Every finding on record at Clark Retirement Community

This citation pertains to intake: 1293524 Based on record review and interview, the facility failed to ensure a safe transfer and implement facility policy to prevent falls in 1 of 4 residents (Resident #2) reviewed for fall prevention, resulting in a fall during a lift transfer resulting in a right fractured humorous for Resident #2, which had impacted the resident's functional status and quality of life with the potential for further injury and falls due to unsafe transfers. Findings include: Resident #2Review of an admission Record revealed Resident #2 was a female with pertinent diagnoses which included fracture of right femur, dementia, quadriplegia (partial or total loss of function in all four limbs and the torso), and polyosteoarthritis (flexible tissue at the ends of the bones wear down). Review of a Minimum Data Set (MDS) assessment for Resident #2, with a reference date of 6/25/25 revealed, .Section GG: Mobility: Chair/bed-to-chair transfer. 01 - Dependent.Review of current Care Plan for Resident #2, revised on 6/30/25, revealed the focus, .SAFETY/FALLS: (Resident #2) has fallen related to balance problems as evidenced by cognitive deficits, with limited insight into risk, psychotropic medication use, incontinence . with the intervention .Dycem on top and bottom of wheelchair cushion .fall mat next to bedside when resident resting in bed .keep frequently used items within reach and cue to call light placement prior to leaving room .Low bed with mat . Review of N-ADV- Fall Risk Evaluation for Resident #2, dated 6/14/25 revealed, .History of falls (past 3 months): 1-2 falls in past 3 months. Fall Risk Score: 16.0 . Score of 16 indicated Resident #2 was a high fall risk. Review of Lift/Transfer Evaluation for Resident #2, dated 6/14/25, .Resident can bear full weight .Resident's right side is dominant/stronger .Resident is cooperative with transfers .Resident is cooperative with repositioning .Resident has upper extremity strength .Resident is not able or partially able to assist with transfers from bed to bed .Resident is partially able to assist with repositioning in bed .Resident is partially able to assist with repositioning in chair .During an observation on 07/28/2025 at 10:35 AM, Resident #2 was observed in her room seated in a low broda/scoot chair facing the TV. She wore a gown, pants, socks, and tennis shoes.During an observation on 07/28/2025 at 1:49 PM, on the closet door in Resident #2's room was a sign which indicated, .Her right arm sling to remain in place at all times, 1. hoyer 2 person transfers - keep right arm still and close to body.In an interview on 07/28/2025 at 1:51 PM, Family Member (FM) O reported Resident #2 was being transferred from the bathroom to bed at some point and the staff dropped her out of the dependent lift. FM O reported the staff called them and reported they did not think she was hurt at the time. Then one of the caretakers saw a bruise on her arm, x-rays were taken, and it was discovered Resident #2 had broken her humerus. Resident #2 was sent out to the emergency room (ER). FM O reported it was decided there would be no surgery and the ER placed Resident #2's arm in a sling to heal. FM O reported Resident #2 was not combative with cares.Review of Health Status Note for Resident #2, dated 7/12/2025 at 07:46 AM, revealed, .discoloration noted to right hip, both knees have light pink discoloration noted. Review of Telehealth - Asynchronous for Resident #2, date of service: 7/12/2025, revealed .Patient: (Resident #2).Situation: Had fall last night out of Sara lift (sit-to-stand lift) - is favoring her right arm. Can we order x-rays? please list what one you would like done and if routine or STAT (immediately).Treatment: OK for STAT x ray of AP & lat shoulder, radius, elbow right arm.Review of Order for Resident #2, dated 7/12/2025 at 08:55 AM, revealed, .Order Note: ELBOW AP (x-ray beam enters from the front) & LAT (x-ray beam enters from the side) -RT (Right)| FOREARM AP&LAT-RT | HUMERUS MINIMUM 2V (views) -RT | SHOULDER COMPLETE, MIN 2V-RT | WRIST AP&LAT-RT.resident had a fall yesterday evening.get x-rays due to pain in right arm and favoring the arm.Review of Incident Report for Resident #2, dated 7/11/25 at 7:40 PM, revealed, .Type: Fall.Location: Resident room.Activity: Transfer.Sent to hospital: No.Immediate Actions Taken: Head to Toe Body Check.Neuro Assessment.Braden scale completed.Skin risk assessment completed.ROM within normal limits for resident.MD Notified.Fall Risk Assessment Completed. Note: Immediate Intervention put in place to ensure resident safety.Review of Incident Report for Resident #2, dated 7/11/25 at 7:40 PM, revealed, .Nurses Notes: At about 19:30 (7:30 PM) this nurse was called into the resident's room by the CNA (Certified Nursing Assistant). Resident was noted to be laying on the floor on her right side in between the open legs of the [NAME] (sit-to-stand) lift. Fall was witnessed and CNA stated that the resident slipped out of the sling and fell to the floor. Vitals stable, neuros WNL (within normal limits), no new skin issues noted, ROM (range of motion) WNL and no s/sx (sign/symptoms) of pain or discomfort noted at this time. Resident had a BM (bowel movement) on the floor prior to the fall, therefore was assisted into a shower chair by this nurse and the CNA via hoyer (dependent) lift and received a shower. Resident is resting comfortably in bed at this time. On call supervisor, on call NP (Nurse Practitioner) notified and message left with spouse to call back. Will continue to monitor.Resident Statement of what happened: I was transferring her from the toilet to the bed when she just slipped out of the sling and fell to the floor.Conclusion: CNA unbuckled resident causing to lose balance during transfer.Root Cause: Human error.Recommendation: 07/14/25: Changed transfer status to Hoyer (dependent) lift.Status: Implemented.Entered by: DON B.Review of a Witness Statement submitted and signed by LPN I revealed, .When I walked into the room (on 7/11/25), I witnessed (Resident #2) laying on the floor on her right side with her legs over one leg of the lift and her head resting on the other leg. BM (bowel movement) was observed on the floor when fall occurred witnessed by CNA. The arms of the lift were all the way up to a standing position and the sling was attached to the machine and the leg straps were not buckled. ROM (range of motion) was normal at that time and (Resident #2) was assisted into a shower chair via Hoyer lift with this nurse and CNA, and CNA assisted (Resident #2) to shower. Night maintenance was called to sanitize the floor. (Resident #2) was assessed post fall for pain and injury, and nothing was noted after time of fall.In an interview on 7/29/25 at 4:00 PM, Certified Nursing Assistant (CNA) C reported he was asked by third shift nurse to boost Resident #2 up in her wheelchair as she had slipped down, and then to get her ready for bed. CNA C reported he had noted she had a bowel movement (BM), and he placed her in the Sit to stand and sling and brought her to the bathroom. CNA C reported she had a bowel movement which was very loose. CNA C reported waited about 15 minutes and went to get her off of the toilet. CNA C reported he did not realize she was not finished yet, stood her up, and cleaned her up, lower sit to stand and seats, and pulled out into her room to clean her up some more and she had additional BM on the floor. CNA C reported he went to sit her down on her bed, removed the leg restraints, and then realized she was at the edge of bed, thought he would stand her up real quick and adjust her. CNA C reported she was noted to be a resident who could support her weight on the sit to stand when she was lifted. CNA C reported she went down and was between the legs on the Sara lift. CNA C reported there was BM all over the floor of her room when he had transferred her from bathroom to the bed she was not finished as he had thought. CNA C reported after she fell, he went to get LPN I to help get her up. CNA C reported the nurse checked to see if she was hurt, bleeding, blood pressure, and pupils before got her up off the floor. CNA C said I get it now.At the time it didn't seem like anything would happen if just stood her up real quick and sit her back further on the bed. CNA C reported after the nurse checked her out; she was taken to the shower room as she had BM all over her. CNA C reported she was taken off the shower chair, used the sit to stand again, and she did not grimace or make any noise.This writer attempted to contact the nurse who was present during the incident but did not hear back from them prior to exit from the facility.In an interview on 07/30/2025 at 1:49 PM, Director of Nursing (DON) B reported (Resident #2) was transferred to her bed from the bathroom and CNA D had unbuckled the sling for the Sara lift at the time Resident #2 fell. DON B reported Resident #2 began grimacing and guarding her arm the next day, she was sent out and that was when the facture was found. DON B reported Resident #2 returned to the facility with a sling on her right arm. DON B reported the nurse conducted range of motion, skin assessment, vitals initially and one other time since she was unable to report any concerns. DON B reported then on the next day Resident #2 was observed pulling on her arm and was different, so we sent her out for evaluation.

Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for 8 consecutive hours per day, 7 days per week, resulting in the potential for unmet care needs, resident change of condition to not be properly assessed and negative clinical outcomes. This deficient practice has the potential to impact all 29 residents currently residing in the facility. Findings include:Review of Nursing Schedules for 1/1-3/31/25 revealed the facility did not provide RN coverage for 8 consecutive hours per day, 7 days per week during 5 of 14 weekends included in this timeframe.Review of Nursing Schedules with a reference date of 5/1-7/27/25 revealed the facility did not provide RN coverage for 8 consecutive hours per day during any of the 13 weekends included in this timeframe. During 8 of the weekends in question, the facility had no scheduled RN coverage at all. Review of a Registered Nurse Job Description with a reference date of 2024 revealed POSITION SUMMARY: the Registered Nurse (RN) provides exceptional care.promoting their health.ensuring their safety and comfort.DUTIES AND RESPONSIBILITIES.conducts initial and ongoing assessments of residents' health status.collaborates with physicians, nurse practitioners, and other healthcare providers to develop and implement effective care plans tailored to the residents' unique needs.Review of a Licensed Practical Nurse Job Description with a reference date of 2024 revealed POSITION SUMMARY: the Licensed Practical Nurse (LPN) is responsible for providing resident care.under the direction of the Director of Nursing and the Nursing Supervisor.DUTIES AND RESPONSIBILITIES.makes routine rounds of assigned residents.ensures that medications are administered.observes and reports symptoms/conditions of residents to the treating physician.In an interview on 7/30/25 at 11:12am, Scheduler Z reported she began working at the facility approximately one month ago. Scheduler Z reported upon reviewing the nursing schedule, she recognized the facility had not provided its residents with at least 8 consecutive hours of RN coverage for several weekends. Scheduler Z reported the facility was aware of the situation. When further queried, Scheduler Z reported the facility currently did not have enough direct care RNs to provide the necessary coverage on the weekends.In an interview on 7/29/25 at 9:46am, Nursing Home Administrator (NHA) A reported she was unaware the facility had not provided RN coverage for at least 8 consecutive hours per day, 7 days a week, until she reviewed the nursing schedules that were requested during the survey. NHA A confirmed the facility did not have sufficient RN coverage for the days in question and thus, was not in compliance. NHA A reported the facility may have to consider having RNs on the management team cover some weekend shifts to ensure resident needs were met, but no steps had been taken as of this date.

Based on interview and record review, the facility failed to ensure that a qualified Infection Preventionist worked at least part-time at the facility, was provided sufficient time to perform the Infection Preventionist role, and to properly assess, implement, and manage the Infection Prevention and Control Program.Findings include:During an interview and record review on 7/29/25 at 10:00 AM, Infection Control Preventionist/Director of Nursing/Unit Manager (ICP/DON) B stated, I am the DON, ICP, and UM not only for the LTC side of the facility but also for AL (Assisted Living). I do MDS (Minimum Data Set) part-time as well. This all takes up a lot of time. I am interrupted by staff from my duties, and it is hard to get everything done with all I have to do.During an interview on 7/29/25 at 4:01 PM, ICP/DON B stated, There is a resident that has been here since sometime in June 2025 that requires the PCV20 vaccine, and I have not ordered it yet. I was going to get the other residents' immunization consent to know how many I needed but I just have not been able to get to them before now. Some resident immunization consent forms are still in my email, and I have not looked at them yet. Other newer residents do not have signed consents yet. I am supposed to do daily audits to check on infection control practices and if enhanced barrier precaution signage is on resident doors. I haven't been able to keep up with that. On an average week I can work about 4 or 5 hours on infection control out of 40-60 hours a week. That is 100% less than 1/2 of my hours dedicated to infection control. I do not know really what staff has been educated on for infection control.During an interview on 7/2925 at 4:01 PM, Nursing Home Administrator (NHA) A stated, (IPC/DON B) is to perform DON, ICP, Unit Manager duties along with overseeing the adjacent assisted living community. The facility is hoping some of the licensed nursing staff in the facility will offer to step up and take on some of the responsibilities the IPC/DON has.Review of the facility's Infection Prevention and Control Program revised 6/1/25, revealed, .Pneumococcal Immunization .Residents will be offered the pneumococcal vaccines recommended by the CDC (Centers for Disease Control) upon admission.Review of Facility Assessment reference date February 2025, revealed, Nursing Services.The Director of Nursing (DON) oversees, all nursing related functions and matters.Additional responsibilities of the DON include but are not limited to, oversight of the infection control process, audits, data gathering and reporting monthly to QAPI, wound management, and education to nursing staff as identified.

Based on observation, interview and record review the facility failed to maintain best practices in accordance with professional standards of food service safety. The deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.Findings include: On 07/28/25 at 9:40 AM, Observation of the clean utensil storage area found a mechanical scoop stored with stuck on food debris. Further observation found that the bins containing whisks and spoons were found with an increased accumulation of crumb debris. When asked how often this area gets cleaned, Dining Services Director (DSD) W stated they should get done every Tuesday. On 07/28/25 at 10:05 AM, An interview with DSD W found that the tabletop mixer and the slicer get used often. Observation of the mixer found dried stuck on food debris on the back shield and front grate of the mixing under arm. Observation of the slicer found stuck debris that looked like tomato seeds on the top backside of the blade. When asked Chef Y if tomatoes are used on the slicer he stated yes.According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 07/28/25 at 10:15 AM, Observation of the dish machine found that it requires 150F for the wash cycle and 180F from the rinse manifold (before it enters the machine) to ensure a contact of 160F or higher for utensils, pots, and pans in the machine. After running the dish machine through four full cycles, it was not able to achieve a contact of 160F or higher with the facility or surveyor dish plate thermometer. Both the facility thermometer and the surveyors read between 153F to 156F after each complete cycle.On 07/28/25 at 3:20 PM, a revisit to the kitchen found that the dish machine was still not achieving proper temperature for the rinse cycle. Further review found that the incoming hot water supply to the booster heater had an indicator on its temperature gauge showing it needed to be 130F or higher. At this time, the incoming hot water temperature for the booster heater was between 118F to 124F.A record review of the facility document entitled Dishmachine Temperature Record, dated July 2025, found multiple low temperatures listed below the requirement of 180F from the manifold and 160F from the surface contact temperature. According to the 2022 FDA Food Code section 4-703.11 Hot Water and Chemical. After being cleaned, equipment food-contact surfaces and utensils shall be sanitized in: (A) Hot water manual operations by immersion for at least 30 seconds and as specified under S 4-501.111; P (B) Hot water mechanical operations by being cycled through EQUIPMENT that is set up as specified under SS 4-501.15, 4-501.112, and 4-501.113 and achieving a UTENSIL surface temperature of 71oC (160oF) as measured by an irreversible registering temperature indicator; On 07/28/25 at 10:18 AM, Observation of the floor in the dish machine area found heavy wear where grout was missing or worn down to the point it was allowing water to accumulate in crevices and stagnate. Under the dish machine, one complete tile was missing allowing the area to consistently accumulate water. The floor under the dish room hand sink was found with a beveled lip creating an uneven surface. When asked about the floor, DSD W stated that the facility is looking into renovating the floor and laying epoxy down but is unsure when.According to the 2022 FDA Food Code section 6-501.11 Repairing. PHYSICAL FACILITIES shall be maintained in good repair.On 07/28/25 at 10:31AM, Observation of the preparation table near the dining room door, found a half full container of less sodium soy sauce stored on the counter. Further review of the item found that it states to Refrigerate After Opening. Upon showing the item to Chef Y, he stated he would discard the item. According to the 2022 FDA Food Code section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57C (135F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54C (130F) or above; or (2) At 5C (41F) or less. On 07/28/25 at 3:26 PM, a revisit to the kitchen found a full six-quart container of pasta tightly covered in saran wrap sitting on a shelf inside walk-in cooler #7. At this time, condensation was observed accumulating at the top of the container and the temperature of the pasta was found to be 57F when measured with a digital rapid read thermometer. Observation of the cooling log outside of the walk-in cooler door, found numerous items actively being cooled, but the pasta was not listed. According to the 2022 FDA Food Code section 3-501.14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. According to the 2022 FDA Food Code section 3-501.15 Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: (1) Placing the FOOD in shallow pans; (2) Separating the FOOD into smaller or thinner portions; (3)Using rapid cooling EQUIPMENT; (4) Stirring the FOOD in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. (B) When placed in cooling or cold holding EQUIPMENT, FOOD containers in which FOOD is being cooled shall be: (1) Arranged in the EQUIPMENT to provide maximum heat transfer through the container walls; and (2) Loosely covered, or uncovered if protected from overhead contamination as specified under Subparagraph 3-305.11(A)(2), during the cooling period to facilitate heat transfer from the surface of the FOOD.

Based on observation and interview, the facility failed to maintain a safe, functional, sanitary, and comfortable environment. This resulted in an increased potential for contamination and a possible decrease in residents' satisfaction of living. Findings include:On 07/28/25 at 1:25 PM, Observation of the 3500 Hall Spa room, with Maintenance Director (MD) X, found a stack of clean towels stored between the sink and the commode open and exposed for contamination. Further review of the shower room found multiple dime size pieces of dried bowel movement on the grate for the shower drain with a used glove and wash cloth found under the shower equipment. When asked if that is where clean linens are normally stored, MD X stated the linen is usually protected in a cabinet or covered cart. On 07/28/25 at 1:31 PM, Observation of the housekeeping closet, next to the pantry room, found that the cold-water line was turned off, indicating a stagnant water line. On 07/28/25 at 1:37 PM, Observation of the soiled utility room found brown and discolored water dispense from the cold-water line on the faucet over the hopper. Further review found that the foot pedals for the hopper spray were turned off, indicating a stagnant water line. On 07/28/25 at 1:39 PM, Observation of the Spa near the elevator, found water lines that were capped off near the floor. When asked about these water lines, MD X stated it was for a tub that was taken out awhile back. When asked if it's something that gets flushed, MD X was unsure.

Based on observation, interview and record review, the facility failed to promote a dignified dining experience for 3 (Resident #21, Resident #4 and Resident #14) of 4 residents reviewed for dignity, resulting in a potential for a reduced quality of life, feelings of frustration, helplessness and a decreased sense of self-worth.Findings include: Resident #21: During an observation on 07/29/25 at 4:41 PM, Resident #21 was placed at the table with Resident #14 and the other female resident who was eating her meal. Resident #21 had a plate covered with a grey top in front of her, she had cooked cinnamon apples in a dessert dish on the table. During an observation on 07/29/25 at 4:45 PM, LPN “J” proceeded to assist Resident #21 by opening her napkin with silverware and removed the top to the plate. LPN “J” proceeded to sit down between Resident #21 and Resident #14 to assist with each with dinner. Review of an admission Record revealed Resident #21 was a female with pertinent diagnoses which included Alzheimer's disease, dysphagia oropharyngeal (swallowing disorder that involves difficulty moving food or liquid from the mouth into the esophagus), protein calorie malnutrition, and weakness. Review of a Minimum Data Set (MDS) assessment for Resident #21, with a reference date of 5/15/25 revealed, Section GG: Functional Abilities and Goals .Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident: 03 - Partial/moderate assistance…” Review of Care Plan dated 3/17/25, with the focus, .Resident #21 requires assistance with her ADLs due to severely impaired cognition due to Alzheimer's disease as well as weakness. She is receiving hospice care with decline anticipated .with the intervention .Resident performance: Eating - Limited assist / one-person physical assist Staff to feed [NAME], she will at times eat on her own . Review of Orders dated 4/21/2025 revealed, .Regular diet, Mechanical Soft texture, Nectar consistency Mechanical Soft meat only, supervision with all meals . Resident #4: Review of an admission Record revealed Resident #4 was a male with pertinent diagnoses which included dementia, hypoglycemia (body's blood sugar level goes below the standard range), diabetes, dysphagia oropharyngeal, and long-term use of insulin. Review of a Minimum Data Set (MDS) assessment for Resident #4, with a reference date of 5/15/25 revealed, Section GG: Functional Abilities and Goals .Eating: 03 - Partial/moderate assistance…” Review of Care Plan dated 7/22/25, with the focus, .Resident is at nutritional risk r/t (related to) dysphagia, diabetes, insulin dependent, low BMI, cognitive impairments . During an observation on 07/29/25 at 4:35 PM, Resident #4 was observed to be seated at the dining table. CNA “C” was prompting him to take a bite of his grilled cheese, Resident #4 refused to take a bite. Licensed Practical Nurse (LPN) “J” spoke to Resident #4 inquired if he had a headache as he had rubbed his head. LPN “J” spoke to CNA “C” to determine if he had given Resident #4 anything to eat or if he had eaten anything. LPN “J” asked Resident #4 if it was okay to go to his room (to check his blood sugar and provide any necessary insulin) and they proceeded to his room and LPN “J” closed the door behind them. During an observation on 07/29/25 at 4:41 PM, Resident #4 was observed in his room and had been waiting for LPN “J” to return after she had taken him to his room to test his blood sugar. During an observation on 07/29/25 at 4:43 PM, LPN “J” proceeded back to Resident #4’s room to provide him with his insulin and she apologized to him for having to wait as she proceeded to close the door to his room. During an observation on 07/29/25 at 4:44 PM, Resident #4 self-ambulated out of his room back to the dining room table to eat his dinner. Note: 9 minutes had passed from when the nurse asked Resident #4 to go to his room until he returned back to the dining room. No staff offered to warm Resident #4's food upon his return. During an observation on 07/29/25 at 4:48 PM, Resident #4 had not begun to eat his meal. No staff prompted resident to eat or offered to warm his food. Using the reasonable person concept, though Resident #4 had decreased ability to verbally express his own thoughts due to her medical diagnoses, any reasonable person would likely feel a decreased desire to proceed with eating their dinner after it had sat for approximately 10 minutes without warming. Resident #14: During an observation on 07/29/25 at 4:38 PM, Resident #14 was observed seated at the table. She had a plate covered with saran wrap of pureed foods- grilled cheese and green beans. Resident #14 did not begin eating and it appeared she needed assistance with her meal. Resident #14 was seated at the table with another female resident who had her meal and was able to eat unassisted and she had begun her meal. During an observation on 07/29/25 at 4:45 PM, LPN “J” asked Resident #14 if she was ready to eat, proceeded to move over to assist Resident #21 by opening her napkin with silverware and removed the top to the plate. LPN “J” proceeded to sit down with Resident #14 and Resident #21 to assist with their meals. In an interview on 07/29/25 at 4:41 PM, CNA “C” reported those residents who came to the 3500 hallway to eat meals were residents who needed assistance with meals. CNA “C” reported there were two other CNAs on the shift but they were on the other hallways still. In an interview on 07/29/25 at 4:48 PM. Dining Services R reported the meal plate should be placed with the resident who needs assistance when a staff member was seated and ready to assist the resident. The staff should not place a meal in front of resident who needed assistance because otherwise the food would get cold. Review of an admission Record revealed Resident #14 was a female with pertinent diagnoses which included dementia, protein-calorie malnutrition, anemia, and muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #14, with a reference date of 7/9/25 revealed, Section GG: Functional Abilities and Goals .Eating: 02 - Substantial/maximal assistance…” Review of Care Plan dated 3/12/25 revealed the focus, .The resident has an ADL self-care performance deficit r/t Dementia and impaired mobility EATING: Extensive assistance x1 staff. Upright for all meals. Alternate small bites/sips. Needs encouragement at times, may wander away from table if meal is not served to her quickly . Review of Order: dated 5/23/25, revealed, .ST Recertification order: treatment 9 times/period for 3 weeks for continued skilled dysphagia therapy to complete therapeutic diet trials, skilled diet texture analysis, patient/staff education and training on use of compensatory swallow strategies . Review of Order dated 5/3/25, revealed, .Upright for all meals. alternate small bites and sips, supervision at meals with assist feeding as needed . Review of Order dated 5/2/25, revealed, .Regular diet, Pureed texture, Thin consistency 1:1 assist as needed, small bites, alternate bites and sips, straws OK, mech soft snacks OK (Banana, soft chocolate chip cookies) . During an observation on 7/28/25 at 9:36am, Resident #14 sat at a table in the common area with 4 peers. Resident #14’s breakfast sat in front of her, untouched, as her peers fed themselves or were assisted by staff. Resident #14 did not initiate eating on her own and occasionally glanced down at the food then glanced at her peers. During an observation on 7/28/25 at 9:45am, Resident #14 continued to sit at the table with her breakfast untouched in front of her. Staff were assisting other residents at the table, another resident continued to feed himself. During an observation on 7/28/25 at 9:50am, Director of Nursing (DON) “B” began assisting Resident #14 with eating. Resident #14 had sat with her breakfast in front of her but was not assisted with eating for at least 14 minutes. During an observation on 7/28/25 at 10:12am CNA “E” assisted Resident #14 by loading the resident’s spoon and brining the food to the resident’s mouth. CNA “E” was noted to be looking downward and was observed using a cellphone that sat on her lap. In a confidential meeting on 7/29/25 at 11:00am, 2 of 5 residents in attendance reported they witnessed staff using their personal cell phones while providing cares to residents. 1 resident voiced frustration and a feeling of decreased self-worth when she had to wait for care because staff were on their cellphones. Review of a Promoting/Maintaining Resident Dignity policy with a reference date of 9/15/24 revealed Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life .1. All staff members are involved in providing care to residents to promote and maintain resident dignity .5. When interacting with a resident, pay attention to the resident as an individual .

Based on interview and record review, the facility failed to ensure residents maintained their right to self-determination for 1 resident (Resident #32), of 1 reviewed for choices, resulting in feelings of anxiety when staff did not wear a surgical mask while caring for the resident, despite her preference for them to do so.Findings include:Resident #32Review of an admission Record revealed Resident #32 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: history of falls.Review of a Minimum Data Set (MDS) assessment for Resident #32 with a reference date of 7/25/25, revealed a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated Resident #32 was moderately cognitively impaired.Review of a Care Plan for Resident #32 with a reference date of 7/29/25, revealed a focus/goal/interventions of: Focus: Resident and family encourage visitors to resident's room utilizing hand sanitizer and PPE (personal protective equipment) before entering residents room. Goal: Resident preferences will be honored until the next review date. Interventions.visitor will be encouraged to comply with residents wishes.During an observation on 7/28/25 at 10:38am, a handwritten 8x10 sign posted on Resident #32's door read Anyone entering this room, please use hand sanitizer and wear a mask. During the observation, a cart containing surgical masks was noted outside the door. In an interview on 7/28/25 at 10:38am, Resident #32 reported she did not want to hurt anyone's feelings, but she preferred to have anyone who entered her room, including staff, use hand sanitizer and wear a surgical mask prior to entering because she was concerned about exposure to possible illnesses. Resident #32 reported she chose to implement the same precautions at home, prior to being admitted to the facility, because she wanted to limit her exposure to potential illnesses. Resident #32 stated you never know where someone has been or what they've been exposed to and I'm already dealing with enough. Resident #32 reported she was at the facility recovering from a fall at home, wanted to return home as soon as possible, and was worried that if she contracted an illness, it could delay her recovery. Resident #32 reported she felt uncomfortable when staff members didn't abide by her wishes regarding masking. In an interview on 7/29/25, at 10:30am, Family Member (FM) M reported Resident #32 chose to ask caregivers and visitors to use hand sanitizer and to wear a mask when they visited her at her home prior to her admission to the facility. FM M reported Resident #32 had expressed a preference to follow the same precautions while at the facility, and as a result, Resident #32's daughter placed the sign on the resident's door a few days earlier.During an observation on 7/28/25 at 11:00am, an unknown Certified Nursing Assistant (CNA) assisted Resident #32 out of the bathroom and then exited her room. The CNA was not wearing a mask while caring for Resident #32.During an observation on 7/29/25 at 1:14pm, the sign that indicated Resident #32 wanted everyone to use hand sanitizer and don a mask before entering her room remained on her door.During an observation on 7/29/25 at 1:15pm, Housekeeping (HSK) F performed light housekeeping tasks in Resident #32's room, while the resident was present. HSK F did not wear a mask while in Resident #32's room.During an observation on 7/29/25 at 1:29pm, Licensed Practical Nurse (LPN) H completed the administration of Resident #32's medications in the resident's room. LPN H did not wear a mask.Review of a Resident Rights Policy with a reference date of 9/20/24 revealed .This policy affirms the facility's responsibility to provide care that respects the dignity, autonomy, safety, and legal protections of every resident.5. Residents have the right to.participate in decisions regarding their care.

Based on interview and record review, the facility failed to follow their policy and Centers for Disease Prevention and Control (CDC) guidance to administer pneumococcal vaccinations to residents who consented for immunization, screen and assess residents for eligibility of receiving pneumococcal vaccinations, and offer pneumococcal vaccinations to residents who were eligible to receive it, for 1 of 5 (R19) residents reviewed for pneumococcal vaccinations, resulting in the potential for contracting the virus. Finding include:Review of the facility's Pneumococcal Vaccine policy revision date October 2023, revealed, Policy statement: All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Policy Interpretation and Implementation.upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within thirty (30) days of admission to the facility.According to the Minimum Data Set (MDS) dated [DATE], R19 was admitted [DATE] and had diagnoses that included dementia, heart disease, and malignant neoplasm of the prostrate. Review of R19's immunization record indicated the resident received Prevnar 13 on 5/14/2015 and no other pneumococcal immunization.During an interview on 7/29/25 at 4:01 PM, Infection Control Preventionist/Director of Nursing (ICP/DON) B stated, There is a resident that has been here since sometime in June 2025 that requires the PCV20 vaccine, and I have not ordered it yet. He needs it and should have it. He is in a compromised health status and would benefit from it.According to Centers of Disease Control (CDC) at www.cdc.gov . Follow the recommended immunization schedule to ensure that your patients get the pneumococcal vaccines that they need. On October 23, 2024, the Advisory Committee on Immunization Practices recommended a single dose of PCV for all adults aged 50 years who are PCV-naive or who have unknown vaccination history.

This citation pertains to intake #MI00146821. Based on observation, interview, and record review, the facility failed to effectively develop and implement comprehensive, person centered care plans for 2 residents (Resident #106 and #107), of 8 residents reviewed, resulting in unmet care needs and the potential for negative physical, mental and psychosocial outcomes. Findings include: Resident #106 Review of an Admission Record revealed Resident #106 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: dysphagia (swallowing disorder) and urinary retention (inability to empty bladder). Review of Resident #106's Orders revealed, Meals: upright in chair, at table. Feeding assist needed. Small bites and sips. Oral care before meals. Would benefit from sippy cup. every day shift for SLP (speech language pathologist: a person who helps with swallowing problems) recommendations. Active 9/21/2024. Review of Resident #106's Nutritional Risk Care Plan revealed, .at nutritional risk r/t (related to) parkinson's disease, tremors, decreased ADLs (activities of daily living). date initiated: 8/15/24. Interventions: Assistance with feeding meals and join with others and res (resident) should not have meals in room unless being assisted, sippy cup, small bites and sips, sitting upright at table for meals. date initiated 8/15/24, revision on 11/14/24. Review of Resident #106's Current Functional Performance Care Plan revealed, .Resident performance: Eating-Independent/set-up only. dated initiated 8/15/24 . The care plan intervention was revised on 9/19/24 and revealed, .Resident performance: Eating-Independent/set-up only needs feeding assistance, sit up at table for meals. There was an additional intervention in place which indicated, .Resident performance: Eating-limited assist/one-person physical assist. date initiated 8/15/24. The interventions were ambiguous (more than one possible interpretation). Review of Resident #106's ADL Care Plan revealed, .Eating: The resident is able to eat with set-up, however, resident does have intermittent confusion at times and will require assistance eating. date initiated 8/12/24. This was not consistent with the revised care plans above. During an observation on 2/19/25 at 11:55 AM in the dining room, Resident #106 was in his wheelchair at a table. Resident #106 and the other resident at the table were the only ones without a lunch tray. Director of Nursing (DON) B, Certified Nursing Assistant (CNA) L and CNA G were in the dining room assisting other residents. At 11:59 AM staff placed Resident #106's lunch in front of him, and walked away. Resident #106 began eating his pudding using the spoon and then he switched to using his fingers to eat. Resident #106 then used the spoon to eat his mashed potatoes, taking 2 large bites, that mostly fell off the spoon before he could get them to his mouth. At 12:06 AM DON B asked Licensed Practical Nurse (LPN) E to retrieve a meal replacement drink for a different resident in the dining room, to which LPN E responded that she would in a few minutes after she finished a task on the unit. At 12:10 PM LPN E sat down between Resident #106 and the other resident that was at the table. Until that time there was no staff assisting or actively supervising Resident #106 with his meal. LPN E prompted Resident #106 to pick up his breadstick and take a bite instead of trying to cut it with his knife. Resident #106 took a bite of his breadstick and then LPN E began loading his spoon with food and cueing him to feed himself. In an interview on 2/19/25 at 1:41 PM, DON B reported that it was his understanding that Resident #106 was independent with eating, but may require assistance if he was having trouble feeding himself. In an interview on 2/19/25 at 12:26 PM, CNA J reported that Resident #106 coughed a lot when he ate, and that someone usually fed Resident #106. Review of Resident #106's Braden Scale for predicting pressure sore risk dated 2/12/25 indicated that the resident was at moderate risk to develop pressure sores. Review of Resident #106's Pressure Ulcer Care Plan revealed, .has potential for pressure ulcer development r/t end-stage parkinson's, immobility, incontinence. date initiated 8/25/24. Interventions: APM (alternating pressure mattress) in place (hospice provided). date initiated 8/25/24. There were no other interventions developed for pressure ulcers. Review of Resident #106's Incontinence Care Plan revealed, .bladder incontinence r/t dementia, parkinson's, impaired mobility. date initiated 8/25/24. Interventions: .Check every 2-3 hours and as required for incontinence. Wash, rinse and dry perineum .date initiated 8/25/24. In an interview on 2/19/25 at 9:00 AM, Family Member (FM) M reported that Resident #106 sat in his chair from about 7:00 AM until after lunch everyday, unless the resident had a bowel movement, and then FM M had to press the call light and request for incontinence care to be done. FM M reported that she thought staff was supposed to check Resident #106 for a wet or soiled brief every 2 hours, but they only check on him from the doorway. FM M reported that Resident #106 was not able to move or offload his buttocks when he is in the chair. At 9:56 AM FM M left the facility for the day. In an interview on 2/19/25 at 12:26 PM, CNA J reported that Resident #106 had gotten up early to eat breakfast, and would be laid down after lunch, for a total of about 6 hours in his chair without incontinence care. CNA J reported that FM M notified the staff when Resident #106 had a bowel movement and needed to be changed, otherwise incontinence care was not provided until after lunch when Resident #106 was in bed. CNA J reported that staff was not able to provide incontinence care more frequently due to having to help other CNA's with their assignments but when hospice staff visited, then Resident #106 received more frequent care. During an observation on 2/19/25 at 12:37 PM, CNA J prepared to transfer Resident #106 into bed. Resident #106 was observed with a wet and soiled brief. In an interview on 2/19/25 at 1:41 PM, DON B reported that Resident #106 was at risk for pressure ulcer development and should be repositioned and have incontinence care every 2 hours. DON B reported that Resident #106 had a roho cushion in his wheelchair and an air mattress to reduce pressure. Review of the facility policy Skin Care Program dated 7/7/22 revealed, .Preventative Interventions: .The Clinical Care Coordinators and/or Licensed Nurses along with the interdisciplinary team will create and revise care plans and CNA instruction to include as appropriate: a) Directions for repositioning . c) special and routine skin care. d) nutrition/hydration interventions. e) Resident toileting preferences or programs. f) use of incontinent products. g) Directives for use of pressure relieving devices. Care plan interventions will be developed based on results of the assessments, determined risk factors and overall needs of the resident . Resident #107 Review of an Admission Record revealed Resident #107 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: bilateral hearing loss. Review of Resident #107's Orders revealed, Hearing aids on and off two times a day place hearing aids in AM and remove at HS (bedtime). start date 7/13/23. Review of Resident #107's Care Plan revealed, .impaired communication related to hearing loss as evidenced by hearing aids. date initiated 3/29/23. Interventions: .Ensure hearing aids bilateral hearing aids are in place. date initiated 3/29/23 . During an observation on 2/19/25 at 11:00 AM Resident #107 was in his wheelchair in the common area. Resident #107 was not wearing hearing aids. In an interview on 2/19/25 at 11:07 AM, LPN E reported that Resident #107's hearing aids are kept in his room, and the nurse was supposed to ensure he has the hearing aids in place when morning medication administration is completed. LPN E reported that Resident #107 had received his morning medication, but that she did not check his hearing aids. During an observation and interview on 2/19/25 at 11:11 AM in the hall outside of Resident #107's room, the resident was observed by this surveyor and LPN E without hearing aids in place. Resident #107 reported that he would like his hearing aids in, but was not able to do it himself. According to Fundamentals of Nursing ([NAME] and [NAME]) 9th edition, The care plan (see Chapter 18) is a map for nursing care and demonstrates your accountability for patient care.A well-planned, comprehensive nursing care plan reduces the risk for incomplete, incorrect, or inaccurate care. As a patient's problems and status change, so does the plan. A nursing care plan is a guideline for coordinating nursing care, promoting continuity of care, and listing outcome criteria to be used later in evaluation (see Chapter 20). The plan of care communicates nursing care priorities to nurses and other health care providers.

This citation pertains to intake #MI00146821 Based on observation, interview, and record review, the facility failed to ensure timely, effective incontinence care was provided for 1 resident (Resident #106) of 3 residents reviewed for bowel and bladder incontinence, resulting in an increased risk for UTI (urinary tract infection) and the potential for skin breakdown. Findings include: Review of an Admission Record revealed Resident #106 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: urinary retention (inability to empty bladder). Review of Resident #106's Incontinence Care Plan revealed, .bladder incontinence r/t (related to) dementia, parkinson's (a disorder that effects movement), impaired mobility. date initiated 8/25/24. Interventions: .Check every 2-3 hours and as required for incontinence. Wash, rinse and dry perineum (genitals and anus) .date initiated 8/25/24. In an interview on 2/19/25 at 9:00 AM, Family Member (FM) M reported that Resident #106 sat in his chair from about 7:00 AM until after lunch everyday, unless the resident had a bowel movement, and then FM M had to press the call light and request for incontinence care to be done. FM M reported that she thought staff was supposed to check Resident #106 for a wet or soiled brief every 2 hours, but they only check on him from the doorway. FM M reported that Resident #106 was not able to move or offload his buttocks when he is in the chair. At 9:56 AM FM M left the facility for the day. In an interview on 2/19/25 at 12:26 PM, CNA J reported that Resident #106 had gotten up early to eat breakfast, and would be laid down after lunch, for a total of about 6 hours in his chair without incontinence care. CNA J reported that FM M notified the staff when Resident #106 had a bowel movement and needed to be changed, otherwise incontinence care was not provided until after lunch when Resident #106 was in bed. CNA J reported that staff was not able to provide incontinence care more frequently due to having to help other CNA's with their assignments but when hospice staff visited, then Resident #106 received more frequent care. During an observation on 2/19/25 at 12:37 PM, CNA J and Registered Nurse (RN) K prepared to transfer Resident #106 into bed. Both staff donned gloves and CNA J was designated to do the incontinence care washing, and RN K would assist. Resident #106 was observed with a wet and soiled brief. CNA J used disposable wipes to remove the feces from the resident's groin and between the legs. CNA J did not wash the resident's penis. CNA J continued washing the resident's buttocks and retrieved multiple wipes out of the package during the care. CNA J continued washing the resident's buttocks and then applied a clean incontinence brief to Resident #106. With the same soiled gloves, CNA J handled the bed controls, straightened the resident's clothing, adjusted the pillow, pulled the blankets over the resident, and clipped the call light on the bedding. In an interview on 2/19/25 at 12:54 PM, CNA J reported that she forgot to change gloves and was trying to get the incontinence care done quickly during the previous observation. CNA J reported that during morning cares there is more time to provide thorough care. In an interview on 2/19/25 at 1:41 PM, Director of Nursing (DON) B reported that Resident #106 should have incontinence care every 2 hours.

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all 35 residents. Findings include: During the initial tour of the kitchen, starting at 9:25 AM on 8/20/24, it was observed that four pans of cooked, whole intact, beef roasts were found on the expediting cart in the preparation walk in cooler dated for 8/20. At this time, there were also a couple pans of beef dated for 8/19, and further review of the walk in cooler found a large container of bean soup (roughly 3 gallons) cooling with two ice wands in the soup. A review of the kitchen's Cooling Log, dated August, found beef roasts that were cooled on 8/19, but none that were logged for being cooked/cooled on 8/20. Further review of the log found the bean soup starting cooling at 8:30 AM this morning (8/20/24), but was unclear if the cooling started at 140F or 190F. At 9:30 AM on 8/20/24, an interview with [NAME] NN found that the beef was all cooked yesterday (8/19/24) and that he had the beef out this morning on the expediting rack while he was making purees. [NAME] NN stated the cart was out for roughly an hour and was recently put back into the walk in. When asked what the temperature of the bean soup was when he started cooling, [NAME] NN stated 140F. At 9:33 AM on 8/20/24, temperatures of the cooked chunks of beef, ranging in roughly 4-8 pound chunks, were found to be 46F-49F, when checked in the middle of the product with a rapid read thermometer. An interview with [NAME] NN found that the beef was cooked off yesterday, cooled down, and staff were unsure why the temperature discrepancy was evident. Food product in the cooler was found to be 37F-39F. A revisit to the kitchen, at 3:35 PM on 8/20/24, found the bean soup that was cooling with two ice wands this morning, was now covered in the walk-in cooler. At this time, the temperature of the bean soup was found to be 55F. A review of the Cooling log found that it states that if food is not below 41F after six hours it should be discarded. According to the 2017 FDA Food Code section 3-501.14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less . According to the 2017 FDA Food Code section 3-501.15 Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: (1) Placing the FOOD in shallow pans; (2) Separating the FOOD into smaller or thinner portions; (3)Using rapid cooling EQUIPMENT; (4) Stirring the FOOD in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. (B) When placed in cooling or cold holding EQUIPMENT, FOOD containers in which FOOD is being cooled shall be: (1) Arranged in the EQUIPMENT to provide maximum heat transfer through the container walls; and (2) Loosely covered, or uncovered if protected from overhead contamination as specified under Subparagraph 3-305.11(A)(2), during the cooling period to facilitate heat transfer from the surface of the FOOD. During a tour of the kitchen, at 10:02 AM on 8/20/24, it was observed that accumulation of dirt and debris was evident behind the three-compartment sink and dish machine area. Dirt and debris was found on the back coving of the wall and drains in these areas. An interview with Dining Services Director LL found that they have begun to hire some outside help for some of the deep cleaning areas of the kitchen. According to the 2017 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions. (A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean .

Based on observation, interview, and record review, the facility failed to effectively implement Transmission-Based Precautions (TBP) for COVID-19 positive residents and Enhanced Barrier Precautions (EBP) per facility policy and Centers for Disease Control and Prevention (CDC) guidance, in 4 of 7 residents (Resident #3, #20, #17, and #11) reviewed for infection control, with the potential to affect all 36 residents who reside at the facility, resulting in the potential for disease exposure, cross-contamination, and the development and spread of infection to a vulnerable population. Findings include: Review of the policy/procedure Infection Prevention & Control: COVID-19, dated 2/28/24, revealed .Personal Protective Equipment .HCP (Health Care Providers) who enter the room of a resident with suspected or confirmed SARS-CoV-2 (COVID-19) infection should adhere to Standard Precautions and use a NIOSH Approved N95 (mask), gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face) . Resident #3 Review of an Admission Record revealed Resident #3 was a female, with pertinent diagnoses which included obstructive lung disease, dementia, and high blood pressure. Review of a current Care Plan for Resident #3 revealed the focus .Resident is positive for COVID-19 and has the potential for complications r/t (related to) infection . initiated 8/22/24, with interventions which included .Follow Droplet/Contact precautions while assisting, treating and assessing resident (PPE (Personal Protective Equipment) to include gloves, gown, eye protection (face shield and/or goggles) and N-95 or greater mask . initiated 8/22/24. Review of an Infection Note for Resident #3, dated 8/22/24 at 8:47 AM, revealed .Resident tested positive for (COVID-19) this morning. No s/s (signs/symptoms) at this time. Droplet precautions initiated . In an observation on 8/22/24 at 8:59 AM, noted a sign posted on Resident #3's door which indicated Droplet Precautions were in place, and a PPE bin in the hallway outside Resident #3's room. Noted the PPE bin contained disposable gowns, gloves, eye protection, and N-95 masks. The Droplet Precautions sign stated .EVERYONE MUST: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry. Remove face protection before room exit . Observed Licensed Practical Nurse (LPN) S and Certified Nursing Assistant (CNA) I respond to Resident #3's activated call light. Observed LPN S and CNA I each don a gown and gloves, in addition to a surgical mask (already in use), prior to entering Resident #3's room to assist with morning care. Noted LPN S and CNA I did not utilize eye protection or an N-95 or greater mask while providing morning care to Resident #3. In an observation on 8/22/24 at 9:14 AM, LPN S and CNA I exited Resident #3's room after providing morning care. Observed Resident #3 sitting up in her wheelchair in her room. Noted LPN S and CNA I had removed and discarded the disposable gowns and gloves, but were still wearing the surgical masks. LPN S then returned to Resident #3's room, wearing only a surgical mask for PPE, placed the foot pedals on Resident #3's wheelchair and assisted Resident #3 into the bathroom to use the mirror. In an interview on 8/22/24 at 9:17 AM, LPN S reported all staff at the facility were wearing surgical masks due to COVID-19 positive residents within the facility. LPN S reported Droplet Precautions are in place for Resident #3 because .She has Crohn's disease . LPN S reported the only PPE required to care for Resident #3 was a gown and gloves. In an interview on 8/22/24 at 9:40 AM, CNA I reported in regard to the Droplet Precautions in place for Resident #3, staff are required to don a gown, gloves, and surgical mask prior to entering the room. CNA I reported a N-95 is only required when a resident has COVID-19. CNA I reported eye protection would be utilized if the resident has a cough. CNA I stated if no cough, eye protection is not required. In an observation on 8/22/24 at 10:59 AM, noted a sign posted on Resident #3's door which indicated Droplet Precautions were in place, and a PPE bin in the hallway outside Resident #3's room. Observed Maintenance Technician D don a gown and gloves, in addition to the surgical mask already in use, prior to entering Resident #3's room to perform maintenance on her bed. Noted Resident #3 was present in her room at this time. No eye protection or N-95 mask utilized by Maintenance Technician D while in Resident #3's room. In an observation and interview on 8/22/24 at 11:04 AM, Maintenance Technician D exited Resident #3's room wearing a gown, gloves, and surgical mask. Maintenance Technician D reported he would follow CDC recommendations for what PPE to utilize in a COVID-19 positive resident room. Maintenance Technician D reported the required PPE when entering a COVID-19 positive resident room would be a gown, gloves, mask (did not specify type), and eye protection. Maintenance Technician D reported eye protection would only be used if .close . to the resident. Maintenance Technician D reported he would wear a N-95 mask .when it's required . Maintenance Technician D reported there would be an extra sign on the resident's door indicating a N-95 mask is required in the room. Noted no signage on Resident #3's door indicating a N-95 mask was required. Observed Maintenance Technician D remove the gown and gloves, walk across the hallway, and discard the soiled gown and gloves in an uncovered trash can below the common area sink. Resident #20 Review of an Admission Record revealed Resident #20 was a female, with pertinent diagnoses which included heart failure, dementia, anxiety, depression, stroke, anemia, high blood pressure, and shortness of breath. Review of a current Care Plan for Resident #20 revealed the focus .Resident is positive for COVID-19 and has the potential for complications r/t (related to) infection . initiated 8/22/24, with interventions which included .Follow Droplet/Contact precautions while assisting, treating and assessing resident (PPE (Personal Protective Equipment) to include gloves, gown, eye protection (face shield and/or goggles) and N-95 or greater mask . initiated 8/22/24. Review of an Infection Note for Resident #20, dated 8/22/24 at 8:44 AM, revealed .Resident tested positive for (COVID-19) this morning. No s/s (signs/symptoms) at this time. Droplet precautions initiated . In an observation on 8/22/24 at 9:23 AM, noted a sign posted on Resident #20's door which indicated Droplet Precautions were in place, and a PPE bin in the hallway outside Resident #20's room. Noted the PPE bin contained disposable gowns, gloves, eye protection, and N-95 masks. The Droplet Precautions sign stated .EVERYONE MUST: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry. Remove face protection before room exit . Observed Housekeeper U don a N-95 mask and gloves, and enter Resident #20's room to clean her bathroom. No gown or eye protection utilized while in Resident #20's room. Noted Resident #20 was present in her room at this time. In an observation and interview on 8/22/24 at 9:30 AM, Housekeeper U exited Resident #20's room wearing a N-95 mask. Housekeeper U reported she was instructed to wear a N-95 mask and gloves when in resident rooms with Droplet Precautions in place. Observed Housekeeper U continue down the hallway, don gloves (while still wearing the same N-95 mask worn upon exiting Resident #20's room), and enter Resident #3's room to clean. No gown or eye protection utilized by Housekeeper U while in Resident #3's room. Noted Resident #3 was present in her room at this time. In an interview on 8/22/24 at 11:02 AM, LPN T reported Resident #3 and Resident #20 are both on Droplet Precautions due to a diagnosis of COVID-19. LPN T reported staff are required to don a gown, glove, N-95 mask, and eye protection prior to entering the room for any resident with a COVID-19 diagnosis. Resident #17 Review of an Admission Record revealed Resident #17 was a male, with pertinent diagnoses which included osteomyelitis (bone infection), spinal abscess (pocket of pus), heart disease, and high blood pressure. Review of an Order Summary Report for Resident #17 revealed the active physician order .Piperacillin Sod-Tazobactam So Solution Reconstituted 3-0.375 GM Use 3.375 gram intravenously (IV) every 6 hours . with a start date of 8/14/24. Review of a current Care Plan for Resident #17 revealed the focus .The resident has infection of the spine . initiated 8/14/24, with interventions which included .Administer antibiotic (Piperacillin Sod-Tazobactam So Solution Reconstituted 3-0.375 GM, Q6 hr (every 6 hours) .IV PICC (Peripherally Inserted Central Catheter) LINE) as per MD (Physician) orders . and .Enhanced Barrier precaution applied . both initiated 8/14/24. In an observation and interview on 8/21/24 at 2:08 PM, Licensed Practical Nurse (LPN) J entered Resident #17's room to administer IV medication. Observed LPN J don gloves and prepare .Piperacillin Sod-Tazobactam So Solution Reconstituted 3-0.375 GM . for Resident #17. Observed LPN J hang the pharmacy prepared antibiotic and prime the IV tubing. LPN J then disinfected Resident #17's PICC line access site with an alcohol wipe, flushed the PICC line with normal saline, connected the IV tubing, and started the IV pump to administer the medication. Noted LPN J did not don a gown prior to accessing Resident #17's PICC line and administering the IV medication. LPN J reported she was unsure if Resident #17 was on Enhanced Barrier Precautions, and stated Enhanced Barrier Precautions were for .wounds and Foley's (indwelling catheters) . No signage noted outside Resident #17's room to indicate Enhanced Barrier Precautions were in place. In an interview on 8/21/24 at 2:32 PM, Certified Nursing Assistant (CNA) E reported the nurse typically notifies the CNA's at the start of the shift about which residents are on Enhanced Barrier Precautions. CNA E reported for residents on Enhanced Barrier Precautions, staff are required to don a gown and gloves for care. CNA E reported the gown is located on the back of the resident's door, and all staff share the same gown. CNA E reported Resident #17 is currently on Enhanced Barrier Precautions. In an observation on 8/21/24 at 2:42 PM, LPN J returned to Resident #17's room to disconnect the IV tubing from his PICC line. Observed LPN J don gloves, disconnect the tubing, disinfect Resident #17's PICC line access site with an alcohol wipe, and flush the PICC line with Heparin per physician orders. Noted LPN J did not don a gown prior to accessing Resident #17's PICC line. In an interview on 8/21/24 at 2:52 PM, CNA P reported information on which residents were on Enhanced Barrier Precautions would be .in the system . CNA P reported if a resident was on precautions, there would be a sign outside the door to the resident's room and a bin containing Personal Protective Equipment (PPE). In reference to the gowns hanging on the backside of some resident room doors, CNA P stated she believed those were .left over . with no further clarification provided. In an interview on 8/22/24 at 12:21 PM, Certified Nursing Assistant (CNA) W reported she did not recall receiving any education in regard to Enhanced Barrier Precautions (EBP). CNA W reported she may have received a text, but does not recall the content of the message. CNA W reported EBP are for residents with indwelling catheters and wounds. CNA W reported these residents have a reusable gown hanging on the backside of the entry door (to their room) that staff are supposed to wear when providing care. CNA W reported she does not recall seeing any signage related to EBP, and stated whether or not a resident is on EBP .might be in the care plan . CNA W reported staff all share the same reusable gown for a resident on EBP. CNA W reported if a resident has COVID-19, staff are required to wear a gown, eye protection, gloves, and a N95 mask when in the resident's room. In an interview on 8/22/24 at 3:27 PM, with Administrator A and Director of Nursing (DON) B, DON B reported for Enhanced Barrier Precautions, there is a reusable gown in the resident room that is changed out at the end of each shift. DON B reported the reusable gown is a visible trigger to identify residents on Enhanced Barrier Precautions. DON B reported the facility does not post signs to indicate when Enhanced Barrier Precautions are in place. DON B reported there should be a physician order for Enhanced Barrier Precautions in the electronic medical record, and the Care Plan should indicate Enhanced Barrier Precautions are in place. DON B reported for a COVID-19 positive staff member, staff should don a gown, gloves, N95 mask, and eye protection prior to entering the resident's room. Review of a current Order Summary Report for Resident #17 revealed no physician order for Enhanced Barrier Precautions. Review of the policy/procedure Enhanced Barrier Precautions, dated 8/2022, revealed .Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents .EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment (PPE) is changed before caring for another resident. c. Face protection may be used if there is also a risk of splash or spray .Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and h. wound care (any skin opening requiring a dressing) .EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization .EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk .Staff are trained prior to caring for residents on EBPs .Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required .PPE is available outside of the resident rooms . 41424 In an interivew on 08/22/24 at 11:38 AM, Unit Manager (UM) V reported she was guessing the night shift nurses were the ones who identified the COVID positive residents or the DON as he was there this morning. UM V reported the residents must've appeared symptomatic and they tested all the residents. UM V reported she woke up to a text message that there was COVID in the building. The scheduler had it a couple weeks ago, but she only came over her to the printer as her office was in another part of the building. During an observation on 08/22/24 at 12:02 PM, COVID-19 Reagent bottle lying on it's side on the counter top at the hand washing station on the 3200 unit. During an observation on 08/22/24 at 12:37 PM, the gowns were hung from the back of the door for room [ROOM NUMBER], the resident in the room was COVID positive. For room [ROOM NUMBER], the gowns were hung on the wall directly ahead when enter the room, the resident would brush against them as he would enter his room. His roommate was COVID positive. 41982 Resident #11 Review of an Admission Record revealed Resident #11 was a male, with pertinent diagnoses which included: Alzheimer's Disease (a form of dementia) with late onset and functional quadriplegia (paralysis of all limbs). Review of a Restorative Nursing Screener / GG Evaluation document dated 8/18/24 at 3:02 PM revealed, .AS_2. Self Care .2. Eating: The ability to use suitable utensils to bring food and / or liquid to the mouth and swallow food and / or liquid once the meal is placed before the resident . Resident #11 was coded as being Dependent. Review of Resident #11's current Care Plan revealed a focus of ADL (Activities of Daily Living) FUNCTIONAL/REHAB POTENTIAL: The resident has an ADL self-care performance deficit r/t (related to) visual impairment, cognitive impairment, and decreased mobility . last revised on 3/7/24 and interventions that included (Resident #11) requires Total assistance x 1 person with eating daily. Allow the resident to maintain independence as much as possible. With a date initiated of 3/23/23. Review of Resident #11's Infection Note dated 8/22/24 at 8:41 AM revealed, Resident tested positive for Covid this morning. No s/s (signs/symptoms) at this time. Droplet precautions initiated. Son, (name omitted), notified. Educated regarding precautions in place if visiting . During an observation and interview on 8/22/24 at 9:36 AM, observed Licensed Practical Nurse (LPN) S outside of Resident #11's door. LPN S reported she was getting ready to go into Resident #11's room to feed him. LPN S was wearing a surgical mask. LPN S donned (put on) a gown and gloves. LPN S then retrieved Resident #11's breakfast tray from the cart, knocked on Resident #11's room door, and entered the room. LPN S did not don an N-95 mask (a type of respirator) nor eye protection prior to entering the room. In an interview on 8/22/24 at 11:49 AM, Director of Nursing, Infection Preventionist (DON, IP) B reported when a resident tested positive for COVID, they were placed on droplet precautions. DON, IP B reported PPE (personal protective equipment) that needed to be worn when entering the room of a resident on droplet precautions included the following: gown, gloves, eye protection (goggles or face shield), N95 mask, and foot booties. DON, IP B reported the staff member who entered Resident #11's room to feed him should have been wearing a gown, gloves, eye protection, N95 mask, and foot booties prior to entering the room.

Based on interview and record review, the facility failed to provide annual required abuse prevention education for all staff members who provide care, services, and supports to the residents. This has the potential to affect all 36 residents residing in the facility at the time of the survey. Findings include: Review of (Vendor) Course Completion Report dated 08/22/24, revealed, 27 employees out of 126 employees had not completed Understanding Abuse and Neglect and/or Recognizing, Reporting, and Preventing Abuse. No Therapy staff or Housekeeping staff listed on the report. Review of Facility Assessment reviewed by the QAA (Quality Assessment and Assurance) Committee on 1/2024, revealed, the abuse and neglect training was provided via the (Vendor) computer module health care education provide to the center staff throughout the year. In an interview on 8/22/24 at 3:27 PM, Administrator A reported in regard to education for abuse and reporting the staff completed the education with the (Vendor) annually. DON B reported the facility provided training through a computer-based program. Requested documentation to verify that all staff had received training in regard to Abuse and Reporting.

Based on interview, and record review, the facility failed to implement an effective training program for all staff in regard to infection prevention and control and Enhanced Barrier Precautions, resulting in the potential for the spread of disease and infection to a vulnerable population. Findings include: In an interview on 8/22/24 at 12:21 PM, Certified Nursing Assistant (CNA) W reported she did not recall receiving any education in regard to Enhanced Barrier Precautions (EBP). CNA W reported she may have received a text, but does not recall the content of the message. In an interview on 8/22/24 at 3:27 PM, with Administrator A and Director of Nursing (DON) B, DON B reported in regard to education for EBP, the facility posted information on the home page for the electronic medical record system. DON B reported this information was visible to the licensed nurses, but was unsure if it was available to the CNA staff or any other departments. No documentation or signature record to indicate which staff reviewed the information posted within the electronic medical record system. DON B reported all staff were educated on Enhanced Barrier Precautions when the requirement was initiated, however, the facility was unable to locate any materials to verify this education had been completed. DON B reported he started at the facility in January of 2024 and was responsible for the Infection Control Program. DON B reported he had not initiated/provided a formal education to staff in regard to Enhanced Barrier Precautions while at the facility (since January 2024). DON B reported the facility also provides training through a computer-based program. Requested documentation to verify that all staff had received training in regard to Enhanced Barrier Precautions. Review of a Facility Assessment, dated January 2024, revealed .Staff training/orientation begins with our orientation process and continues throughout the year via new employee orientation, skills fairs, staff meetings and as needs are identified .computer module health care education provides the (Facility Name) staff with in depth learning modules throughout the year to improve performance .Infection control training is on-going throughout the year and has been throughout the Covid pandemic. For example: Donning and doffing PPE (Personal Protective Equipment), handwashing, proper mask wearing . Reviewed staff education documentation provided related to infection control. Noted no information to verify staff completed education in regard to Enhanced Barrier Precautions. For additional information see F880.

Based on observation, interview, and record review, the facility failed to implement resident comprehensive care plans for 1 resident (Resident #28) of 2 residents reviewed for care planning resulting in a lack of service for residents to maintain their highest practicable physical, mental, and psychosocial well-being Findings include: .A nursing care plan includes nursing diagnoses, goals and/or expected outcomes, individualized nursing interventions, and a section for evaluation findings .The plan promotes continuity of care and better communication because it informs all health care providers about a patient's needs and interventions and reduces the risk for incomplete, incorrect, or inappropriate care measures. Nurses revise a plan when a patient's status changes .The plan of care communicates nursing care priorities to nurses and other health care providers. It also identifies and coordinates resources for delivering nursing care . [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing, Tenth Edition - E-Book (Kindle Location 15861 of 76897). Elsevier Health Sciences. Resident #28: Review of an Admission Record revealed Resident #28 was a female with pertinent diagnoses which included dementia, stroke, and dysphagia (damage to the brain responsible for production and comprehension of speech). Review of Care Plan revised on 8/21/24, revealed the focus, .(Resident #32) is at risk for skin integrity impairment as evidence by impaired mobility and cognition . with the intervention .Encourage resident to wear blue bootie to right foot when up in wheelchair and in bed . Review of Care Plan revised on 8/21/24, revealed the focus, .Resident needs assistance with ADLs due to impaired cognition related to dementia, chronic pain, diagnosis of depression . with the intervention .Keep elevating leg rests and foot pedals in high position and upright at all times when in w/c . During an observation on 8/20/24 at 10:10 AM, Resident #28 was seated at the dining room table with her Ensure, she had a decorative throw pillow on her right side and she had a bed pillow behind her legs while her feet where on the foot rests. Her legs were not elevated nor where the foot pedals in a high position. ssThere was a head support flipped over the back of the wheelchair. No blue boots were noted on her feet. During an observation on 08/20/24 at 10:15 AM, Resident #28's blue boots were observed on the chair next to her dresser in her room. During an observation on 08/21/24 at 09:43 AM, observed Resident #28 seated at the dining room table in her wheelchair. Resident #28 had the decorative throw pillow next to her right side/leg/hip area, the side was opening and stuffing was sticking out. The head rest was flipped over the back of the wheelchair still. Resident #28 had blue boots on both of her feet, and she had a pillow behind her legs. Her legs were not elevated in the footrests. She was observed leaning to the right side. During an observation on 08/22/24 at 09:15 AM, Resident #28 was leaning to the right side in her wheelchair, and she did not have a pillow on her right side, she did not have a pillow behind her legs/calves, she did not have her blue boots on her feet. she did have the head rest pulled down behind her head. During an observation on 08/22/24 at 11:32 AM, observed Resident #28 seated at the dining table without the decorative throw pillow on her right side, she did not have the blue boot on her right foot. The footrests were elevated but she did not have her feet on them. She had her feet dangling from her seated position and not touching the ground. In an interview on 08/22/24 at 11:54 AM, Certified Nursing Assistant (CNA) F reported if a resident refused to wear boots, they would attempt to redirect and/or reapproach later time. CNA F reported she would inform the nurse of the refusal. CNA F reported they used the pillow behind her legs for comfort as her legs do become uncomfortable and they use the decorative throw pillow to assist with positioning to provide the extra support for her. In an interview on 08/22/24 at 03:15 PM, Director of Nursing (DON) B reported Resident #28 had the intervention of one blue boot, her legs were to be elevated when up in the wheelchair. A note would be entered in the record for a refusal. DON B reported he was able to ensure care plan interventions were being completed when audit rounds were completed. Review of the policy, Care Plans, Comprehensive Person-Centered revised March 2022, revealed, .1. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; (2) any specialized services to be provided as a result of PASARR recommendations; and (3) which professional services are responsible for each element of care; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions .12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment .

Based on observation, interview, and record review, the facility failed to update/revise a comprehensive care plan after a change in resident condition in 1 of 14 residents (Resident #30) reviewed for comprehensive care plans, resulting in an inaccurate reflection of the resident's status, and the potential for unmet medical, physical, mental, and psychosocial needs. Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, v1.18.11, Chapter 4: Care Area Assessment (CAA) Process and Care Planning, revealed .the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care . According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing, Tenth Edition - E-Book (Kindle Location 15861 of 76897). Elsevier Health Sciences.A nursing care plan includes nursing diagnoses, goals and/or expected outcomes, individualized nursing interventions, and a section for evaluation findings .The plan promotes continuity of care and better communication because it informs all health care providers about a patient's needs and interventions and reduces the risk for incomplete, incorrect, or inappropriate care measures. Nurses revise a plan when a patient's status changes .The plan of care communicates nursing care priorities to nurses and other health care providers. It also identifies and coordinates resources for delivering nursing care . Resident #30 Review of an Admission Record revealed Resident #30 was a female, with pertinent diagnoses which included Alzheimer's disease, dementia, depression, arthritis, osteoporosis, and a history of falls. Review of a Minimum Data Set (MDS) assessment for Resident #30, with a reference date of 6/3/24, revealed a Brief Interview for Mental Status (BIMS) score of 2, out of a total possible score of 15, which indicated severe cognitive impairment. Review of an Incident Note for Resident #30, dated 8/12/24 at 6:01 PM, revealed .Resident was found lying on the floor next to the curtain (which separates both sides of the room). Resident was found lying on her left side. Wheelchair was right next to her feet. Resident had shoes on. Resident states she was trying to clean something .unable to fully understand statement. Resident was assessed, no injuries noted and no lumps on head noted. Staff was able to transfer her into wheelchair with no issues. Once in the wheelchair, resident stated that she was having pain in her left upper thigh. No visible injuries and/or redness. Resident stated she was in pain when assessing ROM (Range of Motion) in LLE (Left Lower Extremity). Placed an ice pack on site. Notified Hospice, a nurse was sent out to assess, currently in the process of sending resident to ER (emergency room ) . Review of an Admission Summary for Resident #30, dated 8/16/24 at 10:36 PM, revealed .(Resident #30) admitted at (10:30 AM) from (Hospital Name) after repair of left hip fracture . In an observation on 8/20/24 at 10:57 AM, Resident #30 was noted in bed in her room, apparently asleep with her eyes closed. Observed Resident #30's bed in a low position, with the left side of the bed along the wall. Observed a blue padded mat folded and leaning against the wall at the foot of her bed. No padded mat observed along the right side of Resident #30's bed. In an observation on 8/20/24 at 1:48 PM, Resident #30 was noted in bed in her room, with the left side of the bed against the wall. Resident #30 was awake and holding her legs in a folded position, leaning toward the right side of her bed. Observed a blue padded mat on the floor along the right side of Resident #30's bed. In an observation on 8/21/24 at 2:21 PM, Resident #30 was noted in bed in her room, apparently asleep with her eyes closed. Observed Resident #30's bed in a low position, with the left side of the bed along the wall. Observed a blue padded mat on the floor along the right side of Resident #30's bed. In an observation on 8/22/24 at 1:42 PM, Resident #30 was noted in bed in her room, apparently asleep with her eyes closed. Observed Resident #30's bed in a low position, with the left side of the bed along the wall. Observed a blue padded mat on the floor along the right side of Resident #30's bed. Review of a current Care Plan for Resident #30 revealed the focus .Risk for Falls . initiated 5/28/24. No interventions noted related to the use of a padded mat along the right side of Resident #30's bed. In an interview on 8/22/24 at 1:46 PM, Unit Manager V reported Resident #30 experienced a fall with a fracture on 8/12/24 and was sent to the hospital for surgery. Unit Manager V reported when Resident #30 readmitted from the hospital, a padded mat was implemented to be placed along the right side of Resident #30's bed. Unit Manager V reviewed Resident #30's current Care Plan and reported it had not been updated with this new intervention. In an interview on 8/22/24 at 3:17 PM, Licensed Practical Nurse (LPN) S reported the blue padded mat along the right side of Resident #30's bed was a new intervention put in place upon her readmission from the hospital. LPN S reported Resident #30 has confusion and attempts to get out of bed without staff assistance, so the blue padded floor mat was added to prevent injury.

Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse/neglect for 1 of 1 resident (Resident #34) reviewed for abuse, resulting in an allegation of abuse not being identified and thoroughly investigated allowing for the potential for mistreatment and/or abuse. Findings include: Review of an Admission Record revealed Resident #34 was a male with pertinent diagnoses which included amyotrophic lateral sclerosis (ALS), heart disease, muscle wasting and atrophy, repeated falls, and obstructive uropathy (obstructing urine flow). Review of Minimum Data Set (MDS) dated [DATE], revealed, .Section F: Preferences for Customary Routine and Activities: .E. How important is it to you to chose your own bedtime? Very important .F. how important is it to you to do your favorite activities? Very important .H. Bladder and Bowel: Urinary Continence: Frequently incontinent .Bowel Continence: Always incontinent . Review of No Type Specified note dated 8/15/2024 at 5:06 PM, revealed, .Investigation: 8/11/24 Allegation (Resident #34) .IDT- Collaboration with DON (Director of Nursing), Administrator, RN (Registered Nurse) Supervisor completed a full investigation pertaining to abuse and neglect allegation. After interviewing the respected staff and resident, all information states there was no incident of abuse or neglect .Staff working directly with the resident was interviewed and disclosed the resident was in bed prior to her coming onto shift (6p-10p). The allegation stated the resident was in his chair at the time employee arrived on shift 3rd shift with a soiled brief and wetness in his chair (10p-6a) .Resident (Resident #34) was interviewed and had no issues/problems or concerns to endorse when asked about the specific day and timeframe of the alleged allegation. Resident endorsed being tired that day, and wanted to stay in bed. Resident has a current dx of AMYOTROPHIC LATERAL SCLEROSIS which causes muscle weaking and causes him to be wheelchair bound for ambulation. Resident is A & Ox3 (alert & oriented) and is able to make his needs known. Resident skin was assessed by DON and no skin issue present (no redness, no pain, no s/s of infection, clean, dry and intact). Resident had no concerns he wanted to disclose during the interview. Will continue to monitor for health and safety . This writer requested an incident report and investigation for the allegation of abuse/neglect for Resident #34 for the previous three months and none were provided. This writer had to request again and received the investigation completed by DON B but no incident report was provided for the allegation during survey or prior to exit from the facility. This incident was not reported to the state agency. Review of No Type Specified note dated 8/15/2024 at 12:14 PM, revealed, .IDT: Investigated potential allegation: 8/11/24 2nd shift. After full investigation allegation: skin check- no skin issues, no redness, no s/s of infection, skin on buttock is normal color of ethnicity and no pain, interview conducted and follow up. Allegation turned out to be inconclusive with no findings or validity to the claim. Will continue to monitor for health and safety . Review of submitted investigation completed by Director of Nursing (DON) B revealed, the following, .Review of Personal Interview dated 8/14/2024, revealed, .Personal Interview: (Resident #34): Resident (Resident #34) was interviewed by (DON B), RN BSN DON. (Resident #34) Stated he didn't have any concerns about Sunday 8/11/24 2nd shift. He endorsed that Sunday he was feeling a little tired so he did not want to get up into chair, he wanted to stay in bed. The interviewer asked if he was ever up in his chair on Sunday 2nd shift and he endorsed no. (Resident #34) had no further concerns during interview . Review of Phone Interview dated 8/15/24, revealed, .Phone interview: (CNA BB) was interviewed by (DON B) RN, DON. She stated that she worked the 6p-10p shift on Sunday (8/11/24), and when she arrived the resident (Resident #34) was already in bed and not in chair. (CNA BB) called nurse (RN K) in to assist with a soiled brief and linen change. (CNA BB) endorsed after the brief change she lowered the bed and exited the resident room. (CNA BB) endorsed doing her last set of rounds on (RESIDENT #34) (resident) at 9:40pm where resident was still dry from the brief change prior, and bed was lowered in the respected position . Review of Investigation: 8/11/24 Allegation (RESIDENT #34) revealed, .IDT- Collaboration with DON, Administrator, RN Supervisor completed a full investigation pertaining to abuse and neglect allegation. After interviewing the respected staff and resident, all information states there was no incident of abuse or neglect .Staff working directly with the resident was interviewed and disclosed the resident was in bed prior to her coming onto shift (6p-10p). The allegation stated the resident was in his chair at the time employee arrived on shift 3rd shift with a soiled brief and wetness in his chair (10p-6a) Resident (RESIDENT #34) was interviewed and had no issues/problems or concerns to endorse when asked about the specific day and timeframe of the alleged allegation. Resident endorsed being tired that day, and wanted to stay in bed. Resident has a current dx of AMYOTROPHIC LATERAL SCLEROSIS which causes muscle weaking and causes him to be wheelchair bound for ambulation. Resident is A & 0x3 and is able to make his needs known. Resident skin was assessed by DON and no skin issue present (no redness, no pain, no s/s of infection, clean, dry and intact). Resident had no concerns he wanted to disclose during the interview. Will continue to monitor for health and safety . Review of the schedule for 8/11/24 revealed, .First shift had 4 CNAs, 2 Nurses; Second shift had 3 CNAs, 2 Nurses . In an interview on 08/22/24 at 09:23 AM, LPN OO reported it would have been her weekend to work but she did not remember any incident involving (Resident #34). In an interview on 08/22/24 at 08:44 AM, RN K reported she could not remember any incident with Resident #34 and she reported she did not see it on her schedule for her to work that night (Sunday 8/11/24). In an interview on 08/21/24 at 03:23 PM, Director of Nursing (DON) B reported he did not complete an incident report nor was there one in risk management (where the incident reports were completed) and he performed an investigation for the incident which occurred on Sunday, 8/11/24. DON B reported he had received an email from a staff member (Certified Nursing Assistant (CNA) M) she had sent to him when she worked third shift on 8/11/24. DON B reported CNA M tended to over exaggerate and was pointing fingers at other staff members. DON B reported (CNA M) had reported when she came on her shift (10:00 PM) , (Resident #34) was in his chair and his chair was soaked as he had been up since 4:30 PM. DON B reported when he completed his investigation he had not interviewed all the staff who had worked second shift or third shift on 8/11/24. Nor had he interviewed other residents and staff on the concerns expressed by (CNA M) in regards to (CNA BB). DON B reported he had brought the situation up to the Admininstrator in a meeting on Monday, 8/12/24, and sought direction on how to proceed from there. DON B reported (CNA M)had sent the email on Sunday night approximately 1:00 AM, and he reported he did not review it until the next day. In an interview on 08/22/24 at 4:00 PM, Certified Nursing Assistant (CNA) M reported, At 10:00 o'clock, she was told (Resident #34) was in his room watching TV and he didn't want to go to bed, so when the previous shift CNA left, CNA M reported she went into his room to see if he was ready for bed. CNA M reported the first thing she smelled right by the doorway as she went to enter his room was smell of somebody who had an accident. CNA M reported (Resident #34) reported to her the previous staff member had told him she cannot find help to place him in the bed and he wanted to go to bed. (Resident #34) had told her he had waited over at least an hour and a half for her to find someone to place him in his bed and she never got anyone to help place him in bed. CNA M reported Resident #34 was asking if she would be able to put him to bed, and he reported he did not want to call the police, he said Can you make sure you can put me in bed as he did not want to call the police. CNA M reported she got someone to assist her to place him in the bed, his pants were soaked, his wheelchair seat was soaked. CNA M reported when she spoke to other staff who worked second shift, she indicated they were never asked to help the CNA place Resident #34 in bed otherwise they would have assisted her. CNA M reported RN PP helped me help Resident #34 into the bed. CNA M reported CNA E indicated to her that CNA BB never came to ask him for assistance to place Resident #34 in bed or he would've put him to bed. CNA M indicated she reported the concern with neglect to the nurse on the unit, RN PP but she also sent an email to the DON to make sure because she was very concerned it was a case of neglect by allowing the resident to sit in his wheelchair for so long, soiled with urine and feces, and his powerchair seat had been soaked in urine. CNA M reported the feces had dried to his skin/brief because it had been in the brief for so long. CNA M indicated she felt so bad for Resident #34 and no one should have to be left in a situation like that especially those who can't take care of themselves. CNA M reported she had reached out to the DON the next day she worked (Wednesday August 14, 2024), as she was off on Monday and Tuesday and he reported to her he had not even reviewed her e-mail yet. CNA M reported the nurse had placed a note in the DON's mailbox and when the CNA came back to work, she checked his box and the note was still in there. CNA M reported she was happy that she had sent the email as well as he would have never seen it or be aware if she hadn't followed up with him when she had returned to work. CNA M reported when there was suspicion of abuse or neglect, you would inform the nurse and contact the DON as well. Review of policy, Abuse Prevention, Screening & Reporting reviewed on January 2018, revealed, .It is the position of [NAME] Retirement Community that resident abuse, neglect, mistreatment, involuntary seclusion, and misappropriation will not be tolerated and will be fully investigated .Abuse - means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish (42 CFR 488.301) . Neglect-failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . Willful - means the individual deliberately, not that the individual must have intended to, inflict injury or harm .Investigation: All reports of alleged or suspected abuse, neglect, mistreatment, involuntary seclusion, injuries of unknown source exploitation and misappropriation shall be investigated thoroughly, objectively, and expeditiously .The Administrator or designee does an immediate investigation into the alleged incident, ensuring that the following steps are taken: a. Resident(s) will be protected from further abuse, and neglect, mistreatment, involuntary seclusion, and misappropriation .b. An assessment of the resident will be completed under the direction of the administrator/physician/director of nursing/police/designee. The resident and or legal responsible party will be included in the assessment determination .Assessment includes both subjective and objective data and may include and is not limited to, head to toe assessment inspecting for signs of injuries, i.e., bleeding, laceration(s), limitations in range of motion, changes in personality or behavior, guarding, fearful body posture, or statements of harm or fear. Resident may also be sent to an acute care setting for further assessment such as in the case of suspected or actual sexual abuse .Assessments will be conducted with the resident's or legal representatives consent or as otherwise directed law enforcement. c. An Incident/Accident report will be completed . d. The attending physician/designee and legal representative (if in place) will be notified of the incident . e. The resident(s) care plan will be updated based on assessment and identified needs of the resident(s) . f. Any employee(s) suspected of abuse or neglect will be suspended pending results of the investigation . g. Any volunteer or visitor suspected of abuse or neglect will be banned from the facility pending results of the investigation. If visitation is requested by the resident/responsible party, it may be granted in designated areas approved by the administrator . h. When the perpetrator is unknown, appropriate staff will be made aware of the situation and will be asked to monitor for suspicious activity, and asked to report any suspicious activity and or any information which may be related to the incident/: allegation . i. If the alleged or known perpetrator is another resident, interventions will be put into place to protect all residents at risk. Interventions may include, but are not limited to; increased supervision, temporary separation (less than 24 hours), and specific psychological and or medical therapy . j. Interviews with resident(s), staff and or other witnesses will be completed. All interviews will be documented and signed . k. The Administrator and or the Director of Nursing may notify other services as needed to assist with the investigation (i.e. police, ombudsman, etc.). Note: If a crime or a suspicion of a crime occurred anyone may contact the (Local) Police Department . l. If the investigation indicates that the employee did commit abuse, neglect, mistreatment, involuntary seclusion and or misappropriation, he/she will receive disciplinary action up to and including termination . m. The incident and the results of the investigation must be reported according to the reporting guidelines (see Reporting section of this policy) . n. The results of the investigation will be reported to the [NAME] President of Resident Living and Support Services/Designee . o. If the alleged violation is substantiated, appropriate corrective action will be taken. p. During the screening, assessment and investigative process, all materials collected pertinent to the investigation are retained and safe guarded . Other: Residents and/or their responsible party will be informed of the complaint/concern procedure at the time of admission, including to whom they are to make a complaint should it occur. Concern forms will be made accessible to residents and/or their guardian/responsible party .

Based on interviews and record review, the facility failed to report an allegation of neglect in 1 of 1 (Resident #34) of 16 residents reviewed for reporting, resulting in the potential for continued violations involving neglect and/or abuse going unreported. Findings include: Review of an Admission Record revealed Resident #34 was a male with pertinent diagnoses which included amyotrophic lateral sclerosis (ALS), heart disease, muscle wasting and atrophy, repeated falls, and obstructive uropathy (obstructing urine flow). Review of Minimum Data Set (MDS) dated [DATE], revealed, .Section F: Preferences for Customary Routine and Activities: .E. How important is it to you to chose your own bedtime? Very important .F. how important is it to you to do your favorite activities? Very important .H. Bladder and Bowel: Urinary Continence: Frequently incontinent .Bowel Continence: Always incontinent . Review of No Type Specified note dated 8/15/2024 at 5:06 PM, revealed, .Investigation: 8/11/24 Allegation (Resident #34) .IDT- Collaboration with DON (Director of Nursing), Administrator, RN (Registered Nurse) Supervisor completed a full investigation pertaining to abuse and neglect allegation. After interviewing the respected staff and resident, all information states there was no incident of abuse or neglect .Staff working directly with the resident was interviewed and disclosed the resident was in bed prior to her coming onto shift (6p-10p). The allegation stated the resident was in his chair at the time employee arrived on shift 3rd shift with a soiled brief and wetness in his chair (10p-6a) .Resident (Resident #34) was interviewed and had no issues/problems or concerns to endorse when asked about the specific day and timeframe of the alleged allegation. Resident endorsed being tired that day, and wanted to stay in bed. Resident has a current dx of AMYOTROPHIC LATERAL SCLEROSIS which causes muscle weaking and causes him to be wheelchair bound for ambulation. Resident is A & Ox3 (alert & oriented) and is able to make his needs known. Resident skin was assessed by DON and no skin issue present (no redness, no pain, no s/s (signs and/or symptoms) of infection, clean, dry and intact). Resident had no concerns he wanted to disclose during the interview. Will continue to monitor for health and safety . This writer requested an incident report and investigation for the allegation of abuse/neglect for Resident #34 for the previous three months and none were provided. This writer had to request again and received the investigation completed by DON B but no incident report was provided for the allegation during survey or prior to exit from the facility. This incident was not reported to the state agency. Review of No Type Specified note dated 8/15/2024 at 12:14 PM, revealed, .IDT: Investigated potential allegation: 8/11/24 2nd shift. After full investigation allegation: skin check- no skin issues, no redness, no s/s of infection, skin on buttock is normal color of ethnicity and no pain, interview conducted and follow up. Allegation turned out to be inconclusive with no findings or validity to the claim. Will continue to monitor for health and safety . Review of submitted investigation completed by Director of Nursing (DON) B revealed, the following, .Review of Personal Interview dated 8/14/2024, revealed, .Personal Interview: (Resident #34): Resident (Resident #34) was interviewed by (DON B), RN BSN DON. (Resident #34) Stated he didn't have any concerns about Sunday 8/11/24 2nd shift. He endorsed that Sunday he was feeling a little tired so he did not want to get up into chair, he wanted to stay in bed. The interviewer asked if he was ever up in his chair on Sunday 2nd shift and he endorsed no. (Resident #34) had no further concerns during interview . Review of Phone Interview dated 8/15/24, revealed, .Phone interview: (CNA BB) was interviewed by (DON B) RN, DON. She stated that she worked the 6p-10p shift on Sunday (8/11/24), and when she arrived the resident (Resident #34) was already in bed and not in chair. (CNA BB) called nurse (RN K) in to assist with a soiled brief and linen change. (CNA BB) endorsed after the brief change she lowered the bed and exited the resident room. (CNA BB) endorsed doing her last set of rounds on (RESIDENT #34) (resident) at 9:40pm where resident was still dry from the brief change prior, and bed was lowered in the respected position . Review of Investigation: 8/11/24 Allegation (RESIDENT #34) revealed, .IDT- Collaboration with DON, Administrator, RN Supervisor completed a full investigation pertaining to abuse and neglect allegation. After interviewing the respected staff and resident, all information states there was no incident of abuse or neglect .Staff working directly with the resident was interviewed and disclosed the resident was in bed prior to her coming onto shift (6p-10p). The allegation stated the resident was in his chair at the time employee arrived on shift 3rd shift with a soiled brief and wetness in his chair (10p-6a) Resident (RESIDENT #34) was interviewed and had no issues/problems or concerns to endorse when asked about the specific day and timeframe of the alleged allegation. Resident endorsed being tired that day, and wanted to stay in bed. Resident has a current dx of AMYOTROPHIC LATERAL SCLEROSIS which causes muscle weaking and causes him to be wheelchair bound for ambulation. Resident is A & 0x3 and is able to make his needs known. Resident skin was assessed by DON and no skin issue present (no redness, no pain, no s/s of infection, clean, dry and intact). Resident had no concerns he wanted to disclose during the interview. Will continue to monitor for health and safety . Review of the schedule for 8/11/24 revealed, .First shift had 4 CNAs, 2 Nurses; Second shift had 3 CNAs, 2 Nurses . In an interview on 08/22/24 at 09:23 AM, LPN OO reported it would have been her weekend to work but she did not remember any incident involving (Resident #34). In an interview on 08/22/24 at 08:44 AM, RN K reported she could not remember any incident with Resident #34 and she reported she did not see it on her schedule for her to work that night (Sunday 8/11/24). In an interview on 08/21/24 at 03:23 PM, Director of Nursing (DON) B reported he did not complete an incident report nor was there one in risk management (where the incident reports were completed) and he performed an investigation for the incident which occurred on Sunday, 8/11/24. DON B reported he had received an email from a staff member (Certified Nursing Assistant (CNA) M) she had sent to him when she worked third shift on 8/11/24. DON B reported CNA M tended to over exaggerate and was pointing fingers at other staff members. DON B reported (CNA M) had reported when she came on her shift (10:00 PM) , (Resident #34) was in his chair and his chair was soaked as he had been up since 4:30 PM. DON B reported when he completed his investigation he had not interviewed all the staff who had worked second shift or third shift on 8/11/24. Nor had he interviewed other residents and staff on the concerns expressed by (CNA M) in regards to (CNA BB). DON B reported he had brought the situation up to the Admininstrator in a meeting on Monday, 8/12/24, and sought direction on how to proceed from there. DON B reported (CNA M)had sent the email on Sunday night approximately 1:00 AM, and he reported he did not review it until the next day. In an interview on 08/22/24 at 4:00 PM, Certified Nursing Assistant (CNA) M reported .At 10:00 o'clock, she was told (Resident #34) was in his room watching TV and he didn't want to go to bed, so when the previous shift CNA left, CNA M reported she went into his room to see if he was ready for bed. CNA M reported the first thing she smelled right by the doorway as she went to enter his room was smell of somebody who had an accident. CNA M reported (Resident #34) reported to her the previous staff member had told him she cannot find help to place him in the bed and he wanted to go to bed. (Resident #34) had told her he had waited over at least an hour and a half for her to find someone to place him in his bed and she never got anyone to help place him in bed. CNA M reported Resident #34 was asking if she would be able to put him to bed, and he reported he did not want to call the police, he said Can you make sure you can put me in bed as he did not want to call the police. CNA M reported she got someone to assist her to place him in the bed, his pants were soaked, his wheelchair seat was soaked. CNA M reported when she spoke to other staff who worked second shift, she indicated they were never asked to help the CNA place Resident #34 in bed otherwise they would have assisted her. CNA M reported RN PP helped me help Resident #34 into the bed. CNA M reported CNA E indicated to her that CNA BB never came to ask him for assistance to place Resident #34 in bed or he would've put him to bed. CNA M indicated she reported the concern with neglect to the nurse on the unit, RN PP but she also sent an email to the DON to make sure because she was very concerned it was a case of neglect by allowing the resident to sit in his wheelchair for so long, soiled with urine and feces, and his powerchair seat had been soaked in urine. CNA M reported the feces had dried to his skin/brief because it had been in the brief for so long. CNA M indicated she felt so bad for Resident #34 and no one should have to be left in a situation like that especially those who can't take care of themselves. CNA M reported she had reached out to the DON the next day she worked (Wednesday August 14, 2024), as she was off on Monday and Tuesday and he reported to her he had not even reviewed her e-mail yet. CNA M reported the nurse had placed a note in the DON's mailbox and when the CNA came back to work, she checked his box and the note was still in there. CNA M reported she was happy that she had sent the email as well as he would have never seen it or be aware if she hadn't followed up with him when she had returned to work. CNA M reported when there was suspicion of abuse or neglect, you would inform the nurse and contact the DON as well. Review of policy, Abuse Prevention, Screening & Reporting reviewed on January 2018, revealed, .It is the position of [NAME] Retirement Community that resident abuse, neglect, mistreatment, involuntary seclusion, and misappropriation will not be tolerated and will be fully investigated .Abuse - means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish (42 CFR 488.301) . Neglect-failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness .Willful - means the individual deliberately, not that the individual must have intended to, inflict injury or harm .Reporting Procedure: The Administrator/Designee will: 1. Report any known or alleged incidents of abuse, neglect, mistreatment, involuntary seclusion, misappropriation, exploitation and/or injuries of unknown origin to the Department of Licensing and Regulatory Affairs, Long Term Care Division. The Facility Reported Incidents are to be reported utilizing the Long-Term Care Provider Portal .2. Reporting will be done immediately, but not exceeding 24 hours after facility becomes aware of an incident . (Note: policy was not updated to reflect changes in regulations) .3. AFC and HFA licenses require notification of any allegation of abuse, neglect, mistreatment, involuntary seclusion, misappropriation , exploitation and/or injuries of unknown origin to the state Central Intake at [PHONE NUMBER] .Employee Reporting Requirements: 1. Employee(s) are responsible for reporting any abuse, neglect, involuntary seclusion, misappropriation, exploitation and/or injuries of unknown origin. Reporting must be done immediately. The Administrator (Abuse Coordinator), Director of Nursing or facility designee must be notified .

Based on observation, interview, and record review, the facility failed to provide an environment that promoted and enhanced resident dignity for 1 resident (Resident #13) of 2 reviewed for dignity, resulting in the potential of feelings of frustration, anxiety, embarrassment and loss of self-worth, impacting their quality of life and promoting a negative psychosocial outcome for the residents. Findings include: Resident #13: Review of an Admission Record revealed Resident #13 was a male with pertinent diagnoses which included Alzheimer's disease, dementia, heart failure, chronic pain, kidney disease, stage 3, blood in urine, urinary tract infection, edema, duiretic therapy (increased productin of urine) and cellulitis of left lower limb. Review of Care Plan revised on 08/15/24, revealed the focus, .The resident has an ADL self-care performance deficit r/t (related to) Dementia . with the intervention .Toilet Use: The resident is totally dependent on 1-2 staff for toilet use .Encourage the resident to use bell to call for assistance (note: no call light was availabe to the resident while in the dining area) . During an observation on 08/22/24 at 09:19 AM, observed Resident #13 out of his room seated at the dining room table in the recliner type chair with another resident. The resident did not have a book, magazine, music playing, or activities to enterain himself. During an observation on 08/22/24 at 09:53 AM, Resident #13 was seated in the recliner type chair while seated at the dining room table. The resident did not have a book, magazine, music playing, or activities to enterain himself. During an observation on 08/22/24 at 11:38 AM, Unit Manager V was adjusting Resident #13 when he was seated in the recliner type chair at the dinign room table. She spoke to him briefly. The resident did not have a book, magazine, music playing, or activities to enterain himself. During an observation on 08/22/24 at 12:31 PM, Resident #13 was seated in the recliner type chair at the dining room table. The resident did not have a book, magazine, music playing, or activities to enterain himself. During an observation on 08/22/24 at 02:02 PM, Resident #13 was still seated in the recliner type chair while seated at the dining room table. The resident did not have a book, magazine, music playing, or activities to enterain himself. During an observation on 08/22/24 at 02:03 PM, Resident #13 informed visitors there to visit with another resident he had to use the restroom. The visitors reported to the staff in the nursing office, Resident #13 had to use the bathroom. During an observation on 08/22/24 at 2:20 PM, Resident #13 was not assisted by staff, instead the staff assisted returning resident to bed and left him seated in the recliner type chair even after he told them he had to use the bathroom. Informed the Director of Nursing 08/22/24 at 2:22 PM, Resident #13 had requested multiple times to use the restroom and no one had came to provide assistance to him. DON B reported he would get someone to provide assistance for him to take him to the restroom and continued to talk to a CNA while they were standing just behind the resident, near the counter which was just across from the table Resident #13 was seated at, finished his conversation with the CNA and she summoned another CNA to come assist her with providing care to Resident #13. The staff took him to the shower room to use the bathroom as his roommate, Resident #31, was COVID positive and the staff would have to don personal protective equipment to take him to use the bathroom in his room. In an interview on 08/22/24 02:30 PM, Licensed Practical Nurse (LPN) T reported she had come back to the room to gather some pants for Resident #13 as he had soiled them. Using the reasonable person concept, though Resident #13 had decreased ability to verbally express his own thoughts due to his cognitive deficits, he clearly expressed his need to use the bathroom to numerous individuals and was left to sit in soiled briefs and clothing. This emotional distress has the potential to continue well past the date of the incident based on the reasonable person concept.

Based on observation, interview, and record review, the facility failed to ensure residents' mechanical diet order recommeded by the speech language pathologist was added in a timely manner and the recommended diet was followed for meals; 2. resident was evaluated by therapy and interventions implemented to address positioning were in place in 1 of 1 resident resulting in the potential for aspiration, decreased range of motion and worsening of contractures. Findings include: Resident #28: Review of an Admission Record revealed Resident #28 was a female with pertinent diagnoses which included dementia, stroke, and dysphagia (damage to the brain responsible for production and comprehension of speech). Review of Care Plan revised on 8/21/24, revealed the focus, .(Resident #28) is at risk for altered nutrition/hydration status r/t (related to) hypothyroidism with CHF (congestive heart failure) requiring meds which may impact appetite/weight .(Resident #28) also has intolerance to lactose . with the intervention .Observe tolerance to diet; chew/swallow; no drooling, coughing, choking, runny nose or eyes with food/fluids; if notice notify MD (medical doctor) and SLP (speech language pathologist), Nurse .Regular diet, thin liquids, lactose intolerant, may use straws. Sit in upright posture for all meals . Review of Order dated 05/09/24, revealed, .Speech eval r/t (related to) coughing with meals, poor intake . Review of SLP (Speech Language Pathologist) Evaluation and Plan of Treatment dated 5/1/24, revealed, .Patient required supervision at mealtime prior to onset?=Yes .Patient Behaviors: Patient has a decreased appetite and declines certain foods. Staff reported that patient is fearful of eating and worried about choking at times .Patient needs assistance feeding self?+Yes .Clinical Impressions/Reason for Skilled Services: Patient presents with oropharyngeal dysphagia which necessitates skilled SLP services for dysphagia to assess/evaluate for safest level of oral intake . Review of SLP Discharge Summary dated 6/12/24, revealed, .Discharge: Mechanical soft diet and thin liquids .Patient continues to benefit from 1:1 verbal/written/tactile cuing to check and clear pocketed food items from her R-buccal cavity. Additionally, she benefits from small bites/sips, and limiting environmental distractions during PO intake .What modified diet is recommended for the patient to swallow solids safely? = Soft & bite sized .Solids = Mechanical soft/chopped textures .Liquids = Thin liquids .Strategies Compensatory Strategies/Positions: 1. Small bites/sips .2. Slow rate of intake .3. Liquid wash as needed .4. Check for pocketing. 5. Limit environmental distractions/stimuli .6. Setup tray to limit the amount of food presented to increase safety secondary to impulsivity with eating . Review of Orders dated 7/15/24, revealed, .Lactose intolerance diet mechanical soft texture, thin consistency, no dairy, ok for straws. Minced and moist meat . Review of Nutrition/Dietary Note dated 7/18/2024 at 2:24 PM, revealed, .Nutrition Note: Spoke with dtr (daughter). Agreeable to SLP consult . Note: No documented consult completed for Resident #28 following this order. Review of Orders dated 8/1/24, revealed, .Regular diet mechanical soft texture, thin consistency, related to cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it) . Review of Orders dated 8/8/24, revealed, .Lactose intolerance diet mechanical soft texture, consistency . Review of Nutrition/Dietary Note dated 7/15/2024 at 5:14 PM, revealed, .Nutrition Note: Pocketing per CNA (Certified Nursing Assistant) with significant effort to remove. Nursing downgraded to mechanical soft texture with dtr/DPOA consent to trial. Wt (weight) stable per monthly review. Assistance eating provided in 3500 dining room, supervision. Defer to medical for SLP consult as needed . Review of Nutrition/Dietary Note dated 7/18/2024 at 2:03 PM, revealed, .Nutrition Note: Mech soft diet texture downgrade on 7/15. Intake reviewed. FAR primarily 26-50%, similar to prior. Staff report less pocketing. Socially engaged, less invested in food intake despite 1:1 with strong encouragement for intake. Wt stable 122lbs this month. Staff note coughing on beverages. Recommend SLP consult. Called dtr to review, no answer. Emailed and coordinated with CCC (Clinical Care Coordinator) Request for SLP consult placed on medical provider communication log . Note: No documented consult for Resident #28 following this note. Review of Health Status Note dated 8/18/2024 at 6:26 PM, revealed, .48 hour recap .Res has been A&O x1 . Appetite remains poor, with much encouragement needed with both food and fluids. Res is not remembering to drink unless drink is handed to her. Consuming approximately 25% @ meals. Sleeping at her norm. Speech has had increase of slurring. No new coughing episodes noted. She has been monitored when given drinks. No SOB noted. Breaths have been even and unlabored . In an interview on 08/22/24 at 09:36 AM, Nutrition Manager for Dietary JJ reported the nurse/dietician enter the order into the system and the dietary department printed out the slips for the meals. She reported the slips have the likes/dislikes, allergies, and the resident's type of diets on them. Review of Resident #28's lunch dietary meal slip for 08/22/24, revealed, .Allergies: Lactose, Diet: Lactose Intolerance, Fluid Consistency: Thin, Texture: Mechanical Soft; Additional Diet Notes: No dairy, ok for straws, minced and moist meat . In an interview on 08/22/24 at 11:19 AM, Dietitian FF reported nursing would report their concerns to the speech therapist with any resident who had trouble consuming their meals. Dietician F reported the was a diet order system which printed off of the electronic medical record system. The dietary staff would review the meal tray prior to delivery as well as the CNAs when the meal was delivered to ensure the accuracy of the tray. Dietician FF reported there was a resident who had an exception to their mechanical diet order which indicated right in the order the resident was allowed to have strips of bacon. Review of the electronic medical record revealed the except was not provided for Resident #28. During an observation on 08/22/24 at 12:01 PM, observed Resident #28 was seated at the table with her lunch supervised by Certified Nursing Assistant (CNA) N. CNA was prompting her to eat. Resident #28 had ground up meat, whole peas (not mashed), and mashed potatoes with gravy. During an observation on 08/22/24 at 09:15 AM, Resident #28 had pancakes, scrambled eggs, and two strips of bacon. In an interview on 8/21/24 at 2:17 PM, Unit Manager V reported the speech language pathologist (SLP) would have given the nurse a recommendation sheet and the nurse would have put the order in the resident's medical record. When queried why it took so long for the order to be entered when the SLP discharged the resident on 6/12/24, Unit Manager V reported she was not sure why it took so long for the order to be entered. Reviewed the medical record for Resident #28, Unit Manager V reported there should have been an order entered when the resident was discharged from speech therapy. In an interview on 08/21/24 at 02:04 PM, Unit Manager V reported when a resident was already at the facility the request for therapy to re-evaluate the resident was more informal and would request verbally, have a conversation. If a referral was needed, an order would be obtained from the provider. Review of Care Plan revised on 8/21/24, revealed, .(Resident #28) is at risk for altered nutrition/hydration status r/t (related to) hypothyroidism with CHF (congestive heart failure) requiring meds which may impact appetite/weight .(Resident #28) also has intolerance to lactose . with the intervention .Sit in upright posture for all meals . Review of Occupational Therapy Evaluation & Plan of Treatment dated 1/9/24, revealed, .Pt will tolerate upright positioning in w/c at table in order to improve self-feeding independence .Baseline: 1/9/24: semi reclined in w/c. Per staff, she had a lot of discomfort/pain with sitting upright at this time .Current referral: Patient is [AGE] year old female who was referred to OT services for self-feeding assessment d/t (due to) reduced intake and increased difficulty. May also benefit from positioning assessment .Clinical Impressions: Patient presents with significant UB (upper body) weakness, and poor positioning during meals. Assist to place fork into R hand, and then pt with difficulty stabbing food, and increased time to bring to mouth. Will benefit from strengthening as tolerated as well as further assessing positioning changes while self-feeding .Reason for Therapy: .facilitate sitting tolerance and postural control . Review of Care Plan revised on 8/21/24, revealed the focus, .Resident needs assistance with ADLs due to impaired cognition related to dementia, chronic pain, diagnosis of depression . with the intervention .Transfer: 2 staff assist using the hoyer lift with yellow sling .Bed Mobility: The resident is totally dependent on 1-2 staff for repositioning and turning in bed Q (every) 2 hrs and as necessary . Review of the remainder of the care plan showed no interventions in place to address the resident's propensity to lean to the right side when up in her wheelchair. Note: No interventions noted by therapy in the care plan to assist with positioning while up in her wheelchair. Review of Health Status Note dated 7/26/2024 at 1:05 PM, revealed, .Today resident is presenting with slurred speech, poor positioning in wheelchair (poor trunk control), poor appetite, not acting quite like herself. Vitals taken, hypertensive but otherwise WNL(within normal limits) . During an observation on 8/20/24 at 10:10 AM, Resident #28 was seated at the dining room table with her Ensure, she had a decorative throw pillow on her right side, and she had a bed pillow behind her legs while her feet where on the footrests. Her legs were not elevated nor where the foot pedals in a high position. There was a head support flipped over the back of the wheelchair. Resident #28 was observed still leaning to the right side. During an observation on 08/21/24 at 09:43 AM, observed Resident #28 seated at the dining room table in her wheelchair. Resident #28 had the decorative throw pillow next to her right side/leg/hip area, the side was opening up and stuffing was sticking out. The head rest was flipped over the back of the wheelchair still. Resident #28 had blue boots on both of her feet, and she had a pillow behind her legs. Her legs were not elevated in the footrests. She was observed leaning quite far to the right side. During an observation on 08/22/24 at 09:15 AM, Resident #28 was leaning to the right side in her wheelchair, and she did not have a pillow on her right side in the wheelchair seat. During an observation on 08/22/24 at 11:32 AM, observed Resident #28 seated at the dining table without the decorative throw pillow on her right side, she did not have the blue boot on her right foot. The footrests were elevated but she did not have her feet on them. She had her feet dangling from her seated position and not touching the ground. In an interview on 08/22/24 at 11:54 AM, Certified Nursing Assistant (CNA) F reported the staff used the pillow behind her legs for comfort as her legs do become uncomfortable and they use the decorative throw pillow to assist with positioning to provide the extra support for her. In an interview on 08/21/24 at 02:04 PM, Unit Manager (UM) V reported following a review of Resident #13's medical record there was not a recent evaluation from occupational therapy for Resident #13's positioning. UM V reported the facility changed therapy providers in March. When reviewed the speech evaluation, it was indicated Resident #13 had poor positioning during meals .the need to facilitate sitting tolerance and postural control. In an interview on 8/22/24 at 03:32 PM, Physical Therapist HH reported she had not received a request to assess or evaluate Resident #13. PT HH reported when there was a breakdown in function, the nursing staff were told to contact us, referral goes to the physician from the nurse who contacted us. PT HH reported when she was on the units treating other residents, if she saw a concern she would reach out to nursing to gather information on the resident to determine if there was a need to complete an evaluation. PT TT reported when they make recommendations for equipment to assist the resident, she would go back and follow up with the nurses to determine if the resident received the equipment and if needed complete additional follow up.

This citation pertains to Intake #MI00143296. Based on interview and record review, the facility failed to implement fall interventions (utilize a bedside impact/fall mat) for 1 resident (Resident #100) of 4 residents reviewed for accidents and hazards, resulting in Resident #100 falling out of bed sustaining a soft tissue laceration over the midline frontal scalp, non-displaced facial fractures, and mild displaced angular fracture of the left humeral shoulder and the potential for further accidents and hazards to occur for residents at risk for falls. Findings include. Review of an Admission Record revealed Resident #100, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: cerebral infarction (stroke). Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 1/04/24 revealed a Brief Interview for Mental Status (BIMS) score of 03/15 which indicated Resident #100 was cognitively severely impaired. Review of a Facility Reported Incident (FRI) investigation dated 3/8/24 revealed: Incident Summary (Resident #100) is on hospice care. She (Resident #100) sustained a fall with injury after falling from her bed onto the floor. (Resident #100) transferred by (Emergency Medical Services) EMS to hospital for evaluation. During root cause analysis exercise and interviews it was determined today 3/5/24 that Certified Nurse Aide (CNA) I staff did not follow the plan of care (Care Plan) and failed to place the impact (fall) mat next to (Resident #100's) bed before exiting the room. (CNA I) was immediately suspended pending outcome of investigation. Investigation Summary: On 3/2/2024 (Resident #100) fell from her bed onto the floor and sustained an approximate 1.5 inch cut above her right brow midline. (Resident #100) was transferred by EMS to (hospital name omitted) Hospital for further evaluation .Requested hospital documentation was faxed to facility on 3/6/2024 and (Resident #100's) assessment includes soft tissue laceration over the midline frontal scalp, non-displaced facial fractures, small foci hemorrhage along the anterior and inferior right frontal lobe, and mild displaced angular fracture of the left humeral shoulder During an interview on 3/20/24 at 9:45 AM., Director of Nursing (DON) B reported (Resident #100) had a fall from her bed on 3/2/24. DON B reported the Certified Nurse Aide (CNA) on duty and assigned to Resident #100 failed to lower Resident #100's bed, and place an impact/fall mat next to the bed as that was Care Planned for Resident #100. In an interview on 3/20/24 at 10:45 AM., Registered Nurse-Unit Manager (RN-UM) E reported when Resident #100 had a fall from her bed on 3/2/24 the root cause was due to the CNA not placing the impact (fall) mat next to Resident 100's bed prior to exiting the room. RN-UM E reported Resident #100 rolled out of her bed onto the floor and sustained injuries to her face, and shoulder. RN-UM E reported there has been ongoing education and audits of impact/falls mats & call light placement for nursing staff. In an interview on 3/21/24 at 11:55 PM., CNA F reported staff are aware of Resident #100's fall with major injury. CNA F reported there has been ongoing education and audits for impact/fall mat placements, rounding resident rooms, ensuring call light placement and lowering resident beds. CNA F reported DON B has been doing multiple rounds throughout the day checking on residents, and assisting staff with resident care, transfers and overall education on not only falls prevention but all safety hazards. In an interview on 3/21/24 at 1:50 PM., LPN J reported on 3/2/24 at approximately 2:30 PM., she heard a CNA call out for help. LPN J reported she ran down to the area where the CNA waved her over to (Resident #100's) room. LPN J reported she ran in Resident #100's room, the door was propped open slightly. LPN J reported Resident #100 was laying on the floor and the bed was in a higher position. LPN J reported Resident #100 was face down, and it appeared she rolled out of the bed. LPN J reported Resident #100's head was at head of bed, and (LPN J) could see her Resident #100's left eye. LPN J reported Resident #100 had vomited, urininated and had diarrhea on her, and her clothing. LPN J reported around Resident #100's head was quite a bit of blood. LPN J reported she called her Resident #100's name; and noted her left eye and she looked up a little bit. LPN J reported she did not want to move her or roll her over until help arrived. LPN J reported other staff grabbed a pillow, wash clothes and held Resident #100 still. LPN J reported she immediately ran for the phone to call the hospice nurse and Power of Attorney (POA) to see what she (LPN J) should do. LPN J reported the hospice nurse was on her way in, and also calling the POA. LPN J reported the hospice nurse reported to log roll Resident #100 over carefully, stabilize her head and neck. LPN J reported she followed those instructions, and then began gently cleaning Resident #100. LPN J reported upon 1st arrival to the room it was noted the at the bed was in a high up position, and Resident #100's impact/fall mat was leaning up against the opposite wall, and not near the bed. LPN J reported the hospice nurse was able to reach the POA and got the ok to send Resident #100 to the Emergency Department (ED). LPN J reported she was transported to the ED, and to her knowledge sustained multiple facial fractures, and left shoulder fracture. LPN J reported when she originally assisted log rolling Resident #100 over to her back, there was a large gash on her forehead where she (LPN 'J) applied pressure to stop the bleeding. LPN J reported at that time she also noted that Resident #100's left shoulder appeared to look out of sort, dislocated and or broken. LPN J reported after Resident #100 was sent per approvals from hospice, POA and facility physicians order the facility Nursing Home Administrator (NHA) A and DON B were notified and immediately started an investigation. LPN J reported the CNA the failed to put (Resident #100's bed in a low position, and impact/fall mat in in place was suspended pending investigation outcome. LPN J reported there was immediate training for all staff for proper impact/fall mat placements, following resident care plans, as well as ensuring residents have call light in reach at all times. LPN J reported NHA A and DON B have been giving continued education and completing audits of all residents in the facility. During an interview on 3/22/24 at 4:30 PM., NHA A reported after (Resident #100's fall she immediately reported the incident to the State Agency, continued her investigation which lead her to the conclusion that the assigned CNA failed to follow Resident #100') Care Plans for falls. NHA A reported she then started her Plan of Correction (POC) which included all elements of a POC. Review of NHA As POC revealed: Plan of Correction. Element #1 The resident is currently out of the facility for treatment Element #2 All residents who require devices to be placed to prevent falls or injuries have the potential to be affected. A blanket audit on devices for residents who have a care-plan in place to prevent falls or injuries was conducted on March 7 - 8 -2024, to assure the safety intervention(s) in place matches plan of care Element #3 The CENA who could not remember if she placed the impact mat next to the resident's bed was suspended pending the outcome of investigation. All scheduled CENA's and Licensed Nurses will receive education over the next two weeks on following the residents plan of care to ensure all safety interventions are in place before exiting the residents' room .Element #4 Audits will be conducted at varied times at a minimum of three times weekly with three residents by the Director of Nursing and/or RN Nurse Manager to ensure compliance is maintained related to resident's safety interventions in place, appropriate and on the plan of care. The Director of Nursing and/or RN Nurse Manager will identify patterns and trends and report findings to the QAPI Committee monthly x three months for further recommendations. After the three- month period, the QAPI Committee will determine the on-going audit frequency and reporting Element #5 All actions taken to prevent similar occurrences from happening in the future will be completed by March 16th-2024 . During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included process changes to prevent falls, falls with injury and falls with major injury, education with the nursing staff, and collaboration with the Medical Director (MD) DON, and the Interdisciplinary Team (IDT) related to the procedure for residents at risk for falls, and falls protocol/procedures. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to intake number MI 568 Based on interview and record review, the facility failed to ensure goods and services were provided prevent a pattern of neglect and ensure facility staff followed the facility policy and resident care plan regarding transfers in 1 of 4 sampled residents, from a total of 4 sampled residents, resulting in physical harm (fracture) and the initiation of Hospice end-of-life services for Resident #99 Findings include: Resident #99 Resident #99 was an [AGE] year old female admitted to the nursing facility on 6/24/15 with [DIAGNOSES REDACTED]. Resident #99's height and weight on 5/04/18 (MDS assessment) were 60 inches, 93 pounds, was non-ambulatory and completely dependent upon staff for all transfers. Resident #99's care plan for ADL Functional/Rehab Potential' dated 12/17/15 ordered the following treatment/services: (Resident #99) requires extensive assist using full body mechanical lift with two staff for transfers. The Nursing Facility policy and procedure for Safe Resident Lifting and Handling revised 10/05/17 documented: 2. Employees will not lift residents (manually) who exceed 51 pounds, without the use of appropriate mechanical devices. Mechanical Lifts are to be used if the employee or employees conducting the lift must bear 50 pounds or more of the resident weight. Documentation related to Resident #99 on a Resident Incident Report, and dated 7/10/18 revealed, CNA (Certified Nurses Aide H) noted right foot rotated outward and facial grimace when unhooking resident from Hoyer. Dr. (Attending Physician A) on-site and assessed-recommended ER evaluation. The Corrective action to avoid repetition of incident (specific intervention) was documented as follows: (Staff) Education on proper transfer techniques. Therapy screen for all Hoyer residents in building. Purchase of Hoyer sling for each resident that is proper size. The Root Cause Analysis (Summary) in this report written by the Director of Nursing documented: Following extensive investigation (it) was determined that Resident (#99) was improperly transferred resulting in serious injury to resident. A Physician Note related to Resident #99 documented by Attending Physician A on (MONTH) 10, (YEAR) recorded the following : Pain in right lower limb - highly suspicious for right [MEDICAL CONDITION] or possible dislocation .Was noted by nursing to have severe pain with transfer, and right leg laterally deviated. Patient herself is a difficult historian .Exquisite pain with attempt to move leg, and patient reaching for hip. A Radiology report on Resident #99 dated 7/10/18 revealed Imaging Results, Femur Right:Impacted overriding [MEDICAL CONDITION] right femur. Interviews with Resident #99 were attempted at 10:00 a.m. on 7/31/18 and 1:00 p.m. on 8/01/18. Resident #99 was unable to tell this Surveyor how her femur fracture may have occurred. A telephone interview with CNA H (the primary alleged perpetrator implicated in Resident #99's injury) occurred at 12:58 p.m. on 8/01/18. CNA H stated, (CNA D) and I used the Hoyer lift on Mrs. (Resident #99) on the morning of (MONTH) 10th. I never fail to get the assistance of another staff member (Facility policy) or to use the Hoyer lift for anyone care planned to use one (Facility policy). I was discharged (employment terminated) for failing to report abuse in a timely manner, and for alleged inconsistencies in statements made by myself and (CNA D). A review of CNA H's personnel file uncovered a related previous disciplinary action dated 4/09/17 on an Employee Coaching for Improvement form. The Description of Specific Event in Question documented the following: Residents care planned for transfers/assists of two (2) staff cannot ever be transferred by one (1) staff. You must obtain assistance from another aide or your nurse for your safety and the safety of the resident. This coaching document was signed by CNA H on (MONTH) 9, (YEAR). In an interview on 8/1/18 at 10:35 am, Resident #98 (Brief Interview Mental Status (BIMS) score of 14/15 evaluated on 6/13/18) stated, I am a Hoyer lift only. I am routinely transferred by one staff member, including (CNA H). She (CNA H) is always in a hurry. Bossy too. I am aware that they are supposed to use two staff members for every lift. It doesn't happen that way In an interview on 8/1/18 at 10:45 am, Licensed Practical Nurse (LPN) Supervisor G stated, I have personally witnessed (CNA H) inappropriately transfer residents, by herself and/or without using a mechanical lift. In an interview on 8/2/18 at 10:00 am, CNA C stated, (CNA H) and I were the only two (2) aides on duty early in the shift (6:00 a.m. - 6:00 p.m.). She (CNA H) asked me if I would help her manually lift Mrs. (Resident #99). I refused due to I know she (Resident #99) is a Hoyer lift (transfer). (CNA H) said no problem, I will get someone else. We were the only two aides there that morning. She (CNA H) went into Mrs. (Resident #99's) room by herself. I came back a few minutes later to ask (CNA H) a question. I noticed Mrs. (Resident #99) had been transferred from bed to wheelchair. There was no Hoyer (lift) in sight. Typically, after a transfer the Hoyer will be left outside the room it was just used in. I have seen (CNA H) pick people (residents) up manually many times before. A telephone interview with (Agency employee) CNA E at 10:36 a.m. on 8/02/18 provided additional eye witness confirmation of Resident #99 being inappropriately transferred by both CNA E and CNA H. CNA E stated, I don't work often at (Nursing home being investigated), but I was asked by (CNA H) to help manually transfer (Resident #99) from wheelchair to bed after lunch. We picked her up. There was no Hoyer lift used. A physician's orders [REDACTED].#99's return from the emergency room with a prescription for narcotic [MEDICATION NAME]: [MEDICATION NAME] 5/325 mg (1) P.O. TID (three times daily) and q4hr prn (as needed). A physician's orders [REDACTED].#99's need for pain control: Increase [MEDICATION NAME] to 4 times a day. In addition, the above order also evidenced authorization/decision by Family Member I opting for end-of-life care to be provided to Resident #99: Admit to Hospice. In an interview at 3:05 p.m. on 7/31/18, Director of Nursing repoted that Resident #99 did not require [MEDICATION NAME] prior to the injury of unknown origin on or about (MONTH) 10, (YEAR): She (Resident #99) had not been taking anything for pain before (MONTH) 10th. In an interview at 9:10 a.m. on (MONTH) 31, (YEAR), Administrator stated, I gave those two CNA's three chances to tell me the truth. They chose not too. I was involved in the initial stages of the investigation. I noticed the Hoyer lift sling was not under the Resident (#99) after transfer back into her bed, on the morning of (MONTH) 10. I thought that was inconsistent with the Resident's need for mechanical lift transfer. Repeated interviews with (CNA H and CNA D) resulted in inconsistent and changing versions of the story regarding the injury to Mrs. (Resident #99). In an interview on 7/31/18 at 4:05 pm, Family Member I stated, At times I wondered if staff were lifting her without a mechanical lift. My siblings would visit and report to me they had witnessed staff transferring her without a mechanical lift. I would often find different color/size slings under her. It was obvious staff were using whatever size sling they could find .Surgery on her leg has been declined. She doesn't have a chance to heal. We have chosen comfort measures and hospice as a result.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and implement care plan interventions to prevent falls in 1 of 8 residents (Resident #105) reviewed for falls, from a total sample of 8, resulting in a fall with a right humeral shaft fracture and the potential for additional falls with injuries for Resident #105. Findings include: Review of the policy and procedure for Fall Prevention and Management, revised 5/30/16, revealed .It is the policy of (Facility Name) to assess and identify potential fall risk for each resident and to implement person centered interventions with the goal of preventing falls and fall related injuries .Residents evaluated to be at risk for falls and those residents who have changes in their FRA (Fall Risk Assessment) will have care plans evaluated and revised as appropriate. These care plans will contain resident centered interventions to reduce the risk of fall(s) and fall related injury. These care plan(s) will be completed by the licensed nurse and will be reviewed (and revised as needed) at least quarterly by the interdisciplinary team . Review of a Detailed Summary, printed 1/25/17, revealed Resident #105 was a [AGE] year-old female, originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of 10/1/17, revealed a Brief Interview for Mental Status (BIMS) score of 4, out of a total possible score of 15, which indicated severe cognitive impairment. Review of a MDS assessment, with a reference date of 10/1/17, revealed Resident #105 required extensive assistance for transfers, walking, and bed mobility. Review of a MDS assessment for Resident #105, with a reference date of 12/12/17, revealed a BIMS score of 3, out of a total possible score of 15, which indicated severe cognitive impairment. Review of a MDS assessment, with a reference date of 12/12/17, revealed Resident #105 had two falls with no injury and one fall with major injury since the previous MDS assessment, required extensive assistance for transfers, walking, and bed mobility, and utilized a bed/chair alarm less than daily. Review of a current Care Plan for Resident #105 revealed .has falls r/t (related to) poor safety awareness and impulsivity AEB (as evidenced by) BIMS score of 3/15,[MEDICAL CONDITION](hypertension) and DM (diabetes) diagnoses, balance and gait problems .increasing dementia. Resident has a hx (history) of calcified [DIAGNOSES REDACTED] of the L (left) middle cranial fossa which can cause vision disturbance, [MEDICAL CONDITION], weakness and numbness in arms/legs, memory loss and loss of balance. (Resident #105) also receives [MEDICATION NAME] for [MEDICAL CONDITION] which can cause weakness, dizziness, tiredness and lightheadedness. (Resident #105) obtained a R (right) humeral fracture r/t fall . with interventions which included .Wheelchair to be used for transportation or for meals in dining area only. Resident is not to be left in wheelchair unobserved . with a start date of 11/3/17, and .Tab alarm to bed and wheelchair-check placement and function every shift . with a start date of 12/12/17. Review of a CNA Care Guide for Resident #105, revised 1/24/18 at 9:12 a.m., revealed .Resident is not to be left in wheelchair unobserved .Tab alarm to bed and wheelchair-check placement and function every shift . In an observation on 1/24/18 at 1:43 p.m., observed Resident #105 in her wheelchair, in the 3200 dining area adjacent to her room. Resident #105 was unobserved by staff, with no staff present in the dining area or within line of sight. Observed a tab alarm attached to the back of Resident #105's wheelchair, with the clip not secured to the resident's clothing. In an interview on 1/24/18 at 1:46 p.m., Certified Nursing Assistant (CNA) BB checked Resident #105's tab alarm and stated, .This one was not clipped . CNA BB reported that the clip for the tab alarm should be attached to Resident #105's clothing. Review of a Resident/Visitor Incident Report, dated 11/11/17, revealed Resident #105 had a fall in her room on 1/11/17 at 6:30 p.m. with no injury. Per the facility investigation, .Most recent BIMS is 4/15 on 10/9/17 showing significant cognitive impairment which contributes to resident's lack of safety awareness and impulsivity . Review of a Resident/Visitor Incident Report, dated 12/5/17, revealed Resident #105 had a fall in the dining area on 12/5/17 at 4:15 a.m. with no apparent injury. Per the report, .Res. (resident) up since approx. (approximately) 2:00 a.m., staff keeping her company and entertained. CNA left area to toilet another res. and upon return noted res. on the floor on her (L) (left) side. Nurse performed ROM (Range of Motion), which was WNL (within normal limits), denies pain, no injury . Further review of the report revealed a new fall intervention for .Res. to be in staff's line of sight when up in wc (wheelchair) . Review of an Interdisciplinary Note for Resident #105, dated 12/5/17 at 5:02 a.m., revealed .resident was observed on the floor in the 3200 hall dining area. Resident had been restless and wanted to get out of bed at approximately 2:00 a.m. and unit staff had been keeping her company and entertained. Resident was sitting at the table in the dining area looking at a book and waiting for her nail polish to dry. CNA had responded to another resident's call light and resident agreed to stay at the table until she returned. When CNA returned to dining area a few minutes later, she observed resident on the floor, on her left side, beside her wheelchair .New intervention: Resident to be in staff's line of sight when up in wheelchair . Review of a Resident/Visitor Incident Report, dated 12/11/17, revealed Resident #105 had a fall in the 3200 dining area on 12/11/17 at 5:20 p.m. which resulted in a right humerus fracture. Per the report, .Resident was sitting at the dining room table waiting for dinner while staff was getting other resident's ready for dinner. Staff was not in the dining room when resident fell . Further review of the 12/11/17 Resident/Visitor Incident Report for Resident #105 revealed new fall interventions, which included .Tab alarm to bed and wc AAT's (at all times) . Review of an Interdisciplinary Note for Resident #105, dated 12/12/17 at 6:31 a.m., revealed .Res came back from ER (emergency room ) at 0150 (1:50 a.m.) .Res had a humerus fracture and has a splint . with new orders for pain medication noted. Review of a hospital Depart Summary for Resident #105, dated 12/11/17, revealed .XR (X-ray) Shoulder .Right arm pain .Findings: There is a displaced oblique acute [MEDICAL CONDITION] right humeral shaft. The distal fracture is displaced dorsally by 1.2 cm. There also appears to be a right shoulder dislocation . In an interview on 1/24/18 at 3:33 p.m., Resident I reported that she observed Resident #105 on the floor in the dining room on 12/11/17 around dinnertime. Resident I reported that no staff were present at the time of Resident #105's fall, and Resident I had to yell for staff assistance. In an interview on 1/24/18 at 4:11 p.m., Licensed Practical Nurse (LPN) GG reported that at the time of Resident #105's fall on 12/11/17, he and the CNA's on the unit were assisting other residents in their rooms to get ready for dinner. In an interview on 1/25/18 at 10:31 a.m., with Clinical Care Coordinator (CCC) CC, Director of Nursing (DON) B, and Administrator A, CCC CCreported that after Resident #105's fall on 12/11/17, new interventions were put in place to prevent falls which included a tab alarm, and the care plan and care guide were updated with the new intervention. Administrator A reported that the expectation for staff would be to follow the information in the Care Guide when providing care to the residents.

Based on observation, interview and record review, the facility failed to administer and use its resources effectively and efficiently to attain and maintain the highest practicable physical mental and psychosocial well-being of each resident, resulting in the lack of a thorough abuse investigation, failure to implement the facility abuse policy, resident dignity and food service complaints, lack of monitoring of a injury post fall (finding a [MEDICAL CONDITION] 3 days late), failure to prevent an avoidable fall, poor sanitary conditions in the kitchen, failure to properly label and store medications/narcotics, infection control concerns, flying pests in the kitchen, and failure to provide all staff access to residents electronic meal record with the potential to for harm of one (Resident #26) and the potential for injury and harm to all residents. Finding include: See F 225 Based on observation, interview and record review the facility failed to thoroughly investigate and allegation of neglect for one Resident (#26) of 10 Resident reviewed for abuse of a total of 12 Residents, resulting in the failure to interview and identify all staff involved and having staff continue to work after termination. See F 226 Based on interview and record review the facility failed to implement their abuse and neglect policy for 1 Resident (#26) of 10 residents reviewed for abuse of a total of 12 residents reviewed, resulting in allegations of abuse and neglect not being thoroughly investigated and not being reported to the State Agency. See F 241 Based on interview and record review the facility failed to provide care with respect and dignity for 4 out of 4 resident in a confidential group of 10 residents sampled for care of a total of 12 residents sampled, resulting in the potential for feelings of embarrassment, frustration, decreased worth and psychosocial harm. See F 246 Based on observation, interview and record review the facility failed to meet the dietary expectations of 4 of 4 residents in the confidential group and one resident (# ) of 10 residents sampled for care of a total of 12 sampled residents, resulting in food not being delivered timely and potential for decreased oral intake and weight loss. See F 309 Based on observation, interview and record review the facility failed to assess and monitor one resident (Resident #26) of 10 Residents reviewed for care of a total sample of 12 residents, resulting in severe pain, delayed evaluation and treatment (3 days) of a [MEDICAL CONDITION]. See F 323 Based on observation, interview and record review the facility failed to safely transfer (follow care guide) one Resident (#26) of 10 Residents reviewed for accident hazards of a total sample of 12 sampled Residents, resulting in Resident #26 falling and sustaining a [MEDICAL CONDITION]. See F 371 Based on observation, interview, and record review the facility failed to: 1. Maintain cleanliness of food contact surfaces; 2. Properly air dry pots and pans; 3. Provide proper backflow prevention; 4. Maintain cleanliness of Nonfood contact surfaces; 5. Maintain consistent and proper date marking of potentially hazardous foods; 6. Properly store in use wiping clothes. 7. Maintain a freezer at proper temperature. 8. Maintain food temperature logs. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 87 residents consuming food from the kitchen. See F 431 Based on observation, interview, and record review the facility failed to: 1) ensure proper storage, labeling, and dating of medications and 2) failed to ensure controlled substances were secured in 1 of 1 medication rooms (Bristol Household 3600 medication cart- narcotics) and 1 of 1 clean utility rooms, (Bristol Clean Utility Room) resulting in the potential for expired medications being administered, decreased effectiveness of medications, and the potential for the diversion of controlled substances. See F441 Based on observation, interview, and record review the facility failed to properly maintain infection control practices for 51 of 87 residents and (Resident #26 oxygen tubing), in 1 of 1 soiled utility rooms (Bristol Soiled Utility Room), during handling of soiled linens, and after resident care, potentially affecting 51 of 87 residents, resulting in the potential for cross-contamination and the spread of illness and disease. See F 469 Based on observation, interview, and record review, the facility failed to effectively eliminate the presence of flying pests (fruit flies) in the facility with the potential to affect all 87 residents that reside in the facility resulting in the increased potential for the spread of bacteria and disease. See F 514 Based on interview and record review the facility failed to maintain complete and accurate medical records for one Resident (#26) and unknown number of residents of 10 residents sampled for care of a total of 12 residents sampled, resulting in incomplete and inaccurate medical records and the potential for interdisciplinary team member and other professional not having a complete and accurate picture of the resident.

Based on observation, interview and record review, the facility failed to administer and use its resources effectively and efficiently to attain and maintain the highest practicable physical mental and psychosocial well-being of each resident, resulting in the lack of a thorough abuse investigation, failure to implement the facility abuse policy, resident dignity and food service complaints, lack of monitoring of a injury post fall (finding a [MEDICAL CONDITION] 3 days late), failure to prevent an avoidable fall, poor sanitary conditions in the kitchen, failure to properly label and store medications/narcotics, infection control concerns, flying pests in the kitchen, and failure to provide all staff access to residents electronic meal record with the potential to for harm of one (Resident #26) and the potential for injury and harm to all residents. Finding include: See F 225 Based on observation, interview and record review the facility failed to thoroughly investigate and allegation of neglect for one Resident (#26) of 10 Resident reviewed for abuse of a total of 12 Residents, resulting in the failure to interview and identify all staff involved and having staff continue to work after termination. See F 226 Based on interview and record review the facility failed to implement their abuse and neglect policy for 1 Resident (#26) of 10 residents reviewed for abuse of a total of 12 residents reviewed, resulting in allegations of abuse and neglect not being thoroughly investigated and not being reported to the State Agency. See F 241 Based on interview and record review the facility failed to provide care with respect and dignity for 4 out of 4 resident in a confidential group of 10 residents sampled for care of a total of 12 residents sampled, resulting in the potential for feelings of embarrassment, frustration, decreased worth and psychosocial harm. See F 246 Based on observation, interview and record review the facility failed to meet the dietary expectations of 4 of 4 residents in the confidential group and one resident (# ) of 10 residents sampled for care of a total of 12 sampled residents, resulting in food not being delivered timely and potential for decreased oral intake and weight loss. See F 309 Based on observation, interview and record review the facility failed to assess and monitor one resident (Resident #26) of 10 Residents reviewed for care of a total sample of 12 residents, resulting in severe pain, delayed evaluation and treatment (3 days) of a [MEDICAL CONDITION]. See F 323 Based on observation, interview and record review the facility failed to safely transfer (follow care guide) one Resident (#26) of 10 Residents reviewed for accident hazards of a total sample of 12 sampled Residents, resulting in Resident #26 falling and sustaining a [MEDICAL CONDITION]. See F 371 Based on observation, interview, and record review the facility failed to: 1. Maintain cleanliness of food contact surfaces; 2. Properly air dry pots and pans; 3. Provide proper backflow prevention; 4. Maintain cleanliness of Nonfood contact surfaces; 5. Maintain consistent and proper date marking of potentially hazardous foods; 6. Properly store in use wiping clothes. 7. Maintain a freezer at proper temperature. 8. Maintain food temperature logs. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 87 residents consuming food from the kitchen. See F 431 Based on observation, interview, and record review the facility failed to: 1) ensure proper storage, labeling, and dating of medications and 2) failed to ensure controlled substances were secured in 1 of 1 medication rooms (Bristol Household 3600 medication cart- narcotics) and 1 of 1 clean utility rooms, (Bristol Clean Utility Room) resulting in the potential for expired medications being administered, decreased effectiveness of medications, and the potential for the diversion of controlled substances. See F441 Based on observation, interview, and record review the facility failed to properly maintain infection control practices for 51 of 87 residents and (Resident #26 oxygen tubing), in 1 of 1 soiled utility rooms (Bristol Soiled Utility Room), during handling of soiled linens, and after resident care, potentially affecting 51 of 87 residents, resulting in the potential for cross-contamination and the spread of illness and disease. See F 469 Based on observation, interview, and record review, the facility failed to effectively eliminate the presence of flying pests (fruit flies) in the facility with the potential to affect all 87 residents that reside in the facility resulting in the increased potential for the spread of bacteria and disease. See F 514 Based on interview and record review the facility failed to maintain complete and accurate medical records for one Resident (#26) and unknown number of residents of 10 residents sampled for care of a total of 12 residents sampled, resulting in incomplete and inaccurate medical records and the potential for interdisciplinary team member and other professional not having a complete and accurate picture of the resident.

This citation has two deficient practice statements Resident #12 citation pertains to MI 640 Resident #12 Based on interview and record review, the facility failed to assess thoroughly, recognize and document a change in condition for one resident (Resident #12) out of 4 residents reviewed for quality of care from a total sample of 19 residents resulting in a delay in care and an acute hospitalization for [MEDICAL CONDITION] (infection throughout the body), [MEDICAL CONDITION] (change in the brains function) and end organ disruption. Findings include: According to a facility face sheet dated 6/29/17 at 8:13 a.m., Resident #12 was an [AGE] year-old female who was admitted into the facility on [DATE] with the cumulative Diagnoses: [REDACTED]. Multiple organ (or end organ ) dysfunctio[DIAGNOSES REDACTED] (MODS) is a continuum, with incremental degrees of physiologic derangements in individual organs; it is a process rather than a single event. Alteration in organ function can vary widely from a mild degree of organ dysfunction to completely irreversible organ failure. The degree of organ dysfunction has a major clinical impact. http://emedicine.medscape.com/article/ 0-overview According to a facility progress for Resident #12 note dated 4/3/17 at 5:03 p.m., Nasal swab test results are positive for Influenza A. Call placed to (name of durable power of attorney), message left to call (name of unit) nurse. Call placed to daughter (name of daughter) to inform of mom's status and treatment. According to a facility progress note for Resident #12 dated 4/5/17 at 7:09 p.m., Resident continue with isolation precautions, VSS (vital signs stable), denies pain or discomfort. Appetite poor, fluids being encouraged. Lung sounds clear. Only vital signs documented were at 6:00 a.m This was signed by Licensed Practical Nurse (LPN) II. Review of a facility progress note for Resident #12 dated 4/6/17 at 7:21 p.m., Resident continues with contact precautions. VSS, appetite poor, fluids encouraged and tolerated well. Denies pain or discomfort. Resident rested in bed during shift comfortably. Husband (name of husband) updated or (sic) residents condition. The only vital signs documented were at 3:08 a.m. and 4:30 a.m. (an hour and a half apart). This was signed by LPN II. Next progress noted for Resident #12 dated 4/8/17 (Saturday), two days later, at 6:28 p.m. reflected, No complaints of pain or discomfort noted to right breast. VSS, resident alert and oriented times two and able to make needs known. Appetite fair. This was signed by LPN II. There are no noted documentation of vital signs for 4/8/17. Two days later, the next facility progress note for Resident #12 on 4/10/17 at 6:33 p.m. reflected, Resident noted to be weak at 8:00 a.m She is responsive to direct questions. She presented with a temp(erature) of 99.1 (degrees Fahrenheit) at 9:00 a.m. with scheduled Tylenol given. At 3:00 p.m. resident again presented with a temp(erature) of 100.1 (degrees Fahrenheit) and was given Tylenol. At 6:30 p.m., staff notified that resident was less responsive and still weak. Resident had eaten two bowls of jello and drank an 8 oz. (ounce) boost (nutritional supplement). Resident had been eating soft foods and drinking all day. Oncoming nurse notified of resident's condition. This documentation was signed by LPN BB. The last facility progress noted for Resident #12 dated 4/10/17 at 11:04 p.m. reflected, At 6:20 p.m. the resident's husband told this nurse that he would like someone to evaluate (name of Resident #12) as she was looking 'pretty sick'. This nurse (LPN FF) and the first shift nurse (LPN BB) assessed the resident and she was very lethargic and minimally responsive. She was able to only say two word and (sic) a time and was not eating or drinking much of anything. Vitals (vital signs) at that time were B/P (blood pressure) 143/62, Pulse 73, Resps (respirations) 18 and temp(erature) 100 (degrees Fahrenheit, normal is 98.6 degrees Fahrenheit), pulse ox (level of oxygen in the blood) 89% (percent) on room air (normal is 92% to 100%). On call Dr. (name of physician) notified and new order obtained to send resident to (name of acute care hospital) for further evaluation. (Name of ambulance service) called and appropriate paperwork gathered to send with resident. Resident left the unit with her husband via stretcher at about 7:00 p.m Resident has since been admitted to (name of acute care hospital). This documentation was signed by LPN FF. Review of an SBAR (SBAR is an acronym for Situation, Background, Assessment, Recommendation) for Resident #12 dated 4/10/17, no time indicated reflected, Resident is very weak, elevated temp(erature), tiredness. This started today, has been ill with Influenza A. B/P 143/62, HR (heart rate) 73, Respirations 18, Temperature 99.1 now 100.2 (degrees Fahrenheit), Pulse ox 97 % on room air I suggest or request provider (MD, Nurse Practitioner or Physician's Assistant) visit. This document is not signed or dated by the Licensed Practical Nurse (LPN) or Registered Nurse (RN) that filled it out. There is a signature in the Physician's Signature and it is dated 6/11/17 and there is a hand written note at the bottom, In hospital. Review of a facility document titled, Vital States for 00/00/0000 thru 4/11/17 for Resident #12 reflected on 4/3/17 at 4:03 p.m., Resident #12 temperature was 102 (degrees Fahrenheit). The average normal oral temperature is 98.6°F (37°C or Celsius) . An ear (tympanic) temperature is 0.5°F (0.3°C) to 1°F (0.6°C) higher than an oral temperature. http://www.webmd.com/children/tc/fever-temperatures-accuracy-and-comparison-topic-overview. This was the day Resident #12 tested positive for Influenza A. Continued review of this document for Resident #12 reflected vital signs taken were: 4/3/17 at 6:00 a.m. Full set of vital signs, temperature 99 degrees F no vital signs for second or third shift 4/4/17 at 5:52 a.m. Vital signs but no pulse oximetry and Resident #12 had a respiratory infection 4/4/17 at 8:24 p.m. Pulse ox only no vital signs for first shift and no vital signs for third shift and no complete vital signs for second shift 4/5/17 at 6:00 a.m. Full set of vital signs no vital signs for second or third shift 4/6/17 at 3:08 a.m. Full set of vital signs 4/6/17 at 4:31 a.m. Full set of vital signs no vital signs for first or second shifts no vitals signs on 4/7/17, 4/8/17 or 4/9/17 4/10/17 at 2:00 p.m. Full set of vital signs, temperature is 100 degrees F The facility was not able to thoroughly monitor for a change in condition during Resident #12's infection with Influenza type A due to lack of vital sign information. Vital signs include the measurement of: temperature, respiratory rate, pulse, blood pressure and, where appropriate, blood oxygen saturation. These numbers provide critical information (hence the name vital) about a patient's state of health. In particular, they: 1. Can identify the existence of an acute medical problem. 2. Are a means of rapidly quantifying the magnitude of an illness and how well the body is coping with the resultant physiologic stress. The more deranged the vitals, the sicker the patient. https://meded.ucsd.edu/clinicalmed/vital.htm During an interview on 6/29/17 at 1:03 p.m. with Administrator A, Administrator A revealed that vital signs were to be taken every shift when a resident has an infection. During an interview and record review on 6/29/17 at 1:45 p.m. with Director of Nursing (DON) B, DON B stated the facility was notified by the acute care hospital that Resident #12 was admitted to the hospital on [DATE] and that the facility needed to begin an investigation related to Resident #12 having so many infections. DON B stated this call was received on 4/11/17 (no time given) and the investigation was started immediately. DON B stated the facility called Licensed Practical Nurse (LPN) BB who cared for Resident #12 on 4/10/17 (date of hospitalization ) during the day shift and took her statement. This statement was typewritten, no date or time the statement was obtained. The statement was not signed. This statement reflected, On 4/10/17 at 12:30 p.m., spoke with (name of #12's husband) to notify him of his wife's condition. We spoke at length regarding her temperature, conversations/interactions with staff during cares, eating/drinking. We discussed sending her to ER (emergency room ) for evaluation or letting her stay at the facility and having her seen by (name of physician) the following day when he arrived. At the end of our discussion (it lasted about 5 to 10 minutes), (name of Resident #12's husband) decided to have her stay at the facility and see (name of physician) the next day. He also stated that he would contact his daughters and see if one of them could come up and see his wife, since her roommate was on isolation for Influenza A still and he did not want to be exposed to it. DON B stated that there is no documentation regarding this conversation in the resident's medical record. During an interview by phone with LPN BB on 6/29/17 at 1:25 p.m., LPN BB confirmed she had cared for Resident #12 on 4/10/17 from 6:00 a.m. to 6:00 p.m. LPN BB was asked how Resident #12 was on 4/10/17 and LPN BB revealed, just tired, hunched forward. LPN BB stated she called the physician during the day. When asked if this conversation was written in her progress notes, she stated she is unsure. LPN BB was asked if this was placed in an SBAR. LPN BB stated she wasn't sure. LPN BB stated several residents were on quarantine and it was a crazy day, she can't remember. LPN BB stated at changed of shift (approximately 6:00 p.m.) Resident #12's husband stated he wanted Resident #12 to be looked at and she went with LPN FF to assess Resident #12. LPN BB stated Resident #12 had more pallor (pale). LPN BB was asked if Resident #12 could talk and LPN BB stated she can't remember. Review of a typewritten interview by DON B of LPN II regarding Resident #12, dated 4/11/17 at 4:00 p.m. How (name of Resident #12) was doing on Saturday (4/8/17)? Tired, dusky, appetite baseline, pushed fluids. Sunday (4/9/17)? I fed her Sunday, vital signs stable, no fever, alert, dusky (meaning dark, not normal, ill) appearance. She (Resident #12) was up in her wheelchair, told me she was doing ok. Finish(ed) [MEDICATION NAME] ([MEDICATION NAME] is used to treat influenza in people who have had flu symptoms for 2 days or less). Monday (4/10/17, day of hospitalization )? N/A (LPN did not care for Resident #12 that day) How was she (Resident #12) eating? 25 to 30 % intake (food) drank most of fluids. Did she respond to you? Alert and oriented times two (knows person and place), said mandarin oranges were good on Sunday. Was she (Resident #12) voiding (urinating)? Was there any sign or symptom of infection noted? Void (urination), incontinent (unable to control urination), no signs or symptoms of a urinary tract infection, no fever, didn't document vital signs, just looked at them to see if abnormal. Foul odor (to urine) always has since I started here related to [MEDICAL CONDITION] meds. Did you notify the physician of any decline? Who and When? Not that perky, thought related to flu. No not anything to contact about, no change in condition (Sunday). This statement is signed by LPN II on 4/11/17, no time indicated and signed by DON B on 4/11/17, no time indicated. LPN II did not contact a physician even though Resident #12 was fatigued and dusky, not eating well. There is no documentation of vital signs being obtained. A facility policy titled, Change in Resident Condition dated reviewed 2/1/16 reflected, The charge nurse will notify the residents attending physician and representative of changes in the resident's condition and or status. Procedure for notifying the physician: the charge nurse will notify the physician when: .there is a significant change in the resident's physical, mental or psychosocial status .Procedure for documentation: the charge nurse will record in the resident's medical record any changes in the resident's medical condition or status. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted by the Clinical Care Coordinator/IDT (interdisciplinary team), reported to the Director of Nursing. The medical record is a legal document and is used to protect the patient as well as the professional practice of those in healthcare. Documentation of the care you give is proof of the care you provide .Charting is objective, not subjective. This means chart only what you see, hear, feel, measure, and count - not what you infer or assume. All nurses know that if it wasn't charted, it wasn't done the patient's complete and accurate medical record the most reliable source of information on the care of that patient. Proper nursing documentation prevents errors and facilitates continuity of care. https://www.asrn.org/journal-chronicle-nursing/341-charting-and-documentation.html The Professional Standards of Quality for Staff Roles and Responsibilities in Monitoring Patients with Acute Changes of Condition for the nurse includes recognizing condition change early and assessing the patient's symptoms and physical function and document detailed description of observations and symptoms. (Process Guidelines for Acute Change of Condition, AMDA Clinical Process Guidelines, 2003). A licensed nurse shall, in a complete, accurate and timely manner, report and document nursing assessments or observations, the care provided by the nurse for the client, and the patient or to recognize changes in a patient's condition. Failure to recognize the significance of changes or to communicate them clearly and promptly to the attending practitioner could endanger the patient. (McMahon & Associates. Nursing Standards of Practice. HGExperts.com. Retrieved May 19, 2011, from http://www.hgexperts.com/article. ) The profession standard of quality for notifying the physician of acute change in condition is to immediately report a sudden onset of an acute change in mental status to the physician. (Clinical Process Guideline for Acute Change of Condition, MDCH Clinical Advisory Panel, Memorandum dated 6/29/04). Review of the acute care facility History and Physical for Resident #12 dated 4/14/17, no time noted, reflected, Impression and Plan:[MEDICAL CONDITION] suspect secondary to UTI (urinary tract infection), unable to rule out bacteremia (bacteria in the blood) .Lactic Acidosis (Lactic acidosis is a feature of different disorders, usually indicating a metabolic derangement in the acid-base system of the body. Sometimes associated with severe infection. according to medicinenet.com) .altered mental status suspect secondary to infection. The facility failed thoroughly assess, document and recognize a change in condition for Resident #12 leading to a delay in care,[MEDICAL CONDITION] and end organ disruption. Based on interview and record review the facility failed to provide care in an unhurried manner for 7 out of 10 residents in the confidential group and 1 resident (Resident #19) out of a total number of 19 residents sampled, resulting in the potential for the care needs of all 85 facility residents to not be met in a manner to attain or maintain their highest practicable physical, mental and psychosocial well-being. Findings include: On 6/28/17 at 11:00 AM a confidential group interview was conducted with 10 alert and oriented residents. During the group meeting 7 out of 10 residents expressed feeling frustrated and upset due to not receiving timely care and wetting or soiling themselves. Residents reported feeling frustrated, humiliated, upset and not happy when this occurs. One resident stated staff will come in and turn off the light and say they will come back but you never know when they will come back. At least five residents agreed that their light has been turned off without their needs being met and it's a long wait for staff to return. One resident stated you wait and wait and they don't come. At times residents will wait on the toilet and never know when they will come back, a resident remarked it is not the happiest place to sit, waiting on the toilet Two residents stated they have waited more than an hour for call light response. One resident stated they have watched the clock and another stated they watch the clock and have called their daughter to track the time. It was noted that response time takes too long and it's frustrating. Residents also expressed concerns about staff being stressed and not treating them with respect or listening to them. It was noted temp staff are the worst but some regular staff are also rushed and rough. It was stated, everyone is stressed and sometimes staff don't realize they are being rough. One resident stated that Certified Nursing Assistant (CNA) EE was rough with them during showers, another resident also noted she was upset because CNA EE will accidentally spray water in her face during shower and she has told her at least 3 times. The resident stated CNA EE needed to be more careful because the water can get in her nostrils. It was also stated that staff disappear at times and this happens especially around break time or shift change. One resident stated they think it's because staff don't want to get held up before they leave. Another resident stated that they are able to use the slideboard for transfers but that staff will often use the Hoyer lift on her because it takes less time. At least 4 of 10 residents agreed that staff will not let them be more independent with transfers because it takes more time for staff. Another resident commented that staff do not always pay attention to your needs. It was also noted it feels like a battle to change your care plan. Two residents stated they have brought up concerns about staffing, but were told we have enough staff, which felt dismissive. Resident Council Minutes: A review of resident council meeting minutes revealed some concerns for call light response and care and services. Meeting minutes from December 28, 2016 revealed: Are your call lights being answered within five minutes? .Some of the new staff do not seem to be trained well enough, seem to not know what they are doing. Breaks are not spread out enough and its ends up being one person covering three halls-Continues to be a concern, especially of day shifts, weekends and immediately following meals. Aides/staff in general are coming in to respond to a light and shutting it off, whether the need has been met or not.-This continues to be a concern. Meeting minutes from January 31, 2017 revealed: Are your call lights being answered within five minutes? .Sometimes the staff are busy and it may be longer than 5 minutes. Meeting minutes from February 27, 2017 revealed: Staff slam doors and slam things on the table when they are in a bad mood. Meeting minutes from March 30, 2017 revealed: Are your call lights being answered within five minutes? .No, it is hard to find an aide on the weekends. Meeting minutes from April 25, 2017 revealed: Are your call lights being answered within five minutes? .No, not on the weekends and No, not on any day of the week. Staff are turning off the call light before her needs are met. Do you feel you are being treated kindly at bedtime? .No, often feel rushed and that staff are in a hurry and feel rushed by staff. Meeting minutes from May 24, 2017 revealed: Are your call lights being answered within five minutes? .No, it is hard to find staff for assistance during anytime of the day. Resident #19: Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #19 is a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) score indicated Resident #19 was cognitively intact and required extensive assistance for activities of daily life (ADLs). An interview was completed on 6/28/2017 at 3:50 PM with Resident #19. Resident #19 stated that generally staff response is good, but that sometimes care can take forever. Resident #19 stated usually its agency staff that take more time. Resident #19 stated she has waited 30-45 minutes multiple times for call light response and has wet herself because she can only hold it for about 5 minutes. Resident #19 stated it feels terrible and she doesn't like to be wet. Resident #19 stated she has gotten a bruise once due to rushed care from staff. Resident #19 stated she got her arm pinched in the Hoyer (lift) and she got a bruise from it. Resident #19 stated that her care is usually good, but that day they were being careless and going too fast. Resident #19 disclosed that Certified Nursing Assistant (CNA) EE was the aide being careless and there are have been other occasions where she felt CNA EE has been rushed and can be rough. Resident #19 denied any other injuries.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and properly functioning assistive devices for 5 of 14 residents reviewed for falls (Resident #1, #7, #11, #13, and #31), from a total of 19 sampled residents and 11 supplemental residents, resulting in an immediate jeopardy when Residents #1, #7 #11, #13, and #31, who had been identified as fall risks and had continued falls, repeatedly continued to fall with the potential for serious injury and/or death for Residents #1, #7 #11, #13, and #31. This deficient practice places all 93 facility residents, who were identified by the facility as at risk for falls, at risk for serious harm, injury, and/or death Findings include: Resident #7 According to the MDS/Minimum (MDS) data set [DATE], Resident #7 was a [AGE] year old man admitted to the facility on [DATE], who had severe dementia, needed total assistance with hygiene, transfers and 2 person physical assistance to ambulate in his room (staff to provide weight bearing support), was taking an antidepressant, 325 mg of Aspirin every day (blood thinner), and an antibiotic, and had [DIAGNOSES REDACTED]. Resident #7 resided on the short-term rehab unit ever since his admission. Review of Resident #7's Resident/Visitor Incident Reports since his admission revealed he had 11 falls between 3/13/16 - 4/29/16 (47 days); 8 of the 11 falls were without injury. Resident #7 sustained skin tears during 2 of the falls (4/14/16 at 7:05 PM and 4/19/16 at 9:15 PM) and 2 lacerations to the back of the head on 3/29/16 at 8:45 PM. Four of the falls were witnessed by staff but without staff intervention prevented or assisted the falls (3/29/16 at 8:45 PM, 4/06/16 at 8:00 PM, and 4/19/16 at 9:15 PM, and 4/29/16). In an interview, on 5/03/16 at 9:00 AM, DON/Director of Nursing B (who was the Unit Resident #7 resided on and also the Infection Control Coordinator for the facility) reported Resident #7's alarm was not sounding during the fall Resident #7 sustained on 4/06/16 at 8:00 PM, because (Nurse Aide C) did not reapply the alarm after ambulating (Resident #7). DON B reported the nurse on duty (RN/Registered Nurse D) told Nurse Aide C to make sure she hooks the alarm up after ambulating, but there was no formal education or discipline documentation in Nurse Aide C's personnel file because, according to DON B, (Nurse Aide C) is a good Aide; she takes good care of them (residents). DON B reported that the fall Resident #7 sustained on 4/16/16 at 7:05 PM, was last toileted 4 hours prior to the fall, but the Nurse Aide involved (V) had no Verbal Education or Discipline as a result. When asked if they knew why Resident #7 continued to sustain falls, DON B reported Resident #7 had zillions of falls prior to admission to the facility, and Resident #7 had pneumonia and was on an antibiotic when he entered the facility and was diagnosed with [REDACTED]. When discussing Resident #7's 9 th fall (on 4/19/16), DON B stated, at this point, we are now trying to do some root cause analysis. In the same interview with DON B, she reported the alarm did not sound during the another fall Resident #7 sustained on 4/16/16 because the battery was not working; Resident #7 reported, according to the Incident Report, resident was not in bed . , and the report revealed Resident #7 was trying to get from his bed to the bathroom because he needed to urinate. DON B stated, A bathroom alarm was added. (However, according to Resident #7's Fall Care Plan, a bathroom door alarm was added on 3/11/16). DON B reported We talked to staff about rounding around this time .Resident #7 should be on the long term care unit where the activities on the unit would better meet his needs and keep him occupied. We discovered many of his falls were around 9:00 PM; he gets active in the evening and though the night, and sleeps during the day. DON B said, We finally got approval for a 1:1 to start tonight at 8:00 PM. In a telephone interview, on 5/04/16 at 11:12 AM, Resident #7's Son/Responsible Party TT reported Resident #7 had loved golf, reading, aircraft, and preferred to be with people. Son TT said, He (Resident #7) tends to be isolated where he is. He is waiting to be placed on a unit that is more appropriate for him. When asked if he knew how many falls his father had had at the facility, Son TT replied, I have lost count . Son TT reported the alarms Agitate him, that the facility physician told him that Resident #7 is unable to keep weight on his legs and stand due to weakness and deterioration from the disease process. Despite that Resident #7 was unable to sustain weight on his legs, the facility added the following intervention following a fall from leaning forward out of his wheelchair on 4/14/16, gripper socks or shoes at all times . Although it was documented that Resident #7 had a urinary tract infection (diagnosed on [DATE]), and was seeking the bathroom on a fall sustained on 4/16/16 at 7:05 PM, the facility did not initiate 3-Day Bowel and Bladder Pattern documentation until 5/04/16, and his urinal was stored in his bathroom, not at bedside. Although Resident #7 was known to be active in the evening and night and sleep during the day, his care plan (updated 4/18/16 after a fall on 4/16/16 where he was found naked on the bathroom floor) instructed staff to: .lay resident down after dinner if tired to assist with decreasing anxiety and restlessness. Review of Resident #7's Medication Administration Records revealed the licensed nurses were administering Ativan (anti-anxiety agent) sporadically (23 times in April, 2016) for restlessness and/or agitation, and signing that they assessed Resident #7 for pain each shift. However, the same licensed nurses did not record what Resident #7's pain level was, making it impossible to track and trend his pain which may have been the cause of his restlessness and contributed to his falls, or shown an indication of injury following falls. Although Resident #7 was agitated by alarms, the following alarms were added to his plan of care on 3/11/16 and were still in place on 5/02/16: Tab alarm in chair. Sensor alarm to bed. Bathroom door alarm. Although Resident #7 preferred to interact with people, his Fall Care Plan, revealed the following was not added until 5/02/16: .Trial to include attending activities on Bristol (dementia unit) to assist in providing interaction more appropriate than on the rehab unit . Review of Resident #7's Care Plans revealed he had no Activities Care Plan in place until 5/03/16, although and Activity Assessment was completed on 3/14/16. Although Resident #7 sustained at least 6 of the 11 falls from his wheelchair (2 observed slid from and 2 observed leaning forward), the following was not added to his Falls Care Plan until 5/02/16: .include a Broda chair to determine if more comfortable . Review of the Resident #7's Resident/Visitor Incident Report, dated 4/29/16 at 10:45 PM, revealed that although staff were present at the time of the fall, .transferred self to floor in front of aides ., the intervention to avoid repetition of incident was monitor q (every) 15 minutes. In addition, review of Resident #7's Fall Care Plan revealed monitor q 15 minutes was not an added intervention, and review of Nursing Progress Notes revealed no evidence that monitor q 15 minutes was being done. Resident #7 sustained his 11 th fall on 5/02/1 at 7:15 PM; he was found on floor crawling out of his room and alarms sounding . The intervention to avoid repetition of incident listed on the report was to Leave in highly populated areas, but this was not added to the Fall Care Plan either. On 5/03/16 at 10:40 AM, this Surveyor observed Resident #7 sitting with his eyes closed in a recliner in his room; there were no staff within sight on the Unit. On 5/03/16 at 10:30 AM, with RN F, this Surveyor observed the sensor alarm on Resident #7's bed. There was a date written on the pad (9/15). RN F reported the Aides put that date on there. A notice on the pad said, Put into use date .Pad replacement date. For pad replacement date write in 1 year from the above put into use date (a space was provided to write the dates). It was unable to be determined if the date on the pad was the Put into notice or the Pad replacement date. In an interview, on 5/03/16 at 10:50 AM, Nurse Aide H reported she worked full time at the facility for 5 ½ years and had been assigned to Resident #7 since he was admitted . Nurse Aide H reported some of the sensor alarms had dates on them and some did not. Nurse Aide stated she did not know who put the dates on sensor alarms, did not know what the dates meant, and had never been educated as to whether they needed to be dated or not. In an interview, on 5/03/16 at 2:45 PM, DON B reported she considered all facility residents to be at risk for falls. Resident #13 According to the MDS/Minimum Data Set, dated dated dated , 12/09/15, he was an [AGE] year old man who resided at the facility since 3/11/15, had vision impairments, severe dementia with inattention, disorganized thinking, and verbal behaviors directed at others, wandered and ambulated with supervision, was taking an antidepressant and an antipsychotic, had [DIAGNOSES REDACTED]. Resident #13's Fall Risk Tool, dated 9/11/15 revealed he was at high risk for falls because he had the following problems: Memory problem, Impaired decision making, mental health diagnosis, hearing deficits, unsteady gait, impaired balance, bladder and bowel incontinence, cardiovascular disease, use of antipsychotic and antidepressant medications, use of cardiovascular medication, fall in past 30 days and fall in past 31-180 days. Review of Resident #13's Resident/Visitor Incident Reports since 7/17/15 revealed he had 11 total falls (without major injury), with 9 of the falls occurring between 7/17/15 - 12/09/15. According to a Resident/Visitor Incident Report, dated 12/16/15 at 3:00 PM, the facility failed to provide adequate supervision for Resident #13 which put him at high risk for a fall with serious injury; he was alone, unattended (for an unverified amount of time) and descending the stairs in a stairwell on the Bristol Unit where he resided. Former CCC/Clinical Care Coordinator (no longer worked at the facility) Z documented in the Incident Report, At (3:00 PM), life enrichment employee (Y) reporting he was taking stairway near exit 18 unit to Bristol unit and saw (Resident #13) on third stair down . Staff assisted resident back into Bristol unit and reported to charge nurse (Y) immediately. Resident was last seen prior to incident (approximately) 3 minutes prior out in common area the by the CNA (Nurse Aide/not identified AAA) who was assigned to him . In addition,the facility failed to properly investigate the incident; on 5/05/16 at 3:32 PM, Administrator A reported the facility did not document a witness statement and had not identified who the nurse aide mentioned in the Interdisciplinary Notes (AAA), making determination of the amount of time Resident #13 was alone in the stairwell impossible to verify. In an interview, on 5/09/16 at 2:38 PM, Life Enrichment Y reported he was the staff member who found Resident #13 alone and confused in the stairwell, on the third step with no other staff members in the stairwell. Life Enrichment Y stated he was walking up from the 2nd floor when he came upon Resident #13, so he assisted Resident #13 back to the Bristol unit and presented him to Nurse Z. In a telephone interview, on 5/09/16 at 11:01 AM, Current CCC BB reported the incident of Resident #13 liked to follow people and shift change is at 2:00 PM. In a telephone interview, on 5/10/16 at 8:46 AM, Former CCC Z reported I never identified the staff person who went down the stairs .It could have been a family member Shift change is 2:30 PM .I can't remember who last saw him last prior to when it happened. ( ) Resident #31 Review of Resident #31's MDS, dated [DATE], revealed she was a [AGE] year old woman with severe cognitive impairment due to [DIAGNOSES REDACTED]. Review of Resident #31's Fall Risk Tool, dated 1/12/16, revealed she was at high risk for falls due to: memory problem, impaired decision making, requires assist with transfers, requires assist with ambulation, unsteady gait, impaired balance, requires use of assistive devices, bladder incontinence, orthopedic disorder, cardiovascular disease, acute illness (status [REDACTED]. According to Resident/Visitor Incident Reports, Resident #31 had 6 falls between 12/06/15 - 1/23/16 (49 days). According to the Resident/Visitor Incident Report, dated 12/06/15, Resident #31 sustained a hip fracture that required surgical repair during that fall. And, according to the next Resident/Visitor Incident Report related to a fall for Resident #31, dated 12/28/15 at 3:00 AM, Resident was noticed by CNA getting on the floor .Upon an assessment, 2 skin tears were noted to (left) upper arm .about 2.5 cm x 2.5 cm. skin tear to L (left) lower arm about 1.8 cm x 1 cm, a bruise to L wrist about 6 cm x 5 cm noted. C/O (complaint of) Rt (right) knee pain .Tab alarm was not going off . alarm replaced; a sensor pad was added to Resident #31's bed. The Post Fall Summary stated, Her (Resident #31's) TAB was not working, she has not been seen removing her alarm. ( ) The facility was notified of IJ/Immediate Jeopardy at F-323 on 5/04/16 at 10:45 AM, was identified on 5/4/16 and began on 3/29/16, due to the facility's failure to provide adequate supervision and/or assistive devices to prevent continued falls for Resident #1, #7, and #11. (Residents #13 and #31 were added after the IJ notice was issued), who been recognized as at risk for falls and had continued falls, resulting in continued falls with the potential for serious injury and/or death for Residents #1, #7 #11, (#13 and #31). This deficient practice places all 93 facility residents, who were identified by the facility as at risk for falls, at risk for serious harm, injury, and/or death. Immediacy was removed on 5/04/16 at 4:00 PM when the facility had the following in place for Residents #1, #7, and #11 (Residents #13 and #31 were added after the IJ notification): Resident #1 · On 5/04/16 at 12:41 PM, Resident #1's Fall Care Plan was reviewed by CCC BBB, and the following new interventions were added and implemented by 12:50 PM: Encourage sitting in recliner in room; Toileting changed from every 2 hours to before and after meals, upon rising, prior to going to bed, and as needed with rounds at night when awake; Bathroom door on at all times; Personal items (Bible and stuffed animal) within reach; Pronounce name with a long I sound (gets agitated with mispronunciation of her name); Pinch guard to door of room. · On 5/04/16 at 12:50 PM, CCC BBB reviewed Fall Care Plans and verified all safety measures were in place for all of the Epworth Unit residents. · On 5/04/16 at 12:55 PM, caregivers began being educated regarding Resident #1's revised Fall Care Plan interventions, and the expectation that reviewing assigned residents' care plans is to be done at the beginning of shift, and on making sure safety measure are in place are in place throughout the entire shift. Staff was advised that in the event it was determined they did not follow policy or the noted education, disciplinary action would occur up to and including termination. · On 5/04/16 at 4:00 PM, over 50 % (60 of 96 nursing staff) of caregivers had been educated on identified concerns related to care plans, safety interventions, and disciplinary actions. All other facility caregivers will be educated at beginning of shift as they arrive to work and before they start their shift. Resident #7 · On 5/03/16 at 2:00 PM, 1:1 supervision 24/7 to provide companionship and monitoring. · On 5/04/16 at 10:00 AM, a pain assessment was done; Tylenol 650 mg at HS (bedtime) and prn (as needed) was discontinued and Tylenol 500 mg 2 tabs 3 x day was added. · On 5/04/16 at 12:00 PM, Resident #7's Fall Care Plan was reviewed by CCC K, and the following new interventions were added and implemented by 12:16 PM: 1:1 supervision 24/7 to provide companionship and monitoring (added 5/03/16 at 2:00 PM); Provide tactile stimulation activity supplies when resident appears restless or leans in wheelchair, fidgeting with wheelchair pedals, or reaching for floor; Bed low to floor with fall mat on ground next to bed; Monitor orthostatic blood pressure x 7 days. · On 5/04/16 at 3:00 PM, CCC K reviewed and verified all Fall interventions for the residents residing on the Oxford Unit were in appropriate and in place. · On 5/03/16 by 10:30 PM, caregivers began being educated regarding Resident #1's revised Fall Care Plan interventions, and the expectation that reviewing assigned residents' care plans is to be done at the beginning of shift, and to make sure safety measure are in place are in place throughout the entire shift. Staff was advised that in the event it was determined they did not follow policy or the noted education, disciplinary action would occur up to and including termination. · On 5/04/16 at 4:00 PM, over 50 % (60 of 96 nursing staff) of all facility caregivers had been educated on identified concerns related to care plans, safety interventions, and disciplinary actions. All other facility caregivers will be educated at beginning of shift as they arrive to work and before they start their shift. Resident #11 · On 5/04/16 at 12:00 PM, Resident #7's Fall Care Plan was reviewed by CCC BB, and the following new interventions were added and implemented by 12:58 PM: Between 1:30 PM - 6:30 PM, invite to activities after being toileted; if he declines group activity, provide 1:1 activity or small group activity in quiet comfortable area; Assist to movie group after toileting after supper each evening; if he refuses to attend movie group, engage in 1:1 interaction until he is ready to go to bed for the night. · On 5/04/16 at 1:35 PM, CCC BB reviewed and verified all Fall interventions for the residents residing on the Bristol Unit were in appropriate and in place. And, the facility reviewed the Fall Care Plans and verified placement of interventions for the residents residing on the Aldersgate Unit by 5/04/16 at 4:00 PM. · On 5/03/16 by 10:30 PM, caregivers began being educated regarding Resident #11's revised Fall Care Plan interventions, and the expectation that reviewing assigned residents' care plans is to be done at the beginning of shift, and to make sure safety measure are in place are in place throughout the entire shift. Staff was advised that in the event it was determined they did not follow policy or the noted education, disciplinary action would occur up to and including termination. · On 5/04/16 at 4:00 PM, over 50 % (60 of 96 nursing staff) of all facility caregivers had been educated on identified concerns related to care plans, safety interventions, and disciplinary actions. All other facility caregivers will be educated at beginning of shift as they arrive to work and before they start their shift. Although the Immediate Jeopardy (IJ) was removed on 5/04/16, the facility remained out of compliance at a scope of pattern and a severity of No actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to all staff had not been in-serviced on the corrective action implemented to remove the immediacy and sustained compliance has not been verified by the state agency. ( ) Resident #1 Review of a facility Profile Face Sheet indicated Resident #1 was an [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 had short and long term memory impairment and needed assistance for decision making. Resident #1 needed extensive assistance from one person for bed mobility, transfers, dressing, hygiene and bathing. Review of a Resident/Visitor Incident Report dated 3/17/16 at 1:30 PM indicated that Resident #1 had an unwitnessed fall, was noted sitting on the floor beside her bed .sensor alarm in place and on but not sounding. An Interdisciplinary note entered on 3/17/16 by Licensed Practical Nurse (LPN) J indicated the sensor pad was removed from Resident #1's room and given to the restorative coordinator. Resident #11 Review of a facility Profile Face Sheet indicated Resident #11 was a [AGE] year old man admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] indicated Resident #11 had severe cognitive impairment and needed extensive assistance from two people for bed mobility and transfers. Resident #11 was identified as being a high risk for falls. A Safety/Falls care plan dated 3/10/15 indicated (Resident #11) is at risk for falls related to cognitive/functional abilities, weakness, debility, diabetes as evidenced by extensive assistance in transfers, poor safety awareness and little insight in own limitations. Interventions identified on the care plan included Sensor alarm at all times (Bed and Broda). Review of a Resident/Visitor Incident Report dated 2/16/16 at 2:30 PM indicated Resident #11 had an unwitnessed fall in front of his room. The incident report indicated The tab alarm wasn't attached to the resident, it might have detached when he leaned forward. A sensor pad alarm was implemented after the fall on 2/16/16 to replace the tab alarm that malfunctioned. A Resident/Visitor Incident Report dated 2/17/16 at 2:25 PM indicated Resident #11 had another unwitnessed fall in front of his room Alarm not sounding. During an interview on 5/3/16 at 10:20 AM, Director of Nursing (DON) B said that Certified Nursing Assistant's (CNA's) are expected to check placement and functioning of alarms during every shift. DON B and Clinical Care Coordinator (unit manager) RN K said that there was not an investigation into why the sensor pad did not function after Resident #11's fall on 2/17/16. A Post Fall Summary documented after a Clinical Outcomes meeting dated 2/18/16 did not address the non-functioning alarms.

This citation pertains to MI . Based on observation, interview and record review the facility failed to assess an injury of unknown origin and provide the necessary care and services to maintain the highest practicable physical well-being in 1 of 3 sampled residents (Resident #101) reviewed for assessment and treatment of [REDACTED].#101. Findings include: Review of the Face Sheet revealed Resident #101 was a [AGE] year old female admitted to the facility on [DATE]. Review of the undated [DIAGNOSES REDACTED].#101 was diagnosed with [REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated she had severely impaired cognition. In an observation and interview on 12/29/14 at 10:38 a.m., Resident #101 was observed to be in her bed with her eyes closed. Resident #101 did not answer any questions from the surveyor. Review of the Resident/Visitor Incident Report dated 12/13/14 at "7 p.m." revealed Resident #101 had "complained of pain in left shoulder with HS (evening) cares. CNA called this nurse in to look at left shoulder, large yellow bruise noted to area, resident did not want to do full ROM (range of motion), Does not look displaced at all but Tender..." The Incident Report revealed "were any other persons involved? Unknown" and the Incident Report indicated there were no other witnesses to the injury of unknown origin. In an interview on 12/30/14 at 10:30 a.m., Licensed Practical Nurse (LPN) #6 stated she found the bruise to Resident #101's left shoulder on Saturday, December 13th, 2014. LPN #6 stated it was "about 7 to 8 p.m." on 12/13/14, when LPN #6 "saw (a) large bruise to her (Resident #101) left shoulder." LPN #6 stated, "her (Resident #101) arm was bothering her, it (left shoulder) looked yellow (left shoulder bruise)" and a "little swollen." LPN #6 was asked by the surveyor if she reported the incident that evening. LPN #6 stated, "if I had suspected abuse, I would have called (the Director of Nursing), I didn't suspect abuse" and "she's (Resident #101) not a factual historian (indicated Resident #101 could not tell how the injury of unknown origin occurred)." LPN #6 was asked by the surveyor if she contacted Resident #101's doctor regarding the injury. LPN #6 stated, "no" she did not contact the doctor the night the injury was found. LPN #6 stated she put the incident report in the doctors box to sign. Review of the Nurses Notes dated 12/14/14 at 9:16 p.m., revealed "Cena (Certified Nursing Assistant) called this nurse in to residents (Resident #101) room to witness a large yellow bruise on residents shoulder. Resident states she fell off a bike earlier in the week. Does appear tender and does not want to do ROM (range of motion)" authored by LPN #6. In an interview on 12/30/14 at 1:15 p.m., Clinical Care Coordinator (CCC) #4 stated she "first found out (became aware of the injury of unknown origin to Resident #101's left shoulder) on the 17th (12/17/14, indicated 4 days had passed since LPN #6 was notified of the injury). CCC #4 stated the nurse "should have notified me especially because of the pain and range of motion" to Resident #101's left shoulder. Review of the Facility Incident Report dated 12/17/14 (un-timed) and submitted to the State Agency on 12/18/14 revealed "December 13, 2014" Resident #101 "complained of left shoulder pain during her HS (evening) cares." LPN #6 "went to do an assessment and found a yellow bruise, 3.5 centimeters by 4 centimeters on her (Resident #101) distal clavicle (left upper chest). The area was tender touched. (Resident#101) didn't want to do full range of motion on either arm...When asked if she knew what happened Resident #101 stated she fell off a bike last week. Review of the Radiology Report dated 12/18/14 at 12:40 p.m., revealed Resident #101's x-ray results were "a fracture (broken bone) involving the distal clavicle (bone which connects shoulder to rib cage) with minimal displacement" and "Conclusion: Acute (sudden onset) appearing distal clavicle fracture." Review of the Physical Therapy Plan of Care dated 12/19/14 (un-timed) revealed a physical therapy assessment of Resident #101. The Physical Therapy Plan of Care revealed "Range of Motion, LUE (left upper extremity) completes up to 75% of normal range (indicated a 25% decrease in range of motion in left upper extremity)." ( )

This citation pertains to intake numbers MI 434 and MI 446 Based on interview and record review, the facility failed to adequately supervise and prevent the removal from the facility of one resident (Resident #1) who was escorted out of the building by unknown individuals in 1 of 3 residents reviewed for safety, from a total of 3 sampled residents and 3 extended sample residents, resulting in Resident #1 being escorted out of the facility by unknown individuals, without a physician's orders [REDACTED].#1's Guardian and unbeknownst to facility staff. This deficient practice placed all residents at the facility at risk for serious harm, injury, and/or death. The immediate jeopardy began at approximately 6:30 PM on 9/27/14 when, according to the the "Resident Incident Report" Resident #1 was escorted off the premises with 3 unknown visitors (unsupervised by facility staff) for a period of over 3 hours. On 10/21/14 at 4:56 PM the Nursing Home Administrator (NHA) was notified of Immediate Jeopardy that began on 9/27/14 at approximately 6:30 PM, and identified on 10/20/14, due to the facility's failure to adequately supervise Resident #1 and prevent the unauthorized removal and placed all residents at the facility at risk for the potential for unauthorized leave of absences. A request for a written plan of removal was requested at that time. On 10/24/14 at 4:20 PM, the Immediate Jeopardy was removed when the surveyors verified the following: To prevent reoccurrence: 1. Order was received 10/22/14 6:45 PM indicating Leave of Absence (LOA) approval will be made pending interventions/steps are in place to meet resident ' s functional, cognitive, psychosocial needs are being met while on LOA. Resident may leave with Guardian and/or Guardian appointed visitors. 2. Rounding for physical location of Resident #1 has been placed on Resident #1 ' s Treatment Administration Record (TAR) on 10/22/14 and will continue to be completed hourly by charge nurse / designee. 3. On 10/21/2014 the policies titled, " Resident Safety and Well-Being Rounds " and " Accounting for Resident Leaving the Keller Center " were reviewed and revised. 4. All staff will be educated on the policies titled, " Resident Safety and Well-Being Rounds " , and " Accounting for Resident Leaving the Keller Center " . This education was began on 10/21/2014 and continues thru the present time. 5. On 10/22/2014 the Guardian of Resident #1 was provided education/reminder to utilize the Resident sign out/in book when taking Resident #1 to other areas within the Clark Community. This process helps nursing staff ensure knowledge of Resident #1 ' s location. 6. All staff (nursing, activities, therapy, dining, housekeeping, maintenance) will be educated by the DON/Administrator/Designee regarding the process, purpose and requirements of the Resident Sign Out/In Books and the location of these books. This education was began on 10/21/2014 and continues thru the present time. 7. All staff (nursing, activities, therapy, dining, housekeeping, maintenance) will be educated by the DON/Administrator/Designee regarding the specific details with regard to Resident #1 ' s ability to leave the facility and with whom. This education will also include a picture of Resident # 1 and a summary of the descriptions of the visitors who removed Resident #1 from the facility on 9/27/2014. This information will be placed in Resident #1 ' s medical record and in Medication Administration Record book. This education was began on 10/21/2014 and continues thru the present time. 8. On 10/22/2014 the Resident Sign Out/In Book were validated by Clinical Care Coordinators to be in the designated location at each nursing station in the facility. 9. All staff (nursing, activities, therapy, dining, housekeeping, maintenance) will be educated by the DON/Administrator/Designee to be aware of any suspicious individuals/visitors and to notify the charge nurse of the specific resident to whom the visitors are present for. Further education was provided in regard to asking curious questions, involving co-workers, notifying the DON and or Administrator if needed and to provide additional oversight as necessary to provide for resident safety. This education was began on 10/21/2014 and continue thru the present time. 10. All education noted in numbers 4, 6, 7 and 9 above will be completed with all staff prior to staff working his or her next shift. On 10/21/14, 4 of 37 nurses (RNs/LPNs), 9 of 87 CNAs, 1 of 1 Administrator and 1 of 1 Director of Quality were provided education. On 10/22/14, an additional 15 of 37 nurses RNs/LPNs), 28 of 87 CNAs, 1 of 2 Central Supply, 7 of 9 Life Enrichment/Activities, 2 of 3 Pastoral Care, 4 of 28 Dining Services, 2 of 5 Care Coordinators, 1 of 1 Director of Nursing, 16 of 22 Facilities/Maintenance, 2 of 2 Laundry, 10 of 15 Housekeepers, 1 of 4 Receptionists, 1 of 2 Security, 2 of 4 Physical Therapists, 3 of 4 Physical Therapy Assistants, 1 of 4 Occupational Therapists, 2 of 7 Occupational Therapy Assistants, 1 of 1 Speech Therapist were provided education. All staff on any type of leave and unable to receive the education will be sent a certified letter containing the specific education as identified above and a sign off sheet will be enclosed indicating that he or she has completed the enclosed education. This completed sheet will be required to be returned to the facility prior to him or her being placed back on the facility work schedule. Education will be completed by October 31, 2014. Any new employees will receive education prior to being scheduled to work at the facility. Administrator is responsible for overall compliance. All residents residing within Skilled Nursing Facility are at risk for this alleged deficient practice. To prevent occurrence: 1. All current skilled nursing residents and any future skilled nursing residents will be evaluated to determine if he or she is at risk of an inappropriate Leave of Absence (LOA). On 10/22/14, the DON/Administrator/Designee had identified any residents having had a LOA from September 1, 2014 to current. These identified residents will have the following considered, was the LOA appropriate to the residents functional and cognitive abilities, if someone was with the resident during the LOA who was the person and is the person appropriate to be on a LOA with the resident, did the LOA place the resident at risk of any form of injury or harm. Any residents identified at risk will be further assessed for interventions including physicians order indicating restrictions to LOA. If guardians or other legal representatives are in place these individuals will be consulted in developing an appropriate plan for resident. These evaluations and assessments began on 10/22/2014 and continues through the present. These evaluations, assessments and needed intervention will be completed by October 31, 2014. 2. On 10/23/2014, the form titled " Consent for Leave of Absence " began to be completed for all skilled nursing residents. Forms for all skilled nursing residents will be completed by 10/31/2014. Any new skilled nursing residents will have form completed upon admission. 3. On 10/21/2014 the policies titled, " Resident Safety and Well-Being Rounds " and " Accounting for Resident Leaving the Keller Center " were reviewed and revised. 4. All staff will be educated on the policies titled, " Resident Safety and Well-Being Rounds " , and " Accounting for Resident Leaving the Keller Center " . This education was began on 10/21/2014 and continues thru the present time. 5. All staff (nursing, activities, therapy, dining, housekeeping, maintenance) will be educated by the DON/Administrator/Designee regarding the process, purpose, requirements of the Resident Sign Out/In Books and the location of these books. This education was began on 10/21/2014 and continues thru the present time. 6. On 10/22/2014 the Resident Sign Out/ In Books were validated by Clinical Care Coordinators to be in their designated locations in the facility. 7. On 10/22/2014 signs were placed throughout the facility at exit locations reminding resident, families, visitors and staff to notify the charge nurse of any resident leaving the facility. It also stated to sign the resident out and back in utilizing the resident sign out/in book at the nurses ' stations. These signs will be altered to enhance their visibility, i.e., using colored paper and or colored ink. The signs were updated and displayed on 10/22/2014. 8. All staff (nursing, activities, therapy, dining, housekeeping, maintenance) will be educated by the DON/Administrator/Designee to be aware of any suspicious individuals/visitors and to notify the charge nurse of the specific resident to whom the visitors are present for. Further education was provided in regard to asking curious questions, involving co-workers, notifying the DON and or Administrator if needed and to provide additional oversight as necessary to provide for resident safety. This education was began on 10/21/2014 and continue thru the present time. 9. All education noted in numbers 4,5, and 8 above will be completed with all staff prior to staff working his or her next shift. On 10/21/14, 4 of 37 nurses (RNs/LPNs), 9 of 87 CNAs, 1 of 1 Administrator and 1 of 1 Director of Quality were provided education. On 10/22/14, an additional 15 of 37 nurses (RNs/LPNs), 28 of 87 CNAs, 1 of 2 Central Supply, 7 of 9 Life Enrichment/Activities, 2 of 3 Pastoral Care, 4 of 28 Dining Services, 2 of 5 Care Coordinators, 1 of 1 Director of Nursing, 16 of 22 Facilities/Maintenance, 2 of 2 Laundry, 10 of 15 Housekeepers, 1 of 4 Receptionists, 1 of 2 Security, 2 of 4 Physical Therapists, 3 of 4 Physical Therapy Assistants, 1 of 4 Occupational Therapists, 2 of 7 Occupational Therapy Assistants, 1 of 1 Speech Therapist were provided education. All staff on any type of leave and unable to receive the education will be sent a certified letter containing the specific education as identified above and a sign off sheet will be enclosed indicating that he or she has completed the enclosed education. This completed sheet will be required to be returned to the facility prior to him or her being placed back on the facility work schedule. Education will be completed by October 31, 2014. Any new employees will receive education prior to being scheduled to work at the facility. 10. All skilled nursing residents (if resident is own responsible party) and/or Guardians / DPOAs / Legal Representatives will be provided education in person or by certified mail regarding the contents of the policy titled " Accounting for Resident Leaving the Keller Center " . Copies of the policy will be available if desired by the residents or Guardians / DPOAs / Legal Representatives. Education will be completed by October 31, 2014. All new skilled nursing residents (if resident is own responsible party) or Guardians / DPOAs / Legal Representatives will be provided education upon admission and if desired a copy of the policy will be provided. Administrator is responsible for overall compliance. Although the Immediate Jeopardy was removed on 10/24/14, the facility remained out of compliance with a scope and severity of isolated no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to all staff had not received the inservice education preventing unauthorized leave of absences and reporting and sustained compliance had not been verified by the State Agency. Findings include: Review of the policy/procedure for "Accounting for Resident Leaving ...Premises" dated 2/01/13 reflected, Charge Nurse's/CENA's (Certified Nursing Assistants) are responsible for knowing where their residents are at all times (Beauty Shop, Mini-Mart, Chatterbox, Chapel, etc.) ...In case of any type of emergency (i.e., fire tornado), staff is responsible for accounting for their residents and bringing them to safety ...Staff observing a resident leaving the premises, and having doubts about the resident being properly signed out, should notify their supervisor at once." Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], revealed that Resident #1 was an [AGE] year-old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #1's Brief Interview for Mental Status (BIMS) revealed a score of less than zero and reflected that Resident #1 had short/long term memory problems and was "severely impaired..." Resident #1 was on a special pureed diet, required a mechanical lift and 2-staff assistance for transfers and was incontinent of bowel and bladder. A review of the September 2014 (accumulative) Physician order [REDACTED].#1. In an interview on 10/20/14 at 10:00 AM, Certified Nurse Assistant (CNA) "A" stated that on 9/27/14 at approximately 5:00 PM., she changed Resident #1's brief prior to seating her for dinner. CNA "A" stated she last saw Resident #1 at 6:30 PM in the company of three unknown visitors (two women and one male) in the dining room. CNA "A" determined that Resident #1 was missing at approximately 8:15 PM, after a conversation with Resident #1's legal guardian in the facility parking lot. CNA "A" stated Resident #1 was not signed out in the leave of absence book and, at the time, did not know Resident #1's whereabouts. According to Resident #1's care plan she requires assistance to change position every hour while awake and total assistance to check/change incontinence brief every 2 hours. When asked if the care plan interventions of changing position and brief were carried out between 5:00 PM and 8:15 PM (approximately 3 hours), CNA "A" stated, "No, I lost track of time." In an interview on 10/17/14 at 12:00 PM, Receptionist "B" stated that she last saw Resident #1 exit the building with three visitors at approximately 6:30 PM on 9/27/14. In an interview on 10/17/14 at 2:08 PM, Resident #1's Guardian stated that she arrived at the facility parking at approximately 8:15 PM (on 9/27/14) and was met by CNA "A" as she exited her vehicle. Resident #1's Guardian stated that she was informed by CNA "A" that Resident #1 had left the grounds of the facility with Resident #1's family. Resident #1's Guardian and CNA "A" entered the front entrance and found Resident #1's empty wheelchair. When Resident #1 was not located they checked the leave of absence book and found no record of Resident #1 being signed out. Resident #1 ' s Guardian contacted the family members to determine who may have taken Resident #1 from the facility and when it was determined it was not family, " I called the police. " After a period of time Resident #1 ' s Guardian determined with the staffs input that it may have been an old coworker of Resident #1 ' s. Resident #1's Guardian stated, " I lost it because I knew that woman was crazy." Resident #1's Guardian stated that Resident #1 had not seen the woman in 20-[AGE] years. Resident #1's Guardian stated that Resident #1 was returned to the facility at approximately 9:40 PM (approximately 3 hours later) in the company of two females and one male (in a car). Resident #1's Guardian stated that she was so upset with the woman that took Resident #1 that she screamed and pounded on the car window at the woman. Resident #1's Guardian stated, "I just want to know that when I leave (the facility) that she (Resident #1) will be safe here." Resident #1's Guardian stated that she requested that Resident #1 be sent to the hospital to have blood work and be evaluated for sexual abuse. Review of the police report dated 9/27/14 at 9:30 PM reflected that an officer was sent to the home of the women (who removed Resident #1 from the facility) to check on Resident #1's welfare. The report reflected, "I (the officer) arrived on scene and found the lights on but no apparent activity inside. From the front window I could see there was syringes and other medication on the dining room table...found the rear door was open and entered the house to check the welfare of the residents. We cleared the home and found that the residents were not home." As this was done the officer was notified that Resident #1 was returned to the facility. In an interview on 10/17/14 at 12:25 PM, Licensed Practical Nurse (LPN) "F" stated that family are supposed notify the facility and are to sign out residents in the leave of absence book but, "some families don't." (# )

Intake # MI 112 A facility reported incident received online on [DATE], and reported that on [DATE] resident #2 fell and sustained injuries that resulted in the the facility sending the resident to the hospital for further evaluation and treatment. On [DATE] an unannounced, onsite investigation was conducted. Findings include: Based on interview and record review the facility failed to follow their policy to provide adequate supervision and failed to provide functioning safety devices to prevent an avoidable fall for resident #2, on [DATE], that resulted in multiple injuries, including a spinal cervical 2 unstable fracture, facial fractures, and facial lacerations, consequently resident #2 died of complications from the above injuries. A review the facility's face sheet printed on [DATE] for resident #2 reflected that resident #2 was a [AGE] year old female admitted to the facility on [DATE] after hospitalization for a fall at home that resulted in a right hip fracture, other listed [DIAGNOSES REDACTED]. A review of resident #2's closed medical record reflected the following: An admission nursing assessment was completed by a nurse at the facility and reflected that resident #2 was disorientated and had increased nighttime confusion. The admission minimum data set (MDS) (assessment and care screening tool) was completed by the facility for resident #2 on [DATE]. It reflected in the cognitive pattens section that brief interview for mental status (BIMS) was done and resident #2 scored a 1 out of 15, meaning that the resident had severe cognitive impairment. A care assessment (CAA) worksheet generated from the comprehensive assessment reflected that resident #2 was at risk for falls because she fell and fractured her hip prior to admission, she had severe cognitive impairment, and had poor balance with transfers. A care plan titled "Safety" that was developed from the assessment data of the (MDS) reflected the following: "The problem listed was that resident had fallen and was at risk for falls related to fall history, dementia, recent surgery for [REDACTED]. The goal was resident #2 will be free of injuries related to falls. The interventions included were do not leave alone in the bathroom, clutter free environment. Keep frequently used items within reach, a low bed with mats, tab alarm and sensor alarm in chair and bed. A review of the facility's incident reports for resident #2 reflected that on [DATE] at 2:35 PM resident #2 was found sitting on the floor at the foot of her bed and the tab alarm did not sound. Resident #2 sustained a skin tear on left shin. A review of the resident #2's Xray reports reflected that on [DATE] an Xray was done of the lumbar spine and the reason ordered as status [REDACTED]. On [DATE] at 9:40 AM, during an interview with the facility's director of nursing this writer asked about the two Xray's that listed the reason ordered was status [REDACTED]. The (DON) was then asked how many falls resident #2 had since admission to the facility and the (DON) replied stating "Just the two that I gave you the incident reports for". This writer then asked to see the facility's policy for safety alarms and was provided a document that was titled "Safety" and per the administrator is a screen shot of the charting that is completed by the (CNA's), and reflected that safety rounds were to be done at change of shift and every two hours. There was a box with an arrow pointing to another box, that was highlighted in yellow that reflected "This is where the CENA marks that she has done the above". On [DATE] at 3:35 PM during a telephone interview with certified nursing assistant (CNA) staff "A" this writer asked staff "A" can you tell me what you remember about the fall resident #2 had on [DATE] at 2:40 AM, and staff "A" responded by stating " I wrote down the number of times I took her to the bathroom it was six times". This writer then asked staff "A" can you tell me when resident #2 was last toileted prior to the fall and staff "A" responded by stating "It was by the other aid about 15 minutes before the fall". This writer then asked staff "A" when you first came into the room where resident #2's alarms sounding, and staff "A" responded stating "The tab alarm was not attached and the sensor pad box was turned on but it was not sounding. The nurse messed with it after and got it to work again". Staff "A" was asked if she had worked with resident #2 before and if resident #2 had unattached her alarm before. Staff "A" responded stating "yes several times that is my regular neighborhood. I haven't personally ever had her do it when I was working but I was told she had done it once before". This writer then asked staff "A" how often do you check the sensor and tab alarms for placement and function and staff "A" responded stating "at the beginning and end of my shift". On [DATE] at 3:52 PM a voice message was left for Registered nurse staff "K" at the time of exit on [DATE] staff "K" did not return the call. On [DATE] at 8:30 AM certified nursing assistant staff "B" returned this writes call. During the telephone interview this writer asked staff "B" about the details that she remembered of the fall that resident #2 had on [DATE] at 2:40 AM, staff "B" responded by stating "It was a crazy night". This writer then asked staff "B" if she was the last person that toileted resident #2 and she responded stating "Yes I probably was it was a crazy night". This writer then asked staff "B" if it were possible that she forgot to reattached the tab alarm to resident #2. Staff "B" responded by stating "It's possible I was new and so I probably did forget". On [DATE] at 8:50 AM during a telephone interview with resident #2's family member and durable power of attorney (DPOA) this writer asked how resident #2 was doing since the fall and the (DPOA) responded stating "She is dead she died on [DATE] because of the injuries she sustained during the fall at the nursing home". This writer then asked for details of injuries that resident #2 sustained from the fall. The family member responded stating "She had a broken neck at C1 that the doctors called a hangman's fracture and said it was inoperable, a broken nose, stiches in two cuts one on her nose and one above her right eyebrow, and her whole face was bruised. We had her go to another facility with hospice care after the hospital". A review of the hospital records reflected the following: On [DATE] a CAT scan of the head was done to rule out a bleed after a fall. The CAT scan reflected that resident #2 had two injuries. 1. an inoperable Type 2 unstable displaced C1 (cervical) fracture posteriorly impinging on the spinal cord cutting off blood supply to the brain. 2. bilateral nasal bone fracture.

This citation pertains to MI 416. Based on observation, interview, and record review, the facility failed to provide adequate assistive devices and supervision to 1 of 3 sampled residents (Resident #104) reviewed for safe use of hot beverages, from a total of 3 sampled resident, resulting in second degree burns for Resident #104. Findings include: "Second-degree (partial thickness) burns affect both the outer and underlying layer of skin. They cause pain, redness, swelling, and blistering...". (http://www.nlm.nih.gov/medlineplus/ency/article/ 0.htm) "The severity of a scald injury depends on the temperature to which the skin is exposed and how long it is exposed. The most common regulatory standard for the maximum temperature of water delivered by residential water heaters to the tap is 120 degrees Fahrenheit/48 degrees Celsius. At this temperature, the skin of adults requires an average of five minutes of exposure for a full thickness burn to occur. When the temperature of a hot liquid is increased to 140o (degrees) F/60o C it takes only five seconds or less for a serious burn to occur. Coffee, tea, hot chocolate and other hot beverages are usually served at 160 to 180o F (Fahrenheit) /71-82o C (Celsius), resulting in almost instantaneous burns that will require surgery... immediate removal of the hot liquid from the skin may lessen severity...Older adults, like young children, have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults. Older adults may also have conditions that make them more prone...while carrying hot liquids." (http://www.ameriburn.org/Preven/ScaldInjuryEducator'sGuide.pdf) According to the Facility Investigation Report - 5 Working Days, dated 11/12/12, "Date of Incident - (11/06/12) 9:00 AM, (nurse aide #6) assisted Resident #104...About 9:30 (AM), (nurse aide #6) went to the pantry to get (Resident #104's) hot water to be used to make her coffee...prepared a large Styrofoam cup by filling it about half-way with hot water...came to (Resident #104's) room about 9:50 AM. (Nurse aide #6) added (instant coffee) to the hot water and stirred it up, put on the lid and straw. (Resident #104) requested to have the coffee in her room while she watched TV. (Resident #104) was in her wheelchair. The over the bed tray table was in front of her. (Nurse aide #6) put (Resident #104's) clothing protector around her neck and one on her lap...10:15 AM, (nurse aide #7)...heard yelling and a call for help...(Resident #104) had spilled the coffee. (Nurse aide #7) called (RN/Registered Nurse #8) charge nurse to come and help. (RN #8) started soaking towels with cold water and putting them on the wet areas of (Resident #104's) clothing. (RN #8) and (nurse aide #7) began to undress (Resident #104's) upper and lower body and apply wet, cold water towels to (Resident #104's) left arm/hand and left lower abdomen/thigh area...(Resident #104 was assisted to bed...Some red areas where noted on her left arm, abdomen roll, and hip/thigh area. The reddened areas cleared. 11/07/12 - a fluid filled blister on her abdomen measured 1 cm x 2 cm. Her hand/base of thumb had an open blister measuring 1/5 cm x 2.5 cm. The underside of her left arm had a 4 cm x 2 cm blistered area with no fluid..." Per Resident #104's Treatment Records, the skin wounds Resident #104 sustained on 11/06/12 were treated daily per doctor's orders with medications and dressings until "healed" on 12/04/12. In an interview, on 01/07/13 at 8:45 AM, DON/Director of Nursing #1 reported that Resident #104 had "judgement factors", "a pattern of noncompliance", "an old stroke", and a "UTI (urinary tract infection)" that contributed to the burn received from hot liquid on 11/06/12. According to DON #1, the facility did not have a Policy and Procedure that addressed serving hot liquids and treating hot liquid spills prior to 11/14/12. When asked at what temperature the facility decided that hot liquids should be served at, DON #1 stated, "130 degrees (Fahrenheit), I think." In an interview and observation on 01/07/13 at 11:28 AM, Resident #104 was observed sitting at a table, wearing sun glasses, in the dining room. Resident #104 had a travel mug, with a lid on it, sitting next to a plate of food. When Surveyor asked Resident #104 about the temperature of the liquid inside of the mug, Resident #104 said, "It's all gone. I drank it all." Review of Resident #104's Care Plans, in place on 11/06/12, revealed Resident #104 had the following problems: 1. (Resident #104) is at risk for confusion and disorientation due to depressive symptoms and anxiety. (Start Date: 6/16/12) and 2. Self-Care Deficit related to Hx (history) CVA (stroke) with left sided [DIAGNOSES REDACTED] (loss of movement/sensation), muscle weakness...(Start Date: 10/15/12)...(Resident #104) prefers to eat in room but encourage her to go out to dining table to eat. She likes hot water with meals for her coffee mix in her room. She must wear bib/clothing protector with every meal and when she drinks her coffee. (Start Date: 10/15/12)." In an interview on 01/07/13 at 9:31 AM, Clinical Nutrition Coordinator #9 reported she was, "not sure what temperature they (facility) decided on to serve coffee at," and said, "We asked (the store where the coffee machines were purchased) if the machines we have could be adjusted (temperature lowered); they can't be adjusted...Yes, there are machines that can be purchased that can be adjusted but we are still using the same machines." In an interview on 01/07/13 at 9:55 AM, Food Services Director #5 reported the facility, "had not looked at the issue (serving temperature of hot liquids) before (11/06/12)...I don't know who determined the appropriate temperature." This surveyor reviewed hot liquid temperature logs with Food Services Director #5. The logs revealed that, since 11/06//12, the temperature of the coffee and water at the 5 hot beverage stations in the facility was often either not recorded on at least one shift (examples: 12/02/12, 12/03/12, 12/31/12, 1/03/13, 01/04/13), or was often recorded as high as 200 degrees on at least one shift (examples: 12/02/12, 12/03/12, 12/04/12, 12/05/12, 12/06/12, 12/07/12, 12/08/12, 12/18/12, 12/30/12, 12/31/12, 01/01/13, 01/03/13, 01/05/13). Food Services Director #5 confirmed that there was no documentation to show that the temperatures of the hot liquids were reduced before serving the beverages to the residents. When asked how the temperature logs were being used, Food Services Director #5 reported that the logs were supposed to be monitored by the Dietary Supervisor to ensure safe beverage temperatures. On 01/07/13 at 11:15 AM, in the presence of Dietary Supervisor #4, the temperature of hot liquids were checked. The temperature of the hot liquid spigot on the unit where Resident #104 resided was 184 degrees. In an interview, on 01/07/13 at 1:32 PM, RN/Registered Nurse #8 identified herself as the charge nurse assigned to Resident #104 on 11/06/12 at 10:15, and stated she did the initial assessment of Resident #104's skin condition after the hot liquid spill. RN #8 revealed she did not record the size of the "red areas" she found on Resident #104's left arm, hand, abdomen, and thigh. RN #8 stated, "You could tell she spilled the hot water; her clothing was wet and her arm was red. (Resident #104) yelled, I'm burned, I'm burned!...Not cooperating with questioning." RN #8 reported, "I don't know how to measure the temperature of water." RN #8 also stated, "As soon as (nurse aide #6) gave it (the hot liquid) to her (Resident #104), she (nurse aide #6) went to break." In an interview, on 01/07/13 at 1:55 PM, nurse aide #7 identified herself as the first staff person to respond to Resident #104's calls for help on 11/06/12. Nurse aide #7 stated, "I wasn't assigned (to Resident #104); I was working around the corner. I heard someone saying 'Help me, I'm burning'. I went into (Resident #104's) room and saw her hot chocolate on the floor; she was wet. I two-way ' d (walkie-talkie) to call (RN #8)." Nurse aide #7 reported that Resident #104 was wearing a long sleeved shirt at the time of the incident and that she and RN #8 applied wet towels over Resident #104's shirt after she RN #8 entered Resident #104's room. In a telephone interview, on 01/07/13 at 2:47 PM, nurse aide #6 identified herself as the nurse aide who, "got (Resident #104) her hot water. I got hot water from the spout thing (hot water spigot), you pull lever and hot water comes out. I put it in a Styrofoam cup and put a lid on it. I brought it to (Resident #104) right before I went on break. There were 2 clothing protectors on her. I always put on 2 because she's spilled before." Nurse aide #6 reported she had not had not had training from the facility, prior to the event with Resident #104 on 11/06/12, as to how to prevent a resident from sustaining a hot liquid spill. When asked what she would do if a resident spilled a hot liquid onto themselves, nurse aide #6 responded, "Contact the nurse immediately, take their clothes off, have the nurse assess." In an interview, on 01/07/13 at 3:30 PM, OT/Occupational Therapist and Director of Therapy #10 reported that Resident #104 had originally been admitted to the facility in June, 2012, and that an assessment was conducted by the Occupational Therapy Department at that time because Resident #104 had left body weakness due to a stroke. OT #10 stated, "The hot liquid assessment is part of a typical feeding assessment." While looking at Resident #104's 6/12 Occupational Therapy notes, OT #10 stated, "She (Resident #104) needed at least moderate assistance and to be generally observed to be safe with everything. She (Resident #104's) stroke left her with distractibility and impulsiveness. Someone with distractibility and impulsiveness would be at risk with hot liquids. No, we did not recommend 'at risk with hot liquids', even though we saw some safety issues." OT #10 stated, "We (Occupational Therapy) can do a screen without a doctors order if we are notified there is a concern." In an interview, on 01/07/12, DON #1 reported that since Resident #104 sustained burns on 11/06/12, newly devised hot liquid assessment forms revealed that 51 out of the total 99 facility residents were at risk for injury with hot liquids. ( )

This citation pertains to intake MI 477 Based on observation, interview, and record review the facility failed to provide supervision and maintain the safety of 1 (Resident #102) of 3 residents out of a total sample of 3 residents, when a Nurse Aide (CNA #3) failed to activate a safety alarm for Resident #102 who got up from his wheelchair unassisted and fell resulting in a hip fracture. Findings: Per a facility "Profile Face Sheet" dated 2/3/12 Resident #102 was a [AGE] year old man admitted to the facility on [DATE]. A Minimum Data Set ((MDS) dated [DATE] revealed Resident #102 was diagnosed with [REDACTED]. Per a "Safety Cognition ADL Tool" (SCAT) dated 2/2/12, Resident #102 was assessed to be a high risk for falls, repeated falls;requires alarms for safety...including falls requiring emergency room and/or hospitalization and to have a lack of awareness, which puts self and/or others at risk for harm or injury...due to cognitive status, Resident #102 would forget to use walker, due to vision issues (Resident #102) will trip or fall over things. Per a "Care Plan", dated 2/03/12, Resident #102 was at risk for falls related to left total hip replacement and hip fracture (a fracture sustained prior to admission to the facility). Additional risk factors include Parkinson's, cerebral vascular disease, depression and anxiety, osteoporosis, unsteady gait, dementia, and macular degeneration. Interventions included: weight sensitive alarm in wheelchair seat or lounge chair and in bed. Per a facility "Incident Report", dated 4/15/12, Resident #102 had been restless and personal safety alarms had been sounding each time Resident #102 attempted to self ambulate/transfer. CNA #3 assisted Resident #102 to the bathroom at 2:30 PM on 4/15/12, took him via wheelchair to another unit for a snack, returned to Resident #102's unit, positioning Resident #102 at a table with his snack. CNA #3 turned and stepped away from Resident #102 to chart at a computer mounted on a nearby wall. CNA #3 heard a 'thud' and turned to find Resident #102 lying on the floor on his left side. RN #4 responded first, followed by RN #5. No alarms were sounding and upon examination, it was determined CNA #3 had forgotten to turn them on after assisting Resident #102 to the bathroom at 2:30 PM. The conclusion reached by the facility investigation into the incident was "It was an unintended omission of not turning on the alarms that resulted in an accident." Per a "Nurse Progress Note" dated 4/15/12 at 5:00 PM, written by RN #5, Resident #102 "...found on floor. Nurse Aide (CNA) called nurse...resident found laying on left side, alarms (sensor/tab) both noted to be on wheelchair but not alarming nor turned on. Resident (#102) was complaining of severe pain to left hip...transferred to hospital..." Per a "Nurse Progress Note" dated 4/20/12, resident #102 had surgery on his left femur. During an interview on 4/23/12 at 2:00 PM, RN #5 recalled the incident described in the facility report and confirmed she was the RN who assessed Resident #102 after his fall on 4/15/12, stating she knew right away Resident #102 had refractured his left hip. RN #5 reported Resident #102 had a history of [REDACTED].#102's wheelchair at the time of the fall. During an interview on 4/23/2012 at 2:15 PM, RN #4 confirmed she was the first nurse to respond to CNA #3 calling for help when Resident #102 fell on [DATE] and reported no alarms were sounding. RN #4 also reported Resident #102's cognitive status had deteriorated notably since the fall and surgical repair, stating "(Resident #102) was much clearer before the accident". Per a facility "Personnel/Payroll Request", dated 4/16/2012, CNA #3 was "discharged for misconduct and negligence-failure to put fall alarm on (Resident #102) resulting in resident harm." Per a "Nursing Assessment", dated 4/21/12, Resident #102 required extensive assistance with position changes, transfers and ambulation and could not bear any weight on his left lower extremity. Resident #102 was noted to have 65 staples in his left hip and bruising. Resident #102 was observed on 4/23/12 at 1:00 PM seated in a recliner chair in his room, a pressure alarm in place and active with a call light in reach. An attempt to interview the resident about the fall which caused the fracture were unsuccessful due to Resident #102's cognitive status. When asked about the fall, Resident #102 had no recall of the event.

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO MONITOR AND PROVIDE NECESSARY DENTAL SERVICE BASED ON ORAL ASSESSMENT FOR 1 SAMPLED RESIDENT (#6), FAILED TO MANAGE PAIN FOR 1 OF 14 RESIDENTS IDENTIFIED WITH PAIN (#7), AND FAILED TO COORDINATE HOSPICE SERVICE FOR 1 OF 5 RESIDENTS WITH HOSPICE (#4), FROM A TOTAL SAMPLE OF 20 RESIDENTS, RESULTING IN UNRESOLVED PHYSICAL AND MENTAL ANGUISH FOR RESIDENT #6, UNRELIEVED PAIN FOR RESIDENT #7, AND A LACK OF HOSPICE CARE COORDINATION FOR RESIDENT #4. FINDINGS INCLUDE: RESIDENT #6 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. SHE ALSO HAD A [MEDICAL CONDITION] FOR EVACUATION OF HER BOWELS. THE COMMUNICATION CARE PLAN DATED 3/2/10 REFLECTED THAT THE RESIDENT HAD; SOME DIFFICULTY WITH WORD FINDING AND THOUGHT PROCESSING, SHE COULD BE HARD OF HEARING IN NOISY SETTINGS, SHE REFUSED TO WEAR HEARING AIDES AND MAY BECOME IRRITATED AND COMBATIVE IF SHE FELT RUSHED OR MISUNDERSTOOD. THE RESIDENT WAS TO HAVE FAMILIAR STAFF PRESENT WHEN AUXILIARY STAFF NEEDED TO SPEAK WITH HER AND PHYSICAL TOUCHING OF THE RESIDENT WAS TO BE KEPT TO A MINIMUM DURING CONVERSATION. ON 3/8/11 AT 1:00 P.M. THE RESIDENT WAS OBSERVED SITTING IN HER WHEEL CHAIR IN HER ROOM. THE RESIDENT DID NOT SPEAK WHEN GREETED AND ACTED AS IF SHE DID NOT HEAR THE GREETINGS. THE RESIDENT HAD HER LEFT HAND INSIDE HER MOUTH WITH A WASH CLOTH AS IF SHE WAS TRYING TO CLEAN HER TEETH. ON THE FOLLOWING DAY 3/9/11 AT 9:15 A.M., THE RESIDENT WAS OBSERVED LYING IN BED, HOLDING HER LEFT UPPER TEETH WITH THE WASH CLOTH AND ATTEMPTING TO WIGGLE DOWN THE 4-5 LEFT UPPER TEETH THAT WERE LOOSE AND FLOPPING UP AND DOWN. THE RESIDENT LOOKED VERY AGITATED, UPSET AND YELLED AT THIS SURVEYOR TO SIT DOWN ON HER BED NEXT TO HER. WHILE THE RESIDENT WAS YELLING AND BEING AGITATED AND UNABLE TO EXPLAIN WHAT THE PROBLEM WAS, THE HOSPICE AIDE (STAFF "T"), WHO HAD ALREADY BEEN IN THE ROOM TO PREPARE TO GIVE HER A BATH, CAME BACK INTO THE ROOM. STAFF "T" STATED THAT SHE COULD NOT FIGURE OUT WHY THE RESIDENT WAS BEHAVING WITH SO MUCH FRUSTRATION AND ANXIETY. THE HOSPICE AIDE "T" STATED THAT THE RESIDENT MAY BE HAVING PAIN AND ASKED THIS SURVEYOR TO REMAIN WITH THE RESIDENT WHILE SHE WENT OUT TO REPORT TO THE CHARGE NURSE. AT 10:00 A.M., THE HOSPICE AIDE STATED THAT SHE HAD TO LEAVE AND COULD NOT PROVIDE THE RESIDENT'S A.M. CARE BECAUSE HER ASSIGNED 1 HOUR TIME LIMIT HAD BEEN REACHED. AT 10:15 A.M., THE CHARGE NURSE (STAFF "B") STATED THAT SHE DID NOT COME AND ASSESS THE RESIDENT UNTIL 10:00 A.M., BECAUSE SHE WAS PASSING THE MORNING MEDICATIONS TO OTHER RESIDENTS. ON 3/9/11 AT 1:30 P.M., THE RESIDENT WAS AGAIN OBSERVED SITTING AT THE EDGE OF HER BED WITH BOTH LEGS ON FLOOR FRANTICALLY PUSHING DOWN ON THE NUMBERS ON HER TELEPHONE NEXT TO THE HEAD OF HER BED. THE RESIDENT WAS EXTREMELY AGITATED AND UPSET. SHE WAS YELLING, "I CAN'T TAKE IT! I CAN'T TAKE IT!" THE RESIDENT WAS AGAIN WIGGLING AND PULLING ON HER LEFT UPPER TEETH. HER SPEECH WAS GARBLED AND COULD NOT BE CLEARLY UNDERSTOOD. SHE INDICATED THAT SHE WAS TRYING TO CALL A DENTIST. SHE WAS NEITHER APPROACHABLE NOR CONSOLABLE. THE RESIDENT WAS OBSERVED TO BE AT GREAT RISK OF EITHER FALLING OR INJURING HERSELF IF SHE HAD BEEN ALLOWED TO CONTINUE. THIS SURVEYOR WENT OUT OF THE ROOM, SIGNALED DIETARY STAFF WHO WAS CLEARING TABLES IN THE DINING AREA, AND ASKED HIM TO INFORM ANY NURSING STAFF TO COME AND INTERVENE. A FEW MINUTES LATER, CHARGE NURSE "B" CAME AND STATED THAT THE RESIDENT HAD BEEN SEEN BY AN IN-HOUSE DENTIST LAST FRIDAY, BUT SHE DID NOT KNOW EXACTLY WHETHER ANY FUTURE ARRANGEMENTS HAD BEEN MADE FOR SEEING A DENTIST FOR TREATMENT. AN ORAL assessment dated [DATE] REFLECTED THAT THE RESIDENT HAD SEVERAL TEETH MISSING AND DECAYED. SHE WAS ADVISED TO SEE A DENTIST BUT THE RESIDENT HAD REFUSED. AN ORAL assessment dated [DATE] REFLECTED THAT THE RESIDENT HAD MORE MISSING AND DECAYED TEETH. SHE WAS ADVISED TO SEE A DENTIST BUT THE RESIDENT HAD REFUSED. ON 3/9/11 AT 1:30 P.M., THE UNIT MANAGER (STAFF "A") STATED THE RESIDENT HAD COMPLAINED OF TOOTH PAIN ABOUT A MONTH AGO AND SHE HAD NOTICED THE RESIDENT'S LOOSE TEETH AND STATED THOSE WERE A PERMANENT BRIDGE. SHE ADDED ONE PART OF BRIDGE CAME LOOSE FROM THE MOLAR TO WHICH IT WAS ATTACHED. THE UNIT MANAGER "A" ADDED THAT THE RESIDENT'S DURABLE POWER OF ATTORNEY (DPOA) HAD AGREED FOR THE TREATMENT, BUT HE WAS TRYING TO FIND ANOTHER DENTIST TO REPAIR THE TEETH. THE NOTE BY THE IN-HOUSE DENTIST DATED 3/4/11 STATED, " THE RESIDENT'S BRIDGE FROM #11-15 (INCISORS) IS VERY LOOSE. #11 IS BROKEN OFF, #15 IS ONLY TOOTH HOLDING BRIDGE ON. NEED X-RAY TO SEE IF #15 IS OK TO EXTRACT. " AN INCIDENT REPORT DATED 1/11/11 REFLECTED THAT THE RESIDENT HAD A FALL IN FRONT OF HER WARD ROBE CLOSET IN HER ROOM, SUSTAINING SKIN TEARS ON HER LEFT ELBOW AND RIGHT HAND AND BLEEDING FROM HER HEAD. THE REPORT ALSO INCLUDED THAT SHE WAS LOOKING FOR THE PHONE NUMBER FOR THE DENTIST. ON 3/10/11 AT 3:00 P.M., UNIT MANAGER "A" WAS ASKED WHETHER THE HOSPITAL HAD LOOKED AT THE RESIDENT'S TEETH OR NOT WHEN SHE WAS SENT TO THE HOSPITAL RELATED TO THE INCIDENT INVOLVING HER DENTAL ISSUES. THE UNIT MANAGER CLAIMED THAT SHE HAD INCLUDED INFORMATION IN THE TRANSFER FORM. HOWEVER, THE EMERGENCY CARE REPORT DATED 1/11/11 STATED, " ...APPARENTLY SHE fell ...SHE IS AN EXCEPTIONALLY POOR HISTORIAN...THERE IS NO FAMILY OR FRIENDS PRESENT AT BEDSIDE TO PROVIDE INFORMATION...THE PATIENT APPEARS VERY SCARED AND NERVOUS... SHE IS STUTTERING WITH HER WORDS...THE PATIENT DOES NOT HAVE ANY INSIGHT INTO THIS FALL...SHE IS NOT ABLE TO GIVE ANY MODIFYING FACTORS OR ADJECTIVES REGARDING HER FALL... " ON 3/10/11 AT 3:00 P.M., DURING AN INTERVIEW WITH UNIT MANAGER "A", THE RESIDENT WAS DESCRIBED AS A PERSON WITH A STRONG WILL AND COULD NOT BE SWAYED BY ANYONE, INCLUDING ALL STAFF, EVEN THOUGH SHE HAD SIGNIFICANT COGNITIVE IMPAIRMENT AS WELL AS POOR DECISION MAKING SKILLS. UNIT MANAGER "A" ADDED THAT THE FACILITY MADE A DECISION TO RESPECT THE RESIDENT'S WISHES FOR NOT WANTING TO SEE A DENTIST AT THE TIME WHEN HER ORAL EXAMINATION INDICATED THAT SHE NEEDED TO BE SEEN. ON 3/10/11 AT 10:10 A.M., THE NURSING AIDE (STAFF "C") STATED THAT SHE HAD NOTICED THE RESIDENT'S LOOSE TEETH ABOUT A MONTH AGO. DESPITE STAFF (STAFF "A", STAFF "B" AND STAFF "C") KNOWLEDGE REGARDING THE RESIDENT'S DENTAL ISSUES OVER A SPAN OF A MONTH, NO DOCUMENTATION COULD BE FOUND ADDRESSING THE PROBLEM OR IDENTIFYING INTERVENTIONS TO RESOLVE OR MODIFY THE PROBLEM. ( ) ACCORDING TO THE MARCH 2011 physician's orders [REDACTED]. A physician's orders [REDACTED]. CHART, CONDUCTED AT 2:00 P.M. ON 3/8/11, THERE WAS NO WEIGHT LOSS CARE PLAN. THE FACILITY'S DYSPHAGIA CARE PLAN, DATED 12/22/10, DID NOT IDENTIFY WEIGHT LOSS AS A PROBLEM AND DID NOT REFLECT THAT THERE HAD BEEN HOSPICE INTERVENTION. THERE WAS A SEPARATE HOSPICE "TEAM CARE PLAN AS OF 2/28/11" FILED IN THE RESIDENT'S RECORD. THAT CARE PLAN INCLUDED "ASPIRATION RISK" AS A PROBLEM AND DIRECTED "SN" (SKILLED NURSE) TO FEED THE RESIDENT IN SMALL AMOUNTS AND KEEP THE HEAD OF HIS BED ELEVATED AT ALL TIMES. THE FACILITY'S DYSPHAGIA CARE PLAN DID NOT REFLECT THOSE INTERVENTIONS. THE RESIDENT WAS OBSERVED IN THE "BRISTOL" HALL DINING AREA, AT 9:10 A.M. ON 3/9/11, WITH A PLATE OF SCRAMBLE EGGS, MECHANICAL SOFT MEAT AND A MUFFIN PLACED DIRECTLY IN FRONT OF HIM ON A TABLE. THE FOOD WAS UNTOUCHED. TWO OF THE RESIDENT'S BEVERAGES, STILL COVERED BY LIDS, WERE ALSO UNTOUCHED. DURING AN INTERVIEW AT 12:20 P.M. ON 3/10/11, THE "BRISTOL" HALL UNIT MANAGER (NURSE "F") SAID THE RESIDENT WOULD NOT ALLOW STAFF TO ASSIST HIM WITH MEALS. THAT INFORMATION WAS NOT DOCUMENTED IN EITHER THE FACILITY'S CARE PLAN OR THE HOSPICE CARE PLAN. DIETARY MANAGER "P" WAS PRESENT DURING THE SAME INTERVIEW. DIETARY MANAGER "P" WAS UNABLE TO SHOW HOW HOSPICE HAD COORDINATED WITH THE FACILITY IN DEVELOPING A WEIGHT LOSS CARE PLAN FOR RESIDENT #4. WHEN REFERRED TO THE PHYSICIAN'S 2/17/11 ORDER (E.G., THAT HOSPICE EVALUATE THE RESIDENT RELATED TO WEIGHT LOSS), THE DIETARY MANAGER SAID THAT "WEIGHT LOSS" WAS JUST THE admitting [DIAGNOSES REDACTED]. RESIDENT #4 WAS OBSERVED AGAIN AT ANOTHER MEAL ON THE FOLLOWING DAY, AT 11:40 A.M. ON 3/10/11. THE RESIDENT WAS OBSERVED SITTING IN HIS WHEELCHAIR AT ONE OF THE TABLES IN THE "BRISTOL" DINING AREA WITH A "LAP BUDDY" DEVICE SECURED ACROSS THE FRONT OF HIS WHEELCHAIR. AT 11:56 A.M., HE WAS OBSERVED TO PUSH AWAY FROM THE DINNER TABLE WITH HIS FEET AND ATTEMPT TO REMOVE HIS "LAP BUDDY" WITH HIS RIGHT HAND. NURSE AIDE "J" WAS OBSERVED TO CIRCULATE AMONG THE RESIDENTS WHO WERE EATING IN THE "BRISTOL" DINING AREA, BUT SHE DID NOT ASSIST RESIDENT #4 TO REMOVE HIS "LAP BUDDY." BASED ON REVIEW OF THE RESIDENT'S CLINICAL RECORD, THERE WAS NO HOSPICE CARE PLAN THAT ADDRESSED THE USE OF A "LAP BUDDY" RESTRAINT FOR RESIDENT #4. ACCORDING TO THE FACILITY'S MARCH 2011 physician's orders [REDACTED]. THIS INTERVENTION WAS NOT DOCUMENTED ON THE HOSPICE TEAM CARE PLAN. DURING THE INTERVIEW AT 12:20 P.M. ON 3/10/11, UNIT MANAGER "F" SAID THAT THE RESIDENT HAD NOT BEEN RECEIVING THE "BOOST" (DURING MARCH), BECAUSE THE ORDER HAD INADVERTENTLY BEEN OMITTED FROM THE FACILITY'S MEDICATION ADMINISTRATION RECORDS (MAR). UNIT MANAGER "F" SAID THAT THE MAR indicated [REDACTED]. ( ) ACCORDING TO THE PROFILE FACE SHEET, RESIDENT #7 WAS admitted to the facility on [DATE]. ACCORDING TO A "SKILLED NURSING ADMISSION HISTORY AND PHYSICAL", DATED 2/21/11, RESIDENT #7 WAS HAVING"...A LOT OF ISSUES (WITH) HIS SPINAL STENOSIS PAIN..." THE ASSESSMENT FURTHER STATED: "...(RESIDENT) STATES IN THE PAST HE HAS HAD A LOT OF PROBLEMS (WITH) PAIN MEDS IN THE PAST CAUSED A LOT OF [MEDICAL CONDITION]/CONFUSION..." THE RESIDENT WAS INTERVIEWED IN HIS ROOM AT 9:30 A.M. ON 3/9/11 AT WHICH TIME HE STATED, "I'M IN PAIN ALL THE TIME." THE RESIDENT SAID THAT PAIN HAD CURBED HIS DESIRE TO PARTICIPATE IN RECREATIONAL ACTIVITIES AND SOMETIMES AFFECTED HIS SLEEP. DURING THE INTERVIEW, THE RESIDENT CONVERSED EASILY ABOUT HIS LIFE AT THE FACILITY. THE RESIDENT STATED: "YOU CAN ALWAYS MANAGE PAIN, BUT THERE'S A TRADE OFF. THE MEDS CAN MAKE YOU FOGGY. RIGHT NOW, I'D ACCEPT SOME FOGGINESS FOR SOME RELIEF." AT 9:30 A.M., THIS SURVEYOR INFORMED STAFF NURSE "Q" THAT RESIDENT #7 HAD REPORTED BEING IN PAIN. NURSE "Q" SAID THAT THE RESIDENT'S FAMILY DID NOT WANT HIM TAKING A LOT OF EXTRA PAIN MEDICATIONS, SO SHE HAD TRIED TO LIMIT ADMINISTRATION OF PAIN MEDICATIONS TO THE TIMES WHEN HE WAS SCHEDULED TO RECEIVE PHYSICAL THERAPY. DURING A FOLLOW-UP INTERVIEW WITH THE RESIDENT, CONDUCTED LATER THAT SAME MORNING AT 11:15 A.M., THE RESIDENT SAID THAT HE STILL WAS HURTING. BASED ON REVIEW OF THE MARCH 2011 physician's orders [REDACTED]. BASED ON REVIEW OF THE MARCH 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. BASED ON REVIEW OF THE RESIDENT'S PAPER CHART, THE FACILITY HAD NOT DEVELOPED A CARE PLAN TO EXPLAIN HOW THE RESIDENT'S PAIN WOULD BE MANAGED. AN "INITIAL CARE PLAN", DATED 2/18/11 HAD IDENTIFIED PAIN AS A PROBLEM, BUT THERE WERE NO INDIVIDUALIZED INTERVENTIONS DEVELOPED. THE CARE PLAN GOAL WAS FOR THE RESIDENT TO "EXPERIENCE LESS PAIN." THE GOAL WAS NOT MEASURABLE BECAUSE THE CRITERIA FOR DETERMINING "LESS PAIN" WAS NOT EXPLAINED. DURING HIS INTERVIEW, THE RESIDENT HAD BEEN VERY SPECIFIC ABOUT WHAT HE WAS WILLING TO TOLERATE IN ORDER TO EXPERIENCE RELIEF FROM PAIN, BUT THE RESIDENT'S FEELINGS WERE NOT REFLECTED IN HIS CARE PLAN. SIMILARLY, THE CONCERNS REGARDING THE RESIDENT'S PAST HISTORY OF PROBLEMS ASSOCIATED WITH DIFFERENT PAIN MEDICATIONS WAS NOT CARE PLANNED. ACCORDING TO ITEMS #3 AND #6 OF THE FACILITY'S "PAIN MANAGEMENT" POLICY (POLICY NUMBER 431, REVISED 2/21/08), NURSING STAFF WERE TO EDUCATE RESIDENTS ABOUT QUANTIFYING THEIR PAIN ACCORDING A "1 TO 10" SCALE (WHERE "10" REPRESENTED THE WORST POSSIBLE PAIN) AND NURSES WERE TO DOCUMENT THE RESULTS OF THOSE ASSESSMENTS ON THE BACK OF THE MAR. BASED ON ADDITIONAL REVIEW OF THE MARCH 2011 MAR, [MEDICATION NAME] HAD BEEN ADMINISTERED TO RESIDENT #7 ON 8 DIFFERENT OCCASIONS DURING THE MONTH. THE RESIDENT'S PAIN SCORE WAS RECORDED ON ONLY ONE OCCASION. ON THE DATE THAT THE RESIDENT WAS INTERVIEWED (3/9/11), THE MAR indicated [REDACTED].M., ONE HOUR AFTER HE HAD REPORTED BEING IN PAIN. THE DOCUMENTATION DID NOT RECORD THE INTENSITY OF THE RESIDENT'S PAIN (USING THE 1 TO 10 SCALE, OR ANY OTHER DESCRIPTION) EITHER BEFORE OR AFTER THE PAIN MEDICATION WAS ADMINISTERED. THE DOCUMENTATION ON THE BACK OF THE MAR FOR 3/9/11 RECORDED THAT THE RESIDENT HAD FELT "BETTER" (NO TIME RECORDED FOR WHEN THE RESIDENT HAD REPORTED FEELING "BETTER") AFTER RECEIVING THE MEDICATION, EVEN THOUGH THE RESIDENT HAD REPORTED TO THIS SURVEYOR AT 11:15 A.M. THAT HE STILL HURT. COMPARATIVE REVIEW WITH AN EARLIER MAR (FEBRUARY 2011) REFLECTED THAT THE RESIDENT WAS CONSISTENTLY REPORTING PAIN AT A "7" OR "8" LEVEL BEFORE BEING ADMINISTERED [MEDICATION NAME] (ANOTHER TYPE OF NARCOTIC PAIN RELIEVER) PRN. DURING AN INTERVIEW AT 11:30 A.M. ON 3/9/11, THE FACILITY'S ASSISTANT DIRECTOR OF NURSING (NURSE "O") SAID THAT THE RESIDENT'S ATTENDING PHYSICIAN HAD SPOKEN WITH THE RESIDENT'S FAMILY AND WAS AWARE OF THEIR CONCERNS REGARDING GIVING THE RESIDENT TOO MUCH PAIN MEDICATION. NURSE "O" SAID THAT, IF THE PHYSICIAN HAD MADE [MEDICATION NAME] AVAILABLE EVERY 4 HOURS, IT MEANT THAT IT WAS APPROPRIATE TO ADMINISTER IT THAT OFTEN IF IT WAS NEEDED. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT DEVELOPMENT OF PRESSURE ULCERS FOR 4 OF 6 RESIDENTS IDENTIFIED WITH PRESSURE ULCERS (#5, #8, #10, #11) AND FAILED TO PROVIDE NECESSARY treatment for [REDACTED].#11, #6 AND #8, AN UNSTAGEABLE LEFT HEEL PRESSURE ULCER FOR RESIDENT #5, AND A STAGE 2 LEFT BUTTOCK ULCER FOR RESIDENT #10. FINDINGS INCLUDE: RESIDENT #11 WAS AN [AGE] year OLD FEMALE admitted TO THE FACILITY 9/15/08 WITH [DIAGNOSES REDACTED]. ADDITIONAL [DIAGNOSES REDACTED]. THE SAME MDS, UNDER SKIN CONDITIONS, REFLECTED THAT THE RESIDENT WAS AT RISK OF DEVELOPING PRESSURE ULCERS. HOWEVER, SHE WAS DOCUMENTED AS NOT HAVING ANY HEALED OR CURRENT PRESSURE ULCERS. A NURSING NOTE DATED 9/1/10 REFLECTED THE RESIDENT AS HAVING A STAGE 1, NON-BLANCHABLE AREA ON HER COCCYX (TAIL BONE). THE AREA MEASURED 2.4 CM X 0.8 CM. THE NURSING NOTE DATED 9/8/10 DESCRIBED THE RESIDENT'S COCCYX AREA AS BEING HEALED. THE NURSING NOTE DATED 10/3/10 REFLECTED THE RESIDENT AS ACQUIRING ANOTHER OPEN AREA ON HER LEFT BUTTOCK. THE AREA MEASURED 1 CM X 0.5 CM AND IT WAS INCREASED TO 1.0 CM X 1.0 CM ON 11/24/10. THE NURSING NOTE DATED 12/9/10 DESCRIBED THIS WOUND AS BOTH BUTTOCK/COCCYX. THE NURSING NOTE DATED 12/28/10 REFLECTED THE COCCYX WOUND MEASURED 1.0 CM X 0.4 CM, NON-BLANCHABLE SKIN WITH THE TOP SKIN LAYER MISSING, AND NO DRAINAGE OR SLOUGH, SHALLOW CRATER WITH PINK WOUND BED. ON 3/10/11 AT 3:00 P.M., THE UNIT MANAGER, (STAFF "A") STATED THE ONSET OF THE CURRENT COCCYX WOUND AS 12/28/10. HOWEVER, THE PREVIOUS NURSING NOTES REFLECTED THE WOUND MAY HAVE ALREADY DEVELOPED AS EARLY AS SEPTEMBER OR OCTOBER 2010. THE PRESSURE ULCER ASSESSMENT FORM WHICH INCLUDED STAGING, MEASUREMENT AND CHARACTERISTICS OF THE WOUND, DATED 12/28/10 REFLECTED THE COCCYX WOUND WAS AT A STAGE 2 (PARTIAL THICKNESS SKIN LOSS INVOLVING EPIDERMIS, DERMIS OR BOTH), MEASURING 1.0 CM LONG AND 0.4 CM WIDE. THE PRESSURE ULCER ASSESSMENT FORM DATED 1/12/11 REFLECTED THE WOUND HAD MEASUREMENTS OF 0.3 CM (LENGTH) X 0.4 CM (WIDTH) X 0.1 CM (DEPTH). THE PRESSURE ULCER ASSESSMENT FORM DATED 1/19/11, A WEEK LATER, REFLECTED THE COCCYX WOUND HAD WORSENED AND WAS NOW UNSTAGEABLE DUE TO ESCHAR AND NECROTIC TISSUE COVERING. THE PRESSURE ULCER MEASURED 2 CM LONG AND 0.6 CM WIDE. IT HAD YELLOW WAXY NECROTIC (DEAD TISSUE) ESCHAR WITH UNDETERMINED AMOUNT OF EXUDATE (FLUID THAT HAS BEEN FORCED OUT OF THE TISSUES OR ITS BLOOD VESSELS BECAUSE OF INFLAMMATION OR INJURY). THE PRESSURE ULCER ASSESSMENT FORMS DATED 1/25/11 (WOUND SIZE: 1.7 CM X 0.7 CM X 0.1 CM) AND 2/16/11 (WOUND SIZE: 6 CM X 5 CM) REFLECTED THE WOUND AS BEING STAGE 2 (DOWNGRADED), ALTHOUGH THEY DESCRIBED THE WOUND AS HAVING A WHITE AND WAXY COVERING OF SLOUGH. THE PRESSURE ULCER assessment dated [DATE] REFLECTED THAT THE COCCYX WOUND HAD 100 % SLOUGH WITH SCANT AMOUNT OF YELLOW DRAINAGE AND ODOR. THE WOUND WAS STAGED AS UNSTAGEABLE AND MEASURED 1.9 CM X 1.1 CM. THE [MEDICATION NAME] ([MEDICATION NAME]) DRESSING WAS FOUND TO BE ROLLING UP AT THE EDGES. THE RESIDENT WAS REPORTED AS HAVING PAIN (INTENSITY BETWEEN 4-5 ON A SCALE OF 1-10, WITH 10 BEING THE WORST PAIN) RELATED TO THE PRESSURE ULCER. THE NURSING NOTE DATED 2/3/11 REFLECTED THE RESIDENT WAS BEING REFERRED TO THE HOSPICE SERVICE AND AN INDWELLING URINARY CATHETER WAS INSERTED TO PROMOTE WOUND HEALING. THE NURSING NOTES DATED 2/4/11 THROUGH 3/7/11 REFLECTED DETERIORATION OF THE RESIDENT'S COCCYX PRESSURE ULCER AS WELL AS HER INCREASED PAIN LEVEL AND FUNCTIONAL DECLINE. THE RESIDENT HAD BECOME BED-BOUND, WAS NOT EATING OR DRINKING, DEVELOPED A URINARY TRACT INFECTION TREATED WITH AN ANTIBIOTIC AND REQUIRED HIGHER DOSES OF NARCOTICS FOR PAIN CONTROL AROUND THE CLOCK. THE NURSING NOTE DATED 2/7/11 REFLECTED THE AQUA-CELL DRESSING (CHEMICAL DEBRIDEMENT) WAS SATURATED WITH DRAINAGE AND HAD AN ODOR. THE PRESSURE ULCER ASSESSMENT FORM DATED 2/23/11, REFLECTED THE WOUND HAD 75 % ESCHAR AND 25 % SLOUGH WITH UNDERMINING (DESTRUCTION OF TISSUE OR ULCERATION EXTENDING UNDER THE SKIN EDGES). IT HAD A SCANT AMOUNT OF THIN REDDISH BROWN DRAINAGE AND THE RESIDENT'S PAIN SCORE WAS BETWEEN 6-7 OUT OF 10. THE SIZE OF THE WOUND WAS 8 CM LONG, 12 CM WIDE AND 0.2 CM DEEP. THE NURSING NOTE DATED 2/25/11 REFLECTED THE COCCYX AREA HAD GREENISH BROWN DRAINAGE WITH A STRONG ODOR. ON 3/10/11 AT 9:00 A.M., DURING A DRESSING CHANGE IN THE RESIDENT'S ROOM, THE COCCYX WOUND WAS 100% COVERED WITH LARGE, PEAR-SHAPED, BLACK ESCHAR MEASURING APPROXIMATELY 12 CM LONG AND 12 CM WIDE WITH A MODERATE AMOUNT OF YELLOW DRAINAGE. THERE WAS ANOTHER OPEN AREA (2 CM X 2 CM) DISTAL TO THE COCCYX WOUND, APPEARING AS A DEEP CRATER WITH YELLOW DRAINAGE. THE SURROUNDING SKIN AROUND THE BLACK ESCHAR LOOKED RED. THE UNIT NURSE, (STAFF "B") CLEANSED THE WOUND WITH SALINE SOLUTION FOLLOWED BY WET, POWDERED [MEDICATION NAME] (ANTIBIOTIC) SOAKED 4 X 4 GUAZE'S OVER ENTIRE WOUND BED. SHE THEN APPLIED DRY THICK DRESSINGS TO MAINTAIN A MOIST ENVIRONMENT. HOWEVER, SHE LEFT THE DISTAL PORTION OF DRESSING UNTAPED, THUS THE WET-TO-DRY DEBRIDEMENT WOULD BE LESS EFFECTIVE AND THE WOUND WOULD BE EXPOSED TO FECAL CONTAMINATION. THE RESIDENT SHOWED MINIMAL SIGNS OF PAIN AND NO APPRECIABLE ODOR WAS PRESENT. ON 3/11/11 AT 11:00 A.M., THE DIRECTOR OF NURSING (STAFF "H") STATED THE TOPICAL APPLICATION OF [MEDICATION NAME] WAS TO TREAT MALODOROUS SKIN ULCERS. (THERE WERE ALSO 2 WASH BASINS FULL OF CHARCOAL UNDER THE RESIDENT'S BED TO KEEP OFFENSIVE WOUND ODOR UNDER CONTROL.) ON 3/10/11 AT 3:00 P.M., UNIT MANAGER "A" WAS QUESTIONED ABOUT THE CAUSES OR FACTORS RELATED TO THE DEVELOPMENT OF THE RESIDENT'S PRESSURE ULCER. STAFF "A" STATED THAT THE RESIDENT USED TO SIT ON A "BRODER" CHAIR FOR LONG PERIODS OF TIME, NOT WANTING TO GO TO BED, NOT CHANGING HER POSITION, AND LAID ON HER BACK MOST OF THE TIME WHEN SHE WAS IN BED. UNIT MANAGER "A" ALSO STATED THAT THE "[MEDICATION NAME]" DRESSING CAUSED THE FRAGILE SKIN TO BE RIPPED OFF, CAUSING DEEPER SKIN DAMAGE, AND THE CHEMICAL DEBRIDEMENT MADE THE SKIN CONDITION WORSE. WHEN STAFF "A" WAS ASKED ABOUT THE OPTION FOR A WOUND CONSULTATION, SHE SAID IT WAS NOT ALLOWED BECAUSE THE RESIDENT WAS ALREADY admitted TO THE HOSPICE CARE SERVICE. ON 3/8/11 AT 1:00 P.M., THE RESIDENT WAS OBSERVED IN HER ROOM LYING ON HER LEFT SIDE WITH THE HEAD OF THE BED ELEVATED AT APPROXIMATELY 30 DEGREES. AT 3:30 P.M., SHE WAS STILL LYING IN THE SAME POSITION. ON 3/9/11 AT 9:15 A.M., THE RESIDENT WAS AGAIN OBSERVED IN HER ROOM LYING ON HER LEFT SIDE. AT 10:30 A.M., SHE WAS BEING BATHED. AT 12 NOON, THE RESIDENT WAS OBSERVED LYING ON HER LEFT SIDE WHILE THE HOSPICE NURSING AIDE WAS VISITING AT HER BED SIDE. AT 1:15 P.M., THE RESIDENT WAS STILL FACING HER LEFT SIDE. SHE APPEARED LETHARGIC, COUGHING OCCASIONALLY, WITH SOUNDS LIKE SHE HAD A LARGE AMOUNT OF LUNG SECRETIONS. AT 3:30 P.M., THE RESIDENT WAS OBSERVED LYING ON HER RIGHT SIDE FOR THE FIRST TIME. ON 3/10/11 AT 8:00 A.M., THE RESIDENT WAS BEING ASSISTED WITH HER BREAKFAST. SHE LOOKED MORE ALERT, EATING MOST OF HER MEAL. AT 1:30 P.M., THE RESIDENT WAS SITTING UPRIGHT IN BED. SHE SAID SHE WAS HAVING PAIN ON HER BUTTOCKS. THE PHYSICIAN'S PROGRESS NOTE DATED 3/2/11 REFLECTED THAT THE RESIDENT MIGHT HAVE A KENNEDY TERMINAL ULCER, A PRESSURE ULCER THAT SOME PEOPLE GET AS THEY ARE DYING. IT STARTS OUT LARGER THAN OTHER PRESSURE ULCERS, IS USUALLY MORE SUPERFICIAL INITIALLY, AND DEVELOPS RAPIDLY IN SIZE AND DEPTH. IT IS BELIEVED TO BE A BLOOD PROFUSION PROBLEM EXACERBATED BY THE DYING PROCESS THAT MANIFEST IN THE LARGEST ORGAN, SKIN. THE SKIN IS ALMOST INTACT AND THE ULCER LOOKS LIKE A BLACK BLOOD BLISTER. THE PATIENTS HAVE A HISTORY OF DYING WITHIN 8-24 HOURS. THE RESIDENT'S PRESSURE ULCER CARE PLAN DATED 9/25/08 AND UPDATED 2/7/11 REFLECTED THAT THE RESIDENT HAD A POOR APPETITE AND WAS TO BE ENCOURAGED TO DRINK FLUIDS BETWEEN MEALS INCLUDING PROTEIN SNACKS. THE RESIDENT WAS NOTED TO BE IN DECLINE WITH ORAL INTAKE AND SHE HAD A WEIGHT LOSS OF GREATER THAN 10% IN LESS THAN A 2 MONTH PERIOD BETWEEN 12/22/10 AND 2/10/11. ( ) RESIDENT #6 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. SHE ALSO HAD A [MEDICAL CONDITION] FOR EVACUATION OF HER BOWELS. THE MINIMUM DATA SET ((MDS) dated [DATE] REFLECTED THE RESIDENT WAS AT RISK OF DEVELOPING PRESSURE ULCERS AND SHE HAD 1 STAGE 3 PRESSURE ULCER PRESENT ON ADMISSION. THE SIZE OF THE ULCER WAS 3.0 CM LONG AND 2.1 CM WIDE. THE MDS dated [DATE] REFLECTED THE RESIDENT HAD 1 UNSTAGEABLE PRESSURE ULCER PRESENT UPON READMISSION. THE PRESSURE ULCER NURSING CARE PLAN DATED 10/12/10 REFLECTED THE RESIDENT HAD A PRESSURE ULCER ON HER COCCYX DUE TO HER MOBILITY DEFICIT, FRICTION AND SHEAR, AND THE MACERATION FACTOR. OTHER ETIOLOGY FACTORS INCLUDED THE RESIDENT'S INCONTINENCE, NUTRITION, BEING WHEEL CHAIR BOUND AND NARCOTIC USE. THE RESIDENT WAS ALSO DESCRIBED AS HAVING THE HEAD OF BED ELEVATED WHEN SHE WAS IN BED. THE RESIDENT HAD AN INDWELLING URINARY CATHETER PLACED ON 10/12/10 TO PROMOTE HEALING OF HER COCCYX WOUND. THE NURSING NOTE DATED 9/22/10 REFLECTED THAT THE RESIDENT HAD BEEN TRANSFERRED TO THE emergency room DUE TO MULTIPLE SKIN TEARS INCLUDING A SCALP ABRASION AS THE RESULT OF A FALL. THE RESIDENT WAS RETURNED to the facility on [DATE] WITH A STAGE 2 COCCYX PRESSURE ULCER. A WEEK LATER ON 10/6/10 THE ULCER WAS CLASSIFIED AS STAGE 3 WITH MEASUREMENTS OF 3.0 CM LONG AND 2.1 CM WIDE. THE WOUND WAS DESCRIBED AS HAVING SLOUGH (DEAD TISSUE) IN THE CENTER AND A MODERATE AMOUNT OF EXUDATE WITH A SLIGHT ODOR. THE TREATMENT WAS APPLYING A NON-ADHERENT [MEDICATION NAME] (CHEMICAL DEBRIDEMENT) DRESSING WITH A THICK DRY PAD AS A SECONDARY DRESSING. WITH THIS WOUND THE RESIDENT'S PAIN SCALE WAS DOCUMENTED BETWEEN 6-7, 10 BEING THE WORST PAIN. ON 10/21/10, THE COCCYX WOUND HAD PROGRESSED TO AN UNSTAGEABLE PRESSURE ULCER WITH MEASUREMENTS OF 2.0 CM LONG, 1.8 CM WIDE AND 0.1 CM DEEP. THE PRESSURE ULCER ASSESSMENT FORM DATED 11/18/10 REFLECTED THE COCCYX REMAINED AS UNSTAGEABLE WITH OVER ALL SIZE AS 5.0 X 5.0 CM. THE SIZE OF THE CENTER OF THE WOUND WAS 2.2 CM X 1.0 CM. THE PRESSURE ULCER ASSESSMENT FORM DATED 12/28/10 REFLECTED THAT THE COCCYX WOUND HAD INCREASED IN SIZE TO 5.3 CM X 4.5 CM, WITH 75% OF THE WOUND COVERED WITH SLOUGH. THE PRESSURE ULCER ASSESSMENT FORM DATED 1/19/11 REFLECTED THE COCCYX WOUND WAS A STAGE 2 (DOWN GRADED) WITH A SIZE OF 6 CM X 2.0 CM. IT HAD NO SLOUGH AND THE SURROUNDING SKIN WAS HARD AND HAD INDURATION. THE WOUND WAS AGAIN CLASSIFIED AS A STAGE 2 ON 1/27/11. HOWEVER, THE PRESSURE ULCER ASSESSMENT FORMS FROM 2/1/11 THROUGH 3/9/11 REFLECTED THAT THE WOUND WAS UNSTAGEABLE. ON 3/9/11 AT 10:15 A.M., THE COCCYX WOUND WAS OBSERVED AS HAVING A SMALL ROUND OPEN AREA, STAGED AT 2, APPROXIMATELY 1.0 CM LONG AND 1.0 CM WIDE WITH A SCANT AMOUNT OF DRAINAGE ON THE OLD DRESSING. THE OVER ALL SKIN SURFACE ON HER BUTTOCKS WAS FRAGILE AND MACERATED (SOFTENED UP). ON 3/10/11 AT 3:00 P.M., UNIT MANAGER "A" WAS ASKED WHY THE WOUND HAD DETERIORATED QUICKLY DURING THE FIRST WEEK (10/6/10) AFTER THE RESIDENT WAS readmitted . SHE STATED THAT THE PHYSICIAN THOUGHT THE RESIDENT MAY HAVE ALREADY HAD A DEEP TISSUE INJURY WHEN SHE WAS admitted . UNIT MANAGER "A" ADDED THAT EVEN THOUGH THE PHYSICIAN FAILED TO DOCUMENT IN THE PROGRESS NOTE, THE PHYSICIAN SPECULATED THE RESIDENT HAD A "KENNEDY PRESSURE ULCER". ON 3/8/11 AT 1:05 P.M., THE RESIDENT WAS OBSERVED LYING ON HER BACK WITH BOTH LEGS ELEVATED ON "HEELS UP" PADDING. AT 3:15 P.M., THE RESIDENT WAS OBSERVED SLEEPING ON HER BACK IN THE SAME POSITION. ON 3/9/11 AT 12:15 P.M., THE RESIDENT WAS LYING ON HER BACK. AT 3:30 P.M., SHE WAS QUIET AND LYING ON HER BACK, STILL WEARING HER HOSPITAL GOWN. ON 3/10/11 AT 10:00 A.M., THE RESIDENT WAS SITTING IN A WHEEL CHAIR IN HER ROOM. AT 2:30 P.M., THE RESIDENT WAS LYING IN HER BED, SLEEPING. THE PRESSURE ULCERS CARE PLAN DATED 10/12/10 REFLECTED THAT THE RESIDENT HAD A PRESSURE ULCER ON HER COCCYX DUE TO MOBILITY DEFICIT, INCONTINENCE, NUTRITION AND HAVING THE HEAD OF HER BED ELEVATED. ON 3/10/11 AT 3:00 P.M., UNIT MANAGER "A" STATED THE RESIDENT WAS NON-COMPLIANT WITH REPOSITIONING. HOWEVER, THE NURSING INTERVENTIONS DID NOT INCLUDE ADDRESSING THESE LIMITATIONS OR THE EXTENT OF RELATED EFFORTS TO CURB THE RESIDENT'S NON-COMPLIANCE. ( ) RESIDENT #10 WAS AN ALERT AND ORIENTED [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE PRESSURE ULCER CARE PLAN DATED 8/10/09 AND UPDATED 12/23/10 REFLECTED THAT THE RESIDENT WAS AT RISK FOR IMPAIRED SKIN INTEGRITY DUE TO CHRONIC SKIN RASHES, CHRONIC YEAST INFECTIONS, POOR HEALING RELATED TO DIABETES MELLITUS, AND REQUIRED EXTENSIVE ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING (ADL). THE ACUTE CARE PLAN (UTILIZED WHEN THE RESIDENT WAS FOUND HAVING NEW ISSUES) DATED 1/11/11 REFLECTED THE RESIDENT HAD DEVELOPED A STAGE 2 OPEN AREA ON HER LEFT BUTTOCK. THE INTERVENTIONS INCLUDED ENCOURAGING THE RESIDENT TO HAVE 30 MINUTES OF BED REST BETWEEN MEALS AND APPLYING [MEDICATION NAME] OINTMENT TO LEFT BUTTOCK TWICE DAILY. ON 3/10/11 AT 3:30 P.M., THE UNIT MANAGER (STAFF "A") STATED THE RESIDENT WAS NON-COMPLIANT WITH BED REST, BECAUSE SHE WAS ACTIVE WITH VOLUNTEER ACTIVITIES. THE NURSING NOTE DATED 1/8/11 REFLECTED THAT THE RESIDENT HAD A SMALL OPEN SPOT (0.5 CM X 0.5 CM) ON HER LEFT BUTTOCK. THE NURSING NOTE DATED 1/11/11 REFLECTED THAT THE RESIDENT HAD A DARKENED SCATTERED PINPOINT AREA (RASH LIKE) ON HER COCCYX (TAIL BONE). THE NURSING INTERVENTIONS INCLUDED KEEPING 30 MINUTES OF BED REST BETWEEN MEALS AND APPLYING XENODERM OINTMENT TO AFFECTED AREAS. THE PRESSURE ULCER ASSESSMENT FORM DATED 1/19/11 DOCUMENTED THE RESIDENT HAD A STAGE 2, LEFT BUTTOCK PRESSURE ULCER WITH MEASUREMENTS OF 1.0 CM X 1.0 CM. THE NEXT MEASUREMENT DATED 1/28/11 WAS 1.0 CM X 1.0 CM X 0.1 CM. THE WOUND WAS DESCRIBED AS HAVING A CIRCULAR OPEN AREA WITH A DARK RED BORDER AND POINTS OF DARKER RED TISSUE IN THE WOUND BED. THE PRESSURE ULCER ASSESSMENT FORM DATED 2/6/11 REFLECTED THAT THE LEFT BUTTOCK WOUND WAS STILL AT STAGE 2, BUT HAD INCREASED IN SIZE TO 1.8 CM X 1.6 CM X 1.0 CM. THE PRESSURE ULCER ASSESSMENT FORM DATED 3/2/11 REFLECTED THE LOCATION OF THE WOUND WAS NOW CHANGED TO THE COCCYX WITH MEASUREMENTS OF 2.8 CM LONG AND 1.4 CM WIDE. THE STAGING REMAINED THE SAME (STAGE 2) AS THE LEFT BUTTOCK WOUND. THE TREATMENT ALSO REMAINED THE SAME. ON 3/9/11 AT 10:00 A.M., THE PRESSURE ULCER ON THE RESIDENT'S LEFT LOWER BUTTOCK WAS OBSERVED TO BE ABOUT THE SIZE OF A QUARTER WITH A SCANT AMOUNT OF SEROUS DRAINAGE. THE RESIDENT'S LEFT UPPER BUTTOCK AND RIGHT LOWER BUTTOCK WERE RED. UNIT NURSE (STAFF "B") STATED THOSE SKIN BREAKDOWNS WERE BELIEVED TO HAVE BEEN CAUSED BY A SLIDING BOARD TRANSFER. HOWEVER, ON 3/10/11 AT 3:30 P.M., UNIT MANAGER "A" STATED THE RESIDENT'S PRESSURE ULCER WAS CAUSED BY A BUTTON ON THE SKIRT THAT THE RESIDENT ALWAYS WORE TO COVER HER AMPUTATED LIMBS. UNIT MANAGER "A" ADDED THAT THE RESIDENT ALWAYS SAT ON THE BUTTON WHENEVER SHE WAS IN HER WHEEL CHAIR. SINCE THE CAUSE OF THIS PRESSURE ULCER WAS DISCOVERED, MOST RECENTLY THERE WERE NO CARE INTERVENTIONS MANAGING THIS PROBLEM. ( ) ACCORDING TO THE PROFILE FACE SHEET, RESIDENT #8 WAS admitted to the facility on [DATE]. ACCORDING TO THE MDS (MINIMUM DATA SET) ASSESSMENT COMPLETED ON 12/15/10, THE RESIDENT WAS ABLE TO EXPRESS HERSELF VERBALLY AND UNDERSTAND VERBAL CONVERSATION WITHOUT SIGNIFICANT LIMITATION. SHE WALKED WITH EXTENSIVE PHYSICAL ASSISTANCE PROVIDED BY STAFF AND WAS ABLE TO REPOSITION HERSELF IN BED WITH LIMITED ASSISTANCE. SHE DID NOT HAVE ANY UNHEALED PRESSURE ULCERS AT THE TIME OF THE ASSESSMENT. ACCORDING TO A FACILITY NURSE PROGRESS NOTE, DATED 1/10/11, RESIDENT #8 DEVELOPED AN "AREA" ON HER COCCYX (TAILBONE) THAT MEASURED 0.4 CM (CENTIMETERS) BY 0.5 CM. THERE WAS NO FURTHER DESCRIPTION OF THE "AREA" DOCUMENTED. THE "AREA" WAS NOT DESCRIBED AS "OPEN" AND WAS NOT DESCRIBED AS A PRESSURE ULCER. THE NURSE'S NOTE SAID THAT STAFF WERE APPLYING SENSICARE (A TOPICAL SKIN PROTECTORANT) AND ADDED THAT A "NOTE" HAD BEEN LEFT FOR THE PHYSICIAN FOR "TX (TREATMENT) ORDERS." ACCORDING TO A "PRESSURE ULCER ASSESSMENT FORM", DATED 1/19/11, THE RESIDENT'S COCCYX WOUND HAD WORSENED. IT WAS NEWLY DESCRIBED AS AN "INDURATED" (HARDENED) STAGE II PRESSURE ULCER. (A STAGE II PRESSURE ULCER IS AN ULCER THAT INVOLVES PARTIAL THICKNESS SKIN LOSS.) BY 1/19/11, THE ULCER HAD MORE THAN TRIPLED IN LENGTH (FROM 0.4 CM ON 1/10/11 TO 1.3 CM ON 1/19/11) BUT HAD VARIED ONLY A TENTH OF A CM IN WIDTH. ACCORDING TO THE MANUFACTURER OF SENSICARE, APPLICATION OF SENSICARE SHOULD BE STOPPED, AND THE DOCTOR CONSULTED, IF THE CONDITION BEING TREATED WORSENS OR FAILS TO RESOLVE AFTER 7 DAYS. ACCORDING TO RESIDENT #8'S JANUARY 2011 TREATMENT RECORD, NURSING STAFF APPLIED SENSICARE TO HER "COCCYX ULCER" TWICE DAILY FROM 1/11/11 THROUGH 1/26/11. THE TREATMENT RECORD REFLECTED THAT SENSICARE WAS APPLIED ONLY IN THE MORNINGS ON 1/27/11, 1/28/11 AND 1/29/11. (NO EXPLANATION WAS DOCUMENTED.) BASED ON REVIEW OF THE physician's orders [REDACTED]. THERE WAS NO DESCRIPTION OF THE RESIDENT'S WOUND DOCUMENTED ON THAT DATE. THE NEXT DOCUMENTED DESCRIPTION WAS ON THE "PRESSURE ULCER ASSESSMENT FORM", DATED 2/2/11. THE DOCUMENTATION REFLECTED THAT THE WOUND HAD WORSENED IN CHARACTER, AS EVIDENCED BY THE APPEARANCE OF "SLOUGH" (DEAD TISSUE) ON THE WOUND BED. A "PRESSURE ULCER ASSESSMENT FORM", DATED 2/9/11, DESCRIBED THE WOUND AS AN "UNSTAGEABLE" ULCER BECAUSE THE PRESENCE OF SLOUGH OVER THE WOUND PREVENTED VISUALIZATION OF THE ACTUAL EXTENT OF THE TISSUE DAMAGE BELOW THE SURFACE. ACCORDING TO THE RECORDS, A physician's orders [REDACTED]. ON 3/3/11, ANOTHER physician's orders [REDACTED]. A TREATMENT OBSERVATION WAS CONDUCTED IN THE RESIDENT'S ROOM AT 10:20 A.M. ON 3/10/11, AT WHICH TIME NURSE "S" CLEANSED THE RESIDENT'S COCCYX AREA WITH NORMAL SALINE BEFORE APPLYING THE PRESCRIBED DRESSING. A QUARTER-SIZED, HORSESHOE-SHAPED AREA OF REDNESS WAS OBSERVED OVER THE RESIDENT'S COCCYX THAT HAD A PALE, NAIL-SIZED CENTER THAT WAS CONSISTENT IN APPEARANCE WITH SLOUGH. THE RESIDENT DID NOT EXPRESS DISCOMFORT DURING THE OBSERVED TREATMENT. IMMEDIATELY AFTERWARD, THE RESIDENT WAS ASKED ABOUT WHAT MAY HAVE CAUSED THE ULCER, BUT SHE SAID THAT SHE DID NOT KNOW. SHE MADE ADDITIONAL COMMENTS THAT WERE NOT APPROPRIATE TO THE QUESTION, REFLECTING MENTAL CONFUSION. THE FACILITY'S ASSISTANT DIRECTOR OF NURSING (NURSE "O") WAS INTERVIEWED AT 10:40 A.M. ON 3/10/11. THE DOCUMENTATION DATED 1/10/11 FROM THE FACILITY'S NURSES' NOTES WAS REVIEWED WITH NURSE "O" DURING THE INTERVIEW. ACCORDING TO THE NOTES, FACILITY NURSES HAD INITIATED SENSICARE BEFORE AN ACTUAL ORDER WAS OBTAINED FROM THE PHYSICIAN. NURSE "O" COULD NOT EXPLAIN WHY THE FACILITY HAD USED A TOPICAL BARRIER CREAM RATHER THAN ACTING IMMEDIATELY TO PROTECT THE AREA WITH AN OCCLUSIVE DRESSING. SHE COULD NOT PROVIDE ANY WRITTEN PROTOCOL, OR ANY STANDING ORDERS, THAT AUTHORIZED A SPECIFIC treatment for [REDACTED]. SIMILARLY, SHE COULD NOT EXPLAIN WHY THE FACILITY HAD DELAYED IN RE-EVALUATING THE TREATMENT PLAN WHEN THE SENSICARE FAILED TO RESOLVE THE PROBLEM DURING THE FIRST WEEK OF TREATMENT. DURING AN EARLIER INTERVIEW, CONDUCTED AT 10:18 A.M. ON 3/9/11, NURSE "TT" HAD SAID THAT SHE COULD NOT THINK OF ANY REASON WHY RESIDENT #8'S WOUND HAD NOT RESOLVED DURING THE PREVIOUS TWO MONTHS. NURSE "TT" SAID THAT THE RESIDENT ATE WELL, WAS AGREEABLE TO REPOSITIONING OFF HER BOTTOM, AND EVEN CONTINUED TO WALK TO THE DINING ROOM WITH ASSISTANCE FROM STAFF. ( ) ACCORDING TO THE FACILITY INFORMATION SHEET, RESIDENT #5 WAS AN [AGE] year OLD MALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET (A RESIDENT ASSESSMENT TOOL) DATED 9/30/10 REFLECTED THAT THE RESIDENT NEEDED EXTENSIVE ASSISTANCE WITH REPOSITIONING, PERSONAL HYGIENE, TOILETING, DRESSING AND EATING. THE WEEKLY SKIN ASSESSMENT FORM DATED 9/6/10 REFLECTED THAT THE RESIDENT'S SKIN WAS INTACT. THE NURSES NOTES DATED 9/13/10 REFLECTED "...A 2.5 X 2.5 UNSTAGEABLE DARK PURPLE AREA TO LEFT HEEL..." ON 3/11/11 AT 10:25 A.M., DURING AN INTERVIEW WITH THE CLINICAL CARE COORDINATOR (STAFF "F") IT WAS REPORTED THAT THE WOUND WAS NOT ADVANCED UPON IT'S DISCOVERY, DESPITE ITS SIZE AND DESCRIPTION. ( )