Every finding on record at Cascade Senior Care Center

This citation pertains to intake 3055356. Based on observation, interview and record review, the facility failed to ensure staff who identified themselves as a Social Worker had the required credentials, according to State Law, for two (R2 and R5) of two reviewed. Findings include:Review of a complaint intake, received by the State Agency, reflected, .Facility worker [Staff Member (SM) F] incorrectly and fraudulently identifies herself as a licensed social worker to both other professionals, families, and patients/residents at facility. [SM F] does not have any social work degree or license. Identifying oneself or their work as social work without a degree and license is illegal . R2: Review of the medical record reflected R2 admitted to the facility on [DATE], with diagnoses that included unspecified severe protein-calorie malnutrition and hypertension (high blood pressure). According to the medical record, R2 admitted to the facility for a hospice respite stay from 3/8/26 to 3/13/26. R2 did not reside in the facility at the time of the onsite survey. A late entry Social Service Progress Note, dated 3/10/26 at 8:04 AM, reflected, SW [Social Worker] spoke with the resident as she appeared to be upset, the [sic] stated that she wanted to return home. SW informed the resident that she would be leaving on Friday [sic] 3/13/2026. Resident asked to call her family. SW spoke with the family as well . The note was authored by SM F and listed their position as Social Worker. A late entry Social Service Progress Note, dated 3/10/26 at 6:04 PM, reflected, During this encounter, resident overheard the staff laughing which made the resident feel like she was being laughed at. SW ensured the staff were not laughing at her. SW reassured family that staff were not laughing at the resident. The note was authored by SM F and listed their position as Social Worker. An Active Employee list reflected SM F was listed with the title of Social Service Designee. Documents, provided by the facility, reflected a copy of an email, which was authored by a family member of R2 on 3/11/26. The email reflected that the night prior, around 8:00 PM, they received a call from the facility's phone number, from R2. R2 was crying and experiencing emotional distress. R2 wanted to know when they were being picked up and alleged they were being made fun of. According to the email, a staff Social Worker identified herself on the call, asking for activity guidance. R5: Review of the medical record reflected R5 admitted to the facility on [DATE], with diagnoses that included unspecified cirrhosis of the liver and neuromuscular dysfunction of the bladder. The admission Minimum Data Set, with an Assessment Reference Date (ARD) of 6/6/26, reflected R5 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 7/14/26 at 9:27 AM, R5 was observed seated in a wheelchair, in their room. R5 described interactions with the Social Worker, referencing discussions pertaining to money/payments and receiving assistance with applying for Medicaid. A Social Service Progress Note, dated 6/12/26 at 10:25 AM, reflected, SW spoke with the resident regarding the discharge plan . The note was authored by SM F and listed their position as Social Worker. A Social Service Progress Note, dated 7/2/26 at 12:05 PM, reflected, SW spoke with the resident regarding the information provided for Medicaid, SW spoke with the resident that the documents needed to be obtained to proceed with the application . The note was authored by SM F and listed their position as Social Worker. In an interview on 7/15/26 at 2:20 PM, SM F identified her employment title as a Social Worker. SM F reported she did not have a Social Work license, nor did she identify herself to others as being licensed. SM F stated she introduced herself to individuals as the Social Worker at the facility. In an interview on 7/15/26 at 2:44 PM, SM G identified her employment title as Social Work Designee. SM G reported she was not licensed for Social Work and identified herself to residents, families and providers as a Social Work Designee. On 7/16/26 at 11:02 AM, SM G was observed to have the title of Social Service Designee on her name tag. SM G reported she did not have a specific resident caseload within the facility and worked together, with SM F, for facility residents. SM G described that her job duties included completing the nine-item Patient Health Questionnaire (PHQ-9/depressive symptom scale), completing the BIMS and participating in care conferences and discharge planning. On 7/16/26 at 11:08 AM, SM F was observed to have the title of Social Worker on her name tag. SM F reported she was hired as a Social Work Designee and was working towards completion of a bachelor's in social work degree. SM F described that she could assist any resident within the facility census, versus being assigned a specific caseload of residents. Her job duties included discharge planning, checking on the well-being of the residents and assisting with arranging ancillary services. SM F described assisting the MDS nurse with OBRA screening, stating she (SM F) was unable to submit them since she was not licensed. SM F stated besides assisting with OBRA, she and SM G performed the same job duties. SM F reported she had business cards with her contact information, which she could provide to residents, families and providers. Review of a business card for SM F reflected the title of Social Worker. Personnel files for SM F and SM G each included signed Position Descriptions for a Social Worker. The Position Descriptions reflected, .Knowledge/Skills/Abilities: 1. Bachelor's Degree in Social Work, or in related human services field, including but not limited to Sociology, Special Education, Rehabilitation Counseling, and Psychology; must have a minimum of a Limited License in Social Work; LBSW preferred. 2. 1+ years of supervised social work experience in a health care setting working directly with individuals . According to Michigan Legislature, Michigan Compiled Laws (MCL)- Section 333.18503, PUBLIC HEALTH CODE (EXCERPT) Act 368 of 1978, 333.18503 Representation or use of title; prohibition. Sec. 18503 . (2) Only a licensed bachelor's social worker shall use the title licensed bachelor's social worker, social worker, or l.b.s.w. Only a licensed master's social worker shall use the title licensed master's social worker, social worker, or l.m.s.w. (https://www.legislature.mi.gov/Laws/MCL?objectName=mcl-333-18503)

This citation pertains to intake numbers 3052863 and 3069687. Based on observation, interview and record review, the facility failed to ensure timely revision of the Care Plan for two (R2 and R4) of three reviewed. Findings include: R2: Review of the medical record reflected R2 admitted to the facility on [DATE], with diagnoses that included unspecified severe protein-calorie malnutrition and hypertension (high blood pressure). According to the medical record, R2 admitted to the facility for a hospice respite stay from 3/8/26 to 3/13/26. R2 did not reside in the facility at the time of the onsite survey. An Incident Report reflected R2 had a fall on 3/8/26 at 6:00 PM. According to the Incident Report, R2 slid out of their wheelchair, while attempting to self-transfer from the wheelchair to the bed. The Incident Report reflected R2 was re-educated to request assistance for transfers and how to use the call light. Additionally, the Incident Report reflected a fall mat was placed at the left side of the bed. R2's Care Plan reflected the intervention for a floor mat at the left side of the bed was initiated on 3/10/26. An Incident Report reflected R2 had an unwitnessed fall on 3/8/26 at 9:20 PM. According to the Incident Report, R2 was attempting to self-transfer from their bed to the wheelchair. The Incident Report reflected R2 was re-educated and was Care Planned for a low bed (bed in a low height from the floor). R2's Care Plan reflected the intervention for a low bed was initiated on 3/10/26. R4: Review of the medical record reflected R4 was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (stroke) due to unspecified occlusion (blockage) or stenosis (narrowing) of the left middle cerebral artery. The Admission/5-day Medicare Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/14/26, reflected R4 was coded for having short-term and long-term memory impairments. On 7/14/26 at 12:12 PM, R4 was observed seated in a wheelchair, in the dining room, receiving assistance with their lunch meal. On 7/15/26 at 8:35 AM, R4 was observed seated in a wheelchair, in their room. The right side of R4's bed was observed against the wall. An Incident Report reflected R4 had an unwitnessed fall on 5/10/26 at 1:15 PM. R4 was observed lying on their right side, on the floor, with their wheelchair behind them. R4 was unable to give of description of how they fell. An immediate intervention was not noted on the Incident Report. A Fall Assessment, dated 5/12/26, reflected Dycem (non-slip material) was placed in R4's wheelchair to prevent sliding. R4's Care Plan reflected the intervention for Dycem to the wheelchair was initiated and created on 7/14/26. An Incident Report reflected R4 had an unwitnessed fall on 5/19/26 at 7:45 PM. R4 had been observed on the floor, next to their bed. According to the Incident Report, R4's bed was placed in the lowest position (bed in a low height from the floor). R4's Care Plan reflected the intervention for a low bed was initiated and created on 7/14/26. An Incident Report reflected R4 had a fall on 5/22/26 at 11:25 AM, while participating in group therapy. R4 was lying on the dining room floor, on their right side, with the wheelchair behind them. According to the Incident Report, Therapy determined wheelchair positioning may have contributed to the fall and provided R4 with a wheelchair with a high back. R4's Care Plan reflected an intervention for stand-pivot transfers, via assistance of two people, to a high back wheelchair, was initiated and created on 5/8/26. The intervention was revised on 7/14/26. In an interview on 7/15/26 at 4:26 PM, Director of Nursing (DON) B reported that ideally, nurses would update the Care Plan at the time of a fall. DON B indicated nurses got busy, and Care Plans were not always updated at the time. According to DON B, the Interdisciplinary Team (IDT) reviewed the falls and would ensure the Care Plan was updated. In an interview on 7/16/26 at 10:59 AM, Certified Nurse Aide (CNA) I reported the Kardex (CNA Care Guide that is developed from the Care Plan) included resident care needs and safety interventions. CNA I reported they could ask nurses as well, as they had additional information.

Based on observation, interview, and record review, the facility failed to ensure tow out of two emergency (ER) crash carts (used to house CPR -Cardiopulmonary Resuscitation equipment) were checked daily and stocked with life sustaining items. Record review of an ER CART AUDIT FORM/CHECK LIST, placed on a crash cart on the Meadows Unit, and another on the Rehab/Nursing Unit, documented all the items required to be on each of the crash carts upon nursing performing a nightly check of the crash carts. The form revealed, Initial when checked at the top of the form. Observation of the Meadows Unit crash cart revealed a one-liter bag of normal saline (NS) that did not have a sticker on it, nor did it have an expiration date. Upon returning to the same crash cart at 4:00 PM for another observation revealed that the crash cart was missing the blood pressure cuff, paper, one IV (intravenous) start kit, one 1-liter bag of normal saline, and one 500 milliliters (ML) bag of 5% dextrose.Per the ER CART AUDIT FORM/CHECK LIST form there should have been paper, a blood pressure cuff, two IV start kits, two 1-liter bags of NS, and two 500 ML bags of 5% dextrose. Review of the Meadows Unit check list for the months of March and [DATE] revealed nursing staff put checkmarks next to each item on the list meaning that the items were present on the crash cart, with some nurses who used zeroes and others used the letter C, while others used an X. Additionally, for the month of April in the box where the nurse was to initial that the two 500 ML bags of 5% dextrose were on the cart, revealed for the whole month documentation of X1, without any nurse replacing the second missing bag of 5% dextrose that was required to be on the crash cart per the check list. Furthermore, all the items were marked as being present on the crash cart when in fact the above items were missing from the crash cart at the time of the observation, and the crash cart had not been used since the last check the evening before on [DATE] up to the observation. The form revealed no nurse's or staff's initials anywhere on the form, per the form's instructions, and therefore there was no way to identify who performed the checks.Observation of the crash cart on the Rehab and Nursing Units was conducted on [DATE] at 3:45 PM. The cart was observed and per the check list, did not have an oxygen tank, nonrebreather masks, or laminated policy and procedure for the use of the AED (automated external defibrillator). There was only one IV start kit, no saline flushes, or six inch IV extensions (there were supposed to be two). There were supposed to be two 1-liter bags of NS but there were none, and there was only one 500 ML bag of 5% dextrose on the cart there was supposed to be two, per the check list. Another review of the check list revealed the cart was to have one oxygen tank on it, a lamented copy of the AED policy and procedure, two IV start kits, two saline flushes, two six inch IV extensions, two 1-liter bags of NS, and two 500 ML bags of 5% dextrose. Review of the check list on [DATE], for the Rehab and Nursing Unit crash cart for the month of [DATE] revealed only on [DATE] was the crash cart checked for all items stocked. Additionally, the check list required the nurse check the AED device to assure the device was in working order and was charged. The dates of 5/2, 5/3, and [DATE] on the form revealed no initials, or marks. All the boxes were blank, which indicated the cart was not checked for all items in place and the AED device was in working order and charged. In an interview on [DATE] at 2:44 PM, the Assistant Director of Nursing (ADON) C, who was filling in for the Director of Nursing (DON) B confirmed the crash carts did not have the locks, and that nurses were to be initialing the boxes on the check list to indicate each item is on the cart. ADON C said there should be some way to determine who performed the check of the cart. ADON C said the checks were performed by the 6:00 PM to 6:00 AM shift, and stated the nurses were checking and initialing that each item was on the cart and that nothing was expired. ADON C said if an item was missing or expired it was expected that the nurse replace the item(s) at that time. Review of the facility policy and procedure titled, EMERGENCY CART dated [DATE], and revised on [DATE] revealed that this policy did not match the type of crash carts the facility had. The policy did reveal that the supply list was to be on the cart along with the AED policy and procedure. The policy also revealed at #5 It is the responsibility of nursing to visually verify each Emergency cart daily and document on ER cart audit form/ check list that a check has been completed. However, this policy speaks to a lock with a number on it that secures the crash cart, and the lock will be broken for a complete audit to be done of the entire emergency cart to assure correct contents, function of oxygen tank and suction machine, cleanliness of cart and contents, and relock/reseal the cart. The crash carts that were observed did not have the secured locks with numbers on them.

Based on interview and record review, the facility failed to safely transfer one (R200) of three residents reviewed, resulting in an injury.Findings include: Review of the clinical record revealed R200 was admitted into the facility on [DATE] with diagnoses that included: malnutrition, postprocedural complications and disorders of digestive system and had an abdominal surgical wound present. According to the Minimum Data Set (MDS) assessment dated [DATE], R200 scored 13/15 on the Brief Interview for Mental Status exam (which indicated intact cognition).In a telephone interview with Family Member K on 2/5/26 at 8:31 AM, it was reported that R200 sustained 2 skin tears while being transferred back into bed on 12/22/25 and continued to require at home wound care services for them. A review of incident report for R200, dated 12/22/25, revealed the following:Nursing description: Resident noted to have skin tears to her bilateral calves on the lateral aspects of each leg. Resident reports feeling some mild pain in her lower legs after transferring with an EZ stand (a medical mobility aid designed to help people who have trouble standing up on their own) and an aide to the bathroom and back, but due to poor eyesight she was unable to give a clear description of what happened.Resident description: Resident stated I felt the backs of my legs pushing against the bedframe when they were putting me back in bed, and I felt my legs kinda pinched and hurt. Then when I was lying down I could feel something wet under them all of a sudden and they hurt even more. Predisposing Situation Factors: During transfer, Mechanical lift in useImmediate Action Taken: Wounds cleansed and pictured, then covered and bandaged. Treatment orders put into place and daughter notified via phone.On 2/5/26 at 10:14 AM, during an interview with Director of Nursing (DON), it was reported that R200 was being transferred back to bed from the bathroom, by CNA F, using an EZ stand, R200 complained of pain and was bleeding. R200 reported to the DON that when her legs were pushed back to the bed they were pinched. DON reported it was believed that the injury was from loose skin being pinched between the bed frame and EZ stand. It was reported that R200 required 2 people for transfers and that the second person in the room (who was unnamed) was not assisting in the transfer but gathering supplies. DON reported that verbal education was provided to CNA F regarding the importance of the second person for safe transfers, second person is to be used as a spotter and cannot be in the room doing other things. On 2/5/26 at 12:29 PM, during a telephone interview with CNA F, it was reported that on 12/22/25 while caring for R200, CNA F had transferred resident by herself, having R200 pivot from the wheelchair back to the bed. Upon getting back into bed R200 reported that CNA F hurt her leg. CNA F apologized to resident and during her next brief changed discovered both her legs were cut. CNA F reported that she believed the resident was a one person assist at the time and that an EZ stand was not used. A review of R200's care plan revealed Ambulation: non-ambulatory.transfer: 2 PA using 2WW (wheeled walker)A review of R200's physician orders revealed an order with a start date of 12/11/25 (discontinued on 1/5/26) Transfers: 2PA (person assist) EZ stand

Based on interview and record review, the facility failed to provide assistance with Activities of Daily Living for one resident (R200) of three dependent residents reviewed.Findings include:Review of the clinical record revealed R200 was admitted into the facility on [DATE] with diagnoses that included: malnutrition, postprocedural complications and disorders of digestive system and had an abdominal surgical wound present. According to the Minimum Data Set (MDS) assessment dated [DATE], R200 scored 13/15 on the Brief Interview for Mental Status exam (which indicated intact cognition). In a telephone interview with Family Member K on 2/05/26 at 8:31 AM, it was reported that R200 did not receive assistance getting showers while in the facility and was often found to be soiled with urine and not cleaned up for the day.A review of the shower logs for R200, provided by the facility revealed R200 did not receive a shower or bed bath until 12/22/25, 11 days after her admission. A review of R200's progress notes did not reveal any refusals during that time.In an interview with Director of Nursing (DON), on 2/05/2026 at 10:14 AM, it was reported that the expectation for resident showers is that they take place twice a week and refusals are documented in the electronic medical record. No explanation was provided for the lack of showers for 11 days for post-surgical resident, R200.

Based on observation, interview, and record review, the facility failed to consistently use required Personal Protective Equipment (PPE).Findings include:On 2/4/26 at approximately 10 am, Regional Clinical Director A reported that surgical masks were being worn throughout the building due to multiple cases of nausea and vomiting.Review of the clinical record revealed R202 was admitted into the facility on 3/5/25 with diagnoses that included: malnutrition and Type 2 Diabetes Mellitus. According to the Minimum Data Set (MDS) assessment dated [DATE], R202 scored 12/15 on the Brief Interview for Mental Status exam (which indicated moderately impaired cognition).On 2/4/26 at 12:35 PM, a contact precaution sign was observed on the exterior of R202's room door, Certified Nursing Assistant (CNA) D was observed entering then exiting R202's room with only a surgical mask on. On 2/4/26 at 12:37 PM CNA D and CNA C were both observed entering R202's room with only a surgical mask on. On 2/4/26 at 12:39 PM CNA C exited R202's room. Upon exit CNA C was asked what contact precautions mean, they replied they should have gowned up (donned a gown and gloves prior to entering). CNA C confirmed that neither herself nor CNA D donned the required gown/gloves prior to entering R202's room.On 2/4/26 at 2:06 PM, a PPE cart was observed in close proximity to R202's room, it did not contain any gloves. When asked where I could find gloves, CNA B retrieved gloves from another resident room.On 2/4/26 at 2:08 PM R202 was observed sitting up in a manual wheelchair, a small decorative trash can without a lid was observed close to the door, no discarded PPE observed. When asked if staff wear a gown and gloves upon entering her room R202 reported they do not wear a gown but normally wear gloves.On 2/4/26 at 2:29 PM, Laundry Aide E was observed entering 4 resident rooms without any hand hygiene and only a surgical mask on, then entered a resident room with a Contact precautions sign on the door. No additional PPE was donned. Upon exit Laundry Aide E was asked what Contact precautions meant, she reported that she normally just goes in and out with clean laundry (no gown or gloves).On 2/5/26 at 3:57 PM, during an interview with Corporate Infection Control G, it was reported that the expectation is for all staff that enter a room with Contact precautions to don a gown and gloves.A review of R202's physician orders revealed an order dated 2/2/26 through 2/5/26 which read Transmission Based Precautions: Contact, every shift for diarrheaA review of the facilities policy titled Transmission-Based Precautions, documented in part Contact precautions.Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment.Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens.

This citation pertains to intake #2682852Based on observation, interview, and record review the facility failed to maintain required dialysis coordination and communication documentation for two (Resident #20 and Resident #40) out of three reviewed for dialysis. Findings include:Resident #20Review of the medical record reflected Resident #20 (R20) was admitted to the facility on [DATE] with diagnoses that included end-stage renal disease dependent on dialysis and disorder of phosphorus metabolism. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/28/25, reflected R20 scored 13 out of 15, indicating cognitive intactness, on the Brief Interview for Mental Status (BIMS), a cognitive screening tool. R20 no longer resided in the facility.Review of R20's physician orders revealed an active order for transport to dialysis on Tuesday, Thursday, and Saturday. An additional order instructed staff to notify the physician of missed dialysis appointments and obtain R20's weight.According to the dialysis center, Dialysis Employee (DE) F confirmed R20 attended dialysis on Tuesday, November 25th, and Wednesday, November 26th. No dialysis communication forms were located in the medical record, and no staff were able to explain or justify why R20's dialysis days were altered from the ordered schedule. DE F further confirmed the dialysis center was open on Thursday, November 27th. No documentation of physician notification or weights related to missed or altered dialysis appointments was located in R20's medical record. Resident #40Review of the medical record reflected R40 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included end stage renal disease and dependance on renal dialysis. On 12/29/25 at 10:48 PM, R40 was observed in his room seated in his recliner. R40 was interview able and answered questions appropriately. R40 stated that he had been transferred to dialysis, but his schedule had been altered recently and was unsure why. Review of R20's physician orders revealed an active order for transport to dialysis on Tuesday, Thursday, and Saturday. An additional order instructed staff to notify the physician of missed dialysis appointments and obtain R40's weight.Review of R40's medical record revealed that R40 attended dialysis on Saturday, November 22nd however, was not able to complete the dialysis because the facility neglected to send R40 with the Hoyer sling, which is required to transfer the resident with the mechanical lift at the dialysis center.Review of the medical record revealed no documentation that the Physician was notified and no documentation that a weight was obtained. According to the Dialysis employee, DE F, R40 attended dialysis on Tuesday, November 25th and Friday November 28th. R40 did not attend dialysis on his dialysis day of Saturday, November 29th. No dialysis communication forms were located in the medical record, and no staff were able to explain or justify why R40's dialysis days were altered from the ordered schedule. DE F further confirmed the dialysis center was open on Thursday, November 27th. No documentation of physician notification or weights related to missed or altered dialysis appointments was located in R40's medical record.During an interview on 12/20/25 at 11:27 AM, the Director of Nursing (DON) B stated dialysis communication forms for R20 and R40 could not be located and acknowledged the facility was working to improve the dialysis communication process.

This citation pertains to intake #2682852 Based on interview and record review, the facility failed to ensure accurate documentation for one (Resident #20) of three reviewed for accurate medical records. Findings include:Review of the medical record reflected Resident (R20) was admitted to the facility on [DATE] with diagnoses that included end-stage renal disease dependent on dialysis and disorder of phosphorus metabolism. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/28/25, reflected R20 scored 13 out of 15, indicating cognitive intactness, on the Brief Interview for Mental Status (BIMS), a cognitive screening tool. R20 no longer resided in the facility.Review of the physician's orders revealed Sevelamer HCl Oral Tablet 800 milligrams, three tablets by mouth three times daily with meals for chronic kidney disease. Sevelamer is used to treat hyperphosphatemia (excess phosphate in the blood) in patients with chronic kidney disease who are on dialysis. The order was active from the time of admission on [DATE] through discharge on [DATE].Review of the November Medication Administration Record (MAR) revealed the Sevelamer HCl Oral Tablet 800 milligrams was marked as OS (see nurses' note) for two of the three doses on 11/22/25 and 11/23/25. The 5:00 PM dose was marked as administered on both dates.Further review of the MAR reflected all three doses of Sevelamer HCl Oral Tablet 800 milligrams were marked as OS on 11/24/25.Review of the MAR revealed Sevelamer HCl Oral Tablet 800 milligrams was marked as OS for two of the three doses on 11/25/25, with the 5:00 PM dose marked as administered.Review of the MAR reflected all three doses were marked as OS on 11/26/25.Review of the MAR revealed Sevelamer HCl Oral Tablet 800 milligrams was marked as OS for one of the three doses on 11/27/25, with the 8:00 AM and 12:00 PM doses marked as administered.Review of the MAR reflected two doses of Sevelamer HCl Oral Tablet 800 milligrams were marked as administered on 11/28/25.Review of the nurses' notes for the aforementioned dates consistently stated Medication not available.During an interview on 12/29/25 at 1:33 PM, Family Member (FM) I stated that R20 was supposed to receive Sevelamer HCl three times daily. FM I stated it was brought to her attention by the facility on 11/27/25 that R20 had not received a single dose of the ordered Sevelamer since admission. FM I reported being told by the former Director of Nursing that the medication could not be delivered by the pharmacy. FM I further stated that after a phone call, the medication was located at a local pharmacy and was available for pickup the same day.During an interview on 12/30/25 at 11:27 AM, the Director of Nursing (DON) B stated the facility experienced difficulty obtaining Sevelamer. DON B stated the family raised concerns regarding the medication's availability, after which the Nursing Home Administrator contacted a local pharmacy and was able to obtain the medication that day. DON B stated he reviewed the medication cart on 11/28/25 and verified the medication was not in the facility and had not been in-house at any point during R20's admission. R20 was transferred to the local hospital on the afternoon of 11/28/25 due to a change in condition. DON B confirmed the doses of Sevelamer marked as administered on the MAR were not accurate, as the medication was never available in the facility. DON B stated an investigation was initiated regarding falsification of the MAR, and the staff involved received education.According to the National Center for Biotechnology Information (NCBI), missing doses of Sevelamer, particularly when combined with poor nutritional intake, is likely to worsen metabolic balance, which may contribute to increased confusion and lethargy.

This citation pertains to intake #2682852Based on observation, interview, and record review the facility failed to 1) ensure proper medication management, 2) accurate documentation, 3) recognize a change in condition and 4) adherence to physician orders for two (Resident #20, Resident #40) in three reviewed for quality of care. Findings include: Resident #20Review of the medical record reflected Resident #20 (R20) was admitted to the facility on [DATE] with diagnoses that included end-stage renal disease dependent on dialysis and disorder of phosphorus metabolism. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/28/25, reflected R20 scored 13 out of 15, indicating cognitive intactness, on the Brief Interview for Mental Status (BIMS), a cognitive screening tool. R20 no longer resided in the facility.Review of R20's physician orders revealed an active order for transport to dialysis on Tuesday, Thursday, and Saturday. An additional order instructed staff to notify the physician of missed dialysis appointments and obtain R20's weight.According to the dialysis center, Dialysis Employee (DE) F confirmed R20 attended dialysis on Tuesday, November 25th, and Wednesday, November 26th. No dialysis communication forms were located in the medical record, and no staff were able to explain or justify why R20's dialysis days were altered from the ordered schedule. DE F further confirmed the dialysis center was open on Thursday, November 27th. No documentation of physician notification or weights related to missed or altered dialysis appointments was located in R20's medical record.Review of the Discharge summary dated [DATE] documented R20's weight as 229 pounds.Review of the Speech Therapy evaluation dated 11/17/25 noted R20 had poor oral intake and included instructions to monitor intake. R20 was recommended a general renal diet with thin liquids, with a goal to consume 75% (percent) or greater of meals.Review of the Food Acceptance Record revealed 20 documented meal opportunities, all of which indicated R20 consumed less than 75% of meals, with the majority reflecting 0-25% consumption. No documentation was found indicating snacks or meal alternatives were offered.Review of R20's medical record revealed no Registered Dietician consultation or progress notes during the admission.Further review of weight documentation revealed only one weight was obtained during the admission, recorded on 11/26/25 at 214 pounds, reflecting a 15-pound weight loss. There was no documentation addressing the cause of the weight loss or interventions implemented to prevent further decline.Review of physician orders revealed Sevelamer HCl Oral Tablet 800 milligrams, three tablets by mouth three times daily with meals for chronic kidney disease. Sevelamer is used to treat hyperphosphatemia in patients with chronic kidney disease on dialysis. The order was active from 11/22/25 through discharge on [DATE].Review of the November Medication Administration Record (MAR) revealed the following: on 11/22/25 and 11/23/25, two of three doses were marked as OS (see nurses' note), with the 5:00 PM dose marked as administered. On 11/24/25, all three doses were marked as OS. On 11/25/25, two of three doses were marked as OS, with the 5:00 PM dose marked as administered. On 11/26/25, all three doses were marked as OS. On 11/27/25, one of three doses was marked as OS, with the 8:00 AM and 12:00 PM doses marked as administered, and on 11/28/25, two doses were marked as administered.Nurses' notes for the above dates consistently stated, Medication not available.During an interview on 12/29/25 at 1:33 PM, Family Member (FM) I stated R20 was supposed to receive Sevelamer HCl three times daily. FM I reported being informed by the facility on 11/27/25 that R20 had not received a single dose of the medication since admission. FM I stated the former Director of Nursing reported the medication could not be delivered by the pharmacy however, after a phone call, the medication was located at a local pharmacy and available for pickup the same day.FM I further stated R20 experienced chewing and swallowing difficulties, increased confusion, and changes in mood, including depressive symptoms. FM I observed pocketed food in R20's mouth on more than one occasion and reported these concerns to the facility. FM I stated no actions were taken in response to these concerns.Review of hospital documentation dated 11/28/25-12/4/25 revealed R20 reported difficulty eating and described a clogged feeling in his throat. Hospital records also indicated R20 was admitted with skin breakdown on his buttocks, which was not present in any facility skin assessments.During an interview on 12/20/25 at 11:27 AM, the Director of Nursing (DON) B stated the facility had difficulty obtaining Sevelamer. DON B confirmed the medication was never in-house during R20's admission and acknowledged the MAR entries indicating administration were not accurate. DON B stated an investigation was initiated regarding falsification of the MAR, and staff received education. DON B further stated dialysis communication forms for R20 could not be located and acknowledged the facility was working to improve the dialysis communication process. DON B stated the facility did not have a Registered Dietician during R20's admission, accounting for the lack of nutritional oversight. R20 was transferred to the local hospital on [DATE] due to a change in condition.Review of R20's medical record revealed the Social Services assessment was dated 12/1/25, after R20 had already been discharged . The assessment documented that the family reported R20 was not feeling well and that R20 expressed feelings of depression related to declining health.Further review revealed Social Services did not complete required assessments, including the initial assessment, BIMS, and PHQ-9, until the day R20 was transferred to the hospital.During an interview on 12/30/25, Social Worker (SW) H stated Social Services assessments are expected to be completed within 24 hours of admission. SW H stated she attempted to assess R20 but found him lethargic and was unable to complete the assessments. SW H acknowledged she did not notify nursing staff of R20's lethargy. No documentation of assessment attempts was located in the medical record. Family interviews and hospital records indicated R20 was alert and able to communicate his needs.According to the National Center for Biotechnology Information, missing doses of Sevelamer, particularly when combined with poor nutritional intake, may worsen metabolic balance and contribute to increased confusion and lethargy. Resident #40Review of the medical record reflected R40 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included end stage renal disease and dependance on renal dialysis. On 12/29/25 at 10:48 PM, R40 was observed in his room seated in his recliner. R40 was interview able and answered questions appropriately. R40 stated that he had been transferred to dialysis, but his schedule had been altered recently and was unsure why. Review of R20's physician orders revealed an active order for transport to dialysis on Tuesday, Thursday, and Saturday. An additional order instructed staff to notify the physician of missed dialysis appointments and obtain R40's weight.Review of R40's medical record revealed that R40 attended dialysis on Saturday, November 22nd however, was not able to complete the dialysis because the facility neglected to send R40 with the Hoyer sling, which is required to transfer the resident with the mechanical lift at the dialysis center.Review of the medical record revealed no documentation that the Physician was notified and no documentation that a weight was obtained. According to the Dialysis employee, DE F, R40 attended dialysis on Tuesday, November 25th and Friday November 28th. R40 did not attend dialysis on his dialysis day of Saturday, November 29th. No dialysis communication forms were located in the medical record, and no staff were able to explain or justify why R40's dialysis days were altered from the ordered schedule. DE F further confirmed the dialysis center was open on Thursday, November 27th. No documentation of physician notification or weights related to missed or altered dialysis appointments was located in R40's medical record.

This citation pertains to intake #2698300 Based on observation, interview, and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act.Findings Include: Review of the medical record reflected R10 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease. The Minimum Data Set (MDS) reflected R10 scored 5 out of 15 (severe impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the medical record reflected R30 was admitted to the facility on [DATE], with diagnoses that included Unspecified dementia. The Minimum Data Set (MDS) reflected R30 scored 9 out of 15 (moderately impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). According to the Facility Reported Incident Report, R30 was observed grabbing R10's foot. R30 was redirected and provided bathroom assistance. During care, R30 began shouting that a staff member was attempting to rape her. Care was immediately stopped following the allegation. R30 remained fully clothed during the allegation. Both residents were assessed for injury, no injury noted. Law enforcement responded, however, was unable to obtain a statement due to residents being unable to recall the event. Review of the Facility Reported Incident Report revealed that the incident occurred on 12/4/25 at 11:00AM, and was discovered on 12/4/25 at 12:30 PM, however, the incident wasn't reported to the State Agency until 12/4/25 at 5:02 PM, past the 2-hour reporting guideline. In an interview on 12/30/25 at 11:54 am covering Nursing Home Administrator A stated that abuse allegations needed to be reported to the State Agency immediately but no longer than two hours.

Based on interview and record review, the facility failed to assess and monitor respiratory status for one (R51) of one reviewed, resulting in R51 being discovered unresponsive and pronounced deceased . Findings include: A Progress Note for [DATE] at 11:58 PM reflected R51 arrived to the facility, from the hospital, via ambulance, at 11:10 PM. The ambulance company reported R51 was hypoxic (low oxygen level), with an oxygen saturation level in the 70's. The note further reflected the ambulance company applied a non-rebreather mask (delivers high concentrations of oxygen) and gave instructions to begin BiPAP (Bilevel Positive Airway Pressure/machine that helps breathing) upon arrival to the facility. BiPAP was initiated with four liters of oxygen per minute. R51's oxygen saturation remained in the 70's, and their respiratory rate was 30 breaths per minute. R51's oxygen was increased to ten liters per minute. Their oxygen saturation increased to 82 percent (%), their respiratory rate was 34 breaths per minute, and they were using their accessory muscles to breathe. The note reflected R51 was unable to converse due to increased work of breathing. The provider was notified, and R51 was transferred back to the hospital at 11:50 PM. Review of the medical record reflected R51 admitted to the facility on [DATE], with diagnoses that included respiratory failure with hypercapnia (high levels of carbon dioxide in the blood), chronic obstructive pulmonary disease, obstructive sleep apnea, type 2 diabetes and heart failure. The 5-day Medicare Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], reflected R51 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). According to the MDS history, R51 died in the facility on [DATE]. A Progress Note for [DATE] at 10:38 PM reflected R51 was admitted to the facility at 3:30 PM with stable vital signs. R51 was receiving four liters of oxygen per minute and did not have respiratory distress, coughing, wheezing or shortness of breath. A Progress Note for [DATE] at 9:09 AM reflected, the nurse was alerted to a full arrest on the rehab unit. The note reflected R51 was in a supine position (lying on back, face up), with oxygen via nasal cannula in place. According to the note, lividity (bluish-purple discoloration of skin after death) was present. The note reflected R51's mouth, finger tips, stomach and extremities (arms/legs) were purple. Upon arrival of the ambulance and Fire Department, asystole (type of cardiac arrest when the heart stops beating entirely) was present on the cardiac monitor, according to the note. A Progress Note for [DATE] at 10:05 AM further reflected when the nurse responded to notification of R51's full arrest, R51 was cold to the touch, was not breathing and did not have a pulse. Rigor mortis was present in R51's jaw, according to the note. A Progress Note for [DATE] at 11:17 AM reflected that at 7:00 AM, a Registered Nurse (RN) was informed by a Certified Nurse Aide (CNA) that R51 requested their CPAP (Continuous Positive Airway Pressure/machine that delivers continuous air through the mouth and/or nose to help keep airway open during sleep) machine be removed. According to the note, the CNA assisted with removal and placed oxygen on R51. The RN asked the CNA to check R51's oxygen saturation, which was 90%. The RN responded to R51's room at 8:05 AM and noted R51 in a supine position. R51's fingers and nails were purple. The note reflected R51 had dependent lividity to the face and upper and lower extremities. R51 had rigor mortis in the jaw, was cold to touch, was not breathing and did not have a heartbeat. R51 was pronounced deceased at 8:07 AM. A Progress Note for [DATE] at 12:35 PM reflected a late entry note for time correction. The note reflected the RN responded to R51's room at 8:15 AM, and R51 was pronounced deceased at 8:17 AM. During a phone interview on [DATE] at 9:13 AM, Licensed Practical Nurse (LPN) G reported working 6:00 AM to 2:00 PM on [DATE] and receiving report on R51. LPN G reported their first time seeing R51 was around 8:00 AM, when they were noted unresponsive. LPN G described they had exited the room of another resident and were walking by R51's room, which was dark. LPN G turned on R51's light and observed them to be blue and purple in color. LPN G yelled for the crash cart and checked for R51's pulse. R51 did not have a pulse, was cold to touch and had lividity to her entire lower body, according to LPN G. LPN G reported R51 had oxygen in place, but she was uncertain of the oxygen liter flow. LPN G also noted that there was a CPAP in R51's room. The crash cart was brought to the room, and two additional nurses responded. When asked if she knew the last time anyone saw R51 prior to being noted unresponsive, LPN G stated she heard that another nurse and CNA had gone in and were responding to a breathing issue for R51, but she was unsure of the details of that issue. During a phone interview on [DATE] at 9:42 AM, CNA D reported responding to R51's call light, around 7:00 AM, for a request to assist with turning R51's CPAP machine off and providing the nasal cannula, which was out of R51's reach. CNA D stated R51 was requesting oxygen because the CPAP was not helping them breathe. CNA D reported turning the oxygen concentrator on, but she was unsure what the oxygen liter flow was set to at the time of the interview. CNA D stated there was air coming out of the nasal cannula when providing it to R51. CNA D reported notifying a midnight nurse that R51 seemed coherent and used their call light, stating they were struggling to breathe. Approximately ten minutes after having oxygen in place, R51's oxygen saturation was 90% to 91%, and R51 did not indicate any struggles or complaints, according to CNA D. She reported R51's room was dark, so she was unable to see R51's color but did not notice R51 being short of breath when talking. A Physician's Order, dated [DATE], reflected R51 was to receive four liters of oxygen per minute, via nasal cannula, every shift. Review of R51's medical record did not reflect orders for the use of CPAP or BiPAP. The admission nursing respiratory assessment did not indicate the use of CPAP or BiPAP, however a list of personal belongings in R51's medical record reflected R51 had a CPAP machine. In an interview on [DATE] at 11:05 AM, RN E reported working 10:00 PM to 6:30 AM ([DATE] to [DATE]) but was not R51's assigned nurse for the shift. CNA D came to her, stating R51 had a CPAP on but was stating they felt they could not breathe. R51's CPAP was removed, and oxygen was applied. RN E asked for R51's oxygen saturation to be checked, which was reported by the CNA to be 91%, around 7:00 AM to 7:10 AM. RN E reported staying late to document, and around 8:10 AM, LPN G called for the crash cart. RN E went to assist, and 911 was immediately contacted. Upon arrival to the room, RN E noted that R51 was in bed with oxygen via nasal cannula in place and was unsure of the liter flow without looking (in the medical record). RN E stated R51 had dependent lividity, purple fingernails and purple skin. Upon checking R51's airway, rigor mortis was noted to their jaw. RN E reported R51's death was called. When Emergency Medical Services (EMS) arrived, R51 was flat lined (asystole) on the cardiac monitor. Review of the medical record did not reflect that R51 had been assessed by a licensed nurse after report of difficulty breathing on the morning of [DATE]. Review of R51's [DATE] Medication Administration Record (MAR) reflected an order, dated [DATE], for two puffs of Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) micrograms per actuation (mcg/act) to be inhaled orally, every six hours, as needed, for wheezing or shortness of breath. The medication was not documented as being administered. R51's [DATE] MAR reflected an order, dated [DATE], for Ipratropium-Albuterol Inhalation Solution 0XXX,d+[DATE].5 milligrams per three milliliters (mg/3 mL) to be inhaled orally, every six hours, as needed, for wheezing or shortness of breath. The medication was not documented as being administered. In an interview on [DATE] at 1:48 PM, Regional Clinical Director (RCD) I reported reviewing staff statements, speaking with some of the nurses, reviewing R51's medical record and ensuring the RN on duty followed the facility's policy on Cardiopulmonary Resuscitation (CPR). RCD I was not aware of anything clinically acute occurring prior to R51 being noted unresponsive. RCD I acknowledged that there should have been a follow-up assessment by a nurse after R51 reported difficulty breathing. On [DATE] at 2:26 PM, RCD I reported R51 admitted with a BiPAP, from the hospital, which would have already had R51's settings programmed.

This citation pertains to intake MI00150737. Based on observation, interview and record review, the facility failed to ensure call lights were responded to in a timely manner for five (R24, R26, R37, R42 and R43), from a census of 54 residents. Findings include: Resident #37 (R37): Review of the medical record reflected R37 admitted to the facility 12/20/23 and readmitted [DATE], with diagnoses that included type 2 diabetes. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/10/25, reflected R37 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 06/02/25 at 3:41 PM, R37 was observed seated in a recliner, in their room. Approximately three times per week, on third shift, they waited about 30 minutes for staff to answer their call light to use the urinal. On first and second shift, they waited 15 to 30 minutes to get out of bed. R37 reported the facility was understaffed and did they best they could. Reports for call light response times for R37's room, dated 5/5/25 to 6/4/25 at 10:48 AM, reflected their call light was on for greater than 20 minutes a total of 47 times. The same report reflected a call light response time up to 39 minutes and 16 seconds on 5/18/25. Resident #24 (R24): Review of the medical record reflected R24 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included type 2 diabetes, muscle weakness and need for assistance with personal care. The Quarterly MDS, with an ARD of 5/9/25, reflected R24 scored 12 out of 15 (moderate cognitive impairment) on the BIMS. On 06/02/25 at 3:53 PM, R24 was observed seated in a wheelchair, in their room. R24 reported generally, call light response times were 15 to 30 minutes, on day shift, to get assistance to the bathroom. Once in a while, R24 had episodes of incontinence as a result, per their report. Reports for call light response times for R24, dated 5/5/25 to 6/4/25 at 10:30 AM, reflected R24's call light was on for greater than 20 minutes a total of 14 times. The same report reflected a call light response time up to 35 minutes and 20 seconds on 6/1/25. Resident #42 (R42): Review of the medical record reflected R42 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included heart failure. The Quarterly MDS, with an ARD of 5/20/25, reflected R42 scored nine out of 15 (moderate cognitive impairment) on the BIMS. On 06/02/25 at 12:45 PM, R42 was observed seated in a wheelchair, in their room. According to R42, they experienced extended call light wait times from 40 minutes to two hours for staff assistance. Reports for call light response times for R42, dated 5/5/25 to 6/4/25 at 9:44 AM, reflected R42's call light was on for greater than 20 minutes a total of 15 times. The same report reflected a call light response time up to 35 minutes and 20 seconds on 5/7/25. Resident #43 (R43): Review of the medical record reflected R43 admitted to the facility on [DATE], with diagnoses that included peripheral vascular disease and adult failure to thrive. The Quarterly MDS, with an ARD of 3/15/25, reflected R43 scored 13 out of 15 (cognitively intact) on the BIMS. On 06/02/25 at 12:45 PM, R43 was observed in their room, seated in their wheelchair. According to R43, they experienced extended call light wait times from 40 minutes to two hours for staff assistance. Reports for call light response times for R43, dated 5/5/25 to 6/4/25 at 9:44 AM, reflected R43's call light was on for greater than 20 minutes a total of six times. The same report reflected a call light response time up to 37 minutes and 41 seconds on 6/1/25. Resident #26 (R26): Review of the medical record reflected R26 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included end stage renal disease and dependence on renal dialysis. The Admission MDS, with an ARD of 4/2/25, reflected R26 scored 10 out of 15 (moderate cognitive impairment) on the BIMS. On 06/02/25 at 11:54 AM, R26 was observed in their room, seated in a recliner. R26 expressed that at times, their call light was answered in five to ten minutes, and at other times, it took an hour for staff to respond. R26 stated sometimes staff would have to leave their room to get something and would not return. R26 reported issues seemed more problematic at shift change times. Reports for call light response times, dated 5/5/25 to 6/4/25 at 10:34 AM, reflected R26's call light was on for greater than 20 minutes a total of 17 times. The same report reflected a call light response time up to 33 minutes and 6 seconds on 5/29/25. In an interview on 06/04/25 at 1:42 PM, Nursing Home Administrator (NHA) A reported being aware of concerns/complaints pertaining to extended call light response times, and the facility was actively attempting to improve response times. NHA A reported the goal was to answer a call light within 10 minutes, and staff were educated not to turn the call light off until the resident's need had been met.

Based on observation, interview, and record review the facility failed to ensure proper medication storage of medications for two residents (#2, #3) out of 54 current residents residing at the facility and failed to label mediation in accordance with accepted professional standards, dating of open multi-dose medication, observed in one medication room out of three medication rooms reviewed. Findings included: Resident #3 (R3): Review of the medical record demonstrated R3 was admitted to the facility 04/04/2025 with diagnoses that included cellulitis (bacterial infection) of left lower limb, psoriasis (condition in which skin cells build up and form scales and itchy, dry patches) , type 2 diabetes, atrial fibrillation, atherosclerotic heart disease (build-up of fats in artery walls), hypertension, sleep apnea, asthma, hypothyroidism (low thyroid hormone), glaucoma (group of eye conditions that damage the optic nerve), fibromyalgia (wide spread musculoskeletal pain) , irritable bowel syndrome, sepsis (condition resulting in extreme response to infection), pneumonia, depression, and chronic obstructive pulmonary disease (COPD). Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/10/2025, revealed R3 had a Brief Interview for Mental Status (BIMS) of 15 (intact cognition) out of 15. During observation and interview on 06/02/2025 at 11:38 a.m. R3 was observed sitting up in her recliner at the bedside. Trelegy 100mcg(micrograms)/62.5mcg/25mcg inhaler and Azelastine 0.1% nasal solution was observed to be sitting on her over bed table. R3 explained that she is allowed to take those medications without the nurse present. Review of R3's medical record had not revealed a physician order for self-administration of medication. R'3s medical record had not revealed a self-administration of medication assessment. R'3s plan of care had not revealed a self-administration of medication plan of care. In an interview on 06/04/2024 at 08:57 a.m. Director of Nursing (DON) B explained that it was facility policy and practice that residents could keep medication in their room and perform self-administration. DON B explained that residents must be assessed for self-administration prior to medication being left in the room and prior to self-administrated. DON B explained if the resident is assessed as safe a physician order would be obtained, resident plan of care would be updated, and lock box would be provide to the resents for storage of the medication in the resident's room. DON B reviewed R3's medical record and could not demonstrate that R3 had a self-administration assessment completed, a self-administration plan of care, or a physician order for self-administration of medication. DON B could not explain why R3 had been observed with medication at R3's bedside. During review of medication storage room on 06/04/2025 at 01:18p.m., it was observed in Rehabilitation Medication Room refrigerator an opened multi-dose 1 ml (milter) vial of Tuberculin 5 tu (tuberculin unit)/0.1ml that was not dated when the tuberculin had been opened. During an interview on 06/04/2025 at 01:20 p.m. Licensed Practical Nurse (LPN) T explained that the multi-dose vial of tuberculin should have been dated when opened. LPN T explained that multi-dose vial of tuberculin will be disposed of appropriately and would not be used for residents. In an interview on 06/04/2025 at 02:04 p.m. Regional Clinical Director of Clinical Services I explained that it was professional practice to date all multi-use medical at the time that the medication container was opened. 34705 Resident #2 (R2): Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R2 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease and depression. The MDS reflected R2 had a BIM (assessment tool) score of 14 which indicated her ability to make daily decisions was cognitively intact. During an observation and interview on 06/02/25 a 11:58 AM R2 was laying in bed with two medications sitting on the bedside table, dulera inhaler 100mcg/5mcg and fluticasone nasal spray 50mcg. R2 reported the nurse had brought them in earlier and did not administer to R2 and left the room. R2 reported does not take medication on own. During an interview on 6/04/25 at 8:58 AM, Director of Nursing (DON) B reported had been in position at facility for about three months. DON B reported residents should not have medications at the bedside unless they have been assessed to self administer medications. DON B reported R2 had not been assessed to self administer medication, no physician order to self administer and was not care planned for self administration of medications. DON B reported resident medication should be locked in medication carts.

During observation, interview, and record review the facility failed to provide failed to provide meaningful, individualized activities for one resident (#49) of one resident reviewed for activities. Findings included: Resident #49 (R49) Review of the medical record demonstrated R49 was admitted to the facility 04/16/2025 with diagnoses that included fracture of right tibia (the larger of the two bones in the lower leg), infection at surgical site, cellulitis (bacterial infection) of left upper limb, chronic pain, osteoarthritis (degenerative joint) of right knee and right hip, hypertension, atrial fibrillation, malnutrition, depression, prediabetes, gastro-esophageal reflux, neurocognitive disorder with Lewy Bodies (Lewy Body Dementia), anxiety, and schizoaffective disorder. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/22/2025, revealed R49 had a Brief Interview for Mental Status (BIMS) of 10 (moderate cognitive impairment) out of 15. During observation and interview on 06/02/2025 at 11:26 a.m. R49 was observed sitting up in a recliner chair at bedside. R49 explained that she was bored at the facility. It was inquired of R49 if the facility provided her with an activity calendar with activities that she could possibly attend. R49 explained that she was unaware of any Calander of activity programs. No activity Calander was observed posted in R49's room. Review of R49's medical record did not reveal any listed plan of care demonstrating what activity programs R49 may have been interested in attending or completing while at the facility. Review of R49's Life Enrichment Assessment, dated 04/17/2025, listed her activities as passive, centered almost entirely family activities, and solitary activities. R49's Life Enrichment Assessment , dated 04/17/2025 also revealed Will Activities- functional status be addressed in the care plan?, was answered yes. During observation and interview on 06/03/2025 at 01:31 p.m. R49 was observed sitting up in her recliner at bedside. R49 was asked if anyone invited her to facility activity? R49 explained that no one has ever invited her to any activities. R49 denied again that she had ever been provided an activity calendar. No activity calendar was observed in her room. R49 again expressed concern that she was bored at the facility. Review of R49's activity participation, in the medical record, for the last 30 days revealed an activity entitled conversation/reminiscing and documented participation 21 times. R49's activity participation for the last 30 days also revealed that seven times out of those 21 times were only conducted with R49 participating, not staff. The activity record did not demonstrate any group activity being offered to R49. In an interview on 06/03/2025 at 01:53 p.m. Nursing Home Administrator (NHA) A explained that it was her expectation that the Life Enrichment (Activity) Department provide a monthly activity Calander, of list activity programs, to all residents. NHA A also explained that it was her expectation that all residents plan of care included activity preferences. NHA A confirmed that R49 did not have a plan of care demonstrating her activity preferences. NHA A could not explain why no care plan was present for R49's activity preferences. In an interview on 06/04/2025 at 12:54 p.m. Activity Assistant (AA) L explained that activities are documented in the resident's records for each activity that residents are invited to attend or that the resident participates in. AA L explained that all residents are provided an activity calendar that is usually placed on the bathroom door of the residents' room. During observation and interview on 06/04/2025 at 01:08 p.m. R49 was observed sitting up in recliner chair. She was observed coloring with colored pencils. It was also observed that an activity calendar was hanging on the exterior of her bathroom door. R49 explained that someone from the activity program at the facility had come into her room and discussed June's activity calendar and hung it on her bathroom door. R49 also explained that the same person had given her colored pencils and coloring books at that time. R49 explained that she was happy and excited that she was able to color and had been given the option to attend other activities.

Based on observation, interview, and record review the facility failed to develop and implement comprehensive care plans for one resident (#49) of 14 resident reviewed. Findings included: Resident #49 (R49) Review of the medical record demonstrated R49 was admitted to the facility 04/16/2025 with diagnoses that included fracture of right tibia (the larger of the two bones in the lower leg), infection at surgical site, cellulitis (bacterial infection) of left upper limb, chronic pain, osteoarthritis (degenerative joint) of right knee and right hip, hypertension, atrial fibrillation, malnutrition, depression, prediabetes, gastro-esophageal reflux, neurocognitive disorder with Lewy Bodies (Lewy Body Dementia), anxiety, and schizoaffective disorder. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/22/2025, revealed R49 had a Brief Interview for Mental Status (BIMS) of 10 (moderate cognitive impairment) out of 15. During observation and interview on 06/02/2025 at 11:26 a.m. R49 was observed sitting up in a recliner chair at bedside. R49 explained that she was bored at the facility. It was inquired of R49 if the facility provided her with an activity calendar with activities that she could possibly attend. R49 explained that she was unaware of any Calander of activity programs. No activity Calander was observed posted in R49's room. Review of R49's medical record did not reveal any listed plan of care demonstrating what activity programs R49 may have been interested in attending or completing while at the facility. Review of R49's Life Enrichment Assessment, dated 04/17/2025, listed her activities as passive, centered almost entirely family activities, and solitary activities. R49's Life Enrichment Assessment , dated 04/17/2025 also revealed Will Activities- functional status be addressed in the care plan?, was answered yes. During observation and interview on 06/03/2025 at 01:31 p.m. R49 was observed sitting up in her recliner at bedside. R49 was asked if anyone invited her to facility activity? R49 explained that no one has ever invited her to any activities. R49 denied again that she had ever been provided an activity calendar. No activity calendar was observed in her room. R49 again expressed concern that she was bored at the facility. Review of R49's activity participation, in the medical record, for the last 30 days revealed an activity entitled conversation/reminiscing and documented participation 21 times. R49's activity participation for the last 30 days also revealed that seven times out of those 21 times were only conducted with R49 participating, not staff. The activity record did not demonstrate any group activity being offered to R49. In an interview on 06/03/2025 at 01:53 p.m. Nursing Home Administrator (NHA) A explained that it was her expectation that the Life Enrichment (Activity) Department provide a monthly activity Calender, of list activity programs, to all residents. NHA A also explained that it was her expectation that all residents plan of care included activity preferences. NHA A confirmed that R49 did not have a plan of care demonstrating her activity preferences. NHA A could not explain why no care plan was present for R49's activity preferences. In an interview on 06/04/2025 at 12:54 p.m. Activity Assistant (AA) L explained that activities are documented in the resident's records for each activity that residents are invited to attend or that the resident participates in. AA L explained that all residents are provided an activity calendar that is usually placed on the bathroom door of the residents' room. During observation and interview on 06/04/2025 at 01:08 p.m. R49 was observed sitting up in recliner chair. She was observed coloring with colored pencils. It was also observed that an activity calendar was hanging on the exterior of her bathroom door. R49 explained that someone from the activity program at the facility had come into her room and discussed June's activity calendar and hung it on her bathroom door. R49 also explained that the same person had given her colored pencils and coloring books at that time. R49 explained that she was happy and excited that she was able to color and had been given the option to attend other activities.

Based on interview and record review, the facility failed to ensure that the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) were provided accurately and timely to two Residents (R#25 and R#107) of three reviewed. Findings include: Resident #25 Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] revealed Resident 25 (R25) was a [AGE] year old admitted to the facility on [DATE] utilizing Medicare part A benefits. Review of the NOMNC for R25 reflected a last covered day under Medicare A would be 4/16/25. The NOMNC was signed by R25 on 4/15/25, thus not giving the required time frame for the notice . Review of the SNF ABN, also signed by R25 on 4/15/25 revealed R25 would be billed privately starting 4/18/25. Resident #107 Review of the clinical, including the Minimum Data Set (MDS) record reflected Resident 107 (R107) was admitted to the facility on [DATE]. Review of the NOMNC for R107 reflected a last covered day under Medicare A would be 2/19/25 the form was signed by R107 and dated 2/19/25. On 06/03/25 at 03:28 PM, during an interview with the facility Social Worker (SW) K she reported being responsible for issuing NOMNC and SNF ABN and always issued them with 3 days notice to ensure residents had adequate time to appeal. Review of R25's and R107's NOMNC, SNF ABN was completed with SW K whom offered no explanation for why the notices were issued late and inaccurate.

This citation pertains to Intake MI00150266. Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one (R1) of three reviewed. Findings include: Review of the medical record revealed R1 was admitted to the facility on [DATE] with diagnoses that included dementia, contracture of muscle, and presence of other specified devices. Review of the comments entered for the diagnoses of presence of other specified devices revealed R1 had a baclofen pump that was placed on [DATE]. R1 died in the facility on [DATE]. Review of the records obtained from the physician's office that managed R1's baclofen pump revealed R1's last appointment was on [DATE]. At that time, R1's baclofen dose was decreased from 175.7 mg/hr to 96.1 mcg/hr. The note revealed the next low reservoir alarm date was scheduled for [DATE], but the alarm was turned off as R1 was receiving hospice care. The note indicated refill pump before: [DATE], which indicated the pump would be empty at that time. The note revealed a plan to start baclofen 10 milligrams (mg) three times a day as needed for baclofen withdrawal. This record was not included in R1's medical record. R1 did not have any orders or a care plan indicating he still had a baclofen pump with medication being administered until [DATE]. Review of the Nurses Note dated [DATE] and authored by Director of Nursing (DON) B revealed This writer called [physician who managed baclofen pump] regarding expiration of Baclofen Pump. Per resident's wife, the pump is due to expire January of 2025. At that point we are to start oral Baclofen. Message was left with [physician who managed baclofen pump] to call back with exact expiration date, and oral dosage. In a telephone interview on [DATE] at 10:47 AM, Licensed Practical Nurse (LPN) L reported they cared for R1 and were not aware R1 had a baclofen pump until a few days before he passed away. In a telephone interview on [DATE] at 12:10 PM, LPN J reported they cared for R1 and were not aware R1 had a baclofen pump. LPN J reported if a resident had a baclofen pump, there should be a physician's order and a care plan. In an interview on [DATE] at 12:33 PM, Clinical Care Coordinator (CCC) D reported they were not aware R1 had a baclofen pump until approximately one to two weeks before R1 passed away. CCC D reported they became aware because R1's wife mentioned that the baclofen pump was due to run out. CCC D reported if a resident had a baclofen pump, it should be care planned. In an interview on [DATE] at 1:02 PM, Director of Nursing (DON) B reported they were not aware R1 had a baclofen pump until his wife mentioned it in January. DON B reported the information would typically be in the care plan. In an interview on [DATE] at 2:02 PM with Nursing Home Administrator (NHA) A, DON B, and Regional Consultant (RC) R reported the facility's documentation showed R1's baclofen pump was last filled on [DATE]. It was reported that R1 had the baclofen pump care planned, but that care plan intervention was discontinued on [DATE] leading them to believe the pump off/empty at that time.

This citation pertains to Intake MI00150266. Based on interview and record review, the facility failed to ensure coordination of care and monitoring of a baclofen pump (implanted device that delivers the baclofen, a muscle relaxant medication, directly into the spinal fluid) for one (R1) of three reviewed. Findings include: Review of the medical record revealed R1 was admitted to the facility on [DATE] with diagnoses that included dementia, contracture of muscle, and presence of other specified devices. Review of the comments entered for the diagnoses of presence of other specified devices revealed R1 had a baclofen pump that was placed on [DATE]. R1 died in the facility on [DATE]. In a telephone interview on [DATE] at 9:16 AM, Family Member P reported R1 last had an appointment related to their baclofen pump on [DATE] at which time the physician decreased the baclofen dose and turned off all pump alarms. Family Member P reported the medication was scheduled to be completely used and the reservoir empty by [DATE]. Family Member P reported R1's family reminded the facility on [DATE] that the pump was due to run out of baclofen and they were notified on [DATE] that there was nothing on file related to the baclofen pump. Family Member P reported the physician's office that managed the pump was contacted by R1's family on [DATE] at which time they were informed R1 should have started oral baclofen tablets on [DATE] to manage spasticity/muscle spasms and prevent withdrawals. Review of R1's medical record revealed the last documentation of any baclofen pump appointment was on [DATE] at which time R1's baclofen pump was refilled and R1 received 175.7 micrograms (mcg) per hour (hr). Review of the records obtained from the physician's office that managed R1's baclofen pump revealed R1's last appointment was on [DATE]. At that time, R1's baclofen dose was decreased from 175.7 mg/hr to 96.1 mcg/hr. The note revealed the next low reservoir alarm date was scheduled for [DATE], but the alarm was turned off as R1 was receiving hospice care. The note indicated refill pump before: [DATE], which indicated the pump would be empty at that time. The note revealed a plan to start baclofen 10 milligrams (mg) three times a day as needed for baclofen withdrawal. This record was not included in R1's medical record. Review of the Physician' Order dated [DATE] revealed an order to call the surgeon who placed the pump if there were any questions regarding the baclofen pump. The order was discontinued on [DATE]. Review of the Physician's Order dated [DATE] revealed an order for baclofen 10 mg every 8 hours as needed for increased spasticity/muscle spasms or signs and symptoms of baclofen withdrawal (itching, irritability, twitching). R1 did not have any orders or a care plan indicating he still had a baclofen pump with medication being administered until [DATE]. There was no documentation that R1 was being monitored for signs and symptoms of baclofen withdrawal after the baclofen pump was empty ([DATE]). Review of the MAR revealed did not receive any as needed baclofen (ordered [DATE] and still active) in [DATE]. Review of the Nurses Note dated [DATE] and authored by Director of Nursing (DON) B revealed This writer called [physician who managed baclofen pump] regarding expiration of Baclofen Pump. Per resident's wife, the pump is due to expire January of 2025. At that point we are to start oral Baclofen. Message was left with [physician who managed baclofen pump] to call back with exact expiration date, and oral dosage. Review of the Physician's Order dated [DATE] revealed an order for baclofen 10 mg orally three times a day for increased spasticity/muscle spasms. According to the Medication Administration Record (MAR), R1 received the first dose on [DATE] at 3:00 PM. In a telephone interview on [DATE] at 10:47 AM, Licensed Practical Nurse (LPN) L reported they cared for R1 and were not aware R1 had a baclofen pump until a few days before he passed away. LPN L reported there was not any monitoring for adverse reactions or baclofen withdrawal since they were unaware R1 had a baclofen pump. In a telephone interview on [DATE] at 12:10 PM, LPN J reported they cared for R1 and were not aware R1 had a baclofen pump. LPN J reported if a resident had a baclofen pump, there should be a physician's order and a care plan. In an interview on [DATE] at 12:33 PM, Clinical Care Coordinator (CCC) D reported they were not aware R1 had a baclofen pump until approximately one to two weeks before R1 passed away. CCC D reported they became aware because R1's wife mentioned that the baclofen pump was due to run out. CCC D reported if a resident had a baclofen pump, it should be care planned. In a telephone interview on [DATE] at 12:43 PM, Registered Nurse (RN) F reported R1 had a baclofen pump when he first arrived at the facility. RN F reported they thought the baclofen pump had been turned off many years ago. RN F reported most staff that worked with R1 were unaware that he had a baclofen pump. In an interview on [DATE] at 12:51 PM, LPN G reported they became aware of R1's baclofen pump when R1's wife mentioned the pump. LPN G reported they were not aware of any monitoring related to R1's baclofen pump or what dose of baclofen was being administered through the pump. In a telephone interview on [DATE] at 1:16 PM, LPN C reported they were not aware R1 had a baclofen pump until his wife mentioned it in January. In an interview on [DATE] at 1:02 PM, Director of Nursing (DON) B reported they were not aware R1 had a baclofen pump until his wife mentioned it in January. DON B reported the information would typically be in the care plan. Any further documentation related to the baclofen pump was requested. In an interview on [DATE] at 2:02 PM with Nursing Home Administrator (NHA) A, DON B, and Regional Consultant (RC) R reported the facility's documentation showed R1's baclofen pump was last filled on [DATE]. It was reported that R1 had the baclofen pump care planned, but that care plan intervention was discontinued on [DATE] leading them to believe the pump off/empty at that time. It was reported the last Physician and/or Nurse Practitioner documentation related to R1's baclofen pump was on [DATE]. No further documentation regarding the baclofen pump was provided by the facility.

Based on observations, interviews, and record reviews, the facility failed to: (1) effectively clean and maintain food service equipment, (2) date mark all potentially hazardous ready-to-eat food products, and (3) effectively date, label, and store food products effecting 55 residents, resulting in the increased potential for cross-contamination, bacterial harborage, resident foodborne illness, and inadequate mechanical dish machine sanitization final rinse dispersion. Findings include: On 06/06/24 at 08:28 A.M., A comprehensive tour of the food service was conducted with Dietary Manager E. The following items were noted: The Mechanical Dish Machine wash and final rinse temperature gauges were observed loose-to-mount and fogged with excessive moisture accumulation. The final rinse Pounds-Per-Square-Inch (PSI) gauge was also observed 90% full of water and reading off-scale beyond 30 (PSI) during the final rinse cycle. Dietary Manager E indicated he would contact maintenance for necessary repairs. The 2017 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened. The 2017 FDA Model Food Code section 4-501.113 states: The flow pressure of the fresh hot water SANITIZING rinse in a WAREWASHING machine, as measured in the water line immediately downstream or upstream from the fresh hot water SANITIZING rinse control value, shall be within the range specified on the machine manufacturer's data plate and may not be less than 35 kilopascals (5 pounds per square inch) or more than 200 kilopascals (30 pounds per square inch). The Dietary Manager's office flooring surface was observed extremely soiled with accumulated and encrusted dirt and grime residue. The Dietary Manager's office was also observed in complete disarray (boxes, cook pans, etc.). Dietary Manager E indicated he would have staff thoroughly clean and sanitize the flooring surface as soon as possible. Walk-In Cooler: The flooring surface was observed with accumulated and encrusted milk residue, directly beneath the milk storage rack. Dietary Manager E indicated he would have staff thoroughly clean and sanitize the flooring surface as soon as possible. The 2017 FDA Model Food Code section 6-501.13 states: (A) Except as specified in (B) of this section, only dustless methods of cleaning shall be used, such as wet cleaning, vacuum cleaning, mopping with treated dust mops, or sweeping using a broom and dust-arresting compounds. (B) Spills or drippage on floors that occur between normal floor cleaning times may be cleaned: (1) Without the use of dust-arresting compounds; and (2) In the case of liquid spills or drippage, with the use of a small amount of absorbent compound such as sawdust or diatomaceous earth applied immediately before spot cleaning. The garbage disposal overhead spray arm valve assembly was observed invading the flood plane level of the sink basin. Dietary Manager E indicated he would have maintenance make necessary repairs as soon as possible. The 2017 FDA Model Food Code section 5-205.12 states: Nondrinking water may be of unknown or questionable origin. Wastewater is either known or suspected to be contaminated. Neither of these sources can be allowed to contact and contaminate the drinking water system. The 2017 FDA Model Food Code section 5-205.15 states: Improper repair or maintenance of any portion of the plumbing system may result in potential health hazards such as cross connections, backflow, or leakage. These conditions may result in the contamination of food, equipment, utensils, linens, or single-service or single-use articles. Improper repair or maintenance may result in the creation of obnoxious odors or nuisances and may also adversely affect the operation of warewashing equipment or other equipment which depends on sufficient volume and pressure to perform its intended functions. The can opener mounting bracket perimeter was observed soiled with accumulated and encrusted food residue, between the bracket assembly and table surface. The True 2-door reach-in cooler door gaskets were observed soiled with accumulated and encrusted dust and dirt deposits. Dietary Manager E indicated he would have staff thoroughly clean and sanitize the door gaskets as soon as possible. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. The True 2-door reach-in cooler interior light bulb was observed non-functional. Dietary Manager E indicated he would have maintenance replace the faulty light bulb as soon as possible. The 2017 FDA Model Food Code section 6-303.11 states: The light intensity shall be: (A) At least 108 lux (10 foot candles) at a distance of 75 cm (30 inches) above the floor, in walk-in refrigeration units and dry FOOD storage areas and in other areas and rooms during periods of cleaning; (B) At least 215 lux (20 foot candles): (1) At a surface where FOOD is provided for CONSUMER self-service such as buffets and salad bars or where fresh produce or PACKAGED FOODS are sold or offered for consumption, (2) Inside EQUIPMENT such as reach-in and under-counter refrigerators; and (3) At a distance of 75 cm (30 inches) above the floor in areas used for handwashing, WAREWASHING, and EQUIPMENT and UTENSIL storage, and in toilet rooms; and (C) At least 540 lux (50 foot candles) at a surface where a FOOD EMPLOYEE is working with FOOD or working with UTENSILS or EQUIPMENT such as knives, slicers, grinders, or saws where EMPLOYEE safety is a factor. Rehabilitation Refreshment Room: The [NAME] Beach stainless steel toaster was observed with accumulated and encrusted food residue. Dietary Manager E indicated he would have staff thoroughly clean and sanitize the toaster as soon as possible. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 06/07/24 at 04:30 P.M., Record review of the Policy/Procedure entitled: Sanitation Inspection dated 08-11-2022 revealed under Policy: It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary, and in compliance with applicable state and federal regulations. Record review of the Policy/Procedure entitled: Sanitation Inspection dated 08-11-2022 further revealed under Policy Explanation and Compliance Guidelines: (1) All food service areas shall be kept clean, sanitary, free from litter, rubbish, and protected from rodents. 32064 During an initial kitchen tour on 06/05/24 at 10:08 AM with Dietary Manager (DM) E, the following observations were made: - The reach in refrigerator contained a tray of frozen vegetables that were not covered. DM E reported they were to be cooked later that day. - The reach in refrigerator contained a container of grapes with an expiration date of 6/4/24. DM E removed the container from the refrigerator. - The reach in refrigerator contained an opened half gallon of whole milk that was not dated when opened. DM E removed the milk from the refrigerator. - The walk-in refrigerator contained a container of pasta salad that was not dated. DM E reported they believed it was a staff member's lunch. According to the 2017 FDA Model Food Code, section 3-305.14 Food Preparation, During preparation, unPACKAGED FOOD shall be protected from environmental sources of contamination. According to the 2017 FDA Model Food Code, Section 3-501.17 Date Marking Potentially Hazardous Ready-to-Eat Food, 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-TO EAT, 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.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 55 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality. Findings include: On 06/07/24 at 09:25 A.M., A common area environmental tour was conducted with Maintenance Technician G and Director of Housekeeping and Laundry Services F. The following items were noted: Nursing Unit Nurses Station: 1 of 2 chairs were observed with (worn, torn, etched) armrests. The hand sink basin backsplash board was also observed (etched, scored, raised). The caulking bead was further observed loose-to-mount and missing periodically. The damaged backsplash board measured approximately 4-inches-wide by 6-feet-long. Beauty Shop: The cosmetology chair was observed soiled with accumulated and encrusted dust and dirt deposits. Director of Housekeeping and Laundry Services F indicated she would have staff thoroughly clean and sanitize the cosmetology chair as soon as possible. Rehabilitation Unit Nurses Station: 2 of 2 chairs were observed (etched, scored, particulate). Maintenance Technician G indicated he would remove the faulty chairs as soon as possible. Meadow Unit (Memory Care) The 200 Unit and 300 Unit corridor flooring surface carpeting was observed heavily stained and soiled with dust, dirt, and food residue deposits. Dining Room: The return-air-exhaust ventilation grill was observed heavily soiled with dust and dirt deposits. Director of Housekeeping and Laundry Services F indicated she would have staff thoroughly clean and sanitize the ventilation grill as soon as possible. Soiled Utility Room: The hopper faucet assembly spout was observed heavily soiled with mineral (calcium and lime) deposits. Nurses Station: The desk countertop Formica laminate edge surface was observed (etched, scored, missing). The damaged Formica laminate surface measured approximately 12-feet-long. One chair was also observed (etched, scored, particulate). Main Dining Room Corridor Janitor Closet: Three 4-inch-wide by 4-inch-long ceramic tiles were observed missing, adjacent to the mop sink basin. Two 6-inch-wide ceramic coving tiles were also observed missing, within the room perimeter. Maintenance Technician G indicated he would make necessary repairs as soon as possible. Activity Room: The flooring surface carpet was observed sporadically stained and soiled with dust, dirt, and grime deposits. Janitor Room: The overhead light assembly was observed non-functional. On 06/07/24 at 11:40 A.M., An environmental tour of sampled resident rooms was conducted with Maintenance Technician G and Director of Housekeeping and Laundry Services F. The following item was noted: 120: The Bed 2 overbed light assembly switch was observed non-functional. On 06/07/24 at 05:00 P.M., Record review of the Policy/Procedure entitled: Routine Cleaning and Disinfection dated 08-11-2022 revealed under Policy: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. On 06/07/24 at 05:15 P.M., Record review of the Policy/Procedure entitled: Environmental Services Inspection dated 08-11-2022 revealed under Policy: It is the policy of this facility to regularly monitor environmental services to ensure the facility is maintained in a safe and sanitary manner and assessed on a regular basis.

Based on observation, interview, and record review, the facility failed to ensure eight residents (Resident #14, #15, #23, #27, #31, #36, #39, and #47) received skilled nursing services including medication administration and assessments by a licensed nurse, resulting in Immediate Jeopardy when an unlicensed staff member administered medications, performed assessments, and falsified medical records to reflect the skilled nursing services were performed by a Registered Nurse (RN). Findings include: Review of the facility staff list revealed Staff Member J was a Nurse Grad. In an interview on 03/15/23 at 1:43 PM, Staff Member J self reported she was the facility's scheduler and wound nurse. Staff Member J identified herself as a Registered Nurse. When asked why the staff list identified her as a Nurse Grad, Staff Member J reported she still had to take her nursing boards. Staff Member J reported she was not licensed as a Licensed Practical Nurse (LPN) or RN. Review of Staff Member J's personnel file revealed she was a Certified Nursing Assistant (CNA) with certification effective 2/28/22 until 2/28/24. [Staff Member J will now be referred to as CNA J]. Review of the position description signed by CNA J and Human Resources Director (HRD) K on 12/16/21 revealed Position: Charge Nurse Purpose: The primary purpose of your position is to provide residents with direct nursing care in accordance with current federal, state, and local standards, guidelines and regulations governing [facility name], to ensure the highest degree of quality care can be provided to our residents at all times. This includes providing supervision and evaluation of nursing personnel. Duties and Responsibilities: 1. Provide direct nursing care to residents in accordance with LTC (long-term care) requirements, standard nursing practices and [facility name] policies and procedures. 2. Pass and administer resident medications as prescribed by the physician in accordance with LTC regulations, standard nursing practices and [facility name] policies and procedures. 3. Perform treatments for residents in accordance with standard nursing practice and physician orders. 4. Notify physician when automatic medication stop is near. 5. Determine resident meal accommodations (arrangements), report food preferences, and interpret diet to the Dietary Director. 6. Sends diet change orders and resident discharge notification to the kitchen. 7. Evaluate resident need for special equipment, such as wheel chair, chair alarms, etc. 8. Provide head to toe nursing assessment, including fall, elopement, pain, and skin assessments and chart results. 9. Take and chart resident vitals per [facility name] protocol. 10. Write the initial care plan and medication and treatment orders on admission and update as changes occur. 11. Reviews medication orders upon admission and contact the pharmacy to order medications. 12. Ensure that all medication and physician orders are current. 13. Assist residents with social adjustment to the facility, including orientation to the facility and routines. 14. Schedule resident appointments for the dentist, optometrist, ENT, podiatrist, speech therapist, dialysis, etc. and notify the Social Worker if transportation or staff is needed for assist. 15. Notify the physician and family and family of resident condition changes. 16. On discharge of resident contact the physician and notify the responsible relative, the business office, and the Director of Nursing (D.O.N.), and make arrangements for transportation. 17. Maintain an excellent working relationship with the medical profession and other health related facilities and organizations. 18. Work in cooperation with other departments within the facility to provide a holistic approach to meeting resident needs. 19. Assist department directors in the development and use of departmental policies and procedures. 20. Ensure that all employees, resident's, visitors, and the general public follow established policies and procedures. 21. Participate in [facility name] surveys. Supervisory Responsibilities: 22. Supervise, direct, and evaluate nursing personnel performance to ensure that established policies and procedures are being implemented and followed and that residents receive maximum quality care. 23. Counsel and discipline personnel as requested or as may be deemed necessary. 24. Ensure that disciplinary action is administered fairly and without regard to race, creed, color, national origin, age, sex, religion, handicap, or marital status. 25. Provide frequent observation of the nursing department and ensure that all resident charting is completed thoroughly and in a timely fashion. 26. Interpret the facilities policies and procedures to employees, residents, family members, visitors, government agencies, etc., as necessary . Education: Unencumbered Nurse license from the State of Michigan. Requirements: . Must be knowledgeable of nursing practices and procedures, as well as laws, regulations, and guidelines pertaining to long-term care administration . Acknowledgement: I have read this job description and fully understand the requirements set forth therein. I hereby accept the position of Charge Nurse and agree to perform the functions of my job in a safe manner and in accordance with [name of facility] established procedures . CNA J's personnel file revealed her first day of work as a Charge Nurse was 1/3/22. Review of the Nursing Skills Check dated 7/1/22 and 7/6/22, revealed CNA J signed in as having completed the nursing skills check. In an interview on 03/16/23 at 08:51 AM, Director of Nursing (DON) B reported when she started at the facility on 6/30/22, she was not aware CNA J was a graduate nurse. DON B reported CNA J was introduced to her as the wound nurse and scheduler. DON B reported approximately a month ago, she first became aware that CNA J was not a licensed nurse. DON B reported CNA J had administered medications to residents maybe two to three times since she had been the DON. DON B reported when she was first hired, she oversaw CNA J performing wound assessments and treatments on Wednesdays and Thursdays. In an interview on 03/16/23 at 10:15 AM, CNA J reported she attended nursing school, but had failed her nursing board exam twice. CNA J reported it had been a couple months since she worked the floor as a nurse. CNA J reported she began working in the facility on 1/3/22 and was trained on the floor as a grad nurse. CNA J reported her training including medication administration and talking to the physician. CNA J reported she trained alongside another nurse for one to two months and in March 2022, she began independently administering medications. CNA J reported she then began doing wounds [assessments and treatments] with the facility's former DON. CNA J reported the former DON left around June 2022 and she thought her wound assessments and treatments were oversaw by the DON. CNA J reported she independently performed wound assessments and treatments and then reported to DON B. CNA J reported she never had to call the physician regarding any medications, assessments, or treatments. CNA J reported she wrote wound treatment orders and administered medications including insulin injections and controlled substances. CNA J reported if her name or initials were on medication administrations or assessments, she must have performed them. In an interview on 03/20/23 at 08:40 AM, HRD K reported when CNA J was hired, the former DON told her CNA J was a grad nurse and asked her to fill out new hire paperwork. HRD K reported she did not check for a nursing license because CNA J did not have a nursing license yet. HRD K reported she was never notified that CNA J did not pass her nursing board exam. HRD K reported on 8/29/22, CNA J's pay was decreased, but her job classification was not changed. Review of a list (provided by Administer in Training (AIT) C) of all residents for whom CNA J performed assessments and/or medication administration in the last three months, revealed the list included 27 residents. Resident #36 (R36) Review of the medical record revealed R36 was admitted to the facility on [DATE] with diagnoses that included pulmonary embolism, atrial fibrillation, congestive heart failure, and chronic kidney disease stage 3. The Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 12/8/22 revealed R36 scored 10 out of 15 (moderate cognitive impairment on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the progress notes dated 8/5/22 revealed CNA J held R36's Hydralazine (medication to treat high blood pressure) 50 milligrams (mg) due to R36's blood pressure being 122/56. CNA J signed the progress note as a RN. Review of the medical record revealed Certified Nursing Assistant (CNA) J performed R36's Weekly Wound Assessments of a pressure ulcer on 2/20/23, 2/27/23, and 3/10/23. CNA J signed the assessments as a RN. Review of the Physician's Order dated 3/8/23 revealed CNA J wrote the order to cleanse bilateral heels with normal saline, pat dry, and apply skin prep. CNA J signed the order as a RN. Resident #39 (R39) Review of the medical record revealed R39 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, anxiety, peripheral vascular disease, and major depressive disorder. The MDS with an ARD of 1/5/23 revealed R39 was severely cognitively impaired. Review of R39's Medication Administration Record (MAR) revealed CNA J administered R39's divalproex sodium (seizure medication) tablet on 12/4/22. Resident #47 (R47) Review of the medical record revealed R47 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, dementia, hypertension, bradycardia, and anxiety. The MDS with an ARD of 2/16/23 revealed R47 scored 6 out of 15 (severe cognitive impairment) on the BIMS. Review of R47's medical record revealed R47 performed the Skilled Evaluations (nursing assessments) on 9/3/22, 9/4/22, 9/5/22, and 9/6/22. CNA J signed the assessments as a RN. Review of the MAR revealed CNA J administered Magnesium Oxide and acetaminophen to R47 on 12/4/22. CNA J also evaluated R47 for pain on 12/4/22. 45038 Resident #23 (R23) Review of the medical record revealed R23 was originally admitted to the facility 09/01/2018 and readmitted [DATE] (following a recent hospital stay) with diagnoses that included metabolic encephalopathy (brain disfunction), cellulitis left lower limb, chronic obstructive pulmonary disease (COPD), congestive heart disease (CHF), chronic kidney disease, type 2 diabetes, obstructive sleep apnea, vascular dementia, insomnia, atherosclerotic heart disease, hypertension, aortic valve stenosis, anemia (low blood volume), vitamin D deficiency, gastro-esophageal reflux, major depression, hyperlipidemia (high fat in blood) , gout (high uric acid deposits in bone joints) , Parkinson disease, and hypothyroidism (low thyroid levels). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/31/2023, revealed R23 had a Brief Interview for Mental Status (BIMS) of 10 (moderately impaired cognition) out of 15. The most recent MDS, with the ARD of 1/31/2023, demonstrated that R23 was readmitted to the facility with one unstageable pressure ulcer. During review R23's medical record revealed a Weekly wound Assessment completed on 02/24/2023 that demonstrated an unstageable pressure wound to R23's left lateral foot measuring 2.0 centimeters (cm) in length by 2.0 (cm) in width. This assessment was completed by staff member J. R23's medical record demonstrated that was the first Weekly Wound Assessment that had been completed. R23's medical record demonstrated Weekly Wound Assessment had also been completed 02/28/2023, 03/07/2023, and 03/08/2023. All the Weekly Wound Assessment that were completed demonstrated no change of size or staging of the left lateral foot pressure ulcer. All Weekly Wound Assessment were completed by staff member J. CNA J signed Weekly Wound Assessments as a Registered Nurse. In an interview on 03/14/2023 at 01:52 p.m. with CNA J, she explained that she was an RN and was the Wound Nurse at the facility. In an interview on 03/15/2023 at 10:12 a.m. Director of Nursing (DON) B explained that staff member J was the facility RN Wound Nurse. Resident #31 (R31) Review of the medical record revealed R31 was admitted to the facility 01/14/2023 with diagnoses that included absence of right leg, peripheral vascular disease, atrial flutter, type 2 diabetes, end stage renal disease, dependence on renal dialysis, ischemic cardiomyopathy (damage to hearts major blood vessels , depression, anxiety, gastro-esophageal reflux, insomnia, hypothyroidism (low thyroid levels), hypertension, anemia, chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease (build up of fats/cholesterol on artery walls), mitral valve insufficiency, non-pressure chronic ulcer of right foot. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/10/2023, revealed R31 had a Brief Interview for Mental Status (BIMS) of 13 (cognitively intact) out of 15. Review of R31's of medical record revealed a Weekly Wound Assessment completed on 2/17/23 at 05:00 p.m. by staff member J. That assessment demonstrated that R31 had an unstageable left heel ulcer which measured 1.5 centimeters (cm) in length and 1.5 cm in width. CNA J signed Weekly Wound Assessments as a Registered Nurse. Review of the facility policy entitled Pressure Injury Prevention and Management, with an implementation date of 06/23/2022, demonstrated section Policy Explanation and Compliance Guidelines number 3c stated licensed nurses will conduct a full body assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. The same policy demonstrated number 3d stated assessments of pressure injuries will be performed by a licensed nurse and documented on the TAR (Treatment administration record) and under assessments . 46955 Resident # 27 (R27) Review of the medical record revealed that R27 was admitted to facility 1/7/2020 with diagnoses including multiple sclerosis, personal history of malignant neoplasm of breast, restless legs syndrome, and hypertension. Diagnosis list also included COVID 19 with an onset date of 3/4/2023. Review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/29/23 revealed R27 to have a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 10 (moderate cognitive impairment). In an observation and interview on 03/13/23 at 7:15 AM, R27 was observed sitting in a wheelchair just inside the open door of her room. R27 stated that she was doing good but would be doing better when she could get out of her room as stated that she had recently been diagnosed with COVID and was stuck in her room for a few days yet. Review of the medical record revealed Certified Nursing Assistant (CNA) J completed R27's Self Administration of Medication assessment dated [DATE]. CNA J signed the assessment as a Registered Nurse (RN). Review of R27's Medication Administration Record (MAR) dated 12/1/2022-12/31/2022 revealed that CNA J signed out Senna-plus (a bowel medication) on 12/21/22 at 1800 (6:00 PM) as administered as (CNA J's initials) noted in corresponding administration box. Resident # 14 (R14) Review of the medical record revealed that R14 was admitted to facility 10/5/2021 with diagnoses including unspecified dementia, chronic kidney disease stage 3, hypothyroidism, bipolar disorder, generalized anxiety disorder, and presence of cardiac pacemaker. Review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/22/2022 revealed Brief Interview for Mental Status (BIMS) score of 7 (severe cognitive impairment). Review of the progress notes included an Administration Note dated 9/7/2022 which revealed that CNA J completed R14's Behavior Charting and a second dated 9/26/2022 which revealed that CNA J completed R14's pain evaluation. CNA J signed both notes as a RN. Review of R14's MAR dated 9/1/2022-9/30/2022 revealed that CNA J signed the 9/7/22 1200 (12:00 PM) dose of Acetaminophen (a pain medication); the 9/9/22 1700 (5:00 PM) dose of Divalproex Sodium (a seizure medication), Symbicort Aerosol (a respiratory inhaler), and Bupropion HCL (a depression medication); and the 9/26/22 0600 (6:00 AM) dose of levothyroxine (a thyroid medication) as administered as (CNA J's initials) noted in the corresponding administration box for the indicated medications. Resident # 15 (R15) Review of the medical record revealed that R15 initially admitted to facility 8/6/2010 with multiple rehospitalization s and facility readmissions including 3/9/2018 facility readmission with diagnoses including dementia, alcoholic liver disease, and hypothyroidism. Review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/10/23 revealed that resident was rarely/never understood and was unable to participate in a Brief Interview for Mental Status (BIMS) assessment. Staff Assessment for Mental Status indicated short- and long-term memory problems and severely impaired cognitive skills for daily decision making. Section M of the same MDS indicated that R15 was at risk for developing pressure injuries and had one stage 1 pressure injury. In an observation on 3/16/23 at 10:48 AM, R15 was observed lying in bed on right side with eyes open watching TV. R15 smiled but did not respond verbally to any questions pertaining to breakfast or show on TV. Review of the medical record revealed CNA J performed R15's Weekly Wound Assessment on 3/12/23 and 3/14/23. CNA J signed the assessments as a RN. Review of the Physician's Order dated 3/14/23 revealed that CNA J wrote the order for R15's left buttock pressure ulcer treatment. CNA J signed the order as a RN. In an interview on 3/16/23 at 12:03 PM, CNA J stated that she was familiar with R15, was notified recently of the left buttock alteration, and had since completed a wound assessment and written a treatment order. Upon review of the medical record, CNA J confirmed that she completed R15's initial wound assessment on 3/12/23 and wrote a treatment order for a foam dressing on that date as well. Upon review of R15's left buttock treatment order dated 3/14/23, not 3/12/23 as CNA J initially indicated, CNA J stated that although she intended to write the order on 3/12/23 when the wound was first identified, recalled now that upon reassessment of wound on 3/14/23, realized that had not written the order on 3/12/23 so did so on 3/14/23. CNA J denied that she notified the physician of R15's skin alteration or that she consulted with a facility nurse but wrote the physician order for a foam dressing, per her discretion, as the alteration presented on a boney prominence. In an interview on 03/15/23 at 4:30 PM, AIT C reported she was aware CNA J was not a licensed nurse but was always told it was okay since CNA J was practicing under DON B's license. AIT C also reported CNA J worked as the on call supervisor one weekend per month. In an interview on 3/20/23 at 10:06 AM, Nursing Home Administrator (NHA) A reported he was not aware CNA J was not a licensed nurse. On 3/15/23 at 4:30 PM, NHA A and AIT C were notified of the Immediate Jeopardy that was identified on 3/15/23 and began on 1/3/22, due to the facility's failure to ensure residents received skilled nursing services by a licensed nurse. Immediate Jeopardy was removed on 3/20/23 when the facility had the following in place: As of 3/15/23, patient/resident care and services identified as requiring provision by a licensed nurse are provided by a licensed nurse. The identified staff member's duties were reassigned. No graduate nurses are working in a capacity of nursing. As of 3/20/23, residents receiving care from the identified staff member have been evaluated/assessed to determine if there are changes in condition. Care plans will be updated as needed. As of 3/16/2023, Human Resource files were reviewed to verify current nursing licenses for scheduled staff. Human Resource Manager has been educated on graduate nurse requirements and supervision requirements and revised graduate nurse policy is drafted. As of 3/16/23, Graduate Nurse has signed new job description to reflect her current certification. Although the Immediate Jeopardy was removed on 03/20/23, the facility remained out of compliance at a scope of widespread and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency.

Based on observation, interview, and record review the facility failed to follow and implement infection control practices per the Centers for Disease Control (CDC) guidelines to prevent the spread of COVID-19 resulting in Immediate Jeopardy when the facility failed to ensure that facility staff fully utilized Personal Protective Equipment (PPE) for residents with COVID-19 infection. This deficient practice resulted in 27 residents testing positive for COVID-19 including Resident #1, #9, #22, #24, #25, #26, #27, #28, #35, #36, and #53, the hospitalization of Resident #22, Resident #24, and Resident #28, the death of Resident #9 and Resident #53, and the likelihood for further cross contamination of COVID-19 to other residents and staff, thereby putting all 50 residents at risk for infection, hospitalization , and/or death. Findings include: According to the CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom .HCP [Healthcare Personnel] who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). (https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Fnursing-home-long-term-care.html) Upon entrance into the facility on [DATE] at 6:50 AM, a white board was observed that revealed as of [DATE], the facility had five staff and 20 residents who were positive for COVID-19. The facility's resident covid vaccination list revealed 8 out of 50 residents were not vaccinated for COVID-19. Review of a list of residents who tested positive for Covid-19, revealed 25 residents tested positive since [DATE]. Resident #36 (R36) Review of the medical record revealed R36 was admitted to the facility on [DATE] with diagnoses that included pulmonary embolism, atrial fibrillation, congestive heart failure and chronic kidney disease stage 3. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed R36 scored 10 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of R36's Covid vaccination status revealed R36 received a booster on [DATE] and was due for the second booster. Review of the progress notes revealed R36 tested positive for Covid on [DATE]. Review of the Physician's Orders dated [DATE] and [DATE] revealed R36 was on droplet isolation precautions for Covid until [DATE]. On [DATE] at 07:28 AM and 8:55 AM, R36 was observed sitting in a wheelchair in his room. The door was open with droplet precaution signage on the door and a PPE kit hanging on the door. Eye protection was not included in the PPE kit. Staff were observed wearing N95 masks. On [DATE] at 08:08 AM, Certified Nursing Assistant (CNA) P entered R36's room wearing only a N95 mask. CNA P did not don a gown, eye protection, or gloves. CNA P assisted R36 with placing his oxygen on and then left the room. When asked about the droplet precautions, CNA P reported she thought R36 was off isolation. Resident #9 (R9) Review of the medical record revealed R9 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease and diabetes. The MDS with an ARD of [DATE] revealed R9 was severely cognitively impaired. Review of the Interdisciplinary Team Note dated [DATE] at 1:00 AM revealed R9 tested positive for Covid-19. The Health Status note dated [DATE] at 3:13 PM revealed R9 was seen by the hospice nurse and showed signs of declining with increased respirations with use of accessory muscles. The Infection Note dated [DATE] at 4:34 PM revealed R9 required 5 liters of oxygen. The medical record revealed R9 died in the facility on [DATE]. Resident #28 (R28) Review of the medical record revealed R28 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, atrial fibrillation, Parkinson's Disease, bradycardia, major depressive disorder, and diabetes. The MDS with an ARD of [DATE] revealed R28 scored 3 out of 15 (severe cognitive impairment) on the BIMS. Review of the Physician's Note dated [DATE] revealed R28 was seen for evaluation of a new diagnosis of covid. The note revealed R28 had an occasional cough, was more tired, was at increased risk of decline, and okay with hospitalization if needed. The Interdisciplinary Team Note dated [DATE] at 2:14 PM revealed In house staff attempted to start IV with no success. The note revealed another provider was notified and would be out within the hour to start the IV for R28. The Nurses Note dated [DATE] at 10:54 PM revealed Family aware and notified of IV NS [normal saline] and being sent out to the hospital for being lethargic r/t [related to] COVID. Resident #53 (R53) Review of the medical record revealed R53 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, major depressive disorder, chronic kidney disease stage 3, and anxiety. The MDS with an ARD of [DATE] revealed R53 scored 3 out of 15 (severe cognitive impairment) on the BIMS. Review of the Treatment Administration Record (TAR) revealed R53 tested positive for Covid on [DATE] at 5:44 AM. The medical record revealed R53 died in the facility on [DATE]. Resident #24 (R24) Review of the medical record revealed R24 was admitted to the facility on [DATE] with diagnoses that included pneumonia, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, anxiety, and dependence on supplemental oxygen. The MDS with an ARD of [DATE] revealed R24 scored 11 out of 15 (moderate cognitive impairment) on the BIMS. Review of the Health Status Note dated [DATE] at 5:28 AM revealed R24 reported her right ear and throat hurt. R24 tested positive for Covid. The Physician's Note dated [DATE] revealed R24 had a dry cough, felt tired, and had a slight decrease in appetite. Review of the Transfer to Hospital Summary Note dated [DATE] revealed it took three staff members to transfer R24 which was not normal for her. R24's oxygen level was 90% on 4 liters of oxygen, and her temperature was 99.1. R24 was transferred to the hospital. 30337 Breakfast was observed on the Meadow's unit, a dementia care unit, on [DATE]; the breakfast meal cart was delivered to the unit at 7:43 AM. Seven rooms had droplet precaution signs and isolation kits with personal protective equipment (PPE), including gowns and gloves, on the front of the resident room doors. There were no goggles/face shields or N95 respirator masks noted in any of the 7 isolation kits hung resident doors on the unit. A cart for soiled linen and another cart for trash were noted in the center of hallway, placed next to each other, in front of room [ROOM NUMBER], both carts had lids that were attached. Resident #26 (R26) On [DATE] at 7:28 AM, R26's door to his room was open, a Droplet precautions sign was posted on the door, and personal protection equipment kit was hanging on the door that included gloves and gowns. R26 was observed lying in bed on left side. Licensed Practical Nurse (LPN) E was observed giving oral medication and told R26 she was going to apply his medication patch on his stomach. LPN E was not wearing a gown, gloves or goggles/face shield. LPN E had an N95 mask in place. LPN E left the room with the same N95 mask in place. There was no trash bin to doff personal protective equipment (PPE) prior to leaving the resident's room. R26's annual Minimum Data Set (MDS) assessment dated [DATE], revealed he was admitted to the facility on [DATE] and his cognitive skills for daily decision making was severely impaired, he never/rarely made decisions. R26 required extensive assistance for toilet use and personal hygiene. R26's Activities of Daily Living (ADL) care plan revised on [DATE] revealed he had an ADL Self-Care Deficit with a potential for further decline related to progressive Alzheimer's Disease. The same care plan revealed R26 had diagnoses of depression, psychotic and mood disorders. There was no care plan indicating R26 was in droplet precautions for COVID-19. In review of facility list provided on [DATE], R26 was positive for COVID-19 on [DATE]. In review of R26's active physician orders, droplet precautions due to COVID-19 was ordered until [DATE]. Resident #25 (R25) On [DATE] at 7:48 AM Certified Nurse Assistant (CNA) D was observed placing a resident's breakfast tray on top of a soiled linen cart prior to donning a gown and gloves. CNA D picked up the breakfast tray and delivered the tray into R25's room; R25's room had a droplet precautions/isolation kit on front of the door. CNA D did not wear goggles/face shield. CNA D came out of R25's room, removed his gown in the hallway, opened the trash cart in front of room [ROOM NUMBER] with his gloves on, disposed of his gown, removed his gloves, and then closed the trash lid. CNA D continued to wear the same N95 mask. In review of facility list provided on [DATE], R25 was positive for COVID-19 on [DATE]. On [DATE] at 7:56 AM CNA D placed R26's breakfast tray on top of the soiled linen cart and donned gloves and gown, then took R26's breakfast tray into the room. CNA D walked out of R26's room and with gloves on, opened lid to trash, the removed and disposed of the gloves. Resident #35 (R35) On [DATE] at 8:31 AM CNA D was observed with the last breakfast tray to be passed on the unit and placed the tray on the trash cart while donning gloves and a gown. CNA D then took the tray into R35's room; R35's door had a sign indicating droplet precautions were ordered. In review of facility list provided on [DATE], R35 was positive for COVID-19 on [DATE]. R35's MDS dated [DATE] revealed she was admitted to the facility on [DATE] and had diagnoses of dementia and depression. R35's cognitive skills for daily decision making was severely impaired, she never/rarely made decisions. R35 required limited assist with eating and extensive assistance with personal hygiene and toilet use. According to Centers for Disease Control (CDC) website (cdc.gov); the sequence for putting on PPE: gown, respirator mask, googles/face shield and then gloves. The same source indicated to remove all PPE before exiting the room except for the respirator; remove the respirator after leaving the room and closing the door. LPN E was interviewed on [DATE] at 8:24 AM and stated N95 respirator masks were kept in the front office and were given to staff at the beginning of the shift, they were not on the unit. Novel Coronavirus Prevention and Response Policy, dated reviewed/revised [DATE], revealed interventions to prevent the spread of respiratory germs within the facility included to wear gloves, gowns, goggles/face shields, and masks upon entering room and when caring for the residents; promote easy and correct use of PPE by making PPE (facemask, eye protection, gowns, gloves) available immediately outside of the resident's room; and position a trash can near the exit inside room to make it easy to discard PPE. 45038 Resident #1 (R1) Review of the medical record revealed R1 was admitted to the facility [DATE] with diagnoses that included Alzheimer's, dementia, and epilepsy. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed R1 had a Brief Interview for Mental Status (BIMS) of 9 (moderately impaired cognition) out of 15. During tour of the facility on [DATE] at 08:18 a.m. Certified Nursing Assistant (CNA) I entered R1's room after placing on an isolation gown and gloves. CNA I already had a n-95 mask on. No face shield or googles were donned before entering R1's room. During observation and interview on [DATE] at 08:56 R1 was observed setting up in a w/c at the side of her bed. R1 was on droplet precautions and a sign was observed on her room door. Isolation unit was hanging on the door. The isolation unit contained n-95mask, gowns, and gloves. Isolation unit did not contain face shields or googles. R1 explained that she was recently been diagnosed with Covid-19 and that she would be in isolation for 10 days and that isolation should be ending very soon. Review of R1's medical record demonstrated that she had been placed in droplet precautions on [DATE]. In an interview on [DATE] at 09:11 a.m. Director of Nursing (DON) B explained that the contributing factor that staff were not compliant for the wearing of face shields were related to two factors. She explained that the first factor was that the face shields or googles would not fit into the isolation units that were hung on the residents' doors and that second reason was that the facility was having difficulty obtaining enough face shields and/or googles from their distributors. DON B also explained that routine employee Covid-19 outbreak testing was not being conducted at the facility during this current Covid-19 outbreak. Resident #22 (R22) Review of the medical record revealed R22 was originally admitted to the facility [DATE] and readmitted [DATE] (following a recent hospital stay related to covid-19 illness) with diagnoses that included type 2 diabetes, congestive heart failure, visual hallucinations, delusions, depression, obstructive sleep apnea, and cirrhosis of the liver. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed R22 had a Brief Interview for Mental Status (BIMS) of 9 (moderately impaired cognition) out of 15. During observation and interview on [DATE] at 12:56 p.m. R22 was observed laying down in bed. R22 was on droplet precautions and a sign was observed on his room door. Isolation unit was hanging on the door. The isolation unit contained n-95mask, gowns, and gloves. Isolation unit did not contain face shields or googles. R22 explained that he did not know why he was in droplet precautions. Review of R22's medical record revealed that he was transferred to the hospital on [DATE] for unresponsiveness and tested positive for Covid-19 on [DATE] at the hospital. R22's Treatment Administration Record (TAR) for [DATE] demonstrated Rapid covid swab results as a U. R22's medical record revealed he returned to the facility [DATE]. A physician order was written on [DATE] placing R23 on droplet precautions. A physician order was also written on [DATE] to placing R23 in droplet precautions. No order could be found placing R22 on droplet precautions on the date that he returned to the facility following a recent positive covid-19 diagnosis from the hospital. In an interview on [DATE] at 10:30 a.m. Director of Nursing (DON) B explained that R22 had tested positive at facility on [DATE] according to her records. After reviewing R22's Treatment Record for March of 2023 DON B explained that the entry for the rapid covid swab that was administered on [DATE] was documented as U meant undetermined. She also explained that the documentation was entered in error and should have been documented as positive. DON B confirmed that the R22's physician order for droplet precautions was not entered until [DATE]. She explained that R22 should have been placed on droplet precautions when he returned to the facility on [DATE]. DON B could no explain if R22 had been placed on droplet precautions at the time of admission and could not explain why the order was not written until [DATE]. 46955 Resident # 27 (R27) Review of the medical record revealed that R27 was admitted to facility [DATE] with diagnoses including multiple sclerosis, personal history of malignant neoplasm of breast, restless legs syndrome, and hypertension. Diagnosis list also included COVID 19 with an onset date of [DATE]. Review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed R27 to have a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 10 (moderate cognitive impairment). Section G of MDS reflected that R27 required one-person extensive assist with bed mobility, two-person extensive assist with transfer and toilet use and set up assist with eating. In an observation and interview on [DATE] at 7:15 AM, R27 was observed sitting in a wheelchair just inside the open door of her room. R27 stated that she was doing good but would be doing better when she could get out of her room as stated that she had recently been diagnosed with COVID and was stuck in her room for a few days yet. An isolation box which contained surgical masks, disposable isolation gowns, and medium and large gloves was observed to be hanging on the outside of the open door. A sign, also located on the outside of the open door, reflected Droplet Precautions with indication for HAND HYGIENE Before Entering Room, GOWN and GLOVES REQUIRED To Enter Room, Mask with eye shield REQUIRED Within 6 ft (feet) of patient, HAND HYGIENE After Exiting Room. Review of R27's medical record completed with the following findings noted: Order dated [DATE] at 4:52 AM stated, Isolation-droplet precautions for five days .for Covid Positive . Order dated [DATE] at 2:07 PM stated, Isolation-droplet precautions for five days .for Covid Positive until [DATE] at 11:59 PM. Health Status Note dated [DATE] at 7:17 AM stated, .Resident stated that she had a sore throat and body aches. Writer performed rapid covid-19 on resident, results came back positive. Resident was informed of positive results. Droplet precaution signs were hung on resident's door and isolation box was hung outside of resident doorway . On [DATE] at 8:25 AM, Certified Nurse Aide (CNA) I was observed to enter R27's room with a Styrofoam food container, bowl, and silverware and place on top of the dresser just inside of the open door. CNA I was then observed to remove a gown and gloves from the isolation box on the outside of the door and place the gown followed by the gloves. CNA I was noted with regular eyeglasses but was not noted to place additional eye protection, upon room entrance. CNA I proceeded to set-up the Styrofoam box and bowl on the over the bed table positioned directly in front of resident, proceeded back toward room exit, removed gown and gloves, sanitized hands, and then exited room with the same N95 mask that was in place upon room entrance. In an interview on [DATE] at 9:40 AM, CNA I confirmed familiarity with R27 and stated that droplet precautions remained in effect as she had previously tested positive for COVID. CNA I also confirmed that she was assigned to the COVID positive residents in rooms [ROOM NUMBERS] and that they remained on droplet precautions as well. CNA I stated that when entering a room with a COVID positive resident on droplet precautions that she would knock on the door, obtain and put on a gown and gloves from the isolation box hanging on the outside of the door, but would keep on the same N95 mask that she had on upon room entrance. Per CNA I, upon completion of resident care and prior to exiting room, would remove and dispose of personal protective equipment including the gown, gloves, and mask, would sanitize hands and then place a new N95 mask. During the same interview, when CNA I was questioned regarding routine changing of mask upon care completion and prior to exiting a COVID positive room stated, I may not have, just to be fully honest, because it was so hectic trying to get the meals out. CNA I also stated that, to her knowledge, no eye protection was needed when entering a COVID positive room, that the facility had not provided eye protection or face shields for the isolation kits on the doors, and that she had not worn eye protection or a face shield when entering any COVID positive resident room on droplet precautions. On [DATE] at 11:19 AM, CNA I was observed to enter R27's room with a N95 mask and regular eyeglasses in place. CNA I was not noted to place a disposable gown, gloves, or eye protection prior to entering the open door to R27's room. On [DATE] at 11:30 AM, upon request of a face shield or eye protection, Activities Aide (AA) O left unit, went to lobby at front entrance, obtained face shield from the cabinet and stated that to my knowledge this is the only place that they are located. On [DATE] at 11:09 AM, Administrator in Training (AIT) C reported Nursing Home Administrator (NHA) A was out of the building for the next twenty minutes. AIT C was notified of the Immediate Jeopardy that was identified on [DATE] due to the facility's failure to follow and implement infection control practices per the CDC guidelines. Immediate Jeopardy was removed on [DATE] when the facility had the following in place: The following interventions have been implemented [DATE]. - Goggles/face shields for all staff - New Signs for COVID positive rooms - Updated PPE Kits including, N-95s, gowns and gloves - Staff education on Hands washing, PPE, and CDC guidance regarding transmission of COVID-19. Education started [DATE] will be completed by [DATE]. 1. As of [DATE], the resident rooms for those having COVID have restocked with PPE supplies, their doors have been pulled shut unless contraindicated due to condition or physician order. Signs have been posted on these resident doors identifying the type of precaution and the CDC recommendations for PPE use. PPE will be disposed of in the designated trash can provided in each room as they exit, and alcohol based hand rub will be used after removal according to CDC guidelines. 2. As of [DATE], staff members will be educated on hand washing, donning and doffing PPE, and to review signage at resident doors. Licensed nurses will be educated on CDC guidance regarding transmission of COVID-19. Infection Control Protocols and Practices (Policies) will be reviewed. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of widespread and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency.

This citation pertains to Intake MI00134570 and MI00134606 Based on observation, interview, and record review the facility failed to protect the resident's right to be free from physical abuse by staff for one resident (R101) of three reviewed for abuse, resulting in R101 left acute displaced proximal 5th phalanx fracture (pinky finger) and soft tissue swelling. Findings include: Complaints and Facility Reported Incident(FRI) were filed with the State Agency and alleged that R101 sustained an injury of unknown origin (fracture to the left hand) and alleged the resident was abused by employee/certified nursing assistant (CNA) N. The FRI 24 hour report was submitted by the facility on 1/26/23 at 11:53 a.m. Review of the Facility Abuse Policy, dated 6/27/22 and revised 3/1/23, reflected, Protocol: [Named facility] (CSCC) protects the health, welfare, and rights of residents by developing and implementing written protocols, policies and procedures prohibiting, and with the intention of preventing, abuse, neglect, mistreatment, exploitation and misappropriation of resident property . Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment (physical punishment meant to be painful) . Employee Training .New employees will be educated on abuse, neglect, exploitation and misappropriation of resident property during initial orientation .Training topics will be in accordance with federal and/or state requirements and include .1. Prohibition and prevention of abuse, neglect, misappropriation of resident property, and exploitation in accordance with regulatory standards and the Elder Justice Act; 2. Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property; 3. Recognizing signs of abuse, neglect, exploitation and misappropriation of resident property, such as physical or psychosocial indicators; 4. Reporting process for abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources; 5. Understanding behavioral symptoms that may increase risk of abuse and neglect such as: a. Aggressive and/or catastrophic reactions by residents; b. Wandering or elopement-type behaviors; c. Resistance to care; d. Outbursts or yelling out . Identification of Abuse, Neglect and Exploitation . Possible indicators of abuse include, but are not limited to .Resident, staff or family report of abuse .Physical injury of a resident, of unknown source . Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame . Investigation of Alleged Abuse, Neglect and Exploitation . Identifying and interviewing identified involved persons, including alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations .Protection of Resident CSCC takes action to protect residents from physical and/or psychosocial harm during and after an investigation . Reporting/Response .Reporting alleged violations to the Administrator/Abuse Coordinator/designee, state agency, adult protective services and to all other required agencies, if needed, (e.g., law enforcement when applicable) within specified timeframes .Immediately (the Abuse Coordinator has 2 hours to report to the State Agency), after forming suspicion of abuse OR if the allegation involves abuse OR results in serious body injury . Resident #101 (R101) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R101 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that hypertension (high blood pressure), heart failures, diabetes, psychotic disorder, and depression. The MDS reflected R101 had a BIM (assessment tool) score of 9 which indicated his ability to make daily decisions was moderately impaired, and he required two person physical assist with bed mobility, transfers, toileting, dressing and one person physical assist with hygiene and bathing. The MDS reflected R101 did not have behaviors including being physically or verbally aggressive with staff or refusal of care. Review of an Incident/Accident Alleged Abuse document, dated 1/26/23 at 11:14 a.m., reflected, Nursing Description: CNA informed writer that resident had new onset swelling and bruising to left hand. Resident's posterior left hand and digit four and five has dark bruising, swelling present. Resident able to perform ROM in left hand, intermittent pain .Resident Description: Resident states to writer that he was woke up yesterday morning by CNA. Resident states things were fuzzy, but CNA proceeded to grab his hand and bend it. Resident describes CNA as a short, black women. The document indicated R101 was alert to person, place and situation. The document reflected Nursing Home Administrator in training (NHAIT) C, Social Worker (SW) I and the Physician were notified. Review of the FRI investigation, dated 1/26/23, included a five-day summary that reflected, C.N.A [named CNA N] was assigned to [named R101] 1/25/23 2:00PM - 10:30PM. Based off [named R101] description, Administrator in Training and scheduler interviewed [named CNA N] and told her based on the allegations of abuse that she was not allowed in the facility until the investigation was completed. [named CNA N] reported that they were wrestling. When asked to explain wrestling she stated Resident was pushing hands away when she tried to give care. She was rolling him from side to side to do a complete bed change because it was wet. Nurse [named LPN H] entered the room to give meds she could tell [named R101] was agitated and told [named CNA N] not to return to his room for the remainder of the night. Continued review of the investigation included a written statement, dated 1/26/23, signed by CNA G. The statement reflected, Res wanted to sleep in till 10ish went in to do care his left hand was bruised. Res stated that a cena grabed him, stated it was broke. I went and informed unit manager. Continued review of the investigation reflected two interviews with other residents who had reported concerns with CNA N with requests to not receive care from CNA N. Review of the resident interview for room [ROOM NUMBER](same hall as R101), dated 1/26/23 and signed by SW I, reflected, I do think that CNA [named CNA N] is rude and mean! I don't want her back in my room b/c last night around 6:30 p.m. I heard a gasp coming from room [ROOM NUMBER] then I heard [named resident in room [ROOM NUMBER]] crying with [named CNA N] saying You tried to hit me [named resident in room [ROOM NUMBER]] then said no, I didn't and continued to cry! I pushed my call button and after a 1/2 hour I told the nurse [named resident in room [ROOM NUMBER]] was crying .I just don't want [named CNA N] helping me b/c she is not nice. Review of the resident interview for room [ROOM NUMBER] (CNA N assignment 1/25/23 3rd shift), dated 1/26/23 and signed by SW I. The statement reflected, The other day (Tues. evening 1/24/23) the [named CNA N] came into the room grumpy she seemed to be rushed. When transferring me to my chair she pushed my bedside table forcefully breaking the picture frame, she then said, you people have to much stuff here! Last night the same CNA came into my room with the same grumpy attitude and she was with another CNA in which she was training! She told the trainee to get a brief ready b/c we have too much to do. She put me on the toilet continuing to grumble about having so much to do and having to train someone. When she put me on the sit to stand I told her not to high, she said, get used to it. She said the sling twisted causing my skin to get sore .I would prefer if that CNA does not work with me. The investigation reflected no evidence of skin assessments for residents who were unable to report concerns(non-interviewable) with care or evidence that all residents had been interviewed. Review of R101 Nursing Progress Notes, dated 1/26/2023 at 11:24 a.m., indicated, .New order for STAT 2 view XR of left hand, order placed into PCC. Review of the Progress Note, dated 1/26/2023 at 11:44 a.m., reflected, It was brought to this writer's attention by the Unit Nurse Manager that resident made allegations towards a staff member when a bruise on his left hands was noticed this morning. This writer met with resident, and he was alert sitting in his bed . Resident showed this writer his left hand that showed significant bruising on the pinky and on the front of his left hand below his ring and pinky finger. This writer asked if he could tell her what happened. He said he was sleeping yesterday and a CNA (describe as a short, not heavy Mexican or Black female) brought him his breakfast tray and said wake up your food is here .This writer told him that was ok and ask if he could explain what she did to hurt his hand. He said she squeezed it as she was rocking him side to side. He said she was rocking him to get him up he thought. He then said she seemed upset that he was foggy .SW: when she the left the room did you call for help? Resident: No! I did not have to because the other person came in the room (could not describe her) and he told that other person I want her out of my room and I do not want her to come back .SW: Are you sure it was breakfast? Because you take naps during the day and I want to make sure this person does not come back to your room! Resident: He responded let me think!! He then said it was dinner! I am sure it was dinner .This writer asked if he felt safe in this facility and he said I don't have a problem with anyone but I do not want her back in my room because I do not feel safe with her . Review of R101 Interdisciplinary Team Note, dated 1/26/2023 at 4:30 p.m., Left hand XR results received. Reports states the following; There is a fracture involving the proximal 5th phalanx with mild displacement. There is associated soft tissue swelling . Review of the Radiology Report, dated 1/26/23 at 1:11 p.m. reflected R101 had an acute fracture of the proximal 5th phalanx with mild displacement and soft tissue swelling. Review of R101 Progress Note, dated 1/26/2023 at 9:17 p.m., reflected, Resident returned from [named hospital] approximately @ 2020p via EMT on stretcher. Resident arrived with splint on left hand with pinky finger wrapped. Resident is calm and cooperative with care. No c/o pain or discomfort voiced at this time . Review of the Hospital Records, dated 1/26/23, reflected R101 had reported CNA staff had hurt left hand and caused pain. During an interview on 3/15/23 at 11:28 a.m., NHAIT C reported agency staff do not punch in, but they do have hours staff worked and would provide documentation. NHAIT C reported agency staff are provided folder of items to complete upon starting employment at facility that included skills checklist and abuse training and reported some staff do not turn in documentation to Human Recourses. NHAIT C reported facility did not have evidence of skills checklist or abuse training for CNA N. Review of the Agency Staffing Company Invoice, dated 1/24/23 to 1/31/23, reflected CNA N worked at the facility from 1/25/23 at 2:00 p.m. to 6:00 a.m. on 1/26/23 as evidenced by hours worked. During an observation and interview on 3/15/23 at 11:48 a.m., R101 was observed in bed and appeared calm able to answer questions. R101 was asked if he had concerns of anyone ever being physically rough with him at the facility. R101 reported he had one time when staff grabbed left hand and turned and squeezed it very hard and hurt him around the time they were taking tray out of room. R101 reported was unable to recall staff name but reported had dark complexion skin. Reported felt safe and had not had any other incidents with anyone being physically rough or verbally inappropriate with him since. R101 reported incident happened and another staff member came in and he reported he did not want that CNA to come in room again and verified had not seen that CNA staff since. R101 left pinky finger was noted with no splint in place and appeared to be abnormally bent compared to right hand. During an interview on 3/15/23 at 12:41 p.m., CNA G reported was working with R101 on 1/26/23 and reported R101 was not a morning person and liked to sleep in. CNA G reported entered R101 room between 10:00 a.m. and 10:30 a.m. to provided morning care and pulled back blankets and noticed R101 left hand was severely bruised and black in color. CNA G reported she asked what had happened to R101 hand and he reported a black women grabbed him aggressively. CNA G reported she exited the room immediately and reported to Unit Manager Licensed Practical Nurse (LPN) F. CNA G reported she completed a written statement and reported everyone working should have competed statement because that was the protocol. CNA G reported R101 did not tell her when incident happened and reported she had arrived that day at 6:00 a.m. CNA G reported R101 required total care and was alert and oriented with slight forgetfulness and able to express needs. CNA G reported R101 breakfast tray was not delivered to him prior to her entering room that day. During a telephone interview on 3/15/23 at 4:20 p.m., Licensed Practical Nurse (LPN) H reported had worked at the facility as an agency staff for the past seven months. LPN H reported was R101's nurse on 1/25/23 second shift and recalled R101 being agitated that day and had told CNA N to be aware with care. LPN H reported R101 was upset because he could not say what he wanted to say that day. LPN H reported she entered R101 room, and he was yelling and swing at CNA N and reported that was very unlike R101 and LPN H reported asked CNA N to leave R101 room and not come back. LPN H reported documented incident in Progress Notes and reported R101 was upset and would not speak with staff and did not report pain. LPN H reported there was not an on-call manager on that night so reported to next shift nurse about incident. LPN H reported received call form NHAIT C on 1/26/23 and was questioned and received education about reporting because R101 was not at all at his baseline, and she had never observed him acting like that and was informed should have reported immediately. LPN H reported CNA N worked a double that night (2nd and 3rd shift) and was moved to another hall for 3rd shift. LPN H reported recalled two other residents who had reported did not want CNA N to care for them again that evening located in room [ROOM NUMBER](same hall as R101) and 127(CNA N 3rd shift assignment). Review of R101 Nurse Progress Note, dated 1/25/2023 at 7:36 p.m., reflected, Resident refused to get accu check, refused all medications and insulin's. Resident was yelling and combative with staff. Safety and comfort measures were maintained. Note was written by LPN H. During an interview and record review on 3/16/23 at 9:00 a.m. Human Resource Manager (HRM) K provided Employee File for LPN H that reflected no evidence of abuse training or discipline. HRM K verified had received complete employee files for requested staff. Scheduler L joined the interview and reported she was responsible for scheduling agency and did not have any records of agency training or disciplines. During an interview on 3/16/23 at 9:24 p.m., LPN F reported was working on 1/26/23 as Unit Manager when CNA G reported to her that R101 had a bruise to his left hand. LPN F reported CNA G had reported R101 told her a CNA staff had hurt his hand and CNA G immediately reported to her (LPN F). LPN F reported she immediately interviewed R101, who reported CNA staff bend his hand and hurt him and was unable to recall name but described CNA as short black female. LPN F reported R101 reported incident happened around meal service. LPN F reported no one fitting that description was working at that time. LPN F reported incident was reported to NHAIT C, Social Worker (SW) I and Physician who was in the facility at the time. LPN F described R101 left hand as black darkish purple colored bruising and swelling. LPN F reported Physician ordered STAT Xray and received results in about two hours R101 had positive fracture of left pinky. LPN F reported R101 was alert and oriented with occasional forgetfulness. LPN F reported R101 was a nice guy with no history of combative behaviors and would describe R101 behavior on 1/25/23 an example of catastrophic reaction because R101's reaction was very unlike him. LPN F reported R101 was sent to the emergency room and returned with a large splint from fingers to above left elbow and was compliant with splint. LPN F reported R101 did follow up with orthopedic consult after incident. Review of R101 Orthopedic Consult, dated 2/8/23, reflected, Chief Complaint patient presents with Left Hand-Injury DOI 1/26/23 x 1w, 6d. Pt got his left hand grabbed by a CNA and his left little finger bent. He was seen in the ER and splinted. History of Present Illness .He states that the injury occurred when he was grabbed by a CNA and his left hand was struck into a bed rail and he had immediate pain .He reports this his finger is doing better and is less painful than when the injury occurred .Imaging: 02/08/23 Xray: My independent interpretation of radiographs of the left small finger demonstrates a displaced fracture of the small finger proximal phalanx with angulation toward the ulnar side .Plan .Given his physical exam and other health issues I do not recommend surgical interventions; he will still have functional use of his finger. At this point he will be placed in a left ulnar gutter splint .Advised to keep the hand elevated for edema control. No major use of the left upper extremity. This fracture can take 3-5 weeks to heal . Review of R101 Orthopedic Consult, date 2/24/23, reflected, Imaging: 02/24/23 .stable appearance of proximal phalanx base fracture .fracture is not yet healed .he was transitioned from a splint to buddy straps. He will wear the buddy straps for the next 2 weeks. We will see him in clinic in 2 weeks with interval radiographs . Review of the Electronic Medical Record reflected same residents lived in rooms 109, 111 and 127 currently as when interviewed on 1/26/23. During an interview on 3/16/23 at 9:50 a.m., entered room [ROOM NUMBER](same hall as R101). Resident alert and oriented and able to answer questions and verified was questioned by SW I about concerns with CNA N. Resident reported informed SW I CNA N was, impatient, abrupt, and condescending. Resident reported informed SW I had heard resident in 111 crying when CNA N was providing care the night before SW I interviewed resident (1/25/23). Resident reported heard CNA N yell at resident in room [ROOM NUMBER] not to hit her. Resident reported did not believe resident in 111 would ever hit staff and had never heard resident cry out in distress like that. Resident verified statement taken on 1/26/23 by SW I that reflected Resident had a BIM score of 12(cognitively intact). During an interview on 3/16/23 at 10:10 a.m., entered room [ROOM NUMBER] (shared bathroom with room [ROOM NUMBER]). Resident reported unable to recall speaking with SW I about care concerns and reported had no memory of CNA N. During an interview on 3/16/23 at 10:17 a.m., entered room [ROOM NUMBER] (CNA N 3rd shift assignment 1/25/23). Resident verified statement and reported residents should not feel like they are a burden to staff and reported CNA N made her feel that way and reported if she did not need assistance she would not ask. During an interview on 3/16/23 at 10:42 a.m., SW I reported had interviewed R101 about the abuse allegation on 1/26/23. SW I reported R101 told her CNA staff was being rough with him and bent hand back. SW I reported observed dark bruising on R101's left hand and looked like someone squeezed hand. SW I reported investigation done and CNA N was removed from schedule related to R101 description, staff interviews and other resident interviews. SW I reported R101's biggest concern was he did not want that CNA N back. SW I reported R101 was a little foggy on incident time of day initially but clarified was dinner time the day prior (1/25/23). SW I reported did interview few residents on R101 hall post incident with some reported concerns with CNA N as well as complaints reported by resident in room [ROOM NUMBER] on other nursing hall. SW I reported put it together and determined was same CNA N that had new assignment on 1/25/23 3rd shift after R101 incident. SW I reported did not interview all interviewable residents just a few and unable to answer why. During a telephone interview on 3/16/23 at 4:44 p.m., LPN M reported was R101 nurse on 1/25/23 third shift starting about 10:00 p.m. LPN M reported heard agency CNA N hurt R101 hand or bent back finger on 1/25/23 second shift couple days later. LPN M reported could not recall if she went into R101 room during 1/25/23 shift between 10pm and 7am on 1/26/23 and reported if she had noticed anything abnormal, she would have documented in progress note. LPN M reported did not complete witness statements and was not involved in investigation. LPN M reported did recall resident in room [ROOM NUMBER] reported had overheard resident in room [ROOM NUMBER] verbal altercation with CNA N and reported had told LPN M she did not want that CNA N caring for her on 1/25/23 3rd shift. LPN M reported same night resident in room [ROOM NUMBER] reported to LPN M did not want CNA N to care for her. LPN M reported did not recall why and did not report to management. During a telephone interview on 3/20/23 at 8:22 a.m., NHAIT C reported completed the investigation for R101 FRI on 1/26/23. NHAIT C reported was notified of R101's left hand bruising the morning of 1/26/23 by LPN F. NHAIT C reported was told CNA G identified R101's new bruising to left hand who immediately reported to Unit Manager LPN F. NHAIT C reported LPN F ordered Xray after contacting Physician, and reported NHAIT C contacted local police, Adult Protective Services, state agency, CNA registry, and spoke with SW I who assisted with investigation. NHAIT C reported she contacted CNA N because she was only staff that met description and informed not to return to the facility and obtained statement. NHAIT C reported had interviewed LPN H (R101 nurse 1/25/23 2nd shift) who had reported had walked in R101 room on 1/25/23 and observed R101 very agitated during care with CNA N. NHAIT C reported LPN F asked CNA N not to come back to R101 room. NHAIT C reported the investigation was inconclusive because she could not say for sure R101 was abused and reported R101 was, adamant about how incident happened and verified R101 was own responsible person. NHAIT C reported during investigation other residents who received care from CNA N between 1/24/23 and 1/26/23 reported CNA N was rough and rude. NHAIT C was queried, would you expect staff to report rough and rude staff as potential allegation of abuse? NHAIT C stated, No, because other residents did not report abuse and stated they felt safe and reported would expect staff to ask what was meant by rough and rude. During a telephone interview on 3/20/23 at 10:18 a.m., NHAIT C reported skin assessments were not competed for non-interviewable residents during R101 investigation for residents who were cared for by CNA N on 1/25/23 2nd and 3rd shift. NHAIT C reported only a few residents were questioned about CNA N care because of BIM scores. NHAIT C reported did speak with LPN H during R101 investigation, who reported had asked CNA N not to enter R101 again because of his witness agitation with CNA N. NHAIT C reported would not expect LPN H to report R101 unusual behavior. NHAIT C was unable to say was a resident catastrophic reaction was. NHAIT C was queried if LPN H was provided abuse education during R101 investigation of after? NHAIT C reported everyone received abuse education after most recent abuse Plan of Correction.

This citation pertains to MI00134129 Based on interview and record review the facility failed to prevent falls for one (Resident #6) of one reviewed, resulting in multiple falls and falls with major injuries that included a wrist fracture and a head laceration requiring staples. Findings include: Review of the medical record revealed Resident #6 (R6) admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, epilepsy, vascular dementia with psychotic disturbance, visual loss, and a fall with femur fracture. The significant change Minimum Data Set (MDS) with an Assessment Reference Date of [DATE] revealed R6 scored 4 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS), required extensive assistance of one to two staff for Activities of Daily Living (ADLs), had one fall with injury except major, and one fall with major injury since prior assessment. The significant change MDS with an ARD of [DATE] revealed R6 scored 3 out of 15 (severe cognitive impairment) on the BIMS and required extensive assistance of two people for transfers and toilet use. R6 died in the facility on [DATE]. Review of R6's fall care plan initiated [DATE] revealed R6 was at risk for falls, at times may try to transfer/ambulate herself, and had poor safety awareness. Review of the Fall Risk Evaluation dated [DATE] revealed R6 scored 18. The evaluation revealed If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan. Clinical suggestions selected included Rubber-soled shoes or nonskid slippers worn for ambulation and Utilize personal/pressure sensor alarms. Utilize toileting program was also listed as a clinical suggestion but was not selected. Review of R6's fall care plan revealed proper footwear had been an intervention in place since [DATE]. Personal/pressure sensor alarm was not added to the care plan after the [DATE] Fall Risk Evaluation was completed. Review of R6's Incident Report dated [DATE] revealed Resident was sitting in her w/c [wheelchair], in her room with CENA [Certified Nursing Assistant] at her side. When she apparently was responding to mechanical dog that was in her room. She reached for the floor thinking that the dog was at her feet, falling face first onto the floor. She received a 2cm [centimeter] cut to the top of her head . Review of R6's falls care plan revealed there were no new interventions implemented after her fall out of the wheelchair on [DATE]. In a telephone interview on [DATE] at 3:38 PM, CNA I reported R6 was very confused, blind, and fell a lot. CNA I reported on [DATE], she caught R6 leaning over in her wheelchair, calling a dog. CNA I reported she walked towards R6, asked her to sit up, and R6 fell forward. CNA I stated she would sit forward and lean forward a lot. Review of the Fall Risk Evaluation dated [DATE] revealed R6 scored 24. The evaluation revealed If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan. The same clinical suggestions were listed as the [DATE] evaluation, however none of the suggestions were selected. R6's fall care plan was not updated nor were new interventions added after the fall risk score increased on [DATE]. Review of R6's Incident Report dated [DATE] revealed Resident was found on the floor near the bathroom in her room. Resident complaining of pain in the R [right] wrist and back .ROM [range of motion] WNL [within normal limits] except limited ROM to right wrist. Resident stated that she was trying to go to the bathroom but she fell . Did not use the call light for assistance. Review of the x-ray results dated [DATE] revealed R6 sustained an acute distal radial fracture. The incident report did not include any new interventions. Review of the care plan revealed an intervention was added on [DATE] (5 days after the fall) and included a sensor pad alarm on the bed and chair. In a telephone interview on [DATE] at 8:40 AM, CNA M reported she worked the night R6 fell and fractured her wrist. CNA M stated I heard something, went in there [resident's room], found her on the floor. CNA M could not recall any details about the incident. Review of the Fall Risk Evaluation dated [DATE] revealed R6 scored 24. The evaluation revealed If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan. The same clinical suggestions were listed as the [DATE] and [DATE] evaluation, however none of the suggestions were selected. Review of the Behavior Note dated [DATE] revealed Resident attempting to get out of bed. Her alarm was sounding an [sic] the resident was observed in the praying position beside her bed .it appeared that she climbed out .She has been restless during the night thinking that it is time to get up. Review of R6's fall care plan revealed there were no new interventions added after the fall on [DATE]. Review of the Fall Risk Evaluation dated [DATE] revealed R6 scored 18. The evaluation revealed If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan. Clinical Suggestions included Rubber-soled shoes or nonskid slippers worn for ambulation and Utilize toileting program. Neither of the clinical suggestions were selected. Review of R6's Incident Report dated [DATE] revealed Writer was called to the room by the cna. Resident was observed sitting in recliner chair in room. When asked what happened cna stated when wheeling resident out of bathroom she leaned forward in chair and fell to the ground. Pt [patient] was observed with a [sic] injury to her scalp . The incident report revealed R6 was transferred to the hospital. Review of the hospital records dated [DATE] revealed pt was getting pushed in her wheelchair by the CNA when she fell forward and hit her head. Pt does have a laceration to her forehead. The hospital records revealed R6 required five staples to repair the laceration. Review of a facility statement/interview with CNA D revealed she [CNA D] stated they had the resident in the bathroom getting her ready for bed. They transferred her into the chair & scooted her back. Resident lunged forward & fell out of the chair. CNA did range of motion & then had other agency CNA help get the resident off the floor & into the recliner so they could see where she was bleeding from. Then they called nurse down to assess. In a telephone interview on [DATE] 2:30 pm, CNA D reported she was an agency aide who only worked at the facility a couple shifts. CNA D reported on [DATE], the dementia unit was staffed with two aides and one nurse. CNA D reported she worked a double shift on [DATE] and that day, R6 continually bent over trying to pick up stuff off the floor so staff had to place her in the recliner to prevent her from doing so. CNA D reported her and another aide were getting R6 ready for bed, but the other aide was needed to sit in the dining room with the other residents, so she stepped out of R6's room while CNA D waited for her to return. CNA D stated I waited, but by that time [R6] dove over the side of her wheelchair and hit her head. I went and got the nurse. CNA D reported she witnessed R6 fall out of her wheelchair and described the fall as R6 bending over to try to pick up something off the floor and just fell out headfirst. CNA D reported she thought R6 was a fall risk but was unable to list any fall interventions that were in place at the time of the fall. CNA D reported R6 did not have an alarm in place at the time. In a telephone interview on [DATE] at 11:49 AM, CNA N reported on [DATE], R6 was leaning in her chair a lot. CNA N reported that evening, she was taking another resident to their room when she heard a noise. CNA N reported she left the other resident outside the room and entered R6's room where she saw R6 on the floor and CNA D in the room. CNA N reported she assisted CNA D with getting R6 off the floor and into the recliner before notifying the nurse. CNA D was unable to report what fall interventions were in place at the time but reported she did not hear a fall alarm sounding. In a telephone interview on [DATE] at 12:07 PM, Licensed Practical Nurse (LPN) R reported on [DATE], she was called into the room after R6 was placed back into her recliner by the CNAs. LPN R reported R6 had a laceration towards the front of her scalp and R6 was transferred to the hospital. In an interview on [DATE] at 8:56 AM, LPN L reported the nurse on duty at the time a fall risk evaluation was due, completed the evaluation. LPN L reported depending on the score, the facility would try to put interventions in place. LPN L reported the computer automatically populated clinical suggestions for interventions and if a clinical suggestion was selected, that meant it was implemented as an intervention. In an interview on [DATE] at 9:23 AM, Director of Nursing (DON) B reported the computer automatically populated clinical suggestions for the Fall Risk Evaluations. DON B reported if the clinical suggestions were selected/checked, that meant the interventions were implemented. DON B reported on the [DATE], [DATE], and [DATE] Fall Risk Evaluations, all clinical suggestions should have been selected. DON B was unable to provide any new fall interventions that were implemented due to the increase in fall risk evaluation score. The only new intervention that was implemented related to R6's falls was a fall alarm on [DATE]. DON B did not have a root cause analysis of R6's falls.

This citation pertains to Intake: MI 247, MI 816 Based on observation, interview, and record review, the facility failed to monitor, supervise, and provide an environment free from abuse and protect five residents (R9, R26, R32, R40 and R43) of eight residents reviewed for abuse resulting in Immediate Jeopardy when the facility failed to prevent continued resident to resident abuse. Findings include: Review of the facility's CMS-672 Resident Census and Conditions of Residents dated 4/12/22 revealed the facility's census was 54, of which 36 required assistance of one or two staff for bathing, 54 required assistance of one or two staff for dressing, 48 required assistance of one or two staff for transferring, 51 required assistance of one or two staff for toilet use, and 24 required assistance of one or two staff for eating. The CMS-672 also revealed 18 residents were dependent on staff for bathing, 3 were depending on staff for transferring, and 3 were dependent on staff for toilet use. Resident #32(R32) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R32 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS reflected R32 had a BIM (assessment tool) score which indicated her ability to make daily decisions was severely impaired, and she required one person physical assist with bed mobility, transfers, locomotion on the unit, dressing, toileting, hygiene, and bathing. The Face Sheet reflected R32 had activated Durable Power of Attorney(responsible party). During an observation on 4/12/22 at 2:40 PM, R32 was observed sitting in the Meadows Dining Room common area with several other residents present. R32 appeared calm and well groomed. Resident #40(R40) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R40 was a [AGE] year old female admitted to the facility on [DATE] , with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS reflected R40 had a BIM (assessment tool) score which indicated her ability to make daily decisions was severely impaired, and she required two person physical assist with bed mobility, transfers, locomotion on the unit, dressing, toileting, and one person physical assist with hygiene, and bathing. The Face Sheet reflected R40 had activated Durable Power of Attorney(responsible party). During an observation on 4/12/22 at 2:41 PM, R40 was observed sitting in the Meadows Dining Room common are looking out the window and appeared calm and well groomed. Resident #26(R26) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R26 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS reflected R26 had a BIM (assessment tool) score which indicated his ability to make daily decisions was severely impaired, and he required one person physical assist with bed mobility, transfers, locomotion on the unit, dressing, toileting, hygiene, and bathing. The Face Sheet reflected R26 had activated Durable Power of Attorney(responsible party). During an observation on 4/12/22 at 2:27 PM, activity staff L was observed walking with R26 down hall to room on Meadows Unit. R26 appeared well groomed and pleasantly confused. Review of the Admission Summary Progress Note, dated 9/29/2021 at 2:54 p.m., for R26, reflected, Resident arrived to facility at 1100 via facility transport .Resident A&O x 1. Not easily redirected. Immediate exit seeking upon arrival to facility. Wander guard placed at left wrist . Review of the R26's COMMUNICATION - with Family/NOK/POA Progress Note, dated 9/30/2021 at 2:56 p.m., reflected, I spoke to the granddaughter of [named R26] today about memory care facilities for him. Resources was given to the granddaughter to look into .Would there be room for him to transfer to the Meadows? There is not a plan in place for him to return home, it would not be safe. The granddaughter did mention that [named R26] was also violent at HFHS . Review of the Nursing Progress Note, dated 12/27/2021 at 9:56 p.m., for R26, reflected, Resident displaying inappropriate behaviors with female residents. Tried to put his hand down a residents pants and kissed another resident on the mouth. Has previously stated I'm going to be in one of the rooms having sex. During a interview on 4/21/22 at 10:26 AM, RN CC reported had worked at the facility for 9 months and most often worked on Meadows. RN CC reported was familiar with both R26 and R43 and were not own responsible persons with poor memory. RN CC reported R26 has history of behaviors including exit seeking and likes the ladies and tries to kiss R40 and R43. RN CC verified she had completed Progress Notes for R26, dated 12/27/21 that involved R43 as female resident. RN CC reported does not recall if she reported to anyone and reported knows now, after 4/16/22 Abuse training, that she should have documented it as behavior and reported to management staff immediately. RN CC reported did not report 12/27/21 incident as Abuse allegation, complete Unusual Occurrence Document, investigation, or make changes to Care Plan and verified R26 was not care planned for sexual behaviors. RN CC reported knows now that was an allegation of sexual abuse that should be reported immediately. RN CC reported a few residents on Meadows Unit expose themselves to other residents and in past staff attempt to redirect residents to assist with dressing but reported after recent Abuse education incident should be reported as allegation, document behaviors and residents care plans should be updated. Review of the Nurse Progress Note, dated 3/20/2022 at 12:47 p.m., for R26, reflected, needed many redirections away from female residents. cooperative with redirection, but didn't have any [MEDICATION(S)] effect. Review of the Care Plans, dated 9/21/21 through 4/14/22, for R26, included intervions, Cue, reorient and supervise as needed. The Care Plans reflected no mention of inappropriate sexual behavior or no evidence of intervention added after 12/27/21 documented sexual behaviors or 3/15/22 incident. Resident #43(R43) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R43 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS reflected R43 had a BIM (assessment tool) score of 4 which indicated her ability to make daily decisions was severely impaired, and she required one person physical assist with bed mobility, transfers, toileting, hygiene, bathing and two person physical assist with dressing and set up assist for locomotion on unit in wheelchair. The Face Sheet reflected R43 had activated Durable Power of Attorney(responsible party). During an observation on 4/12/22 at 2:43 PM R43 was observed with several other residents in the meadows dining room, sitting in recliner with feet elevated, eyes closed, covered with green blanket. Review of the Nurse Practitioner Notes, dated 3/15/22, for R43, reflected, Chief Complaint /Nature of Presenting Problem: Interaction with another resident .Pt is 82 y/o female, long term care resident at the facility, being seen for interaction with another resident last night. Per nursing report, d/w DON, pt apparently held hand of another resident and wheeled into a room, few minutes later staff found the other resident undressed and intimate with pt, no actual intercourse/penetration was noted. Needed 2 other staff members help to put brief and clothes on male resident . During an interview on 4/13/22 at 2:43 PM, Unit Manager (UM) R reported was responsible for all the the facility Incident and Accident Reports. Requested was made for all Incident and Accident Reports with complete investigation for R43 for three months. During an interview and record review on 4/13/22 at 2:57 PM, UM R provided five Fall Investigations for R43 for the past three months and reported that was all of the Incident and Accidents for R43 for past three months. Review of the provided documents reflected no evidence of 3/15/22 or 3/14/22 incident involving a male resident. During a telephone interview on 4/13/22 at 3:02 p.m., Certified Nurse Aid (CNA) KK reported worked on the Meadows Unit that had several residents with dementia and behaviors. CNA KK reported was frequently required to work as only CNA on second shift on the Meadows unit and reported was unsafe related to several two person assists, increased behaviors, fall risks, and residents that require frequent supervision. CNA KK reported did not have access to Electronic Medical Records(EMR) for residents including Kardex and reported received verbal report from prior shift and communicate with nurse but had no access to EMR to document. CNA KK reported had been scheduled to work shortly after incident when R43 and R26 were found naked in R26's room together as only CNA for Meadows Unit and refused to work alone because of incident. CNA KK reported was not present for incident but occurred week prior to 3/20/22. CNA KK reported was an Agency Staff for several weeks and did not receive abuse training or dementia training from the facility or Agency prior to or during employment. During an interview on 4/13/22 at 3:48 PM, Nursing Home Administrator(NHA) A reported was also the facility abuse coordinator and had worked at the facility since February 2022. NHA A reported the facility only had one allegation of abuse in the past two months and verified it was reported to the State Agency. Review of an Email on 4/13/22 at 4:24 PM, sent by NHA A, reflected the facility had two allegations of abuse in past two month. No mention of the incident between R43 and R26 prior to 3/15/22 Provider note. During a telephone interview on 4/13/22 at 5:02 PM, Registered Nurse (RN) FF reported had worked at facility for eight years. RN FF reported worked the evening of 3/14/22 into 3/15/22, night shift, on both the Meadow and Rehab Unit and reported another nurse worked on Nursing Unit for total of two nurses. RN FF verified one CNA staff on meadows second shift was Agency CNA DD. RN FF reported CNA DD alerted him between 10:00 p.m. and midnight that R43 and R26 were found in R26 room with R43 in R26's bed and R43 pants down saying he wanted to have sex with R43. RN FF reported CNA DD informed him they could not get R43 out of the room. RN FF reported arrived to R26 room and found R43 in R26's bed under blankets and R26 at the side of the bed with pants down and stating he wanted to have sex with R43. RN FF reported residents were separated and R43 was moved to open room on Rehab Unit for the night and R26 remained in room. RN FF reported R26 had pushed R43 in wheelchair into his room prior to CNA DD staff finding R43 and R26. RN FF stated both residents were, demented and not own responsible persons. RN FF reported he was not able to redirect R26 to be able to get R43 out of the room at first and had to go get CNA VV from Rehab Unit, who was able to redirect residents and move R43 to Rehab Unit. RN FF reported received call from Director of Nursing B because she had been alerted of incident by another nurse, Licensed Practical Nurse (LPN) JJ. RN FF reported informed DON B about incident and reported DON B advised him to complete statement and start 15 minute checks for R43 and R26. RN FF reported prior incident R26 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . RN FF reported after the incident attempts to keep R26 away from R43 but reported R26 has kissed R43 a couple of times since 3/15/22 incident. RN FF reported spoke with DON B on the night of 3/15/22 because at the time of incident was not sure how to address and reported not allegation of abuse because both residents were two consenting adults and they did not have sex. RN FF reported CNA safety was more of a concerns because residents were being combative toward staff. RN FF was unable to answer how he knew they were both consenting. RN FF reported completed 15 minute checks, written statement, and called both R43 and R26 responsible party's and immediate interventions were to always have two CNA staff on the Meadow Unit after the incident. RN FF reported had never observed abuse at the facility and did not receive training after the incident. RN FF was able to name 4 of 8 types of abuse. During telephone interview on 4/14/22 at 8:46 AM, LPN JJ reported working at the facility for [AGE] years and verified working on evening of 3/14/22 through 3/15/22 on Nursing Unit with one other nurse RN FF in the building on Meadows and Rehab Units. LPN JJ reported was informed by CNA QQ R43 and R26 were found in R26 attempting to have sexual involvement with each other and Meadows CNA DD had requested assistance separating residents. LPN JJ reported called DON B two times to report incident because both R43 and R26 lived in Dementia Unit and were attempting to have sexual involvement with each other and stated, if mentally impaired they do not know what is going on. LPN JJ reported was an allegation of sexual abuse. During an interview on 4/14/22 at 9:23 AM, CNA VV reported working at facility for [AGE] years and usually worked nights. CNA VV reported was working Rehab Unit 3/14/22 night shift through 3/15/22 with RN FF. CNA VV reported RN FF and Meadows CNA DD requested assist with separating R43 and R26. CNA VV reported entered R26 room and CNA DD was present and unable to redirect residents. R43 was laying in R26's bed covered and R26 was standing at the bedside. CNA VV reported R26 was irritated because staff would not let him touch R43 and became aggressive toward staff when they attempted to removed R43 from room. CNA VV reported was able to redirect residents and moved R43 into empty room on Rehab Unit for night. CNA VV reported usually 2 to 3 CNA staff on nursing, 1 to 2 CNA staff on Meadows and 2 to 3 nursing staff in facility on nights. CNA VV reported immediate interventions after incident were to separate R43 and R26, and frequent monitoring. CNA VV reported neither R43 or R26 were alert and oriented and unsure if incident was reported but believed management was aware. CNA VV reported incident should have been reported because allegation of sexual abuse related to R26 acting upon R43 in a manor she may not want. CNA VV reported all allegation of abuse should be reported to DON B, ADM A, State agency and possibly the local law enforcement. CNA VV reported knowledge of how to care for residents by reviewing Kardex before each shift. CNA VV reported R26 had behaviors that including taking pants and brief off and walking around in common areas without paints and staff would redirect R26 back to room to assist with dressing. CNA VV reported behaviors were documented in EMR and nurses would also document behaviors. CNA VV reported if residents expose themselves to other residents that was documented as behaviors and staff redirects residents to assist with dressing. During an interview on 4/14/22 at 10:17 AM, DON B reported received telephone call from CNA staff about R43 and R26 incident related to some type of sexual act mid March. DON B reported was informed by CNA staff they had reported to Nurse on duty, RN FF, who did not feel it was of concern. DON B reported was informed by CNA VV that she was needed to assist with incident because of R26 was aggressive toward staff. DON B reported was told R26 wanted to spend time with R43. DON B reported Nursing Home Administrator(NHA) A was notified at the time of the incident. DON B reported investigation was completed and they were not able to substantiate abuse. DON B reported R43 and R26 allegation of sexual abuse was not reported to the State Agency because NHA A and Director of Operations XX did not feel it needed to be reported. DON B reported R43 and R26 allegation of abuse should of been reported to the State Agency because residents were not consenting adults and had both been deemed incapable of making own decisions. DON B reported had investigation in her office. Request was made to review complete investigation. During an interview on 4/14/22 at 11:00 AM, CNA YY reported was not present at the time of the incident with R26 and R43. CNA YY reported often worked on Meadows and reported staffing concerns related to most residents had dementia with behaviors, most required assist with care, and required frequent monitoring and often staffed with one to two CNA staff which made it difficult. During an interview on 4/14/22 at 11:23 AM, Nursing Home Administrator(NHA) A reported started employment at the facility as NHA on 2/8/22. NHA A reported received telephone call from DON B on the evening of 3/14/22 to 3/15/22 and was informed R43 and R26 were found in resident room together and had removed cloths and staff walked in. NHA A reported advised DON B to start 1:1 for each resident, assessments including well being of each resident, notify responsible parties, Physician. NHA A reported investigation started. NHA A revealed the incident was not reported to the State Agency or the Local Law enforcement because she felt as though it was a behavior on R26's behalf. NHA A reported did not feel it was a willful act because neither resident displayed pain or anguish. NHA A reported facility Abuse Policy indicated sexual abuse was defined as non-consensual sexual penetration, or touching. NHA A reported R43 and R26 were questioned and neither remembered incident and NHA A stated, did not appear to not want to participate. NHA A reported discussed with Director of Operations XX who agreed was a behavior. NHA A reported would expect staff to report allegation of abuse within two to twenty-four hours to herself, as abuse coordinator, or the DON B. NHA A stated, if actual harm, you want to report as soon as possible, but as a rule of thumb if I do a reportable I don't wait 24 hours, I do it within 24 hours. NHA A reported recalled discussion about if responsible parties could consent for sexual relations with another resident. Request was made for facility Policy for Sexual Consent. NHA A reported both R43 and R26 were assessed after the incident including skin assessments and reported R43 was assessed by Provider the same day to assess for sexual penetration. NHA A reported was unsure if cameras in Meadows halls had been reviewed or even if there were cameras. NHA A reported would contact maintenance staff to review camera footage with surveyor. NHA A reported would expect staff to document behaviors in both R43 and R26 EMR for incident between 3/14/22 and 3/15/22. During an observation and interview on 4/14/22 at 12:30 PM, this surveyor had not yet been provided with requested Abuse Allegation Investigation for R43 and R26. NHA A was observed in Human Resource Office reviewing camera footage. NHA A reported they were having issues with video feed for timeframe of R43 and R26 incident and reported wanted to make sure it worked before notifying surveyor. NHA A reported DON B was also trying to review Meadows camera footage in different location. This surveyor walked with NHA A to side entrance office. DON B was observed reviewing camera footage and reported was having difficulty obtaining 3/14/22 and 3/15/22 footage. DON B verified footage was available prior to 3/14/22 and after 3/15/22 and would continue to attempt to obtain. This surveyor made second request for R43 and R26 Abuse allegation investigation. DON B handed this surveyor a file folder and reported was complete investigation for R43 and R26 incident from 3/15/22. Review of the provided investigation for R43 and R26 included four witness statements, dated 3/15/22, and a face sheet for R43 and R26. The investigation did not include facility Unusual Occurrence document. Review of CNA ZZ witness statement, dated 3/15/22 at 1:55 a.m., reflected, While back meadows trying to get [R43 room #] out of [R26 room #] bed room nurse [named RN FF] walked in [R26] room observed the situation and told us CNA's to let the residents do what they want and to let resident have there privacy and shut the door. We immediately told nurse [named LPN JJ] and other CNA on Nursing and they called DON . The witness statement was signed by CNA ZZ. Review of CNA DD witness statement, dated 3/15/22 at 1:50 a.m., reflected, [R26's room #] and [R43 room #] were wandering in the hallway when [R26 room #] was guiding [R43 room #] into his room. When I noticed that I got up to go check on both residents in [R26 room]. resident [R43 room #] was in the bathroom and [R43 was on his bed clothed (fully). I let the nurse [named RN FF]know what was going on because I had to go to the bathroom and also couldn't re-direct them on my own. When I came out of the bathroom (maybe 5 minutes) I went to check on the residents. That's when I saw resident [R43 room #] had her head down with her brief down and [R26 room #] had his pants off. I immediately went to get help from another CNA in Nursing. Upon entering the room resident [R26 room #] was getting very violent yelling, threatening, and balling fists up, grabbing some electric hair [NAME] and came after me and the other CNA. We told another nurse and they called the DON. [Named CNA VV] was down there and assisted me with getting resident from [R43 room #] to a safer environment. The witness statement was signed by CNA DD. Review of the RN FF witness statement, dated 3/15/22 at 1:50 a.m., reflected, At 1:50 a.m., I observed Resident [R43 room #] laying on her right side in [R26 room #] bed with blankets over her sleeping. Resident [R26 room #] was sitting on the end of the bed by [R43's room #] covered feet with a sweat shirt on and no pants or brief on. CNA's [named CNA DD] and [named CNA ZZ] attempted to put pull-ups on him but he refused to allow this to put pull-ups on him because he said they were women panties. he also raised his right fist, threatening to hit [named CNA DD and CNA ZZ]. I went to Rehab at 2:00 a.m. and had CNA [named CNA VV] go over to Meadows to see if she could calm him down which she was able to then [named CNA DD and CNA VV] brought [named R43] to the PUI unit in [room #] and layed her down . The Witness statements was signed by RN FF. Review of CNA VV witness statement, dated 3/15, reflected, Went back to help, male resident tried to raise hand but put it down and didn't fight. We then removed female resident from the situation. the Witness statement was signed by CNA VV. During a telephone interview on 4/14/22 at 4:36 PM, CNA ZZ reported did complete witness statement for 3/15/22 incident when R43 was found naked in R26 room and kept copies. CNA ZZ reported was working on Nursing Unit, third shift, when CNA DD, who was working on Meadows Unit as only CNA came and asked for assist with R43 and 26. CNA ZZ reported when she arrived on Meadows Unit observed R43 in R26 room. R43 was located in R26 bed with face down and bottom up and R26 was rubbing R43 side with his hand and neither resident had pants on. CNA ZZ reported R43 was not vocal and R26 was very angry and upset because we(cna staff) were trying to remove R43 from the room. CNA ZZ reported meadows/rehab nurse (RN FF) arrived to the room after her and told CNA staff to leave the residents in the room and give them privacy. CNA ZZ reported that did not set well with her and reported to LPN JJ, nurse working on Nursing Unit who called DON B. CNA ZZ reported that incident would never have happened if they had enough staff working on Memory Unit(Meadows) with all the required supervision and behaviors including wandering. CNA ZZ reported wrote statement that included R26 was in bed with R43, and provided to DON under door prior to leaving 3/15/22. CNA ZZ reported Human Resource staff (HR) GG completed schedules and felt it was ok to have one staff on memory unit and it was not safe. Review of provided witness statements from CNA ZZ on 4/15/22 at 9:30 AM, verified did not reflect specific positioning of residents as indicated in from 4/14/22 interview. During a telephone interview on 4/15/22 at 9:58 AM, CNA ZZ verified witness statement she completed discussed resident positioning on 3/15/22 for R26 and R43 incident and including two pages. Review of the witness statement, provided by CNA ZZ on 4/15/22 10:05 AM, included two pages, one that was provided by the facility on 4/14/22 and one that was not. Review of CNA ZZ's signed witness statement dated, 3/15/22, reflected, I was in Rm 129 when another CNA asked for help in meadows around 1:50 a.m. CNA stated she needed help with [R26 room]. the resident in [R26's room] had another resident [R43 room #] in his bed with her head down and butt up in the air with her pants and brief down. When entering the room [R26 room #] had no pants on rubbing on [R43 room #] side stating he was going to have sex with her. me and other CNA was trying to get [R43 room#] out of [R26's] bed and [R26 room#] Immediately got aggressive with me and other CNA. [R26 room#] came after us with an electric head shaver and balled his fist up trying to punch us and yelling at us telling us to get out out his Rm. During a telephone interview on 4/15/22 at 1:37 PM, CNA DD reported was the only CNA working on Meadows Dementia Unit at the time the incident between R43 and R26 and RN FF was working on both Meadows and Rehab Units. CNA DD reported R43 and R26 were wandering in the hall together and R43 was in wheelchair and R26 was able to independently ambulate. CNA DD reported had informed RN FF she had concerns with them being too friendly with no response. CNA DD reported found R43 and R26 in R26 room during rounds at about 1:50 a.m. and reported was unsure how long they had been in the room together. CNA DD reported she observed R26 with brief and pants off standing next to the bed and R43 was laying in the bed with pants off and brief pulled down and they were kissing on the lips. CNA DD reported attempted to separate residents and R26 began cussing at her, yelling get out, and raising arms at her. CNA DD informed RN FF again with no assist who was in Meadows day room, then left Meadows Unit to get help from CNA ZZ. CNA DD reported CNA ZZ immediately came to R26 room to assist and found R43 and R26 in same positions. CNA DD reported they attempted to fix R26 brief and tell R43 she could not be in there and R26 became combative with staff including R26 was coming after CNA DD with electric shaver. CNA DD reported RN FF entered R26 room and told CNA staff to leave the residents alone and give them privacy and shut the door so other residents can't see. CNA DD reported CNA ZZ left room and immediately reported to LPN JJ who was the only other nurse working, who called DON B. CNA DD reported she continued to attempt to redirect R26 and RN FF offered to send CNA VV from Rehab to assist. CNA DD reported CNA VV was able to redirect residents and transferred R43 to an empty room on Rehab for the remainder of the shift. CNA DD reported had worked the night prior(3/13/22 into 3/14/22) and had reported to RN FF that R26 was getting friendly with R43 with attempts to transfer R43 in common area. CNA DD reported had worked at the facility for two months 4 to 7 days per week and had never received log-in to access EMR and was not able to document at all and was told to verbally communicate with nurse. CNA DD reported often worked Meadows unit and reported worked on Meadows at least three times weekly as only CNA per shift. CNA DD reported received verbal report from second shift on 3/14/22 that R43 was wandering into other female resident rooms. CNA DD reported incident was reported immediately because R43 and R26 were not their own responsible person and did not feel right to allow two residents who were not their own person to be intimate. CNA DD reported completed witness statements and reported did not receive Abuse training or dementia training from the facility for the Agency. During a interview on 4/21/22 at 10:26 AM, RN CC reported had worked at the facility for 9 months and most often worked on Meadows. RN CC reported was familiar with both R26 and R43 and were not own responsible persons with poor memory. RN CC reported R26 has history of behaviors including exit seeking and likes the ladies and tries to kiss R40 and R43. This surveyor questioned RN CC who the female resident was she had completed a Progress Noted for on 12/27/2021 at 9:56 p.m. for R26 that reflected, Resident displaying inappropriate behaviors with female residents. Tried to put his hand down a residents pants and kissed another resident on the mouth. Has previously stated I'm going to be in one of the rooms having sex. RN CC verified she had completed Progress Notes for R26, dated 12/27/21 that involved R43 as female resident. RN CC reported does not recall if she reported to anyone and reported knows now, after 4/16/22 Abuse training, that she should have documented it as behavior and reported to management staff immediately. RN CC reported did not report 12/27/21 incident as Abuse allegation, complete Unusual Occurrence Document, investigation, or make changes to Care Plan and verified R26 was not care planned for sexual behaviors. RN CC reported knows now that was an allegation of sexual abuse that should be reported immediately. RN CC reported a few residents on Meadows Unit expose themselves to other residents and in past staff attempt to redirect residents to assist with dressing but reported after recent Abuse education incident should be reported as allegation, document behaviors and residents care plans should be updated. Review of R43 the Progress Notes, dated 12/13/21 at 1:37 p.m., reflected, Resident has bruise on back, that are yellowing, in what appears to be a pattern of circular shapes going from beneath one shoulder blade, down and up to beneath the other shoulder blade. Review of R43 Progress Notes, dated 12/15/2021 at 6:29 p.m., reflected, blue/purple bruise noticed on left back of hand with swelling. this was not visible last night before this nurse clocked out. will continue to monitor. Review of R43 Progress Notes, dated 1/1/2022 at 11:09 a.m., reflected, Resident has bruising on her left hip/buttock that goes down her leg. Area is hardened and painful. Smaller bruise noted to right buttock that is warm to the touch. Resident has no knowledge of how it happened. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .History Of Present Illness .Evaluating this [AGE] year-old female today who is sitting in her chair. Nursing reports that the patient has had increased confusion, they had stated that she is getting where she is reaching for things that are not there and does seem more fatigued and going to the bathroom constantly. The patient reported she had slight burning when she goes to the bathroom and did have suprapubic tenderness. She also complains that her hips are hurting her along with her hand, she does have bruising noted bilaterally and to the hand as well with [CONDITION(S)], I did reach out to the daughter and did make her aware of this and she is requesting x-rays. Review Of Systems General: Pt not able to provide reliable history seco [TRUNCATED]

Based on observation, interview and record review the facility failed to follow and implement infection control practices per the Centers for Disease Control (CDC) guidelines to prevent the spread of COVID-19 facility wide resulting in Immediate Jeopardy when the facility failed to 1) ensure that facility staff fully utilized Personal Protective Equipment (PPE) for all facility residents including Resident #7, #8, #9, #10, and #11, 2) ensure staff and visitors were comprehensively screened and not entering while symptomatic, 3) ensure nursing staff were using proper contact time for disinfectant products for reuse of patient care equipment and 4) ensure staff performed adequate hand hygiene. These deficient practices resulted in the facility widespread infection of COVID-19 and the likelihood for further cross contamination of COVID-19 to other residents and staff, thereby putting all 62 residents at risk for infection, hospitalization and/or death. Findings include: On [DATE] at 11:10 AM, Nursing Home Administrator (NHA) A reported the facility currently had 49 residents who were positive for COVID-19. Review of the CMS 672 revealed the facility had a census of 62 on [DATE]. The list of residents who were negative for COVID-19 included 12 residents. On [DATE] at 12:56 PM, staff working on the COVID negative hallway were observed in resident rooms in full PPE. When asked about what PPE was required on that unit, Licensed Practical Nurse (LPN) O reported full face shield, N95, surgical mask, gown, and gloves were required for resident care. Multiple nightstands/PPE carts were observed outside of rooms, in the hallway. An observation on [DATE] at 12:46 PM revealed Certified Nursing Assistant (CNA) U was in Resident #7's (R7) room, sitting on R7's bed. CNA U was wearing a face shield, KN95 mask, and a surgical mask, but was not wearing a gown or gloves. CNA U was sitting approximately one foot away from R7 who was sitting in her recliner. CNA U and R7 were passing a cellular phone back and forth. At 12:48 PM CNA U was overheard telling R7 that she would take her to the bathroom. CNA U did not don a gown but closed the door and assisted R7 to the bathroom. Review of the medical record revealed R7 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the R7's physician's orders [REDACTED]. Review of R7's laboratory results collected on [DATE] with results dated [DATE], revealed R7 was positive for COVID-19. Review of the physician's orders [REDACTED]. On [DATE] at 12:47 PM Emergency Medical Services (EMS) arrived in full personal protective equipment (PPE). Licensed Practical Nurse (LPN) V escorted the two EMS personnel to Resident #8's (R8) room. LPN V was observed to enter the room without donning a gown. At 12:50 PM the two EMS personnel and LPN V were observed transferring R8 to a gurney. LPN V was observed touching R8 to assist with the transfer. LPN V was not wearing a gown. EMS was overheard telling R8 they would get him into the gurney and start oxygen. LPN V was overheard telling EMS personnel that R8 was [MEDICAL CONDITION] (high heart rate) and hypoxic (low oxygen levels). Review of the physician's orders [REDACTED]. Review of R8's laboratory results collected on [DATE] with results dated [DATE], revealed R8 was positive for COVID-19. On [DATE] at 12:54 PM CNA U was observed without a gown or gloves while taking two lunch trays out of a resident's room. CNA U placed the trays on the meal cart and then proceeded down the hallway and entered Resident #9's (R9) room. CNA U did not perform hand hygiene nor don a gown or gloves. CNA U was then observed bringing R9's meal tray out of the room and to the meal cart. CNA U then walked to the nurse's station and washed her hands with soap and water for ten seconds. CNA U then went into Resident #10 (R10) and Resident #11's (R11) shared room. CNA U did not don a gown or gloves. According to The Guideline for Hand Hygiene in Healthcare Settings, CDC recommends: When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use towel to turn off the faucet. Avoid using hot water, to prevent drying of skin. Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. Either time is acceptable. The focus should be on cleaning your hands at the right times. (https://www.cdc.gov/handhygiene/providers/index.html) Review of R11's laboratory results collected on [DATE] with results dated [DATE], revealed R11 was positive for COVID-19. Review of R11's physician's orders [REDACTED]. In an interview on [DATE] at 12:59 PM LPN V reported the hallway she was currently working on was considered the COVID negative unit. LPN V reported the remainder of the facility was positive for COVID-19. When asked what the nightstands (PPE) carts in the hallway were for, LPN V stated We have the yellow gowns and extra gloves. When asked what the gowns and gloves were used for, LPN V reported they were used for roommates who were considered exposed to possible COVID-19. When asked which residents on the unit required full PPE for care, LPN V reported only one resident who resided in room [ROOM NUMBER]. In an interview on [DATE] at 1:02 PM, CNA U reported she was currently working on the COVID-19 negative unit. When asked if any residents on the unit were on isolation precautions, CNA U stated Yes (room) 121 was on droplet precautions because his roommate was sent to the hospital. CNA U reported there were not any other residents on the unit that required full PPE for isolation precautions. When asked if hand sanitizer was available, CNAU reported she carried some with her. When asked what was being used to disinfect resident care equipment, CNA U reported that was a housekeeping task. When asked about was was used to clean resident equipment such as blood pressure cuffs, CNA U reported the facility used the purple wipes (super sani cloth germicidal disposable wipes). When asked how the wipes were used, CNA U stated pull one or two wipes, clean it off, and dry it off with a paper towel. When asked if there was a certain amount of time the equipment needed to remain wet to ensure disinfection, CNA U stated let it sit for 15 to 20 seconds and dry it off then put it back at the work station. Review of the Super Sani Cloth Germicidal Disposable Wipes revealed an EPA Registration Number of ,[DATE]. Review of EPA's List N, revealed the Super Sani Cloth Germicidal Disposable Wipes had a contact time of one-minute to kill [DIAGNOSES REDACTED]-COV2/COVID-19. Review of the CDC's Infection Prevention and Control Assessment Tool for Nursing Homes Preparing for COVID-19 revealed, Disinfectants used at a facility should be EPA-registered, hospital-grade disinfectants with an emerging [MEDICAL CONDITION] pathogens claim against [DIAGNOSES REDACTED]-CoV-2. List N on the EPA website lists products that meet EPA's criteria for use against [DIAGNOSES REDACTED]-CoV-2 (https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-[DIAGNOSES REDACTED]-cov-2) .All EPA-registered, hospital-grade disinfectants have a contact time which is required to kill or inactivate pathogens. Environmental surfaces must remain wet with the product for the entire contact time duration to work appropriately. Contact times range from 30 seconds to 10 minutes. Keeping a surface wet for 10 minutes is seldom accomplished with a single application. It is important for facilities to know that their product is appropriate (List N as above) and is being used for the entire contact time. Also, it is helpful for the facility to assign responsibility for cleaning and disinfection of specific surfaces and equipment (who cleans what). (https://www.cdc.gov/coronavirus/2019-ncov/downloads/hcp/assessment-tool-nursing-homes.pdf) According to the EPA'S Frequent Questions about Disinfectants and Coronavirus (COVID-19), How does EPA know that the products on List N work on [DIAGNOSES REDACTED]-CoV-2? EPA expects the products on List N to kill [DIAGNOSES REDACTED]-CoV-2, the coronavirus that causes COVID-19, because they: · Demonstrate efficacy against the coronavirus [DIAGNOSES REDACTED]-CoV-2 (COVID-19); · Demonstrate efficacy against a pathogen that is harder to kill than [DIAGNOSES REDACTED]-CoV-2 (COVID-19); or · Demonstrate efficacy against a different human coronavirus similar to [DIAGNOSES REDACTED]-CoV-2 (COVID-19). (https://www.epa.gov/coronavirus/frequent-questions-about-disinfectants-and-coronavirus-covid-19) and What does the column Follow the disinfection directions and preparation for the following virus mean? Why [MEDICAL CONDITION] other than the human coronavirus listed in that column? This column shows the harder-to-[MEDICAL CONDITION] pathogens than the human coronavirus. Products qualify for the emerging [MEDICAL CONDITION] pathogen claim by showing that it works against the listed harder-to-[MEDICAL CONDITION] pathogen. Therefore, if the contact time for this harder-to-[MEDICAL CONDITION] is followed, EPA expects the product to be effective against [DIAGNOSES REDACTED]-CoV-2 (the coronavirus that causes COVID-19) on surfaces. You can also find this information on the product label. It's important to note that EPA expects that all products on the list will be effective against [DIAGNOSES REDACTED]-CoV-2 (COVID-19). In a telephone interview on [DATE] at 3:54 PM Health Department Nurse (HDN) L reported she did not have any conversations with the facility regarding not utilizing full PPE in the entire facility since the majority of the residents had tested positive for COVID-19. HDN L reported she was not sure what changed since [DATE] and reported the facility should be utilizing full PPE for all residents in the facility. Review of the facility's list of cumulative total positive COVID-19 residents and staff, revealed between [DATE] and [DATE], the facility had 42 staff and 48 residents who tested positive for COVID-19. The facility had a total of 14 resident deaths related to COVID-19 (two died at the hospital and 12 died in the facility). In a telephone interview on [DATE] at 11:09 AM, Director of Nursing (DON) B reported on [DATE], the facility had an additional six staff members and nine residents test positive for COVID-19. DON B reported the facility had three residents who remained negative for COVID-19. CNA U was included in the staff who tested positive for COVID-19. According to Centers For Medicare and Medicaid Services' (CMS) COVID-19 Focused Infection Control Survey Pathway dated [DATE], For a resident with known or suspected COVID-19: staff wear gloves, isolation gown, eye protection and an N95 or higher-level respirator if available. A facemask is an acceptable alternative if a respirator is not available. When COVID-19 is identified in the facility, staff wear all recommended PPE (i.e., gloves, gown, eye protection and respirator or facemask) for the care of all residents on the unit (or facility-wide based on the location of affected residents), regardless of symptoms (based on availability) .Objects and environmental surfaces that are touched frequently and in close proximity to the resident (e.g., bed rails, over-bed table, bedside commode, lavatory surfaces in resident bathrooms) are cleaned and disinfected with an EPA-registered disinfectant for healthcare setting (effective against the organism identified if known) at least daily and when visibly soiled. According to the CDC, HCP should use all recommended COVID-19 PPE for the care of all residents on affected units (or facility-wide if cases are widespread); this includes both symptomatic and asymptomatic residents. (https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html) According to The Centers for Disease Control and Prevention (CDC) Preparing for COVID-19 in Nursing Homes guidance, last updated [DATE], .Have a Plan for Visitor Restrictions .Post signs at the entrances to the facility advising visitors to check-in with the front desk to be assessed for symptoms prior to entry. Screen visitors for fever (temperature greater than or equal to 100.0 degrees Fahrenheit), symptoms consistent with COVID-19, or known exposure to someone with COVID-19. Restrict anyone with fever, symptoms, or known exposure from entering the facility. Ask visitors to inform the facility if they develop fever or symptoms consistent with COVID-19 within 14 days of visiting the facility . (https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html) On [DATE] at approximately 11:10 AM, the surveyor entered the facility. Registered Nurse (RN) D, who also assisted with the facility's Infection Control Program, used a no-touch thermometer to take the surveyor's temperature and asked the surveyor if they had any symptoms of COVID-19. The screening did not include asking about any specific symptoms of COVID-19 or exposure to COVID-19. On [DATE] at approximately 8:25 AM, the surveyor approached the facility entrance and rang the doorbell. A housekeeper came to the door in full PPE. The housekeeper told the surveyor she guessed she (surveyor) was to take their temperature and write it down. The housekeeper then said she would go get a nurse. At approximately 8:30 AM, Licensed Practical Nurse (LPN) O came to the entrance and used a no-touch thermometer to take the surveyor's temperature. The surveyor was not asked about any COVID-19 symptoms or exposure to COVID-19. On [DATE] at approximately 10:25 AM, the surveyor entered the facility. Nursing Home Administrator (NHA) A used a no-touch thermometer to take the surveyor's temperature. NHA A asked the surveyor if they had traveled in the past 14 days, had exposure to COVID-19 or if they had any symptoms of COVID-19. The surveyor was not asked about any specific symptoms of COVID-19. On [DATE] at approximately 8:30 AM, the surveyor entered the facility through a different entrance than on previous days, at facility request, related to the facility's weekly COVID-19 testing returning with additional positive residents and staff. A staff member took the surveyor's temperature with a no-touch thermometer and asked the surveyor's name. No additional COVID-19 screening questions were asked. Review of the Resident Visitor Log for [DATE] to [DATE] reflected that the facility was screening for the following: -Date -Time -Visitor Name -Temperature over 100.0 degrees Fahrenheit -Any NEW symptoms: chills, muscle pain, headache, sore throat, shortness of breath, loss of taste or smell -International travel within the last 14 days -Exposure to a confirmed case of COVID-19 -Resident they are visiting -Visitor MOU signed, column with a line through it -Staff initials There were also columns for time and staff initials at exit Review of the COVID-19 Screen for contractors, physicians and lab for [DATE] to [DATE] reflected that the facility was screening for the following: -Date -Name and hand hygiene at entry -Temperature over 100.0 degrees Fahrenheit -Any NEW symptoms: chills, muscle pain, headache, sore throat, shortness of breath, loss of taste or smell -International travel within the last 14 days -Exposure to a confirmed case of COVID-19 -Purpose of visit -Staff initials According to the CDC, .People with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness. Symptoms may appear ,[DATE] days after exposure to [MEDICAL CONDITION]. People with these symptoms may have COVID-19: Fever or chills Cough Shortness of breath or difficulty breathing Fatigue Muscle or body aches Headache New loss of taste or smell Sore throat Congestion or runny nose Nausea or vomiting Diarrhea This list does not include all possible symptoms. CDC will continue to update this list as we learn more about COVID-19 . (https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html) According to the facility's Coronavirus Surveillance Policy, with a reviewed/revised date of [DATE], .3. Screening for visitors and staff: a. Signs or symptoms of respiratory infection, such as fever, cough, shortness of breath, or sore throat or other symptoms of coronavirus (i.e. chills, muscle pain, headache, new loss of taste or smell, fatigue, congestion or runny nose, nausea or vomiting, diarrhea) .In the last 14 days has had contact with someone with a confirmed [DIAGNOSES REDACTED].Travel within the last 14 days to geographic areas with sustained community transmission .Residing in a community where community-based spread of COVID-19 is occurring .Visitors will be denied entry into the facility if they exhibit any of the criteria listed above . On [DATE] at 10:50 am, upon entry to the facility, surveyor was screened in at the entrance by Nursing Home Administrator (NHA) A was observed coughing during the screening process and reported she thought she was coming down with a cold. When queried about Covid 19, she reported she had been tested on [DATE] but had not received results yet. Throughout the day of [DATE] NHA A could be heard coughing as her office was next door to the conference room which housed the survey team. Review of the facility's Covid 19 screening log , NHA As entry dated [DATE] revealed she was symptomatic with a runny nose at 7:45 AM, 2:30 PM and 6:00 PM. Review of Administrators As Covid 19 screening log dated [DATE] at 8:00 AM and 12:32 PM, did not reflect the cough that was observed and heard throughout the day. On [DATE] at 11:37 AM during a phone interview with Infection Control Nurse I , When queried if any staff should/would be allowed to work if symptomatic Infection Control Nurse I , reported No, any symptoms you should stay out of there. According to the facility's Coronavirus Surveillance Policy, with a reviewed/revised date of [DATE], .5. Staff who have signs and symptoms of a respiratory infection shall not report to work. Any staff that develop signs and symptoms while on-the-job-shall: .Immediately stop work, put on a facemask, and self-isolate at home .Inform the Infection Preventionist, and include information on individuals, equipment, and locations the person came in contact with . On [DATE] at 12:15 PM during a phone interview with Registered Nurse (RN) K, he reported working the midnight shift and that he had tested positive for Covid 19 on [DATE] was sent home, retested with a negative result on [DATE] and returned to work on [DATE] with the stipulation that he wore an N95 mask, surgical mask over the N95, a face shield and took his breaks alone. RN K reported his normal routine was to pass medications to residents and obtain vital signs. When queried how reusable resident equipment was cleaned, he reported the facility used a purple wipes (Super Sani-Cloth). When queried about the process he reported he just wiped down whatever needed to be cleaned and let it air dry. When asked about a dwell time RN K stated it dries in 15 to 20 seconds. Immediate Jeopardy began and was identified: [DATE] and Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy (IJ) on [DATE] due to failure to follow and implement infection control practices per the Centers for Disease Control (CDC) guidelines to prevent the spread of COVID-19 facility. The deficient practice had the potential to affect a current census of 62 residents, staff and visitors. The Immediate Jeopardy was removed on [DATE] when it was verified that the facility had the following in place: 1. The Administrator was taken off work [DATE] and will not return to work until proper quarantine of 10 days without elevated temperature and without medication if fever present for at least 24 hours prior to return and no new symptoms. 2. Facility notified staff that all staff that are working need to be re-educated on the below topics: Proper Hand Hygiene, Donning and Doffing PPE, and cleaning equipment between residents. All staff were educated on the need to wear gowns on the area where residents are in order to mitigate the spread of infection throughout the building. In addition, all staff were re-educated on the proper use of our disinfectant, Virex used to clean and disinfect patient equipment. All staff were educated on the following: Virex Plus one step disinfectant and deodorant spray must remain wet on the contact surface for 3 minutes for proper disinfecting and that patient equipment not able to be disinfected cannot be used on multiple residents. Facility had staff come to the Pavilion outside to do education with them on the above concerns. As of 8pm on [DATE], the facility had educated 71 staff members. Those staff that did not attend the in-service have been contacted by the HR Director and will receive one on one training prior to returning to work. 3. On [DATE] the facility began educating staff on the Super Sani-cloth Germicidal disposable wipes and the fact that they have a two minute contact time for effective disinfection. Additionally, staff were also re-educated on proper procedure for notification of any symptoms that they experience associated with Covid-19, including not entering facility if symptomatic and notifying the infection preventionist and/or designee. 4. The policy and procedure for proper hand hygiene, infection control, PPE use and equipment cleaning have been reviewed by Director of Nursing. According to the Food and Drug Administration, under the emergency use authorization, KN95 masks may be used. We are currently under an emergency use authorization and are utilizing N95 masks whenever available and KN95 masks in the absence of N95s. All KN95 masks in use have been approved in congruence with the FDA emergency use authorization approval on Appendix A: Authorized Respirators, Non-NIOSH Respirators Manufactured in China (updated [DATE]) 5. Continued monitoring of proper PPE use, hand washing, screening for symptomatic employees and cleaning of equipment along with proper use of disinfectants will occur. Director of Nursing and/or designee will monitor 50% of staff weekly for four weeks to ensure ongoing compliance. The results of these audits will be presented at QAPI for further recommendations. The Administrator and/or Director of Nursing is responsible for sustained compliance. Upon survey exit on [DATE], it was determined the Immediate Jeopardy was removed on [DATE] and the facility remained out of compliance at a scope of widespread and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency.

Based on observation, interview, and record review, the facility failed to implement interventions to reduce the risk of injuries from falls, ensure environment was free from accident hazards as possible and provide adequate supervision, in 1 of 3 residents reviewed with falls (Resident #25) resulting in a falls with injuries, including a major injury. Findings include: Resident #25 (R25) On 12/05/18 at 11:50 AM R25 was observed lying in bed sleeping. The right side of the bed was placed against the wall and to the left of her bed was a nightstand. R25's most recent Minimum Data Set (MDS) assessment dated [DATE], introduced the Brief interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents score was 08 (scale: 08-12 Moderate Impairment). The same MDS assessment indicated R25 was [AGE] years old, 5 foot 4 inches, 122 pounds, admitted to the nursing home facility on 7/23/16, and had the [DIAGNOSES REDACTED]. The same assessment revealed R25 had an impairment in range of motion (ability to move a joint) in the lower extremity (hip, knee, ankle, foot) on one side. R25's 9/27/18 MDS indicated she required extensive assistance (resident involved in activity, staff provide weight-bearing support) of 2 plus persons for bed mobility (how resident moves to and from lying position, turns side to side and positions body while in bed) and transfers (to or from bed, chair, wheelchair). The same MDS assessment revealed R25 did not have any physical/verbal/other behavioral symptoms during the 7 day look-back period. R25's risk for falls care plan dated 7/19/17, indicated she was readmitted [DATE] with a fracture to her right hip and her goal was to not sustain a fall related injury by utilizing fall precautions. R25's same care plan indicated the interdisciplinary team would provide environmental adaptation if needed, including a lower bed and area free of clutter. Unusual Occurrence Form dated 9/8/18 at 4:20 AM, revealed R25 had fell from bed, following a transfer with staff and struck her head on nightstand. The same report did not indicate to evaluate placement of the nightstand or for therapy to evaluate transfers. The same report indicated, under steps taken to reduce likelihood of recurrence, was staff to keep hands on res. (resident) gait belt when scooting up in bed before lying down. The same report included a statement from a certified nurse assistant (CNA) that the other CNA assisting with the transfer had ahold of the gait belt at the time of the fall. R25's Fall risk assessment dated [DATE] revealed a score of 16, a score of 10 or greater indicated a high risk for falls. Unusual Occurrence Form dated 12/3/18 at 12:03 AM, revealed R25's sensor alarm was sounding and staff found R25 sitting on the floor with her right arm tangled in her foot cradle (holds bed sheets off feet) and she was bleeding from a cut on the back of her head. The same report indicated steps taken to reduce likelihood of reoccurrence was to keep sensor alarm pad centered underneath the resident when she is in bed. Steps to reduce reoccurrence did not include assessing proper bed height or moving R25's night stand. The same report indicated R25's sensor alarm was functioning correctly at the time of her fall. The same report included witness statements from a nurse and 2 certified nurse assistants (CNA's) that were assigned to the unit at the time of R25's fall; the nurse and 1 CNA responded to the alarm, ran to the room, but R25 was on the floor by the time they responded, and the other CNA on the unit did not hear the alarm. The same report indicated R25 did not turn her call light on. R25's nurses notes dated 12/3/18 at 2:05 AM revealed sensor alarm sounding again. Resident attempting to get up unassisted to go to bathroom. She did not use her call light. Physician order [REDACTED]. Physician's Progress Note dated 12/3/18, revealed R25 had recurrent falls, to continue fall precautions, and patient has poor judgment and insight into her own safety. Centers for Medicare and Medicaid Services (CMS's) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0, Version 1.16, (MONTH) (YEAR), instructed A previous fall, especially a recent fall, recurrent falls and falls with significant injury are the most important predictors of risk for future falls and injurious falls and to evaluate the physical environment as well as staffing needs for residents who are at risk for falls. Unusual Occurrence Form dated 12/6/18 at 4:05 AM revealed staff responded to R25's bed alarm and found her on the floor in a fetal position with buttocks in air, her head toward her dresser, a laceration to the left eyebrow, and a skin tear on her right arm. The same report revealed R25's right arm was positioned at an odd angle. The same report indicated R25 was transferred to the emergency room for further evaluation. On 12/6/18 at 1:30 PM, R 25 was observed lying in bed with a bandage on her forehead and a sling supporting her arm. R25's daughter W was interviewed during the same date and time and stated R25 broke her pelvic bone in 3 areas this past (MONTH) (YEAR). Daughter W stated in the same interview that her mom (R25) fell the other day and cut her head, but did not receive a phone call from the facility until the next day. Daughter W stated the Doctor at the hospital told her that her mom broke her humerus (long bone in arm) after her fall on 12/6/18 at 4:05 AM, but did not recommend surgery. Daughter W expressed a concern that she wanted to keep the alarm on her mom's care plan and was concerned regarding staffing on night shift due to her mom's recent falls both on night shift. Daughter W stated a lower bed had not been discussed with her as an intervention to prevent falls. Daughter W also expressed a concern regarding call light response time, in that she had turned the call light on to get help for her mother and waited 45 minutes for a response. On 12/7/18 at approximately 4:00 PM CNA Y was interviewed and stated on 12/6/18 at 4:05 AM, R25 alarm sounded while she and another CNA was providing care to other residents. CNA Y stated she ran to R25's room, she was already on the floor bleeding and stayed with her until the ambulance arrived. CNA Y stated she did not feel that night shift (11:00 PM to 7:00 AM) was staffed appropriately, and could use additional staff. On 12/06/18 at 3:54 PM, Director of Nursing (DON) B was interviewed and stated there were no call in's last night on nights 11:00 AM to 7:00 AM (12/5/18 to 12/6/18) shift, that they were fully staffed on R25's unit, with 1 nurse and 2 CNA's. DON B stated the reason a low bed or a floor mat were not considered previously for R25 was because she could get in and out of bed by herself. On 12/06/18 at 4:29 PM, R25 was observed lying in a new lower bed, her bedside stand was moved to other side of recliner, and her recliner chair was now next to the left side of her bed. R25's assist bed rail care plan dated 12/6/18, revealed she required assist rail on the left side to perform bed mobility tasks and functional transfers secondary to the medical [DIAGNOSES REDACTED]. The same care plan instructed to keep bed in lowest position when clinical care was not being provided, that left assist bed rail was to be used during transfers. On 12/7/18 at 4:30 AM, Nurses Notes indicated R25 was groaning and moving her head from side to side; R25 was treated for [REDACTED]. On 12/07/18 at 11:31 AM, DON B stated the team did not consider a scoop mattress (raised edge on mattress) for R25 because they didn't want her to feel confined. DON B stated during the same interview that they switched R25's and night stand yesterday, but did not know if that was considered when R25 fell from bed on 12/3/18 or previously. On 12/07/18 at 1:15 PM, Therapy Director and occupational therapist (OT) P was interviewed and stated she was not involved in R25's assessment of her previous bed and was not placed on the list for a therapy screen until after her fall on 12/6/18. On 12/7/18 at 1:25 PM CNA X was interviewed regarding R25's previous bed, in place where R25 fell on [DATE] and stated the bed did not go up and down to adjust for height. On 12/07/18 at 2:06 PM, DON B was interviewed and stated after R25's fall on 12/3/18, the interdisciplinary team did not request a therapy screen. Fall Prevention policy, reviewed 8/2018, revealed monitoring residents, their supervision and fall prevention needs should occur on a regular basis, effectiveness of fall interventions were evaluated by monitoring and if interventions were not effective in reducing fall risk, modification of the interventions and care plan should occur.

This citation pertains to MI 793. Based on interview and record review, the facility failed to ensure proper supervision and/or assistive device(s) to prevent a fall from bed during an adult brief change with 2 staff present for 1 of 3 residents reviewed for falls (Resident #3), from a total of 3 sampled residents, resulting in a fractured hip which contributed to her subsequent death. Findings include: According to the Minimum Data Set, dated dated [DATE], Resident #3 was a [AGE] year old woman, admitted to the facility on [DATE], who had severe cognitive impairment, was totally dependent on staff for bed mobility, was always incontinent of bowel and bladder, was taking blood thinning medication, and had [DIAGNOSES REDACTED]. According to Resident #3's Care Plans -Falls, dated [DATE], Resident at risk for falls related to: .L (left) [DIAGNOSES REDACTED] (weakness on one side of the body) . decreased safety .low bed . According to Michigan Physician order [REDACTED].#3 had Full Code Status - Attempt CPR and Advanced Interventions. According to the facility Unusual Occurrence Form, dated [DATE], Staff was performing routine care .slip out of bed .c/o R (right) hip pain. Some displacement was observed. EMS (Emergency Medical Service) called . Review of the facility investigation revealed no witness statements from Nurse Aide E, F, an G who were present at the time of the incident. In a telephone interview, on [DATE] at 12:25 PM, Resident #3's Daughter (C) reported Resident #3 fell from bed while 2 staff were performing an adult brief change on [DATE] resulting in a broken hip and subsequent death due to the broken hip on [DATE] (35 days later). Daughter C stated, One of the CNAs (Nurse Aides) said she became distracted . (Resident #3) broke her good hip. She passed - wasn't able to survive it. It was severe. She went to (the hospital); they operated on her hip. She died [DATE] at home under Hospice. According to the Death Certificate, Resident #3's cause of death on [DATE] was certified by the Hospice Physician I as, Cerebral Vascular Accident/Cerebral Vascular Disease, and Other significant conditions contributing to death but not resulting in the underlying cause were Right hip fracture, CAD (heart disease). In an interview, on [DATE] at 2:20 PM, Nurse Aide E reported she was in the hall in front of Resident #3's room on [DATE] at 6:05 AM and saw one of the Nurse Aide's (Nurse Aide G) looking for cream in the top drawer, and the other (Nurse Aide H) pushed (Resident #3) over while facing the door . I ran to get a nurse . In an interview, on [DATE] at 2:25 PM, Nurse Aide F reported she was passing linens a little after 6:00 AM on [DATE], and while she was standing in the doorway of Resident #3's room, she observed Nurse Aide G and Nurse Aide H standing on either side of Resident #3's bed. Nurse Aide F tearfully reported, I didn't notice if (Nurse Aide H) was touching (Resident #3). They appeared to be changing (Resident #3's brief) because her bottom half was exposed and she was laying on her left hip. (Nurse Aide H) turned around and looked at me, her lower body was facing the bed, and her upper body was facing the door. Nurse Aide H said 'can you bring me some ointment'. Nurse Aide G was looking through the bedside drawer . her hands were not on the bed or Resident #3. As I was leaving, I heard a thud. I reopened the door. I could see (Resident #3) on the floor because the bed was raised (demonstrated a height of approximately 3 feet). There were no bed rails. I've been a nurse aide for a long time. I think it was wrong. They should have been watching her. They shouldn't leave her unattended. It shouldn't have happened. In a telephone interview, on [DATE] at 3:06 PM, Nurse Aide G reported, Basically, I was a new CNA .I told (LPN/Licensed Practical Nurse J) not to give (Resident #3) any more pain medication because earlier in the night she had not been able to hold herself up as much because of a new medication for pain as needed. I told (LPN J) she (Resident #3) did not respond well but, (LPN J) gave her another dose (per Medication Administration Record, Ultram, a narcotic/controlled substance was given at 5:30 AM). (Resident #3) was not able to hold herself up and help us. Nurse Aide G reported she was on her 2nd day as a new Nurse Aide, and was being trained by Nurse Aide H at the time of the incident. Nurse Aide G said Nurse Aide H instructed her to look in the bedside drawer for a barrier cream so she moved her had off of Resident #3's hip and asked Nurse Aide H if she had a good hold of Resident #3, and, according to Nurse Aide G, Nurse Aide H said she did. However, Nurse Aide G added, When (Nurse Aide H) turned, I didn't see what happened. (Resident #3's) legs and hips were off the bed. I whipped around, she was coming on top of me . I think (Resident #3) needed a bigger bed . In the future, I need to make sure the resident is completely secure. Nurse Aide G reported Resident #3 may had startled when Nurse Aide H screamed across the room into the hall to (Nurse Aide F) for ointment . And, Nurse Aide G said, There were no pillows under (Resident #3) .I don't know why Nurse Aide H didn't grab (Resident #3's) legs. Nurse Aide G reported she and Nurse Aide H were told by DON B, We were told we did everything correctly, maybe just be a little more careful, and neither of them were given discipline. In an interview, on [DATE] at 3:45 PM, Administrator A was queried as to what the facility found to be the root cause of Resident #3's fall, and Administrator A replied, It was a freak accident. In an interview, on [DATE] at 4:23 PM, Nurse Educator K reported she, Pulled staff together as a group so they all understood how to do it. When asked what it meant, she said The inservice, and when asked if she had been told how the fall occurred, Nurse Educator said, No, I was just told it was a freak accident. The in-service was entitled Transfers, Turning & Positioning - making sure the resident were in the center of the bed; it was presented on [DATE] to approximately 50% of the nursing staff . Nurse Educator K reported she did not refer to the facility's policy Turning and Positioning, dated ,[DATE] for the in-service, did not educate on gathering all necessary items beforehand, or on securing the resident at all times while performing pericare/brief change for dependent residents. Nurse Aide H was not in attendance for the in-service. According to the facility Turning and Positioning, dated ,[DATE], .Grasp the turning pad, and pull the patient closer to the side of the bed opposite the side he or she will be laying . Stand facing the side of the bed . Using the turning pad raise the resident up onto their side, then lower the turning pad and position your hands to support the upper and lower torso . When positioning a resident on their side use pillows or other support devices to provide comfort and support while on their side. Position pillows behind the back, buttocks . to provide support . The policy did not instruct staff to assemble the needed items prior to beginning or to assure the resident was secure at all times. In a telephone interview, on [DATE] at 9:07 AM, Nurse Aide H reported she thought Resident #3 would not have fallen if she and Nurse Aide G had assembled everything they needed before they started, and if she would have made sure Resident #3's legs were secured, or if she and Nurse Aide G would have placed Resident #3 on her back while they were searching for ointment. Nurse Aide H also said they were way behind in rounds because the night had been very busy and added, If we would have had the (ointment) she (Nurse Aide G) wouldn't have been looking for it. ( )

This citation pertains to MI 821 Based on observation, interview, and record review, the facility failed to provide comprehensive assessments and treatments and follow the facility Skin and Wound Management policy and procedure related to pressure ulcers in 3 of 4 residents (Resident #101, 102, 103) reviewed for pressure ulcers, from a total sample of 4 residents, resulting in the development of a stage 3 pressure ulcer for resident #101 and development of a new facility acquired unstable pressure ulcer for resident #103, and pain. Findings include: According to the facility, Clean Dressing Change policy and procedure, dated 12/2015, reflected under, Policy: The guidelines for the application of dry, clean dressing. Procedure: 1. Verify that there is a physician's order for this procedure .2. Review the resident's care plan, current orders, and [DIAGNOSES REDACTED]. 3. Check the treatment record .3) Information that will be recorded in the resident's medical record and /or reported. a. The date and time the dressing was changed. b. wound appearance, including wound bed, edges, presence of drainage. c. The name and title of the individual changing the dressing. d. The type of dressing used and wound care given. e. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. f. How the resident tolerated the procedure. g. Any problems or complaints (e.g., pain or discomfort) made by the resident related to the procedure. h. If the resident refused the treatment and the reason(s) why. i. The signature and title of the person recording the data. j. Report concerns regarding the appearance of the wound to the residents physician. k. Notify the Care Coordinator/Director of Nursing if the resident refuses the dressing change. According to the facility, Skin and Wound Management policy and procedure, last revised 4/16, reflected under, Policy: Each resident will have a skin assessment and a treatment plan for the maintenance of skin integrity. Each resident will have a treatment plan for care of identified wounds. Purpose: .1. Identify residents at risk for skin breakdown. 2. Promote comfort and mobility. 3. Reduce or relieve pressure and maintain skin integrity. 4. Provide appropriate interventions to manage pressure ulcers and minimize infection. 5. Provide learning opportunities. 6. Monitor and evaluate resident outcome. The interdisciplinary care team participate in the skin and wound management program. 1. Wound Care Nurse/designee 1. Coordinates the skin and wound care program. 2. Collects data, analyzes statistics, identifies trends, evaluates outcomes and presents quarterly statistics to an interdisciplinary committee .4. Educates health care providers regarding best practices to reduce risk factors and prevent skin breakdown. 2. Nursing (RN and LPN) 1. Complete heat-to-toe assessment and Braden Scale within 24 hours of admission. 2. Initiates plan of care to reduce identified risks. 3. Implement interventions for prevention of skin breakdown .6. Coordinates with the wound care nurse for; communication with families and the team, the development and monitoring the plan of care, evaluation of the progress and reporting of the outcome. 7. Addresses and manages underlying cause of pressure ulcer .9. Completes pain assessment and refers to Physician for effective management. 10. Evaluates and documents resident outcomes .5. Wound Nurse/Designee: *Completes and document assessment based on nursing/Physician referral. *Identifies potential underlying causative factors contributing to pressure ulcer development .*Monitors and documents effectiveness of treatment .Procedure: A. Skin Assessment. 1. The interdisciplinary team will: .4. Conduct head-to-toe assessment including skin, fingernails, toenails, mouth, feet and body prominences: within 24 hours of admission, upon return from hospital admission of 24 hours or longer ., Q weekly for 4 weeks after admission or readmission to the facility, and quarterly. 5. Monitor daily if early signs f skin breakdown are present. 6. Document the assessment results .11. Evaluate and document resident outcome .C. Pressure Ulcer/Wound Management: .Stage 2- The Interdisciplinary team will continue with practices used for stage 1 and add: *Complete Braden Scale and implement appropriate interventions. *Refer resident to Dietitian for recommendations on supplements an laboratory investigations .*Refer to Occupational Therapist and /or Physical Therapist for positioning and seating assistance. *Ensure progress is communicated. *Treat the ulcer as per Physician's order and document. *Reassess ulcer weekly and document the following: stage, location, size, and odor, condition of skin at base and at edges of open area .*Refer to the Wound and Skin Specialist if the ulcer deteriorates or ne areas develop and implement recommendations .Process for Residents admitted with/Resident develop pressure ulcers-Resident admitted with Pressure ulcer(Stage I through Stage IV): 1. Document the assessment on the Admission Paper Work. 2. Document the pressure ulcer & other skin concerns on the weekly skin measurement log (CCC or RN D will complete measurements and stage) 3. Complete Skin Occurrence 4. Place the information on the 24 hour log. 5. Place the information in the physician book for the physician to evaluate. 6. Write a physician order for [REDACTED]. Write physician order for [REDACTED]. Resident #101 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected Resident #101 was a [AGE] year of male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS reflected Resident #101's had a BIM (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact, and he required one person physical assist with locomotion on unit, dressing, hygiene, bathing and two person physical assist with transfers, bed mobility, and toileting. In a telephone interview on 4/27/16 at 2:10 pm resident #101's family member C reported resident #101 was admitted to the facility on [DATE] from the hospital after a recent fall with non surgical right [MEDICAL CONDITION] on 2/21/16. Resident #101 family member C reported her husband was discharged from the hospital with no skin issues and throughout the admission at the facility was not informed of any skin concerns. Resident #101 reported via the telephone that RN (registered nurse) D had seen resident #101 two times and looked at his tailbone area and had mentioned a small open area. Resident #101 reported the area on his tailbone was painful and reported he was having difficulty sleeping related to the discomfort and reported the air mattress was added to the bed two days prior to his discharge from the facility on 3/11/16. Resident #101 and his family member reported there was not any information on the facility discharge instructions related to any skin issues. Resident #101's family member C reported when resident #101 was transported from his room to the car on 3/11/16 RN D mentioned he was concerned about an open wound on resident #101's tailbone area and had scheduled a follow up doctor appointment 3/15/16. Resident #101's family member C reported that was the first time she had heard that resident #101 had a wound. Resident #101's family member C reported that a home care nurse came out that same day about 2 hours after they got home and did an initial visit. Resident #101's family member C reported she saw the wound for the first time and could not believe how bad it looked and did not understand why there was no mention of a wound on the facility discharge information or that she was not made aware of the wound prior to discharge. Review of the hospital document labeled, (stated hospital) Continuing plan of care patient, signed and dated 2/24/16 at 12:15 pm reflected resident #101 was to be transferred to named facility. The document reveled under the skin assessment, coccyx intact, fragile, heels intact, sacrum intact, thin. Review of the facility Nursing Admission Assessment, dated 2/24/16 reflected resident #101 had a skin assessment with documentation of skin was warm and dry with a circle over the body of the sacral area and comments that reflected 1 cm x 1 cm stage 2 on coccyx. No additional wound description documentation noted. The document was signed by RN D. Review of the facility Nursing Progress Notes dated 2/24/16 at 1:00 pm reflected resident #101 was admitted to room [ROOM NUMBER] and was cooperative with care. No documentation related to the wound noted. Review all of the Physician Orders dated 2/24/16 through 3/11/16 revealed on wound treatment telephone order for Resident #101 dated 2/28/16 to clean open area on coccyx with normal saline and apply [MEDICATION NAME] every 3 days and as needed and to measure open area weekly. No time of order or verbal orders read back were documented. The order was written by LPN (Licensed Practical Nurse) E. Review of the facility, Treatment Record, undated, reflected Resident #101 had a treatment of [REDACTED]. Review of the facility, Treatment Record, undated, reflected Resident #101 had a [MEDICATION NAME] dressing applied to the coccyx area every 3 days completed by initials present under the 3rd, 6th, 7th, 9th, 10th and 11th of the month. In an interview on 4/24/16 at 5:00 p.m. RN D reported he had competed the admitting for resident #101 on 2/24/16. RN D reported he usually works monday through Friday as the wound care nurse and fills in as needed on other shifts. RN D reported he has worked at the facility for about 2 years and has not had any specialized wound care training. RN D reported that on 2/24/16 he received a verbal reported from the hospital and no information was given related to skin concerns. RN D verified he had completed the Nursing Admission Assessment form dated 2/24/16 and the verbal reported from dated 2/24/16 with not noted documentation for skin. RN D reported, I probably did not document about wound except for the size. RN D reported the facility policy and procedure for a new admission was to complete the Nursing Admission Assessment, complete an admission note in the progress notes and start a Wound Care Assessment Form, verify orders with the doctor and fax orders to the pharmacy. RN D verified there was no documentation about resident #101 wound in the progress note or the wound assessment form on 2/24/16. RN D reported there was a wound assessment completed for 2/26/16 and verified there was no wound description documented. RN D reported a skin care plan was started on 2/24/16 for actual impairment marked with no documented measurements with goal of, skin will remain intact by: 5/25, and interventions that included position changes every 2 hours, pressure reduction cushion, assess skin, measure wound, wound treatment, diet, Braden scale. RN D reported he was not able to locate a physician order for [REDACTED]. RN D reported he has received teaching since than related to the admission process and is much more aware of the facility policy and procedures now. Review of the facility, Wound Care Assessment Form, dated 2/28/16 through 3/11/16, reflected Resident #101 had a 1 cm x 1 cm x 0.25 cm coccyx wound on 2/28/16 with no tracking, tunneling, undermining, slough, eschar or drainage and positive pain and [DIAGNOSES REDACTED] around the wound and indicated a dressing was applied. The documentation for 2/28/16 was signed by LPN(Licensed Practical Nurse) E. The next documented assessment was dated 3/4/16 by RN D and reflected Resident #101 had a 1 cm x 1 cm x 0.25 cm coccyx wound with no documentation related to stage of wound noted, with positive pain marked and under, description of ulcer- continue wound treatment. The next documented assessment was 3/11/16 by RN D and reflected Resident #101 has a 1.5 cm x 3 cm x 0.25 cm coccyx stage 2 wound with positive eschar and [DIAGNOSES REDACTED] to surrounding skin marked and under, description of ulcer- arrow up(increase) in size, treatment in place. Review of the facility, Weekly Skin Assessment-Weekly Skin Assessments are performed by a nurse. Any skin problems are reported to the Wound Care Nurse and the DON in writing and placed on the 24-HOUR REPORT to ensure follow-up, dated 2/26/16, refected Resident #101 an area circled on the posterior body diagram at the coccyx area with, 1 x 1 cm written next to circle. No other skin assessment documentation was competed. Noted under, Describe general appearance of feet including skin, nails & color: No new skin issues, bruises improved. The assessment signed by RN D. Review of the facility, Weekly Skin Assessment, undated, reflected Resident #101 had skin that was warm and intact and had an area circled on the posterior body diagram at the coccyx area. The assessment reflected no new skin issues and continue current treatment. No additional wound description noted. The assessment was signed by RN D. Review of the Physicians Orders dated 3/1/16 through 3/31/16 reflected Resident #101 had no orders related to the treatment of [REDACTED]. Review of the Nursing Progress Notes dated 2/24/16 through 2/27/16 revealed no documentation for resident #101 related to open skin. A Nursing Progress Note dated 2/28/16 reflected, 6-2, resident alert able to make needs known. C/O pain PRN (as needed) pain med given with relief. 1 cm x 1 cm with 0.25 cm depth open area on coccyx area cleaned with NS (normal saline) and DuoDerm applied. encouraged to stay off his bottom. verbalized understanding, [MEDICAL CONDITION] intact. Safety measures in place. Signed by LPN (licensed practical nurse) E. In an interview on 4/27/16 at 1:00 pm CNA(certified nurse aide) F reported she worked on 2/24/16 after looking at the facility document labeled, CNA Flow Sheet. CNA F reported she did not recall if resident #101 had an open wound on 2/24/16. CNA F reported resident #101 was continent of urine and alert and oriented x 3. CNA reviewed the facility document labeled, Nursing Assistant Care Plan and reported that she would have followed the care guide. CNA F reported she was unsure when the air mattress was added to resident #101's bed. In an interview on 4/27/16 at 1:05 pm HCN (Resident #101 Home care Nurse) H reported she saw resident #101 on 3/11/16 shortly after he was discharged from the facility at home. HCN H reported she received an order from the facility and there was no mention of an open wound or pressure ulcer. HCN H was informed by resident #101's wife that he had a wound and that she was informed of verbally that same day by the facility. HCN H reported resident #101 had a large stage 3 sacral pressure wound that measured 8.5 cm x 5 cm x 0.25 cm and reported pain at the wound site during wound care. Review of the undated Nursing Assistant Care Plan reflected resident #101 was at high risk for skin and needed 1 person assist with bed mobility, every 2 hour turning in bed, float heels, pressure reducing mattress and chair pad. Under special preferences documentation was noted, undated, for alternating mattress to bed due to stage 2. Review of the facility document labeled, Braden Scale - For Predicting Pressure Sore Risk, dated 2/29/16 reflected resident #101 had a score of 17 which indicated resident #101 was at risk for skin breakdown. Review of Physician and Nurse Practitioner visits dated 2/25/16, 2/26/15 and 3/9/16 revealed no documentation related to open skin or pressure ulcers for resident #101. Review of the facility Nutritional History, undated, reflected resident #101 had no mention of wounds or pressure ulcers and was ordered a general diet. In an interview on 4/26/16 at 4:30 pm the RD (registered dietician) G reported she completed an assessment on resident #101 on 2/25/16 and refers to the Nursing Admission Assessment to see if residents have wounds. RD G verified she did not mark or document resident #101 for skin issues or pressure ulcers. RN G reported recently the facility has started to add all wounds the the 24 hour documentation so that is what she refers to now. RD G reported the change with recording all wounds on new admissions started within last 2 weeks. In a second interview on 4/27/16 at 1:30 pm RN D reported he did complete discharge instructions for resident #101 on 3/11/16. RN D was observed reviewing resident #101's chart and reported he was not able to locate the discharge instructions. RN D reported he spoke with resident #101 and his family C and informed them of the follow up appointment. with the wound doctor on 3/15/16. RN D reported he was unsure if he completed any information for pressure wound treatments on the discharge instruction. RN D verified he wrote a discharge order on 3/7/16 that stated, Discharge home 3/11/16 with home heath services. Nurse, PT/OT to eval to treat. Needs w/c ht 65, wt 131 lbs. Dx: nondisplaced fx femur, F/U with family dr. in 1 week. RN D reported there was no mention of wound care in order because all of the discharge orders are general and look the same at the facility. RN D verified the, Face to Face Encounter Certification for home care Services form for Resident #101 had no mention or documentation of any wound noted. RN D reported, I did not know what I was doing at that time. RN D reported he is more aware of what to do now. In an interview on 4/27/16 at 1:40 pm the DON (Director of Nursing) B and the Administrator A reported they had not been able to locate the recap of stay/discharge instructions for resident #101. The DON B reported the nurse is expected to complete the discharge instructions and have the resident or family sign and make a copy. In a telephone interview on 4/27/16 at 5:20 pm LPN E reported she worked on 2/28/16 with resident #101. LPN E reported she was unsure if resident #101 had a wound prior to 2/28/16. LPN E verified the Nurse Progress Noted dated 2/28/16. LPN E denied calling the doctor related to resident #101's sacral pressure ulcer and reported she wrote the doctor order for DuoDerm and treatment because the facility has standing orders and thought that resident #101 already had orders. Review of the facility, Provider Standing Orders, undated, revealed no standing orders for pressure ulcers. In an interview and observation and record review on 4/27/16 at 5:55 pm at resident #101 personal residence, resident #101 appeared thin and pale in color sitting on the cough and appeared to be in a pleasant mood and alert and oriented x 3. Resident #101 wife C provided this surveyor with the original copy of the facility discharge instructions dated 3/11/16. No mention of wound or pressure ulcer instructions were noted. Resident #101 reported the nurse from home care continues to come regularly and reports that the wound is healing slowly and had provided teaching for himself and family about interventions to do to reduce pressure. Resident #101 reported he did not have an air mattress until 2 days prior to discharge from the facility and was not aware that the wound on his bottom was as bad as it was until the home care nurse looked at it on 3/11/16. Resident #101 family member C reported she was very surprised to see how large the wound was on 3/11/16 when the home care nurse did the assessment and expressed her concerns related to the care Resident #101 received at the facility and why they were not made aware of the pressure ulcer until 3/11/16. In an interview on 4/28/16 at 4:50 pm DON B reported she would expect nurses completing an admission to document wounds on the Nursing Admission Assessment, the Wound Care Assessment Form and notify the doctor of any wounds and record in the 24 hour record. DON B reported she would expect nurses to document a compete and accurate assessment of wounds weekly or as order by the physician. DON B reported it was her expectation the nurses follow physician orders and contact physician with any change in wound conditions. DON B reported she competed a past non compliance after Resident #101 was discharged related to lack of pressure wounds treatment and prevention and reported there was not a compliance date indicated on the past non compliance form. Further, current non-compliance was determined. Resident #102 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected Resident #102 was a [AGE] year of female admitted to the facility on [DATE] and most recently readmitted on [DATE], with [DIAGNOSES REDACTED]. The MDS reflected Resident #102's had a BIM (assessment tool) score of 9 which indicated her ability to make daily decisions was moderately impaired, and she required one person physical assist with locomotion on unit, dressing, hygiene, eating and two person physical assist with transfers, bed mobility, bathing and toileting. In an observation on 4/26/16 at 1:30 pm Resident #102 was laying on an air mattress with settings of 20/20/20 on her back with a pillow noted under knees with eyes closed. In an observation on 4/26/16 at 2:30 pm Resident #102 was noted to be laying on her right side with pillow under her knees and eyes closed. Review of Physician Orders dated 4/1/16 through 4/30/16 reflected Resident #102 had a treatment order that included, Sacral wound - remove old dressing and cleanse with mild soap and water and water using Gause sponges only - so not scrub or use excessive force, pat dry with gauze sponges only then apply [MEDICATION NAME] GD to undermining and over wound, one piece, place prep peri wound with cavalon 3m no sting barrier then cover wound with [MEDICATION NAME] border. Sacrum change QOD and PRN if soiled/dirty keep clean and dry measure weekly with dressing change. Review of the Treatment Record dated 2/1/16 through 4/30/16 reflected Resident #102 had 12 missed wound care treatments indicated by holes on the treatment record(no initials or documentation). Review of the Weekly Wound Assessment Form(WWAF) dated 1/18/16 reflected Resident #102 had a stage 2 coccyx wound that was closed with a noted that read, area filled in. The WWAF was signed by RN D. Review of the WWAF dated 1/18/16 reflected Resident #102 has a stage 4 sacrum wound with measurements of 3 cm x 4 cm x 2 cm with positive tunneling and serous drainage. Notes indicated tunneling 2 cm at 3 o'clock and 4 cm at 6 o'clock, continues to improve. The WWAF was signed by RN D. Review of the (named hospital) wound clinic dated 1/19/16 reflected Resident #102 was seen for evaluation and treat of her sacral decubitus. The clinic noted indicated, RN's who are taking care of patient stating the wound is with significant drainage and with each dressing change there is foul odor noted .Wound #1 Coccyx is a chronic stage 4 pressure ulcer and has received a status of not healed, initial wound encounter measurements are 3.9 cm length x 3.3 cm width x 2.2 cm depth .Muscle is exposed. No tunneling has been noted. A sinus tract has bee noted at :00. Undermining has been noted at 3:00 and ends at 6:00 with a maximum distance of 1.7 cm. There is additional undermining and at 3:00 and ends at 6:00 with a maximum distance of 5.8 cm. There is a moderate amount of sero-sanguinious drainage noted which has a mild odor. The patient reported a wound pain of level 8 .Wound bed is 51-75% granulation. Review of the WWAF dated 3/17/16 reflected Resident #102 had a stage 4 coccyx wound with measurements of 3 cm x 4 cm x 1 cm with positive tunneling, no drainage, no necrotic tissue and pain not documented with a noted that indicated, tunneling 3 cm at 6 wound bed clean. Review of the (named hospital) wound clinic dated 1/19/16 reflected Resident #102 was seen for evaluation and treat of her sacral decubitus. The clinic note indicated, RN's who are taking care of patient stating the wound size is improving. Drainage is better .Wound #1 Coccyx is chronic stage 4 pressure ulcer and has received a status of hot healed. Subsequent wound encounter measurements are 3 cm length x 2.7 cm width x 2.2 cm depth .No tunneling has been noted, No sinus tract has been noted. Undermining has been noted at 3:00 and ends at 6:00 with a maximum distance of 2.5 cm. There is a moderate amount of sero-sanguineois drainage noted which has not odor. The patient reported a wound pain of level 0. The clinic noted indicated to have Resident #102 on a pressure relief mattress, heel boots, frequent position changes, Shift weight every 20 minutes or more when sitting for prolonged periods of time and when resident is in bed have patient lying on her side and alternate every 1.5 hours. In an observation on 4/27/16 at 9:55 am RN D entered Resident #102's room with supplies needed to perform coccyx dressing change. RN D removed the old dressing dated 4/25/16 and medium amount sero-sernguineois drainage noted on dressing. Wound bed appeared beefy red and clean with peri wound intact and slight redness noted and wound edges rolled. RN D was observed measuring wound and positive undermining noted around 6:00. RN D reported size had continued to improve. RN D reported depth 2 cm with tunneling 4 cm at 6:00. RN D used normal saline to flush wound and tap dry with Gause. RN D packed undermining area and wound bed with Aqua cell silver and applied small of normal saline to moisten. RN D then applied [MEDICATION NAME] border dressing to cover coccyx area. RN D received assistance with turning resident from a CNA during the dressing change. Resident #102 was positioned on left side and tolerated dressing change well. Review of the WWAF dated 4/27/16 reflected Resident #102 has a stage 4 coccyx wound that measured 3 cm x 3 cm x 1 cm with positive tunneling, granulation, no drainage, no pain and no abnormal peri wound. The WWAF notes indicated, wound bed clean, 4 cm tunneling @ 6 cont. current treatment. The WWAF was signed by RN D. In an third interview on 4/28/16 at 3:45 pm RN D reported he followed Resident #102's Physician orders for dressing changes. RN D was observed reviewing Resident #102's treatment orders for the coccyx dressing change. RN D reported when he performed the dressing change 4/27/16 he did not wash the wound with soap and water. RN D reported he was unsure why. This surveyor asked if he used skin prep to peri wound prior to applying [MEDICATION NAME] dressing. RN D reported, No, I guess I forgot. RN D reported that Resident #102 has had the wound treatment orders since she had been initially seen at wound clinic 1/19/16. This surveyor asked why the TAR(Treatment Administration Record) had missing documentation related to every other day coccyx dressing changes for Resident #102. RN D reported he only works monday through Friday and reported a few of the holes occurred on the weekends. RN D reported he had not called the Physician in the past related to changing the dressing schedule. RN D was observed comparing the WWAF to the TAR and reported he was unable to determine why dressing changes were missed except that he may have dated the WWAF incorrectly and forgot to sign the TAR. RN D reported he was unsure why his assessment of Resident #102's wounds where different from that of the wound clinic at the same time. RN D reported he was unsure why when this surveyor observed the dressing change on 4/27/16 the measurement was different on the WWAF then RN D stated during the dressing change. RN D verified Resident #102's WWAF documentation indicated no wound drainage and reported it is difficult to assess wound drainage. RN D reported he has had no specific wound care training since being the wound care nurse for the past 2 years at this facility. In an interview on 4/18/16 at 11:45 am DON B reported the Resident #102's air loss mattress setting is according to the weight entered on the pump. DON B reported the CCC(clinical care coordinator) is responsible for maintaining the proper weight on the mattress pump. CCC K reported she was not how to change or check the weight on the pump. DON B report she would check the weight setting on the air mattress. This surveyor observed Resident #102's mattress settings at 20/20/20 prior to DON adjusting the weight. DON B reported the weight was set at 175# in the pump. DON B changed the weight to 145#. The reading on the pump changed to 19/19/19 and mattress adjustment could be heard. Resident #102 was not in the bed at the time. DON B reported her expectation is that CCC's make adjustments in pumps with weight changes. DON B reported Resident #102 has had an air loss mattress since at least 11/2015 and reported she was unable to locate an physician order for [REDACTED]. Review of the Weight Chart dated 12/2012 through 4/2016 reflected resident #102 last weighted 175# around 5/2015 and was noted as low as 129# since then with a current weight of 145#. In a telephone interview on 4/28/16 at 12:20 pm Air Mattress Representative L reported if a resident weight changes more than 15 to 20 pounds adjustments should be made to the weight setting in the air mattress pump. Representative L reported the beds always maintain the correct pressure if the resident is in or out of the bed. Representative L reported they set of the beds initially and the facility staff can make adjustments. In an interview on 4/28/16 at 4:50 pm. DON B reported she would expect nurses to document a compete and accurate assessment of wounds weekly or as order by the physician. DON B reported it was her expectation the nurses follow physician orders and contact physician with any change in wound conditions. DON B reported she was unsure why there were holes in the TAR were it appeared Resident #102 did not receive ordered dressing changes from January through present. DON B confirmed that despite the nurse being responsible for facility wound care, the facility had not provided the wound care nurse with specific training related to wound care but have a plan to provided training in the future. Resident #103 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected Resident #104 was a [AGE] year of male admitted to the facility on [DATE] and readmitted [DATE], with [DIAGNOSES REDACTED]. The MDS reflected Resident #103 had a BIM (assessment tool) score of 13 which indicated his ability to make daily decisions was cognitively intact, and he required one person physical assist with locomotion on unit, dressing, hygiene, eating and two person physical assist with transfers, bed mobility, bathing, and toileting. Review

This citation is related to intake MI 212. Based on interview and record review the facility failed to monitor and replace a malfunctioning safety device for 1 of 7 residents (Resident #19)reviewed with wander guards from a total of 19 sampled residents, and failed to ensure toilet seats and commodes for bathrooms 106/108 and 206/208 which serviced 8 residents were secured resulting in elopement (#19), the potential for injury and falls. Findings Include: Resident #19 was recently admitted to the facility on [DATE]. The most recent quarterly Minimum Data Set (MDS) completed on 10/30/15 reflected Resident #19 had [DIAGNOSES REDACTED]. She had a Brief Interview for Mental Status (BIMS) score of 10 (8-12=moderately cognitively impaired). Resident #19 required limited assistance of one person for transfers, walking in corridors, dressing, hygiene, and with locomotion on/off the unit. According to physician's progress note dated 10/2/15, Resident #19 was taking haldol (anti-psychotic medication) for psychosis associated with her dementia. The resident was not in the facility during the survey. She had been sent out to a local hospital's emergency department on 11/16/15 around 11:15 AM, related to be violent to herself and others. An Unusual Occurrence Form dated 11/11/15 at 12:30 PM reflected the following for Resident #19, Resident observed outside Room 104 window several staff out to get resident easily redirected back into facility (sic). Wander guard did not respond. Steps taken consisted of the facility replacing and checking a newer device for activation. The facility's 5 day report completed on 11/18/15 reflected Resident #19 was observed outside by a staff member, and was brought back into the building by Licensed Practical Nurse (LPN BB). The wander guard did not go off when bringing her back into the building, whereby LPN BB applied a new wander guard device to the back of Resident #19's wheelchair. The November 2015 Medication Administration Records (MARS) reflected Registered Nurse (RN AA) signed the MAR on 11/10/15 and 11/11/15 on the third shift. RN AA's signature confirmed that 1) the wander guard was checked for placement applied to back of wheelchair and walker bag and that 2) the wander-guard was checked for function on the midnight shift were completed. LPN BB was interviewed on 11/19/15 at 4:04 PM. She revealed she was informed Resident #19 was outside by a staff member. LPN BB went outside and found Resident #19 outside on the pavement (near the front entrance) on the outer side of the pillar, between the pillar and the grass. LPN BB stated, No Resident #19's wander guard alarm was not sounding/going off when she was outside. Also, LPN BB stated, It did not sound when I brought her back in, because the battery was dead it didn't work. LPN BB stated the facility used a wander guard tester for functioning, that would reflect a green or a red light. LPN BB continued to state, Green light if working, red if not. Her's was in the red part. The policy here is for midnight to check them. I would assume it was checked the night before. RN AA and Certified Nursing Assistant (CNA CC) phone numbers were not listed on the employee sheet reflecting dates of hire, titles and phone numbers. On 11/19/15 at 4:32 PM this writer walked out of the front entrance to the area directly in front of the pillar near the front entrance, on the pavement (between the pillar and the grass). Wearing a size 10 women's shoe and pacing at a steady rate/steady gait, it took a total of 1 minutes and 54 steps to reach the area Resident #19 was said to be found. The parking lot was noted to have multiple vehicles entering and exiting the facility from November 17-19, 2015. Traffic was noted to have random to steady traffic. 11/19/15 Administrator (A) was interviewed on 11/19/15 at 4:56 PM related to Resident #`10's elopement, and had participated in the elopement investigation. She revealed that Resident #19's wander guard was activated on 10/28/15 and should have been good up to 12/23/15. The night before the occurrence CNA CC offered to check wander guards while CNA's (DD & EE) passed waters. CNA CC informed RN AA that Resident #19's wander guard did not work, and RN AA told CNA CC she put a new one on a cart for her to replace for the malfunctioned one. Neither staff in the end replaced the malfunctioning wander guard device. RN AA was informed about the malfunctioned wander guard on 11/11/15 around 2:00 AM. A new wander guard was placed on Resident #19 after she got out of the building. Lastly, both RN AA and CNA CC had been terminated. The facility's video related to the occurrence was viewed on 11/19/15 at 5:08 PM. The video reflected Resident #19 exited the building at around 12:10:54 and entered back inside the facility at 12:14:54. Resident #19's most recent Fall Risk Assessment dated 10/30/15 reflected a total score of 24 (Total score of 10 or above represents RISK). Resident #19's most recent elopement risk assessment dated [DATE] reflected the Resident #19 had a history of [REDACTED]. Resident #19's Elopement care plan initiated on 8/25/15 reflected she had a problem of elopement, with the intervention to Check functioning 10-6. The facility's Elopement Prevention/Management Policy dated 8/18/15 reflected that wander guard wrist bands were to be checked for functioning on the third shift. The facility's employee discipline report dated 11/13/15 reflected RN AA was checked off as violating company policy/procedures, safety rules and carelessness. The description of the incident reflected: 11/11/15 This Nurse depended on a CENA to check the wander guards but didn't ensure that all the wander guards were changed & functioning properly. Resident #19 was previously cited on an abbreviated survey, with an exit date of 7/22/15 and plan of correction date 10/5/15. At that time Resident #19 was Resident #4. Resident #19 had eloped out of the facility in her wheelchair, whereby her wander guard had malfunctioned and did not alarm. The elopement dated 11/11/15 is the second time Resident #19 had eloped out of the building related to a malfunctioned wander guard safety device. ( ) During the environmental tour on 11/19/15 starting around 10:00 AM with Maintenance Director (O) the following was noted: -The bathroom shared by rooms 106 and 108 had a loose toilet seat, that shifted from right to left 2 inches past the commode when checked for stability. The commode when checked for stability was observed to be loosed and moveable from left to right approximately 1-2 inches. The commode was not secured tightly to the floor. The bathroom serviced 4 residents. -The bathroom shared by rooms 206 and 208 had a loose toilet seat, that shifted from right to left 1 to 1.5 inches past the commode when checked for stability. The commode when checked for stability was observed to be loosed and moveable from left to right approximately 1-2 inches. The commode was not secured tightly to the floor. The bathroom serviced 4 residents. On 11/19/15 at the end of the environmental tour Maintenance Director O stated he was unaware of the concerns and wound repair them. ( )

This citation relates to intake MI 311: Based on observation, interview and record the facility failed to protect 1 of 3 sampled residents (#1) from physical abuse, resulting in not providing an abuse free staff to resident environment and resident #1 being struck in the abdomen by a nursing assistant. Findings include: The November 2014 physician's orders [REDACTED].#1 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS), a Resident Assessment Instrument Tool, dated 10/31/14 reflected Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7 out of 15. This reflected Resident #1 had a severe cognitive impairment. The MDS further reflected Resident #1 had no negative behaviors. He was totally dependent with one person assistance for locomotion/dressing, hygiene, and was totally dependent with two person assistance for transfers, bed mobility and toilet use. The Physician's Progress Notes dated 10/1/14 reflected Resident #1 had behaviors and psych was to evaluate. The outpatient psychiatric evaluation completed on 10/1/14 reflected Resident #1 was visited because of his aggressive and assaultive behaviors, and was diagnosed as having [MEDICAL CONDITION] with agitation and assaultive behaviors. Record Review of Resident #1 "UNUSUAL OCCURRENCE FORM" dated 11/17/14 reflected as a summary of an incident against the resident as the following: "Resident states he got in a fight last night with his opponent the black guy next door, Black Son of A B*tch he beat me all over he hit me in the face and the Balls". The Unusual Occurrence Form sheet reflected a scar from a recent dermatology surgery, bruise at hand from blood dray, and 2 dime size yellow faded bruises at the abdomen. No other injuries were noted. The unusual occurrence documention completed by the Director of Nursing "B" reflected that on 11/17/14 at 6:00 AM Nursing Assistant ( CNA "K") reported to the Director of Nursing (DON "B") that "Resident #1 said my face hurts, my kids hit me in the face. (Son's name). He has a bruise or a scratch on his face by his right eye." The unusual occurrence documention completed by the Director of Nursing "B" reflected that On 11/17/14 at 6:30 AM Nursing Assistant (CNA "M") reported to DON "B" that Staff "C" revealed to CNA "M" that on 11/16/14 he had punched Resident #1 in the stomach and it left a bruise, he was called racial/gender slurs by Resident #1. The unusual occurrence documention reflected the facility suspended CNA "C" on 11/17/14 pending an investigation of the unusual occurrence; and the residents spouse was notified immediately of the incident. Resident #1 was observed in his room on 11/20/14 at 3:00 PM with Licensed Practical Nurse ("S"). He was sitting up in his bed, cleanly clothed with glasses on, with his call light in reach. When asked about the altercation dated 11/16/14, Resident #1 had abstract conversation varying from sentence to sentence. He then stated, "A big black nurse bend my fingers back. She past me out". Resident #1 allowed his abdomen to be viewed with the assistance of Nurse "S". One small light green area, appeared to be a healing burise, was noted on the right upper quadrant of his abdomen. The resident denied pain, and no cuts or scars were noted. Resident #1's ADL (activities of daily living) care plan dated 08/08/14 reflected he was a 1 person assist for bed mobility, 2 person assist for transfers, toileting 2 person assist with Hoyer (mechanical lift), face resident when speaking, and explain care in simple terms. The behavior care plan updated on 9/29/14 reflected to document changes in mood, implement 15 min checks if needed, praise for appropriate behavior, redirect with sports, educate staff and/or family members concern for residents needs/limitations of care approaches, verbal cues, remove to quiet environment, assure safety, approach, allow choices, ensure no means to carry out threat and offer a drink of water when agitated to calm down. During an telephone interview on 11/19/14 at 2:59 PM CNA "C" revealed that the incident occurred during third shift 11/15/14 to 11/16/14, while he went in to change the brief of resident #1. CNA "C" stated the resident started to call him racial/gender slurs, and degrading names. CNA "C' stated that he was by himself providing care. During the brief change Resident #1 rolled toward CNA "C" and kneed him in the side and stomach. CNA "C" stated he hit the side of the resident to get him off of him, and left the room with the brief not completely attached. CNA "C" stated he did not tell anybody, he did not chart it, he was by himself and that it wasn't a hit for hurting but more of a hit to get the resident's knee off his stomach. After the incident Staff "C" stated he went on about his day, but did report to the nurse on duty that resident #1 had a buries on his stomach. CNA "C" stated he did not report the altercation to the nurse. During an interview on 11/21/14 at 9:50 am, the Human Resource Director ("E") revealed that staff "C" admitted to hitting Resident #1 on 11/16/14. Also, staff "E's" personnel notes, dated 11/18/14, reflected staff "C" admitted that he punched Resident #1 in the stomach due to staff "C' feeling frustrated with the residents name calling. Staff "E's" notes further reflected that staff "C' felt bad about what happened. Certified nursing assistant "C" personnel file reflected he was hired on 5/28/14 and terminated from the facility on 11/18/14 (with his last day of work being 11/16/14). The employee discipline report was signed by the employee on 11/18/14, which reflected in writing that "I lightly hit (Resident #1's name) on his stomach ". Interviews regarding staff education related to managing Resident #1 when he is aggressive/belligerent revealed: On 11/20/14 at 10:24 AM CNA "H" stated, "We are supposed to take two people. I try to offer him water, I don't say anything I just try to get in and get out". We have been instructed to go in with 2 people to give care, and if he is rude chart it down and let the nurse know. So, the nurse can see how bad it is. During care staff "H" stated Resident #1 calls staff whores, b*tches, c*nt, n*gger and had thrown feces on her. On 11/20/14 at 10:56 AM CNA "L" stated, "We are supposed to report it. Leave the resident for a while and come back, and report it to the nurse. Also, take someone in with you of course." On 11/20/14 at 11:07 AM CNA "K" revealed being informed to: "leave the room, let the nurse know, chart in the behavior log, come back later, or bring somebody in with you and work around him. I did not go to the meeting. I have always been told to redirect resident, get someone, go get your supervisor". During care staff "K" stated Resident #1 has called her a b*tch, whore, and makes rude comments. On 11/20/14 at 12:37 PM Registered Nurse "O" revealed that she directly heard CNA "C" referring to a resident in his care as a "B*itch". She informed him that the language was inappropriate. RN "O" stated she monitored him give care with residents during that entire shift. RN "O" conveyed that she did not report this to the Director of Nursing. On 11/20/14 at 2:21 PM CNA "P" stated, "You have to approach him in the correct manner. When a resident is combative/belligerent, just make sure the resident if safe, report it to your nurse and document." On 11/20/14 at 2:27 PM CNA "J" stated, "I would leave for a minute and come back or I would get help." On 11/21/14 at 9:15 AM CNA "M" stated "walk out and chart on him". Last abuse training was a couple of months ago. Denied any other staff being rough and abusive to resident #1. Staff "C" was walking toward Resident #1's room to check on him, but he was working rehab Sunday night (Resident #1's room was on nursing and not part of the rehab assignment). Asked what should be done based on what the facility had informed staff when Resident #1 was combative/belligerent. "The care plan reflects there should be two people in there at all times". During care staff "M" stated Resident #1 had cursed and has had outburst during care. On 11/21/14 at 11:18 AM CNA "G" stated, "I have been instructed to get help to protect yourself and the resident. Try to talk to him to relax him, and protect your face." None of the 7 staff listed above stated that they would physically hit and/or harm Resident #1 in any way related to his behaviors. They convyed they would leave the room, redirect, re-approach, offer water, document, report him to the nurse, get a second person and keep the resident safe were responses given above related to Resident #1's combative/aggressive behavior. Facility education documents reflected staff "C" received training related to "Preventing, Recognizing, and Reporting Resident Abuse" on 5/30/14. Also, staff "C" attended the abuse in-service that discussed all types of abuse and reporting on 9/29/14. Physical abuse reflected: hit, slap, pinch, bite, kick and etc. The facility also educated the staff to "...seek help from co-workers for residents that are frequently combative for personality conflict-consider trading residents with a co-worker". Record review reflected that CNA "M" received training on Abuse prevention on 9/29/14. The training included the following, "REPORTING-IMMEDIATE SUPERVISOR, DIR (DIRECTOR) OF NURSING, ADMINISTRATOR." There was no explanation in the unusual occurrence documentation as to why CNA "M" waited until the day after her knowledge of abuse against resident #1 took place to report this to the Director of Nurisng. The facility's "ABUSE PROGRAM POLICY AND PROCEDURE" revised 2/24/12 reflected: "POLICY: It is the policy of (the name of the facility) to maintain an environment free of abuse and neglect. The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. Residents will not be subjected to abuse by anyone including, but not limit to, facility staff...PHYSICAL ABUSE: is not limited to hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment..." The facility's "RESIDENT ABUSE, NEGLECT, OR MISTREATMENT POLICY & PROCEDURE" revised 2/24/12 reflected: "POLICY: Each resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property...It is the responsibility of all staff to provide a safe environment for the residents..." The facility terminated CNA "C" from employment on 11/18/14, reported the staff to the State Agency Nurse Aide registry, and a police report was filed on 11/19/14. ( )

This citation relates to intake MI 601 Based on observation, interview and record review the facility failed to properly apply and monitor the placement of a safety alarm device for 1 of 4 residents (#120) reviewed with alarms from a total of 5 sampled residents, resulting in a fall with a laceration that required 6 staples. Findings Include: The Significant Change MDS (Minimum Data Set) completed on 6/19/14 and the Re-Admission MDS completed on 8/14/14 reflected the following: Resident #120 required extensive assistance of one person for transfers, hygiene, ambulation and toilet use. The Significant Change MDS reflected Resident #120 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (13-15: cognitively intact), with [DIAGNOSES REDACTED]., Manic Depression, and pulmonary concerns. On 8/27/14 at approximately 1:55 PM Resident #120 was observed in his room lying in his bed. He had the TV on watching a baseball game. His call light was in reach. A string alarm box was lying on the mattress (on top of mattress pad, and clipped to the fold of the bedspread) with the string clip attached to the back of his right shoulder. The alarm box was in reach near his left arm. A sensor alarm was noted on the floor. Resident #120 had glasses on and was cleanly clothed with athletic socks on. A wheelchair with a padded cushion topped with a dycem (anti-slipping fabric) was noted near the empty bed next to the resident. The right shoe was observed to have a thick sole and a brace attached to it. Resident #120 was asked if he could recall the fall he had earlier in the month of August 2014, that resulted in him hitting his head. Resident #120 stated that he was in his wheelchair and had pressed the call light for help to use the bathroom. The call light had been on for a least 10 minutes and no help came. Resident #120 stated that it made him upset that it took that long for someone to come, and that it was uncalled for. "When someone pushes their call light that means they need help, and I needed help". When he went to stand up he lost his balance and fell backwards, hitting his head on the bed frame. Resident #120 stated after he fell and hit his head, it caused him to accidentally use the bathroom on himself and blood started coming out of his head. The fall was painful 10 out of 10 (great pain). Resident #120 stated he was down on the floor after he hit his head. Resident #120 was asked if he had alarms attached to him, and he replied "Yes, but they were not going off". Resident #120 stated, he laid on the floor bleeding until the nurse came, who administered first aide and sent him the hospital. Later the same day at 2:56 PM Resident #120 was observed lying in bed, no changes were noted with the alarms. The String of the tab alarm was measured to be 20 inches (from where the string attached to the clip- to where the string attached to the magnet attached to alarm device). The device was a manufactured product. Resident #120 denied trying to get up from the commode during fall, but re-iterated the fall occurred trying to transfer from wheelchair to bedside commode. At 3:15 PM the sensor alarm was not on the floor near Resident #120's bed, but lying on top of the empty bed next to the resident with a fresh brief, wash cloth, and bath towel. The facility reported incident to the State Agency dated 8/5/14 reflected the incident occurred on 8/4/14. Resident #120 was left on a bedside commode, and the call light and alarm was hooked to the resident. Upon returning to the room, Resident #120 was found on the floor lying supine with blood noted from the back of his head. The resident was sent to the hospital, and returned with 6 staples to the back of his head and a headache. The "CNA FALL CHECKLIST" dated 8/4/14 reflected an alarm was in place, the alarm was on, the alarm did not sound, the alarm was functional, alarm was not attached to bed/chair but the commode, and the string was appropriate length. The facility's Employee Discipline Report dated 8/5/14 reflected a warning for Certified Nursing Assistant (CNA) ("C") related to: "...left a confused resident alone on the toilet resulting in fall with injury Expected behavior: residents that are alarmed are not to be left alone on toilet..." CNA "C" was called on 8/28/14 at 10:23 AM, and was asked to recall incident dated 8/4/14: "He was on the commode and I was waiting for him. He said he needed more time to go because he wasn't ready. So I stepped out of the room, and went across the hall in another room to get stuff ready for night-time (pajamas and towels), so he could use the bathroom. I left the call light on the bed side table next to him. When I came back he was on the floor". CNA "C" was asked if Resident #120 have any alarms? She replied, "He had an alarm on, the alarm box was on the table. When I came back the alarm box was on the table, but the clip attached to his shirt was off. I think he took it off. No alarm was not alarming. I checked on him 2 times and both times he stated he needed more time for the bathroom. I left him once. When I was in the other room I heard a faint help, and when I went in the room he was on the floor". CNA "C" was asked if Resident #120 able to be left alone while using the bathroom? She replied, "There wasn't a care plan in the room when he returned from the hospital. The nurse from the facility, told me that "your not supposed to leave someone on the commode because its a fall risk". Staff "C" revealed, "there was no care guide on the back of the door at the time of the fall, and she was not aware the resident could not be left unattended". Licensed Practical Nurse ("E") at 3:22 PM asked to recall incident: "A new girl was working that section. A new girl who left him on the bedside commode, which was a bad idea because he was a fall risk. When I entered the room, he was lying on the floor,the commode was tip over, he hit the back of his head on the bottom of the bed the frame and blood was coming out the back of his head. I cleaned the area with normal saline and placed an ABD bandage on it." Nurse "E" was asked if any alarms were on the resident. The girl said something about the alarm, but I don't recall seeing or hearing an alarm. I think the CNA "C" thought she should give him privacy while he was toileting. Nurses Notes 6/1/14 to 8/27/14 reflected: 6/5/14 0625 "Resident found removing tab alarm this am, attempting to walk to BR unassisted. Reminded not to remove alarm, to use call light & wait for assistance prior to standing", per Registered Nurse ("D"). 6/7/14 0315 "Upon entering this resident's room, resident observed walking around room unassisted, tab alarm attached & hanging from resident. Assisted resident to BR. Reminded by this nurse that he needs to use his call light & wait for assistance, & not to get up unassisted. He stated, "I know, but I had to go to the BR." New order written for floor sensor", per Nurse ("D"). 6/26/14 0615 Resident continuously getting out of bed unassisted, turning off alarms..." ? staff. 7/19/14 at 0320 Resident frequently coming out of room, removing alarms. Able to be re-directed back to room x 1, then back in hall. Continues to remove alarms, refuses to wear O2 NC (oxygen nasal cannula)..." 8/4/14 8:15 PM nurse called to 130-2 pt laying flat on floor beside commode checked ROM...", per Nurse "E". 8/15/14 0320 "...Pt. will be returning with C-collar for neck pain...", per Nurse "E". 8/15/14 0405 Pt. returned by "name of ambulance service" from hospital with 6 staples to L posterior side of head...", per Nurse "E". Resident #120's fall care plan initiated 6/19/19 did not reflect Resident #120 had a tendency to remove alarms (as documented occurring 4 times). The care plan did not reflect the facility would ensure proper placement of the alarm, or interventions of what should be done with patient removal. The only intervention related to alarms was the following: "...BED/CHAIR ALARM Q SHIFT ENSURE IT IS ON AND CHECK FOR FUNCTIONING Q2H AND PRN"... The facility's "Bed/Chair Alarms" Policy dated 12/19/06 reflected the following: "2. Attach the alarm to the wheelchair, chair, or bed using the belt clip...9. The residents should not be left unattended while toileting.." The manufacturer's directions reflected under patient set-up and use: "1. Securely mount the pull string monitor to a wheelchair using the clip on the back of the monitor. If using on a bed, clip the monitor to the optional bed mounting bracket. 2. Attach the garment clip to the patient's clothing near the back of their neck between their shoulders..." On 8/28/14 at 10:58 AM the Administrator ("A") and the Director of Nursing (DON) ("B") were informed of documentation reflecting removal of call lights, and no care planning updates related to interventions related to such behavior. The facility failed to be in attendance during toileting, add interventions related to previous removal of alarms, failed to mount alarms properly as observed on 8/27/14 and per interview 8/28/14, which had the potential to aid in the prevention of Resident #120's fall that resulted in a laceration requiring staples. ( )

This citation pertains to intake number MI 299 Based on interviews and record review, the facility failed to provide adequate supervision for 1 of 6 sampled residents (Resident #500), out of a total sample of 6 residents, resulting in Resident #500 falling out of her wheelchair and the potential for injury to occur. Findings include: Resident #500: Per the facility face sheet Resident #500 was an [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #500 no longer resided at the facility at the time of the investigation. Record review of a facility incident report dated 5/29/2012 and timed at 6:30 AM, revealed that Resident #500 was found on the floor on her knees by her bed. The report revealed that Resident #500 was assisted back up into her wheelchair. The report did not reveal, under "Steps taken to reduce likelihood of recurrence" any increase in supervision for Resident #500. Another incident report dated 5/29/2012 and timed at 7:00 AM revealed that Resident #500 was found on the floor not responding and sent to the emergency room . Record review of nurses' notes dated 5/18 through 5/28/2012 revealed Resident #500 did not have any falls between 5/18 and 5/28/2012. Nurses' notes dated 5/29/2012 revealed that at 7:00 AM, Resident #500's fall alarm had sounded and upon staff checking on Resident #500, Resident #500 complained that she could not breath very well. The notes revealed that Licensed Practical Nurse (LPN) #16 administered Resident #500 her inhalers and documented that she (LPN #16) would check on Resident #500 in 3 minutes. The nurses notes continued to revealed that Resident #500's alarm sounded again and Resident #500 was found to be leaning forward in her wheelchair and LPN #16 sat Resident #500 back upright and checked Resident #500's oxygen level. The notes revealed that Resident #500's oxygen level was 70% (normal > 90%), and oxygen was administered to Resident #500. The notes revealed that Director of Nursing (DON) #12 went into Resident #500's room and revealed that a Nurse Practitioner was in the facility and would be down to see Resident #500. The notes then revealed that LPN #16 and DON #12 left Resident #500's room. The notes revealed that Certified Nurse Aid (CNA) #17 entered Resident #500's room as LPN #16 and DON #12 left. The notes revealed that at 7:45 AM, Resident #500's fall alarm was sounding and Resident #500 was found lying on her back on the floor. The notes revealed that Resident #500 did not respond to staff and her blood pressure was unable to be obtained. The notes revealed that Resident #500 was transferred to the hospital. The notes did not reveal any documentation in regards to Resident #500's fall on 5/29/2012 at 6:30 AM. In an interview on 3/22/2013 at 3:30 PM, LPN #16 said that she did not remember the events on 5/29/2012 but stated that she did remember having CNA #17 stay in Resident #500's room with her. LPN #16 said she had CNA #17 stay in Resident #500's room with her while Resident #500 received a breathing treatment. LPN #16 said after Resident #500's breathing treatment was completed CNA #17 came out of Resident #500's room and told her Resident #500 was breathing better. LPN #16 said that while CNA #17 was reporting to her that Resident #500 was feeling better Resident #500's fall alarm sounded and Resident #500 was found on the floor. LPN #16 said Resident #500 was not left alone in her room, but for about one minute when CNA #17 came out of Resident #500's room to report to her how Resident #500 was doing. LPN #16 said CNA #17 told her that she (CNA #17) needed to go provide care for another resident, but LPN #16 told CNA #17 "no" to stay with Resident #500. In an interview on 3/22/2013 at 4:50 PM, LPN #16 said she remembered that Resident #500 was restless on 5/29/2012 and that was why she had put her in her wheelchair with a fall alarm on. LPN #16 said she was busy and had 30 residents on 5/29/2012. LPN #16 said CNA #17 was in Resident #500's room the whole time, but stated that it was hard to remember. In an interview on 3/22/2013 at 11:24 AM CNA #17 said that she had heard Resident #500's fall alarm sound on 5/29/2012 and went into Resident #500's room to find Resident #500 on the floor. CNA #17 said she was not aware of Resident #500 having a fall 30 minutes prior. CNA #17 said she had provided care for Resident #500 and left her in her wheelchair in her room. CNA #17 said at the time she heard Resident #500's fall she was not in Resident #500's room, but was across the hall providing care on another resident. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION FOR 1 RESIDENT (#509) WHO HAD EXHIBITED UNSAFE BED MOBILITY AND FAILED TO ASSESS AND ANALYZE THE ROOT CAUSE OF FALL INCIDENT FOR 1 RESIDENT (#508) WHO WAS IDENTIFIED AS HAVING HIGH RISK FOR FALLING FROM A TOTAL 4 SAMPLED RESIDENTS REVIEWED FOR FALLS, RESULTING IN THE MAJOR HEAD INJURY AND RESIDENT #509 SUBSEQUENTLY DYING AND A LEFT SHOULDER FRACTURE FOR RESIDENT #508. FINDINGS INCLUDE: ACCORDING TO THE ADMISSION RECORD DATED [DATE] RESIDENT #509 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH PRIMARY [DIAGNOSES REDACTED]. THE SECONDARY [DIAGNOSES REDACTED]. THE "UNUSUAL OCCURRENCE FORM" DATED [DATE] AT 2300 (11:00 P.M.) WRITTEN BY A REGISTERED NURSE, (STAFF "A") STATED, "I WAS IN ROOM 217 WHEN I HEARD THE ALARM. I FOUND THE PATIENT FACING DOWN LYING IN THE FLOOR BY THE BED, HER CPAP (CONTINUOUS POSITIVE AIRWAY PRESSURE) MASK WAS ON THE FLOOR BY BED. HER NASAL CANNULA WAS MISPLACED ON HER FACE. I REPLACED NASAL CANNULA ON HER NOSE. SHE WAS NON-RESPONSIVE, I CHECKED HER PULSE, RESPIRATION, HEART BEAT. THERE WERE NO SOUNDS AUDIBLE OR PALPABLE. I PUT THE CALL LIGHT ON TO ASK FOR HELP. I PLACED A PILLOW UNDER HER FACE WHICH HAD A HEMATOMA ABOVE LEFT EYE. SHE WAS PALE WITH BLUISH LIPS. THE NURSE'S NOTES DATED [DATE] (NO TIME) REFLECTED, "PATIENT FOUND AT 2250 UNCONSCIOUS. FACING DOWN ON THE FLOOR. SKIN TEAR RIGHT LOWER LEG HEMATOMA ABOVE LEFT EYE. UNRESPONSIVE, PATIENT WAS WEARING (CPAP BY BED), N/C WITH O2 6L. NO VS DETECTED AT 2300. 2310 DOCTOR (DOCTOR'S NAME) INFORMED OF deceased RESIDENT. PHYSICIAN ORDER [REDACTED]." THE "(NAME OF LOCAL SUBACUTE REHABILITATION HOSPITAL) HISTORY AND PHYSICAL" DATED [DATE] REFLECTED, RESIDENT #509 " ...HAD FREQUENT HOSPITAL ADMISSIONS FOR HER ACUTE ON(SIC) CHRONIC RESPIRATORY FAILURE AND COPD EXACERBATIONS. SHE IS OXYGEN DEPENDENT ON 5 LITERS AT HOME ...SHE WAS ALSO ON BIPAP (BILEVEL POSITIVE AIRWAY PRESSURE) DURING THE DAY AS WELL ...HER BIGGEST COMPLAINT AT THIS TIME IS THAT SHE IS HAVING WATERY DIARRHEA ...SHE ALSO DEVELOPED A LARGE HEMATOMA ON HER LEFT LOWER LEG THAT HAS BEEN BLEEDING ONTO A DRESSING ...SHE HAS PITTING EDEMA FROM HER KNEES TO HER FEET ...SHE HAS LOSS OF MUSCLE MASS ...SHE IS VERY ALERT AND ORIENTED. HER SPEECH IS CLEAR. " THE "FALL RISK ASSESSMENT" DATED [DATE] REFLECTED RESIDENT #509 HAD A TOTAL SCORE OF 19 (10 OR ABOVE REPRESENTS HIGH RISK), REPRESENTING HIGH RISK. BASED ON THE TOTAL SCORE OF 10 OR GREATER THE INSTRUCTIONS CALLED FOR INITIATING AN IMMEDIATE PREVENTION PROTOCOL DOCUMENTATION ON THE CARE PLAN. THE "RESIDENT CARE PLANS-FALLS" DATED [DATE] REFLECTED RESIDENT #509 WAS AT RISK FOR FALLS RELATED TO DECREASED MOBILITY, UNSTEADY GAIT, CONFUSION AND DECREASED SAFETY AWARENESS. THE APPROACHES INCLUDED WITH CHECKED BOXES WERE 1) KEEP FREQUENTLY USED ITEMS WITHIN REACH. 2) BED/CHAIR ALARM. 3) DIVERT ATTENTION; OFFER ACTIVITY, TV, BOOKS, MAGAZINES. 4) FALL ASSESSMENT ON ADMIT, QUARTERLY AS NEEDED. 5) REVIEW FALLS CARE PLAN WITH EACH INCIDENT. 6) REFER TO PHYSICAL THERAPY. THE HANDWRITTEN ITEM INCLUDED 7) NON-SLID SEATING TO WHEELCHAIR. THE NURSE AIDES CARE PLAN DATED [DATE] REFLECTED RESIDENT #509 WAS TO BE IN A LOW BED AND NEEDED GRIPPER SOCKS IN ADDITION TO BED/CHAIR ALARM. THE "NURSE'S NOTES" DATED [DATE] REFLECTED RESIDENT #509 WAS "SITTING NEAR EDGE OF WHEELCHAIR. NURSE WAS HOLDING ON TO PATIENT AND ENCOURAGING PATIENT TO SCOOT BACK. SHE PROCEEDED TO SLIDE HERSELF FORWARD UNTIL SHE WAS KNEELING IN FRONT OF WHEELCHAIR ON ONE KNEE AND ONE FOOT WITH NURSE STILL HOLDING ON TO HER. " ON [DATE] AT 10:00 A.M., THE DIRECTOR OF NURSING (DON) STATED RESIDENT #509 HAD HER HEAD SLUMPED FORWARD WHENEVER SHE SAT IN HER CHAIR. THE "NURSE'S NOTES" DATED [DATE] THROUGH [DATE] REFLECTED RESIDENT #509 WAS LETHARGIC, SLEEPING IN A RECLINER, CONFUSED, COMPLAINED OF BEING SHORT OF BREATH, REFUSED BIPAP (CITING THAT THE MACHINE WAS NOT WORKING), UNABLE TO HOLD OBJECTS AND DROPPED DRINKING CUP SEVERAL TIMES. THE "NURSE'S NOTES" DATED [DATE] AT 5:30 A.M., 10:40 P.M., AND [DATE] AT 5:30 A.M. REFLECTED RESIDENT #509 AGAIN COMPLAINED OF HER BIPAP MACHINE NOT WORKING AND CALLED OUT VERY LOUD "HELP-HELP, I CAN'T BREATH." RESIDENT #509'S OXYGEN SATURATION WENT DOWN TO THE 80'S WITH C-PAP BUT OXYGEN SATURATION STAYED ABOVE 90'S WITH 6 LITERS NASAL CANNULA. RESIDENT WENT BACK AND FORTH BETWEEN C-PAP AND NASAL CANNULA 3 TIMES AND WAS ENCOURAGED TO KEEP NASAL CANNULA. THERE WAS NO DOCUMENTATION THAT RESIDENT #509'S CONCERNS RELATED TO HER BIPAP MACHINE NOT WORKING WERE INVESTIGATED. THE FACILITY INVESTIGATION SUMMARY, COMPLETED 5 DAYS AFTER THE INCIDENT ON [DATE] REFLECTED THE RESIDENT WAS POORLY RESPONSIVE ON SECOND SHIFT, NOT EATING OR DRINKING AND HER PHYSICIAN WAS NOTIFIED AT 9:00 P.M. ON [DATE]. ON [DATE] AT 9:15 P.M., THE NURSE AIDE, (STAFF "B") HEARD A LOUD NOISE FROM THE RESIDENT'S (#509) ROOM. WHEN STAFF "B" WENT TO CHECK ON THE RESIDENT SHE WAS SITTING ON THE EDGE OF THE BED LEANING FORWARD. STAFF "B" ASSISTED HER TO LAY DOWN, THE RESIDENT WAS NOT RESPONDING. STAFF "B" MADE SURE THE BODY ALARM WAS IN PLACE AND LOWERED THE BED TO THE LOWEST FLOOR POSITION. AT 10:10 P.M. THE NURSE AIDE, (STAFF "C") WAS GETTING ROOM TO ROOM REPORT FROM NURSE AIDE, (STAFF "D"). STAFF "C" OBSERVED THE RESIDENT RESTING IN THE CENTER OF THE BED WITH BI-PAP AND OXYGEN ON. STAFF "D" REPORTED TO STAFF "C" THAT THE RESIDENT WAS UNRESPONSIVE ALL SHIFT BUT DID ATTEMPT TO SIT UP NOT TOO LONG AGO. AT 10:50 P.M., REGISTERED NURSE, (STAFF "A") RESPONDED TO ALARM SOUNDING AND OBSERVED THE RESIDENT ON THE FLOOR BESIDE THE BED. ON [DATE] AT 2:00 P.M., NURSE AIDE, (STAFF "B") WAS INTERVIEWED REGARDING RESIDENT #509'S FALL [DATE]. STAFF "B" STATED SHE WAS NOT ASSIGNED TO CARE FOR RESIDENT #509 ON THE DAY OF THE INCIDENT BUT SHE WAS HELPING OUT OTHER NURSE AIDES. STAFF "B" HAD NOTICED RESIDENT #509 WAS IN A RECLINER WHEN SHE FIRST CAME TO WORK AT 2:00 P.M. RESIDENT #509 STAYED IN A RECLINER UNTIL 8:30 P.M. RESIDENT #509 LOOKED LIKE SHE WAS SLEEPING AND SHE DID NOT RESPOND WHEN THE AIDES CHECKED FOR HER BRIEF CHANGE BUT SHE WAS DRY ALL SHIFT. AT 9:15 P.M., AFTER RESIDENT #509 WAS ASSISTED TO HER BED AND PUT THE BI-PAP MACHINE ON STAFF "B" LEFT THE RESIDENT'S ROOM STAFF "B" THEN HEARD A CRASH. STAFF "B" STATED THE RESIDENT HAD KNOCKED DOWN THE TABLE AND SHE WAS TRYING TO STAND. STAFF "B" ADDED THAT SHE REPORTED THIS INCIDENT TO THE CHARGE NURSE AND LEFT THE FACILITY AT 10:30 P.M. STAFF "B" STATED RESIDENT #509 ATTEMPTED TO STAND FROM THE BED ABOUT THE SAME TIME 2 DAYS AGO WHEN SHE WAS A PRIMARY CARE GIVER AND THE APPLIED BI-PAP MACHINE FOR THE RESIDENT. STAFF "B" STATED SHE HAD REPORTED THE INCIDENT TO THE CHARGE NURSE AT THAT TIME ALSO. HOWEVER THERE WAS NO DOCUMENTATION OF STAFF "B" REPORTING OF THE SIMILAR INCIDENT. DESPITE RESIDENT #509'S WITNESSED ATTEMPTS TO GET OUT OF THE BED AND STAND TWICE, NEITHER THE NURSING NOTES NOR THE CARE PLAN ADDRESSED THOSE EPISODES. THERE WAS NO IMMEDIATE OR PLANNED INTERVENTIONS OF HOW TO CLOSELY MONITOR OR SUPERVISE RESIDENT #509 FROM A FALL. THE FALL CARE PLAN DID NOT REFLECT AN INTERVENTION FOR THE LOW BED OR THE FLOOR MAT TO MINIMIZE POTENTIAL INJURY TO RESIDENT #509. ( ) ACCORDING TO THE physician's orders [REDACTED]. RESIDENT #508 WAS FIRST admitted on [DATE] AFTER A FALL. THE RESIDENT WAS NOT ABLE TO BEAR WEIGHT ON THE LEFT SIDE AND HAD PAIN. A MRI OF THE HIP REVEALED A LEFT FEMORAL NECK FRACTURE ON [DATE]. RESIDENT #508 WAS TRANSFERRED TO HOSPITAL FOR SURGICAL REPAIR, THEN SHE WAS RETURNED ON [DATE]. RESIDENT #508 WAS PARTICIPATING IN PHYSICAL THERAPY AND OCCUPATIONAL THERAPY. THE RESIDENT WAS ALERT, ORIENTED AND ABLE TO USE CALL LIGHT. AT THE TIME UPON ADMISSION. THE CAA (CARE AREA ASSESSMENT) DETAILED DOCUMENTATION, DATED [DATE], REFLECTED RESIDENT #508 WAS TRIGGERED FOR CARE PLANNING DECISION AREAS DUE TO HER BALANCE PROBLEMS, RECEIVING ANTI-ANXIETY MEDICATION AS WELL AS ANTI-DEPRESSANT MEDICATION. RESIDENT #508 HAD A LEFT HIP FRACTURE ON [DATE] AND RETURNED to the facility on [DATE] AFTER REPAIR. THE RESIDENT WAS TO HAVE A BRACE TO HER LEFT HIP WITH 30 DEGREES HIP AND KNEE FLEXATION. THE "UNUSUAL OCCURRENCE FORM", DATED [DATE], REFLECTED RESIDENT #508 WAS FOUND ON HER LEFT SIDE ON THE FLOOR . UPON ASSESSMENT THERE WERE NOT NOTED LESIONS, CUTS, ABRASIONS. PUPIL EQUAL REACTIVE TO LIGHT (PERRLA) INTACT. ALERT AND ORIENTED X 3, SKIN PINK, WARM. PATIENT COMPLAINED OF LEFT ARM PAIN ,[DATE] UPON MOVEMENT. DOCTOR (DOCTOR'S NAME) CONTACTED. X-RAY ORDERED. TAB ALARM ADDED TO PATIENT. BED LOWERED. THE FACILITY UNUSUAL OCCURRENCE FORM, DATED [DATE] AT 11:30 PM REFLECTED RESIDENT #508 WAS OBSERVED ON FLOOR BY REGISTERED NURSE (STAFF "A".) THE X-RAY OF LEFT ARM WAS NEGATIVE FOR FRACTURE AT THAT TIME. THE RESIDENT #508'S CALL LIGHT WAS WITHIN REACH. STAFF "A" RESPONDED TO NOISE AND OBSERVED THE RESIDENT'S BEDSIDE TABLE WAS KNOCKED OVER. THE "CNA FALL CHECKLIST," A FORM USED TO MONITOR AND EVALUATE THE QUALITY OF CARE FOLLOWING A FALL, DATED [DATE], REFLECTED RESIDENT #508 HAD NO BED/CHAIR ALARM AT THE TIME OF INCIDENT, HAD NO EDGE MATTRESS OR FLOOR MAT, BED NOT IN LOW POSITION, THE CALL LIGHT WAS WORKING AND WAS WITHIN REACH ALTHOUGH THE CALL LIGHT WAS NOT ON. RECORD REVIEW REFLECTED A COMPREHENSIVE CARE PLAN WAS INITIATED ON [DATE] WITH THE PROBLEM, "RESIDENT AT RISK FOR FALLS R/T (RELATED TO) DECREASED SAFETY AWARENESS D/T (DUE TO) ST (SHORT TERM) MEMORY DEFICIT, UNSTEADINESS, FALLS W/FRACTURES IN LEFT LEG/HIP AND LEFT SHOULDER W/IMMOBILIZERS NWB (NON WEIGHT BEARING) LEFT LEG REQUIRING ASSISTANCE W/MOBILITY." RESIDENT #508 CONTINUED TO HAVE PAIN AND AN X-RAY WAS DONE ON [DATE] THAT REVEALED TRANSVERSE FRACTURE OF LEFT HUMERAL NECK RESIDENT #508 HAD FALL RISK ASSESSMENT DONE ON [DATE] WITH A TOTAL SCORE OF 10 (10 OR ABOVE REPRESENTS HIGH RISK) AND 16 ON [DATE]. THE FALL CARE PLAN DATED [DATE] REFLECTED RESIDENT #508 WAS AT RISK RELATED TO DECREASED SAFETY AWARENESS DUE TO SHORT TERM MEMORY DEFICIT, UNSTEADINESS AND NON-WEIGHT BEARING STATUS ON HER LEFT LEG. RESIDENT #508 WAS FORGETFUL BUT PLEASANT AND COOPERATIVE. SHE LET STAFF KNOW HER NEEDS AND MADE HER OWN DECISIONS. ON [DATE] AT 1:30 P.M., RESIDENT #508 WAS OBSERVED LYING IN HER BED, HAVING HER BRIEF CHANGED BY A NURSE AIDE, (STAFF "E"). RESIDENT #508 HAD A SLING OVER HER LEFT SHOULDER AND A BRACE ON HER LEFT LEG. RESIDENT #508 CALLED IT A "CAST." RESIDENT #508 WAS ASKED HOW SHE HAD FALLEN ON [DATE]. SHE STATED, " I TRIED TO CATCH THE STRING (CALL LIGHT CORD) TO LET THEM KNOW I NEEDED TO USE THE BATHROOM, BUT I COULDN'T FIND IT. I REACHED DOWN TO THE FLOOR NEXT TO MY BED (TO GET THE CALL LIGHT) AND SOMEHOW I ROLLED OVER ON TO THE FLOOR." ON [DATE] AT 9:00 A.M., RESIDENT #508 WAS OBSERVED LYING IN BED, LOOKING DISTRESSED AND COMPLAINED OF SEVERE PAIN OVER HER LEFT ARM AND LEG. RESIDENT #508 WAS REMINDED TO USE A CALL LIGHT THAT HAD BEEN LOOPED AROUND TWICE THE ENABLER BAR AND PINNED TO HER UPPER CLOTHING. HOWEVER, THE RESIDENT STATED SHE COULD NOT FIND IT. RESIDENT #508 STATED SHE HAD TOLD THE NURSE AIDE FEW MINUTES AGO THAT SHE NEEDED A PAIN PILL. ON [DATE] AT 1:00 P.M., DIRECTOR OF NURSING (DON) WAS ASKED FOR THE STATEMENT TAKEN FROM RESIDENT #508 AT THE TIME OF THE INVESTIGATION. THE DON STATED SHE HAD AN INTERVIEW STATEMENT FROM THE RESIDENT BUT SHE COULD NOT PROVIDE IT DUE TO QUALITY ASSURANCE CONFIDENTIALITY. THE DON ADDED THAT RESIDENT #508 HAD TOLD HER SHE COULD NOT FIND THE CALL LIGHT. THE DON REPORTED THE CALL LIGHT WAS CLIPPED TO HER (RESIDENT #508'S) CLOTHING. THERE WAS NO ROOT CAUSE ANALYSIS WHETHER THE FALL WAS RELATED TO THE RESIDENT'S PERCEPTUAL PROBLEM, COGNITIVE/BEHAVIOR PROBLEM OR HAND COORDINATION DEFICIT THAT CAUSED THE RESIDENT NOT BEING ABLE TO UTILIZE THE CALL LIGHT. ( )

This Citation pertains to MI 938 Based on observation, interview and record review, the facility failed to ensure the safe transfer of residents by not using a gait belt in 1 of 4 sampled residents (#102), from a total sample of 4 residents, resulting in Resident #102 sustaining a fractured ankle after an improper transfer. Findings include: Upon initial tour of the facility on 8/15/12, residents were observed to be well groomed, interacting with staff during AM care. The facility was clean with no odors, staff knocked on doors prior to entering rooms and addressing resident's by their proper name. Call lights were answered in a timely manner. Observed CNA's (certified nursing assistant) staff were noted to have gait belts on their persons. Review of the face sheet revealed Resident #102 was admitted to the facility on [DATE] with a medical history of [REDACTED]. According to the MDS (minimum data set) dated 4/29/12, Resident #102 was usually able to understand others, was able to make himself understood, and was moderately impaired for daily decision making. Resident #102 required extensive two person assistance for transfers from bed to chair and for toileting. Resident #102 did not have a steady balance and was only able to stabilize for transfer with human assistance when moving from a seated to standing position, moving on and off the toilet or between bed to chair or wheelchair. Review of the Facility Nursing Assistant Care Plan dated 7/19/12 revealed Resident #102 was "at high risk for falls". Resident #102 required transfer with 2 person extensive assist. Review of the Facility "Notification of Change in Care Plan" Discipline: Physical Therapy dated 3/28/12 "all functional Transfer's with strong assist X 2 Please use a gait belt". Review of the Facility "Incident and Accident Risk Analysis Review" dated 7/18/12 revealed "Resident (Resident #102) being transferred by new CNA, proper protocol not fully followed". Facility documentation "CNA Fall checklist" dated 7/18/12 completed by CNA #2 Section: Ambulation" Gait Belt used "NO" was checked. Resident #102 was sent to the hospital for evaluation and treatment for [REDACTED]. In an interview on 8/15/12 at 9:05 AM, CNA (certified nursing assistant) #1 stated, "There was an issue with a new CNA not wearing and using her gait belt, we do use them I don't know why someone wouldn't use it, they are part of our uniform". In an interview on 8/15/12 at 1:50 PM, CNA #2 stated that Resident #102 called for assistance to use the toilet, "I knew he was a 2 person assist but my hall partner told me he's fine by himself with one person. I sat him on the toilet, and when he rose twice, I pulled the cord in the bathroom and no one came. He (Resident #102) slipped to the floor. I did not use a gait belt I did not have one and didn't have one in the room, but we do now". ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT THE DEVELOPMENT OF PRESSURE ULCERS IN 3 OUT OF 7 RESIDENTS REVIEWED FOR PRESSURE ULCERS (#3, 5 AND 13) FROM A TOTAL SAMPLE OF 20 RESIDENTS, RESULTING IN HARM FOR RESIDENT #13 FOR HIS UNSTAGEABLE LEFT HEEL PRESSURE ULCER ACCOMPANIED BY PAIN AND [MEDICAL CONDITION], DECLINE TO NON-WEIGHT BEARING AND FRUSTRATION AND ANGER; UNSTAGEABLE LEFT HEEL PRESSURE ULCER FOR RESIDENT #3, AND TWO STAGE 2 BUTTOCK PRESSURE ULCERS FOR RESIDENT #5. FINDINGS INCLUDE: RESIDENT #13 WAS A [AGE] year OLD MALE admitted to the facility on [DATE] WITH THE FOLLOWING [DIAGNOSES REDACTED]. OTHER MEDICAL [DIAGNOSES REDACTED]. THE NURSING ADMISSION ASSESSMENT FORM DATED 11/23/11 REFLECTED RESIDENT #13 HAD "REDDENED" AREA ON HIS LEFT HEEL, SWELLING ON BOTH FEET, WORE "BLUE" BOOTS FOR HEEL PROTECTION AND KNEE HIGH "TED" HOSE TO REDUCE [MEDICAL CONDITION] (SWELLING). ON 2/9/12 AT 3:30 P.M., THE CLINICAL CARE COORDINATOR (CCC) (STAFF "G") FOR THE MEADOW UNIT STATED THAT SHE admitted RESIDENT #13 WHEN SHE WAS CALLED IN ON HER DAY OFF. SHE STATED THAT THE RESIDENT'S LEFT HEEL WAS JUST RED, NOT MUSHY OR BOGGY AND FELT NORMAL TO TOUCH. STAFF "G" HOWEVER, STATED THAT THE RESIDENT'S LEFT FOOT HAD NOT BEEN SWOLLEN (ALTHOUGH IT WAS DOCUMENTED, "BOTH FEET HAD [MEDICAL CONDITION]") UNTIL RECENTLY (3-4 WEEKS AGO) AND WAS NOT SURE WHAT HAPPENED TO THE RESIDENT'S "TED" HOSE. STAFF "G" ADDED THAT THE RESIDENT HAD WORN "TED" HOSE AND "BLUE" BOOTS FOR A WHILE, BUT WAS NOT SURE WHEN THEY HAD BEEN DISCONTINUED. THE "NURSING ASSISTANT CARE PLAN" UPDATED 1/17/12 REFLECTED THE BLUE BOOTS WERE DISCONTINUED ON 1/18/12 BUT THERE WAS NO DOCUMENTATION OF THE RESIDENT EVER HAVING THE "TED" HOSE. THE NURSING NOTE DATED 11/29/11 REFLECTED RESIDENT #13 TOLD A NURSE HIS LEFT HEEL WAS SORE. THE "WOUND CARE ASSESSMENT" FORM DATED 11/29/11 REFLECTED THE RESIDENT HAD 5 CM LONG AND 5 CM WIDE INTACT BLISTER. THE NURSING NOTE DATED 12/6/11 REFLECTED, "'...THERAPY PLAN OF CARE ' AS OF 12/5/11 WANTING RESIDENT TO AMBULATE IN HALLWAY ... LEFT HEEL BLISTER OPENED SURFACE WHICH NOW HAS SEROUS DRAINAGE ...' ABD (LARGE SIZE GUAZE)' PAD APPLIED TO HEEL...WILL CONTINUE TO OBSERVE". THERE WAS NO STAGING FOR THE OPENED SURFACE. DURING AN INTERVIEW ON 2/10/12 AT 11:00 A.M., THE REHABILITATION COORDINATOR, (STAFF "I") EXPLAINED THE "NOTIFICATION OF CHANGE IN CARE PLAN" FORMS WERE DIRECTIONS FOR NURSING STAFF TO FOLLOW IN TERMS OF TRANSFERS OR AMBULATION FOR RESIDENTS. RESIDENT #13 HAD A SERIES OF THESE FORMS INCLUDING THE ONE DATED 12/5/11 WHICH STATED THAT THE RESIDENT COULD BE AMBULATED TO AND FROM THE BATHROOM/DINING ROOM WITH ONE PERSON ASSIST USING A FOUR WHEELED WALKER. THE NURSING NOTE DATED 12/7/11 REFLECTED THE RESIDENT'S LEFT HEEL CONTINUED TO DRAIN SEROUS SANGNEOUS DRAINAGE. IT WAS UNCLEAR WHETHER ANY PHYSICAL THERAPY STAFF HAD INPUT IN ASSESSING THE RESIDENT'S THE AMBULATION STATUS AND RECOMMENDING APPROPRIATE INTERVENTIONS. THE physician's orders [REDACTED]. ON 2/9/12 AT 3:30 P.M., STAFF "G" EXPLAINED THAT THE WALKING BOOT HAD A SLIT AROUND THE HEEL SO THAT THE HEEL DID NOT TOUCH THE GROUND BUT THE RESIDENT WAS UNSTEADY WITH THE BOOT AND DID NOT LIKE IT. AN ISSUANCE, "NOTIFICATION OF CHANGE IN CARE PLAN" DATED 12/16/11 STATED THAT THE RESIDENT WAS NOT TO AMBULATE TO BATHROOM OR DINING ROOM SECONDARY TO WOUND ON LEFT HEEL. THE "WOUND CARE ASSESSMENT FORM" DATED 12/27/11 A MONTH AFTER THE ADMISSION, REFLECTED RESIDENT #13'S LEFT HEEL PRESSURE ULCER WAS NOW UNSTAGEABLE (COVERING OF NECROTIC TISSUE THAT MAY HAVE EXTENSIVE DAMAGE TO MUSCLE OR BONE) AND MEASURED 7 CM LONG AND 7 CM WIDE. THE "WOUND CARE ASSESSMENT" DATED 12/30/11, 3 DAYS LATER, REFLECTED THE WOUND WAS LABELED AS BEING A STAGE 2 (PARTIAL THICKNESS SKIN LOSS INVOLVING EPIDERMIS, DERMIS, OR BOTH). THE WOUND WAS DESCRIBED AS HAVING ESCHAR (DEAD TISSUE) ENTIRELY WITH MEASUREMENT OF 7 CM X 7 CM X < 0.25. THERE WAS 2 LUMPY PROTRUDING RED ULCERS WITH SEROUS DRAINAGE AND ODOR. ON 2/10/12 AT 10:00 A.M., THE CLINICAL CARE COORDINATOR "G" WAS ASKED WHETHER THE NURSES WERE TRAINED TO STAGE ANY PRESSURE ULCER WOUNDS. SHE STATED THAT THE FACILITY WAS PLANNING TO HIRE A WOUND CARE EXPERT AND PROVIDE INSERVICES TO THE STAFF IN THE NEAR FUTURE. RESIDENT #13 HAD A WOUND CARE CONSULTATION ON 1/10/12. THE CONSULTATION NOTES DATED 1/10/12 REFLECTED THE RESIDENT'S LEFT HEEL PRESSURE ULCER WAS UNSTAGEABLE. IT MEASURED 7 CM X 7 CM. THE WOUND HAD A FOUL ODOR ( SIGN OF INFECTION) AND WAS BEING TREATED WITH ANTIBIOTIC ([MEDICATION NAME]). THE WOUND CARE CONSULTATION INCLUDED APPLICATION OF SILVER [MEDICATION NAME] TO DECREASE THE [MEDICAL CONDITION] (ABNORMAL INCREASE IN THE NUMBER OF CELLS IN THE TISSUE) OF THE WOUND. THE PHYSICIAN'S PROGRESS NOTE DATED 1/19/12 REFLECTED THE RESIDENT NOW HAD 2 SEPARATE WOUNDS, WHICH MEASURED 1 CM X 1 CM AND 2.2 CM X 2.2 CM, HAVING THE MID PORTION OF THE WOUND HEALED. THE NOTE CONTINUED TO STATE THAT THE RESIDENT HAD PAIN 5/10 (A PAIN SCALE, 10 BEING THE WORST PAIN), AND VERY DEPRESSED WITH HOW HIS HEELS HAVE WORSENED. THE physician's orders [REDACTED]. SINCE THE X-RAY FINDINGS WAS NOT CONCLUSIVE THE RESIDENT HAD A BONE SCAN DONE ON 1/11/12. THE REPORT STATED THAT RESIDENT #13 HAD NO OSTEO[DIAGNOSES REDACTED] BUT MAY BE [MEDICAL CONDITION] OR SOFT TISSUE INFLAMMATION OF THE LEFT HEEL. THE NURSING NOTE DATED 1/18/12 REFLECTED THE RESIDENT WAS OBSERVED CRYING AND UPSET ABOUT HIS HEEL ULCER. THE "TREATMENT AND ENCOUNTER NOTES" BY THE PHYSICAL THERAPY DATED 12/6/11 THROUGH 1/30/12 REFLECTED THE RESIDENT OFTEN COMPLAINED OF PAIN RANGING FROM 6-8 ON A SCALE OF 1-10 (10 MOST PAINFUL). THESE WERE CONFIRMED BY NOTES ON 12/17/11, 12/26/11, 1/6/12, 1/23/12 WHEN RESIDENT #13 WAS STANDING OR AMBULATING. THE "NOTIFICATION OF CHANGE IN CARE PLAN" BY THE PHYSICAL THERAPIST DATED 1/17/12 A MONTH AFTER THE "NO AMBULATION ORDER", REFLECTED THE RESIDENT WAS TO CONTINUE NON WEIGHT BEARING STATUS ON LEFT LOWER LEG DURING ALL TRANSFERS. THE LAST "NOTIFICATION OF CHANGE IN CARE PLAN" DATED 1/25/12 REFLECTED THE RESIDENT WAS TO REMAIN ON NON-WEIGHT BEARING ON LEFT LOWER EXTREMITY DURING ALL TRANSFERS. ON 2/9/12 AT 10:30 A.M., RESIDENT #13 WAS OBSERVED SITTING IN A WHEEL CHAIR LOOKING OUTSIDE THE WINDOW IN HIS ROOM. THE FRONT PART OF HIS LEFT FOOT WAS ON A BRICK SIZE SPONGE FOAM BLOCK AND HE ROLLED IT AROUND WHEN HE NEEDED TO MOVE HIS FOOT. HE WORE A GRIPPER SOCK ON HIS LEFT FOOT. THE RESIDENT STATED THAT HE WAS FINALLY GOING HOME NEXT DAY. THE RESIDENT ADDED THAT HE WAS SUPPOSED TO BE discharged HOME AROUND CHRISTMAS BUT HIS HEEL ULCER MADE HIM STAY FOR NEARLY 2 MORE MONTHS. HE WAS CHOKED WITH EMOTION WHEN HE SHARED HE WAS UNABLE TO RETURN HOME AS HE HAD EXPECTED. ON 2/9/12 AT 11:30 A.M., THE DRESSING CHANGE TO RESIDENT #13'S LEFT HEEL WAS OBSERVED IN HIS ROOM. THE CLINICAL CARE COORDINATOR "G" REMOVED THE "[MEDICATION NAME]" (A THICK FOAM DRESSING) AND CLEANSED THE WOUND WITH SALINE SOLUTION. THERE WAS A SMALL OPEN AREA (APPROXIMATELY 0.5 CM X 0.5 CM X <0.25 CM) WITH YELLOW SLOUGH IN THE MIDDLE AND THE SURROUNDING TISSUES WERE COVERED WITH SUPERFICIAL BLACK STAINS. STAFF "G" STATED THAT THE WOUND HAD IMPROVED FROM THE TIME THE WOUND HAD BEEN MECHANICALLY DEBRIDED (2/2/12). STAFF "G" COMPLETED THE DRESSING CHANGE AFTER SHE APPLIED CLEAR "SOLOSITE" GEL AND COVERED THE WOUND WITH "[MEDICATION NAME]" DRESSING. THE INITIAL SKIN CARE PLAN DATED 11/24/11 REFLECTED RESIDENT #13 WAS IDENTIFIED AS A POTENTIAL FOR IMPAIRED SKIN INTEGRITY RELATED TO HIS DECREASED MOBILITY. HOWEVER, THE ADMISSION ASSESSMENT (11/23/11) REFLECTED THE RESIDENT ALREADY HAD A REDDENED AREA ON HIS LEFT HEEL AS WELL AS SWELLING OF THE LOWER EXTREMITIES. THERE WAS NO INTERVENTION TO PROTECT HIS LEFT HEEL UNTIL 11/26/11 WHEN THE BLISTER APPEARED. THE APPROACHES INCLUDED PUTTING "SKIN PREP" ON EVERY SHIFT AND APPLYING BLUE BOOTS WHILE THE RESIDENT WAS IN BED. THE PROBLEM STATEMENT LISTED IN THE CARE PLAN DATED 1/12/11 REFLECTED THE RESIDENT HAD ACTUAL STAGE 2 LEFT HEEL PRESSURE ULCER, ALTHOUGH THE "WOUND CARE ASSESSMENT FORM" DATED 12/27/11 (MORE THAN 2 WEEKS EARLIER) IDENTIFIED THE RESIDENT AS HAVING UNSTAGEABLE LEFT HEEL PRESSURE ULCER. THERE WAS A LACK OF TIMELY AND EFFECTIVE NURSING INTERVENTIONS AND treatment for [REDACTED]. THIS DELAY PREVENTED THE HEALING OF THE ACTUAL WOUND. ON 2/9/12 AT 12 NOON, STAFF "G" COULD NOT EXPLAIN THE REASONS FOR A DELAY IN DEVELOPING THE CARE PLAN WITH THE RESIDENT'S CHANGED SKIN CONDITION. THE "WOUND CARE ASSESSMENT FORM," A RECORD WHERE THE NURSES DOCUMENT THE ULCER DESCRIPTION INCLUDING MEASUREMENTS, DATED 11/29/11 THROUGH 2/6/12 REFLECTED THE FREQUENCY OF THE DOCUMENTATION VARIED FROM 4 DAYS TO 14 DAYS. THIS RANDOM, INFREQUENT DOCUMENTATION PRACTICE MAY HAVE CONTRIBUTED TO THE WORSENING OF THE LEFT HEEL PRESSURE ULCER. ( ) RESIDENT #3 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE " NURSE'S NOTES " DATED 11/22/11 REFLECTED THE RESIDENT HAD A BLACK AREA ON HER LEFT HEEL. THE " WOUND CARE ASSESSMENT FORM " DATED 11/22/11 DESCRIBED THE WOUND AS UNSTAGEABLE WITH MEASUREMENT OF 1.6 CM LONG, 1.5 CM WIDE AND UNKNOWN DEPTH. THERE WAS NO DOCUMENTATION ABOUT RESIDENT #3'S LEFT HEEL SKIN CONDITION PRIOR TO 11/22/11. THE SUBSEQUENT WOUND CARE ASSESSMENT FORMS DATED 12/1/11 THROUGH 2/3/12 REFLECTED RESIDENT #3 ' S LEFT HEEL REMAINED AS UNSTAGEABLE, BLACK ESCHAR WITH SIZES UP TO 1.8 CM LONG AND 2 CM WIDE. THE physician's order [REDACTED]. ON 2/7/12 AT 3:00 P.M., RESIDENT #3'S LEFT HEEL WAS OBSERVED INSIDE THE NURSING STATION. THE WOUND HAD DRIED YELLOW SLOUGH WITH MINIMUM AMOUNT OF DRAINAGE. THE LICENSED PRACTICAL NURSE, (STAFF " M " ) LOOKED AT THE WOUND AND WAS PLEASED AND STATED THAT THE SCAB MUST HAVE JUST COME OFF. THE CARE PLAN FOR " ACTUAL IMPAIRED SKIN INTEGRITY " WAS INITIATED ON 1/11/12, NEARLY ONE AND ONE HALF MONTH LATER AFTER THE INITIAL NOTATION OF THE LEFT HEEL ULCER. THE PROBLEM STATEMENT INCLUDED THE RESIDENT ' S LEFT HEEL ULCER MAY HAVE BEEN CAUSED BY FRICTION/SHEARING FROM USING HER FEET TO PROPEL THE WHEEL CHAIR DOWN THE HALL AND HER [DIAGNOSES REDACTED]. ONE OF SEVERAL INTERVENTIONS INCLUDED THE RESIDENT NOT TO WEAR SHOES AND THE STAFF COULD PUSH THE RESIDENT TO MEALS AND ACTIVITIES. HOWEVER, THE FAILURE TO PROMPTLY INITIATE A CARE PLAN WITH SPECIFIC INTERVENTIONS MAY HAVE LED TO THE DEVELOPMENT OF A PREVENTABLE PRESSURE ULCER TO RESIDENT #3'S LEFT HEEL. ON 2/8/12 AT 10:30 A.M., THE CLINICAL CARE COORDINATOR " G " STATED THAT THE FACILITY STARTED DOING WEEKLY SKIN ASSESSMENTS BY THE LICENSED STAFF FOR ALL RESIDENTS APPROXIMATELY 6 WEEKS AGO. HOWEVER, THE WEEKLY WOUND CARE ASSESSMENT FORMS DATED 11/22/11 THROUGH 2/3/11 REFLECTED THE PERIODS OF THESE ASSESSMENT VARIED BETWEEN 4 DAYS TO 17 DAYS AND NOT THE FACILITY'S PRACTICE OF THEIR WEEKLY SKIN ASSESSMENTS. THE FAILURE TO ASSESS WOUNDS ON A CONSISTENT BASIS COULD LEAD TO A DELAY IN WOUND HEALING RELATED TO A LACK OF MONITORING AND PROMPT TREATMENT. ( ) BASED ON THE MINIMUM DATA SET ASSESSMENTS, DATED 6/30/11, 11/11/11 AND 12/22/11, AND THE physician progress notes [REDACTED]. THE NURSING NOTES, DATED 11/1/11-1/31/12, REFLECTED RESIDENT #5 PREFERRED TO SIT IN HER EASY CHAIR IN HER ROOM AND RESISTED SUGGESTIONS FOR LYING DOWN IN HER BED. RESIDENT #5 WAS INDEPENDENTLY AMBULATORY TO THE BATHROOM WITH HER WALKER, REQUIRED ASSISTANCE OF 1 STAFF IN THE BATHROOM AND WAS OCCASIONALLY INCONTINENT OF URINE. THE RESIDENT HAD ALSO HAD A 25 POUND WEIGHT LOSS SINCE 3/2011 WHICH WAS BEING ADDRESSED WITH DIETARY SUPPLEMENTS AND MEDICATION CHANGES. THE "WOUND CARE ASSESSMENT FORM", DATED 11/4/11, REFLECTED THE IDENTIFICATION OF TWO STAGE 2 PRESSURE WOUNDS AND ONE UNSTAGEABLE PRESSURE WOUND (THE WOUND BED WAS NOT VISIBLE SO STAGING OF THE WOUND COULD NOT BE DONE). THE STAGE 2 WOUNDS WERE ON THE LEFT INNER BUTTOCK MEASURING 6 CM BY 1.4 CM AND ON THE RIGHT INNER BUTTOCK MEASURING 0.8 CM BY 0.8 CM. THE UNSTAGEABLE WOUND WAS ON THE RIGHT BUTTOCK AND MEASURED 5 CM BY 5 CM. BASED ON THE "WOUND CARE ASSESSMENT FORM", DATED 12/3/11, THE LEFT BUTTOCK WOUND WAS HEALED AND THE RIGHT BUTTOCK WOUND WAS A STAGE 2 MEASURING 2 CM BY 1 CM. THERE WAS NO DOCUMENTATION OF WHETHER THIS WAS THE PREVIOUSLY UNSTAGEABLE WOUND OR THE STAGE 2 WOUND OF THE RIGHT INNER BUTTOCK FROM 11/4/11. THE RIGHT BUTTOCK WOUND CONTINUED TO BE PRESENT UNTIL 1/13/12 WHEN THE "WOUND CARE ASSESSMENT FORM" REFLECTED THE WOUND WAS HEALED. THE CARE PLAN RELATED TO SKIN BREAKDOWN, DATED 11/11/11, REFLECTED RESIDENT #5 HAD "...PRESSURE AREA'S (SIC) TO BILAT (BILATERAL) BUTTOCKS..." AND THE APPROACHES FOR CARE INCLUDED; TREATMENTS AS ORDERED BY THE PHYSICIAN, DAILY SKIN EVALUATION, DIET AS ORDERED, MONITORING THE RESIDENT FOR PICKING AT WOUNDS AND REMINDING HER TO LEAVE THEM ALONE AND REMINDING THE RESIDENT TO CHANGE POSITIONS FREQUENTLY. THE CARE PLAN RELATED TO ACTIVITIES OF DAILY LIVING, DATED 11/11/11, REFLECTED RESIDENT #5 PREFERRED TO SLEEP IN HER RECLINER CHAIR AND SHOULD BE ENCOURAGED TO CHANGE POSITIONS EVERY 2 HOURS AND AS NEEDED. THERE WERE NO APPROACHES FOR PRESSURE RELIEVING DEVICES SUCH AS CHAIR CUSHIONS, AN AIR MATTRESS FOR THE BED OR LYING IN BED TO RELIEVE PRESSURE ON THE BUTTOCKS. THE CARE PLAN RELATED TO "ACTUAL SKIN IMPAIRMENT...", DATED 1/11/12, REFLECTED THE ADDITION OF THE PRESSURE RELIEVING CUSHION IN THE RECLINER 2 DAYS BEFORE THE LAST PRESSURE WOUND WAS DOCUMENTED AS HEALED AND MORE THAN 9 WEEKS AFTER THE 3 WOUNDS WERE IDENTIFIED. THE WOUND CARE CENTER NURSE PRACTITIONER PROGRESS NOTES, DATED 1/10/12, REFLECTED "PT (PATIENT) HAS NEW OPEN AREAS ON GLUTEUS (BUTTOCK) STARTED IN NOVEMBER...HAS NEW CHAIR-NEEDS CHAIR CUSHION-SLEEPS IN CHAIR-WILL NOT GET OFF BOTTOM MUCH DURING DAY..." ON 2/9/12 AT 12:55 PM AT THE NORTH NURSING STATION UNIT MANAGER "A" AND THE DIRECTOR OF NURSING (DON) STATED IT WAS THE FACILITY'S STANDARD OF CARE FOR ALL RESIDENTS TO HAVE A PRESSURE RELIEVING CUSHION IN THEIR CHAIRS. HOWEVER, UNIT MANAGER "A" WAS NOT CERTAIN THAT RESIDENT #5 HAD A CHAIR CUSHION UNTIL 1/2012. UNIT MANAGER "A" STATED THE FACILITY HAD TRIED TO ORDER A ROHO CUSHION (PRESSURE RELIEVING CUSHION) BUT DIDN'T GET IT AND WENT BACK TO THE USE OF A GEL (PRESSURE RELIEVING) CUSHION. UNIT MANAGER "A" AND THE DON FURTHER STATED A FACILITY WIDE EVALUATION OF ALL RESIDENTS' SKIN WAS DONE IN 1/2012 AND TREATMENTS AND CARE PLANS WERE UPDATED AFTER THE EVALUATION. UNIT MANAGER "A" WAS NOT AWARE THE CHAIR CUSHION WAS NOT A PART OF THE CARE PLAN UNTIL 1/11/12. ON 2/9/12 AT 1:15 PM THE DON PROVIDED THE FACILITY (STANDARDS OF CARE FOR THE PREVENTION OF PRESSURE ULCERS", REVISION DATE OF 2/2012. AFTER RESIDENT #5 DEVELOPED THE PRESSURE WOUNDS ON HER BUTTOCKS IN 11/2011 THERE WAS NO EVIDENCE THAT ADDITIONAL PRESSURE RELIEVING MEASURES WERE BEGUN TO ASSIST IN THE HEALING OF THE WOUNDS AND PREVENT THE DEVELOPMENT OF ADDITIONAL WOUNDS FROM 11/4/11-1/11/12. ( )

This citation pertains to intake number MI 324 & MI 302. Based on observation, interview, and record review, the facility failed to (1) prevent the elopement and ensure the safety in 2 of 4 sampled residents (#500 and #501), who were assessed as an elopement risk out of a total sample of 7 residents, resulting in an Immediate Jeopardy when Resident #500 signed herself and Resident #501 out on the leave of absence log then left the facility, pushing Resident #501 in her wheelchair, and walked around the front of the facility without staff knowledge placing all 35 residents identified as an elopement risk at high risk for harm, injury and/or death, and (2) provide supervision for 1 of 4 sampled residents (#502) from of a total sample of 7 residents, resulting in Resident #502 sustaining a fractured right hip. Findings include: Resident #500: Per the facility face sheet Resident #501 was originally admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of a "Letters of Guardianship" dated 6/28/2010 revealed that Resident #500 was a "legally incapacitated individual" who was appointed a guardian via the Probate Court. Review of a "Petition/Application for hospitalization ", dated 11/5/2010, revealed that Resident #500 was petitioned by her guardian to enter a hospital for the reason, as revealed in the petition, "Res. (resident) demanding to leave the locked unit ...got out door and refused to re-enter the unit ...Res. has a high elopement risk, combative with staff. Has a long history of elopement from facilities. " Review of a "Minimum Data Set" dated 8/19/2010 revealed that Resident #500 had moderately impaired cognitive skills. Record review of a facility "Alleged Incident Report" dated 5/29/2011 revealed that Resident #500 was observed by Certified Nurse Assistant (CNA) #1, through a window, to be outside pushing Resident #501 around in her wheelchair, unsupervised. The report revealed that Resident #500 and #501 signed out on the resident sign out sheet and proceeded to go outside for a walk. Review of three "Elopement Risk Assessments" dated 11/2/2010, 11/15/2010, and 5/2/2011 revealed that Resident #500 was assessed to be at risk for elopement. Record review of a "Readmission Assessment" per the physician dated 11/22/2010 revealed that Resident #500 was readmitted back to the facility, after a hospital stay, and was admitted to the "Meadows" unit, a locked unit, due to her dementia with elopement risk. Record review of "Social Progress Notes" dated 11/17/2010 revealed that Resident #500 was re-admitted to the facility on [DATE], after a hospital stay, and was admitted to a room in the dementia (Meadows) unit, per her guardian, due to elopement risk. The note revealed that Resident #500 would leave the "Meadows" unit for activities with supervision and also revealed, " Res. has been court ordered to 24 hour supervision ... " The notes dated 12/9/2010 noted that Resident #500 remained an elopement risk, and had a "Wander guard" bracelet on (a bracelet that would alarm when too close to an alarmed door). The note revealed that Resident #500 had not expressed any desire to leave the facility at that time. The note revealed that a plan was put in place to allow Resident #500 to leave the locked unit and go to the un-locked areas for meals and activities without supervision. The notes dated 2/1/2011 revealed that Resident #500 remained on the dementia unit, but had privileges to roam the facility since 12/10/2010. The note revealed that Resident #500 had not exhibited any noncompliance and had accepted re-direction if needed, although it was noted that Resident #500's mood would fluctuate as did her cognitive status. The notes dated 4/1/2011 revealed that Resident #500 was moved out of the "Meadows" locked unit and into the un-locked unit of the facility, with agreement from the guardian. Review of a "Resident Care Plan" dated 8/6/2010 revealed that Resident #500 was, "At Risk of Trauma" evident by wandering/elopement due to dementia. An approach to the problem documented on the care plan was to monitor Resident #500's whereabouts at the beginning of each shift and every two hours as needed. Record review of a "Nursing Assistant Care Plan" dated 8/6/2010 revealed "check whereabouts at beginning of each shift, every 2 hours, and end of each shift." Record review of a "Nursing Assistants Flow Sheet Record" dated for the months of November and December 2010, January, February, March, and April 2011 revealed no documentation as directed from the "Resident Care Plan and/or "Nursing Assistant Care Plan" to check Resident #500's whereabouts at beginning of each shift, every two hours, and end of each shift. The May and June 2011 "Nursing Assistant Flow Record" did reveal that the intervention was completed, per staff initials every shift. Record review of a "Resident Care Plan" dated 3/30/2011 revealed that Resident #500 was transferred from the "Meadows" unit to the "Nursing" unit (un-locked unit). Review of the "At Risk for Trauma/Falls" care plan dated 5/10/2011 revealed that Resident #500 had attempts to leave the facility without supervision. No intervention or approach was on the care plan to direct staff in the event that Resident #500 did go out a door without supervision. A "Social Work" care plan dated 5/31/2011 revealed that Resident #500 was transferred from the "Nursing" unit back to the "Meadows" locked unit. Record review of nurses' notes revealed no notation for attempts to go out of a door on or around the date of 5/10/2011. Review of the nurses' notes also revealed no notation in regards to Resident #500 signing her and Resident #501 out of the facility on 5/29/2011. The notes did not reveal the incident at all nor did the notes reveal that an assessment was conducted on Resident #500 after she returned inside the facility. Record review of the facility policy titled "Elopement Prevention/ Management" dated 9/2005 and reviewed 10/2010 revealed that in the event a residents whereabouts were uncertain and after the resident had been located, "a complete assessment of their condition will be done by the nurse on duty. The nurse on duty will document the incident and appropriate actions taken. Record review of the facility "Release of responsibility leave of Absence Sign In/Out Form" revealed that Resident #500 had signed herself and other residents out of the facility, while putting herself down as the person accepting responsibility for the resident while out of the facility, on multiple dates. The form also revealed that Resident #500 signed herself back into the facility as the "signature of the responsible party" on several occasions and no one signed Resident #500 back into the facility on four separate dates as evidenced by no signature on the sign in and out form, therefore no indication as to when Resident #500 returned to the facility on those dates. Resident #500 was interviewed on 6/22/2011 at 2:30 PM. Resident #500 said that she was happy and on the day she took Resident #501 outside she signed herself and Resident #501 out. Resident #500 said that she removed her wander guard bracelet about 10 minutes before she went outside. Resident #500 said that she took Resident #501 out the front door of the facility, the door that faced the road. Resident #500 said that the two of them went up and down the parking lot and then went back inside. Resident #500 said that she could not remember anything else, but stated that she did not want the wander guard bracelet on so she could go outside. CNA #1 was interviewed on 6/22/2011 at 2:45 PM. CNA #1 said that she was working in the "Meadows" unit and while she was in the dining room she noticed Resident #500 walked by the window. CNA #1 said that Resident #500 disappeared around the fence but she thought the hair she saw was that of Resident #500. CNA #1 said that she ran down the hall to the first room and looked out the window, but did not see Resident #500, so she ran to the next room and again did not see Resident #500. CNA #1 said that she then went back to the dining room and that was when she saw Resident #500 passing by the window while pushing Resident #501 in her wheelchair. CNA #1 said that she then ran out of the unit and told the first two staff members that she saw. CNA #1 said that she verified with Staff CNA #3 that Resident #500 was back in the facility before she proceeded back to her assigned unit. Licensed Practical Nurse(LPN) #2, Resident #501's (resident who Resident #500 signed out) primary nurse, was interviewed on 6/24/2011 at 12:55 PM. LPN #2 said Resident #500 did not understand why she was at the facility. LPN #2 said when Resident #500 resided in the "Meadows" locked unit, she would take her wander guard bracelet off. LPN #2 said Resident #500 had learned the code to open the door and as a result staff would have to change the code. LPN #2 said that on 5/29/2011, when Resident #500 signed herself and Resident #501 out of the facility, she questioned why the door alarm had not sounded. LPN #2 said she then learned that Resident #500 had taken her wander guard bracelet off. LPN #2 said that no staff member had seen Resident #500 sign herself and Resident #501 out of the facility and no staff member had seen the two residents go out the door either. LPN #2 said Resident #500 would commonly sign herself out and if staff had not seen her sign herself out, the door alarm would sound and the common practice had been that staff would watch her through a window while she was outside. LPN #2 said if staff could no longer see Resident #500 through the window, then staff would go outside to be with her. LPN #2 stated Resident #500 was not moved to the "Meadows" locked unit until the next day, 5/30/2011. CNA #3, was interviewed on 6/22/2011 at 3:05 PM. CNA #3 said she heard CNA #1 say that Resident #500 had taken Resident #501 outside. CNA #3 said that when she got to the front door the two residents were on their way back in. CNA #3 said she found Resident #500's wander guard bracelet and her name tag lying on the table by the door, just out of range of the door alarm. CNA #3 said Resident #500 knew at what point the alarm would sound and where she could set the bracelet down to prevent the alarm from sounding. CNA #3 said Resident #500 knew this because she would play cards in the lobby area with her spouse and they figured out where they could sit to prevent the door alarm from sounding. CNA #3 said no one told her to do one on one observation or frequent checks of either Resident #500 or #501 after the incident. LPN #4, Resident #500's primary nurse, was interviewed on 6/24/2011 at 1:35 PM. LPN #4 said at the time of the event she was in another resident's room. LPN #4 said she asked the Unit Manager if she needed to phone the Director of Nursing, and stated the Unit Manger told her she would take care of it. LPN #4 said that she was not around when Resident #500 signed herself and Resident #501 out of the facility. LPN #4 said that no one knew how long the two residents had been outside, and stated that the door alarm had not sounded because Resident #500 had taken her wander guard bracelet off. LPN #4 said she explained to Resident #500 that she could not sign other residents out of the facility. LPN #4 said she tried to stay around the nurses' station as much as she could and stated she did not put Resident #500 on a 1:1 observation or frequent checks after Resident #500 came back into the facility. LPN #4 said Resident #500 knew where the sign out book was located at the nurses' station. LPN #4 said she did not do an assessment of Resident #500 nor did she document the incident in the nurses' notes. LPN #4 did not call the physician or the guardian because, after talking with the Unit Manager, she was under the understanding that the Unit Manager would take care of the phone calls. Observation of the "Release of responsibility leave of Absence Sign In/Out Form" was done on 6/24/2011 at 2:00 PM. The book was located at the nurses' station and readily available and accessible to anyone. The Unit Manager, LPN #5, was interviewed on 6/24/2011 at 2:10 PM. LPN #5 said she phoned the Director of Nursing and that was all she did in regards to the incident. CNA #6, was interviewed on 6/24/2011 at 2:20 PM. CNA #6 said he saw Resident #500 pushing Resident #501 around in her wheelchair about 15 minutes prior to the two residents going outside. CNA #6 said that he worked the following day, on Monday and he was told to check on Resident #500 more frequently because she kept taking her wander guard bracelet off. CNA #6 said Resident #500 was still in the Nursing Unit and had not been moved back to the Meadows Unit, nor was 1:1 observation or 15 minute checks initiated for Resident #500. Observation of all the WanderGuard alarmed doors was conducted for alarm functioning, with Staff Member #11, the Director of Maintenance, on 6/27/2011 at 3:30 PM. All 4 door alarms were observed to be functioning. Two attempts were made to contact the guardian for Resident #500 on 6/24 at 11:40 AM, and 6/27/2011 at 8:37 AM and were unsuccessful. Record review of a "15 Minute Suicide Watch" form dated 5/31/2011 revealed that Resident #500 was documented to be observed every 15 minutes which began, as documented, on 5/31/2011 at 5:00 PM. The form revealed initials as indication of the 15 minute checks. The form revealed initials from 5/31/2011 at 5:00 PM through 5/31/2011 10:15 PM, which then the form was not signed again until 6/1/2011 at 6:00 AM. Resident #501: Per the facility face sheet Resident #501 was an [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of a "Letter of Guardianship" dated 5/27/2009 revealed that Resident #501 was appointed a Court Appointed Guardian effective 5/27/2009. Record review of an "Elopement Risk Assessment" revealed that Resident #501 was assessed to be at risk for elopement on the following dates: 10/26/2010, 1/24/2011, and 4/22/2011. The assessments revealed a notation that stated that Resident #501 refused to wear a wander guard bracelet and staff was to monitor her whereabouts at the beginning of each shift, at the end of each shift, and every 2 hours. Review of a "Nursing Assistant Care Plan" dated for the month of May 2011 revealed that Resident #501 refused to wear a wander guard bracelet and the CNA's were to check her whereabouts at the beginning, at the end of each shift, and every 2 hours. Review of the "Nursing Assistant Flow Record" for the month of June 2011 revealed no documentation of the CNA's checking on the whereabouts of Resident #501. The guardian who was the daughter of Resident #501 was interviewed on 6/24/2011 at 11:45 AM, and said Resident #501 was slow in her wheelchair. The guardian said she did not receive a phone call about the elopement incident until 5/31/2011 and that the Director of Nursing called her and told her what had happened. The guardian said she was told that Resident #500 had signed Resident #501 out of the facility and no staff had noticed because they were all passing medications to other residents. The guardian said that for no reason did she want Resident #501 to leave or go outside of the facility with another resident or any one else, unless directed by her, as she was concerned that Resident #501 could possibly get into the road or the water fountain that was located on the property. Resident #501 was interviewed on 6/24/2011 at 12:25 PM, and said she did not remember going outside. LPN #2, Resident #501's primary nurse, was interviewed on 6/24/2011 at 12:55 PM. LPN #2 said that by the time she had found out what had happened Resident #500 and #501 were back in the facility. LPN #2 said that she was busy and did not do an assessment on Resident #501, did not document the incident in the nurses' notes, did not notify the physician, or phone the guardian. LPN #2 said that she did not put Resident #501 on frequent observation, such as 1:1 observation or 15 minute checks. LPN #2 said that a WanderGuard bracelet was applied to Resident #501 but not until the next day. The Administrator was notified on 6/27/2011 of the Immediate Jeopardy that began on 5/29/2011 when Resident #500 signed herself and Resident #501 out on a leave of absence log then left the facility, pushing Resident #501 in her wheelchair, and walked around the front of the facility without staff having any knowledge that the two residents were outside. On 6/28/2011 the surveyor confirmed that the facility had implemented the following to remove the Immediate Jeopardy: 1) Resident #500 was moved to the secure memory care unit (Meadows) on 5/30/2011. Resident #500 also continued to wear a wander guard bracelet which is checked daily. 2) Resident #501 had a wander guard bracelet placed on her person on 6/6/2011 and is checked daily. 3) On 6/27/2011 care plans for both residents were updated to include the risk for elopement, wander guard bracelets applied, and to check the residents at the beginning and end of each shift and every 2 hours. 4) Elopement risk assessments were completed again on 6/27/2011 and will continue to be done quarterly. 5) The resident sign out book was moved to the nurses' medication cart on 6/28/2011 so residents and visitors will have to contact a nurse prior to signing a resident out of the facility. 6) Beginning 6/27/2011 an in-service was conducted and included the review of the elopement policy, knowing which residents are at risk for elopement and reporting any non-compliance with signing out or removing of a wander guard bracelet, documentation of any attempts to leave the facility, immediate reporting of attempt to leave to immediate supervisor, completion of assessments and incident reports, reporting immediately to the Director of Nursing or Administrator should a resident exit any door, putting immediate safety factors in place such as, 1:1 observation, 15 minute checks etc. and responding immediately to any door alarms. All regularly scheduled staff will be in-serviced within 72 hours and staff that are on-call, part-time, on vacation or medical leave will not be allowed to work until they have received the in-service. As of 6/27/2011 50 of 150 employees had received the in-service. 7) Beginning 6/27/2011 wander guards will continue to be checked on a daily basis and replaced as needed. All residents will continue to be assessed at least quarterly for elopement risk. 8) An audit of all charts was started on 6/27/2011 to ensure all residents had an elopement risk assessment done in the last 90 days. As of 6/27/2011 89 of 89 resident charts were audited. 9) On 6/27/2011 the wander guard door alarms were checked for functioning and all found to be functioning. Maintenance will continue to do weekly audits of wander guard door alarms. 10) Beginning 6/27/2011 the facility will continued to maintain and update the elopement risk list and hold monthly elopement drills. Although the Immediate Jeopardy was removed on 6/28/2011, the facility remained out of compliance at a scope of isolated and a severity of actual harm that is not Immediate Jeopardy for Resident #502 (see below), due to all staff had not received the in-service and sustained compliance had not been verified by the State Agency. Resident #502: Per the facility face sheet Resident #502 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of a "Minimum Data Set" dated 6/26/2011 revealed that Resident #502 did not ambulate at all. Record review of a "Fall Risk Assessment" dated 5/26/2011 revealed that Resident #502 was at a high risk for falls based on his assessment score of 16. The form revealed that a score of ten (10) or higher placed a resident at a high risk for falls. Record review of a "Resident Care Plan-Falls" dated 5/26/2011 revealed that Resident #502 was at risk for falls. An approach on the care plan dated 5/27/2011 revealed that Resident #502 was moved to a room closer to the nurses' station. No intervention for frequent observation or to keep Resident #502 in common areas was noted to be on the care plan. Review of a facility incident report dated 5/28/2011 revealed that Resident #502 got up from his wheelchair and began to walk with his fall alarm in his hand. The report revealed that Resident #502 was not able to walk without assistance. The report revealed that the fall occurred near the nurses' station. The report revealed that x-rays were taken and Resident #502 was transferred to the hospital. Record review of the nurses' notes dated 5/28/2011 revealed that at 7:00 PM, Resident #502 was near the nurses' station on the floor. The notes revealed that Resident #502 complained of hip pain and an x-ray was taken along with transferring Resident #502 to the hospital. Record review of a "Behavioral Monitoring/Intervention Flow Record" dated 5/27/2011 revealed a notation from CNA #12, that revealed Resident #502 had been removing his fall alarm and carried it with him. The notation revealed Resident #502 had done this twice. Registered Nurse (RN) #13, Resident #502's primary nurse, was interviewed on 6/24/2011 at 11:00 AM. RN #13 said Resident #502 was a known fall risk. RN #13 said Resident #502 had dementia and would get up without assistance. RN #13 said Resident #502 did not understand directions and would not wait for assistance. RN #13 said Resident #502 was sitting in his wheelchair in the hall directly across from the nursing station. RN #13 said she was called away from the nurses' station to assist another resident with catheter care, stating that catheter care takes time to complete. RN #13 said when she had come out of the other resident's room she saw Resident #502 standing up and he had his fall alarm in his hand. RN #13 said she was about 20 feet from Resident #502 and could not get to him before he fell . RN #13 said she saw his legs buckle and he fell . RN #13 said that 2 other CNA's were in the unit but were transferring other residents out of the dining room at the time of Resident #502's fall. RN #13 said Resident #502 complained of right hip pain after his fall and after an x-ray confirmed a right hip fracture, he was transferred to the hospital. RN #13 said that she did not tell any other staff that she was leaving the nurses' station area to go into another resident's room and left Resident #502 sitting alone at the nurses' station. CNA #14, was interviewed on 6/28/2011 at 10:10 AM. CNA #14 said he responded to the fall on 5/28/2011 and Resident #502 had yelled out in pain due to his hip fracture. CNA #1, was interviewed on 6/28/2011 at 12:55 PM. CNA #1 said she saw Resident #502 at the nurses' station area prior to his fall. CNA #1 said Resident #502 did have a fall alarm. CNA #1 said she had gone into another resident's room and therefore did not see Resident #502 fall, but stated that she knew no one was at the nurses' station at the time of Resident #502's fall. CNA #1 said that she was not able to leave the room she was in because the resident she was caring for was up in a mechanical lift. CNA #18, was interviewed on 6/28/2011 at 2:05 PM. CNA #18 said that Resident #502 was moved from the "Rehab" unit to the "Nursing" unit. CNA #18 said that Resident #502 had been taking his fall alarm and wander guard alarm off. CNA #18 said she had to keep her eye on Resident #502 all the time because he would attempt to get up on his own and would take his alarms off. CNA #18 said when Resident #502 moved to the "Nursing" unit she did not go with him for the move, therefore she did not give the staff on the "Nursing" unit any report of Resident #502's behaviors. CNA #17, was interviewed on 6/28/2011 at 2:35 PM. CNA #17 said that Resident #502 was admitted to room #228 because he would constantly get up and down from his bed and wheelchair without assistance. CNA #17 said Resident #502 would take his fall alarm off. CNA #17 said that at times Resident #502 would swing his arm around and grab the rope for the fall alarm and pull it off. CNA #17 said as a result Resident #502 was moved closer to the nurses' station for closer observation. CNA #17 said that on 5/28/2011 when Resident #502 had fallen she heard him yell out in pain. CNA #17 said that he was holding his fall alarm in his hand when he was found on the floor. Record review of hospital "Emergency Department Chart" dated 5/29/2011 revealed that Resident #502 was found to have a fracture of his right hip. Review of a hospital operative report dated 5/29/2011 revealed that Resident #502 had surgery to repair his fractured hip. ( )

This citation pertains to MI 060. Based on observations, interviews and records review, the facility failed to provide adequate supervision and assistive devices to prevent falls and the potential for serious harm for 1 of 5 sampled residents (Resident #102) resulting in a facial laceration requiring surgical closure and the potential for serious harm for Resident #102. Findings Include: Resident #102: An unannounced survey was conducted on 10/20/10-10/21/10. Per Resident #102's face sheet, she was admitted to the facility on [DATE]. Per an Incident Report, dated 10/03/10, Resident #102 was (observed), "on floor next to roommate's bed with walker nearby". Per an emergency record, 10/03/10, dated Resident #102 sustained a "laceration located over the left eyebrow which is 3 cm in length. This wound will require surgical closure to stabilize wound edges and ensure optimal healing ...[DIAGNOSES REDACTED]. On 10/20/10 at 4:00 PM, Surveyor observed Resident #102 propelling self in a wheel chair. Surveyor observed a laceration over Resident #102's left eye and blue, green and yellow skin discoloration was observed on her left cheek. Per Resident #102's MDS (Minimum Data Set) dated 12/13/09, Resident #102 had a [DIAGNOSES REDACTED]. Per Resident #102's MDS (Minimum Data Set) dated 8/22/10, Resident #102 fell in the past 31-180 days. Per Fall Risk Assessments, Resident #102 was assessed as being at high risk for falls on 6/03/10, scoring 21 (> 10 = high risk) and on 8/23/10 she scored 17. Per Resident #102's "Resident Care Plans ...At Risk for Falls", "...make sure that alarm is locked to resident clothes to prevent her from removing tab (dated 2/05/09)". Per the director of nursing #5, in an interview on 10/21/10 at 10:15 AM, Resident #102 was not to have a chair alarm on 10/03/10. However, per Resident #102's "Physician's Orders", there was an order for [REDACTED]. No physician order to discontinue the chair alarm was found in Resident #102's subsequent "Physician's Orders". Per Resident #102's "Resident Care Plans" under "At Risk for Falls", "make sure that alarm is locked to resident clothes to prevent her from removing tab" was dated 2/05/09. Per Resident #102's "Medication Administration Record", "Bed chair alarm. Every shift check for functioning every 2 hours and PRN" was signed every shift, by nursing staff, during 10-01/10-10/03/10. In an interview with nurse #9, on 10/21/10 at 10:25 AM, she stated that on 10/03/10 Resident #102 did not have an alarm on her wheel chair and she observed Resident #102 walking, with her walker, by the nurse's station five minutes before she fell . In a telephone interview with Resident #102's daughter/durable power of attorney #10, on 10/20/10 at 11:07 AM, she told Surveyor that Resident #102 had not had a chair alarm on for about six months and said no one at the facility discussed removing Resident #102's chair alarm with her. Surveyor requested to review the facility's policy on fall prevention at the Entrance Conference on 10/20/10 at 3:30 PM. At the Exit Conference, on 10/21/10 at 3:45 PM, The administrator #5 and director of nursing #5 revealed they did not have a policy on fall prevention but they did have procedures regarding fall prevention.