Every finding on record at Corewell Health Rehab & Nursing Center-Commons Far

This citation pertains to intake 2792320Based on interview and record review, the facility failed to ensure a referral for home health care was made and confirmed before discharge for one resident (R901) of two residents reviewed for discharge planning. Findings include:On 4/20/26 a concern submitted to the State Agency was reviewed which alleged R901 did not have a home health referral made and confirmed by the facility prior to their discharge back into the community on 1/23/26 and that a family member had to call back to the facility a few days later to have them make and confirm the referral resulting a delay in starting home health care. On 4/20/26 the medical record for R901 was reviewed and revealed the following: R901 was initially admitted to the facility on [DATE] and had diagnoses including Type two diabetes and Presence of cardiac pacemaker. A review of R901's MDS (minimum data set) with an ARD (assessment reference date) of 12/27/25 revealed R901 needed assistance from staff with most of their activities of daily living. R901's BIMS score (brief interview of mental status) was 15 indicating intact cognition.A review of R901's plan of care revealed the following: Focus-I wish to return home with HHC (Home Health Care) supports. Created on: 12/30/2025 .Interventions-Make arrangements with required community resources to support independence post-discharge (specify: homes care, PT (Physical Therapy), OT (Occupational Therapy), MD (Medical Director), Wound Nurse) Revision on: 02/06/2026 .A post discharge plan of care was reviewed and revealed the following: discharge date [DATE] .In home care or services: [Name of local home health agency] .Starting Date: 1/24/26 .On 4/20/26 at approximately 1:23 p.m., Care Coordinator R (CC R) was queried if they had made the referral to R901's home health agency prior to discharge and they indicated they had not and that a Social Worker that no longer worked for the facility had allegedly made the referral. CC R was queried if they were aware of the concern that R901's home health agency did not receive the referral prior to R901 discharging on 1/23/26 and they reported they were and that they called the Home Health agency the next week and they indicated they had never received the referral. CCR was queried regarding the process for referring and confirmed home healthcare services are linked and they indicated they make the referral via fax, email or phone and they wait for confirmation to ensure the agencies had received the referral and could accept the resident. On 4/20/26 at approximately 2:04 p.m., R901's Home Health Agency was called, and Home Health representative S (HHR S) was queried when they received the referral for R901 to be provided Home Health Care and they reported they had received the medical referral for services via fax on 1/27/26 and services were started on 1/28/26.

This citation pertains to intake 2792320.Based on observation, interview and record review, the facility failed to follow nursing professional standards of practice related to physician orders for medication administration for two (R901 and R905) of three residents reviewed for professional standards. Findings include:R901 On 4/20/26 a concern submitted to the State Agency was reviewed that alleged R901 was not properly administered their medications. On 4/20/26 the medical record for R901 was reviewed and revealed the following: R901 was initially admitted to the facility on [DATE] and had diagnoses including Type two diabetes and Presence of cardiac pacemaker. A review of R901's MDS (minimum data set) with an ARD (assessment reference date) of 12/27/25 revealed R901 needed assistance from staff with most of their activities of daily living. R901's BIMS score (brief interview of mental status) was 15 indicating intact cognition. A Physician's order revealed the following: Midodrine HCl Oral Tablet 10 MG (Milligrams) (used to treat low blood pressure) Give 1 tablet by mouth three times a day for hypotension HOLD SBP (systolic blood pressure) <110 -Start Date- 12/30/2025 2200 -D/C (discontinue) Date- 01/09/2026 1602 A second Physician's order revealed the following: Midodrine HCl Oral Tablet 10 MG (Midodrine HCl) Give 1 tablet by mouth every 8 hours as needed for Hypotension HOLD BP greater than 110 -Start Date- 01/09/2026 1500 -D/C Date- 01/24/2026 1812 A review of R901's January 2026 Medication Administration Record (MAR) revealed R901 had SBP of less than 110 and was administered the midodrine outside of the parameters on 1/2/26 (101/56-1400 dose), 1/6/26 (101/55-0600 dose), 1/6/26 (93/60-1400 dose), 1/9/26 (106/69-1400 dose). Further review of R901's January MAR revealed R901 was administered the midodrine when their SBP was greater than 110 on 1/1/26-118/48 (0600 dose) and 127/89 (2200 dose), 1/2/26-125/59 (0600) 165/78 (2200 dose), 1/3/26-143/84 (0600) 136/88 (1400) 126/79 (2200), 1/4/26-115/66 (0600) 122/66 (1400), 1/5/26-128/76 (0600) 115/62 (1400) 136/73 (2200), 1/6/26-151/74 (2200), 1/7/26-123/71 (2200), 1/8/26-137/59 (2200). On 4/21/26 at approximately 8:48 a.m., Nurse Manager G (NM G) was queried regarding the parameters that were transcribed into R901's midodrine order and they indicated they were the incorrect parameters because midodrine is supposed to be administered when the blood pressure is low not held when it is low. NM G was queried if the parameters were transcribed wrong and if they should have been to hold the midodrine if the SBP was over 110. R901's January MAR was reviewed with NM G that indicated the midodrine was administered outside of the parameters in the order and they reported that the Nursing staff should have clarified the order with the Physician regarding the parameters and corrected the order to reflect the appropriate parameters for administration. On 4/21/26 at approximately 10:42 a.m., A review of R901's midodrine order was reviewed with the Director of Nursing and indicated that the parameters in the scheduled midodrine order were incorrect and should have been clarified with the Physician. Review of R905's active physician orders and corresponding Medication & Treatment Administration Records (MAR/TAR) included: An order started on 2/27/26 for bilateral heel protectors at all times when in bed every shift for heel protection. The MAR was documented as completed via a check mark and nurse initials from 4/1/26-4/20/26 with no documentation of any charting exceptions (such as refusals by resident, missing, etc.). Nurse 'I' had documented the MAR entry with a check mark as completed for today. An order started on 11/21/25 for Skilled care boots while in bed, off while out of bed every shift for Heel Pressure reduction – Start Date- 11/21/2025 2300. The TAR was documented as completed via a check mark and nurse initials from 4/1-4/20/26 (except one blank entry on 4/3/26 day shift) with no documentation of any charting exceptions. Nurse 'I' had document An order started on 10/15/25 for Low air loss mattress (LAL). On 4/20/26 at 10:40 AM, R905 was observed lying in bed slightly on their left side with a green wedge pillow under their left side. There was no hearing aids observed in use at this time. During this time, R905 was observed moaning and stated Ow when trying to reposition themselves in bed (restless). They kept their eyes closed and did not respond when spoken to. The low air loss unit secured to the end of the footboard was set to off power. There was a blue soft boot that had a label for heel drop stored in between the two closet units. R905 was not observed to have any heel protectors in place (feet were bare). On 4/20/26 at 10:45 AM, an interview was conducted with the resident's Nurse (Nurse 'I'). When asked if the resident had any current skin concerns, Nurse 'I' reported they did not. When asked about R905's LAL mattress unit at the end of the bed, Nurse 'I' confirmed it was off and reported that was probably from the old mattress and further reported they had seen maintenance in the room recently. When asked if they were aware there was an active order to have that in place as part of their plan of care, Nurse 'I' reported No. When asked about the resident's moaning, Nurse 'I' reported the physician was making rounds today and intended to see her about increase in pain. Nurse 'I' reported the resident recently signed onto hospice and moved around a lot in bed. When asked about if the resident utilized any soft boots or heel protectors, Nurse 'I' reported they did not. When asked about the soft boot observed between the two closets, Nurse 'I' reported that was one of the boots for R905. When asked if there was another boot, Nurse 'I' proceeded to open R905's closet and removed and placed together with the other boot. When asked to clarify if R905 should have boots or some sort of heel protectors in place, Nurse 'I' reported No. At that time, Nurse 'I' was asked to review the resident's active physician orders and compare to the documentation on the MAR and TAR. When asked about the entries of check marks and visual cue of green which indicated the above orders for the skilled care boots, bilateral heel protectors and LAL mattress were verified as completed, Nurse 'I' confirmed they had marked that as completed this morning. When asked why they had marked it as completed if they had not actually completed it, Nurse 'I' offered no further explanation. Further review of the clinical record revealed R905 was initially admitted into the facility on 4/4/18, readmitted on [DATE] and recently signed onto hospice on 3/30/26. Diagnoses included: Alzheimer's disease with late onset, contusion of unspecified part of head, unspecified fracture of shaft of unspecified fibula, displaced intertrochanteric fracture of right femur, unspecified glaucoma, unspecified convulsions, dementia in other diseases, manic episode, major depressive disorder, and fracture of unspecified part of neck of left femur. According to the Minimum Data Set (MDS) assessment dated [DATE], R905 had severe cognitive impairment and was dependent upon staff for most aspects of care. A significant change MDS assessment was currently in progress. On 4/20/26 at 12:58 PM, an interview was conducted with the Director of Nursing (DON). When informed of the observation and interview with Nurse 'I' regarding R905's lack of soft boots, heel protectors, and LAL mattress, the DON reported they would need to follow up. When asked what their process was for documenting on the MAR and TAR and the DON reported the nurse should process for completion and document once completed. According to the facility's policy titled, Clinical Nurse LTC (Long Term Care) dated 12/2023: .All employees in all positions must.Ensure that services are provide in accordance with state and federal regulations, accreditation and compliance requirements.The clinical nurse, under the ANA scope of practice utilizes the framework of the nursing process to provide not only professional but exceptional nursing care by incorporating.code of ethics and other policies.ESSENTIAL FUNCTIONS.Implements the plan and then continuously re-evaluates the patient/resident status and nursing care to make any necessary modifications to provide the most effective plan of care.Communicates documentation in the patient/resident record in a timely, accurate and concise manner.Administers and documents medication in accordance with established standards, making certain that the Medication Administration Record (MAR) is complete.Documents in the patient/resident record as appropriate including nursing interventions, nursing notes and all other pertinent problems patient/resident may be experiencing.

This citation pertains to intake 2792320.Based on observation, interview and record review, the facility failed to provide a safe, clean, homelike environment for two (R905 and R907) of three residents reviewed for environment. Findings include:Review of a complaint submitted to the State Agency included concerns that the facility was not clean and when they visited the resident, their bedside and overbed tables were frequently dirty with sticky substances.On 4/20/26 at 10:40 AM, R905 was observed lying in bed, leaning slightly on their left side with a green wedge pillow under their left torso. The left side of the bed ran along the wall/window and the other side had an overbed tray table with the call light on the floor, under the feet of the overbed tray table. The entire edging around the overbed tray table was observed to have lifted/peeled edges which exposed the particle board (non-cleanable surface) and the metal portion of the tray table stand was covered with dried dark substance.The top surface of the bedside dresser was observed to be soiled with a thick white substance.There was a blue floor mat folded up and stored vertically against the dresser/television cabinets that was covered in thick unidentifiable dried debris and stains.The low air loss unit secured to the end of the footboard was set to off power.During this time, R905 was observed moaning and stated Ow when trying to reposition themselves in the bed. They kept their eyes closed and did not respond when spoken to.R907 was observed lying in bed with their bed sheets pulled up to their chin. The surrounding carpet on the left side of their bed was observed with crushed food debris and a red, thick substance was observed on the overbed tray table.On 4/20/26 at 10:45 AM, an interview was conducted with R905's Nurse (Nurse 'I'). When asked about the resident's LAL (low air loss-used to aid in the prevention of skin breakdown) mattress being set to Off, Nurse 'I' confirmed the same and reported that was probably from the old mattress and further reported they had seen maintenance staff in the room recently. When asked if they were aware of any concerns with equipment not functioning, they reported they were not. Nurse 'I' then proceeded to ask this surveyor if the mattress that was currently in place was a LAL mattress.When here recently but when asked if that was part of their plan of care, Nurse 'I' reported No.When asked about the call light on the floor, Nurse 'I' confirmed and went to pick it up and stated R905 moved around a lot and they were just in here and it was within reach. There was no clip and when attempted to put it back next to the resident, the call light kept slipping away. When asked if a clip might help, Nurse 'I' reported it might but confirmed there was none currently in place.When asked about the condition of the floor mat, Nurse 'I' confirmed the various unknown substances and stains. When asked what the process was if staff identified concerns with the resident's room environment such as equipment not working or needing housekeeping services, Nurse 'I' reported staff could put a work order in for maintenance or housekeeping by calling the front desk and putting a work order in. When asked if they had done that recently, they reported No.On 4/20/26 at 12:58 PM, an interview was conducted with the Director of Nursing (DON). When informed of the concerns observed with Nurse 'I' regarding R905's environmental concerns, the DON reported they would have to follow-up but they had a process to initiate work orders. The DON was requested to provide the work order log for the past 30 days.Review of the documentation provided by the Maintenance Staff included all work orders from 3/21/26 - 4/19/26. Review of this documentation revealed there were none documented for the room occupied by R905 and R907.On 4/21/26 at 11:00 AM, an interview was conducted with the Environmental Services (EVS) team which included the EVS Manager (Staff 'O'), Lead Housekeeper (Staff 'P'), and Lead Housekeeper (Staff 'Q').When asked about what services were provided for housekeeping, Staff 'O' reported bathrooms, vacuuming, dusting, but if the resident was in the immediate area, dusting would not be done.When asked if the daily cleaning included the overbed tray tables, bedside dressers and floor mats used, Staff 'O' reported they would do all of that except for the floor mats and reported that was up to the nursing staff to clean.When asked if their staff observed any concerns during their rounds that would require maintenance (such as a peeling overbed tray table), Staff 'P' reported their staff would contact the front desk to put a work order in.On 4/21/26 at 11:15 AM, observation of the room occupied by R905 and R907 was made with Staff 'O', Staff 'P' and Staff 'Q'. The floor mat for R905 was observed with dark brown stains, the carpet surrounding R907's bed remained with food debris (present since 4/20/26). R907's overbed tray table remained soiled with thick, dark red substance. R905's bedside dresser continued to be soiled with a white substance.When informed that these concerns were observed since 4/20/26, Staff 'O' reported they were handling some staffing challenges and there was one housekeeper today for the third floor.According to the facility's policy titled, Environmental Services Cleaning and Quality dated 3/7/2024: .All used patient rooms.will be cleaned a minimum of one time per day. The cleaning should include but is not limited to; the floors, horizontal surfaces, visible soiling, and disinfection of high touch surfaces.

This citation pertains to intake 2792320.Based on observation, interview, and record review, the facility failed to implement fall prevention interventions per plan of care for two (R903 and R905) of three residents reviewed for accidents. Findings include:R903 On 4/20/26 at approximately 9:28 a.m., 12:07 p.m., 1:13 p.m. and 2:49 p.m., R903 was observed in their room, laying in their bed. R903's bed was observed to be high (approximately 3.5 ft off the floor) without any floor mats around the bed. A floor mat was observed on its side, laying up against the wall at the foot of the bed. On 4/20/26 the medical record for R903 was reviewed and revealed the following: R903 was initially admitted to the facility on [DATE] and had diagnoses including Alzheimer's and Hearing loss. A review of R903's MDS (minimum data set) with an ARD (assessment reference date) of 2/27/26 revealed R903 needed assistance from facility staff with most of their activities of daily living. R903's BIMS score (brief interview of mental status) was six indicating severely impaired cognition. A review of R903's plan of care revealed the following: Focus-I am at risk for falls Dementia, Gait/mobility impairments, Incontinence, Osteopenia, Weakness fall 8/17/25 Readmit 12/29/25 Created on: 05/22/2024 Revision on: 12/30/2025.Interventions-Bed in lowest position Revision on: 10/03/2024 Do not leave alone in room in wheelchair Dycem Gripper to w/c cushion on top and bottom Revision on: 05/28/2024 Mats on floor non-slip footwear at all times . On 4/20/26 at approximately 2:50 p.m., R903's room was observed with Nurse I and they were shown R903's bed up high and the floor mat against the wall. Nurse I indicated they would have to lower R903's bed to a low bed status (to reduce the potential from injury of a fall) and to place the floor mat on the floor on the side of R903's bed. Nurse I was queried if R903 was a fall risk and they indicated they were and they would have to adjust R903's position in the bed. On 4/21/26 at approximately 8:48 a.m., Nurse Manger G was queried regarding the multiple observations of R903's fall interventions not being implemented and they reported that they should be. R905 On 4/20/26 at 10:40 AM, R905 was observed lying in bed slightly on their left side with a green wedge pillow under their left side. The bed was in an elevated position (not low to the floor). There was an overbed tray table placed to the right side of the bed and the call light was on the floor, out of reach and under the feet of the overbed tray table. There was a soiled blue mat folded and resting against the closet. There was a regular mattress (non-perimeter) in place. On 4/20/26 at 10:45 AM, an interview was conducted with the resident's Nurse (Nurse 'I'). When asked if the resident was considered a fall risk, Nurse 'I' reported they were not. When asked about the folded floor mat, Nurse 'I' didn't respond and proceeded to unfold and place next to the bed. When asked if that should be utilized when the resident was in bed, Nurse 'I' reported It should. Nurse 'I' further reported the staff probably just forgot to put the mat back in place after they assisted with breakfast this morning. When asked about whether the resident should have a perimeter mattress in place, Nurse 'I' reported they were not aware of that. Review of the documentation provided by the facility via the facility matrix identified R905 had a fall with injury. Review of the clinical record revealed R905 was initially admitted into the facility on 4/4/18, readmitted on [DATE] and recently signed onto hospice on 3/30/26. Diagnoses included: Alzheimer's disease with late onset, contusion of unspecified part of head (11/28/25), unspecified fracture of shaft of unspecified fibula, displaced intertrochanteric fracture of right femur (11/28/25), unspecified glaucoma, unspecified convulsions, dementia in other diseases, manic episode, major depressive disorder, and fracture of unspecified part of neck of left femur (4/4/18). According to the Minimum Data Set (MDS) assessment dated [DATE], R905 had severe cognitive impairment and was dependent upon staff for most aspects of care and had no falls since the prior assessment. A significant change MDS assessment was currently in progress. Review of R905's care plans included one for fall risk which was created on 4/4/18 and revised on 11/29/25 which read: I am at risk for falls/injury r/t (related to) decreased mobility, HTN (Hypertension), OA (Osteoarthritis), COPD (Chronic Obstructive Pulmonary Disease), anxiety, dementia, hx (history) of left hip Fracture, Incontinence, high risk medication use. I use sit to stand for transfers. I have my bed against the wall and mat next to bed for safety. I at times sit on the edge of my bed. I tend to reach for my phone and other items on my night stand so I need it to be close to me while I am in the bed. I have a history of placing myself on the floor and taking my clothes off, I will become agitated and frustrated due to my disease process – I don't understand why I am so confused. 11/28/25 Fall with Hematoma and multiple injuries. Interventions included: Added 11/19/18, place resident phone/personal items within reach. Added 5/10/28, Perimeter mattress. Added 7/25/21, I will notify the staff and use my call light when I need to go to bed. Added 5/19/21, bed in low position. Added 5/19/21, Mats on floor. No date of when added, I am on the falling star program. Review of the progress notes included an entry on 11/29/25 at 12:49 AM that read: Writer was called by caregiver that resident fell to the floor. Upon rushing to the room, resident was lying on the floor next to bed with body in curled position leaning towards her right side, bed was in high position with the bed unlocked. The CNA (Certified Nursing Assistant) said she rolled the resident towards herself but unfortunately the bed rolled backwards and resident fell forward to the floor. Resident sustained hematoma to the forehead, skin tear left deltoid and right elbow. Complained of pain to the left foot.Resident was transferred to hospital via 911. R905 returned to the facility with diagnoses that included: contusion of unspecified part of head, and unspecified fracture of shaft of unspecified fibula. (Although this fall with major injuries occurred prior to the recertification survey conducted 12/18/26, as well as an abbreviated survey on 2/25/26 in which accidents was cited, concerns were identified with observations of lack of implemented fall prevention interventions during the current abbreviated survey.) On 4/20/26 at 12:58 PM, an interview was conducted with the Director of Nursing (DON). When informed of the observation and interview with Nurse 'I' regarding R905's lack of fall prevention interventions, and lack of awareness of R905 being at risk for falls, the DON reported the nursing staff should be aware and interventions should be in place. When asked about the lack of perimeter mattress, the DON reported they would have to follow-up. According to the facility's policy titled, Fall Prevention Program dated 12/18/23: .To prevent falls of residents at risk and to communicate resident-specific interventions to staff.The Care Plan will include individualized interventions for fall prevention.

This citation pertains to intake 2792320.Based on observation, interview and record review the facility failed to provide proper assistive devices to maintain hearing for one (R905) of two residents reviewed for assistive devices. Findings include:Review of a complaint reported to the State Agency included concerns that read, I brought her hearing aids to the facility so that she could hear. Staff wouldn't give them to her and wouldn't give her time to get them prior to going to PT (Physical Therapy), so she couldn't hear while in therapy.Review of R905's physician orders and corresponding Medication/Treatment Administration Records (MAR/TAR) included: Apply resident hearing aids upon awaking daily for better communication. every day shift for communication - Start Date - 01/22/2026 0700. The MAR was documented as completed via a check mark and nurse initials from 4/1-4/20/26 with no documentation of any chart codes/follow up codes such as missing, refused, etc. The documentation revealed Nurse 'I' had documented this was completed for 4/20/26 at 7:00 AM. Remove resident hearing aids prior to bedtime and lock up in nursing cart. every evening shift for communication - Start Date - 01/22/2026 1500. The MAR was documented as completed via a check mark and nurse initials from 4/1-4/19/26 with no documentation of any chart codes/follow up codes to indicate concerns such as whether they were missing, refused, etc.On 4/20/26 at 10:40 AM, R905 was observed lying in bed slightly on their left side with a green wedge pillow under their left side. There were no hearing aids observed in use at this time. During this time, R905 was observed moaning and stated Ow when trying to reposition themselves in bed (restless). They kept their eyes closed and did not respond when spoken to.On 4/20/26 at 10:45 AM, an interview was conducted with Nurse 'I'. When asked about the resident's use of hearing aids, Nurse 'I' reported they should be in the charger at the desk. When asked why they were not applied since the order was to be completed upon awaking daily for better communication at 7:00 AM, Nurse 'I' went back to check R905 and confirmed the resident was not wearing any hearing aids. When asked who was responsible to ensure this was done, Nurse 'I' reported that was the Nurse's responsibility.At that time, Nurse 'I' was asked to review R905's current physician orders and compare to what was documented on the Medication Administration Records (MARs). When asked about their entry on 4/20/26 at 7:00 AM that this was completed via a check marks and visual cue of green color, Nurse 'I' which indicated the medication/order had been completed for the provision of the boots, the hearing aids and LAL mattress, Nurse 'I' confirmed they had marked that as completed. When asked why they had marked it as completed if they had not actually completed it, Nurse 'I' reported they had all shift to put the hearing aids in. When asked to confirm the order, Nurse 'I' confirmed it was ordered to be done upon awaking and was scheduled with a time for 7:00 AM.When asked to observe R905's hearing aids in the medication cart as this was indicated on the current orders, Nurse 'I' reported those were not kept in the medication cart, they were kept on the charger at the nursing desk. Nurse 'I' then proceeded to retrieve R905's hearing aids and reported there was only one, the other was missing. When asked when they had last seen both hearing aids, Nurse 'I' reported they were not sure. When asked why their documentation reflected previous entries that had been done when it actually was not in the MAR, Nurse 'I' offered no further response.Review of the clinical record revealed R905 was initially admitted into the facility on 4/4/18, readmitted on [DATE] and recently signed onto hospice on 3/30/26. Diagnoses included: Alzheimer's disease with late onset, unspecified glaucoma, unspecified convulsions, dementia in other diseases, manic episode, and major depressive disorder.According to the Minimum Data Set (MDS) assessment dated [DATE], R905 had severe cognitive impairment , had minimal difficulty with hearing, and was marked (incorrectly) as not using a hearing aid.Review of a communication care plan created on 8/8/22, revised on 11/7/23 documented, I have problems communication <sic> due to I am slightly HOH (hard of hearing). There were no interventions included for the use of hearing aids.On 4/20/2 at 12:58 PM, an interview was conducted with the Director of Nursing (DON). When informed of the concerns observed with Nurse 'I' regarding R905's hearing aids, the DON reported those were never kept in the medication cart but at the nursing desk on the charger. When they were informed of the observation the resident was not wearing their hearing aids and the identification that one was now missing, the DON reported they would have to follow-up. When asked how the missing hearing aid was not identified prior to now if the other nurses were documenting they were being implemented and removed, the DON reported they were not able to offer any further explanation.According to the facility's policy titled, Hearing and Vision Services dated 8/8/25: .Purpose To ensure that residents receive proper treatment and assistive devices to maintain.hearing abilities.Assistive devices include, but not limited to.Hearing aides. This policy did not address the staff's process for ensuring placement per plan of care.

Based on interview and record review, the facility failed to implement safety interventions to prevent an avoidable fall for one resident (R803), of one resident reviewed for falls, resulting in a transfer to the emergency room where it was discovered R803 sustained a left tibia (shin bone) fracture, a contusion (bruise) to the left upper extremity, and an abrasion to the right upper extremity. Findings include: On 2/24/26 at 9:00 AM, a review of a nursing progress note dated 11/29/25 at 12:48 AM entered into the record by Nurse 'E' was reviewed and read, Note Text: Writer was called by caregiver (Certified Nurse Aide 'D') that resident fell to the floor. Upon rushing to the room, resident was laying on the floor next to bed with body in curled position leaning towards her right side, bed was in high position with the bed unlocked. The CNA (Certified Nurse Aide) said she rolled the resident towards herself but unfortunately the bed rolled backwards and resident fell forward to the floor. Resident sustained hematoma to the forehead, skin tear left deltoid and right elbow. Complained of pain to the left foot .Resident was transferred to hospital via 911 . On 2/24/26 at 9:10 AM, a review of a facility provided investigation file for a fall sustained by R803 was conducted. The file contained a document titled, (Facility Name) POST FALL ANALYSIS AND INVESTIGATION that read, .WHAT NEW INFORMATION WAS DISCOVERED: Staff rolled the patient towards her, the bed rolled away due to unlocked wheels, that leads {sic} to her fall .IMMEDIATE INTERVENTION WAS PUT IN PLACE: .patient was sent to the hospital .ROOT CAUSE: .Staff rolled the patient towards her, the bed rolled away due to unlocked wheels, that leads {sic} to her fall .CONCLUSIONS & RECOMMENDATIONS: Staff education completed to make sure that the bed wheels are locked before making any transfers or repositioning to prevent a fall . New onset or worsening of acute illness that may affect resident's cognitive or physical abilities: Left tibia fracture acquired .Continued review of the investigation file revealed a signed, written statement from CNA 'D' that read, Around 4:50 pm I was doing care on the resident. I rolled her from the wall into my body. The resident's bed slid and she fell onto her side .There was bruising to the head, arm and leg. A review of a typed document contained in the file read, Investigative Overview .The facility determined the accident was caused by (CNA 'D')'s priority to care for (R803) without locking the wheels of the bed . Further review of the file revealed another typed document that read, Below is the nurse managers {sic} investigative report . (Hospital Name) Hospital Report: Imaging test: .diagnosis: Closed displaced fracture of left tibia .other findings: 3. contusion of left upper extremity 4. abrasion of the right upper extremity .HOSPITAL ASSESSMENT AND PLAN: orthopedic surgery consulted, splint applied to the left leg, pain management, non weightbearing {sic} LLE (Left Lower Extremity) at this time . On 2/24/26 at 2:30 PM, an interview was conducted with the facility's Administrator regarding the investigation file. They were asked about R803's fall and confirmed CNA 'D' did not have the wheels on the bed locked when they repositioned R803 causing the bed to roll away and R803 falling from the bed to the floor.A review of a facility provided policy titled, Resident Safety and Precautions revised 4/2024 was conducted and read, 1. Purpose: To outline resident safety standards and describe resident precautions and the associated interventions .3.1 Resident Safety Standards .3.1.2.1 Bed wheels locked .

Based on interview and record review, the facility failed to review lab values prior to the administration of D5% 0.45% NS (an intravenous fluid solution that contains .45 grams of sodium chloride (NS) and 5 grams of dextrose (sugar) per 100 milliliters) for one resident (R802), of one resident reviewed for the physician's responsibility to review the resident's total program of care at each visit, resulting in R802 receiving continuous IV fluid containing dextrose for approximately two days after the lab reported a critically high glucose level, which subsequently required an emergency transfer to the hospital for hyperglycemia (elevated blood sugar). Findings include: On 2/25/26 at 8:10 AM, a review of R802's closed clinical record was conducted and revealed R802 admitted to the facility on [DATE] and discharged on 12/10/25. R802's diagnoses included: psychotic disorder with delusions, delirium, Alzheimer's disease, stroke, and mood disorder.A progress note entered into the record by Nurse 'B' on 12/8/25 at 12:25 PM read, Note Text: CNA (Certified Nurse Aide) informed writer that resident wasn't herself during morning part of shift. Writer called on call PA (Physician Assistant) 'A'. New orders to {sic} for lab work for STAT (urgent) CBC (complete blood count lab) .CMP (complete metabolic panel lab) .ALL {sic} blood work .collected and sent to lab awaiting results . A review of R802's labs collected on 12/8/25 at 10:30 AM and reported to the facility on [DATE] at 12:37 PM was conducted and revealed R802's blood sugar level was 732 (normal value 70-99). A follow-up note entered into the record by Nurse 'B' on 12/8/25 at 3:24 PM was reviewed and read, Note Text: Writer reviewed result with PA (PA 'A') while in building. New orders for .45 dextrose (herein referred to as D5% 0.45% NS) at 125ml (milliliter) per hr (hour) x 3 liters . Writer obtained I.V {sic} in left forearm but resident pulled it out. Writer attempted to get new access but was unsuccessful .awaiting new orders .A review of PA 'A's progress note dated 12/8/25 was conducted and read, .DIAGNOSIS, ASSESSMENT AND PLAN .Acute kidney injury .Will plan to give 2L IV fluid continuous . It was noted the progress note did not indicate PA 'A' reviewed the stat labs they ordered earlier in the day or the type of IV fluid to be administered. Continued review of R802's nursing progress notes revealed the following: A progress note entered into the record by Nurse 'B' on 12/8/25 at 4:36 PM that read, Note Text: Update. PA called back with new orders to insert hypodermoclysis (the infusion of fluids into the tissue just under the skin for hydration) .Writer inserted hypodermoclysis to resident's abdomen .A progress note entered into the record by Nurse 'G' on 12/9/25 at 12:33 PM that read, Note Text: .Entered residents {sic} room and explained that a PIV (peripheral IV) need to be replaced .resident tolerated procedure well, Hooked up to IVF as ordered (D5% 0.45% NS as ordered by PA 'A' on 12/8/26) .A progress note entered into the record by Nurse 'H' on 12/9/25 at 2:38 PM that read, Note Text: Writer received order clarification for Dextrose 5% 0.45% Sodium chloride (D5% 0.45% NS) infusing @ 125cc (cubic centimeter)/hr times 2 Liters .A progress note entered into the record by Nurse 'I' on 12/9/25 at 10:30 PM that read, Note Text: .resident has peripheral IV in right forearm .D5.45% sodium chloride (D5% 0.45% NS) @ 125cc x 2L (infusion rate of 125 cubic centimeters per hour for 2 liters, or bags of fluid) .bag 2 of 2 infusing . A progress note entered into the record by Nurse 'C' on 12/10/25 at 12:08 AM that read, Note Text: resident {sic} received resting in bed. IV (D5% 0.45% NS) at 125cc .via right arm peripheral IV resident hard to arouse Blood sugar checked results read Hi {sic} (a value greater than what the glucose meter can detect) .call placed to on call. awaiting return call. A progress note entered into the record by Nurse 'C' on 12/10/25 at 12:21 AM that read, Note Text: writer spoke with (NP 'J') concerning residents abnormal lab (high glucose reading) .new order received: (2) give 12 units of Lispro insulin now, recheck in 2hrs. if {sic} blood sugar is still reading Hi {sic} Give an additional 12 units and recheck in 2 hours. Call back if blood sugar is still reading Hi {sic} after second dose of insulin . A progress note entered into the record by Nurse 'C' on 12/10/25 at 1:29 AM that read, Note Text .Blood sugar reading is Hi {sic} .This has gotten stayed {sic} the same since it started A progress note entered into the record by Nurse 'C' on 12/10/26 at 3:05 AM that read, Note Text: writer rechecked resident's blood sugar and the reading was Hi {sic} 12 units of Lispro insulin given as per order. resident is lethargic and difficult to arouse .A progress note entered into the record by Nurse 'C' on 12/10/25 at 3:50 AM that read, Note Text: (Ambulance) called for transportation to (Hospital Name) . On 2/25/26 at 10:55 AM, a review of R802's hospital records was conducted and read the following, .CHIEF COMPLAINT: HIGH BLOOD SUGAR and ALTERED MENTAL STATUS .HISTORY OF PRESENT ILLNESS: .Per EMS .They report the patient on their arrival was receiving D5 fluid hydration .Patient presents with HIGH BLOOD SUGAR Per EMS pt. was found to be hyperglycemic (high blood sugar) at (Facility Name) and staff administered D5 infusion, unk (unknown) amount of insulin given by nurse POC (Point of Care glucose reading from glucose monitor) 300's (glucose levels) . On 2/25/26 at 11:00 AM, an interview was conducted with Physician Assistant (PA) 'A'. They were asked if they were aware R802's blood glucose level was 732 prior to them ordering D5% 0.45% NS for intravenous infusion. They said they were not aware of the elevated glucose level and if they were, they would not have ordered an IV fluid with dextrose. They were then asked if they, themselves reviewed the labs on 12/8/25 prior to ordering the IV fluid. PA 'A' reviewed their progress note for their visit to R802 on 12/8/25 and said they did not document they reviewed the labs. They were then made aware R802 received a continuous infusion of D5% 0.45% NS from 12/8/25 to 12/10/25 and they subsequently were transferred to the emergency room for hyperglycemia. PA 'A' was then asked what should have happened and said they should have reviewed the labs prior to ordering the IV fluids. On 2/25/26 at approximately 11:30 AM, an interview was conducted with the facility's Director of Nursing (DON) regarding the concern. They indicated PA 'A's order for D5% 0.45% NS could have been questioned by the nurse who received the critically high glucose level and implemented PA 'A's order for D5% 0.45% NS. A review of a facility provided policy titled, Role and Responsibilities of Attending Physicians and Advanced Practice Providers-Continuing Care (Rehab and Nursing Centers) effective 4/2024 was conducted and read, .During a physician or advanced practice provider visits, each resident/patient's overall condition will be determined, including: Status of specific medical issues or diagnoses through proper assessment, review of patient information, and conversations with clinical team members .Review laboratory and other diagnostic test with provider visit .Abnormal test results will be analyzed, and a medical rationale will be documented, in addition to rationale for subsequent interventions or decisions not to intervene based on results .

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include:On 12/16/2025 at 9:20 AM, there were 3 uncovered bins of clean dessert sized cups stored next to the handwashing sink. When queried about the storage of the clean dishware, Certified Dietary Manager (CDM) M stated, they have to have covers on them.According to the 2022 FDA Food Code section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLEUSE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted.On 12/16/2025 at 10:00 AM, there were 2 plastic wrap covered pans of whole, cooked pork loins on a speed rack located in the food prep area. The pans were dated 12/15. When queried about the pork loins, CDM M stated they had been cooked on 12/15/25 and placed in the cooler to be served for lunch on 12/16/25. The internal temperatures of the whole pork loins ranged from 48-51 degrees Fahrenheit. Review of the facility's cooling log revealed the pork loins had not been placed on the cooling log, to ensure the meat was cooled to 41 degrees Fahrenheit or less in the appropriate timeframe. CDM M stated she was unsure why staff did not utilize the cooling log for the pork loins. According to the 2022 FDA Food Code section 3-501.14 Cooling, (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less.

This citation pertains to Complaint #2675245. Based on interview and record review, the facility failed to ensure the physician was notified when a blood pressure medication was not available for four days for one (R121) of one resident reviewed for medication availability. Findings include: On 12/16/25 at 10:45 AM, an interview was conducted with R121 regarding her care in the facility. R121 reported her main concern was when she was admitted into the facility on [DATE], a prescribed medication used to treat high blood pressure was not available and she did not receive it until 12/15/25. R121 reported the nurse told her the medication had to be ordered from the pharmacy, but then there was no follow up after that. A review of an After Visit Summary from the hospital for R121 revealed they were prescribed candesartan-hydrochlorothiazide (a medication used to treat high blood pressure) 32-12.5 milligrams (mg) daily. A review of the facility's Physician's Orders revealed an order for candesartan cilexetil-HCTZ (hydrochlorothiazide) 32-12.5mg daily. A review of R121's Medication Administration Record (MAR) for December 2025 revealed R121 did not received the blood pressure medication on 12/11/25, 12/12/25, 12/13/25, and 12/14/25. A review of R121's progress notes revealed the following: An eMAR (electronic Medication Administration Record) note dated 12/11/25 that noted, Med (medication) not available on cart or (backup medication dispensing machine). A review of a History and Physical progress note written by the Attending Physician on 12/11/25 revealed no documentation of the candesartan cilaxetil-HCTZ not being available. The physician documented to continue with the current treatment for blood pressure. A review of an eMAR progress note dated 12/12/25 noted candesartan cilaxetil-HCTZ was on order. A review of a Provider Progress Note dated 12/12/25 revealed the following documentation, HTN (hypertension): Blood pressure controlled on current Rx (prescription). Continue to monitor blood pressure. It was not documented in the note that the medication was not available for administration to R121. A review of an eMAR note dated 12/13/25 revealed, not available will follow up with pharmacy. A review of an eMAR note dated 12/14/25 revealed, Pharmacy contacted - spoke to (name) states she is not sure why it was not cycling out, but she will send it out today. There was no documentation that indicated a medical provider was notified that the medication was not available or that anyone spoke with the pharmacy prior to 12/14/25. On 12/17/25 at 12:22 PM, an interview was conducted with the Director of Nursing (DON). When queried about the facility's protocol when a prescribed medication was not available for administration, the DON reported the nurse would check in the backup medication dispenser. If the medication is not available in back up, the pharmacy was contacted. The medical provider was usually contacted to see if there were any further instructions, alternative medication to give, or if the delay in administration was okay. The DON reported she was unaware R121 did not receive the blood pressure medication for four days. On 12/18/25 at approximately 1:30 PM, the DON followed up and reported the medication was not available at the pharmacy and therefore it was delayed. However, the pharmacy technician did not communicate with the facility. The DON acknowledged there should have been follow up with the physician. A review of R121's clinical record revealed R121 was admitted into the facility on [DATE] with diagnoses that included: HTN.

Based on observation, interview, and record review, the facility failed to provide adequate positioning and range of motion (restorative therapy services) for two (R71, R97) of three residents reviewed for positioning and range of motion. Findings include: R97 On 12/16/25 at 12:40 p.m., R97 was observed in their room in their hospital bed, wearing a hospital gown. R97 had soft positioning boots on their feet, which placed their feet into dorsiflexion (toes pointed up towards the ceiling). On 12/16/25 at 12:42 p.m., R97 reported they wanted to receive more range of motion exercises, however, said restorative therapy was only about once a week. R97 explained they wanted to receive more range of motion, especially for their feet, which felt tight. R97 stated sometimes staff had difficulty applying their positioning boots because their foot muscles were tight, which caused them discomfort. R97 said they wondered if range of motion exercises for their feet would help. Review of the Minimum Data Set (MDS) assessment, dated 9/16/25, revealed R97 was admitted to the facility on [DATE], with diagnoses including dementia, multiple sclerosis, and depression. The assessment showed R97 required supervision or touching assistance with eating and was dependent for transfers. The range of motion assessment revealed R97 had range of motion impairment on one upper extremity and both lower extremities. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 10/15, which showed R97 had moderate cognitive impairment. Review of R97's most current restorative program, requested and received from the Director of Rehab (DOR), Physical Therapist E, on 12/18/25, revealed the program was dated on 6/24/25, and showed R97 was scheduled to receive restorative therapy two to three times a week for six weeks (through 8/05/25). The program included active assistive range of motion and strengthening exercises for their arms and legs, bed mobility exercises, balloon toss exercises, and hand grip exercises. The goal was to maintain their current level of function and ability to assist with activities of daily living. On 12/17/25 at 1:38 p.m., Certified Nurse Aide (CNA) K was asked about R97's participation in the restorative therapy program, since R97 said they were in restorative therapy. CNA K reported they worked in the restorative therapy program 2-3 times a week, however said they could not recall if R97 was in the program or not. When asked about any missed restorative visits, as reported by R97, CNA K explained they were sometime pulled to the floor to work as a nursing aide, and then the residents missed their restorative therapy, which was not always able to be rescheduled. CNA K reported they worked in the program on their own as a restorative aide, along with another restorative aide. CNA K said they would let the Unit Manager, Registered Nurse (RN) L, know when a resident needed to be discontinued from the program. CNA K reported they documented their visits in the facility progress notes in the Electronic Medical Record (EMR), and they documented in the progress note when a resident was discontinued from restorative therapy. Review of R97's restorative nursing progress notes in the Electronic Medical Record (EMR) with CNA K revealed R97's last restorative progress note was dated 11/14/25. Further review of R97's restorative nursing progress notes revealed there was no documentation showing a discussion with R97 regarding their restorative therapy was ending, including on 11/14/25, the last date of service. There was also no documentation of any skilled oversight by nursing or therapy from 7/04/25 through 11/14/25. Additionally, the note showed R97's restorative program was completed, with an additional six weeks added. This showed the restorative program continued beyond the 12-week duration specified. On 12/17/25 at approximately 5:15 p.m., the Unit Manager, RN L, was asked about R97's restorative program, and any oversight provided. Review of R97's EMR with RN L showed R97's physician orders remained active, beginning 6/24/25, and had not been discontinued. Further review of R97's EMR with RN L revealed the current task section showed current restorative exercises for R97 in the active tasks. On 12/17/25 at approximately 5:25 p.m., RN L clarified R97 was not receiving restorative therapy services and acknowledged the orders and tasks should have been discontinued. RN L was made aware R97 believed they were still receiving restorative services and they reported currently receiving restorative therapy about once a week. RN L reported they planned to follow-up and ensure restorative orders and tasks were discharged once a resident's restorative program was completed. RN L confirmed they oversaw the restorative program and typically discharged a resident's restorative orders upon communication from the restorative aides. RN L stated they were uncertain what occurred, with the orders and tasks being in place, and R97 believing they remained in the restorative program. RN L conveyed they understood the concerns and the importance of restorative program oversight for optimal communication with restorative aides and residents. RN L said they had reclarified the documentation expectations with the restorative aides upon learning of the concern and would address concerns with any missed visits. Review of the policy, provided on 12/19/25, revealed, .Restorative Services, revised 1/2025, Purpose: Improving and maintaining the functional skills and physical conditions of the resident through assessment and implementation of restorative services to restore or maintain the resident's highest level of functioning. Procedure: 1. Rehabilitative Services (OT/PT, etc.) will conduct a screening for restorative needs. 2. A referral will be given to nursing with a recommended restorative plan. 3. Nursing will obtain the order from the provider and implement a care plan. 4. Nursing will give notice to the responsible party. 5. Restorative Services initiate restorative plan with the resident. 6. Documentation of residents' progress weekly and as needed. 7. Assessments for change of function will be quarterly or as needed to change, update or discontinue restorative plan. R71 On 12/16/25 at 10:07 AM, R71 was observed sitting in a wheelchair in the Nutrition/Dayroom. R71 was leaning forward, with a rounded back, and her forehead was pressed against the edge of the table. Facility staff was observed placing a bag of large, plastic building blocks on the table in front of R71. R71 was then observed to keep her eyes level with the edge of the table and reach her arms above the level of her head to play with the building blocks. On 12/16/25 at 1:00 PM, R71 was observed sitting in the same spot in the Nutrition/Dayroom, leaning forward in the wheelchair, with her head pressed against the edge of the table. Certified Nursing Assistant [CNA] 'F' was observed to place a tray of food in front of R71, then sit at an adjacent edge of the square table, then proceed to assist R71 with eating by reaching under the corner of the table and up to R71's mouth due to R71's head being pressed against the edge of the table. Review of the clinical record revealed R71 was admitted into the facility on 9/9/25 with diagnoses that included: dementia, peripheral vascular disease and chronic obstructive pulmonary disease. According to the Minimum Data Set (MDS) assessment dated [DATE], R71 had severely impaired cognition. Review of R71's Physical Therapy care plan created 9/10/25, revealed interventions that read in part, .WC [wheelchair] mobility/management. Adaptive/assistive device. On 12/17/25 at 9:07 AM, R71 was observed sitting in the Nutrition/Dayroom leaning forward in her wheelchair with her head against the edge of the table. On 12/17/25 at 10:50 AM, R71 was observed sitting in the same spot, it the same position, when she dropped an empty can of cola on the floor. Licensed Practical Nurse [LPN] 'G' asked R71 if she wanted another cola then proceeded to place a can of cola with a straw in it on the table in front of R71. R71 sat up, her back against the wheelchair back, reached for the can of cola and take a drink from the straw. R71's head was observed in a slight forward position, when sitting upright. After taking a drink from the cola, R71 leaned forward in her chair and placed her head at eye level with the table and reached her arms above the level of her head to play with the building blocks on the table. LPN 'G' was asked about R71 sitting with her head against the table. LPN 'G' explained R71 always sat leaning forward. On 12/17/25 at 11:01 AM, the Therapy Director was interviewed and asked if R71 was currently receiving therapy. The Therapy Director explained she had been evaluated by Physical Therapy [PT] and Occupational Therapy [OT] when she was first admitted into the facility but was not currently receiving therapy. The Therapy Director was asked about R71 sitting leaning forward with her pressed against the table. The Therapy Director explained R71 was not demonstrating that behavior when she had been evaluated previously. The Therapy Director was asked how the Therapy Department would know if there was a change in a residents' posture. The Therapy Director explained she would expect the facility staff to bring it to their attention so they could be re-evaluated, since R71 was not due for their quarterly assessment. Review of R71's Physical Therapy Evaluation dated 9/10/25 read in part, .New Goal: Patient will increase dynamic sitting balance to Good and dynamic standing balance to Fair- in order to reduce the risk for falls, facilitate upright posture and decrease LOB [loss of balance] during functional mobility. Sitting Balance: Static Sitting = Fair+ (accepts minimal resistance); Dynamic Sitting = Fair (minimal weight shifting ipsilateral/front, difficulty crossing midline). On 12/17/25 at 1:08 PM, observation of CNA 'F' assisting R71 with her lunch revealed R71 leaning forward with her head against the table and CNA 'F' providing the food under the corner of the table up to R71's mouth. On 12/17/25 at 1:15 PM, CNA 'F' was interviewed and asked about R71's positioning, of sitting with her head against the table. CNA 'F' explained R71 had always sat like that since she had been admitted . CNA 'F' was asked about assisting R71 with eating while leaning forward. CNA 'F' explained they would try to get R71 to sit up, but she always wanted her head down, so that was the only way to assist her with eating. On 12/18/25 at 9:40 AM, the Director of Nursing [DON] was interviewed and asked about R71's positioning of sitting leaning forward with her head against the table and having to have her arms above the level of her head to play with the building blocks and not being able to see the other people in the room due to always looking down. The DON explained the Therapy Director had informed her they were going to re-evaluate R71 to see if she needed therapy. The DON was asked who usually informed the Therapy Department if a residents' positioning was declining. The DON explained the nurse would make the referral. On 12/18/25 at approximately 10:00 AM, R71 was observed being pushed in her wheelchair from the Nutrition/Dayroom to her room by a staff member. R71 was observed to be leaning forward in the wheelchair while being pushed. On 12/18/25 at 11:02 AM, R71 was observed sleeping in her bed on her right side. R71 back appeared to be mostly straight with her head a little forward. On 12/18/15 at 11:03 AM, LPN 'H' was interviewed and asked about R71 in her room sleeping. LPN 'H' explained R71 had been leaning forward in her chair and looked tired, so she had someone take her back to her room because she did not want R71 to fall forward out of the wheelchair. LPN 'H' was asked how R71 was usually positioned when sitting. LPN 'H' explained she did not remember R71 leaning that far forward, but if she continued to do so, she would notify the Therapy Department. On 12/18/25 at 11:30 AM, Physical Therapist [PT] 'I' was interviewed and asked about R71 positioning. PT 'I' explained he had evaluated R71 and she had a slight kyphotic posture [excessive forward curve of the spine] but considered R71's leaning forward more of an issue with her core strength [strength of a group of muscles that stabilize and control the pelvis and spine] than structural [curvature of the spine]. When asked about R71 sitting in the wheelchair all day with her head on the table, PT 'I' explained R71 should not be sitting for long periods as her core strength would decrease the longer she was sitting. Review of R71's Physical Therapy Evaluation dated 12/18/25 read in part, .New Goal: will demo [demonstrate] F [forward] balance in sitting without extra leaning in WC [wheelchair] to maintain proper posture for feeding. Reason for Referral: . is referred to rehab due to abnormal posture causing extreme leaning in WC and is at high fall risk, pts [patients] ability to stay in WC is also affected by her poor cognitive function and lack of safety. Therapy Suggested high back [wheelchair] with elevated leg rest with 15-30 degree tilt as needed. Also suggested full lap tray to prevent extreme leaning in WC. Will suggest scheduled seating in WC before dining. Sitting Balance: Static Sitting = Fair- (able to maintain with UE [upper extremity] support); Dynamic Sitting = Poor+ (sits unsupported with Min A [minimal assistance] and reach to ipsilateral side, unable to weight shift). It should be noted this evaluation showed a decline in R71's sitting balance.

Based on observation, interview and record review, the facility failed to ensure ongoing assessment and monitoring for weight loss for one (R79) of two residents reviewed for nutrition. Findings include:On 12/17/2025 at 7:40 AM, 10:30 AM, and 1:00 PM, R79 was observed lying in bed, asleep and did not awaken when approached. At each of these observations an intravenous pole was stored next to the bed but did not have any fluids hung and/or being administered.12/17/2025 7:48 AM an interview was conducted with the resident's Nurse 'B'. When asked about R79's clinical status, Nurse 'B' reported the resident was currently declining clinically. When asked what that meant, Nurse 'B' further reported they were not eating or drinking, recently received intravenous fluids, and had skin breakdown.Review of the clinical record revealed R79 was initially admitted into the facility on 1/25/22 with diagnoses that included: localized swelling, mass and lump, right lower limb, osteoarthritis, hematemesis, Alzheimer's disease with late onset, malignant neoplasm of colon, and pressure ulcer/injury to right gluteal fold (in-house acquired onset date of 11/26/25) and coccyx (in-house acquired onset date 10/21/25).According to the Minimum Data Set (MDS) assessment dated [DATE], R79 had severe cognitive impairment, was dependent upon staff for all aspects of care, weighed 130 pounds (lb) with no weight loss or gain, received a mechanically altered/therapeutic diet, and had no pressure ulcers but was at risk for developing them.Further review of the electronic health record (EHR) revealed the following significant weight changes for R79. Documentation included:On 10/15/25, the resident weighed 130.6 lbs. The EHR system also flagged -7.5% change [Comparison Weight 7/17/2025, 142.3 Lbs, -8.2%, -11.7 Lbs].On 11/13/25, the resident weighed 120.7 lbs. The EHR system also flagged -5.0% change [Comparison Weight 10/15/2025, 130.6 Lbs, -7.6%, -9.9 Lbs] -7.5% change [Comparison Weight 9/10/2025, 136.4 Lbs, -11.5%, -15.7 Lbs].On 12/9/25, the resident weighed 107.6 lbs. The EHR system also flagged -5.0 change [Comparison Weight 11/13/2025, 120.7 Lbs, -10.9%, -13.1 Lbs] -7.5% change [Comparison Weight 9/10/2025, 136.4 Lbs, -21.1%, -28.8 Lbs].There were no re-weights documented as completed for any of the above weights as of this review.Review of the care plans included a nutritional care plan initiated on 1/27/22, and most recently revised on 8/18/25 which included an intervention revision on 8/18/25 which included four nutritional supplements. This care plan had not been revised since, to address the identified significant weight loss, or address what other interventions were implemented once these weight fluctuations were identified.Review of the progress notes revealed the most recent dietary note from Registered Dietitian (RD 'C') was from 4/28/25 which identified a significant weight loss at that time. The note further identified, .RD will cont. (continue) to monitor and F/U (Follow-Up) w/ (with) IDT (Interdisciplinary Team).Review of the most recent nutritional assessment was completed on 10/15/25 by RD 'C'. There was no documentation of an RD evaluation and/or monitoring available for review in the EHR since 10/15/25. This assessment documented, in part: .Current Weight 130 .Usual Body Weight 135-145 .Stable .Other: L. (Left ) gluteus PI (Pressure Injury).per skin & wound note on 10/14 .She continues to be confused, unable to answer questions with reliability. Continues with fair-good appetite with documented intakes averaging ~50-75%. Noted wt. (weight) variance x30d. requested rewt. (re-weight) She continues to be well accepting of (four nutritional supplements).MNA (Mini Nutritional Assessment) score-10 indicating at risk for malnutrition. Recommend continue with poc (plan of care); continues with good intake of meals/supplements. Continue to monitor . There was no further follow-up documented by a RD following this assessment, nor were there any documentation included they had been informed of the changes in the resident's oral intake, decline and issues in obtaining re-weights.Review of the interdisciplinary progress notes included:On 12/11/25 at 10:49 PM, a change of condition assessment by Nurse 'A' read: .Situation.Food and/or fluid intake (decreased or unable to eat and/or drink adequate amounts) Functional decline (worsening function and/or mobility) Skin wound or ulcer.Weight.107.6 lb - 12/9/2025.New or Change in Medications IV or subcutaneous fluids.On 12/9/25 at 10:04 PM, an entry by Nurse 'A' read: .1:1 feed. NAS (No Added Salt) mechanical soft diet/thin liquids. poor appetite.On 12/7/25 at 1:50 PM, an entry by Nurse 'B' read:Resident ate less 0-25% of meal in 16 hours? [sic] Resident has decreased appetite, logged in doctor's book.There was no documentation that the RD had provided nutritional monitoring or assessment/implementation since 10/15/25.On 12/17/25 at 9:45 AM, an interview and record review was conducted with RD 'C'. When asked about their process for evaluating and addressing residents' nutritional risks or impairments, RD 'C' reported concerns with communication between the nutrition and nursing department. RD 'C' further reported they tried their best by looking at progress notes, but that wasn't always clear.When asked about whether they were aware of the residents decline as documented in the progress notes by nursing staff, RD 'C' reported they usually go into the MAR (Medication Administration Record) and make sure the resident is receiving their supplements. RD 'C' reported they had not had a concern for R79 as this was documented as received.When asked what the facility's process was for monitoring weights and what should be done when fluctuations were identified, RD 'C' reported they communicated weight variances within five pounds and sent emails to the Director of Nursing (DON) to obtain re-weights. RD 'C' confirmed there had been no re-weights documented as completed for R79 for the weights identified since October. They were unable to explain why there was no follow-up if the nursing staff had been notified and there was continued concerns with not obtaining re-weights.RD 'C' reported the interdisciplinary team had meetings every morning at 11:00 AM to discuss concerns that included weight fluctuations and need for re-weights. When asked if R79 had been discussed, RD 'C' reported they didn't recall R79 being discussed. When asked if this discussion was documented in the residents' EHR, RD 'C' reported that was not. RD 'C' was asked to confirm their last assessment and confirmed it was 10/15/25. When asked about if there was any other follow-up or monitoring by the RD where would that be located, RD 'C' reported that would be documented in the progress notes and confirmed there was none documented since October. When asked who was responsible for updating the nutritional care plans, RD 'C' reported they did that as well and confirmed the resident's care plan had not been updated to reflect the current decline.On 12/17/25 at approximately 10:05 AM, an interview was conducted with the DON. When asked about their process for obtaining re-weights, the DON reported they would have to defer to their policy. The DON was informed of the interview with RD 'C' and informed of the concerns, but did not offer any further clarification as to the lack of coordination of nutritional monitoring including RD involvement and re-weights. According to the facility's policy titled, Weights: Obtaining dated 12/22/24: .Residents with a weekly weight loss/gain of 5 pounds or more will be re-weighed within 24 hours, aor as ordered by physician, nurse practitioner, physician assistant, or dietitian .Nurse will call provider with weight gain of 3 pound in two days or 5 pounds in one week. Nurse will document notification of weight change in nursing progress note .The Registered Dietician and/or Dietetic Technician, Registered will review resident weights weekly .Dietitian will notify nursing of any weights that vary 5% or 5# or more compared to previous month's weight. See also Administrative Policy N102P Nutrition Status Monitoring.According to the facility's policy titled, Nutritional Status Monitoring dated 8/16/24: .The dietitian will monitor residents' weight and nutritional status, identify any unplanned significant weight change, discuss the etiology of weight changes, and develop and document appropriate interventions both nutritionally and interdisciplinary .The Registered Dietitian (RD) will monitor residents at nutritional risk (residents with .pressure wounds, significant weight changes .) .The dietitian will record actions in the dietary progress note in the EHR until the resident is deemed not at risk .Residents discussed weekly include (but are not limited to) the following .Residents with significant changes in appetite/oral intake .Residents with significant weight changes .Weight change of 5% or greater in past 30 days .

This citation pertains to Complaint #2685171. Based on observation, interview, and record review, the facility failed to ensure food was served according to resident preference for one (R122) of one resident reviewed for food, resulting in resident frustration. Findings include:On 12/16/25 at 12:30 PM, during an observation of the lunch meal in the 1 [NAME] dining area, R122 was observed seated at a table with a container of food that was pushed off to the side. R122 reported she was done eating lunch and she did not eat that food because I don't eat pigs. A slice of pork loin was observed in the container. R122 reported the facility kept serving her pork products and she told them she did not eat pigs. R122 reported the staff ordered her chicken tenders after she complained but did not understand why it was not noted to not serve the pork products in the first place. R122 reported that was not the first time and she had been served eggs that had a pork product mixed in before. A review of R122's meal ticket for the lunch meal on 12/16/25 revealed what R122 was served which included Herb roasted pork tenderloin. On 12/17/25 at 2:47 PM, an interview was conducted with Registered Dietician (RD) 'C'. When queried about when a dietary assessment was completed for new admissions and how residents' dietary preferences are communicated to the kitchen, RD 'C' reported she did a dietary assessment within seven days of admission. If a resident expressed a dietary preference prior to that assessment, it was expected that it was communicated to her and the kitchen to ensure the resident received their preferred foods. On 12/17/25 at approximately 3:00 PM, an interview was conducted with the Director of Nursing (DON). The DON reported if a resident expressed a food preference to the nursing staff, it should be communicated to the dietary staff and RD.

This citation pertains to Complaint #2575124.Based on observation, interview, and record review, the facility failed to thoroughly assess and implement timely treatment for a shearing injury for two (R801 and R803) of three residents reviewed for pressure ulcers, resulting in R801 developing an avoidable Stage III (Full-thickness skin loss) pressure ulcer that worsened to an Unstageable (Obscured full-thickness skin and tissue loss) pressure ulcer. Findings include:A review of R801's clinical record revealed R801 was admitted into the facility on 6/13/25 and discharged on 7/18/25 with diagnoses that included: spinal stenosis. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R801 had intact cognition, required substantial/maximal assistance for bed mobility and transfers, was always incontinent of urine and stool, was at risk for developing pressure ulcers, and did not have any unhealed pressure ulcers at the time of the assessment.A review of an admission Assessment dated 6/14/25 (the day after R801 was admitted into the facility) revealed R801's skin was intact. A review of R801's Shower Skin Assessments conducted on 6/21/25, 6/25/25, and 6/28/25 revealed R801 did not have any new skin issues. The next Shower Skin Assessment was dated 7/9/25, 11 days after the previous assessment, and indicated R801 did not have any new skin issues. A review of R801's progress notes revealed the following:A Nurses Note dated 6/27/25 documented, .dry dressing in place.family notified of situation.wound consult in place. There was nothing documented that indicated where the dry dressing was located, what the situation was, or why a wound consult was needed.A Skin/Wound Note dated 6/30/25, three days later, documented, Resident seen for wound consult r/t (related to) wound to coccyx, wound measuring 4.0 x 2.0 cm (centimeters), pink bed, serosanguinous drainage. Area cleared with ns (normal saline), pat dry, Medihoney (wound dressing) and dry dressing applied. Treatment orders in place. A Skin/Wound Note dated 7/2/25 revealed Resident seen for wound consult (on 7/1/25) r/t wound to coccyx, wound measuring 4.0 x 1.0, pink bed, serosanguinous drainage.A review of R801's physician's orders revealed an order dated 6/27/25 for wound consult: opened area to coccyx area. There was no treatment order for the wound until 7/1/25 which was ordered by the contracted wound provider, Physician ‘B'.A review of a Wound/Vascular Consult written by Physician ‘B' on 7/1/25 revealed R801 was seen for an initial consult for a coccyx ulcer. It was documented in the consult that R801 had a Stage 3 coccyx ulcer that measured 4.0 x 1.0 cm, and the wound bed was pink with slough (non-viable yellow, tan, gray, green or brown tissue). The treatment recommendations were for Medihoney to the ulcer every day. Further review of R801's clinical record revealed the next time R801's coccyx ulcer was evaluated by Physician ‘B' was on 7/15/24, 14 days after the last consult mentioned above. There were no other assessments of the wound documented in the clinical record between 7/2/25 and 7/15/25. A review of a Wound/Vascular Consult dated 7/15/25 revealed R801's coccyx ulcer was Unstageable and measured 4.0 x 2.5 cm and necrotic (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like, usually firmly adherent to the base of the wound). A review of an incident report dated 6/26/25, written by Licensed Practical Nurse (LPN) ‘A' revealed, Aid <sic> made Nurse aware of a small skin tear on pts (patient's) butoxy <sic> while she was changing her brief.writer applied barrier cream to area.A review of an Injury of Unknown Origin - Investigation Report signed off by the Director of Nursing (DON) on 7/1/25 revealed a skin tear to the coccyx area was found on R801 on 6/26/25 (it should be noted that there was no documentation of any skin impairment in the clinical record on that date). It was documented that a dry dressing and barrier cream was applied, R801 was to have a wound consultation, offloading as possible, the area kept clean and dry, and barrier cream applied. It was documented R801 was seen for a wound consultation, five days later, on 7/1/25 and the wound was identified as a Stage 3 pressure ulcer. It was documented the pressure ulcer started as shearing (When layers of skin rub against each other or when the skin remains stationary and the underlying tissue moves and stretches and angulates or tears the underlying capillaries and blood vessels causing tissue damage).Further review of R801's clinical record revealed R801 did not have any ordered treatment in place between 6/26/25 when the skin tear was first identified and 7/1/25 when Physician ‘B' assessed the wound to be a Stage 3 pressure ulcer. There was no further assessment of the skin impairment to R801's coccyx after it was identified as a skin tear on 6/26/25 until the Skin/Wound Note documented on 6/30/25 that did not mention any slough as assessed by Physician ‘B' on 7/1/25. No impairment to R801's skin was identified on any Shower Skin Assessments.A review of R801's care plans revealed a care plan created on 6/13/25 that read, I am at risk for skin breakdown. Interventions included: Daily skin inspections by CNA (Certified Nursing Assistant), Notify treatment nurse of any skin abnormalities, and skin barrier after each cleanse. There were no care plans that addressed R801's new skin impairments including shearing and the development of pressure ulcers. R803On 8/14/25 at 11:58 AM, R803 was observed on his back in bed. R803 reported he had wounds, but did not wish to be interviewed further regarding them.A review of R803's clinical record revealed R803 was admitted into the facility on 7/2/25 and readmitted on [DATE] after a hospital stay that began on 7/9/25. R803 had diagnoses that included: spinal stenosis, aneurysm, and sepsis. A review of a MDS assessment dated [DATE] revealed R803 had intact cognition and was dependent on staff for bed mobility and transfers.A review of an admission Assessment dated 7/25/25 (after R803 returned from the hospital) revealed R803 had a skin tear to sacrum. A review of R803's Skin/Wound Notes revealed no assessment of the sacrum/coccyx skin tear until 7/29/25. A review of a Skin Wound Note dated 7/29/25 revealed R803 had a Coccyx ulcer stage II (partial-thickness skin loss) measuring 11.0 x 11.0 cm. It was documented that Medihoney would be applied daily.A review of R803's Physician's Orders revealed an order with a start date of 8/1/25 for Medihoney Wound/Burn Dressing Gel to the coccyx every day shift. The order instructed to cleanse the area with normal saline, apply Medihoney, and cover with dry dressing. It should be noted that a skin tear was identified and documented six days prior to the area being assessed and a treatment implemented.A review of a Skin/Wound Note dated 8/12/25, 14 days after the previous assessment on 7/29/25, revealed the Stage II ulcer to R803's coccyx measured 14.0 x 7.0 cm. A review of R803's Wound/Vascular Consults conducted by Physician ‘B' revealed R803 was seen by Physician ‘B' on 7/29/25 and it was documented R803 had a Stage II pressure ulcer that measured 11 x 11 cm. R803 was seen by Physician ‘B' on 8/12/25 and it was documented the wound measured 14 x 7 cm.On 8/14/25 at 2:38 PM, an interview was conducted with the facility's Wound Care Coordinator, Registered Nurse (RN) ‘C'. When queried about the facility's protocols for monitoring residents' skin for new skin impairments or worsening skin impairments, RN ‘C' reported on admission, the primary nurse conducted a skin assessment and RN ‘C' did a second assessment. Additionally, the nurses assessed resident's skin during showers two times a week. When queried about the protocol when a new skin impairment was identified, RN ‘C' referred to a document titled, Wound Identification and Follow-Up Checklist and explained it was recently implemented after identified concerns with wounds. A review of the document revealed the following, 1. When a wound is initially identified, it is the responsibility of the Nurse first observed the wound to assess the area, location, size, depth, exudate, etc.2. Document the findings in the Nurse's notes, and 24 Hour Report.3. Notify the Physician of the assessment findings, obtain appropriate Treatment orders based on facility treatment protocols.4. Document the notification of the Physician, and any new orders in the Nurses Notes.6. Follow-up with the Physician's Orders.7. Initiate the Treatment order and document.8. Communicate the new area and treatment orders to the Wound Care Nurse.10. The Wound Care Nurse will update the plan of care with the Current stage and location of the wound. RN ‘C' explained that Physician ‘B' came to the facility once a week to evaluate all skin impairments, including pressure ulcers. When queried about R801, RN ‘C' reported she was not the Wound Care Coordinator at that time. When queried about when the new skin tear to R803's coccyx was assessed, RN ‘C' reported it was evaluated by Physician ‘B' on 7/29/25 and at that time it was a Stage II pressure ulcer. When queried about how the wound first presented upon readmission from the hospital on 7/26/25 and if it should have been assessed when it was identified, RN ‘C' reported it should have so that a treatment could be implemented right away. On 8/14/25 at 3:40 PM, an interview was conducted with the Director of Nursing (DON) regarding R801. When queried about the incident report for R801 dated 6/26/25 that indicated R801 had a skin tear to the buttock and when the skin tear was assessed, the DON said it was assessed at the time of the incident report. When queried about where the assessment was documented to include the size and appearance of the wound, the DON reviewed R801's clinical record and confirmed there was no documented assessment prior to the note on 6/30/25 and Physician ‘B's consult on 7/1/25. When queried about any assessment of the wound, which was classified as a Stage 3 pressure ulcer on 7/1/25, between 7/1/25 and 7/15/24 when Physician ‘B' next evaluated R801, the DON reported there was no documented assessment. When queried about the Shower Skin Assessments and how none of them document any impairment to R801's skin, the DON reported they only document new skin impairments. When queried about whether they should identify worsening wounds on the skin assessments, the DON reported that would likely be identified by the treatment nurse, not the person doing the skin assessment. When queried about any physician's orders for treatment to R801's coccyx prior to 7/1/25, the DON reviewed the clinical record and confirmed there was no ordered treatment until 7/1/25. A review of a facility policy titled, Pressure Injury: Assessment, Prevention and Care, dated 4/21/24, revealed, in part, the following: .Skin Assessment.Head to toe visual examination of all skin surfaces and mucous membranes, monitoring temperature, turgor, color, moisture level and skin integrity, paying special attention to all bony prominences. Performed on admission and weekly. Complete documentation of wounds and pressure injuries will be completed by the nurse on a weekly basis. Dressing condition and dressing care must be documented and may include: .Location.Condition of surrounding tissue and wound edges.Tissue base (majority).Exudate(s) type and odor (if present).Vertical length (longest length) - weekly documentation at minimum.Horizontal Width (widest width) - weekly documentation at minimum.Depth (deepest part of wound or injury).Tunneling/Undermining (if present).Wound bed type and color.Pain prior to and after wound care.Condition of dressing must be documented with every skin assessment, including type, intactness, drainage, and surrounding skin.Documentation of pressure injuries will be done at least once a week by the Nursing Supervisor or designee.Plan of Care: the plan of care will be updated with individualized interventions to address identified risk factors and maximize potential to heal any current pressure injuries.

This citation pertains to Complaint #2575124.Based on observation, interview, and record review, the facility failed to effectively monitor residents' skin, identify new skin impairments in a timely manner, thoroughly assess and determine the root cause of new skin impairments, and implement treatment in a timely manner for two (R802 and R803) of three residents reviewed for wounds. Findings include:R802On 8/14/25 at 12:05 PM, R802 was observed lying in bed. R802 had a dressing dated 8/13/25 applied to the top part of her left lower leg. The skin surrounding the dressing was observed with dark, purple discoloration. When queried about what happened to her leg, R802 stated, Nothing exciting. R802 appeared confused with further questioning. On 8/14/25 at 2:06 PM, R802 was observed lying in bed on her back. When queried about when treatment is completed on her leg, R802 reported the wound nurse said she would do it at 2:30 PM. R803 said, Be ready for some screaming! and reported it was painful when the bandage was removed. On 8/14/25 at approximately 2:06 PM, an observation of wound care to R802's left leg was conducted with the Wound Care Coordinator, Registered Nurse (RN) ‘C'. RN ‘C' confirmed with R802 and their assigned nurse that R802 received pain medication one hour prior to wound care. RN ‘C' said R802 screamed out with all care and treatments but was cooperative with having the treatment rendered. RN ‘C' removed the wound dressing. A small open area was observed on the top of R802's left lower leg with dark, purple discoloration surrounding the open area. A review of R802's clinical record revealed R802 was admitted into the facility on 6/2/23 and readmitted on [DATE] with diagnoses that included: dementia and congestive heart failure. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R802 had severely impaired cognition, was dependent on staff for bed mobility and transfers and did not walk. During that assessment, R802 did not have any non-pressure related skin impairments. On 8/14/25 at 1:44 PM, any incident reports for the past three months for R802 were requested. The DON reported R802 did not have any incident reports for the past three months. A review of R802's progress notes revealed on 6/11/25, R802 had a small pinpoint abrasion on left lower leg. A review of Physician's orders revealed an order for treatment was put into place on 6/12/25 and discontinued on 6/26/25 when it was documented the skin impairment was resolved on 6/24/25. Further review of R802's clinical record revealed no assessment of the pinpoint abrasion to R802's left lower leg.A review of R802's Shower Skin Assessments dated 6/30/25, 7/3/25, 7/10/25, 7/14/25, 7/17/25, 7/21/25, 7/24/25, 7/28/25, 7/31/25, 8/4/25, 8/7/25, and 8/11/25 revealed R802 had skin discoloration to the front of her right and left lower leg and no new wounds. A review of a Skin/Wound Note dated 8/1/25 revealed, Upon inspection of skin during treatment for coccyx PI (pressure injury), left lower leg with bruising with 2 open wound areas were discovered. Distal (farthest from the center of the body) wound measuring 1.1 x 1.5 cm (centimeters) and proximal (closest to the center of the body) wound measuring 0.5 x 0.6 cm. Nurse.reported that this has been present for some time, but no wound care orders nor incident report were found. Treatment orders now in place. (It should be noted that it was documented the previous skin impairment to R802's left lower leg was resolved as of 6/24/25).Further review of R802's clinical record revealed no documentation of how R802 sustained open areas with surrounding discoloration to the left lower leg. A review of R802's active Physician's Orders revealed an order with a start date of 8/2/25 for Medihoney to the left lower leg every day shift. On 8/14/25 at 2:38 PM, an interview was conducted with the facility's Wound Care Coordinator, Registered Nurse (RN) ‘C'. When queried about the facility's protocols for monitoring residents' skin for new skin impairments, RN ‘C' reported on admission, the primary nurse conducted a skin assessment and RN ‘C' did a second assessment. Additionally, the nurses assessed resident's skin during showers two times a week. When queried about the protocol when a new skin impairment was identified, RN ‘C' referred to a document titled, Wound Identification and Follow-Up Checklist and explained it was recently implemented after identified concerns with wounds. A review of the document revealed the following, 1. When a wound is initially identified, it is the responsibility of the Nurse first observed the wound to assess the area, location, size, depth, exudate, etc.2. Document the findings in the Nurse's notes, and 24 Hour Report.3. Notify the Physician of the assessment findings, obtain appropriate Treatment orders based on facility treatment protocols.4. Document the notification of the Physician, and any new orders in the Nurses Notes.6. Follow-up with the Physician's Orders.7. Initiate the Treatment order and document.8. Communicate the new area and treatment orders to the Wound Care Nurse.10. The Wound Care Nurse will update the plan of care with the Current stage and location of the wound. RN ‘C' explained that Physician ‘B' came to the facility once a week to evaluate all skin impairments. When queried about R802's skin impairment on the left lower leg and what happened, RN ‘C' reported she did not know what happened. RN ‘C' explained she had only begun working in the facility as the Wound Care Coordinator a short time ago and identified the area when doing skin assessments of all the residents. When queried about whether R802 was evaluated by the contracted wound provider, Physician ‘B', RN ‘C' reported Physician ‘B' saw R802 on 8/12/25, but did not come to the facility the previous week. RN ‘C' reported she did an assessment of R802's wound in Physician ‘B's absence. At that time, a review of a Wound/Vascular Consult dated 8/12/25 revealed Physician ‘B' evaluated R802 and documented she had a Lt (left) leg wound that measured 1.2 cm x 1.3 cm and documented, pink. There was no further description of the wound on R802's leg or the surrounding skin. On 8/14/25 at 3:40 PM, an interview was conducted with the DON regarding wound care in the facility. When queried about what happened to R802's left lower leg, the DON reported she did not know. The DON reported RN ‘C' should have completed an incident report when she first identified the open areas and discoloration on 8/1/25 so that an investigation could have been started. At that time, Physician ‘B's evaluation of R802's left leg was reviewed with the DON. When queried about whether the evaluation was thorough with only measuring the wound and calling it nothing but a wound, the DON stated, It could be more descriptive. R803On 8/14/25 at 11:58 AM, R803 was observed lying in bed on his back. When queried about any wounds, R803 reported he had some, but did not wish to answer questions. A review of R803's clinical record revealed R803 was admitted into the facility on 7/2/25 and readmitted on [DATE] after a hospital stay that began on 7/9/25, with diagnoses that included: spinal stenosis, aneurysm, and sepsis. A review of a MDS assessment dated [DATE] revealed R803 had intact cognition and was dependent for bed mobility and transfers. A review of an admission Assessment dated 7/25/25 revealed R803 had a skin tear to sacrum and discoloration to right anterior arm. A review of R803's Physician's Orders revealed orders that started on 8/5/25 for Medihoney to the left and right posterior (back) lower legs every day shift. A review of a Skin/Wound Note dated 8/5/25 revealed, Resident seen today by wound team for measurements and evaluation of multiple wounds.right posterior leg wound measuring 2.5 x 5.0 cm.left posterior lower leg wound measuring 5 x 1.3 cm with pink base with some yellow slough (non-viable yellow, tan, gray, green or brown tissue).A review of a Shower Skin Assessment dated 8/6/25 revealed the following documentation, right and left lower rear leg. Previous skin assessments and progress notes prior to 8/5/25 did not note any impairment to the right or left posterior legs. On 8/14/25 at approximately 2:30 PM, an observation of R803's posterior lower leg wounds were conducted with RN ‘C'. A small open area, pink in color was observed on the right lower leg and a small open area that appeared slightly deeper with a darker center was observed on the back of R803's left lower leg. On 8/14/25 at 2:38 PM, an interview was conducted with RN ‘C'. When queried about what type of wounds were on the backs of R803's bilateral lower legs and how he developed wounds there, RN ‘C' reported she did not know. RN ‘C' identified the wounds when doing skin assessments of all the residents. RN ‘C' said she was not sure if they were pressure ulcers or if maybe R803 injured them in the wheelchair. RN ‘C' further reported R803 was evaluated by Physician ‘B' on 8/12/25 and provided the consultation. At that time, a review of a Wound/Vascular Consult done by Physician ‘B' on 8/12/25 revealed documentation that R803 had a Rt (right) leg wound that measured 2.3 cm x 0.3 cm and a Lt leg wound that measured 2.3 cm x 1.5 cm. There was no further description of the wounds included in the assessment.On 8/14/25 at 3:40 PM, an interview was conducted with the DON. When queried about what happened to the backs of R803's lower legs, the DON did not offer a response. When queried about who determined the type of wounds, the DON reported Physician ‘B'. At that time, Physician ‘B's wound consultation for R803 was reviewed with the DON who said it should be more descriptive. When queried about how further breakdown could be prevented if they were not aware of how R803 got the wounds, the DON reported the facility had problems with wounds and they recently hired RN ‘C' to be the Wound Care Coordinator, as they did not previously have one. A policy regarding Skin Management of Non-Pressure Wounds was requested. However, only a policy regarding Pressure Ulcers was provided.

This citation pertains to Intakes: MI00151714, MI00150739 Based on observation and interview, the facility failed to maintain a safe, clean and comfortable environment, resulting in the potential to affect the entire resident population. Findings include: The State Agency received a complaint of an allegation the facility failed to maintain a comfortable clean, homelike environment On 4/2/25 at 8:42 AM, The Second-floor hallway was observed with scattered white colored straw wrappers, crumbs, and debris. The floors in rooms 255, 252, 253, and 250 were observed with straw wrappers, moderate amounts of debris, and scattered crumbs of food. Dried red food matter was noted on the wall in front of room [ROOM NUMBER]. Partition curtains in rooms [ROOM NUMBER] were all observed soiled and unkempt. On 4/2/25 at 9:25 AM, A cabinet in the residential dining room of Dayroom [ROOM NUMBER] was observed with a white clear bag containing red colored clothing and a red purse. RN A opened the bag which contained a red [NAME] Lemon Jacket and a red colored MCM purse. Certified Nurse Assistant (CNA) C walked over and claimed it was their belongings and was observed removing them off the unit. RN A confirmed staff should not be storing personal items amongst residential common areas. On 4/2/25 at 9:30 AM, The third-floor dining room was observed with three moderate sized circled patterned, dried food spillages on the carpet area adjacent to dining tables. The carpet was observed heavily soiled near medication cart in front of room R354. The entrance to room [ROOM NUMBER], had hardwood flooring observed with scattered debris, food crumbs, and straw wrappers. room [ROOM NUMBER], was observed with wrappers from plastic utensils and moderate amount of food crumbs noted on the floor. The common hallway carpeting in front of room [ROOM NUMBER] was observed soiled with a large spill of liquid and brown liquid dripping on the wall was observed. The common hallway carpeting in front of room [ROOM NUMBER] was observed with old food matter and appeared to be run over by a wheel. On 4/2/25 at 12:53 PM, an interview and tour of the facility was conducted with Environmental Services Supervisor (ESS) D who was shown the flooring, walls, and curtains in rooms. ESS D acknowledged the areas of dried food on the carpet and dried spillage of food on the walls should have been identified and spot cleaned. The resident rooms were just vacuumed at the time of the tour with ESS D, who was informed based on earlier observations, the carpet in the residents' rooms and hallway appeared cluutered with various debris and not vacuumed for some time. The partition curtains in rooms [ROOM NUMBER], were also shown to ESS D who acknowledged they were soiled and should have been cleaned and/or replaced. The facility policy for environment and housekeeping was requested and was not available by time of exit.

Based on observation and interview, the facility failed to ensure resident food items brought in from the outside were labeled and dated resulting in the potential of foodborne illness and had the potential to affect all residents who store and consume food from the 2107 Dayroom community residential refrigerator. Findings include: On 4/2/25 at 9:10 AM, The refrigerator in Dayroom [ROOM NUMBER] was opened and the following items were observed no resident identifier or dates: A brown paper bag from (fast food restaurant), a black three compartment container with a clear lid containing cornbread, and a small clear container containing what appeared to be a white dressing located in the door section. The left bottom crisper revealed a white Styrofoam cup/lid containing a brown colored liquid. The freezer was observed storing a container of vanilla ice cream and a Styrofoam cup/lid with an unidentified frozen substance. Review of the facility policy titled Food Brought in by Others for Residents dated 3/2018 documented. .Any food brought in for residents should be identified to the charge nurse .a label to mark the food item with the resident's name and the date it was brought into the facility . On 4/2/25 at 9:15 AM, Unit Manger Registered Nurse (RN) B was shown the observations and acknowledged the items should have been labeled with residential identifiers and dates.

This citation pertains to Intake Number(s): MI00151450. Based on interview and record review, the facility failed to conduct accurate and thorough sepsis screening for one (R902) of one resident reviewed for a change in condition. Findings include: A review of R902's clinical record revealed admission to the facility on [DATE] and R902 was discharged to the hospital on 3/10/25. Diagnoses included: metastatic cancer (prostate and bone), chronic obstructive pulmonary disease (COPD), and chronic respiratory failure. A review of R902's Minimum Data Set (MDS) assessment dated [DATE] revealed R902 had moderately impaired cognition. A review of the Progress Notes for R902 revealed they tested positive for influenza A on 3/1/25. A review of the Physician's Orders revealed R902 was placed on droplet precautions (isolation precautions used to prevent the spread of respiratory illnesses transmitted via droplets) from 3/5/25 through 3/12/25. The physician's orders indicated R902 was prescribed Tamiflu (an antiviral medication) from 2/26/25 through 3/8/25. On 4/2/25 at approximately 1:00 PM, an interview was conducted with the facility's Infection Control Preventionist, Registered Nurse (RN) F. When queried about how the facility monitored residents for sepsis, RN 'F' explained residents were screened for seven days on admission and when a resident had an infection that was treated with an antibiotic or antiviral medication, they were screened for sepsis throughout the duration of the illness (end of antibiotic/antiviral and end of isolation precautions). RN 'F' reported residents were monitored for sepsis by completing the Severe Sepsis Screening Tool assessment which nurses were required to complete according to the instructions on the form. A review of the Severe Sepsis Screening Tool assessments for R902 from 3/1/25 through 3/8/25 (onset of influenza A though the end of isolation precautions/antiviral treatment) revealed the following: On 3/1/25 and 3/2/25, yes was documented in the sections that indicated whether or not the resident had a suspected or documented infection and antibiotic therapy, which according to the instructions on the form, the next section should have been completed to determine if there was evidence of SIRS - Systemic Inflammatory Response Syndrome developing, and based on those answers if there was Organ Dysfunction. Other than indicating R902 had an infection and was on an antibiotic, the rest of the form was left blank. On 3/3/25, it was documented R902 had a suspected or documented infection, and no was documented in the section that indicated whether the resident received antibiotic therapy (or antiviral therapy according to RN 'F'). The rest of the form was left blank and no further assessment was documented. On 3/4/25, 3/5/25, 3/6/25, 3/7/25, and 3/8/25, it was documented R902 did not have a suspected or documented infection and was not on antibiotic therapy. A review of the Infection Control surveillance information provided by the facility, revealed R902 was considered to have an active influenza infection as evidenced by a positive test, was receiving antiviral therapy, and was on isolation precautions. On 4/2/25 at 2:33 PM, an interview was conducted with the Director of Nursing (DON). The above record review was discussed and the DON did not offer a response. A review of a facility policy titled, Sepsis, dated 10/15/24, revealed, in part, the following, .All newly admitted , readmitted and with an infection must be monitored for signs/symptoms of sepsis .Monitoring period .Infections - length of antibiotic therapy .The nurse must .Complete a Severe Sepsis Screening Tool .Using the current shift complete vital signs .and renal output .

This citation pertains to Intake Number(s): MI00151450. Based on interview and record review, the facility failed to appropriately monitor the respiratory status of one (R902) of one resident reviewed for a change in condition. Findings include: A review of the clinical record revealed R902 was admitted into the facility on [DATE] and discharged to the hospital on 3/10/25. Diagnoses included: influenza A, chronic obstructive pulmonary disease (COPD), metastatic cancer of the prostate spread to the bone, obstructive sleep apnea, and chronic respiratory failure. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R902 had moderately impaired cognition and did not require oxygen therapy on admission. A review of the Progress Notes revealed R902 tested positive for influenza A on 3/1/25. A review of the results of a chest X-ray for R902, completed on 3/5/25 revealed, Mild prominent bilateral hilar (wedge shaped middle portion of lungs) markings (may indicate inflammation or congestion). A review of R902's Physician's Orders revealed an order dated 3/5/25 for Oxygen at 2 L (liters) PRN (as needed) for SOB (shortness of breath). A review of R902's Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no order for the PRN oxygen and no place to document when the oxygen was administered. Further review of R902's progress notes from 3/5/25 through 3/10/25 revealed the following documentation: On 3/10/25 at 9:58 AM it was noted R902's oxygen saturation was 94 percent on two liters of oxygen via nasal cannula. There was no documentation noting what R902's oxygen saturation was prior to administering the oxygen. On 3/10/25 at 7:33 PM, it was noted R902 had labored breathing with wheezing and rales (fine high pitched crackling lung sounds). At that time it was documented R902's oxygen saturation was 91 percent on oxygen. There were no other progress notes that indicated R902 required PRN oxygen. A review of a change in condition progress note dated 3/10/25 at 5:55 AM noted R902's oxygen saturation was 95% with oxygen via nasal cannula on 3/10/25 at 6:02 AM. There were no notes documenting R902's oxygen saturation prior to applying the oxygen. A review of R902's O2 (oxygen) sats (saturation) Summary from 3/5/25 through 3/10/25 revealed R902's O2 sats were taken while receiving oxygen via Nasal Cannula) on the following dates and times: 3/6/25 at 6:30 AM 3/7/25 at 12:39 AM, 2:22 AM, and 10:12 AM 3/8/25 at 9:56 AM and 6:34 PM 3/9/25 at 6:14 AM, 10:09 AM, and 5:23 PM 3/10/25 at 6:02 AM, 7:23 AM, 9:30 AM, 7:17 PM, and 9:20 PM. At 9:20 PM, R902's O2 sats were 85% while on oxygen therapy. There was no documentation of R902's oxygen saturation levels prior to the administration of oxygen. On 4/2/25 at 2:33 PM, an interview was conducted with the Director of Nursing (DON). When queried about where PRN oxygen administration was documented, the DON reported either on the MAR/TAR or in a progress note. The DON reported if PRN oxygen was required, the nurse should document what the oxygen level was prior to administration. R902's clinical record was reviewed with the DON who then reported she would look into it to see if R902's oxygen levels were documented somewhere else. On 4/2/25 at 4:01 PM, during a follow-up interview, the DON reported she was unable to find any further information or documentation regarding R902's oxygen monitoring. A policy regarding respiratory therapy was requested. However, it was reported the facility did not have a policy regarding monitoring resident's respiratory status for PRN oxygen.

Based on observation, interview, and record review, the facility failed to maintain the kitchen in a sanitary manner, and failed to ensure potentially hazardous food items were properly cooled. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 10/28/24 between 8:45 AM-9:30 AM, during an initial tour of the kitchen with Director of Dining Services BB, the following items were observed: The handwashing sink located near the entry door to the kitchen, was observed with several gnats flying about. The trash can for the hand sink was observed with no liner, and when the lid was opened, numerous gnats flew out of the can. There were gnats observed in various other areas of the kitchen as well. According to the 2017 FDA Food Code section 6-501.111 Controlling Pests, The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: .4. (D) Eliminating harborage conditions. According to the 2017 FDA Food Code section 5-402.13, (B) Soiled receptacles and waste handling units for REFUSE, recyclables, and returnables shall be cleaned at a frequency necessary to prevent them from developing a buildup of soil or becoming attractants for insects and rodents. In the walk-in cooler, there was milk pooled on the floor underneath the milk crates, an opened cooked ham with a use-by date of 10/24, an undated sliced onion, a tub of ricotta with a use-by date of 10/25, and raw turkey stored on a rack over top of raw beef. Director of Dining Services BB confirmed the turkey should not have been stored above the beef. According to the 2017 FDA Food Code section 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation, (A) Food shall be protected from cross contamination by: .(2) Except when combined as ingredients, separating types of raw animal foods from each other such as beef, fish, lamb, pork, and poultry during storage, preparation, holding, and display by: .(b) Arranging each type of food in equipment so that cross contamination of one type with another is prevented,. According to the 2017 FDA Food Code section 3-501.17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days. Refrigerated, ready-to- eat, potentially hazardous food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. In the walk-in cooler, there were 2 pans of cooked pork butt covered tightly with foil. The pans were dated 10/27-11/1. Director of Dining Services BB confirmed the pork had been cooked on 10/27 and then placed in the walk-in cooler. When queried if cooling logs were utilized, Director of Dining Services BB stated they did use cooling logs. Review of the cooling log revealed an entry on 10/27 that noted: 10/27 Pork 7:00 PM. There were no temperatures recorded on the cooling log for the pork. The internal temperature of the pork was measured to be between 50-53 degrees Fahrenheit. According to the 2017 FDA Food Code section 3-501.14 Cooling, 1. (A) Cooked POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) shall be cooled: 1. (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); P and 2. (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. According to the 2017 FDA Food Code section 3-501.15 Cooling Methods, (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: (1) Placing the FOOD in shallow pans; (2) Separating the FOOD into smaller or thinner portions; (3) Using rapid cooling EQUIPMENT; (4) Stirring the FOOD in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. (B) When placed in cooling or cold holding EQUIPMENT, FOOD containers in which FOOD is being cooled shall be: (1) Arranged in the EQUIPMENT to provide maximum heat transfer through the container walls; and (2) Loosely covered, or uncovered if protected from overhead contamination as specified under Subparagraph 3-305.11(A)(2), during the cooling period to facilitate heat transfer from the surface of the FOOD. The dish machine was observed with a heavy buildup of limescale on the exterior. The interior components of the dish machine were observed with limescale buildup. The digital display noted De-lime recommended. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, .(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. The ice machine was observed with an accumulation of dust on the side vents. The underside of the door to the ice machine was observed with black stains. According to the FDA Food Code section 4-602.11 Equipment Food-Contact Surfaces and Utensils, (E) Except when dry cleaning methods are used as specified under S 4-603.11, surfaces of utensils and equipment contacting food that is not potentially hazardous (time/temperature control for safety food) shall be cleaned: .(4) In equipment such as ice bins .: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold. In the dry storage room, the flooring underneath the racks was observed with cobwebs, food debris, and a leaking can of soda. The flooring underneath the ice machine was observed with debris, a juice cup and an ice cream cup. The floor drain located in front of the ice machine was observed with a heavy accumulation of food debris and grease buildup. Director of Dining Services BB confirmed the floor drain was in need of cleaning. According to the 2017 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions, (A) Physical facilities shall be cleaned as often as necessary to keep them clean. On a lower shelf of the steam table, there was a bin of thickener, with large amounts of the white powder scattered on the shelf. There was a soiled toaster next to the bin of thickener, and a heavy buildup of crumbs mixed with standing water on the shelf surface. According to the 2017 FDA Food Code section 4-602.13 Nonfood-Contact Surface, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.

Based on interview and record review, the facility failed to employ a qualified Social Worker on a full time basis to meet psychosocial, mental and behavioral heath care needs of residents resulting in the potential for unmet needs. Findings include: During the recertification survey conducted from 10/28/24 - 10/30/24, multiple concerns were identified in regard to the facility's social work practices, including mood/behavior management, psychotropic medication, psychosocial assessments, and processes for completion of advance directives and coordination of decision-makers. On 10/29/24 at 8:00 AM, during an interview with the Director of Nursing (DON), when asked if Staff 'D' was the only Social Worker, the DON reported they were. On 10/29/24 at 8:38 AM, an interview was conducted with Staff 'D'. They reported they had worked in their role as a Social Worker since the end of January 2024, but had been with the company since 2023. When asked if there were any other Social Workers Staff 'D' reported they were by themselves. When asked if they were licensed as a Social Worker Staff 'D' reported they were not licensed at this time. When asked when they were last licensed, they reported It's been since 2019. On 10/29/24 at 9:00 AM, the Administrator was requested via email to provide the names, dates of employment, and credentials/license verifications for the Social Workers that were employed since their last recertification survey (12/5/23). On 10/29/24 at 2:16 PM, an interview was conducted with the Administrator. When asked if they were aware Staff 'D' was not a licensed social worker, but was hired for the title of Social Worker, the Administrator reported they had checked with other facilities and their corporate team since a concern with social work qualifications were previously cited in 2022 and was told they didn't need to be licensed. The Administrator confirmed the facility was licensed for 179 beds. The Administrator further reported although they were Staff 'D's manager, the DON provided the oversight for clinical needs. The Administrator confirmed the last licensed Social Worker was on 7/5/24. Since then, Staff 'D' had been working by themselves. On 10/30/24 at 2:00 PM, the Administrator was informed of the concerns identified throughout the survey of the facility's social work practices, and concerns regarding the facility's hiring of a non-licensed staff specifically for the role of a Social Worker. The Administrator expressed difficulty with filling the role of social worker but acknowledged they understood the concern identified as well.

Based on interviews and record review the facility failed to ensure that safe transfer techniques were implemented based on the physician order and assessment for one (R907) resident of one reviewed for accidents, resulting in a fall, with right intertrochanteric/femoral neck (hip) fracture, right maxillary sinus orbital floor (facial bone) fracture, and right nasal bone fracture which required a transfer to hospital and surgical intervention and pain. Findings include: R907 was a long-term care resident of the facility. R907's diagnoses included dementia, anxiety disorder, muscle weakness, spinal cord injury (C5 level), and cervical disc disorder with myelopathy (compression of the spinal cord at the cervical level that can cause weakness/numbness in hands and arms, loss of balance and coordination etc.). R907 had a Brief Interview for Mental Status (BIMS) score of 12/15, indicative of moderate cognitive impairment based on the Minimum Data Set (MDS) assessments dated 7/21/23 and 4/21/23. Based on the 7/21/23 MDS assessment, R907 needed extensive staff assistance with their mobility and Activities of Daily Living (ADL). Review of the MDS assessment also revealed that R907 needed extensive assistance of 2 staff members with their transfers (moving between surfaces including to and from bed, chair, or wheelchair) due to their diagnoses, comorbidities, and functional limitations. A review of the investigative overview on a facility reported incident on R907 read in part, on August 12, 2023, while participating care, (R907 name omitted) was sitting fine on the edge of the bed following a sit to stand transfer. (R907 name omitted) unexpectedly reached down to catch slipping pant and fell off the side of (R907 gender omitted) . (R907 name omitted)'s agency (contract) nursing assistant (staff member H name omitted) was present and moving the sit to stand transfer equipment out of the way .The unexpected movement, leaning down caused (R907 name omitted) to fall forward and to the side of bed. The investigation report included an interview statement from the agency (contract) staff member H, that read, While putting the resident to bed, she fell off the side of the bed. Resident was sitting upright on the bed and tilted falling on the floor, hitting dresser on the way down. There was an attempt to catch resident from completely falling but wasn't successful. The investigation report had a statement from the supervisor, staff member I. The statement from staff member I read in part, . I was sitting on the side of the bed and my pants started to slip down. I reached down to my leg and tumbled off of the bed . There was no indication on the investigation report if there was a second staff member assisting staff member H with the transfer of R907 using the mechanical sit to stand lift. The report did not reveal any further investigation on why a second staff member was not assisting with the mechanical lift transfer as ordered by the physician. The conclusion of the report read in part, The incident was caused by an unexpected movement of (R907 name omitted) while participating in (R907 gender omitted) care. Review of R907's Electronic Medical Record (EMR) revealed a Physician order dated 4/27/23 that read, Transfer status: Mechanical sit to stand lift transfer with 2 person. As noted above, the MDS assessment dated [DATE] indicated that R907 needed extensive assistance from 2 staff members to assist with their transfers. A review of Kardex (electronic communication of resident specific plan of care) for Certified Nursing Assistant (CNA) to care for the residents revealed the transfer task dated 4/27/23 that read ADL: Transfer Status: Mechanical sit to stand lift transfer with 2 person assist. Further review of R907's transfer task history revealed the following: ADL-Transfer status: Mechanical sit to stand lift transfer with 2 person assist effective as of 4/27/23, recommended after PT evaluation on 4/27/23. Prior to this, there was a recommendation to use mechanical total body lift (Hoyer) with 2 person assist on 4/27/23, due to recent decline in R907's status and difficulty to use mechanical sit to stand lift for transfers. R907 was referred for physical therapy evaluation to assess if R907 was able to safely use mechanical sit to stand lift for transfers. Functional assessment summary on Physical Therapy evaluation dated 4/27/23 revealed that R907 needed total assistance from the staff with their transfers to use sit to stand lift. On 4/27/23, based on the physical therapy evaluation a physician order was obtained to have two staff members assist R907 with transfers using sit to stand lift safely. Further review of R907's EMR revealed that staff were inconsistent in following the physician orders and recommendations for safe transfers with assistance from two staff members to use the mechanical sit to stand lift. A progress note dated 6/17/23 at 14:23, read in part, ., transfer by sit to stand, one person. resident is assisted with toileting per request. A progress note dated 6/4/23 at 18:45 read in part, .Resident is transfer by sit-stand, one person assist. Resident is assist with toileting q (every) 2 hour or request . A progress note dated 5/10/23 at 12:49, read in part, .transfer by sit to stand, one person. Resident is assisted with toileting per request . A progress noted dated 4/2/23 at 17:58 revealed that R907 sustained a skin tear and the note read, .CNA (staff member name omitted) stated she was lifting the resident up on the sit to stand when the resident moved her hand out from the holding position and that's when the skin tear happen. Writer also asked resident what happen, she stated she hurt her hand on the sit to stand. Writer cleaned the area with normal saline, applied TAO (Triple Antibiotic Ointment), and two steri strips. Review of R907's care plan for transfers read assist with transfers. Sit to stand for transfers (encore lift) with no other specifics on staff assistance, date of intervention was initiated, review date etc. An interview with Rehab Manager (staff member G) was completed on 8/24/23 at approximately 1:15 PM. Staff member G reported that they had been at the facility for approximately 2 years, and they were familiar with R907. Staff member G had completed the physical therapy (PT) evaluation on 4/27/23. Staff member G was queried on the physical therapy referral for R907 in April 2023 and their recommendations after assessment. Staff member G reported that R907 was referred to PT as they had difficulty using the sit to stand lift. R907 was assessed and recommendations were made to sit to stand lift with assistance from two staff members to perform the transfers safely. Staff member G confirmed that the physician orders were obtained for level of staff assistance needed to safely assist residents with transfers after evaluation and it reflected on the Kardex. Staff member G reported that the sit to stand lift assisted R907 to maintain their level of continence. An interview with Staff member F was completed on 8/24/23 at approximately 1 PM. Staff member Freported that they were seasonal staff and assisted as needed. Staff member F reported that they were assisting as supervisor for the unit on the day of interview. Staff member F was queried on the facility protocol to use the sit to stand lift and reported that staff members used the appropriate straps for the lift and assisted the resident. Staff member F reported that facility staff members were using the level of staff assistance (one or two person for sit to stand mechanical lift) as indicated on the resident's plan and order to perform the transfer. Staff member F was queried specifically on R907's order and plan of care with their transfers. Staff member F reviewed R907's EMR and confirmed that R907 needed two-person assistance for transfers with the sit to stand lift. On 8/24/23 at approximately 2:15 PM, an interview with agency staff (staff member H) was completed. Staff member H confirmed that they were assigned to care for R907 on 8/12/23 and they were assisting the resident with the transfer. Staff member H reported that it was their first day working at the facility. Staff member H was queried how they had obtained the information they needed to care for their residents. Staff member H reported by observation and verbal report from the facility staff. Staff member H was queried specifically if they had reviewed the Kardex prior to providing care for the residents, staff member H reported they were going by the verbal report they were provided by the staff. Staff member H reported that they received a verbal report that R907 used a sit to stand lift but did not receive a report that R907 needed two staff members to assist with transfers with the lift. Staff member H also reported that they did not review the Kardex. Staff member H confirmed that there was not a second staff member assisting them with the transfer when the incident happened. Staff member H also reported that they assisted R907 without assistance from a second staff member, prior to the incident on the same shift from wheelchair to toilet and back to wheelchair. Staff member H reported that they thought R907 would be able to transfer without the second person assistance based on the previous transfers and reported that they moved R907 from wheelchair to bed and they were moving the lift away so they could assist in moving R907's legs to bed. During this time R907 reached over and fell . On 8/24/23 at approximately 3:45 PM, an interview with afternoon supervisor, staff member I was completed. Staff member I confirmed that they were present on the day of fall incident for R907. Staff member I was queried on how they had completed the facility orientation for the agency staff. Staff member I shared the agency staff orientation check list and packet. Staff member I reported that packets were sent ahead of time at times and the rest of the time agency staff were reviewing prior to shift and completing the packet. Staff member I was queried on who was responsible for the reviewing and completing the facility orientation packet with the agency staff and they reported that it was completed either by the supervisor or the nurse on duty, whoever was available. Staff member I was queried R907's incident on 8/12/23. Staff member I reported that R907 was on 2 North unit. The unit was typically staffed with 2 CNA's and a nurse, and the 2 South unit was staffed with 3 CNAs and 1 nurse. Staff member I reported that the unit had enough staff members available to assist, but staff member H did not ask for any assistance with R907's transfer. Staff member I reviewed the EMR and confirmed that R907 needed the second staff member to assist with the sit to stand lift transfer. Staff member I added that having the assistance from the second staff member would have prevented the incident. Staff member H did ask for assistance and followed the order. An interview with Director of Nursing (DON) was completed on 8/24/23 at approximately 4:15 PM. DON was queried on how the information was shared with the CNAs on how to care for their residents. DON reported that outgoing staff rounded with their oncoming staff to share information and resident specific care information was available on Kardex. DON was queried on facility's orientation process for the agency staff. DON reported that the agency staff were expected to arrive an hour prior to their shift time to complete a facility orientation. Supervisors or charge nurses were assisting with the orientation process. The DON was queried on R907's fall incident on 8/12/23 and the recommendations for assistance from two staff members and why that was not followed. DON reported that they would question the accuracy of Kardex and R907 needed assistance from two staff members for toileting. DON was queried on physical therapy evaluation due to difficulty in using the sit to stand lift, recommendations, and the physician order for assistance from two staff members. The DON was also notified of the interview from the staff member H who reported of assistance R907 to toilet without any assistance from a second staff member. No further explanation was provided prior to the exit. A facility provided document titled Back Injury Prevention Program dated, 11/29/18, read in part, Residents will be transferred in a safe and appropriate manner. Policy Implementation: 1. The Education and Training Coordinator will be responsible for the overall training, scheduling, of new employees and continuing education in the safe operation of all mechanical lifting devices. 2. The Manager, Rehabilitation Services will be responsible for completing the initial Lift Assessment for Patients to determine which is the most appropriate lift to be used for the resident. The Manager, Rehabilitation Services will inform the Nurse Manager of their recommendation of which lift is to be used. The Nurse Manager will ensure: the placement of a color-coded sticker to the name plate at the doorway entrance to the resident's room, and update the residents care card, care plan lift precautions and recommendations. 3. The Nurse Manager of the respective floor is responsible for keeping the mandatory lift information up to date. The Manager, Rehabilitation Services and/or Nurse Manager will decide adding or removing a resident from the mandatory status. Valuable assessment input will be necessary from CNAs, licensed professionals, nursing supervisor, physical and occupational therapists. The Manager, Rehabilitation Services and/or therapist will be responsible for contacting the Sub-acute Nurse Manager of any changes or updates of residents on rehab caseload. The Chronic and Dementia Nurse Managers quarterly will review the status of the long-term residents and appropriateness of the assigned lift .

This citation pertains to intake #MI00131354. Based on interview and record review, the facility failed to ensure the placement of a transdermal medication patch for blood pressure control for one resident (R272), of one resident reviewed for appropriate use of transdermal patches, resulting in elevated blood pressure and transfer to the hospital for treatment. Findings include: A request was made for a policy regarding transdermal patches, however; the provided policy was specifically written for the use of Fentanyl (narcotic pain medication) patches. The policy provided, did read, .18. If patch becomes dislodged notify physician date patch was placed on resident for further instructions for replacing On 11/28/22 at 3:21 PM, an interview was conducted with the complainant and they explained R272 experienced a change of condition with decreased level of consciousness, low grade fever, and elevated blood pressure. They further explained they requested the resident be transferred to the emergency room and when R272 was assessed in the emergency room they were found without their catapress (blood pressure medication) transdermal patch. On 11/29/22 at 3:03 PM, a review of R272's closed clinical record revealed they admitted to the facility on [DATE], discharged to the emergency roiagnom on [DATE], returned to the facility on [DATE], discharged again to the emergency roiagnom on [DATE] and did not return back to the facility. R272's diagnoses included: Hypertensive urgency (added 7/20/22), high blood pressure, heart disease, stroke, diabetes, and dementia. A review of R272's progress notes was conducted and revealed a note dated 7/10/22 that read, .writer went to administer medication .blood sugar was 60 (normal is 60-100), BP (blood pressure) 146/10 <sic> (the blood pressure documented in the vitals tab around the time of the note was 146/101) T (temperature) 99.7 .attempted to administer medication and resident was lethargic, unresponsive to name and unable to take medication .contacted daughter @ 1200 (12 PM) to inform her of resident change in condition, family requested that resident be transferred to hospital .EMS (Emergency Medical Services) received resident @ 1246 (12:46 PM) . A review of R272's blood pressures documented in the record on 7/10/22 was conducted and included the following values: 217/65, 203/61, 146/101, and 203/61 (normal blood pressure readings are less than 120/80). Continued review of R272's clinical record included a review of the physician's orders and medication administration record. It was discovered R272 had an order for catapress 0.2 mg blood pressure patch to be applied to the skin one time per week. The MAR documented R272 had the patch placed on 7/7/22, prior to their discharge to the hospital on 7/10/22. It was noted there was no documentation on the MAR or in the progress notes that indicated nurses had been routinely checking for the placement of the patch. A review of R272's hospital records from their admission to the emergency roiagnom on [DATE] was conducted and read, .Chief Complaint, AMS (altered mental status), hypertension (high blood pressure) .ED Course Vitals: 230/107 .T (temperature) 99 .Patient started on nitro drip for hypertension .PLAN Hypertensive emergency .on arrival BP is 230/107 .Clonidine (catapress) patch applied Patient with decreased mental status, likely encephalopathy (altered brain function) from uncontrolled hypertension. Will start nitroglycerin drip and reinitiate medications for hypertensive emergency. Patient normally on Catapres patch but was not wearing it upon presentation . On 11/30/22 at 10:15 AM, an interview was conducted with the facility's DON (Director of Nursing) regarding routine checking of placement of transdermal patches. The DON said they didn't believe every resident had an order to check for the placement of patches, but would be adding it to the MAR to check every shift.

Based on observation, interview, and record review the facility failed to ensure appropriate catheter anchor devices were used for two residents (R14 and R55) of two residents reviewed for urinary catheters resulting in both R14 and R55 sustaining penial tears. Findings include: Resident #55 On 8/10/21 the medical record for R55 was reviewed and revealed the following: R55 was initially admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R55's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/23/20 revealed R55 was dependent on facility staff for most of their activities of daily living. A review of section H indicated R55 had an indwelling catheter. A nursing note dated 10/6/2020 at 7:57 a.m., revealed the following: CNA (Certified Nursing Assistant) reported to writer that resident's Foley catheter was leaking. upon assessment, the catheter bag had no urine and resident's brief was wet. while removing catheter, writer observed a tear on resident's penis from the meatus approximately 1/2 inch long on shaft. writer cleansed area and reinserted 14 Fr (French) catheter using sterile technique. stabilization device used to hold catheter to resident's leg. pain medication giving at this time . An incident/Accident investigation dated 10/6/2020 pertaining to R55's penile split revealed the following: Date Injury Discovered-10/6/20 .Time-7:30 AM .Description of Injury-Skin tear on penis Immediate Protective and Corrective Actions:-Area cleaned, catheter stabilizer applied to hold catheter in place and prevent pulling .preliminary Investigation (Findings)-Catheter tubing was hanging .Follow up-Stabilizer in place Conclusions and Recommendations: Resident will have tube secure to prevent pulling . A Skin/Wound Note dated 10/6/2020 at 2:51 p.m., revealed the following: In for daily wound care .Asked by staff to evaluate residents penis. Split noted to penis with scant amount of serosanguinous drainage noted, no odor, urine noted to be coming from around foley catheter. Unit manager in room and observed area and floor nurse aware. Area cleansed and TAO (Triple Antibiotic Ointment) applied as ordered. Foley Leg Anchor in place and adjusted . A Skin/Wound Note dated 10/7/2020 at 3:23 p.m., revealed the following: Resident seen by wound care provider for evaluation, measurement and daily treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Penile-Split with scant serosanguinous drainage. Treatment plan recommendation is to D/C (discontinue) foley cath (catheter) and apply [MEDICATION(S)] gel to penile split Daily and PRN (as needed) .Foley D/C'd by floor nurse. On 8/12/21 at approximately 9:30 a.m., during a conversation with the Director of Nursing (DON), the DON was queried regarding the securement of R55's catheter and why R55 did not have a securement device to prevent pulling/hanging of their catheter to prevent incidents such as the penile split occurring on 10/6/20. The DON indicated they didn't know but indicated that catheters should be secured to prevent pulling of the tube. R14 On 8/10/21 at approximately 10:58 AM, R14 was observed lying in bed. The resident was alert, but had difficulty responding to questions asked. A foley catheter was observed. On 8/10/21 at approximately 2:30 PM a phone interview was conducted with R14's legal guardian regarding care provided by the facility. The guardian reported that she became aware of a wound on the resident's penis at the urology office and was upset that she was not informed by the facility. A review of the R14 medical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set, dated dated dated [DATE] revealed R14 severly cognitively impaired and required extensive to total assist with bed mobility and transfers. Continued review of the R14's clinical record documented, in part, the following: 7/5/21: Rec'd order to reinsert foley cath . Order reinsert foley catheter re: urinary retention .start date (blank) Revision date (7/5/21). Care Plan (created Date 8/2/21- revised 8/12/21): Focus: I have a Catheter: Urinary Retention .Interventions: Urinary collection bag to be changed monthly, Cath care daily with soap and water .Monitor Catheter for tubing not kinked or compressed. No Care Plan for catheter care was noted prior to 8/2/21. There was no indication R14's that indicated cath care daily with soap and water was being completed. 8/4/21: Consultation Sheet (urology): Date: 8-4-21 .R14 .Findings .urethral erosion (a pressure ulcer/wound commonly caused by an improper securement) .Recommendations .Case D/W (discussed with) patient's guardian .will proceed with suprapubic catheter . 8/6/21: Nurses Note: Writer was call to resident's room during care to observe a tear/split to his penis. Area measuring about 1 inch by .3cm (centimeters). Mild bleeding noted. Area cleanse with normal saline .foley catheter secure to left thigh to prevent pressure or pulling .V.O. (verbal order) to log incident for PCP (primary care physician) to F/U (follow-up) . An I/A(incident/accident) report dated 8/6/21 and authored by Nurse N was reviewed and documented, in part: Skin Tear .Date 8/6/21 .R14 .Incident Description: Writer was call to resident's room during care to observe a tear/split to the meatus through the shaft of his penis. Area measuring 1cm by .5cm. Mild bleeding noted: .Injury of Unknow Origin- Investigation Report .Description of Injury: Small opening to penis .Preliminary Investigation (findings): foley tube came a loose <sic> from secure leg band leg band replaced .follow-up .order in place. Conclusion & Recommendations: tubing from foley may have caused sm (small) opening [NAME] to moving of tube during care . 8/7/2021: Nurses Note (12:11 AM): . resident noted with tear from meatus to shaft of penis .c/o (complains of) pain 4/10 .no Foley catheter secured to leg . Wound Consultation authored by Physician P: Patient Name (R14) .date of service 8/9/21 .Open Penile wound .Measurements L(length).2.0 W (width) .Wound Bed: Pink .Primary Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] ? . On 8/12/21 at approximately 9:48 AM, an interview with Nurse N was conducted regarding the I/A dated 8/6/21. Nurse N reported that during a med pass on the evening of 8/6/21, Nurse O who was working as a CNA came out of the room and said, you have to take a look at this. Nurse N stated she went into the room and noticed a tear from the tip of the penis to the groin area with blood and the resident displayed pain as she was trying to clean the area. She reported that R14 was not able explain what happened. As she could not determine the cause of the injury but believed it may have been due to the tubing or the leg bag, it was considered an injury of unknow origin. Nurse N reported that she was not aware of any issue pertaining to the penis prior to 8/6/21. On 8/12/21 at approximately 10:00 AM, an interview was conducted with Wound Nurse Q. Wound Nurse Q reported that she did not become aware of the penile wound until 8/9/21. On 8/12/21 at 10:24 AM an observation of R14's penile area was conducted. The resident was lying in bed and receiving care from two Certified Nursing Assistants (CNA) who were cleaning the resident's penile area. The resident was yelling in pain when the CNA lifted the penis area to view the wound. No treatment appeared on the wound, an open area (left lateral aspect) from the urethra to the groin approximately one inch was noted with depth. An indentation in the penis, the size of the catheter tubing, was noted. On 08/12/21 at approximately 1:44 PM, an interview and record review were conducted with the DON regarding catheter care for R14. When asked as to the urethral erosion as noted by the urologist on 8/4/21, the DON reported that she was not aware of the erosion or any issues prior to 8/4/21. When queried as catheter care following the placement on 7/5/21 including, but not limited to, cleaning the area with soap and water, the DON reported that there is no indication in the electronic record that it was completed. When asked about the I/A that indicated a tear as an injury of unknown origin, the DON reported that they could not confirm the actual cause. When asked about the treatment order indicated by Wound Physician P dated 8/9/21, that was noted not to be administered until 8/12/21, the DON indicated she was not certain and stated that it should have been implemented by 8/10/21. A review of the Facility Policy titled, Catheter Care: Urinary (effective July 19, 2018) documented, in part, the following: .Purpose: to ensure uniformity in the performance of catheter care .Responsible Person: RN or LPN, CAN .Procedure:9. Cleanse genitalia: Male: Grasp penis, retract foreskin in an uncircumcised male and cleanse glans with disposable wipe moistened with peri wash, making a circular motion from the tip of the penis until enter glans penis is cleansed .10. with a disposable wipe moistened with peri wash, cleanse entire length of catheter from meatus downward with a little manipulation as possible, 11. remove gloves and discard, 12. Secure catheter in catheter strap .Document catheter care on the CNA documentation sheet .

This citation pertains to Intake #MI 259 Based on observation, interview and record review, the facility failed to institute and operationalize appropriate infection control principles and practices per the Centers for Disease Control and Prevention (CDC) including the failure to adequately screen visitors for temperatures, and actively screen staff members for temperature and signs and symptoms of illness as precautionary safety measures to prevent the exposure of residents to 2019 Novel Coronavirus (COVID-19), resulting in the increased likelihood of symptomatic persons entering the facility undetected. The failure to follow current CDC guidelines for COVID-19 resulted in an Immediate Jeopardy (IJ) to the health and safety of all residents, many of whom were at high risk due to age and co-morbidities, to be exposed and/or develop COVID-19, resulting in serious health complications from COVID-19 including the risk of death. Findings include: The IJ began on 3/17/20. The IJ was identified on 5/11/20. The Administrator was notified of the IJ on 5/12/20 at 4:50 PM and a plan to remove the immediacy was requested. The immediacy was removed on 5/13/20 at 7:00 PM based on the facility's implementation of an acceptable plan of removal verified on-site by the survey team. Although the IJ was removed on 5/13/20, the facility remained out of compliance at a scope of widespread and a severity of potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency. A survey was conducted on 5/11/20 to 5/14/20. A complaint was filed with the State Agency that alleged the Facility was failing to implement prevention and safety measures pertaining to COVID-19. On 5/11/20 at 8:35 AM, upon entry to the facility, the survey team was asked to sign the Visitor Logbook. No questions about health, travel, or recent contact with persons positive for COVID-19 were asked. No temperatures (temps) were taken. On 5/11/20 at approximately 9:00 AM, the Administrator was asked the number of residents that were positive for COVID-19 (the first positive case identified on 3/17/20) and how many employees had tested positive. The Administrator explained there were 11 residents in the facility that were positive and four employees that had tested positive. On 5/11/20 at approximately 9:30 AM, Greeter 'A' brought a visitor screening form for each member of the survey team and explained the form should have been filled out upon entry to the facility. The form consisted of two questions: Have you traveled internationally or state-side in the last 14 days: Yes No. If yes, where? And, Do you have signs/symptoms of a respiratory infection such as fever, cough, sore throat? Yes No. There were no temperatures of the survey team taken by any of the staff upon entry or exit of the facility. On 5/11/20 at 11:05 AM, Certified Nursing Assistant (CNA) 'I' was interviewed and asked how the facility screened employees before their work shift. CNA 'I' explained employees took their own temp and filled out their own screening form before and after their shift. When asked if there was any verification of temps, CNA 'I' explained sometimes there was a manager or staffing person in the room. On 5/11/20 at 12:41 PM, an observation of the staffing office in the basement revealed a large room with two vital sign machines and one temporal thermometer that hung on the wall. The employee assessment sheet COVID-19 ASSESSMENT FOR TEAM MEMBERS dated 3/26/2020 at 2:32 PM was on top of a shredder bin that was holding the door open. There was a sign on the staffing room door that read the following: 6:30 AM - 7:30 AM Open 7:30 AM - 11:30 AM Closed 11:30 AM - 1:00 PM Open 1:00 PM - 2:30 PM Closed 2:30 PM - 4:00 PM Open 4:00 PM - 6:30 PM Closed On 5/11/20 at 1:02 PM, Medical Records Staff 'N' came into the staffing room, completed a COVID-19 ASSESSMENT FOR TEAM MEMBERS form, took their own temp, and placed the completed form on top of three other staff members' completed forms that were on a printer sitting on the desk. When asked if staff were usually present in the staffing room when employees sign in and out of their shift, Medical Records Staff 'N' explained there usually was not anyone in the staffing room around the time they left (1:00 PM) and that was the time they usually left for the day. Medical Records Staff 'N' further explained they (staff) are always sitting behind the desk when in the room. It was noted upon observation that staff taking their own temperatures from the vital machines or temporal thermometer could not be verified by designated staff sitting behind the desk. When asked about the times staff were supposed to be in the staffing room, Medical Records Staff 'N' stated, I don't know their schedule. On 5/11/20 at 1:30 PM, during an interview with the Director of Nursing (DON) when queried about the verification of staff screening, the DON explained staff enter through the staff entrance near the back elevator and go down to the basement to the staffing room. They complete the COVID-19 ASSESSMENT FOR TEAM MEMBERS form, take their temp and punch in. When asked if there was verification of staffs' temps, the DON explained the facility's full time Staffing Coordinator 'X' was out on a leave of absence with a broken arm, and they had a part time staffing employee (Staffing Secretary 'Y'). The DON further explained they had a sub-acute coordinator (Clinical Coordinator 'O') that was filling in when Staffing Secretary 'Y' was not there. On 5/11/20 at 1:58 PM, when asked how long they had been monitoring the staff screening of employees, Clinical Coordinator 'O' stated, For the last couple of weeks. When asked about the screening process, Clinical Coordinator 'O' explained staff come in, take their temp, complete the form, and put it in the tray (in the staffing office). Clinical Coordinator 'O' further stated. If they (staff) take their temp and it's high, they call and report symptoms to Employee Health. When asked why there was no one in the staffing room, Clinical Coordinator 'O' explained they were down there, but they had to go upstairs to their office to get something. Clinical Coordinator 'O' further stated, It was cold down there (in staffing room) . On 5/11/20 at 2:23 PM, CNA 'P' was observed in the staffing room completing a COVID-19 ASSESSMENT FOR TEAM MEMBERS form. At that time, Clinical Coordinator 'O' was not in the staffing room. A review of facility provided COVID-19 ASSESSMENT FOR TEAM MEMBERS forms dated 5/4/20 -5/10/20 revealed the following: TEMP IN: TEMP OUT: . ALL FIELDS ARE REQUIRED. Name (first and last), Employee ID, Date and time: . 1. Have you been exposed (which means being within 6 feet for 10 minutes or more without a face mask) to a confirmed diagnosed COVID-19 person? YES NO 2. Have you developed ANY of the following: fever greater than 100F (Fahrenheit), NEW shortness of breath, NEW flu-like symptoms like body aches, NEW diarrhea, NEW abnormal cough, NEW loss of taste or smell (in addition to the above) . YES NO 3. Please check which two answers you selected above: . DO NOT REPORT TO WORK . CLEARED FOR WORK . 5/04/20 - There were four forms that were not marked with any temps for (In or Out) and/or unanswered questions: Staff Member 'Z' filled out the form at 6:55 AM with no temp written for AM or PM. Questions 2 and 3 were left blank. Staff Member 'CC' filled out the form with PM circled and no temp written for AM or PM. Staff Member 'EE' filled out the form at 3:00 PM with no temp written for AM or PM. Staff Member 'GG' filled out the form at 8:00 AM with no temp written for AM or PM. Questions 1 and 2 read, Same as before see previous sheets. Question 3 had a circle around the question with three question marks (???). 5/06/20 - There were four forms that were not marked with any temps for (In or Out) and/or unanswered questions: Staff Member 'V' left Question 3 blank. Staff Member 'FF' filled out the form at 5:07 PM with no temp written for AM or PM. 5/09/20 - There were three forms that were not marked with any temps for (In or Out): Staff Member 'Z' filled out the form at 6:58 AM and another at 4:08 PM with no temps for either form. Staff Member 'AA' filled out a form with PM circled and no temp written. 5/10/20 - There were three forms that were not marked with any temps for (In or Out): Staff Member 'BB' filled out the form at 4:09 PM with no temp written. Staff Member 'CC' filled out a form with PM circled and no temp written. Staff Member 'DD' filled out a form at 7:30 AM with no temp written. On 5/12/20 at 11:06 AM, during a telephone interview, when queried about the facility's screening process for visitors, the DON explained when visitors enter the building, they complete the screening form, they are educated on PPE (Personal Protection Equipment), and given a gown and surgical mask. When asked if visitors' temps were taken by staff, the DON stated, No. The DON was asked why the surveyors' temps were not taken when they entered the building. The DON stated, You should have been sent to the basement for your temps to be taken. The DON was further queried about the CDC guidelines regarding active monitoring of staff. The DON explained, someone is usually in the staffing room, and since there is someone in the staffing room, they consider that monitoring. When queried about the missing In and Out temperatures on the COVID-19 ASSESSMENT FOR TEAM MEMBERS forms dated 5/4/20 -5/10/20 for Staff Members V, Z, AA, BB, CC, DD, EE, FF and GG, the DON explained the clerk responsible at that time should have had the staff to come back and complete the forms. When asked how often the forms are reviewed, the DON stated, After the shift change. On 5/12/20 at approximately 12:29 PM, an interview was conducted with the Administrator. The Administrator was queried about staff self-monitoring temps when CDC guidelines are to actively monitor temps. The Administrator explained the Staffing Department should be monitoring the staff during their assessment, staff had all been educated on the signs and symptoms of COVID-19, and they were instructed to call Employee Health if they showed any signs or symptoms. On 5/12/20 at 2:51 PM, during a telephone interview, when queried about the facility's screening process for visitors/ancillary staff (i.e. doctors, hospice, lab, etc.), the DON explained the doctors come in the front door, get screened and go downstairs to take their own temperature. The DON further stated, We have three doctors that have a form they use from an App (Application) on their phone, because they are corporate employees. The DON further explained the doctors take their own temps and put them on their App. When asked about other ancillary staff coming to the facility, the DON explained when Hospice or a Lab Technician came to the facility they would go downstairs and use the staff COVID-19 ASSESSMENT FOR TEAM MEMBERS form and take their own temps. On 5/12/20 at 5:21 PM, during an interview, when asked what date the facility started screening staff for COVID-19 symptoms, the DON explained the original form was implemented on 3/5/20 but did not include temperatures. The DON stated, The facility's (Name Redacted) Health Questionnaire form was revised on 3/16/20 to include temps. The DON further explained the form had been revised again on 3/26/20 to the COVID-19 ASSESSMENT FOR TEAM MEMBERS form. Further review of facility provided Health Questionnaire forms starting 3/16/20 -3/23/20 revealed staff were taking their own temperatures and completing their own form with no appearance that the forms were continuously verified and/or reviewed by Staffing Coordinator 'X', Staffing Secretary 'Y' or Clinical Coordinator 'O' that were designated to monitor the forms. There was no further review of staff with possible signs and symptoms of COVID-19. A review of facility staff that had tested positive revealed: Staff Member 'R', who tested positive on 3/23/20, worked on 3/17/20, 3/18/20 and 3/20/20, had completed their own form with no apparent verification or review of their form by Staff X, Staff Y or Staff O. Staff Member 'L', who tested positive on 3/23/20, worked 3/18/20, 3/19/20, 3/20/20, and 3/23/20, had completed their own form with no apparent verification or review of their form. The CDC guidelines for Long Term Care facilities read in part, .Screen all HCP (Healthcare Personnel) at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document . Decisions about visitation for [MEDICATION NAME] care situations should be made on a case-by-case basis, which should include careful screening of the visitor for fever or symptoms consistent with COVID-19 . Review of a facility policy titled, Infection Prevention Guidance in the Setting of Ongoing COVID-19 Community Transmission dated 5/1/20 read in part, .All persons entering the facility - including patients, visitors, and HCP - will be screened by questionnaire for fever and other symptoms of COVID-19 upon entering . HCP who are performing screening assessments should wear a face mask, and hand hygiene performed between screenings if any physical contact is involved . The facility provided the following plan to remove the immediacy and it was verified onsite by the survey team: The Nursing Home Administrator and Director of Nursing reviewed the process of Covid-19 symptoms screening which applies to every individual, regardless of reason for entering the facility (including residents, staff, visitors, outside healthcare personnel, vendors, etc.) All residents have potential for being affected by this deficiency. The Covid-19 Assessment form for visitors was revised to monitor temperatures upon entering the facility. The staff Covid-19 assessment form was reviewed and deemed appropriate. The Greeters and Nurse Managers were educated on the new form and taking the temperatures of the visitors. They were also re-educated on the staff Covid-19 assessment form. Both visitors and staff enter at the main entrance. Education provided to greeters on how to use no- touch thermometer and the process. They were also educated on the thermometer function on the vital signs machine and staff assessment form. On 5/13/2020 at 7:00am, a staff member was designated to actively take the assese (sic) and complete staff Covid-19 assessment form. Nurse Managers were educated regarding the new process. Staff members will no longer take their own temperatures or complete their own Covid-19 assessment form. As of 5/12/20 at 5:45pm, the Director of Nursing educated 3 out of 6 Nursing Supervisors and the regarding (sic) the revised employee temperature monitoring process. Employees are no longer allowed to take and document their own temperatures. As of 5/13/2020, staff are being re-educated on the new process as they report for work, 6 out of 6 Nursing Supervisors have been educated on the new process. Staff assessment forms will be monitored daily, by nurse manager or designee, to ensure that they are not positive for signs and symptoms and temperatures are with in (sic) normal limits. These audits will be monitored daily by the Director of Nursing. Audit findings will be reported to the Quality Assessment and Process Improvement committee monthly. Director of Nursing is responsible for compliance. Action will be completed May 12, 2020 at 11:59pm Submitted by (Name Redacted), Administrator

This citation pertains to Intake Number MI 913 Based on interview and record review, the facility failed to ensure staff (including agency) were educated prior to providing resident care for one resident (R#706) that required two-person assist for bed mobility and bathing. This resulted in Immediate Jeopardy (IJ) to the health and safety of the resident when R#706 fell out of bed and sustained a ventricular hemorrhage (brain bleed) to the right side of the head, multiple fractures of the pubic rami (pelvis), required hospitalization and emergency surgery. This deficient practice placed R#706 at risk of serious injury, serious harm, and/or death. Findings Include: The IJ began on [DATE]. The IJ was identified on [DATE]. The Administrator was notified of the IJ on [DATE] at 4:05 p.m. in person and by email. A plan to remove the immediacy was requested. The immediacy was removed on [DATE] at approximately 2:00 p.m., based on an acceptable plan of removal verified onsite by the survey team. Although the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not yet been verified by the State Agency. A complaint was filed with the State Agency on [DATE] that alleged the facility failed to follow the care plan in regard to a 2-person assist with care, and staff left the resident unattended in an elevated bed. On [DATE] at approximately 9:17 am during a phone interview, Complainant 'D' stated, .It's a shame that people don't value your loved one and they don't do what they are supposed to do. A review of the clinical record revealed R#706 was originally admitted into the facility on [DATE] and last readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed R#706 had moderately impaired cognition, with inattention and disorganized thinking and required extensive assistance with two-person physical assist with bed mobility, transfer, and dressing. R#706 required total care with two-person physical assist for bathing. It should be noted that R#706 expired at the Facility on [DATE]. An I/A (Incident/Accident) and Investigation dated [DATE] at 13:35 (1:35pm), Revised 19:32 (7:32pm) revealed the following: Incident Description - Nursing Description: Nurse aide informed writer that patient rolled off bed during care. I went into the patient's room and observed patient lying on her side on the floor beside her bed. Patient has B/L (bilateral) skin tears on knee, skin tear below right nostril, skin tear under right eye, and knot above right eye. Resident unable to give __(no further documentation noted). Immediate Action Taken - Description: Skin assessed and cleaned with NS (Normal Saline) due to slight bleeding to B/L knee right forehead, below right eye and below right nostril. Neuro checks initiated. Vitals taken BP ,[DATE], HR (Heart Rate) 97, RR (Respiratory Rate) 18, T (Temperature) 98.2, PRN (as needed) pain medication given. Family, doctor, and unit manager notified. Ice applied to forehead and cold towel and patient immediately removed. Resident Taken to Hospital? N (No). Injuries Observed at Time of Incident - Injury Type: Abrasion, Injury Location: Face, Injury Type: Hematoma, Injury Location: Top of Scalp. Injury Type: Skin Tear, Injury Location: Right Knee (front), Left Knee (front), and Face. Level of Consciousness: Alert Mobility: Wheelchair bound. Mental Status: Oriented to Person. Injuries Report Post Incident - Injury Type: Injury Location: No Injuries Observed Post Incident. Level of Pain: (Blank). Predisposing Environmental Factors: (Unchecked). Predisposing Physiological Factors: (Unchecked). Predisposing Situation Factors: Other (Checked) - During Transfer: (Unchecked) . Other Info: During patient care, patient was turned to right side for brief changing and rolled off the other side of the bed . Witness - Name: (Blank). Relation: Staff. Date: [DATE]. Statement: I (cena) was giving care, while having the patient turned on side right side. I slightly turned upper body to reach for towels and patient began reaching for open drawer and rolled and hit her head on the nightstand and floor. I ran to get nurse for assistance. (CNA 'F'). Agency / People Notified: Nurse Manager, RN 'I' [DATE] 14:44 (2:44pm); Physician (PA) 'H', [DATE] 14:43 (2:43pm); Family Member 'R', [DATE] 14:44 (2:44pm). The facility's investigation dated [DATE] at 8:00am included an interview with CNA 'F' as follows: It was her scheduled bath day. I put her in bed, removed clothing. I washed her upper body, covered her, wash lower body and then went to peri area. I turned her over to do backside. She had a large bowel movement. The towels were not doing it anymore, so I reached over to get some wipes. The CNA was standing on the left side of the bed. The resident was turned to the right side of the bed. Resident was facing the window. Did not think assistance was needed for bed bath. Care plan does not require two for bed bath. No behavior awareness that would have triggered her asking for assist. I had one hand on her. Resident made a jerking move and rolled out of the bed. Resident hit her head on the nightstand. I went to the other side of the bed . She was face down; she was moaning. I left her in the position; her face was turned to the side. I left to go get the nurse. The nurse came in. We used the lift and transferred back to bed. The nurse took her vitals. Nurse and I finished cleaning her up. We put her clothes back on her with the brief. A review of R#706's Undated Care Guide was requested and revealed the following: Mobility Function - Bed Rest: No; Reposition in bed: (Blank); Assistance needs: Hoyer Lift w/c (wheelchair); Transfer: Independent, 1 Assist, 2 Assist (Blank); Assistance needs: Lift - Hoyer; Mobility: Ambulatory: No - Wheelchair . Safety Interventions: Low bed, Perimeter mattress . Cognition/Orientation to: Person . Fall Risk Assessments: [DATE] (Admission) = 12.0 (High Risk); [DATE] = 7.0; [DATE] = 6.0; [DATE] = 10.0 (High Risk) The facility's Fall Risk Care Plan revealed the following: F[NAME]US: I am at risk for falls/injury r/t history of falls, decreased mobility, medication use, [DIAGNOSES REDACTED]. I am dependent with two person assist for mechanical lift transfer. I like to sit on the edge of my bed. I have a low bed with a mat for safetyXXX[DATE] readmit [DATE] Fall today at 1:35pm Date Initiated: [DATE] . Revision on: [DATE] . GOAL: Minimize risk factors for falls. Date Initiated: [DATE] . Revision on: [DATE] Target Date: [DATE] . Minimize the potential for injury. Date Initiated: [DATE] . Revision on: [DATE] Target Date: [DATE] . INTERVENTIONS: bed in lowest position Date Initiated: [DATE] . Revision on: [DATE] . CNA education immediately Date Initiated: [DATE] .Revision on: [DATE] . I am on the falling star program. Date Initiated: [DATE] . Revision on: [DATE] . Pain Assessment: [DATE] - Due to Fall. Description: Groaning A review of the facility's One to One In-service Training dated [DATE] at 10:30 (am) revealed the following: Topic of inservice: Turning Residents Safely. Content Summary: When turning a resident, have your body in front of them in case they try and roll. Do not face their back. Always keep in contact with resident when turning. If it might require extensive care of resident (cleaning a BM -bowel movement, etc.) obtain help from another staff. Always have supplies near when working with resident. Always have call light near in case you need assistance. (Signed by CNA 'F' and RN/UM 'I') On [DATE] at 1:52 p.m., a telephone interview was conducted with Agency CNA 'F'. During the call, CNA 'F' was queried about the incident that occurred with R#706. When asked if they were the assigned CNA at the time of R#706's fall incident, CNA 'F' stated, Yes. CNA 'F' was asked what type of training they received before they started working at the facility. CNA 'F'' stated, I had one day of orientation, but I never received information to log in and chart until after my 4th or 5th day of working there. When asked if they knew the transfer status of R#706, CNA 'F' stated. Usually, I look in the Kardex, but I did not have the information at that time. That was my first time with her (R#706). When asked how did they know if R#706, was a one or two person assist for bed mobility and transfers, CNA 'F' stated, I didn't know, so I asked another CNA, I don't remember their name, but they told me she (R#706) was a one-person assist. When asked what they were doing when R#706 fell from the bed, CNA 'F' stated, Giving her a bed bath or I was changing her. When asked what the position was of R#706's bed, CNA 'F' stated, I had her in a high position, because I was wiping her. CNA 'F' was asked if they left the bedside at any time to go get additional supplies, CNA 'F' stated, No. CNA 'F' was queried about what happened after R#706's fall and stated, I went and got the nurse . Further review of the facility Progress Notes revealed the following: [DATE] 08:22 (8:00am) - Nurses Note: Note Text: Morning care provide by RN. Resident cleaned, dressed and hoyer lift into wheelchair. Resident tolerated well. [DATE] 15:12 (3:12pm) - Nurses Note: Note Text: Received resident up in wheelchair at 3:00pm. Notice large lump on right side of forehead with open area, red bruise under right eye, labored breathing and confusion. [NAME]M. nurse reported that resident rolled out of bed while receiving care from a female staff member at 1:30pm and that the NP (Physician Assistant PA 'H') has been called with orders to monitor and to report back any changes and that the unit manager is aware of the situation and is handling things. I express my concerns to the a.m. nurse and unit manager, and they agreed that I need to call the NP (PA 'H') back and give her an updated status. I called the NP (PA 'H') back and she stated that if I felt that resident need to be sent to the ER to go ahead and sent (sic) the resident to (Name Redacted) Local Hospital 'E'. Transcriber (LPN 'J') [DATE] 15:55 (3:55pm) - Nurses Note: Note Text: NP (PA 'H') has been called and has authorized transfer to Local Hospital 'E'. Unit manager and Evening shift supervisor has been made aware of situation. [DATE] 16:25 (4:25pm) - Nurses Note: Late Entry: Note Text: Upon arriving on unit resident was at nurses station alert x 1. Left eye was open right eye was closed. Report received from AM nurse that she had a fall. Nero checks continue. Resident did not appear to be in distress. Transcriber (LPN 'J') [DATE] 16:35 (4:35pm) - Nurses Note: Note Text: Resident has emesis x 1. 911 called to take resident to Local Hospital 'E'. Transcriber (LPN 'J') [DATE] 16:45 (4:45pm) - Nurses Note: Note Text: EMS arrived and transferred resident via stretcher 3 techs. Resident is alert and verbal, breathing and has pulse at this time. Evening shift supervisor is aware and has assisted with transfer. Transcriber (LPN 'J') [DATE] 18:48 (6:48pm) - Nurses Note: Late Entry: Note Text: Patient was observed on floor, beside bed. I immediately assessed the patient for injuries, and I observed a knot above right eye, skin tear below right nostril and right eye and B/L (bilateral) skin tears on knee. The cena (Certified Nurse Assistant -CNA) and myself used a lift to get patient in bed. Once in bed neuro checks were initiated and vitals were taken. Ice pack and cold towel applied but patient immediately removed both. PRN pain medication was given, and patient spit it out on her shirt and wouldn't open her mouth after spitting the medication out. Patient begin pushing legs off bed, after attempting to get out of bed staff placed patient back in wheelchair and brought her to the nurses station where I could monitor her. BP ,[DATE] HR 97 RR 18 sP02 96%. Doctor, family and unit manager notified. Transcriber (LPN 'G') The report from the Local Fire Department - EMT (Emergency Paramedics) 'M', 'N', and 'O' dated [DATE] at 16:44 (4:44 p.m.), (approximately 3 hours and 15 minutes post fall) revealed the following: Primary Impression - Injury of Head Secondary Impression - Injury Protocol Used - Head Trauma Chief Complaint - Concussive Injury Duration - 3 Hours Patient's Level of Distress - Severe Signs & Symptoms - Pain - Multiple Injuries Injury - Falls - Fall from other furniture . Nursing Home . [DATE] Medical/Trauma - Trauma Initial Patient Acuity - Critical (Red) Final Patient Acuity - Critical (Red) 17:00 (5:00pm) - Patient Response: Unchanged 17:04 - IV Therapy 20 ga; Hand Right; Saline Lock . 17:05 - BP (Blood Pressure) - ,[DATE]; Pulse 86; RR (Respiratory Rate) - 18 R; SpO2 - 88 Rm; BG (Blood Glucose) - 98; Pain - 2 . 17:06 - Oxygen - Flow Rate 6 lpm (liters per minute) . 17:14 - BP - ,[DATE]; Pulse 88 R; RR - 20; SpO2 - 98 Ox; BG - ; Pain 4 . Mental Status - Combative, Confused . HEENT (Head, Ears, Eyes, Nose and Throat) - Orange Size Hematoma Right Forehead - Swelling . A review of the medical record from local Hospital 'E' revealed the following: [DATE] ED (Emergency Department) to Hospital Admission . . Clinical Indication: Fall, head pain . Findings: Questionable tiny intraventricular hemorrhage is noted in the posterior horn of left lateral ventricle . There is a large extracranial hematoma involving the right forehead measuring approximately 4.7 x 2.3 cm (centimeters) . Pelvic XR (X-ray) shows cortical step off along the superior pubic ramus (pelvic) on the left .Patient was taken to the OR (Operating Room) by trauma surgery for [REDACTED]. She will be transferred to the ICU (Intensive Care Unit) for hemodynamic monitoring and q (every) 1-hour neuro-checks. Hospital Course: R#706 (status [REDACTED]. She was seen by (Name Redacted), [MEDICATION NAME] was started for [MEDICAL CONDITION] . No surgical intervention was recommended. She was taken to the operating room for I&D (Incision & Drainage) and control of hemorrhage for the forehead hematoma. She was placed in the ICU for close observation. She was transferred to the general trauma floor the following day. She was seen by internal Medicine Dr. 'P' and Cardiology, Dr. 'Q' Orthopaedics was recommended regarding the pubic rami fractures. Conservative management was recommended . She was felt stable for discharge by Internal medicine back to facility (Name Redacted). Addendum During transport she became diaphoretic, [MEDICAL CONDITION] and wheezing. She was brought back into the hospital and her discharge was canceled. She underwent a chest x-ray, remained hospitalized overnight . She was discharged on [DATE] back to the facility. On ,[DATE] 19 at 4:48 p.m., an interview was conducted with Licensed Practical Nurse (LPN) 'G' in regard to R#706's fall incident. LPN 'G' stated, As soon as I came back from lunch, CNA 'F' (I don't know her because she was an agency aid) came out of the room and asked me to come here for a second . Once I got into the room (CNA 'F') showed me the lady (R#706) was on the right side of the bed on the floor faced down. It was a nightstand there and the drawer was opened. I rolled her (R#706) over so I could see her face. At that time, she R#706) had a small lump above her right eye. She also had like a carpet burn under her nose because skin was scraped off. Her right knee had some skin scraped off . After that the CNA ('F') assisted me with the lift to put her back in bed, the CNA ('F') told me she was doing a bed bath because that was her (R#706) shower day. She (resident) did not have her brief on, so CNA 'F' must have been trying to roll her over to put her brief on. When asked if CNA 'F' was in the room by herself caring for R#706, LPN 'G' stated, Yes On [DATE] at 4:50 p.m., during an interview with the Director of Nursing (DON), When asked how CNAs determined the bed mobility and transfer status of residents, the DON stated, CNA 'F' should have known not to look at the computer to know what the resident bed mobility status was. The DON further stated, We don't have care guides on the computer. When asked why CNA 'F' didn't know that, the DON stated, I don't know why she didn't know that. She came in for a four-hour orientation. The orientation covers resident's rights, abuse, ADL care, and the computer training. The DON was asked should CNA 'F' have known R#706's bed mobility and transfer status, the DON stated, Yes, CNA 'F' should have gone and looked at the care guide to find out the information. The care guide is the form of communication that we use for residents' care. The DON was asked where residents' care guides are found. The DON stated, the CNA should know to look for the resident care guide in the closet. An interview was conducted with the Administrator on [DATE] at 5:20 p.m., regarding CNA 'F''s ADL care for R#706's bed mobility and transfer status. The Administrator stated, Those findings are not something that I was aware of. We will use this experience to evaluate and reevaluate what we do and are going to understand what we can do better. The nursing assistants are oriented before going out on the floor. Even if they are agency staff. There really should not have been any reason why she CNA 'F' didn't know where the care guides were based on our practice. Review of the facility's policy titled Fall Prevention Program effective (MONTH) 2, (YEAR) documented the following: PURPOSE: To assess if a resident is at risk for potential falls in order to provide interventions to minimize the occurrence of falls . POLICY IMPLEMENTATION: . B. All residents with Fall Risk scores of 10 or higher will be identified as High Risk for falls. A listing of preventive measures for residents at risk for falls will be utilized by staff for appropriate and individualized interventions to add to the plan of care for potential falls The facility submitted the following plan to remove the immediacy on [DATE]: Element 1 Resident #706 no longer resides in the facility. Element 2 On [DATE] at 6:00pm the Nursing Home Administrator and Director of Nursing determined that the residents that have fallen in the last 48 hours are at risk for experiencing delayed consequences of the fall. The Director of Nursing reviewed the medical records and determined that none occurred. The licensed nurses will conduct an assessment of these residents to determine that they are stable. These were completed and documented in the medical records as of [DATE] at 11:00am. Beginning on [DATE] at 6:00pm, the Director of Nursing identified residents at high fall risk and those requiring two assists with bed mobility on the most recent Minimum Data Set as being at risk. Beginning on [DATE] and continuing, the licensed nurses reviewed the most recent fall risk assessment to determine if it reflects the resident's current status. If not, the licensed nurses updated the assessment. They also reviewed the resident's current Activities of Daily Living status. Using these two, the licensed nurses updated the Care Plans and Care guides if needed. As of [DATE] at 9 am 171 out of 171 (total residents to be reviewed) had been completed. We are confident they all will be completed by [DATE] at 9:00am. Element 3 [DATE] 4:05pm Nursing Home Administrator notified president of (Facility Name) Corporation Executive Leadership of facility being placed in Immediate Jeopardy. [DATE] 5:05pm Facility Medical Director was notified of facility being placed in Immediate Jeopardy. [DATE] 5:10pm. The Director of Nursing identified that the Facility does not use electronic nurse aide care guides. The Director of Nursing reviewed the process for using paper care guides. These are updated by the nurses when changes occur. These are located in resident closets for easy access for the nursing assistants. Nurse aide care guides are still on paper. Nurse aides have immediate access. Agency nurse aides are in-serviced on where it is located prior to accepting their assignment. Based on this, the Director of Nursing determined that the process in place is appropriate. Beginning on [DATE] at 7:00pm the Director of Nursing/designees in-serviced the nursing assistants to follow the care guide for care with an emphasis on having two-person assistance as it is deemed necessary on residents' care guide. As of [DATE] at 9am 36 out of 52 full and part time nursing assistants had been in-serviced. In-services will continue multiple times per day until complete. Any nursing assistant on approved leave (personal, medical, and educational), or contingent, will receive the in-service on before the start of their next scheduled shift. Beginning on [DATE] at 8:00pm, the Director of Nursing in-serviced the nursing supervisors. The inservice included their responsibility to orient agency aides to the use of the care guides prior to accepting the assignment. As of [DATE] at 9am 12 out of 12 supervisors have been inserviced, by the Director of Nursing, regarding instructions about proper response when a resident fall and the requirement for licensed nurse responsibility for conducting the proper assessment. As of 9:00am, the supervisors have trained 25 out of 35 of the full time and part time staff. In-services will continue multiple times per day. Any licensed nurse on approved leave (personal, medical, and educational), or any contingent nurse, will receive the in-service on before next scheduled shift. Element 4 Care Guides will be monitored daily, by nurse manager or designee, to ensure that they are accurate and present in resident room closets. These audits will be monitored daily the Director of Nursing. Audit findings will be reported to the Quality Assessment and Process Improvement committee monthly. Director of Nursing is responsible for compliance.

This citation pertains to Intake Number MI 913 Based on interview and record review, the facility failed to monitor changes in condition and immediately transfer a resident to the hospital after a significant fall with severe facial/head injuries for one resident (R#706). This resulted in Immediate Jeopardy (IJ) to the health and safety of R#706 who after a significant fall, had labored breathing, pain, emesis, hematoma, closed right eye, ventricular hemorrhage (brain bleed), fractured pelvis, delayed transfer to the hospital/emergency room (approximately 4 hours), emergency surgery, and continued decline in health. This deficient practice placed R#706 at risk of serious injury, serious harm, and/or death. Findings Include: The IJ began on [DATE]. The IJ was identified on [DATE]. The Administrator was notified of the IJ on [DATE] at 4:05 p.m. in person and by email. A plan to remove the immediacy was requested. The immediacy was removed on [DATE] at approximately 2:00 p.m., based on an acceptable plan of removal verified onsite by the survey team. Although the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not yet been verified by the State Agency. A complaint was filed with the State Agency on [DATE] that alleged the facility failed to notify the responsible party on the resident injury, assess and monitor the resident for a head injury following a fall, and staff failed to sent (sic) the resident to the ER (emergency room ) resulting in a delay of treatment. During a phone interview with, Complainant 'D' on [DATE] at approximately 9:17 AM the Complainant stated, .It's a shame that people don't value your loved one and they don't do what they are supposed to do. Review of the clinical record revealed R#706 was originally admitted into the facility on [DATE] and last readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed R#706 had moderately impaired cognition, with inattention and disorganized thinking and required extensive assistance with two-person physical assist with bed mobility, transfer, and dressing. R#706 required total care with two-person physical assist for bathing. It should be noted that R#706 expired on [DATE]. An I/A (Incident/Accident) and Investigation dated [DATE] at 13:35 (1:35pm), Revised 19:32 (7:32pm) revealed the following: Incident Description - Nursing Description: Nurse aide informed writer that patient rolled off bed during care. I went into the patient's room and observed patient lying on her side on the floor beside her bed. Patient has B/L (bilateral) skin tears on knee, skin tear below right nostril, skin tear under right eye, and knot above right eye. Resident unable to give __(no further documentation was noted ). Immediate Action Taken - Description: Skin assessed and cleaned with NS (Normal Saline) due to slight bleeding to B/L knee right forehead, below right eye and below right nostril. Neuro checks initiated. Vitals taken BP ,[DATE], HR (Heart Rate) 97, RR (Respiratory Rate) 18, T (Temperature) 98.2, PRN (as needed) pain medication given. Family, doctor, and unit manager notified. Ice applied to forehead and cold towel and patient immediately removed. Resident Taken to Hospital? N (No). Injuries Observed at Time of Incident - Injury Type: Abrasion, Injury Location: Face, Injury Type: Hematoma, Injury Location: Top of Scalp. Injury Type: Skin Tear, Injury Location: Right Knee (front), Left Knee (front), and Face. Level of Consciousness: Alert Mobility: Wheelchair bound. Mental Status: Oriented to Person. Injuries Report Post Incident - Injury Type: Injury Location: No Injuries Observed Post Incident. Level of Pain: (Blank). Predisposing Environmental Factors: (Unchecked). Predisposing Physiological Factors: (Unchecked). Predisposing Situation Factors: Other (Checked) -During Transfer: (Unchecked) . Other Info: During patient care, patient was turned to right side for brief changing and rolled off the other side of the bed . Witness - Name: (Blank). Relation: Staff. Date: [DATE]. Statement: I (cena) was giving care, while having the patient turned on side right side. I slightly turned upper body to reach for towels and patient began reaching for open drawer and rolled and hit her head on the nightstand and floor. I ran to get nurse for assistance. (CNA 'F'). Agency / People Notified: Nurse Manager, RN 'I' [DATE] 14:44 (2:44pm); Physician (PA) 'H', [DATE] 14:43 (2:43pm); Family Member 'R', [DATE] 14:44 (2:44pm). Further review of the facility Progress Notes revealed the following: [DATE] 08:22 (8:00am) (sic) - Nurses Note: Note Text: Morning care provide by RN (Registered Nurse). Resident cleaned, dressed and hoyer lift into wheelchair. Resident tolerated well. [DATE] 15:12 (3:12pm) - Nurses Note: Note Text: Received resident up in wheelchair at 3:00pm. Notice large lump on right side of forehead with open area, red bruise under right eye, labored breathing and confusion. [NAME]M. nurse reported that resident rolled out of bed while receiving care from a female staff member at 1:30pm and that the NP (Physician Assistant PA 'H') has been called with orders to monitor and to report back any changes and that the unit manager is aware of the situation and is handling things. I express my concerns to the a.m. nurse and unit manager, and they agreed that I need to call the NP (PA 'H') back and give her an updated status. I called the NP (PA 'H') back and she stated that if I felt that resident need to be sent to the ER to go ahead and sent (sic) the resident to (Name Redacted) Local Hospital 'E'. Transcriber (LPN 'J') [DATE] 15:55 (3:55pm) - Nurses Note: Note Text: NP (PA 'H') has been called and has authorized transfer to Local Hospital 'E'. Unit manager and Evening shift supervisor has been made aware of situation. [DATE] 16:25 (4:25pm) - Nurses Note: Late Entry: Note Text: Upon arriving on unit resident was at nurses station alert x 1. Left eye was open right eye was closed. Report received from AM nurse that she had a fall. Nero checks continue . Transcriber (LPN 'J') [DATE] 16:35 (4:35pm) - Nurses Note: Note Text: Resident has emesis x 1. 911 called to take resident to Local Hospital 'E'. Transcriber (LPN 'J') [DATE] 16:45 (4:45pm) - Nurses Note: Note Text: EMS arrived and transferred resident via stretcher 3 techs. Resident is alert and verbal, breathing and has pulse at this time. Evening shift supervisor is aware and has assisted with transfer. Transcriber (LPN 'J') [DATE] 18:48 (6:48pm) - Nurses Note: Late Entry (emphasis added): Note Text: Patient was observed on floor, beside bed. I immediately assessed the patient for injuries, and I observed a knot above right eye, skin tear below right nostril and right eye and B/L (bilateral) skin tears on knee. The cena (Certified Nurse Assistant -CNA) and myself used a lift to get patient in bed. Once in bed neuro checks were initiated and vitals were taken. Ice pack and cold towel applied but patient immediately removed both. PRN pain medication was given, and patient spit it out on her shirt and wouldn't open her mouth after spitting the medication out. Patient begin pushing legs off bed, after attempting to get out of bed staff placed patient back in wheelchair and brought her to the nurses' station where I could monitor her. BP ,[DATE] HR 97 RR 18 SpO2 96%. Doctor, family and unit manager notified. Transcriber (LPN 'G') The report from the Local Fire Department - EMT (Emergency Paramedics) 'M', 'N', and 'O' dated [DATE] at 16:44 (4:44 p.m.) revealed the following: Primary Impression - Injury of Head Secondary Impression - Injury Protocol Used - Head Trauma Chief Complaint - Concussive Injury Duration - 3 Hours Patient's Level of Distress - Severe Signs & Symptoms - Pain - Multiple Injuries Injury - Falls - Fall from other furniture . Nursing Home . [DATE] Medical/Trauma - Trauma Initial Patient Acuity - Critical (Red) Final Patient Acuity - Critical (Red) 17:00 (5:00pm) - Patient Response: Unchanged 17:04 - IV Therapy 20 ga; Hand Right; Saline Lock . 17:05 - BP (Blood Pressure) - ,[DATE]; Pulse 86; RR (Respiratory Rate) - 18 R; SpO2 - 88 Rm; BG (Blood Glucose) - 98; Pain - 2 . 17:06 - Oxygen - Flow Rate 6 lpm (liters per minute) . 17:14 - BP - ,[DATE]; Pulse 88 R; RR - 20; SpO2 - 98 Ox; BG - ; Pain 4 . Mental Status - Combative, Confused . HEENT (Head, Ears, Eyes, Nose and Throat) - Orange Size Hematoma Right Forehead - Swelling . A review of the medical record from Local Hospital 'E' revealed the following: [DATE] ED (Emergency Department) to Hospital Admission . . Clinical Indication: Fall, head pain . Findings: Questionable tiny intraventricular hemorrhage is noted in the posterior horn of left lateral ventricle . There is a large extracranial hematoma involving the right forehead measuring approximately 4.7 x 2.3 cm (centimeters) . Pelvic XR (X-ray) shows cortical step off along the superior pubic ramus (pelvic) on the left .Patient was taken to the OR (Operating Room) by trauma surgery for [REDACTED]. She will be transferred to the ICU (Intensive Care Unit) for hemodynamic monitoring and q (every) 1-hour neuro-checks. Hospital Course: R#706 (status [REDACTED]. She was seen by (Name Redacted), [MEDICATION NAME] was started for [MEDICAL CONDITION] She was taken to the operating room for I&D (Incision & Drainage) and control of hemorrhage for the forehead hematoma. She was placed in the ICU (intensive care unit) for close observation. She was transferred to the general trauma floor the following day. She was seen by internal Medicine Dr. 'P' and Cardiology, Dr. 'Q'. Orthopaedics was recommended regarding the pubic rami fractures. Conservative management was recommended . She was felt stable for discharge by Internal medicine back to facility (Name Redacted). Addendum During transport she became diaphoretic, [MEDICAL CONDITION] and wheezing. She was brought back into the hospital and her discharge was canceled. She underwent a chest x-ray, remained hospitalized overnight . She was discharged on [DATE] back to the facility. It should be noted that R#706 was transferred back to the hospital on [DATE] and expired on [DATE]. On [DATE] at 1:52 p.m., a telephone interview was conducted with Agency CNA 'F'. During the call, CNA 'F' was queried about the incident that occurred with R#706. When asked if they were the CNA assigned to R#706 on [DATE] (the date of the fall incident), CNA 'F' stated, Yes. CNA 'F' was asked what type of training they received before they started working at the facility as an Agency CN[NAME] CNA 'F'' stated, I had one day of orientation, but I never received information on how to log in and chart until after my 4th or 5th day of working there. When asked if they knew the transfer status of R#706, CNA 'F' stated. Usually, as a CNA I look in the Kardex (an electronic record system) , but I did not have my log in at that time. That was my first time with her (R#706). When asked how did they know if R#706, was a one or two person assist for bed mobility and transfers, CNA 'F' stated, I didn't know, so I asked another CNA, I don't remember their name, but they told me she (R#706) was a one-person assist. When asked what they were doing when R#706 fell from the bed, CNA 'F' stated, Giving her a bed bath or I was changing her. When asked what the position was of R#706's bed, CNA 'F' stated, I had her (the bed) in a high position, because I was wiping her. CNA 'F' was asked if they left the bedside at any time to go get additional supplies, CNA 'F' stated, No. CNA 'F' was queried about what happened after R#706's fall and stated, I went and got the nurse . On [DATE] at 4:48 p.m., an interview was conducted with Licensed Practical Nurse (LPN) 'G' in regard to R#706's fall incident. When asked what time CNA 'F' reported the incident to them, LPN 'G' stated, It was between ,[DATE] (pm) after lunch. LPN 'G' further stated, As soon as I came back from lunch, CNA 'F' (I don't know her because she was an Agency aid) came out of the room and asked me to 'come here for a second.' I put my things down and came into the room. Once I got into the room CNA 'F' showed me the lady (R#706) who was on the right side of the bed on the floor faced down. A nightstand was there and the drawer was opened. I rolled R#706 over so I could see her face. At that time, R#706 had a small lump above her right eye. She also had like a carpet burn under her nose, because the skin was scraped off. Her right knee had some skin scraped off. I did a head to toe assessment while she was still on the floor. I also took her vitals and started neuro checks while she was on the floor. After that CNA 'F' assisted me with the lift to put her back in bed. LPN 'G' further stated, CNA 'F' told me she was doing a bed bath because that was her (R#706) shower day. She (R#706) did not have her brief on, so CNA 'F' must have been trying to roll her over to put her brief on. When asked if CNA 'F' was in the room by herself caring for R#706, LPN 'G' stated, Yes. When asked if they called the doctor, LPN G' stated, Yes, I talked to the NP (Physician Assistant - PA 'H'), she was in the building at the time. When asked if PA 'H' went to R#706's room to assessed them after the fall, LPN 'G' stated, No, she did not come up to assess the resident. She (PA 'H') told me to have the Unit Manager (UM 'I') to come assess the resident and tell me what she thinks from there. LPN 'G' was asked if UM 'I' came to assess R#706 in their room, LPN 'G' stated, No, I went to her office and told her the situation and told her what PA 'H' told me about her (UM 'I') being able to assess the patient since she (UM 'I') worked in ICU . She (UM 'I') did not come right away. It took her approximately ,[DATE] minutes before she came. I had to call her (UM 'I') twice before she came. LPN 'G' further stated, I was getting nervous because the bump on R#706's head was getting bigger and I felt she needed to go out to hospital. When asked what UM 'I' instructed them to do after she assessed R#706, LPN 'G' stated, UM 'I' told me to monitor R#706 and keep an eye on her and continue to take her vitals. When asked what R#706 was doing, the reason why they wanted to send them out to the hospital, LPN 'G' stated, R#706 was moaning like she was in pain, so I gave her Tylenol. She was anxious while moaning and trying to pull her legs out of bed. At that time, me and CNA 'F' put her in the wheelchair and rolled her to the nurses' station. LPN 'G' was queried how long R#706 stayed at the nurses' station. LPN 'G' stated, R#706 was at the nurses' station with me until the end of my shift. When asked what time their shift ended that day, LPN 'G' stated, My shift ended at 3:00 (pm), so about 3:15 or 3:30 (pm) . LPN 'G' further stated, The Agency Nurse (LPN 'J') was nervous about how the resident looked, so he immediately called the supervisor, Registered Nurse (RN 'K'.) . LPN 'G' further stated, LPN 'J' told me that they called PA 'H' and PA 'H' said, 'still don't send out the patient. That's when LPN 'J' called RN 'K' and they came up and saw the patient. RN 'K' told me that she did not know why the patient was not sent out and that R#706 started projectile vomiting, and she sent her out . An interview was conducted with LPN 'J' on [DATE] at 5:31 p.m. At that time, LPN 'J' stated, I was the oncoming nurse. The AM Nurse (LPN 'G') gave me their report. At that time, the resident (R#706) was sitting in a wheelchair at the nurses' station. She had a huge knot on her forehead. She did not look too good, so I inquired with the AM Nurse (LPN 'G') as to what happened, and they informed me that during morning care, the resident rolled out of bed and hit her head on the corner of the night stand. I inquired as to what was being done for her, and LPN 'G' said she was 'instructed to do neuro checks.' I asked LPN 'G' if they had ordered x-rays and they said 'No.' The PA 'H' just wanted to do neuro checks. I called UM 'I' and asked if they would go down to the nurses' station, because it looked like R#706 needed to go out to me. I told UM 'I' what my concerns were, and I wanted to send R#706 out. UM 'I' came down to the nurses' station and I inquired as to why R#706 was not being sent out, and UM 'I' said, 'PA 'H' did not want to send her out and just wanted us to do neuro checks .' I called PA 'H' and gave her my concerns regarding R#706 and she said, 'Ok go ahead and send her out and I will inform Dr. 'L'.' LPN 'J' was asked what time they called 911. LPN 'J' stated, It was approximately between ,[DATE] o'clock. I dialed 911 to dispatch the ambulance around 4:00pm. I called UM 'K' (Evening Shift Supervisor) and she came up. UM 'K' looked at the resident and asked what happened and if the resident had anything for pain. UM 'K' checked for a PRN (as needed) Tylenol, then administered 1 or 2 tablets to the resident. The resident drank some of the water and immediately had projectile vomiting . UM 'K' instructed me to call 911 back and tell them to come with lights and sirens. I called them back. Then I call the emergency contact (Son) and told them we were transferring R#706 to the hospital. After I spoke with the Son, UM 'K' left the floor and asked another nurse to come over and assist me. The EMS (Emergency Medical Services) came and transferred R#706 to the hospital at approximately 4:30pm. When asked if PA 'H' ever came to exam the resident, LPN 'J' stated, Not while I was there. When UM 'I' instructed me to call PA 'H' to get an order for [REDACTED]. On [DATE] at 12:33 p.m., an interview was conducted with UM 'I. When queried about the incident that happened on [DATE] with R#706, UM 'I' stated, When the incident occurred, I had barely been at the facility for a month. I was notified by the nurse (I don't remember their name), that R#706 had a fall. I was told that she was being cleaned up by a CNA and rolled out of bed, and that she had hit her head on the nightstand. The nurse had gone in and assessed her. We had got her up and into a chair and taken her out to the nurses' station/day area so that they could monitor her. During the time we were getting her up, we had called the doctor. It was during change of shift and I believe the day shift nurse talked to the doctor. When asked if R#706 had any visible injuries, UM 'I' stated, She had a big hematoma on her head and an abrasion on the hematoma, and maybe one on the side of her face. Her eye was swollen . On [DATE] at 4:12 p.m., a telephone interview was conducted with RN 'K, when asked about the incident, RN 'K' stated, I can't honestly remember . An interview was conducted with PA 'H' at 4:40 p.m. When asked if they were in the building at the time of the R#706's incident, PA 'H' stated, I don't remember. I received two phone calls one that she had fell and hit her head. PA 'H' was asked what time they received that call. PA 'H' stated, It was late afternoon. The first call I gave instructions to initiate neuro checks and facility protocol for an incident Q (every) one-hour vitals and neuro checks. The second call was after shift change. It was a different nurse (I don't remember). That nurse said R#706 had mental status change, and they did. I did not get a call after that. At that time, PA 'H' was asked if they ever went to see or exam R#706 at any time. PA 'H' stated, No, both calls were over the phone. PA 'H' was asked if they were in the building during any of the calls in regard to R#706's fall incident. PA 'H' stated, I don't remember. On [DATE] at 4:50 p.m., during an interview, when ask at what point should a resident be transferred to the hospital after a serious fall with injuries, the Director of Nursing (DON) stated, If she had a hematoma as a nurse, I probably would have sent her out . They brought her out to the nurses' station and monitored her more closely and notified the manager and person on call. When asked if PA 'H' was in the building, would it be a standard of practice to exam a resident after a serious fall, the DON stated, I would expect, it depends on the information they were giving on the call. The DON was queried why it took until 4:30 - 5:00 p.m., for R#706 to be transferred to the hospital if she had a fall at 1:30 p.m., with a large expanding hematoma. The DON stated, I didn't see the patient . During an interview with the Administrator on [DATE] at 5:20 p.m., when asked about the delayed treatment when R#706 experienced labored breathing, moaning in pain, emesis, an expanding hematoma with the right eye closed Change of Condition, the Administrator stated, We would expected the nurse to have ongoing monitoring of the resident and would have contacted the physician and document all of that. When asked why there was a delay in sending R#706 out to the hospital, the Administrator stated, My understanding is that the resident did not show signs of acute changes . The Administrator further stated, As a result of this incident, we will use this as a learning experience to reevaluate what we did and how we can do it better. Review of the facility's policy titled Change in a Resident's Condition or Status effective (MONTH) 12, 2011 documented the following: Policy Statement The charge nurse shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's condition and/or status. Policy Interpretation and Implementation 1. The Charge Nurse will notify the resident's attending physician when: a. The resident is involved in a fall; b. There is a significant change in the resident's physical, mental or psychosocial status; c. There is a need to alter the resident's treatment; . 2. Unless otherwise instructed by the resident, the Charge Nurse will notify the resident's next-of-kin or representative (sponsor) when: a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source; There is a significant change in the resident's physical, mental, or psychosocial status; . e. It is necessary to transfer the resident to a hospital. 3. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's condition or status . 6. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted by the Unit Nurse Manager . 7. The Charge nurse will notify attending physician after diagnostic test(s) are completed to determine if the patient needs to be transferred. 8. The charge nurse shall monitor the resident's progress and document relevant findings during the acute change of condition . The facility submitted the following plan to remove the immediacy on [DATE]: Element 1 Resident #706 no longer resides in the facility. Element 2 On [DATE] at 6:00pm the Nursing Home Administrator and Director of Nursing determined that the residents that have fallen in the last 48 hours are at risk for experiencing delayed consequences of the fall. The Director of Nursing reviewed the medical records and determined that no delayed consequences occurred. The licensed nurses will conduct an assessment of these residents to determine that they are stable. These were completed and documented in the medical records as of [DATE] at 11:00am. Beginning on [DATE] at 6:00pm, the Director of Nursing identified residents at high fall risk and those requiring two person assist with bed mobility on the most recent Minimum Data Set as being at risk. Beginning on [DATE] and continuing, the licensed nurses reviewed the most recent fall risk assessment to determine if it reflects the resident's current status. If not, the licensed nurses updated the assessment. They also reviewed the resident's current Activities of Daily Living status. Using these two, the licensed nurses updated the Care Plans and Care guides if needed. As of [DATE] at 9 am 171 out of 171 (total residents to be reviewed) had been completed. We are confident they all will be completed by [DATE] at 9:00am. Element 3 [DATE] 4:05pm Nursing Home Administrator notified president of (Facility Name) Corporation Executive Leadership of facility being placed in Immediate Jeopardy. [DATE] 5:05pm Facility Medical Director was notified of facility being placed in Immediate Jeopardy. [DATE] at 5:30pm the Nursing Home Administrator reviewed the policy and procedures for acute change of condition and deemed it appropriate. Beginning on [DATE] the Director of Nursing/designee began in-servicing the licensed nursing staff regarding the critical nature of their responsibility to provide a timely and complete assessment and timely identification as well as monitoring of change in condition. Emphasis was given to the critical nature of a complete assessment as it related to timely discharge to hospital for subsequent care and treatment. As of [DATE] at 9:00am 25 out of 35 (total full and part time nurse on staff) had been inserviced. Inservices will continue multiple times per day. All licensed nurses on approved leave (personal, medical, and educations) and contingent nurses, will receive the in-service before the start of their next scheduled shift. As of [DATE] at 9am 12 out of 12 supervisors have been inserviced, by the Director of Nursing, regarding instructions about proper response when a resident fall and the requirement for licensed nurse responsibility for conducting the proper assessment. As of 9:00am, the supervisors have trained 25 out of 35 of the full time and part time staff. In-services will continue multiple times per day. Any licensed nurse on approved leave (personal, medical, and educational), or any contingent nurse, will receive the in-service on their next scheduled shift. Element 4 Falls will be monitored daily, by nurse manager or designee, to ensure changes of condition are assessed and documented appropriately. These audits will be monitored daily the Director of Nursing. Audit findings will be reported to the Quality Assessment and Process Improvement committee monthly. Director of Nursing is responsible for compliance.

This citation pertains to MI 5561: This citation has two deficient practice statements. Deficient Practice #1: Based on observation, interview and record review, the facility failed to ensure appropriate assessment and investigation following multiple falls to prevent further incidents, and ensure appropriate interventions including adequate supervision and identified interventions were in place for four (R#s 130, 43, 126, and 104) of seven residents reviewed for accidents, resulting in falls with serious and minor injuries (fracture requiring hospitalization for surgical intervention, skin tears and lacerations requiring stitches, bruising) and the increased likelihood for continued falls with serious harm and/or injury. Findings include: Resident #130 On 8/26/19 at 12:40 PM, R#130 was observed seated in a wheelchair at a table in the dining room (located on the facility's secured memory care floor) with the wheelchair brake locked on the right side and an alarm attached to the backrest. The resident's right temple area was observed with a dark red area. Staff were observed wheeling residents into the dining room and setting up meal trays. During this time, R#130 was observed repeatedly attempting to push backwards from the table which tipped the wheelchair back (but not over) due to the locked brake. After a few minutes, a Certified Nursing Assistant (CNA) was observed to set up R#130's meal tray. R#130 repeatedly stated, Help me, help me! while the CNA attempted to have R#130 eat the lunch meal. Review of the clinical record revealed R#130 was admitted into the facility on [DATE], readmitted on [DATE], and admitted on to hospice services on 4/24/19 with [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], R#130 had impaired cognition, no behaviors, required extensive assistance of one person for bed mobility, eating, toilet use, was totally dependent of two plus people for personal assist with transfers, was incontinent of bowel and bladder, had one fall with injury since previous assessment, and used a bed and chair alarm daily during this assessment period. Review of the physician orders [REDACTED].>Falling star program - active 5/30/19 Mechanical lift for transfers - active 5/23/19 Pad alarm for bed and wheelchair - active 4/24/19 Review of the care plans included: I am at risk for falls/injury r/t (related to) Anticoagulant use, Dementia, Gait/mobility impairments, History of Falls, Incontinence. I will try to get up out of my W/C (wheelchair) and walk by myself. I will report that I have fallen and say things like I just fell when it will be proven that I have not had a fall. It may be due to a dream or after I have taken a nap. I am impulsive in the bathroom, I will try to wipe myself, and will attempt to stand up and dress myself. falls: 2/2,14,23,3/17 and 4/19/19 5/9/19 rolled out of bed onto floor mat Date Initiated: 3/21/2019; Created on: 1/1/2019; Revision on: 8/12/2019. Interventions included: 2/15/19 I will sometimes fall asleep in my w/c and wake up startled and say I'm falling. Date Initiated: 3/21/2019; Created on: 2/15/2019; Revision on: 3/21/2019. 2/2/19: I am able to tell you when I need to use the restroom- please offer to take me every 2 hours also. Date Initiated: 3/21/2019; Created on: 2/4/2019; Revision on: 3/21/2019. 2/2/19: Pad alarm to bed./Pad alarm to w/c. Date Initiated: 3/21/2019; Created on: 2/4/2019; Revision on: 4/23/2019. 2/23/19: Remind me to reposition myself if I am sliding down in w/c. Date Initiated: 3/21/2019; Created on: 3/12/2019; Revision on: 3/21/2019. 4/20/19: perimeter mattress applied to bed, with safety mattress on floor beside bed Date Initiated: 4/20/2019; Created on: 4/21/2019; Revision on: 4/24/2019. 5/9/19 (MONTH) roll onto floor mattress. Date Initiated: 5/10/2019; Created on: 5/10/2019; Revision on: 8/12/2019. bed against wall and full mattress on floor next to bed Date Initiated: 3/21/2019; Created on: 1/1/2019; Revision on: 8/12/2019. I am on the falling star program. Date Initiated: 3/21/2019; Created on: 1/1/2019; Revision on: 3/21/2019. Once I am able to use the toilet again- keep me with in an arms reach. Date Initiated: 3/29/2019; Created on: 3/29/2019. Review of the progress notes included: On 2/2/19 at 4:51 AM, .Resident Observed on the floor at her Bedside Notice Skin Tear to Right Shoulder applied Steri Strips and Cleanse With Normal Saline And Covered With Dry Dressing Right Hip Swellin <sic> and Redness Notice <sic> .Call Light given to Resident and Staff informed to continue to Monitor and Bed Remain in the Lowest PositionAt <sic> this time. On 2/23/19 at 9:28 PM, .Resident was observed on the floor on her left side in the hallway of 3 south, when writer arrived there were 2 other Nurses there from 3 North and 3 South, no one saw resident fall . On 2/24/2019 at 7:44 AM, .Post Fall Shift #2/9: Resident was in bed asleep easily aroused with verbal and tactile stimuli. When awake, resident is oriented x 1 with forgetfulness. Resident is sleeping comfortably with no copmplains <sic>. Resident's safety mattress are in place. Head of the bed in semi-Fowler position and whole bed in lowest position. Call light is within reach. Resident is checked for safety and for assistance that resident may need related to non-compliancy in using call light. On 3/17/19 at 11:04 AM, .this writer was standing at the nurses station when I heard someone yelling for help. I opened the door to the bathroom and that is when I discovered resident on bathroom floor, laying on her right side. resident stated that she fell and her right leg was in pain. I asked her where was the pain and she stated it was her right leg. The CNA assisted resident into the wheelchair and wheeled her into her bedroom and put her into bed. I noticed that the resident could not straighten out her right leg. I did not do rom (range of motion) on resident due to pain but I did rom on her other limbs and they were wnl (within normal limits), there was no noted bruising on her body. resident was medicated for pain. Physician was called and notified of fall and xrays ordered stat . On 3/17/19 at 10:41 PM, .Writer received resident lying in bed on her left side .resident had a fall, as (unidentifiable initials) nurse stated she found resident in the visitor's restroom on the floor .The xray dr (doctor) confirmed resident had a right [MEDICAL CONDITION] .Resident left facility around 6:18pm. On 3/20/19 at 10:21 PM, .Resident returned to the facility @ (at) 1900 (7:00 PM) .from (name of local hospital) after suffering a fall which caused resident to have a [MEDICAL CONDITION] .Writer received resident in bed, alert, voicing that she was in pain, writer and CENA got resident as comfortable as possible after assessing resident. Resident has multiple bruising, skin tears, old dark bruises, pressure bandage on right hip, bandages on front of right shin . On 3/21/19 at 2:58 PM, .Res is alert and verbally responsive .Res assessed by therapy staff. Res c/o (complaints of) of pain after therapy session. PRN (as needed) Tylenol given and effective. Res is two person assist with adls and transfers using hoyer lift with two person assist . On 4/19/19 at 9:43 PM, .resident was observed @2000 (8:00 PM) on the floor beside her bed face first with a bleeding laceration on her forehead and 2 skin tears on her right arm .resident complains of pain in her R (right) arm/ribs .orders to transfer resident to hospital for stitches . On 4/20/19 at 9:37 AM, .Res has 5 stitches to front left side of head, skin tear to left shoulder and left lower arm and steri strips to right arm, wrist and hand. Discoloration to B/L (bilateral) LE (lower extremity) and UE (upper extremity). On 4/20/19 at 12:42 PM, .Writer noticed res left hand bent at the wrist with red/purple discoloration and res does not appear to be using the left hand at all. Res was sent out to hospital yesterday for a fall. Res returned to facility this morning. Res c/o pain and when asked where is your pain res stated, all over . (X-ray negative for fracture.) On 4/21/19 at 1:49 PM, .Res alert and verbally responsive with confusion noted .Staff continues to redirect res when she attempts to get out of w/c alone . On 4/26/19 at 3:07 PM, .Left shoulder abrasion wound bed pink, no drainage, edges are attached, [DIAGNOSES REDACTED] present measurements 3.5x3.0 (centimeters). right hand abrasion steri strips intact measurements 0.3x3.0. Right arm abrasion wound bed red 2.7x4.7. [MEDICAL CONDITION] with 4-5 sutures intact hard to count (glue and hair) stuck to incision 4.6 cm long, surgical glue applied, B/L arm bruising. Injuries due to fall. On 5/9/19 at 3:00 PM, .Writer informed that res fell . Writer observed res lying on the floor mat along side of her bed .It appeared that res rolled out of bed onto her right shoulder. Res stated, I fell out of bed. Skin assessed new skin tears to B/L UE . On 8/28/19 10:03 AM, the Director of Nursing (DON) and Administrator were informed of concern regarding R#130's falls and observation of the locked wheelchair. At that time, when asked to discuss the resident's accidents and review incident reports and several other residents, the DON reported Nurse Manager P would be able to assist. On 8/28/19 at 2:40 PM, Nurse Manager P was asked to review R#130's fall interventions as she was identified by the facility as the former nurse manager for third floor and would be able to offer additional information into R#130's accident/fall incidents. Upon review of each incident, Nurse Manager P confirmed the lack of documentation and stated, I see your concern, it does not paint a picture of what actually happened, what was done after, or the staff involved. There was no identification of what nursing staff were involved other than the nurses documenting the incident forms. There were no interview statements from staff to indicate they had been interviewed regarding these multiple incidents. Resident #43 On 8/26/19 at 11:44 AM, R#43 was observed in her room with a male CNA who was attempting to have R#43 sit down. At that time, an alarm on the wheelchair was sounding and the resident was observed crying and repeatedly yelling out for help. Nurse Manager J was just outside the room and when questioned about what was going on, Nurse Manager J directed another CNA to go into the room to assist the resident and stated, That's a pad alarm. She's not having a good morning. Review of the clinical record revealed R#43 was admitted into the facility on [DATE], readmitted on [DATE], and admitted on to hospice services on 2/28/19 with [DIAGNOSES REDACTED]., disorientation and unspecified [MEDICAL CONDITION] (OA). According to the quarterly MDS assessment dated [DATE], R#43 had impaired cognition, exhibited no behaviors, required extensive assistance of one person for bed mobility, transfers, locomotion on unit, dressing, eating, and personal hygiene, required total dependence of one person physical assist for bathing, had two or more falls since prior assessment without injury, had one fall with injury, was always incontinent of bowel and bladder, and used a bed and chair alarm daily. Review of the physician orders [REDACTED].>Sensor alarm to bed and w/c for safety - active 10/1/18 Falling star program - active 7/17/18 Review of the care plans included: The ADL (activity of daily living) read, I require assistance with my ADL'S; (dressing, bathing, grooming, transfers and toileting) related to: Weakness, OA, [MEDICAL CONDITION], anxiety, mood disorder, depression and dementia. I am able to make some of my needs known at times. I get very restless/anxious at times and my need you to walk with me/sit with me until I calm down. I have a gait belt on while I am up in my chair, this way you may assist me when I stand up. I tend to cry and not know why I am crying. I need you to assist me with all my care, mobility and feeding. I am now receiving hospice care due to my overall decline . Date Initiated: 7/25/2018; Created on: 7/17/2018; Revision on: 3/18/2019. Interventions included: I require one person assist with transfers. Keep my gait belt on while I am in my chair. Date Initiated: 7/25/2018; Created on: 7/17/2018; Revision on: 3/18/2019. Wheelchair for seating and locomotion. I require assistance with locomotion Date Initiated: 3/18/2019; Created on: 3/18/2019 RESOLVED: Resident needs to be attended to while she is sitting in her wheel chair at all times. Date Initiated: 3/20/2019; Created on: 3/20/2019; Revision on: 3/29/2019; Resolved Date: 3/29/2019. The fall care plan read, I am at risk for falls/injury r/t History of Falls, [MEDICAL CONDITION], dementia, mood disorder, depression, anxiety, OA and medication use. I will bend over and pick things up off of the floor. this causes me to lean forward and lose my balance easily. Sometimes I do it while I am in my w/c-or I might do it while I am standing up. I also may stand up quickly out of my chair when I am anxious. I have alarms to my bed and chair. Please keep a gait belt on me at all times while I am in the chair- if I allow, so that when I stand up you can walk w/(with) me. 2/20/19 leaned out of w/c. 3/29/19 I rolled out of bed onto pillow and floor mat. I have a low bed and a mat at bedside- I frequently will crawl onto the floor and lay on the mat at bedside. 4/17/19 skin tear to right leg 4/27/19 Fall Date Initiated: 7/25/2018; Created on: 7/17/2018; Revision on: 4/29/2019. Interventions included: 1/31/19: I lean when I am tired, I do not respond to v/c's (verbal cues) to sit back or straighten up- Offer to let me lay down for a nap. Date Initiated: 1/31/2019; Created on: 2/18/2019. 10/1/18 sensor alarm to bed and w/c for safety Date Initiated: 10/1/2018; Created on: 10/1/2018. 10/8/18-When I become agitated/anxious: Apply a gait belt, try to walk w/me; hold me gently by the elbow or hand- I can walk without much assistance. Date Initiated: 8/13/2018; Created on: 8/13/2018; Revision on: 10/8/2018. 2/20/19: keep me seated at table, I will lean forward out of my w/c if I am left in the open. Date Initiated: 2/21/2019; Created on: 2/21/2019. 3/29/19 (MONTH) roll onto floor mat Date Initiated: 3/29/2019; Created on: 3/29/2019; Revision on: 3/29/2019. 3/29/19: I will crawl onto my floor mat and lay down. Please place me back into bed. Date Initiated: 3/29/2019; Created on: 3/29/2019; Revision on: 3/29/2019. 4/17/19 Use w/c leg rest when transporting res in w/c. Remove w/c leg rest when transporting is complete. Date Initiated: 4/17/2019; Created on: 4/17/2019. 4/27/19 I can be impulsive and try to get up from my wheelchair-please monitor me while I am in the living areas. Date Initiated: 4/29/2019. I like to lay on the edge of the bed Date Initiated: 7/25/2018; Created on: 7/25/2018. Mat on floor to bedside Date Initiated: 7/25/2018; Created on: 7/25/2018; Revision on: 2/18/2019. May have arms or legs resting on mat while in bed Date Initiated: 7/25/2018; Created on: 7/25/2018. Toilet every 2 hours/as needed Date Initiated: 10/8/2018; Created on: 10/8/2018; Revision on: 3/18/2019. Review of the progress notes included: On 8/23/18 at 7:36 PM, .Writer waiting MD (medical doctor) .Res transferred to (name of local hospital) related to fall with deep laceration and low BP (blood pressure) . On 8/24/18 at 1:47 AM, Resident returned from hospital @ 0140 (1:40 AM) .dressing to laceration above right eye with 4 stitches noted . On 8/28/18 at 4:55 PM, .Writer heard cena call for writer. Writer then entered res room and observed lying on the floor. Writer asked cena what happen? Cena stated, I was changing her brief. Writer asked cena if res had hit her head during fall and cena stated. No, I was able to break the fall alittle <sic>. Res has confusion and is unable to explain what happen .Writer educated cena on doing brief changes in restroom while res holds onto assist bar or while res is lying in bed for safety . On 9/23/18 at 10:35 PM, .Writer was at med cart and turned to look into res room to observe res and noticed res was not in bed. As writer entered room, writer saw res standing bending over toward floor as if she was trying to pick something up off the floor and res fell over before writer could get to resident .res handed writer a small balled up piece of paper. When asked what were you doing? Res stated, I was getting up.During monitoring of res writer noticed res appeared to have swelling noted to left shoulder .Res alert and verbally responsive rolling around on unit in w/c . On 10/8/18 at 9:15 AM, .Nurse called to room by cna, observed resident laying in prone position on the floor, at the foot of bed, in front of the window, head next to the nightstand. When resident was asked what was she doing she stated, I want to go to the bathroom .Redness noted to right shoulder, right knee and right buttocks . On 12/10/18 at 5:46 PM, .Resident observed on floor in dining area @ 1705 (5:05 PM), writer asked what she was trying to do, resident could not answer .Resident placed in her bed and still trying to get up out of bed . On 1/18/19 at 6:18 PM, .Res is restless. Non-pharmacological interventions used throughout the day with resident .1:1 attention providing reassurance . On 1/31/19 at 1:34 PM, .Writer informed by cena that res had a fall. Res unable to verbalize what happen due to confusion . On 2/12/19 at 12:03 PM, .Shortly after breakfast res began to cry and request that staff remain near her side. Staff provided one on one attention and crying continued .Res began to make several attempts to stand and ambulate out of w/c . On 2/20/19 at 2:40 PM, .Resident was observed on the floor by nursing station, resident was checked for any injury, was assisted back to her wheelchair . On 2/24/19 at 3:16 PM, .After lunch writer noted res leaning forward in w/c. Staff repositioned res, and the leaning continued .Writer noticed res required more assistance than usual with transferring and standing . On 3/12/19 at 4:21 PM, .Writer notified by staff on duty that resident was on the floor in the dining room. No injuries noted . On 3/20/19 at 3:50 PM, .Resident sitting at the table in the common dining area in her wheelchair, kept leaning forward in her chair writer and other staff kept telling her to sit back, CENA walked away from table where resident was sitting and shortly after the resident fell out of wheelchair. Writer observed resident laying on her left side face down. On 3/29/19 at 4:04 PM, .Writer heard residents bed alarm sounding. Writer entered res room and observed res on her buttock in a sitting position on top of a pillow that was laying on her floor mat. When asked what happen res stated, I don't know honey. On 4/27/19 at 4:09 PM, .Patient was sitting in front of nursing station, writer went to 3 south to supply closet, as I was returning to Unit writer observed patient sliding out of w/c onto floor chair . On 4/27/19 at 8:54 PM, .Resident trying to get out of bed around 1900 (7:00 PM). Resident assisted to w/c up in dining room . On 8/28/19 at 2:30 PM, Nurse Manager P was asked to review R#43's fall interventions as she was identified by the facility as the former nurse manager for third floor and would be able to offer additional information into R#43's accident/fall incidents. Upon review of each incident, Nurse Manager P confirmed the lack of documentation and stated, I see your concern, it does not paint a picture of what actually happened, what was done after, or the staff involved. When asked about several of the incidents where the resident was left unattended, or unsupervised, Nurse Manager P reported that particular nurse was no longer employed at the facility and should not have left the resident unattended. When asked about the multiple falls in the dining room, why were they unwitnessed if staff had been supervising, Nurse Manager P was unable to offer any explanation. Nurse Manager P did confirm there was no identification of what nursing staff were involved other than the nurses documenting the incident forms. There were no interview statements from staff to indicate they had been interviewed regarding these multiple incidents. When asked about the resident's impulsivity and need for frequent reminders to sit down, and how current staffing was able to provide adequate supervision for R#43 as well as other residents with similar behaviors, especially when management staff and other staff were not in the building (i.e. evenings, weekends), Nurse Manager P acknowledged the concern at times and reported they worked with what they had. Resident #126 On 8/26/19 at 9:53 AM, R#126 was observed lying in bed, with the right side of the bed against the wall in a high position, and a fall mat was observed placed up and away from the bed near the privacy curtain. The resident was unable to respond verbally to questions asked. Review of the clinical record revealed R#126 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the annual MDS assessment dated [DATE], R#126 was rarely/never understood or able to understand, had severely impaired cognitive skills for daily decision making and impaired long and short term memories, had no behavior concerns, required extensive assistance of two plus persons physical assist for bed mobility, dressing, and personal hygiene, required total dependence of two plus persons physical assist for transfers, toilet use, and had one fall since prior assessment with no injury. Review of the care plans included: The ADL care plan read, she requires total staff assistance with lift when going from bed to chair. Date Initiated: 8/08/2019; Created on: 08/08/2019. Interventions included: BED MOBILITY: The resident is totally dependent on staff for re-positioning and turning in bed. Date Initiated: 10/22/2015; Created on: 10/22/2015; Revision on: 04/18/2016. The fall care plan read, I am at risk for falls/injury r/t decreased mobility, Poor safety awareness, medication use, dementia 5/29/19 fall with no apparent injury. Date Initiated: 10/30/2015; Created on: 10/30/2015; Revision on: 8/15/2019. Interventions included: Bed against wall. Date Initiated: 2/9/2017; Created on: 2/9/2017; Revision on: 5/29/2019. Low bed Date Initiated: 10/30/2015; Created on: 10/30/2015. Mats on floor Date Initiated: 4/22/2017; Created on: 4/22/2017; Revision on: 8/15/2019 Review of the interdisciplinary progress notes included: On 5/29/19 at 2:14 PM, .I&A (incident and accident) fall, observed resident on the floor at the side of her bed in room at 0815 (8:15 AM), call light in reach but unable to use . Review of the fall documentation provided by the facility included the above progress note and for the portion of the form that asked about predisposing situation factors, Other was check marked and a note read, Resident position in bed & floor mat away from bed. There was no identification of what nursing staff were involved other than the nurse documenting the incident form. There were no interview statements from staff to indicate they had been interviewed regarding this incident. On 8/28/19 at 3:15 PM, Nurse Manager P confirmed the documentation reflected the identified fall interventions were not in place and reported that R#126 had likely fallen due to improper position in bed and lack of fall mat in place as documented on the incident report. At that time, Nurse Manager P was informed of the observation of the lack of floor mat in place on 8/26/19 and reported she would follow up with the new Nurse Manager Q. Resident #104 On 8/26/19 at approximately 12:08 p.m. and 1:10 p.m., R#104 was observed in their room, up in their wheelchair. R#104 was observed alone in their room without any supervision. On 8/27/19 at approximately 12:56 p.m., R#104 was observed in their room up in their wheelchair. R#104 was observed alone in their room without any supervision. On 8/28/19 at approximately 11:33 a.m., and 1:33 p.m., R#104 was observed in their room up in their wheelchair. R#104 was observed alone in their room without any supervision. On 8/26/19 the medical record for R#104 was reviewed and revealed R#104 was initially admitted to the facility on [DATE], last admitted on [DATE] and had [DIAGNOSES REDACTED]. A review of R#104's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/13/19 revealed R#104 required extensive assistance from facility staff with most of their activities of daily living and indicated that R#104 had a fall within a month prior to admission. A review of R#104's Resident Care Guide (A set of resident care directives for the clinical staff) revealed the following: Do not leave alone in wheelchair in room .Falling star (a fall awareness program for residents at risk of falling). A review of R#104's careplan revealed the following: Focus-am at risk for falls/injury r/t (related to) Gait/mobility impairments, History of Falls, Incontinence, Poor safety awareness, Weakness .Goal-Minimize risk factors for falls .Interventions-Do not leave alone in room in wheelchair .I am on the falling star program Keep in common area . A review of an incident report dated 7/22/19 revealed the following: Incident Description: Resident was observed on the floor, on his back, next to his bed and wheelchair. Resident stated he fell out of his wheelchair. Resident was assessed and placed in his bed .Predisposing Physiological Factors: 'Confused' .Other info: Resident has been watching television in his room, in his wheelchair. during shift change resident was observed on the floor .Witnesses:No witnesses found . A review of a facility document titled Post fall analysis and investigation for R#104's fall on 7/22/19 revealed the following: 2. Assess and briefly describe: Resident's ability to recognize safety needs-Poor safety awareness . On 8/28/19 at approximately 1:50 p.m., R#104's resident care guide and careplan were reviewed with staff member A[NAME] Staff member AA was queried if R#104 should have been left alone their room unsupervised and they indicated that according to the care guide and the careplan they shouldn't. On 8/28/19 at approximately 2:38 p.m., during a conversation with the Director of Nursing (DON), the DON was queried if it was their expectation that facility staff utilize the fall interventions on the care guide and careplan for residents identified as being at risk for falling and they indicated that it was. Review of the facility's Falling Star Program dated 2/16/18 documented, in part: .The bed should be lowered, making sure the brakes on the bed, chair or commode are locked .Staff will engage restless residents in cognitive activities or crafts .Staff will educate families regarding fall risks and ways to assist staff in preventing fall . Deficient practice #2: Based on observation, interview, and record review the facility failed to ensure adequate supervision and positioning during dining for one (R#114) of seven residents reviewed for accidents, resulting in the potential for aspiration. Findings include: On 8/28/19 at 9:44 AM R#114 was observed in their room. The resident was observed to be positioned in their bed with their breakfast tray present on the overbed table, which was positioned over the resident's bed. The resident's was observed to be coughing, and staff were not present in the resident's room or assisting the resident with the breakfast meal at the time of the observation. R#114 then asked for a pat on the back. Licensed Practical Nurse (LPN) 'EE' and Nursing Assistant 'II' were observed to assist the resident with repositioning in the bed. LPN 'EE' then said to let Nursing Assistant 'GG' know that the resident needed assistance with eating. Review of R#114's clinical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's admission minimum data set (MDS) assessment dated [DATE] revealed the resident scored 11 out of 15 on a brief interview for mental status exam, which indicated the resident was moderately cognitively impaired. Per this assessment, it was documented the resident required the extensive assistance of one person physical assist for eating. Review of two physician orders [REDACTED]. Review of R#114's meal ticket for the breakfast meal on 8/28/19 was not observed to include any documentation to indicate the level of staff assistance the resident required with dining. Review of Resident #114's speech therapy evaluation for a certification period of 8/1/19 to 8/28/19 revealed the following reason for referral: Patient referred to ST (speech therapy) by OT (occupational therapy) due to new onset of coughing/choking during oral intake placing patient at risk for aspiration, malnutrition, pneumonia and dehydration. Patient admitted on a mech (mechanical) soft/thin liquid diet. Patient would benefit from a swallow eval to assess appropriateness of current diet and need for compensations to reduce aspiration risk. Per the Dysphagia Medical Workup section of the document, it was noted that the resident was, found to have a swallowing disorder involving the Pharyngeal Phase. Recommendations for supervision and strategies included the following: Supervision for Oral Intake= Close supervision and Swallow Strategies/Positions: To facilitate safety and efficiency, it is recommended the patient uses the following strategies and/or maneuvers during oral intake: general swallow techniques/precautions, no straws, altercation of liquids/solids, rate modification and bolus size modifications upright posture during meals and upright posture for > (greater than) 30 mins (minutes) after meals. The evaluation also documented the following assessment/summary: Skilled SLP (speech, language. pathology) services for dysphagia are warranted to analyze oral/pharyngeal function, develop & instruct in compensatory strategies and instruct family/staff in compensation techniques in order to enhance patient's quality of life by improving ability to safely consume least restrictive diet and decrease risk of aspiration. Risk factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for: aspiration, falls, dehydration, pneumonia, malnutrition, weight loss and decreased ability to return to prior level of assis

This citation pertains to intake #s: MI 129. Based on observation, interview and record review, the facility failed to provide safe transfer to prevent serious injury for one (#701) of four sampled residents reviewed for fall with injuries, resulting in functional decline and loss of independent mobility when R#701 fell from a mechanical lift during a transfer, and hospitalization with surgical intervention for a displaced and angulated [MEDICAL CONDITION] femur. Findings include: On 11/14/18 at 10:00 AM, review of complaints filed with the State Agency included an allegation that R#701 sustained a fall with injury and that the family suspected foul play. On 11/14/18 at 11:40 AM, an interview was conducted with the Director of Nursing (DON). At that time, the DON reported the facility had filed a report with the State Agency regarding R#701's fall with injury. The DON further reported the alleged perpetrator (Certified Nursing Assistant/CNA B) was not responding to requests for further inquiries into the incident and had been issued a letter of termination by certified mail. On 11/14/18 at 11:42 AM and 1:19 PM, CNA B was attempted to be contacted by phone. There were no return calls from CNA B by the end of the survey. On 11/14/18 at 12:00 PM, observation of the facility's video surveillance from 10/26/18 was conducted with the Security Systems Manager and DON. At that time, there were three video clips available for review. The video imaging was not clear, however the Security Systems Manager and DON were able to identify R#701's room and staff observed on the video. Review of the video footage from 10/26/18 included: The first video clip started at approximately 9:50 PM. At that time, a sit to stand mechanical lift was observed in the hallway just across from R#701's room. At approximately 9:51 PM, CNA B (identified by the DON) was observed exiting R#701's room, and proceeded to obtain the sit to stand mechanical lift from the hallway and brought the lift into R#701's room. The second video clip which started at approximately 10:31 PM showed that at 10:32 PM CNA B removed a wheelchair and lift from R#701's room, placed these in the hallway just outside the room, and then re-entered R#701's room. CNA Bs mannerisms were unhurried, with no visible signs of concern or urgency. At approximately 10:33 PM, CNA B was then observed exiting R#701's room and entered another resident's room further down the hallway (room identified by the DON as a room Licensed Practial Nurse/LPN A was in). The third video clip which started at approximately 10:35 PM showed that CNA B left the room at the end of the hallway and re-entered R#701's room. CNA B then left the room and re-entered the room with the Nurse. LPN A was observed leaving the room, and CNA B left shortly after. LPN A approached another nursing assistant (CNA G), LPN A took the sit to stand lift back into R#701's room with CNA G. At approximately 10:43 PM, Nurse Supervisor F (identified by the DON) was observed entering the doorway of R#701's room. At approximately 10:45 PM, Nurse Supervisor F and LPN A were observed talking in the hallway and LPN A then headed toward the nursing desk. On 11/14/18 at 1:21 PM, a phone interview was conducted with CNA G. When asked to recall the events from 10/26/18, CNA G reported, I was in a patient's room getting them ready for bed. (LPN A) came in and said (R#701) was on the floor. When I went into his room, (R#701) was on the floor, head was turned toward nightstand and feet were toward the TV. He was on his back. He wasn't yelling at all and that's not like (R#701). Usually he's screaming and hollering. I asked him what happened and he didn't say anything. He usually uses a sit to stand lift. When asked if R#701 exhibited any restless behaviors that might have made transfer difficult, CNA G stated, No. I wouldn't say he's restless. He can talk the best he can and we've been around him for a long time. I'm not sure about the nurse aide that had him, she was new. On 11/14/18 at 2:04 PM, an interview was conducted with LPN A. When asked to recall the events of R#701's incident on 10/26/18, LPN A stated, The night of the incident I was in another resident's room. The aide (CNA B) walked to me and said 'You know the guy I layed in bed, he's on the floor.' I asked 'Doing what?' and she said 'I put to bed and put lift back.' I asked her to stay with the other resident while I went to check on him. I walked in and (R#701) was on his back on the floor. Bed was very low to the floor. Asked what happened, saw he still had his pants on. I got another staff (CNA G) to help get him up. As soon as pulled down pants (to observed for injuries) I saw the hip and I said don't touch him. Called the on-call physician and he was sent out. They (hospital) called back at around midnight and said he had a [MEDICAL CONDITION]. That was my first time meeting her (CNA B). When asked if CNA B appeared alarmed or if there was any sense of urgency, LPN A stated, No. Just said 'I put him to bed and (R#701) can't tell what happened. When asked about the resident's transfer status, LPN A reported, With sit to stand lift it is one person. Hoyer is two person, which is what he is now. On 11/14/18 at 2:15 PM, a phone call was received from Attorney J who stated he represented CNA B and would be able to provide information as CNA B had informed him of the multiple requests to discuss the incident. At that time, Attorney J reported there was a meeting with Detective I tomorrow to provide further statements. Attorney J further reported, Here's what happened. (CNA B) tries to do a manual lift assistance, probably should've used two people. Never worked with this patient before. During the course of the transport, (R#701's) feet became entangled under lift mechanism and (CNA B) pulled back and he slipped and fell down. In her panic she got nervous and was concerned about losing her job. She did lie to the Director of Nursing. She never got him into the bed. She panicked. It was essentially a transport issue with an aphasic patient and went awry. When (CNA B) tried to dislodge his feet, he fell . On 11/14/18 at 3:35 PM, R#701 was observed lying in bed resting with his eyes closed. Upon approach, R#701 was non-verbal but agreed to participate in an interview and responded appropriately to simple yes and no questions asked by nodding his head in yes and no motions. At that time, when asked Are you having any pain? R#701 shook his head up and down in a yes motion. When asked Did you have a fall recently? R#701 shook his head up and down in a yes motion. When asked Did you fall from the bed? R#701 shook his head left and right in a no motion. When asked Did you fall from a mechanical lift? R#701 shook his head up and down in a yes motion. When asked Do you feel safe here? R#701 shook his head left and right in a no motion. When asked Have there been any other incidents of falling from the lift, or like that? R#701 shook his head left and right in a no motion. When asked Are you scared? R#701 shook his head up and down in a yes motion. Review of the facility's investigation included: XXX[AGE] year old resident (R#701) resided at (facility name) since 6/28/2016. He is developmentally disabled and aphasic as a result of multiple [MEDICAL CONDITION]. On 10/26/2018, the Certified Nursing Assistant assigned to (R#701) reported to the nurse that her resident was on the floor. (R#701) transferred to the hospital related to pain and inability to perform range of motion. Xrays were performed and confirmed a [MEDICAL CONDITION] femur. (R#701) had hip replacement surgery and is recovering .Due to a lack of evidence, the facility was not able to substantiate abuse or neglect. At this time the facility concludes that the nursing assistant did not tell the truth about what happened. Facility presumes that the resident had an incident while being transferred with a sit to stand lift. This aphasic resident indicated, when prompted, that there was an unintended incident involving the lift that resulted in him falling .Resident returned to facility on 11/03/2018. He is recuperating and rehabilitating .(Physician D), residents attending physician at the facility saw him at the hospital. Speaking to the Director of Nursing on 10/31/2018, he indicated that the fracture was likely caused from a fall from a height higher than a bed in lowest position. He said resident says yes when asked if someone dropped him. He also said that he has weak fragile bones .Facility is unable to substantiate abuse or neglect due to lack of evidence. Nursing assistants accounting of what happened is not consistent with the video of the corridor movement in and out of resident's room .However, she did not leave the room, return to the room and find resident, then get nurse as she reported. She left the room, went in another room, and then got nurse and returned to (R#701's) room. Facility concluded that she must have been in the room when the fall occurred. Facility presumes that nursing assistance <sic> had a problem with the resident during transfer causing a fall that resulted in a [MEDICAL CONDITION] . Review of the clinical record revealed R#701 was initially admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], R#701 had impaired short term memory, had intact long term memory with moderately impaired decision making skills, and required extensive assistance of two people for bed mobility and transfers. Review of the care plans included: I recently broke my right hip. I can no longer use the stand up lift to get into the bathroom and I can't wheel myself around in the w/c (wheelchair) like I use to. I'm at high risk for falls. Date initiated 11/5/16, Revised 11/5/18. I require assistance with my ADL's (Activities of Daily Living) (dressing, bathing, grooming, transfers and toileting) related to: Weakness, Cognitive Impairments, Gait/Mobility Impairments, intellectual disability .11/3/18-RIGHT [MEDICAL CONDITION] Hoyer lift transfer with two person assist. Date initiated 4/5/16, Revised 11/5/18. Intervention added on 11/6/18 included, I use a Hoyer lift for all transfers. Review of the RESIDENT CARE GUIDE at the time of the fall on 10/26/18 documented R#701 was a one person assist with sit to stand lift (which conflicted with the most recent quarterly MDS assessment). Review of the facility's Fall Prevention Program policy dated (MONTH) 2, (YEAR) included: .As part of injury prevention related to falls, each plan of action should be individualized to the specific resident. Review of the facility's Abuse Prohibition Program policy dated (MONTH) 28, (YEAR) included: .Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that area <sic> necessary to avoid physical harm, mental anguish, or emotional distress .

This citation pertains to Intake Number MI 269 and MI 291. This citation has two deficient practices. Deficient Practice #1. Based on observation, interview, and record review, the facility failed to transfer a resident in a safe manner utilizing a gait belt for one (#401) of three residents reviewed for accidents, from a total sample of three, resulting in a leg fracture requiring surgery surgical intervention, increased pain, and decreased mobility. Finding include: On 11/16/17 at 10:45 A.M., Resident #401 was observed seated in a wheelchair with her legs elevated and extended straight. A brace was observed on Resident #401's left leg. When queried about what happened to her leg, Resident #401 did not give a clear answer and stated, I don't know. It was more than a dog bite though. On 11/16/17 at 11:56 A.M., Resident #401's clinical record was reviewed and revealed the following: Resident #401 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented Resident #401 had moderately impaired cognition and required extensive assistance from one staff member for bed mobility, limited assistance for transfers, and extensive assistance for ambulation. A progress note dated 10/28/17 at 11:07 P.M. written by Nurse A documented, Resident complained of pain in left knee and ankle .CNA (certified nursing assistant) and writer had to transfer resident from toilet to wheelchair and wheelchair to bed, facial grimace made as attempted to stand with assistance. Once resident was (safely) put into bed, writer performed ROM (range of motion) on left ankle. Resident's facial expression did not express pain. Writer touched left knee and observed facial grimace .Tylenol given. Will inform oncoming nurse . A progress note dated Late Entry 10/30/17 written by Nurse A documented, Resident son approached writer at the nursing chart. He asked writer, 'Did something happen to my mom? Writer replied, 'I have not been gotten any reports about your mom from any of the CNAs giving care. Shortly after the CNA assigned to the resident at that time came and informed me she needed my help with resident. Writer entered resident room going to restroom. Writer observed resident sitting on the toilet. Resident was dressed with a purple night gown and TED hose was still on resident .When resident went to stand up, resident began to moan 'Oh Lord' and was not able to stand. Resident was placed back on toilet .CNA and writer was able to transfer resident to w/c from toilet and the wheelchair to the bed . An Incident and Accident (I&A) report dated 10/29/17 documented, During morning care resident expressed having pain in her left leg. Res. (resident) did not want anyone touching the left leg . The facility's investigation was reviewed on 11/16/17 at 12:00 P.M. and it revealed the following: A Investigation of Injury of Unknown Origin with a fracture of the lateral tibia plateau documented, .On 10/28/17, Nurse A was called to the room by CNA (certified nursing assistant) B. Resident had complained of pain and was unable to stand and transfer. Nurses assessed the resident and assisted the CNA with transferring the resident .The nurse performed range of motion on the left ankle and resident facial expression did not express pain, the nurse then touched the left knee and observed facial grimacing. The resident was medicated with Tylenol. The report was given to the oncoming nurse. On 10/29/17 Nurse A returned to work and noted the resident was complaining of left ankle pain, and was medicated with (a narcotic pain medication) and called the Primary Care Physician (PCP) on call and received an order to complete a state x-ray to the area .The x-ray was completed and results were reported: Acute fracture of the lateral tibia plateau (leg fracture), the PCP was updated with this information and ordered the resident to be sent to the ER for evaluation . An Injury of Unknown Origin - Investigation Report signed and dated by the Director of Nursing (DON) on 10/31/17, documented the date injury was discovered was 10/29/17 (resident first experienced increased pain and was unable to stand on 10/28/17 per the above nursing note) at 9:00 A.M. Description of Injury: Pain to left leg Immediate Protective & Corrective Action(s): (Nurse A) called (physician) group to update and received the order for an (x)-ray to the left leg (knee to ankle) . Preliminary Investigation (Findings): Resident was taken to her room restroom for HS (evening) care, CNA B had the top part of the resident's clothes replaced with her night gown but could not encourage the resident to stand to remove her pants and to be toileted. Staff asked for son's assistance in the room. Son assisted the staff member (CNA B) by taking off the resident's pant and to stand and pivot to the toilet. (CNA B) could not encourage the resident to stand from the toilet and then requested the nurse (Nurse A) to the restroom for assistance. The staff then completed a two person assist from the toilet to the wheelchair and then to the bed .Follow-Up: .The following dayshift the resident was assessed for pain to the left knee and not allowing CNA to assist with dressing her lower extremities, PCP (primary care physician) on call was made aware and LLE (left lower extremities) ordered STAT x-ray .Conclusions & Recommendations: Resident was transferred to (hospital) ER for evaluation of the LLE due to a fracture report of the fracture lateral tibia plateau. Continue education on gait belt transferring and re-approaching techniques . A timeline of events from 10/28/17 (from video footage in the hallway, per the DON and Administrator) included in the investigation documented between 3:38 P.M. and 6:47 P.M., Resident #401 was observed in the dining room and did not exhibit any signs or symptoms of pain. At 6:47 P.M., CNA B took Resident #401 back to her room in the wheelchair and four minutes later waved the resident's son into the room. At 7:20 P.M., Resident #401's son came out of the room, entered the room again at 7:21 P.M., and Nurse A entered the room at 7:23 P.M. On 11/16/17 at 1:20 P.M., CNA B was interviewed via the telephone. CNA B reported her employment was terminated from the facility. CNA B was asked to explain what happened with Resident #401 on 10/28/17. CNA B stated, (Resident #401) wasn't my aide and then I got switched to her at dinner time. She was complaining of pain so her son took her back to her room. I went to her room (Resident #401) to get ready for the nightly routine. I put her pajama top on and wheeled her to the bathroom. She was in her wheelchair by toilet and said her leg hurt and she couldn't stand. Her son came in and got behind her and was trying to scoop her up and put her on the toilet. She kept saying 'I can't do it' and was holding on to the bar. I kept saying 'She's in pain'. He put her on the toilet and she didn't use the toilet. Then the nurse came in. On 11/16/17 at 1:38 P.M., Resident #401's family member (who was present on 10/28/17) was interviewed via the telephone. The family member was asked to explain what happened with Resident #401 on 10/28/17. The family member stated, She (Resident #401) was fine at dinner, sitting in her wheelchair. I was with her. Her aide (CNA B) took her into her room. I'm not sure how long it was before she came to get me. The family member reported that Resident #401 was seated in a wheelchair in the bathroom when he entered the room. The family member stated, She was in terrible pain when I walked in and she was wearing her nightgown. She was in a lot of pain and the aide didn't offer anything about what happened and why she was in so much pain so I eventually went to get the nurse and then they put her in the bed. They didn't get x-rays until the next morning and that's when we found out she had a fracture. ON 11/16/17 at 5:27 P.M., Resident #401's Medication Administration Record (MAR) was reviewed and it revealed the following for November 2017: An order to Monitor pain every shift, scale 1-10 (with 10 being the worst pain). On 11/9/17, Resident #401 had a pain level of 8 on the day shift and 5 on the evening shift. On 1/10/17, Resident #401 had a pain level of 5 on the evening shift. an order for [REDACTED].#401: 11/3/17 at 9:56 P.M. the pain level = 8 11/4/17 at 2:21 A.M. = 6, 7:26 A.M. = 4 11/5/17 at 9:03 P.M. = 9 11/6/17 at 3:42 P.M. = 7 11/7/17 at 11:08 A.M. = 6 11/9/17 at 11:29 A.M. = 7 and 6:02 P.M. = 5 11/10/17 at 10:47 A.M. = 4 and 5:02 P.M. = 5 11/14/17 at 7:00 P.M. = 7 A Pain assessment dated [DATE] was reviewed at that time and it documented that Resident #401 complained of frequent pain, was guarded and protective of the area (left leg) and exhibited complaining, crying, moaning, restlessness, resistiveness, facial grimacing, guarding, withdrawal, and anger. The pain assessment documented the current [DIAGNOSES REDACTED]. A care plan dated 11/3/17 documented Resident #401 required a mechanical lift for transfers with the assistance of two staff members (The MDS assessment dated [DATE] documented prior to the leg fracture that Resident #401 required limited assistance with transfers) and was non-weight bearing. On 11/16/17 at 5:30 P.M., the DON was interviewed. When asked how Resident #401 fractured her leg, the DON stated, I'm not sure. I spoke with the PA (physician's assistant) after and they said it could have been pathological from osteoporosis. I do know that she did not complain of pain throughout the day and it wasn't until she was taken back to her room after dinner when the pain was noted. The DON was asked why CNA B was terminated from employment. The DON stated, After we did our investigation it was determined she did not use a gait belt when she transferred the resident from the wheelchair to the toilet and she should have used one. The facility's policy titled, Transfer Technique dated April 5, 2011, was reviewed on 11/16/17 at 6:00 P.M. and it documented, Resident will be transferred within the following guidelines: .Use assuasive devices .Safe techniques include: Use a gait belt . Deficient Practice #2 Based on interview and record review, the facility failed to ensure a bed was in a safe position for one (#402) of three residents reviewed for falls, from a total sample of three, resulting in the resident falling out of a bed in the highest position and the potential for injury. Findings include: On 11/16/17 at 1:50 P.M., Resident #402's clinical record was reviewed and revealed the following: Resident #402 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented Resident #402 had severely impaired cognition and required extensive assistance from two staff members for bed mobility and transfers. A MDS assessment dated [DATE] documented, Resident #402 required extensive assistance from one staff member for bed mobility and two staff members for transfers. An Incident Report (I&A) dated 7/11/17 was reviewed on 11/16/17 at 5:00 P.M. The I&A documented, Nurse called to room by CENA, resident observed laying on his stomach on his right side next to bed in front of night stand wrapped in bedding. Resident bed was noticed in highest position. A Post Fall Analysis and Investigation form attached to the I&A documented, .Resident's bed observed to be in high position .Care plan addresses low bed already . A care plan dated 3/8/17 documented, .rolled out of bed when care was being provided . An intervention documented, Low bed/ensure that bed is positioned correctly after procedures and are finished . The intervention was dated 7/11/17. An intervention dated 3/8/17 documented, Staff was educated on making sure the resident is positioned correctly . The DON was interviewed on 11/16/17 at 5:30 P.M. and indicated Resident #401's bed should have been in a low position.

This citation refers to Intake Number MI 369 Based on observation, interview and record review, the Facility failed to ensure a resident transfer was provided in a safe and proper manner for one cognitively impaired Resident (#701) of two residents reviewed for falls, from a total sample of four, resulting in Resident #701 sustaining a right proximal humerus (shoulder) fracture and tramatic hematoma to the forehead. Findings include: A Complaint was filed with the State Agency on 9/11/2017 alleging that the Facility failed to provide a safe transfer for Resident #701 resulting in a fall with injury (right arm fracture and right eye injury). On 10/11/17 at 8:45 a.m., Resident #701 was observed sitting in the dinning room during breakfast. The Resident had her right hand on her lap and was not observed using her left hand to eat. The Resident was queried about life in the Facility, but was not able to answer questions asked. On 10/11/17 at 9:40 a.m., Resident #701's clinical record was reviewed and revealed that the Resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 8/03/2017 documented that Resident #701 had a Brief Interview for Mental Status (BIMS) score of 99 (severely impaired cognition) and required extensive one person assist for transfers and extensive one person assistance for ambulation via wheelchair. A review of the Resident's Care Plans, documented, in part, the following: Focus: I have a past history of falls . Interventions: (9/9/17):Ensure proper body mechanic are being used during transfers Focus: I require assistance with ADLs (activities of daily living) . I can stand and pivot for transfers to bed & chair Interventions: · Assist Resident with transfers · I have visual impairments . I need you to assist me throughout day as needed. An order dated 10/14/16 documented Falling Star Program (a program used for those at Risk for Falls). A review of the Resident's progress notes documented, in part, the following: 9/19/17 at 11:42 (authored by Nurse B) CNA (certified nursing assistant) summons writer to room stating it was a fall, went to room to finding resident on her right side on the floor. Assessed her, obtained vitals and did a neuro check then got Resident on to bed, noticed quarter sized hematoma on her right eye just above her eyebrow as she also complained of arm and shoulder pain, did not tolerate ROM (range of motion) check. Dr. notified and instructed to send to ER (emergency room ) for x-ray and further testing Nurse progress note (9/9/17:16:35): Resident from Hospital (name redacted) with [DIAGNOSES REDACTED]. A Facility Incident and Accident Report documentation dated 9/9/2017 was reviewed and revealed, in part, the following: Resident: #701 Date: 9/9/2017 : 11:19 Incident Description: CNA summons writer to come to room a fall occurred Witnesses: Name (CNA A) Statement: This morning I went into the room to get Resident #701 ready to take a shower. She was in gown with socks .I helped her to stand and she was facing the wheelchair with her hands on both the wheelchair arms. I said to Resident #701 I'm going to help you to turn to sit in the wheelchair and she said ok and she started to move her right hand from the arm to the chair and she shuffled her feet and lost balance and fell on her right side to the floor. In-Service Training: Employee: (CNA A): Topic: Transfers/Gait Belt On 10/11/17 at 11:43 a.m. a phone interview was conducted with CNA A pertaining to the Resident #701's fall. CNA A was queried as to what happened on 9/9/17. CNA A reported that she worked contingent (an independent worker) as a CNA at the Facility and on 9/9/17 she went to assist Resident #701 to the shower. CNA A stated, The Resident was in bed and she was helping her to get into the wheelchair. She was on the side of the bed and I helped her up and asked her to hold on to her wheelchair. She turned to the right and lost her balance and fell to the floor. When queried as to whether she used a gait belt (a device used to transfer residents with mobility issues from one position to another), CNA A stated, No. I did get in-service training on gait belts after she fell . CNA A was further queried as to whether she received training pertaining to Resident transfers and gait belts and responded, Yes, I think I received training when I worked at the Hospital. On 10/11/17 at 1:26 p.m., an interview was conducted with Physical Therapist Manager (PT) C. PT C was queried as to the transfer of Resident's. PT C stated, It depends on the method of transfers. Some Residents need a lift to transfer if they can not bare weight. When further queried as to how Resident #701 who needs extensive one person assist without a lift are to be transferred, PT C stated, A gait belt is used. On 10/11/17 at 3:20 p.m., an interview was conducted with the Director of Nursing (DON). The DON was queried as to the incident involving Residident #701 on 9/9/17. The DON reported that CNA A was attempting to transfer the Resident from the bed to the wheelchair and the Resident lost her balance. When queried as to the Facility Policy pertaining to transfers for those needing a one person assist, the DON reported that gait belts should be used. The DON reported that CNA A was retrained on the use of a gait belt. On 10/11/17 at 4:00 p.m., a review of the Facility Policy titled Gait Belt Use(effective (MONTH) 10, 2008) was conducted and documented, in part, the following: Purpose: To provide a firm grasping surface and to safely transfer weight bearing residents to a wheelchair .or ambulate a resident safely using proper body mechanics and gait belt. Gait-belts are a safety device used for moving a person from one place to another and to assist to hold up a weak person while ambulating. Using a gait belt allows the caregivers the ability to keep a grip on the resident to avoid falls and/or stabilize an unsteady resident during ambulation Procedure: 3.Place gait belt over clothing with buckle in front around residents waist .Place loosely enough to be comfortable, but not fall of waist .This facilitates adequate support of resident during transfer or ambulation. 5. Grasp the gait belt firmly, bring resident to a standing position allowing the resident to assist as much as possible . 7. Use the gait belt to assist in stabilizing and turning the resident. 8. If the resident begins to fall, the gait belt will allow you to redirect the resident to the bed, w/c (wheelchair) or toilet without having to lower them to the floor and will allow you to lower them gently to the floor.

This citation refers to Intake # MI 374. Based on observation, interview, and record review, the facility failed to transfer one (#801) of one resident reviewed for pain, from a total sample of three, according to assessed transfer needs resulting in tibia and fibula fractures and decreased mobility from excruciating pain. Findings include: On 6/22/17, the facility reported an injury of unknown origin to the State Agency. The following was reported: On 6/19/17 at 10pm, (Resident #801) was transferred to bed via Hoyer lift and complained of pain. She was assessed by nursing to have [MEDICAL CONDITION] from right hip to foot. NP (Nurse Practitioner) was notified, pain med ordered and given and order for STAT (immediately) Doppler (a test to check blood circulation in the large veins of the legs). On 6/20/17 Doppler results were negative so x-ray was ordered. On 6/21/17 x-ray results indicate fracture to tibia/fibula (shin bones) and resident transferred to hospital. Investigation started 6/21/17 and appears as of 6/22/17 that resident suffered fracture during transfer on 6/19/17. Investigation continues . On 6/29/17 at 9:20 A.M., during an onsite investigation, Resident #801's clinical record was reviewed and revealed the following: Resident #801 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented Resident #801 had moderately impaired cognition and required extensive physical assistance from two staff members for transfers. A nursing care plan revised on 1/12/17 documented the following interventions: 3/12/17 Assist (Resident #801) with transfers .4/9/15 Use sit to stand (a lift designed to assist weight bearing individuals to a standing position) for transfers. A Post Skin Tear/Discoloration analysis and Investigation assessment completed by Nurse C documented that on 6/19/17, Resident #801 had [MEDICAL CONDITION] (swelling) in the right lower extremity found during a transfer. The assessment documented that the [MEDICAL CONDITION] was discovered when Resident #801 was in her bed. Resident #801's statement of what happened was, I can't remember. Possible causes were noted to be staff transfer, care plan not followed, undetermined. A SBAR (Situation, Background, Assessment, Recommendation - a tool used to communicate changes to the medical team) dated 6/20/17 documented Resident #801 had pain, [MEDICAL CONDITION], and warmth to the right lower extremity (RLE) that started on 6/19/17 at 10 P.M. It was documented that the pain was worse when transferring into bed, turning in bed, touching leg. Other relevant information was documented as Foot drop R (right) foot r/t (related to) MS ([MEDICAL CONDITION]). Change in function documented, Unable to tolerate transfer without pain, need to use (mechanical) lift. Pain level was documented as 8 (on a scale of 1 to 10 with 10 being the worse pain possible) entire RLE from hip to ankle. It was documented that Resident #801 was guarding and exhibited resistance to care, had decreased mobility and was unable to assist in turning self in bed left to right. The SBAR noted that Resident #801 was sent to the emergency roiagnom on [DATE]. A Transfer Form dated 6/20/17 documented the reason for transfer as abnormal x-ray. Resident #801's usual functional status documented, Not ambulatory. A Interdisciplinary Rehabilitation Screen assessment dated [DATE] documented Resident #801 required maximum assistance for bed mobility, and used a stand lift for transfers. The assessment documented, No change in weight bearing status .WBAT (weight bearing as tolerated). Physician's/Provider progress notes were reviewed and revealed the following: On 6/20/17 a note documented, .Asked to see regarding leg [MEDICAL CONDITION] .Nursing states during evening care when pt was put in bed, the patient expressed that her right lower extremity was hurting her. Her right lower extremity was also noted by nursing staff to be swollen from the hip to the ankle. No known injuries. It was documented that a Doppler was completed and results were negative. The note further documented, .Pt continues to c/o (complain of) pain to her RLE .Extremities: [MEDICAL CONDITION] noted to entire RLE, tenderness noted to lower leg just distal knee in anterior aspect .We will get X-rays to rule out fracture. The patient is nonambulatory, but has a long standing history of [MEDICAL CONDITION]. We will rule out pathological fracture (fracture caused by another medical condition) . On 6/21/17 a note documented, .Recent R lower extremity pain and swelling. Workup revealed proximal tib-fib fracture. Sent to ER. Placed in leg immobilizer .Staff reports that it is difficult to even rotate the patient in bed due to her discomfort. Pt admits that lower extremities hurt her .Increase [MEDICATION NAME] (narcotic pain medication) to Q (every) 6 hours for at least next week. If she needs it longer, staff has been advised to use (mechanical) lift to get out of bed and to get her our of bed on a daily basis with leg elevated in wheelchair . Hospital paperwork documented the following: A Radiology Report dated 6/20/17 documented, .Right tibia and fibula acute (rapid onset) nondisplaced fractures of the proximal tibia and fibula . Resident #801's Nurse's Notes were reviewed for June 2017 and they revealed the following: A progress note dated 6/16/17 documented, .Denies any pain or discomfort . A progress note written by Nurse C on 6/19/17 at 10:47 P.M. documented, Resident noted to have pain in Rt leg when being transferred to bed at 10 P.M. by CNA (Certified Nursing Assistant). Upon inspection, RLE [MEDICAL CONDITION], pain, warmth noted. (Mechanical) lift used to transfer resident to bed. [MEDICAL CONDITION] noted from Rt. hip to foot with warmth and pain when area moved. Able to raise leg only a few inches off bed. Dr. (doctor) informed, spoke with (Nurse Practitioner), new order for STAT venous Doppler RLE .[MEDICATION NAME] given at 9 P.M A progress note written by Nurse G on 6/22/17 as a late entry from 6/20/17 at 10:28 A.M. documented, Late Note: Midnight shift CNA alerted the writer of c/o pain from resident upon doing rounds in the A.M. During observation, resident noted to have redness and [MEDICAL CONDITION] with warmth of RLE this A.M. Res. was given scheduled [MEDICATION NAME] .Resident in her bed throughout the day .Res. refused repositioning due to pain . A progress note dated 6/20/17 at 5:10 P.M. documented, Rt leg pain, [MEDICAL CONDITION]. A progress note dated 6/20/17 at 9:27 P.M. documented, RLE X-ray was obtained at 8 P.M. RLE remains warm, painful, [MEDICAL CONDITION]. A progress note dated 6/21/17 at 12:18 A.M. documented, X-ray RLE shows acute injury to tibia, fibula .Order to send to ER. EMS transferred resident at 12:15 A.M. to hospital . A progress note written by Nurse C at 1:04 A.M. documented, Res. noted to have redness and [MEDICAL CONDITION] w/ warmth of RLE when this nurse observed res. in her bed after being transferred with (mechanical) lift by CNA on 6/19/17 at 10 P.M . A late entry progress note written by Nurse G on 6/22/17 for 6/21/17 at 10:20 A.M. documented, Rec'd from hospital at 7:30 A.M. wearing immobilizer on RLE. Regular scheduled [MEDICATION NAME] 5-325 mg (milligram) given at 9 A.M. Resident c/o pain at level 10. Resident stayed in bed today .refused repositioning due to pain . On 6/21/17 at 3:15 P.M., Nurse Manager (Nurse E) documented, S/W (spoke with) provider and agreed to increase scheduled pain medication from Q 12 hours to Q 6 hours for 7 days due to fracture. On 6/29/17 at 10:10 A.M., Resident #801 was observed lying in bed covered with a blanket. Resident #801 was asked how she hurt her leg and the resident stated, I have MS. When queried about how she broke her leg, Resident #801 stated, I fell . I have MS. Resident #801 was asked what kind of assistance was provided by staff members and she stated, I don't need help. I have MS. Resident #801 refused to answer any further questions. On 6/29/17 at 10:18 A.M., the assignment sheets from 6/19/17 for the unit Resident #801 resided on were reviewed and revealed that CNA B and CNA D were assigned to Resident #801's unit on 6/19/17 during the 3-11 P.M. shift. The charge nurse was Nurse C. The staffing coordinator was interviewed at that time and asked who was assigned to Resident #801 on 6/19/17. The staffing coordinator indicated CNA B was assigned to Resident #801. On 6/29/17 at 10:20 A.M., the facility's investigation was reviewed and it revealed the following: A summary typed and signed by the Administrator documented, On June 10, 2017 the assigned CNA alerted nurse of pain in her right leg when being transferred to bed using the (mechanical) lift. The nurse assessed the right leg and called the PCP (primary care physician) for follow up orders. A Doppler was ordered and the scheduled pain management was given. The Doppler was completed on 6/20/17 and was negative. Staff protected the area with rendering of care while in bed. The PCP visited on 6/20/17 and ordered an x-ray that was completed. 6/21/17 Interviewed resident and stated that she fell in the bathroom last night. At first resident stated that she got herself off the floor. Nurse Manager asked more yes or no format questions. Follow up: X-ray reported acute non-displaced fractures of the proximal right tibia and fibula. PCP made aware and resident was transferred to the (hospital) ER for evaluation and returned to facility with a brace to the right leg .Conclusion: After interviewing staff, it was concluded that the resident was not in any pain or discomfort before the resident was transported to her room on June 19, 2017. The resident did not complain of pain until she was in her room with (CNA B). At this time, (CNA B) stated she hurt too bad to transfer. Due to the resident not complaining of any pain or discomfort on the shift before, during the afternoon shift and her inability to self-transfer from wheelchair or floor, it is concluded that a possible incorrect, not reported, transfer led to the fracture. An additional (unsigned) typed document noted, 6/21/17 Interviewed resident and stated that she fell in the bathroom last night. At first resident stated that she got herself off the floor. Nurse Manager asked more yes or no format questions . Are you trying to keep the staff from getting into trouble? Yes Did you fall? Yes. Were you in the bathroom? Yes. Was there staff with you in the bathroom? Yes. Did the staff use the stand-up lift? No. Did the staff stand you up alone? Yes. Did the staff have the stand-up lift? No. Did she stand you up and pivot you? Yes . A written statement by CNA B dated 6/19/17 documented, I was ready to put (Resident #801) to bed. (Resident #801) complained about her leg and foot. I told (Nurse C) that she was in pain, that she didn't want to be lifted. We put a sling under her and use(d) the (mechanical) lift to put (Resident #801) in bed. Then we both saw her whole leg was swollen. (Nurse C) called (Nurse Supervisor - Nurse A) right then . On 6/29/17 at 10:55 A.M., CNA B's personnel file was reviewed. It revealed a Notice of Policy Violation dated 6/27/17 that documented, Termination .Nature of Violation: .After the investigation it was concluded that the resident was not in any pain or discomfort before the resident was transported to her room on June 19, 2017. The resident did not complain of pain until she was in her room with (CNA B). At this time, CNA B states she was going to put the resident to bed and then the resident started complaining of being hurt. (CNA B) stated she hurt too bad to transfer. Due to the resident not complaining of any pain or discomfort on the shift before, during the afternoon shift and her inability to self transfer from w/c or floor, it is concluded that a possible incorrect, not reported transfer led to the fracture. The form was signed by CNA B, the Director of Nursing (DON) and a union representative. A certified letter was sent to CNA B on 6/28/17 regarding termination of employment as of 6/24/17. On 6/29/17 at 11:32 A.M., the CNA tasks were reviewed for Resident #801 in the medical record. The POC history (the electronic charting system for CNAs) documented that on 6/19/17 at 11:51 A.M., CNA H provided extensive assistance with one staff member for transferring and CNA B provided total assistance with two staff members for transferring. On 6/29/17 at 11:50 A.M. and 6/30/17 at 8:22 A.M., a telephone interview was attempted with Nurse C. Nurse C returned the phone call after the survey was completed. Therefore, an interview was unable to be conducted during the survey. On 6/30/17 at 8:23 A.M., CNA D (the other CNA assigned to Resident #801's unit on 6/19/17) was interviewed via the telephone. CNA D reported that she was not assigned to Resident #801 on 6/19/17, but she was familiar with the resident. CNA D reported that Resident #801 required Total assistance. We need two people for her. When queried about whether or not CNA D assisted CNA B (the CNA assigned to Resident #801 on 6/19/17) with Resident #801 on 6/19/17, CNA D stated, No. I didn't have any interaction with her. I was at one end and she was at the other end. She didn't come to get me to help at all that day. On 6/30/17 at 8:54 A.M., CNA B (the CNA assisgned to Resident #801 on 6/19/17) was interviewed via the telephone. CNA B reported that she was an employee of the facility since 1995 and was fired last week because they said I injured someone, but I didn't. CNA B was asked to explain the interaction with Resident #801 on 6/19/17 in the evening. CNA B stated, I took (Resident #801) to bed, she said her leg and foot hurt. She didn't complain all day and she never complains of pain in her leg. I told my nurse (identified at Nurse C). She looked at it and said it was [MEDICAL CONDITION] and instead of ordering an x-ray, they ordered a Doppler. CNA B became tearful and stated, They are saying I never reported something, but I did tell the nurse that the resident was in pain. When she came into assess (Resident #801) she was still sitting in the wheelchair. Nurse C and I transferred Resident #801 to the bed with the (Mechanical) lift. CNA B reported that Nurse C helped transfer Resident #801 to the bed and Resident #801 was screaming and therefore was unable to say what happened. CNA B was queried about Resident #801's transfer status prior to the injury. CNA B stated, She needs assistance. I didn't know at the time, but everyone does this. We body lift her. Everyone did that. Anytime we put her in the stand up lift, her legs buckle and she slides due to her MS and her right foot being turned out. When queried about how many staff members were required to assist Resident #801 with transfers, CNA B stated, One person assist. She's only like 80 pounds. We just grab her pants and then set her down. On 6/30/17 at 9:45 A.M., the DON was interviewed. When asked how Resident #801 broke her leg ,the DON stated, I'm not sure. It's a possible unreported, incorrect transfer. When queried about how that was determined, the DON stated, After interviewing staff that worked that day and the day before, it was determined that Resident #801 had a normal day with no complaints of pain, no hollering out, she fed herself at dinner time, and had no complaints of pain with afternoon meds. When the CNA (CNA B) took her to bed, then she had pain and she got the nurse (Nurse C). Nurse C came to look at the resident and they transferred her to bed. The DON further stated, My conclusion was that CNA B transferred (Resident #801) improperly because she didn't have any pain before going into the room. When queried about where CNAs would look to confirm a resident's transfer status, the DON stated, On the care card, posted on the back of the closet door. The DON reported that Resident #801's had been changed since the fracture, but Resident #801 required assistance from one person using the sit to stand machine prior to the injury (the most recent MDS documented Resident #801 required extensive physical assistance from two staff members for transfers). The DON was asked how it was determined that CNA B transferred Resident #801 incorrectly and the DON stated, Resident #801 was complaining of being hurt. CNA B said she didn't touch her and went to get Nurse C. When I interviewed CNA B and asked her what her normal routine was for transferring Resident #801, she said she body lifted her and that she had to be careful because of her right leg that turns inward.' There was no sit to stand machine in the room. Further review of Resident #801's clinical record was conducted on 6/30/17 at 10:00 A.M. The record review revealed the following: On the June 2017 Medication Administration Record [REDACTED]. Prior to 6/19/17, the MAR indicated [REDACTED]. The following was documented: The MAR indicated [REDACTED]. For June 2017, Resident #801's MAR indicated [REDACTED] On 6/20/17 on the day shift, Resident #801 experienced a pain level of 10 and on the evening shift, a pain level of 5. 6/21/17 - day shift = 10, evening shift = 8, night shift = 5 6/24/17 - day shift = 4, night shift = 5 6/28/17 - day shift = 10, night shift = 5 6/29/17 = evening shift = 9 The MAR indicated [REDACTED]. Resident #801's pain level was documented as a 6 on 6/22/17 at 12:00 A.M. and a pain level of 5 at 6:00 A.M. [MEDICATION NAME] 5-325 mg give 1 tablet by mouth every 6 hours for moderate pain until 6/28/17 23:59 (11:59 P.M.) increase for right leg fracture for 7 days from Q 12 hours to current dose Q 6 hrs. The following pain levels were documented: 6/22/17 - 6:00 P.M. = 8 6/23/17 - 12:00 A.M. = 5, 6:00 A.M. = 5, 12:00 P.M. = 5, 6:00 P.M. = 7 6/24/17 - 12:00 A.M. = 3, 6:00 A.M. = 5, 12:00 P.M. = 9, 6:00 P.M. = 5 6/25/16 - 5, 0, 4, and 6 for the times above 6/26/17 - 5,6,4,6 6/27/17 - 0,6,2,3 6/28/17 - 0,0,10,5 A one time dose of [MEDICATION NAME] was given on 6/22/17 at 12:39 P.M. due to Resident #801 experiencing pain at a level 9. A Interdisciplinary Rehabilitation Screen assessment dated [DATE] documented that Resident #801 was non weight bearing at that time and required the use of a mechanical lift for transfers. The facility's policy titled, Transfer Technique dated June 23, 2017 documented, .Residents will be transferred within the following guidelines: .As designated on Resident's Care Card .Use assistive devices, where indicated .Safe techniques include: Use a gait belt .

This citation refers to Intake Number MI 936 Based on observation, interview and record review, the Facility failed to ensure resident transfer(s) and/or wheelchair mobility were provided in a safe and proper manner for one cognitively impaired Resident (#702) of two residents reviewed for injuries of unknown origin/falls, from a total sample of three, resulting in Resident #702 sustaining a right bimalleolar fracture (fracture of both sides of ankle). Findings include: The Facility reported to the State Agency on 5/18/17 that documented Resident #702 had sustained an injury of unknown origin (fracture right ankle). On 6/7/17 at 11:00 a.m., Resident #702 was observed in the dining area. The Resident had a cast on the right lower extremity from below the knee down the lower leg and covering the ankle. When asked how she sustained her injury, the Resident was not able to provide an answer. On 6/7/17at 9:00 a.m , Resident #702's clinical record was reviewed and revealed the following: Resident #702 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 5/02/2017 documented that Resident #702 had a Brief Interview for Mental Status (BIMS) score of three (severely impaired cognition) and required extensive two person assist for transfers and extensive one person assistance for ambulation via wheelchair. A review of the Resident's progress notes documented, in part, the following: 5/15/17 at 18:23 (authored by Nurse B) Daughter placed mother on sit to stand (a device used for patient who lack muscle strength to rise to a standing position) and toileted her. After putting mother in bed she stated she is c/o (complaining of) knee pain. She has trouble with her knees. Writer asked resident is having pain in her knee. Resident stated yes. Offered Tylenol for pain . 5/16/17 at 16:26 (authored by Nurse B) Cena (certified nursing assistant) stated that resident was c/o pain when she was placed on a sit-to-stand. Writer asked if resident was still having pain in her knee. Resident refused any Tylenol from writer. Able to move knee. Resident denied pain anywhere else. 5/17/17 at 14:31 (authored by Nurse C):Upon rounding noticed resident c/o pain upon being touched on right ankle, assessed noticed swollen, redness and facial grimace upon touching with verbal confirmation of pain .doctor was notified of finding instructed to order stat-x-ray by NP (nurse practitioner), Dr. E came in a and assessed and instructed us to send resident to Hospital . 5/17/17 at 22:45 (authored by Nurse B)Resident returned to facility .Resident had dx (diagnosis) of bimalleolar fracture, right closed . A review of the Facility's investigation record and Investigative Questionnaire(s) was conducted and revealed the following: May 17, 2017-Alerted by the nursing staff that resident's lower leg was swollen and resident was refusing that area to be touched. Resident was assessed, made comfortable and medicated for pain. Primary Care Provider ( Physician F) aware and orders confirmed .After x-ray confirmed a right Inferior Fibula Medial Malleolus fracture, resident's leg was protected and was sent to Hospital. Time line (May 16, 2017) 7:57: In wheelchair and pushed to dining room by CENA, has breakfast 12:02: Therapy works with resident on the 2 south hallways (self-propelling) and then returns resident to table (readjusting the leg-rest after pushing back up to the table.) 15:46: Daughter G visits in dining room then pushes resident to room. 17:25: Daughter returns resident to the dining room and before pushing resident to the table Daughter G takes off the left leg-rest and then pushes resident to the table. 19:42: Daughter leaves resident in the dining room 19:47: CENA takes resident down the hall in the cubby inset of the doors and uses sit-to-stand lift in the hallway; PM Nurse is across the hallway passing medications. Investigative Questionnaire (signed by Therapist Aide H on 5/17/17) What shift were you working? AM When did the incident/problem occur? 5/16/17 When did you become aware of problem? On 5/17/17 came to get pt (patient) for therapy and nurse said she is still in bed. What did you personally see or hear in regard to this issue? Yesterday I pushed pt up to the table after wheelchair mobility and her toe tapped leg of table and patient said ouch then I asked her what is wrong, does she hurt, and she says no. Who did you report this problem to and when? Patient said no so I did not report. Investigative Questionnaire (CENA E) What shift were you working? PM-5/16/17 When did you become aware of this problem? She was a little more in pain. What did you personally see or hear in regard to this issue? When you moved her she said OW didn't see any swelling. Investigative Questionnaire (Nurse C) What shift did you work 7-3- 5/17/17 When did you become aware of this problem? Upon giving am care CENA noticed and informed. What did you personally see or hear in regard to this issue? Upon assessment noticed R (right) ankle swollen, reddened and painful to touch. Investigative Questionnaire (Nurse B) What shift were you working 3-11:30 p.m. 5-16-17 When did you become aware of this problem? 5-17-17 How did you become aware? DON (director of nursing) What did you personally see or hear in regard to this issue? Monday daughter (not named) informed me that mothers knee was bothering her. I gave her Tylenol at this time. Tuesday cena informed me leg was bothering her. On 6/7/17 at 2:30 p.m., a phone interview was conducted with Physical Therapist Assistant (PTA) H regarding Resident #702. PTA H stated that she was not able to talk via phone at the moment and suggested talking with her supervisor. On 6/7/17 at 2:40 p.m., PT Supervisor I was interviewed. When queried about the incident involving Resident #702, he stated, I remember that she told me that she had bumped the Resident into the table leg in the dining area. I told her that she should speak with the Resident's nurse and DON. When asked if he had any documentation pertaining to the incident PT I stated, No, I usually don't have that information, we are contracted with the Facility, a separate entity. A second phone interview with PTA H was conducted and PTA H reported that she never spoke with Supervisor I until after she became aware the Resident had a fracture. PTA H stated, I never told anyone that I had bumped her into the post in the middle of the table, because she did not seem to be hurt and said thank-you when I readjusted it. It was only when the Nurse said she was in bed and was not up for therapy did it job my mind that something had happened the day before. On 6/7/17 at 2:50 p.m., a phone interview was conducted with CNA E regarding the Resident's injury. CNA E stated, I'm not sure what happened. I do remember the night I worked with her (5/16/17) and tried to transfer her with the sit-to-stand she shouted ouch. She was not able to tell me where it hurt. I did not notice any swelling at that time, but it seemed like everything was hurting her. I did tell the nurse. When asked how she was aware a sit-to-stand was to be used for the Resident. CNA E stated, It is posted on a piece of paper in her closet. On 6/7/17 at 3:30 p.m. a phone interview was conducted with Nurse C regarding the Resident's injury of unknown origin. Nurse C stated, I don't really know what happened. I do remember when I came to work on Wednesday (5/17/17) I was told that she was having pain when touched. She had a hard time differentiating where pain was coming from. When queried if she had every witnessed a family member using a sit-to-stand, Nurse C stated, I know that they use it. I don't want to say for sure, but it wouldn't surprise me if something happened when the daughter transferred her. I just can't say for sure and the resident is not able to state what happened. On 6/7/17 at 3:40 p.m., a phone call was made to Nurse B and a message was left. No return call was received. On 6/7/17 at 3:48 p.m., a phone interview was conducted with Physician F regarding the injury. Physician F was queried as to his opinion regarding the injury and stated, I can't say for sure what happened. The Resident was not able to communicate. I know she was a high risk patient. I know she used a sit-to-stand and something could have happened during transfer. On 6/7/17 at 4:15 p.m., an interview with the Director of Nursing (DON) and Administrator was conducted. Both were queried as to the cause of the injury to Resident #702. The DON and Administrator reported that they were unable to determine the root cause of the injury and were not able to substantiate any abuse. The DON indicated that they completed a time line of events from the day before the fracture was identified. Video was used to determine exact timing, but was not available to review during the survey. When asked about use of the Facility's sit-to-stand by people not employed by the Facility, the Administrator stated the Facility did not have a policy. When queried as to whether the Resident's family members were allowed to use the Facility's sit-to-stand equipment to transfer Resident #702, the DON stated, A nurse spoke with the daughter and informed her not to use it. When asked were the equipment is kept, the DON stated that they are often in the hallway or stored in the mechanical room. When queried about the report pertaining to PTA H, the DON reported that it appeared as if she had just tapped her toe against the leg of the table and did not believe that she had reported it to PT Supervisor I that day because she did not believe the Resident was in pain. On 6/8/17 at 9:38 a.m. a phone interview was conducted with Daughter G regarding the Resident's injury. Daughter G stated, They never were able to tell me how it happened. I don't think there was an abuse or anything. I am in the building almost every day. My mom isn't able to say what happened. When queried as to whether she used the Facility's sit-to-stand to transfer the Resident. Daughter G stated, I have used it in the past, the last time I used it was a few months ago. One of the nurses asked me not to use it. You can try and talk with my sister, I know she was there and maybe she used it. On 6/8/17 at 11:00 a.m., a phone interview was conducted with Daughter J regarding the Resident's injury and her use of the Facility's sit-to-stand. Daughter J stated, I remember that I used it on Monday (5/15/17) to help mom to the bathroom. When I used it she said her knee hurt. She's had knee pain before. It was swollen, I thought it was just edema (abnormal accumulation of fluid) and asked the nurse for a pain pill. A request for a Facility policy pertaining to non-employees use of lift devices. The Administrator did not provide a policy. On 6/7/17 at 5:40 p.m., a review of the Facility's Policy titled Transfer Technique (effective 4/5/2011) was conducted and documented, in part, the following: Purpose: To safely transfer the non-weight bearing and/or weight bearing resident to a wheelchair or chair, using proper body mechanics. Policy: All nursing personnel will be instructed by the Director of In-Service Education and or designee, and will be in-serviced on safe transfer techniques of non-weight bearing residents .

Based on observation, interview and record review the facility failed to prevent physical abuse by other residents for five (#'s 711, 715, 719, 720 and 722) of 22 residents reviewed for abuse from a total sample of 25, resulting in a [MEDICAL CONDITION] that required staples, a bite, and a black eye. Findings include: Resident #722 and #720 On 4/27/17 at 9:20 A.M., an incident report dated 3/11/17 was reviewed for Resident #722. The incident report documented, Observe res (resident) standing in hallway stating 'yeah I push her. It's not like I killed her, she should stay out my room.' Writer ender res room observe bedside table on its side, blood on blue mat lying on floor. She came in my room, I told her to leave and she didn't want to so I pushed her. On 4/27/17 at 9:25 A.M., the Director of Nursing (DON) was interviewed about the incident report above. The DON was asked who the resident was that Resident #722 pushed. The DON identified the other resident as Resident #720. When asked if there was an investigation for the documented incident on 3/11/17, the DON reported that whatever was attached to the incident report was the investigation and Resident #720's incident report is documented as a fall. On 4/27/17 at 9:30 A.M., the paperwork attached to Resident #722's incident report was reviewed and revealed the following: An Injury of Unknown Origin - Investigation Report that documented, No injury - Resident stated she pushed her down. I told her to leave - she didn't so I pushed her. Preliminary Investigation (Findings) documented, Resident pushed another resident down in her room - caused a(n) open area to back of her head. On 4/27/17 at 10:30 A.M., Resident #722's clinical record was reviewed and revealed the following: Resident #722 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented Resident #722 had severely impaired cognition with verbal and wandering behaviors and was independent with transfers, walking, and most activities of daily living (ADLs). A nursing progress note dated 3/11/17 at 11:00 P.M. documented the same as the incident report and .Residents kept apart for safety, on call MD (physician), res(ident) son, and nursing supervisor made aware of . A nursing progress note dated 3/12/17 at 11:12 P.M. documented, Son present today. Writer later notified via telephone that resident was making threats towards staff, stating, 'I could kill somebody' 'Bring me some tweezers and razors. I'm going to get out of here, I'm going to show you. According to the electronic medical record (emr) that was reviewed on 4-27-2017 at 11:00 a.m., Resident #720 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] reflected long and short term memory impairment with moderately impaired decision making skills. A care plan initiated 9-27-2015 identified a problem of Resident #720 wandering, with interventions of monitoring her location every 60 minutes. Review of the facility's incident report dated 3-11-2017 reflected Writer was called to dining room by cna, observe res (sic) sitting in chair bleeding from back of her head. A review of the facility form titled Post Fall Analysis And Investigation dated 3-12-2017 revealed Blood on mat in room (resident room #), blood observed coming from back of her head. Resident #720 did not reside in room (room #). Nurses notes dated 3-12-2017 00:16 reflected Resident #720 was transferred to the hospital. Nurses notes dated 3-12-2017 04:43 reflected Resident #720 returned to the facility from the hospital with two staples to the back of her head. Hospital records dated 3-12-2017 revealed Resident #720 was treated for [REDACTED]. On 4-27-2017 at 1:25 PM, during an interview with the Director of Nursing (DON) she revealed the cause of Resident #720's fall was that she was pushed by Resident #722. A copy of the Resident to Resident altercation investigation, complete with staff interviews was requested but not received. I gave you everything I have. On 4-27-2017 at 1:48 PM Certified Nurse Assistant (CNA) W was interviewed via telephone and reported while working on 3-11-2017 she heard a loud Boom coming from room and upon entering the room observed Resident #720 on the floor bleeding from her head, CNA W further stated Resident #722 reported she had told her she had pushed Resident #720. Resident #711 and Resident #720 According to the emr that was reviewed on 4-25-2017, Resident #711 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS dated [DATE] she had a brief interview status of three 3, indicating severe cognitive impairment. According to the facility incident report dated 8-18-2016 reflected that Resident #711 bit other residents left inner arm when other resident (#720) attempted to move her wheelchair. Other resident (#720) hit her (Resident #711) in the right side of her face, then resident attempted to hit other resident. Injury type Bruise Injury location Face Resident #711's statement on the incident report was She was messing with me, so I hit her and bit her. The incident report for Resident #720 dated 8-18-2016 reflected Resident was attempting to move other residents w/c (wheelchair) with her in it in 3 N hall. As this nurse ran to intervene, I viewed other resident (#711) biting her (#720) arm, then she hit the biter with her hand. Injury type Laceration injury location back of hand Nurses notes dated 8-16-2016 located in Resident #720's emr revealed She now has bite marks on her left inner arm, with no bleeding noted, other resident (#711) has reddened skin on left cheek. On 4-27-2017 at 1:25 PM, during an interview with the Director of Nursing (DON) she revealed the cause of Resident #720's fall was that she was pushed by Resident #722. A copy of the Resident to Resident altercation investigations, involving Residents #711, #720 and #722 dated 3-11-2017 and 8-18-2016 complete with staff interviews was requested but not received. I gave you everything I have. The Administrator (identified as the facility's abuse coordinator) was interviewed on 4/27/17 at 10:37 A.M. The Administrator reported that he was not aware of the physical altercation between Resident #722 and Resident #720 on 3/11/17 or the altercation between Residents #711 and #720 and therefore did not investigate it or report it to the state agency. Resident # 715 and Resident #719 On 4/25/17 at 11:35 a.m, Resident #715 was observed sitting in her wheelchair in her room. Resident #715 was alert and able to answer questions asked. On 4/25/17 at 12:00 p.m., the clinical record for Resident #715 was reviewed and revealed the resident was admitted into the facility on [DATE] and with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #715 had a Brief Interview for Mental Status (BIMS)score of 10 (moderate cognitive impairment) and required extensive one person assist for activities of daily living (ADL). Continued review of the Resident's clinical record revealed nursing progress note(s): 3/17/17 (authored by Nurse Y): Resident extremely upset at Resident #719. Resident #719 was placed in Resident space where she usually sits for dinner. Resident #715 proceeded to hit Resident #719 and pull on Resident #719's wheelchair. Resident #719 began to hit at Resident. Both Residents hitting at each other. Writer heard the commotion and intervened between Residents. Resident #719 very upset. 0(zero) injuries. An Incident and Investigation (I &A) pertaining to Resident #715 report dated 3/17/17 was reviewed and documented the following: Person Preparing Report: Nurse Y Nursing Description: Observed both residents hitting at each other. Immediate Action: Writer intervened between both residents People Notified: Family member, Physician, and Nurse Manager No intervention was noted in the document. On 4/26/17 at 4:30 p.m., Resident #719 was observed sitting in her wheelchair next to her bed. The Resident was alert and able to answer questions asked. When queried as to whether she had ever had any altercations at the Facility, Resident #719 stated, There is one resident that is always pulling on my wheelchair. It really bothers me. We got into it a few times. I was not hurt, but I didn't like it. She is always pulling on my chair. On 4/27/17 at 8:00 a.m., Resident #719's clinical record was reviewed and revealed that the Resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Resident MDS dated [DATE] documented that the Resident had a BIMS score of 14 (cognitively intact) and required extensive one and two person assist for activities of daily living. Further review of the Resident's clinical record revealed the following nursing progress note: 3/17/17 (authored by Nurse Y): Resident was observed hitting other Resident, both Residents hitting at each other. Writer intervened and removed Resident #719 who was very upset and stated, I'm going to kick her ass - I'm going to put my foot in her ass. No injury will continue to monitor. An Incident and Investigation (I &A) pertaining to Resident #719 report dated 3/17/17 was reviewed and documented the following: Person Preparing Report: Nurse Y Nursing Description: Resident sitting in dining room in Resident #715's place. Immediate Action: Writer intervened when both resident began to hit each other. People Notified: Family member, Physician, and Nurse Manager Notes: staff will check/monitor placement of resident to lower/stop interchanges with the other resident. On 4/27/17 at 10:37 a.m., an interview with the Administrator (Abuse Coordinator) was conducted. The Administrator was queried as to the process for investigating incidents of resident to resident abuse and whether he was aware of the incident between Resident #715 and #719. The Administrator stated, I was not made aware of this incident. I should have been notified by staff to investigate and further determine through our algorithm whether it was a reportable incident. The facility's policy titled Abuse Prohibition Program dated 11/28/16 was reviewed on 4/27/17 at 10:00 A.M. and it documented the following: (facility name) will maintain an exvironment free from abuse and neglect. The resident has the right to be free from abuse .Residents will not be subjected to abuse by anyone include, but not limited to .other residents .

This citation refers to intake number MI 011. Based on interview and record review, the facility failed to ensure an indwelling urinary catheter placement was checked before inflation of the retention bulb for one (#801) and failed to properly insert and ensure the correct size catheter was used per physician's orders [REDACTED].#802) of three residents reviewed for indwelling urinary catheters, from a total sample of three, resulting in hospitalization for hematuria (blood in the urine) with acute blood loss due to urethral trauma for a resident on blood thinners (#801) and the catheter being dislodged from the urinary tract (#802). Findings include: Resident #801 On 10/31/16 at 8:50 A.M., during a telephone interview with the complainant, it was reported that that Resident #801 had to be transferred to the hospital to stop bleeding after his catheter was improperly replaced. The complainant reported that Resident #801 no longer resided in the facility. On 10/31/16 at 9:00 A.M., an unannounced abbreviated survey was conducted to investigate the complainant's allegation. On 10/31/16 at 9:28 A.M., Resident #801's clinical record was reviewed and revealed the following: Resident #801 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented Resident #801 had intact cognition, required extensive to total assistance for bed mobility, transfers, ambulation, and activities of daily living except for eating, and had an indwelling urinary catheter. physician's orders [REDACTED]. (Brand name - indwelling) catheter, 22 Fr (catheter size), 10 ml balloon to straight drain, every night shift starting on the 12th and ending on the 13th every month and as needed for blockage/leakage or removal. Progress notes from September 2016 documented the following: On 9/13/16 at 8:39 A.M., Nurse Practitioner (NP) C documented, .Resident was seen this am, nursing called to report gross hematuria (visible blood in the urine) with replacement of chronic indwelling catheter this am. Irrigation (procedure to flush blood or clots from the bladder) x 2 completed without slowing of bleeding, large blood clots in tubing on exam, resident c/o burning and warmth and discomfort .Assessment/Plan: .Gross hematuria/supratherapeutic (above the therapeutic range) INR (International Normalized Ratio - a laboratory measurement of how long it takes blood to clot, used to determine the effects of blood thinning medications)/UR ([MEDICAL CONDITION]) chronic indwelling catheter; unable to slow bleeding with irrigation attempts at bedside, give Vitamin K 10 mg (milligrams) .send to (hospital) .will likely need continuous bladder irrigation . On 9/13/16 at 9:17 A.M., Nurse B documented, Changed resident (indwelling) catheter received no resistance. Resident stated as bulb was filling that it hurt. Writer deflated bulb and pulled catheter out some and refilled bulb to no complaint. Blood started flowing with blood clots. Called NP (Nurse Practitioner C) and she gave orders to irrigate q2hrs (every two hours) with 60 cc (cubic centimeters) and give Vitamin K (given to stop bleeding). Hospital records for Resident #801 were reviewed on 10/31/16 at 9:55 A.M. and documented the following: An H&P (History and Physical) report dated 9/13/16 documented, .medical history of [REDACTED]. A. Fib ([MEDICAL CONDITION]) on [MEDICATION NAME] (blood thinning medication), with pacemaker. Patient lives at an assisted living facility (nursing home), this morning when they were changing his (catheter), urine was noted to be tinged with blood and patient was complaining about suprapubic pain. Patient's INR was also noted to be 3.2 (above therapeutic range of 2.0-3.0, which could put resident at risk for bleeding) .Patient also noted swelling in the right inguinal area that he hasn't noticed before. Patient was brought to the emergency department where CT (computed tomography - CAT scan) noted catheter was placed suboptimally, below the level of the bladder lumen (not placed inside the bladder) . .Diagnostic Studies: CT Abdomen/Pelvis No Contrast .Final Result .A (indwelling) catheter is present but suboptimally visualized .The bulb of the catheter appears to be low below the level of the bladder lumen. Advancement by at least 5 cm (centimeters) is suggested . .Hematuria Assessment & Plan .Due to (catheter) trauma, bulb placed inferior (low) to bladder lumen .Resolved after (catheter) replacement from Urology, Manual irrigation PRN (as needed) . A hospital Urology consult dated 9/14/16 documented, .(indwelling) catheter problem .(indwelling catheter) not in bladder on CT scan .Consider SPT (suprapubic tube - a catheter that is inserted into the bladder through the abdomen to drain urine). A hospital discharge summary dated 9/14/16 documented, .Hospital Course: .(Resident #801) presented to the ER (emergency room ) after a (indwelling) catheter was inflated in his urethra. Gross hematuria was noted and he was admitted due to his [MEDICATION NAME] use. His hematuria resolved with appropriate (indwelling catheter) placement. Hemoglobin (a protein in red blood cells that carries oxygen through the blood) did decrease initially but was stable thereafter . On 10/31/16 at 10:45 A.M., Chronic Care Nurse Manager (Nurse A who was identified as the staff member to talk to in the absence of the Director of Nursing) was asked for any in-services on insertion of indwelling catheters for Nurse B. Nurse A was asked at this time to provide contact information for NP C. Nurse A explained that NP C was available by on-call pager and she would page her. At 11:00 A.M., Nurse A provided a One to One in-Service document typed by Nurse A dated 9/14/16 at 1:34 P.M. The in-service documented, Education was provided via telephone: Writer spoke with (Nurse B) today. Questioned why the (indwelling) catheter where (was) changed on midnights for (room number of Resident #801). Writer read the order to Nurse B and it does not state to change the (indwelling) catheter but to change the bag. Comments: (Nurse B) stated that the order says change on the 12th MN and it flagged. Also states that the (indwelling catheter) went in smoothly on (room number of Resident #801), when she inflated the balloon the resident complained of discomfort; so she deflated the balloon and pulled back some on the tubing then re-inflated the balloon. Educated to read and process the order as written. (Indwelling) catheters are as needed most often. On 10/31/16 at 11:11 A.M., Nurse B was interviewed regarding the replacement of Resident #801's indwelling urinary catheter on 9/13/16. Nurse B was asked why she replaced Resident #801's catheter and she stated, It triggered on the MAR (medication administration record) to change it on the 12th (of September). When asked to describe the technique she used to replace the catheter, Nurse B stated, I held the shaft of the penis, used lubrication and slid it in (the catheter into the urethra). There was no resistance when I went in so I inflated the bulb and he complained of discomfort. I deflated the bulb and pulled back some, then re-inflated. (Resident #801) said it felt okay. As soon as I inserted the catheter, blood started flowing through into the bag. Nurse B was queried about when the bulb should be inflated and stated, You insert the tubing about an inch or two, then inflate. Nurse B was asked where the bulb should be placed before it was inflated and Nurse B reported it should be inside the bladder. When queried about how to determine if the catheter bulb was properly placed in the resident's bladder, Nurse B stated, Urine would flow through the tubing. When asked if there was urine return prior to inflating the bulb when replacing Resident #801's catheter, Nurse B stated, No. Nurse B was asked what kind of training the facility provided about indwelling catheter insertion. Nurse B stated, Just what I had in nursing school and general things, like catheter care. Nurse B reported that after Resident #801 had to go to the hospital, she was in-serviced about following the physician's orders [REDACTED].>On 10/31/16 at 1:06 P.M., Nurse A was interviewed regarding the proper technique to reinsert a (indwelling) catheter. Nurse A stated, in part, .Insert (brand name for indwelling catheter) to see if you get urinary return. See if everything is going okay, no pain or anything, then fill the balloon with 5 or 10 cc of sterile water and pull back some. When queried about when the balloon should be inflated, Nurse A stated, After you have some urinary return after you get it in. When asked where the catheter should be when the balloon was inflated, Nurse A stated, It has to be in the bladder before you inflate it. Nurse A was asked what caused the bleeding during the placement of Resident #801's catheter on 9/13/16. Nurse A stated, Trauma to the area. When queried about how trauma to the area might have occurred, Nurse A did not offer a response. When asked if Nurse B properly inserted Resident #801's catheter if she did not wait for urinary return prior to inflating the balloon, Nurse A stated, I don't know if she changed it correctly. I just asked her if there was an order and if there was resistance. I was just trying to figure out what was going on because the family member called and said we punctured his (Resident #801) bladder. The One to One In-service documented above and the physician's orders [REDACTED]. Nurse A was asked why Nurse B was in-serviced on following the physician's orders [REDACTED]. Nurse A stated, The order doesn't say to change it (the catheter). It just says it's there. When queried about why it triggered on the MAR indicated [REDACTED]. At this time, Nurse A was asked to page NP C a second time. No response was received from NP C prior to the end of the survey. On 10/31/16 at 3:46 P.M., the Director of Nursing (DON) was interviewed regarding Resident #801 having to be transferred to the hospital on [DATE] due to catheter trauma and hematuria. The DON reported that Resident #801's daughter said the resident's bladder was punctured, but it was not punctured. The technique described by Nurse B was discussed with the DON at this time (not waiting for urinary return prior to inflating the catheter balloon). The DON was asked what could happen if that was done and the DON did not offer a response. The DON was queried about the in-service provided by Nurse A that documented education to Nurse B regarding following physician's orders [REDACTED]. The DON was queried about what the physician's orders [REDACTED]. All residents who require monthly catheter changes are done on the 12th. When asked why Nurse B was in-serviced on following physician's orders [REDACTED]. At 4:25 P.M., the DON stated, I did not see the in-service in my investigation. Resident #802 On 10/31/16 at 12:16 P.M., the clinical record for Resident #802 was reviewed and revealed the following: Resident #802 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. It was documented that Resident #802 received services from hospice. An MDS assessment dated [DATE] documented that Resident #802 had intact cognition and required extensive to total physical assistance with all activities of daily living and had an indwelling urinary catheter. Current physician's orders [REDACTED]. A progress note dated 9/13/16 at 9:37 A.M. written by Nurse B documented, Resident (indwelling) catheter changed, replaced with a 16 Fr (brand name for indwelling catheter) filled with 10 cc bulb . A progress note dated 9/13/16 at 3:25 P.M. written by Nurse D documented, Writer notified by staff that resident catheter was observed out of penis, balloon still inflated . A Communication Record from the hospice agency nurse, dated 9/13/16 at 11:56 P.M. documented, PRN visit to re-insert (brand name for indwelling catheter) .Approx. 800 ml of urine drained within 15 minutes . On 10/31/16 at 1:06 P.M., Nurse A (Chronic Care Nurse Manager) was interviewed and asked how the nurses would know what size catheter to use on a resident. Nurse A stated, The size would be in the physician's orders [REDACTED]. The progress note written by Nurse B on 9/13/16 that documented she changed Resident #802's catheter and used 16 Fr with 10 cc bulb was reviewed with Nurse A. Nurse A was asked why a 16 Fr catheter was used. Nurse A stated, No comment. On 10/31/16 at 2:00 P.M., the requested in-service trainings provided by Nurse A were reviewed. An In-Service Training for Catheter Documentation dated 10/28/15 was provided. An additional in-service training dated 7/12/16 documented Agenda .Catheters and the sign-in sheet indicated that Nurse B attended. Nurse A explained that the attached policy was what the in-service addressed. The facility's policy (attached to the 7/12/16 in-service), titled, Catheterization: Straight/Female dated March 1, 2008, was reviewed at this time. It documented, .Confirm physician's orders [REDACTED]. The policy/in-service did not address catheterization of a male resident. The facility's policy titled Catheter Care: Urinary dated March 1, 2008 was reviewed and did not address technique for inserting a catheter in a male resident. ( )

This refers to intake(s): # MI 073/M 2151 Based on observation, interview and record review, the Facility failed to provide saftey intevention measures to prevent falls based on the Resident's assessed needs that included saftey check interventions every 30 minutes for one (#701) of three Resident's reviewed for falls and at risk for falls, from a total of three sampled Resident's,resulting in the Resident sustaining a closed fracture of the proximal left femur (hip) requiring surgery, bruising/bleeding to the forehead and a decrease in mobilization. Findings include: On 9/21/16 at 9:20 a.m., the a phone interview was conducted with the Complainant regarding the injury(s)sustained by Resident #701. The Complainant stated, The Resident has had three falls in less than two months. The first fall was on July 18, 2016 and she sustained a fracture to her left arm and right hip that required surgery. She returned to the Facility at the end of July and had another fall in the middle of August with bruising to her arm and finger, I think she hurt her rib as well. The Facility was supposed to have someone checking on her every 30 minutes and helping her to the bathroom. On 9/3/16 she fell again and fractured her other (left) hip. When they called me to let me know about the last fall, it was almost two hours after it happened and they made it seem like it wasn't a big deal. It took almost eight hours before she was transferred to the Hospital and she ended up staying almost two weeks because she had several complications following the fall. I guess I can understand one fall, but how she fell and hurt herself two other times, I don't get. I do not believe they were checking on her or why they didn't put an alarm on her bed. A Facility Reported Incident pertaining to the Resident's fall on 9/3/16 was reported to the State Agency on 9/15/16. On 9/21/16 at 10:00 a.m., the Resident was observed lying in her bed. She had bruising and discoloration to both the right and left side of her forehead. Her left arm was wrapped in an ace bandage and a large bruise was on her right arm. A floor mat was resting against the wall and her bed was in a high position. An alarm was attached to her bed. The Resident was queried as to the falls that occurred in the Facility. Resident #701 stated, I can't really remember what happened. I think I fell a few days ago. I have a headache today. On 9/21/16 at 10:30 a.m., a review of the Resident's clinical record revealed that the Resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] indicated that the Resident was cognitively impaired and required extensive one and two person assist for transfers and ambulation. A review of the Facility's Incident and Accident (I&A) Reports pertaining to Resident #701's falls were reviewed and documented, in part, the following: 7/20/16 (Authored by the Director of Nursing (DON): .On July 18, 2016 at approx 5:50 a.m. the CNA (certified nursing assistant) entered room and found resident on the floor .LPN (licensed practical nurse) assessed the left wrist was deviated from normal position .Resident complained of pain in right hip .positive for a right comminuted fracture of right proximal femur .surgery was performed . positive for distal radius and ulna fractures .Resident will be placed on increased monitoring and encouraged to use call light for assistance. Plan is to set up time for assistance dressing and grooming. 8/15/16 -(authored by Nurse A) .the nurse reported to writer that daughter of the resident reported that she got out of bed and fell . during shift resident was on her bed .writer asked Resident if she had fallen yesterday. Resident answered she fell a week ago .Resident stated she fell , but managed to get back in bed .Writer noted discoloration on residents right arm . 9/3/16 (7:40a.m.) -Authored by Nurse A: Writer was called to room and noted resident on bathroom floor near toilet bowl and lying on back. CNA (certified nursing assistant) B reported that she was in hallway passing water and saw shadow of Resident .she followed resident, but heard resident fall. Apparently Resident walked into bathroom by herself using her bedside table for balance. Writer noted a small cut on her left forehead and left side of face. Writer also noted a knot on residents right forehead. Residents l left hip area was swollen and lower leg is deviated outside . On 9/21/16 a review of the Resident's Fall Risk assessment dated [DATE] indicated that the Resident was at High Risk for falls. On 9/21/16 at 1:00 p.m., the Director of Nursing (DON) was asked what interventions were in place for the Resident following the fall on 7/18/16. The DON stated, After the fall in July we educated the Resident on asking for assistance when getting dressed and added 30 minute safety checks. On August 17, 2016 we put a fall mat next to her bed. When asked whether any alarms were added to the Resident's care plan, the DON stated, No, we added those after she fell in September. The DON was also asked to provide a copy of the Resident's Care Plan that indicated the interventions to prevent further falls. The DON provided a printed version of a Cancelled care plan that indicated the following: Focus: I am at risk for falls, weakness, Antidepressant use. Diuretic use. Gait/mobility impairments. Interventions (in part): · 30 minute monitoring check · resident safety checks to be increased to q 30 minutes · low bed · fall mat (August 17, 2016) The DON provided the Safety Checklist logs from 7/28/16- 9/3/16. The Checklist log for the Midnight shift dated 9/2/16 indicated that the Resident did not receive 30 minute checks from 12:00 p.m. until 7:00 a.m The initials of Nurse A noted that checks were made every hour and no checks were made between 4:00 a.m. and 5:00 a.m. (the time of the fall) On 9/21/16 at 3:03 p.m., a phone conversation was conducted with Nurse A regarding the Resident's fall with injury on 9/3/16. Nurse A when queried about performing safety checks every 30 minutes as indicated in the Resident's care plan, Nurse A stated, I was not able to check on her every thirty minutes. There were only two Nurses working that night and I had the hall where Resident #701 resided as well as another hall to cover. I'm not sure how or when she got out of the bed. She did not have alarms on the bed at that time. On 9/21/16 at 3:30 p.m., an interview was conducted with the Director of Nursing (DON). The DON was queried as to the lack of Nurse A to perform 30 minute safety checks. The DON stated, I guess he did not do the checks that night. I am not sure why not it looks like he did them on other nights. On 9/21/16 at 4:30 p.m., a Facility Policy titled, Fall Prevention Program (effective 10/31/07) was reviewed and documented the following: Purpose: To assess if resident is at risk for potential falls in order to provide interventions to minimize occurrence of falls B. All residents with Fall Risk scores of 10 or higher will be identified as High Risk . 5. The Care Plan will include individualized interventions for fall prevention. All falls will be tracked for trending or patterns and to provide intervention to prevent further occurrences. Preventive measures for Residents at Risk for Falls: A score of 10 or higher on the Fall Risk Assessment need preventative measures added to the care plan: frequent monitoring .bed or wheel chair alarms. ( )

Based on interview and record review, the facility failed to protect one Resident (Resident #712) from abuse and misappropriation of property, out of twenty-two residents reviewed for abuse, out of a total sample of twenty-five residents, resulting in feelings of anger, suffering, frustration and helplessness. Findings include: On 3/21/16 at 2:25 pm, a review of Resident #712's medical record was conducted. During the review it was discovered that Resident #712 was admitted to the facility on [DATE]. Resident #712 had a brief interview for mental status assessment on 2/19/16 and scored 14 out of 15 indicating intact cognition. On 2/22/16 Resident #712 was assessed for competency to make her own decisions and was deemed competent by two physicians to be her own responsible party. Resident #712's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment completed 2/19/16 indicated that Resident #712 did not exhibit any hallucinations, delusions, or behaviors. Resident #712's MDS assessment for functional status indicated she required extensive assistance of two people for transferring, was non ambulatory, and required extensive assistance of one person for wheelchair mobility, hygiene, bathing, and toilet use, and was frequently incontinent of urine and stool. On 3/22/16 at 10:30 am, an interview with Resident #712 was conducted. During the interview Resident #712 indicated that a staff member had taken her cellular telephone away from her. Resident #712 was asked to elaborate on the incident, and explained that she put on her call light during a midnight shift; she said that she didn't remember if she had to use the bathroom or if she was in pain, but said that when she put her call light on, no one came to assist her. When she did not get the assistance, she explained that she used her cellular telephone to dial 911. After dialing 911, Resident #712 indicated that a building security guard and Licensed Practical Nurse (LPN) 'F' came to check on her. She explained that the security guard told her she couldn't dial 911 because she was a resident in the facility. She then stated, that LPN 'F' 'grabbed my phone, and walked out.' When asked if LPN 'F' explained why she took her cellular phone from her, Resident #712 stated, 'She didn't say a word.' Resident #712 went on and said, 'That was completely wrong, I wasn't getting any help and one night it just got to me. Why do I have to suffer? It was so wrong, I will never forget that. It was terrible, that was a very bad situation, to me that was abusive.' She continued to explain that the next day her durable power of attorney (DPOA) visited her at the facility and it was during his visit, her phone was returned to her. On 3/22/16 at 12:00 pm, a review of LPN 'F's nurses note dated 2/15/16 at 3:56 am, read, 'Resident called 911 and request (sic) them to call because she is sick, resident was informed by writer that she was ok and everything she has ordered is given to her, She states she asked for [MEDICATION NAME] (a medication used for the treatment of [REDACTED]. and she needs it, I informed her the DR (doctor) will see her in the am, Resident stated she was just going to keep calling the 911 until she gets it, resident do (sic) have a DX (diagnosis) of [MEDICAL CONDITION]'s disease .resident was informed that her cell phone would be remove (sic) from her persons (sic) and put on the nursing cart, message left for the floor manager and her DPOA .' On 3/22/16 at 1:00 pm, an interview with Unit Manager 'G' was conducted. Unit Manager 'G' was asked if she was aware of the situation regarding LPN 'F' taking Resident #712's cellular phone from her. Unit Manager 'G' indicated she was aware of the incident and stated, 'She was repeatedly calling 911.' When asked where the documentation of Resident #712 repeatedly calling 911 was, Unit Manager 'G' had no response, as it was documented that Resident #712 dialed 911 only the one time as indicated by LPN 'F's note on 2/15/16 at 3:56 am. Unit Manager 'G' was next asked if taking Resident #712's cellular phone from her to prevent her from dialing 911 was an appropriate intervention for the behavior, Unit Manager 'G' stated, 'Absolutely it wasn't right.' When asked what other interventions were used to calm Resident #712, Unit Manager 'G' had no response. On 3/22/16 at 1:20 pm, an interview with the facility's Director of Nursing (DON) was conducted regarding the incident between LPN 'F' and Resident #712. The DON was asked if she had been made aware of LPN 'F' taking Resident #712's cellular phone from her, and the DON indicated that she had not been aware of the incident prior to the survey. The DON was next asked if she felt it was appropriate for LPN 'F' to take Resident #712's cellular phone from her based on Resident #712's threats to call 911 and the DON stated, 'I think we definitely could have come up with something better.' When asked if the incident had been investigated as resident abuse, the DON indicated that it had not. On 3/22/16 at 1:30 pm, a telephone interview with LPN 'F' was conducted regarding the incident between her and Resident #712. LPN 'F' explained that she was not Resident #712's assigned nurse, she was covering for the assigned nurse. She went on and described the security guard making her aware of Resident #712's dialing 911. LPN 'F' then indicated that she took Resident #712's cellular phone and locked it in the medication cart, called and left a message for the unit manager, the DPOA, and informed the resident's assigned nurse. On 3/23/16 at 1:10 pm, an interview with the facility's administrator regarding the incident between Resident #712 and LPN 'F' was conducted. The administrator was asked if she was aware of the incident prior to the survey and she indicated that it was not reported to her at the time the incident occurred. When asked of an instance where she would feel it appropriate for a staff member to take away a resident's cellular phone, the administrator explained that it may be justifiable in an 'unusual circumstance' and used an example of a resident becoming violent and using it as a weapon to physically assault people with it. On 3/23/16 at 3:15 pm, a review of the facility's policy titled, 'Abuse Neglect, Mistreatment, Misappropriation of Property: Abuse Prohibition Program', with an effective date of June 27, 2013 read, It is the responsibility of staff to provide a safe environment for residents .Definitions .Abuse-Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .Misappropriation-Deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money with the resident's consent . The facility was asked if they had any additional information to provide pertaining to the concern, and they did not provide any at the time of exit. ( )

This citation pertains to Intake MI 148 Based on observation, interview, and record review, the facility failed to perform an accurate risk assessment for the development of pressure ulcers, develop and consistently implement interventions for the worsening of a pressure ulcer for one (#701) of three residents reviewed for pressure ulcers, out of a total of three sampled residents, resulting in the worsening of a pressure ulcer. Findings include: On 6/16/15 at 3:10 p.m., intake MI 148 was reviewed. It was alleged that Resident #701 acquired a stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed) to her coccyx area during her stay at the facility and the facility failed to to order a ROHO cushion (a sophisticated pressure reduction cushion that protects those at moderate to high risk for skin breakdown) for Resident #701 after the development of the stage IV pressure ulcer. Resident #701 is no longer in the facility. Resident #701 was admitted into the facility on [DATE] for specialized rehabilitation therapies and was discharged on [DATE] (total of 43 days). On 6/17/15 at 10:00 a.m., the facility's Certified Occupational Therapy Assistant (COTA A) was interviewed regarding the ROHO cushion for Resident #701. COTA A stated, I vaguely remember her family asking for a ROHO cushion. Physical Therapy (PT) would've been responsible for the ROHO cushion. On 6/17/15 at 10:15 a.m., the facility's PT Manager (PTM B) was interviewed regarding the ROHO cushion for Resident #701. The PTM B reported that the ROHO cushion was ordered for home for Resident #701 and that it was no order for it until 11/24/15. PTM B stated, She would have needed a medical reason, but she was given a wheelchair cushion sometime in October. If a person can stand, shift weight or stand, then a ROHO cushion would not be required. It is extremely difficult to get Medicare to cover a ROHO cushion. She has to meet certain criteria. On admission she had no bed mobility. She needed help with weight shifting during that time. On 6/17/15 at 11:00 a.m., record review of Resident #701's closed clinical record revealed the following information: Resident #701's face sheet revealed an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. Diff), Dehydration, Generalized Muscle Weakness, and a Pressure Ulcer to her buttock (stage I, redness only; intact skin with non-blanchable redness of localized area). A new [DIAGNOSES REDACTED]. Resident #701's admission Minimum Data Set (MDS) assessment, dated 11/6/14, indicated an intact cognition, required extensive assistance for bed mobility and for activities of daily living (ADLS). The MDS assessment also indicated that Resident #701 did not walk in room nor in the corridors of the facility. Extensive assistance was required with the assistance of one when ambulating on and off the unit. A stage I pressure ulcer (no location or measurements documented) was also noted on the MDS assessment. On 6/17/15 at 11:05 a.m., review of the nursing progress notes for Resident #701 indicated the date of the coccyx wound was noted on 10/27/15 (11 days after admission). The Admission Assessment, dated 10/16/14, indicated the following skin condition: Coccyx rash. The Braden Scale (assessment for risk of developing a pressure ulcer), dated 10/16/14, revealed a score of 19. A score of 19 indicated that Resident was not be risk for developing a pressure ulcer. The narrative admission nursing note, dated 10/17/14 revealed the documentation: Buttocks and coccyx reddened. A nurse's note, dated 10/22/14, revealed the following documentation: Resident (#701) seen today by tx (treatment) nurse, skin in groin area intact but red with moisture.no other skin issues at this time. Will continue to monitor. A nurse's note, dated 10/27/14, revealed the following documentation: Observed skin on sacral/coccyx area, skin appears black in sacral area but not open measuring 0.5 X 0.5 (? centimeters), resident requires total assist with turning, air mattress and wheelchair cushion ordered, bilateral buttock reddened.wound care consult for NP (Nurse Practitioner) in place to be seen on 11/3/2014. On 6/17/15 at 12:45 p.m., the facility's registered dietician (RD E) was interviewed regarding Resident #701's nutritional status and treatment interventions for the pressure ulcer. RD E stated, She requested a supplement shake on admission. I saw her on 10/17/14. That was the only supplement initiated. I was aware of the [DIAGNOSES REDACTED] diagnosis. Labs were reviewed from the hospital. She had a low hemoglobin and hematocrit, low [MEDICATION NAME] (2.0), sodium level was high, and she had a low creatinine. I developed a care plan from my assessment (for #701). On 11/13/14 I was made aware of her pressure ulcer. I then started her on Prostat Advanced Wound Care (protein supplement) 30 milliliters per day. She was still on the Ensure at that point. I was not aware of her oral intake. I did not know about her pressure ulcer before 11/13/14. The wound nurse is supposed to notify me right away. A wound care log is given to me weekly. Review of the doctor's orders at this time with RD E revealed orders on 11/13/14 written for the Prostat, and Ensure at lunch. There was no prior order for the Ensure supplement drink until 11/13/14. RD E was unable to provide an explanation as to why the order for Ensure was not obtained until 11/13/14. RD E stated, She (#701) reported having a poor appetite due to the [DIAGNOSES REDACTED]. That is why she wanted the Ensure. On 6/17/15 at 1:20 p.m., the Director of Nursing (DON) was queried regarding the accuracy of the Braden Scale for Resident #701. The DON reported that Resident #701 was not identified for at risk for developing a pressure ulcer on admission based on a score of 19. A care plan, I am at risk for skin breakdown was developed on 10/17/14 related to redden area. The interventions at the time included: anti-fungal powder to reddened areas and daily skin inspection by Certified Nursing Assistant (CNA). A second Braden Scale was completed on 10/27/14 (after the development of the coccyx pressure ulcer). The score was 16. That score indicated low risk. By this time Resident #701 had developed a stage IV (Unable To Determine, UTD) pressure ulcer. The DON reported a ROHO cushion was ordered on [DATE]. The DON reported a timeline of interventions that included: On 10/27/14, the following pressure ulcer interventions were ordered for Resident #701: - a standard wheelchair cushion - a low air loss mattress - a wound consult. Resident #701 was seen on 11/3/14 by the Wound Team. The physician's orders [REDACTED]. - Wheelchair Cushion, dated 10/27/14 at 3:05 p.m. (11 days after admission into the facility) - Air Mattress, dated 10/27/14 at 3:05 p.m. (11 days after admission into the facility) - ROHO wheelchair cushion, dated 11/24/14 at 11:44 a.m. (10/27/14 dx with a UTD pressure ulcer on coccyx) At this time (6/17/15 at 1:20 p.m.) the DON was queried as to what pressure ulcer prevention interventions were in place at the time of admission. The DON stated, Only the ones I see are the one on the 27 th (10/27/14). The DON reported the Braden Scale is the only tool the facility uses in determining the risk for developing pressure ulcers in residents. The DON was asked if she thought the Braden Scales were accurate for Resident #701. She answered No. The DON was asked why Resident #701 did not have a standard wheelchair cushion in place at the time of admission. She stated, She did not meet the criteria for a wheelchair cushion. If the Braden Scaled determined she was at risk then she would have gotten a wheelchair cushion. The DON was then queried about daily skin assessments. The daily skin assessments were reviewed with the DON for the time period of 10/16/14 - 11/28/14. There was inconsistent documentation noted. The daily skin assessments indicated an open area on the coccyx on 10/27/14, 11/3/14, 11/16/14, and 11/22/14. The other days within that time period did not note any skin alterations. The wound notes dated 10/27/14 - 11/25/14 indicated a wound to Resident #701's coccyx. A wound note dated 10/28/14 at 11:00 a.m. revealed the following documentation: Observed resident (#701) sacral/coccyx area, area appears discolored and black underneath the skin, skin tears to sacral area and right buttock visible during wiping for brief change, sacral area red, resident unable to turn self, require total assist for turning, currently on ABT (antibiotic) for [MEDICAL CONDITION] and incontinent of bladder, require more frequent brief changes. Wound note dated 10/30/14 at 1 p.m., revealed the following documentation: Observed resident sacral/coccyx area measuring 0.6 X 0.5 (? centimeters), appears to be deep tissue injury with discoloration under the skin, wound bed firm, minimal drainage, periwound red and excoriated. Wound note dated 11/3/14 at 3:41 p.m., revealed the following documentation: Resident (#701) seen by NP (Nurse Practitioner) regarding sacral/coccyx to bilateral buttock unstagable ulcer with soft tissue infection measuring 4.0 X 8.0 X UTD (Unable To Determine), right parasacral area and buttock, minimal serosanguinous drainage, Keflex 500 milligrams (mg) one tab BID (twice a day) X 7 days ordered.limit time up in wheelchair to one hour per episode, ROHO cushion ordered. Wound note dated 11/17/14 at 1:27 p.m., revealed the following documentation: Resident (#701) seen today by wound NP regarding the sacral/coccyx unstagable ulcer measuring 5.0 X 8.0 X UTD.pale necrotic base, edges lifting, moderate serosanguinous drainage noted. recommended surgical debridement of site. Wound note dated 11/24/14 at 1:09 p.m., revealed the following documentation: Resident (#701) seen today by wound NP for sacral/coccyx stage IV ulcer, wound measures 4.5 X 3.0 X 2.8 post surgical debridement at the hospital on [DATE], wound base is still pale with slough, mild excoriation to perimeter with moderate serosanguinous drainage. On 6/17/15 at 3:25 p.m., policies on the Braden Scale, pressure ulcers and the prevention of pressure ulcers were requested. On 6/17/15 at 3:50 p.m., the following policies were reviewed: - Skin Monitoring Record, dated 6/12/2006, indicated The Skin Monitoring Record (SMR) will be generated weekly to track residents who are at high risk and who have breakdown so that they are monitored by the Neighborhood Meeting. Monitor residents identified to have Braden scale of 16 or below and those with active breakdown every 7- 10 days, and make recommendations to committee, re: equipment, positioning devices, or treatment modalities as appropriate. - Pressure Ulcer Prevention, dated 7/13/2011, indicated the following documentation: All residents will be assessed daily by the CNA during a.m. care. Any changes in skin condition will be reported to the charge nurse immediately. Use positioning devices such as pillows, foam wedges to keep bony prominences from direct contact with each other. Use air mattresses. - Pressure Ulcer Staging, dated 5/12/2003, revealed the following documentation: All pressure ulcers will be using the following staging system: Stage I is non-blanchable [DIAGNOSES REDACTED] of contact skin. Stage 4 is full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structure such as tendon or joint capsule. On 6/17/15 at 4:10 p.m., at the time of exit, the DON and the Administrator provided no explanation for the delay and/or lack of interventions that contributed to the development of Resident #701's facility acquired pressure ulcer. The Administrator reported that the facility is working on strategies to prevent further facility acquired pressure ulcers. ( )

This citation has two deficient practices. Deficient practice #1: Based on interview, and record review, the facility failed to ensure that a resident who required a two person assist to perform safe transfers was positioned and transferred appropriately by mechanical lift for one (#517) of nine sampled residents reviewed for accidents falls from a total sample of 24, resulting in the resident falling and sustaining a left leg laceration requiring twelve sutures. Findings include: On 5/8/15 at 9:00 A.M. Resident #517's clinical record was reviewed. The resident's current admission was dated 12/21/15. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) resident assessment and care screening dated 2/27/15, described the resident with moderately impaired cognitive and decision-making skills. Resident #517 required extensive two person physical assistance from staff for transfers, bed mobility and other activity of daily living needs. A plan of care for falls dated 3/23/15, identified that the resident was at risk for falls due to history of falls/injury, and multiple risk factors related to being non-ambulatory and debility. Care plan interventions included: To keep environment free from obstruction, make sure that things are within reach, call light, nonslip footwear, wheelchair wheels locked.etc., and transfer utilizing a (mechanical) lift. On 5/8/15 9:30 A.M., Resident #517's progress notes dated 4/15/15 at 14:13 was reviewed. It identified that Resident #517 returned from the emergency department with twelve sutures and two steri strips to the left leg (lateral lower extremity). A scant amount of bleeding was noted, aftercare instructions to return to ER for removal of sutures, (antibiotic) 500 mg four times a day until done.etc. On 5/8/15 at 9:45 A.M., Resident #517's incident report dated 4/15/15 at 11:58 was reviewed. Nursing description: Called to room by CNA, observed a 3.5 inch laceration to right lower extremity, with minimal bleeding noted. The resident unable to give statement. The area was cleansed and doctor was in to evaluate and gave verbal orders to transfer the resident to emergency for sutures. On 5/8/15 at 10:05 A.M., the Unit Manager, employee 'A' was interviewed. Employee 'A' stated, The incident was a not a fall, the injury was from hitting the resident's leg on the wheelchair during the transfer. She (resident #517) is total care. When queried rather appropriate transfer technics were used employee 'A' was not sure. A review of the incident report did not identify findings or corrective measures related to the incident. At 10:45 A.M., the Unit Manager, was further questioned about the use of mechanical lifts and resident care status. She stated, The (mechanical lift) protocol for safety identify that a two person assist with all transfers are required. The resident care guide is kept in each resident room/closet and should be reviewed prior to care being provided. A review of the resident care guide identified that transfers were by (mechanical lift) with two-person assist (per the physician orders [REDACTED]. On 5/ 8/15 at 10:15 A.M., the nurse on duty (at time of incident), employee 'B' was contacted by phone and interviewed about the incident. Employee 'B' stated, The CNA (employee C) transferred the resident from bed to wheelchair. She looked down (after the resident pointed) and observe the resident's leg was bleeding. The nurse was further questioned about the resident's transfer status. The nurse stated, I can not tell you how the resident was transferred, but the CNA (employee B) was the only one in the room with the resident when I entered. On 5/ 8/15 at 10:35 A.M., CNA, employee 'C' on duty (at time of incident) was contacted by phone and interviewed about the incident. Employee 'C' stated, I was assisting her her (resident #517) to transfer from bed to wheelchair. When she turned to sit in wheelchair, pivot, her leg bumped the wheelchair. The CNA was questioned about the resident's transfer status. The CNA stated, The resident was not a (mechanical lift) transfer, however, I have not looked at the cardex (resident care guide) in awhile. I was familiar with providing her care. On 5/8/15 at 11:30 A.M., the Administrator was interviewed. The Administrator stated, All falls/accidents are reviewed and handled by the Director of Nursing (not available). She indicated no knowledge of the incident. The facility was asked to provide a policy for falls/accidents and (mechanical lift). The policy titled Hoyer Lift Usage (dated revised 2/1998) was reviewed. Purpose: Helps move and transfer heavy residents who are unable to assist mover. Prevents undue strain on mover's body. Responsible person: CNA and/or licensed nurse, minimum of 2 persons. ( ) Deficient practice #2: Based on interview and record review, the facility failed to ensure that a cigarette lighter was not left accessible to one (#91) supplemental sampled resident, who had moderate cognitive impairment, and all other residents on the 2 South unit (a total census of 23), resulting in the potential for a fire to be set and harm from burns. Findings include: Each day of the survey, a sign was observed posted near the facility entrance noting that smoking was not allowed on the grounds. On 5/8/15 at approximately 1 PM, the Human Resources Director (Staff 'V') presented an employee file for nurse aide 'F' and an e-mail by supervisor 'N' to the Director of Nursing (DON) and nurse manager 'M' dated 3/20/15. The e-mail noted the following: (Resident #91's) family found a purple lunch bag in room. After they opened it and found smokes (cigarettes) and lighter, they took it.to nurse ('H').I did find out bag belonged to (aide 'F'). Staff 'V' was asked about a lighter being left accessible to residents on the unit, in a non-smoking facility. Staff 'V' said, (Aide 'F') said that she didn't have a locker, so she put her things in the (resident's) room. When asked if a lighter in a resident's possession could pose a risk to safety, staff 'V' shrugged her shoulders and did not respond. A review of a written statement in aide 'F's file by nurse 'H' revealed: I am writing regarding a bag being in the room (of resident #91). We (the resident's family and nurse 'H') opened it and we knew it wasn't (resident #91's) because it had cigarettes in the bag and we know she doesn't smoke. On 5/8/15 at 2:30 PM, nurse 'H' was interviewed by phone. When asked about the lighter being left in resident #91's room, nurse 'H' said, She (aide 'F') would leave her things in resident's rooms and left the lighter. At 2:45 PM, per review of resident #91's minimum data sets dated 12/17/14 and 4/8/15, the resident scored 8 and 10 respectively, for cognition. A score of 8-12 meant moderately impaired. ( )

THIS CITATION HAS TWO DEFICIENT PRACTICES DEFICIENT PRACTICE #1: BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO CONSISTENTLY IMPLEMENT NECESSARY TREATMENT AND SERVICES TO PROMOTE HEALING FOR ONE (#713) SAMPLED RESIDENT OUT OF FIVE RESIDENTS REVIEWED FOR PRESSURE SORES FROM A TOTAL OF 26 SAMPLED RESIDENTS. RESULTING IN THE WORSENING OF PRESSURE SORES. FINDINGS INCLUDE: REVIEW OF THE ADMISSION FACE SHEET DOCUMENTED RESIDENT #713 WAS ORIGINALLY admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM DATA SET ((MDS) dated [DATE], DOCUMENTED RESIDENT #713 WAS SEVERELY IMPAIRED FOR COGNITION AND REQUIRED EXTENSIVE ASSISTANCE WITH BED MOBILITY AND TRANSFERS WITH ONE PERSON PHYSICAL ASSISTANCE. RESIDENT #713 WAS CODED AS INCONTINENT FOR BOWEL AND BLADDER. ADDITIONALLY, THE MDS CODED RESIDENT #713 WITH FOUR STAGE TWO (PARTIAL THICKNESS SKIN LOSS) PRESSURE SORES. ON 4/23/13 THRU 4/26/13 AT VARIOUS TIMES BETWEEN 9:00 A.M. AND 3:00 P.M. AT TWO HOUR INTERVALS RESIDENT #713 WAS OBSERVED UP IN HER WHEELCHAIR SEATED ON A WHEEL CHAIR CUSHION IN THE DINING/ACTIVITY ROOM SLEEPING. ADDITIONALLY A REGULAR MATTRESS WAS OBSERVED ON RESIDENT #713'S BED AT THE AFOREMENTIONED TIMES. REVIEW OF RESIDENT #713'S ADMISSION NURSING assessment dated [DATE] SKIN CONDITION DOCUMENTED: "...HAS FOUR OPEN AREAS TO COCCYX 1). 2.0 X 0.6 X 0.3, 2). 6.0 X 2.9 X 0.2, 3). 1.0 X 1.4 X 0.1, 4). 0.8 X 1.4." THE NUMERICAL NUMBERS IDENTIFIED DID NOT CORRESPOND TO THE NUMBERED SKIN DIAGRAM ON THE SKIN CONDITION FORM. REVIEW OF PHYSICIAN ORDERS [REDACTED]. "...AIR MATTRESS, WHEEL CHAIR CUSHION." REVIEW OF "WOUND/SKIN CARE MANAGEMENT" FORM, DOCUMENTED: -"4/15/13, PRESSURE STAGE II (PARTIAL THICKNESS SKIN LOSS INVOLVING EPIDERMIS, DERMIS, OR BOTH) 4.5 CM X 3.0 CM X 0.2 CM (CENTIMETERS) WITH 100 % (PERCENT) GRANULATION PERIWOUND [DIAGNOSES REDACTED]." THERE WERE NO FURTHER WOUND ASSESSMENTS DOCUMENTED IN THE CLINICAL RECORD. REVIEW OF NURSING NOTE DATED 4/19/13 DOCUMENTED: "COCCYX ULCER IS PRESSURE STAGE II WITH 100 % GRANULATION TISSUE...WOUND DOCTOR TO EVALUATE." THERE WERE NO MEASUREMENTS DOCUMENTED. THERE WAS NO DESCRIPTION OF THE WOUND BED. REVIEW OF NURSING NOTE DATED 4/22/13 AT 11:00 A.M., DOCUMENTED: "RESIDENT TRANSFERRED FROM room [ROOM NUMBER] TO room [ROOM NUMBER] A.., RECEIVING NURSE GIVEN REPORT, ALL MEDICATIONS TRANSFERRED. FALLEN STAR IN PLACE." REVIEW OF WOUND PHYSICIAN CONSULT DATED 4/22/13 FOR RESIDENT #713'S PRESSURE SORES DOCUMENTED: "PATIENT SEEN ON CONSULT FOR COCCYGEAL ULCER...COCCYX ULCER 5.0 X 5.0 CM (CENTIMETERS) WITH DEEP TISSUE INJURY (PRESENTS AS A DARK BRUISE)." HOWEVER, THE CONSULT DID NOT DESCRIBE THE COLOR OF THE WOUND BED OR SURROUNDING TISSUE, THE PRESENCE OF ESCHAR NOR IF ANY DRAINAGE WAS OBSERVED. REVIEW OF PRESSURE SORE RISK TOOL DATED 4/13 DOCUMENTED: A SCORE OF "16", THAT INDICATED THE RESIDENT WAS AT LOW RISK (15-16) FOR PRESSURE SORES. ON 4/26/13 AT 9:45 A.M., RESIDENT #713 WAS OBSERVED FOR A WOUND CARE DRESSING CHANGE THAT WAS PERFORMED BY TREATMENT NURSE "G". RESIDENT #713 WAS OBSERVED AWAKE IN BED LYING ON HER RIGHT SIDE ON A REGULAR MATTRESS. TREATMENT NURSE "G" WAS OBSERVED AS SHE LIFTED THE TOP COVERS FROM RESIDENT #713 AND OPENED THE RESIDENT'S BRIEF. THERE WAS NO WOUND DRESSING OBSERVED IN PLACE TO PROTECT THE RESIDENT'S COCCYX PRESSURE SORE FROM CONTAMINATION FROM URINE OR FECES. WHEN QUERIED REGARDING THE PRESSURE SORE BEING LEFT OPEN, TREATMENT NURSE "G" STATED, "THE CNA (CERTIFIED NURSE ASSISTANT) REMOVED THE DRESSING BECAUSE IT WAS SOILED." AT THAT TIME RESIDENT #713 WAS OBSERVED WITH TWO SEPARATE OPEN WOUNDS AT THE COCCYX AND ONE OPEN AREA ON THE LEFT LOWER BUTTOCK STAGE II , WITH A PINK WOUND BASE AND [DIAGNOSES REDACTED] TO THE PERIWOUND OBSERVED. TREATMENT NURSE "G" WAS THEN OBSERVED AS SHE CLEANED AND MEASURED RESIDENT 713'S COCCYX PRESSURE SORE. RESIDENT #713'S COCCYX PRESSURE SORE MEASURED 5.0 CM X 4.0 CM WITH 50% GRANULATION AND 50% SLOUGH (NECROTIC TISSUE) WORSENING IN PRESSURE SORE CONDITION. WHEN QUERIED REGARDING THE NUMBER OF WOUNDS THAT WERE OBSERVED FOR RESIDENT #713 AND THE DEVELOPMENT OF NECROTIC TISSUE TO THE COCCYX PRESSURE SORE, TREATMENT NURSE "G" STATED, "I COUNTED THE COCCYX WOUND AS ONE WOUND BECAUSE THERE IS A PINK TISSUE BETWEEN THE TWO WOUNDS." TREATMENT NURSE "G" OFFERED NO EXPLANATION REGARDING RESIDENT #713'S LEFT LOWER BUTTOCK WOUND AND THE PRESENCE OF SLOUGH (TISSUE NECROSIS) IN THE COCCYX PRESSURE SORE. WHEN QUERIED REGARDING THE TYPE OF MATTRESS RESIDENT #713 WAS LYING ON TREATMENT NURSE "G" HESITATED AND STATED, "IT'S A REGULAR MATTRESS SHE WAS ON AN AIR MATTRESS DOWNSTAIRS. THE MATTRESS SHOULD HAVE CAME UP WITH HER." ON 4/26/13 AT 10:00 A.M., DURING AN INTERVIEW AND RECORD REVIEW WITH TREATMENT NURSE "G" REGARDING RESIDENT #713'S WEEKLY WOUND ASSESSMENT FOR THE WEEK OF 4/22/13, TREATMENT NURSE "G" STATED, "I DIDN'T HAVE A CHANCE TO GET BACK UP HERE TO DO IT ON WEDNESDAY." NO FURTHER EXPLANATION WAS OFFERED WHEN TREATMENT NURSE WAS ASKED TO EXPLAIN WHY THERE WERE NO SKIN ASSESSMENT DOCUMENTED SINCE 4/15/13 IN THE CLINICAL RECORD. ON 4/26/13 AT 11:25 A.M., DURING AN INTERVIEW AND RECORD REVIEW WITH THE DIRECTOR OF NURSING (DON), WHEN QUERIED REGARDING RESIDENT #713'S PRESSURE SORE AND INTERVENTIONS TO PROMOTE WOUND HEALING WAS UNABLE TO EXPLAIN WHY RESIDENT #713 WAS NOT ON AN AIR MATTRESS AS ORDERED. WHY THERE WERE NO WOUND ASSESSMENTS AND MEASUREMENTS DOCUMENTED FOR RESIDENT #713 SINCE 4/15/13. WHY TREATMENT NURSE "G" DID NOT MEASURE THE TWO OPEN WOUNDS SEPARATELY. NOR WHY THERE WAS NO EVIDENCE THAT THE WOUND PHYSICIAN HAD EVALUATED RESIDENT #713'S PRESSURE SORE DOCUMENTED IN THE CLINICAL RECORD. REVIEW OF THE FACILITY'S "PRESSURE ULCER STAGING" POLICY DATED, 5/12/03, DOCUMENTED: POLICY: ALL PRESSURE ULCERS WILL BE ASSESSED ON ADMISSION OR DISCOVERY AND WEEKLY THEREAFTER UNTIL DISCHARGE. ASSESSMENT WILL BE DOCUMENTED ON THE SKIN MONITORING RECORD. #1. ALL PRESSURE ULCERS WILL BE USING THE FOLLOWING STAGING SYSTEM: "...B. STAGE 2: PARTIAL THICKNESS SKIN LOSS INVOLVING EPIDERMIS AND OR DERMIS. THE ULCER IS SUPERFICIAL AND PRESENTS CLINICALLY AS AN ABRASION, BLISTER OR SHALLOW CRATER. C. STAGE 3: FULL THICKNESS SKIN LOSS INVOLVING DAMAGE OR NECROSIS OF SUBCUTANEOUS TISSUE THAT EXTENDS DOWN TO, BUT NOT THROUGH UNDERLYING FASCIA. THE ULCER PRESENTS CLINICALLY AS A DEEP CRATER WITH OR WITHOUT UNDERMINING OR ADJACENT TISSUE." REVIEW OF THE FACILITY'S "PRESSURE ULCER PREVENTION" POLICY DATED, JULY 13, 2011, DOCUMENTED: #2. D. USE AIR MATTRESSES: CHECKING IMPROPER INFLATION EACH SHIFT. ( ) DEFICIENT PRACTICE #2 BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE NECESSARY TREATMENT AND SERVICES FOR ONE (#703) OF FIVE SAMPLED RESIDENTS REVIEWED FOR PRESSURE ULCERS, OUT OF A TOTAL OF 26 SAMPLED RESIDENTS, RESULTING IN THE DEVELOPMENT OF AVOIDABLE PRESSURE ULCERS. FINDINGS INCLUDE: ON 4/23/13 AT 1:45 P.M., RESIDENT #703 WAS OBSERVED AMBULATING WITH STAND BY ASSISTANCE FROM STAFF. SHE WAS NOTED WEARING A CERVICAL COLLAR AND A RIGHT ARM BRACE WAS INTACT. MULTIPLE FACIAL BRUISES THAT WERE YELLOWISH, PURPLISH, AND BLACK WERE NOTED. A LARGE HEMATOMA WAS NOTED ABOVE HER LEFT EYE (FOREHEAD AREA). ON 4/24/13 AT 9:00 A.M., RESIDENT #703 WAS NOTED LYING IN BED RESTING. SHE WAS ALERT AND ANSWERED ALL QUESTIONS APPROPRIATELY. THE CAST TO HER RIGHT ARM WAS INTACT. THE CERVICAL COLLAR WAS INTACT. OXYGEN WAS INFUSING AT 2 LITERS PER MINUTE BY WAY OF A NASAL CANNULA. ON 4/24/13 AT 9:15 A.M., RESIDENT #703'S PRESSURE ULCER TREATMENT WAS OBSERVED PERFORMED BY THE FACILITY'S TREATMENT NURSE (NURSE "G"). NURSE "G" REMOVED RESIDENT #703'S CERVICAL COLLAR AND A DRESSING THAT WAS APPLIED TO HER RIGHT COLLAR (CLAVICLE) BONE AREA. THE OLD DRESSING HAD DRAINAGE THAT WAS SEROSANGUINOUS, YELLOWISH, AND GREENISH IN COLOR. OBSERVATION OF THE WOUND REVEALED MODERATE AMOUNTS OF SLOUGH IN THE CENTER OF THE WOUND AND THE POSTERIOR, BASE OF WOUND HAD A NECROTIC AREA (DEEP TISSUE INJURY). NURSE "G" STATED, "IT STARTED OFF AS A DEEP TISSUE INJURY. THE C-COLLAR IS ON AT ALL TIMES. IT IS NOT SUPPOSED TO BE REMOVED EVER." NURSE "G" WAS QUERIED WHETHER THE DOCTOR WAS AWARE OF RESIDENT #703'S WOUND. NURSE "G" STATED, "HER DOCTOR IS AWARE OF THE WOUND, BUT HE STILL WANTS THE C-COLLAR (CERVICAL COLLAR) ON AT ALL TIMES." RESIDENT #703 THEN STATED, "IT'S VERY UNCOMFORTABLE." NURSE "G" THEN CONTINUED TREATING THE WOUND. SHE REPORTED THE WOUND WAS TWO CENTIMETERS (CM) BY TWO CM. THE PERIWOUND WAS REDDENED AND TENDER. RESIDENT #703 WINCED AND REPORTED PAIN AS NURSE "G" CLEANSED THE WOUND AND AREA WITH NORMAL SALINE. SHE THEN APPLIED A DEBRIDEMENT AGENT TO THE WOUND, AND COVERED IT WITH A DRESSING. NURSE "G" REPORTED THAT RESIDENT #703 HAD A [MEDICATION NAME] DRESSING (THIN ADHESIVE DRESSING) TO HER BOTTOM (SACRAL AREA). NURSE "G" STATED, "THERE IS NO OPEN AREA THERE. WE JUST PROTECT IT WITH THE DRESSING. IT IS DUE TO BE CHANGED TOMORROW (ON 4/25/13)." RESIDENT #703 WAS NOT RESTING ON A SPECIALTY MATTRESS OR AN AIR MATTRESS DURING THE TIME OF THE WOUND OBSERVATION. REVIEW OF THE ADMISSION SKIN ASSESSMENT FORM FOR RESIDENT #703, DATED 4/12/13, REVEALED NO OPEN AREAS. THE BRADEN SCALE, DATED 4/12/13, REVEALED A DOCUMENTED SCORE OF 14 WHICH INDICATED RESIDENT #703 WAS A MODERATE RISK FOR THE DEVELOPMENT OF PRESSURE ULCERS. PER THE FACILITY'S "SKIN RISK ASSESSMENT AND PREVENTION PROTOCOLS," THE FOLLOWING INTERVENTIONS SHOULD HAVE BEEN IMPLEMENTED: WEEKLY SKIN ASSESSMENTS DAILY CNA (CERTIFIED NURSING ASSISTANTS) OBSERVATION EVERY A.M. CARE PLAN INITIATED DAILY VITAMIN C DAILY MULTIVITAMIN AIR MATTRESS IMMEDIATELY THERE WERE NO OTHER BRADEN SCALE ASSESSMENTS CONDUCTED AFTER THE INITIAL ONE. REVIEW OF RESIDENT #703'S MEDICATIONS REVEALED NO ORDERS FOR VITAMIN C OR MULTIVITAMIN. NOR WAS THERE AN AIR MATTRESS IMMEDIATELY APPLIED. REVIEW OF RESIDENT #703'S FACE SHEET REVEALED AN ADMISSION INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #703'S ADMISSION MINIMUM DATA SET (MDS), dated [DATE], INDICATED AN INTACT COGNITION, INTACT SKIN (NO OPEN AREAS), AND WAS DEPENDENT UPON THE STAFF FOR ALL ACTIVITIES OF DAILY LIVING (ADL'S). ON 4/25/13 AT 9:35 A.M., THE DIRECTOR OF NURSING (DON) WAS QUERIED REGARDING THE DEVELOPMENT OF RESIDENT #703'S PRESSURE ULCER WHILE IN THE FACILITY. THE DON WAS ALSO QUERIED REGARDING THE FREQUENCY AND DOCUMENTATION OF SKIN ASSESSMENTS. THE DON STATED, "THE SKIN ASSESSMENTS SHOULD BE DONE DAILY DURING CARE. THAT IS NOT DOCUMENTED UNLESS A SKIN ALTERATION IS NOTED." THE DON FURTHER REPORTED THAT SKIN ASSESSMENTS ARE DONE DURING RESIDENTS' SHOWERS. RESIDENT #703 HAD TWO "BATH AND SKIN REPORTS." THE FIRST ONE WAS DATED 4/17/13: INDICATED "UPPER BODY REDNESS." NO OTHER SKIN ALTERATIONS WERE DOCUMENTED. THE SECOND AND LAST "BATH AND SKIN REPORT," DATED 4/19/13 REVEALED DOCUMENTATION THAT READ: REFUSED SHOWER. SAYS SHE GIVES BED BATH DAILY. PATIENT (PT) IS SELF CARE." THERE WAS NO ASSESSMENT OF THE SKIN DOCUMENTED. REVIEW OF RESIDENT #703'S CHART WITH THE DON REVEALED NO PLAN OF CARE FOR THE USE OF THE C-COLLAR/BRACE. THE ADL AND THE SKIN CARE PLAN HAD NO INTERVENTION SPECIFIC TO THE USE OF THE C-COLLAR/BRACE. THE SKIN CARE PLAN INITIATED ON 4/12/13 INDICATED THE ACTUAL DEVELOPMENT OF THE PRESSURE ULCER RIGHT COLLAR DEVELOPED ON 4/16/13. REVIEW OF THE physician's orders [REDACTED]. REVIEW OF A NURSE'S NOTE, DATED 4/17/13 AT 6:25 P.M., REVEALED DOCUMENTATION THAT READ: "WOUND NOTED UNDER CERVICAL COLLAR, RIGHT COLLAR BONE OPEN AREA 4 X 4 CM, WOUND CARE NOTIFIED..." REVIEW OF THE NURSE'S NOTE, WITH THE DON, FOR RESIDENT #703, DATED 4/18/13 AT 2 P.M., REVEALED DOCUMENTATION: "RIGHT COLLAR ULCER NOTED. SCABBED WITH REDDENED PERIWOUND AND TENDER TO TOUCH RELATED TO CERVICAL COLLAR IN PLACE..." THE DON PROVIDED NO EXPLANATION FOR NO FURTHER BRADEN SCALE ASSESSMENTS NOR FOR DAILY SKIN INSPECTIONS SPECIFICALLY CONDUCTED WHILE RESIDENT #703 WORE THE CERVICAL COLLAR. ON 4/26/13 AT 11:00 A.M., RESIDENT #703 WAS IN BED RESTING ON A SPECIALTY AIR MATTRESS. SHE WAS WEARING HER C-BRACE. RESIDENT #703'S COLLAR BONE (CLAVICLE) WOUND WAS ASSESSED AND MEASURED WITH NURSE "G" AFTER THE REMOVAL OF THE C-BRACE. THE OLD DRESSING HAD A YELLOWISH/GREENISH DRAINAGE. THE PERIWOUND WAS BRIGHT RED. MODERATE AMOUNTS OF SLOUGH WAS NOTED TO THE CENTER OF THE WOUND. FIVE PERCENT OF THE WOUND, AT THE BASE WAS NECROTIC. THE ENTIRE WOUND MEASURED 2.0 CM X 2.0 CM. THE TREATMENT WAS THEN TREATED. NURSE "G" THEN REMOVED THE THIN ADHESIVE DRESSING WITH GAUZE FROM RESIDENT #703'S SACRAL/COCCYX AREA. THE OLD DRESSING REVEALED GREENISH DRAINAGE. THREE OPEN AREAS WERE NOTED. NURSE "G" STATED, "I WILL TREAT THEM AS IF THEY WERE STAGE TWO ULCERS. THE THREE OPEN AREAS HAD THE FOLLOWING MEASUREMENTS: (1.) RIGHT ANTERIOR SACRUM 1.0 CM X 1.0 CM, (2.), 2. RIGHT POSTERIOR SACRUM 1.5 CM X 0.4 CM, AND (3.) LEFT POSTERIOR SACRUM 0.3 CM X 0.3 CM. THERE WAS NO DEPTH NOTED TO THE AREAS. ALL OF THE AREAS WERE CLEANSED WITH NORMAL SALINE, WOUND GEL, AND A BULKY DRESSING WAS APPLIED. NURSE "G" REPORTED THESE AS NEW OPEN AREAS. REVIEW OF RESIDENT #703'S TREATMENT ASSESSMENT RECORDS (TAR) REVEALED NO DOCUMENTED AREAS ON THE COCCYX/SACRAL AREA. ON 4/26/13 AT 10:00 A.M., THE DON WAS INTERVIEWED REGARDING THE LACK OF INTERVENTIONS FOR RESIDENT #703'S ACQUIRED PRESSURE ULCERS. THE DON STATED, "SHE (RESIDENT #703) JUST GOT THE AIR MATTRESS ABOUT TWO DAYS AGO. SHE HAD A STANDARD MATTRESS BEFORE THAT, WHICH WAS PRESSURE RELIEVING. RESIDENTS GET A SPECIALTY MATTRESS DEPENDING WHERE THEY FALL ON THE BRADEN SCALE. ALTHOUGH WE DON'T HAVE DOCUMENTED DAILY SKIN ASSESSMENTS, WE DO THEM AS A STANDARD OF PRACTICE." THE DON HAD NO EXPLANATION AS TO WHY RESIDENT #703 DID NOT RECEIVE AN AIR MATTRESS RIGHT AWAY AS INDICATED AS PART OF THE FACILITY'S PROTOCOL WHEN SHE WAS ASSESSED AS A MODERATE RISK FOR PRESSURE ULCERS ON ADMISSION. REVIEW OF THE FACILITY'S POLICY, DATED 6/2000, ENTITLED "PRESSURE SORE RISK FACTORS PREDICTION AND INTERVENTION PROTOCOLS," REVEALED THE FOLLOWING DOCUMENTATION: "THE LICENSED NURSE WILL INITIATE THE PREVENTATIVE MEASURES IMMEDIATELY ON ADMISSION AS ON THE SKIN RISK ASSESSMENT AND PREVENTION PROTOCOLS TOOL. THE LICENSED NURSE WILL CONTACT THE PHYSICIAN AND OBTAIN APPROPRIATE ORDER FOR LABS, MEDICATIONS AND DIETARY SUPPLEMENTS AS OUTLINED ON THE INTERVENTION PROTOCOLS." REVIEW OF THE FACILITY'S POLICY ENTITLED, "PRESSURE ULCER PREVENTION," DATED 7/13/2011, REVEALED THE FOLLOWING DOCUMENTATION: "IMPLEMENT INTERVENTIONS TO REDUCE SHEARING FORCE AND FRICTION." ( )

THIS CITATION PERTAINS TO INTAKES # MI 090 AND MI 181. BASED ON OBSERVATIONS, INTERVIEWS AND RECORDS REVIEW THE FACILITY FAILED TO ENSURE 3 (#104, #106, AND #107) OF 7 RESIDENTS REVIEWED FOR FALLS, FROM A TOTAL SAMPLE OF 7 RESIDENTS, HAD ADEQUATE SAFETY AND/OR SUPERVISION, RESULTING IN A FRACTURED RIGHT FEMUR FOR RESIDENT #107 WHEN SHE fell DURING A TRANSFER, A FALL WITHOUT INJURY FOR RESIDENT #104, AND THE POTENTIAL FOR FUTURE FALLS WITH INJURY FOR RESIDENT #106. RESIDENT #107 REVIEW OF THE FACE SHEET DATED 2/22/2013 REVEALED RESIDENT #107 WAS A [AGE] year OLD FEMALE admitted TO THE FACILITY 5/26/2010 WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM (MDS) data set [DATE] REVEALED RESIDENT #107 HAD IMPAIRED COGNITION, IMPAIRED BALANCE, DID NOT WALK, AND REQUIRED TWO STAFF MEMBERS FOR ALL TRANSFERS. PHYSICIAN ORDERS [REDACTED]. THERAPY NOTES DATED 12/05/2012 REVEALED RESIDENT #107 HAD POOR STANDING BALANCE AND REQUIRED A SIT TO STAND LIFT FOR ALL TRANSFERS. REVIEW OF CARE PLANS DATED 9/04/2012 REVEALED RESIDENT #107 WAS AT RISK FOR FALLS DUE TO A HISTORY OF FALLS, A GAIT DYSFUNCTION, DECREASED MOBILITY AND DEBILITY, FOR WHICH SHE REQUIRED SAFETY ALARMS AND A SIT TO STAND LIFT FOR ALL TRANSFERS. REVIEW OF AN INCIDENT/ACCIDENT REPORT DATED 2/15/2013 AT 7:30 P.M., REVEALED THAT CERTIFIED NURSING ASSISTANT (CNA) #2 INDEPENDENTLY TRANSFERRED RESIDENT #107 FROM HER WHEELCHAIR WITHOUT THE SIT TO STAND LIFT, WHEN THE "RESIDENT'S LEGS WENT WEAK, AND RESIDENT (#107) WAS LOWERED TO THE FLOOR." REVIEW OF NURSING NOTES DATED 2/16/2013 AT 6:60 A.M., REVEALED RESIDENT #107 COMPLAINED OF RIGHT KNEE PAIN, AND WHEN ASSESSED, STAFF NOTED HEAT AND SWELLING PRESENT TO THE SAME AREA. REVIEW OF RADIOLOGY REPORTS DATED 2/16/2013 REVEALED RESIDENT #107 SUSTAINED A RIGHT DISTAL FEMUR FRACTURE. DURING AN INTERVIEW 3/08/2013 AT 3:45 P.M., DIRECTOR OF NURSING (DON) #1 SAID TO ENSURE RESIDENT #107 WAS SAFE DURING TRANSFERS, STAFF WERE REQUIRED TO USE THE SIT TO STAND LIFT. DON #1 SAID THAT ON 2/15/2013 AT 7:30 P.M., CNA #2 FAILED TO COMPLY WITH THIS SAFETY REQUIREMENT AND SUBSEQUENTLY THE RESIDENT fell , SUSTAINING A FRACTURED FEMUR. RESIDENT #104 REVIEW OF THE FACE SHEET DATED 5/25/2011 REVEALED RESIDENT #104 WAS A [AGE] year OLD FEMALE admitted TO THE FACILITY 2/13/2011 WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM (MDS) data set [DATE] REVEALED RESIDENT #104 HAD SEVERELY IMPAIRED COGNITION, LONG AND SHORT TERM MEMORY LOSS, IMPAIRED BALANCE, AND REQUIRED MINIMALLY ONE STAFF MEMBER TO ASSIST WITH TRANSFERS AND AMBULATION. A FALL RISK ASSESSMENT COMPLETED 9/6/2012 PLACED RESIDENT #104 AT "HIGH RISK" FOR FALLS DUE TO HER DISORIENTATION, HISTORY OF FALLS, CHAIR BOUND STATUS, IMPAIRED BALANCE, DECREASED MUSCLE COORDINATION, USE OF ASSISTIVE DEVICES, AND POTENTIAL FOR ADVERSE SIDE EFFECTS FROM HER MULTIPLE PRESCRIBED MEDICATIONS. REVIEW OF RESIDENT #104'S CARE PLANS DATED 8/27/2012 REVEALED THAT RESIDENT #104 WAS AT "HIGH RISK" FOR FALLS AND REQUIRED A TAB ALARM TO ALERT STAFF OF ANY UNDESIRED SELF-TRANSFER ATTEMPTS. REVIEW OF PHYSICIAN ORDERS [REDACTED]. REVIEW OF NURSING NOTES DATED 12/14/2013 REVEALED RESIDENT #104 WAS "FOUND ON (THE) BATHROOM FLOOR AFTER ATTEMPTING TO TRANSFER (HER)SELF." RESIDENT #104 HAD BEEN "LEFT UNATTENDED FOR A FEW MINUTES IN (THE) BATHROOM AND UPON (THE) CNA (CERTIFIED NURSING ASSISTANT) RETURN, RES (RESIDENT #104 WAS) ON (THE) FLOOR." DURING AN INTERVIEW 3/08/2013 AT 3:45 P.M., DON #1 (DIRECTOR OF NURSING #1) SAID RESIDENT #104 WAS LEFT ON THE TOILET UNSUPERVISED, WITHOUT ADEQUATE SAFETY DEVICES, DESPITE HER SIGNIFICANT SELF-TRANSFER HISTORY. DON #1 SAID SHE REPRIMANDED THE STAFF INVOLVED BECAUSE IT WAS NOT SAFE TO REMOVE RESIDENT #104'S SAFETY ALARMS AND LEAVE HER UNATTENDED ON A TOILET. RESIDENT #106 REVIEW OF THE FACE SHEET DATED 1/02/2013 REVEALED RESIDENT #106 WAS A [AGE] year OLD MALE admitted TO THE FACILITY 1/15/2008 WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM (MDS) data set [DATE] REVEALED RESIDENT #106 HAD MODERATELY IMPAIRED DECISION MAKING, LONG AND SHORT TERM MEMORY LOSS, IMPAIRED BALANCE, A RECENT FALL, WAS UNABLE TO WALK, AND REQUIRED MINIMALLY ONE STAFF MEMBER TO ASSIST WITH TRANSFERS, LOCOMOTION, DRESSING, EATING, TOILET USE, PERSONAL HYGIENE AND BATHING. REVIEW OF A CARE PLAN DATED 3/30/2013 REVEALED RESIDENT #106 WAS AT RISK FOR FALLS DUE TO IMPAIRED MOBILITY, POOR COORDINATION, AN UNSTEADY GAIT, AND REQUIRED A TAB ALARM ON HIS WHEELCHAIR TO ALERT STAFF TO ANY UNDESIRED SELF-TRANSFERS. OBSERVATIONS MADE 3/01/2013 AT 11:30 A.M., REVEALED THAT RESIDENT #106 HAD BEEN SITTING IN HIS WHEELCHAIR AT THE DINING ROOM TABLE WHERE STAFF LEFT HIM UNATTENDED WITHOUT THE REQUIRED TAB ALARM IN PLACE.

THIS CITATION PERTAINS TO INTAKE # MI 855 BASED ON INTERVIEWS AND RECORDS REVIEW THE FACILITY FAILED TO ENSURE 1 OF 3 SAMPLED RESIDENTS (#102), REVIEWED FOR ACCIDENTS, FROM A TOTAL SAMPLE OF 3, HAD THE APPROPRIATE LEVEL OF SUPERVISION AND/OR SAFETY DEVICES TO PREVENT ACCIDENTS, WHICH RESULTED IN A FALL FOR RESIDENT #102 WITH MULTIPLE RIGHT RIB FRACTURES. FINDINGS INCLUDE: RESIDENT #102 ACCORDING TO THE FACE SHEET DATED 7/27/2012, RESIDENT #102 WAS A [AGE] year OLD FEMALE ORIGINALLY admitted to the facility on [DATE], REadmitted on [DATE], WITH [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM DATA SET ((MDS) dated [DATE], RESIDENT #102 HAD MODERATELY IMPAIRED DECISION MAKING, LONG AND SHORT TERM MEMORY LOSS, IMPAIRED BALANCE AND REQUIRED MINIMALLY ONE STAFF MEMBER TO ASSIST WITH ALL TRANSFERS, AMBULATION AND TOILETING. DOCUMENTED FALL RISK assessment dated [DATE], 3/25/2012, 3/26/2012, 6/12/2012, 7/03/2012, 7/05/2012 AND 7/10/2012, NOTED THAT RESIDENT #102 WAS AT "HIGH RISK" FOR FALLS DUE TO HER LEVEL OF CONFUSION, HISTORY OF FALLS, NEED FOR STAFF ASSISTANCE WITH ELIMINATION, BALANCE PROBLEM WHILE STANDING, BALANCE PROBLEM WHILE WALKING, REQUIRED ASSISTIVE DEVICES, PRESCRIBED MEDICATION AND PREDISPOSING DISEASES. CARE PLANS DATED 3/10/2012 NOTED THAT RESIDENT #102 WAS AT RISK FOR FALLS AND REQUIRED FREQUENT STAFF OBSERVATION, THE PLACEMENT OF A BED ALARM, PLACEMENT OF A WHEELCHAIR ALARM, ASSISTANCE WITH TRANSFERS AND ASSISTANCE TOILETING BECAUSE SHE ROUTINELY "ATTEMPTED TO GET OUT OF (HER) WHEELCHAIR (AND) BED" WITHOUT ASSISTANCE. PHYSICIAN ORDERS [REDACTED]. DESPITE THE PHYSICIANS ORDER, A NURSING assessment dated [DATE] AT 4:30 P.M., DOCUMENTED THAT RESIDENT #102 INDEPENDENTLY TRANSFERRED AND WALKED WITH ONLY THE ASSISTANCE OF A WHEELED WALKER. NURSING NOTES DATED 3/25/2012 AT 8:05 P.M., DOCUMENTED THAT RESIDENT #102 DID NOT HAVE THE REQUIRED STAFF SUPERVISION REQUIRED FOR SAFETY WHEN SHE fell AT 8:05 P.M., AMBULATING INDEPENDENTLY USING A ROLLING WALKER. A COMPREHENSIVE REVIEW OF THE MEDICAL RECORD FAILED TO IDENTIFY ANY INTERVENTION IMPLEMENTED BY STAFF TO KEEP RESIDENT #102 SAFE AFTER SHE fell . NURSING NOTES DATED 3/26/2012 AT 7:00 A.M., DOCUMENTED THAT STAFF SUPERVISION WAS NOT PROVIDED TO ENSURE RESIDENT #102 WAS SAFE WHEN SHE TRANSFERRED FROM HER BED AND fell TO THE FLOOR. ON 3/26/2012, IN RESPONSE TO THIS FALL, THE RESIDENT'S PHYSICIAN ORDERED RESIDENT #102 HAVE A WHEELCHAIR AND BED ALARM. AN INTERDISCIPLINARY PROGRESS NOTE DATED 4/04/2012 DOCUMENTED THAT RESIDENT #102 HAD "SHORT AND LONG TERM IMPAIRMENTS RELATED TO ADVANCED DEMENTIA ...(HAD) A FALL ON 2/25 AND 2/26 ...NEEDS TO BE IN A WHEELCHAIR INSTEAD OF AMBULATION BY WALKER ...UNSTEADY GAIT....STAND BY ASSISTANCE NEEDED ....DOES NOT FOLLOW DIRECTIONS." DESPITE THIS ASSESSMENT, A COMPREHENSIVE REVIEW OF THE MEDICAL RECORD FAILED TO IDENTIFY ANY NEW INTERVENTION IMPLEMENTED BY STAFF TO KEEP RESIDENT #102 SAFE. A PHYSICAL THERAPY assessment dated [DATE], DOCUMENTED THAT FOR SAFETY, RESIDENT #102 REQUIRED MINIMALLY ONE STAFF MEMBER TO PROVIDE ASSIST WITH ALL TRANSFERS AND AMBULATION WITH HER ROLLING WALKER. NURSING NOTES DATED 4/10/2012 DOCUMENTED THAT RESIDENT #102 COULD NOT BE VERBALLY REDIRECTED AS SHE CONTINUED TO SELF-TRANSFER AND AMBULATE WITHOUT STAFF SUPERVISION OR HER ASSISTIVE DEVICES. DURING AN INTERVIEW ON 9/19/2012 AT 12:43 P.M., LICENSED PRACTICAL NURSE (LPN) #5 SAID THE TAB ALARM ORDERED DID NOT FUNCTION AS A SAFETY DEVICE SINCE THE DAY IT WAS ORDERED FOR RESIDENT #102 BECAUSE SHE (#102) WAS ABLE TO REMOVE IT WITHOUT ASSISTANCE. LPN #5 SAID IT WOULD HAVE BEEN BETTER FOR RESIDENT #102 IF STAFF HAD APPLIED A PRESSURE SENSITIVE ALARM THAT THE RESIDENT COULD NOT REMOVE. LPN #5 SAID STAFF DID NOT FOLLOW THE PHYSICIANS ORDER TO ASSIST WITH AMBULATION AND TRANSFERS BECAUSE THE RESIDENT OFTEN COULD DO IT WITHOUT HELP. NURSING NOTES DATED 5/19/2012 AND 6/20/2012 REVEALED RESIDENT #102 CONTINUED TO SELF-TRANSFER AND AMBULATE. A COMPREHENSIVE REVIEW OF THE MEDICAL RECORD FAILED TO IDENTIFY ANY INTERVENTION IMPLEMENTED BY STAFF TO KEEP RESIDENT #102 SAFE AFTER SHE EXHIBITED THESE UNSAFE BEHAVIORS. A PHYSICAL THERAPY assessment dated [DATE] REVEALED RESIDENT #102 REQUIRED MINIMALLY ONE STAFF MEMBER TO ASSIST WITH ALL TRANSFERS AND AMBULATION, USING A ROLLING WALKER. AN INCIDENT AND ACCIDENT REPORT DATED 7/03/2012 AT 1:30 P.M., REVEALED RESIDENT #102 WAS IN THE DINING ROOM, SELF-TRANSFERRED FROM HER WHEELCHAIR, TURNED AND fell TO THE FLOOR. A COMPREHENSIVE REVIEW OF THE MEDICAL RECORD FAILED TO IDENTIFY ANY NEW INTERVENTION IMPLEMENTED BY STAFF TO KEEP RESIDENT #102 SAFE AFTER SHE fell . ACCORDING TO NURSING NOTES DATED 7/05/2012 AT 3:45 P.M., STAFF FOUND RESIDENT #102 SITTING ON HER BATHROOM FLOOR. AN INCIDENT AND ACCIDENT REPORT DATED 7/05/2012 AT 3:45 P.M., DOCUMENTED THAT NO STAFF WERE PRESENT AND THE TAB ALARM WAS NOT IN PLACE WHEN RESIDENT #102 SELF-TRANSFERRED TO/FROM THE TOILET AND fell TO THE FLOOR. A PHYSICIANS ORDER DATED 7/05/2012, REQUIRED STAFF TO OBTAIN RIGHT SIDE X-RAYS OF THE RIBS, SHOULDER AND HIP TO RULE OUT A FRACTURE. RESIDENT #102 RETURNED to the facility on ,[DATE], HAVING SUSTAINED FIVE (5) BROKEN RIBS. ACCORDING TO AN "INVESTIGATION" FORM, COMPLETED BY DON #1 (DIRECTOR OF NURSING) DATED 7/12/2012, STAFF RESPONDED TO "THE BATHROOM CALL LIGHT" AND FOUND RESIDENT #102 SITTING ON THE FLOOR IN FRONT OF THE TOILET ON 7/05/2012 AT 3:45 P.M. THE DIRECTOR OF NURSING DOCUMENTED THAT RESIDENT #102 LEFT HER WHEELCHAIR AND TAB ALARM AT THE BEDSIDE BEFORE AMBULATING UNASSISTED TO THE BATHROOM AND WHEN SHE (#102) fell . DURING AN INTERVIEW ON 9/19/2912 AT 12:00 P.M., DON #1 (DIRECTOR OF NURSING) SAID THE MINUTE STAFF KNEW RESIDENT #102 WAS ABLE TO INDEPENDENTLY REMOVE HER OWN TAB ALARM IT BECAME AN INEFFECTIVE SAFETY MEASURE. DON #1 REVIEWED THE MEDICAL RECORD AND SAID STAFF FAILED TO CARE PLAN AND IMPLEMENT ANY NEW SAFETY INTERVENTIONS TO KEEP RESIDENT #102 SAFE AFTER 3/26/2012, WHEN THE PHYSICIAN ORDERED A BED AND TAB ALARM THAT STAFF FREQUENTLY FAILED TO IMPLEMENT.

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE APPROPRIATE TREATMENT AND SERVICES TO PREVENT THE DEVELOPMENT OF PRESSURE SORES FOR ONE (#702) OF SEVEN SAMPLED RESIDENTS REVIEWED FOR PRESSURE SORES OUT OF A TOTAL OF 24 SAMPLED RESIDENTS, RESULTING IN THE DEVELOPMENT OF AN AVOIDABLE PRESSURE SORE. FINDINGS INCLUDE: ON 5/8/12 AT 2:00 PM, RECORD REVIEW REVEALED THAT RESIDENT # 702 WAS ORIGINALLY admitted INto the facility on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM DATA SET ((MDS) dated [DATE], DOCUMENTED THE RESIDENT WAS INDEPENDENT FOR DECISION MAKING SKILLS AND WAS TOTALLY DEPENDENT ON STAFF FOR BED MOBILITY AND TRANSFERS. THE MDS DOCUMENTED RESIDENT # 702 WAS AT RISK FOR PRESSURE SORE AND HAD TWO STAGE TWO (II) PRESSURE SORES THAT STARTED ON 3/19/12. REVIEW OF THE "NURSING ADMISSION ASSESSMENT" DATED 6/24/11 DOCUMENTED THAT RESIDENT # 702 HAD MULTIPLE BRUISES ON THE ABDOMEN. THERE WERE NO OTHER SKIN ISSUES NOTED OTHER THAN A BANDAGE OVER A LEFT SURGICAL GROIN SITE AND ONE PLUS LOWER LEG [MEDICAL CONDITION] (SWELLING). REVIEW OF RESIDENT #702'S "BRADEN SCALE" (PRESSURE ULCER RISK TOOL) DATED 6/24/11 DOCUMENTED A SCORE OF "14" (MODERATE RISK). THERE WERE NO DOCUMENTED EVIDENCE OF OTHER BRADEN SCALE ASSESSMENTS. ON 5/10/12 AT 10:30 A.M., RESIDENT #702 WAS INTERVIEWED REGARDING THE DEVELOPMENT OF HEEL WOUNDS, THE RESIDENT DID NOT RESPOND. ON 5/10/12 AT 11:45 A.M., WOUND CARE OBSERVATION WITH STAFF NURSE (D ) REVEALED THAT RESIDENT # 702 HAD BILATERAL HEEL ULCERS AND A RIGHT ANTERIOR FOOT ULCER. THE RIGHT HEEL MEASURED 1.0 CENTIMETERS(CM) BY (X ) 0.5 CM WITH SCANT AMOUNT OF BLOODY DRAINAGE. THE LEFT HEEL MEASURED 7.0 CM X 1.0 CM WITH BLOODY DRAINAGE. THE RIGHT ANTERIOR FOOT MEASURED 2.5 CM X 2.0 CM WITH GREATER THAN 50 PERCENT DARK SLOUGH (DEAD MATTER OR NECROSED TISSUE) WHICH WAS UNSTAGABLE. STAFF NURSE (D) WAS QUERIED REGARDING THE DEVELOPMENT OF RESIDENT # 702 BILATERAL HEEL PRESSURE SORES, NO VERBAL EXPLANATION WAS OFFERED. REVIEW OF THE "POTENTIAL FOR SKIN BREAKDOWN" CARE PLAN, DATED 6/24/11, INCLUDED THE FOLLOWING INTERVENTIONS TO PREVENT THE DEVELOPMENT OF PRESSURE SORES: "WEEKLY BODY AUDITS. MONITOR SKIN FOR SIGNS OF BREAKDOWN WHEN PROVIDING DAILY SKIN CARE AND REPORT ANY SKIN CHANGES TO NURSE EVERY SHIFT. MONITOR AND RECORD SKIN CONDITION." ON 5/10/12 AT 1:45 P.M., DURING INTERVIEW AND RECORD REVIEW, NURSE (D) WAS UNABLE TO PROVIDE WEEKLY SKIN AUDITS RECORDS FOR RESIDENT #702 BETWEEN 3/19/12 AND APRIL 10, 2012. NURSE (D) EXPLAINED THEY SHOULD BE IN THE RESIDENT'S CHART. HOWEVER THERE WERE NO WEEKLY SKIN AUDITS DOCUMENTED AND PROVIDED BY THE END OF SURVEY. THE OLDEST PRESSURE SORE ONSET PER THE MDS WAS ON 3/19/12. REVIEW OF THE RESIDENT'S WEEKLY SKIN AUDITS DOCUMENTED THE FOLLOWING: 4/10/12, RIGHT HEEL STAGE II 1 X 1, LEFT HEEL STAGE II 6 X 4 DARK SKIN TISSUE, RIGHT ANKLE STAGE II 4 X 4 CLEAR DRAINAGE. 4/17/12, RIGHT HEEL STAGE II 3 X 3 BLOODY DRAINAGE, LEFT HEEL STAGE II 6 X 4, RIGHT ANKLE 4 X 4 SEROSANGUINEOUS DRAINAGE. 4/25/12, RIGHT HEEL STAGE II 3 X 3 BLOODY DRAINAGE, LEFT HEEL STAGE II 6 X 4, RIGHT ANKLE STAGE II 4 X 4 SEROUS DRAINAGE. 5/4/12, RIGHT HEEL STAGE II 3 X 3, LEFT HEEL STAGE II 6 X 4, RIGHT ANKLE STAGE II 4 X 3. HOWEVER, THE RESIDENT'S WEEKLY SKIN AUDITS DID NOT IDENTIFY THE RIGHT ANTERIOR PRESSURE SORE. REVIEW OF THE RESIDENT'S BATH AND SKIN SHEETS DATED 4/2/12 - 5/7/12 COMPLETED BY THE CERTIFIED NURSE ASSISTANTS (CNA) AND REVIEWED BY THE NURSE, DOCUMENTED THE FOLLOWING: 4/2/12, NO REDDENED OR OPEN AREAS. SWELLING TO FEET "YES" 4/5/12, NO REDDENED OR OPEN AREAS. SWELLING TO FEET "NO" 4/12/12, "HEELS RED". SWELLING TO FEET "NO", SKIN MONITORING COMMITTEE REVIEW WAS LEFT BLANK. 4/16/12, REDDENED OR OPEN AREAS, "YES". SWELLING TO FEET "NO", SKIN MONITORING COMMITTEE REVIEW WAS LEFT BLANK. 4/19/12, SKIN ABRASION ANTERIOR FOOT, "HEELS RED" TREATMENT ON HEELS. SWELLING TO FEET "NO", SKIN MONITORING COMMITTEE REVIEW WAS LEFT BLANK. 4/23/12, "HEELS RED", SWELLING TO FEET "NO", SKIN MONITORING COMMITTEE REVIEW WAS LEFT BLANK. 4/30/12, NO REDDENED OR OPEN AREAS. SWELLING TO FEET "NO". 5/3/12, NO REDDENED OR OPEN AREAS. SWELLING TO FEET "NO". 5/7/12, NO REDDENED OR OPEN AREAS. SWELLING TO FEET "NO". ON 5/11/12 AT 11:15 A.M., WHEN QUERIED NURSE MANAGER (B) WAS UNABLE TO PROVIDE THE RESIDENT'S BATH AND SKIN SHEETS PRIOR TO 4/2/12. NURSE MANAGER (B) STATED "I CAN'T FIND THEM". REVIEW OF NURSE'S NOTE DATED 4/9/12, "WOUND DOCTOR IN TO SEE PATIENT NEW ORDER "CLEANSE BILATERAL HEELS WITH NORMAL SALINE AND APPLY SANTYL OINTMENT, BULKY DRESSING..." THERE WAS NO DOCUMENTATION OF ASSESSMENT OR INTERVENTIONS RELATED TO THE RIGHT ANTERIOR FOOT ULCER. NURSE'S NOTE 4/23/12, "RESIDENT HAS TREATMENT ORDERED 4/9/12 TO CLEANSE BILATERAL HEELS WITH NORMAL SALINE FOLLOWED BY SANTYL OINTMENT, BULKY DRESSING DAILY." THERE WAS NO DOCUMENTATION OF ASSESSMENT OR INTERVENTIONS TO PREVENT PRESSURE SORES FOR THE RIGHT ANTERIOR FOOT PRESSURE SORE. NURSE'S NOTE 5/2/12, "DRESSING TO BILATERAL HEELS INTACT AND ELEVATED." THERE WAS NO MENTION OF INTERVENTIONS OR ASSESSMENT FOR THE RIGHT ANTERIOR FOOT PRESSURE SORE. ON 5/11/12 AT 11:15 A.M., DURING AN INTERVIEW AND RECORD REVIEW WITH NURSE MANAGER (B) REGARDING THE RESIDENT 702'S PRESSURE SORES, WHEN QUERIED STATED "THE RIGHT TOP FOOT ULCER WAS DUE TO THE RESIDENT'S TIGHT SOCK. IT STARTED AS A SMALL ABRASION." ON 5/11/12 AT 11:30 A.M., WHEN QUERIED NURSE MANAGER (B) WAS UNABLE TO EXPLAIN WHY THE BRADEN SCALE FOR THE RESIDENT WAS NOT UPDATED AFTER 6/24/11, AS INDICATED PER THE FACILITY'S "INTERVENTION PROTOCOL" FOR RESIDENT AT RISK FOR SKIN BREAKDOWN. NURSE MANGER (B) STATED "WE ONLY COMPLETE THE BRADEN SCALE ON THE RESIDENT'S ADMISSION". WHEN FURTHER QUERIED, NURSE MANAGER (B) CONFIRMED THE WEEKLY SKIN SHEETS SHOULD HAVE BEEN IN THE CHART AND THE CARE PLAN SHOULD HAVE BEEN UPDATED TO REFLECT ACTUAL SKIN BREAKDOWN AND UPDATES TO THE RESIDENT'S CARE PLAN. REVIEW OF THE FACILITY'S POLICY TITLED "PRESSURE ULCER PREVENTION" DATED 7/13/11, DOCUMENTED: "ALL RESIDENTS WILL BE ASSESSED DAILY BY THE CNA DURING AM CARE. ANY CHANGES IN SKIN CONDITION WILL BE REPORTED TO THE CHARGE NURSE IMMEDIATELY." ( ) .

This citation pertains to MI 280 and MI 694. BASED ON OBSERVATIONS, INTERVIEWS AND RECORDS REVIEW THE FACILITY FAILED TO ENSURE RESIDENTS RECEIVE ADEQUATE SUPERVISION AND ASSISTANCE DEVICES TO PREVENT ACCIDENTS IN 3 OF 9 SAMPLED RESIDENTS (#102, #105 AND #108), RESULTING IN A FALL WITH FRACTURED LEFT HIP FOR RESIDENT #102, A FALL WITH FRACTURED RIBS FOR RESIDENT #105 AND MULTIPLE UNSUPERVISED TRANSFERS FOR RESIDENT #108 WITH THE POTENTIAL FOR FUTURE HARM IN ALL CASES. Resident #102 According to the face sheet dated 0310/2011, Resident #102 was an [AGE] year-old-female living at the facility since 03/05/2010. Her [DIAGNOSES REDACTED]. According to the minimum (MDS) data set [DATE], Resident #102 suffered moderate impairment in cognitive function with both long and short-term memory loss. She required human assistance to maintain her balance and could not walk. She required extensive assistance with all transfers. According to this assessment tool Resident #102 had never fallen. According to physician orders [REDACTED]. She had been diagnosed by her physician to have " gait instability " . According to a fall risk assessment done on 03/05/2010 and 05/17/2010, Resident #102 was at high risk for falls due to her confusion, self-ambulation with incontinence, balance disturbance while walking, high risk medications and predisposing diseases. Despite policy, no further fall assessments had been completed on Resident #102 for the year 2010. According to a care plan dated 06/10/2010, staff assessed Resident #102 and determined she was at risk for falls due to her impaired balance, unsteady gait and her independent ability to remove her tabs safety alarm. To prevent injury from falls and optimize her safety staff had implemented interventions including appropriate footwear, safety checks every hour, a clutter free environment, and TOILETING every two hours WITH a tab alarm to her bed, by 08/25/2010. According to a therapy evaluation completed on 12/14/2010, Resident #102 was a fall risk with poor safety awareness and a decline in her balance. According to nursing notes dated 12/06/2010 at 3:00 p.m., staff witnessed Resident #102 occasionally swaying with her gait. Following this event staff made no change to the care planned interventions to ensure her safety. According to a " post fall investigation " dated 12/06/2010, the unit manager documented that she was aware Resident #102 "removes her own tab alarm." However, Following this event she made no change to the care planned interventions to ensure Resident #102 remained safe. According to nursing notes dated 01/18/2011 at 11:00 p.m., Resident #102 "will walk up and down (the) hallway until exhausted and unsteady on foot." According to nursing notes dated 01/20/2011 at 12:30 p.m., Resident #102 developed "new gait instability." According to nursing notes dated 01/28/2011 at 11:50 a.m., Resident #102 "attempted to get out of chair and almost fell , staff caught her. Pt (Patients) balance unsteady. Resident (is) also weak. " Following each of these observations staff failed to make any change to the residents care plan to ensure her safety. According to nursing notes dated 01/29/2011 at 8:20 a.m., staff "heard a thump and ran to find Resident (#102) lying on her left side on (the) floor" in front of her roommates bed. Resident #102 complained of "left hip pain." Nursing documented that Resident #102 had once again removed her own tab alarm, leaving it attached to her bed and preventing it from alarming. Resident #102 was then transferred to a local Emergency Department where she was diagnosed with [REDACTED]. Following this event staff made no changes to the care planned interventions to ensure her safety. On 03/09/2011 at 4:30 p.m., the director of nursing said once a resident can remove their own tab alarm without activating the device, it becomes ineffective for their safety and staff should impose alternate safety measures. She said her staff knows this because she has "preached it to them over and over again." She said the facility does have other safety devices. The director of nursing did not comment on the ongoing use of the ineffective tab alarm for Resident #102 or why staff failed to implement changes to the care plan when unsafe conditions were witnessed. On 02/23/2011 at 2:00 p.m., observations revealed Resident #102 lying in her bed. She WORE a tab alarm. THE manufacturer ' S RECOMMENDATIONS ARE to attach one end to the resident and the DEVICES ALARM BOX to a secure and immovable object. One end of the alarm was attached to the resident, HOWEVER The OTHER END sat immediately beside her, unattached to any object and free to move with the resident without alarming. alThough resident #102 was in bed, the bed brakes were not on. Resident #105 According to the face sheet dated 03/10/2011, Resident #105 was an [AGE] year-old-female living at the facility since 04/28/2010. Her [DIAGNOSES REDACTED]. According to her minimum (MDS) data set [DATE], Resident #105 demonstrated some short-term memory loss. She requires minimally one staff member to provide assistance with walking, dressing, toileting, hygiene and bathing. According to physician orders [REDACTED]. She also required assistance with transfers. According to a care plan dated 08/15/2010, staff assessed Resident #105 and determined her to be at risk for falls. To prevent injury from falls staff implemented frequent observation, a call light within reach, transfers with assistance and a bed in low position. According to nursing documentation for 11/2010, staff did not provide consistent transfer assistance for Resident #105 on 11/01/2010, 11/02/2010, 11/03/2010, 11/04/2010, 11/05/2010, 11/06/2010, 11/07/2010, 11/08/2010, 11/09/2010, 11/10/2010, 11/11/2010, 11/12/2010, 11/13/2010, 11/14/2010, 11/15/2010, 11/16/2010, 11/17/2010, 11/18/2010, 11/19/2010, 11/20/2010, 11/21/2010, 11/22/2010, 11/23/2010, 11/24/2010, 11/ 0, 11/26/2010, 11/27/2010, 11/28/2010, 11/29/2010 and 11/30/2010. ACCORDING TO AN "INCIDENT AND ACCIDENT" REPORT DATED 11/05/2010, RESIDENT #105 COMPLAINED OF RIGHT CHEST PAIN. SHE NOTIFIED STAFF SHE HAD FALLEN ON 11/04/2010 AGAINST THE BATHROOM SINK. tHIS INCIDENT REPORT CONFIRMed THAT PHYSICIAN ORDERS [REDACTED]." According to a " Post Fall Investigation " form dated 11/08/2011, RESIDENT #105 HAD NO STAFF ASSISTANCE FOR HER TRANSFER OR AMBULATION ON 11/04/2010 WHILE IN THE BATHROOM. ACCORDING TO NURSING NOTES DATED 11/07/2010 AT 4:30 P.M., AFTER THE FALL AND CONTINUED PAIN THE RESIDENT RECEIVED A CHEST X-RAY AND WAS diagnosed with [REDACTED]. On 03/16/2011 at 3:40 p.m., Employee "N" a certified nursing assistant said she often was assigned to care for Resident #105. According to this employee, Resident #105 was admitted with a tab alarm and since then has proven she can INDEPENDENTLY remove it. She said Resident #105 likes her independence and often self-transfers after removing HER OWN alarm. On 03/09/2011 at 1:30 p.m., Resident #105 was observed standing alone in her bedroom getting dressed. Her tab alarm was not in place. Her wheelchair was behind her. the wheel chair brakes had not been applied. the resident wore only cotton socks on her feet. Resident #105 stated staff provided her with clothing and instructed her to get dressed. Employee "O" a certified nursing assistant, THEN entered the room. Without providing Resident #105 with appropriate footwear, Employee " O " requested SHE (resident #105) transfer to the toilet and back WHILE STANDING on SLIPPERY, uncarpeted flooring. ON 03/09/2011 At 1:40 p.m., the resident WAS OBSERVED seated in a wheel chair WITH A TAB ALARM IN PLACE being returned to her room. STAFF returned HER TO HER BEDSIDE. iMMEDIATELY AFTER THE STAFF LEFt, RESIDENT #105 REMOVED THE TAB ALARM FROM HER SHOULDER and stood UP. rESIDENT #108 According to the face sheet dated 03/11/2011, Resident #108 was an [AGE] year-old-female living at the facility since 09/06/2005. Her [DIAGNOSES REDACTED]. According to the minimum (MDS) data set [DATE], Resident #108 suffered moderately impaired cognitive function with both long and short-term memory loss. She required minimally one staff member to provide assistance with ALL TRANSFERS. ACCORDING TO A CARE PLAN DATED 11/20/2010, STAFF WAS TO ASSIST RESIDENT #108 WITH ALL TRANSFERS USING A MECHANICAL LIFT. THIS CARE PLAN STATEd, "HUSBAND WILL USE (THE) LIFT TO MOVE WIFE WITHOUT STAFF" AND STAFF to " REMIND" the resident's HUSBAND "NOT TO USE THE MECHANICAL LIFT." ON 03/04/2011 AT 12:45 P.M. AND 03/09/2011 AT 10:00 A.M., THE MECHANICAL LIFT USED TO TRANSFER RESIDENT #108 SAT DIRECTLY OUTSIDE OF HER DOOR. ON 03/04/2011 AT 2:35 A.M., EMPLOYEE "M" SAID RESIDENT #108'S HUSBAND "CONTINUEs TO USE THE MECHANICAL LIFT WITHOUT ANY STAFF ASSISTANCE OR SUPERVISION." THIS EMPLOYEE SAID RESIDENT #108 HAS SET ROUTINES FOR HER ACTIVITIES OF DAILY LIVING AND WHEN THERE IS NOT ENOUGH STAFF TO PROVIDE THEM, so HER HUSBAND DOES. EMPLOYEE "M" SAID DESPITE CONVERSATIONS WITH HIM, HE CONTINUES TO USE THE LIFT BECAUSE HE HAS ACCESS, OPPORTUNITY AND REASON. EMPLOYEE "M" DID NOT EXPLAIN WHY THE MECHANICAL LIFT REMAINED READILY ACCESSIBLE DESPITE THIS UNSAFE PRACTICE. ON 03/09/2011 AT 2:00 P.M., THE DIRECTOR OF NURSING SAID DESPITE CONSISTENT EDUCATION RESIDENT #108'S HUSBAND CONTINUES TO USE THE MECHANICAL LIFT TO TRANSFER HIS WIFE. the director of nursing stated that this ACTIVITY WAS NOT SAFE, because the transfer REQUIRED nursing staff SUPERVISION AND ASSISTANCE. SHE DID NOT EXPLAIN WHY RESIDENT #108'S HUSBAND STILL HAD ACCESS TO THE MECHANICAL LIFT. According to the "Fall Prevention Program" policy dated 03/01/2008, "The Fall Assessment will be reviewed and updated at the initial interdisciplinary care conference, and quarterly thereafter, or as needed." the policy states "the care plan will reflect any new interventions to ensure resident safety." Criteria for the use of TAB/Pressure Sensitive Alarms is listed as 1) Resident unwilling to use call light 2) Resident has mental inability to use call light 3) Unsteady gait 4) History of falls within 30 days prior to admission 5) Syncope 6) Impulsiveness 7) Poor balance and 8) A resident ' s willingness/acceptance of alarms and/or monitors.

THIS CITATION PERTAINS TO INTAKE # MI 413. FINDINGS: BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO IMMEDIATELY CONSULT WITH THE RESIDENT'S PHYSICIAN WHEN THERE WAS A SIGNIFICANT CHANGE IN THE RESIDENT'S PHYSICAL STATUS (I.E., A DETERIORATION IN HEALTH) AND A NEED TO ALTER TREATMENT SIGNIFICANTLY OR A DECISION TO TRANSFER OR DISCHARGE THE RESIDENT FROM THE FACILITY IN 1 OF 5 SAMPLED RESIDENTS ( # 104); RESULTING IN DELAYED treatment for [REDACTED]. RESIDENT # 104: ACCORDING TO THE FACESHEET DATED 10/29/2010, RESIDENT # 104 HAS LIVED IN THE FACILITY SINCE 1/26/2006. THE MINIMUM (MDS) data set [DATE], INDICATED THAT RESIDENT # 104 WAS AN [AGE] year OLD COGNITIVELY IMPAIRED FEMALE THAT WAS DEPENDANT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING INCLUDING TOILETING. ACCORDING TO THE PHYSICIAN ' S NOTES DATED 9/1/2010, RESIDENT # 104 HAD SEVERAL [DIAGNOSES REDACTED]. ACCORDING TO THE FACILITY ' S POLICY NUMBER A104P, DATED 4/10/2010, TITLED " ASPIRATION PRECAUTIONS " " ANY CHANGE IN MENTAL OR RESPIRATORY STATUS NECESSITATES ...NOTIFICATION OF THE PHYSICIAN ... " ACCORDING TO THE FACILITY ' S POLICY NUMBER C107P, DATED 5/10/2007, TITLED " CHANGE IN A RESIDENT ' S CONDITION OR STATUS " THE NURSE SHOULD NOTIFY THE RESIDENT ' S ATTENDING PHYSICIAN WHEN " ...THERE IS A SIGNIFICANT CHANGE IN THE RESIDENT ' S PHYSICAL, MENTAL OR PSYCHOLOGICAL STATUS ... " ACCORDING TO THE VITAL SIGN SHEET WHICH RECORDED RESIDENT #104 ' S HEART RATE (PULSE), BLOOD PRESSURE, TEMPERATURE AND RESPIRATORY (BREATHING) RATES FROM 8/30/2010 THROUGH 10/18/2010, RESIDENT #104 ' S PULSE NORMALLY RANGED FROM 70 TO 88 BEATS PER MINUTE. RESIDENT #104 ' S RESPIRATORY RATE NORMALLY RANGED FROM 18 TO 20 BREATHS PER MINUTE. ACCORDING TO THE NURSE ' S NOTES DATED 10/20/1040 AT 12:00 AM RESIDENT # 104 ' S PULSE WAS 116 (NORMAL 60-100). RESIDENT # 104 ' S RESPIRATORY RATE WAS 30 (NORMAL 15-20). RESIDENT # 104 WAS DESCRIBED AS BEING " ...IN RESP (RESPIRATORY) DISTRESS ... " NO EVIDENCE COULD BE FOUND IN THE CLINICAL RECORD TO INDICATE THAT THE NURSE NOTIFIED RESIDENT #104 ' S ATTENDING PHYSICIAN AS REQUIRED. ACCORDING TO THE NURSE ' S NOTES DATED 10/20/1040 AT 4:00 AM RESIDENT # 104 WAS DESCRIBED AS HAVING " ...LABOROUS BREATHING AND INCREASED SECRETIONS, DROOLING OUT OF MOUTH ... " NO EVIDENCE COULD BE FOUND IN THE CLINICAL RECORD TO INDICATE THAT THE NURSE NOTIFIED RESIDENT #104 ' S ATTENDING PHYSICIAN AS REQUIRED. ACCORDING TO THE NURSE ' S NOTES DATED 10/20/1040 AT 8:00 AM RESIDENT # 104 WAS IN RESPIRATORY DISTRESS, PULSE OXYMETRY WAS 85 PERCENT (NORMAL 90 TO 100 PERCENT). RESIDENT # 104 WAS DESCRIBED AS BEING CLAMMY AND CONGESTED. THE ATTENDING PHYSICIAN WAS CONTACTED AND RESIDENT # 104 WAS SENT TO THE HOSPITAL. ACCORDING TO HOSPITAL RECORDS RESIDENT # 104 WAS HYPOXIC (DEFICIENCY IN THE AMOUNT OF OXYGEN REACHING THE BODY TISSUES), SUFFERED FROM PNEUMONIA AND ACUTE [MEDICAL CONDITION]. RESIDENT # 104 WAS PLACED ON A VENTILATOR (BREATHING MACHINE) AND admitted TO THE HOSPITAL FOR FURTHER TREATMENT. ON 11/1/2010 AT 12:05 PM THE LICENSED PRACTICAL NURSE (LPN) #3 REVIEWED RESIDENT # 104 ' S CLINICAL RECORD AND SAID RESIDENT # 104 BEGAN HAVING BREATHING PROBLEMS AT AROUND MIDNIGHT. " ...COULD HAVE BEEN 11:45 ..." LPN #3 SAID SHE DID NOT NOTIFY PHYSICIAN BECAUSE SHE BELIEVED THE DOCTORS WON'T COME IN. LPN #3 SAID SHE " ...MADE A JUDGEMENT TO NOT CALL (THE PHYSICIAN) BECAUSE I THOUGHT I COULD TREAT IT MYSELF ... " ON 11/1/2010 AT 12:05 PM RESIDENT # 104 ' S ATTENDING PHYSICIAN SAID HE FOUND OUT ABOUT RESIDENT # 104 ' S BREATHING PROBLEMS SOME TIME AFTER 7:00 AM THE MORNING OF 11/20/2010 AFTER COMING INTO THE FACILITY. THE ATTENDING PHYSICIAN SAID HE WAS ON CALL THE NIGHT BEFORE, BUT WAS NOT CONTACTED BY ANYONE AT THE FACILITY. THE ATTENDING PHYSICIAN SAID HE ALSO CHECKED WITH THE NURSE PRACTITIONER WHO WAS ON CALL, AND WAS AVAILABLE THAT NIGHT. THE ATTENDING PHYSICIAN SAID THE NURSE PRACTITIONER WAS ALSO NOT CONTACTED BY ANYONE AT THE FACILITY. THE ATTENDING PHYSICIAN SAID AS SOON AS HE KNEW RESIDENT # 104 ' S CONDITION HE ORDERED HER TO BE IMMEDIATELY TRANSFERRED TO THE HOSPITAL. ( )

THIS CITATION PERTAINS TO INTAKE # MI 965 AND MI 413. FINDINGS: BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE IT'S STAFF DID NOT USE PHYSICAL AND VERBAL ABUSE OR NEGLECT TO CONTROL BEHAVIORS OF RESIDENTS WHEN PROVIDING CARE IN 2 OF 5 SAMPLED RESIDENTS (# 103 AND # 105); RESULTING IN RESIDENT # 103 ' S FEAR AND EMOTIONAL DISTRESS, AND RESIDENT # 105 BEING FORCED TO SIT IN A WET OR SOILED BRIEF FOR HOURS, FEAR AND EMOTIONAL DISTRESS; AND THE POTENTIAL FOR FURTHER ABUSE AND NEGLECT. RESIDENT # 103: ACCORDING TO THE FACESHEET (UNDATED), RESIDENT # 103 HAS LIVED IN THE FACILITY SINCE 8/15/2008. THE MINIMUM (MDS) data set [DATE], INDICATED THAT RESIDENT # 103 WAS A [AGE] year OLD COGNITIVELY IMPAIRED MALE THAT WAS DEPENDANT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING INCLUDING TOILETING. HE HAD SEVERAL [DIAGNOSES REDACTED]. ON 10/25/2010 AT 2:00 PM RESIDENT # 103 SAID HE KNEW THAT THE CERTIFIED NURSING ASSISTANT (CNA) #5 WAS NO LONGER WORKING AT THE FACILITY AND SAID "GOOD RIDDANCE." RESIDENT # 103 CHOSE NOT TO PROVIDE SPECIFICS, BUT SAID " ... SHE WAS A HATEFUL PERSON... CURSED AND YELLED AT US ALL THE TIME." RESIDENT # 103 SAID THAT CNA #5 YELLS AT EVERYONE, ALL THE RESIDENTS, USES FOUL LANGUAGE AND " ...IS JUST AN EVIL PERSON..." RESIDENT # 103 DECLINED TO ANSWER WHEN ASKED IF ANY PHYSICAL ABUSE OCCURRED. RESIDENT # 103 BEGAN TO CRY AND SAID " ...PEOPLE SHOULD NOT TREAT US THAT WAY. I TOLD HER THAT I AM NOT A CHILD, AND DON'T TREAT ME LIKE THAT ..." THE RESIDENT # 103 REPEATEDLY SAID HE WAS AFRAID OF CNA #5 AND ASKED " ...IS SHE IN JAIL YET?... " ACCORDING TO A SIGNED STATEMENT FROM CNA # 1 DATED 10/8/2010, CNA # 5 WOULD REGULARLY USE PROFANITY, CURSING AT THE RESIDENTS, " ...INTIMIDATED THE RESIDENTS ... " AND IS KNOWN AS " ...THE DEVIL ... " ON 10/25/2010 AT 11:55 AM CNA #1 REVIEWED THE STATEMENT AND SIGNED AS ACCURATE. CNA #1 SAID SHE HAS ON MANY OCCASIONS WITNESSED CNA #5 CURSE AT ALL RESIDENTS, ESPECIALLY RESIDENT # 103. CNA #1 SAID IF A RESIDENT NEEDED HELP BECAUSE OF HAVING A BOWEL MOVEMENT, CNA #5 WOULD SAY " ...LOOK WHAT THE F ... YOU DID. I DON'T WANT TO CLEAN THIS S ... UP ...." CNA #1 SAID VERBAL ABUSE " ...WAS JUST A NORMAL THING..." CNA #1 SAID SHE SAW PHYSICAL ABUSE ONCE, CNA #5 SLAPPED AN OFF SAMPLE RESIDENT THAT IS NO LONGER AT THE FACILITY ON THE BACK OF THE HEAD AS PUNISHMENT FOR PLAYING IN HIS STOOL. CNA #1 SAID CNA #5 SLAPPED THE RESIDENT ABOUT 2 YEARS AGO IN AN ATTEMPT TO INTIMIDATE THE RESIDENT. CNA #1 SAID DAILY VERBAL ABUSE OCCURRED AND WAS WITNESSED THROUGH NOVEMBER OF 2010. ACCORDING TO A SIGNED STATEMENT FROM THE LICENSED PRACTICAL NURSE (LPN) # 1 DATED 10/1/2010, CNA # 5 WOULD REGULARLY USE PROFANITY, CURSING AT THE RESIDENTS. LPN #1 SAID SHE NEVER SAW ACTUAL PHYSICAL ABUSE, BUT DID WITNESS CNA # 5 RAISE HER HAND AS IF TO STRIKE THE SAME OFF SAMPLE RESIDENT THAT IS NO LONGER AT THE FACILITY. ON 10/25/2010 AT 12:31 PM LPN #1 REVIEWED THE STATEMENT AND SIGNED AS ACCURATE. LPN #1 SAID SHE HAS HEARD CNA #5 SPEAK RUDELY TO ALL RESIDENTS INCLUDING USING PROFANITY FREQUENTLY. LPN #1 SAID RESIDENT # 103 ASKED IF THE FACILITY " ...FINALLY CAUGHT UP TO ..." CNA #5. LPN #1 SAID SHE WITNESSED CNA #5 RAISE A HAND TO THE OFF SAMPLE RESIDENT, BUT NOT MAKE ACTUAL PHYSICAL CONTACT. LPN #1 SAID THE OFF SAMPLE RESIDENT WOULD FLINCH WHENEVER CNA #5 WOULD COME AROUND. ACCORDING TO A SIGNED STATEMENT FROM CNA #3 DATED 10/7/2010, CNA # 5 WOULD REGULARLY USE PROFANITY, CURSING AT THE RESIDENTS. CNA #3 SAID SHE SAW AND HEARD CNA #5 TELL A RESIDENT " ...KEEP YOUR M ...F ... A ... ON YOUR SIDE. I AM TIRED OF OU GOING THROUGH OTHER PEOPLE ' S S ... " WHEN THE CONFUSED RESIDENT WOULD WANDER INTO A DIFFERENT UNIT. ON 10/25/2010 AT 12:50 AM CNA #3 REVIEWED THE STATEMENT AND SIGNED AS ACCURATE. CNA #3 SAID SHE HAS HEARD CNA #5 SPEAK RUDELY TO ALL RESIDENTS INCLUDING USING PROFANITY FREQUENTLY. CNA #3 SAID SHE WITNESSED CNA #5 REGULARLY ABUSE RESIDENTS VERBALLY. ON 10/25/2010 AT 1:25 PM THE NURSE MANAGER SAID RESIDENT # 103 WOULD ACT DIFFERENT WHEN CNA #5 WAS HERE. THE NURSE MANAGER SAID RESIDENT # 103 WAS WITHDRAWN AVOIDED EVERYONE AND WOULD JUST SIT AND WATCH TV ALL DAY. ACCORDING TO A SIGNED STATEMENT FROM CNA #2 DATED 9/30/2010, CNA # 5 WOULD REGULARLY USE PROFANITY, CURSING AT THE RESIDENTS. CNA #2 SAID SHE SAW AND HEARD CNA #5 TELL RESIDENTS TO " ...SIT THE F ... DOWN ... " ACCORDING TO THE SIGNED STATEMENT, CNA #2 WITNESSED CNA #5 " ...HIT OR THUMP THEM (RESIDENTS) ON THE HEAD ... " ON 10/27/2010 AT 12:25 PM CNA #2 REVIEWED THE STATEMENT AND SIGNED AS ACCURATE. CNA #2 SAID CNA #5 USED PROFANITY NORMALLY, ALL THE TIME WITH ALL THE RESIDENTS. CNA #2 SAID CNA #5 WOULD TELL RESIDENTS " ...THEIR P ... STINKS OR THEIR A ... STINKS ... " , TELLS RESIDENTS TO " ...SIT YOU ' RE A ... DOWN ... " CNA #2 SAID CNA #5 WOULD NOT LET RESIDENT 103 OUT OF HIS ROOM WHEN SHE WORKED. CNA #2 SAID THAT IF CNA #5 SAW A RESIDENT ON EAST WING OF THE 3RD FLOOR THAT LIVED IN A DIFFERENT WING, SHE WOULD GRAB THE RESIDENT'S HAND AND SQUEEZE HARD. CNA #2 SAID RESIDENTS WOULD YELL " ...THAT HURTS ... " OR CRY. CNA #5 WOULD TELL RESIDENTS TO " ...SHUT THE [***] UP AND GET OFF HER UNIT ... " CNA #2 SAID SHE ALSO WITNESSED CNA #5 SLAP THE SAME OFF SAMPLE RESIDENT IN THE BACK OF THE HEAD. RESIDENT # 105: ACCORDING TO THE FACESHEET DATED 7/8/2010, RESIDENT # 105 HAS LIVED IN THE FACILITY SINCE 6/11/2010. THE MINIMUM (MDS) data set [DATE], INDICATED THAT RESIDENT # 105 WAS A [AGE] year OLD ALERT FEMALE THAT WAS DEPENDANT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING INCLUDING TOILETING. SHE HAD SEVERAL [DIAGNOSES REDACTED]. ON 10/27/2010 AT 1:00 PM RESIDENT # 105 SAID SHE HAD MULTIPLE PROBLEMS WITH CNA #5. RESIDENT # 105 SAID SHE HAD PROBLEMS WITH BEING LEFT WET OR SOILED, FOR HOURS. RESIDENT # 105 SAID WHEN SHE WAS ON THE THIRD FLOOR SHE WOULD PRESS HER CALL LIGHT AND CNA #5 WOULD REFUSE TO CHANGE HER BRIEF. RESIDENT # 105 SAID CNA #5 WOULD SAY "...NO I WON'T CLEAN YOU UP..." OR "...I'M TIRES OF CLEANING UP YOUR S..." RESIDENT # 105 SAID SHE WOULD THEN SIT FOR HOURS IN A WET OR DIRTY BRIEF. RESIDENT # 105 SAID CNA #5 WOULD ALSO COME INTO THE ROOM AND CURSE AT HER. RESIDENT # 105 BEGAN TO CRY AND SAID CNA #5 WOULD FREQUENTLY TELL HER THAT SHE SMELLED BAD IN PRIVATE AREAS, AND AT OTHER TIMES CNA #5 WOULD REFUSE TO TALK TO HER AT ALL. ACCORDING TO A SIGNED STATEMENT FROM CNA #4 DATED 10/7/2010, CNA # 5 WOULD REGULARLY USE PROFANITY, CURSING AT THE RESIDENTS. CNA #4 SAID SHE SAW AND HEARD CNA #5 TELL A RESIDENTS TO " ...SHUT THE F ... UP ... " ON 10/27/2010 AT 11:55 AM CNA #4 REVIEWED THE STATEMENT AND SIGNED AS ACCURATE. CNA #4 SAID SHE HAS WITNESSED CNA #5 " ...HOLLERING AT RESIDENTS ... " CNA #4 SAID CNA #5 WOULD FORCIBLY REMOVE RESIDENTS FORM THE UNIT. CNA #4 SAID SHE HAS WITNESSED ABUSIVE COMMUNICATION FROM CNA #5 FOR YEARS. ON 10/25/2010 AT 10:00 AM THE DIRECTOR OF NURSING SAID THAT ACCORDING TO THE FACILITY ' S INVESTIGATION, VERBAL ABUSE BY CNA #5 DID OCCUR. ( )