Every finding on record at Evangelical Home - Saline

Based on observation, interview, and record review, the facility failed to treat each resident with dignity and respect for one resident (R1) of three residents reviewed. Findings include: Review of the clinical record revealed R1 was admitted into the facility on 2/16/26 with diagnoses that included: lymphedema, morbid obesity, chronic pain, and age-related osteoporosis without current pathological fracture. According to the Minimum Data Set (MDS) assessment dated [DATE], R1 scored 15/15 on the Brief Interview for Mental Status exam (which indicated intact cognition).On 6/10/26 at approximately 12:45 PM, during an interview with R1, when asked about therapy services, it was reported that is a sore spot with me and described an interaction with Physical Therapist (PT) J where he told her that she didn't want to stand, he became upset with her and told her she just wanted someone to blame for not being able to stand. R1 reported that this upset her and that she had notified the facilities administrator via email but never heard back from her.R1 reported that her family friend (FF) K and family member (FM) L also expressed concerns to facility leadership about how she had been treated by PT J. In review of potential verbal abuse, when R1 was asked if she felt her interactions with PT J were expressed as verbal abuse, R1 stated I saw it that way.On 6/11/26 at 12:15 PM, during an interview with FF K it was reported that the concerns related to how R1 had been treated by PT J were relayed to the facility as concerns of verbal abuse. FF K stated, it was callous and insulting to (name of R1).A review of the Grievance Form provided by the facility revealed an attached, typed letter from FM L which stated On 2/20, (R1) called me. She was extremely upset. The physical therapist (PT J) had (R1) sit on the edge of the bed and do leg kicks then told resident to stand without assistance or equipment which she was unable to do. This had gone on for several days.The grievance form continued: (Name of R1) asked (PTJ) what she could do to improve. Told by (PT J) that she just didn't want to, that she was looking for someone to blame. (R1) described her contact with this physical therapist as verbally demoralizing and rude. R1 requested a different physical therapist. On 2/23 I called (facility name redacted). I requested to speak with case manager, social worker and head of PT. I received a call back from the nurse caring for (R1) that day. I explained my concerns. I stated I still wanted to speak with social worker, case manager and head of PT. I did not receive any call backs.On 6/12/26 at 11:45 AM, during an interview with PT J it was reported that R1 had been transitioned to a different therapist per her request but PT J was not sure why. PT J reported that nobody from leadership spoke with him regarding concerns that R1 had and he was surprised that he had been removed from her care.On 6/11/26 at 1:20 PM, during an interview with Therapy Director F, it was reported that he was aware of a concern expressed by R1 when she initially came in but he was unsure exactly what it was, I think it was a personality conflict.On 6/11/26 at 1:55 PM, during an interview with Unit Manager (UM) G, it was reported that R1 had said something to her about the therapy staff not being patient with her and felt like they were telling her that she wasn't trying.On 6/11/26 at 3:01 PM, during an interview with DON B, it was reported that the expectation would be that if it had been reported that a staff member had been verbally demoralizing and rude that it would be that they should move forward with getting more information, ask the resident how did it make you feel, it would prompt an investigation so that they feel safe and are in a safe environment. On 6/11/26 at 3:26 PM, DONB stated that both NHA A and UM G had copies of the grievance letter from FM I, but they reported not reading it word for word.There was no documentation that requests to speak to social worker, case manager and head of PT was honored on behalf of the resident regarding the filed grievance.

Based on observation, interview and record review, the facility failed to notify resident representative of a change of condition, in a timely manner for one resident (R3) of three reviewed. Findings include:This citation pertains to intake 3022365.Review of the clinical record revealed R3 was admitted into the facility on [DATE] with diagnoses that included: olecranon bursitis-right elbow (inflammation of the fluid-filled sac at the tip of the elbow), encounter for surgical aftercare and need for assistance with personal care. According to the Minimum Data Set (MDS) assessment dated [DATE], R3 scored 13/15 on the Brief Interview for Mental Status exam (which indicated intact cognition). On [DATE] 2:26 PM, during a telephone interview with Family Member (FM) I, it was reported that her father had passed on 5/20, after experiencing a change of condition (low blood pressure) around 11pm on 5/19. FM 'I reported not being called when R3 began to decline and was not notified of his passing until after the body had already been sent out of the facility. FM I reported that the spouse of R3 was notified of his death by the police knocking on her door, which she described as traumatic since the spouse was alone and they were not expecting him to pass. FM I reported that she spoke with the director of nursing (DON) about her concerns related to how the family was notified of R3's passing, about not being able to view the body before it was removed from the facility, not being able to properly say good bye, and not being notified when his condition changed prior to his passing. FM I reported that the DON told her that she wasn't notified of the change of condition because she wasn't the resident's durable power of attorney. FM I added that the facility had called her in the middle of the night on a separate occasion to inform her R3 had fallen, since she was listed as the first emergency contact person which contradicted what the DON had told her. A review of R3's progress notes revealed LPN N documented on [DATE] at 9:19 AM, Resident noted a decline in condition throughout shift. Writer observed resident with labored breathing and breathing with mouth open at approximately 0315. Lung sounds assessed and noted to have abnormal breath sounds/crackles. Resident continued to have shallow respirations throughout shift and was monitored closely. Writer paged Dr. and was preparing a transfer to hospital and contact (name of ambulance service redacted). At approximately 0540, resident found unresponsive in bed. No response to verbal or sternum rubs. Charge nurse notified immediately and code blue initiated at approximately 0541. CPR/compressions initiated per facility protocol and 911 called. Oxygen provided by ambu bag during CPR efforts. Resident remained unresponsive despite emergency interventions. Time of death pronounced at 0623 by EMS. Physician, DON, police, and appropriate parties notified. Family/emergency contact notified per policy. Writer received verbal order from Dr. at 0803 to release body to funeral home. Body released per physician order and facility protocol.Several attempts were made to contact LPN N during the week of survey however; no contact was made prior to survey exit.On [DATE] at 11:34 AM, during an interview with DON, it was reported that she did not know what time the family was notified of the change of condition or death. When asked why the family was not allowed to view the body prior to it being sent out, DON reported it was because the medical examiner had already called for the resident's body to be removed and that when the police contacted the spouse, the family did not indicate which funeral home they preferred. DON confirmed that FM I was upset that R3's spouse was alone when she was told of his passing and that she was not informed by the facility. DON reported that she could not answer why the family was not notified of the change in condition that occurred at approximately 3am (as indicated in LPN Ns progress note) and that the expectation would be that the family would be called.A review of the facilities policy titled Notification of Changes Policy, documented in part The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notified, consistent with his or her authority, resident's representative when there is a change requiring notification.The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. The change in condition, as well as all before mentioned notifications, must be documented in the resident's medical record by assigned nurse unless otherwise designated.Circumstances requiring notification include:.Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-threatening conditions, or b. Clinical complications.Competent individuals:a. The facility must still contact the resident's physician and notify resident's representative, if known. A family that wishes to be informed would designate a member to receive calls. c. When a resident is mentally competent, such a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant affecting 108 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.Findings include:On 01/27/2026 at 3:50 P.M., An environmental tour of the facility Laundry Service was conducted with Environmental Service Manager V. The following items were noted:Clean Laundry Room: The flooring surface was observed (etched, scored, particulate). The flooring surface measured approximately 22-feet-wide by 24-feet-long. Environmental Services Manager V stated: I will enter a maintenance request into WorxHub.Soiled Laundry Room: The flooring surface was observed with black electrical tape adhered to the surface. The black electrical tape measured approximately 4-inches-wide by 60-inches-long. The flooring surface wall/floor junctures and entrance door frames were further observed soiled with accumulated and encrusted dust/dirt deposits.On 01/28/2026 at 10:40 A.M., An environmental tour was conducted with Environmental Services Manager V. The following items were noted:B-Hall/C-Hall Cut-ThroughClean Linen Room: 1 of 2 overhead light assemblies were observed non-functional.D-HallClean Linen Room: The [NAME] Silex microwave oven interior door face plate was observed (etched, scored, bubbled, chipped, corroded), exposing the inner metal surface. The damaged area measured approximately 0.5 inches wide by 3-inches-long. Environmental Services Manager V indicated she would have staff remove and replace the microwave oven as soon as possible.Redies SouthClean Linen Room: 2 of 4 overhead light assemblies were observed non-functional.Chapel: One 24-inch-wide by 24-inch-long acoustic ceiling tile was observed stained from a previous moisture leak.OT/PT: The laminate wood grain board was observed loose-to-mount on the mobile table. The wood grain board measured approximately 24-inches-wide by 60-inches-long.Entrance Foyer: One overhead light plastic lens cover was observed soiled with accumulated and encrusted dust/dirt deposits. Numerous dead insect carcasses were additionally observed within the plastic lens cover. Environmental Services Manager V indicated she would have maintenance remove and thoroughly clean the plastic lens cover as soon as possible.On 01/27/2026 at 2:50 P.M., The environmental concerns (leaking roof) were reviewed, within resident room D-1-2. Three acoustic ceiling tiles were observed missing. Plastic Vis queen sheeting was also observed protruding from the false ceiling cavity, capturing the leaking roof water into a large plastic gray receptacle. Bath towels were additionally placed strategically to absorb moisture. One taupe colored plastic waste bin was further observed with water approximately two-thirds full. On 01/27/2026 at 3:02 P.M., An interview was conducted with Maintenance Technician P regarding the roof leak, within resident room D-1-2. Maintenance Technician P stated: Maintenance was notified around 2:00 A.M. this morning. Maintenance Technician P also stated: Maintenance Technician Q was notified and came to the facility to funnel the water leak. Maintenance Technician P also stated: We moved the resident from D-1-2 to B-8-1.On 01/27/2026 at 3:08 P.M., An interview was conducted with Maintenance Team Lead N regarding the roof leak, within resident room D-1-2. Maintenance Team Lead N stated: (Contractual Vendor Name) from [NAME], OH has been called and will be onsite at approximately 4:30 P.M. today.On 01/27/2026 at 4:53 P.M., An interview was conducted with Facilities Director R regarding the status of the roof leak, within resident room D-1-2. Facilities Director R stated: (Contractual Vendor Name) is onsite and determined a defective seam was creating ice damming and roofing material buckling. Facilities Director R also stated: (Contractual Vendor Name) placed a temporary patch on the defective area, until warmer temperatures are reached for permanent repair.On 01/27/2026 at 5:05 P.M., An interview was conducted with Facilities Director R regarding the maintenance work order system. Facilities Director R stated: We have the Worx Hub software system.On 01/28/2026 at 1:50 P.M., A common area environmental tour was conducted with Facilities Director R. The following items were noted:Redies North Shower Room: The commode seat was observed loose-to-mount. The commode seat could be moved from side to side approximately 4-6 inches. B-Wing Dining Room Restroom: The overhead light assembly was observed non-functional.Beauty Shop: Two 24-inch-wide by 48-inch-long acoustic ceiling tiles were observed stained from a previous moisture exposure. Facilities Director R stated: I will have staff replace the stained ceiling tiles as soon as possible.On 01/29/26 at 10:00 A.M., Record review of the Policy/Procedure entitled: Environmental Services Inspection dated 5/27/2021 revealed under Policy Statement/Purpose: It is the policy of this facility to regularly monitor environmental services to ensure the facility is maintained in a safe and sanitary manner and assessed on a regular basis.On 01/29/26 at 10:15 A.M., Record review of the Policy/Procedure entitled: Routine Cleaning and Disinfection dated 5/27/2021 revealed under Policy Statement/Purpose: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible.On 01/29/26 at 10:30 A.M., Record review of the WorxHub Maintenance Work Orders for the last 60 days revealed no specific entries related to the aforementioned maintenance concerns.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment affecting 108 residents who consume food, resulting in the increased likelihood for cross-contamination and bacterial harborage.Findings include:On 01/27/2026 at 10:25 A.M., An initial tour of the food service was conducted with Director of Dining Services S. The following items were noted:Two 16-inch fry pans were observed (etched, scored, particulate). One of two 16-inch fry pans were also observed out-of-round.Four 8-inch non-stick fry pans were observed (etched, scored, particulate). An interview was conducted with Director of Dining Services S regarding employment longevity. Director of Dining Services S stated: I have only been here since November 17th.The 2022 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened.The clear plastic handled scoop was observed stored internally resting directly upon dry food product (Panko-Breadcrumbs), within the dry food storage bin. An interview was conducted with Director of Dining Services S regarding proper food scoop storage. Director of Dining Services S stated: The general practice is to store the scoop on the inside hanger.The 2022 FDA Model Food Code section 3-304.12 states: During pauses in FOOD preparation or dispensing, FOOD preparation and dispensing UTENSILS shall be stored: (A) Except as specified under (B) of this section, in the food with their handles above the top of the food and the container; (B) In food that is not time/temperature control for safety food with their handles above the top of the food within containers or equipment that can be closed, such as bins of sugar, flour, or cinnamon; (C) On a clean portion of the food preparation table or cooking equipment only if the in-use utensil and the food-contact surface of the food preparation table or cooking equipment are cleaned and sanitized at a frequency specified under SS 4-602.11 and 4-702.11.Numerous soup cups and saucers were observed stored within a black plastic storage tub, resting on the top surface of a transportation cart non-inverted.The 2022 FDA Model Food Code section 4-903.11 states: (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted.On 01/29/26 at 08:45 A.M., Record review of the Policy/Procedure entitled: Storage of Pots, Dishes, Flatware, Utensils dated 5/95 revised 1/26 revealed under Policies: Pots, dishes, and flatware are stored in such a way as to prevent contamination by splash, dust, pests, or other means.On 01/29/26 at 09:00 A.M., Record review of the Policy/Procedure entitled: Food and Supply Storage dated 5/95 revised 1/26 revealed under Policies: All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Record review of the Policy/Procedure entitled: Food and Supply Storage dated 5/95 revised 1/26 further revealed under Procedures: Dry Storage: (4) Store foods in their original packages. Foods that must be opened must be stored in NSF approved containers that have tight-fitting lids. Label both the bin and the lid. Hang scoop. Scoops may be stored in bins on a scoop holder. The food level must be no closer than one inch below the handle of the scoop.

Based on observation, interview, and record review, the facility failed to revise care plans and maintain accurate care plans for six (R2, R5, R32, R56, R91, and R101) of 22 reviewed. Findings include:Findings Include Resident #56 (R56) Review of the medical record reflected that R56 was admitted to the facility on [DATE]. Diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction affecting the right dominate side, Dysarthria following Cerebral Infarction, Expressive language disorder, major depression, Hearing loss bilateral and chronic instability of right knee. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) revealed R56 had a Brief Interview of Mental Status (BIMS) of 14 (Cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R56 was 1 to 2 people for personal care. During observation and interview on 01/27/2026 at 3:58 PM, R56 was sitting in her wheelchair staring at her TV. R56 had her over the bed table beside her and she did not have anything meaningful to do to help add value to her day. No observation of an activity calendar present, no observation of activities that she could do independently. R56 stated she just has TV, not aware of anything else going on. During observation and interview on 01/28/2026 at 12:00 PM, R56 had finished her lunch and was sitting in her wheelchair parked in front of the TV. No visible activities or items to work on for entertainment. R56 stated she didn't have anything to do but watch TV. Record review revealed R56 had received three short one on one visits during the last 30 days. R56 had received four short activity rounds in the last 30 days. The last life enrichment progress note was dated 10/15/2024. No other progress notes were available to reflect visits, participation, or time spent with R56. AD E stated she was the one responsible for updating the care plans. Record review revealed R56 did not have a one-on-one visit documented for the month of January 2026. Record review revealed R56's care plan has not been updated, revised or new interventions added since 2020, six years ago. Encourage to participate in unit activities. Date Initiated: 12/17/2016 Revision on: 04/15/2020 Observe for decline in mental function and assess for physical cause report to MD Date Initiated: 09/17/2016, Revision on: 03/15/2018 COMMUNICATION: Use R56 preferred name. Identify yourself at each interaction. Face the R56 when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. R56 understands consistent, simple, directive sentences. Provide R56 with necessary cues- stop and return if agitated. Date Initiated: 09/05/2024 Revision on: 01/03/2025 Provide R56 with a homelike environment, Date Initiated: 09/17/2016, Revision on: 02/09/2021 R56 needs supervision and assistance with all decision making. Date Initiated: 09/17/2016, Revision on: 02/09/2020 Keep R56 informed about changes in their care, life at the facility, etc. Date Initiated: 12/10/2019, Revision on: 12/10/2019 Encourage R56 to be as independent as possible and encourage them to be involved in their own care, Date Initiated: 12/10/2019, Revision on: 12/10/2019 Encourage relationships with family and friends, Date Initiated: 12/10/2019 Record review revealed R56's care plan had not been updated to reflect changes in several years and is not getting updated or new interventions added during quarterly assessments or care conferences. Resident #101 (R101) Review of the medical record reflected that R101 was admitted to the facility on [DATE]. Diagnoses of Chronic Respiratory Failure, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Depression, Anxiety and Chronic Pain. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) revealed R101 had a Brief Interview of Mental Status (BIMS) of 14 (Cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R101 was dependent of all personal care. During an observation and interview on 01/28/2026 at 9:18 AM, R101 stated he usually watches TV, there was no activity calendar visible, no activity items that would have been brought into his room for him to do at his leisure, R101 stated that nobody had brought anything in for him to do. During an observation and interview on 01/28/2026 at 11:45 AM, R101 sat up in his bed eating lunch, with the TV on. Record review revealed R101 had not had a one-on-one visit in the last 30 days. R101 had three activity rounds in the last 30 days. Care Plan revealed R101 had no interest to attend OOR group activities. Date Initiated: 02/05/2024 Revision on: 02/05/2024 R101 will continue to enjoy independent activities of choice through review date. Date Initiated: 02/05/2024 Revision on: 04/21/2025 Target Date: 03/22/2026 Compile and provide R101 with materials for independent in-room activity participation. Date Initiated: 02/05/2024 Revision on: 02/05/2024 Encourage and guide R101 to OOR group activities of interest. Date Initiated: 02/05/2024 Revision on: 02/05/2024 Provide and document 1:1 visits, per request. Date Initiated: 02/05/2024. R101's care plan had not been updated for two years to see what this resident may or may not enjoy. Provide and document 1:1 visits - enjoys conversation, dogs, her family, etc. Date Initiated: 04/15/2020 Provide pet visits when available – R56 really loves dogs. Date Initiated: 04/09/2019 Revision on: 04/12/2021 Provide weekly schedules and in-room activity handouts. Date Initiated: 05/30/2020 MOBILITY: staff participation required for mobility. Date Initiated: 01/26/2024, Revision on: 09/16/2024 AP mattress Date Initiated: 09/17/2024 Pressure relieving mattress to bed and pad in wheelchair or RPD, non skid pad below cushion. Date Initiated: 01/26/2024, Revision on: 09/16/2024 Bathe biweekly or PRN, Assess skin at bath and PRN Date Initiated: 01/26/2024 Revision on: 09/16/2024 Assist Dean in developing /Provide Dean with a program of activities that is meaningful and of interest. Encourage and provide opportunities for exercise, physical activity. Date Initiated: 05/08/2024, Revision on: 05/08/2024 If/when Dean needs time to talk, encourage Dean to express his feelings. Date Initiated: 01/29/2024, Revision on: 05/08/2024 Record review revealed R101 is not getting his care plan revised or new interventions added during quarterly assessments or care conferences to reflect any changes Resident #32 (R32) Review of the clinical record, including the Minimum Data Set (MDS) with an Assessment Reference (ARD) date of 11/15/25 revealed Resident #32 (R32) was a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses epilepsy and delayed psychological development. R32 scored 5 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). On 01/27/2026 11:05 AM R32 observed in her room sitting up in bed wearing a gown. The room was dark, no television was on, no radio, no books, puzzles or any type of leisure activity observed in room/bedside. Upon approach R32 was engaged in conversation easily and was very, friendly. On 01/28/2026 at 12:15 PM, R32 was observed sitting up in bed, no television, no radio on, no books or other type of leisure activity observed at bedside. At 1:32 PM R32 was observed sitting in the B unit hallway in her wheelchair. Review of R32's activity assessment dated [DATE] revealed R32 like to watch television, coloring, spend time with friends and family and music by Bon Jovi. Review of R32's activity care plan dated 11/17/25 revealed R32 liked to spend her free time in her room with self directed activities of choice. The care plan was not individualized, it did not include what that activity of choice was, what approaches/interventions should be taken to assist R32, and it did not match the activity assessment. On 1/29/2026 at 9:51 am during an interview with Life Enrichment Director (LED) E reported R32 liked to attend anything and everything if nursing got her up and dressed. LED E further reported R32 was very social and had friends in activities that she regularly would socialize with. R32 needed to be transported by staff to and from the activity room and needed regular reminders of planned activities. LED E offered no explanation why the care plan was not person center and individualized. Resident #5 (R5): Review of the medical record reflected R5 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included vascular dementia, unspecified fracture of lower end of right femur (9/3/25), periprosthetic fracture around internal prosthetic right knee joint (9/3/25) and Alzheimer's. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/16/25, reflected R5 scored three out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R5's Risk for Falls Care Plan reflected an intervention, which was initiated 2/25/24 and revised 1/7/25, that R5 and their Power of Attorney (POA) desired to have R5's bed against the wall to provide more living space and decrease clutter, and the bed height was to be in the lowest position. The same Care Plan reflected an intervention, which was initiated 3/6/23 and revised 1/7/25, that R5's bed was to be kept in a low position at night. An intervention dated 10/31/25 reflected to keep R5's bed in a low position. Additionally, the Risk for Falls Care Plan included an intervention, which was initiated 12/6/24 and revised 1/7/25, to offer and encourage R5 to keep their walker in reach. On 01/29/2026 at 11:28 AM, R5 was observed lying in bed. The bed height was noted to be in a low position. An over-bed table was located at the left bedside. A nightstand and folding chair were observed at the right bedside. A walker was not observed in R5's room. Their bed was not observed to be positioned against the wall. In an interview on 01/29/2026 at 11:52 AM, Director of Nursing (DON) B described that Care Plans were multidisciplinary, and each department updated their part of the Care Plan. The MDS nurses also reviewed and updated Care Plans quarterly, as MDS assessments were completed. Resident #2 (R2) Review of the medical record reflected R2 readmitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD) and vascular dementia. The admission MDS, with an ARD of 11/12/25, reflected R2 scored 14 out of 15 (cognitively intact) on the BIMS. R2's Care Plan, which was initiated 10/18/25, reflected they had Clostridioides difficile (C. diff-a highly contagious bacterium that causes diarrhea and colitis/inflammation in the colon). Interventions on the Care Plan included but were not limited, CONTACT ISOLATION: Wear gowns and masks when changing contaminated linens. Place soiled linens in bags marked biohazard. Bag linens and close bag tightly before taking to laundry. and Disinfect all equipment used before it leaves the room. On 01/27/2026 at 3:07 PM, R2 was observed seated in a chair, in their room. Contact precautions were not noted to be in place for R2. R2's medical record did not reflect active Clostridioides difficile infection, nor that contact precautions were in place. In an interview on 01/29/2026 at 11:52 AM, DON B reported R2 did not currently have Clostridioides difficile. DON B acknowledged R2's Care Plan should have been revised, as there was not an active infection. Resident #91 (R91) Review of the medical record revealed R91 was admitted to the facility on [DATE] with diagnoses that included dementia and major depressive disorder. Review of the Physician's Order dated 1/14/26 revealed an order for Quetiapine Fumarate (antipsychotic medication) 25 milligrams (mg) give one tablet by mouth at bedtime for depression. The medication was discontinued on 1/21/26. Review of R91's care plan initiated 1/12/26 and revised 1/19/26 revealed [R91] uses the psychotropic medications antidepressant and antipsychotic. R91's care plan was not updated to reflect the discontinuation of their antipsychotic medication. In an interview on 01/28/2026 at 12:29 PM, Social Worker (SW) I reported care plans were typically updated within two days to reflect medication changes. SW I agreed R91's antipsychotic had been discontinued and R91's care plans still reflected antipsychotic use. In an interview on 01/29/2026 at 11:03 AM, Director of Nursing (DON) B reported care plans should be updated to reflect medication changes. DON B reported each department was responsible for updating the care plans along with Minimum Data Set (MDS) nurses.

Based on observation, interview and record review, the facility failed to preserve the dignity of two residents (resident #78 and resident # 86) of three residents reviewed. Findings include: Findings Include Resident # 78 (R78) Review of the medical record reflected that R78 was admitted to the facility on [DATE]. Diagnoses of Friedreich Ataxia, Dysphagia, Spinal Stenosis Cervical Region, Major Depression, Anxiety, Sensorineural Hearing Loss Bilateral, Expressive Language Disorder, irritability and anger. The most recent Minimum Data Set (MDS) dated [DATE] with an Assessment Reference Date (ARD) revealed R78 had a Brief Interview of Mental Status (BIMS) of 15 (Cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R78 was dependent of all personal care. During an interview on 01/27/2026 at 11:03, R78 stated they do treat her with respect and dignity, and some don't. R78 stated she had reported it, but nothing is done. R78 stated she had been there a long time and didn't want to make things worse. There are day CNA's and afternoon CNAs are not always nice. R78 had a hard time getting these words out with her disease process. During an interview on 01/28/26 at 12:28 PM, CNA AA stated R78 did not have a communication board, stated she has worked with R78 long enough she can understand most of her words. During an interview and observation on 01/28/26 at 12:30 PM, there was a red binder on the medication cart with R78's name on it labeled reference book. The binder included specific instructions on providing R78 care from getting up in the morning, showering, lotion, teeth brushed, dressed, setting up computer for her to use. Also in this binder was a stress relief exercise suggestions when R78 gets upset. During this interview and observation, LPN BB stated she cannot provide care for R78 due to things R78 said to her, another nurse from another floor comes down here to provide care. During an interview on 01/28/26 at 1244 PM, LPN CC stated she was the one caring for R78 today. LPN CC stated R78 was particular with who and how care is provided. During an interview and observation on 01/28/26 at 1:00 PM, Writer asked permission to go into R78's room, walked in to see CNA AA feeding her lunch, R78 asked this writer to come back in 30 mins so she could finish her lunch. During an interview and observation on 01/28/26 at 2:06 PM, R78 stated she turned on her call light last night, and they came in, turned her light off and left her room. Neither nurse nor CNA provided any care, just left her room. R78 stated many CNAs don't know her or her routine. R78 stated it upset her that she didn't know these staff members, she wants to make sure they are trained to care for her. R78 stated she gets mad at staff when they don't listen to her, she doesn't like to wear her shoes, and they won't let her keep them off. As the day goes on and she gets tired, her speech is harder to understand. Writer asked R78 if she had a communication board in the past. R78 stated she did but staff complained that it took too long to understand her. R78 stated a while back, she told the Social Worker about her concerns. R78 stated staff got burnt out, got a T-shirt for showing up to work, but nothing that would make their job easier. R78 stated management has no idea. During an interview on 01/29/2026 at 12:20 PM, LPN/Unit Manager F stated she had only been in her role for a couple of months. LPN/Unit Manager F stated she was aware of R78 having concerns about the staff caring for her that she doesn't know them, and they do not know her needs. LPN/Unit Manager F stated R78 would refuse to allow staff to care for her if they have not taken care of her before, she has that binder with care instructions on the medication cart. LPN/Unit Manager F stated the binder helps tell staff how to care for her the way she likes it done. Writer asked if R78 still had a communication board so she can communicate with staff, LPN/Unit Manager F stated she had not seen one since she started a couple of months ago. LPN/Unit Manager F stated R78 had a computer that she could communicate by the computer reading her eyes. LPN/Unit Manager F stated R78 was now on hospice and was declining in ways that make it hard for her to communicate, give instructions for her care and to make decisions r/t care with her being her own person, BIMBS of 15. Writer asked if R78 had ever voiced any concerns to her about this in the past, LPN/Unit Manager F stated yes, but hadn't followed up on it with SW and management yet. Writer asked what additional services hospice was providing to R78, assisting with care? LPN/Unit Manger F stated she didn't know what hospice was providing and would call the hospice nurse to discuss this. Writer asked if anyone does any activities with her, LPN/Unit Manager F stated she didn't know, that would be an activity question. LPN/Unit Manager F stated that R78 was declining and had very little control over herself anymore. Writer added that this is why it's a concern for R78, it's the only control she had left, was her care, her food, care and activity. Record review of the grievance log did not reveal this concern had been reported or addressed. Resident 86 (R86) Review of the clinical record, including the Minimum data Set (MDS) dated [DATE] revealed Resident 86 (R86) was an [AGE] year-old male admitted to the facility with diagnoses that include dementia and Parkinson's. R86 scored 3 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). On 01/27/2026 at 10:57 AM, Resident 86 was initially observed for 13 minutes wandering up and down B hall in his wheelchair. R86 was observed to have a line of chocolate dripping down his bottom lip to center of his chin and down his neckline coupled with a toothbrush style mustache. R86 stopped by Licensed Practical Nurse (LPN) D who pointed out to R86 that there was chocolate all over his face. LPN D did not offer to assist R86 in removing the food from his face, of note multiple staff were observed walking by R86, none of which offered to assist R86. At 11:20 am R86 was observed on the B hall same toothbrush mustache and cholate dribble from the bottom lip down his neck. On 01/28/2026 at 12:15 PM, R86 was observed sitting in the atrium area, a large ring of chocolate was observed dried around his mouth. An unknown staff member told R86 it was time to eat and transported R86 back to B hall. At 1:31 pm R86 was observed in hallway with the same chocolate ring around his mouth and face. On 01/29/2026 at 12:05 PM, LPN /Unit Manager F, stated R86 had a diagnosis of Parkinsons disease and drooled, then offered that R86 was constantly in food and like chocolate pudding. When queried what the expectation was of staff when they pass R86 in hall or do routine checks, LPN/Uni manager F stated the expectation of staff would be to assist R86 in cleaning his face.

During an interview and observation, the facility failed to maintain privacy and confidential records for one resident (R#135) of one resident investigated.Findings IncludeResident #135 (R135)Review of the medical record reflected that R135 was admitted to the facility on [DATE]. Diagnoses of Cellulitis of Face, weakness, Chronic Kidney Disease, Muscle weakness and history of falls.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) was still being completed due to new admission and data was not available.During an observation and interview on 01/28/2026 at 7:20 AM, phlebotomist W was in the resident's room finishing a lab draw and writer noticed R135's personal health information laying open on the top of the lab draw cart outside of the resident's room. This information was visible to anyone walking by the cart and resident's room, which was not met for the public eye. This writer read the residents' name, date of birth , diagnosis, physician orders, and labs being drawn at this visit.During this same observation and interview, writer asked phlebotomist W if this personal information should be laying out on the top of her lab draw cart for anyone to see. Discussed Health Insurance Portability and Accountability Act (HIPPA) was put in place to protect residents. Phlebotomist W stated, she was just the phlebotomist, she didn't work there. During an interview on 01/28/2026 at 8:00 AM, Licensed Practical Nurse (LPN) Unit Manager C stated she would follow up on this incident as phlebotomist W was a (name of lab) employee and comes in to do their lab draws. LPN Unit Manager C stated the employee's name, and she would address it at this time.

Based on observation, interview and record review the facility failed to provide impactful and meaningful activities for four of four residents reviewed (Resident #'s 32, 56,86 and 101).Findings include: Resident # 32 (R32) Review of the clinical record, including the Minimum Data Set (MDS) with an Assessment Reference (ARD) date of 11/15/25 revealed Resident #32 (R32) was a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses epilepsy and delayed psychological development. R32 scored 5 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). On 01/27/2026 11:05 AM R32 observed in her room sitting up in bed wearing a gown. The room was dark, no television was on, no radio, no books, puzzles or any type of leisure activity observed in room/bedside. Upon approach R32 was engaged in conversation easily and was very, friendly. On 01/28/2026 at 12:15 PM, R32 was observed sitting up in bed, no television, no radio on, no books or other type of leisure activity observed at bedside. At 1:32 PM R32 was observed sitting in the B unit hallway in her wheelchair. Review of R32's activity assessment dated [DATE] revealed R32 like to watch television, coloring, spend time with friends and family and music by Bon Jovi. On 1/29/2026 at 9:51 am during an interview with Life Enrichment Director (LED) E reported R32 liked to attend anything and everything if nursing got her up and dressed. LED E further reported R32 was very social and had friends in activities that she regularly would socialize with. R32 needed to be transported by staff to and from the activity room and needed regular reminders of planned activities. B hall was known to have lower cognitive functioning residents on the unit, the double doors to enter the hallway are consistently shut. At the end of B hall a large living room/dining room type was observed, the room was airy, well lit, and furnished with a television, tables, chairs recliners. The doors to the lounge are was observed closed throughout 1/27 and 1/28/26. On 01/29/2026 12:19 PM, during an interview with Licensed Practical Nurse (LPN) F who also serves as Unit Manager for B, it was queried why the lounge/living rooms/ding room area at the end of the hall was observed to have the doors closed and no residents using the space. LPN F stated residents were not allowed to watch television or use that room at all unless staff were in the room with them. When queried why it was permissible for B hall residents to sit alone in their room unsupervised but not allowed to gather, socialize or watch television in the lounge area unsupervised. LPN F offered no explanation. Resident #86 (R86) Review of the clinical record, including the Minimum data Set (MDS) dated [DATE] revealed Resident 86 (R86) was an [AGE] year-old male admitted to the facility with diagnoses that include dementia and Parkinson's. R86 scored 3 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). On 01/27/2026 at 10:55 AM, R86 was observed wandering up and down B hall, the lounge at the end of the hall was closed, multiple residents on the unit were in bed and in their room. On 01/28/2026 9:10am, Resident #86 sitting alone in the atrium. R86 was again observed sitting in the atrium at 12:15 pm. Review of R86's activity assessment dated [DATE] revealed R86 was at ease interacting with others and at ease doing scheduled activities. The assessment further revealed R86 particularly enjoyed bingo and entertainment. On 01/28/2026 2:33 PM, during an interview with Certified Nursing Assistant (CNA) X stated B hall residents were no longer able to use the dining/living/activity area on the unit unless a staff member was going to be in the room the whole time with them. CNA X explained how this was not feasible as there were other tasks duties. It was pointed out to CNA X that most residents on B unit were in there room alone with no CNA or Nurse present so what would be different? CNA X stated the B hall residents including R86 used to congregate there but the Director of Nursing made the rule that no residents were allowed if staff were not present and they needed to follow her directive. R86 was observed in his room at this time. Of note, Bingo was beginning in the life enrichment room. On 1/29/2026 at 9:51 am during an interview with Life Enrichment Director (LED) E reported R32 liked to attend anything and everything if nursing got her up and dressed. LED E further reported R32 was very social and had friends in activities that she regularly would socialize with. R32 needed to be transported by staff to and from the activity room and needed regular reminders of planned activities. B hall was known to have lower cognitive functioning residents on the unit, the double doors to enter the hallway are consistently shut. At the end of B hall, a large living room/dining room type was observed, the room was airy, well lit, and furnished with a television, tables, chairs recliners. The doors to the lounge area was observed closed throughout 1/27 and 1/28/26. LED E stated the living room area on B hall was no longer able to use unless nursing staff were in the room. when queried if nursing staff was in each resident room with residents, LED E stated she believe so. When queried what the difference was with staff not present in a room or staff not present in living room area? LED E stated she didn't know. When queried about R86, LED E stated R86 enjoyed activities and would usually come in and out with the exception of bingo and entertainment, both of those activities grabbed his attention, and he'd stay the full time for those. When queried why R32 did not attend bingo on 1/28/26 (record review revealed R86 did not refuse to attend) LED E stated she was not sure. Review of the January 2026 activity calendar revealed the facility offered no weekend or evening activities. LED E stated they haven't head evening or weekend activities in 2 years. When queried if she had complaints from residents about nothing being offered at night or weekends, LED E said yes. The Activity calendar offered Monday through Friday at 9:00 am was Morning visits and at 3:30 was 1:1 room visit. LED E stated morning visit was activity staff going to rooms to tell residents what is happening and doing checks, when queried what the 3:30 1:1 visit was, LED E said the same thing, but those were in place when she started working at the facility. On 01/29/2026 12:19 PM, during an interview with Licensed Practical Nurse (LPN) F who also serves as Unit Manager for B, it was queried why the lounge/living rooms/ding room area at the end of the hall was observed to have the doors closed and no residents using the space. LPN F stated residents were not allowed to watch television or use that room at all unless staff were in the room with them. When queried why it was permissible for B hall residents to sit alone in their room unsupervised but not allowed to gather, socialize or watch television in the lounge area unsupervised. LPN F offered no explanation. Resident #56 (R56) Review of the medical record reflected that R56 was admitted to the facility on [DATE]. Diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction affecting the right dominate side, Dysarthria following Cerebral Infarction, Expressive language disorder, major depression, Hearing loss bilateral and chronic instability of right knee. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) revealed R56 had a Brief Interview of Mental Status (BIMS) of 14 (Cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R56 was 1 to 2 people for personal care. During observation and interview on 01/27/2026 at 3:58 PM, R56 was sitting in her wheelchair staring at her TV. R56 had her over the bed table beside her and she did not have anything meaningful to do to help add value to her day. No observation of an activity calendar present, no observation of activities that she could do independently. R56 stated she just has TV, not aware of anything else going on. During observation and interview on 01/28/2026 at 12:00 PM, R56 had finished her lunch and was sitting in her wheelchair parked in front of the TV. No visible activities or items to work on for entertainment. R56 stated she didn't have anything to do but watch TV. During observation on 01/28/2026 at 2:00pm, Bingo was scheduled for 2:15 PM today, R56 was not taken to the activity room to participate in Bingo. During an observation and interview on 01/28/2026 at 2:44 PM, Activity Director (AD) E stated they had Bingo scheduled two times a week, for 30-45 minutes. AD E stated they go and ask every resident if they want to join, they pretty know who wants to play. Writer asked AD E about the residents that can't get down there and want to participate. AD E stated they do one on one visits and during that time they can talk with the residents, do puzzles, work on things in their rooms. AD E stated they do not have any activities in the evenings, they don't have the staff to do that. AD E also stated they do not have any activities all weekend, because they do not have staff to do so. Record review revealed R56 had received three short one on one visits during the last 30 days. R56 had received four short activity rounds in the last 30 days. The last life enrichment progress note was dated 10/15/2024. No other progress notes were available to reflect visits, participation, or time spent with R56. During an interview and record review on 01/29/2026 at 8:51 AM, AD E stated she had been in this role for one year. AD E stated she had four other staff besides herself to provide activities to residents. Two activity staff work full time, and two activity staff work part time. AD E stated they worked from 8:00 AM to 4:30 PM, Monday through Friday. AD E stated at 9:00 AM, the staff go down and talk to the residents, ask if they want to join the activity today or see if they need anything at that time. Writer asked where that would be documented and AD E stated she didn't know, it should be in plan of care (POC), or in her binder, she went to her office to get it. Record review of this binder did reveal one on one documentation for some residents; does not reflect how long they are spending with the residents. Several residents were not visited, and no documentation to validate they were visited, spent valuable time together, or any participation in meaningful conversation or proof that a activity calendar was provided, or if any activities were left for the resident to do independently. AD E stated their first activity of the day was a movie, added that movies were randomly selected based on how long the movie ran and the amount of time allowed for this activity. AD E then stated selection was not based on age appropriate for these residents. AD E also stated that she keeps those logs in her binder and monthly she will empty the binder and start over for the next month and saved them in her office, not scanned into the resident's electron medical record. Writer asked if certain other residents had received a one-on-one visit, and AD E stated no, if there wasn't a one-on-one documentation sheet filled out. AD E also stated she was the one responsible for updating the care plans. Record review revealed R56 did not have a one-on-one visit documented for the month of January 2026. Record review revealed R56's care plan has not been updated, revised or new interventions added since 2020, six years ago. Encourage to participate in unit activities. Date Initiated: 12/17/2016 Revision on: 04/15/2020 Provide and document 1:1 visits - enjoys conversation, dogs, her family, etc. Date Initiated: 04/15/2020 Provide pet visits when available – R56 really loves dogs. Date Initiated: 04/09/2019 Revision on: 04/12/2021 Provide weekly schedules and in-room activity handouts. Date Initiated: 05/30/2020 R56 will participate in on unit activities as desired through review date. Date Initiated: 12/17/2016 Revision on: 05/05/2025 Target Date: 04/06/2026 R56 will participate in 1:1 visits. Date Initiated: 04/15/2020 Revision on: 05/05/2025 Target Date: 04/06/2026 R56 enjoys activities when available and 1:1 visits with staff. Date Initiated: 12/17/2016 Revision on: 04/15/2020. During an observation on 01/29/2026 at 2:30 PM, there were 10 residents that joined Bingo today out of a census of 108 residents. Promptly at 2:45 PM, Bingo was stopped and residents were taken back to their rooms. Bingo began at 2:15 PM and ended at 2:45 PM. Resident #101 (R101) Review of the medical record reflected that R101 was admitted to the facility on [DATE]. Diagnoses of Chronic Respiratory Failure, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Depression, Anxiety and Chronic Pain. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) revealed R101 had a Brief Interview of Mental Status (BIMS) of 14 (Cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R101 was dependent of all personal care. During an observation and interview on 01/28/2026 at 9:18 AM, R101 stated he usually watches TV, there was no activity calendar visible, no activity items that would have been brought into his room for him to do at his leisure, R101 stated that nobody had brought anything in for him to do. During an observation and interview on 01/28/2026 at 11:45 AM, R101 sat up in his bed eating lunch, with the TV on. Record review revealed R101 had not had a one-on-one visit in the last 30 days. R101 had three activity rounds in the last 30 days. Care Plan revealed R101 had no interest to attend OOR group activities. Date Initiated: 02/05/2024 Revision on: 02/05/2024 R101 will continue to enjoy independent activities of choice through review date. Date Initiated: 02/05/2024 Revision on: 04/21/2025 Target Date: 03/22/2026 Compile and provide R101 with materials for independent in-room activity participation. Date Initiated: 02/05/2024 Revision on: 02/05/2024 Encourage and guide R101 to OOR group activities of interest. Date Initiated: 02/05/2024 Revision on: 02/05/2024 Provide and document 1:1 visits, per request. Date Initiated: 02/05/2024. R101's care plan had not been updated for two years to see what this resident may or may not enjoy. During an interview and record review on 01/29/2026 at 8:51 AM, AD E stated she had been in this role for one year. AD E stated she had four other staff besides herself to provide activities to residents. Two activity staff work full time, and two activity staff work part time. AD E stated they worked from 8:00 AM to 4:30 PM, Monday through Friday. AD E stated at 9:00 AM, the staff go down and talk to the residents, ask if they want to join the activity today or see if they need anything at that time. Writer asked where that would be documented and AD E stated she didn't know, it should be in plan of care (POC), or in her binder, she went to her office to get it. Record review of this binder did reveal one on one documentation for some residents; does not reflect how long they are spending with the residents. Several residents were not visited, and no documentation to validate they were visited, spent valuable time together, or any participation in meaningful conversation or proof that a activity calendar was provided, or if any activities were left for the resident to do independently. AD E stated their first activity of the day was a movie, added that movies were randomly selected based on how long the movie ran and the amount of time allowed for this activity. AD E then stated selection was not based on age appropriate for these residents. AD E also stated that she keeps those logs in her binder and monthly she will empty the binder and start over for the next month and saved them in her office, not scanned into the resident's electron medical record. Writer asked if certain other residents had received a one-on-one visit, and AD E stated no, if there wasn't a one-on-one documentation sheet filled out. AD E also stated she was the one responsible for updating the care plans. AD E also stated R101 refuses, only likes pet visits. Doesn't have the pet visits on a routine basis.

Based on interview and record review, the facility failed to administer influenza and pneumococcal immunizations per consent for one (R6) of five reviewed.Findings include: Review of the medical record revealed R6 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, pleural effusion, atrial fibrillation, chronic obstructive pulmonary disease, dementia, and pneumonia.Review of the Consent to Administer Pneumonia Vaccination and the Consent to Administer Influenza Vaccination revealed R6 declined both vaccinations. R6 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Review of R6's Consent to Administer Pneumonia Vaccination and the Consent to Administer Influenza Vaccination revealed R6 consented and wished to receive both vaccinations upon readmission to the facility. Review of the medical record revealed R6 did not receive either vaccination.Review of the Health Status Note dated 1/10/26 revealed R6's chest x-ray results showed pneumonia and they were started on antibiotics. In an interview on 01/29/2026 at 10:30 AM, Infection Preventionist (IP) G was able to review R6's vaccination history through the state's immunization registry and reported R6 received a pneumococcal 23 vaccination in 2011 and an influenza vaccination in 2022. IP G reviewed R6's vaccination consents and reported they did consent to receive the pneumonia and influenza vaccinations and were due for both vaccinations, but the facility did not have record of R6 receiving either.

Based on interview and record review the facility failed to provide ROM and repositioning to one resident (Resident #101) of two residents interviewed for ROM and mobility. Findings Include:Resident 101 (R101)Review of the medical record reflected that R101 was admitted to the facility on [DATE]. Diagnoses of Chronic Respiratory Failure, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Depression, Anxiety and Chronic Pain.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) revealed R101 had a Brief Interview of Mental Status (BIMS) of 14 (Cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R101 was dependent of all personal care.During an interview on 01/28/2026 at 9:08 AM, R101 stated he did not get any range of motion (ROM) or repositioning like he is supposed to be getting. R101 added he cannot reposition himself, so the staff know they had to do it. During an interview on 01/29/2026 at 7:39 AM, Certified Nursing Assistance (CNA) Y stated R101 required being repositioned every two hours as he cannot reposition himself.During an interview on 01/29/2026 at 7:45 AM, LPN Z stated R101 needed repositioning every two hours since he could not do it himself, adding as the wound care nurse, who completed the treatments and followed up on his red areas from not being repositioned every two hours. Record review revealed it was on the kardex and care planned but was not being done. R101 was only repositioned 3 times a shift, not every 2 hours. R101 received ROM for 10 minutes one time in the last 30 days. Care plan record review for R101; was at risk for falls r/t decreased mobility, chronic respiratory failure and COPD with O2 use, right foot drop and other chronic pain, DMII, MDD with med use, Anxiety and Insomnia.Call light in reach, provide adequate light, keep floor clean, dry, and free of clutter Date Initiated: 01/08/2026 Revision on: 01/08/2026 Fall on 1/29/2024 03:30 Intervention: Bariatric bed in place to allow more room to move around. Date Initiated: 02/01/2024Transfer status: 2-person mechanical lift. In room mobility with WC extensive. Locomotion in hallway and on unit via WC provided extensive assistance. Unable to sit in WC for transport. Date Initiated: 12/14/2025 Revision on: 12/14/2025MOBILITY: staff participation required for mobility. Date Initiated: 01/26/2024 Revision on: Revision 09/16/2024ROM: Active and Passive ROM during ADLs, Date Initiated: 06/26/2024 Revision on: 06/26/2024Record review did not reveal any updates or new interventions added to reflect any changes in ability to participate.

Based on observation, interview and record review, the facility failed to implement interventions to prevent falls for one (R5) of two reviewed. Findings include:Review of the medical record reflected R5 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included vascular dementia, unspecified fracture of lower end of right femur (9/3/25), periprosthetic fracture around internal prosthetic right knee joint (9/3/25) and Alzheimer's. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/16/25, reflected R5 scored three out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 01/28/2026 at 11:39 AM, R5 was observed lying awake, in bed. The bed height was noted to be in a low position. An over-bed table was located at the left bedside. R5 was noted to be barefoot on the right foot. Their left foot was beneath the bed linens and unable to be observed. On 01/29/2026 at 11:28 AM, R5 was observed lying in bed. The bed height was noted to be in a low position. An over-bed table was located at the left bedside. A nightstand and folding chair were observed at the right bedside. An Incident Report reflected R5 had an unwitnessed fall on 8/21/25 at 8:45 AM and were found lying on the floor, at the foot of their bed. R5 was near their walker, with the seat up, and was unable to state what occurred. The Incident Report reflected R5 appeared to be reaching for their walker storage compartment, while sitting in bed, and rolled off the foot of the bed. The Predisposing Situation Factors section of the Incident Report reflected R5 asked to use the bathroom at the time of the fall, and their personal items were not in reach. The Incident Report further reflected R5 had last been toileted sometime between the hours of 12:00 AM and 6:00 AM. The intervention was to continue the planof care related to impaired physical mobility/fall risk.In an interview on 01/29/2026 at 11:52 AM, when queried about an intervention for R5's fall on 8/21/25, Director of Nursing (DON) B reportedthey were to continue the plan of care related to impaired physical mobility/fall risk. When asked if there were any changes to R5's Care Plan, DON B stated she was speculating that there were no changes, just to continue what was in the Care Plan related to R5's fall risk. When discussing if there was an expectation for a revised intervention, DON B reported it depended on what was on the Care Plan, as sometimes there were multiple falls, and they could continue to uphold appropriate interventions. An Incident Report reflected R5 had an unwitnessed fall on 8/23/25 at 12:15 AM. R5 was observed lying on the floor, with their head towards the window, facing away from the bathroom door and their feet towards the room entrance. R5 stated a man told them it was time for breakfast, so they were trying to get ready. According to the Incident Report, R5 was not wearing proper footwear at the time of the fall. R5's Risk for Falls Care Plan reflected an intervention, which was initiated 5/17/23 and revised 1/7/25, to offer and encourage gripper socks. An intervention, which was initiated 10/7/24 and revised 1/7/25, reflected to offer and encourage resident to wear proper footwear. An x-ray of the right knee on 8/23/25 revealed R5 had an acute supracondylar periprosthetic distal femur fracture (broken bone near a knee replacement). In an interview on 01/29/2026 at 11:52 AM, when queried about R5's fall on 8/23/25, DON B reported the intervention was to offer and encourage non-skid footwear prior to bed. When discussing R5's prior care planned interventions for footwear, DON B stated they should have said to continue to uphold what was in the Care Plan if the reason for R5's fall was not having appropriate footwear on. When asked if anyone determined why R5 was not wearing appropriate footwear at the time of the fall, DON B stated that conversation may have taken place, but the Unit Manager at the time of the fall was no longer employed by the facility. When asked if that information would be documented, DON B reviewed Progress Notes and stated she did not see anything documented. In a phone interview on 01/29/2026 at 1:31 PM, Registered Nurse (RN) L could not recall what type of footwear R5 had that was improper at the time of the fall on 8/23/25. RN L could not recall if anyone had taken a statement from them after R5's fall. An Incident Report reflected R5 had an unwitnessed fall on 9/30/25 at 8:15 AM. According to the Incident Report, R5 was lying on their left side, pinned between their bed and the adjacent wall. Documentation reflected it appeared R5 rolled in bed and became wedged in the position they were found in. R5 was not able to describe the fall. Additional documentation on the Incident Report reflected that it appeared R5's mattress may have moved as they shifted position, allowing them to slide between the bed and the wall. There was notation to continue with the current fall Care Plan. In an interview on 01/29/2026 at 11:52 AM, when queried about an intervention for R5's fall on 9/30/25, DON B reported they were to continue with the current fall Care Plan and the interventions that were in place. DON B conveyed that interventions for falls needed to match the cause of the fall. If the Unit Manager did not feel an intervention coincided with the cause of a fall, they would not update the interventions.

Based on observations, interviews, record reviews, and 2 (#72, #132) of 22 sampled residents, the facility failed to provide palatable food products affecting 108 residents who consume food, resulting in the increased likelihood for resident decreased food acceptance and nutritional decline.Findings include:On 01/27/2026 at 11:53 A.M., An interview was conducted with Director of Dining Services S regarding the resident food tray delivery schedule. Director of Dining Services S stated: Main Dining Room, C-Wing, D-Wing, B-Wing, East Hall, South Hall, and North Hall. On 01/27/2026 at 11:55 A.M., Lunch meal food trays (19) were observed leaving the food production kitchen, within an insulated food transport cart. On 01/27/2026 at 11:58 A.M., Lunch meal food trays (19) were observed arriving to C-Wing, within an insulated food transport cart. On 01/27/2026 at 12:09 P.M., Lunch meal food trays (23) were observed leaving the food production kitchen, within an insulated food transport cart. On 01/27/2026 at 12:12 P.M., Lunch meal food trays (23) were observed arriving to D-Wing, within an insulated food transport cart. On 01/27/2026 at 12:15 P.M., Lunch meal food trays (24) were observed leaving the food production kitchen, within an insulated food transport cart. On 01/27/2026 at 12:18 P.M., Lunch meal food trays (24) were observed arriving to B-Wing, within an insulated food transport cart. On 01/27/2026 at 12:19 P.M., The B-Wing insulated food transport cart was observed with both access doors wide open between food tray deliveries. On 01/27/2026 at 12:17 P.M., Lunch meal food trays (10) were observed leaving the food production kitchen, within an insulated food transport cart. On 01/27/2026 at 12:20 P.M., Lunch meal food trays (10) were observed arriving to East Hall, within an insulated food transport cart. On 01/27/2026 at 12:32 P.M., Lunch meal food trays (18) were observed leaving the food production kitchen, within an insulated food transport cart. On 01/27/2026 at 12:36 P.M., Lunch meal food trays (18) were observed arriving to South Hall, within an insulated food transport cart. On 01/27/2026 at 12:40 P.M., Lunch meal food trays (12) were observed leaving the food production kitchen, within an insulated food transport cart. On 01/27/2026 at 12:43 P.M., Lunch meal food trays (12) were observed arriving to North Hall, within an insulated food transport cart. On 01/27/2026 at 12:50 P.M., The North Hall insulated food transport cart was observed with both access doors wide open between food tray deliveries. On 01/27/2026 at 12:52 P.M., Food product temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following food product temperatures were recorded for Resident #132's lunch meal food tray: Pork Loin Fricassee - 133.6* Mashed Potatoes - 117.2* Carrots - 122.6* Chedder Dinner Roll - 118.1 Peach Crisp - 63.1* Beverage (Coffee) - 148.4 Beverage (Lemonade) - 48.0* (*) The 2022 FDA Model Food Code section 3-501.16 states: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under 3-501.19, and except as specified under ¶ (B) and in ¶ (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 degrees C (135 degrees F) or above, except that roasts cooked to a temperature and for a time specified in ¶ 3-401.11(B) or reheated as specified in ¶ 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; or (2) At 5 degrees C (41 degrees F) or less. On 01/27/2026 at 1:01 P.M., An interview was conducted with Resident #132 regarding facility food products. Resident #132 stated: The taste of the food is less than desirable. Resident #132 also stated: The lemonade is generally weak in taste. Resident #132 further stated: The food tends to be on the cool side. Resident #132 additionally stated: The meat is generally dry and somewhat tough. On 01/28/2026 at 11:35 A.M., Lunch meal food trays (11) were observed leaving the food production kitchen, within an insulated food transport cart. On 01/28/2026 at 11:36 A.M., Lunch meal food trays (11) were observed arriving to the Main Dining Room, within an insulated transport cart. On 01/28/2026 at 11:48 A.M., Lunch meal food trays (21) were observed leaving the food production kitchen, within an insulated food transport cart. On 01/28/2026 at 11:51 A.M., Lunch meal food trays (21) were observed arriving to C-Hall, within an insulated food transport cart. On 01/28/2026 at 11:50 A.M., Lunch meal food trays (23) were observed leaving the food production kitchen, within an insulated food transport cart. On 01/28/2026 at 11:53 A.M., Lunch meal food trays (23) were observed arriving to D-Hall, within an insulated food transport cart. On 01/28/2026 at 12:01 P.M., Lunch meal food trays (24) were observed leaving the food production kitchen, within an insulated food transport cart. On 01/28/2026 at 12:04 P.M., Lunch meal food trays (24) were observed arriving to B-Hall, within an insulated food transport cart. On 01/28/2026 at 12:03 P.M., Lunch meal food trays (4) were observed leaving the food production kitchen, within a stainless steel non-insulated transport cart. On 01/28/2026 at 12:06 P.M., Lunch meal food trays (4) were observed arriving to B-Hall, within a stainless steel non-insulated transport cart. On 01/28/2026 at 12:09 P.M., Lunch meal food trays (11) were observed leaving the food production kitchen, within an insulated food transport cart. On 01/28/2026 at 12:12 P.M., Lunch meal food trays (11) were observed arriving to East Hall, within an insulated food transport cart. On 01/28/2026 at 12:21 P.M., Lunch meal food trays (24) were observed leaving the food production kitchen, within an insulated food transport cart. On 01/28/2026 at 12:24 P.M., Lunch meal food trays (24) were observed arriving to South Hall, within an insulated food transport cart. On 01/28/2026 at 12:28 P.M., Lunch meal food trays (10) were observed leaving the food production kitchen, within an insulated food transport cart. On 01/28/2026 at 12:30 P.M., Lunch meal food trays (10) were observed arriving to North Hall, within an insulated food transport cart. On 01/28/2026 at 12:33 P.M., The North Hall insulated food transport cart was observed with 1 of 2 access doors wide open between food tray deliveries. On 01/28/2026 at 12:48 P.M., Food product temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following food product temperatures were recorded for Resident #72's lunch meal food tray: Hamburger - 107.4 degrees Fahrenheit* [NAME] Apple Sauce - Room Temperature Cottage Cheese - 63.9 degrees Fahrenheit* Garden Salad - 63.7 degrees Fahrenheit* Pumpkin Pie - 62.9 degrees Fahrenheit* Beverage (Coffee) – 130.2 degrees Fahrenheit (*) The 2022 FDA Model Food Code section 3-501.16 states: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under 3-501.19, and except as specified under ¶ (B) and in ¶ (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 degrees C (135 degrees F) or above, except that roasts cooked to a temperature and for a time specified in ¶ 3-401.11(B) or reheated as specified in ¶ 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; or (2) At 5 degrees C (41 degrees F) or less. On 01/29/26 at 08:00 A.M., Record review of the Policy/Procedure entitled: Meal Quality and Temperature dated 5/95 revised 1/26 revealed under Policies: Food and drinks are palatable, attractive, and served at a safe and appetizing temperature to ensure resident satisfaction and to meet nutrition and hydration needs. On 01/29/26 at 08:15 A.M., Record review of the Policy/Procedure entitled: Meal/Tray Assembly Procedures dated 5/95 revised 1/25 revealed under Policies: Meal service is prompt and accurate to ensure temperatures and nutrient content of food is preserved. On 01/29/26 at 08:30 A.M., Record review of the Policy/Procedure entitled: Food Temperatures/Heating dated 06/29/2023 revealed under Policy: It is the policy of this facility to record food temperatures as needed to ensure food is at the proper serving temperature(s) before serving food to the patient. R72 Review of the medical record revealed R72 was admitted to the facility on [DATE] with diagnoses that included endocarditis, urinary tract infection and chronic respiratory failure with hypoxia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/17/26 revealed R72 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 01/27/2026 at 11:55 AM, R72 was observed sitting in the chair in their room. R72 reported they ate meals in their room, and the food was always cold. R132 Review of the medical record revealed R132 was admitted to the facility on [DATE] with diagnoses that included cellulitis, chronic kidney disease, and moderate protein-calorie malnutrition. R132's MDS assessment was in progress. On 01/27/2026 at 10:32 AM, R132 was observed sitting in a chair in their room. R132 reported they ate all meals in their room, and all meals were served cold. R132 reported they had mentioned to staff that food was cold, and they were told that if the food was cold again, staff could warm it up. Review of a Grievance Form filed by R132 and dated 1/20/26 revealed R132 reported from 1/16/26 to present their meals had frequently been served cold during designated mealtimes. The grievance revealed the facility would review their logs to confirm proper temperature and delivery times. The grievance was listed as resolved on 1/23/26.

Based on observation, interview, and record review, the facility failed to ensure two (R72, R101) of four residents reviewed received care and services in accordance with professional standards of practice and the care plan. Findings include: Resident #101 (R101) Review of the medical record reflected that R101 was admitted to the facility on [DATE]. Diagnoses of Chronic Respiratory Failure, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Depression, Anxiety and Chronic Pain. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) revealed R101 had a Brief Interview of Mental Status (BIMS) of 14 (Cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R101 was dependent of all personal care. During an interview on 01/28/2026 at 9:08 AM, R101 stated he did not get any range of motion (ROM) or repositioning like he is supposed to be getting. R101 added he cannot reposition himself, so the staff know they had to do it. During an interview on 01/29/2026 at 7:39 AM, Certified Nursing Assistance (CNA) Y stated R101 required being repositioned every two hours as he cannot reposition himself. During an interview on 01/29/2026 at 7:45 AM, LPN Z stated R101 needed repositioning every two hours since he could not do it himself, adding as the wound care nurse, who completed the treatments and followed up on his red areas from not being repositioned every two hours. Record review revealed it was on the kardex and care planned but was not being done. R101 was only repositioned 3 times a shift, not every 2 hours. R101 received ROM for 10 minutes one time in the last 30 days. Care plan record review for R101; was at risk for falls r/t decreased mobility, chronic respiratory failure and COPD with O2 use, right foot drop and other chronic pain, DMII, MDD with med use, Anxiety and Insomnia. Call light in reach, provide adequate light, keep floor clean, dry, and free of clutter Date Initiated: 01/08/2026 Revision on: 01/08/2026 Fall on 1/29/2024 03:30 Intervention: Bariatric bed in place to allow more room to move around. Date Initiated: 02/01/2024 Transfer status: 2-person mechanical lift. In room mobility with WC extensive. Locomotion in hallway and on unit via WC provided extensive assistance. Unable to sit in WC for transport. Date Initiated: 12/14/2025 Revision on: 12/14/2025 MOBILITY: staff participation required for mobility. Date Initiated: 01/26/2024 Revision on: Revision 09/16/2024 ROM: Active and Passive ROM during ADLs, Date Initiated: 06/26/2024 Revision on: 06/26/2024 Record review did not reveal any updates or new interventions added to reflect any changes in ability to participate. Resident # 72 (R72) Review of the medical record revealed R72 admitted to the facility on [DATE] with diagnoses the included endocarditis, urinary tract infection and chronic respiratory failure with hypoxia. The Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 1/17/26 revealed R72 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 01/27/2026 at 12:14 PM, R72 was observed sitting in a chair in their room. A Peripherally Inserted Central Catheter (PICC line-catheter inserted into a vein in the arm and threaded to a large vein near the heart) was observed in R72's left upper arm. R72 was receiving antibiotics through their PICC line. The dressing over the PICC line insertion site was dated 1/19/26. R72 reported their PICC line dressing was supposed to be changed every week, and they believed it would be changed today. A PICC line dressing kit was observed in R72's room. Review of the Physician's Order dated 1/14/26 revealed an order to measure PICC line arm circumference and external catheter length one time a day ever 7 days for IV maintenance with each dressing change and one time only for an admission or post insertion for 1 day. There were no other PICC line orders that mentioned a dressing change. Review of the eMAR-Medication Administration Note dated 1/22/26 revealed Resident refused IV pic [sic] dressing change. Resident stated, it got done on the 19th and it get [sic] change every 7 days. The medical record did not indicate that R72 was offered another PICC line dressing change. On 01/28/2026 at 11:15 AM, R72 was observed sitting in the chair in their room. R72 reported staff changed their PICC line dressing that morning (9 days since the last dressing change). The dressing was observed with a date of 1/28/26. In an interview on 01/28/26 at 12:05 PM, Licensed Practical Nurse (LPN) J reported they were R72's nurse that day, but only Registered Nurses (RNs) were able to change PICC line dressing changes. LPN J reported PICC line dressing changes were supposed to be done every 7 days. In an interview on 01/28/26 at 12:10 PM, LPN K reported PICC line dressing changes should be completed upon admission and then every 7 days. LPN K reported they changed R72's PICC line dressing change that morning (1/28/26). LPN K was unable to explain why it had been more than 7 days since R72's last dressing change. LPN K reported R72's PICC line dressing should have been changed two days earlier, on 1/26/26 and that it was expected that nurses check the dressing date every day. In an interview on 01/29/2026 at 11:01 AM, Director of Nursing (DON) B reported R72's PICC line dressing change was completed late, and the facility's policy was to change the dressing every five to seven days. Review of the facility's Catheter Insertion and Care PICC/Midline Dressing Changes dated 2013 revealed PICC/Midline catheter dressings will be changed at specified intervals, or when needed, to prevent catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings .1. Change PICC/midline catheter dressing 24 hours after catheter insertion, every 5-7 days, or if it is wet, dirty, not intact, or compromised in any way.

This citation pertains to intake number MI00150684. Based on observation, interview, and record the facility failed to document one out of three resident's (Resident #3) condition per professional standards of practice, resulting in the potential for a delay in treatment. Findings Included: On 3/11/2025 at 2:50 PM, Resident #3 (R3) was observed in her room lying in bed. R3 stated she that about three weeks ago she had a stroke. R3 said she felt weird, and was not able to speak. R3 was noted to have a slight speech impairment, but was understood. In an interview on 3/12/2025 at 11:11 AM, Certified Nurse Aid (CNA) C stated that on 2/11/2025 R3 seemed off around breakfast time, and stated R3's speech was slurred, was not swallowing food, was drooling food on her gown and face, eating messy, and her speech was slurred enough that is was noticed. CNA C said R3 was pocketing food (not chewing or swallowing the food but holding it in the cheek), was not able to be verbally understood, could not understand what the bed remote was for, and said the symptoms were all new. CNA C said Licensed Practical Nurse (LPN) D was notified by several CNAs that something was wrong with R3, and R3 was not at her baseline. CNA C stated that the response she received from LPN D was that he would check on R3 later, and LPN D did not go right away into R3's room. CNA C said then LPN E was made aware of R3's changes. In an continued interview CNA C stated that R3 told LPN E that she felt ok, but was having a hard time getting words out. CNA C said LPN E then called the Nurse Practitioner (NP). CNA C said herself and two other CNAs kept telling LPN D that R3 was getting worse. CNA C also stated that LPN E went and reported R3's symptoms to LPN F, who was the Unit Manager. Several attempts were made on 3/12/2025 at 10:38 AM to contact LPN E but was not successful. In an interview on 3/12/2025 at 11:35 AM, LPN F stated that a CNA told her on 2/11/2025 R3 was acting different. LPN F said she assessed R3's speech was delayed, but no other symptoms were observed. LPN F said the NP wanted the Tamaflu (medicine to treat and prevent the flu) stopped because the medication can cause stroke like symptoms. LPN F said on 2/11/2025 in the AM R3 was still a bit slow with her words. LPN F said she wrote an order for neurological (neuro) checks and blood pressure checks to be done every four hours. LPN F said the Treatment Administration Record (TAR) had a place for the nurse to sign that the neuro checks were done. LPN F stated LPN D did not sign that he had done the neuro checks. LPN F said the actual neuro checks or assessment were documented on a piece of paper, and that paper was scanned into the resident's electronic medical record (EMR), and then destroyed. LPN F said R3's neuro checks were not scanned into R3's EMR, and therefore she was not able to state the neuro checks were ever done. LPN F said she only saw R3 one time in the morning on 2/11/2025, and not again on that day. Record review of R3's EMR revealed that on 2/11/2025 there were no progress notes documented at all during the dayshift. The only progress note that was documented was documented by LPN G on 2/11/2025 at 6:17 PM and stated as follows: Health Status Note, Note Text: Entered resident room at 1530 (3:30 PM) VS (vital signs) B/P (blood pressure) 184/98 P (pulse) 82 R (respirations) 18 T (temp) 97.1 SPO2 (oxygen level) 96% .Noticed slurred speech. Resident (R3) denies numbness, tingling, headache, hand grips equal, able to swallow without difficulty .NP called informed of condition. Stated to send resident to hospital for possible CVA (stroke) .Resident sent is ambulance at 1605 (4:05 PM) . In an interview on 3/11/2025 at 3:35 PM LPN G said she had just come into work. LPN G said she went to R3 right away and sent her out to the hospital pretty fast. LPN G said R3's speech was slow and slurred, she was confusion. LPN G said she was given report from LPN D who told her about R3's symptoms. LPN G said when she assessed R3 what she found (symptoms) was bad, and stated she spoke with the NP who ordered R3 to be sent out. Per review of the progress notes documented by LPN G, R3 was sent out to the hospital within 35 minutes of LPN G first assessing her. In an interview on 3/12/2025 at 9:15 AM, LPN D stated he was not sure why he did not document any progress notes on R3 on 2/11/2025. LPN D said he did talk to LPN E who told that R3 was talking funny and had slurred speech. LPN D said LPN E assessed R3 and phone the NP who gave orders to take R3's blood pressure every fours hours. LPN D again could not explain why he did not document any progress notes regarding R3's condition on 2/11/2025. LPN D said he was gone from the facility when R3 was sent out to the hospital, In an interview on 3/12/2025, Director of Nursing (DON) B stated there was a lack of documentation regarding R3's condition on 2/11/2025.

This citation includes intake number MI00144468. Based on observations, interviews, record reviews, and 3 (#12, #40, and #89) of 20 sampled residents the facility failed to effectively provide palatable food products effecting 95 residents, resulting in the increased likelihood for decreased resident food acceptance and nutritional decline. Findings include: Resident #40 (R40): In an interview on 11/19/24 at 11:16 AM, R40 stated she would not get a menu daily, and said sometimes when she would mark what she wanted on the menu she would not get what she marked. R40 said that the last week it happened everyday she did not get a menu and did not get what she wanted, and said when she did not get a menu the kitchen just serve me whatever. R40 said sometimes when she would order something for the next days meal and she did not receive that she would be upset because she was looking forward to that meal she ordered. Resident #12 (R12): In an interview on 11/19/2024 at 2:10 PM, R12 stated the food was terrible, the residents were supposed to get a menu every day at breakfast to fill out for all 3 meals for the next day, but stated that did not always happen. R12 stated the hamburgers are always burnt. R12 stated that all the meat served was dried out and tough, stated the food was cold. During a lunch taste test on 11/21/2024 at 1:30 PM, baked garlic butter cod was chewy, not cooked thoroughly and not able to be chewed enough to swallow, and the pinto beans were tasted to be hard and not fully cooked. Resident #89 (R89): On 11/19/2024 at 10:52 AM, R89 stated the mashed potatoes were always cold with big clumps, and powdered eggs were always served and were cold and had no taste. On 11/19/24 at 12:50 P.M., Lunch meal food products were monitored. Wheat Rolls were not supplied on the monitored test trays. One of three test trays did not contain fluffy rice or mashed potatoes for the starch bed. On 11/19/24 at 01:49 P.M., An interview was conducted with General Manager Dining Services C regarding food product availability and portion size. General Manager Dining Services C stated: We use the meal ticket, recipe description, and color-coded utensils to ensure food product portion size. General Manager Dining Services C also stated: Residents are provided a week in a glance menu on Friday of each week. General Manager Dining Services C additionally stated: Menu selections (week in a glance) are made by each resident by Sunday of each week. General Manager Dining Services C further stated: We cook six additional portions of each meal (regular and alternate). On 11/20/24 at 12:50 P.M., Lunch meal was monitored for palatability (taste, texture, appearance). The Baby Lima Beans were undercooked and crunchy. On 11/21/24 at 09:45 A.M., Record review of the Policy/Procedure entitled: Meal Posting Substitution Always Available dated 09/07/22 revealed under Description: Community menus will be posted. Menu substitutions will be posted prior to the meal service. The community will develop a menu featuring Always Available meal options. On 11/21/24 at 10:00 A.M., Record review of the Policy/Procedure entitled: Menu Development dated 10/25/22 revealed under Description: Menus must meet the nutritional needs of residents in accordance with established national guidelines (Dietary Guidelines for Americans). Menus reflect, based on the community reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups. The menu is updated periodically at minimum twice per year: Spring/Summer and Fall/Winter cycles. Menus are created with and approved by the community Dietician for nutritional adequacy including regular, therapeutic, and mechanically altered diets and the Dietician, director and chefs will collaborate on menu planning, revision, and product evaluations. 27446

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 95 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination. Findings include: On 11/19/24 at 09:35 A.M., An initial tour of the food service was conducted with General Manager Dining Services C. The following items were noted: The True two-door reach-in cooler interior 48-inch-long fluorescent light bulbs were observed missing. General Manager Dining Services C indicated she would contact maintenance for necessary repairs as soon as possible. The 2017 FDA Model Food Code section 6-303.11 states: The light intensity shall be: (A) At least 108 lux (10 foot candles) at a distance of 75 cm (30 inches) above the floor, in walk-in refrigeration units and dry FOOD storage areas and in other areas and rooms during periods of cleaning; (B) At least 215 lux (20 foot candles): (1) At a surface where FOOD is provided for CONSUMER self-service such as buffets and salad bars or where fresh produce or PACKAGED FOODS are sold or offered for consumption, (2) Inside EQUIPMENT such as reach-in and under-counter refrigerators; and (3) At a distance of 75 cm (30 inches) above the floor in areas used for handwashing, WAREWASHING, and EQUIPMENT and UTENSIL storage, and in toilet rooms; and (C) At least 540 lux (50 foot candles) at a surface where a FOOD EMPLOYEE is working with FOOD or working with UTENSILS or EQUIPMENT such as knives, slicers, grinders, or saws where EMPLOYEE safety is a factor. The Bizerba meat slicer was observed soiled with accumulated and encrusted food residue. General Manager Dining Services C indicated she would have dietary staff thoroughly clean and sanitize the meat slicer as soon as possible. The two Frymaster fryer exterior cabinetry surfaces were observed soiled with accumulated and encrusted food residue. The [NAME] oven/stove backsplash was observed soiled with accumulated and encrusted food residue. Three sections measuring approximately 10-inches-wide by 10-inches-long were observed soiled and blackened from accumulated food residue. The Continental pull drawer refrigerator was observed soiled with accumulated and encrusted food residue. The four pull drawers were also observed soiled with accumulated and encrusted food residue. General Manager Dining Services C indicated she would have dietary staff thoroughly clean and sanitize the Continental pull drawer refrigerator as soon as possible. The two [NAME] dual convection oven bank interior and exterior surfaces were observed soiled with accumulated and encrusted food residue. General Manager Dining Services C indicated she would have dietary staff thoroughly clean and sanitize the [NAME] oven interior and exterior surfaces as soon as possible. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. Two 7-inch-wide, four 8-inch-wide, five 10-inch-wide, one 16-inch-wide, and three 18-inch-wide fry pans were observed heavily soiled with accumulated and encrusted caramelization. Numerous fry pans were also observed dented and out of round. General Manager Dining Services C indicated she would order new replacement pans as soon as possible. The 2017 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened. On 11/19/24 at 03:58 P.M., Dietary Prep [NAME] F was observed wearing a hair net and beard guard covering only the lower portion of the facial surface and not his mustache. Dietary Prep [NAME] F was queried regarding the length of his employment. Dietary Prep [NAME] F stated: Two months. On 11/20/24 at 03:20 P.M., Dietary Prep [NAME] F was observed wearing a hair net and beard guard covering only the lower portion of the facial surface and not his mustache. The 2017 FDA Model Food Code section 2-402.11 states: (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLESERVICE and SINGLE-USE ARTICLES. (B) This section does not apply to FOOD EMPLOYEES such as counter staff who only serve BEVERAGES and wrapped or PACKAGED FOODS, hostesses, and wait staff if they present a minimal RISK of contaminating exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. On 11/21/24 at 08:30 A.M., Record review of the Policy/Procedure entitled: Oven: Bake/Stack - Degreasing & Cleaning dated (no date) revealed under Procedure Frequency: Weekly: Interior/Exterior. Record review of the Policy/Procedure entitled: Oven: Bake/Stack - Degreasing & Cleaning dated (no date) further revealed under Procedure Steps: (2) When the unit is cool enough to handle, remove drip pans, racks, etc., to the pot sink. Spray with Greasestrip Plus degreaser, allow to penetrate the soil for 5 minutes. Clean and remove the soil with soaking and scrubbing. Wash in Apex Manual Detergent or other Ecolab detergent solution and water, then rinse. (3) Preheat oven to 150 degrees Fahrenheit then turn off. While oven is still warm, spray interior surfaces with Greasestrip Plus degreaser directly from the container. (4) Allow 5 minutes for the cleaning solution to soak into and soften the soil. Do not allow to dry on surface - adjust time accordingly. On heavily soiled of baked-on grease areas, scrub with a stiff brush. (5) Use a damp cloth to pick up dissolved and loosened grease. Rinse with clear water. Let air dry then reinstall the cleaned drip pans and racks. On 11/21/24 at 08:45 A.M., Record review of the Policy/Procedure entitled: Dishmachine - Cleaning & Sanitizing dated (no date) revealed under Procedure Frequency: Daily of as needed. Record review of the Policy/Procedure entitled: Dishmachine - Cleaning & Sanitizing dated (no date) further revealed under Procedure Steps: (1) Turn off and drain the dishmachine. Check drain for blockage. Clear if needed. (2) Remove curtains and scrub clean with brush and Apex Manual Detergent or other Ecolab detergent solution and water. Set aside to dry. (3) Remove scrap accumulation trays from dishmachine and flush trays under running water. Scrub clean is necessary using brush and Apex Manual Detergent or other Ecolab detergent solution and water. Set aside to dry. (4) Clean pump intake screen by flushing under running water. Scrub clean, if necessary, using brush and Apex Manual Detergent of other Ecolab detergent solution and water. Set aside to dry. (5) Unscrew wash arms and end caps. Clean by flushing with water under faucet. Clean nozzles with toothpick. Set aside to dry. (6) Remove soil inside the prewash and wash tank area of dishmachine using a brush and Apex Manual Detergent or other Ecolab detergent solution and water. (7) Rinse out the inside of dishmachine with pre-flush hose. Be certain to rinse in hard-to-reach areas such as the upper corner walls of the prewash and wash tank area. (8) Clean and sanitize adjacent areas with Oasis 146 Multi-Quat Sanitizer (Use 150 ppm-400 ppm for US and 200 ppm for Canada. See product label for use instructions.) (9) Reinstall curtains, scrap accumulation trays, pump intake screens and wash arms. Ensure arms spin freely then turn on the dishmachine for next use. (10) Clean the top and sides of the dishmachine with clean cloth and Ecoshine or another Ecolab stainless steel cleaner and polish if desired.

Based on observation, interview, and record review, the facility failed to securely store medication, resulting in the potential for misuse, and medication administration errors. Findings include: During an observation on 11/20/24 at 12:15 PM, hall D treatment cart, located in the hall, was noted un-locked with no staff in area and residents self propelling in the area. Continued to observe treatment cart un-locked at 12:46 p.m. During an observation and interview on 11/21/24 at 2:15 PM, observed overflowing open bin of medications located on the floor in the charge nurse office between Redies East hall and D hall. LPN Q reported was the nurse manager and exited the charge nurse office, leaving room unoccupied and door open, and entered the Redies North/East medication room. Residents were noted in common area outside nurse manager office. During an observation on 11/22/24 at 12:32 PM Redies East medication cart observed unlocked in hall with no nurse observed in the area. Residents were observed in hall. During an interview on 11/22/24 at 2:10 PM, Licensed Practical Nurse (LPN) T reported after residents discharged home or if medications discontinued medications are taken to the charge nurse office, located between Redies hall and D hall, and place in bin with exception of narcotics. During an observation on 11/22/24 at 2:25 PM, the charge nurse office door was open with no staff present with overflowing, open bin of medication located on the floor. During an observation on 11/22/24 at 2:28 PM, LPN/charge nurse K observed leaving unoccupied charge nurse office area with door open and medication unsecured. LPN K exited unit through locked doors toward facility entrance. Residents observed in common area outside open charge nurse office with unsecured medications. During an interview and observation on 11/22/24 at 245 PM, located in D hall, LPN/charge nurse K reported staff bring discontinued medications to LPN K office and medications are scanned then sent to pharmacy. LPN K reported medications were moved to medication room when she left office about 20 minutes ago. This surveyor followed LPN K to the charge nurse office and verified open bin of medications were still in place on the floor and verified had not been moved. At 2:48 p.m. UM S was present in the charge nurse office and reported the charge nurse office door should be closed and locked if no one present. Review of the facility, Medication Administration Policy, dated 10/2/24, reflected, Procedure .Keep med cart always locked when not in view .

Based on observation, interview, and record review the facility failed to ensure a comprehensive care plan was in place for prevention of skin breakdown for one (Resident 94) of 20 residents. Findings Included: Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed R94 was at risk for pressure ulcers (PU). The MDS also revealed R94 did not have any pressure ulcers, or other skin concerns. The MDS revealed R94 was admitted to the facility on [DATE]. Review of a quarterly MDS dated [DATE], revealed R94 was at risk for PU, and had one unstagable pressure injury (not stageable due to the wound bed not being visible) that presented as a deep tissue injury (DTI) (an area over a bone that appears dark/purple, soft, and the color does not return when pressed on which can indicate a deep wound underneath). Review of R94's electronic medical record (EMR) revealed R94 was admitted to Hospice upon the same date of admission the facility, 5/25/2024. Diagnoses listed were protein-calorie malnutrition , encounter for palliative care (comfort care). The Current Problem List revealed there was a need for observation and assessment of R94's skin, and the need for skilled teaching related to preservation of skin integrity. Review of a Skin Only Evaluation dated 5/25/2024, which was conducted upon R94's admission to the facility, revealed R94 had no skin issues at that time. Review of R94's baseline care plans dated 5/25/2024, revealed R94 was marked for being at risk for impaired skin integrity. Under, Focus: Risk for impaired skin integrity integrity related to there was a goal that R94 would maintain intact skin integrity. Under the goal three interventions were checked for R94 which included, pressure relieving mattress to bed and pad in wheelchair ., non skid pad above and below cushion, bathe weekly or PRN (as needed), assess skin at bath and PRN, and toilet program PRN cleanse after incontinence. Record review of R94's comprehensive care plans that were initiated based on R94's MDS assessed dated 5/25/2024, revealed no Risk for skin integrity care plan was put into place, and no interventions for skin breakdown prevention were put into place for R94's plan of care. Review of a Skin Only Evaluation dated 7/31/2024, revealed R94 had a new skin issue which was identified to be a pressure ulcer/injury located on the right buttocks. The PU was documented to be unstagable. The evaluation lists interventions to be put into place, but none of the interventions were checked. The next Skin Only Evaluation was dated 8/7/2024, which documented the same wound on R94's buttocks however, documented the wound as a skin tear that measured 3 cm (centimeters) x 2 cm x 0 cm. Review of a Skin Only Evaluation was dated 8/14/2024, revealed that it was documented R94 had no current skin issues. Review of a Skin Only Evaluation was dated 8/21/2024, revealed R94 had a new skin issue to her coccyx (back of body above he buttocks). The wound to the right buttocks was not documented on the evaluation. R94's skin issue/pressure ulcer was not added to her comprehensive care plans until 8/21/2024, which revealed, .has a pressure ulcer(s) related to poor PO (by mouth) intake, deconditioning, anemia AEB (as evidence by) unstageable ulcer to coccyx/buttocks. Stage 3 10/2/2024. Meets criteria for unavoidable skin breakdown. Date Initiated 8/21/2024. Record review of progress notes revealed, Effective Date: 07/31/2024 14:04 (2:04 PM) .Skin Resident has current skin issues. Skin Issue: Pressure Ulcer / Injury. Skin Issue Location: buttocks right side On 11/21/2024 at 10:17 AM, and observation was made with Licensed Practical Nurse (LPN) N, who was the wound nurse of R94's PU to her coccyx. The wound revealed a healing stage 3 PU pin point in size with visible bed, no odor, drainage, slough. LPN N said her expectation was that the nurse who performed a skin assessment on a resident, and found a new skin issue was to report it to her that day so she assess the wound, and put new plan of care interventions and treatment orders. LPN N stated that in regards to R94's PU documented on 7/31/2024 she was not made aware of it until 8/5/2024.

Based on interview and record review, the facility failed to develop and implement new interventions after a fall with injury for one resident (#28) of 20 reviewed for care plans. Findings include: Review of the clinical record, including the Minimum Data Set reflected Resident # 28 (R28) was [AGE] years old and resided on the facility's dementia unit. R28 scored 3 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status. Further review of R28's clinical record revealed R28 fell on [DATE] at approximately 8:00 am. R28's fall was not witnessed, and resulted in bruising to bilateral hands. The incident report reflected R28 was taking herself to the bathroom to get cleaned up ready for breakfast. R#28's fall care plan dated 9/21/21 with the most recent revision date of 12/14/23 which added range of motion to be done during care. On 11/20/24 at 01:38 PM, during an interview with Certified Nursing Assistant (CNA) H reported the dementia hall was her permanent assignment, CNA H stated she was aware of R28's fall on 10/19/24 and when queried what was implemented to prevent further falls, CNA H stated nothing new was added. On 11/20/24 at 02:03 PM during an interview with CNA I also reported being regularly assigned to unit and was not made aware of any new interventions implemented after R28's fall on 10/19/24. On 11/22/24 at 10:49 AM, during an interview with Licensed Practical Nurse/ Unit Manager (LPN/UM) L reported after a fall it was the responsibility of the floor nurse to add interventions to prevent further falls add them to the care plan. LPN/UM L stated the interdisciplinary team then reviews falls reports and care plans completion and appropriateness of intervention. LPN/UM L reviewed R28's electronic medical record and agreed there was no new intervention added to the care plan after R28's fall on 10/19/24.

Based on observation, interview, and record review, the facility failed to provide services that met the acceptable standards of clinical practice for PICC (peripherally inserted central catheter) line dressings in 1 of 1 sampled resident (Resident #319) reviewed for PICC lines, resulting in the increased likelihood for infection. Findings include: Resident # 319(R319) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R319 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included infection right knee post joint removal, anemia, heart failure, hypertension (high blood pressure), kidney disease, and chronic obstructive pulmonary disease . The MDS reflected R319 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact. During an observation and interview on 11/20/24 at 4:05pm R319 was laying in bed and appeared calm, pleasant and able to answer questions without difficulty. R319 reported received intraveounous (IV) antoboitics daily in morning through PICC line. Observed single lumen PICC located on R319 right upper arm with dressing dated 11/13/24. R319 reported nurse had reported planned to change that evening. During an observation on 11/21/24 at 8:29 AM, R319 was laying in bed with IV mediation infusing through PICC line located in Right upper arm. R319 PICC dressing was dated 11/20/24 with gauze under clear opsite dressing directly over insertion site. During an interview on 11/21/24 at 2:15 PM, Licensed Practical Nurse(LPN) Q reported was a charge nurse. LPN Q reported would expect PICC line dressings to be changed every 7 days using items in PICC dressing kit. LPN Q reported PICC insertion site should be covered with clear opsite to be able to visualize insertion site with no use of gauze under opsite. During an interview on 11/22/24 at 10:15 AM, Unit Manager (UM) T reported would expect PICC dressing to be changed every 7 days using clear opsite to cover insertion site. Nurse staff expected to assess PICC site for signs and symptoms of infection, including reddness at insertion site every shift. UM T reported would not expect to see gauze over insertion site because of need to visually assess site. UM T reported facility policy included PICC dressing change to be completed every 7 days and covered with clear opsite over insertion site. According to Clinical Nursing Skills & Techniques, 6th edition, ([NAME], A., [NAME], P. 2006. page 937), Gauze dressings should be changed routinely every 48 hours and immediately if integrity is compromised. Gauze used underneath a transparent dressing is considered a gauze dressing and should be changed every 48 hours.

This citation pertains to intake numbers MI00131454, MI00134210 and MI00130635. Based on observation, interview and record review, the facility failed to 1) follow Physician's Orders for medications for one (Resident #2) of three reviewed for medications; 2) assess, monitor and promptly act on a change in condition for one (Resident #3) of three reviewed for assessment and monitoring; 3) ensure appropriate monitoring of blood glucose (sugar) levels for one (Resident #14) of three reviewed for assessment and monitoring; and 4) ensure insulin was administered according to Physician's Orders for two (Resident #14 and #16) of three reviewed for medications, resulting in medications not being administered according to Physician's Orders and/or manufacturer instructions, delayed recognition and treatment for change in condition and lack of appropriate monitoring and management of diabetes. Findings include: Resident #3 (R3): Review of the medical record reflected R3 was admitted to the facility on [DATE], with diagnoses that included heart disease, dementia, atrial fibrillation and long-term (current) use of anticoagulants. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/29/22, reflected R3 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R3 required limited to extensive assistance of one person for activities of daily living and received an anticoagulant (blood thinning medication) for seven days during the look-back period. A Discharge return anticipated MDS, with an ARD of 6/16/22, reflected R3 was sent to the hospital. R3 did not return to the facility. A Progress Note for 6/16/22 at 1:08 PM reflected R3 was sent to the hospital for suspected signs of a gastrointestinal (GI) bleed. An Emergency Medical Services (EMS) report, dated 6/16/22, reflected the call was received at 8:53 AM, EMS was en route at 8:54 AM and on scene at 8:58 AM. At 9:05 AM, R3's blood pressure was 72/37 mmHg and her pulse was 104 beats per minute (bpm). According to the report, EMS was dispatched for a resident coughing up blood. Staff (facility) stated R3 coughed up some bright red blood and had some pinkish blood in her stool. The report reflected R3's family member was on scene and reported R3 had been punky and a little confused since the day prior. According to facility staff, R3's blood pressure was usually in the 130's, and they had a reading of 109 systolic (top number) earlier. The report reflected when EMS arrived on scene, R3 was lethargic and weak, and her skin was pale and cool. An additional EMS report dated 6/16/22 (for the same dispatch) reflected R3 had vomited blood and passed blood in her stool. According to the report, R3 was verbal and reported she had been vomiting blood for the past two days. R3's last blood pressure recorded in the medical record was 118/68 mmHg on 6/15/22 at 7:01 PM. The last pulse in the medical record was 82 bpm on 6/15/22 at 7:01 PM. The last respiratory rate in the medical record was recorded on 5/31/22. A temperature of 97.7 degrees Fahrenheit was recorded by agency Licensed Practical Nurse (LPN) N on 6/16/22 at 1:31 AM. R3's medical record did not reflect notes or assessments pertaining to a change in condition. There was no documentation reflective of communication with a Physician. During a phone interview on 3/1/23 at 1:45 PM, Certified Nurse Aide (CNA) I reported recalling when R3 was sent to the hospital. CNA I reported that pretty quickly after getting on the floor for her shift, there was some commotion in R3's room. Other CNAs were in the room and stated R3 was bleeding from either her mouth or nose. CNA I reported observing some bleeding and some blood on R3's bed. The day shift nurse was made aware of R3's bleeding and complaints of pain, and R3 was sent to the hospital. According to CNA I, CNA J reported they had been concerned about R3 and reported it to their nurse (on the prior shift). CNA I stated it was unclear whether the midnight nurse had addressed it. According to CNA I, from the shift report she received, it sounded like something had been going on with R3 and was reported to the midnight nurse (the shift prior). CNA I reported that former Director of Nursing (DON) Q took a statement from her and wrote everything down on paper. According to facility schedules, agency LPN F was on duty when R3 was sent to the hospital on 6/16/22. Attempts to contact LPN F by phone on 2/23/23 at 12:17 PM and 2/28/23 at 11:18 AM were unsuccessful. According to facility schedules, agency LPN N was on duty the midnight shift of 6/15/22 to the morning of 6/16/22. An attempt to contact LPN N by phone on 3/1/23 at 2:48 PM was unsuccessful. During a phone interview on 3/1/23 at 12:04 PM, CNA J did not recall any vomiting or changes in R3's bowel movements around the time of her discharge to the hospital. During a follow-up interview on 3/1/23 at 2:23 PM, CNA J did not recall anything pertaining to bleeding for R3. If she had noticed, she would have immediately notified the nurse. Attempts to contact former DON Q by phone on 3/1/23 at 2:53 PM and 3/2/23 at 3:44 PM were unsuccessful. According to CNA I's statement obtained by former DON Q on 6/20/22, when CNA I arrived to work, she received report from CNA J from the night before. CNA J reported that R3 had called more than normal overnight because she was not feeling well and had a couple loose stools. Another CNA had answered R3's call light and stated R3 had a tissue with blood on it. According to the statement, it looked like it (blood) was coming from R3's mouth. LPN F went to check on R3 and contacted the doctor. When asked how she was doing, R3 stated it felt like her insides were burning. When taken to the bathroom, R3's stool was dark colored and watery. After being showered, R3 had another bowel movement that was dark in color. The nurse then called the doctor again, and R3 was sent to the hospital. Call light records reflected R3 used her call light 11 times between 3:51 AM and 9:25 AM on 6/16/22. According to CNA J's statement obtained by former DON Q on 6/21/22, CNA J was asked about the night she took care of R3, prior to her hospitalization on [DATE]. CNA J reported caring for R3 on the midnight shift on 6/14/22 and 6/15/22. When she got to work on Tuesday (6/14/22), R3 seemed more unsteady and a bit more confused than normal but overall was good throughout the night. CNA J thought R3 was just tired. On 6/15/22, R3 still seemed confused. R3 got up a couple times during the night and had loose stool but not abnormal looking. CNA J's statement reflected she told the nurse, and he checked on R3. When day shift showed up, CNA J told them R3 did not seem like herself. According to hospital records for a start of care of 6/16/22, R3 had an International Normalized Ratio (INR/blood clotting test) of 8.4 (high) and had been vomiting blood since the night prior. According to the records, R3's goal INR was 2.5 to 3.5. Hospital notes reflected R3 likely had acute upper GI bleeding and supratherapeutic (above therapeutic range) INR. Resident #14 (R14): Review of the medical record reflected R14 was admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included other sequelae of cerebral infarction, altered mental status, multiple fractured ribs of the left side, acidosis, type 1 diabetes with diabetic chronic kidney disease, chronic kidney disease stage 3, hyperlipidemia, hypertension, type 2 diabetes with hypoglycemia without coma and dehydration. The Admission MDS, with an ARD of 5/11/22, reflected R14 scored 14 out of 15 (cognitively intact) on the BIMS. The same MDS reflected R14 required supervision to limited assistance of one person for most activities of daily living and extensive assistance of one person for bathing. The MDS history reflected a discharge return anticipated MDS, with an ARD of 5/17/22. According to the medical record, R14's blood glucose (sugar) was 617 mg/dL on 5/17/22, and she was sent to the hospital. R14 returned to the facility on [DATE] and was discharged back to the hospital on 6/10/22. R14 did not return to the facility. The May 2022 Medication Administration Record (MAR) reflected R14's blood sugars were scheduled to be checked daily at 7:00 AM, 11:00 AM and 4:00 PM. Humalog KwikPen insulin 100 units per milliliter (u/mL) was to be administered subcutaneously (under the skin) via sliding scale (dependent upon blood glucose levels), with meals, as follows: 150-200 mg/dL=2 units of insulin, 201-250 mg/dL=4 units of insulin, 251-300 mg/dL=6 units of insulin, 301-350 mg/dL=8 units of insulin, 351-400 mg/dL=10 units of insulin, 401-450 mg/dL=12 units of insulin. If the blood sugar was below 60 mg/dL or above 450 mg/dL, the Physician was to be notified. During an interview on 2/28/23 at 1:28 PM, LPN G reported she could not recall how close to a meal rapid acting insulin was to be administered and stated she was just going on the orders. According to the May 2022 MAR, R14's blood glucose was recorded by LPN C as 270 mg/dL for the 11:00 AM check on 5/7/22. A code of 5 was documented on the MAR, which indicated, Hold/See Nurse Notes. A Progress Note for 5/7/22 at 2:00 PM reflected R14 was refusing insulin due to not eating much for lunch. The note reflected R14 would be rechecked in one hour, and the need for insulin would be determined. R14's vital signs and Medication Administration Audit Report reflected the 5/7/22 blood glucose of 270 mg/dL was recorded at 2:00 PM, and the next check was at 5:08 PM, with a result of 257 mg/dL. According to R14's vital signs and a Medication Administration Audit Report, the 7:00 AM blood glucose for 5/8/22 was recorded as 225 mg/dL by LPN C at 9:52 AM. On 5/12/22, R14's 11:00 AM blood glucose was documented as 408 mg/dL at 2:07 PM (more than three hours after it was scheduled), according to the vital signs and a Medication Administration Audit Report. The May 2022 MAR reflected R14 had an order dated 5/12/22 for 21 units of Insulin Glargine (long acting insulin) 100 u/mL to be administered subcutaneously at bedtime. The MAR reflected the scheduled dose on 5/14/22 was documented as 5, which indicated, Hold/See Nurse Notes. A Progress Note for 5/14/22 reflected the dose was held due to a low blood sugar of 101 mg/dL. There was no documentation that the Physician had been notified or that an order had been given to hold the insulin. During a phone interview on 2/27/23 at 3:23 PM, LPN D reported the blood glucose value did not determine if a resident would receive their long acting insulin. She reported the long acting insulin would still be administered, and they would have to make sure the resident had a snack. During an interview on 3/2/23 at 9:14 AM, LPN Z reported if she was going to hold medication, she would contact the doctor. If she was holding insulin, she would never not let the doctor know. If a blood sugar was below 60 mg/dL or above 400 mg/dL, there were parameters to call the doctor. During an interview on 3/2/23 at 10:36 AM, DON B was asked if nurses could make an independent judgment to hold or administer insulin. DON B reported she would have to check the policy. She reported there were parameters, and if there was concerns, the doctor should be notified. She reported blood glucose levels were to be checked before a resident ate, and insulin was to be administered once the tray was delivered but before the resident ate. According to the vital signs and a Medication Administration Audit Report, the 7:00 AM blood glucose on 5/15/22 was recorded as 445 mg/dL at 10:42 AM. The May 2022 MAR reflected NA was documented for a blood glucose result for the 4:00 PM blood glucose on 5/15/22. There was no correlating documentation reflective of why R14's blood glucose was not checked. A Comprehensive Metabolic Panel (CMP/laboratory test) collected on 5/16/22 at 6:25 AM, with results reported on 5/16/22 at 10:51 AM, reflected a blood glucose of 609 mg/dL (HH) [a critical high value]. The vital signs and a Medication Administration Audit Report reflected the 7:00 AM scheduled blood glucose on 5/16/22 was recorded as 415 mg/dL at 8:59 AM. According to the vital signs and a Medication Administration Audit Report, the 11:00 AM blood glucose on 5/16/22 was documented as 337 mg/dL at 1:50 PM (almost three hours after the scheduled time). A Basic Metabolic Panel (BMP/laboratory test) collected on 5/17/22 at 6:21 AM, with results reported on 5/17/22 at 10:23 AM, reflected a blood glucose of 617 mg/dL (HH) [a critical high value]. The May 2022 MAR reflected the 7:00 AM blood sugar result on 5/17/22 was documented as 149 mg/dL by LPN C (indicating insulin was not to be administered per the sliding scale). The May 2022 MAR reflected the 11:00 AM blood sugar result on 5/17/22 was recorded as 617 mg/dL by LPN C. According to glucometer (device used to check blood sugar) Manufacturer Instructions provided by the facility, .If your blood glucose is above 600 mg/dL, you will receive a HI [no numbered result] . Attempts to contact LPN C via phone on 2/22/23 at 10:28 AM, 2/23/22 at 12:09 PM and 2/28/23 at 11:12 AM were unsuccessful. Voice messages were left, and no return call was received prior to the exit of the survey on 3/2/23. On 3/1/23 at 12:41 PM, Director of Nursing (DON) B reported LPN C was still a facility employee, but she did not think LPN C would be returning the phone call to the State Agency. During an interview on 3/2/23 at 10:36 AM, DON B reported that it looked like the laboratory report value for a blood glucose of 617 mg/dL on 5/17/22 was documented for R14's 11:00 AM blood glucose check on 5/17/22. DON B stated that based on what the glucometer manual said, it would not give a reading above 600 (mg/dL) and would read high (HI). According to the hospital After Visit Summary for 6/8/22, R14 was found to be in diabetic ketoacidosis (DKA/serious complication of diabetes). Additionally, there was documentation of, .Right cerebellar CVA [cerebrovascular accident/stroke] presented with altered mental status further worsened with DKA . According to the Centers for Disease Control and Prevention (CDC), .Diabetic ketoacidosis (DKA) is a serious complication of diabetes that can be life-threatening .DKA develops when your body doesn't have enough insulin to allow blood sugar into your cells for use as energy. Instead, your liver breaks down fat for fuel, a process that produces acids called ketones. When too many ketones are produced too fast, they can build up to dangerous levels in your body .Causes of DKA Very high blood sugar and low insulin levels lead to DKA. The two most common causes are .Illness .Missing insulin shots, a clogged insulin pump, or the wrong insulin dose . (https://www.cdc.gov/diabetes/basics/diabetic-ketoacidosis.html) During an interview on 2/28/23 at 1:02 PM, Director of Nursing (DON) B was queried on the process for insulin administration via insulin pen and did not describe the process of priming the pen. DON B reported she had not used an insulin pen in a long time. During a phone interview on 3/1/23 at 4:01 PM, LPN Y was queried on the process of administration of insulin via an insulin pen. LPN Y did not describe the process of priming the insulin pen before administration of the ordered insulin dose. During an interview on 3/2/23 at 9:14 AM, LPN Z reported when priming an insulin pen, the dial was to be set to two units. When queried on the positioning of the insulin pen when priming, LPN Z reported she did not think there was a particular position to hold the pen. She then stated she guessed the pen was to be held in a downward position due to wanting the needle full and without air. According to the facility's Insulin Flex Pen Use Policy, with a review date of 5/27/21, .POLICY STATEMENT / PURPOSE To deliver accurate insulin does [sic] thru the flex pen .Remove the protective tab from disposable needle .Screw the needle tightly onto the flex pen .Pull off the big outer needle cap .Pull of the inner needle cap and dispose of it .Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and ensure proper dosing .Turn the dose selector to select 2 units .Hold your flex pen with the needle pointing up .Keep the needle pointing upwards; press the push button all the way in .the dose selector returns to 0, a drop of insulin should appear at the needle tip. If not change the needle and repeat the procedure no more than 6 times. If you do not see a drop of insulin after 6 times, do not use the flex pen .Turn dose selector to the number of units you need to inject .Insert the needle into the skin, inject the dose by pressing the push button all the way until the 0 lines up with the pointer .Keep the needle in the skin for at least 6 seconds and keep the push button pressed all the way until the needle has been pulled out of the skin. This will make sure the full dose has been given . Resident #16 (R16): Review of the medical record reflected R16 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included hypertensive chronic kidney disease, type 2 diabetes, stage 4 chronic kidney disease, atrial fibrillation, long-term (current) use of anticoagulants, long-term (current) use of insulin and peripheral vascular disease. The Quarterly MDS, with an ARD of 12/15/22, reflected R16 scored 15 out of 15 (cognitively intact) on the BIMS. The same MDS reflected R16 did not walk and required supervision to extensive assistance of one person for activities of daily living. On 3/2/23 at 9:33 AM, R16 was observed seated in a wheelchair, in her room. She was appropriately dressed and groomed. A Physician's Order, dated 9/15/21, reflected R16 was to receive four units of 100 u/mL humalog insulin subcutaneously with meals. The insulin was to be held if R16 ate less than 50% of her meal. The 7:00 AM scheduled dose on 2/9/23 was documented as 9 by LPN AA, which indicated Other / See Nurse Notes. A Progress Note for 2/9/23 at 2:41 PM, pertaining to R16's 4 units of humalog insulin, reflected she missed the morning dose. During an interview on 3/2/23 at 11:14 AM, LPN AA reported the only reason she would not have given R16 her morning insulin was if R16 went to an activity or wasn't available to give the insulin, and it was running into the next meal. She reported the insulin was probably already late, so she did not want to give it. LPN AA stated she could not explain why the insulin was not given. 34705 Resident #2 (R2) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R2 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), renal disease, diabetes, arthritis, osteoporosis, fractures, chronic obstructive pulmonary disease, and depression. The MDS reflected R2 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required two-person physical assist with bed mobility, transfers, locomotion, dressing, toileting, and one-person physical assist with eating, hygiene, and bathing. Review of intake, dated 8/9/22, reflected concerns R2 did not received medication for two days on admission. Review of the Electronic Medical record, dated 8/5/22 through 8/15/22, reflected R2 admitted to the facility on [DATE] from local hospital and discharged from facility on 8/15/22. Review of R2 Medication Administration Record (MAR), dated 8/1/22 through 8/31/22 redetected, R2 did not receive Physician orders Pravastatin on 8/5/22 or 8/6/22, three doses of Gabapentin(pain medication) on 8/6/22. Review of the Medication Admin Audit Report, dated 8/5/22 to 8/6/22, reflected R2 did not receive Physician ordered Pravastatin the evening of 8/5/22 or 8/6/22. The reported reflected R2 had Victoza (diabetic injectable medication) ordered at 7:00 a.m. and received at 10:24 a.m. on 8/6/22. Continued review of the report reflected R2 missed three doses of Physician orders Gabapentin on 8/6/22. Review of Nursing Progress Notes, dated 8/5/22 at 3:03 p.m., reflected vitals for R2 obtained at 4:15 p.m. Review of the Physician Progress Note, dated 8/6/2022 at 3:50 p.m., reflected, REASON FOR VISIT: s/p fall, complicated by type II odontoid cervical fracture status post nasal bone fracture, left knee (patella) fracture, HPI : [NAME] Griffin. Is a 78 y.o. Female with past med hx of HTN, Hypothyroidism, DM, hx of cervical fusion who was brought to [named hospital] ED after a fall .Patient reported that her insulin and other medications came late after her arrival into the facility. She finally got her pain medication and Victoza this morning. She is hoping that now her meds are in that she will receive medications promptly . Review of R2 Nursing Progress Note, dated 8/10/2022 at 10:55 a.m., reflected, writer spoke with Pt. daughter, [named], about her mother's care. She is very upset about multiple issues from nursing and therapy .She also states that staff have not been giving medications due to being out of supply . The note was written by Unit Manager U. During an telephone interview on 3/1/23 at 1:59 p.m., Afternoon Charge Nurse (ACN) V(nurse who completed R2 admission) reported did not recall R2 admission but reported usually if new admission from local hospital they send two days of medications to facility with residents. ACN V reported if medications given would expect staff to document as given on the MAR. During an interview on 3/1/22 at 2:30 p.m., Director of Nursing B and Nursing Home Administrator A present for interview. NHA A reported R2 arrived to facility on 8/5/22 at 3:03 pm. DON B reported they have pharmacy back up with medications and R2 diabetic medication should have been available for 8/6/22 morning dose. During an interview on 3/1/23 at 2:45pm, UM U reported spoke with R2 daughter by phone about complaints on 8/10/22 and informed R2 daughter that R2 received medications after reviewing the MAR. Review of R2 Physician Progress Notes, dated 8/6/2022 at 3:50 p.m., reflected, REASON FOR VISIT: s/p fall, complicated by type II odontoid cervical fracture status post nasal bone fracture, left knee (patella) fracture .Grief-she lost her mom about a week ago. She is gratified that she live a long life-over [AGE] years old. Well supported by family including her sister [named] and her friend [named] who were at bedside today. Sister requested antidepressant/anti-anxiety medication which I started-low-dose Cymbalta 20 milligrams daily may up titrate if needed .anxiety and depression 20 milligram Cymbalta was initiated today 08/06/2022. Monitor response Increase dose to 30 milligrams if well tolerated . Review of R2 Physician Progress Notes, dated 8/13/2022 at 10:52 a.m., reflected, [named R2] is seen for a follow up on anxiety, depression, review of ED notes from 8/12, sent for concerns of right arm fracture, redness under b/l breasts, requests change in bowel regimen .TODAY 8/13/2022 Patient was seen today resting comfortably in bed. She does tell me she is quite exhausted from the events yesterday of going to the ED for CT scan to confirm right humerus distal end closed fracture. She denies any current chest pain, shortness of breath, nausea, vomiting, or diarrhea. She requests to change the senna tablets to as needed, can continue on the scheduled MiraLax. She does complain of generalized pain from her initial injuries but more specifically her right arm has been bothering her in the elbow. She currently rates it a 6 to 7/10. She does report some relief taking the scheduled Tylenol and the p.r.n. oxycodone. She has an appointment with [NAME] Orthopedics on Tuesday. She does admit to a lot of anxiety, she reports that she has always been a worrier but since the accident she is having a difficult time keeping herself calm. She recently lost her mother and also going through the grief process. It does appear she was to start on 20 milligrams Cymbalta on 08/06/2022, that medication has not yet started so patient does agree to start that as well as she is requesting to have something else as needed if she develops more of a panic type attack. She does agree to a short course of p.r.n. Xanax. Social work report that they have consulted the psychiatric group who will be seeing patient this week. She denies any thoughts or plans to hurt herself. She feels that she just wants to start to get stronger and do more therapy . Review of the MAR, dated 8/1/22 through 8/31/22, reflected R2 did not receive Cymbalta as ordered by the physician on 8/6/22 until 8/14/22. During an telephone interview on 3/2/22 at 11:52 a.m., DON B reported R2's Pravastatin was not in pharmacy backup and delivery comes at midnight. DON B' verified R2 did not receive Pravastatin dose on 8/5/22 or 8/6/22. and reported would expect nurse to call physician related to missed dose and did not find evidence Physician had been notified. DON B reported R2 Victoza was ordered at 7 to 8 in the morning and was administered late and was unable to answer why. DON B reported would expect nurse to notify physician if medication administered outside one hour of order. DON B reported R2 missed three doses of Gabapentin 8/6/22 and reported was available in pharmacy backup but was not administered. DON B R2 cymbalta order was not entered into EMR by ordering Nurse Practitioner(NP) and should have been and reported would not expect nurse of UM to review NP notes. DON B reported overall Unit Manager were responsible for reviewing ancillary service Physician notes and orders. DON B verified R2 NP noted reflected order for R2 to start cymbalta 8/6/22 and was not started until 8/14/22.

This citation pertains to MI 597 Based on interview and record review, the facility failed to identify and intervene for an acute change in condition for one (Resident #7) of two reviewed for falls, resulting in Immediate Jeopardy when Resident #7 sustained a fall with head injury, changes in neurological status, and a delayed acute care intervention of transfer to the emergency room , death due to complications of subdural and intracerebral hemorrhage, and the likelihood for serious harm, serious injury, serious impairment or death for all 130 facility residents. Findings include: Review of the medical record revealed Resident #7 (R7) was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed R7 had severely impaired cognitive skills for daily decision making, inattention, and disorganized thinking. Review of the Health Status Note dated [DATE] at 4:30 PM revealed Residents roommate called out to nurse to come to residents room because resident has had fall. Upon entering room observed resident setting up with legs straight out in front of her, CNA [Certified Nursing Assistant] was holding resident up, CNA states resident had fallen from shower chair when CNA was getting some pajama pants from closet. The Health Status Note dated [DATE] at 5:03 PM revealed [Nurse Practitioner's name] aware of fall and injuries of bruised right eye, hematoma right top head (1cm x 1cm), bruise to right forearm 2cm x 1.5cm, moderate bleeding from right nares, neuro checks have been per baseline function, PERRL [pupils equal round and reactive to light]/constricted, able to move upper and lower extremities with np [sic] pain. No new orders at this time. The Health Status Note dated [DATE] at 7:20 PM revealed Resident wanting to use bathroom, 2 staff assisted her to wheel chair, then to shower room to use toilet. While seated on toilet CNA observed bulge to right hip, bruising observed and baseball like sized bump to right hip, old healed scar at right hip from old surgery, no redness, no unusual warmth. Resident doesn't seem painful when area touched. Call out to after hours/on call physician. The Health Status Note dated [DATE] at 8:49 PM revealed [Name of Physician] returned call and updated about right hip bruised with raised almost baseball sized lump and old healed incision to area also, doesn't have pain when area touched and no pain when weight bearing. MD ordered xray right hip . The Health Status Note dated [DATE] at 11:18 PM revealed Neuro checks have been per baseline function. A&O x 1 to self, normal confusion, disorganized thought pattern, speech clear, PERRL, able to move upper and lower extremities with no pain. Noticed new bruise to right upper shoulder, light purple in color, measures 2cm x 2cm. Ice applied to right hip x 15 min. for swelling, hip doesn't seem painful with palpation or ice application. presently awake in recliner chair in hallway . In an interview on [DATE] at 3:49 PM, CNA R reported after R7's fall there was a lot of blood from her head .just remember blood going down her face. CNA R reported R7 also had bruising on the right side of her face and around her eye. In an interview on [DATE] at 4:20 PM, CNA S reported on [DATE], R7 fell from the shower chair and hit her head. CNA S stated after the fall, R7's words started getting a little more slurred. I could tell it was a bad fall. By the time midnights got here, they sent her out. She was slurring words. I was very worried. When asked what time it was noticed that R7's speech was more slurred, CNA S stated by 10:30 [PM]. When asked if any other changes were noted during the afternoon shift on [DATE], CNA S reported R7 seemed restless, but weaker .she seemed unwell, hard to explain. She hit her head, seemed a little more out of it . In an interview on [DATE] at 11:02 AM, LPN U reported she recalled R7's roommate calling for her when R7 fell . LPN U reported R7 had hit her head and had a bloody nose. LPN U reported during her shift which ended at 11:30 PM, R7 napped on and off and talked mumble jumble which was her baseline. LPN U reported she was not aware of R7's slurred speech or the increased weakness. In a telephone interview on [DATE] at 2:40 PM, CNA O reported on [DATE], R7 had fallen on the previous shift and when she arrived to work at 11:00 PM, it was horrible .she [R7] was bleeding from her nose, she was sitting up and puking .had a really huge bruise on her hip .she wasn't herself, kind of slurring her words. All of us on midnights questioned why she wasn't sent out [to the hospital]. CNA O stated they were trying to say [R7] always gagged and spit, but CNA O reported that was not normal for R7. In a telephone interview on [DATE] at 3:15PM, Licensed Practical Nurse (LPN) Q reported when she arrived to work on [DATE] at 11:00 PM, R7 was sitting in the hallway in a wheelchair. LPN Q reported R7 had a hematoma on her forehead and a black eye. LPN Q stated she [R7] wasn't speaking to me like the person I know .She was not herself. She wasn't coherent. LPN Q reported she then got report from the previous shift who reported R7 had sustained a fall. LPN Q reported the previous shift reported R7 was fine, but that LPN Q questioned why R7 was not sent out to the hospital. LPN Q stated Personally, I would have sent her out. She wasn't speaking coherently. I told the nurse and everyone it looked like she was dying in front of me. I couldn't explain it. LPN Q reported after shift change report, she was sitting in front of R7 and R7 began spitting up clear, green, and yellow bile. LPN Q reported she left the hall to speak with the charge nurse (LPN Y) because I felt like she [R7] needed to go now [to the emergency room ]. LPN Q reported she called the physician who did not call back within 30 minutes. LPN Q reported she told LPN Y and then called the on-call physician again and did not receive a return call. LPN Q reported it had been an hour with no call back and R7 needed to go now. LPN Q reported she then called 911. LPN Q could not recall what time R7 left the facility. In a telephone interview on [DATE] at 10:04 AM, CNA T reported coming into work on [DATE] at 11:00 PM and R7 was kind of lethargic, seemed really out of it, really weak. She couldn't stand .She looked really bad in my opinion. She just looked like she should have been sent out for a CT scan to make sure she didn't have a brain bleed .She wasn't her normal self when we came on at 11 [11:00 PM]. There was a major change in her condition. CNA T reported sometimes R7 would speak in a word salad, but it was worse than that. CNA T stated around midnight we had a hard time transferring her from the wheelchair to the recliner. CNA T stated They [afternoon shift] said she had fallen. I don't know for what reason they didn't send her out [to the emergency room ]. In a telephone interview on [DATE] at 1:15 PM, LPN Y reported she did not recall R7. When asked about the protocol for paging an on-call physician, LPN Y reported if a return call is not received after the first page, the facility will page a second time. LPN Y reported they had been instructed by the on-call paging service to wait 30 minutes before paging a second time. When asked about the change in neurological assessment that R7 experienced, LPN Y stated I would already be getting them ready to send out as I'm calling the doctor. LPN Y called the surveyor back on [DATE] at 10:58 AM and reported she reviewed R7's notes, spoke with LPN Q, and now recalled more of the situation. LPN Y stated LPN Q paints a clear picture of what happened. LPN Y reported she first saw R7 on [DATE] at 1:00 AM and at that point she vomited. LPN Y reported she then began a change in condition form. As more questions were asked, LPN Y reported it was best to speak with LPN Q. Review of the eINTERACT SBAR Summary for Providers note dated [DATE] at 1:05 AM revealed Called on call MD x2 with no response back, sent to ER for emergent vomiting of blood. To note, EMS was not called until 1:57 AM. The Health Status Note dated [DATE] at 1:59 AM revealed Resident sent to [Hospital Name] for vomiting post fall with head trauma. Resident began vomiting with dark red specs present. MDS paged x 2 with no return call .[Name of Ambulance Company] called to transport [due to] resident declining. The Health Status Note dated [DATE] at 2:35 AM revealed Writer received report from afternoon Nurse about residents fall that happened [at 4:30 PM]. Resident received in the hall in recliner incoherent not at residents baseline. Resident began having emesis and gaging [sic] [at 11:45 PM]. Resident had two more episodes of emesis and writer called on call [Physician name] to send resident out. On call was called 3 times with no call back. VS [vital signs] in [electronic medical record]. Writer called [name of ambulance company] and sent resident out. On call called back while writer was on the phone with [ambulance company] and was made aware of resident being sent out . The Health Status Note dated [DATE] at 2:45 AM revealed .Resident was received in the hall in her recliner. Writer observed resident gaging [sic] and coughing. Afternoon CNA stated resident does that from time to time. Around [12:00 AM] writer observed resident vomiting [MEDICATION(S)] color emesis. Writer gave resident her medication at [12:34 AM] and resident swallowed them fine. Residents NEURO check was not at residents baseline her word salad was incomparable sounds. Resident PERRLA no reaction noted. Resident was sent out to the hospital. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] - Best Verbal Response changed from confused on [DATE] at 11:30 PM to Incomplete Sounds at 12:30 AM - Best Motor Response changed from obeys commands at 11:30 PM to withdraws (pain) at 12:30 AM -Glasgow Coma Scale Total changed from 14 at 11:30 PM to 10 at 12:30 AM - Pupil reaction on right side changed from brisk at 11:30 PM to no reaction at 12:30 AM - Pupil reaction on left side changed from brisk at 11:30 PM to no reaction at 12:30 AM - Arms changed from normal power at 11:30 PM to weakness at 12:30 AM - Legs changed from normal power at 11:30 PM to weakness at 12:30 AM There were no neurological assessments documented after [DATE] at 12:30 AM. Review of R7's vital signs revealed vital signs were obtained on [DATE] at 5:18 PM and not again until [DATE] at 1:07 AM. Review of the Prehospital Care Report Summary (Emergency Medical Services Run Sheet) revealed EMS was called on [DATE] at 1:57 AM. EMS arrived to the facility at 2:01 AM. The dispatch reason was fall not alert. The run sheet revealed staff states patient fell off a shower chair about [4:00 PM]. States patient is normally oriented x 1, but more alert than she is tonight. Staff denies patient being on blood thinners. Arrived to find patient lying back in a recliner. Patient acknowledges her name and follows direction, but isn't opening her eyes unless prompted. Patient has large hematoma and bruising to right forehead, + nosebleed, but just very slow/not actively bleeding. Large bruising around and under right eye. + bruising and deformity to right trochanter area . Review of a second EMS run sheet (two units were dispatched) revealed .Pt [patient] is a 95 YOF [year old female] who reportedly fell in shower around [4:00 PM] according to staff that gave report at shift change. The staff present noticed bruising and hematoma on right forehead/temple and severe swelling of right hip/femur without angulation. pt was altered and normally has dementia with AAOx1 status. Pt was incoherent using inappropriate sounds, opens eyes to verbal, and withdraws to pain. pt was GCS 9 [Glasgow Coma Scale of 9]. Pt has pulses x 4 extremities. Pt has no hx [history] of taking blood thinning meds. Pt is a DNR and family was notified of the incident and transport to [name of hospital emergency room ]. Pt airway was intact with slow shallow breathing. Pt has raccoon eyes and epistaxis [nosebleed]. Pt v/s [vital signs] were elevated with BP in 180 systolic. Pt was place [sic] in C-collar and 2 person carried to cot. Pt bleeding controlled with bandaging . According to the Centers for Disease Control and Prevention (CDC), Glasgow Coma Scale (GCS) Head Injury Classification scores are as follows: Severe Head Injury----GCS score of 8 or less Moderate Head Injury----GCS score of 9 to 12 Mild Head Injury----GCS score of 13 to 15 (https://www.cdc.gov/masstrauma/resources/gcs.pdf) In an interview on [DATE] at 1:55 PM, Director of Nursing (DON) B agreed R7 had a documented change in her neurological assessment on [DATE] at 12:30 AM. DON B reported the facility completed an eEINTERACT form on [DATE] at 1:00 AM, which is our prompt to send to the hospital. DON B reported she would expect staff to call EMS at that time. In a telephone interview on [DATE] at 10:23 AM, when asked about the gagging and vomiting that was documented at 11:45 PM on [DATE], Physician W stated at that point she had a change in her neuro exam. I would expect them to elevate that condition to on call and send to ER. When asked what timeframe she would expect that to happen, Physician W reported it was a very hard question to answer and stated, it sounds very acute to me .it would raise my concern for triaging. When mentioned that it was not until 1:57 AM that EMS was called, Physician W stated Wow. That would not be my overall goal and I am surprised. This sounds like an out of the ordinary experience. Physician W reported there were different methods to paging an on-call physician, depending on the level of emergency. Physician W reported she was not aware of how the facility paged the on-call physician that night. Physician W stated Technically what should have happened, as a nurse I would not have waited that long . they also have medical director coverage. Physician W reported the point of neurological assessments was to pick up subtle changes and not wait for a huge change. In a telephone interview on [DATE] at 10:46, Medical Director (MD) X reported it looked like R7 had a neurological assessment change between [DATE] at 11:30 PM and [DATE] at 12:30 AM. MD X also reported garbled and incoherent speech would indicate a neurological change. MD X reported the eInteract form was timestamped at 1:05 AM, which lead her to believe the facility planned on sending R7 out to the hospital at that time. When asked when she would expect the facility to call EMS, MD X stated Right during that time period. When they identify they were going to send [R7] out. MD X reported according to the EMS run sheet, the facility called EMS at 1:57 AM. MD X reported she did not think this was acceptable, but also did not know what else was going on in the building at the same time. Review of R7's CT scan performed in the Emergency Department on [DATE] revealed Multifocal post traumatic intracranial hemorrhage. Left-sided holohemispheric subdural hematoma measuring up to 14 mm in maximal thickness. There is associated 2.5 mm left to right midline shift. 2 cm hemorrhagic contusion within the left temporal lobe. Small amount of hyperdense acute subarachnoid hemorrhage within the left temporal lobe. Review of R7's Certificate of Death dated [DATE] revealed R7 died as a result of complications of subdural and intracerebral hemorrhage due to a fall. According to the Clevelend Clinic, symptoms of a brain hemorrhage depend on the area of the brain involved. In general, symptoms of brain bleeds can include: Sudden tingling, weakness, numbness, or paralysis of the face, arm or leg, particularly on one side of the body. Headache. (Sudden, severe thunderclap headache occurs with subarachnoid hemorrhage.) Nausea and vomiting. Confusion. Dizziness. Seizures. Difficulty swallowing. Loss of vision or difficulty seeing. Loss of balance or coordination. Stiff neck and sensitivity to light. Abnormal or slurred speech. Difficulty reading, writing or understanding speech. Change in level of consciousness or alertness, lack of energy, sleepiness or coma. Trouble breathing and abnormal heart rate (if bleed is located in brainstem). (https://my.clevelandclinic.org/health/diseases/ -brain-bleed-hemorrhage-intracranial-hemorrhage) On [DATE] at 8:40 AM, Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy that began on [DATE] and was identified on [DATE] when the facility failed to identify and intervene for an acute change in condition. On [DATE] it was verified that the facility implemented the following to remove the Immediate Jeopardy: 1. On [DATE] the Director of Nursing, Administrator and Senior Executive Director reviewed R7's medical record and investigation of fall on [DATE]. 2. On [DATE] the Director of Nursing advised the Facility's Medical Director of the IJ citation. a. The Administrator and Director of Nursing reviewed and revised the facility's Acute Care/ Emergency Department Transfers Policy. b. The Administrator and Director of Nursing reviewed and revised the Notification of Change of Condition Policy. c. The Director of Nursing formulated steps in notification in change of condition of a resident document, this includes on call notification of medical personnel. 3. On [DATE] Nurse Managers, Charge Nurses and/or designee began providing education to licensed nursing staff concerning change in medical condition, neurological assessment, on call notification, and need for medical transfer to higher levels of care. 4. Effective immediately licensed nurses will be educated concerning change in medical condition, neurological assessment, on call notification, and need for medical transfer to higher levels of care. upon the start of their shift. Any nurse not scheduled within the next twenty-four hours will be provided the education by [DATE]. 5. The Director of Nursing will be responsible for continued monitoring of residents with falls with injury, change of condition, and acute outs for continued adherence to the Acute Care/ Emergency Department Transfers Policy and the Notification of Change in Condition Policy. Any issues identified will be reported to the QAPI Committee on a monthly basis, or as directed by the QAPI committee. 6. The Director of Nursing and Administrator are responsible for continued compliance with this Plan of Removal. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency.

This citation pertains to intake MI 895 Based on interview and record review the facility failed to perform a comprehensive assessment prior to the discontinuation of two antipsychotic medications and failed to provide mental health services for 1 resident (#10) of 1 resident reviewed for antipsychotic medications, resulting in resident #10 a severe level of mental distress, agitation, threats of suicide, physical aggression, paranoia and physical injury. Findings include: Review of the clinical record, including the Minimum Data Set, (MDS) with an assessment reference date of 08/07/2021, revealed resident #10 (R10) was admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R10 admission medication orders were [MEDICATION(S)] (antipsychotic) 25 milligrams every evening, [MEDICATION(S)] (anti-psychotic) 5 milligrams every 8 hours as needed for agitation. Admission progress notes reflect upon admission 8/02/21 R10 was tearful upon admission, and when nurse tried to inquire R10 showed paranoia that it was none of his business. The 08/02 progress note reflected R10 verbalized he wanted to kill himself. Review of progress notes dated 8/02/21 read in part at 2015 resident became increasingly agitated and kept stating he will kill him self multiple times. Licensed Practical Nurse (LPN) G contacted the on call Physician and R10's spouse, a 3 way call was completed and the progress notes authored by LPN G reflected the Physician wanted R10 sent to the hospital for a psychiatric evaluation and R10's spouse reported R10 had episodes of these behaviors and calms down when given [MEDICATION(S)] and [MEDICATION(S)] further review of the clinical record reflected the on call physician agreed not to send R10 to the hospital for a psychiatric evaluation per R10's wife's request but ordered an additional 1 time dose of [MEDICATION(S)] 25 milligrams in which LPN G administered and charted was effective within 30 minutes. Nursing progress notes dated 8/03/21 reflected R10 was yelling and agitated and climbing out of bed, and his mental status was confused. physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no risk verses benefit in the clinical record, nor was there any documented discussion with R10's wife whom also serves as Medical Durable Power of Attorney, to obtain further history, knowledge or understanding of how, where, when and why the anti-psychotics were initiated, nor was there a gradual reduction of the anti-psychotic medication use. Nursing progress notes dated 08/04/21 06:24 reflected R10 continuously yelling out Help me, Help me The progress note further stated R10 complains of feeling anxious stating he does not know what was going on. R10 continued to yell out and repeat he wanted to die and continuously calling for his wife. R10 denied pain when assessed and when needs met, will continuously get agitated and will yell out even with 1:1. Nursing progress notes dated 08/04/21 19:12 reflected R10 threatening to kill himself, throw himself on the floor again , the progress note further stated R10 was verbally abusive, using vulgar language and other residents on the hall had complained and that R10 was inconsolable and unable to redirect. Review of the Social Work progress notes dated 8/5/2021 reflected R10 scored a 3 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS) and that his Durable Power of Attorney (DPOA) was R10's spouse had been activated. Later in the Social Work progress note it reflected R10 was offered psychiatry services and declined, there was no documentation that showed that the active DPOA had been made aware of psychiatry services. Review of Nursing progress notes dated 08/06/2021 at 09:38 reflected R10 yelling out, and attempting to throw himself out of bed. Nursing progress notes 08/06/21 18:15 reflect R10 had thrown himself out of bed, calling out for wife. Progress notes 08/06/21 at 19:06 R10 yelling out, combative unable to redirect or complete tasks. Progress notes 08/06/21 at 20:35 it was noted R10 was yelling out Help and Kill me the progress notes reflected R10 was combative with staff when they tried to redirect or provide care, and that he was wearing a soiled brief that he would not allow staff to change. The progress note further reflected several residents on the hall were woken up by R10s yelling and complained of mental exhaustion due to having to listen to R10's continuous yelling out. R10's spouse was notified and came to facility and stayed the night with R10. Review of Nursing progress notes dated 08/07/2021 at 14:17 that R10 was yelling out , refusing care verbally and physically aggressive kicking and banging on wall. R10 did not respond to interventions such as 1:1, dim lighting, offering of food and fluids. Nursing progress notes dated 08/07/2021 at 17:48 reflected R10 threw himself out of bed and sustained a skin tear and abrasion to right upper eyebrow and bump and abrasion to nose and that R10 was observed banging his head on the wall. R10's wife/DPOA arrived at the facility and R10 was verbally abusive toward her and made paranoid statements such as he could not trust her anymore and that she was no longer his wife. R10 was transferred to the hospital at that time. On 8/17/21 at 12:22 PM during an interview with Social Worker (SW) F she reported R10 was admitted under private pay for a short term respite stay until the R10's wife secured an apartment at an assisted living for them. When queried about R10's anti-psychotics both being discontinued without any type of assessment or discussion with his activated DPOA, SW F stated that was not their normal process; usually their would be a thorough evaluation that included a discussion with an activated DPOA along with a risk verses benefit, not a statement that a resident doesn't meet criteria. SW F was asked for documentation as to what evidence the facility had that R10 did not meet criteria or what the facility did on R10's behalf to meet the burden of proof that criteria was not met. No further documents were provided by the facility as of the exit date 8/23/2021. When queried why R10 did not have a psychiatry consult ordered, SW F stated she thought R10's wife refused. Upon review of the notes it was reflected R10 (who had an activated DPOA ) was the one that declined psychiatric services not R10's wife/DPOA, SW F offered no further explanation. On 8/18/2021 at 4:15 PM during a phone interview with LPN G it was reported that R10's behavior worsened with each passing day, the frequency and intensity, punching, kicking, throwing himself on the floor, yelling he wanted to die, verbal abuse, sitting in soiled briefs not allowing anyone to help him. LPN G stated when R10's anti-psychotics were discontinued, he and the other nurses couldn't understand the Physician's rationale. The one time dose of [MEDICATION(S)] I gave him was the only time I saw him calm. LPN G stated R10 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/23/2021 at 10:30am during a phone interview with Certified Nursing Assistant (CNA) C she reported R10's behavior was getting worse over the 5 days he was at the facility and that on the last day he kept swinging and trying to fight everyone, spitting on people, throwing himself on the floor and that R10 was so stressful for the staff they had 3 people as his 1:1 and had to rotate out every 20 minutes or so because R10 was so verbally and physically abuse it was mentally too hard to handle him. On 8/17/2021 at 2:08 PM, during a phone interview with R10's wife and activated DPOA, she reported R10 was once again prescribed [MEDICATION(S)] and [MEDICATION(S)] and that R10 was doing well, calm coherent and not so stressed, he is not delusional anymore. On 8/23/2021 at 1:00 during an interview with Director of Nursing (DON) B, she reported it was not the facility's practice to discontinue 2 antipsychotic medications without ample documentation which included a history or knowledge of how R10 got to be on 2 antipsychotic medications. DON B reported normally a gradual dose reduction after the thorough assessment would be the proper step if the medication was deemed unnecessary. DON B further stated she spoke with the Physician that discontinued the order for both medications and informed DON B that a risk verses benefit was done. A copy of the risk verses benefit was requested at that time as it was not located in the clinical record. The document was not provided by the end of the survey on 8/24/2021 at 4:30 PM.

This citation pertains to intake numbers MI 8279 and MI 9312. Based on observation, interview, and record review the facility failed to ensure two out of six residents (Resident #s 1 & 2) received necessary treatment, resulting in Immediate Jeopardy when Resident #2 developed a stage 4 pressure ulcer and worsening of existing pressure ulcers, placing five other residents identified to have pressure ulcers at risk for harm, injury, and/or death, and failed to ensure pressure ulcer treatments and interventions were documented as completed for Resident #1 resulting in the potential for pressure ulcers to develop. Findings Included: Resident #2 (R2): Per the facility face sheet R2 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a court document, dated 11/21/2019, revealed R2 had a guardian in place. Record review of a Minimum Data Set (MDS), dated [DATE], revealed R2 had one stage one, and one stage two pressure ulcers. The MDS revealed R2 was receiving treatments of turning/repositioning, and pressure ulcer/injury care. Review of a Braden Scale assessment (assessment to identify a person at risk for skin breakdown), dated 12/8/2020, revealed R2 scored a 12 on the assessment, which indicated she was at a high risk for skin breakdown. Another Braden Scale assessment, dated 3/29/2021, revealed R2 scored a 9 on her assessment, which indicated she was a very high risk for skin breakdown. Record review of a Skin/Wound Note,dated 10/12/2020, revealed R2 was noted to have a pressure ulcer (wound) to her right ischium (lower back part of the hip) that measured 1 cm (centimeters) x 0.5 cm x 0.3 cm and had a red moist wound bed, with some serous exudate (clear, thin, watery drainage) noted. Another pressure ulcer was noted to R2's right gluteal fold (fold of the buttocks) that measured 2 cm x 2 cm x 0.1 cm and had a red moist wound bed. There was a small amount of serosangenous exudate (thin, pink, and watery drainage). The note further revealed R2 had a new open area between the two pressure ulcers that measured 0.3 cm x 0.3 cm x 0.1 cm with a pink wound bed that was moist and had serous exudate. The note revealed the new pressure ulcer had white edges with maceration (caused from moisture). The progress notes further revealed that when R2 was repositioned in bed a purple area was noted to her right hip, and that her [MEDICATION(S)] (drainage of urine through a tube in the abdomen that drains into a collection bag) tubing lined up with the purple area, and a foam dressing was applied. The hip wound measured 0.5 cm x 1 cm. The skin notes did not reveal what stage the wounds were. Review of a Skin/Wound Note, dated 10/13/2020, revealed no documentation of R2's purple area to her right hip. No staging of the wound was documented. Review of a Skin Only Evaluation, dated 10/16/2020, revealed, .No current skin issues noted at this time. R2's next Skin/Wound Note regarding her right hip purple area was not documented until 10/16/2020, and revealed, .right hip pressure area measured 1.5 cm x 1.9 cm. Area purple with a white area . No staging of the wound was documented. Review of a Skin/Wound Note, dated 10/27/2020, revealed R2's right hip wound measured 2 cm x 2 cm x <0.1 cm, and continued to have purple tissue. The note also revealed some drainage in the wound bed. No staging of the wound was documented. Another Skin/Wound Note, dated 11/3/2020, revealed R2's right hip wound measured 1.5 cm x 1.8 cm, and the wound was noted to be open. No staging of the wound was documented. Review of progress notes, dated 11/11/2020, revealed a new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Skin/Wound Note, dated 11/17/2020, revealed R2's right hip wound measured 2.8 cm x 3 cm, and revealed the wound was was covered with a thick layer of firmly attached slough (dead tissue). No staging of the wound was documented. Review of a Skin/Wound Note, dated 12/9/2020, revealed R2's right hip wound now measured 6.4 x 8.3 x 2 cm. No staging of the wound was documented. Review of a Skin/Wound Note, dated 12/22/2020, revealed R2's right buttock (ischium and gluteal fold) wounds had merged into one wound, had drainage and a foul odor was noted. No staging of the wound was documented. Review of a Skin/Wound Note, dated 12/23/2020, revealed R2's right hip wound was a stage four pressure ulcer, and her right buttocks and ischium pressure ulcers were a stage three. Review of hospital records, dated 11/22/2020, revealed R2 was admitted to the hospital were she had undergone debridement (removal of dead tissue) of her pressure ulcers, and was discharged back to the facility on [DATE]. Another hospital record revealed R2 was readmitted to the hospital on 12/23/2020, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The record revealed R2 underwent surgical debridement of her pressure ulcers. Review of R2's census report revealed she did not return to the facility until 2/8/2021. Review of a hospital record dated, 4/17/2021, revealed R2 was admitted to the hospital with a temperature of 101.3, [CONDITION(S)], and a concern for wound infection of her right ischium pressure ulcer. The record also revealed R2's pressure ulcers measured, right hip 8 cm x 6 cm x 2 cm, right ischium 8 cm x 8 cm x 1.5 cm, and were stage four pressure ulcers. Record review of R2's Treatment Administration Record (TAR) for the month of December 2020 revealed R2 was to be turned and reposition every 2 hour for wound care. On 12/14/2020 no initials were documented that R2 was turned. Another order, dated 11/11/2020 revealed R2 was to be turned side to side only, with one hour on her right side, then two hours on her left side for right side hip for wound healing. On 12/14 and 12/20/2020 this was not initialed as completed. The TAR further revealed that an order, dated 12/12/2020, was in place for R2 to have Santyl Ointment (an ointment that removed dead tissue from wounds so the wound can start to heal) applied to her right hip wound slough every evening shift for wound care. A further order revealed R2 was to have her right hip ulcer cleansed with saline, patted dry, and apply barrier film to wound her edges and wherever tape would be used, then apply a nickel thick layer of Santyl, cover with moist 4 x 4 gauze, then dry 4 x 4 gauze, cover with a dressing and secure with tape daily. On 12/20/2020 no initials were documented that the two treatment was completed. Review of a TAR for the month of February 2021 revealed R2 was ordered to have a, Strict turn and reposition Q2 (every two) hours and offload (up off the bed mattress) heels every 2 hours Document which side she is placed on and also if she refuses. The order was dated 2/11/2021. The TAR revealed that 18 times it was not documented, per initials, that R2 was turned. Further review of the TAR revealed a treatment dated 2/9/2021, for R2 to have Santyl Ointment applied to her wounds every day and evening shift. The TAR had five times that no initials were documented that the treatment was completed. Continued review of the February 2021 TAR revealed R2 had a treatment, dated 2/9/2021, to apply [MEDICATION(S)] Powder to her wounds via a soaked gauze every day and evening shift. The TAR had five times that no initials were documented that the treatment was completed. Further review of the February 2021 TAR revealed R2 was to have her ischial wounds and right gluteal wound cleansed with saline, patted dry, Santyl applied to her wound beds, packed with [MEDICATION(S)] (topical antiseptic) moistened gauze, then covered with foam dressing twice a day, every day and evening shift for wound care. The treatment was dated 2/9/2021, and revealed five times the treatment was not initialed as being completed. Review of a March 2021 TAR revealed R2 had a treatment in place to turned her every two hours, dated 3/4 through 3/8/2021, and had two times the treatment was not initialed as being completed. Another treatment, dated 3/8 through 3/12/2021 to turn R2 every two hours revealed four times the treatment was not initialed as being completed. A treatment, dated 3/18/2021 through 3/23/2021 revealed 24 times the treatment was not documented as being completed, and dated 3//29/2021 a treatment to turn R2 every two hours revealed 11 times the treatment was not initialed as being completed. The March 2021 TAR revealed a treatment, dated 3/5 through 3/12/2021, for R2 to have Santyl Ointment applied to her buttock wounds every day and evening shift for wound care. The treatment had no initials documented on 3/11/2021 for the evening shift that indicated the treatment had been completed. Another treatment, dated 3/18 through 3/23/221, revealed R2 was to have Santyl Ointment applied to her buttock ulcers every day and evening shift for wound care. The treatment had three times no initials were documented that the treatment was completed. Another treatment that was in place, dated 3/18 through 3/24/2021, revealed R2 was to have her wounds to buttocks cleansed with saline, patted dry, [MEDICATION(S)] (skin protectant) barrier film placed around her wounds, apply nickel thick layer of Santyl gel to necrotic (dead) tissues/slough in wound beds, followed by a moist fluffed gauze, and covered with a comfort foam dressing every day and evening shift. The treatment had four times that no initials were documented that the treatment was completed. Record review of an April 2021 TAR revealed R2 had a treatment in place, dated 3/29 through 4/19/2021, to turn and reposition her every two hours, and to go from her left to back to right, and had 43 times that no initials were documented that the treatment was completed. Further review of the TAR revealed a treatment, dated 4/24 through 5/7/2021, to turn and reposition her every two hours, and to go from her left to back to right. Four times there were no initials that the treatment was completed. Further review of the April 2021 TAR revealed a treatment in place, dated 3/29 through 4/19/2021 to cleanse R2's wounds to her buttocks with saline, pat dry, apply [MEDICATION(S)] barrier film around wounds and let dry, apply nickel thick layer of Santyl gel to necrotic tissues/slough in wound beds, followed by moist fluffed gauze, and cover with a foam dressing every day and evening shift. Nine times the treatment was not initialed that the treatment was completed. A treatment, dated 4/24 through 4/29/2021, to cleanse with saline, pat dry, apply [MEDICATION(S)] barrier film around wounds and let dry, apply nickel thick layer of Santyl gel to necrotic tissues/slough in wound bed, followed by moist fluffed gauze, and cover with 6 x 6 comfort foam bordered foam dressing every day and evening shift both her right gluteal and right ischium pressure ulcers was also in place, however on 4/28/2021 the two pressure ulcer treatments were not initialed that they were completed. Review of a May 2021 TAR revealed R2 was to be turned every two hours, however revealed four times no initials that the the treatment was completed. Further review of the TAR revealed a treatment was in place for R2's right gluteal and ischium pressure ulcer, and revealed no initials on 5/6/2021 that the treatment was completed. Record review the the Certified Nurse Aid (CNA) task records for the months of October, November, December 2020, February, March, April, and May 2021 revealed a task for the CNAs to turn and reposition R2 every two hours, however there were 165 times that the task was not initialed that R2 had been turned throughout the listed months. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of progress notes, dated 3/5 through 3/7/2021 revealed R2 had refused to turn fours times, however there was no documentation that R2's guardian was notified of the refusals. Record review of R2's care plans revealed a plan of care in place titled, (R2) has a pressure ulcer(s) related to pressure ulcers to bilateral ischial tuberosity (hip area) and R (right) gluteal. The care plan was initiated on 12/10/2020. An intervention, dated 12/10/2020, was to turn R2 every two hours, however did not reveal that R2 had an order to be turned on a strict turn schedule left to right to back. Another care plan titled, Risk for impaired skin integrity related to advanced age, altered sensation, complicities, exposure to moisture, physical immobility r/t (related to) MS ([CONDITION(S)]), contractures, arthritis, initiated date was 12/10/2020. Further review of R2's care plans revealed a care plan titled, Risk for Impaired Skin Integrity. was dated 2/15/2021 for the date it was initiated. Two other care plans were in place titled, Wound Management and Documented Pressure Ulcer, both dated 2/15/2021 for the date the care plans were initiated. Another care plan titled, Alterations in skin integrity related to ulcerations to right and left ischium and right gluteal. was in place, the dated initiated was 2/8/2021. Review of the care plans, as listed, revealed no interventions to contact R2's guardian in the event R2 refused care so her sister may assist in R2 complying with care and treatment, nor did the care plans reveal an intervention to assure that her [MEDICATION(S)] tubing was not under her skin, or hip area. In an interview on 5/10/2021, at 1:53 PM, Licensed Practical Nurse (LPN) H, who was the wound care nurse, stated she did not know a lot of details regarding R2's pressure ulcers from October and November 2020, and said she took the position of wound care nurse in December 2020. LPN H stated that R2's pressure ulcers to her right ischium and gluteal were stage four pressure ulcers, and said it was hard to stay how they got to a stage four. LPN H said R2 had her pressure ulcers debrided multiple times. LPN H also stated that she was uncertain as to how R2 kept getting septic. LPN H said R2's October 2020 wound notes did not have any staging documented. In an observation on 5/11/2021 at 10:04 AM, of R2's pressure ulcers with LPN H it was observation that R2's right gluteal wound had slough present and measured 6 cm x 7.2 cm x 2 cm. R2's right hip wound had slough present, which LPN H stated was a stage 4, and was observed to measure 7.5 cm x 8.5 cm. During the observation of R2's pressure ulcers with RN H CNA I was present in R2's room. A turning schedule was noted to be posted on R2's wall. CNA I was asked about the turning schedule posted in which CNA I stated that the posted turning schedule on R2's wall was not the current scheduled used. CNA I said R2's turning schedule was for her to be placed on her left, then right, then back every two hours, and said the posted schedule had not been used for a year. CNA I stated that the only was she new R2's turning schedule had changed was via verbally report from the off going CNA or because LPN H had verbally told her. In an interview on 5/11/2021, at 2:18 PM, Licensed Practical Nurse (LPN) E stated he followed R2's turning schedule that was on her TAR, however stated that if R2 refused to be turned she did not call her sister to let her know about the refusal. LPN E also stated that he did not know if the CNAs were to documenting R2 being turned in tasks documentation. In an interview on 5/11/2021, at 2:28 PM, LPN H said she was not aware that R2's turning schedule was needed to be on documented on her care plan or the Kardex (document used by the CNAs to know the care needs for a resident). LPN H said she expected the nurses to do something at the point of R2's refusals care, and stated that there was no intervention in place for when R2 refused care. LPN H said that at one point she was encouraged the nurses's to call R2's sister for refusals of care but stated that was more in December 2020 and into February 2021. Record review of the CNA Kardex revealed a care need to Monitoring, reminding and assistance as needed to turn/reposition at least every 2 hours, more often as needed or requested. The Kardex did not reveal the strict turning schedule R2 was ordered to be on, and did not reveal to report any times R2 refused to allow care to be done, such as turning. In an interview on 5/12/2021, at 10:50 AM Nurse Practitioner (NP) K stated R2 was admitted to the hospital on 11/22 to 12/8/2020, and said she had went out with a fever and bacteremia with source most likely being her decubitus ulcers (pressure ulcers). In an interview on 5/12/2021, at 11:38 AM, Physician L stated that she was aware of purple area on R2's right hip that was identified on 10/12/2020 which was consistent with her [MEDICATION(S)] tubing. Physician L stated that the purple area measured 0.5 x 1 cm, and then on 11/3/2020 it had become an open wound that measured 1.5 cm x 1.9 cm. Physician L stated that the purple area was deep tissue injury (DTI) which meant that the underlying skin did not get enough blood flow for an extended period of time. Physician L stated that she expected the nurses and CNAs follow R2's care plan, Kardex, and turn her every two hours and per her physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician L further stated that R2 was a very high risk individual for pressure ulcers. In an interview on 5/12/2021, at 1:18 PM, Physician M, who was the wound care Physician, stated that if R2 was not having her dressings changed and being turned as ordered that could have caused her pressure ulcers to become infected. Physician M said the foam dressings were to prevent infections. In an interview on 5/13/2020, at 12:48 PM, LPN H stated that she did notice the missing initials on R2's TARs for her wound treatments. LPN H said if she did the wound treatment herself she would ask R2's nurse to sign the treatment out on R2's TAR, but stated that sometimes she would forgot herself to initial R2's TAR. LPN H said she did not perform any audits of R2's TARs, or CNA tasks to assure that her treatments were documented as completed, and stated that she would confirm that R2 was being turned by verbally asking the staff. LPN H also stated that she was not sure what should be on a Kardex, and said that R2's turning schedule was told to the CNAs by the nurse. LPN H said that calling R2's guardian when she refused care had been discontinued because sister did not answer the phone and it was difficult to get staff to comply, however stated that R2's sister had never requested to stop receiving phone calls when R2 refused care. In an interview on 5/13/2021, at 2:00 PM, R2 stated that she usually slept through the night and was not awaken to be turned. In an interview on 5/13/2021, at 3:25 PM, Director of Nursing (DON) B stated that R2 had a written order to call her guardian when she refused care. In an interview on 5/17/2021, at 12:49 PM, LPN H stated that she had just learned that R2's [MEDICATION(S)] tubing caused her pressure ulcer to her right hip the week prior to this interview. In an interview on 5/17/2021, at 8:39, DON B stated that she expected the nurses and CNAs to follow R2's plan of care, DON B said she did not notice any lack of care for R2, but stated the documentation of her treatments and turning was defiantly a problem. DON B said expectation was that the documentation was complete, and that the CNAs reviewed a resident's Kardex to know the care needs for a resident. On 5/12/2021, at 3:25 PM, the Administrator was notified of the Immediate Jeopardy that began on 10/12/2020, and identified on 5/12/2021 when R2 was noted to have a purple area to her left hip that resulted in a stage four pressure ulcer, and worsening of existing pressure ulcers resulting in the potential for further harm, injury and [CONDITION(S)]. On 5/17/2021 the surveyor confirmed the facility had implemented the following to remove the Immediate Jeopardy: 1. On 5/13/2021 the Director of Nursing and the Wound Care Coordinator audited R2's Treatment Administration Record (TAR) and will monitor documentation of wound treatments for completion going forward. 2. On 5/13/2021 the Administrator and Director of Nursing advised the Facility's Medical Director of the IJ citation. a. The Administrator and Director of Nursing reviewed and revised the facility's Skin Care Management Policy, [NAME]- Prevention of Pressure Areas Policy and Wound Care Treatments and Documentation Policy. b. The Medical Director and Wound Care Coordinator reviewed the Skin Care Management Policy, [NAME]-Prevention of Pressure Areas Policy and Wound Care Treatments and Documentation Policy and did not recommend any updates to these policies. 3. On 5/13/2021 Nurse Managers, Charge Nurses and/or designee began education of the nurses and CNA's on the facility's Skin Care Management Policy, [NAME]- Prevention of Pressure Areas Policy and Wound Care Treatments and Documentation Policy. a. On 5/13/2021 31 were educated b. On 5/14/2021 25 were educated c. From 5/15/21-5/16/21 26 were educated d. Remaining 57 are to be educated by 5/21/2021 4. On 5/14/2021 the Director of Nursing, Unit Managers and Wound Care Coordinator reviewed and revised the turning schedule documentation for R2. The Unit Manager and/or designee will continue to monitor documentation for completion. 5. On 5/14/2021 the Director of Nursing, Unit Managers and Wound Care Coordinator reviewed and revised, if indicated, R2's care plans to reflect further interventions to prevent any new pressure wounds and/or further deterioration of current pressure wounds. 6. On 5/14/2021 Nurse Managers, Charge Nurses and/or designee began education to the nurses and CNAs on completion of documentation. This education included for the CNA to read and check the Kardex for care and instructions for care and safety. a. On 5/13/2021 31 were educated b. On 5/14/2021 25 were educated c. From 5/15/21-5/16/21 26 were educated d. Remaining 57 are to be educated by 5/21/2021 7. On 5/14/2021 the Director of Nursing, Unit Managers and Wound Care Coordinator reviewed and revised, if indicated, care plans of the 5 other residents with pressure ulcers to ensure all appropriate interventions are in place as needed. 8. On 5/14/2021 the Director of Nursing, Unit Managers and Wound Care Coordinator completed an audit of treatment administration records (TAR) of the 5 other residents with pressure ulcers to ensure completion of wound treatments is documented. This audit will be continued to ensure completion of wound treatments and documentation of wound treatments. 9. On 5/14/2021 the current Performance Improvement Project (PIP) for New or Worsening Pressure Injuries was updated to reflect an every-other week review by the Risk Committee of resident wounds and interventions. a. If no improvements to wounds are noted, since last review, then current interventions are to be evaluated, updated as needed, and implemented accordingly. 10. The Director of Nursing will be responsible for continued monitoring of adherence to the standards of wound care, documentation and interventions, and will report any issues identified to the QAPI Committee on a monthly basis, or as directed by the QAPI committee. 11. The Director of Nursing and Administrator are responsible for continued compliance with this Plan of Removal. Resident #1 (R1): Per the facility face sheet R1 was admitted to the facility on [DATE]. Review of an MDS, dated [DATE], revealed R1 was at risk for pressure ulcer development, and treatments in place were a turning and repositioning program, and applications of ointments/medications. Record review of R1's Physician orders, dated 3/23/2021, revealed an order, Coccyx-cleanse, pat dry, apply Renew peri protect with every brief change/toileting. Another physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a TAR for the month of March 2021 revealed a treatment dated 3/23/2021, Bilateral heels-apply barrier film and let dry every day and evening shift for prevention. Three times the treatment had no initials that the treatment was in place. Another treatment, dated 3/23/2021 to, Coccyx (tail bone)-cleanse, pat dry, apply Renew peri protect with every brief change/toileting every shift for MASD (moisture associated skin damage). Five times the treatment had no initials documented that the treatment had been completed. A treatment, dated 3/23/2021, to turn and reposition R1 every two hours was also in place, however five times the treatment was not initialed as completed. Review of a TAR for the month of April 2021 revealed a continued treatment in place, Bilateral heels-apply barrier film and let dry every day and evening shift for prevention. Ten times no initials were documented that the treatment was completed. Another continued treatment in place was, Coccyx (tail bone)-cleanse, pat dry, apply Renew peri protect with every brief change/toileting every shift for MASD. Fourteen times no initials were documented that the treatment was completed. A treatment, dated 3/23/2021, to turn and reposition R1 every two hours was also in place, however 13 times the treatment was not initialed as completed. Review of R1's care plans revealed a Focus, dated 3/22/2021, Risk for impaired skin integrity related to advanced age, co-morbidities, impaired mobility r/t PNA (pneumonia) AEB (as evidence by) weakness.' The care plan did not have an intervention to turn him every two hours, nor was an intervention in place for his coccyx MASD treatment, or his bilateral heels treatment, as indicated per his MDS assessment. Although the Immediate Jeopardy was removed on 5-13-21 deficient practice continued at isolated scope with no actual harm with potential for more than minimal harm that is not immediate jeopardy as sustained compliance could not be verified by the state agency.

This citation pertain to intake numbers MI 8279 and MI 9312. Based on observation, interview, and record review the facility failed to develop and implement a comprehensive care plan for two out of five residents (Residents #1 and 2) that was resident center resulting in the development of stage four pressure ulcers and the potential for further pressure ulcer development and/or worsening of pressure ulcers. Finding Included: Resident #1 (R1) Per the facility face sheet R1 was admitted to the facility on [DATE]. Review of an MDS, dated [DATE], revealed R1 was at risk for pressure ulcer development, and treatments in place were a turning and repositioning program, and applications of ointments/medications. Record review of R1's Physician orders, dated 3/23/2021, revealed an order, Coccyx-cleanse, pat dry, apply Renew peri protect with every brief change/toileting. Another physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a TAR for the month of March 2021 revealed a treatment dated 3/23/2021, Bilateral heels-apply barrier film and let dry every day and evening shift for prevention. Three times the treatment had no initials that the treatment was in place. Another treatment, dated 3/23/2021 to, Coccyx (tail bone)-cleanse, pat dry, apply Renew peri protect with every brief change/toileting every shift for MASD (moisture associated skin damage). Five times the treatment had no initials documented that the treatment had been completed. A treatment, dated 3/23/2021, to turn and reposition R1 every two hours was also in place, however five times the treatment was not initialed as completed. Review of a TAR for the month of April 2021 revealed a continued treatment in place, Bilateral heels-apply barrier film and let dry every day and evening shift for prevention. Ten times no initials were documented that the treatment was completed. Another continued treatment in place was, Coccyx (tail bone)-cleanse, pat dry, apply Renew peri protect with every brief change/toileting every shift for MASD. Fourteen times no initials were documented that the treatment was completed. A treatment, dated 3/23/2021, to turn and reposition R1 every two hours was also in place, however 13 times the treatment was not initialed as completed. Review of R1's care plans revealed a Focus, dated 3/22/2021, Risk for impaired skin integrity related to advanced age, co-morbidities, impaired mobility r/t PNA (pneumonia) AEB (as evidence by) weakness.' The care plan did not have an intervention to turn him every two hours, nor was an intervention in place for his coccyx MASD treatment, or his bilateral heels treatment, as indicated per his MDS assessment. Resident #2 (R2) Per the facility face sheet R2 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a court document, dated 11/21/2019, revealed R2 had a guardian in place. Record review of a Minimum Data Set (MDS), dated [DATE], revealed R2 had one stage one, and one stage two pressure ulcers. The MDS revealed R2 was receiving treatments of turning/repositioning, and pressure ulcer/injury care. Review of a Braden Scale assessment (assessment to identify a person at risk for skin breakdown), dated 12/8/2020, revealed R2 scored a 12 on the assessment, which indicated she was at a high risk for skin breakdown. Another Braden Scale assessment, dated 3/29/2021, revealed R2 scored a 9 on her assessment, which indicated she was a very high risk for skin breakdown. Record review of a Skin/Wound Note,dated 10/12/2020, revealed R2 was noted to have a pressure ulcer (wound) to her right ischium (lower back part of the hip) that measured 1 cm (centimeters) x 0.5 cm x 0.3 cm and had a red moist wound bed, with some serous exudate (clear, thin, watery drainage) noted. Another pressure ulcer was noted to R2's right gluteal fold (fold of the buttocks) that measured 2 cm x 2 cm x 0.1 cm and had a red moist wound bed. There was a small amount of serosangenous exudate (thin, pink, and watery drainage). The note further revealed R2 had a new open area between the two pressure ulcers that measured 0.3 cm x 0.3 cm x 0.1 cm with a pink wound bed that was moist and had serous exudate. The note revealed the new pressure ulcer had white edges with maceration (caused from moisture). The progress notes further revealed that when R2 was repositioned in bed a purple area was noted to her right hip, and that her [MEDICATION(S)] (drainage of urine through a tube in the abdomen that drains into a collection bag) tubing lined up with the purple area, and a foam dressing was applied. The hip wound measured 0.5 cm x 1 cm. The skin notes did not reveal what stage the wounds were. R2's next Skin/Wound Note regarding her right hip purple area was documented on 10/16/2020, and revealed, .right hip pressure area measured 1.5 cm x 1.9 cm. Area purple with a white area . No staging of the wound was documented. Review of a Skin/Wound Note, dated 10/27/2020, revealed R2's right hip wound measured 2 cm x 2 cm x <0.1 cm, and continued to have purple tissue. The note also revealed some drainage in the wound bed. No staging of the wound was documented. Another Skin/Wound Note, dated 11/3/2020, revealed R2's right hip wound measured 1.5 cm x 1.8 cm, and the wound was noted to be open. No staging of the wound was documented. Review of a Skin/Wound Note, dated 11/17/2020, revealed R2's right hip wound measured 2.8 cm x 3 cm, and revealed the wound was was covered with a thick layer of firmly attached slough (dead tissue). No staging of the wound was documented. Review of a Skin/Wound Note, dated 12/9/2020, revealed R2's right hip wound now measured 6.4 x 8.3 x 2 cm. No staging of the wound was documented. Review of a Skin/Wound Note, dated 12/22/2020, revealed R2's right buttock (ischium and gluteal fold) wounds had merged into one wound, had drainage and a foul odor was noted. No staging of the wound was documented. Review of a Skin/Wound Note, dated 12/23/2020, revealed R2's right hip wound was a stage four pressure ulcer, and her right buttocks and ischium pressure ulcers were a stage three. Review of hospital records, dated 11/22/2020, revealed R2 was admitted to the hospital were she had undergone debridement (removal of dead tissue) of her pressure ulcers, and was discharged back to the facility on [DATE]. Another hospital record revealed R2 was readmitted to the hospital on 12/23/2020, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The record revealed R2 underwent surgical debridement of her pressure ulcers. Review of R2's census report revealed she did not return to the facility until 2/8/2021. Review of a hospital record dated, 4/17/2021, revealed R2 was admitted to the hospital with a temperature of 101.3, [CONDITION(S)], and a concern for wound infection of her right ischium pressure ulcer. The record also revealed R2's pressure ulcers measured, right hip 8 cm x 6 cm x 2 cm, right ischium 8 cm x 8 cm x 1.5 cm, and were stage four pressure ulcers. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of progress notes, dated 11/11/2020, revealed a new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of R2's care plans revealed a plan of care in place titled, (R2) has a pressure ulcer(s) related to pressure ulcers to bilateral ischial tuberosity (hip area) and R (right) gluteal. The care plan was initiated on 12/10/2020. An intervention, dated 12/10/2020, was to turn R2 every two hours, however did not reveal that R2 had an order to be turned on a strict turn schedule with one hour on her right side then two hours on her left side. Another care plan titled, Risk for impaired skin integrity related to advanced age, altered sensation, complicities, exposure to moisture, physical immobility r/t (related to) MS ([CONDITION(S)]), contractures, arthritis, however was initiated on 12/10/2020. Further review of R2's care plans revealed a care plan titled, Risk for Impaired Skin Integrity. was dated 2/15/2021 for the date it was initiated. Two other care plans were in place titled, Wound Management and Documented Pressure Ulcer, both dated 2/15/2021 for the date the care plans were initiated. Another care plan titled, Alterations in skin integrity related to ulcerations to right and left ischium and right gluteal. was in place, however the date the care plan was initiated was 2/8/2021. Review of the care plans, as listed, revealed no interventions to contact R2's guardian in the event R2 refused care so her sister may assist in R2 complying with care and treatment, nor did the care plans reveal an intervention to assure that her [MEDICATION(S)] tubing was not under her skin, or hip area. Review of progress notes, dated 3/5 through 3/7/2021 revealed R2 had refused to turn fours times, however there was no documentation that R2's guardian was notified of the refusals. In an observation on 5/11/2021 at 10:04 AM, of R2's pressure ulcers with LPN H it was observation that R2's right gluteal wound had slough present and measured 6 cm x 7.2 cm x 2 cm. R2's right hip wound had slough present, which LPN H stated was a stage 4, and was observed to measure 7.5 cm x 8.5 cm. In an interview on 5/11/2021, at 2:28 PM, LPN H said she was not aware that R2's turning schedule was needed to be on documented on her care plan or the Kardex (document used by the CNAs to know the care needs for a resident). LPN H said she expected the nurses to do something at the point of R2's refusals care, and stated that there was no intervention in place for when R2 refused care. LPN H said that at one point she was encouraged the nurses's to call R2's sister for refusals of care but stated that was more in December 2020 and into February 2021. Record review of the CNA Kardex revealed a care need to Monitoring, reminding and assistance as needed to turn/reposition at least every 2 hours, more often as needed or requested. The Kardex did not reveal the strict turning schedule R2 was ordered to be on, and did not reveal to report any times R2 refused to allow care to be done, such as turning. In an interview on 5/13/2021, at 3:25 PM, Director of Nursing (DON) B stated that R2 had a written order to call her guardian when she refused care. In an interview on 5/17/2021, at 8:39, DON B stated that she expected the nurses and CNAs to follow R2's plan of care, DON B said she did not notice any lack of care for R2, but stated the documentation of her treatments and turning was defiantly a problem. DON B said expectation was that the documentation was complete, and that the CNAs reviewed a resident's Kardex to know the care needs for a resident.

This citation pertains to MI 549. Based on observation, interview, and record review, the facility failed to provide adequate supervision and/or assistive devices during a transfer from one surface to another (Resident #5), resulting in major injury, pain, increased anxiety, and anger. Findings include: According to the Minimum Data Set, dated dated [DATE], R5 was cognitively intact, needed assistance of two or more staff for transfers and had [DIAGNOSES REDACTED]. During an observation/interview, on 7/30/20 at approximately 11:30 AM, R5 was observed alert and lying in bed. R5 stated she blamed Nurse Aide Q (named him) for an injury to her left knee. R5 said, He twisted me. I heard a pop. Immediately, it started hurting. I'm mad. No, I haven't seen him, and I don't want to. No one ever treated me like that before; he as an a**hole. R5 reported she had never seen any staff transfer a resident incorrectly before or after the incident. Then, during a three staff member transfer with an electrical Hoyer lift from her bed to a shower chair, this Surveyor observed a large leg brace was secured to R5's right leg. During the transfer, R5 expressed grimacing/pain and fear, stating repeatedly, I am anxious. According to the Facility Reported Incident Summary, the time of the incident was 7/16/20 at 5:00 PM, (R5) complained of left knee pain following transfer with staff member . CT scan showed . convulsed fracture fragment from the medial femoral condyle measuring approx. (approximately) 1.9 cm. This involves the origin of the medial collateral ligament. There is a comminuted and impacted [MEDICAL CONDITION] tibial plateau .(R5) returned to facility with left knee immobilizer to follow up with ortho (specialist). According to R5's Fall Care Plan, Impaired physical mobility/fall risk R/T limited mobility, musculoskeletal impairment, [MEDICAL CONDITION] left [MEDICAL CONDITION]. will remain free of complications related to immobility and fall related injury/fall risks through the next review date. Date Initiated: 01/19/2013 . TRANSFER STATUS: 2 person Hoyer transfer with large full body sling. Res is to have rom (range of motion) brace on left leg at all times. Date Initiated: 03/28/2018/Revision on: 07/24/2020 . According to R5's Nurse Aide Care Guide at the time of the incident (dated 7//17/20), R5's transfer status was: .2 person pivot transfers using gait belt . According to a Nursing Progress Note, dated 7/16/20 at 5:27 PM and documented by Licensed Practical Nurse (LPN) S, Writer was assisting roommate while CNA (Nurse Aide) was assisting (R5) in the bathroom, (R5) was yelling 'You're a f idiot' numerous times, I walked over to the bathroom and asked what was wrong. (R5) continued to yelled an cuss at CNA while he was changing her brief. She said she was in pain sitting on the toilet .I was across the hall in patient room and heard (R5) screaming and cussing at (Nurse Aide Q) again. CNA had transferred from the toilet to w/c (wheelchair). (R5) stated her knee hurt and that the CNA had twisted knee during transfer . Writer spoke with CNA and ask for him to have someone with him when during care .CNA and writer transferred (R5) from bed to wheelchair and she started yelling and cussing that her knee hurts. After completion of transfer writer assessed knee . area around knee appears swollen and is bigger compared to right knee . (sic). According to a Witness Statement, dated 7/16/20 at 12:30 PM, Unit Manger R documented Nurse Aide Q reported to him the following: .he was assisting (R5) in bathroom. (R5) was screaming when (CNA Q) went in there to assist her . (CNA Q) stood (R5) up from toilet and was using gait belt she told him she was having pain in her knee . (CNA Q) had to sit (R5) back down on toilet and change (R5') brief/pants and then wipe her again .(CNA Q) stood (R5) up she was holding bar and (CNA Q) transferred (R5) to the wc (wheelchair) and (CNA Q) stated (R5) was screaming the entire time and (CNA Q) could not even get in a word .(sic). Attempts to reach CNA Q via phone for interview on 7/30/20 at 11:43 AM and again on 7/30/20 at 4:20 PM were unsuccessful. On 7/30/20 at 11:35 AM, Unit Manager R stated there had been no complaints about CNA Q other than being reprimanded for time management issues. Unit Manager R reported the residents generally liked (CNA Q). The facility provided evidence that CNA Q's employment was terminated on 7/23/20 because he had transferred R5, who was care planned to be a two-person transfer, by himself resulting in injury to R5.

This citation pertains to intake #MI 69 and #MI 040. This citation has two deficient practices. Deficient Practice #1 Based on observation, interview and record review the facility failed to ensure resident safety while providing care for one resident (R#901) of three residents reviewed for accidents/hazards, resulting in R#901 having pain, being sent to the hospital and sustaining bilateral distal femur fractures. Findings include: On 10/2/19 at approximately 10:33 a.m., R#901 was observed in their room lying in their bed. R#901 was observed to have braces on their bilateral legs. On 10/2/19 the medical record for R#901 was reviewed and revealed the following: R#901 was initially admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of R#901's MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 9/19/19 revealed R#901 was totally dependent on facility staff for bathing and transfers and needed extensive assistance with two staff members for toileting, dressing and bed mobility. R#901's BIMS score (brief interview of mental status) was five indicating severely impaired cognition. A health status note dated 9/23/2019 at 14:52 (military time) revealed the following: Cena (Certified Nursing Assistant) bed checking resident and resident slid off side of bed onto knees then eased rest of way to floor. Res (resident) c/o (complained of)bil (bilateral) knee pain and knees painful with range and have visualized redness. Resident hoyer lifted to bed with several staff present. Continues to c/o knee pain. Spoke with son (name of son) to inform him of incident. Will have staff call when x-ray results are obtained. Have called and left message for (name of doctor) also requesting x-ray orders bil knees 2 view. A health status note dated 9/23/2019 at 15:17 revealed the following: staff what happened <sic> and staff stated that she had rolled resident and as she rolled her, her legs went over the side of bed and resident went down on the floor knees first. Writer and several staff members pick resident up using the Hoyer lift and put her back in bed, writer notice that her R (right) knee was a little red, bilateral knee X-rays have been ordered. A heath status note 9/23/2019 at 20:24 revealed the following: Left Knee X-Ray results are in. Findings: there is a fracture of Distal Femoral Diaphysis, with Moderate impaction. Soft tissue swelling seen. Charge Nurse informed, (Name of Nurse Practitioner) Notified and received Phone order to transfer patient to hospital . Patient received HS (evening) medications and Patient c/o pain to Bilat LE (lower extremity), Applied Biofreeze with no relief. Patient is informed of fracture and Is in bed at this time with all safety precautions implemented. A Radiology report dated 9/23/19 revealed the following: Examination: Knee AP (anteroposterior) or lat (lateral) 1-2V (views) Left .Findings: There is a [MEDICAL CONDITION] femoral diaphysis, with moderate impaction .Conclusion: Impacted [MEDICAL CONDITION] femur . Further view of the radiology report revealed the following: Knee AP or Lat 1-2V, Right. Results findings: There is a [MEDICAL CONDITION] femoral diaphysis, with moderate impaction .Conclusion: Impacted distal femur fracture . A heath status note dated 9/24/2019 at 07:20 revealed the following: Resident returned from {Name of local hospital) at 0645 per (name of ambulance company) on stretcher .There is a brace to her RLE (right lower extremity) due to knee fracture, to remain in place . A physician progress notes [REDACTED].History Of Present Illness: This is a bedbound (age of R#901) female with contractures and muscle stiffness with joint stiffness. Patient was found to have fall as nursing aid was helping transfer pt (patient) over. She fell on to her knees B/L (bilateral) and started to have pain associated with her knees s/p (status/post) fall. Patient had knee AP or lateral 1-2 view of left and right with results findings of [MEDICAL CONDITION] femoral diaphysis with moderate impaction. Soft tissue swelling is seen. There is normal alignment no erosions are demonstrated there is osteopenia. Patient was sent to (name of local hospital) hospital's emergency department where she was seen had pelvis 1-2 view x-rays with left 3 view knee x-ray and two-view left femur x-ray with impressions single view pelvis 2 view left femur 3 view left knee lateral films of knee and femur are significantly on penetrated limited evaluation. Commuted and impacted intra-articular lateral and medial femoral condyle fracture. Fracture line extends into the distal femoral metaphysis and diaphysis . A health status note dated 9/24/2019 at 12:31 revealed the following: Left message for res son (name of son) that she had returned to facility. She has bil leg fx's (fractures) and we have her in full leg splints, (brand name of narcotic) has been ordered for pain . On 10/2/19 a facility investigation submitted to the state agency pertaining to R#901's fall was reviewed and revealed the following: Perpetrators-Perpetrator Name: (CNA A) .Type of Alleged Perpetrator: Staff .Title: Cena .Details-Type of Alleged Incident: Mistreatment .Date/Time Incident Occurred: 9/23/2019 02:55 PM .Incident Summary: Cena was providing care to resident that was in the bed. Cena rolled resident and resident's legs slipped over side of the bed and onto her knees on the floor. Cena lowered resident's upper body and protected resident's head. Resident right knee was noted to be lightly red and bilateral x-rays were ordered. X-ray of left and right knee indicated impacted [MEDICAL CONDITION] femurs .Investigation Summary/Actions Taken: The resident, (R#901) was being provided care by cena (CNA A). Cena (CNA A Initials) rolled resident toward her and resident was to close to the edge. Resident's legs slipped over the side of the bed and resident slide <sic> onto knees on the floor. Cena (CNA A Initials) was able to guide resident's upper body to the floor and protected resident's head. The facility has determined that the Cena did not position the resident correctly in the bed resulting in the resident to slip from the bed .Immediate interventions included resident's plan of care updated to be assigned two caregivers to provide all bedside care. Also, resident was placed on a wider bed and mattress. Additionally Cena was provided with re-education on proper positioning of residents when providing bedside care . On 10/2/19 a facility document titled LARA (Licensing and Regulatory Affairs) Determination of Reportable Incident/Investigation (last revised 5/26/16) revealed the following: 1. b. Describe what allegedly occurred-The resident, (R#901) was being provided care by (CNA A). (CNA A) rolled resident toward her and resident was to close to the edge. (R#901) legs slipped over the side of the bed and resident slide onto knees on the floor .2. Assess the resident for injury and/or psychosocial change-a .(R#901) right knee noted to be red there was no bruising or redness noted. Resident did complain on right knee being sore. Bilateral x-rays of left and right knees ordered .b .X-rays indicated impacted [MEDICAL CONDITION] femur in both legs .9.-Review and evaluate any additional information about the affected resident-The resident (R#901) returned to the facility 9/24/19 at 0645 am after ER evaluation. Resident was not a candidate for surgical intervention. Resident had splint in place to right lower extremity upon return. Facility acquired the same splint for resident's left lower extremity. Resident is to follow up with ortho (orthopedic) Dr. in two weeks .Summary Report of Facility's Conclusion: The facility has determined that the Cena did not position the resident correctly in the bed resulting in the slip from the bed .Additionally Cena was provided with re-education on proper positioning of residents when providing bedside care. On 10/2/19 a facility document titled Team Member Verbal Conversation & Re-Education Plan (Singed by CNA A and Director of Nursing on 9/27/19) revealed the following: Description of behavior or deficient Practice: Employee was providing incont (incontinence). care for resident in bed. When turned resident was to close to edge causing resident legs to slide off and resident had to be guided to the floor .Staff education and detailed performance improvement guidelines: Employee was asked to demonstrate how (unreadable) turning resident and was provided instruction improvements at the bedside also given hand outs with proper technique of residents. On 10/2/19 at approximately 1:32 p.m., CNA A was queried regarding R#901's fall on 9/23/19. CNA A indicated they were providing incontinence care to R#901 in their room and when they went to turn R#901 towards them they had them to close to the edge of the bed and R#901's legs went over the side. CNA A indicated that they could not catch R#901 from falling so they held their head so it wouldn't hit when they fell . CNA A was queried if the facility had spoken to them regarding the proper placement of R#901 and they indicated that they had and that the facility told them they had to make sure residents are centered in the bed when providing care. CNA A stated, They also told me I had to make sure their legs are crossed when I turn them. I didn't know that. CNA A indicated that going forward they would ensure residents are centered in the bed and their legs are crossed during turning and repositioning. On 10/2/19 a copy of a facilty document titled How to successfully turn a patient in bed (dated 9/27/19) that was provided to CNA A for re-education on turning residents was reviewed and revealled the following: .Step 2: Prepare the patient-Move the patient to the center of the bed, making sure the rails are up on the side you are turning the patient towards. The patient's bottom arm should be stretched towards you. Place the patient's top arm across their chest. Cross the patient's upper ankle over the bottom ankle . Deficient Practice #2 Based on observation, interview and record review the facility failed to ensure interventions to reduce injury and prevent resident falls were applied for two residents (R#901 and R#902) resulting in the increased potential for falls and injury from falling to occur. Findings include: Resident #901 On 10/2/19 at approximately 10:33 a.m., 11:14 a.m., and 12:18 p.m., R#901 was observed in their room lying in their bed. R#901 was observed to have bilateral braces on their legs. R#901's bed was observed to have only one assist bar attached to it. The other assist bar was observed to be located on the chair next to the bed. R#901's bed was also observed to be approximately waist high not in the low position. On 10/2/19 at approximately 12:33 p.m., R#901 was observed in their room lying in their bed. R#901 was observed to have their bed being lowered into the low position. On 10/2/19 at approximately 12:36 p.m., CNA A was queried why R#901's bed was being lowered into the low position and they stated, She is a fall risk. CNA A was queried why R#901's bed was not in the low position during the morning and they stated, I didn't know that it was supposed to be. CNA A was queried if they had reviewed R#901's careplan to be aware of the fall interventions for R#901 and they indicated that they hadn't. On 10/2/19 the medical record for R#901 was reviewed and revealed the following: R#901 was initially admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of R#901's MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 9/19/19 revealed R#901 was totally dependent on facility staff for bathing and transfers and needed extensive assistance with two staff members for toileting, dressing and bed mobility. R#901's BIMS score (brief interview of mental status) was five indicating severely impaired cognition. A review of R#901's active careplan revealed the following: Focus- Impaired physical mobility/fall risk R/T (related to) limited mobility, cognitive deficits, nonamb (non-ambulatory). Bil LE (bilateral lower extremity) contractures .Goal-(R#901) will remain free of complications related to immobility and fall related injury/fall risks through the next review date .Interventions- .bilateral assist bars .keep bed in low position . A review of R#901's Kardex (a directive of care for the facility direct care staff) revealed the following: Safety-Keep bed in low position. R#902 On 10/2/19 at approximately 10:30 a.m., 11:06 a.m., 12:21 p.m., at 12:41 p.m., R#902 was observed in their room lying in their bed. R#902's bed was observed to be positioned in the middle of the room allowing access to both sides of their bed. Bed was not observed against the wall. On 10/2/19 the medical record for R#902 was reviewed and revealed the following: R#902 was initially admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of R#902's MDS with an ARD of 8/29/19 revealed R#902 needed extensive assistance with most of their activities of daily living. R#902's BIMS score was 10 indicating moderately impaired cognition. A review of R#902's active careplan revealed the following: Focus-(R#902) has Impaired physical mobility/fall risk R/T (related to) dementia & O[NAME]HX ([MEDICAL CONDITION] history) .Goal-By review date (R#902) will have minimized risk factors for falls .Interventions-bed against wall . A review of R#902's Kardex revealed the following: Safety-bed against the wall. On 10/2/19 at approximately 3:55 p.m., during a conversation with the Director of Nursing (DON), the DON was queried what happened regarding R#901's fall. The DON indicated that CNAA was providing incontinence care to R#901 and that during repositioning CNA A had R#901 too close to the edge of the bed and R#901 fell off the side of the bed with CNA A holding her head for safety. The DON was queried if they had re-educated CNA A on proper positioning in the bed to ensure residents were centered before being repositioned and they stated that they did. The DON was also queried if CNA A should have crossed R#901's legs when repositioning and they indicated that they should have. The DON was queried why it was important to ensure residents' legs are crossed and they indicated that it was easier to turn them. During the interview the DON was also queried regarding the fall interventions that were not observed to be in place for R#901 and R#902. The DON was queried if R#901 should have had their bed positioned in the low position. The DON was observed reviewing R#901's careplan and Kardex and indicated that R#901's bed should have been in the low position. The DON was queried if R#902 should have had their bed positioned against the wall as indicated on their careplan and kardex. The DON was observed reviewing R#902's kardex and careplan and indicated that they should have had their bed against the wall according to those documents but that R#902 had moved to another room so they were unsure if R#902's bed still had to be against the wall. The DON stated, I will have to see if they still need that. If not, I will have to get it removed from the careplan. The DON was queried if it was their expectation that the nursing staff apply the interventions that are indicated on the Kardex and careplan and they indicated that it was. On 10/2/19 a facility document titled Falls Management Program (last revised 11/1/18) was reviewed and revealed the following: Policy statement/purpose: [NAME] To identify each resident at risk for falls. to formulate care plans to reduce risk of falls. To educate staff on fall reduction techniques. To effectively monitor fall interventions .[NAME] Identification. 3. If there is a fall or a risk is identified by nursing, the licensed nurse will: a.) Assess for use of positional/protective device(s) b.) Obtain order, implement device and address on care plan .c.) Provide education to staff about the intervention to prevent falls .d.) Re-evaluate risk at least quarterly and/or when a fall or change of condition occurs .

Based on observation, interview and record review, the facility failed to protect the resident and ensure staff to resident physical abuse and involuntary seclusion did not occur for one (R#93) of nine residents reviewed for abuse, resulting in an Immediate Jeopardy (IJ) when it was discovered that R#93 alleged physical abuse by a private duty paid caregiver and it was documented the incident occurred. This deficient practice places the residents at risk for serious harm, injury and/or death and the likelihood of continued abuse. Findings include: The Immediate Jeopardy started on 6/28/18. The Immediate Jeopardy was identified on 12/12/18 at 12:30 PM. The Administrator was notified of the Immediate Jeopardy on 12/12/18 at 2:23 PM and a plan of removal was requested to remove the immediacy. On 12/10/18 at 10:41 AM, R#93 was observed in bed with a private duty caregiver at the bedside. R#93 was asked how she was doing and how her time at the facility had been. R#93 did not respond appropriately, and repeatedly stated, I love you, and You're pretty. An interview with the caregiver was conducted and she indicated her duties were to provide one-to-one companionship and supervision, but her duties did not include providing any type of hands-on care for the resident. A review of R#93's clinical record was conducted and revealed an admission date of [DATE] and a re-admission date of [DATE] with [DIAGNOSES REDACTED]. A review of R#93's most recent Minimum Data Set (MDS) assessment with an assessment reference date of 10/11/18 included a Brief Interview for Mental Status score of 3/15 indicating severe cognitive impairment and the requirement of one to two staff members for all activities of daily living. The MDS assessment also indicated R#93 did not experience any hallucinations, delusions, rejection of care, or wandering; but did exhibit physical and verbal behaviors for 1-3 days during the assessment reference lookback period. A review of R#93's nursing progress notes was conducted and revealed the following notes: 6/28/2018 18:30 Health Status Note Late Entry: Note Text: At approximately 1800 (6 PM) CNA (Certified Nursing Assistant) ('X') informed writer that when she past <sic> residents room she heard two slaps. Resident then yelled out She hit me. Residents 1:1 caregiver responded I couldn't take the abuse anymore. Right after this incident residents caregiver was blocking resident from leaving the room and stated We already left once. Writer was at med (medication) cart on adjacent hall while incident occurred. Writer then observed 1:1 caregiver wheeling resident in wheelchair in hallway and stated she was off duty at 1800 . 6/29/2018 12:39 Health Status Note-Note Text: Resident, caregiver, CNA, and nurse statements taken during evening of 6/28/18. Nurse assessment of resident did not show any signs of physical abnormalities or psychological impact. Caregiver states resident was grabbing at caregiver's hands and digging into hers while caregiver was attempting to redirect resident into safe seated position. Resident was trying to leave room by unsafely standing up. Caregiver stated she did exclaim I can't take this abuse in an area where others could hear her. She stated that directly after this statement, she stopped providing care for the resident as it was the end of her shift. On 12/12/18 at approximately 8:15 AM, a review of a facility provided investigation file was conducted and revealed the following documents: A document titled, (State Agency Name) Determination of Reportable Incident/Investigation Guide that read, .1. Incident: a .CNA reported hearing someone exclaim She hit me from inside residents room. b .CNA reports responding and observing the private caregiver blocking the resident from leaving the room .3. Describe any action taken by the facility to protect the resident(s) and to prevent a possible re-occurrence during the investigation. Private caregiver to be removed from serving resident; re-education and coaching for private caregiver . A hand written and signed statement from CNA 'X' that read, When walking past (R#93)'s room CNA heard two slaps. (R#93) then yelled out 'She hit me'. The caregiver from the agency then said, 'I couldn't take the abuse anymore'. Directly after this, the caregiver was blocking (R#93) from leaving her room and said, 'We already went out once'. Caregiver left. (R#93) was with with nurse, CNA reported to nurse and charge. An unsigned, typed statement that read, Statement from (Private Duty Caregiver 'Y') 6/28/18 1845 (6:45 PM) Private Duty Director ('LLL') and Associate Administrator ('MMM') called (Caregiver 'Y') requesting details of an alleged event at the end of her shift as a private caregiver for (R#93). We asked (Caregiver 'Y') if she hit the resident or if the resident hit her. (Caregiver 'Y') said (R#93) hit her while (Caregiver 'Y') was trying to get (R#93) to sit still in her chair. (R#93) dug her nails into (Caregiver 'Y')'s hands when (Caregiver 'Y') was attempting to reposition (R#93's) feet on the w/c (wheelchair) pedals. (Caregiver 'Y') reports swatting (R#93)'s hand away so that (R#93) would stop trying to dig her nails into (Caregiver 'Y')'s hand. (Caregiver 'Y') says that after this encounter, she left the room to report to the nurse that the end of her shift had arrived and she was leaving. We asked if (R#93) exclaimed she had been hit and (Caregiver 'Y') said no and no one had hit anyone. There was also an allegation that (Caregiver 'Y') said she wasn't going to take (R#93)'s abuse. We asked (Caregiver 'Y') if she said this, and she said yes she did. On 12/12/18 at approximately 10:30 AM, an interview was conducted with the Administrator regarding the use of private duty caregivers in the facility. During the interview, the Administrator explained that R#93 had an around the clock, one-to-one caregiver paid for by the facility. The facility staff would sometimes provide the caregiver and when they were not able to, they used a sister company associated with the facility to provide the caregiver services. The Administrator was then specifically asked about the incident between R#93 and Caregiver 'Y'. The Administrator was asked about CNA 'X's statement in the investigation file and whether CNA 'X' was still employed at the facility; the Administrator indicated CNA 'X' no longer worked in the facility. When asked specifically about what had been done after the investigation to protect R#93, the Administrator said, She (Caregiver 'Y') was re-educated and it was reported to her boss. The Administrator further explained that Caregiver 'Y' had not been re-assigned to R#93. When further queried as to whether Caregiver 'Y' continued to work in the facility with resident's of the facility, the Administrator was not certain, and indicated further questions should be referred to Private Duty Director 'LLL', (from the sister company) who was Caregiver 'Y's supervisor. On 12/12/18 at approximately 3:00 PM, a review of the personnel records for Caregiver 'Y' was conducted and the following was discovered: A document titled EMPLOYEE DISCIPLINARY NOTICE for Caregiver 'Y' that read, Violation: handling of a patient who is being aggressive .Date of Violation: 6/28/18. Description of Violation: Incident: During a shift with a patient at (Facility Name) it was reported to management that there was a confrontation between (Caregiver 'Y') and the patient and it was said by someone in the room 'I don't have to take this kind of abuse.' This writer and (Associate Administrator 'MMM') .called (Caregiver 'Y') to describe to us what occurred .(Caregiver 'Y') stated she was trying to reposition pts (patients) legs, client (R#93) dug her nails into (Caregiver 'Y')'s hand. (Caregiver 'Y') asked her to stop and when she wouldn't stop she 'swatted' her hand away .(Caregiver 'Y') stated that she did say to the patient she 'She did not have to put up with this kind of abuse' .Disciplinary Action This Occurrence: Verbally warned to get assistance when confronted with a situation where a patient is trying to hurt you and gently remove yourself from the situation. Do not swat or say to a patient that you 'Do not have to put up with their abuse.' Just remove yourself from the situation . On 12/13/18 at approximately 9:00 AM, an interview with Private Duty Director 'LLL' was conducted regarding the duties of private caregivers providing services to residents within the facility. Specifically, Private Duty Director 'LLL' was asked if private duty caregivers were to have any sort of hands on contact such as transferring or repositioning residents, and Private Duty Director 'LLL' reported that private duty caregivers were not to have physical contact with the residents. Private Duty Director 'LLL' indicated that a private duty caregiver could push a resident in wheelchair, but in the event of any situation that required physical assistance, a request for assitance should be made to Facility staff. When queried as to whether Caregiver 'Y' was still employed by (name of the sister company) Private Duty Company and whether she continued to work for Residents who resided at the Facility, Private Duty Director 'LLL' stated, She is still working for our company and is able to work as a private duty caregiver for residents in the facility. I will have to check to see if she is providing or has provided care to residents residing at the facility following the incident that occurred on 6/28/18. On 12/13/18 at approximately 10:00 AM, Private Duty Director 'LLL' provided documentation that indicated Caregiver 'Y' had worked with another person, (R#296) on the following dates: 8/8/18, 8/10/18, 8/11/18, 8/17/18 and 8/18/18. On 12/12/18 at 2:00 PM, a review of the Facility's policy titled Abuse Prohibition Program (effective date 8/28/17 and reviewed 11/13/18 documented, in part, the following 1. Purpose/Policy Statements: (name redacted) facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation and reporting of abuse, neglect, mistreatment and misappropriation of property as defined in the Elder Justice Law. Elder Law regulation to be adhered to in conjunction with this policy. The purpose is to assure the facility is doing all that is within its control to prevent occurrences including preventing any exploitation of residents .Procedures Identification .1. Screening: It is the policy of this facility to screen employees and volunteers prior to working with residents .e. all new employees .will be oriented to the Abuse policy .g. Attendance of a yearly in service on the Abuse Policy .is mandatory III. Procedure: A. Any employee, visitor or resident who becomes aware of or suspects any act of physical, sexual, emotional abuse or exploitation, abandonment, act of neglect, or involuntary seclusion to a Resident should report this incident to Administrator and/or Director of Nursing immediately. B. The Administrator and/or Director of Nursing Services shall assure that the resident's medical needs are met and evaluate if there has been serious bodily harm. If there is a potential for, or suspicion of, serious bodily harm the Administrator will report the suspicion immediately, but not later than 2 hours after forming the suspicion E. If the Administrator is uncertain and unable to decide whether abuse occurred, he/she shall consult with the Director of Operation and/or the Chief Executive Officer . H. All venders and outside contractors are held to the same expectations listed in this policy as any and employees of the Facility (name redacted). The facility provided the following plan of removal on 12/13/18 Corrective Action for Resident #93: · The involved resident was immediately assessed 6/28/18. · Nursing did not find any signs or symptoms of distress. · Social Work assessed resident on 6-29-18 and found no recall or signs of distress from the occurrence. · The Administrator was notified immediately. · The staff person involved went home and has never worked with #93 again nor any other resident. · As the occurrence was investigated it was discovered that it was the resident that was hitting, grabbing and scratching the staff member and that it was the staff member that was heard yelling out you are abusing me. · The staff member involved was trying to contain the situation and yelled for a nurse. She wasn't secluding the resident, she was trying to contain the resident from harming others and remain with her. · Despite the injury that was received by aide, the companion aide was counseled and educated on procedures once again. In no instance did anyone at facility or at the home care agency believe that #93 was segregated, restrained or harmed when in fact the companion was trying to keep her safe and receive help for herself and #93. · An investigation occurred. There are many entries in the care plan about #93's behaviors and actions to take. · Since #93 had no harm and it was the companion that was harmed; we did not report it. Corrective Action for Other Resident · Each new resident is assessed using the facility assessment and is care planned according. · All current residents are being reassessed for potential abuse beginning (MONTH) 12, (YEAR) to be completed by (MONTH) 18, (YEAR). · Reviewed and revised the Abuse Prohibition Program policy. · Staff is being re-educated on the Investigation and Abuse Prohibition Program policy beginning (MONTH) 12, (YEAR). This will begin at the afternoon to midnight shift change and continuing through the morning Department Head meeting until all staff has completed the re-education. · The staff education records will reflect all staff that were re-educated. The name and content of the staff education will also remain on record. · All residents will be assessed for potential abuse every shift by the clinical staff and this will be reported daily to the Director of Nursing, the findings will also be reviewed in the next three monthly QAPI meetings and then quarterly. · The Administrator and Director of Nursing were re-educated by the Regional Director of Operations regarding the abuse policy, investigations and reporting. · It is the responsibility of the Administrator to maintain compliance.

Based on observation, interview and record review, the facility failed to thoroughly investigate an actual incident of abuse and an injury of unknown origin for one (#93) of nine residents reviewed for abuse, resulting in an Immediate Jeopardy (IJ) when it was discovered that R#93 alleged physical abuse by a private duty paid caregiver and it was documented that the incident occurred as well as sustained a large bruise on their right forearm, a golf ball size hematoma to the forehead and an upper right eye hematoma, all of unknown origin. This deficient practice put all residents who reside in the facility at risk for serious harm, injury and/or death when the facility failed to perform thorough investigations. Findings include: The Immediate Jeopardy started on 6/28/18. The Immediate Jeopardy was identified on 12/12/18 at 12:30PM. The Administrator was notified of the Immediate Jeopardy on 12/13/18 at 11:02 AM and a plan of removal was requested to remove the immediacy. On 12/10/18 at 10:41 AM, R#93 was observed in bed with a private duty caregiver at the bedside. R#93 was asked how she was doing and how her time at the facility had been. R#93 did not respond appropriately, and repeatedly stated, I love you, and You're pretty. An interview with the private duty caregiver was conducted and she indicated her duties were to provide one-to-one companionship and supervision, but did her duties did not include providing any type of hands on care for the resident. A review of R#93's clinical record was conducted and revealed an admission date of [DATE] and a re-admission date of [DATE] with [DIAGNOSES REDACTED]. A review of R#93's most recent Minimum Data Set (MDS) assessment with an assessment reference date of 10/11/18 included a Brief Interview for Mental Status score of 3/15 indicating severe cognitive impairment and the requirement of one to two staff members for all activities of daily living. The MDS assessment also indicated R#93 did not experience any hallucinations, delusions, rejection of care, or wandering; but did exhibit physical and verbal behaviors for 1-3 days during the assessment reference look back period. On 12/12/18 at 8:40 AM, a review of facility provided Incident and Accident (I&A) Reports and any accompanying investigation files was conducted. The review of the reports and files included the following: An I&A dated 4/23/18, with a revision date of 5/29/18 that read, Bruising .Incident Description: Nurse called to resident room by other staff to inspect large hematoma to right arm. Nurse assessed the hematoma found to be 9x11.5x3cm (centimeters). Warm, firm, and nontender <sic> to palpation .Resident states that she does not know what happened to her arm .Witnesses: No witnesses found . An investigation file into the bruise was provided, that included only a one page typed document that read, .The following is a summary of the facility investigation regarding the incident with (R#93) .On 4/23/18 it was noted in an incident report that (R#93) had a hematoma on her right arm .Resident did not remember how injury occurred .Upon further investigation it was noted that (R#93) had increased agitation on 4/22/18 2-10pm shift. (Caregiver 'NNN') was resident one on one at that time. (Caregiver 'NNN') reported that she observed (R#93) being combative and hitting her, trying to stand up, grabbing at people . The investigation file was not noted to contain the names or any interviews with any other staff other than the statement in the typed summary by Caregiver 'NNN'. The file did not include any follow-up with the resident, staff, or other residents after the discovery of the large bruise. An I&A dated 6/29/18, with a revision date of 12/5/18 that read, Occurrence .Incident Description: CNA (Certified Nursing Aide) walking past (R#93)'s room hear two noises. Someone yelled out, and the caregiver made a stastment. The CNA observed the caregiver blocking the resident's exit from the room. Caregiver's shift ended at this time, and nursing entered room to follow up and examine resident . Review of other documents including progress notes and documents in the investigation file included the following: 6/28/2018 18:30 Health Status Note Late Entry: Note Text: At approximately 1800 (6 PM) CNA (Certified Nursing Assistant) ('X') informed writer that when she past <sic> residents room she heard two slaps. Resident then yelled out She hit me. Residents 1:1 caregiver responded I couldn't take the abuse anymore. Right after this incident residents caregiver was blocking resident from leaving the room and stated We already left once. Writer was at med (medication) cart on adjacent hall while incident occurred. Writer then observed 1:1 caregiver wheeling resident in wheelchair in hallway and stated she was off duty at 1800 . 6/29/2018 12:39 Health Status Note-Note Text: Resident, caregiver, CNA, and nurse statements taken during evening of 6/28/18. Nurse assessment of resident did not show any signs of physical abnormalities or psychological impact. Caregiver states resident was grabbing at caregiver's hands and digging into hers while caregiver was attempting to redirect resident into safe seated position. Resident was trying to leave room by unsafely standing up. Caregiver stated she did exclaim I can't take this abuse in an area where others could hear her. She stated that directly after this statement, she stopped providing care for the resident as it was the end of her shift. A document titled, (State Agency Name) Determination of Reportable Incident/Investigation Guide that read, .1. Incident: a .CNA reported hearing someone exclaim She hit me from inside residents room. b .CNA reports responding and observing the private caregiver blocking the resident from leaving the room .3. Describe any action taken by the facility to protect the resident(s) and to prevent a possible re-occurrence during the investigation. Private caregiver to be removed from serving resident; re-education and coaching for private caregiver . A hand written and signed statement from CNA 'X' that read, When walking past (R#93)'s room CNA heard two slaps. (R#93) then yelled out 'She hit me'. The caregiver from the agency then said, 'I couldn't take the abuse anymore'. Directly after this, the caregiver was blocking (R#93) from leaving her room and said, 'We already went out once'. Caregiver left. (R#93) was with with nurse, CNA reported to nurse and charge. An unsigned, typed statement that read, Statement from (Private Duty Caregiver 'Y') 6/28/18 1845 (6:45 PM) Private Duty Director ('LLL') and Associate Administrator ('MMM') called (Caregiver 'Y') requesting details of an alleged event at the end of her shift as a private caregiver for (R#93). We asked (Caregiver 'Y') if she hit the resident or if the resident hit her. (Caregiver 'Y') said (R#93) hit her while (Caregiver 'Y') was trying to get (R#93) to sit still in her chair. (R#93) dug her nails into (Caregiver 'Y')'s hands when (Caregiver 'Y') was attempting to reposition (R#93's) feet on the w/c (wheelchair) pedals. (Caregiver 'Y') reports swatting (R#93)'s away so that (R#93) would stop trying to dig her nails into (Caregiver 'Y')'s hand. (Caregiver 'Y') says that after this encounter, she left the room to report to the nurse that the end of her shift had arrived and she was leaving. We asked if (R#93) exclaimed she had been hit and (Caregiver 'Y') said no and no one had hit anyone. There was also an allegation that (Caregiver 'Y') said she wasn't going to take (R#93)'s abuse. We asked (Caregiver 'Y') is she siad this, and she said yes she did. An I&A dated 8/5/18, with a revision date of 12/5/18 that read, Bruising .Incident Description: During 7-3pm shift, shared care sitter (private duty caregiver) informed writer that there was a bruise (no measurement included) on the residents left arm. Writer observed a round dark purple bruise on the left upper extremity Writer asked the resident if she knew what happened, resident stated no. (Private duty caregiver), stated the bruise was not there the day prior .Witnesses: No witnesses found . The I&A did not include any accompanying documentation by the end of the survey that evidenced an investigation was conducted regarding the bruise. An I&A dated 9/8/18, with a revision date of 12/5/18 that read, Fall .Incident Description: Resident was seen in hallway with 1:1, 1:1 sitter was in front of resident, resident was in wheelchair .I went to my med cart and passed another resident's medication, this took about 5-10 minutes. When I came out of the other residents room the resident in question (R#93) had a purple mark on her forehead. I asked the 1:1 sitter what happened and she stated she did not know. I said this is fresh her forehead is swelling as we speak. She again said she did not know what happened and I asked resident what happened. Resident is unable to answer appropriately or remember the event that happened .Level of Pain: PAINAD (An observational Pain Scale assessment tool for Advanced Dementia) 4. Body language=2 Rigid, Fists Clenched, .Consolability=2 Unable to Console, Distract or Reassure .Witnesses: Staff . The I&A did not include any accompanying documentation by the end of the survey that evidenced an investigation was conducted regarding the fall or the purple mark on R#93's forehead. An I&A dated 9/9/18, with a revision date of 12/5/18 that read, Bruising .Incident Description: Resident was seen in the hallway with no concerns. I went to pass a medication and upon seeing her in the hallway again 5-10 minutes later her forehead was purple. I asked her 1:1 sitter what happened and was told she did not know what happened. I told her this was fresh I was watching her forehead swell as we were talking. Sitter insisted she did not know what happened. Upon further assessment her forehead was developing golfball <sic> size hematoma and upper right eye hematoma was developing .Witnesses: No Witnesses found . The I&A did not include any accompanying documentation by the end of the survey that evidenced an investigation was conducted regarding the purple mark on R#93's forehead. On 12/12/18 at approximately 9:15 AM, an interview with the facility's Administrator was conducted regarding the I&A's and investigation files for R#93. The Administrator was asked what the revision dates on the I&A's indicated. The Administrator explained that the revision dates indicated the concern had been finalized and reviewed and stated, Those are my final reviews, they are done. During the interview, the Administrator was asked specifically about the I&A's dated 9/8/18 and 9/9/18. It was noted the I&A's documented similar injuries and the I&A dated 9/8/18 had been documented as a Fall and I&A dated 9/9/18 had been documented as Bruising. The Administrator was queried if there was any other investigative documents for the two incidents and indicated there was not. When asked how it was determined that the incident on 9/8/18 had been a fall, without any investigation or interviews from witnesses (for example, the one-to-one caregiver) the Administrator stated, I understand, our documentation does not show she fell . On 12/12/18 at approximately 10:30 AM, a follow-up interview was conducted with the facility's Administrator regarding the incident and investigation into the incident that occurred on 6/28/18. During the interview, the Administrator explained that R#93 had an around the clock, one-to-one caregiver paid for by the facility. The facility staff would sometimes provide the caregiver and when they were not able to, they used a sister company to provide the caregiver services. The Administrator was then specifically asked about the incident between R#93 and Caregiver 'Y'. When asked specifically about the details of the investigation and what had been done to protect R#93 and other residents, the Administrator said, She (Caregiver 'Y') was re-educated and it was reported to her boss. The Administrator further explained that Caregiver 'Y' had not been re-assigned to R#93. When further queried as to whether Caregiver 'Y' continued to work in the facility, the Administrator was not certain, and indicated further questions should be referred to Private Duty Director 'LLL', who was Caregiver 'Y's supervisor. On 12/12/18 at approximately 3:00 PM, a review of the personnel records for Caregiver 'Y' was conducted and the following was discovered: A document titled EMPLOYEE DISCIPLINARY NOTICE for Caregiver 'Y' that read, Violation: handling of a patient who is being aggressive .Date of Violation: 6/28/18. Description of Violation: Incident: During a shift with a patient at (Facility Name) it was reported to management that there was a confrontation between (Caregiver 'Y') and the patient and it was said by someone in the room 'I don't have to take this kind of abuse.' This writer and (Associate Administrator 'MMM') .called (Caregiver 'Y') to describe to us what occurred .(Caregiver 'Y') stated she was trying to reposition pts (patients) legs, client (R#93) dug her nails into (Caregiver 'Y')'s hand. (Caregiver 'Y') asked her to stop and when she wouldn't stop she 'swatted' her hand away .(Caregiver 'Y') stated that she did say to the patient she 'She did not have to put up with this kind of abuse' .Disciplinary Action This Occurrence: Verbally warned to get assistance when confronted with a situation where a patient is trying to hurt you and gently remove yourself from the situation. Do not swat or say to a patient that you 'Do not have to put up with their abuse.' Just remove yourself from the situation . On 12/13/18 at approximately 9:00 AM an interview with Private Duty Director 'LLL' was conducted regarding the duties of private care givers providing services to residents within the facility. Specifically, Private Duty Director 'LLL' was asked if private duty care givers were to have any sort of hands on contact such as transferring or repositioning residents, and Private Duty Director 'LLL' reported that private duty caregivers were not to be having any physical contact with the residents. Private Duty Director 'LLL' indicated that a private duty care giver could push a resident in wheelchair, but in the event of any situation that required physical assistance, a request for assistance should be made to Facility staff. When queried as to whether Caregiver 'Y' was still employed by (name redacted) Private Duty Company and whether she continued to work with Residents who resided at the Facility, Private Duty Director 'LLL' stated, She is still working for our company, I will have to check to see if she is providing or has provided care to residents residing at the facility following the incident that occurred on 6/28/18. On 12/13/18 at approximately 10:00 AM, Private Duty Director 'LLL' provided documentation that indicated Caregiver 'Y' had worked with R#296 on the following dates: 8/8/18, 8/10/18, 8/11/18, 8/17/18 and 8/18/18. The Immediate Jeopardy started on 6/28/18. The immediate jeopardy was identified on 12/12/18 at 12:30PM. The Administrator was notified of the Immediate Jeopardy on 12/13/18 at 11:02 AM and a plan of removal was requested to remove the immediacy. The facility provided the following plan of removal on 12/13/18 Corrective Action for Resident #93: · The Administrator and Director of Nursing were notified immediately. · Resident #93 was assessed by the nurse. No sign of pain was identified. The immediate intervention was removal of the caregiver from the resident's care while being investigated. · Resident will be reassessed by 12-13-18 and will be monitored daily by the nurses. Corrective Action for Other Residents: · Each new resident is assessed using the facility assessment and is care planned according. · All current residents are being reassessed for potential abuse beginning (MONTH) 12, (YEAR) to be completed by (MONTH) 18, (YEAR). · All new occurrences of actual abuse, allegations of abuse, resident to resident incidents and injuries of unknown origin will be investigated and reported accordingly within the required time-frames to the state agency. · Staff education will be documented and will include the subject and content. · All residents will be assessed for potential abuse every shift by the clinical staff and this will be reported daily to the Director of Nursing, the findings will also be reviewed in the next three monthly QAPI meetings and then quarterly. · The Administrator and Director of Nursing were re-educated on proper investigation and reporting by the Regional Director Operations on 12-12-18. · The Administrator is responsible for maintaining compliance.

Based on interview and record review, the facility failed to implement fall prevention safety devices for one (#926) of seven sampled residents reviewed for accidents from a total of 30, resulting in falls and a fracture. Findings include: On 11/15/16 at 9:25 AM, the clinical record and incident reports for resident #926 were reviewed with the Director of Nursing (DON). The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The minimum (MDS) data set [DATE] noted that the resident had severe cognitive and visual impairment and required extensive assistance for transfers and mobility. Fall Assessments dated 2/1/16, 2/10/16, 4/14/16, 9/12/16 and 11/2/16 noted that the resident was at high risk for falls. The 9/12/16 assessment noted: impaired gait with difficulty rising from chair, kept head down when walking and watched the floor, could not walk unassisted, was weak and unable to lift head without losing balance, had a shuffled gait with short steps, had a fall risk score of 65 (a score of 45 or more=high risk). A Fall Risk care plan initiated 10/11/12, included the following interventions: -Assure the resident's recliner chair is reclined in a back position when up in the chair. -Sensor alarm fall safety floor mat in front of the recliner and bed. -Transfer with use of a gait belt. Incident reports for resident #926 noted the following: On 2/1/16-observed on the floor-no noted injury-the fall safety alarm (which at the time was attached to the bed and then clamped to the resident's clothing with a string in between) did not sound due to being found disconnected from the resident's clothing. The corrective action to prevent reoccurrence: staff to check alarm placement. The resident was noted to be confused and not oriented to place or time. Per a 2/15/16 physician order, the string alarm was discontinued and changed to the sensor alarm floor mat, an alarm that sounded off to alert staff of unassisted transfer attempts if stepped on. On 4/14/16-fell on the floor while ambulating with staff with no gait belt on-no noted injury-the corrective action: staff educated to use appropriate equipment (gait belt) during transfers and ambulation. When asked, the DON said that a gait belt should have been used to help prevent the fall. On 11/2/16-observed on floor in room near doorway-no indication floor sensor alarm sounded-yelling out with right leg pain-X-ray dated 11/2/16 noted acute right hip fracture. Corrective action: Alarms need to be in place at all times. When up in recliner-chair needs to be in reclined back position. The incident investigation revealed the following details: Resident #926 was transferred by a nurse aide from her bed to her recliner. The aide left the room to attend to other residents. The aide then heard a resident, who lived across the hall from resident #926, calling for help to report that resident #926 was on the floor. Per that resident's witness statement: She was leaving her room at the time and I saw that (Resident #926) was up and around in her room and I know that she is supposed to have help. She fell and I started calling for help she was walking in her room. I knew she wasn't supposed to. The investigation summary written by the DON noted: Resident #926 got up from her chair unassisted and attempted to ambulate in the room. The resident was confused, non-compliant with safety interventions and has a very unsteady gait due to debility. Resident subsequently fell to floor. When asked why there was no indication that the sensor mat alarm sounded, the DON said that the aide did not place the mat down in front of the recliner as she should have, after transferring the resident to the chair. At 11 AM, per review of a Team Member Disciplinary Notice in the assigned aide's personnel file, the aide was terminated on 11/3/16, reason: failed to follow plan of care for a resident resulting in an injury to that resident. On 11/15/16 at 5 PM, per review of the facility's Falls Management Program dated 10/29/15: If there is a fall or a risk identified, nursing staff must assess for use of positional/protective devices, obtain an order, implement the device and address the device on the care plan. ( )

This deficient practice has two intake numbers Based on observation, interview, and record review, the facility failed to ensure that two of five sampled residents reviewed for falls (resident #201 and # 202), from a total sample of six were provided with appropriate assistance and safety devices while ambulating to shower room and when transferred from wheelchair to bed, resulting in falls with right hip fractures. Findings include: Intake number MI 444 On 5-31-16, during the entrance conference the facility reported incident and five day investigation was reviewed with the executive director and senior director of clinical operations. The director identified, Resident ambulated from the room to shower room with his two wheeled walker assisted by cna (certified nurse aide) on the morning of 5-15-16 at approximately 0630. Upon entry to the shower room the resident turned to close the door and lost his balance falling sideways from a standing position .The resident sustained [REDACTED].Care plan reveals that the resident was a two person assist for transfers and ambulation .with two wheeled walker and use of gait belt. Closet care guide (used by the cna for guidance prior to proving care) reflects the same transfer status. The resident was assisted by one cna to the shower .Evidence support that the plan of care was not followed which directly impacted the care and outcome for the resident. On 5-31-16 at 11:00 a.m., Resident #201's clinical record was reviewed. The resident was admitted [DATE]. diagnosed included: Alzheimer disease, Essential hypertension, Acute kidney failure, Muscular degeneration and Gout. Review of Minimum Data Set (MDS) and assessments, dated 3-28-16, revealed that the resident had cognitive and decision-making patterns that were severely impaired. The resident was ambulatory, but required extensive two person physical assistance. The care plan dated 3-13-16 note that the resident was a fall risk due to impaired physical mobility. Transfer status: two person assist for transfers and ambulation to and from bathroom with use of two wheeled walker and gait belt. A review of the Incident report dated 5-16-16 at 06:47, note that staff (employee A) informed nurse of incident at 0600. The nurse observed resident lying on right side in doorway of shower room. No physical injuries noted, no open areas or active bleeding noted. Patient complaint of verbal pain score 4/10 to right hip. Patient states area aches . prn (as needed) tylenol 325 mg was given. The physician was contacted and ordered radiology reports. The resident was transferred to hospital for evaluation and treatment of [REDACTED]. At 1:38 p.m., an attempt was made to contact employee 'A', cna by phone. A voiced message left. The cna provided a written statement and interview for the facility that states as follows, No one told me he was a two person assist I was walking behind him, we entered the shower room .I turned to sit his stuff down. He leaned to grab the door to shut it and fell to his side. I was unable to reach around the walker to grab him before he fell .complained immediately of hip pain. The cna's personal file was reviewed. The cna was suspended pending the investigation. discharged on [DATE], Performed unsafe transfer, resulting in injury to a resident. Failed to follow transfer orders of two person assist with use of a gait belt and wheeled walker. The employee admits to walking behind the resident on the way to shower room without use of gait belt and another staff member assisting. At 2:20 p.m., employee 'B', the unit manager was interviewed. She stated, I came in later to assess the resident due to concern of right hip pain. I ordered x-rays and spoke with doctor who agreed with the plan. At 2:40 p.m., employee 'C', the director of therapy services was interviewed. He confirmed that resident #201's transfer status had been unchanged since readmit (3-28-16). the resident was a two person assist with use of gait belt and two wheeled walker .and was currently unable to ambulate since sustaining the fracture. Intake number MI 699 On 5-31-16, during the entrance conference the facility reported incident and five day investigation was reviewed with the executive director and senior director of clinical operations. The director identified, An unwitnessed fall occurred on 5-14-16 at approximately 0730. The resident (#202) fell in the doorway of her room and was heard calling out. The call light and safety sensor alarm was not on at the time of the fall. According to the resident care plan she required staff assist with mobility and alarms as ordered for bed and chair on admission. The resident was assessed for injury and exhibited pain to right hip/leg. Stat x-rays were ordered. Radiology finding were inconclusive and cat scan was recommended. The resident was sent to the hospital for further evaluation and treatment per doctor orders .The resident was admitted to hospital for right hip fracture and was scheduled for surgery. On 5-31-16 at 3:00 p.m., Resident #201's clinical record was reviewed. The resident was admitted [DATE]. diagnosed included: Fracture of left femur-closed, Alzheimer disease, and Muscle weakness. Review of Minimum Data Set (MDS) and assessments, dated 5-10-16, revealed that the resident had cognitive and decision-making patterns that were severely impaired. The resident required extensive to total assistance with two person physical assist for transfers and ambulation. The care plan dated 5-4-16 noted that the resident was a fall risk due to history of falls and advance alzheimer disease. Interventions included: staff participation for mobility, low bed and bed/chair sensor alarms to alert staff of unassisted ambulation. A review of the Incident report dated 5-14-16 at 16:45, note that staff was getting report from the midnight nurse when we heard a yell from behind us, we turned to see resident (#202) lying half in and out her room on her right side (alarm not sounding and resident was unable to use call light). On assessment resident was rubbing right hip and yelling out. The physician was contacted and ordered to transfer resident to hospital for evaluation and treatment of [REDACTED].On 5-15-16, the resident was admitted to hospital with right hip fracture with surgery planned . On 6-1-16 at 9:15 a.m., resident #202 was observed sitting up at bedside in wheelchair. the wheelchair alarm was in place. The resident was appropriately dressed and groomed with no new injury noted. Confused and disoriented the resident was not responsive to questions, but appeared to be in no distress. On 6-1-16 at 9:30 a.m., the senior director of clinical operations was further. The director identified, It was concluded that the resident sustained [REDACTED]. The second shift cna (no longer works in facility) failed to transfer the sensor alarm from wheelchair to bed when putting the resident to bed on 5-13-16. There was evidence that rounds were being made regularly. However, two nurse and four cna's on the afternoon and midnight shifts failed to check for the placement and functioning of the sensor alarm as required. On the morning of 5-14-16, the resident got up unassisted and ambulated to doorway without the nursing staff having the opportunity to reach the resident prior to falling, resulting in injury. A review of personal files noted that disciplinary actions were issued to each staff member for failure to check placement and function of alarms. The facility policy and procedure titled Falls Management Program effective date 10-29-15 was reviewed. Policy: To identify each resident at risk for falls. To formulate care plans to reduce risk of falls. To educate staff on fall reduction techniques. To effectively monitor fall interventions .Procedure: 1. Upon admission all residents are assessed for transfer status, safety and equipment needs .This includes .assessing for alarms, wheelchairs, walkers, fall mats, bolsters, side rails, assist rails and bed safety .etc. The policy and procedure titled Transfer Status/Resident Care Summary revision date: 2-16-16 was reviewed. Policy: The facility will assess each resident to determine an appropriate level of transfer assistance needed by the resident in a manner that protects the safety of .residents and that maintain the resident highest level of functioning .C. the resident care summary provides direct care staff with guidelines for providing care to the resident, based on the resident's individualized plan of care .etc. And the facility policy and procedure titled Walking Rounds effective date 7-21-09 was reviewed. Policy: To provide cna's with pertinent resident information and assist with resident care and cna tasks as needed. Procedure: 1. cna from prior shift will verbally give on-coming .information including but not etc . 2. cna's from both shifts will walk down hallway together and discuss resident issues and check residents with increased needs, new equipment or status changes .etc. ( )

This citation pertains to intake number MI 733. Based on observation, interview and record review, the facility failed to maintain placement of the safety device (sensor alarmed floor mat), for 1 (#501) of 5 sampled residents reviewed for falls, resulting in a fall with a laceration to the right side of the head and fracture of the right clavicle. Findings include: According to the Face Sheet Resident #501, was a [AGE] year old female who was originally admitted to the facility on [DATE]. Resident #501's [DIAGNOSES REDACTED]. Per the Minimum Data Set Assessments ((MDS) dated [DATE] and 6/24/13, Resident #501 was severely cognitively impaired and required 1 person physical assist for activities of daily living. Resident #501 had fall assessments dated 4/4/13, 6/26/13 and 9/23/13 which identified her at "Moderate Risk for Falls". Resident #501 had a Care Plan in place titled "Impaired Physical Mobility/Fall Risk" with interventions that included "floor sensor mat". According to the Facility Incident Report dated 8/19/13, Resident (#501) was observed on her right side, walker on it's side. . . bleeding to right outer eye area. . . ER (emergency room report found) right clavicle fracture. Review of Facility incident reports provided by the DON revealed Resident #501's had 4 previous falls without injury, on 12/27/12, 2/23/13, 4/10/13 and 6/9/13. According to the Facility's 24 hour and 5 day reports dated 8/20/13 and 8/27/13, respectively, on 8/19/13 Certified Nursing Assistant/CNA 'E' answered a facility hall phone and then entered Resident #501's room because the call for was for her. CNA 'E' informed her (Resident #501) that her son was on the phone, (then) removed the floor sensor pad (alarmed floor mat), and lowered the foot rest on her recliner, and told her (Resident #501) to stay in the chair while she (CNA 'E') went to get a chair and placed it by the hall phone. When (CNA 'E') turned (back towards Resident #501's room) she saw Resident #501 in the doorway of her room, with her walker turned backwards so the wheels were in the back and the straight legs were in the front. (CNA 'E') stated she said "don't do that" and moved towards the room to get the resident. . . the resident (#501) went down before either CNA could get to her. . . Resident (#501) fell to the right, hitting her head and right shoulder. . .she (Resident #501) was observed with approximately a 1 inch laceration at the right temple with minimal bleeding. She (Resident #501) had her left hand by her right shoulder stating it hurt. The Nurse 'A' gently palpated the right shoulder and she (Resident #501) said "ow that huts's". . . x-ray and CT(Computerized Tomography) revealed a right distal clavicle fracture. . . She (Resident #501) has a history of falling prior but without injury. Resident (#501 )is alert and oriented times one, and had a sensor pad on floor because she had independently removed tab alarms and bed alarms. In an interview on 10/15/13 at 4:10 P.M., CNA 'E' reiterated the incident as documented on the Facility 5 day report. CNA 'E' said after she had removed the alarmed floor mat and sat her (Resident #501) up, then she remembered the resident would need a chair to sit on. CNA 'E' said she "snatched" a chair from the dining room (approximately 10-12 feet from resident #501's room) placed it by the phone, turned and observed her (Resident #501) in the doorway of her room. CNA 'E' said "it was the worst day of my life. I watched her (Resident #501) tip over. . . when she tipped over her glasses cut her head over her eyebrow. . . Nurse's name (Nurse 'A') assessed her (Resident #501) . . . she said her shoulder hurt. . . she ended up going for x-rays." CNA 'E' said Nurse 'A' told her she was going to write her up because Resident (#501) fell and she (CNA 'E') had removed her (alarmed floor) mat. CNA 'E' said she also spoke with the Director of Nursing/DON who had a disciplinary form ready, which stated that "I (CNA 'E') had removed the (alarmed floor) mat." CNA 'E' said the DON told her to pay more attention and be more mindful of safety devices and always keep them in place if the resident is alone. According to a nurse's note dated 8/20/13 and in an interview on 10/15/13 at 3:40 P.M., Nurse 'A' said she was in the dining room when she was informed (Resident #501) had fallen. When she (Nurse 'A'), entered the room she (Resident #501) was on the floor, on her right side, with the walker behind her, and two CNA's with her. She said, "I assessed her (Resident #501) and she had an abrasion on her right forehead. . . She complained of neck pain. . . I touched her clavicle and she screamed. . . we got her on the back board and stretcher and took her over (to the emergency room ) for x-rays. . . they (x-ray's) came back with a (right) clavicle fracture." Nurse 'A' said she (Resident #501) "does attempt to get up on her own. . . she (Resident #501) has an order for [REDACTED]." Nurse 'A' said "I had to write her (CNA 'E') up. I wrote her up for negligence. I told her she had failed , when she left her (Resident #501) alone with the foot rest down and the (alarmed floor) mat removed. . . she (CNA 'E') understood." In an interview on 10/15/13 at 2:40 P.M., the facility DON said, she had been informed by staff that she (Resident #501) had failed when the resident received a phone call and the CNA ('E' ) had removed the (alarmed) floor mat, told the resident to stay there and left to get chair for her (Resident #501) to sit on at the phone. The DON said she spoke to the CNA ('E') about why she had removed the mat and discussed safety measures and informed her not to remove safety devices, then had her repeat everything back. The DON said, she (CNA 'E') was upset and realized she should not have removed the mat and left the Resident (#501) alone in the room. The DON said she felt it was an individual incident that involved only one CNA ('E'). ( )

REFER TO INTAKE # MI 805 BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE THE APPROPRIATE ASSISTANCE DURING A TRANSFER AND TO ENSURE THE SAFETY OF ONE (RESIDENT #101) OF 7 SAMPLED RESIDENTS, ALL 7 REVIEWED FOR FALLS AND SAFE TRANSFER TECHNIQUE, RESULTING IN IMMEDIATE JEOPARDY WHEN RESIDENT #101, WHO WAS LEFT STANDING IN THE BATHROOM, HOLDING A GRAB BAR, fell AND SUSTAINED MULTIPLE FRACTURES TO BOTH OF HER LOWER LEGS. RESIDENT #101 WAS TRANSFERRED TO THE HOSPITAL WHERE SHE SUBSEQUENTLY died . FINDINGS INCLUDE: RESIDENT #101 WAS [AGE] years OLD, ALERT AND ORIENTED TO PLACE, TIME AND PERSON AND RESPONSIBLE FOR HER OWN DECISIONS. SHE WAS admitted to the facility on [DATE] WITH A HISTORY OF ALS ([DIAGNOSES REDACTED]), AND OSTEOARTHRITIS. ON [DATE],SHE HAD BEEN diagnosed with [REDACTED]. A REVIEW OF THE MDS (MINIMUM DATA SET), DATED [DATE], REVEALED RESIDENT #101 REQUIRED EXTENSIVE (2 OR MORE PERSON) PHYSICAL ASSISTANCE IN PERFORMING ADLS (ACTIVITIES OF DAILY LIVING) ESPECIALLY BED MOBILITY, TRANSFER, AND, TOILET USE. RESIDENT #101'S REHABILITATION EVALUATION AND CARE PLAN, DATED [DATE] AND [DATE], INDICATED THAT FOR TRANSFER, RESIDENT #101 REQUIRED "TWO-PERSON ASSIST WITH GAIT BELT OR PRN (AS NEEDED) HOYER LIFT WITH TWO PERSON ASSIST, LARGE SLING, MIDDLE LOOPS TOP AND BOTTOM." A FACILITY INCIDENT REPORT, DATED [DATE], AT 9:40 AM, DOCUMENTED THAT RESIDENT #101 WAS FOUND ON THE BATHROOM FLOOR WITH HER BACK AGAINST THE WALL, BUT HER HEAD IN-BETWEEN THE TOILET PAPER DISPENSER AND THE ASSIST RAIL. RESIDENT #101'S LEFT LEG WAS OBSERVED TO BE OUT IN FRONT OF HER. HER RIGHT KNEE WAS BENT AND THE LEG WAS PARTIALLY UNDER THE RESIDENT. ACCORDING TO THE INCIDENT REPORT, THE CORRECTIVE MEASURE TO PREVENT A SIMILAR INCIDENT WAS "FOLLOW PROPER TRANSFER PROTOCOL." ACCORDING TO THE FACILITY INVESTIGATION, DATED [DATE], THE CAREGIVER, CERTIFIED NURSING ASSISTANT (CNA) #5 FAILED TO FOLLOW PROPER TRANSFER PROTOCOL, WHEN HE "USED 1 PERSON ASSIST FOR THE TRANSFER AND DID NOT USE A GAIT BELT." RESIDENT #101 WAS SENT TO THE emergency room AT 10:00 AM. REVIEW OF HOSPITAL RECORDS FOR RESIDENT #101 REVEALED X-RAYS, DATED [DATE], SHOWING THE FOLLOWING: 1) FRACTURE OF PROXIMAL TIBIA AND FIBULA ON THE RIGHT, 2) TRANSCONDYLAR FEMUR FRACTURE ON THE LEFT, 3) LEFT FIBULAR FRACTURE, AND 4) IMPACTED TRANSCONDYLAR FRACTURE OF THE DISTAL LEFT FEMUR. NURSE IN CHARGE #3 WAS INTERVIEWED ON [DATE] AT 1:04 PM ABOUT THE INCIDENT THAT OCCURRED ON [DATE]. CHARGE NURSE #3 admitted THAT THERE HAD BEEN TWO INCIDENTS WHEN RESIDENT #101 fell AFTER A TRANSFER ATTEMPT- THE INCIDENT THAT OCCURRED ON [DATE] AND AN EARLIER INCIDENT THAT OCCURRED ON [DATE]. NURSE IN CHARGE #3 STATED THAT SHE HAD BEEN THE NURSE ON-DUTY DURING BOTH INCIDENTS AND HAD COMPLETED BOTH INCIDENT REPORTS. CHARGE NURSE #3 REPORTED THAT RESIDENT #101 fell IN THE BATHROOM ON [DATE] WHEN CNA #7 TRANSFERRED HER ALONE WITHOUT ANOTHER STAFF TO ASSIST AND WITHOUT USING A GAIT BELT. ACCORDING TO NURSE 33, CNA #7 "DID NOT FOLLOW THE TRANSFER PROTOCOL OF TWO-PERSON ASSISTANCE WITH GAIT BELT. AS A RESULT, RESIDENT #101 SUSTAINED A RIGHT ANKLE SPRAIN ON THE [DATE] FALL." CHARGE NURSE #3 DESCRIBED THE SECOND FALL INCIDENT ON [DATE] WHEN CNA #5 TRANSFERRED RESIDENT #101 AND DID NOT GET HELP. NURSE #3 SAID THAT CNA #5 FAILED TO USE A GAIT BELT WHILE TRANSFERRING RESIDENT #101. CHARGE NURSE #3 SAID THAT RESIDENT #101 WAS TRANSFERRED TO THE emergency room AND HAD SUSTAINED MULTIPLE FRACTURES DUE TO THE FALL ON [DATE]. NURSE #4 WAS INTERVIEWED ON [DATE] AT 1:46 PM ABOUT THE INCIDENT THAT OCCURRED ON [DATE]. NURSE #4 STATED,"RESIDENT #101 WAS ON THE FLOOR IN THE BATHROOM, BLEEDING FROM SKIN TEARS, WITH HER BACK AGAINST THE WALL. HER LEFT LEG WAS STRAIGHT FORWARD AND HER LEFT ANKLE/FOOT LOOKED BROKEN. HER RIGHT KNEE WAS BENT BACK WITH HER LEG PARTIALLY UNDER HER." NURSE #4 STATED THAT SHE IMMEDIATELY CALLED CHARGE NURSE #3 TO ASSESS THE SCENE. USING A BATH BLANKET AND SEVEN NURSING STAFF, RESIDENT #101 WAS TRANSFERRED FIRST TO A STRETCHER AND THEN TO THE emergency room . NURSE #4 FURTHER STATED THAT RESIDENT #101'S TRANSFER STATUS WAS A 2-PERSON ASSISTANCE USING A GAIT BELT OR PRN (AS NEEDED) HOYER LIFT. NURSE #4 STATED: "RESIDENT #101 DID NOT HAVE A GAIT BELT ON HER AT THE SCENE AND CNA #5 admitted HE WAS ALONE DURING THE TRANSFER." WHEN INTERVIEWED ON [DATE] AT 1:20 PM, THE DIRECTOR OF NURSING (DON) WAS ASKED ABOUT RESIDENT #101'S TWO INCIDENTS OF IMPROPER TRANSFER. THE DON STATED THAT DURING FALL INCIDENT #1, DATED [DATE], CNA # 7 FAILED TO FOLLOW THE PROPER TRANSFER PROTOCOL. CNA #7 admitted TO THE DON THAT DURING TRANSFER , CNA #7 DID NOT USE 2-PERSON ASSISTANCE AND DID NOT HAVE THE GAIT BELT ON RESIDENT #101. THE DON DESCRIBED THAT DURING THE FALL INCIDENT #2, DATED [DATE], CNA #5 ALSO FAILED TO FOLLOW PROPER TRANSFER PROTOCOL. CNA #5 TRANSFERRED RESIDENT #101 WITHOUT USING 2-PERSON TRANSFER AND FAILED TO USE A GAIT BELT. RESIDENT #101 SUSTAINED MULTIPLE FRACTURES AFTER THE FALL INCIDENT #2 ON [DATE]. CNA #5 WAS TERMINATED IMMEDIATELY AFTER THE INCIDENT OCCURRED. THE ADMINISTRATOR ON [DATE] AT 3:06 PM, AGREED THAT CNA #5 DID NOT FOLLOW THE TRANSFER PROTOCOL ALLOWING RESIDENT #101 TO FALL AND SUSTAIN MULTIPLE FRACTURES. PHYSICAL THERAPIST (PT) #8 WAS INTERVIEWED ON [DATE] AT 2:10 PM. SHE STATED THAT RESIDENT #101 WAS EVALUATED ON [DATE] AFTER THE FALL ON [DATE]. PT #8 STATED SHE RECALLED THAT ON [DATE], RESIDENT #101'S LEFT ANKLE WAS SWOLLEN AND THE RESIDENT COMPLAINED OF "BAD PAIN." AFTER THE EVALUATION, PHYSICAL THERAPY TREATMENT WAS NOT PERFORMED ON [DATE], [DATE] AND [DATE], DUE TO THE RESIDENT'S COMPLAINTS OF SEVERE PAIN. THE PT RECOMMENDATION ON [DATE], WAS "MAXIMUM ASSISTANCE 2 PERSON USING GAIT BELT, NO AMBULATION AND LEFT FOOT WEIGHT BEARING AS TOLERATED DUE TO SEVERE PAIN AND SWELLING." RESIDENT #101'S TRANSFER STATUS ON [DATE] AND [DATE], DID NOT CHANGE. RESIDENT #101 WAS TO BE TRANSFERRED BY 2 PERSON ASSISTANCE WITH GAIT BELT AND PRN HOYER LIFT. CNA #7 WAS INTERVIEWED ON [DATE] AT 2:47 PM. SHE admitted TO THE SURVEYOR THAT SHE WAS ALONE DURING THE FALL THAT OCCURRED ON [DATE]. SHE admitted THAT SHE WAS NOT AWARE THAT RESIDENT #101 WAS A 2-PERSON TRANSFER AT THAT TIME. SHE admitted THAT SHE DID NOT LOOK AT RESIDENT #101'S TRANSFER TAG (INSTRUCTIONS OF METHOD OF TRANSFER) THAT DAY. CNA #7 FURTHER EXPLAINED THAT SHE DID NOT LOOK AT THE TRANSFER TAG ON A DAILY BASIS. ON THE DAY OF THE FALL ([DATE]) CNA #7 admitted THAT SHE DID NOT USE A GAIT BELT DURING THE TRANSFER AND DID NOT HAVE ANOTHER STAFF TO HELP DURING THE TRANSFER. SEVERAL ATTEMPTS WERE MADE TO CONTACT CNA #5 BY TELEPHONE ON [DATE] AND [DATE]. CNA #6 DID NOT RETURN THE SURVEYOR'S CALL. REVIEW OF HOSPITAL RECORDS, DATED [DATE] TO [DATE], REVEALED RESIDENT #101 fell on [DATE] AND SUSTAINED MULTIPLE FRACTURES. THE PHYSICIAN CONSULT DATED [DATE], NOTED THAT THE ORTHOPEDIC PHYSICIAN EVALUATED RESIDENT #101 AS "NOT AN OPERATIVE CANDIDATE." RESIDENT #101 WAS IN A LOT OF PAIN AND WAS PLACED ON HOSPICE CARE ON [DATE] AND SUBSEQUENTLY expired on [DATE] AT 12:20 PM. ON [DATE] AT 12:38 PM, THE ADMINISTRATOR WAS INFORMED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON [DATE] AS A RESULT OF THE FACILITY'S FAILURE TO PROVIDE THE APPROPRIATE ASSISTANCE DURING A TRANSFER AND TO ENSURE THE SAFETY OF RESIDENT #101 WHEN SHE WAS LEFT STANDING IN THE BATHROOM, HOLDING A GRAB BAR, fell AND SUSTAINED MULTIPLE FRACTURES TO BOTH OF HER LOWER LEGS. RESIDENT #101 WAS TRANSFERRED TO THE HOSPITAL WHERE SHE SUBSEQUENTLY died . ON [DATE], THE SURVEYOR CONFIRMED THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. AS OF [DATE] THE CLINICAL TEAM, INCLUDING THE RESTORATIVE RN NURSING MANAGER ,IDENTIFIED 66 RESIDENTS REQUIRING TWO PERSON ASSISTANCE DURING TRANSFER AND RESIDENTS REQUIRING THE USE OF HOYER (MECHANICAL LIFT) FOR TRANSFERS. 2. ON [DATE] AT 2:00 PM, NURSING STAFF RECEIVED INSERVICE ON A.) KNOWING THE IMPORTANCE OF FOLLOWING THE TRANSFER DIRECTIONS IDENTIFIED BASED ON RESIDENT'S ASSESSMENT, B.) WHERE TO FIND THE TRANSFER TAG DIRECTIONS IN THE RESIDENT ROOM, C.) UNDERSTANDING THE STEPS REQUIRED TO PERFORM A 2-PERSON ASSIST TRANSFER AND HOYER LIFT AND D.) KNOWING WHICH RESIDENTS ARE THE 2-PERSON ASSISTS ON THEIR ASSIGNED WING. 3. AS OF [DATE], 151 OF 204 NURSING ASSISTANTS, LICENSED NURSES AND REGISTERED PHYSICAL THERAPISTS WERE INSERVICED. ALL CLINICAL AND NURSING STAFF ON LOA (LEAVE OF ABSENCE) WILL RECEIVE IN SERVICE ON ALL PERTINENT POLICY AND PROCEDURES RELATED TO THE INCIDENT PRIOR TO RETURNING TO WORK. 4. AS OF [DATE], ALL POLICIES PERTAINING TO TRANSFER AND FALL PREVENTION WERE REVIEWED TO ASSURE THAT THE POLICIES AND PROCEDURE REFLECTS THE CURRENT PRACTICE. 5. AS OF [DATE], ALL 184 OF 184 CURRENT RESIDENTS WERE RE-EVALUATED BY THE DON TO DETERMINE THAT THE TRANSFER STATUS IN THE RESIDENT'S ROOM (I.E. TRANSFER TAG) MATCHES THE CURRENT TRANSFER ASSESSMENT IDENTIFIED INT HE CHART AND ON THE PLAN OF CARE. 6. AS OF [DATE] AUDITS WILL BE HELD RANDOMLY BY NURSE MANAGERS, TO OBSERVE TRANSFER TECHNIQUE AND ADHERENCE TO TRANSFER TAG STATUS. A LOG WILL BE MAINTAINED AND REPORTED TO THE QA (QUALITY ASSURANCE) MONTHLY. STAFF WILL BE WRITTEN UP (ZERO TOLERANCE) IF FOUND NOT ADHERING TO THE TRANSFER TAG. 7. THE ADMINISTRATOR AND THE DIRECTOR OF NURSING ARE RESPONSIBLE FOR ONGOING COMPLIANCE OF F-323. WHILE THE IMMEDIATE JEOPARDY (IJ) WAS REMOVED ON [DATE], THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF "ISOLATED" AND A SEVERITY OF "NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT AN IMMEDIATE JEOPARDY" UNTIL SUSTAINED COMPLIANCE CAN BE VERIFIED BY STATE AGENCY. ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW THE FACILITY FAILED TO ENSURE PERSONAL SAFETY ALARMS WERE CORRECTLY PLACED AND IN WORKING ORDER IN 4 OF 4 RESIDENTS ( RESIDENTS # 101, #102, #103, AND # 104), FROM A TOTAL SAMPLE OF 4 RESIDENTS REVIEWED FOR FALLS, RESULTING IN RESIDENT #104 SUSTAINING FRACTURES TO THE LEFT HUMERUS AND FEMUR AFTER A FALL AND THE POTENTIAL FOR RESIDENTS #101, #102, AND #103 TO SUSTAIN A FALL. FINDINGS INCLUDE: ACCORDING TO THE FACILITY'S FALL PREVENTION PROGRAM DATED [DATE], THE FALL COMMITTEE REVIEWS FALLS AT LEAST 4 TIMES A WEEK WITH THE UPDATED AND APPROPRIATE SAFETY INTERVENTIONS IMPLEMENTED, CARE PLANNED, AND COMMUNICATED TO STAFF. A NOTE IS WRITTEN ON THE INTERDISCIPLINARY SECTION OF THE CHART AND THE CARE PLAN IS UPDATED TO INCLUDE THESE UPDATED AND APPROPRIATE SAFETY INTERVENTIONS. SAFETY ALARMS ARE CHECKED ON A ROUTINE BASIS BY THE RESTORATIVE COORDINATOR. NURSING STAFF CHECK AND REPORT ALARM CONCERNS DAILY AS NEEDED. RESIDENT #104: ACCORDING TO THE MEDICAL RECORDS, RESIDENT #104 WAS A [AGE] year OLD MALE WHO admitted to the facility on [DATE] WITH MULTIPLE [DIAGNOSES REDACTED]. THE PHYSICIAN'S admission orders [REDACTED]. ON [DATE] AT 7:20 P.M., THE NURSE'S ADMISSION NOTE INDICATED THAT RESIDENT # 104'S WIFE TOLD THE NURSE THE RESIDENT WAS AT RISK FOR FALLS, A TAB ALARM FOR THE BED AND WHEELCHAIR WERE APPLIED AND CARE PLAN INITIATED. A FALL RISK ASSESSMENT ON [DATE] IDENTIFIED RESIDENT # 104 AS A FALL RISK DUE TO UNSTEADY GAIT AND A TAB ALARM FOR BED AND WHEELCHAIR WAS RECOMMENDED. A REVIEW OF THE NURSE'S NOTES REVEALED THE FOLLOWING DOCUMENTATION: ON ,[DATE] AT 5:00 P.M. RESIDENT #104 HAD SELF TRANSFERRED OUT OF WHEELCHAIR. ON [DATE] AT 10:40 P.M., RESIDENT #104 WAS OBSERVED ON FLOOR, RESIDENT fell AFTER SELF TRANSFER. ON [DATE] AT 10:00 P.M., RESIDENT #104 CONTINUES TO ATTEMPT SELF TRANSFERS. ON [DATE] AT 11:50 P.M., ATTEMPTED TO SELF TRANSFER 2 TIMES DURING SHIFT. ON [DATE] AT 10:00 P.M., RESIDENT SELF TRANSFERRED AND WAS OBSERVED IN THE HALLWAY, NO MENTION OF ALARM SOUNDING. ON [DATE] AT 11:25 A.M., RESIDENT #104 WAS OBSERVED IN HALLWAY WITH UNSTEADY GAIT, RESIDENT fell TO THE GROUND PRIOR TO STAFF BEING ABLE TO REACH HIM. ACCORDING TO THE X-RAY REPORTS DATED [DATE], RESIDENT # 104 SUSTAINED A MILDLY DISPLACED LEFT HUMERUS NECK FRACTURE AND A MILDLY DISPLACED LEFT FEMORAL NECK FRACTURE. DURING AN INTERVIEW ON [DATE] AT 12:05 P.M., CERTIFIED NURSING ASSISTANT (CNA) #5 SAID ON [DATE] AT APPROXIMATELY 11:30 A.M., SHE SAW RESIDENT #104 STUMBLING IN THE HALLWAY JUST OUTSIDE OF HIS ROOM, HIS WHEELCHAIR WAS STILL IN THE ROOM. CNA # 5 SAID SHE YELLED FOR HELP AND ATTEMPTED TO REACH THE RESIDENT, BUT HE fell TO THE GROUND BEFORE SHE COULD REACH HIM. CNA # 5 SAID THE RESIDENT'S TAB ALARM WAS NOT SOUNDING. CNA # 5 SAID RESIDENT # 104 WAS KNOWN TO BE ABLE TO REMOVE HIS TAB ALARM CLIP FROM HIS CLOTHES AND SELF TRANSFER HIMSELF OUT OF THE WHEELCHAIR. CNA # 5 COULD NOT EXPLAIN WHY RESIDENT # 104 WAS NOT CHANGED TO A SENSOR PAD ALARM AND SAID RESTORATIVE STAFF WERE RESPONSIBLE TO APPLY AND MAINTAIN THE RESIDENT'S SAFETY ALARMS. DURING AN INTERVIEW ON [DATE] AT NOON, CNA # 4 SAID ON [DATE] AT APPROXIMATELY 11:30 A.M. SHE SAW RESIDENT # 104 STAGGER INTO THE HALLWAY OUT OF HIS ROOM. CNA # 4 SAID SHE YELLED FOR HELP AND ATTEMPTED TO REACH THE RESIDENT, BUT HE fell TO THE GROUND ON HIS LEFT SIDE BEFORE SHE COULD REACH HIM. CNA # 4 SAID THE RESIDENT'S TAB ALARM WAS NOT SOUNDING, NOR DID SHE RECALL SEEING IT ON THE RESIDENT. DURING AN INTERVIEW ON [DATE] AT 11:50 A.M., REGISTERED NURSE (RN) #3 SAID SHE HEARD A CNA YELL OUT FOR HELP AND TURNED TO SEE RESIDENT # 104 WITH AN UNSTEADY GAIT WALKING IN THE HALLWAY JUST OUTSIDE OF HIS ROOM. RN # 3 SAID SHE RAN TO ASSIST RESIDENT # 104, BUT HE fell TO THE GROUND BEFORE SHE COULD REACH HIM. RN # 3 SAID RESIDENT #104 HAD BEEN ASSISTED TO THE BATHROOM 10 MINUTES BEFORE THE FALL AND SHE WAS CERTAIN SHE APPLIED THE TAB ALARM CLIP TO HIS SHIRT. RN # 3 SAID SHE THOUGHT THE TAB ALARM CLIP'S TEETH MAY HAVE BEEN LOOSE AND NOT CLIPPED VERY TIGHT. RN # 3 SAID THAT AFTER THE FALL, RESIDENT # 104'S TAB ALARM WAS NOTED TO BE HANGING FROM HIS WHEELCHAIR AND NOT SOUNDING. RN # 3 COULD NOT EXPLAIN HOW TO REPLACE A FAULTY TAB ALARM CLIP AND STATED THAT RESTORATIVE STAFF ARE RESPONSIBLE FOR THE SAFETY ALARMS. ON [DATE], THE FALL RISK CARE PLAN WAS UPDATED TO INCLUDED THE FOLLOWING INTERVENTION; ASSIST WITH URINAL MANAGEMENT. THERE IS NO MENTION TO CHANGE THE TAB ALARM TO A SENSOR ALARM, OR INCREASE SUPERVISION/SAFETY CHECKS. ON [DATE] THE FOLLOWING INTERVENTION WAS ADDED; FREQUENT CHECKS FOR SAFETY. ON [DATE] AT 3:30 P.M., THE RESTORATIVE NURSE SAID THE RESTORATIVE AIDE IS RESPONSIBLE FOR APPLYING AND MAINTAINING THE FACILITY'S SAFETY ALARMS. THE RESTORATIVE NURSE COULD NOT EXPLAIN WHY RESIDENT #104 WAS NOT CHANGED TO A SENSOR PAD ALARM OR HAVE ADDITIONAL INTERVENTIONS ADDED TO HIS FALL RISK CARE PLAN AFTER MULTIPLE DOCUMENTATION'S OF SELF TRANSFER ATTEMPTS. THE RESTORATIVE NURSE COULD NOT EXPLAIN WHY RESIDENT # 104 DID NOT HAVE AN UPDATED FALL ASSESSMENT. RESIDENT # 101: ACCORDING TO THE MEDICAL RECORD, RESIDENT # 101 WAS A [AGE] year OLD FEMALE WHO admitted to the facility on [DATE] WITH MULTIPLE [DIAGNOSES REDACTED]. THE PHYSICIAN HAD PRESCRIBED TAB ALARMS TO THE RESIDENT'S BED AND WHEELCHAIR UPON ADMISSION DUE TO HISTORY OF FALLS. A CARE PLAN DATED [DATE] IDENTIFIED THE RESIDENT AS A FALL RISK WITH THE FOLLOWING INTERVENTIONS; VISUALLY CHECK RESIDENT EVERY 2 HOURS DUE TO HISTORY OF FALLS AND SAFETY TAB ALARMS TO WHEELCHAIR AND BED. THE QUARTERLY FALL assessment dated [DATE] IDENTIFIED RESIDENT #101 AS REQUIRING A 2 PERSON ASSIST WITH A GAIT BELT BECAUSE OF UNSTEADY GAIT. DURING AN OBSERVATION ON [DATE] AT 12:30 P.M., RESIDENT #101 WAS OBSERVED SEATED IN HER WHEELCHAIR WITH THE SAFETY TAB ALARM NOT CONNECTED TO HER CLOTHING. THE SAFETY TAB ALARM BOX WAS ON THE TOP OF THE WHEELCHAIR WITH THE STRING AND CLIP HANGING OFF THE BACK, RESTING ON THE FLOOR. RN # 8 AND THE ASSISTANT DIRECTOR OF NURSING (ADON) WERE PRESENT DURING THE OBSERVATION AND RN # 8 IMMEDIATELY CLIPPED THE SAFETY TAB ONTO RESIDENT # 102'S CLOTHING. HOWEVER, RN #8 CLIPPED THE SAFETY TAB SO CLOSE TO THE ALARM BOX, THE RESIDENT WOULD HAVE HAD TO MOVE APPROXIMATELY 18 - 24 INCHES AWAY FROM THE WHEELCHAIR BEFORE THE ALARM WOULD HAVE SOUNDED. THE ADON SAID THIS WAS NOT AN APPROPRIATE PLACE TO CLIP THE SAFETY TAB AND MOVED THE ALARM BOX TO A LOWER PLACE ON THE WHEELCHAIR. RESIDENT # 102: ACCORDING TO THE MEDICAL RECORD, RESIDENT # 102 WAS [AGE] year OLD FEMALE WHO admitted to the facility on [DATE] WITH MULTIPLE [DIAGNOSES REDACTED]. THE PHYSICIAN HAD PRESCRIBED SENSOR ALARMS TO BED AND WHEELCHAIR, ALONG WITH A WANDERGUARD ALARM TO PREVENT ELOPEMENT. A CARE PLAN DATED [DATE] IDENTIFIED RESIDENT #102 AS A FALL RISK AND INCLUDED THE FOLLOWING INTERVENTIONS; SENSOR ALARMS FOR BED AND CHAIR, FREQUENTLY CHECK RESIDENT AND HELP HER SIT BACK, PLACE RESIDENT IN HIGHLY VISIBLE AREA. ON [DATE], THE FOLLOWING INTERVENTION WAS ADDED TO THE CARE PLAN: SENSOR ALARMS CHECKED FOR FUNCTION AND PLACEMENT. THE QUARTERLY FALL assessment dated [DATE] IDENTIFIED RESIDENT #102 HAS HAVING 6 FALLS IN THE LAST QUARTER ([DATE] TWICE, [DATE], [DATE], [DATE], AND [DATE]). DURING AN OBSERVATION ON [DATE] AT 12:40 P.M., RESIDENT #102 WAS OBSERVED SEATED IN HER WHEELCHAIR IN THE HALLWAY, JUST OUTSIDE OF HER ROOM. THE RESIDENT WAS ASSISTED INTO A STANDING POSITION TO DETERMINE IF THE SENSOR PAD ALARM WOULD SOUND. THE ALARM DID NOT SOUND WHEN THE RESIDENT WAS IN THE STANDING POSITION FOR 5 SECONDS. THE ADON AND RN # 8 WERE PRESENT DURING THIS OBSERVATION AND THE ADON MANUALLY MOVED THE SENSOR PAD BEFORE IT BEGAN TO SOUND. THE SENSOR PAD WAS OBSERVED BY A INCONTINENCE PAD AND NOT DIRECTLY UNDERNEATH THE RESIDENT. RN # 8 COULD NOT EXPLAIN WHY THE SENSOR ALARM DID NOT SOUND. RN # 8 DID NOT KNOW IF THE SENSOR PAD WAS EXPIRED OR IF THE PAD WAS NOT PROPERLY PLACED. RN # 8 SAID THAT RESTORATIVE STAFF WERE RESPONSIBLE FOR THE MAINTENANCE OF THE SAFETY ALARMS. RESIDENT # 103: ACCORDING TO THE MEDICAL RECORD, RESIDENT #103 WAS A [AGE] year OLD MALE WHO admitted to the facility on [DATE] WITH MULTIPLE [DIAGNOSES REDACTED]. THE PHYSICIAN PRESCRIBED SAFETY ALARMS TO BED AND WHEELCHAIR AND A WANDERGUARD TO PREVENT ELOPEMENT. A CARE PLAN DATED [DATE] IDENTIFIED RESIDENT #103 AS A FALL RISK AND INCLUDED THE FOLLOWING INTERVENTION; TAB ALARM TO BED AND WHEELCHAIR. ON [DATE] THE FOLLOWING INTERVENTION WAS ADDED TO THE CARE PLAN; CHECK INTEGRITY OF ALARM, PLACE AT FAR SIDE OF BED. THE QUARTERLY FALL assessment dated [DATE] IDENTIFIED RESIDENT # 103 HAS HAVING 2 FALLS IN THE LAST QUARTER ( [DATE], AND [DATE]). A REVIEW OF THE INTERDISCIPLINARY NOTES DATED [DATE] REVEALED THAT RESIDENT #103 SUSTAINED A FALL OUT OF BED AFTER A SELF TRANSFER AND THE ALARM WAS NOT SOUNDING. ON [DATE], THERE WAS DOCUMENTATION TO INDICATE THE ALARM HAD BEEN REPAIRED. DURING AN OBSERVATION ON [DATE] AT 12:50 P.M., RESIDENT # 103 WAS OBSERVED SEATED IN HIS WHEELCHAIR, IN THE DINING ROOM . THE LOW BATTERY LIGHT WAS FLASHING ON THE SAFETY ALARM BOX. THE ADON AND THE RN # 8 WERE PRESENT DURING THE OBSERVATION AND COULD NOT EXPLAIN WHAT THAT FLASHING LIGHT INDICATED. RESIDENT # 103 WAS ASSISTED TO A STANDING POSITION TO DETERMINE IF THE ALARM WOULD SOUND. RESIDENT # 103 WAS IN THE STANDING POSITION FOR OVER 3 SECONDS BEFORE THE SAFETY ALARM SOUNDED A VERY LOW 1 TONE BUZZ SOUND. NEITHER THE ADON OR RN # 8 COULD EXPLAIN IF THAT WAS THE NORMAL SOUND OF THE ALARM OR IF IT WAS LOW BECAUSE OF A POSSIBLE LOW BATTERY. DURING AN INTERVIEW WITH THE RESTORATIVE AIDE (RA) #9 ON [DATE] AT 1:20 P.M., SHE SAID SHE IS RESPONSIBLE FOR MAINTAINING ALL THE SAFETY ALARMS. THE RA DID NOT KNOW WHAT TYPE OF ALARMS RESIDENT # 101, #102, OR # 103 HAD, OR WHEN THE BATTERY'S OR PADS HAD BEEN CHANGED. RA # 9 HAD A LIST OF RESIDENTS WITH ALARMS, BUT IT DID NOT INCLUDE WHAT ROOM THE RESIDENTS WERE IN, WHEN THE ALARM WAS APPLIED, WHAT TYPE OF ALARM, OR WHEN THE BATTERY OR SENSOR PAD WAS CHANGED. THE RA SAID SOME ALARMS ARE LOCATED IN THE RESTORATIVE NURSE'S OFFICE. UPON OBSERVATION, ALARMS WERE LOCATED IN A HAPHAZARDLY IN A CLOSET. THERE WERE 4 DIFFERENT TYPE OF ALARM BOXES AND 2 DIFFERENT TYPE OF SENSOR PADS LAYING AROUND. THERE WERE NO MANUFACTURER'S RECOMMENDATIONS OR INSTRUCTIONS NEAR ANY OF THE SAFETY ALARMS, NOR WERE THERE ANY DATES ON THE PADS TO INDICATE WHEN THEY WERE INITIALLY PLACED IN USE. RA # 9 COULD NOT SAY IF THERE WERE ANY INSTRUCTIONS OF MANUALS REGARDING THE ALARM. RA # 9 SAID THE NURSE OR CNA'S COULD REPLACE AN ALARM BATTERY IF IT WERE LOW, BUT DID NOT KNOW IF THEY WERE SPECIFICALLY TRAINED. RA # 9 COULD NOT SAY IF THE PHYSICAL THERAPY STAFF WERE TRAINED IN THE PROPER PLACEMENT OF THE SAFETY ALARMS. ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE A TWO PERSON PHYSICAL ASSIST DURING A TRANSFER FOR ONE (#908) OF SEVEN RESIDENTS REVIEWED FOR FALLS, FROM A TOTAL SAMPLE OF 25 RESIDENTS, RESULTING IN A FALL FROM THE TOILET THAT RESULTED IN A BUMP TO THE HEAD, ABRASIONS, BRUISING AND PAIN. IN ADDITION, THE FACILITY FAILED TO LOCK THE "C" WING MEDICATION CART, RESULTING IN THE POTENTIAL FOR INGESTION OF MEDICATION BY RESIDENTS, FAMILY AND VENDERS. FINDINGS INCLUDE: DURING THE INITIAL TOUR OF THE FACILITY ON 5/03/11 AT 9:00 A.M., RESIDENT #908 WAS OBSERVED IN HER ROOM SEATED IN A WHEELCHAIR VISITING WITH A FAMILY MEMBER. THE FAMILY MEMBER COMPLAINED THAT RESIDENT # 908 HAD A RECENT FALL FROM THE TOILET AS SHE WAS BEING TRANSFERRED BY STAFF FROM THE WHEELCHAIR TO THE TOILET. THE FAMILY MEMBER FURTHER STATED RESIDENT #908 HAD SUSTAINED SOME INJURIES TO THE BACK DURING THE FALL. ON 5/03/11 AT 1:30 P.M., RESIDENT #908'S CLINICAL RECORD AND INCIDENT AND ACCIDENT REPORTS WERE REVIEWED. RESIDENT #908 WAS admitted INto the facility on [DATE] FROM A LOCAL HOSPITAL status [REDACTED]. RESIDENT #908 HAD [DIAGNOSES REDACTED]. THE Minimum Data Set, dated dated [DATE], INDICATED RESIDENT # 908 HAD MEMORY PROBLEMS WITH MODIFIED INDEPENDENCE IN DAILY DECISIONS MAKING. RESIDENT #908 WAS NON-AMBULATORY AND TOTALLY DEPENDENT ON STAFF FOR TRANSFERS, AND REQUIRED EXTENSIVE ASSISTANCE WITH TOILET USE. A FALLS RISK ASSESSMENT FOR RESIDENT #908, DATED 3/24/11, INDICATED RESIDENT # 908 WAS "AT RISK" FOR FALLS RELATED TO A HISTORY OF FALLS WITH SPRAIN LEFT ANKLE, MEDICATIONS AND INCREASED FALL RISK AND SAFETY AWARENESS AND ADVANCED ALZHEIMER'S DISEASE. A NURSING PLAN OF CARE, "IMPAIRED PHYSICAL MOBILITY/FALL RISK", DATED 3/24/11, INDICATED RESIDENT #908 WAS AT INCREASED RISK FOR FALL RELATED TO: INCREASE IN FALLS, COGNITIVE DEFICITS, ALZHEIMER'S; DEMENTIA, OSTEOARTHRITIS, ANTI-ANXIETY AND ANTI-HYPERTENSIVE MEDICATIONS. A RESIDENT CARE SUMMARY (UNDATED, NURSE AIDE CARE GUIDE) FOR RESIDENT #908 INDICATED RESIDENT #908 NON-AMBULATORY AND REQUIRED TWO PERSONS ASSISTANCE WITH A GAIT-BELT FOR TRANSFERS. A NURSING ASSISTANCE FLOW SHEET DATED 5/03/11 FOR THE NIGHT SHIFT INDICATED RESIDENT # 908 WAS TRANSFERRED USING ONLY A ONE PERSON PHYSICAL ASSISTANCE INSTEAD OF A TWO PERSON PHYSICAL ASSISTANCE AS INSTRUCTED IN THE AFOREMENTIONED NURSING PLAN OF CARE AND NURSE AIDE CARE SUMMARY. AN INCIDENT REPORT DATED 5/03/11 AT 4:30 A.M., STATED THE FOLLOWING: " ...CNA (E)(CERTIFIED NURSE ASSISTANT ) WAS TRANSFERRING RES. (RESIDENT) TO TOILET, RES. UNABLE TO PIVOT, THEN SLID OUT OF WHEELCHAIR TO THE FLOOR AND BUMPED HER HEAD ON THE BATHROOM DOOR ... CORRECTIVE MEASURES USE TWO PEOPLE TO ASSIST RESIDENT TO TRANSFER ... " A NURSING NOTE DATED 5/03/11 AT 4:30 A.M., STATED THE FOLLOWING: " ...CNA STATED SHE WAS TRYING TO TRANSFER RES. (RESIDENT) TO TOILET AND WASN'T BEARING WEIGHT OR PIVOTING PUT BACK IN WHEELCHAIR BUT WAS ON THE EDGE AND SLID OFF SEAT AND CNA GUIDED HER (RESIDENT) TO THE FLOOR... FOUR PERSON ASSIST UP TO WHEELCHAIR THEN BACK TO BED ...INJURIES NOTED; ABRASION TO THE RIGHT SIDE ? DOLLAR IN SIZE; ABRASION TO MID-BACK 14.5 CM IN LENGTH; BRUISING TO MIDDLE OF FOREHEAD; RESIDENT COMPLAIN OF PAIN TO RIGHT ARM AND ORBITAL BONE ABOVE RIGHT EYE ...GAVE PRN (AS NEEDED) TYLENOL FOR PAIN...RESIDENT INCREASED WEAKNESS THIS A.M... " DURING THE SURVEY FROM 5/03/11 THROUGH 5/06/11, CNA (E) WAS NOT AVAILABLE FOR INTERVIEW. ON 5/04/11 AT 11:30 A.M. AN OBSERVATION WAS MADE WITH UNIT MANAGER(C) OF RESIDENT #908 ' S INJURIES THAT WERE SUSTAINED FROM THE FALL SUFFERED ON 5/03/11, AS RESIDENT #908 WAS BEING TRANSFERRED FROM THE WHEELCHAIR TO THE TOILET WITH ONE PERSON PHYSICAL ASSISTANCE INSTEAD OF TWO AS DIRECTED IN THE NURSING PLAN OF CARE DATED 3/24/11. IT WAS OBSERVED THAT RESIDENT # 908 HAD A MOON SHAPED REDDENED AREA UNDERNEATH HER LEFT ARM AND ALONG HER RIB CAGE THAT MEASURED APPROXIMATELY 10 CM. AND AN ABRASION TO THE MID-BACK AND ALONG THE SPINE THAT MEASURED APPROXIMATELY 14.5 CM IN LENGTH. DURING AN INTERVIEW ON 5/04/11 AT 11:45 A.M., UNIT MANAGER (C) CONFIRMED THAT RESIDENT #908 WAS TRANSFERRED TO THE WHEELCHAIR TO THE TOILET WITH A ONE PERSON TRANSFER INSTEAD OF A TWO PERSON TRANSFER AT INDICATED IN THE NURSING PLAN OF CARE DATED 3/24/11. ( ) ON 5/6/11 AT 12 NOON, THE COLUMBIA COURT UNIT MEDICATION CART WAS OBSERVED NEAR ROOM C12 UNLOCKED, UNATTENDED AND OUT OF THE DIRECT VIEW OF THE NURSE. THE MEDICATION CART WAS OBSERVED FROM 12 NOON UNTIL 12:05 P.M., UNATTENDED. WHEN QUERIED NURSE "D" STATED, "I WAS JUST DASHING TO GET SOMETHING". WHEN ASKED WHAT WAS THE FACILITY'S POLICY FOR LOCKING THE MEDICATION CART WHEN UNATTENDED AND OUT OF YOUR DIRECT LINE OF VISION, NURSE "D" STATED, "IT MUST BE LOCKED EVERY TIME". ON 5/6/11 AT 2 P.M., THE DIRECTOR OF NURSING WAS QUERIED AND STATED, "IT SHOULD HAVE BEEN LOCKED". ON 5/6/11 AT 2:10 P.M., REVIEW OF THE FACILITY'S POLICY ENTITLED, "GENERAL DOSE PREPARATION AND MEDICATION ADMINISTRATION", REVISED 5/01/10, DOCUMENTED THE FOLLOWING, "FACILITY SHOULD ENSURE THAT MEDICATION CARTS ARE ALWAYS LOCKED WHEN OUT OF SIGHT OR UNATTENDED". ( )