Every finding on record at Coventry House Inn

Based on observation, interview and record review, the facility failed to ensure proper label and dating of foods in the kitchen and the resident refrigerator resulting in the potential to spread food borne illness to residents that consume food from the kitchen and the resident refrigerator. Findings Include:During the kitchen tour on 1/6/2026 at 9:14 AM with Food Service Director (FSD) J, the following was observed:The reach in refrigerator in the kitchen:2 large plastic bowls with salad with no label and date. Another reach in refrigerator contained the following:1 container of liquid eggs on bottom of the refrigerator (not on shelf), slightly open with no label and date.During a tour of the kitchenette with FSD J on 1/6/2026 at 9:28 AM, the following was found:1 ketchup bottle, opened with no label and date. During a tour of the resident refrigerator with FSD J on 1/6/2026 at 9:48 AM, the following was found:2 containers with Chinese food dated 12/27/2025 with room [ROOM NUMBER] noted, moisture underneath lid with no use by date noted.1 16-ounce container of soup dated 12/27/2025 with room [ROOM NUMBER] noted, moisture underneath lid with no use by date noted.1 small rice container dated 12/27/2025 with no use by date.1 plastic container of fruit salad, 1/2 full with no label and date.1 minute maid drink, open and 1/2 full with room [ROOM NUMBER]B with no open date.1 Jam container with soup in it in a plastic bag, 1/3 full with no label and date.1 Styrofoam container with resident name with unidentified food in it with no label and date.1 container with rolls with resident name with no label and date. The resident refrigerator also contained a big ice chuck on the top shelf.A sign was posted on the refrigerator Please label all food items with guest name and date. Food items will be discarded after 3 days. No staff food allowed.There was no temperature log for monitoring the resident refrigerator temperatures.During the tour on 1/6/2026, FSD J stated that the foods should have been labeled and dated in the kitchen refrigerator and in the resident refrigerator. FSD J stated that the resident refrigerator needed to be defrosted and a temperature log should be there. FSD J also stated that it was hard to monitor the resident refrigerator since anyone can put food in there. FSD J said she would get with the Director of Nursing (DON) B to discuss the process. During an interview on 1/6/2026 at 3:53 PM, DON B stated that everyone had access to the resident refrigerator and dietary monitors it and makes sure it was labeled and dated appropriately. DON B said the expectation was that everyone that puts food in there should label and date it. DON B also stated that she thought a temperature log was on the refrigerator. According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED 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, based on the temperature and time combinations specified in (A) of this section 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 .Review of the Label and Dating Foods Policy dated 2021 revealed Policy: to decrease the risk for food borne illness and to provide the highest quality, foods is labeled with the date received, the date opened and the date by which it should be discarded.Procedure: Refrigerated Food.Refrigerated Potentially Hazardous Foods (PHF) or Time/Temperature Controlled for Safety (TCS) foods are labeled with the date received and if not opened, are discarded by the manufacturer's expiration date. If opened, the cold food item is labeled with the date opened and the date by which to discard or use by.Review of the Food Brought In By Family or Visitors Policy dated 2021 revealed .Procedure Refrigerated foods that have been opened or left-over food stored in the refrigerator will be marked with use-by date. The use-by date is six days from the day the food was opened or the day the left-over food was put in the refrigerator.

Based on interview and record review, the facility failed to employ a staff member with appropriate credentials to supervise and manage the dietary department resulting in the potential for food service sanitation failures, food borne illness and for clinical areas of dietary needs of all residents being compromised and unmet. Findings include:During the kitchen tour on 1/6/2026 at 9:14 AM, Food Service Director (FSD) J stated that she had been in the FSD position for over a year and signed up for the Dietary Manager classes the end of October. FSD J said that the Registered Dietitian (RD) isn't full time at the facility but comes in 2-3 times a month. Review of the document FSD J provided revealed that she signed up for the Nutrition and Foodservice Professional Training Program on 10/29/2025. During another interview on 1/6/2026 at 3:12 PM, FSD J stated that her date of hire was 9/30/2024 and the previous Nursing Home Administrator (NHA) said it was fine for her to sign up for the Certified Dietary Manager (CDM) classes at a later date. FSD J clarified and showed this surveyor that the Nutrition and Foodservice Professional Training Program was in fact the CDM classes. During an interview on 1/6/2026 at 3:53 PM, Director of Nursing (DON) B and NHA A stated that they were unaware that FSD J wasn't qualified to run the dietary department and said that the RD comes into the facility a few times a month.

Based on observation, interview, and record review the facility failed to ensure proper use of personal protective equipment for enhanced barrier precautions during high contact care activities; 1.) wound care for 1 (Resident #8); 2.) intravenous medication administration for 1 (Resident #22); and 3.) transfer, bed mobility, and dressing for 1 (Resident #46) of 12 sampled residents resulting in the potential for the spread of infection and disease transmission.Findings include:Resident #8Review of an admission Record revealed Resident #8 was a male who originally admitted on [DATE] and had pertinent diagnoses which included: displaced fracture of shaft of right femur (broken bone in the right thigh), congestive heart failure (a long term condition in which the heart cannot pump blood well enough for the body's needs), and type 2 diabetes (a condition when the body does not produce enough insulin and/or the body can becomes resistant to insulin resulting in high blood sugar levels).Review of a Minimum Data Set (MDS) assessment for Resident #8, with a reference date of 10/30/25 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #8 was cognitively intact; Section M Skin conditions Pressure ulcer/injury checked yes (indicating a wound was present).On 01/06/2025 9:03 AM, signage was observed posted on the wall outside of Resident #8's room indicating enhanced barrier precautions (EBP) were to be utilized during high contact care activities (dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, wound care).On 01/07/26 at 10:10 AM, Registered Nurse (RN) O was observed providing wound care to Resident #8 while RN JJ was observed assisting RN O with Resident #8's positioning during wound care. Neither RN O nor RN JJ were observed wearing a gown while providing or assisting with wound care for Resident #8.Review of Order Summary for Resident #8 reviewed on 01/08/26 revealed .Maintain enhanced barrier precautions (EBP) to prevent infection r/t (related to) wounds every shift. ordered on 12/06/2025.Review of Care Plan for Resident #8 revealed . I require enhanced barrier precautions r/t wounds. intervention: utilized appropriate PPE. initiated on 12/16/25.In an interview on 01/07/26 at 2:30 PM, RN O reported she did not wear a gown when providing wound care to Resident #8 and she should have.In an interview on 01/07/26 at 3:10 PM, RN JJ reported the sign outside of Resident #8's room indicating EBP meant a gown should be worn when providing wound care. When queried, RN JJ reported she didn't wear a gown when she assisted with Resident #8's wound care and probably should have.Resident #22Review of an admission Record revealed Resident #22 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: infection and inflammatory reaction due to unspecified internal joint prosthesis (infection in a joint with artificial replacement parts) and cutaneous abscess of the right lower limb (a swollen area that contains pus). On 01/07/26 at 1:20 PM, RN FF was observed connecting intravenous medication Cefazolin 2 GM (grams) via a PICC (Peripherally inserted central catheter) present in Resident #22's upper left arm for administration. RN FF was not wearing a gown during the handling of Resident #22's PICC line.In an interview on 01/07/26 at 1:31 PM, RN FF reported Resident #22 was not on enhanced barrier precautions. On 01/07/26 at 1:30 PM, no signage indicating Resident #22 was on enhanced barrier precautions was observed posted outside of her room.Review of Order Summary for Resident #22 reviewed on 01/08/26 revealed .Maintain enhanced barrier precautions (EBP) to prevent infection r/t new admit every shift.; cefazolin sodium injection solution reconstituted 2 GM, use 2 grams intravenously every 8 hours for bacterial infectious arthritis of left knee for 31 days. both with the start date of 12/16/25.Review of Care Plan for Resident #22 revealed . I require enhanced barrier precautions r/t wound/PICC. intervention: utilized appropriate PPE. initiated on 12/17/25.Resident #46Review of an admission Record revealed Resident #46 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: sepsis (a blood infection) and pressure ulcer of the sacral region. On 01/06/26 at 10:46 AM, signage was observed posted on the wall outside of Resident #46's room indicating enhanced barrier precautions (EBP) were to be utilized during high contact care activities. On 01/06/26 at 2:19 PM, Certified Nurse Assistant (CNA) HH was observed assisting Resident #46 to transfer from her wheelchair to her bed. CNA HH was not wearing a gown during the transfer.Review of Order Summary for Resident #46 reviewed on 01/08/26 revealed .Maintain enhanced barrier precautions (EBP) to prevent infection r/t sacral and coccyx wounds every shift. ordered on 12/24/2025.Review of Care Plan for Resident #46 revealed . I require enhanced barrier precautions r/t wounds. intervention: utilized appropriate PPE. initiated on 12/29/25.On 01/07/26 at 12:15 PM, RN JJ was observed assisting Resident #46 to remove her pants while in bed. RN JJ then completed an assessment of Resident #46's right leg. CNA DD was observed entering Resident #46's room and assisting RN JJ to reposition Resident #46 in bed and adjust sheets and blankets for Resident #46. Neither RN JJ nor CNA DD wore a gown while assisting Resident #46.In an interview on 01/07/26 at 12:45 PM, RN JJ reported Resident #46 did have a wound, but she was not on enhanced barrier precautions.In an interview on 01/07/26 at 3:15 PM, Director of Nursing (DON) B reported enhanced barrier precautions were to be used for high contact care activities including wound care, intravenous administration, personal care, and bed mobility and gowns and gloves should be worn when performing high contact care activities. DON B reported an electronic training had been assigned about a month ago, but she did not know which employees had completed the training.Review of facility policy Enhanced Barrier Precautions with a review date of 9/25 revealed .EBP.is an approach of targeted gown and glove use during high contact resident care activities.EBP may be applied (when contact precautions do not otherwise apply) to resident with any of the following: wounds or indwelling devices.examples of indwelling medication devices central lines.examples of high-contact activities.dressing, transferring, changing linens, device care or use of device, wound care.

Based on interview and record review, the facility failed to provide appetizing and palatable food products to 2 (Resident #1, Resident #21) of 3 residents reviewed for food palatability, resulting in dissatisfaction with meals and the potential for decreased food acceptance and nutritional decline.Findings include:Resident #1Review of an admission Record revealed Resident #1 was a female, with pertinent diagnoses which included: type 2 diabetes mellitus (a condition where the body is not able to properly use sugar from the blood) with hyperglycemia (high blood sugar) and moderate protein-calorie malnutrition. Review of a Minimum Data Set (MDS) assessment for Resident #1, with a reference date of 12/7/2025 revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated Resident #1 was cognitively impaired.In an interview on 1/6/2026 at 10:48 AM, Resident #1 reported the food at the facility was terrible. Resident #1 reported sometimes the food was not hot enough when she received it.Resident #21Review of an admission Record revealed Resident #21 was a female, with pertinent diagnoses which included: type 2 diabetes mellitus with hyperglycemia, and chronic kidney disease stage 4 (severe). Review of a Minimum Data Set (MDS) assessment for Resident #21, with a reference date of 12/17/2025 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #21 was cognitively intact.In an interview on 1/6/2026 at 10:58 AM, Resident #21 reported the food at the facility was not too good and that it was not to her liking which is why her daughter was bringing her lunch. Resident #21 did not elaborate except to say she did not like the food at the facility.In an interview on 1/7/2026 at 8:25 AM, Certified Nurse Aide (CNA) GG reported residents had complained to her about the food. CNA GG reported residents said they need better choices of food, they complained about the flavor of the food, and they complained about the temperature of the food.In an interview on 1/7/2026 at 8:32 AM, CNA D reported residents had complained to her about the food. CNA D reported residents say they don't like how soft the vegetables are cooked.In an interview on 1/7/2026 at 11:25 AM, CNA F reported almost everybody complained about the food. CNA F reported the residents said the food is disgusting and the flavor of the food was not good. CNA F stated there is a lot of problems with the food.

Based on interview and record review, the facility failed to provide care and services to promote dignity and respect in 2 (Resident #1, Resident #17) of 2 residents reviewed for dignity/respect, resulting in long call light wait times and the potential for feelings of diminished self-worth, sadness, and frustration.Findings include:Resident #1Review of an admission Record revealed Resident #1 was a female, with pertinent diagnoses which included: weakness, difficulty in walking, and need for assistance with personal care. Review of a Minimum Data Set (MDS) assessment for Resident #1, with a reference date of 12/7/25 revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated Resident #1 was cognitively impaired.In an interview on 1/6/2026 at approximately 10:48 AM, Resident #1 reported it can take a half hour to an hour sometimes for staff to answer her call light. Resident #1 reported she felt bad when than happened.Resident #17Review of an admission Record revealed Resident #17 was a male, with pertinent diagnoses which included: weakness, difficulty in walking, acquired absence of right leg above knee, and need for assistance with personal care. Review of a Minimum Data Set (MDS) assessment for Resident #17, with a reference date of 11/21/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #17 was cognitively intact. Further review of said MDS revealed Resident #17 was dependent for Toilet transfer and was Occasionally incontinent (having no or insufficient voluntary control over urination or defecation) of urine and bowel.Review of a current Care Plan for Resident #17 revealed the focus of SKILLED THERAPY/ADL (activities of daily living): Self-Care deficit, require assist with ADLS r/t (related to) limited mobility, debility, and impaired balance with a Date Initiated of 11/18/2025 and care planned interventions which included Toileting: I need total assist of 2 to help me from bed last revised on 11/19/2025.In an interview on 1/6/2026 at 11:24 AM, Resident #17 reported call light response time would depend on the time of day but that sometimes he had to wait over an hour for staff to respond to his call light. Resident #17 reported he ended up having to use the urinal because he couldn't wait for staff to arrive and that made him mad.In a follow-up interview on 1/8/2026 at 10:04 AM, Resident #17 reported long call light response times were on all shifts. Resident #17 reported he had soiled his pants while he was waiting for staff to answer his call light and it made me feel less of a man. It was very degrading.In an interview on 1/7/2026 at 8:32 AM, Certified Nurse Aide (CNA) D reported residents had complained to her in the past about long call light wait times.In an interview on 1/8/2026 at 9:53 AM, Registered Nurse (RN) O reported she had heard residents complain about long call light wait times.In an interview on 1/8/2026 at 9:59 AM, CNA L reported residents had complained to her about long call light wait times. CNA L reported it depends on the shift and that residents say call light response on night shift takes excessively long times but that sometimes residents were not happy with excessive wait times for day shift as well.In an interview on 1/8/2026 at 10:25 AM, CNA I reported she has had residents complain to her about long call light wait times.

Based on interview and record review, the facility failed to maintain complete and accurate medical records for 1 (Resident #21) of 12 sampled residents reviewed for complete and accurate medical records, resulting in incomplete documentation of blood sugar checks and insulin administration.Findings include:Resident #21Review of an admission Record revealed Resident #21 was a female, with pertinent diagnoses which included: type 2 diabetes mellitus (a condition where the body is not able to properly use sugar from the blood) with hyperglycemia (high blood sugar). Review of a MARTAR (Medication Administration Record Treatment Administration Record) for December 2025 for Resident #21 revealed a Physician's Order for HumaLOG KwikPen Subcutaneous Solution Pen-Injector 100 UNIT/ML (Insulin Lispro) Inject 10 unit subcutaneously before meals for Diabetes -Start Date- 12/10/2025 to be given at 0730 (7:30 AM), 1130 (11:30 AM), and 1730 (5:30 PM). There was no documentation on 12/12/25 at 1730 (check box was blank) and no documentation on 12/30/25 at 1730 (check box was blank) to indicate that the HumaLOG had been administered.Review of a MARTAR for December 2025 for Resident #21 revealed a Physician's Order for Accu Checks (blood sugar checks) AC (before meals) and HS (at bedtime) before meals and at bedtime for Diabetes Hold insulin or oral hypoglycemic medication (medication used to lower blood sugar) and call M.D. (medical doctor) for blood sugar <60 (less than). Give insulin or oral hypoglycemic medication and call M.D. for blood sugar >400 (greater than). -Start Date- 12/11/2025 to be checked at 0730, 1130, 1730, and 2100 (9:00 PM). There was no documentation on 12/12/25 at 1730 (check box was blank) and no documentation on 12/30/25 at 1730 (check box was blank) to indicate that Resident #21's blood sugar had been checked.In an interview on 1/7/2026 at 9:32 AM, Director of Nursing (DON) B reported she was Resident #21's nurse on 12/12/2025 at 1730. DON B reviewed Resident #21's December, 2025 MARTAR for 12/12/2025 at 1730 and reported she must have forgotten to document what Resident #21's blood sugar was and must have forgotten to document whether or not insulin had been administered at that time to Resident #21. DON B reported it should be documented what the blood sugar was and if insulin had been administered.In an interview on 1/7/2026 at 9:44 AM, Registered Nurse (RN) O reported she was Resident #21's nurse on 12/30/25 at 1730. RN O reviewed Resident #21's December, 2025 MARTAR for 12/30/25 at 1730 and reported normally she would go back and check her documentation before she left for the day. RN O confirmed there were no entries at 1730 for Resident #21's HumaLOG administration and blood sugar checks. Registered Nurse O reported the insulin administration and blood sugar check should have been documented but wasn't.

Based on interview and record review the facility failed to ensure showers were provided as scheduled in 1 of 3 residents (Resident #12) reviewed for activities of daily living (ADLs) care, resulting in the potential for embarrassment and diminished self-esteem.Findings include:Review of an admission Record revealed Resident #12 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: unspecified fracture of the upper end of the left humerus (broken left upper arm) and history of falling. Review of a Minimum Data Set (MDS) assessment for Resident #12, with a reference date of 12/25/25 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #12 was cognitively intact.In an interview on 01/06/26 at 9:05 AM, Resident #12 reported she went almost 2 weeks without a shower when she first arrived at the facility. Resident #12 reported she was embarrassed.In an interview on 01/06/26 at 1:31 PM, Resident #12 reported she received a shower today. Resident #12 reported her shower days were Tuesday and Friday, and she preferred them in the morning.Review of Grievance/Complaint Report filed by Resident #12 on 12/15/25 revealed .Name Omitted reports she needs a shower. Facility follow up on 12/15/25.Admin ( Nursing Home Administrator NHA A) spoke who reports shower given, asked to check [with] resident again to be cleaned, bed bath, or shower as desired.Resolution of Grievance/complaint. CNA and Nurse alerted and report bathing is being completed. documented signed by NHA A on 12/15/25.Review of Shower Documentation for the dates of 12/10/25 to 01/07/26 revealed .Shower . AM (morning) Tues/Fri (Tuesday and Friday) . a complete bed bath given on 01/01/26; Partial bed bath given on 12/19/25 and 12/25/25; a shower given on 12/18/25, 01/02/26, and 01/06/26.Shower documentation reflected not applicable on scheduled shower days 12/16/25 and 12/30/25; no documentation was available for scheduled shower days 12/23/25 or 12/26/25. In an interview on 01/07/26 at 2:52 PM, Resident #12 reported she thought the facility would do much better making sure she got her showers now that she did not have to wear the sling on her left arm anymore. Resident #12 reported she knew her showers were scheduled on Tuesday and Fridays. Resident #12 reported she had never refused a shower when offered.In an interview on 01/07/26 at 4:58 PM, DON B reviewed shower documentation for Resident #12 with this surveyor and explained that Resident #12's shower days were on Tuesday and Friday and the other days would be documented as NA (Not Applicable) as Resident #12's showers were not scheduled on other days. DON B reviewed shower documentation and confirmed that the first documented shower provided to Resident #12 was on 12/18/25. When queried, DON B confirmed that shower documentation for Resident #12 indicated she did not receive a shower until 12/18/25, 9 days after she admitted to the facility. DON B reported her expectations were that showers were given on the scheduled day.Review of facility policy Activities of Daily Living with a revision date of 5/21 revealed .procedure: hygiene.a resident self-image is maintained.showers or baths will be scheduled per facility protocol while incorporating residents shower/bath preference.

Based on interview and record review, the facility failed to review and revise a comprehensive, individualized plan of care for 1 (Resident #1) of 12 sampled residents reviewed for care plans, resulting in an inaccurate reflection of the resident's advance directive wishes and the potential for the resident's advance directives wishes not to be honored.Findings include:Resident #1Review of an admission Record revealed Resident #1 was a female, with pertinent diagnoses which included: chronic systolic (congestive) heart failure and cerebral infarction (stroke) due to thrombosis (blood clot) of right posterior cerebral artery.Review of a Code Status Form for Resident #1 revealed resident marked an X for DO-NOT-RESUSCITATE (DNR) Resident Consent I request that in the event my heart and/or breathing should stop, no person shall attempt to resuscitate me. Being of sound mind, I voluntarily execute this order, and I understand its full importance. signed by Resident #1 on 10/17/25 and by ( Medical Doctor (MD) V) on 11/6/2025.Review of a current Care Plan for Resident #1 with a focus of I am a FULL CODE with a date initiated of 9/2/2025.In an interview on 1/7/2026 at 8:38 AM, Registered Nurse Minimum Data Set Coordinator (RNMDS) EE reported care planning was a team effort, but the social worker was responsible to care plan advance directives.In an interview on 1/7/2026 at 8:41 AM Social Services Director (SSD) T reviewed Resident #1's care plan with this surveyor for her advance directive and SSD T reported the care plan indicated the Resident #1 was a full code but there was a physician order for DNR. SSD T reported Resident #1's care plan should have been updated to reflect Resident #1's code status for DNR but wasn't.

Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan for 1 (Resident #2) of 12 sampled residents reviewed for care planning, resulting in the potential for unmet care needs.Findings include:Resident #2Review of an admission Record revealed Resident #2 was a female, with pertinent diagnoses which included: essential (primary) hypertension (high blood pressure) and hyperlipidemia, unspecified (high cholesterol in the blood). Review of a Physician's Order For Resident #2 revealed, Apixaban Oral Tablet 5 MG (milligrams) (Apixaban) Give 1 tablet by mouth two times a day for Afib (atrial fibrillation - irregular heart rhythm). Active.Start Date 5/28/2025 Note that Apixaban is an anti-coagulant medication (blood thinner) and considered a high-risk medication.A review of Resident #2's current Care Plan on 1/8/2026 at 11:20 AM revealed no care planned focus, goals, or interventions related to Resident #2's Apixaban use.In an interview on 1/8/2026 at 11:29 AM, Registered Nurse Minimum Data Set Coordinator (RNMDS) EE reported Apixaban was a high-risk medication and should be care planned for the side effects to watch out for. RNMDS EE reviewed Resident #2's current Care Plan and reported there was no care planned focus, goals, or interventions related to Resident #2's Apixaban use but that there should have been.

Based on interview and record review the facility failed to ensure resident participation in care planning for 1 (Resident #12) of 1 resident reviewed for participation in care planning, resulting in feelings of anxiety, frustration, and a fear of uncertainty with the course of treatment while staying in the facility.Findings include:Resident #12Review of an admission Record revealed Resident #12 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: unspecified fracture of the upper end of the left humerus (broken left upper arm) and history of falling. Review of a Minimum Data Set (MDS) assessment for Resident #12, with a reference date of 12/25/25 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #12 was cognitively intact.In an interview on 01/06/26 at 9:05 AM, Resident #12 reported she felt very unsure about her stay at the facility; like she did not know what was going on.In a follow-up interview on 01/06/26 at 1:31 PM, Resident #12 reported she had been at the facility for about a month, and she had not spoken to anyone regarding her plan for care, what happens next or about going home. Resident #12 reported she was now weight bearing (able to put weight on a limb) with her left arm that she could not previously use. Resident #12 was unsure how that change affected her plan of care.In an interview on 01/06/26 at 1:40 PM, Family Member (FM) UU reported the facility did not communicate well and he was unsure of what happened next with Resident #12. When queried, FM UU was unable to recall if there had been a meeting with facility staff to discuss the plan of care for Resident #12.In an interview on 01/07/26 at 3:08PM, Social Service Director (SSD) T reported she was the one responsible for coordinating care conferences for residents. SSD T reported an initial care conference was held with Resident #12 on 12/10/25 the day after she admitted to the facility. SSD T reported that care conferences were as needed, they were not consistently scheduled for residents, they could occur weekly or every other week and the meetings should be documented in the resident's record. SSD T reported she met frequently with Resident #12. When queried if she had coordinated other care conferences SSD T reported she knew they had met with Resident #12, but it was not documented in her record. SSD T reported she met with Resident #12 on 01/06/26 and Resident #12's updated goals included gaining strength and referral for skilled home health when she went home.Review of Order Summary for Resident #12 revealed .Non weight bearing to left arm with an order date of 12/09/25. Weight bearing as tolerated with a start date of 12/23/25.In an interview on 01/08/26 at 9:50 AM, Rehab Director (RD) U reported she participated in one or two care conferences for Resident #12, but she could find documentation for only one. RD U reported there was a care conference scheduled for Resident #12 today (01/08/26) at 3:00 PM to discuss progress and possible assistance when she discharges. When queried, RD U reported she did not know who requested the care conference. RD U reported she participated in all initial care conferences and could request care conferences for things like barriers to resident's therapy, lack of progress, or if the resident was progressing faster or to discuss with family what they need to prepare for the resident. RD U reported there was not an established discharge date for Resident #12 due to her being non weight bearing for so long. RD U reported when Resident #12 or her family inquired about her progress her response was she is doing as expected.

Based on observation, interview, and record review, the facility failed to: 1. Clean non-food contact surfaces; 2. Label and date cooked potentially hazardous food products with a prepared and discard date; 3. Repair or replace a water-damaged temperature gauge on the dish machine; 4. Ensure dish machine was at proper temperature prior to use; 5. Ensure food products reached safe internal temperature prior to service; and 6. Ensure prepared food was properly cooled. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness for all residents who consume food from the kitchen. Findings include: An initial kitchen/food service tour was conducted on 12/3/24 beginning at 9:15 AM with Food Service Director (FSD) M. The following observations/interviews/record reviews were completed: At 9:24 AM in the walk-in cooler it was noted that the floor had a build-up of dirt and debris under the food racks and in the corners. There was a pan of roast beef that was not labeled or dated. FSD M confirmed that the floor needed to be cleaned and that the roast beef had been cooked the day before for use at an upcoming meal. At 9:35 AM, Dietary Aide (DA) F was observed washing dishes from the breakfast meal. It was noted that there was a dish machine temperature log for December 2024 on the wall across from the dish machine that had no temperature entries on it. This surveyor queried DA F if he had taken the temperature of the dish machine prior to washing dishes to which DA F reported he had not. FSD M reported the dish machine was a high temperature dish machine, and the wash cycle had to get to 155 degrees in order for the dishes to be properly sanitized. Visual inspection of the wash cycle temperature gauge on the dish machine revealed water damage and condensation in the interior of the gauge rendering it potentially inaccurate and difficult to read. At 9:43 AM, a review of cooked food temperature logs in a blue binder across from the cooks' station revealed no documented food temperatures of cooked food since 9/17/24 (the last page in the temperature log binder was for the month of September 2024). [NAME] G was queried if she had checked the internal temperatures of the breakfast meal that morning before serving to the residents to which she stated she had not because she .didn't get to it . At 9:53 AM, it was noted that the vent above the meat freezer was caked with a moderate amount of dust build-up. At 9:54 AM in the salad cooler, the following items were noted: cut-up roast beef in a crock pot bowl that was not covered, labeled, or dated. FSD M reported it was more of the roast beef from the walk-in cooler that was going to be used for an upcoming meal. There was a large container of what appeared to be Spanish rice that was not labeled or dated. FSD M reported the rice had been prepared the day before and was for enchiladas that day. At 10:07 AM, FSD M was requested to show this surveyor the cooling log for the precooked roast beef and Spanish rice to ensure proper time/temperature cooling was followed. FSD M reported there was no cooling log. At 10:15 AM in the nourishment room, there was a half empty container of nutrition supplement drink that was not labeled with an opened or discard date; an opened gallon of French dressing that was not labeled with an opened or discard date; and leftover containers of prepared chicken salad and tomato soup that were not labeled with a prepared or discard date. FSD M reported the items should have been labeled with an opened and discard date in order to know when to discard them. In an interview on 12/4/24 at 11:58 AM, Dietary Technician (DT) E was queried about proper time/temperature cooling practices for foods prepared ahead of time. DT E reported they had not been keeping a cooling log for products prepared ahead of time. DT E reported since he and FSD M started, they have been polishing up on all temperature logging with the staff but they were still working on it. According to the 2017 FDA Food Code section 3-501.14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less . According to the 2017 FDA Food Code section 3-501.15 Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: (1) Placing the FOOD in shallow pans; (2) Separating the FOOD into smaller or thinner portions; (3)Using rapid cooling EQUIPMENT; (4) Stirring the FOOD in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. (B) When placed in cooling or cold holding EQUIPMENT, FOOD containers in which FOOD is being cooled shall be: (1) Arranged in the EQUIPMENT to provide maximum heat transfer through the container walls; and (2) Loosely covered, or uncovered if protected from overhead contamination as specified under Subparagraph 3-305.11(A)(2), during the cooling period to facilitate heat transfer from the surface of the FOOD.

Based on observation, interview, and record review, the facility failed to ensure food products were served at a palatable temperature for 2 of 12 sampled residents (Resident #22 and #133) reviewed for food palatability, and 5 of 6 residents from the confidential resident meeting, resulting in dissatisfaction with meals, and the potential for decreased food acceptance and nutritional decline. Findings include: Resident #22 Review of an Admission Record revealed Resident #22 was a male. Review of a Minimum Data Set (MDS) assessment for Resident #22, with a reference date of 9/15/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #22 was cognitively intact. In an interview on 12/3/24 at 11:16 AM, Resident #22 reported concerns with food served at the facility. Resident #22 reported despite going to the dining room for some meals, his food was not consistently hot enough (not served at a palatable temperature). Resident #133 Review of an Admission Record revealed Resident #133 was a female. Review of a Minimum Data Set (MDS) assessment for Resident #133, with a reference date of 11/28/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #133 was cognitively intact. In an interview on 12/3/24 at 10:28 AM, Resident #133 reported the food at the facility was consistently not hot enough (not served at a palatable temperature). Resident Council Meeting During a confidential resident meeting held on 12/4/24 at 2:02 PM, 1 of 6 residents reported the food could be better; 1 of 6 residents reported they have had to send meals back due to hot foods being served cold. This same resident reported food temperatures were usually warm to cool. When asked about the lunch served that day, 5 of 6 residents reported the temperature of the food served was barely warm. During a tray line/meal service observation that began on 12/4/24 at 12:15 PM, noted pans of food set up in the steam table ready for service. Temperatures of the food on the tray line were as follows: Meatballs/Gravy - 128 degrees, Buttered Noodles - 126 degrees, and Spinach - 128 degrees. At 12:15 PM, dietary staff plated 4 plates of food, each with 3 meatballs, a scoop of buttered noodles, and a scoop of spinach. The plates were covered and placed on the non-heated portion of the steam table. At 12:28 PM, Certified Nursing Assistants (CNAs) retrieved the 4 plates of food for delivery to residents. In an interview on 12/5/24 at 9:22 AM, Certified Nursing Assistant (CNA) L reported residents had complained to her about the food, specifically that it was not hot enough when it was served to them.

Based on observation, interview and record review the facility failed to ensure residents received coordination of care in accordance with physician orders and professional standards for skin conditions in 1 resident (Resident #13) of 1 resident reviewed for skin conditions, resulting in burning pain, the potential for an exacerbation of stasis dermatitis and an increased risk for infection due to compromised (weakened) skin integrity. Findings include: Resident #13 Review of Resident #13's Skin Integrity Care Plan revealed, .BLE (bilateral lower extremity) redness from stasis dermatitis (a skin condition caused by poor blood circulation in the lower legs) .Interventions: Monitor for signs and symptoms of infection (swelling, redness, increased pain, firmness, drainage) . There were no interventions specific to dry skin, and/or the lower legs. During an observation on 12/03/24 at 10:17 AM in the hallway, Resident #13 was walking with Occupational Therapist (OT) T. Resident #13's lower legs were observed with brown ace wraps around them. In an interview on 12/03/24 at 01:54 PM, Resident #13 reported that his legs have been wrapped for a while now, and he did not know how long the wraps had been in place. Resident #13 reported that the facility does not change the wraps regularly, and that when they apply the lotion to his legs, it causes a burning pain. Review of Resident #13's Concern Form dated 10/14/24 revealed, .observed (Director of Nursing (DON) B) scraping his legs very roughly while telling (Resident #13) no pain, no gain .told (DON B) to stop and she didn't, and continued to put a dressing on his legs against doctors order . The follow up and resolution did not include a review of the residents treatment orders to ensure appropriateness. In an interview on 12/04/24 at 02:33 PM, Registered Nurse (RN) U reported that they had not observed Resident #13's legs that day, but that there were orders to apply Ammonium Lactate lotion twice a day to his legs, and stated that the lotion helped to remove the dead skin. During an observation and interview on 12/04/24 at 02:35 PM in Resident #13's room, the resident was observed sitting in a chair, and both of his lower legs were wrapped with brown ace bandages. Resident #13 reported that the wraps had been in place for a long time, that his legs were raw. RN U and RN R removed multiple ace wraps and thick absorbent pads that were in place on the resident's lower legs. The wraps did not have a date written on them to indicate when they were applied. The absorbent pads were observed with a small amount of clear fluid. The skin on Resident #13's lower legs was bright red, firm, and slightly shiny. RN V was called to the room, and reported that Resident #13 should have the Ammonium Lactate lotion applied to his lower legs as ordered, and they had a new physician's order to wrap Resident #13's legs as needed if they were weeping. RN V reported that she would call the physician for further instructions regarding if Ammonium Lactate lotion was recommended when the skin on Resident #13's legs was draining fluid. Resident #13 then stated, when they put that white stuff on there it burns for days . In an interview on 12/04/24 at 02:55 PM, RN V reported that the physician (Medical Director (MD) O) had said to discontinue using the Ammonium Lactate lotion for Resident #13, due to his legs being open and draining fluid. RN V reported that she was informed that Resident #13's legs were draining fluids that morning, but could not remember where that information came from. RN V reported that she did not assess the skin on Resident #13's legs, but observed that they were wrapped with brown ace bandages, therefore she called MD O and put an order in for as needed application of the wraps. Review of Resident #13's Treatment Administration Record (TAR)/Physician Orders revealed, Ammonium Lactate External Lotion 12 % (Lactic Acid) apply to BLE topically every shift for Stasis Dermatitis. Start Date 11/13/24. The lotion was documented as refused for 3 of 6 opportunities, administered for 2 of 6 opportunities, and not documented for 1 of 6 opportunities. There was no additional documentation for the refused treatments. According to the Food and Drug Administration (www.fda.org) Ammonium Lactate is used to treat dry, scaly skin. Apply a thin layer of this medication to the affected areas of the skin, usually twice daily or as directed by your doctor. Be careful to avoid your eyes, lips, inside your mouth/nose, the vaginal area, and any areas of broken skin. This medication may cause stinging or burning when applied to skin with fissures, erosions, or abrasions. In an interview on 12/05/24 at 02:15 PM, DON B reported that Resident #13 admitted in a couple months ago with thick dry skin on his lower legs, and an order to use ammonium lactate lotion to the dry skin on legs was in place already. DON B reported that Resident #13 had been in and out of the hospital twice since his admission to the facility, and the order for ammonium lactate lotion had been re-ordered upon hospital discharge. DON B reported that Resident #13's thick dry scaly skin had improved since admission, but that the Ammonium Lactate lotion order had not been discontinued. DON B reported that Resident #13 did not have any record of a skin condition being monitored on his lower legs, except for the ammonium lactate lotion orders, that indicated he was being treated for the dry skin and/or stasis dermatitis. DON B reported that Resident #13 did not have any documentation related to his lower legs draining fluids, and there were no notes about the lotion causing a burning pain. DON B reported that she did not know who applied the wraps and absorbent pads to Resident #13's legs, and/or how long the dressings had been in place, prior to being changed the day before (as noted in above observation). DON B reported that she did not know the current status of Resident #13's skin condition on his legs because there were no assessments documented, and that the current order for as needed application of wraps to the resident's legs, did not include how long the wraps should stay in place, therefore the orders were not appropriate. DON B reported that Resident #13 should have scheduled dressing changes, and regular monitoring of the skin condition on his lower legs. In an interview on 12/05/24 at 03:15 PM, MD O reported that they were not informed that Resident #13's legs were open and draining, until this surveyor questioned RN V about the Ammonium Lactate lotion orders. MD O reported that they did not give an order for the residents legs to be wrapped as needed for the fluid drainage. Review of Resident #13's initial admission from the hospital on 10/10/24 revealed, Physician Discharge Summary: .Ammonium lactate 12% cream, apply topically if needed for dry skin, apply to legs .

Based on observation, interview, and record review, the facility failed to follow professional standards of practice for medication administration for 1 resident (Resident #84) of 7 residents reviewed for medication administration, resulting in medication being administered without a physician order, and the potential for less than therapeutic effects of medications, and the worsening of medical conditions. Findings include: Resident #84 Review of an Admission Record revealed Resident #84 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: diabetes mellitus (a disorder in which the amount of sugar in the blood is elevated) . In an interview on 12/3/24 at 11:32 AM, Resident #84 reported that she had been managing her blood sugar using insulin for [AGE] years, and that the facility didn't seem to understand how to manage her Type 1 diabetes. Review of Resident #84's Physician Orders revealed, Insulin (helps to regulate blood sugar levels) Lispro (1 Unit Dial) 100 UNIT/ML Solution pen-injector. Inject as per sliding scale .before meals and at bedtime for DM (diabetes mellitus). Active 12/3/2024. During a medication administration observation on 12/04/24 at 12:10 PM at the medication cart, Registered Nurse (RN) R was preparing to administer insulin to Resident #84. RN R reviewed the orders and prepared 5 units of Insulin Lispro via pen-injector, then entered Resident #84's room and administered the medication. During a subsequent medication administration observation on 12/05/24 at 12:06 PM at the medication cart, RN J was preparing to administer insulin to Resident #84. RN J reviewed the orders and prepared 3 units of Novolog insulin via a glass vial using a syringe, then entered Resident #84's room and administered the medication. RN J reported that Novolog and Insulin Lispro were the same medication. RN J reported that Resident #84 had both types available to use, and that they would notify the doctor to discuss getting an order for the Novolog insulin. In an interview on 12/5/24 at 3:20 PM, Director of Nursing (DON) B reported that she was not aware that Resident #84 had two different types of fast acting insulin in the medication cart. DON B reported that Resident #84 did not have an order for Novolog insulin, and the vial may have been the resident's insulin from home, and was inadvertently placed in the medication cart.

This citation pertains to intake #MI00146244. Based on interview, and record review, the facility failed to maintain professional standards of care for 1 resident (Resident #83) of 1 resident reveiwed for accidents and hazards, from a total sample of 12 residents, resulting in the potential for unidentified internal bleeding when Resident #83, who was taking an antiplatelet medication (which decreases blood clotting ability) was not sent to the hospital after sustaining head trauma following a fall. Findings include: Resident #83 Review of Resident #83's Care Plan revealed, .Focus: .receiving an antiplatelet medication r/t (related to) CAD (coronary artery disease: common type of heart disease) . Review of Resident #83's Fall Report dated 8/3/24 revealed, .guest was seen laying on the floor in the hallway .Neuro's (neurological checks) initiated due to being unwitnessed. Resident taken to hospital? NO . Review of Resident #83's Fall Report dated 8/4/24 revealed, .Resident was on the floor next to the bed in front of wheelchair with foot pedals .Resident unable to give description .Resident taken to hospital? NO .Appears as if guest attempted to self-transfer and ambulate . Review of Resident #83's Fall Report dated 8/7/24 revealed, .Resident was being combative, and throwing items while being walked around by two CNAs (certified nursing assistant). She tripped over a decorative bag that she threw, CNA unable to avoid her falling. Witnessed by nurse and two CNAs .neuros initiated. Resident taken to hospital? NO .Injuries observed at time of incident: .Hematoma (a bump that forms after trauma due to a collection of blood), Face .Both CNA's and nurse state gait belt was in use and a second CNA was present due to increased agitation and guest wanting to speed up pace. Guest picked up a decorative sack outside of room [ROOM NUMBER] and as she threw it fell forward .momentum was too fast and was unable to keep guest from falling forward onto her face .sustained facial bruising and hematoma from fall . Review of Resident #83's Physician Orders revealed, .Clopidogrel Bisulfate Oral Tablet 75 mg . In an interview on 12/05/24 at 02:55 PM, Director of Nursing (DON) B reported that they did not send Resident #83 for an evaluation at the hospital after her unwitnessed falls, and/or after her witnessed fall with head trauma, considering that she was taking an antiplatelet medication. DON B reported that the facility policy was to monitor for neurological abnormalities post fall with head trauma, and the decision to send to the hospital would be strictly based on the neurological assessment. In an interview on 12/05/24 at 03:08 PM, Medical Director (MD) O reported that the standard of care after an un-witnessed fall, and/or a fall with known head trauma for all residents that take antiplatelet medication, would be to send to the hospital for an evaluation. MD O reported that minor neurological changes may go unnoticed by facility staff, and it would be difficult to identify a slow bleed, without a brain CT (catscan:a detailed xray). MD O reported that antiplatelet medication increase the risk of a brain bleed, and if not identified timely could result in brain injury. MD O reported that they would expect nursing staff to be knowledgeable about these standards of care.

Based on interview and record review, the facility failed to ensure the physician reviewed and responded to the registered pharmacist's monthly medication regimen review recommendations for 1 (Resident #2) of 5 residents reviewed for medications, resulting in the registered pharmacist's recommendations not being addressed in a timely fashion and the potential for negative medication side effects as a result of unaddressed recommendations. Findings include: Resident #2 Review of an Admission Record revealed Resident #2 was a female, with pertinent diagnoses which included: generalized anxiety disorder. Review of a Pharmacist Clinical Record Review dated 11/7/24 for Resident #2 revealed, .5. Recommendations I would make the following recommendations: Medication regimen reviewed see report .(also referred to as Prescriber Recommendations). On 12/4/24 at 1:40 PM, Nursing Home Administrator (NHA) A was requested, electronically, to provide this surveyor with a copy of Resident #2's 11/7/24 Pharmacist Medication Review Report. In an interview on 12/5/24 at 11:03 AM, NHA A reported she had received this surveyors request and was unable to locate the report for Resident #2 but had been in touch with the physician who had a copy of said report and was going to send it to the facility. In an interview on 12/5/24 at 11:56 AM, Director of Nursing (DON) B reported the physician was unable to locate a signed copy of the 11/7/24 Pharmacist Medication Review Report for Resident #2, but signed it today and, as a result, the facility would be making the recommended changes. Review of the Prescriber Recommendations report related to Pharmacist Clinical Record Review on 11/7/24 for Resident #2 revealed, The resident was started on the psychotropic Hydroxyzine 10 mg (milligrams) to be taken PRN (as needed). Per regulatory guidelines, orders for psychotropic medications on a PRN basis must be limited to 14 days with no exceptions. If a new order for the psychotropic medication is to be written, a direct examination of the resident by the attending physician or prescribing practitioner is required to determine if the medication is still needed .Please consider the continued need for this medication. If discontinuation is contraindicated, please document continued need, including any improvement and benefit experienced by the resident as a result of the medication .signature: (prescriber name omitted) 12/5/24. Review of a Physician's Order for Resident #2 revealed, hydrOXYzine HCl Oral Tablet (Hydroxyzine HCl) Give 10 mg by mouth every 6 hours as needed for Anxiety Pharmacy Active 11/6/2024 In a follow up interview on 12/5/24 at 12:05 PM, DON B reported the process to address pharmacist medication review reports was that the pharmacist sent the recommendations to the facility via electronic mail to the DON, the Minimum Data Set (MDS) Nurse, and the doctor. At that point, either the DON or the MDS Nurse printed the report from the computer and placed it in the doctor book for the next time the doctor came to the facility and if there were any recommendations that needed to be addressed, the facility would contact the doctor for an immediate response. Once completed, the doctor signed the report and placed it into the pile to be scanned in the resident medical record. DON B reported was unsure why this process was not followed for Resident #2's 11/7/24 Pharmacist Medication Review Report.

Based on interview and record review, the facility failed to discontinue psychotropic medications (drugs that alter brain chemistry and can affect mood and behavior) prescribed on an as needed (PRN) basis after 14 days and/or document rationale to extend PRN psychotropic medication use in 2 of 5 residents (Resident #2 and #134) reviewed for unnecessary medications, resulting in the potential for unnecessary medication use with the increased potential for adverse side effects. Findings include: Resident #2 Review of an Admission Record revealed Resident #2 was a female, with pertinent diagnoses which included: generalized anxiety disorder. On 12/4/24 at 2:40 PM, a review of Resident #2's current physician's Order Summary revealed a Physician's Order for hydrOXYzine HCl Oral Tablet (Hydroxyzine HCl) Give 10 mg by mouth every 6 hours as needed for Anxiety Pharmacy Active 11/6/2024 It should be noted that there was no stop date identified for this PRN psychotropic medication. Review of a pharmacist clinical record review report for Resident #2 dated 11/7/24 and titled Prescriber Recommendations revealed, The resident was started on the psychotropic Hydroxyzine 10 mg (milligrams) to be taken PRN (as needed). Per regulatory guidelines, orders for psychotropic medications on a PRN basis must be limited to 14 days with no exceptions. If a new order for the psychotropic medication is to be written, a direct examination of the resident by the attending physician or prescribing practitioner is required to determine if the medication is still needed .Please consider the continued need for this medication. If discontinuation is contraindicated, please document continued need, including any improvement and benefit experienced by the resident as a result of the medication .signature: (prescriber name omitted) 12/5/24. In an interview on 12/4/24 beginning at 2:54 PM, Social Services Director (SSD) I confirmed that Resident #2 was prescribed Hydroxyzine 10 mg as needed for anxiety. SSD I reported when the order was entered, there should also have been a 14-day stop date entered to prompt a review of the medication effectiveness and continued need. Resident #134 Review of an Admission Record revealed Resident #134 was a male, with pertinent diagnoses which included: anxiety disorder, unspecified. On 12/4/24 at 2:45 PM, a review of Resident #134's current Order Summary revealed a Physician's Order for KlonoPIN Oral Tablet 0.5 MG (Clonazepam) Give 1 tablet by mouth every 12 hours as needed for anxiety Pharmacy Active 11/18/2024 It should be noted that there was no stop date identified for this PRN psychotropic medication. In an interview on 12/4/24 beginning at 2:54 PM, Social Services Director (SSD) I reported Resident #134's order for the psychotropic medication Klonopin should have been discontinued after 14 days or there should have been a documented rationale for continued use.

Based on observation, interview, and record review the facility failed to follow the standards of infection control for hand hygiene and glucometer (handheld machine used to check blood sugar level) cleaning for 3 residents (Resident #84, #8, and #85) of 3 residents receiving blood sugar assessments, resulting in the potential for cross contamination and the spread of disease to a vulnerable population. Findings include: During an observation on 12/05/24 at 12:06 PM in the hall at the medication cart, Registered Nurse (RN) J was preparing to perform a blood sugar check for Resident #84. RN J donned gloves, entered Resident #84's room, poked Resident #84's left right finger to obtain a blood specimen, and then picked up the glucometer with a test strip in it, and touched it to the drop of blood on the resident's fingertip. RN J sat the glucometer on the resident's table, wiped the blood from the resident's finger, removed his gloves, then picked up the glucometer and exited the resident's room. RN J did not perform hand hygiene after removing his gloves, returned to the medication cart and placed the uncleaned glucometer on the cart, with the used test strip still in place. There was no barrier sheet on the medication cart, and RN J did not clean the glucometer. RN J then used the computer to review the resident's orders, and then obtained a vial of insulin (medication used to manage high blood sugar levels) and prepared Resident #84's dose of the medication using a syringe. RN J donned clean gloves, entered Resident #84's room and administered the syringe of insulin. RN J removed his gloves and exited the room, and did not perform hand hygiene. During an immediate subsequent observation on 12/05/24 at 12:21 PM RN J donned gloves, and with the same glucometer, inserted a new test strip and then entered Resident #8's room. RN J poked Resident #8's right index finger to obtain a blood specimen, and then picked up the glucometer touched the test strip to the drop of blood on the resident's fingertip. RN J sat the glucometer on the resident's table, wiped the drop of blood off the resident's finger, removed his gloves, then picked up the glucometer and exited the resident's room. RN J did not perform hand hygiene after removing his gloves, returned to the medication cart where he removed the test strip without gloves on, and placed the uncleaned glucometer on the cart. There was no barrier sheet on the medication cart, and RN J did not clean the glucometer. During a third subsequent observation on 12/05/24 at 12:26 PM RN J put a new test strip into the same glucometer, donned gloves without performing hand hygiene, and entered Resident #85's room. RN J poked Resident #85's left index finger to obtain a blood specimen, and then picked up the glucometer and touched the test strip to the drop of blood on the resident's fingertip. RN J wiped the drop of blood from the resident's finger, removed his gloves, and then with the uncleaned glucometer in hand, exited the resident's room. RN J returned to the medication cart and placed the uncleaned glucometer on the cart. There was no barrier sheet on the medication cart, and RN J did not clean the glucometer. In an interview on 12/05/24 at 12:32 PM, RN J reported that he should have used hand sanitizer after every resident, and cleaned the glucometer with a bleach or alcohol wipe between each resident. In an interview on 12/05/24 at 3:15 PM, Director of Nursing (DON) B reported that it was expected that the nurses disinfect the glucometer between residents. Review of a facility policy Blood Glucose (sugar) Monitoring Machine Cleaning review date 5/2021 revealed, To provide guidance on how to clean the blood glucose monitoring machine between residents . 3. Take a pre-moistened disinfecting wipe and squeeze out any excess liquid in order to prevent damage to the meter, wipe down the body of the meter, being careful not to allow any liquid to get inside the battery compartment, strip port, or screen for appropriate length of contact time. 4. Cleanse and disinfect meter between each use. 5. Remove gloves and wash hands.

Based on interview, and record review, the facility failed to employ an Activity Director who possessed the required qualifications for the position, resulting in the potential for unmet met psychosocial needs, feelings of boredom and a lack of person-centered activities. This citation has the potential to impact all 27 residents within the facility. Findings include: In an interview on 11/1/23 at 3:22pm, Activities Director (AD) R revealed resident involvement in group and individual activity attendance was currently not being tracked in a manner that would allow for her to ensure residents were being provided with activities of interest and attending activities consistently each week. AD R reported the current system of activity attendance documentation also would not result in timely awareness of a resident's decline in involvement. AD R reported prior to working as the Activities Director, she worked as an Admissions Coordinator at the facility. When queried about her training, AD R revealed she did not possess any of the qualifications required to oversee the activities program. AD R reported she and the facility had been looking into the specialized training she needed to gain those qualifications. AD R reported she had held the position of Activities Director for over a year, and was not under the supervision of a consultant or other staff member who possessed the necessary qualifications for the role. Review of Activity Attendance reports provided by AD R revealed a list of residents with a total number of activities attended over a 3-month period. The report did not allow for tracking of attendance of specific activities listed in the residents' care plans, resident responses to activities, or trending in the residents' level of involvement. In an interview on 11/1/23 at 3:23pm, Nursing Home Administrator (NHA) A reported AD R did not possess the qualifications required to oversee the activities program. NHA A reported she was aware of this deficient practice for some time and had been exploring options to ensure compliance was obtained, but no action had been taken. Review of certification standards of a nationally recognized Activities Professional organization revealed ADC (Activity Director Certified) Certification ensures an individual has the knowledge and skills to lead and direct an activities and life enrichment department. ADC Certification validates the competencies necessary to be an Activity Director including leadership, management, advocacy, care planning and documentation. Review of Participating in Activities You Enjoy as You Age, published by the National Institute on Aging, 3/28/22, revealed: Research has shown that older adults with an active lifestyle: Are less likely to develop certain diseases. Participating in hobbies and other social activities may lower risk for developing some health problems, including dementia, heart disease, stroke, and some types of cancer . Studies looking at people's outlooks and how long they live show that happiness, life satisfaction, and a sense of purpose are all linked to living longer. Doing things that you enjoy may help cultivate those positive feelings . Studies suggest that older adults who participate in activities they find meaningful, .say they feel happier and healthier . When people feel happier and healthier, they are more likely to be resilient, which is our ability to bounce back and recover from difficult situations. Positive emotions, optimism, physical and mental health, and a sense of purpose are all associated with resilience .research suggests that participating in certain activities, such as those that are mentally stimulating or involve physical activity, may have a positive effect on memory - and the more variety the better. Other studies are providing new information about ways that creative activities, such as music or dance, can help older adults with memory problems or dementia.

Based on observation and interview, the facility failed to: 1. properly date and discard food items, 2. securely store packaged food product after opening, 3. clean food and non-food contact surfaces, 4. properly store clean cooking utensils and pans to prevent bacterial harborage and contamination. Findings include: On 10/30/23 beginning at 9:33 AM, an initial tour of the kitchen/food service was conducted with Dietary Manager (DM) Q. The following observations/interviews occurred during this initial tour: At 9:33 AM in the dry storage area, noted the following: an opened, bulk-sized container of baking soda labeled with an opened date of 12/2/22 and a discard date of 5/2/23; an opened, bulk-sized bag of puffed rice cereal labeled with an opened date of 4/19/23 and a use by date of 8/19/23; 2 opened bottles of food coloring labeled with a delivery date of 12/17/18 but no label for opened or discard dates; 4 unopened cans of evaporated milk with a best by date of July, 2023; an opened, 8 ounce container of baking powder that was not labeled with opened or discard dates; and opened bulk boxes of rice (1 box) and breadcrumbs (1 box), both of which were opened with the bags inside the boxes that contained the food product not securely closed. DM Q immediately discarded the items that were past the discard dates and the items that were opened but not labeled, all of which were discovered by this surveyor. DM Q reported the bulk rice and breadcrumbs should have been securely sealed to prevent contamination. At 9:45 AM at the stand-up meat freezer, noted a heavy accumulation of dust on the grate of the air vent above the freezer. DM Q reported maintenance usually cleaned the vent, but that they hadn't been in to do it for about 3 months. Also noted a significant amount of debris, food crumbs, and spillage (both wet and dried) on the bottom shelf of the stand-up breakfast freezer and a moderate amount of debris and frozen spillage on the bottom shelf of the stand-up vegetable freezer. At 10:02 AM in the skilled nursing kitchenette serving area, noted the following: an opened bag of potato chips that was not securely sealed was in the cupboard; an opened, bulk-sized jar of peanut butter that was not labeled with an opened or use by date on the counter; there was spillage and debris found on the bottom shelf of the cooler; 6 nutritional shakes in the cooler and 1 case plus 2/3 case of nutritional shakes in the freezer. DM Q reported nursing usually took the shakes out of the freezer and put into the refrigerator to thaw but was unable to state the timeframe that the shakes had to be used after thawing. There was no notation on the nutritional shake cartons in the refrigerator to indicate when they had been removed from the freezer to thaw. The delivery date label on each of the nutritional shake case boxes was 10/20/22. There was a date stamp on the nutritional shake case boxes with a BB date of 10/20/23. DM Q reported thought the BB stamp stood for best by date but was unsure. There was a collection of black dirt and grime around the perimeter of the floor where the floor and walls meet. On 10/31/23 beginning at 11:40 AM, a follow-up tour of the kitchen/food service was conducted with Dietary Manager (DM) Q. The following observations/interviews occurred during this follow-up tour: At 11:40 AM, at the spice shelf area in the kitchen near the cook's food preparation area, noted the following: curry powder labeled as opened 5/30/22 and discard 5/30/23; ground cloves labeled as opened 12/15/21 and discard 12/15/22; rosemary leaves labeled as opened 5/11/22 and discard 5/11/23; dill weed labeled as opened 9/2/22 and discard 9/2/23; and ground mustard labeled as opened 10/16/22 and discard 10/16/23. DM W reported the spices should have been discarded by the discard dates. At 11:47 AM in the kitchen on the rack at the end of the cooks' food preparation area, noted multiple blue plastic bins that contained cooking and serving utensils (one utensil type per bin). DM Q reported the bins were where the clean cooking and serving utensils were stored after they had been washed. There was a moderate amount of food crumbs and debris found in the bottom of each of the bins that contained tongs, spatulas, and scoops. DM Q reported the bins were supposed to be cleaned out and washed once a month or so and reported the crumbs were likely breadcrumbs that had fallen down from the upper shelf of the rack. DM Q reported there were no lids for the bins and the bins were not covered when not in use. At 11:52 AM in the kitchen at the clean pan storage rack, noted 2 full size pans that had dried food residue on the inside food contact surface of the pans, 2 third pans stacked one inside the other that were still wet, 1 half pan stacked inside another half pan that was wet and had dried food residue on the interior and exterior of the pan surfaces, and 2 sixth pans that were stacked inside one another that were wet and had dried food residue on the interior of the pan surfaces.

This citation pertains to intake number MI 991. Based on interview and record review, the facility failed to ensure adequate supervision to prevent accidents in 1 resident (Resident #1) of 4 residents reviewed for accidents, from a total of 4 residents, resulting in a fall with a fracture and subsequent hospitalization for Resident #1. Findings include: According to the Face Sheet, Resident #1 was an [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Data Set assessment ((MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 5/15 which indicated Resident #1 was severely cognitively impaired. Review of an Activities of Daily Living (ADL) care plan revealed: Focus: Guest has an ADL Self Care Performance Deficit r/t Impaired balance initiated 8/14/17. Interventions: Transfers: extensive assistance of 1 resolved 8/21/17. Transfers: limited assistance of 1 initiated 8/21/17. Uses Wheelchair initiated 8/14/17. Uses roller walker initiated 8/21/17. Review of a Fall care plan revealed: Focus: Guest is Low-Moderate risk for falls r/t confusion, deconditioning, gait/balance problems, Actual fall 8/21/17. Initiated 8/11/17, revision on 8/22/17. Intervention: Anticipate and meet the guest's needs. Initiated 8/15/17. Review of an undated, written witness statement signed by CNA B (aide assigned to Resident #1 on 8/21/17) revealed, On 8/21/17 I did witness Resident #1 try to stand on her own and make her bed. I re-directed her to her wheelchair and made the bed for her. I also explained to her that she should use her call light if ever she was in need of assistance. Because she seemed a little more confused than usual, Resident #1 and I both decided that it was best for her to go to the dining room by the nurses' station, so she wouldn't be alone. On our way to the dining room I explained to the nurse Resident #1's confusion and her behavior. Sometime after that, during dinner Resident #1 told me that she had forgotten her bill fold in her room so she needed to get it in order to pay for her meal. With me knowing that Resident #1 had no billfold here, I explained to her that her meal was taken care of and that there was no need for her to get up. She believed me and continued eating. I did not see Resident #1 fall in the dining room. At that time I was located in the kitchen helping a guest. Review of another undated written witness statement signed by CNA B revealed, On 8/21/17 at 3:30 p.m. I saw Resident #1 in her room trying to stand by herself. I let the nurse know that she seemed confused and I brought her out to the dining room. After that I did not see her try to stand alone. Last time I saw her she was sitting at the dining room table with other residents. Review of a written witness statement dated 10/13/17 and signed by CNA E revealed, To whom it may concern, other than the fall in the dining room, I can't recall Resident #1 doing anything unsafe. She would push her call light when she needed help such as go to her bed, water, bathroom, pail pill, etc. If I would have seen her being unsafe I would reminded her of how important it is to be safe and ask for help. Review of a written witness statement dated 10/14/17 and signed by CNA C revealed, I never had Resident #1 in my group when I worked. I have answered her call lights before. She used her call light often, anytime she wanted to use the bathroom or needed anything. I never seen her stand or try and walk on her own. The night she fell I was standing the kitchen with by back to the dining area. I heard a commotion and then someone say she fell . I turned around and Resident #1 was on the floor . Review of an Incident/Accident Report dated 8/21/17 completed by Registered Nurse, (RN) H revealed, Nursing Description: CNA reported to this nurse, dining supper in dining room [ROOM NUMBER], Resident #1 stood up, pushed her wheelchair under table, lost balance and fell before staff could reach her. In an interview on 1/18/18 at 12:52 p.m., Nursing Home Administrator (NHA) A stated, Resident #1 was in dining room [ROOM NUMBER] in a wheelchair. She had been on the walk to dine program. She was with a table mate. Staff are used to her standing. The CNA (E) walked by with waters. (Resident #1) stood, took a step and fell . CNA (E) couldn't get to her in time. She was about an arm's length away. It happened so fast. CNA (B) reported confusion to RN (H) her nurse. I was proud of her for identifying a change and taking action. Review of the video surveillance of the fall on 8/21/17 with NHA A present revealed the following sequence of events: 18:36:20 Resident #1 was seated in a wheelchair at a table toward the middle of the dining room, against the windows. CNA E walked in the room. 18:37:13 Resident #1 stood after her table mate stood up. At the same time, CNA B walked in the dining room toward the sub kitchen and did not appear to lay eyes on Resident #1. 18:37:34 CNA C walked out of the dining room and did not aknowledge Resident #1. 18:37:43 CNA E walked past Resident #1 with 2 drinks in her hands and walked toward the back of the dining room out of the line of site of the camera. Resident #1 remained in a standing position at her table. 18:38:02 CNA E set the drinks down and walked back through the dining room. Resident #1 turned toward the door. There was no visible change in pace as CNA E walked through the dining room. 18:38:04 Resident #1 took one step and fell . CNA E reacted with a startled jump. In an interview on 1/18/18 at 1:08 p.m., NHA A reported staff had already identified a change in condition for her. She was put in the dining room, in a wheelchair for increased supervision and safety. Resident #1 had only stood for less than 1 minute and there were plenty of staff around. This surveyor questioned why CNA E didn't set her drinks down on the very first table and why CNA B her primary CNA didn't go to her or check on her? NHA A stated, It's not uncommon to see people more independent when they're getting ready to go home. And she was getting ready to go home. Should she have stood? Probably not. Could (CNA E) have been faster?? Yeah maybe. Review of a Shift to Shift Report In-service provided on 10/19/17 revealed: 1. Report must be given to nurses and CNAs at the beginning of each shift! 2. Any nurse of CNA who does not comply should be reported immediately. 3. Report should include transfer status and any special needs. Review of an Inter-Disciplinary Progress Note dated 8/22/17 revealed: (Resident #1) admitted on [DATE] from post hospital stay for fall resulting in left femur fracture. On admission guest was identified to be at low-moderate risk for falls. Care plan was initiated, and interventions implement to reduce the risk for falls. Guest is pleasantly confused, oriented to self. Requires Limited assist x 1 for transfers with wheel chair/walker. (Resident #1) demonstrated proper use of call light when requiring assistance for transfers. On 8/21/17 guest was in dining room for supper. Guest was observed to stand without assistance, push her wheelchair under table, lost balance and fell before staff could reach her. Earlier on day shift of 8/21/17, guest was noted to have increased confusion along with foul odor and cloudy urine appearance and orders were obtained to collect UA to rule out UTI. Post fall, (Resident #1) was assessed by nurse and noted Guest guarding her left hip. MD was notified, and orders were obtained to send to (Local) ER for Eval and treatment of [REDACTED]. Review of a Health Status progress note dated 8/22/17 revealed, Received report from (Local) ER nurse . (Resident #1) has been admitted to the ortho/neuro floor with a [DIAGNOSES REDACTED]. In an interview on 1/18/18 at 2:47 p.m., Physical Therapy Assistant K stated, I worked with Resident #1 on her last day only. She was a limited assist with a gait belt for ambulation, which is hands-on. She transferred with contact guard assist, with a gait belt, hands on and verbal cues. She would be able to understand sit down but would need to have a tactile cue as well. Resident #1 would've had red tape on her walker. She needed someone with her at all times. Just because someone is going home doesn't mean they can be more independent than their plan of care states. Everyone is an individual. In an interview on 1/18/18 at 2:57 p.m., Social Worker D stated, Her discharge goal was to go home to live with her son and family. At the time of her fall she was not going home soon per se, Resident #1 definitely wasn't days away. We had nothing on the calendar at the time. In an interview on 1/18/18 at 3:55 p.m., RN G and RN, Unit Manager F reported, the CNA's know who's a fall risk because they get the shift to shift report., the Kardex, and by the green dots on the doors. RN G stated, They have a report sheet for each hall so that even if the Resident isn't theirs, they have access to their info. We also use red tape on walkers for people who need assistance. Yellow tape on walkers for people who need supervision. And green tape on walkers for people who can be independent in their rooms. If they're in a wheelchair they are not going to be independent. The fact that they're in a wheelchair should alert you. RN, Unit Manager F reported that when a Resident they don't know stands up out of their wheelchair, they should go to them directly to help them. In an interview on 1/18/18 at 4:00 p.m., NHA A reported that CNA B is no longer employed by the facility. This surveyor called the telephone number for CNA B provided by facility which was disconnected. In a telephone interview on 1/18/18 at 4:08 p.m., CNA E stated, No one told me to keep a close eye on Resident #1. I think she was a walk to dine. I didn't think anything of her standing cause we have so many guests who walk. It just didn't dawn on me. (CNA B) was there, (CNA C) was there, and couple of nurses came in and out. Resident (#1) didn't look wobbly or any indication that she would fall. I wasn't assigned to her. I was just helping in the dining room. I think she needed help with transfers and walking. (Resident #1) didn't say anything to me and I didn't say anything to her. I didn't think anything of it. When I know them, I'm gonna tell them, sit down, I'll help you! I was surprised and horrified when she fell in front of me! In an interview on 1/18/18 at 4:23 p.m., NHA A stated, We didn't get a witness statement from RN H because she is the nurse who completed the I/A report . We don't keep the shift to shift reports. In an interview on 1/18/18 at 7:00 p.m., RN H stated, I worked the Day shift the day (Resident #1) fell . I remember pulling the Foley and noticing the odorous urine which is why I called for a UA. No other staff member told me she was acting differently. After the fall (CNA B) told me that she saw her try to transfer by herself earlier. If I had known, I wouldn't made sure the DR staff knew to keep extra eyes on her. I would expect them to let me know so we can figure out what they need and what's going on. I never ignore the CNA's when they come to me. We anticipate their needs and if someone needs more supervision, we will even keep them by the med cart when we're passing medications. If a CNA sees a resident standing, they should go help them right away.

This citation pertains to MI 524. Based on observation, interview, and record review, the facility failed to provide the necessary assistive device (a functioning alarm) to 1 of 3 sampled residents (Resident #101), from a total sample of 3 residents, resulting in a fall with a fractured rib for Resident #101. Findings include: Review of the Face Sheet revealed Resident #101 was an [AGE] year old female admitted to the facility on [DATE]. Review of the [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 had a Brief Interview for Mental Status (BIM'S) score of 15 out of 15 which indicated she was cognitively intact. The MDS revealed Resident #101 required an extensive assistance of 1 person for transfers and extensive assistance of 1 person for locomotion in her wheelchair. During the Survey, Resident #101 was not in the facility. Review of the Fall Risk Assessment Form dated 4/11/12, revealed Resident #101 was a "low to moderate risk for falls." Review of the Adaptive/Safety Equipment form dated 4/11/12, revealed Resident #101 was documented as a "fall risk" and had "sensor alarm bed" and "chair" (alarm) documented. Review of the facility Incident Report dated 6/4/12 revealed, on 5/17/12, Resident #101 was taken to the therapy room for treatment. The report indicated Physical Therapy Assistant (PTA) #5 was working with Resident #101 then "decided to give the guest a therapeutic rest before continuing the exercise." The report indicated that Resident #101 "sat in her (wheel)chair" and (PTA #5) asked the "guest to sit tight, she would be right back" and exited the therapy room. Resident #101 was found sitting on her buttocks on the floor in the therapy room. Resident #101 stated she was trying to get the ball that she had been using for the exercise program. The report indicated Resident #101 had complaints of pain on 5/17/12 and an x-ray taken which revealed no evidence of a fracture at that time. The report documented, "between 5/18/12 and 5/24/12", Resident #101 verbalized occasional pain complaints with some related to her back and some related to her shoulder. According to the report, on 5/24/12 an x-ray was performed which indicated Resident #101 had a fractured 5th rib and a second x-ray on 6/1/12 identified a 6th rib as fractured as well. The report indicated a Computerized Tomography (CT scan - Imaging procedure used to assist in [DIAGNOSES REDACTED].#101's rib fractures. An observation on 8/17/12 at 9:46 a.m. of the Therapy Room was done by this Surveyor. The Therapy room was rectangular in shape with an approximately 5 foot high x approximately 12 feet long divider wall placed length wise in the room. The wall was solid in construction (could not see through it) and this Surveyor had to walk around the wall to view all areas of the Therapy Room. In an interview on 8/16/12 at 1:35 p.m. PTA #5 stated, on 5/17/12, she brought Resident #101 to the Therapy Room. PTA #5 stated Resident #101 was "working with her throwing the ball against the wall." PTA #5 stated because Resident #101 "had been up and down in (the) treatment session, I (PTA #5) had turned it off (Resident #101's wheelchair alarm)." PTA #5 reported she did not turn the wheelchair alarm back on prior to leaving Resident #101 unattended in the Therapy room. PTA #5 stated when she returned to the Therapy Room, she was told that Resident #101 "slid off her chair onto the floor." In an interview on 8/16/12 at 1:45 p.m., PTA #6 stated she was in the Therapy Room and had "went to get some weights around the wall (dividing wall)" and found Resident #101 on the floor. PTA #6 stated Resident #101 told her she was "going to get the ball." PTA #6 stated Resident #101's wheelchair was "4-5 feet behind her". PTA #6 stated Resident #101 was sitting on the floor with her legs "drawn up" and "hands around her knees." PTA #6 stated PTA #4 came out of the office and said "we need to call a nurse." PTA #6 stated, "I wasn't aware of any other patients in the room (Therapy Room)" when PTA #5 had left Resident #101 in the Therapy Room unattended. In interviews on 8/16/12 at 12:55 p.m. and 8/17/12 at 11:30 a.m., PTA #4 stated that on 5/17/12, she heard PTA #6 say 'what are you doing?' to Resident #101. PTA #4 stated she came out of her office (adjacent to the Therapy Room) and saw Resident #101 sitting on the floor. PTA #4 stated Resident #101's wheelchair was behind her. PTA #4 stated, "it was just (PTA #6) and I in the therapy room." PTA #4 stated she disciplined PTA #5 for "leaving a guest out of line of sight" and because PTA #5 "didn't ask another staff member" to watch Resident #101. PTA #4 stated she did not hear an alarm in the Therapy Room on 5/17/12. Review of Rehabilitation Services Disciplinary Action Form dated 6/7/12 revealed PTA #5 had a "documented verbal warning" for "guest left unattended and out of line of sight in PT (Therapy Room) gym and was discovered on floor in front of w/c (wheelchair) by another therapist event occurred on 5/17/12 in PT gym." The Disciplinary Action Form revealed "per employee handbook and policy and procedure manual guests' safety to be maintained at all times during treatment" and "guest to be kept in line of sight at all times in gym and during treatment to ensure safety." Review of Interdisciplinary Progress Notes dated 5/17/12 (unable to read time) revealed Resident #101 had "complaints of right shoulder pain" and "STAT (right away)."x-ray of right shoulder...included x-ray of ribs." Review of physician's orders [REDACTED]. Review of the Radiology Report dated 5/18/12 revealed Resident #101 had "no definite radiographic evidence of acute fracture or dislocation of ribs in these projections" and "no definite radiographic evidence of acute fracture or dislocation" of right shoulder. Review of Interdisciplinary Progress Notes dated 5/19/12 (un-timed) revealed Resident #101 had "hot pack applied to right back related to previous fall, Tylenol (pain medication) given." Review of Interdisciplinary Progress Notes dated 5/23/12 at 10:25 a.m. revealed Resident #101 had stated "she is sore...all over her body." Review of physician's orders [REDACTED]." Review of the Radiology Report dated 5/24/12 at 11:54 p.m. revealed Resident #101 had a chest x-ray compared to the x-ray taken on 5/18/12. The "conclusion" was "acute displaced fracture of the 7 th right rib since prior exam suggesting an occult fracture at that time unless there has been an interval injury"(an occult fracture cannot be detected by radiographic standard examination, break is most likely to occur in the ribs, tibia, metatarsals or hip. It is accompanied by the usual signs of pain and trauma). Review of physician's orders [REDACTED]." Review of the Radiology Report dated 6/1/12 at 12:14 p.m. revealed Resident #101 had a chest x-ray performed. This x-ray was compared to the previous x-ray's and the radiologist concluded there was "slightly displaced fractures of the sixth and seventh ribs on the right." Review of physician's orders [REDACTED]." Review of the CT Scan Report dated 6/4/12 (un-timed) revealed Resident #101's "right sided rib fractures were present."

This citation pertains to Intake Number MI 417. Based on observation, interview, and record review, the facility failed to ensure adequate fluid intake to maintain hydration for 1 of 5 sampled residents (Resident #101), from a total sample of 5 residents, resulting in an Immediate Jeopardy when Resident #101 did not receive daily fluid needs of 2640 cc/day from [DATE]-[DATE], became unresponsive on [DATE], and was transferred to the hospital with [DIAGNOSES REDACTED]. Resident #101 subsequently died on [DATE]. These deficient practices place all residents at risk for dehydration and subsequent serious harm, injury, and/or death. Findings include: Review of the facility Face Sheet and Minimum Data Set (MDS), dated [DATE], revealed Resident #101 was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #101 was moderately cognitively impaired for daily decision-making skills, had short-term memory problems, and required encouragement, cueing and set up for eating. Review of the Initial Dietary Assessment, dated [DATE], completed by Dietary Manager (DM) #4 revealed Resident #101's estimated fluid needs were 2640 cc/day based on his weight of 194 lbs (88 kgs). In interviews on [DATE] at 3:25 PM and [DATE] at 9:35 AM, DM #4 stated Resident #101 had been assessed on [DATE] and that she (DM #4) would usually complete another assessment weekly. DM #4 stated she relies on nursing staff and/or the Certified Nursing Assistants' (CNA) documentation for her weekly reviews. DM #4 stated that nursing staff would tell her if a resident was not eating or drinking. Review of the Hydration Policy, dated ,[DATE], revealed the goal was "To ensure that all guests receive sufficient fluids to maintain general well being and prevent dehydration." The procedure included: "1. Hydration status may be monitored in the following residents; a) new admissions for 14 days, f) guests with excessive urine loss or scant urine output, g) guests with unexplained weight loss or gain; 6. Dietary and Nursing will assess whether fluid intake is meeting needs". Review of the 5 Day Bowel and Bladder Assessment, dated ,[DATE], revealed Resident #101 was assisted to the toilet eight times on [DATE], six times on [DATE], four times on [DATE] with two episodes of incontinence, toileted two times on [DATE] with three episodes of incontinence and toileted three times on [DATE] with one episode of incontinence, which indicated a decrease in urination and bowel movements. Each time Resident #101 was toileted, he had positive results. Review of the Food Acceptance Record, dated ,[DATE], and the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s fluids on [DATE] (1080 cc deficit), 1440 cc's fluid on [DATE] (1200 cc deficit), 1060 cc's fluid on [DATE] (1580 cc deficit), 1320 cc's fluid on [DATE] (1320 cc deficit), 1080 cc's fluid on [DATE] (1560 cc deficit), and 870 cc's fluids on [DATE] (1770 cc deficit). Based on DM #4's calculations, Resident #101 should have had a total of 2640 cc's of fluid daily or 15,840 cc's of fluid over the six days he was at the facility, but actually received 7,330 cc's of fluid, resulting in a deficit of 8,510 cc's over six days. Review of the Dehydration Care Plan, dated [DATE], revealed Resident #101 was at risk for dehydration. Interventions included monitoring food acceptance for at least 14 days and monitoring for signs/symptoms of dehydration, such as increased pulse, decreased urine output and decreased skin turgor. Review of the Daily Nursing Notes, dated [DATE]-[DATE], revealed documentation to indicate Resident #101's mucous membranes were moist/pink and his skin turgor was fair. Nurse's Note, dated [DATE], revealed Resident #101's pulse was elevated at 105 bpm (beats per minute), 101 bpm on [DATE], 118 bpm, on [DATE], and 142 bpm on [DATE]. Review of the Interdisciplinary Progress Notes, dated [DATE] at 10:00 PM, revealed a late entry for [DATE] on the 7P-7A shift by Registered Nurse (RN) #21. The Interdisciplinary Progress Notes revealed, "guest (Resident #101) observed to be lethargic; he can slightly move his arms and legs but does not respond to any question. 9 PM medications held, guest unable to take meds. vitals signs are BP ,[DATE], P 132, R 20, T 98.0. At around elevenish ....guest (Resident #101) non responsive. Vital signs taken BP ,[DATE], P 146, R 20, T 98.2. MD paged; message regarding guest's (Resident #101's) condition left on voice mail. Pulse palpable bilaterally; guest (Resident #101) appears to breath rapidly. MD called back, new order received to check vital again in an hour and to call with results. MD requested the guest (Resident #101) code status. Guest reassessed frequently; vital signs are: BP ,[DATE], P 142, R 22, T 98.0. MD ordered to keep checking on guest (Resident #101). He called around 0630 AM and stated that the PA (physicians assistant) will be coming soon in AM to follow up on guest (Resident #101) condition". Review of the Laboratory Data, collected [DATE] at 6:15 AM and first reported [DATE] at 1:59 PM, revealed High results of Hemoglobin A1C of 8.40% (normal 4.00 - 6.00 %) (a blood test used to determine how a person with diabetes controls their blood sugar, if the range is above 8% the test shows that the diabetes is poorly controlled, (MedicineNet.com [DATE])), Glucose (blood sugar level) 397 mg/dL (normal ,[DATE] mg/dL), Sodium 136 mEq/L (normal ,[DATE] mEq/L), and BUN (Blood Urea Nitrogen - marker of kidney functions) 25.5 mg/dL (normal 1XXX,[DATE].5 mg/dL). In an interview on [DATE] at 2:43 PM, Physician's Assistant (PA) #19 stated she was not aware of Resident #101's laboratory results, dated [DATE]. Review of the Laboratory Data, collected on [DATE] at (no time indicated) and first reported on [DATE] at 7:14 AM, revealed High results of Glucose 641 mg/dL, Sodium 144 mEq/L and BUN 42.6 mg/dL. According to http://medical-dictionary.thefreedictionary.com/p/osmolality, serum osmolality is "a measure of the number of dissolved particles per unit of water in serum... Measurement of the serum osmolality gives information about the hydration status within the cells because of the osmotic [MEDICATION NAME] that is constantly being maintained on either side of the cell membrane (homeostasis). Water moves freely back and forth across the membrane in response to the osmotic pressure being exerted by the molecules of solute in the intracellular and extracellular fluids. Serum osmolality reflects the status of hydration of the intracellular as well as the extracellular compartments and thus describes total body hydration". Normal adult blood osmolality is 285 to 296 mOsm/kg H2O with greater than 296 defined as dehydration. Serum Osmolality is calculated using the following formula: (2 x (NA) + (BUN/2.8) + (Glucose/18). The lab results from [DATE] for Resident #101, calculate his serum osmolality at 303.2 or dehydrated. The lab results from [DATE] for Resident #101 calculate his serum osmolality at 338.8 or dehydrated. In an interview on [DATE] at 10:10 AM, Licensed Practical Nurse (LPN) #12 stated that on [DATE] she was doing rounds with the physician, who stated Resident #101 looked to be dehydrated and he wrote an order for [REDACTED]. In an interview on [DATE] at 10:50 AM, CNA #17 stated on [DATE] she could not get Resident #101 awake at all that day. CNA #17 stated Resident #101 was still sleeping at lunch, she check him for incontinence and he was not wet and did not wake when he was rolled side to side while she checked him. In an interview on [DATE] at 4:10 PM, CNA #20 stated that on [DATE] she got Resident #101 up to eat supper and he fell asleep in his plate. CNA #20 stated Resident #101 had been sleepy all day, [DATE]. In an interview on [DATE] at 4:25 PM, RN #24 stated that she does not always look at labs for residents, and that she did not have a whole lot of time to review the 5 Day Bowel and Bladder Assessment that would indicate how often residents went to the bathroom. RN #24 stated that she had been assigned Resident #101 during his stay at the facility. Review of the Emergency Department report, dated [DATE] at 4:50 PM, revealed Resident #101 was unresponsive, had dry mouth and lips, and had [MEDICAL CONDITION](rapid heart rate). Resident #101 had a rectal temperature of 101.8 degrees Fahrenheit, a pulse of 135, and a respiratory rate of 32. Resident #101 was admitted to the hospital with [REDACTED]. Review of the Hospital Admission Assessment, dated [DATE] at 10:15 PM, revealed Resident #101's weight was measured at 83 kg, a loss of 5 kg or 11 lbs. since admission to the facility on [DATE] (seven days), the oral cavity had sores and his tongue was red and dry. Review of the Hospital History and Physical, dated [DATE], revealed Resident #101's BUN (blood urea nitrogen) was 86 mg/dL (normal ,[DATE] ml/dL), creatinine was 3.4 mg/dL (normal 0XXX,[DATE].3 mg/dL), and a sodium of 149 MMOL/L (normal ,[DATE] MMOL/L). In an interview on [DATE] at 5:00 PM, LPN #7 stated she was unaware of Resident #101's diet and the CNA's did not report anything unusual to her regarding Resident #101's diet. Observations and interviews, on [DATE] from 11:00 AM to 12:00 PM and at 3:00 PM, on [DATE] at 9:00 AM and 10:00 AM, on [DATE] from 7:30 - 8:30 AM and at 3:10 PM, on [DATE] at 9:15 AM, on [DATE] at 11:00 AM while in the facility, revealed residents with water at bedsides. Residents were asked if they were able to reach the water and they demonstrated that they could and if they could not, the residents stated staff would assist them. This surveyor also noted fresh water being passed. Administrator #1 was notified on [DATE] at 6:00 PM of the Immediate Jeopardy that began on [DATE] and was identified on [DATE] as a result of the facility's failure to ensure adequate fluid intake to maintain hydration for Resident #101, who did not receive daily fluid needs of 2,640 cc/day from [DATE]-[DATE], resulting in Resident #101 becoming unresponsive on [DATE] and being transferred to the hospital with [DIAGNOSES REDACTED]. Resident #101 subsequently died on [DATE]. On [DATE], surveyor # verified that the facility implemented the following to remove the Immediate Jeopardy. 1. Resident #101 no longer resides in the facility. 2. On [DATE], the General Manager performed a hydration evaluation of current guests. The evaluation included the facility management moving room to room observing the guest visually and ensuring each guest had water at the bedside and that staff were offering additional fluids in-between meals. The General Manager did not identify any guest, who appeared under-hydrated during her rounds. Charts were reviewed, no care plans required changes. 3. On [DATE], a physical hydration assessment for each guest was performed by the Director of Health Services or the MDS Coordinator. The assessment included skin turgor, presence of dry mouth or swollen tongue, presence of nausea or vomiting, recent labs, urine color, voiding patterns, and the amount of fluids being offered. 4. Between [DATE] - [DATE], the General Manager and Unit Manager held face to face in-services for all nurses, CNA's and Activity Staff regarding hydration. The in-service covered keeping fluids at the bedside unless NPO, offering fluids each time in the room, offering at least 2 drinks at meals, signs and symptoms of dehydration (dry mouth, tenting, thirst, etc), and to inform a nurse if a guest is not eating or drinking. As of [DATE] all staff will have received the education. 5. As of [DATE], the Unit Manager or Designee initiated weekly chart audits of guests at risk for dehydration. The Unit Manager or Designee will report her findings to the Director of Health Services and the Administrator. The General Manager or Director of Health Services or Designee perform walking rounds daily to ensure water is kept at the bedside, fluids are offered according to the guests' needs, and the hydration policy is implemented. The Administrator is responsible for attaining and maintaining compliance with this regulation. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of widespread and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance has not verified by the State Agency. #

This citation pertains to Intake Number MI 417 Based on observation, interview, and record review the facility failed to ensure adequate diabetic blood sugar monitoring in 1 of 4 reviewed for Diabetes (Resident #101), from a total of 5 sampled residents, resulting in an Immediate Jeopardy when Resident #101 became unresponsive and required emergent transfer to the hospital where it was discovered he had an elevated blood sugar of 630 mg/dL (normal ,[DATE] mg/dl) on [DATE]. Resident #101 subsequently died on [DATE]. This deficient practice places all residents, who are diabetic and may require emergency treatment, at risk for serious harm, injury, and/or death. Findings include: Review of the facility Face Sheet and Minimum Data Set (MDS), dated [DATE], revealed Resident #101 was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #101 was moderately cognitively impaired for daily decision-making skills and had short-term memory problems. In an interview on [DATE] at 12:00 PM, Registered Nurse (RN) #8 (agency nurse) reported that she assisted with Resident #101's admission assessment on [DATE]. RN #8 stated that she was shown the location of the policy and procedure books, was oriented to the physical layout of the facility and was then immediately given her assignment to begin. RN #8 stated that she did not have time to review the policies and procedures and was unaware of a policy and the need to monitor the blood glucose levels of residents on carbohydrate diets. Review of the Physician Admission Order Sheet, dated [DATE], revealed Resident #101 was ordered a carbohydrate counting diet with no added salt. Review of the Diabetes Care Plan, dated [DATE], revealed Resident #101 had orders for an oral diabetic medication, that staff were to maintain Resident #101's blood sugar level between ,[DATE], and prevent crises from the inadequate control of diabetes mellitus ([DIAGNOSES REDACTED], [MEDICAL CONDITION]). Interventions for Resident #101 included being on a carbohydrate controlled diet. Review of Carbohydrate Controlled Diet Policy, approved ,[DATE], revealed the policy was "to provide liberalization of diet to guests with Type I and Type II Diabetes Mellitus, or altered glucose function. Goals for the Carbohydrate Controlled Diet Policy were 1. Blood glucose levels will be controlled. 2. Guest will have liberalized diets. Procedure for the Carbohydrate Controlled Diet Policy were 1. Guests admitted with [DIAGNOSES REDACTED]. M. (Diabetes Mellitus) will be placed on a Carbohydrate Controlled Diet upon admission...3. Accu checks will be taken by nursing two times per day, in the am and pm, for one week and recorded on the MAR (Medication Administration Record...". In an interview on [DATE] at 11:30 AM, General Manager in Training #2 stated she could not comment on the Carbohydrate Controlled Diet Policy in relation to Resident #101 because she "did not look at it at the time". General Manager in Training #2 stated the physician saw the [DATE] labs because his signature was on them, but since no time or date was noted she could not tell this surveyor when the physician was made aware of the high Hemoglobin A1C of 8.40 % (normal 4.00 - 6.00 %) or the Glucose of 397 mg/dL. In a second interview on [DATE] at 10:30 AM, General Manager in Training #2 stated the only note on the physicians log for Resident #101 was on [DATE] in regard to "hitting" and that there were no other notations for Resident #101 made to the physician. In interviews on [DATE] at 3:36 PM and [DATE] at 7:40 AM, Director of Health Service #3 stated she was not aware of the Carbohydrate Controlled Diet Policy and the procedure to do accu checks twice a day on Type I or Type II diabetics. Review of the Laboratory Data, collected [DATE] at 6:15 AM and first reported [DATE] at 1:59 PM, revealed High test results for Hemoglobin A1C (blood test used to determine how a person with diabetes controls their blood sugar, if the range is above 8% the test shows that the diabetes is poorly controlled, (MedicineNet.com [DATE])) 8.40% (normal 4.00 - 6.00 %), Glucose (blood sugar level) 397 mg/dL (normal ,[DATE] mg/dL), and BUN (Blood Urea Nitrogen - marker of kidney functions) 25.5 mg/dL (normal 1XXX,[DATE].5 mg/dL). In an interview on [DATE] at 2:43 PM, Physician's Assistant (PA) #19 stated that typically, every patient with diabetes mellitis has accu check to monitor blood sugar. PA #19 stated that she was not aware of the laboratory results, dated [DATE], for Resident #101. Review of the Interdisciplinary Progress Notes, dated [DATE] at 10:00 PM, revealed a late entry for [DATE] 7P-7A shift by Registered Nurse (RN) #21. The Interdisciplinary Progress Notes revealed, "guest (Resident #101) observed to be lethargic; he can slightly move his arms and legs but does not respond to any question. 9 PM medications held, guest unable to take meds. vitals signs are BP ,[DATE], P 132, R 20, T 98.0. At around elevenish ....guest (Resident #101) non responsive. Vital signs taken BP ,[DATE], P 146, R 20, T 98.2. MD paged; message regarding guest's (Resident #101's) condition left on voice mail. Pulse palpable bilaterally; guest (Resident #101) appears to breath rapidly. MD called back, new order received to check vital again in an hour and to call with results. MD requested the guest (Resident #101) code status. Guest reassessed frequently; vital signs are: BP ,[DATE], P 142, R 22, T 98.0. MD ordered to keep checking on guest (Resident #101). He called around 6:30 AM and stated that the PA (Physicians Assistant) will be coming soon in AM to follow up on guest (Resident #101) condition". In interviews on [DATE] at 2:20 PM, [DATE] at 12:55 PM, and [DATE] at 12:00 PM, Registered Nurse (RN) #5 was asked how the facility would achieve the goal for Resident #101's Diabetic Care Plan, which was to maintain blood sugar levels between ,[DATE] (mg/dL). RN #5 stated she did not know how the facility would know if this goal was achieved if Resident #101's blood sugar was not monitored through testing. RN #5 stated there were no accu checks on Resident #101 until [DATE] (date transferred to the hospital). RN #5 stated she did not know about the lab report completed [DATE] with a Hemoglobin A1C of 8.40% and Glucose 397 mg/dL until [DATE] and was unable to verify if and when the information in the [DATE] lab report was reported to the physician. RN #5 stated she was not aware of Resident #101's change of condition on [DATE] until [DATE] after PA #19 was at the facility. RN #5 stated she was not aware of the Carbohydrate Controlled Diet Policy approved ,[DATE], which required monitoring with accu checks twice a day for Type I and Type II diabetics admitted to the facility. Review of the MAR (Medication Administration Record), dated ,[DATE], revealed that there were no blood sugar levels recorded for Resident #101 from [DATE]-[DATE]. In an interview on [DATE] at 5:00 PM, Licensed Practical Nurse (LPN) #7 stated she was unaware of a policy regarding carbohydrate diets and the need for blood glucose monitoring for Resident #101 who was on a carbohydrate controlled diet. Review of lab documentation reveals the blood sugar results, which were called to the facility on [DATE] at 9:00 AM, were 641 mg/dl (normal ,[DATE] mg/dL). Review of the Daily Nurse's Note, dated [DATE] at 1:00 PM, revealed Resident #101 was "found hot to the touch and sweaty, BS (blood sugar) reported 561 by lab, Physician Assistant (PA) at the facility - received 12 units of regular insulin and 6 units of regular insulin later in AM, BS (blood sugar) continues to read high on glucometer, wife and daughter aware, do not want hospitalization at this time. Guest non-responsive at this time in bed." Review of the Blood Glucose Monitoring System User Instruction Manual (no date) revealed if the blood glucose is above 600 mg/dL, you will receive a "Hi". Review of the Interdisciplinary Progress Notes, dated [DATE] at 4:30 PM, documented as "additional information for [DATE]" revealed Registered Nurse (RN) #8 documented at 11:00 AM (2 hours prior to previous note in the Daily Nurse's Note) she received report on Resident #101. RN #8 documented, "Status had decreased since admission. Last accu check registered "HI" on glucometer. Re-checking to see if status changes. 12:00 PM, accu check still reading "HI". 6 units Novulink ([MEDICATION NAME] - regular insulin) given per PA's orders. 2:,[DATE]:00 PM wife calls and states she is going to hospital. Wife told guest is not at the hospital. To clarify phone conversation with wife, daughter's number obtained. Daughter states she wants her father to be transferred to (name of hospital) to "get his blood sugars under control". 4:00 PM, guest remains unresponsive. VS (vital signs) 97.3 - 153 - 32 - ,[DATE] - 90%. Blood sugar "HI". 4:15 PM (name of ambulance) here for transport". In an interview on [DATE] at 12:00 PM, RN #8 (agency nurse) stated when the wife called and said she was going to the hospital, it confused RN #8, because she had been told in report that the wife had not wanted Resident #101 to go to the hospital. In an interview on [DATE] at 5:00 PM, Licensed Practical Nurse (LPN) #7 stated she was unaware of a policy regarding carbohydrate diets and the need for blood glucose monitoring. LPN #7 stated she did not believe Resident #101 ate a lot, and that the Certified Nursing Assistants (CNA)'s keep the food log and inform nursing if the residents are not eating. In an interview on [DATE] at 10:10 AM, LPN #12 stated, that on [DATE] she was doing rounds with the doctor and that he ordered labs to be done on Resident #101 because, he had thought Resident #101 looked "dehydrated". In an interview on [DATE] at 11:10 AM, Family Member #1 stated Family Member #2 was updating her on Resident #101's condition. Family Member #1 stated that Family Member #2 felt it was the facility's job to take care of Resident #101 and that by the afternoon of [DATE] he would improve. Family Member #1 stated she did not believe Family Member #2 even realized what was going on with Resident #101 on [DATE]. Review of the Ambulance Run Sheet, dated [DATE], revealed at 4:13 PM the Emergency Medical Technicians (EMT's) were dispatched to the facility and, upon arrival, found that Resident #101 "had been unresponsive since 9 AM. Pt (patient) lying in bed with agonal (abnormal pattern of breathing characterized by gasping, labored breathing, accompanied by strange vocalizations and twitching) respirations. Extremely warm to the touch. While walking past nurses' station, asked for code status papers. The nurses said they don't keep them there but think he's a DNR. Treated patient according to presentation. Blood glucose continued to run 'High'. Transported Priority 1 to hospital". Resident #101's primary signs and symptoms were documented as "[MEDICAL CONDITION]". Review of the Emergency Department report, dated [DATE] at 4:50 PM, revealed Resident #101 had been unresponsive for 8 hours, had a rectal temperature of 101.8 degrees Fahrenheit, a pulse of 135, and a respiratory rate of 32 (normal ,[DATE] bpm, breaths per minute ). The report indicated Resident #101 was "sent in from nursing home for non-responsiveness and increased BS (blood sugars) - unsure of code status. Patient has been like this for whole day". Clinical impression was documented as "[MEDICAL CONDITION], a-fib ([MEDICAL CONDITION] - irregular heart beat),[MEDICAL CONDITION]." Resident #101 was admitted to the hospital. Review of the Hospital Discharge Summary, dated [DATE], revealed Resident #101's discharge [DIAGNOSES REDACTED].com, [DATE]). Review of the Certificate of Death, dated [DATE], revealed Resident #101 died on [DATE] at 10:04 AM while in the hospital. Cause of death was listed as [MEDICAL CONDITION] - hours, Pneumonia - days, Hyperosmolar Diabetic Coma - days which, according to the death certificate, led to Resident #101's [MEDICAL CONDITION]. In observations on [DATE] from 7:,[DATE]:00 AM, [DATE] from 11:,[DATE]:45 AM, and an interview/observation on [DATE] at 11:50 AM, this surveyor noted RN "AA" checking Medication Administration Records (MAR) prior to entering residents rooms, then preparing supplies to do accu checks per physician order [REDACTED]. RN "AA" stated that since some time in ,[DATE] all diabetic residents admitted to the facility will have an accu check 4 times a day for the first week and then the physician will review the results. RN "AA" showed this surveyor the MAR's of 4 residents with diabetes, and all records had an entry 4 times a day with accu check results. Administrator #1 was notified on [DATE] at 6:00 PM of the Immediate Jeopardy that began on [DATE] and was identified on [DATE] as a result of the facility's failure to ensure adequate diabetic blood sugar monitoring for Resident #101, who was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On [DATE], surveyor # verified that the facility implemented the following to remove the Immediate Jeopardy. 1. Resident #101 no longer resides in the facility. 2. On [DATE], 4 out of 4 guests with a [DIAGNOSES REDACTED]. The review verified appropriate care and treatment of [REDACTED]. 3. On [DATE], face-to-face in-services for nurses was completed by the Unit Manager, regarding initiating blood glucose monitoring 4 times per day for all diabetics admitted without glucose monitoring orders. 12 of 14 licensed nursing employees have been in-serviced. 4. On [DATE], 10 of 13 licensed nursing employees were in-serviced on the definition of diabetes, causes of diabetes, types of diabetes, blood draws (Hemoglobin A1C) done quarterly, blood glucose monitoring, intervention options (i.e. diet control, oral hypoglycemics, insulin), accu check 4x/day for guest with [DIAGNOSES REDACTED]. 5. Beginning on [DATE], the Unit Manager/designee has performed an audit of all new admission charts. If diabetic, the chart was reviewed to ensure the orders for glucose monitoring 4x/day for one week, with physician follow up are in place. The Unit Manager/designee will immediately institute orders for glucose monitoring 4x/day for one week if, upon audit, it glucose monitoring is not in place. The Unit Manager will report her findings to the Director of Health Services and the Administrator. The Administrator is responsible for attaining and maintaining compliance with this regulation. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of pattern and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, due to all staff having not been in-serviced and sustained compliance had not been verified by the State Agency. #

This citation pertains to Intake Number MI 417. Based on observation, interview, and record reviews the facility failed to ensure facility staff followed the standards of practice and facility policy regarding diabetic blood sugar monitoring and assessing dehydration in 1 of 5 sampled residents (Resident #101), from a total of 5 sampled residents, resulting in allowing changes in blood sugar and hydration to go un-noticed from [DATE] (date of admission) until [DATE] when Resident #101 became unresponsive, was hospitalized , and died on [DATE]. Findings include: According to "Laboratory and Diagnostic tests with Nursing Implications", (Kee, L., 6th Edition, 2002, pg. 199), Regarding Blood Glucose Levels, "Reference values - adult serum and plasma: (Normal) ,[DATE] mg/dL, panic value: (less than) <40 mg/dL and/or (greater than) >700 mg/dL". According to the "Executive Summary: Standards of Medica Care in Diabetes - 2011" (American Diabetic Association, Diabetic Care; Volume 334, Supplement 1, [DATE]), Regarding diabetic care, "All patients with diabetes should have their diabetes clearly identified in the Medical Record. All patients with Diabetes should have an order for [REDACTED]. According to "Diabetes Control", Volume 35, Supplement 1, January, 2012, Severe [MEDICAL CONDITION] in a person with Diabetes could be the result of an intercurrent illness or inadequate or missed medication. treatment of [REDACTED]. According to Mayfield J.A., Partha D., and Potter D.E.B., (no date), Diabetes and Long-Term Care, Chapter 28, pg. 582, "Glucose monitoring, performed by the resident or nursing staff, is fundamental to appropriate glycemic control and early recognition of [DIAGNOSES REDACTED] or [MEDICAL CONDITION]". According to Laboratory and Diagnostic Tests (Kee, 6th edition, 2002), an elevated BUN (Blood Urea Nitrogen- evaluates kidney function) level could be an indication of dehydration, pre-[MEDICAL CONDITION], or [MEDICAL CONDITION]. If both BUN and Creatinine are elevated, kidney disease should be highly suspected. The signs and symptoms of fluid volume deficit and dehydration include: 1) from 2%-20% loss body weight, 2) headaches and dizziness, lethargy, confusion, and disorientation, 3) sunken dry eyes, 4) sticky, dry mucous membranes, 5) low blood pressure, 6) hyperactive bowel sounds with diarrhea, 7) decreased body temperature, 8) dry, flushed, cold, clammy, decreased elasticity of the skin, and 9) dark colored urine with an increase in concentration. (Fundamentals in Nursing, Potter & Perry, 2005, pgs. ,[DATE]). The Clinical Process Guidelines for Maintaining Hydration and Electrolyte Balance indicate that when staff and practitioners identify situations where an individual's hydration is at risk or may be impaired, they should seek additional information such as current or subsequent changes in food or fluid intake, the level of consciousness, mental status, urine output, or rapid or sudden changes in body weight. For hydration, the amount and rate of weight change are relevant, 1 liter of fluid = 1 kilogram = 2.2 pounds. (MDCH, [DATE]) Review of Carbohydrate Controlled Diet Policy, approved ,[DATE], revealed the policy was "to provide liberalization of diet to guests with Type I and Type II Diabetes Mellitus, or altered glucose function. Goals for the Carbohydrate Controlled Diet Policy were 1. Blood glucose levels will be controlled. 2. Guest will have liberalized diets. Procedure for the Carbohydrate Controlled Diet Policy were 1. Guests admitted with [DIAGNOSES REDACTED]. M. (Diabetiks Mellitus) will be placed on a Carbohydrate Controlled Diet upon admission...3. Accu checks will be taken by nursing two times per day, in the am and pm, for one week and recorded on the MAR...". Review of the facility Face Sheet and Minimum Data Set (MDS), dated [DATE], revealed Resident #101 was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #101 was moderately cognitively impaired for daily decision-making skills and had short-term memory problems. In an interview on [DATE] at 11:30 AM, General Manager in Training #2 stated she could not comment on the Carbohydrate Controlled Diet Policy in relation to Resident #101 because she "did not look at it at the time". General Manager in Training #2 stated the physician saw the [DATE] labs because his signature was on them, but since no time or date was noted she could not tell this surveyor when the physician was made aware of the high Hemoglobin A1C of 8.40 % (normal 4.00 - 6.00 %) or the Glucose of 397 mg/dL. In a second interview on [DATE] at 10:30 AM, General Manager in Training #2 stated the only note on the physician's log for Resident #101 was on [DATE] in regard to "hitting" and that there were no other notations for Resident #101 made to the physician. In interviews on [DATE] at 3:36 PM and [DATE] at 7:40 AM, Director of Health Services #3 stated she was not aware of the Carbohydrate Controlled Diet Policy and the stipulation to do accu check twice a day for Type I or Type II diabetics. In an interview on [DATE] at 12:00 PM, Registered Nurse (RN) #8 (agency nurse) reported that she assisted with Resident #101's admission assessment on [DATE]. RN #8 stated that she was shown the location of the policy and procedure books, was oriented to the physical layout of the facility, and was then immediately given her assignment to begin. RN #8 stated that she did not have time to review the policies and procedures, and was unaware of a policy and the need to monitor the blood glucose levels of residents on carbohydrate diets. Review of the Physician Admission Order Sheet, dated [DATE], revealed Resident #101 was ordered a carbohydrate counting diet with no added salt. Review of the Diabetes Care Plan, dated [DATE], revealed Resident #101 had orders for an oral diabetic medication and that staff were to maintain Resident #101's blood sugar level between ,[DATE] and prevent crises from the inadequate control of diabetes mellitus ([DIAGNOSES REDACTED], [MEDICAL CONDITION]). Interventions for Resident #101 included being on a carbohydrate controlled diet. Review of the Laboratory Data collected [DATE] at 6:15 AM, first reported [DATE] at 1:59 PM revealed High results of Hemoglobin A1C of 8.40% (normal 4.00 - 6.00 %) (a blood test used to determine how a person with diabetes controls their blood sugar, if the range is above 8% the test shows that the diabetes is poorly controlled, (MedicineNet.com [DATE])), Glucose 397 mg/dL (normal ,[DATE] mg/dL) (sugar in the blood), and BUN (Blood Urea Nitrogen) 25.5 mg/dL (normal 1XXX,[DATE].5 mg/dL) (marker of kidney functions). In an interview on [DATE] at 2:43 PM, Physician's Assistant (PA) #19 stated that typically every patient with diabetes mellitis get accu check to monitor blood sugar. PA #19 stated that she was not sure if they were aware of the laboratory results, dated [DATE], for Resident #101. Review of the Interdisciplinary Progress Notes dated [DATE] at 10:00 PM, revealed a late entry for [DATE] on the 7P-7A shift by Registered Nurse (RN) #21. The Interdisciplinary Progress Notes revealed, "guest (Resident #101) observed to be lethargic; he can slightly move his arms and legs but does not respond to any question. 9 PM medications held, guest unable to take meds. vitals signs are BP ,[DATE], P 132, R 20, T 98.0. At around elevenish ....guest (Resident #101) non responsive. Vital signs taken BP ,[DATE], P 146, R 20, T 98.2. MD paged; message regarding guest's (Resident #101's) condition left on voice mail. Pulse palpable bilaterally; guest (Resident #101) appears to breath rapidly. MD called back, new order received to check vital again in an hour and to call with results. MD requested the guest (Resident #101) code status. Guest reassessed frequently; vital signs are: BP ,[DATE], P 142, R 22, T 98.0. MD ordered to keep checking on guest (Resident #101). He called around 6:30 AM and stated that the PA (physicians assistant) will be coming soon in AM to follow up on guest (Resident #101) condition". In interviews on [DATE] at 2:20 PM, [DATE] at 12:55 PM, and [DATE] at 12:00 PM, RN #5 was asked how the facility would achieve the goal for the Diabetic Care Plan, which was to maintain Resident #101's blood sugar levels between ,[DATE] (mg/dL). RN #5 stated she did not know how the facility would know if this goal was achieved if Resident #101's blood sugar was not monitored through accu check testing. RN #5 stated there was no accu check testing on Resident #101 until [DATE] (day transferred to hospital). RN #5 stated she did not know about the lab report completed [DATE] with a Hemoglobin A1C of 8.40% and Glucose 397 mg/dL until [DATE], and was unable to verify if and when the information in the [DATE] lab report was reported to the physician. RN #5 stated she was not aware of Resident #101's change of condition on the 7P-7A shift on [DATE] until [DATE] after PA #19 was at the facility. RN #5 stated she was not aware of the Carbohydrate Controlled Diet Policy approved ,[DATE]. Review of the Medication Administration Record (MAR), dated ,[DATE], revealed that there were no blood sugar levels recorded for Resident #101 from [DATE]-[DATE]. Review of lab documentation reveals the blood sugar results for Resident #101, which were called to the facility on [DATE] at 9:00 AM, were 641 mg/dl. Review of the Daily Nurse's Note, dated [DATE] at 1:00 PM, revealed Resident #101 was "found hot to the touch and sweaty, BS (blood sugar) reported 561 by lab, Physician Assistant (PA) at the facility - received 12 units of regular insulin and 6 units of regular insulin later in AM, BS continues to read high on glucometer, wife and daughter aware, do not want hospitalization at this time. Guest non-responsive at this time in bed." Review of the Blood Glucose Monitoring System User Instruction Manual (no date) revealed if the blood glucose is above 600 mg/dL, you will receive a "Hi". Review of the Interdisciplinary Progress Notes, dated [DATE] at 4:30 PM, documented as "additional information for [DATE]" revealed RN #8 documented at 11:00 AM that she received report on Resident #101. RN #8 documented, "Status had decreased since admission. Last accu check registered "HI" on glucometer. Re-checking to see if status changes. 12:00 PM, accu check still reading "HI". 6 units Novulink ([MEDICATION NAME] - regular insulin) given per PA's orders. 2:,[DATE]:00 PM wife calls and states she is going to hospital. Wife told guest is not at the hospital. To clarify phone conversation with wife, daughter's number obtained. Daughter states she wants her father to be transferred to (name of hospital) to "get his blood sugars under control". 4:00 PM, guest remains unresponsive. VS (vital signs) 97.3 - ,[DATE]-,[DATE]-90%. Blood sugar "HI". 4:15 PM (name of ambulance) here for transport." Review of the Ambulance Run Sheet, dated [DATE], revealed at 4:13 PM the Emergency Medical Technicians (EMT's) were dispatched to the facility and, upon arrival, found Resident #101 "had been unresponsive since 9 AM. Pt (patient) lying in bed with agonal (an extremely serious medical sign requiring immediate medical attention) respirations. Extremely warm to the touch. Blood glucose continued to run 'High'. Transported Priority 1 to hospital". Resident #101's primary signs and symptoms were documented as "[MEDICAL CONDITION]". Review of the Emergency Department report, dated [DATE] at 4:50 PM, revealed Resident #101 had been unresponsive for 8 hours, had a rectal temperature of 101.8 degrees Fahrenheit, a pulse of 135 (normal pulse rate 60 - 100 beats per minute), and a respiratory rate of 32 (normal breaths per minute ,[DATE]). The report indicated Resident #101 was "sent in from nursing home for non-responsiveness and increased BS (blood sugars) - unsure of code status. Patient has been like this for whole day". Clinical impression was documented as "[MEDICAL CONDITION], a-fib ([MEDICAL CONDITION] -irregular heart beat),[MEDICAL CONDITION]." Resident #101 was admitted to the hospital. Review of the Hospital Discharge Summary, dated [DATE], revealed Resident #101's discharge [DIAGNOSES REDACTED].com, [DATE]). Review of the Certificate of Death, dated [DATE], revealed Resident #101 died on [DATE] at 10:04 AM while in the hospital. Cause of death was listed as [MEDICAL CONDITION] - hours, Pneumonia - days, Hyperosmolar Diabetic Coma - days which, according to the death certificate, led to Resident #101's [MEDICAL CONDITION]. In interviews on [DATE] at 3:25 PM and [DATE] at 9:35 AM, Dietary Manager (DM) #4 stated Resident #101 was a high risk for dehydration and was receiving 4 ounces of fluid 4 times a day from nursing, which is the minimum amount of fluid Resident #101 is supposed to get. DM #4 stated fluids are documented on the food acceptance record by the Certified Nursing Assistants (CNA) and the nurses record the 4 ounces of fluid in the Medication Administration Record (MAR). DM #4 stated the last time she monitored Resident #101 was [DATE] and she would wait a week before reassessing, unless staff told her he was not eating. Review of the Hospital Admission Assessment, dated [DATE] at 10:15 PM, revealed Resident #101's weight was measured at 83 kg, a loss of 5 kg or 11 lbs. since admission to the facility on [DATE] (seven days). In an interview on [DATE] at 10:10 AM, LPN #12 stated that on [DATE] she was doing rounds with the physician, who stated Resident #101 looked to be dehydrated and he wrote an order for [REDACTED].#101 was sleeping and the physician did not wake Resident #101 when they went into his room. LPN #12 stated lab results are faxed to the facility unless it is a critical value, and day shift tries to look over the labs, but at times has to pass it on to the next shift. In an interview on [DATE] at 10:50 AM, CNA #17 stated on [DATE] she could not get Resident #101 awake at all that day. CNA #17 stated Resident #101 was still sleeping at lunch, she checked him for incontinence and he was not wet and did not wake when he was rolled side to side while she checked him. CNA #17 did not recall if she notified anyone, but nursing staff and family had been in Resident #101's room during the day. In an interview on [DATE] at 4:10 PM, CNA #20 stated that on [DATE] she got Resident #101 up to eat supper and he fell asleep in his plate. CNA #20 stated Resident #101 had been sleepy all day on [DATE]. Observations on [DATE] from 11:00 AM to 12:00 PM and at 3:00 PM, on [DATE] at 9:00 AM, 10:00 AM, on [DATE] from 7:30 - 8:30 AM, 3:10 PM, on [DATE] at 9:15 AM, on [DATE] at 11:00 AM while in the facility, revealed residents receiving medication pass, on the unit in activities, or in their rooms while watching television, reading, sleeping, or visiting. Water was noted at bedsides and residents were asked to demonstrate that it was within reach. Review of the Medication Administration Record revealed that diabetic residents were tested 4 times a day. #

Complaint Intake Numbers: MI 858 & MI 014 Based on observation, interview, and record review the Facility failed to ensure adequate and appropriate supervision and assistive devices for 2 of 3 residents who fell (#101 & #102) in the sample of 3 resulting in actual harm (#101-fractured rib, #102-fractured pelvis). Findings include: Resident #101 Per the Incident Report dated [DATE] Resident #101 was found sitting on the floor in his bathroom with his trunk against a shower chair. Resident #101 used his "walker without assistance" and did not call for help. Reddened areas were noted to his left lateral back and an x-ray was obtained on [DATE] which noted a fractured rib. The plan of correction was to remove the walker from his room. Per the Emergency and Pre-Hospital Documentation dated [DATE] Resident #101 was involved in a motor vehicle accident and sustained fractures to his left tibia and left fibula (lower leg bones). Per the face sheet dated [DATE] Resident #101 was admitted to the facility on [DATE]. Per the Nurses' Notes dated [DATE] Resident #101 sustained fractures to the tibia and fibula (lower leg bones) in a motor vehicle accident and was admitted to this Facility after surgical repair to the the fractures. Per the Nurses' Notes dated [DATE] Resident #101 was still wearing an immobilizer (removable brace/splint) on his left leg and was not allowed to bear any weight on his left leg. In a telephone interview on [DATE] at 11:02 a.m. LPN #15 said on [DATE] she was "called to" Resident #101's room by a nurse aide. LPN #15 said Resident #101 was sitting on the floor in his bathroom with "his back towards a shower chair that was opposite of the toilet. He said he was going to the bathroom and lost his balance. He had a scrape to his left lateral back. He did not complain of pain then but because of the scrape I called the Doctor and asked for an order to get an x-ray." LPN #15 said Resident #101 had walked to the bathroom with a walker but he "was not supposed to be up walking. He used a walker with therapy. We (nursing) did not ambulate him. I took the walker out of his room. I let therapy know not to leave the walker in his room." In an interview on [DATE] at 12:55 p.m. Therapy Program Manager PTA #18 said Resident #101 was able to transfer using his walker with constant cueing not to bear weight on his left leg at the time he fell on [DATE]. PTA #18 said nursing staff were given instructions on how to ambulate Resident #101 so that he hopped and used the walker without bearing weight on his left leg. PTA #18 said Resident #101 was not capable of walking without supervision and his walker "was supposed to be folded and stored in his closet when staff was not using it to transfer him." PTA #18 said Resident #101 was not allowed to walk with the walker "since he broke his rib." Per the Therapy Progress Summary Notes "for the period [DATE] to [DATE]" Resident #101 "made no progress this week...has no carry over of any safety instructions due to dementia...At this time pt is able to ambulate 150 x 3 feet with standard walker and contact guard assist and walks to dine with staff with occasional cueing for walker placement but cannot be independent again due to his cognition level..." In an observation on [DATE] at 12:15 p.m. Resident #101 was seated in a wheelchair at the dining table and was wearing a personal fall alarm. Resident #101 said he did not remember how he got hurt and indicated he had a "sore rib right there. It is just a little tender." Resident #101's table-mate reminded Resident #101 he had fallen and broke his rib. ( ) Resident #102 Per the Incident Report dated [DATE] Resident #102 "while self transferring from his bed to use his urinal lost his balance" and was found on the floor. X-rays were obtained and revealed a "non-displaced fracture of the right pubis ramus (pelvic bone)." Resident #102 was sent to the hospital. Per the hospital Discharge Summary dated [DATE] Resident #102's condition was deemed too poor to withstand surgery to repair the pelvic fracture and during this hospitalization Resident #102 suffered an acute myocardial infarction (heart attack). Per the hospital Discharge Summary dated almost a month earlier on [DATE] Resident #102 had fallen and sustained a hip fracture which was surgically repaired. Per the Minimum (MDS) data set [DATE] Resident #102 had significant cognitive deficits (score of 7 out of a possible 15); he required extensive assistance with transfers; he was unable to walk; he required extensive assistance with toileting, personal hygiene and dressing; and his [DIAGNOSES REDACTED]. Review of the Nurse Aide Care Plan dated [DATE] revealed Resident #102 was identified as at risk of falls and interventions included a bed and a chair alarm. Per Resident #102's Nurses' Care Plan (not dated) "problem" of "High risk for falls related to new left hip repair secondary to a fall" an intervention dated [DATE] instructed staff to provide a sensor alarm to Resident #102's bed and to his chair. Per Resident #102's Treatment Administration Record (TAR) dated [DATE] and the TAR dated [DATE] Licensed Nurses documented Resident #102 was "Position(ed)...every 2 hours while in bed. Review of the Facility's summary of staff activity while they were observed and recorded by surveillance cameras revealed the following activity: [DATE] at 9:51 p.m. Resident #102's call light was activated and a Nurse Aide (not identified) entered his room. The Aide was "out by 9:57." [DATE] at 10:16 p.m. a nurse went in and exited Resident #102's room at 10:20 p.m. [DATE] at 12:19 a.m. staff provided fresh ice water. [DATE] at 2:13 a.m. (2 hours later) a nurse entered the room "for a few seconds." [DATE] at 7:29 a.m. (more than 4 hours later) Nurse Aide #11 "checked on him in room for 20 seconds." Six minutes later (at 7:35 a.m.) Nurse Aide #14 was filmed walking out of the room across the hall from Resident #102's room and going into Resident #102's room; she then came out and "went to get a nurse." In 2 minutes (7:37 a.m.) Nurse #15 and Nurse Aide #11 were recorded re-entering Resident #102's room. In an interview on [DATE] at 2:34 p.m. Nurse Aide #11 said on [DATE] at 7:29 a.m. she checked on Resident #102 and offered assistance with toileting. Nurse Aide #11 said Resident #102 was "in bed sleeping. He was covered up and the call light was pinned to his blanket. He said he didn't want to get up. I said 'OK-I'll come back' and answered a call light across the hall." Nurse Aide #11 said she did not know if Resident 102 had a fall alarm in place at 7:29 a.m. however when she cared for him "a couple of days before" there was no fall alarm used. Nurse Aide #11 said a few minutes later she "heard someone yelling 'help'" and saw staff members "running. I followed" and entered Resident #102's room. Nurse Aide #11 said Resident #102 was lying on the floor beside his bed. Nurse Aide #11 said there was no fall alarm sounding. Nurse Aide #11 said inspection revealed there was no fall alarm on Resident #102's bed or chair and no fall alarm was seen anywhere in Resident #102's room. Nurse Aide #11 said the Facility had no system whereby fall alarms were checked at the change of shift to ensure the alarms were in place and were functioning. Nurse Aide #11 stated, "I know who has them and I check them." Nurse Aide #11 stated she "did not know" Resident #102 was supposed to have a bed alarm. Nurse Aide #11 said she had not read the Nurse Aide Care Plan. Nurse Aide #11 said she "had not had him and I had been off so I didn't know" Resident #102 was supposed to have a fall alarm on his bed and in his chair. In an interview on [DATE] at 10:20 a.m. Nurse Aide #14 said on [DATE] she was in another resident's room when she heard Resident #102 "yelling 'Hey!' I went in his room. There was no alarm sounding. He was on the floor on the side of his bed on his right side. His head was toward the foot of his bed. It was like he sat up in bed and fell out. I don't recall seeing an alarm (on Resident #102's bed). I ran out" and found LPN #15. "I ran back and put a pillow under his head. I left to care for another resident who was in the bathroom. (Resident #102)'s alarm was not sounding. I didn't return to his room. I only work 3 to 4 times a month. I don't recall" whether Resident #102 was supposed to use "an alarm or not." Nurse Aide #14 said she did not read the nurse aide care plan; she learned what residents required from the nurses and nurse aides. "We all meet" at the change of shift and "see what's been done." In an interview on [DATE] at 10:48 a.m. LPN #15 said on [DATE] she was "called out of report" to Resident #102's room and saw him "lying on the ground parallel with his bed. His feet were towards the head of the bed." LPN #15 said Resident #102's head and upper body were beyond the foot of his bed while his legs and lower trunk were alongside the bed. LPN #15 said no alarm was sounding and no alarm was found on Resident #102's bed or on the dresser. LPN #15 said she "scanned the whole room" and did not find an alarm. LPN #15 said Resident #102 was not cognitively or physically able to get out of bed and dispose of an alarm. LPN #15 said the licensed nurses checked alarms were in place and in working order at some time during their shifts and documented such in the Treatment Administration Record however the Facility had no procedure that set a time for checking the alarms (such as at the change of shift). In an interview on [DATE] at 3:26 p.m. Nurse Aide #12 said she was responsible Resident #102 on the night shift that ended at 7:00 a.m. on [DATE]. Nurse Aide #12 said she depended on "word of mouth" for information about the residents and said she "occasionally" read the Nurse Aide Care Plans but had not read any when she came on duty or while she was on duty on the shift that ended at 7:00 a.m. on [DATE]. Nurse Aide #12 said "I believe there is a list" of residents who use fall alarms but admitted she had not checked the list. Nurse Aide #12 said she was "not aware" Resident #102 "had an alarm." Nurse Aide #12 said Resident #102 was "in bed asleep" when she came on duty. Nurse Aide #12 said she "went in" Resident #102's room "one time-maybe two" during her shift. When informed that no nurse aide was recorded by the surveillance camera entering Resident #102's room after the ice water was delivered at 12:19 a.m. Nurse Aide #12 evidenced surprise. In a written statement of a phone interview dated [DATE] Nurse Aide #12 said, "I cannot recall if he (Resident #102) ever had a bed alarm." In an interview on [DATE] at 11:37 a.m. Nurse Aide #16 said she assisted Nurse Aide #12 to deliver fresh ice water to Resident #102's room on [DATE] at 12:19 a.m. and "would have noticed it" had she looked for an alarm. Nurse Aide #16 said she did not check for an alarm. Nurse Aide #16 said Resident #102 was in bed sleeping when she delivered the fresh water with Nurse Aide #12. Nurse Aide #16 said she did not recall seeing Nurse Aide #12 check for a fall alarm on Resident #102's bed. In a written statement of a phone interview dated [DATE] Nurse Aide #16 said, "I cannot recall if he (Resident #102) had a bed alarm prior to his fall however I have answered his bed alarm in the past three weeks." In an interview on [DATE] at 11:48 a.m. Nurse Aide #17 said she knew the "chair alarm was there when I put (Resident #102) to bed" on the evening of [DATE]. Nurse Aide #17 said she did not recall "actually seeing a box" and knew there was no alarm on Resident #102's bed when she put him to bed. Nurse Aide #17 said she knew there was a "care plan in the charting book" but she "did not read it that day." Nurse Aide #17 said she did not read the care plans if there was "no new admits that day. I have the same section every day." Nurse Aide #17 said Resident #102 did not use a bed alarm when she was on duty. Nurse Aide #17 said she and Resident #102 "had a good relationship" and "he'd push the call light for me." When informed that no alarm was found on Resident #102's bed or his chair or anywhere in his room and no staff member was recorded by the surveillance camera taking an alarm out of his room Nurse Aide #17 repeated her statement that there was an alarm in Resident #102's wheelchair. In a written statement dated [DATE] RN #19 said on "the 10th/,[DATE] (sic) the bed alarm was on and functioning. At one time during the shift it went off when guest was trying to get out of bed." RN #19 was identified as the nurse on the video recording from the surveillance camera who entered Resident #102's room on [DATE] at 2:13 a.m. In an interview on [DATE] at 2:25 a.m. RN #19 was informed she was recorded by the surveillance camera entering Resident #102's room only one time during her shift which ended at 7:00 a.m. on [DATE]. RN #19 said she entered Resident #102's room at 2:13 a.m. in response to "hearing an alarm." RN #19 said she found Resident #102 "trying to use his urinal. I might have helped him"and then left the room. RN #19 was asked to explain how she could have heard Resident #102's alarm sound at 2:13 a.m. when no alarm was found when he fell and she was the last person recorded by the surveillance camera entering Resident #102's room before Nurse Aide #11"checked on" Resident #102 at 7:29 a.m.-just moments before he fell and neither she nor Nurse Aide #11 were seen on film carrying an alarm (removing it from Resident #102's room). RN #19 said she must have "heard something" which prompted her to enter Resident #102's room at 2:13 a.m. on [DATE]. RN #19 said she might be remembering another night when she saw his alarm "on and functioning." RN #19 admitted she did not check Resident #102's bed alarm was on his bed and in working order as she had documented on the Treatment Administration Record. During the interview on [DATE] at 2:25 p.m. RN #19 was informed that shortly before interviewing RN #19 this Surveyor and the Administrator stood outside the room that had been occupied by Resident #102 on the night in question. The Administrator said the now empty bed was positioned where it had been on the night in question. From the corridor this Surveyor was unable to see the bed except for a small portion of the foot of the bed. The Administrator agreed she could not see the bed except for the end of the bed. RN #19 said when residents were sleeping she did not go into their rooms and disturb them. RN #19 admitted she did not go into Resident #102's room and reposition him every two hours on her shift as she had documented on the Treatment Administration Record. Per the Nurses' Notes dated [DATE] Resident #102 was discharged to an assisted living facility for hospice care. Per the death certificate Resident #102 expired on [DATE]. The cause of death was "Acute Myocardial Infarction." ( )