Every finding on record at Cherry Hill for Nursing and Rehabilitation

Based on interview and record review, the facility failed to ensure arbitration agreements were signed by the resident or appropriate responsible party, and in a manner which was explained and understood by the resident or responsible party for four residents (R23, R35, R90, and R104) of reviewed for arbitration agreements. Findings include: On 1/13/26 at 10:38 AM, an entrance conference was completed with the Nursing Home Administrator (NHA) indicating the facility offers arbitration agreements. At that time, a request for the residents who entered into an agreement was requested. A review of the list noted 77 residents who had entered into arbitration agreements. R23A review of the arbitration agreement list revealed R23 had entered into an arbitration agreement. Further review revealed a signing date of 7/25/25 by someone other than the resident. A request for guardianship documentation was requested on 1/15/26 at 10:26am however, this was not received by end of survey. A review of R23's medical record revealed the resident was their own responsible party but had a significant other listed as an emergency contact which was the person who signed R23's arbitration agreement on the date of admission. R90A review of R90's signed arbitration agreement was noted to be in English and was dated and signed by the resident on 5/10/25. Further review of the resident's medical record revealed a progress note indicating that English is not the resident's primary language: 3/12/2025 22:19 (10:19pm) admission Summary .Late Entry: Resident is non-English speaking, which presents challenges in effectively communicating needs and concerns. Alternative communication methods will be utilized as needed to ensure understanding and support . R104On 1/15/26 at 3:05 PM, R104 was asked if they had signed an arbitration agreement and explained what exactly an arbitration agreement was. The resident explained they would not have signed something like that upon admission. R104 was listed as being a resident who had entered into an arbitration agreement. R35On 1/15/26 at 3:22 PM, R35 was asked if they had signed an arbitration agreement and was explained what exactly an arbitration agreement was. The resident explained they would not have signed something like that upon admission. R35 was listed as being a resident who had entered into an arbitration agreement. On 1/15/26 at 1:35 PM, the Nursing Home Administrator (NHA) was asked about the expectation for the proper completion of arbitration agreements and acknowledged this is a new concern identified which will be worked on.On 1/15/26 at 12:14 PM, the facility's Arbitration Agreement policy was requested and not provided by end of survey.

Based on observation, interview, and record review, the facility failed to maintain the cleanliness of the 200-hallway shower room for one (R105) and failed to maintain linen in good repair for one (R111) of three residents reviewed for the environment. Findings include: On 01/13/2026 at 11:04 AM, R105 was interviewed in their room and reported they did not want to use the 200-hallway shower room because they felt it had mold present that was visible along the lower rear wall seam between the wall and floor. On 01/14/2026 at 1:15 PM, observation of the 200-hallway shower room revealed: 1. A black substance along the seam of the back wall and the floor where there was a gap of approximately two-three inches in the tile leaving an area that was only grout. The black substance was easily wiped onto a napkin. 2. Two areas of broken tile on wall corners leaving exposed drywall approximately four to six inches wide. 3. A clump of brown substance that appeared to be feces and a large clump of hair. On 01/15/2026 at 2:45 PM, the facility Administrator (NHA) observed the 200-hallway shower room with the surveyor and acknowledged the presence of the areas of concern within the shower room and expressed the intention to clean/repair the areas. On 01/13/26 at 9:30 AM, R111 was observed lying in bed in their room watching television. Two golf ball sized holes in the sheets were observed near their pillow, and several smaller pea sized holes were observed on the side of the sheets. R111 said the holes bothered them and were unacceptable and would not use sheets with holes if they were in their own home. On 01/14/26 at 11:00 AM, an interview was held with Unit Manager D and was asked about the holes in the bed linens. UM D stated the nursing assistants change the beds at least once a week and as needed. Any worn or torn sheets are to be sent back to laundry to be taken out of rotation. A record review revealed that R111 was admitted on [DATE] with the following medical diagnoses of Heart Failure and Chronic Respiratory Failure with Hypoxia / Hypercapnia. R111's most recent Brief Inventory for Mental Status assessment revealed a score of 15/15 indicating intact cognition. A review of the facility's policy titled Quality of Life - Homelike Environment, dated May 2017, revealed the policy statement: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management shall maximize to the extent possible, the characteristics of the facility that reflect a personalized homelike setting. These characteristics include . clean bed and bath linens that are in good condition.

Based on observation, interview and record review, the facility failed to ensure a low air loss mattress (LAL) was powered on for one resident (R59) of three reviewed for wound management. Findings include:On 01/13/2026 at 10:37 AM and 11:35 AM, R59 was observed to be in a LAL specialty bed. The bed had side bolsters and R59 was sunk low in the bed between the bolsters. An observation of the power unit for the bed revealed no active lights or display screen to indicate the mattress was powered on. R59 had a green wedge behind their torso and faced toward the right side of the bed. At 4:01 PM, the power unit for the mattress remained not powered on. The base of the mattress was firm and R59 reported they felt like they were laying on the frame and was adjusted their position slightly. R59 further noted they did not get out of bed often. On 01/14/2026 at 8:47 AM, R59 was observed to be in bed, sitting up and eating breakfast. The power unit for the bed had no lights or active display screen and was not powered on. At 4:23 PM, the mattress and power unit were observed with Licensed Practical Nurse (LPN) A. LPN A checked the mattress and reported they were not aware it was not working and confirmed no lights nor display were activated. On 01/15/2026 at 8:48 AM, the LAL mattress was observed with the unit manager and wound nurse LPN B. The mattress power unit had visible green lights and an active display. LPN B reported they were not aware of the mattress having been off and reported they locked the power screen to ensure it was not turned off inadvertently. LPN B reported R59 had resolved the buttocks wounds but had leg wounds which still required the LAL mattress intervention. On 01/15/26 at 1:15 PM, the Director of Nursing (DON) confirmed all beds with a LAL mattress should be checked to ensure they are powered on. A review of the record for R59 revealed R59 was admitted into the facility on [DATE]. Diagnoses included Diabetes and Mild Cognitive Impairment. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 6/15 which indicated mild to severe cognitive impairment. The MDS also documented R59 was dependent on staff to roll left and right while in bed, dressing and toileting hygiene. The active care plan documented R59 has potential for new onset pressure ulcer development r/t (related to) debility, incontinence, DMII (Diabetes-high blood sugars). Guest prefers to remain in bed almost all of the time. Date Initiated: 10/22/2024. Revision on: 08/12/2025. The care plan also documented: Resident has actual skin integrity impairment r/t: immobility, Lack of sensation, have wounds b/l (bilateral) toes I have wounds to b/l knees, b/l buttock, left side of face and chest (resolved). Date Initiated: 10/29/2024. Revision on: 03/20/2025. Interventions included, Ensure special mattress is in place (LAL) Date Initiated: 10/29/2024. Revision on: 01/14/2026. A review of the Medication and Treatment administration records for January 2026 and December 2025 revealed no monitoring of the LAL mattress was documented. A review of the facility policy titled, Care Plans, Comprehensive Person-Centered revised 03/2022 revealed, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. A review of the facility policy titled, Support Surface Guidelines revised 09/2013 revealed, Purpose: The purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown . Any individual at risk for developing pressure ulcers should be placed on a redistribution support surface, such as foam, gel, static air, alternating air, or air-loss or gel when lying in bed . The policy did not indicate the need for monitoring a LAL mattress.

Based on observation, interview, and record review, the facility failed to float (positioning the heels to prevent sustained contact between the heels and the bed) a resident's heels per physician order for one (R19) of three resident's reviewed for pressure ulcer prevention. Findings include: Review of the medical record for R19 revealed they were admitted into the facility on [DATE] with diagnoses including Type-Two Diabetes Mellitus and Chronic Kidney Disease. Review of R19's Minimum Data Set (MDS) information indicated a history of facility-acquired pressure ulcers and the Brief Interview for Mental Status (BIMS) score of 8/15 indicated moderate cognitive impairment. Review of R19's current physician orders confirmed an active order stating Skin prep to bilateral heels, float heels while in bed. On 01/13/2026 at 1:47 PM, R19 was observed in bed. Their feet were laying directly on the mattress without any support to float the heels or any float boots in place. R19 was queried as to whether they knew if their heels were ever placed in a floated position or if they ever have soft boots on their feet while in bed and they indicated they could not recall. Further review of R19's facility record revealed a Braden Assessment (Assessment of pressure sore risk) dated 01/04/26 indicating the resident had moderate risk for pressure sores. On 01/14/2026 at 10:27 AM, R19 was observed in bed. The resident's heels were not floated and were laying directly on the mattress. On 01/15/2026 at 9:43 AM, R19 was observed in bed. Their heels were not floated and were laying directly on the mattress. On 01/15/2026 at 12:41 PM, Certified Nursing Assistant (CNA) F was interviewed and reported when a resident has orders for their heels to be floated, they float the heels either by using heel float boots or by placing a pillow under the lower legs to elevate the heels off the bed surface. On 01/15/2026 at 12:46 PM, Registered Nurse (RN) G, Unit Manager of R19's living area, was interviewed and asked their expectation when a resident has orders for their heels to be floated and said the heels should be floated either by use of heel float boots or use a pillow under the lower legs to elevate the heels. RN G indicated that use of the heel boots is usually specified in the order. On 01/15/2026 at 1:15 PM, the facility Director of Nursing (DON) was interviewed and asked their expectation when a resident has orders for their heels to be floated in bed. The DON reported their heels should be floated either by placing a pillow under the lower legs or via use of heel float boots. Review of the facility policy Prevention of Pressure Injuries, dated April 2020, revealed the intervention Select appropriate support surfaces based the resident's risk factors, in accordance with current clinical practice.

Based on observation, interview, and record review, the facility failed to address the behavioral health needs of one resident (R23) of one reviewed for behavioral health resulting in an assault of another resident. Findings include: On 1/13/26 at 11:44 AM, R23 was observed lying in bed and asked about a recent incident involving their previous roommate and stated, [they] thought I was [their] whipping boy and I hit [them] with a weight. R23 did not provide any additional information regarding the incident.A review of R23's medical record revealed they were admitted into the facility on 7/23/25 with diagnoses which included Post-Traumatic Stress Disorder, Hemiplegia and Hemiparesis, and Hypertension. Further review revealed the resident was cognitively intact and required one-person assist with activities of daily living (ADL's).A review of the following progress notes revealed the following: 10/8/2025 08:30 (8:30am) Behavior Note: Patient has been observed being confused and aggressive. Patient was redirected several times because [they were] trying to climb out of bed and walk without assistance. Patient is A + O x 2 (alert and oriented to person and place) and has left side weakness in arm and leg. While trying to put patient's legs back into the bed and the bed in the lowest position, the patient was seen and observed by staff striking the nurse with [their] fist. The patient was redirected and the Administrator and DON (Director of Nursing) have been notified of this behavior. The patient will continue to be monitored for safety. 11/9/2025 06:37 (6:37am) Behavior Note: Resident was having a behavior issue causing and throwing things on the floor writer told [them] to be calm and behavior ceased and sleeping. 1/10/2026 20:44pm (8:44pm) Nursing Note: At 6:20pm writer observed resident throwing roommate's items at [them]. Roommate stated [R23] hit [them] with a hand weight on [their] left forehead and underneath left eyelid. Writer separated them. Propelled [R23] out to hallway. No signs of injury to patient . 1/12/2026 08:57am (8:57am) Nursing Note: Writer went to resident's room and asked resident to discuss the events that transpired between [themselves] and [their] former roommate. Resident stated that [they] struck the roommate and stated [they] would do so again. Writer redirected resident and informed [them] that physical assault of another resident is not acceptable. Resident became dismissive and stated [they] would do what [they] wants and instructed writer to leave the room. Writer acknowledged and exited the room . Further review of R23's medical record revealed the following care plan, Focus: Problematic manner in which resident acts characterized by ineffective coping; Agitation related to: Anxiety, Frustration, No apparent reason, and physically aggressive. Date Initiated: 10/08/2025 .Interventions: Be careful of not invading residents' personal space. Date Initiated: 10/08/2025. Initiate Behavior Management consult. Date Initiated: 10/08/2025. Keep schedules routine & predictable. Date Initiated: 10/08/2025. Praise/ reward resident for demonstrating consistent desired/acceptable behavior. Date Initiated: 10/08/2025. Remove resident from public area when behavior is disruptive/ unacceptable. Talk with resident in a low pitch, calm voice to decrease/eliminate undesired behavior and provide diversional activity. Date Initiated: 10/08/2025. Resident on 15 min (minute) check for 72 hours to be followed by 30 mi (minute) checks for 72 hour and 1-hour checks for last 72 hours. Date Initiated: 01/10/2026 . Further review of R23's medical record did not reveal any additional behavioral interventions or monitoring of their triggers and behaviors following any of R23's behaviors. On 01/15/2026 at 11:55 AM, an interview was completed with Social Worker E regarding R23's behavioral health. SW E explained the resident declined to receive behavioral health services. She was also asked about the resident's care plan and completion of their OBRA assessment (Omnibus Budget Reconciliation Act of 1987, mental health and intellectual disability screening) related to services needed and acknowledged she is new to the position and isn't familiar with the resident. She advised she would look into it and get back with the surveyor; however, no additional information was provided prior to the end of survey. Further review of R23's medical record did not reveal any refusals for behavioral health services. On 01/15/2026 at 1:35 PM, an interview was conducted with the Nursing Home Administrator (NHA) and asked about R23 assaulting another resident and explained he had no prior knowledge of behaviors that may have predicted the incident between the two residents.

Based on interview and record review, the facility failed to follow pharmacy recommendations for one resident (R77) of five reviewed for Medication Regimen Reviews (MRRs). Findings include: A review of R77's monthly MRR's noted the following dates the resident had irregularities reported by the pharmacist: 5/19/25, 6/24/25, and 7/21/25. A review of the irregularities report for 5/19/25 indicated the following, Please ensure lab results for the following labs are completed and scanned into [electronic medical record] as ordered 4/14/25, as results could not be located in this resident's chart at the time of review, CMP and CBC (comprehensive metabolic panel and complete blood count), Fasting lipid panel (measures the amount of certain fat molecules in the blood), HgbA1c level (measures the amount of glucose in the blood). A review of the irregularities report dated for 6/24/25 indicated the following, Please ensure lab results for the following labs are completed and scanned into [electronic medical record] as ordered 4/21/25, as results could not be located in this resident's chart at the time of review, CMP and CBC, Fasting lipid panel, HgbA1c level. A review of the irregularities report dated 7/21/25 indicated the following, Please ensure lab results for the following labs are completed and ***scanned into [electronic medical record] *** as ordered 4/21/25, as results could not be located in this resident's chart at the time of review, CMP and CBC, Fasting lipid panel, and HgbA1c level. The irregularities reports did not reveal the attending physician reviewed the identified irregularity, the action, if any, taken, or a rationale for the action not being taken. On 1/15/26 at 2:42 PM, a request for R77's labs were requested from the facility for April 2025 to present however, the Director of Nursing (DON) indicated the resident has declined having their labs drawn, therefore they had not been completed. A request for the refusals was made and was provided with one progress note dated 7/30/25 indicating the resident declined labs on that date. The DON acknowledged the lack of documentation. A review of R77's medical record revealed the resident was admitted into the facility on 9/30/22 with diagnoses which included Diabetes, Heart Disease, Hypertension and Chronic Kidney Disease. Further review revealed the resident was cognitively intact and required limited assist with activities of daily living. Further review did not note previous refusals of lab draws.

Based on observation, interview and record review, the facility failed to store medication not at the bedside for one resident (R50) of one resident reviewed for storage of drugs and biologicals.Findings include: On 1/13/26 at 9:30 AM, R50 was observed laying in their bed watching television. Their bed was cluttered with papers other items. A bag of cough drops, an over-the-counter inhaler, and two prescription inhalers were observed at the bedside. When asked about the medications at bedside R50 stated the nurse gave them to them.On 1/14/26 at 10:30 AM, R50 was observed sitting up on the side of their bed going through the clutter. Three inhalers were observed at the bedside.Record review on 1/15/26 revealed R50 was admitted into the facility on 2/25/23 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD); anxiety disorder and acute cough. R50's most recent Brief Interview for Mental Status (BIMS) assessment revealed a score of 15/15 indicating intact cognition. Further review identified no active physician orders for R50 to self-medicate.01/15/2026 at 1:46 PM, an interview was conducted with the facility's Director of Nursing (DON) and were asked about self-medication of residents. The DON revealed residents are assessed for self-administration. A request was made for R50 self-administration assessments prior to 1/14/26 and there were none.A facility policy on self-administration of medications was requested but not received by end of the survey.

This citation refers to Intake MI00153374. Based on interview and record review, the facility failed to protect the resident's right to be free from verbal and physical abuse by staff (Certified Nursing Assistant - CNA I) for one (R903) of three resident's reviewed for abuse. Findings include: A review of the Intake MI00153374 revealed: On 05/24/25 at about 4:00 PM, R903 approached the nurses' station with a packet of sweetener and requested assistance to open it. Licensed Practical Nurse (LPN) E assisted R903 to open the packet. CNA K, CNA L, and CNA I were seated at the nurse station. R903 threw the open packet of sweetener over the nurses station towards CNA I. CNA I started to swear at R903. R903 was observed to stand up and R903 and CNA I then grabbed each other by the wrists over the nurses' station. Staff were then reported to have separated R903 and CNA I. On 6/04/25 at 11:30 PM and during the survey, R903 was observed to be walking round and round the halls talking appropriately with staff and other residents. On 6/04/25 around 2:00 PM, LPN E was asked about the incident between R903 and CNA I and reported: CNA I was having a bad day and their mouth ran away with them and R903 became agitated because of what CNA I said. LPN E also reported R903 gets frustrated when they cannot get their words out and throws a tantrum of sorts and a history of throwing items. A statement by LPN E from the facility investigation further documented, .(R903) approached nurses station making noise to get staff attention. Writer observed resident holding (name of flavor subsitute) packet to be open. Writer assisted resident with opening packet. Writer then observed resident throw packet at staff member. Writer attempted to deescalate situation. Staff member began to use profanity at resident. Resident and staff member observed to be holding each others wrist . A review of the record for R903 revealed R903 was admitted into the facility on 8/11/22. Diagnoses included Aphasia (difficulty speaking), Memory Deficit, Dementia and Stroke. The Minimum Data Set (MDS) assessment dated [DATE] documented moderate impaired cognition with a 6/15 Brief Interview for Mental Status score and R903 was independent for eating, required supervision/assistance for dressing and personal hygiene and independent for walking. A review of the Social Services staff (SS) G progress note dated 05/27/25 at 12:45 PM, revealed, .SS provided wellness check with resident on 5/27/25. (R903) was in (their) room, appeared happy and was laughing. Resident was sitting in wheelchair. When asked if (R903) felt safe in facility, resident smiled and nodded yes . A review of the facility Abuse Policy revised 9/2022 revealed, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The resident has a right to be treated with respect and dignity .Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals . Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Willful is defined in the definition of abuse, and means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .

This citation pertains to MI00153028 and MI00153168. Based on observation, interview and record review, the facility failed to acknowledge and ensure the Durable Power of Attorney (DPOA) was allowed to exercise the residents' rights for one resident (R901) out of three residents reviewed for resident rights exercised by their representative. Findings include: On 6/3/25 at 02:30 PM, an interview with DPOA A revealed they were told, when presenting to facility staff the DPOA paperwork, it was not valid because signatures on the papers were not notarized. Review of the document revealed a DPOA document containing two witness signatures, the resident signature, and the DPOA signature as prepared by a law firm, dated 3/30/21. DPOA A was advised by facility staff to provide the DPOA paperwork to the Social Worker the next business day. DPOA A further revealed they told the staff member, the current document had been in effect since 2021 (the signature date). On 6/3/25, a review of the Electronic Medical Record (EMR) revealed R901 was admitted to the facility on [DATE] with the following relevant diagnoses: Vascular Dementia and Cognitive Communication Deficit. A Brief Interview for Mental Status (BIMS) score of 4/15 indicated severe cognitive impairment. R901 was dependent for activities of daily living and used a wheelchair for mobility. R901 was minimally verbal. A review of the EMR nursing progress note documented on 4/26/25, at 06:16 PM, DPOA A inquired regarding R901's medical care and was informed that we could not discuss the resident's case as (DPOA A) is not listed as a contact. A review of the EMR documented a progress noted dated, 4/27/25 at 14:09 PM, R901 was Sent to hospital by DPOA A, emergency contact. According to the EMR, this occurred after Medical Doctor (MD) was notified of a fall on 4/27/25 at 08:00 AM. R901 was transferred to hospital and assessed for a syncopal episode. On 6/4/25 at 10:36 AM, during an interview with Social Worker (SW)G they confirmed the DPOA process was explained to DPOA A on 5/2/25 (no documentation noted in EMR), noting the document had not been activated. SW G revealed they had discussed with the DPOA next steps. SW G revealed they attempted to obtain a capacity evaluation (to determine R901's ability to make their own decisions), revealing the house psychiatric staff were not available to determine capacity. There is no documentation regarding attempts to obtain capacity. On 6/4/2025, an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) revealed an expectation the activation of the DPOA should have been addressed soon after admission. A review of the facility policy titled, Advance Directives dated September 2022 revealed the following definition: Durable Power of Attorney for Health Care (i.e. Medical Power of Attorney) - a document delegating authority to a legal representative to make health care decisions in case the individual delegating that authority subsequently becomes incapacitated. The policy further reveals 4. Written information includes a description of the facility's policies to implement advance directives and applicable state law.

This citation pertains to Intake MI00153028. Based on observation, interview, and record review, the facility failed to develop a care plan for bladder incontinence with interventions to address resistance to toileting for one (R901) of two residents reviewed for care plans. Findings include: A review of the Electronic Medical Record (EMR) revealed R901 was admitted to the facility on [DATE] with the following relevant diagnoses: Vascular Dementia, Gastroesophageal Reflux Disease, and a Cognitive Communication Deficit. A Brief Interview for Mental Status was conducted resulting in a score of 4/15 indicating severe cognitive impairment. R901 was dependent for activities of daily living, was incontinent of urine and R901 requires prompting and assistance for toileting. On 6/3/25 at approximately 2:56 PM, R901 was interviewed in their room with their Durable Power of Attorney (DPOA) A. DPOA discussed R901's sometimes resistance to toileting and R901 is sometimes willing to walk to the bathroom with assistance. DPOA A further revealed R901 can be incontinent and sometimes resists changing. On 6/4/25 at 8:00 AM, R901 was noted to have a housekeeper in the room cleaning up a puddle. R901 was observed lying on their back. R901 was calm, looking straight up, and did not appear to be engaging with staff. Certified Nursing Assistant (CNA) B revealed R901 can be incontinent, sometimes will allow assistance to the bathroom, and has been known to urinate in places other than the toilet. CNA B further revealed when R901 is agitated they can be uncooperative with toileting or brief changes by refusing to go into bathroom and stiffening their body intentionally when care is attempted. On 6/4/25 at 8:15 AM, an interview with Housekeeper J revealed they were called to the room to clean a very large puddle of urine. On 6/4/25 a review of the Electronic Medical Record (EMR) revealed R901 did not have a care plan for bladder incontinence and the resistance to toileting. On 6/4/25 at 10:22 am, during an interview with Unit Manager (UM), F revealed R901 ambulated with assistance to the bathroom when R901 wants to. UM F further revealed urine is sometimes found in places other than the bathroom such as waste basket or on the floor. At 11:13 am, an interview with the Director of Nursing (DON) revealed R901 should have a care plan for bladder incontinence and the resistance to toileting R901 exhibits. A review of the facility policy titled, Care Plans, Baseline reveals the following, baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. The policy further reveals . 2. The baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan (no later than 21 days after admission). The baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed .4. The resident and/or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand) .6. If the participation of the resident and his/her resident representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative in the process.

This citation refers to Intake MI00153168. Based on observation, interview, and record review, the facility failed to identify 6% weight loss from 5/1/25 to 5/29/25 for one (R901) of three residents reviewed for weight loss. Findings include: On 4/25/25, R901 was admitted to the facility on [DATE] with the following relevant diagnoses: Vascular Dementia and Cognitive Communication Deficit. A Brief Interview for Mental Status was conducted resulting in a score of 4/15 indicating severe cognitive impairment. R901 is dependent for activities of daily living and uses a wheelchair for mobility. R901 is minimally verbal. R901 is dependent on for nutritional and hydration needs through a percutaneous gastrostomy tube (PEG-feeding tube) inserted into R901's abdomen. On 6/4/25 an interview with R901's Durable Power of Attorney (DPOA) revealed they were aware that R901 becomes agitated and fidgety pulling on the feeding tube. DPOA A said they were unaware if the tube was ever pulled out on any occasion since admission. On 6/4/25 a review of the Electronic Medical Record (EMR) revealed: - A progress note dated 4/28/25 at 11:52 AM, R901 was pulling on feed tube line. -A progess note dated 5/3/25 at 4:53 AM, R901 fidgets and disconnects PEG tube feeding, needs to be monitored and redirected consistently. -A progress note dated 5/29/25 at 11:06 AM, R901 with increased anxiety and attempting to pull out PEG tube numerous times and is not easily redirectable. A review of the EMR related to weight revealed an admission weight on 5/1/25 of 147.4. On 5/29/25 a weight of 138.5 was revealed showing a weight loss of 6.03% over a 28-day period. On 6/4/25 at 11:31 AM, a re-weight of 138 was obtained On 6/4/25 at 9:02 AM, Registered Dietician (RD) C was interviewed by telephone and confrimed they review resident weights weekly and this is discussed with the team. RD C indicated R901 was discussed on Thursday (May 29, 2025) and believed the documented weight loss may be an error because it was a significant amount over one month and requested a new weight. RD C indicated the team revealed resident was pulling on tube and their understanding was it was pulled out so that R901 was not getting the full benefit of the nutrition. There is no documentation in the EMR to indicate the feeding tube was pulled out by R901 or required replacement. On 6/4/25 at 2:00 PM, an interview with the Director of Nursing (DON) confirmed R901's weight loss was discussed on 5/29/25 during a team meeting. The DON further revealed R901 expends a lot of energy when their anxiety is high. A review of the facility policy, titled Weight Assessment and Intervention, dated March 2022, revealed the following: .4. Unless notified of significant weight changes, the dietitian will review the unit weight record monthly to follow individual weight trends over time. 1. The threshold for significant unplanned and undesired weight loss will be based on the following criteria - b. 1 month - 5% weight loss is significant; greater than 5% is severe . Individualized care plans shall address, to the extent possible, r. identified causes of weight loss, t. time frames and parameters for monitoring and reassessment . A review of the policy titled Enteral Nutrition, dated November 2018 revealed, The dietitian monitors residents who are receiving enteral nutrition, and makes appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings. In addition, Residents receiving enteral nutrition are periodically reassessed for the continued appropriateness and necessity of the feeding tube. Results of these assessments are documented and any changes are made to the care plan. Input from the resident or legal representative is included in the assessment.

This citation relates to Intake #MI00146436. Based on observation, interview, and record review, the facility failed to provide palatable, appetizing meals at the proper temperature for 19 of 19 confidential group meeting residents. Findings include: On 10/23/24 at 11:31 a.m., residents collectively shared concerns related to the meals at the facility which had been occurring over the past few months, and possibly longer. The resident council President and [NAME] President were in attendance, as well as the Activity Director, Staff F, per their request. Residents collectively shared their concerns as follows: 1. They wanted hot meals at mealtimes, and reported the trays were frequently not served from the meal carts anywhere from 15 minutes to 45 minutes. 2. The meals tasted bland and were not appetizing, as they had no flavor. 3. They wanted more variety of the menu, and said they had the same foods most weeks. 4. They did not like the Tilapia fish, and several residents said, It tastes nasty. 5. They reported they were told there was no budget for any extra preferences. 6. Most did not want sandwiches for dinner, and reported the sandwiches did not have lettuce, tomato, and oftentimes cheese, and only one slice of meat. 7. They would like to have a food committee, as they did in the past and they did not know why it was cancelled. 8. They reported receiving too much pork and hot dogs. 9. They reported their food was sometimes wet, from condensation from the food sitting on the trays and older food covers, which made the food wet and soggy. 10. They had asked for dietary staff to be present at their resident council meetings to hear their food concerns, which had not occurred. On 10/23/24 at 1:32 p.m., during an obervation of a lunch meal tray, the following entree was observed, a chicken and biscuit entree and green beans. The chicken appeared wet at the base, from condensation on the plate. There was condensation on the tray under the beverages, inside the plate lid, on the tray below the plate, and on the plate itself. Further observaiton revealed the hard plastic plate cover appeared worn, with jagged, worn edges, which prevented the lid from fully sealing against the plate. Review of the resident council minutes for July, 2024, August, 2024, and September, 2024 showed no kitchen or dietary staff attended the meetings. Review of the resident council minutes, dated 9/2024, showed residents reported they were receiving wet sweaty food from food condensation from sitting in the plate cover too long. Residents reported the cups, plates, utensils, and plate lids were sometimes dirty, and requested staff did a better job of washing them. Review of resident council minutes, dated 8/13/24, revealed residents asked for more variety on the menus. Review of the resident council minutes, dated 7/09/24, showed residents wanted less sandwiches and an updated menu. On 10/24/24 at 1:48 p.m., the Director of Nursing (DON) was asked about the collective resident food concerns, and reported they were addressing them, and understood the concerns. Review of the policy, Food preferences, revised 7/2023, revealed, Individual food preferences will be assessed and upon admission and updated as needed. Reasonable efforts will be made to accommodate resident choices and preferences .6. A periodic Food Committee meeting will be held to review issues related to food preferences and meals and try to identify more widespread concerns about meal offerings, food preparation, etc . Review of the policy, Temperatures, revised 7/2023, revealed, .Foods should be transported as quickly as possible to maintain temperatures for delivery and service. If food transportation time is extensive, food should be transported using a method that maintains temperature (i.e. hot/cold carts, pellet systems, insulated plate bases and domes, etc ). Review of the policy, Food and Nutrition Services, revised October 2017, revealed, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional needs and special dietary needs, taking into consideration the preferences of each resident . 38207 On 10/23/24 at 12:55 PM, a lunch tray was test. The biscuit with chicken, vegetables, and gravy on it was tasted and the chicken tasted processed. On 10/24/24 at 1:03 PM, a lunch tray was tested from a food cart on the two hundred unit and temperature checked. Unidentified staff E who was serving trays out of the food cart, indicated the cart had been sitting on the unit for approximately twenty minutes. The temperature of the food on the tray was the following, marinated mixed vegetable salad: 109 degrees Fahrenheit; and the apple juice was 51 degrees Fahrenheit. On 10/24/24 at 1:20 PM, Dietary Manager (DM) D was interviewed about interventions available for residents regarding food concerns, and if residents were able to obtain fresh fruit. DM D stated, We used to have a food committee, but no one showed up, so we discontinued it. I meet with the residents all of the time. DM D stated, We don't really do fresh fruit unless it is in season. In the summer the residents were served strawberries and we had watermelon. On 10/24/24 at 1:30 PM, the Administrator (NHA) was interviewed via phone regarding their expectations for the food served to the residents at the facility. The NHA indicated the food served to residents should be at the appropriate temperature, served timely, and appropriate for the individual's diet. A facility policy titled Temperatures Rev [Review] 7/2023 was reviewed and revealed the following, 1. All hot foods must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 F .2. All cold foods items must be maintained and served at a temperature of 41 F or below. A facility policy titled Resident Food Preferences Rev. 7/2023 was reviewed and revealed the following, Policy Statement: 5. The Food Services Department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks.

Based on interview and record review, the facility failed to answer call lights timely for eight confidential group meeting residents (C1, C2, C3, C4, C5, C6, C7, and C8) of 19 residents reviewed for dignity. Findings include: On 10/23/24 at approximatley 11:40 a.m., eight confidential interviewable group residents (C1, C2, C3, C4, C5, C6, C7, C8) reported feeling frustrated and being discouraged as they were waiting more than a half hour for their call light to be answered. Resident C1, reported they had filed grievances with the Activity Director, Staff F, and had made the facility aware of the resident's call light concerns, with limited follow up. Two residents described specific incidents, as follows: C2: Reported they waited 45 minutes for staff to answer their call light a couple weeks ago, at night, when he fell and hurt their shoulder. C3: Reported they sometimes waited an hour and a half to use the bathroom, during the day shift, causing incontinence. Five of the eight residents indicated they waited 45 minutes or more at times for their call lights to be answered, which caused them feelings of discouragement and helplessness, as they needed assistance with care. On 10/24/24 at approximately 11:45 a.m., the Activity Director, Staff F, who was present at the group meeting per residents' invitation, was asked about residents reporting extended call light wait times. Staff F confirmed residents reported longer call wait times in the monthly meetings. Staff F reported they had observed longer wait times in the evenings when they were in the facility working until 7:30 p.m Staff F confirmed sometimes staff were difficult to locate, and they turned in the grievance forms. On 10/24/24 at approximately 1:55 p.m, the resident council group concerns were collectively reviewed with the Director of Nursing (DON) who confirmed they had planned to address the residents' concerns, and would attend the next resident council group meeting. Review of resident council minutes and attached concern forms showed: 7/09/24: One call light concern noted on the minutes and concern form, showing extended call wait times. 9/10/24: Six call light concerns noted on the minutes or concern forms, showing five residents and the resident council group reported collective concerns. Further review of the September (2024) concern forms showed residents reported they were unable to locate nursing staff for assistance, their call lights were not being answered, and one resident reported being left soiled. There was follow-up documented on one of the six concern forms; the rest of the forms were blank below the complaints, i.e. in the summary of findings or conclusions sections. Review of the policy, Quality of Life, Dignity, revised April 2009, revealed, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. 1. Residents shall be treated with dignity and respect at all times. 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth . A policy was requested specific to call light answering, and not received by survey exit on 10/24/24.

Based on observation, interview, and record review, the facility failed to provide adequate space and privacy for resident counsel group meetings for 19 of 19 residents reviewed for organized group meetings. Findings include: On 10/23/24 at approximately 11:20 a.m., 19 residents were observed in the activity room, with the Activity Director, Staff F present. Residents were observed crowded into this smaller room, with some seated only one to three feet apart. There were frequent knocks at the closed door, either by staff or residents. A few residents arrived later, or left, and had difficulty negotiating room entry or exit around the residents who were seated in wheelchairs. On 10/23/24 at 11:31 a.m., the group meeting participants collectively reported feelings of frustration and privacy concerns meeting in the activity room at the facility. Two residents reported they and the residents preferred to meet in the large facility dining room, however there were too many interruptions by staff coming in an out of the space, no matter what time they held the meeting. Staff F said they tried to meet in the dining room in the past a few times, and they had to return to the activity room to meet due to the staff interruptions. Residents collectively reported feelings of frustration, as they wanted to meet privately and would be most comfortable in a larger space, like the dining room. During an interview on 10/24/24 at 1:43 p.m., the Director of Nursing (DON) was asked about the limited space available for the monthly Resident Council meeting, with resident's reporting in the group meeting they were frustrated with the small space of the activity room and were interrupted in the larger dining room when they had attempted to meet there in the past. The DON stated, I am agreeable for them to being in the dining room [to meet for Resident Council meetings], and they should be able to be [meet] non-interrupted and have that time and space for an hour. The DON reported they were familiar with the activity room where residents met for their monthly meetings, and acknowledged this was a small space for the number of residents who attended the monthly resident council meetings. Review of the policy, Quality of Life - Homelike Environment, revised May 2017, revealed, Residents are provided with a safe, clean, comfortable and homelike environment .

Based on observation, interview, and record review, the facility failed to place call light within reach and provide a closet door for two residents (R89 and R84) of four residents reviewed for accommodation of needs. Findings include: R89: On 10/22/24 at 1:11 p.m., R89 was observed laying in their bed, wearing a hospital gown. They were observed leaning to the left side of their bed, resting their head on the enabler bar, which appeared uncomfortable. R89 reported they were in significant pain and wanted pain medication. Further observation revealed their touch pad call light was out of reach, on the right side of the bed on their dresser. On 10/22/24 at 1:15 p.m., R89 was asked if they used their call light. R89 reported they used their call light for pain medication, or if they needed other assistance. On 10/24/24 at 11:44 a.m., R89 was observed sleeping in their hospital bed, leaning against the left enabler bar. R89's call light was on the right side of their bed, on their dresser, out of reach. Review of R89's Minimum Data Set (MDS) assessment, dated 9/18/24, revealed R89 was admitted to the facility on [DATE], with diagnoses including high blood pressure, malnutrition, and depression. R89 required maximal assistance with toileting, moderate assistance with bed mobility, and was dependent for transfers. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 14/15, which showed R89 was cognitively intact. On 10/24/24 at 11:46 a.m., Certified Nurse Aide (CNA) G was asked if R89 used their call light, and why it was on their dresser, and showed CNA G the location. CNA G reported R89 used their call light and had asked for a blanket earlier this morning by activating their call light. CNA G responded it must have been removed during care and not replaced. CNA G confirmed the call light was out of R89's reach. On 10/24/24 at 11:47 p.m., Licensed Practical Nurse (LPN) H was asked if R89 used their call light. LPN H confirmed they had used their call light this morning to request pain medication and a cup of milk. LPN H reported the call light should always be in R89's reach as they used it regularly and it must be in their reach. R84: On 10/24/24 at 12:00 p.m., R84's closet (room [ROOM NUMBER]-1) was observed per their request. Their clothes closet was completely open, with no closet door or curtain covering the clothing. R84's clothing and his roommate's clothing were showing, as well as some clear garbage bags and miscellaneous personal items of R84's, which were on the floor of the closet, visible from the doorway. R84 said they had filed a grievance a few months ago reporting this bothered them, as they wanted their room to look neater and have their clothes and personal items covered. R84 reported they had not received adequate follow-up, as their closet door was still opened, and looked bad to them. Review of the Electronic Medical Record (EMR) showed R89 was admitted to the facility on [DATE]. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 15/15, which showed R84 was cognitively intact. Review of July's grievance forms, provided by the Director of Nursing (DON) on 10/23/24, revealed a grievance form dated 7/10/24. The grievance showed: No closet doors. We [residents] pay too much for doors to not work. There was no response at the bottom of the form or attached. On 10/24/24 at 1:58 p.m., the DON, was asked about R89's call light being out of reach on two occasions. The DON confirmed the call light should always be on R89 and must have been removed during cares. The DON noted the call light could be clipped to R89 to prevent it from sliding off. Environmental concerns including R84's concerns were shared with the DON, who confirmed they would be addressed. A policy was requested related to accommodation of needs and call lights and was not received by survey exit on 10/24/24.

Based on observation, interview and record review the facility failed to ensure medications were labeled and dated when opened and or discarded when expired in two of four medication carts and one supply room reviewed. Findings include: On [DATE] at 9:09 AM a check of the medications in medication cart three with Licensed Practical Nurse (LPN) I revealed: A Breo Ellipta inhaler was not dated on the actual inhaler; A Humalog insulin vial with open date of [DATE] was expired; A Lantanoprost eye drops vial dated ,d+[DATE] on the box was not dated on the vial; a brimonidine eye drop was not dated when opened on the vial or the box; a second Latanoprost eye drop was not dated when opened on the vial or box; and a Dorzolomide eye drop was not dated when opened on the vial. On [DATE] 9:36 AM, a review of the number four medication cart with LPN J revealed: the glucose strips not dated when opened, an Ademolog insulin was dated ,d+[DATE] on the box but not on the vial, a novolg insulin had an expired dated of [DATE] and a second vial of novolog insulin had an expired date of ,d+[DATE]. On [DATE] at 9:00 AM, an observation of the supply room with LPN A revealed six max protein shakes which expired [DATE]. On [DATE] at 11:06 AM, the Director of Nursing (DON) reported the nurse should check the medication carts they are on. A review of the facility policy titled Storage of Medications dated [DATE] revealed Policy Statement The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation 1. Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. 3. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. 4. The facility shall not use discontinued, outdated, or deteriorated . A review of the prescribing information at drugs.com revealed, .Safely throw away Breo Ellipta in the trash 6 weeks after you open the tray or when the counter reads 0, whichever comes first. Write the date you open the tray on the label on the inhaler and the Novolog vial when opened is good for .28 days (refrigerated/room temperature) The Manufacturer's web site for Ademlog insulin documented .Must be used within 28 days after first use .

Based on observation, interview, and record review, the facility failed to store an oxygen tank in an safe manner involving one resident (R45) of four residents reviewed for environment. Findings include: On 10/22/24 at 12:44 PM, an observation was made of an oxygen tank without a holder, behind the bed, against the wall in R45's rooom. R45 was interviewed about the oxygen tank in their room and stated, I don't know, saying the oxygen tank had been in their room ever since admission. R45 denied receiving oxygen therapy. A record review of R45's electronic medical record (EMR) confirmed that R45 did not receive oxygen therapy. Further review of R45's EMR revealed that R45 was originally admitted to the facility on [DATE] with diagnoses that included, Paroxysmal atrial fibrillation (Irregular rapid heartbeat) and Alcohol abuse. R45's most recent minimum data set assessment (MDS) dated [DATE] indicated R45 had an intact cognition. On 10/24/24 at 11:06 AM, Licensed Practical Nurse (LPN) D was interviewed and asked if R45 was receiving oxygen therapy. LPN D stated, [R45] doesn't have an order for oxygen. On 10/24/24 at 11:15 AM, Maintenance Director (MD) C was shown the oxygen tank in R45's room and stated, That shouldn't be there. MD C further indicated all oxygen tanks not in use, should be stored in the facility's oxygen storage room in a holder. On 10/24/24 at 1:30 PM, the Administrator (NHA) was interviewed via phone regarding their expectations for the storage of oxygen tanks. The NHA indicated that oxygen tanks should be stored in a locked area in the appropriate holder. A facility policy titled Small Compressed Oxygen Cylinders dated, 2006 was reviewed and revealed the following, Safety: The safe use of compressed oxygen cylinders requires it to be used as instructed, which includes the following safety precautions .store oxygen cylinders in approved carts or holders .

This citation pertains to Intakes M100144781 and M100145103. Based on observation, interview, and record review, the facility failed to maintain a clean, comfortable, homelike environment for four (R701 and R703) of four residents reviewed for homelike environment. Findings include: R701 On 06/27/24 at 10:25 AM, R701 was observed lying in bed in their room watching television. R701 stated, The shower room is so nasty; I wouldn't dare walk in there barefoot. Its just nasty and it's not fair. On 6/27/24 at 11:30 AM, an observation was made of the shower room on 2 hall. Upon entering the area a dried brown stain was noted on the floor outside of door and trailing inside the room. A pile of feces was noted in the shower room drain. Trash and debris was noted in the corners of the room. A record review revealed that R701 was admitted on [DATE] with the following medical diagnoses of Morbid Obesity, Bipolar Disorder, Raynaud's syndrome with Gangrene. A review of the most recent Minimum Data Set assessment dated [DATE] was completed with a Brief Interview for Mental Status (BIMS) score of 15 which indicates intact cognition. 06/27/24 at 1:30 PM, a tour of the shower rooms and an interview with the Director of Nursing (DON) revealed, The shower room is cleaned daily at several times. R703 Review of the facility record for R703 revealed an original admitted [DATE] with diagnoses including cerebral infarction with right hemiplegia. The Brief Interview for Mental Status (BIMS) assessment dated [DATE] was scored 15/15 indicating intact cognitive function. On 06/27/24 at 10:40 AM, a strong odor of urine was noted in the area of room [ROOM NUMBER] where R703 resides. R703 was interviewed and expressed no general care concerns. The odor of urine remained strong while in the residents room. On 06/27/24 at 11:51 AM, the odor of urine remained strongly present near and inside the room of R703. On 06/27/24 at 2:30 PM, Certified Nurse Assistant (CNA) A reported they were the current CNA for R703. CNA A reported both residents require brief changes as both are generally incontinent and not able to be assisted to use the toilet. CNA A acknowledged the odor of urine near room [ROOM NUMBER] and indicated they thought it may have been coming from across the hall as a large puddle of liquid was observed on the floor in the room across from 221. On 06/27/24 at 2:35 PM, the facility Director of Nursing (DON) was interviewed at room [ROOM NUMBER] regarding the urine odor and they reported that sometimes residents lay in bed and urinates on the floor and we have it care-planned. On 06/27/24 at 3:11 PM, R703 was interviewed in their room where the odor of urine remained strong despite the puddle of liquid in the room across the hall having been cleaned. R703 was asked about the odor of urine noted in their room over the course of the day and stated Yeah, I notice it. Everyone who comes in here does. When asked if the odor bothers them R703 stated Yes, it does. On 06/27/24 at 3:30 PM, the DON was asked their expectation regarding residents living in a room with a persistent odor of urine. The DON indicated they expect any related housekeeping and patient care protocols to be followed in order to attempt to control the issue. On 06/27/24 at 3:39 PM, the facility Administrator (NHA) reported that their expectation regarding cleanliness in the facility is that housekeeping and cleanliness protocols be followed. Review of the facility policy Quality of Life-Homelike Environment dated 05/17 revealed the policy statement Residents are provided with a safe, clean, comfortable, and homelike environment . The Policy Interpretation and Implementation portion includes the following entries: - The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. The characteristics include: a. Clean, sanitary, and orderly environment; f. Pleasant, neutral scents; - The facility staff and management shall minimize, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. These characteristics include: b. Institutional odors.

This citation pertains to MI00142238, MI00141119, MI00140817, MI00140327. Based on observation, interview and record review, the facility failed to ensure four residents (R904, R905, R906, R909) of four reviewed for adaptive equipment were allowed to have reachers (device about two feet long with a trigger/grip at one end that activates a jaw at the opposite end which can be used to grip and pick up items), resulting in feelings of lost independence, decreased self esteem, and fear of falls. Findings include: A review of four complaints called into the State Agency revealed; - .the removal of reachers from all residents poses an increased risk of falls and injuries. This decision, stemming from an isolated incident, has received numerous complaints from residents and their families, highlighting the need for a reconsideration of this policy . - .Residents report concerns that the nursing home has taken reachers away from residents. Residents report this affects their ability to be self-sufficient as possible. The lack of reachers for the residents infringes on their rights and dignity, autonomy, and their rights to be as self-sufficient as possible. Residents report that when staff took reachers away from residents, staff told residents that if they needed anything to be picked up and or anything to be put in arms reach to use the call light and staff will assist. Residents report that only lasted four days and now staff does not answer call lights and or assist when items are dropped and or not within reach . - .Resident reports that the incident on 09/29/2023 where a resident hit another resident and used their reacher as a weapon which resulted in the reachers being taken away. The resident also reports that due to reachers being taken away there have been numerous falls .The administrator thought it would be acceptable to take reachers away from residents who use them as a tool to assist them and to assist them being as independent as possible. That is not acceptable and the home is taking away resident's independence, autonomy, and their rights to be as independent as possible . -Complainant states there was a recent incident where a resident hit a staff person with a grabber. As a result, all of them were taken away from the residents .The resident was told to use their call light if they need anything. When they use their call light it's 1-2 hrs. before it's answered. On 05/15/24 at 9:25 AM, a resident who requested to remain anonymous commented a reacher was discussed as something that could be provided once they return home. On 05/15/24 at 12:02 PM, the ombudsman reported the taking away of the reachers was an ongoing concern verbalized by residents at the resident council meeting held on 05/14/24. R904 On 5/15/2024 at 1:16 PM, an interview with R904 revealed that since October, when reachers were removed, a fall was experienced by them while trying to reach something dropped on the floor. It took two persons to get me up. Since the loss of the reacher, if anything falls on the floor, I put the light on or leave it where it falls until someone comes in to get it. R904 revealed, it is very frustrating. If I put the light on for something I need, it takes forever for the light to be answered, 45 minutes to an hour .I should not be punished. A review of the record revealed R904 was admitted in the facility on 12/19/23. Diagnoses included Paralysis of one side, Heart Failure and Foot Drop. A review of the active care plan documented, .Resident is at risk for falls (related to) gait/balance problems .resident has an (activities of daily living) ADL self care performance deficit (revised 04/10/24) .anticipate needs not verbalized as resident does not always make needs clearly known. Keep call bell in reach, encourage to use, answer promptly. R905 On 05/15/24 at 3:20 PM, R905 reported they had their own reacher before admission into the facility and had been at the facility about three years. R905 reported there was an incident between two residents and they should not be punished because of them. R905 reported, I am bedridden and if something falls I don't have to turn on the light. I can use my grabber to pick it up. I can also pull my blankets up. It is an inconvenience when I have to call an aide for something I can do myself. I can use the reacher as guide to see where to drop the trash. I feel bad enough about myself and they have taken away my independence. I like to be able to do for myself what can I can do for myself. A review of the record revealed R905 was admitted into the facility on [DATE]. Diagnoses included Multiple Sclerosis, Contracture of the left and right knee, and Diabetes. A review of the active care plan documented, .Patient prefers to stay in bed .has an (activities of daily living) ADL self care performance deficit .one person assist to reposition and turn in bed .one person assist with personal hygiene .Set up and clean up assist to eat .I need to be evaluated for and supplied appropriate adaptive equipment or devices as needed, date initiated 11/30/2020 . The Minimum Data Set (MDS) assessment dated [DATE] indicated intact cognition with a 15/15 Brief Interview for Mental Status score and the need for substantial assistance to roll left and right and personal hygiene and dependent for toilet hygiene, bathing, transfer, and upper and lower body dressing. A review of an occupational therapy (OT) note dated 09/20/23 documented, .skilled interventions to facilitate safety and independence with hygiene/grooming .patient instruction in use of (adaptive equipment) AE reacher/towel to facilitate washing feet . R906 On 05/15/24 at 9:31 AM, R906 was observed to be laying in bed on their left side. R906 reported they could not get out of bed on their own and staff do not check on them unless they call them and then it can be ten minutes or more before they receive help. R906 commented the facility also took away their reacher and it should not be that way when someone get theirs taken away, everybody should not have to pay. On 5/15/2024 at 12:02 PM, an interview with R906's family member said that R906 began being bedridden many months ago. R906's family member reported (R906) used the reacher a lot for retrieving things out of their drawer, off the floor, and sometimes from the end of the bed. R906's family member indicated that R906 has managed without the reacher but that it has impacted R906's life, decreased their quality of life, increasing debility and dependence and some increasing depression. On 5/15/2024 at 10:03 am, R906 was interviewed regarding a reacher as an adaptive piece of equipment. R906 stated, I cannot sit up very high, the reacher helps me to reach things I drop, things at the end of the bed out of reach, or from my bedside drawer. A review of the record revealed R906 was admitted into the facility 09/28/21. Diagnoses included Depression, Anxiety and Muscle Contracture of the the right and left lower legs. The Minimum Data Set (MDS) assessement dated 03/01/24 indicated intact cognition with 13/15 Brief Interveiw for Mental Status (BIMS) score. The active care plan documented, .has potential for pressure ulcer development related to immobility . has Activities of Daily Living self performance deficit .and was dependent on staff for bed mobilty, personal hygiene and dressing. R909 On 05/16/24 at 11:36 AM, R909 was observed to be in bed. A wheelchair was at the side of the bed. R909 reported they had a right lower leg amputation and required assistance to get out of bed. R909 commented they had a reacher they brought into the facility with them and when they had gone out to smoke one day the staff had removed the reacher. R909 noted they used their reacher to pick up the foot rest on their power wheelchair and pick up items around their bed. R909 commented the reacher made them more independent and helped them feel better about themselves as at times one can wait hour and half or two hours for help. A review of the record for R909 revealed, R909 was admitted into the facility on [DATE]. Diagnoses included Absence of right leg below knee, Diabetes and Heart Attack. The Minimum Data Set (MDS) assessment dated [DATE] indicated intact cognition with a 15/15 Brief Interview for Mental Status score and the need for partial/moderate assistance for lower body dressing, putting on footwear and bathing, independent for sitting to lying and lying to sitting and substantial to maximal assist for chair to bed and bed to chair transfer. On 05/15/24 at 2:15 PM, the Director of Nursing (DON) reported they felt the reachers were more important for the resident to have them at night and did not know how important the reachers were until they were taken. The DON reported they had multiple meetings about the reachers and did not indicate the residents were involved in the decision to remove all the reachers from residents. The DON said that the removal of the reachers was a safety issue. On 05/15/24 at 3:48 PM, Occupational Therapist (OT) C reported that therapy was asked to no longer provide reachers for residents and taking away the reachers removes the residents independence to reach items. OT C revealed that for the last number of months, after the incident, administration told OT not to issue reachers. OT C further revealed residents are not assessed for reachers at this time. On 05/15/24 at 4:01 PM, the Rehab Manager (RM D) noted they recalled around 15 residents who had reachers some of which were bedridden but all would benefit from the use of a reacher. RM D revealed they're understanding was, corporate told us to retrieve all reachers and not to give any out. RM D revealed close to 20 reachers were removed from residents. When queried about what interventions were put in place to substitute for the use of a reacher, RM D revealed, staff. On 05/16/27 at 3:24 PM, the identified concerns with person centered care and the reachers were reviewed with the DON and the Administrator. The Administrator state person centered care and examples of different devices (like reachers) used by residents were looked at as a safety issue and not considered a necessary device,like a urinal. A review of the Emergency Resident Council Meeting dated 09/29/23 revealed, .A policy of zero tolerance for any type of abuse was reinforced. The residents were told they should act responsibly and respectfully toward each other and staff. They deserve a good safe quality of life. Personality conflicts will arise, your roommates were not chosen without thought. Please take any conflicts to one of the administrators where matters will be discussed. Do not take matters into your own hands. Report to the (Director of Nursing) DON or administrator. There will be no assaulting each other, no cursing at each other or name calling. If you do take any negative action against another resident the police will be called and you will be served a 30 day notice to move out. If you are unhappy here, see the social worker and request a transfer to a different nursing home. There will be no longer any grabber/reachers allowed at (name of nursing facility) nursing home due to inappropriate use. All incidents/concerns will be reviewed and investigated. We need to treat each other better. There are complaint and suggestion boxes located in the front lobby. Please use them. The minutes noted 36 of 108 residents and 12 management staff were in attendance at the meeting. The minutes did not provide individual resident comment, discussion or resident concerns about the reachers. The Resident Council minutes for the last four months were requested on 05/15/24 at 11:13 AM and were not provided. 49699 A review of the facility policy titled, Personal Property revised September 2012 revealed .Residents are permitted to retain and use personal possessions and appropriate clothing, as space permits . 5. The resident ' s personal belongings and clothing shall be inventoried and documented upon admission and as such items are replenished. 6. The facility will promptly investigate any complaints of misappropriation or mistreatment of resident property . A review of the facility policy titled, Care Plans, Comprehensive Person-Centered revised December 2016, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident. The services provided or arranged by the facility, as per the comprehensive care plan, must be culturally-competent and trauma-informed . 4. Each resident ' s comprehensive person-centered care plan will be consistent with the resident ' s rights to participate in the development and implementation of his or her plan of care, including the right to: a. Participate in the planning process; b. Identify individuals or roles to be included; c. Request meetings; d. Request revisions to the plan of care; e. Participate in establishing the expected goals and outcomes of care; f. Participate in determining the type, amount, frequency and duration of care; g. Receive the services and/or items included in the plan of care .

This citation pertains to Intake MI00141238. Based on observation, interview, and record review the facility failed to provide safe storage of medication for three residents (R903, R907, and R908) of three residents reviewed for storage of biologicals. Findings include: R903 On 5/16/2024 at 10:00 AM, R903 was observed in their bed with the head of the bed elevated to 45-60 degrees, leaning to the right. The bedside table was in front of the resident with many items on the table and a medicine cup with a blue and white small capsule, an orange coated tablet, a large white oval tablet, and a small white tablet. R903 was not attempting to consume the tablets. When queried if they knew what the medications were and how did they get there, the response was, I'd rather not answer that. A record review of R903 revealed an admitted [DATE] with diagnoses that included: Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side; Diabetes Mellitus, Type Two; Chronic Kidney Disease; Diabetic Neuropathy; History of Transient Ischemic Attack and Cerebral Infarction; Iron Deficiency Anemia; Depression; Glaucoma; Essential Hypertension; Hyperlipidemia Cognitive Communication Deficit. R903's Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) revealed a score of 12/15 indicating moderate cognitive impairment. A review of R903's care plan on 05/15/24 failed to reveal a care plan indicating the resident had been assessed to self-administer medications. R907 On 05/16/2024 at 10:15 AM, R907 was observed sitting on the side of their bed with two medication tablets in a small plastic medicine cup, a cup of light-yellow liquid, and a 20-ounce cup with straw on the overbed table. When R907 was approached R907 was consuming one pill. One tablet was left in the medicine cup as well as the light-yellow liquid. Upon inquiry, R907 revealed the last pill was their Xanax. The light-yellow liquid was for the bowels. R907 proceeded to take the tablet with a sip of liquid from the cup. When queried about medications at beside without nurse observation, R907 responded, The nurse knows I will take them. A record review of R907 revealed an admitted [DATE] with diagnoses that included: Generalized Muscle Weakness, Intervertebral Disc Degeneration, Lumbar Region, Low Back Pain, Intra-Abdominal and Pelvic Swelling, Mass and Lump, Abnormalities of Gait and Mobility, Anxiety Disorder, Wedge Compression Fracture of Lumbar Vertebra. R907s Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) revealed a cognitive score of 15/15 indicating intact cognition. On 5/15/2024 a review of R907's care plan failed to reveal a care plan indicating the resident had been assessed to self-administer medications. R908 On 05/15/2024 AM was observed with an empty medicine cup on her overbed table. R908 was queried and said, their medication is usually handed to them in the medication cup and the nurse leaves the room while R908 takes it. A record review on 05/15/2024 revealed that R908 was admitted with the following diagnoses: Atherosclerosis of native arteries with ulceration, Chronic Congestive heart failure, Asthma, Essential Hypertension, Chronic Kidney Disease, Stage 4; Acquired Absence of Right Leg Below the Knee; Peripheral Vascular Disease; Anemia; Gastro-esophageal Reflux Disease; Depression; Adjustment Disorder with Anxiety; Diabetes Mellitus-Type Two; Morbid Obesity; Hyperlipidemia; Muscle Weakness. R908's Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) revealed a cognitive score of 15/15 indicating intact cognition. On 05/15/2024 a review of R908's care plan failed to reveal a care plan indicating the resident had been assessed to self-administer medications. On 05/15/2024, Registered Nurse (RN) A was queried about leaving medication for R903 at the bedside to take when they leave the room. They responded, (R903) won't take it when standing there looking at (them). On 05/15/2024, RN A was further queried regarding medication administration. RN A responded, I will only leave them for the residents I know will take them and not leave them sitting there. On 05/15/2024 at 11:16 AM contact was made with the complainant via telepone. An introduction and query were presented. The line was disconnected in 32 seconds after being told a return call would be made. That call was not returned. On 05/15/2024 the Director of Nursing (DON) was queried regarding expectations during regarding leaving medication at bedside for resident to take without supervision/observation. The DON replied, the nurse should observe the resident taking their medication, if the resident does not want to take in front of the nurse, then the medication should be removed from the bedside. The DON revealed any resident assessed to self-administer medication would have a care plan. A review of the policy titled, Bedside Medication Storage (not dated), revealed, Bedside medication storage is permitted for residents who are able to self-administer medications, upon the written order of the prescriber and when it is deemed a ppropriate in the judgment of the facility ' s interdisciplinary resident assessment team .A written order for the bedside [NAME] ge of [NAME] tion is present in the resident ' s [NAME] l record .All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and to give unauthorized medications to the charge nurse . A review of the policy titled, Administering Medications revised December 2012, revealed, Medications shall be administered in a safe and timely manner, and as prescribed .Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely .

This citation pertains to M 7524 Based on observation, interview and record review, the facility 1) Failed to operationalize policies and procedures to ensure the provision and implementation of adequate and necessary supervision and monitoring and 2) Failed to provide an environment free from physical sexual inappropriateness of two Residents (R901 and R902) of three Residents reviewed for abuse, resulting in R901 being found in the room of R902 with their hand in R902's pants, and from a reasonable persons perspective potential feelings of violation and anxiety. Findings include: A review of the Facility investigation report received via online submitted on 3/11/22 noted the following: Investigation Summary Initial Incident Summary: Reported to DON (Director of Nursing) that (R901) was observed in (R902) room with (R901) right hand in the top of (R902's) brief .(R901) was removed from room and placed on a 1 to 1 while the investigation going on. (R902) denies any harm or pain or any mental anguish. Post-incident the following interventions were initiated .1. (R901) and (R902) were immediately separated by staff. 2. (R902) was assessed for injury and no injuries were noted. 3. (R901) was immediately removed from the area, assisted to his room. 4. (R901) was immediately put on a 1:1 sitter. 5. Q 15-minute checks were initiated on 3/11/22 for (R902). 6. Both Resident's guardians were notified. (R901) stated that (R902) had invited (to room) to watch TV and then (R902) started touching (R901) and asked (901) to reciprocate. (R902) stated that (they) had asked (R901) to touch (their private area) . On 4/13/22 at 3:09 PM, R901 was observed in the dining room watching a movie (R902?) Was observed in the hall listening to a radio. R901 was sitting in a wheelchair and observed to have bilateral knee amputations. R901 was asked if they remembered touching another resident's private area. R901 replied, I don't remember (R902's) name, but I did touch (their privates) and (R902) touched my private first. (R902) asked to touch me and then asked me to touch (R902's private) .(R902) pushed me in my wheelchair .we started watching TV in (their) room .I did not know that we couldn't touch each others .They (the facility) told my (parent) .I got in trouble . R901 was asked if they ever touched other residents in their previous facility or at the current facility and R902 answered no. On 4/13/22 at 3:35 PM, R902 was observed in the dining room watching a movie eating popcorn. R902 was well dressed and had a steady gait with ambulation. R902 was able to tell this surveyor what movie they were watching. R902 stated they had a lot of friends at the facility and that they liked helping other residents. R902 was asked if they were touched inappropriately and said, No. No one bothers me . On 4/14/22 at 10:05 AM, R902 was observed in their room sitting on her bed, looking at a magazine. R902 was asked how they were doing and if they had ever been treated inappropriately. R902 said, I have lots of friends here . A review of R901's medical record noted an admission to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R901's had a Brief Mental Status (BIMS) score of 11 out of 15 (moderate cognitive impairment) and required extensive supervision with Activities of Daily Living (ADL). A review of R902's medical record noted an admission to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/14/22 at 1:43 PM, CNA (Certified Nurse Aide) D was interviewed and queried about the incident with R901 and R902. CNA D stated, I was walking down the hall and I heard someone moaning and someone saying Ooh yeah that's how I like it .that's the spot. I pulled the curtain back and saw (R901's) hand in (R902's) pants. I separated them and then told the nurse. On 4/14/22 at 1:58 PM, the DON was interviewed and queried about the incident with R901 and R902. The DON stated, The staff called me and told me that R901 had his hand in R902's pants. I interviewed R902 and R901 . R902 said R901 was their friend .R902 said they didn't know that they couldn't touch each others .R902 was sent to the hospital for additional assessment. Both residents were placed on 1:1 and then continued q15 minutes (checks every 15 minutes). Both guardians were notified. A review of the facility's Abuse Policy dated 1/2020 noted the following: Investigation and Reporting Allegations of Abuse Guidelines All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by the administrator and or designee .Prevention- Provide staff, residents, and family members information on how to and whom to report concerns, incidents, and grievances without fear of retribution, and provide feedback regarding the concerns; identify, intervene, and correct situations of alleged, suspected, or substantiated abuse; supervision of staff, monitoring of resident's with needs and behaviors, communication deficits, and/or those totally dependent on staff . The resident has a right to be treated with respect and dignity .Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.

This citation pertains to intake MI 041 and pertains in part to intake MI 405. Based on interview and record review, the facility failed to document follow-up after R701's noted change in condition and notification of Physician, and failed to adequately recognize and address a change in condition in R705 as exhibited by significant weight gain, shortness of breath, and need for supplemental oxygen, affecting two (R701 and R705) sampled residents of six reviewed, resulting in delay in treatment, decline in health status, and the discharge of a resident to the community after noted onset of a new health diagnosis ([CONDITION(S)]). Findings include: Resident #701 (R701) A review of R701's facesheet revealed that the resident was admitted into the facility from another nursing home on 9/13/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facesheet noted that R701 was discharged to an acute care hospital from the facility at 9:22 AM on 9/24/21. A review of R701's vital signs during their stay at the facility indicated that the resident's oxygen saturation had consistently been 97% (normal is typically 92-100%) or above on room air since admission into the facility. Further review revealed The following: -9/22/2021 03:50 (AM) 97.0 % Room Air -9/22/2021 13:17 (1:17 PM) 97.0 % Room Air -9/22/2021 21:32 (9:32 PM) 94.0 % Room Air -9/23/2021 05:49 (AM) 87.0 % Room Air -9/23/2021 08:30 (AM) 91.0 % Oxygen via Nasal Cannula -9/23/2021 21:46 (9:46 PM) 89.0 % Oxygen via Nasal Cannula -9/24/2021 05:57 (AM) 92.0 % Oxygen via Nasal Cannula -9/24/2021 09:13 (AM) 83.0 % Oxygen via Mask A review of R701's progress notes revealed the following: Effective Date: 9/23/2021 06:15 (AM) Type: Nursing Note Note Text: Resident noted with Spo2 (oxygen saturation) 87% room air at 0549 (AM) alert with slow response took morning med (medication) with no problem. Oxygen applied at 2L/HR via nasal cannula. Rechecked resident at 0620 (AM) 02 (oxygen) sat 93% at this time via nasal cannula at 2L/HR will continue to monitor. MD (Physician) called, awaiting call back. Author: [Licensed Practical Nurse (LPN) I]. A review of R701's medical record did not include any follow-up note or nursing assessment after 9/23/21 at 6:15 AM regarding a response from Physician notification or additional provider contact, until notation entered into the record on 9/24/21, indicating that the resident was unresponsive, receiving oxygen via oxygen mask, and being sent out to the emergency room . On 11/17/21 at 1:30 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were interviewed and asked what their expectation was related to documentation after a resident's noted change in condition and if a provider is notified. The DON stated, We expect them (Physician/provider) to either come in and see the patient or to call us back and give us direction as far as orders or changes. [For nursing staff,] I would expect them to document if the doctor didn't call back or if they did and gave orders, etc. The DON and NHA both indicated that if staff does not receive a call back from a provider, they can always call the medical director or document a follow-up call with the Physician who was originally notified. Resident #705 (R705) A review of R705's facesheet revealed that the resident was admitted into the facility from an acute care hospital on 8/24/21 and discharged on [DATE] (length of stay: 49 days). R705's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R705's admission Minimum Data Set (MDS) assessment dated [DATE] did not include a heart failure diagnosis. The admission MDS also indicated under Section O that while NOT a resident of the facility (within the last 14 days), as well as while a resident of the facility, R705 did not require oxygen therapy. A review of R705's hospital paperwork, pre-admission into the facility, revealed the following: After Visit Summary (AVS) dated 8/18/21 to 8/24/21 included - Patient History: Medical: Past Medical History: Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/24/21 per the AVS, the resident's BUN (blood urea [MEDICATION(S)]) was 12 mg/dL, Creatinine was 0.8 mg/dL, and Glomerular Filtration Rate (GFR) was > (greater than) 60.0 mL/min, (all used in determining kidney function and all within normal limits). Hospital Problem List: Active Problems: Prosthetic hip infection, initial encounter. Assessment/Plan: -Right Hip PJI (Prosthetic Joint Infection) -Acute [CONDITION(S)] (urinary tract infection) Recommendations: -Continue [MEDICATION(S)] and [MEDICATION(S)] -Follow up on operative cultures and change antibiotics as needed -Place PICC (peripherally inserted central catheter - used for long-term infusion of antibiotics) line as the pt (patient) will require 6 weeks of IV antibiotics . A review of intake MI 041 revealed, .When resident (R705) was discharged , she was diagnosed with [CONDITION(S)]. Resident couldn't move, walk or bend her knees, without oxygen she had a hard time breathing .She was gaining a lot of water weight .She mentioned they gave her a few [MEDICATION(S)], but it did nothing .[R705] told me the water weight made it hard to move and they put her on oxygen to help her breathe easier .I .received a call that they did a chest X-ray and the doctor says [R705] has [CONDITION(S)] .She was so swollen with water and couldn't move. It took awhile to get her in the car (at discharge). She was so out of breath . It was alleged the facility failed to properly address the resident's weight gain It was alleged the facility discharged the resident in an unstable medical condition and without oxygen . A review of R705's care plan revealed: Observe for/document/report to MD PRN (as needed) the following s/sx (signs/symptoms): [CONDITION(S)]; weight gain of over 2 lbs a day; neck vein distension; difficulty breathing (Dyspnea); increased heart rate ([CONDITION(S)]); elevated blood pressure (Hypertension); skin temperature; peripheral pulses; level of consciousness ; Monitor breath sounds for crackles. Date Initiated: 09/07/2021. A review of R705's weights taken while in the facility (all recorded by Registered Dietitian (RD) G) revealed: -8/30/2021 - 234.8 Lbs (pounds) -9/9/2021 - 241.7 Lbs -9/16/2021 - 243.7 Lbs -9/23/2021 - 254.5 Lbs -9/30/2021- 256.0 Lbs (no additional weight recorded after this date). On 08/30/2021, the resident weighed 234.8 lbs. On 09/30/2021, the resident weighed 256.0 pounds which is a 21.2 lb (9.03 %) Gain. A review of R705's record revealed no documentation that the resident's weight gain was addressed by staff, RD G, or the resident's Nurse Practitioner/Physician. No documentation of the weight gain was found in the resident's care plan. R705's Nutritional Risk Assessment (Admit/Readmit/Quarterly/COC), dated 8/26/21 and completed by RD G included, .[CONDITION(S)] present: b. No. No additional documentation or nutritional assessments from RD G were found. A review of R705's progress notes throughout the resident's stay at the facility was conducted and revealed the following: -8/25/2021 01:37 (AM) .Resident admitted from [hospital] .admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .Skin assessment completed surgical incision with 27 on right hip, PICC Line right arm, and hip abduction brace in place, [CONDITION(S)] bilateral lower leg/feet . -9/6/2021 10:23 (AM) .Skilled Nursing Note .Extensive assist with bed mobility, transfers, changing briefs .Respiratory/Cardiac/Ortho Patient CMST (Circulation, Motion, Sensation, Temperature) (as applicable): no cough, no sob (shortness of breath) . -From 8/25/21 until 9/14/21, R705's oxygen saturation on room air had consistently been documented as 92% or greater. -9/18/2021 16:21 (4:21 PM) .Received patient in bed, alert, responsive .On assessments patient noted with decreased oxygen levels, 85% on RA (room air), MD (doctor) notified, writer receive orders for oxygen 2L (2 liters) via nasal canula, oxygen administered, pt.'s SpO2 (oxygen saturation) 93% on 2L. Order for CBC, BMP (complete blood count, basic metabolic panel) weekly until ABT (antibiotic) therapy is done . -9/18/2021 21:09 (9:09 PM) .93% (oxygen saturation) @ (at) 3L/min (3 liters per minute) . -A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] >92%, was entered into R705's record on 9/18/2021. -Effective Date: 9/19/2021 17:45:00 Department: Physician Services Position: Nurse Practitioner (NP) [Entered by NP K] Created Date: 9/26/2021 03:50:40 9/19/2021 17:45 (5:45 PM) Nurse Practitioner Note Late Entry: Note Text: note from 9/19/21 [Resident] with recent hip arthroplasty on 7/19/21, developed prosthetic joint infection infection, and underwent I & D (incision and drainage) and poly-exchange. Seen and evaluated for pain management, right hip. Denies fever, N/V (nausea/vomiting). PMH (Past Medical History): Arthritis, chronic kidney disease (hx of kidney stones), Diabetes mellitus, disease of the [CONDITION(S)], MI, pericarditis, ROS (Review of Systems): All systems reviewed, negative except as mentioned .P.Exam (Physical Exam): .Alert, awake responsive, no distress .Resp: Non Labored, no use of accessory muscle .A/P (Assessment/Plan): Pain right hip: current meds as ordered, Type 2 diabetes mellitus, Physical debility, Impaired mobility. Plan: Supportive care with current pain meds, PT/OT (Physical Therapy/Occupational Therapy, Nutrition support for healing, Discussed with nursing/patient. NP K's note did not address the resident's decrease in oxygen saturation and need for supplemental oxygen use. -9/27/2021 19:29 (7:29 PM) [Entered by NP K] Nurse Practitioner Note Late Entry: Note Text: Note from 9/27/21 .Seen for concern for rash on skin with pruritus, and [CONDITION(S)] of left arm. Patient is current receiving Vanco abx (antibiotic) for knee infection .A/P Rash with pruritus: Start on [MEDICATION(S)] lotion .Left arm [CONDITION(S)]: Elevate with pillow, [MEDICATION(S)] 40 mg (milligrams) q day (a day) x4 days (for four days) . A review of R705's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R705 was not noted to be weighed again after 9/30/21 and/or prior to discharge. NP K's progress note on 10/4/21 revealed, Left arm [CONDITION(S)]: Continue to Elevate with pillow, significant improvement noted. The resident's overall weight gain and continued use of supplemental oxygen was not addressed. No additional notes from NP K were noted in the record after 10/4/21 and before the resident's discharge on 10/12/21. Further review of R705's progress notes and medical record revealed: -Occupational Therapy Treatment Encounter Note(s): Date of Service: 10/10/2021 .Resident is tested for spo2 (oxygen saturation) levels at rest without O2 and with activity without O2. At rest, resident spo2 is 82 (%) with activity spo2 is 75 (%) [Signed by Certified Occupational Therapy Assistant (COTA) N]. -10/10/2021 13:44 (1:44 PM) .PT/OT in progress, needs one person assist for transfers, able to propel self slowly while up in wheelchair .Respiratory/Cardiac/Ortho Patient CMST (as applicable): 2L of O2 (oxygen) continuous with signs of discomfort, and PO (pulse ox - oxygen saturation) is at 97% . -10/11/2021 11:12:00 (AM) .Resident c/o (complains of) sob (shortness of breath) with activities . Resident on O2 at 2 liters per nc (nasal cannula). At rest after with 2 liters of Oxygen resident pulse ox 82%. After activities resident pulse ox 75% on O2 at 2 liters. -10/11/2021 17:43 (5:43 PM) Social Services Note .Resident will return home on on Tuesday .does not qualify for O'2 (oxygen) Concentrator due to no supporting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . -Effective Date: 10/12/2021 14:35:00 (2:35 PM) [Written by Registered Nurse (RN) E] .pt to be discharged today, has picc line dcd (discontinued) .ordered stat chest xray no remnants seen in xray of picc line, CHF ([CONDITION(S)]) noted called [Physician F] he ordered [MEDICATION(S)] 20mg q day (20 milligrams a day) said to have [R705] see her doctor asap (as soon as possible) or make appt (appointment) with his office pt was discharged with dc (discharge) papers and belongings and scripts. A review of R705's orders revealed the following: Stat (immediate) X-ray of chest ap (anterior/posterior) and lat (lateral) to ensure picc line extraction, order date: 10/12/21 [Ordered by Physician F]. Review of the chest x-ray for R705 dated 10/12/21 (electronically signed at 10:18 AM) revealed: Findings: Frontal, portable chest x-ray was obtained. There are no prior studies for comparison. There is demonstration of moderate bilateral pleural effusions, cardiomegaly and mild pulmonary vascular congestion consistent with [CONDITION(S)] (CHF). Impressions: 1. Findings consistent with CHF. On 11/15/21 at 10:43 AM, during review of R705's record, the resident's Physician History and Physical, by Physician F, was noted to indicate the following: Description: Admission Date: 8/26/2021 17:27 (5:27 PM), Section Status: In Progress, Lock Date: [Blank]. The only information present in the form included: -A.: 1. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] Right Hip Prosthesis, Subsequent Encounter Z96.641 Presence Of Right Artificial Hip Joint M16.11 Unilateral Primary [CONDITION(S)], Right Hip E11.9 Type 2 Diabetes Mellitus Without Complications I10 Essential (Primary) Hypertension N18.9 Chronic Kidney Disease, Unspecified Additional Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . -C. 1. Interval History: late note for 8-24-21 (no other information included). -E. Vital Signs (Included blood pressure, temperature, pulse, respiration, and oxygen saturation readings dated 8/26/21 at 11:38 AM. Most recent weight section was left blank). -The remaining sections B. Surgeries; D. Review of Systems; F. Physical Exam; G. Impression; H. Plan; I. Level of Care Review; J. Psychoactive Medication Review; K. Consults; L. Advance Care Planning; and M. Additional Comments, were all noted to be blank. The form was not signed and submitted as complete at this time, and no progress note in R705's medical record from Physician F was found upon record review for the duration of the resident's stay in the facility. On 11/15/21 at 2:00 PM, Registered Nurse (RN) E, who discharged R705 on 10/12/21, was interviewed. RN E was asked if R705 was discharged with oxygen to which she replied that the resident was not. RN E added, [R705's oxygen saturation] was okay prior to that day and wasn't low enough for oxygen at home. When asked if the CHF noted on the x-ray was a change for the resident, RN E stated, Yes. I had to get an x-ray to check her picc line because I took it out before she went home, and that was the day of discharge. I called [Physician F] and told him the findings, and told the DON (Director of Nursing). I told him. He said I could discharge [R705] but she was to go see him in the morning or her regular doctor. If they're being discharged , they're being discharged . [R705] was ordered [MEDICATION(S)], was to go home with that and see a doctor in the morning .The CHF was new for her, that is what the doctor ordered me to do. RN E was then asked if anyone had spoken with SSD A about the CHF result on R705's x-ray prior to the resident's discharge. RN E indicated that SSD A was not working the day R705 was discharged . On 11/16/21 at 9:27 AM, review of R705's record revealed that the resident's Physician History and Physical, by Physician F dated 8/26/21 remained as In Progress. On 11/16/21 at 9:38 AM, Physician F was contacted via phone as he was not in the facility. When queried regarding overseeing the care for R705 while the resident was in the facility, Physician F indicated he needed to review the resident's record and would get back into contact with this surveyor. No call back from Physician F was received on 11/16/21. On 11/16/21 at 9:50 AM, SSD A was interviewed regarding R705's discharge. SSD A provided a list of diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . SSD A revealed that the CHF diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . SSD A indicated she had spoken with the medical supply company prior to the resident's discharge and informed the resident that an oxygen concentrator could have been rented, but the resident declined. When queried if she had documentation of that conversation and the resident's declination, the SSD A indicated she did not. SSD A further indicated that if something changes with a resident's health, it is up to the clinical team to decide how to proceed. SSD A stated, We knew [R705] needed the oxygen, but we had no supporting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . SSD A indicated she did not work on 10/12/21. On 11/16/21 at 10:42 AM, COTA N was interviewed and queried regarding the treatment encounter note from 10/10/21, regarding R705's oxygen saturation levels. COTA N stated that she Did the resident's exertion and resting oxygen levels over the weekend because she was having difficulty breathing, and I knew she was going home. I just wanted to see how she was doing. SSD A stated that for insurance submission, the oxygen testing needs to be done within 48 hours of the resident going home, so the testing was done Sunday 10/10 due to the resident's discharge date being set for 10/12/21. On 11/16/21 at 1:09 PM, RD G was called and interviewed via phone. RD G indicated she could remotely access R705's record. RD G was queried if she had recalled the weight gain R705 experienced while in the facility, and where her documentation regarding the weight gain could be found in the resident's record. RD G stated, I recall she was gaining weight vaguely. My documentation would be .I did a risk assessment for her when she came in .It looks like my documentation would probably be in the care plan and the nutrition assessment. I don't see that I put in a progress note. R705's weights were reviewed with RD G. RD G was asked if it would have been her responsibility to notify the physician of the resident's weight gain, since she had been the one who had entered all of R705's weights into the record. RD G stated, I do not believe that I did notify [the Physician]. I did not document that I notified him, and I honestly can't remember if I wrote in his book for him to look at her or not at this point. The procedure, yes, would be to notify the Physician of the weight gain and they take over from there. Physician F was contacted via phone on 11/17/21 at 9:20 AM and was left a voicemail message for call back. Physician F returned the phone call on 11/17/21 at 9:51 AM and was then interviewed. When queried regarding R705's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked where CHF was noted in R705's pre-admission hospital paperwork, Physician F stated, On the medical diagnoses. When queried regarding the CHF diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Physician F was asked what was the protocol or procedure for a resident experiencing weight gain along with shortness of breath requiring oxygen supplementation to which he responded, Usually we follow the weight and tell nursing staff/facility to follow the weight. If the weight is getting worse you need to see why it's getting worse. This patient also has CKD (chronic kidney disease). We can try a medication, we can look at some of the medication side effects. And follow up with labs. Physician F was asked if he was notified of any weight gain R705 resident experienced. Physician F stated, I was notified about some swelling and there was a low dose of [MEDICATION(S)] given because of the kidney disease. If there's swelling that usually means there is weight gain, too. Physician F was asked if he was notified of the resident's difficulty breathing or results of the activity tolerance test (oxygen at rest, with activity) the weekend before she was sent home. Physician F stated, No, I do not recall that. Physician F was asked if R705 experienced a change in their health condition towards the end of their stay at the facility that may justify additional or different interventions. Physician F responded, Medication is usually the first thing you do. Need to bear in mind the chronic kidney disease which can contribute to the fluid retention. CHF building up, plus kidneys. First thing we do is medication. Second thing was that the patient was in bed, lack of ambulation itself can cause fluid retention, and that can cause difficulty breathing. If we get to the point where maybe patient needs to go to the hospital then we do that. But oxygen can always be applied for CHF or anything causing the shortness of breath. Physician F was asked if he was notified that R705 gained just under 22 pounds during her stay at the facility. Physician F stated, I do not recall .If I would've been informed of that, maybe increased the dose (of [MEDICATION(S)]) from 20 to 40 (mg), and monitor the urine output, but if not responding to any of this then maybe patient needs to go to the hospital. Physician F added, When [R705] was discharged we emphasized that she go see her doctor right away or follow up with me. Upon reviewing R705's medical record on 11/17/21 at 10:13 AM, it was noted that Physician F's Physician History and Physical, form dated 8/26/21 was now marked as Complete with, Lock Date: 11/16/2021 18:27 (6:27 PM). All sections of the H&P that had been noted to be blank on 11/15/21 and 11/16/21 were now completed. The H&P now included that R705 had a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/17/21 at 10:28 AM, MDS Coordinator RN L was interviewed and asked to review R705's pre-admission hospital records and indicate if the resident had a noted past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . RN L reviewed R705's record and confirmed that R705 did not have CHF in their paperwork as a past or admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 11/17/21 at 10:35 AM, the DON was interviewed and queried regarding Physician F's now completed H&P that indicated that R705 had crackles, [CONDITION(S)], and a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated, He (Physician F) never told us .If [R705] had that, what did he prescribe for it? Nothing. It wasn't there. I scrubbed the hospital records for this and it wasn't in there. The only reason (CHF was) caught on x-ray was because we got the x-ray for the PICC removal. The DON was queried regarding the resident gaining just under 22 lbs during their stay at the facility. The DON stated, I don't know, seems like we would've physically seen 22 lbs. The DON was asked about Physician F completing and submitting his H&P documentation on 11/16/21 and indicated that it should have been completed and submitted prior to 11/16/21. On 11/17/21 at 1:30 PM, the Nursing Home Administrator (NHA) and DON were interviewed. The NHA was asked what the process was for determining whether a resident can be discharged back to the community. The NHA stated, It depends on if (the resident is) short-term or long-term. We start discharge planning upon admission, and if insurance cuts, we inform them (resident). The DON added, It's a case-by-case situation. [Residents are] assessed upon admission and continuously. A review of the facility's policy/procedure titled, Change in a Resident's Condition or Status, revealed, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status .1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): a. accident or incident involving the resident; b. discovery of injuries of an unknown source; c. adverse reaction to medication; d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; f. refusal of treatment or medications two (2) or more consecutive times); g. need to transfer the resident to a hospital/treatment center; h. discharge without proper medical authority; and/or i. specific instruction to notify the Physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b. Impacts more than one area of the resident's health status; c. Requires interdisciplinary review and/or revision to the care plan; and d. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument 1. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . A review of the facility's policy/procedure titled, Weight Assessment and Intervention, revealed, 3. Any weight change of 5 pounds or more since the last weight assessment will be retaken for confirmation. If the weight is verified, nursing will notify the Physician and Dietitian. 4. The Dietitian and/or Certified Dietary Manager will review the individual weight records to follow individual weight trends over time, making recommendations as appropriate.

This citation pertains to intake number M 322 Based on observation, interview, and record review the facility failed to ensure appropriate monitoring and supervision of one sampled resident (R500) of four residents reviewed for elopement, allowing R500 to exit the building unbeknownst to staff, resulting in Immediate Jeopardy due to the likelihood of serious injury or death from being outside near a heavily trafficked congested road, for an extended period of time. Findings include: On 7/27/21 at 10:36 AM R500's Electronic Health Record (EHR) was reviewed and revealed the following, 5/22/2021 15:14 (3:14 PM) Alert Note Text: Staff found the resident outside on the same side of street of facility, Resident was out on her W/C (wheelchair) going towards the [convenience store] close to the facility, Resident was aggressive to staff and did not want to come back, staff able to convince the resident and pushed the resident along with W/C in facility, Resident received back in facility in stable condition, no injuries, no skin issues noted, Vitals monitored, as per Resident, she was trying to go to her home, Resident said, MD (Medical Director) notified, guardian care aware, Wander guard was placed on R (right) ankle, Resident took it off and threw it in the trash, said she does not like it at all, Supervisor notified and replaced the wander guard onto her W/C while resident was distracted, Resident is on Q (every) 15 Patient monitoring at this time, Resident in her Room on her W/C, will cont. to monitor. On 7/27/21 at 10:39 AM an additional progress note in R500's EHR reflected the following, 5/22/2021 14:50 (2:50 PM) Nursing Note Text: Wander guard found in trash in room. Resident has stated she will take it off again, so was replaced onto back of w/c on left side when resident was distracted. Per NHA (Nursing Home Administrator) R (Resident) had torn her wander guard off prior to exiting. On 7/27/21 at 11:10 AM, the NHA was interviewed and asked if he had reported the incident involving R500 to the state agency. The NHA indicated that initially they were provided inaccurate information regarding the incident. Once the information was clarified A few days had gone by and I thought because the resident was only out of the building for about 5 minutes, I didn't need to report it. This building is difficult to monitor due to its design. On 7/27/21 at 11:15 AM, the NHA was asked if the facility had video tape of this incident. The NHA indicated that their video only goes back, A week. On 7/27/21 at 11:20 AM, documentation involving an informal investigation the NHA had completed on the incident involving R500 was reviewed and revealed a copy of a video tape picture of R500 exiting the front door of the facility. A written summary of the incident indicated the following, On 5/22/21 at approximately 12:33 PM, [R500] left through the front door of the facility. The door alarm was working and activated. The door opened after they held down the release bar for fifteen seconds .Certified Nursing Assistant (CNA) entered the front lobby area to investigate the alarm. CNA found another resident walking around the area and assumed that they had been the one to set off the alarm .CNA looked outside the glass doors and did not see anyone and reset the door alarm. At approximately 12:36 PM, a passerby pulled into the facility parking lot and told [Nurses] there was someone in a wheelchair down the block trying to hitchhike. [Nurses] got in a car and drove to where the resident was, they found the resident approximately two tenths of a mile from the facility, on the same side of the street .Resident returned to the facility safely. Guardian and doctor were notified. Skin assessment was completed, and resident was found to have no injuries. Resident showed no signs of dehydration. The temperature was 88 degrees and partially cloudy. The resident was outside for a total of 17 minutes. On 7/27/21 at 2:00 PM, Nurse B was interviewed regarding the incident which occurred involving R500 on 5/22/21. Nurse B stated, Myself and two other nurses were returning from lunch and a man pulled up and indicated that he had seen an elderly woman wheeling her wheelchair on the sidewalk. Myself and the other nurses jumped in my car and drove to where [R500] was, they were on the building side of the street on the sidewalk sitting in their wheelchair across from the [convenience store] We brought [R500] back to the facility. On 7/27/21 at 3:05 PM, Nurse C was interviewed by phone regarding the incident involving R500. Nurse C stated, We were notified by an outside source that one of our residents was down [traffic congested road] trying to hitch a ride. I went about a block down the road and saw [R500] standing by the side of the road. Other nurses were there, I was able to get [R500] into the nurse's car and we brought her back to the building. She was not injured. On 7/27/21 at 3:15 PM R500 was observed in their room and interviewed about the incident which occurred on 5/22/21. R500 was asked specifically if they remembered exiting the building on 5/22/21, R500 stated, No, why would I do that. On 7/28/21 at 9:30 AM CNA A was interviewed regarding the incident involving R500 and indicated that they heard the front door alarm go off, came up front, saw another resident up front and assumed that the resident had pushed on the door handle and engaged the alarm. CNA A stated, I opened the front door and looked both ways. I didn't see anything. I reported the incident to my nurse [Nurse E]. CNA A was interviewed and asked if any staff were present near the receptionist area located by the front door. CNA A stated, No, no one was there, they don't staff that area on the weekends only during the week, I suggested that they place a staff up there on weekends following the incident, they haven't done it yet. On 7/28/21 at 9:43 AM, Nurse E was attempted to be contacted by phone for an interview. Nurse E did not answer her phone and a voice mail message was left for them. On 7/28/21 at 1:30 PM, a review of R500's EHR revealed that, R500 was most recently admitted to the facility on [DATE] with diagnoses that included: [CONDITION(S)] ([CONDITION(S)]) and Dementia with behavioral disturbance. R500's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed that R500 had a severely impaired cognition. On 7/28/21 at 1:40 PM, a review of the Elopement/Wander Risk Evaluations completed on R500 since January 2021 revealed the following: R500 had an evaluation completed on 5/22/21 and was rated with a score of 8 which indicated that they were a Moderate wander risk; R500 had an evaluation completed on 7/27/21 and scored a 14 which indicated High wander risk. On 7/28/21 at 1:45 PM, a review of R500's most recent care plan revealed the following, Focus: I have hx (history) of attempts to leave facility unattended and voice desire to leave facility without assist at times. I remove wander guard at times. Date Initiated: 10/25/2019 Revision: 03/23/2020. Goal: I will not leave the facility unattended through the review date. Date Initiated: 02/10/20 Revision on: 03/23/20 Target Date: 09/12/2021. Interventions: Educate all staff, including receptionist, on my tendency to wander . Date Initiated: 02/10/2020 Revision on: 03/23/2020. Identify pattern of wandering: Is wandering purposeful, aimless, or escapist .intervene as appropriate. Date Initiated: 02/10/2020 Revision: 09/30/2020. Removes wander guard when applied. Date Initiated: 05/22/2021. Wander Alert: wander guard in place. Wrist band and photo ID (Identification) on record. Date Initiated: 02/10/2020 Revision: 03/23/2020. Wander guard applied to wheelchair 5/22/21. Date Initiated: 05/22/2021. On 7/28/21 at 2:00 PM a facility policy titled Elopement Revised January 2019 was reviewed and reflected the following, It is the policy of this facility to provide a safe and secure environment for our residents and to be proactive in preventing resident elopement. Residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement is defined as the resident leaving the premises of the facility without the knowledge of facility staff. Staff shall investigate and report all cases of missing residents .The Department of Health will be notified of the elopement. 10. Post Elopement/upon return to the facility, The Director of Nursing Services or Charge Nurse shall: .Complete and file an Incident Report . The Administrator (NHA) was notified of the Immediate Jeopardy on 7/27/21 at 2:17 PM and a plan of correction was requested to remove the immediacy that began on 7/27/21. The facility provided the following removal plan. Immediate Jeopardy was removed on 7/28/21 as validated by the team on 7/28/21. Element 1 Resident #500 was returned to the facility on [DATE] at 12:45 pm. She was unharmed and remains at the facility with no adverse effects from the incident. A full body assessment was completed, and no injuries were noted. She is currently on a 1:1 and has had a wander guard placed. The facility will continue to monitor her care plan interventions for appropriateness. The facility currently has a receptionist Monday through Friday from 8 am to 4:30 pm and has added a receptionist on Saturdays and Sundays from 8 am to 4:30 pm to monitor the front door. Element 2 Residents with exit seeking behaviors are at risk for elopement. All current residents have been assessed for elopement risk. All residents at risk for elopement have had their care plans reviewed and updated as needed. All new admissions will be evaluated upon admission and quarterly for elopement risk. Elopement binders have been reviewed to ensure residents at risk were identified. Alarmed doors were checked by maintenance to ensure proper function. Element 3 Elopement Policy and Procedure has been reviewed by the IDT (Interdisciplinary Team) on 7/27/2021 and deemed appropriate. DNS (Director of Nursing Services) or designee has educated all staff as of 7/28/2021 on the Elopement policy and Procedure. New hires will be educated during orientation. Any staff that has not received the in-service has been removed from the schedule and will be educated before their next scheduled shift. Element 4 The DNS or designee will conduct random audits of elopement risk residents interventions to prevent elopement to ensure they are in place and appropriate. These random audits will be conducted weekly for 4 weeks and then monthly thereafter to ensure compliance. The findings of these audits will be presented to the monthly facility QA (Quality Assurance) Committee for review and recommendations. Date of compliance is 7/28/21. The Administrator will be responsible to ensure that compliance is achieved and maintained. Although the immediacy was removed on 7/28/21, the deficient practice was not corrected by the facility and remained isolated with actual harm that was not Immediate Jeopardy, as sustained compliance could not be verified by the state agency. .

This citation is pertains to intake MI 094 Based on observation, interview and record review, the facility failed to ensure residents were free from physical abuse by other residents for two sampled Residents (R503 and R507) of six residents reviewed for abuse, resulting in R503 and R507 being struck by another resident. Findings include: A review of a facility reported incident revealed On 6/11/21, at approximately 8:50 am, (certified nursing assistant) [CNA L] witnessed (R502) come out into the hallway agitated and with (their) right hand made contact with the left side of (R503's) face. A review of facility reported incident from July 2021 indicated R506 had been walking by R507 and struck R507 without an apparent physical injury. On 07/27/21 at 9:23 AM, R502 was observed to be in their room, dressed and seated at the side of their bed. R502 did not appear to recall an incident with another resident, when interviewed. On 07/27/21 at 9:29 AM, R503 was observed to be dressed, with shoes on, wheeling themselves around the facility using their feet and legs, intermittently clapping. R503 did not respond to queries about the incidents with another resident, when an interview was attempted. On 07/27/21 at 10:10 AM, Nurse I was interviewed about the incident between R507 and R506. Nurse I reported that the day before R506 had become upset with the CNA in the room who was trying to clear out some of the trash in the room. Nurse I reported R506 was known to hoard trash and steal items from other resident's rooms thinking they had been taken from them. It was also noted that R506 had been treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse I reported R506 had been physical with staff, but was not aware of any resident to resident incidents prior to the incident with R507. Nurse I also noted R506 walks without assistive devices and R507 used a wheelchair. On 07/27/21 at 12:18 PM, Nurse J was asked about any incidents between R503 and R502. Nurse J reported they had heard about the altercation between the two residents but was not at the facility that day. Nurse J reported they were not aware of any prior incidents with other residents. Nurse J reported that R502 usually stays in their room but will sometimes come out if R502 sees a staff member walk by. Nurse J reported R502 was alert to their name, occupied their time with stuffed animals and coloring, and was not a wanderer. Nurse J reported they were not familiar with R503. On 07/27/21 at 1:20 PM, (Certified Nursing Assistant) CNA K was asked if they had knowledge of any incident between R506 and R507 and reported they did not. On 07/27/21 at 1:31 PM, R507 was observed to be in bed, dressed in a hospital gown. R507 was asked if they had been involved in any incident with another resident and reported, I was sitting minding my own business and (R506) came up and hit me twice. R507 touched the side of their head to indicate where R506 had struck them. R507 reported they did not know why it happened; It had not happened again and the other resident had walked by them since, without incident. R507 reported they had no other incidents with residents or staff. On 07/27/21 at 3:20 PM, a male resident was seated in a wheelchair outside their room facing the doorway of their room. A shoulder high, approximately three foot long, linen cart on rollers was behind him. R503 was observed to wheel themselves down the hall and stop just behind the linen cart. R503 then began to push the linen cart into the back of the male resident's wheelchair three times. The male resident told R503 to stop, but R503 continued to push and pull the linen cart back and forth each time striking the wheelchair of the male resident. The male resident seemed to know something was coming as they had told R503 to go around them just prior to the incident. This incident was unwitnessed by staff. On 07/27/21 at 3:58 PM, R503 was seen to wheel themselves into room [ROOM NUMBER] (not R503's room). Two male residents in the room were heard to yell at R503 to get out. R503 did not respond to the verbal requests of the residents and continued to wheel into the room. The resident call light was activated. Staff were observed in the hall and did not appear to notice R503's entry into the room. Staff did not respond until the call light had been activated and a resident in the room was pushing R503 toward and out the door of the room. R503 continued to propel themselves around the facility seated in their wheelchair with no verbal response to any query. R503 did not appear to be easily redirected verbally. On 07/28/21 at 9:38 AM, R506 was observed to be in their room, dressed and seated on the side of their bed. R506 was queried about any incidents with other residents and denied that there had been any incidents or hitting anyone. R506 did indicate they would hit back if someone attempted to hit them. On 07/28/21 at 9:48 AM, CAN A was asked if they had heard about any resident-to-resident incidents that involved R502, R503, R506 or R507 and denied knowledge of any incidents. On 7/28/21 at 1:40 PM, the resident to resident incidents were reviewed with the Administrator. The Administrator reported R503 was rolling past the door way of R502 and R502 came out of their room and hit R503 and went back into their room. The Administrator indicated that R502 had struck R503 due to R503 clapping. It was also reported that R502 had not had any other resident to resident incidents and usually stays in their room. The Administrator also noted they were aware of R503's roaming around the building and need for redirection at times. The Administrator reported that R506 reported, R507 had cussed at them and that was why they had hit R507. The Administrator noted that R506 had not been physically violent with other residents prior to the incident. The observations of R503's interaction with other residents during the survey and the potential for additional resident to resident incidents also were noted. The Administrator reported they were not sure what else the facility could do about R503 and that staff are aware but cannot be at all places. The Director of Nursing also noted R506 had not put hands on any one before and reported staff are to keep vigilant for resident-to-resident incidents. On 07/28/21 at 2:20 PM the (Assistant Director of Nursing) ADON was asked about the resident-to-resident incidents and did not appear to be fully informed about the incidents. On 07/28/21 at 2:26 PM, CNA L was interviewed about the incident between R502 and R503 and reported they had R503 up and dressed and out by the nurse's station. R502 then came out of their room and slapped R503 hard enough to leave finger marks. CNA L commented R502 was irritated by R503's clapping. CNA L further reported a history of R502 having been physical with staff during care. CNA L was aware of R503 and their wandering and reported R503 can be redirected. A review of the record for R502 revealed, R502 was admitted into the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The nursing care plan reflected: (R502) has a risk of alteration in mood .wandering .anger .hallucinations .(revised 04/07/21). A review of the record for R503 revealed, R503 was admitted into the facility on [DATE]. R503's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The nursing care plan reflected: (R503) .needs frequents cues and direction .(revised 05/18/20) .wanders aimlessly in (their) wheelchair and does significantly intrude on the privacy of others . will wander into other rooms and rummage through other's drawers .revision on 07/07/2020. A review of the record for R506 revealed, R506 was admitted into the facility on [DATE]. R506's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The nursing care plan reflected: (R506) exhibits alteration in mood/behaviors .agitation .verbally threatening to others .delusional thoughts .03/20/19 .cursing, physically threatening towards staff and roommate .04/29/18 .physical aggression with peer .05/03/19 physical aggression toward (Peer) .revision on 05/15/20. A review of the record for R507 revealed, R507 was admitted into the facility on [DATE]. R507's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .revision on 01/25/21. A review of the facility Abuse Policy revised January of 2020, revealed: The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation as defined in this subpart .Resident must not be subjected to abuse by any one, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardian, friends, or other individuals .Definitions: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled through the use of technology.

This citation pertains to intake: MI 593 and MI 425. Based on observation, interview, and record review, the facility failed to prevent physical abuse from Resident #18 (R18) and failed to separate the residents after the incident, for one unsampled Resident (R76) of three sampled residents reviewed for abuse, resulting in physical abuse and psychosocial distress using the reasonable person concept. Findings include: On 3/18/21 at 12:00 PM, R76 was observed sitting on the unit in their wheelchair next to the door of R18. R18 was observed sitting in their doorway near R76. R76 appeared to have a cognitive impairment as observed to make incoherent verbal sounds and clapping of their hands. While R76 was sitting in front of R18's door, R18 was observed to smack R76 on top of their head. The smack was observed to make a loud sound and R76 was observed to grab the top of R76's head and make a face of pain. Housekeeper J was observed standing at a cleaning cart grabbing items out of the cart. The cart was observed on the other side of the hall across R18's room door. Housekeeper J was asked why did R18 just hit R76. Housekeeper J was observed to look up and stated, 'Why did you just hit (R76), (R18) why did you do that.' R18 did not reply. Housekeeper J was observed to continue to grab items from the cleaning cart and not observed to remove R76 away from R18. The Nursing Home Administrator (NHA) was observed down the hallway, the NHA was reported the observation of R18 smacking R76 across the head. The NHA was observed to talk to R18 and asked if R18 hit R76. R18 stated, 'Yes.' The NHA was observed to ask, 'Why did you hit (R76).' R18 stated, 'Because.' The NHA asked, 'What do you mean, did (R76) hit you.' R18 replied, 'Never mind.' On 3/18/21 at 1:10 PM, an interview with R76 was attempted but due to R76's cognitive impairment was unable to be conducted. A review of R76's medical record noted, R76 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Cognitive patterns: Should Brief Interview of Mental Status (BIMS) be conducted? No, (resident is rarely/never understood), BIMS Severely impaired. R76's activities of daily living noted to require extensive assistance with two staff. On 3/18/21 at 1:12 PM, R18 was asked the reason they smacked R76 on the head. R18 offered no response. A review of R18's medical record noted, R18 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. as intact with a score of 15 out of 15, which indicated no impairment. Continued review of R18's care plan noted, Focus: MOOD/BEHAVIORS (R18) exhibits Alt. (alternative) Mood / Behaviors aeb (as evidence by) periods of increased anxious statements, phy (physical) restlessness, difficult coping w (with)/ SNF (skilled nursing facility) placement w/ hx (history) of frequent SNF placements. Periods of ^ (increase) irritability, screaming at staff, cursing and confrontational behaviors. Fabricates stories. Dx (diagnosis) include adjustment disorder, anxiety, [MEDICAL CONDITION], Hx ETOH (alcohol) dependence with alcohol induced anxiety disorder, nicotine disorder. Date Initiated: 09/30/2019. Revision on: 12/30/2020. Goal: Will show signs of adjusting to new SNF aeb (As Evidenced By) voiced positives regarding placement and mood/behavioral symptoms will be easily altered or resolved by next review date x (times) 90 days. Date Initiated: 10/07/2019. Interventions: Assess all potential causative factors behind fluctuating mood/behaviors including time of day, location, comfort levels, labs, meds etc. Doc (document) and report to Dr (doctor) and psych services noted factors Date Initiated: 10/07/2019. On 3/18/21 at 1:15 PM, the Director of Nursing (DON) was asked about the facility's expectation on what to do when a resident has been hit by another resident or person. The DON stated, Remove the resident from harm immediately. A review of the facility's policy titled, Abuse Policy revised date, 1/2020 noted, . Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals .

This citation pertains to intake # MI 285. Based on observation, interview and record review, the facility failed to follow up and evaluate interventions for weight loss for one resident (#15) of three residents reviewed for nutrition, resulting in the likelihood of continued weight loss, poor wound healing and an over all health decline. Findings include: On 3/15/2021 at 7:15 AM, Resident #15 was observed awake in bed. Resident #15 appeared thin. When queried about care, Resident #15 mentioned that their foot was sore and pointed to their feet. Each foot had a soft boot on them. A dressing was observed underneath the boot, wrapping around their entire left foot. Resident #15 stated, I just had surgery on it. On 3/15/2021 at 12:42 PM, Resident #15 was sitting up in their wheelchair. Resident #15 was asked about lunch and had explained that they had ate lunch already. Resident #15 was asked how the food was and stated it was, Good. On 3/16/2021 at 11:12 AM, Resident #15 was observed in the Physical Therapy gym pedaling a bike. Resident #15 appeared thin and tired. On 3/17/2021 at 12:40 PM, Resident #15 appeared very thin and stated that they are losing weight and did not know why. Resident #15 explained that they could feed themselves, denied trouble swallowing but stated they did not know why they were, Skin and bones, I don't know why I am losing weight. Resident #15 thought their weight was at 208#. A review of the weights for Resident #15 revealed the following: 12/10/2020-116.7 pounds (#) 12/15/2020-116.2# 12/28/2020-116.1# 1/04/2021-117# 2/04/2021-101# 2/11/2021-108.4# 2/18/2021-103.5# 2/25/2021-99.1# There were no weights after 2/25/2021 documented in the medical record. A review of the Minimum Data Set assessment dated [DATE] revealed that Resident #15 was admitted to the facility originally on 12/10/2020 with the [DIAGNOSES REDACTED]. Resident #15 had a Brief Interview for Mental Status score of 03, indicating a severely impaired cognition and needed extensive assistance with dressing, bed mobility and transfers. Section K of the assessment revealed the resident had coughing/choking and/or pain with swallowing. A record review of the progress notes for Resident #15 revealed the following: 12/17/2020 11:30 (AM) Nurse Practitioner .Follow up dehydration .Awake and responsive .Completed two bags of IV (intravenous) fluids, continue to encourage hydration. REVIEW PHYSICAL EXAM: General Appearance: weak and frail .ASSESSMENT/PLAN: 1. dehydration: completed IV fluids . 2/4/2021 14:01 (2:01 PM) .Resident discussed at Risk meeting d/t (due to) weight loss 13.7% past month. Currently on regular diet, puree texture, NTL (nectar thick liquids). Per FAR (Food Acceptance Record) consumes < (less than) 50% most meals. Current weight 101#, BMI (body mass index) 15.8 (underweight). Receives med pass 2.0 120 ml (milliliter) tid (three times per day) and Prostat AWC 30 ml tid to increase intake and aid in healing. Refer to MD (Medical Doctor) for eval, recommend 1:1 assist with meals. Will add to weekly weights. 2/16/2021 12:14 (PM) Nurse Practitioner Note .follow up poor appetite (sic) nursing staff has reported poor appetite. Weight loss noted and gaining some back. Will order [MEDICATION NAME] (appetite stimulant) before lunch and dinner .General appearance .frail appearance .New medications: [REDACTED] [MEDICATION NAME] (dronabinol) 2.5 mg (milligrams) capsule Take 1 capsule by mouth as directed, before lunch and before dinner X 30 Days, Disp (dispense) 60 .Start Date: 02/16/2021 Plan Note 1. poor appetite: will order [MEDICATION NAME] before lunch and dinner, continue supplements . A review of the current and discontinued orders revealed the following for Resident #15: Regular puree/nectar diet and a 2.0 house supplement ordered for three times per day, all ordered 3/08/2021. There was no current or discontinued order for [MEDICATION NAME]. A review of the Nutritional Risk Evaluations for Resident #15 revealed the following: 12/10/2020-Weight 116.7#; 67 inches height. Holding food in mouth/cheeks or residual food in mouth after meals Coughing or choking during meals or when swallowing medications Complaints of difficulty or pain when swallowing Goal weight 120-130 weight loss suspected, exact amt (amount)/time unknown Identified cause of weight change (if known) poor po intake No further weight loss Intake >75% of meals Aid in healing Maintain hydration 3/08/2021-Weight 99#; 67 inches height. Holding food in mouth/cheeks or residual food in mouth after meals Coughing or choking during meals or when swallowing medications Complaints of difficulty or pain when swallowing Goal weight 120-130 weight loss suspected, exact amt/time unknown Identified cause of weight change (if known) poor po intake No further weight loss Intake >75% of meals Aid in healing Maintain hydration A review of the food acceptance from 2/17/2021-3/17/2021 revealed the following for Resident #15: 18 meals of less than 25% intake, 13 meals of 25-50% intake and 1 meal refusal. A review of the Nutrition care plan initiated 12/10/2020 for Resident #15 revealed the following: Focus-(Resident #15) has nutritional problem or potential nutritional problem r/t (related to) intake <50% of meals, increased needs r/t pressure ulcers on toes and L (left) heel, underweight r/t BMI 18.2. Goal-Aid in healing thru next review .maintain adequate nutritional status as evidenced by maintaining weight within 3% of 117#, no s/sx (signs and symptoms) of malnutrition, and consuming at least 75% of at least 3 meals daily through review date. Resident will gain 2-4#/mo. (month). Interventions-Offer Substitutes for refused food items. Provide and serve supplements as ordered: Prostat AWC 30 ml bid (twice per day), Medpass 2.0 120 ml tid with med pass. Serve diet as ordered Regular diet, puree texture with nectar thick liquids. Observe for/document/report to MD PRN (as needed) s/sx of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes. Monitor weight and food intake. On 3/18/2021 at 11:21 AM, Registered Dietician (RD) D was interviewed in regards to Resident #15's weight change. RD D was asked about the procedure for monitoring weights on residents and explained that, the weight is obtained within 3 days of admission to establish a baseline. RD D further explained that she creates a list to give to the staff to complete weights and then reviews the list and discusses them at their weekly risk meeting. RD D was asked if any weights were obtained after 2/24/2021 and stated, I am not seeing them. RD D explained that Resident #15 was on the list for last week for an admission weight. RD D explained that she creates her list every Monday with the intention of getting them by Thursday for the risk meetings and that the initial weight should ideally be obtained upon admission. RD D was asked what interventions had been put into place following the House supplement that was started. RD D stated, (Resident #15) gets our 2 cal house supp TID (Three Times a Day) with med pass, and prostat (a protein powder utilized to promote wound healing). RD D was asked how she knew about the intake of the house supplement since the amount taken in was not documented in the medical record. RD D stated, I ask them (nurses and nurse aides) how much (Resident #15) takes, I believe (Resident #15) takes it (drinks the house supplement). RD D was asked about the [MEDICATION NAME] that was ordered in February but never carried out and ordered and stated, They just (re) ordered it today, just now. Speech is working with (Resident #15), and actually their intake is improving since (Resident #15) has come back (from hospitalization ). On 3/18/2021 at 11:33 AM, Speech Therapist (ST) N was interviewed in regard to the progress of Resident #15. ST N explained that Resident #15 was still on their case load, but planed to discontinue ST services soon. ST N explained that Resident #15 was having difficulty swallowing regular textured foods and did not expect to upgrade their diet. ST N was asked if Resident #15 could feed themselves, and did say that they could. On 3/18/2021 at 11:39 AM, the Director of Nursing (DON) was interviewed in regard to the weight loss of Resident #15. The DON explained that the Interdisciplinary Team discusses weight loss at the weekly risk meeting. The DON stated, We did notice that (they) had a decreased appetite. We interviewed (Resident #15). We put interventions to have (Resident #15) get up in their wheelchair for meals in the hallway for nurses to feed (Resident #15). (Resident #15) was refusing a lot because of the texture (of the food). They would eat small amounts. We would bring (Resident #15) up in risk every week. (Resident #15) needs cueing and assistance with feeding. (Resident #15) came in with malnutrition and failure to thrive. We attempted supplements and just put them on [MEDICATION NAME]. Speech Therapy consulted them as well and is helping them with meals. We do monthly weights, the dietician gives us a list of weekly weights. We have a QAPI (quality assurance process improvement) plan on weights because we noticed that we had a problem (obtaining) weights. We have one specific person getting weights now (to avoid discrepancies). Last week she (assigned staff member to get weights) had a death in the family. We didn't get the weights. Today is our day for risk meeting. The DON was asked about the follow up with weights for Resident #15 and stated, We get admission weights usually the next week; (Resident #15)'s weight is 99.2# today. On 3/18/2021 at 1:00 PM, the Nursing Home Administrator (NHA) was queried in regard to weight loss within the facility. The NHA explained that they were working on weight loss in QAPI and that dietary was working on food preferences and resident choice meals. The NHA also stated, We have a food committee that meets once per month. We educated staff on making food more appealing. The residents also pick a meal once per month and we make it for them. A review of the facility policy titled Weight Assessment and Intervention dated 2001, revealed the following: Policy Statement-The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Weight Assessment-1. The nursing staff will measure resident weight on admission, and then weekly for two weeks. If no weight concerns are noted at this point, weights will be measured monthly thereafter or as per Dietician or MD. 2. Weights will be recorded in each individual's medical record.

This citation pertains to intakes MI 405 and MI 425. Based on observation, interview, and record review, the facility failed to provide adequate supervision, and create and/or implement effective and individualized interventions for fall prevention for three sampled residents (R#18, R#28, and R#446) of seven reviewed for falls, resulting in multiple falls and falls with injury that required hospitalization . Findings include: Resident #28 On 3/15/21 at 7:33 AM, R#28 was observed leaning off the left side of their bed, with their left elbow hanging off the edge of the bed. A fall mat was in place on the floor on the left side of R#28's bed, however, the resident's bed was not placed in the lowest position. An attempt to interview R#28 was made but the resident indicated they did not know where they were and was asking for help. R#28 was asked if they were in pain and stated, No. R#28 was asked if they were uncomfortable and replied, Yes. On 3/15/21 at 7:42 AM, staff entered R#28's room and placed the resident's bed into the lowest position, however, R#28 was still leaning toward the left edge of the bed with their elbow hanging off. On 3/15/21 at 8:24 AM, R#28's right leg, which was crossed over their left, was observed hanging off the left side of the bed along with their left elbow. R#28 continued to verbalize confusion. On 3/15/21 at 8:38 AM, R#28 was noted to now be sitting up in their wheelchair in their room. On 3/15/21 at 9:07 AM, R#28 was observed in their wheelchair. R#28 was noted to be sitting on a folded white top-sheet on the seat of their wheelchair and had regular white socks on with no shoes. R#28's breakfast tray sat on a table in front of them but R#28 vocalized that they did not want it. On 3/15/21 at 12:43 PM, R#28 was observed to still be sitting up in their wheelchair. R#28 continued to wear regular socks, no non-skid pad was observed on their wheelchair seat. R#28 appeared slightly distressed at this time, and was observed calling out to anyone that walked past their room, stating, Help me, I don't know what I'm doing here. On 3/16/21 at 11:18 AM, the white top-sheet was observed to still be on the seat of R#28's wheelchair. R#28 was observed in bed at this time. The resident's bed was observed to not be placed in the lowest position. A review of R#28's care plan revealed: (R#28) is at risk for falls r/t (related to) decreased mobility, impaired safety awareness and judgement. Date Initiated: 09/30/2019 Revision on: 06/16/2020. Be sure call light is within reach and encourage (them) to use it for assistance as needed. Provide a prompt response to all requests for assistance. Date Initiated: 09/30/2019 Revision on: 06/16/2020. Concave mattress Date Initiated: 01/20/2020. Ensure (R#28) is wearing appropriate footwear such as non skid socks when mobilizing in w/c (wheelchair). Date Initiated: 09/30/2019 Revision on: 06/16/2020. Floor mat recommended. Date Initiated: 03/10/2021. Frequent checks for proper positioning while in bed 2-9-21. Date Initiated: 02/09/2021. Keep person(al) items within reach 7-16-2020 Date Initiated: 07/16/2020. Non skid pad to wheel chair 10-25-2020 Date Initiated: 10/25/2020. Re-orientated to use call light for assistance with transfers with toileting. 8-4-2020 Date Initiated: 08/04/2020. Turn and reposition every 2 hrs (hours) Date Initiated: 07/17/2020. Wedges while in bed for positioning and safety 3-10-21 Date Initiated: 03/10/2021. A review of R#28's fall incidents revealed that the resident had a fall on 10/25/20 at 3:45 PM, 2/9/21 at 3:17 AM, 2/10/21 at 11:00 PM, and 3/10/21 at 12:57 PM. A review of R#28's most recent fall risk assessment dated [DATE] indicated that the resident is at High Risk for falling (Score of 15). On 3/16/21 at 12:19 PM, R#28 was observed in bed. No non-skid pad was observed in their wheelchair. No wedges were observed in bed with R#28 and the resident's mattress was observed to not be concave. On 3/16/21 at 12:59 PM, R#28 remained in bed. No concave mattress or wedges were observed. R#28's bed was observed to not be placed in the lowest position. On 3/17/21 at 9:30 AM, wedges were now observed in bed with R#28. On 3/17/21 at 11:00 AM, R#28 was observed sitting up in their wheelchair. No non-skid pad was observed, and the resident was observed to be wearing regular white socks. On 3/17/21 at 1:36 PM, R#28 was observed to still be in their wheelchair. The resident was observed to be scooted forward to the edge of their wheelchair seat, reaching their arms out over their bed, with their legs stretched out. R#28 continued to have regular white socks on at this time, and no non-skid pad was seen in the resident's wheelchair. Certified Nursing Assistant (CNA) G was called over to the room and asked what was needed. R#28's roommate shouted, (R#28) wants to get back into bed! CNA G asked R#28 if they wanted to get back into bed. R#28 nodded their head yes. On 3/18/21 at 12:47 PM, the Director of Nursing (DON) was interviewed and queried regarding implementation of fall risk interventions. The DON indicated she would expect fall interventions to be carried out per the care plan. The DON was then asked to observe R#28's wheelchair. Upon review of the wheelchair, the DON was asked what color non-skid pads for wheelchair seats are and stated, Normally, blue. The DON confirmed no non-skid pad was in place on R#28's wheelchair seat. When queried regarding R#28 sitting on top of a folded sheet in their wheelchair, the DON indicated that is not an intervention she would expect to see. A review of R#28's medical record and Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on [DATE] with medical [DIAGNOSES REDACTED]. Further review revealed the resident was severely cognitively impaired and required extensive assistance from staff for bed mobility, transfers, dressing, toilet use, and hygiene, and required supervision of one staff for locomotion on the unit. Resident #446 On 3/15/21 at 9:35 AM, R#446 was observed sitting on the edge of their bed. The resident's bare feet were halfway sitting in slippers with the heel backs pushed down on them. The resident's blanket was partially lying on the floor, right next to the resident's feet. R#446's rolling walker was observed on the other side of the room, out of reach. The resident had no pants on and was mumbling to themselves. R#446 was observed with disheveled hair and healing bruises on their face (on cheeks, forehead, around eyes) with a large, protruding hematoma on their forehead. R#446 was asked if they fell and responded, Again, and again, and again. When asked what happened when they fell , R#446 stated, They said they were going to put something on there, and the brother goes to go to um . R#446 was asked if someone had hurt them intentionally and stated, No, I told you that three times already! They get fixed up and you're helping the helper you. R#446 continued to speak in incomplete, incoherent sentences. On 3/15/21 at 9:52 AM, Confidential Witness K was interviewed via phone. Confidential Witness K was queried regarding R#446's recent health status and stated, My biggest concern is that (R#446) has fallen and been to the hospital three or four times in the last 6 weeks. On 3/16/21 at 11:27 AM, R#446 was observed to be sleeping on their left side almost completely sideways (perpendicular) in bed. R#446's feet were hanging off the edge of the bed. The resident's bed was not in a low position. R#446's walker remained on the other side of the room, out of reach. R#446's call light was observed to be closed into the bottom drawer of the resident's bedside dresser, also out of reach. Three un-identified female staff members were observed sitting behind the nurses' station desk talking amongst themselves. On 3/16/21 at 1:02 PM, the door to R#446's room was shut. Upon knocking and entering, R#446 appeared to be in the same position in bed as they were at 11:27 AM, with their feet hanging off the edge, bed not in low position, call light closed in drawer, and walker across the room out of reach. On 3/16/21 at 1:47 PM, the door to R#446's room remained shut. Upon knocking and entering, R#446 appeared to be in the same position in bed as they were at 11:27 AM and 1:02 PM, with their feet hanging off the edge, bed not in low position, call light closed in drawer, and walker across the room out of reach. A lunch tray was now sitting untouched on the resident's bedside table next to their bed. On 3/16/21 at 2:53 PM, the door to R#446's room remained shut. Upon knocking and entering, R#446 remained lying on their left side in bed. Their bare left foot was observed hanging farther off the edge of the bed, and no sock was observed on their right foot. The resident's call light remained closed in the drawer, out of reach. The resident's lunch tray was no longer on their bedside table. The resident's walker remained in the same position across the room, out of reach. Four un-identified staff members were observed standing/sitting at the nurses' station desk talking amongst themselves at this time. On 3/17/21 at 9:32 AM, R#446 was observed lying in bed with the head of the bed elevated. R#446 was asked how they were doing and replied, Just sitting here hurting. Because all this stuff is bashed into my head, and proceeded to touch their forehead with their hand. R#446's walker remained on the other side of the room, out of reach, and their call light was observed to be on the floor on the right side of their bed, also out of reach. When queried further about their falls, R#446 stated that the fall was, Like somebody kicked me. When R#446 was asked if they tripped, they replied, Yeah. It hurts so bad. I don't have any shoes. It still hurts. Somebody tripped on me on the back. I know when I got knocked on the floor I had somebody taking care of me. On 3/17/21 at 9:40 AM, Certified Nursing Assistant (CNA) I entered R#446's room and was queried regarding R#446's status as a fall risk. CNA I indicated that R#446 is a fall risk and stated, (The resident) has been falling lately. When queried regarding fall interventions, CNA I stated, Try to check on (R#446), (R#446) likes to feed (their) teddy bears, walks around puts them on another bed. If (R#446) has to use the bathroom, but is having a bad day, (they will) use it on (themselves). Most of the time (they do) do (things) for (themselves). CNA I continued and stated, (R#446) does seem different, (with a) decline since being back (from the hospital). When queried regarding the resident's call light being on the floor, CNA I indicated it should be within reach of the resident and proceeded to put it back near R#446. On 3/18/21 at 9:38 AM, R#446 was observed to be lying on their left side with their legs hanging off the left side of the bed, toward the window. R#446's walker remained across the room, out of reach. R#446's door to their room was open, with four staff members observed walking past the room without looking at the resident. On 3/18/21 at 9:42 AM, the Therapy Director was asked to enter R#446's room and was queried regarding the resident's fall risk status. The Therapy Director stated, (They are) a high fall risk, as he helped the resident sit up in bed, Very confused. Totally independent before. This episode, no (no longer independent). Not able to do much. (R#446 is) getting therapy now. The Therapy Director was asked to observe R#446's call light closed in their bottom dresser drawer and out of the resident's reach. The Therapy Director stated, That should not be in the drawer. A review of R#446's care plan revealed the following: (R#446) is High risk for falls r/t (related to) impaired cognition, unsteady at times, recent fall. Actual fall 5-5-20 minor injury, 6-13-20 no apparent injury, 1-9-21 minor injury, 1-25-21 no apparent injury, 2-14-21 fall with injury, hematoma, Date Initiated: 05/06/2020, Revision on: 02/14/2021. (R#446) will have reduced risk of fall related injury through the review date. Date Initiated: 05/06/2020 Revision on: 05/06/2020 Target Date: 06/13/2021. Be sure call light is within reach and provide prompt response to all requests for assistance. Date Initiated: 05/06/2020 Revision on: 06/23/2020. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. 3/5/21 Date Initiated: 03/05/2021 Revision on: 03/05/2021. Encourage to attend activities, diversional activities 3-4-21 Date Initiated: 03/04/2021. Ensure (R#446) is wearing appropriate footwear for safety. 1-9-2021, 1-24-21, 2-14-21 Date Initiated: 01/09/2021 Revision on: 02/14/2021. Frequent checks for safety, Medication review CT scan done 2-14-21 Date Initiated: 02/14/2021. Pt (physical therapy) evaluate for strength and safety. 2-14-21 Date Initiated: 05/06/2020 Revision on: 02/14/2021. Remind to use walker when ambulating 7-18-21, 2-14-21. Date Initiated: 07/18/2020 Revision on: 02/14/2021. Sent to ER for evaluation R/T frequent falls 3-6-21. Date Initiated: 03/06/2021. No additional care plan interventions or updates were noted in R#446's record since the resident's readmission into the facility on [DATE]. A review of R#446's most recent fall risk assessment dated [DATE] indicated that the resident is at High Risk for falling (Score of 19). A review of R#446's fall incidents revealed that the resident had recently fallen on 1/9/21 at 11:00 AM, 1/25/21 at 7:10 AM, 2/14/21 at 10:40 AM, and 3/6/21 at 5:31 AM. The falls on 1/9/21, 2/14/21, and 3/6/21 all resulted in injury and transfer to an acute care hospital. A review of R#446's acute care hospital records from the fall on 3/6/21 revealed that the resident was admitted to the hospital on [DATE] until 3/12/21 with admission [DIAGNOSES REDACTED]. The hospital documentation included a CT scan of the residents head dated 3/6/21 that included: Large frontal scalp hematoma, significantly larger than on recent prior study . Further review of the incident/accident reports corresponding with R#446's falls revealed the following: Fall, Date: 1/9/2021 11:00 (AM), Incident Location: Resident's Room .Nursing Description: Writer called to resident room, resident observed lying on the floor next to (their) bed with blood on (their) face and on floor next to (them), writer and other nurse assessed and resident glasses broke off into resident face right above left eye, large open area noted and large amount of blood, area secured with towel to control bleeding and to keep resident from injuring more, 911 called and resident assisted into wheelchair, MD (doctor) and (family member) notified, awaiting 911 to arrive .Resident Description: Resident lying on floor next to bed, unable to tell staff what (they were) doing prior to fall .Resident taken to hospital? (Yes) .Injury Type: Head Injury .Injury Location: Face .Mobility: Ambulatory with assistance .Mental Status: Oriented to Person .Predisposing Environmental Factors: (blank) .Predisposing Physiological Factors: History of recent fall .Predisposing Situation Factors: Bare feet or inappropriate footwear, Ambulating without Assist, Not Using Walker .Witnesses: No witnesses found. Fall, Date: 1/25/2021 07:10 (AM), Incident Location: Resident's Room .Nursing Description: Resident was observed sitting on the floor next to (their) bed. When asked what (they were) doing that caused .(the fall) the resident stated (their) children were sitting in (their) bed and they pushed (them) off the bed. The resident has no c/o (complaints of) pain. The resident stated (they were) not hurting. Physician called, no answer. Will inform oncoming nurse to follow up and notify family. Resident Description: Resident stated (their) children were in the bed with (them) and they pushed (them) off the bed .Mobility: Ambulatory with assistance .Mental Status: Oriented to Person, Alert, disoriented, but can follow, Not alert, Confused/Disoriented .Predisposing Environmental Factors: Other .Predisposing Physiological Factors: Confused, Impaired Memory, Specific co-morbidities: Dementia, Alzheimer's, Hallucinations .Predisposing Situation Factors: Ambulating with Assist, Rising from sitting to standing, Using Wheeled Walker, Bed in Lowest Position .Witnesses: No witnesses found .Agencies/People Notified: No notifications found. Fall, Date: 2/14/2021 10:40 (AM), Incident Location: Resident's Room .Nursing Description: Observed resident sitting on (their) buttocks by (their) bed on the floor 1040. Left hand planted on the floor at and was complaining of left hip and leg pain. Lower extremities were at an angle. Observed hematoma on forehead, large, purple, blue and red in color. Writer assessed resident, all extremities are within ROM (range of motion) and assisted into bed. Notified Doctor .new order was to be sent out for CT scan .Resident Description: Resident appears to be confused more than normal state. Patient speaking in third party and making accusations and hallucinations of a person being in the room to make (them) fall .Notified all parties and new order was to be sent to hospital for CT scan and X-Ray .Resident taken to hospital? (Yes) .Injury Type: Hematoma .Injury Location: Left Forehead .Mobility: Ambulates with assistive device .Mental Status: Oriented to Person, A&O (alert and oriented) with confusion. Never complained of pain .Predisposing Environmental Factors: None of the above .Predisposing Physiological Factors: Confused, Gait Imbalance, Hallucinations, Gait, balance, visual impairment .Predisposing Situation Factors: None of the Above .Witnesses: No witnesses found. Fall, Date: 3/6/2021 05:31 (AM), Incident Location: Resident's Room .Nursing Description: Resident observed laying on floor next to (their) bed .Resident Description: Resident unable to tell what happened/confused .Resident assisted by writer and another staff to bed .Resident taken to hospital? (Yes) .Injury Type: Abrasion; Unable to Determine .Injury Location: Right forehead; Top of Scalp .Mobility: Ambulates with assistive device .Mental Status: Alert, oriented, follows, Oriented to person .Predisposing Environmental Factors: Clothing, Foot Wear .Predisposing Physiological Factors: Confused, Gait Imbalance .Predisposing Situation Factors: Improper Footwear .Witnesses: No witnesses found. On 3/18/21 at 12:40 PM, the Director of Nursing (DON) was interviewed and queried regarding any root cause analysis information that could be reviewed for R#446's falls. The DON indicated that information was on different forms that would need to be obtained from a different staff member. That information was requested from the DON at this time, however, it was not provided for review prior to survey exit. The DON was asked about expectations for implementing fall interventions on the care plan. The DON indicated her expectation is that staff carries out interventions per the care plan. When queried further regarding the observations of R#446 in their room, the DON stated, So, (R#446's) shoes, we purchased new shoes because (their) shoes were not appropriate. We prefer (R#446) to use the non-skid socks but (they do) have a preference with what (they) want to wear. When queried if the resident's footwear preference was care planned, the DON stated, Just on the care plan as non-skid footwear. When queried regarding R#446's call light observed in their drawer on multiple occasions, the DON stated, We position (their) call light but (R#446) will move their animals and things in (their) room and (will put the) walker somewhere else. When queried if this information was found in R#446's care plan, the DON stated, It's care planned that (R#446) has impulsive behaviors. When queried regarding fall interventions put into place since R#446's most recent hospitalization , and what fall interventions have been put into place based on the root causes of their recent falls, the DON stated, The resident has had several falls. We send (them) to the hospital and they send (R#446) right back. No conclusions. They run labs. Magnesium was low. They did a medical workup on (R#446). Nothing is giving us the reason as to why (R#446) keeps falling. (They) have dementia and it's getting worse. We consulted psych (services). When queried regarding the most recent fall intervention in place for R#446, the DON stated, At the time of the fall (on 3/6/21) we sent (R#446) out to the hospital related to frequent falls. We still are trying to figure out why (R#446) keeps falling. When asked how often staff is expected to be checking on R#446, the DON indicated that the resident's room is positioned near the nurses' station and stated, Nurses are every other hour and CNAs are every hour. A review of R#446's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was originally admitted into the facility on [DATE]. R#446's medical [DIAGNOSES REDACTED]. This MDS assessment indicated the resident was severely cognitively impaired and was mostly independent or required supervision from one staff for transfers, bed mobility, ambulation/locomotion, dressing, eating, and toilet use. A review of R#446's discharge-return anticipated MDS assessment dated [DATE] indicated the resident was severely cognitively impaired and was no longer independent in any activities of daily living. Resident #18 On 3/15/21 at 7:21 AM, during an initial tour of the facility, R18 was observed sitting in their room with a gauze bandage on the left side of their forehead. R18 was queried on if they had a recent fall at the facility and stated, Evidently. R18 was unable to provide any further information regarding their fall. On 3/16/21 at 9:00 AM, an observation was made of R18 in their room. R18 continued to have a gauze bandage on the left side of their forehead and they were observed to have a black left eye. R18 was further queried on falls at the facility and were unable to respond to any questions. On 3/16/21 at 9:15 AM, a review of R18's electronic health record (EHR) revealed that R18 had fallen at the facility on, 8/30/20, 10/14/20, 11/26/20, 1/9/21, 1/17/21, and 3/13/21. On 3/16/21 at 9:18 AM, a review of R18's progress notes involving the falls revealed the following information, 11/26/2020 14:57 (2:57 PM) Nursing Note Text: At 1130 pt (patient) was observed on knees and right palm of hand near nightstand in pts room. Pt was able to explain that they were attempting to get something out of their nightstand unassisted and slipped on their urine due to them knocking over their urinal earlier cause (because) they set it on the floor instead of hanging it where they usually do and slipped onto their knees. Writer asked pt if they hit their head at all pt pointed to the back of their head stating they hit the back of their head. No signs of head injury were noted. Writer assessed pts ability to move extremities and pt was able to be assisted off the floor and on their bed. Pts Vitals BP 121/77 HR 63 R 16 T 98.0. Pt is at their baseline level of A&O 2-3. Pupils were round and reactive to light. MD (Medical Doctor), Hospice and pts son were contacted and made aware. No new orders were given from either hospice or MD. Education of call light use and the importance of asking for assistance when ambulating were provided to pt. Also pt was educated on where to place urinal once done utilizing it. 12/21/2020 17:41 (5:41 PM) Nursing Note Text: observed resident on the floor in the residents room positioned on his buttocks. resident stated they hit their head. resident sustained [REDACTED]. area cleansed and covered with gauze. MD notified of injury, new order; X-ray to skull. noted and carried out. continue to monitor. 1/17/2021 03:07 (3:07 AM) Incident Note Text: Resident was observed on the floor beside bed, which was at the lowest setting. Resident stated, That they were trying to get up and slipped from the bed onto the floor. Writer exchanged regular socks for non-slip socks. Resident stated that they did not hit their head. Resident has a skin tear on left elbow. Accompanying nurse cleansed tear and put dry dressings. Will call emergency contact, MD and hospice nurse. 3/13/2021 02:57 (2:57 AM) Incident Note Text: Resident found on the floor bleeding calling for help. Blood noted bleeding from their left forehead and left elbow. Pressure applied to both head and elbow till EMS arrived. R (Resident) sent to ER for further treatment . On 3/17/21 at 9:45 AM, R18's fall care plan was reviewed and revealed the following, Focus: Fall Risk .risk for falls based on use of medication that can increase drowsiness, new environment, decreased mobility. Date Initiated: 09/26/2019 Revision on: 10/19/2020. Goal: .will be free of injury from falls through the review date. Date Initiated: 10/09/19 Revision on: 10/09/19 Target Date: 06/10/2021. Interventions: Anticipate and meet .needs. Date Initiated: 10/09/2019 Revision on: 10/09/2019. Be sure .call light is within reach and encourage .to use it for assistance .Provide a prompt response to all requests for assistance. Date Initiated: 10/09/2019 Revision on: 7/08/2020. Check urinal and empty as needed. Date Initiated: 11/26/20 Revision on: 02/16/2021. Encourage .to participate in activities that promote exercise, physical activity for strengthening and improved mobility .Date Initiated: 10/09/2019 Revision on: 10/09/2019. Ensure is wearing appropriate footwear such as non skid socks .Date Initiated: 10/09/2019 Revision: 12/10/2019. Frequent checks for proper positioning. Date Initiated: 01/17/2021. Sent out to hospital for evaluation. Date Initiated: 03/13/2021. On 3/17/21 at 11:09 AM, the Director of Nursing (DON) and Unit Nurse Manager (UNM) C were interviewed and R18's falls/interventions at the facility were reviewed with them. UNM C indicated that she handled all falls and interventions at the facility. Both the DON and UNM C agreed that the intervention for R18's fall on 3/18/21 of sending the resident to the hospital, was not an appropriate intervention. Review of fall on 1/17/21 revealed that R18 was not wearing non skid socks. UNM C stated, The resident should be wearing non skid socks all of the time. Review of fall on 12/21/20 revealed no incident/accident report (I/A) completed and no intervention noted on care plan. The DON and UNM C acknowledged that an I/A report should have been completed and an intervention should have been added to the resident's care plan. The DON stated, That nurse no longer works here. UNM C stated, A lot of my interventions have been removed from the care plan. I'm sorry. On 3/17/21 at 12:54 PM, an observation was made of R18 seated on the edge of their bed with their eyes closed. The floor in their room was observed to be wet. On 3/18/21 at 12:48 PM, An observation was made of R18 ambulating out of their room into the hallway with their oxygen tubing dangling behind them. R18 was observed to be unsteady during ambulation. On 3/18/21 at 1:14 PM, a review of R18's EHR revealed an original admission to the facility on [DATE] with [DIAGNOSES REDACTED]. R18's most recent minimum data set assessment ((MDS) dated [DATE], indicated that R18 had an intact cognition and required extensive assistance of one to two people for all activities of daily living (ADLs) other than eating. A review of the facility's policy/procedure titled, Falls Management System, revealed, It is the policy of this center to provide each resident with appropriate evaluation and interventions to prevent falls and to minimize complications if a fall occurs. Additionally, all resident falls in this center are analyzed and trended through the Performance Review process to maintain a safe environment .A Falls Risk Evaluation score of 10 or above represents a high risk for falls and will require the development of a care plan implementing interventions designed to present falls .When a resident sustains a fall, an evaluation may include investigation to determine probable causal factors considering environmental factors, resident medical condition, resident behavioral manifestations, and medical or assistive devices that may be implicated in the fall. The investigation and appropriate interventions will be evaluated at the time of the fall and reviewed by Nursing Management or the IDT. Interventions secondary to the investigation will be documented in the Care Plan, as indicated .Other follow-up to a resident fall will be conducted depending on the nature of any injury sustained and in keeping with accepted standards of practice .Residents with a Falls Risk Evaluation score of 10 or above will have an individualized care plan developed that includes measurable objectives and time frames. The care plan interventions will be developed to prevent falls and will consider the particular elements of the evaluation that put the resident at risk. The care plan for a resident evaluated as at risk for falls will be developed at the time the risk is identified with ongoing evaluation and revisions documented .Residents who sustain a fall will have a care plan developed or the existing care plan updated to include the fall and measurable objectives and time frames. The care plan interventions will address those elements determined by investigation as probable causal factors that contributed to the fall. The updated plan will be reviewed and revised as indicated by the Falls Management Action Team at the meeting. Documentation of implementation will be in accordance with accepted standards of clinical record keeping as outlines in Federal and State regulations and industry standards of practice.

This citation pertains in part to intake MI 285. Based on observation, interview, and record review, the facility failed to consistently implement, initiate treatment timely, and document implementation of preventative and current pressure ulcer interventions and/or update the resident's care plan to reflect current skin status and treatment, for three sampled residents (R#15, R#20, and R#96) of four reviewed for pressure ulcers, resulting in the re-opening and development of a Stage III (full thickness skin loss) pressure ulcer, development of a new wound to the buttocks, pain, and/or the potential for further skin breakdown. Findings include: R#15 On 3/15/21 at 7:15 AM, R#15 was observed awake in bed. R#15 appeared thin. When interviewed about care, R#15 mentioned that their foot was sore and pointed to their feet. Each foot had a soft boot on them. A dressing was observed underneath the boot, wrapping around their entire left foot. On 3/16/21 at 11:51 AM, R#15 was observed sitting up in their wheelchair in their room. The resident did not have any protective boots present on their feet. Soft heel boots were noted to be on the floor in the corner of the room. On 3/17/21 at 12:39 PM, R#15 was interviewed while sitting up in their wheelchair. A review of R#15's medical record at this time revealed that the resident weighed 99.1 pounds as of 2/25/21. R#15 had soft boots on their feet, and a second pair of soft boots (for while in bed) was noted in the room. R#15 indicated they are supposed to wear boots while in bed, too. On 3/17/21 at 3:40 PM, R#15 was observed sleeping in bed. The resident's feet were observed without foam boots. Both pairs of foam boots were observed sitting on the seat of R#15's wheelchair. On 3/18/21 at 8:42 AM, R#15 was observed sleeping in bed. The resident's feet were observed without foam boots. Both pairs of boots were observed sitting on the seat of R#15's wheelchair. Certified Nursing Assistant (CNA) L entered the room and was queried regarding if R#15 was supposed to have foam boots on while in bed. CNA L asked R#15 if they were supposed to have boots on in bed to which the resident replied, Yeah. CNA L stated, They've (staff) been taking them off while (R#15) is in bed but I think these are the ones that are supposed to be on. CNA L proceeded to put R#15's protective boots on. A review of R#15's care plan revealed: The resident has potential/actual impairment to skin integrity r/t (related to) (blank). Date Initiated: 12/10/2020. The resident will be free from injury through the review date. Date Initiated: 12/11/2020 Target Date: 04/07/2021. Encourage good nutrition and hydration in order to promote healthier skin. Date Initiated: 12/10/2020. Keep skin clean and dry. Use lotion on dry skin. Do not apply to open areas. Date Initiated: 12/10/2020. Treatment as ordered by MD (doctor). Date Initiated: 12/10/2020. R#15's care plan did not include any current alterations in skin status nor mention of the placement of foam boots while in bed/wheelchair. A review of R#15's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on [DATE] and discharged to an acute care hospital on [DATE]. R#15's MDS assessment dated [DATE] revealed that the resident was readmitted into the facility on [DATE] with medical [DIAGNOSES REDACTED]. Further review revealed the resident was severely cognitively impaired and required extensive assistance from staff for bed mobility, transfers, dressing, toilet use, and hygiene. A review of R#15's skin/wound progress notes revealed: -12/20/20: Residents skin assessed upon admission. Resident present c (with) fragile skin upon admission. (1) Rt (right) top of big toe pressure ulcer (2) Lt (left) top of big toe pressure ulcer (3) Lt heel pressure ulcer (4) redness to bottom without any open areas .Resident requires extra pillows and heel protectors when possible to promote wound healing and assist with further wound prevention . -12/18/2020: Resident seen by facilities wound consultant. (1) Lt heel cicatrix (scar tissue) (2) Rt hallux tip 100% eschar 0.5 x 0.6 Dry c no drainage (3) Lt hallux tip 0.4 x 0.5 Dry c no drainage Tx (treatment) orders updated and added to POC (plan of care). Resident requires extra pillows and heel protectors when possible to promote wound healing and assist with further wound prevention . -12/24/2020: Resident seen by facilities wound consultant. (1) Lt heel cicatrix is Resolved (2) Rt hallux tip 100% eschar 0.7 x 0.9 Dry c no drainage (3) Lt hallux tip is Resolved New Tx orders updated and added to POC. Resident requires extra pillows and heel protectors when possible to promote wound healing and assist with further wound prevention . -2/18/2021: Writer alerted that resident has wound on Lt heel. Writer called facility wound consultant to obtain order for treatment. TX: Cleanse with NS (normal saline), apply dermalginate and wrap with [MEDICATION NAME]. POC (plan of care) updated. Author: (Wound Care Nurse (WCN)). -2/24/2021: Resident seen by facility wound consultant. (1) Lt. heel, stage 3, 1.0 x 2.2 x 0.3, wound bed is pink with moderate s/s (serosanguineous)drainage. Surrounding skin intact. TX: Cleanse with NS, apply dermaginate, cover with ABD, wrap with [MEDICATION NAME]. POC updated. Will continue to monitor. Author: (WCN). -2/25/2021 sent to hospital, readmitted [DATE]. -3/8/2021: Resident readmitted to facility from hospital. Writer did skin inspection to find, Lt heel open, and bruising on both arms. Scarring from old wound on buttock. Resident open heel Cleansed with NS, dermaginate and ABD applied, wrapped with [MEDICATION NAME]. No further skin issues seen. Author: (WCN). -3/11/2021: Resident seen by facility wound consultant. Resident has stage 3 pressure ulcer on the left heel. Left heel, stage 3, 1.4 x 2.7 x 0.3, wound bed is pink with minimal serous drainage, surrounding skin intact. TX: Cleanse with NS, apply dermaginate, cover with ABD, wrap with [MEDICATION NAME]. Treatment in progress, no change to orders, POC (plan of care) in place. Author: (WCN). -3/16/2021: Writer went in to see resident and perform wound care. Writer noticed that resident has redness on side of foot. Writer applied ABD to cushion side of foot and relieve pressure. Writer finished dressing and reapplied cushion boots. Resident had no complaint of pain or discomfort. Author: (WCN). On 3/18/21 at 9:11 AM, the WCN was interviewed regarding R#15's current wound. When queried regarding provision of foam boots while up in the wheelchair or in bed, the WCN stated, (R#15) will kick them off but we try to keep them on for both. For the most part (R#15 does) okay. A wound care observation by the WCN was then observed. When asked if their heel could be observed, R#15 stated, Yes, it's very sore. Tender. When asked which foot, the resident replied, The left foot. The heel. The WCN stated, Yes, (R#15's heel) is very sore. R#15 stated, Very tender. R#15's left heel wound was then observed. The WCN confirmed the following observation: a Stage III irregular/oval-shaped wound on the left heel, approximately the size of a quarter, with granulation tissue present. R#15 groaned audibly and was observed with facial grimacing while the wound was treated and a new dressing was applied. The WCN indicated she was placing a protective foam dressing to the side of the resident's left foot and stated, Obviously, (R#15) is tiny, we are trying not to do more damage than what's already there. R#15 was asked if staff put their protective boots on them while in bed last night to which the resident replied, No. The WCN was asked if the resident was currently getting a nutritional supplement for wound healing to which she replied, I believe so. The WCN was then interviewed and queried regarding the timeline of R#15's wounds. The WCN indicated R#15 came into the facility in December 2020 with wounds on their feet, but that the left heel wound had healed. When queried regarding preventative measures put into place after the left heel wound had healed, the WCN stated, (R#15) was seen by wound care for quite some time, and was seeing wound care when I took over (the position). I think we were giving extra nutrition. I know (R#15) had boots in place before they went out to the hospital but I don't know what the orders were. When queried where pressure ulcer interventions are documented, the WCN stated, I put those on my TAR (treatment administration record). When asked if there was a current order for foam boot placement to be documented on R#15's TAR, the WCN reviewed the record and stated, Looks like (R#15) doesn't have an order for [REDACTED].#15's care plan with a new skin alteration, the WCN stated, Management usually does care plans. I would expect the care plan to be updated with skin status. The WCN reviewed R#15's care plan related to skin and stated, That looks like a completely non-existent care plan. The WCN was queried regarding R#15's current left heel wound and stated, (R#15) developed the Stage III here. Someone came and told me about it a few weeks ago. They took (R#15's) sock off and reported it. The WCN indicated she felt the re-development of R#15's left heel wound could have possibly been prevented if there would have been care plan interventions and/or orders in place in R#15's record prior to the development of the wound. On 3/18/21 at 12:49 PM, the Director of Nursing (DON) was interviewed and queried regarding R#15's Stage III pressure ulcer on the left heel. The DON explained that the resident was initially admitted with a pressure ulcer on that heel, then it healed in the facility, and the resident went to the hospital and returned to the facility with the re-opened wound. When queried regarding the resident's progress note dated 2/18 that indicated the skin impairment developed before going to the hospital on 2/25, the DON confirmed that the re-opened area was facility-acquired and stated, But it's the same area (R#15) came here with, there is going to be sensitive scar tissue, it re-opened. The DON was asked if she would expect preventative interventions to be put into place in the record after a wound had healed to which she responded, Yes. When asked where those preventative interventions would be found, the DON stated, In the care plan. When asked where R#15's preventative skin interventions could be found in the care plan, the DON stated, Preventative skin care with incontinence, we put them on ProStat (supplement). Treatment and plan by MD (Medical Doctor) for the skin. We do have a wound book with the interventions. We have a weekly pressure ulcer log that has those interventions. When asked if the interventions on the wound log should be in the care plan where they can be accessed, viewed, and carried out by all staff, the DON stated, Yes. Resident #20 On 3/15/21 at 10:21 AM, during the initial tour R20 stated, My bottom is hurting. R20 was asked, how long has their bottom been hurting and stated, On and off for about one day. R20 was observed in a large bed, regular mattress, and without assist bars. A review of R20's medical record revealed, 3/3/21 Weekly Skin Review Skin intact. Dry. Resident has [MEDICAL CONDITION] of BLE (bilateral lower extremities) treatment in place. Other: L (left) Buttocks pressure ulcer. Wound NP (nurse practitioner) rounding to place treatment. Authored by Unit Manager M. On 3/16/21 at 3:45 PM, a request was made to observe R20's skin. At that time the WCN stated, R20 does not have any wounds. WCN was explained that R20 reported pain on their bottom. On 3/17/21 at 9:40 AM, the WCN stated, Yesterday after we talked about (R20), I went to look at (R20). (R20) does have an open area and one abrasion. The WCN continued and explained, that at one point it was reported that R20 had an open area, I rounded with the wound NP and we didn't see anything. The WCN was asked if she documented that they did rounds after the report was made of an open area and that they did not see anything. The WCN stated, No. I didn't, that's my mistake. On 3/17/21 at 9:48 AM, R20 was observed partially on their right side facing the door. R20 stated, I just moved like this myself, because my butt hurts. It hurts. It's from laying on my back for most of the night. R20 was observed trying to roll more to the right side. R20 was grabbing at the mattress to try and pull to their right side. A review of R20's medical record revealed, R20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R20's MDS assessment noted R20 to have an intact cognition and assessed as independent with one staff with bed mobility. A review of R20's medical record noted, Care plan. Focus: SKIN INTEGRITY RISK (R20) is at risk for impairment to skin integrity and pressure injury development r/t (related to) Muscle wasting and atrophy, poor mobility, abnormal posture, muscle weakness, Diabetes type II. (R20) is incontinent of bladder, refuses incontinence care at times. Date Initiated: 08/30/2016. Revision on: 09/23/2020. Goal: My skin will be intact skin without signs of breakdown to the extent practicable through next review. Date Initiated: 08/30/2016. Revision on: 12/05/2018. Intervention: Observe for & (and) encourage turning and repositioning q2hr (every two hours) and as needed. Reposition in chair frequently for comfort and pressure reduction. Provide incontinence care after each incontinent episode, or per established toileting plan. Barrier cream to bilateral buttocks and groin as ordered. Date Initiated: 08/30/2016. Revision on: 02/15/2021. On 3/17/21 at 11:03 AM, Unit Manager Nurse M was interviewed about R20's shower sheets and stated, Here is one, but I can't tell you from when. The sheet was observed with the resident's name, room, an image of the front and back of a body, Nurse name, and no date. There were no comments or concern areas marked on the sheet. The Unit Manager Nurse M provided a pile of shower sheets for the unit. There were two other shower sheets found for R20 in the pile, one sheet was undated and documented as a refused shower. The other sheet was completed fully, dated 2/23/21 and had no wounds or skin concerns documented. On 3/17/21 at 12:25 PM, Unit Manager Nurse M was asked about the skin assessment that she completed on 3/3/21 that noted pressure and redness on R20's bottom. Unit Manager Nurse M stated, (R20) had like redness and scuffing I reported it to (WCN). On 3/17/21 at 3:40 PM, R20 was observed laying on their right side facing the door. On 3/18/21 at 9:03 AM, during a wound care observation for R20 with the WCN she stated, We have been putting this on (R20's) bottom (barrier cream) ever since you guys told us it was hurting. R20 was observed with a pencil sized open area on the right buttock, pinpoint on the left, the top layer of the skin was visibly removed with fragile pink tissue present. The WCN explained that she thinks the treatment may change when the NP comes in later today. No measurements were done during this observation. During the observation, the WCN was asked, if R20 would benefit from having assist bars or had been assessed for assist bars and explained she was unsure if R20 was assessed but thought R20 would benefit. During the time R20 stated, I am use to having bars to grab on to. On 3/18/21 at 1:09 PM, the DON, was asked about R20's skin and stated, The Wound NP is here, and I will have them come in. I will check the wound care notes in the book. The DON was asked how often the facility expects for a resident with skin concerns to be repositioned. The DON stated, Every two hours. On 3/18/21 at 2:35 PM, the Wound NP was asked about documentation after the report of a pressure ulcer on 3/3/21. The Wound NP stated, (R20) didn't have anything so we didn't chart on (R20). Resident #96 A record review of the Minimum Data Set assessment dated [DATE] revealed that Resident #96 had an intact cognition and needed extensive assistance with toileting, transfers and bed mobility. Resident #96 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A review of the progress notes for Resident #96 revealed the following: 1/19/2021 14:50 (2:50 PM) Skin/Wound Note .Patient seen for skin verification. Patient has open sacral wound, and surgical wound on rt. (right) heel. This nurse will refer to facility wound consultant, to be evaluated 1/21/2021. There were no other wound notes in the medical record. A record review of the measurements provided by the Wound Nurse for Resident #96 reflected the following: 1/21/2021: 3.1 x 2.0 x 0.9 centimeters (there were no other measurements provided). A record review of the Treatment Administration Record (TAR) for January 2021 for Resident #96 revealed the following: Coccyx stage IV, Cleanse with NS (Normal Saline), apply [MEDICATION NAME], cover with foam dressing every day shift every 2 day(s) for coccyx wound until 02/18/2021. The treatment was not signed out as being completed on 1/26/2021 or 1/28/2021. The wound treatment was not initiated until 1/21/2021. A record review of orders revealed the following for Resident #96: Cleanse with NS, apply foam dressing. Coccyx stage IV Cleanse with NS, apply [MEDICATION NAME], cover with foam dressing. Initiated 1/21/2021. A record review of the care plan for Resident #96 revealed the following: Focus-The resident has .pressure ulcer or potential for pressure ulcer development .Date Initiated: 01/18/2021 Goal-The resident's Pressure ulcer will show signs of healing and remain free from infection. Interventions- .Administer treatments as ordered and observe for effectiveness. On 3/18/21 at 2:10 PM, the Wound Nurse was interviewed in regards to the measurements dated for 1/21/2021 with no treatment initiated until 1/21/2021, when Resident #96 was admitted to the facility on [DATE]. The Wound Nurse stated, I do not measure them until she is here (pointing to coworker). They (new residents) come in, I do an initial skin assessment. If I see something on the bottom, I automatically put [MEDICATION NAME] on. The Wound Nurse did not have any explanation for not initiating a treatment upon admission. A review of the facility's policy/procedure titled, Skin and Wound Management System, revised April 2017, revealed, .Preventative intervention will be implemented for residents identified at risk as appropriate, for example beds, wheelchair cushions, nutrition, incontinence, therapy, etc. These interventions are documented in the medical record based on overall score .Residents identified with skin impairments will have appropriate interventions implemented to promote healing. Wound location, characteristics and a physician's orders [REDACTED].An Interdisciplinary Care Plan will be developed, and will identify the contributing risks for breakdown, or the actual skin impairment and the interventions implemented and updated as needed .The Interdisciplinary Care Plan should address, (as appropriate), hydration, nutrition, preventative devices, treatments/topical agents, physical activity, as well as positioning requirements, redistribution and proper body alignment.

This citation pertains to Intake: 7 Based on interview and record review, the facility failed to properly maintain infection control practices during a COVID-19 Infection Control Survey affecting two residents (R901 and R902) of three sampled residents not being consistently assessed and monitored for COVID-19 symptoms and a change in condition, resulting in both residents being hospitalized . Findings include: R901 On [DATE] at 3:16 PM, an interview was completed with Family Member A, who stated that their family member had been hospitalized in the ICU and placed on a ventilator after contracting COVID-19 in the facility. They further expressed concerns that their family member had been suffering for several days with signs and symptoms of [MEDICAL CONDITION], and nothing had been done about it. A review of R901's medical record revealed that they were admitted into the facility on [DATE] and had a readmission date of [DATE]. Admitting [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated for [DATE] revealed that R901 had a moderately impaired cognition, and required extensive assistance for Activities of Daily Living. Further review of R901's medical record revealed the following progress notes: [DATE] 16:55 (4:55 PM). Nursing Note: Resident presents with low grade temperature. No C/O (complaint of) SOB (shortness of breath). Semi-alert. Ate very little today, C/O thirst. Water given by writer x3 (3 times). All medication taken. Resting at present temperature 99.1. [DATE] 17:35 (5:35 PM). Nursing Note: Resident resting in bed, alert and able to make needs known. Resident with low grade temp of 99.5, no cough noted,denies any pain, PRN (as needed) Tylenol given, will cont (continue) to monitor. [DATE] 16:15 (4:15 PM). Nursing Note: Dr (doctor) in to see resident, new orders for cbc, bmp, and hgA1c (blood work). Enter into (Lab) website and requisitioned and order printed. [DATE] 17:04 (5:04 PM). Physician Note: patient not feeling good at no specific complaints. No cough, No sore throat, No fever, and chills, no difficulty in breathing Continue the current medication. I did order the basic metabolic panel, CBC, Hemoglobin, A1c. Patient will be monitored for cough, temperature, and oxygenation. [DATE] 06:37 (6:37 AM). Nursing Note: Resident has been lethargic. Vitals WNL (within normal limits) - BP (Blood Pressure) ,[DATE], P92 (Pulse), 02 96% (Oxygen). Temp was 99.3 at 0330 (3:30 AM). Gave 2 Tylenol rechecked temp at 0400 (4:00 AM) 97.7. [DATE] 08:00 (8:00 AM) Nursing Note: Resident sent out 911 for mental status change and r/o (Rule out) corvin 19 (COVID 19) physician, (family members) notified . Let it be noted that there were no progress notes between [DATE] and [DATE] which addressed R901's temperatures and/or signs and symptoms of COVID-19. A review of R901's hospital records revealed the following, Details of Hospital Stay: Presenting Problems/History of Present Illness: Stupor, [MEDICAL CONDITION] (low oxygen levels), Non-ST elevated [MEDICAL CONDITION] infarction (a type of [MEDICAL CONDITION]), Coronavirus Infection. (R901) with positive past history [MEDICAL CONDITION](stroke) with left-sided residual deficits, dementia, hypertension, presenting to (local hospital) due to progressively worsening altered mental status. Patient is from a nursing home. Patient was intubated and sedated due to hypoxic [MEDICAL CONDITION] secondary to COVID 19 in the ICU and extubated on ,[DATE] to 2 L (liters) nasal cannula. On [DATE] at 10:49 AM, an interview was completed with Nurse B. They were asked to explain R901's physical and mental health status at the time of their transfer to the hospital. Nurse B stated, Everything about R901 was different, they were not their usual self. R901 wasn't talking clearly, had a temperature, and looked pale. I hate to say it but R901 looked like they were on death's door. Nurse B further explained that R901 had a temperature and hadn't been out of the bed in a couple of days which is not like them. Nurse B also explained that R901's lungs weren't clear and were congested. A review of R901's Medication Administration Record [REDACTED]. -D/C (discharge) Date: [DATE] 2122 (9:22 PM). Further review revealed that R901 had a temperature of 99.0 or higher on ,[DATE], ,[DATE], ,[DATE], ,[DATE] and ,[DATE]. Morning vitals on the date of [DATE] were not completed. On [DATE] at 9:54 AM, the labs that were ordered by the physician on [DATE] were requested from the facility. On [DATE] at 10:44 AM, an email was received from the facility indicating the request for labs that were ordered for R901 on [DATE], At the time this lab was ordered, our lab (Lab name and contact information), stated that they were short staffed due to covid 19 and that some labs would have to (be) rescheduled. The lab was ordered but was not taken on regular lab day which was on Monday [DATE]th. Physician gave orders to send (R901) out on [DATE]. On [DATE] at 1:05 PM, interviews were completed with the Administrator, DON and Infection Control Preventionist (ICP). They were asked if COVID testing is completed in the facility. They explained that they have not had the capability to test the residents in the facility, and that they have to be sent to the hospital for tests. They were asked how residents are being monitored for signs and symptoms of COVID-19. The DON explained that starting on [DATE]th, vital signs are taken on each shift and that they are assessing for cough, respiratory, o2 stats and temperature. They were asked if there were any other assessments completed, and the ICP indicated that they follow CDC guidelines and are currently integrating the other symptoms of COVID-19 such as loss of taste and gastrointestinal issues. The DON was asked what signs and symptoms they are expecting for nursing staff to observe when determining when a COVID-19 test should be completed, and they explained that they should be completing thorough assessments and notifying the physician of temperatures of 99.0 or higher. The physician will then have to give the order to have the resident sent out. The DON was further asked about R901, specifically the lack of documentation for monitoring symptoms of R901 between [DATE] and [DATE] especially to the point that R901 was placed in ICU and intubated. The DON explained that R901 did have COVID-19 but that they also had a stroke which is why they were placed in the ICU. It was further explained that R901 was still getting out of bed, had no cough and no fever. The ICP stated that R901 had a Rapid onset. The DON was asked why R901 wasn't sent to the hospital to have their labs drawn, and explained that at [MEDICAL CONDITION]'s peak, if they would have called EMS (Emergency Medical Services), they would have refused to take the resident because they were not showing signs and symptoms of COVID-19. 902 A review of R902's medical record revealed, R902 had a readmission date of [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated for [DATE] revealed, that R902 had a moderately impaired cognition, and required assistance for Activities of Daily Living. Further review of R902's medical record review revealed, the following progress notes and vitals: [DATE] 15:12 (3:12 PM) Nursing Note Text: pt (patient) not swallowing well is lethargic not eating well (Physician) ordered to hold (R902) [MEDICATION NAME] and Chorizmine ([MEDICATION NAME]). [DATE] NP (Nurse Practitioner) CC (chief complaint): follow up lethargy and cough. HISTORY OF PRESENT ILLNESS: Nursing staff has reported (R902) was lethargic and [MEDICATION NAME] and Chorizmine. Today (R902) is awake and able to follow simple commands. Lungs with scattered rhonchi, will continue nebulizers, currently satting at 98% on room air. Afebrile 97.8. No cough, no abdominal pain, no nausea . Vitals [DATE] at 01:30, (temperature) 97.7 , at 17:24 (5:24 PM) 100.5. [DATE] 17:23 (5:23 PM) eMar (electronic medication administration record) - Medication Administration Note Text: Tylenol Tablet 325 MG, Give 2 tablet by mouth every 6 hours as needed for pain. [DATE] 02:45 eMar - Medication Administration Note Text: Tylenol Tablet 325 MG Give 2 tablet by mouth every 6 hours as needed for pain PRN (as needed) Administration was: Effective. Follow-up Pain Scale was: 1. [DATE] 22:45 (10:45 PM) eMar - Medication Administration Note Text: Tylenol Tablet 325 MG Give 2 tablet by mouth every 6 hours as needed for pain. [DATE] 22:42 (10:42 PM) eMar - Medication Administration Note Text: Tylenol Tablet 325 MG Give 2 tablet by mouth every 6 hours as needed for pain PRN Administration was: Effective. Follow-up Pain Scale was: 0. [DATE] at 02:43 temperature 98.7, at 22:48 (10:48 PM) temperature 97.9. [DATE] 03:10 Nursing Note Text: Resident alert and verbally responsive Spo2 (Oxygen saturation) 88% room air at 0200, oxygen applied @ (at) 2L (Liters)/NC (nasal cannula) Spo2 now 94%. Bed in lowest position and call light within (R902) reach. Will continue to monitor. -Bc (because) the O2 (Oxygen) (R902) went up to 95%. [DATE] 02:45 eMar Medication Administration Text: Geri-[MEDICATION NAME] Syrup Give 1 dose by mouth every 6 hours as needed for Cough. [DATE] 03:10 Nursing Note Text: Resident alert and verbally responsive Spo2 88% room air at 0200, oxygen applied @ 2L/NC Spo2 now 94%. Bed in lowest position and call light within (R902) reach. Will continue to monitor. [DATE] 05:39 eMar Medication Administration Note Text: Geri-[MEDICATION NAME] Syrup Give 1 dose by mouth every 6 hours as needed for Cough PRN (as needed) Administration was: Effective. [DATE] 06:39 Nursing Note Text: Resident slept in intervals during the night shift. Alert but slow to respond. All scheduled meds (medication) received as ordered including 02 via face mask 02 sat 95% receiving ,[DATE] liters. No s/s (signs or symptoms) of respiratory distress. Hydration encouraged. Extensive assist provided with ADL (activities of daily living) care by staff. Safety measures in place to ensure no injuries occur. Call light and H20 (water) within reach. Denies any discomfort. Will inform oncoming nurse for follow up care. Vitals: [DATE] at 02:42 temperature 98.1, at 14:30 (2:30 PM) temperature 104.2. [DATE] 14:45 (2:45 PM) Nursing Note Text: At 820am resident with labored breathing and a temp of 104.2, (Physician Assistant notified order to send to ER (emergency room ) pt (family) notified at 8:40 pt (patient) transported to (local) hospital via 911 ambulance . [DATE] 14:27 (2:47 PM) eINTERACT SBAR (Situation, Background, Assessment, Recommendation) Summary for Providers Situation: The Change In Condition/s reported on this CIC (Change in condition) Evaluation are/were: Abnormal vital signs (low/high BP, heart rate, respiratory rate, weight change) Fever Functional decline (worsening function and/or mobility) Other change in condition Tired, Weak, Confused, or Drowsy At the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP ,[DATE] - [DATE] 14:29 (2:29 PM) Position: Lying l/arm - Pulse: P 104 - [DATE] 14:29 (2:29 PM) Pulse Type: Regular - RR: R 16.0 - [DATE] 12:02 - Temp: T 104.2 - [DATE] 14:30 (2:30 PM) Route: Tympanic - Weight: W 203.5 lb - [DATE] 09:31 Scale: Wheelchair - Pulse Oximetry: O2 91 % - [DATE] 14:31 (2:31 PM) Method: Oxygen via Nasal Cannula - Blood Glucose: BS 132.0 - [DATE] 07:58 . Resident/Patient had the following medications changes in the past week: placed on 02 . Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: - Mental Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) Increased confusion(e.g. disorientation) Other - Functional Status Evaluation: Needs more assistance with ADLs Decreased mobility - Behavioral Status Evaluation: Other behavioral symptoms - Respiratory Status Evaluation: Labored or rapid breathing Inability to eat or sleep due to SOB (shortness of breathe) Cough Abnormal lung sounds(rales, rhonchi, wheezing) Other respiratory changes - Cardiovascular Status Evaluation: Resting pulse greater than 100 or less than 50 Nursing observations, evaluation, and recommendations are:may have aspirated food not able to swallow well Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: send to ER . A review of the facility's line listing for COVID-19 noted, R902, Lowest Temp: 91, Highest Temp: 104.2, Shortness of Breath: Labored Resp. (Respiratory), Date tested : [DATE], Results: Positive, Other notes: Acute [MEDICAL CONDITIONS], Resident return date: Expired [DATE]. On [DATE] at 1:03 PM, during a interview via phone, the Director of Nursing (DON) was asked about R902's change in condition on [DATE], the DON stated, [DATE] was the first day of symptoms. (R902) was having problems swallowing, we reached out to speech and talked to the family. The DON was asked, what happened after the NP saw (R902) on [DATE], the DON stated, We assumed that it was (R902's) [MEDICAL CONDITION]'s disease. (R902) was the first person to test positive. We got labs on [DATE]. The DON was asked if COVID-19 was considered with R902's symptoms. The DON stated, (R902) didn't have symptoms of COVID at that time. The DON was asked about the NP's note dated [DATE], for the change in condition for R902 on [DATE], that noted R902 being seen regarding the complaint of a cough. The DON stated, When (R902) was trying to eat (they) would cough, (R902) could not swallow. The DON was asked for documentation regarding R902's cough and the reason. The DON stated, We gave two doses of cough medication on ,[DATE]. I don't have a note on why (R902) was coughing. The DON was asked at anytime was R902 put into isolation away from R902's roommate or the general population. The DON stated, No. We did not think (R902) had COVID. (R902) was not considered positive, (R902) was positive at the hospital. The DON was asked about R902's temperatures greater than 100 and if there was a follow up temperature after the Tylenol was given. The DON stated, We chart by exception. We kept monitoring (R902) and stayed in contact of NP, nothing was out of range. The facility's Change in a Resident's Condition or Status policy was reviewed and outlined the following, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): a. accident or incident involving the resident; b. discovery of injuries of an unknown source; c. adverse reaction to medication; d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; f. refusal of treatment or medications two (2) or more consecutive times); g. need to transfer .

This citation pertains to intake MI 627. Based on observation, interview, and record review, the facility failed to ensure one ( # 902) cognitively impaired resident of five sampled residents reviewed for abuse was free from physical and verbal abuse, resulting in an agency nursing assistant swearing while forcefully holding the resident's arms to their neck, preventing the resident from speaking and the resident's face becoming red. The resident was intentionally held down and sworn at by staff, and the agency nursing assistant continued to work at the facility, resulting in an Immediate Jeopardy (IJ) and the likelihood for serious physical and/or psychosocial harm, injury, impairment, or death. The Immediate Jeopardy (IJ) started on 10/26/19 and was identified on 11/13/19. The Administrator was notified of the Immediate Jeopardy on 11/13/19 at 3:12 PM and was asked for a plan to remove the immediacy. The IJ was removed on 11/13/19, based on the facility's implementation of the removal plan as verified onsite on 11/13/19. Although the immediacy was removed, the facility's deficient practice was not corrected and remained isolated with actual harm that is not immediate jeopardy. Findings Include: Review of the Minimum Data Set assessment dated [DATE] revealed that R#902 was admitted into the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was severely cognitively impaired and required assistance from staff for dressing, toilet use, and hygiene. A review of R#902's electronic medical record (EHR) progress notes revealed the following: Late Entry 10/26/2019 at 06:45 (AM), Type: Nursing Note, Note Text: Upon entering residents room, 3 nursing Assistants were in the process of attempting to clean resident, one young lady had her hand on (R#902's) right hand to (R#902's) chest, the other 2 were trying to clean genital area. Once the writer came fully in, there was an attempt to turn resident to (their) left side, that's when I observed a skin tear to the left hand. When ask how it happen, the CENA (Nursing Assistant) who was holding (the resident's) hand said she was trying to keep the resident from swinging, and hitting. Author: (Nurse F) - Licensed Practical Nurse (LPN). On 11/13/19 at 12:20 PM, Certified Nursing Assistant (CNA) G was interviewed via phone regarding caring for R#902 on 10/26/19. CNA G stated: It was on midnight shift, and I had an orientee. (R#902) sometimes fights and can be aggressive and combative. There was another girl on midnights working through agency. Me and the orientee were trying to get (R#902) cleaned up. Before she came in the room, (CNA H) offered to help us but she said she was, 'Going to beat (R#902's) a-word if (they) tried to hit her.' Then she came in and she basically was aggressive with (R#902) trying to get (them) into bed. Then (the resident) was sitting down and she told (the resident) to shut up and she was going to beat (their) a**. (The resident) got a new skin tear on (their) hand and I think it came from her. She was really rough and aggressive with (R#902). They say there wasn't enough evidence of her choking (R#902) but from what the orientee and I saw, she was choking (R#902). So then we told the nurse (Nurse F) and she reported it to the administrator (NHA). CNA G was asked if she had ever worked with CNA H and stated, Yes, once before but had no problems. CNA G was then asked to elaborate on what happened with R#902 and stated, (R#902) was up walking around. (They) were soiled and needed to be cleaned but wouldn't let us. We tried to change (them) standing up, but we had to sit (them) on the bed and lay (them) down. (CNA H) had the resident's hands pinned up to their neck like choking them. It was me, (CNAH), and the orientee (NA I) in the room and the door was closed. I went and got the nurse to help us. (CNA H's) aggression had changed when the nurse walked in. I don't believe the nurse saw anything. It happened when we were in there and the door was shut - that was about 10 minutes. (CNA H) held (R#902's) arms the whole time, had (their) hands pinned up toward (their) neck telling (them) to shut up. She was being aggressive and it made me uncomfortable. When asked what R#902 was doing while this was occurring, CNA G stated, There wasn't much for (them) to do, they were trying to kick and fight back. (R#902) does that usually, when anyone comes to try to touch them that's what they do. So, we need at least three people to try and help clean them up. CNA G then stated, I told the nurse, told the administrator and the police all of this. I thought this situation was over because they let the girl come back and she's been working. I talked to the nurse (Nurse F) about it and she said there wasn't enough evidence that the resident was choked. On 11/13/19 at 12:31 PM, Agency Certified Nursing Assistant (CNA) H was interviewed via phone regarding caring for R#902 on 10/26/19. When queried what happened, CNA H stated, I didn't have (R#902) that night, I had other people. I happened to be walking past the room. (CNA G) who had the resident had an orientee. They couldn't get (R#902) under control. (The resident) had urine and feces all stuck to them. I guess they were told to change the resident and get it off. She (CNA G) and her (the orientee) couldn't get it off and asked for my help. (R#902) was swinging, irritated, and didn't want to do it, but I guess they'd been soiled too long. We will usually leave (R#902) alone when they fight but it was time to get it off. So I held (R#902) by both wrists and put their wrists down by their shoulders so they couldn't hit us while we were changing them. I guess that wasn't working too well, so we went and grabbed the nurse. (CNA G) came back and the nurse began to help us out and help clean (the resident) off. Their genitals were red and I think irritated. When queried if anyone said anything to R#902, CNA H stated, I'm closer with my job to hold (them) and to keep (them) from scratching and hitting. (R#902) is pretty strong. (The resident) was moving around a lot, I guess they were irritated being in pain and wanting to be combative. CNA H was asked again if anyone said anything to R#902 and stated, I was closer to them, no, I guess no one said anything to them. I was saying, 'S***! Uh, damn!' Trying to keep (R#902) from hitting me but cursing at my resident? No. I was in the room with a nurse and two other CNAs, if they felt uncomfortable with what I was doing I would think they would've made a comment towards me. CNA H was asked if they said anything threatening to R#902 or tell them they needed to shut up. CNA H stated, No. When queried further regarding their cursing in front of the resident, CNA H stated, The only cursing that came out of my mouth was, 'Oh damn! Oh s***! (R#902) is trying to get us to stop! Oh s***, wait (R#902), stop!' And I'm holding them at the wrists while I'm saying this. I know (R#902) doesn't know what they're doing. When queried if they had received any training for how to handle residents during care, CNA H stated, The administrator had me sign a paper that night, I can't remember what it said but it was something about resident care and how you are supposed to handle it. CNA H was then asked if they had worked at the facility since the incident with R#902 on 10/26/19 and stated, Yes, it took about a week before they got clearance. I didn't go back until about 5 or 6 days later. This happened on a Saturday and I went back I think that following Thursday. They called and told me I was cleared. The police were called, they talked with me separately, then talked with me with the administrator. They said they didn't see any signs of abuse. The facility provided staffing sheets which were reviewed and revealed that CNA H worked on 10/31/19, 11/2/19, 11/3/19, 11/8/19, 11/10/19, and 11/11/19. On 11/13/19 at 12:51 PM. Nurse Assistant (NA) I was interviewed via phone regarding caring for R#902 on 10/26/19. NA I stated, It was my first day working night shift and I was with another younger CNA (CNA G). The lady who was older than us who had been working there (CNA H), was using too much force to where (R#902's) face was turning red and everything. (R#902's) skin tore and was bleeding on (their) hand. I know it was on the top of (their) hand. NA I was asked to describe the incident from the beginning and stated, I was going to give care with (CNA G). The other (CNA H), came in and said, 'If I come in here there ain't gonna be no talking.' As we were giving care, (R#902) tried to kick at us. (CNA H) came in and was holding (R#902) down and holding them improperly. Her hands were on (R#902's) arms. There is a right way you are supposed to hold but she had them cross-hatched. But one of (R#902's) arms was like, choking (them). It looked like (R#902) was trying to talk but couldn't talk and that's what caused (their) face to turn red, the way (CNA H) had (their) arm over (their) neck. When asked what CNA H said while in the room with R#902, NA I stated, She told (R#902) to, 'Shut the f*** up before I beat your a**.' NA I was then asked what she and/or CNA G did when this happened. NA I stated, I was like, oh my gosh, like in shock. Once the nurse came in there, (CNA H's) whole demeanor changed and she wasn't like that anymore. She wasn't trying to be aggressive or nothing anymore. But when (CNA H) left out, (CNA G) told me we needed to tell the nurse what happened. And (R#902's) hand was bleeding so I think she would have a lot of questions about that, too. So the nurse called the administrator and the police. We felt that what happened was abusive so that's why we told the nurse what happened right away. On 11/13/19 at 2:51 PM, R#902 was observed up walking in the hallway. A CNA (CNA J) was observed to say something to the resident and motioned for them to walk with her. Nurse A was queried regarding R#902 and stated, (They) will hit sometimes and won't let us change them, they can be very difficult to change. It can depend on who's working. They often sleep all day and are up all night. (CNA J) is really good with them, they take well to her. (R#902) also seems to take better to males. We do have one male CNA on night shift. They also feed the resident a lot of finger foods on midnights, that seems to help. On 11/13/19 at 2:55 PM, CNA J was observed holding a clean brief, and to calmly direct R#902 into their room. CNA J stated, (R#902), come with me, I'm going to help you with something. R#902 followed CNA J into their room without any resistance. CNA J was observed to exit the resident's room with a dirty linen bag shortly after. On 11/13/19 at 3:00 PM, CNA J was interviewed and queried regarding providing care to R#902. CNA J stated, Well, it can be considered abuse if we DON'T care for the resident, but staff needs to be careful to not cross that line over to abuse when the resident needs to be changed. I lucked out with (R#902) today and I had a good day with them, they let me change them. I just approach them calmly and had no problems today. [NAME]orrow might be a different story. They were well rested so that helped. It's just best to have a calm approach with (R#902). And when they are in one of those moods when they don't want nothing done, you have to come back in a short while and try another approach. On 11/13/19 at 3:29 PM, Nurse F was interviewed via phone regarding caring for R#902 on 10/26/19. Nurse F stated, All I can tell you is what was told to me. I was told after we were done cleaning up (R#902), by (CNA G and NA I) that the third CNA (H) had choked the resident. All I saw was (CNA H) holding the resident's hand to their chest. So, I can just basically go by what the other CNAs said. When asked if the resident said anything to her, Nurse F stated, No, they ramble and can't hold a conversation. I told them I would get them a bag of chips if they let us finish cleaning them up. They never pointed or gestured at any of the aides. When asked if the resident sustained [REDACTED]. I can't say she (CNA H) did it because I wasn't in there. Maybe it was from (R#902) swinging their arms. It was my first or second day on the job so I wasn't all that familiar with the resident. The two aides told me the one CNA (H) was choking the resident and aggressive with them. The one CNA said that (CNA H) said something to the effect of, 'I don't wanna get hit, girl come on f*** this s***, kick their a**,' but that isn't verbatim. It was something like that. I went by what they told me and called the administrator. I didn't talk to (CNA H) about it. I didn't see the aggressiveness from the CNA myself. I didn't hear anything from where I was at before I got in there. Nurse F was asked if the door was shut prior to her entering R#902's room. Nurse F said, Yes, it was shut. But I didn't hear any yelling. One of the CNAs came out and said they needed another pair of hands. That's when I went in and told the resident I would get them some chips if they let the girls finish cleaning them up. They just laid there. So I don't know if mentioning chips calmed them down? I can't give you their history. When asked if the resident was trying to kick or punch when they walked into the room, Nurse F stated, No. They were tightening their legs together like they didn't want to be cleaned. I told the girls you can't try to pry their legs open. (CNA H) had her hand on the resident's right hand and looked like they were trying to prevent the resident from hitting or scratching. A review of R#902's Wound Evaluation Flow Sheet dated 10/26/19 at 16:11 (4:11 PM) revealed that the resident had a skin tear on the back of the left hand. On 11/13/19 at 4:30 PM, the Director of Nursing (DON) was interviewed and queried regarding the incident involving CNA H and R#902 on 10/26/19. The DON stated, The administrator (NHA) notified me because she is the abuse coordinator, so she is better to speak with regarding the situation. The DON was then queried regarding the facility's policy/procedure related to abuse, and handing residents during care. The DON stated, We are to report and investigate any allegations or suspicion of abuse immediately. Everyone is inserviced on abuse and resident rights upon hiring and annually. This is mandatory. The expectation when handling residents is that no one has been trained to hold any resident's hands down during care. They are told if they need additional assistance to request it, and they are not told to use any type of aggressive force. On 11/13/19 at 4:35 PM, the Nursing Home Administrator (NHA) was interviewed regarding the incident involving R#902 and CNA H on 10/26/19. The NHA stated, I got a phone call and came straight in here. I had a hard time understanding what they were explaining that took place. The police waited for me to get here. I told the CNAs to show me what happened. So, I came in and they said that the way they felt it happened, was that she (CNA H) held (R#902's) hands like this (the NHA crossed her hands over her upper chest). There were no markings. They had turned the resident while in bed so maybe that is why their face had appeared red. I talked to the police, and we looked at (R#902). There was no redness or markings. (Nurse F) was in the room and she said nothing happened. The NHA was then asked if Nurse F had mentioned that there was a time before she entered when the three aides were in R#902's room with the door closed. The NHA stated, I was not aware there was a time when the aides were in the room with the door shut without the nurse in there. The NHA was then queried regarding abuse training for staff. The NHA stated, We do training annually, for new hires, and anytime we have an allegation. It is mandatory training. When queried regarding the expectation for staff handling a combative resident, the NHA responded, We want staff to look at the care plan and look at the task list. I expect staff to follow the care plan for the resident's care. It depends on the resident. If they are upset, you might want to walk away and try again. Then come back and see if you can get them in the shower if you're having a hard time cleaning them up in bed or see again if they will let you do so in their room. We are going to have (psychiatry group) come in and train staff on how to handle residents with behaviors during care. (CNA H) stated she was afraid she was going to get hit. I would not expect staff to continue with care though. Any resident that is having difficulty I would walk away from. When queried regarding swearing in front of or at residents, the NHA stated, That is not the expectation. The two aides (CNA G and NA I) did state that there were cuss words said during the incident. (CNA H) told me she did not swear. (Nurse F) stated she did not hear any swearing. A review of R#902's care plan revealed the following: ADLs (activities of daily living), Self care deficit for ADLs: Bathing, dressing, hygiene, toilet use, transfers, mobility R/T (related to) difficulties making self under stood and follow directions r/t cognitive impairment. Date Initiated: 04/13/2018 Revision on: 07/11/2018. Observe for pain or discomfort .Est. (establish) routine as able. Approach in calm manner, reapproach at later time if agitated or anxious. Adjust approach to mood/behavior and signs of pain. Date Initiated: 04/25/2018 Revision on: 09/03/2019. (R#902) exhibits Alt. (alterations) in mood/behaviors aeb (as exhibited by) periods of (increased) phy (physical) restlessness, wandering, angery (sic), (occasional) tearfulness, voiced delusional thoughts r/t bar fights, resistive to care, showers, taking rxs (medications), txs (treatment), etc. At times not easily redirected. Confounded by severely impaired cogn. (cognition) A&Ox1 (alert and oriented times one), easily distracted, verbalizes inapprop. (inappropriately) to subject matter & diff. (difficulty) following direction. Further confounded by Long hx (history) of ETOH Dep. (alcohol dependence)/Abuse w/ Dxs (with diagnosis) of Dementia & hx of violence & agitation .Date Initiated: 04/25/2018 Revision on: 10/02/2019. During periods of increased agitation, 1st ensure safety then allow a cool off period and reapproach after a short period of time with calm friendly manner. Date Initiated: 04/30/2018 Revision on: 09/03/2019. During periods of increased phy restlessness offer diversional acts including 1x1 (one on one) conversation, snacks approp. (appropriate) to diet, redirect to scheduled group act including exercise, reduce environmental stressors of (increased) noise levels, crowding etc .Date Initiated: 04/27/2018 Revision on: 09/30/2019. Communication/Cognitive Impairment. (R#902) has dx dementia, [MEDICAL CONDITION] .answers simple questions mostly nonsensically .does not follow directions at times and is not easily redirected .Not able to make needs known. Date Initiated: 04/20/2018 Revision on: 01/19/2019. Communication: Use (R#902's) name, identify yourself at each interaction. Face .when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. (R#902) understands consistent, simple, directive sentences. Provide (R#902) with necessary cues- stop and return if agitated. Date Initiated: 04/20/2018 Revision on: 09/03/2019. When resident displays aggression during care, back off and re approach at a later time with assistance. 10-28-19. Date Initiated: 10/28/2019. A review of the facility's investigation report for the incident involving R#902, CNA G, CNA H, NA I, and Nurse F revealed the following: Resident Summary: .On 10/26/19 at approximately 240 am administrator received a call from the facility stating that there is an allegation of abuse with a resident who was combative kicking at direct care staff and allegedly a CNA was startled and grabbed resident's wrists . Statement taken from (CNA H) by (NHA): Did you assist with giving care to (R#902)? 'Yes.' What happened while you were giving care to (R#902)? '(R#902) had dried feces and urinated on .clothes .(groin) is red .(R#902) started hitting, swinging, and scratching while we were already doing peri care. I grabbed (their) wrist so we could finish cleaning (R#902) we put (them) to bed to finishing .giving care .and I was ensuring that (they) didn't hit us, so I put (R#902's) arms toward (their) chest and shoulders to stop .from hitting us. The nurse and two other CNA's were assisting .while I was assisting.' At any time did you curse at (R#902)? 'No.' Did you physically abuse (R#902)? 'No.' Statement taken from (NA I) by (NHA): Did you assist with giving care to (R#902)? 'Yes.' What happened while you were giving care to (R#902)? 'We were trying to take (R#902's) pants off and (they) started kicking and that's when (CNA H) came in the room to help us. (CNA H) put her gloves on to assist us and she grabbed (the resident's) arms and pushed them towards (the resident's) chest and neck and (the resident) started turning red. I was standing behind another CNA when this occurred. I noticed a skin tear to left hand .The CNA said shut the 'F' up or I will beat your a**.' Statement taken from (CNA G) by (NHA): Did you assist with giving care to (R#902)? 'Yes.' What happened while you were giving care to (R#902)? 'Nurse asked us to change (R#902) and at first (they) didn't allow it and I gave (them) some crackers, then (R#902) followed me to (their) room. Me and orientee we needed help so (CNA H) came in to assist and she .started cursing and grabbed (the resident's) arms because (they) were swinging and kicking. By the was (sic) (CNA H) had (R#902's) hands she placed them by (the resident's) neck chocking (sic) (them). If (the resident) hits or kicks you, you should beat (their) a**. I went to get a nurse to assist us and (CNA H) behavior changed. (R#902) also has a skin tear on .left hand.' Conclusion: After investigation was performed, Facility unable to substantiate abuse/neglect occurred during resident receiving care . A review of the facility's policy titled, Abuse and Neglect - Clinical Protocol, revised (MONTH) (YEAR), revealed, .The physician and staff will help identify risk factors for abuse within the facility; for example, significant numbers of residents/patients with unmanaged problematic behavior .issues related to staff knowledge and skill; or performance that might affect resident care .Along with staff and management, the physician will help identify situations that might constitute or could be construed as neglect; for example .inappropriate management of problematic behavior . A review of the facility's policy titled, Quality of Life - Dignity, revised (MONTH) 2009, revealed, 1. Residents shall be treated with dignity and r respect at all times .7. Staff shall speak respectfully to residents at all times .8. Staff shall keep the resident informed and oriented to their environment. Procedures shall be explained before they are performed .11. Demeaning practices and standards of care that compromise dignity are prohibited. A review of the facility's policy titled, Activities of Daily Living (ADLs) , Supporting, revised (MONTH) (YEAR), revealed, 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care .4. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. Facility Abatement Plan: Element 1 Resident #902 remains at the facility with no changes in his psychosocial needs, no appetite changes, no changes in his ADL status, I & A completed on 10/26/2019. Skin assessment completed on 10/26/2019, with documentation of pre-existing skin tear. In-service on Abuse started immediately with the night shift on 10/26/2019 by the administrator and continued through the remaining shifts by the in-service director. 10/26/2019 DPOA, physician and police were notified. Police report number (redacted). Administrator called the nursing agency on 11/13/2019 .and spoke with Supervisor at 402pm, to inform them that (CNA H) is no longer allowed to work at (facility). Element 2 On 11/13/19 Cognitively intact residents were in-serviced on types of abuse with definitions. Residents were questioned on abuse and neglect to ensure that they understand the importance of reporting to staff immediately. DON conducted random interviews of 10 alert and oriented residents regarding abuse and neglect and no issues or concerns were identified on 11/13/19. On 11/13/19 DON reviewed 10 cognitively impaired resident records for changes in behavior and skin assessments with no abnormalities found. DON/designee will continue to monitor the cognitively impaired residents for any changes in a resident's behaviors and weekly skin assessments will be completed to look for any bruises/markings etc. of unknown origin that may be indicative of abuse. Element 3 The Abuse and Neglect policy has been reviewed and deemed appropriate on 10/28/19 and again on 11/13/2019. On 10/26/2019 the night shift nursing staff were educated on abuse and neglect regarding types of abuse, definitions, assessment, recognition, cause, identification, treatment/management, monitoring and follow-up. That education continued into the day and evening shifts to in-service Housekeeping, Laundry, Dietary, Therapy, Activities, maintenance, office staff, IDT and nursing staff. On 11/13/2019 employees (Housekeeping, Laundry, Dietary, Therapy, Activities, maintenance, office staff, IDT and nursing staff) have been re-educated on the abuse and neglect policy regarding types of abuse, definitions, assessment, recognition, cause, identification, treatment/management, monitoring and follow-up and reporting any findings to the abuse coordinator immediately. Any staff member who has not been in-serviced due to medical, vacation or off ill and FMLA will be educated on abuse and neglect prior to working their next scheduled shift. Agency staff has been in-serviced on abuse and Neglect regarding types of abuse, definitions, assessment, recognition, cause, identification, treatment/management, monitoring and follow-up, and reporting any findings to the abuse coordinator immediately. Staff will continue to be educated annually and upon hire. (Administration, Business Office, Nursing, Dietary, Housekeeping, Maintenance, Social Service, Activities, Laundry). Element 4 The Administrator/designee will conduct random interviews and observations of 5 cognitively intact residents per week for identified concerns of abuse and 5 cognitively impaired residents for changes in behavior and/or injuries of unknown origin for 4 weeks and then monthly thereafter to ensure that this deficient practice does not re-occur. Any concerns will be addressed immediately. The administrator/designee will present the findings to our monthly QAPI committee meetings for review and recommendations and will be discontinued when substantial compliance is achieved and approved by the QAPI committee meeting. Element 5 The Administrator will be responsible to ensure that compliance is achieved and maintained.

This citation has 2 deficient practice statements. Deficient Practice Statement #1 This citation pertains to Intake: 1 Based on observation, interview, and record review, the facility failed to provide adequate monitoring and supervision to prevent an elopement from the facility for one ( R 900) of five sampled resident who has a [DIAGNOSES REDACTED]. The facility was unaware that the resident had exited the facility until a concerned citizen called the facility to make them aware. The resident was found with a night gown on, and according to the website weather. com, the temperature low was 46 degrees. The Immediate Jeopardy (IJ) started on 10/24/19 and was identified on 11/12/19. The Administrator was notified of the Immediate Jeopardy on 11/12/19 and was asked for a plan to remove the immediacy. The IJ was removed on 11/13/19, based on the facility's implementation of the removal plan as verified onsite on 11/13/19. Although the immediacy was removed the facility's deficient practice was not corrected and remained isolated with the likelihood of actual harm that is not immediate jeopardy. Findings Include: Review of a Nursing note dated 10/24/2019 at 22:17 (10:17 PM) indicated, Resident stated that (R900) went out the front door because (R900) wanted to see their husband. Resident stated that (R900) cut the wires to shut off the alarm. Police aware, MD (Medical Doctor) notified, Family notified. Review of a Nursing note dated 10/25/2019 at 03:14 (3:14 AM) indicated: Resident skin assessed by this writer .resident is 1:1 at this time with q (every) 15 minutes checks in progress, resident in bed with call light in easy reach . Review of a Behavior note dated 11/11/2019 at 20:04 (8:04 PM): Found in room with (2 other residents) trying to cut (R900's) wander guard off of (R900's) ankle with toenail clippers. Writer educated the (residents) about the wander guard and the importance of the wander guard being in place. Writer left the room and returned and the (residents) actively trying to remove the wander guard .Writer then told (and) re-educated the (residents) regarding the wander guard and the importance of the device Writer personally saw (R900) to the room at which time (R900) stated, 'Good my scissors are here .' On 11/12/19 at 1:02 PM, R900 was interviewed and was asked about the incident that occurred when they left the building. R900 stated, I went outside to get some fresh air because they never let us go outside. R900 was asked,what time they left the facility and stated, It was during the day, but it was cold outside, I won't do that again. R900 was asked what door they left out of and stated, Out of the front door. R900 was asked if an alarm went off. R900 stated, Yes, but I kept going anyway. R900 was asked where they went, and stated, I made it to the golf course. According to the website weather. com, the temperature low on 10/24/19 was 46 degrees. An observation was made between the distance of the facility to the location of the golf course that R900 was located at. It was approximately 0.8 miles West of the facility, and across the street. The main street was observed as busy with traffic,with a railroad crossing approximately 0.2 miles West of the golf course. In addition, there were no sidewalks observed on the route between the facility and where R900 was located. Record review revealed that R900 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident required limited to extensive assistance for Activities of Daily Living, and required a wheelchair for mobility. A review of R900's care plan initiated on 9/24/18 and revised on 7/8/19 outlines the following: Focus: Cognition. Alt. (alterations) in Cognition aeb (as evidenced by) A&Ox2-3 (alert and oriented) with some noted forgetfulness and short term memory loss to new information, fluctuating mental alertness, easily side tracked r/t (related to) activities attended, money placement etc. Requiring reminders and direction Dx (diagnosis) Dementia. Interventions: Info (information). Approach: Res. (resident) has noted hx (history) of miss placing money- false allegations of people stealing money then locates it &/or forgetting (R900) when on an out trip requiring reminders and direction. Date Initiated: 09/24/2018 Revision on: 09/03/2010. Observe for potential causative factors behind fluctuating mental alertness including time of day, location, labs, meds etc. Doc (document) and report potential factors to Dr (doctor) and psych (psychiatric) services. Date Initiated: 09/24/2018 Revision on: 09/03/2019. R900 did not have a care plan in place pertaining to Leave of Absences (LOA) from the facility and/or elopement until 10/25/19 and 11/13/19. On 11/12/19 at 1:18 PM, Nurse A was interviewed regarding what occurred when R900 eloped from the facility. Nurse A stated, (R900) has gone on a LOA (leave of absence) before, and once (R900) was questioned about what occurred, (R900) reported that they thought they had signed themselves out. Nurse A was asked where R900 was located, and stated, Down the street at the golf course, that's far. Nurse A was asked what R900 had on once located and stated, (R900) had on a long sleeve shirt and pants, with a gown over it. Nurse A was asked if they heard a door alarm go off, and they stated, No. On 11/12/19 at 1:45 PM, the Administrator was interviewed and asked about R900 eloping from the facility and how long the resident was outside. The administrator stated, Approximately 20 minutes. The administrator further explained that Nurse B and their orientee located R900 down the street after a Good Samaritan called the facility. A review of R900's incident and accident report dated 10/24/19 outlined the following, Nursing Description: Writer was notified by staff nurse that a call was received that resident was seen out side. Resident was found by 2-staff nurses. Resident Description: Near railroad tracks down the street from the facility. Other info: Resident has h/o (history of) dementia, is not aware of concerns/issues or importance of safety measures. On 11/13/19 at 9:22 AM, Nurse C was interviewed about what occurred with R900's elopement from the facility. Nurse C stated, We got a call that a resident was outside, so we immediately went outside and we saw a bunch of cars at the golf course, so I drove my car down there. We asked (R900) why they left, and (R900) said they left out because they wanted to leave. (R900) said, 'I'm a master electrician and let myself out.' Nurse C was asked if they heard an alarm and stated, An alarm did not go off, I didn't hear an alarm. Nurse C was asked what R900 was wearing when they were located. Nurse C stated, (R900) had a gown on top of a long sleeve shirt. On 11/13/19 at 4:25 PM, the Director of Nursing (DON) was interviewed and asked if staff should have responded when the door alarm went off. The DON stated, Yes. The DON was asked what was put into place to prevent another elopement. The DON explained that they had in-service training's and explained that training's will also be completed at orientation, and annually. On 11/13/19 at 4:45 PM, the Administrator was interviewed and was asked about what occurred the night of the elopement. The Administrator stated, Nurse B contacted the DON, who came to the building, made sure all of the residents were accounted for, and immediate training occurred afterwards. On 11/13/19 at 4:55 PM, Nurse B was interviewed and was asked about the incident regarding R900 leaving the facility. Nurse B stated,We got a phone call from some good Samaritans that someone from the facility was down the road. My orientee and myself ran a head count and looked up the road and saw cars at the golf course. There were three cars, two guys and a woman. The orientee got her truck and we drove over there. (R900) was sitting in their wheelchair in the entrance of the golf course. One of the guys had put a blanket on (R900). I had the orientee flip around and put on her flashers while I pushed (R900) back towards the building. As we were walking, the cops pulled up behind us, and followed behind the orientee in her truck with their flashers on. The cops came into the building and got (R900's) facesheet and asked (R900) had they done this before. (R900) stated that they left because they wanted to go see their husband I called another head count to make sure everyone was in the facility, and (R900) was put on a 1:1 with an aide .We asked (R900) how they got out of the facility and stated, 'I disabled the wires, I'm a master electrician.' (R900) claimed they popped off the panels and got out. Nurse B was asked if they heard an alarm door going off, and stated, I did not hear an alarm going off. I was in and out of rooms doing med pass. A review of the facility's Elopement policy outlines the following, It is the policy of this facility to provide a safe and secure environment for our residents and to be proactive in preventing resident elopement .Elopement is defined as a resident leaving the premises of the facility without the knowledge of facility staff. The facility submitted the following plan to remove the immediacy: Element 1 Resident #900 was returned to the facility on [DATE] at 10:00 PM unharmed and remains at the facility with no adverse effects from incident. Full body assessment and a urinalysis was completed on 10/24/19. No injuries noted. Resident elopement assessment and care plan was reviewed and updated on 10/25/19 and reviewed again on 11/12/19. Resident was placed on Q 15 minutes rounds starting on 10/24/19 x 24 hours and ended 10/25/19. Resident has made no attempt to leave the facility. Element 2 A Head count was completed to ensure that all residents were accounted for a total of 86. All residents were reassessed for risk of elopement on 11/12/19. There are currently 10 residents at risk for elopement. Care plans were reviewed, and all 8 alarm doors were checked to ensure their functioning ability on 10/24/2019. All residents will continue to have a comprehensive assessment upon admission including elopement. updated as needed. Elopement binders were reviewed by Social Services on 10/25/19 to ensure residents at risk were identified. Binders are located at the 2 nursing stations, the social service office and the front receptionist desk. Element 3 Elopement Policy and Procedure has been reviewed by the IDT on 10/25/19 and deemed appropriate. On 10/24/2019 the Nurse Educator reeducated facility staff 10/24 & 10/25 on Elopement Policy, Responding to Door Alarms to ensure no resident has left the facility. The Administrator educated the staff on the location of the Alarm Box to ensure staff is aware which door is alarming. There are 2 boxes, 1 located at each nursing station with the locations of the doors right below the box. The alarm volume was increased 10/25/2019. Staff was reeducated again on 11/12/2019 on the Elopement policy. Fifteen staff that has not received the in-service have been removed from the schedule until education can be provided on their next scheduled shift. Staff will continue to be educated annually and upon hire. (Business Office, Nursing, Dietary, Housekeeping, Maintenance, Social Service, Activities, Laundry) Element 4 The Maintenance Director/designee will conduct random door alarm audits which will be entered into our TELS system for all three shifts for 4 weeks and then monthly thereafter to ensure that all staff remain in compliance with our door alarm policy and Procedure. The Maintenance Director will present these findings to the facility QAPI Committee for review monthly recommendation and will only be discontinued when substantial compliance is achieved and no further concerns have been identified and approved by the QAPI committee. Element 5 Date of Compliance 10/25/2019 The Administrator will be responsible to ensure that compliance is achieved and maintained. Deficient Practice Statement #2 This citation pertains to Intake: 1 Based on observation, interview, and record review, the facility failed to ensure safety measures were followed to prevent a fall from a bed for one ( R 901) of six sampled residents reviewed for accidents, resulting in R901 falling out of bed onto the floor with the potential for pain and discomfort. Findings include: On 11/7/19 at 1:52 PM, Confidential Witness K was interviewed by telephone and stated, R901 sustained a fall while at the facility due to the bed being broken. R901 is a paraplegic and is confused as to how and why they fell out of the bed. The facility did not call 911. Record review revealed that R901 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set assessment dated [DATE] revealed that the resident was cognitively intact and required extensive assistance to total dependence for Activities of Daily Living including bed mobility. Review of a Nursing Note, dated 10/23/2019 at 06:54 (6:54 AM) noted, Resident's roommate came out in hall and said that (R901) was on the floor and had fallen out of bed. Writer found resident on floor. Assessment showed no injuries and resident said (R901) had no injuries and that (R901) did not hit their head. Writer called RCS D (resident care specialist) and told her to get hoyer lift. Nurse came and the 3 of us used hoyer and got resident back in bed. Vitals were taken BP 146/75, P90, T 98.7, 02 sat 98%. Writer called (doctor) and resident's mother .Neuro checks started with no deficits. Will endorse ongoing Neuro checks to dayshift nurse. Review of Interdisciplinary Note dated , 10/23/2019 at 10:05 (10:05 AM) noted, IDT (Interdisciplinary Team) met to discuss incident. Resident rolled out of bed. Interventions put in place. Resident will have bed at lowest position and floor mat at bedside. On 11/12/19 at 10:19 AM, the resident's roommate, Resident [NAME] was interviewed and was asked about R901's fall. Resident [NAME] stated, The bed wasn't locked and (R901) was laying against the wall. The bed rolled away from the wall and (R901) fell . Resident [NAME] was asked if R901's bed was high or low when they fell . Resident [NAME] stated, High. fell a long way. Resident [NAME] was asked what happened after R901 fell , and stated, I got the nurse and (R901) went to the hospital a couple of days later. Resident [NAME] was asked if the bed still remaining in the room was the same bed their roommate fell out of, and stated, Yes. The bed was observed in the corner of the room unoccupied, pushed against the wall. Wheel locks were observed on the front wheel and the back steering wheel however, the bed was still easily moved. A review of the incident and accident report outlined the following,Nursing Description: Writer was on west hall getting medication pass started. (Resident E) came out of the room saying that roommate fell out of bed. Writer saw resident on floor. (R901) said they rolled out of bed. (R901) had no apparent injuries and did not hit their head .Resident Description: I fell out of bed. I was sleeping and fell out of bed. Other Info: RCS said she had just changed (R901) and left the room a few minutes before the fall. The bed was unlocked. A review of the Fall Root Cause Investigative Report dated 10/24/19 outlined the following, Recent Fall or Other Incident in past 24-48 hours: Specify: 10/23/19. Unusual Circumstances contributing to fall risks?: Unlocked Bed. Environmental Concerns: Position of Bed and other furniture (bedside stand/trash can). Summary: Resident was not injured. Bed was unlocked when resident moved (R901) fell out of bed. On 11/13/19 at 12:41 PM, an interview was completed with RCS D. RCS D was asked about R901's fall from their bed and stated, (R901) scared me because (R901) fell out of the bed. We came in and got a hoyer lift to get (R901) off the floor. (R901) likes to keep their bed high. The bed rolls a lot, It doesn't lock. The wheels don't lock. On 11/13/19 at 4:25 PM, the Director of Nursing (DON) was asked about R901's fall from the bed, specifically if the bed should have been locked with them in it. The DON stated, Yes. On 11/13/19 at 4:45 PM, the Administrator was asked about R901's fall from the bed, specifically if the bed should have been locked with them in. The DON stated, Yes. A review of the facility's Assessing Falls and Their Causes policy was reviewed and did not address fall precautions.

Based on interview and record review, the facility failed to properly position one resident (R61) while dressing, of four residents reviewed for accidents resulting in R61 sustaining an injury to the head and hospitalization . Findings include: A review of R61's medical record revealed that they sustained a head injury on 4/6/19 resulting in them being transported to an acute care hospital: 4/6/2019 07:45 (7:45 AM) Nursing Note: Resident alert and responsive at 0610 (6:10 AM) RCS (resident care specialist) reported to the writer that when (RCS F) was given (giving) morning care to the resident, (RCS F) stated that (RCS F) turned the resident on (R61's) side and (RCS F) noted that the resident was about to roll over to the floor and in the process of keeping (R61) from falling out of bed the resident head hit the bed rail. The resident had hematoma/bruise on (R61) left front forehead and neuro (neurological) check initiated. Supervisor on duty notified, MD (medical doctor) called still awaiting call back, DON (Director of Nursing) and guardian notified. Guardian ok to sent (send) resident to ER (emergency room ) for treatment, 911 called at 0625 (6:25am) they arrived at 0632 (6:32am) and transported resident to (local hospital) at 0634 (6:34am) . Further review of R61's medical record revealed that R61 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. R61 is severely cognitively impaired according to their Minimum Data Set (MDS) assessment dated [DATE]. The MDS also revealed that the resident is an extensive 2 person physical assist for bed mobility. Bed mobility is defined by the MDS as, How resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. On 6/5/19 at 9:49 AM, an interview was conducted with RCS F. RCS F was asked what occurred when R61's head was hit causing bruising to their forehead. RCS F stated, I was turning (R61) over, and (R61) was close to the side of the bed. I was dressing (R61) and it happened so fast. (R61) was laying on the left side of their body and I was putting on their top. RCS F was asked if they were positioned in front or behind the resident. RCS F stated, I was standing behind R61, and they started rolling over to the opposite side. I should have been on the other side of their body. RCS F was asked what R61 hit their head on. RCS F stated,On the steel side of the bed rail. (R61's) head was elevated. I didn't know the bruise was on (R61's) head until I rolled (R61) back over. RCS F was asked if they received any education following this incident. RCS F stated, I got a long inservice about it, from the unit manager. A review of RCS F's one on one inservice record revealed that their inservice was held on 4/9/19 on Proper turning and Repositioning while in bed. The inservice further revealed, Informed RCS to always turn resident towards (RCS F) body and to ask for assistance as needed with ADL (activities of daily living) care and repositioning while residents in bed. On 6/5/19 at 3:29 PM, an interview with completed with the DON. The DON was asked about R61 sustaining the bruise to their forehead. The DON stated, They are always told to turn a patient towards them when they are repositioning them. The DON was asked if residents are supposed to be dressed while laying down. The DON stated, Some of them will do it while they're laying down based on what their mobility is, and what's easier for them. Staff should be looking at the care plan. They are not to put their hands on a resident until they look at the kardex. A review of the facility's Routine Resident Care policy did not address correctly positioning during resident care or following the resident's care plan.

Based on observation, interview and record review, the facility failed to ensure the provision of care and treatment per professional standards of practice to prevent the development of facility acquired pressure ulcers (wound caused by pressure), prevent the worsening of pressure ulcers, promote wound healing, operationalize policies and procedures for concise wound documentation, and failed to ensure the application of infection control principles during wound care for two (#'s 9 and 58) of five Residents reviewed for pressure ulcers, from a total sample of 20, resulting in Resident # 9 developing a stage IV (full thickness loss of tissue with exposed bone, tendon or muscle) and a stage II (partial thickness loss of tissue) pressure ulcer, Resident #58 having multiple non-healing pressure ulcers, including one stage II, three stage III (full thickness tissue loss), and two stage IV pressure ulcers, inappropriate infection control during wound care, unnecessary pain, and the potential for delayed wound healing, infection, and overall deterioration in health status. Findings include: Resident #9 On 3/20/18 at 12:10 PM, Resident #9 was observed in their room sitting in a high back reclining wheelchair with a solid footrest for both feet. The Resident was wearing white socks and a wound dressing was visible on the lateral (outside) of their right ankle through their sock. An interview was attempted with the Resident at this time. When queried regarding the dressing on their ankle, the Resident was pleasant but unable to provide a meaningful response. Record review on 3/20/18 at 3:44 PM of facility provided pressure ulcer list revealed Resident #9 had a facility acquired pressure ulcer. Record review on 3/20/18 at 3:50 PM revealed the Resident was originally admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required extensive to total assistance to perform Activities of Daily Living (ADL's). Further review of the Resident's Face sheet revealed a secondary [DIAGNOSES REDACTED]. 10/9/16 . during stay. Review of Resident #9's care plans on 3/21/18 at 7:25 AM revealed a care plan entitled, Pressure Ulcer: I have PU (Pressure Ulcer) to coccyx, left lateral ankle. I am at risk for further skin breakdown r/t (related to) Moisture/Incontinence, Decreased activity, Impaired mobility, Nutrition/Hydration risks, Friction and shear, Drugs that increase risk of pressure ulcer development (Antipsychotics, Antidepressants, Narcotics), HX (history) of healed pressure ulcer, Altered mental status. Coccyx 2.5 cm (centimeter) x 1.5 cm x 1 cm no s/s (signs/symptoms) infection, drainage present. Left Lateral ankle 1.8 cm x 0.6 cm x .01 cm, no s/s infection, drainage present. (Date Initiated: 5/5/16, Revised: 3/20/18). Care plan interventions included: -Provide incontinence care after each incontinent episode. T&R (Turn and Reposition) at least Q (every) 2 hr (hour) and PRN (as needed) when in bed and up in chair. Always float heels while in bed. Barrier cream to bilateral buttocks and groin as ordered (Initiated: 1/7/18) -Wound care consult to measure and stage weekly. Document findings. Complete a full body check weekly and document. Monitor lab values as ordered. Pressure ulcer treatment as ordered. Pressure reduction mattress. Apply pressure reduction cushion to chair or wheelchair (Initiated and Revised: 1/7/18) On 3/21/18 at 8:05 AM, an interview was completed with Wound Care Nurse Q. When queried regarding Resident #9's pressure ulcers and treatments including observation of wound care, Nurse Q replied, The treatment is already done for today. With further inquiry Nurse Q stated, (Resident #9) has pressure ulcers on their left lateral ankle and coccyx. When asked if the pressure ulcers were facility acquired, Nurse Q indicated they just started working at the facility 12 days ago and they believed the pressure ulcers were facility acquired. On 3/21/18, Resident #9 was observed sitting in their wheelchair with padded spacer brace positioned on their knees at the following times: 9:00 AM, 11:00 AM, 1:00 PM, and 3:30 PM. The Resident was in the same position in the wheelchair at each observation. Review of wound documentation for Resident #9 on 3/31/18 at 4:05 PM revealed the Resident was currently receiving treatment from the wound care physician for a stage IV pressure ulcer on their coccyx and a stage II pressure ulcer on their left lateral ankle. A review of the physician documentation revealed the most recent wound measurements were as follows: -Physician documentation, dated 3/13/18: Wound #1 Coccyx is a Stage 4 Pressure Injury . Status of Not Healed . Moderate amount of sero-sanguineous drainage . Patient refused wound evaluation . Wound #2 Left, Lateral Ankle is a Stage II Pressure Injury . Status of Not Healed. Measurements are 1.8 cm length by 0.6 cm width X 0.01 cm depth . small amount of serous drainage . Irregular edges. Physician documentation, dated 3/6/18: Wound #1 Coccyx is a Stage 4 Pressure Injury . Status of Not Healed . Subsequent wound encounter measurements are 2.2 cm length X 1.2 cm width X 1 cm depth . Moderate amount of sero-sanguineous drainage . Irregular edges . Wound #2 Left, Lateral Ankle is a Stage II Pressure Injury . Status of Not Healed. Measurements are 0.8 cm length X 0.4 cm width X 0.01 cm depth . Irregular edges, Ankle is laterally rotated. On 3/22/18 at 7:57 AM, Resident #9 was observed in their room lying in bed, positioned on their back. On 3/22/18 at 8:10 AM, an interview was completed with Nurse Q. When queried regarding the Resident's pressure ulcers, Nurse Q stated, They have a pressure ulcer on their coccyx and left lateral ankle. They also have a dressing to their right lateral ankle but that is for protection. With further inquiry, Nurse Q stated, They are both facility acquired. When queried regarding the onset date of the pressure ulcers, Nurse Q indicated they were not sure of the date. Observation of wound care treatment for [REDACTED]. While gathering supplies to complete the dressing change, Nurse Q was observed cutting Kerlix (rolled bandage) into pieces. When asked why they were cutting the Kerlix into pieces, Nurse Q stated, We don't have any 4X4's (4 inch by 4 inch gauze pads), they didn't come in. Upon entering the Resident's room, Nurse Q obtained an over bed table from beside the Resident's roommate's bed. Nurse Q wiped the top of the table and placed the supplies to complete Resident #9's dressing change on the table. When queried regarding why they utilized the Resident's roommates table, Nurse Q indicated they did not know where the Resident's table went. At this time, Nursing Assistant U entered the room and the treatment began. The Resident was lying in bed with their legs bent at their hips and knees. When queried, Nursing Assistant U indicated the Resident's legs were contracted. Nurse Q removed the dressing on the Resident's right lateral ankle. The area directly over the Resident's lateral malleolus was slightly larger than a quarter and irregularly shaped. The area was red in color with a black colored area in the center. When queried if the area was blanchable, Nurse Q pressed on the area. The wound was observed to have non-blanchable redness. Nurse Q proceeded to cleanse the wound with wound cleanser and place the wound cleanser spray bottle on the bed. Nurse Q then dried the wound and applied the cut Kerlix bandage and a border gauze dressing. Resident #9's brief was removed to complete the dressing change on the Resident's coccyx pressure ulcer. When the Resident's brief was removed to complete wound care on their coccyx pressure ulcer, stool was observed in the Resident's brief and on their buttocks. Nurse Q removed the dressing from the Resident's coccyx pressure ulcer. The removed dressing had a moderate amount of gray and yellow colored drainage. After removing the dressing, Nurse Q indicated the Resident had a bowel movement and restored the Resident's hygiene. The coccyx wound was noted to be open with irregular edges and approximately the size of a quarter. The wound edges were detached and white in color. The wound bed was noted to have tunneling and undermining. The wound bed that was visible was pink, white and gray in color. The entire wound bed was unable to be completely observed due to the depth of the wound. The tissue surrounding the wound was red in color. Nurse Q cleansed the wound bed with wound cleanser, changed their gloves, and applied a new dressing. Nurse Q did not wash their hands after cleansing the wound bed before applying a clean dressing. When queried regarding the Resident's pressure ulcer on their left lateral ankle, Nurse Q stated, There is no xeroform dressing in the facility (dressing ordered for treatment). The Resident's left lateral ankle pressure ulcer was not able to be visualized at this time. After completion of the dressing change, Resident #9 was positioned on their back and a pillow was placed between their knees. The pillow was visibly soiled with stool. The Resident was then covered with their blanket. On 3/22/18 at 9:01 AM, observation of the pillow soiled with stool in-between Resident #9's legs was completed with Nurse Q. After observed the pillow, Nurse Q removed the pillow. When queried, Nurse Q stated, No, that is not okay. On 3/22/18 at 10:15 AM, a review of progress note documentation within Resident #9's medical record indicating the onset date of each wound was unable to be located. Documentation pertaining to the Resident's wounds included: -Skin/Wound Note, Dated 5/3/17: Wound #1: Left lateral ankle stg (stage) IV; Drainage (Med), Red in color, [DIAGNOSES REDACTED] noted. No Infection, [MEDICAL CONDITION], odor, purulent, gangrene, necrotic, slough noted at this time. Measurements: 1.2 x 1.1 . Wound # 2: Sacral Stg IV: Drainage (Med), Red in color, [DIAGNOSES REDACTED], Infection noted. No [MEDICAL CONDITION], purulent, odor, gangrene, necrotic, slough noted at this time. Measurements: 4.5 x 5.0 x 1.5. Wound #3: Right lateral ankle stg IV; Drainage (Med), Red in color, [DIAGNOSES REDACTED] noted. No Infection, [MEDICAL CONDITION], odor, purulent, gangrene, necrotic, slough noted at this time. Measurements: 1.3 x 1.3 . -Skin/Wound Note, Dated 3/29/17, Wound #1: Left lateral ankle stg IV; Drainage (Med), Red in color, [DIAGNOSES REDACTED] noted. No Infection, [MEDICAL CONDITION], odor, purulent, gangrene, necrotic, slough noted at this time. Measurements: 2.3 x 1.7. Wound # 2: Sacral: Drainage (Med), Red in color, [DIAGNOSES REDACTED], noted. No infection, [MEDICAL CONDITION], purulent, odor, gangrene, necrotic, slough noted at this time. Measurements: 5.0 x 5.5 x 1.5 . Wound #3: Left lateral ankle stg IV; Drainage (Med), Red in color, [DIAGNOSES REDACTED] noted. No Infection, [MEDICAL CONDITION], odor, purulent, gangrene, necrotic, slough noted at this time. Measurements: 2.2 x 1.5 . -Skin/Wound Note, Dated 2/17/17, Per Wound Doctor: Wound #1: Left ankle Stg IV, Drainage noted, red in color, [DIAGNOSES REDACTED] noted. No purulent, order, gangrene, necrotic, slough, infection noted at this time. Wound measures 3.0 x 2.5 x 0.2 . Wound #2: Sacral stg IV, Drainage, order, [DIAGNOSES REDACTED], Red in color noted. No Purulent, gangrene, necrotic, slough, infection noted at this time. Wound Measurements 5.0 x 7.0 x 1.5 .Wound #3: Right ankle stg IV: Drainage, [DIAGNOSES REDACTED], red in color noted. No Order, gangrene, necrotic, slough, infection noted at this time. Measurements 3.0 x 2.0 x 0.3 . -Nutrition Note, Dated 10/10/16, Noted new wounds . Continue to monitor weekly weights, wound healing and po (oral) intake. -Skin/Wound Note, Dated 8/18/16, Resident has two small stage I on buttocks surrounding skin intact care plain update to prevent further breakdown wound consult ordered for wound DR. On 3/22/18 at 11:00 AM, Resident #9 was observed lying in their bed, positioned on their back in the same position as previously observed. An interview was conducted with Nursing Assistant P. When queried if Resident #9 had been repositioned in bed, Nursing Assistant P stated, No, (the Resident) hasn't been repositioned. With further inquiry regarding the Resident's pressure ulcers and repositioning, Nursing Assistant P stated, I get you. Nursing Assistant P then indicated they would get assistance to reposition the Resident. On 3/22/18 at 1:00 PM, Resident #9 was observed lying in their bed, positioned on their back. An observation of wound care completion of Resident #9's treatment on their left lateral ankle pressure ulcer occurred with 3/22/18 at 1:46 PM with Nurse Q. Upon entering the room, Resident #9 was observed lying in their bed, positioned on their back. Nurse Q removed the dressing from the Resident's ankle. The area directly over the Resident's left lateral malleolus was irregularly shaped and approximately a half dollar in size. The area was red in color with a dark area in the center of the red area that was approximately the size of a dime. When queried if the area was blanchable, Nurse Q pressed on the area. The wound was observed to have non-blanchable redness. Resident #58 On 3/20/18 at 10:20 AM, 10:43 AM, and 1:00 PM, Resident #58 was observed in their room lying in bed, positioned on their left side. The Resident's eyes were closed. On 3/20/18 at 3:52 PM, review of facility provided pressure ulcer list revealed Resident #58 was listed as having been admitted with the pressure ulcer. Record review on 3/20/18 at 4:00 PM revealed Resident #58 was originally admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required extensive to total assistance to perform Activities of Daily Living (ADL's). The MDS further revealed the Resident had two stage II pressure ulcers with one being present upon admission or reentry, one stage three pressure ulcer and one unstageable pressure ulcer. Review of Resident #58's care plans revealed a care plan entitled, (Resident #58) has actual skin impairment to Left Proximal Flank, Right Gluteal Fold, Left Hip, Coccyx and Abdomen r/t Diabetes type II, Obesity, Muscle Weakness. (Resident #58) declines to reposition, declines to get in wheelchair (Initiated: 8/26/17; Revised: 3/8/18). Care plan interventions included: -Assess for pain before, during, and after treatment (Initiated: 3/8/18) -Float Heels (Initiated: 3/8/18) -Educate me on risk of not repositioning. Report and document refusals (Initiated: 11/26/17, Revised: 3/8/18) -Identify/document potential causative factors and eliminate/resolve where possible (Initiated: 8/26/17) -Observe/document location, size and treatment of [REDACTED]. to MD (Initiated: 3/8/18) -Obtain blood work such as CBC with Diff, Blood Cultures and C&S (Culture and Sensitivity) of any open wounds as ordered by Physician (Initiated: 3/8/18) Review of nursing progress note revealed documentation dated 10/5/17 and 11/29/17 indicated the Resident #58 refused to turn and reposition in bed. No additional nursing note documentation pertaining to refusal to turn and reposition was located within the Resident's medical record. On 3/21/18 at 7:51 AM, Resident #58 was observed in lying in their bed. The Resident was positioned on their left side. An interview was completed with Nurse W on 3/21/18 at 7:55 AM. When queried regarding Resident #58, Nurse W stated, (The Resident) has multiple pressure ulcers on both of their hips and their coccyx. On 3/21/18 at 10:19 AM, Resident #58 was observed in their room lying in bed, positioned on their left side facing the door of their room. On 3/21/18 at 10:27 AM, a review of Resident #58's Medication orders and Medication Administration Record [REDACTED]. When queried regarding the antibiotics, Nurse X indicated Resident #58 was receiving the medications due to their pressure ulcers. When queried regarding diagnostic studies related to the Resident's infection, Nurse X did not provide further explanation. When queried regarding the medication [MEDICATION NAME] not having an end date, Nurse X reviewed the Resident's medication order and stated, That's not right. On 3/21/18 at 2:27 PM, Resident #58 was observed in bed positioned on their left side. The Resident was visibly shaking and crying, with tears noted on their cheeks. An interview was completed and Resident #58 indicated they were having pain. When queried regarding their pain level on a scale of zero to 10 with 10 being the worst pain possible, Resident #58 stated, It's a 10. Review of Resident #58's facility provided wound documentation on 3/21/18 at 3:00 PM revealed the following: -Wound Care Nurse Practitioner documentation, dated 3/13/18: Wound #1 Left Hip is a Stage 3 Pressure Injury . Status of Not Healed . Wound encounter measurements are 2 cm length X 5.5 cm width X 1.7 cm depth . large amount of sero-sanguineous drainage. Wound bed has Necrotic Base [MEDICATION NAME] . Irregular edges . Wound #3 Left Gluteal fold is a Stage 3 Pressure Injury . Status of Not Healed . measurements are 2 cm length X 7 cm width x 0.5 cm depth . large amount of sero-sanguineous drainage. necrotic mid core, irregular edges .Wound #4, Left Proximal Flank is a Stage 4 Pressure Injury . Status of Not Healed . measurements are 10 cm length X 7 cm width X 2 cm depth . large amount of sero-sanguineous drainage. Necrotic tissue to the proximal aspect of wound, irregular edges . Wound #5 Abdomen -LLQ (Left Lower Quadrant) is a Surgical wound . Status of Not Healed . measurements are 3.6 cm length X 1.5 cm width X 0.6 cm depth . moderate amount of sero-sanguineous drainage .minimal yellow slough .irregular edges . Wound #6 Right Buttocks is a Stage 3 Pressure Injury . Status of Not Healed . measurements are 1.5 cm length X 3 cm width X 0.01 cm depth . irregular edges . Wound #7 Coccyx is a Stage 2 Pressure Injury . Status of Not Healed . Measurements are 1.8 cm length X 1 cm width X 0.01 cm depth . scant amount of yellow drainage noted . irregular edges . The document further indicated there were No labs. -Wound Care Physician documentation, dated 3/6/18: Wound #1 Left Hip is a Stage 3 Pressure Injury . Status of Not Healed . Wound encounter measurements are 2 cm length X 5 cm width X 0.1 cm depth . moderate amount of sero-sanguineous drainage. Wound bed has Necrotic Base [MEDICATION NAME] . Irregular edges . Wound #3 Left Gluteal fold is a Stage 3 Pressure Injury . Status of Not Healed . measurements are 2.5 cm length X 6 cm width x 0.8 cm depth . moderate amount of sero-sanguineous drainage. Irregular edges .Wound #4, Left Proximal Flank is a Stage 4 Pressure Injury . Status of Not Healed . Measurements are 9.5 cm length X 6 cm width X 2.5 cm depth . large amount of sero-sanguineous drainage. Scattered necrosis, irregular edges . Wound #5 Abdomen -LUQ (Left Upper Quadrant) is a Surgical wound . Status of Not Healed . measurements are 4 cm length X 1 cm width X 0.6 cm depth . moderate amount of sero-sanguineous drainage .irregular edges . Wound #6 Right Buttocks is a Stage 3 Pressure Injury . Status of Not Healed . measurements are 2 cm length X 2.5 cm width X 0.01 cm depth . moderate amount of serous drainage . irregular edges . Wound #7 Coccyx is a Stage 2 Pressure Injury . Status of Not Healed . Measurements are 2 cm length X 1 cm width X 0.01 cm depth . scant amount of serous drainage noted . irregular edges . The document further indicated there were No labs. Further review of Resident #58's medical record revealed the following: -Nursing Admission Data Collection assessment, dated 8/25/17: Skin issues .coccyx small open area, left hip wound, left iliac skin tears . On 3/22/18 at 9:34 AM, Resident #58 was observed in bed and positioned on their left side. The Resident was displaying facial grimacing and was crying with tears noted their cheeks. When queried, the Resident stated, It hurts so bad. On 3/22/18 at 10:33 AM, an interview was conducted with Therapy Manager H. When queried regarding Resident #58's mobility and observations of the Resident always being positioned on their left side, Therapy Manager H stated, (Resident #58) is supposed to get out of bed everyday. Therapy Manager H further revealed the Resident had a specialized wheelchair. When queried regarding the location of the wheelchair, Therapy Manager H indicated it was in the Resident's room. With further inquiry regarding a wheelchair not being observed in the Resident's room, Manager H was unable to provide an explanation. An interview was completed with Resident #58 on 3/22/18 at 10:06 AM. The Resident was positioned on their left side in their bed. When queried, Resident #58 stated, I got some medicine (for pain) but it hasn't helped yet. An interview and record review of Resident #58's medical record was completed with the Director of Nursing (DON) on 3/22/18 at 11:10 AM. When queried regarding documentation of the Resident's wounds including the onset date of each of the pressure ulcers, the DON stated, I'm looking at the wound care orders and having trouble following it as well. The DON additionally revealed, We got cited (for pressure ulcers) on a complaint recently, we are working on it. Resident #58's care plan related to pressure ulcers was reviewed with the DON at this time. Initial physician documentation of Resident #58's pressure ulcers and wounds was requested at this time. When queried regarding the intervention to float heels and the Resident's heels never being observed as elevated or floated, the DON replied, Should be included that sometimes (the Resident) refuses. When queried regarding turning and repositioning the Resident and last documentation indicating Resident refusal on 11/29/17, the DON did not provide an explanation. With further inquiry related to pressure ulcer information indicated on the MDS not correlating with facility and health care documentation of pressure ulcers, the DON was unable to provide an explanation. On 3/22/18 at 11:24 AM, observation occurred of Resident #58's wounds with Physician T and Nurse Q. Upon entering the Resident's room, a strong, foul odor was noted. The Resident was positioned on their right side. The Resident was moaning and stating it hurts. There were no dressings in place on the Resident's wounds. When queried, Nurse Q indicated the prior dressings had been removed and disposed of already. Resident #58 was observed to have pressure ulcers and open wounds on their coccyx, left hip, left flank, left Gluteal, left lateral thigh, right buttocks, left lower back, and left upper abdomen. The Resident's left flank pressure ulcer was irregularly shaped and approximately the length of a dollar bill by appropriately four inches wide. The wound was approximately the depth of a dime. The wound base was red in color with a unattached edges and undermining. A black area, approximately the size of a nickel, was observed on the distal area of the wound. The coccyx wound was irregularly shaped and approximately the size of a quarter. The tissue surrounding the wound was white in color with light pink tissue surrounding the wound bed. The edges of the wound were unattached. Black colored tissue was noted at the base of the wound bed. The area on the Resident's left lower back was red in color, with red colored drainage, and approximately the size of a nickel. The wound on the Resident's left Gluteal was irregularly shaped and approximately two inches long by one and a half inches long by half a centimeter deep. Two open areas were noted on the Resident's distal left thigh, towards their knee. The proximal wound (closest to the Resident's head) was open with underlying red and white tissue visible. The wound was irregularly shaped and approximately the length of a post-it note and the width of a pen. The distal wound (closest to the Resident's knee) was open with underlying red and white tissue visible. The wound was irregularly shaped and was approximately the length of two quarters and the width of a pen. At this time, Physician T obtained measurements of Resident #58's wounds. Physician T was observed touching and measuring each wound. Physician T did not wash their hands or perform hand hygiene after obtaining measurements of one wound before obtaining wound measurements for any of Resident #58's wounds. After obtaining wound measurements, Physician T removed their gloves. Following this, Nurse Q was observed applying new dressings to each of the Resident's wounds. Nurse T did not change their gloves and/or perform hand hygiene between application of a new dressing to each open wound. Throughout the dressing change, Resident #58 was observed moaning and crying in pain. When queried regarding their pain level, Resident #58 indicated their pain level was a 10 on a scale of one to 10 with 10 being the worst pain. An interview was completed with Physician T on 3/22/18 at 11:37 AM. When asked about treatment and status of the Resident's pressure ulcers, Physician T stated, (Resident #58) needs to lay on their other side. They only lay on their left side. When queried regarding the Resident's bed placement and that the Resident would be facing the bare brick wall if they laid on their right side, Physician T did not provide an explanation. Physician T then stated, (Resident #58) has good potential to heal. When queried regarding coordination with other health care providers and disciplines including dietary involvement in care, Physician T indicated they write an order to consult if needed. When queried regarding laboratory monitoring including Resident #58's uncontrolled blood glucose levels, Physician T reviewed the Resident's medical record with their assistant and stated, The labs aren't current. They are over three months old. Physician T then indicated they would order labs. With further inquiry regarding the strong, foul odor noted upon entering Resident #58's room and potential infection, Physician T indicated they did not smell an odor. Physician T then stated, It is not bad enough to treat. With further inquiry pertaining to laboratory testing and cultures of the Resident's wounds due to lack of healing and prolonged duration, Physician T indicated cultures have not been completed because all wounds are colonized with bacteria. When asked about the Resident currently receiving antibiotics for their wounds, Physician T did not provide an explanation. When queried regarding not washing their hands in-between each wound while obtaining wound measurements, Physician T stated, I don't have to do that. Physicians do not have to do that. Physician T further indicated they were aware of infection control and prevention procedures. When queried regarding the potential spread of infectious organisms from wound to wound, Physician T indicated the Resident's wound were not infected. With further inquiry related to Resident #58's positioning, Physician T indicated the Resident is always lying on their left side and a different mattress would be needed in order to assist the wounds to heal. Physician T then revealed they were going to recommend the facility obtain the mattress. When asked why they had not recommended the specialized mattress previously, Physician T indicated the mattress is costly. An interview was conducted with the Director of Nursing (DON) on 3/22/18 at 12:04 PM. When queried regarding the Resident always being positioning on their left side and the right side of Resident #58's bed being against the bare brick wall, the DON stated, We can look into that. When queried regarding hand hygiene during wound care, the DON indicated staff should wash their hands before wound care treatment, after dressing removal and wound cleansing, and after completion of treatment. When queried, the DON indicated each wound should be treated separately. When queried regarding Physician T and Nurse Q not performing hand hygiene, the DON indicated hand hygiene should be performed and they would have to re-educate. Review of facility policy entitled, Skin Management (Revised (MONTH) (YEAR)) on 3/22/18 at 5:55 PM revealed, Residents receive care to aid in the prevention or worsening of wounds and/or pressure ulcers. Individuals at risk for skin compromise are identified, assessed and provided treatment to promote healing, prevent infection, and prevent new ulcers from developing . Staging as pressure injuries heal: When a pressure ulcer is staged appropriately . the staging of the wound does not change as the wound heals . Record review of facility policy entitled, Hand Hygiene (No Date) on 3/22/18 at 6:00 PM revealed, Handwashing/hand hygiene is generally considered the most important single procedure for preventing health care associated infections .

This citation pertains to intake #MI 529. Based on interview and record review, the facility failed to secure a body lift sling for one (#620) of four sampled residents reviewed for accidents from a total of 20, resulting in the resident falling during a mechanical lift two-person transfer, experiencing severe pain, sustaining a fractured hip and requiring emergency hospital treatment due to the sling not being not properly connected to the lift. Findings include: The facility reported to the State agency that resident #620 had a fall from a mechanical lift. On 5/18/17 at 11 AM, the clinical record, an Incident/Accident (I/A) Report and an incident investigation were reviewed. The resident was re-admitted on [DATE] with [DIAGNOSES REDACTED]. The minimum data set completed 2/21/17 noted that the resident had moderate cognitive impairment, required extensive two-person assistance for transfers and bed mobility and had limited range of motion to bilateral lower extremities. According to Activities of Daily Living and Fall Risk care plans, last revised 1/25/17, interventions included: Transfers via mechanical (total body) lift device, requiring two-person assistance and Observe for placement and function of devices per facility protocol. The I/A report dated 5/8/17 noted that resident #620 was observed on the floor in her room from a fall, equipment was involved, complained of pain to the left hip and right knee and the fall was witnessed by two nurse aides. The I/A investigation noted the following: Two nurse aides summoned the nurse to the resident's room. A mechanical lift was observed next to the bed and the resident was lying on the floor at the base of the lift. The nurse observed one of the loops (of the sling placed underneath the body) 'unhooked' from the device causing the sling to be hanging on one corner Both (nurse aides) stated that during the transfer, one of the loops 'came off' of the lift suddenly causing the resident to slide 'feet first' out of the sling and on to the floor Resident confirmed that she slide from the lift sling during transfer Conclusion: .a thorough inspection of the lift and sling (found to be intact and fully functional by maintenance (staff) one of the loops of the sling was not properly secured to one of the loop hooks of the lift device, causing the resident to slide to the floor on her buttocks a thorough inspection of the sling and lift suggest that the root cause is that one of the loops were not properly seated. Resident #620 was transported to the hospital on [DATE] and had not returned by time of the survey. A hospital x-ray report dated 5/8/17 noted: Comminuted intertrochanteric fracture of the left hip. On 5/18/17 at 2:30 PM, when the incident was discussed with the Administrator, he did not offer a response. There was no documented indication that the two nurse aides involved in the incident had been evaluated for demonstration of proficiency/competency in proper operation and use of the mechanical lift in 2016 and thus far, in 2017. This information was requested, but not provided by survey exit. On 5/18/17 at 5 PM, per review of the facility's policies on Fall Management dated 8/2012 and Lift, Transfer, and Repositioning dated 2010: Each resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices to minimize the risks for falls. Training: .the direct care staff will be required to attend and complete training related to resident lifts and transfers during orientation and then annually and/or as required to re-emphasize the instructions set forth staff will receive training with pertinent instructional/materials from lift manufacturers and complete 'hands-on' skills competency.

This citation pertains to MI 398 Based on interview and record review, the facility failed to timely treat, evaluate, and use assessment data gathered in progress notes and other medical record documents of an anxious cognitively impaired resident after a fall that resulted in right [MEDICAL CONDITION] for 1 of 3 (# 103) sampled residents from a total of three sampled residents, by failing to perform a timely x-ray, notify facility physician on time, and transport Resident to the hospital for emergency treatment immediately, resulting in Resident #103 being hospitalized after 6 days post fall with a [DIAGNOSES REDACTED]. Findings include: An abbreviated survey was conducted on 4/7/17 in response to a complaint which alleged that resident sustained [REDACTED]. The facility's investigation report, Resident #103's clinical record, and the incident report of the fall that occurred on 3/31/2017 were initially reviewed on 4/5/2017 at an unknown time. According to the facility's incident report dated 4/5/17 with no specified time, Resident #103 fall incident was not witnessed, injury of unknown origin. The findings: Received report from X-ray that residents right hip was fractured, physician notified at 9:34 AM, on 4/5/17, and Resident 103 was transferred to the hospital. The Hospital transfer form from the Nursing Home dated 4/5/17, revealed that Resident #103 was sent to the hospital to rule out right [MEDICAL CONDITION]. Alert, disoriented, but cannot follow simple instructions. The risk alerts was falls. Review on 4/7/17 at 10:24 AM, of the statement of witness dated 4/5/17 at no specified time, indicated that CNA#B was doing patient care on Resident #103 at 7:30 AM on Monday, 4/3/17, when resident stated, My leg hurts I pressed on several areas of her legs and hips while asking her if there was pain in these areas. She did not confirm verbally to my questions nor did she demonstrate nonverbal actions of pain at this time. At 2:30 PM while putting resident #103 back to bed she complained pain in her right leg during the transfer. I reported it to her nurse . On Tuesday, 4/4/2017 at 7 AM during the morning care Resident #103 again stated, My leg hurts. I again pressed different areas with no confirmation of pain. No bruising noticed. I reported her concerns of pain to Nurse #LW. While transferring resident back to bed at 3 PM she stated You don't know how much pain I am in. I reported this to nurse #LW again and she stated that an x-ray was ordered. Review on 4/7/17 at 10:34 AM, of the statement of witness dated 4/5/17 from the resident's room mate #104 revealed She witnessed and observed Resident #103 being transferred by a female RCS from her bed to a wheel chair. She was lying in bed. She does not remember the date, but believes it was last Friday which have been March 31st. Resident #104 claims that while resident #103 was transferred, the resident was dropped during the transfer by the RCS. The resident described the RCS with red/blonde hair. As being a white tall female. Another review on 4/7/17 at 10:37 AM, of the statement of witness with no specified date or time noted that the Nurse #C who worked Friday indicated Resident #103 was under care. No one came to him to report any fall or sliding out of wheel chair. when providing care to resident, no signs of distress or pain was noticed. Nurse worked Sunday and nothing was noted. No one notified him of any fall or injury. Review of the Hospital medical record with an encounter date of 4/5/17 recorded reason for the exam : fall, trauma, pain. The impression was comminuted intertrochanteric [MEDICAL CONDITION] femur with pronounced varus angulations. Comminuted intertrochanteric [MEDICAL CONDITION] hip. Felt to be acute or subacute. Review of the facility progress notes dated 4/5/17 at 01:00 noted that X-ray tech arrived at facility and performed a hip X-ray and informed writer that resident's right hip was fractured. Assessed resident and swelling and warmth was noted. Administrator and DON was notified, pain medication was given and resident sent to the hospital. 4/4/17 at 15:04, RCS reported to Nurse #E that resident with complaints of pain to right hip last few day, ROM to all extremities, no redness or bruising noted, notified MD with order for an X-ray. On 4/7/17 at 10:39 AM, during an interview with the facility Administrator, he indicated that he was aware of the fall incident relating to resident #103 and that he was investigating the incident. On 4/7/17 at 10:40 AM, during an interview with the complainant, he voiced concerns about how he received a message that his mother had hip pain for an unknown reason, sent to emergency room and an X-ray indicated [MEDICAL CONDITION] in 4 places. He stated the orthopedic surgeon told me that my mother will never walk again. It was a bad brake. Her hip broke in four places. She is going to spend the rest of her life in pain. On 4/7/17 at 10:45 AM, during an interview with the CNA#A, she stated On 3/31/17 at 7 PM, I was in the room feeding resident #103's room mate when I saw resident #103 slid off her wheel chair on her butt trying to pick up pictures of her Mom on the floor. I called for the nurse #C, he didn't come right away because he had an orientee with him that evening. I was there when he came into the room and told me to put resident back to bed. The nurse did not assess the resident. I had another RCS help me put her on her wheel chair. It was never reported to the physician and no X-ray was done. I had her throughout the rest of the afternoon on 3/31/17 and she never complained. I had her Saturday 4/1/17 from 7 AM to 11 PM, never complained, and didn't notice anything. I had her Sunday 4/2/17 from 7 AM to 11 PM, never complained. Monday 4/3/17, from 3 PM to 11 PM. I had her on 4/4/17 from 3 PM to 11 PM. Upon changing her at 4:30 PM, noticed that her right hip was swollen. When asked why she was assessing the resident by concluding she was not in pain when she was not a nurse, she stated the nurse's usually don't come when asked and offered no further explanations. On 4/7/17 at 10:57 AM, during an interview with CNA#B, she indicated that she worked with resident #103 on 3/31/17 at 3:30 PM from 7 AM to 3:30 PM. CNA#B revealed that On 4/2/17 Monday at about 2 PM, resident #103 complained to her that she was in pain. I felt her and touched and she wouldn't answer me. She didn't tell me she slid off her chair. I went out the hall and called the nurse. I told the new nurse that Resident #103 was in pain. When CNA#B was queried as to the name of the new nurse and why she was assessing the resident when she is not a nurse? She indicated that it takes the nurses a long time to respond timely and offered no further explanations. The CNA#B further indicated that on the next day 4/3/17, I worked with resident #103 at 7 AM. Resident #103 was still complaining about pain, and I went and complained to Nurse#E and told her that Resident #103 stated her leg hurts. The Nurse #E later in the afternoon got the X-ray and MD involved. On 4/7/17 at about 11:47 AM, during an interview with the Nurse #C, he indicated that he worked the Friday the day of the incident but that Nobody came and reported any fall or sliding off the wheel chair for any resident during his shift. He revealed that he was orienting another nurse#D on that day and that no incident was brought to his attention. On 4/7/17 at 12:05 PM, during an interview with the Nurse#D the orientee, she confirmed that she was with Nurse #C during her orientation and that nobody, reported any fall incident relating to resident #103 to them. She indicated that she was at this facility for one day and left. On 4/7/17 at 12:14 PM, during an interview with the Nurse #E, She revealed that the incident was reported to her on 4/4/17 before the end of the shift. She indicated that CNA#B reported to her that something might be wrong with resident #103. I went and assessed her and found that some pain was going on her right hip. CNA#B reported that she reported the incident to the nurse that worked on Monday and nothing was done. MD said to order a start X-ray and left a report for the nurse for the patient not to be moved. On 4/7/17 at 2:30 PM, during an interview with resident #104, she was alert and can answer questions. Resident #104 recalled that her room mate did fall. Resident #103 was put back to bed by two women after she fell out from her wheel chair because the brakes on the wheelchair was not locked. On 4/7/17 at 3:18 PM, during an interview with the Director of nurse's DON, she revealed that she interviewed most of the staff along with the facility Administrator. The DON indicated that resident #104 during their interview investigation revealed that someone dropped resident #103 during a transfer, and picked her back up and put her on her wheel chair. A review of the clinical record on 4/7/17 at 3:57 PM, revealed that Resident #103 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MD'S) dated 3/19/17 signed by an RN assessment coordinator revealed that Resident #103 required one person physical assist from staff with all Activities of Daily Living (ADLS) including bed mobility, transfers, and toileting. Resident #103's Brief Interview for Mental Status (BIMS) score of 02 (A score of 2 indicates long and short term memory loss). The fall risk assessment dated [DATE], revealed Resident #103 is at high risk for falls. Review on 4/7/17 at 4:15 PM, of the medication administration records for the month of March and April 2017, revealed that Resident #103 was prescribed Tylenol 500 mg every 6 hours as needed for pain. Observe for pre and post pain every 6 hours as needed for pain. Their was no documented record on the MAR indicated [REDACTED]. Request for the facility's policy on pain, falls, was not made available by the end of the survey.

This citation pertains to intake #MI 110, MI 169, #MI 298 and #MI 117. Based on interview and record review, the facility failed to properly monitor and implement proper and appropriate care and services for one (#706) of 11 sampled residents reviewed for abuse from a total of 11, resulting in essential medical appointments not being scheduled and emergency hospitalization for clinical decline in health status as evidenced by the resident being left dehydrated, with bladder distention, an elevated temperature, acute kidney injury, antibiotic resistant respiratory infection, pneumonia and critical blood test results due to neglect of care. Findings include: The complainant/hospital employee reported in writing that resident #706 was sent from the facility to the hospital in a neglected and compromised medical state. On 2/22/17 at 10 AM, the resident's clinical record and hospital records were reviewed. The resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] noted that the resident was independent with cognition, non-ambulatory, able to fully communicate, required extensive assistance with hygiene and bed mobility, total assistance with bathing and was incontinent with bowel/bladder. The resident was transferred to the hospital on [DATE] in respiratory distress and did not return. There was no documented indication of Do Not Resuscitate in the resident's clinical record should he have a cardiopulmonary arrest. His Death With Dignity care plan initiated 11/25/16 noted that the resident wished Full Code (resuscitation). The chart indicated that the resident was a Navy veteran. Per review of a hospital History and Physical dated 1/27/17, the resident was admitted into the hospital on [DATE] for the following: presented from the nursing home with worsening lethargy and hypoxemia (oxygen saturations in the low 70) Per EMS reports, patient was hypoxemic in low 70s. It was unclear if it was on oxygen, however, EMS had placed a non-rebreather (oxygen) mask at 15 liters/minute, bringing up his oxygen saturations to mid 90's. Furthermore, it appears that the patient was quite neglected at Hope Nursing (facility) as he was covered in stools, had over 1300 milliliters (of urine) in his bladder after inserting a urinary catheter and his (gastric feeding tube insertion) site was completely crusted over It is also unknown how long the patient has been experiencing oxygen desaturations and [MEDICAL CONDITION](rapid heart rate). Patient is currently denying any chest pain, but admits to shortness of breath. He nodded his head in regards to his symptoms becoming progressively worse the past few days. Furthermore, his calcium (level) was noted to be 15.7 (normal range=8.5-10.2) Aggressive measures to decrease patient's calcium were initiated. An elevated calcium level can be caused by factors, such [MEDICAL CONDITION] and dehydration that can cause kidney damage. Per nursing notes dated 1/28/17, the resident's blood pressure was 100/51, pulse 127 and oxygen saturation level was 77% (normal range=95-100%) when he was transported to the hospital. At 10:15 AM, the Director of Nursing (DON) read the hospital record, shook her head and did not respond regarding the resident's appearance and condition when he arrived at the hospital on [DATE]. She did not respond how and why the resident was dehydrated if he was receiving the tube feeding formula and water from nursing staff as prescribed (6 cans of formula and a total of 2,610 cc (cubic centimeters) of water per day). The hospital record further noted: (The resident) was admitted for (facility) acquired pneumonia and he was given aggressive intravenous (IV) hydration and Calcitonin (used to decrease calcium blood levels). He also had acute kidney injury (a sign of dehydration). He was severely dehydrated and had [DIAGNOSES REDACTED] and [MEDICAL CONDITION] (elevated potassium and sodium levels) He has [MEDICAL CONDITIONS] His respiratory cultures are positive for [MEDICAL CONDITION]-resistant Staphylococcus (MRSA bacteria) Per an Oncology consult dated 2/1/17: It appears there are hygiene issues at Hope Nursing (facility). He was treated appropriately with antibiotics and was given IV fluids He responded well to IV fluids and calcitonin He was noted to have severe [MEDICAL CONDITION] with hemoglobin down to 7.1 (normal range=13.6-17.6) on admission He was noted to be iron deficient and he was placed on iron supplementation appears malnourished. Electrolyte imbalances improved He only had total laryngectomy (in August 2016), no [MEDICAL CONDITION] or [MEDICAL CONDITION] workup done is unclear. Other hospital lab and test results on 1/27/17 were as follows: White Blood Count=28.8 (normal range 4.0-11.3), a sign of infection. Potassium=2.8 (3.5-5.3), a sign of dehydration. Blood Urea Nitrogen (BUN)=42 (9-28), a sign of kidney malfunction. Radiographic (X-ray) findings consistent with left lower lobe pneumonia. The resident's tube Feeding care plan initiated 10/11/16 noted: maintain adequate nutritional and hydration status no signs/symptoms of malnutrition or dehydration Cleanse (tube) insertion site with soap and water daily and PRN. The resident's [MEDICAL CONDITION] (trach) care plan initiated 10/11/16 noted: Resident will have clear and equal breath sounds bilaterally will have no abnormal drainage [MEDICAL CONDITION] Ensure [MEDICAL CONDITION] (used to hold [MEDICAL CONDITION] properly in place) are secured at all times Observe/document for increased heart rate Observe/document mental status and lethargy observe/document respiratory rate, depth and quality. Check and document every shift (There was no mention of monitoring/documenting oxygen levels.) On 10/13/16, 10/14/16 and 12/22/16, the resident was prescribed:[MEDICAL CONDITION] and suctioning every shift and PRN. The resident's 'facility' clinical record revealed the following events prior to hospitalization : 11/4/16 Nurse Practitioner (NP) note-Trach completely out (an indication that the tube was not securely tied), complaining of difficulty breathing, suctioned for thick copious secretions, after care completed (tube re-inserted), he denied shortness of breath, appointment with surgeon as ordered. 11/17/16 nutritional note-significant weight loss in one month, recommend 1 can of tube feeding formula at 11 PM and continue 1 and 1/2 cans 4 times a day (a total of 7 cans) and 2,610 cc of water daily, resident receptive to increase in formula to promote weight gain. 12/5/16 nutrition note-resident ate 25% of a puree diet, working with speech therapy, continue tube feeding until oral food intake is consistent. 12/22/16 nutritional notes-poor intake of oral puree diet, will increase the formula (however, physician orders [REDACTED].) 1/3/17 nursing note-Continues to have dried frank blood [MEDICAL CONDITION] Area around opening continues slight blood. 1/9/17 NP note-Staff reported open area [MEDICAL CONDITIONS], crusted lacerations noted at site, wound consult-trach site. 1/12/17 nursing notes-signs of distress with labored breathing, oxygen level 93%, temperature 101.8, unable to clean [MEDICAL CONDITION], while cleaning [MEDICAL CONDITIONS] observed coming out of throat (an indication that the tube was not tied), pain [MEDICAL CONDITION], physician order [REDACTED]. (Per a hospital emergency room record dated 1/12/17, the resident was seen for [MEDICAL CONDITION] complication.) 1/17/17 order-cleanse gastric tube insertion site with soap and water. 1/18/17 NP note-spoke with staff regarding insurance, needed to see [MEDICAL CONDITION] doctor. There were no documented progress notes by the resident's physician. The physician was not available for comment and could not be reached by phone. There was no documented blood work in the clinical record for 11/2016 thru 1/2017. There were only three documented oxygen levels (on 10/11/16, 10/12/16, 11/5/16) in the record prior to 12/19/16. On 12/19/16, the resident was prescribed: Daily vital signs-afternoon shift document in (electronic clinical record). One oxygen level was obtained on 12/21/17. On 12/22/16, the order was changed by nurse unit manager 'H' to: vital signs 'weekly' every day shift every Thursday for monitoring 'blood pressure'. The oxygen levels were then monitored weekly (on 1/5/17, 1/12/17, 1/19/17 and 1/26/17). On 2/23/17 at 9:40 AM, a family representative (Rep) for resident #706 reported the following during a phone interview: The resident did not get shaved, a haircut, fingernails trimmed or received showers. She would frequently come in and see where the resident had his call light on and staff not responding for 30 minutes with no staff in sight. The Rep said that the resident was often found to be in need of suctioning and having problems breathing due to a build up of mucous and said, You would think they would have checked on him more often by him having a trach. When the Rep met the resident at the hospital on [DATE], he smelled really bad, complained of pain and itching to his legs and his legs looked like alligator skin. (On 2/23/17 at 2 PM, the resident's bath/shower sheets and shower schedule were presented by MDS nurse 'N' and reviewed. The resident was to receive showers twice a week. Nurse 'N' provided all of the documented bath/shower sheets that she said she could find. There were a total of five sheets dated 11/11/16, 11/30/16, 1/12/17, 1/23/17 and 1/26/17. Bed baths were given and one documented shower (on 11/30/16). There was only one documented Weekly Head To Toe skin assessment (dated 10/16/16) in the clinical record for the resident. The Rep said that the resident was supposed to have a follow-up appointment [MEDICAL CONDITIONS], but it was not arranged and felt that the resident'[MEDICAL CONDITION] may have spread because he did not receive further treatment as recommended. A consultation report dated 11/17/16 from the resident's appointment with an ear/nose/throat (ENT) specialist, noted: Recommendation chemo-[MEDICAL CONDITION]. Patient should be referred to (cancer institute) Medical oncology, [MEDICAL CONDITION] oncology, Head and Neck Surgery (departments). There was an order dated 11/23/16 by facility staff: Refer to (cancer institute) Medical oncology, [MEDICAL CONDITION], Head and Neck Surgery). On 2/23/17 from 11:15 AM to 11:45 AM, unit clerk 'A', who was responsible for scheduling appointments, nurse 'H' and the DON were interviewed regarding the order for the follow up appointment at [MEDICAL CONDITION] center. Staff 'A' and the DON said that the resident did not have insurance, so the appointment was not scheduled. There was no mention of insurance via the resident's Veteran status. When asked what happened on 11/23/16 when the order was written and the resident still had insurance, staff 'A' said, I don't know. I gave the order to (nurse 'H'). The order noted that nurse 'H' signed it on 1/12/17. When asked what happened with the referral order, why so much time had passed between the order date and the date that she signed it and if she had notified her superiors (Administrative staff) about this critical appointment and insurance concerns, nurse 'H' responded, I don't schedule appointments. I don't have anything to do with that. The DON did not respond. The Administrator was then asked about the appointment not being scheduled and he said, I didn't know anything about it. I wasn't told. Had I known, I would have told them to go ahead and send him to the appointment. Nurse 'H' was asked in the presence of the DON, why she changed the resident's order for monitoring of vital signs, from every shift to once a week. She said, He didn't have any orders for vitals at all, so I wanted to make sure that everyone got vitals taken at least once a week. She said that she decided to establish orders for each resident to have vital signs monitored at a minimum of once a week. She looked through the resident's paper chart and electronic record, saw the 12/19/17 order for daily vitals and did not respond why this resident, with his medical history, [MEDICAL CONDITION] suctioning and with a feeding tube inserted, was being monitored the same as any other resident without these tubes and direct, open ports for introduction of infectious organisms. When shown the 1/27/17 hospital record and asked why the resident presented to the hospital as described in the hospital record, nurse 'H' did not respond. The hospital records contained a hospital ENT specialist' noted on 2/3/17: (The resident) has a history of [MEDICAL CONDITION] and underwent total laryngectomy in summer of 2016. It does not appear he ever followed up [MEDICAL CONDITION] surveillance visits or post-op [MEDICAL CONDITION] and [MEDICAL CONDITION]. On 2/24/17 at 8 AM, per review of the facility's Abuse and Neglect Prohibition policy dated 1/2017: Each resident has the right to be free from neglect Neglect means a failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

This citation pertains to intake #MI 110, #MI 117, #MI 169 and #MI 298. Based on observation, interview and record review, the facility failed to properly assess, monitor and implement appropriate care and services for two (#706 and #708) sampled residents, who had [MEDICAL CONDITION] (breathing tube inserted through the throat) and gastric (inserted through the abdomen) feeding tubes and an arterial/vascular wound, out of 11 sampled residents reviewed for quality of life from a total of 11, resulting in missed medical appointments essential for health maintenance and/or restoration, emergency hospitalization for decline in health status and the potential for further compromise in physical well-being. Findings include: Resident #706- The complainant reported in writing that resident #706 was sent from the facility to the hospital in a compromised medical state. On 2/22/17 at 10 AM, the resident's clinical record and hospital records were reviewed. The resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] noted that the resident was independent with cognition, non-ambulatory, able to fully communicate, required extensive assistance with hygiene and bed mobility, total assistance with bathing and was incontinent with bowel/bladder. The resident was transferred to the hospital on [DATE] in respiratory distress and did not return. There was no documented indication of Do Not Resuscitate in the resident's clinical record should he have a cardiopulmonary arrest. His Death With Dignity care plan initiated 11/25/16 noted that the resident wished Full Code (resuscitation). The chart indicated that the resident was a Navy veteran. Per review of a hospital History and Physical dated 1/27/17, the resident was admitted into the hospital on [DATE] for the following: presented from the nursing home with worsening lethargy and hypoxemia (oxygen saturations in the low 70) Patient was reportedly found to be desaturating. Per EMS reports, patient was hypoxemic in low 70s. It was unclear if it was on oxygen, however, EMS had placed a non-rebreather (oxygen) mask at 15 liters/minute, bringing up his oxygen saturations to mid 90's. Furthermore, it appears that the patient was quite neglected at Hope Nursing (facility) as he was covered in stools, had over 1300 milliliters (of urine) in his bladder after inserting a urinary catheter and his (gastric feeding tube insertion) site was completely crusted over It is also unknown how long the patient has been experiencing oxygen desaturations and [MEDICAL CONDITION](rapid heart rate). Patient is currently denying any chest pain, but admits to shortness of breath. He nodded his head in regards to his symptoms becoming progressively worse the past few days. Furthermore, his calcium (level) was noted to be 15.7 (normal range=8.5-10.2) Aggressive measures to decrease patient's calcium were initiated. An elevated calcium level can be caused by factors, such [MEDICAL CONDITION] and dehydration that can cause kidney damage. Per nursing notes dated 1/28/17, the resident's blood pressure was 100/51, pulse 127 and oxygen saturation level was 77% (normal range=95-100%) when he was transported to the hospital. At 10:15 AM, the Director of Nursing (DON) read the hospital record, shook her head and did not respond regarding the resident's appearance and condition when he arrived at the hospital on [DATE]. She did not respond how and why the resident was dehydrated if he was receiving the tube feeding formula and water by nursing staff as prescribed. The hospital record further noted: (The resident) was admitted for (facility) acquired pneumonia, severe hypercalcemia and he was given aggressive intravenous (IV) hydration and Calcitonin (used to decrease calcium blood levels). He also had acute kidney injury (a sign of dehydration). He was severely dehydrated and had [DIAGNOSES REDACTED] and [MEDICAL CONDITION] (elevated potassium and sodium levels) He has [MEDICAL CONDITIONS] His respiratory cultures are positive for [MEDICAL CONDITION]-resistant Staphylococcus (MRSA bacteria) Per an Oncology consult dated 2/1/17: It appears there are hygiene issues at Hope Nursing (facility). He was treated appropriately with antibiotics and was given IV fluids He responded well to IV fluids and calcitonin He was noted to have severe [MEDICAL CONDITION] with hemoglobin down to 7.1 (normal range=13.6-17.6) on admission. He had an endoscopic workup revealed mild gastritis and a small hiatal hernia He was noted to be iron deficient and he was placed on iron supplementation appears malnourished. Electrolyte imbalances improved He only had total laryngectomy (in August 2016), no [MEDICAL CONDITION] or [MEDICAL CONDITION] workup done is unclear. Other hospital lab and test results on 1/27/17 were as follows: White Blood Count=28.8 (normal range 4.0-11.3), a sign of infection. Potassium=2.8 (3.5-5.3), a sign of dehydration. Blood Urea Nitrogen (BUN)=42 (9-28), a sign of kidney malfunction. Radiographic (X-ray) findings consistent with left lower lobe pneumonia. The resident's tube Feeding care plan initiated 10/11/16 noted: maintain adequate nutritional and hydration status no signs/symptoms of malnutrition or dehydration Cleanse (tube) insertion site with soap and water daily and PRN. The resident's [MEDICAL CONDITION] (trach) care plan initiated 10/11/16 noted: Resident will have clear and equal breath sounds bilaterally will have no abnormal drainage [MEDICAL CONDITION] Ensure [MEDICAL CONDITION] (used to hold [MEDICAL CONDITION] properly in place) are secured at all times Observe/document for increased heart rate Observe/document mental status and lethargy observe/document respiratory rate, depth and quality. Check and document every shift (There was no mention of monitoring/documenting oxygen levels.) The resident's 'facility' clinical record revealed the following details of events that occurred prior to hospitalization : 10/13/16 and 10/14/16 orders-trach care and suctioning every shift and PRN (as needed). 11/4/16 Nurse Practitioner (NP) note-Trach completely out (an indication that the tube was not securely tied), complaining of difficulty breathing, suctioned for thick copious secretions, after care completed (tube re-inserted), he denied shortness of breath, appointment with surgeon as ordered. 11/17/16 nutritional note-significant weight loss in one month, recommend 1 can of tube feeding formula at 11 PM and continue 1 and 1/2 cans 4 times a day (7 cans total, provided by nursing staff), recommend flushing with 60 cc (cubic centimeters) of water pre and post bolus and 250 cc of water every shift to provide 2,610 cc of water daily, resident receptive to increase in formula to promote weight gain. 12/5/16 nutrition note-resident ate 25% of a puree diet, working with speech therapy, continue tube feeding until oral food intake is consistent. 12/9/16 NP note-[MEDICAL CONDITION] capped (meaning [MEDICAL CONDITION] was not being used at that time in order to breathe, but was left in place if needed.) 12/22/16 nutritional notes-poor intake of oral puree diet, will increase the formula (however, physician orders [REDACTED].) 12/22/16 order-trach care and suctioning every shift and PRN. 1/3/17 nursing note-Continues to have dried frank blood [MEDICAL CONDITION] Area around opening continues slight blood. 1/9/17 NP note-Staff reported open area [MEDICAL CONDITIONS], crusted lacerations noted at site, wound consult-trach site. 1/12/17 nursing notes-signs of distress with labored breathing, oxygen level 93%, temperature 101.8, unable to clean [MEDICAL CONDITION], while cleaning [MEDICAL CONDITIONS] observed coming out of throat (the tube was not secured), pain [MEDICAL CONDITION], physician order [REDACTED]. (Per a hospital emergency room record dated 1/12/17, the resident was seen for [MEDICAL CONDITION] complication.) 1/17/17 order-cleanse gastric tube insertion site with soap and water. 1/18/17 NP note-spoke with staff regarding insurance, needed to see [MEDICAL CONDITION] doctor. There were no documented progress notes by the resident's physician. The physician was not available for comment and could not be reached by phone. There was no documented blood work in the clinical record for 11/2016 thru 1/2017. There were only three documented oxygen levels (on 10/11/16, 10/12/16, 11/5/16) in the record prior to 12/19/16. On 12/19/16, the resident was prescribed: Daily vital signs-afternoon shift document in (electronic clinical record). One oxygen level was obtained on 12/21/17. On 12/22/16, the order was changed by nurse unit manager 'H' to: vital signs 'weekly' every day shift every Thursday for monitoring 'blood pressure'. The oxygen levels were then monitored weekly (on 1/5/17, 1/12/17, 1/19/17 and 1/26/17). On 2/23/17 at 9:40 AM, a family representative (Rep) for resident #706 reported the following during a phone interview: The resident did not get shaved, a haircut, fingernails trimmed or received showers. She would frequently come in and see where the resident had his call light on and staff not responding for 30 minutes with no staff in sight. The Rep said that the resident was often found to be in need of suctioning and having problems breathing due to a build up of mucous and said, You would think they would have checked on him more often by him having a trach. When the Rep met the resident at the hospital on [DATE], he smelled really bad, complained of pain and itching to his legs and his legs looked like alligator skin. (On 2/23/17 at 2 PM, the resident's bath/shower sheets and shower schedule were presented by MDS nurse 'N' and reviewed. The resident was to receive showers twice a week. Nurse 'N' provided all of the documented bath/shower sheets that she said she could find. There were a total of five sheets dated 11/11/16, 11/30/16, 1/12/17, 1/23/17 and 1/26/17. Bed baths were given and one documented shower (on 11/30/16). There was only one documented Weekly Head To Toe skin assessment (dated 10/16/16) in the clinical record for the resident. The Rep said that the resident was supposed to have a follow-up appointment [MEDICAL CONDITIONS], but it was not arranged and felt that the resident'[MEDICAL CONDITION] may have spread because he did not receive further treatment as recommended. A consultation report dated 11/17/16 from the resident's appointment with an ear/nose/throat (ENT) specialist, noted: Recommendation chemo-[MEDICAL CONDITION]. Patient should be referred to (cancer institute) Medical oncology, [MEDICAL CONDITION] oncology, Head and Neck Surgery (departments). There was an order dated 11/23/16 by facility staff: Refer to (cancer institute) Medical oncology, [MEDICAL CONDITION], Head and Neck Surgery). On 2/23/17 from 11:15 AM to 11:45 AM, unit clerk 'A', who was responsible for scheduling appointments, the facility business office manager (staff 'I'), nurse 'H' and the DON were interviewed regarding the order for the follow up appointment at [MEDICAL CONDITION] center. There was a hand written note by staff 'A' dated 1/11/17 next to the order: No insurance, can not make appointment, Medicaid pending, therefore, staff A' said that she did not schedule the appointment. Staff 'I' provided paperwork noting that the resident had insurance until 11/30/16, then was dis-enrolled and awaiting a decision for Medicaid enrollment, which did not get approved until 2/1/17, after the resident had already been discharged from the facility. There was no mention of insurance via the resident's Veteran status. When asked what happened on 11/23/16 when the order was written and the resident still had insurance, staff 'A' said, I don't know. I gave the order to (nurse 'H'). The order noted that nurse 'H' signed it on 1/12/17. When asked what happened with the referral order, why so much time had passed between the order date and the date that she signed it and if she had notified her superiors (Administrative staff) about this critical appointment and insurance concerns, nurse 'H' responded, I don't schedule appointments. I don't have anything to do with that. The DON did not respond. The Administrator was then asked about the appointment not being scheduled and he said, I didn't know anything about it. I wasn't told. Had I known, I would have told them to go ahead and send him to the appointment. Nurse 'H' was asked in the presence of the DON, why she changed the resident's order for monitoring of vital signs, from every shift to once a week. She said, He didn't have any orders for vitals at all, so I wanted to make sure that everyone got vitals taken at least once a week. She said that she decided to establish orders for each resident to have vital signs monitored at a minimum of once a week. She looked through the resident's paper chart and electronic record, saw the 12/19/17 order for daily vitals and did not respond why this resident, with his medical history, [MEDICAL CONDITION] suctioning and with a feeding tube inserted, was being monitored the same as any other resident without these tubes and direct, open ports for introduction of infectious organisms. When shown the 1/27/17 hospital record and asked why the resident presented to the hospital as described in the hospital record, nurse 'H' did not respond. The hospital records contained a hospital ENT specialist' noted on 2/3/17: (The resident) has a history of [MEDICAL CONDITION] and underwent total laryngectomy in summer of 2016. It does not appear he ever followed up [MEDICAL CONDITION] surveillance visits or post-op [MEDICAL CONDITION] and [MEDICAL CONDITION]. Recent imaging is very suspicious for metastatic disease (spread of [MEDICAL CONDITION]). The resident was transferred from hospital (#1) on 2/4/17 to hospital (#2) where the laryngectomy was performed. The transfer/discharge summary from hospital #1 noted: (Resident) was clinically improving. The plan was for follow up with his specialists at (hospital #2). He was evaluated by Oncology prior to discharge. They recommended CAT Scan imaging of his neck and thorax. Unfortunately, this suggested metastatic spread of [MEDICAL CONDITION] to both lungs. More concerning was likely metastatic disease of the [MEDICATION NAME] spine. Resident #708- The complainant/vascular physician's office manager reported via e-mail and during a phone interview on 2/21/17 at 4:20 PM about resident #708: He had gangrene of the left third toe and was scheduled for an angiogram (to determine a blockage in blood flow) and debridement (removal of dead tissue) on 2/7(17), but he missed the appointment. We scheduled a second one on 2/9 (17) and he was a no show. We scheduled a third one for 2/23 (17). I spoke to (nurse unit manager 'H') last week on Tuesday (2/14/17) about this and offered solutions about these appointments, but was blown off. This is a repeat of a pattern with Hope (the facility). Instructions were faxed to two fax numbers given for Hope. Specifically one directly to (nurse 'H's) office. I confirmed the appointment and so did the Cardiac Cath lab at (the hospital). This is our business, we know how to do it to best serve all our patients. Down time for a surgeon and a cath lab is rare because we are so busy. I have seven patients waiting for a time slot at any given day. We don't mess around by failing to notify a facility, let alone multiple times for the same patient. Again, this is a pattern of no shows for surgery for [REDACTED]. On 2/22/17 at 11:30 AM, the resident was observed sitting in a wheelchair in the hallway. The resident was confused and unable to reliably respond to most questions. He had an amputated right leg and had the fourth and fifth toes amputated from the left foot. The left foot was swollen and placed directly on the floor without a sock or shoe. There was a red sore covering the top of the third toe, that was on the floor with no protective dressing. The DON was immediately asked about the resident's foot and wound and said that his foot should have had a dressing on it and elevated. The remaining toes were covered with large, black, scaly, lifting flakes of skin. The DON said that his foot should have been covered and elevated and did not respond regarding his overall appearance. When asked about appointments for the resident's angiogram and debridement, the DON and staff 'A' looked for scheduled appointments in the resident's clinical record and found the consultation for the office visit on 1/20/17. The report noted that the resident's foot was cool to the touch and there was drainage at that time from an ulcer on the heel. The angiogram was recommended with interventions to improve blood flow and noted, I again suspect worsening skin necrosis (dead tissue) related to underlying peripheral artery disease (PAD). Staff 'A' said, I don't know anything about an appointment for him. There's nothing in the chart. No appointment was set up. When asked about the process for making appointments, the DON explained: When they come back from appointments, a (appointment) slip is given to the nurse and the nurse gives it to the clerk (staff 'A') to set up the next appointment. Staff 'A' presented a binder of appointments and said that there was none set up for the resident and there were no slips or notes in the attending physician's book about follow up appointments. On 2/22/17 at 1:30 PM, the resident's clinical record was reviewed and revealed: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] noted that the resident had severe cognitive impairment, difficulty communicating and was non-ambulatory and exhibited no behavior regarding rejection of care. The resident's 1/2017 treatment record noted an order dated 1/7/17: Cleanse open area on top of 3rd toe on left foot with wound cleanser, pat dry and apply triple antibiotic ointment and a dry dressing every shift and PRN until wound care (specialist) evaluates and treats. The record indicated that wound care was not performed on 1/8/17, 1/20/17 thru 1/22/17 and 1/26/17 thru 1/30/17 on any shift. The 2/10/17 wound record noted that care was not provided on 2/3/17, 2/10/17, 2/14/17 and 2/19/17 on any shift. The resident's Health Maintenance care plan initiated 7/19/16 noted: I am at increased risk for complications related to acute and chronic illnesses Diagnoses: [REDACTED].

This citation pertains to intake #MI 298 and #MI 110. Based on observation, interview and record review, the facility failed to properly document wound care and assessments, provide wound care treatment as prescribed, implement timely and consistent pressure relief measures and ensure adequate stock of wound care supplies for two (#709 and #711) of three sampled residents reviewed for pressure sores from a total of 11, resulting in development of facility acquired pressure sores and the potential for delayed wound healing, infection from wound contamination, development of further sores and decline of existing pressure sores. Findings include: Resident #711- On 2/22/17 at 12:20 PM, resident #711 was overheard crying and yelling out into the hallway and was lying on her back. When asked what was wrong, the resident did not answer and was immobile. Nurse aide 'R' was asked if she had changed the resident since the start of the day shift and said yes. When asked to observe the resident's skin, aide 'R' and nurse 'S' entered the room. They were asked if the resident had any sores. The aide said yes. The nurse looked puzzled and said to the aide, She has a sore? They unfastened the resident's incontinence brief and turned the resident to her side. The resident was incontinent of urine and feces and had a large, deep, open pressure sore on the coccyx that was not covered with a dressing. When asked why there was no dressing and if one was present when she was last changed, aide 'R' said, She didn't have one on. When asked if the previous shift nurse had reported off to her that the resident had a sore and if aide 'R' had told her that the resident did not have a dressing after being changed, nurse 'S' said no. When asked if the nurse should have been told about the missing dressing, the aide said yes. The resident had foam pads on bilateral ankles and on the left hip, all dated 2/18/17 and she was wearing bilateral pressure relief heel protectors. The foam pad on the right ankle was completely saturated with dark brown/yellow drainage with a pressure sore underneath. The pad on the left ankle was totally saturated with dark brown/yellow drainage that covered a pressure sore, which had drained heavily into the heel protector. Approximately 15 minutes later, the wound care specialist (physician) and restorative aide 'Q' entered the resident's room during rounds to assess and measure the sores. The right ankle sore measured 3 centimeters (cm) by 2 cm and was identified as stage IV (full thickness skin loss down to bone). The left ankle sore measured 2.2 cm by 2.8 cm and identified as a stage IV. The coccyx sore measured 5.5 cm by 6 cm by 1.5 cm deep at a stage IV. The specialist demonstrated with the measuring tape that the sore had undermining (was larger in diameter underneath the wound surface than it appeared from above). All of the sores were facility acquired. The specialist was about to leave the room and was told that there was a pad on the left hip. He said, Oh, that's new. The pad was saturated with dark brown/yellow drainage, but a closed, bright red, non-blanchable (stage I) pressure sore was observed underneath the pad measuring approximately 1.5 cm. The specialist said, Where did all that drainage come from? The skin is closed. Aide 'Q', who typically conducted rounds with the specialist, said, It looks like a dressing was removed from the ankle and put up here (on the hip). The drainage looks the same. When informed that there was no dressing on the coccyx sore earlier when the resident was changed, the specialist said, What happened to it? That's not good. It was infected about a month ago. That's why I ordered Dakin's (a bleach-type antiseptic solution that kills most forms of bacteria [MEDICAL CONDITION]). I am trying to keep it clean. That's not good. On 2/23/17 at 12 noon, a review of the resident's clinical record revealed: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] noted the resident had moderately impaired cognition, was non-ambulatory, incontinent of bowel/bladder, required extensive assistance for bed mobility and had one-stage I and three-stage IV pressure sores. The MDS dated [DATE] noted the resident had no pressure sores. The resident's Braden pressure ulcer risk assessment dated [DATE] noted that the resident was at risk for development. The Braden assessment dated [DATE] noted moderate risk and the assessment dated [DATE] noted very high risk. The resident's Actual Skin Breakdown care plan initiated 12/8/16, noted Provide wound care per order. It did not note interventions related to pressure relief specific for feet, such as heel protectors or floating the feet nor did the resident's Actual Impairment to Skin care plan initiated 8/18/16. There was no documented care plan indicating that the resident was resistant to care, such as turning/repositioning or wearing heel protectors. Head to Toe Skin check records dated 8/30/16 and 10/5/16 noted that the resident had no pressure sores. However, per a Weekly Pressure Ulcer record dated 10/5/16, the resident was noted to have new pressure sore on 'left' ankle measuring 1.5 cm by 1 cm. There were no documented weekly records after 10/12/16. A Head to Toe Skin check record dated 10/19/16, noted sores on 'both' ankles. 10/2016- On 10/9/16, the resident was prescribed heel protectors at all times. Per the resident's treatment record for 10/2016, heel protectors were applied only on 10/9/16 and 10/11/16. Per physician orders, the resident was prescribed wound treatments and dressings daily and PRN (as needed) beginning 10/10/16 for a stage II (partial skin thickness loss) left ankle pressure sore. There were no documented treatments provided for the left ankle from 10/21/16 thru 10/30/16. There was no mention of treatments for the right ankle in 10/2016. 11/2016- Beginning on 11/3/16, the resident was prescribed wound treatments daily and PRN for the right ankle. On 11/10/16, nurses noted that the resident had a stage I pressure area on the sacrum. There was no documented indication that a protective dressing was applied to the area on 11/2016 treatment records. The treatment record noted that the right ankle was treated 10 out of 27 days and the left ankle was treated 10 out of 30 days in November. Nursing notes on 11/10/16 noted that the left ankle sore was at stage III (full thickness skin loss) and the right ankle sore was at stage II with an odor present. On 11/15/16, the resident was prescribed Keflex (antibiotic) every 8 hours to start after wound culture results were obtained. On 11/18/16, the physician noted that he reviewed the culture results, both ankle sores were infected and prescribed Keflex every 12 hours for 14 days. Per the medication record, 11 of the 28 doses were missed from 11/19/16 thru 11/30/16. There were no documented wound measurements provided as requested for 11/2016. 12/2016- The 12/2016 treatment record noted that sores to bilateral ankles were treated 12 out of 31 days. Beginning 12/9/16 thru 12/15/16, the resident was prescribed Dakins soaked gauze packed into the sacral sore, once a day. There were no documented wound measurements provided as requested. The sore was treated during that time on 12/10/16 and on 12/13/16, not daily as prescribed. On 12/15/16, the treatment was increased to twice a day, but the sore continued to be treated once a day on 8 out of 17 days from 12/15/16 thru 12/31/16. Per nursing and nurse practitioner (NP) notes dated 12/20/16, the NP said that the sacral wound was getting worse, had an odor and [MEDICATION NAME] (antibiotic) was prescribed for 10 days. The resident's Skin Integrity care plan noted that on 12/8/16, a pressure relief specialty mattress was initiated. 1/2017- The 1/2017 treatment record indicated that the bilateral ankle pressure sores were treated five out of 31 days and the sacral sore was treated once a day on six dates, twice a day on three dates from 1/1/17 thru 1/18/17 and the ankle sores were treated five days during the same period. The resident was hospitalized from [DATE] thru 1/26/17 due to copious amount of blood coming from her wound on her coccyx. Resident had a debridement of wound today on day shift with the wound care Dr. Resident has a pool of blood and multiple clots, massive bleeding per a change in condition (SBAR) form. There was no documented wound care from 1/26/17 thru 1/31/17 on the treatment record to any of the pressure sores. On 1/4/17, heel protectors at all times were prescribed. The record noted that they were applied 15 out of 31 days. There was no mention of heel protectors on the treatment records for 11/2016 and 12/2016. 2/2017- On 2/9/17, the resident was prescribed treatment to bilateral ankles sores once a day and Dakins solution once a day to the sacral sore. The 2/2017 treatment record indicated that the sores were treated one time on 2/18/17. There was no mention of heel protectors. All wound records by the specialist were requested. Records were provided for 1/18/17, 2/1/17, 2/8/17 and 2/15/17. On 2/15/17, the specialist noted that the wounds measured as follows: Left ankle-stage IV, 3 cm by 2.5 cm by 0.2 cm. Right ankle-stage IV, 3 cm by 2 cm by 0.3 cm. Sacrum-stage IV, 6 cm by 7 cm by 1.5 cm. On 2/23/17 at 3:30 PM, when the Director of Nursing (DON) was asked how and why the pressure sores developed and then advanced to stage IV and informed that there was no dressing on the resident's previously infected sacral wound, the DON said, I don't know. I will have to find out and said that the wound should have been covered. Resident #709- On 2/22/17 at 10:40 AM, resident #709 was observed lying on his back. The resident was alert and oriented and was paralyzed from the chest down with limited movement to the left arm. He had a call light pad positioned next to his cheek to press for assistance and a suprapubic urinary catheter. He said that he was supposed to be turned and repositioned every two hours, but was last repositioned at 6:30 AM by midnight shift staff. When asked to be turned at 9 AM, he was told by staff that he would have to wait until all of the residents were fed breakfast and the breakfast trays were picked up. He said that he needed to be turned every two hours, but usually had to wait because staff always said that there was not enough staff help and that his call light stayed on for an extended period of time, at least 30 minutes or more. The resident said that on 2/21/17 at 2:30 PM, nurse unit manager 'H' came to reposition him and give him a daily suppository. He said, I asked her to keep the routine of leaving the same old wound dressing on until I had my bowel movement so the wounds could be protected from the bowel movement and then I could be cleaned up and then get new wound dressings, but she was so busy talking about how she testified against a man who hurt his daughter and went to jail. She was so caught up in her story she forgot what I said and took the wound dressing off. I didn't know until 6 (PM) when I was getting cleaned up and (nurse aide 'T') said, You know that you don't have any dressing over your wounds and the bowel movement got all around the wounds.' My dad came in around 7 (PM) and saw me turned over and the (afternoon shift) nurse said, 'We don't have any more wound care supplies,' so I had to wait for my dad to get supplies (from home). The nurse tried to find supplies and improvise and said no more supplies would be in for 2 days. His father left, retrieved the dressings from a home supply, returned and he dressed the sores himself. On 2/22/17 at 11 AM, the resident's skin was observed with the wound care specialist and nurse unit manager 'H' in the presence of the resident's father. When turned to his side, saturated foam pads fell from pressure sores on the coccyx and left ischium. The father said, I put those on. I had to get some from home because they ran out. A large amount of wound drainage was observed on blue plastic bed pads (provided from home) and on the underlying cloth bed pad. When asked how often the resident's wound dressings were to be changed, nurse 'H' said, once a day and PRN. The resident said that his dressings were being changed twice a day at the hospital before admission. When asked why the resident was not repositioned, which would have allowed staff to see that the dressings needed to be changed and asked why the wound supplies were not available, nurse 'H' said she did not know. She said that wound supplies were due to be delivered the next day. The wound specialist measured and described the wounds, which were present on admission, as follows: Coccyx-2 cm by 1 cm at stage III with heavy drainage. Left ischium-3 cm by 2.3 cm x 4 cm deep at stage IV with heavy drainage. On 2/22/17 at 4 PM, when asked about the resident not having a dressing on 2/21/17, aide 'T' said, Yes, it was off and he had a bowel movement and the nurse said that she didn't have any supplies and would have to improvise. The resident reported the following which was also documented like a journal in his cell phone: On 2/11/17, he was repositioned at 5 PM and did not get turned again until 9 PM, which was done by his father. On 2/12/17, he was turned at 7 AM, put the call light at 9 AM to be repositioned, 10 AM came around and the call light was unanswered. His father came to visit and turned the resident. On 2/13/17, the resident received a suppository at 11 AM and called at 12:40 PM to be cleaned up and get his soiled dressing changed on the sacral wound. No one came to do it, but staff kept saying that they would. At 3 PM, he was still lying in stool and did not get cleaned up, the dressing change or repositioned until 3:50 PM. On 2/23/17 at 2 PM, the resident's clinical record was reviewed and revealed: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS was unavailable. The Braden assessment dated [DATE] noted that the resident was at risk for development of pressure sores. He was prescribed a rectal suppository once a day. On 2/9/17, the physician prescribed wound treatments daily and bordered foam dressings to cover the wounds. His Nursing Initial Plan of Care dated 2/4/17 noted interventions that included: Provide wound care per physician orders [REDACTED]. On 2/24/17 at 8 AM, per review of the facility's policies on Standards of Care for Certified Nursing Assistant (CNA) Practice dated 2/2017 and Skin Management dated 8/2012: CNA required skills include: Assisting the resident in ADLs, such as turning and repositioning, bathing, grooming and toileting. Appropriate preventive surfaces should be implemented for all residents identified at risk for pressure sores and the interventions documented on the care plan. Appropriate interventions should be implemented to promote healing, such as the physician orders [REDACTED]. Change position in bed every two hours for dependent residents. The DON said that there was no facility policy regarding the ordering of wound care supplies to ensure adequate stock on hand.

This Citation Refers to Intake Number MI 242 Based on interview and record review, the facility failed to provide adequate supervision and a fully functioning alarm system that did not properly register at the nursing station, which allowed one resident (#802) of three residents reviewed as having exit seeking behavior to exit the facility through an alarmed door unbeknownst to staff who failed to properly respond with facility protocols until the facility was later called and notified by the police. This deficient practice had the potential to result in serious harm, injury or death, and required immediate corrective action. Findings Include: On 1/19/17 at 11:55 a.m., during an interview and record review of the facility reported incident along with the Administrator, it was revealed that Resident #802 eloped from the facility on 1/3/17, and was not discovered missing until he was returned to the facility by the (city name) local police. It was also detected that the facility's door alarms were not properly functioning at nurses' stations #1 and #7 and Maintenance Technician (Tech) 'C' was called to the facility to check the doors. The Administrator further stated, I believe it was door #7 that Resident #802 left out, but I can't be sure . When Maintenance Tech 'C' arrived, he did a door check, and that's when it was discovered door #1 and #7 was not annunciating at the nurses' stations. The alarm was sounding, but it wasn't very loud. The Administrator was queried approximately what time did Resident #802 leave the facility? The Administrator stated, I don't know. No one knew he was gone until the police brought him back. On 1/19/17 at 12:10 p.m., Maintenance Tech 'C' was interviewed and stated, I check the doors three times a week. I didn't know door #1 and #7 were not lighting up at the nurses' stations. I reported the problem to the IT (Information Technology) Department. The problem was forwarded to (company name) who came out and made a door adjustment. On 1/19/17 at 12:30 p.m., an Immediate Jeopardy was identified. A review of the clinical record revealed Resident #802 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the unplanned discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #802 had modified independence for cognitive decision-making, received anti-psychotic medication 7 days of the assessment, and anti-anxiety medication 1 out of 7 days of the assessment. Further review of the MDS revealed Resident #802 had wandering behavior that occurred 1 to 3 days of the assessment. The admission elopement assessment, dated 12/28/16, documented that Resident #802 was not at risk for elopement. On 1/19/17 at approximately 1:00 p.m., the Administrator stated, Resident #802 started exhibiting exiting behaviors earlier in the day on 1/3/17. Resident #802 was reassessed for risk for elopement. The facility called the physician, and got an order for [REDACTED]. A review of the physician's orders [REDACTED]. The at risk for elopement care plan was initiated on 1/3/17 and documented the following: Focus: Resident #802 is an elopement risk/wanderer r/t (related to) adjustment to nursing home History of attempts to leave facility unattended, impaired safety awareness, and resident wanders aimlessly. Intervention: Check placement and function of safety monitoring device every shift. Observe location at regular and frequent intervals. Document wandering behavior. Orient resident to environment. Resident to be checked on every 15 minutes. The facility's investigation record contained statements which documented the following: Certified Nursing Assistant (CNA) 'D' stated, Saw Resident (#802) around 7:40 p.m. on the east side . Was walking him back to the room on the west side . Saw CNA 'E', she took him to his room 106. CNA 'E' stated, Resident #802 was walking the hall when my shift started. I took him to his room at 7:40 p.m., changed him, and gave him some water. Then sat him down and let him watch TV . Resident #802 kept trying to leave out his room while I was doing patient care on other residents, and I had to keep redirecting him to his room, over three times. The final time, Licensed Practical Nurse (LPN) 'F' heard Resident #802 getting loud and upset, and stepped in. He told me to just let him (resident) walk around . LPN 'F' stated, .Resident spotted walking down .hall .angry and resistive when took back to room. Reminded that resident's family was coming at 2100 (9:00 p.m.). Remained in room until shortly after 2100, then wandering in halls. At 2145 (9:45 p.m.), returned to building by (city name) police at this time . A statement taken from Resident #802's wife revealed the local police found him in the middle of the street after a motorist called and reported he was almost hit by a car. The local police took Resident #802 to the home where his wife resided. Resident #802's wife asked the local police to return him back to the facility, and to call her after he was there. A review of the facility's policy titled Elopement Management dated 2012 documented the following: .Practice Guidelines 9. a. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected to being missing, to the charge nurse or available nursing manager. b. If a resident is determined to be missing and cannot be located in the facility, staff is to immediately notify the Administrator and Director of Nursing and initiate the Missing Resident Guideline . 17. Director of Maintenance of designee will complete preventive maintenance. Instructions for preventive maintenance for door monitor testing, door range testing, function tester maintenance and elopement drills . On 1/19/17 at 1:30 p.m., an Immediate Jeopardy (IJ) was identified. On 1/19/17 at 2:55 p.m., the Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy that began on 1/3/17 as a result of the facility's failure to prevent the elopement and ensure safety for Resident #802, who displayed wandering behavior, risk for elopement, and the risk of serious harm, injury, or death, failed to properly respond with facility protocols, and ensure a fully functioning alarm system that properly registered at the nursing stations. A plan to remove the immediacy was requested. On 1/19/17 at 4:30 p.m., the surveyor confirmed that on 1/3/17, the facility had implemented the following to remove the Immediate Jeopardy: Element 1: Total head count of all residents in facility completed by line staff and 100% of all residents were accounted for. Total head to toe assessment completed, pain evaluation completed on Resident #802 with no negative findings upon return to facility. Vital signs were within normal limits. Administrator was notified and the IDT notified and came into facility and identified and completed total head count of all residents in facility. Resident #802 was initiated on 15 minute checks. All residents were accounted for. Immediate check of Resident #802 wander guard was checked and proper function was verified. Maintenance Assistance verified that exit doors were in proper working order. Doors #1 and #7 were identified as not functioning properly on sensor panel at the nursing station. The motion detector of door # 7 was disabled and corrected by Maintenance immediately. Door #1 was corrected by door tech on 01/04/17. Element #2: Verification completed on elopement book for elopement risk residents. All wander guards were checked for placement and function with no negative findings. Wander guard doors were checked for proper working condition with no negative findings. Element #3: Administrator in serviced Maintenance on proper function and working order of doors and wander guard systems. Floor staff was in serviced on policy and procedure of elopement management. Elopement drills were conducted on all shifts for 3 consecutive days and continue on a weekly basis. Elopement risk assessments were reviewed and changes were made as deemed necessary. Care plans were reviewed and deemed appropriate. Service Company was called on 1/4/17 and replaced audible tone and replaced with louder component. Service Company installed relay switch for door #7 on 01/19/17, but did not affect the operation of the door alarm. Element #4: Maintenance department/designee will conduct audits of all exit doors and wander guards for functioning 5 times per week. Facility will conduct elopement drill weekly for 6 months. Results of the audit will be brought by the maintenance department/designee to the Quality Performance Improvement Committee monthly for review. Any abnormal findings will immediately be corrected. Administrator will attain and sustain compliance. The IJ was removed, and the facility's deficient practice remained isolated with no actual harm, but with the potential for more than minimal harm that was not immediate jeopardy. ( )

This pertains to intake MI 904. Based on observation, interview, and record review, the facility failed to provide pain medication for one (#301) of three sampled residents reviewed for pain management from a total of three, resulting in prolonged pain, frustration and anxiety. Findings include: On 6/28/16 at 10 AM, resident #301 was observed lying in bed with a gastric tube feeding infusing. The resident was alert, oriented and had an indwelling urinary catheter and a [MEDICAL CONDITION]. The resident's nose was bleeding bright red blood and numerous bloody tissues were observed on the floor around the wastebasket. The resident was putting pressure on her nose to get the bleeding to stop. The resident said that she was taken to the hospital on [DATE], brought back the same day, and did not receive her pain medication ([MEDICATION NAME]) from 2 PM before she left, until about 9 AM the following morning. She said that she had put on her call light to ask for the pain pills, but no one responded to the call light. Resident #301 said that when a nurse aide finally answered the light at about 7 AM the following morning, the aide said that there was no available nurse to administer the pain pill. The resident said, I had so much pain, I couldn't even move. I was so anxious. It was frustrating. Where were they? I know a nurse was here somewhere. When asked what her pain level was at that time, on a scale of 1-10 with 10 being the worse, the resident said, It was beyond a 10 after spending all that time in ER (emergency room ). I had surgery on my back and my stomach. I am supposed to get it ([MEDICATION NAME]) every 4 hours. She described the abdominal pain as burning and the back pain as stabbing. On 6/28/16 at 1 PM, the clinical record and hospital records for resident #301 were reviewed. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The minimum (MDS) data set [DATE] noted that the resident had no cognitive impairment and experienced frequent, moderate pain. The resident was prescribed [MEDICATION NAME] (nerve pain) 200 milligrams (mg) 3 times a day, Tylenol 650 mg every 4 hours PRN (as needed), [MEDICATION NAME] 10 mg every 4 hours PRN and [MEDICATION NAME] 100 micrograms every 72-hours. Per hospital records, resident #301 was hospitalized from [DATE] thru 6/3/16 for jaundice due to liver failure and abdominal distention. On 6/5/16, nurses noted on the resident's medication record, that she was given [MEDICATION NAME] at 2:12 PM. She was then sent to theER on [DATE] and arrived by about 4:30 PM for epistaxis (nose bleed). The record noted The nose bleed has stopped, but she swallowed a lot of blood throughout the day and is now passing blood through her ([MEDICAL CONDITION]). The record also noted the resident's medical history included: [MEDICAL CONDITION] due to a spinal hematoma following back surgery, repair of an abdominal wall hernia, intestinal fistula, bowel resection, repair of incisional and ventral hernias and bilateral muscle flap closure of the abdominal wall. Per nursing notes, the resident returned from the ER by 9:45 PM. On 6/28/16 at 1:30 PM, resident #301's Medication Administration Records (MARs) were reviewed with the Director of Nursing (DON). The MARs noted that on 6/5/16, the resident had received [MEDICATION NAME] that day at 2:12 PM, but did not receive the next dose until 8:16 AM the following morning (6/6/16). When asked why, the DON was unable to explain and said, It looks like she didn't get it. At 3 PM, the resident was observed with dried blood that had dripped down the side of her abdomen and was holding her [MEDICAL CONDITION] bag that was leaking bright bloody drainage from around the outside of the bag, that she said was again coming from her nose. ( )

Based on observation, interview and record review the facility failed to halt food preparation and discard exposed food products during kitchen sanitization of a foul smelling, grey tinged liquid with observed black sludge containing grease and food particles coming from the grease trap and two floor drains resulting in an Immediate Jeopardy (IJ) which has the potential to cause serious foodborne illness for 106 of 109 Residents that receive meals prepared within the kitchen. The IJ was identified on 6/6/16 at 12:05 p.m. The IJ began on 6/6/16 at 8:20 a.m. Upon the initial tour of the kitchen at 8:20 a.m. the floor drains were noted to have a liquid substance containing black sludge. At 8:40 a.m., and again at 9:40 a.m. observations were made of uncovered food items being cooked and prepared while the kitchen was being sanitized from the black sludge greasy water. At 12:05 p.m., the same food items were observed being plated and loaded onto the cart for delivery to Residents for consumption. The Administrator was notified of the IJ on 6/6/16 at 2:20 p.m. A plan of correction was requested to remove the IJ. The IJ was removed on 6/6/16 at 4:45 p.m., when the facility submitted the acceptable plan of correction that was implemented and verified on site by the survey team. Although the IJ was removed, the facility's deficient practice was not corrected and remained at widespread with no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings Include: On 6/6/16 at 8:20 a.m. to 9:40 a.m. during a tour of the kitchen with the Dietary Manager (DM A) and the following observations were made: -8:20 a.m., a floor drain located in the dishwasher area was noted to have an approximate 36 inch () x 28 liquid circumference around the drain. The liquid contained a black sludge. DM A stated, We have a back up of the plumbing. I'll get ahold of maintenance. -8:40 a.m., the grease trap located under the three compartment sink was noted to have active liquids bubbling up from the floor extending to an approximate circumference of 24 x 36. The liquid was noted to contain floating grease particles. DM A stated, I just had the grease trap cleaned last week. -8:45 a.m., a floor drain located under the steamer (next to the cook top stove) was noted to have an approximate 28 x 56 liquid circumference around the drain. The liquid contained food particles. Observations at this time revealed two pans of vegetables (peas/carrot combination and corn) cooking uncovered on the stove top. DM A was heard directing kitchen staff to halt food production in the kitchen. A staff member from maintenance was observed with a wet/dry vacuum sucking up the liquid substance from around the grease trap, around the floor drains and from under the cook top stove. -8:55 a.m., a foul odor was noted in the air as kitchen and maintenance staff proceeded to vacuum and mop up the backed up liquids from around the drains and from under the stove. Observation at this time was made of the same two pans of vegetables cooking uncovered on the stove top. The Maintenance Director was observed in the kitchen and said that a plumbing company had been contacted to come out and snake (unclog) the drain. -9:40 a.m., DM A was observed mopping the kitchen floor in the food preparation area. DM A was interviewed and stated, I'm still sanitizing the kitchen. I'm the only one doing it. At this same time observation was made of Cook C preparing a pan of food. Cook C was interviewed and stated, I'm making rice for lunch today. On 6/6/16 at 12:00 p.m., while checking food temperatures for the lunch meal with Cook C observation was made (along with other food items) of a pan of peas/carrot combination, a pan of corn and a pan of rice located on the steam table. Cook C was asked if the pan of peas/carrot combination and the pan of corn were the same pans of vegetables that were observed cooking uncovered earlier on the top of the stove. Cook C stated, Yes. Those are the same pans of vegetables from earlier. Cook C was also asked if the pan of rice on the steam table was the same pan of rice that was observed being prepared at approximately 9:20 that morning to which she replied, Yes. That's the same pan of rice. At 12:05 p.m., observation was made of Cook C dishing up plates of food containing the potentially contaminated vegetables and rice. The plates were then put on a tray by the dietary staff and loaded onto a food cart for delivery to the residents for consumption. On 6/6/16 at 2:16 p.m., review of the facility's policy titled Environment dated May 2014 documented, It is the center policy that all food preparation areas, food service areas, and dining area will be maintained in a clean and sanitary condition .The Food Service Director will insure that all employees are knowledgeable in the proper procedures for cleaning all food service equipment surfaces. The policy did not indicate what staff were to do when drainage backed up into the kitchen from a floor drain. On 6/6/16 at 2:30 p.m., during an interview with the Administrator, he was asked about the facility's policy on kitchen sanitation and what actions should be taken to prevent cross contamination when potentially contaminated backflow backs up into the kitchen. The administrator stated he didn't have a policy that addressed kitchen drain backup, but his expectations would be that food production would be stopped and any potentially contaminated food should be discarded. ( ) The following plan of correction was submitted by the facility. Abatement of Immediate Jeopardy Date of Compliance: 6/6/2016- 4:45 p.m. Element 1: Certified Dietary Manager discarded all food products which were potentially exposed during the kitchen sanitation. Drain was cleaned / snaked by professional vendor on 6/6/2016 to eliminate blockage and prevent additional backup. Element 2: Certified Dietary Manager audited kitchen and food preparation areas to ensure that there were no additional food products which were potentially exposed during kitchen sanitation. No additional food products were identified. Director of Maintenance audited all drains in kitchen / food preparation to ensure unimpeded drainage with no evidence of backup. Element 3: Nursing Home Administrator in-serviced Certified Dietary Manager the Dietitian and Health Services Group Divisional Manager regarding the requirement that the facility must halt food preparation and discard exposed food products during kitchen sanitation, and that drains must be observed daily to ensure unimpeded drainage with no evidence of backup. (HCSG policies #015 and #031.) Certified Dietary Manager and/or Dietitian and/or Health Services Group Divisional Manager in-serviced dietary personnel regarding the requirement that the facility must halt food preparation and discard exposed food products during kitchen sanitation. (HCSG policies #015 and #031.) Nursing Home Administrator in-serviced Director of Maintenance regarding the expectation of regular surveillance and regular maintenance of drains in kitchen / food preparation areas to ensure unimpeded drainage with no evidence of backup. (HCSG policies #015 and #031.) Element 4: Certified Dietary Manager, Dietitian, and Health Services Group Divisional Manager, and/or Designee will conduct audits of all food preparation areas to ensure that no food items are exposed to potential contaminants during kitchen sanitation five (5) times per week times four (4) weeks, then three (3) times were week times two (2) months. Certified Dietary and/or Designee will conduct audits of all drains in food preparation areas to ensure unimpeded drainage with no evidence of backup five (5) times per week times four (4) weeks, then three (3) times were week times two (2) months. Results of the audits will be brought by the Certified Dietary Manager and/or Designee and discussed at monthly Quality Assurance Performance Improvement meetings. Administrator will ensure compliance.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and implement safety interventions for one (#720) of four sampled residents reviewed for accidents from a total of 22, resulting in a fall, fracture, emergency hospitalization and surgery. Findings include: On 6/7/16 at 11 AM the clinical record for resident #720 was reviewed. The resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum data sets ((MDS) dated [DATE] and 4/15/16 noted that the resident had no cognitive deficits, was non-ambulatory, had limited range of motion and movement to lower extremities and per the 4/15/16 MDS, required extensive 2-person assistance for transfers and bed mobility. Per ADL (activities of daily living), safety, mobility and dialysis care plans initiated on 7/22/15 for resident #720: The resident received dialysis three times a week on Tuesday-Thursday-Saturday, had a potential for injury due to weakness and balance disturbance, had limited physical mobility due to obesity and spinal stenosis, used half siderails to assist with turning and positioning and was non-weight bearing. There was no documented care plan that mentioned the osteoporosis [DIAGNOSES REDACTED].>2-person assistance was required for bed mobility/transfers, as coded in the MDS. Fall risk assessments dated 7/10/15, 10/5/15, 1/3/16 and 5/19/16 noted that the resident was at high risk for falls. Per a nursing note dated 5/24/16 by nurse 'Q': Resident #720 was observed dangling while (nurse aide 'P') was holding her upper body beside her bed The fire department staff were called to put the resident back in bed. The resident later complaining of pain in the legs. STAT (immediate) X-rays were ordered for bilateral knees and legs but were later cancelled because the resident stated she wanted to go to hospital for the X-ray and she was sent out at 5:45 AM). The resident was still in the hospital at the time of this record review. On 6/7/16 at 4:50 PM, nurse 'Q' was interviewed by phone and gave the following account of the incident: I was going into (resident #720's) room to give meds to her roommate. When I opened the door, I saw (aide 'P') trying to hold (resident) up against the bed. Her legs were on the floor. I asked the aide what she was doing and she said she was cleaning and changing the resident (due to incontinence) and rolled her over and she rolled out of bed. I asked the aide why she didn't ask for help. I dropped everything and called for help. Five people came, but we couldn't get her up. I assessed her (while she was still on the floor) and she said she was okay. We had to get the fire department to put her back in bed. After a while she complained of pain in her leg and we sent her to the hospital. At 6:30 PM, during a phone interview with the complainant (resident #720's sister), she reported that the resident told her the following: A nurse aide came in to change the resident and as she was rolling the resident over, the bed moved and the resident rolled out onto the floor. The wheels on the bed were not locked. The resident went to the hospital complaining of pain in the right leg. The right leg was X-rayed, but not the left leg. A fracture was found and surgery was performed on the right leg. A few days later, the resident had pain in the left leg. An X-ray was done that revealed a fracture and she was taken back to surgery on the left leg. The surgeon told the complainant that rods and screws were inserted into the right leg, but the left leg could not be repaired in the same manner because it was too complicated, so an [DEVICE] was applied (multiple screws inserted externally above and below the fracture to keep the bone stabilized). On 6/7/16 at 7 PM, nurse aide 'P' was interviewed by phone and gave the following account of the incident: She was providing incontinence care to resident #720 and the resident rolled herself over and rolled over the edge of the bed. Her legs went over first. The aide was behind the resident and tried to catch her. She said at first her knees were aching as usual. When the fire department got her back in bed she said her legs were hurting more than usual and asked to go to the hospital. When asked, the aide said the bed was not involved in the incident, the resident was in the middle of the bed when turned, not on the edge and She was not a 2-person assist. She is very particular and tells you how to do things. She is very specific. When asked how the resident rolled out if she was not on the edge of the bed and there was no problem with the bed, the aide said, I don't know. It happened so fast. On 6/8/16 at 9:30 AM, an Incident/Accident (I/A) Report, incident investigation and hospital records were reviewed. The report, written by nurse 'Q', noted that resident #720 fell on [DATE] at 12:30 AM and was observed on her knee dangling while aide 'P' was holding her upper body. The nurse noted that a skin assessment (no mention of assessing limb movement) was done with no injury or bruises noticed at the moment. Complaining of pain on leg. Sent to hospital. An undated, unsigned investigation summary noted that aide 'P' said regarding the incident: I washed the front of her body and (resident) rolled herself over so I could clean her up in the back. I turned to reach for the (incontinence) brief and turned around to see she was not stopping and was continuing to roll. I saw her leg dangling over the side of the bed but all I could do was grab her upper body Per a hospital emergency room note, resident #720 arrived at 5:55 AM. Per a hospital History and Physical physician note: Chief complaint: right hip pain last night they were trying to change her bed linen. When they rolled her to side, she apparently fell off the bed and onto her right side. She had 'immediate' pain. This morning, she was to be transported for dialysis and they brought her here for evaluation of the pain and she was found to have a right distal femur fracture was just recently discharged from hospital where she had been for several days while they were trying to repair her (dialysis access site) in her right arm still not working catheter on the right side of her neck Distal right femur fracture due to fall The femur X-ray results on 5/24/16 noted: comminuted, impacted fracture, meaning the bone was splintered or crushed with fragments driven into one another by force, typically from a fall. Per an Operative Report, screws and nails were inserted on 5/27/16 to repair the fracture. (Per review of a second Operative Report, the resident began to complain of left hip pain when she was being transported to the nursing unit from surgery on the right leg. An X-ray was taken and revealed a left distal femur fracture, which was probably caused by when she was being moved or by her initial fall.) The etiology of the left leg fracture was unknown, as there was no initial X-ray performed and the X-ray report was not provided. On 6/8/16 at 10 AM and 11 AM, resident #720 was observed back from the hospital in the same room and bed (had returned the afternoon of 6/7/16) and was interviewed. The resident was alert and oriented and was in an oversized bed with half rails, facing the doorway with the left side of the bed against the wall. The resident said that the bed was in the same position as during the incident. The resident had a catheter inserted into the right neck, extensive scarring to the right upper arm from a former dialysis access site, staples in the right lateral knee area and an [DEVICE] inserted above and below the left knee. The right calf was swollen with tight, shiny skin. When asked how her legs were fractured, the resident said the following: Aide 'P' pulled the bed away from the wall and was standing behind her between the bed and the wall to clean her up. She grabbed the siderail to help the aide turn her onto her right side facing away from the aide. She was unable to move her legs. The resident said that when she turned over, the bed started to roll. The wheels were not locked and I was too weak to hold on from a procedure and stitches in my (right) arm. She said that her legs hurt when she fell , but began to hurt worse, so she wanted to go to the hospital. The resident said, It was supposed to be two people, but they never have enough help. On 6/8/16 at 12 Noon, when asked about resident #720's fall and fractures, particularly of the right leg, the Director of Nursing (DON) said she was not told that the wheels were not locked on the bed. The DON said, When she was turning, she threw her leg over and her weight, the momentum, made her roll out. When told that she could not move her legs independently and asked how she could have rolled out if she was not on the edge of the bed, the DON said she did not know. She said, If it was me, I would have made her a 2-person assist. The resident's (undated) Master Care Guide (a care plan used by nurse aides that they were supposed to reference) included in the incident investigation, did not mention 2-person assistance required for turning/repositioning and ADL care. The DON was then asked to have maintenance staff check the locks on the resident's bed for stability, in her presence. The Maintenance Director was met at the room and was observed checking the function of the locks and he ensured that the bed did not move when the locks were on. He said however, When I first got here (to the room before the DON arrived), these weren't locked (pointing to both wheels on the right side). So, I locked them. At 2 PM, when resident #720's fall and injury were discussed with the Administrator, he said, As far as I know, she was always a 2-person assist. ( )

This citation pertains to MI 457 Based on interview and closed record review, the facility failed to correctly identify 1 of 3 sampled residents (# 901) resulting in neglect of appropriate care, by administering the wrong medications that resulted in adverse medication consequences, altered mental status, shock, acute [MEDICAL CONDITION], hospitalization and decline in highest practicable wellbeing. Resident #901 was admitted to the Intensive Care Unit (ICU) in an unstable condition on 3/18/16. Findings include: An abbreviated survey was conducted on 4/7/16 in response to a complaint which alleged that the resident was given someone else's medication resulting in hospitalization . On 4/7/16 at 10:22 AM during an interview with the Director of Nurse's (DON), she acknowledged and confirmed that Resident #901 was administered the wrong medication's by a new nurse A on 3/17/16 at 5 PM. She indicated that the Resident received multiple tablets/medications with a protein liquid supplement. The DON reported nurse A normally works on the NE wing and was pulled to SW wing that evening. When she entered the residents room, she called Robert and Michael the resident's roommate responded Hey. She took med's over to the resident (#901) and one of them was med pass and the resident said to her what is this for? and the nurse replied it was for wound healing and the resident proceeded to take the med's/pills. The DON reported, the nurse realized after the fact that she had given the med's to the wrong resident. The nurse reported the incident to the afternoon supervisor who filled out the Report, called the DON, and family. The DON further stated that the nurse practitioner NP was in the building and she saw the resident first and the facility physician was notified and he ordered a comprehensive metabolic panel (CMP), phosphorus and ionized calcium drawn ASAP and in the morning. The stat labs was called in at 11:22 PM, and Resident #901's blood urea nitrogen (BUN) was 76 (range 8-18 mg/dl) and creatinine (Cr) was 4.8 (range 1.2 mg/dl). Talked back to the NP, and she ordered [MEDICATION NAME] to be held in the morning of 3/18/16. At 1:11 AM, another lab drawn indicated BUN 82, Cr 5.7, Blood pressure BP 85/45, heart rate HR 100, large emesis, called physician and he ordered for resident to be transferred to the hospital. In an interview on 4/7/16 at 11:11 AM, with the facility Administrator regarding concerns of negligence relating to the wrong medications being administered to Resident #901, he indicated that he was notified by the DON that resident #901 was given the wrong medications that belonged to his roommate. He stated I have had med errors before. I am used to a 2-form identification (ID) for the residents. The current facility policy doesn't indicate that safe guard. On 4/7/16 at 12:11 PM, during an interview with the Medical Director (MD), he revealed that clinically when this incident occurred, his NP contacted him and informed him what the med's were. The (MD) stated I ordered a set of labs, total of 8 med's wrongly administered to the resident, obtained labs baseline from the hospital, factually the resident had an episode of vomiting, Resident #901 became hypotensive the next morning with acute [MEDICAL CONDITION]. The MD revealed that he had concerns that the incident was as a result of the wrong medication's (Sevelamer 800 mg 6 tablets, [MEDICATION NAME] 30 mg tablet) because it took some time frame for the adverse events to happen. The acute kidney injury caused the fluid shift. The MD explained that he had a discussion with the DON and his philosophy is that people make mistakes, this is a problem with the system than with anything else, what happened and the sequence of events, identifying the residents, educating the nurse's and how to improve the system was implemented after the incident. On 4/7/16 at 3:58 PM, during an interview with the nurse A, she revealed that she administered the wrong medications to resident #901 between 5 to 6 PM in the evening. She stated I got the med's for resident #902 and I put them down with the prostat drink. Resident (#901) asked what is this, I told him that it was used for skin healing. When he (#901) asked for his pain med's, I went and checked and found that he was not resident #902. I reported to the NP and did the incident report. Resident #901 threw up after 11:30 PM at the next shift. Nurse A also, revealed that resident #901's blood pressure was low, like hypotensive. The NP ordered blood work stat, and the BUN was high. I got inserviced. During an interview on 4/7/16 at 4:02 PM with the NP, she stated the med nurse came to me and told me that she had given Resident #901 the wrong medications, [MEDICATION NAME] and [MEDICATION NAME]. I told her to notify her supervisor, I called the physician about concerns about the wrong medications administered and he ordered stat labs now and another in the morning. The NP indicated that she saw the resident prior to the medication error incident and he was doing very well and was not in any form of distress. The Facility Resident Admission Record printed on 3/15/16 revealed that resident #901 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set resident Assessment , dated 3/18/16, revealed that resident #901 was cognitively intact having scored 15 of 15 on the Brief Interview for Mental status screening tool. On 4/7/16 at 2:20 PM, review of the progress notes type activities dated 3/18/16 at 16:35 revealed Resident #901 was alert, oriented and able to make his needs known, has a supportive family, college educated and works as Electronic Design Engineer, resident was wheelchair dependent and was on oxygen. On 3/18/16 at 07:29, the note text was Hospital. This progress report was inconsistent, incomplete with omissions and failed to address events of 3/17/16 at 5 PM. On 3/17/16 at 23:22 the Lab Results Text: noted Abnormal labs, called to the physician. HGB 3.95, HCT 37.6, RDW 54.1, Eosinophil 9.0, Chloride 94, BUN 76, Creatinine 4.8, EGFR 12, New order from physician to hold [MEDICATION NAME] and log for Nurse practitioner (NP) to review on 3/18/16. On 3/18/16 at 01:11 AM, the nurse ' s notes documented: Resident Stat labs BUN 82 and creatinine 5.7 called to MD on call no return call. Vital signs (VS) and blood pressure (BP) 85/45 and Heart rate (HR) 100 and resident had large emesis. Paged on call and sent resident to ER for Evaluation and treatment . On 4/7/16 at 2: 37 PM, review of the medication variance report dated 3/17/16 at 5:30 PM, revealed that the error type was that wrong medication was administered to the wrong resident. The medication error type for administration failed to check wrong medication. The dispensing section failed to indicate wrong medication, wrong resident, monitoring error, and interaction The outcome was coded as no apparent injury. The medication variance failed to check and identify change in vital signs, change in prognosis, and hospitalization . Review of the hospital record printed 3/21/16 at 1:02 PM, and dated 3/18/16 at 4:24 revealed that the MICU consultation was shock. The assessment and plan: Altered mental status, shock, etiology undetermined, [MEDICAL CONDITION], acute [MEDICAL CONDITION] and [MEDICAL CONDITION]. The facility discharge summary dated 3/18/16, and signed by the facility physician on 3/22/16, documented condition of discharge as nausea and vomiting. Follow up and discharge instructions; Resident #901 was transferred to the hospital emergency room (ER) for nausea and vomiting and abnormal labs. On 4/7/16 at 3:03 PM, review of resident #902 a [MEDICAL TREATMENT] patient physician's orders [REDACTED]. (evening), [MEDICATION NAME] 10 mg tablet by mouth every 8 hours related to end stage [MEDICAL CONDITION] (evening), [MEDICATION NAME] tablet 5 mg tablet by mouth (evening), [MEDICATION NAME] 30 mg tablet by mouth in the evening related to end stage [MEDICAL CONDITION](evening), [MEDICATION NAME] 100 mg capsule by mouth twice daily for constipation (evening),and Protein liquid give 30 milliliters (ml) twice daily (evening). Resident #901 received a total of 10 tablets/ medications meant for his roommate resident #902 as his evening medication. ( )

This citation pertains to MI 949 and has two (2) deficient practice statements. Deficient practice statement #1 Based on interview and record review the facility failed to evaluate declining International Normalized Ratio (INR) values obtained in response to increased dosing of [MEDICATION NAME] (an anticoagulant which acts to prevent the formation of blood clots) for one (#503) of three sampled residents reviewed for [MEDICATION NAME] administration from a total sample of seven resulting in the resident coughing up clotted blood and subsequent hospitalization for [MEDICATION NAME] toxicity. Findings include: On 5/20/14 at 2:00 pm, Resident #503 was observed seated at the side of his bed. Resident #503 was alert but confused and unable to recall any recent hospitalization s. On 5/21/14 at 10:00 am, clinical record review revealed that Resident #503 was readmitted into the facility on [DATE]. According to the Medication Administration Record [REDACTED]. In addition, according to the MAR, Resident #503 was on [MEDICATION NAME] (generic for [MEDICATION NAME]) therapy. Although Resident #503 was at increased risk for bleeding, there was no care plan in place indicating that Resident #503 should be monitored closely for bleeding. On 5/21/14 at 10:15 am, during an interview, the Director of Nursing (DON) explained that Resident #503 was transferred to the hospital on [DATE] "because he was bleeding. His (family member) telephoned me that Saturday night and said that he was being admitted because he received too much [MEDICATION NAME]." Resident #503 was diagnosed with [REDACTED]. On 5/21/14 at 10:30 am, Resident #503's chart was reviewed and the DON, the Administrator and Unit Manager Nurse 'A' were interviewed regarding Resident #503. Review revealed that Resident #503 returned to the facility on [DATE] after being treated for [REDACTED].#503's [MEDICATION NAME] was replaced by Eloquis (an anticoagulant that does not require INR testing). There was a nurse's note dated 3/1/14, documenting that the doctor was notified "INR 2.4 and (doctor) ordered [MEDICATION NAME] 5.5 mg one by mouth every day and (order lab draw) PT/INR on 3/3/14." The INR was within normal parameters for Resident #503. (The INR is a laboratory standard used to measure the effects of [MEDICATION NAME]/[MEDICATION NAME]. A high INR indicates a higher risk of bleeding, while a low INR suggests a higher risk of developing a clot.) The Physician order dated 3/1/14 documented, "[MEDICATION NAME] 5.5 mg by mouth every day at 5 pm. PT/INR on 3/3/14." The DON explained that Resident #503's INR value of 2.4 reported on 3/1/14 had been obtained from blood analyzed by the facility's contracted laboratory, but after 3/1/14, the facility nurses were responsible for the subsequent INR testing with the use of the facility's PT/INR monitoring machine. The DON went on to say that the facility nurses were expected to use the monitoring machine and record the INR value on the "red" sheet. When asked how the facility monitored and tracked Resident #503's INR, the DON stated some nurses were using the "red sheet" and some were using the MAR (Medication Administration Record). Record review revealed there were no documented INR lab values after 3/1/14 for the month of March 2014 to monitor and track changes in Resident #503's INR. The "red" sheet (as identified by the DON where INR results were to be documented by facility nurses) was requested and was unable to be located. However there were physician's orders that reflected a change in [MEDICATION NAME] orders for March 2014. A Physician's order dated 3/3/14 documented the following increase in [MEDICATION NAME], "Discontinue previous [MEDICATION NAME] orders. Start [MEDICATION NAME] 6 mg by mouth every Monday, Wednesday and Friday. Start [MEDICATION NAME] 5.5 mg by mouth every Tuesday, Thursday, Saturday and Sunday." There was no documented lab value on the MAR indicated [REDACTED]. A Physician order dated 3/27/14 documented another increase in [MEDICATION NAME] "Start [MEDICATION NAME] 6 mg by mouth daily." There was no documented lab value on the MAR indicated [REDACTED]. Physician order dated 3/31/14 documented yet another increase "[MEDICATION NAME] 7 mg, one tab, oral, daily" with no documented lab value on the MAR indicated [REDACTED]. Review of the MAR for the month of April 2014 revealed documentation of an INR value for 4/7/14 that was 1.2 (sub-therapeutic). On 4/10/14, the INR was documented as 1.5 (sub-therapeutic). A Physician order dated 4/10/14 noted, "Discontinue [MEDICATION NAME] 6 mg. Start [MEDICATION NAME] 6.5 mg." On 4/14/14, the INR was documented as 1.3 (sub-therapeutic). On 4/17/14, the INR was documented as 1.2 (sub-therapeutic). A Physician order dated 4/17/14 documented, "Discontinue [MEDICATION NAME] 6.5 mg. Increase to 7 mg on 4/17/14." The DON and Nurse 'A' were queried why Resident #503's INR continued to decrease, even after repeated increases in the medication by the physician. The DON then reported that the facility did not recognize that the facility's PT/INR monitoring machine had been giving false readings until 4/19/14, the day she received a notice from the manufacturer of the PT/INR monitor. The DON provided a notice dated 4/16/14 from the company that reported that the test strips used with the monitor "may report an inaccurately low INR result." When queried the DON and Nurse 'A' were unable to explain why nursing staff did not question the reading of 1.2 when Resident #503's [MEDICATION NAME] was increased. The DON then explained that the PT/INR monitoring machine was no longer in use at the facility. The facility used the contracted lab for those residents who remained on [MEDICATION NAME] while other residents were placed on Xarelto and Eloquis (anticoagulants that do not require INR testing). The Medical Director was telephoned for query but did not return the phone call. The Administrator further explained that the facility PT/INR monitoring machine had no way of calibrating the test strips to determine the accuracy of test results. When asked if the facility considered requesting the outside laboratory to check Resident #503's INR levels since increasingly higher doses of [MEDICATION NAME] could place Resident #503 at risk for bleeding. The DON and Nurse 'A' did not respond. When asked if one person monitoring the PT/INR readings would have been able to identify nearly four weeks of suspicious readings and prevent Resident #503 from being hospitalized , the DON stated "Maybe if the same nurse or person was monitoring it. I didn't have any one person monitor INR levels." On 5/22/14 at 2:30 pm during an interview, Nurse 'B' explained that she was the nurse that cared for Resident #503 on 4/19/14 on the afternoon shift. Nurse 'C' (who was not available for interview on 5/22/14) had reported to her that Resident #503 had some blood in his mouth during the day shift and stated that he may have bitten his mouth. Nurse 'B' further explained that while making rounds with Nurse 'C', they observed Resident #503 coughing and spitting up blood clots. Nurse 'B' stated she notified the physician and the family. According to the nurse's notes dated 4/19/14, the family instructed the facility to send Resident #503 out to the hospital. There was no physician order to send Resident #503 to the hospital. When queried further, Nurse 'B' said that she did monitor for Resident #503 for bleeding, but was unable to identify the significance of Resident #503 coughing up blood clots. According to the hospital report, dated 4/19/14, Resident #503 was found to have an INR result of 6.3, indicating [MEDICATION NAME] toxicity. On 5/22/14 at 4:00 pm, according to the Lippincott Manual of Nursing Practice 9th edition, "There is risk of bleeding in any patient receiving anticoagulants." On 5/22/14 at 4:00 pm, review of the facility policy related to [MEDICATION NAME] use titled, "Laboratory Management" dated 8/2012, revealed no evidence that the policy addressed the use of the PT/INR monitoring system and did not address issues related to multiple dose increases in [MEDICATION NAME]. ( ) Deficient practice statement #2 Based on observation, interview and record review the facility failed to provide the appropriate care and treatment of [REDACTED].#502) of one three residents reviewed for wound care from a total of seven sampled residents resulting in an excoriated and painful gastrostomy site. Findings include: On 5/20/14 at 10:20 am, at 10:40 am, at 11:30 am, at 12:30 pm, at 1:30 pm, at 2:30 pm and again at 3:30 pm, Resident #502 was observed seated in a wheelchair adjacent to her bed. A tube feeding was infusing at 73 millimeters per hour. At 3:30 pm, Certified Nurse Assistant (CNA) 'D' explained that she (CNA 'D') needed to "get (Resident #502) out of the wet clothes. She has tube feeding (formula) all over her." CNA 'D' assisted Resident #502 into bed. Resident #502's clothing was partially covered with copious amounts of tube feeding. When Resident #502's shirt was removed, a face cloth was observed to be wrapped around the tube at the insertion site. CNA 'D' stated, "I did not put the washcloth there. The nurse must have done that. That means she knows that the tube feeding is leaking." CNA 'D' then removed the face cloth, revealing a 4x4 dressing underneath that was covered with tube feeding formula. Formula was observed coming out of Resident #502's stoma. CNA 'D' stated, "See. It is coming out of her stomach." CNA 'D' notified Nurse 'E.' On 5/20/14 at 3:40 pm, Nurse 'E' entered Resident #503's room and removed the 4x4 dressing, revealing an excoriated area around the stoma site. Small amounts of tube feeding formula and yellowish-green fluid that smelled of gastric juices, was observed to come out from around Resident #502's gastrostomy tube at the stoma site. Nurse 'E' was asked who placed the face cloth at the resident's stoma site and Nurse 'E' stated "The CNA did that." When Nurse 'E' was made aware that CNA 'D' stated that she had not placed the face cloth on Resident #502, Nurse 'E' did not respond. When queried about the appearance of the skin around the stoma, Nurse 'E' stated, "I don't know what it looks like because Midnights (shift) puts it (4x4 dressing) on." Nurse 'E' then walked out of the room. CNA 'D' then began to clean around the stoma site. Resident #502 was observed to wince, moan and attempted to move CNA 'D's hands away from her stoma site. While cleaning the site, a scant amount of tube feeding was observed to come out of the stoma along with a greenish-yellow substance. When Unit Manager Nurse 'F' was made of aware of the findings, Nurse 'F' reported that "This (leakage of formula) happens all the time. We send her out and she comes right back." When asked to look at Resident #502's feeding tube insertion site, Unit Manager 'F' reported that she was unaware of the excoriation of the stoma and that "It probably needs antibiotic ointment." The clinical record, Medication Administration and Treatment Records for the month of May 2014 were reviewed and revealed no order for medical treatment of [REDACTED].#502's stoma site. On 5/21/14 at 10:00 am, when the Director of Nursing and Unit Manager 'F' were queried, they were unable to identify how long the tube feeding had been seeping out of Resident #502's stoma. The Unit Manager was unable to determine who identified that tube feeding formula was coming out of Resident #502's feeding tube insertion site and why staff did not immediately address the leaking stoma, since Resident #502 had a history of [REDACTED]. ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 458 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE APPROPRIATE CARE AND TREATMENT AND FAILED TO UTILIZE PREVENTIVE DEVICES IN ACCORDANCE WITH THE PLAN OF CARE IN ORDER TO PREVENT THE DEVELOPMENT OF PRESSURE SORES FOR ONE (#510) RESIDENT WHO WAS admitted WITH BILATERAL HEEL BLISTERS, OF SIX RESIDENTS REVIEWED FOR PRESSURE SORES, FROM A TOTAL OF TEN SAMPLED RESIDENTS, RESULTING IN THE DEVELOPMENT ESCHAR (NECROTIC TISSUE) AND THE SUBSEQUENT DEVELOPMENT OF STAGE IV PRESSURE SORES TO BILATERAL HEELS. FINDINGS INCLUDE: ON 7/30/13 AT 11:30 A.M., DURING A TOUR OF THE UNIT, #510 WAS OBSERVED SEATED IN A WHEELCHAIR IN HER ROOM VISITING WITH FAMILY. ON 7/31/13 AT 11:09 A.M., #510 WAS OBSERVED IN HER BED IN SUPINE POSITION (ON HER BACK) THERE WERE NO PILLOWS IN PLACE THAT ELEVATED #510'S HEELS. THERE WERE NO PROTECTIVE FOAM BOOTS APPLIED TO #510'S HEELS. DURING A WOUND OBSERVATION, #510 WAS OBSERVED DRESSINGS TO BILATERAL HEELS. LPN #1 REPOSITIONED #510 TO ALLOW FOR DRESSING CHANGE AND WOUND OBSERVATION. UPON MOVEMENT, #510 MOANED AND STATED, "...OUCH, MY HEELS HURT..." LPN #1 THEN PROCEEDED WITH REMOVAL OF #510'S DRESSINGS. UPON ASSESSMENT, #510'S LEFT HEEL WAS NECROTIC. NO CURRENT MEASUREMENTS WERE PROVIDED. #510'S RIGHT HEEL REVEALED MINIMAL DRAINAGE AND WAS GRAY IN APPEARANCE WITH MINIMAL SLOUGH. ADDITIONAL OBSERVATIONS OF #510 WERE MADE THROUGHOUT THE INVESTIGATION AT VARIOUS TIMES TO FIND #510 IN SUPINE (BACK LYING) POSITION WITH NO POSITIONING DEVICES IN PLACE. #510'S HEELS HAD NOT BEEN ELEVATED AND WERE IN DIRECT CONTACT WITH THE MATTRESS. ACCORDING TO THE FACILITY'S "FACE SHEET", #510 WAS A [AGE] year OLD FEMALE WHO WAS INITIALLY admitted to the facility on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM (MDS) data set [DATE] REVEALED THAT #510 REQUIRED EXTENSIVE ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING (ADLS) INCLUDING BED MOBILITY, TRANSFERS, DRESSING, EATING, TOILETING, PERSONAL HYGIENE AND BATHING. A REVIEW OF THE "NURSING ADMISSION ASSESSMENT" DATED 5/2/13 REVEALED THAT #510 HAD A BRADEN SCORE OF 15 (TOTAL SCORE OF 12 OR LESS REPRESENTS HIGH RISKS) AND WAS admitted WITH LEFT HIP SURGICAL SUTURES, BRUISES TO RIGHT FOREARM AND BILATERAL HEEL PRESSURE ULCERS. A REVIEW OF THE " NURSING ADMISSION ASSESSMENT NURSE ' S NOTES " DATED 5/2/13 REVEALED NO DOCUMENTATION OF #510 ' S PRESSURE ULCERS. ON 7/30/13 AT 12:00 P.M., RN #1, UNIT MANAGER, WAS QUERIED AND ASKED TO SUBMIT A LIST OF RESIDENTS WITH PRESSURE SORES. DURING THE DISCUSSION, RN #1 WAS ASKED ABOUT #510'S BILATERAL HEEL WOUNDS AND REPORTED, "...SHE (#510) WAS admitted FROM THE HOSPITAL WITH BLISTERS ON HER HEELS..." ON 7/30/13 AT 2:38 P.M., DURING AN INTERVIEW, THE DIRECTOR OF NURSING (DON) REPORTED, "...#510 RETURNED FROM THE HOSPITAL WITH BILATERAL HEEL BLISTERS..." A " WOUND SPECIALISTS " NOTE DATED 5/13/13 REVEALED, " ...RIGHT HEEL: SHE (#510) HAD A FALL AND WENT TO THE HOSPITAL. UPON RETURN SHE HAD THESE HEEL ISSUES. THEY ARE BLEBS (BLISTERS, FLUID FILLED SACKS) THAT ARE BREAKING. THE WOUND MEASURES 4 X 5. LEFT HEEL: AGAIN WE HAVE BLEBS THAT ARE BREAKING. THE WOUND MEASURES 4 X 4. WE WILL DO XEROFORM WITH DAKIN ' S (WOUND DRESSING/ANTIBACTERIAL SOLUTION) AND A DRY PROTECTIVE COVER ON A EVERY 72 HOUR BASIS. REEVALUATE IN ONE WEEK ... " A WOUND SPECIALIST NOTE DATED 7/8/13 REVEALED, " ...RIGHT HEEL, LEFT HEEL, THE ESCHAR IS READY FOR REMOVAL. THEY ARE BOTH STAGE IV DECUBITUS ULCERS NOW AND WE WILL DO DAKIN ' S SOAKED XEROFORM AND A DRY PROTECTIVE DRESSING ON A DAILY BASIS ... " A NURSE'S NOTE DATED 5/9/13 REVEALED, "...RESIDENT NOTED WITH OPEN BLISTER LEFT HEEL AND INTACT BLISTER RIGHT HEEL. DOCTOR INFORMED, DRY DRESSING BILATERAL HEELS APPLIED AND WAFFLE BOOTS ON WILL CONTINUE TO OBSERVE..." THERE WAS NO DOCUMENTED EVIDENCE THAT TREATMENT HAD BEEN INITIATED FOR #510'S BILATERAL HEEL BLISTERS PRIOR TO 5/9/13. A NURSE ' S NOTE DATED 5/16/13 REVEALED, " ...INITIAL VISIT WITH WOUND CARE, THIS WEEK, admitted WITH AREAS TO BILATERAL HEELS, RIGHT HEEL BLISTER INTACT COVER WITH DRY DRESSING. LEFT HEEL OPEN, XEROFORM WITH DAKIN'S IN PROGRESS ... " A NURSE ' S NOTE DATED 5/23/13 REVEALED, " ...AREA TO RIGHT HEEL BLISTER DAKIN'S WITH XEROFORM CONTINUED. LEFT HEEL IS ESCHAR (NECROTIC TISSUE). HEEL PROTECTORS TO BILATERAL FEET ... " A NURSE ' S NOTE DATED 5/30/13 REVEALED, " ...AREAS TO RIGHT AND LEFT HEEL CONTINUE, BOTH AREAS ESCHAR TISSUE ... " A NURSE'S NOTE DATED 6/13/13 REVEALED, "...IDT (INTERDISCIPLINARY TEAM) DECIDED NOT TO PROVIDE AIR MATTRESS DUE TO HIGH RISK FOR FALLS AT THIS TIME. CONTINUE TO ELEVATE HEELS (FLOAT)..." THERE WAS NO DOCUMENTED EVIDENCE THAT A LOW BED WAS OR OTHER FALL PREVENTION MEASURES HAD BEEN IMPLEMENTED IN ORDER TO ALLOW THE USE OF AN AIR MATTRESS IN ORDER TO CUSHION THE SURFACE #510'S HEELS RESTED UPON. AN " INTERDISCIPLINARY TEAM " NOTES DATED 7/11/13 REVEALED, " ...RESIDENT SEEN BY WOUND CARE TEAM THIS WEEK AND BOTH HARD ESCHAR AREAS WERE READY FOR SURGICAL INTERVENTIONS. PROCEDURE PERFORMED AT BEDSIDE TO REMOVE ESCHAR. BOTH WOUNDS ARE NOW CLASSIFIED AS STAGE IV PRESSURE ULCERS ... " THE " RESIDENT CARE CARDEX WORKSHEET " (GUIDE FOR CNAS (CERTIFIED NURSING ASSISTANTS) TO FOLLOW TO KNOW THE NEEDS OF THE RESIDENTS) UNDATED, REVEALED, " WAFFLE BOOTS, REMOVE WITH ADLS AND SKIN CHECK ... " THE CARDEX DID NOT PROVIDE INFORMATION WHICH INSTRUCTED CNAS TO ELEVATE OR FLOAT #510 ' S BILATERAL HEELS WHEN IN BED IN ORDER TO OFF LOAD PRESSURE TO #510 ' S HEELS. UPON REVIEW OF THE CLINICAL RECORD, THERE WAS NO physician's order [REDACTED]. #510 ' S " PRESSURE ULCERS " CARE PLAN UPDATED 5/2/13 REVEALED, " ...PRESSURE ULCERS RELATED TO DECREASED ACTIVITY, IMPAIRED MOBILITY. APPROACH: TURN AND REPOSITION WHILE IN BED FREQUENTLY FOR COMFORT AND PRESSURE REDUCTION, APPLY PRESSURE REDUCTION MATTRESS TO BED, ELEVATE (FLOAT) HEELS IN BED ... " ON 8/5/13 DURING AN INTERVIEW, THE DON WAS QUERIED. WHEN ASKED WHY #510'S HEELS HAD NOT BEEN ELEVATED/FLOATED, WHY #510 HAD NOT BEEN REPOSITIONED FREQUENTLY OFF OF HER BACK, AND WHY #510 DID NOT HAVE ON PROTECTIVE HEEL COVERS IN LIGHT OF THE CHOICE NOT TO APPLY A SPECIALTY MATTRESS, THE DON REPORTED, "...I HAD A DISCUSSION ABOUT THIS WITH THE DAY SHIFT CNA (CERTIFIED NURSING ASSISTANT) (CNA #4) IN ORDER TO MAKE SURE #510'S HEELS ARE ELEVATED. WE HAVE TO ADD THAT TO THE CARE PLAN AS WELL. THERE IS NO INSTRUCTION ON THE CNA CARE GUIDE (CARDEX) THAT GIVES DIRECTIONS TO ELEVATE HER (#510) HEELS..." THE DON FURTHER REPORTED, "...I HAD TO HAVE THE UNIT MANAGER WRITE AN ORDER TO FLOAT HER (#510) HEELS. I SAW THAT IT HAD BEEN CARE PLANNED BUT THERE WAS NO ACTUAL ORDER TO FLOAT #510'S HEELS..." THE DON PROVIDED THE SURVEYOR WITH A COPY OF THE physician's orders [REDACTED]. FURTHER, THE DON PROVIDED THE SURVEYOR WITH AN UPDATED COPY OF THE CNA'S CARDEX (CARE GUIDE) WHICH SHOWED THAT "FLOAT HEELS" HAD BEEN ADDED. THE FACILITY ADMINISTRATIVE STAFF WAS UNABLE TO EXPLAIN WHY #510'S HEELS HAD NOT BEEN ELEVATED IN ACCORDANCE WITH THE PLAN OF CARE, WHY STAFF FAILED TO APPLY #510'S HEEL PROTECTORS AND WHY STAFF FAILED TO REPOSITION #510 FREQUENTLY IN ORDER TO PREVENT THE DEVELOPMENT AND PROGRESSION OF PRESSURE ULCERS. A REVIEW OF THE FACILITY ' S " SKIN MANAGEMENT " POLICY DATED AUGUST 2012 REVEALED, " ...RESIDENTS WHO ARE AT RISK OR WITH WOUNDS AND/OR PRESSURE ULCERS AND THOSE AT RISK FOR SKIN COMPROMISE ARE IDENTIFIED, ASSESSED AND PROVIDED APPROPRIATE TREATMENT TO ENCOURAGE HEALING AND/OR INTEGRITY. ONGOING MONITORING AND EVALUATION ARE PROVIDED TO ENSURE OPTIMAL RESIDENT OUTCOMES ... "

THIS CITATION PERTAINS TO INTAKE NUMBER MI 665 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT ONE (#501) OF FIVE RESIDENTS REVIEWED FOR UNKNOWN INJURIES, RESTRAINT USE AND ABUSE FROM A TOTAL SAMPLE OF 10, WAS FREE FROM UNNECESSARY RESTRAINT USE AND APPLICATION, AS #501'S RESTRAINT WAS TIED TO HIS BED FRAME, RESULTING IN REDNESS TO #501'S LEFT WRIST, RESTRICTION FROM FREEDOM OF MOVEMENT AND PSYCHOLOGICAL HARM AND DESPAIR. FINDINGS INCLUDE: ON 7/19/13 AT 12:19 P.M., #501 WAS OBSERVED SITTING IN A WHEELCHAIR IN THE DINING ROOM. #501 HAD ON A NON-RELEASE SEATBELT AND HAD A LAP TRAY ATTACHED TO HIS WHEELCHAIR. #501 WAS OBSERVED FLAILING HIS LEFT ARM CONSTANTLY AND GRABBED ONTO THE BACK OF A STAFF MEMBER'S UNIFORM. #501 WAS OBSERVED TO HAVE NO MOVEMENT OF HIS RIGHT SIDE. A REVIEW OF THE FACILITY'S "INCIDENT/ACCIDENT REPORT" DATED 5/10/13 REVEALED, "...RCS (RESIDENT CARE SPECIALIST) STATED RESTRAINT/MITT APPLIED INCORRECTLY. FOUND REDDENED AREA ON INNER LEFT WRIST, NOTED REDDENED AREA ABOVE WRIST. RESIDENT CONFUSED, DISORIENTED. RESIDENT OUTCOME: ABRASION. MITT TO BE DISCONTINUED. TREATMENT ORDERS WRITTEN. INVESTIGATION INITIATED..." A REVIEW OF THE FACILITY'S "INVESTIGATIVE ANALYSIS" DATED 5/15/13 REVEALED, "...ON 5/10/13 AT 8:30 A.M., IT WAS REPORTED TO THE DIRECTOR OF NURSING (DON) THAT #501'S LEFT HAND WAS TIED TO THE BED ON AFTERNOON AND MIDNIGHT SHIFT 5/9 - 5/10. ASSESSMENT OF #501'S LEFT UPPER EXTREMITY WAS DONE AT THAT TIME THERE WAS NO REDNESS OR SWELLING NOTED TO HIS HAND OR WRIST, THERE WAS A BLISTER NOTED TO WRIST AREA, #501 WAS NOTED TO HAVE SMALL SCATTERED OPEN AND SCABBED AREAS ON BILATERAL LOWER ARMS, #501 WAS UNABLE TO VERBALIZE WHAT OCCURRED AND DID NOT RESPOND TO QUESTIONS ASKED..." A REVIEW OF THE FACILITY'S "FACE SHEET" REVEALED THAT #501 WAS A [AGE] year OLD MALE WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] REVEALED THAT #501 HAD SEVERELY IMPAIRED COGNITIVE SKILLS FOR DECISION MAKING AND WAS EXTENSIVELY TO TOTALLY DEPENDENT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING (ADLS) INCLUDING BED MOBILITY, TRANSFERS, (NON-AMBULATORY), DRESSING, EATING, TOILETING HYGIENE AND BATHING. THE "physician's orders [REDACTED]. A physician's orders [REDACTED]. A REVIEW OF #501'S "BEHAVIOR SYMPTOMS" CARE PLAN INITIATED 1/12/12 AND LAST UPDATED 7/15/13 REVEALED, "...CAN BE TERRITORIAL; MAY GRAB AT STAFF AND PEERS WHO GET TOO CLOSE. RESIDENT BECAME AGITATED DURING ADL CARE. RESIDENT BECAME COMBATIVE WHEN RCS WAS ATTEMPTING TO GET RESIDENT DRESSED. APPROACH: REMOVE RESIDENT FROM HARM TO ASSURE SAFETY, REDIRECT AS NEEDED, IGNORE VERBAL OUTBURSTS. (2/25/13 AND 4/16/13) BRING ANOTHER STAFF TO ASSIST WITH REDIRECTION..." ON 7/20/13 AT 2:25 P.M., DURING AN INTERVIEW, THE DIRECTOR OF NURSING (DON) REPORTED, "...HE (#501) HAS VERY LIMITED USE OF HIS RIGHT UPPER EXTREMITY AND FULL USE OF HIS LEFT. THE DAY SHIFT CNA (CERTIFIED NURSING ASSISTANT) REPORTED THAT HIS (#501) MITT WAS ATTACHED TO THE FRAME OF HIS BED. I DIDN'T ACTUALLY SEE THE MITT WHEN I GOT THERE. CNA #2 SAID IT WAS TIED TO THE BED FRAME..." WHEN ASKED IF #501 SUSTAINED ANY INJURIES AS A RESULT OF HIS RESTRAINT/MITT BEING TIED TO HIS BED FRAME, THE DON REPORTED, "...HIS (#501) RIGHT WRIST WAS REDDENED WITH AN ABRASION..." ON 7/31/13 AT 8:44 A.M., DURING AN INTERVIEW, CNA #2 REPORTED, "...AT APPROXIMATELY 7:15 A.M., I WENT INTO #501'S ROOM. HE HAD A MITT ON HIS LEFT HAND RELATED TO HIM HITTING STAFF. THE MITT WAS INITIALLY ORDERED BECAUSE OF ME. (CNA #2 RAISED UP HER SLEEVE AND REFERENCED AN OLD BRUISE TO HER RIGHT UPPER EXTREMITY). THESE CAME FROM HIM. THE MITT HAD A LONG CORD THAT WAS TIED TO THE BED FRAME. I UNTIED IT AND REPORTED IT TO THE NURSE RIGHT AWAY. I DON'T KNOW WHAT MIDNIGHTS WAS THINKING. HIS (#501) WRIST WAS RED. THAT WAS HIS GOOD ARM. IT WAS DEFINITELY INTENTIONAL..." WHEN ASKED IF THERE WAS ANYWAY #502 COULD HAVE TIED THE MITT RESTRAINT TO THE BED FRAME HIMSELF, CNA #2 REPORTED, "...NO. HE (#501) COULDN'T DO THAT BY HIMSELF. HE ONLY HAD USE OF THE ONE ARM AND HIS GOOD ARM WAS THE ONE THAT WAS TIED DOWN TO THE BED FRAME..." ON 7/31/13 AT 9:25 A.M., THE DON REPORTED, "...WE DID AN IMMEDIATE INVESTIGATION. I DISCONTINUED THE USE OF THE MITT RIGHT AFTER THAT INCIDENT. I DON'T CONDONE ANYONE TYING THE RESTRAINTS TO THE BED..." ON 8/1/13 AT 11:14 A.M., DURING A SUBSEQUENT INTERVIEW, THE DON REPORTED, "...CNA #2 ALWAYS PROVIDED CARE FOR #501 BY HERSELF; BUT #501 WAS CARE PLANNED TO HAVE TWO PERSON ASSIST. I SUGGESTED THE MITT TO PROTECT THEIR (STAFF) BODIES..." WHEN ASKED IF THE LEFT HAND MITT RESTRAINT WOULD HAVE EVEN BEEN NECESSARY IF STAFF PROVIDED TWO PERSON ASSIST DURING CARE, THE DON OFFERED NO RESPONSE. THE SURVEYOR REQUESTED TO VIEW #501'S LEFT HAND MITT, HOWEVER, ACCORDING TO THE ADMINISTRATOR AND THE DON, THE MITT HAD BEEN DISCARDED. A CATALOG IMAGE OF A MITT RESTRAINT WAS SUBMITTED INSTEAD. A REVIEW OF THE FACILITY'S "RESTRAINT MANAGEMENT" POLICY DATED FEBRUARY 2011 REVEALED: "...PHYSICAL RESTRAINTS ARE DEFINED AS ANY MANUAL METHOD PHYSICAL OR MECHANICAL DEVICE, MATERIAL, OR EQUIPMENT ATTACHED OR ADJACENT TO THE RESIDENT'S BODY THAT THE INDIVIDUAL CANNOT REMOVE EASILY, WHICH RESTRICTS FREEDOM OF MOVEMENT OR NORMAL ACCESS TO ONE'S BODY..." "...IF A RESIDENT'S UNANTICIPATED BEHAVIOR PLACES HIM IR HER OR OTHERS IN IMMINENT DANGER, THE USE OF A RESTRAINT IS A MEASURE OF LAST RESORT TO PROTECT SAFETY AND MUST NOT EXTEND BEYOND THE IMMEDIATE EPISODE, AND MUST BE FULLY DOCUMENTED IN THE NURSING NOTES. AN INTERVENTION WILL NEED TO BE IMPLEMENTED TO MONITOR/CHECK AT FREQUENT INTERVALS..." "...THESE DEVICES ARE NEVER USED AS A DISCIPLINARY ACTION OR FOR THE CONVENIENCE OF THE FACILITY TO CONTROL BEHAVIOR..."

THIS CITATION PERTAINS TO INTAKE NUMBER MI 758 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE APPROPRIATE SUPERVISION, AND FAILED TO KEEP ONE (#502) OF FIVE RESIDENTS REVIEWED FOR ACCIDENTS, FROM A TOTAL OF TEN SAMPLED RESIDENTS, FREE FROM INJURY AND HARM RESULTING IN #502 BEING BURNED BY HOT COFFEE WITH A RESULTANT ABDOMINAL BURN REQUIRING MEDICAL ATTENTION AND TREATMENT. FINDINGS INCLUDE: ON 7/29/13 AT 12:49 P.M., #502 WAS OBSERVED SITTING IN THE HALLWAY IN HER WHEELCHAIR. REVIEW OF THE FACILITY'S "FACE SHEET" REVEALED THAT #502 WAS AN [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE]. THE "physician's orders [REDACTED]. THE MINIMUM (MDS) data set [DATE] REVEALED THAT #502 HAD A BIMS (BRIEF INTERVIEW FOR MENTAL STATUS) SCORE OF 11 (8 - 12 = MODERATELY IMPAIRED COGNITIVE SKILLS FOR DECISION MAKING AND REQUIRED EXTENSIVE TO TOTAL ASSISTANCE FROM STAFF WITH ALL ACTIVITIES OF DAILY LIVING (ADLS) INCLUDING BED MOBILITY, TRANSFERS, DRESSING, EATING, HYGIENE, BATHING AND TOILETING. A REVIEW OF THE FACILITY'S "INCIDENT/ACCIDENT REPORT" DATED 7/8/13 REVEALED, "...ACTIVITIES GAVE RESIDENT (#502) A HOP CUP OF COFFEE WHICH SHE (#502) SPILLED ON HERSELF. OBSERVED PEELING SKIN TO ABDOMEN AND REDNESS. LIST [DIAGNOSES REDACTED]. A REVIEW OF THE FACILITY'S "INVESTIGATIVE FOLLOW-UP" DATED 7/8/13 REVEALED: "...SERVED A HOP CUP OF COFFEE IN DINING ROOM.." "...RESIDENT (#502) STATED SHE DROPPED CUP OF COFFEE..." "...RECOMMENDATIONS: WILL NOT BE SERVED COFFEE WITHOUT STAFF PRESENT TO ASSIST. RESIDENT TO HAVE SIPPY CUP WITH LIDS FOR HOT BEVERAGES. STAFF (ACTIVITIES) TO ONLY USE COFFEE FROM DIETARY WHICH IS TEMP (TEMPERATURE) CONTROLLED..." THE FACILITY'S "ADMINISTRATIVE STATEMENT INVESTIGATIVE ANALYSIS" UNDATED, REVEALED "...ON 7/8/13 AT APPROXIMATELY 11:45 A.M., #502, WAS ESCORTED INTO THE DINING ROOM FOR A MORNING ACTIVITY. NO OTHER RESIDENTS WERE PRESENT IN DINING ROOM. #502 REQUESTED A CUP OF COFFEE FROM THE DIRECTOR OF ACTIVITIES (STAFF #1) AND GAVE INSTRUCTION ON HOW SHE WANTED IR PREPARED. ON CE THE TASK WAS COMPLETED, THE COFFEE WAS PLACED IN FRONT OF THE RESIDENT (#502). STAFF #1 STATES SHE TURNED AROUND TO CLEAN UP THE AREA AND THEN HEART #502 SCREAM SAYING IT WAS "HOT AND BURNING"..." "...REFERRAL SENT TO DIETARY FOR RESIDENT TO HAVE A LIDDED CUP FOR HOT BEVERAGES AT ALL MEALS. RESIDENT CARE GUIDE UPDATED WITH THE USE OF LIDDED CUPS FOR HOT BEVERAGES. NURSING UPDATED CARE PLAN TO INCLUDE LIDDED CUP AS WELL AS ONLY HOT BEVERAGES SERVED FROM KITCHEN..." ON 7/29/13 AT 12:01 P.M., THE DIRECTOR OF NURSING (DON) WAS QUERIED. WHEN ASKED ABOUT THE EVENTS THAT TRANSPIRED WHEN #502 WAS BURNED BY HOT COFFEE, THE DON REPORTED, "...#502 IS ALERT WITH CONFUSION. SHE DOESN'T KNOW THE DATE AND YEAR. #502 WAS TAKEN TO THE DINING ROOM AND SHE (#502) ASKED FOR A CUP OF COFFEE. THE ACTIVITY DIRECTOR GAVE HER A CUP OF COFFEE AND TURNED AWAY. #502 YELLED OUT. WE DID OBSERVE A COLOR CHANGE TO HER ABDOMEN. THE LPN #1 APPLIED SILVADENE CREAM (BURN CREAM). #502 LOST THE TOP LAYER OF HER SKIN ON THE SAME DAY..." WHEN ASKED IF #502 HAD BEEN ASSESSED AND FOUND FIT TO HANDLE HOT LIQUIDS INDEPENDENTLY, THE DON REPORTED, "...I DIDN'T LOOK AT THAT..." ON 7/29/13 AT 12:38 P.M., DURING AN INTERVIEW, THE ACTIVITY DIRECTOR (STAFF #1) REPORTED, "...#502 IS ALERT/ORIENTED 1-2 DEPENDING ON THE DAY. YOU OFTEN HAVE TO REMIND HER OF HER LIMITATIONS. THERE WAS A COFFEE/TEA SOCIAL THAT DAY AND I OFFERED HER SOME COFFEE. I MADE IT AND HANDED IT TO HER THEN I TURNED AROUND AND I HEARD HER SCREAM. SHE WAS IN HER WHEELCHAIR AND SCREAMING. YOU COULD SEE COFFEE ON HER CLOTHES. HER SKIN WAS AFFECTED BY THE TEMPERATURE OF THE COFFEE..." ON 7/29/13 AT 12:56 P.M., RESIDENT #502 WAS INTERVIEWED AND REPORTED, "...THAT COFFEE WAS REALLY HOT. I WENT TO DRINK IT AND IT BURNED MY LIP SO BAD AND IT WAS SO HOT, I JUST DROPPED IT AND IT BURNED ME RIGHT HERE (#502 POINTED TO HER UPPER ABDOMINAL AREA). I HAVE A DRESSING ON MY STOMACH NOW. THEY JUST CHANGED IT TODAY..." A LARGE DRESSING (ABD PAD) WAS OBSERVED TO #502'S UPPER ABDOMEN. #502 ATTEMPTED TO REMOVE THE DRESSING FOR VISUALIZATION BUT WAS DISCOURAGED FROM REMOVAL BY THE SURVEYOR PENDING THE NURSE'S OVERSIGHT. ON 7/29/13 AT 2:42 P.M., THE PHYSICAL THERAPIST (PT/STAFF #2) WAS INTERVIEWED AND REPORTED, "...ACTIVITIES DIDN'T CHECK HER (#502) CARE PLAN. WE (PT STAFF) EDUCATED EVERYONE. #502 WAS TO HAVE THE SIPPY CUP BUT DURING THE INCIDENT (BURN) SHE WAS GIVEN A REGULAR CUP. OT (OCCUPATIONAL THERAPY) INITIALLY EVALUATED HER ON ADMISSION ON 5/22/13. SHE (#502) WAS TO USE SIPPY CUPS IN THE DINING ROOM BECAUSE SHE HAS BILATERAL UPPER EXTREMITY WEAKNESS..." A REVIEW OF #502'S "OCCUPATIONAL THERAPY (OT) EVALUATION (EVAL) AND PLAN OF TREATMENT" DATED 5/22/13 REVEALED, #502'S "...RUE (RIGHT UPPER EXTREMITY) AND LUE (LEFT UPPER EXTREMITY) SHOULDER = IMPAIRED; ELBOW/FOREARM = IMPAIRED; WRIST = IMPAIRED..." THE OT EVAL FURTHER REVEALED: "...SELF FEEDING: UNDERLYING IMPAIRMENTS: DECREASED COORDINATION, DECREASED FUNCTIONAL ACTIVITY TOLERANCE, DECREASE RANGE OF MOTION (ROM), FINE MOTOR COORDINATION DEFICITS, PAIN AND STRENGTH IMPAIRMENTS..." "...COORDINATION: FINE MOTOR COORDINATION = IMPAIRED (FINE MOTOR IMPAIRED, RIGHT HAND MORE IMPAIRED THAN LEFT HAND; GROSS MOTOR COORDINATION = IMPAIRED (GROSS MOTOR IMPAIRED, RIGHT HAND WEAKER)..." A "physician's orders [REDACTED].#502) WILL HAVE BUILD UP UTENSILS, COFFEE CUP WITH LID..." A physician's orders [REDACTED].#502) TO HAVE 1/2 LAP TRAY ON RIGHT SIDE OF W/C (WHEELCHAIR) FOR RESTING R/T EDEMA MANAGEMENT SECONDARY TO MUSCULAR WEAKNESS..." A physician's orders [REDACTED]. A REVIEW OF THE "RESIDENT CARE CARDEX WORKSHEET" (GUIDE FOR CNAS (CERTIFIED NURSING ASSISTANT) TO FOLLOW IN ORDER TO KNOW THE NEEDS OF THE RESIDENTS) INITIATED 5/22/13 PROVIDED NO INFORMATION REGARDING #502'S NEED TO USE SPECIAL UTENSILS (LIDS ON CUPS). ON 7/30/13 AT 10:24 A.M., DURING A SUBSEQUENT INTERVIEW, STAFF #1 REPORTED, "...THE CNA (UNIDENTIFIED STAFF) WHO BROUGHT #502 DIDN'T COMMUNICATE ANYTHING TO ME ABOUT #502 NEEDING A SPECIAL CUP. I WASN'T AWARE OF THE NEED FOR SPECIAL UTENSILS, CUPS OR LIDS UNTIL AFTER IT HAPPENED..." WHEN ASKED WHAT KIND OF CUP WAS USED WHEN SHE (STAFF #1) GAVE #502 THE COFFEE, STAFF #1 SAID, "...I GAVE HER A REGULAR 6 OUNCE STYROFOAM CUP... WHEN ASKED WHERE THE COFFEE WAS MADE AND RETRIEVED, STAFF #1 REPORTED, "...I GOT IT FROM OUR (ACTIVITIES DEPARTMENT) OWN COFFEE MACHINE..." STAFF #1 FURTHER REPORTED THAT SHE WAS NOT AWARE IF #502 WAS EVEN ALLOWED TO HAVE LIQUIDS AND THAT THE HOT COFFEE WAS NOT TEMPERATURE tested PRIOR TO GIVEN IT TO #502. "...I JUST ASSUMED SHE WAS ABLE TO HAVE IT..." ON 7/30/13 AT 11:42 A.M., A BODY AUDIT AND SKIN ASSESSMENT WAS CONDUCTED. UPON REMOVAL OF THE DRESSING, #502 WAS OBSERVED TO HAVE A LARGE AREA OF EPIDERMAL SKIN (TOP LAYER OF THE SKIN) MISSING FROM HER UPPER ABDOMINAL AREA, WITH SCATTERED SCAB FORMATION. NO DRAINAGE WAS OBSERVED. DURING THE OBSERVATION, #502 REPORTED, IT DOESN'T HURT ANYMORE BUT IT ITCHES LIKE CRAZY NOW..." THE DON PROVIDED THE SURVEYOR WITH A DOCUMENT ENTITLED "SCALDING INJURIES CAUSED BY EXCESSIVE HOT WATER, FOOD AND HOT BEVERAGE TEMPERATURES" REVISED AUGUST 5, 2008 WHICH REVEALED: "...WATER TEMPERATURE: (EXPOSURE) 140 DEGREES - 3 SECONDS TO RECEIVE 2ND DEGREE BURN; 5 SECONDS TO RECEIVE 3RD DEGREE BURN..." "...150 DEGREES - <ONE SECOND TO RECEIVE 2ND DEGREE BURN; ONE SECOND TO RECEIVE 3RD DEGREE BURN..." FURTHER REVIEW OF #502'S CLINICAL RECORD REVEALED THAT THERE WAS NO DEFINITIVE [DIAGNOSES REDACTED].

REFER TO INTAKE #MI 742. BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE AND APPROPRIATE SUPERVISION TO PREVENT ELOPEMENT FOR 1 (#101) OF 6 SAMPLED RESIDENTS AT RISK FOR ELOPEMENT FROM A TOTAL SAMPLE OF 7 RESIDENTS, RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #101, WHO LEFT THE FACILITY PREMISES ON 12/6/12, AT APPROXIMATELY 8:00 PM, UNBEKNOWNST TO FACILITY STAFF AND DID NOT RETURN UNTIL 10:35 PM, WHEN A FAMILY MEMBER BROUGHT HIM BACK TO THE FACILITY. THIS DEFICIENT PRACTICE PLACED RESIDENT #101 AND 18 OTHER RESIDENTS, IDENTIFIED AS BEING AT RISK FOR ELOPEMENT, AT HIGH RISK FOR PHYSICAL HARM, INJURY AND/OR DEATH. FINDINGS INCLUDE: ACCORDING TO THE FACILITY "ADMINISTRATIVE STATEMENT INVESTIGATIVE ANALYSIS," DATED 12/6/12, AT 8:00 PM, THE NURSE (IDENTIFIED AS REGISTERED NURSE #3) "WITNESSED RESIDENT (#101) PASSING BY THE EAST NURSING STATION WITH A HAT AND COAT ON. NURSE (NAME OF REGISTERED NURSE #3) ASKED RESIDENT (#101) WHERE HE WAS GOING AND (#101) REPLIED THAT HE WAS GOING TO THE FRONT DOOR TO LET SOMEONE INTO THE BUILDING. AT APPROXIMATELY 8:45 (PM) NURSE (#3) RECEIVED PHONE CALL FROM RESIDENT'S DAUGHTER-IN-LAW (IDENTIFIED AS FAMILY MEMBER #4) THAT RESIDENT (#101) WAS AT THEIR HOUSE AND THEY WANTED HIM TO RETURN TO THE FACILITY." RESIDENT #101 WAS RETURNED TO THE FACILITY BY A FAMILY MEMBER ON 12/6/12 AT 10:35 PM. ACCORDING TO REGISTERED NURSE (RN) #3, WHO WAS INTERVIEWED ON 12/17/12 AT 1:05 PM, SHE HAD SEEN RESIDENT #101, WHO WAS WEARING A COAT AND HAT, PASS BY THE NURSE'S STATION ON 12/6/12 AT 8:00 PM. RESIDENT #101 TOLD RN #3 THAT HE WAS MEETING SOMEONE AT THE FRONT DOOR. RN #3 SAID THAT SHE WAS NOT AWARE OF RESIDENT #101'S WHEREABOUTS AFTER THAT UNTIL SHE RECEIVED A CALL FROM A FAMILY MEMBER AT AROUND 8:45 PM. RN #3 FURTHER STATED THAT NO ONE (STAFF) REPORTED THAT RESIDENT #101 WAS MISSING AND NO STAFF HAD NOTICED THAT HE WAS GONE. RN #3 STATED THAT SHE DID NOT HEAR ANY OF THE DOOR ALARMS GO OFF THAT NIGHT. RESIDENT #101 WAS RETURNED TO THE FACILITY BY HIS SON AT APPROXIMATELY 10:35 PM. WHEN RN #3 ASKED HIM, RESIDENT #101 SAID HE TOOK OFF HIS WANDERGUARD BRACELET (A WANDERGUARD IS A DEVICE THAT TRANSMITS A SIGNAL WHICH ACTIVATES AN ALARM WHEN THE SIGNAL IS RECEIVED, USUALLY AT A DOORWAY), BUT DID NOT SAY WHEN HE TOOK THE BRACELET OFF OR WHERE HE HAD PLACED IT. CERTIFIED NURSING ASSISTANT (CNA) #7 WAS INTERVIEWED ON 12/17/12 AT 1:31 PM. CNA #7 STATED THAT SHE (CNA #7) DILIGENTLY CHECKED RESIDENT #101'S WHEREABOUTS EVERY 15 MINUTES AND SHE IMMEDIATELY REPORTED TO RN #3 THAT RESIDENT #101 WAS NOT IN HIS ROOM AT 8:15 PM. CNA #7 STATED THAT SHE DID NOT LOOK FOR RESIDENT #101. SHE SAID THAT SHE JUST TOLD THE NURSE AND WENT ON TO HELP OTHER RESIDENTS BECAUSE THEY (THE FACILITY) "WERE SHORT (OF STAFF) THAT DAY." FAMILY MEMBER #4 WAS INTERVIEWED ON 12/17/12 AT 1:50 PM. FAMILY MEMBER #4 STATED THAT ACCORDING TO HER CELL PHONE RECORD, SHE CALLED THE FACILITY AT PRECISELY 9:26 PM BECAUSE RESIDENT #101 HAD BEEN DROPPED OFF BY A STRANGER (UNKNOWN TO THE FAMILY) AT 9:15 PM AT THEIR (THE FAMILY MEMBER'S) FRONT DOOR. ACCORDING TO THE CLINICAL RECORD, RESIDENT #101 WAS A [AGE] year- OLD MALE, WHO WAS admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. ON 6/25/12, RESIDENT #101 WAS DEEMED NOT ABLE TO MAKE MEDICAL DECISIONS FOR MEDICAL, LEGAL OR FINANCIAL MATTERS BY A LICENSED PSYCHOLOGIST. A LEGAL GUARDIAN WAS APPOINTED FOR RESIDENT #101 ON 8/27/12. ACCORDING TO A LETTER DATED 8/29/12, SIGNED BY THE LEGAL GUARDIAN, "WARD (RESIDENT #101) HAS A HISTORY OF ELOPEMENT...THEREFORE, WARD (RESIDENT #101) CANNOT GO ANYWHERE WITHOUT (NAME OF LEGAL GUARDIAN)'S PRIOR KNOWLEDGE AND APPROVAL." ACCORDING TO MULTIPLE ELOPEMENT RISK REVIEWS, DATED 7/3/12, 9/13/12 AND 10/8/12, RESIDENT #101 CONSISTENTLY VERBALIZED A DESIRE TO LEAVE THE FACILITY UNAUTHORIZED. THESE THREE (3) RISK REVIEWS INDICATED THAT RESIDENT #101 WAS AT A VERY HIGH RISK FOR ELOPEMENT (A SCORE GREATER THAN 12 INDICATED ELOPEMENT RISK AND RESIDENT #101 HAD SCORES OF 25 AND 30). RESIDENT #101'S ELOPEMENT RISK CARE PLAN WAS INITIATED ON 6/25/12, AND INCLUDED INTERVENTIONS TO ADDRESS HIS ELOPEMENT RISK SUCH AS THE PLACEMENT OF A WANDERGUARD BRACELET AND HAVING HIS WHEREABOUTS CHECKED BY NURSING STAFF EVERY 15 MINUTES. ACCORDING TO RESIDENT #101'S DOCTOR'S ANCILLARY ORDERS, DATED 10/11/12, RESIDENT #101 WAS TO WEAR THE WANDERGUARD (BRACELET) (WITH) VISUAL CHECK PLACEMENT (OF WANDERGUARD) Q (EVERY) SHIFT; CHECK WANDERGUARD (FUNCTIONING) VIA ELECTRONIC MACHINE Q (EVERY) D (DAY) (DURING THE 11 PM TO 7 AM SHIFT) AND TO CHANGE (THE) WANDERGUARD Q (EVERY) 80 DAYS. REVIEW OF THE TREATMENT ADMINISTRATION RECORD (TAR) FOR THE TIME PERIOD 12/1/12 THROUGH 12/6/12 (THE DATE OF RESIDENT #101'S ELOPEMENT) REVEALED THAT DURING THE DAY (7 AM THROUGH 3 PM) AND AFTERNOON (3 PM THROUGH 11 PM) SHIFTS, THE WANDERGUARD BRACELET WAS RARELY WORN BY RESIDENT #101, AS INDICATED BY THE NURSES' CIRCLED INITIALS (5 OCCASIONS) OR NOT DOCUMENTED AS CHECKED BY THE NURSE (2 OCCASIONS). FOR THE SAME TIME PERIOD, NURSES ON THE MIDNIGHT SHIFT DOCUMENTED DAILY THAT THE WANDERGUARD WAS CHECKED "VIA ELECTRONIC MACHINE." OBSERVATION OF RESIDENT #101 ON 12/17/12 AT 3:00 PM AND 12/19/12 AT 12:00 PM, REVEALED THAT RESIDENT #101 WAS NOT WEARING A WANDERGUARD BRACELET. WHEN ASKED BY SURVEYOR, RESIDENT #101 STATED THAT HE DID NOT WISH TO HAVE ONE. DURING THE ONSITE SURVEY ON 12/17/12 AT 12:00 PM., MAINTENANCE STAFF MEMBER #5 DEMONSTRATED HOW THE DOOR ALARM ACTIVATION SYSTEM IN THE FACILITY WORKED. ACCORDING TO MAINTENANCE STAFF MEMBER #5, EACH DOOR HAD BOTH A CONVENTIONAL ALARM AND A WANDERGUARD ALARM. INDIVIDUALS WEARING A WANDERGUARD BRACELET WOULD AUTOMATICALLY TRIGGER THE WANDERGUARD ALARM SHOULD THEY ATTEMPT TO EXIT THE BUILDING, BUT, EVEN INDIVIDUALS NOT WEARING A WANDERGUARD BRACELET WOULD TRIGGER THE CONVENTIONAL ALARM, IF THEY DID NOT ENTER THE CORRECT CODE ONTO A KEY PAD BEFORE OPENING THE DOOR. IF EITHER ALARM WAS TRIGGERED, A STAFF MEMBER WOULD NEED TO ENTER THE CORRECT CODE TO TURN OFF THE ALARM. ACCORDING TO ADMINISTRATOR #1, STAFF MEMBERS DID NOT REPORT THAT ANY ALARMS SOUNDED ON THE NIGHT OF 12/6/12. ON 12/17/12 AT 12:00 PM, THE SURVEYOR, ADMINISTRATOR #1 AND MAINTENANCE STAFF MEMBERS #5 AND #6 OBSERVED THAT THE WANDERGUARD ALARM FOR THE BACK DOOR (#4) DID NOT GO OFF, WHEN TRIGGERED. AN OUTSIDE CONTRACTOR FOR THE WANDERGUARD ALARM SYSTEM CAME IN TO REPAIR THE PROBLEM ON 12/17/12 AT 4:00 PM. ON 12/19/12 AT 12:00 NOON, THE WANDERGUARD ALARMS OF THE EXIT DOOR UNITS WERE tested . DOORS #1, #2 AND #4 DID NOT ALARM. ON 12/19/12 AT 12:45 PM, ADMINISTRATOR #1 CONTACTED THE OUTSIDE CONTRACTOR FOR THE WANDERGUARD ALARM SYSTEM TO IDENTIFY THE CAUSE OF MALFUNCTION. THE FACILITY "ADMINISTRATIVE STATEMENT INVESTIGATIVE ANALYSIS," DATED 12/6/12, CONCLUDED THAT "THE RESIDENT CALLED TRANSPORTATION HIMSELF, REMOVED THE WANDER GUARD BRACELET, DISABLED THE DOOR LOCK BY OBSERVING THE CODE ENTERED ON THE KEYPAD AND TOOK AN UNREPORTED AND UNAUTHORIZED LEAVE FROM THE FACILITY." ON 12/17/12, AT 10:45 AM, AN INTERVIEW WAS CONDUCTED WITH ADMINISTRATOR #1. ADMINISTRATOR #1 STATED THAT RESIDENT #101 LEFT THE BUILDING WITHOUT NOTIFYING STAFF AND WITHOUT ACTIVATING THE DOOR ALARMS. IT WAS NOT KNOWN IF SOMEONE HAD PROVIDED RESIDENT #101WITH THE KEY PAD CODE FOR THE EXIT DOORS OR IF HE HAD OBSERVED OTHER STAFF AND VISITORS PUT THE CODE IN. RESIDENT #101 LEFT THE BUILDING WITHOUT ACTIVATING EITHER THE CONVENTIONAL OR THE WANDERGUARD DOOR ALARMS. AFTER RESIDENT #101 WAS RETURNED TO THE FACILITY BY A FAMILY MEMBER ON 12/6/12, STAFF DISCOVERED THAT HE WAS NOT WEARING THE WANDERGUARD BRACELET. ON 12/18/12 AT 2:50 PM, THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 12/6/12 AT 8:00 AM WHEN RESIDENT #101 EXITED THE FACILITY UNBEKNOWNST TO STAFF AND WAS RETURNED BY A FAMILY MEMBER ON 12/6/12 AT 10:35 PM, PLACING RESIDENT #101 AS WELL AS 18 OTHER RESIDENTS IDENTIFIED AS BEING AT RISK FOR ELOPEMENT AT HIGH RISK FOR PHYSICAL HARM, INJURY AND/OR DEATH. ON 12/19/12, THE SURVEYOR VERIFIED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON 12/6/12, RESIDENT #101 WAS RETURNED TO THE FACILITY UNHARMED. RESIDENT #101 WAS PLACED ON ONE-TO-ONE SUPERVISION IMMEDIATELY AND WAS ASSESSED APPROPRIATELY. NO EVIDENCE OF INJURY WAS PRESENT. 2. ON 12/7/12, ALL RESIDENTS IN THE FACILITY WERE REVIEWED FOR ELOPEMENT RISK BY NURSING STAFF USING THE FACILITY ELOPEMENT ASSESSMENT. ALL 19 RESIDENTS IDENTIFIED AT RISK OF ELOPEMENT WERE ASSESSED AND HAVE WANDERGUARD BRACELETS IN PLACE AND FUNCTIONING, AS VALIDATED BY NURSING STAFF. 3. ON 12/7/12, THE IDT (INTER DISCIPLINARY TEAM) REASSESSED RESIDENT #101 AND 18 OTHER RESIDENTS IDENTIFIED AT RISK FOR ELOPEMENT, INCLUDING CHART REVIEWS TO VERIFY THAT THE physician's orders [REDACTED]. CARE PLANS FOR ELOPEMENT WERE BEEN UPDATED FOR ALL 19 RESIDENTS AT RISK FOR ELOPEMENT. 4. PRIOR TO AND CONTINUING FROM 12/7/12, ALL RESIDENTS WILL BE ASSESSED FOR ELOPEMENT RISK UPON ADMISSION, QUARTERLY, ANNUALLY AND WITH SIGNIFICANT CHANGE IN CONDITION. THE IDT WILL EVALUATE EACH ASSESSMENT AND UPDATE CARE PLANS AND CARE CARDS AS NECESSARY. 5. PRIOR TO AND CONTINUING FROM 12/7/12, THE WANDERGUARD TAG/BRACELET WERE REPLACED IN ACCORDANCE TO MANUFACTURER'S RECOMMENDATION. TAGS THAT HAD A BATTERY LIFE OF 90 DAYS WERE REPLACED ON THE 80TH DAY. REPLACEMENT DATES ARE NOW DOCUMENTED IN THE RESIDENT'S TAR. 6. PRIOR TO AND CONTINUING FROM 12/7/12, NIGHT SHIFT NURSE WILL VERIFY THE FUNCTION OF EACH WANDERGUARD BRACELET USING A HANDHELD TESTING DEVICE PROVIDED BY THE MANUFACTURER. THE NURSE WILL DOCUMENT RESULTS OF THE TEST. 7. ON 12/18/12, A LETTER WAS DRAFTED TO ALL RESIDENT'S RESPONSIBLE PARTY INFORMING THEM THAT THE CODE ON EACH EXIT DOORS WILL BE CHANGED EVERY 30 DAYS FOR RESIDENTS' SAFETY. THE CODE SHOULD NOT BE SHARED WITH OTHERS, ESPECIALLY THE RESIDENTS, TO MAINTAIN SAFETY AND PREVENT ELOPEMENT. 8. EFFECTIVE 12/7/12, RESIDENTS DEEMED APPROPRIATE FOR A WANDERGUARD DEVICE THAT REFUSE TO WEAR OR ARE KNOWN TO REMOVE THE WANDERGUARD DEVICE WILL BE PLACED ON ONE-TO-ONE CARE BY THE CHARGE NURSE UNTIL ALTERNATIVE MEANS OF DEVICE PLACEMENT ARE SAFELY ACHIEVED OR AN ALTERNATE PLACEMENT TO ANOTHER FACILITY TO ANOTHER FACILITY THAT MEETS THE RESIDENT'S NEEDS. 8. ALL ELOPEMENT ATTEMPTS AND INCIDENTS WILL BE REPORTED IN THE IDT MEETINGS DAILY. THE IDT WILL DISCUSS RESIDENTS AT RISK FOR ELOPEMENT, WEEKLY, MONTHLY AND DURING CARE MANAGEMENT RISK REVIEW MEETING. 9. ALL STAFF RECEIVED INSERVICE BEGINNING ON 12/7/12 ON ELOPEMENT MANAGEMENT POLICY AND RESIDENTS REFUSING AND REMOVING WANDERGUARD PLACEMENT. STAFF THAT HAS NOT RECEIVED THE EDUCATION WILL NOT BE ALLOWED TO RESUME WORK RESPONSIBILITIES UNTIL REEDUCATION IS COMPLETE. 10. THE DON (DIRECTOR OF NURSING) OR DESIGNEE WILL CONDUCT RANDOM OBSERVATIONS DAILY OF WANDERGUARD BRACELETS TO ASSURE THEY ARE IN PLACE AND FUNCTIONING PROPERLY. 11. THE DON WILL OR DESIGNEE WILL CONDUCT AN AUDIT FOR RESIDENTS AT RISK FOR ELOPEMENT ACCORDING TO ELOPEMENT CARE PLAN ON A WEEKLY BASIS FOR ONE MONTH, BI-WEEKLY FOR ONE MONTH AND MONTHLY THEREAFTER. FINALLY THE DON OR DESIGNEE WILL AUDIT THE TARS ON A WEEKLY BASIS FOR ONE MONTH, BI-WEEKLY FOR ONE MONTH AND MONTHLY THEREAFTER. THE DON OR DESIGNEE WILL TREND THE RESULTS OF THE AUDITS AND WILL DISCUSS THE RESULTS DURING THE MONTHLY QA (QUALITY ASSURANCE) COMMITTEE MEETING. 12. THE QA COMMITTEE WILL MEET ON A WEEKLY BASIS FOR ONE MONTH AND MONTHLY THEREAFTER. FINDINGS FROM THE RESULTS OF AUDITS AND OVERSIGHTS WILL BE REPORTED TO THE COMMITTEE ON A MONTHLY BASIS. THE COMMITTEE WILL MAKE RECOMMENDATIONS FOR POLICY CHANGES OR FURTHER EDUCATION IF NECESSARY. 13. FACILITY POLICIES FOR ELOPEMENT MANAGEMENT DATED AUGUST 2012, RESIDENT ELOPEMENT DATED AUGUST 2012, AND TESTING THE WANDERGUARD SYSTEM DATED FEBRUARY 2010 WERE DEEMED APPROPRIATE. THE IMMEDIATE JEOPARDY (IJ) WHICH BEGAN ON 12/6/12 WAS REMOVED ON 12/7/12. THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF "PATTERN" AND SEVERITY OF "NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY" UNTIL ALL FACILITY STAFF MEMBERS HAVE BEEN TRAINED AND SUSTAINED COMPLIANCE CAN BE VERIFIED BY THE STATE AGENCY. ( )

THIS REGULATION HAS MULTIPLE DEFICIENT PRACTICES. DEFICIENT PRACTICE #1 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE HOT WATER TEMPERATURES WERE WITHIN A SAFE RANGE BETWEEN 105 AND 120 DEGREES FAHRENHEIT. HOT WATER TEMPERATURES RANGED FROM 122 DEGREES FAHRENHEIT TO 132.8 DEGREES FAHRENHEIT AT THE HANDWASHING SINKS IN SEVEN (104, 105, 109, 110, 111, 126, AND 228) OF 60 RESIDENT ROOMS. THE HOT WATER TEMPERATURES HAD THE POTENTIAL TO AFFECT SEVEN (#'S 6, 7, 18, 20, 46, 425 & 426) OF 23 RESIDENTS, RESULTING IN AN IMMEDIATE JEOPARDY (IJ) AND THE POTENTIAL FOR HARM, SERIOUS INJURY AND/OR DEATH FROM SERIOUS BURNS AND SCALDING. THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON 5/8/12 AT 7:00 A.M. THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 5/8/12 AT 10:15 AM, AND WAS ASKED FOR A PLAN OF CORRECTION TO REMOVE THE IMMEDIACY. THE IJ WAS REMOVED ON 5/8/12 BASED ON THE PROVIDER'S IMPLEMENTATION OF CORRECTIVE ACTIONS ON 5/8/12 AS VERIFIED BY THE SURVEY TEAM WHILE ONSITE ON 5/8/12. ALTHOUGH THE IJ WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE WAS NOT CORRECTED AND REMAINED AS A PATTERN WITH NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT WAS NOT IMMEDIATE JEOPARDY. FINDINGS INCLUDE: ON 5/8/12 AT 6:10 AM, DURING THE INITIAL TOUR, THE HOT WATER TEMPERATURE FROM THE FAUCET IN THE HANDWASHING SINK IN THE ACTIVITIES ROOM WAS 124.2 DEGREES FAHRENHEIT. THERE WERE NO RESIDENTS IN THE ACTIVITY ROOM AT THIS TIME. ON 5/08/12 AT 6:30 A.M., THE HOT WATER TEMPERATURE AT THE HAND SINKS IN RESIDENT BATHROOMS RANGED BETWEEN 122.0 TO 132.8 DEGREES FAHRENHEIT AS FOLLOWS: 1. ROOM #104: THE HOT WATER TEMPERATURE MEASURED 125.6 DEGREES FAHRENHEIT. ACCORDING TO THE RESIDENT'S FACE SHEET, RESIDENT #6 WAS admitted INto the facility on [DATE] AND diagnosed with [REDACTED]. ACCORDING TO THE Minimum Data Set, dated dated [DATE], RESIDENT #6 WAS ALERT AND ORIENTED. ON 5/8/12 AT 8:00 AM, THE DIRECTOR OF NURSING (DON) AND UNIT MANAGER "I" WAS QUERIED REGARDING RESIDENT #6'S MOBILITY TO ACCESS THE HANDWASHING SINK. BOTH THE DON AND UNIT MANAGER "I" AGREED THAT RESIDENT #6 WAS ABLE TO INDEPENDENTLY ACCESS THE HANDWASHING SINK IN THE RESIDENT'S ROOM. 2. ROOM #105: THE HOT WATER TEMPERATURE MEASURED 132.8 DEGREES FAHRENHEIT. ACCORDING TO THE RESIDENT'S FACE SHEET, RESIDENT #7 WAS admitted INto the facility on [DATE] AND diagnosed with [REDACTED]. ACCORDING TO THE Minimum Data Set, dated dated [DATE], RESIDENT #7 ALERT AND ORIENTED. ON 5/8/12 AT 8:00 AM, THE DIRECTOR OF NURSING (DON) AND UNIT MANAGER "I" WAS QUERIED REGARDING RESIDENT #7'S MOBILITY TO ACCESS THE HANDWASHING SINK. BOTH THE DON AND UNIT MANAGER "I" AGREED THAT RESIDENT #7 WAS ABLE TO INDEPENDENTLY ACCESS THE HANDWASHING SINK IN THE RESIDENT'S ROOM. 3. ROOMS #109 AND #111 SHARED THE SAME BATHROOM: THE HOT WATER TEMPERATURE MEASURED 130.6 DEGREES FAHRENHEIT. ACCORDING TO THE RESIDENT'S FACE SHEET, RESIDENT #18 WAS admitted INto the facility on [DATE] diagnosed with [REDACTED]. ACCORDING TO THE Minimum Data Set, dated dated [DATE], RESIDENT #18 HAD LONG AND SHORT-TERM MEMORY PROBLEMS, SEVERELY IMPAIRED COGNITIVE SKILLS FOR DAILY DECISION-MAKING, AND WAS ABLE TO AMBULATE. ACCORDING TO THE FACE SHEET, RESIDENT #20 WAS admitted INto the facility on [DATE] diagnosed with [REDACTED]. ACCORDING TO THE Minimum Data Set, dated dated [DATE], RESIDENT #18 HAD LONG AND SHORT-TERM MEMORY PROBLEMS, SEVERELY IMPAIRED COGNITIVE SKILLS FOR DAILY DECISION-MAKING. ON 5/8/12 AT 8:00 AM, THE DIRECTOR OF NURSING (DON) AND UNIT MANAGER "I" WAS QUERIED REGARDING RESIDENTS #18 AND #20'S MOBILITY TO ACCESS THE HANDWASHING SINK. BOTH THE DON AND UNIT MANAGE "I" AGREED THAT RESIDENTS #18 AND #20 WERE ABLE TO INDEPENDENTLY ACCESS THE HANDWASHING SINK IN THEIR ROOM. 4. ROOM #110: THE HOT WATER TEMPERATURE MEASURED 127.2 DEGREES FAHRENHEIT. A REVIEW OF RESIDENT #426'S FACE SHEET REVEALED AN admission date of [DATE] WITH [DIAGNOSES REDACTED]. ACCORDING TO THE MOST RECENT Minimum Data Set, dated dated [DATE], AND INTERVIEW WITH UNIT MANAGER "I", RESIDENT #426 HAD NO COGNITIVE IMPAIRMENTS AND WAS ABLE TO PROPEL HERSELF FREELY INTO THE BATHROOM AND ACCESS THE HANDWASHING SINK. ON 5/10/12 AT 1:00 P.M., RESIDENT #426 WAS QUERIED ABOUT WATER TEMPERATURES AND STATED, "THE WATER IS ALWAYS VERY HOT. YOU CAN'T TRUST IT." 5. ROOM #126: THE HOT WATER TEMPERATURE MEASURED 122.0 DEGREES FAHRENHEIT. ACCORDING TO THE RESIDENT'S FACE SHEET, RESIDENT #46 WAS admitted INTO THE FACILITY 4/25/07 diagnosed with [REDACTED]. ACCORDING TO THE MOST RECENT Minimum Data Set, dated dated [DATE], AND INTERVIEW WITH UNIT MANAGER "I", RESIDENT #426 HAD NO COGNITIVE IMPAIRMENTS AND WAS ABLE TO PROPEL HERSELF FREELY INTO THE BATHROOM AND ACCESS THE HANDWASHING SINK. 6. ROOM #228: THE HOT WATER TEMPERATURE MEASURED 122 DEGREES FAHRENHEIT. REVIEW OF THE RESIDENT'S FACE SHEET REVEALED RESIDENT #425 WAS admitted INto the facility on [DATE] AND diagnosed with [REDACTED].#425 HAD "SEVERELY IMPAIRED" COGNITIVE SKILLS FOR DAILY DECISION-MAKING AND WAS ABLE TO PROPEL HERSELF FREELY INTO THE BATHROOM AND ACCESS THE HANDWASHING SINK. ON 5/08/12 AT 7:30 A.M., AN INTERVIEW WAS CONDUCTED WITH CERTIFIED NURSE ASSISTANT (CNA) "L" ABOUT WATER TEMPERATURES AND SHE STATED, "THE WATER IS ALWAYS HOT. I ADD COLD WATER SO THAT IT ISN'T TOO HOT FOR THE RESIDENTS." THE FACILITY'S WATER TEMPERATURE LOG BOOK, DATED 3/01/12 TO 5/07/12, WERE REVIEWED. THE WATER TEMPERATURE LOGS REVEALED THAT WATER TEMPERATURES WERE MEASURED IN 10 TO 12 RESIDENT AREAS TWICE A WEEK. HIGH TEMPERATURES WERE DOCUMENTED IN THE LOG ON 3/19/12 IN ROOM # 128 THAT MEASURED 120.8 DEGREES FAHRENHEIT AND ON 3/27/12 IN ROOM 209 MEASURED 122.0 DEGREES FAHRENHEIT. ON 4/13/12, SEVERAL ROOMS (102, 200, AND 209) MEASURED BETWEEN 120.5 AND 122.0 DEGREES FAHRENHEIT. THE MAINTENANCE DIRECTOR WAS INTERVIEWED AND WAS UNABLE TO DESCRIBE WHAT ACTION WAS TAKEN TO ADDRESS THE HOT WATER TEMPERATURES. ON 5/8/12 AT 1:00 PM, THE MAINTENANCE DIRECTOR WAS QUERIED REGARDING THE HOT WATER TEMPERATURES AND HOW OFTEN THEY WERE MEASURED. THE MAINTENANCE DIRECTOR STATED, "I SPOT CHECK THEM EVERY COUPLE OF DAYS. I DON'T KNOW WHY THE SAME ROOMS WERE CHECKED." THE FACILITY'S POLICY ENTITLED, "MONITORING WATER TEMPERATURES," DATED JUNE 2007 WAS AS FOLLOWS: "1. CHECK HOT WATER TEMPERATURES AT BOTH INDIVIDUAL AND COMMON RESIDENT USE AREAS. 2. SCHEDULE SAMPLING TO CHECK TEMPERATURES...THROUGHOUT THE ENTIRE BUILDING EVERY THREE DAYS...SAMPLE PROBLEM AREAS DAILY...ROTATE THRU THE SETS SO THAT ALL FIXTURES ARE COVERED OVER A PERIOD OF TIME. (THE ACCEPTABLE TEMPERATURE RANGE FOR HOT TAP WATER IS 100 DEGREES FAHRENHEIT THRU 110 DEGREES FAHRENHEIT.)" THE ADMINISTRATOR AND DIRECTOR OF NURSING WERE INTERVIEWED ON 5/08/12 AT 11:00 A.M. AND WERE NOT AWARE THAT HOT WATER TEMPERATURES EXCEEDED 120 DEGREES FAHRENHEIT. THEY WERE UNABLE TO EXPLAIN WHY HOT WATER TEMPERATURES WERE NOT DONE AS INDICATED IN THE FACILITY'S POLICY AND WHY THEY WERE NOT AWARE OF DAYS WHEN THE TEMPERATURE OF THE HOT WATER MEASURED ABOVE 120.0 DEGREES FAHRENHEIT (3/19, 3/27, AND 4/13/12). THE FACILITY SUBMITTED THE FOLLOWING PLAN OF CORRECTION ON 5/8/12: 1. HOW CORRECTIVE ACTION HAS BEEN ACCOMPLISHED FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE. RESIDENTS CURRENTLY RESIDING IN THE FACILITY ARE AT POTENTIAL RISK. THE SURVEYOR NOTIFIED THE FACILITY ADMINISTRATOR AT 10:50 A.M. ON 5/8/12 THAT THE HOT WATER TEMPERATURE WAS BETWEEN 122 AND 132 DEGREES. THE MAINTENANCE SUPERVISOR IMMEDIATELY TURNED OFF THE WATER TO THE AFFECTED LOCATIONS AND PLACED SIGNS TO NOT USE THE HOT WATER UNTIL REPAIRED. THE RESIDENTS #6, #7, #15 (DELETED), #16 (DELETED), #17 (#426), #18, #20, #46 AND #114 (#425) THAT WAS AFFECTED BY THE DEFICIENT PRACTICE WERE INTERVIEWED AND PHYSICALLY ASSESSED TO ENSURE THEY HAVE NOT SUSTAINED INJURY. 2. HOW THE FACILITY WILL IDENTIFY OTHER RESIDENTS THAT COULD BE AFFECTED BY THE DEFICIENT PRACTICE. THE LICENSED NURSES HAVE ASSESSED 68 OF 107 HAVE BEEN ASSESSED AND SHOW NO ILL AFFECTS OR INJURY AND THE REMAINING 39 RESIDENT ASSESSMENTS WILL BE COMPLETED BY 5/8/2012 TO ENSURE NO INJURIES WERE SUSTAINED. HOT WATER WAS TURNED BACK ON AND WAS tested BEFORE AN FACILITY USE TO ENSURE TEMPERATURES WERE IN SAFE RANGE. MAINTENANCE SUPERVISOR AND ADMINISTRATOR HAVE CONTACTED OUTSIDE VENDOR TO INSPECT HOT WATER SYSTEM, INCLUDING THE MIXING VALVE BETWEEN HOT AND COLD WATER SYSTEMS. THE MAINTENANCE SUPERVISOR, MAINTENANCE TECHNICIAN AND/OR ADMINISTRATOR OR DESIGNEE WILL CHECK HOT WATER TEMPS THREE TIMES DAILY FOR FOUR WEEKS, THEN TWO TIMES WEEKLY, IN RANDOM LOCATIONS AND THROUGHOUT THE BUILDING AND COMPLETE A DAILY TEMPERATURE LOG. IF HOT WATER IS FOUND TO BE AT OR ABOVE 120 DEGREES THE FAUCET WILL BE SHUT OFF IMMEDIATELY AT THE LOCATION AND TEMPERATURE WILL BE ADJUSTED IMMEDIATELY. WATER WILL BE RESTORED WHEN IT IS WITHIN SAFE TEMPERATURE RANGE. 3. SYSTEMIC CHANGE MONITORING WATER TEMPERATURES POLICY WAS REVIEWED AND WAS DEEMED APPROPRIATE FOR USE. STARTING 5/8/2012 ALL STAFF CURRENTLY WORKING WILL BE RE-EDUCATED ABOUT SAFETY REGARDING HOT WATER, AND THE MONITORING WATER TEMPERATURE POLICY, AND TO NOTIFY THE MAINTENANCE DIRECTOR OR ADMINISTRATOR IN CASE OF EMERGENCIES OR WATER TEMPERATURE PROBLEMS. AS OF 4:00 PM, 36 EMPLOYEES WERE RE-EDUCATED REGARDING THE WATER TEMPERATURE RANGE AND SAFETY. STAFF NOT WORKING WILL NOT BE ABLE TO ASSUME THEIR DUTIES UNTIL THEY HAVE RECEIVED THE EDUCATION. RE-EDUCATION WILL CONTINUE UNTIL THE REMAINING 92 EMPLOYEES HAVE BEEN EDUCATED. THE SAFE HOT WATER TEMPERATURES RANGE WILL BE POSTED AT THE NURSE'S STATIONS FOR REFERENCE ON MAY 8, 2012. THERMOMETERS WILL BE PLACE ON EACH NURSING UNIT FOR USE BY STAFF MAY 8, 2012. ALL STAFF WILL BE EDUCATED TO REPORT IMMEDIATELY TO THEIR SUPERVISOR IF THERE ARE COMPLAINTS OF WATER BEING TOO HOT. ANY STAFF NOT EDUCATED BY THE DATE WILL NOT BE ABLE TO ASSUME THEIR DUTIES UNTIL THEY HAVE RECEIVED THE EDUCATION. THE MAINTENANCE SUPERVISOR, MAINTENANCE TECHNICIAN AND/OR ADMINISTRATOR OR DESIGNEE WILL CHECK HOT WATER TEMPS THREE TIMES DAILY TIMES FOR FOUR WEEKS, THEN TWO TIMES WEEKLY, IN RANDOM LOCATIONS THROUGHOUT THE BUILDING AND COMPLETE A DAILY TEMPERATURE LOG. STAFF HAS BEEN MAD AWARE THAT THEY ARE REQUIRED TO REPORT ANY INJURIES OR CONCERNS RELATED TO HOT WATER IMMEDIATELY TO THEIR SUPERVISOR. THE MAINTENANCE SUPERVISOR AND/OR ADMINISTRATOR WILL IMMEDIATELY ADDRESS CONCERN AND MAKE ARRANGEMENTS FOR ALTERNATE SOURCE OF HOT WATER UNTIL DEEMED SAFE TEMPERATURE. THE ADMINISTRATOR AND/OR A DESIGNEE WILL MONITOR RESIDENT COUNCIL MEETING MINUTES, CONCERN FORMS/LOGS AND WATER TEMP LOGS TO ENSURE THAT THERE ARE NO OUTSTANDING COMPLAINTS RELATED TO WATER TEMPERATURES. SUCH COMMENTS OR ISSUES WILL BE SHARED WITH THE FACILITY'S QUALITY ASSESSMENT AND ASSURANCE COMMITTEE AT THE MONTHLY COMMITTEE MEETING. THE ADMINISTRATOR IS RESPONSIBLE FOR COMPLIANCE. 4. QUALITY ASSURANCE AND ASSESSMENT ON MAY 8, 2012 THE FACILITY HELD AN EMERGENCY QUALITY ASSURANCE AND ASSESSMENT COMMITTEE MEETING TO DISCUSS AND APPROVE THIS PLAN. THE MEDICAL DIRECTOR WAS INFORMED AND HAS APPROVED THIS PLAN. THE MAINTENANCE SUPERVISOR, MAINTENANCE TECHNICIAN, AND ADMINISTRATOR AND/OR DESIGNEE WILL MONITOR & RECORD TEMPERATURES OF HOT WATER DAILY. MAINTENANCE SUPERVISOR WILL BRING THE COMPLETED LOGS TO QA& MONTHLY. ANY PROBLEMS IDENTIFIED WILL BE PRESENTED AND ACTION PLANS WILL BE ESTABLISHED AND IMPLEMENTED. ANY DISCREPANCIES OR ISSUES WITH TEMPERATURES WILL BE IMMEDIATELY ADDRESSED AND DOCUMENTED. TRENDS AND CORRECTIVE ACTION WILL BE DISCUSSED AT EACH MONTHLY QUALITY ASSESSMENT AND ASSURANCE MEETING. RECOMMENDATIONS OF THE COMMITTEE FOR ACTIONS AND WILL BE IMPLEMENTED AND MONITORED. 5. DATE OF COMPLIANCE FACILITY WILL BE IN COMPLIANCE BY 5/8/2012. ( )( )( )( )( ) DEFICIENT PRACTICE #2 BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO MONITOR THE USE OF EXTENSION CORDS AND POWER STRIPS IN 19 OF 60 RESIDENT ROOMS (ROOM #S 116, 118, 119, 120, 121, 123, 124, 126, 127, 130, 206, 210, 213, 217, 224, 225, 226, 227, AND 228). THIS HAD THE POTENTIAL TO AFFECT SIX (#S 411, 412, 414, 418, 419, AND 425) OF 26 SAMPLED RESIDENTS AND 16 SUPPLEMENTAL SAMPLED RESIDENTS (#S 28, 31, 33, 37, 41, 43, 47, 49, 54, 77, 78, 95, 108, 109, 110, AND 112), RESULTING IN THE POTENTIAL FOR ELECTRICAL FIRES. FINDINGS INCLUDE: DURING THE INITIAL TOUR ON 5/8/12 AT 6:10 AM, AND DURING A TOUR OF THE FACILITY WITH MAINTENANCE WORKER "G" AND EMPLOYEE "F", THE MAINTENANCE/ HOUSEKEEPING/ LAUNDRY SUPERVISOR, THE FOLLOWING ITEMS WERE OBSERVED: ROOM 116: THERE WAS ONE POWER STRIP IN USE FOR THE TUBE FEEDING PUMP AND BED. ROOM 118: THERE WAS ONE POWER STRIP IN USE FOR THE BED. ROOM 119: THERE WAS ONE POWER STRIP IN USE FOR THE TUBE FEEDING PUMP FOR BED ONE. THERE WAS A POWER STRIP IN USE FOR THE LOW AIR LOSS MATTRESS PUMPS. ROOM 120: THERE WERE TWO POWER STRIPS IN USE FOR BED-2. POWER STRIP #1 WAS PLUGGED INTO THE WALL AND WAS USED FOR THE PUMP FOR THE SPECIALTY BED. POWER STRIP #1 WAS PLUGGED INTO POWER STRIP #2 AND WAS USED FOR THE TUBE FEEDING PUMP AND THE ELECTRIC BED. ROOM 121: THERE WAS ONE POWER STRIP IN USE FOR THE BED. ROOM 123: THERE WAS ONE POWER STRIP IN USE FOR THE BED. ROOM 124: THERE WAS ONE POWER STRIP IN USE FOR THE BED AND BREATHING MACHINE. ROOM 126: THERE WAS ONE POWER STRIP IN USE FOR THE BED. ROOM 127: THERE WAS ONE POWER STRIP IN USE FOR THE BED. ROOM 206: THERE WAS ONE POWER STRIP IN USE FOR THE BED AND OXYGEN CONCENTRATOR. ROOM 209: THERE WAS ONE POWER STRIP USED FOR TUBE FEEDING PUMP AND OXYGEN CONCENTRATOR FOR BED ONE. THERE WAS ANOTHER POWER STRIP USED FOR THE TUBE FEEDING PUMP AND INTRAVENOUS MEDICATION PUMP FOR BED TWO ROOM 210: THERE WAS ONE POWER STRIP IN USE FOR THE BREATHING MACHINE. ROOM 213: BED ONE - THERE WAS ONE POWER STRIP IN USE FOR THE TUBE FEEDING PUMP, SUCTION MACHINE AND OXYGEN CONCENTRATOR. BED TWO - THERE WAS A POWER STRIP IN USE FOR THE TUBE FEEDING PUMP, BREATHING MACHINE, OXYGEN CONCENTRATOR, AND ELECTRIC BED. ROOM 217: THERE WAS ONE POWER STRIP IN USE FOR THE BED AND OXYGEN CONCENTRATOR. ROOM 224: BED TWO - THERE WAS ONE POWER STRIP IN USE FOR THE TUBE FEEDING PUMP, BREATHING MACHINE, OXYGEN CONCENTRATOR, ELECTRIC BED, AND LOW AIR LOSS MATTRESS PUMP. BED ONE - THERE WAS A BROWN, EXTENSION CORD IN USE FOR THE TELEPHONE. ROOM 225: BED ONE - THERE WAS A POWER STRIP IN USE FOR THE BED AND BREATHING MACHINE. BED TWO - THERE WAS A POWER STRIP IN USE FOR THE BED AND BREATHING MACHINE. ROOM 226: THERE WAS A POWER STRIP IN USE FOR THE BED, SUCTION MACHINE AND TUBE FEEDING PUMP. ROOM 227: THERE WAS A POWER STRIP IN USE FOR THE BED. ROOM 228: THERE WAS A POWER STRIP IN USE FOR THE BED. ON 5/10/12 AT 3:10 PM, THE EMPLOYEE "F", THE MAINTENANCE/ HOUSEKEEPING/ LAUNDRY SUPERVISOR, WAS ASKED IF THE FACILITY HAD A POLICY FOR AND MONITORED THE USE OF POWER STRIPS. EMPLOYEE "F" REVEALED THERE WAS NO POLICY ON THE USE OF POWER STRIPS AND THAT HE HAD NOT MONITORED THE USE OF POWER STRIPS OR EXTENSION CORDS. EMPLOYEE "F" REVEALED THAT EXTENSION CORDS WERE REMOVED AS HE CAME ACROSS THEM. ON 5/11/12 AT 8:45 AM, THE ADMINISTRATOR WAS ASKED ABOUT THE USE OF POWER STRIPS AND EXTENSION CORDS. THE ADMINISTRATOR STATED, "THIS BUILDING DOESN'T HAVE AS MANY PLUGS AS MODERN BUILDINGS. I'VE TALKED TO THE REGIONAL VICE-PRESIDENT IN JANUARY 2012 ABOUT AN ELECTRICAL UPGRADE."HOWEVER, THE ADMINISTRATOR WAS UNABLE TO REVEAL DOCUMENTATION THAT THE UPGRADE HAD BEEN DISCUSSED OR WHEN THE UPGRADE WOULD BE DONE. THE ADMINISTRATOR FURTHER STATED, "EMPLOYEE "F" INSPECTS THE ROOMS DAILY". THE ADMINISTRATOR WAS INFORMED THAT EMPLOYEE "F" HAD REVEALED THAT ROOM INSPECTIONS HAD NOT BEEN DONE AND THAT THERE WERE NO LOGS, THE ADMINISTRATOR STATED, "REALLY, OKAY." ON 5/11/12, A REVIEW OF THE FACILITY POLICY ENTITLED "ELECTRICAL SAFETY", REVISED 3/08, STATED, "MULTI-RECEPTACLE STRIPS CANNOT BE USED AS A SUBSTITUTE FOR PERMANENT WIRING AND MUST BE USED ONLY FOR A TEMPORARY POWER SOURCE." ( )

,THIS CITATION PERTAINS TO INTAKE NUMBER MI 998 BASED ON INTERVIEW AND CLOSED RECORD REVIEW, THE FACILITY 1) FAILED TO PROVIDE SUPERVISION; 2) FAILED TO PROVIDE ASSISTANCE WITH TRANSFERS AND AMBULATION AND; 3) FAILED TO IMPLEMENT EFFECTIVE PREVENTIVE INTERVENTIONS TO PREVENT FALLS FOR ONE (#503) OF FOUR RESIDENTS REVIEWED FOR FALLS FROM A TOTAL OF FOUR SAMPLE RESIDENTS, RESULTING IN RESIDENT #503 SUSTAINING A FALL WITH A FRACTURED HIP. FINDINGS INCLUDE: A COMPLAINT ON FILE ALLEGED THAT RESIDENT #503 WAS LEFT UNSUPERVISED AND fell . RESIDENT #503 died on [DATE]. THE CAUSE OF DEATH WAS UNKNOWN AT THE TIME OF THE INVESTIGATION. ACCORDING TO THE FACILITY'S "PHYSICIAN'S ADMISSION ORDER SHEET," RESIDENT #503 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #503 WAS REadmitted on [DATE] WITH A [DIAGNOSES REDACTED]. THE MINIMUM DATA SET (MDS) dated [DATE] INDICATED THAT RESIDENT #503 REQUIRED EXTENSIVE ASSISTANCE WITH ACTIVITIES OF DAILY LIVING WHICH INCLUDED BED MOBILITY, TRANSFERS, DRESSING, TOILETING, PERSONAL HYGIENE AND WAS TOTALLY DEPENDENT ON STAFF FOR BATHING. THE MDS FURTHER DOCUMENTED THAT "...HE (#503) IS ABLE TO MAKE DAILY DECISIONS. HOWEVER, HE DOES FORGET TO ASK FOR ASSISTANCE WITH TRANSFERS, AMBULATION, HAS A HISTORY OF FALLS PRIOR TO PLACEMENT HERE. FALLS HAVE RESULTED IN CEREBRAL BLEEDS - HAS HAD SURGERY TO RELIEVE SUBDURAL HEMATOMAS. HE DOES FORGET PIECES OF HISTORY AND MAY CONFUSE TIMES CERTAIN THINGS OCCURRED." A REVIEW OF RESIDENT #503'S "FALL RISK" assessment dated [DATE] AND [DATE], REVEALED THAT ON BOTH OCCASSIONS, THE RESIDENT WAS ASSESSED AS HAVING A FALL RISK SCORE OF 24. "...TOTAL SCORE OF 10 OR ABOVE REPRESENTS HIGH RISK..." A physician's orders [REDACTED]. A REVIEW OF RESIDENT #503'S "AT RISK FOR FALLS" CARE PLAN REVEALED THAT ON [DATE] RESIDENT #503 REFUSED THE ALARMS AND BED BOLSTERS. THE CARE PLAN FURTHER REVEALED "...REFUSED LOW BED..." THERE WAS NO DOCUMENTED EVIDENCE IN THE CLINICAL RECORD THAT ANY ALTERNATE MEASURES OR INTERVENTIONS WERE APPLIED OR ATTEMPTED IN ORDER TO PREVENT FALLS. A REVIEW OF THE PHYSICAL THERAPY EVALUATION DATED [DATE] REVEALED, "...HAND HELD ASSIST. UNSTEADY GAIT..." A "REHAB NOTE" DATED [DATE] REVEALED, "...CONTINUE ALARM IN BED, ASSIST WITH TRANSFERS, AMBULATE WITH HAND HEAL ASSIST, ROOM UNCLUTTERED, COMMODE CHAIR, ROOM CHANGE..." A "THERAPY PROGRESS AND UPDATE" NOTE DATED [DATE] INDICATED THAT RESIDENT #503 HAD "...DECREASED STRENGTH, DECREASED ACTIVITY TOLERANCE, DECREASED STANDING BALANCE, DECREASED SAFETY AWARENESS..." A REVIEW OF AN OCCUPATIONAL THERAPY EVALUATION DATED [DATE] REVEALED, "...HE (#503) PROPELS HIMSELF WITH HIS FEET AND ARMS. HE CAN AMBULATE WITH A ROLLING WALKER AND CONTACT GUARD ASSIST..." A REVIEW OF THE "RESIDENT STATUS SHEET" (GUIDE USED TO INFORM DIRECT CARE STAFF OF RESIDENT'S NEEDS) REVEALED "...CONFUSED AT TIMES, LOCOMOTION BED TO CHAIR X 2 ASSIST, AMBULATORY WITH ASSIST. LEVEL OF CARE: ONE ASSIST SUPERVISE..." ON [DATE] AT 12:15 P.M., DURING AN INTERVIEW, THE PHYSICAL THERAPY MANAGER (PTM) REPORTED THAT RESIDENT #503 "...WAS TO HAVE AN ALARM TO HIS BED SECONDARY TO A FALL ON [DATE]. HE WAS TO HAVE ASSISTANCE WITH TOILETING AND AMBULATE WITH HAND HELD ASSIST, CONTACT GUARD..." THE PTM FURTHER REPORTED THAT RESIDENT #503 "...COULD AMBULATE 100 FEET WITH HAND HELD ASSISTANCE. HE WAS TO AMBULATE WITH A ROLLING WALKER AND SUPERVISION AND HE NEEDED MAXIMUM ASSISTANCE WITH TRANSFERS FROM LOW BED TO WHEELCHAIR AND FROM WHEELCHAIR TO THE BED..." A REVIEW OF THE FACILITY'S "INCIDENT/ACCIDENT REPORT" DATED [DATE], REVEALED THAT ON [DATE] AT 10:00 P.M., RESIDENT (#503) "...fell WHILE AMBULATING BACK TO HIS BED USING HIS WALKER. VOICED PAIN TO RIGHT HIP. POSSIBLE FRACTURE. COGNITIVE STATUS CONFUSED. TRANSFERRED TO ER (emergency room )..." A REVIEW OF THE "INTERDISCIPLINARY POST FALL REVIEW" REVEALED, "...RESIDENT (#503) HAD BEEN IN SOUTH EAST HALL USING TELEPHONE TO CALL HIS WIFE. AMBULATED AS WITHOUT ASSISTANCE WITH WALKER TO PHONE. RESIDENT WALKED BACK TO HIS ROOM WITH WALKER AND fell NEXT TO HIS BED..." THE POST FALL REVIEW FURTHER REVEALED THAT RESIDENT #503 "...TOOK AMBIEN AT 10:00 P.M..." (USED FOR INSOMNIA TO HELP THE INDIVIDUAL TO FALL ASLEEP. MAY CAUSE DROWSINESS, LIGHTHEADEDNESS, WEAKNESS). "...ACTIVITY AT THE TIME OF THE FALL: UNASSISTED AMBULATION, UNASSISTED TRANSFER, UNSTEADY GAIT, HISTORY OF FALLS..." A REVIEW OF THE FACILITY'S "CHANGE OF CONDITION" DOCUMENT DATED [DATE] REVEALED: "...WHEN PATIENT AMBULATED TO HIS ROOM, HE fell . RESIDENT WANTS TO GO TO emergency room STATING "I THINK MY LEG IS BROKEN" RESIDENT (#503) YELLED OUT WHILE WRITER WAS WALKING TOWARDS DINING ROOM, WRITER WENT INTO RESIDENT'S ROOM TO FIND RESIDENT ON FLOOR NEXT TO HIS BED. RESIDENT (#593) STATED, "I THINK I BROKE MY LEG"..." A REVIEW OF THE EMS (EMERGENCY MEDICAL SERVICE) RUN SHEET DATED [DATE] REVEALED THAT EMERGENCY PERSONNEL ARRIVED TO THE FACILITY AT 10:36 P.M., "...(#503) FOUND ALONE LYING IN HIS ROOM ON THE FLOOR. ASSESSMENT REVEALS A POSSIBLE RIGHT HIP DISLOCATION/FRACTURE. (#503) REPORTS A ,[DATE] PAIN SCORE..." A REVIEW OF THE HOSPITAL X-RAY REPORT DATED [DATE] REVEALED: "...FALL WITH CHEST WALL INJURY. STABLE CHEST. THERE IS NO ACUTE PROCESS IDENTIFIED..." "...HISTORY: FALL WITH LEG INJURY. FRONTAL LATERAL VIEWS OF RIGHT FEMUR PERFORMED. THESE ARE PERFORMED IN CONJUNCTION WITH THE RIGHT HIP STUDY. COMMINUTED INTERTROCHANTERIC FRACTURE OF THE PROXIMAL FEMUR IS IDENTIFIED..." "...MULTIPLE INJURIES AND RIGHT LEG INJURY. 2 VIEWS OF RIGHT HIP ARE PERFORMED. COMMINUTED INTERTROCHANTERIC FRACTURE OF THE PROXIMAL RIGHT FEMUR..." "...FALL WITH CHEST WALL INJURY. STABLE CHEST. THERE IS NO ACUTE PROCESS IDENTIFIED..." A REVIEW OF THE HOSPITAL DISCHARGE SUMMARY DATED [DATE] REVEALED, "...THE PATIENT (#503) IS A [AGE] year OLD MALE THAT PRESENTED TO THE HOSPITAL AFTER A FALL AT THE NURSING FACILITY. THE PATIENT STATES HE WAS TRYING TO COME OUT OF THE BATHROOM AND HE LOST HIS FOOTING AND fell on TO HIS RIGHT HIP AND EXPERIENCED IMMEDIATE PAIN IN THE RIGHT HIP WITH THE INABILITY TO BEAR ANY WEIGHT..." "...THE PATIENT (#503) WAS SEEN BY ORTHOPEDIC SURGERY WHO RECOMMENDED THE PATIENT UNDERGO AN OPEN REDUCTION AND INTERNAL FIXATION OF THE RIGHT HIP..." A REVIEW OF THE HOSPITAL "OPERATIVE REPORT" DATED [DATE] REVEALED THAT RESIDENT #503 UNDERWENT RIGHT HIP OPEN REDUCTION AND INTERNAL FIXATION WITH CEPHALOMEDULLARY DEVICE (SURGICAL NAIL USED TO REPAIR FRACTURED HIP)..." ON [DATE] AT 12:25 P.M., DURING AN INTERVIEW, THE DIRECTOR OF NURSING (DON) WAS QUERIED ABOUT RESIDENT #503'S HISTORY OF FALLS WHILE AT THE FACILITY AND REPORTED THE FOLLOWING: "...HE (#503) WAS SENT OUT TO THE HOSPITAL ON [DATE] AFTER A FALL HE HAD ON [DATE]. HE WASN'T FEELING WELL AND COMPLAINED OF FEELING WEAK. HE DIDN'T GO OUT ON [DATE] BECAUSE HIS NEUROLOGICAL ASSESSMENTS WERE OK. HE WAS SENT OUT TO THE HOSPITAL ON [DATE] FOR COMPLAINTS OF DIZZINESS AND HE CAME RIGHT BACK..." THE DON FURTHER REPORTED, "...ON [DATE], HE fell IN HIS BATHROOM. WHEN HE fell , HE HIT HIS HEAD ON THE TOILET, SAT THERE FOR A MINUTE THEN WENT BACK TO BED..." WHEN ASKED IF RESIDENT #503 HAD AN ALARM, THE DON SAID, "...HE REFUSED HIS ALARMS..." WHEN ASKED IF RESIDENT #503 WAS TO AMBULATE INDEPENDENTLY, WITHOUT STAFF ASSISTANCE, THE DON SAID, "...NO. HE WAS TO BE OFFERED AND ASSISTED. I SEE THAT HE WAS DOING UNASSISTED TRANSFERS AND REFUSING ALARMS..." WHEN ASKED WHY RESIDENT #503 REFUSED HIS ALARMS, THE DON SAID, "..I DON'T REMEMBER..." THE DON REPORTED, "...ON [DATE] WHEN HE fell , HE WAS AMBULATING BACK TO HIS BED USING HIS WALKER. HE HAD JUST COME FROM MAKING A PHONE CALL IN THE HALLWAY. THE "POST FALL REVIEW" SAYS HE WAS UNASSISTED, WITHOUT ASSIST, JUST HIM AND HIS WALKER..." WHEN ASKED WHY RESIDENT #503 WAS ALLOWED TO AMBULATE WITHOUT STAFF ASSISTANCE TO PROVIDE HAND HELD ASSIST AND CONTACT GUARD AS INDICATED BY THE PHYSICAL THERAPIST, THE DON SAID, "...THIS IS FRUSTRATING. I WASN'T THE DIRECTOR OF NURSING HERE DURING THAT TIME FRAME. IT'S REALLY UNFORTUNATE THAT THIS HAPPENED. I HAVE NO ANSWER. THE RESIDENT (#503) WAS TO AMBULATE WITH ASSISTANCE FROM STAFF. HE WAS VERY SICK..." ADDITIONALLY, THE DON REPORTED, "...THERE WERE NO INTERVENTIONS IN PLACE. AFTER WE REMOVED THE ALARMS, WE DIDN'T ADD ANY OTHER INTERVENTIONS. WE WERE LACKING IN INTERVENTIONS..." THE DON COULD NOT EXPLAIN WHY FACILITY STAFF ALLOWED RESIDENT #503 TO AMBULATE INDEPENDENTLY, WITHOUT HAND HELD ASSISTANCE OR CONTACT GUARD ASSISTANCE AS INDICATED IN THE PLAN OF CARE AND PHYSICAL THERAPY. A REVIEW OF THE FACILITY'S "FALL MANAGEMENT" POLICY REVISED ,[DATE] REVEALED, "...EACH FACILITY IS RESPONSIBLE FOR IMPLEMENTING INDIVIDUALIZED INTERVENTIONS RELATED TO/FOR EACH RESIDENT'S FALL RISKS..."

This citation pertains to Intake #'s MI 932, MI 787 and MI 908. Based on observation, interview and record review, the facility failed to provide adequate and appropriate skin care for four (#401, #402, #403 and #404) of seven sampled residents, resulting in maggots in wound (#403), increased necrotic tissue (#402), skin excoriation and stage one pressure ulcers (#401, #404). Findings include: Resident #403: A family interview on 12/7/10 at 1:14 p.m., revealed resident #403's wound was observed on 10/9/10 during a visit with no dressing covering his wound. The following day on 10/10/10, maggots were observed in resident #403's wound. He was transferred to a local area hospital for treatment. According to the hospital emergency room notes dated 10/10/10, resident #403 presented with [MEDICAL CONDITION], right foot necrosis, and maggots in his right foot wound. The note also stated the course/duration of symptoms is worsening of his right foot. The character was pain, swelling, drainage and necrosis. On 12/1/10 at 11:00 a.m., a review of resident #403's clinical record revealed a change of condition form dated 10/10/10, the problem/symptom identified was "maggots to LLE (Left Lower Extremity). (According to the hospital record dated 10/10/10 maggots were observed in his right foot). The facility's change of condition form stated, the maggots were noted for the first time at 7:00 p.m. on 10/10/10. According to the physician order dated 10/10/10 at 8:00 p.m., resident #403 was ordered to be send to a local area hospital for wound assessment of his right lower extremity. Review of the facility incident/accident report dated 10/10/10 at 8:00 p.m., revealed the resident's (#403) dressing was being changed due to large amount of drainage and maggots were found to be on the right lower extremity. Review of the clinical and treatment records for resident #403 revealed documented evidence of once a day wound care treatments. According to the Director of Nursing and Nurse #D resident #403 received prn (as needed) wound care treatments and dressing changes. They could not explain why there was no documented evidence resident #403 received more frequent dressing changes, treatment, and wound care assessments. On 12/6/10 at 3:00 p.m., during an interview with nurse #D, nurse #D stated, resident #403's wound care was ordered for once per day because that was the physician's order. Nurse #D also stated the maggots in resident #403's wound occurred sometime over the weekend. Review of the facility policy entitled "Skin Management" revised February, 2010, revealed "residents with wounds and/or pressure ulcers and those at risk for skin compromise are identified, assessed and provided appropriate treatment to encourage healing and/or integrity." The skin management policy also revealed, interventions are implemented that are consistent with resident needs, goals and recognized standards of practice; monitored and evaluated for the impact of the interventions; and revised as appropriate. All of this must be clearly documented in the resident's clinical record. The most current physician order dated 10/1/10 at 3:45 p.m., stated "cleanse right foot with wound cleanser/normal saline, apply [MEDICATION NAME] cream to foot, apply calcium alginate to foot cover with gauze, wrap with Kerlix every day." According to the facilty treatment record for skin, a weekly head to toe skin check/assessment was to be completed weekly on Friday during the 11 PM to 7 AM shift. The weekly head-to-toe skin check was to be performed by a licensed nurse. The nurse was to document the findings on the head-to-toe skin check form and in the nurse's notes. **If skin alteration is found, notify the treatment nurse for completion of the appropriate form (weekly pressure ulcer record or non-pressure skin condition record) and other documentation per facility policy.** There was no documented evidence in the nurse's notes of the head-to-toe skin checks. Review of the nurse's notes dated 9/11/10 through 10/1/10 revealed the following: 1. On 9/11/10 at 3:00 p.m., the nurse's note stated, treatment nurse in today, redressed left stump and right leg as ordered. No other documented evidence of assessment, treatments or dressing changes until 10/2/10. 2. On 10/2/10 (No time), nurse's note stated, right leg dressing changed, continues to weep purulent drainage. There was no documented evidence of assessment, treatments, or dressing changes again until 10/10/10. 3. On 10/10/10 (No time), nurse's note stated, please see change of condition form. The head to toe skin check form dated 10/10/10 at 12:30 a.m., stated resident (#403) with complaint of right lower extremity dressing wet from shower (Afternoon shift 3-11 PM). Dressing changed, slight discoloration, no foreign bodies noted. Dressing applied, covered with Kerlix. During an interview on 12/6/10 at 3:00 P.M., nurse #D could not explain why resident #403's dressing was not changed until 12:30 a.m. on 10/10/10 and why there was no documentation on the skin check forms to reveal the status of resident #403's wound on a weekly basis. Nurse #D stated, his (#403) wound was cared for by the wound clinic outside of the facility. Review of the care plans entitled "Pressure Ulcers and Non-pressure ulcer skin impairment" dated 9/11/10 revealed the following: There were no updates to the care plans. Resident #403's Braden scale score was 12. (Score of 10 or higher indicated high risk). Pressure ulcer treatment as ordered was blank on the care plan. The non-pressure ulcer skin impairment care plan stated resident #403 had co-morbid conditions and diabetes. The approach (interventions) included the following: 1. Observe skin weekly and document findings as indicated. Documentation on the weekly skin assessments did not include the status of resident #403's wounds. 2. Document observation of any non-pressure related skin impairments on facility non-pressure ulcer wound documentation form. Documentation on the weekly skin assessment did not include the status of resident #403's wounds. 3. Wound care as ordered. There was no documented evidence of wound care provided in the nurse's notes or on the skin assessments except for three (3) dates on 9/11/10, 10/2/10 and 10/10/10. Resident #403 was admitted to the facility on [DATE]. The weekly head to toe skin check forms did not include the location of his wounds. There was no order for PRN (as needed) dressing changes or wound care treatments from 9/11/10 through 10/10/10. 4. Refer to RD (Registered Dietitian) or therapy services as needed. There was no documented evidence Resident #403's care plan was updated with interventions to adequately and appropriately care for his wound. Review of the clinical record on 12/1/10 at 11:00 a.m., revealed resident #403 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #402: On 12/6/10 at 11:00 a.m., reviewed of the local area hospital physician progress notes [REDACTED]. He had complaints of less attentive nursing staff at the discharging facility and he complained of being turned only 2-3 times per day unless he persistently asked. He also stated his wound care dressing changes were only done every 2-3 days. An interview with the complainant on 12/7/10 at 12:35 p.m., revealed resident #402's wounds had deteriorated due to a lack of assistance from the facility nursing staff. Resident #402 was alert and oriented, however, he was unable to provide his own physical care and that's why he was admitted to the facility for assistance on 8/10/10. Review of the wound consultation dated 8/17/10 revealed the following three (3) wounds: 1. Right trochanter wound measuring approximately 0.7 x 1.5 centimeters (cm). The wound was pale colored with some slough and scant drying of the medial aspect of the wound. 2. Sacrum wound measuring approximately 3.5 x 2.0 x 1.7 cm, the wound was clean with pale colored tissue. 3. Left ischium wound measuring approximately 1.5 x 1.5 x 1.0 cm with some areas opened into the space. The wound was clean with no slough. The surrounding area around all of the wound was reddened, dry and had a very thickened type skin. Review of the wound consultation dated 11/9/10 revealed the following: 1. Right trochanter wound increased in size measuring approximately 1.5 x 1.5 x 1.5 cm. 2. Sacrum/Ischium wound was now delineated and grossly necrotic, the wound was full of bacteria except the areas of tracking. According to the wound care physician, one sacral ischial wound was better controlled after removal of an abscess. The wound increased in size measuring approximately 15 x 8.0 x 7.0 cm. 3. A new wound developed on the left heel wound with superficial slough. 4. A new wound developed on the left lateral malleolus wound measuring approximately 3.0 x 2.0 x 0.4 cm with thick bacterial slough. 5. A new wound developed on the left lateral leg wound measuring approximately 4.5 x 0.6 cm. Review of the wound care orders dated 8/10/10 through 11/12/10 for resident #402 revealed daily wound care was ordered with daily dressing changes. Resident #402 was to be monitored for any alterations in his wound during weekly skin checks. According to resident #402's care plan entitled "pressure ulcers" dated 8/10/10, resident #402 was to be turned every two hours while in bed and repositioned every 2 hours while in bed or chair. His wounds were to be measured and staged weekly using the pressure ulcer healing assessment form. Resident #402 skin was to be observed weekly and the findings documented by the facility nursing staff. According to the nurse's notes reviewed from 8/10/10 through 11/12/10, resident #402 required extensive assistance with his personal care. The nurse's note dated 10/16/10 revealed resident (#402) was "friendly/cooperative with care." The most current minimum data set assessment dated [DATE], revealed resident #402 required extensive assistance with transfers, ambulation, dressing, hygiene and bathing. Notifications made on resident #402's wound care plans, related to "difficulty repositioning and turning," however, the notes did not include a date, time or initials of the individual who reviewed the care plan. The information did not clarify the reason for the difficulty in repositioning and turning resident #402. On 12/6/10 at 3:00 p.m., during an interview with Nurse #D (Treatment nurse), Nurse #D stated, resident #402's wound care was done once per day and his dressings were changed once a day because that was the physician's order. During this interview with Nurse #D, she stated, according to facility protocol resident with wound are to be turn every two hours even with an alternating pressure mattress. Nurse #D stated, resident #402 was not turned because he was able to turn on his own. Nurse #D could not explain why resident #402's care plan was not updated to reflect his ability to turn and reposition himself. Nurse #D could not explain why the weekly skin care assessments for resident #402 did not include documentation of his current wound status. Nurse #D also could not explain why the nursing staff did not consult with resident #402's wound care physician or his primary care physician to provide more frequent wound care and dressing changes as needed when resident #402's wound was soiled with drainage, to decrease the bacteria growth and to enhance his wound healing. According to Nurse #D, "prn" (as needed) dressing changes were done, however, she could not explain why there was no documented evidence of the prn dressing changes in the clinical record. Review of the resident #402's clinical record on 12/2/10 at 10:30 a.m., revealed resident #402 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #401: On 11/30/10 at 3:45 p.m., resident #401 was observed to be alert and oriented, she was sitting in her room in her wheelchair on the side of her bed. During an interview with resident #401, she stated, I've been sitting up in this wheelchair since 7:00 a.m. this morning. On 11/30/10 at 3:50 p.m., during an interview with Nurse #F, she stated, she was not sure how long resident #401 was up in her wheelchair. Nurse #F stated, she had not been working on this side of the unit but she would check. Nurse #F stated, when she did work on this side of the unit, the certified nursing assistants (CNA) would assist residents to bed. On 11/30/10 at 4:30 p.m., an observation of resident #401 revealed she was still sitting up in her wheelchair at the bedside. Resident #401 began to cry and stated, "I'm sorry but my legs hurt so bad, I've been sitting here all day long and I need my brief changed." On 12/1/10 at 1:00 p.m., a skin care observation revealed resident #401 had excoriation on the back of her thighs and a red open area on her buttocks (stage one pressure ulcer). According to the care plan entitled "care plan for skin" dated 7/12/10, resident #401 had a Braden scale score of 16. (Score of 12 or less represents high risk). The care plan interventions included encourage/assist with repositioning, every 2 hours in bed and every one hour in chair. Resident to be in bed after lunch except for activities resident wants to attend such as bowling and bingo. The care plan entitled "pressure ulcers" dated 7/12/10, revealed the following interventions for resident #401: 1. She was to be repositioned in her chair frequently for comfort and pressure reduction. Resident #401 remained sitting up in her wheelchair from 7 am to after 4:30 p.m. on 11/30/10 and again on 12/1/10 from 7:30 a.m. until 1:00 p.m. without repositioning. 2. She was to be turned and repositioned while in bed frequently for comfort and pressure reduction. Resident #401 was not turned and repositioned while in bed frequently for comfort and pressure reduction resulting in skin excoriation and stage one pressure ulcer. 3. She was to be provided with incontinence care after each incontinent episode. Resident #401 was not provide incontinent care as needed on 11/30/10. Review of the physician orders dated 11/24/10, resident #401 was ordered to have her right thigh cleansed with wound cleanser or normal saline and [MEDICATION NAME] paste applied every day and prn (as needed). According to the physician progress notes [REDACTED]. Resident #401 required maximum to total assistance with all bathing, dressing, transfers, and she was unable to transfer herself. Resident #401 was able to make her needs known but required the assistance of the nursing staff to use a Hoyer lift for transfers to and from her bed and wheelchair. On 11/30/10 at 4:30 p.m., during an interview with the Director of Nursing, she could not explain why resident #401 was sitting up in her wheelchair from 7 am until after 4:30 p.m. and nursing assistance was not provided as needed. Resident #404: During a wound care observation on 12/1/10 at 11:40 a.m., it was observed resident #404 had multi areas of redness on her buttocks and the back of her thighs. She also had a sacral pressure ulcer of indeterminate stage. The wound measured approximately 2.0 x 12.0 cm and included a lot of open areas. Resident #404 had left lateral malleolus (ankle) ulcer, the wound measuring approximately 2.0 x 1.0 x 0.1 cm with thick facial slough. According to the change of condition form dated 11/6/10, resident #404 was observed with open areas to her bilateral buttocks by the CNA during personal care. Review of the MDS assessment dated [DATE] revealed resident #404 did not have a pressure ulcer upon admitted d 9/28/10. The MDS assessment revealed resident #404 required extensive assistance with personal care and transfers. The care plan entitled "pressure ulcers" dated 10/20/10 included the following interventions: 1. Reposition in chair every two hours. Observations during the survey from 11/30/10 to 12/6/10 revealed resident #404 was observed up in her gerichair on 12/1/10 at 11:50 a.m. until 12:32 p.m. only. Observation on 11/30/10 and 12/1/10, revealed resident #404 lying in bed on her back. She was alert and oriented with some confusion. 2. Turn and reposition every two hours while in bed. There was no documented evidence resident #404 was turned and repositioned every two hours while in bed. 3. Provide incontinence care every shift and as needed and after each incontinent episode. 4. Measure and stage wound weekly using the pressure ulcer healing assessment form. The treatment nurse (#D) stated during an interview on 12/6/10 at 3:00 p.m., resident #404 wound was taking care of by the wound care physician. 5. Up in gerichair every other day. There was no documented evidence resident #404 was up in her gerichair every other day. On 12/6/10 at 3:00 p.m., during an interview with nurse #D, she stated, resident #404 was seen by the wound care specialist and resident #404 is suppose to be turned every two hours. She could not explain why there was no documented evidence of resident #404 being turned and repositioned every two hours to relieve pressure. Review of resident #404's clinical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility policy entitled "Skin Management" revised February, 2010, revealed "residents with wounds and/or other pressure ulcers and those at risk for skin compromise are identified, assessed and provided appropriate treatment to encourage healing and/or integrity." Interventions implemented that are consistent with resident needs, goals and recognized standards of practice.

This citation pertains to Intake #'s MI 932, MI 787 and MI 908. Based on observation, interviews and record review, the facility failed to accommodate three (#401, #402, #403) of seven sampled residents with positioning, appointments/treatments and accommodation of needs, resulting in pain/discomfort, deteriorating ulcers and skin excoriation. Findings include: Resident #401 On 11/30/10 at 3:45 p.m., an interview with resident #401 revealed she had being sitting up in her wheelchair from 7:00 a.m. until 4:30 p.m. During an interview on 11/30/10 at 3:50 p.m. with nurse #F, nurse #F stated, she did not know how long resident #401 had been sitting up in her wheelchair. Nurse #F also stated, when she works on the unit with resident #401, the certified nursing assistants (CNA's) would assist resident #401 to bed prior to dinner (5:00 p.m.). Observation at 4:30 p.m. on 11/30/10, revealed resident #401 still sitting up in her wheelchair at the bedside crying. Resident #401 stated, "I am sorry, but my legs hurt so bad, I've been up in this chair all day long and I need my brief changed." During an interview with the Director of Nursing (DON) on 11/30/10 at 4:40 p.m., the DON stated she would get a CNA to assist resident #401 to bed. During the interview the DON could not explain why resident #401 was left sitting up in her wheelchair from 7:00 a.m. until approximately 4:40 p.m. without repositioning. The DON also could not explain why resident #401 had not received toileting assistance from 3:50 p.m. until approximately 4:40 p.m. A skin observation on 12/1/10 at 1:00 p.m. revealed resident #401 had skin excoriation on the back of her thighs bilaterally with an open stage one pressure ulcer on her buttocks reddish in color. Resident #401's care plan entitled "Pressure Ulcers" dated 7/12/10 revealed interventions included were to repositioned resident #401 in her chair frequently for comfort and pressure reduction. Resident #401 complained of having a "bad tooth" that required surgical intervention during an interview with her on 11/30/10 at 3:50 p.m. Review of her clinical record revealed resident #401's need for dental care (decayed tooth) was identified on 9/2/10 according to a facility dental consultation. Review of the physician orders [REDACTED]." On 12/6/10 at 2:45 p.m., an interview with social worker (#L) revealed resident #401 had an appointment with the dentist on 11/30/10. According to social worker #L, the dentist was unable to accommodate resident #401's wheelchair so she (#401) did not receive any dental care. The social worker (#L) could not explain why reasonable accommodations were not initiated in a timely matter for resident #401 to receive the appropriate dental care she needed. On 12/6/10, there was no documented evidence resident #401 was scheduled for a dental appointment to remove her cracked lower right wisdom tooth. Review of the clinical record for resident #401 also revealed she was ordered to have Cytoxin treatment for [REDACTED]. The order stated for an appointment to be scheduled with the physician. On 12/6/10, there was no documented evidence resident #401 had an appointment schedule with the physician or arrangements made for her to resume her Cytoxin treatments for her [MEDICAL CONDITION]. Review of the clinical record on 12/1/10 at 11:00 a.m. revealed resident #401 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #402 Review of resident #402's physician progress notes [REDACTED]. According to the local area hospital emergency room record dated 11/13/10, resident #402 complained he was turned only 2-3 times per day at the facility and his dressings were changed only every 2-3 days. Review of resident #402's care plan entitled "Pressure Ulcer" dated 8/10/10 revealed interventions included repositioning every two hours in chair and while in bed. Review of resident #402's clinical record revealed he was admitted to the facility on [DATE]. According to his initial wound assessment, resident #402 had three wounds located on his right trochanter measuring approximately 4.0 cm x 1.5 cm x 2.0 cm, sacrum measuring 3.5 cm x 2.0 cm x 2.0 cm and left ischium measuring 2.5 cm x 3.0 cm x 2.75 cm. On 11/13/10 when resident #402 was readmitted to the hospital he had the following five wounds: 1. Right trochanter (Stage 4) measuring 1.5 cm x 1.5 cm x 1.5 cm. 2. Sacrum/ischium (Stage 4) measuring 15 cm x 8.0 cm x 7.0 cm, this wound was grossly necrotic and full of bacteria. 3. Left heel (Stage 2) wound with superficial slough. 4. Left lateral malleolus (Ankle) (Stage 4) measuring 3.0 cm x 2.0 cm x 0.4 cm with thick bacterial slough. 5. Left lateral leg measuring 4.5 cm x 0.6 cm. Resident #402 also had a left wrist skin tear. On 12/6/10 at 3:00 p.m. During an interview with nurse #D, she stated according to the facility protocol residents with wounds are to be turned every two hours even with an alternating pressure mattress. Nurse #D also stated resident #402 was not turned because he was able to turn on his own. Nurse #D could not explain why resident #402's care plan was not updated to reflect his ability to turn and reposition himself. Review of resident #402's clinical record on 12/2/10 at 10:30 a.m., revealed resident #402 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most current MDS assessment dated [DATE], resident #402 required extensive assistance with transfers, ambulation, dressing, hygiene and bathing. On 12/7/10 at 12:35 p.m. during an interview with the complainant, the complainant stated resident #402's wounds deteriorated due to a lack of assistance from the facility's nursing staff. Resident #402 was alert and oriented to time, person and place, however, he was unable to provide his own physical care and required assistance. Resident #403: On 10/10/10, resident #403 was transferred to a local area hospital for assessment of his right lower extremity wound. Review of the local area hospital report revealed resident #403 was treated for [REDACTED]. Review of the nurse's note dated 10/10/10 (No time), revealed resident #403 received a shower on the afternoon shift (between 7-9 pm), and he (#403) complained his right lower extremity dressing was wet. According to the nurse's note dated 10/10/10 at 12:30 a.m., resident #403's dressing was not changed until the midnight shift (11 pm-7 am). The nurse documented resident #403's wound was observed to be slightly discolored and continued to weep purulent drainage. Nurse #D stated during an interview on 12/6/10 at 3:00 p.m., resident #403 received once a day wound care treatments because that was the facility's protocol. She could not explain why resident #403 did not receive more frequent wound care treatments or dressing changes due to the purulent drainage coming from his wounds. Review of the facility incident report dated 10/10/10 at 8:00 p.m. revealed resident #403's dressing was changed due to a large amount of drainage and maggots were found to be on his right lower extremity. Review of the nurse's notes, physician orders, and wound care documentation from 9/10/10 through 10/9/10 revealed there was no documented evidence in the clinical record resident #403 received dressing changes and treatment as needed for his comfort and to enhance his wound healing. Resident #403 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the facility policy entitled "The Resident's Rights" revised November, 2005, "A resident is entitled to receive adequate and appropriate care, and to receive, from the appropriate individual within the health facility or agency, information about his or her medical condition, proposed course of treatment, and prospects for recovery, in terms that the resident can understand, unless medically contraindicated as documented by the attending physician in the medical record."