Every finding on record at Fairlane Senior Care and Rehab Center

Based on observation, interview and record review, the facility failed to properly dispose of garbage, medical supplies, yard refuse debris, for one opened dumpster top, affecting all residents, staff and visitors, resulting in the potential for the harborage of pests and insects.Findings include:On 9/2/25 at 07:35am, two dumpster containers were observed near the building with separate top lids. The dumpster on the right-side was observed with its lid opened, exposing multiple boxes, loose paper, and tree branches. In between the dumpster and the compressor was a wheelbarrow filled with tree branches, pieces of cardboard, leaves, and loose papers. Behind the compressor was a fence with leaves, paper, Styrofoam cups, plastic water bottles, medical gloves, yellow face mask and broken tree branches. In front of the dumpster and compressor were yellow medical face masks, examination gloves, multiple cigarette butts, pieces of paper and pieces of cardboard, and small tree branches. There were also flies swarming around the dumpsters. No staff were observed near the dumpster area.On 9/2/25 at 07:48am, an interview was conducted with the Director of Maintenance in the dumpster area. The Director of Maintenance asked who was responsible for making sure the dumpster area was clean and free from debris. The Director of Maintenance said, The staff that was assigned to clean the dumpster area was fired.Now I'm cleaning this area.On 9/5/2025 at 9:40am, the Nursing Home Administrator (NHA) was interviewed about the expectation of maintaining cleanliness of the dumpster and compressor area. The NHA said the expectation is that the dumpster and compressor area would be kept clean.The NHA said the facility did not have a policy for dumpster/compressor cleanliness. The NHA provided a Director of Maintenance job description that revealed the following: The Director of Maintenance is responsible for managing and assisting with the completion of day-to-day activities involving maintenance of the facility, equipment and machinery.grounds keeping, and the overall facility appearance.

Based on observation, interview and record review the facility failed to ensure a specialty call light was within reach of one resident (R59) out of ten residents reviewed for call light, resulting in unmet care needs. On 9/2/2025 at 10:39 a.m., R59 was observed lying in bed with a specialty call light (can be used by the resident only with the shoulders and the back of the head) pinned to the bed covers on the right side of the bed. During an interview, R59 reported trying to get staff attention for about half an hour since no staff had been in the room to have oral care provided and to be assisted with getting up out of bed. During the interview and observation, R59 confirmed the call light was unable to be used by hands, only with the shoulder and the back of the head. R59 stated, I have difficulties using a regular call light because my arms don't move to get it.On 9/2/2025 at 10:42 a.m. Licensed Practical Nurse (LPN) C (R59's assigned nurse) said during an interview that R59 can't use the call light by hands and was unable to verbalize what part of the body R59 could use the call light with. LPN C' left the room and entered again and stated, Oh, it's a motion call light, he can move his head around and the call light will go off. LPN C' pinned R59 call light on the right side of the resident's pillow under R59's head. LPN C verified R59 was unable to turn the call light on from the position the call light was pinned previously. R59 demonstrated using the back of the head to turn the call light on and then verbalized wanting assisting with ADL care to LPN C.According to the electronic medical records, R59 was initially admitted into the facility on 1/31/2013 and re admitted [DATE] with diagnoses of multiple sclerosis, seizure, pressure ulcer of sacral region stage four, arthritis, osteomyelitis of vertebra, sacral and sacrococcygeal region, major depressive disorder, adjustment disorder with mixed anxiety, and hypertension. R59's quarterly Minimum Data Set (MDS) with a reference date of 7/10/2025, indicated R59 had intact cognition with a BIMS (brief interview for mental status) score of 13/15, required extensive assistance of two-person with bed mobility, totally dependent on two-person for transfers, extensive assistance of one person with Activities of Daily Living (ADLs), and was incontinent of bowel and bladder. Review of the ADLS care plan dated 7/10/2025 documented, I have an actual ADL deficit related to multiple sclerosis, hypertension, Neuropathy, generalized muscle weakness, impaired mobility, muscle wasting & atrophy, bilateral contractures to upper extremities, deep vein thrombosis, anxiety . Interventions as following:- Allow/Encourage me (R59) to participate in my own ADLs of choice.On 9/4/2025 at approximately 12:15 p.m., the Director of Nursing (DON) was interviewed and was informed of R59 's specialty call lights was not within reach to aid in assistance with ADLs care. The DON said that all managers have pagers to answer call lights, and the call lights should always be in reach of the residents. The DON stated, The purpose of having the call light is to get assistance with ADLs and for safety. According to the facility's 5/1/2017 Call Light policy: Call lights will receive consistent and adequate response to best meet the individual needs of each resident. Procedure: Call lights will be placed within reach of the resident.

Based on interview and record review the facility failed to ensure a Pre-admission Screening and Annual Resident Review (PASARR-determines whether or not an individual who has a diagnosis of Mental Illness or Intellectual/Developmental Disability [ID/DD] meets the criteria for a nursing home and they're needs are met) Level I (3877) was completed for two residents (R6 and R160) out of five residents reviewed for PASSARs. Findings include:R6A review of R6's Electronic Health Record (EHR) did not reveal the current 3877 form. There was not a Mental Illness/Intellectual/Developmental Disability/Related condition exemption Criteria Certification (DCH-3878) form. (The DCH-3878 is a State of Michigan Department of Health and Human Services (MDHHS) form used to claim exemption for level ll screening). R6 was admitted to facility on [DATE] with most recent readmission on [DATE] with pertinent diagnoses of Dementia, and Suicidal Ideations. Review of a Minimum Data Set (MDS) assessment, with a reference date of [DATE] revealed R6 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 13/15.On [DATE] at 1:07 PM, Social Worker B was interviewed and said the annual 3877 was not completed for R6 and should have been completed on [DATE].R160A review of R160's Electronic Health Record (EHR) did not reveal the current 3877 form. The Mental Illness/Intellectual/Developmental Disability/Related condition exemption Criteria Certification (DCH-3878) form expired on [DATE]. (The DCH-3878 is a State of Michigan Department of Health and Human Services (MDHHS) form used to claim exemption for level ll screening). R160 was admitted to facility on [DATE] with pertinent diagnoses of Schizoaffective Disorder, Bipolar Type, and Altered Mental Status.Review of a Minimum Data Set (MDS) assessment, with a reference date of [DATE] revealed R6 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 3/15.On [DATE] at 1:07 PM, Social Worker B was interviewed and said the hospital exemption discharge expired on [DATE] and a new Passar should have been completed.On [DATE] at 1:10 PM, the Nursing Home Administrator (NHA) was interviewed and said PASARRs should be completed thoroughly and timely. On [DATE] at 3:00 PM The NHA was interviewed said the facility did not have a Passar policy since the facility follows OBRA (Omnibus Budget Reconciliation act of 1987).

Based on observation, interview and record review, the facility failed to provide at least 80 square feet per Resident in multiple resident bedrooms and at least 100 square feet for single Resident bedrooms, affecting 58 Resident rooms. Findings include: Observations made of the resident rooms on 09/04/2025 at 11:30 AM and review of the Facility Bed Count Information sheet revealed the following: ROOM # SQ. FT # OF BEDS # of Residents 20 154 2 221 154 2 223 147 2 224 147 2 226 147 2 228 147 2 229 147 2 230 153 2 233 147 2 234 147 2 235 147 2 238 147 2 239 147 2 240 147 2 242 147 2 244 147 2 245 147 2 246 147 2 247 153 2 251 147 2 252 147 2 262 153 2 264 147 2 265 147 2 269 148 2 272 147 2 275 147 2 278 142 2 280 144 2 283 142 2 284 143 2 287 142 2 291 144 2 292 142 2 2102 142 2 2107 144 2 2112 141 2 2116 141 2 2117 141 2 231 153 2 136 147 2 141 147 2 143 147 2 149 153 2 150 147 2 161 153 2 167 148 2 168 148 2 1 70 147 2 171 147 2 173 147 2 176 147 2 177 147 2 1100 142 2 1104 142 2 1109 141 2 1115 141 2 174 158 2 0 On 09/05/2025 12:57 PM, he Nursing Home Administrator (NHA) was interviewed and said the facility has 58 rooms that do not meet square footage requirements. Eighteen rooms have two residents, and 39 rooms have one resident and one room was unoccupied. The NHA explained even though some rooms only had one resident or was not occupied all the rooms were intended to be two room occupancy. Documents reviewed revealed the rooms varied in sizes but did not meet the square footage requirements.

Based on observation, interview and record review, the facility failed to properly dispose of garbage, medical supplies, yard refuse debris, for one opened dumpster top, affecting all residents, staff and visitors, resulting in the potential for the harborage of pests and insects.Findings include:On 9/2/25 at 07:35am, two dumpster containers were observed near the building with separate top lids. The dumpster on the right-side was observed with its lid opened, exposing multiple boxes, loose paper, and tree branches. In between the dumpster and the compressor was a wheelbarrow filled with tree branches, pieces of cardboard, leaves, and loose papers. Behind the compressor was a fence with leaves, paper, Styrofoam cups, plastic water bottles, medical gloves, yellow face mask and broken tree branches. In front of the dumpster and compressor were yellow medical face masks, examination gloves, multiple cigarette butts, pieces of paper and pieces of cardboard, and small tree branches. There were also flies swarming around the dumpsters. No staff were observed near the dumpster area.On 9/2/25 at 07:48am, an interview was conducted with the Director of Maintenance in the dumpster area. The Director of Maintenance asked who was responsible for making sure the dumpster area was clean and free from debris. The Director of Maintenance said, The staff that was assigned to clean the dumpster area was fired.Now I'm cleaning this area.On 9/5/2025 at 9:40am, the Nursing Home Administrator (NHA) was interviewed about the expectation of maintaining cleanliness of the dumpster and compressor area. The NHA said the expectation is that the dumpster and compressor area would be kept clean.The NHA said the facility did not have a policy for dumpster/compressor cleanliness. The NHA provided a Director of Maintenance job description that revealed the following: The Director of Maintenance is responsible for managing and assisting with the completion of day-to-day activities involving maintenance of the facility, equipment and machinery.grounds keeping, and the overall facility appearance.

Based on observation, interview and record review the facility failed to ensure a specialty call light was within reach of one resident (R59) out of ten residents reviewed for call light, resulting in unmet care needs. On 9/2/2025 at 10:39 a.m., R59 was observed lying in bed with a specialty call light (can be used by the resident only with the shoulders and the back of the head) pinned to the bed covers on the right side of the bed. During an interview, R59 reported trying to get staff attention for about half an hour since no staff had been in the room to have oral care provided and to be assisted with getting up out of bed. During the interview and observation, R59 confirmed the call light was unable to be used by hands, only with the shoulder and the back of the head. R59 stated, I have difficulties using a regular call light because my arms don't move to get it.On 9/2/2025 at 10:42 a.m. Licensed Practical Nurse (LPN) C (R59's assigned nurse) said during an interview that R59 can't use the call light by hands and was unable to verbalize what part of the body R59 could use the call light with. LPN C' left the room and entered again and stated, Oh, it's a motion call light, he can move his head around and the call light will go off. LPN C' pinned R59 call light on the right side of the resident's pillow under R59's head. LPN C verified R59 was unable to turn the call light on from the position the call light was pinned previously. R59 demonstrated using the back of the head to turn the call light on and then verbalized wanting assisting with ADL care to LPN C.According to the electronic medical records, R59 was initially admitted into the facility on 1/31/2013 and re admitted [DATE] with diagnoses of multiple sclerosis, seizure, pressure ulcer of sacral region stage four, arthritis, osteomyelitis of vertebra, sacral and sacrococcygeal region, major depressive disorder, adjustment disorder with mixed anxiety, and hypertension. R59's quarterly Minimum Data Set (MDS) with a reference date of 7/10/2025, indicated R59 had intact cognition with a BIMS (brief interview for mental status) score of 13/15, required extensive assistance of two-person with bed mobility, totally dependent on two-person for transfers, extensive assistance of one person with Activities of Daily Living (ADLs), and was incontinent of bowel and bladder. Review of the ADLS care plan dated 7/10/2025 documented, I have an actual ADL deficit related to multiple sclerosis, hypertension, Neuropathy, generalized muscle weakness, impaired mobility, muscle wasting & atrophy, bilateral contractures to upper extremities, deep vein thrombosis, anxiety . Interventions as following:- Allow/Encourage me (R59) to participate in my own ADLs of choice.On 9/4/2025 at approximately 12:15 p.m., the Director of Nursing (DON) was interviewed and was informed of R59 ‘s specialty call lights was not within reach to aid in assistance with ADLs care. The DON said that all managers have pagers to answer call lights, and the call lights should always be in reach of the residents. The DON stated, The purpose of having the call light is to get assistance with ADLs and for safety. According to the facility's 5/1/2017 Call Light policy: Call lights will receive consistent and adequate response to best meet the individual needs of each resident. Procedure: Call lights will be placed within reach of the resident.

Based on interview and record review the facility failed to ensure a Pre-admission Screening and Annual Resident Review (PASARR-determines whether or not an individual who has a diagnosis of Mental Illness or Intellectual/Developmental Disability [ID/DD] meets the criteria for a nursing home and they're needs are met) Level I (3877) was completed for two residents (R6 and R160) out of five residents reviewed for PASSARs. Findings include:R6A review of R6's Electronic Health Record (EHR) did not reveal the current 3877 form. There was not a Mental Illness/Intellectual/Developmental Disability/Related condition exemption Criteria Certification (DCH-3878) form. (The DCH-3878 is a State of Michigan Department of Health and Human Services (MDHHS) form used to claim exemption for level ll screening). R6 was admitted to facility on [DATE] with most recent readmission on [DATE] with pertinent diagnoses of Dementia, and Suicidal Ideations. Review of a Minimum Data Set (MDS) assessment, with a reference date of [DATE] revealed R6 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 13/15.On [DATE] at 1:07 PM, Social Worker B was interviewed and said the annual 3877 was not completed for R6 and should have been completed on [DATE].R160A review of R160's Electronic Health Record (EHR) did not reveal the current 3877 form. The Mental Illness/Intellectual/Developmental Disability/Related condition exemption Criteria Certification (DCH-3878) form expired on [DATE]. (The DCH-3878 is a State of Michigan Department of Health and Human Services (MDHHS) form used to claim exemption for level ll screening). R160 was admitted to facility on [DATE] with pertinent diagnoses of Schizoaffective Disorder, Bipolar Type, and Altered Mental Status.Review of a Minimum Data Set (MDS) assessment, with a reference date of [DATE] revealed R6 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 3/15.On [DATE] at 1:07 PM, Social Worker B was interviewed and said the hospital exemption discharge expired on [DATE] and a new Passar should have been completed.On [DATE] at 1:10 PM, the Nursing Home Administrator (NHA) was interviewed and said PASARRs should be completed thoroughly and timely. On [DATE] at 3:00 PM The NHA was interviewed said the facility did not have a Passar policy since the facility follows OBRA (Omnibus Budget Reconciliation act of 1987).

Based on observation, interview and record review, the facility failed to provide at least 80 square feet per Resident in multiple resident bedrooms and at least 100 square feet for single Resident bedrooms, affecting 58 Resident rooms. Findings include: Observations made of the resident rooms on 09/04/2025 at 11:30 AM and review of the Facility Bed Count Information sheet revealed the following: ROOM # SQ. FT # OF BEDS # of Residents 20 154 2 221 154 2 223 147 2 224 147 2 226 147 2 228 147 2 229 147 2 230 153 2 233 147 2 234 147 2 235 147 2 238 147 2 239 147 2 240 147 2 242 147 2 244 147 2 245 147 2 246 147 2 247 153 2 251 147 2 252 147 2 262 153 2 264 147 2 265 147 2 269 148 2 272 147 2 275 147 2 278 142 2 280 144 2 283 142 2 284 143 2 287 142 2 291 144 2 292 142 2 2102 142 2 2107 144 2 2112 141 2 2116 141 2 2117 141 2 231 153 2 136 147 2 141 147 2 143 147 2 149 153 2 150 147 2 161 153 2 167 148 2 168 148 2 1 70 147 2 171 147 2 173 147 2 176 147 2 177 147 2 1100 142 2 1104 142 2 1109 141 2 1115 141 2 174 158 2 0 On 09/05/2025 12:57 PM, he Nursing Home Administrator (NHA) was interviewed and said the facility has 58 rooms that do not meet square footage requirements. Eighteen rooms have two residents, and 39 rooms have one resident and one room was unoccupied. The NHA explained even though some rooms only had one resident or was not occupied all the rooms were intended to be two room occupancy. Documents reviewed revealed the rooms varied in sizes but did not meet the square footage requirements.

This citation pertains to intake MI00153194. Based on interview, and record review the facility failed to maintain one resident's (R101) right to privacy and confidentiality when a staff member posted a video of the resident on social media without their or their Legal Guardian's consent. Findings include: The State Agency (SA) received a Facility Reported Incident (FRI) and a Complaint that a video had been temporarily posted on a social media site unbeknownst to the resident or their Legal Guardian. On 6/3/25 at approximately 10:30 AM the Nursing Home Administrator said R101's family informed them that on 5/18/25 the resident's image had been posted on a staff member's social media site for a short period of time before it was deleted. During an immediate investigation it was confirmed the video had been temporarily posted on a staff member's social media site and the SA was notified. The video was viewed and revealed the resident was seated in a wheelchair fully clothed in a common area by themselves yelling out. The video was approximately 20 seconds. There was no signs or symptoms of injury. The resident was sent to the hospital for evaluation per the family's request. The resident of concern has diagnoses of mood disorder, psychotic disorder with delusions, and dementia with behaviors. The NHA immediately suspended the staff member, Certified Nursing Assistant (CNA) A, and ultimately terminated their employment with the facility for violating the facility's privacy and abuse policy. The NHA initiated re-education for all facility staff on the facility's privacy and abuse policy and began auditing other residents to determine an on-going concerns. The NHA said no additional concerns had been identified. R101 no longer resides at the facility. On 6/3/25 at 11:07 AM during an interview with CNA A they said it was all a misunderstanding. CNA A said they were unaware the video was being posted to their social media site. I'm a new CNA and was not paying attention to what I was doing. I'm very sorry this happened. CNA A confirmed they had been terminated from the facility for violating the facility's privacy policy. On 6/3/25 at 11:22 AM, R101's family member and Legal Guardian (LG) was interviewed regarding the incident. R101's LG said the resident has a history of behaviors shown on the video and did not believe the resident (R101) was abused. The LG said they would be making arrangements to have the resident transferred back to the facility. According to R101's Electronic Health Record (EHR) they admitted on [DATE] with multiple diagnoses that included altered mental status, unspecified dementia with behaviors, and psychotic disorder with delusions. A care plan for behaviors included the following intervention; allow the resident to have space in a stress free environment. During the onsite survey, past noncompliance was cited after the facility implement actions to correct the noncompliance which included: Review of the facility's education sessions from 5/18/25 and 5/19/25 revealed all staff had been re-educated on the facility's abuse policy by 5/19/25. Review of the facility's resident audits revealed that no additional residents had been affected or had concerns with staff. Review of the facility's resident council meeting minutes from 2/2025, 3/2025, and 4/2025 revealed there were no complaints or concerns regarding abuse or violations of resident's privacy. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on interview and record review, the facility failed to ensure adequate temperature monitoring of the facility's hot water holding tanks, resulting in the potential for inadequate water temperatures to go undetected that could cause the growth and spread of waterborne pathogens. Findings include: On 9/11/24 beginning at 3:22 PM, an interview and record review were conducted with Maintenance Director C and the Nursing Home Administrator (NHA) regarding the monitoring of the facility's hot water holding tanks. Maintenance Director C said the facility had three hot water holding tanks that were monitored weekly. Two tanks were located in the [NAME] boiler room and one tank was located in the East boiler room. The hot water holding tank temperature logs for April 2024, May 2024, and June 2024 were reviewed and only documented the water temperature of the East boiler room tank. The Maintenance Director did not provide documentation of the temperature readings for the two tanks located in the [NAME] boiler room. The NHA said the temperatures of all three boilers should have been obtained and documented individually to ensure the water was at an adequate temperature to prevent bacterial growth. A facility document provided during the survey titled, Identification of Areas Where Legionella Could Grow and Spread, documented in part the following: - The hot water holding tanks were identified as potential areas for Legionella growth. - The domestic tank that supplies water directly to sinks/showers and water fountains has a thermometer and temperature is monitored and recorded weekly and maintained between 105-120 degrees Fahrenheit. - Temperatures of the two holding tanks that supply water to kitchen are also monitored and recorded weekly. The temperatures of these holding tanks are higher with a maximum of 140 degrees Fahrenheit. - All temperatures are logged into TELS by the facility Maintenance Director.

Based on interview and record review the facility failed to provide a qualified social worker to meet resident psychosocial, mental and behavioral health needs. This has the potential to affect all residents who reside in the nursing facility. Findings include: 09/11/24 01:12 PM, Social Work Tech (SWT) A was interview regarding her current position. Social Work Tech (A) said she was the Activities Assistant prior to her current position. SWT A reported they had been a Social Work Tech since April of 2024. 09/11/24 at 01:32 PM, the Acting Director of Nursing (ADON) was interviewed regarding the facility employing a qualifed Social Worker and explained at this time they (facility) do not have a social worker. The ADON said nor do they have a Corporate Social Worker at this time. 09/11/24 at 04:10 PM, an interview with Social Work Tech B revealed they have worked at the facility since February of 2024. Social Work Tech B said she does not have a bachelor's degree. Hence, Social Work Tech B does not meet the minimum qualifications. On 9/12/24 at 09:45 AM, an interview with the Nursing Home Administrator (NHA) revealed the facility had made several attempts to hire a qualified Social Worker. The NHA stated for a few months they had the Social Worker from another facility come over to train Social Worker Techs (A and B) twice a week. On 9/12/24 at approximately at 3:45 P.M., the Medical Director was interviewed and indicated being aware that the facility did not have a qualified Social Worker. Record review showed the last staffed Social Worker at the facility was in February 2024. The facility's job description for Social Worker was reviewed and noted the qualification for the Social Worker is a bachelor's degree in social work or related human service field. To date the position has not been filled.

Based on observation, interview, and record review, the facility failed to honor food allergies for one resident (R240) of 28 reviewed for dining. Findings include: On 9/10/24 at 10:51 AM, R240 was asked about the food at the facility. R240 reported, Yesterday they had shrimp on my plate and I'm allergic to that (shrimp). A review of R240 Electronic Medical Record (EMR) profile noted, Allergies: Iodine, Shell Fish, diagnostic x-ray materials. Further review of R240's EMR noted, R240 was admitted to the facility on [DATE] with diagnosis of Acute and Chronic Respiratory Failure. A review of R240's admission Minimum Data Set assessment dated [DATE], noted R240 with an intact cognition. Care plan reviewed and allergies are noted on the care plan Iodine, Shell Fish, diagnostic x-ray materials. A review of the facility's dinner menu titled, Spring Summer 2024 Dinner: Monday Shrimp & grits, Collard Greens, Cornbread, Peach Cobbler. A review of R240's meal ticket dated 9/9/24 noted, Meal Period: Week 2 Monday Dinner, Cold Items, 1. Lemonade. Hot Items: 1. Collard [NAME] (4 oz spoodle), Cornbread, Grilled Chicken Breast (3 oz). Expo Items: 1. Fresh Fruit Cup (4oz spoodle) 1. Italian Dressing, Mrs. Dash (2 packet), 1. Garden Salad (1 cup), 1. Peach Cobbler. In a highlighted RED box revealed, ALLERGIES: SHELL FISH On 9/12/24 at 3:21 PM, the Dietary Manager (DM) was asked about R240's meal tray and allergies. The DM explained, the kitchen staff uses the meal ticket with three staff to make sure the food items are correct and the last person to give the final check before served. The Dietary Manager was asked about the shrimp that was served on R240's tray. The DM explained, R240 having shrimp served was an error. The Dietary Manager continued and stated, I looked on [R240's] menu for that day and [R240] should have gotten grilled chicken breast. A review of R240's care plan noted, Interventions: Diet order: regular diet w/ low sodium modifications Allergies: Shellfish. Date Initiated: 09/03/2024. Honor food preferences as feasible. Date Initiated: 08/31/2024. On 9/12/24 at 3:37 PM, the Nursing Home Administrator (NHA) was asked their exceptions for meal services. The NHA explained for the kitchen staff to be accurate according to the tray card. A review of the facility's policy titled, ALLERGIES dated, July 1, 2009 revealed, PURPOSE: 1. To prevent anaphylaxis. 2. To prevent all allergic reactions. EQUIPMENT: 1. Resident ' s admission record indicating drug and food sensitivities. 2. Adverse reaction (allergy) labels. PROCEDURE: . 5. Notify dietary department if allergic to certain foods .

Based on interview and record review the facility failed to ensure aPreadmission Screening and Resident Review, (PASARR) II was completed for one R114 of three residents reviewed for PASARR's resulting in the potential for unmet mental health needs. Findings include: Record review of the electronic medical record (EMR) revealed R114 admitted in to the facility on [DATE] with pertinent diagnosis of bipolar disorder. A care plan dated 9/11/2024 noted R114 was on antidepressant medications. Review of the Medication Administration Record (MAR) noted R114 was administered duloxetine (antidepressant) for bipolar disorder. The resident had an initial, PASARR dated 11/6/2023 on file which stated R114 did not have mental illness. According to the quarterly Minimum Data Set, (MDS), dated [DATE], revealed R114's Brief Interview for Mental Status, (BIMS) of 11/15 (moderately impaired cognition.) 09/11/24 01:12 PM, the Social Work Tech (SWT) A was asked if R114 should have a PASSAR II and said they would check and see if resident should have a PASSAR II. 09/11/24 01:32 PM, the Acting Director of Nursing (ADON) was interviewed regarding the missing PASSAR II for R114. The ADON explained, at this time the facility does not have a Social Worker, and this is possibly why the PASSAR II was not obtained. The ADON added the Inter Disciplinary Team (IDT) should have caught this discrepancy. The ADON said there should have been a PASSAR done.

Based on observation, interview, and record review, the facility failed to provide 80 square feet per resident, in multiple resident rooms in 57 of 109 resident rooms (#'s 20, 21, 23, 24, 26, 28, 29, 30, 31, 33, 34, 35, 36, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 49, 50, 51, 52, 61, 62, 64, 65, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 80, 83, 84, 87, 91, 92, 100, 102, 104, 107, 109, 112, 115, 116, and 117), resulting in the potential for inadequate living space. Findings include: Review of the Room Waiver sheet, dated 1/9/20, revealed the following Medicare/Medicaid rooms that did not provide adequate square footage for residents: ROOM # SQUARE FT. BEDS 20 154 2 21 154 2 23 147 2 24 147 2 26 147 2 28 147 2 29 147 2 30 153 2 31 153 2 33 147 2 34 147 2 35 147 2 36 147 2 38 147 2 39 147 2 40 147 2 41 147 2 42 147 2 43 147 2 44 147 2 45 147 2 46 147 2 47 153 2 49 153 2 50 147 2 51 147 2 52 147 2 61 153 2 62 153 2 64 147 2 65 147 2 67 148 2 68 148 2 69 148 2 70 147 2 71 147 2 72 147 2 73 147 2 74 158 2 75 147 2 76 147 2 77 147 2 78 142 2 80 144 2 83 142 2 84 143 2 87 142 2 91 144 2 92 142 2 100 142 2 102 142 2 104 142 2 107 144 2 109 141 2 112 141 2 115 141 2 116 141 2 117 141 2 Observations and interviews with various residents revealed no complaints, and no health and safety concerns.

This citation pertains to MI000143957 Based on observation, interview, and record review, the facility failed to ensure call lights were within reach for three (R101, R102 and R103) of three residents reviewed for accommodation of needs resulting in unmet care needs. Findings include: R101 On 5/17/2024 at 9:30 AM R101 was observed in bed with bedside table approximately two feet from head of bed. When asked can you reach for your water on your bedside table R101 replied I can't reach it and demonstrated limited arm movement. When asked can you use your call light R101 said he didn't know where it was. R101's call light was observed at the head of bed between the mattress and headboard. Record review of R101's Electronic Medical Record (EMR) revealed admitted to facility on 9/13/2023 with most recent readmission on 4/16/2024 with pertinent diagnosis of Multiple Sclerosis. Review of the Minimum Data Set (MDS) dated [DATE] for R101 revealed a Brief interview for Mental Status (BIMS) of 15/15 intact cognition and dependent assistance for Activities of Daily Living (ADLs). On 5/17/2024 at 9:45 AM R101's call light was observed with Registered Nurse (RN) A. RN A said R101's call light was between the mattress and headboard and R101 cannot reach it to call for help. The call light should be within reach of the resident. Review of R101's care plan intervention dated 9/14/2023 noted to make the Call light accessible. R103 On 5/17/2024 at 9:35 AM R103 was observed in bed and asked to have his feet repositioned. When R103 was asked can you use your call light to ask for help R103 replied I can't find my call light otherwise I would have used it to call for help already. R103's call light was observed attached to the left side of the mattress hanging near the floor. R103 was not able to reach for the call light when asked. Record review of R103's EMR revealed admitted to facility on 1/31/2024 with most recent readmission on 2/18/2024 with pertinent diagnosis of Dependence of Renal Dialysis and Functional Quadriplegia. Review of the MDS dated [DATE] for R103 revealed a BIMS of 14/15 intact cognition and substantial assistance for ADLs. On 5/17/2024 at 9:48 AM R103's call light was observed with Registered Nurse (RN) A. RN A said R103's call light was on the side of the bed near the floor out of reach of R103. The call light should be within reach of the resident. Review of R103's care plan intervention dated 1/31/2024 revealed to ensure resident Call light accessible. R102 On 5/17/2024 at 9:50 AM R102 was observed in bed and asked to be repositioned. When asked can you use your call light for help R102 replied I can't reach for it my arms don't work. R102's call light was observed at the head of the bed between the mattress and headboard. Record review of R102's EMR revealed admitted to facility on 1/31/2013 diagnosis included Multiple Sclerosis. Review of the MDS dated [DATE] for R102 revealed a BIMS of 15/15 intact cognition and dependent assistance for ADLs. On 5/17/2024 at 10:25 AM R103's call was observed with Certified Nursing Assistant (CNA) B. CNA B said R103's call light was out of reach observed at head of bed between mattress and headboard. CNA B said the call light should be within reach of the resident. Review of R102's care plan intervention dated 1/4/2022 revealed to ensure resident Call light accessible. On 5/17/2024 at 2:00 PM the Nursing Home Administrator was interviewed and said call lights should be within reach of dependent residents. Review of the facility's policy titled Call Light Use dated 4/1/2008 revealed in part .When providing care to residents be sure to position the call light conveniently for the resident to use. Tell the resident where the call light is and show him/her how to use the call light, be sure call lights are placed within resident reach, never on the floor or bedside stand.

Based on interview and record review, the facility failed to perform and document neurological checks per physician's order for one resident (R507) of three resident reviewed for falls. Findings include: A review of R507's Electronic Medical Record (EMR) revealed R507 was admitted to the facility on [DATE]. R507 had the following medical diagnoses: Cerebral Infarction (Stroke), Seizures, Dementia, Difficulty Walking, and a History of Falling. A review of R507's Quarterly Minimum Data Set (MDS) dated [DATE] revealed R507 could not be assessed for a Brief Interview of Mental Status. According to the Quarterly MDS, R507 had impairment to their left upper extremity. A review of R507's ADL care plan dated 4/7/23 revealed the following interventions: Ambulation: non-ambulatory .Wheelchair w/footrest for locomotion .transfer: 1 person assist. A review of R507's incident report dated 2/2/24 revealed the following: R507 had an unwitnessed fall. R507 was observed by the Nurse C on the floor with a bedside table in hand. Nurse C asked R507 if he hit his head. R507 said no. R507 was not able to describe what happened. Action was taken by initiating neurological checks, conducting vital signs, range of motion, and a skin assessment. R507 suffered no injuries and was placed back in bed. It was found that R507 did not use his call light. The physician and emergency contact were notified. A review of the neurological assessments in the EMR revealed R507 had one neurological check for the interval of every hour for 4 hours. Also, R507 had one neurological check for the interval of one neurological check for 24 hours. There were no other neurological checks documented in the EMR. On 2/6/24 at 3:58 PM the Nursing Home Administrator (NHA) and Regional Director of Operations (RDO) A were queried about the missing neurological checks. The NHA and RDO verified there were only two neurological checks in the EMR and there was not any paper documentation of the neurological checks. The NHA stated, R507 should have absolutely had neurological checks done.

This citation pertains to intake 141501. Based on interview and record review, the facility failed to perform and document administration of catheter care in the Electronic Medical Record (EMR) for one resident (R501) of three residents reviewed for catheter care. Findings include: A review of R501's EMR revealed R501 was admitted to the facility initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. R501 had medical diagnoses that included: Urinary Incontinence and Flaccid Neuropathic Bladder (dysfunction of the bladder in which the bladder is weakened). A review of R501's Quarterly Minimum Data Set (MDS) dated [DATE] revealed R501 had a Brief Interview of Mental Status (BIMS) score 15/15 (cognitively intact). According to the quarterly MDS, R501 had an indwelling catheter. A review of R501's Activities of Daily Living (ADL) care plan dated 9/14/23 revealed that R501 was non-ambulatory and required one person assistance with bed mobility. A review of R501's Indwelling Catheter care plan, dated 9/14/23, revealed the following interventions: Assure catheter and drainage bag are below the level of the bladder and anchored; Change catheter collection bag as needed; Check catheter system every shift for patency and integrity; Document color, clarity and odor of urine as needed; Empty drainage bag & record output every shift and PRN; Ensure the foley catheter is anchored every shift. A review of R501's Physician orders revealed the following: Foley catheter care per shift. Assess catheter placement, tubing and anchor. Record output. Order date 9/13/23. AND Foley catheter care per shift. Assess catheter placement, tubing and anchor. Record output. Order date 12/13/23 A review of R501's Treatment Administration Record (TAR) for the months of October 2023, December 2023, January 2024, and February 2024 revealed missing documentation for the following days and shifts: October 7th during day shift October 8th during day shift October 28th during day shift December 1st during day shift December 2nd during day shift December 8th during day shift December 11th during day shift January 2nd during night shift January 14th during day shift January 18th during night shift January 29th during evening and night shift February 5th during day shift On 2/6/24 at 3:49 PM Regional Director of Operations (RDO) A, who confirmed she had been working at the facility, was queried regarding the missing documentation in the TAR. RDO A verified the documentation for catheter care documentation was not in the EMR. The RDO A said catheter care should be done every shift and as needed as outlined in the care plan.

This citation pertains to intake MI00141501. Based on observation, interview, and record review, the facility failed to perform proper hand hygiene, catheter hygiene, and glove usage when providing catheter care for one resident (R501) of three residents reviewed for adequate catheter care. Findings include: On 2/6/24 at 1:34 PM Certified Nurse Assistant (CNA) B was observed performing catheter care for R501. CNA B entered put on gloves and began to position R501 to be changed. R501's urinal fell off the bedside table. CNA B picked up the urinal with gloved hands and placed the urinal back on the bedside table. CNA B continued to position R501 to be changed. CNA B took a cleansing wipe and cleansed the catheter portion entering the penial shaft several times with the same section of the cleansing wipe. After R501 was cleaned and changed, CNA B removed the gloves and walked out of the room. On 2/6/24 at 1:43 PM CNA B was queried about infection control practices while performing catheter care. CNA B said she did not sanitize her hands at the start, during, and after care. CNA B said she should have changed gloves when something dirty (urinal) was touched. CNA B said she should have not wiped with the same section of the wipe while cleansing the catheter. A review of R501's EMR revealed R501 was admitted to the facility initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. R501 had medical diagnoses that included: Urinary Incontinence and Flaccid Neuropathic Bladder (dysfunction of the bladder in which the bladder is weakened). A review of R501's Quarterly Minimum Data Set (MDS) dated [DATE] revealed R501 had a Brief Interview of Mental Status (BIMS) score 15/15 (cognitively intact). According to the quarterly MDS, R501 had an indwelling catheter. A review of R501's Activities of Daily Living (ADL) care plan dated 9/14/23 revealed that R501 was non-ambulatory and required one person assistance with bed mobility. A review of R501's Indwelling Catheter care plan dated 9/14/23 revealed the following interventions: Assure catheter and drainage bag are below the level of the bladder and anchored; Change catheter collection bag as needed; Check catheter system every shift for patency and integrity; Document color, clarity and odor of urine as needed; Empty drainage bag & record output every shift and PRN; Ensure the foley catheter is anchored every shift. On 2/6/24 at 3:55 PM the Nursing Home Administrator (NHA) was queried about infection control practices and expectations of nursing staff when providing catheter care. The NHA said the facility nursing staff should follow the infection control process and protocol when providing care. A review of the facility's policy titled Handwashing and Hand Hygiene dated 7/1/18 revealed in part, Hand hygiene must be performed to avoid transfer of microorganisms to self, other residents, personnel, equipment and/or the environment. Specific examples include but are not limited to: Before and after providing personal care for a resident .after removing gloves.

This citation has two deficient practice statements. Deficient Practice Statement #1. This citation pertains to intake MI00138127. Based on interview and record review the facility failed to ensure that a physician's order was followed for one resident (R12) out of three residents reviewed for medication administration, resulting in R12 missing two scheduled colonoscopy appointments. Findings include: Record review revealed R12 was admitted into the facility on [DATE] with diagnoses of Spina Bifida (birth defect where spinal cord does not develop properly), paraplegia (paralysis of lower body). According to the Minimum Data Set (MDS) dated [DATE], R12 had intact cognition and required extensive to total assistance with most Activities of Daily Living (ADLS). During a phone conversation on 8/8/23 at 2:45 PM with Concerned Family Member (CFM) D it was reported that the facility had not provided the medications before the colonoscopy and the appointment had to be cancelled twice. Record review of physician's order dated 5/19/23 at 1:14 PM documented the following: Appointment: with Provider, for colonoscopy w/ [NAME] (Anesthesia) on Monday 7-03-23 @12pm . Record Review of the Medication Administration Record (MAR) dated for the month of July 2023. The following order was documented to administer on 7/2/23, Golytely Oral Solution (solution used to cleanse bowel before colonoscopy) Reconstituted 236 GM (grams). Give 2 liter by mouth one time only for colonoscopy until 07/02/2023 21:00 Drink 8 oz of GoLYTELY every 10 to 15 minutes until half of the container is gone. Patient to drink 2 out of the 4 liters from 6pm to 7:30pm . Further review of the MAR revealed Golytley was not administered to resident as ordered. Review of the Nursing Progress Notes dated 7/3/23 documented, 7/3/2023 10:00 - (Medication Administration Note)- Note Text held for outpatient procedure at 12pm today at (Hospital Provider). Record review of physician's order dated 7/3/23 at 5:08 PM documented the following: Appointment: with Provider, for colonoscopy w/ [NAME] (Anesthesia) on Monday 7-11-23 @12pm . Record Review of Medication Administration Record (MAR) dated for the month of July 2023, revealed the physician's order for Golytley for the second scheduled procedure was not entered on the MAR. Record review of the Nursing Progress Notes dated 7/11/23 at 5:24 PM documented, Resident procedure cancelled for prep not administered and informed brother (name redacted), states ok please inform him of new appointment date and time. During interview on 8/10/23 at 11:27 AM with the Director of Nursing (DON), it was reported that nursing should follow and administer all orders given by the physician. When asked if the orders were followed by staff on 7/2/23, DON stated, No. When asked if nursing failed to transcribe the order to administer Golytley on 7/10/23, DON stated, Yes. When asked what the consequence of nursing not administering those orders, DON said, The resident missed both appointments to have the colonoscopy performed. Record review of policy PHYSICIAN ORDERS - RECEIVING, CHANGING, DISCONTINUING AND NOTING dated 7/1/08 documented the following: . Resident medications and treatments must be ordered by the physician. Charge nurses are responsible to receive, transcribe, change, discontinue and note physician orders per standard of nursing practice. 39958 Deficient Practice Statement #2. This citation pertains to intakes MI00134550. Based on observation, interview, and record review, the facility failed to ensure medication was administered timely per physician's orders and failed to accurately document medication administration for one residents (R38) of six residents reviewed for medication administration, resulting in the potential for less than therapeutic effect of the prescribed medication when medications were not taken or administered properly. Findings include: In an observation on 8/9/23 at 10:54 a.m., Licensed Practical Nurse (LPN) A prepared medications for Resident #38 (R38). LPN A removed Oxycodone (pain) 5mg and Pregabalin (nerve pain) 25mg from the narcotic backup box and placed them in a cup. LPN A then documented the two medications as given on the MAR (Medication Administration Record). LPN A then placed nine medications in the medication cup. On 8/9/23 at 10:57 a.m., LPN A entered R38's room and administered medication. LPN A then exited the room and returned to the medication cart. On 8/9/23 at 11:02 a.m., LPN A did not document R38's medication administration. LPN A reported medication administration will be documented when all residents receive their medication because they are running behind. LPN A then reported the Oxycodone and Pregabalin was documented before the administration so that the medications can be time stamped. In an interview on 8/9/23 at 11:12 a.m., the Director of Nursing (DON) reported medication should be documented after the administration. Review of an admission record revealed, R38 admitted to the facility 6/1/23 with pertinent diagnoses which included Non-Pressure Chronic Ulcer of the right and left foot. Review of Physician orders revealed R38 had orders which included, Oxycodone 5 mg give 1 tablet by mouth every 4 hours as needed for pain. Pregabalin 25mg give 1 capsule by mouth three times a day. In an interview on 8/10/23 at 2:13 p.m., the DON reported the Physician should be called for late medications. The DON then reported the acceptable time to administer medication 60 minutes before or after scheduled time. Review of a Medication Administration policy with a date of 01/21 revealed, Medications are administered as prescribed in accordance with manufacture's specifications, good nursing principles and practices . Medication Administration . 14. Medications are administered within 60 minutes of scheduled time . Documentation: 1. The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given .

This citation pertains to intake MI000134636. Based on interview and record review the facility failed to apply bed locking measures to ensure the safety of two residents (R101 and R103) of three residents reviewed for falls, resulting in a fall and one fall with injury. Findings include: R101 Review of the facility's incident report dated 2/13/23 at 6:15 am CNA B reported to Nurse A that R101 was on the floor. Nurse A entered the room and observed R101 between the bed and the wall with their back against the wall. R101 was alert and oriented and denied pain. Nurse A observed bleeding coming from the right side if R101's forehead and a laceration. Vital signs were taken. The doctor was notified. A skull and forehead x-ray was ordered. Nurse A cleaned the resident and initiated neuro checks. The Predisposing Situation Factors section of the incident report revealed that the bed was not locked when the incident took place. A review of R101 medical record revealed R101 was initially admitted to the facility on [DATE] and readmitted [DATE]. R101 discharged from the facility to the hospital on 2/13/23. Medical Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis of the right side after a stroke), muscle weakness, difficulty in walking. The admission Minimum Data Set MDS) dated [DATE] revealed R101 was cognitively intact as demonstrated by a BIMS 13/15 and R101 required one person assistance with bed mobility due to total dependence. On 3/21/23 at 4:00 pm, Nurse A was interviewed regarding R101's fall from the bed and stated, (CNA B) advised me the resident had fallen out of bed. I observed the bed in the high position. The resident was between the bed and the wall. When I made rounds beginning and during shift the resident's bed was positioned against the wall. The way (CNA B) described it there should have been two CNAs. On 3/22/23 at 9:40 am, CNA B was queried regarding R101's fall from the bed and stated, I was taking care of the lady. She's a one person assist. The bed was locked, and I turned her away from me because I couldn't clean her with her facing towards me. The bed started sliding. I grabbed a CNA to help me get her into bed. On 3/22/23 at 1:35 pm, the Administrator stated, I was told by CNA B and Nurse A that CNA B unlocked the bed to get to the side flush against the wall. At that time CNA B pulled the foot and of the bed out with the head of the bed staying against the wall, locked the bed, and provided care on the side of the bed that was lying flush against the wall. Then CNA B unlocked the bed put the bed back flushed against the wall without locking the bed. This is when the resident fell between the wall and the bed. CNA B should have locked the bed during care. After she moved the bed away from the way and once placing the bed back the bed should have been locked. R103 A review of the facility's incident report dated 2/13/23 at 11:09 pm revealed: Nurse C was called to the room by CNA D. Nurse C observed R103 lying on the floor next to his bed on his back. The bed was in the high position and the resident was soiled. An assessment was done, all responsible parties were notified, pain medication given as ordered, and neuro checks were started. The Predisposing Situation Factors section of the incident report revealed that the bed was not locked when the incident took place. A review of R103's medical record revealed R103 was admitted to the facility on [DATE]. R103's Medical Diagnoses include hemiparesis following cerebral infarction affecting left non-dominant side (paralysis of the left side after a stroke), muscle weakness, repeated falls, and history of falls. The Quarterly MDS dated [DATE] revealed R103 was severely cognitively impaired as demonstrated by a BIMS 0/15 and required one person extensive assistance with bed mobility. On 3/21/23 at 3:29pm, Nurse C was interviewed regarding the incident involving R103 and stated, (CNA D) saw he was leaning towards the side of the bed and (CNA D) then assisted the resident to the floor. The bed is normally supposed to be locked and during care if it is not locked, I will lock it. On 3/21/23 at 3:34pm, CNA D was interviewed regarding the incident involving R103 and stated, I was passing supplies to another resident. I walked passed his door and the resident (was) on the side of the bed. He looked like he was about to fall, so I came in and guided the resident down to the floor. On 3/22/23 at 1:35pm, the Administrator was interviewed regarding the fall incidents regarding R101 and R103 and stated, We don't have a standard policy for bed locking, but to me it is a standard practice that should be done.

Based on observation, interviews, and record review, the facility failed to ensure two readmitted residents (Resident (R) R4, and R8) from the acute care facility with unknown COVID-19 status were placed in 14-day quarantine. Instead, the two readmitted residents were placed in rooms with residents who had a negative COVID-19 status. In addition, facility staff failed to discard Personal Protective Equipment (PPE) after providing personal care to the two readmitted residents, R4 and R8, before leaving these residents' rooms and providing care to residents with negative COVID-19 status. The facility failed to ensure eight new admission residents (R1, R2, R5, R6, R7, R9, R10, and R11) with negative COVID-19 tests that were completed at the acute care facility, were placed in quarantine isolation for 14-days after admission to the facility. This failure had the potential to affect all 80 residents and staff on the negative COVID-19 Units B and C. On 05/14/20 at 5:35 PM, the Executive Director, the Director of Nursing (DON), and the Regional Clinical Director were notified that the failure to identify two residents, R4 and R8, who were readmitted to the facility with unknown COVID-19 status were placed in quarantine isolation for 14-days constituted an immediate jeopardy at F880. The facility presented an acceptable removal plan for the immediate jeopardy at F880 on 05/15/20 at 3:30 PM. The removal plan indicated that the two readmitted residents, R4 and R8, were placed into private rooms and that droplet isolation precautions were implemented which included droplet isolation signage on the doors and a PPE cart placed outside R4's and R8's rooms. The facility educated staff about the change of these two residents' status and room change and the facility's revised admission policy to implement the 14-day observation droplet isolation for all new and readmitted residents to the facility. The removal plan was validated through observations, interview of staff and record review. Observations verified that the readmitted residents were placed in private rooms, signage was on the doors with a date to end the 14-day quarantine, and PPE carts stocked with supplies outside each of the rooms. Staff was observed to remove their PPE and perform hand hygiene after providing care to residents in the droplet isolation 14-day quarantine rooms and apply new PPE before entering other residents' rooms. Review of the revised admission policy included new and readmitted residents would be placed on 14-day observation droplet isolation. Review of the facility's inservice education indicated that staff would use PPE specific for the observation droplet isolation rooms, remove the PPE after providing care to residents in droplet isolation 14-day quarantine, perform hand hygiene and apply new PPE prior to providing care to a resident with negative COVID-19 status. The surveyor notified the Executive Director that the immediate jeopardy at F880 was removed on 05/15/20 at 5:00 PM. Findings include: On 05/13/20 at 11:15 AM, during the tour of the facility with the DON and Executive Director, the Executive Director stated, the facility was divided into two sections: a COVID-19 positive area (Unit D and E) and a COVID-19 negative area (Unit B and C). During the interview on 05/13/20 at 11:30 AM, the LPN1 confirmed that nursing staff did not remove their PPE, except for the gloves, when they exited the rooms of a readmitted residents with unknown COVID-19 status and then going to provide care to a resident with a negative COVID-19 status. LPN1 stated, On the negative COVID-19 side of the facility, nursing staff do not remove their PPE after performing personal care for the residents who had returned from the acute care setting and their COVID-19 status was unknown. LPN1 verified, Nursing staff would exit these rooms, remove their gloves and perform hand hygiene, however, did not remove their PPE. We used to isolate residents for 14-days, but we do not do that anymore. After the interview on 05/13/20 at 11:35 AM with LPN1, the Executive Director and the DON confirmed that the COVID-19 negative unit (B and C) residents were all on a form of droplet isolation with staff wearing double masks, gowns, goggles and changing gloves between residents. Due to the lack of isolation gown inventory, staff were using patient gowns as isolation gowns, and not changing the gowns between the residents. Review of the facility's list of new admissions or readmission residents from the acute care facilities from 05/01/20 to 05/14/20 identified eight new admissions with documented negative COVID-19 test results from the acute care facility and two residents, R4 and R8, which were readmissions with unknown COVID-19 status. R4 and R8 were placed in rooms with a resident who had a negative COVID-19 test result. Of the eight residents with negative COVID-19 test results from the acute care facility, four residents (R5, R7, R10 and R11) were admitted to private rooms; R9 and R8 were roomed together and three residents (R1, R2, and R6) were roomed with other residents who had a negative COVID-19 test result. During an interview on 05/14/20 at 1:30 PM, the Executive Director stated, It made sense, although the facility was not doing it, to isolate for observation of new admission or readmission residents for 14-days after admission in order to monitor for symptoms prior to these residents being placed on the units with negative COVID-19 residents. During the interview on 05/14/20 at 2:05 PM, the Executive Director stated, The facility does not accept a resident for admission from an acute care facility without a COVID-19 test result. If the resident was a readmission and had a previous negative COVID-19 test prior to their admission to the acute care facility and readmission to the facility, the readmission resident would be accepted back to the COVID-19 negative unit B or C. New admissions or readmission residents were not placed on 14-day observation isolation. Only new admissions or readmission with a positive COVID-19 status are placed on the positive COVID-19 units of the facility. Record review revealed that R2 was a new admission to the facility on [DATE]. The acute care facility provided a negative COVID-19 test dated 04/21/20, which was 23 days prior to discharge from the acute care facility and admission to this facility. R2 was admitted to the same room with R13 who had documented evidence in the clinical record of a negative COVID-19 test. Record review revealed that R5 was a new admission to the facility on [DATE]. The acute care facility provided a negative COVID-19 test dated 04/13/20, which was 21 days prior to discharge from the acute care facility and admission to this facility. R5 was admitted to a private room. Record review revealed that R6 was a new admission to the facility on [DATE]. The acute care facility provided a negative COVID-19 test dated 04/21/20, which was 18 days prior to discharge from the acute care facility and admission to this facility. R6 was admitted to the same room with R16 who had documented evidence in the clinical record of a negative COVID-19 test. Record review revealed that R9 was a new admission to the facility on [DATE]. The acute care facility provided a negative COVID-19 test dated 04/27/20, which was 16 days prior to discharge from the acute care facility and admission to this facility. R9 was admitted to a room with R8, a readmission resident with unknown COVID-19 status. R9 and R8 were both placed in a room on the negative COVID-19 unit of the facility on the same day. Record review revealed that R8 was admitted to the acute care facility on 05/07/20 and readmitted to the facility on [DATE]. R8 was originally a resident of this facility and had a negative COVID-19 test result. Due to a change in mental status, R8 was transferred to an acute care facility. R8 was not tested for COVID-19 status by the acute care facility before admission the facility on 05/13/20. R8 was admitted to a room with R9, who was a new admission to the facility and had documented evidence of a negative COVID-19 status. R8 and R9 were both placed in a room on the negative COVID-19 unit of the facility on the same day Record review revealed that R11 was a new admission to the facility on [DATE]. The acute care facility provided a negative COVID-19 test dated 05/04/20, eight days prior to discharge from the acute care facility and admission to this facility. R11 was admitted to a private room. Record review revealed that R1 was a new admission to the facility on [DATE]. The acute care facility provided a negative COVID-19 test dated 04/27/20, seven days prior to discharge from the acute care facility and admission to this facility. R1 was admitted to the same room with R12 who had documented evidence in the clinical record of a negative COVID-19 test. Record review revealed that R10 was a new admission to the facility on [DATE]. The acute care facility provided a negative COVID-19 test dated 04/25/20, six days prior to discharge from the acute care facility and admission to this facility. R10 was admitted to a private room. Record review revealed that R7 was a new admission to the facility on [DATE]. The acute care facility provided a negative COVID-19 test dated 04/28/20, three days prior to discharge from the acute care facility and admission to this facility. R7 was admitted to a private room. Record review revealed that R4 was admitted to the acute care facility due to a swollen right eye on 04/28/20 and readmitted to the facility on [DATE]. R4 was not tested for COVID-19 status by the acute care facility before readmission to the facility. R4 was admitted into the same room with R15 who had documented evidence in the clinical record of a negative COVID-19 test. Review of the facility's policy titled, Fairlane Pandemic Plan, updated on 04/21/20, under the section Evaluate and Manage residents with symptoms of COVID-19 revealed, as roommates of residents with COVID-19 might already be exposed it is generally not recommended to place them with another roommate until 14-days after their exposure, assuming they have not developed symptoms or had a positive test. The facility did not provide a policy to isolate new admission or readmission residents for 14-days after their admission to the facility.

This citation pertains to intake number MI 332. Based on observation, interview and record review, the facility failed to develop and implement a plan of care and to provide prompt, appropriate treatment for one (#714) of 14 sampled residents reviewed for quality of care, resulting in prolonged pain, and delays in application of care devices and emergency hospital treatment following an acute fracture. Findings include: The complainant reported to the State agency that resident #714 sustained a broken arm and that the injury was not properly treated. On 11/5/18 at 10 AM, resident #714 was observed lying in bed with eyes opened, in a vegetative state, unresponsive to verbal stimuli and had a gastric feeding tube. The left arm was contracted (permanently flexed at the elbow) with a splint in place. The right hand/forearm was in a splint and in proper alignment. At 2 PM, the resident's clinical record was reviewed. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was placed under Hospice care on 2/2/18. On 2/2/18, the resident was prescribed Tylenol 650 milligrams (mg) for pain scheduled every 8 hours by gastric feeding tube. On 2/6/18, [MEDICATION NAME], 0.5 milliliters (ml), was prescribed underneath the tongue every four hours PRN (as needed) for breakthrough pain. Nursing progress notes revealed the following: 4/27/18 at 7:30 PM- The staff (nurse aide 'A') called me to the room stated, 'I went to change (resident). I pulled up her sleeve to take off her shirt and I heard her arm pop' resident unable to move arm the same as before. Crying when repositioned arm. Dr was notified. New order for x-ray of right shoulder and right elbow hospice called made aware of x-ray to right shoulder and elbow for increase in pain when arm is moved. Per Medication Administration Records (MARs), [MEDICATION NAME] was given at 10 PM. Per review of the resident's progress notes and MARs, there was no [MEDICATION NAME] given or any documented signs/symptoms of pain during (MONTH) prior to the injury on 4/27/18. 4/28/18 at 6:59 AM- Portable X-ray results: No acute fracture or dislocation. 4/28/18 at 11:19 AM- repositioned frequently for comfort with facial grimacing noted, medicated for pain with prn ([MEDICATION NAME]) MARs noted PRN [MEDICATION NAME] was given at 11:19 AM and 5:15 PM that day. 4/29/18 at 8:30 AM- Writer received contradicting xray results. Unable to verify the conclusion of the results. Spoke with (x-ray company) however no radiologist available. Results revealed a 'old healed humerus fracture.' The conclusion statement indicates an 'Acute humerus fracture.' D.O.N (Director of Nursing) notified Hospice notified Physician also paged Administrator also informed. 4/29/18 at 9:30 AM- I received call from hospice whom stated, I spoke with our physician, he states the fracture is old and resident has history of malignancy, our physician suggest a right arm sling for discomfort. 4/29/18 at 3:53 PM- resident assessed this am resident appear to be crying with facial grimacing, medicated with prn ([MEDICATION NAME]), right arm warm to touch, ice pack applied to r. shoulder and elbow, physician suggested r. arm sling for discomfort due to conflicting xray results new orders received scheduled [MEDICATION NAME], res repositioned frequently as tolerated for comfort. 4/29/18 at 9:16 PM- Right arm remains swollen Resident handled gently. The MAR indicated [REDACTED]. Later on 4/29/18, the resident was prescribed: [MEDICATION NAME] 'scheduled' every 8 hours via gastric tube at 7 AM-3 PM-11 PM for pain and swelling, in addition to the PRN [MEDICATION NAME] and Tylenol scheduled every 8 hours. The 11 PM dose of scheduled [MEDICATION NAME] was also given on 4/29/18, a total of four doses that day. 4/30/18 at 7:19 AM- Resident with facial grimaces and tensing during care medicated with scheduled pain med and prn 4/30/18 Physician's Note- Reason for Appointment Fx humerus Staff has showed me x-ray report the x-ray is showing old fracture upper end of the humerus and acute fracture lower end of humerus looks swollen at elbow contractures pathologic fx humerus due to [MEDICAL CONDITION], patient not a surgical candidate, high risk for surgery, recommended conservative management apply ice pain control, sling , splint the arm spoke to hospice nurse and hospice has ordered a splint they said it will be delivered this evening patient has brittle bones due to [MEDICAL CONDITION], high risk for recurrent fx The [MEDICAL CONDITION] [DIAGNOSES REDACTED]. Prior to that date, there was no documentation of this diagnosis. 4/30/18 at 7:30 PM- hospice called about the order for the splint for right arm. To be delivered on 5-1-18 from hospice 4/30/18 at 9:19 PM- facial grimacing and tenseness observed during care per hospice nurse will call supply company to order sling for resident's r.arm, as of this time sling has not arrived 4/30/18 at 9:29 PM- Order noted: .APPLY SPLINT TODAY TO RT ARM FOR FX DISTAL END OF HUMERUS 5/4/18 Physician's Note- Reason for Appointment 1. Swelling limb 2. Follow-up on fractured distal humerus swelling rt elbow noted Swelling of right upper extremity from upper hand to lower hand with increased warmth patient is supposed to get splint I have called the hospice nurse they said it was ordered but not arrived yet I have spoke to the hospice Dr. about ordering the splint if they agree will transfer patient to hospital for possible splint and soft cast 5/5/18 at 7:55 AM- Sling to right arm applied by hospice. On 5/5/18, the [MEDICATION NAME] order was changed from every 8 hours, to every 6 hours for pain and anxiety scheduled at 6 AM-12 noon-6 PM-12 AM. 5/6/18 at 12 AM- right arm upper arm [MEDICAL CONDITION] in sling with cold instant pack applies. 5/7/18 Physician's Note- Reason for Appointment 1. Fx 2. Swelling rt upper extremity swelling rt elbow noted I have communicated again with hospice about splint I spoke to Dr he said he will ask the nurse to go to (a medical supply company) and buy the splint and apply it today so we will wait for the splint. 5/8/18 at 3 PM- right arm remain in the sling and elevated, DR still expected hospice to use splint, she will give Hospice a call 5/9/18 at 3:53 PM- right arm remain in the sling, hospice nurse stated, she will bring splint and apply on her right arm today and writer told her if no splint apply today she will be sent to hospital for splint or soft cast application. 5/9/18 at 5:44 PM- Writer was called by hospice nurse that their hospice doctor did not call her back and she talked to her supervisor and she said we can send the resident to get cast or splint going to (hospital emergency room ) for splint or soft cast. 5/9/18 at 8:30 PM nurses note- sling to r.arm in place, arm still swollen received orders for resident to be transferred to (hospital) for r.arm humerus fracture, split or soft cast to be applied Per review of the hospital X-ray report of the right humerus dated 5/09/18 at 11:59 PM: history of [MEDICAL CONDITION] humerus, now with increasing soft tissue swelling structures are diffusely demineralized (loss of minerals that make up bone structure) IMPRESSION: 1. Acute appearing oblique [MEDICAL CONDITION] humeral shaft (occurring most often when a bone is trapped in something remaining stationary while an adjacent bone moves or twists.) 2. Remote appearing deformity of the midshaft of the right humerus. 5/10/18 at 4:25 PM- Informed via (hospice staff) that resident was admitted to (hospital) for further evaluation 5/11/18 at 8:34 PM- Hospice notified of residents returned resident has a R humerus fracture wrapped. DON made aware, Dr also made aware. 5/14/18 at 11:32 AM- Soft cast to (R) upper arm extending to wrist. Fingers are exposed and present with 2+ [MEDICAL CONDITION]. On 11/5/18 at 3:15 PM, when asked why there was a delay in receiving the sling and a splint, the DON said, Hospice wouldn't approve the splint because of her insurance. The DON did not respond when asked why the delay in emergency hospital treatment for more appropriate and timely interventions. When asked about an investigation and corrective actions regarding the fracture and asked if it was an injury of unknown origin, the DON said, We know how it happened. The aide was taking off her (resident's) shirt. She has [MEDICAL CONDITION]. The doctor said it was pathological. The DON did not respond when asked if an arm fracture was expected to occur from removal of a shirt. The incident report was reviewed with the DON. The resident was noted as non-verbal, but was crying and moaning while in a vegetative state, after a pop was heard in the arm. There were no documented corrective actions to prevent reoccurrence, such as two person assistance when dressing, staff education or to avoid dressing in pullover attire. When asked if it was known before the injury that the resident had [MEDICAL CONDITION], the DON said, yes. An individualized care plan, with specific interventions addressing care of this resident with brittle bones, was requested. The DON looked at the clinical record, but there was none. The DON said that the right arm was contracted. She was asked if the arm had been pulled or forced out of the sleeve at the time of the injury. The DON deferred to nurse aide 'A' for details. At 3:30 PM, aide 'A' said that she was removing a pullover-type shirt from the resident by pulling the sleeve to get the contracted arm out and the arm popped loud. She said, Usually she wears a (hospital) gown. The aide said, Nobody told me she had brittle bones. I didn't know that, when asked. The aide said that she got another aide to help her finish undressing the resident because the pop scared me, rather than immediately informing the nurse. She said that after she and the other aide saw swelling develop to the upper arm, the incident was reported to the nurse. Aide 'A' said, I don't know how long it took for her (nurse) to go into the room. I had left, so I didn't see her.

This citation pertains to Intake # MI 624. Based on observation, interview, and record review, the facility failed to ensure one resident #501 from a sample of three residents reviewed for elopement risk from a total sample of eight residents, was adequately supervised after a code-locked exit door (Door #15) was found to be malfunctioning at 11:30 p.m., on 4/14/17, allowing R#501 to elope from the facility at 11:59 p.m., on 4/14/17. Facility staff did not become aware of R#501's elopement until 2:15 a.m., on 4/15/17. As of 4/19/17, the whereabouts of R#501 remained unknown. The Immediate Jeopardy (IJ) was identified on 4/18/17 at 4:35 p.m., and the Administrator was asked for a plan of removal of the immediacy at 5:15 p.m., on 4/18/17. The IJ was removed at 5:00 p.m. on 4/19/17, based on the facility's implementation of the plan of removal of the immediacy as verified by the surveyor. Although the IJ was removed the facility's deficient practice was not corrected and remained isolated with no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. On 4/18/17 at 1:45 p.m. the Administrator and the DON (Director of Nursing) was asked about the facility reported incident involving the elopement of R#501, and provided the following timeline, On 4/14/17 at 11:30 p.m., Security staff realizes door 15 was not alarming, so she resets it, at the same time the Charge Nurse conducts a head count on unit E. All residents were accounted for. Before Midnight the patient was lying on the floor drawing as observed by CNA. 11:59 p.m., patient exits door 15. On 4/15/17 at 2:15 a.m., during CNA rounds R#501 could not be accounted for. A unit search is conducted. At 2:30 a.m., the Nurse returns from break and conducts a search. At 2:53 a.m., the Nurse goes out door 15 and searches the parking lot. At 3:01 a.m., the Nurse returns, calls the front desk to announce a Doctor Walk and all nurses in the center conduct rounds to account for their patients. At the same time two Nurses and the Security Guard search the neighborhood. At 3:12 the Administrator is notified. At 3:22 a.m., the DON is notified and instructs staff to call the Police. Between 3:35 and 4:00 a.m., the police arrive and state if they can't find him they will return and file a missing person report. At 6:15 a.m., the Administrator contacts the State of Michigan Hotline. The DON adds, Today (4/18/17) we have people calling or going to his former homes, local hospitals and jails. Also provided was the I&A (Incident and Accident) report with the facility's internal investigation. On 4/18/17, at 1:45 p.m., review of the medical record revealed that Resident #501 was admitted to the facility on [DATE], directly to the locked unit (E-unit), from a local hospital as indicated on the Admission Face Sheet. Further review of the medical record revealed Psychiatric notes from the hospital dated 2/24/17, indicating, The patient (R#501) stated he lives in a group home-per RN he walked away from the home (in Allen Park) and walked to Pontiac. The psychiatric notes from the hospital dated 3/5/17, stated The patient needs a supervised situation like a nursing home. Otherwise he will walk away because of his confusion. The facility was aware that R#501 had an elopement history from the group home where he previously resided as evidenced by interviews conducted with facility staff and review of the facility's admission packet. On 4/18/17, at 2:00 p.m., review of R#501 medical record revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) revealed that R#501 had an intact cognition with a score of 13 out of 15 during a BIMS (Brief Interview for Mental Status). Review of the March 2017 and April 2017 MAR (Medication Administration Records) revealed that R#501 was prescribed and received the following psychotropic medications: Abilify (an atypical antipsychotropic medication for Schizophrenia) 10 mg (milligrams) in the morning and 5 mg in the evening. Depakote (a mood stabilizer) 125 mg in the morning and 500 mg in the evening. The last medications recorded as given to R#501 was on 4/14/17 at approximately 9:00 p.m., as indicated on the April 2017 MAR. On 4/18/17 at 3:37 p.m., the Admission Coordinator was questioned regarding R#501's admission to the facility's locked unit and stated, the hospital Social Worker requested a locked unit. I didn't meet him (R#501) that day, but when I did, I didn't think he was all there. On 4/18/17 at 2:02 p.m., observation of the E-unit (locked) exit door #15 was conducted with the Maintenance Director. Door #15 was observed to have two code-locks, and a sign that read Push (on the handle) for 15 seconds to open. The Maintenance Director demonstrated the procedure to exit the facility, upon pushing on the handle the primary alarm sounded and after 15 seconds the door opened and the secondary alarm sounded. Outside of door #15 was a small fenced in area with a code-locked gate. The Maintenance Director was asked about the functioning of the locks on the night that R#501 eloped and stated, It happened Friday night, Saturday morning I called for repair, they found a transformer caused the malfunction (with the primary lock) which also caused the gate lock to malfunction. The alarms are checked every shift, on Friday at 4:54 p.m., the door checked out fine. At 10:50 p.m., the female security guard noted the primary lock not working but the secondary lock worked. The Maintenance Director also reported that the female security guard failed to report the malfunctioning lock for Door #15. The Maintenance Director was asked if it was possible to open the door without sounding the alarms and stated, by entering a code. The two locks had two different codes, the secondary lock was a rudimentary and sequential four digit code. On 4/18/17 at 3:30 p.m., further review of the facility's I&A was conducted. Statements from three of the E-unit staff , CNA's ( Certified Nurses Aides) B and E and Nurse F and on duty on 4/14/17 from 11:00 p.m. to 7:00 a.m. (4/15/17) revealed that R#501 was last accounted for between 11:30 p.m., and 11:45 p.m. at 2:15 a.m., CNA B wrote at 2:15 a.m., I was making rounds and I didn't see him, I told (CNA E) he was missing. We both started looking everywhere for him everywhere, going room to room. The Nurse (F) opened door #15 and I heard the page overhead then I followed the Nurse outside to search the parking lot. CNA E wrote, At 11:45 p.m., I saw the resident sitting on the floor drawing, he had on a jacket and was fully dressed with shoes on. Around 2:15-2:30 the other CNA told me the man is missing. We went to his room and searched everywhere, When I went to his room I saw he had packed his things in a pillow case. On 4/19/17, at approximately 8:00 a.m., CNA's B and Nurse F were called and asked if they heard a door alarm sound between 11:59 p.m. on 4/14/17, and 12:02 a.m. on 4/5/17, both stated they did not hear any alarms. CNA F did not answer the call. On 4/19/17, at 12:25 p.m., Nurse R was asked to describe R#501 and stated, He used to like to draw and write, he never told me he wanted to leave, he never ever exhibited any exiting behavior. On 4/19/17 at 12:30 p.m., CNA O was asked to describe R#501's behavior and stated, He never told me that he wanted to leave, he never tried to leave that I know of. At most he'd walk around the circle. On 4/19/17 at 12:40 p.m., Social Worker K was asked about R#501's elopement and stated, He said to me, 'I'd like to go home. I asked where's home, he couldn't respond. I'd ask for an address, he couldn't name one. On 4/19/17 at 12:55 p.m., review of the facility video of R#501's elopement was conducted with the Director of Maintenance and the Administrator. Using the video's time line (Hours:Minutes:Seconds) the following was observed: At 23:58:44 on 4/14/17, R#501 exits the building through door #15 and was observed walking across the parking lot. At 00:01:44 R#501 is observed sitting on a bench that is adjacent to the electronic fence and is also seen briefly walking around the area. At 00:05:27 the security car is seen to pull-up to the locked gait exiting from the facility grounds and when the gait opens R#501 follows the security car out of the parking lot. On 4/19/17 at 5:00 p.m., the facility provided the following removal plan for the immediate jeopardy regarding the failure to prevent the elopement of Resident #501 on 4/14/17. The IJ removal plan: Element 1: On April 15, 2017 the following were initiated and implemented after Resident #501 exited the premises of the facility that occurred on 4/15/17 at 12:02 AM resident 501 eloped from the facility. Resident 501 resided on Unit E which is a secured locked unit. The resident exited out of door # 15 located directly across from his room and next to the dining room. A complete head count of all residents in the facility on 4/15/17 revealed 190 residents accounted for, resident 501 was not located during head count at 02:45 AM. The facility initiated the Missing Resident policy on 4/15/17 at 02:30 AM. The Administrator was notified on 4/15/17 at 03:12; AM, the Director of Nursing was notified on 4/15/17 at 03:22 AM, the legal guardian was initiated on 4/15/17 at 06;43 AM by voicemail and the police 6 th precinct was notified on 4/15/17 at 03:26 AM and arrived to the facility at 4 am. After the elopement incident the Maintenance Director verified that exit doors were in proper working order on 4/15/17 at 09:15 AM. Door #15 was identified as malfunctioning on 4/14/17 at 11:30 PM by Security Guard (Proper Name). Nurse (Proper Name) monitored door #15 on 4/15/17 starting at 3:01 AM after Dr. Walk was called until door alarm was repaired on 4/15/17 at 8:45 AM. All of the facility exit alarmed doors was verified by Cintas on 4/15/17 at 9:15 AM and they were noted as properly functioning and in working appropriately. The following were implemented upon notification that resident 501 was missing on 4/15/17 at 02:15 AM 1. See Missing Resident Policy for initial steps taken once resident was identified as missing. Additional Steps Taken to locate resident 501: 1. Six employees searched the neighborhood, including crack houses, abandoned houses, most 24 hour restaurants and gas stations within five miles of center 4/15/17 at approximately 3:10 a.m. 2. Secured two additional Guardian Alarm Patrol cars to search the neighborhood on 4-15-17 (7:47 a.m. requested) in addition to the car on sight (car on sight started at 3:12 a.m.). 3. Facility staff (Proper Names) contacted area hospitals including: St John Providence, Southfield; St Johns, Pontiac; Sinai Grace, Mclaren-Pontiac, Creighton Hospital, Oakwood, Beaumont-Dearborn, Beaumont-Wayne, Henry Ford Main; Beaumont-Royal Oak, Botsford, VA, Receiving, Harper, Oakland Regional and Garden City Hospital. This continued three times a day minimum and remains ongoing. This started on 4-15-17 between 4:30 and 5:00 a.m. 4. Following shelters were visited by staff beginning on the 15 th: Mighty Voices of Hope, Detroit; Detroit Rescue Mission; NSO; COTS; Hope in Pontiac. This started approximately 9:00 a.m. and after. 5. The following shelters were called by (Proper Name) on 4-15-17: Transitions 1, 2,3 Inc; Christnet 6. The following centers were visited by (Proper Names) on April 18, 2017 approximately leaving at 10:00 a.m.: Shirlee Street Home AFC in Pontiac; Oakland County Health Division; Oakland County Jail, 84 South Genesse St; Alllen Park Police; Allen Park Motor Lodge; Park Motel; Rising Motel; Almar Motel; Hollywood Motel; CLS Plasma Center; Lincoln Park. 7. The following morgues were visited: Wayne County and Oakland County starting on 4-18-2017 during travels by (Proper Names)- see number 6 above. 8. The following Physician Offices Contacted on 4-18-17 at 12:15 p.m. (Dr. Proper Name) primary care physician stated has not seen the resident since April of 2016); (Proper Name) at Oakland DHS Office on 4-18-17 at 12:30 p.m. and gave prior address of the group home; case manager at Molina was notified on 4-18-17 at 12:45 p.m. - no info obtained; Guardian Munger on 4-18-17 at 11:30 a.m. asked to contact Social Security for previous addresses on resident. 9. Private Investigator discussion started at 4-16-17 at 1:25 p.m. contacted attorneys for recommendations of a PI and Guardian Alarm Company. (Proper Name) private investigator , Harris Investigations, was contracted to assist in locating resident on 4-18-17 at 3:40 p.m. Guardian was contacted by DON via telephone approximately 4:00 p.m. and gave permission for PI (Private Investigator) to utilize personal and medical information including photo ID to locate resident on 4-18-17 while PI present. This has been ongoing since. PI checked at 9:29 p.m. on 4-18-17 and had focused on Southfield area and had not located resident. He will continue search in daylight hours on 4-19-17. 10. Police were notified initially and follow up has been done daily by the center since. 4-15-17 at approximately 3:26 a.m. 11. Department of Transportation was contacted by (Proper Name) on 4-16-17 at and 11:56 a.m. description was provided. 12. (Proper Names) contacted Checker Cab on 4-15-17 at 8:45 and Checker Cab would not provide assistance. 13. Community Liaisons provided picture and demographics to assist as travel to hospitals. 4-17-17 at 8:16 p.m. information provided for tours on 4-18-17 and has been ongoing since. 14. Fairlane Senior Care and Rehab Center Medical Director (4-16-17 at 11:17 a.m.) and Nexcare Medical Director (4-18-17 at 4:28 p.m.) requested to aide in search at hospital systems. Element 2: All residents except resident 501 were accounted for on 4/15/17 during the head count. All residents who reside on unit E, risk assessments, care plans were reviewed and updated as necessary including the elopement book started and achieved on 4/15/17. The facility identified 30 residents that display elopement or exit seeking behavior. Out of the total number identified:1 resident resides on unit A, 2 residents reside on unit B, 3 residents reside on unit C , 1 resident resides on unit D and 23 residents reside on unit E. Care plans and risk assessments were reviewed and revised as necessary for all 30 residents identified as elopement risk. Element 3: On April 15, 2017 the facility began in-servicing staff on policy and procedure of elopement and exit seeking management and for missing resident. The total number of employees including contracted in the center are 269. The number of employees that have been in-serviced is 230. Fourteen (14) employees are on leave of absence. We have a total of twenty-five (25) that need re-inservicing. The education of this change will be completed on the first day the employee returns to work. This has been texted to the employees by human resources and in addition a letter was sent by close of 4-19-17. If an employee does not complete this they will be unable to work. Elopement drills were conducted on all shifts for 3 consecutive days beginning on April 15, 2017 and continue on a weekly basis thereafter as directed by QAPI committee. The total number of employees including contracted in the center are 269. The number of employees that have participated in the elopement drill is 127. Fourteen (14) employees are on leave of absence. We have a total of 128 that need elopement drill. The elopement drill will be completed on the first day the employee returns to work. This has been texted to the employees by human resources and in addition a letter was sent by close of 4-19-17. If an employee does not complete this they will be unable to work. On April 15, 2017, elopement risk assessments, care plans and elopement books were reviewed and changes were made as deemed necessary. The facility identified 30 total residents who were assessed with [REDACTED]. The security guard company staff were re-educated on how to verify that doors were properly functioning by the Maintenance Director on 4/15/17. Security guard A was suspended pending an investigation. An Emergency Quality Assurance Committee was held on 4/15/17 by the Administrator, Director of Nursing, Maintenance Director, Social Workers, Regional Clinical Director, VP for Operations and by phone is Medical Director. During this meeting the Elopement policy was reviewed and appropriate revisions were made. System change to include: Each shift the licensed nurses on Unit E will conduct an additional audit of door #15 to ensure that it is functioning appropriately. The nurses on unit E were trained by the Maintenance Director starting on 4/15/17. This will be ongoing until directed otherwise by the QAPI Committee. Additionally, the security guard and nurse checking the door alarm will ensure no residents in view next to the security guard or nurse to avoid potentially accessing the code to disarm alarm system. Beginning on 4-18-17, the door alarm code was changed and will be changed quarterly at a minimum and as needed. It is mandatory that the NHA will be notified by the Maintenance Director or designee before any alarm code changes will be implemented. It is the mandatory that the Maintenance Director, NHA and/or DON will be notified by security guard or designee for any door alarm malfunctioning or concerns and must speak to someone in real time. In the event that door alarm malfunctions, a staff member or designee will be stationed at the door until door alarm is verified as repaired and/or replaced. Security staff and licensed nurses will be in-serviced beginning 4-19-17. This has been texted to the employees by human resources and in addition a letter was sent certified by close of 4-19-17. If an employee does not complete this they will be unable to work. Element 4: As of April 15, 2017 thru April 17, 2017 the facility conducted elopement drills every shift x 3 days. The facility will continue to conduct weekly elopement drills for 6 months or as directed by QAPI committee. The drills will include malfunctioning of doors as deemed appropriate by the Maintenance Director. Results will be brought by the Maintenance Director or Designee to the Quality Assurance Process Improvement Committee monthly for review and recommendations. Any abnormal findings will be immediately corrected. As of 4/19/17 at 3:05 p.m., the whereabouts of resident #501 remains unknown to the facility.

REFER TO INTAKE MI 972. BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE AND APPROPRIATE WOUND CARE (PRESSURE SORE) FOR 1 (#102) OF 7 SAMPLED RESIDENTS REVIEWED FOR PRESSURE SORES FORM A TOTAL SAMPLE OF 9, RESULTING IN THE DEVELOPMENT OF AN INFECTED PRESSURE SORE. FINDINGS INCLUDE: RESIDENT #102 WAS admitted to the facility on [DATE]. ACCORDING TO THE PHYSICIAN'S PHYSICAL EXAMINATION DATED 10/30/12, RESIDENT #102 WAS WEAK AND DEBILITATED. RESIDENT #102 HAD AND WAS treated for [REDACTED]. AT THE TIME OF RESIDENT #102'S SKIN assessment dated [DATE], THE ONLY SKIN ALTERATION ON RESIDENT #102'S COCCYX-SACRAL AREA WAS A RASH, DESCRIBED AS MOISTURE-ASSOCIATED SKIN DAMAGE (MASD) AND INCONTINENCE ASSOCIATED [MEDICAL CONDITION]. REVIEW OF THE SKIN ASSESSMENT 10/30/12, REVEALED THAT RESIDENT #102'S COCCYX-SACRAL AREA WAS DESCRIBED AS HAVING MULTIPLE CICATRIX (A SCAR THAT REMAINS AFTER THE DEVELOPMENT OF NEW TISSUE OVER A RECOVERING WOUND OR SORE), BUT DID NOT INDICATE THAT A WOUND OF ANY KIND WAS PRESENT. ACCORDING TO WOUND ASSESSMENT REPORT DATED 11/20/12, RESIDENT #102 WAS NEWLY diagnosed with [REDACTED]. ACCORDING TO THE WOUND ASSESSMENT REPORT DATED 12/14/12, RESIDENT #102 NOW HAD A SACROCOCCYX WOUND (IDENTIFIED ON 11/20/12), THAT MEASURED 6.4 X 5.00 X 1.40 (L X W X D) AND A RIGHT HEEL WOUND, (IDENTIFIED ON 10/31/12), THAT MEASURED 5.00 X 6.00 X 0.00 (L X W X D). THERE WERE NO DOCUMENTATION REGARDING WOUND CARE AND TREATMENTS FOUND IN THE NURSE'S NOTES. RESIDENT #102'S MINIMUM DATA SET (MDS) assessment dated [DATE], DOCUMENTED THAT RESIDENT #102 HAD (1) ONE VENOUS ARTERIAL ULCER PRESENT (RIGHT HEEL) AND (1) ONE STAGE 4 PRESSURE ULCER. FURTHERMORE, ACCORDING TO THE MDS, RESIDENT #102 HAD A FEEDING TUBE IN PLACE (STARTED ON 11/13/12) AND REQUIRED 2-PERSON PHYSICAL ASSISTANCE AND WAS COMPLETELY DEPENDENT ON STAFF FOR ACTIVITIES OF DAILY LIVING (ADLS). REVIEW OF THE CLINICAL RECORD REVEALED THAT ON 11/17/12, THE PHYSICIAN ORDERED [MEDICATION NAME] (A SKIN TREATMENT) TO (BE APPLIED TO THE) COCCYX Q (EVERY) 3 DAYS AND PRN (AS NEEDED). ON 11/19/12, THE PHYSICIAN ORDERED THE PLACEMENT OF AN INDWELLING URINARY FOLEY CATHETER TO PROMOTE WOUND HEALING. ON 11/20/12, THE PHYSICIAN CHANGED THE WOUND CARE ORDER SPECIFYING SITE: COCCYX/SACROCOCCYX/LEFT BUTTOCKS. NEW TREATMENT: CLEANSED SITE WITH SAF CLENS (WOUND CLEANSER); APPLY [MEDICATION NAME] AG (WOUND TREATMENT); COVER WITH FOAM DRESSING Q 3 DAYS AND PRN. ON 11/28/12, THE TREATMENT ORDER WAS CHANGED AGAIN, TO DISCONTINUE THE PREVIOUS ORDER AND THE NEW ORDER WAS: SACROCOCCYX AND LEFT BUTTOCKS: CLEANSE WITH SAF CLENS; APPLY [MEDICATION NAME] GEL (WOUND TREATMENT); COVER WITH DRY DRESSING Q DAY AND PRN. THE LEFT HEEL TREATMENT ORDER WAS CHANGED TO: SAF CLENS AND APPLY [MEDICATION NAME] GEL COVER WITH DRY DRESSING Q DAY AND PRN. THE FACILITY COULD NOT SHOW EVIDENCE THAT TREATMENTS AS SPECIFIED ABOVE WERE ADMINISTERED TO RESIDENT #102 DURING NOVEMBER 2012. NO TREATMENT RECORDS FOR THE MONTH OF NOVEMBER 2012 WERE AVAILABLE FOR THE SURVEYOR TO REVIEW. RESIDENT #102'S TREATMENT ADMINISTRATION RECORDS (TAR) FOR THE MONTHS OF 10/12 AND 12/12 WERE AVAILABLE FOR REVIEW. AN ATTEMPT TO INTERVIEW THE PREVIOUS WOUND NURSE WAS MADE ON 2/1/13 AT 8:00 AM., BUT WAS UNSUCCESSFUL. ON 12/15/12, RESIDENT #102 WAS TRANSFERRED TO A LOCAL ACUTE CARE HOSPITAL FOR RESPIRATORY DISTRESS. ACCORDING TO HOSPITAL RECORDS DATED 12/15/12, "RESIDENT (#102) ARRIVED THE ER (emergency room ) AT 1:21 PM. UPON ER PHYSICIAN'S PHYSICAL EXAMINATION, RESIDENT'S CHIEF COMPLAINT WAS: SHORTNESS OF BREATH AND DIARRHEA. ER NOTES: PATIENT CURRENTLY DOES NOT APPEAR TO BE IN RESPIRATORY DISTRESS. HOWEVER, PATIENT HAS C.DIFF. ([MEDICAL CONDITION] BACTERIAL INFECTION CAUSING DIARRHEA) SMELL ABOUT HIM AND DIAPER IS OVERFLOWING WITH RUNNY FOAMY STOOL, LIGHT BROWN IN COLOR." RESIDENT #102 WAS diagnosed with [REDACTED]. PER emergency room PHYSICIAN'S NOTES DATED 12/15/12: "THE PATIENT WAS TRANSPORTED FROM SKILLED NURSING FACILITY TO ER FOR SUPPOSED DYSPNEA OR HYPOXEMIA. DIARRHEA AND STAGE 4 DECUBITUS ULCER WAS NOTED BY ER PHYSICIAN AND STOOL WAS POSITIVE FOR [DIAGNOSES REDACTED]., PLACED ON OXYGEN, RECTAL TUBE WAS PLACED, ANTIBIOTICS STARTED, BLOOD CULTURES OBTAINED. admitted OVERNIGHT. ER DESCRIBED: SACRAL DECUBITUS ULCER STAGE 4: FULL THICKNESS, SOILED WITH BROWNISH MATERIAL. EXPOSED UNDERLYING TENDONS SEEN WITH UNDERMINING AT 5 O'CLOCK POSITION. WOUND HAS A FOUL ODOR. resident underwent [REDACTED]. PRE-OPERATIVE Diagnosis: [REDACTED]." REVIEW OF NURSE'S NOTES DATED 12/10/12 THROUGH 12/15/12, REVEALED NO DOCUMENTATION OF LOOSE STOOLS OR DIARRHEA FOR RESIDENT #102. ON 12/12/12, THE PHYSICIAN ORDERED "FECAL POUCH TO BE APPLIED" TO RESIDENT #102 "FOR DIARRHEA/TO PREVENT WOUND CONTAMINATION." NO DOCUMENTED ASSESSMENT, MONITORING OR FOLLOW-UP REGARDING RESIDENT'S DIARRHEA, SUCH AS LAB TESTS REQUEST OR INFECTION CONTROL PRECAUTIONS WERE FOUND IN RESIDENT #102'S RECORD. THE DIRECTOR OF NURSING (DON) WAS INTERVIEWED ON 1/29/13 AT 11:00 AM. ACCORDING TO THE DON, THE TAR FOR NOVEMBER 2012 WAS MISSING. ACCORDING TO THE DON, THERE WAS NO OTHER DOCUMENTATION TO SHOW THAT THE TREATMENTS FOR RESIDENT #102 WERE DONE AS ORDERED. THE DON WENT ON TO SAY THAT ON DECEMBER 11, 2012, THE SACROCOCCYX WOUND WAS CLASSIFIED AS STAGE 4 BY THE WOUND TEAM THAT WAS FOLLOWING UP THE WOUND EVERY WEEK. ACCORDING TO THE DON, THE PREVIOUS WOUND NURSE NO LONGER WORKED IN THE FACILITY AND HAD BEEN TERMINATED IN NOVEMBER OF LAST YEAR (2012). THE DON DID NOT EXPLAIN HOW RESIDENT #102 HAD DEVELOPED AN INFECTED STAGE 4 SACRAL PRESSURE ULCER WHILE LIVING IN THE FACILITY. ( )

THIS CITATION HAS TWO DEFICIENT PRACTICES: DEFICIENT PRACTICE #1: BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO APPLY SPLINTS AND PROVIDE RESTORATIVE SERVICES FOR ONE (#305) OF 19 SAMPLED RESIDENTS REVIEWED FOR RANGE OF MOTION FROM A TOTAL SAMPLE OF 30 RESULTING IN CONTRACTURES, DECREASED MOBILITY, DECLINE IN THE ABILITY TO PERFORM ACTIVITIES OF DAILY LIVING AND [MEDICAL CONDITION] OF THE LOWER EXTREMITIES. FINDINGS INCLUDE: ON 11/27/12 FROM 12:20 TO 12:50 P.M., RESIDENT #305 WAS OBSERVED IN A WHEELCHAIR IN THE DINING ROOM ASSISTED BY STAFF WITH HIS MEAL. THE RESIDENT WAS CONFUSED, AND HAD BOTH HANDS TIGHTLY FISTED, WITH BENT WRISTS, ELBOWS, KNEES AND HIPS. THE RESIDENT WAS NOT WEARING ANY SPLINTS OR DEVICES. ON 11/27/12 AT 2:15 P.M., CERTIFIED NURSING ASSISTANT (CNA) "CC" WAS OBSERVED GIVING CARE TO RESIDENT #305. CNA "CC" USED A SIT TO STAND LIFT (MECHANICAL LIFT) TO TRANSFER RESIDENT #305 TO BED. DURING THE TRANSFER, THE RESIDENT'S LEGS AND HIPS WERE BENT IN THE SEATED POSITION WHILE SUSPENDED IN THE AIR BY THE LIFT SLING. THE RESIDENT WAS NOT WEARING ANY SPLINTS OR DEVICES TO PREVENT CONTRACTURES. AFTER CARE WAS COMPLETED, THE RESIDENT REMAINED IN THE FETAL POSITION WITH KNEES, HIPS, ELBOWS AND WRISTS TIGHTLY BENT, AND BOTH HANDS TIGHTLY FISTED. ON 11/28/12 AT 10:45 A.M., RESIDENT #305'S CLINICAL RECORDS AND THERAPY NOTES WERE REVIEWED WITH THE THERAPY DIRECTOR "F". DIRECTOR "F" STATED THE RESIDENT WAS #305 WAS REFERRED TO PHYSICAL (PT) AND OCCUPATIONAL (OT) THERAPY ON 10/19/12 FOR A DECLINE IN ABILITY TO PERFORM ACTIVITIES OF DAILY LIVING (ADLS), DECREASED MOBILITY, A DECREASED RANGE OF MOTION (ROM). DIRECTOR "F" STATED, "HE NOW HAS NEW CONTRACTURES OF THE KNEES, AND A DECLINE IN ROM OF THE RIGHT HAND." ON 11/28/12 AT 11:00 A.M., RESIDENT #305'S CLINICAL RECORD AND OT NOTES WERE REVIEWED WITH OT "DD" AND DIRECTOR "F". THE FOLLOWING WAS NOTED: A FACE SHEET DOCUMENTED RESIDENT #305 WAS admitted INto the facility on [DATE], WITH [DIAGNOSES REDACTED]. AN ADMISSION MINIMUM DATA SET ASSESSMENT ((MDS) dated [DATE], DOCUMENTED THE RESIDENT HAD SEVERELY IMPAIRED COGNITION, AND HAD A RANGE OF MOTION (ROM) LIMITATION ON ONE SIDE OF THE UPPER BODY. THE MOST RECENT MDS, dated [DATE], DOCUMENTED THAT RESIDENT #305 HAD A DECLINE IN UPPER BODY ROM, NOTING ROM LIMITATIONS ON BOTH SIDES OF THE UPPER BODY. REVIEW OF RESIDENT #305'S ADMISSION OCCUPATIONAL THERAPY (OT) ASSESSMENT, DATED 3/22/12, REVEALED, "WITHOUT THERAPY, PATIENT IS AT RISK FOR FURTHER DECLINES." AN "OT THERAPIST PROGRESS REPORT" NOTE FOR RESIDENT #305, DATED 4/5/12 NOTED, "PATIENT (PT) IS ABLE TO FEED SELF AFTER SET-UP', THE PATIENT IS ABLE TO SAFELY DON/DOFF UPPER BODY CLOTHING REQUIRING MODERATE (26-75%) ASSISTANCE." REVIEW OF RESIDENT #305'S MOST RECENT OT ASSESSMENT, DATED 10/25/12, DOCUMENTED THE RESIDENT HAD DECLINED IN RANGE OF MOTION IN THE RIGHT UPPER EXTREMITY AND HAD DECLINED IN ADL ABILITIES SINCE THE PREVIOUS OT ASSESSMENT ON 3/22/12. THE OT ASSESSMENT DOCUMENTED THE FOLLOWING DECLINES IN ADL SELF CARE SINCE 3/22/12, "SELF FEEDING." ON 11/28/12 AT 11:00 A.M., OCCUPATIONAL THERAPIST (OT) "DD" STATED SHE DID NOT THINK THAT RESIDENT #305 HAD A SPLINT OR DEVICE TO PREVENT CONTRACTURE, STATING, "HE HAD A SOFT PALM PROTECTOR FOR HIS LEFT (CONTRACTED) HAND TO PREVENT HIS NAILS FROM CUTTING INTO HIS HAND. I DON'T BELIEVE HE EVER HAD A BRACE OR SPLINT." WHEN QUERIED REGARDING THE 6/29/12 REFERRAL TO THE RESTORATIVE SPLINT/BRACE PROGRAM, OT "DD" STATED, "I DO RECALL THAT THE ORTHOTICS COMPANY WAS CONSULTED, MAYBE THEY ISSUED A SPLINT." ON 11/28/12 AT 11:10 A.M., RESIDENT #305'S RESTORATIVE THERAPY DOCUMENTS AND LOGS WERE REVIEWED WITH RESTORATIVE AIDES "O" AND "L". RESTORATIVE AIDE "O" STATED, "HE HASN'T HAD A SPLINT." RESTORATIVE AIDES "O" AND "L" AND OT "DD" THEN SEARCHED RESIDENT #305'S DRAWERS AND CLOSETS. A LEFT HAND SPLINT WAS FOUND IN THE BEDSIDE DRESSER DRAWER. "RESTORATIVE AIDE "O" STATED, "WE (RESTORATIVE STAFF) ARE THE ONES WHO PUT SPLINTS OR BRACES ON AND OFF. I NEVER KNEW HE HAD A SPLINT." ON 11/28/12 AT 11:15 A.M., RESIDENT #305'S CLINICAL RECORDS AND PHYSICAL THERAPY NOTES WERE REVIEWED WITH PT "G". PT "G" STATED, "WHEN PT discharged HIM ON 5/11/12, HE WAS ABLE TO WALK 200 FEET. HE WAS REFERRED BACK TO US ON 10/19/12 BECAUSE HE DEVELOPED KNEE CONTRACTURES, COULD NOT STAND OR WALK, AND NEEDED TO BE TRANSFERRED BY MECHANICAL LIFT. I JUST ORDERED KNEE SPLINTS FOR HIM BECAUSE HE HAS DECLINED IN ROM BY 50%." ON 11/28/12 AT 11:30 A.M., THE WOUND CARE PHYSICIAN'S EXAMINATION OF RESIDENT #305 WAS OBSERVED. THE WOUND CARE PHYSICIAN STATED THAT RESIDENT #305 HAD DEVELOPED [MEDICAL CONDITION] OF THE RIGHT SHIN ON NOVEMBER 24, 2012. OBSERVATION REVEALED MULTIPLE MOIST RED WOUNDS MEASURING 3.1 CENTIMETERS (CM) LONG BY 1.5 CM WIDE, SURROUNDED BY DARKENED, DISCOLORED, HARDENED SKIN ON THE ANTERIOR SURFACE (SHIN BONE) OF RESIDENT #305'S RIGHT LEG. WHEN ASKED WHAT CAUSED THE WOUND, THE WOUND PHYSICIAN STATED, "CONTRACTION OF THE LEGS POSES A RISK. THERE'S A HIGH POTENTIAL FOR DECREASED CIRCULATION LEADING TO SKIN DETERIORATION. GERMS JUST GET INTO THE WEAKENED SKIN AND CAUSE [MEDICAL CONDITION]. WHEN THE KNEES ARE CONTRACTED, THE BLOOD VESSELS ARE KINKED, WHICH IMPAIRS CIRCULATION. IT'S A NIGHTMARE TO HEAL [MEDICAL CONDITION] WITH CONTRACTURES. IF HIS LEGS WERE STRAIGHT, HIS CIRCULATION WOULD IMPROVE, AND HE'D GET BETTER." THE RESIDENT WAS NOT WEARING ANY SPLINTS OR DEVICES TO PREVENT CONTRACTURES. ON 11/29/12 AT 8:15 A.M., RESIDENT #305'S CAREGIVER, CNA "CC" REPORTED THAT RESIDENT #305 HAD NOT WALKED SINCE TRANSFER TO THE UNIT "SOMETIME LAST SUMMER", AND REPORTED THAT RESIDENT #305 HAD "GOTTEN HARDER TO TRANSFER LATELY", NOW NEEDING A MECHANICAL LIFT. RESIDENT #305 WAS NOT WEARING A SPLINT OR OTHER DEVICE TO PREVENT CONTRACTURES. A LEFT HAND SPLINT WAS OBSERVED ON TOP OF THE RESIDENT'S DRESSER. ON 11/29/12 AT 9:25 A.M., RESIDENT #305'S CLINICAL RECORD WAS REVIEWED WITH THE RESTORATIVE MANAGER, NURSE "FF".REVIEW OF RESTORATIVE LOGS FROM 5/17/12 THROUGH 9/12/12 REVEALED RESIDENT #305 WAS discharged FROM THE RESTORATIVE PROGRAM ON 9/12/12. WHEN QUERIED WHAT WAS DONE TO PREVENT DECLINES IN MOBILITY AND ROM , RESTORATIVE MANAGER "FF" STATED, "(RESIDENT #305) SHOULD NOT HAVE BEEN discharged FROM RESTORATIVE. HE SHOULD HAVE REMAINED ON THE RESTORATIVE PROGRAM FOR ROM." ON 11/29/12 AT 9:35 A.M., RESIDENT #305'S CLINICAL RECORDS WERE REVIEWED WITH RESTORATIVE MANAGER "FF" AND ACTING UNIT MANAGER/ASSISTANT DIRECTOR OF NURSING (ADON), NURSE "M", AND REVEALED THE FOLLOWING: ON 11/29/12 AT 10:15 A.M., RESIDENT #305'S DECLINE IN RANGE OF MOTION, MOBILITY, ADL CAPABILITIES, AND SUBSEQUENT LEG [MEDICAL CONDITION] WERE DISCUSSED WITH THE DIRECTOR OF NURSING (DON). THE DON STATED, "HE SHOULD HAVE BEEN KEPT ON THE RESTORATIVE ROM PROGRAM." THE DON WAS UNABLE TO PROVIDE ANY ADDITIONAL DOCUMENTATION OR INFORMATION PER REQUEST. ON 11/29/12 AT 2:30 P.M., ORTHOTIST "HH" WAS INTERVIEWED AND REPORTED THAT RESIDENT #305 HAD RECEIVED BILATERAL (BOTH RIGHT AND LEFT) HAND/ WRIST SPLINTS IN MAY 2012. ORTHOTIST "HH" STATED, "I UNDERSTAND THE RIGHT HAND/WRIST SPLINT IS MISSING IN ACTION." REVIEW OF THE FACILITY POLICY ENTITLED "SCREENS", REVISED 10/17/07, REVEALED THE FOLLOWING NOTATIONS: "PROCESS FOR REHAB REFERRAL TO RESTORATIVE NURSING: THE WRITTEN RESTORATIVE PROGRAM IS REVIEWED WITH THE RESTORATIVE AIDE, WITH INSTRUCTION AND EDUCATION PROVIDED (ONGOING).( ) DEFICIENT PRACTICE #2 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED APPLY ASSISTIVE DEVICES FOR THREE (#S 305, 323 AND 327) RESULTING IN POTENTIAL DECLINES IN RANGE OF MOTION, SKIN BREAKDOWN AND THE ABILITY TO PERFORM ACTIVITIES OF DAILY LIVING. FINDINGS INCLUDE: ON 11/27/12 AT 8:50 A.M., RESIDENT #314 WAS OBSERVED LYING IN BED. THE RESIDENTS RIGHT ARM WAS HELD UP AGAINST CHEST WITH RIGHT HAND AND WRIST TUCKED AGAINST SELF. THERE WERE NO HAND OR WRIST APPLIANCES IN PLACE. ON 11/27/12 AT 12:05 P.M., 12:45 P.M., 3:35 P.M., 11/28/12 AT 8:50 A.M., AND 11:15 A.M., RESIDENT #314 WAS OBSERVED WITH NO HAND OR WRIST APPLIANCE IN PLACE. RESIDENT #314'S MEDICAL RECORD WAS REVIEWED AND REVEALED A FACE SHEET INDICATING A RE-ADMISSION INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE RESIDENTS MINIMUM DATA SET assessment dated [DATE], REVEALED THAT THE RESIDENT HAD A SEVERELY IMPAIRED COGNITION, WAS DEPENDENT FOR ACTIVITIES OF DAILY LIVING (ADLS) AND HAD A RANGE OF MOTION (ROM) IMPAIRMENT TO THE UPPER AND LOWER EXTREMITY OF ONE SIDE OF THE BODY. RESIDENT #314'S CARE PLAN TITLED "ADL" INITIATED 5/23/12, REVEALED THE FOLLOWING "FOCUS: I HAVE CONTRACTURE OF MY RIGHT SHOULDER, ELBOW, RIGHT ANKLE. I HAVE RIGHT HAND STIFFNESS (3RD, 4TH AND 5TH FINGERS). INTERVENTIONS: SPLINT RT (RIGHT) HAND, DATED 6/20/12." ON 11/28/12 AT 11:15 A.M., RESTORATIVE AIDE (RA) "O" WAS QUERIED REGARDING RESIDENT #314'S RESTORATIVE TREATMENT PLAN AND STATED "(RESIDENT #314'S) PALM PROTECTOR GETS PUT ON SOMEWHERE BETWEEN 7-7:30 A.M. FOR FOUR HOURS A DAY. THE REFERRAL DOES NOT INDICATE WHAT TIME IT (THE PALM PROTECTOR) NEEDS TO BE PUT ON SO I PUT IT ON AFTER I COME IN. RESTORATIVE PUTS THE PALM PROTECTOR ON FIVE DAYS A WEEK UNLESS WE ARE PULLED FROM THE FLOOR." RA "O" WAS QUERIED ABOUT WHY RESIDENT #314'S CARE PLAN STATED RIGHT HAND SPLINT AND STATED, "SHE HAS A PALM PROTECTOR." RA "O" WENT TO RESIDENT #314'S ROOM AND PLACED A PALM PROTECTOR ON THE RESIDENTS RIGHT HAND." RESIDENT #314'S MEDICAL RECORD WAS FURTHER REVIEWED AND REVEALED "OCCUPATIONAL THERAPY PLAN OF CARE," DATED 5/18/12, "SKILLED OT (OCCUPATIONAL THERAPY) INDICATED LONG TERM GOAL: EDUCATE STAFF REGARDING W.H.O. (WRIST/HAND ORTHOTIC ALSO KNOWN AS A SPLINT) WEARING SCHEDULE." RESIDENT #314'S "OT THERAPIST PROGRESS NOTES," AND "OT TREATMENT NOTES," REVEALED: 5/24/12 AND 5/31/12: PATIENT IS AT RISK FOR ADDITIONAL CONTRACTURE AND SKIN BREAKDOWN WITHOUT UTILIZING W.H.O. (SPLINT). 6/1/12: RIGHT UPPER EXTREMITY PASSIVE ROM PROVIDED TO DIGITS, ARM AND WRIST PRIOR TO TOWEL-ROLL PLACEMENT 2*UNABLE TO LOCATE SPLINT AT THIS TIME 6/8/12: PATIENT TOLERATES SPLINT TIMES 4-6 HOURS, NO PAIN NOTED, STILL UNABLE TO LOCATE SPLINT, HOWEVER TOWEL ROLL TO BE PLACED TO MAINTAIN PROPER POSITIONING. RESIDENT #314'S "OT-THERAPIST PROGRESS REPORT AND DISCHARGE SUMMARY," SIGNED 6/11/12, REVEALED: PATIENT TOLERATES WHO (SPLINT) 4-6 HOURS, NO PAIN NOTED, STILL UNABLE TO LOCATE SPLINT..." A "RESTORATIVE REFERRAL," DATED 6/5/12 REVEALED "GOAL: RESIDENT WILL WEAR RIGHT HAND/WRIST SPLINT FOR UP TO 6 HOURS AT A TIME, ONE TIME PER DAY." RESIDENT #314'S "RESTORATIVE SPLINT/BRACE PROGRAM," DATED 6/2012, REVEALED "RIGHT HAND/WRIST SPLINT. RESIDENT WILL WEAR SPLINT/BRACE FOR 6 HOURS AT AT TIME, ONE TIME PER DAY. SPECIAL INSTRUCTIONS: TOWEL ROLLS APPLIED UNTIL SPLINT FOUND." ON 11/28/12 AT 4:00 P.M., OT "H" STATED, "I EVALUATED HER (RESIDENT #314) FOR A HAND SPLINT, IT WAS MISPLACED SO A TOWEL WAS USED IN ITS PLACE." WHEN QUERIED IF A TOWEL IN THE PLACE OF A WRIST SPLINT IS APPROPRIATE, OT "H" STATED, "IT WOULD NOT TAKE ITS PLACE." ON 11/28/12 AT 4:15 P.M., THE DIRECTOR OF NURSING (DON) WAS QUERIED REGARDING THE MISSING SPLINT AND STATED, "I CAN'T SAY THAT THE SPLINT WAS EVER RE-ORDERED." ON 11/29/12 AT 9:25 A.M., OCCUPATIONAL THERAPIST, OT "S" WAS QUERIED ABOUT RESIDENTS STATUS WHEN discharged IN 6/2012 AND STATED, "SHE (RESIDENT #314) DIDN'T HAVE ANY ISSUES WITH RANGE IN HER RIGHT HAND. SHE WAS discharged FROM THERAPY PRIOR TO THE SPLINT BEING FOUND." OT "S" WAS FURTHER QUERIED REGARDING THE DIFFERENCE BETWEEN THE PALM PROTECTOR AND THE RIGHT HAND WRIST/SPLINT AND STATED, "THE PALM PROTECTOR IS MORE FOR HYGIENE, IT WON'T GIVE WRIST SUPPORT WHICH WOULD PREVENT ANY START IN CONTRACTURE. A SPLINT IS USED TO PREVENT SKIN BREAKDOWN AND CONTRACTURE." OT "S" WENT TO RESIDENT #314'S ROOM TO ASSESS THE RESIDENT AND ATTEMPTED TO DO ROM. RESIDENT #314 MOANED IN PAIN AND MADE A CRYING NOISE. OT "S" STATED, "THE SPLINT WOULD HAVE PREVENTED THIS, I COULD STRAIGHTEN IT (THE WRIST) OUT BUT SHE WOULD BE IN A LOT OF PAIN. I TRIED TO RANGE TO NEUTRAL POSITION (WHAT YOUR HAND WOULD BE AT REST IF DANGLING DOWN BY YOUR SIDE) BUT BECAUSE SHE HAD PAIN, I STOPPED. HER ARM IS MORE GUARDED THAN BEFORE. THIS IS DEFINITELY DIFFERENT, SHE WASN'T AS RESISTANT TO THE ARM OR HAND (RANGE OF MOTION)." RESIDENT #314'S "OCCUPATIONAL THERAPY PLAN OF CARE," DATED 11/28/12, REVEALED "THERAPY NECESSARY TO REISSUE RUE (RIGHT UPPER EXTREMITY) FUNCTIONAL POSITION SPLINT. WITHOUT OT PATIENT IS AT RISK FOR SKIN BREAKDOWN AND FURTHER CONTRACTURE AND PAIN. R (RIGHT) WRIST IS AT NEUTRAL POSITION OF 0 DEGREES FOR EXTENSION AND WFL (WITHIN FUNCTIONAL LIMITS) FOR FLEXION (MEANING SHE HAS NORMAL MOVEMENT MOVING WRIST DOWN BUT CANNOT MOVE HAND ABOVE NEUTRAL POSITION/CAN'T TILT WRIST UP); THUMB PIP (PROXIMAL INTERPHALANGEAL JOINT-JOINT CLOSEST TO THE KNUCKLE) CONTRACTED AT 90 DEGREES FLEXION, 4TH DIGIT PIP IS CONTRACTED AT 130 DEG EXTENSION WITH WFL FOR FLEXION," (INDICATING TWO NEW CONTRACTURES). ON 11/30/12 AT 11:15 A.M., THE DON WAS QUERIED REGARDING RESIDENT #314'S SPLINT. OT "S" PHONED THE DON AND STATED, "I KNEW THE SPLINT WAS LOST, SO IT SHOULD HAVE BEEN RE-ORDERED (NEW SPLINT)." THE DON STATED, "IT DOESN'T MAKE THE SITUATION ANY BETTER FOR THE RESIDENT BUT AT LEAST WE KNOW WHAT HAPPENED." ( ) ON 11/30/12 AT 9 AM, RESIDENT #327 WAS OBSERVED LYING IN BED ON HER BACK WITH THE HEAD OF THE BED SLIGHTLY ELEVATED (ABOUT 20 DEGREES) ATTEMPTING TO FEED HERSELF BREAKFAST. THE RIGHT SIDE OF THE BED WAS AGAINST THE WALL. THE RESIDENT WAS LEANING TO THE EXTREME RIGHT WITH HER NECK BENT AND TWISTED TO THE RIGHT CAUSING THE RIGHT CHEEK TO REST ON THE RIGHT SHOULDER. THE TOP OF THE RESIDENT'S HEAD TOUCHED THE WALL. THE RESIDENT CONSTANTLY SPILLED FOOD FROM THE SPOON WHEN IT WAS BROUGHT TO HER MOUTH. THE RESIDENT STATED, "I WANT SOMEONE TO STRAIGHTEN ME OUT" WHEN ASKED ABOUT HER POSITION. THE RESIDENT ACTIVATED THE CALL LIGHT AND A NURSE AIDE ENTERED THE ROOM. THE AIDE PULLED THE RESIDENT'S UPPER BODY OVER AND POSITIONED THE SHOULDERS IN THE CENTER OF THE BED, WHICH ALLOWED THE RESIDENT'S NECK TO STRAIGHTEN. AT 9:30 AM, RESIDENT #327'S UPPER BODY WAS OBSERVED LEANING TO THE RIGHT WITH THE RIGHT CHEEK RESTING ON THE RIGHT SHOULDER AND THE TOP OF THE HEAD ANGLED TOWARD THE WALL. AT 9:55 AM, THE THERAPY DIRECTOR (THERAPY DIRECTOR 'F'), THE OCCUPATIONAL THERAPIST (OT 'H'), AND THE PHYSICAL THERAPIST (PT 'G'), CAME TO THE RESIDENT'S ROOM TO OBSERVE THE RESIDENT'S POSITION IN BED. UPON ENTERING THE RESIDENT'S ROOM, NURSE 'C' WAS OBSERVED GIVING THE RESIDENT WATER WHILE THE RESIDENT WAS LEANING TO THE EXTREME RIGHT WITH HER NECK BENT AND TWISTED. WHEN QUERIED, NURSE 'C' STATED THAT RESIDENT #327'S BODY ALWAYS LEANED. WHEN ASKED WHY THE RESIDENT WAS BEING GIVEN WATER WITHOUT STRAIGHTENING HER UPPER BODY, THE NURSE SAID, "OH, I SHOULD HAVE RAISED HER HEAD (THE HEAD OF THE BED). WHEN QUERIED FURTHER, THE NURSE LOOKED PUZZLED AND DID NOT EXPRESS AN UNDERSTANDING THAT THE LEANING AND THE TWISTED NECK WOULD NOT BE CORRECTED BY RAISING THE HEAD OF THE BED. PT 'G' ASSESSED RESIDENT #327'S NECK AND UPPER BODY POSITION. AFTER MANIPULATING THE UPPER BODY AND CENTERING HER IN BED, PT 'G' STATED, "HER NECK IS STIFFENING, BUT IT IS NOT CONTRACTED." PT 'G' ASKED THE RESIDENT IF SHE WAS IN PAIN AFTER CENTERING HER BODY. THE RESIDENT SAID, "NO, THAT FEELS BETTER." RESIDENT #327'S WHEELCHAIR HAD A BOLSTER ON THE RIGHT ARM. THE BOLSTER WAS THIN (APPROXIMATELY FOUR INCHES THICK, BADLY RIPPED AND TORN, AND UNSTABLE (NOT ANCHORED TO THE ARM OF THE CHAIR). OT 'H' LOOKED AT THE BOLSTER AND SAID, "SHE HAS THAT (BOLSTER) ON HER CHAIR TO PREVENT HER FROM LEANING," BUT WAS UNABLE TO EXPLAIN HOW WHEN QUERIED AND STATED THAT OTHER TYPES OF EQUIPMENT COULD BE USED INSTEAD. THERAPY DIRECTOR 'F', PT 'G', AND OT 'H' STATED THEY WERE UNAWARE OF THE RESIDENT'S POOR POSITIONING AND THAT A REFERRAL FOR A THERAPY EVALUATION WAS NOT REQUESTED BY NURSING STAFF. IMMEDIATELY FOLLOWING THE OBSERVATION, THE CLINICAL RECORD FOR RESIDENT #327 WAS REVIEWED WITH THERAPY DIRECTOR 'F'. THE RESIDENT WAS admitted on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF MINIMUM DATA SETS ((MDS) dated [DATE] AND 9/6/12 NOTED THAT THE RESIDENT HAD NO COGNITIVE DEFICITS AND HAD LIMITED RANGE OF MOTION TO THE LOWER EXTREMITIES. THE CARE AREA ASSESSMENT SECTION OF THE 12/5/11 MDS FOR ACTIVITIES OF DAILY LIVING (ADLS), NOTED THAT STAFF HAD TO PERFORM ALL OF THE RESIDENT'S ADLS, EXCEPT EATING. REVIEW OF AN ADL CARE PLAN FOR RESIDENT #327 DATED 12/5/11 (LAST UPDATED 9/6/12), NOTED THAT THE RESIDENT COULD NOT TURN OR REPOSITION HERSELF AND THAT "I KEEP MY HEAD/NECK TILTED TO THE RIGHT. WHEN I'M IN MY WHEELCHAIR, I SUPPORT MY HEAD WITH MY HAND." INTERVENTIONS ON THE CARE PLAN INCLUDED: "ENCOURAGE ME TO KEEP HEAD/NECK STRAIGHT, REMIND ME AS NEEDED" AND "I WOULD LIKE PHYSICAL AND OCCUPATIONAL THERAPY TO EVALUATE AND TREAT ME AS NEEDED." RESIDENT #327'S CLINICAL RECORD INCLUDED A "REHAB SERVICES SCREENING FORM" DATED 12/8/11 COMPLETED BY A SPEECH THERAPIST THAT NOTED: "RECOMMEND POSITIONING EQUIPMENT (FOR THE WHEELCHAIR ONLY) TO DECREASE LATERAL LEANING, HOWEVER WHEN APPROACHED AND EQUIPMENT OPTIONS DISCUSSED WITH PATIENT, SHE DECLINED STATING, 'I CAN SIT UP.'" AN OCCUPATIONAL (OT) AND PHYSICAL THERAPIST (PT) SIGNED THE FORM AND NOTED THAT NO SKILLED SERVICES WERE NEEDED. THERE WAS NO FURTHER DOCUMENTATION BY OT OR PT TO SHOW THAT THE RESIDENT WAS EVER REAPPROACHED, THAT AN EVALUATION WAS DONE FOLLOWING THE REHAB SCREEN, OR ANY RECOMMENDATION FOR RANGE OF MOTION EXERCISES BY RESTORATIVE OR NURSING STAFF TO PREVENT A NECK CONTRACTURE. THERAPY DIRECTOR 'F' WAS UNABLE TO STATE WHY, BUT SAID THAT THERE SHOULD HAVE BEEN AN EVALUATION AND FURTHER FOLLOW-UP. THE ASSISTANT DIRECTOR OF NURSING (ADON) ENTERED THE ROOM DURING THE INTERVIEW WITH THERAPY DIRECTOR 'F' AND WAS QUERIED REGARDING THE RESIDENT'S POOR POSITIONING AND LOOSE, TORN BOLSTER. THE ADON STATED THAT SHE WAS UNAWARE OF THE BOLSTER, BUT WAS AWARE OF THE RESIDENT'S LATERAL LEAN, DID NOT REQUEST A REFERRAL FOR THERAPY INTERVENTIONS AND COULD NOT EXPLAIN WHY. AT 10:15 AM, THE DIRECTOR OF NURSING (DON) WAS QUERIED REGARDING RESIDENT #327'S POOR POSITIONING, LOOSE AND TORN BOLSTER, AND THE RESIDENT BEING GIVEN WATER BY NURSE 'C' WHILE HER NECK WAS TWISTED. HOWEVER, THE DON DID NOT EXPLAIN OR RESPOND. PER REVIEW OF THE FACILITY'S POLICIES ON REHAB SCREENS DATED 10/17/07, AND UNDATED "PROCESS FOR REHAB REFERRAL TO RESTORATIVE NURSING:" THE SCREENING PROCESS IS BRIEF, HANDS OFF, AND SHOULD INCLUDE DIRECT OBSERVATION OF THE RESIDENT. THE SCREEN IS NOT AN EVALUATION. THE SCREENING PROCESS WILL RESULT IN A REQUEST FOR AN EVALUATION. IF ANY FUNCTIONAL NEEDS ARE IDENTIFIED DURING THE SCREENING, A PHYSICIAN'S ORDER FOR AN EVALUATION SHOULD BE REQUESTED IN A TIMELY MANNER BY OT OR PT. DUE TO THE BRIEF NATURE OF THE SCREEN, "UNDER NO CIRCUMSTANCES" ARE SPECIFIC RECOMMENDATIONS TO BE MADE REGARDING TREATMENT OR INTERVENTIONS. ONLY AN EVALUATION PROVIDES THE BASIS FOR ANY RECOMMENDATIONS. ( ) REVIEW OF RESIDENT #323'S FACE SHEET REVEALED AN ADMISSION INto the facility on [DATE] AND A RE-ADMISSION ON 6/26/12 WITH [DIAGNOSES REDACTED]. RESIDENT #323'S MOST RECENT ANNUAL MINIMUM DATA SET (MDS), dated [DATE], INDICATED AN INTACT COGNITION AND REQUIRED EXTENSIVE TO TOTAL ASSISTANCE WITH ALL ACTIVITIES (ADL'S). ON 11/29/12 AT 12:30 P.M., RESIDENT #323 WAS OBSERVED SITTING IN A WHEELCHAIR IN THE DINING ROOM CONSUMING LUNCH WITH MINIMAL DIFFICULTY. THE USE OF HIS RIGHT HAND WAS IMPAIRED DUE TO A CONTRACTURE. HE WAS NOTED WEARING A PALM PROTECTOR TO THE RIGHT HAND. RESIDENT #323 ANSWERED QUESTIONS APPROPRIATELY. ON 11/30/12 AT 10:15 A.M., RESIDENT #323 WAS OBSERVED LYING IN BED WATCHING TV AS HE AWAITED A.M. CARE. HIS RIGHT HAND WAS COMPLETELY CLOSED (CONTRACTED). HIS PALM PROTECTOR WAS NOTED ON HIS NIGHTSTAND. THE RESTORATIVE CERTIFIED NURSING ASSISTANT (CNA "L") ENTERED THE ROOM. WHEN QUERIED HOW OFTEN RESIDENT #323 WEARS HIS RIGHT HAND SPLINT, CNA "L" STATED, "I APPLY HIS HAND SPLINT EVERYDAY I AM HERE." RESIDENT #323 THEN STATED, "WHEN SHE IS NOT HERE THEY DON'T PUT ON MY BRACE." REVIEW OF RESIDENT #323'S RESTORATIVE REFERRAL, DATED 3/2/12, RECOMMENDED "GOAL: RESIDENT WILL WEAR RIGHT HAND/WRIST SPLINT FIVE HOURS AT A TIME, ONE TIME PER DAY." A SIGNATURE FROM THE THERAPIST AND A SIGNATURE FROM CNA "L" WAS NOTED ON THE REFERRAL. REVIEW OF THE FACILITY'S FORM ENTITLED, "RESTORATIVE SPLINT/BRACE PROGRAM," FOR THE MONTHS OF 3/2012, 4/2012, 6/2012, AND 11/2012 REVEALED MULTIPLE DAYS AND WEEKS THAT INDICATED THE RIGHT HAND SPLINT WAS NOT APPLIED. REVIEW OF THE "RESTORATIVE SPLINT/BRACE PROGRAM" FORM FOR THE MONTH OF: 3/2012 REVEALED 26 DAYS THAT MONTH WHERE THERE WAS NO DOCUMENTATION TO INDICATE THAT THE SPLINT WAS APPLIED OR APPLICATION ATTEMPTED. 4/2012 REVEALED 7 DAYS THAT MONTH WHERE THERE WAS NO DOCUMENTATION TO INDICATE THAT THE SPLINT WAS APPLIED OR APPLICATION ATTEMPTED. 6/2012 REVEALED 26 DAYS THAT MONTH WHERE THERE WAS NO DOCUMENTATION TO INDICATE THAT THE SPLINT WAS APPLIED OR APPLICATION ATTEMPTED. 11/2012 REVEALED 9 DAYS THAT MONTH WHERE THERE WAS NO DOCUMENTATION TO INDICATE THAT THE SPLINT WAS APPLIED OR APPLICATION ATTEMPTED. REVIEW OF THIS MONTH WAS ON 11/30/12 AT 10:30 A.M. WITH THE RESTORATIVE CNA (CNA"L"). CNA "L" WAS QUERIED REGARDING THE LACK OF DOCUMENTATION INDICATING RESIDENT #323'S RIGHT HAND BRACE WAS CONSISTENTLY APPLIED. THERE WERE BLANK BOXES ON THE "RESTORATIVE SPLINT/BRACE PROGRAM" FORM WHERE THERE WERE NO INITIALS BY THE STAFF TO INDICATE THE RIGHT HAND BRACE WAS APPLIED. CNA "L" STATED, "SOMETIMES THERE IS NO RESTORATIVE CNA ON THE WEEKENDS." THERE WAS NO FURTHER EXPLANATION PROVIDED BY CNA "L." ON 11/30/12 AT 11:10 A.M., THE REHAB DIRECTOR "F" REPORTED THAT RESIDENT #323 WAS discharged FROM OCCUPATIONAL THERAPY AND PHYSICAL THERAPY IN MARCH 2012. REHAB DIRECTOR "F" WAS QUERIED AS TO HOW LONG THE REFERRAL FOR RESTORATIVE IS IN EFFECT. REHAB DIRECTOR "F" STATED, "IT IS EFFECTIVE UNTIL A DIFFERENT RECOMMENDATION IS FROM THERAPY, OTHERWISE NOTHING CHANGES UNLESS THERE IS A CHANGE IN THE RESIDENT'S CONDITION." DOCUMENTATION INDICATING RESIDENT#323'S RIGHT HAND SPLINT WAS APPLIED DURING THE MONTHS OF MAY, JULY, AUGUST, SEPTEMBER AND OCTOBER OF 2012 WAS REQUESTED BUT NOT FOUND. REVIEW OF RESIDENT #323'S CARE PLAN TITLED "ADL," DATE INITIATED 10/13/11 AND LAST REVISED 10/10/12, INCLUDED THE INTERVENTION TO APPLY "RIGHT HAND SPLINT/BRACE." ON 11/30/12 AT 8:50 A.M., THE DIRECTOR OF NURSING (DON) WAS QUERIED REGARDING THE INCONSISTENT APPLICATION OF RESIDENT #323'S RIGHT HAND SPLINT. THE DON PROVIDED NO EXPLANATION. REVIEW OF THE FACILITY'S POLICY ENTITLED, "SCREENS," DATED 1/1/2003, AND REVISED 10/17/2007, REVEALED THE FOLLOWING DOCUMENTATION: "PROCESS FOR REHAB REFERRAL TO RESTORATIVE NURSING: THE THERAPIST DEVELOP A RESTORATIVE NURSING PROGRAM UTILIZING THE FACILITY'S RESTORATIVE REFERRAL FORM. THE WRITTEN RESTORATIVE PROGRAM FOR THE RESIDENT IS REVIEWED WITH THE RESTORATIVE AIDE, WITH INSTRUCTION AND EDUCATION PROVIDED (ONGOING). THE RESTORATIVE PROGRAM IS SIGNED BY THE TREATING THERAPIST AND THE RESTORATIVE AIDE FOLLOWING INITIAL INSTRUCTION." ( )

THIS CITATION HAS THREE DEFICIENT PRACTICES: DEFICIENT PRACTICE #1: BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THE SAFETY OF A RESIDENT THAT WAS LEFT STANDING UNASSISTED FOR ONE (#318) OF 10 RESIDENTS REVIEWED FOR FALLS OUT OF A TOTAL SAMPLE OF 30, RESULTING IN A LACERATION, SUBDURAL HEMATOMA, FRACTURE AND hospitalization . FINDINGS INCLUDE: ON 11/28/12 AT 9:00 A.M., RESIDENT #318 WAS OBSERVED IN THE DINING ROOM SEATED IN A WHEELCHAIR WITH A PERSONAL SAFETY ALARM. THE RESIDENT WAS ALERT, AND DID NOT EAT INDEPENDENTLY, BUT WAS FED BY STAFF. REVIEW OF THE ADMISSION FACE SHEET REVEALED RESIDENT #318 WAS admitted on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM DATA SET ((MDS) dated [DATE] NOTED THAT THE RESIDENT HAD SEVERE COGNITIVE IMPAIRMENT AND WAS AMBULATORY WITH A ROLLING WALKER, WITH SUPERVISION. REVIEW OF THE MDS dated [DATE] NOTED THAT THE RESIDENT REQUIRED SUPERVISION DURING AMBULATION AND MINIMAL STAFF ASSISTANCE. REVIEW OF INCIDENT/ACCIDENT (I/A) REPORTS NOTED THAT RESIDENT #318 HAD A PAST HISTORY OF FALLING ON 3/28/12 WHEN SHE ATTEMPTED TO SIT DOWN AND MISSED THE CHAIR. THE RESIDENT ALSO fell on [DATE] WHEN HER BLOOD PRESSURE DROPPED AFTER RISING FROM A CHAIR. REVIEW OF THE CARE AREA ASSESSMENT SECTION OF THE 10/4/12 MDS FOR COGNITIVE SKILLS, NOTED: "(RESIDENT #318) REQUIRES MORE ASSISTANCE WITH HER ACTIVITIES OF DAILY LIVING (ADLS) DUE TO HER COGNITIVE DECLINE....SHE CONTINUES TO AMBULATE INDEPENDENTLY WITH HER ROLLING WALKER WITH STANDBY ASSISTANCE, HOWEVER, SHE IS AT RISK FOR FALL/INJURY. SHE HAD POOR SAFETY AWARENESS, IMPAIRED RANGE OF MOTION IN HER BILATERAL LOWER EXTREMITIES....DECREASED MOBILITY." REVIEW OF AN OCCUPATIONAL THERAPY INITIAL ASSESSMENT FOR RESIDENT #318 DATED 10/19/12 NOTED REGARDING HER BALANCE: "FALL RISK." CURRENT LEVEL-"HIGH RISK." REVIEW OF AN I/A REPORT DATED 10/24/12 AND INCIDENT INVESTIGATION DATED 10/24/12-10/25/12 NOTED: RESIDENT #318 WAS AMBULATING WITH THE ROLLING WALKER FROM THE DINING ROOM TO HER ROOM WHILE ACCOMPANIED BY NURSE AIDE 'D'. AIDE 'D' DOCUMENTED, "WE WALKED IN THE ROOM. SHE (STOPPED) AT THE BED. SHE THEN TURNED. I ASKED HER TO STOP. SHE CAME TO A COMPLETE STOP. I WAS AT HER LEFT SIDE. I THEN STEPPED AWAY APPROXIMATELY 5 FEET TO GET GLOVES FROM THE WALL. WHEN I TURNED BACK TO HER, SHE WAS FALLING TO THE FLOOR....WHEN WE GOT HER OFF THE FLOOR I (ASKED) HER WHAT (HAPPENED), SHE SAID SHE WAS TRYING TO SIT DOWN." PER REVIEW OF THE NURSE UNIT MANAGER (CLINICAL CARE COORDINATOR 'B') DOCUMENTATION IN THE INVESTIGATION: "THE RESIDENT WAS FACING THE BED AND (AIDE 'D') STATES SHE INSTRUCTED (RESIDENT #318) TO HOLD ON FOR A SECOND SO THAT SHE COULD GRAB SOME GLOVES....(AIDE 'D') THEN STATED THAT SHE TURNED TO GET A PAIR OF GLOVES AND AS SHE TURNED BACK, (RESIDENT #318) WAS FALLING TO THE FLOOR....AT THE TIME OF THE INCIDENT, THE RESIDENT STATED THAT SHE WAS TRYING TO SIT ON THE BED." THE INVESTIGATION NOTED THAT THE RESIDENT WAS BLEEDING FROM THE MOUTH FROM A LACERATION BECAUSE, "IT APPEARS THAT HER TOOTH WENT THROUGH HER BOTTOM LIP" AND COMPLAINED OF PAIN DURING MOVEMENT OF THE RIGHT ARM. THE RESIDENT WAS TRANSPORTED TO THE HOSPITAL FOLLOWING THE INCIDENT. PER REVIEW OF A UNDATED PHYSICIAN CONSULTATION HOSPITAL REPORT, THE FOLLOWING FINDINGS WERE NOTED FOR RESIDENT #318: A 1.5 CENTIMETER LACERATION TO THE INSIDE OF THE LOWER LIP AND ABRASIONS AND A LACERATION OUTSIDE THE LOWER LIP. "RIGHT HUMERAL FRACTURE" (CONFIRMED BY A 10/25/12 X-RAY REPORT). A BRAIN SCAN "WAS READ BY RADIOLOGY AND REVIEWED BY MYSELF....SUBARACHNOID HEMORRHAGE (BLEEDING BETWEEN THE BRAIN AND THE TISSUE THAT COVERS THE BRAIN) IN THE MEDIAL LEFT PARASAGITTAL PARIETAL SULCI; ACUTE (NEW) SUBDURAL HEMATOMA (A BLOOD CLOT BETWEEN THE BRAIN AND THE OUTER COVERING OF THE BRAIN) (IN) THE LEFT TENTORIUM...." A SECOND BRAIN SCAN WAS CONDUCTED THAT NOTED OLD SUBDURAL HEMATOMAS AND AN OLD INFARCT THAT WERE SEEN IN OTHER LOCATIONS OF THE BRAIN (THE FRONTAL LOBES). RESIDENT #318 WAS SENT TO THE SURGICAL INTENSIVE CARE UNIT AT THE hospital on [DATE] AND WAS TRANSFERRED BACK to the facility on [DATE]. THE RESIDENT'S PRIMARY CARE PHYSICIAN NOTED DURING A HISTORY AND PHYSICAL DATED 10/29/12 THAT [DIAGNOSES REDACTED]." ON 11/29/12 AT 2:15 PM, NURSE AIDE 'D' WAS INTERVIEWED BY PHONE REGARDING RESIDENT #318'S FALL. THE AIDE STATED, "I WAS WALKING WITH HER TO HER ROOM. IF YOU DON'T WALK WITH HER SHE STUMBLES. WE GOT TO THE ROOM. I TOLD HER TO STAND STILL AND WAIT WHILE I GOT GLOVES....I TURNED MY BACK AND WHEN I TURNED AROUND, SHE WAS FALLING." WHEN QUERIED ABOUT LEAVING THE RESIDENT TO GET GLOVES, AIDE 'D' SAID, "I USUALLY HAVE ALL MY SUPPLIES WITH ME, BUT I FORGOT." THE AIDE WAS UNABLE TO STATE WHY SHE DID NOT HAVE THE RESIDENT SIT DOWN AS A SAFETY MEASURE BEFORE GETTING THE GLOVES. ( ) DEFICIENT PRACTICE #2 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO IMPLEMENT SAFETY DEVICES AND PROVIDE ADEQUATE SUPERVISION FOR THE PREVENTION OF FALLS FOR TWO (#'S 302 AND 324) OF 10 RESIDENTS REVIEWED FOR FALLS OUT OF A TOTAL SAMPLE OF 30, RESULTING IN A FALL WITH LACERATION AND THE INCREASED RISK FOR FURTHER FALLS. FINDINGS INCLUDE: ON 11/29/12 AT 3:30 PM, WHEN QUERIED ABOUT RESIDENT #318'S INJURIES AFTER THE FALL, THE ADMINISTRATOR STATED THAT SHE WAS UNAWARE THAT THE RESIDENT REQUIRED SUPERVISION DURING AMBULATION AND COULD NOT EXPLAIN WHY AIDE 'D' DID NOT SEAT THE RESIDENT BEFORE GETTING THE GLOVES. ON 11/29/12 AT 9 AM, RESIDENT #324 WAS OBSERVED BEING FED BY STAFF IN THE DINING ROOM. THE RESIDENT APPEARED SLEEPY AND THE STAFF HAD A DIFFICULT TIME KEEPING THE RESIDENT AWAKE. REVIEW OF THE ADMISSION FACE SHEET REVEALED RESIDENT #324 WAS admitted on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE MDS dated [DATE] NOTED THAT THE RESIDENT HAD SEVERE COGNITIVE IMPAIRMENT, WAS NON-AMBULATORY, AND REQUIRED EXTENSIVE ASSISTANCE FOR TRANSFERS AND BED MOBILITY. REVIEW OF AN ADMISSION CARE PLAN FOR RESIDENT #324 NOTED ON 9/26/12: "ALL RESIDENTS ARE AT RISK ON ADMISSION (FOR FALLS) DUE TO CHANGE OF ENVIRONMENT." THERE WERE NO SAFETY DEVICES CHECKED AS INTERVENTIONS, SUCH AS PERIMETER (RAISED EDGE) MATTRESSES AND FALL FLOOR MATS. REVIEW OF NURSES NOTES DATED 10/7/12 AT 4 AM DOCUMENTED THAT THE RESIDENT WAS UP ALL NIGHT AND ATTEMPTING TO AMBULATE WITHOUT ASSISTANCE. ON 10/10/12, 10/11/12, 10/13/12, AND 10/24/12, 10/26/12, 10/27/12, 10/28/12, 10/30/12, 11/2/12, AND 11/4/12, THE RESIDENT WAS NOTED TO BE UP ALL NIGHT, CONFUSED, RESTLESS, ATTEMPTING TO GET UP OR AMBULATE WITHOUT ASSISTANCE, AND HAD AN ON-GOING POOR SLEEP PATTERN DURING THE HOURS OF 2 AM TO 7 AM. REVIEW OF A FALL CARE PLAN DATED 10/31/12 AND THE CURRENT RESIDENT CARE GUIDE FOR RESIDENT #324 NOTED INTERVENTIONS THAT INCLUDED: "ENSURE THAT I HAVE A PERIMETER MATTRESS ON MY BED." REVIEW OF AN I/A REPORT AND INVESTIGATION FOR RESIDENT #324 DATED 11/5/12 NOTED THAT THE RESIDENT HAD A FALL THAT MORNING AT 4:55 AM IN HIS ROOM. THE resident sustained [REDACTED]. HE RETURNED to the facility on [DATE] AFTER RECEIVING 5 SUTURES TO THE FOREHEAD, ACCORDING TO NURSES NOTES DATED 11/7/12. THERE WERE NO DOCUMENTED NURSES NOTES FOR 11/5/12. A LATE NOTE ENTRY ON 11/7/12 DOCUMENTED THAT THE RESIDENT WENT TO THE hospital on [DATE], BUT NO CIRCUMSTANCES REGARDING THE FALL AND THE RESIDENT'S CONDITION PRIOR TO THE FALL THAT MORNING. HOWEVER, 24-HOUR REPORTS DATED 11/2/12, 11/3/12, AND 11/4/12 NOTED THAT THE RESIDENT WAS UP ALL NIGHT EACH OF THOSE NIGHTS PRIOR TO THE INCIDENT. REVIEW OF AN MDS CARE AREA ASSESSMENT FOR BEHAVIORAL SYMPTOMS DATED 11/2/12 NOTED: THE RESIDENT "HAS A HISTORY OF BEING UP ALL NIGHT. FAMILY REPORT SAME HISTORY WHEN HE WAS LIVING AT HOME. HE IS NOT RECEIVING ANY PSYCHOTROPIC MEDICATIONS....HIS INSOMNIA IS NOT CREATING A PROBLEM FOR HIM...." ON 11/29/12 AT 10:20 AM, SOCIAL WORKER (EMPLOYEE 'I') AND NURSE UNIT MANAGER (CLINICAL CARE COORDINATOR 'B') WERE QUERIED REGARDING NOTIFICATION OF THE PHYSICIAN OR MENTAL HEALTH SERVICES REGARDING RESIDENT #324'S POOR SLEEP PATTERN, TO HELP PREVENT FALLS FROM UNSUPERVISED AMBULATION ATTEMPTS DURING THE NIGHT. EMPLOYEE 'I' PRESENTED A BEHAVIOR LOG BOOK WHERE SHE DOCUMENTED, ON 11/28/12, A REQUEST FOR THE RESIDENT TO BE SEEN BY MENTAL HEALTH SERVICES BECAUSE THE RESIDENT WAS "UP ALL NIGHT ONGOING." THERE WAS NO REFERRAL PRIOR TO THAT DATE PER EMPLOYEE 'I'. NURSE 'B' AND EMPLOYEE 'I' WERE UNABLE TO EXPLAIN WHY. 24-HOUR REPORTS, REVIEWED WITH NURSE 'B', DATED 11/7/12, 11/8/12, 11/9/12, 11/12/12, 11/14/12, 11/15/12, 11/17/12, AND 11/25/12, NOTED THAT THE RESIDENT CONTINUED TO REMAIN UP ALL NIGHT AFTER THE FALL. NURSES NOTES DATED 11/7/12, 11/9/12, 11/10/12, 11/12/12, 11/13/12, 11/17/12, 11/21/12, 11/25/12, AND 11/28/12 ALSO DOCUMENTED THAT THE RESIDENT WAS UP ALL NIGHT, HAD A POOR SLEEP PATTERN, AND ATTEMPTED UNASSISTED TRANSFERS. REVIEW OF POST FALL INTERVENTIONS FOR THE FALL ON 11/5/12 INCLUDED ADDING FLOOR SAFETY MATS. NURSE 'B' WAS UNABLE TO EXPLAIN WHY RESIDENT #324 DID NOT ALREADY HAVE THE MATS IN PLACE, BUT STATED THAT THE PERIMETER MATTRESS WAS PRESENT AT THE TIME OF THE INCIDENT. ON 11/29/12 AT 1:10 PM, WHEN QUERIED FURTHER ABOUT RESIDENT #324'S PERIMETER MATTRESS, NURSE 'B' SAID, "HE HAS A PERIMETER MATTRESS." NURSE 'B' WAS ASKED TO OBSERVE THE RESIDENT'S BED. THERE WAS NO PERIMETER MATTRESS ON THE BED. THERE WAS NO PERIMETER MATTRESS OBSERVED ON THE BED ON 11/27/12 AT 10 AM, 11/28/12 AT 4:15 PM, OR 11/29/12 AT 9 AM AND 11 AM. NURSE 'B' WAS UNABLE TO EXPLAIN WHY THE PERIMETER MATTRESS WAS NOT IN PLACE TO HELP MAINTAIN SAFETY. AT 12:30 PM, WHEN QUERIED ABOUT THE MISSING PERIMETER MATTRESS, AND RESIDENT #324'S SLEEP DISORDER NOT BEING ADDRESS, WITH THE NUMEROUS UNASSISTED SELF-TRANSFERS IN THE MIDDLE OF THE NIGHT WHICH COULD LEAD TO MORE FALLS, THE DON AND ADMINISTRATOR WERE UNABLE TO EXPLAIN. THE DON STATED, "WE USUALLY GET HIM UP AND BRING HIM OUT OF HIS ROOM (FOR OBSERVATION)." THE DON DID NOT ADDRESS THE SLEEP DISORDER. AT 12:55 PM, NURSE 'A' WHO WAS ON DUTY WHEN RESIDENT #324 fell THE MORNING OF 11/5/12, WAS INTERVIEWED BY PHONE. THE NURSE STATED THAT THE RESIDENT WAS IN BED ASLEEP THAT MORNING AND THAT HE DID NOT HAVE FLOOR SAFETY MATS OR A PERIMETER MATTRESS IN PLACE. WHEN QUERIED, NURSE 'A' STATED THAT SHE DID NOT DOCUMENT THE CIRCUMSTANCES OF THE FALL IN NURSES NOTES, "BECAUSE I WAS FOCUSED ON TAKING CARE OF (THE RESIDENT)." WHEN QUERIED, NURSE 'A' STATED THAT SHE NOTED SEVERAL TIMES ON THE 24-HOUR REPORT THAT THE RESIDENT WAS NOT SLEEPING "MOST NIGHTS." SHE SAID, "I PUT IT ON THE LOG BECAUSE I WAS HOPING THAT HE WOULD GET SOMETHING TO HELP HIM SLEEP. MOST PEOPLE HAVE SOMETHING ORDERED, BUT HE DIDN'T." PER REVIEW OF THE FACILITY'S "FALLS REDUCTION PROGRAM" REVISED 8/31/10: -THE PURPOSE IS "TO PROVIDE A SAFE ENVIRONMENT FOR RESIDENTS, MODIFY THE RISK FACTORS, AND REDUCE RISK OF FALL-RELATED INJURY." -IF A FALL OCCURS, DOCUMENT THE INCIDENT IN THE MEDICAL RECORD. -COMPLETE A PHYSICAL REVIEW OF THE ENVIRONMENT, DISCUSS AND DETERMINE THE ROOT CAUSE. ( ) REVIEW OF RESIDENT #302'S FACE SHEET REVEALED AN ADMISSION INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #302'S MOST RECENT SIGNIFICANT CHANGE MINIMUM DATA SET (MDS), dated [DATE], INDICATED A SEVERELY IMPAIRED COGNITION AND REQUIRED TOTAL CARE FOR ALL ACTIVITIES OF DAILY LIVING (ADL'S). ON 11/28/12 AT 9:45 A.M., RESIDENT #302 WAS OBSERVED LYING IN A LOW BED WITH A FALL MAT ON THE LEFT SIDE OF THE BED AS THE RIGHT SIDE OF THE BED WAS PUSHED AGAINST THE WALL. RESIDENT #302 WAS ALERT BUT WAS UNABLE TO ANSWER QUESTIONS. A FOLEY CATHETER WAS NOTED DRAINING PALE YELLOW URINE. THERE WAS NO SAFETY DEVICE NOTED TO THE RESIDENT'S BED. REVIEW OF RESIDENT #302'S INCIDENT AND ACCIDENT REPORTS WITH THE UNIT MANAGER (NURSE "K") REVEALED THAT SHE HAD A TOTAL OF FOUR FALLS FROM HER BED ON THE FOLLOWING DATES: 4/19/12 AT 8:30 A.M., 6/15/12 AT 12:30 A.M.,8/5/12 AT 5:20 P.M., AND 10/1/12 AT 10:32 P.M. ALL FOUR TIMES, THE STAFF DISCOVERED HER ON THE FLOOR NEXT TO HER BED. REVIEW OF A THE PHYSICIAN'S ORDER, DATED 8/5/12, REVEALED AN ORDER THAT READ, "PUT BED ALARM TO BED NOW." REVIEW OF RESIDENT #302'S CARE PLAN TITLED "AT RISK FOR FALLS," INITIATED 5/19/12 AND LAST REVISED ON 10/17/12, DID NOT INCLUDE THE INTERVENTION TO APPLY A BED ALARM. ON 11/28/12 AT 11:15 A.M., RESIDENT #302'S CARE GUIDE WAS REVIEWED WITH NURSE "K." THE CARE GUIDE INCLUDED THE INTERVENTION TO APPLY A SENSOR PAD ALARM TO RESIDENT #302'S BED. IN THE PRESENCE OF NURSE "K,"THE ASSIGNED CERTIFIED NURSING ASSISTANT (CNA "J") WAS THEN QUERIED AS TO WHY THERE WAS NO SENSOR PAD IN PLACE FOR RESIDENT #302. CNA "J" STATED, "SHE DOES NOT WEAR A BED ALARM. I HAD HER FOR AT LEAST A WHOLE MONTH AND SHE NEVER HAD ONE (BED ALARM)." NURSE "K" THEN STATED, "WHEN THEY CHANGED HER MATTRESS TO AN ALTERNATING AIR MATTRESS, THAT IS WHEN WE STOPPED USING THE SENSOR PAD ALARM BECAUSE IT WOULD SOUND CONSTANTLY WITH THE ALTERNATING PRESSURE OF THE MATTRESS." REVIEW OF THE CNA ASSIGNMENT SHEETS REVEALED THAT CNA "J" WAS ASSIGNED TO RESIDENT #302 ON A CONSISTENT BASIS OVER THE PAST SIX WEEKS. FURTHER REVIEW OF THE PHYSICIAN'S ORDERS DID NOT REVEAL AN ORDER TO DISCONTINUE THE BED ALARM. THERE WAS NO DOCUMENTATION OF THE FACILITY TRYING ANOTHER TYPE OF BED ALARM FOR THE PREVENTION OF FURTHER FALLS FROM THE BED. ON 11/30/12 AT 9 A.M., THE DIRECTOR OF NURSES (DON) WAS INFORMED OF THE OBSERVATION. THE DON REPORTED THAT THE SENSOR PAD ALARM SHOULD HAD BEEN POSSIBLY CHANGED TO A CLIP ALARM. THERE WAS NO EXPLANATION AS TO WHY THIS WAS NOT DONE. ( ) DEFICIENT PRACTICE #3: BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO CLEAN THE DRYER LINT TRAPS FOR FOUR OF FOUR DRYERS, AND FAILED TO ENSURE RESIDENT CARE EQUIPMENT WAS NOT PLUGGED INTO POWER STRIPS IN THREE RESIDENT ROOMS (24 A, 28 A AND 47 A) FROM A TOTAL SAMPLE OF 96 RESIDENT ROOMS. THIS HAD THE POTENTIAL TO AFFECT 3 SUPPLEMENTAL SAMPLED RESIDENTS ( #27, #36 AND #68), RESULTING IN THE POTENTIAL FOR EQUIPMENT MALFUNCTION AND FIRE HAZARDS. FINDINGS INCLUDE: ON 11/29/12 AT 9:00 A.M., THE LAUNDRY AREA WAS TOURED WITH TEAM LEADER, STAFF "X". DURING THE TOUR, OBSERVATION WAS MADE OF THE FOUR FACILITY DRYER LINT TRAPS. EACH OF THE LINT TRAPS WERE BLANKETED WITH AN APPROXIMATE HALF-INCH LAYER OF LINT. ON THE BOTTOM FLOOR OF EACH OF THE DRYERS WERE CLUMPS OF LINT. AT THIS SAME TIME, STAFF "X" WAS QUERIED AS TO WHEN THE LINT TRAPS WERE LAST CLEANED. STAFF "X" STATED "I DON'T KNOW. THE PORTER USUALLY CLEANS THEM, AND SIGNS OUT ON THE LOG." REVIEW OF THE DOCUMENT TITLED "NOVEMBER 2012. LINT TRAP CLEANING SCHEDULE" REVEALED THAT THE LAST TIME THE LINT TRAP CLEANING WAS DOCUMENTED AS COMPLETED WAS ON 11/28/12 AT 10:30 A.M. (ONE DAY PRIOR). THE DOCUMENT INDICATED THAT THE LINT TRAP CLEANING WAS TO BE DONE EVERY TWO HOURS. ON 11/29/12 AT 9:15 A.M., LAUNDRY PORTER, STAFF "W" WAS INTERVIEWED REGARDING THE DRYER LINT TRAPS. STAFF "W" STATED, "I STARTED AT 7 (A.M.). THEY HAVE NOT BEEN DONE (CLEANED) YET TODAY. THEY WERE CLEANED LAST NIGHT BEFORE I LEFT. I JUST FORGOT TO SIGN IT OUT." ON 11/29/12 AT 11:00 A.M., THE HOUSEKEEPING SUPERVISOR WAS INTERVIEWED REGARDING THE DRYER LINT TRAP CLEANING AND STATED, "THE PORTER HAS BEEN INSERVICED ON THE LINT SCREEN CLEANING." REVIEW OF THE FACILITY DOCUMENT TITLED "LAUNDRY INSERVICE; LINT SCREEN CLEANING; DRAIN CLEANING", DATED 10/5/12; REVEALED AN INSERVICE DOCUMENTING "AS DRYERS RUN, LINT WILL ACCUMULATE INSIDE THE DRYERS. TO KEEP LINT FROM TRAVELING UP TO THE TOP OF THE DRYERS, NEAR THE FLAME, THE DRYERS ARE EQUIPPED WITH A SCREEN TO CATCH LINT AND HOLD IT AWAY FROM THE FLAME. THESE SCREENS WILL EVENTUALLY BE COVERED WITH LINT AND MUST BE CLEANED. IF NOT CLEANED, THE SCREENS WILL PREVENT AIR FROM CIRCULATING THROUGH THE DRYERS AND IS A DEFINITE FIRE HAZARD" AND SIGNED BY STAFF "W". A POLICY REGARDING THE CLEANING OF THE DRYER LINT TRAPS WAS REQUESTED. THE HOUSEKEEPING SUPERVISOR SAID THE FACILITY HAD NO POLICY. ON 11/29/12 AT 11:30 A.M.,A TOUR OF THE FACILITY WAS CONDUCTED WITH THE MAINTENANCE DIRECTOR. THE FOLLOWING ROOMS HAD RESIDENT CARE EQUIPMENT PLUGGED INTO POWER STRIPS: ROOM 24 A, RESIDENT #27'S OXYGEN CONCENTRATOR AND NEBULIZER WERE PLUGGED INTO A POWER STRIP. THE MAINTENANCE DIRECTOR STATED, "THERE WAS AN ISSUE WITH THAT OUTLET, NOW IT HAS BEEN REPAIRED." ROOM 28 A, RESIDENT #36'S BED WAS PLUGGED INTO A POWER STRIP. THE MAINTENANCE DIRECTOR STATED, "NO PATIENT CARE EQUIPMENT SHOULD BE PLUGGED INTO THE POWER STRIPS." ROOM 47 A, RESIDENT #68'S AIR MATTRESS WAS PLUGGED INTO A POWER STRIP. THE MAINTENANCE DIRECTOR STATED, "THAT SHOULD NOT BE PLUGGED INTO THERE (THE POWER STRIP)." ON 11/29/12 AT 1:15 P.M., THE MAINTENANCE DIRECTOR WAS INTERVIEWED REGARDING THE MONITORING OF POWER STRIPS AND THEIR USE FOR RESIDENT CARE EQUIPMENT. THE MAINTENANCE DIRECTOR STATED " I DID KNOW THAT RESIDENT CARE EQUIPMENT COULD NOT BE PLUGGED INTO THE POWER STRIPS, BUT THERE HAS NOT BEEN A MONITORING SYSTEM IN PLACE." A REQUEST WAS MADE FOR THE FACILITY'S POLICY ON MONITORING POWER STRIPS AND THEIR USE WITH RESIDENT CARE EQUIPMENT AND THE INFORMATION PROVIDED DID NOT ADDRESS POWER STRIPS RELATED TO MEDICAL DEVICES IN PATIENT CARE AREAS. ( )

THIS CITATION PERTAINS TO INTAKE: MI 036. BASED ON INTERVIEWS AND RECORD REVIEWS, THE FACILITY FAILED TO FOLLOW THE THEIR OWN FACILITY'S POLICY IN REGARD TO ASSESSING AND MONITORING A RESIDENT AFTER A FALL FOR 1 (#102) OF 3 SAMPLED RESIDENTS REVIEWED FOR FALLS, IN A TOTAL SAMPLE OF 5, WHEN RESIDENT #102 WAS OBSERVED TO HAVE A CHANGE IN HER MENTAL STATUS AFTER FALLING, RESULTING IN THE NEED FOR A TRANSFER TO LOCAL HOSPITAL emergency room FOR IMMEDIATE EVACUATION OF A SUBDURAL HEMATOMA (HEMORRHAGE IN THE SKULL). FINDINGS INCLUDE: ACCORDING TO THE FACILITY'S INCIDENT DOCUMENTATION FORM, DATED 10/18/12 AT 7:30 A.M., RESIDENT #102 WAS FOUND LYING ON HER LEFT SIDE IN THE HALLWAY. RESIDENT #102 WAS ASSISTED BACK TO BED WITH WAS NOTED TO HAVE COMPLAINTS OF RIGHT LEG PAIN AND AN ABRASION TO HER FOREHEAD. THE PHYSICIAN AND THE FAMILY WERE NOTIFIED. A CLOSED MEDICAL RECORD REVIEW REVEALED THAT RESIDENT #102 WAS [AGE] year OLD FEMALE WHO admitted to the facility on [DATE] WITH MULTIPLE [DIAGNOSES REDACTED]. RESIDENT #103 HAD an order for [REDACTED]. A REVIEW OF THE physician's orders [REDACTED].#102 WAS PRESCRIBED NEUROLOGICAL CHECKS IN ACCORDANCE WITH THE FACILITY'S PROTOCOL ON 10/18/12 AT 7:30 A.M. ACCORDING TO RESIDENT #102'S NEUROLOGICAL CHECK FLOW SHEET FORM, THE RESIDENT DID NOT DISPLAY ANY SIGNS OF MENTAL STATUS CHANGES FROM 10/18/12 AT 7:30 A.M., THROUGH 10/18/12 AT 6:15 P.M. THERE WERE NO ADDITIONAL NURSING NOTES OR NEUROLOGICAL ASSESSMENTS TO SUPPORT ANY FURTHER ASSESSMENTS OR MONITORING OF NEUROLOGICAL FUNCTION. ACCORDING TO THE FACILITY'S "FALLS PROGRAM," REVISED ON 8/31/2010, RESIDENTS ARE TO HAVE NEUROLOGICAL ASSESSMENTS COMPLETED IN ACCORDANCE TO THE FLOW SHEET DIRECTIONS. THE FLOW SHEET DIRECTIONS ARE AS FOLLOWS: NEUROLOGICAL CHECKS ARE TO BE COMPLETED EVERY 15 MINUTES, 4 TIMES; EVERY 1 HOUR, 4 TIMES; EVERY 2 HOURS, 4 TIMES; EVERY 4 HOURS, 3 TIMES; THEN EVERY 8 HOURS, 48 HOURS (TOTAL 25 CHECKS). THE PROGRAM PROTOCOL ALSO INDICATED THAT NURSES WERE TO DOCUMENT A PHYSICAL ASSESSMENT IN THE NURSING NOTES EVERY SHIFT FOR 72 HOURS TO ENSURE ONGOING MONITORING FOR DELAYED CONSEQUENCES. A REVIEW OF RESIDENT #102'S NEUROLOGICAL FLOW SHEET AND NURSING NOTES REVEALED THAT THE RESIDENT ONLY HAD NEUROLOGICAL ASSESSMENTS AND MONITORING UNTIL 10/18/12, AT 6:15 P.M., (ONLY FOR APPROXIMATELY 11 HOURS AFTER THE FALL FOR A TOTAL OF 11 CHECKS). DURING AN INTERVIEW ON 11/14/12 AT 12:20 P.M., LICENSED PRACTICAL NURSE (LPN) #4 SAID SHE (#4) REALIZED ON 10/19/12, AT APPROXIMATELY 6:30 OR 7:00 A.M., THAT RESIDENT #102 WAS, "NOT HERSELF" BECAUSE SHE (#102) DID NOT WANT TO GET OUT OF BED, OR EAT, LIKE SHE USUALLY DID. LPN # 4 SAID THAT AT AROUND 9:00 A.M., RESIDENT #102'S DAUGHTER WAS AT THE BEDSIDE AND INSISTED THAT SOMETHING WAS WRONG WITH HER MOTHER (RESIDENT #102). LPN #4 SAID THAT SHE ASSESSED RESIDENT #102 AND NOTED THAT SHE WAS NOT RESPONDING TO VERBAL STIMULI. LPN #4 SAID SHE NOTIFIED THE PHYSICIAN AND HIS ORDER WAS FOR HER TO HAVE NEUROLOGICAL ASSESSMENTS. LPN #4 SAID THAT RESIDENT #102'S DAUGHTER INSISTED THAT THE RESIDENT BE SENT OUT TO THE HOSPITAL. RESIDENT #102 WAS THEN TRANSFERRED TO A LOCAL HOSPITAL emergency room . LPN #4 COULD NOT EXPLAIN WHY THERE WAS NO DOCUMENTATION TO SUPPORT THAT ALL NEUROLOGICAL ASSESSMENTS WERE COMPLETED. WHEN LPN #4 WAS ASKED TO PROVIDE SPECIFIC DETAILS IN REGARD TO WHAT WAS TO BE INCLUDED IN THE FACILITY'S NEUROLOGICAL ASSESSMENT, LPN #4 WAS NOT ABLE TO ANSWER. ACCORDING TO THE HOSPITAL'S emergency room RECORDS, DATED 10/19/12 AT 12:09 P.M., RESIDENT #102 WAS ASSESSED TO BE NON-VERBAL AND ONLY WITHDRAW HER LEFT EXTREMITIES WHEN EXPOSED TO TACTILE STIMULI. A COMPUTED TOMOGRAPHY (CT) SCAN OF THE HEAD WAS IMMEDIATELY ORDERED AND REVEALED THAT RESIDENT #102 HAD A LARGE LEFT SUBDURAL HEMATOMA (BLEED/HEMORRHAGE) WITH AN 11 MM MIDLINE SHIFT FROM LEFT TO RIGHT. RESIDENT #102 WAS IMMEDIATELY SENT TO surgery for [REDACTED]. ( )

This citation pertains to MI# 456 Based on observation, interview, and record review, the facility failed to prevent the elopement and ensure the safety of 1 (#105) of 5 sampled residents, resulting in an Immediate Jeopardy when Resident #105, who was identified by the facility as an elopement risk and was on 15 minute checks, eloped out of the back door of the facility, unbeknownst to the facility staff. This deficient practice places 53 residents, identified as at risk for elopement, at risk for serious harm, injury, and/or death. Findings include: Observation on 5/22/12 at 9:25 AM, of the center hallway, revealed the Social Worker Tech (SWT) #5 and Registered Nurse (RN) #10 to be searching each unit. The staff was noted to be searching resident rooms, restrooms and the main dining room. On 5/22/12 at 10:15 AM, Director of Nursing (DON) #2 verbally notified the state surveyor on the premises that Resident #105 had eloped 15 minutes prior out the back door and that the back door had no alarm, but had a coded key pad for exiting and that Resident #105 must have walked out behind a visitor or ambulance (personnel). DON #2 stated that Resident #105 did wander the halls and was a high-functioning dementia person. DON #2 stated that Resident #105 was already on 15 minute checks since admission and had elopement precautions in place. Resident #105 was assessed and had been placed in the elopement book/binder at the front desk and on the units. DON #2 stated that the Ward Clerk #11 had seen Resident #105 last and was being cared for and monitored by Certified Nursing Assistant (CNA) #12. DON #2 stated that Resident #105 was found in the back parking lot outside of the facility gated area. DON#2 stated that the facility did not have or use a wander guard system to secure residents from leaving/exiting the facility. Record review of resident #105's hospital psychiatry & consultation liaison services notes, dated 5/4/12, revealed a behavioral problem of agitation requiring restraints and then a sitter. It was noted that Resident #105 wanted to leave to have a cigarette. The note identified that the resident was impulsive and did not follow commands and had been acting out of control. Record review of Resident #105's face sheet information revealed that the responsible party was a guardian. Record review of State of Michigan Probate Court County of Wayne, Order Appointing Guardian ad litem/ Attorney Lawyer-Guardian ad litem form, dated 5/21/12, revealed that the Resident #105 was a legally incapacitated individual. In an interview on 5/22/12 at 10:20 AM, Resident #105 revealed, "I was going to the store. A guy was coming in and I got out, the door closed behind me. I went out through the double glass doors. Out into the parking lot pass the dumpster out there. I saw a store and a gas station. A grocery store next door, I went in the back door and there were big trucks unloading". The resident thought that he was at 7 Mile road in Hamtramck. In an interview on 5/23/12 at 10:10 AM, Ward Clerk #11 revealed that she did go out the back door looking for Resident #105, on 5/22/12, and that she looked in the big parking lot next door (behind the store/warehouse), but did not see him and then came back into the facility. Observation and interview on 5/22/12 at 10:50 AM, while observing the back of the facility with RN #10, revealed that she and SWT #5 found Resident #105 outside the gated area in back past the dumpster (on 5/22/12), toward the back parking lot of the store/warehouse next door. Observation of the back parking lot while outside with RN #10 revealed there to be 2 semi-trucks backing up to the building next door and an alley with traffic that ran between the two buildings. RN #10 stated that the security gate is left open during the day because ambulances use it for appointments/pick-ups. In an interview on 5/22/12 at 10:45 AM, SWT #5 revealed, "I went to Resident #105's room. He was not there. Nurse with pony tail stated that he went down the hall toward C-unit (back of building). I checked the dining room, he wasn't there. So, I went and looked outside, out the back door. Found Resident #105 outside the gated area (on 5/22/12). Resident #105 said that he was going for cigarettes". SWT #5 stated that Resident #105 was new to her and that he was bipolar and schizophrenic. SWT #5 stated that Resident #105 had previously verbalized wanting to leave, so the facility put him in the elopement book and on 15 minute checks. Observation on 5/22/12 at 11:20 AM, of the surveillance camera video of the back door at 9:07 AM camera time (time on camera not set with care unit time) , revealed a male and female visitor entered into the facility through the back entrance. Resident #105 was seen in a camouflaged jacket and exiting out the back door before it closed. A second camera in the back parking lot caught Resident #105 going out through the open gated drive across to the next parking lot out of camera view. Further viewing of the back entrance door camera tape revealed that at 9:29 AM (camera time), Ward Clerk #11 was seen exiting out of the facility and returned. At 9:29 AM (camera time), SWT #5 and RN #10 were seen exiting out the back door. Observation of the back parking lot camera tape revealed SWT #5 and RN #10 and Resident #105 to be walking back into camera view, coming toward the open gate drive and then back through the open gated drive. It was also noted that there were automobiles going through the open gate drive. At 9:31 (AM) camera time, Resident #105 came back into the building. Resident #105 was missing from the facility for 23 minutes per camera time. Observation of the camera tapes revealed there to be no staff member stationed at the back entrance. Record review of resident #105's admission data collection form, dated 5/10/12, revealed that Resident #105 has a history of bipolar disorder and schizophrenia. Resident #105 was noted to be alert and oriented times 2 (person, place), ambulated with minimal assistance, noted slow to understand and mental function varies. Record review of admission care plan dated 5/10/12 identified Resident #105 was an exit seeking/elopement risk. Record review of facility 'Elopement and/or exit Seeking Management' policy/procedure, dated 8/31/10, revealed that an elopement is when a resident leaves a safe or secure area, for an unsafe area without assistance or supervision. Record review of Resident #105's elopement and/or exit seeking behavior risk analysis (undated) revealed that there was a history of elopement attempts or actual elopement in previous living situation-yes, noted Resident #105 had a sitter during hospital stay. Resident ambulates independently, excessive motor activity; such as pacing. Verbalized the desire to leave center-yes to go smoke. Impaired or inconsistent decision making ability-yes. Record review of Resident #105's 'Resident Care Guide' located in the resident care guide binder at the nurses' station, which is used by staff to provide care, revealed that Resident #105 was identified to have a behavior of wandering. There were no checks noted to elopement or exit seeking. Record review of facility CNA assignment sheet, dated 5/22/12, revealed that there were 2 CNA's working the A-unit. CNA #13 was assigned to Resident #105. Under CNA #13's name was listed dining for resident meal assignment. In an interview on 5/22/12 at 11:50 AM, CNA #13 revealed that she got Resident #105 dressed and ready for the day and that he sat in his chair waiting for breakfast. CNA #13 stated that she was assigned to go to the dining room to feed other residents down on C-unit at the back of the building, and when she does that someone is supposed to continue with the 15 minute checks while she is feeding. CNA #13 stated that she left the unit and CNA #12 was the CNA assigned to the floor and that CNA #12 was passing meal trays. CNA #13 stated that CNA #12 was to continue the 15 minute checks on Resident #105. CNA #13 stated that the last time she saw Resident #105 was at 8:45 AM sitting in a chair next to his bed. In an interview on 5/22/12 at 11:40 AM, CNA #12 revealed that she passed a breakfast tray about 9:00 AM to Resident #105 and at 9:15 AM Resident #105 came out into the hall with his tray. CNA #12 stated that she took the tray from Resident #105 and told Licensed Practical Nurse (LPN) #14 and she told SWT #5 to talk to Resident #105. CNA #12 stated that Resident #105 did not go back to his room and the last she saw him was in the center hallway. CNA #12 stated that she was busy passing meal trays. Record review of Resident #105's nurse notes, dated 5/12/12 at 2:00 PM, revealed that the resident was up ambulating in hall, noted with coat on and looking for the door to catch the bus. Record review of Resident #105's nurse notes, dated 5/14/12 at 8:45 PM, revealed resident walked through hallway going to c-unit to go to the store. Staff got resident back to A-unit and in room. At 9:45 PM a second nurse note revealed that Resident #105 came out of his room wanting to go to the store. Record review of resident #105's 'Frequent Visual Checks Log', dated 5/22/12, revealed the reason for frequent visual checks: exit seeking and elopement risk. Review of the 5/22/12 at 9:30 AM time slot revealed there to be no initials of staff noted and again at 10:15 AM no initials of staff member. Observation on 5/23/12 of the front lobby desk, revealed there to be a monitor screen with 11 different camera angles noted to view areas throughout the facility. The back door access could be triggered by the front desk lobby staff member. Record review of a facility 5 day report dated 5/29/12 revealed: Review of camera revealed that Resident #105 walked out as a visitor came into the back door. He (Resident #105) was returned to the facility by 2 staff members who located him outside of the parking lot gate. He (Resident #105) stated he was going to the store. On 5/22/12 at 4:46 PM, Administrator #1 and DON #2 were notified of an Immediate Jeopardy identified on 5/22/12 and began on 5/22/12 at 9:07 AM (camera time), when Resident #105, whom was on 15 minute visual checks, eloped from the facility. On 5/23/12 at 2:10 PM, the surveyor confirmed that the facility implemented the following to remove the Immediate Jeopardy: 1.) On 5/22/12 at 9:40 AM Resident #105 was assessed and there were no signs of harm or ill effects noted. Resident #105 denied pain. 2.) On 5/22/12 at 2:30 PM Resident #105's care guide and care plans were updated to reflect the one-on-one sitter for 24 hours a day. 3.) On 5/22/12 at 10:00 AM, one-on-one monitoring was started and is to continue until alternate placement can be secured. 4.) On 5/22/12 at 1:00 PM, primary care physician was in to assess resident. 5.) On 5/22/12 at 3:00 PM, the facility administrator and director of nursing reviewed the elopement policy and procedure and deemed it appropriate. 6.) On 5/22/12 at 4:35 PM, the social workers completed an audit of the residents identified as an elopement risk to identify any issues or concerns and their care plans were reviewed to reflect current appropriate interventions. Social Workers will continue to audit all residents in the facility utilizing the elopement risk tool to identify new residents at risk for elopement. 7.) On 5/22/12 at 4:45 PM, maintenance staff conducted an audit of all exit doors to ensure alarms and codes were functioning properly. No issues identified. 8.) On 5/22/12 at 12:30 PM, the back door will be staffed 24 hours a day, 7 days a week for increased monitoring and a written schedule was done. 9.) On 5/22/12 at (no time listed), a sign was posted on the back door to alert family/visitors to not allow anyone to leave out the door behind them. 10.) On 5/22/12 at 5:45 PM, in services on the elopement policy were initiated. 11.) On 5/22/12, the social services director started to audit all residents at risk for elopement weekly for 4 weeks to ensure ongoing compliance. All identified areas of concern will be reported to the administrator weekly and to the QA committee monthly. Although the Immediate Jeopardy was removed on 5/22/12, the facility remained out of compliance at the scope of pattern and severity of no actual harm with potential for more than minimal harm, that is not Immediate Jeopardy, due to the State Agency had not yet verified sustained compliance. #

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO FOLLOW PHYSICIAN ' S ORDERS FOR THE ADMINISTRATION OF [MEDICATION NAME] (BLOOD THINNER) AND FAILED TO ASSESS AND MONITOR [MEDICATION NAME] TIME AND INTERNATIONAL NORMALIZED RATIO (PT/INR) TESTS (LABORATORY TEST USED TO DETERMINE THE BLOOD'S ABILITY TO FORM CLOTS) FOR SIX (#'S 904, 911, 922, 923, 924 AND 925) OF 10 RESIDENTS RECEIVING [MEDICATION NAME] THERAPY FROM A TOTAL SAMPLE OF 32 RESIDENTS, RESULTING IN AN IMMEDIATE JEOPARDY (IJ) TO THE HEALTH AND SAFETY OF RESIDENTS. FAILURE TO MONITOR ANTICOAGULANT THERAPY HAS THE POTENTIAL TO CAUSE SERIOUS HARM AND DEATH FROM UNCONTROLLABLE BLEEDING. THE IMMEDIATE JEOPARDY BEGAN ON 5/23/11 AND THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON 2/16/12 AT 11:30 A.M. THE ADMINISTRATOR WAS NOTIFIED OF THE IJ ON 2/16/12 AT 2:50 P.M. A PLAN OF CORRECTION WAS REQUESTED TO REMOVE THE IMMEDIATE JEOPARDY. THE IJ WAS REMOVED ON 2/17/12 AT 2:45 P.M., BASED ON THE PROVIDER'S IMPLEMENTATION OF CORRECTIVE ACTIONS ON 2/16/12 AND 2/17/12 AS VERIFIED ONSITE ON DURING THE COMPLETION OF THE EXTENDED SURVEY. ALTHOUGH THE IJ WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE REMAIN AT A PATTERN WITH NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY. FINDINGS INCLUDE: ON 2/15/12 AT 1:55 P.M., RESIDENT #911'S CLINICAL RECORD AND LABORATORY (LAB) RESULTS WERE REVIEWED WITH UNIT MANAGER "D". AND REVEALED THAT ON 12/07/11 A VASCULAR STUDY NOTED A POSITIVE [MEDICAL CONDITIONS] (BLOOD CLOT)) OF THE RIGHT ARM JUGULAR VEIN. THE PHYSICIAN WAS NOTIFIED AND ORDERED, "[MEDICATION NAME] 80 MILLIGRAM (MG) SUBCUTANEOUS (SUB Q) TWICE A DAY, 9 AM, 9 PM. D/C (DISCONTINUE) WHEN INR IS 2-3. DO AN INTERNATIONAL NORMALIZED RATIO (INR), THIS FRIDAY 12/9/11. THEN START [MEDICATION NAME] 5 MG AT HS (BEDTIME). THEN WEEKLY PT/INR ON MONDAYS. " REVIEW OF A PHYSICIAN'S ORDER DATED 12/7/11 REVEALED THAT RESIDENT #911 SHOULD HAVE RECEIVED HIS FIRST DOSE OF [MEDICATION NAME] ON 12/9/11. REVIEW OF THE MEDICATION ADMINISTRATION RECORD (MAR), FOR 12/2011 INDICATED THAT RESIDENT #911 DID NOT RECEIVE HIS FIRST DOSE OF [MEDICATION NAME] UNTIL 12/12/11 (3 DAYS AFTER THE START ORDER DATE.) REVIEW OF A LAB TEST RESULT DATED, 12/12/11, INDICATED [MEDICATION NAME] TIME (PT) WAS 11.5 (THERAPEUTIC RANGE 9.0-11.5 SECONDS) AND THE INR WAS 1.1 (THERAPEUTIC RANGE 2.0-3.0). THERE WAS NO DOCUMENTED EVIDENCE IN RESIDENT #911'S MEDICAL RECORD THAT THE PHYSICIAN GROUP WAS NOTIFIED OF THE SUBTHERAPEUTIC PT/INR LEVEL. UNIT MANAGER "D" WAS QUERIED AND WAS UNABLE TO EXPLAIN WHY RESIDENT #911 HAD NOT RECEIVED HIS [MEDICATION NAME] AS ORDERED BY THE PHYSICIAN ON 12/9/11. SHE WAS ALSO UNABLE TO EXPLAIN WHY THE FACILITY HAD tested RESIDENT 911'S BLOOD TO MEASURE THE EFFECTIVENESS OF [MEDICATION NAME] BEFORE ANY [MEDICATION NAME] HAD BEEN GIVEN, NOR WHY THE PHYSICIAN HAD NOT BEEN INFORMED. REVIEW OF PHYSICIAN ORDERS DATED 12/14/11 DOCUMENTED PHYSICIAN ORDERS TO INCREASE [MEDICATION NAME] FROM 5 MILLIGRAMS (MG) TO 6 MG BY MOUTH (PO) EVERY (Q) HOURS SLEEP (HS). THERE WAS NO DOCUMENTATION TO INDICATE THE PHYSICIAN WAS AWARE, BEFORE, INCREASING THE DOSE, THAT THE [MEDICATION NAME] HAD NOT BEEN STARTED UNTIL 12/12/11. REVIEW OF THE MAR FOR 12/2011 REVEALED THAT RESIDENT #911 DID NOT RECEIVE ANY [MEDICATION NAME] OR [MEDICATION NAME] ON 12/14/11 AT 9:00 P.M., OR ON 12/15/11 AT 9:00 A.M.. THERE WAS NO DOCUMENTATION TO EXPLAIN THIS AND UNIT MANAGER "D" COULD PROVIDE NO FURTHER INFORMATION OR EXPLANATION. REVIEW OF LAB RESULTS COLLECTED 12/19/11 AT 6:25 A.M., REVEALED RESIDENT #911'S PT WAS 119.5 AND INR WAS 12.1 (EXCEEDED THE RANGE FOR HIGHER-INTENSITY [MEDICATION NAME] THERAPY 3.0-4.0), POSING A RISK FOR HEMORRHAGE (UNCONTROLLED BLEEDING). REVIEW OF NURSING NOTES DATED 12/19/11 AT 5:35 P.M., REVEALED THE LAB CALLED THE FACILITY AT 5:15 P.M., TO ALERT THEM OF THE EXCESSIVELY HIGH PT AND INR RESULTS. A NURSING NOTE, DATED 12/19/11 AT 5:35 P.M. DOCUMENTED, "WRITER NOTIFIED DR (PHYSICIAN). DR ORDERED STAT (IMMEDIATE) VITAMIN K 10 MG (ACTS IN OPPOSITION TO [MEDICATION NAME]) IM INJ (INTRAMUSCULAR INJECTION). WRITER OBTAINED THE VITAMIN K." REVIEW OF A PHYSICIAN'S ORDER FOR RESIDENT #911, DATED 12/19/11, DOCUMENTED "VITAMIN K 10 MG IM INJECT NOW. STAT LAB DRAW (IMMEDIATE BLOOD TEST) PT AND INR." RESIDENT #911'S 12/2011 MAR INDICATED THAT ON 12/19/11 6 MG OF [MEDICATION NAME] WAS GIVEN AS WELL AS 10 MG VITAMIN K. THE [MEDICATION NAME] WAS DISCONTINUED. WHEN QUERIED WHY THE DOSE OF [MEDICATION NAME] WAS STILL GIVEN DESPITE THE LAB TEST INDICATING AN OVERDOSE OF [MEDICATION NAME], UNIT MANAGER "D" STATED, "THERE WERE NO ORDERS TO DISCONTINUE THE [MEDICATION NAME]." UNIT MANAGER "D" COULD NOT EXPLAIN WHY [MEDICATION NAME] WAS STILL GIVEN WHEN VITAMIN K, AN ANTIDOTE TO [MEDICATION NAME] TOXICITY, WAS GIVEN (THE TWO MEDICATIONS COUNTERACT EACH OTHER). REVIEW OF A STAT LAB RESULT DATED, 12/19/11 AT 9:48 P.M., INDICATED RESIDENT #911'S PT WAS 147.5 AND INR WAS 15.0, INDICATING THAT RESIDENT #911'S INR LEVELS HAD INCREASED, POSING A GREATER RISK OF SPONTANEOUS HEMORRHAGE. REVIEW OF RESIDENT #911'S PHYSICIAN'S ORDER, DATED 12/20/11, REVEALED A SECOND STAT PT/INR ORDER. REVIEW OF RESIDENT #911'S NURSING NOTES DATED 12/20/11 AT 6:30 A.M., DOCUMENTED THAT THE LAB CONTACTED THE FACILITY VIA PHONE TO NOTIFY THE FACILITY THAT RESIDENT #911'S PT AND INR WERE ELEVATED; PT OF 74.5 AND INR OF 7.5. REVIEW OF A NURSING NOTE FOR RESIDENT #911, DATED 12/20/11 AT 3:30 P.M., READ "ORDER GIVEN BY (DR) VIA PHONE FOR 10 MG VITAMIN K IM. ORDER WRITTEN, FAXED TO PHARMACY, NOTED IN MAR. MEDICATION N/A (NOT AVAILABLE) IN EITHER BACK UP BOX. SPOKE WITH (PHARMACY) WHO STATED THAT IT WOULD BE CALLED IN TO A BACK UP PHARMACY AND DELIVERED ASAP (AS SOON AS POSSIBLE." REVIEW OF PHYSICIAN'S ORDER FOR RESIDENT #911, DATED 12/20/11, REVEALED an order for [REDACTED]. REVIEW OF THE 12/2011 MAR REVEALED THAT RESIDENT #911 RECEIVED 6 MG OF [MEDICATION NAME] ON 12/20/2011. REVIEW OF A PHYSICIAN NOTE FOR RESIDENT #911, DATED, 12/21/11, REVEALED THE FOLLOWING, " EVALUATION FOR [MEDICATION NAME] COAGULOPATHY, "INR WENT FROM 1.1 TO 12 ON 6 MG ([MEDICATION NAME]) Q HS. WILL CLARIFY TO HOLD [MEDICATION NAME] AS PATIENT CONTINUED TO RECEIVE IN CONJUNCTION WITH VITAMIN K. PT/INR NEXT DRAW." REVIEW OF RESIDENT #911'S PHYSICIAN ORDER DATED 12/21/11 DOCUMENTED, " PT/INR NEXT DRAW, HOLD [MEDICATION NAME] UNTIL INR <3 (LESS THAN 3); NOTIFY DR (DOCTOR) FOR CONTINUED ORDER." REVIEW OF RESIDENT #911'S MAR FOR 12/2011, DATED 12/21/11, REVEALED A NOTATION, "6 MG [MEDICATION NAME] HOLD UNTIL FURTHER NOTICE." REVIEW OF RESIDENT #911'S LAB, DATED 12/23/11 AT 5:40 A.M., INDICATED THAT RESIDENT #911'S PT WAS 21.0 AND INR WAS 2.0. RESIDENT #911'S LAB DATED 12/28/11 7:15 A.M., NOTED A SUBTHERAPEUTIC PT OF 11.6 AND INR OF 1.1. LAB RESULTS DATED 12//30/11, REVEALED A PT OF 11.1 AND INR OF 1.1. REVIEW OF NURSING NOTES FOR RESIDENT #911 REVEALED NO DOCUMENTATION THAT THE PHYSICIAN GROUP WAS NOTIFIED THAT RESIDENT #911'S INR WAS <3 PER THE PHYSICIAN ORDER, DATED 12/21/11, "HOLD [MEDICATION NAME] UNTIL INR<3 (LESS THAN 3); NOTIFY DR (DOCTOR) FOR CONTINUED ORDER." WHEN QUERIED, UNIT MANAGER "D" WAS UNABLE TO PROVIDE DOCUMENTATION THAT THE PHYSICIAN GROUP WAS NOTIFIED OF THESE LAB RESULTS OR THAT NEW ORDERS WERE OBTAINED. THE UNIT MANAGER WAS UNABLE TO PROVIDE EXPLANATION OR DOCUMENTATION. REVIEW OF RESIDENT #911'S MAR FOR 12/2011 INDICATED THAT NO [MEDICATION NAME] WAS RECEIVED FOR THE DATES OF 12/23/11 THROUGH 1/1/12, A TOTAL OF 10 DAYS AFTER #911'S INR WAS 2.0 AND THE PHYSICIAN SHOULD HAVE BEEN CONTACTED FOR CONTINUED ORDERS. RESIDENT #911'S PHYSICIAN ORDER DATED 12/27/2011 READ, "PT/INR ON MONDAYS/FRIDAYS UNTIL FURTHER NOTICE." RECORD REVIEW REVEALED A PHYSICIan order for [REDACTED]." RESIDENT #911'S PHYSICIAN NOTES DATED 12/29/11 READ, "[MEDICATION NAME] COAGULOPATHY MEDS/LABS REVIEWED, CONTINUE WEEKLY PT/INR." THERE WAS NO DOCUMENTATION THAT INDICATED THAT THE PHYSICIAN WAS AWARE OR NOTIFIED THAT RESIDENT #911 HAD NOT RECEIVED [MEDICATION NAME] SINCE 12/21/11. REVIEW OF RESIDENT #911'S PHYSICIAN ORDER, DATED 1/01/12, READ, "[MEDICATION NAME] 3 MG PO Q HS." REVIEW OF LAB RESULTS FOR RESIDENT #911 REVEALED NO DOCUMENTATION THAT BIWEEKLY PT/INR TEST WERE PERFORMED FOR 2 WEEKS. LABS WERE SCHEDULED BUT NOT PERFORMED FOR 1/2/12, 1/6/12, 1/9/12 AND 1/13/12. RESIDENT #911 ' S PREVIOUS LAB ORDER DATED 12/27/2011 READ " PT/INR ON MONDAYS/FRIDAYS TILL FURTHER NOTICE." REVIEW OF RESIDENT #911'S MAR, FOR 1/2012, INDICATED THAT RESIDENT #911 RECEIVED 3 MG [MEDICATION NAME] DAILY FROM 1/2/2012-1/13/12 WITHOUT MONITORING OF PT/INR (TOTAL OF 11 DAYS). REVIEW OF A physician progress notes [REDACTED]. WILL REQUEST STAT AND CLARIFY 2 TIMES A WEEK ORDER." REVIEW OF RESIDENT #911'S PHYSICIAN ORDER, DATED 1/14/12 REVEALED "DECREASE [MEDICATION NAME] TO 2 MG VIA PEG Q HS." REVIEW OF RESIDENT #911'S LAB DATED 01/16/12 REVEALED AN INR OF 4.3 AND PT OF 43.8. REVIEW OF RESIDENT #911'S MAR FOR 1/2012 REVEALED THAT RESIDENT #911 WAS NOT ADMINISTERED [MEDICATION NAME] FROM 1/17/12 THROUGH 1/25/12. REVIEW OF RESIDENT #911'S MEDICAL RECORD REVEALED NO PHYSICIan order for [REDACTED]. REVIEW OF RESIDENT #911'S PHYSICIAN ORDER, DATED 1/25/12, REVEALED an order for [REDACTED]. REVIEW OF A LAB REPORT FOR RESIDENT #911, DATED 1/27/12, REVEALED A SUBTHERAPEUTIC PT OF 11.8 AND INR OF 1.1. REVIEW OF RESIDENT #911'S PHYSICIAN ORDER DATED 1/29/12 REVEALED, "INCREASE [MEDICATION NAME] TO 2.5 MG P/T (PER TUBE) DAILY." REVIEW OF RESIDENT #911'S MAR, FOR 1/2012, REVEALED THAT RESIDENT #911 RECEIVED TWO DOSES OF [MEDICATION NAME] ON 1/29/12, 2 MG AND 2.5 MG OF [MEDICATION NAME]. THERE WAS NO DOCUMENTATION THAT THE PHYSICIAN GROUP WAS NOTIFIED THAT THE RESIDENT RECEIVED TWO DOSES OF [MEDICATION NAME]. WHEN QUERIED, UNIT MANAGER "D" WAS UNABLE TO PROVIDE ANY FURTHER DOCUMENTATION REGARDING THIS CONCERN. THE DIRECTOR OF NURSING (DON) AND UNIT MANAGER "D" WERE REQUESTED TO PROVIDE ANY FURTHER LAB RESULTS, DOCUMENTATION REGARDING RESIDENT #911'S [MEDICATION NAME] MONITORING AND VITAMIN K ADMINISTRATION AND THE POLICY FOR ANTICOAGULANT THERAPY. ON 2/15/2012 AT 4:30 P.M., THE DIRECTOR OF NURSES (DON) AND UNIT MANAGER "D" WERE QUERIED REGARDING RESIDENT #911. THE DON STATED THAT SHE WAS NOT AWARE ANY CONCERNS REGARDING RESIDENT #911'S ANTICOAGULATION THERAPY. ON 2/16/2012 AT 10:50 A.M., THE FOLLOWING INFORMATION WAS REQUESTED FROM THE DON: RESIDENT #911'S DOCUMENTATION OF VITAMIN K ADMINISTRATION FOR 12/20/11, MISSING LAB RESULTS, PT/INR FLOW SHEET FOR DECEMBER 2011 AND JANUARY 2012, STOOL TEST FOR OCCULT BLOOD AT INITIATION OF ANTICOAGULANT THERAPY, CARE PLAN FOR ANTICOAGULANT THERAPY AND DIETARY NOTIFICATION OF ANTICOAGULANT THERAPY. ON 2/16/2012 AT 11:10 A.M., PHYSICIAN "C" WAS QUERIED REGARDING RESIDENT #911'S ANTICOAGULANT THERAPY. PHYSICIAN "C" STATED THAT HE DID ORDER VITAMIN K FOR RESIDENT #911 ON 12/19/11 AND 12/20/11 AND THAT RESIDENT #911 SHOULD NOT HAVE RECEIVED [MEDICATION NAME] WITH VITAMIN K." WHEN QUERIED AS TO WHEN NURSING SHOULD NOTIFY THE PHYSICIAN OF PT/INR TEST RESULTS, PHYSICIAN "C " STATED, "THE FACILITY SHOULD CALL THE PHYSICIAN WITH ALL PT/INR RESULTS." PHYSICIAN "C" ALSO STATED, "NURSES CALL WITH PT/INR RESULTS. THE PHYSICIAN HAS NO ACCESS TO THE RESIDENTS' MEDICAL RECORDS. THE NURSES ARE EXPECTED TO RELAY INFORMATION THAT MAY IMPACT ANTICOAGULANT THERAPY SUCH AS IF A MEDICATION IS BEING HELD." REVIEW OF RESIDENT #911'S CLINICAL RECORD REVEALED A FACE SHEET THAT INCLUDED Diagnoses: [REDACTED]. REVIEW OF AN INTER-AGENCY TRANSFER SUMMARY DATED 11/21/2011, INDICATED THAT RESIDENT #911 WAS readmitted TO THE FACILITY AFTER hospitalization FOR GASTRO INTESTINAL BLEEDING. RESIDENT #911'S MOST RECENT MINIMUM DATA SET ASSESSMENT (MDS), dated [DATE], INDICATED A MODERATELY IMPAIRED COGNITION, REQUIRED EXTENSIVE ASSISTANCE FOR TRANSFER AND WAS TOTALLY DEPENDENT FOR TOILETING AND HYGIENE. REVIEW OF NURSING CARE PLANS REVEALED NO CAREPLAN FOR ANTICOAGULANT THERAPY OR RISK OF BLEEDING. THE FOLLOWING ITEMS WERE REQUESTED BUT NOT PROVIDED PRIOR TO SURVEY EXIT: LABS FOR THE FOLLOWING DATES; 12/26/11, 1/2/12, 1/6/12, 1/9/12, AND 1/13/12. THE PT/INR FLOW SHEETS FOR DECEMBER 2011 AND JANUARY 2012, STOOL FOR OCCULT BLOOD, CARE PLAN FOR ANTICOAGULANT THERAPY UPON INITIATION ON 12/7/11 AND DIETARY NOTIFICATION OF ANTICOAGULOPATHY. ON 2/17/12 AT 11:50 P.M., REVIEW OF RESIDENT #925'S FACE SHEET REVEALED AN ADMISSION INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. A MINIMUM DATA SET ASSESSMENT ((MDS) dated [DATE] INDICATED THAT RESIDENT #925 REQUIRED ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING (ADLS) AND WAS INCONTINENT OF BOWEL AND BLADDER. MEDICATIONS DOCUMENTED ON THE MDS INCLUDED [MEDICATION NAME] (AN ANTI COAGULANT OR BLOOD THINNER) 3.5 MILLIGRAMS (MG) PO (BY MOUTH) Q HS (ONCE DAILY AT BEDTIME). RESIDENT #925'S LABORATORY REPORTS REVEALED NO DOCUMENTED RESULTS OF [MEDICATION NAME] TIME/ INTERNATIONAL NORMALIZED RATIO (PT/INR) FOR THE TIME PERIOD OF 1/11/12 THROUGH 2/16/12, TO MONITOR FOR SUBTHERAPEUTIC (TOO LOW A DOSE TO TREAT THE DISEASE) OR TOXIC [MEDICATION NAME] LEVELS. ON 2/17/12 AT 11:50 A.M., WARD CLERK, "J" WAS QUERIED ABOUT THE MISSING PT/INR LABORATORY (LAB) TESTS FOR RESIDENT #925 BETWEEN 1/11/12 AND 2/16/12. WARD CLERK "J" WAS UNABLE TO FIND ANY LAB TESTING FOR RESIDENT #925 IN RESIDENT #925'S RECORDS OR IN THE LAB COMPUTER. WHEN QUERIED, WARD CLERK "J " WAS UNABLE TO PROVIDE DOCUMENTATION OF A PHYSICIAN'S ORDER FOR LAB TESTING OF PT/INR FOR RESIDENT #925. ON 2/17/12 AT 12:17 P.M., UNIT MANAGER, NURSE "M" WAS ASKED WHY RESIDENT #925 WAS PRESCRIBED [MEDICATION NAME]. NURSE "M" THEN CONTACTED RESIDENT #925' S PHYSICIAN BY PHONE, AND REPORTED THAT RESIDENT #925 WAS admitted INto the facility on [MEDICATION NAME] (AN INJECTABLE ANTICOAGULANT) DUE TO SEVERE DEBILITY FROM ACUTE POLIO[DIAGNOSES REDACTED] AND NON AMBULATORY STATUS (NOT ABLE TO WALK). NURSE "M" STATED THAT RESIDENT #925 WAS DISCONTINUED FROM [MEDICATION NAME] IN JUNE OF 2011 AND HAD BEEN ON [MEDICATION NAME] SINCE THEN. WHEN QUERIED WHY RESIDENT #925 DID NOT HAVE PT/INR LABS BETWEEN 1/11/12 AND 2/16/12 TO MONITOR FOR [MEDICATION NAME] OVERDOSE, NURSE "M" WAS UNABLE TO ANSWER. NURSE "M" WAS UNABLE TO PROVIDE A THERAPEUTIC GOAL RANGE FOR THE PT/INR FOR RESIDENT #925. RESIDENT #925'S NURSING CARE PLAN LABELED, "I HAVE THE POTENTIAL FOR BLEEDING R/T ANTICOAGULANT THERAPY," DATED 9/26/11, WAS REVIEWED AND REVEALED THE FOLLOWING GOAL, "I WOULD LIKE FOR MY LAB VALUES TO BE WNR (WITHIN NORMAL RANGE) FOR ME". THERE WAS NO NOTATION INDICATING WHAT WNR VALUES FOR RESIDENT #925 WERE OR SHOULD BE. INTERVENTIONS INCLUDED, "ALWAYS ASSESS MY LAB VALUES AND NOTIFY MY MD (MEDICAL DOCTOR) OF ANY ABNORMALS FOR APPROPRIATE INTERVENTIONS," AND, "PT/INR OR PTT AS ORDERED." LAB DATA FOR RESIDENT #925 BETWEEN 1/11/12 AND 2/16/12 WAS REQUESTED BUT NOT PROVIDED. ( )( ) ON 2/16/12 AT 1:05 P.M., RESIDENT #922 WAS OBSERVED IN A WHEELCHAIR. RESIDENT #922 REPORTED THAT SHE ONCE HAD A BLOOD CLOT IN HER LEFT LEG. ON 2/16/12 AT 2:00 P.M., RESIDENT #922'S ADMISSION FACE SHEET INDICATED AN ADMISSION INto the facility on [DATE], WITH [DIAGNOSES REDACTED]. THE Minimum Data Set, dated dated [DATE], INDICATED THE RESIDENT'S COGNITION WAS MILDLY IMPAIRED AND RELIED ON STAFF FOR ALL CARE NEEDS. REVIEW OF THE MEDICATION ADMINISTRATION RECORD (MAR) REVEALED RESIDENT #922 HAD BEEN PRESCRIBED [MEDICATION NAME] (BLOOD THINNER) SINCE ADMISSION IN 2010. REVIEW OF THE LABORATORY RESULTS, DATED 5/23/11, REVEALED PT/INR RESULTS FOR RESIDENT #922 WERE ELEVATED. THE PT WAS 62.2 (NORMAL RANGE 20-30) AND INR WAS 6.2 (NORMAL RANGE 2.0- 3.0). THERE WAS NO DOCUMENTATION THAT INDICATED THE PHYSICIAN WAS CONTACTED CONCERNING THE ELEVATED LABORATORY RESULTS. REVIEW OF THE MAR REVEALED [MEDICATION NAME] 6 MG WAS DOCUMENTED AS GIVEN AT 8:00 PM ON THAT DAY (5/23/11). ON 5/24/11, RESIDENT #922'S INR WAS 5.4 AND THE PT WAS 54.4, BOTH ELEVATED. A NURSES NOTE DATED 5/24/11 AT 8:00 P.M., DOCUMENTED, "SPOKE WITH DOCTOR ("N"). LAB RESULTS FOR PT/INR. HOLD [MEDICATION NAME] FOR 3 DAYS." REVIEW OF THE MAR REVEALED [MEDICATION NAME] 6 MG WAS DOCUMENTED AS GIVEN AT 8:00 P M ON THAT DAY (5/24/11). REVIEW OF RESIDENT #922'S PT/INR FLOW SHEET (MONTHLY FLOW SHEET USED TO DOCUMENT THE RESIDENT'S LAB RESULTS) REVEALED THE FOLLOWING: MAY 2011, THERE WERE ONLY TWO PT/INR LAB RESULTS FOR RESIDENT #922 DOCUMENTED, ON 5/24 AND 5/31/11. JUNE 2011, THERE WAS ONE PT/INR RESULT DOCUMENTED FOR RESIDENT #922, ON 6/6/11. NOVEMBER 2011, THERE WERE FOUR PT/INR RESULTS DOCUMENTED, ON 11/4, 11/7, 11/21 AND 11/29. NO OTHER PT/INR FLOW SHEETS WERE FOUND FOR RESIDENT #922 IN THE ACTIVE CLINICAL RECORD OR THINNED RECORDS. ON 2/17/12 AT 1:15 P.M., THE CARE PLAN FOR ANTICOAGULANT THERAPY ([MEDICATION NAME]), DATED 4/5/11, WAS REVIEWED, THE GOALS WERE " ...BE FREE FROM BLEEDING, LABS TO BE WITHIN NORMAL RANGE. THE INTERVENTIONS WERE " CHECK LABS AS ORDERED. NOTIFY DOCTOR OF ABNORMAL RESULTS. GIVE [MEDICATION NAME] AS ORDERED. " ON 2/17/12 AT 1:55 P.M., UNIT MANAGER "L" WAS QUERIED CONCERNING THE CONTINUED ADMINISTRATION OF [MEDICATION NAME] WHEN RESIDENT #922 PT/INR WERE CRITICALLY HIGH ON 5/23/11 AND 5/24/11. IN ADDITION, NO INDICATION THAT THE NURSING STAFF HAD CONTACTED THE PHYSICIAN CONCERNING THE RESIDENT ' S CRITICALLY ELEVATED INR /PT ON 5/23/11. AFTER REVIEWING THE NURSES NOTES, MAR AND LAB RESULTS FOR THE ABOVE DAYS, UNIT MANAGER (NURSE "L") STATED, "THE NURSES SHOULD BE CONTACTING THE PHYSICIAN FOR ELEVATED LABS. THEY SHOULD ALSO HOLD THE [MEDICATION NAME], IF THE RESULTS ARE HIGH AND MAKE A NURSES NOTE IN THE CHART. THE NURSES SHOULD BE COMPLETING THOSE INR/PT FLOW SHEETS. THE SHEETS ARE KEPT ON THE MAR'S TO TRACK THE LAB RESULTS." ( ) ON 2/15/12 AT 1:00 P.M., RESIDENT #904'S ACTIVE CLINICAL RECORD WAS REVIEWED. THE ADMISSION FACE SHEET INDICATED THE RESIDENT WAS RECENTLY admitted INto the facility on [DATE], WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE], INDICATED THE RESIDENT WAS COGNITIVELY IMPAIRED AND NEEDED EXTENSIVE ASSISTANCE WITH ALL CARE NEEDS. AN ULTRASOUND RESULT DATED 2/3/12, INDICATED RESIDENT #904 WAS POSITIVE FOR A THROMBUS (BLOOD CLOT) IN THE RIGHT SUPERFICIAL FEMORAL VEIN OF THE RIGHT LEG. A PHYSICIAN'S ORDER DATED ON 2/3/12, DOCUMENTED "[MEDICATION NAME] (TO TREAT ACUTE BLOOD CLOTS) 50 MILLIGRAM EVERY 12 HOURS AND [MEDICATION NAME] (REDUCES THE FORMATION OF BLOOD CLOTS) 5 MG DAILY." REVIEW OF THE MEDICATION ADMINISTRATION RECORD (MAR) REVEALED THE RESIDENT WAS RECEIVING [MEDICATION NAME] (PREVENTS BLOOD CLOTS FROM FORMING 75 MG DAILY. REVIEW OF laboratory results dated [DATE], INDICATED RESIDENT#904'S INR WAS 4.2 (NORMAL RANGE 2.0 TO 3.0) AND PT WAS 42.1 ( RANGE 20.0 - 30.0). ON 2/13/12, THE INR WAS 8.1 (ELEVATED ABOVE THE RANGE) AND THE PT WAS 80.6 (ELEVATED ABOVE THE RANGE). NURSES NOTE DATED 2/13/12, DOCUMENTED, "CONTACTED DOCTOR (DR "C") FOR CRITICAL RESULTS OF INR/PT RESULTS OF INR 8.1 AND PT 8.6. NEW ORDER TO HOLD [MEDICATION NAME] AND [MEDICATION NAME]." NURSES NOTE DATED 2/15/12, DOCUMENTED "CONTACTED DR. "C" WITH RESULTS, PT 93.6 AND INR 9.4. DR. "C" GAVE A VERBAL ORDER FOR STAT ( RIGHT AWAY) VITAMIN K 5 MG SUBCUTANEOUSLY. THE ADMINISTRATION OF THE VITAMIN K WAS GIVEN TWO DAYS AFTER THE INITIAL ELEVATED LAB RESULTS WERE REPORTED TO THE DOCTOR. ON 2/17/12 AT 11:00 A.M., UNIT MANAGER (NURSE "M") WAS QUERIED CONCERNING THE ADMINISTRATION OF THREE BLOOD THINNERS FOR RESIDENT #904, PUTTING THE RESIDENT AT INCREASED RISK FOR BLEEDING. UNIT MANAGER (NURSE "M") STATED, "NURSING DID NOTICE IT ON 2/6/12 (DAY THREE) AND BROUGHT IT TO THE PHYSICIAN ASSISTANTS ATTENTION." THE WEBSITE "DRUGS. COM " NOTED THE FOLLOWING MANUFACTURERS INFORMATION: "WHENEVER POSSIBLE, AGENTS WHICH MAY ENHANCE THE RISK OF HEMORRHAGE SHOULD BE DISCONTINUED PRIOR TO THE INITIATION OF [MEDICATION NAME] THERAPY. AN INR OF GREATER THAN 4.0 APPEARS TO PROVIDE NO ADDITIONAL THERAPEUTIC BENEFIT IN MOST PATIENTS AND IS ASSOCIATED WITH A HIGHER RISK OF BLEEDING." 'REVERSAL OF [MEDICATION NAME] ANTICOAGULATION THERAPY MAY BE OBTAINED BY DISCONTINUING [MEDICATION NAME] THERAPY... AND ADMINISTRATION OF VITAMIN K." CO-ADMINISTRATION OF [MEDICATION NAME] WITH [MEDICATION NAME] INCREASES THE RISK OF BLEEDING." ( ) ON 2/14/ 12, AT 10:45 A.M., RESIDENT #924 WAS OBSERVED ON HIS BED VERY UNCOMFORTABLE AND APPEARED TO BE HAVING DIFFICULTY BREATHING. WHEN QUERIED PATIENT INDICATED THAT HE HAS BEEN HAVING SHORTNESS OF BREATH FOR MONTHS ESPECIALLY IN THE EVENING. HE ALSO, INDICATED THAT IT WAS VERY BOTHERSOME. RECORD REVIEW ON 02/15/12, AT 2:38 P.M., REVEALED THAT RESIDENT #924 WAS admitted INto the facility on [DATE], WITH [DIAGNOSES REDACTED]. REVIEW OF THE MOST CURRENT QUARTERLY MINIMUM DATA SET (MDS), dated [DATE], INDICATED THE RESIDENT HAD "CLARITY OF SPEECH", USUALLY UNDERSTOOD AND COMPREHENDED MOST CONVERSATION RESIDENT #924 WAS COGNITIVELY INTACT, HAD NO LONG AND SHORT TERM MEMORY PROBLEMS AND THERE WAS NO INDICATION OF POSSIBILITY FOR THIS RESIDENT TO HARM HIMSELF. BEHAVIORAL SYMPTOMS WERE IDENTIFIED AS FEELING DOWN, TIRED OR HAVING LITTLE ENERGY. RESIDENT #924 WAS A [MEDICAL TREATMENT] PATIENT TOTALLY DEPENDENT ON STAFF FOR [MEDICAL TREATMENT] CARE AND MANAGEMENT. RESIDENT #924 WAS PRESCRIBED [MEDICATION NAME] 5 MG ( AN ANTICOAGULANT TO THIN BLOOD AND PREVENT CLOTTING) AT BEDTIME, SINCE 10/16/09. THE NARRATIVE NOTE IN THE NURSING ADMISSION ASSESSMENT, DATED 10/16/09, AND NURSES NOTES, DATED 10/19/11, FAILED TO DOCUMENT PHYSICIAN'S ORDERS, SCHEDULED MONITORING PARAMETERS, AND OR INTERVENTIONS FOR RESIDENT #924.. IN AN INTERVIEW AND REVIEW OF RESIDENT #924'S CLINICAL CHART ON 2/15/12, AT 2:25 P.M., TOGETHER WITH THE UNIT MANAGER ON THE C-HALL, THERE WAS NO PHYSICIAN'S ORDERS TO MONITOR FOR INTERNATIONAL NORMALIZED RATIO (INR STANDARD MEASUREMENT), [MEDICATION NAME] TIME (PT) RELATING TO [MEDICATION NAME] USE ORDERED SINCE 10/19/09. IT WAS ALSO NOTED, THAT FOR THE PAST ONE YEAR, THE RESIDENT IDR'S WERE SUB-THERAPEUTIC, ON SAME DOSE OF 5 MG [MEDICATION NAME] WITHOUT ANY CHANGES MADE TO HIS DRUG REGIMEN, OR EXPLANATIONS. THERE WAS NO MONITORING LOG FOR ANY MONTH TO ADDRESS THE PATIENTS LOW LEVELS OF INR. REVIEW OF THE CLINICAL LAB RESULTS WAS AS FOLLOWS: 2/15/12.. INR 1.98 ( NORMAL RANGE 2 TO 3 ) PT 22.5 ( NORMAL RANGE 12.1- 14.5) SEC. 2/6/12.. INR 1.75 AND PT 20.5. 2/1/12.. INR 1.60 AND PT 19.1. 1/16/12.. INR 1.71 AND PT 20.1. 1/9/12... INR 1.70 AND PT 20.0. 1/2/12... INR 1.97 AND PT 22.4. 12/26/11... INR 1.84 AND PT 21.3. 12/19/11... INR 1.64 AND PT 19.4. 12/12/11... INR 1.92 AND PT 22.0. 12/5/11.... INR 1.52 AND PT 18.4. 11/28/11... INR 1.37 AND PT 17.0. 11/21/11... INR 1.65 AND PT 19.6. 11/14/11... INR 1.76 AND PT 20.6. 11/07/11.. INR 1.53 AND PT 18.5. 9/26/11... INR 1.84 AND PT 21.3. 9/19/11... INR 1.78 AND PT 20.7. 9/12/11... INR 1.67 AND PT 19.8. 8/11.... INR NONE. 10/11... INR NONE. REVIEW OF THE PHYSICIAN'S PROGRESS NOTES DATED 11/23/11, 12/22/11, 12/1/11, 2/7/12, 11/1/11, AND 10/4/11, FAILED TO ADDRESS RESIDENT #924'S USE OF [MEDICATION NAME] 5 MG TABLET. THERE WERE NO MONITORING PARAMETERS AND CHANGES RELATING TO USE OF DRUG TO PREVENT BLEEDING AND OR CLOT FOR RESIDENT #924. RESIDENT #923'S ACTIVE CLINICAL RECORD WAS REVIEWED, ON 2/15/12 AT 3:38 P.M. THE ADMISSION FACE SHEET INDICATED THE RESIDENT WAS RE-admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE], INDICATED THE RESIDENT WAS COGNITIVELY IMPAIRED AND NEEDED EXTENSIVE ASSISTANCE WITH ALL CARE CONCERNS. THE laboratory results dated [DATE], 2/6/12, 1/30/12, 1/23/12, 1/19/12, 12/18/11, 12/19/11, 11/28/11, AND 11/211, INDICATED RESIDENT #923 ' S INR REGISTERING BELOW RANGE ( INR STANDARD RAGE 2 TO 3) FROM 1.0 TO 1.1. REVIEW OF THE NURSE ' S NOTES DATED 11/24/11, FAILED TO DOCUMENT ANY MONITORING PARAMETERS OR LOG FOR THE USE OF 3 MG TABLET. [MEDICATION NAME], AND THERE WAS NO INTERVENTIONS NOTED FOR SUBTHERAPEUTIC LEVELS OF [MEDICATION NAME], AND OR ANY INDICATIONS THAT THE PHYSICIAN WAS NOTIFIED TIMELY. ON 2/15/12 AT 4:08 P.M., DURING A INTERVIEW WITH THE NURSE UNIT MANAGER ON THE D-HALL, SHE OFFERED NO EXPLANATIONS AND INDICATED THAT NURSING CONTINUED TO CHECK PATIENTS INR, AND IT IS UP TO THE PHYSICIAN ASSISTANT OR PHYSICIAN TO NOTIFY THEM ON WHAT TO DO WHEN RESULTS ARE SUBTHERAPEUTIC LIKE IN RESIDENT #923. ( ) REVIEW OF THE FACILITY POLICY AND PROCEDURE TITLED "SCREENING AND ASSESSMENT ANTICOAGULANT THERAPY MANAGEMENT, " DATED 1/1/09, REVEALED THE FOLLOWING STATEMENTS: "ALL RESIDENTS ON ANTICOAGULANT MEDICATION WILL BE MONITORED FOR ANTICOAGULANT THERAPY MANAGEMENT. TO MINIMIZE POTENTIAL HARM TO RESIDENTS, THE FACILITY HAS A PROCESS TO ADMINISTER AND MONITOR APPROPRIATE DOSAGE OF ANTICOAGULANT MEDICATION TO RESIDENTS RECEIVING ANTICOAGULATION THERAPY. AN INDIVIDUALIZED CARE PLAN WILL BE DEVELOPED AND DEFINED TARGET GOALS WILL BE ESTABLISHED. THE INTERDISCIPLINARY TEAM WILL ESTABLISH A DEFINED TARGETED INR RANGE FOR THE INDIVIDUAL RESIDENT. THE TARGETED INR RANGE WILL BE DOCUMENTED ON THE MAR AND THE PT/INR FLOW SHEET. RECOMMENDED INR RANGE ACCORDING AMERICAN COLLEGE OF CHEST PHYSICIANS (AACP). [MEDICATION NAME] AND treatment of [REDACTED]. CBC (COMPLETE BLOOD COUNT), PT AND INR WILL BE DRAWN ON INITIATION OF ANTICOAGULANT THERAPY. RESIDENTS RECEIVING ANTICOAGULANT THERAPY WILL HAVE INR/PT DRAWN PER PHYSICIAN ORDER. ALL RESIDENTS ON ANTICOAGULANTS WILL HAVE A PT/INR FLOW SHEET. DOCUMENTATION OF THE INR DRAW DATE, THE FOLLOW UP DATE, THE CURRENT DOSE OF ANTICOAGULANT MEDICATION, THE NEW DOSE OF ANTICOAGULANT MEDICATION MUST BE ON THE PT/INR FLOW SHEET. THE NURSE WILL VERIFY ALL THE INFORMATION BEFORE THE ANTICOAGULANT MEDICATION WILL BE GIVEN. AN ANTICOAGULANT THERAPY CARE PLAN WILL BE INITIATED AND UP DATED FOR ALL RESIDENTS RECEIVING ANTICOAGULANT THERAPY. DIETARY DEPARTMENT WILL BE NOTIFIED OF ALL RESIDENTS ON ANTICOAGULANT THERAPY. ABNORMAL LABORATORY INR RESULTS WILL BE CALLED TO PHYSICIAN. DOCUMENTATION OF THE ABNORMAL LABORATORY RESULTS, DATE AND TIME THE RESULTS WERE RECEIVED AND THE DATE AND TIME PHYSICIAN WAS NOTIFIED WITH ORDERS OBTAINED WILL BE PUT IN THE NURSES NOTES. ANTICOAGULANT MEDICATION WILL BE GIVEN PER PHYSICIAN ORDER. ANCILLARY TESTING BASED ON PHYSICIAN ORDER: ASSESSMENT AND RE-EVALUATION OF ANTICOAGULANT THERAPY IS AN ONGOING PROCESS. EVALUATION AND RE-ASSESSMENT OF LABORATORY RESULTS, ANTICOAGULANT MEDICATION AND THE INDIVIDUAL RESIDENT TREATMENT WILL BE MONITORED." THE FACILITY SUBMITTED THE FOLLOWING PLAN OF CORRECTION ON 2/17/12 WITH SUPPORTING DOCUMENTATION: Element #1 Residents 904, 911,922, 923, 924 and 925 were assessed by the clinical case managers on 2/16/2012. Orders were obtained on 2/16/2012 from the physicians for stool for occult blood and a dietary consult related to [MEDICATION NAME] use. Care plans were reviewed and revised as needed on 2/16/2012 to reflect their current status. PT/INR logs were audited on 2/16/2012 by the clinical nurse managers, appropriate follow up will be completed on 2/16/2012. PT/INR orders were reviewed and re submitted to the lab on 2/16/2012. All residents that are cited above have a current PT/INR lab result on file in which the physicians have been notified of, all orders received have been noted and carried out. Element #2/3 It is the facilities standard of practice that all residents that are receiving [MEDICATION NAME] are assessed and monitored according to physician orders. All residents that are currently receiving [MEDICATION NAME] will be assessed by the clinical nurse managers for signs of active bleeding on 2/16/2012 by 5 p. Orders were obtained on 2/16/2012 from the physicians for stool for occult blood and a dietary consult for all residents on [MEDICATION NAME]. Care plans were reviewed and revised as needed on 2/16/2012 to reflect the current status for all residents that are receiving [MEDICATION NAME]. PT/INR logs were audited on 2/16/2012 by the clinical nurse managers, appropriate follow up will be completed on 2/16/2012. PT/INR orders were reviewed and re submitted to the lab on 2/16/2012. All residents that are receiving [MEDICATION NAME] have a current PT/INR lab result on file in which the physicians have been notified of, all orders received have been noted and carried out. Nurses will be in serviced on the anticoagulation management policy by 2/17/2012. Element # 4/5 Monitoring of [MEDICATION NAME] orders and the completion of the PT/INR flow sheet will be completed weekly times 4 weeks and then monthly under the direction of the Director of Nursing. The Director of nursing will report to the QA committee monthly for 6 months. The Administrator is responsible for sustained compliance. ( , , , , , , , , )

This citation is specific to intake # MI 427 Based on interviews and record review, the facility failed to provide adequate, appropriate supervision and implement safety devices (locked or alarmed exit windows) to prevent the elopement of 1 of 6 (#201) residents reviewed for elopement from a total sample of 8 residents, resulting in Immediate Jeopardy for Resident #201, when Resident #201 unlocked and opened a room window and exited the facility after pushing out the window screen, placing 32 other residents, identified as elopement risks, at risk for elopement which could have resulted in physical harm, injury and/or death. Findings include: On entrance, 9-14-2011 at 10:00 A.M. the Administrator and Director of Nursing were interviewed. The facility investigation, employee written statements and the Unusual Occurrence report were reviewed. The Unusual Occurrence report and nurses' notes, dated 9-9-2011 at 8:45 P.M., were reviewed. Certified Nurse Aide #1 reported to the nurse that she was unable to find the resident on the unit and a search of every room was initiated. The window in Room 107 was found opened with the screen removed. The Nurse Supervisor #6 concluded that Resident #201 had eloped from the facility and so she initiated the full elopement protocol. All available nursing staff searched outside the facility and the surrounding area. At 8:55 P.M., Certified Nurse Aide #2 found Resident #201 at the intersection of two major, city of Detroit thoroughfares, approximately one block away from the facility on the opposite side of a busy and dark street, standing outside a gas station. The resident was alone and unsupervised from approximately 8:40 P.M. to 8:55 P.M. Resident #201 was brought back to the facility. The resident was examined and had no injury. According to the Unusual Occurrence report, "vital signs: blood pressure 110/60, temperature 98.4, pulse 72, respiration 18." The responsible party and physician were notified and the physician ordered a 1:1 (one-to-one) sitter. The resident was petitioned for psychiatric hospitalization and transfer to a geriatric-psychiatric unit for evaluation and treatment. On 9-9-2011 at 11:45 P.M. the resident was transferred to a geriatric-psychiatric unit at a local acute care hospital. The facility elopement/missing resident policy and procedure, dated 8/31/2010, was reviewed. According to the policy, elopement is defined as "when the resident leaves a safe or secure area, for an unsafe area without assistance or supervision." Exit-seeking is defined as "purposeful movement with the intent to leave the center." The stated purpose of the policy was "to promote the safety of residents by assessing and managing elopement or exit-seeking behavior, therefore minimizing risk." The facility followed their guidelines for when elopement occurs. Resident #201's clinical record was reviewed. The resident was admitted to the facility on [DATE] from another long term care facility and had a legal guardian. The resident's [DIAGNOSES REDACTED]. The Elopement and Exit Seeking Behavioral Risk Analysis, dated 8-31-11, noted that the resident was at risk for elopement. The nursing home resident assessment and care screening, dated 9-6-11, identified that the resident's cognitive skills were severely impaired. The resident was alert to name with periods of confusion. The resident required supervision to total dependence with activity of daily living skills and self performance. A plan of care was in place that included potential for elopement and exit-seeking related to an attempt at the previous facility and related to impaired cognition. The interventions included monitoring resident with frequent visual checks, redirection when the resident was noted to be preoccupied with exit doors and reassurance to the resident of his whereabouts. The resident was housed on a locked Dementia Unit and wore an identification bracelet. As of 9-20-2011, Resident #201 remained in the hospital. The assigned certified nurse aide (CNA #8) was not available for interview. Her written statement dated 9-9-2011 (time not indicated) documented, "I was the night care giver for Resident #201, at about 8:30 P.M. I was in the large dining room with the residents and Resident #201 left me. I went looking for the resident to get him ready for bed. I made two laps around the unit and checked all rooms and bathrooms. I could not find him. I checked doors and windows and that is when I saw that the window in Room 107 was pushed out. I returned to the desk to tell the nurse (#6). We checked everywhere." On 9-14-2011 at 2:15 P.M. certified nurse aide (CNA #2) (who found resident #201) was interviewed by phone. He stated, "I was outside going on break when I saw everyone going out the back door, stating that a resident got out. I am familiar with the area so I got in my car and went to look. I went to the gas station at the corner of Greenfield and Joy. I saw the resident wearing blue jeans but he was not wearing the white striped shirt (wearing a red sweatshirt that had been placed over white shirt) as described. So I called back to the facility to verify the description. I approached the resident who denied he was from the nursing home. I noticed his shoes had his name on them, but he was not wearing the identifying wrist band. I was on the phone talking with staff and trying to pronounce his name when the resident spoke up (verified the correct way to pronounce his name). I asked him to come with me back to the facility and he came without a problem. He got in my car and I drove him back to the facility and walked him back to the Dementia Unit. The Supervisor and nurse (nursing staff #6 and #9) took over. I observed no injury." A written statement for the facility investigation was reviewed and consistent with the interview. On 9-14-2011 at 4:00 P.M. the nurse supervisor #6 (on duty) was interviewed. She stated, "I was at the nursing station on the Dementia Unit (at 8:20 P.M.). The assigned certified nurse aide #8 reported the incident (8:40 P.M.). I had seen the resident walking in hallway just ten minutes prior. She (the nurse aide #8) stated that the resident normally just walks around. We began looking when we noted that the window was open and the screen was off the window in Room 107. I had been at the nursing station down the hall and heard nothing. The missing resident protocol was initiated. We were back and forth on the phone and the resident was found within minutes. Upon return the resident was assessed and had no bruises, marks or injury." On 9-15-2011 at 2:24 P.M. the Director of Maintenance was interviewed. He stated, "My staff and I have ensured that all windows in the facility can no longer open more than six inches. I have been employed here for [AGE] years and never had a resident exit through the window." CNA #2 observed that Resident #201 was alone and unsupervised, standing outside a gas station, at the intersection two major, city of Detroit thoroughfares, one block away from the facility on the opposite side of a busy and dark street from approximately 8:40 P.M. to 8:55 P.M. and at high risk for serious physical harm, injury and/or death. On 9-15-2011 at 10:30 A.M., the Administrator and the Director of Nursing were informed of the Immediate Jeopardy that began on 9-9-11, and was identified on 9-14-11, as a result of the facility's failure to supervise and implement safety devices (locked or alarmed exit windows) to prevent the elopement of Resident #201, placing 32 other residents, identified as elopement risks at a potential for elopement. On 9-15-2010 the surveyor confirmed that the facility had implemented the following to remove the Immediate Jeopardy: 1. Resident #201 was located on 9-9-2011 and returned to the facility at 8:55 P.M. 2. Resident #201 was assessed on 9-9-2011 at 9:00 P.M., there were no signs of harm or ill effects related to the incident and he denied pain. 3. Resident #201's care guide and care plans were updated on 9-9-2011 to reflect his current status. 4. One on one monitoring was conducted on 9-9-2011 at 8:55 P.M. to assure that the resident had no psychosocial effects related to the incident until he was transferred to a geriatric-psychiatric unit, on 9-9-2011 at 11:45 P.M. 5. The facility reviewed its Elopement policy and procedure on 9-12-2011 and deemed it appropriate. 6. Social workers completed an audit of 33 residents identified as an elopement risk on 9-12-2011 to identify any issues or concerns. Their care plans were reviewed and reflect current appropriate interventions. 7. Maintenance placed new locking mechanisms on the windows to prevent elopement attempts on 9-10-2011, 9-12-2011 and 9-14-2011. 8. The Maintenance Director conducted an audit on 9-15-2011 to ensure all resident windows had new locking mechanisms in place. 9. Staff was in-serviced on 9-14-2011 and 9-15-2011 by the Staff Development Coordinator and Nurse Managers on the new locking system on the windows, which prevent the window from opening further than six inches. 10. Social Service Director will audit all residents at risk for elopement weekly for four weeks to ensure ongoing compliance. All identified areas of concern will be reported to the Administrator weekly and to the QA committee monthly. The Immediate Jeopardy (IJ) was removed on 9-14-2011. The facility remained out of compliance at a scope of "pattern" and severity of "no actual harm" with potential for more than minimal harm that is not immediate jeopardy until sustained compliance can be verified. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO IMPLEMENT PRESSURE RELIEVING DEVICES, MONITOR A PRESSURE ULCER, AND PROVIDE NECESSARY TREATMENT AND SERVICES TO PROMOTE HEALING, MINIMIZE INFECTIONS, AND PREVENT NEW PRESSURE SORES FROM DEVELOPING FOR THREE (#'S 500, 517 AND 526) SAMPLED RESIDENTS OUT OF TEN RESIDENTS REVIEWED FOR PRESSURE ULCERS OF 28 SAMPLED RESIDENTS, RESULTING IN THE DEVELOPMENT OF NEW FACILITY ACQUIRED PRESSURE ULCERS AND WOUND COMPLICATIONS. FINDINGS INCLUDE: THE FACILITY FAILED TO PROVIDE A THOROUGH EVALUATION AND TIMELY INTERVENTIONS TO PREVENT THE DEVELOPMENT AND SUBSEQUENT COMPLICATIONS OF THREE PRESSURE SORES FOR RESIDENT #526. THE DETAILS ARE AS FOLLOWS: ON 3/24/11 AT 9:45 AM AND ON 3/24/11 AT 10:30 AM, THE CLINICAL RECORD FOR RESIDENT #526 WAS REVIEWED WITH THE TREATMENT NURSE (I) AND THE DIRECTOR OF NURSING(DON), RESPECTIVELY. THE RESIDENT WAS ORIGINALLY admitted on [DATE] WITH [DIAGNOSES REDACTED]. THE RESIDENT WAS hosptalized on [DATE] FOR A RESPIRATORY COMPLICATION AND RETURNED to the facility on [DATE] UNDER HOSPICE CARE AND SERVICES. A MINIMUM DATA SET ((MDS) dated [DATE], PRIOR TO hospitalization , NOTED THAT THE RESIDENT HAD SEVERE COGNITIVE IMPAIRMENT, REQUIRED TOTAL CARE FOR ALL ACTIVITIES OF DAILY LIVING, AND DID NOT HAVE PRESSURE SORES. A SKIN ASSESSMENT FOR RESIDENT #526 DATED 8/5/10, AFTER RETURN TO THE FACILITY, NOTED THAT THE RESIDENT HAD NO PRESSURE SORES. A BRADEN (PRESSURE ULCER RISK) SCALE DATED 8/5/10 NOTED THAT THE RESIDENT WAS AT "MODERATE" RISK. A "PRESSURE ULCER RISK" CARE PLAN, DATED 8/6/10, NOTED INTERVENTIONS THAT INCLUDED: TURNING AND REPOSITIONING AT LEAST EVERY TWO HOURS, ELEVATION OF THE HEELS, AND A PRESSURE REDUCTION SURFACE BED. THE DON STATED THAT THIS TYPE OF MATTRESS WAS THE STANDARD PRESSURE RELIEF MATTRESS PROVIDED TO ALL OF THE RESIDENTS, INCLUDING RESIDENTS WITH INTACT SKIN. PRESSURE ULCER #1- ON 8/9/10, RESIDENT #526'S PHYSICIAN NOTED IN THE RESIDENTS HISTORY AND PHYSICAL THAT THE RESIDENT HAD A "BLISTER" ON THE LEFT ELBOW. THE BLISTER REPRESENTED A STAGE TWO (II) PRESSURE SORE, WHICH WAS A PARTIAL THICKNESS LOSS OF THE TOP LAYER OF SKIN THAT PRESENTED CLINICALLY AS A BLISTER. THERE WAS NO MENTION OF THE BLISTER IN NURSES NOTES. ON 8/11/10, NURSE 'I' NOTED ON A "WEEKLY NON-PRESSURE WOUND DOCUMENTATION" FORM THAT THE BLISTER WAS A "SKIN TEAR" MEASURING 1 X 1 CM (CENTIMETER). THE NURSE DID NOT APPROPRIATELY IDENTIFY THE BLISTER AS A PRESSURE SORE. THERE WAS NO MENTION OF ELBOW PROTECTORS ON THE CARE PLAN. ON 8/18/10, 8/25/10, AND 9/1/10, NURSE 'I' CONTINUED TO NOTE ON THE WOUND FORM THAT THERE WAS A "SKIN TEAR" ON THE LEFT ELBOW. THE AREA WAS CLEANED WITH WOUND CLEANSER AND COVERED WITH A PROTECTIVE EXTRA-THIN DRESSING EVERY 3-5 DAYS. THERE WAS NO DOCUMENTED DESCRIPTION OF THE ELBOW WOUND BY NURSE 'I' FOR THE WEEKS OF 9/8/10 AND 9/15/10. ON 9/20/10, NURSE 'I' BEGAN TO IDENTIFY THE BLISTER (A STAGE II) AS A STAGE THREE (III) PRESSURE SORE ON A "WEEKLY PRESSURE ULCER WOUND DOCUMENTATION" FORM MEASURING 1 X 1 CM WITH SCANT SEROUS (RED) DRAINAGE. A PRESSURE SORE AT STAGE III PRESENTED A FULL THICKNESS LOSS OF SKIN DOWN TO THE UNDERLYING TISSUE. NURSE 'I' AND THE RESIDENT'S PRIMARY CARE PHYSICIAN(PCP) CONTINUED TO USE WOUND CLEANSER AND COVER THE WOUND WITH THIN DRESSINGS. THE WOUND WAS MEASURED EVERY WEEK BY NURSE 'I' UNTIL 11/8/10. ON 11/8/10, THE ELBOW WOUND INCREASED IN SIZE TO 3 X 3.5 CM, HAD A MODERATE AMOUNT OF SEROUS DRAINAGE, AND WAS NOT RESOLVING. PRESSURE ULCER #2- ON 9/1/10, NURSES NOTED, FOR THE FIRST TIME, THAT RESIDENT #526 HAD AN OPEN, NECROTIC (DEAD TISSUE) AREA TO THE "NATAL CLEFT" (AT THE TOP OF THE FOLD OF THE BUTTOCKS)," MEASURING 4 X 2 CM. ON 9/1/10, NURSE 'I' NOTED THAT THE AREA WAS UNSTAGEABLE (COULD NOT BE ADEQUATELY VISUALIZED DUE TO THE DEAD TISSUE). THE WOUND, IDENTIFIED AS A PRESSURE ULCER, HAD HEAVY, YELLOW DRAINAGE. THE WOUND WAS CLEANED WITH WOUND CLEANSER AND COVERED WITH AN EXTRA THIN NON-ABSORBENT DRESSING. ON 9/7/10, THE WOUND WAS TREATED WITH AN ABSORBENT COVER AND THEN COVERED WITH A THIN PROTECTIVE DRESSING TO BE CHANGED EVERY 3-5 DAYS. ON 9/14/10, NURSE 'I' NOTED ON THE PRESSURE ULCER FORM THAT THE NATAL CLEFT WOUND WAS UNSTAGEABLE, WAS NOT RESOLVING, HAD SLOUGH (WET, DEAD TISSUE), ESCHAR (BLACK, DEAD TISSUE), AND HAD INCREASED IN SIZE TO 6 X 3.2 CM X 1.2 CM DEEP. ON 9/14/10, NURSE 'I' BEGAN TO TREAT THE WOUND WITH A WOUND DEBRIDEMENT AGENT (TO DISSOLVE THE NECROTIC TISSUE), APPLY THE ABSORBENT COVER, AND COVER WITH A THIN PROTECTIVE DRESSING EVERY DAY. ON 9/20/10, NURSE 'I' NOTED THAT THE NATAL CLEFT WOUND "EVOLVED INTO THE COCCYX REGION." ON 9/27/10, THE WOUND BEGAN TO BE TREATED WITH THE [MEDICATION NAME] AGENT AND COVERED WITH A FOAM DRESSING. NURSE 'I' NOTED THAT WOUNDS REQUIRING A [MEDICATION NAME] AGENT HAD THE POTENTIAL TO INCREASE THE SIZE OF THE WOUNDS DUE TO THE [MEDICATION NAME] PROCESS. NURSE 'I' DOCUMENTED IN NOTES DATED 9/22/10 THAT THE SACRO WOUND HAD AN ODOR. ON 10/5/10 AND 10/12/10, IT WAS DOCUMENTED THAT THE WOUND HAD AN ODOR AND MEASURED 6.3 X 7.5 CM AND 7 X 9 CM RESPECTIVELY. ON 10/6/10, NURSE 'I' BEGAN TO ADD CRUSHED [MEDICATION NAME] (ANTIBIOTIC) TABLETS TO THE WOUND CARE REGIME WITH EACH DRESSING CHANGE UNTIL 10/21/10. AFTER 10/21/10, THE [MEDICATION NAME] AGENT AND FOAM DRESSINGS WERE CONTINUED UNTIL 11/8/10. (THIS WOUND WILL BE FURTHER DISCUSSED). PRESSURE ULCER #3- ON 9/20/10, NURSE 'I' NOTED ON A PRESSURE ULCER WOUND FORM THAT RESIDENT #526 HAD A STAGE II PRESSURE SORE ON THE LEFT LATERAL ANKLE WITH SCANT SEROUS DRAINAGE MEASURING 1.5 X 1 CM. THERE WAS NO MENTION OF THE WOUND IN NURSES NOTES AND NO DOCUMENTATION ON TREATMENT RECORDS THAT WOUND CARE WAS RENDERED UNTIL 9/27/10. ON 9/27/10, WOUND CLEANSER WAS USED, A DEBRIDEMENT COVER, AND A FOAM DRESSING TO BE CHANGED EVERY 3-5 DAYS. ON 9/30/10, THE PCP NOTED IN PROGRESS NOTES: "CONTINUE LOCAL WOUND CARE" FOR THE SACRO-COCCYX AND ELBOW PRESSURE SORES. THERE WAS NO EVIDENCE THAT HE OBSERVED THE WOUNDS. ON 10/4/10, THE PCP NOTED ONLY THAT THE RESIDENT HAD PRESSURE SORES. THE DON SAID, "THE PHYSICIAN AND THE PHYSICIAN ASSISTANT(PA) WERE VERY INVOLVED. THEY SAW THE RESIDENT "REGULARLY". WHEN QUERIED, NURSE 'I' STATED THAT SHE WROTE THE WOUND TREATMENT ORDERS FOR RESIDENT #526 AND THE PCP CO-SIGNED THE ORDERS. WHEN ASKED WHY A WOUND SPECIALIST WAS NOT CONSULTED WHEN THE WOUNDS BEGAN TO SHOW SIGN OF INFECTION (ODOR) AND BEGAN TO INCREASE IN SIZE, SHE SAID, "NO ONE WAS BEING SEEN BY A WOUND DOCTOR." ON 10/12/10, THE ANKLE WOUND MEASURED 3 X 3 CM, WAS UNSTAGEABLE, AND COVERED WITH SLOUGH (WET, STRINGY, YELLOW DEAD TISSUE). BY 11/8/10, THE WOUND HAD MODERATE SEROUS DRAINAGE AND MEASURED 2.5 X 2.4 CM. THERE WAS NO EVIDENCE NUTRITIONAL SUPPORTS, SUCH AS VITAMIN/MINERAL SUPPLEMENTS TO AIDE IN WOUND HEALING. THE RESIDENT DID NOT RECEIVE ADDITIONAL PROTEIN TO AIDE IN WOUND HEALING UNTIL 10/15/10 WHEN PROSTAT WAS PRESCRIBED, PER THE ENTERAL (TUBE FEEDING) REVIEW WRITTEN BY THE DIETITIAN. THE PROSTAT PROVIDED 17 GRAMS OF PROTEIN IN ADDITION TO THE 67 GRAMS PROVIDED BY THE TUBE FEEDING FORMULA. ON 11/9/10, RESIDENT #526 RECEIVED A CONSULTATION WITH A WOUND CARE SPECIALIST. THE DON WAS ASKED WHY THE RESIDENT WAS NOT SEEN EARLIER WHEN THE WOUNDS INITIALLY BEGAN TO WORSEN. SHE RESPONDED THAT THE FACILITY DID NOT HAVE A CONTRACT WITH A WOUND CARE SPECIALIST UNTIL HE SAW THE RESIDENT ON 11/9/10. SHE WAS ASKED WHETHER A CONTRACT WAS REQUIRED IN ORDER FOR THE RESIDENT TO BE SEEN BUT SHE SAID NO. THE DON WAS ASKED IF THERE WAS A DISCUSSION WITH HOSPICE STAFF REGARDING WHETHER THE HOSPICE AGENCY COULD HAVE PROVIDED A WOUND SPECIALIST. THE DON COULD NOT FIND DOCUMENTED EVIDENCE OF A DISCUSSION. THE DON WAS UNABLE TO STATE WHY. SHE THEN STATED THAT THE PCP DID NOT WANT THE RESIDENT TO BE SEEN BY A WOUND SPECIALIST BECAUSE THE RESIDENT WAS TO RECEIVE "COMFORT CARE ONLY." SHE SAID, "THE (PCP) DIDN'T WANT AGGRESSIVE TREATMENT." FROM 11/1/10 THRU 11/8/10, NURSE 'I' TREATED THE SACRO/COCCYX WOUND WITH A [MEDICATION NAME] AGENT AND A FOAM DRESSING DAILY. THE ELBOW RECEIVED AN EXTRA THIN DRESSING EVERY 3-5 DAYS. THE ANKLE WAS TREATED WITH A DEBRIDEMENT COVER AND FOAM DRESSING DAILY. THE WOUND CONSULTANT SAW RESIDENT #526 ON 11/9/10, AND OBSERVED AND NOTED THE FOLLOWING: PRESSURE ULCER #1-THE LEFT ELBOW HAD HEAVY NECROSIS WITH MODERATE SEROUS DRAINAGE AND MEASURED 2.8 X 2.8 X 0.5 CM. THE TREATMENT WAS CHANGED TO A DAILY DEBRIDEMENT AGENT. PRESSURE ULCER #2-THE NATAL CLEFT WOUND DEVELOPED INTO A WOUND INVOLVING THE SACRUM, COCCYX, AND BILATERAL BUTTOCKS MEASURING 5.5 X 8 X 1.6 CM WITH UNDERMINING (TUNNELING UNDER THE SURFACE) OF 2.4 CM WITH NECROSIS AND HEAVY SEROUS DRAINAGE. HE SHARPLY DEBRIDED THE WOUND (CUT AWAY DEAD TISSUE) AT THE BEDSIDE TO PREVENT FURTHER INFECTION AND GENERATE NEW TISSUE. HE CHANGED THE TREATMENT TO AN ABSORBANT COVER AND DISCONTINUED THE DEBRIDEMENT AGENT. PRESSURE ULCER #3-THE LEFT LATERAL ANKLE HAD MODERATE SEROUS DRAINAGE AND MEASURED 2.2 X 2 X 0.2 CM. HE CHANGED THE TREATMENT TO A DIFFERENT TYPE OF DEBRIDEMENT AGENT. THE SPECIALIST CLASSIFIED THE ELBOW AND ANKLE PRESSURE SORES AS STAGE III. THE SACRO/BUTTOCK PRESSURE SORE WAS AT STAGE FOUR (IV). STAGE IV MEANT THAT THERE WAS FULL THICKNESS SKIN LOSS WITH EXTENSIVE DESTRUCTION TO MUSCLE, BONE, OR SUPPORTING STRUCTURES, WITH UNDERMINING. HE ALSO NOTED THAT THE LEFT HEEL WAS "FRAGILE," ON THE VERGE OF BREAKING DOWN. THE SPECIALIST RECOMMENDED THE FOLLOWING: FREQUENT REPOSITIONING OF THE RESIDENT, ELEVATION OF THE HEELS, AND A SPECIALTY PRESSURE RELIEF MATTRESS, SUCH AS AN AIR- LOSS (INFLATABLE) MATTRESS. WHEN ASKED WHY THE RESIDENT DID NOT HAVE A SPECIAL MATTRESS, THE DON STATED THAT THE RESIDENT ALREADY HAD A SPECIALTY AIR-LOSS MATTRESS WHEN SHE WAS SEEN BY THE SPECIALIST. SHE SAID, "SHE GOT ONE A LONG TIME AGO. I DON'T KNOW WHY HE WROTE THAT (REQUEST ON THE CONSULTATION FORM)." HOWEVER, SHE WAS UNABLE TO VERIFY THAT THE RESIDENT HAD THE MATTRESS PRIOR TO 11/9/10. A SECOND "PRESSURE ULCER RISK" CARE PLAN FOR RESIDENT #526 DATED 9/1/10, HAD A HAND WRITTEN INTERVENTION: "AIR LOSS (MATTRESS)." THERE WAS NO DATE TO INDICATE WHEN THE MATTRESS WAS PROVIDED. WHEN QUERIED, NURSE 'I' COULD NOT VERIFY WHEN THE RESIDENT RECEIVED THE MATTRESS. SHE STATED THAT THE DATE WOULD HAVE BEEN IN HER WOUND DOCUMENTATION; HOWEVER, SHE WAS NOT ABLE TO LOCATE IT AND WAS UNABLE TO EXPLAIN WHY. THE DON PRESENTED RESIDENT #526'S MONTHLY CARE GUIDES, DATED 2/2010 THRU 11/2010 (INSTRUCTIONS USED BY STAFF SPECIFIC TO EACH RESIDENT). EACH OF THE CARE GUIDES HAD A CHECK MARK INDICATING THAT THE RESIDENT HAD AN AIR LOSS SPECIALTY MATTRESS. THE DON STATED THAT RESIDENT CARE GUIDES WERE ALWAYS ACCURATE, COMPLETE, AND UP TO DATE. HOWEVER, THE GUIDES FOR RESIDENT #526 WERE ALL FOUND TO BE IDENTICAL COPIES OF EACH OTHER, MARKED WITH A DIFFERENT MONTH, AND CONTAINING INACCURACIES SUCH AS: ON 11/17/10, THE WOUND SPECIALIST NOTED THE FOLLOWING: -THE SACRO/BUTTOCK WOUND MEASURED 5.9 X 7.0 X 2.0 CM WITH HEAVY SLOUGH ANS SEROUS DRAINAGE. -THE ELBOW WOUND MEASURED 2.8 X 3 X 0.2 CM WITH MODERATE SEROUS DRAINAGE. -THE ANKLE WOUND MEASURED 3 X 2.5 X 0. 2 CM WITH MODERATE SLOUGH AND SEROUS DRAINAGE. THE RECOMMENDATION: FREQUENT REPOSITIONING. THE SPECIALTY MATTRESS WAS NO LONGER MENTIONED WHICH INDICATED THAT THE RESIDENT WAS PROVIDED WITH THE AIR LOSS MATTRESS SOMETIME BETWEEN THE 11/9/10 VISIT AND THE 11/17/10 VISIT. THE WOUND SPECIALIST CONTINUED TO SEE THE RESIDENT WEEKLY. ON 12/1/10, THE WOUND SPECIALIST NOTED THE SACRO/BUTTOCK WOUND IMPROVED; HOWEVER, ON 12/9/10 THE WOUNDS WERE DESCRIBED AS FOLLOWS: -SACRO/BUTTOCK=4.8 X 6.2 X 1.2 CM WITH HEAVY SEROUS DRAINAGE. -ELBOW=3 X 3 X 0.3 CM WITH HEAVY SEROUS DRAINAGE. -ANKLE=4.2 X 3 X 0.8 CM WITH NECROSIS, HEAVY SEROUS DRAINAGE, AND "BONE AND TENDON EXPOSURE." RECOMMENDATION: FREQUENT REPOSITIONING AND AN X-RAY OF THE ANKLE "IF IT'S OKAY WITH HOSPICE" TO RULE OUT OSTEO[DIAGNOSES REDACTED] (BONE INFECTION). ON 12/9/10, THE WOUND SPECIALIST CHANGED THE treatment for [REDACTED]. PER NURSE 'I'S 12/10/10 WOUND NOTES, THE HOSPICE NURSE WAS CONTACTED AND AGREED TO THE X-RAY. THE REPORT OF A PORTABLE (AT BEDSIDE) X-RAY OF THE ANKLE DATED 12/11/10 WAS INCONCLUSIVE AND NOTED: "A BONE SCAN IS SUGGESTED TO EXCLUDE OSTEO[DIAGNOSES REDACTED]." ACCORDING TO THE DON, A BONE SCAN WAS NOT DONE. THERE WAS NO EXPLANATION WHY. PER THE WOUND NOTES ON 12/13/10, THE PCP WAS NOTIFIED BY PHONE OF THE X-RAY RESULTS. THERE WERE NO NEW ORDERS. ON 12/15/10, THE WOUND SPECIALIST NOTED: SACRO/BUTTOCK WOUND=4.7 X 6.2 X 0.9 CM WITH HEAVY SEROUS DRAINAGE. ELBOW=3 X 3 X 0.4 CM WITH MODERATE SEROUS DRAINAGE. ANKLE=4.8 X 3.4 X 0.5 CM WITH NECROSIS, HEAVY SEROUS DRAINAGE, AND BONE EXPOSURE. ON 12/16/10, THE PCP NOTED THE FOLLOWING IN PROGRESS NOTES: THE RESIDENT DEVELOPED REDNESS TO THE POSTERIOR LEFT LOWER EXTREMITY ABOUT "THREE DAYS AGO" AND "THE REDNESS SPREAD ANTERIORLY AND UPWARDS. NOW DEVELOPED SWELLING OF LEFT KNEE. PATIENT HAS TEMPERATURE OF 101.6 (DEGREES). ON 12/13/10, STARTED [MEDICATION NAME](ANTIBIOTIC)." ON 12/21/10, NURSE 'I' DOCUMENTED IN HER WOUND NOTES FOR THE LEFT ELBOW: "RESIDENT TO BE SEEN ONCE A MONTH BY WOUND CARE PHYSICIAN (FOR THE HOSPICE AGENCY)" AND THAT THE WOUND WAS PINK AND HAD GRANULATION (HEALING) TISSUE. SHE NOTED THE SACRO/BUTTOCK WOUND WAS PINK WITH GRANULATION TISSUE AND WAS "STABLE." NURSE 'I' NOTED FOR THE ANKLE WOUND: THE PCP VISUALLY SAW THE WOUND WHICH HAD REGRESSED. THIS WAS THE ONLY DOCUMENTED EVIDENCE IN THE RESIDENT'S RECORD THAT THE PCP ACTUALLY VISUALIZED THE WOUNDS, AFTER REVIEW OF THE RECORD WITH THE DON. ON 3/24/11 AT 9:20 AM, THE RESIDENT'S PCP EXPLAINED THAT HE DID NOT WANT AGGRESSIVE treatment for [REDACTED]. HE STATED THAT A WOUND TEAM WAS NOT CONSULTED "BECAUSE CARE WAS BEING DONE BY US." PER THE FACILITY'S "WOUND MANAGEMENT PROGRAM" POLICY DATED 10/8/10, IF A PRESSURE SORE IS IDENTIFIED, THE FACILITY WAS SUPPOSED TO IMPLEMENT THE FACILITY'S CORPORATE PROTOCOL FOR TREATMENT AND INTERVENTION OPTIONS. THE PROTOCOL WAS NOT PROVIDED AND THE POLICY DID NOT MENTION MEASURES TO PREVENT DEVELOPMENT OF PRESSURE SORES. THE POLICY NOTED: "A WOUND CARE PHYSICIAN IS NOT REQUIRED UNLESS RECOMMENDED BY THE ATTENDING PHYSICIAN. RESIDENT #500 ON 3/22/11 AT 9 AM IN THE PRESENCE OF NURSE UNIT MANAGER 'K,' RESIDENT #500 WAS OBSERVED IN BED WITH AN AIR LOSS SPECIALTY PRESSURE REDUCTION MATTRESS. HOWEVER, THE MATTRESS WAS IN THE "OFF" POSITION. MANAGER 'K' WAS UNABLE TO EXPLAIN WHY THE MATTRESS WAS TURNED OFF. WHEN SHE PRESSED THE "ON" BUTTON, THE MATTRESS DID NOT ACTIVATE. SHE HAD TO CALL FOR ASSISTANCE TO DETERMINE WHY THE MATTRESS WOULD NOT TURN ON. THE RESIDENT WAS COMPLETELY IMMOBILE, UNRESPONSIVE, AND ONLY ABLE TO OCCASIONALLY OPEN HER EYES WHEN OBSERVED. ON 3/22/11 AT 11:30 AM, RESIDENT #500 WAS OBSERVED IN A GERI-CHAIR, RECLINED, AND LEANING TOWARD TO THE RIGHT; AT 2 PM, THE RESIDENT WAS IN THE SAME POSITION. AT 3:30 PM, THE RESIDENT'S POSITION REMAINED UNCHANGED. ON 3/23/11 AT 8:45 AM, RESIDENT #500 WAS OBSERVED IN A GERI-CHAIR, RECLINED, AND LEANING TOWARD THE RIGHT. AT 11:30 AM, THE RESIDENT'S POSITION REMAINED UNCHANGED. AT 2:30 PM, THE RESIDENT'S POSITION WAS THE SAME. SHE WAS OBSERVED WITH A DRESSING ON THE RIGHT FOOT DATED 3/22/11. A FEW MINUTES LATER, NURSE AIDE 'J,' THE RESIDENT'S DAY SHIFT AIDE, WAS OBSERVED CONDUCTING ROUNDS AT SHIFT CHANGE IN THE RESIDENT'S ROOM WITH A MALE AIDE FROM THE ON-COMING SHIFT. AIDE 'J' WAS EXPLAINING THE RESIDENT'S CARE. THEY DID NOT CHECK THE RESIDENT'S INCONTINENT BRIEF TO SEE IF IT NEEDED TO BE CHANGED. AS THE AIDES WERE LEAVING THE RESIDENT'S ROOM, THEY WERE QUERIED REGARDING HOW MUCH LONGER THE RESIDENT WAS TO REMAIN UP IN THE GERI-CHAIR. THE MALE AIDE STATED TWO MORE HOURS. WHEN QUERIED, AIDE 'J' STATED THAT SHE PLACED THE RESIDENT IN THE GERI-CHAIR AROUND 11:30 AM. THE AIDES PROCEEDED TO ANOTHER ROOM. AT 2:50 PM, THE AIDES WERE OBSERVED TAKING A MECHANICAL LIFT INTO RESIDENT #500'S ROOM AND WERE PREPARING TO PUT THE RESIDENT IN BED. WHEN ASKED, THEY WERE UNABLE TO EXPLAIN WHY THEY CHANGED THE PLAN TO LEAVE THE RESIDENT UP SEVERAL MORE HOURS. AIDE 'J' WAS THEN ASKED WHAT TIME THE RESIDENT'S INCONTINENT BRIEF WAS LAST CHECKED. SHE SAID, "WHEN I GOT HER UP (AT 11:30 AM)." NURSE MANAGER 'K' ENTERED THE ROOM. THE NURSE AND THE AIDE WERE ASKED TO EXPLAIN HOW OFTEN INCONTINENT BRIEFS WERE SUPPOSED TO BE CHECKED. THEY SAID, "EVERY TWO HOURS." THEY WERE UNABLE TO EXPLAIN WHY THIS WAS NOT DONE AND WHY THE RESIDENT WAS LEFT IN THE SAME POSITION IN THE GERI-CHAIR FROM 11:30 AM TO 2:50 PM. ON 3/24/11 AT 9 AM, RESIDENT #500'S RIGHT FOOT, COVERED WITH A DRESSING DATED 3/23/11, WAS OBSERVED WITH NURSE 'K.' THE RESIDENT HAD AN OPEN, RED, STAGE II PRESSURE SORE, MEASURING 4.3 X 2.8 CM, WITH A MODERATE AMOUNT OF BEIGE DRAINAGE, ON THE LATERAL GREAT TOE. ON 3/24/11 AT 9:30 AM, RESIDENT #500'S CLINICAL RECORD WAS REVIEWED WITH TREATMENT NURSE 'I.' THE RESIDENT WAS ORIGINALLY admitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MDS NOTED THAT THE RESIDENT HAD SEVERE COGNITIVE IMPAIRMENT AND REQUIRED TOTAL CARE FOR ALL ACTIVITIES OF DAILY LIVING INCLUDING MOBILITY. BRADEN (PRESSURE SORE RISK) SCALES DATED 3/8 AND 3/16/11 NOTED THAT RESIDENT #500 WAS AT MODERATE RISK. THE RESIDENT WAS hospitalized from [DATE] THRU 3/16/11 FOR RESPIRATORY COMPLICATIONS. ADMISSION NURSING NOTES ON 3/16/11 REVEALED THAT THE RESIDENT DID NOT HAVE PRESSURE SORES. A NURSING NOTE ON 3/17/11 REVEALED THAT THE RESIDENT HAD A "RIGHT BIG TOE BLISTER (STAGE II PRESSURE SORE)." NURSE 'I' SAW THE RESIDENT ON 3/17/11 AND NOTED THAT THE RESIDENT'S DAUGHTER TOLD HER THAT THE RESIDENT HAD THE TOE BLISTER. ON 3/17/11, AN ORDER WAS WRITTEN FOR THE BLISTER TO BE CLEANED DAILY WITH WOUND CLEANSER AND COVERED WITH A DRY DRESSING. HOWEVER, THERE WAS NO DOCUMENTATION ON THE RESIDENT'S TREATMENT RECORD THAT THE WOUND WAS EVER CLEANED, OBSERVED, AND DRESSED UNTIL 3/23/11 BY NURSE 'I'. NURSE 'I,' WHO STATED THAT SHE WAS OBSERVING AND PROVIDING DAILY CARE FOR THE BLISTER, WAS UNABLE TO EXPLAIN WHY. ON 3/23/11, THE TREATMENT WAS CHANGED TO AN ABSORBANT COVER WITH AN EXTRA THIN DRESSING DAILY. WHEN ASKED WHY THE TREATMENT WAS CHANGED, THE NURSE SAID, "THE BLISTER RUPTURED ON ME." WHEN ASKED IF THE BLISTER RUPTURED WHEN SHE CHANGED THE DRESSING ON 3/23/11, SHE THEN SAID, "NO, I FOUND IT RUPTURED." NURSE 'I' DOCUMENTED ON 3/23/11 THAT THE WOUND HAD "SCANT" SEROUS DRAINAGE BUT WHEN OBSERVED ON 3/24/11, THE WOUND HAD A MODERATE AMOUNT OF BEIGE DRAINAGE. A REVIEW OF THE FACILITY'S "WOUND MANAGEMENT PROGRAM" POLICY DATED 10/8/2010 NOTED THAT IF A PRESSURE WAS IDENTIFIED, THE FACILITY MUST REFER TO THE FACILITY'S CORPORATE WOUND PROTOCOL, WHICH WAS NOT PROVIDED BY THE END OF THE SURVEY. ( ) RESIDENT # 517 WOUND WAS OBSERVED ON 3/24/11 AT 8:35 AM, AND REVEALED A QUARTER SIZED WOUND ON HER LEFT HEEL THAT HAD A DRY CENTER AND EDGES. ON 3/23/11 AT 2:00 P.M., RECORD REVIEW REVEALED THAT RESIDENT #517 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE RESIDENT'S ADMISSION MINIMUM DATA SET ASSESSMENT (MDS), dated [DATE], DOCUMENTED THE RESIDENT'S COGNITION AS MODERATELY IMPAIRED, AND REQUIRED EXTENSIVE ASSISTANCE FROM STAFF FOR TRANSFERS, TOILETING, DRESSING AND HYGIENE. THE MDS DID NOT DOCUMENT ANY PRESSURE ULCERS OR HISTORY OF HAVING PRESSURE ULCERS. THE ADMISSION SKIN ASSESSMENT, DATED 9/24/10 DOCUMENTED, "AREA OF CONCERN: BILATERAL HEELS, VERY DRY-POOR". NO PRESSURE ULCERS WERE DOCUMENTED ON THE INITIAL ADMISSION SKIN ASSESSMENT. RESIDENT #517'S INITIAL BRADEN SCALE, (A TOOL FOR PREDICTING PRESSURE SORE RISK), DATED 9/24/10 DOCUMENTED A SCORE OF 12 (HIGH RISK FOR PRESSURE ULCER DEVELOPMENT). THE ADMISSION SKIN CARE, PRESSURE ULCER RISK CARE PLAN DATED 9/24/10 AND REVISED ON 11/4/10, DOCUMENTED THE FOLLOWING INTERVENTIONS: 1. CERTIFIED NURSING ASSISTANT (CNA) DAILY SKIN ASSESSMENT, NURSE WEEKLY SKIN ASSESSMENT. 2. TURN AND REPOSITION MINIMUM OF EVERY TWO HOURS IN BED AND ONE HOUR IN CHAIR. 3. FLOAT HEELS. 4. PRESSURE REDUCTION SURFACE TO BED, PRESSURE REDUCTION SURFACE TO CHAIR. REVIEW OF THE ADMISSION NURSES NOTE DATED 9/24/10 DOCUMENTED "NO OPEN AREAS, DRY HEELS". NURSES NOTES DATING 9/25/10 TO 10/30/10 REVEALED NO DOCUMENTED EVIDENCE THAT RESIDENT #517'S HEELS WERE FLOATED OR IF PRESSURE REDUCTION SURFACES WERE PROVIDED TO THE BED OR CHAIR. THE SKIN ASSESSMENTS DOCUMENTED THE FOLLOWING: 1. 10/4/10, 19/10/10 AND 10/18/10 "NO IDENTIFIED CONCERNS". 2. 10/25/10-"LEFT HEEL ESCHAR,TREATMENT NURSE NOTIFIED." THERE WAS NO DOCUMENTED EVIDENCE THAT TREATMENT WAS INITIATED. 3. 11/1/10- "NO NEW IDENTIFIED CONCERNS" 4. 11/8/10 AND 11/17/11, "NO IDENTIFIED CONCERNS". 5. 11/23/10- "TREATMENT IN PROGRESS" DOCUMENTED. 6. 12/6/10 AND 12/13/11-"NO IDENTIFIED CONCERNS". 7. 12/20/10-SACRAL AND HEEL AREAS CIRCLED ON BODY. MARKED AREAS INDICATED "DRYNESS, DISCOLORATION-DARK AREA NON OPEN, AND DRESSING IN PLACE/NOT REMOVED". THERE WAS NO DOCUMENTED EVIDENCE OF MONTHLY TREATMENT SHEET OR WEEKLY PRESSURE ULCER WOUND DOCUMENTATION SHEET FOR THE MONTH OF OCTOBER 2010. THE WEEKLY PRESSURE ULCER WOUND DOCUMENTATION SHEET DATED 11/1/10 DOCUMENTED A "UTD" (UNABLE TO DETERMINE)STAGE OF WOUND, MEASURING 5.4 CENTIMETER (CM) BY 7.5 CM IN SIZE WITH ESCHAR. THE TREATMENT RECORD DATED 11/1/10-11/30/10 DOCUMENTED INTERVENTIONS WITH THE START DATE OF 11/10/10; "HEELS FLOATED" AND "PRESSURE REDUCTION MATTRESS", AND BILATERAL HEELS CLEAN...DRY DRESSING EVERY 2 DAYS AND AS NEEDED, CHECK DAILY". REVIEW OF A NURSES NOTE DATED 11/1/10 AT 4:00 P.M., DOCUMENTED "STAFF ALERTED WRITER OF ESCHAR (BLACKENED TISSUE) AREA ON RIGHT/LEFT HEEL" AND 6:00 P.M. "BILATERAL HEEL PRESENTS ESCHAR TISSUE AND BULKY DRESSING APPLIED..TREATMENT HAS BEEN INITIATED". ON 3/25/11 AT 9:45 A.M., THE TREATMENT NURSE "E", WAS INTERVIEWED REGARDING THE DEVELOPMENT OF RESIDENT # 517 PRESSURE ULCER AND STATED, " I WAS NOT AWARE OF THE PRESSURE ULCER UNTIL 11/1/10." WHEN ASKED WHAT INTERVENTIONS WERE PUT INTO PLACE TO PREVENT FURTHER PRESSURE ULCER BREAKDOWN AFTER THE INITIAL DISCOVERY ON 10/25/10, TREATMENT NURSE "E" STATED, "I DIDN'T HAVE ANYTHING DONE." ON 3/25/11 AT 10:45 A.M., THE DIRECTOR OF NURSING (DON) WAS INTERVIEWED REGARDING RESIDENT # 517 PRESSURE ULCER AND STATED, "THE FACILITY ACQUIRED PRESSURE ULCER WAS AN AREA OF CONCERN THAT SHE HAD BACK IN OCTOBER 2010. THAT IS WHY WE MADE PRESSURE ULCERS A PART OF QUALITY ASSURANCE." ON 3/25/11 AT 1:00 P.M., REVIEW OF THE FACILITY'S POLICY TITLED, "WOUND MANAGEMENT PROGRAM" DATED 7/1/08, DOCUMENTED, "PLACE INITIAL INTERVENTIONS FOR RESIDENTS AS RISK FOR DEVELOPMENT OF SKIN BREAKDOWN ON: ADMISSION CARE PLAN...CARE PLAN...RESIDENT CARE GUIDE...MONITOR SKIN CHANGES DURING ROUTINE DAILY CARE (CNA),...REPORT CONCERNS/OBSERVATIONS TO THE CHARGE NURSE...COMPLETE WEEKLY HYDRATION AND SKIN ASSESSMENT ACCORDING TO SCHEDULE...REPORT ANY ABNORMAL FINDINGS TO THE PHYSICIAN AND CERTIFIED DIETARY MANAGER...INITIATE TREATMENT ACCORDING TO PHYSICIAN GUIDANCE." ( )