Every finding on record at Ambassador, A Villa Center

Based on interviews and record review, the facility failed to report an allegation of sexual abuse to the State Agency for one resident (R901) out of four residents reviewed for abuse. Findings include:R901 was interviewed on 8/12/26 at 3:51 PM. During the interview, R901 reported that an allegation of sexual abuse was made against Certified Nursing Assistant (CNA) A on 7/20/26 to the Director of Nursing (DON).Record review of electronic medical records (EMR) revealed the resident was admitted to the facility on [DATE] with a pertinent diagnosis of unspecified disorder of adult personality and behavior.Review of Brief Interview for Mental Status (BIMS) dated 7/2/26 revealed R901 scored 15 out of 15, indicating the resident was cognitively intact.Record review of Progress Notes dated 7/2/26 at 4:35 PM documented, Note Text: Resident reported an allegation of inappropriate sexual behavior involving a CNA. The entry was authored by the Director of Nursing (DON).The Nursing Home Administrator (NHA) was interviewed on 8/12/26 at 4:15 PM. The NHA stated the allegation was not reported to the State Agency because, based on R901's history, they, .did not think it was a true allegation and did not need to be reported. The NHA reported that an investigation was completed and the sexual abuse was not substantiated.The DON was interviewed on 8/13/26 at 10:05 AM and confirmed that R901 made an allegation of sexual abuse involving a staff member on 7/20/26, and the NHA was informed. When asked why the allegation was reported only to the local police department, the DON stated it was because it involved sexual abuse. The DON later acknowledged: In retrospect I should have reported the incident because it was an allegation of sexual abuse to the State Agency.A follow up interview conducted with the NHA on 8/13/26 at 11:00 AM revealed that the allegation should have been reported to the State Agency in a timely manner.An interview was conducted on 8/13/26 at 11:15 AM with Medical Director M, it was reported it was an expectation that the facility reports abuse to the State Agency in a timely manner. Review of facility policy Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property it was documented, . C. Reporting and Response-Abuse Policy Requirements: It is the policy of this facility that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in the facility.

This citation pertains to intake 3018700. Based on interview and record review the facility failed to notify the resident representative for one resident (R502) of three reviewed for notification of changes.Findings include:Review of a complaint, dated 5/19/26, revealed R502's family members (including Family Member X) were not notified of R502's transfer to the hospital. The complaint also noted that family members were instructed to call around to various hospitals to locate R502.A review of R502's electronic health record (EHR) was conducted on 6/16/2026 and revealed R502 admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, type II diabetes, cirrhosis of liver, chronic obstructive pulmonary disease, sleep apnea, obesity, hypertension, atrial fibrillation, anxiety, and chronic heart failure. Section C of the Minimum Data Set with an Assessment Reference Date of 5/1/2026 indicated R502 scored a 15 out of 15 on the Brief Interview for Mental Status questionnaire, indicative of no cognitive impairment. Section GG of the same Minimum Data Set indicated R502 needed substantial to maximum assistance with activities of daily living. R502s face sheet (demographic information) indicated Family Member X as the emergency contact which included a telephone number. A review of nursing progress notes in the electronic health record (EHR) revealed the following note dated 5/14/2026, Resident was transferred to hospital for respiratory distress. Sp02 (peripheral capillary oxygen saturation - used to measure the amount of oxygen in the blood) 61 at the time of transfer. There was no further documentation in the EHR related to this incident. On 6/16/2026 at approximately 11:45 AM, an interview was conducted with Licensed Practical Nurse C (LPN C). When queried as to the process for documenting a change in resident condition and resulting emergency transfer to the hospital, LPN C said nurses were required to document the incident in the EHR progress notes, initiate a SBAR (a tool used to communicate critical information to the physician), contact the resident's physician to notify them of the incident and receive any orders, then call the residents guardian or emergency contact and inform them of the incident. On 6/16/2026 at approximately 12:00 PM, an interview was conducted with Unit Manager Nurse B (UM B). UM B confirmed that R502 was transferred to the hospital for respiratory distress. UM B was unable to provide any further documentation related to the incident and confirmed that the electronic health record did not indicate that R502's emergency contact was notified of the change in condition and subsequent transfer to the emergency department. On 6/16/2026 at approximately 3:25 PM, an interview with the Nursing Home Administrator (NHA) was conducted (the Director of Nursing was not available). The NHA said it was their expectation that changes in resident conditions are documented in the electronic health record as well as notifications to the physician, emergency contacts, and any interventions attempted. A policy titled, Notification of Changes Guideline last revised 5/11/2018 was provided and revealed the following: 1. Requirements for notification of resident, the resident representative and their physician: .b. A significant change in the resident's physical, mental, or psychosocial status that is a deterioration in the health, mental or psychosocial status in either life threatening conditions or clinical complication; e. A decision to transfer or discharge the resident from the facility. In addition, 3. Document the notification and record any new orders in the resident's medical record.No other information was provided by the facility related to this event upon request and prior to exiting the facility.

Based on observation, interview, and record review the facility failed to: 1. Properly store food items; 2. Remove undated, unlabeled food from the kitchen walk-in cooler and the reach in freezer; 3. Adequately clean kitchen surfaces. These deficient practices had the potential to affect all residents who consumed food from the kitchen, resulting in an increased potential for foodborne illness.Findings include:On 1/6/2025 beginning at 8:45 AM, the initial tour of the kitchen was conducted with Kitchen Manager (KM) A. During the tour, the following items were observed:-in the walk-in cooler a prepared pan of rice and a prepared pan of gravy were stored on the bottom shelf directly next to raw ground meat. KM A said prepared food should not be stored next to raw food. -an undated, unlabeled container full of approximately two dozen packages of lunch meat. KM A said the container contained bologna and should be labelled and dated.-In the reach in freezer an undated, unlabeled bag of frozen turkey legs and an open bag of breaded tilapia. KM A stated, They are freezer burned, they should be labelled dated and need to be thrown out due to freezer burn. -the deep fryer surface was soiled with grease and debris. KM A said the fryer was not in use this morning and was not cleaned after the last use.-the double door warmer exterior was soiled with grease and food debris. -the clean pot/pan shelves area where clean sheet pans were stored was soiled with debris. KM A said the clean pan shelves should be clean.-the flooring under and between the deep fryer and flat grill was heavily soiled.-the flooring under the dish machine line was heavily soiled. KM A said both the line floor and dish room floor needed a deep clean and hasn't been done lately.On 1/6/2025 at 9:30 AM a kitchen cleaning schedule was requested and was not provided by survey exit.On 1/08/2026 at 9:56 AM, the Nursing Home Administrator (NHA) was interviewed and said the expectation is for the kitchen staff to follow kitchen policies and the food code. The kitchen should be clean and sanitary, and food should be stored properly. Review of the facility policy titled Food Storage date issued 9/2/2021 revealed in part.Standard all time/temperature control for safety foods, frozen and refrigerated will be appropriately stored in accordance with guidelines of the FDA food code. 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of the facility policy titled Clean & Sanitary date issued 9/1/2021 revealed in part. All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. 1. The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation. 4. The dining Services Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces.

Based on observation, interview, and record review the facility failed to properly secure protected health information for one resident (R28) of 30 residents reviewed for privacy, resulting in the potential for unauthorized disclosure and access. Findings include: On 01/07/2026 at 12:50 PM, observations revealed R28's personal information face up on a medication cart on the 1 (one) north hallway. R28's personal information was available for anyone to see walking through the hallway. The hallway had staff, residents, and visitors walking down the hallway. The personal information pertained to resident R28 being readmitted to the facility. The admission notification sheet listed the R28's diagnosis as well as other personal information. 01/07/2026 12:55 PM, Licensed Practical Nurse (LPN) F approached the medication cart. LPN F was queried and if that was their medication cart. LPN F said that was their medication cart. LPN F acknowledged seeing R28's admitting information face up on the medication cart. LPN F said the admitting office or concierge may have left the information on the medication cart. LPN F said information should not have been left face up for everyone to see that was walking by because it had patient diagnosis and other information was on the documentation. 01/08/2026 12:57 PM, Unit Manager (UM) G was interviewed and said the information may have been left by admissions department. The UM G said the information should have been turned (placed) face down or given to another nurse or the UM G. 01/08/2026 11:15 AM, the Director of Nursing (DON) was interviewed and said that readmit information should have been given to another nurse for best practice (instead of being placed on the medication cart). Record review of R28's medical record revealed an Initial admission of 11/28/2025. R28 was admitted with diagnosis as follows: Pneumonia, OSTEOMYELITIS OF VERTEBRA, SACRAL AND SACROCOCCYGEAL REGION, PARAPLEGIA, CONGESTIVE HEART FAILURE and MAJOR DEPRESSIVE DISORDER. R28 was readmitted on [DATE] with a diagnosis of sepsis. Review Minimum Data Set (MDS) dated for 12/4/2025 revealed R28 Brief Interview for Mental Status (BIMS) was noted as 15 out of 15 indicating R28 was cognitively intact.A policy was requested regarding HIPPA and confidentiality. The policy provided was titled Resident Rights with an effective date of 11/28/2017. However, the document provided did not specifically address confidentiality of resident's medical records.

Based on interview, observation and record review, the facility failed to provide Influenza and Pneumococcal Immunizations for three residents (R9, R128 and R7) of five residents reviewed with compromised health conditions resulting in the potential for infection and a decrease in health status.Findings include: On 01/08/2026 at 9:00 AM, Infection Preventionist (IP) B was interviewed, and vaccine consents and administration forms were reviewed. Three of five residents reviewed had signed consents, however, there was no record of immunizations being administered to R7, R9 and R128. There was also no evidence that R7, R9 and R128 had refused these immunizations or that they were contraindicative. A record review revealed signed consents dated 10/13/25 for R7 and R9 to receive Influenza and Pneumococcal vaccinations. A record review revealed a signed consent dated 10/21/25 for R128 to receive Influenza and Pneumococcal vaccinations. As of 1/08/2026 there was no evidence of influenza and pneumococcal immunizations administered for R7, R9, and R128 or documentation that they were refused or contraindicated. On 01/08/2026 at 9:20 AM, IP B was asked to provide a reason why immunizations were not provided upon consent. IP B explained they were new in the position, unfamiliar with the vaccine clinic protocol, and had not realized the amount of time required to administer immunizations to facility residents. On 01/08/2026 at 9:40 AM, the Director of Nursing (DON) was interviewed and reported having no knowledge of late or missing vaccinations. The DON stated, Usually the IP would report this to me. The DON was queried as to how many residents are currently awaiting vaccinations. The DON stated, I don't know, I'll ask the IP. Record review revealed the following:R7 was admitted to the facility on [DATE] and has a diagnosis of Heart Failure, Type 2 Diabetes, Schizophrenia, Hypertension, Peripheral Vascular Disease, Dysphagia and Mood Disorder.R9 was admitted to the facility on [DATE] and has a diagnosis of End of Stage Heart Failure, Osteomyelitis of the Vertebrae, Hemialgia, Psychotic Disorder, Dysphasia, Hyperlipidemia, Kidney Disease and Blindness. R128 was admitted to the facility on [DATE] and has a diagnosis of Encephalopathy, Diabetes, Heart Failure, Hypertension, Pressure Ulcer and Kidney Failure. According to the facility's 4/1/22 Guidelines for Administering Pneumococcal Vaccinations Policy: Most pneumococcal infections are mild. However, some can result in long term problems such as brain damage or hearing loss. Meningitis, bacteremia and pneumonia caused by pneumococcal disease can be fatal. According to the facility's 11/28/17 Influenza Vaccination Guideline Policy: It is recognized that influenza is a serious risk for the elderly. Therefore, residents will be encouraged to have the vaccine.

Based on observation, interview and record review, the facility failed to provide Covid-19 vaccinations for three residents (R7, R9 and R128) of five residents reviewed for vaccination administration. Findings include:On 01/08/2026 at 9:00 AM, immunization consents were reviewed with Infection Preventionist (IP) B. Record review for R7 and R9 revealed a signed consent dated 10/13/25 for the Covid-19 vaccination. However, there was no record of this immunization being administered to R7 and R9. There was no evidence that R7 and R9 refused the Covid-19 immunization. Record review revealed a consent signed by R128, dated 10/21/25, for the Covid-19 vaccination. However, there was no record of this immunization being administered to R128. On 01/08/2026 at 9:20 AM, IP B was asked to provide a reason why immunizations were not provided upon consent. IP B explained they were new in the position, unfamiliar with the vaccine clinic protocol, and had not realized the amount of time required to administer immunizations to facility residents. On 01/08/2026 at 9:40 AM, the Director of Nursing (DON) was interviewed and reported having no knowledge of late or missing vaccinations. The DON stated, Usually the IP would report this to me. The DON was queried as to how many residents are currently awaiting the Covid-19 vaccination. The DON stated, I don't know, I'll ask the IP. Record review revealed the following:R7 was admitted to the facility on [DATE] and has a diagnosis of Heart Failure, Type 2 Diabetes, Schizophrenia, Hypertension, Peripheral Vascular Disease, Dysphagia and Mood Disorder.R9 was admitted to the facility on [DATE] and has a diagnosis of End of Stage Heart Failure, Osteomyelitis of the Vertebrae, Hemialgia, Psychotic Disorder, Dysphasia, Hyperlipidemia, Kidney Disease and Blindness. R128 was admitted to the facility on [DATE] and has a diagnosis of Encephalopathy, Diabetes, Heart Failure, Hypertension, Pressure Ulcer and Kidney Failure.

Based on observation, interview and record review, the facility failed to provide at least 80 square feet per Resident in multiple resident bedrooms and at least 100 square feet for single Resident bedrooms, affecting 32 Resident rooms (#'s 113, 115, 117, 119, 120, 121, 122, 123, 124, 125, 126, 127, 129, 130, 131, 132, 133, 135, 138, 213, 215, 217, 219, 221,223, 224, 225, 226,227, 228, 229 and 230). Findings include: Observation of the resident rooms on 1/7/2026 at 4:00 P.M, and review of the facility documentation revealed the following: Room# Sq. Footage # of Bed Residents 113 141' 1.5 2 2 115 141' 1.5 2 1 117 141' 1.5 2 2 119 141' 1.5 2 2 120 141' 1.5 2 2 121 141' 1.5 2 2 122 141' 1.5 2 2 123 141' 1 2 2 124 141' 1 2 1 125 141' 1 2 2 126 141' 1 2 0 127 141' 1.5 2 1 129 141' 1.5 2 2 130 141' 2 2 1 131 141' 1.5 2 2 132 141' 1.5 2 2 133 141' 1.5 2 1 135 141' 5 2 2 138 141' 1.5 2 1 213 150' 5 2 2 215 150' 6 2 2 215 150' 6 2 2 217 150' 6 2 2 219 150' 6 2 2 221 150' 6 2 2 223 150' 5.5 2 2 224 150' 6 2 2 225 150' 6 2 1 226 150' 6 2 2 227 150' 6 2 2 228 150' 5.5 2 2 229 150' 5.5 2 2 230 150' 5 2 2 On 1/7/26 at 3:15 P.M. and 4:00 P.M, during observation and interview of the residents that resided in the aforementioned rooms, no concerns or complaints were voiced or noted regarding resident room size.

This citation pertains to intake MI00151504. Based on observation, interview and record review the facility failed to ensure an injury of unknown origin for one resident (R905) of four sampled residents reviewed for abuse was reported to the State Agency, resulting in the potential for further injury of unknown origin or abuse to go unreported and not investigated. Findings include On 6/9/25 at 3:00 P.M. R905 was observed sleeping in a low bed with a fall mat placed on the right side. On 6/10/25 at 8:30 A.M. during a meal observation R905 was observed in a low bed with bilateral fall mats on both sides of the bed. The resident appeared alert but responded to questions in short, simple words. During the interview a dark faded area was observed on the resident's left cheek area. On 6/10/25 at 1:50 P.M. review of the admission Record revealed R905 was admitted to the facility on [DATE], with pertinent diagnoses of chronic obstructive pulmonary disease, communication deficit, chronic kidney disease, vascular dementia, metabolic encephalopathy, cerebral infraction due to occlusion stenosis of cerebral artery and severe protein-calorie malnutrition. According to the Minimum Data Set (Significant change) dated 6/5/25, R905 had a Brief Interview For Mental Score (BIMS) of 6 of 15 (indicating R905 was cognitively impaired), required substantial/maximal assistance to perform Activities of Daily Living (ADL's) and was always incontinent of urine and frequently incontinent of bowel. On 6/10/25 at 2:00 P.M., review of the care plan section of R905's clinical record stated: The resident has a behavior problem r/t (related to) dementia AEB (as evidenced by) accusatory behavior against staff and other residents. Resident has a skin tear on her face and accused staff of hitting her. (initiated 5/14/25). At 2:05 P.M. the Acting Director of Nursing (ADON) was asked about the incident and whether it was determined how the resident received the facial skin tear. A request was made to review the investigation related to the incident. On 6/10/25 at 2:30 P.M. Unit Manager (UM) D was interviewed concerning what happened to R905's face. UM D stated, It was reported to me, I observed the area, it appeared to be a broken, open blister. When I observed the area, I reported it to the wound care team. No one knew how the resident got the dark area on her left cheek, and I did not want anybody to think we had done anything to her. The resident said we hit her. UM D was not able to provide any additional information as to how R905 sustained and injury on her left cheek. On 6/10/25 at 2:45 P.M. interview with Wound care nurse A confirmed UM D had requested the team to evaluate R905's skin tear to the face. Per nurse A the area in questioned was described as: Left cheek abrasion as reported given per UM D open area measures 1.0 x 1.1 cm, pale, pink base scanty serious drainage peri skin normal new treatment (TX): Apply Gentamicin ointment everyday x 14 days PO (Physician Order) Dr E. Record review of the Physician Order's dated 5/14/25, confirmed the same description and treatment indicated by nurse A. On 6/10/25 at 3:00 P.M. ADON reported he couldn't confirm or locate an investigation for R905 related to the incident involving the skin tear but would ask the Administrator for assistance. On 6/10/25 at 3:15 P.M. the Administrator confirmed the incident had not been reported to the State Agency. In retrospect the Administrator verbally acknowledged and indicated because staff did not know how R905 sustained the injury the incident should have been investigated and reported to the State Agency. The Administrator stated, Information wasn't forwarded to me until now. Review of the facility's policy dated 11/28/2017, titled: Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property including injuries of unknown sources under the subtitled: Abuse Reporting stated: . It is the policy of this facility that (abuse, neglect, exploitation or mistreatment including injury of unknown source and misappropriation of resident property) are reported per State and Federal, law. Employees must always report any abuse or suspicion of abuse immediately to the Administrator. (I). Investigation of injury of unknown origin or suspicious injuries must be investigated to rule out abuse. (I) injuries included but not limited to bruising, the inner thigh, chest, face and breast, bruises of an unusual size, multiple unexplained bruises and or bruising in an area not typically vulnerable to trauma. On 6/10/25 at 4:10 P.M. no additional information was provided upon exiting the facility.

This citation pertains to intake MI00151504 Based on observation, interview and record review the facility failed to ensure an injury of unknown origin was investigated for one (R905) of four sampled residents reviewed for abuse, resulting in the potential for abuse to occur. Findings include: On 6/9/25 at 3:00 P.M., R905 was observed sleeping in a low bed with a fall mat placed on the right side. On 6/10/25 at 8:30 A.M. during a meal observation R905 was observed in a low bed with bilateral fall mats on both sides of the bed. The resident appeared alert but responded to questions in short, simple words. During the interview a dark faded area was observed on the resident's left cheek area. On 6/10/25 at 1:50 P.M. review of the admission Record revealed R905 was admitted to the facility on [DATE], with pertinent diagnoses of chronic obstructive pulmonary disease, communication deficit, chronic kidney disease, vascular dementia, metabolic encephalopathy, cerebral infraction due to occlusion stenosis of cerebral artery and severe protein-calorie malnutrition. According to the Minimum Data Set (Significant change) dated 6/5/25, R905 had a Brief Interview for Mental Status (BIMS) of 6 of 15, indicating R905 was cognitively impaired (the ability to think), required substantial/maximal assistance to perform Activities of Daily Living (ADL's) and was always incontinent of urine and frequently incontinent of bowel. On 6/10/25 at 2:00 P.M., review of the care plan section of R905's clinical record stated: The resident has a behavior problem r/t (related to) dementia AEB accusatory behavior against staff and other residents. Resident has a skin tear on her face and accused staff of hitting her. (initiated 5/14/25). At 2:05 P.M. the Acting Director of Nursing (ADON) was asked about the incident and whether it was determined how the resident received the facial skin tear. A request was made to review the investigation related to the incident. On 6/10/25 at 2:30 P.M. Unit Manager (UM) D was interviewed concerning what happened to R905's face. UM D stated It was reported to me, I observed the area, it appeared to be a broken, open blister. When I observed the area, I reported it to the wound care team. No one knew how the resident got the dark area on her left cheek, and I did not want anybody to think we had done anything to her. The resident said we hit her. UM D was not able to provide any additional information as to how R905 sustained and injury on her left cheek. On 6/10/25 at 2:45 P.M., interview with Wound care nurse A confirmed UM D had requested the team to evaluate R905's skin tear to the face. Per nurse A the area in questioned was described as: Left cheek abrasion as reported given per UM D open area measures 1.0 x 1.1 cm, pale, pink base scanty serious drainage peri skin normal new treatment (TX): Apply Gentamicin ointment everyday x 14 days PO (Physician Order) Dr E. Record review of the Physician Order's dated 5/14/25, confirmed the same description and treatment indicated by nurse A. On 6/10/25 at 3:00 P.M., the ADON reported he couldn't confirm or locate an investigation for R905 related to the incident involving the skin tear but would ask the Administrator for assistance. On 6/10/25 at 3:15 P.M., the administrator confirmed there was no investigation related to the injury of unknown origin and based on the information reviewed the incident should have been investigated and reported to the state agency. Review of the facility's policy dated 11/28/2017, titled: Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property stated: It is the policy of this facility that reports of abuse, mistreatment, neglect, or abuse including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. (I). Investigation of injury of unknown origin or suspicious injuries must be investigated to rule out abuse. (I) injuries included but not limited to bruising, the inner thigh, chest, face and breast, bruises of an unusual size, multiple unexplained bruises and or bruising in an area not typically vulnerable to trauma. On 6/10/25 at 4:10 P.M., no additional information was provided upon exiting the facility.

Based on observation, interview and record review the facility failed to ensure enhanced barrier precautions (EBP) were implemented during wound care for two residents (R911 and R912) out of two residents reviewed for quality of care. Findings include: R912 Review of R912's electronic medical records (EMR) revealed resident was diagnosed with a stage 3 pressure ulcer (injury to skin from prolonged pressure) located on the sacrum (upper area of buttocks). On 6/9/25 at 12:00 PM, a wound care observation was conducted in R912's room. A sign was posted on the door indicating the requirement for enhanced barrier precautions. Additionally, a door - mounted storage unit containing gloves, gowns and masks were observed. The three staff members -Registered Nurse (RN) A, Licensed Practical Nurse (LPN) B, and LPN C entered the room and participated in this high contact wound care without donning (applying) gowns prior to initiating the procedure. Further review of R912's EMR revealed an admission date of 12/24/24, with a pertinent diagnosis of pressure ulcer of sacral (sacrum) area. Documentation also indicated the resident had moderate cognitive impairment and required substantial to maximal assistance with activities of daily living (ADLs). Review of R912's care plan dated 6/9/25 documented The resident requires enhanced barrier precautions r/t (related to) wounds. R912's Interventions documented Donn (apply) PPE (gown and Gloves) before entering the room when providing high contact res (residents) activities and doff (remove) PPE before exiting the room. Perform hand hygiene every time you enter and every time you exit the room, refer to door sign as needed. R911 Review of R911's EMR revealed resident was diagnosed with the following: right heel vascular (poor circulation) ulcer, right anterior (front) knee abrasion, right lateral (on side) hip/buttock stage four pressure ulcer, sacrum-stage four (full thickness skin loss) pressure ulcer, and left lateral hip-stage three pressure ulcer. Further review of R911's EMR revealed an admission date of 4/23/25, with a pertinent diagnosis of Fournier gangrene (a rare life-threatening infection that rapidly destroys soft tissues). Documentation also indicated the resident had intact cognition and required substantial to maximal assistance with bed mobility. On 6/9/25 at 12:37 PM, a wound care observation was conducted in R911's room. A sign was posted on the door indicating the requirement for enhanced barrier precautions. Additionally, a door - mounted storage unit containing gloves, gowns and masks were observed. The three staff members -Registered Nurse (RN) A, Licensed Practical Nurse (LPN) B, and LPN C entered the room and participated in this high contact wound care without donning gowns prior to initiating the procedure. Review of R911's care plan dated 4/23/25 documented The resident requires enhanced barrier precautions catheter (indwelling urinary), wounds requiring dressings. Further review of care plan documented, . Interventions-Staff will wear gloves and gowns for device care or use of central lines (tubing inserted into large veins; used to administer medications, fluids and blood), urinary catheters (tube inserted to remove urine), feeding tubes(tube inserted into stomach to provide nutrition, hydration and medication), tracheostomy (tube inserted into throat to maintain breathing), colostomy/ileostomy ( a surgical incision to allow removal of waste) or any wound care. Gown and glove one use only and for only one resident. An interview conducted on 6/9/25 at 1:05 PM with RN A, it was reported that a gown was not donned before providing treatment to residents R911 and R912. It was further reported that enhanced barrier precautions should be worn before providing wound care treatments. An interview conducted on 6/9/25 at 1:06 PM with LPN B, it was reported that a gown was not donned before providing treatment to residents R911 and R912. It was further reported that enhanced barrier precautions should be followed before providing wound care treatments. An interview conducted on 6/9/25 at 1:07 PM with LPN C, it was reported that a gown was not donned before providing treatment to residents R911 and R912. It was further reported that enhanced barrier precautions should be followed before providing wound care treatments. An interview conducted on 6/9/25 at 2:30 PM with Acting Director of Nursing (ADON). It was reported that staff are expected to follow the facility's policies and procedures for implementing enhanced barrier precautions when providing care to residents identified as requiring such measures. Review of facility's policy Personal Protective Equipment Guideline dated 4/12/24 documented the following: Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs (Multidrug-Resistant Organisms) to staff hands and clothing. MDROs may be indirectly transferred from resident to resident during these high contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization.

Based on observation, interview and record review the facility failed to post and plan alternate meals and All Time Available food choices, resulting in numerous complaints of dissatisfaction with meal choices and food. This deficient practice affected 159 of 170 residents who received meals from the kitchen. Findings include: On 9/25/24 at 9:38 A.M. during an observation in the kitchen, the menu posted identified the following meal choices: Crusted Chicken, Buttered pasta, Buttered Carrots, Apple Crumble, Beverage. There were no alternates written on the menu or posted. On 9/25/24 at 1:40 P.M. on the 2 south and 2 north Units during a lunch meal observation, no alternate meal selection was posted. The menu board had one meal (Today's Meal) posted and there was no other food items or choices for the residents. During the observation resident's H, J, K and L (who wanted to remain anonymous) were observed requesting nursing staff for alternates. Each of these residents were identified as being cognitively intact. On 9/26/24 at 12:35 P.M., during an observation on the tray line Dietary Manager G answered a call from the unit requesting an alternate food item for residentsH and J. Dietary Manager G asked the cook, what was the alternate for today's meal? The cook responded, I have chicken and rice. Dietary Manager G was asked why the residents were served the same food choices as the meal served the previous day for lunch? During the observation Dietary Manager G was asked how residents knew what alternate meal was served and where was it posted? Dietary manager G explained the facility had an ALL Time Available menu and it was posted in the dining rooms on each floor. Dietary Manager G was asked to show the location of the Alternate Menus for the residents. Escorted by Dietary managers G the 2 south, 2 north and 3 rd floor menu boards and dining areas were checked. There were no alternates, or All times Available menu posted on any of the floors. Dietary manager's G provided no explanation why the Alternates were not posted or planned. On 9/26/24 at 2:30 P.M. review of the Food Committee minutes from the Resident Council for May, June, and August 2024 indicated there had been identified concerns with alternate menus not being posted and not being followed. No minutes were provided for the month of July, 2024. On 9/27/24 at 12:30 P.M. review of the facility's policy under #2. stated in part . Menus will be periodically presented for resident review, including the resident council . The menu will identify the primary meal, the alternate meal, and any always offered food and beverage items. #8. Menus will be posted in the Dining Services Department, dining rooms and resident/patient care areas. Upon exiting the facility 9/27/24 at 3:30 P.M.,no additional information was provided concerning why the resident's Alternates food choices and alternate meals were not planned and posted.

Based on observation, interview and record review the facility failed to maintain the physical plant and steam table wells used in the kitchen, affecting 159 of the 170 residents who consume food from the kitchen, resulting in the potential for cross contamination, bacterial harbage and staff injury. Findings include: On 9/25/24 at 9:38 A.M. during an observation of the kitchen the grease trap drain was observed overflowing with water from the three-compartment sink. Dietary Manager G indicated the grease drain had been cleaned out a couple of weeks ago but was now draining slow again. On 9/26/24 at 12:35 P.M., the grease trap drain overflowed during an observation of the lunch service. Employees on the tray line was observed standing,and sliding through standing water, attempting to complete the lunch service. During this observation two rubber tubs used to maintain food temperatures on the trayline leaked water between two tables running into the pathway under the tray line. During each of the above observations the wells on the steam table were observed with pieces of old food particles, ash, and burnt on residue. On 9/26/24 at 12:45 P.M. Dietary manager G was queried concerning the steam wells being cleaned. The manager indicated the wells had not been cleaned since starting the job, and acknowledged the wells needed cleaning. A request was made to review the master cleaning schedule, but was not presented as requested. Review of 2022 Food Code Titled Cleaning of Equipment and utensils Section 4-601.11 Equipment, Food-Contact Surfaces, Non-Food Contact Surfaces, and Utensils under (C) Nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, food residue and other debris. On 9/27/24 at 1:40 P.M. interview with Corporate Maintenance Director N concerning the cleaning of the grease trap reported the drain had been cleaned 9/20/24, and the company was scheduled to return on 9/26/24 however did not return. At 2:40 P. M, towels and old rags were observed being used as a barrier for the spilling water from the grease drain. Upon exiting the facility on 9/27/24 at 3:30 P.M. no other additional information was provided.

Based on observation, interview, and record review the facility failed to ensure the dignity for one resident (R110) of three residents reviewed for dignity, resulting in verbalized feelings of embarrassment and frustration. Findings included: On 9/25/24 at 11:47 a.m. R110 reported that the physician placed an order at least two months ago to be seen by a podiatrist to get the residents toenails cut and for the dry skin and it has not happened. R110 stated, I want my long thick toenails to be cut on both feet because I don't want anyone to see my toenails like that. Its embarrassing and that is why I got very angry. R110 pointed to their feet and the great toe and the second toe on the left foot were observed with dry scaly skin on top of the toes and between the toes with dark areas and long thick toenails with an unpleasant odor. The right foot also had long, thick, discolored toenails and dry skin between the toes. The fifth toenail on the right foot appeared to have been broken and exposed thick dried skin from the top of the toe to the top of the nail. According to the electronic health record (EHR), R110 was initially admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses of Neuropathy, major depressive disorder, and functional quadriplegia. R110 's annual Minimum Data Set (MDS) with a reference date of 9/1/2024 indicated R110 was cognitively intact with a BIMS (brief interview for mental status) score of 14/15 and required one person-assistance for hygiene. Review of the Activity Daily Living (ADL) care plan-initiated date of 8/27/2022 documented, The resident has an ADL self-care performance deficit related to impaired mobility related to Neuromyelitis Optica, functional quadriplegia. Interventions: Check nail length and trim and clean on bath days and as necessary. Report any changes to the nurses. On 9/27/24 at 12:10 p.m. the Director of Nursing (DON) was interviewed regarding the lack of foot care for R110. The DON confirmed R110 was not seen by the podiatrist and could not explain why nursing staff did not provide basic hygiene to the resident's feet. The DON said that R110 had a reason to be frustrated and embarrassed about the long thick toenails and malodorous feet. According to the facility's 11/28/2017 Resident Rights policy: Our facility will treat each resident with respect and dignity and care for each resident in a manner an in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.

Based on interview and record review, the facility failed to ensure the Preadmission Screening (PAS)/ Annual Resident Review (ARR) form for Mental Illness/ Intellectual Disability/ Related Conditions Identification (DCH-3877) document was accurate, complete, and sent to the local state agency for an evaluation for a Level II determination for one (R57) of seven residents reviewed for PASSARs, resulting in the potential for unmet intellectual/ developmental disability care needs. Findings include: R57: According to the Electronic Health Record (EHR), R57 admitted to the facility on [DATE] with diagnoses that included Adjustment Disorder, Bipolar Disorder, Anxiety, and Depression. R57 was prescribed two antipsychotic medications; Cymbalta (an anti-depressant) 30 milligrams (mg) twice a day and Olanzapine (an anti-psychotic) 2.5 mg twice a day (used to treat schizophrenia). On 8/24/24 a care plan was initiated for 'use of psychiatric medications'. A review of the only DCH-3877 form in the resident's EHR was dated 8/21/24 and indicated that R57 had no mental illness and was not being treated with antidepressants or antipsychotic medications. On 9/11/24, R57 was seen by Psychiatric services and the following was documented; Complaints of bipolar, depression, insomnia, and anxiety. Resident was tearful during interview and said they were emotionally and physically not well. Olazapine was added during resident's hospital stay. On 9/26/24 at 10:15 AM Social Worker (SW) D was asked to review if R57 had an updated PAS/ARR (DCH-3877 form). SW D reviewed the resident's EHR and acknowledged that it was inaccurate and had not been updated at this time. SW D said, Yes, we missed it (DCH-3877). It should have been done upon admission. It was on my list to do, I hadn't completed it yet. According to the facility's PASARR Guideline Effective dated 11/28/17 in part: Purpose: This facility promotes and supports a resident centered approach to care. The purpose of this guideline is to define and set expectations regarding the appropriate preadmission assessment of all individuals with a mental disorder and individuals with intellectual disability. It is the practice of the facility to coordinate the assessment process with the preadmission screening and annual resident review (PASARR) program under Medicaid in Subpart C to the extent practicable to avoid duplicative testing and effort. This includes incorporating the recommendations from the PASARR level II determination and evaluation in the residents' assessment, care plan, and transition of care: and referring all level II residents and all residents with new or evident conditions related to Level II review upon significant change in status assessment. The facility will not admit any new residents with: Mental Disorder- unless the State mental health authority has determined, prior to admission that, because of the physical and mental condition of the individual, the individual requires the level of services provided by the facility and whether the individual requiresspecialized services: or Intellectual Disability - unless the State intellectual disability or developmental disability authority has determined, prior to admission that, because of the physical and mental condition of the individual, the individual requires the level of services provided by the facility: and if the individual requires such level of services, whether the individual requires specialized services for intellectual disability. The PASARR process consists of the completion of a Level I screen per State and Federal requirements as well as the review and implementation of the Level II recommendations upon admission into the facility.

Based on observation, interview, and record review the facility failed to ensure podiatry services and treatment were provided in a timely manner for one resident (R110) of one resident reviewed for foot care, resulting in the growth of long toenails, build-up of flaky skin on resident's feet, and delay in needed treatment. Findings include: On 9/25/24 at 11:47 a.m. R110 was observed resting in bed. During the resident interview, the resident complained of needing to be seen by the podiatrist due to long thick toenails. R110 pointed to both feet and said, The physician placed an order for a podiatrist appointment at least two months ago to get the toenails cut and for the dry skin and it has not happened. I don't know if they put my name on the list or not, but I have been mentioning it for about two months. R110's great toe and the second toe on the left foot had dry scaly skin on top of the toes and between the toes with dark areas and long thick toenails. The right foot also had long, thick, discolored toenails and dry skin between the toes. The fifth toenail on the right foot appeared to have been broken and exposed thick dried skin from the top of the toe to the top of the nail. R110 stated, I do not want my toes to get infected. I want the long thick toenails to be cut on both feet. On 9/25/24 at 12:12 p.m., the wound care nurse, Licensed Practical Nurse (LPN) E assessed R110's feet and said, The resident toes had dry skin, an odor, the left foot third toe had some discolorations, the toenails were long and the fifth toe on the right foot appeared to be detached. LPN E agreed R110's toenails needed to be cut and the resident should have been seen by a podiatrist for the dry skin and discoloration on the toes. According to the electronic health record (EHR), R110 was initially admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses of Neuropathy, pressure ulcer of sacral region stage four, major depressive disorder, and functional quadriplegia. R110 's annual Minimum Data Set (MDS) with a reference date of 9/1/2024 indicated R110 was cognitively intact with a BIMS (brief interview for mental status) score of 14/15. A care plan initiated 9/3/2024 for Activity Daily Living (ADL)' had the following: The resident has an ADL self-care performance deficit related to impaired mobility related to neuromyelitis Optica and functional quadriplegia. Interventions as following: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Review of the physician orders documented the following: Podiatrist consult as needed dated 1/26/2024. Refer to podiatry for toenails fungus, and trim dated 8/27/2024. Further review of the R110's EHR did not revealed any podiatry consults or progress notes. On 9/27/24 at 12:10 p.m. the Director of Nursing (DON) was interviewed regarding the delay in foot care for R110. The DON confirmed R110's podiatrist consult order was missed, and the resident was not seen by the podiatrist. The DON could not explain why R110 was not seen by the Podiatrist during his monthly visit to the facility and was unable to provide any evidence of podiatry consult for R110 for 8/24/2024. According to the facility's 11/2023 Foot Care policy: 1. Residents will be provided with foot care and treatment in accordance with professional standards of practice . 3. Residents will be assisted in making transportation appointments to and from specialists (podiatrist) as needed.

Based on observation, interview and record review the facility failed to provide medically related social services for one resident (R70) of two residents reviewed resulting in the delay of obtaining a legal guardian to initiate discharge planning in a timely manner and the resident expressing frustration. Findings include: On 9/27/24 at 10:00 AM, R70 was observed sitting on the side of the bed. R70 was queried about any concerns regarding the care by the facility, R70 responded, I want to be discharged , I don't want to be here. Review of R70's electronic health record (EHR) revealed admission into the facility on [DATE] with a pertinent diagnosis of vascular dementia (brain damage caused by multiple strokes). According to the Minimum Data Set (MDS) dated [DATE], R70 scored 8 out of 15 on Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Further review revealed resident did not have a guardian. Review of Report of Physician or Mental Health Professional dated and signed by the Psychiatrist on 4/18/23, documented, I believe the individual due to these described conditions, is not presently able to make informed decisions in the following areas: determining where to live, consenting for supportive services, handling financial affairs, authorizing or refusing medical treatment. Further review of R70's EHR revealed, on 9/28/23, SW (Social Worker) received a call from the receptionist reporting resident is attempting to leave facility AMA (Against Medical Advice). On 8/5/24, SW was asked to talk to resident because is adamantly seeking to D/C (discharge) back into the community with no real discharge plan in place because he is homeless. Interview on 9/27/24 at 10:48 AM with Social Worker (SW) D, acknowledged that R70 had made several requests to be discharged from the facility, but had no legal guardian to assist with discharge planning. SW D reported that a decision could not have been made to discharge to another location because a legal guardian had not been obtained. SW D stated, In all honesty, I should have been more consistent in monitoring why the resident did not get a legal guardian sooner and the (discharge) process initiated related to the courts. An interview on 9/27/24 at 12:52 PM the Nursing Home Administrator (NHA), said, When a resident is determined to be clinically unable to make decisions, a legal guardian should be obtained. The Social Worker did not try to obtain a legal guardian in a timely manner. If a guardian had been obtained, a decision could have been made to ensure the best discharge or placement for the best interest for the resident.

Based on observation, interview and record review, the facility failed to provide at least 80 square feet per resident in multiple resident bedrooms affecting 38 Resident rooms (#'s113, 115, 117, 119, 120, 121, 122, 123, 124, 125, 126, 127, 129, 130, 131, 132, 133,135, 138, 213, 215, 217, 219, 221, 223, 224, 225, 226, 227, 228, 229, 230, 231, 232, 234, 235, 236, and 238). Findings include: Observation of the Resident rooms on 9/27/2024 at 2:00 P.M., and review of the Facility Bed Count Information sheet revealed the following: ROOM # SQ. FT # OF BEDS # of Residents 113 141' 1.5 2 2 115 141' 1.5 2 2 117 141' 1.5 2 2 119 141' 1.5 2 1 120 141' 1.5 2 2 121 141' 1.5 2 2 122 141' 1.5 2 2 123 141' 1 2 2 124 141' 1 2 2 125 141' 1 2 2 126 141' 1 2 2 127 141' 1.5 2 1 129 141' 1.5 2 2 130 141' 2 2 2 131 141' 1.5 2 2 132 141' 1.5 2 2 133 141' 1.5 2 2 135 141' 5 2 2 138 141' 1.5 2 2 213 150' 5 2 2 215 150' 6 2 2 217 150' 6 2 2 219 150' 6 2 2 221 150' 6 2 2 223 150' 5.5 2 2 224 150' 6 2 2 225 150' 6 2 2 226 2 2 227 150' 6 2 2 228 150' 5.5 2 2 229 150' 5.5 2 2 230 150' 5 2 2 Interviews conducted on 9/27/2024 at 2:30 PM with residents in the rooms listed above, express no concerns regarding room size in relation to their health and safety.

Based on observation, interview, and record review, the facility failed to provide adequate safety measures to ensure resident safety for one resident (R40) of four residents reviewed for accidents and hazards, resulting in R40 falling with fractures during staff assisted shower and increased likelihood for accidents and/or injuries. Findings include: Review of the Face Sheet and Annual Minimum Data Set (MDS) dated [DATE], reflected R40 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), dementia without behavior disturbances, and depression. The MDS reflected R40 had a BIM (Brief Interview for Mental status) score of 4 which indicated her ability to make daily decisions was severely impaired, and she required one-person physical assist bed mobility, transfers, walk in room and corridor, locomotion on unit, toileting, hygiene, and bathing and no mention on behaviors. Continued review of R40 MDS reflected a significant change MDS, dated [DATE], with re-admitted [DATE] post hospital admission for fall at facility resulting in left shoulder and hip fractures. The MDS reflected R40 had changes in need for increased assistance including required two-person assist with bed mobility, transfers, and one person physical assist with eating and dressing. During an observation on 8/15/23 at 11:51 AM, R40 was observed in bed with eyes closed, dressed in a hospital gown, a small spot of blood noted on covers with mat on floor next to left side of bed. Review of the facility Matrix on 8/15/23 at 12:43 PM, reflected R40 had a fall with major injury. Review of R40 Nursing Progress Notes, dated 6/21/2023 at 10:12 PM, reflected, Writer called to the shower room by staff ,writer observed resident on the floor writer ask what happen staff stated 'I was washing her and she tried to get up and walk and slipped' writer did head to toe assessment skin indicated no injury noted writer attempted to to ROM (range of motion) resident was yelling and guarding her left arm, hip and leg writer and staff assisted resident back to bed called MD (medical doctor) whom order to send her to ER (emergency room ) to r/o (rule out) FX (fracture) writer give PRN (as needed) .Writer notified guardian [named] also ADON (assistant director of nursing). Review of R40 Nursing Progress Note, dated 6/30/2023 at 5:20 PM, reflected, Patient is [AGE] year old readmission, admitted via ems from [named hospital]. Patient primary language is Japanese, but is able to respond well to commands and is pleasant. patient diagnosis multiple fracture including left arm fracture, from fall. Patient is a regular diet. no complaints of pain or discomfort, vital signs: blood pressure 170/87 pulse 72 spo2 (oxygen saturation) 98% on room air respirations 18. patient has scattered bruising throughout left side of body. 14 staples to the left hip intake no drainage present. orders placed for removal date .Call light in reach, bed in low position and patient encouraged to use call light when in need. Review of the Fall Care Plan, dated 3/25/21, reflected, The resident is at risk for falls r/t Dementia, Non Compliance, Bipolar Disorder, Poor Safety Awareness, and Mental Disorder aeb:-with mildly impaired standing balance -ambulates at will -requires supervision to occasional limited assist with transfers and ambulation . The resident will be free of minor injury through the review date.Date Initiated: 09/25/2019 Target Date: 10/05/2023 .Interventions .Bed in low position when in bed Date Initiated: 12/13/2019 . Anticipate and meet the resident's needs. Date Initiated: 02/23/2023 . Follow facility fall protocol. Date Initiated: 12/13/2019 . The resident needs a safe environment with: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach .The resident has had an actual fall with injury r/t Poor Balance -resident sustained a witnessed fall while in the shower due to loss of balance, resident transferred to the hospital to r/o FX Fx of left hip and shoulder Date Initiated: 06/21/2023 . Ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date Initiated: 06/21/2023 .Continue interventions on the at-risk plan. Date Initiated: 06/21/2023 .For no apparent acute injury, determine and address causative factors of the fall. Date Initiated: 06/21/2023 . During an interview and record review on 8/16/23 at 2:38 PM, Assistant Director of Nursing (ADON) D reported they had worked at the facility for about [AGE] years and provided a, Soft file, for R40's fall in shower room with fracture to left arm and hip on 6/21/23. Review of R40 Incident/Accident Report, dated 6/21/23, reflected R40 had a witnessed fall in the shower. The report reflected R40 as oriented to person and unable to give description of what happened and had pain of 8 out of 10 on pain scale. The report appeared incomplete as evidenced by no named witness, predisposing environmental factors indicated, none, and wet floor was not marked, and injuries reported post incident reflected none. Continued review of the report reflected the legal guardian was notified 6/21/23 at 10:07 p.m., ADON D was notified at 10:03 p.m., and Physician was notified at 11:01 p.m. Review of the soft file provided by the ADON D for R40's fall on 6/21/23 reflected an In-Service staff sign in sheet, dated 6/23/23, for Shower Room Safety Grips for 42 staff. Continued review reflected an In-Service staff sign in sheet, dated 6/23/23, for Shower Technique that included check Kardex and gather all supplies, do not leave the resident unattended, ensure shower bed/chair locked prior to transfer with 36 staff signatures. Review of nursing schedules, dated 6/21/23, reflected CNA GG worked on 6/21/23 on the R40 unit. During an interview on 8/16/23 at 3:08 PM, Certified Nurse Aid(CNA) JJ reported received education after R40 fall in shower on 6/21/23 related to not leaving residents alone in shower and adding anti-skid tape to floor in shower room floor. During an interview and observation on 8/16/23 at 3:10 PM, CNA GG reported had worked at the facility for over five years. CNA GG reported often worked with R40, who was a risk for falls, and was caring for R40 on 6/21/23 when R40 fell and fractured left arm and hip in shower. CNA GG reported around 7:00 p.m. they were giving R40 a shower in third floor shower room and R40 was in the shower chair. CNA GG reported R40 had soap in hair and turned back to R40 to adjust the water temperature and R40 stood up and fell to floor. CNA GG reported R40 landed on left side of their body and CNA GG reported they yelled from the shower room for help. CNA GG reported nurse arrived and assessed R40 and reported R40 did not communicate well in English but stated, Ouch, when left shoulder and leg moved. CNA GG reported three staff physically picked up R40 from the floor to the geri chair and R40 repeated, ouch during transfer. CNA GG reported three staff dried off R40, dressed her in a gown and physically picked up R40 and transferred from them from the geri chair to the bed and Emergency Medical Services(EMS) arrived to transfer R40 to hospital not long after. CNA GG reported they received education from management after R40 fall that included proper management, adding anti-slip strips to shower room floor, not to turn back to residents during shower, and stated, like I did, not to leave residents in shower room alone, prepare all supplies in advance, and use emergency call light in shower room. During the interview CNA GG entered R40 room at 3:30 PM and verified R40 was laying in bed and verified R40's bed was elevated too high and observed a about hip level, with call light located under the bed, out of reach. CNA GG lowered the resident's bed and placed a call light within reach and reported staff should have had R40 bed in low position and call light in reach for R40 safety. CNA GG entered the third floor shower room and verified the shower chairs front two brakes were not functional and there was no anti-slip tape on the shower room floor. During an interview on 8/16/23 at 4:06 PM, ADON D reported R40 was readmitted for m the hospital post fall with a new diagnosis of osteo and is why facility did not do Past non-compliance related to R40 fall on 6/21/23. During an observation on 8/17/23 at 9:09 AM, no anti-slip tape on the floor of the third floor shower room.

Based on observation and interview, the facility failed to ensure palatable food temperatures and food texture, resulting in poor satisfactory of meals by residents, affecting all resident who consume food from the kitchen. Findings include: On 8/16/23 at 12:16 PM, a food cart was observed to be delivered to the second level. At 12:21 PM, staff were observed to begin passing trays. At 12:27 PM, a test tray was pulled from the cart, before staff were done passing all of the trays. The following food temperatures were recorded using a digital probe thermometer: Salisbury steak - 117 degrees F, mashed potatoes - 108 degrees F, and cooked cabbage - 115 degrees F. At this time, Regional Dietary Manager FF was queried on what temperature the facility expects the meals to be delivered at, and stated as close to 135 degrees F as possible. The tray that was pulled was observed to have the insulated base used as the lid. When queried regarding the irregular tray set-up, Regional Dietary Manager FF stated that the staff might have thought that the base was the lid, and reassured that they have an adequate supply of insulating dome lids. 46954 In a confidential resident group interview on 8/16/23 at 11:29 AM, 10 of 10 residents reported the lunch and dinner meals was not palatable. Several residents stated that they feel that have to order out to get a decent meal. 10 of 10 residents reported that the portion sized of the meal is small, comparing the portion to kid sized meals. 9 of 10 residents reported that the pork is too tough to cut or chew. 10 of 10 residents reported that the food is not warm and have observed the staff leaving the meal cart doors open and conversating instead of passing trays. In an interview on 08/17/23 at 10:24 AM, Dietary Manager (DM) reported that the residents have had some food committee meetings to discuss food concerns but has cancelled the past few monthly meetings. DM reported that he is aware of food concerns and had been speaking to a few select residents monthly regarding food concerns and possible resolutions.

Based on observation, interview, and record review, the facility failed to maintain the physical facility, maintain plumbing in good repair, and maintain equipment, resulting in the potential for contamination of the physical facility and food product, affecting all residents who consume food from the kitchen. Finding include: On 8/16/23 at 11:04 AM, the floor underneath the dish machine drain board was observed to have dissolved floor tile grout. Two tiles were observed to be loose at this time. Additionally, the waste disposal flex cuff, in the dish washing area, was observed to be leaking slightly. According to the 2017 FDA Food Code 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. On 8/16/23 at 11:15 AM, the two-compartment sink drain line was observed to be leaking on to the floor. Additionally in the back corner, beyond the two compartment sink, a black liquid was observed to be surrounding a PVC drain line. According to the 2017 FDA Food Code Section 5-205.15 System Maintained in Good Repair. A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; P and (B) Maintained in good repair. On 8/16/23 at 11:19 AM, the can opener blade was observed to have a groove in the blade, and metal shaving were observed around the gear. Additionally, the hand sink drain line was observed to be excessively leaking, with a catch pan collecting the water under the sink. At this time, Director of Kitchen EE stated that is was reported to Maintenance around two to three weeks prior. On 8/16/23 at 11:21 AM, the reach-in cooler, across from the cookline, was observed to not be provided with an internal ambient thermometer. On 8/16/23 at 11:30 AM, a window, in the dry storage room, was observed to be cracked open with no screen to prevent insects from entering the premises. According to the 2017 FDA Food Code Section 6-202.15 Outer Openings, Protected. (A) Except as specified in (B), (C), and (E) and under (D) of this section, outer openings of a FOOD ESTABLISHMENT shall be protected against the entry of insects and rodents by: (1) Filling or closing holes and other gaps along floors, walls, and ceilings; (2) Closed, tight-fitting windows; and (3) Solid, self-closing, tight-fitting doors .

This citation pertains to MI 104. Based on interview and record review, the facility failed to ensure safe repositioning interventions while providing care for one (#502) of three residents reviewed for falls/accidents, resulting in a fall out of bed, an emergency hospital encounter, and a displaced [MEDICAL CONDITION] and proximal fibula. Findings include: The facility reported to the State Agency that Resident #502 (R502) fell from her bed during ADL (activities of daily living) care which resulted in a fracture to the left ankle and left fibula. A review of the clinical record for R502 documented an admission into the facility on [DATE]. R502 was discharged from the facility on 7/16/19. The resident's [DIAGNOSES REDACTED]. Minimum Data Sets ((MDS) dated [DATE] and 7/15/19 documented moderate cognitive impairment and extensive two persons physical assist for bed mobility. According to the MDS, bed mobility was how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. Additional MDS documentation revealed the following regarding dressing defined according to the MDS as how resident puts on fastens and takes off all items of clothing .Dressing includes putting on and changing pajamas and housedresses. The MDS of 4/14/19 documented R502 required extensive two-persons physical assist for dressing. The MDS of 7/15/19 at 3:18 PM documented R502 required extensive two-persons physical assist for dressing. The MDS of 7/17/19 at 8:20 AM documented R502 required extensive one-person physical assist for dressing. physician's orders [REDACTED]. --Bilateral assist bars for enhanced mobility. Ordered 2/17/18. --Provide bariatric bed (an extra wide and extra heavy-duty bed to safely accommodate larger individuals). Ordered 4/24/19. R502's Nutrition Quarterly Evaluation of 7/5/19 documented a body weight of 250 lbs., height of 65 inches, and body mass index of 41.6 (obese). The resident's ADL self-care performance deficit care plan revised 4/17/19 noted impaired standing balance -requires 2 persons total assistance with use of Hoyer lift during transfers - requires extensive to total assist with ADLs - uses wheelchair for locomotion -incontinent of bowel and bladder. The resident's ADL self-care performance deficit care plan revised 7/15/19 noted: -impaired standing balance -requires 2 persons total assistance with use of Hoyer lift during transfers - requires extensive to total assist with ADLs - uses wheelchair for locomotion - incontinent of bowel and bladder. The resident's fall risk care plan revised 4/17/19 noted: requires 2 persons total assist during transfers with use of Hoyer lift -impaired standing balance -poor safety awareness -episodes of confusion and disorientation. The resident's skin integrity care plan included the following intervention created on 8/3/18: use draw sheet when turning/repositioning. The following occurred to R502 per nursing notes: 7/15/19 at 11:28 PM- Nurse was summoned to resident's room; saw resident lying on the floor next to her bed on her left side. Alert and responsive; assessed her condition; ROM (range of motion) to all extremities; c/o (complained of) pain to left foot; denied hitting her head; resident assisted into bed; bed in lowest position; call light in easy reach; (vitals obtained); will continue to monitor. 7/15/19 at 11:30 PM- Open area noted to left foot area cleansed. (Treatment) done; Nail on her left thumb broken bandage applied. 7/16/19 at 12:34 AM- Resident's daughter and son-in -law in the facility; resident's ankle is now discolored family requesting she be transferred to hospital for x-ray. Afternoon Supervisor informed. A review of R502's radiology report dated 7/16/19 documented the following: --Left ankle and left tibia-fibula radiographs. --There is diffuse severe disuse osteopenia (bones are weaker than normal but not so far gone that they break easily) which limits evaluation for fracture. There is a comminuted [MEDICAL CONDITION] fibula (the outer and usually smaller of the two bones between the knee and the ankle) with approximately 5 mm (millimeters) of lateral displacement. There is also a minimally displaced [MEDICAL CONDITION] fibula. A [MEDICAL CONDITION] malleolus (a bony projection with a shape likened to a hammer head on either side of the ankle) is suspected. Diffuse soft tissue swelling is seen about the ankle joint. On 9/4/19, the facility was requested to provide their complete investigation into R502's fall. A review of the investigative documents provided included an interview/statement attributed to Certified Nurse Aide (CNA) G. The interview was conducted on 7/16/19 at 12:30 PM and documented the following: (R502) was in bed when I came in to provide care. While giving care, patient turned on her left side. (Later reported to be the right side.) Patient was told to turn back flat on her back, and instead she continued going further left which in turn caused her to continue to roll and eventually ending up on the floor. I notified the nurse and me along with two others assisted with getting her back in bed. This document was not signed by CNA G. On 9/5/19 at 11:50 AM, a telephone interview was conducted with CNA G. When queried about R502's fall on 7/15/19, CNA G said, Sometime after 8 PM, I was giving her care. I was cleaning her up because she had just urinated. I was going to clean her back side and replace her brief and linen or whatever needed to be replaced at the time. I went to roll her, and she swung her leg over. She's kind of hippy and her leg went too far. She kept going and fell out of the bed. CNA G added that as soon as she rolled over, I was trying to grab her to save her from falling. I told her to come back. She fell on the right side of the bed. CNA G was queried what did R502 say once she hit the floor, CNA reported R502 said, My leg. When CNA G was queried if she turned the resident by herself, she said, Yes. CNA added, (R502) is a one-person assist. On 9/5/19 beginning at 2:35 PM, the Director of Nursing (DON) was interviewed regarding R502's positioning in the bed prior to her fall. The DON stated that at the time of the fall, R502 was in a bariatric bed which was used for larger residents. When queried about R502's position in the bed prior to the fall, the DON said, (R502) was positioned closer to the right side of the bed. When queried if R502 was closer to the right side of the bed so she could use the assist bar for positioning, the DON said, Correct. The DON added, (R502) used the assist bars to reposition herself. When queried if R502 had impaired mobility? The DON said, Yes. When queried about how this fall could have been avoided, the DON said, Knowing that she needed more assistance, we could have had two people assist. One on either side of the bed. When the MDS coding for bed mobility of 4/14/19 and 7/15/19, which indicated the resident was a two-person assist, was reviewed with the DON, she said, I can't tell you about that because I didn't know they did that. On 9/5/19 at 4:35 PM, CNA G was re-interviewed over the phone with the DON present. CNA G was queried about turning R502, Was it one complete motion or was there a pause? CNA G said, It was pretty much a continuous motion. There was maybe a pause of a second or two. When queried if she had started washing the resident's backside? CNA G said, No. In reference to CNA G's statement, the DON was queried if there was a concern about the resident's position in bed prior to the fall, she said, I wouldn't say the position, but maybe the maneuvering involved. When the DON was queried, If R502 was not positioned so close to the edge of the bed when she swung her leg over (to expose her backside for care), her leg would have landed on the bed, correct? The DON said, Correct. The DON was asked, So that fall was avoidable? The DON said, Yes. On 9/5/19 at 5:15 PM, the facility Administrator stated that CNA G's signed written statement contradicted what she verbally reported to the DON and State Surveyor. CNA G's signed written statement was requested. At 5:30 PM prior to exiting the facility, when asked about CNA G's signed written statement, the Administrator stated they did not have it. The facility document titled Fall Evaluation Safety Guideline, effective date 11/28/17, was reviewed and the following was noted: --Any failure to maintain an appropriate lying, sitting or standing position resulting in a resident's sudden, unintentional relation either to the ground or into contact with another object below his or her starting point defines falling. --Fall prevention is achieved through an IDT (Interdisciplinary Team) approach of managing predicting factors and implementing appropriate interventions to reduce risk for falls.

This pertains to intake #MI 188. The facility failed to assess and provide appropriate, necessary equipment to facilitate a safe wheelchair transport for one (#620) of five sampled residents reviewed for accident hazards, resulting in pain, crying and emergency hospital treatment for two leg fractures. Findings include: The complainant reported to the State Agency: Resident #620, who was typically in a reclining geri-chair when out of bed, was transported from the hair salon in a wheelchair without footrests causing two leg fractures. The resident was not transferred to the hospital until the following day, was in pain all day and night and was in so much pain, she could not be changed and left soiled before the transfer. On 5/22/18 at 2:30 PM, the clinical record, Incident and Accident (I/A) Investigation Form and incident investigation were reviewed with the Corporate Consultant (staff 'M') and nurse Unit Manager 'Q' in the presence of Activities aide 'N'. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The minimum data set completed 3/11/18, noted that the resident was cognitively intact, non-ambulatory, required total two-person assistance for transfers, incontinent of bowel/bladder and was five foot seven inches in height with a weight of 353 pounds. Per the resident's undated Kardex (care guide used by nurse aides), the resident was to be transferred via mechanical full body lift. Nurse 'Q' said the resident was typically transported in a geri-chair. The I/A Form dated 5/2/18, written by nurse 'Q' noted: Resident stated that she dropped her leg while being transported in her 'wheelchair' for hair dresser. Resident stated she didn't inform Activities aide ('N') she needed to rest her leg. Resident dropped her leg and felt a pop in her knee. The investigation included a written statement by aide 'N', which he read aloud and explained. The aide said, as noted in the statement, that resident #620 was being transported down the hall in a wheelchair and asked to hold her legs up during transport. The resident said ouch, was asked what was wrong, tears started to form and complained of knee pain. The aide reported the situation to a nurse. When asked what happened to the resident's leg, aide 'N' said that he did not see what happened. The Investigation Follow-Up dated 5/3/18 written by nurse 'Q', noted a summary of the investigation: During investigation, resident has [MEDICAL CONDITIONS] (brittle bones that could easily break spontaneously), diabetes mellitus, obesity. X-ray results show osteopenia (bones that are weakened, but not easily breakable). When asked, nurse 'Q' said that resident #620 was known to have [MEDICAL CONDITION], however, there was no documentation in the clinical record of this diagnosis. After reading the X-ray report and not seeing [MEDICAL CONDITION] mentioned, nurse 'Q' then said that she made a mistake in noting that [DIAGNOSES REDACTED]. The Investigation Follow-Up further noted: Facility concludes spontaneous (fracture) Recommendations/New Interventions: Staff will ensure that all wheelchairs will have footrests. An inservice form in the investigation noted: Activity aide ('N') inserviced on proper resident transport while in wheelchair and use of leg rest. Activity aide is to ensure that the leg rests are in place prior to transporting resident in wheelchair. The form was signed by aide 'N'. The I/A form noted that the incident occured at 2:24 PM during the day shift, in which nurse 'S' was resident #620's nurse. A portable, in-house X-ray was ordered Stat (immediately) following the incident. The X-ray report of the resident's right knee, dated 5/2/18, read by a radiologist at 7:56 PM that evening, noted: Acute fracture involving right femur with modest displacement and modest depression [MEDICAL CONDITION] medial tibia plateau modest osteopenia, meaning a break with abnormal position of the thigh bone and a break in the shinbone affecting the knee joint. There were no nursing notes of the incident written on 5/2/18 by day shift nurse 'S'. There were notes created and entered by nurse 'S' the following day on 5/3/18 at 7:55 AM. When asked why there were no notes until the following day, staff 'M' reviewed the notes and said that the nurse should not have done that. (When copies of these 5/3/18 notes were requested at the end of the survey, the facility provided notes with a date of 5/2/18 instead. However, the 5/3/18 notes had been photographed by the resident's family when the clinical record was left unattended and the photo was sent to the State Agency.) The notes were as follows: The incident occurred as documented in the I/A form and investigation, resident #620 complained of right knee pain, the resident was placed back in bed and the X-ray was ordered Stat by the physician. The resident had a prior prescription for a [MEDICATION NAME] 5-325 milligram (narcotic) pain pill, scheduled every 8 hours at 6 AM-2 PM-10 PM. The resident's medication record indicated that nurse 'S' gave her the regularly scheduled 2 PM dose of [MEDICATION NAME]. There was no documented assessment of the resident's leg or overall condition. There were no nursing notes documented on the afternoon shift on 5/2/18 about the resident's condition. Per a nursing note written the following day (5/3/18) at 7:28 AM by the resident's midnight shift nurse (nurse 'R'): The physician was notified of the X-ray result and an order was obtained to transfer the resident to the hospital. There were no documented notes by nurse 'R' regarding the resident's leg and her overall condition throughout that night. When asked why resident #620 was transported in a wheelchair without footrests and not a geri-chair, nurse 'Q' said that the resident no longer used a geri-chair and that footrests were not on the chair in case the resident wanted to use her feet to propel the wheelchair herself. When asked if the resident was able to use her feet for propulsion, nurse 'Q' said, I have never seen her do it. I don't know. When asked why the resident did not receive emergency hospital care for 19 hours following the two leg fractures, nurse 'Q' said, We didn't know about the fractures. They (X-ray company) never called us with the results. I don't know why they didn't call us. I happened to be by the fax machine (the morning of 5/3/18 at approximately 7 AM) and heard the fax (X-ray report) come over and saw that she had the fractures. When asked why the facility did not call to get the results sooner, nurse 'Q' said, They were supposed to call us when the report came back. On 5/22/18 at 3:10 PM, upon further review of the X-ray report, it noted that the report was faxed to the facility on [DATE] at 8:01 PM, five minutes after the radiologist read it. The X-ray company was called at that time and the company representative (Rep) said that the X-ray order was received by them on 5/2/18 and marked to be done Stat. The Rep said Stat X-rays were typically performed within four to six hours, the X-ray was completed at 7:40 PM and the report was faxed to the facility at the date and time printed on the report, at 8:01 PM. There was no explanation by the facility as to why the results were not sought or retrieved timely and reported to the physician. On 5/22/18 at 3:30 PM, nurse 'S' was interviewed and resident #620's clinical record was reviewed with her. The nurse said that she was present on 5/2/18 when the incident took place. When asked if she assessed the resident post incident and observed her right leg, nurse 'S' said, Yes, I looked at her and her leg looked normal. The nursing notes were reviewed with nurse 'S'. When asked why there was no documented indication that she monitored the resident and no notes documented by her until the next day on 5/3/18, nurse 'S' said, I was busy. I had two admissions. I know I should have. The nurse said that she gave the resident a pain pill and she seemed okay by the end of her shift at 3:30 PM. (At 4:30 PM, a review of resident #620's medication records revealed that nurse 'S' was also the resident's afternoon shift nurse on 5/2/18 and had given the resident her evening medications, including the [MEDICATION NAME] scheduled for 10 PM. There was no documented note during the afternoon shift by nurse 'S' regarding an assessment of the resident's leg and overall condition.) On 5/22/18 at 3:45 PM, the Therapy manager (staff 'O') was asked why there were no footrests on resident #620's wheelchair and if she should have been in a geri-chair. Staff 'O' said that the resident was being transitioned from a geri-chair to a wheelchair to make her more independent and to be able to use her arms or feet to propel herself. She said, In the geri-chair, her feet didn't touch the ground and that footrests on the wheelchair would not allow the resident to use her feet. When asked if the resident could use her feet, staff 'O' said, We stood her up for the first time the day before (the incident). It took three people. She could only take one step. Staff 'O' said that she had given the resident a new wheelchair, but the resident did not like it and felt uncomfortable, so (nurse 'Q') said that she knew where to get another chair and got (the resident) another wheelchair, the chair used during the incident. When asked if she had assessed resident #620 in the new chair provided by nursing rather than therapy staff, to see if it was appropriate without the footrests, staff 'O' said, No, I didn't get a chance to. (The resident) was in bed and it was already after it (the incident) happened. She said that therapy staff typically conducted a wheelchair assessment. She looked at the resident's electronic and paper clinical records and said that there was none. Staff 'O' reviewed the resident's Occupational Therapy and Discharge Summary notes dated 3/1/18-5/3/18 and said the notes did not address the transition from geri-chair to wheelchair and use of footrests. When asked, staff 'O' said there was no written policy on wheelchair assessments. On 5/23/18 at 5:30 AM, resident #620's midnight shift nurse ('R') the night of 5/2/18 to the morning of 5/3/18, was queried by phone about the incident and whether she had assessed the resident during her shift. She said, I got report from the afternoon nurse ('S'). She said something about (the resident's) leg falling off the chair when she was coming from (an activity) and that an X-ray was done and to look out for it. I did my rounds at the start of the shift and asked if (the resident) was in pain and she said, no. I looked in again and she was asleep. I didn't ask her what happened. I received the X-ray (report) from another (midnight shift) nurse from another unit (contrary to nurse 'Q' reporting that she retrieved the report from the fax machine herself) at the end of the shift and called the doctor and let (nurse 'Q') look at it. I gave (the resident) a (scheduled 6 AM) pain pill. Then the day shift nurse ('S') took over. There was no documented note during the midnight shift by nurse 'R' regarding an assessment of the resident's leg and overall condition and no indication following the injury that PRN (as needed) pain medication was given for breakthrough pain between the scheduled doses of [MEDICATION NAME] every eight hours. On 5/23/18 at 9:20 AM, when asked, aide 'N' said that the resident was transported from the hair salon in the basement to the elevator then from the elevator almost to the doorway of her room when her leg was injured. (At 10:30 AM, the Maintenance Director measured the distance at 80 feet from the elevator to the resident's doorway at the opposite end of the hall.) On 5/23/18 at 9:45 AM, resident #25, a former roommate of resident #620, was interviewed about her knowledge of the incident and the resident's condition. Resident #25 said, She was in a new wheelchair and said she dropped her leg. It didn't have a footrest. She was told to hold her legs up. She was very heavy. Someone that large couldn't hold their leg up that long. She was moaning and crying in her sleep all night. No one changed her. She didn't want to move. Every time she tried to move, she cried out. When EMS came, they told them (staff) not to touch her because it was too much pain, so they (EMS) took her to the hospital as is. There was no documented note during the day shift on 5/3/18 about the resident's leg or overall condition. Nurse 'S', the day shift nurse on 5/3/18, noted that the resident was transferred to the hospital that morning at 9:15 AM. On 5/23/18 at 8:15 PM, resident #620's afternoon shift nurse aide on 5/2/18 (aide 'P') said by phone, She said her leg hurt and she was really screaming and crying. I never heard her like that before. Her leg didn't look right. You could tell something was wrong. She was a big lady anyway, but her right leg around the knee was bigger than the other. It was swollen. I told the nurse, but I don't know what happened after that. I changed her and she tried to help me. She screamed. On 5/23/18 at 10:15 PM, resident #620's midnight shift nurse aide the night of the incident, said by phone, She said that someone was pushing her in her wheelchair after coming from getting her hair done and said her leg fell and went backwards and she heard a pop. We changed her twice. She was in a lot of pain each time I went in there to check on her. She was crying. I told the nurse. I don't know what she (the nurse) did. Her leg was swollen at the knee. On 5/24/18 at 8 AM, per review of the facility's Wheelchair Mobility Procedure dated 12/2012: Provide resident a properly fitting wheelchair and knee positioning. Allow resident's feet to touch the floor if they require their feet for propulsion Precautions: Foot placement on floor or foot pedals

This citation pertains to MI 436. Based on interview and record review, the facility failed to ensure one (#801) of three residents reviewed for mealtime assistance and supervision, received adequate cueing to prevent pocketing of food that resulted in aspiration, acute [MEDICAL CONDITION], and [MEDICAL CONDITION]. Findings include: On [DATE] at 8:10 AM, the complainant was called regarding her concerns about the care Resident 802 (R801) received at the nursing home. The complainant said, (R801) was found unresponsive in his bed during breakfast on (MONTH) 23, (YEAR). The Unit Manager told me that they removed eggs from his mouth. He shouldn't have been in the bed during breakfast. I told them to get him up and out of the bed in the morning. The complainant added, When EMS came they put a tube in his mouth. When (R801) arrived at the emergency room (ER), the tube was removed, and it had eggs on it. When I got to the ER, the doctor said, '(R801) was impacted with eggs. He had so much in his throat that he choked.' They had to deal with removing the eggs just so they could intubate him. (R801) was admitted to the Cardiac ICU. After days of being there, I was told that there was nothing more that they could do for him. He was put into hospice because he had suffered brain damage on (MONTH) 23rd. (R801) died on (MONTH) 19, (YEAR). On [DATE] at 10:00 AM, a review of the clinical record for R801 was begun. R801 was initially admitted into the facility on [DATE] with a readmission date of [DATE]. His [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] documented intact cognition and R801 was able to eat independently with set-up help only. The Discharge Assessment - Return Anticipated MDS dated [DATE] documented R801 required limited assistance for eating. Review of ADL (activity of daily living) care plans documented the following regarding Eating: The resident required set-up assistance only for eating, date initiated [DATE]. Monitor at meal times that he feeds self safely; monitor for aspiration, date initiated [DATE]. R801's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Clinical progress notes documented the following: --Nursing, [DATE] at 9:40 AM: Found unconscious --Nursing, [DATE] at 10:46 AM: At 9:40 AM, informed by CNA of resident's unresponsiveness. Upon coming to the room, resident was unresponsive to stimuli. CPR (Cardiopulmonary Resuscitation) was initiated, and 911 was called at 9:45 am .no vital signs were obtained until 9:49 am .911 arrived at 9:58 am and continued with CPR .Resident was alert, and breathing before being transferred to (hospital name) at 10: 05 am. --Medical Provider, [DATE] at 11:15 AM: Reason for visit: code blue. Facility: answered to a code called on the second floor. reach and found the patient unresponsive and CPR has been started. start leading the code. check BP, and pulse. nursing staff doing what they are supposed to do. (One) nurse was bagging the patient, the other suctioning and the others are alternating doing CPR. The patient was pulseless almost ten minutes but finally was able to get the pulse back. EMS came shortly and transported the patient to the hospital with a pulse . On [DATE] at 12:10 PM, when Certified Nurse Aide (CNA), Staff D was queried about monitoring residents during mealtime, she said, Residents that require monitoring while eating are brought to the dining room. Even at breakfast if they require monitoring, they should be in the dining room. On [DATE] at 12:25 PM, when Unit Manager, Staff E was queried about monitoring residents during mealtime, she said, Everyone (all residents) requires supervision during mealtime. If a resident requires monitoring, they're in the dining room. If the resident doesn't want to leave their room, but requires monitoring, we would sit in the room. When Staff E was asked to identify who determines the level of monitoring residents require during mealtimes, she stated the Speech Therapist. On [DATE] at 12:50 PM, Staff Scheduler, Staff B identified CNA, Staff F and CNA, Staff H as the staff assigned to work R801's unit during breakfast on [DATE]. On [DATE] at 1:15 PM, when CNA, Staff F was queried about R801, she said, Some days he needed supervision and some days he did not. When queried about how she determined the level of supervision he required, she stated that when she delivered his meal tray, she would talk to him and would determine if he needed supervision depending upon how he responded to her. When queried about the meaning of supervision and cueing during mealtime, Staff F said, Supervision and cueing means watching and cueing so the resident doesn't aspirate. When Staff F was queried if she delivered the breakfast tray to R801 on [DATE], she said, No. I did not pass his tray; the other CNA (Staff H) did. Staff F said, He had already received his tray when I walked by his room with (Staff H). When I looked into his room, he looked unresponsive. I went into the room and did a sternum rub four times. On the fourth time, he gasped for air. I tried to scoop the food out of his mouth. At that time, I told (Staff H) to go get help. When queried about Staff H's location during that time, Staff F said, She was outside the door. When Staff F was queried about what food was scooped out of R801 mouth, she said, I scooped out hardboiled egg. He was a double portion eater; so, he got two boiled eggs at breakfast. One egg had already been eaten. On [DATE] at 4:10 PM, when CNA, Staff H was queried about R801, she said, I got R801 ready for breakfast, delivered his tray to him room, and told him I would be right back. We (Staff F and Staff H) were two rooms down the hall. When we went back to his room, Staff F looked at (R801) and he didn't look well. Staff F was rubbing his chest and trying to wake him up. I went to get the nurse. When queried about which nurse she went to get, Staff H said, I can't remember. When queried about the level of supervision R801 required during meals, Staff H said, (R801) normally ate on his own. To my knowledge he didn't require supervision. He didn't require any more monitoring than anyone else. On [DATE] at 1:25 PM, when Registered Nurse, Staff G was queried about R801, he said, I was passing meds and had spoken with him earlier that morning. He knew everyone's name. (R801) was eating in his room. A CNA found him unresponsive. A code was called; we gave him CPR; swept and suctioned his mouth. Staff G stated he didn't see anyone perform a [MEDICATION NAME] maneuver on R801, but saw particles of food in his mouth which was evidence that he had been eating. On [DATE] at 2:20 PM, when Unit Manager, Staff C was queried about R801, he said, (CNA, Staff F) initially found him unresponsive. When Staff C was queried about CPR response, he said, When you start CPR, you sweep the mouth and bag the resident. Staff C added that food was removed when they swept R801's mouth, but to his knowledge no one perform the [MEDICATION NAME] maneuver on him. On [DATE] at 2:35 PM, when the Director of Nursing (DON) was interviewed about staff CPR response, she said, Mouth sweeps are part of the CPR process. It could be assumed that an unresponsive resident was choking if at mealtime he was found unresponsive. The [MEDICATION NAME] could have been performed. When the [DATE] Nursing-Part B nurse documentation was reviewed with the DON, it revealed the following: R801 required extensive assistance for feeding. When the DON was queried if a resident should be left alone that required extensive assistance for feeding, the DON said, Absolutely not. The DON added, There was a breakdown in communication. When the DON was asked to provide documentation that someone was in the room supervising R801 while he was eating, she stated all residents are provided supervision while eating and R801 did not require someone to be in the room with him at all times while he was eating. On [DATE] at 1:35 PM, when the facility Speech Therapist (ST) was queried about R801, she said, He was pocketing food and his diet had been down graded to mechanical soft. I was seeing him three times a week. A review of orders for R801 documented the following order written on [DATE]: ST Clarification Order: Skilled ST services 3x/wk for 60 days to address new onset of oral dysphagia/decreased swallow safety. Pt is downgraded to Mechanical Soft textures at this time. Please supervise pt during meals and encourage small bites as well as checking for pocketing of bolus. When the ST was queried about her expectations for staff implementation of supervise patient during meals, she said, It meant staff needed to be in the room. I would indicate '1:1' feeder, if a resident needed to be fed and was 100% dependent on staff to eat. R801 had taken a downturn (but he was not a 1:1 feeder). With his [MEDICAL CONDITION], he may have a good day or a bad day. When I was with him during meals, I never observed him choking; but he needed cueing to clear pocking. Pocking (of food) will happen, so you need to say, '(R801) clear your cheek.' The following Speech Therapy notes of [DATE] were reviewed with the ST: --Reason for Referral: Pt. was discovered late last week with a mouth full of food several hours after meal time. Pt required consistent verbal cueing to continue mastication and swallow pocketed food. Pt. has demonstrated decrease in awareness and task participation. --Diet Texture Analysis: Mechanical Soft = Mild; Clinical (signs/symptoms of) Dysphagia: pocketing bilaterally and oral residue. --Strategies: To facilitate safety and efficiency, it is recommended the patient use the following strategies and/or maneuvers during oral intake: rate modification, bolus size modifications and lingual sweep/reswallow, upright posture during meals and upright poster for > 30 minutes after meals. --Clinical Reasoning: Pt's primary functional deficit is in the new onset of oral dysphagia. Pt. has demonstrated decreased activity tolerance as well as increase pocketing, decreased lingual coordination and strength, and decreased sensation for oral residue. The ST stated that a deficit in tongue coordination is often seen in people diagnosed with [REDACTED]. Emergency Medical Service (EMS) sent to the nursing home documented the following: Dispatched: [DATE] at 9:47 AM At Scene: [DATE] at 9:55 AM Narrative: .CPR was executed prior to EMS arrival .#4 King Tube (tube used to quickly and efficiently establish a secure airway) was placed and secured, lung sounds confirmed . Hospital Emergency Treatment Note [DATE], (YEAR) 10:21 AM (Hospital name) Emergency Department Visit --History of Present Illness: Patient .presents to (Hospital name) Emergency Department with a chief complaint of being found unresponsive. According to EMS, this patient was found unresponsive around 9:30 this morning at his residence .EMS was called, they arrived on scene, placed a defibrillator on the patient, initiated a single round of CPR, and a single shock was discharged . They administered no medications and placed a King tube in the patient's airway. ROSC (return of spontaneous circulation) was achieved after the single round of CPR. Patient has maintained a pulse throughout the duration of his transport here. --Physical Examination: .Evidence of aspiration as there is gastric contents in the patient's oropharynx (portion of the throat that lies near the rear of the mouth) Coarse lung sounds bilaterally during bagging . --Medical Decision Making: .Given the history and physical examination [REDACTED].Patient initiated on IV (antibiotics) for likely aspiration pneumonia. --Final Impression: 1. Suspicion for hypoxic driven [MEDICAL CONDITION] from aspiration. 2. Acute [MEDICAL CONDITION] with need for intubation and mechanical ventilation. 3. Suspicion for aspiration pneumonia. Hospital History and Physical Final Report: [DATE], (YEAR), 1:20 PM History of Present Illness: .(R801) was brought from his nursing home as he was found unresponsive. There (at the) nursing home, patient was last seen at 9 AM this morning and then later on when they checked on him they found him unresponsive around 9:40 AM. Patient had CPR 2 round; no medication were given and he achieved ROSC by the time EMS (was) there, patient was brought to the emergency and intubated. Per the ED (emergency room doctor), they found some food particles (when they) intubated the patient .We contacted nursing home staff, they stated that the patient at baseline (was) alert x1, and he needs assistance with feeding. Discharge Summary: [DATE], (YEAR), 8:54 AM --Subjective: Not responsive and not following commands. --Hospital Course: Because of the poor prognosis and poor quality of life, discussion with family was held and the the family agreed for him to be DNR/DNI (Do Not Resuscitate/Do Not Intubate) and comfort care. Hospice was consulted and patient was transferred to hospice for terminal wean.

Based on observation, interview and record review the facility failed to administer medications as ordered by the physician for one sampled resident (R501), from a total sample of 3 residents reviewed for medications, resulting in missed medications to be administered for conditions of diabetes, [MEDICAL CONDITION], and hypertension. The failure to administer the resident's blood pressure medication; eye drops for [MEDICAL CONDITION]; and diabetic medication had the potential to result in significant medication errors. Additionally, failure to administer the resident's diabetic medication resulted in the necessity to transfer the resident to an area hospital to treat symptoms of [MEDICAL CONDITION] where her blood glucose level was 602 mg/dl. upon arrival. Findings include: On 8/22/17, at 1:00 p.m., review of R501's facesheet revealed an original admission date of [DATE], and discharge date of [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] indicated the resident has impaired cognition and required extensive assistance with all activities of daily living. On 8/22/17 at 1:15 p.m., during a review of R501's clinical record, a document titled, MAR (Medication Administration Record) for the month of August 2017, revealed missing medication administration opportunities. The MAR indicated [REDACTED]. The ordered medications and the missed opportunities included:: Insulin [MEDICATION NAME] (used to treat Diabetes, to lower blood glucose) per 2 unit Sliding Scale, Accu-Check (blood glucose monitor) and insulin coverage (if required) scheduled twice daily per order, on August 10th, 11th at 9 p.m., were not performed or omitted per MAR indicated [REDACTED] [MEDICATION NAME] (used to treat type 2 Diabetes, to control blood glucose) 2.5 mg tablet ordered, twice daily before Breakfast and Dinner, scheduled for administration at 9:00 a.m. and 5:00 p.m., on August 10th and 13th at 5:00 p.m., were not given or omitted per MAR indicated [REDACTED] Prior to R501's transfer to Detroit Receiving Hospital at 7:00 p.m., on 8/13/17, the final facility nursing note, dated 8/13/17, indicated, The resident in bed completely lethargic, slow to arouse and elevated blood pressure of 170/77. Review of R501's MAR from the admission date of [DATE] until transfer to hospital 8/13/17, revealed documented blood glucose results of up to 350 mg/dl, no results greater than 350 mg/dl were documented during her LOS (length of stay) within the facility. Review of a hospital laboratory report dated 8/14/17, showed a blood specimen collected on 8/13/17 at 19:57 p.m., and a blood glucose of 602 mg/dl and 557 mg/dl at 22:42 (Military Time). In addition to the diabetic medications missed for R#501 there was evidence by review of the MAR (Medication Administration Records) that there were three other medications ordered and scheduled to be given and missed. These medications included: [MEDICATION NAME] (used to treat blood pressure) 100 mg tablet ordered, twice daily, scheduled for administration at 9:00 a.m. and 5:00 p.m. on August 10th, 11th, 12th and 13th at 5 p.m., were not given or omitted per MAR indicated [REDACTED] Review of R501's final nursing note prior to transfer to Detroit Receiving hospital on [DATE], revealed a blood pressure of 170/77 at 7p.m. Dorzolamide (used to treat [MEDICAL CONDITION]) eye drops, ordered 1 drop both eyes twice daily, scheduled for administration at 9:00 a.m. and 5:00 p.m., on August 10th, 12th and 13th at 5:00 p.m., were not given or omitted per MAR indicated [REDACTED] Latanoprost (used to treat [MEDICAL CONDITION]) eye drops, ordered 1 drop both eyes, scheduled for administration every night, at 9:00 p.m. (Bedtime), on August 10th, 11th, and 12th, were not given or omitted per MAR indicated [REDACTED] On 8/22/17 at 3:23 p.m., the Director of Nursing was queried regarding the missing signatures on R501's MAR, she replied, If it's wasn't documented, it wasn't done. On 8/23/17 at 1:51 p.m., review of the facility policy titled, 6.0 General Dose Preparation and Medication Administration, section 6.1, states, Document necessary medication administration/ treatment information (e.g., when medications are opened, when medications are given, injections site of a medication, if medication are refused, PRN medications, applications sight) on appropriate forms.

The citation pertains to intake MI 035 Based on interview and record review, the facility failed to ensure that the sling for a Hoyer Lift (mechanical lift) was inspected and in good condition for safe use for one (#802) of two residents reviewed for Hoyer Lift transfer out of a total of 6 sampled residents, resulting in the sling tearing in two places and the resident falling to the floor sustaining a left leg fracture. Findings include: On 1/31/17 at 2:00 PM, Unit Manager B was asked about Resident #802's fall from the Hoyer Lift. Unit Manager B stated, I was off. I came in when they called me. The nurse (Nurse C) called me. Also, the daughter was in the room when it happened and said 'They were transferring her (Resident #802) and all of a sudden it just snapped'. Unit Manager B was asked what snapped. At 4:18 PM, the Director of Nursing (DON) and Unit Manager B revealed the 2 of the black straps (loops) that hooked onto the Hoyer machine itself had split. On 1/31/17 at 3:20 PM, a review of the closed clinical record revealed that Resident #802 was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set (MDS), dated [DATE], indicated that Resident #802 was cognitively intact and required total physical assistance from two staff to complete transfers. The clinical record revealed that Resident #802 required the use of a Hoyer Lift to be moved between the bed to the Geri-chair. On 1/31/17 at 3:29 PM, a review of the facility's Incident and Accident Report, dated 1/11/17, documented that at 4:25 PM, while in Resident #802's room Resident was being transferred from Geri-chair to bed by Hoyer. The straps on the Hoyer broke and the resident fell to the floor. PA (Physician's Assistant) examined resident and said to transfer to Hospital for evaluation. The Interdisciplinary Post Fall Review, dated 1/11/17 at 4:25 PM, documented, Hospital X-ray showed FX (fracture) of (L) left leg. On 1/31/17 at 4:21 PM, Nurse C was asked about Resident #802's fall from the Hoyer Lift. Nurse C stated, I was summons to the room by CNA (Certified Nurse Aide) D. When I got in the room, the resident was on the floor on her right side. The Hoyer pad was still hanging on the Hoyer. Two straps had broken, one in the front and one in the back. Nurse C was asked to explain exactly where the separation had occurred. Nursing C stated, Where it connects to the pad. Where it connects to the sling itself is where it popped. Nurse C revealed the two straps on the right, that connect to the Hoyer Lift Machine, had completely separated from the sling that held Resident #802 while suspended in the air to be placed in the bed. On 1/31/17 at 4:27 PM, CNA D was asked about Resident #802's fall from the Hoyer Lift. CNA D stated, I didn't see any tears in it and the color looked good. Both straps on the right came off the sling. The two straps were still on the Hoyer, but had totally separated from the sling. CNA D was asked who was supposed to inspect the slings to make sure they were safe to use. CNA D stated, I'm not sure who is responsible to check them. On 2/1/17 at 12:10 PM, the DON revealed she believed it was a flaw in the sling that caused the accident and that she had contracted the company was told the slings were good for a year. The DON revealed that Resident #802 required the use of a large sling which could hold 450 pounds. The DON revealed that Resident #802 weighed 217 pounds. The DON revealed a limited warranty for the slings that stated, .the products manufactured to be free from defects in materials and workmanship for a period of one year from the date of purchase. The DON revealed invoices, dated 11/4/15, 12/4/15, and 1/4/16 where Large Mesh Slings had been purchased. The DON was asked about the facility's process to remove older slings when when new ones are put in circulation. The DON stated, If you are asking about a process to remove old ones when new ones are opened, I don't have one for that. But laundry is supposed to remove any torn slings they find when they are doing laundry and the aides (CNAs) are supposed to check them before they use them. And if they (CNAs) find anything wrong with them, they are not supposed to use them. The DON was unable to reveal how old the sling used to transfer Resident #802 was or revealed that Hoyer Lift Slings had been inspected. On 2/1/17 at 3:30 PM, a review of the facility's policy titled Total Mechanical Lift, revised 4/1/14, documented, Total Mechanical Lift is a mechanical device used to transfer a patient/resident who otherwise would not be considered safe when transferred by two staff members. Sling is a fabric device in various sized that attaches to the mechanical lift and allows the patient/resident to rest comfortably while being transferred from one surface to another .Prior to usage, staff member will examine the total mechanical lift to assure it is in good working order and functional, also that the sling is appropriate size and in good condition . ( )

This citation pertains to Intake MI 632 Deficient Practice #1 Based on observation, interview and record review the facility failed to monitor, assess, identify, and implement timely individualized interventions, including dietary recommendations to prevent the development and worsening of a pressure ulcer for one (#906) of five residents reviewed for pressure ulcers from a total of 25 sampled residents, resulting in a facility acquired Stage III pressure ulcer worsening and progressing to a Stage IV pressure ulcer. Findings include: On 4/26/2016 at 12:16 p.m., (resident) R#906 was observed lying on his back in a supine position. Further observation revealed that at 12:45 p.m., 1:30 p.m., and 3:19 p.m., R#906 remained in the same position awake in bed and lying supine (on his back). A wedge cushion used for positioning, was observed to be propped up against the wall on top of bedside table. On 4/27/2016 at 11:10 a.m., R#906 was observed in the facility's dining room sitting up in his geri chair with his left leg exposed and bent so that the knee was resting up against the left arm of the chair and foot perched on the extended foot rest (covered with blanket). Observation of R#906 at these times, 11:45 a.m., and 3:50 p.m., revealed that the resident had not been repositioned. There was no evidence that staff provided R#906 with turning or repositioning throughout this time period of time. On 4/26/16 at 3:30 p.m., during an interview and clinical record review, Treatment Nurse D was queried regarding R#906 on when did he developed the pressure ulcer and she explained that a Certified Nursing Assistant (CENA) found it (Stage III pressure sore) on 2/22/16. Treatment Nurse D further explained that the ulcer had measured 7.6 centimeter (cm) x 8.5 cm x no depth. She further explained that it had, Irregular edges, pink purple base. Treatment Nurse D stated that the wound had not been staged at that time and she had waited for the wound care physician to come and see the resident in a couple of days. Treatment Nurse D added, based on my documentation, I would say it was a Stage III pressure sore. (Stage III is a full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue). Further review of the clinical record for R#906 revealed the following documentation: Treatment Progress Notes dated 2/23/26 at 1:16 p.m., Called to room by the CNA (Certified Nursing Assistant). Observed open area to sacral coccyx bilateral buttocks pink purple base, moderate seroserous drainage. 7.6 by 8.5 irregular edges. Treatment per physician's orders [REDACTED].care plan updated. Continue with care plan. On 2/29/16 at 11:15 a.m., the physician progress notes [REDACTED]. Sacral coccyx and bilateral buttocks 9.0 by 8.0 by 0.5 multiple scattered pink bases with moderate serosang drainage. Irregular wound edges .treatment changed per physician's orders [REDACTED]. 3/7/16 at 1:00 p.m., seen by wound care today for weekly evaluation .Sacral coccyx and bilateral buttocks 9.2 by 10.0 by 0.3 multiple pink base with moderate drainage .continue with plan of care. 3/14/16 (no time), seen by wound care for weekly evaluation (sacral coccyx wound bilateral buttocks not mentioned). 3/28//16 (no time), R#906 seen once a week by wound care. Sacral coccyx bilateral buttocks 6.0 by 7.4 by 0.4 .heavy serosang. drainage. Treatment changed per physicians orders. Continue with Plan of Care. On 4/28/16 at 1:30 p.m., R#906 was observed awake in bed during a wound care treatment observation that was performed by the Treatment Nurse D. Treatment Nurse D was not observed when she removed and discarded the soiled dressing that was on the resident's sacral region, but rather had taken off the dressings prior to wound care observation. Treatment Nurse D was observed measuring the Sacral Coccyx Pressure Ulcer and stated, the wound measures 4.5 centimeters length (cm) by 5.0 cm width by 3.0 cm deep (wound appeared to be a crater in appearance with the muscle exposed, with tunneling and had a slight odor). Treatment Nurse D stated that the wound was a Stage III. (4/25/16 per Wound Care Physician's documentation, resident was a Stage IV). On 4/27/16 at 10:32 a.m., during an interview with the visiting wound care physician, he explained: He (R#906) had now progressed to a Stage IV. The physician further explained that the wound is a re-occurring pressure ulcer .he had one years ago, and he is at a very high risk for developing a pressure sore . (Stage IV is a full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures (i.e. Tendon, Joint Capsule). (Undermining and sinus tracts (tunneling) also may be associated with Stage IV pressure ulcers.) On 4/26/16 at 12:19 p.m., a review of the clinical record for R#906 documented the following: an admission face sheet documented R#906 was initially admitted on [DATE], and re-admitted on [DATE] with [DIAGNOSES REDACTED]. There was no mention of previous Pressure Ulcers or Vascular ulcers. Review of the Physician's History and Physical dated 12/25/15, R#906 had an ulcer to the right foot and was a quadriplegic. A review of the Significant Change Minimum Data Set ((MDS) dated [DATE], indicated that the resident was severely impaired for decision making skills and required extensive assistance for all activities of daily living including bed mobility and transfers (Hoyer lift with two people). Additionally, the (MDS) coded the resident as having a stage one or greater pressure ulcer, is at risk of developing pressure ulcers, has one pressure sore or more unhealed pressure ulcers at Stage I or higher. One Stage III. Measured: 9.0 cm x 8.0 cm x 0.5 cm with granulation tissue, is a Stage III. Was not present on the Prior assessment. A review of the resident's Admission Nursing assessment dated [DATE] at 5 :20 p.m., documented a pressure sore to the right heel with drainage, a skin tear to the right lateral calf and a PICC (type of IV access) site darkened area. A pressure sore risk assessment upon re-admission could not be found. The Wound Care Treatment Nurse D was requested to give all information pertaining to R#906's assessment, care and prevention including orders for R#906's pressure ulcer care. A review of physician progress notes [REDACTED]. On 2/15/16 at 10:54 a.m., addressing vascular sores to right heel. No mention of wound to sacral coccyx area. On 2/22/16 at 11:15 a.m., addressing vascular sores to right heel. No mention of wound to sacral coccyx area. On 4/25/16 at 12:10 p.m., .Pressure Ulcer Stage Four sacral coccyx bilateral buttocks and Vascular Ulcer right heel. Dermaginate AG Q2D and PRN (every two days and as needed) to sacral coccyx and bilateral buttocks .turn and reposition, float heels and low loss air mattress. A review of physician's summary orders documented the following: On 12/23/2015, No mention for sacral/coccyx area skin care. 1/8/16, Cleanse right buttock with normal saline and apply dermaterin every two days and as needed; On February 2016, Risamine Ointment apply topically to right buttock after soap and water cleanse every shift and as needed .heel protectors on check every shift, weekly skin assessment. On 2/22/2016, 1. Cleanse Sacral Coccyx with normal saline apply [MEDICATION NAME] everyday and as needed, On 2/29/16, Discontinue [MEDICATION NAME] cream as ordered, start cleanse sacral coccyx bilateral buttocks with normal saline then apply [MEDICATION NAME] gel dry dressing every day and as needed, On 3/3/16, Zinc Sulfate 220 mg one orally everyday for 14 days, Vitamin C 500 mg po everyday for 30 days and prostat 30 milliters three times a day, On 3/11/16, Cleanse sacral coccyx and bilateral buttocks with normal saline then apply dermaglicate AG every other day and as needed, On 4/25/2016, Insert Foley catheter to rule out wounds, There were no further wound care orders documented in the clinical record for the resident's right heel pressure sore after 3/27/15. A review of the resident's nursing Weekly Head to Toe Skin Checks, Assessment Notes' dated 2/18/16 - 3/28/16 revealed the following: On 2/18/16, the skin was intact, that there were no previously identified areas; no bruises, no rashes and that the nails were clean and trimmed, no further documentation; On 2/22/16 the right heel was identified, no further documentation defined any other areas however documented that the right heel was previously identified, On 2/25/16 revealed a right heel and coccyx wound, both. No evidence of measurements were documented. No other identifiable changes to the sacral coccyx area were documented that reflected R#906 developed a Stage III pressure ulcer. A review of the nursing notes revealed that after 4/14/16, no further nursing notes were found and could not confirm whether resident had been turned and repositioned every two hours or as needed and whether the wound had worsened or got better. A review of resident #906's Comprehensive Care Plan titled, Alteration in Skin initiated on 1/11/16, and updated on 1/18/16, 1/25/16, 2/2316, and 3/24/16, revealed an alteration in skin as evidenced by open areas to sacral coccyx/bilateral buttocks. Goal: Ulcer will decrease in size and show no signs or symptoms of infection, daily review in 90 days and as needed. Plan: 1. Assist with repositioning every two hours and as needed, 9. monitor skin for new skin breaks, 11. Weekly and daily skin checks notifying treatment nurse and MD of any new signs and symptoms of breakdown. 14. Medications, supplements if needed i.e., vitamin C, Zinc etc . A review of the Dietary Progress Notes dated 2/25/16, (no time) indicated the following: Current weight 199 pounds, refected a two pound weight loss in past week. Per wound care nursing, resident presents with a stage three pressure ulcer, Sacrococcygeal bilateral buttocks receive Vitamin C for 30 days, Zinc for 14 days .to promote wound healing. A review of the resident's Medication Administration Record [REDACTED]. The TAR did not reveal that the resident was to be turned or repositioned and there wasn't any monitoring of the wound. Furthermore, the TAR did it reveal documentation that supported monitoring for wound changes or revealing changes in wound character or progression; from a Stage III to a Stage IV daily or weekly. On 4/28/16 at 2:36 p.m., an interview and record review for R#906 was conducted with the Director of Nursing (DON). When queried regarding the the development of the resident's Sacral-Coccyx Bilateral Buttock now Stage III pressure ulcer, she explained, The care plan was not updated to reflect the changes of the stage three to four. No one knows where the recommendations are and they are supposed to turn and reposition him. A review of the facility's Treatment Protocol for Wound Care policy dated 7/2014 indicated the following: Overview: The following guidelines should be initiated when a skin condition is assessed. Pressure/Venous Ulcers: Stage III- .Treatment - Cleanse with normal saline and for moderately draining wounds apply santyl .cover all wounds with a dry dressing after treatment with appropriate ointments, Stage Four - same as that of Stage III. The facility's Pressure Ulcer/Skin Ulcer/Wound Protocol dated, 7/2014 documented, 1. Skin Risk Assessment: A pressure Risk Assessment Scale will be performed on every new admission, weekly for four weeks after admission, upon the development of a pressure ulcer, quarterly and with a significant change in condition and when the resident acquires a new risk factor for developing a pressure ulcer (i.e., a decline in level of consciousness, infection or new onset of [MEDICAL CONDITION]); Procedures: Document findings on the 'Pressure Risk Assessment Scale,' 'Assign a numerical score to each category,' 'Based on the total score for the resident at risk level is determined by the 'Pressure Risk Assessment Scale,' 'Refer to preventative Approaches for identified groups on the Care Plan and implement appropriate interventions.' 2. A skin assessment will be completed weekly utilizing the Bath and Skin Report,' Document skin integrity and tissue tolerance in the interdisciplinary progress notes and any other alterations in skin integrity from the Bath and Skin Report worksheet,' Procedure: For Stage III: Add Zinc Supplement, Vitamin C supplement, Increase House supplements to four ounces or eight ounces twice a day. 5. Monitoring: When a pressure ulcer is present the licensed nurse will assess daily. Accompanying documentation when a complication or change is identified, should include: a. An evaluation of the ulcer, if no dressing is present, b. an evaluation of the status of the dressing if present, whether it is intact and whether drainage, if present, is or is not leaking; c. the status of the area surrounding the ulcer .5. Pressure must be reduced over the involved area with turning, proper positioning, and use of supportive devices. CENA's turned and reposition the resident every two hours and as needed. ( ) Deficient Practice #2 Based on observation, interview, and record review, the facility failed to ensure that measures were implemented to reduce pressure on an existing pressure ulcer (PU) and/or a healed PU according to the plan of care for two (#901, #913) of five residents reviewed for pressure ulcers out of a total of 25 sampled residents, and one (#71) supplemental sampled resident, resulting in the potential for the worsening (#901) and reopening (#71, #913) of pressure ulcers. Findings Include: Resident #71 On 4/26/16 at 8:25 AM, during the initial tour, Resident #71 was observed sitting up in the wheelchair in her room. Resident #71 was observed to be small in stature and there was no pressure relieving device in the seat of the wheelchair. On 4/27/16 at 9:55 AM, Resident #71 was observed seated in her wheelchair in her room. There was no pressure relieving device in the seat of the wheelchair. Unit Manager G was asked about the above observation and if Resident #71 was at risk for skin breakdown. Unit Manager G stated, All residents are at risk for skin breakdown, but she has never had any pressure ulcers. However, a review of the clinical record with Unit Manager G revealed that on 1/17/16 Resident #71 developed a Stage II PU to the right buttock that was treated by the wound care team on 1/18/16 and was described and measured as 0.7 centimeters (cm) long X 0.4 cm wide X < 0.01 cm deep with a pink base, scant serous drainage PU stage II. A review of the care plan titled Potential for alteration in skin integrity related to impaired mobility, diabetes, and incontinence listed the plan to include Provide pressure relieving devices in bed and chair . At 10:07 AM, observation of Resident #71's skin revealed an area of scar tissue on the right buttock. Unit Manager G revealed that Resident #71 was supposed to have a cushion in the seat of the wheelchair. On 4/27/16 at 10:15 AM, a review of the clinical record revealed that Resident #71 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], indicated that Resident #71 had moderately impaired cognition and required extensive physical assistance from staff to complete activities of daily living. The Pressure Ulcer Risk Evaluation, dated 12/3/15, revealed Resident #71 scored 9 points. The form stated, Total score of 8 or above represents HIGH RISK. Resident #901 On 4/26/16 at 4:08 PM, a review of the clinical record revealed that Resident #901 was readmitted into the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], indicated that Resident #901 had severely impaired cognition, and required total physical assistance from staff to complete activities of daily living, included movement in bed. The Pressure Ulcer Risk Evaluation, dated 3/8/16, revealed that Resident #901 scored 13 points and was high risk to develop pressure ulcers. The nursing care plan titled Potential for impaired skin integrity related to impaired mobility, incontinence .adult failure to thrive and history of recurrent skin breakdown with the goal Will maintain or develop clean and intact skin, dated 3/30/16, listed the following approach (Intervention) Turn and reposition every 2 hrs every (and) prn (as needed) The record review further revealed the following notes from the wound care consultant: - 3/7/16, Initial consultation, documented a recurrent pressure ulcer, Stage III, on the coccyx and right buttock. The PU was described as being 4.0 cm long X 6.0 cm wide (no depth), multiple pink bases, minimal serosanguinous drainage, irregular edges, periwound cicatrix. The recommendations included Frequently reposition. - 3/14/16, Coccyx/right buttock, 4.2 cm long X 6.0 cm wide X < 0.01 cm deep, multiple wounds, pink bases, moderate serous drainage, irregular edges. The recommendations included Frequently reposition .Note change in treatment due to wound not responding to current treatment. - 3/21/16, Coccyx/right buttock, pink base (not documented as multiple wounds), moderate serous drainage, irregular edges. The wound measured 3.7 cm long X 2.7 cm wide X < 0.01 cm deep. The recommendations included Frequently reposition. - 3/28/16, coccyx/bilateral buttocks, 4.0 cm long X 5.5 cm wide X < 0.01 cm deep, pink base, moderate serosanguinous drainage, irregular edge, marked periwound [DIAGNOSES REDACTED] (redness). The recommendations included Frequently reposition. - 4/11/16, the PU to the coccyx/bilateral buttock was noted to have pink base, scattered necrosis (dead tissue), moderate serosanguinous drainage, irregular edges and measure 4.0 cm long X 5.2 cm wide X 0.3 cm deep. -4/25/16, Coccyx/right buttock measured 7.2 cm long X 10.0 cm wide (positional) X 1.8 cm deep with yellow necrotic midcore, moderate serosanguinous drainage, irregular edges. The recommendations included Frequently reposition off her back .Absolute bed rest X 2 weeks, continue Foley for gravity drainage, wound is not improving with current treatment . On 4/27/16, Resident #901 was observed lying in bed on her back. There were bed bolsters attached to the bed on both sides of the resident. Resident #901 was observed on her back at 7:30 AM, 8:11 AM, 10:30 AM. At 10:30 AM, the treatment observation was done with Wound Care Nurses D & E. Resident #901 was observed to have a stage III PU on the coccyx/bilateral buttock that measured 7.0 cm long X 12.0 cm wide X 3.0 cm deep. The PU had a pink base with scattered necrotic areas. There was heavy serosanguinous drainage, irregular edges, and was mildly malodorous. After the treatment observation, which lasted only 20 minutes, a pillow was placed between Resident #901's left thigh and the bed bolster. Resident #901 was not off-loaded off her buttocks. At 11:06 AM, Foley catheter care was observed with Certified Nurse Aide (CNA) C. After observation of the catheter care, Resident #901 was placed on her back with a pillow between the right thigh and the bed bolster. Resident #901 was not positioned in a manner to be off her buttocks. Resident #901 was observed was lying on her buttocks at 12:00 PM, 2:36 PM, and 3:00 PM. On 4/27/16 at 3:06 PM, the Director of Nursing (DON) was asked about the above observations for Resident #71 and Resident #901. The DON stated, Basically, residents should be turned every 2 hours, some more frequently. You need to push pillows, fold it to get the resident over, and put another pillow behind them to hold them over. The DON further stated, The skin assessment that they (wound care nurses) do (is how they know to put interventions in place.) If they (resident) shows they are at high risk, they put the prevention in place. We use two scales here, the Braden Scale and the Pressure Ulcer Risk Evaluation. On the Pressure Ulcer Risk Evaluation if you score 8 points or more you put the interventions in place. On 4/27/16 at 12:50 PM, a review of the facility's policy titled Pressure Ulcer/Skin Ulcer/Wound Protocol, dated 7/2014, stated, .Pressure must be reduced over the involved area with turning, proper positioning, and use of supportive devices. Certified Evaluated Nurse Aides (CENA) turned and reposition the resident every two hours and as needed .Residents who are at risk for pressure ulcer development based on the Braden Scale Risk Assessment or who have existing alterations will have pressure redistribution devices used. ( ) Resident #913 On 04/26/16 at 2:00 p.m., a review of the medical record revealed Resident #513 was admitted in to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment dated [DATE], indicated Resident #913 required extensive assist of one person for bed mobility, dressing, hygiene and toileting and total assist of one person for ambulation and bathing. The MDS further indicated a stage four (full thickness) skin ulcer was present. The nursing skin care plan dated 04/18/16, revealed a: Stage 4 left lateral leg. The nursing ADL (activities of daily living) care plan dated 01/22/16 indicated: float heels, apply heel protectors. On 04/28/16, at 1:45 p.m., Resident #913 was observed with Wound Care Nurse 'D'. Nurse 'D' rolled back the blankets covering the legs of Resident #513 and the feet and ankles were observed to be resting on a pillow with the heels not floated and no heel protectors in place. Nurse 'D' was queried about the position of the heels and stated, (Resident #913) should have heel protectors on. The heels should be floated. I will instruct the aides to fold the pillow under to off-load the heels. The right lateral heel was observed to have a quarter size dry patch/scar and when queried Nurse 'D' indicated it was an old pressure ulcer site. On 4/27/16 at 12:50 p.m., a review of the facility's policy titled Pressure Ulcer/Skin Ulcer/Wound Protocol, dated 7/2014, stated, .Pressure must be reduced over the involved area with turning, proper positioning, and use of supportive devices. Certified Evaluated Nurse Aides (CENA) turned and reposition the resident every two hours and as needed .Residents who are at risk for pressure ulcer development based on the Braden Scale Risk Assessment or who have existing alterations will have pressure redistribution devices used. ( )

Based on observation, interview and record review the facility failed to ensure that staff used appropriate repositioning techniques while providing care to one (#706) of five sampled residents reviewed for falls, from a total sample of 24, resulting in the resident sustaining a closed head injury. Findings include: On 03/02/15 at 10:15 am, Resident #706 was observed in bed wearing a cervical collar around his neck, with steri-strips (bandages) applied to a laceration approximately 2 centimeters in length to the left eyebrow area. There were several areas of broken blood vessels to the sclera of his left eye, and swelling and redness to the left eyebrow/orbit/facial areas. Attempts to interview Resident #706 were unsuccessful due to cognitive deficits. According to acute care hospital discharge records dated 02/28/15, reviewed on on 03/02/15 at 1:00 pm, Resident #706 was admitted to the hospital on [DATE] after falling at the nursing home and was discharged back to facility on 02/28/15 with [DIAGNOSES REDACTED]. During an interview, on 03/02/15 at 2:00 pm, licensed practical nurse manager (LPN) "B" said that on 02/26/15 at approximately 12:00 pm, Certified Nurse Aide (CNA) "A" was providing care to Resident #706, alone and unassisted, while Resident #706 lay in bed. LPN "B" said at some point during care, CNA "A" repositioned Resident #706 onto his left side, and Resident #706 rolled off the opposite side of the bed, striking the floor. LPN "B" said Resident #706 was totally dependent on staff to provide for his bed mobility needs. LPN "B" said she did not witness the fall, but did respond immediately after the fall. LPN "B" said when entering the room, she observed Resident #706 on the floor between the bed and wall, near the window and radiator. LPN "B" said Resident #706 had incurred injuries including a laceration to his left eyebrow and swelling to the left side of his face. LPN "B" said pain medication and general first aid was administered to the resident for the obvious injuries. LPN "B" said the initial x-rays taken by the facility were inconclusive for the degree of injury, but upon further assessment by medical staff it was decided that Resident #706 should be transferred to the hospital. LPN "B" said it was not acceptable practice for CNA "A" to reposition resident 706 in the bed by rolling the resident away from her. LPN "B" said correct practice would include rolling the resident toward her, especially since the repositioning was completed while the CNA was alone and unassisted. During an interview with CNA "A" on 03/02/15 at 2:15 pm, CNA "A" said she was alone and unassisted while providing perineal care (on a male, the general area between the scrotum and anus) to Resident #706 as he lay in bed on a low air mattress. CNA "A" said Resident #706 was totally dependent on staff for provision of bed mobility needs. CNA "A" said she crossed Resident #706's legs prior to repositioning in the bed and then she rolled Resident #706 away from her toward the wall. Then, the air mattress sank downward, causing Resident #706 to roll off the opposite side of the bed and strike the floor. On 03/02/15 at 1:00 pm and 03/03/15 at 1:00 pm, the following documents were reviewed. There was a face sheet (undated) that indicated Resident #706 was a [AGE] year old male with [DIAGNOSES REDACTED]. There was a Minimum Data Set (MDS) assessment with the ARD date (assessment reference date) of 01/27/15 that indicated Resident #706 had a BIMS score (brief interview for mental status) score of zero (indicating severe cognitive deficits) and was totally dependent on staff, needing at least one staff physical assistance for bed mobility needs and was totally dependent on staff, needing at least two person physical assistance for transfer needs. This MDS assessment also indicated that Resident #706 had impairments to both upper and lower extremities. There was a monthly summary dated 02/14/15 that indicated Resident #706 had severely impaired cognitive patterns and never/rarely made decisions and was totally dependent on staff for bed mobility and transfers. There was an incident and accident report dated 02/26/15 that indicated, on 02/26/15 (no time noted) inside room 110-2, Resident #706 fell and incurred injuries identified as bump to left cheek, abrasion to knee, reddened skin, cut and laceration. This report indicated certified nurse aide (CNA) "A" was assigned to care for Resident #706 and when providing patient care, Resident #706 fell out of bed. There was an Interdisciplinary post fall review dated 02/26/15 that indicated on 02/26/15 at 12:00 pm, Resident #706 was receiving care and fell out of bed and that pain medication was given, as well as other interventions. This review identified injuries as left eyebrow and cheek lacerations. There was an investigation follow up report last dated 02/27/15 that indicated, under description section, Resident #706 was observed on the floor by CNA "A" and, under summary section, was noted to have lacerations to left eyebrow at the side of the left eye and on left cheek, with swelling, redness and scratches to left cheek. This report indicated x-rays were ordered, Resident #706 was transferred to the hospital and x-rays from the hospital showed a fracture. There was a physician's orders [REDACTED].#706 was to have an x-ray to left facial bones, left arm, left ribs, left hip, left knee and left leg as well as Tylenol 480 milligrams for pain relief. There was a diagnostic report (x-ray) of skull and facial bones dated 02/26/15 taken before Resident #706 went to the acute care hospital by the facility's radiologic testing provider that indicated, under impression section, Resident #706 had no significant abnormalities. This report also indicated that if intracranial abnormalities were clinically suspected, CT scan or MRI if clinically indicated may be helpful for further evaluation. There were History and Physical notes from a local acute care hospital, dated 02/26/15 at 6:24 pm that indicated Resident #706 presented to the hospital with left sided facial lacerations after a fall at "his ECF" (extended care facility). These notes also indicated Resident #706 had pain in the left eye and had a laceration less than 1 centimeter in length to his left eye along with left sided peri-orbital edema (swelling around the general eye area). A CT (computed tomography) scan of the head was also completed with results indicating "mildly comminuted fracture involving the floor of the left orbit..." The facility policy for bed mobility (undated) was reviewed on 03/03/15 at 2:10 pm. This policy indicated, under fundamental information section, "Movements should be performed slowly..." because "Slow small movements help prevent injury to the resident..." and, under assisting resident to roll section, "1. Instruct the resident to bring his or her arms over the stomach, bend the knees, and then roll the resident toward the staff member." ( )

This citation pertains to intake #MI 916 The facility failed to provide adequate supervision and operational tab alarms for 1 of 3 sampled residents (902), out of a total sample of 3 residents, to prevent resident 902 from entering the room of resident 901, unbeknown by staff and physically assaulting him with a wheelchair footrest. Resident 901 incurred fractured left ulna and radius, abrasions, contusion, and facial lacerations from the assault. Findings include: Review of the record revealed an incident and accident report dated 09/21/13 that indicated on 09/21/13 at 5:20 am, resident 901 was struck by resident (resident 902) with footrest on left side of forehead periorbital area, left knee and mid chest. This incident and accident report said resident 901 had fracture to left forearm and laceration to face. Review of the record revealed an incident and accident report dated 09/21/13 that indicated on 09/21/13 at 5:20 am, resident 902 struck resident in room 233-2 (resident 901) with footrest on left side of forehead, left knee and mid chest. This incident and accident report said, under conclusion section, resident had [DIAGNOSES REDACTED]. Review of the record revealed a facility investigation summation (undated and unsigned) that indicated on 09/21/13 at 5:20 am resident 901 was struck by resident 902 to the forehead, chest, left ear, left knee and left forearm with a wheelchair footrest. This summation indicated the assault occurred in room 233-2 (resident 901 ' s room). This summation indicated resident 902 was assigned to room 231-2. This summation indicated licensed practical nurse (LPN) " E " responded to room 233-2 after hearing calls for help from resident 903 who also resided in room 233. This summation indicated LPN " E " separated the residents, removed the footrest from resident 902, provided first aid, notified the physician and family, and transferred both residents to outside hospitals for further evaluation. This summation indicated resident 901 returned to the facility with a fractured left forearm and laceration to face. This summation indicated resident 902 returned to the facility, was separated from resident 901 and later transferred to a group home. Review of the record revealed a written statement made by licensed practical nurse (LPN) " E " dated 09/21/13 that indicated LPN " E " was summoned to room 233 by " the cry out for help " and observed resident (902) standing over residents bed (901) with foot/leg rest of wheelchair in hand. This statement indicated resident in room 233-2 (resident 901) had a 2 centimeter laceration over left periorbital area, lump on left side of forehead, superficial cut on left ear, and abrasions to mid chest and left knee. This statement indicated both resident 901 and 902 where transferred from the facility on an emergent basis. Review of the record revealed hospital discharge instructions dated 09/21/13 at 11:25 am that indicated resident 901 had orthopedic trauma, radius and ulna fracture and facial laceration from physical assault. Review of the record revealed nursing home to hospital transfer form dated 09/21/13 that indicated resident 902 was transferred to hospital for assaultive behavior against another resident. Review of the record revealed nurse's notes dated 09/21/13 at 1:00 pm that indicated resident 901 was received back to the facility with injuries noted, including small cut on left ear, left knee abrasion, mid-chest abrasion, lump on left side of forehead and cast to left arm. Review of the record revealed a face sheet dated 07/11/13 that indicated resident 901 was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. This face sheet indicated residents 901 ' s room as 233-2. Review of the record revealed a minimum data set (MDS) assessment dated [DATE] that indicated resident 901 had a BIMS (brief interview for mental status) score of 7 (severe cognitive impairment) and needed extensive assistance and one person physical assistance for bed mobility and was totally dependent needing one person assistance for ambulation. Review of the record revealed a face sheet dated 08/23/13 that indicated resident 902 was a [AGE] year old male originally admitted to the facility on [DATE] with latest admission date of [DATE]. This face sheet indicated resident 902 had [DIAGNOSES REDACTED]. This face sheet indicated residents 902 ' s room as 231-2. Review of the record revealed discharge instructions from hospital printed 03/27/13 that indicated resident 902 had a primary problem identified as frequent falls. Review of the record revealed progress notes dated 04/09/13 that indicated resident 902 had recent history of falls and senile dementia with aggression. Review of the record revealed fall risk assessment dated [DATE] that indicated resident 902 had total score of 19 which indicated high risk to fall. This assessment included points for balance problems while standing and walking, and being chair bound, as well as others. Review of the record revealed an admission nursing assessment dated [DATE] that indicated resident 902 needed 1 person assist for transfers and was partial weight bearing. Review of the record revealed physicians order dated 08/23/13 that indicated resident 902 had orders for tab alarms while in bed and wheelchair. Review of the record revealed wheelchair assessment dated [DATE] that indicated resident 902 had poor safety awareness and was recommended to have a regular wheelchair. Review of the record revealed a care plan for falls dated 08/29/13 (edited 09/04/13) for resident 902. This care plan indicated, under approach section, provide one person limited to extensive assist with transfers and mobility and encourage resident to be in common areas with line of sight by staff when out of room, and provide assistance as needed for mobility tasks and assure utilization of appropriate devices. Review of the record revealed a minimum data set (MDS) assessment dated [DATE] that indicated resident 902 had a BIMS (brief interview for mental status) score of 9 (moderate cognitive impairment) and needed limited assistance and one person physical assistance for bed mobility and transfers, and walking in room/corridor was assessed as not occurring over a 7 day period. This MDS assessment indicated, under balance during transition and walking section, resident 902 was not steady and only able to stabilize with staff assistance for moving from seated to standing position and surface to surface transfers, and walking and turning around did not occur. This MDS assessment indicated, under functional limitation in range of motion section, resident 902 has impairments to both sides in the upper and lower extremities. During an interview with the Director of Nursing (DON) on 10/16/13 at 9:00 am, the DON said resident 903 (901's roommate) was the first person to witness the assault. On 10/16/13 at 9:15 am attempts to interview resident 901 were unsuccessful due to resident 901 having severe cognitive deficits. During this time, the surveyor observed resident 901 having cast to left forearm reinforced with wrap. Other wounds to resident 901 ' s body directly related to the assault appeared to be healing without difficulty. It should be noted that further attempts to observe resident 901 where unsuccessful as the facility transferred resident 901 to an outside hospital mid-survey for a change in mental status. During interviews with resident 903 on 10/16/13 at 9:20 am and 10/17/13 at 9:15 am, resident 903 said he shared a room with resident 901 during the time frames of the assault. Resident 903 said he heard resident 901 yell out, " stop hitting me " and heard sounds like " someone getting hit over and over " . Resident 903 said he is legally blind and can only see shadows and was unable to visualize who was in the room. Resident 903 said he continued to hear resident 901 yelling and " getting beat " so he started yelling for help. Resident 903 said once he started yelling for help, licensed practical nurse (LPN) " E " came to the room quickly with other staff following. Resident 903 said he did not hear any tab alarms sounding during the assault. Resident 903 said he knew exactly what a tab alarm sounded like because they " go off all the time " in the facility and are very loud. During an interview with the Director of Nursing (DON) on 10/16/13 at 11:15 am and 10/16/13 at 12:00 pm, the DON said the facility had a total of 6 staff assigned to work the unit (2 north) during the time frames in which the assault took place. The DON said the facility had no video evidence of the event. Review of the record revealed a staffing sheet dated 09/20/13 from 11:30 (pm) until 7:30 (am) for unit 2 N (north) that indicated there were a total of 6 employees assigned to work during the time frames of the assault. The employees listed were licensed practical nurse (LPN) " E " , certified nurse aide (CNA) " I " , CNA " J " , CNA " L " , CNA " M " , and CNA " N " . During an interview with licensed practical nurse (LPN) " F " on 10/16/13 at 12:30 pm, LPN " F " said resident 902 was assessed as needing one person assist for transfers and ambulation. LPN " F " said she never observed resident 902 ambulate alone and unassisted but did observe him try and stand from wheelchair. LPN " F " said resident 902 was a fall precaution, had poor safety awareness, very limited cognition, altered gait, and poor balance, and was ordered tab alarms to bed and wheelchair to mitigate the risk of further falls. LPN " F " said tab alarms would alert staff by triggering a loud electronic alarm indicating resident 902 was attempting to ambulate without assistance. During an interview with occupational therapy staff (OTA) " H " on 10/16/13 at 1:10 pm, OTA " H " said it was not safe for resident 902 to ambulate alone and unassisted. OTA " H " said resident 901 was strong enough to ambulate but it was not safe due to poor balance and diminished cognitive status. OTA " H " said resident 902 worked on transferring and endurance building in therapy and was instructed to use the call light. OTA " H " said she had received past reports from nursing staff that resident 902 would attempt to stand from wheelchair and get out of bed alone and unassisted. OTA " H " said resident 902 had tab alarms ordered to bed and wheelchair to mitigate the risk of falling. During an interview with certified nurse aide (CNA) " I " on 10/16/13 at 1:40 pm, CNA " I " said she was assigned to work on unit 2 north on 09/21/13 at approximately 5:20 am when resident 902 physically assaulted resident 901 with a wheelchair footrest inside resident 901 ' s room. CNA " I " said she did not hear or see anything. CNA " I " said she did not hear resident 902 ' s tab alarm triggered prior to the assault. CNA " I " said she did not know how resident 902 was able to enter into resident 901 ' s room. During an interview with certified nurse aide (CNA) " L " on 10/16/13 at 2:40 pm, CNA " L " said she was assigned to work on unit 2 north on 09/21/13 at approximately 5:20 am when resident 902 physically assaulted resident 901 with a wheelchair footrest inside resident 901 ' s room. CNA " L " said she did not hear or see anything because she was " 3 rooms away " providing care to another resident. CNA " L " said she did not hear resident 902 ' s tab alarm triggered prior to the assault. CNA "L" said if resident 902 had tab alarms ordered then they should have triggered once he left the bed. CNA " L " said she did not know how resident 902 was able to enter into resident 901 ' s room. During an interview with certified nurse aide (CNA) " M " on 10/16/13 at 2:55 pm, CNA " M " said she was assigned to work on unit 2 north on 09/21/13 at approximately 5:20 am when resident 902 physically assaulted resident 901 with a wheelchair footrest inside resident 901 ' s room. CNA " M " said she first became aware of the assault upon hearing LPN " E " call for assistance near resident 901 ' s room. CNA " M " said she dropped the linen she was carrying and hurried toward resident 901 ' s room and once there observed resident 901 lying in bed with bruises and cuts to face and arms. CNA " M " said by the time she got there, CNA " N " had already escorted resident 902 from resident 901 ' s room. CNA " M " said she did not hear resident 902 ' s tab alarm trigger prior to the assault. CNA " M " said resident 902 had a history of [REDACTED]. CNA " M " said resident 902 ' s room was right next to resident 901 ' s room. CNA " M " said she did not know how resident 902 was able to enter into resident 901 ' s room. During an interview with certified nurse aide (CNA) " K " on 10/16/13 at 3:05 pm, CNA " K " said he was not assigned to work unit 2 north on the night of the assault, but came over briefly to assist CNA " M " to carry linen. CNA " K " said he saw CNA " N " escort resident 902 back into resident 902 ' s room, and saw LPN " E " at resident 901 ' s door assessing the situation. CNA " K " denied hearing any tab alarms triggered during these time frames. CNA "K" said if resident 902 had tab alarms ordered then they should have triggered once he left the bed. During an interview with certified nurse aide (CNA) " N " on 10/16/13 at 3:10 pm, CNA " N " said he was assigned to work on unit 2 north on 09/21/13 at approximately 5:20 am when resident 902 physically assaulted resident 901 with a wheelchair footrest inside resident 901 ' s room. CNA " N " said he first became aware of the assault upon hearing LPN " E " call for assistance in an urgent tone near resident 901 ' s room. CNA " N " said he hurried to resident 901 ' s room and once inside, saw resident 902 attacking resident 901 with a wheelchair footrest. CNA " N " said LPN " E " took the wheelchair footrest from resident 902 and CNA " N " escorted resident 902 out of room 233 (resident 901 ' s room) back into room 231 (resident 902 ' s room next door). CNA " N " said he did not hear resident 902 ' s tab alarm trigger but did observe the tab alarm attached to resident 902 ' s bed frame once escorting resident 902 back into room. CNA " N " acknowledged resident 902 had a history of [REDACTED]. CNA " N " said he had told nurses in the past about resident 902 manipulating the tab alarm. CNA " N " said he did not know how resident 902 was able to enter into resident 901 ' s room. During an interview with certified nurse aide (CNA) " J " on 10/17/13 at 8:50 am, CNA " J " said she was assigned to work on unit 2 north on 09/21/13 at approximately 5:20 am when resident 902 physically assaulted resident 901 with a wheelchair footrest inside resident 901 ' s room. CNA " J " said he first became aware of the assault upon hearing LPN " E " call for assistance. CNA " J " said she was inside another resident room performing care and did not hear any tab alarms trigger prior to LPN " E " calling for help. CNA " J " said when tab alarms trigger they are very loud and can be heard quite a distance away. CNA " J " said resident 902 had a history of [REDACTED]. CNA " J " said she does not know how resident 902 entered into resident 901 ' s room that night. During an interview with licensed practical nurse (LPN) " E " on 10/17/13 at 9:30 am, LPN " E " said on 09/21/13 at approximately 5:20 am, she was sitting at the nurse station on unit 2 north when she heard resident 903 calling for help. LPN " E " said she did not hear resident 902 ' s tab alarms trigger prior to hearing resident 903 calling for help near room 233 (resident 901 ' s and 903 ' s room). LPN " E " said she hurried toward room 233 and once inside observed resident 902 standing over resident 901 holding a wheelchair footrest in hand and resident 901 was clearly injured, having lacerations and lumps to the face and body. LPN " E " said she removed the wheelchair footrest from resident 902 ' s hand and when questioned what he was doing inside the wrong room, resident 902 claimed resident 901 was " in his house " and "in his bed ". LPN " E " said she was the first responder to room 233 and immediately called for staff assistance which arrived quickly. LPN said she assessed both resident 901 and 902 and transferred both from the facility for emergent medical services. LPN " E " said an x-ray revealed resident 901 also incurred a fractured left arm from the assault. LPN " E " said, prior to the assault, she observed resident 902 in own bed inside room 231. LPN " E " said she had no idea how resident 902 was able to enter into resident 901 ' s room. LPN " E " said resident 902 had tab alarms ordered to wheelchair and bed. LPN " E " said she had 5 CNA ' s working with her on the floor that shift but did not know who was in the hallway because the hours of 5 am-6 am are quite busy on the midnight shift and staff are likely to be inside resident rooms rendering care. LPN " E " said she had no knowledge that resident 902 had a history of [REDACTED]. During an interview with the Director of Nursing (DON) on 10/17/13 at 10:10 am, the DON said the facility requires staff to check residents every two hours on the midnight shift. The DON said at the time of the incident tab alarms were being checked on a weekly basis, not daily. The DON said the facility completed an internal investigation of the incident and did not issue any corrective action toward any employee. The DON said resident 902 had tab alarms ordered to mitigate the risk of falling and, after consulting with other nursing staff, denied having any knowledge that resident 902 had a history of [REDACTED]. When asked how resident 902 was able to enter into resident 901 ' s room without triggering ordered tab alarms, the DON said, " I can only go by what others tell me " . During record review on 10/16/13 and 10/17/13, the surveyor could not find any care plan documenting resident 902 ' s noncompliance with tab alarms. During further observations on 10/17/13 at 9:10 am, the surveyor observed resident 902 ' s former bedroom (231, bed 2) to be approximately 25 to 30 feet in distance from resident 901 ' s bedroom (233, bed 2). The two rooms are not connected by any internal doorway or bathroom. Based on these observations one must enter the hallway on unit 2 north in order to exit room 231. Also, the nurse station on unit 2 north is recessed into the wall which greatly impacts one ' s ability to make direct visual contact of most resident rooms on unit 2 north, especially rooms 231 and 233. ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW THE FACILITY FAILED TO ENSURE THAT 1 OF 5 SAMPLED RESIDENTS (#501) WAS PROVIDED ADEQUATE SUPERVISION AND PREVENT AN AVOIDABLE ACCIDENT WHEN IMPROPER POSITIONING OF THE RESIDENT DURING A BED LINEN CHANGE CONTRIBUTED TO A FALL OUT OF THE BED CAUSING THE RESIDENT TO SUSTAIN A RIGHT HIP FRACTURE. FINDINGS INCLUDE: REVIEW OF THE CLOSED CLINICAL RECORD FOR RESIDENT #501 REVEALED ON THE [DATE] MONTHLY PHYSICIAN ORDERS [REDACTED]. THE COMPREHENSIVE assessment dated [DATE], INDICATED RESIDENT #501 WAS ALERT AND HAD MODIFIED INDEPENDENCE WITH COGNITION. RESIDENT #501 REQUIRED EXTENSIVE ASSISTANCE WITH HER PERSONAL CARE NEEDS INCLUDING BED TRANSFERS AND POSITIONING. REVIEW OF AN INCIDENT REPORT INDICATED THAT ON [DATE], "ASSIGNED CNA (CERTIFIED NURSING ASSISTANT) REPORTED TO WRITER THAT SHE HAD TO LOWER RESIDENT TO FLOOR". THE REPORT INDICATED NO EVIDENCE OF INJURIES. THE INCIDENT REPORT WAS SIGNED BY THE LICENSED NURSE BUT NOT DATED. ON [DATE], AT 11:30 A.M., INTERVIEW WITH THE CERTIFIED NURSING ASSISTANT WHO IS ALSO KNOWN AS EMPLOYEE "B" REVEALED THAT SHE WAS ASSIGNED AS THE CNA FOR RESIDENT #501 DURING THE MIDNIGHT SHIFT ON [DATE]. EMPLOYEE "B" STATED THAT AT APPROXIMATELY 1:00 A.M., WHILE MAKING HER ROUNDS SHE FOUND RESIDENT #501 SATURATED IN URINE AND THE RESIDENT'S BEDDING NEEDED TO BE CHANGED. EMPLOYEE "B" STATED THAT RESIDENT #501 IS UNABLE TO ASSIST WITH BED MOBILITY DUE TO A [DIAGNOSES REDACTED].#501 HAD BILATERAL BED BOLSTERS (ROLLS USED TO ASSIST WITH POSITIONING IN BED) ON THE BED AND SHE WOULD CHANGE THE BED LINEN WHEN RESIDENT #501 OCCUPIED THE BED. EMPLOYEE "B" SAID THAT WHEN CHANGING THE SOILED BED LINEN SHE PROCEEDED TO PULL THE BED SHEET TOWARD HER AND THE RESIDENT STARTED MOVING TOWARD THE EDGE OF THE BED. EMPLOYEE "B" STATED THAT SHE TRIED TO HOLD ON TO THE RESIDENT TO BREAK A FALL OCCURRENCE BUT THE RESIDENT SLID DOWN TO THE FLOOR. EMPLOYEE "B" STATED THAT SHE IMMEDIATELY NOTIFIED THE CHARGE NURSE, EMPLOYEE "A", ABOUT THE INCIDENT AND RESIDENT #501 WAS ASSESSED BY THE NURSE. EMPLOYEE "B" STATED THAT THE RESIDENT HAD NO COMPLAINTS OF PAIN OR DISCOMFORT THROUGHOUT THE MIDNIGHT SHIFT ON [DATE]. REVIEW OF THE RESIDENT'S CLINICAL RECORD INDICATED IN THE "NURSE'S NOTES" DATED [DATE], AT 4 A.M., "ASSIGNED CNA HAD CALLED NURSE TO ROOM AND REPORTED THAT SHE HAD TO LOWER RESIDENT TO FLOOR TO BREAK HER FALL. WRITER OBSERVED RESIDENT SITTING ON FLOOR NEXT TO BED. NO S/S (SIGNS AND SYMPTOMS OF DISTRESS. BED BOLSTERS INTACT. NO BRUISING NO SCRATCHES NOTED." THE PROGRESS NOTE WAS DOCUMENTED BY A LICENSED PRACTICAL NURSE KNOWN AS EMPLOYEE "A". A "NURSE'S NOTE" DATED [DATE], AT 1:00 A.M., INDICATED, "RESIDENT COMPLAINED OF PAIN TO RIGHT THIGH. MEDICATED FOR PAIN AND OBTAINED ORDER FOR X-RAY TO BE DONE DUE TO RESIDENTS INCIDENT AND S/S (SIGNS AND SYMPTOMS) OF BRUISING OBSERVED." THE PROGRESS NOTE WAS DOCUMENTED BY A LICENSED PRACTICAL NURSE KNOWN AS EMPLOYEE "A". ON [DATE], AT 8:15 A.M., INTERVIEW WITH EMPLOYEE "A" VERIFIED THAT SHE WAS THE MIDNIGHT SHIFT CHARGE NURSE AND FACILITATED THE TRANSFER FOR RESIDENT #501 TO AN AREA HOSPITAL emergency room DUE TO COMPLAINTS OF PAIN IN THE RIGHT THIGH ON [DATE]. EMPLOYEE "A" STATED THAT RESIDENT #501 DID NOT COMPLAIN OF PAIN IN HER RIGHT THIGH ON [DATE], WHICH WAS THE DAY THAT THE INCIDENT OCCURRED. EMPLOYEE "A" FURTHER REPORTED THAT THE CNA, ALSO KNOWN AS EMPLOYEE "B", HAD DENIED THAT RESIDENT #501 HAD A FALL. EMPLOYEE "A" STATED THAT EMPLOYEE "B" STATED THAT SHE HAD "LOWERED THE RESIDENT (#501) TO THE FLOOR TO BREAK THE FALL". EMPLOYEE "A" STATED THAT ON [DATE], RESIDENT #501 HAD NO COMPLAINTS OF PAIN OR DISCOMFORT ASSOCIATED WITH THE INCIDENT. EMPLOYEE "A" STATED THAT SHE ,"DID NOT COMPLETE AN INCIDENT REPORT NOR REPORT THE INCIDENT ON [DATE], SINCE (I) SHE DID NOT CONSIDER THE INCIDENT A FALL". EMPLOYEE "A" STATED THAT WHEN SHE REPORTED TO WORK ON [DATE], DURING THE MIDNIGHT SHIFT SHE OBSERVED THE AREA OF RESIDENT #501'S RIGHT THIGH TO HAVE BRUISING AND RESIDENT #501 COMPLAINED OF PAIN UPON PALPATION. EMPLOYEE "A" STATED THAT SHE IMMEDIATELY NOTIFIED THE PHYSICIAN WHO ORDERED FOR AN X-RAY. REVIEW OF AN X-RAY REPORT DATED [DATE], INDICATED "DEGENERATIVE ARTHRITIS WITH IRREGULARITY OF THE INTERTROCHANTERIC REGION OF THE PROXIMAL RIGHT FEMUR PROBABLY DUE TO OLD TRAUMA". EMPLOYEE "A" STATED THAT SHE NOTIFIED THE PHYSICIAN OF THE RADIOLOGICAL FINDINGS AND HE ORDERED FOR RESIDENT #501 TO BE TRANSFERRED TO THE emergency room FOR FURTHER EVALUATION. REVIEW OF THE HOSPITAL emergency room RECORD FOR RESIDENT #501 REVEALED ON A CT (COMPUTED TOMOGRAPHY) SCAN DATED [DATE], "SLIGHTLY DISPLACED AND SLIGHTLY COMMINUTED IMPACTED FRACTURE IN THE NECK OF THE RIGHT FEMUR". RESIDENT #501 WAS admitted TO THE HOSPITAL AND REVIEW OF A HOSPITAL SURGICAL REPORT DATED [DATE], INDICATED "RIGHT HIP HEMIARTHROPLASTY" WAS PERFORMED. THE RESIDENT RETURNED TO THE NURSING HOME ON [DATE], AND expired on [DATE]. ON [DATE], AT 1:00 P.M., INTERVIEW WITH THE DIRECTOR OF NURSING REVEALED THAT BASED ON THE FACILITY'S INTERNAL INVESTIGATION IT WAS CONCLUDED THAT EMPLOYEE "B" HAD IMPROPERLY POSITIONED RESIDENT #501 DURING THE BED LINEN CHANGE WHICH CONTRIBUTED TO THE RESIDENT'S FALL OUT OF BED AND RIGHT HIP FRACTURE. ON [DATE], AT 1:30 P.M., THE DIRECTOR OF NURSING DEMONSTRATED TO THE SURVEYOR A RE-ENACTMENT OF THE INCIDENT AND HOW IT WAS CONCLUDED THAT EMPLOYEE "B" HAD FAILED TO PROVIDE RESIDENT #501 WITH PROPER POSITIONING IN BED AND PROPERLY CHANGE THE BED LINEN. THE DIRECTOR OF NURSING STATED THAT SHE CONCLUDED THAT WHEN EMPLOYEE "B" PULLED THE LINEN TOWARD HER, RESIDENT #501 HAD ROLLED OVER THE BED BOLSTER AND ONTO THE FLOOR. THE DIRECTOR OF NURSING STATED THAT THE TECHNIQUE USED TO CHANGE THE BED LINEN WAS IMPROPER, AND EMPLOYEE "B" DID NOT ENSURE RESIDENT #501 WAS PROVIDED THE REQUIRED SUPERVISION AND POSITIONING IN BED TO PREVENT AN ACCIDENT. THE DIRECTOR OF NURSING FURTHER REPORTED THAT EMPLOYEE "B" WAS TERMINATED ON [DATE]. THE DIRECTOR OF NURSING ALSO REPORTED THAT EMPLOYEE "A" FAILED TO INITIATE APPROPRIATE NOTIFICATION TO NURSING MANAGEMENT IN ACCORDANCE WITH THE FACILITY'S "INCIDENT AND ACCIDENT REPORTING PROTOCOL." THE DIRECTOR OF NURSING STATED THAT EMPLOYEE "B" HAD FAILED COMPLETE THE ACCIDENT REPORT OR NOTIFY MANAGEMENT STAFF ABOUT THE INCIDENT UNTIL [DATE], RATHER THAN [DATE] WHEN THE INCIDENT OCCURRED. THE DIRECTOR OF NURSING SAID THAT LICENSED NURSING STAFF ARE REQUIRED TO COMPLETE AN ACCIDENT REPORT ON THE DAY OF THE INCIDENT AND IMMEDIATELY NOTIFY MANAGEMENT STAFF ABOUT THE INCIDENT TO ENSURE THAT APPROPRIATE EVALUATION, TREATMENT, AND SUPERVISION IS PROVIDED TO THE RESIDENT.

THIS CITATION REFERS TO INTAKE NUMBER MI 172 BASED ON OBSERVATIONS, INTERVIEWS, AND RECORDS REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND A FUNCTIONAL ALARM FOR 1 (#506 ) OF 4 SAMPLED RESIDENTS RESULTING IN A FALL AND FRACTURE OF LEFT RADIUS. FINDINGS INCLUDE: RESIDENT #506, [AGE] years OLD, WAS ORIGINALLY admitted to the facility on [DATE] AND REadmitted on [DATE] PER THE FACE SHEET. [DIAGNOSES REDACTED]. THE MDS (MINIMUM DATA SET) DATED 6/20/10 AND 8/11/10 DOCUMENTED RESIDENT # 506 HAD SHORT AND LONG TERM MEMORY IMPAIRMENTS AND COGNITIVE SKILLS WERE MODERATELY IMPAIRED. SHE WAS ABLE TO MAKE HERSELF UNDERSTOOD AND TO UNDERSTAND OTHERS. SHE REQUIRED 1-2 PERSON ASSIST WITH ADL'S (ACTIVITIES OF DAILY LIVING). THE 6/20/10 MDS NOTED RESIDENT # 506 REQUIRED LIMITED 1 PERSON ASSIST WITH TRANSFERS AND EXTENSIVE 1 PERSON ASSIST WITH TOILETING. THE RAP (RESIDENT ASSESSMENT PROTOCOL) DATED 6/20/10 DOCUMENTED RESIDENT #506 WAS AT RISK FOR FALLS DUE TO WANDERING BEHAVIOR, MEDICATION, IMPAIRED JUDGEMENT AND INSIGHT, POOR SAFETY AWARENESS, IMPAIRED BALANCE AND GAIT, AND NO RECALL OF SAFETY INSTRUCTIONS. THE RAP DOCUMENTED THE PHYSICIAN DISCONTINUED TAB ALARMS RELATED TO RESIDENT REMOVING ALARMS. SENSOR ALARMS WERE ADDED TO BED AND WHEELCHAIR. RESIDENT # 506'S CARE PLAN, POTENTIAL FOR FALLS AND INJURY, DATED 6/8/10 INCLUDED UNDER PLAN -SENSOR PAD ALARM TO BED AND WHEELCHAIR AND ASSIST WITH TRANSFERS, AMONG OTHERS. THE RESIDENT SAFETY GUIDE (UNDATED) IDENTIFIED RESIDENT #506 AT RISK FOR FALLS, TAB AND SENSOR PAD ALARM IN BED AND WHEELCHAIR, AND OFFER ASSISTANCE WITH TOILETING NEEDS EVERY TWO HOURS. ON 9/7/10 PER PHONE CNA (CERTIFIED NURSING ASSISTANT) # 18 STATED THAT ON 8/7/10 SHE WAS ACROSS THE HALL WHEN SHE "HEARD SOMEONE HIT THE FLOOR". SHE STATED SHE ENTERED RESIDENT # 506'S BATHROOM AND FOUND HER ON THE FLOOR COMPLAINING OF LEFT WRIST PAIN AND OBSERVED HER LEFT WRIST TO BE SWOLLEN. CNA # 18 STATED RESIDENT # 506 SAID "SOMEONE PEED ON THE FLOOR AND I SLIPPED", THE CNA NOTED A TRAIL OF URINE FROM THE RESIDENTS BED. CNA # 18 STATED SHE DID NOT HEAR ANY ALARM SOUNDING, BUT WAS TOLD BY RESIDENT 506'S CNA (# 21) THE RESIDENT DID HAVE A BED ALARM. ON 9/8/10 PER PHONE NURSE # 20 STATED SHE WAS ON THE FIRST FLOOR WHEN SHE WAS PAGED AND TOLD RESIDENT # 506 HAD FALLEN. SHE STATED SHE ENTERED RESIDENT #506'S BATHROOM AND FOUND HER ON THE FLOOR ON HER RIGHT SIDE HOLDING UP HER LEFT ARM. NURSE # 18 STATED RESIDENT # 506 SAID " I HIT MY HAND, I WAS GOING TO THE BATHROOM AND SLIPPED. THE FLOOR WAS WET AND I HIT MY HAND ON THE SINK". NURSE #18 STATED SHE ASSESSED THE RESIDENT AND NOTED SWELLING ON THE OUTER LEFT WRIST, AND RESIDENT VERBALIZED LEFT ARM PAIN. A FACILITY INCIDENT/ACCIDENT REPORT DATED 8/7/10 DOCUMENTED RESIDENT # 506 AMBULATED TO THE BATHROOM, STATED SHE SLIPPED ON WATER ON THE BATHROOM FLOOR AND COMPLAINED OF LEFT WRIST PAIN. THE PHYSICIAN AND RESPONSIBLE PARTY WERE NOTIFIED. PER THE INVESTIGATION SUMMARY, BY THE DON (DIRECTOR OF NURSING) DATED 8/7/10 RESIDENT # 506 SUSTAINED A LEFT WRIST FRACTURE AFTER HAVING A FALL IN HER BATHROOM. IT STATED THAT CNA #18 DENIED HEARING ACTIVATION OF THE RESIDENTS ALARM WHEN RESIDENT (#506) WAS NOTED ON THE FLOOR IN THE BATHROOM., BUT EXPRESSED THE RESIDENT HAD A BED ALARM. CNA # 21'S INTERVIEW BY THE DON STATED SHE DENIED CHECKING RESIDENT (#506'S) SAFETY GUIDE OR TOILETING THE RESIDENT. IN OBSERVATIONS OF RESIDENT #506 ON 8/31/10 AT 10:00 AM AND ON 9/2/10 AT 12:55 PM, SHE WAS CLEAN, WELL GROOMED AND DRESSED APPROPRIATELY, SHE HAD A CAST ON HER LEFT ARM TO THE ELBOW. TAB AND SENSOR PAD ALARMS WERE IN PLACE. SHE WAS NOT ABLE TO ANSWER QUESTIONS CONSISTENTLY. AN X-RAY DATED 8/27/10 DOCUMENTED DISTAL RADIUS FRACTURE OF LEFT WRIST. ( )