Every finding on record at Evergreen Manor Senior Care Center

Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in the potential for increased risk of respiratory infection among all residents in the facility.Findings include: On 3/31/26 at 10:02 AM, observation of the mop sink closet in the kitchen found that a hot water storage tank was placed where the old mop sink was located. At this time, it was observed that the hot water line from the old mop sink was connected to the storage tank and the cold-water line was observed connected to nothing, indicating a stagnant water line. On 3/31/26 at 10:49 AM, observation of the 300 hall Soiled Utility room found that the hopper fixture had been removed from the room. When asked if the water lines that were left, from the hopper being removed, were on a flushing schedule, Plant Operations Director (POD) P stated that the facilities flushing schedule is every Friday for eye wash stations and some minimal use fixtures, but the lines for the removed hoppers are not flushed. When asked if their water lines ran through the cement floor or through the ceiling, POD P stated that they ran through the ceiling. On 3/31/26 at 10:55 AM, observation of the housekeeping closet, between the 300 and 400 halls, found that the cold-water valve had been taken off the mop sink. When asked why, POD P stated that the housekeeping chemicals are only used with hot water. When asked if the cold side ever gets flushed on Fridays, POD P stated it was not something they currently did. On 3/31/26 at 11:27 AM, observation of the 400 hall Soiled Utility room found the hopper was removed and the water lines were left intact (same set up as the 300 Soiled Utility room). On 3/31/26 at 11:43 AM, observation of the housekeeping closet between the 100 and 200 halls, found that the cold valve was removed from the mop sink faucet, indicating minimal use and a stagnant water line. On 3/31/26 at 11:52 AM, observation of the 100 hall Soiled Utility room found a removed hopper with water lines still present. POD P stated that he would get their plumber out and remove all the stagnant unused lines to within six inches of the main line (so they are no longer creating areas of domestic water stagnation). On 3/31/26 at 12:02 PM, observation of the shared bathroom at the end of the 100 hall, between the end of the hall storage room and the conference room, found that the commode and sink had been removed from this area and the water fixtures were left intact. When asked how long ago this area has been without a sink and commode intact, POD P stated it has been that way since covid (2020). When asked if this was on a flushing schedule, POD P stated that he will make sure it gets addressed. On 3/31/26 at 2:20 PM, a discussion of the facilities WMP plan occurred with POD P and Assistant POD Q. When asked about testing for free chlorine, POD P stated that they use a test strip monthly and that their results are typically 0.5 or 1.0 parts per million (ppm).Observation of the facility provided test strips found that Total Chlorine was underlined, and the range was in half (0.5) ppm increments via a color variant. The test strips left no viable way to discern between levels of free chlorine that were in between 0 ppm and 0.5 ppm, or 0.5 ppm to 1.0 ppm, leaving the POD P to pick the closest resembling color for a concentration.A record review of the facility provided document entitled Water Management Plan, dated July 1, 2025, found that a listed control measure for the facility is Disinfectant (Free Chlorine) Level Checks. Under the Task 1 heading it states that, Use a free and total chlorine test kit that can accurately read to 0.1 ppm.

Based on observation, interview, and record review the facility failed to ensure that one resident (#100) was treated with dignity and care in manner that promotes maintenance or enhancement of her quality of life out of one resident reviewed for dignity.Findings included: Resident #100 (R100)Review of the medical record revealed R100 was admitted [DATE] with diagnoses that included metabolic encephalopathy (brain dysfunction caused by chemical imbalance, urinary tract infection, hypertension, difficulty walking, and muscle weakness. Review of R98's document entitled Brief Interview of Mental Status (3.0 BIMS), completed 03/30/2026, revealed a BIMS score of 15 (cognitively intact) out of 15.On 03/31/2026 at 09:31 a.m. during observation and interview R100 was observed lying down in bed. R100's daughter V was observed sitting in a chair at her bedside. R100 explained that she had a concern regarding her care. She explained that sometime in the middle of the night an aide had told her just to urinate in her brief because the aide did not have time to take her to the bathroom. R100 explained that she urinated in her brief. R100 explained that the aide came back later and provided continent care to her.During the same interaction above R100's daughter V explained that R100 had told her about an incident that occurred Sunday evening around 04:00 a.m. R100's daughter V explained that her mother explained that she had placed her call light on, because she needed to go to the bathroom. R100's daughter V explained that her mother told her that an aide had told her to go in her brief because she did not have time to take her to the bathroom. R100's daughter V explained that her mother told her that she urinated in her brief. R100's daughter V explained that her mother was being treated for a Urinary infection and could not hold her urine. R100's daughter V explained that her mother had not been treated with dignity and respect. R100's daughter explained that she had explained this to the Nursing Home Administrator and was just told that the aide that was involved was new and that the issue had been addressed with the employee.On 04/01/2026 at 09:03 a.m. Director of Nursing (DON) B explained that it was her expectation that residents would be provided urinary care based upon their needs and their plan of care. DON B was asked if she had any knowledge of R100 being told to urinate in her brief because the aide did not have time to take her to the bathroom? DON B explained that she did not have knowledge of the incident and explained that it would not be acceptable for staff to inform a resident to urinate in a brief. DON B explained that staff should have taken her to the bathroom, provided her a bed pan, or provided a bedside commode.

Based on observation, interview, and record review the facility failed to report an allegation of neglect/abuse to the appropriate state survey agency for one resident (#100) of one resident reviewed for neglect/abuse.Findings Included:Resident #100 (R100)Review of the medical record revealed R100 was admitted [DATE] with diagnoses that included metabolic encephalopathy (brain dysfunction caused by chemical imbalance, urinary tract infection, hypertension, difficulty walking, and muscle weakness. Review of R98's document entitled Brief Interview of Mental Status (3.0 BIMS), completed 03/30/2026, revealed a BIMS score of 15 (cognitively intact) out of 15.On 03/31/2026 at 09:31 a.m. during observation and interview R100 was observed lying down in bed. R100's daughter V was observed sitting in a chair at her bedside. R100 explained that she had a concern regarding her care. She explained that sometime in the middle of the night an aide had told her just to urinate in her brief because the aide did not have time to take her to the bathroom. R100 explained that she urinated in her brief. R100 explained that the aide came back later and provided continent care to her.During the same interaction above R100's daughter V explained that R100 had told her about an incident that occurred Sunday evening around 04:00 a.m. R100's daughter V explained that her mother explained that she had placed her call light on, because she needed to go to the bathroom. R100's daughter V explained that her mother told her that an aide had told her to go in her brief because she did not have time to take her to the bathroom. R100's daughter V explained that her mother told her that she urinated in her brief. R100's daughter V explained that her mother was being treated for a Urinary infection and could not hold her urine. R100's daughter V explained that her mother had not been treated with dignity and respect. R100's daughter explained that she had explained this to the Nursing Home Administrator and was just told that the aide that was involved was new and that the issue had been addressed with the employee.Review of the facility concern logs did not reveal any concern for R100.On 04/01/2026 at 08:31 a.m. the Nursing Home Administrator (NHA) A explained that he had been the facility Nursing Home Administrator for approximately a week and a half. NHA A explained that he was the facility abuse coordinator. NHA A explained the definitions of abuse and neglect. NHA A was asked if he had knowledge that R100 had reported that she was told to urinate in her brief because an aide did not have time to take her to the bathroom. NHA A explained that he was aware of the allegation and had investigated it and could not substantiate that it occurred. NHA A was asked if he any documentation that he could demonstrate that the incident was investigated. NHA A responded that he could put something together. NHA A was asked if he currently had any documentation demonstrating that the incident was investigated. NHA A responded that he did not currently have any documents. NHA A was asked if he had reported the allegation to the appropriate state agency. NHA A explained that since he could not substantiate the allegation, he did not report the incident. On 04/01/2026 at 09:03 a.m. Director of Nursing (DON) B explained that it was her expectation that residents would be provided urinary care based upon their needs and their plan of care. DON B was asked if she had any knowledge of R100 being told to urinate in her brief because the aide did not have time to take her to the bathroom? DON B explained that she did not have knowledge of the incident and explained that it would not be acceptable for staff to inform a resident to urinate in a brief. DON B explained that staff should have taken her to the bathroom, provided her a bed pan, or provided a bedside commode. DON B explained that this would have been an allegation of potential abuser or neglect and she would have reported this to the Nursing Home Administrator (NHA).On 04/01/2026 at 09:12 a.m. a telephone interview was conducted with Licensed Practical Nurse (LPN) BB. LPN BB explained that R100's daughter V had voiced a concern to her on Monday morning. LPN BB explained that R100's daughter V had told her that a CNA (Certified Nurse Aide) had told her mother to urinate in her brief or bed because they were short staffed and the CNA did not have time to take her to the bathroom. LPN BB explained that she immediately had report the incident to NHA A because this was an allegation of abuse or neglect.On 04/01/2026 at 2:03 p.m. Nursing Home Administrator (NHA) A explained that he had reported the above allegation to the appropriate state agency today and provided a MIFRI number of 00064131. NHA A also explained that he was starting an investigation into the incident. Review of facility policy NEX-156K entitled Abuse, Neglect, and/or Misappropriation of Resident Funds or Property, origination date of 05/13/14 and revision date of 03/15/23, revealed e). Investigation i) Time Frame for Investigation (1) The investigation shell be initiated immediately, after the Administrator has knowledge of the incident, but in no event shall the investigation take longer than five (5) working days. The same policy revealed f) Reporting /Response i) for the alleged violation involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, the Center will report immediately but not later that than two hours after the allegation is made, if the events cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the state survey agency, local authorities as appropriate, adult protective services where stat law provide for jurisdiction in long term care facilities), in accordance with state law, and within 5 working days of the incident with the conclusion.

Based on observation, interview, and record review the facility failed to adequately investigate an allegation of neglect/abuse for one resident (#100) of one resident review of neglect/abuse.Findings Included: Resident #100 (R100)Review of the medical record revealed R100 was admitted [DATE] with diagnoses that included metabolic encephalopathy (brain dysfunction caused by chemical imbalance, urinary tract infection, hypertension, difficulty walking, and muscle weakness. Review of R98's document entitled Brief Interview of Mental Status (3.0 BIMS), completed 03/30/2026, revealed a BIMS score of 15 (cognitively intact) out of 15.On 03/31/2026 at 09:31 a.m. during observation and interview R100 was observed lying down in bed. R100's daughter V was observed sitting in a chair at her bedside. R100 explained that she had a concern regarding her care. She explained that sometime in the middle of the night an aide had told her just to urinate in her brief because the aide did not have time to take her to the bathroom. R100 explained that she urinated in her brief. R100 explained that the aide came back later and provided continent care to her.During the same interaction above R100's daughter V explained that R100 had told her about an incident that occurred Sunday evening around 04:00 a.m. R100's daughter V explained that her mother explained that she had placed her call light on, because she needed to go to the bathroom. R100's daughter V explained that her mother told her that an aide had told her to go in her brief because she did not have time to take her to the bathroom. R100's daughter V explained that her mother told her that she urinated in her brief. R100's daughter V explained that her mother was being treated for a Urinary infection and could not hold her urine. R100's daughter V explained that felt her mother had not been treated with dignity and respect. R100's daughter explained that she had explained this to the Nursing Home Administrator and was just told that the aide that was involved was new and that the issue had been addressed with the employee.Review of the facility concern logs did not reveal any concern for R100.On 04/01/2026 at 08:31 a.m. the Nursing Home Administrator (NHA) A explained that he had been the facility Nursing Home Administrator for approximately a week and a half. NHA A explained that he was the facility abuse coordinator. NHA A explained the definitions of abuse and neglect. NHA A was asked if he had knowledge that R100 had reported that she was told to urinate in her brief because an aide did not have time to take her to the bathroom. NHA A explained that he was aware of the allegation and had investigated it and could not substantiate that it occurred. NHA A was asked if he any documentation that he could demonstrate that the incident was investigated. NHA A responded that he could put something together. NHA A was asked if he currently had any documentation demonstrating that the incident was investigated. NHA A responded that he did not currently have any documents. NHA A was asked if he had reported the allegation to the appropriate state agency. NHA A explained that since he could not substantiate the allegation, he did not report the incident. On 04/01/2026 at 09:03 a.m. Director of Nursing (DON) B explained that it was her expectation that residents would be provided urinary care based upon their needs and their plan of care. DON B was asked if she had any knowledge of R100 being told to urinate in her brief because the aide did not have time to take her to the bathroom? DON B explained that she did not have knowledge of the incident and explained that it would not be acceptable for staff to inform a resident to urinate in a brief. DON B explained that staff should have taken her to the bathroom, provided her a bed pan, or provided a bedside commode. DON B explained that this would have been an allegation of potential abuser or neglect and she would have reported this to the Nursing Home Administrator (NHA).On 04/01/2026 at 09:12 a.m. a telephone interview was conducted with Licensed Practical Nurse (LPN) BB. LPN BB explained that R100's daughter V had voiced a concern to her on Monday morning. LPN BB explained that R100's daughter V had told her that a CNA (Certified Nurse Aide) had told her mother to urinate in her brief or bed because they were short staffed and the CNA did not have time to take her to the bathroom. LPN BB explained that she immediately had report the incident to NHA A because this was an allegation of abuse or neglect.On 04/01/2026 at 2:03 p.m. Nursing Home Administrator (NHA) A explained that he had reported the above allegation to the appropriate state agency today and provided a MIFRI number of 00064131. NHA A also explained that he was starting an investigation into the incident. Review of facility policy NEX-156K entitled Abuse, Neglect, and/or Misappropriation of Resident Funds or Property, origination date of 05/13/14 and revision date of 03/15/23, revealed e). Investigation i) Time Frame for Investigation (1) The investigation shell be initiated immediately, after the Administrator has knowledge of the incident, but in no event shall the investigation take longer than five (5) working days. The same policy revealed f) Reporting /Response i) for the alleged violation involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, the Center will report immediately but not later that than two hours after the allegation is made, if the events cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the state survey agency, local authorities as appropriate, adult protective services where stat law provide for jurisdiction in long term care facilities), in accordance with state law, and within 5 working days of the incident with the conclusion.

Based on observation, interview, and record review the facility failed to provide a written summary of the baseline care plan to one resident (#98) or residents representative out of 18 residents reviewed for baseline care plan.Findings included: Resident #98 (R98)Review of the medical record revealed R98 was admitted [DATE] with diagnoses that include stroke, atrial fibrillation, hyperlipidemia (high fat content in blood), respiratory failure, type 2 diabetes, aphasia (language disorder), right sided paralysis (loss of muscle function), dysphagia (difficulty swallowing), and insomnia. Review of R98's document entitled Brief Interview of Mental Status (3.0 BIMS), completed 03/31/2026, revealed a BIMS score that was not assessed related to R98's medical condition. On 03/31/2026 at 09:06 a.m. R98 was observed lying down in bed. R98 did not respond to verbal questions.Review of R98's medical record revealed an interim plan of care that was initiated upon admission. During an interview on 03/31/2026 at 03:08 p.m. R98's daughter R was asked if she or her father (R98) had received a copy of R98's base line plan of care. R98's daughter explained that she had not nor her father (R98) had received a copy of R98's base line plan of care.On 03/31/2026 at 03:09 p.m. Director of Nursing (DON) B explained that it was her expectation that each Resident or Residents representative would receive a copy of their baseline plan of care. DON B explained that it was her expectation that the copy of a Residents baseline plan of care would be provided in within 48 hours. DON B explained that documentation would be included in the base line plan of care that demonstrated that the Resident or the Residents representative would have been given a copy of the baseline plan of care. DON B was asked to review R98's base line care plan. DON B confirmed that documentation was not present in R98's plan of care that demonstrated that he or his representative had received a copy of his base line plan of care.

This citation pertains to intake 2648236.Based on observation, interview, and record review, the facility failed to provide adequate post-surgical wound care for one (R201) of one resident reviewed.Review of the clinical record revealed R201 was admitted into the facility on 9/25/25 with diagnoses that included: encounter for surgical aftercare following surgery on the nervous system, depression, anxiety, and difficulty walking.According to the Minimum Data Set (MDS) assessment dated [DATE], R201 required substantial/maximal assistance for shower/bathing and scored 15/15 on the Brief Interview for Mental Status exam (which indicated intact cognition).A review of R201's After Visit Summary (instructions provided to resident at discharge from the hospital) dated 9/25/25 revealed resident underwent spinal surgery. The incision care instructions documented in part Shower every day, when showering, use a mild soap and let warm soapy water wash over the incision. If unable to shower daily, wash the incision gently with a mild soap and water twice a day. Pat dry with a clean towel. A review of physicians orders for R201 revealed the following:9/26/25 Monitor Staples to Spine Q-Shift, every shift for surgical care related to encounter for surgical aftercare following surgery on the nervous system. Monitor for Dehiscence, Drainage, increased redness, intractable pain report to MD and (neurosurgeon name and phone number redacted).10/3/25 Nrsg (nursing)>> keep incision clean and dry>> apply dry gauze drsg (dressing) BID (twice daily) and as needed, Wound nurse to follow, Enc (encourage) pt (patient) to lay on right or left side>>Avoid lying on back, two times a day for skin infectionA review of the treatment Administration Record revealed the order dated 10/3/25, to keep the incision clean and dry, wound nurse to follow and to encourage resident to lay on her right or left side twice a day for skin infection was not documented as being completed until 10/14/25. No documentation was found that the wound was routinely being kept clean and dry from her admission on [DATE] through 10/14/25. A review of R201's progress notes revealed the following:9/25/25 6pm Resident arrived from (hospital name redacted) via stretcher. Dx (diagnosis): L1-L5 surgery (surgery on lower back) r/t Foraminal stenosis of Lumber Region-with staples-intact.Skin remarkable with surgical incision to back.10/2/25 10:56pm .She requires help toileting and performing hygienic care. Her incision has reddening and is painful to touch, shows no discharge and is odorless, she has a follow-up appointment with Neuro tomorrow 10/3. Symptoms reported to (Nurse practitioner name redacted).10/3/25 3:58am (Nurse practitioner name redacted) in to see resident, new order received for Augmentin 500mg/125mg BID x10 days. Wound/surgical site dressing orders10/3/25 2:34pm Returned from outpatient consultation today. Started on ABX (antibiotic), pt is aware. Called physician to clarify what abx they would like to start as two medication orders prescribed. Awaiting clarification.10/3/25 11:05pm (R201) had a offsite appointment this morning to remove staples. Staples were left intact. Surgeon suspects a probable infection. Was started on ABX. This RN assessed the wound: all staples intact, redness around staples, no drainage Applied one Aquacel dressing to cover staples.10/4/25 10:16pm .She requires help toileting and performing hygienic care. Her incision appears less red than last time this nurse assessed area and is still painful to touch but less sensitive, shows small amount of discharge and is malodorous.10/9/25 3:10pm Wound had moderate amount of sanguineous drainage, concerns of dehiscence staples remain intact. Wound cleansed and dressing reapplied.10/16/25 10:28am Labs reviewed with (physician's name redacted). Wants nurse to contact (Neurosurgery name redacted) for increased pain tenderness to surgical site on her back.Resident up in w/c (wheelchair) this AM to therapy. Incision site tender and painful to touch. Staples intact.10/17/25 5:28pm Resident out to Neuroscience consult for purulent drainage to Laminectomy Site. Resident recently completed oral ATB therapy, but Purulent drainage persists with increased tenderness to site. Staples intact.10/17/25 11:23pm In the hospital.Review of Outpatient consultation Record dated 10/3/25 revealed R201 was seen by an outside provider. Consultation report read as follows:Wound appears angry-possible infectionKeflex 500mg QID (four times per day)Keep incision clean and dry-dress as neededNext appt one weekA review of R201's shower task log revealed bed baths were provided on 10/6, 10/9, 10/13 and 10/16. Two paper shower sheets were provided, which revealed on 9/19 resident was provided a shower and on 10/2 resident refused a shower and was provided a bed bath. On 12/16/25 at 11:21 AM during an interview with Wound Nurse A, it was reported that post-surgical wound care instructions usually come from the hospital discharge orders. Wound Nurse A confirmed the records from the hospital indicated R201's incision site should have been cleaned daily. Wound Nurse A confirmed there was an order dated 10/3 for Wound nurse to follow R201's incision. It was reported that he had observed the incision on 9/26 then not again until 10/15, when a concern for infection was reported.

Based on observation, interview, and record review the facility failed to provide and document evidence of prompt resolution to a grievance for missing personal clothing of one (resident #48) out of one resident reviewed resulting in unresolved grievance. Findings Included: Resident #48 (R48) Review of the medical record revealed R48 was admitted to the facility 12/06/24 with diagnoses that included sepsis (complicated infection), cellulitis (bacterial skin infection) of left lower limb, chronic pain syndrome, depression, gastro-esophageal reflux, hypertension, neuropathy (pain from nerve damage), osteoarthritis (degenerative joint disease), rheumatoid arthritis (chronic inflammation of joints), spinal stenosis(spinal narrowing), obesity, lymphedema (swelling of extremities cause by lymphatic system blockage), and difficulty walking. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/12/2024, demonstrated a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview 01/13/2025 at 02:01 p.m. R48 was observed sitting up in a reclining chair in her room. R48 explained that she was missing a blue pair of pants. R48 explained that she had told a Certified Nurse Aide (CNA) sometime last week but could not recall the exact date or time. R48 explained that the blue pants still had not been located. R48 denied that she had been offered to complete a Resident Assistance Form. During review of the facilities concern log, which included concerns for the last 90 days, had not demonstrate that R48 had completed a concern form regarding a pair of blue pants. During an interview on 01/14/2025 at 10:11 a.m. Certified Nurse Aide (CNA) I explained that she was the CNA that was providing care to R48 today. She explained that she frequently provides care to R48 and had lost worked with her the previous week. CNA I was asked if R48 had reported to her that she was missing any clothing items. CNA I explained that R48 had informed her that she was missing a blue pair of pants sometime last week. CNA I explained that she could not locate the pants that day and had not completed or offered R48 to complete a Resident Assistance Form. CNA I explained that she had not reported the missing item of clothing to another facility staff member. During an interview on 01/14/2025 at 10:27 a.m. Director of Nursing (DON) B explained that if residents reported missing clothing to staff, it would be the expectation and policy that the staff either provide the resident with a Resident Assistance Form or they assist the resident in completing a Resident Assistance Form. DON B explained that the Resident Assistance Form would be given to the Nursing Home Administrator (NHA) A. DON B explained that then someone form laundry would attempt to locate the missing clothing and a response would be provided in writing to the resident. DON B could not provide information if R48 was missing any clothing items. During an Interview on 01/14/2025 at 10:33 a.m. Nursing Home Administrator (NHA) A explained that it was the facility policy and her expectation that when residents reported missing clothing that a Resident Assistance Form be provided by staff or staff assisted the residents to complete a Resident Assistance Form. The complete form then would be provided to her and an investigation to locate the items would be conducted. NHA A explained that she always expected staff to provide a Resident Assistance Form with any resident issues were reported because it allowed her to track and trend concerns in the facility. NHA A denied that she had knowledge of R48's missing blue pants and could not provide a Resident Assistance Form for R48's missing pants. NHA A explained that a concerns form would be completed as soon as possible and the process of locating the item would be started. Review of policy entitled Resident Concern Policy- ADM-155D, original date of 08/31/2015 and revision date of 11/14/2023, revealed the following procedure: Step 1. Tell your grievance (s) to one of the individuals list below: - Director of Nursing - Administrator (Grievance Official) - Social Services Director - Charge Nurse (if after hours) Step 2. If you are not satisfied with the staff person's response, please complete our Resident Assistance Form. Let us know if you need help in completing the form. Step 3. Submit the form to our Administrator or Director of Nursing. Step 4. If you are not satisfied with the center's written response, complete a request for the administrator to review the investigation findings.

Based on observation, interview, and record review, the facility failed to justify the ongoing use of an indwelling urinary catheter for one (R11) of three reviewed. Findings include: Review of the medical record revealed R11 was admitted to the facility on [DATE] with diagnoses that included functional urinary incontinence. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/18/24 revealed R11 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool, did not have an indwelling catheter, was not on a urinary toileting program, and was always incontinent of urine. On 01/13/25 at 09:31 AM, R11 was observed sitting in their wheelchair in their room, eating breakfast. R11 reported she had an indwelling urinary catheter that was uncomfortable. R11 reported the facility inserted the catheter because the resident was sick, really sick and had pus in their bladder. R11's catheter tubing was observed with clear, yellow urine. Review of the Nurses Note dated 12/19/2024 revealed Resident had a large emesis this AM. [Physician E] was in the facility and ordered repeat [laboratory tests] for Diarrhea and Vomiting. Start [intravenous [IV] fluids]. IV was successfully inserted .infusing without any issues .Resident was offered oral fluid and was able to drink. Review of a second Nurses Note dated 12/19/24 revealed This nurse called [Physician E] with lab results. [Physician E] stated continue IV fluids. [Physician E] alerted resident still appears weak but is able to coherently answer questions. Review of a third Nurses Note dated 12/19/24 revealed [Physician E] notified of BP [blood pressure] 140/60 and Pulse of 104. Order noted to Give Rocephin [antibiotic] 1GM IM QD x 3 days [1 gram intramuscular every day for three days]. May Insert Foley Catheter to monitor Fluid output. Review of the Physician's Order dated 12/19/24 revealed an order for an 18 French urinary foley catheter. Another Nurses Note dated 12/19/2024 revealed Upon Foley Catheter Insertion, Dark Odorous, cloudy urine obtained- 500ml [milliliters] output via Catheter. Resident tolerated Foley insertion procedure well. [Physician E] notified of Urine obtained and order noted to send it out for UA with C&S [urinalysis with culture and sensitivity] if indicated. Review of the Physician E's Note dated 12/19/24 revealed Basically, this patient does have: 1. Acute toxic metabolic encephalopathy 1. Acute sepsis 2. Dehydration 3. Acute gastroenteritis with nausea vomiting and diarrhea The Physician's note did not mention an indwelling urinary catheter or monitoring of urine output. Review of the Nurses Note dated 12/20/2024 revealed [Physician E] in this shift. Ordered labs . Also when current IV @80/hr is complete, continue IV @ 40/hr x 2 more days . Resident was more alert and talkative. Meds taken this shift without problems. Taking fluids well. Review of Physician E's Note dated 12/20/24 revealed Basically the patient does have: 1. acute toxic metabolic encephalopathy, improving 2. acute sepsis due to urinary tract infection, on Rocephin, improving 3. Acute pyelonephritis 3. Acute kidney failure due to dehydration 3. s/p acute gastroenteritis with nausea and vomiting and diarrhea .Symptomatically patient is improving. Mental status is improving no acute confusion anymore patient able to converse patient able to drink water. The Physician's note did not mention an indwelling urinary catheter or monitoring of urine output. Review of the Medication Administration Record revealed R11's antibiotic ended on 12/22/24 and the IV fluids ended 12/23/24. There was no documented indication as to why R11 continued to have an indwelling urinary catheter. Review of the MAR and Treatment Administration Record (TAR) revealed urinary output was documented on every shift except 12/29/24 dayshift, 1/1/25 dayshift, and 1/7/25 evening shift. The medical record did not reveal any indication that R11's output was evaluated and/or discussed with the physician. In an interview on 01/14/25 at 09:59 AM, Unit Manager (UM) D reported R11's indwelling urinary catheter was inserted to monitor their output while on IV fluids. When asked how long the foley was indicated for, UM D reported Physician E did not indicate at the time of the order. In an interview on 01/14/25 at 10:08 AM, Director of Nursing (DON) B reported R11's indwelling urinary catheter was indicated to monitor urine output while receiving IV fluids. When asked why R11's urinary catheter was not removed sooner than 1/14/25, DON B reported it must have been an oversight In a telephone interview on 01/14/25 at 10:20 AM, Physician E reported R11 had extreme dehydration, signs of sepsis and was totally out of it. Physician E reported R11 had low urine output, was started on IV fluids and antibiotics, and therefore an indwelling catheter was inserted to monitor urine output. Physician E reported the next day (12/20/24), R11 looked a little better. When asked how long they expected R11 to have the catheter, Physician E reported about a week or so, but reported they may not have given any clear instruction.

Based on interview and record review, the facility failed to ensure two of seven staff reviewed who performed cardiopulmonary resuscitation (CPR) on Resident #2 maintained current CPR certification for healthcare providers. Findings include: Resident #2 (R2) Review of medical record revealed R2 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, diabetes, and lymphedema. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed R2 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). R2's wishes were to be a full code and have CPR performed. R2 died in the facility on [DATE]. Review of the Nurses Note dated [DATE] revealed in part At 0543 [5:43 AM] this nurse grabbed the crash cart and yelled for the other nurse in the facility for help with CPR if necessary. At 0545 [5:45 AM] two nurses noted resident was no longer breathing and no pulse. Resident was immediately lowered her to the floor and chest compressions started at 0546 [5:46 AM]. Second nurse attached AED [automated external defibrillator]. Called 911 immediately from cell phone in room while performing CPR. EMTs [Emergency Medical Technicians] arrived on the scene at approximately 0555AM and CPR continued. EMT delivered 5 doses of Epi while running fluids and continuing chest compressions until 0646AM when EMTs alerted staff to stop CPR per MD at hospital. In a telephone interview on [DATE] at 8:28 AM, CNA J reported when R2 became unresponsive on [DATE], CPR was performed for a very long time by numerous people. CNA J reported they were asked to assist with performing CPR but were unable to get on the floor due to their knee problem. CNA J reported CNA M performed chest compressions during one round of CPR and they later found out that CNAs were not supposed to perform CPR in the facility. In a telephone interview on [DATE] at 3:15 PM, CNA M reported when it was noticed that R2 was not breathing, R2 was transferred from the recliner chair to the floor where CPR began. On [DATE] at 8:55 AM, CNA M reported Licensed Practical Nurse (LPN) F was the one who initiated CPR along with LPN Q. CNA M reported they were asked to assist with CPR at which point they performed chest compressions for about five minutes. CNA M reported a few days after, Nursing Home Administrator (NHA) A informed them that CNAs were not supposed to perform CPR at the facility. CNA M reported they were certified in CPR, but the facility never asked for a copy of their CPR certification. Review of the personnel files on [DATE] revealed CNA M did not have a CPR certification on file. LPN F's file included a printable wallet card dated [DATE] for Standard-CPR/AED from an online only CPR class. In an interview on [DATE] at 11:42 AM, LPN F reported they had a more recent, in person CPR certification that was not in their personnel file. On [DATE] at 1:46 PM, LPN F texted a copy of their most recent CPR certification. Review of the certification revealed on [DATE], LPN F completed Adult CPR/AED certification. The certification did not include any indication that it included basic life support or that the class was for healthcare professionals. In an interview on [DATE] at 2:15 PM, Director of Nursing (DON) B reported CNAs were not allowed to do CPR and staff who were not certified in CPR could not initiate CPR. In a telephone interview on [DATE] at 10:51 AM, American Red Cross Representative (ARCR) U reported anyone could take the Adult CPR/AED course and that it was not geared toward healthcare providers. ARCR U reported the healthcare provider course was called Basic Life Support. ARCR U reported LPN F obtained their CPR certification through their organization, but the certification was not for healthcare providers. In a telephone interview on [DATE] at 11:19 AM, ARCR V reported LPN F completed an adult CPR/AED class/certification through their organization which was different than the class offered for healthcare professionals. ARCR V reported the class LPN F completed was for lay responders. ARCR V reported if the certificate was for healthcare providers, it would list Basic Life Support on the certificate.

Based on observation, interview, and record review the facility failed to ensure two out of two residents (Resident #46 & 190) were free from misappropriation of property when $70 and a purse were identified to be missing. Findings Included: In an interview on 3/06/2024 at 9:38 AM, Resident # 46 (R46) stated that she had $70 stolen, and said it was on her windowsill under a small bag (resembled a makeup bag). R46 said about one week ago was when her $70 was found to be missing. R46 said a Certified Nurse Aid (CNA), who's name she could not recall, was in her room cleaning off her windowsill approximately one week ago from this interview, and said she told the CNA not to lift the bag up off the windowsill, but the CNA did anyhow and saw the money. R46 said that no staff had interviewed her nor got a statement from her regarding her missing $70. Record review of a care plan dated 12/23/2023, and titled COMMUNICATION/SENSORY revealed R46 was able to communicate her wants and needs, understood others, and her vision and hearing were adequate. In an interview on 3/07/2024 at 9:51 AM, CNA N said R46 told her that someone stole her $70. CNA N said the $70 could have fallen into the trash can that was by the window, but stated again R46 said the $70 was stolen, and someone took it. In an interview on 3/07/2024 at 9:57 AM, CNA O told her someone stole her $70 from under a bag that was on the windowsill. CNA O said R46 did not suggest that the $70 fell into the trash can. CNA O said the money was in a bank envelope which fit under the bag on the windowsill. On 3/06/2024 at 1:01 PM, Administrator A was requested to provide the Facility Reported Incident (FRI) (submission of the incident to the state agency) investigation for R46's missing $70. In an interview on 3/06/2024 at 2:47 PM, Administrator A stated that R46 filled out a grievance form regarding her missing $70. Administrator A said she did not fill out an incident repot, did not investigate or report the incident to the state agency, because it was assumed that the money possibly fell into the trash can which was directly below the windowsill where the money was located. Record review of an assistance request form dated 2/21/2024, revealed R49's daughter brought R46 the $70 on 12/14/2024. The form also revealed documentation that R46 thought the money fell it the trash can. The form did not have any resident interviews, no staff education, no evidence of a thorough investigation to attempt to try to identify a possible perpetrator. No other documents were received regarding R46's missing $70. In an interview on 3/07/2024 at 12:35 PM, R46 stated that she knew for a fact the envelope the $70 was in did not fall into the trash can, and stated that she had never told anyone that it could have fallen into the trash can. R46 further stated that Administrator A and two other staff members had suggested that could have been the case, but R46 said there was no way that was possible. In an interview on 3/07/2024 at 1:03 PM, Director of Nursing (DON) B stated that the incident was not reported to the state agency because it was concluded that most likely the $70 fell into the trash can. Resident #190 In an interview on 3/05/2024 at 1:00 PM, Resident # 190 (R190) stated that her purse was missing. R190 stated that her wallet was in the purse which had her drivers license, social security card, debit card, a bottle of Norco (narcotic pain medication) that had approximately 90 pills in the bottle, and a bottle of Xanax (narcotic antianxiety medication) that had approximately 25 pills in it. R190 stated that she always slept with her purse under her pillow. Stated on 3/4/2024 she woke up at 4:00 am to use the bathroom and when she went back to bed her purse was gone. In an interview on 3/07/2024 at 9:47 AM, CNA N stated that she had seen R190's purse which she said was a very large purse. CNA N she said R190 always slept with her purse under her head. In an interview on 3/07/2024 at 10:01 AM, CNA O said she came in to work on the next day, R190's purse was missing. CNA O said R190 told her that someone had stolen her purse. CNA O confirmed that she saw R190's purse everyday she worked. In an interview on 3/07/2024 at 11:04 AM, R190 stated that she did not know how the person could steel her purse out of her room without it being seen, and stated, yes, I now someone stole it. R190 said she was pressing charges when she finds out who took her purse. R190 said the purse was sentimental to her, because he daughter had it made just for her. R190 began to cry. R190 stated that she wanted to go home to finish her treatment, because she was uncomfortable being at the facility, and was afraid something else would be stolen, and she felt violated.

Based on observation, interview, and record review the facility failed to immediately report an allegation of misappropriation of $70 that was fund to be missing for one of one residents (Resident #46). Findings Included: In an interview on 3/06/2024 at 9:38 AM, Resident # 46 (R46) stated that she had $70 stolen, and said it was on her windowsill under a small bag (resembled a makeup bag). R46 said about one week ago was when her $70 was found to be missing. R46 said a Certified Nurse Aid (CNA), who's name she could not recall, was in her room cleaning off her windowsill approximately one week ago from this interview, and said she told the CNA not to lift the bag up off the windowsill, but the CNA did anyhow and saw the money. R46 said that no staff had interviewed her nor got a statement from her regarding her missing $70. Record review of a care plan dated 12/23/2023, and titled COMMUNICATION/SENSORY revealed R46 was able to communicate her wants and needs, understood others, and her vision and hearing were adequate. In an interview on 3/07/2024 at 9:51 AM, CNA N said R46 told her that someone stole her $70. CNA N said the $70 could have fallen into the trash can that was by the window, but stated again R46 said the $70 was stolen, and someone took it. In an interview on 3/07/2024 at 9:57 AM, CNA O told her someone stole her $70 from under a bag that was on the windowsill. CNA O said R46 did not suggest that the $70 fell into the trash can. CNA O said the money was in a bank envelope which fit under the bag on the windowsill. On 3/06/2024 at 1:01 PM, Administrator A was requested to provide the Facility Reported Incident (FRI) (submission of the incident to the state agency) investigation for R46's missing $70. In an interview on 3/06/2024 at 2:47 PM, Administrator A stated that R46 filled out a grievance form regarding her missing $70. Administrator A said she did not fill out an incident repot, did not investigate or report the incident to the state agency, because it was assumed that the money possibly fell into the trash can which was directly below the windowsill where the money was located. Record review of an assistance request form dated 2/21/2024, revealed R49's daughter brought R46 the $70 on 12/14/2024. The form also revealed documentation that R46 thought the money fell it the trash can. The form did not have any resident interviews, no staff education, no evidence of a thorough investigation to attempt to try to identify a possible perpetrator. No other documents were received regarding R46's missing $70. In an interview on 3/07/2024 at 12:35 PM, R46 stated that she knew for a fact the envelope the $70 was in did not fall into the trash can, and stated that she had never told anyone that it could have fallen into the trash can. R46 further stated that Administrator A and two other staff members had suggested that could have been the case, but R46 said there was no way that was possible. In an interview on 3/07/2024 at 1:03 PM, Director of Nursing (DON) B stated that the incident was not reported to the state agency because it was concluded that most likely the $70 fell into the trash can.

Based on observation, interview, and record review the facility failed to thoroughly investigate for one out of one resident (Resident #46) an incident of $70 coming up missing that kept in Resident #46's room. Findings Included: In an interview on 3/06/2024 at 9:38 AM, Resident # 46 (R46) stated that she had $70 stolen, and said it was on her windowsill under a small bag (resembled a makeup bag). R46 said about one week ago was when her $70 was found to be missing. R46 said a Certified Nurse Aid (CNA), who's name she could not recall, was in her room cleaning off her windowsill approximately one week ago from this interview, and said she told the CNA not to lift the bag up off the windowsill, but the CNA did anyhow and saw the money. R46 said that no staff had interviewed her nor got a statement from her regarding her missing $70. Record review of a care plan dated 12/23/2023, and titled COMMUNICATION/SENSORY revealed R46 was able to communicate her wants and needs, understood others, and her vision and hearing were adequate. In an interview on 3/07/2024 at 9:51 AM, CNA N said R46 told her that someone stole her $70. CNA N said the $70 could have fallen into the trash can that was by the window, but stated again R46 said the $70 was stolen, and someone took it. In an interview on 3/07/2024 at 9:57 AM, CNA O told her someone stole her $70 from under a bag that was on the windowsill. CNA O said R46 did not suggest that the $70 fell into the trash can. CNA O said the money was in a bank envelope which fit under the bag on the windowsill. On 3/06/2024 at 1:01 PM, Administrator A was requested to provide the Facility Reported Incident (FRI) (submission of the incident to the state agency) investigation for R46's missing $70. In an interview on 3/06/2024 at 2:47 PM, Administrator A stated that R46 filled out a grievance form regarding her missing $70. Administrator A said she did not fill out an incident repot, did not investigate or report the incident to the state agency, because it was assumed that the money possibly fell into the trash can which was directly below the windowsill where the money was located. Record review of an assistance request form dated 2/21/2024, revealed R49's daughter brought R46 the $70 on 12/14/2024. The form also revealed documentation that R46 thought the money fell it the trash can. The form did not have any resident interviews, no staff education, no evidence of a thorough investigation to attempt to try to identify a possible perpetrator. No other documents were received regarding R46's missing $70. In an interview on 3/07/2024 at 12:35 PM, R46 stated that she knew for a fact the envelope the $70 was in did not fall into the trash can, and stated that she had never told anyone that it could have fallen into the trash can. R46 further stated that Administrator A and two other staff members had suggested that could have been the case, but R46 said there was no way that was possible. In an interview on 3/07/2024 at 1:03 PM, Director of Nursing (DON) B stated that the incident was not reported to the state agency because it was concluded that most likely the $70 fell into the trash can.

Based on observation, interview and record review, the facility failed to provide the necessary care with activities of daily living (ADL) to one (Resident #339) of two residents reviewed for ADL care. Resident # 339 (R339) Review of the medical record revealed Resident #339 (R339) was admitted to the facility on [DATE] with diagnoses that included unspecified fracture of the right forearm, Congestive Heart Failure, muscle weakness and history of a CVA. According to Resident #339 (R339)'s Minimum Data Set (MDS) dated [DATE], revealed R339 scored 10 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R339 required partial to moderate assistance due to impairment on one side and use of a walker and wheelchair. During an interview on 03/05/24 at 01:05 PM, R339 stated he had only received one bed bath since he arrived there, and nobody had offered him a shower. Record review revealed R339 had received one bed bath from admitted [DATE] to 03/06/24. The shower/bath/bed-bath task sheet had a check mark on 03/01/24 for a bed bath. The other nine days had a check mark under the not scheduled or assigned. During an observation on 03/06/24 at 02:55 PM, R339 laying in his hospital bed disheveled with hair stand out, half-dressed watching TV. During an interview on 03/06/24 at 03:06 PM, afternoon shift Certified Nursing Assistant (CNA) F, stated she needed to look at the shower schedule on the medication cart for his scheduled days. CNA F walked to the medication cart and noted R339 is scheduled for showers Tues and Saturdays on the afternoon shift. CNA F stated that was how they tracked who got showers on what day on what shift then document it under the task section. During an interview on 03/07/24 at 09:57 AM, Minimum Data Set (MDS) Registered Nurse (RN), G stated she was one of the first staff to initiate the care plan, did not see the activity of daily living assigned to CNA's. Stated it was not on there but should have been put on the care plan. Writer asked about his showers, MDS RN G stated he got a bed bath on 03/01/24. MDS RN G looked at the shower/bath/bed-bath task sheet for scheduled shower days, then stated he should have received them Tuesday and Saturdays. MDS RN G stated they put it on the shower sheet on the medication cart, then it was supposed to go on the Plan of Care (POC). MDS RN G added that the Clinical Care Coordinator puts them on the POC. MDS RN G also stated that it was on the POC, but the CNA did not give it. MDS RN G going through the calendar to see why it was missed and could not find a reason. Task sheet revealed R339 had only had one bed bath since his admission. During an interview on 03/07/24 at 10:20 AM, DON B stated they have a shower sheet and residents are scheduled two times a week. Writer asked her why R339 hasn't had a shower since admission, only one bed bath. DON B stated he may have refused, writer pulled up the shower/bath/bed bath task sheet and CNAs marked not scheduled-not assigned. Don B stated she would have to do some education with her staff.

Based on interview and record review, the facility failed to prevent the administration of an unnecessary dose of a pneumococcal immunization for one (Resident #2) of five reviewed. Findings include: Review of the medical record revealed Resident #2 (R2) admitted to the facility on [DATE] with diagnoses that included dementia. R2 had an activated durable power of attorney for healthcare (DPOA). Review of the R2's pneumococcal immunizations revealed they received PPSV23 on 3/28/12, PCV13 on 3/14/17, PCV20 on 7/2/23, and PCV20 on 11/24/23. Review of the Consent for Flu, Pneumococcal, and Shingles Vaccine revealed R2's DPOA gave verbal consent for R2 to receive the PCV20 immunization. The consent form revealed the immunization was administered on 7/2/23. Review of the Consent for Flu, Pneumococcal, and Shingles Vaccine revealed R2's DPOA again gave verbal consent for R2 to receive the PCV20 immunization. The consent form revealed the immunization was administered a second time, on 11/24/23. Review of the Medication Administration Record (MAR) revealed R2 received the Prevnar 20 (PCV20) on 7/3/23 and 11/24/23. In an interview on 03/07/24 at 9:57 AM, Licensed Practical Nurse (LPN) E reported they were the facility's Infection Preventionist and tracked resident immunizations. LPN E agreed the medical record reflected R2 received two doses of PCV20 when only one was necessary. LPN E was not able to explain why the second dose was given and was offered the opportunity to provide additional information. Additional information was not received prior to the survey exit. According to CDC's PneumoRecs VaxAdvisor, R2's pneumococcal immunizations were complete and up to date after one dose of the PCV20.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 87 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination. Findings include: On 03/06/24 at 09:25 A.M., An environmental tour of the facility Laundry Service was conducted with Assistant Maintenance Manager D. The following item was noted: Four white acoustical ceiling tiles were observed stained from a previous moisture leak. Assistant Maintenance Manager D indicated she would contact staff for necessary repairs. On 03/06/24 at 09:38 A.M., A common area environmental tour was conducted with Assistant Maintenance Manager D. The following items were noted: Nursing Station: The laminate veneer was observed (etched, scored, particulate), adjacent to the outer corner edge. The damaged laminate veneer measured approximately 1-inch-wide by 6-inches-long. The laminate veneer was also observed (etched, scored, particulate), adjacent to the inner corner edge. The damaged laminate veneer measured approximately 1-inch-wide by 18-inches-long. One of four chairs were further observed (etched, scored, particulate), adjacent to the arm rests. The damaged arm rest surface measured approximately 3-inches-wide by 5-inches-long. Assistant Maintenance Manager D indicated she would have staff remove and replace the chair as soon as possible. Beauty Shop: One acoustical ceiling tile was observed stained from a previous moisture leak. Laboratory Closet: One acoustical ceiling tile was observed stained from a previous moisture leak. Central Supply Room: Three acoustical ceiling tiles were observed stained from a previous moisture leak. Occupational/Physical Therapy Room: Two acoustical ceiling tiles were observed stained from a previous moisture leak. Main Dining Room: Three acoustical ceiling tiles were observed stained from a previous moisture leak. Staff Development Room: Two acoustical ceiling tiles were observed stained from a previous moisture leak. Women's Locker Room: One of two hand sink faucets were observed loose-to-mount. 300 Hall Dining Room: The hand sink faucet was observed loose-to-mount. 400 Hall Corridor: 1 of 4 glass windowpanes were observed cracked and broken. The damaged windowpane measured approximately 12-inches-wide by 24-inches-long. On 03/06/24 at 02:07 P.M., An environmental tour of sampled resident rooms was conducted with Assistant Maintenance Manager D. The following items were noted: 103: The drywall surface was observed (etched, scored, particulate), adjacent to the Bed 1 headboard. The drywall surface was also observed (etched, scored, particulate), adjacent to Bed 2. 207: 2 of 2 overhead light assembly plastic lens covers were observed soiled with accumulated dead insect carcasses. 208: 2 of 2 overhead light assembly plastic lens covers were observed soiled with accumulated dead insect carcasses. The drywall surface was also observed (etched, scored, particulate) in numerous locations, throughout the resident room. 212: 2 of 2 overhead light assembly plastic lens covers were observed soiled with accumulated dead insect carcasses. The drywall surface was also observed (etched, scored, particulate), adjacent to Bed 1 and Bed 2. 401: The drywall was observed (etched, scored, particulate), adjacent to the restroom entrance door. 402: The hand sink faucet assembly was observed sporadically functioning. Assistant Maintenance Manager D indicated she would replace the faulty hand sink faucet assembly as soon as possible. 410: The restroom hand sink hot water valve was observed loose-to-mount. Assistant Maintenance Manager D indicated she would have staff tighten the hot water valve collar nut as soon as possible. On 03/06/24 at 03:35 P.M., An interview was conducted with Assistant Maintenance Manager D regarding the facility maintenance work order system. Assistant Maintenance Manager D stated: We have the TELS software system. On 03/07/24 at 10:00 A.M., Record review of the Policy/Procedure entitled: Housekeeping Room Cleaning dated (no date) revealed under Purpose: The Complete Room Cleaning Schedule ensures that each resident room is discharge-cleaned on a monthly basis. On 03/07/24 at 10:15 A.M., Record review of the Policy/Procedure entitled: Environmental Services Guidelines dated (no date) revealed under Cleaning of Other Surfaces: (1) Doorknobs, handrails, bath rails, sink handles, etc. will all be cleaned at least once daily and more often as needed. This is especially important during cold and flu season, to help prevent transmission of these illnesses from one person to another. (2) Cleaning of walls, curtains, blinds, etc. will be completed when dust/soil is visible. (3) Daily dusting will be done to remove possibly organism-laden particles from the air and from surfaces in the resident area. On 03/07/24 at 10:30 A.M., Record review of the Direct Supply TELS Work Orders for the last 60 days revealed no specific entries related to the aforementioned maintenance concerns.

This citation pertains to MI00139275. Based on observation, interview and record review, the facility failed to ensure call lights were answered in a timely manner for four (Resident #2, #6, #7 and #8) of six reviewed for call light response time, resulting in call lights not being answered for extended periods of time and resident needs not being met in a timely manner. Findings include: Resident #2 (R2): Review of the medical record reflected R2 admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included aftercare following joint replacement surgery, presence of artificial left knee joint, difficulty walking, diabetes, atrial fibrillation, congestive heart failure and chronic kidney disease. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/31/23, reflected R2 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), did not walk and performed activities of daily living (ADLs) with supervision to extensive assistance of one to two or more people. On 10/11/23 at 10:11 AM, R2 was observed lying in bed with heel protector boots in place. R2 reported call light response times to be slow and sometimes waiting over an hour for assistance. R2 reported being left on the toilet for over an hour while her call light was on. Review of R2's call light reports for 9/1/23 to 9/10/23 and 10/4/23 to 10/11/23 reflected call light response times that included but were not limited to: 65 minutes and 55 seconds, 99 minutes and 59 seconds, 26 minutes and 8 seconds, 31 minutes and 4 seconds, 24 minutes and 9 seconds, 21 minutes and 24 seconds, 55 minutes and 54 seconds, 58 minutes and 14 seconds, 28 minutes and 47 seconds, 53 minutes and 1 second, 23 minutes and 29 seconds, 65 minutes and 2 seconds, 21 minutes and 20 seconds, 26 minutes and 55 seconds, 25 minutes and 11 seconds, 27 minutes and 50 seconds, 33 minutes and 47 seconds, 47 minutes and 19 seconds, 77 minutes and 27 seconds, 42 minutes and 22 seconds, 30 minutes and 56 seconds, 54 minutes and 6 seconds, 26 minutes and 28 seconds, 62 minutes and 23 seconds, 31 minutes and 15 seconds, 40 minutes and 20 seconds, 78 minutes and 1 second, 48 minutes and 6 seconds, 88 minutes and 22 seconds, 62 minutes and 54 seconds, 33 minutes and 27 seconds, 84 minutes and 25 seconds, 33 minutes and 38 seconds, 29 minutes and 24 seconds, 45 minutes and 23 seconds, 34 minutes and 52 seconds, 35 minutes and 1 second, 30 minutes and 37 seconds and 39 minutes and 43 seconds. Resident #6 (R6): Review of the medical record reflected R6 admitted to the facility on [DATE], with diagnoses that included pneumonia, urinary tract infection and difficulty walking. On 10/10/23 at 1:52 PM, R6 was observed seated in a wheelchair, in her room. R6 reported that on a daily basis, while she was in bed, there was about an hour and a half delay for her call light to be answered to use the bathroom. Review of R6's call light reports for 10/1/23 to 10/11/23 reflected call light response times that included but were not limited to: 26 minutes and 49 seconds, 29 minutes and 34 seconds, 29 minutes and 25 seconds, 24 minutes and 28 seconds, 30 minutes, 24 minutes and 35 seconds, 76 minutes and 38 seconds, 37 minutes and 58 seconds, 25 minutes and 10 seconds, 45 minutes and 42 seconds, 41 minutes and 35 seconds, 69 minutes and 11 seconds, 32 minutes and 25 seconds, 53 minutes and 47 seconds, 27 minutes and 11 seconds, 24 minutes and 21 seconds, 43 minutes and 27 seconds, 29 minutes and 5 seconds, 26 minutes and 55 seconds, 57 minutes and 17 seconds, 38 minutes and 35 seconds, 62 minutes and 57 seconds, 55 minutes and 39 seconds, 38 minutes, 42 minutes and 13 seconds, 64 minutes and 55 seconds and 77 minutes and 24 seconds. Resident #7 (R7): Review of the medical record reflected R7 admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included fracture of the left femur, chronic obstructive pulmonary disease and difficulty walking. The quarterly MDS, with an ARD of 9/13/23, reflected R7 score 15 out of 15 (cognitively intact) on the BIMS and required limited to extensive assistance of one to two or more people for many ADLs. On 10/10/23 at 2:38 PM, R7 was observed seated in a wheelchair, in her room. She reported call light response times were around a half hour. R7 described that a few weeks prior, she did not get to the bathroom in time and had an incontinent bowel movement, after waiting too long for her call light to be answered. R7 reported feeling ashamed about the incident. Review of R7's call light reports for 9/27/23 to 10/11/23 reflected call light response times that included but were not limited to: 93 minutes and 36 seconds, 33 minutes and 15 seconds, 44 minutes and 58 seconds, 26 minutes and 49 seconds and 31 minutes and 4 seconds. Resident #8 (R8): Review of the medical record reflected R8 admitted to the facility on [DATE], with diagnoses that included atrial fibrillation, difficulty walking and diabetes. The quarterly MDS, with an ARD of 7/18/23, reflected R8 scored 15 out of 15 (cognitively intact) on the BIMS and required limited to extensive assistance of one to two or more people for ADLs. On 10/11/23 at 10:03 AM, R8 was observed seated in a recliner, in her room. R8 reported she sometimes waited up to an hour or longer for her call light to be answered because staff had a lot of people to care for. R8 reported the extended call light response times were usually after meals, when everyone had to use the bathroom. Review of R8's call light reports for 9/27/23 to 10/11/23 reflected call light response times that included but were not limited to: 25 minutes and 52 seconds, 29 minutes and 14 seconds, 65 minutes and 34 seconds, 39 minutes and 58 seconds, 43 minutes and 30 seconds, 29 minutes and 35 seconds, 25 minutes and 12 seconds, 33 minutes and 28 seconds, 47 minutes and 31 seconds, 54 minutes and 12 seconds, 33 minutes and 45 seconds and 24 minutes and 30 seconds. During an interview on 10/11/23 at 1:38 PM, Nursing Home Administrator (NHA) A reported call lights were monitored, and the facility had identified they wanted a shorter average call light response time. NHA A reported they would like to get call light response times to 10 minutes or less.

Based on observation, interview, and record review the facility failed to prevent implement effective interventions to prevent falls for two (Resident #3 and Resident #5) of five reviewed for falls, resulting in a fall with major injury and repeated hospital transfers (Resident #3) and repeated falls and the potential for major injury (Resident #5). Findings include: Resident #3 (R3) Review of an Admission Record revealed Resident #3 (R3) admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnoses which included nondisplaced intertrochanteric fracture of left femur, difficulty in walking, multiple fractures of pelvis, dementia, history of falling, unspecified fracture of the lower end of right radius, traumatic hemorrhage of cerebrum, and major depressive disorder. The Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/3/23, reflected R3 scored three out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). An Admission MDS with an ARD of 3/17/23 revealed R3 was independent with one-person physical assist for ambulation, transferring, and eating. R3 required limited assistance of one person to toilet, dress, and for personal hygiene. In an observation on 5/17/23 10:55 AM, R3 was observed resting in her bed, turned toward the fall, with her eyes closed. R3's bed was against the wall and in the lowest position. In an interview on 5/18/23, Family Member E reported that he had a phone call conversation with R3 on 3/4/23. During that conversation R3 was able to speak to Family Member E, stating that R3 was in good spirits and was able to converse with the family member. Family member E reported that he had visited R3 on 4/22/23. During the visit, R3 had a bruise above her eyebrow, was in a groggy state and was not able to carry on a conversation with the visiting family members. When inquiring with staff regarding R3's current state, Family Member E reported that R3 had fallen three times and hit her head and was transferred to the hospital. Review of the Care Plan revealed that R3 had a risk for falls section initiated on 8/27/23 related to diagnoses including but not limited to recent falls, history of dementia, poor short-term memory and ability to follow cues, and poor safety awareness. Some interventions included assist resident to keep her clothing off the floor and in her closet and dresser, bed against the wall, medication review by pharmacist, nightlight in room to help orient resident, put concave mattress on bed, and PT (physical therapy) screen for strength and ambulation. A Nurse's Note dated 1/2/2023 at 8:00 PM revealed R3 was discovered on the floor of her room. R3 reported to staff that she was attempting to get something for her roommate and slipped. R3 sustained a bump on her head. An Incident Report dated 1/2/23 at 9:27 PM revealed the Interdisciplinary Team determined that R3 stated she was attempting to help her roommate per request and got weak on her way back to her bed. As an intervention, R3 and her roommate were educated on call light use. A Nurse's Note dated 2/26/23 at 12:29 AM revealed R3 was observed sitting on the edge of her bed and scooted down to the floor onto her bottom. Two-hour checks were initiated as an immediate intervention. An Incident Report dated 2/2/6/23 at 4:02 AM revealed the Interdisciplinary Team determined that it was possible that R3 was disoriented at the time of the fall, so a nightlight was placed in R3's room. A Nurse's Note dated 3/1/2023 at 12:39 AM revealed R3 was discovered in another resident's room sitting on the floor. R3 stated that she got tired and sat down. R3 was assisted up and back into her room. An Incident Report dated 3/1/23 revealed the Interdisciplinary Team determined that prior to this incident, R3 was ambulating around the unit. It is likely she got confused as to where her room was . will refer to therapy . she is getting out of her room more and walking around so perhaps she needs strengthening . The immediate intervention was to reorient R3 to her room when she was observed wandering the unit. In a Nurse's Note dated 3/21/2023 at 5:38 PM, R3 had left hip pain after sustaining a fall however, details regarding the fall were not revealed in the Nurse's Note. An Incident Report dated 3/21/23 at 2:20 PM revealed R3 was observed laying on her left side next to her bed, between bed and bedside dresser. When asked what happened, R3 stated that she did not know. It is under suspicion that the resident lost her balance as there was nothing obstructing the walkway . The Interdisciplinary Team determined that the nurse had been in the residents room approximately 2 minutes prior to the fall. At that time, R3 was observed sitting on her bed. R3 is independent with bed mobility and transfers. The fall intervention for R3 was to place a recliner in her room to allow her to sit in a chair to rest instead of her bed. It was unsure if R3 rolled out of bed or fell while ambulating in her room. In a Nurse's Note dated 4/2/2023 at 1:04 PM, R3 was discovered laying on a floor face down. Blood on floor noted. Resident was alert and un oriented upon assessment. Resident had blood coming from laceration to right side of head above the eyebrow. Resident has bump to backside top of head with noopen [sic] areas noted. Resident was unaware of what happened and was unable to inform staff of incident . R3 was transported to the Emergency Department for further evaluation. An Incident Report dated 4/2/23 at 12:00 PM revealed resident was observed in her room on the floor face down there was blood noted to resident's face and the floor around her head. Immediate assessment noted a laceration above her right eyebrow and a lump on the back of her head. Resident was unable to tell staff what had occurred . during the investigation it was noted that there were some clothing items strewn about the living area. It was not confirmed whether these items may have played a role in the fall . an order was given to send resident to (ED) Emergency Department for evaluation . intervention for fall was to assist resident to keep her clothing off the floor in her closet and dressers. In a Nurse's Note dated 4/8/23 at 4:30 AM, R3 was lying on the floor in another resident's room. She attempted to ambulate throughout facility independently and fell on to the floor . was transferred by two staff back into her room into bed. She did c/o (complain of) pain of left thigh during transfer into bed .Pain seems to be only with movement . An Incident Report dated 4/8/23 at 4:36 AM revealed a Physical/Occupational therapy request was made for R3. The Incident Report stated that the pain seems to be only with movement resident denied pain at first but had complaints of pain with transfer into bed. 15-minute checks were also initiated. In a Nurse's Note dated 4/8/23 at 9:58 AM R3 had a witnessed fall out of bed. R3 was discovered on her back/right side . Total body assessment done, resident is reporting left side thigh pain, resident was assisted into bed with help of another LPN (Licensed Practical Nurse) and a CNA (Certified Nursing Assistant). Positioned farther toward wall in bed to avoid falling off the edge. [Physician H] notified, said to continue neuro checks, no need for an x ray . In a Nurse's Note dated 4/8/23 at 12:35 PM, R3 was being assessed for neurological checks when R3's left leg was observed to be shorter than right and slightly turned out. When asking resident to move that leg she stated she can't. Extremely painful to the touch. Upon visual inspection left hip has some swelling. Imaging was ordered for R3's left leg. A Nurse's Note dated 4/8/23 at 4:33 PM revealed Resident in bed this shift restless, asked if she was in pain said yes but couldn't rate it .Resident was extremely painful when log rolled to be changed .They (Imaging company) arrived at 1415 (2:15 PM) to do x-ray, at 1455 (2:55PM) received results .Received order to send to ER (Emergency Department) .ambulance at 1620 (4:20 PM). Review of Hospital Discharge Paperwork dated 4/12/23 revealed R3 sustained an acute intertrochanteric proximal left femur fracture Ground level fall with history of frequent falls. At time of presentation in the Emergency Department presents today due to fall. Patient has dementia and is unable to provide history. Guardian called but unable to reach. Patient brought in from [Facility] by EMS (Emergency Medical Services). Per chart review, patient had ground level fall last night and had left hip pain . Of note, patient was recently seen in ED (Emergency Department) on 04/02 for a fall with head injury. CT (Computed Tomography) brain with no acute fractures and patient was discharged back to facility. She had injury above right eyebrow and hematoma of posterior aspect (back) of head that was stable.Left hip XR (x-ray) with Acute comminuted intertrochanteric proximal left femur fracture . As a result of her injuries, R3 underwent hip surgery for repair of the fracture. In an interview on 5/22/23 at 9:09 AM, Certified Nursing Assistant (CNA) F reported that R3 enjoyed ambulating around but would often go into other resident's rooms. Staff tried to keep an eye on her when R3 was up ambulating about. CNA F stated that R3 had a problem with falling out of her bed. In an interview on 5/22/23 at 11:39 AM, Registered Nurse (RN) D reported that after a resident sustains a fall an assessment of the resident is completed. Regarding assessment of the resident's extremities, complaining of pain would be the basis for getting an x ray. If a resident were to complain of pain, especially pain with range of motion, a stat (immediate) x ray would be ordered. RN D also reported that R3 would fall out of bed. This could be attributed to R3's habit of laying awkwardly on the bed or lay to more to one side of the bed than the other. In an interview on 5/22/23 at approximately 11:00 AM, Registered Nurse (RN) C reported that the process for falls included assessing the resident and performing any necessary first aid. If a resident did not have proper range of motion, best practice was to leave them. RN C reported that part of the assessment does include a pain assessment. If they can't move that extremity or grimacing or has pain, at that point we tell the doctor that they need an x-ray. RN C reported that R3's x-ray was not ordered when R3 fell the first time because she did not complain of pain. RN C reported that the x-ray was not ordered until 12:51 PM, hours after the first and second fall R3 sustained on 4/8/23. RN C stated that x-rays should be ordered when a resident has complaints of pain, pain with movement, or swelling. A Nurse's Note dated 4/30/23 at 6:32 AM revealed R3 was discovered lying on the floor of her bedroom laying on her right side. An Incident Report dated 4/30/23 at 6:00 AM revealed resident was observed lying on her right side on the floor with her right arm under her body . LPN (Licensed Practical Nurses) states that resident chooses to lie close to the edge of her bed and suspects that she rolled out of bed. Suggested to place perimeter mattress on bed to provide boundary . falls have occurred when resident tries to sit down on edge of bed slides off bed becomes weak when walking and sets down . Resident was given a Broda chair (wheelchair with tilt and recline abilities) and given graded papers to occupy her time as R3 was a retired schoolteacher. R3 had not sustained any further falls after the 4/30/23 fall. 38383 Resident #5 (R5): Review of the medical record reflected R5 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included hemiplegia and hemiparesis affecting the left dominant side, muscle weakness and vascular dementia. The Significant Change in Status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/2/23, reflected R5 had short-term and long-term memory problems, did not walk and required limited to total assistance of one to two or more people for activities of daily living. The MDS was coded for two or more falls without injury. On 5/18/23 at 10:41 AM, R5 was observed lying in bed, with the bed height in a low position. The head and knees of the bed were elevated, and a perimeter mattress was in place. What appeared to be a pillow, was beneath the sheet on his right side. The left side of the bed was against the wall. A pillow boot and blanket were observed on the floor at the right bedside. R5's eyes were closed, and he was observed to be intermittently moving in bed. Upon knocking on the room door, no response was received from R5. R5 did open his eyes briefly but did not verbalize. R5's medical record reflected he required staff assistance for transfers. Review of R5's Incident Reports since 1/1/23 reflected falls on 1/27/23, 2/8/23, 2/20/23, 2/26/23, 3/2/23, 3/10/23, 3/15/23, 4/15/23, 4/27/23 and 5/1/23. R5's Progress Notes reflected an additional fall on 5/10/23. An Incident Report for 1/27/23 at 2:10 AM reflected R5 was observed lying on his back, perpendicular to the bed. R5 stated he went to sit down, and the chair moved out from underneath him. The left brake on his wheelchair was not engaged, and the anti-rollback brakes were not functioning properly. The root cause analysis note reflected when R5 attempted to self-transfer from his bed to the wheelchair, his wheelchair moved backwards, causing him to slip out of the front. There was no documentation as to why R5 was self-transferring. The report reflected he was assisted into his wheelchair and with toileting. A facility-wide audit for anti-rollback brakes was put in place. Review of a facility document reflected an anti-rollback audit was conducted on 1/27/23, and R5's anti-rollback brakes were adjusted. An Incident Report for 2/8/23 at 9:49 AM reflected R5 reported entering his bathroom that morning and attempting to self-transfer to the toilet. The floor was wet with water, and he slipped, fell and landed on the garbage can. Upon inspection of the commode, it was plugged and leaking water onto the floor. The water was cleaned up and maintenance was notified of the needed repair. The root cause analysis note reflected R5 entered the bathroom, the floor was wet with water, and he slipped. R5 landed chest first on the garbage can. There was no intervention to address R5 transferring to the bathroom unassisted. During an interview on 5/22/23 at 12:34 PM, Director of Nursing (DON) B indicated the root cause of the fall on 2/8/23 was related to the floor being wet, causing R5 to fall. The immediate intervention was to wipe the water and notify maintenance for repair of the leaking toilet. When asked if there was an intervention pertaining to R5 self-transferring to the toilet, DON B stated it did not look like there was an intervention for that. An Incident Report for 2/20/23 at 4:10 AM reflected R5 was observed sitting on the floor, in front of his bed. The left wheelchair brake was not locked. R5 reported he was trying to get into the chair and it moved. The root cause analysis note reflected R5 was attempting to self-transfer into his wheelchair and only locked the right brake. R5 stood, the wheelchair moved, and he lost his balance. R5's wheelchair was taken out of service for inspection of the brakes and anti-rollback brakes. The note reflected the wheelchair passed inspection. There was no documentation as to why R5 was self-transferring. The report reflected he was assisted to his wheelchair and with toileting. R5 was educated to take his time and double check that all safety measures were engaged before using his chair. R5's medical record did not reflect that he was independent for transfers. R5 required staff assistance. During an interview on 5/22/23 at 10:33 AM, Registered Nurse (RN) C reported once a resident with anti-rollback brakes stood from their wheelchair, the wheelchair was not supposed to move back. When their weight was moved off the seat, the wheelchair could not be pushed back. During an interview on 5/22/23 at 12:34 PM, when asked how the wheelchair moved if the anti-rollback brakes were functioning, DON B reported she did not know about the function of anti-rollback brakes. The Incident Report for 2/26/23 at 10:25 AM reflected R5 was observed on the bathroom floor by the Certified Nurse Aide (CNA). He was crawling on the floor, and his wheelchair was tipped on it's side. The report reflected R5 had been toileted about 30 minutes prior. He did not use his call light before taking himself to the bathroom unassisted. R5 reported he tried to go to the bathroom, grabbed the bar and slipped. His wheelchair fell over, and he hit his head. The root cause analysis note reflected R5 had a strong desire to be independent and did not always use his call light. A sign was to be posted on the bathroom door to cue R5 to ask for assistance to use the bathroom. An Incident Report for 3/2/23 at 6:25 AM reflected R5 was sitting on the floor, in front of his bed. R5 reported he stood to change his pants, leaned on the chair, the cart moved away from him and he sat on the floor. The report reflected his anti-rollback bars were assessed and were in working order. The root cause analysis note reflected when standing to change his pants, he held onto the wheelchair, and it rolled away from him. R5 sustained an abrasion to the right leg and a bruise to the left inner/upper arm. The intervention reflected staff was to offer to assist R5 with morning care and dressing for the day during the final rounds of third shift. R5's falls on 1/27/23, 2/20/23 and 3/2/23 reflected instances of his wheelchair moving, causing him to fall during transfers. R5's Care Plan reflected an intervention of anti-rollback brakes was initiated on 10/28/22 and revised on 10/31/22. During an interview on 5/22/23 at 1:49 PM, Director of Maintenance (DM) I reported they installed a lot of anti-rollback brakes and tested them when they were installed. They did not follow-up on them unless told by the nurses or CNAs that they were not working properly. What he corrected the most, was when the arms that stuck out over the wheels got caught on something, bent and were knocked out of adjustment. MD I reported anti-rollback brakes were mechanical and could fail. MD I reported having to work on R5's anti-rollback brakes several times. Maintenance Assistant (MA) J and MD I agreed they usually found that R5 knocked his anti-rollback brakes out of adjustment. They reported they may have been able to look in their tracking system to see if they had any requests to look at R5's anti-rollback brakes. No additional documentation pertaining to evaluation and/or repair of R5's anti-rollback brakes was provided during the survey. An Incident Report for 3/15/23 at 7:29 AM reflected R5 attempted to get out of bed at 2:40 AM and fell to the floor. R5 was incontinent at the time of the fall. The immediate intervention reflected the Plan of Care was updated with a toileting schedule. The Interdisciplinary Team (IDT) note reflected R5 had been restless and had difficulty sleeping after returning from the hospital after a possible stroke. Sleep tracking was initiated. An Incident Report for 4/27/23 at 7:00 PM reflected R5 was observed on the floor and stated he slid from his wheelchair and laid on the floor. The report reflected R5 was wet and soiled and incontinent of bowel and bladder at the time. The IDT root cause note reflected to assist R5 to the toilet upon waking, after supper and upon request to promote a toileting pattern. An Incident Report was not received for R5's fall on 5/10/23. A Progress Note for 5/10/23 at 7:59 AM reflected R5 was observed lying on the floor and sustained a skin tear to the left elbow. He was assisted back to bed via hoyer lift and instructed to call for assistance with reaching for things. During an interview on 5/22/23 at 12:34 PM, DON B was queried about bowel and bladder tracking in attempt to establish a toileting schedule and reported they would maybe do it for a fall, depending on the situation. When asked about a situation when they might do that, she reported if a resident was incontinent and kept falling at the same time and each time they were incontinent. Regarding R5's fall on 5/10/23, DON B reported he was not able to tell staff about the incident and was incontinent of bowel and bladder at the time of the incident. New interventions were to include a 72 hour sleep study and a bladder incontinence journal. When queried what a bladder incontinence journal was, DON B reported she could ask the Clinical Care Coordinator, and it would be on a separate form. Review of R5's MDS history since admission to the facility reflected occasional to frequent urinary incontinence, without the trial of a toileting program.

This citation pertains to intake MI00135852. Based on observation, interview and record review, the facility failed to report a foreign body object in the vagina to the Nursing Home Administrator and State Agency for one (Resident #2) of three reviewed for abuse, resulting in a vaginal foreign body not being reported and the potential for unrecognized and unreported sexual abuse. Findings include: Review of the medical record reflected Resident #2 (R2) was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included paranoid schizophrenia, foreign body in vulva and vagina (2/17/23), dementia, vascular dementia and hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting non-dominant side. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/3/23, reflected R2 scored nine out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), did not walk and required extensive to total assistance of one to two or more people for most activities of daily living. According to the MDS, R2 fed herself with set up assistance and did not have upper extremity impairments that interfered with daily functions or placed her at risk for injury. On 5/18/23 at 10:24 AM, R2 was observed in bed, with the bed height in a low position. Her eyes were closed, and she was covered by blankets to her chin. Upon knocking on the door, R2 opened her eyes. On 5/18/23 at 12:55 PM, R2 was observed seated in a Broda chair (specialty chair) at the dining table. A staff member was seated beside her, providing assistance with R2's meal. On 5/18/23 at 2:11 PM, R2 was observed seated in a Broda chair, in her room, watching TV. Her arms were under a sheet. R2 denied concerns with how others were treating her. She denied going out to any recent appointments, to the hospital or having any recent surgeries or procedures. Review of a State Agency Intake document reflected R2 had a surgical procedure for a foreign body removal. The object was in R2's vaginal canal and was believed to be soap or a urinal cake of some sort. The document referenced that R2 was unable to verbalize what happened. Physician H's Progress Note for 2/17/23 reflected the Physician was asked to see R2 regarding report of a foreign body in her vagina. According to the note, review of R2's records reflected report of a computerized tomography (CT) scan showing calcification in the vaginal area. R2 denied pelvic pain and did not know what the foreign body was about. The note reflected it was possible it was a fibroid (growth), and a gynecology consult would be scheduled. A Progress Note for 3/8/23 at 10:07 PM reflected R2 returned from an Obstetrics and Gynecology (OB/GYN) consult. The note referenced the OB/GYN office stated the foreign object was felt upon inspection but the Physician was unable to visualize the object due to R2 being combative and screaming. A recommendation was made for an exam under anesthesia. Physician H' Progress Note for 3/9/23 reflected R2 was seen for follow-up after consultation with gynecology for evaluation of a foreign body in the vaginal cavity. R2 was unable to tolerate the exam, and a recommendation was made to use general anesthesia. A Progress Note for 3/17/23 at 1:11 PM reflected R2 returned from surgery to remove a foreign body in her vagina. The foreign body was removed and sent to the lab, and R2 was placed on antibiotics. During an interview on 5/22/23 at 9:08 AM, Certified Nurse Aide (CNA) F reported R2 had a foreign object in her vaginal area and had to go to the hospital. CNA F stated they were not sure how that could have happened. R2's left hand and arm were somewhat stiff, according to CNA F. R2 put her hand in her brief but did not cleanse her own vaginal area, to CNA F's knowledge. During an interview that began on 5/22/23 at 10:33 AM, Registered Nurse (RN) C reported the foreign body in R2's vagina was an incidental finding when she had an x-ray at the hospital. RN C stated the hospital notified the facility they found a foreign body. R2 had a gynecology consult, and the foreign body was removed. According to RN C, they (hospital) did not say what it was. RN C reported the hospital said it was clam-sized when they called report to the facility. She reported asking if it was an abnormal growth and was told it was out for biopsy. When asked if the facility ever received results on the foreign body, RN C reported they printed them out and placed them in Physician H's folder. When asked if they had any idea how R2 had a foreign body in her vagina, RN C stated the facility did not know. According to RN C, the word foreign body was confusing to them. She reported Physician H thought it was a growth. A hospital History and Physical for 3/17/23 reflected, .seen in the office because she supposedly had a foreign body in the vagina. Is uncertain as to what it actually was. Patient has altered mental status and difficult for her to understand what we are trying to do. In the office attempts were made to remove what appeared to be a foreign body of unknown etiology but this was uncomfortable for the patient and she was screaming and fighting us . The Operative Note for 3/17/23, reflected, .Preoperative Diagnosis: Foreign body in vagina .Postoperative Diagnosis: Same pending pathology. A 2 inch whitish-gray disc with a crusty surface was removed from the vagina. I am uncertain as to what this foreign body actually is .Narrative: .I did a pelvic exam on the patient and I could feel a hard foreign body within the vagina. It had a lot of crusty like surface and we went ahead and placed a pediatric speculum so we could visualize the foreign body. It was gray in color. I then was able to grasp it with an [NAME] clamp and tease it out of the vagina. It came out in 1 piece .A piece of the foreign body was removed and sent for culture. Then the actual foreign body which was a round disc like object with a whitish-gray crusty surface was sent to pathology for evaluation . The note reflected R2's vagina was irrigated because of the likelihood of infection from the foreign body, which had been present for an unknown amount of time. During an interview on 5/22/23 at 12:34 PM, Director of Nursing (DON) B stated the (pathology) report said mineralization. She reported R2's body made the foreign body. When asked how she knew it was something R2's body made, DON B then stated not to quote her on that and began reading the pathology report. When asked how they would determine it was something R2's body made versus an external foreign body, DON B stated she would not but the Physician would. When asked if there was documentation showing it was determined to be something R2's body made versus an external foreign body, DON B stated she could look. She then called for RN C, who then participated in the interview. DON B stated Physician H said the mineralization was something organic that R2's body made. DON B stated gross examination (as referenced on the patholgy report) meant it was just looked at. When asked if there were additional notes from Physician H, after 3/9/23, it was reported they called Physician H's office, and there was nothing else to follow-up on. During an interview on 5/22/23 at 3:47 PM, Nursing Home Administrator (NHA) A was queried about R2's foreign body and reported she did not recall it, as she had been off during that time. She stated she had heard about it since the survey started (survey entered on 5/17/23). She then stated she may have been aware. When queried if she would report and investigate something of that nature, NHA A stated she was thinking the foreign body was something medical, not an actual object, and it would depend on the circumstances around it. If it was something where a resident could have put something in their vagina themselves, it may be something they would look at. As far as investigating, they would want to know what was found. NHA A stated she was not sure how it (foreign body) would get in there (R2's vagina), maybe during pericare or R2's own hand. NHA A stated she could investigate it more, do staff interviews to see if she had any history of putting items in her vagina and if staff had any ideas how an object like that could be in the vagina. NHA A reported it was not reported or investigated, and if it had been suspected sexual abuse, they would have reported it. During a phone interview on 5/22/23 at 4:04 PM, Physician H reported R2 did not have a foreign body and had what was more accurately described as a granulomatous growth that was removed and biopsied. He reported initially, there was concern of a foreign body there, but the growth was organic to R2 and not foreign. When asked how it was determined that it was a growth, Physician H reported the pathology report described it but said specifically that it was not a foreign body. According to Physician H, the descriptions from the pathology report were all descriptions of organic tissue. The Result Summary for Biopsy, pathology exam, with a final result on 3/21/23 at 8:30 AM reflected the source was Foreign body/material that was collected on 3/17/23 at 8:07 AM. The report reflected, .Specimen: Foreign body/material .Final Diagnosis Result: A. Foreign body, vagina, removal: Foreign material identified, see gross description .Microscopic Description Result: Gross examination only .Clinical Information Result: Foreign body in vagina, initial encounter .Gross Description Result: A. Labeled foreign body. Received in formalin is a discoid portion of gritty pale tan mineralized material with a somewhat friable surface measuring 3.7 x [by] 3.7 x 1.7 cm [centimeters]. Numerous small fragments of similar material aggregating to 2.4 x 1.5 x 0.5 cm. A photograph is taken. Upon sectioning, the main specimen is pale tan and gritty throughout without a central foreign object. Gross examination only . .Foreign bodies are objects lying partially or wholly within the body that originated in the external [outside] environment . (https://radiopaedia.org/articles/foreign-body-1) Prior to the survey exit on 5/22/23, no additional documentation had been provided pertaining to the foreign body being made by R2's body versus being a foreign body from the external environment. The facility's Abuse, Neglect and/or Misappropriation of Resident Funds or Property policy, with a revision date of 3/15/23, reflected, .Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion or sexual assault and includes non-consensual sexual contact of any type with a resident .Injury of Unknown Origin -is an injury that was not observed and could not be easily explained by resident and the injury is suspicious do [sic] the severity, location, or the number of injuries at once or over time .For the alleged violation involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, the Center will report immediately but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .to the administrator of the facility and to other officials (including to the state survey agency .) .

This citation pertains to intake MI00135852. Based on observation, interview and record review, the facility failed to investigate a foreign body object in the vagina for one (Resident #2) of three reviewed for abuse, resulting in a vaginal foreign body not being investigated and the potential for unrecognized sexual abuse. Findings include: Review of the medical record reflected Resident #2 (R2) was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included paranoid schizophrenia, foreign body in vulva and vagina (2/17/23), dementia, vascular dementia and hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting non-dominant side. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/3/23, reflected R2 scored nine out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), did not walk and required extensive to total assistance of one to two or more people for most activities of daily living. According to the MDS, R2 fed herself with set up assistance and did not have upper extremity impairments that interfered with daily functions or placed her at risk for injury. On 5/18/23 at 10:24 AM, R2 was observed in bed, with the bed height in a low position. Her eyes were closed, and she was covered by blankets to her chin. Upon knocking on the door, R2 opened her eyes. On 5/18/23 at 12:55 PM, R2 was observed seated in a Broda chair (specialty chair) at the dining table. A staff member was seated beside her, providing assistance with R2's meal. On 5/18/23 at 2:11 PM, R2 was observed seated in a Broda chair, in her room, watching TV. Her arms were under a sheet. R2 denied concerns with how others were treating her. She denied going out to any recent appointments, to the hospital or having any recent surgeries or procedures. Review of a State Agency Intake document reflected R2 had a surgical procedure for a foreign body removal. The object was in R2's vaginal canal and was believed to be soap or a urinal cake of some sort. The document referenced that R2 was unable to verbalize what happened. Physician H's Progress Note for 2/17/23 reflected the Physician was asked to see R2 regarding report of a foreign body in her vagina. According to the note, review of R2's records reflected report of a computerized tomography (CT) scan showing calcification in the vaginal area. R2 denied pelvic pain and did not know what the foreign body was about. The note reflected it was possible it was a fibroid (growth), and a gynecology consult would be scheduled. A Progress Note for 3/8/23 at 10:07 PM reflected R2 returned from an Obstetrics and Gynecology (OB/GYN) consult. The note referenced the OB/GYN office stated the foreign object was felt upon inspection but the Physician was unable to visualize the object due to R2 being combative and screaming. A recommendation was made for an exam under anesthesia. Physician H' Progress Note for 3/9/23 reflected R2 was seen for follow-up after consultation with gynecology for evaluation of a foreign body in the vaginal cavity. R2 was unable to tolerate the exam, and a recommendation was made to use general anesthesia. A Progress Note for 3/17/23 at 1:11 PM reflected R2 returned from surgery to remove a foreign body in her vagina. The foreign body was removed and sent to the lab, and R2 was placed on antibiotics. During an interview on 5/22/23 at 9:08 AM, Certified Nurse Aide (CNA) F reported R2 had a foreign object in her vaginal area and had to go to the hospital. CNA F stated they were not sure how that could have happened. R2's left hand and arm were somewhat stiff, according to CNA F. R2 put her hand in her brief but did not cleanse her own vaginal area, to CNA F's knowledge. During an interview that began on 5/22/23 at 10:33 AM, Registered Nurse (RN) C reported the foreign body in R2's vagina was an incidental finding when she had an x-ray at the hospital. RN C stated the hospital notified the facility they found a foreign body. R2 had a gynecology consult, and the foreign body was removed. According to RN C, they (hospital) did not say what it was. RN C reported the hospital said it was clam-sized when they called report to the facility. She reported asking if it was an abnormal growth and was told it was out for biopsy. When asked if the facility ever received results on the foreign body, RN C reported they printed them out and placed them in Physician H's folder. When asked if they had any idea how R2 had a foreign body in her vagina, RN C stated the facility did not know. According to RN C, the word foreign body was confusing to them. She reported Physician H thought it was a growth. A hospital History and Physical for 3/17/23 reflected, .seen in the office because she supposedly had a foreign body in the vagina. Is uncertain as to what it actually was. Patient has altered mental status and difficult for her to understand what we are trying to do. In the office attempts were made to remove what appeared to be a foreign body of unknown etiology but this was uncomfortable for the patient and she was screaming and fighting us . The Operative Note for 3/17/23, reflected, .Preoperative Diagnosis: Foreign body in vagina .Postoperative Diagnosis: Same pending pathology. A 2 inch whitish-gray disc with a crusty surface was removed from the vagina. I am uncertain as to what this foreign body actually is .Narrative: .I did a pelvic exam on the patient and I could feel a hard foreign body within the vagina. It had a lot of crusty like surface and we went ahead and placed a pediatric speculum so we could visualize the foreign body. It was gray in color. I then was able to grasp it with an [NAME] clamp and tease it out of the vagina. It came out in 1 piece .A piece of the foreign body was removed and sent for culture. Then the actual foreign body which was a round disc like object with a whitish-gray crusty surface was sent to pathology for evaluation . The note reflected R2's vagina was irrigated because of the likelihood of infection from the foreign body, which had been present for an unknown amount of time. During an interview on 5/22/23 at 12:34 PM, Director of Nursing (DON) B stated the (pathology) report said mineralization. She reported R2's body made the foreign body. When asked how she knew it was something R2's body made, DON B then stated not to quote her on that and began reading the pathology report. When asked how they would determine it was something R2's body made versus an external foreign body, DON B stated she would not but the Physician would. When asked if there was documentation showing it was determined to be something R2's body made versus an external foreign body, DON B stated she could look. She then called for RN C, who then participated in the interview. DON B stated Physician H said the mineralization was something organic that R2's body made. DON B stated gross examination (as referenced on the patholgy report) meant it was just looked at. When asked if there were additional notes from Physician H, after 3/9/23, it was reported they called Physician H's office, and there was nothing else to follow-up on. During an interview on 5/22/23 at 3:47 PM, Nursing Home Administrator (NHA) A was queried about R2's foreign body and reported she did not recall it, as she had been off during that time. She stated she had heard about it since the survey started (survey entered on 5/17/23). She then stated she may have been aware. When queried if she would report and investigate something of that nature, NHA A stated she was thinking the foreign body was something medical, not an actual object, and it would depend on the circumstances around it. If it was something where a resident could have put something in their vagina themselves, it may be something they would look at. As far as investigating, they would want to know what was found. NHA A stated she was not sure how it (foreign body) would get in there (R2's vagina), maybe during pericare or R2's own hand. NHA A stated she could investigate it more, do staff interviews to see if she had any history of putting items in her vagina and if staff had any ideas how an object like that could be in the vagina. NHA A reported it was not reported or investigated, and if it had been suspected sexual abuse, they would have reported it. During a phone interview on 5/22/23 at 4:04 PM, Physician H reported R2 did not have a foreign body and had what was more accurately described as a granulomatous growth that was removed and biopsied. He reported initially, there was concern of a foreign body there, but the growth was organic to R2 and not foreign. When asked how it was determined that it was a growth, Physician H reported the pathology report described it but said specifically that it was not a foreign body. According to Physician H, the descriptions from the pathology report were all descriptions of organic tissue. The Result Summary for Biopsy, pathology exam, with a final result on 3/21/23 at 8:30 AM reflected the source was Foreign body/material that was collected on 3/17/23 at 8:07 AM. The report reflected, .Specimen: Foreign body/material .Final Diagnosis Result: A. Foreign body, vagina, removal: Foreign material identified, see gross description .Microscopic Description Result: Gross examination only .Clinical Information Result: Foreign body in vagina, initial encounter .Gross Description Result: A. Labeled foreign body. Received in formalin is a discoid portion of gritty pale tan mineralized material with a somewhat friable surface measuring 3.7 x [by] 3.7 x 1.7 cm [centimeters]. Numerous small fragments of similar material aggregating to 2.4 x 1.5 x 0.5 cm. A photograph is taken. Upon sectioning, the main specimen is pale tan and gritty throughout without a central foreign object. Gross examination only . .Foreign bodies are objects lying partially or wholly within the body that originated in the external [outside] environment . (https://radiopaedia.org/articles/foreign-body-1) Prior to the survey exit on 5/22/23, no additional documentation had been provided pertaining to the foreign body being made by R2's body versus being a foreign body from the external environment. The facility's Abuse, Neglect and/or Misappropriation of Resident Funds or Property policy, with a revision date of 3/15/23, reflected, .Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion or sexual assault and includes non-consensual sexual contact of any type with a resident .Injury of Unknown Origin -is an injury that was not observed and could not be easily explained by resident and the injury is suspicious do [sic] the severity, location, or the number of injuries at once or over time .The investigation shall be initiated immediately, after the Administrator has knowledge of the incident, but in no event shall the investigation take longer than five (5) working days .As part of the investigation, the Administrator, or his/her designee, shall take the following action .Interview the resident, the accused .and all witnesses .Obtain all medical reports and statements from physicians and/or hospitals, if applicable .Review the resident's records .Review the Unusual Occurrence Report and complete the sections identified to be completed by the Administrator .Cases of physical or sexual abuse, for example by facility staff or other residents, always require corrective action and tracking by the QAA Comittee .

Based on observation, interview, and record review the facility failed to ensure fluids were being offered and accepted and administer pain medication for one of one resident (Resident #3) resulting in the potential for worsening dehydration and uncontrolled pain. Findings include: Review of an Admission Record revealed Resident #3 (R3) admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnoses which included nondisplaced intertrochanteric fracture of left femur, difficulty in walking, multiple fractures of pelvis, dementia, history of falling, unspecified fracture of the lower end of right radius, traumatic hemorrhage of cerebrum, and major depressive disorder. The Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/3/23, reflected R3 scored three out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). An Admission MDS with an ARD of 3/17/23 revealed R3 was independent with one-person physical assist for ambulation, transferring, and eating. R3 required limited assistance of one person to toilet, dress, and for personal hygiene. In an observation on 5/17/23 at 10:55 AM, R3 was observed resting in her bed, turned toward the wall, with her eyes closed. R3's bed was against the wall and in the lowest position. In an observation on 5/18/23 at 2:35 PM, R3's Styrofoam water cup was placed on R3's bedside table, out of reach of R3. On the Styrofoam cup was a handwritten date of 5/18/23 1st. The straw wrapper was still attached to the exposed end of the straw in the cup. The Styrofoam cup was full, and there was no ice in the cup. In an interview on 5/18/23 at 3:06 PM, Certified Nursing Assistant (CNA) G reported that water pass happens at shift change so R3's water was passed around 6:30-7:00 AM that morning. CNA G reported that it was unlikely that R3 had any drinks from the water at her bedside because it was out of reach and the wrapper was still on the straw which indicated the straw had not been used. Review of a Nurse's Note dated 4/18/23 at 10:21 PM revealed NP (Nurse Practitioner) in facility and assessed resident. Abnormal labs noted with increased BUN (Blood Urea Nitrogen) and creatine (BUN level means your kidneys aren't working well. Elevated BUN can also be due to dehydration, resulting from not drinking enough fluids) . Orders noted to start IV (intravenous) and infuse 0.545% (percent) at 75 CC (cubic centimeter) an hour for up to two liters for hydration . Review of a Nurse's Note dated 4/19/23 at 12:50 PM revealed nurse walked into resident's room and observed blood stain on resident's pad. Resident pulled out her IV access . A Nurses Note dated 4/20/23 at 6:24 PM revealed [Physician H] in to assess patient. Reviewed for 4/2023 labs . continue to push fluids . A Nurse's Note dated 4/26/23 at 1:50 AM revealed that R3 was currently receiving IV fluids. A Nurses Note dated 4/26/23 at 9:33 AM revealed IV infusion changed . continuously to infuse to complete the 2L (liter) total . Continue to encourage oral fluids. A Nurses Note dated 5/10/23 at 11:49 PM revealed notified NP of lab results by phone and NP stated that we needed to really push fluids d/t (due to) results . Review of the Physician Order's for R3 revealed an order dated 5/10/23 that stated push fluids on every shift and chart on acceptance. Push fluids three times a day for [sic] avoid dehydration The order was discontinued on 5/18/23 after an inquiry regarding the order was brought to the facilities attention. Review of the Task Documentation revealed no task for documenting fluid acceptance and/or amount of fluid consumed. Review of the Kardex (portion of Electronic Medical Record that Certified Nursing Assistant's access for resident care needs) on 5/18/23 revealed encourage fluids under R3's Eating/Nutritional Preferences section. A Nurse's Note dated 5/12/23 at 3:22 PM revealed R3 had signed into Hospice services. In an interview on 5/18/23 3:35 PM, Director of Nursing (DON) B DON reported that the facility is not documenting R3's fluid intake. In an interview on 5/22/23 at 1:54 PM, Director of Nursing (DON) B reported that R3 was starting to decline after her surgical repair of her hip fracture and poor kidney function. IV rehydration was attempted but R3 removed the IV access on more than one occasion. An order came in to push fluids but the documentation did not get triggered to allow for documentation of fluid acceptance. In an interview on 5/22/23 at approximately 2:30 PM, Registered Nurse C reported that the provider placed an order to push fluids. When queried what push fluids means, RN C stated that it meant to have her drink and get her to drink. The intent of the order was due to R3 struggling with dehydration as evidenced by recent lab work. RN C reported that the order to push fluids was discontinued on 5/18/23 because it was no longer appropriate because R3 had signed onto Hospice service. However, the Electronic Medical Record (EMR) Revealed that R3 signed onto Hospice on 5/12/23. Further review of the Progress Notes revealed a Nurse's Note dated 3/25/23 at 10:47 PM which revealed resident was in bed all of the shift. said she had some pain. gave prn (as needed) Tylenol (pain reliever) .repositioned and asked if she would like to sit up and watch TV(television). she said no. Called (the physician) he gave the order to make the prn to Acetaminophen (Tylenol-a pain reliever) tablet 325 two tabletsmy [sic] mouth q (every) 4 hours . Review of the Physician Order dated 3/25/23 revealed an order for Acetaminophen (Tylenol) tablet 325 x 2 tablets by mouth q 4 hours. Review of the March Medication Administration Record revealed R3 did not receive the ordered Tylenol for the dates of 3/26/23-3/31/23. A total of 36 opportunities to medicate for pain were missed. Review of the April Medication Administration Record revealed R3 did not receive the ordered Acetaminophen for the dates of 4/1/23-4/7/23. A total of 42 opportunities to medicate for pain were missed. In an interview on 5/22/23 at 1:54 PM, Director of Nursing B reported that the Physician Order was inputted inaccurately in R3's Electronic Medical Record (EMR) and the nurse that was responsible would be receiving education on adding orders to the EMR.

Based on observation, interview and record review the facility failed to ensure that recommendations for prevention of injury from hot beverages were followed and interventions planned for one (#63) and failed to implement interventions to prevent a fall with major injury for one (#41) out of six reviewed for accidents, resulting in an Immediate Jeopardy due to the likelihood [MEDICAL CONDITION] hot liquids, pain and infection (#63) and a fall with major injury (#41). Findings include: A review of the facility policy titled, Hot Beverages, dated 4/12/10 and revised on 9/9/19, Purpose: 1. to provide an interdisciplinary approach to minimizing the risk [MEDICAL CONDITION] hot beverages .Procedure: 1. Upon admission, quarterly and with significant change in status, the patient's ability to handle and consume hot beverages will be assessed. 2. Nursing will complete an initial observation of the patient's ability to handle and consume hot beverages with recommendations for further screening or evaluation by therapy if indicated .3. Dietary department and nursing department will respond to Therapy's recommendations to ensure tray ticket, care plan and Kardex is updated. [NAME] Patient and staff education reinforced. 5. Dietary will update the tray tickets . A review of the face sheet, care plans and Minimum Data Set (resident assessment), dated 8/3/19, reflected that R63 was admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. R63 had moderate cognitive impairment, was dependent two staff persons for all activities of daily living and required supervision or being fed for meals. A review of care plans for R63 reflected, I am to have lidded cups when giving hot liquids. Initiated on 9/4/19 and created on 9/9/19. A review of physician's orders for R63, started on 4/26/19, revised on 7/13/19 and no end date, reflected, lids on all cups with hot liquids. On 9/9/19 at 12:11 PM, the meal service in the main dining room was observed. Resident 63 (R63) was observed seated in his wheelchair, wearing a clothing protector and bringing a mug of a dark beverage to his mouth. No lid was observed on the mug, and steam was observed rising from the mug. At approximately six inches from his mouth, R63 tipped the mug as if to sip, and the entire contents poured in his lap. No physical reaction was seen, nor did this Surveyor hear if R63 said anything. Certified Nurse Assistant (CNA) P was seated on R63's left, stood and wheeled R63 to his room. CNA P used the clothing protector to mop up the spilled coffee in R63'd lap. CNA Q failed to lift the fabric of the slacks away from R63's thighs, nor did he pour cool water onto R63's lap to reduce the potential for burns. R63 smelled strongly of coffee. When this surveyor placed her hand around the mug, it was almost too hot to touch. In R63's room, CNA P and a second CNA lifted R63 from his wheelchair using a standing lift and removed his shoes and wet socks and slacks. The coffee had run down the top of his wheel/chair cushion and two palm-sized, irregular areas of pink were observed on the top and inner aspects of both thighs. At 12:15 PM, Registered Nurse (RN) Q joined us and inspected R63's anterior thighs and asked him, three times, if anything hurt, but R63 did not answer. When this Surveyor asked if anything hurt after he spilled the coffee in his lap, R63 said, Oh, burns. No. RN Q failed to remove his brief to inspect his bottom, groin, posterior thighs, or down his legs to his feet. Upon touch, this surveyor placed the top of their hand on the pink areas and the areas were considerably warmer than the cool skin of his thighs. When asked if the pink areas on R63's thighs felt grainy during her assessment, RN Q said they did not. On 9/09/19 at 12:34 PM, when asked what the temperature of the coffee was in the serving containers in the dining room, Director of Food Services D looked at the hand-written temperature tracker and said 140 degrees Fahrenheit. When asked if the kitchen had a list of residents that required lids on hot beverages, Director D said there was not a list. Each resident's meal ticket would have that information. A review of R63's lunch meal ticket reflected no mention of lids on hot beverages. On 9/9/19 the NHA A was presented with an Immediate Jeopardy Notification due to the facility's failure to follow therapy recommendations for lids on hot beverages for R63. A corrective action plan was requested from the facility. On 9/10/19 at 9:16 AM, Family V was interviewed about R63 via phone. Family V said I visit weekly. (R63) doesn't handle utensils well, can't balance food once he scoops it up and can't find his mouth. This was happening before he came to the facility. I wasn't there when he spilled hot chocolate on himself. They (facility) called and told me. A review of electronic medical records titled, Interact, dated 7/13/19 reflected R63 spilled hot cocoa in his lap. No injuries were noted, and nothing was documented about a lid on the hot beverage. A review of a diet requisition form for R63, dated 9/4/19 with no signature, reflected, please provide resident c (with) lidded cups. On 9/11/19 at 3:18 PM, Occupational Therapist (OT) O was interviewed. After looking at electronic medical records, OT O said that R63 received therapy for fine motor coordination from 7/15/19 through 7/25/19, and a recommendation for lids on hot beverages was made. I filled out the diet requisition form that goes to the kitchen, and they should have put the recommendations on the R63's meal ticket. I don't keep a copy of the diet requisition form, said OT O, But the kitchen should have it. On 9/12/19 at 12:52 PM, RN R was interviewed via phone. I was his nurse the evening (R63) spilled 'a few drops' of hot chocolate on himself during dinner. There was no injury, and I did forms for an occupational therapy assessment for lids on hot beverages and a change of condition. I remember R63 was very tired that day. RN R said that she didn't work with R63 for about one and a half months after this and had no idea why there was no care plan for lids on hot beverages. On 09/09/19 at 12:55 P.M., Hot beverage temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following beverage temperatures were recorded: Coffee: 162.5 degrees Fahrenheit * Hot water: 172.9 degrees Fahrenheit * Note: Hot beverages were drawn directly from the main dining room dispensing decanters, located on the beverage table. On 09/10/19 at 08:05 [NAME]M., Food Service Director D was interviewed concerning a specific Policy/Procedure for dispensing and serving hot beverages to residents. Food Services Director D indicated she would provide the requested Policy/Procedure to this surveyor as soon as possible. On 09/10/19 at 08:14 [NAME]M., Hot beverage temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following beverage temperatures were recorded: Coffee: 142.5 degrees Fahrenheit * Hot Water: 154.9 degrees Fahrenheit * Note: Hot beverages were drawn directly from the main dining room dispensing decanters, located on the beverage table. On 09/10/19 at 09:35 [NAME]M., Record review of the Coffee Temperature Log revealed the following breakfast meal coffee temperatures for (MONTH) 2019: 08/02/19 - 162 degrees Fahrenheit * 08/12/19 - 170 degrees Fahrenheit * 08/18/19 - 180 degrees Fahrenheit * 08/20/19 - 160 degrees Fahrenheit * On 09/10/19 at 09:40 [NAME]M., Record review of the Coffee Temperature Log revealed the following breakfast meal coffee temperatures for (MONTH) 2019: 09/01/19 - 165 degrees Fahrenheit * 09/03/19 - 160 degrees Fahrenheit * 09/09/19 - 160 degrees Fahrenheit * Note: (*) Water Temperature - Water may reach hazardous temperatures in hand sinks, showers, tubs, and any other source or location where hot water is accessible to a resident.[MEDICAL CONDITION] to hot water/liquids may also be due to spills and/or immersion. Many residents in long-term care facilities have conditions that may put them at increased risk [MEDICAL CONDITION] by scalding. These conditions include: decreased skin thickness, decreased skin sensitivity, [MEDICAL CONDITION], decreased agility (reduced reaction time), decreased cognition or dementia, decreased mobility, and decreased ability to communicate. The degree of injury depends on factors including the water temperature, the amount of skin exposed, and the duration of exposure. Some States have regulations regarding allowable maximum water temperature. Table 1 illustrates damage to skin in relation to the temperature of the water and the length of time of exposure. Table 1. Time and Temperature Relationship to [MEDICAL CONDITION] Water Time Required for a 3rd Degree Temperature Burn to Occur _________________________________________________________________ 155°F 68°C 1 sec 148°F 64°C 2 sec 140°F 60°C 5 sec 133°F 56°C 15 sec 127°F 52°C 1 min 124°F 51°C 3 min 120°F 48°C 5 min 100°F 37°C Safe Temperatures for Bathing (see Note) _________________________________________________________________ NOTE:[MEDICAL CONDITION] occur even at water temperatures below those identified in the table, depending on an individual's condition and the length of exposure. Based upon the time of the exposure and the temperature of the water, the severity of the harm to the skin is identified by the degree of burn, as follows. o First-[MEDICAL CONDITION] the top layer of skin (e.g., minor sunburn). These may present as red and painful to touch, and the skin will show mild swelling. o Second-[MEDICAL CONDITION] the first two layers of skin. These may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin. o Third-[MEDICAL CONDITION] the entire thickness of the skin and permanently destroy tissue. These present as loss of skin layers, often painless (pain may be caused by patches of first- and second-[MEDICAL CONDITION] third-degree burns), and dry, leathery skin. Skin may appear charred or have patches that appear white, brown, or black. On 09/10/19 at 09:45 [NAME]M., Record review of the Policy/Procedure entitled: Beverage Temperature Procedures and Documentation revealed the following: (3) Once coffee and/or hot water is done filling the shuttle you will need to take a temperature of the product. Coffee temperature is not to be taken until put out for service. (7) Coffee and hot water temperatures must be taken and documented after each brewed pot following the above procedures. The Immediate Jeopardy was removed on 9/11/19 when the facility had implemented the following corrective action interventions: -R63 was assessed and care plan updated to reflect lids with hot beverages. -All resident records audited by 9/9/19 to ensure safety interventions met the need of the residents. -All meal tickets audited by 9/9/19 to ensure safety needs are reflected. -All care plans were audited to ensure interventions to reduce risk are in place. -ALL STAFF educated: validate meal ticket against what was served and that safety measures were in place; first aide in case of hot beverage spill; all staff are to be educated prior to their next scheduled shift. -Director of Therapy makes recommendations for adaptive equipment/safety measures and will communicate all new recommendations on the PCC Communication Dashboard (in the electronic medical record). -Nurse Managers will check the dashboard and obtain physician's orders as needed, update the dietary care plan and write a diet requisition form to the dietary manager or designee to update the tray card. -The policy for hot beverages was reviewed and updated to include changing CENA plan of care to Kardex, and omit keeping a cool pitcher of water in the dining room. First aide posters were posted in the dining rooms. -The system was changed to include that Nurse Managers review the 24-hour reports Monday through Friday for acute Change of condition that may require additional screens from the IDT (Interdepartmental Team) and /or therapy. -Licensed nurses, department heads and CENA's are responsible to ensure that adaptive equipment was present prior to serving a meal to a resident. -Random audits for 5 residents during meal times will be done to ensure safety devices/adaptive equipment are utilized as needed. Results to QA (Quality Assurance meetings). Although the Immediate Jeopardy was removed on 9-11-19 the facility remained out of compliance at the 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 could not be verified by the State Agency. Resident #41 (R41) Review of the medical record reflected that Resident #41 (R41) was admitted to the facility on [DATE] and was readmitted on [DATE], with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment for 5/8/19, reflected that R41 scored three out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R41 was coded as independent for bed mobility, transfers and ambulation (walking) in her room. Ambulation in the corridor was coded for supervision, and toileting was coded for limited assistance of one person. The Significant Change in Status MDS assessment for 7/5/19, reflected that R41 had short-term and long-term memory impairments and that her cognitive skills for daily decision making were severely impaired. R41 was coded for ambulation occurring once or twice in the 7-day look-back period. She required extensive assistance of one to two or more people for her Activities of Daily Living (ADL's). The assessment coding reflected that R41 had a fall with major injury since admission or the prior assessment. On 9/09/19 at 10:38 AM, R41 was observed seated in her wheelchair in the doorway of her room with her buttocks toward the edge of the wheelchair seat. A wheelchair seating cushion was observed with dycem (a non-skid material) above it. The cushion was observed hanging approximately 4 inches off the front of R41's wheelchair. Review of R41's Care Plan reflected the following interventions: -RESOLVED: Ambulation with walker and 1 staff for dining room and toileting. The intervention was created and initiated on 1/30/19. The intervention was revised and resolved on 6/28/19. -Transfer: 2 staff assist with use of walker in room only with walker. The intervention was created and initiated on 1/30/19. The intervention was revised on 8/23/19. -I am incontinent of bowel and bladder. I wear briefs for incontinence. Assist me to the toilet upon waking, before/after meals and as needed for bowel, bladder training. The intervention was created and initiated on 2/11/19. -I am 1 person assist for all ADL'S. The intervention was created and initiated on 1/30/19. The intervention was revised on 7/2/19. A Bowel and Bladder Patterning Log, dated for 1/30/19, 1/31/19, 2/1/19 and an undated day after 2/1/19, reflected that R41 was dry at 1:00 AM on 1/31/19, 2/1/19 and an undated day after 2/1/19. The log reflected that on 1/31/19, 2/1/19 and an undated day after 2/1/19, R41 was incontinent at 2:00 AM on each of the three days. A Progress Note for 6/21/2019 at 2:57 AM reflected, .At 0145 (1:45 AM) resident found by staff on (sic) the sitting position on the floor in her room. She stated that she was trying to get up and use the bathroom and she lost her balance and fell . She was assessed for bruises, pain, neuro (neurological) and ROM (range of motion),skin (sic) tear noted on left elbow , it was cleaned and dressing applied. Tylenol administered for pain on left elbow and on buttocks. Resident was assisted with getting up and she walked to the bathroom with staff assistance and a walker, she showed no signs of pain with walking and no limbing (sic) noted. Resident is using the bathroom at the time of the entry . A Progress Note for 6/23/2019 at 10:38 PM reflected, .resident seems afraid to stand up. and (sic) has not ambulated per her normal this shift. denies (sic) pain when asked. but (sic) resident is confused and sometimes yells at staff for asking questions. A Progress Note for 6/24/2019 at 2:16 AM reflected, .Resting quietly with eyes closed .Cont (continues) on routine Tylenol per order with effective relief noted during night. (Company Name) in to do xrays at 0130 (1:30 AM). Awaiting results. Noted discoloration to right elbow and resident pulling at arm, skin tear noted to area with dried blood . A Progress Note for 6/24/2019 at 7:18 AM reflected, .X ray results received at approx. (approximately) 0650 (6:50 AM). (Physician Name) called and informed of results showing left femoral neck fx (fracture). N.O. (new order) received to send to (Hospital) . Documentation for an Incident Report on 6/21/19 at 1:45 AM, was consistent with the Progress Note for 6/21/19 at 2:57 AM (see above). In addition, the Incident Report reflected that R41 fell after trying to get up and use the restroom. She missed a step and fell , according to the report. The Interdisciplinary Team (IDT) note on the Incident Report reflected that R41 lost her balance when getting up to go to the bathroom. The IDT note reflected that R41 was independent with ambulation and was independent in her room. According to the IDT note, R41 had a previous history of falls, and an intervention to take R41 to the bathroom on first rounds for night shift was added. A typed facility summary of R41's fall for 6/21/19 reflected that Medical Records/Certified Nurse Aide (CNA) L was working when R41 was observed on the floor. According to the typed summary, CNA L reported that R41 would get up at night and go to the bathroom on her own. The typed investigation reflected: .(R41's first name) fall was not preventable. She has shown the ability to transfer and ambulate independently without problem . In an interview on 9/11/19 at 3:16 PM, Registered Nurse (RN) N reported that R41 required constant watching and reminders to use her walker. She would walk down the hall without her walker .She would get up in the middle of the night, and that is when the falls would happen . RN N stated that R41 would try to be independent prior to her fall on 6/21/19, but she could not be due to not using her walker. RN N stated, A lot of times, we would catch her dragging her walker behind her .Now since the fall, she does not walk . RN N reported that R41 needed constant reminders to use her call light. RN N was not aware of a toileting schedule for R41. She stated, That was one of the things, she did not tell us she needed to use the bathroom .She cannot remember to use her call light . During an interview on 9/12/19 at 9:38 AM, Licensed Practical Nurse (LPN) Q was asked about R41's fall on 6/21/19. LPN Q reported that R41 was trying to get into the bathroom and was found sitting on the floor by her bed. LPN Q reported that R41 was wet (had voided/been incontinent) at the time of the fall. LPN Q reported that prior to R41's fall on 6/21/19, she needed assistance of one person to ambulate and use the toilet. LPN Q reported that they did every two hour checks and toileting, and R41's next check was to be at 2:00 AM. In an interview on 9/12/19 at 12:53 PM, Director of Nursing (DON) B reported that R41 normally slept at night and got up to use the bathroom. Regarding the fall on 6/21/19, DON B reported that the CNA observed R41 sitting on the floor, and she stated she was going to the bathroom. According to DON B, R41 was independent with transfers and ambulation (at the time of the fall). When asked if R41 was on a toileting program prior to her fall on 6/21/19, DON B reported that R41 was not, as she could toilet herself. DON B reported that R41 had poor safety awareness due to cognitive deficits, and her call light was not on at the time of the fall. When asked if R41 had a habit of getting up unassisted to use the bathroom during the night, DON B stated, Yeah, I would say she would at least get up two times a night. DON B denied knowledge of anything else that may have happened between 6/21/19 and 6/24/19 to cause R41's fracture. DON B stated that R41 was independent with ambulating in and out of her room prior to the fall. When asked if R41 was care planned for independent ambulation and transfers, DON B reviewed the medical record and was unable to find that documentation. DON B reported that the new interventions for R41 were to change her Senna (laxative medication) from PM to AM, have staff take her to the bathroom on first rounds and for a therapy evaluation. When asked about the bowel and bladder patterning log that reflected incontinence at 2:00 AM on three consecutive days, DON B reported that was another reason to toilet R41 on first rounds (for midnight shift). In a follow-up interview on 9/16/19 at 10:32 AM, DON B reported that R41's care plan did state she was a one person assist with ambulation in her room, including toileting. DON B stated, That was not updated. She was pretty mobile throughout the building. In an interview on 9/16/19 at 10:52 AM, LPN M reported that R41 had always been confused, especially if they tried to tell her what to do with her walker. LPN M reported that R41 would drag the walker beside her. According to LPN M, R41 had very poor safety awareness and did not use her call light. LPN M stated that every once in a while, R41 would say she needed to use the bathroom, but she was not consistent. According to LPN M, staff anticipated R41's needs. LPN M reviewed the facility's process for bowel and bladder patterning and reported that the facility had a packet that was filled out for incontinence. According to LPN M, the packet included a form to be completed with modifiable factors that contributed to incontinence, a Bowel and Bladder Patterning Log, a Bowel and Bladder Patterning Log Evaluation and a Toileting Program Log. LPN M reported that the information from the Bowel and Bladder Patterning Log was used to establish the Toileting Program Log. LPN M reported that all of those forms were scanned into the Electronic Medical Record (EMR). LPN M was unable to locate all of the forms in R41's EMR. Review of R41's EMR did not reveal any toileting program forms, other than the Bowel and Bladder Patterning log, which was started on 1/30/19. There was no documentation that R51's bowel and bladder patterning was evaluated and/or interventions implemented due to her repeated documented incontinence at 2:00 AM. Review of CNA task documentation from R41's medical record reflected the last entry for toileting prior to her fall (on 6/21/19 at 1:45 AM) was on 6/20/19 at 7:15 PM. R41 was documented as being continent at that time. Further review of R41's urinary continence documentation from 6/7/19 to 6/21/19, reflected that she was both continent and incontinent of her bladder. According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated (MONTH) (YEAR), .An individualized, resident-centered toileting program may decrease or prevent urinary incontinence, minimizing or avoiding the negative consequences of incontinence .Many incontinent residents (including those with dementia) respond to a toileting program, especially during the day .The steps toward ensuring that the resident receives appropriate treatment and services to restore as much bladder function as possible are .completing an accurate, thorough assessment of factors that may predispose the resident to having urinary incontinence .implementing appropriate, individualized interventions and modifying them as appropriate .Research has shown that one quarter to one third of residents will have a decrease or resolution of incontinence in response to a toileting program .

Based on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors in accordance with accepted profession standards in one of 20 residents reviewed for medication regimen (Resident #30), resulting in the likelihood of major or fatal bleeding. Findings include: Resident #30 (R30) On 9/10/19 at 8:21 AM, R30 was observed lying in bed sleeping. R30's Minimum Data Set (MDS) assessment dated [DATE] revealed she was admitted to the facility on [DATE], was [AGE] years old, and her cognitive skills for daily decision making were severely impaired (never/rarely made decisions). The same MDS indicated R30 had daily physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing). R30's Hospice Client Coordination Note Report dated 7/31/19, indicated [MEDICATION NAME] ([MEDICATION NAME]) 4 milligrams (mg) was ordered for possible [MEDICAL CONDITION] ([MEDICAL CONDITION], blood clot) and International Normalized Ratio (INR, used as a standard for monitoring the effects of anticoagulant treatment with [MEDICATION NAME], where the aim to maintain an INR in target range) was to be obtained on 8/05/19. physician progress notes [REDACTED]. The same note indicated R30 was under hospice care, and decided it was not necessary to do a venous ultrasound but treatment with [MEDICATION NAME] was initiated. The same physician progress notes [REDACTED]. The same note indicated R30 had an unsteady gait, and had the [DIAGNOSES REDACTED]. R30's fall risk care plan, revision date 6/13/19, revealed she had a history of [REDACTED]. roam the facility. R30's Activities of Daily Living ADL care plan dated 11/2/19, reflected she required a two person assist with showers due to combative behaviors. R30's Hospice log dated 8/05/19 indicated an INR of 2.1, there was no mention of continued INR monitoring. Last documented INR for R30 was on 8/05/19. R30's Physician order [REDACTED]. There was no PT/INR result documented in R30's medical record. According to <https://www.uwhealth.org/files/uwhealth/docs/.pdf2/ambulatory_warfain_guideline.pdf>, guidelines based on American College of Chest Physicians Clinical Practice Guidelines, a baseline INR should be obtained prior to initiating [MEDICATION NAME] therapy and appropriate dosing was based on INR measurements. The same source indicated frequency of INR monitoring for maintenance of [MEDICATION NAME] for patients with multiple high sensitivity risk factors was: after 1 week if start/stop interacting medication, change in diet, change in activity level or other change that could affect INR; every 1-2 weeks if dose needed adjustment by 5-10%; every 4 weeks if patent maintained on same stable dose less than 6 months; then every 6-8 weeks if patient maintained on same stable dose for at least 6 months. The manufactures insert located at <http://www.[MEDICATION NAME].bmscustomerconnect.com/inr>, indicated to individualize dosing regimen for each patient, and adjust based on INR response. R30's Physician order [REDACTED].D. for new orders. According to R30's medical record, the last INR obtained was on 8/05/19. In review of R30's (MONTH) 2019 Medication Administration Report (MAR), she received 4 mg of [MEDICATION NAME] every day in (MONTH) 2019, except for 8/22/19. According to R30's (MONTH) 2019 MAR, she received 4 mg of [MEDICATION NAME] on 9/01/19, 9/02/19, 9/03/19, 9/04/19, 9/06/19, 9/07/19, 9/08/19, 9/09/19, and 9/10/19. R30 refused [MEDICATION NAME] on 9/05/19. Hospice log dated 9/10/19 reflected that they were not able to obtain R30's INR, the physician was notified and ordered to discontinue INR monitoring. There was no order to discontinue [MEDICATION NAME]. According to R30's (MONTH) 2019 MAR, she received 4 mg of [MEDICATION NAME] on 9/10/19. On 9/11/19 at 2:49 PM, Licensed Practical Nurse (LPN) Unit Manager M, was interviewed and stated she was not aware of the hospice log note dated 9/10/19, to discontinue R30's INR monitoring. LPN M stated she was not aware of the plan for R30's treatment with [MEDICATION NAME] and stated she was going to call hospice for more information. There was no physicians order in R30's medical record to discontinue INR monitoring. On 9/11/19 at 3:12 PM, Hospice Registered Nurse (RN) BB was interviewed and stated she notified R30's physician, on 9/10/19, that she was unable to obtain an INR, and the Physician discontinued INR monitoring. RN BB stated she planned to contact R30's physician later, on this same day, to obtain orders to discontinue [MEDICATION NAME] and consider aspirin. R30's physician orders [REDACTED]. R30 was administered 4 mg of [MEDICATION NAME] from 8/6/19 to 9/10/19 (with exception of 8/22/19 and 9/05/19) without monitoring. The Immediate Jeopardy began on 8/12/19, was identified on 9/12/19, and removed on 9/13/19. On 9/12/19 the NHA A was presented with an Immediate Jeopardy Notification due to the facility's failure to monitor [MEDICATION NAME] for R30. A corrective action plan was requested from the facility to remove the immediate jeopardy. An abatement plan was accepted and the Immediate Jeopardy removed on 9/13/19 when it was verified that the facility had the following in place: 1. R30 was assessed on 9/12/19 by the Director of Nursing (DON). R30's [MEDICATION NAME] was discontinued on 9/11/19. 2. An audit was completed on 9/12/19 of all residents currently taking an anticoagulant that required blood test for monitoring was competed to ensure appropriate blood monitoring was done. The audit was completed by nurse managers on 9/12/19. There were five residents currently taking [MEDICATION NAME] that required blood monitoring. RN and/or LPN's were re-educated on anticoagulants that require blood monitoring to ensure monitoring was completed timely and reported to the physician. The DON and Nurse Managers (7 RN/LPN's) were re-educated by the Nurse Consultant regarding anti-coagulants that require blood monitoring. Education was initiated on 9/12/19 with current staff members in the building on first shift and verbal education was completed by designated Nurse Managers. Licensed staff will be educated by the the designated Managers continuing on 9/12/19 prior to staff working their next scheduled shift. Nurse Managers were responsible for checking new orders Monday through Friday for new anticoagulants requiring blood monitoring and to obtain physician's orders [REDACTED]. 3. The facility policy for anticoagulants was reviewed. Nurse Managers to review the order listing reports Monday through Friday to ensure any new anticoagulants that require a blood level was followed up on timely. Hospice residents that require treatment and laboratory monitoring will be managed by the facility attending physician and monitoring of laboratory results will be completed by facility staff. The physician may choose to have pharmacy dose [MEDICATION NAME]. 4. Beginning 9/13/19, the DON or designee(s) will pull 5 charts of residents that were taking anticoagulants to check for appropriate care plan and if required blood test was needed. The results will be taken to Quality Assurance (QA). Although the Immediate Jeopardy was removed on 9-13-19 the facility remained out of compliance at the 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 could not be verified by the State Agency.

Based on observation, interview and record review, the facility failed to prevent two instances of abuse affecting 2 residents (#63, #35) of 4 residents reviewed for abuse resulting in the likelihood of feelings of shame, embarrassment, psychosocial effects, mental anguish. Findings include: On 9/6/19, the facility submitted a report to the State indicating an incident where a facility resident (#63) had his picture taken during morning care and posted to an on-line app called SnapChat by a facility employee, Certified Nursing Assistant (CENA) F. On 9/10/19 at 4:05 PM, a record review of the initial report submitted by the facility indicated Resident # 63 was being transferred using a sit-to-stand with 2 CENAs assisting him. A third CENA took a video of the 2 CENAs and the resident and posted it on SnapChat with a banner across the picture that said LMAO which meant Laughing My A** Off. CENA G had her back to the camera and CENA H was facing the camera. Resident #63 A review of the face sheet, care plans and Minimum Data Set (resident assessment), dated 8/3/19, indicated that Resident #63 (R63) was admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. R63 had moderate cognitive impairment, was dependent two staff persons for all activities of daily living and required supervision or being fed for meals. On 9/10/19, an interview with R63 determined that R63 did not know of the incident where his picture was taken or did not remember the incident. On 9/11/19 at 9:30 AM, CENA H was interviewed. According to CENA H, she did not know anything was going on. (CENA F name) was joking around and acting like she was the boss. CENA H indicated the facility had a policy where you were not to have a cell phone on your person when working and you'll be suspended if you are caught. Although CENA H maintained she was unaware that a picture was being taken while she was caring for R63, CENA H was facing the camera. On 9/11/19 at 10:00 AM, CENA F, who took the picture of R63 and posted it on social media, was interviewed. CENA F indicated she worked for the facility for 5 years and, when asked how she would feel if someone took her picture without permission she stated I would feel horrible if something like this happened to me. I would be very angry. CENA F said I realize now that doing a video of a resident without permission is abuse. I knew taking a picture of a resident without their clothes on would be considered abuse. I am embarrassed and ashamed. On 9/11/19 at 10:30 AM, an interview with CENA G occurred. She stated she and another CENA were caring for a resident (R63) and getting him out of bed. R63 had a shirt on but his pants were halfway up his thighs as we would pull his pants totally up when R63 stood up. His brief was exposed. R63 was not totally awake and was holding on to the EZ stand (a device used to help a resident from a sitting to a standing position). CENA F was in the recliner and was joking that she was supervising us. Initially, CENA G stated she was unaware that CENA F had taken a picture of R63 during care and only discovered it later in the day. However, when CENA G was shown the interview statement to the Administrator, which was signed by CENA G, she admitted she was aware CENA F had a cell phone in the resident room and was taking a picture of R63 during care. On 9/11/19 at 11:00 AM, a record review of the facility policy titled Cell Phone/Camera Equipped Devices, Policy # HRD-107C, Revision Date of 7/20/15, indicated: 1) Employee ' s personal camera-equipped, cell phones, smartphones and related devices are not permitted in resident care areas. Employees should plan to keep these items in their personal vehicles or lockers. No camera-equipped devices are to be taken into any restroom, exercise area, or shower facility at any time. 2) Employer issued smartphones and camera-equipped devices may be used and permitted in the resident care areas for job related purposes only. 3) Any employee who takes pictures of resident/ patients or employees without written consent will be terminated. On 9/16/19, a record review of the final report sent by the facility to the State revealed the following information: After a thorough investigation, the facility has concluded that (CENA F name) is responsible for mental abuse as evidenced by taking an unauthorized recording of a resident in a manner that would demean or humiliate him and distributed it on social media. (CENA F name) was terminated on 9/11/2019. (CENA G name)is responsible for not reporting mental abuse as evidenced by her statement that she knew (CENA F name) was recording in the resident room, although she claims she did not know the resident was recorded. She did know a phone was being used in a resident room for recording while a resident was being cared for. (CENA G name) was terminated on 9/11/2019. (CENA H name) claimed to have been unaware that a video was taken in the resident room, therefore, abuse is not substantiated, however, she was terminated based on knowing the CENA (CENA F) was on her phone texting in a resident room while resident care was being given which puts the resident at risk for potential mental abuse. (CENA H name) was suspended on 9/11/2019 and terminated on 9/13/2019. A Reasonable Person (a fictional person with an ordinary degree of reason, prudence, care, foresight, or intelligence whose conduct, conclusion, or expectation in relation to a particular circumstance) would prefer to not have his picture taken when he was not totally clothed and without his permission and not have his picture posted on social media. Resident #35 (R35) Review of the medical record reflected that R35 was admitted to the facility on [DATE] and was readmitted on [DATE], with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) for 4/12/19 reflected that R35 scored five out of 27 (mild depression) on the PHQ-9 (questionnaire for depression scoring). The Quarterly MDS for 7/13/19 reflected that R35 scored 13 out of 27 (moderate depression) on the PHQ-9. The same MDS for 7/13/19 reflected that R35 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R35 was non-ambulatory (did not walk) and required extensive to total assistive of one to two or more people for Activities of Daily Living (ADL's). On 9/09/19 at 11:34 AM, R35 was observed in her room. R35 stated that the Certified Nurse Aide's (CNA's) felt underappreciated. When asked how the staff treated her, she said some CNA's gave extra care, and some didn't. The ones that did not give extra care were kind of rough and vindictive. R35 stated that she had talked to a few people about it but could not say who. R35 stated that she reported a CNA named (CNA G) on the day shift. According to R35, that CNA still worked for the facility and still took care of her. R35 stated that she reported (CNA G), and she did better for a while. R35 stated that (CNA G) could be down right nasty. On 9/09/19 at 11:41 AM, the surveyor reported the conversation with R35 to Nursing Home Administrator (NHA) [NAME] NHA A stated that she had followed up with R35 before regarding R35's concerns with CNA G. According to NHA A, CNA G was complaining that R35 would not get out of bed and had stated something similar to, it doesn't matter to me if you don't get out of bed. NHA A stated that they did a concern form and followed up with CNA G. NHA A reported that CNA G was given a final written warning 7/11/19. When asked if R35's concern had been reported to the State Agency, NHA A stated it was not. According to NHA A, R35 had reported that CNA G was unkind and unprofessional. According to an email received from NHA A on 9/10/19 at 4:27 PM, there were no incident reports or investigations pertaining to R35 in the prior 3 months. During an interview on 9/11/19 at 11:59 AM, CNA G reported they had worked at the facility as a CNA for three years, and they were still an active facility employee. When asked to describe their interactions with R35, CNA G reported that R35 was supposed to get out of bed. CNA G stated, we ask her, sometimes she yells at me. When asked what their response was to R35 yelling at them, CNA G responded with, I tell her ok, that's fine. CNA G reported that they had to notify the nurse when R35 did not get out of bed so that it could be charted. During the same interview, CNA G proceeded to report that the 300 hall was short-staffed. CNA G stated, I'm stressed out a lot. When asked if R35 had any concerns with the way they treated R35, CNA G stated, she probably has concerns with the way I talk to her. When asked how they talked to R35, CNA G stated, I raise my voice a little. When asked if they raised their voice to other residents, CNA G responded with, not really. When asked why they raised their voice to R35, CNA G stated, The way she talks to me bothers me. I know I shouldn't raise my voice at her. When asked if they had ever reported to management how they felt stressed out and short-staffed, CNA G reported that NHA A and Director of Nursing B had talked to them about verbal abuse towards R35. CNA G could not recall when that was but stated it was when corporate staff were at the facility. When asked to describe the conversation with NHA A and DON B, CNA G stated that R35 told corporate staff that she (CNA G) said, this is why my back hurts, because we have to roll you all the time. According to CNA G, R35 reported that they said that R35 lays in bed like a bump on a log. CNA G reported, I probably said that to her. When asked if they felt like they had ever been abusive towards R35, CNA G stated, no. CNA G then reported, I feel like maybe one time. CNA G stated that NHA A and DON B asked her if she wanted to move off of the 300 hallway. CNA G stated they liked the 300 hallway and were told by NHA A and DON B to take a break. When asked if they had received any educations or disciplines, CNA G stated, they talked to me about verbal abuse. On 9/11/19 at 12:23 PM, R35 was observed lying in bed. When asked if CNA G had ever said or done anything mean to them, R35 stated, she makes reference to my weight, that I am killing her back, she's not going to ruin her back because of someone like me. R35 stated that CNA G did not say those things often. In regards to the tone/volume of CNA G's voice, R35 reported that it did not sound that great. When asked if CNA G had ever said that she lays around like a bump on a log, R35 stated, Oh yeah. She says that my problems are my own fault because I stay in bed, but they don't get me up. When asked how it made her feel when CNA G spoke to her in that manner, R35 stated, Well, it hurts my feelings. R35 stated that CNA G had taken care of her maybe a few days ago. When asked how long it had been since CNA G had hurt her feelings, R35 stated, maybe a few weeks. When asked if she had reported the concerns to anyone and if anyone had talked to her about the situation, R35 stated, just people from here, but she did not remember who. NHA A and DON B were interviewed on 9/11/19 at 12:46 PM. When asked about their knowledge with CNA G and R35's interactions, NHA A reported that they believed there was a personality conflict. NHA stated the only thing she could get out of R35 was that CNA G was irritable and that CNA G's mood was hot or cold. NHA A reported that when she spoke with R35 (on 9/9/19), R35 stated CNA G was back to her old ways, was easily irritated and took everything personally. R35 reported that CNA G did not treat her very good but could not give specific examples, according to NHA [NAME] R35 stated that staff was angry with management and took it out on the residents, according to NHA [NAME] Regarding R35's concern in (MONTH) 2019, NHA A stated that the facility had a peer review at that time. R35 told someone that they had a concern with a nurse named (First Name of CNA G). NHA A reported that there was not a nurse with that first name, and they realized it was CNA G. According to NHA A, the most she got out of R35 at that time was that CNA G was unkind, hot and cold and did not act very professional. NHA A reported that she interviewed CNA G, who said they were stressed out but did not want to move from the 300 hallway. NHA A reported that at the time, in July, CNA G admitted to getting irritable with R35. When asked if they had ever considered changing R35 off CNA G's assignment, NHA A and DON B reported that they did not think they offered that. We thought she would be ok. (CNA G) felt bad and was tearful when she talked to us. According to DON B, CNA G had last worked at the facility on 9/6/19. Review of CNA G's personnel file on 9/11/19 at 2:13 PM, reflected that CNA G received a written warning on 7/11/19. The warning reflected, Employee Handbook: Group 1 Rules: #14 Unprofessional behavior toward a resident - Perception of a resident is that you have been unkind. Employee educated on caregiver stress burnout and ways to reduce as well as expectations for treating residents with dignity and respect. On 9/11/19 at 2:32 PM, NHA A reported that CNA G had been terminated from employment with the facility. According to the facility policy titled, ABUSE, NEGLECT AND/OR MISAPPROPRIATION OF RESIDENT FUNDS OR PROPERTY with a revision date of 12/10/18, .PURPOSE: To assure each resident in the center is free from abuse, neglect and exploitation .Mental Abuse includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation .Verbal abuse refers to any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents. Verbal abuse includes but is not limited to using spoken, written or gestured language that include insulting, offensive or disapproving terms to any resident (or within his or her hearing distance), regardless of age, disability, or ability to comprehend .

Based on observation, interview, and record review, the facility failed to implement individualized interventions and honor resident preferences to prevent a severe weight loss of 5.8 percent (%) in one month, in 1 of 3 sampled residents reviewed with weight loss (Resident #8), in a total sample of 15 residents, resulting in unmet nutrition goals, falls and a potential for muscle wasting, weakened immune system, and delayed discharge back to the community. Findings include: Resident #8 was observed sitting at a table in the main dining room eating lunch on 9/11/17 from 12:10 PM to approximately 1:10 PM. Resident #8 was observed drooling and spitting liquid into several napkins throughout the meal. In an interview on 9/11/17 at 1:05 PM, Certified Nurse Assistant (CNA) Z stated Resident #8 had the most difficulty eating the lunch meal and indicated his drooling had increased. CNA Z stated Resident #8 received a regular diet with thin liquids. Resident #8's lunch meal was observed and he had only consumed approximately half of his meal in an hour's time. Progress Notes dated 8/9/17 at 8:12 PM revealed Resident #8 was admitted to the facility from the hospital and had the [DIAGNOSES REDACTED]. The same note revealed Resident #8 was alert, spoke Burmese fluently and spoke some English. The Minimum Data Set (MDS) 3.0 dated 9/6/17, introduced the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, score was 9 out of 15 (08-12 indicated a moderate impairment). In review of the Comprehensive Nutritional assessment dated [DATE], Resident #8 fed himself with limited assistance/verbal cues and his food acceptance was fair, with a 25% to 50% intake. The same assessment revealed Resident #8's most recent weight was 161.4 pounds (lbs.), that he reported he had a good appetite and that he denied any recent weight changes. The same Comprehensive Nutritional assessment dated [DATE] indicated Resident #8 was willing to try butter pecan Med Pass (liquid nutritional supplement) with a plan to provide 120 milliliters (ml) of butter pecan only Med Pass supplement twice daily. A Nurses Note dated 8/19/17 at 3:21 PM revealed Resident #8 stated he had slipped off the bed when he tried to move his leg. In review of Resident #8's nutritional care plan, revised on 9/8/17, his nutritional goal was to maintain stable nutritional status, that his weight was stable and to provide supplements as ordered. The same care plan did not include Resident #8's preference for butter pecan Med Pass. Resident #8's electronic medical record document, under weight summary revealed the following weights: 8/10/17 161.4 8/18/17 156.0 8/25/17 153.5 9/1/17 150.6 9/8/17 151.9 In review of the Transfer Report with an Encounter Date of 8/4/17, [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]) 25-100 milligrams (mg), 2.5 tablets by mouth, was instructed to administered three times daily before meals. In review of the Medication Administration Record [REDACTED]. The same report indicated an order for [REDACTED]. The National Parkinson Foundation website (http://www.parkinson.org/understanding-[MEDICAL CONDITION]/treatment/Medications-for-Motor-Symptoms/[MEDICATION NAME]-[MEDICATION NAME]) recommended to take [MEDICATION NAME]-[MEDICATION NAME] 30 to 60 minutes before eating a meal to allow the medication to be quickly absorbed before the food could interfere with absorption. The same reference indicated [MEDICATION NAME], after converted into [MEDICATION NAME] was stored in the neurons (cells) until needed by the body for movement; and [MEDICATION NAME] was a [MEDICATION NAME] enhancer and helped reduce the side effects of nausea and vomiting. The same website revealed some people with PD feel full after eating a small quantity of food and recommenced eating smaller, more frequent meals. The Hormel Health Labs website (http://www.hormelhealthlabs.com/product-support/product-protocols/med-pass) revealed a potential drug nutrient interaction with Med Pass especially if given in amounts greater than 2 ounce (oz.)/serving (1 ounce = 30 ml). The same source indicated it was probably best to avoid taking [MEDICATION NAME]-[MEDICATION NAME] with high protein foods and amino acids (Med Pass = 5 gm protein/2 oz). The Medication Administration Record [REDACTED]. Med Pass 2.0 Sugar Free was scheduled at 8:00 AM and 5:00 PM. The same report revealed [MEDICATION NAME]-[MEDICATION NAME] was scheduled to be administered at 8:00 AM, 11:00 AM, and 5:00 PM. In review of the Meal Schedule and Location document (no date), retrieved from the survey book presented to the survey team on 9/11/17, revealed meal times in the Main Dining Room for breakfast was between 7:00 AM to 8:45 AM, Lunch was at 12:00 PM, and Dinner was served at 5:00 PM. Registered Nurse (RN) M was interviewed on 9/12/17 at 9:30 AM and stated she usually administered Resident #8's [MEDICATION NAME]-[MEDICATION NAME] on his way to breakfast and typically administered the next dose at 12:00 PM, at lunch. In an interview on 9/12/17 at 11:20 AM, Licensed Practical Nurse (LPN) Unit Manager S was not able to explain why the order for [MEDICATION NAME]-[MEDICATION NAME] did not include instructions from the hospital to administer the medication prior to meals and stated that the instructions should have been included in the order. Following the above interview, the September 2017 Medication Administration Record [REDACTED]. The same record did not reflect instructions to not administer medication with the Med Pass supplement. The same record indicated Med Pass was to be administered twice daily between 7:00 AM and 10:00 AM and again between 4:00 PM and 7:00 PM. The same MAR indicated [REDACTED]. Registered Nurse (RN) M was interviewed on 9/13/17 at 9:45 AM and stated she had administered vanilla flavored sugar free Med Pass supplement for Resident #8 for the past two days on day shift during the survey. Registered Dietitian (RD) H was interviewed on 9/13/17 at 9:15 AM and stated upon her initial assessment, Resident #8 was found to be at risk for weight loss because he was not eating well. RD H stated she had recommended Butter Pecan flavored Med Pass because he had indicated he did not like vanilla flavor. RD H stated in the same interview that she, the unit manager and the assistant director of nursing (ADON C) attended the nutrition at risk meeting held weekly. RD H stated in the same interview that 6 small meals instead of 3 meals were considered by the team, but the kitchen would not able to accommodate that schedule. RD H stated offering extra snacks during the day or offering a substantial snack at night were not discussed with the team. RD H stated in the same interview that enhanced foods (boosting calories/protein) or magic cups (ice cream like protein dessert) were not considered. On 9/13/17 at 11:10 AM, LPN Unit Manager S stated they only had sugar free vanilla Med Pass in the facility, but could order butter pecan if a resident did not like vanilla. LPN Unit Manager S continued in the same interview to state the facility routinely used the vanilla because it was sugar free, and appropriate for diabetic residents. Resident # 8's medical record did not indicate he was diabetic.

This citation pertains to MI 321 Based on interview and record review, the facility failed to respond timely to an acute change in condition in 1 of 2 sampled residents (Resident #103) reviewed for an acute change of condition, out of a total sample of 3 residents, resulting in dehydration, blood infection (sepsis), and the need for hospitalization . Findings include: According to a facility policy dated 7/1/08, titled Change in Condition reflected, Family and/or responsible party are notified anytime there is a change in the resident's condition or plan of care. Procedure notification of any change in the resident's condition will be done in a timely manner. The designated party will be notified if more than a nursing intervention is needed. Check the medical record for specific family/responsible party instructions regarding notification If unable to notify designated person, continue to call at regular increments until party has received the message. A facility policy titled, Hydration and Electrolyte Management Program dated 11/11/06 reflected, Sufficient fluid means the amount of fluid needed to prevent dehydration that results from output far exceeding intake. The amount of fluid needed for each resident fluctuates as the residents condition fluctuates (e.g. fever, diarrhea, draining wounds) Risk factors: change in mood, fluid restriction or nothing by mouth, repeated refusal or change in food intake, elevated temperatures greater than 48 hours, infectious processes that affect fluid intake or loss, weight loss, Gastrointestinal complaints, behavior change, change in level of consciousness, dysphagia, blood chemistries, draining wounds or pressure ulcers, excessive seating, depression, some medications, rapid breathing or a prior history of dehydration. Signs and Symptoms of dehydration: dry skin and mucus membranes, cracked lips, poor skin turgor, increased thirst, abnormal labs: hemoglobin, hematocrit, chloride, sodium, potassium, transferrin, creatinine, glucose, [MEDICATION NAME] .lethargy. According to the Face Sheet dated 10/21/15 at 4:08 p.m., Resident #103 was a [AGE] year old female admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to this face sheet for Resident #103, Resident #103 had an appointed guardian service that had telephone numbers for the office, a cell phone and an after hours service. Review of the Minimum Data Set ((MDS) dated [DATE] reflected Resident #103 could not complete the Brief Interview for Mental Status (BIMS) and staff evaluation of her mental status score was 3 indicating Resident #103 was severely cognitively impaired. Review of the document dated 12/4/14 titled, Advance Directives reflected that Resident #103 and her guardian consented or marked yes for, Transfer to an acute care hospital, blood [MEDICAL CONDITION], artificial hydration (Intravenous fluids), artificial nutrition (tube feedings), antibiotic therapy for infections, maximum pain control regardless of side effects and [MEDICAL TREATMENT]. Resident #103 and her guardian refused or said no to palliative care. There was a note to the side of the document, Call to consult. Review of the Nurses notes dated 1/17/16 at 10:43 a.m. for Resident #103 reflected, Resident (#103) pocketing food and drools out back out of mouth. Takes 1 hour to get 2 glasses of liquids down. (name of Unit Manager (UM) J) informed of pocketing. States will talk to guardian tomorrow re(garding) swallow eval(uation) and issues with hydration and swallow . This note was completed by Registered Nurse P. Nurses notes dated 1/18/16 at 3:20 p.m. for Resident #103 reflected, Appetite very poor. Fed by staff--usually will take couple of bites of food, but then holds the food in her mouth and will not attempt to swallow. Does the same with all foods and thickened fluids. Very lethargic. Message left for guardian on call for (name of guardian) re: need to call facility ASAP (as soon as possible) re: patients condition. Nurses notes dated 1/18/16 at 7:50 p.m. for Resident #103 reflected, VS (vital signs) Temperature 96.3, Respirations 16, heart rate 104 (normal is 70 to 100) pulse oxygenation 94 %, and B/P 123/85. Resident observed up in W/C (wheelchair) for meals and activities; continues with poor appetite, staff attempted to feed and resident kept pocketing food and coughing was observed at times. Meds were taken without any difficulties, resident unable to respond to verbal command, no signs or symptoms of discomfort or respiratory distress noted. During rounds, resident observed napping, repositions every 2 hours. ADL's (activities of daily living) assisted. Safety precautions in place. Still expecting return phone call from guarding (sic). Nurses notes dated 1/19/16 at 10:51 a.m. for Resident #103 reflected, Resident continues to trigger for eating less than 25 % of meals, supplements in place and snacks offered but does refuse those at times. Resident has been noted to pocked food and not swallow. Will try again today to contact guardian today. This note was written by UM J. Nurses notes dated 1/1916 at 10:58 a.m. for Resident #103 reflected, left message for guardian (name of guardian) for return call to update on condition. This noted was written by UM J. Nurses notes dated 1/20/16 at 3:10 p.m. for Resident #103 reflected, Resident (#103) sent out for evaluation and treatment to (name of local hospital/acute care facility) per Guardians order. Resident left the facility around 2:45 p.m. via stretcher . During an interview on 2/5/16 at 11:34 a.m., UM J stated that Resident #103 began to decline on the weekend on 1/15 or 1/16/16. UM J stated Resident #103 began to have difficulties swallowing, Resident #103 was not eating well. UM J was asked if Resident #13 was drinking and she stated, A little, not too much. During an interview with Physician's Assistant (PA) R on 2/5/16 at 11:04 a.m. PA R was asked what Resident #103's advance directives stated. She stated the Advance Directives were unsure of treatment options. PA R stated they were to call the guardian consult their wishes each time. PA R stated on 1/20/16 she needed to decide whether to keep her here (in the facility) or send her out (to an acute care facility for evaluation). PA R was asked if Intervenous (IV) fluids were considered. PA R stated once she felt better, she would just pull them out and cause trauma. PA R stated she began [MEDICATION NAME] (a broad spectrum antibiotic given intramuscularly) empirically (before knowing if there was an infection or the type of infection). PA R stated they got labs and Resident #103's sodium level was 182 (normal is 135 to 145 mEq/L (milliequivilants per liter)). PA R stated Resident #103 was, in bed, lethargic, not well hydrated. PA R was asked if a sodium level of 182 mEq/L occurred over a short amount of time and she agreed it did not. PA R felt Resident #103's Advance Directives directed her to wait before transferring to an acute care facility. PA R stated she didn't see any good coming from treatment. Review of the Hospital Acute care notes dated 1/20/16 reflected that Resident #103's laboratory results on admission to the acute care facility was: Sodium 183 mEq/L (normal 135 to 145 mEq/L), Creatinine was 1.2 (no units noted, flagged as elevated) and BUN (level of blood urea nitrogen used to evaluate kidney function) was 58 (no units noted, flagged as elevated). White blood cell count (indicate an infection) was 12.5 (no units noted, flagged as elevated), and hemoglobin (red blood cells that carry oxygen) was 17.1 (no units noted, flagged as elevated). These elevated labs indicate that Resident #103 was dehydrated upon arrival to the acute care facility. Review of the Hospitalist Discharge Summary dated 1/23/16 at 10:02 a.m. for Resident #103 reflected, Discharge Diagnosis: [REDACTED].Hospital course: (Resident #103) is a [AGE] year old female who present from (name of long term care facility). The patient does not respond to verbal commands .today she had an urinalysis showing positive for urinary tract infection [MEDICAL CONDITION]. The pt (patient) was given [MEDICATION NAME] (antibiotic) IV at 1:20 p.m. by EMS (emergency medical services). RN (Registered Nurse) in ED (emergency department) report showed the patients blood glucose was around 78. On arrival to the ED the pts temperature was 100.5 rectally (99.5 orally). Patient was found to have critical [MEDICAL CONDITION] (high sodium level) and [MEDICAL CONDITION] due to UTI. Blood cultures are negative. Ample fluid was given in ICU (Intensive Care Unit) and sodium level is coming down to 170, which is still critically high. ( )

This citation pertains to MI 132 Based on observation, interview, and record review, the facility failed to provide adequate supervision for 2 of 4 sampled residents reviewed for 2 person assist transfers, (Resident #1 and Resident #3), from a total of 4 sampled residents, resulting in a right hip fracture during a transfer for Resident #1 and injury during transfers for Resident #3 who required a 2 person assist. Findings include: Review of the face sheet in the medical record dated 2/4/13 revealed Resident #1 was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a falls care plan dated 12/23/11 and updated 7/3/13 revealed Resident #1 was at risk for falls related to limited mobility, impaired cognition and communication, frequent attempts to self-transfer, and a potential for adverse side effects of antidepressant medication therapy. Review of an Activities of Daily Living (ADL) care plan dated 12/23/11 and updated on 3/13/13 revealed Resident #1 was a two person assist with transfers, bed mobility, and dressing. In an interview on 8/30/13 at 3:15 PM, Director of Nursing (DON) "B" reported Resident #1 required the assistance of 2 staff members and the sit to stand lift for transfers secondary to morbid obesity and being unreliable with his ability to maintain his balance. Review of an Unusual Occurrence form dated 7/30/13 revealed on 7/30/13 at 8:15 PM, Certified Nursing Assistant (CNA) "C" transferred Resident #1 to the bed with the aid of a walker. The form revealed Resident #1's knees buckled down to the floor. The form revealed Resident #1 complained of right hip pain with no bruising or swelling noted. Review of a nurse's note dated 7/30/13 revealed the physician was notified and ordered an x-ray of Resident #1's right hip. The note revealed Resident #1 received pain medication and family was notified. Review of a nurse's note dated 7/31/13 revealed on 7/31/13 at 1:40 AM, the physician ordered to send Resident #1 to the hospital. Review of a hospital record dated 8/3/13 revealed Resident #1 sustained a right hip fracture and had an open reduction and internal fixation (surgical procedure to fix a broken bone) of the right hip. Review of an interview statement dated 8/2/13 revealed CNA "C" stated he changed Resident #1's brief and was getting him ready for bed. The statement revealed CNA "C" had Resident #1 standing next to the bed with the walker in front of him. The statement revealed Resident #1's legs began to give out and Resident #1 began to fall to the ground while holding on to the walker. The statement revealed CNA "C" was behind Resident #1 and held him up around his chest. The statement revealed CNA "C" heard CNA "D" in the hallway and yelled for CNA "D" to come into Resident #1's room. The statement revealed CNA "C" and CNA "D" stood Resident #1 and transferred him to bed. The statement revealed CNA "C" reported the incident to Licensed Practical Nurse (LPN) "E" and came to Resident #1's room. The statement revealed CNA "C" reviewed Resident #1's care guide with LPN "E" and noted Resident #1 was a two person assist with a sit to stand. The statement revealed CNA "C" did not have a gait belt on Resident #1 and was aware of Resident #1's transfer status on the care guide. The statement revealed CNA "C" was a bigger aide and was able to transfer Resident #1 easier than other staff members. In an observation on 8/30/13 at 2:45 PM, four CNAs assisted Resident #1 from the Barton (bariatric chair) chair to the bed using an air lift mattress with no issues or concerns noted. Resident #1's bed was low to the floor and against the wall with a floor mat and a bed sensor in place and functioning. The facility administrator provided a quality action process (completion date 8-23-13) which reflected in-service completed with nursing staff on reviewing care guides at the beginning of the shift for transfer instruction and implementing the correct transfer instructions. ( ) August 2013 physician's orders [REDACTED]. Resident #3 was observed on 8/30/13 at noon in the main dining room at lunch time. Resident #3 was sitting up in her wheelchair, cleanly clothed, a sensor alarm was attached to her clothing and she had a hearing aide in her left ear. During the observation nurse manager "F" stated that Resident #3 was blind. Resident #3 was observed later that day at 2:20 P.M. in her room. Resident #3's pant leg was raised and a bandage (gauze dressing covered with paper-like tape) with a dime size of drainage (at the center) pink in color was noted at her right lateral lower leg. When referring to the injured area, resident #3 stated "it hurts when you touch it". An "Unusual Occurrence" sheet reflected resident #3 bumped her right lower leg on a bed frame during a transfer from a wheelchair to her bed on 8/26/13 at 5:45 A.M. Resident #3 was transferred by one nursing assistant "H", which resulted in a 3.5 centimeter skin tear to her right lateral lower leg. The skin tear was treated with first aid and steri-strips were applied. Resident #3's ADL (activity of daily living) care plan revised on 11/14/12 and reviewed on 7/30/13 reflected the following interventions: 12/04/12 one person assistance for bed mobility and 03/15/13 transfer with 2 person assist. The undated "RESIDENT CARE GUIDE " for resident #3 reflected: 1 assist with bed mobility and transfer 2 assist. Nursing assistant staff "H" was telephoned on 8/30/13 at 1:38 P.M. and asked about the transfer of resident #3 that resulted in a skin tear to the residents lower leg. When asked if she referred to Resident #3's care guide prior to transferring resident #3 staff "H" stated that, "we went through the care plan before shift started." Nursing assistant staff "H" stated she did not get another staff to help with the transfer and she transferred Resident #3 by herself despite the resident needing 2 staff to transfer. Staff "H" added that it was a mistake to transfer the resident by herself. Staff "H" stated she reported the injury to the nurse on duty. The facility's "EMPLOYEE ACTION IMPROVEMENT PROCESS" dated 8/26/13 reflected staff "H" failed to complete job duties satisfactorily, failed to follow safety procedures and failed to follow care guide related to transfers causing skin tear. A letter dated 8/9/13 signed by the Director of Nursing "B" reflected staff "H" was terminated by the facility on 8/29/13. The facility quality action process regarding using the resident care guides to implement the correct transfer instructions for residents was not being followed resulting in an injury to resident #3. ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO TRANSFER RESIDENTS SAFELY FOR 3 OF 9 RESIDENTS (#11, #13, #14) REVIEWED FOR FALLS OUT OF A TOTAL SAMPLE OF 16 RESIDENTS, RESULTING IN A PUNCTURE WOUND TO THE BACK OF RESIDENT #14'S HEAD, A BLEEDING HEMATOMA TO RESIDENT #13'S FOREHEAD, AND THE POTENTIAL FOR FURTHER INJURY DUE TO IMPROPER TRANSFER FROM THE FLOOR FOR RESIDENT #15. FINDINGS INCLUDE: RECORD REVIEW OF THE "MINIMUM DATA SET" (MDS) ASSESSMENT INSTRUMENT FOR RESIDENT #13 REVEALED RESIDENT #13 WAS A [AGE] year OLD FEMALE admitted WITH [DIAGNOSES REDACTED]. SHE SCORED 8 OUT OF A POSSIBLE 15 ON THE BIMS COGNITION TEST WHICH INDICATED MODERATE DEMENTIA. SHE WAS CODED ON THE MDS AS NEEDING "LIMITED ASSISTANCE AND GUIDANCE WITH LIMBS" FOR TRANSFERS, AMBULATION, DRESSING, AND EATING. THE FALLS RISK CARE PLANS IN HER CHART WERE DATED AS INITIATED ON 9/20/12 AND STATED: "I AM AT RISK FOR FALLS R/T LIMITED MOBILITY, WEAKNESS/FATIGUE, VISUAL DEFICITS, PAIN, ATTEMPTS TO SELF TRANSFER RESULTING IN FALLS, HX OF FALLS, COGNITIVE DEFICITS, AND POTENTIAL FOR ADVERSE SIDE EFFECTS OF ANTIDEPRESSANT AND ANTIANXIETY MEDICATION THERAPY." THE PLAN DIRECTED THAT RESIDENT #13 BE TRANSFERRED WITH 1 ASSIST. RECORD REVIEW OF THE "INTERDISCIPLINARY PROGRESS NOTES" FOR 1/31/13 IN RESIDENT #13'S MEDICAL RECORD REVEALED THE RESIDENT HAD SUSTAINED A FALL WITH INJURY ON THAT DAY. THE "INTERDISCIPLINARY PROGRESS NOTES" FOR 1/31/13 12:00 A.M. RECORD "THIS NURSE CALLED TO RM (ROOM OF RESIDENT), OBSERVED RES. (RESIDENT) LYING ON (RIGHT) SIDE ON FLOOR, PILLOW UNDER HEAD, LG AMT (LARGE AMOUNT) OF BLOOD AROUND RES HEAD, LG HEMATOMA NOTED (RIGHT) TEMPLE - SQUIRTING BLOOD - PRESSURE APPLIED TO HEMATOMA, BLEEDING CONTROLLED IN APPROX. 8 MINS (MINUTES). RES ALSO NOTED TO TO HAVE SKIN TEAR X 2 (RIGHT) ELBOW . . . C/O (COMPLAINT OF) PAIN TO RIGHT TEMPLE. " RESIDENT #13'S "INTERDISCIPLINARY PROGRESS NOTES" DATED 1/31/13 CONTINUED WITH, "12:40 A.M. CENA (NURSE AIDE) STATES RES HAD GAIT BELT ON DURING TRANSFER FROM W/C (WHEELCHAIR) BUT LIFTED ARM STRAIGHT UP IN AIR BIL (BOTH ARMS) & THEN fell TO (RIGHT), ONTO FLOOR." THE RESIDENT HAD XRAYS TAKEN OF HER HEAD AND RIGHT ARM WITH THE REASON LISTED AS PAIN AND CONTUSION WHICH WERE NEGATIVE FOR ACUTE FRACTURE. THE FACILITY INVESTIGATION REVEALED THE NURSE AIDE (STAFF "BB") WHO WAS INVOLVED IN THE INCIDENT RELATED 3 DIFFERENT VERSIONS ABOUT HOW THE FALL HAPPENED. IN ONE VERSION SHE STATED SHE HAPPENED UPON THE RESIDENT AS THE RESIDENT ATTEMPTED TO CLIMB OUT OF BED AND COULD NOT STOP THE FALL. IN ANOTHER VERSION SHE STATED SHE HAD TOILETED THE RESIDENT AND WAS TRANSFERRING HER FROM THE WHEELCHAIR INTO BED WHEN THE FALL OCCURRED.. IN THE THIRD VERSION, STAFF "BB" STATED SHE WAS AMBULATING THE RESIDENT BACK FROM THE BATHROOM WHEN THE FALL OCCURRED. WHAT ACTUALLY OCCURRED REMAINS UNCLEAR. A REQUEST WAS MADE TO THE DIRECTOR OF NURSING TO INTERVIEW STAFF "BB" HOWEVER, SHE HAD BEEN TERMINATED AFTER THE FALL. RESIDENT #13 WAS APPROACHED IN HER ROOM ON 2/21/13 AT 2:00 P.M. SHE WAS LYING IN BED AWAKE WITH A DISTRESSED LOOK ON HER FACE. A LARGE BANDAGE WAS ON HER RIGHT FOREHEAD. SHE WAS ASKED HOW SHE FELT AND SHE SAID "NOT GOOD, NOT GOOD". SHE WAS ASKED HOW SHE HURT HER HEAD AND SHE REPLIED "I DON'T KNOW, I DON'T KNOW". SHE WAVED HER HAND IN A "GO AWAY" GESTURE INDICATING SHE DID NOT WANT TO TALK ANY FURTHER. SHE WAS REAPPROACHED ON 2/22/13 AT ABOUT 10:15 A.M. AND AGAIN STATED SHE DID NOT KNOW HOW SHE HURT HER HEAD AND DID NOT REMEMBER FALLING. ( ) ACCORDING TO THE MOST RECENT QUARTERLY MINIMUM DATA SET (MDS) COMPLETED ON 12/13/12 RESIDENT #14 WAS AN [AGE] year OLD FEMALE RESIDENT WITH [DIAGNOSES REDACTED]. THE SOCIAL WORK QUARTERLY ASSESSMENT NOTES DATED 9/10/12 AND 12/3/12 FOR RESIDENT #14 REFLECTED A BRIEF INTERVIEW FOR MENTAL STATUS (BIMS) WAS UNABLE TO COMPLETE, AND THAT THE RESIDENT HAD A RESIDENT MOOD INTERVIEW (PHQ-9) = 9 (THE PHQ TEST IS A TOOL USED FOR ASSISTING IN DIAGNOSING DEPRESSION). ON 2/22/12 AT 9:10 AM RESIDENT #14 WAS OBSERVED UP IN HER WHEELCHAIR IN THE SMALL DINING ROOM/TELEVISION (TV) AREA. SHE WAS DRESSED IN A PINK SWEAT SUIT AND HAT. HER WHEELCHAIR WAS LOW TO THE GROUND WITH A CUSHION, AND NO ALARMS WERE OBSERVED. SHE WOULD SLEEP OFF AND ON WHILE WATCHING TV. AT 9:11 AM HER BEDROOM WAS OBSERVED TO HAVE A BED WITH BILATERAL GRAB BARS AND RIGHT/LEFT FLOOR MATS. ACCORDING TO THE FACILITY'S "UNUSUAL OCCURRENCE" DOCUMENT DATED 9/18/12 AT 8:15 PM, REFLECTED RESIDENT #14 HAD A WITNESSED FALL. THE FALL OCCURRED IN THE RESIDENT'S ROOM AS FOLLOWS: "CENA'S (COMPETENCY EVALUATED NURSING ASSISTANTS) WERE STANDING (RESIDENT'S NAME) UP WITH EZ (MECHANICAL) STAND. (RESIDENT'S NAME) WAS TRYING TO FIGHT HER WAY OUT OF IT WHEN SHE SLIPPED OUT. CENA'S TRIED TO PUT CHAIR UNDER HER BEFORE SHE fell TO FLOOR. HIT HER HEAD ON W/C (WHEELCHAIR)". THE FALL RESULTED IN 1 PUNCTURE WOUND TO THE BACK OF HER HEAD. RESIDENT #14 WAS NOT SENT OUT TO THE LOCAL HOSPITAL, BUT INSTEAD TREATED AT THE FACILITY. THE IMMEDIATE INTERVENTIONS TAKEN CONSISTED OF A PAIN ASSESSMENT, ON-SITE FIRST AID, AND NEUROLOGICAL CHECKS. CENA'S "Y" AND "Z" WERE PRESENT DURING THE INCIDENT DATED 9/18/12. THE "UNUSUAL OCCURRENCE" FORM WAS SIGNED AND COMPLETED BY REGISTERED NURSE "X" ON 9/18/12. THE ACCOMPANYING "SUPERVISOR/MANAGER'S INVESTIGATION" WAS COMPLETED ON 9/18/12 BY REGISTERED NURSE "B" ON 9/18/12. THE INVESTIGATION REFLECTED THE RESIDENT HAD BEEN ALERT PRIOR TO THE EVENT. ADDITIONAL CORRECTIONAL ACTION OF A REFERRAL TO PHYSICAL THERAPY/RESTORATIVE AND EVALUATION FOR A HOYER LIFT HAD TAKEN PLACE. THE ROOT CAUSE ANALYSIS CONCLUSION REFLECTED THE FOLLOWING: "PT (PATIENT) IS BEING EVALUATED FOR HOYER LIFT. CNA'S (CERTIFIED NURSING ASSISTANT) WERE USING E-Z STAND PT BEGAN TO FIGHT OUT OF THE SLING. ONE OF THE CNA WENT TO PUT A W/C UNDER PT BUT SHE fell OUT BEFORE". A STATEMENT OF THE EVENT WAS DOCUMENTED BY CENA "Y" REFLECTING THE FOLLOWING: "(CENA Z'S NAME) AND I WERE USING EZ-STAND TO STAND (RESIDENT #14'S NAME) UP TO CHANGE & PUT HER IN BED. (RESIDENT #14'S NAME) STARTED FIGHTING HER WAY OUT OF THE SLING SO I PUT HER W/C UNDER HER, BUT BEFORE I GOT THE CHAIR UNDER HER SHE SLIPPED OUT OF THE SLING AND fell TO THE FLOOR. HIT WHEELCHAIR". THE STATEMENT WAS SIGNED BY BOTH CENA "Y & Z", BUT AN INDIVIDUAL STATEMENT FROM CENA "Z" HAD NOT BEEN OBTAINED. ON 2/22/13 AT 9:57 AM RESIDENT #14 WAS BROUGHT INTO HER ROOM TO LAY DOWN BY CENA'S "T & U". THE DOOR AND PRIVACY CURTAIN WAS CLOSED IN THE EMPTY ROOM. CENA "U" EXPLAINED WHAT SHE WAS DOING TO THE RESIDENT AS SHE PLACED HER GAIT BELT AROUND HER. BOTH CENA'S THEN PUT ON GLOVES. AN ATTEMPT WAS MADE TO VIEW THE BACK OF RESIDENT #14'S HEAD (AT THE OLD PUNCTURE WOUND SITE) BUT THE RESIDENT REFUSED TO HAVE HER HAT REMOVED. THE WHEELS TO THE W/C WERE LOCKED, AND THE RESIDENT WAS ENCOURAGED TO STAND BY CENA "U" WHO HAD HER HANDS ON THE GAIT BELT AS CENA "T" STOOD DIRECTLY TO RESIDENT #14 FOR ADDITIONAL ASSISTANCE. THE RESIDENT REFUSED TO MOVE, AND MADE HAND GESTURES TO STOP. THE STAFF EXPLAINED THEY WERE GOING TO LAY HER DOWN TO GET REST AND AGAIN SHE REFUSED. THE STAFF THEN ASKED WOULD SHE LIKE TO GO TO THE RESTROOM TO BE CHECKED/CHANGED FOR INCONTINENCE. THE RESIDENT REFUSED TO BE TOILETED. CENA'S "T & U" STATED THEY WOULD GIVE THE RESIDENT SOME TIME TO HERSELF AND RE-APPROACH HER LATER. ON 2/22/13 AT APPROXIMATELY 10:00 AM CENA "U" WAS ASKED WHAT WAS DONE WHEN THE RESIDENT BECAME COMBATIVE WITH TRANSFER ATTEMPTS. CENA "U" STATED SHE WOULD LEAVE THE RESIDENT ALONE AND RE-APPROACH HER LATER. WHEN ASKED HOW SHE TRANSFERS THE RESIDENT WITH THE SIT TO STAND, CENA "U" REVEALED THE RESIDENT WAS NOT WITH A SIT TO STAND BUT A 1-2 PERSON TRANSFER WITH A GAIT-BELT. ON 2/22/13 AT APPROXIMATELY 10:05 AM CENA "T" WAS ASKED IN PRIVATE WHAT WAS DONE WHEN THE RESIDENT BECAME COMBATIVE WITH TRANSFER ATTEMPTS. CENA "T" STATED SHE WOULD RE-APPROACH AND ENCOURAGE HER. WHEN ASKED HOW SHE TRANSFERS THE RESIDENT WITH THE SIT TO STAND, CENA "T" STATED RESIDENT #14 DID NOT TRANSFER WITH A SIT TO STAND. ON 2/22/13 AT 10:18 AM LICENSED PRACTICAL NURSE (LPN) "K" WAS ASKED WHAT SHE DOES AND/OR INSTRUCTS CENA'S TO DO WHEN RESIDENT #14 BECOMES COMBATIVE WITH TRANSFERS. NURSE "K" STATED SHE WOULD GIVE THE RESIDENT A FEW MINUTES TO CALM DOWN, HAVE HER LOOK OUT THE WINDOW (WHICH SHE ENJOYS), THEN RE-APPROACH HER. TO TRANSFER OR TOILET COULD CAUSE RESIDENT TO HURT HERSELF, SOMETIMES A QUICK NAP HELPS HER CALM DOWN. SHE DID NOT CONSIDER THE RESIDENT TO BE COGNITIVE BUT AT TIMES KNEW WHEN SHE HAD TO TOILET. ON 2/22/13 AT 10:22 AM REGISTERED NURSE "X" WHO COMPLETED THE UNUSUAL OCCURRENCE WAS INTERVIEWED. NURSE "X" STATED THE FOLLOWING WHEN ASKED TO RECALL THE FALL ON 9/18/12 AND REVEALED THE FOLLOWING: BOTH OF THE CENA'S STILL WORK HERE AT THE FACILITY. THEY WERE TRANSFERRING HER TO BED. THEY SAID SHE SOMEHOW GOT HER ARMS OUT AND SLID OUT. SHE CAN BE REALLY COMBATIVE. I WAS ORIENTING WITH ANOTHER NURSE, AND WE DID VITAL SIGNS, ASSESSMENT AND NEUROLOGICAL CHECKS. IT WAS HARD TO TELL WHEN THE RESIDENT WAS PAINFUL BECAUSE SHE COULD NOT REALLY ANSWER QUESTIONS. THE PUNCTURE LOOKED LIKE A PENCIL PUNCTURE, THEY STATED IT CAME FROM THE W/C. THERE WAS A SMALL AMOUNT OF BLEEDING AND NO REAL CHANGE IN HER LEVEL OF CONSCIOUSNESS. A DRESSING CHANGE WAS DONE, AND CHANGED UNTIL IT HEALED. EDUCATION WAS GIVEN TO THE CENA'S ABOUT EZ STAND USE, AND QUESTIONS WERE ASKED RELATED TO ALL STRAPS BEING DONE, ARMS IN RIGHT PLACES AND FEET ON BASE OF EZ STAND. ON 2/22/13 AT 1:42 PM NURSE MANAGER "B" WHO COMPLETED THE INVESTIGATION FOR THE OCCURRENCE ON 9/18/12 WAS INTERVIEWED. NURSE "B" REVEALED SHE HAD TALKED TO THE NURSES AND CENA'S WHO WORKED THAT DAY. CENA "Y" WROTE THE STATEMENT AND CENA "Z" SIGNED IN AGREEMENT WITH THE STATEMENT. NO OTHER INTERVIEWS WITH ADDITIONAL STAFF HAD BEEN DONE, AND NO OTHER STATEMENTS HAD BEEN TAKEN OTHER THAN CENA "X'S". NURSES INTERDISCIPLINARY PROGRESS NOTES DATED 9/18/12 THRU 9/21/12 DID NOT REFLECT ANY EDUCATION HAD BEEN GIVEN TO THE CENA'S OR NURSES WHO WERE INVOLVED IN THE OCCURRENCE OR IN THE FACILITY IN GENERAL. IN ADDITION, NEITHER THE OCCURRENCE OR INVESTIGATION REPORT REFLECTED EZ STAND USE EDUCATION HAD BEEN GIVEN TO THE CENA'S OR NURSES INVOLVED IN THE OCCURRENCE OR IN THE FACILITY IN GENERAL. CENA "S" WHO WAS WORKING ON 2/22/13 IN THE 400 HALL AT 1:44 PM WAS ASKED TO DESCRIBE HOW THE SIT TO STAND DEVICE (OBSERVED IN THE 400 HALL) SHOULD BE USED. NURSE "B" WAS USED AS A PRETEND RESIDENT FOR APPLICATION AND PLACEMENT OF DEVICE. CENA "S" THEN REVEALED THE FOLLOWING: "MAKE SURE THE DEVICE IS LOWERED, OPEN WHEELS TO MAKE SURE YOU GET AROUND THE RESIDENT. PUT FEET ON STRIP BASE TO PREVENT FALL NOT TOO FAR FORWARD, STRAPS LEGS, TAKE HARNESS AND BUCKLE AROUND WAIST AND TIGHTENED TO SECURE, NOT TOO TIGHT OR TOO LOOSE (CHECKED WITH 1-2 FINGERS FOR SPACING TO ASSURE DEVICE SECURED), PADDED HARNESS APPLIED TO UPPER TORSO UNDER BILATERAL ARMS AND SECURED, HAVE RESIDENT HOLD ON TO THE BLACK BAR HANDLE, TELL THEM TO COUNT TO 3 AND LIFT ON 3. ONE PERSON STANDS CLOSE TO THE RESIDENT TO MAKE SURE RESIDENT DOESN'T FALL. STANDING PERPENDICULAR TO THE RESIDENT FACING STRAIGHT, WITH ONE LEG POSITIONED BEHIND RESIDENT AND THE OTHER SLIGHTLY IN FRONT OF THE RESIDENT TO SUPPORT/ASSIST FROM THE FRONT/BACK ASPECT DURING THE TRANSFER UNTIL COMPLETED". WHEN ASKED IF A RESIDENT COULD SLIDE OUT AND FALL, CENA "S" DISAGREED. SHE STATED THAT THE STAFF BY THE RESIDENT IF NEEDED COULD LOWER RESIDENT TO GROUND BUT BECAUSE OF THE STRAPS AND STAFF BEHIND RESIDENT THE RESIDENT SHOULD NOT FALL. ON 2/22/13 AT 3:40 PM CENA "Y" WAS INTERVIEWED, AND ASKED TO RECALL THE OCCURRENCE WITH RESIDENT #14 DATED 9/18/12. CENA "Y" EXPLAINED CENA "Z" PUT THE RESIDENT IN THE LIFT AND WHEN SHE (RESIDENT #14) GETS IN A BAD MOOD SHE SWINGS HER ARMS AND SHE GOT LOOSE. SHE GOT OUT OF THE DEVICE AND fell . I TRIED TO GET THE THE W/C I WAS STANDING BEHIND HER, SHE WENT FAST. CENA "Y" WAS ASKED WHY THE RESIDENT WASN'T LOWERED TO THE FLOOR. CENA "Y" REPLIED, "THE MIDDLE STRAP WAS LOOSE AND WOULD NOT HOLD, IT COMES APART. I DON'T KNOW AT THE TIME THE BELT WAS LIKE THAT. MY FIRST INSTINCT WAS TO GRAB THE CHAIR." CENA "Y" WAS ASKED IF SHE RECEIVED ANY EDUCATION RELATED TO E-Z STAND USE AFTER THE OCCURRENCE TO DATE. CENA "Y" REPLIED, "I DID NOT RECEIVE ANY EDUCATION FROM NURSE'S WHO WERE WORKING OR FROM IN-SERVICE." CENA "Y" NEVER STATED SHE TRIED TO USE ANY INTERVENTIONS TO CALM THE RESIDENT DOWN. BASED ON HER STATEMENT, SHE DID NOT REMAIN POSITIONED BY THE RESIDENT DURING THE TRANSFER BUT LEFT TO TRY TO RETRIEVE A WHEELCHAIR, LEAVING THE RESIDENT UNASSISTED. THE FACILITY'S ADL (ACTIVITIES OF DAILY LIVING) CARE PLAN WAS INITIATED 4/4/12 AND REVIEWED ON 9/19/12 AND 12/13/12. IT STATED, CAN BE COMBATIVE WITH CARE SO RE-APPROACH AS NEEDED UNTIL CARE IS FINISHED WAS LISTED AS AN INTERVENTION. NO NEWER INTERVENTIONS WERE NOTED AFTER 9/18/12 OTHER THAN, "SOMETIMES IS A TOTAL ASSIST W/ FEEDING SOMETIME SHE FEEDS SELF 2/5/13". THE FACILITY'S FALLS CARE PLAN WAS INITIATED ON 4/4/12 AND REVIEWED ON 9/18/12, 9/19/12 AND 12/13/12. NO DOCUMENTATION EXISTED THAT REFLECTED AN E-Z STAND DEVICE WAS TO BE USED FOR TRANSFER. THE MOST RECENT REVIEW OF INDICATOR OF FALL RISK FOR RESIDENT #14 WAS DATED 3/5/12. THE FACILITY'S DEPRESSION CARE PLAN INITIATED ON 3/13/12 AND REVIEWED ON 12/12 REFLECTED "IF RESIDENT IS AGITATED ASSESS FOR HUNGER OR TOILETING NEEDS; SHE OFTEN WILL CALM DOWN WITH A SNACK SUCH AS PUDDING, ETC. SHE ALSO LIKES TO HAVE A BLANKET AROUND HER. THE FACILITY FAILED TO EDUCATE STAFF ON PROPER PLACEMENT OF STAFF WHILE USING THE EZ STAND DEVICE, FAILED TO EDUCATE STAFF OF PROPER USE OF THE EZ STAND DEVICE AND FAILED TO IMPLEMENT INTERVENTIONS DURING PERIODS OF AGITATION FOR RESIDENT #14. ( ) ON 2/22/13 AT APPROXIMATELY 11:40 AM, STAFF DEVELOPMENT NURSE "L", STATED THAT ALL NURSES AND NURSE ASSISTANTS WERE CHECKED OFF FOR TRANSFER COMPETENCY, INCLUDING TRANSFERS USING THE EZ LIFT (TOTAL LIFT) AND EZ SIT TO STAND MECHANICAL LIFT DEVICES IN JULY 2012, OVER 6 MONTHS AGO. STAFF "L" ALSO STATED IN THE SAME INTERVIEW, THAT STAFF ARE RE-INSERVICED ON TRANSFER LIFT DEVICES AS NEEDED FOLLOWING AN INCIDENT INVOLVING A RESIDENT TRANSFER. ( ) RESIDENT #11 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH DIAGNOSES, PER HOSPITAL PHYSICIAN'S HISTORY AND PHYSICAL DATED 02/11/2013, THAT INCLUDED: PELVIC FRACTURES SECONDARY TO FALL AT HOME, CHRONIC [DIAGNOSES REDACTED](ABNORMAL HEARTBEAT), LOW THYROID FUNCTION, HIGH BLOOD PRESSURE, MILD DEMENTIA, TRANSIENT ISCHEMIC ATTACK (MINI-STROKES), CONGESTIVE HEART FAILURE, HISTORY RHEUMATOID ARTHRITIS, AND GASTRIC REFLUX DISEASE. ON 02/21/2013 AT 9:30 AM A PERSONAL ALARM WAS HEARD SOUNDING FROM RESIDENT #11'S ROOM. RESIDENT #11 WAS OBSERVED ON THE FLOOR BETWEEN HER BED AND WINDOW, LYING ON HER RIGHT SIDE. STAFF LICENSED PRACTICAL NURSE (LPN) "F", MDS COORDINATOR REGISTERED NURSE (RN) "W", AND 3 CERTIFIED NURSING ASSISTANTS (CNA) RESPONDED TO THE ALARM. WHEN STAFF LPN "F" ASKED IF RESIDENT #11 HAD ANY PAIN, RESIDENT #11 STATED SHE HAD PAIN IN HER LEFT HIP. STAFF LPN "F" AND MDS COORDINATOR RN "W" ASSESSED RESIDENT #11. AT 9:35 AM STAFF LPN "F" AND MDS COORDINATOR RN "W" PLACED A GAIT BELT AROUND RESIDENT #11'S TORSO AND PROCEEDED TO ASSIST HER TO A SITTING POSITION ON THE FLOOR. THEN STAFF LPN "F" AND MDS COORDINATOR RN "W" ASSISTED RESIDENT #11 TO A STANDING POSITION AND PIVOT TRANSFERRED HER TO A SEATED POSITION ON HER BED. RESIDENT #11 AGAIN COMPLAINED OF LEFT HIP PAIN. STAFF LPN "F" CALLED THE PHYSICIAN AND RECEIVED ORDERS TO PERFORM A STAT (IMMEDIATE) XRAY ON RESIDENT #11'S CERVICAL SPINE AND LEFT HIP. ON 02/21/2013 AT 3:05 PM CLINICAL COORDINATOR "A" WAS INTERVIEWED. CLINICAL COORDINATOR "A" STATED THAT THE APPROPRIATE WAY TO TRANSFER A RESIDENT WITH A POTENTIAL HIP FRACTURE FROM THE FLOOR TO THE BED WOULD BE TO UTILIZE A "LIFT SHEET" WITH STAFF HOLDING THE LIFT SHEET SO THAT THE RESIDENT REMAINED AS IMMOBILE AS POSSIBLE TO REDUCE THE RISK OF COMPLICATING A POSSIBLE FRACTURE OR DISLOCATION. ON 02/21/2013 AT 3:10 PM, STAFF LPN "F" WAS INTERVIEWED. STAFF LPN "F" STATED THAT SHE HAD PALPATED (FELT WITH HER HANDS) RESIDENT #11'S HIP AND DID NOT FEEL ANY FRACTURES. STAFF LPN "F" STATED THAT ALL FRACTURES COULD BE PALPATED SO SHE FELT CONFIDENT THAT RESIDENT #11 WAS "OK" TO STAND AND PIVOT TRANSFER. ON 02/21/2013 AT 3:15 PM, THE DIRECTOR OF NURSING WAS INTERVIEWED. THE DIRECTOR OF NURSING STATED "THEY (THE NURSING STAFF THAT RESPONDED TO RESIDENT #11'S FALL) SHOULD HAVE USED A LIFT SHEET." REVIEW OF THE FACILITY'S "FRACTURE/DISLOCATION: EMERGENCY PROCEDURE" POLICY DATED 7/1/2008, #8 "DO NOT MOVE THE PERSON IF BACK OR NECK INJURY IS SUSPECTED.", "...MOVE AS ONE UNIT (LOG ROLL) KEEPING AREA IMMOBILIZED..." ( )

This citation pertains to MI 674 and MI 021. Based on observation, interview, and record review, the facility failed to consistently implement resident care plans in 2 of 3 sampled residents (Resident #102 and Resident #101), in a total sample of 3 residents, resulting in: 1.) Resident #102 sustaining a fractured leg after facility staff did not follow the Falls Care Plan regarding transfers, Resident #102 also sustained a 6 centimeter left leg ulcer when an immobilizer was left on and unchecked for 30 days, and 2.) Resident #101 having left rib pain after facility staff did not follow a care plan for bed mobility. Findings include: Review of American Nurses Association, Standards of Professional Nursing Practice 2010 Edition, revealed that standard practice of care includes collaborating with healthcare providers from diverse backgrounds to implement and integrate the plan of care once developed. Resident #102 - improper transfer Review of the Face Sheet dated 11/13/2011, revealed that Resident #102 was an [AGE] year old female with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE], revealed Resident #102 had no cognitive impairments and required extensive assistance with Activities of Daily Living (ADL's). Review of the Fall Care Plan dated 12/27/12 and reviewed 5/15/12, revealed Resident #102 required an EZ Stand with all transfers with 2 person assist. Review of Physical Therapy Plan of Care dated 5/30/12, revealed Resident #102's transfer status was "E/Z stand with 2 person assist to ensure safety". Review of OT (Occupational Therapy) Therapist Progress note dated 9/18/2012, revealed Resident #102 "prefers use of EZ stand with 2 CENA's (Certified Nursing Assistants)". Review of Facility's Unusual Occurrence report dated 12/19/2012, revealed on 12/19/2012 at 10:15 a.m. Resident #102 twisted left leg while transferring with the use of EZ Stand resulting in Resident #102 fracturing her left lower leg in three places. Resident #102 was sent to the Hospital and returned wearing an immobilizing brace on her left leg. Review of ER (emergency room ) Triage/assessment dated [DATE], revealed Resident #102's skin was "intact" (no sores noted). In an interview on 2/8/2013 at 12:32 p.m., CNA #8 reported Resident #102 was sitting in a wheelchair and was going to lift Resident #102 up and adjust her pants and sit her back down. CNA #8 reported normally she would have assistance when using the EZ stand, but CNA #8 did not use a second person to stand Resident #102 this time. CNA #8 reported that Resident #102 was wearing a shoe on her right foot, and a non-slip sock on her left foot. CNA #8 reported as Resident #102 was being lifted with the EZ Stand, she noticed the resident was "going down" and reached and grabbed her by the pants, then pulled her back into the wheelchair. CNA #8 reported that while using the EZ Stand with Resident #102, the leg straps were never used, as resident complained the straps hurt her legs. CNA #8 reported after the incident she was counseled on proper use of the EZ Stand, and was suspended pending investigation. In an interview on 2/8/2013 at 1:30 p.m., Inservice Director, RN #10, reported that all staff are trained to use 2 people whenever they use the EZ Stand, and that the leg straps are to be used at all times. RN #10 reported if a resident refused to use the leg straps, the CNAs are to report this to the Clinical Care Coordinator or directly to Physical Therapy so the resident can be re-evaluated for proper transfers. Review of Violation Warning dated 12/21/2012, revealed CNA #8 received a written warning for failing to follow Resident #102's care guide and care plans, "(Resident #102) is to have 2 assist when the EZ stand is being used". Resident #102 - skin assessment Review of the Nursing Notes between 12/3/12-12/30/12 revealed no documentation regarding Resident #102's skin integrity to the left leg. Per physician order [REDACTED].K. for nurse to remove to inspect skin daily". Review of the Altered Comfort/Pain Care Plan dated 12/27/11 and updated 12/19/12, revealed Resident #102's Left Lower Leg Immobilizer was to be in place at all times and was to be removed by nurse every day to check the skin. Review of Resident #102's Treatment Record revealed that between 12/20/12 and 1/23/13, the brace on Resident #102's left leg was not removed and the skin checked. In an interview on 2/8/13 at 4:30 p.m. Nurse Manager, Registered Nurse (RN) #3, stated, according the the treatment record the brace was not removed and skin checked until 1/23/13, "unfortunately". On 2/8/13 at 10:30 a.m., in the presence of Nurse Manager, RN #4, surveyors # and observed a stage II pressure ulcer to Resident #102's left medial lower leg and Stage 1 pressure ulcers on Resident #102's knee. RN #4 stated the sores on the leg were caused by the brace itself. In an interview on 2/8/13 at 12:12 p.m., Physician's Assistant (PA) #7 stated, "from day one, knew it was going to be a challenge to prevent sores". Review of Wound Assessment Details Report dated 1/2/2013, revealed a Stage II pressure ulcer was identified on Resident #102's coccyx and a Stage I pressure ulcer was identified on Resident #102's left knee and lower left leg. (# and # ) Resident #101 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #101 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed that Resident #101's ability to make daily decisions was cognitively intact and she required the extensive physical assistance of two staff members for transfers, bathing, and toileting. Review of the Care Review/Conference Summary dated 11/27/12 revealed, that Resident #101 "would like transfer with 2 CNA's (Certified Nursing Assistants) to help her feel more confident with transfers. All transfers". Review of the Activity of Daily Living (ADL) Care Plan initiated 11/18/12, revealed Resident #101 was a 2 person assist with bed mobility. Review of the Resident Care Guide (no date), revealed Resident #101 required the assistance of 2 staff members to reposition in bed. In an interview on 2/7/13 at 2:50 PM, Registered Nurse (RN) #14 reported that Resident #101 was a 2 person assist for bed mobility and on 12/4/12 she had obtained an order for [REDACTED]. In an interview on 2/8/13 at 11:30 AM, Certified Nurse Assistant (CNA) #13 reported that Resident #101 was transferring back to bed and wanted pulled up in bed. CNA #13 reported that she stood at the side of the bed, raised the foot of the bed, lowered the head of the bed, held one side of the incontinent pad and reached across Resident #101 to grab the other side of the pad and slide Resident #101 up in bed. CNA #13 reported this was how she had always repositioned Resident #101 in bed. CNA #13 reported that Resident #101 stated "OW" CNA #13 reported she asked if she was all right and Resident #101 stated she had broke her ribs before and was rubbing her left side, but then said she was OK. CNA #13 reported that she did not report the incident to the nurse because Resident #101 stated she was OK. In an interview on 2/11/13 at 10:55 AM, CNA #15 reported that CNA #13 was repositioning Resident #101 in bed and she heard her say "OW you hurt my rib". CNA #15 reported that she asked Resident #101 is she was OK, Resident #101 said she was fine. CNA #15 reported that she did not inform nursing staff about the incident. (# and # )

This citation pertains to intake numbers MI 6749 and MI 021. Based on observation, interview, and record review, the facility failed to implement proper transfer interventions in 1 of 3 sampled residents (Resident #102), in a total sample of 3 residents, resulting in Resident #102 sustaining fractures to her Left Tibia, Fibular Head and Proximal Fibula (breaking 2 different bones in left lower leg), when Resident #102 was not transferred per the care plan by facility staff. Findings include: Resident #102 Review of the Face Sheet dated 11/13/2011, revealed that Resident #102 was an [AGE] year old female with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE], revealed Resident #102 had no cognitive impairments and required extensive assistance with Activities of Daily Living (ADL's). Review of the Fall Care Plan dated 12/27/12 and reviewed 5/15/12, revealed Resident #102 required an EZ Stand (a device to transfer weight bearing patients to and from a chair, wheelchair, toilet, or bed) with all transfers with 2 person assist. Review of Physical Therapy Plan of Care dated 5/30/12, revealed Resident #102's transfer status was "E/Z Stand with 2 person assist to ensure safety". Review of OT (Occupational Therapy) Therapist Progress note dated 9/18/2012, revealed Resident #102 "prefers use of EZ Stand with 2 CENA's (Certified Nursing Assistants)". Review of Facility's Unusual Occurrence report dated 12/19/2012, revealed on 12/19/2012 at 10:15 a.m. Resident #102 twisted left leg while transferring with the use of EZ Stand resulting in Resident #102 fracturing her left lower leg in three places. Resident #102 was sent to the Hospital and returned wearing an immobilizing brace on her left leg. Review of Facility's Investigation Report - 5 Working Days dated 12/26/2012, revealed on 12/19/12 at 10:15 a.m., "(CNA #8) was standing Resident (#102) with EZ stand...Resident (#102) verbalized to the aide during the transfer she felt her left knee buckle and (Resident #102) began to slide down...(CNA#8) was able to pull (Resident #102) back and into her wheelchair...(Resident #102) complained of left ankle and lower leg pain...(Physician's Assistant (PA) #7) was consulted...and decided to transfer (Resident #102) to the ER (emergency room )." Review of Radiology Report dated 12/19/2012, revealed Resident #102 sustained fractures of the fibular head and proximal third of the fibula as well as the proximal tibia. On 2/8/13 at 11:48 a.m. Resident #102 was observed resting in bed with her left leg in an immobilizing brace. Resident #102 reported on the day she broke her leg, that she felt weak. Resident #102 reported she was wearing a non-slip "booty" on her left foot, but could not recall what she was wearing on her right foot. Resident #102 reported when CNA #8 began to raise her with the EZ Stand her foot slipped in her booty, causing her knee to buckle and began to slide down in the EZ Stand. In an interview on 2/8/2013 at 12:32 p.m., CNA #8 reported Resident #102 was sitting in a wheelchair and was going to lift Resident #102 up and adjust her pants and sit her back down. CNA #8 reported normally she would have assistance when using the EZ stand, but CNA #8 did not use a second person to stand Resident #102 this time. CNA #8 reported that Resident #102 was wearing a shoe on her right foot, and a non-slip sock on her left foot. CNA #8 reported as Resident #102 was being lifted with the EZ Stand, she noticed the resident was "going down" and reached and grabbed her by the pants, then pulled her back into the wheelchair. CNA #8 reported that while using the EZ Stand with Resident #102, the leg straps were never used, as resident complained the straps hurt her legs. CNA #8 reported after the incident she was counseled on proper use of the EZ Stand, and was suspended pending investigation. In an interview on 2/8/2013 at 1:30 p.m., In-service Director, Registered Nurse (RN) #10, reported that all staff are trained to use 2 people whenever they use the EZ Stand, and that the leg straps are to be used at all times. RN #10 reported if a resident refused to use the leg straps, the CNA's are to report this to the Clinical Care Coordinator or directly to Physical Therapy so the resident can be re-evaluated for proper transfers. Review of Violation Warning dated 12/21/2012, revealed CNA #8 received a written warning for failing to follow Resident #102's care guide and care plans, "(Resident #102) is to have 2 assist when the EZ Stand is being used". (# and # ) Resident #101 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #101 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed that Resident #101's ability to make daily decisions was cognitively intact and she required extensive physical assistance of two staff members for transfers, bathing, and toileting. Review of the Care Review/Conference Summary dated 11/27/12 revealed, that Resident #101 "would like transfer with 2 CNA's (Certified Nursing Assistants) to help her fell more confident with transfers. All transfers". Review of the Physician Phone Order dated 12/4/12, revealed Resident #101 had an order to x-ray the left rib cage due to increased discomfort. Review of the Activity of Daily Living (ADL) Care Plan initiated 11/18/12, revealed Resident #101 was a 2 person assist with bed mobility. Review of the Resident Care Guide (no date), revealed Resident #101 required the assistance of 2 staff members to reposition in bed. Review of the Resident Assistance Form dated 12/3/12 (no time), revealed Resident #101 filed a complained that a CNA lifted her in bed by herself and hurt her ribs. Review of the Resident Assistance Form Facility Follow-Up dated 12/4/12, revealed that on 12/3/12 CNA #13 stated she assisted Resident #101 with bed mobility (pulling her up in bed) by herself when the care guide indicates to utilize 2 person assistance with bed mobility. The Resident Assistance Form Facility Follow-Up revealed that as a result of the failure to to provide care as instructed on the care guide Resident #101 complained of left side pain requiring further intervention of an x-ray. Review of the Social Worker Progress Notes dated 12/4/12, revealed a visit with Resident #101 where she stated she was a little sore and did not understand why the CNA repositioned her by herself. In an interview on 2/7/13 at 2:50 PM, Registered Nurse (RN) #14 reported that Resident #101 was a 2 person assist for bed mobility and on 12/4/12 she had obtained an order for [REDACTED]. In an interview on 2/8/13 at 11:30 AM, CNA #13 reported that Resident #101 was transferring back to bed and wanted pulled up in bed. CNA #13 reported that she stood at the side of the bed, raised the foot of the bed, lowered the head of the bed, held one side of the incontinent pad and reached across Resident #101 to grab the other side of the pad and slide Resident #101 up in bed. CNA #13 reported this was how she had always repositioned Resident #101 in bed. CNA #13 reported that Resident #101 stated "OW" CNA #13 reported she asked if she was all right and Resident #101 stated she had broke her ribs before and was rubbing her left side, but then said she was OK. CNA #13 reported that she did not report the incident to the nurse because Resident #101 stated she was OK. In an interview on 2/11/13 at 10:55 AM, CNA #15 reported that CNA #13 was repositioning Resident #101 in bed and she heard her say "OW, you hurt my rib". CNA #15 reported that she asked Resident #101 is she was OK, Resident #101 said she was fine. CNA #15 reported that she did not inform nursing staff about the incident. (# and # )

This citation pertains to MI 375 and MI 117. Based on observation, interview, and record review the facility failed to provide adequate supervision and failed to assure proper use of assistive devices to prevent accidents in 2 of 3 ampled Residents (Resident #101 and Resident #103) sampled for needed assistance for bathing and transfers, from a total of 3 Sampled Residents, resulting in a fractured finger for Resident #101 and a laceration requiring sutures for Resident #103. Findings include: Resident #101 On 6/20/12 an unannounced onsite investigation was conducted. Resident #101 no longer resided at the facility. Per the MDS/Minimum Data Set, dated dated [DATE], Resident #101 was admitted to the facility on [DATE], had no cognitive deficits, had minimal difficulty hearing, needed the assistance of 2 staff members for transfers, weighed 234 pounds, and had [DIAGNOSES REDACTED]. Per the "Facility Investigation Report - 5 Working Days", dated 4/16/12, regarding Resident #101, "...On 4/10/12 during a transfer from bed to w/c (wheelchair), obtained a fracture to the third digit of her right hand...(Resident #101) reported that just before breakfast on 4/10/12, she was transferring from her bed to w/c while holding the grab bar with both hands. She states she stood up and swung her butt around with the assist of one CNA (nurse aide) while the other CNA was holding her w/c. She felt her fingers twist during the transfer. Her words were, 'My fingers got all twisted up on the bar when I swung my butt around to the w/c'. She states that once she was in her w/c, the CNA's left the room and she looked at her finger, which looked crooked. (Resident #101) she states she pulled her finger and felt a pop. (Resident #101) didn't feel any pain in her hand or finger and went on to breakfast...When questioned as to why she used the grab bar for the transfer, she stated, 'I feel like I'm helping if I can swing myself over to the w/c. It let's me keep some control in my care. I try to help myself as much as I can'...An x-ray confirmed a fracture to the third digit of the right hand..." In an interview, on 6/20/12 at 9:05 AM, nurse aide #3 stated she was assigned to Resident #101 on 4/10/12, and had transferred her several times that morning with nurse aide #4. Nurse aide #3 said that to transfer from her bed to her wheelchair, Resident #101 would roll to her left side, put her right hand on the grab bar, sit/pull herself up on her own, then switch her hands so that her right hand was on her walker and her left hand was on the grab bar. Nurse aide #3 stated that in the future she would, "Try to be more aware of where residents' fingers are". On 6/20/12 at 11:30 AM, this Surveyor discovered Resident #101 was at an adult care center attending activities, and attempted to contact her there. This Surveyor was informed, that Resident #101 told receptionist #15 that she was unable to converse over the phone because of difficulty hearing, but would speak to the adult care center's SW/Social Worker #16. Social Worker #16 reiterated Resident #101's comments to this Surveyor. SW #16 stated that Resident #101 told her she couldn't remember their names, but that '2 nurse aides (at the facility) broke her finger'. Per a written statement submitted by SW #16, dated 6/20/12, "Statement taken from (Resident #101). (Resident #101) stated she was in bed when two aides came in to get her up and put her into her wheelchair. They had her sit up on the side of the bed. The "bar" on the side of the bed was up and it had lots of wires wrapped around it to operate the bed. The aides told her to take hold of the bar, which she states she did with her right hand. (Resident #101) says the aids were talking to each other when they went to move her. The aides moved (Resident #101) from the bed and "just flopped" her into the wheelchair. She said that when they turned her, her fingers got caught in the wires wrapped around the bar. The aides kept turning her, and "flopped" her into the wheelchair. They moved her so quickly that she could not tell them to stop...(Resident #101) also stated that the staff "dropped" her a couple of times. She reports being under the bed one time. The staff went to get her up out of bed, when they moved her the bed moved away from her because it wouldn't lock. She states she hit her right shoulder on the bed and reports that it still hurts..." Per a facility "Unusual Occurrence" report, "4/08/12 at 7:00 PM. (Resident #101) sitting on the floor with CENA (nurse aide) at her side...(Nurse aide) educated to always have bed in locked position and follow the care guide (two person transfer)". In an interview, on 6/20/12 at 1:36 PM, nurse aide #21 revealed she did not have assistance when she attempted to transfer Resident #101 on 4/08/12 at 7:00 PM, and stated, "I don't think the situation when I lowered (Resident #101) to the floor broke her finger. The nurse didn't check her out. No one else was there when it happened". Resident #103 Per the MDS/Minimum Data Set and CAAs/Care Area Assessments, dated 6/05/12, Resident #103 was admitted to the facility on [DATE], had severe cognitive impairment, and had [DIAGNOSES REDACTED]. Per Resident #103's Fall Care Plan, dated 9/27/11, "I am at risk for falls r/t (related to) dx (diagnosis) of depression, dementia, anemia, poor safety awareness, limited mobility, impaired cognition, unsteady gait with transitions, incontinence, and medication use of an antidepressant and antipsychotic...Anticipate and meet all of my needs..." Per a Therapy "Plan of Care", dated 5/16/12, "Resident #103" was referred to skilled OT (Occupational Therapy) services for w/c (wheelchair) positioning". Per a Therapy "Plan of Care", dated 5/24/12, "Nursing staff reports (Resident #103) is frequently leaning laterally (to the side) in w/c..." On 6/20/12 at 9:52 AM, this Surveyor observed bolsters on Resident 101's bed and fall mats on both sides of Resident #103's bed; at 9:57, Resident #103 was observed sitting in a wheelchair with a pressure alarm under her, in the TV room. When this Surveyor spoke to her, Resident #103's responses were garbled and nonsensical. Per "Interdisciplinary Progress Notes", dated 5/09/12 (not timed), "...rushed into shower room and observed (Resident #103) on the floor in shower room lying on her left side. (Resident #103) obtain(ed) a 5 cm laceration to left forehead, 1 x 1 cm skin tear to R (right) knee and bruising to left knuckles..." Per the "Facility Investigation Report - 5 Working Days", dated 5/10/12, regarding the Resident #103, "On 5/09/12 at approximately 3:40 PM, (Resident #103) was receiving a shower and fell out of the chair...sent to ER (emergency room ) had laceration to left side forehead 4 cm; received approximately 10 sutures." In an interview, on 6/20/11 at 9:57 AM, Clinical Care Coordinator #9 stated, "(Resident #103) had a long history of combative behavior". In an interview, on 6/20/12 at 10:38 AM, when this Surveyor asked nurse aide #5 how Resident #103 fell in the shower room on 5/09/12, nurse aide #5 stated, "There was another nurse aide in the room but she was not assisting me". Nurse aide #5 stated she was not standing directly in front of Resident #103, and she leaned further away from Resident #103 to reach into a cabinet for lotion; when she turned back around, she saw Resident #103 falling head first from the shower chair. When this Surveyor asked if Resident #103 had a long history of being combative, nurse aide #5 stated, "True...I didn't know (Resident #103) was supposed to be a 2 person for her shower. I don't remember it being on the Care Guide...Even if you approach (Resident #103) in the right way, she can be combative. I knew she had a personal alarm; that would be a fall risk. From here on out, it will be 2-person for my safety with combative people, fall risk people, and people who lean forward in their chairs". In an interview, on 6/20/12 at 11:00 AM, nurse aide #6 told this Surveyor she always made sure there was always another staff member with her when she gave showers to people who are known to be combative. Nurse aide #6 stated, "It wasn't specified in (Resident #103's) Care Guide prior to (Resident #103's) fall". Nurse aide #6 stated she was in the shower room on 5/09/12, standing on the other side of the room with another resident, when she observed Resident #103 fall from the shower chair. Nurse aide #6 said, "(Resident #103's) feet weren't touching the floor when she was sitting in the shower chair. Her legs are too contracted. (Nurse aide #5) had to lean away to get to the lotion in the cabinet...You should always make sure you're directly in front of the resident in the shower room because it only takes a spit second for someone to end up on the floor." ( )

This Citation pertains to intake number MI 350 Based on observation, interview and record review the facility failed to prevent a significant medication error in 1 of 4 sampled residents (Resident #102) from a total of 6 sampled residents, resulting an Immediate Jeopardy when Resident #102 received medications prescribed for another resident, became unresponsive to painful stimuli, and required emergent transfer to the hospital. This deficient practice places all residents, who reside in the facility and receive medications, at risk for serious harm, injury and/or death. Findings include: Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], revealed Resident #102 was a [AGE] year old female admitted to the facility 8/29/11. The MDS revealed Resident #102's mental status was moderately impaired, she had a disorganized thought process, and required the extensive physical assistance of one person to eat. The MDS revealed Resident #102's [DIAGNOSES REDACTED]. Review of the Nutritional Care Plan, dated 9/22/11, revealed Resident #102 had a recent stroke and removal of a [MEDICAL CONDITION] (artificial airway), and that staff would assist/cue as needed with her meals. Review of the Medication Discrepancy Report Dated, 11/4/11 (no time), revealed Licensed Practical Nurse (LPN) #4 administered medications to Resident #102 that were prescribed for Resident #106, while Resident #102 was in the small dining room on the 300 hall. LPN #4 documented that on 11/4/11 at 8:00 a.m. Resident #102 was given Klonopin 0.5 mg (is used to treat [MEDICAL CONDITION] and panic disorders), [MEDICATION NAME] 3 mg (antipsychotic used to treat severe [MEDICAL CONDITION]), [MEDICATION NAME] Insulin (long acting insulin) 6 Units, [MEDICATION NAME] 100 mg (antipsychotic used to treat severe [MEDICAL CONDITION] symptoms), and [MEDICATION NAME] 1 mg ([MEDICATION NAME] which reduces the effects of certain chemicals in the body that may become unbalanced as a result of disease such as [MEDICAL CONDITION]). The type of discrepancy was documented as "other: wrong patient" (resident misidentified). LPN #4's documentation of the incident was "another patients meds were given to this patient (Resident #102)...It was realized at 8:30 a.m. that meds had been given - none of patients (Resident #102's) own meds were given to her". LPN #4 documented the outcome to Resident #102 as "increased lethargy (tiredness) sent to Emergency Department". LPN #4 documented that measures to prevent recurrence was to slow down. The in-depth analysis of how the deficiency occurred was documented as "nurse did not do the 5 rights of medication pass - picture of resident not available". Review of the Nursing Progress Notes, dated 11/4/11 8:00 a.m., by LPN #4 revealed she gave Resident #102 the wrong medications, 8:30 a.m. Physician Assistant #3 was called to notify of increased lethargy and the medication error, "8:55 a.m. called Physician Assistant #3 notified of low blood pressure 68/44, pulse 62, respiration 32, pulse oxygen 94% on room air and order obtained to send Resident #102 to the hospital., 9:05 a.m. Emergency Medical Services (EMS) and family called, 9:20 a.m. (EMS) arrived at facility, Resident #102 had emesis-was suctioned for remaining phlegm in mouth. Remains lethargic, but opening eyes. Transferred to hospital via ambulance". Review of the Medication Administration - General Guidelines Policy and Procedure, dated 10/1/09, revealed under Administration; "..Medications are administered in accordance with written orders of the attending physician...Residents are identified before medication is administered. Methods of identification include: a) Checking identification band, b) Checking photograph attached to medical record and c) If necessary, verifying resident identification with other facility personnel...Medications supplied for one resident are never administered to another resident...". The six rights of medication administration include: 1) the right medication, 2) the right dose, 3) the right client, 4) the right route, 5) the right time, 6) the right documentation. To identify a client correctly, the nurse checks the medication administration form against the client's identification bracelet. When asking the client's name, the nurse should not merely speak the name and assume that the client's response indicates that he or she is the right person. Instead, the nurse asks the client to state his or her name. (Fundamentals of Nursing, 6 th edition, 2005, pgs. 841-842.) In interviews on 1/31/12 at 12:45 and 3:45 p.m., 2/6/12 at 11:20 a.m., and 2/7/12 at 4:04 p.m., LPN #4 stated on 11/4/11 at about 8:00 a.m. (unable to recall exact time), she gave Resident #106's medications to Resident #102. LPN #4 stated that Resident #102 was in the small dining room on the 300 hall in her Lumex (type of padded reclining chair with wheels for mobility) chair for breakfast (which started at 7:45 a.m.) when she administered the wrong medications to Resident #102 . LPN #4 was unable to recall if she asked Resident #102 her name or looked for any other means of identification prior to giving Resident #102 another resident's medications. LPN #4 was unable to recall if the medications were whole or crushed when she administered them. LPN #4 stated there was no picture of Resident #102 in the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. LPN #4 stated she continued the morning medication pass to her assigned residents and later, about 8:30 a.m., was walking up the hallway, when someone asked where Resident #102's room was, and she realized she had given Resident #102 the wrong medication. In interview on 1/31/12 at 2:00 p.m. and 2/2/12 at 9:45 a.m., DON #2 stated as soon as LPN #4 informed her of the medication error she went to the dining room on the 300 hall where Resident #102 was in her Lumex chair. DON #2 stated she had to verify with a Certified Nursing Assistant (CNA) who worked with Resident #102 if it was normal for Resident #102 to sleep after breakfast. DON #2 stated that she shook Resident #102, called Resident #102 by name and that Resident #102 opened her eyes then went right back to sleep. In interviews on 1/30/12 at 3:23 p.m. and 2/1/12 at 3:40 p.m., CNA #10 stated that about 8:45 a.m., the DON asked her if Resident #102's breathing pattern was normal for her. CNA #10 stated that Resident #102 was breathing in normal easy breaths and then would gasp, which was normal for her. CNA #10 stated that CNA #8 and CNA #9 assisted with the transfer of Resident #102 from the Lumex chair to her bed with the assistance of a mechanical lift. CNA #10 stated they had just started to roll Resident #102 to clean her up and remove the Hoyer pad from under her when they rolled her on her right side and she began to vomit. CNA #10 stated CNA #8 went to inform staff that Resident #102 was vomiting. In interviews on 1/31/12 at 4:15 p.m. and 2/1/12 at 10:25 a.m., CNA #9 stated that on 11/4/11, she assisted with the transfer of Resident #102 from the Lumex chair to her bed. CNA #9 stated Resident #102 was really limp when they got her to her room and, after she was transferred to the bed and rolled, Resident #102 started to vomit. In interviews on 1/31/12 at 3:10 p.m., on 2/1/12 at 10:07 a.m. and 5:20 p.m., CNA #8 stated on 11/4/11, Resident #102 was in the dining room on the 300 hall in her Lumex chair and LPN #4 was trying to talk to Resident #102 who was snoring and hard to arouse. CNA #8 stated she was told to take Resident #102 to her room and put her to bed. CNA #8 stated, when she, CNA #9 and CNA #10 were transferring Resident #102 with the mechanical lift, she was snoring, lethargic and so limp that CNA #8 had to support her neck even with the Hoyer pad behind it. CNA #8 stated Resident #102's color was a white/pale, and that her snoring stopped when they had her lying on her back, like she was not breathing, so they hurried and put her on her right side and her breathing had a gurgling sound. Resident #102 began to vomit a small amount of beige/white with yellowish mixture that was lumpy with runny parts. CNA #8 stated she went to get help. CNA #8 stated it was a very short period of time after Resident #102 was put in her bed that EMS arrived. CNA #8 stated no one took Resident #102's vital signs once she was brought to her room until EMS came. In an interview on 2/1/12 at 10:50 a.m., EMS #14 stated Resident #102 was on her right side and vomiting when they arrived in her room. EMS #14 stated that Resident #102 was so drowsy the the vomit did not project, and Resident #102 needed to have vomit suctioned mechanically from her mouth. EMS #14 stated Resident #102 had labored breathing with a gurgling, grunting sound and she started coughing and gagging. EMS #14 stated her partner suctioned the resident's mouth again. EMS #14 stated Resident #102 appeared very close to respiratory arrest and they had to use a bag to assist Resident #102 with her breathing and that a nasopharyngeal (through the nose) airway had been placed. EMS #14 stated Resident #102 did not respond to painful stimuli. Review of the EMS Run Sheet, dated 11/4/11, revealed the EMS ambulance was called at 9:21 a.m., arrived at the facility at 9:26 a.m. and that EMS personnel found Resident #102 vomiting with suctioning of the mouth needed, diaphoretic (sweating), pale, both pupils sluggish, unresponsive to verbal and painful stimuli, with labored, rapid breathing pattern, and wet lung sounds. At 9:51 a.m. Resident #102 was transported to the hospital by ambulance. Review of the Emergency Department Physician Notes, dated 11/4/11 (no time), revealed Resident #102 arrived unresponsive, with pulse oxygen of 94% on 100% oxygen via a non rebreather mask, and she was given intravenous fluids for low blood pressure of 87/43. Emergency Department Physician Notes revealed "Assessment - [MEDICAL CONDITION], questionably secondary to the accidental medications..". Observations on 2/1/12 from 7:10 - 8:55 a.m. by this surveyor of the morning medication pass, revealed Registered Nurse (RN) #24, LPN #4, LPN #17, and LPN #30 looked at the picture identifier in the MAR prior to removing medication from the medication cart, located the resident, stated the resident's name, and administered medications to that resident. This surveyor did not observe RN #24, LPN #4, LPN #17, and LPN #30 ask any residents what their name was, prior to administering medications. Nurse Manager/Registered Nurse (RN) #26 was notified on 2/6/12 at 5:50 p.m. of the Immediate Jeopardy that began on 11/4/11 and was identified on 2/2/12 as a result of the facility's failure to prevent a significant medication error, when Resident #102 received medication prescribed for Resident #106, because LPN #4 did not follow the Standards of Care and Facility Policies for medication administration. On 2/7/12, Surveyor # verified that the Facility implemented the following to remove the Immediate Jeopardy: 1. On 2/6/12 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 2. On 2/6/12, 79 out of 79 residents have current pictures for visual identification in the MAR. 3. On 2/6/12, 9 RN's and 16 Licensed Practical Nurses (LPN)'s were in-serviced on the 6 rights of medication pass and to use not only the picture in the MAR, but to also ask residents their name to identify residents when passing medication. Prior to their next shift, all other licensed nursing staff will be in-serviced face-to-face on the 6 rights of medication pass and to use not only the picture in the MAR, but to also ask residents their name to identify residents when passing medication. 4. On 2/7/12, the procedure for picture taking was reviewed to assure all residents are clearly identified. 5. On 2/6/12 the Policy and Procedure for medication pass including the 6 rights has been reviewed and deemed appropriate. 6. On 11/4/11 LPN #4 was in-serviced by the RN Clinical Care Coordinator and a 1:1 medication pass review was completed by the RN Clinical Care Coordinator with LPN #4. 7. On 11/4/11 nurses were in-serviced on safe medication pass including the 5 rights of medication and the handout of medication administration policy, which included the 5 rights of medication and the handout of medication administration policy with the "documentation" of medication as the 6 th right. 8. Starting on 2/8/12, the Director of Nursing/Designee will do weekly random staff audits of mediation pass for one month then do quarterly random medication pass audits. 9. On 1/10/12, 6 medication pass reviews were completed by the Apothecary Nurse Consultant and 3 more were completed 2/6/12. Although the Immediate Jeopardy was removed on 2/7/12, the Facility remained out of compliance at a scope of isolated and severity of actual harm that is not Immediate Jeopardy, due to all staff having not been in-serviced and sustained compliance not being verified by the State Agency. (# )

This Citation pertains to intake number MI 350 Based on observation, interview and record review the facility failed to ensure facility staff followed the standards of practice and facility policy regarding medication administration in 1 of 4 sampled residents (Resident #102) from a total of 6 sampled residents, resulting in Resident #102 receiving another resident's medications and subsequent emergency transfer to the hospital for treatment. Findings include: Review of the Medication Administration - General Guidelines Policy and Procedure, dated 10/1/09, revealed under Administration; "..Medications are administered in accordance with written orders of the attending physician...Residents are identified before medication is administered. Methods of identification include: a). checking identification band b). Checking photograph attached to medical record c). If necessary, verifying resident identification with other facility personnel...Medications supplied for one resident are never administered to another resident...". The six rights of medication administration include: 1) the right medication, 2) the right dose, 3) the right client, 4) the right route, 5) the right time, 6) the right documentation. To identify a client correctly, the nurse checks the medication administration form against the client's identification bracelet. When asking the client's name, the nurse should not merely speak the name and assume that the client's response indicates that he or she is the right person. Instead, the nurse asks the client to state his or her name. (Fundamentals of Nursing, 6th edition, 2005, pgs. 841-842.) Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], revealed Resident #102 was a [AGE] year old female admitted to the facility 8/29/11. The MDS revealed Resident #102's mental status was moderately impaired, she had a disorganized thought process and required the extensive physical assistance of one person to eat. The MDS revealed Resident #102's [DIAGNOSES REDACTED]. Review of the Nutritional Care Plan, dated 9/22/11, revealed Resident #102 had a recent stroke and removal of a [MEDICAL CONDITION] (artificial airway) and that staff would assist/cue as needed with her meals. Review of the Medication Discrepancy Report, dated 11/4/11 (no time), revealed Licensed Practical Nurse (LPN) #4 administered medications to Resident #102 that were prescribed for Resident #106, while Resident #102 was in the small dining room on the 300 hall. LPN #4 documented that on 11/4/11 at 8:00 a.m. Resident #102 was given Klonopin 0.5 mg (used to treat [MEDICAL CONDITION] and panic disorders), [MEDICATION NAME] 3 mg (antipsychotic used to treat severe [MEDICAL CONDITION]), [MEDICATION NAME] Insulin 6 Units (long acting insulin), [MEDICATION NAME] 100 mg (antipsychotic used to treat severe [MEDICAL CONDITION] symptoms), and [MEDICATION NAME] 1 mg ([MEDICATION NAME] which reduces the effects of certain chemicals in the body that may become unbalanced as a result of disease such as [MEDICAL CONDITION]). The type of discrepancy was documented as "other: wrong patient" (resident misidentified). LPN #4's documentation of the incident was "another patients meds were given to this patient (Resident #102)...It was realized at 8:30 a.m. that meds had been given - none of patients (Resident #102's) own meds were given to her". LPN #4 documented the outcome to Resident #102 as "increased lethargy (tiredness) sent to Emergency Department". LPN #4 documented that measures to prevent recurrence was to slow down. The in-depth analysis of how the deficiency occurred was documented as "nurse did not do the 5 rights of medication pass - picture of resident not available". Review of the Physician's Admission Order Sheet, dated 11/11, revealed Resident #102 was prescribed orally; a multivitamin daily, Zinc (essential mineral) 50 mg tablet daily, Vitamin D-3 1000 IU cap daily, Vitamin E 400 IU daily, [MEDICATION NAME] (increase bone calcium) 70 mg tablet once a week, [MEDICATION NAME] (for [MEDICAL CONDITION] ulcers) 20 mg tablet daily, [MEDICATION NAME] (for depression) 25 mg tablet twice a day, [MEDICATION NAME] (blood pressure medication) 20 mg tablet twice daily, [MEDICATION NAME] (blood pressure medication) 3.123 mg tablet twice daily, [MEDICATION NAME] (cholesterol medication) 4 gram packet dissolved in 6-8 ounces of water twice a day, [MEDICATION NAME] (blood pressure medication) 100 mg tablet every 8 hours (with notation to hold if Systolic blood pressure was less than 110 or Diastolic blood pressure less than 50), 4 [MEDICATION NAME] (increases bacteria in the colon) chewable tablets three times daily, [MEDICATION NAME] XR (antidepressant) 150 mg capsule daily, [MEDICATION NAME] (cholesterol medication) 40 mg tablet daily at bedtime, [MEDICATION NAME] (blood thinner) 5 mg tablet daily, [MEDICATION NAME] (for anxiety or panic disorders) 0.25 mg every 8 hours as needed, and [MEDICATION NAME] (pain medication) 5/325 tablet every 4 hours as needed. [MEDICATION NAME] Insulin (short acting) was prescribed on a sliding scale based on blood sugar level, [MEDICATION NAME] Insulin (long acting insulin) 27 units at bedtime was prescribed to be administered subcutaneously, Atrovent Inhaler (opens airway) via nebulizer three times daily, and her blood pressure was to be taken and recorded 3 times a day. Review of the MAR, dated 11/11, indicated that Resident #102 had received her 6:00 a.m. [MEDICATION NAME] 100 mg tablet, blood pressure was recorded as 118/72, and her blood sugar at 7:30 a.m. was 125 with no insulin coverage given (for blood sugar of 101-150, 2 Units of [MEDICATION NAME] Insulin was ordered to be given). The MAR indicated [REDACTED]. Review of the Nursing Progress Notes, dated at 11/4/11 8:00 a.m., by LPN #4 revealed she gave Resident #102 the wrong medications, "8:30 a.m. Physician Assistant #3 was called to notify of increased lethargic and medication error 8:55 a.m. called Physician Assistant #3 notified of low blood pressure 68/44, pulse 62, respiration 32, pulse oxygen 94% on room air and order obtained to send Resident #102 to the hospital., 9:05 a.m. Emergency Medical Services (EMS) and family called, 9:20 a.m. (EMS) arrived at facility, Resident #102 had emesis-was suctioned for remaining phlegm in mouth. Remains lethargic, but opening eyes. Transferred to hospital via ambulance". In interviews conducted 1/31/12 at 12:45 p.m. and 3:45 p.m., 2/6/12 at 11:20 a.m., and 2/7/12 at 4:04 p.m., LPN #4 stated on 11/4/11 at about 8:00 a.m., (unable to recall exact time); she gave Resident #106's medications to Resident #102. LPN #4 stated that Resident #102 was in the small dining room on the 300 hall in her Lumex (type of padded reclining chair with wheels for mobility) chair for breakfast (which started at 7:45 a.m.) when she administered Resident #102 the wrong medications. LPN #4 did not recall if she asked Resident #102 her name or looked for any other means of identification prior to giving Resident #102 another resident's medications. LPN #4 was unable to recall if the medications were whole or crushed when she administered them. LPN #4 stated that there was no picture of Resident #102 in the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. LPN #4 stated that she continued the morning medication pass to her assigned residents and later, about 8:30 a.m., was walking up the hallway, when someone asked where Resident #102's room was, and she realized she had given Resident #102 the wrong medication. In interviews conducted on 1/31/12 at 3:10 p.m., 2/1/12 at 10:07 a.m. and 5:20 p.m., Certified Nursing Assistant (CNA) #8 stated that on 11/4/11, Resident #102 was in the dining room on the 300 hall in her Lumex chair and LPN #4 was trying to talk to Resident #102 who was snoring and hard to arouse. CNA #8 stated that she was told to take Resident #102 to her room and put her to bed, so she and CNA #9 and CNA #10 pushed the Lumex chair to Resident #102's room. CNA #8 stated that, when they were transferring Resident #102 with the mechanical lift in the Hoyer sling, she was snoring, lethargic and so limp that CNA #8 had to support her neck even with the Hoyer pad behind it. CNA #8 stated Resident #102's color was a white/pale, and that her snoring stopped when they had her lying on her back, "like she was not breathing", so they hurried and put her on her right side and her breathing had a gurgling sound. Resident #102 began to vomit a small amount of beige/white with yellowish mixture that was lumpy with runny parts. CNA #8 stated she went to get help. CNA #8 stated that no one took Resident #102's vital signs once she was brought to her room until Emergency Medical Services (EMS) came. Review of the EMS Run Sheet, dated 11/4/11, revealed the EMS ambulance was called at 9:21 a.m., arrived at the facility at 9:26 a.m., and EMS found Resident #102 vomiting with suctioning of the mouth needed, diaphoretic (sweating), pale, both pupils sluggish, unresponsive to verbal and painful stimuli, with labored, rapid breathing pattern, and wet lung sounds. At 9:51 a.m. Resident #102 was transported to the hospital. Review of the Emergency Department Physician Notes, dated 11/4/11 (no time), revealed Resident #102 arrived unresponsive, with pulse oxygen of 94% on 100% oxygen via a non rebreather mask, and she was given intravenous fluids for low blood pressure of 87/43. Emergency Department Physician Notes revealed "Assessment - [MEDICAL CONDITION], questionably secondary to the accidental medications..". Review of the Hospital Consultation Report, dated 11/05/11, revealed, Resident #102 was sent to the emergency room became unresponsive at the facility, after she had been given incorrect medications. Resident #102 is unresponsive and on a ventilator (assists or replaces breathing), Assessment; -Urosepsis. - [MEDICAL CONDITION] - History of accidental medication administration, questionable cause of above. Review of the Hospital Consultation Report, dated 11/06/11, revealed, two days ago Resident #102 was found unresponsive and brought to the hospital for evaluation, where she was noted to be hypoxic (low oxygen), admitted to the Intensive Care Unit, placed on a ventilator. The Neurologic exam documented that Resident #102 was in a coma. Observations on 2/1/12 from 7:10 a.m. - 8:55 a.m. by this surveyor of morning medication pass, revealed Registered Nurse (RN) #24, LPN #4, LPN #17 and LPN #30 looked at the picture identifier in the MAR prior to removing medication from the medication cart, located the resident, stated the residents name, and administered medications to that resident. This surveyor did not observe RN #24, LPN #4, LPN #17 and LPN #30 ask any residents what their name was, prior to administering medications. (# )

This Citation pertains to intake number MI 570 Based on observation, interview and record review the facility failed to ensure the functionality of safety devices to prevent falls for 1 of 2 sampled residents (Resident #104) and one uun-sampled resident (Resident #1) from a total of 6 sampled residents, resulting in a fall with a fracture for Resident #104 and the potential for falls with injury for Un-sampled Resident #1. Findings include: Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], revealed Resident #104 was a [AGE] year old female admitted to the facility 6/3/10. The MDS revealed Resident #104's mental status was moderately impaired, she had a history of [REDACTED]. The MDS revealed Resident #104's [DIAGNOSES REDACTED]. The MDS Care Area Assessment (CAA), dated 12/21/11, for ADL Functional Status revealed Resident #104 had "poor safety awareness...is extensive assist while walking in her room..is a fall risk..has a sensor pad to her bed". Review of the Alarm Devices Policy, dated 7/1/08, revealed the purpose of alarm devices is to alert staff to aid in the prevention and/or reduction of resident accidents and falls and to ensure the proper functioning of alarm systems and devices. Review of Nurse's Notes, dated 1/23/12 9:45 p.m., revealed Resident #104 was "Confused, forgets what she's trying to do, transfers herself to wheelchair from bed and wheelchair to bed several times. Unhooked alarm". Review of the Unusual Occurrence Repor,t dated 1/26/12 at 12:18 a.m., revealed Resident #104 fell in her room between the bed and the television on the floor with her head towards the closet (foot of bed). The Unusual Occurrence Report revealed that the alarm was in place, but not working. Review of the Diagnostic Radiology Report, dated 1/26/12, revealed Resident #104 had distal radius and ulnar fractures (wrist fracture). In an interview on 2/3/12 at 10:19 a.m., Certified Nursing Assistant (CNA) #13 stated on the day Resident #104 fell out of bed, she was at the top of the hall and heard a loud boom noise and went to Resident #104's room behind CNA #15. CNA #13 stated Resident #104 was on the floor with her head positioned at the end of the bed and her body laying next to the bed. CNA #13 stated that she did not hear a bed alarm sound. CNA #13 stated that when a resident repositions themselves, the pressure alarms go off and that, if Resident #104's alarm had been working, they might have been able to get to her room before she fell . In interviews and observations on 2/3/12 at 9:00 a.m. and 3:00 p.m., and on 2/7/12 at 10:00 a.m., Resident #104 was noted to be in bed, splint cast to right arm elevated on a pillow, dressed appropriately for the day. Resident #104 stated she did not recall how she broke her arm and that her care was "OK". An interview and observation in the hall by the surveyor on 2/7/12 at 1:20 p.m., revealed Un-sampled Resident #1 in bed, with an alarm box in place on the right side of the bed, but no light flashing to indicate functionality. Un-sampled Resident #1, who was dressed in a brief and shirt, removed his covers, and got out of the left side of the bed. CNA #28 walked between this surveyor and the doorway to Un-sampled Resident #1's room without looking in the room and continued down the hallway. This surveyor got the attention of CNA #28 and asked if Un-sampled Resident #1 was care planned to have a bed pressure and tab alarm in place. CNA #28 checked the pressure alarm box, stated that it was working yesterday and that the alarm box usually flashes when it is functioning or beeps if the battery is low. Further investigation of the pressure alarm revealed that the cord was disconnected from the sensor pad. Review of the Fall Care Plan, dated (reviewed) 10/24/11, revealed Un-sampled Resident #1 was at risk for falls due to self transfer and ambulating ad lib within the facility. Fall Care Plan interventions in place included sensor pad and tab alarms to bed. In an interview on 2/8/12 at 4:30 p.m., CNA #28 stated that Un-sampled Resident #1 should have also had a tab alarm when he was in bed, but that Un-sampled Resident #1 had taken the tab alarm off on 2/7/12.

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT THE DEVELOPMENT OF PRESSURE ULCERS FOR 2 OF 6 RESIDENTS (#5, #6) REVIEWED FOR PRESSURE ULCERS FROM A TOTAL SAMPLE OF 18 RESIDENTS, RESULTING IN A STAGE 4 LEFT BUTTOCK PRESSURE ULCER FOR 1 RESIDENT (#5) AND AN UNSTAGEABLE RIGHT LATERAL FOOT ULCER AND A STAGE 4 LEFT LOWER LEG PRESSURE ULCER FOR ANOTHER RESIDENT (#6). FINDINGS INCLUDE: RESIDENT #5 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE COMPREHENSIVE NUTRITIONAL assessment dated [DATE] HAD AN ADDITIONAL [DIAGNOSES REDACTED]. HOWEVER, THE WEEKLY PRESSURE ULCER WOUND DOCUMENTATION DATED 5/25/10 REFLECTED THE LEFT BUTTOCK WOUND WAS HEALED. THE ADMISSION SKIN assessment dated [DATE] REFLECTED, THAT THE RESIDENT HAD THREE STAGE 2 PRESSURE ULCERS: LEFT BUTTOCK, COCCYX AND RIGHT BUTTOCK. THE WEEKLY PRESSURE ULCER DOCUMENTATION DATED 5/25/10 DESCRIBED RIGHT AND LEFT BUTTOCK PRESSURE ULCERS AS BEING HEALED. THE COCCYX PRESSURE ULCER WAS DESCRIBED AS BEING HEALED ON 6/30/10. THE LEFT BUTTOCK WOUND, HOWEVER, REAPPEARED ON 8/17/10 AND WAS HEALED AGAIN ON 9/7/10. THE PRESSURE ULCER CARE PLAN UPDATED SEVERAL TIMES, WITH THE MOST RECENT REVIEW DATE AS 2/16/11, REFLECTED THAT THE RESIDENT WAS PROVIDED AN ALTERNATING PRESSURE MATTRESS ON 11/23/10 (NEARLY 6 MONTHS AFTER THE LEFT BUTTOCK WOUND KEPT REAPPEARING), A HEELS UP CUSHION IN BED, PRESSURE RELIEVING BOOTS (THE RESIDENT HAD ALSO DEVELOPED AN UNSTAGEABLE LEFT LATERAL FOOT PRESSURE ULCER ON 1/11/11) AND TREATMENT AS ORDERED. THE WEEKLY PRESSURE ULCER WOUND DOCUMENTATION DATED 11/3/10 REFLECTED THAT THE RESIDENT HAD A RECURRENT STAGE 2 LEFT BUTTOCK WOUND THAT MEASURED 1.2 CM (CENTIMETERS) X 1.2 CM. ON 11/22/10, THE WOUND MEASURED 4 CM X 3 CM, STATING THE WOUND WAS WORSE WITH [MEDICATION NAME] AND SENSICARE WAS APPLIED. ON 12/14/10, THE LEFT BUTTOCK WOUND MEASURED 2 CM X 0.8 CM X 0.1 CM AND HAD MACERATED WOUND EDGES. IT WAS STILL STAGED AS 2, ALTHOUGH IT WAS DESCRIBED AS WORSE, HAVING A DEPTH AND SEROSANGUINOUS DRAINAGE, AND THE RESIDENT WAS GIVEN PAIN MEDICATION. ON 3/17/11 AT 10:30 A.M., THE DIRECTOR OF NURSING, (STAFF "A"), WHO HAD STARTED WORKING AT THE FACILITY IN LATE DECEMBER 2010, STATED THAT THE RESIDENT'S LEFT BUTTOCK WOUND WAS ALREADY UNSTAGEABLE WHEN SHE FIRST EXAMINED IT. SHE SAID THAT THE WOUND HAD A THICK, BLACK ESCHAR (DEAD TISSUE). THE WEEKLY PRESSURE ULCER DOCUMENTATION DATED 12/23/10 REFLECTED THAT THE WOUND HAD MEASURED 2.5 CM X 3 CM, WITH A NECROTIC WOUND BED WITH SOME SLOUGH AROUND THE EDGES. IT WAS NOW STAGED AS UNSTAGEABLE. THE WEEKLY PRESSURE ULCER DOCUMENTATION DATED 1/27/11 REFLECTED THAT THE WOUND HAD INCREASED IN SIZE TO 3.5 CM X 4.4 CM X 2.0 CM WITH INCREASED SLOUGH, DECREASED HEALTHY PINK TISSUE, AND CLEAR YELLOW DRAINAGE AND ODOR. THE NURSING NOTE DATED 2/10/11 REFLECTED, " ...DRESSING CHANGE DONE...4 CM X 4 CM X 2 CM DEEP WOUND LOCATED LEFT SACRUM (REFERS TO LEFT BUTTOCK WOUND)...PUNGENT FOUL ODOR, PURULENT SLOUGH, LIGHT EXUDATE DRAINAGE ON OLD DRESSING... " THE WEEKLY PRESSURE ULCER WOUND DOCUMENTATION DATED 2/22/11 REFLECTED THE WOUND NOW DEVELOPED A TUNNELING (A PASSAGEWAY OF TISSUE DESTRUCTION UNDER THE SKIN SURFACE THAT HAS AN OPENING AT THE SKIN LEVEL) FROM THE EDGE OF THE WOUND. THE NURSING NOTE DATED 2/24/11 REFLECTED, " ...CHANGED WOUND DRESSING ON LEFT BUTTOCK...REMOVED PACKING WITH SEROSANGUINOUS DISCHARGE...SCANT AMOUNT OF PURULENT DISCHARGE, SLIGHT FOUL ODOR, STAGE 4 ULCER (FULL THICKNESS SKIN LOSS WITH EXTENSIVE DESTRUCTION, TISSUE NECROSIS, OR DAMAGE TO MUSCLE, BONE, OR SUPPORTING STRUCTURES), IRREGULAR BORDER 3 CM CIRCLE...RESIDENT GRIMACES SLIGHTLY... " THE WEEKLY PRESSURE ULCER DOCUMENTATION DATED 3/2/11 REFLECTED THE LEFT BUTTOCK WOUND MEASURED 2.5 CM X 3 CM X 1 CM WITH 2 CM OF TUNNELING. THE WOUND WAS DESCRIBED AS IMPROVING EVEN THOUGH THE TUNNELING WAS STILL COVERED WITH SLOUGH AND HAD INCREASED IN LENGTH. ON 3/17/11 AT 9:30 A.M., THE DRESSING CHANGE TO THE RESIDENT'S LEFT BUTTOCK WAS OBSERVED IN HER ROOM. THE WOUND LOOKED LIKE A ROUND DEEP CRATER WITH WHITE GRAYISH SLOUGH AROUND THE EDGES. IT MEASURED 3 CM X 2 CM X 2 CM. THERE WAS A MODERATE AMOUNT OF DARK BROWNISH DRAINAGE PRESENT ON OLD DRESSING BUT IT HAD NO ODOR. ON 3/15/11 AT 11:45 A.M., THE RESIDENT WAS OBSERVED LYING ON HER BACK. ON 3/16/11 AT 9:30 A.M., THE RESIDENT WAS OBSERVED LYING ON HER RIGHT SIDE. AT 11:00 A.M., SHE WAS LYING ON HER RIGHT SIDE. AT 12:30 P.M., THE RESIDENT WAS STILL LYING ON HER RIGHT SIDE AT 2:00 P.M., SHE WAS ON HER BACK AND CONTINUED LYING ON HER BACK AT 4:00 P.M. ON 3/17/11 AT 8:30 A.M., THE RESIDENT WAS AGAIN OBSERVED LYING ON HER RIGHT SIDE WHILE BEING FED BY A NURSING AIDE. ON 3/17/11 AT 10:30 A.M., THE DIRECTOR OF NURSING "A" STATED THAT THE RESIDENT WAS TO BE TURNED ONLY TO RIGHT SIDE AND ON HER BACK TO PROMOTE HEALING OF THE LEFT BUTTOCK WOUND. SHE ADDED THAT THE RESIDENT HAD [MEDICAL CONDITION] WITH LOW PROTEIN LEVELS. THE RESIDENT'S PROTEIN LEVEL WAS 4.8 G/DL ( EXPECTED RANGE: 6-8) AND [MEDICATION NAME] LEVEL WAS 2.5 G/DL (EXPECTED RANGE:3.5-5.0) ON 11/26/10. THE REPEATED PROTEIN LEVEL WAS 5.3 G/DL AND HER [MEDICATION NAME] LEVEL WAS 2.7 G/DL ON 1/20/11. THERE WAS NO PREVIOUS MONITORING OF PROTEIN AND [MEDICATION NAME] LEVELS OR EARLY, ACTIVE IMPLEMENTATION OF PROTEIN SUPPLEMENTS FOR WOUND HEALING. ACCORDING TO THE NUTRITION SERVICES PROGRESS NOTE DATED 2/22/11 THE RESIDENT HAD A 9.2 % WEIGHT LOSS IN 90 DAYS. ( ) RESIDENT #6 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE], ACCORDING TO THE FACILITY'S ENTRY SHEET. THE MOST RECENT physician's orders [REDACTED]. RESIDENT #6 WAS OBSERVED ON 3/15/11 AT 11:58 A.M. IN HER BED, WITH THE HEAD OF THE BED ELEVATED APPROXIMATELY 40 DEGREES, TUBE FEEDING INFUSING AT A RATE OF 65 MILLILITERS AN HOUR, AND WAS RECEIVING OXYGEN AT 3 LITERS BY NASAL CANNULA. HER LEGS WERE ELEVATED ON A RISER, AND SHE WAS MAKING MOANING/GROANING SOUNDS. THE FACILITY'S ACTIVITIES OF DAILY LIVING (ADL'S) CARE PLAN REVISED ON 10/11/10 REFLECTED THAT THE RESIDENT HAD PROBLEMS THAT CONSISTED OF: SELF CARE DEFICIT, DEMENTIA, IMPAIRED COGNITION, DID NOT COMMUNICATE NEEDS VERBALLY, AND WAS DEPENDENT ON STAFF TO ANTICIPATE HER NEEDS. THE FACILITY'S "WEEKLY PRESSURE ULCER WOUND DOCUMENTATION SHEET", REFLECTED THE RESIDENT DEVELOPED FACILITY ACQUIRED STAGE 2 PRESSURE ULCERS TO HER LEFT LOWER CALF ON 11/19/10 AND TO HER RIGHT LATERAL FOOT ON 2/10/11. THE NURSE'S NOTES DATED 10/31/10 TO 10/17/10 (THE LAST NOTE PRIOR TO PRESSURE ULCER DEVELOPMENT OF THE LEFT LOWER LEG) REFLECTED NO DOCUMENTATION OF ANY TYPE OF SKIN BREAKDOWN. YET, THE NURSE'S NOTES DATED 11/12/10 REFLECTED THAT A NEW ORDER WAS WRITTEN FOR A PHYSICAL THERAPY (PT). PHYSICAL THERAPY WAS TO DO AN EVALUATION TO REASSESS HER LEG BRACES AND WEAR SCHEDULE, 3 TIMES A WEEK FOR 2 WEEKS, FOR THE RESIDENT. PT WAS TO PROVIDE STAFF INSTRUCTION FOR BRACE PLACEMENT, MONITORING FOR SKIN BREAK DOWN (AS NEEDED WITH PREVIOUS WEAR SCHEDULE), AND ADJUSTMENT OF BRACES AS APPROPRIATE. YET, NO DOCUMENTATION WAS AVAILABLE ON SKIN SHEETS OR TREATMENT SHEETS INDICATING SKIN CHECKS HAD BEEN PERFORMED. AS NOTED ABOVE, THE RESIDENT DID HAVE A [DIAGNOSES REDACTED]. THE RESIDENT THEN DEVELOPED A STAGE 2 PRESSURE ULCER TO HER LEFT LOWER LEG ON 11/19/10. THE PRESSURE ULCER RISK CARE PLAN INITIATED ON 9/17/10 REFLECTED THAT WOUND TREATMENTS WERE STARTED ON 11/19/10 AND, DUE TO DETERIORATION, CHANGED UP TO 3 TIMES UNTIL 12/14/11. THE TREATMENT RECORD DATED FOR THE MONTH OF DECEMBER 2010, REFLECTED A CHANGE IN TREATMENT DATED 12/22/10. THE TREATMENT RECORD REFLECTED THE FOLLOWING: "CLEANSE L (LEFT) CALF WITH SAF CLENZ AFTER (SIC), PAT DRY, APPLY SANTYL TO WOUND BED, COVER WITH [MEDICATION NAME] AND WRAP WITH KERLIX CHANGE BID (TWO TIMES A DAY)." THE TREATMENT SHEET REFLECTED DRESSING CHANGES TO THE AFFECTED AREA WERE NOT DONE ON 12/29/10 (7:00 A.M. - 3:00 P.M.), AND ALSO NOT DONE 12/26/10 THRU 12/30/10 (3:00 P.M. - 11:00 P.M.). THE RESIDENT DID NOT RECEIVE A TOTAL OF 6 DRESSING CHANGES (5 OF THOSE MISSED CONSECUTIVELY ON THE SECOND SHIFT). THE NURSE'S NOTES DATED 12/20/10 - 12/30/11 DID NOT MENTION DRESSING CHANGES (OR A DESCRIPTION OF THE WOUND) WHICH WERE TO BE CHANGED FROM DAILY TO TWICE A DAY. ON THE FACILITY'S WEEKLY PRESSURE ULCER WOUND DOCUMENTATION SHEET, DATED 12/28/10, THE WOUND WAS NOTED TO HAVE SCANT BROWN DRAINAGE, UNSTAGEABLE, RED COLORING AROUND WOUND BED, AND THE RESIDENT HAD AN ELEVATED TEMPERATURE. THE WOUND MEASURED 3 X 2 CENTIMETERS. ON 12/31/10 NURSE'S NOTES DATED 12/31/10 AT 7:00 PM REFLECTED THE RESIDENT'S WOUND EDGES WERE RED, SWOLLEN, AND WARM TO TOUCH. SHE ALSO HAD SMALL AMOUNTS OF PURULENT DRAINAGE (INDICATIVE OF INFECTION). PERRY & POTTERS CLINICAL NURSING SKILLS & TECHNIQUES 7 TH EDITION REFLECTED "...AN INFECTED ACUTE WOUND USUALLY DEMONSTRATES SIGNS OF LOCAL INFLAMMATION; REDNESS AND WARMTH IN THE AREA; PRESENCE OF DRAINAGE, PAIN, OR TENDERNESS; AND AN UNUSUAL ODOR..." THE REFERENCE ALSO DESCRIBED PURULENT AS THICK, YELLOW, GREEN, OR BROWN DRAINAGE..." , AND SLOUGH AS "...YELLOW TISSUE REPRESENTS NONVIABLE TISSUE AND IN SOME CASES THE PRESENCE OF AN INFECTION. IT IS OFTEN YELLOW, CREAM COLORED, OR GRAY SLOUGH, WHICH IS USUALLY ACCOMPANIED BY PURULENT DRAINAGE..." ON 1/5/11 physician's orders [REDACTED]. THE ORDER READ, "CLEANSE LEFT CALF OPEN AREA WITH SAF CLENS, APPLY SAFGEL TO AREA AROUND SLOUGH, THEN APPLY SANTYL TO CENTER AREA WITH SLOUGH-COVER WITH [MEDICATION NAME] AND 4 X 4-WRAP WITH KLING." ON 3/17/11 AT 11:47 A.M., THE DIRECTOR OF NURSING (STAFF "A") WAS ASKED HOW THE WOUND TO THE LEFT LOWER LEG HAD DEVELOPED INTO AN UNSTAGEABLE ULCER AND WHY THE DRESSING CHANGES HAD NOT BEEN DONE. STAFF "A" REPLIED THAT SHE DID NOT KNOW, AND THAT HER BEST GUESS WAS THAT THE ULCER HAD DEVELOPED FROM THE BRACE. SHE SAID THAT WHEN SHE FIRST SAW THE WOUND IT ALREADY HAD ESCHAR. THE TREATMENT RECORD, WITH THE MISSING DRESSING CHANGES, WAS PRESENTED TO STAFF "A" , WHO AGREED THAT THE DRESSING CHANGES HAD NOT BEEN DONE. THE LACK OF DRESSING CHANGES COULD POTENTIALLY HAVE CONTRIBUTED TO DELAYED WOUND HEALING. RESIDENT #6 WAS ALSO LISTED AS HAVING A STAGE 2 PRESSURE ULCER ON HER RIGHT LATERAL FOOT, WHICH MEASURED 0.8 X 1.0 CENTIMETERS ACCORDING TO THE WEEKLY PRESSURE ULCER WOUND DOCUMENTATION SHEET DATED 2/10/11. NURSE'S NOTES DATED 1/2/11 THROUGH 2/8/11 CONTAINED NO DOCUMENTATION RELATED TO SKIN BREAKDOWN OF THE RIGHT LATERAL FOOT. ON 2/10/11, A STAGE 2 PRESSURE ULCER WAS DESCRIBED WITH SANGUINOUS DRAINAGE. PRIOR TO ENTERING THE RESIDENT'S ROOM ON 3/17/11 AT 12:20 P.M., A REGISTERED NURSE (STAFF "R") HAD DOCUMENTED ON THE WEEKLY PRESSURE ULCER WOUND DOCUMENTATION. THE SHEET REFLECTED THE WOUND WAS ON THE RIGHT LATERAL FOOT AND A STAGE 2 WITH SEROSANGUINEOUS DRAINAGE, MEASURING 1.8 X 1.2 CENTIMETERS. THE RESIDENT'S WOUND WAS OBSERVED ALONG WITH STAFF "A". UPON REMOVAL OF THE OLD DRESSING, THE SITE WAS OBSERVED TO HAVE YELLOW COLORED SLOUGH AT THE CENTER, AND THE SKIN AROUND THE CENTER WAS REDDENED. STAFF "A" STATED THAT, "THE WOUND WAS RIGHT ON THE BONE, WE PROBABLY NEED TO GET AN X-RAY OF THIS, THIS IS NEW." PURULENT AND SEROSANGUINOUS DRAINAGE WAS NOTED ON THE OLD GAUZE DRESSING. WHEN ASKED HOW SHE WOULD STAGE THE WOUND AT THE TIME OF THE OBSERVATION, STAFF "A" REPLIED, "I THINK I'D HAVE TO GO FOR A FOUR, IT'S HARD TO TELL HOW DEEP." STAFF "A" SAID THAT THE NURSES WERE TO UPDATE HER WHEN THINGS LIKE THAT OCCURRED. SHE HAD NOT KNOWN ABOUT THE CURRENT STATUS OF THE WOUND. SHE ALSO SAID THAT PRESSURE ULCER SITES WERE TO BE MEASURED WEEKLY, BUT SHOULD BE CHANGED DAILY, OR WHENEVER THE TREATMENT RECORD ORDERED. THE FACILITY DID NOT PERFORM THE DRESSING CHANGES FOR RESIDENT #6 AS ORDERED BY THE PHYSICIAN, DID NOT MONITOR THE RESIDENT'S SKIN FOR BREAKDOWN, AND DID NOT PROPERLY STAGE AND TREAT HER PRESSURE ULCERS. ( )

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO RE-EVALUATE CARE PLAN INTERVENTIONS FOR FALLS RISKS AND SUPERVISE RESIDENTS TO PREVENT FALLS FOR 3 OF 4 SAMPLED RESIDENTS (#1, #2 AND #12) WHO WERE REVIEWED FOR FALLS FROM A TOTAL SAMPLE OF 18, RESULTING IN FRACTURES FOR RESIDENTS #2, AND #12, AND HEAD INJURY FOR RESIDENT #1. FINDINGS INCLUDE: RESIDENT #12 WAS AN [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE RESIDENT WAS RECEIVING SEVERAL PSYCHOACTIVE MEDICATIONS INCLUDING NAMENDA, DEPAKOTE, ATIVAN, ARICEPT AND CELEXA IN THE EVENING HOURS. THE FALL CARE PLAN INITIATED 3/22/10, UPDATED MULTIPLE TIMES, AND REVIEWED MOST RECENTLY ON 3/15/11, REFLECTED THAT THE RESIDENT WAS AT RISK FOR FALLS BECAUSE OF HER WEAKNESS, FORGETFULNESS, SELF TRANSFER STATUS AND HISTORY OF FALLS. THE PROBLEM STATEMENT ALSO INCLUDED THE RESIDENT TAKING TRILAFON (A NEUROLEPTIC ANTIPSYCHOTIC DRUG INDICATED TO MANAGE MANIFESTATIONS OF PSYCHOTIC DISORDERS). A POTENTIAL SIDE EFFECT OF TRILAFON IS ORTHOSTATIC HYPOTENSION (DROP IN THE BLOOD PRESSURE UPON STANDING). HOWEVER, THE RESIDENT WAS NO LONGER RECEIVING THIS DRUG. THERE WERE MANY NURSING INTERVENTIONS, INCLUDING MONITORING OF MEDICATION SIDE EFFECTS (SUCH AS ORTHOSTATIC HYPOTENSION), LOW BED, PROPER FOOT WEAR, CALL LIGHT WITHIN REACH, TAB ALARM TO WHEEL CHAIR, SENSOR PAD ON BED, NOT LEAVING RESIDENT ALONE IN THE BATHROOM, AND FALL MAT ON FLOOR TO PREVENT THE RESIDENT'S FALLS. HOWEVER, MANY OF THESE INTERVENTIONS HAD BEEN CROSSED OFF AND NEW INTERVENTIONS WERE WRITTEN AS OF 3/1/11. IT WAS NOT CLEAR WHICH INTERVENTIONS HAD BEEN IN PLACE BEFORE THE RESIDENT'S RECENT FALL (2/23/11). THE NURSING NOTE DATED 2/23/11 AT 3:15 A.M., REFLECTED, " ...CNA (CERTIFIED NURSING ASSISTANT) ENTERED ROOM AND NOTED RESIDENT STANDING IN FRONT OF CLOSET REACHING FOR DOOR. CNA ATTEMPTED TO ASSIST RESIDENT BUT WAS UNABLE TO REACH HER. RESIDENT fell TO FLOOR, HITTING HER LEFT SIDE ON FLOOR ...COMPLAINED OF PAIN LEFT HIP...SWELLING NOTED LEFT THIGH AND HIP...RESIDENT SENT TO HOSPITAL... " THE X-RAY REPORT DATED 2/23/11 REFLECTED THE RESIDENT HAD A RECENT DISPLACED FRACTURE OF THE PROXIMAL SHAFT OF THE FEMUR (THIGH BONE) THAT EXTENDS UP TO INTO THE SUBTROCHANTERIC AREA." THE RESIDENT WAS RETURNED ON 2/25/11 WITH AN ABDOMINAL ABDUCTION HIP BRACE. THE SUPERVISOR/MANAGER'S INVESTIGATION REPORT DATED 2/23/11 AND THE SUMMARY REPORT PREPARED BY THE DIRECTOR OF NURSING AND THE ADMINISTRATOR REFLECTED THE RESIDENT HAD TAKEN OFF HER TAB ALARM, THE STRING LYING ON THE BED ATTACHED TO THE ALARM BOX HOOKED ON THE LEFT SIDE OF HER BED, THUS NO SOUND OF ALARM COULD BE HEARD. ON 3/17/11 AT 10:30 A.M., THE DIRECTOR OF NURSING, (STAFF "A") STATED THAT THE RESIDENT WAS NOTED TAKING OFF HER ALARMS BY BOTH NURSES AND NURSING AIDES ABOUT A WEEK BEFORE THE INCIDENT, BUT THE CLIP ALARM WAS NOT REPLACED WITH A BED SENSOR ALARM WHICH SHE HAD NOW IN PLACE. THE FALL MAY HAVE BEEN AVOIDABLE IF THE ALARM SYSTEM WAS CHANGED. BUT, THE ALARM INTERVENTION WAS NOT RE-EVALUATED AND THE resident subsequently sustained [REDACTED]. THE RESIDENT WAS ASKED WHAT HAPPENED. SHE STATED, "I JUST STAND ACCIDENTLY." ( ) RESIDENT # 1 WAS AN [AGE] year OLD SEVERELY IMPAIRED FEMALE REadmitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. ADDITIONAL [DIAGNOSES REDACTED]. RECORD REVIEW REFLECTED A MINIMUM DATA SET (MDS) ASSESSMENT REFERENCE DATE 09/20/10 WHICH CODED RESIDENT #1 AS INDEPENDENT WITH TRANSFERS AND WALKING IN ROOM. RECORD REVIEW REFLECTED MEDICATION CHANGES FOR RESIDENT #1 DURING OCTOBER 2010 WHICH INCLUDED: 10/04/10 ULTRAM 50 MG THREE TIMES A DAY, 10/07/10 DEPAKOTE ER 250 MG AT BEDTIME DAILY AND 10/14/10 CELEXA STARTED AT 10 MG AND ON 10/27/10 CELEXA INCREASED TO 20 MG AT BEDTIME DAILY. RECORD REVIEW REFLECTED A physician progress notes [REDACTED]. FALLS ASLEEP EASILY IN CHAIR. PULSE OX (OXIMETRY) DECREASED, STARTED ON OXYGEN PER NC (NASAL CANNULA). INCREASED CONGESTION AND WHEEZING PER STAFF. POSITIVE SLEEP APNEA-UNABLE TO TOLERATE COMPLETE EVAL FOR CPAP (CONSTANT POSITIVE AIRWAY PRESSURE). SLOW TO RESPOND." RECORD REVIEW REFLECTED AN UNUSUAL OCCURRENCE REPORT DATED 11/14/10 AT 8:45 A.M. WHICH STATED, "2.5 BY 2.5 PURPLE BRUISE, LEFT KNEE." AN UNUSUAL OCCURRENCE REPORT DATED 11/14/10 AT 10:15 A.M. STATED, "RESIDENT OBSERVED LYING FLAT ON BACK ON BATHROOM FLOOR WITH WHEELED WALKER ON TOP OF HER. STATED PASSED OUT NOT MOVED R/T (RELATED TO) C/O (COMPLAINT OF) PAIN BACK/HEAD. GOTTEN OFF FLOOR BY AMBULANCE ATTENDANTS." THE REPORT CONCLUSION STATED, "RESIDENT IN BATHROOM WITH WALKER STATES SHE PASSED OUT. ANTICIPATING POSS (POSSIBLE) DROP IN O2 (OXYGEN) SAT (SATURATION) WITH RECENT CHANGE IN CONDITION RELATED TO HYPOXIC EVENTS." THE CORRECTIVE ACTION STATED, "THERAPY REFERRAL FOR POSS W/C (WHEEL CHAIR) TRANSPORT FOR DISTANCE AND EVAL FOR RESTORATIVE AMBULATION WITH SBA (STAND BY ASSIST). RECORD REVIEW OF THE EMERGENCY DEPARTMENT PHYSICIAN NOTE DATED 11/14/10 STATED, " IMPRESSION: HEAD CONTUSION WITHOUT EVIDENCE OF INTERNAL BLEED. COCCYGEAL CONTUSION WITHOUT EVIDENCE OF HEMATOMA OR DEFORMITY. MEDICATION INDUCED SOMNOLENCE." THE DISCHARGE PLAN INCLUDED FAMILY, "ENCOURAGED TO DISCUSS WITH SUPERVISING PHYSICIAN AT (FACILITY NAME) THE PATIENT'S MEDICATION PROFILE FOR THE PURPOSE OF POTENTIALLY READJUSTING THIS SO SHE IS NOT SOMNOLENT." RECORD REVIEW REFLECTED A "NURSE'S NOTE" DATED 11/22/10 AT 2:15 PM. WHICH STATED, "RES OBSERVED ON FLOOR IN ROOM IN FROM OF BR (BATHROOM) DOOR LYING ON BACK." THE UNUSUAL OCCURRENCE REPORT DATED 11/22/10 STATED, " ONE HEMATOMA 3 CM BY 3 CM BUMP BACK OF HEAD." THE CONCLUSION STATED, "RESIDENT WAS BEING ASSISTED TO THE BATHROOM BY ANOTHER RESIDENT AND SHE LOST HER BALANCE AND fell . RESIDENT'S TAB ALARM WAS NOT ON, COULD HAVE BEEN REMOVED BY THE OTHER RESIDENT." THE CORRECTIVE ACTION STATED, "SENSOR ALARM TO BED AND CHAIR." ON 03/17/11 AT 11:00 A.M., RESIDENT #1'S CLINICAL RECORD AND CARE PLANS WERE REVIEWED WITH THE UNIT MANAGER (STAFF "I"). STAFF "I" CONFIRMED THAT PRIOR TO THE SIGNIFICANT DECLINE IN CONDITION NOTED BY THE PHYSICIAN ON 11/11/10 RESIDENT #1 WAS INDEPENDENT IN HER ROOM. STAFF "I" STATED, "THE IDT (INTERDISCIPLINARY) REVIEW WAS COMPLETED ON 10/25/10 AND DETERMINED SHE WAS NOT AT RISK FOR FALLS, AFTER THE FIRST FALL (11/14/10) SHE WAS REFERRED TO THERAPY AND AFTER THE SECOND FALL (11/23/10) SHE WAS PUT ON A TAB ALARM." STAFF "K" CONFIRMED THAT RESIDENT #1'S CARE PLANS WERE NOT COMPREHENSIVELY REVIEWED AT THE TIME OF HER SIGNIFICANT DECLINE IN CONDITION AND THAT THE CARE PLAN INTERVENTIONS FOR FALLS, PSYCHOTROPICS AND RESPIRATORY STATUS WERE ADDED ON 12/02/10 AFTER A SIGNIFICANT CHANGE IN CONDITION MDS WAS COMPLETED. ON 03/18/11 AT 11:45 A. M, THE DIRECTOR OF NURSING (STAFF "A") WAS INTERVIEWED IN HER OFFICE RELATED TO RESIDENT #1'S FALL RISK ASSESSMENTS AND CARE PLANS. STAFF "A" STATED, "SHE WAS DECLINING, WE KNEW IT, IT WAS BLACK AND WHITE, WE SHOULD HAVE PUT INTERVENTIONS IN PLACE FOR BETTER MONITORING AND FALLS PREVENTION." ( ) ACCORDING TO THE MARCH 2011 MONTHLY physician's orders [REDACTED].#2 NEEDED "...VERBAL REMINDERS AND CUEING FOR TASK COMPLETION." RESIDENT #2'S HISTORY AND PHYSICAL DATED 11/23/10, REFLECTED SHE HAD A PAST SURGICAL HISTORY OF A HIP FRACTURE. RESIDENT #2'S FALL CARE PLAN DATED 11/12/10 REFLECTED SHE AMBULATED INDEPENDENTLY. THIS SAME FALL CARE PLAN WAS UPDATED 2/8/11 TO REFLECT AMBULATION WITH ASSIST OF ONE, A BED SENSOR ALARM AND A TAB ALARM IN HER CHAIR WERE ADDED ON 1//28/11. THE INCIDENT AND ACCIDENT REPORT DATED 1/28/11 AT 7:35 AM REFLECTED THE DIRECTOR OF NURSING INTERVIEWED NURSE "O" AND NURSE "O" "STATED SHE HAD GONE INTO (RESIDENT #2'S) ROOM; (RESIDENT #2) WAS SITTING ON HER BED SHE HAD JUST RETURNED FROM THE BATHROOM. NURSE "O" NOTICED THERE WAS FECES ON THE FLOOR BY THE BATHROOM DOOR, NURSE "O" STEPPED OUT TO GET THE MATERIAL TO CLEAN UP THE AREA. NURSE "O" STATED SHE WAS OUT OF THE ROOM ABOUT ONE MINUTE WHEN SHE RE-ENTERED THE ROOM THE RESIDENT WAS UP WITH HER WALKER. NURSE "O" STATED (RESIDENT #2) WAS STANDING IN HER FECES, (RESIDENT #2) HAD ONE HAND ON WALKER AND WAS TRYING TO OPEN THE BATHROOM DOOR WITH THE OTHER ONE. NURSE "O" STATED THAT BEFORE SHE COULD REACH (RESIDENT #2) SHE STARTED TO SLIP. NURSE "O" STATED AS (RESIDENT #2) fell SHE TRIED TO CATCH HERSELF WITH HER RIGHT WRIST, (RESIDENT #2 fell on TO HER BUTTOCKS AND DID NOT HIT HER HEAD. NURSE "O" STATED THAT (RESIDENT #2) WAS WEARING HER SHOES; THE CALL LIGHT WAS IN REACH ON THE BED IT HAD NOT BEEN TURNED ON..." THIS SAME REPORT ALSO REFLECTED THAT RESIDENT #2 WAS INTERVIEWED AND STATED "SHE HAD GOTTEN UP TO GO BACK TO THE BATHROOM..." THE INCIDENT AND ACCIDENT INVESTIGATION CONCLUDED THAT RESIDENT #2 WAS INCONTINENT, THAT NURSE "O" HAD STEPPED OUT FOR A MINUTE TO GET SOMETHING TO CLEAN THIS RESIDENT, AND THAT NURSE "O" COULD NOT HAVE ANTICIPATED THAT THE RESIDENT WOULD ATTEMPT TO GO BACK TO THE BATHROOM SO QUICKLY. ON 3/17/11 AT 10:00 AM, NURSE "O" STATED WHEN SHE STARTED HER SHIFT ON 1/28/11 AT 6:30 AM, RESIDENT #2'S BEDROOM FLOOR WAS COVERED IN FECES, RESIDENT #2 HAD DIARRHEA WHICH HAD RUN DOWN THE BACK OF HER THIGH, SHE WENT TO GET CLEANING SUPPLIES AND WHEN SHE RETURNED, RESIDENT #2 WAS ON THE FLOOR. NURSE "O" STATED THE TWO NURSE AIDES THAT WERE WORKING ON THAT UNIT WERE ALREADY BUSY WITH RESIDENTS AND WERE UNABLE TO ASSIST HER. NURSE "O" STATED THAT SHE WAS UNABLE TO PAGE FOR HELP UNLESS SHE LEFT THE RESIDENT'S ROOM AND SHE DID NOT PUT THE CALL LIGHT ON BECAUSE THE AIDES WORKING ON THAT UNIT WERE NOT AVAILABLE. SHE STATED THAT ORDINARILY RESIDENT #2 WAS ABLE TO USE THE BATHROOM AND CLEAN HERSELF INDEPENDENTLY, BUT NOT WHEN SHE HAD DIARRHEA. THE FACILITY'S IMMEDIATE INTERVENTIONS INCLUDED NON SKID TAPE ON THE FLOOR FROM THE BED TO THE BATHROOM AND SENSOR BED ALARM. ACCORDING TO ACTION #6 IN THE INVESTIGATION REPORT THE "SENSOR ALARM IN BED TO REMIND (RESIDENT #2) TO ASK FOR ASSIST IN WALKING AND TRANSFERS..." ON THE AFTERNOON OF 3/16/11 RESIDENT #2 WAS JUST BEGINNING TO SIT UP IN HER BED, SHE WAS ASKED WHERE WAS HER CALL LIGHT, SHE STATED SHE DID NOT HAVE A CALL LIGHT. THE CALL LIGHT WAS BEHIND HER, THE CALL LIGHT WAS HANDED TO HER AND SHE PRESSED THE BUTTON, SHE WAS ASKED DO THE STAFF COME RIGHT AWAY WHEN SHE PRESSES THAT BUTTON? RESIDENT #2 REPLIED "I DON'T KNOW I NEVER USED IT BEFORE." DURING AN INTERVIEW ON 3/18/11 AT 1:35 P.M., THE ADMINISTRATOR AND NURSE "O" DISCUSSED THAT IT WAS PROBABLE THAT RESIDENT #2 DID NOT REMAIN SEATED WHILE LEFT UNSUPERVISED BECAUSE SHE HAD DIARRHEA. RESIDENT #2'S ROOM WAS FOUND WITH FECES ON THE FLOOR AT THE BEGINNING OF THE DAY SHIFT ON 1/28/11 AT 6:30 AM. THE RESULT OF THE RADIOLOGY REPORT DATED 1/28/11 REFLECTED "THERE IS OSTEOARTHRITIS AT THE BASE OF THE THUMB IN AN UNDISPLACED INTRA-ARTICULAR FRACTURE OF THE DISTAL RADIUS." THE REPORT REFLECTED THAT RESIDENT #2 HAD A "HISTORY OF TRAUMA AND PAIN." THE PHYSICIAN REPORT DATED 1/31/11 REFLECTED THAT RESIDENT #2 "HAD A SLIP AND FALL HERE IN THE FACILITY ... AND X-RAYS DID REVEAL A RIGHT [DIAGNOSES REDACTED] FRACTURE..." THE ORTHOPAEDIC CONSULTATION DATED 3/7/11 REFLECTED RESIDENT #2 HAD COMPLAINED OF PAIN IN THE RIGHT WRIST AND DIRECTED: "...RECHECK RIGHT WRIST FRACTURE..." ( )

This citation pertains to intake MI 061. Based on observation, interview, and record review the facility failed to ensure the safety and ensure the consistent use of safety alarms in 1 of 4 sampled residents resulting in Resident #101 sustaining a fall with a resulting hip fracture. Findings include: Record review of the facility's "Face Sheet" dated 12/13/10, indicated Resident #101 was a [AGE] year old woman, originally admitted to the facility on [DATE], under hospice care, with [DIAGNOSES REDACTED]. Record review of an "Order regarding appointment of guardian of incapacitated individual", dated 3/06/09, found Resident #101, by reason of mental illness and mental incompetence, had impairment to the extent of lacking sufficient understanding or capacity to make or communicate informed decisions as is an incapacitated individual, and found Resident #101 was totally without the capacity to care for himself/herself. Record review of a "Minimum Data Set", dated 1/12/11, indicated Resident #101 had unclear speech, was sometimes able to make self understood, would sometimes understand others, had impaired vision, and short and long term memory problems, and had severely impaired, and never/rarely made decisions regarding tasks of daily life. The mood assessment revealed that Resident #101 had been noticed feeling tired or without energy for several days (2-6 days) prior to a fall, and moved or spoke so slowly that other people had noticed or had been so fidgety or restless that she had been moving around a lot more than usual nearly all of the 14 days prior to being discharged to the hospital (with a hip fracture). Resident #101 required extensive assistance with bed mobility and transfers, toileting, and personal hygiene, and never walked in her room or in the corridor. Balance during transfer and walking indicated the resident did not walk or turn around, was not steady, only able to stabilize with human assistance when moving from a seated to standing position, moving on and off toilet, and with surface-to surface transfers. Functional limitations in Range of Motion were present on both sides in the upper and lower extremity. Record review of a "Fall Risk Assessment", dated 11/09/10, indicated Resident #101 was a low risk for falls. On the reverse side of the assessment form it was noted that environmental factors should be considered in assessing a resident's risk of falls and included responding to bladder or bowel urgency. No new fall risk assessment was done for Resident #101 since 11/09/10. Record review of a "Nurses Note", dated 11/17/10, timed 5:30 PM, indicated a new physician order [REDACTED]. A "Nurses Note" dated 11/17/10, timed 11:00 PM, indicated Resident #101's Foley catheter had been removed without difficulty. Record review of a "Resident Care Guide", indicated Resident #101 was oriented to person only, used a wheel chair, needed the assistance of one person for transfers and two people for ambulation, was both continent and incontinent of urine, and would use the bathroom for toileting at times. Resident #101 was not continent of bowel and wore briefs for protection and dignity. On 1/12/11 the "assistance needs" portion of the " Resident Care Guide" was updated to include the intervention "Needs assistance to bathroom. Offer the resident assistance to the bathroom every two hours." Resident #101 needed set up assistance during meals and at times required assistance with eating. Restorative Interventions/Programs indicated Resident #101 used a hand roll (for the prevention of contractures) in her right hand. Safety Interventions for the resident included having the bed in the lowest position, the use of a perimeter mattress (raised edge mattress to prevent rolling out of bed), a wheelchair tab alarm and a floor mat (cushioned mat for protection in the event a resident falls) along the right side of the bed. Skin management Interventions revealed the resident needed to be turned and repositioned every two hours. A bed alarm was added to the resident care guide on 1/12/11 at 10:35 PM, the day the resident fell . Record review of an "Unusual Occurrence" report dated 1/12/11 at 9:00 p.m., written by LPN# 8, indicated that on 1/12/11 Resident #101 was observed on the floor in her room and stated she had been coming from the bathroom. It was noted that no equipment was involved. The "Physical Assessment Abnormalities" portion of the report noted Resident #101 had pain, and was sent to the emergency room for evaluation. It was noted that Resident #104 was a witness to the occurrence. Items observed and in place at time of event included: bed in low, locked position, call light within reach. The occurrence report indicated that Resident #101 was ambulating independently. Immediate interventions/preventive measures taken were to transfer to the hospital, assess pain, neurological checks were done and monitoring for bruises. Adding a bed alarm to the bed when the resident returns to the facility. Staff assigned to the resident as indicated on the occurrence report were CNA # 9 and CNA #10. Record review of a "Supervisor/Manager Investigation", dated 1/14/11, completed by the Director of Nursing, indicated Resident #101 had a Foley catheter discontinued on 11/18/10, had not been toileted prior to being assisted to bed at 7:00 or 7:30 PM on 1/12/11, and the call light had been in place but not used. The investigation did not include statements from Resident #104 who allegedly witnessed the fall, or from CNA #11, also assigned to care for residents in the hall where Resident #101 lived, and was with CNA #10 after LPN #8 called for help and was involved in retrieving equipment needed by LPN #8 after the fall. The Physical Therapist interviewed for the investigation into the circumstances surrounding the fall had not worked with Resident #101 since evaluating her for a splint and did not have current knowledge of her strengths or limitations. The conclusion reached by the director of nursing at the end of the investigation was that Resident #101 had gotten up out of bed and to the bathroom by herself and fell . During an interview with Resident #104, on 2/11/11 at 3:00 PM, Resident #104 reported that she saw Resident #101 get up out of bed and walk to the bathroom by herself. She stated she told Resident #101 to use a wheelchair but there was not one in the room. Resident #104 was interviewed again on 2/14/11 and reported to the surveyor that she had seen Resident #101's fall after using the bathroom without assistance and that Resident #101 told Resident #104 not to tell anyone that she fell , and that they talked for quite a while before Resident #104 went to get help for Resident #101. An interview, on 2/12/11 at 10:00 AM, with physical therapy director #13 revealed she was the physical therapist who was interviewed by the director of nursing regarding Resident #101's fall and stated, "We (PT/OT) had worked with her a long time ago with splinting because of her right sided paralysis, but I didn't do a full assessment on her." On 2/11/11, a review of a call light audit screen for Resident #101's room on the day of the fall was conducted by the surveyor at the central nurses station and witnessed by LPN #12 and maintenance employee #14 due to the inability to print reports from the system for the surveyors review. Both LPN #12 and Maintenance #14 conferred with the surveyor that the call light had not been activated at all in 24 hours (1/11/11-1/12/11) in Resident 101's room from either bed 1 or bed 2, or from the bathroom. On 2/14/11, a test of the call light system for Resident #101's room was conducted at the surveyor's request, and witnessed by LPN #12 and Maintenance Director #14, and no system malfunction was identified. During an interview, on 2/11/11 at 4 PM, CNA #9 reported Resident #101 started getting in and out of bed about a month before she fell , that he always put her tab alarm on her while she was in bed, and that Resident #101 was able and had been known to disable the tab alarm by pulling up her shirt and unhooking the clip that attached to the tab alarm. When asked if Resident #101 was good about using the call light for assistance, he said that it wasn't used very often. An interview on 2/11/11, at 4:45 PM, with CNA #10 revealed she would always apply the tab alarm to Resident #101 when she was in bed. She also reported that CNA #9 had asked earlier that shift if anyone had transferred Resident #101 on the toilet and left her there, and CNA #9 denied assisting Resident #101. CNA #11 was interviewed on 2/14/11, at 3:00 PM, and reported being a witness to the scene after LPN #8 called for help. When asked, CNA #11 reported the only contact she had with Resident #101 on the day of the fall was when she passed water to the residents at the start of her shift at 2:30 PM. A telephone interview with LPN #8, on 2/14/11 at 11:45 AM, LPN #8 reported it had been rumored Resident #101 was getting herself out of bed or wheelchair and onto the toilet but because she had never witnessed it she didn't take it seriously. A telephone interview with Admissions Director (AD) #15, on 2/14/11 at 12:00 PM, revealed she had spoken with Resident #101's daughter on the phone the day after Resident #101 fell and fractured her hip. She denied telling the resident's daughter that Resident #101 was in a wheelchair when she fell and denied telling the resident's daughter that Resident #101 could have disabled a tab alarm, even if one had been in place. The admissions director said she thought she might have had a tab alarm on and knew she could remove it. When asked how she knew Resident #101 could remove a tab alarm by herself AD #15 stated, "She was so alert, I think they (facility aids) caught her (removing the alarm) a few times." An observation, on 2/10/11 at 11:30 AM, of a transfer by Occupational Therapist #6 of Resident #101 from her wheelchair into bed with the assistance of a gait belt. A tab alarm was in the chair the resident had been seated in but was not attached to the resident. The OT transferred the tab alarm from the resident's chair and attached it to the resident in the bed. When asked by the surveyor if the resident was supposed to have the alarm on while in bed, OT #6 said she assumed so, because it was in the chair. She did not retrieve Resident #101's care guide from the closet in the room for verification.