Every finding on record at Corewell Health Grand Rapids Hospitals Rehabilitat

Based on observation, interview, and record review, the facility failed to implement a resident comprehensive care plan (placement of pillow behind the neck to reduce/prevent contractures) for 1 of 23 residents (Resident #7) reviewed for care plan implementation, resulting in the potential for breathing complications and increased contractures.Findings include:Resident #7: Review of an admission Record revealed Resident #7 was a male with pertinent diagnoses which included chronic respiratory failure with hypoxia (a condition were the lungs fail to oxygenate the blood for tissues) intracranial hemorrhage (serious type of stroke, bleeding in the skull), and contracture (muscles, tendons, joints and other tissue tighten or shorten causing a deformity) of muscle of both hands and neck. Review of current Care Plan for Resident #7, revised on 9/17/21, revealed the focus, .(Resident #7) has a tracheostomy tube (a hollow tube inserted into a surgically created opening in the neck and windpipe to keep the airway open) and is at risk for occlusion of patent airway (blockage of a clear airway) related to inability to hold head up. Review of Resident Care Summary for Resident #7 dated 11/21/25 revealed, .use neck pillow .Positioning Devices .encourage to use rolled towel for neck positioning.During an observation 01/14/2026 at 9:57 AM, Resident #7 observed to be lying in his bed, and did not have the u-shaped pillow/towel for support under his head/neck/shoulder area. Resident #7's neck was contracted to that his left jaw/side of his face were almost touching his shoulder/collarbone area with very little space between the two. Resident #7 had a washcloth lying on his upper chest area by his mouth area to capture secretions. During an observation 01/14/2026 at 12:14 PM Resident #7 was observed in his bed, the neck u shaped pillow was on the recliner in the room, there was a washcloth lying flat under his left jaw line/face/chin area. Resident #7's head was in the same position, leaning to the left almost touching his left shoulder with very little space between his jaw line and his collarbone/shoulder area. During an observation on 01/14/2026 at 3:29 PM, Resident #7 was observed in his bed, and he did not have the u-shaped neck pillow/rolled up towel in place for his neck for support. Review of Outpatient Referral to Otolaryngology (Ear, Nose, and Throat medicine) dated 11/26/25, revealed, .Need for Referral: Pt (Patient) with worsening contracture of neck. Eval if trach placement and function is appropriate.Has been grabbing more at trach and more painful with trach care. In an interview on 01/15/2026 at 8:39 AM, Certified Nursing Assistant (CNA) K reported Resident #7 had a grey cloth that was a treatment for moisture tucked under his left side of his face between the jawline and his neck, it was to help keep moisture away from that area. Resident #7 had the towel placed on his chest/shoulder area due to he drooled out the side of his mouth on left side. During an observation Resident #7 did not have the u-shaped pillow/rolled up towel in place to provide support. CNA K reported she was going to adjust him in the bed; a draw sheet was used to scoot him up in the bed. CNA K adjusted Resident #7's head some and was able to place the u pillow in place. CNA K reported it was used to provide support for Resident #7's head and neck.

Based on observation, interview, and record review, the facility failed to promote dignity during meals and ensure residents are treated with respect in 3 of 5 residents (Resident #13, #56, & #21) reviewed for dignity/respect, resulting in the potential for feelings of embarrassment, frustration, and impaired self-worth. Findings include: Time management, therapeutic communication, patient education, and compassionate implementation of bedside skills are just a few of the essential skills you need. It is important for your patients to leave the health care setting with a positive image of nursing and a feeling that they received quality care. Your patients should never feel rushed. They need to feel that they are important and are involved in decisions and that their needs are met. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 1589-1592). Elsevier Health Sciences. Kindle Edition. In an interview on 11/19/24 at 11:04 AM, Confidential Information (CI) CC reported in the dining room, staff often are .just talking amongst themselves . and .feeding people too quickly . Resident #13 Review of a Face Sheet revealed Resident #13 was a male, with pertinent diagnoses which included dementia, diabetes, and depression. Review of a Minimum Data Set (MDS) assessment for Resident #13, with a reference date of 10/4/24, revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, which indicated moderate cognitive impairment. Review of a current Care Plan for Resident #13 revealed the problem .at risk for Altered Nutrition and Hydration .(related to) self-feeding deficits . In an observation on 11/19/24 at 12:58 PM, Certified Nursing Assistant (CNA) O assisted Resident #13 with his lunch meal. Observed Resident #13 seated in a wheelchair at a table in the corner of the main dining room. CNA O stood beside Resident #13, offering large spoonfuls of his lunch meal. Noted CNA O did not speak/interact with Resident #13 while providing assistance with the lunch meal. Resident #56 Review of a Face Sheet revealed Resident #56 was a female, with pertinent diagnoses which included dementia, depression, and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #56, with a reference date of 8/8/24, revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated she was cognitively intact. Review of a current Care Plan for Resident #56 revealed the problem .at risk for altered nutrition and hydration status .(related to) self-feeding deficits . In an observation on 11/19/24 at 1:15 PM, Certified Nursing Assistant (CNA) O approached Resident #56 in the main dining room to assist her with her lunch meal. CNA O stood beside Resident #56, quickly offering large bites of the lunch meal. Noted CNA O did not speak/interact with Resident #13 while providing assistance with the lunch meal. In an interview on 11/19/24 at 1:30 PM, CNA O stated in regard to the decision to sit or stand when providing meal assistance to residents, it .depends on if I feel like standing up or sitting down . In an interview on 11/19/24 at 1:32 PM, CNA K reported staff should sit down at the table beside the resident when providing meal assistance. 41027 Resident #21 Review of an Admission Record revealed Resident #21 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: stroke (damage to brain causing paralysis of left side of body). Review of a Minimum Data Set (MDS) assessment for Resident #21, with a reference date of 9/27/24 revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated Resident #21 had moderate cognitive impairment. In an interview on 11/19/24 at 02:21 PM, Resident #21 reported that he had his call light on so that he could get help to go to bed. Resident #21 reported that he had told staff earlier, but they never came back. Resident #21 reported that staff treat him badly, and when he asks for things they ignore him or make excuses. In an observation on 11/19/24 at 2:25 PM in Resident #21's room, Certified Nursing Assistant (CNA) E entered the room and turned the call light off. Resident #21 requested to go to bed, and CNA E said that she would have to go find a lift machine, and left the room. During an observation and interview on 11/21/24 at 09:05 AM, in the hallway near Resident #21's room, Resident #21 reported that the staff in the dining room ignored him when he asked them to bring him his hot cocoa, and that he sat there as long as he could waiting for it. Resident #21 presented his breakfast order ticket to this surveyor, and hot cocoa was listed on the ticket. At 09:07 AM in the hallway, Resident #21 was observed asking dietary staff to get him his hot cocoa. The dietary staff stated that they would have to check on it, and walked away. In an interview on 11/21/24 at 09:09 AM, Restorative Aide (RA) JJ reported that she was assisting residents in the dining room earlier that morning. RA JJ reported that Resident #21 was on a fluid restriction and that may have been why he could not have hot cocoa. In an interview on 11/21/24 at 10:52 AM, Nurse Manager (NM) KK reported that Resident #21 was not on a restricted fluid diet, and should be able to have hot cocoa as requested. During an observation on 11/21/24 at 09:35 AM Resident #21's call light was on, and his roommate exited the room requesting assistance for Resident #21. Then Registered Nurse (RN) F was observed talking to Resident #21. Resident #21 requested to use the toilet and lay down, to which RN F replied that they would need to find help and in the meantime would turn the call light off. Resident #21 then replied loudly, No, leave the light on! At 09:39 AM an unknown CNA asked Resident #21 what he needed, and the resident replied again they he needed help to use the toilet and lay down in bed, to which the CNA told him that she would have to get a lift machine, and walked away. At 09:41 AM a different CNA, CNA H was walking towards Resident #21's room and stated, What's your problem .do you want to go to bed? CNA H proceeded to assist Resident #21 to the toilet, and asked him if he was having a good day. Resident #21 became agitated and said No! CNA H replied by referring to him as Honey and said that he should calm down, be more positive, and that she could solve all of his problems. Then CNA H told Resident #21 that she wanted to be sure that he didn't need anything else before she helped him to bed and stated, .after I leave I don't want you to be calling for this and that . Resident #21 did not reply and was observed to shake his head in a frustrated way. During an observation and interview on 11/21/24 at 10:00 AM, Resident #21 was lying in bed, and reported that the way CNA H had treated him was typical and that he didn't feel like he mattered to them. Resident #21's fingernails on his left hand were long and dirty, with a bandage covering the ring finger nail. Resident #21 reported that staff at the dialysis clinic applied the bandage a long time ago because his nails dug into his hand and made it bleed. Resident #21 reported that that finger was tender to touch. In an interview on 11/21/24 at 10:09 AM, Licensed Practical Nurse (LPN) U reported that she was not aware that Resident #21 had a Band-Aid on his finger, and that she did not see anything in his chart about it. LPN U entered Resident #21's room and asked the resident about his finger. Resident #21 tried to explain, but LPN U kept interrupting and asking him questions. Resident #21 stated, Listen to me! Then LPN U's phone rang, and she answered the phone at the beside. After the phone call was finished, LPN U walked away from the resident, and reported to this surveyor that the resident did not know anything about the Band-Aid, but that it looked old. Then Resident #21 asked LPN U to come back so that he could explain to her what the Band-Aid was.

Based on observation, interview, and record review, the facility failed to provide assistance with fingernail grooming/hygiene for 2 of 5 residents (Resident #21 and #19) reviewed for activities of daily living (ADL's), resulting in the potential for diminished dignity, alteration in skin integrity, nail infection. Findings include: Resident #21 Review of an Admission Record revealed Resident #21 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: stroke (damage to brain causing paralysis of left side of body). Review of a Minimum Data Set (MDS) assessment for Resident #21, with a reference date of 9/27/24 revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated Resident #21 had moderate cognitive impairment. Reveiw of Resident #21's Care Plan with a 9/16/21 start date revealed, .requires assistance with ADLs related to chronic disease progression r/t (related to) comorbidities, fatigue, weakness . In an interview on 11/19/24 at 02:21 PM, Resident #21 reported that staff treat him badly, and when he asks for things they ignore him or make excuses. In an observation on 11/19/24 at 2: 25 PM Resident #21's fingernails on his right hand were long and dirty, his left hand was closed tightly, and his nails were not visible. In an interview on 11/19/24 at 02:29 PM, Certified Nursing Assistant (CNA) E reported that she had given Resident #21 a shower that morning, but did not clean or trim his nails. CNA E reported that it was the first time taking care of Resident #21, and that staff in the dining room should be cleaning his hands. During an observation on 11/20/24 at 03:23 PM, Resident #21's fingernails were still long on his right hand, but were shorter than the day before. During an observation and interview on 11/21/24 at 10:00 AM, Resident #21 was lying in bed, and the fingernails on his left hand were long and dirty, with a bandage covering the ring finger nail. Resident #21 reported that staff at the dialysis clinic applied the bandage a long time ago because his nails dug into his hand and made it bleed. Resident #21 reported that that finger was tender to touch. Resident #21 reported that he would like all of his nails to be shorter. In an interview on 11/21/24 at 10:09 AM, Licensed Practical Nurse (LPN) U reported that she was not aware that Resident #21 hand a Band-Aid on his finger, and that she did not see anything in his chart about it. In an interview on 11/21/24 at 10:18 AM, CNA P reported that he had cared for Resident #21 frequently, but had not noticed a Band-Aid on his finger. CNA P reported that Resident #21 preferred to cut his own nails, and refused staff assistance. CNA P reported that he did not know what he was supposed to do if Resident #21 refused cares. In an interview on 11/21/24 at 10:52 AM, Nurse Manager (NM) KK reported that there was no record of Resident #21 having any issues with his left ring finger. In an interview on 11/21/24 at 11:13 AM, Nurse Supervisor (NS) D reported that she had just then visited with Resident #21, and that his fingernail was thick and tender to touch, and that the resident had requested to have a professional cut the nail for him. NS D reported that she would arrange for the services. Resident #19 Review of Resident #19's Care Plan with a start date of 9/20/21 revealed, .requires assistance with ADLs r/t TBI (traumatic brain injury) with left hemiparesis (paralysis) . During an observation on 11/19/24 at 02:00 PM in Resident #19's room, Resident #19 was lying in bed. Resident #19's fingernails were very long and dirty. In a subsequent interview on 11/19/24 at 2:15 PM, LPN T reported that Resident #19 was completely dependent on staff for all care, and should have regular nail care done during his bed baths, but that she had thought the CNA's reported refusals. In an interview on 11/20/24 at 03:18 PM, LPN T reported that Resident #19 had allowed her to cut his nails that day, and they were now short and clean.

Based on observation, interview, and record review, the facility failed to ensure that thorough documentation of a death in the facility was completed and fingernail issues were recorded for 1 of 23 residents (Resident #113 ) reviewed for accurate and complete medical records, resulting in insufficient details related to death in the facility for Resident #113. Findings include: Resident #113 Review of Resident #113's Flow Sheets dated [DATE] at 5:11 AM indicated, date of death [DATE] at 4:25 AM. Review of Resident #113's discharged as deceased Summary dated [DATE] at 12:13 PM revealed, .history of stroke, .multiple hospitalization s for sepsis and infections and progressive decline in the nine months preceding his passing. He passed away on [DATE] . Review of Resident #113's Nurse's Note dated [DATE] at 5:36 AM revealed, Contacted resident's daughter via phone. Explained to her what happened. She became very upset and hang (sic) up. Will try to call her back to get information. In an interview on [DATE] at 01:08 PM, Nurse Supervisor (NS) N reported that she was not certain of the details of Resident #113's death in the facility. In an interview on [DATE] at 01:27 PM, NS G reported that she did not know Resident #113 and that the medical record did not indicate how he had passed away, there was not a nurse's note describing how/where the resident was found, or the condition he was in prior to his passing. In an interview on [DATE] at 01:56 PM, Nurse Manager (NM) C reported that a nurse's note is not typically written when a resident passed away. In an interview on [DATE] at 02:20 PM, Director of Nursing (DON) B reported that there was no documentation related to Resident #113's death, but that she was told that he passed away peacefully in the night. DON B reported that the facility had a policy in place related to the documentation of death, and that a nursing narrative note should have been created.

This citation pertains to intake #MI00142952. Based on interview and record review, the facility failed to report an allegation of neglect facility staff did not follow a resident care plan to prevent falls to the State Agency for 1 of 3 residents (Resident #103) reviewed for falls, resulting in the potential for continued violations involving neglect and/or abuse going undetected, unreported, or without thorough investigation. Findings include: Review of Resident #103's Care Plan revealed, Problem: .at risk for falls: Start Date: 10/24/23 .INTERVENTIONS: .See Resident Care Summary (RCS) .PROBLEM: .requires assistance with mobility. Start Date: 10/24/23 .INTERVENTIONS: .See RCS. Review of Resident #103's RCS revealed, .Transfer: Dependent: Lift - Sit to Stand. Review of Resident #103's Fall Report dated 10/29/24 at 3:15 PM revealed, .IDT (interdisciplinary team) met and reviewed a witnessed/assisted fall where the POC (plan of care) was not followed. CNA (Certified Nursing Assistant) was transferring resident from bed to his wheelchair without checking the RCS instead just asking the resident how he transferred. CNA stood the resident up and began sitting him down when she noted that he was not sitting back enough and would fall. She quickly called for help from the nurse where they were able to assist the resident to the ground being unable to guide him back further into the wheelchair . In an interview on 6/28/24 at 3:20 PM, Licensed Practical Nurse (LPN) E reported that she responded to CNA M's yell for help with Resident #103 on 10/29/23. LPN E reported that when she entered Resident #103's room, he was half on his wheelchair and half on the bed. LPN E reported that Resident #103 was falling. An attempt was made on 6/28/24 at 3:29 PM to interview CNA M regarding Resident #103's fall, but no return call was received prior to survey exit. In an interview on 6/28/24 at 4:00 PM, NHA (Nursing Home Administrator) A reported that CNA M did not follow Resident #103's care plan for transfer needs, which resulted in a witnessed fall on 10/29/23. NHA A reported that she did not report the violation to the State Agency. Review of the facility policy Resident Abuse Porgram Procedure dated 10/30/23 revealed, .Reporting/response 11.1. All allegations and substantiated incidents will be reported, analyzed, and responded to with corrective actions to prevent further or repeated situations from occurring. 11.2. Any allegation, even if it does not seem credible, or if the resident is known to make frequent, unsubstantiated allegations, must be reported. 11.3. When abuse, neglect or exploitation is suspected, follow the appropriate steps: 11.3.1. [NAME] reporting: In compliance with Federal law, an immediate report is provided to the Administrator/designee and the State Survey Agency ([NAME]) of alleged violations involving physical, mental, involuntary seclusion and sexual abuse, as well as neglect, mistreatment, misappropriation, and injuries of unknown origin. The Administrator/designee must report to [NAME] within two hours. The initial report must provide sufficient information to describe the alleged violation and indicate how the residents are being protected .

This citation pertains to intake #MI00142952 Based on interview, and record review, the facility failed to implement care plan interventions, and perform safe transfers in 1 of 3 residents (Resident #103) reviewed for falls, resulting in a fall and the potential for harm. Findings include: Review of a Face Sheet revealed Resident #103 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: weakness, chronic pain of both lower extremities, and left foot fracture. Review of Resident #103's Fall Risk assessment dated [DATE] indicated a moderate risk for falls. In an interview on 6/28/24 at 8:43 AM, Family Member F reported that Resident #103 admitted to the facility on [DATE] for rehabilitation following a fall at home where he had fractured his foot. Review of Resident #103's Care Plan revealed, Problem: .at risk for falls: Start Date: 10/24/23 .INTERVENTIONS: .See Resident Care Summary (RCS) .PROBLEM: .requires assistance with mobility. Start Date: 10/24/23 .INTERVENTIONS: .See RCS. Review of Resident #103's RCS revealed, .Transfer: Dependent: Lift - Sit to Stand. Review of Resident #103's Fall Report dated 10/29/24 at 3:15 PM revealed, .IDT (interdisciplinary team) met and reviewed a witnessed/assisted fall where the POC (plan of care) was not followed. CNA (Certified Nursing Assistant) was transferring resident from bed to his wheelchair without checking the RCS instead just asking the resident how he transferred. CNA stood the resident up and began sitting him down when she noted that he was not sitting back enough and would fall. She quickly called for help from the nurse where they were able to assist the resident to the ground being unable to guide him back further into the wheelchair . Review of Resident #103's Nurse Note dated 10/29/23 at 3:41 PM revealed, Witnessed fall .CNA transferring resident to wheelchair, he sat on edge of wheelchair, cna called for help, nurse came and both cna and nurse tied to sit resident back in wheelchair without success, resident was lowered to the ground in a sitting position against wheelchair . In an interview on 6/28/24 at 3:20 PM, Licensed Practical Nurse (LPN) E reported that she responded to CNA M's yell for help with Resident #103 on 10/29/23. LPN E reported that when she entered Resident #103's room, he was half on his wheelchair and half on the bed. LPN E reported that Resident #103 was falling. An attempt was made on 6/28/24 at 3:29 PM to interview CNA M regarding Resident #103's fall, but no return call was received prior to survey exit. In an interview on 6/28/24 at 4:00 PM, NHA (Nursing Home Administrator) A reported that CNA M did not follow Resident #103's care plan for transfer needs, which resulted in a witnessed fall on 10/29/23.

Based on observation, interview, and record review, the facility failed to maintain professional standards of care and provide timely incontinence care in 2 of 4 residents (Resident #106 and #108) reviewed for bowel and bladder incontinence, resulting in an increased risk for UTI (urinary tract infection) and the potential for skin breakdown. Findings include: Resident #106 Review of a Face Sheet revealed Resident #106 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: cerebrovascular accident (stroke). Review of Resident #106's Resident Care Summary revealed, 11/28/23: .Skin Care Precautions: Cream - Barrier .Toileting: bladder incontinent, bowel incontinent .Dependent (resident unable to help) . During an observation on 1/31/24 at 11:34 AM Resident #106 was in his room, sitting in a geri chair (used for those with mobility issues, that have difficulty sitting upright in a conventional wheelchair) next to his bed. There was a mechanical hoyer lift sling underneath Resident #106, his chair was slightly reclined and his eyes were closed. During observations at 12:07 PM, 1:20 PM, and 3:07 PM, Resident #106 had remained in that same position and location, except for that his head was leaning further to his left side. In an interview on 1/31/24 at 3:10 PM, Licensed Practical Nurse (LPN) J reported that Resident #106 usually stayed up in his chair from mid morning to around supper time. LPN J reported that Resident #106 does not have the ability to move or reposition on his own, was always incontinent, and had been up in his chair for approximately 4 hours. LPN J reported that Certified Nursing Assistant (CNA) S was on break at that time, but when she returned, LPN J would have her lay Resident #106 down. LPN J reported that Resident #106 cannot make his needs known, nor does he refuse care. LPN J reported that Resident #106 is at risk for pressure ulcers, has a specialty mattress, and at this time his skin looked good. During an observation on 1/31/24 at 3:20 PM in Resident #106's room, CNA S and LPN J are preparing to transfer Resident #106 into bed using a mechanical hoyer lift. When Resident #106 was lifted up from his chair, his incontinence brief was observed bulging with urine, and the surface of the chair was wet. CNA S and LPN J were both wearing gloves and gowns, and LPN J reported that Resident #106 was on enhanced barrier precautions. CNA S obtained a package of disposable wipes and sat it on the bed. CNA S performed the incontinence care, while LPN J assisted as needed. CNA S cleaned Resident #106's front side, wiping over the pubic area, but did not attempt to clean the penis, which was retracted and covered by excess tissue. The wipes were noted to have BM (bowel movement) on them after each wipe. Resident #106 was then positioned on his right side and CNA S removed the incontinence brief, which was heavy with urine and BM. CNA S used several wipes and wash clothes to remove the BM from Resident #106's backside, but did not attempt to lift Resident #106's leg up to ensure the area between the scrotum and anus was clean, and did not apply skin barrier cream prior to applying a clean brief. In an interview on 1/31/24 at 3:50 PM, CNA S reported that she would normally have laid Resident #106 down right after lunch, but that she had multiple hoyer lift transfers that day, and was too tired. CNA S reported that Resident #106 had been up in his chair since about 11:00 AM (4 1/2 hours), and that he was a heavy wetter. In an interview on 1/31/24 at 3:58 PM, Nurse Supervisor (NS) A reported that Resident #106 should have incontinence care every 2 hours, he was at risk for pressure ulcers, and should be repositioned at least every 2 hours. Resident #108 Review of a Face Sheet revealed Resident #108 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: multiple sclerosis (nerve damage causing a communication disruption between the brain and the body). Review of Resident #108's Resident Care Summary revealed, .1/12/24 Toileting: Bowel Incontinent; Bladder incontinent; brief medium; Toilet hygiene: Dependent . During an observation on 2/1/24 at 8:47 AM Resident #108 was sitting in his geri chair in the hall near the nurses station, with a mechanical hoyer lift pad underneath of him. At 2:06 PM (5 hours later) Resident #108 was observed in the same location sitting in his geri chair, with food residue on his shirt, leaning to his left, and sound asleep. In an interview on 2/1/24 at 2:11 PM, CNA P reported that Resident #108 had been up in his chair since before breakfast, and had not had his incontinence brief checked or changed. CNA P reported that normally Resident #108 was laid down right after lunch, but that she (CNA P) had gotten really busy and that she would be getting to him shortly. During an observation on 2/1/24 at 3:00 PM in Resident #108's room, CNA P and CNA M had transferred Resident #108 into bed using a mechanical hoyer lift. CNA M then asked CNA P if further assistance with incontinence care was needed, and CNA P declined needing CNA M's assistance, therefore CNA M exited the room. CNA P then proceeded to provide incontinence care to Resident #108. Resident #108's brief was soaked with urine and BM (bowel movement). CNA P rolled Resident #108 onto his left side, using both of her (CNA P's) hands, and then began washing Resident #108's backside. Resident #108 had thick BM (bowel movement) stuck to his buttocks, and CNA P used 6 or more disposable wipes to clean the area.

Based on observation, interview and record review, the facility failed to implement interventions to prevent skin breakdown for residents at risk for pressure ulcers, for 2 of 2 residents (Resident #106 and #108) reviewed for pressure ulcer prevention, resulting in the potential for the development of an avoidable pressure ulcer, infection, and overall deterioration in health status. Findings include: Resident #106 Review of a Face Sheet revealed Resident #106 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: cerebrovascular accident (stroke). Review of Resident #106's Resident Care Summary revealed, 11/28/23: .Bed Mobility: Dependent assist x 2 .Toileting: bladder incontinent, bowel incontinent .Dependent .Skin Care and Precautions: 11/28/23 Cream - barrier, specialty mattress . There were no other interventions related to pressure ulcer prevention. Review of Resident #106's Braden Score (for predicting pressure ulcer risk) dated 1/10/24 indicated 11, high risk. During an observation on 1/31/24 at 11:34 AM Resident #106 was in his room, sitting in a geri chair (used for those with mobility issues, that have difficulty sitting upright in a conventional wheelchair) next to his bed. Their was a mechanical hoyer lift sling underneath Resident #106, his chair was slightly reclined and his eyes were closed. During observations at 12:07 PM, 1:20 PM, and 3:07 PM, Resident #106 had remained in that same position and location, except for that his head was leaning further to his left side. In an interview on 1/31/24 at 3:10 PM, Licensed Practical Nurse (LPN) J reported that Resident #106 usually stayed up in his chair from mid morning to around supper time. LPN J reported that Resident #106 does not have the ability to move or reposition on his own, was always incontinent, and had been up in his chair for approximately 4 hours. LPN J reported that Certified Nursing Assistant (CNA) S was on break at that time, but when she returned, LPN J would have her lay Resident #106 down. LPN J reported that Resident #106 cannot make his needs known, nor does he refuse care. LPN J reported that Resident #106 is at risk for pressure ulcers, has a specialty mattress, and at this time his skin looked good. During an observation on 1/31/24 at 3:20 PM in Resident #106's room, CNA S and LPN J prepared to transfer Resident #106 into bed using a mechanical hoyer lift. When Resident #106 was lifted up from his chair, his incontinence brief was observed bulging with urine, and the surface of the chair was wet. Resident #106 was positioned on his right side and CNA S removed the incontinence brief, which was heavy with urine and feces. Staff performed incontinence care, and Resident #106 was position directly on his back with head of bed approximately 30 degrees. Staff did not use any pillows for positioning. In an interview on 1/31/24 at 3:50 PM, CNA S reported that she would normally have laid Resident #106 down right after lunch, but that she had multiple hoyer lift transfers that day, and was too tired. CNA S reported that Resident #106 had been up in his chair since about 11:00 AM (4 1/2 hours), and that he was a heavy wetter. In an interview on 1/31/24 at 3:58 PM, Nurse Supervisor (NS) A reported that Resident #106 should have incontinence care every 2 hours, he was at risk for pressure ulcers, should be repositioned at least every 2 hours, and not up in his chair for more than 2 hours at a time. Resident #108 Review of a Face Sheet revealed Resident #108 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: multiple sclerosis (nerve damage causing a communication disruption between the brain and the body). Review of Resident #108's Resident Care Summary revealed, .1/12/24 Skin Care and Precautions: w/c (wheelchair cushion) - standard cream -barrier .Encourage patient to float heels as tolerated. Encourage turn side to side as tolerated .Toileting: Bowel Incontinent; Bladder incontinent; brief medium; Toilet hygiene: Dependent .Bed Mobility: Dependent assist x 2 . Review of Resident #108's Braden Score (for predicting pressure ulcer risk) dated 12/13/23 indicated 11, high risk. During an observation on 2/1/24 at 8:47 AM Resident #108 was sitting in his geri chair in the hall near the nurses station, with a mechanical hoyer lift pad underneath of him. At 2:06 PM (5 hours later) Resident #108 was observed in the same location sitting in his geri chair, with food residue on his shirt, leaning to his left, and sound asleep. In an interview on 2/1/24 at 2:11 PM, CNA P reported that Resident #108 had been up in his chair since before breakfast, and had not had his incontinence brief checked or changed. CNA P reported that normally Resident #108 was laid down in his bed right after lunch, but that she (CNA P) had gotten really busy and that she would be getting to him shortly. During an observation on 2/1/24 at 3:00 PM in Resident #108's room, observed CNA P and CNA M transfer Resident #108 into bed using a mechanical hoyer lift. Resident #108's brief was soaked with urine and BM (bowel movement). Resident #108 had thick BM (bowel movement) stuck to his buttocks, and CNA P used 6 or more disposable wipes to clean the area. Resident #108's buttocks were red, with white scared areas on bilateral lower buttocks. CNA P then rolled Resident #108 back onto his backside and raised the head of bed to approximately 30 degrees. Resident #108 verbalized that he was happy to be in bed.

This citation pertains to intake #MI00142371 and #MI00142124. Based on observation, interview, and record review, the facility failed to ensure residents were free from accident hazards for 3 of 4 residents (Resident #101, #108 and #109) reviewed for falls, resulting in the potential for serious injury from a fall when care plan interventions were not implemented for bed mobility. Findings include: Resident #101 Review of a Face Sheet revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: cerebrovascular accident (stroke). Review of Resident #101's Resident Care Summary (care guide for direct care givers) revealed, High Fall Risk .1/10/24 Safety: Bed low, Orientation: Unable to makes needs known .Bed Mobility (moving from one bed position to another): Dependent (resident unable to help at all) assist x 2 (requires 2 people to safely perform task) .Toileting: .Dependent assist x 2 . Review of Resident #101's Fall Risk assessment dated [DATE] indicated 18, high risk. Review of Resident #101's Fall Event Report dated 1/13/24 at 6:20 AM revealed, .Details: Resident had a witnessed fall. A CNA (Certified Nursing Assistant) was rolling resident in bed for cares and rolled out of bed .Resident sustained abrasion to right knee .POC (plan of care) was not followed .Immediate intervention was education to CNA to always check RCS (Resident Care Summary). Resident was indicated to be a 2 person assist for cares. Review of Resident #101's emergency room Visit Note dated 1/13/24 revealed, .History of present illness: .presents to the emergency department from her long-term care facility after a fall. Reportedly, the patient was being changed in (sic) receiving her daily cares when she rolled out of bed. Patient is nonverbal and nonambulatory at baseline. Does not have any independent motor function .Medical Decision Making: .small abrasion over her right knee as well as a small hematoma on the right tib-fib (lower leg) . In an interview on 1/30/24 at 4:08 PM, Certified Nursing Assistant (CNA) I reported that he was providing incontinence care to Resident #101 on 1/13/24, when she fell off the bed while in high position. CNA I reported that he was aware that Resident #101 required 2 staff for assistance with bed mobility, but that CNA I began incontinence care on his own, turning Resident #101 onto her side, and that was when she rolled off the bed and fell on to the floor. CNA I reported that he rolled Resident #101 away from him (CNA I) and that she slowly slid off the edge of the bed. CNA I reported that he had not worked with Resident #101 prior to 1/13/24, but that he had known she required 2 people for cares, because he checked her care plan. CNA I reported that although Resident #101 was completely dependent and non-verbal, after the fall Resident #101's eyes were wide open, and she appeared uncomfortable. In an interview on 1/31/24 at 10:23 AM, RN O reported that she was passing medications on 1/13/24, when CNA I came down the hall and reported that Resident #101 had fallen on the floor during cares. RN O reported that CNA I had not asked her for help with Resident #101's care, and that she (RN O) had not provided care to the resident prior to the incident. RN O reported that Resident #101 did not have any serious injuries from the fall, but did sustain an abrasion on her knee. In an interview on 1/31/24 at 9:12 AM, Licensed Practical Nurse (LPN) T reported that prior to Resident #101's fall on 1/13/24, she (LPN T) had not ever provided care to the resident. LPN T reported that CNA I came out of Resident #101's room to alert other staff of the resident's fall, and that when LPN T entered the room, Resident #101 was lying face down on the floor, and the bed was in high position. In an interview on 1/31/24 at 8:31 AM, LPN X reported that on 1/13/24 at approximately 6:30 AM CNA I said that he was having problems and asked her for assistance with Resident #101, but that she (LPN X) was in the middle of providing care to a different resident, and had informed CNA I that she would be able to help him in a few minutes. LPN X reported that about 10 minutes later CNA I was in the hallway upset, saying that Resident #101 had fallen off the bed while he (CNA I) was providing care. LPN X reported that Resident #101 was completely dependent for cares, had a tracheostomy, but that she was not sure if Resident #101 always required 2 staff for assistance for bed mobility. In an interview on 2/1/24 at 10:40 AM, DON reported that Resident #101's fall was a result of staff not following the resident's care summary, which indicated that she required 2 assist for bed mobility. DON reported that after Resident #101's fall on 1/13/24, all staff were re-educated related to resident care summaries being followed, and audits were being performed weekly to ensure that staff are implementing the appropriate safety measures for bed mobility. DON reported that direct care staff audits were being performed by managers and a CNA. Resident #108 Review of a Face Sheet revealed Resident #108 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: multiple sclerosis (nerve damage causing a communication disruption between the brain and the body). Review of Resident #108's Resident Care Summary revealed, High fall risk .1/12/24 Bed Mobility: dependent assist x 2 .Toilet hygiene: Dependent . During an observation on 2/1/24 at 2:33 PM in Resident #108's room, CNA P and CNA M transferred Resident #108 into bed using a mechanical hoyer lift. CNA M then asked CNA P if further assistance with incontinence care was needed, and CNA P declined needing CNA M's assistance, therefore CNA M exited the room. CNA P then proceeded to provide incontinence care to Resident #108. CNA P rolled Resident #108 onto his left side, using both of her (CNA P's) hands, and then began washing Resident #108's backside. Resident #108 was facing away from CNA P, with his arms crossed on his chest, and not holding on to the handrail or assisting in any way. Resident #108 was approximately 6 inches from the edge of the bed and the bed was in mid-high position. Resident #109 Review of a Face Sheet revealed Resident #109 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: quadriplegia (paralysis of all of body from neck down) and bilateral below the knee amputations. Review of Resident #109's Resident Care Summary revealed, High fall risk .Bed Mobility: 1/12/24 Dependent . During an observation on 2/1/24 at 2:12 PM in Resident #109's room, CNA P was providing incontinence care. CNA P rolled Resident #109 onto his left side, away from her to wash the backside of Resident #109. While holding onto Resident #109 with one hand, CNA P grabbed her phone and made a call to a nurse to report redness in Resident #109's groin. Resident #109 was on his side, leaning downward towards the floor and CNA P was holding on tightly with one hand as she was trying to clean the BM (bowel movement) off of Resident #109's backside. Resident #109's hands and arms were in front of his face and chest, and he was not holding on to the handrail. The bed was in high position. In an interview on 2/1/24 at 3:16 PM, CNA P reported that Resident #108 and #109 were completely dependent with bed mobility and could not assist or keep themselves from falling off the bed, but only required one assist for bed mobility and incontinence care. CNA P reported that she was confident that she could handle the residents on her own, and could catch them if they started to fall. In an interview on 2/1/24 at 3:29 PM, Nursing Supervisor (NS) A reported that when a resident is dependent status, that indicated they were not able to help with cares. Resident #108 and #109 are both in need of 2 staff assistance with bed mobility due to their dependent status. NS A reported that Resident #108 used to be able to hold the handrail, but with his condition had declined, and he was no longer strong enough to hold the handrail. NS A reported that Resident #109 was definitely an assist of 2 with bed mobility, was completely dependent, and reported that the resident's hands were stiff and rigid. NS A reported that she would expect that there are 2 CNA's providing all cares that involve bed mobility for Resident #108 and #109. Review of facility Educational Materials that were presented to all staff following Resident #101's fall on 1/13/24 revealed, Resident Care Summary (RCS): .Remember safety first! That means, checking the RCS before caring for a resident. If you do not check the RCS to confirm a residents plan of care, you are putting yourself and the resident at risk for injury, decline and death .How to roll a resident: Residents must always be rolled towards the caregiver. It is never appropriate to roll a resident away from you unless there is another person on the other side of the bed .

Based on observation, interview, and record review, the facility failed to maintain safe infection control practices in regard to hand hygiene (glove use), and consistently implement enhanced barrier precautions in 3 of 4 residents (Resident #106, #108 & #109) reviewed for infection control, resulting in the potential for cross-contamination and the development and spread of multi-drug resistant bacteria. Findings include: The following residents (Resident #106, #108, and #109) were all in the same room. During repeated observations from 1/31/24-2/1/24 at 3:10 PM, the door signage indicated, enhanced barrier precautions in place and N95 mask use was required during nebulizer (breathing) treatments. Review of Resident #106's Resident Care Summary indicated no precautions in place. Review of Resident #108's Resident Care Summary indicated no precautions in place. Review of Resident #109's Resident Care Summary revealed, 10/2/22, Initiate Enhanced Barrier Precautions. Continuous. During an observation on 1/31/24 at 1:23 PM in Resident #108's room, CNA (Certified Nursing Assistant) S and CNA F were providing incontinence care to Resident #108. Both staff were wearing gloves. CNA S washed the front side of Resident #108 with wash clothes, then rolled the resident to wash his backside. CNA S opened the resident's nightstand drawer and was digging around looking for soap with her soiled gloves on, and then asked CNA F to get the soap from the bathroom. CNA S then grabbed the soap bottle, applied liquid soap to a wash cloth and began cleaning Resident #108's backside. There was a small amount of BM (bowel movement) on the washcloths. The CNA's rolled Resident #108 back and forth to reposition the pad on the bed, CNA S covered the resident with a blanket, and then used the bed controls to raise the head of the bed. CNA S did not remove or changed her gloves when going from dirty to clean areas of the resident, touching objects in the room; CNA S did not remove her soiled gloves until all cares were completed. In an interview on 1/31/24 at 3:10 PM, with Licensed Practical Nurse (LPN) J regarding the signage posted on the resident's' door, reported that Resident #106 was currently the only resident in the room on enhanced barrier precautions due to having a Tracheostomy (an opening into the trachea (windpipe) with a tube inserted to breathe), and that it required a gown and gloves for direct care, and an N95 mask during nebulizer treatments. During an observation on 2/1/24 at 2:12 PM in Resident #109's room, CNA P was wearing gloves, no gown, and preparing to perform incontinence care. At the bedside, CNA P emptied Resident #109's catheter bag. With the same gloves on, CNA P then began incontinence care using disposable wipes that were in a plastic package. CNA P washed the residents front side, and there was BM notes on the wipes. CNA P rolled Resident #109 onto his left side, away from her to wash his backside, and grabbed multiple wipes from the container. While holding onto Resident #109 with one hand, CNA P grabbed her phone and made a call to a nurse to report redness in Resident #109's groin. CNA P did not change or remove her soiled gloves. CNA P was holding on tightly with one hand as she was trying to clean the BM (bowel movement) off of Resident #109's backside, and handling the wipes package with her soiled gloves. CNA P rolled the resident onto his back, placed the wipes package on the nightstand, adjusted the pad underneath him, covered him with a sheet, and then removed her soiled gloves. CNA P did not wear a gown during cares. During an observation on 2/1/24 at 2:27 PM, CNA P and CNA B were in Resident #106's room to provide incontinence care. Both staff were wearing gloves and no gown. CNA P cleaned the front of Resident #106 and then rolled the resident, removed his soiled incontinence brief, and wash his buttocks. Resident #106 had a small amount of BM (bowel movement) in the crease of his buttocks. After cleaning the area, CNA P grabbed a clean incontinence brief, tucked it under the residents buttocks, and then rolled the resident back towards her and finished attaching the brief. CNA P then noticed that Resident #106's towel around his tracheostomy had fallen down, so she placed it back up under his chin, so that any fluid from his tracheostomy would be caught on the towel. After care was finished, CNA P removed her soiled gloves. During an observation on 2/1/24 at 3:00 PM in Resident #108's room, CNA P and CNA M both were unsure of which resident in the room had enhanced barrier precautions in place, but had been informed by management that they should wear a gown and gloves for all 3 residents in the room, therefore they both donned a gown and gloves. CNA P and CNA M transferred Resident #108 into bed using a mechanical hoyer lift. CNA M then asked CNA P if further assistance with incontinence care was needed, and CNA P declined needing CNA M's assistance, therefore CNA M exited the room. CNA P then proceeded to provide incontinence care to Resident #108. Resident #108's brief was soaked with urine and BM (bowel movement). CNA P rolled Resident #108 onto his left side, using both of her (CNA P's) hands, and then began washing Resident #108's backside. Resident #108 had thick BM (bowel movement) stuck to his buttocks, and CNA P used 6 or more disposable wipes to clean the area. CNA P used her soiled gloved hand to pull the wipes from the container as needed during the care. CNA P then used her gloved hands to open the nightstand and pull out Resident #108's skin barrier cream, and apply it to his buttocks, still using her soiled gloved hands. CNA P then rolled Resident #108 back onto his backside, adjusted the pillow under his head, and covered him with a blanket. After the cares were finished, CNA P removed her soiled gloves. In an interview on 2/1/24 at 3:16 PM, CNA P reported that she keeps forgetting to change her gloves during incontinence care and stated that she should change gloves after washing a resident's front side. CNA P reported that she did not know if Resident #106, Resident #108 or Resident #109 were on enhanced barrier precautions, but that based on the signage on the door, she would assume that staff were required to wear gowns, gloves and N95 when in the room. In an interview on 2/1/24 at 3:29 PM, Nurse Supervisor (NS) A reported that Resident #109 is the only resident in that room with enhanced barrier precautions ordered, for bacterial colonization in his catheter. NS A reported that the bacteria is resistant to multiple antibiotics, can cause a bad infection, and therefore was very important to keep it from spreading to other residents. NS A reported that she would expect staff to wear gloves and gowns when emptying Resident #108's catheter, providing direct care, and be careful not to cross contaminate with roommates. NA A reported that touching Resident #106's tracheostomy towel with contaminated gloves could pose a serious risk of infection. In an interview on 2/2/24 at 12:00 PM, Infection Preventionist (IP) reported that staff should refer to the resident's Resident Care Summary to determine if the resident had orders for transmission based precautions. IP Reported that the room that Resident #106, #108, and #109 are in, the only resident that was currently on any type of precautions was Resident #109 and that was related to MDRO in his catheter. Regarding glove use during incontinence care, IP reported that CNA's are expected to perform hand hygiene prior to donning gloves, remove gloves with dirty, perform hand hygiene again and don new gloves. IP reported that staff should not be touching any clean areas during incontinence care with the gloves that they provide incontinence care with, and should don clean gloves before applying barrier cream. IP reported that staff should not be touching soap bottles, the wipes packaging, nightstand drawers, and/or barrier cream containers with dirty gloves. Review of a facility policy Infection Prevention Hand Hygiene dated 1/5/23 revealed, .Indications for hand hygiene with soap and water, or alcohol-based hand sanitizer: .Before moving from work on a soiled body site to a clean body site on the same patient. After touching a patient or objects in her/his immediate surroundings. After contact with a patient's intact skin .After contact or risk of contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings, even if hands are not visibly soiled. Before donning and after the removal of any personal protective equipment (e.g., gloves, gown, mask) . Review of a facility policy Isolation Specifics dated 9/27/23 revealed, .Enhanced barrier precautions are required when a resident has an infection or colonization with a novel or targeted MDRO (multi-drug resistant organism), when Contact Precautions do not apply .Enhanced barrier precautions require gown and glove use for certain residents during specific high-contact resident care activities that have been found to increase MDRO transmission such as: .bathing .providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: .urinary catheter, feeding tube, tracheostomy .

Based on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect in 5 (Residents #30, #477, #480, #25, and #54) of 7 residents reviewed for dignity, resulting in staff not respecting privacy for Resident #30, long call light wait time following incontinence episode for Resident #477, staff speaking disrespectfully about Resident #480 in his presence during incontinence care as well as long call light wait time following incontinence episode, and staff not promoting dignity and self-determination for Resident #25 and Resident #54. Findings include: Resident #30 Review of an Admission Record revealed Resident #30 was a male, with pertinent diagnoses which included: moderate episode of recurrent major depressive disorder, and moderate vascular dementia with agitation. Review of a Minimum Data Set (MDS) assessment for Resident #30, with a reference date of 8/25/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #30 was cognitively intact. An interview was being conducted by this surveyor on 11/14/23 at 8:45 AM with Resident #30, who was in his room lying in his bed, and his spouse, who was on speaker phone. During the interview, a nurse walked into Resident #30's room. She did not knock, nor did she ask permission to enter. Once in the room, Resident #30 told the nurse that we were on a call with his spouse and needed privacy. The nurse stood there, looked at this surveyor and said, I have his pills. She then handed the pills to Resident #30 and reported she wanted him to have his pills before he went to therapy. Resident #30 told the nurse he did not have therapy that day to which the nurse reported she had already waited a while before coming in. After handing Resident #30 his pills, the nurse walked out of the room without saying another word. In a follow up interview on 11/15/23 at 1:14 PM regarding the interaction with the nurse during the interview the day before, Resident #30 stated, That happens all the time. They don't introduce themselves. They aren't pleasant. Resident #477 Review of an Admission Record revealed Resident #477 was a male, with pertinent diagnoses which included: cerebral palsy, spastic (a disorder affecting movement and muscle tone), debility, and history of seizures. Review of a Minimum Data Set (MDS) assessment for Resident #477, with a reference date of 11/6/23 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #477 was cognitively intact. Further review of said MDS revealed Resident #477 was, on admission, dependent on staff for toileting hygiene (the ability to maintain perineal hygiene) and that Resident #477 was Always incontinent of bowel and bladder. In an interview on 11/13/23 at 2:54 PM, Resident #477 reported staff didn't always answer his call light, mostly at night. Resident #477 reported he has had instances when he has had a bowel movement in his brief and had to lay in it until morning. Resident #477 reported he has had to call security to have them call up to his unit to have someone come to his room. Resident #480 Review of an Admission Record revealed Resident #480 was a male, with pertinent diagnoses which included: weakness following cerebrovascular accident (stroke), physical deconditioning, decreased activities of daily living, and incontinence. Review of a Minimum Data Set (MDS) assessment for Resident #480, with a reference date of 11/7/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #480 was cognitively intact. Further review of said MDS revealed Resident #480, on admission, was Always incontinent of bowel. In an interview on 11/14/23 at 9:26 AM, Resident #480 reported was new to the facility, had just transferred from a local hospital for rehabilitation and that he wanted to go home badly. Resident #480 reported the day shift certified nurse aides (CENAs) were marvelous but that the night shift aides were not. Resident #480 reported he had reported two of the night shift CENAs to the nurse because they were verbally vulgar in front of him. Resident #480 reported he required 2 staff to change his brief and when he had had a bowl movement, 2 CENAs came into his room to change him and one of the CENAs said to the other CENA that he f*cked up his brief again. Resident #480 reported they said the F word three or four more times to himself and to each other during the brief change. Resident #480 reported he felt degraded. Resident #480 reported it has also taken up to an hour to get his brief cleaned up and stated, I have to set in my own filth and don't want to have to do that. Resident #480 became visibly tearful and upset when speaking about his experiences to this surveyor. In an interview on 11/16/23 at 11:18 AM, Licensed Practical Nurse (LPN) V reported Resident #480 had bought a concern to her that the night nurse aides had not been very nice to him and that he was upset. LPN V reported Resident #480 had said they had used the F word when referring to his brief during a brief change. LPN V reported Resident #480 seemed upset when he reported the concern to her and that she could tell that it bothered him. Review of a Concern Form: for Resident #480 revealed, .Brief Factual Description Resident shared concern that 2 cnas (CENAs) were unprofessional in their communication with him. Resident needs were met. Resident asked for follow up to be completed with cnas to promote therapuetic (sic) communication . In an interview on 11/16/23 at 11:47 AM, CENA B reported more than one resident has complained to her that the night shift CENAs don't treat the residents with respect and that the night shift CENAs didn't do brief changes in a timely fashion, if at all. In an interview on 11/16/23 at 11:56 AM, CENA HH reported residents complained to her every day about the night shift CENAs, specifically that they didn't change the residents' briefs, they didn't check on the residents, and that they didn't treat the residents with respect. 46999 Resident #25 Review of a Face Sheet dated 4/11/22 revealed Resident #25 was admitted to the facility with the following pertinent diagnoses: paraplegia with spasticity (paralysis of the legs with muscle stiff or rigid muscles), chronic pain, muscle spasms of left lower extremity, chronic left hip pain, moderate recurrent major depressive disorder, and back muscle spasm. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 scored 15/15 on a Brief Interview for Mental Status (BIMS) assessment, which indicated the resident was cognitively intact. Section E of the MDS indicated Resident #25 had no episodes of refusing care during the assessment period. Section GG revealed Resident #25 required maximal assistance (helper does more than half the effort) for transferring from a lying to sitting position, transferring from a sitting to standing position, and for transferring from the bed to a wheelchair. Section J of the MDS revealed Resident #25 was in almost constant pain. Review of a Care Plan for Resident #25, dated 4/12/22 revealed the following problems and interventions: Problem: (Resident #25) requires assistance with mobility related to paraplegia .chronic pain .Intervention: mobility performance/assist, Problem: Resident has an actual mood impairment .Interventions: assist to identify .strategies to overcome obstacles, provide relaxation .Problem: (Resident #25) has a comfort impairment .Intervention: Distraction .Problem: (Resident #25) has identified need to participate in activities to enhance psychosocial well-being, Interventions: Customary routine .initiates time out of room to sit with family room, is social with staff and other residents, enjoys time outdoors as weather permits. In an interview on 11/16/23 at 1:37pm, Resident #25 reported it was important to her to get out of bed every day because it helped with her mood and pain level. Resident #25 sat in her wheelchair, applying make-up during the interview, and stated, I have to get out of that bed every day or I'm in terrible pain and my emotions get the best of me. Resident #25 reported getting out of bed, getting her make-up on, and going out of the room to visit others, spend time outdoors, go to activities helped her cope with stress and kept her mind off her pain. Resident #25 reported she had been told several times, on the weekends, that staff would not be able to assist her with getting up because they were too busy, and that she'd have to stay in her bed for the day. Resident #25 reported she insisted that staff help her get up and ultimately, they did but she felt helpless and frustrated when staff said they would not get her up. Resident #25 stated I advocate for myself to get out of bed, but I shouldn't have to. In an interview on 11/16/23 at 2:21pm, Certified Nursing Assistant (CENA) F reported she worked some weekends and had witnessed staff leaving residents in bed for the entire day on the weekend, and telling residents they were too busy to get them up. CENA F reported some residents were very upset when they were told they could not get up for the day but were only assisted if they continued to insist upon getting up. Review of a Resident Rights policy dated 10/30/23 revealed a statement that read Every resident shall be entitled to humane care and treatment provided with dignity and respect. Residents are entitled to all the freedom and privileges of any other citizen. Section 3.6.1.1. of the policy stated Appropriate care will not be denied on the basis of .handicap .Equal access to care will be provided regardless of diagnosis, severity of condition . 41027 Resident #54 Review of a Minimum Data Set (MDS) assessment for Resident #54, with a reference date of 8/25/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #54 was cognitively intact. In an interview on 11/14/23 at 09:34 AM, Resident #54 reported that staff are kind, but that he always has to wait a long time for things; he had asked to have his clock reset to daylight savings time several times and facility staff say that they will come back and do it, but they never do. The time on the clock was observed set incorrectly for 10:34 AM. Resident #54 reported that he frequently waits 30-60 minutes for his call light to be answered, and then staff tell him that they are too busy to help him. Resident #54 reported that he had asked for a glass of lemonade that morning and 2 hours later the CNA came back and apologized because she had forgotten and stated, .its all the little things that bug me .

Based on observation, interview, and record review, the facility failed to obtain and/or honor meal preferences for 4 (Residents #4, #106, #123, and #73) of 29 sampled residents reviewed for meal services, resulting in resident dissatisfaction with their meal experience, feelings of frustration related to meals, and the potential for inadequate food/fluid intake and weight loss. Findings include: Resident #4 Review of an Admission Record revealed Resident #4 was a male, with pertinent diagnoses which included: type 2 diabetes mellitus (a condition where the body is not able to properly use sugar from the blood) with hyperglycemia, with long-term current use of insulin; hypertension (high blood pressure) associated with diabetes; and weight loss. Review of a Minimum Data Set (MDS) assessment for Resident #4, with a reference date of 9/1/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #4 was cognitively intact. During an observation/interview on 11/13/23 at 12:26 PM, Resident #4 was lying in his bed in his room with his lunch meal tray on the beside table in front of him. The meal tray was untouched. Resident #4 reported he had not eaten his lunch because he did not want what was served to him. Resident #4 lifted the lid off his plate and showed this surveyor what appeared to be a grilled cheese sandwich. Resident #4 reported what was on the menu for lunch that day was shrimp and french fries but that somebody else filled out his menu and he received the sandwich instead. Resident #4 reported, given the choice, he would have wanted the shrimp and french fries. Resident #4 reported if he were to say anything about it, staff would say they would get him the menu item if we have any left. Resident #4 reported it has happened before that nobody came to take his meal order. In an interview on 11/16/23 at 11:18 AM, Licensed Practical Nurse (LPN) V reported residents have complained to her that staff had not taken their meal order or that they didn't get what they ordered. In an interview on 11/16/23 at 11:47 AM, Certified Nurse Aide (CENA) B reported residents have complained to her that they don't get what they ordered or that staff hadn't come to take their meal order. In an interview on 11/16/23 at 11:56 AM, CENA HH reported residents have complained to her about the food quite often. CENA HH reported residents have said that nobody came to take their meal order and that they didn't order what they received. CENA HH stated, it is an ongoing issue. 47955 Resident # 106 Review of an Admission Record revealed Resident #106 had pertinent diagnoses which included bipolar affective disorder with episode hypomanic, congestive heart failure, and general weakness. Review of a Minimum Data Set (MDS) assessment for Resident #106, with a reference date of 10/1/23 revealed a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated Resident #106 was cognitively intact. During an interview on 11/13/23 at 11:47 AM., Resident #106 reported that the facility will not allow her have lasagna. Resident #106 reported lasagna was her favorite food. Review of Physician Orders for Resident #106 revealed: Dietary orders from admission, onward, with a start date of 9/29/2023 adult diet, diet type: General; fluid restriction: 2000ml daily/1200 with meals; Sodium Restriction: 3-4 grams sodium (NAS (no added salt)) . During an interview on 11/14/23 at 09:47 AM., Resident #106 reports that she did not get to make personal choices about the food she ate. Resident #106 reports when she ordered lasagna, she did not get it. During an interview on 11/14/23 at 2:58 PM., Resident #106 reported that when she ordered lasagna the menu taker (a dietary staff member who was assigned to take menu orders from residents on the unit) told Resident #106 the computer did not allow for Resident #106 to order lasagna. Resident #106 reported not being able to order her favorite food made her mad and frustrated. Resident #106 reported she was told she could not order lasagna so many times she stopped asking for it when it was on the menu. During an interview on 11/14/23 at 3:07 PM., Nutrition Tech (NT) A reported every day there was a menu taker assigned to the units. NT A reported the daily menu taker would take resident's orders for the following day or two days. NT A reported Resident #106 had a daily sodium limit in the menu program on the tablet used to take orders. NT A reported if the food option was over the total sodium grams allowed for the day, the resident would not be able to select the food choice. NT A reported if there was a discrepancy with the resident's choice and the diet's limits in the menu program, the diet office and the dietitian were notified to make changes. During an interview on 11/14/23 at 3:16 PM., NT A reported that when a resident ordered options from the menu the menu program totaled sodium (or other limitations). When the limit has been reached for the day, the food options on the menu above the preset limit turned red and were no longer available to the resident as choices. NT A reported if the resident was insistent in wanting an item from the menu, the nutrition tech would discuss it with the dietary office where an alternative option could be put into the menu program and the dietitian would be notified of the need to meet with the resident to discuss menu options. During an interview on 11/14/23 at 3:46 PM., Registered Dietitian (RD) SS reported she had not been notified of the resident #106's request for lasagna. RD SS reported she had spoken to Resident #106 about other food options she had requested in the past and changes had been made to allow for Resident #106's food choices. During an interview on 11/15/23 at 09:38 AM., Resident #106 reported the registered dietitian met with her the day before to discuss an evaluation of her diet to accommodate Resident #106's request for lasagna. Review of facility policy SHCC: Resident Rights - Continuing Care (Rehab and Nursing Centers) with an effective date of 10/30/23 revealed: .3.6.1.18. Each resident shall be provided with meals that meet the recommended dietary allowances for their age and gender and may be modified according to special dietary needs, preferences, or ability to chew/swallow. The facility will consider residents' needs, preferences, and the cultural and religious make-up of its population in food and meal preparation . 46999 Resident #123 Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #123 was admitted to the facility with following pertinent diagnoses: heart failure (chronic condition in which the heart doesn't pump blood as well as it should), pressure ulcer (injury to the skin and underlying tissue resulting from prolonged pressure on the skin), anemia (condition the body does not have enough red blood cells and results in reduced oxygen flow to the body's organs), diabetes mellitus(condition resulting in abnormal metabolism of carbohydrates and elevated glucose in the blood), anxiety, depression, and hypokalemia( deficiency of potassium in the blood stream). Section C of the MDS revealed a Brief Inventory for Mental Status (BIMS) score of 15/15 which indicated Resident #123 was cognitively intact. In an interview on 11/15/23 at 10:55am Resident #123 reported ongoing problems with her menu selections not being honored. Resident #123 stated My food is wrong almost every day. Resident #123 reported she ordered the same breakfast every day (3 pancakes and a slice of bacon) and this date she received a boiled egg, 1 sausage and a piece of toast. Resident #123 expressed frustration with the food she selected not being provided. Resident #123 reported she felted stressed about having to ask staff to bring her something else to eat because she did not want to interfere with them caring for other people. In an interview on 11/14/23 at 2:43pm, Certified Nursing Assistant (CENA) I reported residents quite often don't get the food they ordered on their meal tray. CENA I reported the staff try to contact the kitchen to reorder the residents' food, but the kitchen often has issues accommodating the request. Resident #73 Review of a Face Sheet dated 8/4/18 revealed Resident #73 was admitted to the facility with the following pertinent diagnoses: end stage renal disease (condition in which the kidneys lose the ability to remove waste and balance fluids), hypertension (high blood pressure), chronic constipation (difficulty emptying the bowels), chronic dialysis (procedure to remove waste products and excess fluid from the blood). Review of a Minimum Data Set (MDS) assessment for Resident #73 dated 8/11/23 revealed a Brief Inventory for Mental Status (BIMS) score of 12/15 which indicated the resident had a moderate cognitive impaired. Section C of the MDS revealed Resident #73 displayed no inattention, disorganized thinking, or altered level of consciousness during the assessment period. Review of a Care Plan dated 9/16/21 revealed problem/goal/interventions as follows: Problem: (Resident #73) has a nutritional risk related to therapeutic diet/end stage renal disease/hemodialysis. Goal: (Resident #73) will maintain nutrition .Interventions: diet as ordered . honor food preferences as able . In an interview on 11/15/23 at 9:48am, Resident #73 reported he frequently did not get the food he ordered when his meal tray arrived. Resident #73 explained that he had limited options for food due to his health issues/need for a special diet, and he felt frustrated when he ordered something that was on his menu, but it was not provided. Resident #73 stated I can't eat a lot of things, so if I pick something that's on my menu, I'm mad when it doesn't come.

Based on interview and record review, the facility failed to ensure an annual PASARR II (PASARR Level II is a comprehensive evaluation by the appropriate state-designated authority and determines whether the individual has mental disability, intellectual disability, or a related condition, determines the appropriate setting for the individual and recommends what, if any, specialized services and/or rehabilitative services the individual needs) assessment was completed timely for 1 resident (R21) of 2 residents reviewed for PASARR, resulting in the potential for the resident to not maintain or achieve their highest practicable psychosocial well-being. Findings include: According to the Minimum Data Set (MDS) dated [DATE], R21 scored 9/15 (moderately cognitively impaired) on his BIMS (Brief Interview Mental Status), with diagnoses that included schizoaffective disorder (a combination of symptoms of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly and mood disorder, such as depression or bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). During an interview and record review on 11/15/2023 at 11:49 AM of R21's PASARR with Social Worker (SW) KK, who stated, I believe (R21) had a PASARR done. He qualifies for a PASARR II due to his diagnosis of schizoaffective disorder. The SW reviewed R21's medical record stating, I am not seeing his PASARR II right now. SW KK continued reviewing R21's medical records for the due date for having the PASARR II completed. SW KK stated, Social Services is responsible to submit the paperwork to have the PASARR II done annually. SW KK continued to look for R21's PASARR schedule and could not find the schedule. SW KK stated, Usually there is an Excel spreadsheet that has the resident due dates. I cannot find it. During an interview and record review on 11/15/2023 at 3:22 PM, SW KK stated, I was given a spreadsheet of PASARR due dates by another SW. SW KK reviewed the spreadsheet, stating, I do not think I can find (R21's) due date for his PASARR II to be done. It was not done. The last one he had was in February 2022.

Based on observation, interview, and record review, the facility failed to ensure maintenance, cleaning, and sanitary storage of CPAP (continuous positive airway pressure) and BIPAP (bilevel (alternating) positive airway pressure) respiratory equipment in accordance with physician orders and professional standards 4 of 6 residents (Resident #1, #54, #3, #7) reviewed for respiratory care, resulting in an increased potential for respiratory infection and respiratory distress. Findings include: Resident #1 Review of an Admission Record revealed Resident #1 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: chronic respiratory failure with hypoxia (deprived of oxygen) and hypercapnia (elevated carbon dioxide levels), COPD (chronic obstructive pulmonary disease) and asthma. Review of a Minimum Data Set (MDS) assessment for Resident #1, with a reference date of 9/29/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #1 was cognitively intact. During an observation and interview on 11/13/23 at 02:24 PM Resident #1 was lying in her bed in her room and reported that her breathing had been bothering her. A CPAP machine was observe on Resident #1's nightstand, covered in dust, and without a power cord. Resident #1 reported that the facility gave her the CPAP machine when she admitted , but it stopped working and stated, .the filter seemed clogged and the power cord was not right . Resident #1 reported that a man from (outside durable medical equipment provider name omitted) looked at it some months ago and was supposed to fix it. Resident #1 reported that when staff ask her to use the machine, she tells them no because it doesn't work right and stated, .no one asks anymore .I thought maybe I didn't need to use it anymore . Resident #1 reported that someone comes and changes the bag and mask regularly, but that no one cleans the machine or tries to turn it on. Resident #1 was using oxygen via nasal cannula tubing and reported that she has to wear it all the time. Review of Resident #1's Physician Orders revealed, 8/22/22 start .CPAP level 10 .at night . In an interview on 11/14/23 at 08:56 AM, Resident #1 reported that no one had been in to fix her CPAP machine yet. In an interview on 11/14/23 at 02:53 PM, Registered Nurse (RN) DD reported that Resident #1 is supposed to use the CPAP at night and stated, .it is already off her when I get here in the morning .I am not sure who takes it off . In an interview on 11/15/23 at 09:01 AM, Resident #1 reported that she did not use the CPAP the night before and stated, .it doesn't have a plug .they don't want me to do it myself .I couldn't do it if I wanted to . The CPAP was observed as it was 2 days prior, covered in dust. In an interview on 11/15/23 at 09:05 AM, Licensed Practical Nurse (LPN) EEE reported that Resident #1 was supposed to wear her CPAP at night and stated, .she has it off in the morning when I get here .I have not ever talked to her about it .it is my job to clean it . LPN EEE entered Resident #1's room and observed the CPAP machine covered in dust and without a power cord and stated, .we don't have a respiratory department here and that is the problem . Resident #1 reported to LPN EEE that she does not use the machine, and she never has used the machine because it didn't have a power cord. In an interview on 11/15/23 at 09:14 AM, Nursing Supervisor (NS) R reported that Resident #1 had orders for CPAP use at night and that it was the nurses responsibility to assist the resident with application of the mask and turning the machine on. NS R reported that the documentation in Resident #1's work list (administration record for CPAP) indicated that the resident refused the CPAP at times, and then at times there was no documentation at all and stated, .she doesn't like to wear it .her family is aware . This surveyor requested documentation on how the facility was addressing Resident #1's refusal to use the CPAP. NS R was not aware that the CPAP machine in Resident #1's room was covered in dust and did not have a power cord. Review of Resident #1's Work List in the electronic medical record, indicated that on 11/7/23 refused the CPAP and stated that the machine was broken. There were refusals on 11/15/23, 11/14/23, 11/13/23, 11/9/23, 11/8/23, 11/4/23, 11/3/23, etc. On 10/9/23 the record indicated that CPAP was not functional. In an interview on 11/15/23 at 02:32 PM, Physician Assistant (PA) BBB reported that Resident #1 had orders for CPAP to be applied every night and that PA BBB was not aware that the resident had been refusing to use the CPAP. PA BBB reported that the electronic health record system did not allow nursing staff to convey day to day concerns or narratives to other nurses or providers. Review of Resident #1's Quarterly Care Conference dated 10/5/23 revealed, .continues on O2 (oxygen) via nasal cannula PRN (as needed) during the day and she has a recommended CPAP at night. Declines use, continue to encourage . Review of Resident #1's Quarterly Care Conference dated 8/10/23 revealed, .continues on O2 (oxygen) via nasal cannula PRN (as needed) during the day and CPAP orders at night .continues to decline the use of CPAP, guardian aware. Continue to encourage . Review of Resident #1's Family/Patient Representative Notification dated 11/15/23 at 09:30 revealed, .(NS R) touched base with resident regarding CPAP - resident verbalized and acknowledged that although she previously declined, she would like to start wearing the CPAP again . Resident #54 Review of an Admission Record revealed Resident #54 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: respiratory failure. Review of a Minimum Data Set (MDS) assessment for Resident #54, with a reference date of 8/25/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #54 was cognitively intact. In an interview on 11/14/23 at 09:34 AM, Resident #54 reported that he wears a BIPAP at night and that he was waiting for a new mask/head strap because the current one is worn out and does not hold the mask to his face anymore and stated, .(NS R) is supposed to be getting it .that was 3 weeks ago .I haven't heard anything .I guess I have to wait until the company comes to the facility . Review of Resident #54's Physician Orders revealed, Start 8/22/22 .BIPAP .at night . In an interview on 11/14/23 at 03:08 PM, NS R reported that she was unaware of any issues with Resident #54's BIPAP mask/strap. In an interview on 11/15/23 at 09:00 AM, Resident #54 reported that NS R was ordering a new mask strap for him. Resident #54 reported that the nursing staff removes his mask in the morning and puts the mask into the bag and stated, .they take it into the bathroom about once a week and do something to it . 47955 Resident #3 Review of an Admission Record revealed Resident #3 had pertinent diagnoses which included acute on chronic respiratory failure, paraplegia, and morbid obesity. Review of a Minimum Data Set (MDS) assessment for Resident #3, with a reference date of 10/1/23 revealed a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated Resident #3 was cognitively intact. During an observation on 11/13/23 at 12:44 PM., Resident #3's CPAP mask was on the floor under her nightstand. During an interview on 11/13/23 at 12:45 PM., Resident #3 reported she was able to manage her CPAP herself. Review of Physician Orders for Resident #3 revealed, .CPAP non-invasive type: face-mask CPAP Level: RT BIPAP/CPAP at night. Pt should wear CPAP on home settings . During an observation on 11/15/23 at 1:20 PM., Resident #3's CPAP mask was on top of the machine on top of the nightstand not in a bag and without a barrier, and out of Resident #3's reach. During an interview on 11/16/23 at 11:57 AM., Nursing Supervisor (NS) R reported that a work list task is generated in the EMAR and a CPAP should be applied in the evening and removed in the morning. The floor nurse was responsible for applying and removing and documenting any refusals. NS R reported that the floor nurse could delegate to the CNA to clean a CPAP mask, machine, and tubing. NS R was unsure how often a CPAP mask should be cleaned. NS R reported orders to clean the machine and the tubing is assigned to the nurse. NS R reported the mask should be set on top of the machine when it was removed from the resident. During an observation and interview on 11/16/23 at 12:16 PM., Resident #3's CPAP mask was on the nightstand on top of the CPAP machine. No barrier noted between mask and machine. Resident #3 reported staff would fill the canister with water every night and help her put on the mask as needed. Resident #3 reported Staff pushed the button to turn the machine on because she cannot reach it. Resident #3 reported she cleans the filter on the machine and the staff has never cleaned her CPAP mask. During an interview on 11/16/23 at 12:24 PM., Registered Nurse (RN) UU reported the work list would contain the orders to clean a CPAP mask, machine, and tubing daily. RN UU reported that Resident #3 did not have any orders on the work list to clean her CPAP machine, tubing, or mask scheduled for today. During an interview on 11/16/23 at 2:25 PM., Director of Nursing (DON) B reported that her expectations were that CPAP masks were to be cleaned after each removal and stored in a black antimicrobial bag that was to be stored at the bedside. Review of Care Plan for Resident #3 revealed: .Problem .Resident has pulmonary disease, asthma, history of respiratory failure, recent PNA (Pneumonia) and is at risk for healthcare complications. Interventions: Administer oxygen as ordered . Follow facility protocol during aerosolized generating procedures eg CPAP, BIPAP, Nebulized treatments . Review of facility policy Infection Prevention Standard Precautions & Other Infection Prevention measures with an effective date of 7/13/2021 revealed 4.5.2.8.2 Items dropped on the floor are contaminated and should be reprocessed, disinfected, discarded, or laundered as appropriate. 38384 R7 According to the Minimum Data Set (MDS) dated [DATE], R7 scored 15/15 (cognitively intact) on her BIMS (Brief Interview Mental Status) with diagnoses that included heart-failure with history of chronic respiratory failure with hypoxia. Review of R7's Order Summary, 10/12/23, revealed, CPAP Non-Invasive CPAP .CPAP at night .full face mask . Review of R7's Care Plan, 1/24/2023, reported the resident had pulmonary disease and was at risk for healthcare complications. The goal was the resident was not to experience signs/symptoms of disease progression. Interventions to meet this goal included CPAP .as ordered. During an observation and interview on 11/14/23 at 2:41 PM, R7's CPAP was on a bedside dresser to the left side of her bed. The CPAP mask was lying on top of personal items with a towel on top of it with no bag in sight. R7 stated, I had to put the CPAP mask on the dresser myself this morning. I have been asking staff who takes care of me who is supposed to clean the mask and no one seems to know. Some staff tell me respiratory does it but there is no respiratory staff here. I have had the CPAP for a couple of months and it has not been cleaned. During an observation and interview on 11/15/23 at 11:06 AM, R7 was in her bed listening to television. Her CPAP mask was hanging from a hook on the wall behind her. The mask was not in a bag. The resident stated, I took it off this morning and gave it to the nurse. She hung it up but did not clean it. During an interview on 11/15/2023 at 1:13 PM, Infection Preventionist (IP) LL stated, Normally the nurse takes the CPAP when the resident is done with it and they clean the mask. When not in use, the CPAP should be kept in a black bag. This is to keep the resident from getting an infection and from keeping bacteria from growing. During an interview on 11/15/2023 at 2:52 PM, Licensed Practical Nurse (LPN) Z stated, CPAPs should be removed by the nurse in the morning and cleaned. It should air dry and put in a black bag for infection control. The CPAP should be on the Care Plan. During an interview on 11/15/2023 at 2:52 PM, LPN G stated, CPAPs should be cleaned and let air dry. I do not know about a black bag. In a document received 11/16/2023 at 13:48 (1:48 PM), the Nursing Home Administrator (NHA) reported, We (pertaining to the facility) do not have a oxygen policy for CPAP/BiPAP. We follow manufacturer guidelines and [NAME]. Review of facility provided [NAME] & [NAME]. 2023. Nursing Procedures, [NAME]'s - 9th ed. Philadelphia., Oxygen Administration did not provide a CPAP specific cleaning guide.

Based on observation, interview, and record review the facility failed to perform a thorough assessment for past trauma, identify post-traumatic stress disorder (PTSD) triggers and develop individualized care plan interventions to mitigate triggers for 2 (Resident #5 and Resident #7) of 3 residents reviewed for trauma informed care, resulting in the potential of re-traumatization due to staff not being informed and knowledgeable of the resident's past trauma and Resident #7 did not receive direct care that could trigger PTSD. Findings include: Review of an Admission Record revealed Resident #54 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: PTSD, depression and anxiety. Review of Resident #5's Care Plan revealed, .actual or potential for mood/behavior impairment: Start: 9/21/21. Dx (diagnosis): major depressive disorder, recurrent episode, moderate, generalized anxiety disorder, PTSD and other insomnia. Rx (prescription): psychotropic medications. Resident at times chooses to refuse meds, tx (treatment) and cares. Self reported claustrophobia. Resident has expressed always being introverted/recluse which she prefers. Resident has hx (history) of thoughts r/t (related to) being better off dead; no plan/thoughts r/t self-harm (hx of making statement about wanting to die, with no plan or intent to harm self) often related to increased anxiety or stress often related to past deaths or events in her life. hx of extensive abuse (physically, sexually, emotionally and spiritually from age 9-15 by her father). hx of multiple psychiatric hospitalization s .Per resident all hospitalization s were related to her feeling very depressed .Goal: .will continue to engage in leisure preference and continue to socialize with staff and peers with awareness of personal responsibility. Start: 9/21/21. Interventions: Assist to identify possible support systems, strategies to overcome obstacles as needed. Evaluate behavior for potential contributing factors. Give resident time to express concerns, feelings, fears. Consult BCS (mental health provider) for change in mood/behavior and as needed. Observe resident for side effects of psychotropic medications .Offer cues, reminders, and clear explanations as needed . There were no specific triggers related to PTSD included in the care plan. In an interview on 11/14/23 at 12:19 PM, Resident #5 reported that she mostly stays in her room, and is very lonesome. Resident #5 reported that she had not seen a social worker recently, but that she has told other staff members that she would like to see a therapist. In an interview on 11/14/23 at 02:10 PM, Quality of Life Supervisor (QOL-S) FFF reported that she was not aware of Resident #5 having a PTSD diagnosis and that it had never been brought up during the interdisciplinary team meetings. In an interview on 11/14/23 at 02:55 PM, Registered Nurse (RN) DD reported that Resident #5 did not have PTSD. In an interview on 11/16/23 at 12:00 PM, Certified Nursing Assistant (CNA) GGG was providing incontinence care for Resident #5 and afterwards reported that she was not aware of Resident #5 having a PTSD diagnosis. In an interview on 11/16/23 at 01:21 PM, Social Worker (SW) FF reported that Resident #5 had a diagnosis of PTSD listed in her records, but that she was not familiar with the details and/or triggers related to her specific PTSD. SW FF reported that all residents have trauma assessments completed upon admission and Resident #5 was admitted in 2014, so she was not able to locate a trauma assessment for the resident. SW FF reported that Resident #5 had a care plan related to mood and behaviors, but that it did not include anything specifically related to the resident's PTSD. This surveyor requested additional information if available related to Resident #5's PTSD and specific individual triggers. In an interview on 11/16/23 at 03:13 PM, SW FF reported that she had found a care plan for Resident #5 that included the specifics related to a history of abuse by her father. SW FF then went on to report that SW FF had evaluated Resident #5 on 11/13/23 for trauma and that Resident #5 denied having any trauma, therefore SW FF did not perform a trauma assessment, or ask any additional questions. SW FF reported that Resident #5's care plan was last revised on 10/27/23. Review of a screen shot of Resident #5's Flow sheets dated 11/13/23 revealed, Trauma Screening: Have you had any life experience that has interfered with you .(line cut off) No . There was a blank space for Trauma Assessment. 38384 R7 According to the Minimum Data Set (MDS) dated [DATE], R7 scored 15/15 (cognitively intact) on her BIMS (Brief Interview Mental Status) with diagnoses that included Post-Traumatic Stress Disorder (PTSD), migraines, and insomnia. During an interview on 11/14/23 at 2:23 PM, R7 became emotional, as evidence of crying, while stating, It happened when I was younger, I ended up basically held hostage in my apartment. The man that did it, he hurt me bad. It took me many years to be able to talk about it. I talked to somebody here about it; she took notes. I asked if she had to put it in my records, I did not want to talk to anyone else about it. There was another resident that always had certain programs on her television that would discuss certain things that had to do with people with psychological things about babies. That really bothered me and brought back memories. That resident had it on so loud that I would put something on louder, but I would still hear those programs. I told nursing, aides, I told them it was something difficult for me to hear, they told me the resident had the right not to wear headphones. For a long time, I put up with it, I always had a headache. I am easy going but I do not trust anybody very easy. For a long time, I did not want a male person in my room at all. I then got numb. I do not have a problem with everybody, the aides, just a few have been difficult for me to have them in my room. If I do not have a male caregiver there will not be anyone else to help me. I have told the social workers that male caregivers could trigger flashbacks. During an interview on 11/15/2023 at 11:28 AM, SW KK stated, (R7) has PTSD due to a history of sexual assault. It affects her mood and sleep. When the facility tried to look at discharging her home, with her history of sexual assault, we were only able to find male caregivers and (R7) did not want male givers. If a male caregiver was to be floated to her hall on the 3rd floor, and I discovered it, I would see if it would be appropriate for her at that time. If she had a problem with a male caregiver, she would let us know. I do not think anyone, including the Unit Manager knows what triggers (R7's) PTSD. SW KK then reviewed the resident's care plan Mood and Behavior and stated, Her care plan covers more general and not circumstantial to what her actual triggers are to her PTSD. I do not know what other staff, other than myself, know of what caused (R7's) PTSD. Staff could look in her medical records and find it but not right away because it is in her admission assessment for January 2022. I do not know if they would even know to look there to schedule staffing for her. During an interview on 11/15/1023 at 3:15 PM, male Certified Nursing Assistant (CNA) Y stated, I am assigned to rooms 3123-3141 for the next 12 hours. If a call light goes off on another part of the 3rd floor and I'm not helping my assigned area, I would go answer that call light. I do not know of any residents on the 3rd floor that do now want a male CNA. I will work all night. Review of R7's Admission assessment dated [DATE], revealed, Reviewed and discussed trauma focused care. Asked patient (R7) if they had any life experiences that interfered with their day-to-day function, had caused distress and/or had affected them negatively. (R7) stated that they have experienced a significant life event that would affect her normal functioning. She had an incident involving violence in her past that at times impacts her mood and sleep. (R7) is requesting that staff knock before entering her room. Completed PTSD checklist with (R7), but (R7) requested it not be uploaded to (name of electronic charting). PTSD screening was shredded at (R7) request. Review of R7's Care Plans did not reveal a resident-specific treatment plan for PTSD triggers had been developed. Review of R7's Resident Care Summary (a guide for aides on how to provide resident-specific care) did not include PTSD triggers.

Based on observation, interview, and record review, the facility failed to assist a resident with legal matters and follow up regarding acquisition of guardianship and/or potential discharge to a lower level of care1 of 29 residents (Resident #79), resulting in Resident #79 feeling frustrated and helpless related to his placement. Findings include: Resident #79 Review of a Face Sheet for Resident #79 dated 4/20/21 revealed the resident was admitted to the facility with the following pertinent diagnoses: end-stage renal disease (condition in which the kidneys lose the ability to remove waste and balance fluids), current moderate episode of major depressive disorder without prior episode, and moderate vascular dementia. Review of a Minimum Data Set (MDS) assessment for Resident #79 dated 10/13/23 revealed a Brief Inventory for Mental Status (BIMS) score of 12/15 which suggested a moderate cognitive impairment. Section GG of the MDS revealed Resident #79 was independent with eating, oral hygiene, toileting, showering, dressing, personal hygiene, bed mobility, and transferring self to and from the wheelchair. Review of a Care Plan for Resident #79 provided by the facility on 11/15/23 revealed no problem/goal/approaches related to discharge planning or coordination of services with resident's immigration attorney. In an interview on 11/14/23 at 10:02am, Resident #79 reported he was unhappy at the facility and had asked for support from social services for several months regarding discharge planning, but there had been no follow-up. Resident #79 said I'm stuck here, and I don't like it. I get angry because they won't help me go, and they won't listen to me. The resident reported he wanted to go back to where he was before but did not elaborate. Review of Progress Note dated 7/6/23 written by Nurse Practitioner (NP) DDD revealed a statement: Pt. (patient) verbalizes feelings of depression, related to his health and in part due to feeling his concerns are not heard/addressed by staff. SW (social worker) notified. Review of a Progress Note dated 11/16/23 written by Nurse Practitioner (NP) CCC revealed Resident #79 verbalized thoughts of leaving the facility. NP CCC documented the resident had been evaluated by a neuropsychologist in 12/22 and it was felt at that time guardianship should be pursued due to Resident #79's cognitive deficits. During the neuropsychology evaluation, Resident #79 scored 8/30 on a Montreal Cognitive Assessment (MoCA) which indicated the resident had a severe cognitive impairement. Review of social services progress notes for Resident #79 from 4/22-11/23 revealed no documentation of progress toward discharge planning, follow up with resident's attorney or progress toward obtaining guardianship for the resident. In an interview on 11/16/23 at 2:42pm, Medical Social Worker (MSW) KK reported she inherited Resident #79 to her caseload in December 2022, when 15 additional residents were added. MSW KK reported it had been difficult to keep track of resident needs since that time. When queried about any neuropsychology testing, discharge planning, and potential guardianship for Resident #79, MSW KK reported she would have to review the resident's electronic medical record because she was not aware of the information. MSW KK reported she did not believe Resident #79 had undergone neuropsychological testing. Upon looking up social work notes for Resident #79, MSW KK reported the resident was assigned an immigration attorney in 12/22, that a social worker would need to reach out to the attorney to coordinate services, and that no discharge plans were underway at this time. When asked if a social worker should have already done so prior to 11 months elapsing, MSW KK stated yes, someone should have reached out to the resident's attorney, but it's been difficult to keep up. MSW KK reported she was aware that Resident #79 was not happy at the facility, and she felt some of the behavioral issues the resident was experiencing were related to his placement. MSW KK reported prior to his admission, the resident was enrolled in a program that would provide temporary housing and assist with permanent housing, but no contact had been made to inquire about this resource for the resident. MSW KK reported guardianship had not been obtained.

Based on interview and record review, the facility failed to discontinue psychotropic as needed (PRN) medications after 14 days and/or document clinical rationale and indicate a timeframe for extended prn psychotropic medication use in 1 of 5 residents (Resident #18) reviewed for unnecessary medications, resulting in the potential for unnecessary medication use and inability to monitor the effectiveness of the prescribed treatment due to lack of documented supporting evidence. Findings include: Resident #18 Review of an Admission Record revealed Resident #18 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: generalized anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #18, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #18 was cognitively intact. In an interview on [DATE] at 11:50 AM, Resident #18 reported that he was very drowsy that day because he had taken Xanax (a medication for anxiety) and stated, .if I don't take it, then I don't get tired like this . Review of Resident #18's Physician Orders revealed, .Xanax 0.25 mg .3 times daily PRN. PRN Reason: Anxiety. The order had a start date of [DATE] and an end date of [DATE]. In an interview on [DATE] at 03:17 PM, Social Worker (SW) FF reported that Resident #18's current medication order for Xanax 0.25 mg PRN (as needed) TID (three times a day) was started on [DATE], reordered several times, and the last attempt to GDR (gradual dose reduction) the Xanax was [DATE]. SW FF reported that she found the GDR information in the resident's MDS assessment, and was not sure how often GDR's were attempted because that was not one of her responsibilities. SW FF reported that she was not familiar with the regulations related to PRN psychotropic medication use, and that BCS (behavioral care solutions) handled all psychotropic medication recommendations. In a follow up interview on [DATE] at 11:07 AM, SW FF reported that she had reviewed Resident #18's medications with the BCS provider that morning, along with NHA and DON. SW FF was not able to provide a rationale or timeframe for the recommendation to continue the Xanax PRN order. In an interview on [DATE] at 02:01 PM, Physician Assistant (PA) BBB reported that Resident #18 used Xanax infrequently, for intermittent agitation and fixations that cause him to repeatedly ask the same questions. PA BBB reported that all residents are seen every 60 days, and all medications are reviewed during those visits and stated, .I did not document on the need for PRN Xanax during those every 60 day visits . PA BBB reported that he had not documented a rationale and/or time frame for Resident #18's PRN use of Xanax, and that it was his understanding that after the first 14 day order expired, the prescription could be rewritten with a 6 month end date. Review of Pharmacy Note to Attending Physician dated [DATE] revealed, .has a PRN order for Xanax 0.25 mg three times daily as needed. Recommendation: Please update the patient record with a six month expiration date for PRN Xanax order in accordance with current regulations. Rationale for Recommendation: CMS requires that PRN orders for non-antipsychotic psychotropic drugs be limited to 14 days unless the prescriber documents the diagnosed specific condition being treated, the rationale for the extended time period, and the duration for the PRN order .Physician/Prescriber Response: Agree . Review of Resident #18's all available Physician Visit Notes provided by NHA from the past 6 months ([DATE] through [DATE]). There was no mention of anxiety and/or Xanax PRN use, except for in the autopopulated history and medication lists. There was no rationale included for Xanax PRN use greater than 14 days. Review of Resident #18's BCS Visit Note dated [DATE] revealed, .Denied (sic) of anxiety, depression, restlessness, hopelessness, fatigue, thoughts of self harm .Assessment & Plan: .Generalized anxiety disorder .Continue with monitor use of PRN Xanax. Benefits outweigh risks to continue medications since patient able to be redirected and engaged when he becomes to (sic) anxious/agitated . Review of Resident #18's BCS Visit Note dated [DATE] revealed, .Denied (sic) of anxiety, depression, restlessness, hopelessness, fatigue, thoughts of self harm .Assessment & Plan: .Generalized anxiety disorder .Continue with monitor use of PRN Xanax. Benefits outweigh risks to continue medications since patient able to be redirected and engaged when he becomes to (sic) anxious/agitated . Review of Resident #18's BCS Visit Note dated [DATE] revealed, .Assessment & Plan: .Generalized anxiety disorder .Continue with use of PRN Xanax. Benefits outweigh risks to continue medications since patient able to be redirected and engaged when he becomes to (sic) anxious/agitated .

Based on observations and interviews, the facility failed to ensure proper infection control measures were implemented for cleaning and disinfecting resident shared equipment, resulting in the increased potential for the development and transmission of communicable diseases and infection in a vulnerable population. Findings include: During an observation on 11/13/23 at 2:06 PM, Licensed Practical Nurse (LPN) W administered pain medications to a resident in room [ROOM NUMBER]. Certified Nursing Assistants (CNAs) NN and T transferred a resident from wheelchair to bed with a mechanical lift in the same room. LPN W removed the mechanical lift from the room and took it to another hall. The mechanical lift was not cleaned before leaving the resident's room. During an interview on 11/14/2023 at 9:09 AM, CNA NN stated, Mechanical lifts should be cleaned before and after resident use because you do not know if it was cleaned after the last resident use. Observed on 11/14/23 at 9:32 AM, outside of room [ROOM NUMBER], 1- sit to stand and 1-mechanical lift. The mechanical lift had dried white and light tan substances on the covering that held the straps to lift the resident, and on the bar that raised and lowered the lift. The base of the lift had dried white substances with dirt and debris. It was noted both bars had dark blue covers that attached with Velcro for easy removal. The entire sit-to-stand lift was covered with splatters of dried white/tan substances. The lift's handles that the resident hangs onto during the transfer, was covered with dried substances. The base of the lift, where residents placed their feet, was covered with dirt and debris. The structure/bar that wrapped around the back of the resident was covered with dried white/tan substances. This area was covered in a dark blue cover that attached to the lift with zippers. Observed on 11/15/23 at 10:54 AM, a sit-to-stand lift stored on the 3rd floor hall between rooms [ROOM NUMBERS]. Resident hand holds splattered with a dried white substance. The base area where residents placed their feet was covered with dirt, debris and dried white substances. The framing of the lift had a splattering of dried substances. Observed on 11/15/2023 at 10:57 AM, a mechanical lift on the 3rd floor hall between rooms [ROOM NUMBERS]. Coverings of bars in navy blue removal protectors splattered with dried substances. Metal framing of the lift was covered with dirt, debris, and dried substances. During an interview on 11/15/2023 at 1:13 PM, Infection Preventionist (IP) LL, stated, Resident-shared equipment should be cleaned right after use by a resident to reduce the spread of infections.

Based on interview and record review, the facility failed to resolve written resident concerns in a timely manner for 1 resident (Resident #100) of 12 sampled residents reviewed for resolution of grievances, resulting in the potential for care concerns to go unreported and not investigated. Findings include: Review of an Admission Record revealed Resident #100 admitted to the facility on [DATE] with pertinent diagnoses which included morbid obesity, depression, and vascular dementia. Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 6/6/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #100 was cognitively intact. Review of email response to requested medical records received from Nursing Home Administrator NHA A on 7/31/2023 at 4:28 PM revealed there were no grievances for R100 during the requested time frame of 12/20/2022 to 7/31/2023. In an interview on 8/1/2023 at 12:20 PM, NHA A reported she is the facility grievance officer and residents have the right to file a grievance verbally, in writing, and anonymously. In an interview on 8/2/2023 at 8:25 AM, Resident #100 reported he filed 2 or 3 written grievances since December and never received any response or feedback from the facility. Resident #100 reported the last written grievance was addressed to the NHA about 4 weeks ago. In an interview on 8/2/2023 at 9:23 AM, Family Member of Resident #100 H reported Resident #100 had written 3 grievances that calendar year. Family Member of Resident #100 H reported it bothered her that they had not received written responses to these grievances. Family Member of Resident #100 H reported it concerned her that the facility might be ripping these up or sweeping things under the rug. In an interview on 8/2/2023 at 10:29 AM, Nursing Supervisor J reported resident concern forms are transferred from the paper form into the Event Reporting System (ERS) and then reviewed by supervisors and addressed by appropriate staff. In an interview on 8/2/2023 at 10:57 AM, NHA A reported any written concern form is automatically placed into the Event Reporting System. NHA A confirmed that Resident #100 did not have any documented written grievances available in the ERS system during the calendar year. Review of facility policy/procedure Patient Complaint & Grievance, effective 2/7/2023, revealed .The purpose of this policy is to support each patient/resident/representative of their right to voice grievances . Complaint/Grievance Process for Rehab and Nursing Centers . Patients/Resident/Representative and families are informed how to file a complaint/grievance (including in writing, verbally and anonymously) . When a complaint/grievance is raised, a team member or provider will acknowledge and attempt to resolve all patient/resident concerns as soon as possible . Patient Relations or the Grievance Officer/designee will involve the appropriate leadership team for additional review and follow up as appropriate . The patient/resident/representative or family will be kept appropriately apprised of progress towards resolution of the grievance, by either the Patient Relations Department or the facility Grievance Officer/designee . The Patient Relations or Grievance Officer/designee will offer decision on the grievance to the patient/resident or their representative. Documentation will include: the date the grievance was received, a summary statement of the person's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the person's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued .

Based on interviews, observations, and record review, the facility failed to provide sufficient, daily, meaningful activities of choice, for 1 (Resident #14) of 28 sampled residents and 8 of 13 residents in attendance at a confidential group meeting, resulting in feelings of boredom, loneliness, and a potential for increased anxiety. Findings include: Resident #14 A review of a Face Sheet revealed Resident #14 was a male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: alcohol induced dementia (a type of alcohol-related brain damage), bipolar disorder (a mental condition marked by alternating periods of elation and depression), and generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities). A review of a Minimum Data Set (MDS) assessment for Resident #14, dated 12/02/22, revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #14 was cognitively intact. Review of Resident #14's Interview for Activity Preferences revealed Resident #14 indicated doing things with groups of people and doing favorite activities were very important to him. A review of Resident #14's care plan, initiated on 09/21/21, revealed a problem: Activities: (Resident #14) has identified need/desire to participate in activities to enhance psycho-social well-being with care planned interventions which included verbal cueing as needed to assist Resident in staying on task. Rephrase questions as needed for Resident to understand, Invite to groups of potential interest as available and provide verbal reminders. In an interview on 12/16/22 at 11:20 AM, Resident #14 reported he often felt bored, lonely, and anxious on weekends. Resident #14 stated I need group activities because I like being around groups of people and doing things that keep my mind busy. Resident #14 reported he tried to socialize with peers and pursue independent activities on the weekend but was unsuccessful. A review of the Activity Calendars (dated 10/22-12/22) for the floor on which Resident #14 resided, revealed no group activities had been scheduled for the 14 Saturdays during that time frame. Review of scheduled group activities for Sundays (10/22-12/22) revealed 1 group activity scheduled each day (Travel Spiritual Support). In a confidential group interview on 12/15/22 at 3:00 pm, 8 of 13 residents in attendance reported a need for more group activities on the weekend. Residents reported that those who are able sometimes hosted their own group activities on the weekend, but residents who need any kind of assistance were not able to participate and were often unengaged in meaningful activities throughout the weekend. An independent resident stated, I feel so bad for the residents that just sit around on the weekend. I can do things for myself, and I even get bored. In an interview on 12/20/22 at 9:30am, Unit Aide, AAA reported that residents often sat around the nurses' station on the weekend, that residents' behaviors worsened and they needed more attention from nursing staff. A review of Behavior Tracking Logs for Resident #14, for the period of 6/19/22-12/10/22, revealed that 11 out of 17 behavior logs provided involved negative behaviors that occurred on a weekend. Resident #14's negative behaviors identified on the weekends included refusing care, shaking fist at staff, yelling, and entering other residents' rooms. In an interview on 12/20/22 at 12:00 PM, Quality of Life Supervisor (QLS) GG, reported that there were no scheduled group activities on Saturdays, and that only a single spiritual group activity was scheduled on Sundays. QLS GG reported that activity supplies were provided for residents who were able to pursue independent activities on the weekend and that residents who wanted to attend the spiritual activity on Sundays were assisted to do so, but that no other opportunities for meaningful activities were scheduled for those who needed support for activity involvement on the weekends. During an observation on 12/16/22 at 02:11 PM, Recreational Therapy (RNC) G, distributed weekend activity packets to each Resident. The packet includes 1 coloring sheet, 1 word search puzzle, and an activity summary for the coming week.

This citation pertains to Intake # MI 374. Based on interview and record review, the facility failed to keep resident free from significant medication errors in 1 of 4 residents (Resident #100) reviewed for medication administration, resulting in adverse effects and hospitalization . Findings include: According to the Fundamentals of Nursing, 6th edition (Mosby, Patricia A. Potter, Anne G. Perry, 2005 page 419) the physician should write all orders, and the nurse must make sure that they are transcribed correctly. According to The Long Term Care Health Information Practice and Documentation Guidelines, Version 1.0, September 2001, retrieved 5/6/2021 at 1:57 PM: 6.9.8 Transcription of Orders and Noting Orders: Transcription of orders, such as telephone orders, is a responsibility of professional nurses (Registered Nurse (RN), Licensed Practical Nurse (LPN)/Licensed Vocational Nurse (LVN) per scope of practice defined by State law/practice acts), but can be delegated to a trained individual if allowed by state law or practice acts. If the transcription process is delegated, the nurse still must sign off on the order and retain responsibility for accurate transcription. When a telephone or fax order is transcribed into the medical record, it should be transcribed verbatim as given from the physician. Review of a Face Sheet revealed Resident #100 was a male, with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 1/12/21, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #100 was cognitively intact. Review of the March 2021 Medication Administration Record (MAR) revealed [MEDICATION(S)] 20 mg tablet (1) oral three times daily starting 3/22/2021. Resident #100 had 10 doses documented as administered before it was discontinued on 3/25/2021. In an interview on 5/3/21 at 8:00 PM, Licensed Practical Nurse (LPN) E stated .on 3/22/21 I saw that there was an order in a resident book that was flagged, but did not pay attention to the full name on the order that needed to be put in the computer system and I put the order in the wrong residents chart (Resident #100) . LPN E reported that the nurses should have the order double checked, one nurse puts a draft order in and the second nurse double checks the order, but I had a lot going on that night and so I just went ahead and completed the order without the double check. LPN E reported that the order was for [MEDICATION(S)] 20 mg. In interviews on 5/4/21 at 1:15 PM and 5/5/21 at 9:41 AM, LPN F stated the computer program in the MAR will have a dot pop, it is our warning system, that informs her that an order was still in draft, so she will verify the order and then activate the order in the computer, which was what she did for the original order of [MEDICATION(S)] 20 mg that was written for the original resident. LPN F reported that it had been a while since this incident and even though LPN E had signed off that she completed this double check she did not question it at that time that she could recall. LPN F did see the order in Resident #100's chart and stated, since the order was in the computer, I felt it was in the computer and it had gone through all the double checks. In an interview on 5/4/21 at 2:40 PM, LPN H reported that if there is an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN H reported that if the order was in electronic MAR then you do not question the order you would presume to be correct with the double check process, the nurses do not have time to verify all the orders. In an interview on 5/4/21 at 1:29 PM, Registered Nurse (RN) G reported that when she administered the [MEDICATION(S)] to Resident #100 on 3/25/21 it was not the first time he had received it. RN G reported that she did wonder why the pharmacy had not sent his prescription, but that faxes do not go through to pharmacy sometimes. RN G reported that when reviewing the chart for the [MEDICATION(S)] physician to order refax to the pharmacy, RN G reported that she did not find an order and went in the computer to check for the doctor and call to see if he prescribed the medication to Resident #100. RN G reported that the Physician Assistant reported that he did not recall ever prescribing Resident #100 [MEDICATION(S)], so then she started a med error packet and then checked to see how the order got in the computer system. RN G reported that when checking the order in Resident #100's system she noted that only one name was on the order when it was placed in the computer, so the order was not double checked (was not put into draft and then had a second nurse verify the order prior to activating the order). In an interview on 5/5/21 at 2:10 PM, LPN M stated Resident #100 was fine when I had spoken to him earlier in the shift about a medication error that had occurred we had discovered the medication error and he seemed ok. LPN M reported that the day shift nurse found the error and there was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] #100 chart in error. LPN M stated Resident #100 was told that he was given a medication that was not prescribed to him, but it could help with pain and he reported he did not have any pain. LPN M reported that the doctor said to start looking for lethargy and started about 1:00 AM on 3/26/21 it was like he was grabbing something from the bedside table possibly leaned over too far and fell . LPN M reported that he was sitting on the floor next to the bed, was very confused when she ask her questions, when earlier in the evening he was not like that he had been able to answer questions. LPN M reported that the doctor had him send him out for an evaluation due to mental status changing so quickly and he could not tell us if he hit his head. Review of the Nursing General Progress Notes dated 3/25/21 at 10:04 PM, revealed LPN M charted It was discovered that a med error had taken place with this resident. On 3/22/21 an order was written for (name of resident roommate) and was entered into both (name of resident's roommate) emar and (Resident #100's) emar (they are roommates.) It was discovered on 3/25/21 that the resident had been receiving [MEDICATION(S)] 20 mg TID. This was not ordered. The resident had received 9 doses when the error was discovered. Medstaff was notified and the medication was discontinued and a Stop and Watch for three days started, watching for lethargy. Resident was notified, and supervisor was notified. VS 139/82, 92, 19, 98.1, 95% on room air. Resident denies a negative effect from taking the medication. Will continue to monitor. (SIC). Review of the Hospital Records dated 3/26/21 revealed (Resident #100's) chief complaint was altered mental status, assessment/plan, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] overdose, accidental or unintentional, initial encounter 3. Chronic renal impairment, Medical Decision Making: Report came from nurse that according to his health facility, patient was receiving [MEDICATION(S)] the last 3 days that was meant for his roommate. This could explain his altered mental status. Due to the patient's difficulty with staying awake and continued altered mental status I have admitted him to the hospital service for further workup. Patient was stable prior to admission. History of Present Illness: According to Emergency Medical Services (EMS) the patient is normally alert and oriented x4. A his last known well was at 8:00 p.m. He was found 30 minutes prior to arrival in the hospital by his bed. His is not responding to verbal stimulation command, as well as moves his limbs .Review of Systems (Unable to perform), Physical Exam: Neurological: Mental Status: He is disoriented. Psychiatric: Cognition and Memory: Memory is impaired. History and Physical: Hospital Day: (1) Chief Complaint [MEDICATION(S)] overdose, accidental or unintentional, initial encounter, fall without loss of consciousness 1. Place in observation. 2. Consult toxicology .3. Telemetry for acute drug toxicity. 4. Check [CONDITION(S)]-stimulating hormone (TSH). CT head unremarkable. [MEDICATION(S)] normal 30. UA unremarkable with trace blood. 5. Called facility again at 8:07 a.m. and transferred to 2nd floor and spoke to (name of RN) Sounds like there are two (residents with the same name there and they got mixed up for approximately 3 or 9 days (I've heard varying durations. (SIC)) The only information she knows from night shift is that he was lethargic with loose stool earlier in the night and a fall apparently. Review of the Physician History and Physical dated 3/29/21, revealed that on 3/26/21 Resident #100 was transferred to the hospital with altered mental status which was secondary to [MEDICATION(S)] overdose The patient had become more progressively lethargic, had a fall on the day of transfer to the hospital. The patient was followed in the hospital by Toxicology. His mental status improved while off [MEDICATION(S)] The patient remained in hospital for 39 hours and his mentation returned back to his baseline and the patient felt stable to return to facility. (SIC) The facility was granted a Past Non-Compliance at the time of exit due to no further like incidents had occurred, the facility re-trained pertinent staff, and the facility had achieved sustained compliance prior to the start of the survey.

This citation pertains to intake number MI 583. Based on interview and record review, the facility failed to ensure 1 of 5 residents (#98) received physician ordered anticoagulation (blood thinner) medicatiaon (Xarelto) resulting in an Immediate Jeopardy when facility staff failed to administer the medication daily from 2/7/2019 through 2/10/2019 and Resident #98 had to be emergently transferred to a local hospital with complaints of shortness of breath, hypoxemia (low blood oxygen levels), and subsequent [DIAGNOSES REDACTED]. Findings include: Review of the medical facesheet, revealed Resident #98 was admitted to the facility on [DATE] with an extensive history of coagulation issues that included the following Diagnoses: [REDACTED]. review of the resident's medical record revealed [REDACTED]. Review of the History and Physical dated 2/18/2019 at 14:34 pm, revealed that Resident #98 had been admitted to a local hospital for emergent care following a [MEDICAL CONDITION] which occurred at the facility; she was hospitalized for [REDACTED]. She had a CT of her chest as a part of that admission, which was negative for [MEDICAL CONDITION] embolism. The document noted that the Resident was returned to the facility on [DATE] to continue care, which included daily administration of Xarelto due to her prior history of [MEDICAL CONDITION] embolism and sedentary lifestyle. The document continued, . did well until 2/10/2019, at which time she was noted to have acute onset of shortness of breath and [MEDICAL CONDITION] (low blood oxygen level). She had a CT chest in the ER (emergency room ), which noted an acute [MEDICAL CONDITION] embolism. Of note, her Xarelto was discontinued for unclear reasons since return from her recent hospital admission (1/24/2019 through 1/31/2019). There was no order by med(ical) staff to discontinue the Xarelto. Review of the local hospital's transfer orders dated 1/31/2019 at 5:40 pm, and the re-admission orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the Discharge Summary from the local hospital dated 2/21/2019 (untimed), documented Resident #98 had been admitted to the hospital on [DATE] with acute [MEDICAL CONDITION] embolism. Resident #98 was discharged from the hospital on [DATE]. The summary hospital course entry identified Resident #98 had been admitted with low blood oxygen levels (high 70's and low 80's - normal 98-100%) and was placed on [MEDICAL CONDITION]. subsequent evaluation noted acute PE (pulmonary embolism). Apparently her Xarelto was discontinued . During a telephone interview on 3/12/2019 at 1:37 pm, Registered Nurse G said, I've given Xarelto before, all the time. You just don't stop it. I was on her (Resident #98) hall on 2/6/2019; I don't recall her specifically. It was unusual to be on her hall, center section, but they were short staffed 2 nurses. I had about 20 residents I took care of. Likely the only time I worked on center section was on that day. I work 12 hour shifts; I worked a full 12 hour shift that day on the center hall . I absolutely did not discontinue her Xarelto; I wouldn't have discontinued her Xarelto without a doctor's order. I don't know how it was discontinued; I told the supervisor there's a problem with the computer program. It doesn't log you out, and anyone could've come behind me and put the order in. We've had several problems with the (computer) program. Doctors should be putting in their own orders but they fight it. They need to put them in; it would decrease errors. During an interview on 3/13/2019 at 9:00 am, Licensed Practical Nurse (LPN) F said, I know that Resident (#98). She's on Xarelto; has some history, but I don't recall why she's on it. She was in the hospital for an MI ([MEDICAL CONDITION]); I remember it 'cause I was one of the first responders to her code here in the facility. She went to the hospital until 1/31/2019, and came back to the 5th floor, which is my floor. I remember she did come back on Xarelto. I discontinued the med to change it from being given at HS (bedtime) to AM instead. That way I could sign it out appropriately; daily administered meds are given at 9 am, not at HS. I don't know why a discontinue date of 2/6/2019 came up on the MAR; I believe it's a systems error. I know there's an investigation on-going about this. When they did the investigation, I was made aware that the system must've put 2/6/2019 as the discontinuation date. I didn't put a discontinuation date in. They've been investigating what happened for weeks. We weren't told what really happened, but we were inserviced about discontinuing meds and the process. I didn't do anything wrong. I got Xarelto in the AM delivery packet from the pharmacy on 2/4/2019, so on 2/4/2019 I changed the order from HS to AM. Daily here means meds are given at 9 am, so it just made sense to change it from daily at HS to daily at 9 am. So, I changed it in the computer. I'm not sure why the medication, Xarelto, was discontinued on 2/6/2019; I just believe it was a system error. We looked for other orders that could've happened that same day to other residents on Xarelto on the 5th and 6th floors; there were no other errors, just (Resident #98).'' During an interview on 3/13/2019 at 10:45 am, Unit Manager E said, I talked with (RN G); he didn't remember the Resident (#98). He didn't work that wing before. He had no recollection of discontinuing Xarelto on 2/6/2019. He was sent home, then called a few days later; still had no memory. He denied discontinuing the Xarelto. We went over the process; he denied he received a verbal order to discontinue the med. He said he couldn't recall even discontinuing the Xarelto. He said he has a process to do orders; had no knowledge of how the medication was discontinued. I think it resulted from human error. We are in the process of root cause analysis; we take this very seriously. We'll have our second meeting on this; it's scheduled for (MONTH) 9, 2019 at 2:00 pm. Our risk management and compliance team is overseeing this and IS (informational services department) are getting into this. The order for the Xarelto should've been continuous with no stop date. The Xarelto was last given in the AM of 2/6/2019. From 2/7/2019 to 2/10/2019 the medication was not given; it had been discontinued from the system. During an interview on 3/13/2019 at 11:15 am, Resident #98's attending physician, H said, The medication, the Xarelto, was discontinued. We couldn't figure out what happened; it's freaky. It's possible, very logical, that the Resident's (#98) PE resulted from the missed doses of Xarelto. She missed 3 to 4 doses. She's had a history of [REDACTED]. Xarelto is short-acting; 24 hours after you stop it, its effect is gone. I didn't discontinue the Xarelto; there was no order to discontinue it. During an interview on 3/14/2019 at 1:50 pm, Nurse Manager N acknowledged the facility first became aware that Resident #98 had experienced a [MEDICAL CONDITION] embolism as a result of the missed doses of Xarelto, when the facility received an e-mail from the Resident's public guardian; the guardian had been informed by the Resident's hospital physician of the details of the incident, which included missed doses of Xarelto not given at the facility, which subsequently lead to the acute onset of the [MEDICAL CONDITION] embolism, shortness of breath and [MEDICAL CONDITION], and emergent hospitalization . Nurse Manager N said, I got an e-mail on 2/18/2019 that was sent by the Resident's guardian as forwarded to me from our Social Worker (L). I did a chart review immediately. I created a timeline . I also gave my investigation to (Nurse Manager E); it was a significant med error. During an interview on 3/13/2019 at 9:20 am, Resident #98 said, I had a blood clot to my lungs about 2 years ago. They put me on Xarelto. I took it every day. About a month ago I had a [MEDICAL CONDITION] here; they sent me to the hospital.The doctor at the hospital said I needed to stay on the Xarelto to make sure I didn't have any more clots. I had to go back to the hospital (2/10/2019). I'm not sure what happened and why I had to go back to the hospital; not at all. My memory has gotten worse. On 3/13/2019 at 4:20 pm, interim NHA K acknowledged, We reviewed the incident and learned we didn't have a procedure to verify discontinuation of medications, like Xarelto. We're putting that procedure together now. On 3/13/2019 at 1:50 pm, Interim NHA K was notified of the immediate jeopardy that began on 2/7/2019, and was identified on 2/15/2019, as a result of the facility's failure to prevent a significant medication error, discontinuation of the physician ordered anticoagulation medication Xarelto for treatment of [REDACTED]. On 3/14/2019 and 3/18/2019, the following was verified to remove the immediate jeopardy: 1. Identification of Residents affected or likely to be affected: On 3/13/2019 at 6:25 pm, Resident #98 has been reassessed and no further adverse effects have been noted. All medications discontinued from EMR between 2/19/19 to 3/13/19 have been reviewed and verified against written orders for accuracy. No errors found. On 3/13/19 starting at 5:30 pm and completed on 3/14/19 at 12:50 pm, 162 residents who were residing in the facility on 3/13/19 with medications (all classifications) discontinued from EMR between 2/6/19 to 3/13/19, had the potential to be affected. As of 3/14/19, these EMR discontinued orders were reviewed and verified against written orders to ensure written order was present. If an error of an order not being present is identified, the medication error protocol will be started ad order corrected in EMR. On 3/14/19 at 11:30 am, one medication ([MEDICATION NAME]-[MEDICATION NAME] nebulizer PRN) was identified to be discontinued in the EMR without a written order for one patient. On 3/14/19 at 11:30 am, medication error protocol initiated and will be completed on 3/17/19 at 7:00 am when required monitoring of patient is completed. 2. Actions to prevent occurrences/recurrence: On 3/13/19 at 2:57 pm, a request ticket was submitted to Information Services to request an EMR requirement for a two-person verification for discontinuing orders. On 3/13/19 at 8:30 pm, the two-person verification of discontinued medication process was developed. Until the EMR can be modified, as of 3/14/19 at 9:09 am the two-person verification of discontinued medication process was started. Reports to identify all medications discontinued in the EMR will be run exclusively by Nurse Managers and/or supervisors every day (not excluding weekends and holidays). *Morning Nurse Managers and/or supervisors will run the report for current and previous day *Evening Nurse Managers and/or supervisors will run the report for the current day Any orders discontinued on the above reports will be verified against written orders for accuracy as a two- person verification. If an error in orders is identified, the medication error protocol will be started and order corrected in EMR. As of 3/14/19 at 8:30 am, a total of 10 of 11 RN's and 4 of 5 LPN's (Nurse Managers and Supervisors) have been educated on the two-person verification of discontinued medication process which will be run in the morning and evening of every day (not excluding weekends and holidays). The remaining 1 RN and 1 LPN will not work until education is completed. Under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, the Nurse Manager, or designee, will complete an audit three times per week of discontinued medications to verify changes made in EMR have a written order and is entered correctly. A summary report of findings will be provided to the QAPI Program/Committee for review. The QAPI Committee will review findings monthly and determine ongoing need for audits. Although the immediate jeopardy was removed on 3/18/2019, the facility remained out of compliance at a scope of isolated and severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to all staff had not yet received education and the State Agency had not verified sustained compliance.

Based on observation, interview, and record review the facility failed to prevent the decrease in range of motion in 1 of 3 residents (Resident #19) reviewed for mobility, from a total sample of 35 residents, resulting in decreased mobility, decreased independence, and psychosocial distress. Findings include: Resident #19 Review of a facility Admissions Record revealed Resident #19 was a [AGE] year-old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, completed on 5/7/18, revealed Resident #19 required extensive assistance and 2 staff for bed mobility, transfers, dressing, ambulation, and extensive assistance and 1 staff for eating. Brief Interview for Mental Status (BIMS), on 5/7/18, revealed Resident #19 was severely cognitively impaired. During an observation on 8/28/18 at 3:28 PM, Resident #19 bilateral hands and fingers were contracted in to fists and her elbows had limited range of motion. In an interview on 8/28/18 at 3:29 PM, Resident #19 indicated her hands and fingers have become more contracted in the last year and nothing has been done to prevent the worsening of the contractures. Resident #19 indicated it has become even more difficult to feed herself or grasp anything if it was not right by her hands. Resident #19 became upset and began to cry. Review of Resident #19's MDS dated [DATE] revealed Functional Limitation in Range of Motion .Upper extremity .Impairment on both sides . Review of Resident #19's MDS dated [DATE] revealed Functional Limitation in Range of Motion .Upper extremity .Impairment on both sides . Review of Resident #19's Care Plan Report revealed, .Notes: Care Conference: .Dietary: .Resident (#19) (has) multiple digit deformities and contractures ., no revision date. No care plan problem or interventions noted for these bilateral hand and digital contractures. Review of Resident #19's assessments, no assessments found in the last year identifying the extent of mobility or limitations of range of motion in her upper body. In an interview on 8/08/30/18 at 9:06 AM, Supervision Nurse (SN) EE indicated has worked on Resident #19's unit for about 1.5 years. SN EE indicated Resident #19 has had bilateral hand contractures for as long as SN EE has worked on the unit. SN EE indicated Resident #19 has limited use of her hands and fingers. SN EE indicated there were no care plan interventions addressing her contractures or how to prevent the worsening of Resident #19's contractures. SN EE indicated the Resident Summary Template (Certified Nursing Assistant guide) does not identify Resident #19 has bilateral hand contractures and it does not have interventions related to those contractures. In an interview on 8/30/18 at 12:10 PM, Occupational Therapist (OT) EEE indicated last ordered evaluation of Resident #19 was 5/19/17 and worked with Resident #19 until 7/6/17. OT EE indicated the evaluation was for a decline in self-feeding function. Resident #19's bilateral hands had limited mobility resembling a pincher grasp (demonstrated crab like claws with straight fingers and flexed wrist). OT EEE indicated went to visit Resident #19 today (8/29/18) per request of Supervisor Nurse EE. Resident #19 has worsened contractures in her bilateral hands and fingers. Resident #19's hands and fingers were curled up in balls with finger nails touching palms. OT EE indicated to prevent decline in mobility would complete range of motion evaluation, trial of range of motion exercises, and splinting. For a resident to qualify for an evaluation and services to prevent decline, the nursing staff would need to fill out a change in condition form and place a clinical note, then the Interdisciplinary Team would meet and discuss how to address the resident's needs. OT EE indicated was unaware Resident #19 had declined until today. Review of the Psychosocial Outcome Guide indicated that Resident #19 being upset and crying due to her having more difficulty with feeding herself and her ability grasp anything decreased if it was not right by her hands caused her undue distress and harm.

This citation pertains to intake number MI 641 Based on observation, interview, and record review, the facility failed to ensure the use a gait belt during a resident transfer for 1 of 6 residents (Resident #105) reviewed for accidents and supervision, from a total sample of 6 residents, resulting in Resident #105 sustaining a pelvic fracture. Findings include: Review of the Facility staffing education Gait Belts revealed Gait belts are to be worn as part of CNA & Nurse uniforms. Failure to do so will result in performance correction. Follow RST (resident summary template). Any resident requiring Limited or Extensive assist needs to have a gait belt used during their transfer and/or ambulation. Prepare your environment prior to starting transfer (locking wheelchair, clearing a path, organizing any lines or drains). Always keep one hand holding onto the gait belt. Inform nurse and therapy of any refusals with a gait belt in order to assess the safest method of transfer (sic). Review of the Facility Policy and Procedure Falls: Risk Screening, Prevention and Post-fall Follow up- Continuing Care effective date 1/31/18 revealed, A licensed nurse will initiate and update the plan of care to address whether a resident/patient is at risk for falls. The resident summary template (RST) will reflect interventions as needed to prevent resident/patient falls from occurring. Review of a Face Sheet 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 5/25/18 revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated Resident #105 had moderate cognitive impairment. The MDS Functional Status revealed that on 5/6/18, prior to a fall on 5/15/18, Resident #105 required extensive assistance of one staff member for walking and toileting. Review of Resident #105's Resident Summary Template prior to fall revealed, Fall Risk-High .Extensive assist x1. Review of Resident #105's Fall Event dated 5/15/18 at 12:45 A.M. revealed Res (resident) had non-skid socks on, room was free of clutter, no gait belt was on res. When asked what happed Res stated that she lost her balance when walking to the bathroom and fell . CNA stated that she was assisting res to walk to the bathroom with the walker and stepped away to open the door, res lost her balance and fell backward. CNA stated that she reached out to grab her and res fell against the night stand (sic). Review of Resident #105's CENA Post Fall Report dated 5/15/18 at 12:45 A.M. written by CNA V revealed, (Resident #105) and I were walking to restroom with walker. As I (CNA V) stepped away to open door I believe she got off balance and started going backwards. As I reached out to grab her she fell against the nightstand. Review of Resident #105's FSI-Fall Scene Investigation Report dated 5/15 at 12:45 A.M. revealed, I (Certified Nursing Assistant CNA V) started with (Resident #105) at 11pm. Around 12:45 (A.M.) was the time of the incident. I (CNA V) escorted her towards the bathroom using her walker as I stepped forward towards the door she started going backwards with the walker as I reached out to grab her she fell against the nightstand .Root Cause of This Fall .resident lost her balance while ambulating Gait Assist devices at time of fall: (Blank) What appears to be the root cause of the fall? Resident lost her balance while ambulating to bathroom with walker and assistance of CNA. Describe initial interventions to prevent future falls: Gait belt to be used with all transfers and ambulation. Review of a Nursing Progress Note dated 5/15/18 at 11:00 A.M. revealed, Physician called and was ordered to send resident to (Hospital). Review of an Imaging Report dated 5/16/18 at 12:14 A.M. revealed, There are mildly displaced fractures involving the left superior and inferior pubic rami (Pelvic Fracture). Review of the Facility Investigation completed after the fall revealed, 5/15, 1:30am- Resident fell while transferring with CNA .5/15, 8:45am- Resident noted to have increased pain and dyspnea while in bed .Resident sent to ED where pelvic fracture was found on imaging. Resident also found to have pneumonia and UTI. Resident was placed on 4L of oxygen and admitted to the hospital .5/18-discharged from hospital and return to facility. The MDS Functional Status revealed that on 5/25/18, after the fall, Resident #105 required extensive assist with two staff for toileting. The MDS Functional status revealed that walk in room/corridor Activity did not occur over a seven day period. In an interview on 6/7/18 at 3:45 P.M., Resident #105 was observed in her room in bed. When asked if the fall from 5/15/18 could be discussed she refused to interview. During an interview on 6/6/18 at 3:40 P.M. CNA N reported that gait belts are used for all residents for transfer without exception. During an interview on 6/6/18 at 3:50 P.M. CNA E reported that any resident that is a limited and extensive assist must use the gait belt when transferring. During an interview on 6/7/18 at 11:40 A.M., CNA D reported that the RST will reveal if a resident must have a gait belt on for transfer. CNA D reported that she follows the RST. During an observation on 6/7/18 at 11:40 A.M., CNA D did not have a gait belt on her person. During an interview on 6/7/18 at 11:46 A.M., CNA K reported that the RST reveals if a resident requires a gait belt for transfer. CNA D stated Typically I have my gait belt on. During an observation on 6/7/18 at 11:46 A.M., CNA K did not have a gait belt on her person. During an interview on 6/7/18 at 11:50 A.M., CNA O reported that a gait belt is used for residents that are a limited to extensive assist. CNA O reported that information can be found on the RST. CNA O stated, If it's not specified you use one just to be safe. During an interview on 6/7/18 at 1:40 P.M., CNA R reported the use of gait belts is discussed during new employee orientation. CNA R reported she was educated, during new patient orientation, that the gait belt is part of the uniform and must be worn at all times. CNA R reported that residents that are limited to extensive assist require a gait belt for transfer.

This citation pertains to intake MI 849 Based on interview and record review, the facility failed to maintain the highest practicable level of emotional and physical well-being and provide services care planned (neglect) for 1 (Resident #3), of 8 Residents sampled for care, of a total of 8 Residents, resulting in Resident #3 having severe pain, wanting to die, not receiving care/catheter care, care as care planed, fecal impaction and refusing readmission to the facility. Findings include: Resident #3 was discharged from the facility on 10/10/10 to the emergency room and is not going to be readmitted . Resident #3 was not available during the investigation. Review of Resident #3's face sheet, dated 10/31/17 revealed Resident #3 was a [AGE] year old female admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #3 was her own responsible party. Review of Resident #3's Brief Interview of Mental Status (BIMS) score dated 7/30/17 was 10/15 (moderate cognitive impairment). During an interview with facility Social Worker (SW) F on 11/21/17 at 2:40 PM, SW F said Resident #3 Refused to do all BIMS testing and neuropsychiatric testing after 7/30/17. No other cognitive testing could be located after 7/20/17. SW F said Resident #3 was competent. Review of Resident #3's Emergency & Pre Hospital Documentation dated, admitted [DATE], revealed she was admitted with acute on chronic [MEDICAL CONDITION] (low blood level) with suspected GI (gastrointestinal) blood loss 2/2 Xarelto (medication used to thin the blood that can cause bleeding). Under Emergency Department Course/medical decision documented, She was not sent with records. The patient also had some right lower quadrant tenderness on exam for which we ordered a CT abdomen and pelvis which only noted fecal impaction for which she received a [MEDICATION NAME] suppository. Nursing staff planned to change out her suprapubic catheter given that there was some clotting in it; however, it seems to have been surgically placed and nursing staff was uncomfortable changing it but we did give her 2 mg IV [MEDICATION NAME] in preparation for changing as the patient was tearful and very scared that it would hurt to have it changed. I gave her 3.375 g of IV [MEDICATION NAME] to cover her for what we thought was a Pseudomonas infection in her [MEDICAL CONDITION] on the lateral surface of her right foot. Diagnosis 1. Acute-on-chronic [MEDICAL CONDITION] (low blood) 2. Possible osteo[DIAGNOSES REDACTED] (infection in foot) 3. Fecal impaction (harden stool stuck in the colon due to chronic constipation). Review of Resident #3's Resident Summary Template dated 10/16/17 revealed she required assistance of 2 people for bed mobility, assist of 3 people for showers, assist of 2 people with a lift for transfers, assist of 2 people for dressing and no male caregivers. Review of Resident #3's Emergency care plan, no date, revealed: name of resident has a risk for constipation r/t (related) to decreased mobility and use of PRN (as needed) narcotics. Interventions included monitor bowel elimination. (Resident #3's bowel record was requested form Clinical Care Specialist (CCS) C on 11-1-17 at 1:28 pm when the emergency room documentation was reviewed with her. This documentation was requested again in a follow up meeting on 11/2/17 at 10:25 am and again CCS C acknowledged she would provide Resident #3's bowel tracking record). There was no indication Resident #3's bowel elimination was being tracked as care planed and Resident #3 was admitted to the hospital on [DATE] with a diagnose of fecal impaction. Review of Resident #3's Elimination care plan, no date, revealed: name of resident requires a suprapubic catheter due to [MEDICAL CONDITION]/urinary incontinence with urethral erosion/[MEDICAL CONDITION] bladder s/p (status [REDACTED]. Interventions included, catheter care every shift - follow aceteic acid flush schedule per TAR (treatment administration record) and urology to follow related to urinary incontinence with suprapubic catheter. (Multiple clinical notes documented Resident #3 frequently refused catheter care. Notes and interviews revealed when Resident #3's catheter was flushed the fluid leaked right back out her urethra causing pain, discomfort and anxiety) There were no clinical notes located as to how this care could be provided without causing pain, discomfort and anxiety). Review of Resident #3's Comfort care plan, no date, revealed: name of resident has a comfort/impairment related to history of left BKA ([MEDICAL CONDITION]), wounds to the right foot, chronic pain, [MEDICAL CONDITION], muscle spasms, migraines, [MEDICAL CONDITION] and [MEDICAL CONDITIONS]. Interventions included: monitor location, description and timing of pain, monitor pain level based on indicator of pain, positioning, elevation, relaxation, distraction, monitor effectiveness of medication and non-pharmacological interventions. Notify medical staff of pain not effectively managed. (There was no indication of what Resident #3's tolerable pain level was or what Resident #3 thought effective pain control was for her). Nursing pain assessments only documented foot and abdominal pain. There was no indication that Resident #3 suffered pain with care and catheter care. Review of Resident #3's October 2017 Physician order [REDACTED]. There was no way to determine how often this was performed or refused. There were multiple clinical notes indicating Resident #3 was refusing this care. There were no notes that discussed the reason for refusals or interventions attempted to get Resident #3 to allow this treatment. Review of Resident #3's October 2017 Physician order [REDACTED]. Cleanse with NS, wipe open area with alcohol pad, cover with dry gauze wrap with [MEDICATION NAME] twice daily. Review of Resident #3's October 2017 Physician order [REDACTED]. Review of Resident #3's October 2017 Physician order [REDACTED]. (There was no way to determine how often Resident #3 allowed this and how often she refused this care. There was no indication of interventions attempted to get Resident #3 to allow this treatment). Review of Resident #3's October 2017 Physician order [REDACTED]. Started 9/1/17. Review of Resident #3's October 2017 Physician order [REDACTED]. (Could have had 6 a day). Review of Resident #3's Controlled Substances Proof of Use record documented this medication was not given on 9/1/17, 9/8/17, 9/9/17, 9/14/17, 9/16/17, 9/17/17, 9/18/17, 9/19/17, 9/10/17, or 9/13/17. Resident #3 only used 20 doses form 9/2/17 to 9/24/17 and never used more than 2 in 24 hours. Review of Resident #3's October 2017 Physician order [REDACTED]. Started 9/1/17. Review of Resident #3's October 2017 Physician order [REDACTED]. (Medication used for anxiety and muscle spasms). Review of Resident #3's October 2017 Physician order [REDACTED]. (notes were requested to see when this procedure was done and no documentation was provided). Review of Resident #3's face sheet, dated 10/31/17 revealed Resident #3 was a [AGE] year old female admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #3 was her own responsible party. During an interview with Physician Assistant (PA) L on 11/1/17 at 1:28 PM, PA L explained Resident #3 had a suprapubic catheter placed and due to the opening to the urethra still being open Resident #3 was to see a Urologist on occasion (could not be done frequently) to have injections to dam the whole. PA L said Resident #3 refused to have this procedure done. CCS L confirmed Resident #3 refused her appointments and provided a Scheduling record that documented Resident #3 refused to go to the Urologist on 9/14/17, Clinical notes from 8/1/17 to 10/10/17 only indicated one cancellation of this procedure 9/13/17 at 8:14 am; however it was not canceled due to refusal it was canceled because Resident #3 had an MI (heart attach). Resident #3's family member confirmed in an interview on 11/2/17 at 2:45 pm, that Resident #3 never refused any Urological appointments and the appointment in September was canceled due to medical problems. Review of Resident #3's October 2017 Physician order [REDACTED]. Clinical notes were reviewed 8/1/17 to 10/10/17 and pain was documented on multiple occasions but not every day or every shift. Most notes indicated that pain medication was effective; however there was rarely any indication of a pain scale used to determine how bad the pain was prior to, and after receiving pain medication, to determine how well Resident #3's pain was being controlled. Registered Nurse (RN) I was interviewed on 11/2/17 at 1:30 pm. RN I frequently work on Resident #3's unit. RN I said she does not have to rate a residents pain prior to giving pain medication but generally does. RN I demonstrated in the electronic medical record that they have multiple ways to document pain and one was a pain scale of 1-10 however when going back in a hour or so to document if the pain medication helped the scale of 1-10 was available but she was not required to use it. RN I said when she asks a resident if the pain medication helped and if they respond yes she marks the box effective. CCS C was able to print a record of Resident #3 complaints of pain from 9/1/17 to 10/10/17. This record indicated Resident #3 complained of a level 5 of pain level or above out of 1-10 on 39 occasions but did not indicate where the pain was, what pain medication was given, when or what the response to any treatment was, and if pain decreased after medication was provided. During a follow-up meeting on 11-2-17 at 10:25 AM, CCS C and CCS HH went into an extensive explanation of facility electronic medical record process for pain evaluation. CCS C and HH confirmed there was no way to go to one page of the electronic medical record or provide a print out that indicated when or what pain medication was given, the pain level at the time that the medication was given, or the effectiveness of that pain medication. CCS C made hand written notes on several pages of Resident #3's Medication Administration Record [REDACTED]. CCS C provided Resident #3's Controlled Substance Proof of use documentation for [MEDICATION NAME] (narcotic pain medication) for June 2017, July 2017, August 2017 and part of September 2017 (ended 9/22/17) because CCS C could not locate documentation on Residents #3's Medication Administration Record [REDACTED]. CCS C confirmed staff are expected to document all medications in Residents' MARs. The August Controlled Substance Proof of use documentation for [MEDICATION NAME] (narcotic pain medication) showed that 22 [MEDICATION NAME] 5/325 were given and the September 9/2/17 to 9/22/17 showed 20 doses were given. Review of Clinical Notes Report for Resident #3 dated 9/5/17 at 1:21 AM documented, Assisted Cena (caregiver) with changing residents brief, as we turned her to her side resident began to cry and c/o (complain of) pain. Resident then stated 'I cant (sp) take this anymore, the pain, the wetting myself from this catheter, no one can help me, the doctor cant (sp) help m. I am so tired of this. I just wish I can commit suicide. When asked if she had a plan resident shook her head in 'NO' motion. PRN [MEDICATION NAME] and [MEDICATION NAME] administered. Bed lowered to lowest position. Checked surrounding area for possible object to use for suicide. Notified night supervisor, Suicide risk tool assessment completed, resident is now placed on 1:1 with cena at bedside, will continues to monitor. Review of Clinical Notes Report for Resident #3 dated 9/5/17 at 10:46 AM, electronically signed by Social Worker (SW) F documented, Met with Resident to discuss statements made r/t (related to) harming herself. Resident shared that she is sick of being tired. That she is sick of this pain and that she does think sometimes she would be better off not living. Resident is able to express her emotions and share what is causing her to be upset. Resident verbalized her coping skills (e.g. watching TV, talking with family) and stated that she will use them. Resident shared that she does feel safe and that she does not have a plan nor intent to hurt herself. Resident verbalized that she will let staff know if she feels unsafe. Resident's interaction with me was appropriate and she was able to effectively express her feelings and needs. Resident has no intention of taking her life and is not harm to herself or others. Resident does not present as imminent danger to self. Informed Nursing Manager of visit. Recommended discontinuing sitter. Resident out to name of hospital. Called ED (emergency department) Social worker and provided update. Review of Clinical Notes Report for Resident #3 dated 9/5/17 at 4:05 PM documented, Per med staff OK to send resident to name of hospital ER (emergency room ) via name of Ambulance Company. Resident had c/o (complained of) abdominal pain and stated she must go out to ER. Family notified by unit manager. None of the previous notes that spoke about Resident #3's pain and giving pain medication indicated that the Residents pain was managed to her tolerance or indicated what her acceptable pain level was. None of the notes of suicide mentioned that Resident #3's family was notified but did indicate talking to family was one of her coping skills. There was no note indicating the resident was returned from the hospital. There was no note that the Physician was notified of the severe pain and the suicide statement. The next note that showed Resident #3 was back at the nursing home was 9/6/17 at 8:52 PM and documented, Resident denied pain today. Denies SOB (short of breath) LS (lung sounds) CTA (clear throughout) No [MEDICAL CONDITION] noted. VS (vital signs stable on room air. Right foot wounds done by CCM (clinical care manager) will continue to monitor. There was no indication of what care or treatment was provided at the hospital. No nursing notes that addressed Resident #3's pain or medical status could be located for 9/10/17 or 9/11/17. Review of Resident #3's controlled substance proof of use sheet for [MEDICATION NAME] 5/325 documented [MEDICATION NAME] was given 3 times from 9/10/17 to 9/11/17. Review of Clinical Notes Report for Resident #3 dated 9/13/17 at 3:10 PM documented, resident reported pain 7/10 in her chest. Denied SOB and nausea. Resident given [MEDICATION NAME] and reported relief and pain 0/10. VSS (vital signs stable) med staff notified. Will continue to monitor. (This was the only note indicating pain index was used at the time of pain medication administration and at follow up). Review of Clinical Notes Report for Resident #3 dated 9/13/17 at 8:14 PM, documented med staff in contact with urology regarding scheduled procedure in AM. Procedure canceled r/t recent MI (heart attach) Resident upset & refused 1st attempt at prn meds. Accepted on 2nd attempt with prn [MEDICATION NAME] for general body pain. Will continue to monitor. (No indication whether or not pain medication provided relief). Review of Clinical Notes Report for Resident #3 dated 9/14/17 at 9:27 am documented, Wound to R (right) foot has declined since previous assessment. Drainage has increased and wound has gotten bigger with more eschar and odor. Med no consult ordered. Consult with name of doctor Orders changed to Dankins and kerlix 2x daily ant to reevaluate next week. Also stated that we might have to reevaluate amputation. Review of Clinical Notes Report for Resident #3 dated 9/15/17 at 3:20 PM documented, Resident refuses all cares, medicine and dressing change. Was in a very bad mood most of the day. Thinks everyone is conspiring against her in this building. Will continue to monitor. Review of Clinical Notes Report for Resident #3 dated 9/16/17 at 4:05 PM documented, Resident complained of some abdominal pain this morning. Requested pain pill and [MEDICATION NAME], both given. [MEDICATION NAME] effective. No results for [MEDICATION NAME] yet. Oncoming nurse aware to follow up with bowel protocol. No [MEDICAL CONDITION] noted. No chest pain. Oncoming nurse aware to attempt one more shower offer. Will continue to monitor. Review of Clinical Notes Report for Resident #3 dated 9/21/17 at 9:49 pm documented, Resident c/o increased right foot wound pain & felt like her knee may have been disjointed during a turn during cares this shift. Knee pain decreased late in shift but med staff order XR to ensure it was OK. XR completed & flagged for med staff. No fracture or issues noted. Note written & placed on nurse station computer for acting secretary to follow-up with bone scan scheduling. Prn [MEDICATION NAME]& [MEDICATION NAME] effective for decreasing pain. Note to med staff per resident request for increase in [MEDICATION NAME] prn dosage. (There was no physician note or indication that this request was reviewed or honored). This Resident's requested note indicated Resident #3 was not satisfied with her pain control and there was no indication her pain medications were reevaluated). All physician notes and pain assessments for Resident #3 were requested. During the follow-up meeting on 11/2/17 at 10:25 am, CCS C confirmed she had provided all of this documentation. There were only three physician progress notes [REDACTED]. No physician notes could be located for the Resident's request to have her pain medication increased on 9/21/17. Review of Resident #3's typed assessment dated [DATE], signed by the Medical Director (MD) XX documented, Pain: Well controlled. Comfortable with current medication. (See nurses note 9/21/17 at 9:49 pm as Resident #3 requested an increase in pain medication, see note 9/5/17 at 1:21 am when Resident complained of pain and wanted to commit suicide. Multiple clinical notes documented pain). Review of Resident #3's typed assessment dated [DATE], signed by the Medical Director (MD) XX documented, Family issues, involvement, concerns or problems: blank. Residents and family had requested not to return to the hospital on [DATE] see note near end of report showing a patient advocate was assigned due to care concerns. During an interview with Physician Assistant (PA) L on 11/1/17 at 1:28 pm, PA L was asked if staff had ever reported to him that Resident #3 had severe pain with care and catheter care. PA L did not confirm or deny that staff had informed him that Resident #3 was having severe pain during these times. PA L looked into Resident #3's electronic medical record and said, Resident #3 was having problems with medications and he had lowered Resident #3's medication due to these problem. Narcotic pain medication is in the news every day I cannot give her more narcotic pain medication. PA L was informed the ER gave Resident #3 IV pain medication on 10/10/17 in preparation to change Resident #3's catheter because she expressed fear of pain if they were going to change the catheter. PA L opened Resident #3's ER report on the computer and said, I could not do that because I do not have fast access to lab work like a hospital does. When asked what he could do if he knew, he said he would premedicate and give [MEDICATION NAME] (medication that can be used to numb the skin). PA L was asked if this was being done for catheter care and he did not answer. CCS L was in the room and was asked the same question. CCS L said she would check Resident #3's medical record. (There was no evidence provided that this was ordered, care planned or being done with all catheter care). Review of Clinical Notes Report for Resident #3 dated 9/23/17 at 6:45 PM documented, resident accepted bed bath. VSS. Weight refused. Wound dressing change with increased pain and smell. No other skin issues. Resident refused catheter flushes. Claims she does not have one but something is inside her will continue to monitor. (Sounds confused? Pain has increased and no response to resident note asking for increased pain medication on 9/21/17). Review of Clinical Notes Report for Resident #3 dated 9/27/17 at 3:10 PM documented, Resident out on LOA (leave of absence) for apt today, returned about 1410. Complained of pain 10/10 Refused drsg changed and adjusting in bed. Administered prn meds. (No indication if the pain medication offered any relief). Review of Clinical Notes Report for Resident #3 dated 9/29/17 at 3:30 am, documented, Resident observed crying loudly and stated that she wanted to die, when approached by nurse with HS medications and alerted of the intent to change dressing on the RLE. Resident stated. You are looking on a corpse. What need is there to change a wound dressing, what need is there to take medications? I want to die. I'm a corpse. Resident re-approached again and stated she did not want anything done to her. But to be left alone the way she was to die. Denied pain on all occasions, but persisted that staff leave her alone and not bother her with toileting and changing and with wound dressing changes. Resident allowed the assigned CNA to give her peri care and change the soiled briefs. But resident refused to roll to the opposite direction for the cena to complete the toileting and changing. Resident made aware her gown was soiled with urine and offered a clean gown, but declined it and continued to insist that she wanted to be left alone to die. Resident noted to be depressed, unpleasant and non-complaint with all cares, medication and tx (treatment) at HS (bed time) S/P catheter continues to leak and resident mostly incontinent. Review of Clinical Notes Report for Resident #3 dated 9/29/17 at 10:18 am documented, MSW (Master Social Worker) evaluated resident. Resident placed on 30 min checks. Dietary notified to send plastic utensils going forward. Med staff notified. (No indication of family notification). Review of Clinical Notes Report for Resident #3 dated 9/29/17 at 7:51 pm documented, Resident on 30 minute checks for suicidal ideation. Resident refused all insulin this AM but accepted meds. State that it didn't matter anyway because her foot wasn't to get better. Tylenol given & effective for headache. Right foot wound cleaned & redressed per order. Foul odor & moderate amounts of bloody serosangeous drainage noted. Suprapubic foley changed out per monthly order. Prn [MEDICATION NAME] given prior to change. Resident tearful & painful prior & during procedure but tolerated well & new 18 gauge foley place successfully & draining. Resident still refused foley flushes. Prn Tylenol given again to ease pain from foley change. (No indication of pain level with pain scale before or after medication, and still no response to residents request for increased pain medication on 9/21/17). Review of Clinical Notes Report for Resident #3 dated 9/30/17 at 2:52 am, documented, Resident continues on 30 min checks for suicidal ideation's. No expression of harming self. Noted to be weepy and withdrawn with flat affect. Compliant with HS medication but refused wound dressing change. Review of Clinical Notes Report for Resident #3 dated 9/30/17 at 6:54 PM documented, C/o moderate pain during dressing change. (No indication of pain medication given). Review of Clinical Notes Report for Resident #3 dated 10/1/17 at 7:01 pm documented, no suicidal ideation noted this shift. Resident in good spirits. Family visited for a couple hours. Took all medications without any complaints. Ate all meals. Review of Clinical Notes Report for Resident #3 dated 10/2/17 at 7:45 am documented, c/o generalized pain. Pain med administered. (No indication of pain relief). Review of Clinical Notes Report for Resident #3 dated 10/3/17 at 8:47 am documented, c/o pain and anxiety at 2045 (8:45 pm). (No indication if pain medication given). Review of Clinical Notes Report for Resident #3 dated 10/8/17 at 3:11 am documented, Notified by cena that resident requested to speak with nurse. Resident c/o cena jerking her right shoulder. Noted no swelling or deformities to Right shoulder, resident is able to move her RUE. Resident refused cold compress. Prn [MEDICATION NAME] and [MEDICATION NAME] administered, repositioned resident. Review of Clinical Notes Report for Resident #3 dated 10/8/17 at 4:38 am, documented, CCS interviewed Resident at 2:35. Resident stated, An aide came in and jerked my shoulder. Then she stated that the ccs came in a pulled her arm, hurting her shoulder. Resident was given pain medication and repositioned by nurses. (No indication if pain medication gave relief). Review of Clinical Notes Report for Resident #3 dated 10/8/17 at 6:59 pm documented, C/o pain in am Prn [MEDICATION NAME] given & resident reported that the pain was easing up. Prn [MEDICATION NAME] given as requested & effective for pain. Review of Clinical Notes Report for Resident #3 dated 10/9/17 at 3:25 am documented, Resident refused her HS (bed time) medications stating I don't want that, take it away. Resident also refused cares, Foley flush and to be repositioned. Educated resident on importance of compliance. Resident declined. (No reason given for refusals or how many attempts were made.) Review of Clinical Notes Report for Resident #3 dated 10/9/17 at 10:14 am documented, Note for 10/5/17 at 10:09 am, electronically signed by SW F, Met with Resident to follow up on her statement of not wanting to live. (Last statement of wanting to die in notes was 9/29/17 at 3:30 am) Resident shared that she has never had feelings like this and to leave her alone. (Note 9/5/17 at 1:21 am documented, just wish I can commit suicide) Acknowledged what Resident said and shared that staff is here out of concern for her and want to ensure she is feeling safe and supported. Resident stated I never said that, I'm sick of people coming in here and asking me stupid questions. Acknowledged what Resident said and shared that staff will exit but wanted to ensure her safety. Resident declined to answer whether or not she feels safe and just continued to yell about staff coming in here asking her stupid questions taking up her time. Exited room per Residents request. Resident presented as frustrated and agitated. (no notes were located that Resident #3's family was notified after statements of suicide or wanting to die, SW F acknowledged in the note 9/5/17 at 10:45 that talking to family was a coping skill). Review of Clinical Notes Report for Resident #3 dated 10/10/17 at 6:55 pm documented, Resident was sent to name of hospital ER the AM at 1000 by name of ambulance company. Resident had critical HBG lab of 6.3 (low blood level) Med staff evaluated pt and wrote order to send out. VSS (vital signs stable). Residents son was notified. On 11/2/17 at 2:40 pm, CCS C confirmed Resident #3 was her own responsible party and Resident #3 had 2 family members she wanted involved in her care and never requested they were not to be informed of any care concerns. CCS C provided Resident #3's Designation of Patient Advocate Form, dated 9/21/17, that indicated she had 3 family members named as advocates. During a telephone interview with Resident #3's family member VV on 11/2/17 at 2:45 pm, VV confirmed she visited Resident #3 frequently and Resident #3 wanted her and 2 other family members involved in her care. VVsaid she made all of Resident #3's Urology appointments and said Resident #3 never refused to go. VV said the only appointment Resident #3 did not go on was because she could not go after her [MEDICAL CONDITION]. VV said Resident #3 was very upset about her care there and when she was in the hospital in September Resident #3 told the hospital she did not want to go back. VV said the hospital could not find another nursing home bed available at that time so they had the facility assigned a patient advocate to help with the care problems. VV said care got a little better at first but Resident #3 was still very unhappy with her care. VV said she could not remember all the details because he did not have her notes. VV said the hospital was able to find another nursing home with an open bed when Resident #3 went to the hospital in October and Resident #3 will not be going back there. On 11/2/17 at 3:40 pm, NHA A was asked if Resident #3 made complaints of care while being in the hospital in September and if she was provided a patient advocate. NHA A confirmed this complaint and said an advocate was assigned. NHA provided a Current Summary Multiple Issues Feedback form dated closed 11-2-2017. Review of the Current Summary Multiple Issues Feedback form dated closed 11-2-2017 for Resident #3 documented, Item #1 Perceived standard of care. Communication between members of care team. Brief Factual Description. Pt (patient) family had concern related to standard of care received. Patient feels staff didn't listen to her concerns. Date of Issue 8/24/17. Date of Notification 8/31/17 Event Reporting System. WW was listed as the person doing follow -up. WW was not located on the facility staff list. WW documented on 8-31-17 that he received a call from name of hospital regarding Resident #3 and Resident #3 was currently in the hospital. Under description documented, She (Resident #3 did not want to return back to name of facility but at his time no other LTC (long term care) facilities have open beds. name of hospital person is requesting that someone from the name of facility admin team or Mgr (manager) from the 4th floor where she was residing come and speak to the pt and name of family member tomorrow am. Their biggest concern involved the fact that she had been complaining of chest pains for 2-3 days and felt like her concerns were being ignored. Hospital test confirm that she did have a MI. Review of the Current Summary Multiple Issues Feedback form dated closed 11-2-17 under item #4 was documented, 'name of Resident #3 wasn't fully on board, but did agree to partner with us to help improve her experience moving forward. (There was no documentation of another meeting or care plan changes once Resident #3 returned to the facility). There was no documentation located in Resident #3's medical record to indicate she had care concerns and did not want to return to the facility. Review of Resident #3's complaint intake revealed the complainant was appalled at the condition of the patient and how she was treated. Right now she has a catheter in which causes her great pain .her pain is to the point of tears. She has stated that she gets no response when she asks to go see a doctor. When notifying a nurse about the request they just rolled their eyes and said something along the lines of do you know how long that would take to get her ready. I also had a nurse tell me that the patient had asked to see the paper regarding a previous unrelated doctor visit and that she told the patient no because she didn't feel like there was anything of importance on the papers. Nurses talk in the hall about how much they can't stand the patient. The patient told me how much she (TRUNCATED)

This citation pertains to intake MI 849 Based on interview and record review, the facility failed to adequately evaluate and treat 1 Resident's (#3) pain, of 8 Residents reviewed for pain, of a total of 8 Residents sampled, resulting in Resident #3 experiencing extreme pain with care and treatments to the point of wanting to commit suicide on 2 occasions. Findings include: Resident #3 was discharged from the facility on 10/10/10 to the emergency room and is not going to be readmitted . Resident #3 was not available during the investigation. Review of Resident #3's face sheet, dated 10/31/17 revealed Resident #3 was a [AGE] year old female admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #3 was her own responsible party. Review of Resident #3's Brief Interview of Mental Status (BIMS) score dated 7/30/17 was 10/15 (moderate cognitive impairment). During an interview with facility Social Worker (SW) F on 11/21/17 at 2:40 PM, SW F said Resident #3 Refused to do all BIMS testing and neuropsychiatric testing after 7/30/17. No other cognitive testing could be located after 7/20/17. SW F said Resident #3 was competent. Review of Resident #3's Emergency & Pre Hospital Documentation dated admitted [DATE] revealed she was admitted with acute on chronic [MEDICAL CONDITION] (low blood level) with suspected GI (gastrointestinal) blood loss 2/2 Xarelto (medication used to thin the blood that can cause bleeding). Under Emergency Department Course/medical decision documented, She was not sent with records. The patient also had some right lower quadrant tenderness on exam for which we ordered a CT abdomen and pelvis which only noted fecal impaction for which she received a [MEDICATION NAME] suppository. Nursing staff planned to change out her suprapubic catheter given that there was some clotting in it; however, it seems to have been surgically placed and nursing staff was uncomfortable changing it but we did give her 2 mg IV [MEDICATION NAME] in preparation for changing as the patient was tearful and very scared that it would hurt to have it changed. I gave her 3.375 g of IV [MEDICATION NAME] to cover her for what we thought was a Pseudomonas infection in her [MEDICAL CONDITION] on the lateral surface of her right foot. Diagnosis 1. Acute-on-chronic [MEDICAL CONDITION] (low blood) 2. Possible osteo[DIAGNOSES REDACTED] (infection in foot) 3. Fecal impaction (harden stool stuck in the colon due to chronic constipation). Review of Resident #3's Resident Summary Template dated 10/16/17 revealed she required assistance of 2 people for bed mobility, assist of 3 people for showers, assist of 2 people with a lift for transfers, assist of 2 people for dressing and no male caregivers. Review of Resident #3's Elimination care plan, no date, revealed: name of resident has a risk for constipation r/t (related) to decreased mobility and use of PRN (as needed) narcotics. Interventions included monitor bowel elimination. (Resident #3's bowel record was requested form Clinical Care Specialist (CCS) C on 11-1-17 at 1:28 pm when the emergency room documentation was reviewed with her. This documentation was requested again in a follow up meeting on 11/2/17 at 10:25 am and again CCS C acknowledged she would provide Resident #3's bowel tracking record) There was no indication Resident #3's bowel elimination was being tracked as care planed and Resident #3 was admitted to the hospital on [DATE] with a diagnose of fecal impaction. Review of Resident #3's Elimination care plan, no date, revealed: name of resident requires a suprapubic catheter due to [MEDICAL CONDITION]/urinary incontinence with urethral erosion/[MEDICAL CONDITION] bladder s/p (status [REDACTED]. Interventions included, catheter care every shift - follow aceteic acid flush schedule per TAR (treatment administration record) and urology to follow related to urinary incontinence with suprapubic catheter. (Multiple clinical notes documented Resident #3 frequently refused catheter care. Notes and interviews revealed when Resident #3's catheter was flushed the fluid leaked right back out her urethra causing pain, discomfort and anxiety) There were no clinical notes located as to how this care could be provided without causing pain, discomfort and anxiety). Review of Resident #3's Comfort care plan , no date, revealed: name of resident has a comfort/impairment related to history of left BKA ([MEDICAL CONDITION]), wounds to the right foot, chronic pain, [MEDICAL CONDITION], muscle spasms, migraines, [MEDICAL CONDITION] and [MEDICAL CONDITIONS]. Interventions included: monitor location, description and timing of pain, monitor pain level based on indicator of pain, positioning, elevation, relaxation, distraction, monitor effectiveness of medication and non-pharmacological interventions. Notify medical staff of pain not effectively managed. (There was no indication of what Resident #3's tolerable pain level was or what Resident #3 thought effective pain control was for her). Nursing pain assessments only documented foot and abdominal pain. There was no indication that Resident #3 suffered pain with care and catheter care. Review of Resident #3's October 2017 Physician order [REDACTED]. There was no way to determine how often this was performed or refused. There were multiple clinical notes indicating Resident #3 was refusing this care. There were no notes that discussed the reason for refusals or interventions attempted to get Resident #3 to allow this treatment. Review of Resident #3's October 2017 Physician order [REDACTED]. Cleanse with NS, wipe open area with alcohol pad, cover with dry gauze wrap with [MEDICATION NAME] twice daily. Review of Resident #3's October 2017 Physician order [REDACTED]. Review of Resident #3's October 2017 Physician order [REDACTED]. (There was no way to determine how often Resident #3 allow this and how often she refused this care. There was no indication of interventions attempted to get Resident #3 to allow this treatment). Review of Resident #3's October 2017 Physician order [REDACTED]. Started 9/1/17. Review of Resident #3's October 2017 Physician order [REDACTED]. (Could have had 6 a day). Review of Resident #3's Controlled Substances Proof of Use record documented this medication was not given on 9/1/17, 9/8/17, 9/9/17, 9/14/17, 9/16/17, 9/17/17, 9/18/17, 9/19/17, 9/10/17, or 9/13/17. Resident #3 only used 20 doses form 9/2/17 to 9/24/17 and never used more than 2 in 24 hours. Review of Resident #3's October 2017 Physician order [REDACTED]. Started 9/1/17. Review of Resident #3's October 2017 Physician order [REDACTED]. (Medication used for anxiety and muscle spasms). Review of Resident #3's October 2017 Physician order [REDACTED]. (notes were requested to see when this procedure was done and no documentation was provided). During an interview with Physician Assistant (PA) L on 11/1/17 at 1:28 pm, L explained Resident #3 had a suprapubic catheter placed and due to the opening to the urethra still being open Resident #3 was to see a Urologist on occasion (could not be done frequently) to have injections to dam the whole. PA L said Resident #3 refused to have this procedure done. CCS L confirmed Resident #3 refused her appointments and provided a Scheduling record that documented Resident #3 refused to go to the Urologist on 9/14/17, Clinical notes from 8/1/17 to 10/10/17 only indicated one cancellation of this procedure 9/13/17 at 8:14 am however it was not canceled due to refusal it was canceled because Resident #3 had an MI (heart attach). Resident #3's family member confirmed in an interview on 11/2/17 at 2:45 pm that Resident #3 never refused any Urological appointments and the appointment in September was canceled due to medical problems. Review of Resident #3's October 2017 Physician order [REDACTED]. Clinical notes were reviewed 8/1/17 to 10/10/17 and pain was documented on multiple occasions but not every day or every shift. Most notes indicated that pain medication was effective. It was rare to have a number rating to what the pain was after pain medication was given and rarely was there a pain number given to describe Resident #3's level of pain. Registered Nurse (RN) I was interviewed on 11/2/17 at 1:30 pm. RN I frequently work on Resident #3's unit. RN I said she does not have to rate a residents pain prior to giving pain medication but generally does. RN I demonstrated in the electronic medical record that they have multiple ways to document pain and one was a pain scale of 1-10 however when going back in a hour or so to document if the pain medication helped the scale of 1-10 was available but she was not required to us it. RN I said when she asks a resident if the pain medication helped and if they respond yes she marks the box effective. CCS C was able to print a record of Resident #3 complaints of pain from 9/1/17 to 10/10/17. This record indicated Resident #3 complained of a level 5 of pain level or above out of 1-10 on 39 occasions this record did not indicate where the pain was, what pain medication was given/when or what was the response to any treatment given within an hour of these pain levels. During a follow-up meeting on 11-2-17 at 10:25 CCS C and CCS HH went into an extensive explanation of facility electronic medical record process for pain evaluation. CCS C and HH confirmed there was no way to go to one page of the electronic medical record or provide a print out that indicated when a what pain medication was given, the pain level at the time or the response to that pain medication. CCS C made hand written note on several pages of Resident #3 Medication Administration Record [REDACTED]. CCS C provided Resident #3's Controlled Substance Proof of use documentation for [MEDICATION NAME] (narcotic pain medication) for June 2017, July 2017, August 2017 and part of September 2017 (ended 9/22/17) because CCS C could not locate documentation on Residents #3's Medication Administration Record [REDACTED]. CCS C confirmed staff are expected to document all medications in Residents' MARs. The August Controlled Substance Proof of use documentation for [MEDICATION NAME] (narcotic pain medication) showed that 22 [MEDICATION NAME] 5/325 were given and the September 9/2/17 to 9/22/17 showed 20 doses were given. Review of Clinical Notes Report for Resident #3 dated 9/5/17 at 1:21 AM documented, Assisted Cena (caregiver) with changing residents brief, as we turned her to her side resident began to cry and c/o (complain of) pain. Resident then stated I cant (sp) take this anymore, the pain, the wetting myself from this catheter, no one can help me, the doctor cant (sp) help m. I am so tired of this. I just wish I can commit suicide. When asked if she had a plan resident shook her head in NO motion. PRN [MEDICATION NAME] and [MEDICATION NAME] administered. Bed lowered to lowest position. Checked surrounding area for possible object to use for suicide. Notified night supervisor, Suicide risk tool assessment completed, resident is now placed on 1:1 with cena at bedside, will continues to monitor. Review of Clinical Notes Report for Resident #3 dated 9/5/17 at 10:46 AM, electronically signed by Social Worker (SW) F documented, Met with Resident to discuss statements made r/t (related to) harming herself. Resident shared that she is sick of being tired. That she is sick of this pain and that she does think sometimes she would be better off not living. Resident is able to express her emotions and share what is causing her to be upset. Resident verbalized her coping skills (e.g. watching TV, talking with family) and that will use them. Resident shared that she does feel safe and that she does not have a plan nor intent to hurt herself. Resident verbalized that she will let staff know if she feels unsafe. Resident's interaction with me was appropriate and she was able to effectively express her feelings and needs. Resident has no intention of taking her life and is not a harm to herself or others. Resident does not present as imminent danger to self. Informed Nursing Manager of visit. Recommended discontinuing sitter. Resident out to name of hospital. Called ED (emergency department) Social worker and provided update. Review of Clinical Notes Report for Resident #3 dated 9/5/17 at 4:05 PM documented, Per med staff OK to send resident to name of hospital ER (emergency room ) via name of Ambulance Company. Resident had c/o (complained of) abdominal pain and stated she must go out to ER. Family notified by unit manager. None of the previous notes that spoke about Resident #3's pain and giving pain medication indicated that the Residents pain was managed to her tolerance or indicated what her acceptable pain level was. None of the notes of suicide mentioned that Resident #3's family was notified but did indicate talking to family was one of her coping skills. There was no note indicating the resident was returned from the hospital. There was no note that the Physician was notified of the severe pain and suicide statement. The next note that showed Resident #3 was back at the nursing home was 9/6/17 at 8:52 PM and documented, Resident denied pain today. Denies SOB (short of breath) LS (lung sounds) CTA (clear throughout) No [MEDICAL CONDITION] noted. VS (vital signs stable on room air. Right foot wounds done by CCM (clinical care manager) will continue to monitor. There was no indication of what care or treatment was provided at the hospital. No nursing notes that addressed Resident #3's pain or medical status could be located for 9/10/17 or 9/11/17. Review of Resident #3's controlled substance proof of use sheet for [MEDICATION NAME] 5/325 documented [MEDICATION NAME] was given 3 times from 9/10/17 to 9/11/17. Review of Clinical Notes Report for Resident #3 dated 9/13/17 at 3:10 PM documented, resident reported pain 7/10 in her chest. Denied SOB and nausea. Resident given [MEDICATION NAME] and reported relief and pain 0/10. VSS (vital signs stable) med staff notified. Will continue to monitor. (This was the only note indicating pain index was used at the time of pain medication administration and at follow up). Review of Clinical Notes Report for Resident #3 dated 9/13/17 at 8:14 PM, documented med staff in contact with urology regarding scheduled procedure in AM. Procedure canceled r/t recent MI (heart attach) Resident upset & refused 1st attempt at prn meds. Accepted on 2nd attempt with prn [MEDICATION NAME] for general body pain. Will continue to monitor. (No indication if pain medication provided relief). Review of Clinical Notes Report for Resident #3 dated 9/14/17 at 9:27 am documented, Wound to R (right) foot has declined since previous assessment. Drainage has increased and wound has gotten bigger with more eschar and odor. Med no consult ordered. Consult with name of doctor Orders changed to Dankins and kerlix 2x daily ant to reevaluate next week. Also stated that we might have to reevaluate amputation. Review of Clinical Notes Report for Resident #3 dated 9/15/17 at 3:20 PM documented, Resident refuses all cares, medicine and dressing change. Was in a very bad mood most of the day. Thinks everyone is conspiring against her in this building. Will continue to monitor. Review of Clinical Notes Report for Resident #3 dated 9/16/17 at4:05 PM documented, Resident complained of some abdominal pain this morning. Requested pain pill and [MEDICATION NAME] both given. [MEDICATION NAME] effective. No results for [MEDICATION NAME] yet. Oncoming nurse aware to follow up with bowel protocol. No [MEDICAL CONDITION] noted. No chest pain. Oncoming nurse aware to attempt one more shower offer. Will continue to monitor. Review of Clinical Notes Report for Resident #3 dated 9/21/17 at 9:49 pm documented, Resident c/o increased right foot wound pain & felt like her knee may have been disjointed during a turn during cares this shift. Knee pain decreased late in shift but med staff order XR to ensure it was OK. XR completed & flagged for med staff. No fracture or issues noted. Note written & placed on nurse station computer for acting secretary to follow-up with bone scan scheduling. Prn [MEDICATION NAME]& [MEDICATION NAME] effective for decreasing pain. Note to med staff per resident request for increase in [MEDICATION NAME] prn dosage. (There was no physician note or indication that this request was reviewed or honored). This Resident requested note indicated Resident #3 was not satisfied with her pain control and there was no indication her pain medication were reevaluated). All physician notes and pain assessments for Resident #3 were request. During the follow-up meeting on 11/2/17 at 10:25 am, CCS C confirmed she had provided all of this documentation. There were only three physician progress notes [REDACTED]. No physician notes could be located for the Residents request to have her pain medication increased on 9/21/17. Review of Resident #3's typed assessment dated [DATE], signed by the Medical Director (MD) XX documented, Pain: Well controlled. Comfortable with current medication. (See nurses note 9/21/17 at 9:49 pm as Resident #3 requested an increase in pain medication, see note 9/5/17 at 1:21 am when Resident complained of pain and wanted to commit suicide. Multiple clinical notes documented pain). Review of Resident #3's typed assessment dated [DATE], signed by the Medical Director (MD) XX documented, Family issues, involvement, concerns or problems: blank. Residents and family had requested not to return to the hospital on [DATE] see note near end of report showing a patient advocate was assigned due to care concerns. During an interview with Physician Assistant (PA) L on 11/1/17 at 1:28 pm, PA L was asked if staff had ever reported to him that Resident #3 had severe pain with care and catheter care. PA L did not confirm or deny that staff had informed him that Resident #3 was having severe pain during these times. PA L looked into Resident #3's electronic medical record and said, Resident #3 was having problems with medications and he had lowered Resident #3's medication due to these problem. Narcotic pain medication is in the news every day I cannot give her more narcotic pain medication. PA L was informed the ER gave Resident #3 IV pain medication on 10/10/17 in preparation to change Resident #3's catheter because she expressed fear of pain if they were going to change the catheter. PA L opened Resident #3's ER report on the computer and said, I could not do that because I do not have fast access to lab work like a hospital does. When asked what he could do if he knew he said he would premedicate and give [MEDICATION NAME] (medication that can be used to numb the skin). PA L was asked if this was being done for catheter care and he did not answer CCS L was in the room and was asked the same question. CCS L said she would check Resident #3's medical record. (There was no evidence provided that this was ordered, care planned or being done with all catheter care). Review of Clinical Notes Report for Resident #3 dated 9/23/17 at 6:45 PM documented, resident accepted bed bath. VSS. Weight refused. Wound dressing change with increased pain and smell. No other skin issues Resident refused catheter flushes. Claims she does not have one but something is inside her, will continue to monitor. (Sounds confused? Pain has increased and no response to resident note asking for increased pain medication on 9/21/17) Review of Clinical Notes Report for Resident #3 dated 9/27/17 at 3:10 PM documented, Resident out on LOA (leave of absence) for apt today, returned about 1410. Complained of pain 10/10 Refused drsg changed and adjusting in bed. Administered prn meds. (No indication if the pain medication offered any relief). Review of Clinical Notes Report for Resident #3 dated 9/29/17 at 3:30 am, documented, Resident observed crying loudly and stated that she wanted to die, when approached by nurse with HS medications and alerted of the intent to change dressing on the RLE. Resident stated. You are looking on a corpse. What need is there to change a wound dressing, what need is there to take medications? I want to die. I'm a corpse. Resident re-approached again and stated she did not want anything done to her. But to be left alone the way she was to die. Denied pain on all occasions, but persisted that staff leave her alone and not bother her with toileting and changing and with wound dressing changes. Resident allowed the assigned CNA to give her peri care and change the soiled briefs. But resident refused to roll to the opposite direction for the cena to complete the toileting and changing. Resident made aware her gown was soiled with urine and offered a clean gown, but declined it and continued to insist that she wanted to be left alone to die. Resident noted to be depressed, unpleasant and non-compliant with all cares, medication and tx (treatment) at HS (bed time) S/P catheter continues to leak and resident mostly incontinent. Review of Clinical Notes Report for Resident #3 dated 9/29/17 at 10:18 am documented, MSW (Master Social Worker) evaluated resident. Resident placed on 30 min checks. Dietary notified to send plastic utensils going forward. Med staff notified. (No indication of family notification). Review of Clinical Notes Report for Resident #3 dated 9/29/17 at 7:51 pm documented, Resident on 30 minute checks for suicidal ideation. Resident refused all insulin this AM but accepted meds. Stated that it didn't matter anyway because her foot wasn't going to get better. Tylenol given & effective for headache. Right foot wound cleaned & redressed per order. Foul odor & moderate amounts of bloody serosangeous drainage noted. Suprapubic foley changed out per monthly order. PRN [MEDICATION NAME] given prior to change. Resident tearful & painful prior to & during procedure but tolerated well & new 18 gauge foley placed successfully & draining. Resident still refused foley flushes. PRN Tylenol given again to ease pain from foley change. (no pain scale numbers given and still no response to residents request for increased pain medication on 9/21/17). Review of Clinical Notes Report for Resident #3 dated 9/30/17 at 2:52 am, documented, Resident continues on 30 min checks for suicidal ideation's. No expressions of harming self. Noted to be weepy and withdrawn with flat affect. Compliant with HS medication but refused wound dressing change. Review of Clinical Notes Report for Resident #3 dated 9/30/17 at 6:54 PM documented, C/o moderate pain during dressing change. (No indication of pain medication given). Review of Clinical Notes Report for Resident #3 dated 10/1/17 at 7:01 pm documented, no suicidal ideation noted this shift. Resident in good spirits. Family visited for a couple hours. Took all medications with any complaints. Ate all meals. Review of Clinical Notes Report for Resident #3 dated 10/2/17 at 7:45 am documented, c/o generalized pain. Pain med administered. (No indication of pain relief) Review of Clinical Notes Report for Resident #3 dated 10/3/17 at 8:47 am documented, c/o pain and anxiety at 2045 (8:45 pm). (No indication if pain medication given). Review of Clinical Notes Report for Resident #3 dated 10/8/17 at 3:11 am documented, Notified by cena that resident requested to speak with nurse. Resident c/o cena jerking her right shoulder. Noted no swelling or deformities to Right shoulder, resident is able to move her RUE. Resident refused cold compress. PRN [MEDICATION NAME] and [MEDICATION NAME] administered, repositioned resident. Review of Clinical Notes Report for Resident #3 dated 10/8/17 at 4:38 am, documented, CCS interviewed Resident at 2:35. Resident stated, An aide came in and jerked my shoulder. Then she stated that the ccs came in a pulled her arm, hurting her shoulder. Resident was given pain medication and repositioned by nurses. (No indication if pain medication gave relief). Review of Clinical Notes Report for Resident #3 dated 10/8/17 at 6:59 pm documented, C/o pain in am Prn [MEDICATION NAME] given & resident reported that the pain was easing up. PRN [MEDICATION NAME] given as requested & effective for pain. Review of Clinical Notes Report for Resident #3 dated 10/9/17 at 3:25 am documented, Resident refused her HS (bed time) medications stating I don't want that, take it away. Resident also refused cares, Foley flush and to be repositioned. Educated resident on importance of compliance. Resident declined. (No reason given for refusals or how many attempts were made.) Review of Clinical Notes Report for Resident #3 dated 10/9/17 at 10:14 am documented, Note for 10/5/17 at 10:09 am, electronically signed by SW F, Met with Resident to follow up on her statement of not wanting to live. (Last state met of wanting to die in notes was 9/29/17 at 3:30 am) Resident shared that she has never had feelings like this and to leave her alone. (Note 9/5/17 at 1:21 am documented, just wish I can commit suicide) Acknowledged what Resident said and shared that staff is here out of concern for her and wanted to ensure she is feeling safe and supported. Resident stated I never said that, I'm sick of people coming in here and asking me stupid questions. Acknowledged what Resident said and shared that staff will exit but wanted to ensure her safety. Resident declined to answer whether or not she feels safe and just continued to yell about staff coming in here asking her stupid questions taking up her time. Exited room per Resident's request. Resident presented as frustrated and agitated. (no notes were located that Resident #3's family was notified after statements of suicide or wanting to die, SW F acknowledged in the note 9/5/17 at 10:45 am that talking to family was a coping skill). Review of Clinical Notes Report for Resident #3 dated 10/10/17 at 6:55 pm documented, Resident was sent to name of hospital ER the AM at 1000 by name of ambulance company. Resident had critical HBG lab of 6.3 (low blood level) Med staff evaluated pt and wrote order to send out. VSS (vital signs stable) Residents son was notified. On 11/2/17 at 2:40 pm, CCS C confirmed Resident #3 was her own responsible party and Resident #3 had 2 family members she wanted involved in her care and never requested they were not to be informed of any care concerns. CCS C provided Resident #3's Designation of Patient Advocate Form dated 9/21/17 that indicated she had 3 family members named as advocates. During a telephone interview with Resident #3's family member VV on 11/2/17 at 2:45 pm, VV confirmed she visited Resident #3 frequently and Resident #3 wanted her and 2 other family members involved in her care. VVsaid she made all of Resident #3's Urology appointments and said Resident #3 never refused to go. VV said the only appointment Resident #3 did not go on was because she could not go after her [MEDICAL CONDITION]. VV said Resident #3 was very upset about her care there and when she was in the hospital in September Resident #3 told the hospital she did not want to go back. VV said the hospital could not find another nursing home bed available at that time so they had the facility assigned a patient advocate to help with the care problems. VV said care got a little better at first but Resident #3 was still very unhappy with her care. VV said she could not remember all the details because he did not have her notes. VV said the hospital was able to find another nursing home with an open bed when Resident #3 when to the hospital in October and Resident #3 will not be going back there. On 11/2/17 at 3:40 pm, NHA A was asked if Resident #3 made complaints of care while being in the hospital in September and if she was provided a patient advocate. NHA A confirmed this complaint and said an advocate was assigned. NHA provided a Current Summary Multiple Issues Feedback form dated closed 11-2-2017. Review of the Current Summary Multiple Issues Feedback form dated closed 11-2-2017 for Resident #3 documented, Item #1 Perceived standard of care. Communication between members of care team. Brief Factual Description. Pt (patient) family had concern relate to standard of care received. Patient feels staff don't listen to her concerns. Date of Issue 8/24/17. Date of Notification 8/31/17 Event Reporting System. WW was listed as the person doing follow -up. WW was not located on the facility staff list. WW documented on 8-31-17 he received a call from name of hospital regarding Resident #3 and Resident #3 was currently in the hospital. Under description documented, She (Resident #3 did not want to return back to name of facility but at his time no other LTC (long term care) facilities have open beds. name of hospital person is requesting that someone from the name of facility admin team or Mgr (manager) from the 4 th floor where she was residing come and speak to the pt and name of family member tomorrow am. Their biggest concern involved the fact that she had been complaining of chest pains for 2-3 days and felt like her concerns were being ignored. Hospital test confirm that she did have a MI. Review of the Current Summary Multiple Issues Feedback form dated closed 11-2-17 under item #4 was documented, 'name of Resident #3 wasn't fully on board, but did agree to partner with us to help improve her experience moving forward. (There was no documentation of another meeting or care plan changes once Resident #3 returned to the facility) There was no documentation located in Resident #3's medical record to indicate she had care concerns and did not want to return to the facility. Review of Resident #3's complaint intake revealed the complainant was appalled at the condition of the patient and how she was treated. Right now she has a catheter in which causes her great pain .her pain is to the point of tears. She has stated that she gets no response when she asks to go see a doctor. When notifying a nurse about the request they just rolled their eyes and said something along the lines of do you know how long that would take to get her ready. I also had a nurse tell me that the patient had asked to see the paper regarding a previous unrelated doctor visit and that she told the patient no because she didn't feel like there was anything of importance on the papers. Nurses talk in the hall about how much they can't stand the patient. The patient told me how much she hates staying in her room all day but due to the pain that she feels hasn't been addressed she feels like she has too. Overall I'm concerned about the extreme pain of this patient and the sometimes inadequate care that she receives. During a telephone interview with Certified Nurse's Aide (CNA) Q on 11/1/17 at 11:40 am, CNA Q confirmed she worked with Resident #3 regularly, CNA Q said Resident #3 needed encouragement to allow care because her care was so painful. CNA Q said many of the staff were rude and talked about Resident #3's bad odor and not wanting to care for her outside Resi (TRUNCATED)

This citation pertains to intake MI 849 Based on interview and record review, the facility failed to assess, monitor and treat 1 Residents (#3) for signs and symptoms of a Urinary Tract Infections, of a sample of 1 Resident with a catheter, of a total sample of 8 Residents, resulting in Resident #3 having a chronic urinary tract infection that was antibiotic resistant and the potential [MEDICAL CONDITION] (life threatening infection). Findings include: Resident #3 was discharged from the facility on 10/10/10 to the emergency room and is not going to be readmitted . Resident #3 was not available during the investigation. Review of Resident #3's face sheet, dated 10/31/17 revealed Resident #3 was a [AGE] year old female admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #3 was her own responsible party. Review of Resident #3's Brief Interview of Mental Status (BIMS) score dated 7/30/17 was 10/15 (moderate cognitive impairment). During an interview with facility Social Worker (SW) F on 11/21/17 at 2:40 PM, SW F said Resident #3 Refused to do all BIMS testing and neuropsychiatric testing after 7/30/17. No other cognitive testing could be located after 7/20/17. SW F said Resident #3 was competent. Review of Resident #3's Emergency & Pre Hospital Documentation dated admitted [DATE] revealed she was admitted with acute on chronic [MEDICAL CONDITION] (low blood level) with suspected GI (gastrointestinal) blood loss 2/2 Xarelto (medication used to thin the blood that can cause bleeding). Under History of Present Illness documented, She also states that she had a procedure done on her suprapubic catheter recently that caused her urine to turn purple an she is not sure exactly what they did. Under Emergency Department Course/Medical Decision Making documented, She was not sent with record. Nursing staff planned to change out her suprapubic catheter given there was some clotting in it; however it seems to have been surgically placed and nursing staff was uncomfortable changing it but we did give her 2 mg of IV [MEDICATION NAME] in preparation for changing as the patient was tearful and very scared that it would hurt to have it changed. Review of Resident #3's Resident Summary Template, dated 10/16/17, revealed she required assistance of 2 people for bed mobility, assist of 3 people for showers, assist of 2 people with a lift for transfers, assist of 2 people for dressing and no male caregivers. Review of Resident #3's Comfort care plan revealed, no date, revealed: name of resident has a comfort/impairment related to history of left BKA ([MEDICAL CONDITION]), wounds to the right foot, chronic pain, [MEDICAL CONDITION], muscle spasms, migraines, [MEDICAL CONDITION] and [MEDICAL CONDITIONS]. Interventions included: monitor location, description and timing of pain, monitor pain level based on indicator of pain, positioning, elevation, relaxation, distraction, monitor effectiveness of medication and non-pharmacological interventions. Notify medical staff of pain not effectively managed. (There was no indication of what Resident #3's tolerable pain level was or what Resident #3 thought effective pain control was for her). Nursing pain assessments only documented foot and abdominal pain. There was no indication that Resident #3 suffered pain with care and catheter care. Review of Resident #3's October 2017 Physician order [REDACTED]. There was no way to determine how often this was performed or refused. There were multiple clinical notes indicating Resident #3 was refusing this care. There were no notes that discussed the reason for refusals or interventions attempted to get Resident #3 to allow this treatment Review of Resident #3's October 2017 Physician order [REDACTED]. Review of Resident #3's October 2017 Physician order [REDACTED]. (There was no way to determine how often Resident #3 allow this and how often she refused this care. There was no indication of interventions attempted to get Resident #3 to allow this treatment). Review of Resident #3's October 2017 Physician order [REDACTED]. (notes were requested to see when this procedure was done and no documentation was provided that showed this procedure was ever done). During an interview on 11/1/17 at 1:28 PM with Physician Assistant (PA) L and Clinical Care Specialist (CCS) C, PA L said Resident #3 had a suprapubic catheter placed and due to the opening to the urethra still being open Resident #3 was to see a Urologist on occasion (could not be done frequently) to have injections to dam the whole. PA L said Resident #3 refused to have this procedure done. CCS L confirmed Resident #3 refused her appointments and provided a Scheduling record that documented Resident #3 refused to go to the Urologist on 9/14/17, Clinical notes from 8/1/17 to 10/10/17 only indicated one cancellation of this procedure 9/13/17 at 8:14 am; however, it was not canceled due to refusal it was canceled because Resident #3 had an MI ([MEDICAL CONDITION]). Resident #3's family member confirmed in an interview on 11/2/17 at 2:45 PM that Resident #3 never refused any Urological appointments and the appointment in September was canceled due to medical problems. There was no documentation located in the record to show any interventions/conversations with a Urologist to assist with comfort during catheter care. During an interview on 11/1/17 at 1:28 PM, Physician Assistant (PA) L was asked if staff had reported that Resident #3's catheter bag and tubing had turned purple and he only recalled seeing it was purple the day she discharged to the hospital on [DATE], and said she was going to the emergency room so he did not address it at that time. PA L said the only thing he would have done if he was informed of the purple bag and tubing is assess Resident #3's cognition because even if it was a sign of infection he may have treated because he uses the Mcgeer Criteria for treatment of [REDACTED]. PA L reviewed Resident #3's electronic medial record and said Resident #3 did have an antibiotic resistant infection in her urine in July 2017 and the antibiotic he had to use is a very bad antibiotic and he would only do that again if Resident #3 was having some confusion. PA L could not locate any information in Resident #3's electronic medical record indicated she had a purple catheter bag or tubing or any information he had evaluated Resident #3 using the Mcgeers criteria when Resident #3 had a purple catheter bag and tubing. Review of a urine culture for Resident #3 dated 7/28/17 revealed she had a positive culture for Esherichia coli **ESBL PRODUCER** (means antibiotic resistant) isolated (History of ESBL/Amp C production). 10,000 - 100,00 cfu/ml Entercocus species. Susceptibility testing performed on request. (determines treatment). Review of Clinical Notes Report for Resident #3 dated 9/13/17 at 8:14 PM, documented med staff in contact with urology regarding scheduled procedure in AM. Procedure canceled r/t recent MI (heart attach). Review of Clinical Notes Report for Resident #3 dated 9/23/17 at 6:45 PM documented, resident accepted bed bath. VSS. Weight refused. Wound dressing change with increased pain and smell. No other skin issues Resident refused catheter flushes. Claims she does not have one but something is inside her will continue to monitor. (Sounds confused? Review of Clinical Notes Report for Resident #3 dated 9/29/17 at 3:30 am, documented, Resident noted to be depressed, unpleasant and non-complaint with all cares, mediation and tx (treatment) at HS (bed time) S/P catheter continues to leak and resident mostly incontinent. On 11/2/17 at 2:40 PM, CCS C confirmed Resident #3 was her own responsible party and Resident #3 had 2 family members she wanted involved in her care and never requested they were not to be informed of any care concerns. CCS C provided Resident #3's Designation of Patient Advocate Form dated 9/21/17 that indicated she had 3 family members named as advocates. During a telephone interview with Resident #3's family member VV on 11/2/17 at 2:45 PM, VV confirmed she visited Resident #3 frequently and Resident #3 wanted her and 2 other family members involved in her care. VVsaid she made all of Resident #3's Urology appointments and said Resident #3 never refused to go. VV said the only appointment Resident #3 did not go on was because she could not go after her [MEDICAL CONDITION]. VV said Resident #3 was very upset about her care there and when she was in the hospital in September Resident #3 told the hospital she did not want to go back. VV said the hospital could not find another nursing home bed available at that time so they had the facility assigned a patient advocate to help with the care problems. VV said care got a little better at first but Resident #3 was still very unhappy with her care. VV said she could not remember all the details because he did not have her notes. VV said the hospital was able to find another nursing home with an open bed when Resident #3 when to the hospital in October and Resident #3 will not be going back there. Review of Resident #3's complaint intake revealed the complainant was appalled at the condition of the patient and how she was treated. Right now she has a catheter in which causes her great pain .her pain is to the point of tears. She has stated that she gets no response when she asks to go see a doctor. When notifying a nurse about the request they just rolled their eyes and said something along the lines of do you know how long that would take to get her ready. I also had a nurse tell me that the patient had asked to see the paper regarding a previous unrelated doctor visit and that she told the patient no because she didn't feel like there was anything of importance on the papers. Nurses talk in the hall about how much they can't stand the patient. The patient told me how much she hates staying in her room all day but due to the pain that she feels hasn't been addressed she feels like she has too. Overall I'm concerned about the extreme pain of this patient and the sometimes inadequate care that she receives. During a telephone interview with Certified Nurse's Aide (CNA) Q on 11/1/17 at 11:40 am, CNA Q confirmed she worked with Resident #3 regularly, CNA Q said Resident #3 needed encouragement to allow care because her care was so painful. CNA Q said many of the staff were rude and talked about Resident #3's bad odor and not wanting to care for her outside Resident #3's door and Resident #3 could hear staff talking. CNA Q said Resident #3 was a lot of work and it took a long time so some staff would approach Resident #3 in a way they knew she would refuse, so they did not have to work as hard. CNA Q she had found crusted poop in the folds of Resident #3's labia. CNA Q said Resident #3's catheter bag and tubing was purple for 2 to 3 weeks before her last hospitalization . When CNA Q was asked if she had ever reported any of this information she said no, and indicated she had not worked there very long and would be terminated if she reported this information to anyone. During a telephone interview with Licensed Practical Nurse (LPN) J on 11/1/17 at 10:49 am, J confirmed she worked with Resident #3 regularly and confirmed Resident #3 had a lot of pain with catheter care and care in general. When asked if LPN J ever reported this pain concerns to a doctor she said, no, but they all knew she was in pain. LPN J was asked if Resident #3 had a purple catheter bag and tubing and LPN J said yes. LPN J' could not recall when it turned purple or what she was told had caused it to turn purple but thought the medication [MEDICATION NAME] (medication for irritable) had caused it to turn purple (no documentation found to support this medication can cause the Foley bag and tubing to turn purple). During an interview with CNA YY on 11/1/17 at 11:45 AM, CNA YY confirmed she worked with Resident #3 multiple times and Resident #3 always had pain with care and frequently did not allow cleaning of her peri area or catheter care because of pain. CNA YY did not recall a purple catheter bag or tubing. During an interview with CNA P on 11/2/17 at 10:15 am, CNA P confirmed she frequently worked with Resident #3 and knew that many of the staff did not want to work with her and would do things like talk loud about her outside the door where she could hear them. CNA P said staff hoped Resident #3 would refuse so they did not have to do the care. CNA P said care took a long time because Resident #3 had a lot of pain. CNA P said Resident #3 frequently requested to see PA L and on more than one occasion CNA P told PA L that resident #3 wanted to see him and she had pain. CNA P said PA L would always say things like, I saw her yesterday and she never saw PA L follow up on Resident #3's concerns. When asked if CNA P had ever reported this information to anyone she said, No. When asked why she did not report this information she said it was scary to go above CCS C and PA L. During a telephone interview with Registered Nurse (RN) I on 11/1/17 at 11:00 AM, RN I recalled working with Resident #1 frequently and Resident #3 having a purple catheter bag and tubing. RN I said she did not know why it was purple and did not recall informing a physician when it was purple. Review a the CUAJ Spotlight article dated, August 2011, titled, The purple urine bag syndrome: a visually striking side effect of a high alkaline urinary tract infection, revealed on page 234, Numerous organisms have been reported as being responsible for the purple urine bag and include Providencia bacteria, Escherichia coli, Proteus mirabblis or [DIAGNOSES REDACTED] pneumonia. Medical management of purple urine bag syndrome does not require any special treatment apart from changing the catheter and administering appropriate antimicrobial therapy to treat the underlying bacterial infections. (there was no documentation located in Resident #3's medical record that indicated the physician was aware Resident #3 had a purple catheter bag/tubing, was assessed for signs/symptoms when her catheter system was purple or that the bag/tubing was changed when it became purple).

Based on observation, interview, and record review, the facility failed to ensure monitoring of a medication regimen and failed to identify clinically significant adverse consequences for one resident (Resident #11) out of 27 residents reviewed for medication regimen, out of a total sample of 30 residents, resulting in a potentially life threatening adverse medication event, bleeding. Findings include: Review of the Profile Face Sheet and Minimum Data Set (MDS) date printed 04/07/2017 revealed Resident #11 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED].coli (blood infection), Altered Mental Status, [MEDICAL CONDITION] ,Diabetes, and Contracture of the left hand. The Brief Interview for Mental Status (BIMS) score was noted to be 12 out of 15 indicating moderately impaired cognition. Resident #11 was assessed to require extensive assistance for activities of daily life (ADLs). Observation of Resident #11 on 10/12/2017 at 10:10 a.m., revealed dark red fluid (blood) flowing through resident's Foley catheter and collecting into the Foley bag. Record review of Resident #11's Urine Analysis, performed by Spectrum Health Regional Labs on 10/11/2017, states, specimen appears grossly bloody . Record review of Resident #11's Interdisciplinary Progress Record noted by Physician's Assistant (PA) KKK, dated 10/11/2017, stated, Hematuria (blood in urine) onset 10/11/17 . Interview and observation with Licensed Practical Nurse (LPN) M on 10/12/2017 at 10:10 a.m., regarding Resident #11's Foley contents, yes, that's blood. According to Drugs.com, [MEDICATION NAME] is an anticoagulant drug that helps prevent or break up dangerous blood clots that form in your blood vessels. The dosage and administration of [MEDICATION NAME] must be individualized for each resident according to the resident 's International Normalized Ratio (INR)(blood test that measures how long it takes blood to clot) response to the drug. [MEDICATION NAME] can cause major or fatal bleeding. Risk factors for bleeding which include high intensity of anticoagulation (INR >4.0), history of highly variable INRs, and [MEDICAL CONDITION] disease (bleeding in the brain which causes damage such as [DIAGNOSES REDACTED]). The dose of [MEDICATION NAME] is based on the patient's INR and the condition being treated. Regular INR tests help the physician decide if the [MEDICATION NAME] is at the right level in your body. [MEDICATION NAME] can have dangerous side effects of a risk of bleeding. [MEDICATION NAME] has a narrow therapeutic range (index), Therefore, anticoagulation must be carefully monitored during [MEDICATION NAME] therapy. Regular monitoring of INR for those at high risk of bleeding may benefit from more frequent INR monitoring, (https://www.drugs.com/pro/[MEDICATION NAME].html).(https://www.drugs.com/pro/[MEDICATION NAME].html). Record review on 10/12/2017 of the Medication Administration Record [REDACTED].every one day starting 9/29/2017 .Notes: increase [MEDICATION NAME] 4 mg po (by mouth) q (once daily) daily. [MEDICATION NAME] Time (PT/INR) Bedside (to be done at resident bedside) .One Time Daily for One Day Starting 10/2/2107 Order Date: 9/29/2017 Discontinued (10/02/2017) Notes: inr 10/02. Record review on 10/12/2017 of Resident #11's PT and INR History (a log that has is kept by nursing staff in the computer of bedside INR results) revealed no INR results were recorded on 9/29/2017. Record review on 10/12/2017 of Resident #11s PT and INR History revealed no INR results dated 10/2/2017 were entered for 10/2/2017. Record review on 10/12/2017 of the MAR for Resident #11 revealed [MEDICATION NAME] 2 mg tablet (2.5 mg) TABLET .Starting 10/02/2017 Order Date:10/02/2017 Notes: increase to 4.5 mg po q hs(at bedtime) take 2 mg with 2.5 mg for 4.5 mg total. [MEDICATION NAME] 2.5 mg tablet (2.5 mg) TABLET .Every One Day Starting 10/02/2017 Order Date; 10/2/2107 Notes: increase to 4.5 mg take 2.5 mg with 2 mg for 4.5 mg total. [MEDICATION NAME] TIME (PT/INR) BEDSIDE .One Time Daily for One Day Starting 10/04/2017 Order Date: 10/02/2017 DISCONTINUED (10/04/2017) Notes: inr 10/04/2017. Record review on 10/12/2017 of Resident #11's PT and INR History revealed INR results to be 1.91 on 10/4/2017. Record review on 10/12/2017 of the MAR for Resident #11 revealed, [MEDICATION NAME] 2 mg tablet (2.5 mg) TABLET .Starting 102/2017 Order Date: 10/2/2017 DISCONTINUED (10/11/2017) Notes: increase to 4.5 mg po q hs take 2 mg with 2.5 mg for 4.5 mg total. [MEDICATION NAME] 2.5 mg tablet (2.5 mg) TABLET .Every One Day Starting 10/02/2017 DISCONTINUED (10/11/2017) Notes: increase to 4.5 mg take 2.5 mg with 2 mg for 4.5 mg total. Record review on 10/12/2017 of Treatment Administration Record (TAR) for Resident #11 revealed, [MEDICATION NAME] TIME (PT/INR) BEDSIDE (inr) .One Time Daily for One Day Starting 10/06/2017 Order Date: 10/4/2017 COMPLETED Notes: inr Friday. Record review on 10/12/2017 of Resident #11's Interdisciplinary Progress Record dated 10/4/2017 and written by PA KKK, stated, [MEDICAL CONDITIONS] INR 1.9 on 4.5 mg No change check Friday (10/6/2017). Record review on 10/12/2017 of Resident #11's PT and INR History revealed no INR results for 10/6/2017. Record review on 10/12/2017 of Resident #11's Clinical Notes Report dated 10/10/2017 at 11:51 p.m., entered by LPN NNN Resident (#11) has large amount of bright red blood in Foley .NP MMM called no answer. Voicemail left . Record review on 10/12/2017 of Resident #11's MAR indicated [REDACTED].One Time Daily for One Day Starting 10/11/2017 Order Date: 10/11/2017 Notes: inr 5 pm today. Record review on 10/12/2017 of Resident #11's PT and INR History revealed INR results to be 8.0 on 10/11/2017. Record review on 10/12/2017 of Resident #11's TAR revealed, [MEDICATION NAME] TIME (PT/INR) BEDSIDE (1) .One Time Daily for One Day Starting 10/12/2017 Order Date: 10/12/2017 Notes: PT INR IN THE AM. Record review on 10/12/2017 of Resident #11's Interdisciplinary Progress notes written and signed 10/11/2017 by PA KKK, stated, Labs INR 4.3 with another entry that stated INR 7.0 Hold [MEDICATION NAME] give Vitamin K+ (no dosage written) .Hematuria onset 10/10/2017 . Record review on 10/12/2017 of Resident #11's PT and INR History has no documentation of INR of 4.3 nor 7.0. During an interview on 10/12/2017 at 4:30 p.m., Director of Nursing (DON) B states when asked her expectations of a resident given [MEDICATION NAME], We (the facility) don't have a monitoring system for [MEDICATION NAME] or critical lab values .I'm not sure of the time frame to call the physician or the lab values .If not a critical value the chart is flagged for the physician to review the next time they are in .the physicians don't come in on weekends, when they come in on Monday they look at charts. On 10/6/2017 a 4.3 INR was found and a Pink Alert Sheet was filled out, placed in the front of the resident's chart (#11) and the chart was flagged with a pink strip of paper at the outside binder. The physician did not sign and no staff followed up. I assume [MEDICATION NAME] was given 10/6 through 10/11. There was no monitoring of INR. I don't know why nobody called. There is no anticoagulant protocol. Record review on 10/12/2017 of Resident #11's pink sheet labeled as INR VALUES TO REVIEW stated VALUE as 3.2. Review of Resident #11's PT and INR History has no documentation of INR as 3.2. A Care Plan Report for Resident #11 did not indicate a specific plan of care for anticoagulant medication. Review of the State Operations Manual (SOM) reflected in 483.45(d) Unnecessary Drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used--(1) In excessive dose (including duplicate drug therapy); or (3) Without adequate monitoring; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.

This citation pertains to intake # MI 675 Based on observation, interviews, and record review, the facility failed to maintain a medication administration free of significant error in 1 of 3 sampled residents (residents # 1) reviewed for medication administration, from a total sample of 3 residents, resulting in [MEDICAL CONDITION], and an emergency department (ED) evaluation for 1 resident (Resident #1) and the potential for continued [MEDICAL CONDITION] activity, and increased risk of serious adverse reactions and or serious side effects. Findings include: Resident #1 Review of a facility Face Sheet revealed Resident #1 was [AGE] year old male, originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was a extensive assist with 2 staff for transfers, and bed mobility and 1 staff for dressing A Brief Interview for Mental Status (BIMS) revealed a score of 15/15 indicating Resident #1 was cognitively intact. Review of Resident #1's physicians orders for 4/29/17 revealed: [MEDICATION NAME] ([MEDICATION NAME] anti-[MEDICAL CONDITION] medication) 200 mg by mouth or feeding tube 4 times per day with a start date of 4/20/16 Review of a facility Medication/Fluid Event form dated 4/29/17 revealed: (Resident #1) did not receive his anti-[MEDICAL CONDITION] medication as pharmacy did not send and went to the emergency department (ED) with [MEDICAL CONDITION]. Details-an investigation into this matter showed the medication was ordered by the nurse when it ran out. however the pharmacy did not send. The following day the nurse called again and the medication was still not filled. Upon further inquiry, it was stated too early for refill. The supervisor was then notified of the issue and called pharmacy to follow up and give approval. The medication was then ordered, however resident had a [MEDICAL CONDITION] and was sent to the ED before medication administered. Review of a facility document untitled with a timeline of events for Resident #1's missing medication revealed: 4/26/17-10:12 pm-1st time recorded not given. 4/27/17-12:45 pm- nurse ordered again on line with pharmacy. 4/29/17- 1:02 pm- nurse called pharmacy and they said it was too soon to dispense as insurance wouldn't pay. 4/29/17- 8:53 pm-marked as not given by nurse (Resident #1) was at the hospital by this time. received in report that resident went to hospital with [MEDICAL CONDITION]. (Resident #1) returned from hospital at 9:30 pm. 4/30/17- next dose given (no time noted as to when dose was given). Review of a facility Resident #1's Medication Administration Record [REDACTED] 4/26/17- 10:12 pm through 4/27/17 9:07 pm medication marked as not given. 4/28/17- 7:23 am marked as given. 4/28/17 1:15 pm, 5:03 pm marked as not given. 4/28/17- 9:44 pm marked as given. 4/29/17- 6:49 am 1:02 pm marked as given. 4/29/17- 8:53 pm marked as not given. Review of a facility Physicians Progress note dated 4/27/17 revealed [MEDICAL CONDITION] disorder-continue [MEDICATION NAME] 200 mg 4 times daily, [MEDICATION NAME] 50 mg daily [MEDICATION]). no recent [MEDICAL CONDITION]. During an interview on 6/26/17 at 9:40 a.m., Licensed Practical Nurse (LPN) D indicated medications not available for residents is a continuing problem, most times it's a day, or two, and they have a back up cabinet which stores a lot of medications, but not all medications are available in the cabinet (pixis). LPN D indicated over the weekend the facility was out of Vitamin C for residents, which is a stock medication. LPN D indicated she was out of Dilitzen 2 % gel for Resident #1 since last week Thursday when the facility did audits and found expired medications. LPN D indicated Resident #1's Dilitzen 2% gel is a topical (skin) get to be applied 3 times daily to Resident #1's rectum. During an interview on 6/26/17 at 10:30 a.m., Registered Nurse/Unit Manager (RN/NM) E indicated in April 2017 Resident #1 went without his anti-[MEDICAL CONDITION] medication ([MEDICATION NAME]) for 4 days resulting in a [MEDICAL CONDITION]. RN/UM E indicated she was unaware of Resident #1's Dilitzen 2% gel not being available since last week. During an interview on 6/26/17 at 12:15 p.m., Resident #1 indicated he was unaware when in April 2017 they were not giving him his anti-[MEDICAL CONDITION] ([MEDICATION NAME]) medication. Resident #1 indicated he recalls that for a couple days he didn't feel right. Resident #1 indicated he was afraid, and knew he was going to have a [MEDICAL CONDITION] because he starts to see spots in his eyes, and they get blurry. Resident #1 indicated he has not had a [MEDICAL CONDITION] in years, and he is the person who requested to go to the ED due to not feeling well at the end of April 2017. During an interview on 6/26/17 at 2:30 p.m., Director of Nursing (DON) B indicated she was unsure why nursing staff charted on 4/28/17 & 4/29/17 that Resident #1 received his anti-[MEDICAL CONDITION] medication, when in reality the medication was not available. DON B indicated the nurse who signed the medication was given, was an agency nurse and no longer works at the facility. DON B indicated that according to the timeline document given to this surveyor it appears no follow up was done on an unavailable anti-[MEDICAL CONDITION] medication ([MEDICATION NAME]) for 2 days. No follow up documentation was available from 4/27/17 12:45 p.m.- 4/29/17 1:02 p.m. (approximately 48 hours).

Based on observation, interview, and record review, the facility failed to prevent the development and failed to evaluate and treat pressure sores timely for 1 resident (Resident #7) of 3 residents reviewed for pressure sores, from a total sample of 12 residents, resulting in the development and worsening of pressure sores and delayed care and treatment of [REDACTED]. Resident #7 Resident #7 was a [AGE] year old female admitted to the facility 12/2/16, with [DIAGNOSES REDACTED]. Review of the Admission Minimum (MDS) data set [DATE], revealed Resident #7 was unable to walk, required total care and was severely cognitively impaired. Review of the facility document titled, Skin Concern/Skin Care Monitoring Tool', dated 4/11/17, reflected a Certified Nurse Aide (CNA) had identified an open area on the coccyx of Resident #7 and had informed a nurse. The Progress Note entry dated 4/12/17 at 1:38 AM, was reviewed. The entry reflected a Registered Nurse (RN) visualized, 3 pea size openings to coccyx note left for wound team, and will continue with plan of care. The entry did not reveal any measurements of the areas had been recorded or that immediate interventions were implemented to protect or treat the newly identified open areas on the coccyx. Review of the medical record did not reveal the open areas identified were further evaluated or that a treatment plan was implemented until 4/20/17. On 5/18/17 at 1:49 PM, an observation and interview was conducted with Registered Nurse Supervisor (RNS) E in the room with Resident #7. RNS E reported she does all wound dressing changes on her floor when she is at the facility. RNS E reported she was off during the time period the wound was identified on the coccyx of Resident #7. RNS E reported she addressed the concern on her return on 4/20/17. RNS E reported after she evaluated the area on 4/20/17, she scheduled a consult by medical provider, ordered a pressure reducing bed mattress, and changed the turning protocol to side to side to keep the Resident off of the coccyx wound. RNS E preformed a dressing change at this time. The wounds presented as 2 open areas on the coccyx/ buttocks area with the wound on the right side larger than the wound on the left. Two facility documents both titled, Pressure Ulcer Document Report, dated 4/20/17, were reviewed. One document reflected measurements of a wound on the left buttocks that measured 5 centimeters (cm), approximately 2 inches in length, by 2 cm wide and a depth of 0.1 cm. These measurements reflected an increase in size from pea size openings when first identified on 4/12/17. The second document reviewed indicated a wound on the right buttocks that measured 1 cm by 0.5 cm by 0.1 cm. These documents reflected documentation of, new stage II decub ulcer, and that a treatment plan was being implemented on 4/20/17. Review of the the Treatment records for April 2017 provided by the facility, reflected Resident #7 was on a schedule of, every 2 hours turn and reposition in wheelchair, with an order date of 12/22/16, and discontinued 4/16/17. The record indicated this had been completed every 2 hours although the order did not include turning for when Resident #7 was in bed until April 16th. The April Treatment record reflected side to side turning of Resident #7 began on 4/20/17. The time line of the identification and development of the pressure sore on Resident #7 provided by RNS E and reviewed. The time line indicated the wound was identified as pea size open area on 4/12/17, and assessed more thoroughly 8 days later on 4/20/17. The time line included a narrative comment from RNS E that the preventative measures, as indicated on the Resident's summary (a facility guide to daily care) were appropriate. However, the time line did not reveal a change from preventative measures to treatment measures from when the wound was first identified as pea size on 4/12/17, until 4/20/17, when a documented increase in size was noted. The documentation of a Medical Provider encounter, dated 5/2/17, was reviewed. The documentation indicated, Nursing staff reports the buttocks wound was first documented on 4/20/17. The documentation of the Medical Provider revealed, Encounter Diagnosis: [REDACTED]. 2) Decubitus ulcer of left buttock, stage 3.

This citation pertains to MI 985. Based on observation, interviews, and record review, the facility failed to prevent a fall with injury for 1 (Resident #14) of 1 reviewed for falls, from a total sample of 19 residents, resulting in Resident #14 sustaining a fracture after a fall. Findings include: Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #14 was a [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #14 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS), she required extensive assist of 1 staff member for transfers and toileting and limited assist of 1 staff member for ambulation. Review of Resident #14's Fall Risk Assessment, dated 10/8/16, revealed Resident #14 scored 12 (a total score equal to or greater than 10 represents high risk). Review of the Resident Summary Template (RST/Care Guide) active on 1/16/17, revealed Resident #14 had bed and wheelchair sensor alarms, tab alarm to bathroom door, and staff was to leave the walker by the door when not in use. The RST indicated Resident #14's walker should not be left by the bed. Review of Resident #14's Clinical Note dated 1/23/17, revealed resident was found laying on the floor by the CENA (Certified Nursing Assistant). She was laying on her back. When the resident was asked what happened, resident stated that she was trying to remove the tabs alarm off the bathroom door and lost her balance . Review of the CENA Post Fall Report dated 1/22/17 at 11:45 pm, revealed Resident #14's call light was on, that Resident #14 turned off her bed alarm, and fell in her room, outside the bathroom. Review of the Nurse Call Executive Information System Detailed Patient Activity Report (Call Light Log), revealed on 1/22/17, at 11:30 pm, Resident #14 had her call light on for 14 minutes and 48 seconds. In an observation and interview on 2/8/17 at 2:18 pm, Resident #14 was observed lying in bed wearing a back brace. When asked about her fall, Resident #14 reported she got out of bed and used her walker to walk to the bathroom. Resident #14 reported she was reaching for the cord (tab alarm on bathroom door) and lost her balance and fell . In an interview on 2/8/17, at 2:25 pm, Supplemental Resident #20 (Resident #14's roommate), reported she witnessed Resident #14's fall. Resident #20 reported Resident #14's walker was right next to her bed, Resident #14 got up, shut the bed alarm off, walked to the bathroom, reached up to turn the alarm off of the bathroom door, could not turn it off, then reached higher and fell . Supplemental Resident #20 reported she yelled for help for what seemed like 3 minutes before staff responded. Review of the MDS, dated [DATE], revealed Supplemental Resident #20 scored 15 out of 15 (cognitively intact) on the BIMS. In a telephone interview on 2/10/17 at 8:46 am, Licensed Practical Nurse (LPN) S, reported she was receiving shift report at the time of Resident #14's fall. LPN S reported the CNA on duty reported she was alerted to the fall due to hearing someone yell for help. LPN S reported Resident #14 was known to turn her alarms off, and usually when a resident is known to turn alarms off, the intervention included zip tying the alarm box out of sight. LPN S reported this was not done prior to Resident #14's fall. The surveyor attempted to contact CNA C, assigned to care for Resident #14 at the time of the fall, via telephone on 2/8/17 at 2:32 pm, 2/9/17 at 8:56 am, 2/9/17 at 3:53 pm, 2/10/17 at 8:13 am. Voicemail's were left, and no return phone calls were received prior to the exit of the survey. Review of an e-mail sent by Registered Nurse (RN) M, to other facility management, dated 1/23/17, revealed Resident #14 fell at 2345 (11:45 pm) while trying to unhook the tab alarm from the bathroom door. Per her roommate, while she was reaching for the alarm, (Resident #14) fell backward onto her back. The resident denies hitting her head but is complaining of right hip and foot pain. Also the RST was not followed, the walker was next to the bed and not by the door. The sensor alarm was not sounding, the resident is known to turn off her alarms and was witnessed doing so by the roommate . Review of the Performance Feedback Discussion Documentation, presented by RN M to CNA C dated 1/23/17, revealed Walker was left by bed in reach of resident, RST indicated to keep at door due to the resident frequently trying to get up without assistance. The Performance Feedback Discussion Documentation revealed that CNA C did not know that the RST was updated with that safety intervention. Review of the CT Spine Thoracic without Contrast Scan, dated 1/24/17, revealed, There is compression deformity of the superior endplate of T12 resulting in about 25-30% loss of central vertebral body height. There is disruption of the cortex of the superior endplate suggesting that this is an acute injury .There is subtle cortical step-off along the superior endplate of L1 suggesting an acute superior endplate fracture .

This citation pertains to MI 524 Based on interview and record review, the facility failed to prevent mental and verbal abuse of 1 (Resident #4) of 8 reviewed for abuse, from a total sample of 11, resulting in Resident #1 being upset, crying, and feeling unsafe. Findings include: Review of the Face Sheet and quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #4 was a [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #4 scored 8 out of 15 (mild cognitive impairment) on the Brief Interview for Mental Status (BIMS). Review of the facility's Summary of Allegation, (Certified Nursing Assistants (CNA) E and F) were providing cares for (Resident #4) when (CNA G) came into the (Resident #4's) room and allegedly told (Resident #4) that she was not going to be laying her back down and that she hoped (Resident #4) liked sitting in the chair because she was going to be sitting there all night. The Summary revealed the incident occurred on 9/10/16 at approximately 5:30 pm, was discovered or reported on 9/12/16 at approximately 4:30 pm, and was determine to be a reportable event on Monday 9/12/16. The Summary revealed CNA G was removed from the scheduled on 9/12/16 at 5:30 pm and it was determined through the course of the investigation that the allegation can likely be substantiated. (CNA G) has been terminated. In an interview on 10/18/16 at 4:10 pm, CNA E reported he was working on the other end of the unit and wasn't assigned to Resident #4, but Resident #4 really wanted to get out of bed. CNA E reported he went to get CNA F to assist him. CNA E reported while he and F were providing care to Resident #4, CNA G came into the room and stated, in a raised voice, to Resident #4 I don't know who you think is going to put you back in this bed. I hope you like sitting in that chair until 11 (11:00 pm). CNA E reported Resident #4 was upset and crying. CNA E stated it wasn't stuff you should say to a resident. It was verbal abuse. I told (CNA G) to leave. CNA E reported that CNA F called Supervisor/Licensed Practical Nurse (LPN) D. In a telephone interview on 10/20/16 at 8:32 am, CNA F reported she was in Resident #4's room with CNA E, assisting him with cleaning her up and getting her out of bed. CNA F reported CNA G came in and started slamming things around saying I hope you like your seat because you will be in there a long time. I'm not getting you back in bed. You' re too heavy you will break my back. CNA F reported Resident #4 responded by saying I'm not a child. Don't treat me like a child, get the 'F' out of here, you can't talk to me like that. CNA F reported she called Supervisor/LPN D and told her verbatim what she just told this surveyor. CNA F stated this was abuse and she witnessed this blatantly. In an interview on 10/18/16 at 9:21 am, when queried about how staff treated her, Resident #4 was able to recall CNA G's name and reported that CNA G said mean things to her. When asked what CNA G said to her, Resident #4 stated I don't want to talk about it. I've been trying to forget about it. It's bothered me for a long time. Resident #4 reported there were 2 other CNAs in the room when the incident occurred. When asked if the things CNA G said were abusive towards her, Resident #4 stated yeah. When asked if she felt safe in the facility, Resident #4 stated sometimes. The surveyor attempted to contact CNA G by telephone on 10/18/16 at 2:21 pm, but the phone number had been disconnected. There was no other phone number available. In an interview on 10/20/16 at 12:54 pm, Unit Manager (UM) S reported she was made aware of the incident between Resident #4 and CNA G on Monday, 9/12/16 and she conducted another interview with both CNA E and CNA F. UM S reported abuse was substantiated. Review of Termination of Employment dated 9/20/16, revealed CNA G was terminated for unprofessional conduct and stated .she also made unprofessional witnessed comments to the resident such as I hope you like being in your chair because (you're) going to be there all night .This behavior upset the resident and those who overheard the conversation . ( )

This citation pertains to intake MI 469 Based on interview and record review the facility failed to prevent a fall with injury by not implementing identified fall interventions to prevent a fall for 1 Resident (Resident #5) of 3 Residents reviewed for falls from a total sample of 8 residents, resulting in an immediate jeopardy when Resident #5, who had been identified to be at risk for falls, wore a padded helmet due to a history of frequent falls, and had a documented intervention to not be left unattended when sitting on the edge of the bed, was left unattended sitting on the edge of the bed, fell to the floor with her breakfast tray and laid on top of a heated plate and heated plate base resulting in 2nd degree burns which required surgical intervention with skin grafts. This deficient practice placed all 3 residents reviewed for falls to be at risk for serious harm, injury, or death. Resident #5 was a [AGE] year old female originally admitted to the facility 10/17/13, with [DIAGNOSES REDACTED]. The medical record revealed Resident #5 required wearing a foam helmet due to frequent falls from poor balance and episodes of vertigo. Review of the facility document Fall Event revealed Resident #5 fell during the 11 to 7 shift on 4/3/16 and was sent to the Emergency Department (ED) for evaluation. The document revealed Resident #5 returned from the ED on 4/3/16, at 8:55 AM, was placed in bed at 9:00 AM, and was served breakfast at 9:05 AM. The document revealed at 9:10 AM, Resident #5 was found face down on the floor of her room laying on top of her food tray and plate. The report revealed the Resident was evaluated and transported back to the ED for evaluation. Resident #5 subsequently returned to the facility with a bandage on her left hand. The report indicated an area on the left hand that measured 4 centimeters (cm) x 13 cm. The document revealed Certified Nurse Aide (CNA) N , who had provided care for the Resident was given education about not leaving Resident #5 unattended sitting on the edge of the bed. The document revealed, Interventions in place prior to fall: do not sit at the edge of the bed, offer to sit in recliner . In a telephone interview conducted 8/29/16, at 12:39 PM, CNA N reported on the morning of 4/3/16, Resident #5 has just returned from the hospital. CNA N reported the Resident was sitting on the edge of the bed when she carried a breakfast tray in to the room. CNA N reported she set the tray on the table in front of the Resident. CNA N did not indicate she offered to assist the Resident to the recliner to sit to eat. CNA N reported she left the room with the Resident sitting on the edge of the bed and continued delivering trays to other residents. CNA N reported several minutes later she heard a crash and went directly to the room of Resident #5. CNA N reported the Resident was laying on the food tray. CNA N reported she removed the tray from underneath the Resident and noted redness on her hand but thought it was due to the Resident laying on her hand while on the floor. CNA N reported she did not know the Resident had been burned until the Resident returned from the hospital. In an interview conducted 8/29/16, at 1:56 PM, Registered Nurse (RN) Q reported she had just received morning report when she was summoned by staff to the room of Resident #5. RN Q reported the Resident was on the floor when she entered the room. RN Q reported she assessed the Resident and had noted a red mark on the hand of the Resident. RN Q reported she arranged for transport to the hospital for evaluation. RN Q reported she later received a call from the hospital asking about the red mark because it was suspicious of a burn. RN Q reported at the time of the fall it had not been reported to her the Resident had fallen onto her food tray and hot plate (a base that held a plate and is designed to keep the plate and food warm). RN Q reported Resident #5 required skin grafts to the left hand and abdomen in the following weeks. The hospital Operative Report dated 4/28/16, was reviewed. The report revealed, Indications for surgery: Full thickness skin burns of the left hand .full thickness burn of the left lower quadrant of the abdomen. Left dorsal hand full thickness burn 8x5 cm. Left lower abdominal wall full thickness burn 5x3 cm and 3x2 cm. The report indicated, Operation Performed, .skin graft of the same sizes. General anesthesia was required for the procedure. On 8/30/16, at 5:50 PM, an interview was conducted with Food Service Supervisor (FSS) X in the facility kitchen. FSS X reported prior to putting food on a plate the plate is warmed in a plate warmer. FSS X indicated the plate rested on a base that had a material in the bottom of the base that was warmed with a demand heater. FSS X reported the heated base and heated plate keep the food warm for, about a half hour. The facility was notified on 8/30/16 at 6:20 PM of the Immediate Jeopardy(IJ) at F-323 that was identified on 8/29/16 and began on 4/3/16 due to the facility failure to prevent a fall with injury by not implementing identified fall interventions when Resident #5, who had been identified to be at risk for falls, wore a padded helmet due to a history of frequent falls, and had a documented intervention to not be left unattended when sitting on the edge of the bed, was left unattended sitting on the edge of the bed, fell to the floor with her breakfast tray and laid on top of a heated plate and heated plate base resulting in 2nd degree burns which required surgical intervention with skin grafts. This deficient practice placed all 3 residents reviewed for falls to be at risk for serious harm, injury, or death. Immediacy was removed 8/31/16, at 2:15 PM when the facility had the following in place: On 8/31/16, Resident #105 was evaluated and determined to have all appropriate fall interventions in place. On 8/31/16, all residents with a fall risk assessment score greater than 10 (high risk for falls) on the most recent quarterly or significant change fall risk assessment were reviewed for appropriate fall interventions. On 8/31/16, The Fall Care Plans for all residents at risk for falls were reviewed and updated, as necessary. On 8/31/16, began education of staff that all fall interventions were properly implemented. On 8/31/16, a meeting was help with all supervisory staff regarding implementation of fall interventions. Although the Immediate Jeopardy (IJ) was removed on 8/31/16, the facility remained out of compliance at a scope of isolated and a severity of No actual harm with the 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 had not been verified by the state agency.

This citation pertains to MI 899 Based on interview and record review, the facility failed to prevent a fall with injury for 1 (Resident #9) of 1 reviewed for falls, from a total sample of 12, resulting in Resident #9 sustaining 2 unwitnessed falls in one day and a subsequent C1 fracture (cervical spine/neck). Findings include: Review of the Face Sheet and the quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #9 was a [AGE] year old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #9 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS), used limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) with 1 staff member physical assist for locomotion on the unit, and had a history of [REDACTED].#9 had 1 fall with major injury. Review of the Current Summary Fall Event dated 3/27/16, revealed Resident was on floor at 1745 (5:45 pm), upon entering small TV room down center hallway pt (patient) was noted to be sitting on floor on bottom with BLE's (bilateral lower extremities) straight out in front of him. CNA (Certified Nursing Assistant) stated that she witnessed the fall completely, stating that she observed pt fall forward from a seated position in w/c (wheelchair), adding that pt did hit head hard on the floor .When asked what happened pt stated I was reaching down to get that piece of paper off of the floor . but no piece of paper could be located on the floor . The Follow-Up Actions section revealed an intervention of Will attempt to keep reacher by him at all times-remind hi to take it with him. Review of the Fall Risk assessment dated [DATE], revealed Resident #9 scored 22 (a total score equal to or greater than 10 represents HIGH RISK). Review of the Resident Summary Template (care guide), printed on 8/3/16, with an effective date of 5/5/16 (according to the electronic medical record), revealed SAFETY: Reacher at all times. Review of the Current Summary Fall Event dated 5/6/16, revealed at 4:40 pm, Resident was found sitting on the ground in the TV room with wheelchair beside him. Resident reports I was trying to pick up some money . The following questions/prompts on the Current Summary, under fall event details, were not completed: -Patient's level of mobility prior to fall -Type of fall safety precautions in place at time of fall -Prior to fall, was patient cooperative with fall risk interventions -Patient's attempted action prior to fall -Restraints in place? -Has the patient had another fall during this hospitalization or episode of care? -Environmental conditions -Cognition prior to fall -Patient risk factors for fall -What environmental risk factors contributed to fall? -What preventative measures were initiated post fall? -Who was made aware of the patient's fall? -Were there any additional contributing factors to the fall? Review of the post fall Neuro assessment dated [DATE], revealed the first neurological assessment was completed at 4:30 pm. There were 2 more assessments completed after that (untimed, but written in the every 15 minutes x 4 section). According to the Neuro Assessment, assessments were due every 15 minutes x 4 (4:30 pm (documented), 4:45 pm, 5:00 pm, 5:15 pm) and then every 30 minutes x 2 (5:45 pm, 6:15 pm). There was no documented assessment for 5:15 pm and 5:45 pm. Review of the Current Summary Fall Event dated 5/6/16, revealed at 5:50 pm (70 minutes after previous fall, 5 minutes after a neurological assessment was due), Pt fell from wheelchair in hallway and reports hitting his head on wall .Orders to send pt to (hospital name) .Two small scratches to top of Lt (left) hand and pt bit lip with mild bleeding. Reports pain in head and neck . The following questions/prompts on the Current Summary, under fall event details, were not completed: -Patient's level of mobility prior to fall -Was this related to a clinical alarm? -Type of fall safety precautions in place at time of fall -Prior to fall, was patient cooperative with fall risk interventions -Patient's attempted action prior to fall -Restraints in place? -Has the patient had another fall during this hospitalization or episode of care? -Environmental conditions -Cognition prior to fall -Patient risk factors for fall -What environmental risk factors contributed to fall? -What preventative measures were initiated post fall? -Who was made aware of the patient's fall? -Were there any additional contributing factors to the fall? In an interview on 8/2/16 at 11:17 am, when asked what new intervention was put into place after Resident #9's first fall on 5/6/16, Licensed Practical Nurse (LPN)/Interim Supervisor K stated At that time, I didn't deem it necessary to put an intervention in place When asked why not, LPN K reported if he had great concerns about another fall happening, he would have put an additional intervention in place. When asked what interventions were in place at the time of Resident #9's falls, LPN K stated I would have to look at the RST (Resident Summary Template). LPN K reported that the second fall on 5/6/16, appeared as though Resident #9 was pulling himself on the handrails in the hallway and slipped out of his wheelchair. In a telephone interview on 8/2/16 at 11:35 am, LPN M reported she was the nurse assigned to care for Resident #9 on 5/6/16. LPN M reported after Resident #9's second fall, his level of consciousness seemed different and he was lethargic. When asked when the last time she saw Resident #9 after the first fall, LPN M stated I can't recall. When asked if any new interventions were put into place after the first fall, LPN M stated I can't recall. LPN M reported Resident #9 had a non-skid/grippy pad in his wheelchair which was bunched up at the time of the first fall, but she did not recall checking the pad at the time of the second fall. LPN M reported she did not know how Resident #9's second fall happened. When queried if there was anything that could have prevented the second fall, LPN M stated probably somebody with him. In an interview on 8/2/16 at 4:18 pm, CNA I reported she was assigned to care for Resident #9 on 5/6/16. When asked if anything was done differently for Resident #9 after the first fall on 5/6/16, CNA I stated no, just keep an eye on him. I don't think anything else. CNA I could not recall how much time passed between her last seeing Resident #9 and his second fall. CNA I reported she heard a thud when Resident #9 fell the second time and stated he went forward again (out of his wheelchair). CNA I reported the wheelchair was not tipped over and she could not recall if Resident #9 reported how the fall happened. In a second telephone interview on 8/2/16 at 9:59 am, CNA I reported Resident #9 did not have his reacher at the time of the second fall. When asked if Resident #9 had a reacher available to use that day, CNA I stated I never saw a reacher in his room. Review of a Staff Statement dated 5/6/16 and written by CNA I (part of the facility's investigation), revealed CNA W was someone else to talk to regarding Resident #9's fall. In a telephone interview on 8/3/16 at 8:47 am, CNA W reported he did not recall Resident #9's falls. In a telephone interview on 8/3/16 at 10:41 am, CNA S reported she found Resident #9 after his first fall on 5/6/16 and he did not have a reacher with him. When asked if anything was done differently for Resident #9 after the first fall, to prevent further falls, CNA S stated just to keep a close eye on him. Review of the Clinical Notes dated 5/10/16 and completed by Occupational Therapist (OT) V, revealed Patient screened by skilled OT due to fall on 5/6/16, per patient reaching for item from floor and fell from wc (wheelchair). Provided patient with reacher and patient indep (independent) to use reacher to grab item from floor, and educated patient to not reach for items to prevent falls. No skilled services required at this time . The surveyor attempted to contact OT V for a telephone interview on 8/3/16 at 12:16 pm and 2:09 pm. There was no answer and voicemail was not set up. Review of the CT scan dated 5/6/16, revealed no acute findings. Review of the Clinical Notes, revealed Resident #9 complained of a headache on 5/7/16, neck and back pain on 5/8/16, 5/10 pain scale on 5/9/16 with Tylenol providing mild relief and a new order for Norco (narcotic pain medication), a headache on 5/10/16, discomfort on 5/11/16, weakness, fatigue, and pain from top of his head to his spinal column on 5/11/16, lethargy and neck pain on 5/12/16. There was no documentation of any additional falls or incidents between 5/6/16 and 5/12/16. Review of the CT scan dated 5/12/16, revealed acute C1 posterior arch fractures with lateral atlantoaxial subluxation. In an interview on 8/2/16 at 10:10 am, Registered Nurse (RN)/Nurse Manager N stated nothing else happened between 5/6/16 and 5/12/16. RN/Nurse Manager N stated no immediate interventions were put into place after Resident #9's first fall on 5/6/16. In an interview on 8/3/16 at 11:04 am, when queried how Resident #1's C1 fracture happened, Director of Nursing (DON) B stated From the fall. The first time they sent him (to the hospital), it didn't show up. There were some things that weren't right, staff noticed, sent him back (to the hospital), and then it (fracture) showed up on the second CT scan. Review of the Physician's progress note dated 5/17/16, revealed .Assessment and Plans: 1. status [REDACTED]. ( )

This citation pertains to intake MI 400 Based on observation, interviews, and record review, the facility failed to report to law enforcement and thoroughly investigate allegations of sexual abuse for 1 resident (Resident #101) out of 12 sampled residents reviewed for abuse and neglect, from a total sample of 12 residents, resulting in an Immediate Jeopardy with the potential for abuse, neglect, injury, harm and/or death due to resident incidents not being thoroughly investigated and reported to local law enforcement in order to determine origin of, or identification of staff or residents, who may be sexually abusing residents. This deficient practice placed any facility resident alleging sexual abuse at risk for serious physical and psychosocial harm, injury and/or death. Findings: A review of a facility Abuse Program Policy and Abuse Program Procedure, dated 2/22/16, revealed that sexual abuse is defined as, 5. Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. The policy indicated that Allegations of physical, mental, involuntary seclusion and sexual abuse, as well as neglect, mistreatment, misappropriation and injuries of unknown origin will be promptly and thoroughly investigated. The policy also indicated 8. Investigation, 1. Any allegation made by anyone who becomes aware of physical, mental, involuntary seclusion and sexual abuse, as well as neglect, mistreatment, misappropriation and injuries of unknown origin must immediately report it to a supervisor or department head who will report to the Administrator. Any allegation, even if it foes not seem credible, must be reported. Any allegation, even if the resident is known to make frequent, unsubstantiated allegations, must be reported. 2. The Elder Justice Act's requirement is to report to local law enforcement a reasonable suspicion of a crime is in addition to those required by state law and those required my Medicare and Medicaid certification. The policy further directs that the Administrator/designee or Director of Nursing/designee shall take the following actions to ensure that the investigation is conducted effectively: A. If the incident has resulted in an injury (requiring acute intervention) or was a sexual assault, the resident will be transferred to the hospital emergency room . The physician and family/legal/representative will be notified of the transfer. Note: If a possible rape has occurred: the facility will notify Med Staff and request an examination, if appropriate. The Med Staff will determine if a rape examination should be conducted. The resident's clothes will not be changed. The resident will not be bathed. First aide will be provided if necessary. B. In all cases where the police are notified, evidence will be preserved at the location of the incident until the police arrive. C. Entry into the area will be prevented. If entry is necessary, one person will be designated to enter the area. Nothing will be removed from the area. D. The Administrator or Director of Nursing/designee shall call local police when assault, sexual abuse, homicide, forgery or neglect are suspected or have occurred. E. If surveillance video exists, it will be preserved. In addition, the policy describes reporting the Reasonable Suspicion of a Crime and reflected A covered individual must timely report any reasonable suspicion of a crime against a resident/patient to the (State Agency) and at least one local law enforcement entity. If the events that cause the reasonable suspicion result in serious bodily injury, then the report must be made immediately after forming the suspicion (but not later than 2 hours after). If the events that cause the reasonable suspicion do NOT result in serious bodily injury, then the report must be made no more than 24 hours after forming the suspicion. Resident #101 Resident #101 was a [AGE] year-old woman, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 2/22/16, indicated Resident #101 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 13/15. Resident #101 needed extensive assistance from two people for bed mobility and transfers, personal hygiene and toilet use and needed extensive assistance from one person for dressing and eating. A review of a Facility Reported Incident 24-hour (FRI), dated 5/17/16, indicated a 911 call had been placed to the local police department by Resident #101 who alleged she had been raped by two women. The facility staff changed Resident #101's sheets and, initially, placed Resident #101 on 1:1 supervisory status and did 15-minute checks after that. The alleged perpetrators were placed on a Do Not Allow Entry List and it was confirmed no staff on duty went by the names of the alleged perpetrators. Visitor Logs would be reviewed for the names of the alleged perpetrators. During an interview on 5/17/16 at 10:48 a.m., Assistant NHA (ANHA) B said he got a call about the alleged rape on 5/16/16 at approximately 8:00 p.m. ANHA B said that he notified Nursing Home Administrator A of the allegation at approximately 9:30 p.m. once he had a clear picture of the clinical and criminal aspects of the investigation. ANHA B said that NHA A would confirm the direction of the facility investigation and that (local law enforcement) would drive the criminal investigation. ANHA B also reported that security footage had not yet been reviewed. During a follow up interview on 5/18/16, ANHA B said security footage had been reviewed for the 24 hour period prior to Resident #101's 911 call to the facility and reported a lot of activity (people coming and going) out of Resident #101's room and the room next door, connected to Resident #101's room through an adjoining bathroom. During an interview on 5/17/16 at 2:04 p.m., NHA A confirmed he did get a call from ANHA B at approximately 9:30 p.m. that a patient on the 5th floor alleged rape. NHA A was unable to describe the facility procedure for handling allegations of rape or sexual abuse. NHA A reported that they would contact police and follow their lead and a skin assessment would be done. During an interview on 5/17/16 at 10:48 a.m., Registered Nurse (RN) E said he was the unit manager for the 5th floor. RN E reviewed clinical notes for Resident #101, which revealed that no physical assessment of Resident #101 had been completed after the allegation of rape on 5/16/16. RN E reported he finished the search of facility employees for the names given by Resident #101 earlier that morning (the day after Resident #101's 911 call.) During an interview on 5/17/16 at 11:38 a.m., LPN G reported she cared for Resident #101 on 5/16/16 during the 7:00 a.m. - 7:00 p.m. shift. LPN G reported that Resident #101 had become agitated and she had to call security for assistance at approximately 6:30 p.m. LPN G said she had not done any kind of physical assessment on Resident #101 and reported she had not known until the next day that Resident #101 alleged she had been raped. When asked, LPN G was not able to describe what actions to take if a resident alleged sexual abuse or rape. LPN G said that if a resident alleged abuse or rape she would report it to the clinical care manager (CCM), check the resident's vitals and do whatever the CCM told me to do. When asked, LPN G reported visitors were in and out of the room next door to Resident #101's room, which is connected via an adjoining bathroom, and indicated the daughters to the resident living in the room next to Resident #101's room were in and out all day. During an interview on 5/17/16 at 12:29 p.m., LPN I said he was the clinical care supervisor on 5/16/16. LPN I said he got a call from Security Officer (SO) J at approximately 6:30 p.m. letting him know Resident #101 had called 911. LPN I said he and SO J went to Resident #101's room and found Resident #101 agitated and that she became increasingly agitated when he started asking her questions about what had happened. LPN I said that Resident #101 said she didn't feel safe because they are trying to rape and kill me. LPN I reported he did not direct any staff to do a physical assessment on Resident #101. LPN I reported he and RN K changed Resident #101's sheets and did not save them for evidence. LPN I said he suggested to ANHA B that a rape kit be done on Resident #101 and that security footage be reviewed and was told the only intervention that would be done would be to place the alleged perpetrator's names on the Do Not Allow Entry list. During an interview on 5/17/16 at 1:28 p.m., ANHA B said he did not request that a rape kit be done on Resident #101 because that would be the criminal aspect of the investigation and would be med staff's call. When asked, ANHA B could not identify interventions directed in the abuse policy and procedure in the event an allegation of rape or sexual abuse is made. During an interview on 5/17/16 at 12:15 p.m., Physician's Assistant, Certified (PA-C) H reported he had been on call the evening on 5/16/16 and recalled getting a call about Resident #101's behaviors early in the evening and prescribing [MEDICATION NAME] for increased agitation. PA-C H did not initially recall being told Resident #101 had made an allegation of rape until prompted. PA-C H said Oh wait, I did get a call back from a nurse who said a manager said med staff needed to be aware an allegation was made .I don't remember specifics of what they said happened . PA-C H reported that he didn't want to send her (Resident #101) to the emergency room (ER) for a rape kit, because the allegation seemed unfounded and didn't sound credible. When asked, PA-C H said he does not get his abuse prevention training from the facility, but from the hospital. PA-C H reported the universal protocol is to send a person to the ER if there is a credible allegation (of rape). When asked how credibility is determined, PA-C H said, If a person had hallucinations, is known to say off the wall type things are said, they would not be credible. Review of Clinical Notes dated 5/16/16 at 7:11 p.m., documented by LPN G reflected Patient yelling and screaming and throwing things in room, this nurse telephoned med staff and [MEDICATION NAME] prn (as needed) was ordered. No physical assessment was documented, no mention Resident #101 called 911 regarding an allegation on sexual abuse was noted. Review of Clinical Notes, dated 5/17/16 at 2:34:00 a.m., documented by Licensed Practical Nurse (LPN) F, indicated Med staff contacted to inform them of earlier behaviors and complaint spoke with med staff around 10:30 p.m. (four hours after the 911 call was made) also called mother to update her on condition and recent behaviors of patient. Clinical Care Manager (CCM) aware, patient was one to one cares and had PRN (as needed) [MEDICATION NAME] (an anxiolytic) for agitation, continue to monitor and document any behavior and status change. Review of Clinical Notes dated 5/17/16 at 6:46 a.m. documented by LPN F reflected Resident #101 had incontinent episode, patient very agitated refused to allow staff to clean her up and change bed, nurse explained hygiene and patient allowed, continued to curse and yell at staff, continue to states wanted to go home with her family, continue on 15 minute checks, will report to oncoming nurse about documented behaviors and possible need of one to one staff if behaviors increase. During an interview on 5/17/16 at 3:30 p.m., the Manager of Security and Police Services for the facility (MSPS) L said Law enforcement would NOT decide if a rape kit were necessary or not. Law enforcement defers to the statute for how to investigate rape allegations. In a follow-up interview on 5/17/16 at 5:02 p.m., MSPS L said that there is an established protocol/agreement for any 911 call that goes to the city police central dispatch (as was the case when Resident #101 called 911 on 5/16/16). MSPS L explained that the facility Security/Police are a police authority supervised by the city police and any call that originates from the entity facilities would be routed directly to the hospital/entity central dispatch and a person with police authority would respond. In the case of the 911 call placed by Resident #101 on 5/16/16 at approximately 6:25 p.m., the city police central dispatch operator did not follow protocol and called a security officer at the facility (not a police authority). No law enforcement personnel were dispatched to the facility as a result of the telephone call made by Resident #101 due to MSPS L had learned SO J told them not to send anyone. A recording of the 911 call Resident #101 made on 5/16/16 at 18:25:22 (6:25 p.m.) was reviewed in the presence of NHA A and ANHA B in the office of ANHA B on 5/19/16 at 2:34 p.m. Resident #101 was heard saying I need you guys to come up to (facility) .they're molesting me .the therapy camp place .see a police officer .some stuff they tried to do to me and they still trying to do it .molest me . Resident #101 was heard naming two women when asked by the dispatcher who was molesting her, then said Its a lot of them here, like I said, it's a therapy camp place. Resident #101 sounded very distressed and was begging for the dispatcher to send a police officer and expressed fear at being disconnected and of facility staff denying her presence at the facility. Resident #101 was able to state her name, location and room number when asked by the dispatcher. The dispatcher disconnected the call and police officers were not dispatched to the call. On 5/23/16 at 2:00 p.m., NHA A was informed of an Immediate Jeopardy (IJ) that was identified on 5/19/16, and began on 5/16/16, as a result of the facility's failure to thoroughly investigate and report to law enforcement an allegation of sexual abuse for one resident (Resident #101) and for failing to operationalize the facility abuse program policy and abuse program procedure. This deficient practice placed all 194 residents, who live at the facility, at risk for serious physical and psychosocial harm, injury and/or death. On 5/23/16 at 3:50 p.m. the State Agency surveyor was able to verify the following interventions had been started to remove the Immediate Jeopardy: -On May 17, 2016 a complete skin assessment was completed by the Clinical Care Supervisor. -On May 17, 2016 a supportive visit was completed with the patient by the MSW. -On May 17, 2016 and May 18, 2016 MSW contacted patient ' s mother to gain a better understanding of the patient social history. -On May 17 Med staff assessed the patient. -On May 17, 2016 care plan and resident summary template was reviewed and updated as appropriate. -On May 19, 2016 (Resident #101) was placed in a private room secondary to over stimulation regarding patient diagnosis. -On May 19, 2016 the facility started to assess the residents/patients. The facility assessed patients/ residents with a BIMS score of 11 or above were interviewed by the Interdisciplinary Team and residents/ patients with a BIMS score of 10 or below received a skin assessment by nursing and a letter was mailed to the guardian/ family member. -On May 19, 2016 Interdisciplinary team was instructed via the interview tool If any patient/resident reports any allegations of sexual abuse/contact the administrator will be notified immediately . -On May 19, 2016 NHA Acommunicated with MSPS L to remove SO J from the schedule and not to return to the(NAME)Campus. -On May 19, 2016 security officers were educated that all calls from the (local law enforcement) or other law enforcement to the (facility) Security Team that allege violations involving mistreatment, neglect, or abuse (sexual, physical, verbal, mental), including injuries of unknown source and misappropriation of residents/ patients property MUST be reported to the Administrator, NHA A at (phone number)immediately. -On May 19, 2016 the Abuse Program Procedure was reviewed and appropriate sections were updated to reflect the changes listed below. Abuse Program Procedure - An allegation of rape 1. The Administrator/designee or Director of Nursing/designee shall take the following actions to ensure that the investigation is conducted effectively. a. If the incident has resulted in an injury (requiring acute intervention) or was a sexual assault, the resident will be transferred to a hospital emergency room . The physician and family/legal/representative will be notified of the transfer. Note: If an allegation of rape has occurred: · The Administrator on call is notified immediately. · The Administrator on call/designee shall call local police (911) and request (city police department) and ambulance response. · Nurse Leader/designee will interview the resident to gather details of the allegation. · The resident ' s belongings will be untouched. · The room will be secured by two people until ambulance arrives. o Roommate(s) will be removed from the room as appropriate. · The facility will notify the Med Staff to obtain an order for [REDACTED].>· The resident ' s clothes will not be changed. · The resident will not be bathed. · First aid will be provided if necessary. · The resident ' s linen and bedding will not be disturbed. o If patient calls 911, Security is to notify Administrator on call immediately b. Entry to the area will be restricted from anyone not securing the scene or on the discretion of the Nursing Leader. -On May 19, 2016 staff received education on the above Abuse Program Procedure - An allegation of rape Although the Immediate Jeopardy (IJ) was removed on 5/19/16, the facility remained out of compliance at a scope of isolated 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. ( )

This citation pertains to intake MI 400 Based on observation, interviews, and record review, the facility failed to operationalize its Abuse Program Policy and Procedure and report to law enforcement and thoroughly investigate allegations of sexual abuse for 1 resident (Resident #101) out of 12 sampled residents reviewed for abuse and neglect from a total sample of 12 residents, resulting in an Immediate Jeopardy with the potential for all residents living at the facility to be victims of abuse, neglect, injury, harm and/or death due to resident incidents not being thoroughly investigated, reported to local law enforcement in order to determine origin of, or identification of staff or residents, who may be abusing residents. Findings: A review of a facility Abuse Program Policy and Abuse Program Procedure, dated 2/22/16, revealed that sexual abuse is defined as, 5. Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. The policy indicated that Allegations of physical, mental, involuntary seclusion and sexual abuse, as well as neglect, mistreatment, misappropriation and injuries of unknown origin will be promptly and thoroughly investigated. The policy also indicated 8. Investigation, 1. Any allegation made by anyone who becomes aware of physical, mental, involuntary seclusion and sexual abuse, as well as neglect, mistreatment, misappropriation and injuries of unknown origin must immediately report it to a supervisor or department head who will report to the Administrator. Any allegation, even if it foes not seem credible, must be reported. Any allegation, even if the resident is known to make frequent, unsubstantiated allegations, must be reported. 2. The Elder Justice Act's requirements to report to local law enforcement a reasonable suspicion of a crime is in addition to those required by state law and those required my Medicare and Medicaid certification. The policy further directs that the Administrator/designee or Director of Nursing/designee shall take the following actions to ensure that the investigation is conducted effectively: A. If the incident has resulted in an injury (requiring acute intervention) or was a sexual assault, the resident will be transferred to the hospital emergency room . The physician and family/legal/representative will be notified of the transfer. Note: If a possible rape has occurred: the facility will notify Med Staff and request an examination, if appropriate. The Med Staff will determine if a rape examination should be conducted. The resident's clothes will not be changed. The resident will not be bathed. First aide will be provided if necessary. B. In all cases where the police are notified, evidence will be preserved at the location of the incident until the police arrive. C. Entry into the area will be prevented. If entry is necessary, one person will be designated to enter the area. Nothing will be removed from the area. D. The Administrator or Director of Nursing/designee shall call local police when assault, sexual abuse, homicide, forgery or neglect are suspected or have occurred. E. If surveillance video exists, it will be preserved. In addition, the policy describes reporting the Reasonable Suspicion of a Crime and reflected A covered individual must timely report any reasonable suspicion of a crime against a resident/patient to the (State Agency) and at least one local law enforcement entity. If the events that cause the reasonable suspicion result in serious bodily injury, then the report must be made immediately after forming the suspicion (but not later than 2 hours after). If the events that cause the reasonable suspicion do NOT result in serious bodily injury, then the report must be made no more than 24 hours after forming the suspicion. Resident #101 Resident #101 was a [AGE] year-old woman, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 2/22/16, indicated Resident #101 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 13/15. Resident #101 needed extensive assistance from two people for bed mobility and transfers, personal hygiene and toilet use and needed extensive assistance from one person for dressing and eating. A review of a Facility Reported Incident 24-hour (FRI), dated 5/17/16, indicated a 911 call had been placed to the local police department by Resident #101 who alleged she had been raped by two women. The facility staff changed Resident #101's sheets and, initially, placed Resident #101 on 1:1 supervisory status and did 15-minute checks after that. The alleged perpetrators were placed on a Do Not Allow Entry List and it was confirmed no staff on duty went by the names of the alleged perpetrators. Visitor Logs would be reviewed for the names of the alleged perpetrators. During an interview on 5/17/16 at 10:48 a.m., Assistant NHA (ANHA) B said he got a call about the alleged rape on 5/16/16 at approximately 8:00 p.m. ANHA B said that he notified Nursing Home Administrator A of the allegation at approximately 9:30 p.m. once he had a clear picture of the clinical and criminal aspects of the investigation. ANHA B said that NHA A would confirm the direction of the facility investigation and that (local law enforcement) would drive the criminal investigation. ANHA B also reported that security footage had not yet been reviewed. During a follow up interview on 5/18/16, ANHA B said security footage had been reviewed for the 24 hour period prior to Resident #101's 911 call to the facility and reported a lot of activity (people coming and going) out of Resident #101's room and the room next door, connected to Resident #101's room through an adjoining bathroom. During an interview on 5/17/16 at 2:04 p.m., NHA A confirmed he did get a call from ANHA B at approximately 9:30 p.m. that a patient on the 5th floor alleged rape. NHA A was unable to describe the facility procedure for handling allegations of rape or sexual abuse. NHA A reported that they would contact police and follow their lead and a skin assessment would be done. During an interview on 5/17/16 at 10:48 a.m., Registered Nurse (RN) E said he was the unit manager for the 5th floor. RN E reviewed clinical notes for Resident #101, which revealed that no physical assessment of Resident #101 had been completed after the allegation of rape on 5/16/16. RN E reported he finished the search of facility employees for the names given by Resident #101 earlier that morning (the day after Resident #101's 911 call.) During an interview on 5/17/16 at 11:38 a.m., LPN G reported she cared for Resident #101 on 5/16/16 during the 7:00 a.m. - 7:00 p.m. shift. LPN G reported that Resident #101 had become agitated and she had to call security for assistance at approximately 6:30 p.m. LPN G said she had not done any kind of physical assessment on Resident #101 and reported she had not known until the next day that Resident #101 alleged she had been raped. When asked, LPN G was not able to describe what actions to take if a resident alleged sexual abuse or rape. LPN G said that if a resident alleged abuse or rape she would report it to the clinical care manager (CCM), check the resident's vitals and do whatever the CCM told me to do. When asked, LPN G reported visitors were in and out of the room next door to Resident #101's room, which is connected via an adjoining bathroom, and indicated the daughters to the resident living in the room next to Resident #101's room were in and out all day. During an interview on 5/17/16 at 12:29 p.m., LPN I said he was the clinical care supervisor on 5/16/16. LPN I said he got a call from Security Officer (SO) J at approximately 6:30 p.m. letting him know Resident #101 had called 911. LPN I said he and SO J went to Resident #101's room and found Resident #101 agitated and that she became increasingly agitated when he started asking her questions about what had happened. LPN I said that Resident #101 said she didn't feel safe because they are trying to rape and kill me. LPN I reported he did not direct any staff to do a physical assessment on Resident #101. LPN I reported he and RN K changed Resident #101's sheets and did not save them for evidence. LPN I said he suggested to ANHA B that a rape kit be done on Resident #101 and that security footage be reviewed and was told the only intervention that would be done would be to place the alleged perpetrator's names on the Do Not Allow Entry list. During an interview on 5/17/16 at 1:28 p.m., ANHA B said he did not request that a rape kit be done on Resident #101 because that would be the criminal aspect of the investigation and would be med staff's call. When asked, ANHA B could not identify interventions directed in the abuse policy and procedure in the event an allegation of rape or sexual abuse is made. During an interview on 5/17/16 at 12:15 p.m., Physician's Assistant, Certified (PA-C) H reported he had been on call the evening on 5/16/16 and recalled getting a call about Resident #101's behaviors early in the evening and prescribing [MEDICATION NAME] for increased agitation. PA-C H did not initially recall being told Resident #101 had made an allegation of rape until prompted. PA-C H said Oh wait, I did get a call back from a nurse who said a manager said med staff needed to be aware an allegation was made .I don't remember specifics of what they said happened . PA-C H reported that he didn't want to send her (Resident #101) to the emergency room (ER) for a rape kit, because the allegation seemed unfounded and didn't sound credible. When asked, PA-C H said he does not get his abuse prevention training from the facility, but from the hospital. PA-C H reported the universal protocol is to send a person to the ER if there is a credible allegation (of rape). When asked how credibility is determined, PA-C H said, If a person had hallucinations, is known to say off the wall type things are said, they would not be credible. Review of Clinical Notes dated 5/16/16 at 7:11 p.m., documented by LPN G reflected Patient yelling and screaming and throwing things in room, this nurse telephoned med staff and [MEDICATION NAME] prn (as needed) was ordered. No physical assessment was documented, no mention Resident #101 called 911 regarding an allegation on sexual abuse was noted. Review of Clinical Notes, dated 5/17/16 at 2:34:00 a.m., documented by Licensed Practical Nurse (LPN) F, indicated Med staff contacted to inform them of earlier behaviors and complaint spoke with med staff around 10:30 p.m. (four hours after the 911 call was made) also called mother to update her on condition and recent behaviors of patient. Clinical Care Manager (CCM) aware, patient was one to one cares and had PRN (as needed) [MEDICATION NAME] (an anxiolytic) for agitation, continue to monitor and document any behavior and status change. Review of Clinical Notes dated 5/17/16 at 6:46 a.m. documented by RN F reflected Resident #101 had incontinent episode, patient very agitated refused to allow staff to clean her up and change bed, nurse explained hygiene and patient allowed, continued to curse and yell at staff, continue to states wanted to go home with her family, continue on 15 minute checks, will report to oncoming nurse about documented behaviors and possible need of one to one staff if behaviors increase. During an interview on 5/17/16 at 3:30 p.m., the Manager of Security and Police Services for the facility (MSPS) L said Law enforcement would NOT decide if a rape kit were necessary or not. Law enforcement defers to the statute for how to investigate rape allegations. In a follow-up interview on 5/17/16 at 5:02 p.m., MSPS L said that there is an established protocol for any 911 call that goes to the city police central dispatch (as was the case when Resident #101 called 911 on 5/16/16). MSPS L explained that the facility Security/Police are a police authority supervised by the city police and any call that originates from the entity facilities would be routed directly to the hospital/entity central dispatch and a person with police authority would respond. In the case of the 911 call placed by Resident #101 on 5/16/16 at approximately 6:25 p.m., the city police central dispatch operator did not follow protocol and called a security officer at the facility (not a police authority). No law enforcement personnel were dispatched to the facility as a result of the telephone call made by Resident #101 due to MSPS L had learned SO J told them not to send anyone. A recording of the 911 call Resident #101 made on 5/16/16 at 18:25:22 (6:25 p.m.) was reviewed in the presence of NHA A and ANHA B in the office of ANHA B on 5/19/16 at 2:34 p.m. Resident #101 was heard saying I need you guys to come up to (facility) .they're molesting me .the therapy camp place .see a police officer .some stuff they tried to do to me and they still trying to do it .molest me . Resident #101 was heard naming two women when asked by the dispatcher who was molesting her, then said Its a lot of them here, like I said, it's a therapy camp place. Resident #101 sounded very distressed and was begging for the dispatcher to send a police officer and expressed fear at being disconnected and of facility staff denying her presence at the facility. Resident #101 was able to state her name, location and room number when asked by the dispatcher. The dispatcher disconnected the call and police officers were not dispatched to the call. On 5/23/16 at 2:00 p.m., NHA A was informed of an Immediate Jeopardy (IJ) that was identified on 5/19/16, and began on 5/16/16, as a result of the facility's failure to thoroughly investigate and report to law enforcement an allegation of sexual abuse for one resident (Resident #101) and for failing to operationalize the facility abuse program policy and abuse program procedure. This deficient practice placed all 194 residents, who live at the facility, at risk for serious physical and psychosocial harm, injury and/or death. On 5/23/16 at 3:30 p.m. the State Agency surveyor was able to verify the following interventions had been started to remove the Immediate Jeopardy: -On May 17, 2016 a complete skin assessment was completed by the Clinical Care Supervisor. -On May 17, 2016 a supportive visit was completed with the patient by the MSW. -On May 17, 2016 and May 18, 2016 MSW contacted patient ' s mother to gain a better understanding of the patient social history. -On May 17 Med staff assessed the patient. -On May 17, 2016 care plan and resident summary template was reviewed and updated as appropriate. -On May 19, 2016 (Resident #101) was placed in a private room secondary to over stimulation regarding patient diagnosis. -On May 19, 2016 the facility started to assess the residents/patients. The facility assessed patients/ residents with a BIMS score of 11 or above were interviewed by the Interdisciplinary Team and residents/ patients with a BIMS score of 10 or below received a skin assessment by nursing and a letter was mailed to the guardian/ family member. -On May 19, 2016 Interdisciplinary team was instructed via the interview tool If any patient/resident reports any allegations of sexual abuse/contact the administrator will be notified immediately . -On May 19, 2016 NHA Acommunicated with MSPS L to remove SO J from the schedule and not to return to the(NAME)Campus. -On May 19, 2016 security officers were educated that all calls from the (local law enforcement) or other law enforcement to the (facility) Security Team that allege violations involving mistreatment, neglect, or abuse (sexual, physical, verbal, mental), including injuries of unknown source and misappropriation of residents/ patients property MUST be reported to the Administrator, NHA A at (phone number)immediately. -On May 19, 2016 the Abuse Program Procedure was reviewed and appropriate sections were updated to reflect the changes listed below. Abuse Program Procedure - An allegation of rape 1. The Administrator/designee or Director of Nursing/designee shall take the following actions to ensure that the investigation is conducted effectively. a. If the incident has resulted in an injury (requiring acute intervention) or was a sexual assault, the resident will be transferred to a hospital emergency room . The physician and family/legal/representative will be notified of the transfer. Note: If an allegation of rape has occurred: · The Administrator on call is notified immediately. · The Administrator on call/designee shall call local police (911) and request (city police department) and ambulance response. · Nurse Leader/designee will interview the resident to gather details of the allegation. · The resident ' s belongings will be untouched. · The room will be secured by two people until ambulance arrives. o Roommate(s) will be removed from the room as appropriate. · The facility will notify the Med Staff to obtain an order for [REDACTED].>· The resident ' s clothes will not be changed. · The resident will not be bathed. · First aid will be provided if necessary. · The resident ' s linen and bedding will not be disturbed. o If patient calls 911, Security is to notify Administrator on call immediately b. Entry to the area will be restricted from anyone not securing the scene or on the discretion of the Nursing Leader. -On May 19, 2016 staff received education on the above Abuse Program Procedure - An allegation of rape Although the Immediate Jeopardy (IJ) was removed on 5/19/16, the facility remained out of compliance at a scope of widespread and a severity of No actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to 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. ( )

This citation pertains to intake MI 400 Based on observation, interview and record review the facility failed to prevent the neglect of 1 resident (Resident #101) out of 12 residents reviewed for abuse and neglect, from a total sample of 12 residents, when facility staff failed to respond to an allegation of sexual abuse, according to established policy and procedures, resulting in ongoing fear and a deterioration of the resident's mental and emotional condition. Findings: A review of a facility Abuse Program Policy and Abuse Program Procedure, dated 2/22/16, revealed that sexual abuse is defined as, 5. Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. The policy indicated that Allegations of physical, mental, involuntary seclusion and sexual abuse, as well as neglect, mistreatment, misappropriation and injuries of unknown origin will be promptly and thoroughly investigated. The policy also indicated 8. Investigation, 1. Any allegation made by anyone who becomes aware of physical, mental, involuntary seclusion and sexual abuse, as well as neglect, mistreatment, misappropriation and injuries of unknown origin must immediately report it to a supervisor or department head who will report to the Administrator. Any allegation, even if it foes not seem credible, must be reported. Any allegation, even if the resident is known to make frequent, unsubstantiated allegations, must be reported. 2. The Elder Justice Act's requirements to report to local law enforcement a reasonable suspicion of a crime is in addition to those required by state law and those required my Medicare and Medicaid certification. The policy reflects Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. the policy indicated There is a presumption that neglect has occurred whenever a facility or individual fails to provide a treatment or service to a resident which is necessary for a resident's health or safety, and the failure to provide that treatment or service results in a deterioration of the resident's physical, mental or emotional condition. A resident has been neglected when all of the following conditions are satisfied: -The facility fails to provide or arrange for medical, dental, nursing, dietary, physical therapy, pharmacy, habilitation, psychological, speech, audiological or other treatments or services to the resident in question; and -The facility's failure to provide these treatments or services is either intentional or the result of carelessness; and -The failure to provide these treatments or services, results in a deterioration of the resident's physical, mental or emotional condition. The policy further directs that the Administrator/designee or Director of Nursing/designee shall take the following actions to ensure that the investigation is conducted effectively: A. If the incident has resulted in an injury (requiring acute intervention) or was a sexual assault, the resident will be transferred to the hospital emergency room . The physician and family/legal/representative will be notified of the transfer. Note: If a possible rape has occurred: the facility will notify Med Staff and request an examination, if appropriate. The Med Staff will determine if a rape examination should be conducted. The resident's clothes will not be changed. The resident will not be bathed. First aide will be provided if necessary. B. In all cases where the police are notified, evidence will be preserved at the location of the incident until the police arrive. C. Entry into the area will be prevented. If entry is necessary, one person will be designated to enter the area. Nothing will be removed from the area. D. The Administrator or Director of Nursing/designee shall call local police when assault, sexual abuse, homicide, forgery or neglect are suspected or have occurred. E. If surveillance video exists, it will be preserved. In addition, the policy describes reporting the Reasonable Suspicion of a Crime and reflected A covered individual must timely report any reasonable suspicion of a crime against a resident/patient to the (State Agency) and at least one local law enforcement entity. If the events that cause the reasonable suspicion result in serious bodily injury, then the report must be made immediately after forming the suspicion (but not later than 2 hours after). If the events that cause the reasonable suspicion do NOT result in serious bodily injury, then the report must be made no more than 24 hours after forming the suspicion. Review of Employee Files on 5/24/16 indicated Certified Physician's Assistant (PA-C) H, Licensed Practical Nurse (LPN) G, Assistant Nursing Home Administrator (ANHA) B, Registered Nurse (RN) E, LPN I and Security Officer (SO) J had all been educated on the facility Abuse Program Policy and Abuse Program Procedure within the last year. Resident #101 Resident #101 was a [AGE] year-old woman, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 2/22/16, indicated Resident #101 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 13/15. Resident #101 needed extensive assistance from two people for bed mobility and transfers, personal hygiene and toilet use and needed extensive assistance from one person for dressing and eating. A review of a Facility Reported Incident 24-hour (FRI), dated 5/17/16, indicated a 911 call had been placed to the local police department by Resident #101 who alleged she had been raped by two women. The facility staff changed Resident #101's sheets and, initially, placed Resident #101 on 1:1 supervisory status and did 15-minute checks after that. The alleged perpetrators were placed on a Do Not Allow Entry List and it was confirmed no staff on duty went by the names of the alleged perpetrators. Visitor Logs would be reviewed for the names of the alleged perpetrators. During an interview on 5/17/16 at 10:48 a.m., Assistant NHA (ANHA) B said he got a call about the alleged rape on 5/16/16 at approximately 8:00 p.m. ANHA B said that he notified Nursing Home Administrator A of the allegation at approximately 9:30 p.m. once he had a clear picture of the clinical and criminal aspects of the investigation. ANHA B said that NHA A would confirm the direction of the facility investigation and that (local law enforcement) would drive the criminal investigation. ANHA B also reported that security footage had not yet been reviewed. During a follow up interview on 5/18/16, ANHA B said security footage had been reviewed for the 24 hour period prior to Resident #101's 911 call to the facility and reported a lot of activity (people coming and going) out of Resident #101's room and the room next door, connected to Resident #101's room through an adjoining bathroom. During an interview on 5/17/16 at 2:04 p.m., NHA A confirmed he did get a call from ANHA B at approximately 9:30 p.m. that a patient on the 5th floor alleged rape. NHA A was unable to describe the facility procedure for handling allegations of rape or sexual abuse. NHA A reported that they would contact police and follow their lead and a skin assessment would be done. During an interview on 5/17/16 at 10:48 a.m., Registered Nurse (RN) E said he was the unit manager for the 5th floor. RN E reviewed clinical notes for Resident #101, which revealed that no physical assessment of Resident #101 had been completed after the allegation of rape on 5/16/16. RN E reported he finished the search of facility employees for the names given by Resident #101 earlier that morning (the day after Resident #101's 911 call.) During an interview on 5/17/16 at 11:38 a.m., LPN G reported she cared for Resident #101 on 5/16/16 during the 7:00 a.m.-7:00 p.m. shift. LPN G reported that Resident #101 had become agitated and she had to call security for assistance at approximately 6:30 p.m. LPN G said she had not done any kind of physical assessment on Resident #101 and reported she had not known until the next day that Resident #101 alleged she had been raped. When asked, LPN G was not able to describe what actions to take if a resident alleged sexual abuse or rape. LPN G said that if a resident alleged abuse or rape she would report it to the clinical care manager (CCM), check the resident's vitals and do whatever the CCM told me to do. When asked, LPN G reported visitors were in and out of the room next door to Resident #101's room, which is connected via an adjoining bathroom, and indicated the daughters to the resident living in the room next to Resident #101's room were in and out all day. During an interview on 5/17/16 at 12:29 p.m., LPN I said he was the clinical care supervisor on 5/16/16. LPN I said he got a call from Security Officer (SO) J at approximately 6:30 p.m. letting him know Resident #101 had called 911. LPN I said he and SO J went to Resident #101's room and found Resident #101 agitated and that she became increasingly agitated when he started asking her questions about what had happened. LPN I said that Resident #101 said she didn't feel safe because they are trying to rape and kill me. LPN I reported he did not direct any staff to do a physical assessment on Resident #101. LPN I reported he and RN K changed Resident #101's sheets and did not save them for evidence. LPN I said he suggested to ANHA B that a rape kit be done on Resident #101 and that security footage be reviewed and was told the only intervention that would be done would be to place the alleged perpetrator's names on the Do Not Allow Entry list. During an interview on 5/17/16 at 1:28 p.m., ANHA B said he did not request that a rape kit be done on Resident #101 because that would be the criminal aspect of the investigation and would be med staff's call. When asked, ANHA B could not identify interventions directed in the abuse policy and procedure in the event an allegation of rape or sexual abuse is made. During an interview on 5/17/16 at 12:15 p.m., Physician's Assistant, Certified (PA-C) H reported he had been on call the evening on 5/16/16 and recalled getting a call about Resident #101's behaviors early in the evening and prescribing [MEDICATION NAME] for increased agitation. PA-C H did not initially recall being told Resident #101 had made an allegation of rape until prompted. PA-C H said Oh wait, I did get a call back from a nurse who said a manager said med staff needed to be aware an allegation was made .I don't remember specifics of what they said happened . PA-C H reported that he didn't want to send her (Resident #101) to the emergency room (ER) for a rape kit, because the allegation seemed unfounded and didn't sound credible. When asked, PA-C H said he does not get his abuse prevention training from the facility, but from the hospital. PA-C H reported the universal protocol is to send a person to the ER if there is a credible allegation (of rape). When asked how credibility is determined, PA-C H said, If a person had hallucinations, is known to say off the wall type things are said, they would not be credible. Review of Clinical Notes dated 5/16/16 at 7:11 p.m., documented by LPN G reflected Patient yelling and screaming and throwing things in room, this nurse telephoned med staff and [MEDICATION NAME] prn (as needed) was ordered. No physical assessment was documented, no mention Resident #101 called 911 regarding an allegation on sexual abuse was noted. Review of Clinical Notes, dated 5/17/16 at 2:34:00 a.m., documented by Licensed Practical Nurse (LPN) F, indicated Med staff contacted to inform them of earlier behaviors and complaint spoke with med staff around 10:30 p.m. (four hours after the 911 call was made) also called mother to update her on condition and recent behaviors of patient. Clinical Care Manager (CCM) aware, patient was one to one cares and had PRN (as needed) [MEDICATION NAME] (an anxiolytic) for agitation, continue to monitor and document any behavior and status change. Review of Clinical Notes dated 5/17/16 at 6:46 a.m. documented by RN F reflected Resident #101 had incontinent episode, patient very agitated refused to allow staff to clean her up and change bed, nurse explained hygiene and patient allowed, continued to curse and yell at staff, continue to states wanted to go home with her family, continue on 15 minute checks, will report to oncoming nurse about documented behaviors and possible need of one to one staff if behaviors increase. During an interview on 5/17/16 at 3:30 p.m., the Manager of Security and Police Services for the facility (MSPS) L said Law enforcement would NOT decide if a rape kit were necessary or not. Law enforcement defers to the statute for how to investigate rape allegations. In a follow-up interview on 5/17/16 at 5:02 p.m., MSPS L said that there is an established protocol for any 911 call that goes to the city police central dispatch (as was the case when Resident #101 called 911 on 5/16/16). MSPS L explained that the facility Security/Police are a police authority supervised by the city police and any call that originates from the entity facilities would be routed directly to the hospital/entity central dispatch and a person with police authority would respond. In the case of the 911 call placed by Resident #101 on 5/16/16 at approximately 6:25 p.m., the city police central dispatch operator did not follow protocol and called a security officer at the facility (not a police authority). No law enforcement personnel were dispatched to the facility as a result of the telephone call made by Resident #101 due to MSPS L had learned SO J told them not to send anyone. Multiple requests were made for documentation of or a policy and procedure related to the agreement between the facility/entity police authority and local law enforcement. No such documentation was provided to this surveyor during the investigation. A recording of the 911 call Resident #101 made on 5/16/16 at 18:25:22 (6:25 p.m.) was reviewed in the presence of NHA A and ANHA B in the office of ANHA B on 5/19/16 at 2:34 p.m. Resident #101 was heard saying I need you guys to come up to (facility) .they're molesting me .the therapy camp place .see a police officer .some stuff they tried to do to me and they still trying to do it .molest me . Resident #101 was heard naming two women when asked by the dispatcher who was molesting her, then said Its a lot of them here, like I said, it's a therapy camp place. Resident #101 sounded very distressed and was begging for the dispatcher to send a police officer and expressed fear at being disconnected and of facility staff denying her presence at the facility. Resident #101 was able to state her name, location and room number when asked by the dispatcher. The dispatcher disconnected the call and police officers were not dispatched to the call. During an interview on 5/17/16 at 1:10 p.m., Resident #101 was observed in her room in her bed wearing a hospital gown and an adult brief. Resident #101 said The people that work here and live here raped me. Don't nobody believe me. When asked when the rape occurred, Resident #101 said A month ago. When asked if she could identify who raped her Resident #101 gave the first name of a man and his wife or girlfriend. Resident #101 reported she thought she was in another city, More like Hell. Resident #101 said she does not feel safe and said They (facility staff) always tell me there will be no problem. Resident #101 said I don't want to stay here, they'll put tacks in my chair, they'll do anything to hurt me. I'm going to jump out the window. Review of Clinical Notes dated 5/17/16 at 1:37 p.m. indicated Social Worker (SW) O had followed up with Resident #101 regarding the allegations of rape made the night prior and reflected (SW O) has offered intermittent support to patient throughout the day related to continued agitation and paranoia and continued statements regarding last night's allegations. Patient able to be re-directed when reminded that staff has taken patient's concerns and are working on rectifying situation. Patient requested to call her mother. Patient talked to mom on the phone asking to be picked up and stating If no one is going to get me, I'm going to jump out the window. (SW O) also talked with patient's mother who indicated continued concern regarding patient's medical condition and status and behaviors . Review of Clinical Notes dated 5/18/16 at 10:32 a.m., indicated SW O had learned by talking again to Resident #101's mother that (Resident #101) does have a history of sexual assault. Patient's mother stated that during the mid-90's patient's step-brother (name of step brother) raped (Resident #101). Patient's mother indicated Resident #101's step-brother is serving a life term in prison for like charges .

Based on observation, interview and record review, the facility failed to prevent an unstageable coccyx pressure ulcer for one resident (#16) out of 5 residents reviewed for pressure ulcers, in a total sample of 30 residents, resulting in worsening of the coccyx ulcer and the potential for systemic infection. Findings included: Review of Resident #16's undated face sheet reflects Resdent #16 was a [AGE] year old male initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #16 was discharged to the hospital on [DATE] for pneumonia and placement of a gastric feeding tube. Resident #16 was re-admitted to the facility on [DATE]. Review of Resident #16's Admission Minimum Data Set (MDS), an assessment tool, Assessment Reference Date (ARD) of 9/23/2015, reflected Resident #16's skin was intact on admission, he required extensive assistance with bed mobility (turning and repositioning), transfers, hygiene and he was cognitively intact with a 15/15 Brief Interview for Mental Status (BIMS) score. Review of Resident #16's (Re-)Admission MDS, ARD of 10/27/2015, which reflected Resident #16 had one unstageable pressure ulcer, required extensive assistance with bed mobility (turning and repositioning), transfers, hygiene and was cognitively intact with a 14/15 BIMS score. Review of Resident #16's Admission Assessment, dated 10/10/2015, under the skin section reflected excoriation (raw irritation of the skin) right buttocks. Review of the facility's Braden Scale for Predicting Pressure Sore Risk, dated 10/10/2015, reflects under Mobility-Ability to change and control body position Very Limited. Review of clinical notes for 10/19/2015 reflects New open area on coccyx. Wound referral done. Resident #16's coccyx wound status, documented on the facility's Pressure Ulcer Documentation Reports were reviewed for the dates: -10/21/2015 (initial) wound size: 6.2 centimeters (cm) or 2.44 length x 2 cm or 0.78 width x 0.1 cm or .04 depth. 90% yellow slough (dead tissue) on wound bed -11/04/2015 wound size: 4 cm or 1.57 x 2.5 cm or 0.98 x 0.2 cm or .07 20% slough with red granulation tissue (healing tissue) on wound bed -11/18/2015 wound size: 4 cm or 1.57 x 2.8 cm or 1.10 x 0.1 cm or .04 (No percentage documented) yellow slough on wound bed -11/26/2015 wound size: 2.9 cm or 1.14 x 1.8 cm or 0.70 x 0.1 cm or 0.04 (No percentage documented) yellow slough on wound bed -12/23/2015 wound size: 3.8 cm or 1.49 x 2.0 cm or 0.78 x 1.0 cm or 0.39 50% yellow slough, light purulent drainage -01/01/2016 wound size: 3.5 cm or 1.37 x 2.0 cm or 0.78 x 1.4 cm or 0.55 40% yellow slough on wound bed Review of the Wound Progress Notes, dated 12/2/2015, authored by the wound Nurse Practitioner under PE (Physical Examination): 100% necrotic (dead) tissue . unable to assess level of tissue involvement . and under Impression: Sacral decub unstagable (sic) deteriorating. Observation of Resident #16's coccyx wound on 1/5/2015 at 1:25pm, in Resident #16's room with Registered Nurse (RN) W. Wound observed was approximately the size of a walnut in circumference with irregular edges. The wound was observed to be approximately 1/2 in depth with stringy yellow slough on wound bed. RN W packed the wound with .25% Dakins (very dilute bleach) solution soaked gauze and covered with a clean 4x4 gauze. During an interview with Resident #16 on 1/5/2016 at 9:55 a.m. Resident #16 stated that the staff repositioned him only when he requested to be repositioned, instead of every 2 hours automatically as indicated by the current careplan interventions. Resident #16 stated that sometimes he would be watching a movie or playing a game on his tablet and forget to put on his call light to be turned, so there were times that he would go 3 to 4 hours without being repositioned. Durng an interview with the Director of Nursing and the 4th Floor RN Manager --- on 1/6/2015 at 3:30 p.m., this surveyor posed the question if Resident #16's facility acquired unstageable coccyx ulcer had developed unavoidably. Both the Director of Nursing and 4th Floor RN Manager stated they did not know if the development of the ulcer had been avoidable. The 4th Floor Manager --- stated that she had not visualized Resident #16's wound and was surprised that the wound was that bad.

This citation pertains to intake #MI 403 Based on observation, interview and record review the facility failed to provide the necessary care and services to attain and maintain the highest practicable physical, mental and psychosocial well-being of 1 Resident (#1) of 7 residents sampled for code status and 2 Residents (#1 and #3) of 4 residents sampled for use of [MEDICATION NAME] (an injectable medication used to treat critically low blood sugar) of a total of 80 residents identified as receiving treatment for [REDACTED].#1 not receiving Cardiopulmonary Resuscitation (CPR) in a timely manner and not receiving [MEDICATION NAME] in a timely manner when he was found unresponsive on [DATE] and was unable to be revived. Findings include: Review of the Resident #1's face sheet, run date/time [DATE], 6:04 PM revealed Resident #1 was a [AGE] year-old male, who was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Additionally, the review of Resident #1's face sheet, revealed Resident #1's decision for Cardiopulmonary Resuscitation (CPR) was unknown because there were not a current code status specified in the medical record documentation. During a telephone interview on [DATE] at 2:55 PM, Licensed Practical Nurse (LPN) C said she found Resident #1 warm and unresponsive in his bed at approximately 6:00 AM on [DATE]. LPN C said she was Resident #1's assigned caregiver and had cared for Resident #1 that night but was not his primary nurse. LPN C said she ran to report Resident #1's condition to his primary nurse LPN D and asked LPN D what Resident #1's code status was. LPN D did not know Resident #1's code status so LPN C went to get the chart. The chart did not indicate if Resident #1 wanted CPR, so LPN C took the chart to Registered Nurse (RN) G. RN G told LPN C she needed to call a Code Blue and 911. LPN C went to make the calls. LPN C said she did not know who started CPR but not knowing the code status delayed the initiation of CPR for Resident #1. LPN C said she was CPR certified and could have started CPR when she found Resident #1 unresponsive, if she had known his code status. During a telephone interview with RN E on [DATE] at 11:35 AM, RN E said she was working on [DATE] around 6:10 AM when she heard a Code Blue called and ran to Resident #1's room. RN E said she started the CPR and sent LPN D to get the crash cart. RN E said she had no idea what time Resident #1 was found unresponsive. RN E said they were unable to revive Resident #1. A telephone interview with LPN D on [DATE] at approximately 9:30 AM, revealed that she had worked the night shift which began at 10:45 PM on [DATE] into the morning of [DATE]. LPN D stated that she was motioned by LPN C to come to Resident #1's room. LPN D stated when she entered the room, Resident #1 was laying there with his mouth open, there was no pulse, he was cold and Resident #1 was unresponsive. LPN D did not initiate nor observe any CPR at that time. LPN D stated she went to the medication cart to ascertain Resident #1's code status, but it was not listed on the report sheet so she went to the desk to obtain Resident #1's chart. LPN D stated that there was no listing of Resident #1's code status so she called her manager and was instructed to call a Code Blue. LPN D stated after she called the Code Blue she returned to Resident #1's room and took the crash cart with her. Review of the facility Record Resuscitation Sheet revealed, Registered Nurse M entered Resident #1's room with the crash cart at 6:13 AM. RN M documented on the Record Resuscitation Sheet for Resident #1, dated [DATE] at 6:00 AM, compressions started at 6:00 AM, 6:10 AM IV (intravenous) access/bad ., 6:12 AM monitor applied and [MEDICATION NAME] BS ( blood sugar) 33, 6:20 AM [MEDICATION NAME] IM, 6:20 IV access, 6:22 AM no shock, 6:23 AM no shock, 6:24 BS 330 and no shock, 6:32 Asystole .6:38 Asystole, 6:42 Time of Death. On [DATE] at this Surveyor's request a list of all residents in the facility that had not completed an advanced directive. The Assistant Nursing Home Administrator L provided a list of 4 residents (#5, #6, #7, #8) that did not have an advanced directive in their medical record when this Surveyor entered the building on [DATE]. Review of Resident #5, #6, #7, and #8's medical record confirmed, revealed they did not have an advanced directive in place the morning of [DATE]. Review of the facility Code Blue Policy and Procedure dated, last revised [DATE], documented under Policy Content: I. CPR, In the event of a cardiopulmonary arrest, CPR will be initiated, code blue with be paged overhead and ,[DATE] will be called to activate the EMS system. A licensed nurse will verify the resident/patient preferences on the Treatment Preference Sheet or on the worksheet pertaining to CPR. Under Purposes the Code Blue Policy documented, Residents/patients are also presumed to be CPR candidates unless otherwise indicated on the Treatment Preference Sheet. On [DATE] at 3:15 PM, the Nursing Home Administrator A was notified of the Immediate Jeopardy that began on [DATE] when Resident #1 was found unresponsive and CPR was not immediately started, additionally [MEDICATION NAME] was not readily available. On [DATE] the Immediate Jeopardy was removed when the surveyors verified the following: 1. [DATE] All residents received a code status review for completion. A total of ,[DATE] residents were re-evaluated for the accuracy of their code status and updated. 2. [DATE] The Nurse Report Sheet was updated to reflect current code status for emergent notification of resident code status. 3. [DATE] ,[DATE] Licensed Nurses were educated on the Code Status roles and responsibilities and will not be permitted to return to work until educated. 4. [DATE] the Medical Director was educated. 5. [DATE] ,[DATE] Licensed Nurses were educated on the location of [MEDICATION NAME] and will not be permitted to return to work until educated. 6. [MEDICATION NAME] par (availability) levels were increased to 10 vials on each unit. 7. [DATE] Nursing Agency staff was granted access to the Pyxis machine (where the [MEDICATION NAME] was kept). 8. The Quality Assurance and Performance Improvement committee will oversee the audit of each new admission, upon physician order [REDACTED]. 9. [DATE] The Quality Assurance and Performance Improvement committee recommended minor nonsubstantive revision to the Code Blue Policy and Procedure to reflect the education staff already received. 10. [DATE] The Quality Assurance and Performance Improvement committee will oversee the audit to monitor [MEDICATION NAME] par levels as the facility's pharmacy will audit activity levels of [MEDICATION NAME] usage and provide a report each week. 11. [DATE] The Quality Assurance and performance Improvement committee recommended revisions to the [DIAGNOSES REDACTED] Policy. The Policy was revised to reflect current standing orders. Licensed nurses will be educated on the new policy. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity of actual harm with the potential for more than minimal harm that is not Immediate Jeopardy due to the facts that not all staff have been educated and sustained compliance has not been verified by the State. ( ) During the facility initial tour on [DATE] at 9:20 AM, three of four (2nd, 4th and 5th) floors of the skilled nursing facility did not have [MEDICATION NAME] available. A telephone interview with LPN D on [DATE] at approximately 9:30 AM, revealed that she had worked the night shift on [DATE] into the morning of [DATE]. LPN D stated that she was motioned by LPN C to come to Resident #1's room. LPN D stated when she entered the room, Resident #1 was laying there with his mouth open, there was no pulse, and Resident #1 was unresponsive. LPN D stated that she obtained Resident #1's blood sugar level when compressions were started and they were low at 33 mg/dL (milligrams/deciliter) and she reported that to the record keeper (a person responsible for keeping a record of medications administered and events that transpire during a Code Blue). LPN D also stated, that another nurse went to obtain [MEDICATION NAME] while she stayed to assist. On [DATE] a review of the facility's physician's standing orders, dated [DATE], reflected an additional treatment for [REDACTED]. Resident #1's physician's standing orders, signed and dated [DATE] reflected on page 2, under Unresponsive resident or unable to take oral fluids resident: 1a. If resident does not have a patent IV, administer [MEDICATION NAME] 1 ML (milliliter) injection IM (intramuscularly). [DIAGNOSES REDACTED] at number 1. was defined as less than 70 mg/dL. The standing orders also reflected that [MEDICATION NAME] could be administered twice (with a wait of ,[DATE] minutes between re-testing and the injections) in an attempt to raise a blood sugar to 70 mg/dL and then the physician was to be notified. At the time Resident #1 was found unresponsive, with a low blood sugar and without a pulse on the morning of [DATE], no IV was available/established. ( )

This citation pertains to MI 449 Based on interview, and record review, the facility failed to ensure residents were transfered safely per the care plan in 1 of 4 sampled residents (Resident #3) reviewed for falls, from a total sample of 4, resulting in Resident #3 sustaining a fractured right hip after a fall. Findings include: Review of the Face Sheet dated 10/3/14 and Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #3 had unclear speech, usually understood, understands and was moderately impaired cognitively. The MDS also revealed that Resident #3 required extensive of assistance of 2 people for transfers. Review of the Fall Event form dated 10/1/14 revealed that on 9/5/14 at 5:45 a.m., "CNA (Certified Nursing Assistant "H") was toileting (Resident #3) as a 1 assist, pt (patient, Resident #3) was in RST (Resident Summary Template, a care guide use by CNA's) as 2 assist. There was no gait belt in place. Pt was standing washing hands when she stumbled backwards, CNA was able to catch patient, but right leg was caught between toilet and wall and awkwardly twisted." Review of the MI-ACTS Incident Summary dated 9/27/14 revealed that on 9/5/14, "...the patient did land on the floor...It was noted that the CNA didn't have a gait belt on the patient and according to the care plan the patient required extensive assistance x2 (two people) and the CNA was assisting the patient x1 (1 person)". Review of CT (Computed Tomography, an advanced x-ray) Final Report dated 9/9/14 for Resident #3 revealed she had sustained a, "nondisplaced right femoral greater trochanteric fracture (right hip fracture). Review of the Occupational Therapy (OT) note dated 7/8/14 revealed, that Resident #3 required the assistance of 2 people for pivot transfers. Review of the Occupational Therapy noted dated 7/9/14 revealed, "(Resident #3) demonstrated very few gains with OT...(discharge) from OT at this time..." Review of the RST that was in place when Resident #3 fell , undated, revealed, "Transfer: Extensive Assist x2 (extensive assistance of 2 people)...Toileting: Toilet Transfer-Ext x2 ". Review of Resident #3's risk for falls care plan dated 6/19/14 revealed, "(Resident #3) will be provided with individual safety measures to sustain a safe environment...Safety devices: see RST (Resident Summary Template)". The Risk for Falls care plan and the RST for Resident #3 failed to reveal an intervention for using a gait belt. During an interview on 10/3/14 at 9:20 a.m., Director of Nursing (DON) "C" stated, "If a resident requires any type of assistance with transfers, then they require the use of a gait belt". During a telephone interview on 10/3/14 at 12:45 p.m., CNA "H" stated that on 9/5/14, CNA "H" assisted Resident #3 from her bed to the bathroom without the help of a second staff member. CNA "H" stated, "I didn't know that (Resident #3) was a 2 person assist". ( )

This citation pertains to MI 086 This citation contains two deficient practice statements (A and B). A. Based on observation, interview, and record review, the facility failed to implement and monitor care planned fall interventions for 1 (Resident #17) of 15 residents reviewed for falls from a total sample of 30, resulting in Resident #17 being placed in immediate jeopardy to her health and safety on 3/3/14 when Resident #17 fell and sustained a subdural hematoma (collection of blood on the surface of the brain) after her bed sensor alarm was found nonfunctional. Resident #17 was hospitalized for [REDACTED]. This deficient practice placed 14 residents reviewed for fall alarms (Resident # 5, #6, #7, #8, #10, #11, #13, #16, #17, #21, #22, #23, #24, and #25) from a total sample of 30, at risk for serious harm injury, and/or death. The facility was placed in Immediate Jeopardy as a result of the facility's failure to implement and monitor care planned fall interventions for 1 (Resident #17) who was care planned to have a sensor alarm to her bed and chair. On 3/3/14 at 9:45 pm, Resident #17 sustained a fall with a subdural hematoma after her bed sensor alarm was found nonfunctional. Resident #17 was hospitalized for [REDACTED]. On 3/12/14 at 2:30 pm, Resident #17 was observed sitting in her recliner chair in her room at the facility without a sensor alarm in place. On 3/13/14 at 1:20 pm, the Nursing Home Administrator (NHA) was notified of the Immediate Jeopardy that began on 3/3/14, and identified on 3/12/14, due to the facility's failure to protect Resident #17 from a fall with injury and the potential for 14 sample residents (# 5, #6, #7, #8, #10, #11, #13, #16, #17, #21, #22, #23, #24, and #25) with fall alarms to remain at increased risk for fall with injury. A request for a written plan of removal was requested at that time. On 3/14/14 at 9:00 am, the surveyor verified that the facility had done the following to remove the Immediate Jeopardy: - On 3//13/14 residents identified were reassessed for fall risk including medication regimen review. - On 3/13/14 care plans for the identified residents were reviewed and revised as needed. - On 3/13/14 currently placed fall alarm devices were checked for placement and operability. - On 3/13/14 the facility began re-educating all licensed nurses and CNAs (Certified Nursing Assistants) on placement of alarms and the 4 Ps (position, personal needs, pain, placement); licensed nurses were re-educated on completing the fall risk assessment and fall risk care plan development. - On 3/13/14 the CNA report tool was revised to reflect alarm placement and operability; the CNA tool will be reviewed by the licensed nurse for completion and accuracy per shift. - On 3/13/14 the placement and operability of the alarms was documented by licensed nurses on the Treatment Administration Record (TAR) - On 3/13/14 the fall risk assessment tool was reviewed and deemed appropriate. The device check tool was also reviewed and deemed appropriate. - On 3/13/14 the residents will continue to be assessed for alarm use and alarms will continue to be in place per assessment and reflect on the Resident Summary Template (RST). Although the Immediate Jeopardy was removed on 3/13/14, the facility remained out of compliance with a scope of pattern and severity of "No actual harm with a potential for more than minimal harm that is not immediate jeopardy" due to all staff having not received the inservice education, and sustained compliance having not been verified by the State Agency. Findings include: Resident #17 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #17 was a [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The 3/5/14 MDS revealed Resident #17 scored 10/15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). Review of Resident #17's Fall Risk Assessment, dated 11/20/13, revealed Resident #17 was ambulatory, had a balance problem while standing, required the use of assistive devices, and had a total fall risk score of 10. A total score equal to, or greater than, 10 represents a high risk for falls. Review of Resident #17's monthly physician's orders [REDACTED]." Review of Resident #17's safety care plan, with a goal date of 6/6/14, revealed "safety devices-see RST." Review of Resident #17's Resident Summary Template (RST), dated 2/21/14, revealed "safety: alarm-sensor bed; alarm-sensor chair." Review of the clinical notes, dated 3/3/14, revealed "pt (patient) was observed on the floor in her room next to another patients bed lying on her back...said that her head and left arm hurt...bleeding from the back of her head and had extremely limited range of motion in her left arm...the sensor alarm on her bed had the battery cover disabled so no alarm was sounding at the time of the fall..." Review of the hospital "Radiology Results CT (computerized tomography) Head...", dated 3/5/14, revealed "[DIAGNOSES REDACTED]. Review of the facility's "Re-enactment of fall", dated 3/4/14, revealed Licensed Practical Nurse (LPN) "B" had reported to Assistant Director of Nursing (ADON) "BB" that she assisted Resident #17 into bed on 3/3/14 at approximately 7:30 pm. According to the "Re-enactment of the fall", ADON "BB" questioned LPN "B" if Resident #17's sensor alarm beeped indicating that it had engaged. LPN "B's" response was "No and I didn't even think about it." LPN "B" was then queried by ADON "BB" if she visualized the alarm, to which she responded "No, I didn't look at it after she got into the bed. I knew she had the alarm, I just didn't even think about it. I normally don't work second shift so I didn't think about the bed alarm." During the re-enactment, LPN "B" reported to ADON "BB" that she left Resident #17's room at approximately 8:00 pm. In a telephone interview on 3/14/14 at 3:02 pm, LPN "B" reported that on 3/3/14, she was mandated to work second shift as a CNA. LPN "B" reported that she performed bedtime care for Resident #17 from approximately 7:30 pm until 8:00 pm. LPN "B" reported that she assisted Resident #17 into bed at approximately 8:00 pm. When queried if the bed alarm beeped when Resident #17 got into bed, LPN "B" stated "No." When queried if she checked Resident #17's bed alarm, LPN "B" stated "I did not. I don't normally work second shift. On first shift she didn't go to bed. I honestly didn't think about it." LPN "B" reported that she was aware Resident #17 had a bed alarm, but stated she "didn't think to check it." LPN "B" reported that Resident #17's alarm was not sounding at the time of the fall on 3/3/14. Review of the facility's Current Summary, Fall Event dated 3/12/14, revealed "upon investigation the reason the alarm box was not sounding was that the battery cover was lifted from the box...based on her (Resident #17's) history sensor alarms were an appropriate safety intervention...she (Resident #17) has returned to the facility with the same safety precautions in place, with an emphasis on checking the integity (sic) of the entire alarm when turned on with each use... " Review of the Nursing Notes dated 3/6/14, revealed Resident #17 was readmitted to the facility from the hospital. Review of the physical therapy notes dated 3/6/14, revealed that Resident #17 had a physical therapy evaluation and reported increased confusion, dizziness and weakness after the fall. The physical therapy notes revealed "Pt (patient) was a SBA (stand by assist) prior to hospitalization and able to amb (ambulate to/from bathroom at (sic) 4ww (4 wheeled walker). Pt presents with decr (decreased) BLE (bilateral lower extremity) strength, difficulties with transfers, decr (decreased) balance with static stand and incr (increased) gait with amb (ambulation)". Review of the occupational therapy notes dated 3/6/14, revealed Resident #17 required increased assistance for functional transfers for toileting and pericare needs and also demonstrated decreased functional endurance. Review of the clinical notes dated 3/7/14, revealed Resident #17 made "several attempts to self transfer, sounding alarm with immed (immediate) staff response..." Review of Resident #17's Treatment Administration Record (TAR) dated March 2014, revealed "fall safety alarm-check placement, function and expiration q (every) shift" which started on 3/7/14. Review of the RST dated 3/3/14, revealed Resident #17's safety measures included a sensor alarm to her bed and chair. There was no indication that her sensors were to be checked when turned on with each use. In an interview on 3/12/14 at 2:25 pm, when queried as to what the procedure was for checking alarms, the interim Director of Nursing (DON) reported that CNAs make rounds at shift change to make sure alarms were in place. The interim DON reported that CNAs carried a report tool sheet on which the CNAs wrote out interventions for each resident. An observation on 3/12/14 at 2:30 pm, revealed Resident #17 was sitting in her recliner in her room. Resident #17 did not have a sensor alarm in place. There was a sensor alarm on her bed and the "hold" light was blinking red. In an interview and record review on 3/12/14 at approximately 2:30 pm, CNA "A" provided this surveyor with her CENA Report Tool (undated). Review of the report tool revealed Resident #17's room number, last name, and sections labeled transfer ambulation, any changes in physical or mental? Changes noted?, safety interventions, recent falls, fluid consistency, diet, and notes. The report tool revealed a "/" written in the safety interventions section and no check marks for "sensor: chair/bed/both", and a "/" in the recent falls section. CNA "A" reported she was on duty since 7:00 am, was caring for Resident #17, and had not updated her report tool yet. When queried if Resident #17 was to have a sensor alarm in her recliner chair, CNA "A" stated "maybe so...I haven ' t had her since she fell ...I'm aware she's a bed alarm". Review of the TAR dated 3/12/14, revealed Resident #17's fall safety alarm placement, function, and expiration were checked by the nurse on first shift. Review of the facility's Sensor Pads (Bed or Chair Alarms)/Tab Alarm Use policy dated 6/2003 and reviewed 11/2012, revealed "The sensor alarm (bed/chair) should be appropriately placed to ensure it's functionality if the resident/patient moves in the bed or chair" and "The assigned CNA ensures placement/function for each sensor pad alarm." ( ) B. Based on interview and record review, the facility failed to provide adequate supervision to prevent falls for 1 (Resident #16) of 15 residents reviewed for falls from a total sample of 30, resulting in Resident #16 sustaining repeated falls with the potential for serious injury. Findings include: Resident #16 was not residing at the facility at the time of the survey. According to Resident #16's MDS/Minimum Data Set, dated dated [DATE], she was cognitively intact, weighed 130 pounds, was receiving dialysis, and had [DIAGNOSES REDACTED]. According to facility Incident Reports dated 1/04/14, 2/10/14, 2/17/14 and 2/23/14, Resident #16 had 4 falls without injuries within 51 days (1/04/14 -witnessed, 2/10/14 -unwitnessed), 2/17/14 - unwitnessed, and 2/23/14 - unwitnessed). In an interview, on 3/13/14 at 9:25 AM, Clinical Care Manager "HH" reported Resident #16 did not have a tab alarm in place on 1/04/14. "HH" stated, "I didn't think (Resident #16) could walk. (Resident #16) was not supposed to stand or walk. Although she was a fall risk, this (1/04/14 fall) was her first fall." According to Resident #16's Care Guide, a winged mattress was added to her bed on 1/04/14. Clinical Care Manager "HH" reported the sensor alarm was not sounding at the time of the falls that occurred on 2/10/14 and 2/23/14 because "(Resident #16) took it off." Clinical Care Manager "HH" stated she had requested a motion sensor be ordered, but was denied the request. According to Care Plans printed on 3/13/14, the Fall Care Plan, created 1/26/14 (12 days after the fall on 1/04/14), read: "(Resident #16) is at risk for falls or injury related to: impaired balance r/t (related to) TIA (stroke), Impaired vision (wears glasses), Impaired gait, Medical condition...Hx (history) of falls, Incontinence....Medications...Need for assist with mobility - transfers with 1 assist, Resident has need for mobility bars to assist with bed mobility..." The Fall Care Plan created 1/26/14 revealed no subsequent changes to reflect increased supervision or different alarm types (motion sensor) that would be less likely to be removed by the resident, and there was no Care Plan to explain how staff would address the resident's lack of compliance with the alarms. According to the Incident Report, dated 2/10/14 at 2:16 PM: "(Resident #16) observed on the floor in her room...(Resident #16) had pain in her left hip and lower left back...Fall safety precautions in place at time of fall: Yes...Immediate intervention with this fall was to change tab alarm to a sensor alarm..."According to the Incident Report, dated 2/23/14 at 6:40 AM, "Fall safety precautions in place at time of fall: Yes." However, the Fall Team Analysis paperwork, dated 2/24/14, revealed "Tab alarm not sounding." According to the Incident Report, dated 2/17/14 at 8:15 PM, "Fall safety precautions in place at time of fall: Yes." However, during an interview on 3/13/14 at 6:00 PM, Nurse Aide "GG" reported he was the nurse aide assigned to Resident #16 on 2/17/14 at the time of the fall and he failed to assure Resident #16's tab alarm was on and functioning at the beginning of his shift. Nurse Aide "GG" stated, "Neither the call light or any alarms were sounding. (Resident #16) was supposed to have a tab alarm. Yes, I was talked to about her not having her tab alarm on by Clinical Care Manager "FF". Nurse aide "GG" stated he was not given a written discipline. According to the Incident Report, dated 2/23/14 at 6:40 AM, "Fall safety precautions in place at time of fall: Yes." However, the Fall Team Analysis paperwork, dated 2/24/14, revealed "Tab alarm not sounding." ( )

Based on observation, interview and record review, the facility failed to implement timely interventions to address positional changes for pressure relief and other care interventions to prevent the development and worsening of pressure ulcers for 2 (#16, #19) of 6 residents reviewed for pressure ulcers, from a total sample of 30 residents, resulting in Resident #16 developing a facility acquired stage IV pressure ulcer and Resident #19 developing a facility acquired stage II pressure ulcer. Findings include: Resident #16 was not residing at the facility at the time of the survey. According to Resident #16's MDS (Minimum Data Set) assessment, dated 8/12/13, she was cognitively intact at the time of the assessment, weighed 130 pounds, was receiving [MEDICAL TREATMENT], and had [DIAGNOSES REDACTED]. According to Resident #16's MDS dated [DATE], Resident #16 was incontinent of bowel and bladder and weighed 104 pounds. Based on review of a facility "Pressure Ulcer Documentation Report", dated 12/23/13, Resident #16 had a new, facility acquired pressure ulcer on her "left gluteal thigh crease" that was "unstageable" with "eschar/slough" (dead tissue) present. According to the Resident Assessment Instrument (RAI) Version 3.0 Manual, a wound cannot be "staged" (described accurately in terms of the degree of tissue destruction) if slough or eschar on the wound bed prevents visualization of the extent of the wound. The following entries were recorded in Resident #16's clinical record pertinent to her daily routine during the two weeks prior to the 12/23/13 entry on "Pressure Ulcer Documentation Report": According to Nursing Clinical Notes, dated 12/08/13 at 3:43 PM, "(Resident #16) sleeping in her pink recliner by the nurses' station throughout shift..." According to Nursing Clinical Notes, dated 12/09/13 at 4:00 AM, "(Resident #16) sleeping in pink recliner at nurse's station throughout shift." According to Nursing Clinical Notes, dated 12/10/13 at 3:33 AM, "(Resident #16) asleep throughout shift in pink recliner at nurse's station." According to Nursing Clinical Notes, dated 12/10/13 at 11:22 AM, "(Resident #16) Complained that her bottom was sore...Hadn't realized that she'd soiled herself." According to Nursing Clinical Notes, dated 12/10/13 at 11:07 PM, "Resident #16)...said I might sleep in my room if I get a TV. Social worker told me that she would look into getting (Resident #16) a TV." According to Nursing Clinical Notes, dated 12/13/13 at 7:32 AM, "(Resident #16) Sleeping most this shift in pink chair by nurse's desk." According to Nursing Clinical Notes, dated 12/13/13 at 11:09 PM, "Appetite sufficient. (Resident #16) sat up in wc (wheelchair) for most of shift." According to Nursing Clinical Notes, dated 12/17/13 at 2:12 PM, "Several attempts made by myself to assess (Resident #16's) excoriated buttocks and left inner thigh open area but (Resident #16) again out for an appointment..." The next mention of Resident #16's skin condition in the Nursing Clinical Notes was dated 12/22/13 at 11:17 AM (5 days later): "2 cm wide x 1.5 - 2 cm deep opening in the area of the L (left) ischium (buttock)...Edu (educated) res (Resident #16) that she needs to be sleeping in her bed instead of in the chair d/t (due to) the pressure applied to that open area while sitting..." The education documented on 12/22/13 was provided 14 days after it was on documented on 12/8/13 that Resident #16 was in her recliner "throughout shift". According to Resident #16's Progress Notes, dated 12/23/13 at 10:00 AM, Nurse Practitioner "Y" documented, "L (left) gluteal thigh crease - 3.4 x 3.4 x at least 1 inch deep. Base is greyish, nonviable (without life), some adhered (sticking) and some non adhered. No odor...lg (large) amt (amount) serosan (bloody drainage)...(Resident #16) stated that sore hurts. (Resident #16) sleeps in chair per nursing..." The first mention of facility staff repositioning Resident #16 was in the Nursing Clinical Notes, dated 12/31/13 at 7:45 AM: "(Resident #16) rested well in her bed, turned and repositioned q (every) 2 hrs. (hours)." Review of Resident #16's Care Plan, created 1/26/14 (35 days after the facility acquired pressure ulcer was first documented) revealed "Refusal of care/treatment/compliance with turn schedule...Remind and/or assist with position change q 2 hrs and prn (as needed)." In an interview, on 3/14/14 at 10:30 AM, Clinical Care Supervisor/LPN/Licensed Practical Nurse "V" confirmed that Resident #16's pressure ulcer was "facility acquired", but added that Resident #16 was "very noncompliant; refused rest periods." When asked where and when Resident #16''s noncompliance was addressed in her resident care plan, Clinical Care Supervisor "V" searched through Resident #16's care plans and RSTs (Nurse aide care guides) said, "I can't see when changes were made to her care plan or care guide. There is a way to view that, but I don't know how." When asked if there was documentation to show how often Resident #16 was repositioned, or if there was any documentation regarding noncompliance behaviors, Clinical Care Supervisor "V" stated, "I honestly can't answer that." Clinical Care Supervisor "V" reported that Resident #16's pressure ulcer had worsened and said, "It's tunneling now...5 cm (deep)." Clinical Care Supervisor "V" did not present any tracking of noncompliant behaviors or turning/repositioning documentation. Review of laboratory data revealed Resident #16's [MEDICATION NAME] (an indicator of body protein stores needed for healing) was first monitored on 1/15/14; and it was low at 12.5 (normal range 20.0 - 40.0 mg/dL). Review of the facility Nutrition Clinical Notes written by Registered Dietitian "CC", dated 3/06/14, revealed that (43 days after the pressure ulcer was first documented) Resident #16's diet was liberalized, "Weight = 113.3 pounds...left gluteal crease declined...Food intake continues to be averaging approximately 25%...continues with Nepro tid (supplement three times a day) which (Resident #16) states she is drinking all of it. Also has promod 30 md (supplement) bid (twice a day)...(Resident #16) states today that meals are not that interesting and sack lunches are boring...Denies difficulty feeding self. Recommend liberalizing Renal, Consistent carbohydrate diet for more interest and to encourage improved po (oral intake) for (Resident #16)." There was no documentation to support that Resident #16 was asked which foods she liked, or to indicate that she was offered the foods she thought would increase her intake. According to Resident #16's Pressure Ulcer Documentation Report, dated 3/04/14, her wound was described as: "Left gluteal crease - stage IV. 3.0 cm x 1.5 cm x 2.0 cm. Granulation Tissue. Red. Serosanguinous (bloody drainage) Heavy." According to the Resident Assessment Instrument (RAI) Version 3.0 Manual, a Stage IV (Stage 4) pressure ulcer is a wound with full thickness tissue loss, with exposed bone, tendon or muscle, that may also have slough or eschar present, as well as undermining (destruction of tissue under the skin edges) or tunneling (destruction under the skin with an opening at skin level). According to Resident #16's Pressure Ulcer Documentation Report, dated 3/11/14, her wound was described as: "Left gluteal crease - stage IV. 2.5 cm x 2.5 cm. 2.4 cm (depth). Serosanguinous (bloody drainage) Heavy. Wound is now tunneling." ( ) ( ) Review of Resident #19's face sheet revealed he was a [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #19's Brief Interview of Mental Status (BIMS) dated 3-11-14 revealed he scored 13/15 (normal cognition). During an interview with Resident #19 on 3/13/14 at 3:50 p.m., Resident #19 said, "the Occupational Therapist found an open area on my bottom yesterday." Resident #19 said he had an open area on his bottom when he was in the hospital, but it had healed before he came here. Resident #19 said he could not turn himself in bed and, in the hospital, staff had turned him. Resident #19 said today was the first time anyone in the facility had turned him since he was admitted . Review of Resident #19's Admission Nursing assessment dated [DATE] documented Resident #19 had "reddish discoloration on right buttock and pink on coccyn (sic)." Review of Resident #19's Clinical Note Report revealed, on 3-12-14 at 12:58 PM, Resident #19 was receiving Occupational Therapy and the note documented, "Consulted with nursing related to wound on buttocks and treatment provided; addressing turning schedule when in bed for maintaining optimum skin integrity, also. Consulted with nurse aides related to patient report of lack of awareness with bowel movements, for frequent checks and bathroom use--patient present and agreed to monitor this closely together." Review of Resident #19's Clinical Note Report revealed on 3-13-14 at 12:19 PM, Registered Nurse (RN) "O" documented, "pt (patient) seen for wound referral. Pt has discolored non-blanchable area noted on coccyx. Pt stated that wound was present while he was in hospital prior to arriving to this facility. Cleanse with NS (normal saline), apply foam border dressing. Area has no drainage at this time. Edges contracted and defined." Review of Resident #19's care plan revealed an undated care plan "skin: (Resident #19's name) is at risk for breaks in skin integrity related to: sensory /perceptual deficit, moisture, mobility deficit, friction/shear, nutrition/hydration." The goal for the skin care plan documented, "(Resident #19's name), will not experience any preventable pressure ulcer and will have no negative outcomes r/t (related to) the use of mobility bars. Goal Date: 6/9/14." Under Interventions was documented, Positioning: RST (Resident Summary Template)." Review of Resident #19's Resident Summary Template, revealed an area for Skin Integrity/Positing Devices, with nothing documented about the condition of the resident's skin; under "Bed Mobility", staff had documented, "Limited Assist x 1." Review of Resident #19's, "March 2014 Treatments", revealed under orders, "Dressing change, Every One Day Starting 3/13/14, Order date 3/13/14, Notes: Cleanse coccyx with NS (normal saline). Apply foam border dressing until healed. Reposition with pillows." Only one treatment was documented on 3/14/14 by RN "O". Review of Resident #19's "Skin Scan & Nail Monitoring" document dated 3/12/14 revealed, Resident #19 had an area of discoloration and [DIAGNOSES REDACTED]/redness and the body picture was circled in the area of the coccyx. The Skin Scan document was signed by Certified Nurses Aide CNA "M". During a telephone interview with CNA "M" on 3/14/14 at 11:35 AM, CNA "M" said she gave Resident #19 a bed bath on 3/12/14 and noticed he had a dressing on his right buttock. CNA "M" said she reported the dressing to Licensed Practical Nurse (LPN) "L", and LPN "L" said she did not need to document the dressing on the "Skin Scan". Resident #19's buttock was observed on 3/14/14 at 8:00 AM, in his room, when he was receiving care. Resident #19 had a red area on his right buttock approximately the size of a 50 cent piece. Resident #19 said someone had placed a dressing on his buttock on 3/13/14, but then said the nurse last night had only put cream on his bottom. During a telephone interview with LPN "L" on 3/14/14 at 11:25 AM, LPN "L" said she removed Resident #19's dressing on his buttock last night 3/13/14 because it was soiled. LPN "L" said she put a medicated cream on Resident #19 right buttock, and did not put a dressing back over the wound. LPN "L" said, "I know I should have put a dressing on the wound." Resident #19's wound was observed during treatment in the resident's room on 3/14/14 at 9:35 AM. RN "O" measured the wound on Resident #19's right buttock and said the wound was 2 cm x 3.5 cm. There was a scant amount of blood in Resident #19's brief in the area of the wound. During an interview immediately following the observation, this Surveyor asked RN "O" why Resident #19 has a dressing ordered for his buttock, now, but not when he was admitted and RN "O" said," because the area is open now." According to the Resident Assessment Instrument (RAI) Version 3.0 Manual, a shallow open ulcer with a red-pink wound bed, without slough (dead tissue) present on the wound, is consistent with the definition of a Stage 2 pressure ulcer. Review of a Clinical Note Entry, for Resident #19, dated 3/14/14 at 9:43 AM, revealed RN "O" documented, "Pt (patient) seen for dressing change. Clean dressing applied at this time. Open area noted on right buttock measuring 2.0 x 3.5 x 0.1. Area is reddened, blanchable with small area of purple discoloration near medial end of wound. Wound appears to be [MEDICATION NAME] at this time. Small amount of drainage in brief when brief removed." During an interview with Unit Manager RN "N" on 3/14/14 at 8:05 AM, this Surveyor asked for all wound documentation for Resident #19. RN "N" was unable to locate a "pushtool" (i.e., pressure ulcer staging tool). Review of the facility policy "Pressure Ulcer, Care and Prevention of, original effective date 4/2/14 and review date 3/2014 revealed under documentation, "Pushtool, 1. When a pressure ulcer is present the PUSH (Pressure Ulcer Stages of Healing Tool) will be initiated and used on a weekly basis to track wound healing. 2. The most recent PUSH tool is placed in the MAR (Medication Administration Record)." The Pressure ulcer policy documented under Bed positioning, 1. Residents/patients are assigned a turn schedule at admission, if appropriate. This schedule is noted as a colored dot on their door nameplate. ( )

This citation pertains to intake #MI 686 Based on interview and record review, the Facility failed to ensure that the necessary care and services (suctioning to maintain a patent airway), were provided by not assessing, monitoring and providing prompt intervention for an acute change of condition in 1 of 2 sampled Residents with tracheostomies (#101), from a total sample of 8 Residents, resulting in immediate jeopardy (IJ), when Resident #101 experienced respiratory distress and needed suctioning on [DATE] at approximately 11:10 PM and was not suctioned and was found unresponsive with no heart beat or respirations on [DATE] at 1:40 AM and was a Full code and subsequently died . This deficient practice placed all 6 Residents with tracheostomies, who have the potential for an acute change of condition, at risk for serious harm, injury and/or death. Findings Include: Review of the closed, medical record revealed Resident #101 was an [AGE] year old female admitted to the facility on [DATE]. Review of the Face Sheet (undated) revealed her [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. The following definition was written next to Full Code to define it, "Desire all possible interventions be administered in order to maintain life." Review of the Facility transfer form dated [DATE] at (no time), revealed Resident #101 was sent to the Hospital for an "Impaired [MEDICAL CONDITION] Function". Review of the care plan problem titled: "[MEDICAL CONDITION]", dated as effective on [DATE] through [DATE], under the section titled, "Goals", was written; (named Resident #101), will maintain a patent airway." Under the sections titled "Interventions" was written; Emergency [MEDICAL CONDITION] bedside at all times, Suction prn (as needed), [MEDICAL CONDITION] patency prn In a phone interview on [DATE] at 1:50 PM, Certified Nurse Assistant (Staff #4), said she worked the midnight shift (from 11:00 PM on [DATE] until 7:00 AM on [DATE]).Staff #4 said she was scheduled to work on the 5th floor but the second floor was short due to a "call off", and her supervisor sent her to work on the second floor. Staff #4 said she arrived on the second floor and was assigned to care for Resident #101. Staff #4 said she went in Resident #101's room at approximately 11:10 PM and observed Resident #101 appeared restless. Staff #4 said Resident #101 moved her head back and forth and her [MEDICAL CONDITION] was intact, however sounded "full, (liked she needed to be suctioned)". Staff #1 left Resident #101 and went down the hall and reported to Registered Nurse (Staff #3) that Resident #101's [MEDICAL CONDITION] sounded full . Staff #4 said Staff #3 told her she would suction Resident #101. Staff #4 did not return to Resident #101 said she did not get vital signs on Resident #101. In a phone interview on [DATE] at 7:48 AM, Staff #3, said she worked the midnight shift (from 11:00 PM on [DATE] until 7:00 AM on ,[DATE] and was the Charge Nurse for Resident #101. Staff #3 said she punched in at 10:45 PM, received report from the previous shift and was notified by a CNA (unable to recall which CNA), that Resident #108 had fallen and notified by Staff #4 that Resident #101's [MEDICAL CONDITION] "sounded full" and she needed suctioning. Staff #3 said she went to assist Resident #108, who took a long time (about 45 minutes or more), to assess and transfer to bed from the floor with a mechanical lift. When asked if she instructed anyone to have another Nurse check on Resident #101 who was in respiratory distress, Staff #3 said, "No. It just slipped my mind." Staff #3 said when she did get to Resident #101, "she wasn't breathing". Staff #3 said that was the first time she checked on Resident #101 that evening. Staff #3 said she turned the light on, called out her name, her [MEDICAL CONDITION] was in place and noticed her ties were a little loose so she attempted to tighten them and noticed she wasn't breathing (didn't see her chest rise). Staff #3 said Resident #101 did not have a heartbeat and said, "so I did a few chest compressions." When asked if she used a backboard to place under Resident #101, Staff #3 said, "there's no back boards in the room, they're on the crash cart." When asked if it was the protocol to do chest compressions without a backboard Staff #3 said, "No, usually we turn the bed off"(unplug the bed to obtain a firm mattress). Staff #3 said after she did a few chest compressions she then stopped CPR, left Resident #101 alone and went down the hall to the nurse's station to page a "Code Blue" because she was a full code. Staff #3 said she did not complete an incident report regarding Resident #101's incident described above. Staff #3 said another Nurse called ,[DATE]. In a phone interview on [DATE] at 8:51 AM, Registered Nurse (Staff #5), said he was the Supervisor for the Facility on the midnight shift (from 11:00 PM on [DATE] until 7:00 AM on ,[DATE]). Staff #5 said a Code Blue was called and he was on the 5th floor and went down to the second floor. When he arrived in Resident #101's room, Staff #5 said she was unresponsive and her [MEDICAL CONDITION] was out. Staff #5 said he didn't know how it happened (Resident #101's [MEDICAL CONDITION] being out ) but, "it was partially out". Staff #5 said, "when I entered the room, we initiated CPR." We used a backboard. When asked if Staff #3 followed the Facility's protocol for Resident #101, who was a full code, Staff #5 said, "CPR must be initiated immediately because the chance to resuscitate a person increases." When asked if Staff #3 responded to the emergency of Resident #101 when she was found unresponsive, Staff #5 said, "The right thing to do is for the Nurse to stay with the patient." Staff #5 said Staff #3 should have stayed with Resident #101 and called out for help. Review of the Facility's "Resuscitation Record" dated [DATE] revealed Resident #101 arrested and initial interventions were not provided until 1:40 AM. Review of the back of the form titled, "Code Evaluation", revealed all areas were not answered and left blank which indicated there was no evaluation done. Under #6, the question was; "Were difficulties experienced with airway interventions? and the responses under "Yes" were "Delay in ventilation (greater that 5 minutes), Repeat attempt at intubation, [MEDICAL CONDITION] could not be placed". Review of the Emergency Medical Services (EMS) Patient Care Report dated [DATE] revealed dispatch received a call at 1:41:A.M. and arrived at Resident #101's side at 1:52 AM and Resident #101 was in Asystole (absence of heart beat).According to the narrative documentation of the report was written, "...Staff state that they found pt in bed with [MEDICAL CONDITION] and it is unknown to them how long it had been out. They state that it could have been 2 hours. Staff state that when they found pt she was in [MEDICAL CONDITION]. Respiratory Therapist states that the first rhythm that they recorded was asystole....after [MEDICAL CONDITION] being worked by a team from (named Facility) and (named local fire department), ...transported to (named hospital).at 2:31 AM" During a phone interview on [DATE] at 2:40 PM, Respiratory Therapist (Staff #6) said she responded to a code blue for Resident #101 on [DATE]. When asked if Resident #101's [MEDICAL CONDITION] was in place or out of Resident #101, Staff #6 said, "it was out. When I arrived the Nurse", (Named Staff #3), had it in her hand and kept saying she couldn't get it back in. I grabbed it out of her hand and used my pinky finger to dilate the stoma and put it back in ." Staff #6 continued to describe the observation of Resident #101 and said, "when we (the code team), walked in to the room the patient was cold, blue and rigor had set in. Her arms were at a 90 degree angle and were hard to straighten out, like she had been there for a while." On [DATE] at 5:30 PM,during a phone interview, the senior paramedic that responded to the [DATE] call for resident #101 called to respond to a message. The paramedic was asked if he remembered any of details from the [DATE] call for resident #101. The paramedic responded reporting that he had reviewed his documentation, and he stated "when we first got the call it wasn't clear if it was respiratory distress or respiratory arrest. The paramedic stated "My initial communication was with the respiratory therapist from the 6th floor. She reported [MEDICAL CONDITION] been out for several hours because she had to dilate the stoma site with her fingers in order to get the [MEDICAL CONDITION] back in place". The paramedic then stated "The thing that seemed out of the ordinary to me is that no one seemed to know when or how [MEDICAL CONDITION] out, or for how long it had been out". Review of the Hospital Emergency Department History and Present Illness, dated [DATE] for the event dated [DATE] at 2:49 AM revealed the following regarding Resident #101, "EMS reports the patient was at a nursing home facility where her [MEDICAL CONDITION] was suddenly dislodged, and the patient went into respiratory arrest. The patient's [MEDICAL CONDITION] was replaced. The patient went into [MEDICAL CONDITION]. In between the time that EMS arrived and the patient was brought to the emergency department, the patient underwent approximately 2 separate codes for which chest compressions were initiated.... Review of the Hospital Emergency Department Course dated [DATE] dated [DATE] at 2:49 AM revealed Resident #101 arrived at the Hospital and had no palpable pulse. Cardiac compressions were initiated. Ventilation was continued through her [MEDICAL CONDITION] and after 2 minutes and minimal to no cardiac activity was observed, it was the general consensus that no further interventions were indicated and the Resident #101 was pronounced dead at 2:48 AM, according to the report. The Director of Clinical Services (Staff #2), in an interview on [DATE] at 1:30 PM, said there were no incident reports for Resident #101 in the past 6 months. The Administrator was notified on [DATE] at 4:36 PM of an Immediate Jeopardy that began on [DATE] as a result of the facility's failure to provide the necessary care and services to maintain patent airway by not assessing, monitoring, and providing prompt intervention for an acute change of condition when Resident #101 experienced respiratory distress, and who needed tracheal suctioning and was not provided it and was found unresponsive on [DATE] at 1:40 AM., transferred to a hospital and was pronounced dead at 2:48 AM. On [DATE] the surveyor confirmed that the facility staff completed the following to remove the Immediate Jeopardy: 1. On [DATE], the Facility removed the RN (staff #3), from the Schedule. 2. On [DATE], the Facility identified residents affected and residents having potential to be affected by the same situation. All 237 Residents living at the Facility were visualized to identify those with trach's. The Facility identified 6 Residents. A Licensed Nurse assessed each of the 6 identified residents with trach's for air exchange and need for suctioning. A Respiratory Therapist assessed each of the 6 residents for air exchange and need for suctioning. Any concerns were addressed immediately. Hourly checks were initiated for each of the 6 residents with trach's. These hourly checks were documented on a newly [MEDICAL CONDITION] Check Log form. 3. On [DATE] from 6:00 PM-9:00 PM, the Facility implemented measures to ensure that the situation would not reoccur. Upon admission, quarterly, and with a significant change residents with trach's will be assessed and a care plan developed or updated as needed. Any new resident with [MEDICAL CONDITION] be added to the process identified in the plan of correction. On [DATE] between 6:00 PM and 9:00 PM, the Director of Clinical Services and the Administrator reviewed and revised the "Code Blue" Policy to include the following additions. The Licensed Nurse, Respiratory Therapist, Physical Therapist, Occupational Therapist and Medical Staff will stay with the resident and call out for help. In the after code section, the RNC nurse will complete a clinical note and an ISIS report Incident report). Following the Code Blue, the Clinical Care Manager/Designee will oversee the evaluation of the Code Blue, completion of all documentation (e.g. clinical notes, ISIS report, initial investigation with statements of what happened prior and after, code sheet), CSR notification for a new cart, and debriefing of staff as needed. One copy of the code sheet with education will go to the Code Blue Committee, one copy of the code sheet goes in resident chart, and one copy to EMS responders as needed. The results will be reported to the Quality Improvement Committee. On [DATE] from ,[DATE] PM, the Nurse Educator educated facility staff , however not all staff education was completed. 318 out of a total of 495 facility staff had received education regarding the new policy for "Code Blue". Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at the scope of isolated and severity of no actual harm with the potential for serious harm that is not Immediate Jeopardy due to all staff had not been in-serviced and sustained compliance had not yet been verified by the State Agency. # &#

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT FALLS IN 2 OF 4 SAMPLED RESIDENTS (#2, AND #8) REVIEWED FOR FALLS, FROM A TOTAL SAMPLE OF 30 RESIDENTS, RESULTING IN PAIN FOR BOTH RESIDENTS, AND AN INCREASED LENGTH OF STAY FOR RESIDENT #8. FINDINGS INCLUDE: ACCORDING TO THE DOCUMENT "HISTORY AND PHYSICAL" SIGNED BY THE NURSE PRACTITIONER (NP) "X" ON 12/29/11, RESIDENT #8, A [AGE] year OLD FEMALE, WAS admitted to the facility on [DATE] AFTER ENTERING A LOCAL HOSPITAL ON "12/21/11 WITH SEVERE HEADACHE AND ALTERED MENTAL STATUS... SHE ALSO HAD AN "UNSTEADY GAIT." THE NP "X" ASSESSED RESIDENT #8 AS HAVING "ACUTE CEREBROVASCULAR ACCIDENT WITH ISCHEMIC CHANGES (STROKE) THROUGHOUT THE OCCIPITAL LOBE" AND "CHRONIC PAIN, FIBROMYALGIA." THE physician's orders [REDACTED]." THE INITIAL "OCCUPATIONAL THERAPY EVALUATION" DATED 12/29/11 REFLECTED AN X OVER THE BOX NEXT TO "FALL RISK" WITH THE WORD "SAFETY" WRITTEN NEXT TO IT, AND REFLECTED "HAD HISTORY OF FALLS" PER RESIDENT #8 UNDER THE "PRIOR LEVEL OF FUNCTION" SECTION. THE DOCUMENT "THERAPY STATUS COMMUNICATION" DATED 12/29/11 REFLECTED THAT RESIDENT #8 REQUIRED SUPERVISION WHILE BATHING, DRESSING, AND PERFORMING HYGIENE. RESIDENT #8'S ACTIVITIES OF DAILY LIVING (ADL'S) CARE PLAN DATED 12/29/11, REFLECTED THE INTERVENTION "*SHOWERS AS NEEDED* PROVIDE SUPERVISION IN SHOWER ROOM". ACCORDING TO THE MINIMUM DATA SET ((MDS) dated [DATE], RESIDENT #8 REQUIRED LIMITED ASSISTANCE FROM ONE PERSON WHILE DRESSING AND PERFORMING PERSONAL HYGIENE. IT ALSO REFLECTED RESIDENT #8 REQUIRED PHYSICAL HELP WHILE BATHING. THE THERAPY "PROGRESS NOTE" DATED 1/17/12 REFLECTED "PT. (PATIENT) IMPROVEMENT WITH FUNCTIONAL MOBILITY EXCEPT CONTINUES TO HAVE BALANCE ISSUES IN TRANSITIONAL MOVEMENTS." DURING AN INTERVIEW ON 1/27/12 AT 9:45 AM, IN HER ROOM, RESIDENT #8 REVEALED THAT SHE HAD FALLEN IN THE SHOWER ROOM ON 1/24/12. RESIDENT #8 REVEALED SHE WAS "GETTING READY FOR A SHOWER" WHEN CERTIFIED NURSES AID (CNA) "G" "LEFT ME ALONE TO GO GET TOWELS" WHEN SHE fell . RESIDENT #8 WENT ON TO SAY THAT THE FALL CAUSED HER PAIN IN HER BACK. "IT SET ME BACK. PHYSICAL THERAPY TOLD ME THEY CAN'T SEND ME HOME. I THOUGHT SOMEBODY'S SUPPOSED TO BE WITH YOU" REFERRING TO WHEN IN THE SHOWER ROOM. CNA "G" WAS INTERVIEWED OVER THE PHONE ON 1/27/12 AT 11:05 AM. CNA "G" WAS ASKED WHAT OCCURRED WITH RESIDENT #8'S FALL ON 1/24/12. HE RESPONDED, "I WENT IN WITH HER, GOT HER SETUP IN A CHAIR, SHE DIDN'T WANT SOMEBODY THERE WATCHING HER, PROBABLY BECAUSE I WAS A GUY. I ENDED UP LEAVING HER THERE AND SHE CONTINUED GETTING UNDRESSED" AND THEN CONFIRMED RESIDENT #8 fell WHILE LEFT ALONE IN THE SHOWER ROOM. CNA "G" WAS THEN ASKED IF HE WAS AWARE RESIDENT #8 WAS TO BE SUPERVISED IN THE SHOWER ROOM AND HE RESPONDED "NO I WASN'T. I UNDERSTOOD SHE WAS INDEPENDENT AT THAT TIME." THE "CLINICAL NOTE" WRITTEN BY LPN "AA" ON 1/24/12 AT 9:29 AM REFLECTED "THIS WRITER HEARD RESIDENT YELLING FRON (SIC) SHOWER ROOM. ENTERED SHOWER ROOM AND OBSERVED RESIDENT ON BOTTOM WITH BACK UP AGAINST SHOWER BENCH. NO PAIN IN HIPS AND LEGS WHEN ROM (RANGE OF MOTION) PERFORMED. C/O (COMPLAINED OF) LOWER BACK PAIN. INCREASED PAIN WHEN WEIGHT BEARING AND BENDING. MED STAFF NOTIFIED. ORDER RECEIVED FOR STAT XRAYS." THE DOCUMENT "FALLS CHECKLIST/ANALYSIS - CONTINUING CARE" DATED 1/24/12, REFLECTED "INJURIES SUSTAINED ... BRUISING TO LEFT, LOWER BACK". THE DESCRIPTION OF THE FALL ON THIS DOCUMENT WAS "RESIDENT WAS SHOWERING INDEPENDENTLY PER RST (RESIDENT SUMMARY TEMPLATE - AN ALTERNATE CARE PLAN USED BY CNA'S) SLIPPED HIT BACK ON SHOWER CHAIR STOOD UP C/O (COMPLAINED OF) PAIN TO LUMBAR SPINE AND LEFT HIP." THE "FALLS CHECKLIST/ ANALYSIS - CONTINUING CARE" DOCUMENT ALSO REFLECTED "CARE PLAN AND RST DID NOT MATCH RST UPDATED TO EXT (EXTENSIVE) ASSIST X1 (WITH ONE STAFF)" AND THE RECOMMENDATION "PT (PATIENT) NOT TO BE LEFT UNATTENDED IN SHOWER." THE "OCCUPATIONAL THERAPY GENERAL NOTE" DATED 1/25/2012 AT 11:16 AM REFLECTED, "PER NURSING, PT. NOT TO HAVE ANY OT (OCCUPATIONAL THERAPY) AND PT (PHYSICAL THERAPY) TODAY SECONDARY TO INCREASED PAIN AND HAVING TO HAVE SOME MORE X-RAYS." THE "PHYSICAL THERAPY GENERAL NOTE" DATED 1/26/2012 AT 4:45 PM REFLECTED, "PT COMPLAINED OF 6/10 PAIN IN LEFT SIDE NECK, BACK AND GLUTE BEFORE TX (TREATMENT).... GAIT PATTERN PRESENTS WITH DECREASED STEP/STRIDE LENGTH AND SLOW PACE DUE TO PAIN; PT HAD TO STOP AND SIT IN WALKER SEAT DUE TO 9/10 PAIN ON LEFT SIDE OF BACK AND GLUTE.... PT STATED PAIN 7/10 AT END OF TX." THE "OCCUPATIONAL THERAPY GENERAL NOTE" DATED 1/26/2012 REFLECTED, "PT IS PAINFUL IN LOWER BACK, HAS DIFFICULTY WITH MOVING LEGS OVER THE EOB (EDGE OF BED) - TAKES INCREASED TIME WITH HOB (HEAD OF BED) RAISED. ONCE TO EOB, PT TAKES INCREASED TIME AND CUES FOR UB (UPPER BODY) LB (LOWER BODY) BATH DRESS - INCREASED TIME FOR ADL D/T (DUE TO) MUCH NEEDED REST BREAKS." THE FACILITY POLICY "FALLS PREVENTION" WITH A REVISED DATE OF 02/2011 REFLECTED, "PREVENTATIVE MEASURES WILL INCLUDE, BUT ARE NOT LIMITED TO; PROVIDING A SAFE ENVIRONMENT AND PROVIDING PROPER SUPERVISION OF RESIDENTS/PATIENTS TO PREVENT FALLS." THE FACILITY FAILED TO IDENTIFY AND IMPLEMENT APPROPRIATE SUPERVISION NEEDED TO PREVENT RESIDENT #8 FROM FALLING, CAUSING INCREASED PAIN, AND EXTENDING RESIDENT #8'S STAY AT THE FACILITY. ( ) THE FACILITY ' S FACE SHEET REFLECTED RESIDENT #2 WAS AN [AGE] year OLD FEMALE WHO HAD RESIDED IN THE FACILITY SINCE 12/2/09. THE JANUARY 2012 MEDICATIONS SHEET REFLECTED RESIDENT #2 HAD [DIAGNOSES REDACTED]. THE ANNUAL MINIMUM DATA SET (MDS) assessment dated [DATE], REFLECTED RESIDENT #2 HAD A BRIEF INTERVIEW FOR MENTAL STATUS (BIMS) SCORE OF 3 OUT OF A TOTAL OF 15, WHICH REPRESENTS SEVERE COGNITIVE IMPAIRMENT. ACCORDING TO THE NURSES NOTES FROM 11/25/11 THROUGH 1/4/12 RESIDENT #2 HAD HISTORY OF WANDERING, INCLUDING WANDERING INTO OTHER RESIDENT ROOMS, CHASING STAFF WITH HER CANE, RAISING HER CANE TO STRIKE ANOTHER RESIDENT, CONFUSED, UNCOOPERATIVE, ANXIOUS AND OFTEN NOT EASILY REDIRECTED. ACCORDING TO THE FACILITY ' S INCIDENT REPORTS, RESIDENT #2 ALSO had a history of [REDACTED]. NURSES NOTES DATED 12/19/11 REFLECTED RESIDENT #2 WAS "STANDING BEHIND THE NURSES STATION AT 1320 (1:20 PM). STAFF WALKED BY HER TO PLACE A CHART ON THE DESK AT WHICH TIME SHE TRIED TO REACH OUT AND GRAB AT STAFF AND LOST HER BALANCE. STAFF GRABBED HER WITH HAND IN AN ATTEMPT TO PREVENT HER FROM FALLING, BUT WAS UNABLE TO KEEP HER FROM GOING DOWN TO THE FLOOR. RESIDENT ... DID NOT HIT HER HEAD. THE NURSES NOTES DATED 12/20/11 REFLECTED SHE WAS STILL ABLE TO USE HER CANE. NURSES NOTES DATED 12/21/11 REFLECTED RESIDENT #2 WAS STILL ABLE TO WALK WITH HER CANE, HOWEVER, SHE DID COMPLAIN OF RIGHT KNEE PAIN." NURSES NOTES DATED 12/24/11 REFLECTED RESIDENT #2 " WAS ALERT TO SELF ONLY, APPEARS MORE CONFUSED THAN USUAL. (HAD BEGUN) TO SLUR WORDS AND IS HARD TO UNDERSTAND. BALANCE IS OFF, RES (RESIDENT) IS UNABLE TO AMBULATE OR SIT ON TOILET UNASSISTED. WILL CONTINUE TO MONITOR. " NURSES NOTES DATED 12/24/11 REFLECTED "RESIDENT UNSTEADY ON FEET, INTERVENED BY PLACING RESIDENT IN WHEELCHAIR TEMPORARILY... " NURSES NOTES DATED 12/28/11 REFLECTED "SHE REMAINS WITH AN UNSTEADY GAIT AND WEAKNESS..." THE "FALLS DETAILS REPORT" DATED 12/19/11 ADDED LITTLE NEW INFORMATION EXCEPT TO ADD THE 15 MINUTE CHECKS THAT HAD BEEN INITIATED HAD BEEN DISCONTINUED. ON 1/27/12 AT 9:30 AM, INCIDENT AND ACCIDENT REPORTS HAD BEEN REQUESTED ON RESIDENT #2 ALONG WITH THE INVESTIGATION PORTION OF THE REPORT, HOWEVER, THE INVESTIGATION PORTION OF THE REPORT WAS NOT INCLUDED WITH ANY OF THE INCIDENT AND ACCIDENT REPORTS RECEIVED. THE "FALLS DETAILS REPORT" DATED 1/6/12 REFLECTED RESIDENT #2 WAS TRYING TO STAND UP OUT OF HER WHEELCHAIR AND SAT DOWN ON THE FLOOR IN FRONT OF HER WHEELCHAIR. THE SENSOR PAD ALARM WAS SOUNDING, NO INJURIES NOTED. ... RESIDENT DID NOT HIT HER HEAD. THERE WERE NO ADDED INTERVENTIONS ON THIS REPORT TO PREVENT THE NEXT FALL. THE "FALLS DETAILS REPORT" DATED 1/8/12 REFLECTED RESIDENT #2 WAS A " HIGH FALL RISK " WITH [DIAGNOSES REDACTED]. THE NURSES NOTES DATED 1/8/12 REFLECTED RESIDENT #2 WAS "OBSERVED LYING FACE UP NEAR DINING ROOM WITH HEAD AGAINST WALL. HEAD TO TOE ASSESSMENT, NO INJURIES NOTE. NO COMPLAINTS OF PAIN WITH PASSIVE RANGE OF MOTION. NURSE AND CNA (CERTIFIED NURSE AIDE) ASSISTED RESIDENT BACK IN HER WHEELCHAIR...NEW INTERVENTION RESIDENT IS NOT TO BE LEFT ALONE IN DINING AREA." DURING AN INTERVIEW ON 1/27/12 AT 9:30 AM, SECOND FLOOR UNIT MANAGER "A" AGREED THAT RESIDENT #2 WAS ANXIOUS AND WAS ONLY ABLE TO SIT IN HER WHEELCHAIR FOR SHORT PERIODS, AND HAD NO EXPLANATION WHY THE INTERVENTION TO SUPERVISE HER WASN'T PUT IN PLACE BEFORE THE FALL ON 1/8/12. ON 1/27/12 AT ABOUT 11:30 AM, ASSISTANT DIRECTOR OF NURSING (ADON) "P" WAS ASKED WAS RESIDENT #2 LEFT ALONE IN THE DINING ROOM. ADON "P" STATED RESIDENT #2 WAS NOT LEFT IN THE DINING ROOM, BUT IN THE DINING AREA, AND SHE EXPLAINED THAT RESIDENT #2 WAS INDEPENDENTLY AMBULATORY AND COULD GO WHEREVER SHE WANTED WITHOUT SUPERVISION. AT THIS TIME ADON "P" WAS TOLD THE INVESTIGATION PORTION OF THE INCIDENT AND ACCIDENT REPORTS WERE REQUESTED BUT WERE NOT RECEIVED, ADON "P" REPLIED THE INVESTIGATION PORTION WAS QA (QUALITY ASSURANCE) PROTECTED,AND NO INVESTIGATION PORTION OF THE FACILITIES INCIDENT AND ACCIDENT REPORT HAD BEEN RECEIVED DURING THE SURVEY. THE "FALLS DETAILS REPORT" DATED 1/12/12 REFLECTED THAT RESIDENT #2 WAS "FOUND SITTING IN HER ROOM ON THE FLOOR WITH BED SENSOR ALARM SOUNDING WITH A LACERATION TO THE BACK OF HER HEAD. RESIDENT #2 WAS UNABLE TO VERBALIZE THE CIRCUMSTANCES OF THE FALL D/T (DUE TO) DECREASED LEVEL OF COGNITION." THE NURSES NOTES DATED 1/12/12 REFLECTED "RESIDENT WAS FOUND ON THE FLOOR AT 1445, IN HER ROOM WITH ALARM SOUNDING, SITTING ON THE FLOOR, FACING THE DOOR WITH A LACERATION TO THE BACK OF HER HEAD. RESIDENT WAS AWAKE AND ALERT, TALKING WITH NO NEURO ABNORMALITIES VS @ BASELINE FOR RESIDENT AND DENIED PAIN WITH ROM (RANGE OF MOTION) TO EXTREMITIES. SHE WAS ASSISTED TO STAND, THEN INTO A WHEELCHAIR. A MOD (MODERATE) AMOUNT OF BLOOD WAS NOTED FROM LACERATION TO THE BACK OF HER HEAD, WHICH MEASURED APPROX. 3 CM IN LENGTH...RESIDENT WITH ORDERS TO SENT TO (HOSPITAL) ED (EMERGENCY DEPARTMENT) FOR CT (CAT SCAN) OF HEAD AND LACERATION... " NURSES ' NOTES DATED 1/12/12 REFLECTED THAT RESIDENT #2 "RETURNED FROM THE HOSPITAL ER (emergency room ) AT 2100. STAPLES PLACED IN HOSPITAL TO REPAIR LACERATION TO BACK OF HEAD. SKIN ASSESSMENT COMPLETE, STAPLES INTACT TO BACK OF HEAD.... " ON 1/26/12 AT 4:20 PM, DURING AN INTERVIEW WITH RESIDENT #2'S GUARDIAN, HE STATED RESIDENT #2 WAS NO LONGER ABLE TO WALK INDEPENDENTLY AND HAS HAD A PERMANENT DECLINE REQUIRING THE USE OF A WHEEL CHAIR. ON 1/27/12 DURING AN INTERVIEW WITH THE SECOND FLOOR UNIT MANAGER "A", SHE CONFIRMED THAT RESIDENT #2 WAS NO LONGER ABLE TO WALK UNASSISTED. ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 043. BASED ON OBSERVATION, INTERVIEW, AND RECORDS REVIEW THE FACILITY FAILED TO SUPERVISE, ENSURE THE SAFETY AND PREVENT THE ELOPEMENT FOR 1 (#106) OF 7 SAMPLED RESIDENTS OF A TOTAL SAMPLE OF 29 RESIDENTS WHO WERE IDENTIFIED TO BE AT RISK FOR ELOPEMENT, RESULTING IN AN IMMEDIATE JEOPARDY WHEN ON 8/23/11, RESIDENT #106, WHO HAD A [DIAGNOSES REDACTED]. FINDINGS INCLUDE: REVIEW OF RESIDENT #106'S MEDICAL RECORD REVEALED AN [AGE] year OLD MALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. HIS MINIMUM (MDS) data set [DATE] DOCUMENTED THAT HE HAD SHORT TERM AND LONG TERM MEMORY PROBLEMS, WAS MODERATELY IMPAIRED WITH COGNITIVE SKILLS FOR DAILY DECISION MAKING, AND REQUIRED LIMITED ASSISTANCE OF ONE PERSON FOR TRANSFERS, LOCOMOTION, DRESSING AND HYGIENE. RESIDENT #106'S ELOPEMENT PLAN OF CARE DATED 8/8/11 REVEALED RESIDENT #106 WAS AT RISK FOR ELOPEMENT DUE TO "A HISTORY OF ELOPEMENT ATTEMPTS AND FAMILY REQUEST THAT HE BE IDENTIFIED AS AN ELOPEMENT RISK". THE GOAL WAS IDENTIFIED THAT RESIDENT #106 "WILL NOT LEAVE THE FACILITY UNDETECTED". THE INTERVENTIONS LISTED ON THE ELOPEMENT CARE PLAN INCLUDED: "CODE ALERT/TAG ON THE LEFT ANKLE, MONITOR CODE ALERT/TAG FOR PLACEMENT AND FUNCTION, IF (RESIDENT #106) NEARS AN EXIT AT ANY TIME OF THE DAY STAFF SHOULD APPROACH AND REDIRECT AWAY FROM DOORWAY, DOCUMENT ELOPEMENT ATTEMPTS, AND EVERY 15 MINUTE CHECKS". THERE WAS NO DOCUMENTATION IN THE MEDICAL RECORD OF 15 MINUTE CHECKS FOR RESIDENT #106. RESIDENT #106'S FALL PLAN OF CARE DATED 8/8/11 IDENTIFIED HIM TO BE AT RISK FOR FALLS RELATED TO IMPAIRED BALANCE, IMPAIRED SAFETY AWARENESS, IMPAIRED GAIT AND ALCOHOL DEPENDENCE WITH DELIRIUM. RESIDENT #106'S COGNITIVE PLAN OF CARE DATED 8/8/11 IDENTIFIED HIM TO HAVE COGNITIVE/COMMUNICATION IMPAIRMENT RELATED TO MEMORY IMPAIRMENT, IMPAIRED DECISION MAKING AND A [DIAGNOSES REDACTED]. FACILITY PHYSICAL THERAPY PROGRESS NOTES FOR RESIDENT #106, DATED 8/16/11, STATED, "WITH AMBULATION PATIENT IS DEMONSTRATING HE IS A HIGH FALL RISK DUE TO FREQUENT STAGGERING." IN AN INTERVIEW ON 8/30/11 AT 11:19 AM, THE DIRECTOR OF NURSING (DON) STATED THAT RESIDENT #106 WAS AT RISK FOR ELOPEMENT AND AT RISK FOR FALLS WHEN HE ELOPED FROM THE FRONT DOOR OF THE FACILITY ON 8/23/11 AT 4:51 P.M. A REVIEW OF PHOTOS FROM THE FACILITY CAMERA THAT FACES THE FRONT ENTRANCE OF THE FACILITY REVEALED THAT RESIDENT #106 EXITED THE FRONT DOOR OF THE FACILITY AT 4:51 P.M. ON 8/23/11. ON 8/30/11 AT 1:30 PM, OBSERVATIONS REVEALED THAT THE FRONT ENTRANCE TO THE FACILITY WAS NOT ALARMED. IT WAS ALSO OBSERVED BY THE SURVEYOR AT THIS TIME THAT CITIZENS ENTERED AND EXITED THE FRONT ENTRANCE OF THE FACILITY WITHOUT BEING APPROACHED OR QUESTIONED BY FACILITY STAFF OR FACILITY SECURITY AND WERE NOT REQUIRED TO SIGN IN OR SIGN OUT OF THE SIGN IN/OUT BOOK, WHICH WAS LOCATED ON THE COUNTER OF THE RECEPTION AREA. ON 9/2/11 DURING A TOUR OF THE FACILITY WITH THE BUILDING SERVICES MANAGER, THE SURVEYOR OBSERVED ALL EXIT DOORS, EXCLUDING THE FRONT ENTRANCE, OF THE FACILITY TO BE ALARMED WITH A KEY PAD SYSTEM. THE FRONT DOORS AND ALL OTHER FACILITY DOORS EXITING THE FACILITY, EXCLUDING THE MAINTENANCE ENTRANCE DOOR WAS EQUIPPED WITH THE CODE ALERT SYSTEM AND WERE FUNCTIONING APPROPRIATELY. IN AN INTERVIEW 8/30/11 AT 3:45 PM, LICENSED PRACTICAL NURSE (LPN) #8 STATED THAT HE HAD BEEN THE NURSE WHO admitted RESIDENT #106 to the facility on [DATE] AND PLACED THE CODE ALERT BRACELET ON RESIDENT #106's ANKLE DUE TO HIS CONFUSION AND MAKING STATEMENTS ABOUT LEAVING THE FACILITY. LPN #8 STATED THAT HE HAD VISUALIZED A CODE ALERT BRACELET ON RESIDENT #106's LEFT ANKLE AT SHIFT CHANGE, WHICH WAS APPROXIMATELY 3:00 PM ON 8/23/11. LPN #8 STATED THAT HE WAS UNABLE TO LOCATE RESIDENT #106 AT 5:00 PM ON 8/23/11 AND ALERTED HIS UNIT MANAGER. LPN #8 STATED THAT RESIDENT #106 WAS LOCATED APPROXIMATELY 15 MINUTES LATER IN A PARKING LOT OUTSIDE OF THE FACILITY AND, WHEN HE WAS BROUGHT BACK TO HIS ROOM, HE WAS CONFUSED AND THE CODE ALERT BRACELET WAS NOT ON RESIDENT #106. LPN #8 STATED THAT RESIDENT #106 DID NOT KNOW WHERE THE CODE ALERT BRACELET HAD GONE, AND THE BRACELET WAS NEVER LOCATED. IN AN INTERVIEW ON 8/30/11 AT 12:40 PM, LPN #3 STATED THAT HE WAS THE FIRST STAFF MEMBER TO FIND RESIDENT #106 AFTER HE ELOPED FROM THE FACILITY ON 8/23/11. LPN #3 STATED THAT HE FOUND RESIDENT #106 SITTING IN THE GRASS NEAR A PARKING LOT LOCATED BEHIND THE FACILITY. LPN #3 STATED THE PARKING LOT IS SHARED BY THE FACILITY AND THE COUNTY JAIL, WHICH IS NEXT TO THE FACILITY. LPN#3 STATED THAT RESIDENT #106 WAS CONFUSED ABOUT WHERE HE WAS, WHERE HE WAS STAYING, AND ABOUT THE WHOLE SITUATION IN GENERAL. LPN #3 STATED THAT RESIDENT #106 WALKED TO THE BACK OF THE FACILITY BUILDING, SAT DOWN ON THE CEMENT NEAR THE EMPLOYEE ENTRANCE, AND REQUESTED TO WAIT FOR SOMEONE TO COME AND GET HIM. FACILITY "ELOPEMENT - MISSING RESIDENT - CODE PINK CALL CENTER/SEARCH TEAM CHECKLIST" DATED 8/23/11 DOCUMENTED THAT RESIDENT #106 LEFT THE FACILITY AT 4:51 PM, A "CODE PINK" WAS CALLED AT 5:05 PM, AND THE TIME THE CODE PINK WAS RESOLVED WAS 5:20 PM. FACILITY INCIDENT REPORT DATED 8/8/11 DOCUMENTED THAT RESIDENT #106 LOST HIS BALANCE AND LOWERED HIMSELF TO THE FLOOR. FACILITY INCIDENT REPORT DATED 8/23/11 DOCUMENTED THAT RESIDENT #106 WAS NOTICED MISSING AT 5:05 PM, AND LOCATED OUTSIDE OF THE FACILITY, SITTING ON THE GRASS AT 5:20 PM. FACILITY INCIDENT REPORT DATED 8/26/11 DOCUMENTED THAT ON 8/26/11 RESIDENT #106 STEPPED TOWARD THE END OF THE BED WHEN HE fell . FACILITY INCIDENT REPORT DATED 8/27/11 DOCUMENTED THAT ON 8/27/11 RESIDENT #106 WAS FOUND ON HIS BOTTOM ON THE FLOOR. IN AN INTERVIEW ON 8/30/11 AT 2:40 PM, THE FACILITY ADMINISTRATOR STATED THERE WAS AN ELOPEMENT BOOK AT THE RECEPTION DESK NEAR THE FRONT ENTRANCE OF THE FACILITY WITH PHOTO'S OF RESIDENTS WHO WERE IDENTIFIED TO BE AT RISK FOR ELOPEMENT, SO STAFF AT THE FRONT ENTRANCE COULD IDENTIFY AN ELOPING RESIDENT WHEN THEY ATTEMPT TO LEAVE THE FACILITY. THE ADMINISTRATOR STATED THE PHOTO OF RESIDENT #106 WAS TAKEN UPON ADMISSION AND AT THE TIME RESIDENT #106 HAD LONG HAIR AND A FULL BEARD. THE ADMINISTRATOR STATED SINCE THE INITIAL PHOTO HAD BEEN TAKEN, RESIDENT #106 HAD HIS HAIR CUT WAS WAS CLEAN SHAVEN, SO HE DID NOT LOOK ANYTHING LIKE THE PHOTO IN THE ELOPEMENT BOOK WHEN HE WALKED OUT THE FRONT DOOR. WHEN ASKED IF A NEW PHOTO WAS TAKEN OF RESIDENT #106 AFTER HIS APPEARANCE WAS CHANGED WITH A HAIR CUT AND SHAVE, THE ADMINISTRATOR STATED NO. DURING AN INTERVIEW ON 8/30/11 AT 10:45 AM, IN RESIDENT #106'S ROOM, RESIDENT #106 STATED THAT HE REMEMBERED GOING OUTSIDE BECAUSE HE WAS TRYING TO CLEAN HIS BOOTS. RESIDENT #106 THEN DISCUSSED HIS TWO YOUNG CHILDREN WHO LIVED BEHIND THE BAR IN THEIR OWN ROOMS. DURING THE INTERVIEW, THE SURVEYOR OBSERVED A DRESSING ON RESIDENT #106's LEFT ARM. THE RESIDENT STATED THAT HE WAS, "TRYING TO FIX THAT THING" AND THE CAT JUMPED OUT AND SCRATCHED HIM. ON 9/1/11 AT 9:32 AM, THE ADMINISTRATOR AND THE DIRECTOR OF NURSING WERE NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 08/23/11 WHEN RESIDENT #106 EXITED THE FACILITY, UNBEKNOWNST TO FACILITY STAFF. ON 9/2/11 AT 3:00 PM, THE SURVEYOR CONFIRMED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY. 1. ON 8/23/11 FACILITY STAFF AND NURSE PRACTIONER ASSESSED RESIDENT #106 AND FOUND NO INJURIES, AND A CODE ALERT WAS REAPPLIED ON HIS LEFT ANKLE. 2. ON 8/31/11, RESIDENT #106 WAS discharged FROM THE FACILITY TO A FACILITY WITH A "MEMORY UNIT". 3. 8/29/11 A ONE TO ONE FOR CONTINUED SUPERVISION BY STAFF, WAS INITIATED FOR RESIDENT #106 AND CONTINUED UNTIL DISCHARGE. 4. RESIDENT #106 CONTINUED TO WEAR A CODE ALERT UNTIL DISCHARGE FROM THE FACILITY. 5. 8/23/11 - RESIDENT #106'S CARE PLAN WAS REVIEWED AND REVISED. 6. 8/24/11 ALL RESIDENTS WERE REASSESSED FOR ELOPEMENT RISK STARTED ON 8/24/11 WITH 29 OUT OF 256 RESIDENTS DEEMED TO BE AT RISK FOR ELOPEMENT. NEWLY admitted RESIDENTS ARE ASSESSED ON ADMISSION FOR ELOPEMENT RISK. 7. 8/24/11 RESIDENTS DEEMED AT RISK FOR ELOPEMENT WERE REVIEWED IN THE ELOPEMENT BOOKS AND PICTURES IN THE ELOPEMENT BOOKS WERE UPDATED AS NEEDED. 8. 8/25/11 RESIDENTS DEEMED AT RISK FOR ELOPEMENT WERE CONFIRMED TO HAVE A CODE ALERT BY 8/25/11, AND ORDER FOR THE CODE ALERT IS WRITTEN AND DOCUMENTED ON THE TREATMENT ADMINISTRATION RECORD STATING, "CHECK FUNCTION AND PLACEMENT OF ELOPEMENT ALARM EVERY SHIFT". 9. 8/24/11 ROOM SEARCHES INITIATED FOR THOSE RESIDENTS IDENTIFIED AT RISK FOR ELOPEMENT TO ENSURE THEY DID NOT HAVE ITEMS IN THEIR POSSESSION TO REMOVE CODE ALERTS. 10. 8/30/11 CARE PLANS FOR RESIDENTS IDENTIFIED AS AN ELOPEMENT RISK, WERE REVIEWED AND REVISED AS NEEDED BY 8/30/11. 11. ELOPEMENT RISK ASSESSMENT TOOL REVIEWED AND REVISED 8/30/11. 12. POLICY AND PROCEDURES RELATED TO ELOPEMENT WERE REVIEWED ON 8/23/11. 13. PROTOCOL FOR ENSURING INTERVENTIONS AND DOCUMENTATION IS IN PLACE WHEN A PATIENT IS IDENTIFIED AS AN ELOPEMENT RISK, PER THE ELOPEMENT ASSESSMENT, WAS REVIEWED ON 8/25/11. 14. RESIDENTS IDENTIFIED AS AN ELOPEMENT RISK HAVE THE ELOPEMENT PROTOCOL IMPLEMENTED AS OF 8/30/11. 15. RESIDENTS IDENTIFIED ON THE CODE ALERT LIST ARE CHECKED EVERY 15 MINUTES TO OBSERVE THE PRESENCE OF THE RESIDENT AND THE CODE ALERT BEGINNING 8/30/11. THE COMPLETED CHECK IS DOCUMENTED ON THE CODE ALERTS CHECKS FORM. ANY CONCERNS WILL BE ADDRESSED IMMEDIATELY AND REPORTED TO THE CLINICAL CARE MANAGER/DESIGNEE. 16. RESIDENTS IDENTIFIED ON THE CODE ALERT LIST HAVE THEIR ROOMS SEARCHED EVERY SHIFT FOR ITEMS THAT COULD BE USED TO REMOVE THE CODE ALERT, BEGINNING 8/30/11. 17. RESIDENTS IDENTIFIED ON THE CODE ALERT LIST HAVE THE CODE ALERT CHECKED BY THE LICENSED NURSE TO ENSURE PLACEMENT AND FUNCTION EACH SHIFT AND THE COMPLETED CHECK IS DOCUMENTED ON THE TAR BEGINNING 8/25/11. 18. FRONT LOBBY DOORS WERE LOCKED STARTING AT 4:00 PM ON AUGUST 30, 2011. BEGINNING AT THIS TIME, PERSONS ENTERING THE BUILDING MUST SIGN IN AND PERSONS EXITING THE BUILDING MUST SIGN OUT. 19. SECURITY WORKS IN THE FACILITY 24 HOURS A DAY/7 DAYS A WEEK. THE SECURITY GUARD/DESIGNEE WILL REVIEW THE ELOPEMENT BOOK AT THE BEGINNING OF THEIR SHIFT AND SIGN THE SHIFT REPORT FORM TO VERIFY THIS REVIEW WAS COMPLETED BEGINNING 8/1/11. 20. OTHER EXIT DOORS FROM THE FACILITY ARE KEYED AND SECURED AT ALL TIMES. 21. NURSING STAFF EDUCATION WAS INITIATED ON 8/30/11 BY THE STAFF DEVELOPMENT NURSE/DESIGNEE ON : - COMPLETION OF THE ELOPEMENT ASSESSMENT FORM - THE ELOPEMENT PROTOCOL ONCE A NEW PATIENT IS IDENTIFIED AS AN ELOPEMENT RISK. - CONDUCTING ROOM SEARCHES - FRONT LOBBY SECURITY PROCEDURES * 176 OUT OF 267 NURSING STAFF WERE EDUCATED. NURSING STAFF WILL NOT BE ABLE TO WORK UNTIL THEY RECEIVE THE EDUCATION. 22. EDUCATION OF SECURITY STAFF, RECEPTIONISTS AND OTHER DEPARTMENTS WAS INITIATED ON 8/30/11, BY THE STAFF DEVELOPMENT NURSE/DESIGNEE, ON THE FRONT LOBBY SECURITY PROCEDURE ON 8/30/11. * 113 OUT OF 228 STAFF WAS EDUCATED. STAFF WILL NOT BE ABLE TO WORK UNTIL THEY RECEIVE THE EDUCATION. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON 8/30/11, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF ISOLATED, AND SEVERITY OF NO ACTUAL HARM BUT POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT AN IMMEDIATE JEOPARDY, DUE TO NOT ALL FACILITY STAFF HAVE RECEIVED THE IN-SERVICE EDUCATION AND SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY. #

This citation pertains to intake number MI 416 Based on observation, interviews, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest physical well-being for 1 of 6 sampled residents (Resident #502), who had a physician's orders [REDACTED]. Findings Include: Per the facility face sheet Resident #502 was a [AGE] year old male admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the Minimum Data Set ((MDS) dated [DATE] revealed that Resident #502 had moderately impaired cognitive skills, he was able to understand others and was well understood by others, he required extensive assistance for bed mobility, he did not have any pressure ulcers or ulcers of other types. Record review of a "History and Physical" (H&P) dated 10/18/2010 revealed that Resident #502 had fracture of his right leg and was admitted to the hospital on [DATE] where he had surgery to repair the fracture. The H&P revealed that Resident #502 had [DIAGNOSES REDACTED] of his right lower leg (swelling in the extremity that can cause loss of blood flow to the extremity). The H&P revealed that Resident #502 had a fasciotomy (surgical opening of the leg in order to relieve the pressure from the swelling, the incision is left open) performed to his right leg. Record review of physician orders [REDACTED]. The order did not reveal when to take the wrap off or when to reapply it. Review of the "Treatment Administratio Record" (TAR) dated 12/1/2010 revealed a treatment of [REDACTED]. The TAR revealed that the wrap was to be placed on Resident #502 in the AM and taken off in the PM. Review of the manufactures instructions (insert) for use of a Setopress wrap was done on `1/4/2011 at 2:50 PM. The insert revealed that the wrap had two (2) different colors on it, brown and blue. The physician was to order which color he wanted for what ever compression amount he wanted to order. The wrap, when taken out of the package, had brown squares on one side and green squares on the other side. The physician was to order whether he wanted the use of the green or brown squares. The insert revealed that if the physician order [REDACTED]. The insert revealed that when the person applying the wrap began the wrapping process they were to begin on the foot. The insert revealed that the first wrap around the foot and ankle no pulling or pressure was to be applied. The insert revealed that the extension of the wrap or the pulling for compression was to begin after a second time around the foot began. The insert revealed that the wrap should only be applied by a trained bandager. Staff Member #4, a Unit Manager, was interviewed on 1/4/2011 at 2:50 PM. He said that the wrap was not used very much at the facility. He said that no other compression stocking or wrap was used. Staff Member #4 said that if the physician did not order how often the wrap was to be removed and replaced then staff would phone the physician to clarify the order. He said that he did not know what the normal changing of the wrap was. Observation of Resident #502's right leg was conducted on 1/4/2011 at 2:50 PM. Staff Member #4 removed the dressing that was on Resident #502's right foot. Observation revealed a large open blister on Resident #502's right ankle area to the side of the front of his foot. Drainage was noticed, no odor, or bleeding noted. The Setopress wrap was not used on Resident #502 at the time of the observation. Staff Member #5, a Registered Nurse and the Director of Nursing (DON), was interviewed on 1/5/2011 at 9:45 AM. She said that the Setopress wrap was not removed per the TAR by the second shift nurse and therefore left on Resident #502's right leg all through the night. She said that it was brought to her attention by Staff Member #6, the Assistant Director of Nursing (ADON). She said the wrap was to be removed on the second shift, by Staff Member #7, on 12/9/2010 but was not. She said that on the morning of 12/10/2010 Resident #502 had swelling and a blister on his right foot. Staff Member #5 said that Resident #502 had the swelling before the incident of the wrap not being removed. She said that due to the recent fracture of Resident #502's leg the physician transferred him to the hospital for evaluation of his right foot. Staff Member #5 said that when she investigated the incident she had discovered that Staff Member #7 was on her way to remove the wrap on the evening of 12/9/2010 but was distracted by another employee and never returned to Resident #502's room to remove the wrap. Staff Member #5 said that the TAR revealed that Staff Member #7 had initialed that she had removed the wrap on the evening of 12/9/2010. She said that she phoned Staff Member #7 and asked why the wrap was not removed and Staff Member #7 did not realize that she had forgotten. Staff Member #5 said that when the wrap was removed on 12/10/2010 in the AM a blister was noted to be on Resident #502's ankle. She said the blister was not present before the date of 12/9/2010. Staff Member #5 said that the wrap had been used at the facility for a long time and typically education was given to staff at the annual skills fair. Staff Member #4, a Licensed Practical Nurse (LPN) who cared for Resident #502, was interviewed on 1/5/2011 at 2:41 PM. He said that he went to Resident #502's room to administer him his medications on the morning of 12/10/2010, and he found that the Setopress wrap was still on Resident #502's right foot. Staff Member #4 said that he took the wrap off of Resident #502's foot and noticed a blister was present. He said that he then assessed to make sure Resident #502 had a pulse in his foot. He said that he did not speak to Staff Member #7 in regards to the incident. Staff Member #4 said that the wrap should have been removed the evening before on the 3:00-11:00 PM shift. Staff Member #4 said that he was taught how to use the Setopress wrap while in nursing school two (2) years ago. He said that he received education on the Setopress wrap from the facility but not until after the incident with Resident #502. He said that he was given a pamphlet to read and then had to sign that he had read it. Staff Member #4 said that he would have to read the manufactures instructions on the proper application technique, such as when to begin applying pressure upon wrapping the extremity. Staff Member #8, a Registered Nurse (RN) and previous manager of the fourth floor, was interviewed on 1/5/2011 at 11:55 AM. She said that Staff Member #4 came to her on the morning of 12/10/2010 and told her that the Setopress wrap was still on Resident #502's foot from the day before. She said that a blister was noted to be on Resident #502's right ankle area and his foot was red. She said the blister got bigger as time went by in the AM. She said the wrap should have been removed on the evening of 12/9/2010 at bedtime. She said Resident #502 went out the the hospital at about 1:00 PM. Staff Member #8 said that Staff Member #7 told her that at the end of her shift on 12/ at 11:00 PM, she noticed that she had not initialed the TAR for removal of the Setopress wrap. Staff Member #7 told Staff Member #8 that she then got up to go remove it when another staff member requested her help and therefore she forgot to remove the wrap, for a second time on the evening of 12/9/2010. Staff Member #8 said that when Staff Member #7 noticed at 11:00 PM that she had not initialed the TAR for removal of the wrap, she remembered that she had not removed the wrap earlier either. Staff Member #8 said that Setopress wrap had been in use for a long time. She said that she learned how to apply it in nursing school, but had not ever received any training on the application and use of the Setopress wrap at the facility. She said that the wraps were typically removed at bedtime and re-applied in the AM. Staff Member #9, the wound care nurse, was interviewed on 1/5/2011 at 12:30 PM. She said that she had not applied a Setopress wrap in a long time. Staff Member #9 said that the last skills fair was December 2010 and she did not remember receiving any education on the Setopress wrap, nor remember any education at the skills fair previous to December 2010. She said after the incident with Resident #502 the DON handed out a pamphlet for everyone to read and then staff had to sign that they had read it. Staff Member #7, an LPN who cared for Resident #502 the evening of 12/9/2010, was interviewed on 1/7/2011 at 2:00 PM. She said that she was to remove the Setopress wrap at 9:00 PM on 12/9/2010. She said that she did not remember what happened and typically would do the resident treatments while she did her medication administration to residents. Staff Member #7 said that she did not remove the wrap at 9:00 PM while administering Resident #502 his medications. Staff Member #7 said that at 11:00 PM she went to sign out all of the treatments at she did that night and saw that she had not signed out the treatment of [REDACTED]. She said that she then got up to do it and someone stopped her for assistance and she forgot to remove the wrap again for the second time. She said that she initialed that she removed the wrap before she actually went to remove it. Staff Member #7 said that she had not ever received any education on application of a Setopress wrap at the facility until after the incident. Staff Member #7 said that after the incident she was given a handout to read and she had to verbalize application technique to the facility educator. An attempt was made, on 1/7/2011 at 2:25 PM, to contact Staff Member #9, the LPN who cared for Resident #502 on the third shift, but was unsuccessful. The Medical Doctor, who cared for Resident #502 was interviewed on 1/7/2010 at 2:45 PM. She said that she was notified about the blister formation on Resident #502's ankle on the morning of 12/10/2010. She said that she was called for a second time because the swelling in Resident #502's foot had increased. The physician said that when she assessed Resident #502's foot she noticed imprints in his skin that were consistent with were the Setopress wrap was located. She said that she couldn't be sure that the blister on Resident #502's ankle was from the wrap, but stated that the wraps were not left on all night and are to be removed at bedtime. She said the blister may have been from the infection that Resident #502 had in his leg, because he was post surgery for [REDACTED]. Observation of application of a Setopress wrap was conducted on 1/7/2011 at 11:40 AM with Staff Member #11. This was observation was done with a mannequin as no residents at the time required application of a Setopress wrap. Staff Member #11 verbalized that she would check the physician orders [REDACTED]. Staff Member #11 began at the based of the foot applying pressure to change the green squares to rectangles at the beginning of application. Staff Member #11 was asked if she know that no pressure or stretching was to be applied on the first wrap around the foot and ankle per the manufacture's instructions. Staff Member #11 said that she did not know that. Record review of Resident #502's hospital records indicated that he was admitted to the hospital on [DATE] and discharged from the hospital on [DATE]. ( )