 10:28 AM, the Administrator and Director of Nursing were asked to provide all incident reports with any associated investigation documentation since February 2024 for R7. A review of an incident report for R7 dated 2/27/24 at 9:25 PM revealed R7 had a witnessed fall on that date. It was documented by the nurse that upon entrance to R7's room, R7 was on the floor sitting on her bottom with (CNA) standing right behide <sic> resident .Resident states that her legs became weak and could no longer complete the stand pivot to bed. It was documented an x-ray to the right arm was ordered. In the section labeled statements, no name was included. R7's pain level was noted as seven out of 10 with 10 being the highest level of pain. There were no additional documents that indicated the incident was investigated to determine the root cause of the fall. A review of R7's clinical record revealed R7 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: hemiplegia and hemiparesis right dominant side and osteoarthritis. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R7 had moderately impaired cognition and required substantial/maximum assistance for bed mobility, transfers, including toilet transfers, and partial/moderate assistance to walk 10 feet. R7 did not have any falls within the assessment period. R7 was assessed to have occasional mild pain. A review of a significant change MDS dated [DATE] (after R7's fall resulting in a fracture) revealed R7 had severely impaired cognition and was dependent on staff for bed mobility and transfers and was unable to walk. Further review of R7's incident reports revealed on 6/11/24 at 7:50 AM, R7 fell during a staff assisted transfer from the bed to the wheelchair. It was documented R7 was unable to continue standing and was assisted to the floor by staff. The staff member involved was not included in the information provided. In the notes section, the following was documented, IDT (Interdisciplinary Team) reviewed fall .Care Plan was updated to reflect educating staff on the use of gait belt when transferring resident . On 12/4/24 at 9:01 AM, an interview was conducted with the former Director of Nursing (DON), Administrator in Training (AIT) 'A'. When queried about what was done to investigate the root cause of R7's fall that occurred during the CNA assisted transfers on 2/27/28 and 6/11/24, AIT 'A' reported education was provided to the CNAs and he will provide it. At that time, the name of the CNAs involved were requested and AIT 'A' reported he would get that information. A review of R7's care plans revealed the following: A care plan initiated on 5/31/23 revealed R7 had ADL and mobility deficits R/T (related to) ongoing health events, minimal right sided weakness. An intervention initiated on 11/14/23, indicated R7 required 2 person assist for bed mobility and toileting. It was documented that R7 required 2 person assist for transfers at the time of the falls on 2/27/24 and 6/11/24. According to the care plan, as of 5/31/24, R7 required 2 person assist with a sit to stand lift. On 12/4/24 at 12:05 PM, an interview was conducted with CNA DD'. CNA 'DD' was able to recall the incident with R7 on 2/27/24. When queried about what happened, CNA 'DD' reported she was getting her in the bed using a gait belt after taking her to the toilet and R7 was unable to stand and pivot and her legs gave out and CNA 'DD' was unable to hold her up and she fell and sustained an injury. At the time of the fall, CNA 'DD' was the only CNA providing assistance. When queried about any education that was provided to CNA 'DD' after the incident, CNA 'DD' reported she talked to the DON (AIT 'A') and R7 was changed to use a sit to stand lift. The facility provided a document titled, Employee Counseling & Corrective Action Record dated 6/19/24 for CNA 'EE'. The document noted CNA 'EE' did not follow the resident's (R7's) plan of care for transfers (two person assist). No further information was provided for the incident with R7 that occurred on 2/27/24. On 12/4/24 at 1:31 PM, a follow up interview was conducted with the DON and AIT 'A'. AIT 'A' reported additional information was unable to be located and acknowledged R7 was not assisted by two people on 2/27/24 and 6/11/24 according to their plan of care. 34208 R129 On 12/2/24 at 12:00 PM and 2:00 PM, R129 was observed seated in their wheelchair in the common area near the 100 unit. Dycem (a non-slip, rubber-like material used to stabilize surfaces and improve grip) could not be observed in the seat of the wheelchair. On 12/3/24 at approximately 10:00 AM, R129 was observed sleeping in their bed. Their wheelchair was at the bedside and there was no Dycem on top of the wheelchair cushion. The top of the wheelchair cushion was observed to be slightly shiny and had a slippery texture. On 12/3/24 Nurse 'AA' and Certified Nurse Aide (CAN) 'X' were asked if R129 could stand with assist and said they could. They were asked if they could assist them to stand so an observation of the wheelchair cushion could be made. Nurse 'AA' and CAN 'X' assisted R129 to stand and no Dycem to the top of the wheelchair cushion was observed. They did say Dycem was under the cushion to prevent the cushion from sliding out of the wheelchair. They were asked what was in place to prevent R129 from sliding off the top of the slippery cushion and they said Dycem should probably be on the top of the cushion as well. A review of R129's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: dementia and repeated falls. R129's most recent Minimum Data Set assessment revealed they had severe cognitive impairment. A review of R129's progress notes revealed they sustained a fall on 11/12/24. A note dated 11/12/24 at 6:35 PM read, .writer waked by room and observed staff in room with resident sitting at the edge of the bed. writer <sic> asked staff what happened. staff <sic> member informed resident was found sitting on the ground . No incident report or investigation into the fall was provided by the facility. Continued review of R129's progress notes revealed a note dated 11/13/24 that indicated R129 had an unwitnessed fall in the bathroom. An incident/accident report was provided, and indicated R129 was ambulatory without assistance Predisposing factors to the fall listed on the report included: poor lighting, confusion, incontinence, impaired memory, weakness, improper footwear, and ambulating without assistance. A new care plan intervention after the fall on 11/13/24 was to apply dycem to R129's wheelchair. A progress note dated 11/22/24 was reviewed and read, Pt. (patient) was leaning too far forward and slid out of wheelchair onto his buttocks . A follow-up progress note dated 11/23/24 read, IDT (interdisciplinary team) team reviewed. Care plan updated to reflect the use of dycem in the wheelchair to prevent sliding . It was noted this was not a new intervention as it had been added on 11/13/24. It was unclear from the investigation whether R129 had dycem in the wheelchair at the time of the fall on 11/22/24 as suggested by the care plan intervention on 11/13/24. On 12/4/24 at 8:45 AM, an interview was conducted with the former Director of Nursing (DON) who was currently an Administrator in Training (AIT) in the presence of the new DON. They explained that when a fall occurs, staff should implement new and appropriate interventions. A review of a facility provided policy titled, Fall Management Workflow dated 12/2023 was conducted and read, .Post-Fall Evaluation: .Attempt to determine the root cause of the event and initiate modifications to the resident's care plan as indicated. Complete an incident report in risk management . 34275 R59 On 12/2/24 at approximately 8:55 AM, R59 was observed lying in bed. The resident was alert but confused and not able to answer questions asked. On 12/4/24 at approximately 10:01 AM, R59 was observed attempting to get out of their bed. The resident had yellow gripper socks on, was alert, non-combative, but confused as to where they were and where they wanted to go. Their call light was out of reach. CAN S was asked to come assist the resident who appeared confused and was trying to get out of bed on their own. A review of R59's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Dementia, type II diabetes and atrial fibrillation. A review of the resident Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 1/15 (severely cognitively impaired). Continued review of R59's clinical record revealed, in part, the following: 5/28/24: Note Text: Resident observed on floor sitting on buttocks holding on to wheelchair . 10/8/24: Note: Resident found sitting on floor . 10/26/24: Note: Pt (Patient) usually stands up on her own to transfer, when attempting to transfer patient fell on the floor . 12/1/24: Note: resident in wheelchair asking for help with her bed, writer told the resident ok, head back to your room and I will assist you. When going to assist the resident, observed resident in room [ROOM NUMBER]P (not the resident's assigned room) trying to transfer herself to the bed when the resident lost balance and fell on her buttock . 12/2/24: IDT (interdisciplinary team): IDT team reviewed fall .Care plan was updated to reflect Staff was educated on the importance of taking the resident back to her room and assisting her into the bed . Review of R59's care plan revealed, in part, Focus: Resident is at Risk for Falls and Potential for Injury r/t (due to): Gait/balance problems; confusion with Dementia .use of psychoactive and/or narcotic medications(s) .date initiated 10/2/22 .Interventions/Task .fall intervention per facility protocol (10/2/22) .Staff is to do frequent rounding on resident (5/31/24) .staff was educated on the importance of taking the resident back to her room and assisting her into bed (12/2/24) . On 12/4/24 at approximately 2:00 PM an interview was conducted with AIT A. AIT A was queried as to the interventions put into place to prevent falls for R59 who had a history of falls and was noted as having severe dementia. AIT A reported that they were aware of the resident's inability to follow directions provided and reported that the last fall on 12/2/24 the Nurse was provided education as to assisting resident into their room for assistance into bed. A review of the facility policy titled, Fall Management Workflow (12.13.24) revealed, in part: .To provide a workflow for licensed nurses in conjunction with the Fall Management Guidelines Policy to assist with fall risk .The fall risk evaluation should be completed: upon admission .Quarterly .After a resident falls- to ensure there are no new or changed risk factors for the resident that need to be addressed .with a significant change of condition .

This citation pertains to intake(s): MI00137355 & MI00138070. Based on interviews and record reviews the facility failed to consistently assess, monitor, and implement a plan of care of a surgical site (R806) and failed to identify a head abrasion and follow up on the origin of the head abrasion (R809) for two of three residents reviewed for non-pressure wounds. Findings include: R809 Review of an intake submitted to the State Agency (SA) documented concerns of bruising to the resident head that was not reported to the family. An onsite investigation was conducted of the complainant's concerns. Review of the medical record revealed R809 was admitted to the facility on [DATE] with diagnoses that included: dementia, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, aphasia, and type 2 diabetes mellitus. A Minimum Data Set (MDS) assessment dated [DATE], documented Severely impaired cognitive skills for daily decision making and required staff assistance for all Activities of Daily Living (ADLs). Review of the medical record revealed no documentation of the identification of any head bruising or trauma to R809. On 9/19/23 at 12:04 PM, the facility's Administrator and Director of Nursing (DON) was asked to provide all grievances and Incident and Accident reports completed for R809. Review of a grievance form provided, dated 4/28/23 documented the following in part . reported from the floor nurse that family was in room stating there was a bruise noted to the patient's forehead . Investigation: upon entering the room family stated there was a bruise on the patients head yesterday when they were here . family stated they had a picture but would not show this nurse. Assessment of head/scalp performed, and no sign of bruising noted . No further concerns noted . Message left with daughter . There were no Incident and Accident reports provided for R809. Review of the progress notes revealed R809 was transferred to the hospital on 5/2/23 for concerns with a sacral coccyx wound. Review of the hospital ER (emergency room ) Provider note dated 5/2/23 at 3:51 PM, documented the following assessment in part . Physical Exam . Head: Normocephalic . Abrasion to top of head, redness on middle forehead . On 9/20/23 at 8:43 AM, the DON was interviewed and asked about the family to have verbalized their concern regarding bruising identified on their loved one's head, a grievance completed documenting no findings, compared to an initial ER physical examination that was conducted when the resident was transferred from the facility to the ER, in which the ER physician identifies an abrasion and redness to R809's head. The DON stated they vaguely remember the incident, however stated there was nothing found on the resident when they completed their assessment. When asked how R809 obtained an abrasion with redness to their head with nothing documented in the medical record and no Incident and Accident reports revealing any falls and/or accidents, the DON was unsure of how it could have occurred. No further explanation or documentation was provided by the end of the survey. 48680 This cite pertains to intake MI00138070. R806 Review of an intake submitted to the State Agency (SA) documented concerns of surgical site dressing changes not being completed. Record review revealed that R806 was admitted to the facility on [DATE] with the diagnoses of Spinal Stenosis lumbar region, Low back pain and encounter for surgical aftercare following surgery on the nervous system. Record review revealed that R806 Brief interview mental status(BIMs) was a 13 and the minimum data set(MDS) showed that they needed moderate assistance with activities of daily living(ADLs). Record review revealed that R806 on 6/21/23 has a spinal stenosis lumbar incision with several sutures. Record review revealed that on 6/25/23 a treatment and care plan was put in place for the surgical site. Record review revealed on 6/27/23 there was a progress note R806 was started on oral antibiotics (for infection) for the surgical site. On 9/20/2023 at 11am Nurse D was interviewed for if there was a care plan or treatment ordered for R806 and if treatment orders go in upon admission. Nurse D noted there was a treatment order in place four days after arriving to facility. Nurse D was asked if there would be orders to monitor a surgical site upon admission. Nurse D replied, Yes there should. On 9/21/2023 at 12 pm, the DON was interviewed and asked if incision sites need treatments ordered upon admission. The DON explained that there would be an incision monitoring order unless it was an occluded surgical dressing, and the treatment should be documented as completed per day. Record review revealed that on 6/27/23, R806 was sent out to hospital for lower back pain and dark green drainage from her back and uncontrolled pain to the lower back area. There was no addition information given by the exit of survey.

This citation pertains to intake(s): MI00136632 and MI00137232. Based on observation, interview and record review, the facility failed to ensure consistent and comprehensive skin assessments and implement interventions for two (R811 and R820) of two residents reviewed for pressure ulcers(PU), resulting in R820 developing an unstageable (the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) PU and R811 developing multiple PU's. Findings include: On 9/20/23 around 11:30AM, R820 was observed in his room lying in the bed. R820 was asked if he had any wounds or sores. R820 believed so and that they (the facility) put a dressing on it. Review of the clinical record revealed that R820 was admitted into the facility on [DATE] with diagnoses that included weakness, multiple fractures of ribs right side and traumatic pneumothorax. Record review of the most recent Minimum Data Set(MDS) revealed that R820 needed supervision and assistance with activities of daily living(ADL's) and had an intact cognition. The MDS assessment indicated that R820 did not have any PUs upon admission. Review of R820's nursing admission entrance assessment dated [DATE] revealed there were no open areas but did document redness on the coccyx area. Reviewed R820's comprehensive care plan revealed no interventions to prevent skin break down. Review of R820's physicians orders revealed no orders for preventative measures to protect skin integrity. Review of R820's clinical record revealed no skin assessments after the inital assessment upon admission. On 9/20/23 at 11AM, Nurse D, who serves as the facilities wound care nurse, was interviewed in regard to R820's skin and the skin management program of the facility. NurseD explained that there is one unstageable wound located on the coccyx of R820 and that the floor nurses are responsible for the initial skin assessment and if issues with skin are noted, a wound consult will be put in as an order. Nurse D was asked if R820 came into the facility with any skin issues. Nurse D explained that the admitting nurse put redden area in the progress notes of R820. Nurse D was asked if redden areas receive interventions or treatments? Nurse D stated, They should put in an order for barrier creams and frequent repositioning. Nurse D was asked if the facility conducts assessments of the skin and replied Yes, they are done weekly. On 9/20/23 around 12PM Nurse L was interviewed who acted as the interim Unit manager for the unit. Nurse L was asked after admission to the facility, what is the process for assuring that skin assessments are completed correctly. Nurse L explained that they to check to make sure everything is signed and locked, but do not physically go and assess the residents for accuracy. On 9/20/2023 at 4:30 PM the Director of Nursing(DON) and Administer was interviewed and asked a how are skin assessments completed with new admissions, how do the nurses know to do skin assessments, and what orders would be put in for reddened areas? The DON replied, Skin assessments are to be done upon admission and then weekly. The DON explained the nurse who admitted a resident will look at the skin and if there is a problem, [Nurse D] will be consulted. The DON further explained that weekly skin assessments are auto populated (by the computer system) and if its (the skin assessment) is not in (the computer) then it (the assessment of the skin) could be on shower sheet. The DON stated, We instruct certified nursing assistants to notify a nurse no matter how big, little or old an area may be. I would hope to see and order for peri guard (a barrier cream) if a person has a redden area. There was no addition information provided by the exit of survey. 41415 R811 Review of the medical records revealed R811 was readmitted to the facility on [DATE] with diagnoses that included: dementia, chronic kidney disease (stage 3), and glaucoma. A MDS assessment dated [DATE], documented a BIMS score of 3 (which indicated severely impaired cognition) and required staff assistance for all ADLs. Review of an admission Braden assessment dated [DATE], documented a score of 19. The facility's Braden categorization documented in part . At Risk 15-18, Moderate Risk 13-14, High Risk 10-12, very high risk 9 or below . Review of a Nursing - Admission Note dated 2/25/23 at 7:18 PM, documented in part . Rec'vd (received) pt (patient) via ambulance stretcher . Alert and oriented x1-2 with confusion noted . Skin assessment complete with no open areas noted, skin clean dry and intact. Bil (bilateral) feet dryness noted with brille (sic) yellowish toenails observed . Review of a skin assessment completed on 2/27/23 documented no skin abnormalities identified and on 2/28/23 documented . scattered superficial scratches to bilateral upper extremities, toenails are discolored, brittle and uneven. Patient has dry flaky skin to bilateral feet . no other skin abnormalities were identified. Review of a Physician note dated 3/21/23 at 5:24 AM, documented in part . Continue wound care as ordered . Review of the March 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed the following: . Skin Evaluation weekly . Check skin for open areas . PLEASE OPEN SKIN EVALUATION UNDER ASSESSMENTS TAB: two times a day every Mon (Monday), Thu (Thursday) . Start Date: 2/27/23. . Medihoney Wound/Burn Dressing External Paste (Wound Dressings) Apply to left buttocks topically one time a day for wound care cleanse wound, pat dry, apply medihoney and border gauze . Start Date 3/30/23. Review of the medical record revealed no documented weekly skin evaluations completed (from admission until discharge) under the assessment tab as ordered. Further review revealed no wound treatment in place on 3/21/23 as documented by the practitioner. Review of a Health Status Note dated 3/29/23 at 11:37 AM, documented in part . resident has two open areas on his left buttocks. Area cleaned and treatment applied. Wound consult done . Review of a care plan titled Risk for Pressure Injury Formation related to: generalized debility and weakness as evidence by: decreased mobility in bed and wheelchair, incontinence of bowel and bladder. Resident need staff assistance with incontinence care, turning and repositioning . Date initiated 2/27/23, documented the following interventions . Braden scale to be completed per facility protocol . Cushion to wheelchair daily . Encourage intake of 75-100% of diet and fluids daily. RD (Registered Dietician) to assess dietary needs quarterly and with significant changes . These three interventions were not adequate in preventing pressure wounds for R811, who had decreased mobility, utilized a wheelchair, was incontinent of urine and bowel and required staff assistance for all ADLs. Review of a care plan titled The resident has potential/actual impairment to skin integrity of the (SPECIFY location) r/t impaired bed mobility and fragile skin (Date Initiated 3/7/23) documented the following interventions . Keep skin clean and dry. Use lotion on dry skin. Do not apply on (Specify: site of injury) . Monitor for side effects of the antibiotics and over-the-counter pain medications; gastric distress, rash, or allergic reactions which could exacerbate skin injury . Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration etc to MD (Medical Doctor), Obtain blood work such as CBC (complete blood count) with Diff, Blood Cultures and C&S (cultures and sensitivity) of any open wounds as ordered by Physician . Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations . This care plan failed to implement resident specific, adequate and effective interventions in attempts to prevent wounds. Review of a Skin & Wound evaluation dated 3/30/23 at 3:28 PM, documented in part . skin tear . Left Buttock . In-House Acquired . How long has the wound been present . 1 week . Area 6.2 cm2 (centimeters squared) . Length 3.8 cm (centimeters) . Width 2.3 cm . Depth Not Applicable . Exudate . Light . Serosanguineous . Patient has full skin loss secondary to shear tear on the sacral region . On the left buttock area, patient again has a full skin tear with complete skin loss . Further review of the care plan titled Risk for Pressure Injury Formation related to: generalized debility and weakness as evidence by: decreased mobility in bed and wheelchair, incontinence of bowel and bladder. Resident need staff assistance with incontinence care, turning and repositioning . (initiated 2/27/23), documented the addition of the following interventions on 4/3/23: . Low Air Loss mattress on bed . Monitor skin daily during care for redness, excoriation, or breakdown . Review of a Wound Rounds Note' dated 4/4/23 at 11:01 AM, documented in part . seen for follow up management of his wound . On the coccyx there is an unstageable wound measuring 1.49cm x 0.87 2.46cm x 0.87, wound base has slough . On the sacrum there is an unstageable wound measuring 3.29 cm x 2.33cm . On the right heel there is a deep tissue injury measuring 3.22 cm x 2.53cm . Review of a Skin & Wound evaluation dated 4/4/23 at 11:12 AM, documented in part . Pressure . Deep Tissue Injury: Persistent non-blanchable deep red, maroon or purple discoloration . Right heel . In-House Acquired . New . Area 6.1 cm2 . Length 3.2 cm . Width 2.5 cm . Depth Not Applicable . Review of a Skin & Wound evaluation dated 4/4/23 at 11:19 AM, documented in part . Skin Tear . Sacrum . Area 5.7 cm2 . Length 3.3 cm . Width 2.2 cm . Depth Not Applicable . Exudate . Light . Serosanguineous . On the left buttock area, patient again has a full skin tear with complete skin loss . Review of a Skin & Wound evaluation dated 4/4/23 at 11:25 AM, documented in part . Blister . Coccyx . In-House Acquired . New . Area 0.9 cm2 . Length 1.5 cm . Width 0.8 cm . Depth Not Applicable . Ruptured serum filled blister . Exudate . Light . Serous . patient has full skin loss secondary to shear tear on the sacral region; it has irregular borders; periwound is intact . Review of the physician orders documented the following order, . Wound Care Order Site: right/left heel 1) Cleanse wound with NS (normal saline) 2) Pat Dry with Gauze 3) Apply skin prep, let dry 4) Cover with ABD (abdominal dressing), 5) Wrap in kerlix 6) Tape - (date and initial the tape) every day shift for wound care . This order had a start date of 4/5/23. Review of the medical record revealed no documentation of the identification of a wound on the resident's left heel. Review of a Wound Rounds Note dated 4/11/23 at 11:13 AM, documented in part . seen for follow up management of his wound. He has an unstageable wound on the sacrum . On the coccyx there is an unstageable wound . On the right heel there is a deep tissue injury . Further review of the medical record revealed R811 was discharged from the facility three days later on 4/14/23. The resident admitted to the facility two months prior with no wounds and discharged home with three documented wounds (two unstageable wounds and one deep tissue injury). On 9/20/23 at 4:00 PM, Wound Care Nurse (WCN) D was interviewed and asked about the skin management protocol in the facility, WCN D replied all resident's have a weekly skin assessment completed and documented in their record. WCN D was asked to provide the weekly skin assessments completed for R811. WCN D was then asked about the 19 (indicating a low risk for skin breakdown) braden score and questioned the accuracy of the Braden assessment, WCN D stated they would look into it and follow back up. WCN D was then asked about the lack of adequate resident specific interventions implemented to prevent wound development to R811's skin and WCN D replied they would look into it and follow back up. WCN D was also asked to provide the documentation regarding the identification of the left heel wound and WCN D again replied they would look into it and follow back up. On 9/21/23 at 9:57 AM, WCN D returned and stated there was an unavoidable pressure ulcer document put in the system for R811. WCN D was asked how they could say R811's was unavoidable if the facility failed to implement the bare minimum of preventative interventions and accurate assessments for this resident, and WCN D did not have a response. WCN D was then asked for the documentation regarding the resident's left heel wound and WCN D stated they could not provide any documentation. WCN D stated they believed the Braden score was inaccurate because R811 had an overall decline in the two months that they were admitted into the facility, WCN D was then asked why the facility did not implement additional interventions to reflect the decline for R811 and to help prevent the development of wounds and WCN D did not have a response. WCN D stated they were unable to provide documentation of weekly skin assessments completed for R811. No further explanation or documentation was provided by the end of the survey.

This citation pertains to intakes: MI 343, MI 649, MI 888, and MI 953. Based on observation, interview and record review, the facility failed to accurately assess, identify, and implement timely treatments and interventions for four (R24, R49, R50 and R122) of nine residents reviewed for pressure ulcers, resulting in the residents developing new and/or worsening pressure ulcers at the facility. Findings include: Review of multiple complaints reported to the State Agency included allegations that the facility failed to provide adequate and appropriate care to prevent and/or treat pressure ulcers. According to the facility's policy titled, Skin & Wound Policy dated 2/2022, .A full body, or head to toe, skin and oral cavity assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury .Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change .Treatment decisions will be based on .Etiology of wound .Characteristics of the wound .Location of the wound .Guidelines for dressing selection may be utilized in obtaining physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Treatments will be documented on the Treatment Administration Record .The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. Lack of progression towards healing. B. Changes in the characteristics of the wound . According to the National Pressure Injury Advisory Panel (NPIAP) Pressure Injury Stages https://www.npiap.com: Stage 2 Pressure Injury: Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink, or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. Stage 3 Pressure Injury: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location: areas of significant adiposity can develop deep wounds. Undermining or tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Deep Tissue Pressure Injury: Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or [MEDICATION(S)] separation revealing a dark wound bed or blood-filled blister .Discoloration may appear differently in darkly pigmented skin. According to https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/IRF-Quality-Reporting/Downloads/IRF-QRP-Training-%E2%80%93-PrU-Staging-May-12-2014, .Do not reverse or back stage .If the pressure ulcer has ever been classified at a higher numerical stage than what is observed now, it should continue to be classified at the higher numerical stage . R49: On 9/26/22 at 3:17 PM, R49 was observed seated in a wheelchair next to their bed. There was no low air loss mattress, and the footboard was observed tilted down with one side hanging down towards the floor. R49 was asked about the bed and reported that had been broken for a while. When asked about general care in the facility, the resident reported they had arrived at the facility in August (2022) with pressure sores but the sores have gotten worse. R49 further reported they were concerned because they used to get dressings twice a day in the hospital and now, they were lucky to be done once a day as there were many times their treatments were not done. When asked about whether they were able to reposition independently while in bed, they reported they were not. When asked about whether they had interventions to offload pressure, such as a low air loss mattress, they reported they used to have one, but since they've been back at the facility for about two weeks, they have not. R49 reported they were ok with discussing these concerns with facility staff. Review of the clinical record revealed R49 was admitted into the facility on [DATE], discharged to the hospital on 8/30/22 and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) assessment dated [DATE], R49's cognition was intact, required extensive assistance of one person for bed mobility, extensive assistance of two people for transfers, and had three stage two pressure ulcers that were present on admission. Review of R49's Actual Pressure Ulcer Formation care plan was last initiated and reviewed on 8/23/22. This care plan identified the resident was admitted with stage two pressure ulcers. Current interventions included, Low Air Loss Mattress. Review of the hospital discharge instructions on 9/15/22 included, .Why you were hospitalized .Your primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .Pressure injury of right buttock, stage 4 .Pressure injury of sacral region, stage 3 .Patient instructions .Wound Care Instructions: twice daily wound tx (treatment) to sacrum and buttocks. Cleanse wound space with wound cleanser. Gently remove exudate from wound space, do not scrub down to wound bed. Apply Triad ointment, cover with dry 4x4 gauze, secure with [MEDICATION(S)] tape. Prep periwound with skin barrier wipes. There will always be a white residue with Triad, warmed incontinence wipes will remove stubborn paste . Review of R49's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders implemented on 9/15/22 to start on 9/16/22 read: Santyl Ointment 250 UNIT/GM ([MEDICATION(S)]) Apply to sacrum topically one time a day for wound care. Wound Care Order Site: (left blank) 1) Cleanse Wound with NS (Normal Saline) 2) Pat Dry with Gauze 3) Apply any ordered ointments (santyl) 4) Cover with ABS (an abdominal pad which is an extra thick dressing used for moderate to heavily draining wounds) 5) Tape and Date every day shift for wound care. The wound site sections of this order were left blank and was not clarified until 9/27/22 after the concern was identified during the survey. Prior to R49's hospitalization on [DATE], a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . every shift. This order did not get re-implemented upon R49's readmission on 9/15/22, and the resident remained without a LAL mattress through 9/28/22. Review of R49's progress notes and wound assessments from the resident's attending physician (Physician 'CC'), wound care physician (Physician 'T'), wound nurse practitioner (NP 'U') and the wound nurse (Nurse 'R') revealed multiple conflicting wound assessments. The resident's weekly Skin & Wound Evaluation from Wound Nurse 'R' on 9/16/22, 9/20/22 and 9/27/22 all documented these assessments were still in progress. The sections to identify the wound descriptions were left incomplete (blank) and only included measurements and pictures of the wounds. R49's pressure ulcer measurements included: Right buttock: On 9/16/22, stage 2: 0.3 cm2 (square centimeter) area; L (Length)=0.6 cm; W (Width)=0.6 cm; D (Depth)=0.2 cm. On 9/20/22, stage 2: 1.6 cm2 area; L=1.1 cm; W=2.0 cm; D=not applicable. On 9/27/22, stage 2 pressure: 1.2 cm2 area; L=3.1 cm; W=1.4 cm; D=not applicable. Sacrum: On 9/16/22, stage (none identified): 1.4 cm2 area; L=2.0 cm; W=0.9 cm; D=0.5 cm. On 9/20/22, stage (none identified): 4.8 cm2 area; L=3.3 cm; W=1.9 cm; Depth=not applicable. On 9/27/22, stage (none identified): 6.6 cm2 area; L=3.2 cm; W:2.8 cm; Depth=not applicable. Left Buttock: On 9/16/22, stage 2: <0.1 cm2 area; L=0.1 cm; W=0.2 cm; Depth = 0.1 cm. On 9/20/22, stage 2: 0.3 cm2 area; L=0.6 cm; W= 0.6 cm; Depth=not applicable. On 9/27/22, stage 2: 5.3 cm2 area; L=3.9 cm; W=1.6 cm; Depth=not applicable. Review of a history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] .Patient has recuperated in the hospital from 8/30/2022 to 9/15/2022 .Inability to walk, patient is wheelchair-bound and bedbound .Patient found to have a left buttock stage III ulcer and stage IV ulcer on the right buttock .On examination .Left buttock stage III ulcer and right buttock stage IV ulcer which has been dressed up with a wound dressing. Previous sacral ulcer also stage IV . Review of a progress note from Physician 'CC' on 9/17/22 at 3:48 PM read, .Skin examination; patient found to have left buttock stage III decubitus and right buttock stage IV decubitus and sacral ulcer as previously. Wound care team is following the patient . Review of an additional progress note from Physician 'CC' on 9/23/22 at 10:03 AM read, .Patient's wound care team has been following for the bilateral buttock ulcers. Right buttock ulcer is stage IV and left buttock ulcer is stage III which is spread from sacral area according to nurse report .Skin evaluation; sacral ulcer spread to the both buttocks according to the notes right buttock decubitus stage IV and left buttocks decubitus stage III for which patient is getting wound care by the wound care team .Requested wound care team to evaluate and update the progress notes on the wound care on the bilateral buttock wounds . Review of a progress note from the Wound Nurse Practitioner (NP 'U') on 9/20/22 at 3:00 PM read, .WOUND CARE FOLLOW UP .She has multiple wounds .On the left buttocks, a healing stage 2 ulcer which has good granulation, no odor, no discharge; periwound is fragile, measure 0.6 x 0.6 cm (centimeters). Periwound is moist; Sacral has stage 3 ulcer, measuring 3.3 cm x 2.0 cm periwound has moisture associated skin damage; On the right buttocks, the wound appearing as a stage 3 ulcer with the tissue being pink, length is 1.0 x 2.0 cm cm <sic>, deepest point is 0.2 cm; no discharge ASSESSMENT AND PLAN: 1. We will use Adeptic <sic> ([MEDICATION(S)] - a non-adhering dressing) to the wound, peri wound will be treated with TRAID <sic> 2. Low air loss mattress 3. The patient needs to be turned frequently .8. The patient is high risk as she is wheelchair bound .11. Offload heels. Review of a progress note from the Wound Physician (Physician 'T') on 9/27/22 at 12:38 PM read, .On the left buttocks, a healing stage 2 ulcer central region is darkened, surrounding tissue pink measuring 3.9 cm x 1.6 cm, no odor, no discharge; Sacral has stage 3 ulcer, measuring 3.2 cm x 2.8 cm, tissue is still pale borders regular, no oder <sic>; On the right buttocks, the wound appearing as a stage 3 ulcer with the tissue being pink, length is 3.1 x 1.4 cm cm <sic>, deepest point is 0.2 cm; no discharge .ASSESSMENT AND PLAN: 1. We will use Camaseptine <sic> to all wounds, need to change daily 2. Low air loss mattress, will benefit from wedge 3. The patient needs to be turned frequently .7. The patient is high risk as she is wheelchair bound . On 9/28/22 at 8:21 AM, review of R49's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Wound care Order Site: left buttock 1) Cleanse wound with NS 2) Pat Dry with Gauze 3) Apply Dermaseptine to area 4) Cover with ABD 5) Tape - (date and initial the tape) every evening shift for wound care. - order date 9/27/22, start date 9/28/22 Wound Care Order Site: left buttock 1) Cleanse wound with NS 2) Pat Dry with Gauze 3) Apply Dermaseptine to area 4) Cover with ABD 5) Tape (Initial and date) as needed for wound care - order date 9/27/22, start date 9/27/22 Wound Care Order Site: right buttock 1) Cleanse wound with NS 2) Pat Dry with Gauze 3) Apply Dermaseptine to area 4) Cover with ABD 5) Tape (Initial and date) as needed for wound care - order date 9/27/22, start date 9/27/22 Wound care Order Site: right buttock 1) Cleanse wound with NS 2) Pat Dry with Gauze 3) Apply Dermaseptine to area 4) Cover with ABD 5) Tape - (date and initial the tape) every evening shift for wound care. - order date 9/27/22, start date 9/28/22 Wound Care Order Site: sacrum 1) Cleanse wound with NS 2) Pat Dry with Gauze 3) Apply Dermaseptine to area 4) Cover with ABD 5) Tape (Initial and date) as needed for wound care - order date 9/27/22, start date 9/27/22 Wound Care Order Site: sacrum 1) Cleanse wound with NS 2) Pat Dry with Gauze 3) Apply Dermaseptine to area 4) Cover with ABD 5) Tape (Initial and date) every evening shift for wound care - order date 9/27/22, start date 9/28/22 The documentation from Physician 'T' for recommendation to use Camaseptine to all wounds conflicted with the order change above for Dermaseptine. On 9/28/22 at 8:44 AM, an interview was conducted with the Wound Care Coordinator (Nurse 'R'). When asked how the nurses would know the location of the wound site to be treated if there was no wound site identified, Nurse 'R' acknowledged the order upon R49's readmission did not identify the wound sites and the Santyl order was only for the sacrum and they had just changed that order to include wound sites (after identified as a concern during the survey). When asked about why the resident has not had a LAL mattress since readmission, they reported they had just call yesterday when they noticed that and that the resident should have had one since readmission. When asked if they had ever discussed R49's wounds with Physician 'CC', Nurse 'R' reported they had not. When asked how the pressure ulcers were being identified as healing stage two and three if the hospital readmission documentation and Physician 'CC' identified stage IV and stage III and their own assessments identified depth for some areas, they were unable to offer any further explanation. (It should be noted that once a pressure ulcer is staged it can progress to a higher stage, but cannot be back-staged, or down-staged.) On 9/28/22 at 10:28 AM, a phone interview was conducted with Nurse 'F' who was the nurse identified as completing R49's readmission on 9/15/22. When asked about why the resident's pressure ulcer treatment orders had not been processed as twice daily as indicated in the hospital discharge instructions, Nurse 'F' reported they were not sure as they would normally go off the discharge orders from the hospital. Nurse 'F' further reported they were unable to recall any additional details as they had been assigned to complete the readmission, but were not assigned to that unit. When asked how they happened, Nurse 'F' reported it happened a lot since the facility had a lot of admissions and the nurse that's already assigned might already have another admission, they were responsible for completing. On 9/28/22 at 11:24 AM, an interview was conducted with R49's assigned nurse (Nurse 'D') for 9/26, 9/27 and 9/28. They were asked to observe the resident's wounds and reported the resident was currently out of the facility for a dental appointment. When asked about how they knew where to do the treatment on 9/26 and 9/27 since there were no specific areas identified other than the Santyl on the sacrum, Nurse 'D' acknowledged the order did not identify the wound sites and since they were experienced with wounds and the wound was one large area for the sacrum and both buttocks, they had done it to the whole area. When asked to review the most recent pictures of R49's wounds from 9/27, Nurse 'D' reported all three areas (right buttock, left buttock and sacrum) all had areas of slough and some with dark purplish/blackish areas. Nurse 'D' further reported they would consider some portions of the wounds as unstageable since the areas that were not able to be seen due to slough and darker red/purplish/black areas. On 9/28/22 at 11:33 AM, a phone interview was conducted with Physician 'T'. When asked about the process of who was seen, Physician 'T' reported when they came into the facility, they got a list of new residents or residents that had concerns or were at high risk and rounded with the wound nurse. Physician 'T' also reported they reviewed hospital records and if needed to change anything, that would be discussed with the wound nurse and reflected in their notes. Physician 'T' further reported residents that were considered high risk would have a low air loss mattress in addition to other recommendations. When asked if they were aware that R49 did not have a LAL mattress, they reported they had seen about 30 residents and didn't have any resident information available. When asked if they had every had any discussion of R49's wounds with Physician 'CC', they reported they did not. Physician 'T' recalled R49 had a darkened area. When asked about the discrepancies of their wound assessments, Physician 'T' reported no further explanation. When asked about the pressure ulcer treatment orders, Physician 'T' reported the Santyl was used for necrotic areas and Dermaseptine was used for moist areas, around the wound, and possible fungal or infection issues. When asked about their process for when they rounded with the wound nurse, Physician 'T' reported they did the measurements and the wound nurse took the pictures. On 9/29/22 at 7:52 AM, a phone interview with Physician 'CC' was conducted. When asked about R49's pressure ulcers and whether they could recall implementing changes to the wound care orders upon the resident's readmission on 9/15/22 from twice daily to once daily, they reported they relied upon the wound care Physician for treatments and they had not assessed the wounds. When asked to clarify if they had not assessed the resident's wounds, why did their documentation identify assessment and evaluation of the pressure ulcers, Physician 'CC' offered no further explanation. When asked if they had been aware of any changes such as worsening or deterioration of the resident's wounds since readmission, Physician 'CC' reported they were not as that was deferred to the wound care Physician and further reported, clinically she's a lot better. R50 On 9/26/22 at 10:25 AM, R50 was observed lying on her back, sleeping. A low air loss mattress was observed on R50's bed. R50 woke up and stated she was sleepy and did not wish to talk. On 9/26/22 at approximately 11:30 AM and 1:15 PM, R50 was observed lying on her back. Review of R50's clinical record revealed R50 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R50 was transferred to another facility on 7/2/22 due to testing positive for COVID-19 and returned to the current facility on 7/13/22. Review of a MDS assessment dated [DATE] revealed R50 had severely impaired cognition, no behaviors including rejection of care, and required extensive physical assistance from two staff members for bed mobility and transfers. The MDS documented R50 had one Stage 4 pressure ulcer present upon admission. Review of a Nursing-Progress Note dated 7/13/22 revealed, .wound consult entered for buttocks . Review of a Physician Team - Progress Note dated 7/14/22 revealed, .Chronic Sacral Decubitus ulcer stage IV .Foley catheter as recommended by wound care physician for reopened sacral wound, healed again since catheter reinsertion . Review of a Nursing - Skin/Wound Note dated 7/14/22, written by Wound Care Coordinator, Nurse 'R', revealed, .The following skin alterations were noted during assessment .Coccyx Pressure injury, area measures 1.1 cm x 0.8 cm x 0.2 cm . Review of a Wound Rounds Note dated 7/19/22 revealed, .previously treated for [MEDICAL RECORD OR PHYSICIAN ORDER] .On the sacral area, previous stage 4 ulcer has reopened, measuring 1.5 cm x 1.5 cm x 0.3 cm, no discharge, no odor .ASSESSMENT AND PLAN: 1. Moisture associated skin damage in the sacral regions to the previous stage 4 sacral ulcer .We will use alginate (an absorbent wound dressing) to the area . Review of a Wound Rounds Note dated 7/26/22 revealed, .On the sacral area, previous stage 4 ulcer has reopened, measuring 1.8 cm x 1.0 cm x 0.3 cm, scant bloody drainage .We will use alginate to the area . Review of a Wound Rounds Note dated 8/4/22 revealed, .seen for follow up wound management .sacral area, previous stage 4 ulcer has reopened, MEASURING 1.5 (cm) X 0.6 CM X 0.5CM .We will use alginate to the area .Patient needs to be turned frequently . Review of a Wound Rounds Note dated 8/8/22 revealed, .seen for follow up wound management. She has a sacral ulcer .She has been getting Alginate to her wound .Sacral area, previous stage 4 ulcer has reopened, MEASURING 1.3 (cm) x 0.9 CM x 1.0 CM, there is some slough to the wound, scant drainage .We will discontinue Alginate and use [MEDICATION(S)] (an antibacterial wound dressing) to the area . Review of R50's Physicians Orders revealed the following order that started on 7/14/22, Wound Care Order Site: coccyx (sacrum) 1). Cleanse wound with wound cleanser 2) Pat Dry with Gauze 3) Apply Triad paste (wound dressing) 4) Cover with ABD (abdominal pad) 5) Tape - (date and initial the tape) as needed for wound care AND every day shift for wound care. This order was discontinued on 7/21/22. On 7/21/22, R50's wound care treatment order was changed to .Apply Calcium Alginate to area .as needed for wound care AND every day shift for wound care . This order was active until it was discontinued on 9/19/22. (It should be noted that as of the Wound Rounds note dated 7/19/22, calcium alginate was the documented treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The treatment was not ordered until two days after R50 was evaluated by the wound provider. Further review of R50's Physicians Orders revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .Apply to coccyx topically every day shift for wound care was started on 8/10/22, two days after the wound provider evaluated R50's pressure ulcer and documented it had worsened (increased width and depth and appearance of slough) and the order for Calcium Alginate was also active and not discontinued. Review of a Wound Rounds Note dated 8/16/22 revealed, follow up wound management. She has a chronic sacral ulcer .On the sacral area, has a stage 4 ulcer measuring 1.0 cm x 0.5 cm, periwound is red, has positive drainage, greenish, mild oder <sic> .will get wound culture, clean with normal saline (NS), and use [MEDICATION(S)] (an antibiotic wound dressing) to the wound, will follow up the cultures . Review of R50's Physicians Orders revealed an order dated 8/16/22 for [MEDICATION(S)] Gel 1% (percent) ([MEDICATION(S)]) Apply to coccyx topically as needed for wound care. Clean area with NS, dry, apply gel to area, cover with 4x4 gauze and ABD pad, secure with tape AND apply to coccyx topically every day shift for wound care . At the time of that order, the orders for Calcium Alginate and [MEDICATION(S)] remained active and were not discontinued and therefore there were three different orders for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of an Order Note dated 8/17/22, written by Nurse 'R', revealed Obtain culture of coccyx wound to R/O (rule out) infection .Specimen obtained by writer .Specimen placed in .fridge on (unit) for pick-up . Review of laboratory results in R50's electronic medical record (EMR) revealed no results from the wound culture obtained on 8/17/22. Review of a Wound Rounds Note dated 8/23/22 (six days after the wound culture was obtained), revealed, .wound has green discharge .has been feeling tired .stage 4 ulcer measuring 1.6 cm x 0.7 cm x 0.5 cm, periwound is red, has positive drainage, greenish, mild odor .Wound culture pending. Clean with normal saline, and use metro gel to the wound, will follow up with the cultures . Review of R50's Physicians Orders revealed a new order for [MEDICATION(S)] Gel 0.75 % apply to coccyx topically every day shift for wound treatment . The orders for Calcium Alginate and [MEDICATION(S)] remained active at that time. Review of a Wound Rounds Note dated 8/30/22 revealed, .Wound cultures not done (it should be noted that it was documented by Nurse 'R' that the specimen was taken on 8/17/22 and there was no documentation that indicated any follow up had been completed) .has been feeling tired .stage 4 ulcer measuring 1.6 cm x 0.7 cm x 0.5 cm, periwound is red, has positive drainage, greenish, mild odor .now looking unstageable, periwound has multiple satellite lesion (secondary [CONDITION(S)] in close proximity to the primary lesion), and skin is red .Plan Clean with normal saline, and use [MEDICATION(S)] to wound, use antifungal to the periwound, will treat for suspected [MEDICATION(S)] (fungal) infection with [MEDICATION(S)] x 5 days, 100 mg (milligrams) a day . Review of R50's Physicians Orders revealed [MEDICATION(S)] was not ordered, per the wound provider's recommendations on 8/30/22. [MEDICATION(S)] was ordered since 8/10/22. However, [MEDICATION(S)] was not discontinued and either was Calcium Alginate. All three orders remained active until 9/19/22. Review of R50's Medication and Treatment Administration Records (MAR and TAR) for August 2022 and September 2022 revealed nurses signed off that R50's coccyx pressure ulcer was treated with Calcium Alginate and [MEDICATION(S)] from 8/11/22 through 9/19/22 and Calcium Alginate, [MEDICATION(S)], and [MEDICATION(S)] from 8/17/22 through 9/19/22. It is unknown which treatment was done to R50's coccyx or how three different wound treatments were administered. Review of a Nursing - Progress Note dated 9/4/22 revealed, Pt (patient) lethargic only responding to painful stimuli . A second progress note dated 9/4/22 revealed the physician ordered R50 to be sent to the hospital via 911. Review of R50's Hospital Records revealed an H&P (History and Physical) dated 9/4/22 that documented, .Upon arrival to ED (emergency department) .foul odor noted from perineal region .lower back wound noted .Assessment .[CONDITION(S)] likely secondary to #2, #3, #4 (#4 was sacral decubitus ulcer . A Hospital ICU (intensive care unit) Progress Note documented, .INFECTIOUS .Blood culture showing Proteus mirabilis and gram-negative bacilli .wound cultures growing gram-negative bacilli and Enterococcus . Further review of R50's clinical record revealed the following: A Skin & Wound Evaluation dated 7/14/22, completed by Nurse 'R', documented R50 had a Stage 2 (Partial-thickness skin loss with exposed dermis) pressure ulcer to the coccyx that was present on admission that measured 1.1 cm x 0.8 cm with no depth. At that time, it was documented that a hydrophilic fiber wound dressing (Triad Paste) was implemented. (It should be noted that Nurse 'R' completed a progress note that same day with the following measurements: 1.1 cm x 0.8 cm x 0.2 cm which indicated the wound had measured depth and did not fit the description of a Stage II pressure ulcer. A Skin & Wound Evaluation completed on 8/30/22 by Nurse 'R' documented, R50's wound was unstageable and measured 2.3 cm x 0.8 cm and was 100 % filled with slough. It was documented there was no change in treatment. However, the wound provider note (Wound Rounds Note dated 8/30/22 documented the wound culture was not done and the wound treatment was changed to [MEDICATION(S)] to wound, use antifungal to the periwound, will treat for suspected [MEDICATION(S)] (fungal) infection with [MEDICATION(S)] x 5 days, 100 mg (milligrams) a day which was not ordered. Only the [MEDICATION(S)] order that had been in place since 8/10/22. It should be noted that the measurements documented by Nurse 'R' were different than the measurements documented by the wound provider on 8/30/22. On 9/28/22 at 8:44 AM, Nurse 'R' was interviewed. Nurse 'R' explained she was the facility's Wound Care Coordinator and had been in that position since April 2020. Nurse 'R' explained she was a Licensed Practical Nurse and had not had any formal training or certification in wound care. When queried about her role, Nurse 'R' reported she maintained wounds, did weekly rounds with the wound providers, answered consultations, and collaborated with the interdisciplinary team (IDT) and Director of Nursing (DON). Nurse 'R' was asked to explain how the facility monitored resident's skin for any changes. Nurse 'R' explained that weekly skin assessments were completed by the floor nurses when residents were showered and if any changes in skin were identified, the nurse would notify Nurse 'R'. Nurse 'R' reported the weekly skin assessments were documented in the residents' EMR on a Skin - Total Body Evaluation assessment form. Nurse 'R' explained there were other forms used in the past that were titled, Skin & Wound - Total Body Skin Evaluation and SKIN OBSERVATION TOOL but they were also located in the EMR. Nurse 'R' reported that once a nurse contacted her about a change in skin integrity, she assessed the resident, and requested a consultation from the wound provider. Nurse 'R' reported she determined the type of wound and stage of a pressure ulcer by referring to the facility's policy and the wound provider would confirm when they evaluated the resident. Nurse 'R' reported if the resident's wound matches up with our policy then she would enter the treatment documented on the policy. If she was unsure, she would contact the primary provider or wound provider. When queried about who entered the treatment and intervention orders into the EMR, Nurse 'R' reported she entered them into the EMR immediately after she completed her assessment which she tried to complete by the next business day. If she was not there, the floor nurse should contact the physician and go off the policy. At that time, the policy Nurse 'R' was referring to was requested. When queried about how often pressure ulcers were assessed, Nurse 'R' reported they received treatment daily which was done by either the floor nurses or Nurse 'R' and the wounds were assessed by the contracted wound provider weekly. Nurse 'R' explained she rounded with the wound providers, took photographs of the wounds, and documented her assessment based off of the wound providers' evaluations. Nurse 'R' further explained that since she rounded with them, she wrote down any new interventions or treatments recommended by the wound providers, entered the orders into the EMR, and confirmed the orde [TRUNCATED]

This citation pertains to intake: MI 513. Based on observation, interview and record review the facility failed ensure staff consistently assessed, identified and reported timely to the physician, the worsening of a right hip surgical incision site for one R908 of three residents reviewed for quality of care, resulting in severe pain, hospitalization for debridement, initiation of wound VAC (vacuum assistant closure) device and the insertion of a PICC (Peripherally Inserted Central Catheter- a catheter inserted into a large vein near the heart) line for antibiotic treatment. Findings include: Review of a hospital Physician Discharge Summary dated 7/8/21 at 4:58 PM, documented in part . presented to ED (Emergency Department) 6/30/2021 with pain at incision site from ROH (Removal of Hardware) after plate failure and revision of ORIF (Open Reduction Internal Fixation) in R (right) femur 6/4/2021. Patient presented with 10/10 pain of enter RLE (Right Lower Extremity), warmth and foul-smelling odor with blue-green discharge coming from the incision site. Received [MEDICATION(S)] 4mg and oxycodone 5 mg for pain management. Wound cx (culture) revealed GNB. Started on [MEDICATION(S)]/[MEDICATION(S)] by mouth x 7 days for possible infections . the patient elected to undergo Procedure . DEBRIDEMENT LOWER EXTREMITY (Right). Procedure revealed large amounts of dark hematoma. Wound vac placed . Swab for cx obtained 6/30/21 of superficial thigh and 7/1/21 of superficial femur intraoperatively revealed Pseudomonas aeruginosa and coag-negative Staph (bacteria) and is being treated with [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] (antibiotics) via peripherally inserted central catheter x 6 weeks . On 7/13/21 at 1:40 PM, R908 was observed sitting up in bed. When asked about their PICC line R908 stated in part . they (nurses) never look at it and one nurse came in with no gloves trying to take off my dressing and I said . no I already had one infection before . I went out on the 30th of June because of my leg. It started bleeding with pus, and they (nurses) never looked at my leg. That dressing stayed on, and no one looked at it for a couple of days . I asked her (facility nurse) to change it and it was green discharge . I had an infection in my leg. That's when the hospital gave me the PICC to heal the infection . Review of the medical chart revealed R908 was admitted into the facility on [DATE] with a readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition and required staff assistance for all Activities of Daily Living (ADLs). Review of the medical record revealed the following physician orders: Skin Assessment upon admission and weekly . PLEASE OPEN SKIN ASSESSMENT UNDER ASSESSMENTS TAB: every evening shift every Mon (Monday) . Check skin for open areas, bruises, abrasions, DTI (Deep Tissue Injury), incisions . Monitor right hip incision QS (every shift) every shift for monitoring- Blanks were noted for : Day shift- 28th, 29th , Evening shift- 24th 26th, 27th & Night shift- 29th. Monitor surgical incision noted to right hip every shift for changes. Report adverse changes to primary physician/wound care every shift This order was discontinued on the 18th and resumed on the 21st on Night shift. Blanks were noted for: Day shift- 28th, 29th, Evening shift- 24th, 26th, 27th & Night shift- 29th. A second interview was conducted with R908 on 7/13/21 at 2:52 PM, to discuss the skin assessment and hip monitoring orders that was in place in June 2021 and R908 stated in part, . They (nurses) never looked at my hip. I am a Registered Nurse, I know. I had to tell the practitioner about my hip when she came in to see me . Despite the documentation revealing that some of the nurses documented the assessment of the resident's right hip, the resident remained adamant that the nurses never assessed their surgical site for days prior to the practitioner assessment. Review of a Physician Team - Progress Note dated 6/25/21 at 9:12 AM, documented in part . Pt (patient) was seen sitting at the edge of bed and is getting washed up. She states she noticed purulent drainage from her incision site and some bleeding noted while she was washing up. Staples seem to be intact and slight area of dehiscence noted at top of incision. Will start [MEDICATION(S)] (antibiotic) PO (by mouth) for 5 days . team to evaluate incision . This note indicated the resident did inform the physician regarding the worsening of their surgical site, despite the facility nurses documenting that the area was assessed. The clinical record revealed no documentation noted by the nurses regarding any abnormal findings to the surgical site prior to this note. This note was documented by Nurse Practitioner (NP) B. Review of a Nursing note dated 6/28/21 documented in part, . Writer assessed staples on right hip, large amount of green drainage, 38 staples intact. Writer cleaned wound and applied new dressing. Pt was given ABT (antibiotic) as scheduled . Pt states she will be speaking with a doctor in the morning regarding her right hip and the healing process . A Physician Team - Progress Note dated 6/28/21 at 7:15 AM, documented in part . Pt was resting in bed, and she admits to pain in her right hip. It is draining now per pt. Wound noted to be dehiscing and purulent drainage noted along entirety of wound not just at the top as noted last week. Continue [MEDICATION(S)] PO for now and WBC (White Blood Cell) stable 4.2 and she is afebrile. Pt to call ortho today and attempt to reschedule appt (appointment) sooner as her next appt scheduled for 7/13 . discussed with nursing management in detail . will follow up in 3 days . A Physical Medicine and Rehabilitation note dated 6/29/21 at 1:52 PM, documented in part . I am seeing her as follow up for her incision since she does have drainage and she is concerned about the drainage today. There is some greenish drainage coming from her wound, and I did notify Internal Medicine, who is going to assess her today. She has been started on [MEDICATION(S)], but it does not appear to be working at this point. She also notes that she is having increased pain and has required increased pain medication since the last couple of days, which is also concerning to me . She is having some greenish drainage, which is concerning, and increased pain. I have spoken to Internal Medicine . who is going to assess her and possibly send her out to the hospital if needed . A Physician Team - Progress Note dated 6/30/21 at 7:22 AM, documented in part . continues to be in severe pain despite pain meds. She is completing PO [MEDICATION(S)] today and wound still continues to drain dark purulent drainage. Leg is now also warm although pt. has remained afebrile . concern for wound infection and possible need for washout and IV (Intravenous) abx (antibiotics). Pt was agreeable to return to (hospital name redacted) for further evaluation of her surgical site . SKIN: Warm, dry, right knee and right hip surgical site with dehiscence and purulent drainage along entirety of wound, warmth to leg noted . Further review of the clinical record revealed no documentation of the identification of the warmth noted to the right leg prior to the practitioner assessment. On 7/14/21 at 10:20 AM, Nurse Practitioner (NP) B was interviewed and asked if they were ever notified by staff regarding the changes to the resident surgical site prior to the resident informing them on 6/25/21. NP B stated No, she was informed that day when she went to see the resident and they prescribed antibiotics at that time. When asked if they were concerned that the staff did not identify and notify the physician of the surgical site changes despite signing off that they are assessing it every shift, NP B stated the resident did tell them that the nurses were not looking at the surgical site. NP B stated she talked to the staff about it. When asked about the PICC line orders not being implemented until five days after the resident was readmitted back into the facility and the resident stating that a nurse attempted to change her PICC line dressing with no gloves on, NP B stated in part . I saw her (R908) on Monday, and she brought it to my attention, normally we don't put in those orders the nurses do, but I talked to (Unit Manager- UM C name redacted) and (Infection Control Nurse- ICN D name redacted) to educate the staff about it. NP B stated it was brought to their attention on Monday (7/12/21), which was the date noted on the PICC line dressing observed on 7/13/21. At 10:32 AM, UM C was asked about the incomplete nursing assessments to the residents surgical site area and stated in part . this is the first time that it was brought to my attention . When asked how it was possible for the resident to identify the changes noted to their surgical site and not the nurses being that they signed off they assessed the area most of the days, UM C stated in part . they should have noticed it . When asked about the resident PICC line orders and a nurse attempting to change the dressing with no gloves, UM C stated in part I wasn't aware of it (a nurse attempting to change the dressing with no gloves), but It looked like it was dirty so I changed it . UM C also stated the orders should have been implemented upon readmission into the facility and additional education will be provided to the staff. On 7/14/21 at 10:57 AM, ICN D was interviewed and asked about the nurse attempting to change the resident's dressing without gloves on and stated in part . It was brought to my attention on Monday afternoon by the Nurse Practitioner. She wasn't able to identify the nurse. I told the NP that I would develop education on PICC line, gloves usage and infection control . I plan to trace back to identify the nurse . Review of a Nursing - Admission Note dated 7/8/21 at 6:21 PM, documented in part . Resident arrived . via ambulance . DX (diagnosis): Rights Surgical Wound Infection . PICC line noted in residents left arm. All needs met by staff . The clinical record was reviewed and revealed no documentation and or orders for PICC dressing changes, monitoring or care implemented until 7/13/21 (5 days after being readmitted back into the facility). A facility policy titled IV- Dressing Changes for Central Lines, Midlines, and [MEDICATION(S)] Lock/Peripheral Catheters (Short) (Issue Date 9/26/17) documented in part . The catheter insertion site is a potential entry site for bacteria that may cause a catheter-related infection. A transparent dressing is the preferred dressing . Sterile dressing change using transparent dressings is performed . upon admission . at least weekly . If the integrity of the dressing has been compromised (wet, loose, or soiled) . Before and after administration of intermitted infusions . At least once every shift when not in use . A facility policy titled IV- Flushing and Locking of Central Line Catheters, Midline Catheters, and Implanted Venous Access Ports (Issue Date 5/24/18) documented in part . Flushing/locking is performed to ensure and maintain catheter patency and to prevent the mixing of incompatible medications/solutions . Specific flush/locking orders must be documented . Further review of the clinical record revealed no documentation of the transparent dressing change for the PICC line applied on admission, measurement of upper arm circumference and external catheter length. On 7/13/21 the following PICC line orders were implemented: Monitor IV insertion site for signs & symptoms of infection every shift. Set the Schedule to match the times of IV medication . Instill 10 ml (milliliters) prefilled normal saline Administer medication . instill 10 ml of prefilled normal saline . instill 5 ml 10 units of [MEDICATION(S)]. Change Needless connector during a routine flush, every evening shift every 7 days for infection prevention and as needed for infection prevention. Change if connector become soiled or after blood draw. Change Dressing according to policy, every day shift every Sun for safety monitoring AND as needed for safety monitoring. Measure PICC external IV catheter length, from insertion site, including IV Hub, every evening shift for 1 administration document the centimeters in supplement documentation and every day shift every Sun document the centimeters in supplement documentation and as needed document the centimeters in supplement documentation. On 7/14/21 at 11:15 AM, the Director of Nursing (DON) was interviewed and asked about the inconsistent and or lack of surgical site assessments and the delay in implementing PICC line orders and acknowledged that PICC line orders should have been implemented with a dressing change to the PICC line site upon admission. The DON stated they would have to look further into the assessments to see what happened however further training will be provided to all staff. The DON stated the facility had no grievances for R908. A Skin Management policy was requested from the Administrator and DON and a Skin- Pressure Ulcer Guidelines policy (Issue Date 8/13/2020) was provided. The policy documented in part, . If there is any change in the patient's skin condition, the nurse or nurse manager should review and revise the patient's care plan accordingly and consult with the director of nursing, physician and/or wound care specialist as needed .

This citation pertains to Intake Number MI 070. Based on observation, interview, and record review, the facility failed to provide care in a safe manner according to the resident's plan of care for one (R2) of three residents reviewed for falls, resulting in the resident rolling off the bed, hitting their head causing a scalp laceration to the back of the head that required four sutures. Findings include: Hospital records for R2 were reviewed and revealed a History and Physical note that documented, .Date of Admission: 5/1/2021 .Per staff in NH (nursing home), pt 'rolled' out of bed to the floor striking her head while applying harness to left her from bed to chair. Noted scalp contusion with laceration. EMS was called and brought to ED .Witnessed Fall at NH with head trauma .Posterior scalp laceration sutured in ED .Pt is Wheelchair and bed bound at baseline . A Nursing - Progress Note dated 5/4/21 documented, Resident admitted to [nursing home name redacted] from [hospital name redacted] via ambulance at 6:45 pm. DX: S/P (status post) Fall. AOx1 (alert and oriented to person only) .Skin assessment completed .4 stitches noted on back of residents head with some scattered bruising noted . On 5/25/21 at 9:45 AM, 10:01 AM, and 11:45 AM, R2 was observed lying in bed. R2 was restless and yelling out. A scoop mattress was observed to be used and a fall mat was observed beside the resident's bed. R2 did not appear to be able to move around the bed independently. R2's clinical record was reviewed and revealed the following: R2 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: heart failure, Alzheimer's Disease, Peripheral Vascular Disease, Protein Calorie Malnutrition (5/4/21), [CONDITION(S)], and dysphagia. A Minimum Data Set (MDS) assessment dated [DATE] and 1/29/21 documented R2 had severely impaired cognition, no behaviors, required physical assistance from at least two staff members for bed mobility, transfers, dressing, and toilet use, and had impaired range of motion bilaterally of the upper and lower extremities. An incident report for R2 dated 5/1/21 at 12:00 PM documented, Observed resident on floor, next to bed, resident noted with nodule to back of head and bleeding from nodule. Prior to observation, CNA (Certified Nursing Assistant) was in room with patient and had just provided all ADL (activities of daily living) care. CNA was prepping resident to for <sic> [brand name redacted] (mechanical) lift, turned around to get [brand name redacted] sling so it could be placed under resident and resident them <sic> rolled onto floor (See Attached) .Writer notified on-call physician and new order received to Transfer resident to ER (emergency room ) and 911 called . The incident report documented R2 had a bleeding hematoma to the back of the head and that there were no predisposing environmental, physiological, or situation factors that contributed to the fall. CNA BB was listed as a witness to the incident. Notes included on the incident report written by the Director of Nursing (DON) documented, 5/3/2021 Resident was being Assisted with ADL am care when the CNA completed cleaning and dressing her, she reached for the sling behind her and when she turned back the resident had fallen out of bed. CNA yelled for the nurse and stayed monitoring the resident till <sic> the nurse arrived. See progress note and Witness statement. On 5/27/21 at 3:21 PM, the DON was interviewed. When queried about what occurred and how R2 fell from the bed on 5/1/21, the DON reported the CNA was getting R2 ready and turned to get the sling for the mechanical lift and the resident rolled from the bed. When queried about the level of assistance required by R2 for activities of daily living, the DON reported R2 only needed two people to conduct the transfer with the mechanical lift. The facility's investigation, including witness statements, into the incident documented above was requested. In addition, any education provided to CNA BB was requested. On 5/27/21 at 3:44 PM an interview was conducted via the telephone with CNA BB. When queried about how R2 rolled out of the bed on 5/1/21, CNA BB reported she provided care to the resident and washed her up and got her ready for the day and when she turned her back to reach for the sling for the mechanical lift, R2 reached for CNA BB and rolled out of the bed. CNA BB was queried about how R2 was positioned in the bed. CNA BB reported R2 was positioned on her back in the center of the bed. When queried about whether R2 could roll over and move in the bed without assistance, CNA BB did not offer a response. When queried about whether CNA BB had assistance from another CNA at the time of the incident or if care was being provided by herself, CNA BB stated, I was doing the care by myself because there were only two of us that day. CNA BB reported she was getting the sling ready to put underneath the resident and then she was going to call for help to transfer her. CNA BB reported she was washing her up and did not require assistance for that. At 4:40 PM, the DON followed up with additional information and reported R2 was sent out to the hospital after the fall, that R2's behaviors were not usual for her and that the resident did not usually move around like that. The DON reported he talked with CNA BB and stated, She should have had two people in the room during care. There was no investigation or education provided prior to the end of the survey. A review of POC Response History (documentation made by CNAs regarding care provided) for R2 for Transferring, Bed Mobility and Hygiene on 5/1/21 revealed CNA BB documented, Resident not available. A review of R2's care plans revealed the following: A care plan initiated on 6/1/20 documented, ADL and mobility deficits R/T ongoing health events with the following interventions: Bed mobility: 2 person assist (initiated on 7/11/20) . A care plan initiated on 6/1/20 documented, The resident is at risk for falls and potential injury r/t Deconditioning, Gait/balance problems, Poor communication/comprehension, Unaware of safety needs including the following interventions: Low air loss perimeter mattress (initiated on 12/15/20) .

This citation pertains to Intake Number MI 070. Based on observation, interview, and record review, the facility failed to accurately assess pain, address expressions of pain, consult the physician when pain was unrelieved by current medication regimen, and ensure resident did not experience pain during wound care for one (R2) of one resident reviewed for pain, resulting in prolonged unrelieved pain as evidenced by yelling out, grimacing, and verbalized expressions of pain. Findings include: Review of R2's medical record revealed that R2 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) assessment dated [DATE] documented R2 had severely impaired cognition, no behaviors, and required physical assistance from at least two staff members for bed mobility and transfers. The MDS documented R2 was not on scheduled pain medications, did not receive non-pharmacological interventions for pain, and was prescribed pain medications on an as needed (PRN) basis. The staff assessment of pain documented R2 expressed verbal sounds and vocal complaints of pain on one to two days during the assessment period. A MDS assessment dated [DATE] documented R2 received scheduled pain medications and was not assessed to have any pain. On 5/25/21 at 9:45 AM, 10:01 AM, and 10:19 AM, R2 was heard from the hallway yelling, Ow ow ow! R2 was observed lying in bed and appeared restless. At 10:01 AM, R2 was observed from the hallway, hitting herself in the head and yelled, Ow ow ow! I want to die. Let me die. At 11:45 AM, R2 was observed lying in bed. Three staff members were observed entering R2's room. Wound Care Nurse, Licensed Practical Nurse (LPN) C was observed to be carrying a tray that contained wound care treatment supplies and reported she was going to administer wound treatment to R2, and the Certified Nursing Assistant (CNA) reported she was going to change the resident's brief. On 5/25/21 at 12:11 PM, R2 was observed seated in a geriatric chair in her room, yelling out, Ow ow ow! Registered Nurse (RN) CC was seen inside of the resident's room next to R2 holding a medication cup. RN CC told R2 that she had something to give her to help with pain. R2 was heard verbalizing pain and when RN CC asked R2 if the pain was in her leg and on her bottom, R2 stated, Yes. RN CC attempted to give R2 a doll and R2 yelled, I don't want no doll! Ow ow ow! A review of R2's clinical record revealed a Wound - Weekly Observation Tool dated 5/25/21 that documented R2 had a 16 centimeter by 3 centimeter vascular wound to the right lateral (back) calf. 5/27/21 at 9:35 AM, an observation of wound care to R2's right lower leg was conducted. LPN JJ provided the treatment. No other staff members were present during the treatment to R2's right lower leg. R2 repeatedly yelled out stating, Ow! Ow! Ow! She's hurting me! during wound care and whenever LPN JJ moved the resident's leg. R2 was observed to grimace when expressing pain. When LPN JJ cleaned R2's wound, R2 yelled out, Ow! Ow! Ow! That hurts! Just let me die! At that time, LPN JJ was queried about R2's pain. LPN JJ reported she gave R2 their scheduled pain medication prior to conducting wound care. When queried about whether R2 typically yelled out in pain, R2 stated, I don't know if it is normal for her to yell out. LPN JJ reported it was the first time she was assigned to R2. LPN JJ continued with wound care and when the treatment was applied to R2's wound, R2 yelled out, Ow! That hurt me! On 5/27/21 at 11:05 AM, LPN JJ was interviewed. When queried about what was in place to address R2's expression of pain, LPN JJ reported again that she administered the scheduled pain medication prior to conducting wound care and stated, I consoled her. Further review of R2's clinical record was conducted and revealed the following: physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Assess Resident for Pain Every Shift started on 5/4/21. [MEDICATION(S)] Tablet 50 MG (milligrams) Give 1 tablet by mouth three times a day for pain started on 5/19/21. A review of R2's progress notes was conducted and revealed the following: A Nursing - Progress Note dated 5/25/21 at 12:53 PM written by RN CC documented, Resident received alert with confusion resting in bed. Resident took all scheduled medications .Resident screaming in pain and pain medications given. Wound dressings changed by wound nurse . (Note: Wound care was completed prior to pain medications being given per observations documented above). A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . RN CC' was observed in R2's room attempting to administer pain medications at 12:11 PM. RN CC documented R2 experienced a pain level of zero (out of 10) on the day shift on 5/25/21 despite R2 yelling out in pain throughout the shift and RN CC's documentation of R2 screaming in pain. A Nursing - Progress Note dated 5/27/21 at 2:22 PM written by LPN JJ documented, Resident in bed resting .Dressing changes performed and charted. No s/s (signs or symptoms) of distress or discomfort noted during shift . (Note: R2 yelled out in pain and verbalized pain throughout the provided wound treatment as documented above). LPN JJ documented R2 experienced a pain level of zero on the day shift of 5/27/21. There were no progress notes that indicated a physician was notified of R2's unrelieved and persistent expressions of pain on 5/25/21 and 5/27/21. Care plans for R2 were reviewed and did not include a care plan for pain management. On 5/27/21 at approximately 3:30 PM, R2 the Director of Nursing (DON) was interviewed. When queried about what should be done if a resident expressed pain, verbally or non-verbally, the DON reported the nurse should assess the resident to try to determine the cause of the pain, attempt non-pharmacological interventions, notify the physician, and implement any updates or orders as needed. A facility policy titled Pain Management Program dated 3/1/10 was reviewed and it documented the following: .Upon admission to the facility all residents will be assessed for pain as part of the initial nursing assessment and any time there has been a condition/significant change .The assessment will describe and characterize the pain, including location, cause of pain (if able to determine), type of pain, chronic vs. acute, and intensity level. A scale of 0-10 will be used (with 10 being the worst pain) .diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . If it is determined that a cause cannot be identified, it shall be documented to explain why the cause or causes of pain could not be or should not have been determined or why it was decided that in doing so would not affect the treatment or outcome. (Please seek out physician input) .If current medications and complementary therapies (non-pharmacologic) i.e., PT, OT, positioning, psychological and/or spiritual counseling, are not effective in relieving pain the physician will be notified to review the situation and prescribe or modify regimen. All unrelieved pain will be addressed with the physician if it persists .A treatment plan shall be developed for all residents who may have risk factors that make them very likely for pain to occur. This plan shall take into consideration the patients underlying diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .Plans of care shall be developed for each resident with established goals to relieve pain, reduce pain to a tolerable level, or reduce the need for breakthrough pain. Plans of care should include individual interventions to meet the patient's needs such as giving a pain medication before certain events or activities known to regularly exacerbate the patients pain such as turning, dressing changes or therapy. In addition, the care plan should also include a statement regarding what intensity level we expect the patient to achieve. (i.e., what is the realistic pain level we expect the patient to be at. If a resident has chronic pain and always rates his/her pain at a 10 with current medication regimen, it would not be acceptable for this patient to be pain free.) .Pain management effectiveness will be monitored according to the following: All residents will have pain monitored at least once a shift. Pain will be assessed and documented according to the Wong Scale (0-10). This documentation shall be placed on the MAR. If the resident is experiencing pain and an [MEDICATION(S)] medication is not ordered the physician will be notified and results documented in the nursing notes .

This citation pertains to Intake Numbers: MI 617, MI 211, MI 636, MI 020 and MI 428. Based on observation, interview and record review the facility failed to complete thorough skin assessments, implement timely interventions and continuously administer treatments per physician orders to prevent the development and worsening of a pressure ulcer(s) for three (R#901, R#907 and R#909) of five residents reviewed for pressure wounds, resulting in the development of a facility acquired Stage III (full thickness loss of skin) pressure ulcer that deteriorated to a Stage IV (full thickness skin and tissue loss that extends into muscle, tendons, ligaments or bone) that required hospitalization and debridement (removal of damaged tissue) of the wound for R#909 and the potential for further skin breakdown for R#901, R#907 and R#909. Findings include: A complaint was made to the State Agency (SA) that alleged R#909 was not turned or repositioned and developed a Pressure Ulcer at the Facility that required hospitalization and debridement of the wound. On 7/22/20 at approximately 2:00 PM, R#909 was observed lying in bed with full boots on both feet. The resident was sleeping and not able to answer questions at that time. On 7/27/20 at 9:25 AM, R#909 was observed in bed. R#909 was observed to be on a low air loss mattress, had a wound vac, an indwelling urinary catheter, and was receiving enteral nutrition (tube feeding) via an automatic feeding pump. R#909 was asked for permission to have the wound observed and consented. Wound Care Nurse 'C' was present and positioned R#909. The wound was observed to be round, approximately 3 inches in diameter with irregular edges. The peri-wound area appeared necrotic. A suction tube leading from inside the wound to the wound vac was visible with a translucent, occlusive dressing in place. The wound bed could not be visualized through the dressing. The wound vac was observed and had a small amount of serosanguinous drainage in the collection chamber of the wound vac. Review of R#909's medical record revealed that the resident was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R#909's Minimum Data Set (MDS), dated [DATE], documented that the resident had a Brief Interview for Mental Status (BIMS) score of four (severely cognitive impaired) and required two person assist for transfers, bed mobility and toilet use. Continued review of the record documented that upon admission to the Facility, R#909 had a Braden Score (tool used to assess risk of a pressure sore) of 16 that indicated the resident was at mild risk for developing a pressure sore. An initial care plan titled, Potential for Impaired Skin Integrity with an effective date of 1/3/2020 documented, in part, .potential for impaired skin .incontinence .decreased mobility .Interventions . encourage or assist the resident, if needed, to turn and change positions every 2 hours .encourage resident to consume greater than 75% of food and fluids .manage urinary and fecal incontinence .monitor skin changes during daily bathing and routine care, especially over bony prominences for color change, warmth .pressure relieving mattress on bed .skin assessments upon admission, weekly and PRN (as needed) . A physician order dated: 1/6/2020 documented, in part, Low Air-Loss Mattress to be ordered 1/3/2020: Assess sacral area daily for redness or open areas. Notify physician of abnormal findings. (Document on paper Tx (treatment) sheet. The following were the only nurse observations of R#909's sacral area that were documented on paper Tx sheets from admission 1/3/2020 - 5/15/2020: 1/3/2020: .blanchable redness to bilateral heels, coccyx skin intact . 2/2020: No skin assessments form was completed for the month of February 2020 3/24/2020: No pressure ulcers noted 4/7/2020: Buttocks Red 4/18/2020: Open wound to buttocks/sacrum: width: 3.4 - length 1.25 (no signature noted, no units of measurements were noted) 5/1/2020: Blank form 5/15/2020: Sacrum: width: 6- length 5 (no units of measurement were noted). It should be noted that there were no other paper skin assessments noted in the resident's electronic record. A request for any paper documents pertaining to skin assessments was requested. None were provided by the end of the survey. Review of R#909's TAR (treatment administration record) noted daily initials starting 3/24/20 that indicated nurses Assess sacral area daily for redness or open areas . (document on paper Tx). It should be noted that no documentation on paper as indicated were noted following the identification of red buttocks on 4/7/2020. A Progress Note dated 4/18/20 and authored by Nurse T documented, in part, the following: .Wound present to buttocks/sacrum. TRIAD (wound paste) ordered and Wound Consult ordered . A Progress Note dated 4/21/20 and authored by Wound Physician (WP) U was reviewed and documented, in part, the following: Patient was seen in consultation for Wound Management .right buttock has a skin tear, coccyx has stage 3, with a necrotic tissue .Assessment and Plan .Right buttock skin tear, will use TRAID, need to have single sheet to transfer, Coccyx stage 3 will need low air loss mattress, need to turn frequently, need to use wedge . A Progress Note dated 4/22/20 and authored by Facility Wound Nurse C was reviewed and documented, in part, the following: Resident was seen by wound care regarding skin tear noted to right buttock and Stage 3 Ulcer noted to coccyx. Area to right buttock measures 2.7cm (centimeters) x .2 cm. Light serosanguineous drainage, no odor noted. Area to coccyx measures 1.9 cm x 2.5 cm x .3 cm. Light serosanguineous drainage, no odor noted. Per wound care physical area to be cleaned with wound cleanser, dried, Triad paste to be applied to both areas. A Progress Note dated 5/5/20 and authored by WP U documented in part, the following: Patient was seen and examined .right buttock wound, status unhealed .coccyx has stage 3, with necrotic tissue it has odor to it measuring 7.2 x 5.2 x 1.1 undermining 1.6 cm from 6-9 .Assessment and Plan .Right buttock skin tear now has joined the coccyx ulcer. Coccyx stage 3 with necrotic issue and odor, will change dressing to Dakins . A Progress Note dated 5/5/20 and authored by Physician Extender, Nurse Practitioner (NP) A was reviewed and documented as in part, the following: The patient is seen .abnormal lab results and follow up on sacral decubitus ulcer . has a stage 4 sacral decubitus ulcer and WP U has been following up .we did place a call to WP .regarding lab results and he is in agreement .ASSESSMENT AND PLAN: 1) Stage 4 decubitus ulcer .concerning for possible [DIAGNOSES REDACTED] or other worsening infection process .WP U is advising the patient be transferred to the hospital for complete evaluation . A review of R#909's TAR for the Month of April 2020 was reviewed. A treatment for [REDACTED].#909 did not receive treatment on the following dates: 4/24 (9 PM), 4/25 (9 AM), 4/25 (2 PM), 4/26 (9 AM), 4/26 (2PM), 4/27 (2PM), 4/29 (2PM). A review of R#909's Hospital Records dated 5/6/20 was reviewed and documented, in part, ED (emergency department) notes .Chief Complaint .Patient presents with Tailbone Pain .pt(patient)to ER from nursing home for debridement of ulcer on coccyx and MRI (magnetic resonance imaging) for [DIAGNOSES REDACTED] (infection of the bone) .Patient has a history of possible stage III Stage IV ulcer buttocks 3 x 5 cm, 7 x 5 cm and 1.76 cm deep around the 6 to 9 o'clock position .they have been using wound care .there is some necrotic tissue around the wound bed .Patient initiated [MEDICATION NAME] of 2.4 which I believe is related to dehydration .patient requires .stay because of the complex nature of the patient who had large wound infection with debridement . On 7/23/20 at approximately 11:30 AM, an interview was conducted with Wound Nurse C. Nurse C reported that they have been working at the Facility since April 2020. When queried as to the Facility protocol pertaining to wound care, Nurse C explained that residents should be assessed upon admission and they should be notified if there is evidence of a wound. They also indicated that weekly skin assessments should be completed by staff. When queried as to R#909, Nurse C stated that when they started at the Facility they conducted a full sweep of all the residents and determined that R#909 had a Stage III pressure ulcer to the coccyx that was facility acquired. Nurse C noted that they spoke with the Director of Nursing (DON) and that the resident started to treat with WP U. Nurse C indicated that they were not aware as to what was done prior to her hire to prevent the development R#909's pressure ulcer. On 7/23/20 at approximately 1:30 PM a phone interview was conducted with WP U concerning R#909. When queried as to their protocol pertaining to resident's with wounds, WP U reported that when wounds/pressure ulcers are noted by facility staff they are contacted and generally make weekly visits. Staff are to assess residents and ensure interventions, such as oral intake and turning/repositioning are done regularly, and treatments are completed. When asked specifically about R#909, WP U reported that they recalled R#909 had a decline in skin and was sent to the Hospital for debridement. On 7/27/20 at approximately 2:15 p.m., an interview was conducted with the DON, when queried about the Facilities policy pertaining to pressure sores and the missing treatment entries for R#909. The DON explained that treatments provided should be documented on the TAR when they are completed, and interventions should have been put into place and followed to prevent the development of pressure sores. On 7/28/20 at approximately 10:20 AM a phone interview was conducted with Nurse T pertaining to R#909 and the 4/18/20 note indicating the appearance of a wound. Nurse T explained that they generally worked weekends and recalled that Certified Nursing Assistant (CNA) W, who they believed was changing the resident, informed them of an issue with the resident's skin. Nurse T reported that they informed the doctor of their observation and an order was placed for treatment. Nurse T indicated that they were not to note the stage of the wound. On 7/28/20 at approximately 10:30 AM a phone interview was conducted with CNA W. When queried as to R#909's wound, CNAW reported that they recalled working frequently with the resident and for many months never noticed any wounds, but at some time in April (CNA W) could not recall the date, they noticed a large area was opening on the resident's bottom and told Nurse T that something needed to be done. Resident #901 A complaint was filed with the SA on 6/27/20 that alleged facility staff failed to provide adequate and appropriate care to prevent and/or treat pressure sores. The complainant further explained 3 and half weeks after they (R#901) came to the (Name Redacted) facility. Their doctor, (Name Redacted) Dr. 'CC', called for an ambulance to have my husband taken to the hospital (Name Redacted) 'DD' again. Because R#901 was so bad with infection do (sic) to a stage 4 bed sore over his whole rear-end that they didn't even treat them for (sic) until 4/22/2020 when their nurse (Name Redacted) Nurse 'EE' saw it when they were leaning out of the bed. Then (Name Redacted) Nurse 'EE' alerted the family and (Name Redacted) Dr. 'CC' who order a bunch of tests and x-rays . Which also determined they had gotten pneumonia on top of everything else, urinary trac (sic) infection, severely dehydrated, severely malnourished. They (facility) hadn't taken care of their catheter, his penise (sic) was infected and oozing and split open. They were septic and their kidneys were starting to show injury . How does a full functional man come in for rehabilitation and leave on their death bed!! At the hospital they had to have 5 antibiotics. 5 surgeries to debreed (sic) their bed sore that covered their whole butt, perineum, and scrotum . they had to have a couple bags of blood due to all the debreedings (sic) they had to have. And all of this means R#901 has to suffer through for atleast (sic) a year. Because that is how long it will take for them sever (sic) bedsore will take to heal, and that is after weeks of depression for R#901 and family. Because we didn't know if they were going to survive this . All of this is a result of this (Name Redacted) facility not taking care of R#901 and doing their jobs. A review of the clinical record revealed R#901 was originally admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the 5 Day MDS dated [DATE] revealed R#901 had a BIMS score of 3 out of 15 which indicated severe cognitive impairment and required extensive assistance with two-person physical assist for activities of daily living. The MDS further revealed R#901 had 1 Stage II pressure sore that was not present upon admission, 2 Unstageable deep tissue injury with 1 present upon admission. The discharge MDS dated [DATE] revealed R#901 had 3 Unstageable slough/eschar pressure ulcers . Interventions: .Turning/repositioning program (Not checked) . The facility's care plan initiated on 3/27/20 revealed Focus: Potential for Impaired Skin Intergrity (sic). Goals: Residents skin will remain free from breakdown. Interventions: . Monitor skin for changes during daily bathing and routine care, especially over bony prominences for color changes, warmth, and induration. Notify physician and the responsible party for health care of all new skin breakdown and worsening of pressure areas . Encourage or assist the resident, if needed, to turn and change positions every 2 hours . Monitor lab values per MD order (i.e. Hgb (Hemoglobin, [MEDICATION NAME] .) and notify physician of abnormal findings . Record review of R#901's Braden Scale revealed a score of 14 (Moderate Risk) on 3/31/20, 4/3/20, and 4/10/20. Further review of an assessments dated 4/17/20 revealed a score of 17(Mild Risk). Review of the March Skin assessment dated [DATE] revealed R#901 had a scab on (R) right great toe. (R) leg. (L) left toe. small bumps on back & left side. The Skin Assessment for April 2020 revealed the following: Date: 4/1/2020, Treatment No.: A, Width: Blank, Length: 2 in (inch), Depth: 2 in, Stage: Blank, Comments/Description: Open area on (L) buttocks, Skin and feet dry and intact. Date: 4/3, Treatment No.: B, Width: 5.2, Length: 6.0, Depth: 0.1, Stage: U (Unstageable), Comments/Description: (R) buttock open area with bloody drainage and skin flap. Surrounding skin intact and moist. Wound edges attached. Date: 4/3, Treatment No.: A, Width: 7.0, Length: 9.0, Depth: - , Stage: U, Comments/Description: (L) buttock dark area 0 drainage. Date: 4/3, Treatment No.: C, Width: 1.0, Length: 2.0, Depth: 0.5, Stage: U, Comments/Description: dark area to coccyx 0 drainage. Date: 4/7, Treatment No.: A, Width: 5.4, Length: 8.1, Depth: Blank, Stage: Blank, Comments/Description: (L) buttock dark area unstageable. Date: 4/7, Treatment No.: B, Width: 6.0, Length: 9.0, Depth: Blank, Stage: Blank, Comments/Description: (R) buttock dark area unstageable. Date: 4/7, Treatment No.: C, Width: 1.5, Length: 2.0, Depth: 0.3, Stage: Blank, Comments/Description: Coccyx open area wound bed red, edges attached, surrounding skin intact. Date: 4/14, Treatment No.: A, Width: 3 in, Length: 2.5 in, Depth: Blank, Stage: Blank, Comments/Description: (L) buttocks. Date: 4/14, Treatment No.: B, Width: 2.5 in, Length: 3.5 in, Depth: Blank, Stage: Blank, Comments/Description: (R) buttocks. Date: 4/14, Treatment No.: C, Width: 1.5 in, Length: 1.5 in, Depth: 0.2, Stage: Blank, Comments/Description: Coccyx. Date: 4/24, Treatment No.: D, Width: Blank, Length: Blank, Depth: Blank, Stage: Blank, Comments/Description: Open area; slough in between coccyx. A review of the physician's orders revealed the following: 3/27/2020 at 06:45 pm Assess sacral area daily for redness or open areas. Notify physician of abnormal findings. (Document on paper Tx sheet). The only documented paper tx sheets for this resident are those noted above. It was also noted no indication of assessment was done on 4/10/20. An order dated 3/30/2020 at 02:23 pm read resident to receive, in part, the following:[MEDICAL CONDITION] Screen Monitoring .every shift . This treatment was not performed on 4/6/20 on the 11:00p -7:00a shift and 4/10/20 on the 3:00p - 11:00p shift. A physician order dated 4/3/2020 at 1:43 pm documented, Medication Triad Wound Dressing paste SIG: apply 1 applicatorful by topical route 2 times per day and as needed apply to bilateral buttocks and coccyx. This treatment was not performed on 4/10/20 at 9:00p. On 7/23/20 at 11:35 a.m., during an interview with Wound Care Nurse 'C', when asked about R#901's wound care treatments and missed entries, Wound Care Nurse 'C' explained that they had started on the floor the end of April/beginning of May, and was not sure of R#901's wound care. The DON was also not aware of R#901's care at the facility as they were new to the position. On 7/23/20 at 12:10 p.m., when asked about the blanks on R#901's TAR, the Administrator stated, I will check. When queried how it could be determined if R#901's treatment was completed if it were not documented, the Administrator stated, In the progress notes. At that time, the progress notes were reviewed along with the Administrator. There were no entries documented that R#901 refused any treatments. Review of the facility's Medical Progress Notes dated 4/25/20 at 7:01 p.m., read in part: DISCHARGE Diagnoses: [REDACTED]. Bilateral buttock decubitus ulcer infection. b. Pneumonia. c. UTI (urinary tract infection. 2. [MEDICAL CONDITION] secondary to inadequate intake and also [MEDICAL CONDITION] . 3) Blood cultures positive for cocci in clusters . 5) Acute kidney injury, secondary to the inadequate intake and dehydration . 10) Bilateral buttock decubiti, probable infection . Further review of the Progress Notes revealed PHYSICAL EXAM BEFORE DISCHARGE: . EXTREMITIES: . Bilateral lower extremities normal, other than the buttock decubiti. SKIN: Bilateral buttock wounds, stage 2. They are getting worse. Also, sacral ulcer is also noted. NURSING HOME COURSE: .In the second week of April, the patient was found to have COVID-19 pneumonia, for which the patient moved to the (Name Redacted) special COVID Unit . Later, he was going into a septic way because of UTI and decubiti infection . His wounds are not getting better. They are getting worse. To prevent further problem, I initiated the transfer to (Name Redacted) local Hospital 'DD' ER . The patient needs wound debridement of the bilateral buttocks. That is why I sent him. Otherwise, he will go into more septic. R#901's Medical Records obtained from Hospital 'DD' were requested and reviewed, and read in part the following: 4/25/2020 @ 2249 - Discharge 05/19/2020 @ 2000 Visit Diagnoses Chief Complaint - Wound Infection (Sacral) Pressure injury of sacral region, stage 4 Yes (CMS/HCC) (primary) Wound infection Yes . Acute kidney injury (CMS/HCC) Yes Urinary tract infection associated with indwelling Yes urethral catheter, sequela Hospital Problems Sepsis (CMS/HCC) (primary) 4/26/2020 - Yes . Pressure injury of sacral region, stage 4 (CMS/HCC) 4/25/2020 - Yes . Discharge Final Diagnosis: [REDACTED]. Stage IV infected decubitus sacral ulcer Furnier's (sic) gangrene Resident #907 A complaint was filed with the State Agency (SA) on 3/23/20 that alleged staff failed to prevent and treat pressure sores. On 7/21/20 at 12:55 p.m., during a telephone call, the Complainant stated, There was a time when it was four days in a row there was no changes of the dressing of their (R#907's) wounds. they are supposed to date when dressings are changed. I noticed on March 7th the bandages were dated March 3rd. I called the Administrator and told her. She wasn't on duty, so I talked to (Name Redacted) Nurse Supervisor 'O' and he went in and changed them (bandages). The Complainant further stated, I have pictures that show date and times of bandages. A review of the clinical record revealed R#907 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the 5 Day MDS dated [DATE] revealed R#907 had a BIMS score of 5 out of 15 which indicated severe cognitive impairment and required extensive assistance with one to two-person physical assist for ADLs. The MDS further revealed R#907 had 2 - Stage II pressure sores upon admission, 1 - Unstageable slough/eschar upon admission, 1 - Unstageable deep tissue injury, and 2 - Venous and Arterial Ulcers. A review of the facility's care plan effective 2/01/2020 revealed the following: Focus: Potential for Impaired Skin Integrity. Goals: Residents skin will remain free from new or worsening skin breakdown. No new breakdown will occur. Interventions: .Monitor skin for changes during daily bathing and routine care, especially over bony prominences for color changes, warmth, and induration. Notify physician and the responsible party for health care of all new skin breakdown and worsening of pressure areas. Pressure relieving mattress on bed. Skin assessments upon admission, weekly and PRN. Implement skin protocol as appropriate. Encourage or assist the resident, if needed, to turn and change positions every 2 hours. Review of the TAR and Physician's Orders revealed the following: Start Date: 02/27/2020 11:26 am - Cleanse right lower leg and right middle leg with normal saline, apply solosite (wound gel), ABD (pad use to absorb discharges from heavily draining wounds) and kerlix (gauze used for wound care) every day. The TAR was blank for 3/6/20 and 3/14/20. Start Date: 02/11/2020 03:14 pm. - Triad Wound Dressing paste. SIG: apply 1 applicatorful by topical route to bilateral buttocks. The TAR was blank for 3/5/20 and 3/15/20 (7:00a - 3:00p shift), 3/6/20 and 3/14/20 (3:00p - 11:00p shift). Start Date: 02/05/2020 08:02 pm - Heel Protectors while in bed. The TAR was blank 3/5/20 and 3/15/20 (7:00a - 3:00p shift), 3/6/20 and 3/14/20 (3:00p - 11:00p shift). On 7/23/20 at 12:10 p.m., during an interview, when asked about blanks on R#907's TAR, the Administrator stated, I will check. When asked how it could be determined if R#907's treatment was completed if it was not documented, the Administrator stated, In the Progress Notes. R#907's Progress Notes were reviewed along with the Administrator. There were no entries documented that R#907 had refused any of their treatments. On 7/23/20 at 2:20 p.m., an interview was conducted with Dr. 'AA'. When asked how often the treatment dressings should be changed for residents with wounds, Dr. 'AA' stated, Check skin daily. Sacral area and heels if patients have a wound. On 7/23/20 at 2:55 p.m., during an interview with LPN 'BB' who was assigned to care for R#907, when queried about the blanks on the TAR, LPN 'BB' stated, Things like that happen at (Name Redacted) facility the way the schedule is set up. Some people work 8 hours and some work 12 hours. I probably worked half of that shift and was not responsible for that documentation. I can't really remember . a lot of people were going in and out. On 7/27/20 at approximately 2:15 p.m., an interview was conducted with the DON, when queried about the missing treatment entries on R#907' TAR, the DON explained that treatments provided should be documented on the TAR when they are completed. A review of the Facility Policy titled, Pressure Ulcer/Injury Protocol (undated) documented, in part, the following: Policy: Based on the Comprehensive Assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individuals clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing .3. Identify the resident at risk of developing pressure ulcers; the level and nature of risks including specific conditions, causes and/or problems, needs and behavior; and identify the presence of pressure ulcers .The following are examples of risk factors .impaired/decreased mobility and decreased functional ability .exposure of skin to urinary and fecal incontinence .under nutrition, malnutrition and hydration deficits .once the assessment has been completed immediately develop a plan of care .10. If there is any change in the patient's skin condition, the nurse . should review and revise the patients care plan. 14. If a determination is made that the development of a pressure sore was unavoidable, it must be documented by the nurse and physician that the elements for an unavoidable pressure ulcer were met .

This citation pertains to Intake Numbers: MI 617, MI 443, MI 211 and MI 817. Based on interview and record review the Facility failed to ensure fall safety measures were put in place to prevent falls and ensure falls were timely reported for two residents (R#907 and R#908) out of four residents with a high risk for falls, resulting in resident #908 sustaining a laceration to the back of the head, emergency transfer to the hospital requiring stitches and pain and R#907 not timely assessment and delay in treatment for [REDACTED]. Findings include: R#908 A complaint was filed with the State Agency that alleged R#908 fell at the Facility and sustained an injury that required four staples to the head and a hospital stay. A review of R#908's medical record documented that the resident was originally admitted to the facility on [DATE] for therapy following a fall that resulted in a fractured femur (right hip). R#908 also had [DIAGNOSES REDACTED]. A review of R#908's Minimum Data Set ((MDS) dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of three (severely cognitively impaired) and required one to two person assist for transfers and bed mobility. An initial Safety Skills assessment dated [DATE] documented R#908 had a High Fall Risk Score of 19 and had a history of [REDACTED]. A nursing note dated 4/28/20 and authored by Nurse Y documented, in part, the following: Patient observed on the floor at the foot of the bed laying on right side leaning on right elbow .no injury noted at this time .transferred back to wheelchair .patient interviewed .trying to help roommate who had fallen out of bed .patient seated at nursing station . A nursing note dated 5/10/20 at 7:52 and authored by Nurse X documented, in part, the following: At 6:40 PM resident was in his wheelchair eating dinner. Aide walked in found resident on floor called out for assistance .discovered abrasion to the back of resident's head and blood on resident's shirt .Asked resident how did the fall happen .I don't know, I guess I slipped .Writer called on physician .and informed physician of anticoagulation medication. Physician ordered resident to be sent out 911 . On 7/22/20 at approximately 9:00 AM, the Administrator was asked to provide all Investigation/Accident (I/A) reports for R#908. On 7/22/20 an I/A was provided for R#908's fall that occurred on 5/10/20. The Administrator reported that was all the I/A's pertaining to R#908. A second I/A pertaining to the fall that occurred on 4/28/20 was provided on 7/27/20. The I/A for the incident that occurred on 4/28/20 documented, in part, the following: Date of Incident: 4/27/20 .Time of Incident: 8:00 PM. 2. State exact location of Incident .in patients bedroom at the foot of bed sitting on butt .3. Describe what you observed at the scene of the incident: (a) Statement by resident .patient states he was trying to help his roommate .4 .call light was attached to wheelchair .6 unable to stand alone .18 .Initial corrective action/taken Recommendation for prevention of similar occurrence .when patient awake keep in close observation, patient up front with nurse (emphasis added) .25. Was there a medical cause that may have contributed .gait/balance deficiencies .physician signature (NP) A. Care Plans pertaining to R#908 were reviewed on 7/22/20 and documented in part, the following: Admission .Fall Risk .Etiology: Risk for Falls .History of falls; Unable to ambulate without assistance .unable to transfer without assistance (Effective 4/27/20) .Goals: Resident will remain free from injuries (Effective 4/27/20) .Interventions: Clean up spills immediately (4/27/20), PT(physical therapy) and/or OT(occupational therapy) evaluation as ordered, Maintain room and pathways free of clutter (Effective 4/27/20), Continually assess ability to use call light (Effective 5/5/20) .(Keep glasses clean and fit .(Effective 5/5/20). It should be noted that the corrective action initiated after R#908's fall on 4/28/20 that stated: When patent awake keep in close observation, patient up front with nurse was not incorporated into R#908's care plan as recommended. The I/A pertaining to the incident that occurred on 5/10/20 documented in part, the following: .Date of Incident: 5/10/20: Time of Incident 6:54 PM. 2. State exact location of Incident: Resident's Room between bed and dresser. 3. Describe what you observed at the scene of the incident (a) Statement by resident .: 'I don't know, I guess I slipped' .(b) Statement by staff, roommate: Fall was unwitnessed .Did resident have an alarm on (a negative line was filled in) .8. Appearance of involved part: Bleeding-Yes-Describe (back of head) .Indicated on diagram location of injury and check below .Type of Injury: Laceration .Abrasion (back of head) .Treatment ordered: .sent to hospital . 18. Initial corrective action taken .Order for Dycem .Name of person reporting incident . LPN X .Name of CNA A hospital record dated 5/11/20 was reviewed and documented in part, Date of Admission: 5/10/20 .Chief Complaint: Fall .History of Present Illness: .(R#908) was found on the floor yesterday evening by staff at the nursing facility .fall was unwitnessed .noted to have a laceration in the back of the scalp and was confused as well as agitated .patient was disoriented and calling for help. (R#908) would yell any time I touched or tried to speak to them .able to tell me . name and that it 'hurts all over' .Assessment 1. Fall, with scalp laceration, Staples placed in ER (emergency room ) . An attempt to contact Nurse Y via phone was made during the survey. No return call was made. On 7/27/20 at approximately 2:00 PM an interview was conducted with Nurse X pertaining to the fall on 5/10/20. Nurse X reported that they did not witness the fall and could not recall what interventions were in place for R#908 to prevent falls. On 7/28/20 at approximately at 10:00 AM an interview via phone was conducted with NP A pertaining to R#908 NP A stated that they no longer provided services for the Facility and could not recall details about the resident and the event. When queried as to whether interventions recommended in an I/A report should be put into place for residents that are at risk for falls, NP A stated, Yes. On 7/28/20 at approximately 10:30 AM an interview was conducted with CNA W. CNA W was queried as to the incident that occurred on 5/10/20. CNA W reported that they had found R#908 lying on the floor in the room and called the nurse. When asked what fall interventions were implemented for R#908, CNA W reported that they generally worked on the weekends and was not made aware of the interventions implemented to prevent falls for R#908 and/or other residents in the Facility. CNA W stated that they knew R#908 liked to try and get up and move on their own and that they would try to do the best they could to keep the resident safe. An interview was conducted with the Administrator on 7/28/20. When queried as to why no interventions, including the recommendation noted on the 4/27/20- I/A that stated Initial corrective action/taken Recommendation for prevention of similar occurrence .when patient awake keep in close observation, patient up front with nurse was not implemented following the fall on 4/27/20, the Administrator reported that the incident on 5/10/20 happened during dinner time and due to COVID-19 the residents were not able to eat in the main dining room. When queried as to whether additional interventions other than eating in a dining room could have been implemented to protect R#908 who was at risk for falls, the Administrator reported that they could. Resident #907 A complaint was filed with the State Agency (SA) on 3/23/20 that alleged the resident fell and sustained an injury, and the facility staff failed to make out an incident report on the resident's fall. On 7/21/20 at 12:55 p.m., during a telephone interview, the Complainant stated, During a two-week period he (R#907) had two falls. The first fall was late at night (March 10th or early in the morning on March 11th. It was never documented until it was reported to the Administrator. They got the doctor (Dr. 'I') to notice the lump. It was a new CNA gentleman (CNA 'J') who rolled him out of bed, pick him up, and put him back in the bed and didn't say anything. They didn't even call me. The second fall was on March 22nd. The nurse rolled him to change him and he fell out of bed . He (R#907) had a brain bleed and was in the hospital 29 days before going to (Name Redacted) Hospice . He passed away on May 18th. A review of the clinical record revealed R#907 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the 5 Day MDS dated [DATE] revealed R#907 had a BIMS score of 5 out of 15 which indicated severe cognitive impairment and required extensive assistance with two-person physical assist for bed mobility and toilet use. The discharge MDS dated [DATE] revealed R#907 had (1) fall with no injury, (1) fall with an injury that was not major, and no falls with a major injury. A review of the facility's care plan dated 2/1/20 revealed R#907 revealed the following: Focus . Fall risk . resident will remain free from injuries . Assess resident's balance, endurance, gait, stability and ability to perform ADL's safely . Maintain record of falls and evaluate for patterns . Make sure that all staff members are aware that resident is at high risk for falls . Toilet resident per their request. If resident is unable to request, toilet and/or check brief for wetness every 2 hours and as needed . Low bed. There was no care plan for bed mobility. Fall #1 Review of the facility's I/A (Incident/Accident) dated 3/11/20 at 4:30 p.m., revealed the following: .Fall Risk Score 21 (High Risk). BIMS: 5/15. 1. Date of Incident: 3/10/20 (it should be noted that the 3/10 date was scratched and replaced with 3/11/20, however resident had reported event occurred the evening prior 3/10/20) . Time of Incident: 4:30 p.m . 2. State exact location of Incident (where did it occur): In residents bedroom . 3. Describe what you observed at the scene of the incident: (a) Statement by resident: Self reported to family stating he fell last night out the bed and a staff member picked him up and put him back in the bed . 5. State the effect of the Accident/Incident on the resident .: Resident complained of pain . 7. Was a body exam completed? Yes . 8. Appearance of involved part: Swelling: Yes. Describe: Knot on the (R) Posterior of head. Pain: Yes . 10. Examination revealed: Knot noted on the right posterior of the head . Treatment ordered: Sent to hospital . 18. Initial corrective action taken/Recommendation for prevention . Bed in lowest position . 20. Name of person reporting incident: (Name Redacted) License Practical Nurse (LPN) 'K' . Physicians' Statement 23. Extent of Injury: Hematoma (scalp hematoma of (R) temporal parietal area . Review of the Investigation submitted by the facility revealed the following: Allegation: Fall out of bed. History and Physical: .Resident's BIMS score is 5/15 and he is alert and orientated times 2. (Name Redacted) R#907 is a two person transfer lateral scoot with locomotion at wheelchair level and toileting at bed level. Summary: On 3/11/2020, around 4:30 pm, (Name Redacted) reported to his sister (Name Redacted) (Family Member 'G') that he fell out of bed the previous night (3/10/20). (Name Redacted) Family Member 'G' requested to speak to the Administrator and discussed the findings. (Name Redacted) family Member 'G' stated that there was 'bump' noted on the resident's head. Nursing Administration and (Name Redacted) NP (Nurse Practitioner) 'A' and (Name Redacted) Dr. 'I' were notified, and resident was evaluated. It was determined that resident should be sent out for a CT (Computed Tomography) scan. Several staff members were interviewed regarding this allegation by phone . (Name Redacted) CENA (Certified Nursing Assistant) CENA 'J' stated that he changed resident, however there was fall and the resident did not fall out of bed . During the evening shift into the midnight shift, there was no report of the fall from the staff or the resident. Conclusion: The facility was immediately able to rule out abuse and an injury of an unknown origin. (Name Redacted) R#907 was able to state that he rolled out of bed with CENA ('J') present in the room and the CENA ('J') assisted him back to bed . Review of the facility's Grievance Documentation, Investigation & Follow-up form submitted by R#907's wife revealed the following: .Nature of Concern 3/11/2020: Resident's sister stated that resident had a bump on his head and that resident reported to her that he had rolled out of bed last night . Investigation 3/11/2020: Administrator interviewed assigned nurse, no fall was reported to her, Administrator and ADON interviewed assigned CENA ('J') and CENA 'J' stated that no fall occurred with him. Interviewed resident and (Name Redacted) R#907 stated that he did fall. Action Taken 3/11/2020: CENA was followed up with and asked again if fall occurred with resident. Follow Up 3/11/2020: (Names Redacted) NP 'A' and Dr. 'I' evaluated resident. Resident was sent out to (Name Redacted) Local Hospital 'L' for a CT scan . As a precautionary measure and previous concerns, facility assigned resident 1:1 (one-on-one) companion . Review of physician's Progress Notes dated 3/13/2020 at 12:15 a.m., revealed Visit Date: 3/11/2020 . Patient was reported to have fallen out of bed. Patient actually reported this himself to his sister who came to visit him this afternoon. She then discussed with nursing, and they asked me to evaluate the patient . Patient tells me he describes the incident as that he rolled towards the right side of the bed onto his right side and fell off the bed; however, his sister also tells me that when she came into the room the patient stated somehow nursing staff was involved in the incident . the patient is clear that he did roll off the right side of the bed onto the floor, and he feels he struck the right side of his posterior head. The progress notes further revealed . very small scalp hematoma along the right upper temporal area . somewhat swollen, and patient reports it is a little bit tender there . On 7/22/20 at 1:45 p.m., during an interview, the Administrator was asked if CENA 'J' still worked at the facility. The Administrator stated CENA 'J' no longer work here. I will get the phone number. At that time CENA 'J's personnel record was requested. The Administrator returned at 2:20 p.m., and stated, The resident was alert times three and reported that he had fallen, and the resident was able to state who the aide was that helped him get back in bed. On 7/22/20 at 2:31 p.m., a telephone interview was conducted with CENA 'J'. When asked about the incident with R#907, CENA 'J' explained that they were in orientation and new to the facility and was working the midnight shift. I got to work at 7pm and did not see him (R#907) until about 10pm. I just happened to be coming down the hall. I heard him (R#907) cussing. I called the Charge Nurse (LPN 'K'). He was not my patient, but anybody can answer a call light . That was my first time seeing him. I asked if I could help him and he said, 'I'm wet.' He was on the phone with wife. His wife was pi**ed and on the phone complaining about something . I propped something behind his back. I changed him . He (R#907) did not have a fall . When asked if R#907 was a one or two-person assist, CENA 'J' stated, I'm not sure. That was my first time seeing him. I'm a big guy. I'm 6 feet . and weigh over 250 pounds. I've been a CNA for over [AGE] years . I know what I'm doing . When asked if they still worked at the facility, CENA 'J' stated, No, they let me go. When asked why they were let go, CENA 'J' stated, I'm not sure . On 7/22/20 at approximately 2:40 p.m., during an interview, when queried about CENA 'J''s statement that R#907 did not have a fall while being changed, the Administrator stated, The resident was alert times three and reported that he had fallen, and the resident was able to state who the aide was that helped him get back in bed. On 7/27/20 at 3:18 p.m., a call was placed to LPN 'K', who was assigned to R#907 and a message was left on the voicemail. There was no return call by the end of the survey. Fall #2 Review of the facility's I/A (Incident/Accident) dated 3/22/20 at 13:45 p.m., revealed the following: .Fall Risk Score (Blank). BIMS: (Blank) 1. Date of Incident: 3/22/20. Time of Incident: 13:45 p.m . 2. State exact location of Incident (where did it occur): In residents room. Resident rolled off bed. 3. Describe what you observed at the scene of the incident: (a) Statement by resident: Resident states he fell , rolled off bed while being changed (b) Statement by (staff, .) (Name Redacted) LPN/Companion 'S', who observed: was changing resident and yelled out for help from staff because resident had rolled off bed . 5. State the effect of the Accident/Incident on the resident .: Resident hit head on nightstand and has laceration to forehead (right side near eyebrow) . 7. Was a body exam completed? Yes . 8. Appearance of involved part: Bleeding: Yes . Pain: Yes . 9 . Type of Injury: Laceration (1 cm - centimeter) 10. Examination revealed: Laceration/bleeding to right forehead near eyebrow. Resident states forehead hurts, but no other pain or discomfort. 11. Can the involved part be moved freely without pain? No. If no, please have resident describe pain: Aching/burning pain. 12. Did functional status change immediate post incident? No. 13. If head injury or loss of consciousness occurred: No loss of consciousness. 14. Was a Neuro check on the chart? No . 16. Treatment ordered: Apply bandage, X-ray, Sent to hospital . 17. Family/Responsible Party Notification: (Names Redacted) . Date: 3/22/20 Time: 14:20 p.m. 18. Initial corrective action taken/Recommendation for prevention of similar occurrence: Nurse educated nurse (LPN/Companion 'S') on proper technique for changing resident in bed . 20. Name of person reporting incident: (Name Redacted) Registered Nurse (RN) 'T' . Physicians' Statement 23. Extent of Injury: Blank . Comments: Not seen sent to hospital. Review of the Investigation submitted by the facility revealed the following: . Summary: On 3/22/2020, around 1:45 pm, (Name Redacted) (R#907) was assisted with bed level toileting. Resident did have a 1:1 companion (Name Redacted) LPN 'S' , LPN 'S' was changing (R#907) in bed. LPN 'S' gathered her supplies before starting to change resident. (Name Redacted LPN 'S' began to change resident, turning him and cleaning him up. R#907 began to have a bowel movement. Once resident was finish, LPN 'S' continued to provide care to resident and when resident was on his left side, (Name Redacted) R#907 reached over to his nightstand and rolled over the bed. During the change of position, R#907 was witnessed to bump his head on the nightstand. LPN 'S' immediately assessed the resident and called for help . The on call physician was called and it was determined that resident was going to be sent out 911 . Resident was sent to Local Hospital 'L'. Conclusion: . R#907 was able to state that he rolled out of bed with a Nurse present in the room . On 7/22/20 at approximately 2:20 p.m., during an interview, when queried if the companion/sitter that was in the room at the time of R#907's fall was a CNA, the Administrator stated, The LPN/Companion was also the person changing the resident. When asked who was in the room with LPN/Companion 'S', the Administrator stated, At the time, it was just the nurse (LPN 'S') and the patient. The Administrator was queried if R#907 was a one or two-person assist with bed mobility and toilet use. The Administrator stated, I'll have to check. On 7/23/20 at 9:22 a.m., during a phone interview LPN/Companion 'S' was asked if they still worked at the facility and stated, No, I was fired . When queried if they provided care for R#907 while at the facility, LPN/Companion stated, I was asked to be (Name Redacted) R#907's sitter that day. He had a bowel movement and I was doing peri-care and (Name Redacted) R#907 reached over attempted to get in his side drawer of the nightstand. I was not able to catch his full body so (Name Redacted) R#907 rolled over onto the floor. When asked if they were providing care for R#907 alone, LPN/Companion 'S' stated. Yes. When asked if R#907 was a one or two-person physical assist with bed mobility/toileting, LPN/Companion 'S' explained from their knowledge they (R#907) were a one-person assist and it was their first time caring for them. When asked if they had checked R#907's care guide before providing peri-care, LPN/Companion 'S' stated, (Facility's Name) has a transfer sheet called 'Happy Feet' and it read assist times one . Review of the facility's care plans effective 2/01/2020 - Review: 5/01/2020 revealed the following: Focus: Self Care Deficit. Goals: Resident will demonstrate doing ADLS to the best of her/her ability. Staff will assist as needed. Interventions: . Toileting: Assist resident with toileting. Assist with peri-care, if resident is unable to cleanse themselves . The care plan did not indicate if R#907 was a one or two-person assist with toileting. Focus: Alteration in Mobility. Goals: Resident will maintain maximum function while here at the facility. Interventions: . Assist resident to maintain proper body alignment. Encourage mobility, within physician's orders [REDACTED]. Ensure personal items of need are provided and within reach On 7/23/20 at 11:15 a.m., during an interview, when queried about specific care plans for R#907's bed mobility during toileting and how it could be determined if R#907 required one or two-person physical assist, the Administrator stated, I'll have to check. I don't think we have a specific care plan . At that time, the Administrator was asked what was the 'Happy Feet' guide? There was no explanation and R#907's 'Happy Feet' guide was guide was requested. On 7/23/20 at 12:26 p.m., an interview was conducted with Corporate MDS Nurse 'P' and new MDS Coordinator Nurse 'Q' (since May 2020) in regard to the bed mobility and toilet use code that documented R#907 was a two-person physical assist. MDS Nurse 'P' explained the CNAs' look back period was 7 days from the ARD. The CNA coded the resident was assisted by two people at least 7 times . CNAs gauge it by the resident's transfer status . Bed mobility is not a solid order for the patient . They have to go by the transfer order. It depends on the resident's ability . When queried about the 'Happy Feet' guide, MDS Nurse 'P' stated, The 'Happy Feet' guides staff on how many people it takes to safely transfer a person. This is for transfer only. When asked if the CNAs used the Kardex as a guide to provide care, MDS Nurse 'P' stated, I will find the Kardex. A review of R#907's electronic record was reviewed along with MDS Nurse 'P' and MDS Coordinator 'Q'. the Kardex Instructions could not be reviewed and revealed Error. MDS Nurse 'P' stated, I will contact IT (Information Technology). R#907's care plan was reviewed along with MDS Nurse 'P' and MDS Coordinator 'Q'. The care plan did not address bed mobility. MDS Nurse 'P' stated, I don't know why bed mobility is not there. Further review of the PT/OT (Physical Therapy/Occupational therapy) Notes revealed the following: PT/OT: 2/2/20 Total dependence with attempts to initiate (Bed Mobility). PT: 2/28/20 - 3/16/20 Recertification same as 2/2/20. OT: 2/26/20 - 3/16/20 - addressed upper body dressing, hygiene, and self-feeding. This evaluation did not address bed mobility at that time. On 7/23/20 at 1:22 p.m., during an interview with the DON, when queried about R#907 bed mobility and toileting status, the DON explained she was new to the position and did not have any knowledge of R#907. When asked how physical assistance for bed mobility and toilet use is determined, the DON stated, By therapy, nursing and CNAs . The medical record for R#907 was requested from Local Hospital 'L' revealed the following: admitting [DIAGNOSES REDACTED]. Chief complaint: Fall . Ataxia (loss of full control of bodily movements), Trauma (primary), Subdural hematoma, acute . HCAP (healthcare associated pneumonia) . Discharge to hospice facility on 04/17/202 . CT (Computed Tomography - medical imaging procedure) of the head showed subdural hematoma . Further review of the medical record read . Wife reports he was making progress with pt/ot up until lst fall approx. 10 days ago, after 1st fall, wife noticed him slow to respond, spacing him out, reports altered mental status changes, reports decreased comprehension since then. Reported that he mentioned that he blacked out after fall . Reports nausea and vomiting . Imaging Studies: Head CT without contrast from 3/22/2020 3:20PM . Comparison: 3/11/2020 There is a left parasagittal subdural hematoma with thickness approximately 9 mm (millimeter) near the left frontal lobe with extension over the tentorium with (sic) is focally thickened on the left side with a thickness of 2.2 cm (centimeter). It predominantly extends along the left side of the tentorium. There is also a low-density subdural lateral to the higher density to the left of the falx (small [MEDICAL CONDITION] shaped fold dura matter) . There is some subdural hemorrhage over the anterolateral aspect of the left frontal lobe with a thickness of approximately 4 mm . admitted to ICU (Intensive Care Unit) for Q (every) 1 hr (hour) neuro check . On 7/28/20 a review of the Facility's Policy titled, (Name of Facility Redacted) issue date 9/28/17 was conducted. The Policy documented, in part, the following: Purpose: It is the policy of the facility to identify each resident at risk for falls and to adequately plan care and implement procedures to prevent falls .Fall Committee: .4. To review each fall related accident/incident in order to assess for possible cause to determine appropriate interventions to prevent similar occurrences . It should be noted that the Facility was asked to provide all Facility Policies pertaining to Falls. No additional Fall Policies were provided by the end of the survey.

This citation pertains to Intake #MI 428. Based on observation, interview, and record review the facility failed, to timely assess and monitor weight changes, ensure food acceptance records were recorded and obtain weekly weights as ordered for one (R#909) out of three residents reviewed for weight loss. This deficient practice resulted in a significant weight loss, malnutrition and the insertion of a peg tube (percutaneous endoscopic gastrostomy-tube used to provide feeding when oral intake is not adequate). Findings include: A complaint was made to the State Agency that alleged R#909 developed a Stage IV Pressure Ulcer at the Facility that required hospitalization and the insertion of a PEG tube. On 7/27/20 at 9:25 AM, R#909 was observed in bed. R#909 was observed to be on a low air loss mattress, had a wound vac, an indwelling urinary catheter, and was receiving enteral nutrition via an automatic feeding pump. R#909 appeared thin and was alert and able to answer questions. Review of R#909's medical record revealed that the resident was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R#909's Minimum Data Set (MDS), dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of four (severely cognitive impaired) and required two person assist for transfers, bed mobility. Continued review of R#909's medical record indicated that on 1/5/2020, R#909 weighed 105.8 lbs. A progress note dated 1/6/2020 documented, Will continue regular diet and will add Plus 2 (a nutritional supplement) TID (three times daily) for weight loss .feeds .self .and denies any difficulty chewing or swallowing . A progress note dated 4/13/20 and authored by Nurse Practitioner NP A documented, in part, .is being evaluated today for protein/calorie malnutrition .ASSESSMENT AND PLAN .1.) Protein/calorie malnutrition with weight loss. The patient will have reevaluation by the dietitian .will await further recommendations from the dietitian. We will start weighing at least three times per week .no areas of skin breakdown are noted . Continued review of the resident's medical record documented the following weights for the month of April 2020: April 1, 2020: 102.2 lbs. April 8, 2020: 96.6 lbs. No additional weights for the month of April 2020 were noted in the resident's medical record as ordered by NP A on 4/13/20 (3X per week). The next weight noted in the resident's medical record was 5/15/2020 (the date the resident returned from the Hospital with the PEG tube). A progress note authored by Dietitian Z dated 4/30/20 titled Weight Loss Evaluation documented in part, This resident has lost 9.72 % within the past 30 days .the weight history indicates A.5% weight discrepancy since last months weight .The following orders and approaches already in place .1. Diet: reg.(regular) Supplements in place: Plus 2 120 cc TID .Weigh resident weekly x4 then monthly .Dietitians Comments: Consuming 50% most meals, 75% some .Stage 3 coccyx wound present per wound care .Suggestions: Plus 2 120 cc QID, weekly weights . A review of R#909's Hospital Records dated 5/6/20 was reviewed and documented, in part, ED (emergency department) notes .Chief Complaint .Patient presents with Tailbone Pain .pt to ER from nursing home .Patient has a history of possible stage III Stage IV ulcer buttocks .Nutritional Diagnosis: [REDACTED].patient is not eating .5/12/20 . PEG tube placement today. On 7/27/20 at approximately 11:05 AM, an interview was conducted with Dietician Z concerning R#909's weight loss. Dietician Z was queried as to why R#909 was not weighed weekly and monitored once it was discovered that they had had a significant weight loss on 4/8/20. Dietitian Z reported that they were fairly new to the Facility and had started in October. They further reported that they usually did assessments one time per month and thus waited until the end of the month to add additional interventions. When further asked why the resident was not weighed following the reporting of a significant weight loss and whether the food acceptance was being monitored, Dietitian Z indicated that she needed to go review the resident's documents. Dietitian Z returned along with a corporate representative and indicated that R#909's food acceptance forms from 1/3/2020-6/1/2020 could not be provided, no further documentation as to acceptance forms was provided by the end of the Survey. With respect to 3x weekly weights as initiated by NP A, it was reported that due to COVID-19 pandemic in April 2020, obtaining residents weights were not always completed due to infection concerns. A review of the Facility Policy titled, QAPI (quality assurance performance improvement) Weight Monitor Policy (Issue Date 6/1/2020) documented, in part, the following: Policy: It is the policy of our facility to be both proactive in preventing weight loss as well as reactive when weight loss occur in one of our residents . Procedure: All residents will be weighed on the day of admission and the day after admission .As per current standards of practice, after admission, the resident will be weighed weekly for four weeks .Residents will be weighed monthly as a routine after the first 30 days .Nursing .will be responsible for obtaining monthly weights. All residents with a 5# (pound) weight change .weight reports will be run by the dietitian to determine who has had significant weight change .Weight reports will be reviewed by the dietitian. Significant weight change will be defined as: A. a 5% weight discrepancy (increase or decrease) from previous month's weight .the dietitian will assess each resident to determine why the weight change occurred .He or she will document findings and recommendations in a progress note. The dietitian will document on the weight loss .in the progress notes in the resident's chart .A. reasons for weight change, B. future risk factors; C. Interventions .D. Changes in plan of care .

This citation pertains to intake #MI 495 Based on interview and record review the facility failed to ensure direct supervision was provided for one resident (R#902) based on their assessed needs of three residents reviewed for accidents, resulting in R#902 sustaining a fractured elbow and requiring hospitalization . Findings include: On 9/17/18 the medical record for R#902 was reviewed and revealed the following: R#902 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. R#902's MDS (minimum data set) with an ARD (assessment reference date) of 4/19/18 revealed R#902 needed extensive assistance from facility staff with bed mobility, transfers, dressing and bathing. R#902's BIMS score (brief interview of mental status) was three indicating severely impaired cognition. A nursing progress note dated 5/13/18 revealed the following: Approximately at 5:45 pm resident was wheeled into the small dining room up to a table to prepare for dinner on Cranbrook (name of a nursing unit at R#902's facility) Aide went to get residents trey for dinner, when (R#902) got out of her wheelchair and fell on to her buttock and hit her left elbow. Resident left elbow is swollen and she is complaining of pain 6/10. (brand name of pain releiver) given to help with swelling and pain. Contacted daughter (name of daughter) and she is aware of the situation. Contacted (name of Physician) and he is aware of the situation. Stat x-ray was ordered. Will continue to monitor. An additional nursing progress note for 5/13/18 revealed the following: Within the two hours that I spoke to the (name of Physician) the residents elbow double in size which concerned the writer. Approximately at 8:45 pm writer contacted on-call (name of Physician). Writer explained to the Doctor the situation with the resident about the fall and the medical professionals still hadn't showed up to do the x-ray. Per (name of Physician) the best outcome was to send the resident to the hospital. Resident departed from facility around 10 pm to (name of local hospital). Family notified. A hospital X-ray dated 5/14/18 revealed the following: Impression:-Comminuted, displaced [MEDICAL CONDITION] with elbow hemarthrosis. Minimal anterior subluxation of the radial head relative to the capitellum. Soft tissue swelling/hematoma dorsal to the proximal ulna No convincing humeral or distal forearm fractures identified. Overlying cast material limits. A hospital discharge summary dated 5/22/18 revealed the following: History of Present Illness:-The patient is an (age of R#902) female who apparently fell out of her wheelchair in the ECF (extended care facility) and sustained a left olecranon fracture .Hospital Course-The patient seen in consultation (name of multiple Physicians) from Cardiology and (name of Physician) from Orthopedics. The patient was treated initially with her usual medications including intravenous fluids, electrolytes, and [MEDICATION NAME]. She was on (brand name of blood thinner) on admission but had to be switched to IV (another brand name of blood thinner) for surgical repair of her left elbow . A review of R#902's care plan with an effective date of 4/12/18 revealed the following Focus-Fall Risk .Goals-Resident will remain free from injuries .Interventions-Monitor resident when call light is not available (e.g. Dining Room, Activities) A Resident Accident/Incident Report dated 4/21/18 revealed the following: Statement by (staff, roommate)-Patient lying on the floor in front of the bathroom by the door. Stating 'I fell someone come and help me.' .Initial corrective action taken/Recommendation for prevention of similar occurrence: Patient to CDR (Cranbrook Dining Room) for meals for direct supervision. A Resident Accident/Incident Report dated 5/13/18 revealed the following: State exact location of incident (where did it occur):Small dining room on Cranbrook Unit . Statement by (staff, roommate)-Wheeled (R#902) into small dining room on Cranbrook to a table. Aide went to get (R#902's) food trey and resident fell on buttock, while hitting her elbow. On 9/17/18 at approximately 3:55 p.m., Staff member A was queried regarding R#902's fall on 5/13/18. Staff member A was queried if they knew that R#902 was identified as a fall risk and they indicated that they did. Staff member A stated, I took (R#902) and another resident to the dining room early so they could get out of their rooms and I could keep an eye on them. Staff member A was queried if R#902 had history of trying to stand up in their wheelchair and they indicated that they did. Staff member A was queried why they left R#902 unattended in the dinning room without supervision and they indicated they left because the cart that had the dinner meal trays was down the hallway at the nursing station. On 9/17/18 at approximately 5:58 p.m., the Assistant Director of Nursing (ADON) was queried regarding R#902's fall on 5/13/18. The ADON was queried if R#902 was a fall risk in the facility and they stated that they were. R#902's fall intervention monitor resident when call light is not available in the care plan was reviewed with the ADON. The ADON was queried if R#902 was being monitored in the Cranbrook Dinning Room when staff member A left R#902 unattended and R#902 fell and they indicated that she wasn't. The Accident/Incident Report for R#902 dated 4/21/18 including the Recommendation for prevention of similar occurance which stated patient to CDR (Cranbrook Dining Room) for meals for direct supervision was reviewed with the ADON. The ADON was queried if R#902 was being provided direct supervision in the dinning room when they fell and they stated that she wasn't A facility document titled Accident and Incident Report with an issue date of 11/2017 was reviewed and revealed the following: Purpose-Incident/Accident reports will be completed on any accident or incident involving a facility resident, visitor or facility personnel. This specific policy addresses facility residents only The purpose of this policy is:(e) to properly care plan for residents; (f) to prevent reoccurrence of a similar incident.

This citation refers to Intake Number(s): MI 304. Based on observation, interview, and record review, the facility failed to ensure a reclining geriatric chair (geri-chair) was maintained in a safe manner and the resident was positioned properly before moving to an upright position for one (R#802) of three residents reviewed for accidents, resulting in a laceration to the leg that exposed adipose (fatty) tissue, required an emergency hospital transfer, and 27 sutures. Findings include: On 8/22/18 at 8:45 A.M., R#802 was observed in the dining room, seated in a geri-chair (a reclining chair that provides additional comfort and support to otherwise bed bound individuals). R#802 did not respond when spoken to. On 8/22/18 at 10:23 A.M., R#802 was observed seated in a geri-chair in her room accompanied by Nurse H. An observation of R#802's skin was conducted with Nurse H. R#802's lower legs were observed to have shin protectors (a fabric sleeve that protects skin) applied to both legs. Nurse H administered wound care to R#802's right shin/calf which was observed to have a very large crescent shaped laceration closed with sutures that extended from above the ankle to the outer side of the shin/calf. When queried about what happened to R#802's right leg, Nurse H stated, I was told in report that an aide transferred her and she got cut on the wheelchair and her leg got smashed. A review of R#802's clinical record revealed the following: R#802 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented R#802 had severely impaired cognition and required extensive physical assistance from at least two staff members for bed mobility and transfers. Progress notes were reviewed from (MONTH) (YEAR) through (MONTH) (YEAR) and revealed the following: On 8/12/18 at 4:03 P.M., Nurse I documented, Observed skin tear on right lower ext. (extremity) 13 cm (centimeters) x 4 cm with anchored skin flap. Observed subcutaneous fat at edges of wound .Ordered to send pt (patient) to hospital for stitches. Two staff members were present in room during (mechanical lift) transfer to bed . On 8/13/18 at 8:33 A.M., a Nursing Progress Note documented, .Resident returned from (name of hospital) at 9p due to skin tear and receiving 27 stitches, resident was placed on (an antibiotic medication) . On 8/13/18 at 4:58 P.M., Nurse Practitioner J documented, Chief complaints: laceration to right lower leg, s/p (status [REDACTED].x-ray revealed soft tissue injury .laceration right lower leg, s/p repair with 27 sutures . A review of an Incident and Accident (I&A) report and investigation into the above injury to R#802 conducted by the facility revealed the following: A Resident Accident/Incident Report dated 8/12/18 at 2:00 P.M. documented the incident occurred in R#802's room and R#802 was unable to give a statement. A Statement by staff who observed documented, Pt was transferred from geri-chair to bed with (mechanical) lift. Injury was observed at that point. Nurse observed pt laying in bed with towel around pt's RLE (right lower extremity), propped up on a pillow. Scant blood observed on towel . The I&A documented R (right) lower ext skin tear 13 cm x 1 cm x 4 cm .redness/bruising to edges of wound .scant bright red blood .mild pain stated .subcutaneous fat was visible in wound .first aide applied .send pt to ER for treatment . A Non Fall Related Team Report dated 8/12/18 documented a skin tear to R#802's right calf/shin that measured 13 cm in length by 4 cm in width. The environmental factors that may have contributed to the incident documented, plastic knob on end of geri-chair. Comments documented, Staff reported they noticed bleeding of RLE after transfer to bed with (mechanical) lift. 13 cm long x 4 cm width with skin flap. Observed subc. (subcutaneous) fat at edges of wound. Scant bleeding . The Certified Nursing Assistants (CNAs) that were caring for R#802 were identified as CNA C and CNA E. On 8/22/18 at 12:34 P.M. an interview with CNA E was attempted via the telephone. The number provided by the facility was a non-working number. CNA E was unavailable for interview prior to the end of the survey. On 8/22/18 at 1:45 P.M., an interview was conducted with CNA C. CNA C was asked about what happened when R#802 sustained the large laceration to her right leg on 8/12/18. CNA C stated, Her aide that day was CNA E. I was just a spot (assisting with the mechanical lift transfer). CNA E operated the lift and positioned the geri-chair at the foot of the bed and put her (R#802) into a sitting position. I don't know what happened. I did not see her (R#802) leg hit anything during the transfer. She didn't scream or moan or groan. When we were transferring her to the bed we noticed a little bit of blood dripping from her pants. CNA E wrapped her leg up and I went to go get the nurse. On 8/22/18 at 2:23 P.M., the Director of Nursing (DON) was interviewed about the investigation into the laceration sustained by R#802 on 8/12/18 and the actual geri-chair utilized by R#802 at the time of the accident was observed. The DON reported she initially thought the laceration was from the plastic locking stud. The geri-chair was observed to have a plastic mechanism that was attached to the end of the arm of the chair. The DON explained that the mechanism could be used to attach a tray to the chair. The corner of the plastic locking stud where it locked into the metal part of the chair was observed to be slightly sharp and underneath there was a metal screw exposed that was also sharp. The DON explained R#802 had a history of [REDACTED]. The DON stated, There were 3 inches between the plastic locking stud and the foot rest, but I was not convinced it was the screw. That would not make a clean cut in a crescent shape so I re-interviewed (CNA E). CNA E explained that after R#802 was brought to an upright position, R#802's right leg was hanging off the side (This required moving the foot rest down underneath the chair and the back of the chair upright using a lever on the back of the chair. The DON explained it would take three movements to get the chair into a full upright position and demonstrated this with the Assistant Director of Nursing). The DON explained CNA E reported she had to lift R#802's leg out from the side between the footrest and arm of the geri-chair. The DON pointed out that the hard plastic that attached around the metal reclining mechanism (which prevents pinching when the reclining mechanism extends and retracts) on the right side of the geri chair was damaged and completely severed with very sharp edges with the edge bent upward. The DON stated, If CNA E did not know R#802's leg drifted to the side and continued to move the chair into an upright position, it would explain the clean cut that was crescent shaped as (R#802's) leg was pushed three times into the plastic. The DON was asked what the other CNA (CNA C) was doing at that time. The DON stated, She was probably preparing the (mechanical) lift. We need to make sure we have a spot checker. Like driving a car, we need to check for blind spots. When queried about how often geri-chairs were checked for maintenance, the DON reported the maintenance department would be able to answer that. On 8/22/18 at 4:30 P.M., Maintenance Staff F was interviewed. The Maintenance Director was unavailable for interview at that time. When queried about the process of making sure geri-chairs were in safe working condition, Maintenance Staff F stated, I'm not sure about geri-chairs. We will give them to residents, but we don't regularly check them unless staff contact us. Maintenance Staff F reported he did not have any recent reports of broken geri-chairs on the afternoon shift. On 8/22/18 at 5:30 P.M., the Administrator was interviewed. When queried about the facility's policy for maintaining geri-chairs in safe conditions, the Administrator stated, There is a log book on each nurse's station. We also check the chairs when a resident is discharged . When asked if there was anything logged for R#802's geri-chair and the broken plastic, the Administrator stated, If it was logged, it would have been fixed. Further review of R#802's clinical record revealed the following: Hospital records dated 8/12/18 included ED (Emergency Department) Triage Notes that documented, Pt presents with approx 15 cm lac(eration) to RLE above ankle. Son sts (states) pt tore it on a protruding sharp screw on a chair today at her ECF (Extended Care Facility). Adipose (fatty) tissue visible . Policies regarding two person transfers and maintenance of geri-chairs were requested from the DON. A policy regarding maintenance of geri-chairs was not provided prior to the end of the survey. The policy regarding transfers did not address how a two person transfer should be conducted.

Based on observation, interview, and record review, the facility failed to assess, recognize, and implement appropriate interventions to prevent a reduction in range of motion for one Resident (R#24), of one resident reviewed for range of motion, from a total sample of 33 residents, resulting in a functional decline in range of motion. Findings include: On 5/7/18 at 9:01 AM, R#24 was observed seated in her geri-chair in her room. R#24's right hand was observed to have digits 3, 4, and 5 (middle finger, ring finger, and pinkie finger) clenched/contracted tightly into her fist with digits 1 and 2 (thumb and forefinger) extended. At this time, her visitor/companion was asked about R#24's right hand. R#24's companion explained that R#24's fingers were not clenched in that position when she admitted to the facility. R#24's companion was then queried if R#24 had ever had anything placed in her palm (such as a device or a splint) to prevent the worsening of the clenched/contracted digits. R#24's companion said, Sometimes they put a wash cloth in there but not very often. One time she got a sore on her palm from her nails, and now it's starting on the left one too. On 5/7/18 at 12:15 PM, and 2:54 PM, R#24 was observed in her geri-chair with her companion. R#24's right hand digits 3, 4, and 5 were observed clenched/contracted tightly into a fist with digits 1 and 2 extended. It was not observed that there was a handroll or device present to prevent the worsening of the clenching/contracting of the right hand. On 5/8/18 at approximately 8:15 AM and 3:20 PM, R#24 was observed sleeping in bed. R#24's right hand digits 3, 4, and 5, were observed clenched/contracted. A device or washcloth in R#24's palm were not observed to prevent to the clenching/contraction of the digits. On 5/8/18 at 2:58 PM, all therapy documentation pertaining to R#24 was requested from Therapy Department Manager 'K' On 5/8/18 at 3:01 PM and 3:30 PM, R#24's clinical record was reviewed and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of R#24's admission Minimum Data Set (MDS) assessment dated [DATE] was reviewed. The MDS revealed severe cognitive impairment, non-ambulatory, and extensive to total assistance of 1-2 staff members for all activities of daily living. The MDS assessment was also reviewed and section, G0400. Functional Limitation in Range of Motion was reviewed and was discovered to be coded for 0. No impairment for upper extremities including the shoulder, elbow, wrist, and hand. A review of a second MDS assessment (the most recent) dated 2/24/18 was also reviewed and also indicated severe cognitive impairment, non-ambulatory, and extensive to total assistance of 1-2 staff members for all activities of daily living. A review of section G0400. Functional Limitation in Range of Motion was reviewed and was coded for 0. No impairment for upper extremities including the shoulder, elbow, wrist, and hand. A review of R#24's physician's orders [REDACTED]. in her skin. A review of the record also indicated R#24 had orders for Restorative therapy. At the time of the clinical record review, a Occupational Therapy (OT) Evaluation & Plan of Treatment document dated 8/18/17 conducted by Occupational Therapist (OT) 'L' was reviewed and revealed the following: .Reason for Referral: Referred to OT services .concern related to rigidity in BUE (Bilateral Upper Extremities) .Musculoskeletal Assessment-Range of Motion (ROM) and Strength .Contracture: Does Patient Present with Contracture(s)=No . On 5/9/18 at 8:25 AM, a second interview with R#24's companion was conducted regarding the R#24's right hand being clenched/contracted. R#24, stated That developed here, and reiterated that he was in the facility spending time with R#24 almost every day for multiple hours a day. He explained he had never seen any splinting or devices placed in R#24's right hand to prevent the worsening of the right hand. R#24's companion was then asked if R#24 received Restorative Services and stated, I've seen them a couple of times, they only work with her for less than five minutes, then they leave. On 5/9/18 at 10:31 AM, an interview with OT 'L' (who completed the evaluation on 8/18/17) was conducted. OT 'L' was asked if R#24 had a right hand contracture during the evaluation in (MONTH) of (YEAR). OT 'L' explained she did not. At that time, OT 'L' and Therapy Director 'K' were made aware of the observations of R#24's right hand and explained that nursing staff should have made them aware of the change in R#24's right hand. OT 'L' stated, We can put things in place like a resting hand splint, a carrot (a rolled device resembling a carrot to be applied in the hand to prevent further decrease in the range of motion of the fingers) or other adaptive equipment. We have things to prevent her hand from taking that form. The Restorative program should have let us know. On 5/9/18 at 10:42 AM, an interview with the facility's Director of Nursing (DON) was conducted regarding the observations and concern with the clenching/contracting of R#24's right hand. The DON stated, She should have been referred to OT, I will do that right now. On 5/9/18 at 10:47 AM, an interview with Restorative Certified Nursing Assistant (CNA) 'J' was conducted regarding the types of restorative services R#24 receives. Restorative CNA 'J' said she provided passive range of motion exercises to R#24's shoulders and elbows as well as gentle range of motion to the wrists. CNA 'J' was asked if she performed any Range of Motion exercises to R#24's hands or fingers on her right hand and stated, She won't naturally open and close her fingers. It's contracted really bad, If I try to separate her fingers her hand closes. A review of R#24's care plans was conducted on 5/9/18 at 11:12 AM. A care plan dated 1/6/18, read, .Resident will remain free from contracture deformities. Interventions: Maintain proper body alighnement in bed/chair. Note any stiffness or spasticiity in joints while providing activities of daily living (ADLs) . A review of a second care plan dated 3/15/17 read, .Restorative-ROM .Monitor resident for endurance and toleraince with ROM activity. Restorative CENA to document progress or changes including refusals. Restoravie Cena to follow FMP (Functional Maintenance Plan) as directed by PT (Physical Therapy) recommendation . It was noted that R#24's care plan did not address R#24's specific ROM or restorative therapy needs. On 5/9/18 at 1:27 PM, an OT evaluation conducted by OT 'L' was observed for R#24. During the evaluation OT 'L' assessed range of motion for R#24's left upper extremity. It appeared that R#24 was slightly resistive to the evaluation but OT 'L' was eventually able to open R#24's left hand and all fingers on R#24's left hand were extended. At that point R#24's companion said, I know she can open that hand, I've seen her sleeping and relaxed in bed and her left hand is normal, but the right one stays clenched. OT 'L' then moved to R#24's right side and assessed upper extremity range of motion. OT 'L' was observed to not be able to extend R#24's 3rd, 4th, and 5th digit from being clenched into her fist. OT 'L' tried twice to extend the digits and during the attempts, R#24 became more resistive, was squirming and made audible moaning noises. It was also observed that while OT 'L' was trying to seperaate R#24's digits 3, 4, and 5, from her palm, R#24 was pinching and poking at OT 'L' with her thumb and forefinger. OT 'L' stated, It feels like she has a little callous on that spot in her palm, referring to spot where R#24's digits 3, 4, and 5 were clenched into her palm. At the completion of the evaluation, OT 'L' stated, I definitely want to get something in there, this is her new norm now to have those fingers clenched. A review of a facility policy titled, Functional Restorative Plans & Frequency Guideline with an issue date of 12/6/17 was reviewed on 5/9/18 at 5:00 PM, and revealed the following, .4. Treatment approaches will include: .E. Instruction of caregivers for precautions and recognition of a change in status and reason for referral back to the therapist . A review of a second provided policy titled, physician's orders [REDACTED]. The facility was asked if they had any additional documentation to provide regarding the concern and none was received by the end of the survey.

Based on observation, interview and record review, the facility failed to implement new interventions to prevent the development of a pressure ulcer and notify the physician in a timely manner about skin changes for one (#806) of six residents reviewed for pressure ulcers, from a total sample of 24, resulting in the development of a facility acquired, unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered in slough - yellow, tan, gray, green, brown and/or eschar - tan, brown or black in the wound bed) to the right heel. Findings include: On 2/7/17 at 11:45 A.M., Resident #806's clinical record was reviewed and revealed the following: Resident #806 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented Resident #806 had intact cognition and required extensive physical assistance from two staff members for bed mobility and transfers and did not have, but was at risk for development of pressure ulcers. Progress notes for Resident #806 were reviewed from December 2016 through February 2017 and revealed the following: A note written by the nurse practitioner on 1/3/17 at 9:07 A.M. that documented, .Right heel has a dark discolored area that represents an unstageable right heel ulcer .Unstageable right heel ulcer float right heel off the bed all the time. Monitor for further tissue injury. Encourage oral intake, position patient every 2 hours in bed and float left heel as well . There were no progress notes prior to 1/3/17 that documented an ulcer or skin changes to Resident #806's right heel. Skin assessments from December 2016 through January 2016 documented the following Treatment Record Nursing Observations/Comments: On 12/28/17 Nurse O documented, .Heels soft intact slow to blanch . On 1/4/17 Nurse O documented measurements of 3 cm (centimeters) (width) by 3 cm (length). No stage was documented. The description was documented as Non-blanchable right heel with odor and serosanguineous (a combination of clear and bloody drainage pink/yellow in appearance) drainage .Left heel blanchable, dry, reddened . On 1/11/17 Nurse O documented measurements of 0.8 cm by 1 cm by 0.1 cm (depth) .Yellow slough (necrotic tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and stringy at times) right heel area . On 1/17/17, another nurse documented, Skin CDI (clean, dry and intact) . On 1/18/17, Nurse O documented measurements of 0.6 cm by 0.4 cm, .Scab skin area to right heel area . On 1/25/17, Nurse O documented measurements of 0.8 cm by 0.6 cm by 0.3 cm, .Right heel area open . On 2/7/17 at 12:15 P.M., Resident #806 was observed lying in bed. Foam boots were observed on the window sill. At 2:15 P.M., Resident #806 was observed lying on his back in bed. Foam boots were observed on the window sill. Resident #806 was asked when the boots were worn. Resident #806 stated, They haven't put them on in about a week. They irritate me. Resident #806 indicated that there was a wound that required treatment located on his right foot. On 2/7/17 at 2:18 P.M., Nurse O was interviewed regarding any wounds that Resident #806 had. Nurse O stated, One foot just gets a dry dressing that I just put on there to protect it and the other foot gets (brand name of a topical ointment used to promote growth of healthy tissue). On 2/8/17 at 12:03 P.M. a wound treatment observation of Resident #806 was conducted with Nurse O. Nurse O removed the dressing from Resident #806's right foot. Nurse O described the drainage on the dressing as A small amount of bloody serosanguineous drainage. Nurse O cleaned the area on Resident #806's right posterior heel with normal saline which resulted in Resident #806 flinching, grunting, and exhibited facial grimacing. Nurse O was asked to describe the wound on Resident #806's right heel. Nurse O stated, It has white slough around the edges with red tissue in the center. Nurse O measured the wound and reported the measurements as 0.5 cm by 0.8 cm. The Unit Manager (Nurse H) for the Cranbrook Unit was interviewed on 2/9/17 at 9:50 A.M. regarding the unstageable pressure ulcer on Resident #806's right heel. Nurse H was asked when skin changes were first observed on Resident #806's right heel, when was the physicain notified of any skin changes, what interventions were put in place prior to the development of the pressure ulcer, and what interventions were implemented when skin changes were first observed. Nurse H reported that she would find out. Nurse H reported that Resident #806 refused to wear the physician ordered foam heel boots and did not like to elevate his feet. On 2/9/17 at 12:10 P.M., Nurse H provided physician's orders [REDACTED]. btwn (between) knees and underneath LUE (left upper extremities) for pressure relief as tolerated in bed and all times when in motorized chair. (The order did not address Resident #806's lower extremities). Nurse H reported that on 1/6/17 an order was written for Pressure relief from right heel at all times and Resident #806 was seen by the wound doctor on 1/11/17 (14 days after it was documented that Resident #806's heel was slow to blanch). No documentation of physician notification was provided. The Director of Nursing (DON) was interviewed on 2/9/17 at 12:15 P.M. regarding the unstageable pressure ulcer on Resident #806's right heel. The DON was asked when skin changes were first observed on Resident #806's right heel. The DON reviewed the clinical record at this time and reported that on 1/3/17 there was a progress note written by the nurse practitioner that documented, .dark discolored area that represents an unstageable right heel ulcer .Unstageable right heel ulcer float right heel off the bed all the time. Monitor for further tissue injury. Encourage oral intake, position patient every 2 hours in bed and float left heel as well . There was no documentation in the progress notes regarding Resident #806's right heel prior to 1/3/17. A consult by the wound doctor was reviewed at this time that was dated 1/18/17 that documented, The PU (pressure ulcer) right posterior heel on the right, posterior heel is active. It measures 0.6 by 0.4 by 0 and has a total area of 0.24 cm squared .The wound base exposed structure has Other (scab) .Pressure ulcer stage: Unstageable .(Resident #806) .with technically unstageable ulcer to his right heel. I saw him for the first time last week, January 11 .The wound now has a small, dry, stable eschar (black/brown necrotic tissue) .Recommendations: Continue Posey Heel offloader boot . The wound consult from 1/11/17 was requested at this time. The DON was asked what interventions were in place prior to the development of the pressure ulcer and reported that Resident #806's heels should be elevated with a pillow because he refused the foam boots. The DON was asked when the foam boots were first ordered and reported that she would find out. When queried about the process that staff should follow if redness, slow or non-blanching of skin, or open areas were observed, the DON reported that the physician should be contacted and interventions would be implemented. When queried about what should be done if a resident refused interventions, such as the foam boots, the DON stated, They should use a pillow to elevate the feet and ask the doctor about alternative interventions. (Resident #806) is very in tune about what he wants so we should offer options and if he had requests we should contact the doctor. The DON did not provide the wound consult from 1/11/17 or the date the foam boats were ordered by the end of the survey. On 2/9/17 at 2:00 P.M., Nurse H provided a copy of a document titled, In-House Pressure Ulcer Investigation Form dated 1/12/17 (eight days after the first documentation of the pressure ulcer). Nurse H checked [MEDICAL CONDITION] on the copied document and stated, I forgot to check that. Nurse H reported that the document explained how Resident #806 developed the facility acquired pressure ulcer. It was documented on the form that Resident #806 was at moderate risk for pressure ulcers and unavoidable status due to consistent turning and position, use of pressure reduction surface, good skin care, clean and dry bed linens, and maintain adequate nutrition and hydration as possible . In section #5 it documented, Moribund (terminally ill, comatose, semi-comatose) and life measures have been withdrawn, or if treatment is limited by Advance Directive. Under these circumstances, pressure ulcer(s) may be clinically difficult to prevent. Check is appropriate, and explain . This section was not checked. In the explanation section it was documented that, Secondary to physical mobility bilateral heels in contact directly with base of his equipment. Unpredictable muscle spasm creating shift in position of BLE (bilateral lower extremities) despite of offloading. Currently on (medication to treat muscle spasms) . In the Summary section it documented, If unavoidable, has the physician written a note? .See #5 .If the pressure ulcer was avoidable, what performance improvement measure have been implemented? .Resident has heel boot protector, float heels . The skin assessment from 12/28/17 was reviewed with Nurse H at this time and Nurse H was asked what the protocol was if the resident's skin was slow to blanch as documented by Nurse O for Resident #806. Nurse H stated, The physician should be contacted for all changes in skin and interventions put in place. Nurse H indicated that slow to blanch areas could be a trigger for development of a pressure ulcer. Resident #806's clinical record was further reviewed at 2:30 P.M. on 2/9/17 and revealed that Foam boot to right heel at all times was ordered by the physician on 1/4/17 (after the development of the pressure ulcer). There was no documentation by the physician that noted the pressure ulcer on Resident #806's right heel as being unavoidable. Care plans were reviewed at this time and documented the following: An admission care plan for Potential for Impaired Skin Integrity dated 9/29/16 documented, Potential for impaired skin integrity R/T (related to): Decreased mobility, pain with movement, altered nutritional state . On 1/6/17 and 1/12/17 an intervention for Heel protector boots while in bed was documented. Prior to 1/6/17, an intervention effective on 9/29/16 documented, Daily foot checks and provide pressure relief if appropriate .Skin assessments upon admission, weekly, and PRN (as needed). Implement skin protocol as appropriate .Monitor skin for changes during daily bathing/care routine, especially over bony prominences for color changes, warmth and induration . A Skin-Pressure Ulcers care plan with an effective date of 1/12/17 (nine days after the development of an unstageable pressure ulcer) documented, Alteration in skin integrity AEB (as evidenced by): Site: right heel, Location: right heel, Stage UTD (unable to determine), Size: 1.0 x 0.8 . Interventions effective on 1/12/17 documented, .heel boot protector while in bed .float heels while in bed . There were no care plans that documented Resident #806's refusal of pressure sore interventions. The facility's policy titled, Guidelines for Pressure Ulcers dated 5/13, was reviewed on 2/9/17 at 3:00 P.M. and it documented the following: .If there is any change in the patient's skin condition, the nurse or nurse manager should review and revise the patient's care plan accordingly and consult with the director of nursing, physician and/or wound care specialist as needed . .In addition, at the time of development staff should identify and document factors that they believe affected their ability to prevent or heal a pressure ulcer . .If a determination is made that the development of a pressure sore was unavoidable, it must be documented by the nurse and physician that the elements for an unavoidable pressure ulcer were met .

Based on observation, interview and record review, the facility failed to ensure one (#809) of eight residents who were assessed at high risk for falls from a total sample of 25, received adequate supervision to prevent a fall, resulting in a fall with fracture requiring hospitalization . Findings include: On 1/14/14 at 9:38 a.m., during the initial tour of the facility with Unit Manager "C" Resident #809 was observed sitting in her room in a wheel chair. Resident #809 had a wheel chair alarm in place. When queried as to if she had any falls since admission, Resident #809 stated, "I'm not sure." Unit Manager "C" stated, "(Resident #809) did have a recent fall with hip fracture." On 1/15/14 at 12:20 p.m., Resident #809's medical record and Incident/Accident report was reviewed and revealed an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #809's Minimum Data Set assessment (MDS), dated [DATE], revealed that the residents cognition was severely impaired and required extensive assistance for transfer with one person physical assist. The MDS also indicated that the resident was "Not steady, only able to stabilize with human assistance," when; moving from seated to standing position, walking, turning around, moving on and off toilet and with surface to surface transfer." Review of Resident #809's "Patient Transfer Form," dated 12/19/13 revealed the following: "[DIAGNOSES REDACTED]. Secondary: Kyphoplasty. Additional Pertinent Information: Resident at beauty shop and stood up and fell with possible rotation of the right hip area noted." Review of Resident #809's "Discharge Instructions and Physician Orders," dated 12/24/13, revealed "Procedure (s)/Surgeries during current admission: Cephalomedullary Nail Right Femur." On 1/15/14 at 12:30 p.m., Resident #809's "Resident Accident/Incident Report," dated 12/19/13 at 2:45 p.m., was reviewed and revealed the following: "Location of incident: in salon. Statement by staff (contracted beautician, Beautician "D") Resident was dropped off in the salon for hair services that were requested by family. Within moments resident kept standing up and setting off alarm. As I turned around to finish another residents hair, (Resident #809) stood up, setting off alarm and fell to floor before I could catch her..." Resident #809's medical record was further reviewed and revealed the following: Resident #809's "Resident Safety Assessment," completed 12/13/13, revealed the following information: "Poor insight into disability. Confused at times. History of falls- greater than two in the last 6 months. Current fall risk=High with a score of 16, (high risk being greater or equal to 15). Recommendations: bed and chair pressure sensitive alarms." Nursing notes dated 12/13/13 at 6:52 a.m., "Resident remains alert with confusion, bed alarm in place observed attempting to ambulate without assistance..." Nursing notes dated 12/18/13 at 8.26 a.m., "Resident has increased confusion throughout the shift. Resident asked writer several times why she was in the facility....Resident continuously out of bed without assistance, with a need for constant urination attempts. To ensure residents safety, the resident was brought to the nursing station to receive close monitoring from staff. Resident still managed to get up out of the w/c (wheel chair) on several occasions and walk around without supervision. Resident is not easily redirected and with the increased confusion and increased urination writer obtained a urine sample on the resident. The dip stick showed positive for nitrates and +2 for leukocytes (indicators for possible urinary tract infection). Writer advised all of the above to the oncoming nurse. A note has been placed in the physician's book for him as well." Physician notes, dated 12/18/13 at 10:50 a.m., "The patient is seen in request of staff regarding frequency of urination and increased confusion. The patient is seen. She is in the cozy corner with her son. He indicates that mom is not able to put words together at times to make coherent sentences...She seems to be a little off her usual sharpness." Nursing notes dated 12/18/13 at 5:12 p.m., "Resident received alert but extremely confused words are garbled, rambling speech unclear...U/A (urinalysis) pending..." Nursing notes dated 12/19/13 at 12:45 p.m., "Resident son ... report 'You would have no way of knowing this because this is the only way you have really seen her, but my mother doesn't usually shake like this and her speech is not right.' He stated he noted the change last Friday. (Son) states it seems like she has a hard time finding the right words and that this is different behavior for her. He also stated that she never had tremors before last Friday either. Nurse assigned to her notified and physician logged and faxed." Nursing notes dated 12/19/13 at 4:35 p.m., "Resident taken to hair salon for services that were requested by family. Resident stood up with alarm sounding and fell to floor in a slow fall to sitting position. This nurse called to come to beauty salon where resident was found sitting on buttocks area c/o (complaints of) right hip area pain. Dr. notified to send resident to ER (emergency room ) for evaluation to rule out right hip fracture at this time." On 1/15/14 at 12:40 p.m., Beautician "D" was queried regarding Resident #809's fall. When queried as to if she was an employee of the facility, Beautician "D" stated, "No. I am contracted." When queried regarding what training she received, Beautician "D" stated, "Abuse training and infection control training for the beauty shop." Beautician "D" was queried as to if she received any training in regards to resident safety, supervision or fall prevention, Beautician "D" stated, "No." Beautician "D" was queried as to the events that took place on 12/19/13 and stated, "She (Resident #809) was a new person. I called the nurse's station to have Nurse "E" bring her down. I was working on another resident. She (Nurse "E") parked her (Resident #809) behind me. Within 5 seconds the chair alarm was going off. She was trying to stand. I told her to sit down and turned myself back to the resident I was working on. I heard the alarm and turned around, it was in slow motion. (Resident #809) was doing a slow gradual fall to the floor. I called the nursing station for assistance." Beautician "D" was queried as to how she would be notified if a resident was at high risk for falls and stated, "I did not know her. Usually I know if they are a fall risk if they have alarms. But this is the first time I seen her. (Nurse "E") dropper her off and was out the door. I had my back to her. If I would have know she was a fall risk I would have had family in to sit with her. The crazy thing was that she also had heels on." On 1/16/14 at approximately 1:40 p.m., Unit Manager "C" was queried regarding resident supervision and stated, "If a resident is at risk for falls they have an alarm in place. They have to be in an area that staff is near." When queried as to how the Beautician was made aware that Resident #809 was at risk for falls, Unit Manager "C" stated, "She is aware of alarms and that being a fall risk." When queried as to how the Beautician was to supervise a resident at risk for falls with her back to the resident, Unit Manager "C" stated, "I don't have an answer." On 1/16/14 at 2:00 p.m., Nurse "E" was queried regarding Resident #809's fall in the beauty shop and stated, "We thought the different stimuli would keep her attention. We didn't think she would get up. Usually (residents with fall risk) we would have family to sit with them." On 1/17/14 at 11:15 a.m., the facility's Director of Nursing (DON) was queried regarding Resident #809's fall and stated, "The routine is that we don't bring anyone down (to the beauty shop) until they are ready to be seen." When queried as to if Beautician "D" received training in fall prevention, supervision or safety, the DON stated, "Not really." On 1/17/14 at 1:30 p.m., the facility Administrator and the facility's Medical Director were queried regarding the supervision of Resident #809 and the Administrator stated, "The appropriate interventions were in place." On 1/17/14 at 3:00 p.m., Resident #809's care plan titled "Fall Risk," dated 12/12/13 was reviewed and revealed the following: "Potential for injury related to: unsteady gait, weakness, impaired mobility, balance problem. As evidenced by: history of falls. Unable to ambulate without assistance. Unable to transfer without assistance. Goals: Resident will remain free from injuries." On 1/17/14 at 3:10 p.m., the facility's policies "Falls Management Resident Safety Assessment," dated 11/2011 and "The Star Program (Falls Management)," dated 8/2011, were reviewed but provided no information on resident supervision in the beauty shop. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE CONTINUOUS SUPERVISION, ACCORDING TO THE RESIDENT'S ASSESSED NEED, FOR ONE (#809) OF NINE RESIDENTS REVIEWED FOR FALLS, FROM A TOTAL SAMPLE OF 24, RESULTING IN A FALL WITH A SUBDURAL HEMORRHAGE (BLEEDING AROUND THE BRAIN), AN INTRACRANIAL BLEED (BLEEDING INSIDE OF THE BRAIN), AND A hospitalization . FINDINGS INCLUDE. ON 11/13/12 AT 6:30 AM, RESIDENT #809 WAS OBSERVED IN BED. THE RESIDENT'S EYES WERE OPEN AND SHE WAS MOANING. WHEN QUERIED, CERTIFIED NURSE ASSISTANT 'U' (CNA), STATED, "SHE MOANS OCCASIONALLY...WE DON'T THINK SHE'S IN PAIN...SHE JUST DOES THAT OFF AND ON." ON 11/14/12 AT 2:05 PM, RESIDENT #809 WAS OBSERVED IN A WHEELCHAIR IN THE HALLWAY BEING PUSHED BY STAFF. THE RESIDENT WAS OBSERVED SMILING BUT REMAINED NONVERBAL WHEN SPOKEN TO. ON 11/15/12 AT 9:00 AM, RESIDENT #809 WAS OBSERVED SEATED IN A WHEELCHAIR. CNA 'U' REPORTED THAT RESIDENT #809 WAS WAITING TO GO TO A DOCTOR'S APPOINTMENT FOR A FOLLOW-UP CT (COMPUTED TOMOGRAPHY), SCAN OF THE HEAD. THE RESIDENT WAS ALERT AND WHEN SPOKEN TO RESPONDED IN A GARBLED MANNER OF SPEECH. ON 11/16/12 AT 10:00 AM, RESIDENT #809 WAS OBSERVED IN BED. CNA 'S' WAS QUERIED AND REPORTED THAT RESIDENT #809 WAS BEING TRANSFERRED TO AN ACUTE CARE FACILITY. AT 10:15 AM, UNIT MANAGER 'R' WAS ASKED WHY RESIDENT #809 WAS GOING TO THE HOSPITAL AND STATED, "SHE HAD A CT SCAN DONE AND IT LOOKS LIKE SHE HAS MORE FLUID ON THE BRAIN." REVIEW OF THE CLINICAL RECORD REVEALED THAT RESIDENT #809 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #809 WAS readmitted INto the facility on [DATE] WITH A NEW [DIAGNOSES REDACTED]." THE 14-DAY MINIMUM DATA SET ENTRY, DATED 10/1/12, REVEALED THAT RESIDENT #809 WAS SEVERELY COGNITIVELY IMPAIRED AND REQUIRED EXTENSIVE ONE TO TWO PERSON ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING WHICH INCLUDED TRANSFERS AND AMBULATION. THE FALLS RISK ASSESSMENT, DATED 9/18/12, REVEALED A SCORE OF "16." PER THE FACILITY "RESIDENT SAFETY ASSESSMENT" A SCORE OF MORE THAN 15 INDICATED A HIGH RISK FOR FALLS. REVIEW OF THE "NURSING ADMISSION ASSESSMENT" DATED 9/17/12, REVEALED THAT THE RESIDENT'S SPEECH WAS CLEAR AND THE CONDITION OF THE TEETH WAS "GOOD." REVIEW OF THE ACUTE CARE FACILITY'S RECORD DOCUMENTED AN ADMISSION TO THE hospital on [DATE] WITH THE CHIEF COMPLAINT OF A FALL AND NOTED THE FOLLOWING, "THE PATIENT WAS TRANSFERRED FROM (THE FACILITY) FOLLOWING A FALL....DIAGNOSTIC STUDIES...THERE IS A SMALL AMOUNT OF HEMORRHAGE LAYERING IN THE ATRIA AND BODY OF THE RIGHT LATERAL VENTRICLE (AREAS OF THE BRAIN)." REVIEW OF RESIDENT #809'S ACCIDENT/INCIDENT REPORT REVEALED THAT ON 9/28/12 AT 2:40 PM, RESIDENT #809, "...WAS RUNNING DOWN THE HALL, SHE BEGAN FALLING SO (STAFF MEMBER) GRABBED HER TO SLOW HER FALL AND WE BOTH WENT DOWN." THE REPORT REVEALED THAT THERE WAS NO INJURY AND THE RESIDENT WAS TO BE FOLLOWED UP BY THE PHYSICIAN. REVIEW OF THE FALL RISK CARE PLAN DATED 9/18/12 AND UPDATED ON 10/4/12 DOCUMENTED, "INCIDENT ON 9/28/12, NO INJURY NOTED, 1 ON 1 SITTER, AND CONTINUE SENSOR ALARM." REVIEW OF THE MEDICAL DIRECTOR'S PROGRESS NOTE DATED 10/5/12 DOCUMENTED, "THE PATIENT ALSO HAS HAD INTERMITTENT AGITATIONS, CONFUSION, RESISTING CARE AT TIMES, AND SHE IS AT HIGH RISK FOR FALL. SHE IS CURRENTLY IN LOW BED WITH ONE ON ONE SITTER." REVIEW OF THE ACCIDENT/INCIDENT REPORT DATED 10/24/12 REVEALED, "RESIDENT (#809) STOOD UP OUT OF WHEELCHAIR TOOK THREE STEPS AND fell AGAINST WALL ON RIGHT SIDE ALARM WAS SOUNDING, WHEELCHAIR WAS LOCKED." FURTHER REVIEW OF THE INVESTIGATION REVEALED THAT NURSE 'P' DOCUMENTED, "RESIDENT WAS SITTING IN WHEELCHAIR AT NURSING STATION. SEVERAL ATTEMPTS TO GET UP OUT OF WHEELCHAIR ALARM SOUNDING WRITER HEARD ALARM WENT TO STATION EVERY TIME ALARM SOUNDED...BROUGHT RESIDENT THE SAME AMOUNT OF DISTANCE FROM NURSING STATION IN HALLWAY AT NURSES MEDICATION CART WHERE TWO NURSES AND TWO CNA'S WERE WORKING." THE HAND WRITTEN NOTE BY NURSE 'P', DATED 10/24/12, DOCUMENTED, "I THEN WENT TO ROOM 213 A TO DISCUSS DISCHARGE PAPERWORK...WHEN I CAME OUT OF THE ROOM I SAW THE RESIDENT LYING ON THE FLOOR. ON A HANDWRITTEN DOCUMENT (UNDATED), WARD CLERK 'V' DOCUMENTED, "I WENT TO THE NURSES STATION...I NOTICED THAT I SAW (RESIDENT #809) GETTING UP OUT OFF HER WHEELCHAIR AND NOBODY WAS DOWN THAT HALLWAY. I TRIED TO SCREAM FOR HELP THAT WHEN SHE fell DOWN." UNIT MANAGER 'T' DOCUMENTED ON 10/25/12 NOTED, "NURSE WHO WAS ASSIGNED TO RESIDENT WENT DOWN TO ANOTHER ROOM TO DISCHARGE A RESIDENT. IT WAS AT THIS TIME THAT THE RESIDENT STOOD UP, TOOK THREE STEPS TO THE SIDE AND fell INTO THE WALL, HITTING HER HEAD ON THE HAND RAILS AND LANDING ON HER RIGHT SIDE ON THE GROUND....NURSE ASSIGNED TO OPPOSITE SIDE OF THE HALL SAW THE RESIDENT GET UP AND ATTEMPTED TO INTERCEPT THE FALL, BUT WAS NOT ABLE TO GET TO HER IN TIME." THE FACILITY TRANSFER FORM, DATED 10/24/12, DOCUMENTED, "RESIDENT GOT UP OUT OF WHEELCHAIR ATTEMPTED TO AMBULATE IN HALL, fell HIT HEAD BEGAN A SEIZURE 911 CALLED." THE physician progress notes [REDACTED]." ON 11/15/12 AT 1:25 PM, UNIT MANAGER 'T' WAS QUERIED REGARDING RESIDENT #809'S FALL WHICH RESULTED IN A HEAD INJURY. THE CARE PLAN THAT WAS IN EFFECT AT THE TIME OF THE FALL INDICATED THAT RESIDENT #809 WAS TO HAVE A "ONE TO ONE SITTER." UNIT MANAGER 'T' WAS QUERIED AND REPORTED THAT RESIDENT #809 WAS TO HAVE, "A SITTER ALL DAY EVERYDAY." WHEN ASKED WHO WAS ASSIGNED TO MONITOR THE RESIDENT AT THE TIME OF THE RESIDENT'S FALL WITH INJURY ON 10/24/12, UNIT MANAGER 'T' STATED THAT SHE WAS UNAWARE WHO WAS ASSIGNED TO BE THE RESIDENT'S SITTER AND THEN STATED, "IT WAS A STAFFING ISSUE, SHE DIDN'T HAVE A SITTER." AT THE TIME OF THE INTERVIEW A LOG FOR THE STAFF ASSIGNED TO BE RESIDENT #809'S SITTER WAS REQUESTED. ON 11/15/12 AT 1:50 PM, RESIDENT #809'S FAMILY MEMBER WAS INTERVIEWED REGARDING THE FALL THAT CAUSED THE HEAD INJURY. THE FAMILY MEMBER REVEALED THAT RESIDENT #809 WAS TO HAVE A STAFF MEMBER WITH HER ALL THE TIME AND, "SHE WAS NOT SUPPOSED TO BE LEFT ALONE." SINCE THE ACCIDENT HER TEETH WERE LOOSENED, "SHE SEEMS TO BE SPIRALING (DECLINING) DOWN" AND "SHE IS NOT WHO SHE WAS WHEN SHE WALKED IN THERE (THE FACILITY)." ON 11/16/12 REVIEW OF THE PHYSICIAN ORDERS REVEALED, "TRANSFER TO HOSPITAL FOR EVALUATION OF WORSENING CT SCANS PER NURSE PRACTITIONER." ON 11/16/12 AT 9:45 AM, RESIDENT #809'S FAMILY MEMBER REPORTED THAT RESIDENT #809 WAS SUPPOSED TO BE discharged FROM THE FACILITY BUT, "NOW SHE CAN'T BECAUSE SHE HAS FLUID ON THE BRAIN. THEY FOUND OUT WHEN SHE WENT FOR THE CT SCAN AND NOW SHE HAS TO GO BACK TO THE HOSPITAL." ON 11/16/12 AT 12:05 PM, DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) REGARDING RESIDENT #809'S FALL THAT LED TO A HEAD INJURY REVEALED THAT RESIDENT #809 WAS ASSESSED AS BEING A HIGH RISK FOR FALLS. THE DON STATED THAT NO STAFF WAS ASSIGNED AS A ONE ON ONE SITTER WITH RESIDENT #809 AT THE TIME OF THE INCIDENT. THE DON REPORTED THAT STAFF WERE PRESENT TO SUPERVISE BY OBSERVING THE RESIDENT IN PASSING, WHILE PERFORMING OTHER DUTIES. THE DON WAS UNABLE TO EXPLAIN HOW STAFF SUPERVISION FROM A DISTANCE COULD PREVENT THE RESIDENT FROM FALLING WHEN THE CARE PLAN SPECIFICALLY INDICATED THAT RESIDENT #809 WAS TO HAVE A "ONE TO ONE SITTER." THE CRITERIA FOR ONE ON ONE SITTER WAS REQUESTED AND REVIEWED WITH THE DON. THE DON REPORTED THE FOLLOWING: THAT PRIOR TO RESIDENT #809'S FALL ON 10/24/12 "THERE WAS NO SPECIFIC POLICY" OR PROCEDURE RELATED TO "ONE ON ONE SITTER" SUPERVISION, THAT "ONE ON ONE SITTER" SUPERVISION WAS NOT CLEARLY DEFINED AND THAT STAFF HAD NO POLICY NOR A PROCEDURE TO REFERENCE TO MAINTAIN RESIDENT SAFETY WHEN "ONE ON ONE SITTER" WAS ADDED TO THE PLAN OF CARE. THE DON FURTHER ADDED, "IF I HAD SOMEONE TO SIT WITH THEM, I DID IT. IF I DID NOT, THEN THERE WAS NO ONE TO SIT WITH THEM (RESIDENTS)." THE DON THEN REPORTED THAT NO LOGS WERE KEPT THAT INDICATED WHO WAS RESPONSIBLE FOR THE ROLE OF RESIDENT #809'S ONE TO ONE SITTER AND STATED, "THERE WAS NO ONE ACCOUNTABLE." REVIEW OF THE FACILITY POLICY TITLED, "FALLS MANAGEMENT," WITH AN ISSUE DATE OF 8/2011, REVEALED THE FOLLOWING DOCUMENTATION: "PURPOSE: A PROGRAM TO IDENTIFY AND ALERT ALL STAFF OF THE RESIDENTS WHO ARE AT HIGH RISK FOR FALLS AND INITIATE INDIVIDUAL INTERVENTION TO POTENTIALLY REDUCE THE RISK OF INJURIOUS FALLS....THOSE RESIDENTS IDENTIFIED WITH SAFETY INTERVENTIONS MUST NOT BE LEFT WITHOUT THOSE INTERVENTIONS IN PLACE." ( )

THIS CITATION HAS MULTIPLE DEFICIENT PRACTICES. DEFICIENT PRACTICE #1. THIS CITATION PERTAINS TO FRI INTAKE #MI 050 BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO IMPLEMENT A CHAIR ALARM FOR ONE (#801) SAMPLED RESIDENT OF TEN RESIDENTS REVIEWED FOR ACCIDENTS OUT OF 26 SAMPLED RESIDENTS RESULTING IN A FALL WITH FRACTURE. FINDINGS INCLUDE: ON 1/24/12 AT 1:45 P.M., A FACILITY REPORTED INCIDENT (FRI) DATED 12/23/11 WAS REVIEWED. THE FRI DOCUMENTED THAT RESIDENT #801 WAS "OBSERVED IN HER ROOM AND IN FRONT OF HER WHEELCHAIR, SITTING IN FRONT OF THE WHEELCHAIR LEG RESTS". THE 12/23/11 "RESIDENT ACCIDENT/INCIDENT REPORT" DOCUMENTED "NO INJURY TO BIL (BILATERAL) UE (UPPER EXTREMITY) AND LE (LOWER EXTREMITY)-ABLE TO MOVE FREELY LEFT SIDE...." ADDITIONALLY, AN X-RAY REPORT, DATED 12/28/11, DOCUMENTED; "RIGHT TIBULA/FIBULA: ACUTE COMMINUTED SLIGHT DISPLACED FRACTURE PROXIMAL FIBULA." ON 1/24/12 AT 2:30 P.M., RECORD REVEALED THAT RESIDENT #801 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE ADMISSION MINIMUM DATA SET ASSESSMENT ((MDS) dated [DATE] REVEALED RESIDENT #801'S COGNITION WAS MODERATELY IMPAIRED, AND REQUIRED EXTENSIVE ASSISTANCE FROM STAFF FOR TRANSFERS, DRESSING AND HYGIENE. THE MDS DOCUMENTED RESIDENT #801 WAS "NOT STEADY, ONLY ABLE TO STABILIZE WITH HUMAN ASSISTANCE" WITH SURFACE TO SURFACE TRANSFERS AND MOVING FROM SEATED TO STANDING POSITION. THE ADMISSION "RESIDENT SAFETY ASSESSMENT", DATED 12/22/11, CODED RESIDENT #801'S FALL RISK SCORE AT "21" (ANY SCORE GREATER THAN 15=HIGH RISK FOR FALLS). THE "RESIDENT SAFETY ASSESSMENT" DOCUMENTED THAT RESIDENT #801 HAD "1-2 FALLS IN THE LAST 6 MONTHS" AND RECOMMENDED A LOW BED WITH MATS. PER THE ADMISSION "POTENTIAL FOR INJURY" CARE PLAN, ONE INTERVENTION IMPLEMENTED BY NURSING ON 12/22/11, WAS "CHAIR ALARM". HOWEVER, THE INCIDENT/ACCIDENT REPORT DATED 12/23/11 DID NOT DOCUMENT THAT THE CHAIR ALARM WAS SOUNDING AT THE TIME OF THE INCIDENT. ON 1/24/12 AT 3:00 P.M., RESIDENT #801'S NURSING PROGRESS NOTES WERE REVIEWED. THE NURSING PROGRESS NOTES DID NOT DOCUMENT ANY RESIDENT PAIN OR THE FALL EVENT FROM 12/23/11, UNTIL 12/29/11, (AFTER THE DISCOVERY OF THE FRACTURE)-AS A "LATE" ENTRY. PHYSICAL THERAPY DAILY COMMUNICATION WORKSHEETS DATED FROM 12/22/11 TO 12/27/11 DOCUMENTED "WINCING" DURING THE 12/24/11 THERAPY SESSION. DURING THE 12/27/11 THERAPY SESSION, RESIDENT #801 EXPERIENCED "PAIN RIGHT (R) LE WITH PASSIVE MOVEMENT". THERE WERE NO DOCUMENTED EVENTS OF PAIN ON THE INITIAL THERAPY EVALUATION OR THERAPY SESSIONS PRIOR TO 12/24/11. ON 1/25/12 AT 11:00 A.M., NURSE UNIT MANAGER "E" WAS QUESTIONED REGARDING THE FALL ON 12/23/11. NURSE "E" SAID THAT EACH RESIDENT HAD A FALL RISK ASSESSMENT DONE BY THERAPY UPON ADMISSION AND THE FACILITY STAFF TRIED TO FOLLOW THE RECOMMENDATION. NURSE "E" STATED THAT SHE WAS THE NURSE ON DUTY THE DAY OF THE FALL, AND THERE WAS NO CHAIR ALARM ON PRIOR TO THE FALL. MANAGER "E" SAID, "THE ALARM WAS AN INTERVENTION SOMETIME AFTER THE FALL". WHEN QUESTION ABOUT THE CARE PLAN WITH THE "CHAIR ALARM" INTERVENTION DATED 12/22/11, SHE STATED THAT THE CARE PLAN WAS A "CANNED (STANDARDIZED)" CARE PLAN AND THAT THE CARE PLAN WAS NOT INDIVIDUALIZED (FOR RESIDENT #801)." ON 1/26/11 AT 8:30 A.M., INFORMATION TECHNOLOGIST (IT) "P" WAS QUERIED REGARDING THE ELECTRONIC CARE PLANS. HE STATED THAT CARE PLANS WERE INDIVIDUALIZED BY THE NURSE UPON CREATION OF THE CARE PLAN. ON 1/27/12 AT 10:45 A.M., THE DIRECTOR OF NURSING (DON) WAS QUERIED REGARDING THE FALL AND SAFETY DEVICES FOR RESIDENT #801. THE DON SAID, "THE NURSE JUST CLICKED ALL THE INTERVENTIONS. SHE SHOULD HAVE INDIVIDUALIZED THE CARE PLAN." ON 1/27/12 AT 12 NOON, DURING A PHONE INTERVIEW WITH RESIDENT #801'S SISTER, WHO WAS ALSO HER RESPONSIBLE PARTY, STATED THAT RESIDENT #801 NEVER HAD A CHAIR ALARM IN HER CHAIR UNTIL AFTER THE FALL. RESIDENT #801'S SISTER WENT ON TO STATE THAT SHE HAD REQUESTED UPON ADMISSION, THAT HER SISTER (RESIDENT #801) BE "TIED DOWN" SO THAT SHE DOES NOT FALL OUT OF THE CHAIR OR BED. SHE SAID "BECAUSE OF HER STROKE, MY SISTER WOULD LEAN TO THE RIGHT SIDE, AND I DID'NT WANT HER TO FALL". PER THE FACILITY'S "THE STAR PROGRAM (FALLS MANAGEMENT)" POLICY, DATED 8/11; "THOSE RESIDENTS IDENTIFIED WITH SAFETY INTERVENTIONS MUST NOT BE LEFT WITHOUT THOSE INTERVENTIONS IN PLACE..." ( ) DEFICIENT PRACTICE #2. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO SECURE A MEDICATION CART AND DOUBLE LOCK CONTROLLED SUBSTANCES, RESULTING IN THE POTENTIAL FOR ACCIDENTAL INGESTION, ABUSE OR DIVERSION OF MEDICATIONS. FINDINGS INCLUDE: ON 1/24/12 AT 2:40 P.M., DURING GENERAL OBSERVATIONS ON THE FACILITY'S 400 UNIT, IT WAS OBSERVED THAT THE 400 UNIT MEDICATION CART WAS UNLOCKED AND UNATTENDED. THE MEDICATION CART WAS LOCATED IN THE HALL ADJACENT TO RESIDENT ROOMS. THE HALL WAS ACCESSIBLE TO NON-CLINICAL STAFF, RESIDENTS AND VISITORS. THE CART WAS OUT OF VIEW OF THE UNIT NURSE. AT 2:55 P.M., STAFF NURSE "M" APPROACHED THAT MEDICATION CART STATING "I THOUGHT IT WAS LOCKED". PER THE FACILITY'S "GENERAL DOSE PREPARATION AND MEDICATION ADMINISTRATION" POLICY, DATED 12/1/07, REVISED 5/1/10; "FACILITY SHOULD ENSURE THAT MEDICATION CARTS ARE ALWAYS LOCKED WHEN OUT OF SIGHT OR UNATTENDED". ( ) DEFICIENT PRACTICE #3: BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT THE BED AREA WAS FREE FROM SAFETY HAZARDS, PERSONAL SAFETY DEVICES WERE APPLIED, PERSONAL SAFETY DEVICES WERE DOCUMENTED ON THE CARE PLAN WHEN IMPLEMENTED, AND FAILED TO IMPLEMENT POST FALL INTERVENTIONS FOR ONE (#808) OF 10 RESIDENTS REVIEWED FOR FALLS FROM A TOTAL SAMPLE OF 26, RESULTING IN TRANSFER TO THE emergency room FOR SUTURES TO AN EAR LACERATION, A FALL WITH BRUISING, AND THE POTENTIAL FOR INJURY FROM ADDITIONAL FALLS. FINDINGS INCLUDE: ON 1/24/12 AT 12:40 P.M., RESIDENT #808 WAS OBSERVED WEARING A PERSONAL SAFETY TAB ALARM, IN A WHEELCHAIR. CERTIFIED NURSING ASSISTANT (CNA) "B" WAS FEEDING THE RESIDENT, WHO WAS CONFUSED. RESIDENT #808 WAS POSITIONED IN THE WHEELCHAIR WITH HIPS PUSHED FORWARD AT THE EDGE OF THE SEAT AND UPPER BODY LEANING BACK, CAUSING THE RESIDENT TO APPEAR AS IF HE WAS SLIDING DOWN FROM THE WHEELCHAIR. ON 1/25/12 AT 12:30 P.M., RESIDENT #808'S SPOUSE WAS INTERVIEWED, AND REPORTED THAT RESIDENT #808 HAD DEMENTIA AND WAS CONFUSED. ON 1/26/12 AT 12:15 P.M., RESIDENT #808'S CLINICAL RECORD AND FACILITY RESIDENT ACCIDENT/INCIDENT REPORTS (I&A) WERE REVIEWED WITH THE DIRECTOR OF NURSING. THEY REVEALED THAT RESIDENT #808 HAD FALLEN TWICE IN THE FACILITY, INCLUDING A FALL RESULTING IN BRUISING. IN ADDITION, THE RESIDENT HAD ALSO SUFFERED AN EAR LACERATION FROM AN UNWITNESSED CAUSE, WHICH REQUIRED TRANSFER TO THE emergency room (ER) FOR SUTURES (STITCHES). REVIEW OF A FACE SHEET REVEALED RESIDENT #808 WAS ORIGINALLY admitted to the facility on [DATE], AND readmitted AFTER hospitalization on [DATE]. A MINIMUM DATA SET ASSESSMENT ((MDS) dated [DATE] DOCUMENTED THAT RESIDENT #808 NEEDED EXTENSIVE STAFF ASSISTANCE FOR TRANSFERS TO THE WHEELCHAIR, WALKING, DRESSING AND HYGIENE. THE MDS NOTED THAT RESIDENT #808 HAD DIFFICULTY BALANCING, AND NEEDED STAFF ASSSISTANCE FOR STABILITY. REVIEW OF RESIDENT #808'S FALL RISK ASSESSMENT, DATED 10/19/11 REVEALED THE RESIDENT WAS AT RISK FOR FALLS DUE TO UNSTEADY GAIT, COGNITIVE DEFICITS (DEMENTIA), IMPAIRED SAFETY AWARENESS, BALANCE PROBLEM, IMPAIRED VISION, AND A HISTORY OF FALLS. A POTENTIAL FOR INJURY NURSING CARE PLAN FOR RESIDENT #808, DATED 10/19/11 REVEALED NO DOCUMENTATION OF ANY PERSONAL SAFETY DEVICES. REVIEW OF ALL OF RESIDENT #808'S CARE PLANS REVEALED NO DOCUMENTATION OF PERSONAL SAFETY DEVICES TO PREVENT FALLS, ANTI SLIP DEVICES ADDED TO WHEELCHAIR, OR INSTRUCTIONS TO KEEP SHARP OR HARD OBJECTS/FURNITURE AWAY FROM THE RESIDENT'S BED. A RESIDENT ACCIDENT/INCIDENT REPORT (I&A) FOR RESIDENT #808 DOCUMENTED A FALL FROM THE WHEELCHAIR ON 12/8/11 AT 6:30 P.M., AND NOTED THE RESIDENT'S PERSONAL SAFETY ALARM WAS ON AND HAD SOUNDED. THE REPORT DOCUMENTED THE REASON FOR THE FALL AS, "RESIDENT SLID OUT OF WHEELCHAIR ONTO THE GROUND." A POST FALL REVISION NOTE, DATED 12/12/11, ADDED TO RESIDENT #808'S (1/19/11) POTENTIAL FOR INJURY CARE PLAN, REVEALED THE FOLLOWING, "RESIDENT SLID OUT OF CHAIR ON TO THE GROUND, WIFE WAS PRESENT WHEN THIS HAPPENED. PERSONAL ALARM WAS IN PLACE AND SOUNDING WHEN PATIENT WAS FOUND. NO INJURY. CONTINUE WITH PLAN OF CARE." THERE WAS NO DOCUMENTATION OF ANY ADDED INTERVENTIONS TO PREVENT FUTURE FALLS DUE TO SLIPPING OUT OF THE WHEELCHAIR. WHEN QUERIED, THE DON STATED NO INTERENTIONS WERE ADDED AT THIS TIME. A NURSING NOTE DATED 1/2/12 AT 8:20 A.M., DOCUMENTED, "RESIDENT OBSERVED IN BED WITH LEFT EAR BLEEDING FROM ONE CENTIMETER (CM) LACERATION (DEEP CUT THROUGH ALL LAYERS OF SKIN). MANUAL PRESSURE APPLIED AND PRESSURE DRESSING APPLIED, BUT BLEEDING WAS STILL UNCONTROLLED. DR NOTIFIED. OBTAINED ORDERS TO SEND RESIDENT OUT TO HOSPITAL FOR EVALUATION. TRANSFERRED (EARLIER) AT 6:45 A.M." A FACILITY "NON-FALL RELATED TEAM REPORT" DATED 1/2/12 DOCUMENTED THAT RESIDENT #808 SUFFERED A ONE CENTIMETER (CM) LACERATION ON THE LEFT EAR ON 1/2/12. THE REPORT NOTED THERE WERE NO ENVIRONMENTAL FACTORS THAT MAY HAVE CONTRIBUTED TO THE INCIDENT. THE INVESTIGATIVE MEASURES WERE DOCUMENTED AS, "ASKED RESIDENT HOW INCIDENT OCCURRED. HE STATED, 'I BUMPED MY EAR ON THE WALL." WHEN QUERIED ABOUT WHETHER RESIDENT #808'S 1/2/12 INJURY OF UNKNOWN ORIGIN WAS INVESTIGATED TO RULE OUT POSSIBLE ABUSE, WRITTEN STATEMENTS FROM UNIT MANAGER (UM) "D", AND FROM THE STAFF NURSE ON DUTY AT THE TIME THE INJURY WAS DISCOVERED, WERE PROVIDED AND REVIEWED WITH THE DON. WHEN QUERIED WHY NEITHER RESIDENT #808'S ROOMATE NOR CNAS WERE INTERVIEWED TO IDENTIFY POSSIBLE WITNESSES TO THE INJURY, THE DON STATED, "IT WAS BECAUSE THE CAUSE OF THE INJURY WAS KNOWN. (THE RESIDENT) HAD CUT HIS EAR ON THE ARM OF A CHAIR PLACED AT HEAD LEVEL BESIDE HIS BED." THE STATEMENT FROM UM "D" DATED 1/3/12 NOTED, "UPON INVESTIGATING THE INJURY, IT WAS SEEN THAT THE HEIGHT OF THE HEAD OF THE BED WAS PARALLEL WITH THE WOODEN ARM OF THE CHAIR. THE PATIENT HAS RECENTLY BEEN NOTED SLIDING TO THE LEFT SIDE OF THE BED MANY TIMES WHILE HE IS IN BED. THE SIDE OF THE CHAIR ARM MAKES A 90 DEGREE ANGLE WHERE AN EDGE IS FORMED, IT IS MORE LIKELY THAT, WHILE SLIDING TO THE LEFT IN BED, HE BUMPED HIS EAR ON THE SHARP EDGE OF THE CHAIR ARM, AND, DURING THE NIGHT, THOUGHT IT WAS THE WALL." ON 1/26/12 AT 1:20 P.M., UM "D" WAS INTERVIEWED IN THE PRESENCE OF THE DON, AND REPORTED THAT NO FURTHER INVESTIGATION HAD BEEN DONE, AS IT WAS DETERMINED THAT RESIDENT #808 SUFFERED THE EAR LACERATION ON 1/2/12 FROM HITTING HIS HEAD AGAINST THE ARM OF A CHAIR PLACED BESIDE THE BED. UM "D" STATED THE EDGE OF THE CHAIR ARM WAS EXACTLY AT THE LEVEL OF RESIDENT #808'S HEAD IN BED, AND WAS VERY SHARP. WHEN QUERIED, NEITHER THE DON NOR THE UM COULD EXPLAIN WHY A CHAIR WITH A SHARP EDGE AT HEAD LEVELWAS POSITIONED NEXT TO THE BED OF A RESIDENT WHO HAD BEEN NOTED TO SLIDE TO THAT SIDE OF THE BED "MANY TIMES WHILE HE IS IN BED." THE UM STATED THAT THE CHAIR HAD SINCE BEEN MOVED AWAY FROM THE RESIDENT'S BEDSIDE, BUT COULD PROVIDE NO DOCUMENTATION THIS WAS ADDED TO ANY CARE PLAN OR CNA GUIDE TO ENSURE THAT ALL STAFF WERE AWARE OF THIS. WHEN QUERIED WHETHER THE INJURY HAD BEEN REPORTED TO THE STATE AGENCY, AS REQUIRED, THE DON REPORTED IT WAS NOT REPORTED AS THE CAUSE OF THE INJURY WAS KNOWN TO BE CAUSED BY THE RESIDENT BUMPING HIS HEAD ON A SHARP EDGE OF A CHAIR NEXT TO THE BED. WHEN REQUESTED, NEITHER THE DON NOR THE UM WAS ABLE TO PROVIDE DOCUMENTATION OR INFORMATION ON HOW MANY SUTURES RESIDENT #808 RECIEVED AS A RESULT OF THIS INJURY, BUT REPORTED THAT NURSING NOTES AND THE TREATMENT RECORD FOLLOWING THE INJURY DID DOCUMENT BRUISING, BLEEDING AND SUTURES TO RESIDENT #808'S EAR AS A RESULT OF THIS INJURY. REVIEW OF A A FACILITY I&A REPORT FOR RESIDENT #808, SIGNED 1/6/12, REVEALED THAT RESIDENT #808 SUFFERED A FALL ON 1/5/12 AT 4:40 P.M. THE REPORT NOTED THAT "PATIENT STAND FROM GERI-CHAIR. TOOK ONE STEP AND fell BACKWARDS." THE REPORT ALSO NOTED THAT THE RESIDENT WAS NOT WEARING HIS PERSONAL ALARM, NOTING, "PHYSICAL THERAPIST (PT) HAD RESIDENT IN THERAPY ROOM AND RETURNED HIM TO COMMON AREA, NOTIFYING CNA TO MONITOR HIM. PERSONAL ALARM (PA) WAS LEFT IN RESIDENT'S ROOM AND WAS NOT ATTACHED." WHEN QUERIED, THE DON WAS UNABLE TO EXPLAIN HOW PT STAFF WOULD KNOW RESIDENT #808 NEEDED A PERSONAL ALARM IF THE ALARM WAS NOT DOCUMENTED AS A SAFETY INTERVENTION ON ANY OF THE RESIDENT'S NURSING CARE PLANS. A NURSING NOTE DATED 1/6/12 AT 10:31 P.M., AFTER THIS FALL, NOTED THAT RESIDENT #808 SUFFERED A BRUISE AS A RESULT OF THE FALL ON 1/5/12, "DAY 2 FALL, PATIENT (PT) HAS A BRUISE TO HIS BACK RESULTING FROM A FALL." WHEN QUERIED ABOUT POST FALL INTERVENTIONS TO PREVENT THIS TYPE OF FALL FROM REOCCURRING, THE DON STATED THE PT STAFF HAD BEEN COUNSELED AND REPRIMANDED. REVIEW OF THE FACILITY POLICY TITLED "THE STAR PROGRAM (FALLS MANAGEMENT)" DATED 8/11 REVEALED THE FOLLOWING NOTATION, "THOSE RESIDENTS IDENTIFIED WITH SAFETY INTERVENTIONS MUST NOT BE LEFT WITHOUT THOSE INTERVENTIONS IN PLACE." ( )( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 023 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO MAINTAIN THE HIGHEST PRACTICABLE WELL BEING FOR FOUR OF SEVEN SAMPLED RESIDENTS (#501, #503, #505, #507) BY FAILING TO ADMINISTER MEDICATIONS AS ORDERED, RESULTING IN RESIDENT #501 BEING DISCOVERED UNRESPONSIVE, WITH A CRITICALLY ELEVATED BLOOD SUGAR LEVEL, AND THE POTENTIAL FOR UNMET CARE NEEDS FOR RESIDENTS #503, #505 AND #507. FINDINGS INCLUDE: RESIDENT #501 ACCORDING TO THE FACILITY ' S ADMISSION SHEET, RESIDENT #501 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. A NURSING NOTE DATED 1/17/11 (TIMED 3-11) DOCUMENTED " ...PT (PATIENT; #501) WAS FOUND IN HER BED UNRESPONSIVE TO STERNAL RUB, USUALLY IS ABLE TO SPEAK AND ANSWER QUESTIONS, TWITCHING NOTED AND LEANING TOWARDS HER LEFT SIDE ... " " ...UNABLE TO ADMINISTER 9 PM MEDICATIONS BECAUSE PT WAS UNABLE TO OPEN HER MOUTH... " " ...PT UNABLE TO OPEN HER EYES AS WELL ... " " ...911 CALLED, ARRIVED AND TOOK PT TO HOSPITAL ... " THE EMS (EMERGENCY MEDICAL SYSTEM) RUN SHEET DOCUMENTED THE FOLLOWING: "...72 YO FEMALE IN BED AT NURSING HOME BEING TRANSFERRED TO HOSPITAL PER AMBULANCE STRETCHER..." "...NURSING STAFF STATES THAT HER (#501) LOC (LEVEL OF CONSCIOUSNESS) HAS BEEN DECREASING FOR SEVERAL HOURS..." "...SEMI ALERT TO PAIN ONLY WITH MUSCLE TWITCHING..." "...BLOOD SUGAR WAS "HI", PT (PATIENT) GIVEN 150 CC [MEDICATION NAME] OF NS (NORMAL SALINE), BLOOD SUGAR REtested , BLOOD SUGAR WAS 557..." ACCORDING TO RESIDENT #501 ' S HOSPITAL RECORDS, RESIDENT #501 WAS admitted TO THE ED (EMERGENCY DEPARTMENT) ON 1/17/11 AT 9:44 P.M. A REVIEW OF RESIDENT #501 ' S HOSPITAL INPATIENT FACE SHEET DATED 1/17/11 REVEALED THAT RESIDENT #501 ' S admitting [DIAGNOSES REDACTED]. ACCORDING TO THE HOSPITAL DISCHARGE SUMMARY SHEET "...THE PATIENT (#501) DID NOT RECEIVE [MEDICATION NAME] (INSULIN) AT THE SUBACUTE REHAB..." A REVIEW OF RESIDENT #501 ' S HOSPITAL laboratory results dated [DATE] AT 9:21 P.M. REVEALED A BLOOD GLUCOSE LEVEL OF 581 (REFERENCE RANGE 60-139). A HOSPITAL NURSING ADMISSION NOTE DOCUMENTED " ...PATIENT (#501) RECEIVED TO FLOOR VIA STRETCHER ... " " ...CURRENTLY ON INSULIN DRIP ... " " ...PATIENT UNRESPONSIVE CURRENTLY ... " " ...I NOTICED WHEN PATIENT ARRIVED THAT SHE WAS TWITCHING ALL OVER ... " A REVIEW OF RESIDENT #501 ' S HOSPITAL HISTORY AND PHYSICAL REPORT DATED 1/18/11 DOCUMENTED THE FOLLOWING: " ... THE FAMILY SAW HER YESTERDAY MORNING AND PATIENT WAS SITTING UP IN CHAIR EATING ALTHOUGH SHE WAS A LITTLE LETHARGIC IN THE AFTERNOON AT THAT TIME BUT AT NIGHT PATIENT WAS FOUND TO BE UNRESPONSIVE TO VERBAL STIMULUS AND DID NOT EVEN RESPOND TO STERNAL RUB ... " " ...SHE (#501) WAS TRANSFERRED TO THE HOSPITAL FOR FURTHER WORKUP ... " " ...HER (#501) BLOOD SUGAR WAS ELEVATED AT 581. SHE WAS STARTED ON INSULIN DRIP ... " " ...I DID CALL THE NURSING (FACILITY) AND TALKED TO THE MANAGER AND IT APPEARS THAT SHE (#501) DID NOT GET ANY [MEDICATION NAME] (INSULIN) OVER THE LAST TWO DAYS AND WAS ONLY ON SLIDING SCALE INSULIN. THERE WAS ALSO AN ERROR OF [MEDICATION NAME] DOSE BUT SHE DID NOT GET ANY [MEDICATION NAME] DOSE OVER THE LAST TWO DAYS ... " " ...SHE WAS ON ALL OF HER PREVIOUS MEDICATIONS EXCEPT [MEDICATION NAME] DOSE WHICH WAS WRITTEN FOR TWICE A DAY BUT PER PATIENT ' S FAMILY SHE ONLY TAKES ONCE AT NIGHT 0.5 MG ... " A REVIEW OF RESIDENT #501 ' S physician's order [REDACTED]. " ... (SLIDING SCALE COVERAGE) [MEDICATION NAME] (RAPID ACTING INSULIN) 100 UNITS/ML 1-8 UNITS WITH MEALS AND AT BED TIME ... " GLUCOSE WITH MEALS HS (BEDTIME) 150-199 1 UNIT NONE 200-249 3 UNITS 2 UNITS 250-299 5 UNITS 3 UNITS 300-349 7 UNITS 4 UNITS >349 8 UNITS 5 UNITS " [MEDICATION NAME] 10 MG 2 TABLETS TWICE A DAY ... " (USED TO TREAT DEPRESSION). " [MEDICATION NAME] ([MEDICATION NAME]) 100 MCG EVERY DAY ... " (USED TO TREAT [MEDICAL CONDITION]). " [MEDICATION NAME] 10 MG BY MOUTH EVERY NIGHT AT BEDTIME ... " (USED TO TREAT DEMENTIA). " [MEDICATION NAME] 10 MG BY MOUTH TWICE A DAY ... " (USED TO TREAT ALZHEIMER ' S DISEASE). " [MEDICATION NAME] 10 MG BY MOUTH EVERY NIGHT AT BEDTIME ... " (TO REDUCE CHOLESTEROL). " [MEDICATION NAME] 0.5 MG BY MOUTH TWICE A DAY ... " (USED TO TREAT [MEDICAL CONDITION]). " [MEDICATION NAME] 12.5 MG 1 BY MOUTH TWICE A DAY FOR 60 DAYS... " (USED TO TREAT HEART FAILURE AND HIGH BLOOD PRESSURE). " [MEDICATION NAME] (INSULIN) 20 UNITS SUB Q (SUBCUTANEUS) EVERYDAY IN A.M ... " RECORD REVIEW REVEALED THAT THE FACILITY CHANGED THE TIME OF ADMINISTRATION ON THE physician's order [REDACTED].M., HOWEVER, IT WAS INDICATED ON THE MEDICATION OBSERVATION RECORD (MORS) THAT [MEDICATION NAME] WAS IN FACT TO BE GIVEN Q HS (EVERY NIGHT AT BEDTIME AT 9:00 P.M.). A REVIEW OF RESIDENT #501 ' S MORS FOR THE MONTH OF JANUARY 2011 REVEALED THAT THE FOLLOWING MEDICATIONS HAD NOT BEEN ADMINISTERED ACCORDING TO THE physician's order [REDACTED]. [MEDICATION NAME] 20 UNITS DUE ON 1/15/11 AND 1/16/11 AT 9:00 P.M.; NOT GIVEN [MEDICATION NAME] 12.5 MG DUE ON 1/15/11 AND 1/16/11 AT 9:00 P.M.; NOT GIVEN [MEDICATION NAME] 0.5 MG DUE ON 1/15/11 AND 1/16/11 AT 9:00 P.M.; NOT GIVEN [MEDICATION NAME] 10 MG DUE ON 1/15/11 AT 9:00 P.M.; NOT GIVEN [MEDICATION NAME] ([MEDICATION NAME]) DUE ON 1/17/11 AT 6:00 A.M.; NOT GIVEN [MEDICATION NAME] 10 MG DUE ON 1/15/11 AND 1/16/11 AT 9:00 P.M.; NOT GIVEN [MEDICATION NAME] 10 MG DUE ON 1/15/11 AND 1/16/11 AT 9:00 P.M.; NOT GIVEN [MEDICATION NAME] 10 MG DUE ON 1/15/11 AND 1/16/11 AT 9:00 P.M.; NOT GIVEN THERE WAS NO DOCUMENTATION ON THE BACK OF THE MORS THAT INDICATED THE REASON THE ABOVE NOTED MEDICATION WERE NOT ADMINISTERED TO RESIDENT #501 ACCORDING TO THE physician's order [REDACTED]. FURTHER REVIEW OF THE MORS REVEALED THAT RESIDENT #501 WAS TO HAVE HER BLOOD SUGAR LEVEL CHECKED ON 1/15/11 AT 4:00 P.M. AND ON 1/16/11 AT 9:00 P.M. AND RECEIVE CORRESPONDING INSULIN COVERAGE AS INDICATED IN THE physician's order [REDACTED]. THERE WAS NO DOCUMENTED EVIDENCE ON BACK OF THE MORS OR IN THE CLINICAL RECORD THAT INDICATED THAT RESIDENT #501 ' S BLOOD SUGAR LEVEL HAD BEEN CHECKED AT THE ABOVE NOTED TIMES OR THAT THE APPROPRIATE AMOUNT OF INSULIN WAS GIVEN IF THE TEST REVEALED AN ELEVATED BLOOD SUGAR. ON 3/17/11 AT 12:55 P.M., AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) WAS CONDUCTED. WHEN ASKED WHY RESIDENT #501 DID NOT RECEIVE HER PRESCRIBED MEDICATIONS AS ORDERED BY THE PHYSICIAN, THE DON SAID RESIDENT #501 WAS admitted to the facility on [DATE] AT 2:56 P.M. AND THEREFORE, HER MEDICATIONS WOULD NOT HAVE BEEN AVAILABLE. THE DON FURTHER STATED " ...THE FAMILY CALLED ABOUT INSULIN CONCERNS ... " " ...WE DID AN INTERNAL INVESTIGATION BECAUSE OF THIS. WE FOUND OUT THAT THE NURSES GAVE THE INSULIN BUT DID NOT SIGN ON THE MORS THAT IT HAD BEEN GIVEN ... " WHEN QUERIED ABOUT THE NURSES FAILING TO PROPERLY DOCUMENT IN THE CLINICAL RECORD WHEN AND IF MEDICATIONS ARE ADMINISTERED OR NOT AVAILABLE, THE DON HAD NO EXPLANATION. ALTHOUGH THE DON STATED THAT THE INSULIN HAD BEEN ADMINISTERED BY THE FACILITY NURSING STAFF, THERE WAS NO DOCUMENTATION IN THE CLINICAL RECORDED THAT SUPPORTED THAT RESIDENT #501 HAD RECEIVED HER PRESCRIBED INSULIN AND OTHER MEDICATIONS. A REVIEW OF THE FACILITY ' S MEDICATIONS POLICY DATED 9/28/04 REVEALED THE FOLLOWING: " ...IF THE MEDICATION IS NOT AVAILABLE IN THE BACKUP PYXIS SYSTEM AND IT HAS BEEN DETERMINED THAT THE RESIDENT MUST RECEIVE THE MEDICATION AT THE FIRST SCHEDULED DOSING TIME, THE NURSE SHALL CALL THE PHARMACY TO SEND THE MEDICATION AS AN ASAP (AS SOON AS POSSIBLE) ORDER ... " " ...IF, BASED ON THE PROJECTED DELIVERY TIME, THE RESIDENT WILL MISS AN ORDERED DOSE OF A MEDICATION, THE NURSE SHOULD: NOTIFY THE PHYSICIAN OF THE EXPECTED DELAY IN TREATMENT ... " " ...AT NO TIME SHOULD THERE BE MORE THAN ONE DOSE OF THE SAME MEDICATION NOT ADMINISTERED WITHOUT THE NURSE RESPONDING TO THE SITUATION BY FOLLOWING THIS POLICY ... " THERE WAS NO DOCUMENTED EVIDENCE IN RESIDENT #501'S CLINICAL RECORD THAT THE PHYSICIAN HAD BEEN NOTIFIED THAT RESIDENT #501'S MEDICATIONS HAD NOT BEEN ADMINISTERED AS ORDERED. RESIDENT #503 ACCORDING TO THE FACE SHEET, RESIDENT #503 WAS admitted to the facility on [DATE] AT 11:45 A.M., WITH [DIAGNOSES REDACTED]. RECORD REVIEW OF THE physician's order [REDACTED]. " [MEDICATION NAME] 20 MG ([MEDICATION NAME]) BY MOUTH TWICE A DAY ... " (USED TO TREAT FLUID RETENTION) " ...LEVETIRACETAM 500 MG BY MOUTH TWICE A DAY ... " (USED TO TREAT [MEDICAL CONDITION]) " [MEDICATION NAME] 12.5 MG BY MOUTH TWICE A DAY ... " (USED TO TREAT HIGH BLOOD PRESSURE) A REVIEW OF RESIDENT #503 ' S MORS FOR THE MONTH OF FEBRUARY 2011 REVEALED THAT THE FOLLOWING MEDICATIONS HAD NOT BEEN ADMINISTERED ACCORDING TO THE physician's order [REDACTED]. [MEDICATION NAME] 12.5 MG DUE ON 2/24/11 AT 9:00 P.M.; NOT GIVEN [MEDICATION NAME] ([MEDICATION NAME]) 20 MG DUE ON 2/24/11 AT 2:00 P.M.; NOT GIVEN LEVETIRACETAM 500 MG DUE ON 2/24/11 AND 2/25/11 AT 9:00 P.M.; NOT GIVEN RESIDENT #505 ACCORDING TO THE FACE SHEET, RESIDENT #505 WAS admitted to the facility on [DATE] AT 3:00 P.M. WITH [DIAGNOSES REDACTED]. RECORD REVIEW OF THE physician's order [REDACTED]. " ...SODIUM [MEDICATION NAME] 650 MG BY MOUTH THREE TIMES A DAY ... " (INDIGESTION, HEARTBURN) FURTHER RECORD REVIEW REVEALED THAT SODIUM [MEDICATION NAME] 650 MG WAS DUE ON 2/25/11 AT 9:00 P.M. AND HAD NOT BEEN ADMINISTERED TO RESIDENT #505 ACCORDING TO THE physician's order [REDACTED]. RESIDENT #507 ACCORDING TO THE FACE SHEET, RESIDENT #507 WAS admitted to the facility on [DATE] AT 5:10 P.M. WITH [DIAGNOSES REDACTED]. RECORD REVIEW OF THE physician's orders [REDACTED]. "[MEDICATION NAME] 100 MG VIA PEG (FEEDING TUBE) TWICE A DAY..." (HIGH BLOOD PRESSURE) "[MEDICATION NAME] 0.4 MG VIA PEG EVERY DAY..." (USED TO IMPROVE URINATION) FURTHER RECORD REVIEW REVEALED THAT [MEDICATION NAME] 100MG WAS DUE ON 3/3/11 AT 9:00 P.M.. [MEDICATION NAME] WAS DUE ON 3/3/11 AT 9:00 P.M. NEITHER MEDICATION HAD BEEN ADMINISTERED TO RESIDENT #507 AS ORDERED BY THE PHYSICIAN. THERE WAS NO DOCUMENTATION ON THE BACK OF THE MORS THAT EXPLAINED WHY MEDICATIONS WERE NOT ADMINISTERED TO RESIDENTS RESIDENTS #503, #505 AND #507 IN ACCORDANCE WITH THE physician's orders [REDACTED]. FURTHER, THERE WAS NO DOCUMENTED EVIDENCE IN THE CLINICAL RECORDS THAT THE PHYSICIAN HAD BEEN NOTIFIED ABOUT THE MISSED MEDICATIONS FOR ANY OF THESE RESIDENTS. THE DON OFFERED NO EXPLANATION OF WHY MEDICATIONS HAD NOT BEEN ADMINISTERED IN ACCORDANCE WITH THE physician's orders [REDACTED].