Every finding on record at Aberdeen Rehabilitation and Skilled Nursing Center

This citation pertains to 2794609. Based on interview and record review, the facility failed to provide proper transfer assistance for one resident (R106) out of three residents reviewed for falls, resulting in a fall. Findings include: A review of the clinical record for R106 documented an admission date of 1/16/26 and discharge date of 2/24/26. R106's diagnoses included congestive heart failure, chronic obstructive pulmonary disease, type 2 diabetes mellitus, peripheral vascular disease, and morbid obesity. A Minimum Data Set assessment dated [DATE] documented moderate cognitive impairment and dependence upon staff for transfer assistance. Additional record review documented in part the following progress notes, orders, and care plans: 1. 2/18/26 at 1:36 PM nursing progress note: Resident stated (they) slid to the floor from (their) wheelchair onto (their) back, mild pain noted. Assessed and no injury noted. Witnessed. 2. 2/18/26 at 2:29 PM nursing progress note: Resident c/o (complained of) low back pain r/t (related to) fall. PA (Physician Assistant) contacted, new order received for lumbar x-ray. All Stat (immediately). Portable called verbal order given. 3. 2/18/26 at 7:58 PM PA note (note entered 2/22/26 at 8:00 PM): Subjective: Patient seen and examined at bedside. Patient had been reported to have slid out of wheel chair. Did have some low back pain. No head trauma reported. Fall. Slid out of wheel chair, lumbar pain reported. Obtain x-ray imaging. Pain management. Supportive care. Patient education. Fall precautions. Monitor for changes. 4. Review of facility document titled, Event Report for R106 documented in part the following:Safety Event - FallEvent Date: 2/18/26 at 1:31 PMDescription: FallLocation of Fall: Resident RoomWhat was resident doing just prior to fall? Resident states she slid from wheelchair onto back.Was Fall Witnessed? Yes 5. Review of facility document titled, Fall Assessment for R106, dated 2/18/26 documented in part the following: What is the resident's current transfer status? 2 Person Assist. 6. 2/19/26 at 4:07 PM nursing progress note: Resident c/o lower back pain and pain in hands and feet which resident states is chronic and more of a neuropathy pain level is an 8. Writer administered pain med per (resident) request. Pillows requested and arms placed on pillows - resident stated hour post medication that pain in back is gone but arms and hands still aching 7. Physician order dated 1/19/26: Transfers: (Mechanical lift) with two persons assist. 8. Care plan problem: I need help with transfers, bed mobility, locomotion and range of motion due to my diagnosis of muscle weakness. Approach: Supervise, cue, and encourage me as needed to participate in my mobility. Transfers: two person assist, (mechanical) lift. Dated 1/17/26. 9. Care plan problem: I am at risk for falls and injury r/t my impaired balance, muscle weakness, and history of falls. Approach: Please assist me with all transfers as needed. Dated 1/16/26. On 4/9/26 at 3:35 PM, the Director of Nursing (DON) identified Certified Nurse Aide (CNA) E as the person who witnessed R106's fall on 2/18/26. The DON indicated CNA E was alone when a mechanical lift was used to transfer R106 into their wheelchair. The DON identified this transfer was unsafe and indicated this was the reason CNA E received disciplinary action. A review of a facility document titled, Corrective Action Form dated 2/18/26 revealed in part the following: (CNA E) transferred resident via (mechanical lift) without assistance. Resident's transfer order reads, Transfers: (Mechanical) lift with two persons assist. A review of a facility policy titled, Hoyer Lift, dated September 2018, documented in part the following: A Hoyer Lift transfer requires a minimum of two nursing employees in attendance to provide resident safety. On 4/9/26 at 4:30 PM, the DON and Regional Director of Operations did not offer additional documentation or information pertaining to this concern when asked.

Based on observation, interview, and record review, the facility failed to: 1. Properly date-label food in the walk-in cooler and walk-in freezer; 2. Adequately clean surfaces in the kitchen; 3. Consistently ensure the dish machine was operating properly; and 4. Maintain cleanable wall surfaces near the dish machine. These deficient practices had the potential to affect all the residents who consumed from the kitchen resulting in the potential for food-borne illness. Findings include: During tours of the kitchen beginning on 9/9/25 at 8:30 AM with Dietary Manager (DM) G the following was observed: Inside the walk-in cooler a plastic container of feta cheese was dated 8/9/25. DM G stated the opened cheese should be thrown out in seven days. There was an open and undated bag of cinnamon raisin bread. Inside of the walk-in freezer the following items were opened and undated: a bag containing four individual size cheese pizzas and a bag of sausage patties. The stove drip tray was soiled with dried and burnt food debris. DM G said the drip tray was supposed to be cleaned on Sunday. DM G added, I doubt that it was cleaned (yesterday). DM G indicated the dish machine used sodium hypochlorite (a bleach used as a disinfectant) to sanitize dishware and other kitchenware processed through the dishwashing unit. DM G said they use a chlorine test strip to test the dish machine for proper sanitization of the dishware once a week. When the dish machine sanitizing log was requested, none was available. Sections of the walls surrounding the dish machine were observed to be missing tiles. The exposed surfaces were not smooth. Approximately ten square wall tiles, measuring approximately 4 x 4 each, were missing. On 9/10/25 at 3:36 PM, Certified Dietary Manager (CDM) I, who worked at another building but oversees the kitchen operation of the facility being surveyed, incorrectly stated that the facility's dish machine used quaternary ammonium to sanitize dishware. CDM I confirmed and agreed with DM G that the dish machine was tested for proper sanitization once weekly. CDM I stated that if the dish machine was not tested prior to each use that we don't have a guarantee that it was properly sanitizing the dishware. CDM I acknowledged that the walls with missing tiles were not easily cleanable. On 9/11/25 at 11:42 AM, the Regional Director of Operations said opened food items should be dated. According to the 2013 FDA Food Code:Section 3-101.11, Safe, Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under S 3-601.12, honestly presented. Section 4-204.117 Warewashing Machines, Automatic Dispensing of Detergents and Sanitizers. (B) Incorporate a visual means to verify that detergents and sanitizers are delivered.Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Section 4-602.13, Nonfood-Contact Surfaces, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Section 6-201.11 Floors, Walls, and Ceilings. Except as specified under S 6-201.14 and except for antislip floor coverings or applications that may be used for safety reasons, floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable.

Based on interview and record review, the facility failed to ensure proper use of the legally protected professional designation of Registered Dietitian. Findings include:On 9/9/25 at 3:00 PM, the facility provided survey prep book was examined and revealed that dietitian H was listed as the Registered Dietitian (RD) that worked at the facility. However, the RD credentials available in the survey prep book were for RD J. On 9/9/25 beginning at 3:49 PM the Regional Director of Operations (RDO) D was interviewed about dietitian H. RDO D acknowledged that dietitian H was not a Registered Dietitian, but RD J, who worked at another building, was a Registered Dietitian and supervised dietitian H. RDO D added that RD J does not have to be physically in the building and It has never been a problem before. On 9/9/25 at 4:05 PM during an interview, Human Resources (HR) K said that dietitian H completed a Coordinated Undergraduate Program at a local university September 2018 but had not obtained Registered Dietitian status. HR K stated, 100% I would know if she obtained a RD status. On 9/10/25 at 4:08 PM during an interview, RD J said Registered Dietitians are certified through the Commission on Dietetic Registration (CDR). RD J said she oversees the work that dietitian H performs at the facility. RD J said dietitian H completed a dietetic program, but she had not been certified as a registered dietitian. RD J said she was aware that dietitian H was using RD credentials but did not have the authority to use them. RD J acknowledged that she cannot impart her credentials on anyone and that the CDR was the organization that grants permission for an individual to use RD credentials. On 9/11/25 at 8:33 AM, dietitian H said she was eligible to become a RD and has been using RD credentials for six years but never put thought into if this was a concern. On 9/11/25 at 11:37 AM, RDO D said dietitian H was put into the electronic health record (EHR) computer system as a RD, but that designation was in the process of being corrected. The following dietary progress notes, designated with an electronic signature of RD H (signifying a legally recognized confirmation of accountability), for the following residents were reviewed on 9/9/25 at 3:30 PM:- R8. Dietary note written on 9/2/25.- R17. Dietary note written on 2/13/25- R22. Dietary note written on 9/2/25.- R43. Dietary note written on 8/1/25. On 9/11/25 at 1:10 PM, the electronic signature for the dietary notes referenced above had been changed to RD-EC for dietitian H. On 9/11/25 at 1:26 PM, dietitian H reported that RD-EC refers to Registered Dietitian-Exam Candidate. On 9/11/25 at 1:30 PM, Representative L from the CDR reported that Registered Dietitian-EC was not a standard, recognized credential by the CDR. The RD credential stands alone for those who earned it and cannot be modified or used for those who have not earned it. Representative L provided the following link related to misuse of RD credentials: https://www.cdrnet.org/use-misuse. The CDR affirmed that only individuals who have met the academic and professional requirements, completed supervised practice, and passed the national registration examination administered by the Commission on Dietetic Registration (CDR) can use the Registered Dietitian (RD/RDN) credentials. These credentials are legally protected designations, meaning they cannot be used by anyone without meeting the specific standards set by the CDR.

Based on observation, interview, and record review, the facility failed to ensure consistent proper working order of the walk-in freezer and that the drain line from the commercial ice machine was protected against contamination from sewage or other sources of contamination. These deficient practices had the potential to affect all residents that eat from the kitchen. Findings include:During the initial tour of the kitchen on 9/9/25 at 8:30 AM with Dietary Manager (DM) G the following was observed:- The internal temperature of the walk-in freezer was 11 F (Fahrenheit). The temperature documented on the freezer temperature log, obtained earlier in the day, was 5 F. A four-ounce cup of ice-cream stored in the freezer was observed soft, not frozen solid. DM G said the temperature in the freezer should be zero or below. DM G added that there was a leak in the freon line, and they have been refilling it.- The drain line from the commercial ice machine was observed to not have an airgap (an unobstructed vertical space between the end of the ice machine drain line and the flood rim of the floor drain). DM G said if water backed up from the floor drain, the water could contaminate the ice machine. On 9/11/25 at 11:42 AM, the Regional Director of Operations said kitchen staff should have notified maintenance if the freezer was not operating correctly, and acknowledge a deficiency with the air gap. A review of the 2013 FDA Food Code revealed the following:- Section 3-501.11. Stored frozen foods shall be maintained frozen.- Section 5-402.11. Backflow prevention. Except as specified in paragraph (B), (C), and (D) of this section, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed.

Based on observation, interview, and record review the facility failed to follow the standard of practice for transcribing physician's orders for one (R47) of seven residents reviewed for medication administration resulting in R47 missing nine doses of a multivitamin. Findings include:During observation of medication administration for R47 on 9/10/25 at 8:37 AM with Registered Nurse (RN) C, R47 did not receive a Multi-Vitamin (MVI) with minerals. According to R47's Electronic Health Record (EHR) the physician ordered MVI with minerals once a day on 8/18/25. A review of the R47's Medication Administration Record (MAR) for 9/2025 revealed the order for 'MVI with minerals once a day', did not get transcribed on the September 2025 MAR. On 9/10/25 at 9:56 AM, the Director of Nursing (DON) reviewed R47's EHR and confirmed that R47 and was supposed to get MVI w minerals once a day as of 8/18/25. The DON said the resident had not received the MVI with minerals since 8/31/25 because that order (MVI with minerals once a day) did not get transcribed onto 9/2025 MAR. The DON said the physician's prescription order was accidentally placed under the wrong category in 9/2025 and did not get transcribed on R47's MAR. The DON confirmed that R47 had missed 9 days of the MVI with minerals: 9/1/2025 - 9/09/2025. According to the facility's undated Medication Administration policy: Procedure:3. Medications must be administered in accordance with the orders, including any required time frame.

Based on observation, interview, and record review the facility failed to have a medication error rate below 5%.During the medication administration task three errors were observed from 28 opportunities and subsequently a 10.4% medication error rate. #1. On 9/10/25 at 9:19 AM, Registered Nurse (RN) C was observed to administer R28 medications at the bedside. RN C proceeded to sign out all the medications that were administered. R28 did not receive Ozempic 2 milligram (mg)/3 milliliter (ml)give 0.5 ml subcutaneous injection. Upon inquiry RN C confirmed all the resident's medications were given. R28's Medication Administration Record (MAR) was reviewed with RN C, and they were asked about the Ozempic prescription. RN C said, Oh, was that supposed to be given today? Yes, I should have given that. Its every Wednesday. Today is Wednesday. According to R28's Electronic Health Record (EHR) on 3/5/25 the physician prescribed Ozempic (2mg/3 ml) administer 0.5 ml subcutaneous once a day on Wednesdays. R28's MAR accurately documented the physician's order for the Ozempic every Wednesday.#2. On 9/10/25 at 8:10 AM Registered Nurse (RN) B was observed to administer R47 medications at the bedside. RN B proceeded to sign out all the medications that were administered. R47 did not receive Eliquis 5 milligrams (mg). Upon inquiry RN B confirmed all the resident's medications were given. R47's Medication Administration Record (MAR) was reviewed with RN B, and they were asked about the Eliquis prescription. RN B said, Yes, that should have been given. It wasn't in the medication cart at the time I was passing meds. According to R47's Electronic Health Record (EHR) on 8/24/25 the physician prescribed Eliquis 5 mg twice a day 9:00 AM and 9:00 PM. R47's MAR accurately documented the physician's order for the Eliquis 5 mg twice a day. #3. During reconciliation of R47's Medication Administration it was determined the resident had not received a multi-vitamin with minerals since 8/31/25. According to R47's Electronic Health Record (EHR) the physician ordered MVI with minerals once a day on 8/18/25. A review of the R47's Medication Administration Record (MAR) for 9/2025 revealed the order for 'MVI with minerals once a day', did not get transcribed on the September 2025 MAR. R47 had not received the multi-vitamin since 8/31/25 and missed 9 doses. On 9/10/25 at 9:56 AM the Director of Nursing (DON) reviewed R47's EHR and confirmed that R47 and was supposed to get MVI w minerals once a day as of 8/18/25. The DON said the resident had not received the MVI with minerals since 8/31/25 because that order (MVI with minerals once a day) did not get transcribed onto 9/2025 MAR. The DON said the physician's prescription order was accidentally placed under the wrong category in 9/2025 and did not get transcribed on R47's MAR. The DON confirmed that R47 had missed 9 doses of the MVI with minerals: 9/1/2025 - 9/9/2025. Procedure:3. Medications must be administered in accordance with the orders, including any required time frame.

Based on interview and record review the facility failed to transmit Minimum Data Set (MDS) assessments for three (R15, R17, and R29) of six residents reviewed for resident assessments in a timely manner. Findings include: On 9/10/25 at 3:05 P.M. Registered Nurse (RN)/ MDS Coordinator M, was queried regarding the MDS submissions to CMS. RN M said that she completes the MDS assessments and then puts them in a 'batch' to be sent to MDS. RN M said that she has to obtain a code from the Corporate Director of Operations, RN D. RN M said the following resident's MDS assessments are completed but in batched status and had not been sent or accepted by CMS at this time. We usually send them all at the same time to CMS. Usually twice a month. 1. R15's quarterly MDS assessment dated [DATE] was in 'batch status', due for submission on 8/21/25 but had not been submitted. 2. R17's quarterly MDS was dated 8/9/25 was in 'batch status', due for submission on 8/23/25 but had not been submitted. 3. R29's quarterly MDS was dated 8/7/25 was in 'batch status', due for submission on 8/21/25 but had not been submitted. On 9/11/25 at approximately 12:00 PM, RN D said that RN M could obtain their own code to submit MDS assessments to CMS and was unsure why that had not been done. RN D said it was the facility's expectation that MDS assessments be submitted timely and in accordance with CMS regulations.

This citation pertains to MI001221903.Based on observation, interview, and record review, the facility failed to ensure that a call button was within reach for one resident (R110) out of four residents reviewed for call light access.Findings include: It was reported to the State Agency that residents' call lights were placed out of reach.On 7/16/25 at 3:05 PM, R101 was observed sitting in her wheelchair in her room. R101 was heard calling for help. R101 stated, I'm hurting, and I need to get in bed.On 7/16/25 at 3:06 PM, Activity Aide (AA) H entered R101's room and stated, (R101) likes to lay down. R101's call button was positioned approximately three feet from where R101 was sitting in her wheelchair. AA H said that R101 was not able to reach her call light.On 7/16/25 at 3:40 PM, the Director of Nursing (DON) joined the Surveyor in R101's room. R101 was observed sitting in her wheelchair but no longer stated she was in pain and needed to get in bed. The call light remained approximately three feet from where R101 was sitting in her wheelchair. The DON stated, The call light was not within her reach.A review of the clinical record for R101 documented an admission date of 12/7/24 and readmission date of 6/16/25. R101's diagnoses included chronic obstructive pulmonary disease, hemiplegia and hemiparesis, muscle weakness, and difficulty in walking. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment and the use of a wheelchair for mobility. Record review of R101's risk for fall care plan, dated 6/16/25 documented, Keep call light in reach at all times while I am in my room.A review of the facility policy titled, Answering the Call Light, dated 3/10/2010, documented When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.On 7/17/25 at 12:45 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information when asked.

This citation pertains to MI1221903.Based on observation, interview, and record review, the facility failed to ensure the Unit 300 shower room was maintained in a clean and sanitary manner, resulting in the residents' environment not being homelike and the potential for spread harmful pathogens. Findings include:It was reported to the State Agency that the facility was not maintained clean and sanitary.On 7/16/25 at 2:54 PM, observations of two shower stalls located in a Unit 300 shower room were made with Certified Nurse Aide (CNA) G. A wet, used face cloth and gloves were on the floor of the shower stall typically used with a shower chair. On the floor of the shower stall typically used with a shower gurney was a used patient gown and two wet used face cloths. CNA G said she was at the end of her shift and neglected to clean the shower. CNA G said the shower rooms should not have been left that way.On 7/17/25 at 11:53 AM, the Director of Nursing (DON) said approximately 18 residents use the shower room on Unit 300. The DON said staff were supposed to clean the shower room after every shower for infection control purposes. Used linen should be placed in a bag and put in the soiled utility room.A review of the facility policy titled, Showers, dated 9/2018, documented in part the following:- Pick up all towels, bath cloths, soiled clothing, etc. Discard in the soiled laundry container inside the bath area. (Note: Laundry/linen soiled with visible blood should be discarded in a biohazard container [e.g., red bags].) - Clean equipment used. Use a disinfectant solution.On 7/17/25 at 12:45 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information when asked.

Based on interview and record review the facility failed to obtain and address Medication Regimen Review (MRR) recommendations timely for two residents (R3 and R12) of five residents reviewed for medication regimen review, resulting in the potential for the continuance of unnecessary medications and lack of communication of recommended medication changes between pharmacist and physician. Findings include: R12: On 8/24/24 at 11:14 a.m. review of the clinical record documented R12 was admitted into the facility on [DATE] with diagnoses that included diabetes mellitus, type 2, acute respiratory failure with hypoxia, congestive heart failure, dementia, and asthma. According to the quarterly Minimum Data Set (MDS) dated [DATE], R12 had moderate cognitive impairment and dependent for most activities of daily living. Review of R12's physician orders documented the resident's current medications as follows: - Basaglar Kwik Pen U-100 Insulin (insulin glargine) 100 unit/mL (3 mL) inject 33 units subcutaneous daily. Start date 8/13/24. - Insulin Aspart U (Novolog)-100 unit/ml inject 8 units subcutaneous twice a day. Start date 7/12/24. - Metformin 1000 mg oral twice a day. Start date 6/6/24. Review of monthly pharmacy recommendations in the electronic medical record documented the following: -3/19/24- Pharmacist Drug Regimen Review . Please take the following action described below . See report: Note to Attending Physician/Prescriber: This resident is currently on a sliding scale coverage with Novolog insulin. Recent AGS Beers Criteria suggest avoiding the use of a sliding scale insulin due to the risk of hypoglycemia without improvement in hyperglycemia management. Please evaluate if this patient may benefit from the addition of a long-acting insulin or an increase in their current medications. If the sliding scale insulin is continued, please provide documentation to support therapy. Response: 1. Change sliding scale Insulin to . 2. Continue sliding scale insulin. The benefits outweigh the risks. The Physician/Prescriber Response was blank. There was no documented response from the facility. -4/2/24- Pharmacist Drug Regimen Review. There was no Recommendation made by facility. -5/6/24- Pharmacist Drug Regimen Review. There was no Recommendation made by facility. On 8/28/24 at 2:05 p.m. the Director of Nursing (DON) submitted an email from the pharmacist dated 8/28/24 at 1:33 p.m. the pharmacy recommendation for 3/19/24 was attempted to be updated in the electronic medical record. The DON said the recommendation had not been addressed because it was missed. 22349 R3: According to R3's Electronic Health Record (EHR) the resident admitted to the facility with multiple diagnoses that included Intellectual Disabilities and altered Mental Status. The Pharmacist's Drug Reviews dated 5/6/24 and 7/2/24 indicated there were pharmacy recommendations and documented; Please take the following action described below. There was no further documentation to describe the recommendation of action from the Pharmacist. On 8/28/24 at approximately 1:00 PM the Director of Nursing (DON) was asked where the Pharmacist's recommendations for R3 were. The DON reported that they were located in an office and were not part of the clinical record. The DON could not produce or determine what the pharmacist's recommendations on 5/6/24 or 7/2/24 for R3 were at this time. On 8/28/24 at 3:30 PM the Regional Director of Operations (RDO) said the facility could not locate the actual Pharmacist's recommendations and the pharmacy was requested to fax them over to the facility. The RDO said, The Pharmacist reports and recommendations should be part of the resident's medical record and the physician should be notified of them. On 8/29/24 at 9:00 AM the DON provided R3's pharmacy recommendations for 5/6/24 and 7/2/24. The pharmacy recommendation for 5/6/24 did not have any notation or signature by the physician or a physician extender to indicate they had been notified of the recommendations. Review of the facility's policy titled, Pharmacy Medication Review revision date 8/2021 documented in part the following: Guidelines: 1. The MRR should be conducted by a pharmacist with specialized training and clinical expertise to perform medication reviews. 2. The Medical Records Designee is responsible to the Director of Nursing for maintaining the Medical Records program. 3. The intent of a MRR is to address any clinically significant medication issues in a timely manner. Procedure: 1. The MRR will be completed by a pharmacist on a monthly basis and as needed or required. 2. The pharmacist will submit a recommendation for each resident reviewed. 3. The recommendation will be submitted via email to the Director of Nursing (DON) and the Medical Records Designee within 48-72 hours of the review. 4. The Medical Records Designee will place all pharmacy recommendations on the attending physician's clipboard for review. 5. The physician/physician extender may agree or disagree with the pharmacy recommendation and must sign off on all recommendations. Once the pharmacy recommendation has been signed, a medication order must be created and added to the resident's Medication Administration Record (MAR), once the order is added the document should be returned to the attending physician ' s clipboard to be uploaded into the resident's EHR, by the Medical Records Designee. The Physician is required to provide a rationale for not agreeing with any pharmacy recommendations, and the rationale must be documented in a progress note or on the pharmacy recommendation 7. The Medical Records Designee is responsible for reporting any discrepancies/concerns to the DON and/or Medical Director in a timely manner, all emergency matters should be reported immediately. 8. The DON is responsible for overseeing the Pharmacy Recommendation process and reporting any discrepancies/concerns to the Medical Director and Administrator.

Based on interview and record review, the facility failed to maintain complete and accurate medical records for two (R3 and R12) of 15 residents reviewed for medical records, resulting in resident's pharmacy recommendations being unclear and not maintained in the resident's Electronic Health Record (EHR) with the potential for miscommunication of pharmacy recommendations, physician's orders, and an unclear picture of the resident's health care status. Findings include: R3: According to R3's Electronic Health Record (EHR) the resident admitted to the facility with multiple diagnoses that included Intellectual Disabilities and altered Mental Status. The Pharmacist's Drug Reviews dated 5/6/24 and 7/2/24 indicated there were pharmacy recommendations and documented; Please take the following action described below. There was no further documentation to describe the recommendation of action from the Pharmacist. On 8/28/24 at approximately 1:00 PM the Director of Nursing (DON) was asked where the Pharmacist's recommendations for R3 were. The DON reported that they were located in an office and were not part of the clinical record. The DON could not produce or determine what the pharmacist's recommendations for R3 were at this time. On 8/28/24 at 3:30 PM the Regional Director of Operations (RDO) said the facility could not locate the actual Pharmacist's recommendations and the pharmacy was requested to fax them over to the facility. The RDO said, The Pharmacist's reports and recommendations should be part of the resident's medical record. According to the facility's Pharmacy Medication Review policy last revised 8/2021 in part reads; Purpose: The purpose of a Pharmacy Medication Regimen Review (MRR) is to identify Medication-related problems and to provide a safe and effective medication treatment plan for all residents. Pharmacy recommendations will provide guidance to the interdisciplinary team and a thorough evaluation of the medication regimen for each resident, with the goal of promoting positive outcomes and minimizing adverse consequences related to medications. The review should include preventing, identifying, reporting, and resolving medication-related problems, medication errors, or other irregularities as well as collaboration with other members of the interdisciplinary team. Procedure: 5. The physician/physician extender may agree or disagree with the pharmacy recommendation and must sign off on all recommendations. Once the pharmacy recommendation has been signed, a medication order must be created and added to the resident ' s Medication Administration Record (MAR), once the order is added the document should be returned to the attending physician ' s clipboard to be uploaded into the resident ' s EHR, by the Medical Records Designee. The Physician is required to provide a rationale for not agreeing with any pharmacy recommendations, and the rationale must be documented in a progress note or on the pharmacy recommendation. 38230 R12: On 8/24/24 at 11:14 a.m. review of the clinical record documented R12 was admitted into the facility on [DATE] with diagnoses that included diabetes mellitus, type 2, acute respiratory failure with hypoxia, congestive heart failure, dementia, and asthma. According to the quarterly Minimum Data Set (MDS) dated [DATE], R12 had moderate cognitive impairment and dependent for most activities of daily living. Review of monthly pharmacy recommendations in the electronic medical record documented the following: 3/19/24- Pharmacist Drug Regimen Review . Please take the following action described below . See report. 6/4/24- Pharmacist Drug Regimen Review . Please take the following action described below . See report. The pharmacy recommendation reports were not readily available in the electronic medical record and the facility had to search for them. On 8/28/24 at 2:05 p.m. the Director of Nursing (DON) submitted an email from the pharmacist dated 8/28/24 at 1:33 p.m. for the pharmacy recommendation dated 3/19/24 that read an attempt was made to update in the electronic medical record.

Based on observation, interview, and record review the facility failed to practice proper infection control techniques for one (R4) of one resident reviewed with enhanced barrier precautions, resulting in the potential for widespread infection. Findings include: 08/28/24 at 2:15 PM, R4 was observed to be returned to bed for brief changed and wound care. Registered Nurse, (RN) O and Certified Nursing Assistant, (CNA) S were observed to perform care on R4 without wearing a gown. Review of R4 Electronic Medical Record, (EMR) noted an admitted to the facility on [DATE] with a pertinent diagnosis of Stage II to buttocks. R4's Brief Interview of Mental Status, (BIMS) score was 14/15 (intact cognition). 08/28/24 at 2:25 PM, RN O was interviewed and acknowledged staff should have been wearing a gown. Unit Manager, UM R was interviewed and added there was a sign on the door and the staff should have been wearing a gown when performing change of brief as well as wound care.

This citation pertains to Intake MI00138801. Based on interview and record review, the facility failed to seek timely medical evaluation of an injury of unknown origin for one resident (R102), out of three residents reviewed for falls, resulting in the potential for delay in the provision of resident care needs. Findings include: The State Agency received a complaint that the resident fell , and the facility failed to seek timely medical evaluation and treatment. A review of Resident #102's (R102) clinical record documented an admitted [DATE]. R102's diagnoses included Alzheimer's Disease, Atrial Fibrillation, and Diabetes Mellitus-Type 2. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. A review of R102's care plans documented resident was at risk for falls due to muscle weakness and diagnosis of dementia with a start date of 7/20/2023. A review of nursing notes documented the following: - Date/time: 8/3/2023 at 4:48 AM: Resident was pleasant and cooperative with staff. All medications administered as ordered. Resident observed walking in the hall at 4:00 AM, was naked from the waist down. CNA (Certified Nurse Aide) went and retrieved a brief, bottoms, and socks for him. Upon putting the garments on resident, CNA called me to come look at resident's skin. Resident has purple bruising that encompasses his left buttocks and down the back of his left leg to behind his knee. Resident does not remember falling or how the bruising occurred. Continue with current POC (plan of care) and monitor skin. - Date/time: 8/3/2023 at 3:49 PM: Resident has c/o (complaint of) waist and left hip pain 5/10 while wife in room. Wife is aware of the bruise on this resident. Purple bruising in his left buttocks and down the back of his left leg to behind his knee reported to (R102's Physician), ordered to transfer resident to (local hospital emergency room ) for further evaluation and treatment as resident is on (apixaban: a blood thinner that reduces blood clotting). Resident does not remember falling or how the bruising occurred. (Medical transportation) called, awaiting pick up. Endorsed to assigned nurse to follow-up at this time. A review of a facility document titled, Staff Statement of Event, dated 8/3/2023, CNA M acknowledged the following: On Wednesday, 8/2/2023 during 3p - 11p shift, I gave shower to (R102). I saw a big bruise around his butt and thigh (bottom). Asked him if he fell . He answered No. What happened? He did not know. I reported to the nurse (Nurse N) about it. An interview and record review were conducted with Registered Nurse (RN) C on 9/11/2023 at 3:47 PM. RN C was designated as the Charge Nurse in the absence of the Director of Nursing (DON). A review of R102's clinical record and witness statements documented that on the afternoon shift of 8/2/2023, CNA M observed a bruise on R102's body and reported it to the nurse. RN C said that when the nurse knew about R102's bruises that she should have called and notified the doctor, DON, and family, obtained an order for a stat x-ray, and told R102 to stay in bed to potentially prevent further injury. RN C stated, It's not good that they waited that long, because if he had broken his hip, he could have fallen again. There is no reason (R102) should have had to wait until the next day to get an x-ray. Record review revealed the DON created a stat x-ray order on 8/3/2023 at 3:19 PM of R102's right and left hip and lumber spine related to pain. During an interview on 9/11/2023 at 4:28 PM, the Nursing Home Administrator (NHA) acknowledged there was a delay in the initiation of an assessment of R102's bruising. The nurse should have reported it to the physician to see how to proceed. On 9/11/2023 at 5:45 PM, during the exit conference, the NHA was asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and no substantially new information was provided.

Based on interview and record review, the facility failed to dispose of expired medications in one of two medication carts and two of two medication rooms reviewed, resulting in the potential for decreased medication efficacy and adverse side effects in a current facility census of 34 residents. Findings include: On 8/8/23 at 8:49 AM, Station 3 Medication Room was reviewed in the presence of Director of Nursing (DON) B. During the review, it was noted that the medication refrigerator within the medication room contained a Tuberculin Purified Protein Derivative box with a handwritten open date of 7/6/23. An open, undated Tuberculin vial was noted within the box. DON B confirmed the 7/6/23 open date indicated on the box, stated that Tuberculin was good for thirty days after opening, and therefore would have expired on 8/5/23 and would be disposed of immediately. Station 1 Medication Room was reviewed, also in the presence of DON B, immediately following Station 3 review with a second Tuberculin Purified Protein Derivative box with a handwritten open date of 7/6/23 and an open, undated Tuberculin vial within noted. DON B again confirmed the 7/6/23 open date, reiterated that it was also expired, and would be disposed of. On 8/8/23 at 9:17 AM, Station 1 Medication Cart was reviewed in the presence of Licensed Practical Nurse (LPN) L. During the review, a Fluticasone Propionate-Salmeterol Inhaler (Advair HFA) was noted with a pharmacy label reflecting R8's name and a handwritten open date of 5/10/23 on both the opened box and the inhaler. LPN L confirmed that R8 had an active order for the Advair Inhaler, stated that she was not positive how long the inhaler was good for after opening, but would be disposing of the current inhaler and ordering a new one from the pharmacy. Review of R8's medical record revealed an active order dated 4/24/23 for Fluticasone Propionate-Salmeterol Inhaler with twice daily administration. Review of the corresponding Medication Administration Record (MAR) dated 8/1/2023-8/31/2023, reflected twice daily administration on 8/1, 8/2, and 8/7 and once daily on 8/3, 8/4, 8/5, and 8/8. During the same Station 1 Medication Cart review in presence of LPN L, a Fluticasone Propionate Nasal Spray was noted with a pharmacy label reflecting R16's name and a handwritten open date of 5/11/23 on the box. An open, undated nasal spray bottle was noted within the box. LPN L confirmed that R16 had an active order for the nasal spray and although she did not know how long the nasal spray was good for after opening, would be disposing of the open bottle. An unopened bottle of Fluticasone Propionate Nasal Spray with a pharmacy label reflecting R16's name was noted within the medication cart. Review of R16's medical record revealed an active order dated 6/5/23 for Flonase Allergy Relief (Fluticasone Propionate) Nasal Spray with daily administration. Review of the corresponding MAR dated 8/1/2023-8/31/2023 reflected daily administration from 8/1/23 - 8/8/23. Additionally, during the same Station 1 Medication Cart review, a Fluticasone Propionate Nasal Spray was noted with a pharmacy label reflecting R11's name and a handwritten open date of 4/28/23 on both the box and nasal spray bottle. LPN L confirmed that R11 had an active order for the nasal spray, reiterated that she was uncertain how long the opened nasal spray was good for, but would be disposing of and ordering a new bottle from the pharmacy. Review of R11's medical record revealed an active order dated 5/17/23 for Flonase Allergy Relief (Fluticasone Propionate) Nasal Spray with twice daily administration. Review of the corresponding MAR dated 8/1/2023-8/31/2023 reflected twice daily administration 8/1/23-8/6/23 and the morning dose on 8/7/23. In an interview on 8/8/23 at 9:42 AM, DON B stated that she was unsure of how long both the Fluticasone Nasal Spray and Advair Inhaler were good for after opening but would check the facility policy for that information. DON B further stated that it was an expectation that every nurse monitor expiration dates prior to that medications administration and dispose of accordingly and that the night shift nurse routinely completed medication cart audits to double check that medications remained within the expiration date. Review of the facility policy titled Storage of Medications with an effective date of 9/2018 stated, Policy Statement .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .Policy Interpretation and Implementation .4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .a. The nursing staff will date all inhalers, eye drops, ointments, nasal sprays, and insulin immediately after opening b. Medication is expired after the last day of the designated time frame for each medication .Inhalers-30 days from date of opening or manufacturers expiration date, whichever comes first .Nasal Sprays .30 days from date of opening or manufacturers expiration date, whichever comes first .

Based on observation, interview, and record review the facility failed to develop and implement comprehensive care plans for 7 (Resident #6, #9, #16, #35, #139, #188, and #189) of 12 reviewed resulting in the potential for unmet care needs. Findings include: Resident #35 (R35) Review of the medical record revealed R35 admitted to the facility on [DATE] with diagnoses that included fracture of the left shoulder, muscle weakness, multiple myelomoa, and pain. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/10/23 revealed R35 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Review of R35's care plans revealed an intervention dated 5/17/23 for Physical Therapy for 12 weeks and Occupational Therapy for 09 days. An intervention dated 5/12/23 revealed R35 was doing exercises with restorative. In an interview on 08/08/23 at 08:25 AM, Certified Occupational Therapy Assistant (COTA) O reported R35 was not receiving therapy services, and he believed R35 was receiving restorative services. COTA O reported R35 was evaluated by therapy on 5/17/23, but insurance would not cover skilled services. In an interview on 08/08/23 at 11:03 AM, Director of Nursing (DON) B reported R35 was not on restorative services. Review of the Physician's Order dated 5/16/23 revealed R35 had an order for Cymbalta for major depressive disorder. R35's care plans did not mention that he had major depressive disorder or that he was utilizing a psychotropic medication. Resident #139 (R139) Review of the medical record revealed R139 admitted to the facility on [DATE] with diagnoses that included heart failure, hypertension, diabetes, Parkinson's Disease, stage 4 pressure ulcer, and osteomyelitis of vertebra sacral and sacrococcygeal region. On 8/7/23 at 10:25 AM, incontinence care and wound care were observed for R139. R139 had a stage 4 pressure ulcer present on her coccyx. R139 had a wound vac. Review of R139's care plans revealed there was no mention of a stage 4 pressure ulcer or wound vac. In an interview on 08/08/23 at 2:48 PM, Licensed Practical Nurse (LPN) P reported she was the facility's wound nurse. LPN P reported R139 had a stage 4 pressure ulcer and a wound vac. LPN P agreed R139's pressure ulcer and wound vac were not care planned. 27306 Resident #16 (R16) According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] Resident 16 (R16) was an [AGE] year old male admitted to the facility with diagnoses that included heart peripheral vascular disease and diabetes. Review of MDS reflected R16 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status. Further review of the medical record including the monthly Physician orders reflected R16 was started on an anti-anxiety medication on as as needed basis on April 28, 2023 with no stop date. Review of R16's care plan dated 7/13/23 reflected R16's problem for the care plan was a diagnosis of anxiety with a goal of stabilize/improve mood and approaches were 1. appropriate referrals 2. encourage activities of interest. 3 explain all procedures of care calmly. 4. identify possible stressors to resident that need to be eliminated . 5. maintain medications as ordered. 6. Offer support and encouragement as needed. On 08/08/23 at 09:06 AM, during an interview with Social Worker/Activity Director C, R 16's care plan was reviewed and Social Worker/Activity Director C agreed it was not personal or individualized, such as what is an appropriate referral, what are R16's activities of interest, what are R16's triggers/stressors, what medications as ordered. 45038 Resident #6 (R6) Review of the medical record revealed R6 was admitted to the facility 05/04/2023with diagnoses that included compression fracture of T(thoracic) 6-T7 vertebrae, muscle weakness, age related physical disability, iron deficiency anemia, pain, hypertension, gastro-esophageal reflux, chronic kidney disease, hypokalemia (low potassium), hypomagnesaemia (low magnesium), anxiety, depression, bipolar disorder, stage 3 pressure ulcer of left buttock, protein-calorie insufficiency, atherosclerosis (cholesterol plaque in the walls of arteries), hyperlipidemia (high fat amount in blood), and chronic obstructive pulmonary disease (COPD). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/21/23, revealed R6 Brief Interview of Mental Status (BIMS) was not completed as resident is rarely understood. Section M-Skin Conditions, with the same ARD, demonstrated that R6 had unhealed pressure ulcers. Review of the medical record revealed wound progress notes, dated 05/09/2023 at 03:22 p.m., that demonstrated, Coccyx with stage 2 open area that measures 1.0 cm (centimeters) length by 0.2 cm width, pink base, scant serosanguinous drainage. Review of R6's plan of care did not demonstrate that she had a pressure wound to her coccyx. In an interview on 08/08/2023 at 01:11 p.m. Licensed Practical Nurse (LPN) P explained that R6 had a stage 2 pressure wound to her coccyx upon admission. LPN P explained that she was the facility wound nurse at the facility. LPN P explained that it was her responsibility to care plan all resident wounds. LPN P could not demonstrate that a plan of care for R6's coccyx wound had been initiated. LPN P could not explain why a care plan of R6's coccyx wound had not been initiated. During observation and interview on 08/08/2023 at 03:23 p.m. R6 was observed lying down in bed. R6 explained that the nursing staff was going to complete her dressing change. R6 could not explain what wounds were present. During the observation of LPN P removing R6 coccyx dressing, it was observed that R6 coccyx pressure wound was healed. Resident #188 (R188) Review of the medical record revealed R188 was admitted to the facility 12/01/2022 with diagnoses that included displaced fracture of shaft left femur, muscle weakness, multiple sclerosis, pain, hypertension, hyperlipidemia (high fat content in blood), fracture of left calcaneus (heel bone), paraplegia (paralysis of legs and lower body), type 2 diabetes, vitamin deficiency, and constipation. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/12/2023, revealed R188's Brief Interview of Mental Status (BIMS) was 12 (mildly impaired cognition) out of 15. R188 was discharged from the facility 04/03/3023. During review of R188 medical record demonstrated that R188 was discharged the hospital on 01/20/2023 and readmitted to the facility 1/27/23. R188 medical record demonstrated that she was readmitted with an unstageable pressure ulcer to her coccyx that measured 7.0 centimeters (cm) in width by 7.0 cm in length. Review of R188's plan of care did not demonstrate that R188 had a pressure sore to her coccyx during her stay at the facility. Review of R188 care plan did not demonstrate that R188 had a pressure wound to her coccyx. In an interview on 08/08/2023 at 01:11 p.m. Licensed Practical Nurse (LPN) P explained that R188 had an unstageable pressure wound to her coccyx upon R118's return from the hospital. LPN P explained that she was the facility wound nurse at the facility. LPN P explained that R188's wound was healed by the time of discharge. LPN P explained that it was her responsibility to care plan all resident wounds. LPN P could not demonstrate that a plan of care for R188's coccyx wound had been initiated. LPN P could not explain why a care plan of R188's coccyx wound had not been initiated. Resident #189 (R189) Review of the medical record revealed R189 was admitted to the facility 07/13/2023 with diagnoses that included diabetes, hypertension, end stage renal disease, chronic obstructive pulmonary disease (COPD), muscle weakness, epistaxis, diarrhea, kidney transplant, asthma, constipation, arthritis, angina pectoris, atherosclerotic heart disease, breast cancer, hypothyroidism, hypertension, bipolar disorder, and kidney failure. During observation and interview on 08/08/2023 at 07:39 R189 was observed standing in the doorway of her room. Resident appeared well groomed. R189 explained that she received hemodialysis three times per week and demonstrated a dressing on her left arm that covered her dialysis port. During record review of R189's medical record demonstrated that she was to receive dialysis Monday, Wednesday, and Friday at a local dialysis center. Review of R189's care plan did not demonstrate that resident was receiving dialysis services. In an interview on 08/08/2023 at 10:19 a.m. Director of Nursing (DON) B reviewed R189's medical record and confirmed that R189 was to receive dialysis services. DON B explained that it was the expectation of the facility that dialysis services were to be included in a resident plan of care. DON B could not demonstrate that R189's plan of care included dialysis services. DON B could not explain why R189 did not have a care plan for dialysis services. 46955 Resident #9 (R9) Review of the medical record reflected that Resident #9 (R9) was readmitted to facility 4/28/23 with diagnoses including syncope and collapse, muscle weakness, Parkinson's Disease, Diabetes Mellitus, peripheral vascular disease, chronic anemia, and pulmonary fibrosis. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) Of 6/7/23 reflected that R9 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 14 (cognitively intact). Section G of the MDS indicated that R9 required one-person extensive assist for bed mobility and transfers, one-person limited assist for toilet use, and was independent with eating after set-up. Section M of the same MDS revealed that R9 was at risk for developing a pressure ulcer, had a pressure reducing device for bed and chair, but was not on a turning/repositioning program. In an observation and interview on 8/07/23 at 10:10 AM, R9 was observed in a bedside chair with back of chair reclined and legs elevated. R9 stated that he did not have control of his feces or urine and was incontinent of both bowel and bladder, that he had history of recurrent irritation to his bottom even prior to facility admission and that the staff put cream on his buttocks to protect the now intact skin. R9 also stated that although he had developed a sore on his left heel either at the hospital or at the facility, that area was now healed as well. Skin Treatments Progress Note dated 6/6/23 indicated that R9 and a Grade 1 Diabetic Ulcer (a superficial wound not involving tendon or bone) at left heel with subsequent 6/13/23, 6/21/23, and 6/27/23 notes reflecting gradual wound improvement. Review of R9's comprehensive care plans included no care plan to reflect that R9 was ever at risk for or had an actual impairment in skin integrity. In an interview on 8/08/23 at 1:12 PM, Licensed Practical Nurse/Wound Nurse (LPN/WN) P stated that she had been the facility's wound nurse for the past 4 years and that the facility's wound management program included an outside wound team as well. LPN/WN P stated that when a resident was admitted with a wound or when a wound developed within the facility, she would assess the wound either that day or the next day, would coordinate and review wound care orders with the physician, would initiate all needed precautions, and would formulate a care plan to reflect the alteration. During the same interview, LPN/WN P confirmed familiarity with R9, stated that he had developed a left heel wound after facility admission, physician assessed and diagnosed as a diabetic ulcer, treatment was implemented, wound was monitored weekly and was now healed, and a dry dressing remained in placed for protection. LPN/WN P stated that as R9 was at high risk for skin alterations upon facility admission, an at risk for skin alterations care plan should have been implemented and when R9 was diagnosed with a diabetic ulcer at his left heel, an actual alteration in skin integrity care should have been formulated to reflect. Upon review of R9's comprehensive care plans, LPN/WN P confirmed that R9 did not have an at risk or potential for alterations in skin integrity care plan implemented at facility admission nor was an actual alteration in skin integrity care plan formulated at the time of R9's left heel diabetic ulcer diagnosis. Furthermore, LPN/WN P confirmed that although R9 remained at risk for recurrent skin breakdown, he still did not have a care plan to reflect that risk nor the approaches the staff should have implemented and stated that she would be formulating the at risk care plan at that time. Review of the facility policy titled Care Planning - Interdisciplinary Team with an effective date of 9/2018 stated, Policy Statement .Our Facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident .Policy Interpretation and Implementation .1. A comprehensive care plan for each resident is developed within seven (7) days of the resident assessment (MDS) .2. The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team .

This citation pertains to Intakes MI00132462 and MI00135054. Based on observation, interview, and record review, the facility failed maintain sufficient staff for one (Resident #2) and Resident Council, resulting in extended call light response times and the potential for unmet care needs. Findings include: Review of the Resident Council minutes revealed on 2/21/21, 5/30/23, and 6/27/23, the Resident Council expressed concerns with call light response times. During a Resident Council meeting on 08/08/23 at 1:35 PM, five of the six residents responded when asked about staffing and call light response time. Four of the five residents who participated in the discussion expressed concerns with staffing and extended call light response times. The Resident Council participants reported waiting up to one hour for staff to respond to their call lights. They reported staff seemed rushed and did not have time to stop and ask if the residents needed anything. Resident #2 (R2) Review of the medical record revealed R2 admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, major depressive disorder, anxiety, and acquired absence of right upper limb. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/11/23 revealed R2 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) and was dependent on staff for activities of daily living. On 08/07/23 at 11:15 AM, R2 was observed lying in his bed. R2 reported he would like to get up in his wheelchair more often. R2 reported he informed staff earlier that morning that he wanted to get up, but staff had still not assisted him. On 08/08/23 at 09:33 AM, R2 was observed lying in bed. R2 reported he needed to have a bowel movement and had told staff earlier, but he had not heard back from staff yet. R2 then turned on his call light. Continuous observations until 10:10 AM revealed no facility staff were present on R2's end of the hallway. At 10:11 AM, a staff member answered R2's call light. The call light had been on for 38 minutes. In an interview on 08/09/23 at 08:51 AM, Director of Nursing (DON) B reported the expectation was that call lights were answered immediately.

Based on observation, interview and record review the facility failed to promptly make good faith attempts to resolve grievances for members of the Resident Council resulting in the potential for frustration and unmet care needs. Findings include: During a Resident Council meeting on 08/08/23 at 1:35 PM, six of six residents reported they did not know how to file a grievance or that it was an option to file a grievance. Resident Council participants reported communication in the building was poor. They reported if a concern was voiced, it was not addressed. Five of the six residents responded when asked about staffing and call light response time. Four of the five residents who participated in the discussion expressed concerns with staffing and extended call light response times. The Resident Council participants reported waiting up to one hour for staff to respond to their call lights. They reported staff seemed rushed and did not have time to stop and ask if the residents needed anything. One participant expressed there had been an ongoing concern with not receiving restorative therapy services. Review of the Resident Council minutes revealed on 2/21/21, 5/30/23, and 6/27/23, the Resident Council expressed concerns with call light response times. On 2/21/21, 4/18/23, 5/30/23, 6/27/23, and 7/28/23, the Resident Council expressed they would like restorative therapy. The facility's grievance log was requested on 8/7/23 during the entrance conference. The facility did not provide a grievance log prior to the survey exit. Grievances for the last 12 months were requested. The facility provided two Quality Concern Form-Action and four Resident Missing Item forms. The Quality Concern Forms were dated 3/17/23 and 6/2/23. The forms had a section for follow up and signature by the Nursing Home Administrator. Neither form had this section completed. Review of the Quality Concern Form-Action revealed the Resident Council concerns were not recorded on the forms. In an interview on 08/09/23 at 8:51 AM, Director of Nursing (DON) B reported Social Worker (SW) C was responsible for grievances. DON B reported if there were any nursing concerns, the nursing department would be notified. When asked if she was aware of Resident Council's concerns with call lights, DON B stated yes. When asked what was being done to resolve the concern, DON B reported the facility tried their best to address the concern with residents and let the residents know that staff might be in another room and not see their call light. DON B reported some residents were satisfied with that response. DON B reported she was also aware of Resident Council's concern with restorative therapy. When asked what was being done to resolve the concern, DON B reported the facility has put out job openings. DON B reported she was verbally notified of Resident Council concerns and that the concerns were not placed on a Quality Concern Form. DON B reported she had only ever witnessed one person use a Quality Concern Form. In an interview on 08/09/23 at 10:02 AM with Nursing Home Administrator (NHA) A and Regional Director of Operations (RDO) H, RDO H reported the facility's grievance form was not the same as a missing items form. When asked about the ongoing concerns from Resident Council, NHA A reported SW C distributed concerns to each responsible department by providing the Resident Council minutes. When asked how the grievances, follow-up, and resolutions were tracked, NHA A reported they usually reapproached and discussed by following up with managers. When asked about monitoring call lights, NHA A reported the facility tried to keep an eye on call lights but did not have any reports or audit tools. Regarding restorative therapy. NHA A reported the facility had hired multiple people into the position, but they have come and gone. NHA A reported the facility was continuously trying to hire for that position, but in the meantime, one staff member is coming in to assist and CNAs have been doing range of motion and ambulation during care. On 08/09/23 at 11:23 AM, when asked where the forms were located, DON B went behind the nurses' station and obtained a Resident Concern Form out of the filing cabinet. In an interview on 08/09/23 at 12:38 PM, SW C reported the Resident Concern form that was found at the nurses' station was not in use and that the facility used the Quality Concern Form. SW C reported Resident Council concerns were not placed on Quality Concern Forms. When asked how she tracked if Resident Council concerns were resolved, SW C reported she followed up at the next resident council meeting. SW C reported she had noticed that Resident Council had continuous concerns with call lights which was first mentioned to administration in February or March 2023.

Based on interview and record review, the facility failed to ensure the physician received, reviewed and acted upon identified medication regimen irregularities for four residents (Resident #9, 16, 17, and 35) of five reviewed for unnecessary medications, resulting in the potential for unnecessary medications and adverse reactions. Resident #16 (R16) According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] Resident 16 (R16) was an [AGE] year old male admitted to the facility with diagnoses that included heart peripheral vascular disease and diabetes. Review of MDS reflected R16 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status. Further review of the medical record including the Pharmacy reviews and revealed the Pharmacist had found irregularities and had made recommendations for the Physician on 5/07/23, 06/01/23 and 07/05/23 . Resident #17 (R17) According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] Resident 17 (R17) was an [AGE] year old female admitted to the facility with diagnoses that included heart failure and diabetes. Review of MDS reflected R17 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status. Further review of the medical record including the Pharmacy reviews and revealed the Pharmacist had found irregularities and had made recommendations for the Physician on 03/05/23, 5/07/23 and 06/01/23. On 08/07/23 at 03:40 PM, during an interview with the Director of Nursing (DON) B she reported she was not aware of where the pharmacy reports were located for R16 and R17 and would have to follow up. On 08/08/23 at 07:36 AM, DON B reported in an interview that she had to contact pharmacy and the would send the missing reports/recommendations for R16 and R17 later today. DON B stated the former Unit Manager was responsible for this task and has since resigned. DON B elaborated she did not see any progress notes or order changes that may coincide with pharmacy report dates, and could not account for what any of the pharmacists findings were. 32064 Resident #35 (R35) Review of the medical record revealed R35 admitted to the facility on [DATE] with diagnoses that included fracture of the left shoulder, muscle weakness, multiple myelomoa, and pain. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/10/23 revealed R35 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Review of the Physician's Order dated 5/16/23 revealed R35 had an order for Cymbalta for major depressive disorder. Review of the Pharmacist Drug Regimen Review dated 4/5/23 revealed see report under please take the following action described below. On 08/08/23 at 07:44 AM, Director of Nursing (DON) B was asked for the report for R35's medication regimen review on 4/5/23. On 08/08/23 at 11:16 AM, DON B reported she was not able to get the recommendation from the pharmacy yet and was still waiting for pharmacy to fax it to the facility. R35's medication regimen review recommendation from 4/5/23 was not received prior to the survey exit. 46955 Resident #9 (R9) Review of the medical record reflected that Resident #9 (R9) was readmitted to facility 4/28/23 with diagnoses including syncope and collapse, muscle weakness, Parkinson's Disease, Diabetes Mellitus, peripheral vascular disease, chronic anemia, and pulmonary fibrosis. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) Of 6/7/23 reflected that R9 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 14 (cognitively intact). Review of the medical record revealed Pharmacist Drug Regimen Reviews dated 3/5/23, 5/7/23, and 6/1/23 which indicated see report under please take the following action described below. Further review of R9's medical record included no scanned documents nor nursing or physician progress notes on or around the indicated dates to reflect that the recommendations were addressed by either a nurse or physician. In an interview on 8/8/23 at 3:43 PM, Director of Nursing (DON) B stated that a prior nurse manager had coordinated the completion of the monthly medication regimen reviews up until her resignation two weeks ago and that the manager would print and forward the recommendations to the nurse assigned to the resident for completion. DON B stated that the expectation was for that nurse to then review the recommendation with the physician and write an order and a corresponding nursing progress note to reflect any changes. Per DON B, the completed recommendation would then be signed by the physician and scanned into the electronic medical record. Upon review of both R9's electronic medical record and paper chart, DON B confirmed that the pharmacy reviews/recommendations could not be located within the scanned documents or paper chart, verbalized unawareness of where the reports were, and stated that she would have to contact the pharmacy for the prior recommendations. R9's medication regimen reviews dated 3/5/23, 5/7/23, and 6/1/23 were not received prior to survey exit. Review of the policy titled Organizational Aspects-The Consultant: Medication Regimen Review (Monthly Report) with an effective date of 3/1/2018 stated, The consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly .Findings and recommendations are reported to the director of nursing and the attending physician .H .Recommendations are acted upon and documented by the facility staff and or the prescriber .

Based on observation, interview, and record review, the facility failed to ensure accurate completion of advance directive information for 3 (Resident #23, #27, and #35) of 4 residents reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility. Findings include: Resident #27 Review of the medical record revealed that Resident #27 (R27) was admitted to the facility 11/21/2017 with diagnoses including major depressive disorder, pain, and difficulty in walking. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/13/23 revealed that R27 had clear speech, was understood by others, and was able to understand others. Section C of the same MDS revealed that R27 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 12 (moderately impaired cognition). In an observation and interview on 8/07/23 at 10:48 AM, R27 was observed sitting in wheelchair, in room, with right upper arm positioned at side, arm bent at elbow with right forearm and hand resting on abdomen. R27 was noted with delayed responses to questions but stated that she could not walk, needed staff help to get into her wheelchair, and had a difficult time feeding herself as my hands just don't work right. Review of R27's electronic medical record indicated a code status of DNR (Do Not Resuscitate. Review of advance directive information located within R27's paper chart included a document titled, ACKNOWLEDGEMENT OF RECEIPT ADVANCE DIRECTIVES/MEDICAL TREATMENT DECISIONS. Document reflected Do Not Resuscitate signed and dated by R27 on 12-01-2017. Both witness signature lines within the same form were noted to be blank. In an interview on 8/07/23 at 3:32 PM, Social Worker (SW) C stated that advance directive paperwork was completed upon admission with a resident who was capable of making his/her own medical treatment decisions, a guardian, or an activated power of attorney. SW C further stated that when a resident opted to be a DNR, a resident completed the facility's Advance Directives/Medical Treatment Decisions form to reflect and that form was then forwarded to the physician to review and sign. Per SW C, the facility did not have witnesses oversee and sign the resident's completion of the DNR form as stated that the facility policy indicated that the facility staff could not witness the completion of the form and therefore the DNR form was not witnessed by anyone. Additionally, SW C stated that the facility's current advance directive form was the same form that the facility had used for the last twenty six years and although the form contained two lines labeled Witness for witness signatures, the forms completion had never been witnessed. During the same interview, SW C confirmed familiarity with R27, stated that R27 continued to make her own medical treatment decisions, that she reviewed her code status with her at least quarterly, and that she had been and continued to be a DNR. Upon review of the Advance Directives/Medical Treatment Decisions form within R27's chart located behind the nurses' station, SW C confirmed that form signed/dated by R27 on 12-1-17 was the most current form and acknowledged that the form was unwitnessed as both witness signature lines within the form were noted to be blank. Review of the facility policy titled Advance Directives with a revised/reviewed date of 2/2019 stated, .Guidelines .Resident Code Status Form: The completed and signed Resident Code Status Form (CSF) that is completed pursuant to this Policy that summarizes the resuscitation desires .Witnesses .Individuals who observe the resident place his/her signature on the DPOA-HC (Durable Power of Attorney for Healthcare) signed after December 18, 1990 shall not be the resident's spouse, parent, child, grandchild, sibling .or an employee of this facility (home for the aged, adult foster care facility, hospital, nursing home, or county medical care facility) where the resident resides .Admitting .1.08 .If the Resident has the proper capacity, the Resident will be asked to complete and sign the Resident Code Status Form .1.09 .The Resident Code Status Form is the primary document in the medical record to identify resident code status . Further review of the policy included no guidance pertaining to the completion and witnessing of the facility's code status form. Review of the MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT, Act 193 of 1996 (Revised 3-25-14), revealed that, An order executed under this section shall be on a form described in section 4. The order shall be dated and executed voluntarily and signed by each of the following persons: (a) The declarant, the declarant's patient advocate, or another person who, at the time of the signing, is in the presence of the declarant and acting pursuant to the directions of the declarant. (b) The declarant's attending physician. (c) Two witnesses [AGE] years of age or older, at least 1 of whom is not the declarant's spouse, parent, child, grandchild, sibling, or presumptive heir. (3) The names of all signatories shall be printed or typed below the corresponding signatures. A witness shall not sign an order unless the declarant or the declarant's patient advocate appears to the witness to be of sound mind and under no duress, fraud, or undue influence. Further review of this Act revealed, Sec. 4. A do-not-resuscitate order executed under section 3 or 3a shall include, but is not limited to, the following language, and shall be in substantially the following form: DO-NOT-RESUSCITATE ORDER This do-not-resuscitate order is issued by _______________________________________, attending physician for _________________________________________. (Type or print declarant's or ward's name) Use the appropriate consent section below: A. DECLARANT CONSENT I have discussed my health status with my physician named above. I request that in the event my heart and breathing should stop, no person shall attempt to resuscitate me. This order will remain in effect until it is revoked as provided by law. Being of sound mind, I voluntarily execute this order, and I understand its full import. _______________________________________ _______________ (Declarant's signature) (Date) _______________________________________ _______________ (Signature of person who signed for (Date) declarant, if applicable) _______________________________________ (Type or print full name) B. PATIENT ADVOCATE CONSENT I authorize that in the event the declarant's heart and breathing should stop, no person shall attempt to resuscitate the declarant. I understand the full import of this order and assume responsibility for its execution. This order will remain in effect until it is revoked as provided by law. _______________________________________ _______________ (Patient advocate's signature) (Date) _______________________________________ (Type or print patient advocate's name) C. GUARDIAN CONSENT I authorize that in the event the ward's heart and breathing should stop, no person shall attempt to resuscitate the ward. I understand the full import of this order and assume responsibility for its execution. This order will remain in effect until it is revoked as provided by law. _______________________________________ _______________ (Guardian's signature) (Date) _______________________________________ (Type or print guardian's name) _______________________________________ _______________ (Physician's signature) (Date) _______________________________________ (Type or print physician's full name) ATTESTATION OF WITNESSES The individual who has executed this order appears to be of sound mind, and under no duress, fraud, or undue influence. Upon executing this order, the declarant has (has not)received an identification bracelet. ______________________________ ______________________________ (Witness signature) (Date) (Witness signature) (Date) ______________________________ ______________________________ (Type or print witness's name) (Type or print witness's name) THIS FORM WAS PREPARED PURSUANT TO, AND IS IN COMPLIANCE WITH, THE MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT. 45038 Resident #23 (R23) Review of the medical record revealed R23 was admitted to the facility 08/21/2016 with diagnoses that included Alzheimer's disease, muscle weakness, dementia, psychotic disturbances, mood disturbance, anxiety, disc degeneration of the lumbar region, pain, spondylosis (wear and tear of spinal disk) of cervical region, insomnia, hyperkalemia (high potassium), osteoarthritis, and constipation. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/16/2023, revealed R23 Brief Interview of Mental Status (BIMS) was dashed out because resident cognition could not be assessed. During observation and attempted interview on 08/08/2023 at 08:11 a.m. R23 was observed sitting up in her w/c, in her room. During attempted interview with resident responded oh to questions and nodded head. She also would start talking in a foreign language. Review of R23's medical record demonstrated that she had a family member who was her Durable Power of Attorney (DPOA) for healthcare. R23's medical record that she had been declared mentally incompetent by one physician on 09/02/2017 and another physician on 09/16/2017. Review of R23's Acknowledgement of Receipt Advance Directives/Medical Treatment Decisions demonstrated Do Not Resuscitate had been checked and dated 02/18/2020. The document entitled Acknowledgement of Receipt Advance Directives/Medical Treatment Decisions was signed by the DPOA and was witnessed by the DPOA's spouse on 02/18/2020. The document entitled Acknowledgement of Receipt Advance Directives/Medical Treatment Decisions did not have another witness documented. In an interview on 08/07/2023 at 03:58 p.m. Director of Nursing (DON) B explained that the facility does not obtain two witness signatures when completing the document entitled Acknowledgement of Receipt Advance Directives/Medical Treatment Decisions. 32064 Resident #35 (R35) Review of the medical record revealed R35 admitted to the facility on [DATE] with diagnoses that included multiple myeloma, major depressive disorder, and heart disease. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/10/23 revealed R35 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Review of R35's Acknowledgement of Receipt Advance Directives/Medical Treatment Decisions revealed R35 chose Do Not Resuscitate and signed the form on 11/8/22. The form did not have any witness signatures nor was the form compliant with the verbiage required per the Michigan Do Not Resuscitate Act.

This Citation Pertains To Intake #MI00135054 Based on observation, interview and record review the facility failed to develop and operationalize an abuse policy consistent with regulations for three (Resident #'s 1, 9 and 23) of five reviewed, resulting in allegations of abuse to go unreported to the State Agency, not thoroughly investigated and the potential for further abuse allegations not be reported. Findings include: Resident #9 According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] reflected Resident 9 (R9) was a [AGE] year old male admitted [DATE] with diagnosis that included Parkinson's disease and depression. Further review of the MDS reflected R9 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status. On 08/09/23 at 09:00 AM, R 9 was interviewed in his room, R 9 was observed sitting in his recliner. R9 was engaging and articulate when queried about former facility employee Licensed Practical Nurse (LPN) D, R9 winced and made a grimaced facial expression. R9 further reported LPN D was not very nice, he had a very evil attitude and was rough. R9 further reported he had made several complaints to multiple staff members (unable to recall names) about LPN D being mean. On 08/08/23 at 07:32 AM, during an interview with Director of Nursing (DON) B she confirmed that several residents had complained that LPN D Was not nice. DON B further elaborated that LPN D was terminated due complaints of being too rough with residents. When queried if that was reported to the State Agency, DON B stated that was a question for the Nursing Home Administrator (NHA) A. On 08/08/23 at 07:50 AM, during an interview with NHA A she reported the Regional Director of Operations (RDO) H would have been the person that reported abuse to the State Agency and she was not certain if that was done. On 08/08/23 at 01:32 PM , during an interview with NHA A and RDO H, the facility Abuse Prohibition Policy was discussed, RDO H stated R9's allegation was not reported to the State Agency because she had attended a training recently and thought the reporting requirements were going to change. 32064 Resident #1 (R1) Review of the medical record revealed R1 admitted to the facility on [DATE] with diagnoses that included muscle weakness, hemiplegia and hemiparesis, osteoarthritis, insomnia, anxiety, and pseudobulbar affect. The Minimum Data Set (MDS) with an Assessment Reference Date of 7/9/23 revealed R1 scored 6 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). On 08/08/23 at approximately 1:50 PM, during the Resident Council meeting, R1 was observed sitting in her wheelchair. R1 reported the black girl with red hair grabbed my hand so hard it was black and blue and stated she (the staff member) keeps it a secret. Another resident stated, yeah she is a little rough. On 08/08/23 at 2:02 PM, Nursing Home Administrator (NHA) A was notified of the allegations. NHA A reported if it was the aide she was thinking of, the aide no longer worked at the facility. NHA A reported the aide was rushing through care and not providing the quality of care the facility expected. NHA A reported the staff member was Certified Nursing Assistant (CNA) I. At that time, all documentation regarding the allegation and investigation was requested. Review of the facility's investigation revealed written statements from staff. A statement dated 7/31/23 and written by Registered Nurse (RN) J revealed Writer was informed by agency nurse on station one that resident [R1] was c/o [complaining of] abuse, by her CNA [CNA I]. Writer spoke with activities [Activities Aide (AA) K] b/c [because] the resident spoke with [AA K] regarding allegations of abuse by her CNA this AM. Writer then spoke with resident, resident stated her CNA with the black and red hair who is a black woman was mean to her this morning. Resident stated, she didn't smile at all like you do and she was very rough with me getting me out of bed and I don't want her to take care of me anymore. Resident also stated, I like [names of two other CNAs] they don't treat me like a ragdoll and are very nice to me. Review of a statement dated 7/31/23 and written by AA K revealed On Monday I went to pick up [R1] for activities, she said that the girl was being rough with, just pushing her over. She described a black girl with red hair. Review of a third written statement by an unknown staff member revealed During medication pass writer appreciated resident to give 9am medications. I spoke to [R1] and stated Good morning [R1] how are you feeling today?' Resident then responded I won't be here longer. I'm leaving and you won't be seeing me. The black lady with the burgundy hair is always so mean. I have bruises all over! Writer attempted to ask resident when did this happen when she screamed She's abusing me. She's always so mean. Writer was accompanied by the activities aide during complaint. Writer made sure resident was safe. Then proceeded to contact the administrator. Review of CNA I's Corrective Action Form dated 7/31/23 revealed Unacceptable job performance for incident types 012 and 117. Incident type 012 was listed as Unacceptable job performance, including failure to perform in a courteous, conscientious, and caring manner in responding to the needs of patients, visitors, and fell ow employees. Incident type 117 was listed as failure to fulfill the responsibilities of the job to an extent that might reasonably or does cause injury to a patient, visitor, or another employee. The action taken was termination. In an interview on 08/09/23 at 09:45 AM, AA K reported on 7/31/23 at approximately 9:15 AM, R1 reported to her that the CNA was being rough and pushed her over. AA K reported she notified the front office staff and the Social Worker. On 08/09/23 at 08:42 AM and 11:18 AM, attempts were made to contact RN J via telephone. RN J did not return the call prior to the survey exit. In an interview on 08/09/23 at 10:02 AM with Nursing Home Administrator (NHA) A and Regional Director of Operations (RDO) H, NHA A reported that R1 reported to a staff member that an aide rushed her, moved her around, and that she didn't like her. NHA A reported CNA I was immediately sent home and an investigation was started. NHA A reported the allegation was not reported to the State Agency because after the investigation, the facility felt it was more of a rushed situation. NHA A reported the investigation took two days to complete. RDO H reported rushing a resident was not abuse. When the staff statements were read, RDO H reported the statements were abuse allegations and it should have been reported to the State Agency. Review of the facility's Abuse Investigations Policy dated 9/2018 and revised/reviewed 2/2019 revealed 17. Inquiries concerning abuse reporting and investigation will be reported immediately to the Administrator or to the Designee whom will report according to the State of Michigan and federal guidelines and investigations to include the state standardized materials. 18. Incidents will be investigated and the Administrator or Designee will report according to the guidelines. If the resident suffers serious bodily injury, it must be reported within two hours of the event. If there is no serious bodily injury, then a report must be filed within 24 hours of the event. The facility will submit the Facility Incident Report-24 Hours no later than 24 hours after the discovery at https://bhcs.mihealth.org 19. Within 5 working days the facility will submit the Facility Investigation Report. 20.Facility emergencies (fires, loss of water, power or food services for more than 4 hours; the failure of a backup emergency generator, a natural disaster; roof failure; mechanical disaster' unplanned failure of the fire alarm system; evacuation must be reported. Non-business hours [PHONE NUMBER]. Licensing Officer during regular business hours. Review of facility's Reporting of Abuse to Facility Management policy effective 9/2018 and revised/reviewed 2/2019 revealed. 9. When an incident of resident abuse is suspected or confirmed, the incident must be immediately reported to Administrator or Designee regardless of the time lapse since the incident occurred. Reporting procedures should be followed as outlined in this policy. There are two reporting timeframes depending on whether the resident suffers serious bodily injury. Serious bodily injury is defined as an injury involving extreme physical pain: involving substantial risk of death: involving protracted loss or impairment of the function of a bodily member, organ, or mental facility: or requiring medical intervention such as surgery, hospitalization , or physical rehabilitation. If the resident suffers serious bodily injury, it must be reported within two hours of the event. If there is no serious bodily injury, then a report must be filed within twenty-four hours of the event. On 8/9/23 at 10:02 AM, NHA A and RDO H were asked if there were further facility policies for reporting abuse allegations to the State Agency. NHA A and RDO H reported they would look for a policy. An additional policy was not received prior to the survey exit. 45038 Resident #23 (R23) Review of the medical record revealed R23 was admitted to the facility 08/21/2016 with diagnoses that included Alzheimer's disease, muscle weakness, dementia, psychotic disturbances, mood disturbance, anxiety, disc degeneration of the lumbar region, pain, spondylosis (wear and tear of spinal disk) of cervical region, insomnia, hyperkalemia (high potassium), osteoarthritis, and constipation. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/16/2023, revealed R23 Brief Interview of Mental Status (BIMS) was dashed out because resident cognition could not be assessed. During observation and attempted interview on 08/07/2023 at 10:08 a.m. R23 was observed lying in bed. R23 did not respond to verbal questions. During a telephone interview on 08/07/2023 at 11:09 a.m. R23's family member N explained that R23 had a fall at the facility that had occurred within the last year. She explained that fall had resulted in R23 having a broken hip. During observation and attempted interview on 08/08/2023 at 08:11 a.m. R23 was observed sitting up in her w/c, in her room. During attempted interview with resident responded oh to questions and nodded head. She also would start talking in a foreign language. Review of R23's facility Event Report, dated 11/22/2022, demonstrated that she had an occurrence on 11/22/2022 at 10:39 a.m. The document entitled Event Report demonstrated that on 11/13/2022 at 01:30 a.m. R23 had been favoring her left thigh/hip during transfers and had not been able to bear her weight on that leg. The Event Report also demonstrate that staff observed R23 to have facial grimacing and holding her left hip. The Event Report demonstrated that an x-ray was ordered. The same Event Report demonstrated that mobile x-ray could not be performed on 11/13/22 at 10:22 p.m. because R23 could not hold still during the attempted x-ray. R23 was sent out to the hospital at that time. The same Event Report demonstrated that on 11/14/23 at 12:56 a.m. that the facility was notified that R23 had a Impact angulated left subcaptial femoral fracture. Review of the investigation file provided by the facility did not demonstrate the cause of R23's fracture and did not indicate that the injury of unknown origin had been reported to the appropriate state agency. In an interview on 08/09/2023 at 10:01 a.m. Nursing Home Administrator (NHA) A explained that she was aware of R23's Event Report dated 11/12/2022. She explained that she was aware that R23 had a left hip fracture that required hospitalization . When asked if this injury had been reported to the appropriate state agency, she responded No. NHA explained that during the investigation of this incident the facility had determined that the fracture was a result of an unwitnessed fall. NHA A could not provide any documentation supporting that finding. When NHA A was asked why the injury was not report to the appropriate state agency she could not provide an answer. When asked if the facility policy included that injuries of unknown origin are to be reported to the appropriate state agency she responded, I believe so. During record review of facility policy entitled Abuse Investigation, effective date of 09/2018 and a revision date of 02/19, number 1 stated 18. Incidents will be investigated, and the Administrator or Designee will report according to the guidelines. If the resident suffers serious bodily injury, it must be reported within two hours of the event. If there is no serious bodily injury, then a report must be filed within 24 hours of the event. The facility will submit the Facility Incident Report-24 Hours no later than 24 hours after the discovery .

This citation pertains to intake MI 600 and MI 865 Based on interview and record review the facility failed to perform proper technique during a gait belt transfer (an assistive device which can be used to help safely transfer a person . a proper use of a gait belt will prevent the caregiver from handling the person by the arm, wrist or underarms and injuring a weak patient) for one resident (Resident #601) out of seven residents reviewed for injuries, resulting in a preventable fracture and hospitalization . Findings include: Resident #601 Review of an Admission Record revealed, Resident #601 admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment, with a reference date of 10/21/20, revealed Resident #601 had severe cognitive impairment with a Brief interview for Mental Status (BIMS) score of 6, out of a total possible score of 15. Resident #601 required extensive assistance of one staff with transfers. Review of Nurse Progress Notes for Resident #601 on 12/29/20 at 12:29 p.m. revealed, documentation by the Director of Nursing (DON) on 12/16/20 at 10:36 a.m., Per MN (midnight) nurse patient has pain to the right arm, not able to extend arm. Seen and examined patient. Patient has large bruise to the antecubital area (area on the opposite of the elbow) with redness and swelling, painful to touch and can't extend arm. No protrusion or abnormalities on the bone noted. MN nurse called NP (Nurse Practitioner) and Family regarding patient condition and transfer to (hospital name). Report given to ER (emergency room ). Ambulance in to transport patient. Patient daughter aware of patient leaving the facility to hospital. UM (Unit Manager) aware. Further review of Nurse Progress Notes revealed, documentation by Nurse B on 12/15/20 at 12:53 p.m., (Recorded as Late Entry on 12/16/2020 12:46 PM) Nurse called to room, patient c/o (complained) right arm aching. ROM (range of motion) complete, no redness or discoloration noted. Patient states it only hurts a little, with slight facial grimace. Nurse gave prn Tylenol per order . Patient lying in bed resting. Continue to monitor . Further review of progress notes revealed no incidents/Accidents or falls prior to arm pain. In an interview on 12/29/20 at 2:25 p.m., the Administrator reported there is a Facility Reported Incident (FRI) for Resident #601 regarding the injury. Review of the Incident Summary provided by facility on 12/29/20 at 2:35 p.m. revealed, .At approximately 12/16/20 Administrator was notified by the hospital that resident was diagnosed with [REDACTED]. The investigation summary revealed, . it was concluded that the fracture to resident's arm was sustained in a transfer from the wheelchair to bed . The nurse applied a gait belt and asked the resident to place her hands on the Nurses shoulders and the Nurse completed a pivot transfer. In a return demonstration from the Nurse, it was very plausible that the fracture occurred during the transfer from the angle of the resident's arms and the height of the nurse . Review of an X-ray report on 12/29/20 at 2:53 p.m. revealed, Resident #601 had a displaced oblique proximal humeral shaft fracture (caused by twisting of upper arm ) of the right shoulder with an effective date of 12/16/20. Review of a Care Plan on 12/29/20 at 2:57 p.m., revealed I need help with transfers, bed mobility, locomotion, and ROM due to my [DIAGNOSES REDACTED]. In an interview on 12/30/20 at 9:25 a.m., the Administrator reported that Nurse B transferred Resident #601 to bed after a visit with daughter. The Administrator then reported Nurse B used a gait belt for the transfer and instructed Resident #601 to place hands on her shoulders. The Administrator reported she believes that is when the fracture occurred. Review of statement written by Nurse B on 12/30/20 at 9:35 a.m. revealed, . Patient continued to request to lay in bed. Nurse placed on proper PPE (personal protection equipment) on in patient room. Aligned w/c (wheelchair) angled toward bed. Gait belt was applied, Nurse squatted & assisted patient arms on Nurse shoulders, hand grip on gait belt. one knee between patients' knee & pivot patient into bed. Covered patient up & went to ask CNA (Certified Nursing Assistant) to with changing brief . signed and dated on 12/15/2020. Review of a Discharge Summary with a dated of 12/17/20 revealed, . Plan . According to nursing patient was being transferred into bed and during that transfer the fracture most likely occurred since the patient has not had a fall in the facility. In this type of fracture that she has which is a spiral [MEDICAL CONDITION] humerus shaft more likely correlated to transferring the patient by holding her upper extremity and she is high risk for fractures due to severe [MEDICAL CONDITION]. Patient was transferred to (hospital name) will consultation to orthopedic surgery . Review of Physician order [REDACTED]. Use a gait belt for all transfers with a start date of 6/23/20. Transfer to (Hospital Name) due to pain and swelling to the right arm, with a start date of 12/16/20. In a telephone interview on 12/30/20 at 11:43 a.m., Nurse B reported she put on a gait belt on Resident #601 and fastened it securely. Then Nurse B reported she put her right knee between Resident #601's legs, squatted down, put Resident 601's hands on her shoulders ,grabbed the back of gait belt and stood and pivoted Resident #601 into bed. Nurse B reported she normally places residents' hands on her shoulder to support them. Nurse B discovered Resident #601 had pain within a half hour of transfer. In an interview on 12/30/20 at 12:44 p.m., Nurse Educator F reported the therapy department trained the staff on transfers. Nurse Educator F stated I wouldn't necessary do that . I don't do that, when asked if it is normal to ask a resident to place their hands on your shoulders during a gait belt transfer. In an interview on 12/30/20 at 1:00 p.m., Physical Therapist (PT) Assistant E and Occupational Therapist (OT) Assistant D present. OT Assistant D reported the staff is trained to not hold patient under arms during a gait belt transfer. Also, the staff is not trained to put the resident hands on their shoulder because it can cause harm. OT Assistant D then reported that is not a method that is taught because it puts the resident and employee at risk. In an interview on 12/30/20 at 1:12 p.m., the DON reported she was present when the midnight nurse sent Resident #601 to the hospital. The DON then reported she assessed Resident #601 and Resident #601's arm was swollen and could not hyperextend. The DON reported she does not usually ask a resident to place their arms on her shoulders during a gait belt transfer. The DON then reported Resident #601's fracture occurred from the transfer. In an interview on 12/30/20 at 1:38 p.m., the Administrator reported the conclusion of the investigation for Resident #601 was the transfer caused the fracture. The Administrator reported it is not normal for staff to ask residents to place their hands on their shoulders during a gait belt transfer. The Administrator then demonstrated how the nurse placed Resident #601's arms on her shoulders. During the reenactment, the Administrator reported her arm when up a little (by doing a twisting motion) when the nurse demonstrated the gait belt transfer on her. Review of the facility Safe Lifting and Movement of Residents policy with a revised date of 1/15 and Gait Belt policy with a revised date of 2/15 revealed, documentation does not include procedure for gait belt transfer.

Based on observations, interviews, and record review the facility failed to prevent the development of pressure ulcers in one of three residents (#102) from a total sample of three, resulting in R#102 developing two unstageable pressure ulcers, one ulcer on both the right and left heel, and two stage 3 pressure ulcers to the Right and Left sides of the sacral/buttocks area. Unstageable pressure ulcers are defined as full thickness loss of tissue in which the base of the ulcer is covered by tan or blackened skin, that is necrotic. Stage 3 pressure ulcers are defined as an opening in the skin presenting as a shallow crater that exposes soft tissue and fat. Findings include: During an observation on 3/26/18 at 2:00 p.m., R#102 was alert, and resting in bed with a specialty mattress in place, and proafo boots on both feet (proafo boots are soft, thick, cushioned boots used to protect and off-load pressure to the heels and ankles). R#102 was non-verbal, but could nod his head appropriately to simple questions. R#102 agreed to have dressings on the heels changed with the surveyor present. The wound care nurse, staff 'D', and the nurse manager, staff 'A' completed the prescribed wound care to R#102's heels. The resident's right heel had a dried eschar cap that covered part of the heel, and was partially lifting off at the edges, with a small amount of brownish drainage. The resident's left heel had two separate areas of dried eschar cap, that covered over the heel on the right and left sides that also had small parts lifting off at the edges. R#102 had a dry and intact dressing to his sacral/buttocks area that had recently been applied. Staff 'D' said the resident acquired his pressure ulcers while at the facility a few months ago. Staff 'A' said that R#102's pressure ulcers had been slowly resolving. A medical record review was conducted for R#102 on 3/26/18. According to the initial Minimum Data Set ((MDS) dated [DATE], R#102 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Section M (skin condition) indicated that R#102 had no pressure ulcers at this time, but was at risk for developing pressure ulcers due to incontinence and immobility. In Section G (functional status), R#102 was identified to be totally dependent on staff for bed mobility and required two persons for assistance with repositioning and transfers from surface to surface. On 11/17/17, an order to apply ABD pads to bilateral heels and wrap with kerlix every other day, and to 'float heels' while in bed was written. A care plan for skin breakdown was initiated on 11/17/17 which included the following interventions; conduct systematic skin assessments 2 x weekly on shower days and monitor for any skin breakdown or discolorations, incontinence care after each episode of incontinence and minimize skin exposure to moisture, 'encourage' resident to reposition every 2 hours while in bed and 'encourage' resident to 'off-load' and stretch every 2 hours while in chair, and elevate heels while lying in bed for pressure relief. All of these interventions were identified as 'unchecked' and therefore 'not' chartable tasks in P[NAME]. A review of the progress notes from 11/16/17 through 1/5/18 revealed the following skin assessments: On 11/16/17, admission skin assessment documented by Staff 'A', identified that R#102 had 'bilateral reddened heels, Right heel boggy (soft/mushy) and non-blanchable (skin does not fade when pressed on, a sign of obstructed blood flow). On 11/27/17, no new skin alterations. On 11/30/17, no open areas. On 12/4/17, no new skin concerns. On 12/4/17,an order for [REDACTED]. On 12/7/17, treatment done to coccyx, barrier cream applied. There are no additional documentations, orders, or descriptions of the resident's coccyx area. On 12/14/17, shower given, no open areas. On 12/18/17, shower, no new skin issues. On 12/21/17, shower, no new skin issues. On 12/26/18, Resident's bilateral buttocks with necrotic (blackened area) with yellow drainage. There is no skin assessment or documentation on the status of the resident's heels. On 12/27/18, Staff 'A' documented; upon request from floor nurse skin assessment as follows; left buttocks with 10.0 cm ( centimeters) x 5.0 cm area of 'moisture associated skin damage' (MASD), and right buttocks 5.0 cm x 3.0 cm with MASD. There is no assessment or documentation on status of the resident's heels. There are no new skin treatment orders, or updates to plan of care. On 12/28/17, no new skin issues noted. Barrier cream to buttocks. On 1/3/18, Staff 'A' documented; Left buttocks with 9.0 cm x 5.0 cm area of MASD and Right buttocks has 6.0 cm x 3.0 cm area of MASD, that are dark purple/gray and non-blanchable. There is no assessment regarding the resident's heels. On 1/5/18, Staff 'D' documents the following weekly wound assessment: L buttock has MASD 9.0 cm x 5.0 cm with small area of eschar surrounded by slough (yellow devitalized tissue). R buttock MASD measures 6.0 cm 3.0 cm, areas are non-blanchable, and dark purple/gray in color, no drainage. Right heel is noted with intact eschar tissue with scant amount of sero-sang drainage (pink-tinged thin fluid) 5.2 cm x 3.2 cm. Left heel is noted with intact eshcar tissue measuring 6.3 cm x 2.5 cm. On 1/5/18 an order for [REDACTED]. Staff educated on pillow repositioning. According to the quarterly MDS, dated [DATE], section M indicated that R#102 now had three pressure ulcers; one,' stage 3', on the buttocks area, and two 'unstageable' pressures ulcers on bilateral (both) heels. There was no other significant changes to the resident's MDS. On 2/20/18, the care plan for skin breakdown was updated to include the following interventions; assess the pressure ulcer for stage, size, presence of granulation tissue, and condition of surrounding skin. Apply dressings as ordered. CNA to observe mattress for proper inflation and function. Proafo boots to be worn with bilateral heels floated while in bed. During an interview with the Director of Nursing, Staff 'A' and Staff 'D' on 3/26/18 at 4:45 p.m., they acknowledged that R#102 had acquired his pressure ulcers while at the facility, and did not supply any additional documentation regarding what treatment was given to R#102 on 12/7/17, and 12/26/17, or if the physician was notified of the changes in the resident's skin condition.

This citation pertains to complaint: MI 077 Based on observation, interview and record review the facility failed to install shower gurney side rail pins to prevent accidents for one of one shower gurneys and for one (#601) out of five sampled residents reviewed for falls, resulting in Resident #601 being left alone on a shower gurney unsupervised, falling to the floor, sustaining a closed head injury with loss of consciousness. This resulted in an Immediate Jeopardy (IJ) to the health and safety of the residents in the facility. The Immediate Jeopardy (IJ) was identified on 12/28/16 at 11:30 a.m. The Director of Nursing was notified of the IJ on 12/28/16 at 5:00 p.m. and was informed to submit a plan of correction to remove the immediacy. The IJ was removed on 12/22/16 based on the providers implementation of corrective actions as verified onsite during the completion of the extended survey. Although the Immediate Jeopardy was removed, the facility's deficient practice was not corrected and remained out of compliance at a scope of isolated with actual harm Findings Include: On 12/28/16 at 9:00 a.m., record review revealed that Resident #601 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set Assessment ((MDS) dated [DATE] documented the resident's cognition as severely impaired. The MDS also documented that Resident #601 had upper and lower extremity contractures and was totally dependant on staff for all activities of daily living, including personal hygiene/bathing. Review of the two documents titled, Resident Profile (a guide with individual resident approaches to guide the Certified Nurse Assistant (CNA)) and Fall Care Plan dated 10/20/16, for Resident #601 documented, Problem Category-Falls. Approach Description-Be sure I am closer to wall when placing me on my right side .and not near edge of bed. I prefer to lay on my left side .Continuous visual monitoring . On 12/28/16 at 9:40 a.m., Review of the facility provided Event Investigation dated 12/17/16 revealed the following sequence of events for Resident #601; On 12/17/16 at 4:30 p.m., (CNA A) had assistance with transferring (Resident #601) to shower gurney. Both rails were up. Resident was on her back and taken to shower room with brakes locked. (CNA A) noticed pins (device that secured the gurney side rails in the upright position) were missing and went to clean utility room to get orange stick (wooden dowel stick used to clean fingernails) to secure the gurney railing, there was none. (CNA A) then went to her purse to get one (an orange stick) and there was not one. (CNAA) went back into shower room, railing was still up, turned to get wash cloths. Resident was still on her back. When (CNA A) turned around she heard railing (of shower gurney) 'go down', as (CNA A) turned back around (Resident #601) was falling off the gurney toward left and landed on her right side. (Resident #601) hit her right hip first then hit head on right side temporal area. An immediate knot was seen on the right temporal area with bleeding noted. On 12/28/16 at 10:10 a.m., review of Resident #601 medical record revealed a late entry nurses note dated 12/17/16 at 5:17 p.m., documenting Recorded as late entry on 12/19/16 8:19 p.m. (two days after the fall event). Resident observed on floor laying on her right side in shower room. Assisted other nurse with assessment. Hematoma on right side of forehead, with small cut below the hematoma observed. Cut on second toe on right foot. Cut on forehead cleansed with normal saline, toe cleansed with normal saline and small dressing applied. Ice applied to hematoma on forehead, 20 minutes on, 20 minutes off. Swelling to forehead remained same size after applying ice. No signs or symptoms of pain noted. Resident non-responsive after fall for approximately 30 minutes. Vitals obtained by other nurse, pupils 5 millimeter (mm), round and non-reactant. Staff assisted resident back to bed, resident began responding to name and pupils became sluggish, but reactive to light. Physician contacted, orders to send resident out to hospital .Resident sent out via (name of ambulance company) at approximately 6 p.m. An hour and a half after the fall. On 12/28/16 at 10:30 a.m., the facility's Director of Nursing (DON) was interviewed about the incident with Resident #601. The DON said that she was aware of the incident and that it was not acceptable practice to place any resident at risk by using faulty equipment. The DON went on to say the faulty equipment should have been tagged as faulty and pulled off the unit until necessary repairs were completed. The DON was asked about Resident #601 remaining in the facility for one and a half hours after a fall with an unconscious episode and stated, The nursing staff should have sent (Resident #601) out 911 (lights and sirens) due to the resident being unconscious for 30 minutes and having a history of subdural bleeding. On 12/28/16 at 10:45 a.m., the Maintenance Director (Staff B) was interviewed regarding the monitoring of facility equipment. Staff B said that he has a Daily Maintenance Inspection Log that is used to monitor facility equipment. Staff B said that he was aware that the pins for the shower gurney were missing back in November (2016), but was not aware that they went missing again until after the event that occurred on 12/17/16. Review of a local hardware receipt provided by the facility dated 11/18/16 documented that clevis and hitch pins (three piece fastener system) along with 1 rings were purchased to replace the missing shower gurney pins. Review of the Daily Maintenance Inspection Logs for the months of November and December 2016 had no documented evidence that the shower gurney was ever monitored for defects, even after it was found faulty (on 11/18/16) and repaired. On 12/28/16 at 11:05 a.m., review of the hospital emergency room records dated 12/17/16 with an arrival time of 18:15 (6:15 p.m.) documented, Per reports, 'the patient fell in the shower'. The patient has contractures of all extremities and is unlikely able to be able to stand on her own. She presents in a C-collar (neck brace) with a large hematoma (bruising) above her Right eye. She does not respond to verbal, physical or painful stimuli .Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: Cardiac failure (heart failure), Respiratory failure (inadequate gas exchange), and shock (intracranial hemorrhage) .Emergency Department (ED) final Diagnoses: [REDACTED]. On 12/28/16 at 3:15 p.m., CNA A was interviewed regarding the incident with Resident #601. CNA A said she had been using the shower gurney without pins since she started working at the facility (August 2016). CNA A stated, This was my first time showering (Resident #601) on the shower gurney, but I have used the gurney without pins at least 3 to 4 times (previously for other residents). That day (12/17/16) I was showering (Resident #601). I put her on the gurney and I noticed that the pins were missing and there were no pins anywhere. I pulled the left side rail to the upward position. The right side rail was already secured with pins in the upright position. I was told (by her peers), that management was aware that the pins were missing, that is why I didn't report it. I then pushed (Resident #601) into the shower room on the gurney and went to the clean utility room to find an orange stick (a device CNA A admits to have used previously to secure the gurney side rail in the upright position). There were no orange sticks in the clean utility room, so I went to my purse (located at the nurses station) to see if I had one in my purse, which I didn't. I should never have left the resident unsupervised, but I didn't think she would move. I then returned to the resident in the shower room and as I turned to grab some towels and wash cloths, I heard the side rail 'go down'. If you 'breath' that side rails goes down. It goes down very easily. I then saw the resident roll off the left side of the gurney (the side of the gurney that the side rail was down) hitting her right hip and then the right side of her head on the shower room floor. As I ran to the resident, I called out for help. The nurse came immediately. CNA A was asked if Resident #601 was responding to her after the fall to which she stated, No. Not immediately. She just had a blank stare and that is when the nurse came in and took over. On 1/4/17 at 2:20 p.m., the Medical Director (MD-whom is also Resident #601's Attending Physician) was interviewed regarding the incident for Resident #601. The MD stated that falls and fall prevention are a key part of the Quality Assurance (QA) process (a process to prevent mistakes or defects). The MD stated that monitoring and staff reporting is a way in which problem equipment can be identified and removed from use until repaired and safe for use again. The MD was queried regarding the incident with Resident #601. He was asked if the standard of practice for a resident with a prior history of subdural hematoma, sustaining a head injury during a fall, demonstrating unconsciousness for 30 minutes, should wait one and a half hours before being sent out to the hospital for evaluation, to which he replied, No. She should have been sent out immediately. On 1/4/17 at 2:45 p.m. along with the DON and MD the shower gurney was inspected. Along the top of the side rails on each side of the gurney was a manufacture's warning sticker; INSERT SIDE RAIL PINS BEFORE USE. The side rail on the right side of the gurney had pins installed in place and the rail was not able to be lowered. The side rail on the left side of the gurney was pulled to and upright position with out pins. The side rail remained up momentarily and subsequently 'drop down' leaving the left side of the gurney unsecured. At this time the MD stated, Oh, now I see how that fall happened. On 1/4/16 at 3:20 p.m., review of the facility's Lock Out or Tag Out Policy dated 9/10/11, revised 9/2012 documented, Procedure for Equipment: When a piece of equipment is not operable, malfunctioning or requiring repairs the staff member that identifies the problem must tag the piece of equipment unusable . Review of the facility's undated,Fall Clinical Protocol Policy documented, Risk factors for falling include lightheadedness or dizziness, multiple medications, musculoskeletal abnormalities, peripheral neuropathy, gait and balance disorders, cognitive impairment, weakness, environmental hazards, confusion, visual impairment, and illnesses affection the central nervous system and blood pressure. Aberdeen Rehabilitation and Skilled Nursing Immediate Jeopardy Abatement · On 12-17-16 Resident # 601 was assessed for injury and negative outcomes by RN. Resident was then transferred to the hospital for further evaluation. · On 12-17-16 Shower Gurney was pulled from use following facility Lock out tag out policy. Shower Gurney was inspected and noted with a missing pin, and was deemed inoperable until replacement pin arrives. · On 12-17-16 the assigned CNA was removed from schedule pending investigation. · On 12-17-16 all shower chairs in the facility were assessed by unit manager, with no issues/concerns noted. · On 12-19-16 investigation continued, Administrator, DON, and Unit Manager interviewed CNA and provided education which included a corrective action and CNA was suspended. · On 12-21-16 Direct Supply was contacted regarding replacement of manufacturer ' s shower pins, and order was placed. · On 12-22-16 Replacement pins were located and purchased from a local supply company. Pins were put in use until the delivery from manufacturer. · On 12-28-16 Vendor was contacted regarding the purchase of a new shower gurney. · On 12-29-16 Shower chairs were labeled and added to daily maintenance inspection rounds for equipment. · On 1-3-17 A new shower gurney was ordered, facility is currently awaiting it ' s arrival, follow up phone call was made to manufacturer regarding estimated time and date of delivery. · Education for new equipment to be provided upon arrival. · Beginning on 12-29-16 education provided to the maintenance department regarding daily inspection of shower chairs/gurneys. · Beginning on 12-17-16 education provided to nursing staff regarding the prompt reporting of inoperable equipment and process for inspection, repair, and maintenance of equipment. · Beginning week of 1/2/17 and monthly Administrator will complete an audit of maintenance inspection rounds to be reviewed in Q/A · Beginning week of 1/2/17 and monthly Administrator will conduct an audit of shower chairs/gurneys to be reviewed in Q/A · Beginning week of 1/2/17 and monthly Administrator will meet with maintenance department to discuss need for addition to or modification of existing maintenance rounds. · Residents were assessed and none were identified to be at risk, CNA assigned was re-educated by the Facility Management Staff, on showers, safety and supervision of residents, and lock out tag out policies and procedures. Daily maintenance inspection rounds were updated to include shower chairs/gurneys. An audit of maintenance rounds and equipment will be conducted on a monthly basis and brought to Q/A until substantial compliance is achieved. * Continued education will be provided on Lock out tag out process, safety and supervision of residents and equipment to all staff. ( / )

This citation pertains to intake: MI 671. Based on observations, interviews, and record review the facility failed to provide adequate supervision, or a functioning alarm system to three outside doors (kitchen delivery door, north door, and south door) to prevent the elopement for one of five (#302) residents identified as having 'exit seeking behaviors', reviewed for elopement from a total sample of eight, resulting in resident #302 exiting the building through the kitchen delivery door, and walking down a road with posted speeds of 55 mph, at 6:30 p.m., that was unbeknownst to staff, until another resident's family member called the facility to notify staff. This deficient practice had the potential to result in serious harm and/or injury and required immediate corrective action. The Administrator was notified of the Immediate Jeopardy (IJ) on 10/18/16 at 1:00 p.m. A plan to remove the immediacy was requested. The Immediate Jeopardy was identified on 10/18/16 at 9:30 a.m. The IJ was removed on 10/18/16 at 4:30 p.m., based on the facility's implementation of the plan of removal as verified by the surveyor. Although the IJ was removed the facility's deficient practice was not corrected and remained isolated with no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Findings include: During an interview on 10/18/16 at 9:15 a.m., the Administrator said that R#302 had eloped out of the facility on 10/11/16 at approximately 6:30 p.m., after following a family member down the mid-hall stairwell and then out through the kitchen delivery doors. The staff was unaware that R#302 had eloped from the facility until another resident's family member called the facility informed them that R#302 was seen walking across the street toward the gas station that was approximately a block away from the facility. The Administrator confirmed that there were no alarms on the kitchen delivery doors. There are two doors in the facility that have wanderguard alarms, the main front door, and the kitchen entry door. Once a resident gets into the kitchen area there is direct access out the delivery doors. During an interview on 10/18/16 at 10:30 a.m., the Director of Nursing (DON) said that the kitchen delivery doors have a video camera that revealed how R#302 eloped out of the facility on 10/11/16. The kitchen delivery doors are not locked and do not have any type of alarm system installed. During an observation on 10/18/16 at 10:30 a.m., it was determined that the kitchen delivery doors were not locked, or set with an alarm system. A continued tour of the facility revealed that neither the north or south exit doors were locked, or alarmed. All three doors (kitchen, north, and south) had direct access to the facility's parking lot. During an interview and observation of R#302 on 10/18/16 at 8:30 a.m., he was pacing up and down the hallway and then sat in a chair that directly faced the stairwell door. R#302 was pleasantly confused and unable to be meaningfully interviewed. R#302 had a wanderguard alarm bracelet on his left wrist, and there were no visible sign of injury on the resident. During an interview with Licensed Practical Nurse (LPN) 'A' on 10/18/16 at 8:30 a.m., she said that R#302 has intermittent periods of 'exit seeking behavior', and has requested to 'go home' on multiple occasions. LPN 'A' said that R#302 had even used the nursing station phone to call 911 in the past. LPN 'A' said that R#302 did not have a wanderguard bracelet on until after he eloped on 10/11/16. LPN 'A' said that visual checks were suppose to be done every hour on the resident, but could not produce documentation to support that. During an interview on 10/18/16 at 10:15 a.m., with the family member who discovered that R#302 had eloped, said that R#302 always paces up and down the hall and tries to open the stairwell doors. The family member said on 10/11/16 at approximately 6:30 p.m., he saw R#302 crossing the street to get to the gas station and he called the facility to confirm that he was missing. The family member said that the facility staff came right over in a car and picked up the R#302 without any problem. According to the medical record, reviewed on 10/18/16, it was revealed that R#302 had been identified as an elopement risk at the time of his re-admission on 7/15/16. The Minimum Data Set, dated dated [DATE] indicated that R#302 was independent with ambulation without any staff oversight. On 10/5/16, a progress note by the nurse practitioner indicated that R#302 had demonstrated pacing behaviors and verbalized 'wanting to go home'. On 10/9/16, the Social Worker documented that R#302 was demonstrating 'exit-seeking' behaviors and a care plan was initiated. However, no wanderguard alarm bracelet was placed on the resident at this time, and there was no additional documentation by nursing staff to support that additional interventions or increased supervision was initiated. On 10/11/16 at 7:30 p.m., it was documented that wanderguard alarm bracelet was placed on R#302's left wrist. According to the facility's 'Elopement' policy revised on 9/2012 the following protocols were identified; 1.A. Residents identified as an elopement risk will have a wanderguard alarm bracelet applied. The nurse applying the bracelet is responsible for addressing the resident's care plan. 1.B. All staff are responsible for re-directing residents when an elopement is attempted. The facility submitted the following plan to remove the immediacy on 10/18/16. Aberdeen Rehabilitation and Skilled Nursing Immediate Jeopardy Removal · On 10/11/2016 Resident # 302 was assessed for injury and negative outcomes by RN. None were identified · On 10/18/2016 an audit to assure exit door alarms were in working order was completed by Maintenance Assistant and daily thereafter and reviewed by the administrator. Those found to be not functioning were repaired or replaced immediately. · On 10/11/2016 and continuing until discharge a Wanderguard was placed on the resident to monitor for exit seeking behaviors and promote safety. · On 10/18/2016, new alarms were installed on the North End and South End doors of 100 Hall · On 10/12/2016 an audit of current residents 105 of 105 residing in the facility was completed by Administrator to ensure current residents were safe and accounted for. · On 10/12/2016 an audit of residents 5 of 105 current resident, with wander guards in place has been completed to check placement, function, and expiration date was conducted by LPN · On 10/12/2016 a sign was verified to be in place on the 2nd floor stairwell doors by Administrator alerting persons that exit the facility to use the front door only and never to enter or exit via the stair wells. · On 10/12/2016 Elopement Prevention and management Program was reviewed by the Director of Nursing and Nursing Home Administrator and deemed appropriate. · On 10/12/2016 Resident # 302 Elopement risk assessment was updated, Care Plan reviewed, Care delivery guide reviewed to ensure appropriate assessment and interventions were in place. · On 10/19/2016 and monthly thereafter at various times to include each shift. Elopement drills will be conducted by Administrator and/or DON and other members of the IDT each shift and recorded on the record of in-service form. · On 10/18/2016 the process for alarm checks was changed to include utilizing a facility map, for all checks, with alarmed doors identified by number which requires a signature attesting to functionality. These reports are reviewed by the Administrator or designee on the next business day. · On 10/12/2016 Residents at risk for elopement 5 of 105, were reviewed by LPN and DON to review/revise elopement risk, care plan, care delivery guides to ensure appropriate assessment and intervention in place. · On 10/12/2016 an audit was completed by LPN of the elopement book to verify that all residents at risk for elopement 5 of 105 had an elopement photo sheet in place. · Beginning on 10/11/2016. Facility staff, including nursing, maintenance, dietary, activities, social services, billing, staffing, payroll, and medical records in addition to contracted housekeeping, laundry, and therapy staff, were re-educated by the Facility Management Staff, on the elopement policy including, prevention, reporting responsibilities, management, maintaining door alarms and Wanderguard systems, responding to alarms and ensure doors are secured when passing through. The education that was initiated on 10/11/2016 and continued until 10/21/16 at which time 158 of 158 staff members were educated. · Beginning 10/11/16 employees newly hired to the facility will receive the elopement training by the completion of classroom training. · On 10/18/2016 the Front door code alert system was changed to a new code by Maintenance Director. · On 10/18/2016 the plan was reviewed with the Medical Director by phone by the Director of Nursing. · Beginning 10/18/2016 weekly the Administrator/designee is reviewing alarm checks which include all exit doors to ensure they are completed. · Daily checks for placement of Wanderguard are completed by Nurse using MAR. Weekly charge nurses will complete an audit to verify documentation on wander guard checks daily are being documented in the Medical Administration record. · Beginning 10/17/2016 and monthly the Director of Nursing/designee and IDT will complete the Wanderguard Audit for residents at risk for elopement. · Beginning week of 10/17/2016 an Elopement drill will be completed weekly for one month then monthly thereafter. ( )

Based on observation, interview, and record review, the facility failed to implement adequate, appropriate and timely interventions for prevention and treatment of [REDACTED].#701) of four sampled residents reviewed for pressure sores from a total of 21, resulting in the development and/or worsening of pressure sores. Findings include: On 5/24/16 at 9:10 AM, resident #701's skin was observed with wound care nurses 'L' and 'M'. The resident was non-verbal, totally immobile and had bilateral foot drop (toes pointed downward in a permanent, fixed position-plantar flexion contractures). A dressing was on the resident's left elbow was saturated with dark brown drainage that had drained downward onto his shirt. The nurses said that there was not that amount of drainage present when wound care was conducted by them the day before. The dressing was removed to reveal a stage III (full thickness skin loss) pressure sore on the elbow. The wound was malodorous with purulent (pus) drainage. The entire elbow and the surrounding skin above and below the elbow was swollen, rose colored ([DIAGNOSES REDACTED]tous) and appeared infected. Per review of wound notes provided by the wound nurses dated 5/20/16, the sore measured 3 centimeters (cm) by 3.5 cm by 0.9 cm with moderate serous drainage. When asked what caused the elbow pressure sore, nurse 'L' said, It was a skin tear, meaning a stage II (partial skin thickness) pressure sore. Nurse 'L' indicated that the resident would press his elbow down into the mattress due to the elbow being contracted (permanently fixed in a bent/flexed position). The current wound treatment consisted of gauze packing placed into the wound with hydrogel (for moisture and debridement) twice a day. Nurse 'L' said that the resident's primary care physician (PCP) was going to be notified of the change in the wound. When asked if the resident had been seen by a wound specialist (physician), nurse 'L' said that the specialist was seeing the resident once a month and last saw the resident on 4/21/16, but repeated that the PCP was going to be notified and said that the PCP would direct further care of the pressure sore. When queried whether the wound specialist was going to be involved, nurse 'L' and nurse 'M' then said they would notify him. Resident #701 was observed to have other pressure sores to bilateral hips, bilateral heels, and the sacral area. The right hip was at stage III and required packing. The sacral wound was at stage IV with exposed bone observed. Nurse 'L' said that the resident was admitted with numerous pressure sores. She said that most of the sores had since healed, but the sores on the heels had re-opened when pressure relief/positioning (non-flexible) boots were placed on the resident's feet to relieve pressure and for foot drop after the resident's feet had already dropped, which caused the boots not to fit properly. (Once foot drop has occurred, the foot is incapable of being flexed-toes pointed upward in a normal position).The left heel had a small, dark intact scab-type pressure sore and the right heel had an open pressure sore noted as a stage III measuring 3.9 cm by 3.3 cm. When asked why this resident with stage III and IV pressure sores, was just seen once a month by the wound specialist, nurse 'L' said, He only comes to the building once a month. On 5/24/16 at 11:30 AM, the clinical record and wound care notes for resident #701 were reviewed. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The left elbow was noted as reddened, but blanchable (blood flow was not impaired). He was receiving Hospice services at that time, which was later discontinued. Minimum data sets dated 12/11/15 and 3/9/16 noted that the resident had severe cognitive impairment, pressure sores, required total assistance for mobility and repositioning and had limited range of motion to one upper extremity. Per wound care nursing notes regarding the pressure sores on the heels: 11/16/15-left heel pressure sore re-opened, stage II measuring 1 cm by 1 cm, pressure relief/positioning boots re-applied. 2/15/16-right heel pressure sore observed, stage II measuring 1 cm by 1.1 cm, boots re-applied; 3/7/16-size increased to 4.6 cm by 4.5 cm, bilateral heel protectors started being applied rather than the pressure relief/positioning boots; 3/31/16-increased to stage III measuring 6.5 cm by 5 cm. 5/20/16-left heel pressure sore measuring 1.2 cm by 1.5 cm, unstageable (scabbed); right heel measuring 3.9 cm by 3.3 cm with 100% pink granulation (new, healthy) tissue. Per review of nursing notes beginning 9/2/15, there was no mention of the left elbow until 11/27/15. On 11/27/15, nurses noted: areas continue to left elbow, but with no documented description. There was no mention of the left elbow in wound notes dated 11/30/15, 12/7/15, 12/14/15, 12/21/15, 1/4/16, 1/11/16 and 1/18/16 by wound care staff until 1/29/16. On 1/29/16, a wound nurse noted: Writer assessed resident's left elbow with noted open area measuring 1.3 cm by 0.9 cm x 0.4 cm scant amount of drainage noted will continue to monitor, elbow protector in place, resident's left elbow elevated. There was no mention of an elbow protector being used or the elbow being floated for pressure relief prior to 1/29/16, even though the left elbow was contracted. All documented notes by the wound specialist were requested. There were none provided dated prior to 1/30/16. On 1/30/16, the specialist noted that the elbow wound was at stage II. Per the next note by the specialist dated 2/24/16: The resident's left elbow wound was at stage II. There was no documented note indicating that the resident was seen by the specialist during 3/2016. A care plan dated 3/10/16 noted: I am at risk for skin breakdown; The goal: My pressure ulcer will improve in 90 days. Interventions included Make sure I'm wearing my elbow protector on left elbow and Keep a pillow to my left axilla to make sure my elbow is not touching anything. Per wound care nursing notes dated 3/21/16: Stage II left elbow is 1.4 cm by 1.6 cm with small amount of serosanguinous drainage noted. On 3/28/16, however, the left elbow pressure sore was noted to be at stage III, measuring 2 cm by 2.5 cm by 1.5 cm, [DIAGNOSES REDACTED]tous (red/swollen) around the wound with a small amount of serous drainage and contacting physician (PCP) for possible antibiotic treatment. On 3/31/16, the wound measured 3 cm by 2.5 cm by 1.3 cm with moderate serous drainage and the resident was on a 10 day course of Keflex (antibiotics). On 4/11/16, the [DIAGNOSES REDACTED] around the elbow wound was noted as resolved. On 4/15/16 [DIAGNOSES REDACTED] was again noted. On 4/21/16, the wound specialist saw the resident and wound care was continued to the stage III elbow pressure sore, the coccyx, right heel and bilateral hips. 4/22/16, the left elbow pressure sore was noted as [DIAGNOSES REDACTED]tous around the wound with maceration (the softening and breaking down of skin from prolonged exposure to moisture) and moderate serous drainage. On 5/6/16 the elbow sore was noted to have maceration and moderate serous drainage. On 5/13/16, the sore was noted to have an opening of 2.8 cm by 2 cm by 0.9 cm with undermining (was larger underneath the opening than on the surface), maceration and moderate serous drainage. The wound dressings were increased from once a day to twice a day due to the maceration. On 5/20/16, the left elbow pressure sore was noted to measure 3 cm by 3.5 cm by 0.9 cm with maceration and moderate serous drainage and the sacral stage IV pressure sore was 5 cm by 5.8 cm. On 5/24/16 at 12:25 AM, a staff nurse noted: Left elbow is reddened, swollen and warm to touch with moderate, large amount of dark brown drainage noted. At 1:45 PM, nurse unit manager 'E', who was the previous wound care nurse, looked in the computer and found no documented indication that the PCP, the wound specialist or the wound care nurses were notified by the staff nurse that the elbow area and elbow pressure sore had further declined. During the skin observation earlier that day, the area appeared infected as previously mentioned, the sacral wound, when measured at that time, was 5.8 cm by 9 cm and the wound specialist had not seen the resident during May 2016. On 5/24/16 at 2 PM, when the decline of the wounds to the left elbow and sacral area and the frequency of the wound consults were discussed with the Director of Nursing and nurse 'E', nurse 'E' said, He (wound specialist) comes once a month and did not respond further. At 2:30 PM, the wound specialist said during a phone interview, The wounds were not that bad when I saw him before. I saw him last month. I come there once a month. When asked how frequently he was able or allowed to see the resident, the specialist said, I would come everyday if they wanted me to. On 5/25/16 at 8 AM, per review of the facility's Prevention of Pressure Ulcers policy dated 5/2011: Pressure sores usually form when a resident remains in the same position for an extended period of time causing increased pressure and form most commonly where the bone is near the surface, such as elbows. Pressure ulcers are often made worse by continued moisture, such as wound drainage. Contractures need to be addressed and managed to prevent development of pressure sores. Protect bony prominences as needed. Review the resident's care plan to assess for any special needs of the resident. By survey exit, the staff did not offer or provide an additional information regarding this citation. ( )

This citation refers to Intake # M 0346 Based on interview and record review, the facility failed to ensure a gait belt was used during a wheelchair to toilet transfer for one (#801) of three sampled residents reviewed for falls, from a total sample of three, requiring hospitalization for bilateral hip fractures and a spinal fracture. Findings include: On [DATE] at 10:00 A.M., Resident #801's clinical record was reviewed a.m. and revealed that Resident #801 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] documented that Resident #801 required one person physical assistance for transfers and toileting. According to a "Facility Event Summary Report" (incident and accident report) dated [DATE] at 5:24 A.M., Resident #801 started to lose balance while being assisted to the toilet in the bathroom and was "lowered to the floor" by a CNA (certified nursing assistant). The resident was then transferred back in to a wheelchair by two people. According to the document, Resident #801 complained of pain in his left lower extremity above the knee where redness and swelling were present. Resident #801 was sent to the emergency room per the physician's orders [REDACTED]. Staffing assignment sheets were reviewed for [DATE] and [DATE] and revealed that CNA "A" was the CNA assigned to Resident #801 on the midnight shift of [DATE]. CNA "A" was interviewed on [DATE] at 11:30 A.M. regarding the incident mentioned above. CNA "A" reported that on [DATE] around 4:45 A.M., she responded to Resident #801's call light and he said he had to use the bathroom. CNA "A" stated, "He is a one person assist so I transferred him to the wheelchair, took him into the bathroom, measured him up to the toilet. I assisted him while he held on to the hand rails and he started to lose his balance. I hurried up and pulled the cord (emergency call light) and continued holding him. He did not fall. The 'pool CNA' (CNA "F" who was a contracted employee through a staffing agency) came in and did not want to help me get him on the toilet. Instead, she grabbed him from under his arms and then let go of him and yelled for a nurse. The nurse came in and told me to lower him to the ground so, CNA "F" and I lowered him to the ground. LPN "G" was near the resident and then jumped back really fast. I don't know if she heard a popping sound or something. LPN "G" and CNA "F" tried to get him up without a gait belt and then asked CNA"F" to get a gait belt. When she got the gait belt, they got me to help. When he got up, his leg didn't look right. He went to the hospital." CNA "A" reported that she was not using a gait belt at the time she transferred the resident from the bed to the wheelchair and the wheelchair to the toilet. CNA "A" was interviewed a second time on [DATE] at 1:20 P.M. regarding gait belt use and explained that a gait belt should be used for all transfers. When asked why she did not use a gait belt when she attempted to transfer Resident #801 from the wheelchair to the toilet on [DATE], she stated, "Because I didn't have one." When queried about why she did not have a gait belt, CNA "A" stated, "They never gave me a gait belt. They gave me this one the day after this incident." An "ADL Functional/Rehabilitation Potential" Care Plan dated [DATE] for Resident #801 was reviewed on [DATE] at 12:30 P.M. and documented the resident needed "...need help with transfers, bed mobility, locomotion, and ROM (range of motion) due to my [DIAGNOSES REDACTED].XXX[DATE] Transfers and toileting: I need 1 PA (person physical assist)." The Care Plan did not document the need for use of a gait belt for transfers. Unit Manager "D" was interviewed on [DATE] at 12:20 P.M. and was asked where the CNAs would look to find out about a resident's care needs--such as how they should be transferred. Unit Manager "D" explained that the resident care guides were generated from the care plans and printed off and placed in the resident's room for CNA's to review/access. A copy of Resident #801's resident care guide was requested at this time and it was printed. Review of Resident #801's resident care guide gave no additional instruction to CNA's regarding approaches to be used to transfer the resident safely. The care plan did not instruct staff to use a gait belt for transfers. The facility's investigation of the incident for Resident #801 was reviewed on [DATE] at 1:25 P.M. and included a "One on One In-Service" dated [DATE] (not the day after the incident, which was [DATE]) for CNA "A". The topic of the inservices documented, "Gait belt is used with every transfer to prevent injury to self and safe transfer of residents..." The Administrator was interviewed on [DATE] at 1:30 P.M. regarding the facility's policy on manual lift transfers and indicated that a gait belt should have been used for Resident #801. The Administrator reported that all CNAs automatically receive a gait belt during orientation and sign off on a form that indicated they received it. The form that documented that CNA "A" and CNA "F" received a gait belt from the facility was requested at this time as well as documentation of inservice training on using a gait belt, per facility policy. The facility was unable to provide any documented evidence that CNA "F" (pool aide) had receiving training from the facility on using a gait belt or that a gait belt had been issued to her. On [DATE] at 2:50 P.M. a form titled, "Gait Belt" was provided by the Administrator for CNA "A". The Administrator reported that Registered Nurse (RN) "B" was responsible for maintaining the "Gait Belt" forms. The form received from the Administrator concerning CNA "A" was dated [DATE] and signed by CNA "A". The form stated, "I understand that the gait belt is part of my uniform. I have read the gait belt policy and understand it. I have been given a gait belt and a copy of the procedure. I have been inserviced on the use of the gait belt..." On [DATE] at 2:55 p.m. a third interview was conducted with CNA "A". CNA "A" was shown the "Gait Belt" form, that indicated she was provided with a Gait belt, inservice and facility policy for manual transfers on [DATE]. CNA "A" stated, "I just signed this today." When asked who had her sign the form, CNA "A" stated, "(name RN "B")." CNA "A" further stated, "It's the honest truth. I just signed that today." When queried about the documented date of [DATE], CNA "A" stated, "They told me to write that date. I swear I did not have a gait belt until the day after the incident ([DATE]). They trained me to use it, but did not give one to me. This was my first time on the floor by myself after training." RN "B" and the Administrator were interviewed on [DATE] at 3:30 P.M. RN "B" was asked when the Gait Belt form was signed by CNA "A". RN "B" stated, "I didn't have her (CNA "A") sign it." When asked where the form came from, RN "B" stated, "I don't know who gave it to me. They got it from her file." When asked who got it from CNA "A"'s file, RN "B" stated, "I don't know." The Administrator was asked who gave her the form and the Administrator stated, "I got it from (RN "B"). When asked who the form was requested from, the Administrator stated, "I don't know. There are a bunch of people back there (in the office) scrambling to get stuff." Hospital records for Resident #801 were reviewed on [DATE] at 2:00 P.M. and documented Resident #801 was admitted [DATE] with [DIAGNOSES REDACTED]. The discharge [DIAGNOSES REDACTED]. The hospital records also documented the following: [DATE]--- Resident #801 was brought to the hospital from the facility with complaints of right hip and left leg pain after he was assisted to the bathroom, began to feel weak, and "gently" sat down by nursing home staff. - X rays in the ED revealed "displaced, oblique (diagonal) fracture of left femoral shaft (thigh bone); comminuted subtrochanteric fracture of right femur (part of the thigh bone that attaches to the hip was broken into several pieces), avulsion (forcible tearing away of a body part from trauma) of lesser trochanter of right femur (upper part)". - An Open Reduction Internal Fixation (ORIF - surgical procedure) was performed on the right hip fracture and a closed reduction with splintage was performed on the left femoral fracture. - Resident was found to have low urine output and significant elevation of myoglobin levels (a protein released from damaged muscles and filtered through the kidneys that in large amounts can cause kidney damage.) [DATE]--Resident #801 was hypotensive (low blood pressure) and required a Central Line with pressure support. - Resident #801 was evaluated for possible PE with results that showed Intermediate probability for PE - Resident #801 complained of back pain, a CT scan was performed and revealed an unstable L2 (a vertebrae in the lower back) chance fracture (a fracture that extends from the back to front of the bony structure of a vertebrae in which the line of the break forms a right angle with the axis of the bone, typically seen after motor vehicle accidents or falls). [DATE]--Resident #801 experienced acute respiratory failure with hypoxemia (low level of oxygen in the blood) and required intubation (a tube placed into the windpipe to assist with breathing) and remained intubated and sedated until [DATE] [DATE]--Resident was admitted into hospice, terminal weaning (intentional reduction of mechanical respiration allowing a patient to die) was done and Resident #801 expired the same day. The facility's policy titled "Gait Belts", with a revision date of ,[DATE], was reviewed on [DATE] at 3:30 P.M. and documented, "...To prevent injury to self and safely strainers residents...All CENA'S are to have on their person a gait belt at all times...A form will be signed by each CENA upon hire that a gait belt was received; they received training, and read the policy...The nurses on each unit will be responsible for ensuring the CNA's have and are using their gait belts..." The facility's policy titled, "Safe Lifting and Movement of Residents", with a revision date of ,[DATE] was reviewed on [DATE] at 3:35 P.M. and documented, "...Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts...)...Best practice is to use a gait belt during transfers..."

THIS DEFICIENT PRACTICE HAS MULTIPLE DEFICIENCIES: DEFICIENT PRACTICE 1# BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO IDENTIFY AND IMPLEMENT MEASURES TO MAINTAIN THE SAFETY OF ONE (#706) OF ONE RESIDENTS REVIEWED WHO fell MULTIPLE TIMES WHILE BEING TRANSPORTED BY STAFF VIA WHEELCHAIR FROM A TOTAL OF 20 SAMPLED RESIDENTS, RESULTING IN A FRACTURED NOSE. FINDINGS INCLUDE: ON 4/24/11 AT 9:00 A.M. WITH NURSE (A), RESIDENT #706 WAS OBSERVED RESTING IN BED. AT 3:00 P.M., RESIDENT #706 WAS OBSERVED IN A WHEELCHAIR SEATED IN FRONT OF THE NURSING STATION. ON 4/26/12 AT 2:30 P.M., RESIDENT #706 WAS OBSERVED MIDWAY THE 100 UNIT HALLWAY SEATED IN A WHEELCHAIR. THE ADMISSION CLINICAL ASSESSMENT, DATED 2/27/12, INDICATED RESIDENT #706 WAS ORIGINALLY admitted INto the facility on [DATE] AND REadmitted on [DATE], WITH [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM DATA SETS, DATED 10/07/11 AND 1/03/12, RESIDENT #706 HAD SEVERELY IMPAIRED COGNITIVE SKILLS FOR DECISION MAKING, WAS NON-AMBULATORY, HAD POOR POSTURAL SITTING BALANCE, AND REQUIRED EXTENSIVE PHYSICAL ASSISTANCE FROM TWO STAFF MEMBERS FOR MOBILITY AND TRANSFERS. RESIDENT #706'S PRIMARY MODE OF TRANSPORTATION WAS VIA WHEELCHAIR. THE RESIDENT WAS UNABLE TO PROPEL THE WHEELCHAIR INDEPENDENTLY AND WAS TRANSPORTED BY STAFF. THE FALL RISK assessment dated [DATE], INDICATED RESIDENT #706 WAS AT "HIGH RISK" FOR FALLS. THE ACTIVITIES OF DAILY LIVING SKILLS ANALYSIS, DATED 8/05/11 AND 11/15/11, INDICATED RESIDENT 706 REMAINED AT RISK FOR FALLS AND REQUIRED THE PHYSICAL ASSISTANCE OF TWO STAFF MEMBERS FOR TRANSFERS. REVIEW OF THE FACILITY'S "SAFETY EVENTS-FALLS" (INCIDENT/ACCIDENT REPORT) AND NURSING NOTES FOR RESIDENT# 706 REVEALED THE FOLLOWING: 1. SAFETY EVENT: 9/02/11 AT 7:00 P.M., RESIDENT WAS SITTING IN HER WHEELCHAIR BY STATION ONE AND LEANING FORWARD IN HER CHAIR AND fell on TO THE FLOOR-- LANDING ON BOTH KNEES--BOTH KNEES SLIGHTLY REDDENED..." INTERVIEW WITH THE FACILITY'S "FALLS INVESTIGATOR" NURSE MANAGER (A) ON 4/2712 AT 10:00 A.M. REVEALED THE FALLS THAT OCCURRED ON 9/02/11 WAS ":ISOLATED" AND NO NEW SAFETY INTERVENTIONS WERE IMPLEMENTED. 2. SAFETY EVENT: 10/2/11 AT 8:37 P.M., "...AT APPROX. (APPROXIMATELY) 7 P.M., WRITER WITNESSED RES. PLAYING WITH WHEELCHAIR IN HALLWAY. WRITER BEGAN PUSHING RESIDENT DOWN HALL 3 TOWARD NURSING STATION 3 AND RESIDENT fell FORWARD OUT OF WHEELCHAIR ONTO FLOOR. RESIDENT'S NOSE BEGAN TO BLEED AND WRITER CALLED FOR HELP. STAFF ASSESSED RESIDENT ON STATION 3 FLOOR, THEN RESIDENT WAS TRANSFERRED BACK TO WHEELCHAIR. INJURY NOTED TO NOSE. MD (MEDICAL DOCTOR) ORDERED RESIDENT TO BE TRANSFERRED TO emergency room ..." ACCORDING TO THE NURSING NOTE, DATED 10/2/2011 AT 8:53 P.M., "...RESIDENT FULLY ASSESSED HEAD TO TOE, 1 INCH LACERATION NOTED TO BRIDGE OF NOSE...POSSIBLE CHIPPED TOOTH...COMPRESSION TO BRIDGE OF NOSE TO STOP BLEEDING..." RESIDENT #706 WAS TRANSFERRED TO A LOCAL HOSPITAL FOR EVALUATION AND TREATMENT. INTERVIEW WITH THE FACILITY'S "FALLS INVESTIGATOR" NURSE MANAGER (A) ON 4/27/12 AT 10:00 A.M. REGARDING THE FALL AND INJURY RESIDENT #706 SUFFERED ON 10/02/11, REVEALED THE STAFF MEMBER FAILED TO IMPLEMENT TACTILE CUEING TO ASSIST RESIDENT #706 TO SIT BACK IN THE WHEELCHAIR DURING TRANSPORTATION. "CUEING" WAS TO HELP PREVENT THE FALL A HOSPITAL RADIOLOGY (X-RAY) REPORT, DATED 10/02/11 REVEALED RESIDENT #706 SUSTAINED "A NONDISPLACED NASAL BONE FRACTURE ...HEMORRHAGE IS SEEN WITHIN THE LEFT MAXILLARY SINUS..." SUBSEQUENT NURSING NOTES REVEALED THE RESIDENT RETURNED FROM THE hospital on [DATE] AT 1:50 A.M., WITH [DIAGNOSES REDACTED]. 3. SAFETY EVENT -FALLS: 11/21/11, 8:56 P.M., "...ACTIVITY LADY WAS PUSHING RESIDENT IN HER WHEELCHAIR BY THE STORE AND THEY STOPPED TO TALK TO ANOTHER RESIDENT...RESIDENT #706) QUICKLY TIPPED FORWARD AND fell HEAD FIRST (FROM WHEELCHAIR) WITH BOTH KNEES LANDING ON THE FLOOR LAYING ON HER LEFT SIDE. SMALL LACERATION PRESENT TO LEFT EYEBROW. SMALL AMOUNT OF BLOOD NOTED. SLIGHT SWELLING NOTED...SMALL REDDENED AREA PRESENT TO BOTH KNEES..." DURING INTERVIEW WITH FALLS COORDINATOR "A" ON 4/27/12 AT 10:00 A.M., IT WAS REPORTED THE PERSON TRANSPORTING THE RESIDENT WHEN SHE fell on [DATE] WAS "ACTIVITY STAFF" AND SHE WAS NOT AWARE OF "TACTILE CUEING" INTERVENTION. A FORM ENTITLED, "TEACHING, COACHING, AND COUNSELING" DATED 11/23/11, REVEALED AN ACTIVITY STAFF MEMBERS WAS PROVIDED INFORMATION ON "SAFETY DEVICES"; HOWEVER, THE COUNSELING DID NOT REVEAL INSTRUCTIONS ON HOW TO SAFELY TRANSPORT RESIDENTS. THE CARE PLAN LISTED THE "FALL" EVENT ON "11/21" AND WRITTEN BESIDE IT "NO NEW INTERVENTIONS". 4. SAFETY EVENT-FALLS: 12/31/11 - 5;40 P.M., "...CENA (COMPETENCY EVALUATED NURSE ASSISTANT) AND NURSE WERE ASSISTING RESIDENT TO THE TABLE IN DINING ROOM B WHEN RESIDENT LEANED OVER IN HER WHEELCHAIR AND SLID ONTO FLOOR LANDING ON BOTH KNEES...SMALL SKIN TEAR AND BUMP PRESENT TO LEFT KNEE..." DURING INTERVIEW ON 4/27/12 AT 10:00 A.M., THE FACILITY'S FALLS INVESTIGATOR (NURSE "A" REPORTED THE FALL ON 12/13/11 OCCURRED WHEN RESIDENT #706 LEANED FORWARD AND fell on TO FLOOR WHILE BEING TAKEN TO THE DINING ROOM BY TWO STAFF MEMBERS. THE FALLS INVESTIGATOR WAS UNABLE TO PROVIDE EVIDENCE THIS INCIDENT WAS ADDRESSED TO PREVENT RECURRENCE. THE NURSING PLAN OF CARE, DATED 3/04/12, ENTITLED, "HISTORY OF FALLS--RISK FOR INJURY R/T (RELATED TO) DEMENTIA, AS EVIDENCED BY EXTENDED REACHING FOR ITEM..." INDICATED RESIDENT #706 REMAINED AT RISK FOR FALLS. THE PLAN OF CARE INTERVENTIONS/APPROACHES INCLUDED: "...VISUAL SAFETY CHECKS EVERY TWO HOURS AND AS NEEDED; FREQUENT VISUAL MONITORING; FRONT AND REAR ANTI-TIPPERS ON WHEELCHAIR; ASSIST WITH BED TO CHAIR TRANSFERS 2 PERSON ASSIST; TACTILE (TOUCH) CUEING DURING TRANSPORTATION IN WHEELCHAIR; SENSOR PAD IN BED AND WHEELCHAIR..." THERE WERE NO "NEW" INTERVENTIONS LISTED BETWEEN 9/15/11 AND 3/31/12" TO ADDRESS THE FALLS DURING RESIDENT TRANSPORT VIA WHEELCHAIR. THE FACILITY PROVIDED THEIR FALLS POLICY ENTITLED, "MANAGING FALLS AND FALLS RISKS", DATED 01/2011. THE POLICY INSTRUCTED STAFF TO EVALUATIONS CURRENT DATA, AND WITH STAFF INPUT AND THE INPUT OF THE ATTENDING PHYSICIAN, IDENTIFY INTERVENTIONS RELATED TO THE RESIDENT'S SPECIFIC RISKS AND CAUSES TO TRY TO PREVENT THE RESIDENT FROM FALLING AND TRY TO MINIMIZE COMPLICATIONS FROM FALLING. THIS POLICY DID NOT ADDRESS STAFF TRAINING TO ENSURE SAFE TRANSPORTATION OF RESIDENTS IN WHEELCHAIRS. DURING THE AFOREMENTIONED INTERVIEW, THE FACILITY'S FALLS INVESTIGATOR WAS UNABLE TO EXPLAIN WHY THE FALLS PREVENTION MEASURES, STATED IN THE FALL PREVENTION PLAN OF CARE HAD NOT BEEN IMPLEMENTED FOR RESIDENT #706 TO HELP PREVENT FALLS AND COMPLICATIONS FROM FALLS, SUCH AS INJURIES TO THE KNEES, EYEBROW AND A FRACTURED NOSE. ( ) DEFICIENT PRACTICE #2 BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO MONITOR THE USE OF EXTENSION CORDS AND POWER STRIP CORDS IN RESIDENT'S ROOMS, IN 27 OF 100 RESIDENT ROOMS (#'S 100, 102, 103, 107, 109, 111, 116, 118, 122, 128, 301, 305, 307, 308, 312, 315, 323, 330, 334, 403, 405, 409, 410, 412, 424, 429, AND 431). THIS HAD THE POTENTIAL TO AFFECT SEVEN OF 20 SAMPLED RESIDENTS (#'S 701, 704, 706, 709, 710, 711, AND 719), AND 32 OFF-SAMPLED RESIDENTS (#'S 3, 8, 9, 11, 15, 25, 29, 30, 31, 33, 36, 40, 41, 46, 47, 50, 58, 60, 61, 67, 68, 73, 76, 81, 86, 88, 90, 92, 93, 95, 97, AND 98), RESULTING IN THE POTENTIAL FOR ELECTRICAL FIRES. FINDINGS INCLUDE: DURING A TOUR OF THE FACILITY WITH MAINTENANCE STAFF "H", THE FOLLOWING ROOMS WERE OBSERVED WITH POWER STRIP CORDS OR EXTENSION CORDS IN USE: ROOM 100: ONE POWER STRIP IN USE FOR AN OXYGEN CONCENTRATOR AND AN INTRAVENOUS PUMP. ONE POWER STRIP IN USE FOR A BED AND AIR MATTRESS. ROOM 102: ONE POWER STRIP IN USE FOR A BED. ROOM 103: ONE POWER STRIP IN USE FOR A BED. ROOM 107: ONE POWER STRIP IN USE FOR A BED. ROOM 109: ONE POWER STRIP IN USE FOR AN OXYGEN CONCENTRATOR, A NEBULIZER, AND A LAMP. ROOM 111: ONE POWER STRIP IN USE FOR TWO BEDS. ROOM 116: ONE POWER STRIP IN USE FOR A TUBE FEEDING MACHINE AND A BED. ROOM 118: ONE POWER STRIP IN USE FOR A GAME CHARGER, PHONE AND BED. ROM 122: ONE BROWN EXTENSION CORD IN USE FOR A FAN. THE BROWN EXTENSION CORD WAS PLUGGED INTO A POWER STRIP CORD. ROOM 128: ONE POWER STRIP CORD IN USE FOR A TUBE FEEDING MACHINE AND AN EXTENSION CORD. THE EXTENSION CORD WAS IN USE FOR THE BED. ROOM 301: ONE POWER STRIP IN USE FOR A TUBE FEEDING MACHINE, AN OXYGEN CONCENTRATOR, AND A BED. ROOM 305: ONE POWER STRIP IN USE FOR A BED. ROOM 307: ONE EXTENSION CORD IN USE FOR A BED. ROOM 308: ONE POWER STRIP IN USE FOR A LAMP, BED, CHARGER, AND POWER CHAIR. ROOM 312: ONE POWER STRIP IN USE FOR AN OXYGEN CONCENTRATOR, BED, CHARGER, AND COMPACT DISC PLAYER. ROOM 315: ONE POWER STRIP IN USE FOR A BED. ROOM 323: ONE POWER STRIP IN USE FOR A BED AND COMPACT DISC PLAYER. ROOM 330: ONE POWER STRIP IN USE FOR A BED. ROOM 334: ONE POWER STRIP IN USE FOR A LAMP AND COMPACT DISC PLAYER. ROOM 403: ONE POWER STRIP IN USE FOR A CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) MACHINE, LAMP, AND BED. ROOM 405: ONE POWER STRIP IN USE FOR A BED AND LAMP. ROOM 409: ONE POWER STRIP IN USE FOR A BED. ROOM 410: ONE POWER STRIP IN USE FOR A NEBULIZER, LAMP, AND BED. ROOM 412: ONE POWER STRIP IN USE FOR A BED. ROOM 424: ONE POWER STRIP IN USE FOR A BED. ROOM 429: ONE POWER STRIP IN USE FOR A LAMP AND BED. ROOM 431: ONE BROWN EXTENSION CORD PLUGGED INTO THE WALL OUTLET. WHEN QUERIED ON 4/26/12 AT 11:00 A.M., MAINTENANCE STAFF "H" CONFIRMED THAT EXTENSION CORDS WERE NOT TO BE USED IN RESIDENT ROOMS. STAFF "H" FURTHER STATED THAT THE FACILITY DID NOT HAVE WRITTEN DOCUMENTATION FOR THE MONITORING OF EXTENSION CORD AND POWER STRIP USAGE IN RESIDENT ROOMS. REVIEW OF THE FACILITY'S POLICY, "ELECTRICAL SAFETY FOR RESIDENTS", REVISED 5/2011, NOTED: "8. POWER STRIPS SHALL NOT BE USED WITH MEDICAL DEVICES IN RESIDENT CARE AREAS.". ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE TREATMENT AND SERVICES TO PREVENT THE DEVELOPMENT OF NEW PRESSURE SORES/WOUNDS FOR TWO OF FOUR SAMPLED RESIDENTS (#510 AND 503) REVIEWED FOR PRESSURE SORES FROM A TOTAL SAMPLE OF 22, RESULTING IN THE DEVELOPMENT OF AVOIDABLE PRESSURES SORES. FINDINGS INCLUDE: ON 6/14/11 AT 1:30 P.M., A DRESSING CHANGE AND WOUND CARE OBSERVATION WAS CONDUCTED FOR RESIDENT #510 WITH TREATMENT NURSE (E). IT WAS OBSERVED THAT RESIDENT #510 HAD A STAGE THREE (III) PRESSURE SORE/ULCER ON THE LEFT LATERAL FOOT THAT MEASURED 1.5 CENTIMETER (CM) X 0.5 CM WITH A SCANT AMOUNT OF SLOUGH ON THE WOUND BASE. ON 6/15/11 FROM 1:30 P.M. TO 2:30 P.M., RESIDENT #510 WAS OBSERVED LYING IN BED, ASLEEP. IT WAS OBSERVED THAT RESIDENT #510 FEET HAD NOT BEEN FLOATED. THE HEEL PILLOWS HAD BEEN PLACED ON THE BED, NEXT TO RESIDENT #510 AND NOT BENEATH HER FEET AS ORDERED BY THE PHYSICIAN. RESIDENT #510'S LATERAL FOOT (SITE OF THE STAGE III PRESSURE SORE/ULCER) WAS PRESSED DIRECTLY AGAINST THE MATTRESS. UNIT MANAGER (A) STATED RESIDENT #510'S FEET SHOULD HAVE BEEN FLOATED. RESIDENT #510'S CLINICAL RECORD WAS REVIEWED ON 6/14/11 AT 1:30 P.M. THE CLINICAL ADMISSION ASSESSMENT, DATED 2/25/09, INDICATED RESIDENT #510 WAS admitted INto the facility on [DATE] diagnosed with [REDACTED]. THE ANNUAL MINIMUM DATA SET (MDS), dated [DATE], INDICATED RESIDENT #510 WAS MODERATELY IMPAIRED IN COGNITIVE SKILLS FOR DAILY DECISION MAKING. RESIDENT # 510 WAS NON-AMBULATORY, REQUIRED EXTENSIVE ASSISTANCE IN BED MOBILITY AND WAS TOTALLY DEPENDENT ON STAFF FOR DRESSING AND PERSONAL HYGIENE. THE ANNUAL MINIMUM DATA SET INDICATED RESIDENT #510 HAD NO PRESSURE ULCERS DURING THAT OBSERVATION PERIOD. THE RESIDENT ASSESSMENT PROTOCOL (RAP) SUMMARY DATED 9/30/10, STATED THE FOLLOWING: "RESIDENT'S NAME, HAS INTACT SKIN, SHE IS AT RISK FOR PRESSURE ULCERS DUE TO LIMITED BED MOBILITY, INCONTINENCE AND THE [DIAGNOSES REDACTED]." A PHYSICIan order for [REDACTED]. THE QUARTERLY MDS, DATED 12/25/10, INDICATED RESIDENT #510 REMAINED AT RISK FOR PRESSURE SORES; HOWEVER, DURING THAT OBSERVATION PERIOD RESIDENT #510 STILL HAD NO PRESSURE ULCERS. A NURSING NOTE, DATED 1/26/11, FOR RESIDENT #510, INDICATED RESIDENT #510 HAD DEVELOPED A SMALL BLISTER TO THE MID/INNER (R) RIGHT FOOT AND THAT THE TREATMENT NURSE HAD BEEN NOTIFIED. A WOUND/TREATMENT NOTE, DATED 1/27/11, INDICATED RESIDENT #510 HAD A " STAGE 3 PRESSURE SORE, LEFT OUTER FOOT (LATERA) SLOUGH CENTER, PINK INTACT PERIMETER, SCANT SEROUS DRNG. (DRAINAGE)." (STAGE III PRESSURE ULCER-FULL THICKNESS SKIN LOSS INVOLVING DAMAGE TO, OR NECROSIS OF, SUBCUTANEOUS TISSUE THAT MAY EXTEND DOWN TO, BUT NOT THROUGH, UNDERLYING FASCIA) FURTHER REVIEW OF RESIDENT #510'S CURRENT CLINICAL RECORD REVEALED THERE WERE NO INTERVENTIONS IN PLACE TO APPLY HEEL PILLOWS ON RESIDENT #510 WHEN SHE WAS IN BED, AS STATED IN THE PHYSICIAN ORDER DATED 10/22/10. FURTHERMORE, THE FACILITY FAILED TO PROCEED TO A PLAN OF CARE FOR PRESSURE ULCER PREVENTION FOR RESIDENT #510 AS STATED IN THE ANNUAL RAP SUMMARY, DATED 9/28/10. THE CLINICAL RECORD REVEALED THAT A PRESSURE ULCER PREVENTION PLAN OF CARE FOR RESIDENT #510 WAS NOT DEVELOPED UNTIL 1/27/11-- AFTER RESIDENT # 510 HAD ALREADY DEVELOPED A STAGE III PRESSURE ULCER ON THE LEFT LATERAL FOOT. AN INTERVIEW WAS CONDUCTED ON 6/15/11 AT 2:45 P.M. WITH THE ADMINISTRATOR AND TREATMENT NURSE (E). THE ADMINISTRATOR AND TREATMENT NURSE (E) STATED THAT IT WAS THE RESPONSIBILITY OF THE TREATMENT NURSE TO DEVELOP PRESSURE ULCER/SORE INTERVENTIONS AND PLANS OF CARE FOR PRESSURE ULCER PREVENTION. THE ADMINISTRATOR CONFIRMED THAT RESIDENT #510 HAD NOT RECEIVED THE APPROPRIATE TREATMENT AND SERVICES REQUIRED TO HELP PREVENT THE DEVELOPMENT OF THE NEW PRESSURE SORES. THE FACILITY'S "...DECUBITUS ULCER (PRESSURE SORE TREATMENT GUIDELINES" WERE REVIEWED ON 6/16/10 AT 2:45 P.M., THE GUIDELINES STATED THE FOLLOWING:"WHILE IN BED: INDIVIDUALS WHO ARE IN BED SHOULD NOT BE POSITIONED ON THE PRESSURE SORE (S)...POSITIONING DEVICES SHOULD BE USED TO RAISE THE ULCER OFF THE SUPPORT SURFACE..." ( ) ON 6/14/11 AT 1:00 PM, A REVIEW OF THE FACE SHEET REVEALED THAT RESIDENT #503 WAS RE-admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE "BRADEN SCALE FOR PREDICTION OF PRESSURE SORE", DATED 1/10/11, INDICATED RESIDENT #503 WAS AT RISK FOR THE DEVELOPMENT OF PRESSURE SORES. THE MINIMUM DATA SET (MDS), dated [DATE], INDICATED THAT RESIDENT #503 HAD A STAGE 3 PRESSURE SORE. ON 6/14/11 AT 11:30 A.M. WOUND CARE OBSERVATION REVEALED A HEALING STAGE III ON THE LEFT BUTTOCK MEASURING 2.0cm x 2.7cm x 0.2cm ON 6/16/11, THE PROGRESS NOTES, DATED 1/22/11, WERE REVIEWED WITH TREATMENT NURSE "E". THEY REVEALED THAT RESIDENT #503 WAS IDENTIFIED AS HAVING EXCORIATION (AN ABRASION OF THE SKIN. - TABER'S DICTIONARY, 21ST EDITION) TO THE COCCYX AREA ON 1/22/11 DESCRIBED AS "PINK EXCORIATION WITH PEELING SKIN, AREA HEALING". THE PHYSICIAN ORDERS, DATED 1/22/11, STATED THAT "MEDISEPTIC CREAM (A MOISTURE BARRIER: ESPECIALLY FORMULATED TO TREAT ADULT DIAPER [MEDICAL CONDITION], DENUDED SKIN AND [MEDICAL CONDITION] ORDERED TO BE APPLIED ONCE A DAY." ON 2/8/11, THE EXCORIATED AREA WAS DOCUMENTED AS BEING A STAGE III PRESSURE SORE (STAGE III: IS CHARACTERIZED BY FULL THICKNESS SKIN LOSS INVOLVING DAMAGE OR NECROSIS OF SUBCUTANEOUS TISSUE THAT MAY EXTEND DOWN TO, BUT NOT THROUGH, UNDERLYING FASCIA (IT CONNECTS THE SKIN TO THE MUSCLES-TABER'S DICTIONARY, 21ST EDITION) THAT MEASURED 2.0 CM (CENTIMETERS) LENGTH X 2.5 CM WIDTH X 0.3 CM DEPTH. THERE WAS NO DOCUMENTATION, BETWEEN 1/22/11 AND 2/8/11, THAT INDICATED THE EXCORIATED AREA WAS WORSENING. THE TREATMENT NURSE "E" HAD NO EXPLANATION FOR THE LACK OF DOCUMENTATION NOR COULD SHE EXPLAIN WHY THE TREATMENT WAS NOT CHANGED UNTIL UNTIL 4/20/11 ONCE THE ABRADED SKIN BECAME AN OPEN WOUND. ON 6/15/11 AT 2:30 PM, A REVIEW OF THE FACILITY POLICY ENTITLED "DECUBITUS ULCER (PRESSURE SORE) TREATMENT GUIDELINES", REVISED 8/6/10, STATED, "PRESSURE SORES ARE ASSESSED ONCE A WEEK, BUT DETERIORATION EITHER IN THE RESIDENT'S OVERALL CONDITION OR IN THE PRESSURE SORE ITSELF MANDATES MORE IMMEDIATE REASSESSMENT AS WELL AS REEVALUATION OF THE TREATMENT PLAN." ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 159 BASED ON OBSERVATION, INTERVIEW AND RECORDS REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND A FUNCTIONAL ALARM FOR 1 (#504) OF 5 SAMPLED RESIDENTS RESULTING IN A FALL AND LACERATION TO THE FOREHEAD. FINDINGS INCLUDE: RESIDENT #504 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. SHE WAS ORIGINALLY admitted to the facility on [DATE]. SHE WAS REadmitted on [DATE] AFTER FALLING AND SUSTAINING A LACERATION TO THE FOREHEAD REQUIRING SUTURES. THE FACILITY'S "EVENT REPORT", DATED 3/28/11 AT 7:45 P.M., DOCUMENTED "RESIDENT (#504) OBSERVED ON FLOOR WITH LACERATION TO LEFT EYEBROW AREA. MODERATE AMOUNT OF RED DRAINAGE OBSERVED. DR. NOTIFIED AND ORDER RECEIVED TO TRANSFER TO (ACUTE CARE HOSPITAL) FOR OBSERVATION." THE EVENT REPORT INCLUDED A NURSE'S NOTE DATED 3/28/11 AT 7:34 P.M. WHICH DOCUMENTED NURSE # 1 "OBSERVED RESIDENT (#504) ON THE FLOOR LAYING ON HER LEFT SIDE . LACERATION TO LEFT EYEBROW WITH MODERATE AMOUNT OF RED DRAINAGE PRESENT..." ACCORDING TO THE REPORT A SENSOR PAD WAS UTILIZED AT THE TIME OF THE FALL. THE ACUTE CARE HOSPITAL EMERGENCY PHYSICIAN RECORD DOCUMENTED RESIDENT #504 WAS SEEN ON 3/28/11 AT 9:30 P.M. WITH A 2 CM LACERATION TO LEFT FOREHEAD REQUIRING SUTURES. A REVIEW OF RESIDENT #504'S CLINICAL RECORD REVEALED: A MDS (MINIMUM DATA SET) DATED 3/26/11 DOCUMENTED RESIDENT #504 REQUIRED EXTENSIVE ASSISTANCE WITH ALL (ADL'S) ACTIVITIES OF DAILY LIVING. A 2/28/11 CAA (CARE AREA ASSESSMENT) REPORT FOR FALLS DOCUMENTED RESIDENT #504 WAS AT RISK OF FALLS RELATED TO A HISTORY OF FALLS AND HIP FRACTURE, POOR BALANCE DURING TRANSFERS, TOILETING AND SIT TO STAND, UNSTEADY GAIT EVEN WITH MOBILITY AID AND PERSONAL ASSISTANCE, COGNITIVE IMPAIRMENT, POOR SAFETY AWARENESS, PAIN, FATIGUE, MEDICATIONS AND CARDIAC DYSRHYTHMIA'S. A 2/22/11 FALL RISK ASSESSMENT DOCUMENTED RESIDENT #504 WAS AT HIGH RISK FOR FALLS WITH A TOTAL SCORE OF 19 (SCORE OF 10 OR HIGHER REPRESENTS A HIGH RISK FOR FALLS). A NURSES NOTE DATED 3/20/11 AT 3:23 A.M. DOCUMENTED, "RESIDENT (#504) VERY NON COMPLIANT WITH SAFETY MEASURES, MULTIPLE ATTEMPTS TO SELF AMBULATE." A (PT) PHYSICAL THERAPY NOTE DATED 3/28/11 AT 12:29 P.M., DOCUMENTED RESIDENT #504 WAS UNABLE TO STAND AFTER TWO ATTEMPTS. AN (OT) OCCUPATIONAL THERAPY NOTE DATED 3/28/11 AT 1:33 P.M., DOCUMENTED RESIDENT #504 REQUIRED MAXIMUM ASSISTANCE FOR SIT TO STAND, AND STANDING TOLERANCE WAS LESS THAN 20 SECONDS. ACCORDING TO RESIDENT #504'S CLINICAL RECORD CARE PLAN SNAPSHOT 8/21/10 INTERVENTIONS TO ADDRESS FALLS INCLUDED SENSOR PAD TO BED AND WHEELCHAIR, CHECK FUNCTIONING AND PLACEMENT EVERY SHIFT AND LOW BED WITH MAT ON FLOOR. ON 4/5/11 AT 4:00 P.M. RESIDENT #504 WAS OBSERVED BY THE SURVEYOR OUTSIDE HER ROOM, ACROSS AND TO THE LEFT OF THE UNIT 3 NURSES STATION, RECLINED IN A GERI CHAIR WITH A SENSOR ALARM ATTACHED TO THE BACK OF HER CHAIR. SHE WAS CLEAN, DRESSED APPROPRIATELY AND NOTED TO HAVE EDEMA AND 4 INTACT STERI STRIPS TO LEFT EYEBROW. RESIDENT #504 WAS QUERIED BY THE SURVEYOR ABOUT THE INJURY TO HER EYEBROW AND STATED "I BUMPED IT". ON 4/6/11 AT 1:10 P.M. PER PHONE, PHYSICAL THERAPIST #5 STATED, RESIDENT #504 WAS A 2 PERSON TRANSFER PRIOR TO THE FALL AND WAS NON-WEIGHT BEARING. THERAPIST #5 STATED, THE RESIDENT WAS KEPT IN VIEW OF NURSING STAFF FOR OBSERVATION BECAUSE SHE WOULD ATTEMPT TO GET OUT OF HER WHEELCHAIR AND FALL. IN AN INTERVIEW PER PHONE, ON 4/6/11 AT 6:35 P.M., WHEN QUERIED BY THE SURVEYOR ABOUT RESIDENT #504'S FALL ON 3/28/11, CNA #14 STATED HE WAS ASSIGNED TO RESIDENT #504 ON 3/28/11 BUT WAS AT LUNCH WHEN SHE fell . CNA # 14 STATED HE HAD GOTTEN RESIDENT #504 UP INTO HER GERI CHAIR AND ATTACHED AND CHECKED HER ALARM FOR FUNCTION AT APPROXIMATELY 4:45 P.M. AND TRANSPORTED HER TO THE DINING ROOM. HE STATED WHEN HE LAST OBSERVED RESIDENT #504, A DINING ROOM STAFF CNA WAS PUSHING HER OUT OF THE DINING ROOM ABOUT 6:50 P.M. AS HE WAS GOING TO LUNCH. ON 4/6/11 AT 11:45 A.M., CNA #2 STATED SHE RETURNED THE RESIDENT (#504) FROM THE DINING ROOM TO HER ROOM AFTER "LUNCH" (APPROXIMATELY 6:15 TO 6:30 P.M.). CNA #2 SAID THE ALARM WAS IN PLACE. SHE RECLINED RESIDENT #504 AND "FACED HER AWAY FROM THE BED SO SHE WOULDN'T ATTEMPT TO GET UP," AND THEN INFORMED ANOTHER CNA (UNABLE TO IDENTIFY THE CNA) THAT THE RESIDENT WAS IN HER ROOM. IN AN INTERVIEW PER PHONE, ON 4/6/11 AT 6:15 P.M., VISITOR # 13 STATED, "IT WAS ABOUT 7:00 P.M. AFTER DINNER, MY MOM'S OXYGEN TANK WAS GETTING LOW AND I COULDN'T FIND ANYONE, SO I WAS PUSHING HER DOWN THE HALL AND HEARD (RESIDENT #504) CALLING 'HELP ME.' I WENT INTO HER ROOM AND SHE WAS SITTING UP ON THE FLOOR NEXT TO THE BLUE CHAIR AND BLOOD WAS EVERYWHERE. SHE WAS BLEEDING FROM THE LEFT SIDE BY HER EYE. I YELLED FOR SOMEONE BUT NO ONE WAS THERE, I RAN OUT THE DOORWAY AND THE ONLY PERSON I COULD SEE WAS ANOTHER RESIDENT'S DAUGHTER. I YELLED FOR HER TO GO AND GET HELP, RESIDENT #504 WAS HURT. I DID NOT SEE ANY STAFF IN THE HALLS." WHEN QUERIED BY THE SURVEYOR ABOUT THE USE OF AN ALARM, VISITOR #13 STATED "NO, NO ALARM WAS SOUNDING, I'M SURE OF IT. IT SEEMED FOREVER, BUT I THINK IT WAS JUST A FEW MINUTES, CNA (#11) CAME IN FIRST AND I STAYED WITH RESIDENT #504 WHILE SHE (CNA #11) WENT FOR HELP. WHEN QUERIED BY THE SURVEYOR ABOUT HOW LONG RESIDENT #504 WAS ALONE IN HER ROOM, VISITOR #13 STATED, "I DON'T KNOW... BUT SHE'S NOT USUALLY ALONE LIKE THAT IN HER ROOM UNLESS SHE IS IN BED..." IN AN INTERVIEW PER PHONE, ON 4/7/11 AT 9:10 A.M. VISITOR #15 STATED, ON 3/28/11 "I WAS IN THE HALL...PUSHING MY MOM...DID NOT SEE ANY STAFF... I HEARD (VISITOR #13) YELLING 'HELP, HELP'. I RAN DOWN AND (RESIDENT #504) WAS ON THE FLOOR AND (VISITOR #13) WAS WITH HER AND BLOOD WAS EVERYWHERE". "I RAN OUT YELLING HELP, HELP VERY LOUDLY. I LOOKED DOWN BOTH HALLS AND COULD NOT FIND ANYONE. I RAN TOWARDS THE DINING ROOM AND FINALLY A CNA (NOT IDENTIFIED) CAME OUT AND I TOLD HER A LADY fell ." IN AN INTERVIEW ON 4/6/11 AT 3:45 P.M., CNA #11 STATED, SHE WAS IN A RESIDENT ROOM WHEN SHE HEARD A VISITOR (#15) YELLING "I NEED HELP." CNA #11 STATED, SHE RAN TO (RESIDENT #504'S) ROOM AND OBSERVED HER ON THE FLOOR NEXT TO HER GERI CHAIR , BLEEDING (VISITOR #13) WAS WITH HER. SHE STATED "I DID NOT HEAR THE ALARM SOUNDING". "I RAN OUT OF THE ROOM BUT COULDN'T FIND ANYONE. I CHECKED THE LUNCH SIGN OUT SHEET AT THE DESK AND NO ONE WAS SIGNED OUT. I COULDN'T FIND ANYONE FROM UNIT 3..." " SO I RAN TO UNIT 4 AND GOT (NURSE # 10), THEN WHEN I GOT BACK TO UNIT 3, I CALLED UNIT 1 TO TRY TO FIND OUR NURSE'S, AND BOTH STATION 1 NURSE'S CAME." WHEN QUERIED BY THE SURVEYOR ABOUT RESIDENT #504'S ALARM CNA # 11 STATED, "IT WAS NOT SOUNDING, I'M SURE OF THAT. I THOUGHT (RESIDENT #504) SHOULD HAVE BEEN IN THE HALL IN VIEW IF (CNA #14) WASN'T GOING TO PUT HER TO BED. (RESIDENT #504) IS ALWAYS IN THE HALL IF SHE'S IN HER CHAIR." IN AN INTERVIEW ON 4/7/11 AT 12:15 P.M., UNIT MANAGER, LPN (LICENSED PRACTICAL NURSE) #16 EXPLAINED THAT THERE WAS VIDEO SURVEILLANCE FOR THE HALLWAY OUTSIDE RESIDENT #504'S ROOM AND THAT THIS VIDEO CAPTURED ACTIVITY IN THE HALLWAY AT THE TIME OF THE FALL. LPN # 16 STATED THAT THE VIDEO WAS NO LONGER AVAILABLE, BUT SHE HAD REVIEWED THE VIDEO ON 3/29/11 AND DOCUMENTED A TIME LINE. THE FACILITIES TIME LINE DOCUMENTED: 6:49 P.M. CNA (CERTIFIED NURSING ASSISTANT) #2 "RETURNED RESIDENT (#504) TO HER ROOM LEFT IN GERI CHAIR IN A RECLINING POSITION IN FRONT OF TV ALARM BOX ATTACHED TO RIGHT SIDE OF HANDLE AND NOTED PLUGGED IN...REPORTED TO CNA #11 THAT RESIDENT WAS IN HER ROOM...". 6:58 P.M. CNA #17 "LOOKED INTO RESIDENT'S (#504) ROOM WHILE PASSING BY AND OBSERVED RESIDENT IN RECLINING POSITION IN FRONT OF TV LYING BACK WITH EYES CLOSED APPEARING TO BE ASLEEP". 7:08 PM A RESIDENTS FAMILY MEMBER OBSERVED TO "LOOK INTO (RESIDENT #504'S ) ROOM...LOOK DOWN HALL... AND ENTER ROOM..." 7:09 P.M. CNA #11 "OBSERVED COMING UP HALL IN RESPONSE TO FAMILY MEMBER CALLING OUT FOR ASSISTANCE WITH (ANOTHER RESIDENTS FAMILY MEMBER) FOLLOWING BEHIND HER." 7:10 P.M. CNA #11 "WENT FOR ASSISTANCE". 7:10 P.M. CNA #11 "RETURN WITH NURSE (#10) FROM STATION 4". IN AN INTERVIEW ON 4/7/11 AT 11:50 A.M., WHEN QUERIED BY THE SURVEYOR ABOUT WHY RESIDENT #504 WAS ALONE IN HER ROOM AND INTERVIEW STATEMENTS WHICH REVEALED THE ALARM WAS NOT SOUNDING AT THE TIME OF THE FALL, THE ADMINISTRATOR STATED "THE ALARM WAS CHECKED THAT SHIFT I DON'T KNOW WHAT MORE WE COULD HAVE DONE. (RESIDENT #504) REQUIRED INCREASED SUPERVISION AND OBSERVATION AND WAS CHECKED ACCORDING TO THE VIDEO. WE DID SPEAK TO THE VISITOR WHO FOUND HER AND SHE SAID SHE DID NOT HEAR THE ALARM." THE ADMINISTRATOR STATED "I BELIEVE WE DID EVERYTHING WE COULD. I DON'T KNOW HOW WE WOULD ADDRESS IT IN A POC (PLAN OF CORRECTION)." ( )