Every finding on record at Canal View - Houghton County

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 1/26/2026 at 1:45 PM, during initial kitchen walk through with Dietary Data Tech D, an open container of sour cream was observed in an upright cooler. Written in marker on the outside of the container was Sour Cream O with a slash mark through the O (for date opened) 1/25/26, then below that X 2-18-26 for a total of 25 days. Dietary Data tech D stated the last date X was the date the product was to be thrown out.On 1/26/2026 at 3:40 PM, a bag of milk was observed in the bulk milk dispenser in the 1st floor kitchen dining area with a dispose by date sticker of 2/3/26, which is a total of 8 days since it was opened. Per Dietary Manager (DM) A this milk was placed in the unit that day (1/26/2026).On 1/27/2026 at 8:25 AM, while on kitchen tour with DM A and Dietician C, the 2 door Hoshizaki reach-in upright cooler was observed with a bag of boiled shelled eggs with a prepared date of 1/22/26 and a use by date of 01-29-26, totaling 8 days. Also noted was a bag of prepared lettuce dated 1-26-26 with use by date of 2-2-26, and sliced onions with a prepared date of 1-26-26 and a dispose by date of 2-2-26 totaling 8 days from date of prep to dispose by date for all of these items.According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.On 1/26/2026 at 1:50 PM, kitchen Staff B was observed washing his hands at a hand sink, dried them with paper towel, lifted the lid of the garbage can container with a clean hand to throw the towel into the garbage and then return to his workstation. When asked what the facilities handwashing policy was, DM A stated, employees must wash their hands when they touch anything other than food or utensils, before returning to the task they are doing and before putting on clean gloves. A review of the facilities handwashing policy indicated hand washing should occur after touching garbage.According to the 2022 FDA Food Code section 2-301.14 When to Wash.FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (E) After handling soiled EQUIPMENT or UTENSILSOn 1/26/2026 at 2:05 PM, the floor mixer was observed covered with plastic. When asked what the cover was for, DM A stated, it was to show the unit has been cleaned. The plastic was removed and the mixer was observed soiled with food debris.According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch.On 1/26/2026 at 2:30 PM the floor under the dish machine was observed soiled with food debris. According to the 2022 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions. (A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. On 1/26/2026 at 3:30 PM the vegetable wash sink in the first floor kitchen was observed with an air break instead of an air gap. The tips of the drain pipes were cut off, but extended down below the lip of the floor drain. According to the 2022 FDA Food Code section 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed.On 1/27/2026 at 8:10 AM, while on a tour of the second floor kitchen, 5 packages of single serve drink cup covers were observed with one of these packages being opened and lying in the space between the splash guard of the sink and the wall and where the drip zone was also located just below the hand towel dispenser used for hand drying for this hand sink.On 1/27/2026 at 8:39 AM, while on a tour of the third-floor kitchen, packages of single serve drink cup covers were observed lying in the space between the splash guard of the sink and the wall and in the drip zone just below the hand towel dispenser used for hand drying for this hand sink.According to the 2022 FDA Food Code section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLEUSE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted.

Based on observation, interview, and record review, the facility failed to ensure that environmental equipment utilized by residents was maintained in a manner that allowed equipment to be appropriately cleaned and sanitized for seven Residents (#34, #120, #103, #11, #18, #53, & #138) of eight residents reviewed for a clean, sanitary and homelike environment. Findings include:Resident #34 (R34) On 1/26/26 at 3:13 PM, R34 was observed sitting in a wheelchair in her room. The wheelchair had black tape wrapped around the entire perimeter of the hand rims (circular component on the outside of a wheelchair's wheels that allow users to grip and turn the rims to propel the wheelchair forward) on both sides of the wheelchair. The tape was visibly soiled and noted to be frayed in several places along the perimeter of the hand rims. R34 was asked the reason the black tape encompassed the hand rims of her wheelchair. R34 said the tape had been present for months but she did not know the reason the tape was applied. When queried regarding the frequency of wheelchair cleaning, R34 replied, It looks like they never clean them [hand rims on wheelchair] – they're filthy. A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating R34 had intact cognition. The MDS disclosed R34 utilized a wheelchair for mobility and independently propelled the wheelchair. An ADL (Activities of Daily Living) care plan in the electronic medical record (EMR) of R34 included an intervention Wheelchair use – independent. R34 did not have a care plan for the placement of black tape around the wheelchair hand rims. Resident #120 (R120) On 1/26/25 at 3:22 PM, R120 was observed sitting in a wheelchair next to her bed. Bed rails were noted to be attached to both sides of the bed, and flexible foam tubes encapsulated the entirety of both bed rails. The foam tubes were secured to the bed rails with tape placed intermittently along the length of the tubes. R120 said she used bed rails for turning and repositioning in bed. When asked the reason for the foam tubes and tape on the bed rails, R120 replied she did not know the reason for the tubes and tape on the bed rails and said the foam tubes and tape were on the rails when she was admitted to the facility. R120 said, They're unsightly. They probably belonged to the person who had this bed before I got here and they probably didn't change them out. They're all raggedy. A quarterly MDS dated [DATE] documented a BIMS of 15 indicating R120 had intact cognition. The MDS disclosed R120 required partial assistance from staff for bed mobility and transfers from the bed to the wheelchair. An ADL care plan in the EMR of R120 contained an intervention Roll left and right: independent. Resident #103 (R103) On 1/26/25 at 3:15 PM, R103 was observed sitting in a wheelchair in her room. The wheelchair had flexible foam tubes encapsulating the entire perimeter of the hand rims of her wheelchair. The foam tubes were secured to the hand rims by tape placed intermittently along the length of the foam tubes. The tubes were torn in numerous areas, and the tape was frayed in several areas. R103 was asked the reason for the foam tubes on the hand rims of her wheelchair. R103 said she did not know why the foam tubes were on the chair. R103 said, It looks like they need to be fixed and cleaned. A quarterly MDS dated [DATE] documented a BIMS score of 12 indicating R103 had moderately impaired cognition. The MDS disclosed R103 utilized a wheelchair for mobility and was able to propel her own wheelchair for locomotion. An ADL care plan in the EMR of R103 documented R103 independently propelled her wheelchair for locomotion. On 1/27/26 at 1:35 PM, Housekeeper (HSKP) E was asked about cleaning wheelchairs and bedrails. HSKP E said the night shift housekeeper utilized a specialized machine for washing wheelchairs and the day shift housekeeper cleaned resident environmental surfaces. When asked about cleaning the bed rails on the bed of R120, HSKP E said, I wipe them down with a sanitizer daily, but they're not very easy to clean with the foam and tape on them. The nurse manager, Registered Nurse (RN) F, was interviewed on 1/28/26 at 9:18 AM. RN F was questioned regarding the efficacy of cleaning wheelchair hand rims or bed rails with flexible foam tubes and/or wrapped in tape. RN F agreed padding was shredded and tape was frayed for some of the residents who used padding on the wheelchair hand rims or bed rails. RN F agreed cleaning items with the foam tubes or tape was an infection control concern and was not visually appealing. RN F could not recall when the foam tubes and/or tape was applied to the wheelchair hand rims of R34 and R103. When asked the reason for the foam tubes and/or tape, RN F reviewed the EMR of R34 and the EMR of R103 and said the reasons were not documented and the residents' care plans did not include the reason for or the need for foam tubes and/or tape to the wheelchair hand rims. RN F said the foam tubes and tape were on the bed rails of R120 when R120 was transferred to the unit from another unit in the facility. RN F reviewed the EMR of R120 and said she could not determine when the foam tubes and tape were applied to the bed rails of R120. Resident #11 (R11) On 1/26/26 at 3:00 PM, R11 was observed lying in bed in her room. The bedside table had black foam bordering the outer edges and an inch came over the top of the table. The top of the table was visibly soiled around the foam edges. R11's bed had bilateral mobility bars covered in flexible, porous foam tubes which encapsulated both bed rails. The foam tubes were secured to the bed rails with electrical tape placed intermittently along the length of the tubes. Resident #18 (R18) R18 was observed on 1/26/26 at 3:04 PM, lying in bed in their room had the same foam bordering their bedside table and bilateral assist bars. R18's bedside table was soiled with debris around and under the foam bordering the bedside table. Resident #53 (R53) On 1/27/26 at 10:37 AM, R53 was observed sitting on the edge of their bed. R53's foot of the bed had a duct taped piece of foam padding the length of the foot board and a right sided assist bar with flexible, porous padding secured with electrical tape. R53 was asked the reasoning for the padding on the assist bar and the footboard and replied, I slide down in bed sometimes. I am not sure about the rail, but that was there when I got here. An ADL care plan in the EMR of R53 contained an intervention Roll left and right: independent. On 1/28/26 at 9:10 AM, an interview was conducted with Staff E who was asked about the addition of foam in R11, R18, and R53's rooms of their bedside tables and assist bars and replied, I think they are used for residents on blood thinners, but I am not sure. They are difficult to clean and disgusting. Staff E was shown R11 and R18's bedside tables and confirmed that they were both visibly dirty and had debris under the foam attached to the tables. Resident #138 (R138) On 1/26/2026 at 2:39 PM, R138 was observed sitting in her wheelchair with her bedside table in front of her. The bedside table wheelbase had flexible, porous foam tubes secured with tape placed intermittently along the length of the tubes. The porous tubes were noted to have scuff marks and chunks missing. R138 could not state the reason for the addition of the porous tubes. R138 said she had been in the facility about three weeks and it (the bedside table) has been like that. The electronic medical record for R138 revealed an admission date of 1/5/26 with diagnoses including multiple fractures. During an interview on 1/27/2026 at 1:22 PM, Maintenance Staff G stated he did not recall adding the porous foam tubing to the bedside table but would look for a work order. Maintenance Staff G stated most likely therapy did this (the addition of foam to this piece of equipment.) No work order was presented as found. During an interview on 1/27/2026 at 1:40 PM, Physical Therapy (PT) staff L reviewed the tubing on the wheelbase of the bedside table and did not recall a reason this resident would have the porous tubing attached. PT Staff L stated he could find no care plans or interventions related to this resident regarding a padded foot rail. PT Staff L suggested this modification could have been potentially for a past resident. He could give no reason for this tubing from a therapy standpoint. During an interview on 1/27/2026 at 1:45 PM, RN M stated, I don't know if it (wheelbase modification) was for her (R138). She has been here a short time, and it probably was from a previous resident.

Based on observation, interview, and record review, the facility failed to provide adaptive dining equipment for six Residents (#82, #26, #33, #59, #16 & #115) of seven residents reviewed for adaptive dining equipment needs.Findings include: Resident #82 (R82)During the breakfast meal service on 1/27/2026 at 8:52 AM, R82 was observed with a meal tray card indicating a need for adaptive equipment including 2-Handled Spout Cups. R82 did have these adapted cups for two of her beverages but did not for two other beverages. The tray card also indicated a need for Flat Handled [NAME] or [NAME] Utensils. She received regular silverware wrapped in a napkin.During an interview on 1/27/26 at approximately 9:30 AM, R82 confirmed the 2-handled cups were much easier for her to use. She pointed to the beverages in her room on her bedside table in these 2-handled cups.The Electronic Medical Record (EMR) for R82 included a quarterly nutritional assessment dated [DATE] which read in part: Resident is able to feed herself independently after initial set up assistance with the use of 2 handled spout cups, an inner lipped plate, and a flat handled fork and spoon.The interventions on R82's current care plan included: Resident is able to feed herself independently after initial set up assistance with the use of 2 handled spout cups, an inner lipped plate, and a flat handled fork and spoon.Resident #26 (R26)During the breakfast meal service on 1/27/2026 at 8:41 AM, R26 was observed with her breakfast in front of her with a tray card indicating **NO KNIVES** on the bottom of the card and NO KNIVES in bold in the box midway down the tray card. R26 had been given regular silverware including a knife.During the breakfast meal service on 1/28/2026 at 8:25 AM, R26 was observed with her breakfast in front of her with a tray card indicating **NO KNIVES** on the bottom of the card and NO KNIVES in bold in the box midway down the tray card. R26 had been given regular silverware including a knife.An interview conducted on 1/28/2026 at 8:26 AM, with Registered Nurse (RN) N revealed R26 had a history of aggression and the intervention had been to remove knives from this resident.Resident #33 (R33)During the breakfast meal service on 1/27/2026 at 8:38 AM, R33 was observed with a meal tray card indicating a need for adaptive equipment including a Tall Spout Cup and Flat Handled [NAME] or [NAME] Utensils. R33 did not have these pieces of adaptive equipment. R33 received regular silverware wrapped in a napkin.The EMR for R33 included a quarterly nutritional assessment dated [DATE] which read in part, Resident (R33) is able to feed herself independently after initial set up assistance w/ encouragement/supervision. She (R33) is told placement of foods. She uses flat handled utensils.The care plan for R33 included a focus of: I have a fair appetite and intake and included interventions of: .I may have non-finger foods, but I may require increased assistance with self-feeding of these items due to my visual impairment. I use a flat handled fork and spoon and a red high-lipped plate to help aid me with my self-feeding ability.Resident #59 (R59)During the breakfast meal service on 1/28/2026 at 8:39 AM, R59 was observed being assisted with his meal. The tray card for R59 stated he needed the adaptive equipment of a Spoon, Flat-Handled. R59 did not receive this special spoon.The EMR for R59 included a quarterly nutritional assessment dated [DATE] which included: .He uses a flat handled spoon and a scoop plate at meals.Resident #16 (R16)During the breakfast meal service on 1/28/2026 at 8:42 AM, R16 had a tray card indicating **NO KNIVES** on the bottom of the card. R16 received regular silverware wrapped in a napkin including a knife. R16 was being assisted with the meal by Certified Nurse Aide (CNA) Q. When asked if R16 should receive a knife, CNA Q stated R16 had been aggressive in the past but had declined and was no longer aggressive. The tray card had further instructions of: Dependent/Total Assist with meals.Resident #115 (R115)During the breakfast meal service on 1/28/2026 at 8:29 AM, R115 had a tray card indicating she needed a Smaller Fork to assist her with meal intake. R115 received regular silverware wrapped in a napkin including a regular sized fork.The EMR for R115 included a quarterly nutritional assessment dated [DATE] which included: She is using ReFlo cups, a divided plate, small/flat handled spoon and smaller fork to help maintain her self-feeding ability. The facility policy titled Meal Supervision and Assistance dated as effective 10/2025 was reviewed. This policy read in part, 1. The facility will utilize a systemic approach to ensure safety throughout the resident's environment and among all staff. 6. Ensure that the necessary non-food items (i.e. silverware, napkin, special devices, straw, etc.) are on the tray' especially assistive and adaptive devices. Report or replace missing items.

Based on observation, interview, and record review, the facility failed to prevent worsening and the development of a pressure ulcer for one Resident (Resident #53) of one resident reviewed for pressure ulcer development.Findings include:Resident #53 (R53)Review of R53's face sheet revealed an admission to the facility on 8/5/25, with diagnoses including heart failure, hypertension, diabetes mellitus, and depression.R53's quarterly minimum data set (MDS) assessment, dated 8/21/25, included Section M Skin which revealed R53 had a risk for developing pressure ulcers.The facility matrix disclosed R53 had developed a facility acquired pressure ulcer stage III which was not present on admission.On 1/27/26 at 10:37 AM, wound care was observed performed on R53 by contracted Physical Therapist (PT) / Wound Care Specialist (WCS) P. R53's pressure ulcer was located on her right sacral area and was circular in shape with some redness of the surrounding skin area. R53 did not have an air mattress on her bed. R53 was wearing an incontinence brief.Review of R53's wound clinic progress note, dated 1/27/26, revealed R53's stage III pressure ulcer on her right sacral area had worsened and deteriorated, with wound measurements of 0.99 centimeters (cm) in length x 1.02 cm in width x 0.2 cm depth, with an area measuring 1.01 cm 2. Additional orders read in part, .Off-loading.Avoid 'Granny Pads'.Other: Avoid full briefs if possible.Do not cross legs while sitting.Reposition every 2 hours in bed.Review of R53's wound clinic progress note, dated 1/15/26, revealed R53 had a stage III pressure ulcer on her right sacral area which developed on 11/23/25, with wound measurements of 0.68 cm in length x 0.79 cm in width x 0.2 cm depth, with an area measuring 0.53 cm2. Additional orders read in part, .Off-loading.Avoid 'Granny Pads'.Other: Avoid full briefs if possible.Do not cross legs while sitting.Reposition every 2 hours in bed.R53's care plan, date revised 11/26/25, read in part .Focus: I have a stage 3 to my buttock. I am at further risk for skin impairments r/t (related to) incontinence, limited mobility, need for assistance with self-cares, cognitive deficits, nutritional risks.Goal: My risk for skin impairment will be minimized.Interventions/Tasks: Monitor my ability to turn and reposition. If I am unable to adjust my weight, assist me as I allow to redistribute my weight frequently.On 1/28/26 at 9:35 AM, R53 was observed in her room lying in bed on her back with her legs crossed. R53 was asked if she had the pressure ulcer on her sacral area before she was admitted and replied, No, it opened up after I was here. R53 stated she only eats breakfast sitting on the side of her bed. R53 was asked if she was willing to try an air mattress to help off-load the area so it could heal and replied, Yes, I would try that.On 1/28/26 at 11:30 AM, Unit manager Registered Nurse (RN) O was interviewed and asked if R53 had any documented education on the importance and reason for an air mattress regarding the off-loading to enhance healing of her pressure ulcer in her electronic medical record. RN O did not provide any documented education for R53 by the end of the survey on 1/28/26.On 1/28/26 at 2:35 PM, an interview was conducted with the Director of Nursing (DON) and the Assistance Director of Nursing (ADON) who both agreed R53 should have been educated and reapproached about the importance of using an air mattress. The DON further explained there are several different types of air mattresses and they could try a different one to see if it would be more appropriate for R53.Policy titled Pressure Injury Prevention and Management, dated 12/2025, read in part Policy: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries.6. Modifications of Interventions.b. Interventions on a resident's plan of care will be modified as needed. Considerations for needed modifications include.Lack of progression towards healing.

Based on observation, interview and record review, the facility failed to use foot pedals to safely propel three wheelchair dependent Residents (#33, #115 and #126) of five residents reviewed for safe wheelchair mobility. Findings include: Resident #33 (R33)On 1/27/2026 at 7:56 AM, Certified Nurse Aide (CNA) I was observed transporting R33 into the dining room from the hall. R33 had her feet scraping the floor as CNA I pushed the resident forward. R33 continued to propel herself out of the dining room and at 7:58 AM, Registered Nurse (RN) J redirected R33 by pushing her toward R33's room. No foot pedals were used and R33's feet dragged on the floor as she was pushed. R33 continued to propel herself and then RN J transported R33 back to the dining room, again without using foot pedals.On 1/27/2026 at 8:58 AM, CNA I was observed pushing R33 out of the dining room. CNA I said, Hold your feet up but R33's feet dragged on floor as her wheelchair did not have foot pedals.Resident #115 (R115)On 1/27/2026 at 8:00 AM, CNA H was observed transporting R115 into the dining room from the hall. CNA H instructed R115 to lift her feet, but R115 could not accomplish this request, and no foot pedals were applied to prevent R115's feet from dragging on the floor.Resident #126 (R126)On 1/27/2026 at 8:04 AM, CNA H was observed transporting R126 to the dining room. R126's wheelchair did not have foot pedals. R126 attempted to lift her feet but upon arrival to the dining room, she put her feet down and was jarred forward.During an interview on 1/28/2026 at 1:57 PM, the Nursing Home Administrator (NHA) stated the facility policy was to use foot pedals when transporting wheelchair dependent residents.The facility policy titled: Safety During Transportation dated as last approved 8/2025, was reviewed. It read in part, .A resident shall remain safe while being transported by staff with in [sic} and outside the building. 5. Protect the resident's feet by putting their feet on foot pedals during any assisted propulsion of the wheelchair.

Based on interview and record review, the facility failed to ensure adequate toileting assistance to prevent a fall, for one Resident (R2) of three residents reviewed for falls. This deficient practice resulted in a fall with major injury, including fractured facial bones and subdural hematoma. Findings include: This deficiency pertains to Intake 2625013,Review of R2's Electronic Medical Record, revealed R2 was admitted to the facility on [DATE], with diagnoses that included the following, in part: Alzheimer's disease with late onset, dementia with agitation, dementia with anxiety, reduced mobility, need for assistance with personal care, stiffness of right hip, stiffness of left hip, and stiffness of right knee. R2 score 0/15 on the Brief Interview for Mental Status (BIMS) performed in August of 2025, reflective of severe cognitive impairment.Review of the Incident Report dated 9/14/25 at 1545 (3:45 p.m.), revealed the following: .Incident Description: . CNA (Certified Nurse Aide) called this nurse into common bathroom stating resident fell on floor. Upon entering the bathroom resident (R2) was observed lying face down on bathroom floor bleeding from the head. Resident assessed with assistance of CNA for bleeding and pressure applied to laceration on right side of head. Attempted to get blood pressure twice but unable to related to positioning and resident crying out. Charge nurse informed of situation and took control of notifying EMS (Emergency Medical Services) and family . Immediate Action Taken: Pressure applied to laceration and transferred to ER (emergency room) via EMS . 9/17/25 Notes: .The resident was assisted to the toilet in the shower bathroom by [CNA's J and I] with an EZ Stand. While standing, [Resident R2] was unable to wait and soiled his clothing. [R1] was then seated on the toilet. CNA I exited the room, and CNA J continued assisting the resident by changing his soiled clothing. A towel was placed on the floor to prevent slipping. While removing clothing from the resident's legs he leaned to the right, lost balance, and fell. R1 sustained lateral and floor (sic) right orbital wall fractures, right zygomatic arch fracture (a break in the bone that forms the lower part of the cheekbone and extends to the temple), right maxillary sinus wall fracture, and a subdural hematoma. Root cause: Care plan was not followed. Resident is care planned to have two caregivers present for the entire toileting process . Intervention: CNA was re-educated on the importance of adhering to the resident's care plan. The care plan was updated to specify use of commode with two-person assist for the full toileting duration and contact guard assist during clothing changes. Therapy will evaluate residents. Review of R2's Care Plans revealed the following, in part: DO NOT leave me unattended as I have fallen in the past. Two people must remain with for the entire toileting duration. Date Initiated: 08/17/2023 . Revision on 05/16/2025.Review of the facilities' Investigation Summary revealed the following interventions to prevent recurrence and ensure residents' safety, in part: .Staff members will remain with the residents throughout the entire toileting process. During clothing changes, staff will remain contact guard assist to ensure stability and prevent loss of balance. A commode with armrests will be used to provide additional support and stability during toileting. Random audits will be conducted daily for 2 weeks, 3x's week for 1 week, 2x week for 1 week and 1x a week for 1 week for a duration of 5 weeks to ensure adherence to the updated protocol and care plan requirements .

This deficiency pertains to Intake 2574829.Based on observation, interview and record review the facility failed to provide comfort care based on the individual's personalized care plans, for one Resident (R1) of one resident reviewed for quality of care. This deficient practice resulted in unaddressed anxiety and fear related to shortness of breath during the dying process. Findings include: Review of R1's Minimum Data Set (MDS) assessment, dated [DATE], revealed R1 was re-admitted to the facility on [DATE] with active diagnoses that included the following, in part: cancer, septicemia, anxiety disorder, chronic obstructive pulmonary disease (COPD), respiratory failure, parainfluenza virus pneumonia and pulmonary embolism. R1 Scored 14 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. The Resident (R1) was placed on Hospice on [DATE] and remained as her own responsible party for medical decisions until [DATE], the day of the Resident's death. An abbreviated survey was conducted on [DATE] in response to a complaint, which included the following information, in part: . Resident (R1) was on Hospice due to COPD and emphysema . On [DATE] at approximately 8:30 p.m., the resident was struggling to breathe and begging for help . The resident was in a complete panic because she couldn't breathe . Complainant states the resident died in agony and fear at (approximately) 9:30 p.m. and staff didn't give her anything to ease her pain or help her breathe .Review of R1's Physician Order Summary revealed the following medication orders, in part:1. Ipratropium-Albuterol Inhalation Solution 2.5 - 0.5 MG/3ML (Ipratropium-Albuterol) 1 vial inhale orally every 4 hours for SOB (shortness of breath). This order was addressed by R1's attending physician on [DATE] in response to a written request from Hospice Registered Nurse (RN) K. Attending Physician/Medical Director T ordered this medication to be retained as an active prescription for R1's shortness of breath.2. Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 0.75 ml by mouth every 2 hours as needed for comfort.3. Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 0.75 ml by mouth every 4 hours for Comfort.4. Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 2 tablets by mouth every 4 hours as needed for anxiety give 0.5mg - 1mg every 4 hours PRN. Review of R1's Progress Notes documented the following, in part: [DATE] 6:27 (a.m.): Resident resting in bed with eyes closed at this time. Arouses to name and will answer questions appropriately. [DATE] 8:13 (a.m.): . Resident presents s/s (signs and symptoms) of pain, morphine gave as PRN order (every 2 hours) . [DATE] 12:05 (p.m.) Order was received via telephone from hospice nurse (Hospice RN K), conveying the physician's (Physician S's) directive to discontinue the following medications and interventions: .DuoNeb [an inhalation solution containing a combination of two bronchodilators, albuterol and ipratropium, that is used to treat bronchospasm in people with chronic obstructive pulmonary disease (COPD)] . [DATE] 12:10 (p.m.), Communication Method: Phone .Order Summary: Ipratropium-Albuterol Inhalation Solution 2.5 - 0.5 MG/3ML (Ipratropium-Albuterol, 1 vial inhale orally every 4 hours for SOB, DISCONTINUE: [DATE] 12:10 (p.m.), Discontinue Date/Reason: MD (Physician) order per hospice nurse [RN K]. [DATE] 12:19 (p.m.): Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML. Give 0.75 ml by mouth every 2 hours as needed for comfort. PRN Administration was: Effective. Follow-up Pain Scale was: 1. [DATE] 13:13 (1:13 p.m.): Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML. Give 0.75 ml by mouth every 4 hours for Comfort. No documentation of Follow-up effectiveness. 7/18.25 19:33 (7:33 p.m.): Lorazepam Oral Tablet 0.5 MG. Give 2 tablet(s) by mouth every 4 hours as needed for anxiety give 0.5 mg - 1 mg every 4 hours PRN . Resident (R1) very anxious. No follow-up documentation of effectiveness. Medication administered by Licensed Practical Nurse (LPN) E. [DATE] 19:36 (7:36 p.m.): Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML. Give 0.75 ml by mouth every 2 hours as needed for comfort. Resident (R1) asked for pain medication. No follow-up documentation of effectiveness. Medication administered by LPN E. [DATE] 20:35 (8:35 p.m.): Lorazepam Oral Tablet 0.5 MG. Give 2 tablets by mouth every 4 hours as needed for anxiety give 0.5 mg - 1 mg every 4 hours PRN. PRN Administration was Effective. Medication documented as given to R1 by LPN E. [DATE] 20:57 (8:57 p.m.): Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML. Give 0.75 ml by mouth every 2 hours as needed for comfort. PRN Administration was Effective. Follow-up Pain Scale was: 2. Documented as given to R1 by LPN E. [DATE] 21:45 (9:45 p.m.): Called to res. (resident R1's) room to confirm res. Death. Observed absent respirations and absent apical pulse for 1-2 minutes. Comfort offered to family who were still present in res. Room . Funeral home updated per phone per family request . Signed by Registered Nurse (RN) N. Review of R1's Controlled Substance Proof-of-Use Record for the Lorazepam 0.5 tablets, provided by the Director of Nursing (DON) on [DATE] at approximately 11:55 a.m., revealed on [DATE] LPN E documented the administration of two 0.5 tablets at 1933 (7:33 p.m.), consistent with the medication administration progress note documentation. No Lorazepam tablets were signed out as administered at 8:35 p.m. with a follow-up for effectiveness by LPN E on [DATE] at 8:35 p.m. as documented in the medication administration progress note. Review of R1's Controlled Substant Proof-of-Use Record for Morphine Sulfate 20 MG/ML revealed the following, in part:[DATE] 1518 (3:18 p.m.) 0.75 ML, prn administered by LPN E. No medication administration progress note was present showing this was administered to R1XXX[DATE] 2057 (8:57 p.m.) no PRN administration of Morphine Sulfate was documented as administered to R1 on the Proof-of-Use Record at this time. Observation of surveillance video footage of R1's hall with the DON on [DATE] at 3:00 p.m., showed LPN E entered R1's room two times between 7:00 p.m. and the time of R1's death documented as 9:45 p.m.: once at approximately 7:25 p.m., and once shortly following at approximately 7:30 p.m. LPN E was not observed to entered R1's room after what appeared to be the administration of Morphine Sulfate documented at 7:36 p.m. until after R1 had passed. The surveillance video did not show LPN E entered R1's room at approximately 8:35 p.m., or 8:57 p.m. when progress notes documented those medications administered by LPN E. The DON was asked to compile a timeline of the surveillance video showing who had entered and exited R1's room between 7:00 p.m. and 9:45 p.m. The DON provided the surveillance video timeline on [DATE] at approximately 3:10 p.m., which detailed all individuals who entered and exited from R1's room between 7:00 p.m. and 9:45 p.m. on [DATE]. The DON's timeline showed LPN E entered R1's room at 7:24 p.m. and exited at 7:25 p.m. LPN E then entered R1's room at 7:30 p.m. and exited at 7:31 p.m. The DON's timeline also covered [DATE] beginning at 12:45 p.m. and progressing up until R1's time of death. The timeline showed, LPN E did not enter R1's room at approximately 3:18 p.m., when 0.75 ML of Morphine Sulfate was documented as administered to R1 by LPN E. During a telephone interview on [DATE] at 11:05 a.m., when asked to clarify the details of the complaint, Complainant B stated, .As it came closer to the evening [R1] was drastically going down (declining) and she was alert. She was talking . she could not breathe. She was very agitated. She was sitting up in bed . She was crying out for help (because) she could not breathe . I asked her (the nurse) to call Hospice, and I told her [R1] is wide awake and asking for help. She (R1) was grabbing the side of the rail, and she was sitting straight up. No nurse came in to give her the breathing treatment or anything . they didn't turn her oxygen up - that one nurse didn't do anything (LPN E) . her (R1's) worst fear was to go (die) with shortness of breath. They did not keep her comfortable . She (LPN E) did not come in and check on us . The aide went out to tell her that [R1] needed more morphine . (the nurse) said 'No, not until 9:30 p.m.' I guess the nurse [LPN E] was supposed to call (hospice) but she didn't. During a telephone interview on [DATE] at 1:41 p.m., when asked about the discontinuation of R1's DuoNeb on [DATE], Hospice RN K stated, They (family) never told me they wanted them to continue. Hospice RN K said the family should have called hospice and then they could have had a visit or talked them through something else to do. Hospice RN K acknowledged the family did call her personal work cell phone number, but she was not working that day and responded with a text. When asked if the facility nursing staff had contacted hospice regarding R1's increased anxiety, fear, and crying out that she could not breathe, Hospice RN K stated, There was never any notice that they (facility staff) had contacted hospice . If they had called us (hospice), we would have asked when she had her last dose, (as) we always wait at least one hour. If they called us (hospice) we would have given her an additional dose. During a telephone interview on [DATE] at 1:49 p.m., when asked to describe the observations and interactions with R1 on [DATE], LPN E stated, I was her primary nurse. I would say my whole shift she (R1) was not in distress. She was comfortably lying in bed. I did give her the scheduled medications . She didn't complain of any shortness of breath. LPN E confirmed the family had asked if R1 needed more medication, could she get it. LPN E stated, I said, '[R1] looks pretty comfortable. She (R1) was not talking to say she needed pain medication, but I could try calling hospice and see if I could get her morphine times changed.' I didn't feel like she needed it . I did try calling Hospice. When asked what time Hospice was called, LPN E stated, A half hour before she passed. LPN E confirmed she called Hospice at approximately 9:00 p.m. LPN E stated, She (R1) didn't look like she needed more medication. She was resting comfortably in there . Review of telephone documentation, received from the Nursing Home Administrator (NHA) at approximately 3:15 p.m., revealed a call was placed to Hospice from the facility at 1800 [6:00 p.m. Eastern Daylight Savings Times (EDST)], which would have been 7:00 p.m., prior to LPN's administration of Morphine and Lorazepam to R1. This documentation did not support LPN E's report of contacting Hospice at approximately a half hour before R1's death at about 9:00 p.m. During a telephone interview on [DATE] at 1:58 p.m., Family Member (FM) C was asked to describe their observation during the evening hours on [DATE] with R1's decline and passing. FM C stated, I would say the last two and a half hours were really rough for her . For somebody that is supposed to sedated with morphine, I have never seen anybody sit straight up and ask for help . She kept asking [another family member] for help (because) she could not breathe . the nurse said it wasn't time for her morphine . she (R1) was not resting comfortably. The last couple of hours were pretty brutal in my opinion. You think they would have made her more comfortable. She (R1) was asking for [another family member to], 'Help me I can't breathe', she was gasping for breath . Nobody deserves to die like that. Review of R1's Care Plans revealed the following, in part: At this time my family and I have opted for Hospice Care. My participation with ADL's (activities of daily living) may fluctuate. Date Initiated: [DATE] . Interventions/Tasks, included, in part: Collaborate with team members to identify and implement appropriate pharmacological and non-pharmacological interventions to reduce pain and promote comfort.Coordinate my care with [Hospice], Update with any changes in condition . Observe me closely for signs of pain, administer pain medications as ordered and notify hospice if there is breakthrough pain . Promote a calm, supportive environment by actively listening to myself/family when expressing feelings . (all) Initiated: [DATE]. Review of the Coordination of Hospice Services policy, effective 11/2024, revealed the following, in part: Policy - When a resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice staff in order to promote the resident's highest practicable physical, mental, and psychosocial well-being . 9. All residents receiving hospice will continue to receive the same facility services as residents who have not elected hospice . 10. The facility will immediately contact and communicate with hospice staff, attending physician/practitioner and the family resident representative regarding any significant changes in the resident's status, clinical complications or emergent situations . Review of the Medication Administration policy, effective 3/2025, revealed the following, in part: Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection . Administration should occur within 60 minutes prior to or after scheduled time, unless otherwise ordered by physician, or given per individual resident circumstances or preferences as applicable . Review of the Pain Assessment and Management policy, effective 12/2024, revealed the following, in part: The facility will keep its residents as pain free as possible so they can achieve their highest level of function and quality of life. Pain relief measures will be implemented to comply with professional standards of practice, focusing on comprehensive person-centered care planning to include the resident's goals and preferences .G. Nursing should evaluate pain status, interventions and effectiveness of pain interventions and document in the nursing notes and EMAR as applicable. Update the Physician as needed. H. When giving PRN pain medications, nursing should document follow-up assessment in the EHR. I. Non-pharmacological interventions for pain (i.e., repositioning, massage, turning lights off, warm cloth, etc.) should be attempted and documented appropriately. These may be used alone or in combination with pharmacological interventions.During the exit conference, at approximately 3:10 p.m., in the presence of the NHA, DON and Corporate Compliance Officer U. the NHA and DON acknowledged LPN E should have assessed the effectiveness of the Morphine Sulfate and Lorazepam both administered at approximately 7:30 p.m., to determine if additional interventions and/or medications were necessary to provide comfort during the dying process. The NHA acknowledge and agreed that nursing documentation should have included assessment of the resident's condition. This Surveyor expressed concern that R1's primary nurse, LPN E did not enter the resident's room after administration of Morphine Sulfate and Lorazepam, until more than two hours later, and no assessment of her comfort level was performed or documented.During a return telephone interview on [DATE] at 5:33 p.m., Friend D, who was present with R1 on the evening of her passing, was asked to provide details of the evening of [DATE]. Friend D stated, .around 8:00 p.m. she [R1] started breathing a lot heavier, but by 8:30 p.m. she was gasping for air. Between 8:30 p.m. and 9:20 p.m., she would literally sit up and cry out and say ,'Please help me I can't breathe. I can't breathe'. [A family member] went out to talk to one of the med techs that was on that night, to ask if [R1] could get her morphine dose . She (R1) would shoot up, sitting right up and begging for us to help her . we waited . and were told she (nurse) could not give another dose (of morphine) . The last hour was the worst thing I have ever seen in my whole life. It would be one thing if she wasn't asking us for help, but she was begging us to help her and there was nothing we could do. The nurse never came back into the room after giving the morphine at 7:30 p.m. The nurse did not come back in until a half hour after [R1] was already gone.

Based on observation, interview and record review, the facility failed to ensure expiration dates were present on multi-dose medications and biologicals and failed to remove expired medications from the active supply in one medication cart of four medication carts reviewed, resulting in the potential for administration of expired medications and biologicals and the potential to have a reduced medication effect. Findings include: A review of the 200 Hall medication cart with Licensed Practical Nurse (LPN) C on 11/19/2024 at 1:54 p.m. revealed the following: A multi-dose Trelegy Ellipta (inhaled medication used to treat asthma and chronic obstructive pulmonary disease) 200-62.5-25 MCG (microgram) inhaler with 22 doses out of 30 doses remaining. Further review of the inhaler and the box housing the inhaler revealed no date indicating when the medication was first opened or when the medication would expire. An open insulin aspart (rapid-acting insulin) FlexPen with 75 units out of 100 units remaining. The insulin pen and the clear plastic bag housing the pen contained no legible date indicating when the medication was first opened or when the medication would expire. An open container of latanoprost (medication used to treat glaucoma) eye drops with a written expiration date of 11/16/2024, indicating the medication expired three days prior to the observation. During an interview at the time of the observation, LPN C reported there were no open dates written on the multi-dose Trelegy Ellipta inhaler or the insulin aspart FlexPen, so she was unable to determine if or when the medications expired. LPN C confirmed the open container of latanoprost eye drops were expired and should have been removed from the medication cart and a new container ordered from the pharmacy. Review of the facility policy titled, Medication Storage, Labeling, Dating, Expirations, Destructions, and Returns, last revised 12/2023, revealed the following: Once a medication or biological package is opened . Record the date opened on the primary medication container (vial, bottle, inhaler) and storage packaging if, once opened, the item has a different expiration date than the manufacturer expiration date . Apply an expiration label (i.e. neon orange or yellow) when the medication has a shortened expiration date once opened (i.e. less than 30 days) . Facility should destroy or return all discontinued, outdated/expired or deteriorated medications or biologicals .

Based on observation, interview, and record review, the facility failed to provide adequate pain management for one Resident (#30) of two residents reviewed for pain management resulting in R30 experiencing uncontrolled pain during a routine dressing change. Findings include: Resident 30 (R30) Review of R30's face sheet revealed the following diagnosis: low back pain. Review of R30's Minimum Data Set (MDS) assessment, dated 9/4/24, revealed a Brief Interview for Mental Status (BIMS) assessment of 9 (0-15) indicating moderately impaired cognition. R30 had no rejections of care, was dependent on staff for all cares except substantial/maximal assistance for upper body dressing, and had an unhealed pressure ulcer, not present on admission. Review of R30's Electronic Medication Administration Record (EMAR), revealed the following, Morphine Sulfate (concentrate) Oral Solution 20 MG/ML (milligrams per milliliters) Give 0.25 ml by mouth every 2 hours as needed for pain . (5 mg) . Review of R30's Treatment Administration Record (TAR), revealed the following, Pressure injuries to coccyx: Cleanse ., pat dry, apply (brand name dressing) to wound bed after moistening with NS (normal saline), then apply 4 x 4 (brand name) dressing. Check daily on every shift and change if there is ANY exudate shadow. Change on shower day, also, (Tuesday am) . R30 was receiving daily dressing changes. On 11/19/24 at 11:07 AM, an observation was made of R30 receiving a dressing change. R30 was observed to be crying out, Ow, Ow, Ow, (repeatedly) .I can't do it .I want my son . Review of R30's MAR, dated 9/26/24 through 11/18/24, revealed no documentation of medication being provided prior to receiving dressing changes on the following dates: a.) September 28th and 29th, b.) October 1st, 2nd, 3rd, 4th, 9th, 11th, 12th, 13th, 14th, 15th, 16th, 17th, 18th, 20th, 23rd, 25th, 26th, 27th, and 28th, c.) November 3rd, 6th, 8th, 9th, 11th, 15th, 17th, and 18th. Review of R30's care plan, dated 9/10/24, read in part, .I have pain related to my osteoarthritis, coccyx wound .I will not have an interruption in normal activities due to pain through the review date .Evaluate the effectiveness of pain interventions Review for compliance, alleviating of symptoms, dosing schedules and my satisfaction with results, impact on functional ability and impact on cognition .Monitor/record/report to Nurse my complaints of pain or requests for pain treatment .Notify physician if interventions are unsuccessful or if current complaint is a significant change from my past experience of pain. Observe and report changes in usual routine, sleep pattens, decrease in functional abilities . On 11/19/24 at 11:10 AM, an interview was conducted with Certified Nursing Assistant (CNA) D and was asked about R30's discomfort during the dressing change observation and replied, It is hard for them to roll on their right side., which was the side CNA D had to R30 roll on. During the dressing change R30 also stated, It hurts so bad while cleaning the wound. I can tell when it hurts. R30 also refused their shower on 11/19/24. On 11/19/24 at 3:10 PM, an interview was conducted with R30 in their room regarding their pain during the dressing change that morning and how they were feeling now and replied, Pain is ok right now. This morning it was worse during the dressing change and hurt bad during that time. On 11/19/24 at 3:27 PM, an interview was conducted with CNA D who was asked about R30 and her pain during dressing changes. CNA D agreed R30 had increased pain with dressing changes, with rolling on their side and with changing their incontinence brief. CNA D was asked if they have ever let nursing know about R30's pain issues observed while providing cares for R30 and replied, No, I don't think so. On 11/20/24 at 9:05 AM, an interview was conducted with Registered Nurse (RN) E who was asked about R30's pain with dressing changes. RN E replied, I'm not sure why they haven't had an increase in pain medication or why it is not scheduled prior to their dressing changes as that is when they need it most. I did pre-medicate them. When they are resting, they are not in any pain. Just pain with movement and the dressing changes. On 11/20/24 at 12:20 PM, an interview was conducted with the Assistant Director of Nursing (ADON) A who was asked about R30 and the observation of R30 crying out during the dressing change. The ADON A replied, If they were having that much pain during dressing change after being pre-medicated then that was not enough medication. On 11/20/24 at 1:49 PM, an interview was conducted with the Director of Nursing (DON) who was asked about pain management and re-assessment after implementation of medication when pressure ulcer and dressing changes started for R30 and replied, Normally discuss with quarterly reviews. The DON reviewed the progress notes for R30 and confirmed a lack of any discussion or follow up in care conference or reviews regarding R30's pain management. The DON stated, It should be scheduled prior to each dressing change if they are in that much pain. The DON was going to address R30's pain with the physician. Review of policy titled, Pain Assessment and Management, dated 11/2024, read in part, The facility will keep its residents as pain free as possible so they can achieve their highest level of function and quality of life. Pain relief measures will be implemented to comply with professional standards of practice, focusing on comprehensive person centered care planning to include the resident's goals and preferences . D. When assisting residents with ADL's (Activities of Daily Living), direct care staff should observe for pain by assessing for signs and symptoms of pain and or verbally inquiring about a resident's pain, such as: intensity, duration, frequency, location, onset, pattern etc. Documentation and follow-up should occur as needed . F. A plan for pain and symptom management will be developed based upon the assessment data . G. Nursing should evaluate pain status, interventions and effectiveness of pain interventions and document in the nursing notes and the EMAR as applicable. Update the Physician as needed .

Based on interview and record review, the facility failed to ensure that appropriate interventions were in place to prevent a burn for one Resident #70 (R70) of ten residents reviewed for burns resulting in the potential for further burns, pain and disfigurement. Findings include: Resident #70 (R70) Review of R70's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE], with active diagnoses that included: coronary artery disease, hypertension, heart failure, diabetes mellitus, and anxiety disorder. R70 scored a 7 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of severe cognitive impairment. Review of facility incident notes, read in part . per video review of the day 10/25/24 .R70 was seating in the dining tower for supper. R70 was observed picking up a bowl from the table and holding it over her chest while spooning something into her mouth. R70 puts the spoon and bowl back on the table and began to fan the clothing protector that was on [R70's] chest .A copy of the supper meal ticket that day was reviewed, and tomato soup was on the menu .Certified Nurses Aide (CNA) .recalls serving soup to [R70]. Review of facility document titled Hot Food Temperature Log dated 10/2024, read in part . (10/25/24) food item tomato soup .temp 188 degrees Fahrenheit. Review of R70's Incident report dated 10/25/24 revealed [R70] was unable to rate pain, but does state there is some there . Other info .Hot beverage -spillage. Review of R70's Hot liquid assessment dated [DATE], read in part . There exists a high probability to cause the resident to spill a liquid every time a resident handles a hot liquid, the resident is deemed at high risk with hot liquids .Resident is at high risk for liquid spills due to .muscle weakness . [Resident} is not safe to have hot liquids without a lid Review of R70's care plan did not reveal any intervention to prevent further burns from hot soup. During an interview on 11/19/24 at 10:04 a.m., R70 touched her chest and stated that is where my burn was . During an interview on 11/20/24 at 1:38 p.m., the Nursing Home Administrator (NHA) acknowledged that R70 received a burn from hot soup. During an interview on 12/20/24 at approximately 3:15 p.m., the Director of Nursing (DON) stated, I have not considered safety related to hot soup as the hot liquid assessment was only for drinks. Review of facility policy titled Hot Liquids Policy last revised 5/2024, read in part . Residents will be assessed for management of hot liquids to determine risk for hot liquid spills .the facility's hot liquid assessment addresses lid use on hot liquids .lids should be placed on hot liquids .

Based on observation, interview, and record review, the facility failed to utilize appropriate dementia care techniques in the provision of care and services to one Resident (R3) of three residents reviewed for dementia care. This deficient practice resulted in the potential for escalation of behaviors by use of physical force to ensure resident complied with staff care. Findings include: This deficiency pertains to Complaint Intake #MI00143128, which alleged facility staff were being physically aggressive and neglectful of R3 while residing in the facility locked Alzheimer's unit. Observation of surveillance video, in the presence of IT (Information Technology) Director (Staff) E showed the following staff/resident (R3) interactions: 12/16/2023: At 4:39 p.m., R3 had fallen asleep in a straight-backed chair. He was leaning forward as he was sleeping. At 4:40 p.m., two unidentified facility staff members (unknown names) grabbed R3 underneath the armpits (one on each side) and dragged him forcibly across the floor. R3 appeared to be resisting the move, as his feet were out in front of him, in a skiing position as they moved him across the room. The staff members placed R3 in a softer chair and he resumed sleeping. Review of the surveillance video confirmed R3 was not checked on by facility staff between 4:40 p.m. and 8:16 p.m., when he fell out of the chair onto the floor. Staff did not assist R3 from the floor in the congregate dining room of the Alzheimer's unit for five minutes. 2/20/24: At approximately 7:35 p.m., R3 was seen to gently touch another Resident. Two unidentified facility staff (same as observed in the above surveillance video) grabbed R3 by his arms and tried to physically redirect the Resident to his room. R3 is seen pulling away repeatedly as staff grip him tightly by the arms. R3 resisted strongly and pushed one of the staff members against the wall. Staff held him tightly by the arms and put him into his room. 3/26/24: At approximately 6:20 p.m. R3 can be seen in the congregate dining room of the Alzheimer's unit, reaching for a bowl of soup on the kitchen counter. The soup is quickly moved out of R3's reach, and R3 then reaches and holds the water pitcher. Resident Care Coordinator of the Alzheimer's unit (Staff) B is observed grabbing the water pitcher in R3's hand and struggling to take the water pitcher from the resident as they both move back and forth and from side to side as Staff B pulls the pitcher from R3 and water spills onto the floor. It appeared as a tug of war between R3 and Staff B. During an interview on 4/24/24 at 10:51 a.m., Staff E was asked about social work services in the facility. Staff E stated, We haven't had a (licensed) social worker since [Former Staff Name] left. We have a Social Worker Tech and a Social Worker Designee. We do not have an actual social worker. During an interview on 4/24/24 at 11:40 a.m., Registered Nurse (RN) G, who was working in the Alzheimer's unit, was asked how they would handle a resident who was resisting attempts to relocate them. RN G stated, We would stop and wait for them - give them time to decide what they wanted to do and try to talk them into the move. It would not be appropriate to drag them from one chair to another. When asked about attempting to remove something from a Resident's hands, RN G stated, I would not wrestle with the resident. You try light pressure on their arm - try to talk them into giving it to you. During an interview on 4/24/24 at 12:23 p.m., Staff B was asked about the 3/26/24 incident with R3 when they tried to physically grab and remove the water pitcher from R3. Staff B stated, That is what I thought would be most appropriate because he (R3) was super angry. When asked about movement of a resident by grabbing them under the arms and forcing them to move, Staff B stated, A resident should not be grabbed under his arms. We tell our staff we should walk away. He (R3) does better if you just walk away . It is not acceptable behavior to pull or push a resident against their will . That day (with the pitcher) I told the girl he was in front of to turn away, and he eventually let go of the pitcher. Staff B was informed this Surveyor had observed the surveillance video of the altercation between R3 and themselves in the attempt to remove the pitcher from R3. When asked what Staff B would instruct her staff in the unit, in regard to attempting to physically force a resident to relinquish an item like the water pitcher, Staff B stated, I would probably tell them to let him be and walk away. When asked who the dementia care expert in the facility was, Staff B stated, I don't know if we have a dementia expert in the building. [Former Interim Nursing Home Administrator] was supposed to do a training to get me certified (in Dementia Care). (It is) supposed to be still in the works. Staff B confirmed they had begun working as the manager of the Alzheimer's unit in January of 2024. Staff B also confirmed no licensed social workers were currently employed by the facility. Review of the [Name of Facility] Resident Services Handbook, distributed upon admission to each facility resident or resident representative, revealed the following, in part: Social Services: The Facility employs Licensed Social Workers to assist both the residents and their families. The Social Workers provide assistance with application, resident admissions, and provide for the psychosocial needs of residents as well as prepare the residents for discharge. During an interview on 4/24/24 at 12:44 p.m., Social Services Designee (Staff) K confirmed they were responsible for oversight of R3 in the Alzheimer's unit. Staff K said they were hired in March of 2023, and confirmed the Resident Services Handbook had been distributed to all new facility admissions for the last four years. When asked who was the dementia care expert that would handle challenging resident behaviors in the Alzheimer's unit, Staff K named previous Interim NHA L, who he indicated also had a specialty in Social Work. When asked to provide documentation of Interim NHA L's direct participation with behavioral interventions specific to R3, Staff K was unable to provide any documentation supporting Interim NHA L's participation with R3's behavioral interventions. Staff K stated, She (Interim NHA L) has been here, but I don't know if she has seen [R3]. When asked for Staff K's educational background, Staff K said he had worked for a regional mental health agency for [AGE] years and had a bachelor's degree in psychology. When asked about the appropriateness of a tug of war in attempting to remove an item in the possession of a resident, Staff K stated, Absolutely not, I would not play tug of war over an item a resident had. A water pitcher they will probably put down eventually. Physically they could get hurt and emotionally they could as well. That is like the worst thing you could do - one of them at least I would say - to play tug of war with a resident. During an interview on 4/24/24 at 12:52 p.m., when asked if a resident should be pulled by them armpit across the floor, Staff K stated, No, they should not pull the resident up by his shoulder (and drag him across the floor). Good God, I hope this isn't happening here. The armpit thing is not good. A resident should not be left for four hours in a chair . we encourage a resident to make their own choices even in [the Alzheimer's Unit]. Physical restraint is the last resort. During an interview on 4/24/24 at 1:49 p.m., Staff K returned to the conference room where this Surveyor was located and stated, [RN M], on the third floor (non-dementia floor) is the dementia expert. I was told by the Director of Nursing today. We could definitely use her . as much as I am embarrassed to say it - I didn't know that until today. During an interview on 4/24/24 at 2:10 p.m., the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) both acknowledge it was not acceptable to physically push/pull a resident against their will. The ADON stated, You walk away if you are not in the middle of moving (them). The DON and ADON stated they use specific dementia training videos for education of the Alzheimer unit's staff, and agreed those training videos would not recommend struggling with a resident to remove something from them unless it posed a very serious danger. Review of the ADL (Activities of Daily Living) Care of Dementia Unit Residents policy, last approved 12/2023, revealed the following, in part: . 6. A variety of approaches, such as task segmentation, should be utilized in assisting the dementia unit residents with ADLs. 7. Approaches will be in accordance with dementia care principles. Dementia care resources should be kept on the unit for staff use . Review of the [Alzheimer's unit] marketing information found online and provided by the facility on 4/24/24 revealed the following, in part: .Our secure memory care unit provides a specially designed living and program environment for residents in the early to middle stages of Alzheimer's disease or dementia. Change in memory is normal with age, but when that change becomes worrisome as a loved one begins having difficulty communicating, thinking, and reasoning, our specially trained nursing team at [Alzheimer's Unit Name] is here to help them with day-to-day living . Residents are respected and honored with their individual preferences and schedules .

This citation pertains to Intake MI00142963. Based on observation, interview, and record review the facility failed to provide a safe transfer for one Resident (R1) of three residents reviewed for accidents and hazards. This deficient practice resulted in hospitalization for a right, lower leg fracture. Findings include: Resident #1 (R1) Review of the history and physical from the hospital dated 2/16/24, revealed R1 experienced pain in her leg and then transferred to hospital where an X-ray was performed on right knee. Review of progress note from the hospital records dated 2/17/24, stated R1 sustained a fracture of the proximal tibial metadiaphysis fracture near the knee in the larger of the two bones in the lower leg. The report also stated R1 was in pain despite the use of Morphine and Roxicodone (Oxycodone). Review of the Facility Reported Incident (FRI) Investigative Summary dated 2/15/24, at 10:07 a.m , revealed Certified Nursing Assistant, (CNA) D and CNA E entered the room of R1 to assist with a transfer from the bed to wheelchair without the use of a gait belt (safety belt for transfers/walking). R1 experienced a fall during the transfer. Review of R1's Minimum Data Set (MDS) assessment, dated 5/10/23, revealed admission to the facility on [DATE], with active diagnoses that included: expressive aphasia, (difficulty speaking) hemiplegia (one-sided paralysis) following cerebral infarct (stroke) affecting right dominant side, obesity, and unsteadiness on feet. R1 scored 15 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. R1 had unclear speech, was sometimes able to be understood and always able to understand others. During an interview on 3/5/24 at 3:15 p.m , R1 confirmed two people attempted to help them out of bed on 2/15/24. R1 stated two CNA's (D & E) attempted to transfer them out of the bed into a wheelchair. When asked if they fell during the attempted transfer, R1 pointed to the ground and nodded her head yes. When asked about pain, R1 acknowledged pain in the right leg during the night which worsened the next day. R1 expressed an increase in severe pain to her leg the next day and was then transferred to Emergency Department (ED) on 2/16/24. Record review of the physical therapy initial evaluation at hospital dated 2/17/24 reflected that R1 had no active movement of the right upper or lower extremity. The report also stated that patient had an incident at the nursing home where they dropped R1. During an interview on 3/6/24 at 9:44 a.m., CNA D was asked to explain the details of the incident with R1. CNA D stated CNA E assisted and explained how they attempted to transfer R1 from a sitting position on the side of the bed to a wheelchair positioned on the right side of R1(paralyzed right side) on 2/15/24. CNA D stated they assisted R1 to a standing position and pivoted R1 on the right leg and the left leg buckled. CNA D confirmed they had not placed a gait belt on R1 prior to the attempted transfer and were unable to support the resident without the gait belt and the resident fell to the floor. CNA D was asked to demonstrate the position of the wheelchair R1 would use when transferring from the bed to wheelchair. CNA D placed the wheelchair on R1's right (non-weight bearing) side. Note: R1's right leg was paralyzed, and they were unable to pivot safely. During an interview on 3/6/24 at 10:07 a.m , CNA E acknowledged assisting CNA D with transferring R1 from the bed to the wheelchair on the morning of 3/15/24. CNA E stated that R1 was raised to a standing position without a gait belt. R1 attempted to pivot on the right leg which gave out and R1 fell to the floor. When asked when the gait belt was placed on R1 CNA E said it was placed on R1 after the fall to the floor. CNA E did not know why the gait belt was not used prior to the attempted transfer. CNA E stated, We didn't have a gait belt (on R1), but we should have . I have always used a gait belt with R1 in the past. CNA E stated, [CNA D] told me not to tell the nurse, because [CNA D] said it was not a fall (because they lowered her to the floor). CNA E said R1's legs were crossed with the right leg over the top of the left leg, underneath the bed and R1 was crying. CNA E stated, I was concerned [R1] may have been hurt because she was crying, and she does not randomly cry like that. I thought she may have been hurt. I wanted to tell the nurse, but I remember what CNA D said - not to tell the nurse. CNA E stated they were not educated or observed during resident transfers for proper techniques and safety when asked. CNA E was asked to demonstrate the position of the wheelchair R1 would use when transferring from the bed to wheelchair. CNA E' placed the wheelchair on R1's right (non-weight bearing) side. (Note: R1's right leg is paralyzed and unable to pivot safely.) On 3/6/24 at 10:50 a.m., during a telephone interview family member (FM) G confirmed R1 was non weight bearing on her right side. FM G stated [R1] would not have been able to bear any weight on [the] right side. [R1] would step out on [the] left leg which was the only leg that would bear weight. During an interview on 3/6/24, at 11:26 a.m., Rehab Director C was asked about the use of gait belts and said, I do new hire orientation. Even if there is one CNA (doing a transfer) I tell them they must use a gait belt. You never do anything without a gait belt. Even those residents who are refusing, you need to go to the nurse and get assistance. During the same interview with Rehab Director C was asked to demonstrate the position of the wheelchair R1 would use when transferring from the bed to wheelchair. Rehab Director C placed the wheelchair on R1's left (weight bearing) side to safely transfer R1 into the wheelchair. Record review of the Physical Therapy assessment dated [DATE] and R1's care plan dated 4/27/23 revealed, at the time of the fall, R1 required extensive assist with two people for transfers with a third person to stand by. On 3/6/24, at 11:50 a.m., Assistant Director of Nursing (ADON) A provided a policy/procedure titled Basic Guidelines and Safety Procedures for all Transfers. In the Procedure is states: use a transfer/gait belt during transfers. On 3/6/24 at 11:50 a.m., the DON and ADON A were asked to demonstrate how to safely transfer R1. The DON and ADON placed the wheelchair on the left side (weight bearing) side of R1 to safely transfer R1 into the wheelchair. The DON was asked what R1's transfer status was prior to the fall on 2/15/24. The Director of Nursing (DON) stated, Transfer status was two assist (two staff members to assist) I believe. The DON said resident transfers performed by CNA D and CNA E were not monitored or observed following the fall on 2/15/24. The DON and Assistant Director of Nursing (ADON) agreed all CNAs involved knew they needed to use a gait belt during resident transfers.

This deficiency pertains to Facility Reported Incident (FRI) MI00141290. Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent an elopement which resulted in the likelihood of serious harm, injury, impairment, or death to one Resident (R102) out of one resident reviewed for safety and supervision. Review of the facility Investigation Summary Conclusion: [R102] exited the main door of Woodland Haven (secured Alzheimer's unit) unattended . [R102] was observed to have exited the (main entrance) of the building .He was outside of the building for a total of one minute and thirty-four seconds . Review of R102's Minimum Data Set (MDS) assessment, dated 9/13/23, revealed R102 was admitted to the facility on [DATE] with current, active diagnoses of non-traumatic brain dysfunction, Alzheimer's dementia, and depression. R102 scored 5 of 15 on the Brief Interview for Mental Status (BIMS) reflective of severely impaired cognition. R102 was independent with ambulation. Review of facility surveillance showed the following movement of R102 on 11/28/23 following his unobserved and unattended exit through the alarmed secured Alzheimer's unit main entrance/exit doors: 11:57:08 p.m. - R102 pushed on the alarmed (30 second) egress bar on the door, attempted to push buttons on the keypad to the right of the door, wheelchair maintains contact with the egress bar and the door opens. 12:00:00 a.m. - R102 walks out the first set of main entrance/exit doors from the facility. The interior door to the small foyer, and the exterior door are not alarmed. 12:01:00 a.m. - R102 exits the foyer out of the building through the second set of entrance/exit doors. 12:01:14 - Registered Nurse (RN) Y walks to the secured Alzheimer's unit exit door and is observed re-setting a sounding door alarm. RN Y leans to the left and the right as she appears to look outside the exit door through a narrow window. RN Y did not open the secured Alzheimer's unit exit door to look for any potential resident elopement from the facility. R102 is seen exiting out of the facility as RN Y is re-setting the door alarm in the secured Alzheimer's unit. 12:02:37 - R102 comes back inside the foyer between the first and second sets of entrance/exit doors. R102 is unable to get back inside the facility because the second set of entrance doors were locked, with no method of contacting facility staff present inside the small foyer. R102 is seen repeatedly pulling on the interior entrance door for the following seven minutes, unable to enter the facility. 12:08:00 - Pharmacy Technician (who had delivered medications to the facility) exited the interior entrance/exit door pushing a cart. R102 holds the door open for the Pharmacy Technician, who says thank you as observed by her mouth movements, and confirmed by IT Director S, present during the electronic surveillance review. 12:09:10 - R102 re-enters the facility interior entrance door he was holding open, and the door closes behind him. 12:10:59 - R102 sits down in a chair in the front sunroom. 12:19:52 - R102 gets up and moves to a loveseat in view of the nurses' station on the 1st floor. 12:21:36 - House Supervisor/RN U positioned near the elevators, sees R102 and approaches him. 12:23 - RN U uses her phone to telephone (presumably) secured Alzheimer's unit staff. 12:24:34 - RN Y leaves secured Alzheimer's unit to retrieve R102 from the front lobby. 12:29:30 - R102 was returned to the secure Alzheimer's unit by RN Y. Following review of all surveillance video pertaining to R102's elopement from the facility on 11/28/23, in the presence of IT Director S, it was confirmed R102 was unattended and unsupervised for 21 minutes following exit from the secured Alzheimer's unit. Review of Wunderground.com for daily weather history near the facility at; wunderground.com/history/daily/us/mi/[city name]/[air navigation identifier]/date 2023-11-28, revealed a temperature of 18 degrees Fahrenheit with a wind speed of 18 miles per hour (mph) gusting to 26 mph, resulting in a wind chill temperature of 2.4 degrees Fahrenheit as calculated on the National Weather Service Wind Chill Calculator at the time (12:00 a.m. on 11/28/23) of R102's elopement from the facility. Review of RN Y's Witness Statement Form and accompanying phone interview conducted by the DON, dated 11/29/23, revealed the following, in part: When putting away meds (medications) away after delivery she heard like a faint dog whistle sound. Opened conf. (conference) room door to alarm going off. She (RN Y) walked to door, turned off code. No one was in hall .didn't know Res (R102) was outside, just thought he was in the lobby . Code alert on placed (on R102) at 0700 (7:00 a.m.) . Review of the facility Code Alert/Resident Elopement policy, last revised 06/2023, revealed the following, in part: Elopement occurs when a resident leaves the premises or a safe area without authorization . and/or any necessary supervision to do so. It is the policy of this facility to assure a safe environment and well-being for residents residing in our facility. Staff members are responsible to immediately respond when the Code Alert/Door Alarm system is activated . ELOPEMENT RISK ASSESSMENT: .A code alert transmitter will be applied, as appropriate to any resident deemed at risk for elopement . 5. A photo of the resident will be maintained in the MAR (Medication Administration Record) for reference by staff if consent to photo is obtained. An additional copy should be placed in facility Elopement Risk books/binders. 6. All Residents residing in (secured Alzheimer's unit) are considered at elopement risk being that it is a lock down unit. Colored pictures are on file in the MAR for reference if photo was allowed. No Elopement risk binder needed for this area. ELOPEMENT PREVENTION: 1. Residents identified to be at risk for elopement will have a Code Alert transmitter placed on them unless otherwise determined by the Interdisciplinary Team. 2. Each nursing unit will maintain a list of residents wearing Code Alerts. 3. Nursing staff will document any elopement attempts or other wandering behavior as needed. 4. The Interdisciplinary Team will monitor each resident's mood and behavior and revise care plans as needed . RESPONSE TO CODE ALERT/DOOR ALARMS: 1. When the Code Alert/Door Alarm sounds, the nearest staff from any location should immediately respond: a. Immediately check the area around the alarmed door. B. Look inside and proceed out the door to the surrounding areas on all sides as application. C. Go around corners and be sure no resident exited the building. 2. If no one is in sight, thoroughly check the perimeter (walk around the entire building checking surrounding parking areas). Check adjacent lots also. 3. If no one is found around the alarmed door or outside, account for all residents on each nursing unit by visual check. Someone must physically see each and every resident and report whereabouts to the licensed nurse in charge . RETURN OF RESIDENT: A licensed nurse will place a Code Alert transmitter on the resident if one is not already in place . Review of an email correspondence from Unit Manager/RN U to the DON (Director of Nursing) on 11/28/23 at 3:27 a.m., revealed the following, in part: During night shift tonight - 0015 (12:15 a.m.) I was heading to the main elevator and noticed someone sitting in the front lobby. I went to check out the situation. I recognized that it was [R102] who resides in (secured Alzheimer's unit). He was sitting on the couch, wearing his boots and light weight jacket. He had his walker sitting in front of him with his shoes and socks sitting on seat of the walker . I called (secured Alzheimer's unit) nurse on my [Name Brand] phone and alerted her that he was in the lobby. She was un-aware (sic) he was missing .He is not listed in our facility Elopement Risk Binder and doesn't wear a code alert. Wanted to bring this to your attention. Signed by RN U on 11/29/23. Review of emails to the DON on 11/28/23 revealed facility head counts, as directed in the facility elopement policy were not performed to ensure all facility residents were present in the facility, including secured Alzheimer's unit, until 9:30 a.m. on two units, and 9:45 a.m. on the remaining unit. Family Member (FM) T was not notified of the elopement of R102 from the building until 11/28/23 at 11:45 a.m. During an interview on 12/5/23 at 3:11 p.m., the DON confirmed, after their review of all surveillance video, staff needed additional training on the Code Alert/Resident Elopement policy. The DON stated, If an alarm is going off you do not stop; you continue until you find who set off the alarm . The alarm was going off - she was sorting off her (pharmacy) delivery, (and) she (RN Y) did not see who went out the door (secured Alzheimer's unit alarmed exit door). She (RN Y) should have told the aides [Certified Nurse Aides (CNAs)] to get a head count, and I would have ran (sic) until I found out who set the alarm off . During an observation and interview on 12/6/23 at 7:49 a.m., Maintenance Director V and Maintenance (Staff) W performed alarm testing of the alarmed egress door from secured Alzheimer's unit in the presence of this Surveyor. Egress from secured Alzheimer's unit was timed and verified to be a 30 second, delayed release. Maintenance Director V said the egress door was also equipped with a code alert alarm, which would activate and prevent the door from opening, if the resident had a Code Alert alarm in place on them. When asked if residents would be visible if they were in the outer hallway (outside of the egress door), Maintenance Director V stated, No, they would not be visible. When asked about the outside egress door, Maintenance Director V said the interior facility entrance door had a Code Alert alarm but would only sound and prevent the door from opening if the resident was wearing a Code Alert. When asked what would happen if a resident got outside, Maintenance Director V stated, That would not be good, and confirmed the resident would be unable to re-enter the building at night as the button to sound the alarm was located on the outside of the building and no button or staff contact information was present in the foyer. Maintenance Director V said the interior egress door at the front entrance locked at 8:00 p.m. each night and were not unlocked until 8:00 a.m. in the morning. During a telephone interview on 12/6/23 at 9:37 a.m., Family Member (FM) T was asked if there were any concerns related to R102's care in the facility. FM T stated, They (administrative staff) addressed the 'Alcatraz escape' (11/28/23 elopement from the facility). When things happen like this, they do not call us right away. They call the next day. Quite a bit of time goes by (before we are notified) .They said he had been putting on his boots and jacket and saying I got to go they are coming to get me. He walked outside. We were in the middle of that winter storm .It was one minute 34 seconds he was outside .The whole time of his escape was 31 and 1/2 minutes .He was only unsupervised for 9 minutes they told me . During an interview on 12/6/23 at 12:20 p.m., when asked to review the facility Code Alert/Resident Elopement policy, the Nursing Home Administrator (NHA) said he interpreted the policy to mean all (secured Alzheimer's unit) residents are considered elopement risks and therefore should have a Code Alert placed to prevent elopement from the facility. During an interview on 12/7/23 at 8:36 a.m., secured Alzheimer's unit Resident Care Coordinator/MDS/RN M was asked for R102's Care Plans and any knowledge she had regarding R102's elopement on 11/28/23. RN M stated, I was out of town. I woke up to an email (regarding R102's elopement and said (to myself) 'How, how, how?' (did R102 elope). RN M said R102's Elopement Care Plan was initiated on 11/29/23, and prior to that date R102 did not have an elopement care plan. RN M stated, If I had known he was having multiple elopement attempts I would have put a code alert on him. Review of R102's Progress Notes revealed the following Behavior Note entries related to exit-seeking behaviors by R102 during November of 2023, prior to the elopement: 11/4/23 - 13:00 (1:00 p.m.), Resident with some exit seeking behaviors. Walked to Home 2, telling staff, I couldn't open the door. Walked around looking for a way out . 11/13/23 - 21:37 (9:37 p.m.), Resident seen by home one entrance doors, when asked if he needed something resident responded I'm trying to get out, I can't get out . 11/24/23 - 18:42 (6:42 p.m.), Resident exit seeking this evening. Found standing behind home one doors and trying to keep them open when someone enters . During an interview on 12/7/23 at 11:15 a.m., when asked to review R102's Behavior Notes, Assistant Director of Nursing (ADON) L acknowledged that R102 did have exit-seeking behaviors in November 2023, prior to the elopement, which did not prompt the development or implementation of an elopement Care Plan or interventions. During a telephone interview on 12/11/23 at 11:42 p.m., CNA X, who was working in the facility at the time of R102's elopement, was asked to describe any details she recalled about the incident. CNA X said she was on break and did not know anything was going on until the nurse popped her head in the door and said [R102] got out . the next day I had talked to [the DON] and I heard he had gotten outside. When asked about completion of a head count, CNA X stated, No, we did not do a headcount. At the time the protocol would be to do a headcount; go out the door and look around. When I found out what was going on he had already been found . I talked to the administrator. I think anybody that comes over to the (secured Alzheimer's unit) - everyone should have a Code Alert. If he would have had one of those (Code Alert) on, he would not have gotten out. I think everyone in (secured Alzheimer's unit) should have a Code Alert . The Immediate Jeopardy began on 11/28/23 at 12:00 a.m., when inadequate supervision and failure to implement the elopement policy resulted in R102's elopement from the facility outside into inclement weather. The Nursing Home Administrator (NHA) was notified of the Immediate Jeopardy on 12/6/23 at 12:20 p.m. This Surveyor confirmed, by observation and interview, that the Immediate Jeopardy was removed on 12/6/23 at 4:30 p.m., but noncompliance remained at the potential for more than minimal harm due to sustained compliance that has not been verified by the State Agency. The Immediate Jeopardy that began on 11/28/23 at 12:00 a.m., was removed on 12/6/23 at 4:30 p.m., when the facility took the following actions to remove the immediacy: 1. Education Coordinator was provided with a new form that will be given to all new oncoming nurses and contract nurses with pertinent information for daily floor nursing. 2. Code alerts applied to all residents that reside in (secured Alzheimer's unit), care plans updated. 3. Additional education to all staff in regard to the closure of (secured Alzheimer's unit) main doors. 4. All staff education complete. 5. Several elopement drills continue to be completed since elopement and will continue to be reviewed in QAPI (Quality Assurance Process Improvement). Date Facility Asserts likelihood for Serious Injury or Death No Longer Exists: 12/6/2023. 13791 On 12/06/23 at 7:02 AM, an attempt to enter the facility via the front/main entrance was made. The door from the outside opened into a foyer area where another door leading into the building was found locked and inaccessible. A search for information regarding entry was conducted with no signs or other sources of information available indicating how entry to the building was to be accomplished. Located on the outside of the building and to the left of the doors, a door bell button was located. This button was pushed multiple times. No staff responded to the bell. A return to the foyer and additional search for information regarding entry was made. The interior door remained locked with no staff responding to the door bell. Approximately 8 minutes after the attempted and failed entry, as staff person entered the foyer and stated she had witnessed the attempted entry, and offered to use her key to open the door. On 12/6/23 at approximately 7:16 AM the Nursing Home Administrator (NHA) arrived near the door. An interview was conducted at this time. The NHA stated visitors coming to the building when the doors were locked, were supposed to the call the nurses' station on first floor. No information regarding a phone number or instructions for contacting the nurses' station could be found. At 11:13 AM, an interview with Receptionist Staff B was conducted related to the locking of the main entrance doors. Staff B stated the doors are generally locked at 8:00 PM and are unlocked the following morning around 8:00 AM. Staff B was not aware of any communication procedure to allow visitors access after the doors were locked.

Based on observation, interview, and record review, the facility failed to provide necessary treatment and services to promote healing of a pressure injury and prevent the development of an additional pressure injury for one resident (R73) of two residents reviewed for wounds. This deficient practice resulted in harm when R73 developed a stage 3 pressure injury to the coccyx in addition to an existing facility-acquired pressure injury on the coccyx. Findings include: Resident 73 (R73) was admitted to the facility on [DATE] with diagnoses that included but were not limited to: need for assistance with personal care, contracture of the right shoulder, contracture of the left shoulder, dependence on wheelchair, symptoms and signs involving cognitive functions and awareness, catatonic schizophrenia, dementia with psychotic disturbance, and others. The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded R73 as not having any pressure injuries. The MDS assessed R73 with functional limitation in range of motion to both arms and legs. The MDS coded R73 as being fully dependent on staff for ADL (activities of daily living) tasks and functional mobility, including but not limited to toileting hygiene, bed mobility, sitting, and transfers. R73 was assessed on the MDS as always incontinent of bowel and bladder. On 12/7/23 at 7:30 a.m., R73 was observed in the dining room sleeping in her wheelchair prior to breakfast. A cushion was observed on the seat of the wheelchair. R73 had a palm protecting orthotic device in her left hand and an elbow extension orthotic device on her left upper arm. There was a full-body mechanical lift sling directly under R73. Registered Nurse C (RN C) was questioned regarding the condition of R73's skin. RN C stated R73 had a SDTI wound (Suspected Deep Tissue Injury) on the coccyx (tailbone). RN C said [brand name dressing, an adhesive foam dressing] was being used to treat the wound in accordance with facility standing orders. RN C further said the wound was on R73's coccyx (tailbone). RN C said she completed R73's treatment and dressing change the evening of 12/6/23. On 12/7/23, a document in R73's medical record, WOUND - WEEKLY OBSERVATION TOOL, dated 12/5/23, was reviewed. The document noted the following assessment information: R73's coccyx wound was acquired on 12/5/23. The wound was identified as SDTI pressure injury with granulation tissue (beefy, red tissue) and necrotic tissue (brown, black, leather, scab-like). The wound had a small amount of serosanguineous (fluid that is light pink to red) drainage and measured 7.5 cm (centimeters) x 2.5 cm x unable to determine depth. Under the evaluation section of the document, First observation was entered. There were no additional wound forms or documents noted during this review on 12/7/23. On 12/7/23 R73's current physician orders were reviewed. There was no treatment order for the pressure injury on R73's coccyx. The Treatment Administration Record (TAR) for December 2023 contained the order, Check [brand name dressing] to coccyx every shift. Change every 3 days and PRN (as needed) every shift. D/C (discontinue) when resolved. The treatment order had a start date of 12/2/23 and a D/C date of 12/5/23. The treatment was last signed out on day shift 12/5/23. There were no other orders for treatments or dressing changes on the TAR for the pressure injury on R73's coccyx. The Director of Nursing was interviewed on 12/7/23 at 12:32 p.m. regarding expectations and standard of practice when a standing order was implemented. The DON said she would expect the order to be documented in the medical record on the Medication Administration Record (MAR) or the TAR, depending on the order to be initiated. The DON stated her expectation is that the order would be added to the MAR or TAR and signed out on the MAR or TAR but not documented in progress notes. R73's medical record was reviewed with the following progress note entries: 12/2/23 at 11:43 p.m.: Res. Coccyx is moist and fragile. [Brand name foam dressing] placed for protection. 12/3/23 at 04:46 a.m.: Repositioning every 2 hours. 12/5/23 at 03:49 a.m.: Continuing to off-load pressure and reposition every 2 hours. [Brand name foam dressing] to coccyx area remains CDI. 12/5/23 at 7:13 p.m.: Resident has current skin issues. Skin issue: pressure ulcer/injury. Skin issue location: coccyx. Pressure ulcer/injury stage: suspect deep tissue injury - depth unknown. On 12/07/23 at 1:58 p.m., R73's wound care was observed being completed by RN C with Certified Nursing Assistant D (CNA D) assisting with positioning of R73 to a right side-lying position. There were areas of redness observed across R73's back, buttocks, and upper posterior thighs. These areas were indented and coincided with the straps and edges of the mechanical lift sling. RN C assessed the areas and said they were caused by R73 sitting up too long in the wheelchair. CNA D said R73 was in her wheelchair before breakfast. CNA D admitted she had not provided any incontinence care or pressure-reducing endeavors such as repositioning to R73 from the time R73 was placed in her wheelchair before breakfast until R73 was placed in bed for wound treatment observation at 1:58 p.m. During treatment observation on 12/07/23 at 1:58 p.m., RN C removed a dressing with an unreadable date from R73's coccyx. There were two pressure injuries observed: one pressure injury (PI #1) on the superior coccyx near the sacrum, and one pressure injury (PI #2) on the inferior coccyx approximately two centimeters below PI #1. The dressing RN C had removed from PI #1 contained no exudate or drainage. There was no dressing on PI #2. RN C measured PI #1 and determined the wound to be 7.5 cm x 2.5 cm. P1 #1 presented as an unstageable pressure injury with yellow, stringy slough (yellow, stringy tissue) adhering to approximately 2.5 cm x 1.0 cm of the wound bed which obscured the depth of the wound. RN C stated the treatment was a [brand name dressing]. When asked regarding the treatment of PI #2, RN C appeared surprised. The surveyor informed RN C there was a second wound inferior to PI #1. RN C assessed R73's coccyx and said PI #2 was brand new. She stated, I didn't notice it when I did the dressing change this morning. RN C measured PI #2 with surveyor observing. RN C stated, it's a stage 3. Surveyor observed PI #2 measurement as 1.0 cm x 0.8 cm. PI #2 was located on the coccyx below PI #1 and had no drainage. PI #2's wound base contained an area of yellow slough approximately 0.2 cm x 0.2 cm in the inferior portion of the wound. RN C said she was going to use [brand name dressing] on PI #2 based on standing orders for wound care. RN C then completed treatments for PI#1 and PI#2 using [brand name dressing]. RN C said [brand name dressing] is not a good choice for these wounds. And said she planned on contacting the NP or physician for a change in treatment orders. Surveyor informed RN C that there was no treatment order for PI #1 or PI #2. RN C said she would ensure orders were obtained and entered onto R73's TAR. Facility standing orders were reviewed. The physician signature and date lines of the standing orders form were blank. The standing orders contained directives for pressure injury treatments for stage 1, stage 2, and stage 3/stage 4 pressure injuries. SDTI was not mentioned or addressed in the standing orders. The standing orders for a stage 3 pressure injury were: notify physician for treatment and/or wound consult orders. There was no mention of [brand name dressing] for stage 3 or stage 4 pressure injuries. A progress note was entered into R73's medical record on 12/7/23 at 2:24 p.m. The note read, Situation: Call placed to [name of nurse practitioner] who is taking calls for [name of physician] at this time. Updated on new stage 3 wound on coccyx just inferior to wound #1 on coccyx. Inquiring about what dressing to utilize. Background: Current dressing is [brand name dressing] per standing order. Has wound care consult for wound #1 on coccyx. Assessment/Appearance: New stage 3 wound inferior to coccyx wound #1. Measures 1cm x 0.8cm x <0.1 cm. Full thickness wound with 100% serosanguineous. Surrounding skin with black color an scaly. No foul odor. See wound UDA for details. Recommendations: [name of nurse practitioner] ordered wound consult for new wound #2 on coccyx. She will also consult wound care for new dressing orders, and call us back. A WOUND - WEEKLY OBSERVATION TOOL, dated 12/7/23, was entered into R73's medical record. The document assessed PI #2 as a stage 3 pressure injury inferior to PI #1 on the coccyx, measuring 1.0 cm x 0.8 cm x 0.1 cm with black, scaly peri-wound tissue. The evaluation section documented that the 12/7/23 assessment of PI #2 was new wound, first observation. The policy Care of Pressure Sores [injury], dated as effective 10/2023, was reviewed. The policy said, in part: 1. Change the resident's position as least every 2 hours, depending on the resident's need. Some residents will need to be turned more frequently. Chair-bound residents should be repositioned/encouraged to off-load every hour.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: 1. Failing to ensure four packages of lunch meat were disposed of after the expiration date stamped by the packager. 2. Failing to ensure resident care staff on the locked units were wearing hair restraints when they entered the kitchen, during meal service. These deficient practices have the potential to result in food borne illness among any and all 124 residents of the facility. Findings include: 1. On 12/05/23 at approximately 1:35 PM, observations were made in the walk in cooler in the main kitchen on ground floor. Four packages of lunch meat were observed on a shelf in the walk in cooler, two containing ham and two containing roast beef. The packages of ham had use by/freeze by date of 11/6/23, and the two roast beef packages had use by/freeze by date of 11/20/23. Both packages were bloated. An interview with Certified Dietary Manager (CDM) A was conducted at this time who acknowledged the packages of lunch meat should have been discarded. The FDA Food Code 2017 states: 3-101.11 Safe, Unadulterated, and Honestly Presented. FOOD shall be safe, unadulterated, 2. On 12/05/23 at approximately 5:05 PM, the evening meal was observed in the locked unit's dining areas. An open steam table was being used to hold hot food in a kitchen area. Direct care staff were observed in and around the steam table, while the food was uncovered, [NAME] about. None of these staff had their hair restrained.

Based on interview and record review, the facility failed to complete a comprehensive facility-wide assessment that included an assessment and determination of staffing levels based on resident acuity, and training programs that would be provided to facility staff. This deficient practice resulted in the potential for insufficient staff and staff training necessary to care for residents. Findings include: Review of the 43 page Facility Assessment 2023-2024 provided by the Nursing Home Administrator (NHA) on 12/5/23 at 15:49 (3:49 p.m.) revealed Section II. Staffing, Training, Services & Personnel were all documented as Evaluated with the following Sufficiency Analysis Summary, in part: Staffing patterns have been reviewed on [Staffing Name Program]. The facility continues to utilize [Name Brand] Learning platform for annual and supplemental training . For additional information see attachments . No attachments were present with the Facility Assessment. Staffing levels based on acuity were not delineated in the Facility Assessment, nor were the required staff trainings offered to facility staff. During an interview on 12/8/23 at 1:00 p.m., the NHA confirmed the Facility Assessment provided on 12/5/23 did not have any of the required staff trainings specified within the document. The NHA said he had updated the Facility Assessment, that same day 12/8/23, to include all of the required staff trainings. The NHA also acknowledged the Facility Assessment did not include the staffing levels required and or currently utilized based on resident acuity. Necessary staffing level needs were neither numerically nor verbally described in the Facility Assessment document. The NHA said he had not updated the Staffing section of the assessment but would be working on inclusion of the information in the updated Facility Assessment. The NHA said he was aware that this information was to be completed and part of the Facility Assessment, but he had only been employed by the facility since September 2023 and there were many tasks to accomplished in the last several months.

Based on interview and record review, the facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly with the required committee members. This deficient practice resulted in the potential for ineffective coordination of medical care and delayed resolution of facility issues, placing all 124 residents in the facility at risk for quality care concerns. Findings include: During an interview on 12/08/23 at 11:00 the QAPI process was discussed with the Nursing Home Administrator (NHA). The NHA stated the QAPI team met at least quarterly and as needed to coordinate and evaluate quality assessment program activities. The attendance documents were reviewed for the 1/27/23, 4/27/23, and 10/28/23 meetings. No attendance documentation was found between April and October. The NHA had assumed his role recently and could not speak to the attendance during that time frame. The facility Quality Assurance Performance Improvement (QAPI) Plan dated as last approved 12/2023, read in part The QA & A (Quality Assurance) Committee reports to the Administrator and Governing Body and is responsible for: 1) Meeting, at minimum, on a quarterly basis, more frequently if necessary .

Based on interview and record review, the facility failed to report resident-to-resident incidents involving physical altercations for seven Residents (R50, R52, R66, R84, R119, R102, and R120) of nine residents reviewed for reporting of abuse. This deficient practice had the potential for undetected abuse, and adverse outcomes. Findings include: R50 Review of the Minimum Data Set (MDS) assessment, dated 11/02/23, revealed R50 was admitted to the facility on [DATE], with diagnoses including dementia, anxiety, and depression. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 8/15, which indicated moderate cognitive impairment. R50 required moderate assistance with toileting and was independent with walking and transfers. Review of R50's progress note, dated 10/17/23 at 1:56 p.m., revealed, [R50] was sitting on the couch in the TV (day) room when a male resident [R119] walked behind her and hit her on the top of the head. Staff reports .male resident [R119] started hollering and a CNA [unnamed] witnessed a male resident strike [R50] on the top of the head. [R50] states, 'A man hit me. I was just sitting here watching TV and I never even looked at him and he hit me. It scared me .' The note indicated R50 was fearful of R119. R119: Review of R119's MDS assessment, dated 9/19/23, revealed admission to the facility on [DATE], with diagnoses including Alzheimer's disease, arthritis, and insomnia. R119 required one-person assistance for toileting, and supervision for transfers and walking. R119 was unable to participate in the BIMS cognitive assessment and was rarely or never understood nor understood others. The behavioral assessment revealed R119 demonstrated physical and verbal behaviors directed at others, other behaviors not directed at others, wandering behaviors, and rejection of care behaviors which significantly intruded on the privacy of others, and significantly disrupted care or the living environment. Review of R119's progress note, dated 10/16/23 at 4:01 p.m. showed R119 was aggressive towards facility staff, including, .[R119] hit her [CNA unnamed] with a flat hand to the head and attempted to put his hands around her neck. [Nurse] put up hands up between the [CNA] and the resident and tried to divert his attention .[R119] [swore] and [R119] hit me in the back of the head . Note: This staff incident occurred a day before the incident between R50 and R119. R52 Review of R52's MDS assessment, dated 8/16/23, revealed R52 was admitted to the facility on [DATE] with diagnoses including dementia, depression, and mild intellectual difficulties. R52 required supervision with toileting and walking and was independent with transfers. The BIMS assessment revealed a score of 4/15, which showed R52 had severe cognitive impairment. The behavior assessment showed R52 had verbal behaviors one to three days a week during the look-back period. Review of R52's Accident and Incident report, dated 9/24/23 at 9:15 p.m. provided by the Director of Nursing (DON), revealed, .[R52] was in the sunroom. Another resident was walking the unit .and had an interaction with [R52]. Camera footage noted on Page 2 showed the following: .[R119] reaches down a [sic] slaps [R52] on her left knee and [R52] kicks [R119] in the left leg . R66 Review of R66's MDS assessment, dated 10/25/23, revealed R66 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease and depression. The assessment revealed R66 was independent with transfers, walking and toileting. The BIMS assessment revealed a score of 12/15, which indicated moderate cognitive impairment. Review of R66's progress note, dated 11/24/2023 at 3:33 p.m., revealed, .This nurse was called to the Home 2 [secured unit] dining room by a CNA, saying that a lady punched another resident. This resident [R66] had been sitting at a table when a male resident [R119] was walking by her and started rubbing her arm. [R66] said I punched him . R84 Review of R84's MDS assessment, dated 5/5/23, revealed R84 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease and osteoporosis (brittle bone disease). The assessment revealed R84 required supervision with transfers, toileting, and walking. The BIMS assessment revealed a score of 4/15, which revealed severe cognitive impairment. The behavioral assessment revealed other behaviors not directed at others one to three times during the look-back period. Review of R84's Accident and Incident report, dated 11/27/23, revealed .Observed [R84] upset that .resident [R120 - a second resident] was in her room sitting on her bed. [R84] stated, [R120] hit me; get him away from me. [R120] was very confused and difficult to redirect. Writer and CNA [unnamed] assisted [R120] to stand and escorted him out of the room . R84 sustained two scratches on her face from the physical altercation. R120 Review of R120's MDS assessment, dated 10/3/23, revealed R120 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, arthritis, and cognitive communication deficit. R120 required set up with toileting and was independent with walking and transfers. R120 was unable to participate in the BIMS assessment and was rarely or never understood nor understood others. The behavioral assessment revealed R120 demonstrated physical and verbal behaviors directed at others, other behaviors not directed at others, wandering behaviors, and rejection of care behaviors which significantly intruded on the privacy of others, and significantly disrupted care or the living environment. Review of a progress note, dated 10/8/23, revealed, [R120] wandering/pacing .[R120] wandering from room to room, lying in other resident's beds. Was in a female resident's bed .[R120] out [of his room] to another man's bed near his room. A roommate of that other resident [unnamed] found this resident in the wrong bed and said he chased [R120] out. [R120] spit toward him .This is not a new behavior for [R120] . Review of R120's progress note, dated 10/15/23, revealed, This nurse [unnamed] [was informed] by staff that [R120] initiated physical aggression toward another resident [R102] . R102 Review of camera footage transcript, dated 10/18/23, provided by the DON, revealed R102 pushed R120 away. During an interview on 12/8/23 at approximately 2:00 p.m., the DON and the Assistant Director of Nursing (ADON), RN L, were asked about each of the physical resident-to-resident incidents perpetrated by male residents R119 and R120 towards residents on the secured memory care unit. Surveyor reviewed concerns regarding several residents involved in resident-to-resident physical altercations, and the lack of reporting the incidents involving residents R50, R52, R66, R84, and R102 to the State Agency. Both reported they understood the concern and the need to report resident-to-resident physical altercations to the State Agency. Review of the policy, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, revised 03/2023, revealed, [Facility] will not tolerate Abuse, Neglect, and Exploitation of its residents . All incidents and allegations of Abuse, Neglect, and Exploitation, Mistreatment of a Resident .incidents that result in serious injury, and all injuries of Unknown Source must be reported immediately to the Administrator and Director of Nursing .b. [State Agency]. If abuse or serious bodily injury is alleged. If the event that caused the allegation involves an allegation of abuse or serious bodily injury, it should be reported to [State Agency] immediately, but not later than two hours after the allegation is made .The Administrator, Director of Nursing, or designee will notify [State Agency] of all other alleged violations that do not involve abuse or serious bodily injury, as soon as possible, but in no event later than twenty-four hours from the time the incident/allegation was made known to the staff member .

Based on interview and record review, the facility failed to fully investigate resident-to-resident incidents involving physical altercations for seven Residents (R50, R52, R66, R84, R119, R102, and R120) of nine residents reviewed for investigating abuse allegations. This deficient practice had the potential for undetected abuse, and adverse outcomes. Findings include: R50 Review of the Minimum Data Set (MDS) assessment, dated 11/2/23, revealed R50 was admitted to the facility on [DATE], with diagnoses including dementia, anxiety, and depression. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 8/15, which showed R50 had moderate cognitive impairment. R50 required moderate assistance with toileting and was independent with walking and transfers. The behavioral assessment showed no behaviors. Review of R50's progress note, dated 10/17/23 at 1:56 p.m., revealed, [R50] was sitting on the couch in the TV (day) room when a male resident [R119] walked behind her and hit her on the top of the head. Staff reports .male resident [R119] started hollering and a CNA [unnamed] witnessed a male resident strike [R50] on the top of the head. [R50] states, 'A man hit me. I was just sitting here watching TV and I never even looked at him and he hit me. It scared me . R119 Review of R119's MDS assessment, dated 9/19/23, revealed R119 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, arthritis, and insomnia. R119 required one-person assistance for toileting, and supervision for transfers and walking. R119 was unable to participate in the BIMS cognitive assessment and was rarely or never understood nor understood others. The behavioral assessment revealed R119 demonstrated physical and verbal behaviors directed at others, other behaviors not directed at others, wandering behaviors, and rejection of care behaviors which significantly intruded on the privacy of others, and significantly disrupted care or the living environment. Review of R119's progress note, dated 10/16/23 at 4:01 p.m. showed R119 was aggressive towards facility staff, including, .[R119] hit her [CNA unnamed] with a flat hand to the head and attempted to put his hands around her neck. [Nurse] put up hands up between the [CNA] and the resident and tried to divert his attention .[R119] [swore] and [R119] hit me in the back of the head . R52: Review of R52's MDS assessment, dated 8/16/23, revealed R52 was admitted to the facility on [DATE] with diagnoses including dementia, depression, and mild intellectual difficulties. R52 required supervision with toileting and walking and was independent with transfers. The BIMS assessment revealed a score of 4/15, which showed R52 had severe cognitive impairment. The behavior assessment showed R52 had verbal behaviors one to three days a week during the look-back period. Review of R52's Accident and Incident report, dated 9/24/23 at 9:15 p.m., provided by the Director of Nursing (DON), revealed, .[R52] was in the sunroom. Another resident was walking the unit .and had an interaction with [R52]. Camera footage noted on Page 2 showed the following: [R119] reaches down a [sic] slaps [R52] on her left knee and [R52] kicks [R119] in the left leg . R66: Review of R66's MDS assessment, dated 10/25/23, revealed R66 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease and depression. The assessment revealed R66 was independent with transfers, walking and toileting. The BIMS assessment revealed a score of 12/15, which indicated moderate cognitive impairment. Review of R66's progress note, dated 11/24/2023 at 15:33 (3:33 p.m.), revealed, .This nurse was called to the Home 2 [secured unit] dining room by a CNA, saying that a lady punched another resident. This resident [R66] had been sitting at a table when a male resident [R119] was walking by her and started rubbing her arm. [R66] said I punched him . R84: Review of R84's MDS assessment, dated 5/5/23, revealed R84 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease and osteoporosis (brittle bone disease). The assessment revealed R84 required supervision with transfers, toileting, and walking. The BIMS assessment revealed a score of 4/15, which revealed severe cognitive impairment. The behavioral assessment revealed other behaviors not directed at others one to three times during the look-back period. Review of R84's Accident and Incident report, dated 11/27/23, revealed .Observed [R84] upset that .resident [R120 - a second resident] was in her room sitting on her bed. [R84] stated, '[R120] hit me; get him away from me.' [R120] was very confused and difficult to redirect. Writer and CNA [unnamed] assisted [R120] to stand and escorted him out of the room . R84 sustained two scratches on her face from the physical altercation. R120 Review of R120's MDS assessment, dated 10/03/23, revealed R120 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, arthritis, and cognitive communication deficit. R120 required set up with toileting and was independent with walking and transfers. R120 was unable to participate in the BIMS assessment and was rarely or never understood or could understand others. The behavioral assessment revealed R120 demonstrated physical and verbal behaviors directed at others, other behaviors not directed at others, wandering behaviors, and rejection of care behaviors which significantly intruded on the privacy of others, and significantly disrupted care or the living environment. Review of a progress note, dated 10/8/23, revealed, [R120] wandering/pacing .[R120] wandering from room to room, lying in other resident's beds. Was in a female resident's bed .[R120] out [of his room] to another man's bed near his room. A roommate of that other resident [unnamed] found this resident in the wrong bed and said he chased [R120] out. [R120] spit toward him .This is not a new behavior for [R120] . Review of R120's progress note, dated 10/15/23, revealed, This nurse [unnamed] [was informed] by staff that [R120] initiated physical aggression toward another resident [R102] . R102 Review of camera footage transcript, provided by the Director of Nursing (DON), dated 10/18/23, revealed R102 pushed R120 away. During an interview on 12/08/23 at approximately 2:30 p.m., the DON and the Assistant Director of Nursing (ADON), RN L, were asked about each of the physical resident-to-resident incidents perpetrated by male residents R119 and R120 towards residents on the secured memory care unit. Survey team reviewed concerns regarding several residents involved in resident-to-resident physical altercations, and the lack of completed investigations involving the victims, residents R50, R52, R66, R84, and R102. Both reported they understood the concern, had no formal analysis of the data they collected (such as a root cause analysis), or a statement of conclusion, including if abuse and/or allegations of abuse were substantiated or unsubstantiated, per their policy. Review of the policy, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, revised 03/2023, revealed, [Facility] will not tolerate Abuse, Neglect, and Exploitation of its residents . It is the facility's policy to investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of a resident .as well as injuries of unknown source, in accordance with policy .The Director of Nursing is the Chief Investigative Officer. In the absence of the Director of Nursing, the ADON and/or Nursing Supervisor assumes the role of chief Investigative Officer. 1. Time frame for investigation. The investigation must be completed within five (5) working days, unless there are special circumstances causing the investigation to continue beyond 5 working days .Investigation protocol. The investigation of the incident shall generally take the following actions: Interview the resident, the accused, and all witnesses .Obtain a statement from the resident, if possible, the accused, and each witness .Obtain all medical reports and statements from physicians and/or hospitals, if applicable .Documentation: Evidence of the investigation shall be documented. Reach a conclusion. After completion of the investigation, all of the evidence should be analyzed, and the Administrator (or his/her designee) will make a determination regarding whether the allegation or suspicion is substantiated Timing: The results of the investigation will be reported to the Administrator, and a final report will be submitted to [State Agency] no later than five (5) working days after discovery of the incident (excluding holidays, Saturday, and Sunday). The final report should include sufficient detail of the investigation to show the facility conducted a thorough investigation. The outcome of the investigation should state what effect the incident had on the resident. The facility should identify corrective actions (e.g., disciplinary action, in-service to staff, care plans updated, etc.) .

Based on observation, interview, and record review, the facility failed to maintain medication storage areas free of expired medications and securely store medications, for one of two medication rooms and three of three medication carts reviewed for medication storage. This deficient practice resulted in the potential for administration of lessened efficiency medications. Findings include: On 12/6/23 at 4:30 PM, medication cart B on the first floor was inspected. In the second drawer beneath the medication cards an observation was made of several loose pills identified as; one quetiapine 25 mg (milligrams), one pantoprazole 40 mg, one acetaminophen 325 mg, one baclofen 5 mg, and two other pieces of unidentified pills. In the first drawer an observation was made of a bottle of cetirizine with a worn, unreadable expiration date. Registered Nurse (RN) C confirmed night shift routinely cleaned medication carts, and no loose pills or pieces should be left in the medication cart and should be stored accordingly. On 12/6/23 at 4:45 PM, the medication store room on the first floor was inspected with RN F. In the cupboard an observation was made of 38 expired acetaminophen suppositories with lot number 0G6671 and expiration date 6/2023. RN F verified the medication was expired and no expired medications were to be kept in the medication storage room if expired. On 12/6/23 at 4:55 PM, RN F provided this Surveyor with a check list titled, Monthly Expiration Checklist for the first floor medication room and was incomplete for the month of December. A second document was provided titled, Med Room/Med Cart Weekly Audit for the first floor and was dated completed on December 3rd, 2023. RN F was asked if the audits for expired medications and clean medication cart were being performed, and why there were still expired medications and loose pills in the medication carts and replied, There should not be any. On 12/6/23 at 5:00 PM, medication cart A on the first floor was inspected. In the second drawer beneath the medication cards an observation was made of one loose lisinopril 20 mg. On 12/6/23 at 5:30 PM, medication cart B on the third floor was inspected. In the second drawer beneath the medication cards an observation was made of loose pills identified as; one sertraline 50 mg, one metoprolol 50 mg, and one other piece of an unidentified pill. In the third drawer an observation was made of two bottles of glucose control solution, one for high range and the other for low range with both dated as opened on 8/30/23. In the first drawer an observation was made of a bottle of cetirizine with a worn, unreadable expiration date. On 12/6/23 at 5:45 PM, an interview was conducted with RN G. RN G was asked how long the glucose control solution was good for after opening it and replied, I am not sure I would have to check. I think until it expires. I will find out. RN H Unit Manger was asked how long the solution was good for and replied, I will find out from pharmacy. Both RN G and RN H confirmed that the glucose testing solution was only good for 3 months after opening and that the solution was no longer ok to use to ensure the glucometer was calibrated properly and was past expiration for almost a week. RN H also confirmed night shift routinely cleaned medication carts, and no loose pills or pieces should be left in the medication cart and should be stored accordingly. On 12/7/23 at 8:50 AM, an interview was conducted with the Nursing Supervisor for the third floor RN E. RN E provided a document titled, Monthly Expiration Checklist for the third floor medication room and was incomplete for the months of March, June, November and December 2023. A second document was provided titled, Med Room / Med Cart Weekly Audit for the third floor, was dated December 2023, and was incomplete for the first week. RN E was asked if the audits for expired medications and clean medication cart were being performed, and why there were still loose pills in the medication carts and replied, Carts should be cleaned regularly, and medications should not be loose. Review of facility document titled, Common Short Date Medication Expirations and Labeling, read in part, .Stock Items .Glucometer Test Strips and Control Solutions .Expiration 3 months . Review of facility policy titled, Medication Storage, dated 11/2023, read in part, Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security .The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs Policy.

This citation refers to Intake MI # 248: Based on observation, interview and record review, the facility failed to ensure that one Resident (#208) was adequately supervised out of three Residents reviewed for supervision. This deficient practice resulted in Resident #208 entering Resident #108's room during the evening hours, and Resident #108 experiencing psychosocial outcome of [CONDITION(S)] ([CONDITION(S)]). Findings include: A review of a facility reported incident, dated 9/14/20, revealed the following, .Social Worker (SW) F was working in the Memory Care Unit and noted Resident (#108) to appear to look upset. (SW F) asked (Resident #108) what was wrong and she stated she was, Raped last night. (Resident #108) indicated that it was a male resident that also resided in the Memory Care unit as she glanced over at (Resident #208) who was in the common area. When asked what happened, she (Resident #108) kept stating she did not know, but knew what rape was because her Grandfather did it to her and her sisters . (SW F) spoke with (Family of #108, Family Member (FM) G) . (FM G) replied, Gramps he was inappropriate with the granddaughter and their youngest sister was molested. He was inappropriate with (Resident #108) when she was 10 or 11, touched her and kissed her . Facility surveillance reviewed by DON (Director of Nursing) from 9/13/20 at 0700 (7:00 a.m.) through 9/14/20: .(Resident #208) looked to his left at room #414 (Resident #108's room) where the door was open a couple of inches. He (Resident #208) reached the door at 0157:05 (1:57 a.m.) and started to open it the rest of the way, stood there and ambulated in at 0157:19 At 0159:17 (1:59 a.m.) he (Resident #108) walks to the main door to the room . then with is right hand reaches for the door handle to the room and slowly closes it . the door closes at 0159:39 . At 0208:37 (2:08 am, 9 minutes later) the door to (Resident #108's) room is observed to slowly open and (Resident #208) is observed exiting with a water mug in his right hand and what appears to be a black sock in this [NAME] . At 0209:57 (Resident #108) is observed ambulating out of her room and down the hall toward the commons area . she (Resident #108) exited her room, she ambulated down the hall to the commons area, stopped by (Certified Nurses Aide (CNA) H), and spoke with her and the two walked away . (Resident #108) then sat on the sofa in the commons area and talked for about 15 minutes . (CNA H) sat back down with (Resident #108) as she was sitting calmly on the sofa with a blanket over her lap . (Resident #108) appeared in no apparent distress . A review of Resident #108's record revealed she admitted to the facility on [DATE] with diagnoses including [CONDITION(S)] and [CONDITION(S)]. A review of the 5/19/21 Minimum Data Set (MDS) assessment revealed she scored 3/15 on the Brief Interview for Mental Status (BIMS) assessment indicating severely impaired cognition. Further review of her diagnoses list revealed a new diagnosis of [CONDITION(S)] on 9/28/20. A review of the 11/18/2020 MDS revealed Resident #108 scored 3/15 on the BIMS and 3 on the PHQ9 (an assessment to evaluate signs of depression). A review of Resident #108's progress notes revealed the following: 1/2/20 . Spoke with Resident (#108) regarding other residents entering her room uninvited and rummaging through her belongings. She states she knows the (they) don't realize what the yare (they are) doing, but she needs to have her space to herself . discussed stop gate on her door, and she would like to have one put on her door. Explained that it may not stop all residents, but may help some and also may slow them down, giving staff time to get to her room and other resident . will also put up sign on door stating 'Stop. Ladies room.' to help deter male residents from entering. Maintenance notified of need for stop gate, will update care plan. 1/16/20 Resident has been exhibiting increased tearfulness at times, ie reported by therapy she burst into tears talking about her last name and the bad memories it brings back . A further review of Resident #108's progress notes revealed the following: 9/16/20 . Encouraged her (Resident #108) to voice her feelings and provide reassurance so we could work together to find a solution, but resident was too angry and upset, i.e. as roommate started to come into room and she yelled at this writer and nursing to get her the (explicative) out. This is very unusual behavior for resident, and her mood had been stable prior to this 9/16/20 .Verbal consent obtained via telephone from (Family Member G) for [MEDICATION(S)] (antipsychotic medication) and [MEDICATION(S)] as ordered by PCP. A review of a 9/18/20 Behavioral health note revealed, .She (Resident #108) tells me that she woke up with someone (Res #208, identified in video surveillance review) in her room and she was afraid. She knew who it was. She states that she got up and tried to get up and explain - knows that he was there and it was him. She states that she does not know what happened and feels that she had a flashback . States that at this time she is unsure about moving to another place in the building because of her friends. States that if she could just be sure he would not (be) back in her room she would be ok A review of Resident #108's cognitive impairment care plan developed 11/22/19 revealed, .I have a mesh stop gate on my door to help deter other residents from entering my room uninvited . with an intervention initiation date of 01/02/20. This intervention was implemented prior to the 9/13/20 incident, yet per the investigation it was not noted to be in place at the time. On 7/14/21 at 2:30 p.m., the surveillance footage of the 9/13/20 event was reviewed with the Director of Nursing (DON). The following was observed: At 1:56 a.m., Resident #208 exits his own room and shuts the door. At 1:58 a.m., Resident #208 enters the room of Resident #108, and at 1:59 a.m., Resident #208 is observed slowly shutting the door of Resident #108. At 2:08 a.m., the door of Resident #108's room is opened slowly by Resident #208 and he is observed to wander out of the room. At 2:10 a.m., Resident #108 is observed to quickly ambulate out of her room and down the hall toward the common area. Resident #108 is wearing a T-shirt and underwear only. The video surveillance switches to the view form the common area where CNA H is observed sitting (for an undetermined amount of time) at the dining table with her feet up on a chair and using her cell phone. Resident #108 appears on the screen where she is observed with CNA H trying to console her. Resident #108 appears to be crying and very visibly upset. On 7/14/21 at 2:40 a.m., the DON was asked about the above described incident and following investigation. When asked about when Resident #108 first reported the incident, the DON reported that Resident #108 didn't use the word rape until the following day. When asked why the investigation had not started prior to this after the Resident reported that she had woken up with Resident #208 in her room, the DON provided no answer. When asked why the stop sign that was care planned for Resident #108 was not observed in place in the video, the DON reported that she did not believe that intervention was in place at that time and was implemented after this incident. When the DON was informed per the care plan and notes that the stop sign intervention was implemented in January of 2020, the DON reported she would need to speak with SW F. When asked to provide a policy on wandering residents, the DON reported the facility considered wanderers an elopement risk, and the facility did not have a policy to address and supervise wandering residents from a behavioral aspect. On 7/14/21 at 3:10 p.m., an interview was conducted with SW F. When asked about Resident #108, SW F reported the Resident had a consistent BIMS of 3, indicating severely impaired cognition. When asked about the care planned intervention of the mesh stop gate, SW F reported it was implemented prior to the 9/13/20 incident due to another resident coming into her room and going through her things. When asked why the incident was not investigated until the following day on 9/14/20, SW F reported it was due to the staff saying that Resident #208 had been in her (Resident #108's) room, and that Resident #108 didn't make a real allegation until the next day. A review of Resident #208's medical record revealed he admitted to the facility on [DATE] with diagnoses including [CONDITION(S)] and hearing loss. A review of his 8/19/20 MDS revealed he scored 3/15 on the BIMS assessment, indicating severely impaired cognition and was noted to be wandering daily. A review of Resident #208's progress notes revealed the following about his wandering: 7/14/21 Resident (#208) is pacing all around the unit . just continues to pace the area . 8/22/20 . Going from door to door and hitting/shaking on the doors . A review of Resident #208's Elopement Risk Evaluation dated 8/13/20 revealed, .Wandering behavior a pattern or goal-directed: No. Wanders aimlessly or non-goal-directed: Yes. Wandering behavior likely to affect the safety or well-being of self/others: No. Wandering behavior likely to affect the privacy of others: Yes . Clinical Suggestions: Staff notified of resident's elopement risk. Resident's location frequently monitored . A review of Resident #208's care plan revealed, 8/12/20 I am a long term resident due to my cognitive impairments related to dx (diagnosis) of Alzheimer's late onset and dementia. I also have dx of depression . (8/13/20)Due to my dementia/cognitive loss it is expected that I will explore my surroundings. Attempt to redirect me as much as possible if you feel I could come into harms way. Redirect me away from other residents' rooms as needed . Phone interview attempts were made with CNA H on 7/14/21 at 3:08 p.m., and 4:03 p.m,. but the calls were not answered nor returned. Phone interviews were attempted on 7/14/21 with Registered Nurse (RN) J, who was supervising the unit during the incident involving Resident #208 entering Resident #108's room. The calls made to RN J at 3:30 p.m., and 4:04 p.m. were not returned.

Based on observation, interview, and record review the facility failed to provide adequate supervision and secure exit doors to prevent elopement, resulting in Immediate Jeopardy, for one Resident (#2), of three residents reviewed for safety. This deficient practice had the likelihood of serious harm, injury, impairment, or death for Resident #2. The Immediate Jeopardy began on 5/8/19 at 1:16 p.m. when Resident #2 eloped from the secure (locked), second-story Memory Care unit, and was identified on 5/14/19. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were notified of the immediate jeopardy at 2:50 p.m. on 5/14/19. The immediate jeopardy was removed, and the deficient practice corrected, on 5/8/19, prior to the start of the survey, and the deficient practice was therefore Past Noncompliance. Findings include: Review of the facility Investigative Summary draft, received from the NHA on 5/14/19, revealed a construction worker had entered the patio (sunroom) from the outdoor balcony, without locking the door behind him at 11:25 a.m. on 5/8/19. The sunroom, was accessible from Home One of the memory care unit, . as many of the residents enjoyed observing the work being completed outdoors and the sunroom was not yet under construction. Resident #2 entered the sunroom at 1:15 p.m. and exited through the (unlocked) patio door, onto the elevated balcony at 1:16 p.m. It is assumed that (Resident #2) was able to negotiate onto the scaffolding and down the ladder to the ground . where he was then observed by (CNA J) and subsequently returned to the facility . Review of Resident #2's Minimum Data Set (MDS) assessment, dated 3/20/2019, revealed Resident #2 was rarely/never understood, sometimes was able to understand others, and was unable to complete the Brief Interview for Mental Status (BIMS) for cognitive assessment. Resident #2's functional status reflected the need for supervision with transfers, walking in room and corridors, and movement on and off the unit, with support of setup help only. Resident #2 used no assistive devices for ambulation. Resident #2's [DIAGNOSES REDACTED]. Review of the Care Area Assessment (CAA) Work Sheet attached to the 3/20/19 MDS assessment, completed by Social Worker (SW) M on 3/26/19, revealed the following: (Resident #2) has increased his exit seeking behavior, will go to the exit doors daily and try to punch the codes in to get out and push on the doors . (Resident #2) has become more difficult to redirect away from the doors . This is a change for him over the past three months . Review of Resident #2's Wandering Risk Scale assessments, completed 3/20/19 and 5/8/19, revealed a score of 16 on each, reflective of a High Risk to Wander. Review of Resident #2's Progress Notes between 4/8/19 and 5/8/19 revealed exit-seeking behaviors on 24 separate days. During an interview on 5/14/19 at 9:45 a.m., Registered Nurse (RN) Supervisor H explained that no staff had witnessed Resident #2 exit from the building on 5/8/19. RN H stated, We didn't see him leave. Observation of the memory care unit's sunroom, previously accessible through double doors from each side (Home 1 & Home 2) of the locked memory care unit, showed an exit door (now locked) that accessed an elevated, second-story balcony surrounded by scaffolding. The scaffolding was blocked by a green metal railing, just inside the balcony wall, preventing access to the scaffolding and the extension ladder placed up to the scaffolding from the ground. RN H stated, I don't believe the metal rails (preventing resident access to the scaffolding) was there before. I think they put that up after (Resident #2's egress onto the scaffolding and down the extension ladder). During an interview on 5/14/19 at 9:50 a.m. Construction Worker I confirmed he did not have a key to the exit door between the memory unit sunroom and the outdoor balcony under construction. Construction Worker I confirmed the position of the elevated, second-story scaffolding and extension ladder, as observed, were in the same position on 5/8/19. On 5/14/19 at 10:00 a.m. Resident #2 was observed ambulating independently, without any staff assistance in Home One of the memory care unit. He was verbally and physically unresponsive to this Surveyor's communication. His affect did not show an affirmative or negative response to verbal communication. On 5/14/19 at 10:30 a.m. Certified Nurse Aide (CNA) J confirmed she and her partner CNAN had gone into a room across the hall from Resident #2 to make up a resident's bed following lunch. (CNA J) said, Oh, my God! What is he (Resident #2) doing out there? CNA J said she immediately went down the end exit door. He was halfway down (the parking lot) trying the handles on one of the car doors . I thought he knelt to get on the ladder (on the elevated scaffolding), because he had cement on his right knee . Incident Progress Note on 5/8/19 at 13:40 (1:40 p.m.) revealed the following, in part: .the only obvious injury noted at this time was slight discoloration on bilateral knees that was blanchable . During an interview on 5/14/19 at 1:10 p.m. Construction Project Manager F, regarding Resident #2's elopement on 5/8/19, stated, It was a mistake. He (Construction Worker O) didn't lock the door (exit door from the sunroom to the outside balcony . Now, I am the only person who has the key to the patio (exit to balcony) door. The sunroom doors, sunroom, exit door to balcony, and outside rails, scaffolding, and ladder were observed with Project Manager J. A block of wood was positioned between the handles of the double doors used to enter the sunroom from Home One and Home Two. A piece of wood was present, secure to the floor (scab) to prevent opening either set of double doors from the Home One or Home Two to the sunroom. Project Manager J confirmed construction staff had been educated concerning resident safety prior to beginning work at the facility and were re-educated following Resident #2's elopement from the memory care unit. Observation of the 5/8/19 surveillance video of the memory unit sunroom, with Information Technology (IT) Director D showed Resident #2 pushing open the double door between Home One and the sunroom at 1:16 p.m. The video clearly showed there was no block of wood between the handles of the double doors between Home One and the sunroom, to prevent opening of the doors. Resident #2 walked to the unlocked exit door, stepped onto the outside balcony and was able to access the scaffolding, as one section of the metal railing had been removed by a construction worker at 11:24 a.m. Resident #2 is seen beginning to climb over the block balcony wall before leaving view of the sunroom surveillance camera. At 1:17 p.m. CNA J is observed on different surveillance camera footage, moving quickly to exit the memory unit and retrieve Resident #2 from outside. Review of the Timeline received from the facility included the following, in part: 11:25:36 a.m. Door to patio left unlocked by (Company) construction worker. 1:12:14 p.m. (CNA J) exits (Resident #2's) room. 1:14:58 p.m. (Resident #2) exits his room. 1:16:33 p.m. (Resident #2) opens door and is visualized out on the patio per video review. Outdoor temperature at that time was 47 degrees. 1:16:51 p.m. No longer able to visualize (Resident #2) on camera. 1:17:59 p.m. (CNA J) observed running out of a resident's room, down the hallway and exits outside. 1:18:21 p.m. (CNA J), per video review, is observed walking over to (Resident #2) and guides him back into the facility. Review of the (Company Name) Incident/Injury Report, dated 5/8/19, revealed the following: .The patio door was left unlocked. A resident of the facility opened door from the north house (Home One) which was unlocked and entered the sunroom unsupervised. He proceeded through the unlocked patio door to the exterior patio which is in the construction zone. The resident hopped onto the scaffolding and climbed down to the ground via extension ladder before being seen by staff member . The immediate jeopardy was removed, and the deficient practice corrected on 5/8/19 after the facility implemented a systemic plan that included the following actions: Resident #2 was assessed by nursing upon return to the facility and management reviewed his care plan. VSS (vital signs) and no injuries were noted other than a blanchable area to the knee which later resolved. Staff continued 15-minute safety checks upon Resident #2's return. Family/DPOA was notified and had no concerns for his safety. MD (Physician) was notified of Resident #2 exiting the building. Immediately following the incident, location of all residents were verified. Resident #2's safety and the other (memory care unit) residents' safety was ensured by the following: 5/8/19 at approximately 1330 (1:30 p.m.), the work zone was immediately secured and all construction workers vacated the premises per the (NHA's) request. 5/8/19 at approximately 1330 (1:30 p.m.), the sunroom area was secured so that residents do not have access to the patio door, nor sunroom. 5/8/19 at approximately 1400 (2:00 p.m.), scabs (boards secured to floor at base of door to prevent opening) were installed to prevent entry into the sunroom, as well as to the ground floor construction areas. 5/8/19 at approximately (2:00 p.m.), exterior key that unlocked the door from the patio to the sunroom was secured by the Plant and Building Supervisor (P), thereby preventing unwanted exiting. This key will be . under the control of the Plant and Building Supervisor. 5/8/19 at approximately 1600 (4:00 p.m.), (Construction Company Name) modified their workflow so that construction workers working outside will not access the interior building except in the event of receiving supplies or in an emergency. 5/8/19 at approximately 1515 (3:15 p.m.), the latch sets were reversed from the conference room to the sunroom as an added layer of security. 5/8/19 at approximately 1535 (3:35 p.m.), a walk-through of all construction areas was completed . to identify any potential safety concerns was completed by the DON, ADON, Administrator, Maintenance Supervisor, and (Construction Company Name) staff. Any concerns were immediately addressed. During the assessment of other possible exit points of the building the following change was made: the windows were capable of opening 8 to 9 inches at (memory care unit). Maintenance (staff) relocated the restrictor on the windows. The open is now at a maximum of 4 inches. All office, resident, living, and dining room windows along with the walkway windows to (memory care unit) were also changed. Early evening 5/8/19, (Construction Company) employee received education and corrective action as a result of the event. (employee resigned instead of signing corrective action that was presented.) 5/8/19 at approximately 1430 (2:30 p.m.), modifications to (Construction Company Name) Safety Orientation Checklist were made and all (Construction Company) employees and subcontractors were educated on the revised checklist prior to being permitted to work on the premises. Any new worker will be educated prior to working on-site. 5/8/19 at approximately 1630 (4:30 p.m.), reviewed education that (Construction Company) staff had provided to their employees and subcontractors regarding job safety and security measures. Beginning 5/9/19, (Construction Company) will perform daily security checks of all doors in the immediate construction areas at 7 am, 10 am, 1pm, 5:30 pm on all days that construction employees are on-site. 5/9/19 at approximately 0630 (6:30 a.m.), (Construction company) safety officer was on site conducted a safety review and revised their safety training for staff and sub-contractors. 5/9/19 at approximately 0700 (7:00 a.m.), (Construction Company) morning safety meeting was revised to emphasize the significance of Resident safety. Beginning 5:30pm on 5/8/19, (facility) staff will perform daily security checks of the doors after 5:30pm - 6:30pm. 5/9/19, Plant and Building Supervisor (P) created addition safety checklist specific to the construction site and implemented it. 5/9/19 Code Alert/Resident Elopement Policy reviewed. Education of elopement was provided to (facility) staff. Also reviewed historical documents for elopement drills and weekly testing of doors alarms. All measures implemented by facility following Resident #2's elopement from the building on 5/8/19 were reviewed and verified by this Surveyor, including quality assurance audits implemented to monitor and maintain continued compliance. The facility was found to be in substantial compliance at the time of this abbreviated survey.

Based on interview and record review, the facility failed to ensure one of four Residents (#101) with gastrostomy tube received the appropriate treatment and services to prevent dehydration and metabolic abnormalities resulting in elevated blood urea nitrogen (BUN) and sodium with rapid weight loss. Findings include: According to the Minimum Data Set ((MDS) dated [DATE], Resident #101 was admitted from the hospital to the facility on [DATE], after suffering an acute [MEDICAL CONDITION] infarction and the placement of a pacemaker. Resident #101's [DIAGNOSES REDACTED]. In addition, Resident #101 developed progressive dysphagia with significant weight loss (35 pounds) for which a PEG (percutaneous endoscopic gastostomy) tube was inserted for nutrition and hydration prior to his admission to the facility on [DATE]. A Registered Dietitian (RD) note dated 4/1/15, read "Glucerna 1.2 via PEG tube: 1512 kilocalories (kcals)=1260 at 60 milliliters (ml) every hour times 21 hours. If well tolerated times 2 days, increase feeding to 70 ml every hour times 21 hours. Flush tube with 30 ml water before and after medications to a total of 850 ml daily. Note: total water via feeding and flush at 70 ml every hour=2033 ml, his estimated water need=2140 ml." The Care Area Assessment (CAA) for tube feeding dated 4/3/15 read, "Resident (#101) required TF (tube feeding) due to severe dysphagia/[MEDICAL CONDITION] strictures with the inability to consume adequate fluid and nutrition. Revision in tube feeding had been recommended due to declining sodium level and progressive dehydration from subadequate fluid level, which was ordered to normalize sodium level but was having the opposite effect." On 4/3/15, a Physician Fax Form written by Registered Nurse (RN) "I" read, "Dietary recommends the following: Glucerna 1.2 via PEG tube:1512 kcals=1260m ml at 60 ml every hour times 21 hours. if tolerated times 2 days, increase feeding to 70 ml every hour times 21 hours. Flush tube with 30 ml H20 (water) before and after meals to a total of 850 ml H20 daily." A review of enteral feeding intake record from 4/1/15 to 4/27/15, indicated Resident #101 did not receive the 850 ml of H20 as recommended by the RD on 4/1/15. The total H20 amount ranged between 120ml to 560ml. In addition, the enteral feeding intake record indicated Resident #101's hydration need was 2127 ml. Without the 850 ml of H20, Resident #101 did not receive his estimated fluid needs of 2140 ml (as recommended by the RD) or the 2127 ml H20 needs identified on the enteral feeding intake record. A review of the facility policy for "Enteral Feedings" dated 1/2/13, page 3 section 16 read, "Recording of enteral feeding/water intake", paragraph b: "The top part of the form will be completed at the end of the month for the next month and anytime changes occur due to the resident's status by by the Resident Care Coordinator/Clinical Charge Nurse and/or Dietitian. Hydration requirements for the resident will be reviewed at these times." Paragraph e: "Document intake and output shall be reviewed on a frequent basis by the licensed nurse, Resident Care Coordinator, Clinical Charge Nurse and/or dietitian so that discrepancies between estimated fluid requirements and fluids actually delivered can be identified." An interview with the Clinical Charge Nurse (RN "I") on 5/7/15 at 1:20p.m., revealed she had transcribed the water flush of 850 ml to flush the feeding tube with 30 ml before and after medication administration, to a total of 850 ml, not that Resident #101 should receive a total of 850 ml of H20 flushes daily. Clinical Charge Nurse RN "I" also confirmed she did not review the Enteral Feeding Intake record to verify Resident #101 was receiving the daily estimated fluid needs. In an interview with Floor Care Coordinator (RN "E") on 5/7/15 at 11:10 a.m., she confirmed she had not reviewed the Enteral Feeding Intake record from 4/7/15 to 4/27/15, when the RD "C" had identified insufficient fluid intake for Resident #101 through his PEG tube. A note written by RD "C" in Resident #101's medical record on 4/27/15 read, "Order received for dietary consult to evaluate current lab work. Labs reveal sodium high at 152, BUN high at 60, BUN/creat high at 66.6, and normal GFR (glomerular filtration rate) and creatinine. These values reveal severe dehydration with no actual renal impairment. Investigation with (RN "E") revealed that RD's request for 850 ml total water flush, which was approved by MD on 4/6/15, was never transcribed correctly. Current water flush is severely deficient and likely cause of elevated sodium and BUN." An interview with RD "C" on 5/7/15 at 11:30 a.m., revealed she had not reviewed the Enteral Feeding Intake record prior to 4/27/15 to identify insufficient H20 intake, which RD "C" described as severe dehydration as indicated by the elevated BUN and sodium, with a rapid weight loss. ( ) --

Based on observation, interview and record review, the facility failed to provide adequate and appropriate care to heal a recurrent pressure sore and prevent development of further skin breakdown by not following the comprehensive care plan for one (Resident #7) of five residents reviewed for pressure ulcers from a total facility population of 190 residents. This deficient practice resulted in the redevelopment of a stage II pressure ulcer on the right buttocks for Resident #7 and additional skin breakdown on the resident's left buttocks. Findings include: According to her Record of admitted d 11/12/08, Resident #7 is a [AGE] year-old female admitted to the facility on that date with [DIAGNOSES REDACTED]. A Plan of Care initiated 11/26/2008, showed Resident #7 at "Risk for skin impairment R/T (related to) impaired mobility..." with a history of skin breakdown on coccyx (October 2010) and both right and left buttocks (August 2012). Recent skin impairment on the Plan of Care for Resident #7 dated 9/02/14 reads: "Stage II wound to R (Right) Butt"; 9/15/14 "Open area healed"; Interventions for the problem include: "Reposition Resident every 2 hours or sooner." On 9/18/14, an observation was made of Resident #7 in bed with the head of the bed elevated to an approximate 40 degree angle, from 8:30-8:40 a.m. She was observed eating breakfast in bed at this time, and Certified Nurse Aide (CNA) "F" left her sitting at this angle, on her back, after breakfast. She was observed again on 9/18/14 in the same, upright position on her back at 11:20 a.m. and 1:15 p.m. Resident #7 remained on her back sitting in this upright, unchanged position on all three observations. The facility policy and procedure entitled, "Care of Pressure Sores" Original 09-30-97, "Preventative Nursing Interventions" includes, "Change the resident's position every 2 hours, depending on the resident's need. Some residents will need to be turned more frequently... Maintain the head of the bed at the lowest degree of elevations... Limit the amount of time the head of the bed is elevated." An electronic document titled, "CORP-Individual Plan Report" for Resident #7 printed 9/16/14, under ADL (Activity of Daily Living) reads, "Reposition in bed frequently to reduce risk of decubitus ulcer. Mood and Behavior: Resident (#7) is alert but confused... She needs much cueing and reminders." An observation was made by this surveyor on 9/18/14 at 2:05 p.m. of Registered Nurse (RN) "DD" conducting a dressing change on Resident #7's buttocks. Resident #7 was noted to have open wounds, identified as a stage II pressure ulcer on her right buttocks and an additional open area on her left buttocks. An interview was conducted with RN "DD" at that time and she confirmed the observation of two open areas on Resident #7's buttocks. RN "DD" stated, "The one (ulcer) on the left buttock is new." An interview was conducted with the 200 hall charge nurse, RN "CC", on 9/18/14 at 2:30 p.m., following the dressing change. At that time, RN "DD" informed RN "CC" that Resident #7 had developed two new pressure ulcers. RN "CC" stated the previous pressure ulcer on Resident #7's right buttocks had healed and said, "I'll have to measure (the wounds) and start a new pressure ulcer sheet on (Resident #7's) buttocks..." A review of "Interdisciplinary Progress Notes (Facility name)" dated 9/15/14, read "Open areas noted to resident right buttock noted to be healed, but fragile. [MEDICATION NAME] (dressing) on to protect." Further review of "Interdisciplinary Progress Notes (Facility name)" showed an entry dated 9/18/14 at 3:18 p.m., which read in part, "[MEDICATION NAME] dressings on areas on left and right buttock. Right Stage II measured 1 x 0.5 cm (centimeters)... Suspected deep tissue injury, dark purple area on left buttock measured 4 x 2 cm." Documentation was requested on 9/18/14 by this surveyor to show evidence Resident #7 was being repositioned, and provided treatment and care to prevent skin breakdown and promote healing. No documentation was provided by the facility at the time of exit. ( ) --

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for 1 of 4 sampled residents (Resident #200), from a total sample of 194 residents residing in the facility, resulting in Immediate Jeopardy, when the facility failed to adequately assess and provide the necessary care and services prior to transport via a facility vehicle and failed to obtain medical services from the closest emergency medical care facility, resulting in the lack of needed assessment and treatment as the resident experienced a change in condition (diminished level of consciousness), ultimately resulting in the resident ' s death. The Immediate Jeopardy began on [DATE] at approximately 3:20 p.m., when Resident #200 was transported in a facility van/bus by Certified Nurse Aide (CNA) "F", transport driver and maintenance staff, none of whom were trained in assessment and/or CPR, placing Resident #200 in Immediate Jeopardy to her health and safety. Resident #200 had fallen at approximately 1:20 p.m. on [DATE]; following two-person assisted transfers. Resident #200's knee was swollen and an order was received for X-ray of the knee. There was no further assessment of condition. No notice was communicated to the hospital to expect Resident #200, who required specialized equipment. CNA "F" alerted Licensed Practical Nurse (LPN) "D" to Resident #200's declining condition, prior to departure and again during transport. However, no 911 call was made, nor was a change in instruction made to divert to a closer emergency facility. After arrival at the hospital when Resident #200 was noted by Emergency staff to have fixed pupils and difficulty breathing, CPR procedures were initiated. Resident #200 was pronounced dead at 5:05 p.m. The Administer was notified of the IJ on [DATE] at 3:10 p.m., and a plan of correction was requested to remove the IJ at this time. The Immediate Jeopardy which began on [DATE] was removed on [DATE] at 4:22 p.m. when the facility provided documentation which indicated staff currently working were directed to send all resident transports via EMS (Emergency Medical Services ambulance) until further notice. The three residents still out of the building at the time were to be accompanied back to the facility by the afternoon shift Nursing Supervisor. All licensed staff not on duty were being contacted prior to their next shift regarding all resident transport via EMS until further notice. Although the IJ was removed, the Facility's deficient practice remained at an "isolated" level due to the need for education of staff regarding recognition of residents' need for emergency care while in transport. Findings include: An abbreviated survey was conducted at the facility from [DATE] - [DATE], in response to an anonymous complaint filed on behalf of (Resident #200) dated [DATE] and timed as 3:30 p.m. The complaint reads as follows: "Complainant states on [DATE] at 3:30 p.m., the Resident (#200) fell and the Resident Care Coordinator (named) was sending the Resident to (Emergency Dept. initials) to have her leg x-rayed. When nurse's aide (named) brought the Resident (#200) down from the 3rd floor in a wheelchair the Resident (#200) was not conscious. The staff had to take the facility bus because of the size of the resident (morbidly obese), she could not fit in the van. The driver of the bus (named) and a maintenance man (named) told the aide that the resident should be taken by ambulance and she could go to the nearest Hospital emergency room because she was not conscious. Nurse aide (named) called the Resident Care Coordinator who insisted she (Resident #200) be taken by bus and to (named) Hospital instead of the nearest hospital. Complainant states that the nurse aide told the Resident Care Coordinator that the Resident (#200) was not conscious. The Resident was going in and out of consciousness once in the bus and would say to staff 'Help me!' Once staff got the Resident (#200) to (named) Hospital the Resident (#200) remained in the facility bus in her wheelchair for 20 minutes, hospital stated they did not have a room for her. The Resident died a few minutes later." A review of the closed medical record for Resident #200 revealed, she was a [AGE] year old woman admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. disorder ([DATE]). According to the most recent Minimum Data Set (MDS) assessment dated [DATE], Resident #200 was cognitively intact, scoring ,[DATE] on her BIMS (Brief Interview of Mental Status); she required the assistance of two staff members for transfers and the extensive assistance of one staff member for walking, dressing, hygiene and bathing needs. The MDS assessment revealed Resident #200 used a walker for transfers and a wheelchair for most of her ambulation needs. A review of Resident #200's "hospitalization Treatment Choices" & "(Facility Name) Medical Treatment Choices" dated [DATE], were checked showing Resident #200 wanted: "CPR, hospitalization , and comfort measures" both in the facility and in the hospital. An incident report dated Friday [DATE], and timed as 13:20 (1:20 p.m.), revealed while Resident #200 was being transferred via gait belt and walker by CNA ("I"), "Resident (#200) began lowering her head/not standing up straight. CNA ("I") yelled for help. Another CNA and housekeeper(unidentified) assisted to get resident into w/c (wheelchair). Resident went down on her knees." The "Nursing Assessment" portion of the incident report dated [DATE], revealed "knee bruised/swollen. Complaints of pain in left knee. Vital signs: ,[DATE], ,[DATE]. Level of consciousness: Alert". An interview was conducted with CNA "I" on [DATE] at 8:50 a.m. CNA "I" described the incident on [DATE] as follows: "It was after lunch, I got (Resident #200) washed up, changed her brief and clothes, I couldn't get her pants pulled up, so I had her stand with her walker to pull her pants up. I put my gait belt on her and she was standing too close to the bed, so I asked her to take a few steps forward... She (Resident #200) was putting her head down and leaning over the front of the walker (two times), I told her to stand up, she replied 'I can't'... I yelled for my partner (CNA "J")... we couldn't hold her up... she's (Resident #200) too heavy so we lowered her the best we could to the floor... she fell to her knees... the nurse (LPN "B") told me to put her in her chair because she (Resident #200) was going to bingo. (Resident #200) wanted to go to bed... I put her in her chair (wheelchair) and took her to bingo. About 15 minutes later, the activity aide (unidentified) brought her back to the hallway because she was screaming in bingo... (Resident #200) was sitting in the hallway and screaming... I asked the nurse (LPN "D") 'What do you want me to do, I can't leave her in the hallway screaming'. (LPN "D") told me to put her to bed... so I did." CNA "I" stated when she transferred Resident #200 into bed, the left knee was swollen like a 'football' and she was screaming and yelling 'help me'. I asked the nurse (LPN "D") if she wanted any ice put on the knee and she replied, 'No, she is going out anyhow (being transferred to the hospital)'." A telephone interview was conducted with CNA "F" on [DATE] at 10:50 a.m. CNA "F" stated she has been (Resident #200's) primary CNA on the afternoon shift for years, very familiar with her and had witnessed 'several' incidents of [MEDICAL CONDITION] activity by Resident #200. CNA "F" stated on [DATE], she had just reported to work at 3:00 p.m., "I was told I was going on a transfer to the hospital... So my co-workers (CNAs "B" and "C") helped me mechanically lift (Resident #200) out of bed and into her wheelchair. She (Resident #200) was awake then. We had to use a draw sheet to turn her to get the sling under her for the transfer. She (Resident #200) hurt too much and couldn't help us at all. (CNA "C") supported her leg the whole transfer, she (Resident #200) was yelling and wincing in pain... her skin was cold to the touch and she was pale looking... We covered her up with a lap blanket and I wheeled her down to the nurses station/elevators to get ready to leave. I went behind the nurses desk to get the paperwork for the hospital from the nurse (LPN "D"). I asked again where I was taking her (Emergency Department (ED) 12 miles away) or to the (ED 2 miles away), the nurse stated, 'The order is for the ED (12 miles away)'. I told the nurse (LPN "D") I felt bad for her (Resident #200) because she's in so much pain and 'kinda with it, and kinda out of it'... I got her downstairs to get loaded on the bus for the transport and the transporter (Staff "G") and the maintenance man (Staff "E") met me at the doors... (Staff "E") stated 'We don't take patients who are unconscious...' I told him the nurse (LPN "D") said we are to transport her... While we were wheeling her out to the bus, her (Resident #200's) head was down, and when we lifted her up via the wheelchair lift, she woke up and yelled, 'Help Me!', then her head would go back down and tip to the side... She (Resident #200) was like that the whole way there (ED)." A second telephone interview was conducted with CNA "F" on [DATE] at 1:42 p.m. CNA "F" was asked if she contacted the facility at all regarding (Resident #200's) condition. CNA "F" stated she called once and sent a text via phone to the nurse. CNA "F" emailed screenshots (pictures) of the call log and the text messages to this Surveyor. The first screenshot is of the call log from CNA "F's" cell phone to (LPN "D's") cell phone, the date is [DATE] and timed at 3:31 p.m., the call lasted 1 minute. CNA "F" stated, "I called her (LPN "D") to tell her she (Resident #200) 'wasn't doing good' and that she was 'in and out of consciousness', (LPN "D") said for us to 'get her there (ED 12 miles away)'." The second screenshot is of the text messages from CNA "F's" phone to LPN "D's" phone. The text messages revealed CNA "F" texted at 3:33 p.m. on [DATE]: "For safety reasons (Staff "E") maintenance is with us because she (Resident #200) kept passing out we didn't want her flipping out of chair for being unconscious". LPN "D" responded with a text message at 3:35 p.m.: "Good lord. ok. (Staff "E") is a fricken saint". At 4:07 p.m., CNA "F" texted LPN "D": "Now we are waiting for a bed because they weren't ready or anything :/ (emoticon)". At 4:18 p.m., LPN "D" replied "Crap". At 4:19 p.m., CNA "F" replied, "They still haven't taken her back said they need to talk to the doctor ....". During this telephone interview (on [DATE] at 1:42 p.m.) CNA "F" stated, "All the time we were waiting in the ED, she (Resident #200) was crying and saying '(CNA "F"), Help me, I can't see, (CNA "F") help me'... we (all three staff) were rubbing her arms, telling her things would be okay." CNA "F" was asked if she knew the "code" status of Resident #200 and she stated "No, I think she's a 'No Code'." CNA "F" was asked if she was CPR certified, she replied "No." A review of the surveillance video was conducted with the Director of Nursing (DON) on [DATE] at 11:00 a.m. This video revealed (Resident #200) being pushed in her wheelchair to the door to be loaded on the bus. CNA"F's" body is blocking view of the resident (#200), Staff "G" is seen exiting the doors and entering the bus, Staff "E" is holding the door open for CNA "F" to push Resident #200 out and to enter the bus. The video is too far away from the bus, unable to determine Resident #200's condition at this time. The time stamp on the video revealed the facility bus departed the parking lot at 15:29 (3:29 p.m.). CNA "F" had called and texted LPN "D" within minutes of the loading and departure from the facility via the bus. An interview was conducted with Transporter-Staff "G" on [DATE] at 9:00 a.m., who stated, "I was called by (Staff "H") and was told I had a transport to (local hospital)... when the resident (#200) got downstairs she 'looked unconscious to me'... the CNA ("F") said she was awake upstairs... I think the maintenance man (Staff "E") could see the concern on my face that's why he came with us... When we would move her (Resident #200) she would wake up and say "Help me!".... When we were going up the (named) hill I asked the aide again which ED, she told me (ED 12 miles away). I knew I had to get her (Resident #200) somewhere, but I was hoping for the closest ED. We got to the ED (12 miles away) and got her registered, we (all three staff) were sitting beside (Resident #200) and she was crying and stating "Help me! Help Me!" It (time) was taking forever, we were there (ED) for 30 minutes, they (ED) weren't ready for her.... they needed to get a bariatric bed and lift or something like that... the maintenance man couldn't take it (Resident #200's cry's for help) anymore. He went outside, I joined him just a few minutes later, we were trying our best to comfort her, it was awful!... the aide came out about 10 minutes after I did and said they finally took her (Resident #200) back (into the ED).... we got into the bus and returned to the facility." Staff "G" was asked if she was CPR certified, she replied "No." A telephone interview was conducted with Maintenance man (Staff "E") on [DATE] at 10:22 a.m. He stated, "When the aide (CNA "F") brought her (Resident #200) down (to the bus loading area) she was unconscious and slumped over, she would wake up and then go back out... she was asking for help... I thought 'why the h*** are we going way up there (ED 12 miles away)... she (Resident #200) was a big lady and I thought I would help load her, then seeing her, I knew I should go along to keep her from falling out of her wheelchair in the van because she was unconscious.... She (Resident #200) didn't look good... It (ride and wait in the ED) was not pleasant at all.... I know the aide (CNA "F") called and texted the nurse, but I don't know what was said, I stood up the whole ride there to hold (Resident #200) in her wheelchair. After we got there (ED), I was in the waiting room with her (Resident #200). I couldn't listen to her beg for help anymore, we (Staff "G", myself and CNA "F") all asked her what was wrong, I don't think she (Resident #200) could tell us what was wrong. I went outside (ED) and (Staff "G") came out a few minutes later, she couldn't take it anymore either... about 10 minutes later the aide (CNA "F")came out and we returned to the facility." Staff "E" was asked if he was CPR certified, he replied "No. I once was, but not anymore." A telephone interview was conducted with LPN "D" on [DATE] at 9:30 a.m. LPN "D" was asked about the events of [DATE] pertaining to Resident #200. LPN "D" stated, "She (Resident #200) was her 'usual self' and did have a fall at 1:20 p.m. She complained that her left knee hurt, but she was alert and oriented after the fall. I assessed her knee and at that time there was no injury observed, later it (knee) was swollen and she had increased pain.... so (Registered Nurse (RN) "A") obtained an order to have her transferred to the ED for evaluation. (Resident #200) told me she was sorry for falling, I told her 'Everything will be okay'. I didn't see any [MEDICAL CONDITION] activity on that Friday (for Resident #200)." LPN "D" was asked about the transfer papers used for Resident #200. LPN "D" stated she had used the vital signs from the fall (1:20 p.m.) and did not reassess the resident before leaving at 3:30 p.m. (2 hours post fall). A second telephone interview was conducted with LPN "D" at 11:05 a.m. on [DATE]. LPN "D" was asked if she received any phone calls or text messages from (CNA "F"), she stated, "Let me check my phone... Oh, yes I was asked to clarify the destination (which ED) and was notified that the maintenance man (Staff "E") went along for 'safety reasons'." There was no mention from LPN "D" that Resident #200 was having any difficulty with level of consciousness, or that the facility staff had to wait in the ED, because the ED was not prepared to receive a resident of this size. LPN "D" was asked if she had telephoned the receiving facility, and gave them report on the nature of the transfer and the resident status ("super morbidly obese"). LPN "D" stated "No, I thought (RN "A") did (called report)." A third telephone call was placed to LPN "D" on [DATE] at 8:45 a.m., a message was left. The facility informed this writer that LPN "D" had 'called in sick' for the day, no return phone call was received. An interview was conducted with Resident Care Coordinator (RN "A") on [DATE] at approximately 9:40 a.m. RN "A" stated she had returned to the floor about 2:30 p.m. on [DATE] after a meeting. "I was alerted that (Resident #200) had fallen and was complaining of increased pain in her knee, I saw the knee, it was bruised and swollen.... I called (Resident #200's) physician's office and obtained an order to transfer her to ED (12 miles away) because her physician was there. (Resident #200) was talking to me at that time.... then about 5:00 - 5:10 p.m., (Resident #200's) physician called me and told me she (Resident #200) had passed away in the ED. I saw (CNA "F") after she returned from dinner and told her (Resident #200) had passed away, it was then she (CNA "F") told me 'She (Resident #200) was dozing off'." RN "A" denies being told by any staff member that Resident #200 was 'unconscious' during transport. RN "A" was asked if she had called the receiving facility to give them a report on the resident (#200) being transferred to them, "No, it's the nurse who is filling out the transfer paperwork responsibility to call the ER (emergency room )." An interview was conducted with the Administrator and the DON on [DATE] at 11:00 a.m. The Administrator stated, "I would expect staff to contact the nurse if a non-emergent transport turns bad, I wouldn't expect them (transporter and additional staff) to turn around." A policy dated [DATE] titled "Residents Transportation/Ambulance" revealed: "A. In-house facility transportation is considered a non-emergency type. Our vehicles are used for resident transports within our local area.... 1. Transportation is normally provided to residents who are required or authorized to need medical treatment, special services, or planned activities outside the facility.... 3. The facility vehicle driver must maintain a valid chauffeurs license. The vehicle will be attended by a qualified nursing assistant or if necessary a professional nurse, when residents are being transported." This policy fails to instruct staff in the event a non-emergent transfer turns into an emergency. An "Inter-office Memorandum" dated [DATE] regarding a job position titled "Storeroom Custodian Assistant/Driver Transporter", lists under "Requirement/Qualifications for Driver Transporter: 1. Primary responsibility is driving facility vehicles used to transport residents. Also performs deliveries and pickups outside the facility as assigned. Driver must be able to assist with transferring residents. 2. Possess a valid Michigan Driver's License with a Chauffeur's Endorsement." This job description does not instruct the Transporter as to what actions to take if a transport becomes an emergency. A review of the policy and procedure titled "Acute Change of Condition" dated [DATE], revealed: "Policy: We strive to provide care that enables each of our residents to achieve and maintain the highest, practicable level of living possible for him/her given his/her physical and mental conditions. In order to do so, we must promptly identify, assess, and intervene when a resident experiences an acute change in condition that may be reversible or that may have the effects mitigated by prompt medical attention. Procedure: Note: If the resident's condition is life-threatening and the resident's Advance Directives request acute care, then the licensed nurse calls '911', notifies the physician, and sends the resident to the hospital. Assessment and Problem Recognition.... 3. When interacting with residents, staff is to note any changes in the resident. These changes include, but are not limited to, changes in: a. Level of consciousness b. sudden onset or increase in severity of pain... Falls... Staff is to report any and all changes noted to the licensed nurse assigned to the resident on that shift. 4. The licensed nurse promptly assesses the resident. If this assessment determines that the resident may be experiencing an acute change in condition the Licensed Nurse describes the symptoms in detail and accurately in the medical record in a timely manner. 5. The Licensed Nurse communicates with the attending physician...." A review of the facility's "Nursing Home Transfer Form" for (Resident #200) dated [DATE], not timed and signed by LPN "D", revealed the vital signs recorded as 13:40 (1:40 p.m.) after the fall and almost two hours prior to (Resident #200's transfer). "Most recent pain level" is left blank, "Most recent pain med" is blank also. The area to record "Report Called in By: (Name/Title)" is blank and the area to record "Report Called To" is blank as well. A review of the "PRN (as needed medication) Administration Record dated [DATE] - [DATE], revealed Resident #200 did not receive any "[MEDICATION NAME]-[MEDICATION NAME] (narcotic pain medication) ,[DATE] (strength) one every 6 hours as needed on [DATE]. A review of the "nurses notes" for Resident #200 dated [DATE], has three entries for the entire day. First entry is timed as 10:37 a.m., which described the wound/skin condition of a chronic area on Resident #200's left thigh. The second nurse note is timed as 16:29 (4:29 p.m.) "Category: Falls/Fall Follow-up: At 1320 (1:20 p.m.) CNA was transferring resident using a gait belt and a walker from bed to the wheelchair. The resident began lowering her head and not standing up straight... The CNA got this nurse. Vital signs were taken. The resident was hoyered (total mechanical lift) into the wheelchair and then into bed. Resident complained of left knee pain. Left knee observed to be swollen and bruised. Order obtained to send to ED (12 miles away). Vitals: ,[DATE] P 80, R 18 O2 97% RA" and signed electronically by LPN "D". This "nurses note" fails to describe the events that took place in-between the fall (1:20 p.m.) and the transfer to the ED at 3:,[DATE]:30 p.m.) including 2 mechanical lift transfers, the change from initially "no swelling of the knee, to increased swelling of the knee", and the Resident (#200) screaming in pain during Bingo and while sitting in her wheelchair in the hallway. There is no documentation of a pain assessment or if any pain medication was administered. There is no documentation of a re-assessment post fall and after Resident #200's condition had changed. The third and final nurses note for Resident #200 was recorded on [DATE] at 18:30 (6:31 p.m.) when RN "A" documented the telephone call received from Resident #200's attending physician which notified the facility that Resident #200 expired at 1705 (5:05 p.m.) in the ED. A review of the "Emergency Department Record" (12 miles away) dated [DATE] and timed as 1542 (3:42 p.m.), revealed "History of Present Illness - This patient is a [AGE] year-old nursing home resident with history of [MEDICAL CONDITION] who comes for evaluation of a left knee and ankle injury which occurred during a transfer. In the triage (pre-assessment) time, the patient was not responsive and her pupils were dilated and fixed, and it looks like she had abnormal breathing. Physical Examination: Unable to get the full set of vital signs, but the pulse was faint at 66, pupils fixed and dilated, no carotid (large artery taking blood to the brain) pulses noted., severe [MEDICAL CONDITION] (slow heartbeat) 66... no breath sounds, non-responsive to command, no painful stimuli. ED Course: CPR was started at 1637 (4:37 p.m.) following ACLS (Advanced Cardiac Life Support) protocol with chest compressions. The patient was pronounced dead at 1652 (4:52 p.m.) after a full 15 minutes of CPR. Cardiac monitor showed asystole (no heartbeat) for the last 10 minutes of CPR procedure." A review of the "Report of Consultation" from the ED, dated [DATE] and dictated by Resident #200's attending physician, revealed under "Impression/Plan... At this point in spite of the 15-minute code the patient did not survive and the code was called... At this point there is concern that the patient may have had a some kind of [MEDICAL CONDITION] (stroke) event because of the Doll's eyes (medical term used to describe eyes that are dilated and always return to the center no matter which way the head is tuned) and the fixed-dilated pupils, and that perhaps that caused her to fall..." ( ) --

Based on interview and record review, the facility failed to consistently assess post-fall medical changes, specifically increased pain and swelling and repeated calls of "help me", for one Resident (#200), out of 4 resident's reviewed for changing medical conditions prior to transfer via facility vehicle to a local hospital emergency department (ED). This deficient practice resulted in Resident #200 being transported in a facility vehicle with inadequately trained staff, and delayed treatment at the receiving facility, with no report called to the ED to prepare them for a bariatric (morbidly obese) patient. Resident #200 expired at 17:05 (5:05 p.m.) in the ED. Findings include: An abbreviated survey was conducted at the facility from [DATE] - [DATE] in response to a complaint filed on behalf of (Resident #200) dated [DATE] and timed as 3:30 p.m. The complaint reads as follows: "Complainant states on [DATE] at 3:30 p.m. the Resident fell and the Resident Care Coordinator (named) was sending the Resident to (ED initials) to have her leg x-rayed. When nurses aide (Certified Nurse Aide (CNA) "F") brought the Resident down from the 3rd floor in a wheelchair the Resident (#200) was not conscious. The staff had to take the facility bus because of the size of the resident (morbidly obese), she could not fit in the van. The driver of the bus (named) and a maintenance man (named) told the aide (CNA "F") that the resident should be taken by ambulance and she could go to the nearest Hospital emergency room because she was not conscious. Nurse aide (CNA "F")called the Resident Care Coordinator who insisted she be taken by bus and to (named) hospital instead of the nearest hospital. Complainant states that the nurse aide (CNA "F") told the Resident Care Coordinator that the Resident (#200) was not conscious. The Resident was going in and out of consciousness once in the bus and would say to staff 'Help me!' Once staff got the Resident to (named) hospital the Resident (#200) remained in the facility bus in her wheelchair for 20 minutes, hospital stated they did not have a room for her. The Resident died a few minutes later." A review of the closed medical record for Resident #200 revealed, she was a [AGE] year old woman admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. disorder ([DATE]). According to the most recent Minimum Data Set (MDS) assessment dated [DATE], Resident #200 was cognitively intact; scoring ,[DATE] on her BIMS (brief interview of mental status). She needed extensive two staff assist for transfers, and extensive assist of one staff for ambulation, dressing, hygiene and bathing needs. The MDS revealed Resident #200 used a walker for transfers and a wheelchair for most of her ambulation needs. A review of Resident #200's "hospitalization Treatment Choices" & "(Facility Name) Medical Treatment Choices" dated [DATE], revealed Resident #200 chose (by marking 'yes') "CPR, hospitalization , and comfort measures" both in the facility and in the hospital. An incident report dated Friday [DATE] and timed as 13:20 (1:20 p.m.), revealed Resident #200 was being transferred via gait belt and walker by CNA ("I"), "Resident (#200) began lowering her head/not standing up straight. CNA yelled for help. Another CNA and housekeeper assisted to get resident into w/c (wheelchair). Resident went down on her knees." The "nursing assessment" revealed "knee bruised/swollen Complaints of pain in left knee. Vital signs: ,[DATE], P(ulse) 80/R(espirations)18. Level of consciousness: Alert". A telephone interview was conducted with LPN "D" on [DATE] at 9:30 a.m. LPN "D" was asked about the events of [DATE], pertaining to Resident #200. LPN "D" stated, "She (Resident #200) was her 'usual self' and did have a fall at 1:20 p.m., she complained that her left knee hurt, but she was alert and oriented after the fall. I assessed her knee and at that time there was no injury observed, later it (knee) was swollen and she had increased pain.... so (Registered Nurse {RN} "A") obtained an order to have her transferred to the ED for evaluation. (Resident #200) told me she was sorry for falling, I told her 'Everything will be okay.' I didn't see any [MEDICAL CONDITION] activity (for Resident #200) on that Friday ([DATE])." LPN "D" was asked about the transfer papers used for Resident #200. LPN "D" stated she had used the vital signs from the fall (1:20 p.m.) and did not reassess the resident before leaving at 3:30 p.m. (2 hours post fall). A second telephone interview was conducted with LPN "D" at 11:05 a.m. on [DATE]. LPN "D" was asked if she received any phone calls or text messages from (CNA "F"). She stated, "Let me check my phone... oh, yes I was asked to clarify the destination (which ED) and was notified that the maintenance man (Staff "E") went along for 'safety reasons'." There was no mention from LPN "D" that Resident #200 was having any difficulty with level of consciousness, that the facility staff had to wait in the ED, because the ED was not prepared to receive a resident of this size. LPN "D" was asked if she had telephoned the receiving facility and gave them report on the nature of the transfer, and the resident status ("super morbidly obese"). LPN "D" stated, "No, I thought (RN "A") did it (called report)." A third telephone call was placed to LPN "D" on [DATE] at 8:45 a.m., a message was left. The facility informed this writer that LPN "D" had 'called in sick' for the day; no return phone call was received. A telephone interview was conducted with CNA "F" on [DATE] at 10:50 a.m. CNA "F" stated she had been (Resident #200's) primary CNA on the afternoon shift for years, very familiar with her and had witnessed 'several' episodes of [MEDICAL CONDITION] activity by Resident #200. CNA "F" stated on [DATE], she had just reported to work at 3:00 p.m., "I was told I was going on a transfer to the hospital.... So my co-workers (CNAs "B" and "C") helped me mechanically lift (Resident #200) out of bed and into her wheelchair. She (Resident #200) was awake then, we had to use a draw sheet to turn her to get the sling under her for the transfer, she (Resident #200) hurt too much and couldn't help us at all. (CNA "C") supported her leg the whole transfer, she (Resident #200) was yelling and wincing in pain.... her skin was cold to the touch and she was pale looking.... we covered her up with a lap blanket and I wheeled her down to the nurses station/elevators to get ready to leave. I went behind the nurses desk to get the paperwork for the hospital from the nurse (LPN "D"). I asked again where I was taking her (emergency department (ED) 12 miles away) or to the (ED 2 miles away), the nurse stated 'The order is for the ED (12 miles away)'. I told the nurse (LPN "D") 'I felt bad for her (Resident #200) because she's in so much pain' and 'kinda with it, and kinda out of it'.... I got her downstairs to get loaded on the bus for the transport and the transporter (Staff "G") and the maintenance man (Staff "E") met me at the doors... (Staff "E") stated 'We don't take patients who are unconscious... I told him the nurse (LPN "D") said we are to transport her.... while we were wheeling her out to the bus, her (Resident #200's) head was down, and when we lifted her up via the wheelchair lift she woke up and yelled 'Help Me!', then her head would go back down and tip to the side... She (Resident #200) was like that the whole way there (ED)." A second telephone interview was conducted with CNA "F" on [DATE] at 1:42 p.m. CNA "F" was asked if she contacted the facility at all regarding (Resident #200's) condition. CNA "F" stated she called once and sent text messages via phone to the nurse. CNA "F" emailed screenshots (pictures) of the call log and the text messages to this Surveyor. The first screenshot is of the call log from CNA "F's" cell phone to (LPN "D's") cell phone, the date is [DATE] and timed at 3:31 p.m., the call lasted 1 minute. CNA "F" stated, "I called her (LPN "D") to tell her she (Resident #200) 'wasn't doing good' and that she was 'in and out of consciousness', (LPN "D") said for us to 'get her there (ED 12 miles away)'." The second screenshot is of the text messages from CNA"F's" phone to LPN "D's" phone. The text messages revealed: (CNA "F") texted at 3:33 p.m. on [DATE], "For safety reasons (Staff "E") maintenance is with us because she (Resident #200) kept passing out we didn't want her flipping out of chair for being unconscious." (LPN "D") responded with a text message at 3:35 p.m., "Good lord. ok. (Staff "E") is a fricken saint". At 4:07 p.m., (CNA "F") sent a text to (LPN "D"): "Now we are waiting for a bed because they weren't ready or anything :/ (emoticon)". At 4:18 p.m., (LPN "D") replied "Crap". At 4:19 p.m., (CNA "F") replied via text, "They still haven't taken her back said they need to talk to the doctor...". During the telephone interview, CNA "F" stated, "All the time we were waiting in the ED she was crying and saying '(CNA's name) Help me, I can't see, (CNA's name) help me'. We (all three staff) were rubbing her arms, telling her things would be okay." CNA "F" was asked if she knew the "code" status of Resident #200 and she stated, "No, I think she's a no code (no CPR requested)." CNA "F" was asked if she was CPR certified (trained in CPR procedure), she replied "No." LPN "D" failed to re-assess Resident #200 (before leaving the 3rd floor nurses station) after CNA "F" stated, "I feel bad for her (Resident #200) because she's in so much pain and 'kinda with it, and kinda out of it"; LPN "D" failed to re-assess an acute change of condition for Resident #200 when CNA "F" first called LPN "D" at 3:31 p.m., and notified her she (Resident #200) was having difficulty with her level of consciousness, and again when CNA "F" texted at 3:33 p.m. on [DATE], "For safety reasons (Staff "E") maintenance is with us because she (Resident #200) kept passing out we didn't want her flipping out of chair for being unconscious." In addition, LPN "D" failed to call/communicate with the receiving facility to prepare them for a "morbidly obese" resident who was enroute to their facility and needed specialized equipment to accommodate her body size. The "Nursing Practice Standards for the Licensed Practical Nurse" published by the National Federation of Licensed Practical Nurses, Inc. dated ,[DATE] reads under the section titled "Practice: ....4.) Shall know and utilize the nursing process in planning, implementing, and evaluating health services and nursing care for the individual patient or group. a.) Planning: The planning includes: 1) assessment/data collection of health status of the individual patient, the family and community groups 2) reporting information gained from assessment/data collection.... b.) Implementation: The plan for nursing care is put into practice to achieve the stated goals and includes: 1) observing, recording, and reporting significant changes which require intervention or different goals 2) applying nursing knowledge and skills to promote and maintain health, to prevent disease and disability and to optimize functional capabilities of an individual patient..." ( ) --

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE NECESSARY CARE AND SERVICE, SPECIFICALLY NOT PERFORMING CARDIOPULMONARY RESUSCITATION (CPR) AS INDICATED, FOR ONE RESIDENT (#101) WHO REQUIRED EMERGENCY CARE TO BE IMPLEMENTED OF TWO SAMPLED RESIDENTS OUT OF 45 RESIDENTS IN THE FACILITY IDENTIFIED AS CPR CANDIDATES, FROM A TOTAL OF 186 RESIDENTS IN THE FACILITY. THIS FAILURE RESULTED IN CPR NOT BEING INITIATED TIMELY, WHICH PLACED RESIDENT #101 IN IMMEDIATE JEOPARDY TO HER HEALTH AND SAFETY. RESIDENT #101 died on [DATE]. FINDINGS INCLUDE: THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON [DATE] AT 3:00 P.M. THE IMMEDIATE JEOPARDY BEGAN ON [DATE] AT APPROXIMATELY 5:50 P.M., WHEN RESIDENT #101 BECAME UNRESPONSIVE AFTER LICENSED PRACTICAL NURSE (LPN) "A" PUT TWO PILLS ON A SPOON AND PLACED THEM IN RESIDENT #101'S MOUTH AND DID NOT STAY WITH THE RESIDENT DURING AN EMERGENCY SITUATION TO PROVIDE APPROPRIATE EMERGENCY CARE. RESIDENT #101 WAS LEFT UNATTENDED BY FACILITY STAFF FOR A PERIOD OF TIME, WAS FOUND PALE, CYANOTIC AND CONTINUED TO BE NON-RESPONSIVE. THE FACILITY "PROGRESS NOTES" DATED [DATE], REVEALED A "CODE BLUE" WAS CALLED FOR RESIDENT #101 AT 5:58 P.M. ACCORDING TO THE AMERICAN HEART ASSOCIATION (AHA) STANDARDS PER THE FACILITY'S POLICY TITLED, "CPR-CARDIOPULMONARY RESUSCITATION", DATED [DATE], THE "CODE BLUE" IDENTIFIED THE RESIDENT AS A CPR CANDIDATE IN NEED OF EMERGENCY INTERVENTION. THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY (IJ) ON [DATE] AT 3:12 P.M. AND A WRITTEN PLAN FOR REMOVAL OF THE IJ WAS REQUESTED. ON [DATE] AT 9:43 A.M., THE IMMEDIATE JEOPARDY WAS REMOVED WHEN THE SURVEYOR VERIFIED THE FOLLOWING: - ON [DATE], THE DIRECTOR OF NURSING (DON) REVIEWED AND UPDATED THE FACILITY'S POLICY AND PROCEDURE ADDRESSING BLS/CPR AND EMERGENCY MEASURES FOR CHOKING. -ON [DATE], [DATE], [DATE], [DATE] AND [DATE], THE NURSING EDUCATION COORDINATOR RE-TRAINED ALL LICENSED NURSING AND DIRECT CARE STAFF ON CURRENT STANDARDS/EMERGENCY MEASURES FOR CHOKING EPISODES. -ON [DATE], THE DON BEGAN REVIEWING THE FACILITY'S UPDATED POLICY AND PROCEDURE ADDRESSING BASIC LIFE SUPPORT/CPR AND EMERGENCY MEASURES FOR CHOKING WITH THE LICENSED NURSING STAFF. -ON [DATE], A BLS FOR HEALTHCARE PROVIDERS/CPR RE-CERTIFICATION CLASS WAS HELD FOR 9 LICENSED NURSES WHICH ENSURED THAT 41 OF 52 (79%) OF LICENSED NURSES ACTIVELY WORKING ARE CURRENTLY BLS/CPR CERTIFIED. -ON [DATE], THE NURSING SUPERVISORS CONTINUED REVIEWING THE FACILITY'S UPDATED POLICY AND PROCEDURES ADDRESSING BLS/CPR AND EMERGENCY MEASURES FOR CHOKING WITH LICENSED NURSING STAFF (NAMELY, ,[DATE] (65%) OF LICENSED NURSES ACTIVELY WORKING ARE TRAINED). -ON [DATE], THE DON AND NURSING SUPERVISORS HAD TWO ADDITIONAL TRAINING SESSIONS FOR LICENSED NURSES TO REVIEW THE FACILITY'S POLICY AND PROCEDURE ADDRESSING BLS/CPR AND EMERGENCY MEASURES FOR CHOKING. NURSES WHO HAD NOT ALREADY ATTENDED ONE OF THE PREVIOUS TRAINING SESSIONS HAVE BEEN CONTACTED AND MANDATED TO ATTEND ONE OF THESE TWO TRAININGS. THIS ENSURED THAT 100% OF LICENSED NURSES ACTIVELY WORKING HAVE BEEN TRAINED. -ON [DATE], TWO ADDITIONAL BLS FOR HEALTHCARE PROVIDERS/CPR RECERTIFICATION CLASSES HAVE BEEN SCHEDULED (2:00 P.M. AND 6:00 P.M.). ONCE COMPLETED, 100% OF LICENSED NURSES ACTIVELY WORKING WILL BE BLS/CPR CERTIFIED. UNTIL THIS OCCURS, IT WAS VERIFIED THAT ON [DATE], THE DAY SHIFT (7:00 A.M. TO 3:00 P.M.) WILL HAVE ,[DATE] LICENSED NURSES IN HOUSE WHICH ARE BLS/CPR CERTIFIED. THIS WILL ENSURE ENOUGH BLS/CPR LICENSED NURSES ARE AVAILABLE TO ADDRESS ANY POTENTIAL CODE SITUATION THAT MAY OCCUR. THE AFTERNOON SHIFT ON [DATE], 3:00 P.M. TO 11:00 P.M., WILL HAVE 100% OF LICENSED NURSES WORKING THAT ARE BLS/CPR CERTIFIED. -ON [DATE] AT 9:55 A.M., 10:10 A.M. AND 10:25 A.M., THREE REGISTERED NURSES (RN), NAMELY, RN "L", RN "M" AND RN "N", RESPECTIVELY, WERE INTERVIEWED TO ENSURE EDUCATIONAL CRITERIA WERE MET. -ON [DATE], THIS SURVEYOR REVIEWED SIGN-IN SHEETS AND CONTENT OUTLINE FOR INSERVICES HELD TO ENSURE COMPLIANCE WITH IJ REMOVAL PLAN. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE CONTINUES AT AN ISOLATED LEVEL WITH HARM, DUE TO: - LACK OF COMPLIANCE WITH THE CPR POLICY DATED [DATE]. - THE FACILITY HAS NOT DEMONSTRATED COMPLIANCE WITH THE FACILITY'S REVISED POLICY TITLED, "CPR-CARDIOPULMONARY RESUSCITATION", DATED [DATE]. - THE FACILITY HAS NOT DEMONSTRATED A PROCESS TO ENSURE ACTIVE LICENSED STAFF MAINTAIN CURRENT CPR CERTIFICATION. FINDINGS INCLUDE: THE FACILITY CLINICAL RECORD WAS REVIEWED AND THE FACE SHEET REVEALED RESIDENT #101 WAS A [AGE] year OLD WOMAN admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #101'S FACE SHEET ALSO INDICATED SHE WAS HER OWN RESPONSIBLE PERSON. A FORM TITLED, "(FACILITY) MEDICAL/TREATMENT CHOICES" DATED [DATE], SHOWED RESIDENT #101 REQUESTED, (BY CHECKING "YES" TO) "CPR: IF MY HEART STOPS BEATING, I DESIRE TREATMENT WITH MEDICATIONS, CHEST COMPRESSIONS AND LUNG VENTILATION TO SEE IF I CAN SURVIVE..." WHETHER (RESIDENT #101'S) CONDITION IS TERMINALLY ILL OR NOT. A REVIEW OF THE FACILITY'S POLICY TITLED "CPR CARDIOPULMONARY RESUSCITATION" DATED [DATE], READ: "CPR WILL BE WITHHELD OR ADMINISTERED TO A RESIDENT BASED ON AN INFORMED DECISION ONCE THE BENEFITS, RISKS AND ALTERNATIVES ARE DISCLOSED TO THE RESIDENT OR LEGAL REPRESENTATIVE/RESPONSIBLE PARTY... CPR WILL BE PROVIDED ACCORDING TO THE AMERICAN HEART ASSOCIATION'S BLS FOR HEALTHCARE PROVIDERS (CPR AND AED (AUTOMATIC EXTERNAL DEFIBRILLATOR)) PROGRAM AND CURRENT STANDARDS. 6. PROTOCOL TO FOLLOW IF CPR IS WARRANTED FOR A RESIDENT IDENTIFIED AS REQUESTING CPR: .... C. CPR, CONSISTING OF PRECORDIAL CHEST COMPRESSIONS AND VENTILATIONS WILL BE INITIATED BY THIS LICENSED NURSE OR ANOTHER HEALTHCARE WORKER CERTIFIED IN CPR." IN ACCORDANCE WITH THE FACILITY'S POLICY TITLED "CPR..." THE AHA PROTOCOL WILL BE FOLLOWED. A REVIEW OF THE "BLS FOR HEALTHCARE PROVIDERS - AMERICAN HEART ASSOCIATION - GUIDELINES (FOR) CPR", COPYRIGHT 2011, READ: "BLS CONSIST OF THESE MAIN PARTS: -(FIRST) CHEST COMPRESSIONS -(SECOND) AIRWAY -(THIRD) BREATHING -(FOURTH) DEFIBRILLATION... CAUTION - AGONAL GASPS ARE NOT NORMAL BREATHING. AGONAL GASPS MAY BE PRESENT IN THE FIRST MINUTES AFTER SUDDEN [MEDICAL CONDITION]. A PERSON WHO GASPS USUALLY LOOKS LIKE HE IS DRAWING AIR IN VERY QUICKLY. THE MOUTH MAY BE OPEN AND THE JAW, HEAD OR NECK MAY MOVE WITH GASPS. GASPS MAY APPEAR FORCEFUL OR WEAK ...IF A VICTIM IS NOT BREATHING OR THERE IS NO NORMAL BREATHING (I.E., ONLY AGONAL GASPS), YOU MUST ACTIVATE THE EMERGENCY RESPONSE SYSTEM, CHECK (CAROTID) PULSE, AND START CPR... IF YOU ARE ALONE AND FIND AN UNRESPONSIVE VICTIM NOT BREATHING, SHOUT FOR HELP... PULSE CHECK... HEALTHCARE PROVIDERS SHOULD TAKE NO MORE THAN 10 SECONDS TO CHECK PULSE. TO PERFORM A PULSE CHECK IN THE ADULT, PALPATE A CAROTID PULSE. IF YOU DO NOT DEFINITELY FEEL A PULSE WITHIN 10 SECONDS, START CHEST COMPRESSIONS... OPENING AIRWAY FOR BREATHS: HEAD TILT-CHIN LIFT... START RESCUE BREATHING... WHEN A SECOND RESCUER IS AVAILABLE TO HELP, THAT SECOND RESCUER SHOULD ACTIVATE THE EMERGENCY RESPONSE SYSTEM AND GET THE AED. THE FIRST RESCUER SHOULD REMAIN WITH THE VICTIM TO START CPR IMMEDIATELY, BEGINNING WITH CHEST COMPRESSIONS. AFTER THE SECOND RESCUER RETURNS, THE RESCUER SHOULD USE THE AED AS SOON AS IT IS AVAILABLE.... TWO-RESCUER CPR. THE FIRST RESCUER PERFORMS CHEST COMPRESSIONS. THE SECOND PERFORMS BAG-MASK VENTILATION USING A MASK WITH SUPPLEMENTARY OXYGEN. THE SECOND RESCUER ENSURES THAT THE CHEST RISES WITH EACH BREATH.... WHEN 3 OR MORE RESCUERS ARE PRESENT, 2 RESCUERS CAN PROVIDE MORE EFFECTIVE BAG-MASK VENTILATION THAN 1 RESCUER. WHEN 2 RESCUERS USE THE BAG-MASK SYSTEM, ONE RESCUER OPENS THE AIRWAY WITH A HEAD TILT-CHIN (OR JAW THRUST) AND HOLDS THE MASK TO THE FACE WHILE THE OTHER RESCUER SQUEEZES THE BAG... RELIEF OF CHOKING - IF A CHOKING VICTIM BECOMES UNRESPONSIVE, ACTIVATE THE EMERGENCY RESPONSE SYSTEM. LOWER THE VICTIM TO THE GROUND AND BEGIN CPR, STARTING WITH COMPRESSIONS...IF YOU SEE AN OBJECT THAT CAN EASILY BE REMOVED, REMOVE IT WITH YOUR FINGERS....SOMETIMES THE CHOKING VICTIM MAY BE UNRESPONSIVE WHEN YOU FIRST ENCOUNTER HIM OR HER. IN THIS CIRCUMSTANCE YOU PROBABLY WILL NOT KNOW THAT AN AIRWAY OBSTRUCTIONS EXISTS. ACTIVATE THE EMERGENCY RESPONSE SYSTEM AND START CPR (C-A-B (CHEST COMPRESSIONS - AIRWAY - BREATHING) SEQUENCE." THE FACILITY "PROGRESS NOTES" DATED [DATE] AT 17:50 (5:50 P.M.) READ, "(LPN "A") WENT IN ROOM TO GIVE SUPPER PILLS, RES (RESIDENT #101) WAS LAYING IN BED (AT 30 DEGREE ANGLE) WITH EYES HALF-CLOSED - VERY DROWSY... PUT 2 PILLS ON SPOON WITH PUDDING AND PUT IN MOUTH. RES VISIBLY SWALLOWED WITH SMALL SIP WATER. I THEN PUT 2 MORE PILLS ON SPOON AND PUT IN MOUTH TRIED TO GIVE ANOTHER SIP OF WATER... BUT RES CLENCHED MOUTH SHUT - URGED RES TO TAKE A DRINK AND PUT STRAW TO LIPS. BUT RES WAS UNRESPONSIVE TO VERBAL STIMULI.... LEFT ROOM AT 17:55 (5:55 P.M.) TO GET ASSISTANCE - RETURNED WITH OTHER NURSE TO FIND RES PALE & CYANOTIC... CODE BLUE (AN EMERGENCY SYSTEM WHICH IDENTIFIES A RESIDENT IN NEED OF CPR) INITIATED AT 17:58 (5:58 P.M.)". DURING AN INTERVIEW ON [DATE] AT 8:30 A.M. WITH LPN "A", SHE STATED SHE HAD NOT USED THE CALL LIGHT IN THE ROOM OR RESIDENT'S BATHROOM, NOR YELLED OUT FOR HELP TO ACTIVATE THE EMERGENCY SYSTEM; FURTHERMORE, LPN "A" CONFIRMED SHE LEFT RESIDENT #101 ALONE AFTER SHE ESTABLISHED RESIDENT #101 WAS UNRESPONSIVE. LPN "A" STATED, "WHAT YOU ARE SAYING IS RIGHT, I SHOULD HAVE NEVER LEFT HER (RESIDENT #101)... I WAS IN COMPLETE PANIC... I COULDN'T THINK STRAIGHT... NO, (WE DID NOT INITIATE CHEST COMPRESSIONS OR RESCUE BREATHING)... WHEN CODE (BLUE) WAS CALLED I CHECKED (THE) BLOOD PRESSURE... (AND WAS) UNABLE TO OBTAIN AND NO NEVER CHECKED CAROTID PULSE... THE PULSE OX (OXIMETER) (AN NONINVASIVE METHOD OF MEASURING SATURATED HEMOGLOBIN) WAS ON AND SHOWED NO PULSE OX READING OR NO PULSE... I DID A FINGER SWEEP AND FOUND NO PILLS... (ONCE OTHER LICENSED STAFF ARRIVED) EVERYONE THOUGHT SHE WAS CHOKING... BUT NO, I NEVER SAW CPR (BEING PERFORMED) THEY WERE SUCTIONING HER (RESIDENT #101)." LPN "A" STATED THAT CHEST COMPRESSIONS WERE NOT STARTED ON RESIDENT #101, NOR AN AIRWAY ESTABLISHED PER PROTOCOL OR ATTEMPTS AT RESCUE BREATHING. THIS SURVEYOR AND LPN "A" REVIEWED THE PROTOCOL FOR THE AHA GUIDELINES FOR CPR, COPYRIGHT 2011, AND LPN "A" CONFIRMED THE AHA PROTOCOL WAS NOT FOLLOWED. IN AN INTERVIEW WITH REGISTERED NURSE (RN) "B" ON [DATE] AT 11:30 A.M., HE STATED, "(RN "I") WAS REQUESTING TO SUCTION... THEY LOOKED IN THROAT (AND) TRIED TO DO A FINGER SWEEP BUT COULDN'T REACH HER PILLS... WE WERE ALL UNDER THE GUN... HIGH STRESS... WE DID WHAT WE THOUGHT WAS RIGHT TO SAVE HER LIFE... I DIDN'T NOTICE ANY (RESCUE) BREATHING... SHE HAD A FISH MOUTH... GASPING CONTINUED... BUT NO, I DIDN'T SEE ANYONE CHECK FOR A PULSE OR ASSESS RESPIRATORY STATUS... NO, I DIDN'T SEE ANY CHEST COMPRESSION UNTIL EMS (EMERGENCY MEDICAL SERVICE) CAME." DURING AN INTERVIEW ON [DATE] AT 4:00 P.M. WITH RN "I", SHE STATED NO ONE WAS PERFORMING CPR WHEN SHE ARRIVED AND THAT SHE WAS THE 5TH NURSE ON SITE. RN "I" STATED, "WHEN I WALKED IN (RESIDENT #101'S) FACE WAS DUSKY... SHE (RESIDENT #101) TRIED TO TAKE GASPING BREATHS AND I ASKED IF SHE WAS CHOKING. (LPN "P") OPENED HER MOUTH AND I COULD SEE 2 LARGE PILLS AND DID A FINGER SWEEP AND COULDN'T REACH THEM... SO I SUCTIONED HER... NO, I DIDN'T ATTEMPT TO DO RESCUE BREATHING OR CARDIAC COMPRESSIONS... NO ONE MENTIONED TO GIVE HER A BREATH OR CARDIAC COMPRESSIONS... NO ONE GAVE ANY KIND OF INPUT TO ASSIST... EXCEPT (RN "B")." WHEN ASKED IF SHE WAS AWARE OF THE AHA GUIDELINES FOR CPR AND CHOKING VICTIMS SHE STATED, "I'VE BEEN TOLD, SINCE THE INCIDENT THAT APPROPRIATE PROTOCOL WAS NOT FOLLOWED. I DID WHAT I THOUGHT I WAS TRAINED TO DO... BUT APPARENTLY IT WASN'T (APPROPRIATE CPR/CHOKING PROCEDURES)." DURING AN INTERVIEW ON [DATE] AT 5:55 P.M. WITH RN "E", SHE STATED, RN "P" WAS ON THE RIGHT SIDE OF (RESIDENT #101) AND RN "I" WAS ON THE LEFT SIDE OF HER. "THEY WANTED TO SUCTION... (THE) AED WAS AT HER (RESIDENT #101'S) FEET... NO, WE DID NOT DO CPR... NO, WE DID NOT DO ANY RESCUE BREATHING OR CARDIAC COMPRESSIONS... NO, I NEVER SAW ANYONE CHECK A CAROTID PULSE - ONLY THE PULSE THAT WAS ON THE PULSE OX WHICH MAY NOT BE AN ACCURATE READING, I KNOW." THE FACILITY'S "CPR REPORT" DATED [DATE], DOCUMENTED EMS (EMERGENCY MEDICAL SERVICES) ARRIVED ON [DATE] AT 18:09 (6:09 P.M. AND RESCUE BREATHING WAS STARTED AND AT 18:10 (6:10 P.M.), AED APPLIED. CHEST COMPRESSIONS AND RESCUE BREATHING WAS STARTED AT 6:12 P.M. BY EMS WHEN RESIDENT #101 WAS BEING TRANSPORTED TO THE HOSPITAL FOR EMERGENCY CARE. THE EMS REPORT (NOT TITLED) DATED [DATE], REVEALED AT (6:08 P.M.)RESIDENT #101 HAD "FIXED/DILATED" PUPILS AND "ECG" (ELECTROCARDIOGRAM) SHOWED "ASYSTOLE" (FLAT LINE INDICATING [MEDICAL CONDITION]- NO HEART BEAT). THE HOSPITAL EMERGENCY DEPARTMENT'S "PHYSICIAN DOCUMENTATION" DATED [DATE], READ, "PHYSICAL EXAM: PULSELESS, GREY, APNEIC (AN ABSENCE OF SPONTANEOUS RESPIRATION), NO SIGNS OF TRAUMA, EMESIS ON FACE AND SHEETS. NO HEARTBEAT, ABDOMEN DISTENDED... CPR/BVM (BAG VALVE MASK) CONTINUED UNTIL INTUBATED WITH 7 ET (ENDOTRACHEAL TUBE). BILAT BREATH SOUNDS AFTER INTUBATION AND GOOD COLOR CHANGE ON CO2 MONITOR. ASYSTOLE THROUGHOUT ED COURSE... PUPILS FIXED AND DILATED.... DEPARTURE: DISPOSITION: THIS PATIENT EXPIRED Diagnosis: [REDACTED]. DURING AN INTERVIEW ON [DATE] AT 10:50 A.M. WITH BLS INSTRUCTOR "J" (WHEN ASKED ABOUT THE PROCEDURE TO BE USED WITH A CHOKING VICTIM), SHE STATED, "...THE KEY WORD IS EASILY REMOVED WITH FINGERS... SUCTION? NO, YOU WOULDN'T SUCTION FOR FEAR OF LODGING IT (THE OBJECT) DEEPER IN THE THROAT." SHE STATED, THE CURRENT BLS PROTOCOL IS CHEST COMPRESSION, THEN ADDRESS AIRWAY AND BREATHING. BLS INSTRUCTOR "J" STATED, "NO... AGAIN YOU WOULDN'T USE SUCTION TO REMOVE AN OBJECT DEEP IN THE THROAT... YOU ONLY REMOVE THE OBJECT IF YOU CAN EASILY REMOVE IT WITH YOUR FINGERS." BASED ON THE ABOVE INVESTIGATION, IT WAS DETERMINED THAT NECESSARY CARE AND SERVICE WAS NOT APPROPRIATELY PROVIDED BY THE FACILITY PER THE FACILITY'S WRITTEN POLICY. RESIDENT #101 BECAME UNRESPONSIVE AND STAFF LEFT RESIDENT WITHOUT PROVIDING EMERGENCY CARE. CPR WAS NOT INITIATED TIMELY; FURTHERMORE, THE CHOKING PROCEDURE WAS INAPPROPRIATELY IMPLEMENTED. CPR WAS ONLY STARTED ONCE EMS ARRIVED, 10 MINUTES AFTER THE CODE BLUE WAS CALLED. AT THAT TIME, RESIDENT #101 WAS ASSESSED TO HAVE FIXED AND DILATED PUPILS AND NO CARDIAC ACTIVITY. ( )

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ADHERE TO THE STANDARDS OF PROFESSIONAL PRACTICE FOR THE ADMINISTRATION OF CARDIOPULMONARY RESUSCITATION (CPR) FOR ONE RESIDENT (#101) WHO BECAME UNRESPONSIVE, AND WAS ASSESSED TO HAVE NO HEART RATE OR RESPIRATIONS AND REQUESTED CPR, OF TWO SAMPLED RESIDENTS, OF 45 RESIDENTS IN THE FACILITY DESIGNATED AS CPR CANDIDATES FROM A TOTAL 186 FACILITY RESIDENTS. THIS FAILURE TO PERFORM CPR, ACCORDING TO THE FACILITY'S POLICY BASED ON THE AMERICAN HEART ASSOCIATION'S (AHA) CURRENT STANDARDS/PROTOCOLS, RESULTED IN A 10 MINUTE DELAY IN RESIDENT #101 RECEIVING THE NECESSARY CPR. RESIDENT #101 died on [DATE]. FINDINGS INCLUDE: THE CLINICAL RECORD WAS REVIEWED AND THE FACE SHEET REVEALED RESIDENT #101 WAS A [AGE] year OLD WOMAN admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. RESIDENT #101'S FACE SHEET ALSO INDICATED SHE WAS HER OWN RESPONSIBLE PERSON. THE CODE DETERMINATION TITLED, "(FACILITY) MEDICAL/TREATMENT CHOICES" DATED [DATE], SHOWED RESIDENT #101 REQUESTED, (BY CHECKING "YES" TO) "CPR: IF MY HEART STOPS BEATING, I DESIRE TREATMENT WITH MEDICATIONS, CHEST COMPRESSIONS AND LUNG VENTILATION TO SEE IF I CAN SURVIVE..., WHETHER (RESIDENT #101'S) CONDITION IS TERMINALLY ILL OR NOT." A REVIEW OF THE FACILITY'S POLICY TITLED "CPR CARDIOPULMONARY RESUSCITATION" DATED [DATE], READ: "CPR WILL BE WITHHELD OR ADMINISTERED TO A RESIDENT BASED ON AN INFORMED DECISION ONCE THE BENEFITS, RISKS AND ALTERNATIVES ARE DISCLOSED TO THE RESIDENT OR LEGAL REPRESENTATIVE/RESPONSIBLE PARTY... CPR WILL BE PROVIDED ACCORDING TO THE AMERICAN HEART ASSOCIATION'S BLS (BASIC LIFE SUPPORT) FOR HEALTHCARE PROVIDERS (CPR AND AED (AUTOMATIC EXTERNAL DEFIBRILLATOR)) PROGRAM AND CURRENT STANDARDS. 6. PROTOCOL TO FOLLOW IF CPR IS WARRANTED FOR A RESIDENT IDENTIFIED AS REQUESTING CPR: .... C. CPR, CONSISTING OF PRECORDIAL CHEST COMPRESSIONS AND VENTILATIONS WILL BE INITIATED BY THIS LICENSED NURSE OR ANOTHER HEALTHCARE WORKER CERTIFIED IN CPR." IN ACCORDANCE WITH THE ABOVE FACILITY'S POLICY TITLED "CPR...", THE AHA PROTOCOL WILL BE FOLLOWED. A REVIEW OF THE "BLS FOR HEALTHCARE PROVIDERS - AMERICAN HEART ASSOCIATION - GUIDELINES (FOR) CPR", COPYRIGHT 2011, READ: "BLS CONSIST OF THESE MAIN PARTS: -(FIRST) CHEST COMPRESSIONS -(SECOND) AIRWAY -(THIRD) BREATHING -(FOURTH) DEFIBRILLATION... CAUTION - AGONAL GASPS ARE NOT NORMAL BREATHING. AGONAL GASPS MAY BE PRESENT IN THE FIRST MINUTES AFTER SUDDEN [MEDICAL CONDITION]. A PERSON WHO GASPS USUALLY LOOKS LIKE HE IS DRAWING AIR IN VERY QUICKLY. THE MOUTH MAY BE OPEN AND THE JAW, HEAD OR NECK MAY MOVE WITH GASPS. GASPS MAY APPEAR FORCEFUL OR WEAK ...IF A VICTIM IS NOT BREATHING OR THERE IS NO NORMAL BREATHING (I.E., ONLY AGONAL GASPS), YOU MUST ACTIVATE THE EMERGENCY RESPONSE SYSTEM, CHECK (CAROTID) PULSE, AND START CPR... IF YOU ARE ALONE AND FIND AN UNRESPONSIVE VICTIM NOT BREATHING, SHOUT FOR HELP... PULSE CHECK... HEALTHCARE PROVIDERS SHOULD TAKE NO MORE THAN 10 SECONDS TO CHECK PULSE. TO PERFORM A PULSE CHECK IN THE ADULT, PALPATE A CAROTID PULSE. IF YOU DO NOT DEFINITELY FEEL A PULSE WITHIN 10 SECONDS, START CHEST COMPRESSIONS... OPENING AIRWAY FOR BREATHS: HEAD TILT-CHIN LIFT... START RESCUE BREATHING... WHEN A SECOND RESCUER IS AVAILABLE TO HELP, THAT SECOND RESCUER SHOULD ACTIVATE THE EMERGENCY RESPONSE SYSTEM AND GET THE AED. THE FIRST RESCUER SHOULD REMAIN WITH THE VICTIM TO START CPR IMMEDIATELY, BEGINNING WITH CHEST COMPRESSIONS. AFTER THE SECOND RESCUER RETURNS, THE RESCUER SHOULD USE THE AED AS SOON AS IT IS AVAILABLE.... TWO-RESCUER CPR. THE FIRST RESCUER PERFORMS CHEST COMPRESSIONS. THE SECOND PERFORMS BAG-MASK VENTILATION USING A MASK WITH SUPPLEMENTARY OXYGEN. THE SECOND RESCUER ENSURES THAT THE CHEST RISES WITH EACH BREATH.... WHEN 3 OR MORE RESCUERS ARE PRESENT, 2 RESCUERS CAN PROVIDE MORE EFFECTIVE BAG-MASK VENTILATION THAN 1 RESCUER. WHEN 2 RESCUERS USE THE BAG-MASK SYSTEM, ONE RESCUER OPENS THE AIRWAY WITH A HEAD TILT-CHIN (OR JAW THRUST) AND HOLDS THE MASK TO THE FACE WHILE THE OTHER RESCUER SQUEEZES THE BAG... RELIEF OF CHOKING - IF A CHOKING VICTIM BECOMES UNRESPONSIVE, ACTIVATE THE EMERGENCY RESPONSE SYSTEM. LOWER THE VICTIM TO THE GROUND AND BEGIN CPR, STARTING WITH COMPRESSIONS... IF YOU SEE AN OBJECT THAT CAN EASILY BE REMOVED, REMOVE IT WITH YOUR FINGERS... SOMETIMES THE CHOKING VICTIM MAY BE UNRESPONSIVE WHEN YOU FIRST ENCOUNTER HIM OR HER. IN THIS CIRCUMSTANCE YOU PROBABLY WILL NOT KNOW THAT AN AIRWAY OBSTRUCTION EXISTS. ACTIVATE THE EMERGENCY RESPONSE SYSTEM AND START CPR (C-A-B (CHEST COMPRESSIONS - AIRWAY - BREATHING) SEQUENCE." THE FACILITY "PROGRESS NOTES" DATED [DATE] AT 17:50 (5:50 P.M.) READ, "(LPN "A") WENT IN ROOM TO GIVE SUPPER PILLS, RES (RESIDENT #101) WAS LAYING IN BED (AT 30 DEGREE ANGLE) WITH EYES HALF-CLOSED - VERY DROWSY... PUT 2 PILLS ON SPOON WITH PUDDING AND PUT IN MOUTH. RES VISIBLY SWALLOWED WITH SMALL SIP WATER. I THEN PUT 2 MORE PILLS ON SPOON AND PUT IN MOUTH TRIED TO GIVE ANOTHER SIP OF WATER... BUT RES CLENCHED MOUTH SHUT - URGED RES TO TAKE A DRINK AND PUT STRAW TO LIPS. BUT RES WAS UNRESPONSIVE TO VERBAL STIMULI... LEFT ROOM AT 17:55 (5:55 P.M.) TO GET ASSISTANCE - RETURNED WITH OTHER NURSE TO FIND RES PALE & CYANOTIC... CODE BLUE (AN EMERGENCY SYSTEM WHICH IDENTIFIES A RESIDENT IN NEED OF CPR) INITIATED AT 17:58 (5:58 P.M.)". DURING AN INTERVIEW ON [DATE] AT 8:30 A.M. WITH LPN "A", SHE STATED SHE HAD NOT USED THE CALL LIGHT IN THE ROOM OR RESIDENT'S BATHROOM, NOR HAD SHE YELLED OUT FOR HELP, TO ACTIVATE THE EMERGENCY SYSTEM; FURTHERMORE, LPN "A" CONFIRMED SHE LEFT RESIDENT #101 ALONE AFTER SHE ESTABLISHED RESIDENT #101 WAS UNRESPONSIVE. LPN "A" STATED, "WHAT YOU ARE SAYING IS RIGHT, I SHOULD HAVE NEVER LEFT HER (RESIDENT #101)... I WAS IN COMPLETE PANIC... I COULDN'T THINK STRAIGHT..." LPN "A" CONFIRMED THAT THE "CODE BLUE" WAS CALLED, BUT CPR WAS NOT INITIATED. LPN "A" STATED, "NO, (WE DID NOT INITIATE CHEST COMPRESSIONS OR RESCUE BREATHING)... WHEN CODE (BLUE) WAS CALLED I CHECKED (THE) BLOOD PRESSURE... (AND WAS) UNABLE TO OBTAIN AND NO NEVER CHECKED CAROTID PULSE... THE PULSE OX (OXIMETER) (A NONINVASIVE METHOD OF MEASURING SATURATED HEMOGLOBIN) WAS ON AND SHOWED NO PULSE OX READING OR NO PULSE... I DID A FINGER SWEEP AND FOUND NO PILLS (AFTER OTHER LICENSED STAFF ARRIVED)... THIS WAS (REGISTERED NURSE (RN) "D") SAYING SHE WAS CHOKING ON PILLS BECAUSE I DON'T BELIEVE SHE WAS... SHE HAD NO SIGNS OR SYMPTOMS OF CHOKING...(BUT) EVERYONE THOUGHT SHE WAS CHOKING... BUT NO, I NEVER SAW CPR (BEING PERFORMED) THEY WERE SUCTIONING HER (RESIDENT #101)." LPN "A" FURTHER STATED THAT CHEST COMPRESSIONS WERE NOT STARTED OR AN AIRWAY ESTABLISHED PER PROTOCOL OR ATTEMPTS AT RESCUE BREATHING. THIS SURVEYOR AND LPN "A" REVIEWED THE PROTOCOL FOR THE AHA GUIDELINES FOR CPR, COPYRIGHT 2011, AND LPN "A" CONFIRMED THE AHA PROTOCOL WAS NOT FOLLOWED. IN AN INTERVIEW WITH RN "B" ON [DATE] AT 11:30 A.M., RN "B" STATED HE WAS THE 4TH NURSE TO ARRIVE ON THE SCENE, WITH RN "I" FOLLOWING CLOSE BEHIND HIM. . LPN "P" WAS AT RESIDENT'S (#101) SIDE ASSESSING HER AND LPN "A", "WAS UPSET... WASN'T REALLY DOING ANYTHING... (RN "I") WAS REQUESTING TO SUCTION... THEY LOOKED IN THROAT (AND) TRIED TO DO A FINGER SWEEP BUT COULDN'T REACH HER PILLS... WE WERE ALL UNDER THE GUN... HIGH STRESS... WE DID WHAT WE THOUGHT WAS RIGHT TO SAVE HER LIFE... I DIDN'T NOTICE ANY (RESCUE) BREATHING... SHE HAD A FISH MOUTH... GASPING CONTINUED... BUT NO, I DIDN'T SEE ANYONE CHECK FOR A PULSE OR ASSESS RESPIRATORY STATUS... NO, I DIDN'T SEE ANY CHEST COMPRESSION UNTIL EMS (EMERGENCY MEDICAL SERVICE) CAME... SHE (RESIDENT #101) NEEDED (THE [MEDICATION NAME]) NO ONE WAS MOVING SO I STEPPED IN... YEAH SHE WAS STILL SITTING... I WENT BEHIND HER IN BED... NO, WE DID NOT LAY HER DOWN." DURING AN INTERVIEW WITH RN "I" ON [DATE] AT 4:00 P.M., RN "I" STATED NO ONE WAS PERFORMING CPR ON RESIDENT #101 WHEN SHE ARRIVED AND THAT SHE WAS THE 5TH NURSE ON SITE. RN "I" STATED, "WHEN I WALKED IN (RESIDENT #101'S) FACE WAS DUSKY... SHE (RESIDENT #101) TRIED TO TAKE GASPING BREATHS AND I ASKED IF SHE WAS CHOKING. (LPN "P") OPENED HER MOUTH AND I COULD SEE 2 LARGE PILLS AND DID A FINGER SWEEP AND COULDN'T REACH THEM... SO I SUCTIONED HER... NO, I DIDN'T ATTEMPT TO DO RESCUE BREATHING OR CARDIAC COMPRESSIONS... NO ONE MENTIONED TO GIVE HER A BREATH OR CARDIAC COMPRESSIONS... NO ONE GAVE ANY KIND OF INPUT TO ASSIST... EXCEPT (RN "B")." WHEN ASKED IF SHE WAS AWARE OF THE AHA GUIDELINES FOR CPR AND CHOKING VICTIMS SHE STATED, "I'VE BEEN TOLD, SINCE THE INCIDENT, THAT APPROPRIATE PROTOCOL WAS NOT FOLLOWED. I DID WHAT I THOUGHT I WAS TRAINED TO DO... BUT APPARENTLY IT WASN'T (APPROPRIATE CPR/CHOKING PROCEDURES)." AN INTERVIEW TOOK PLACE ON [DATE] AT 5:55 P.M. WITH RN "E". RN "E" STATED, RN "P" WAS ON THE RIGHT SIDE OF (RESIDENT #101) AND RN" I" WAS ON THE LEFT SIDE OF HER. "THEY WANTED TO SUCTION... (THE) AED WAS AT HER (RESIDENT #101'S) FEET... NO, WE DID NOT DO CPR... NO, WE DID NOT DO ANY RESCUE BREATHING OR CARDIAC COMPRESSIONS... NO, I NEVER SAW ANYONE CHECK A CAROTID PULSE - ONLY THE PULSE THAT WAS ON THE PULSE OX WHICH MAY NOT BE AN ACCURATE READING, I KNOW." THE FACILITY'S "CPR REPORT" DATED [DATE], REVEALED NO ACTION DOCUMENTED UNTIL 6:00 P.M. AT THIS TIME, THE "CPR REPORT" REVEALED THAT RESIDENT #101 WAS SUCTIONED FROM 6:00 P.M. THROUGH 6:07 P.M. WITH NO CHEST COMPRESSION, NO POSITIONING PERFORMED TO ENSURE AN OPEN AIRWAY OR RESCUE BREATHING BEING PERFORMED OR ATTEMPTED. AT 6:08 P.M., THE [MEDICATION NAME] MANEUVER WAS STARTED. THIS DOCUMENT SHOWED RESCUE BREATHING WAS INITIATED AT 6:09 P.M. WHEN EMS (EMERGENCY MEDICAL SERVICES) ARRIVED. THE "CPR REPORT" DOCUMENTED THAT "CPR STARTED BY: EMS"... AT 6:10 P.M. THE AED DEVICE WAS APPLIED AND AT 6:12 P.M., CHEST COMPRESSIONS AND RESCUE BREATHING WERE BOTH INITIATED, WHILE RESIDENT #101 WAS BEING TRANSPORTED TO THE HOSPITAL FOR EMERGENCY CARE. THE EMS REPORT (NOT TITLED) DATED [DATE], REVEALED AT 6:08 P.M., RESIDENT #101 HAD "FIXED/DILATED" PUPILS AND "ECG" (ELECTROCARDIOGRAM) SHOWED "ASYSTOLE" (FLAT LINE INDICATING [MEDICAL CONDITION] - NO HEART BEAT). ( ) --